Encyclopedia of Couple and Family Therapy [1st ed. 2019] 978-3-319-49423-4, 978-3-319-49425-8

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Jay L. Lebow Anthony L. Chambers Douglas C. Breunlin Editors

Encyclopedia of Couple and Family Therapy

Encyclopedia of Couple and Family Therapy

Jay L. Lebow • Anthony L. Chambers Douglas C. Breunlin Editors

Encyclopedia of Couple and Family Therapy With 54 Figures and 14 Tables

Editors Jay L. Lebow The Family Institute at Northwestern University Center for Applied Psychological and Family Studies Northwestern University Evanston, IL, USA

Anthony L. Chambers The Family Institute at Northwestern University Center for Applied Psychological and Family Studies Northwestern University Evanston, IL, USA

Douglas C. Breunlin The Family Institute at Northwestern University Center for Applied Psychological and Family Studies Northwestern University Evanston, IL, USA

ISBN 978-3-319-49423-4 ISBN 978-3-319-49425-8 (eBook) ISBN 978-3-319-49424-1 (print and electronic bundle) https://doi.org/10.1007/978-3-319-49425-8 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

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

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Preface

systemic interventions, and descriptions of the many models of couple and family therapy. This comprehensive resource also emphasizes topics relating to the conceptualization, treatment, and assessment of common problems facing couples and families. Furthermore, this text not only provides stateof-the-art coverage of important topics, but also cements the legacy and identity of couple and family therapy as effective modalities for treating a range of problems facing the human condition. The encyclopedia includes entries that overview broad areas such as family therapy or attachment, more specific concepts and approaches such as emotionally focused therapy and family structure, and even more specific topics such as enactment or family boundaries. It covers each of the specific area of research and each of the specific approaches in the field, regardless of the underlying therapeutic orientation. Therefore, it ranges widely and comprehensively across cognitive-behavioral, emotion-focused, psychoanalytic, third-wave behavioral, post-modern, intergenerational, common factor, integrative, and other relevant models. The encyclopedia format enables readers to readily access a vast array of information relating to their professional and clinical needs. As an online resource, it is updated at frequent intervals with the latest information relevant to the field. Its target audience include psychologists (including clinical, counseling, family, and developmental psychologists); counselors; social workers; marriage and family therapists; psychiatrists; family life educators; nurses; and family physicians; as well as graduate and undergraduate students with an interest in this area. We hope you, the reader, find it as useful as we have found it exciting and informative to compile. IL, USA August 2019

Jay L. Lebow Anthony L. Chambers Douglas C. Breunlin

About the Editors

Jay L. Lebow, Ph.D., ABPP, is Senior Scholar and Senior Therapist at The Family Institute at Northwestern, and Clinical Professor of Psychology at Northwestern University. He is Editor-in-Chief of the journal Family Process. He has authored seven books and edited seven other books, including Treating the Difficult Divorce: A Practical Guide for Psychotherapists, Couple and Family Therapy: An Integrative Map of the Territory, Research for the Psychotherapist, Common factors in Couple and Family Therapy (with Doug Sprenkle and Sean Davis), Integrative Systemic Therapy (with Bill Pinsof, Doug Breunlin, Bill Russell, Cheryl Rampage, and Anthony Chambers), Clinical Handbook of Couple Therapy (with Alan Gurman and Doug Snyder), Handbook of Family Therapy (with Tom Sexton), and Encyclopedia of Couple and Family Therapy (with Anthony Chambers and Doug Breunlin). He is also author of 200 articles and book chapters, most of which focus on couple and family therapy, research about psychotherapy, therapy for high conflict divorce, and research and practice. He is the author of many review papers summarizing the state of theory, practice, and research in couple and family therapy, including the decade review of couple therapy for Journal of Marital and Family Therapy, the decade review of couple therapy research for Journal of Marital and Family Therapy, the summary of couple and family therapy for The Handbook of Psychology, the summary of integrative methods for the Handbook of Family Therapy, two papers about the practice of integrative family therapy in Family Process, a paper describing a method for treatment of high conflict couples in divorce in Journal of Family Psychology, and summaries of methods of family therapy in the Comprehensive Handbook of Psychiatry and the Psychologist PDR. Dr. Lebow is a major proponent of integrative methods of practice in couple and family therapy and movement

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toward a common base for practice. He wrote a column for a decade for the Psychotherapy Networker on the relationship of research and practice, and now writes an editorial for each issue of Family Process. Dr. Lebow has engaged in clinical practice, supervision, and research for over 40 years, is board certified in couple and family psychology, and is an American Association for Marriage and Family Therapy approved supervisor. He has received the Society of Couple and Family Psychology’s Family Psychologist of the Year Award as well as the American Family Therapy Academy’s Lifetime Achievement Award. He served as President of the Society of Couple and Family Psychology and served for many years on the Board of Directors and as committee chairs for the American Family Therapy Academy.

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

About the Editors

About the Editors

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

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

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Richard Schwartz) of the Handbook of Family Therapy Training and Supervision, coauthor of Integrative Systemic Therapy: Metaframeworks for Problem Solving with Individuals, Couples and Families, an Editor-in-Chief of the Encyclopedia of Couple and Family Therapy, and the author of over 70 published articles and chapters in books. He has served on the Editorial Boards of Family Process, Couple and Family Psychology, the Journal of Marital and Family Therapy, and the Journal of Family Therapy. He has served as secretary, treasurer, and board member of the American Family Therapy Academy.

About the Editors

Section Editors

Brian R. W. Baucom Department of Psychology, University of Utah, Salt Lake City, UT, USA

Maria Borcsa University of Applied Sciences Nordhausen, Nordhausen, Germany

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Douglas C. Breunlin The Family Institute at Northwestern University, Center for Applied Psychological and Family Studies, Northwestern University, Evanston, IL, USA

Kristina S. Brown Couple and Family Therapy Department, Adler University, Chicago, IL, USA

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

Section Editors

Section Editors

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Sean D. Davis California School of Professional Psychology, Alliant International University, Sacramento, CA, USA

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

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

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Adam R. Fisher The Family Institute at Northwestern University, Evanston, IL, USA Brigham Young University, Provo, UT, USA

Molly F. Gasbarrini California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA Farrah Hughes McLeod Health, Florence, USA

Eli Karam University of Louisville, Louisville, KY, USA

Section Editors

Section Editors

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David Kearns University of Iowa, Iowa City, USA

Jay L. Lebow The Family Institute at Northwestern University, Center for Applied Psychological and Family Studies, Northwestern University, Evanston, IL, USA

Thorana Nelson Santa Fe, NM, USA

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Heather Pederson Council for Relationships, Philadelphia, USA

Kelley Quirk Marriage and Family Therapy Program, Human Development and Family Studies, Colorado State University, Fort Collins, CO, USA

Mudita Rastogi Illinois School of Professional Psychology, Argosy University, Schaumburg, IL, USA

Section Editors

Section Editors

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Jessica Rohlfing Pryor The Family Institute at Northwestern University, Northwestern University, Chicago, IL, USA

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

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

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

Margarita Tarragona PositivaMente and Grupo Campos Elíseos, Mexico City, Mexico

Section Editors

About the Managing Editors

Jessica Rohlfing Pryor, M.S., Ph.D., is full-time faculty in the Counseling Program (MA) and a Staff Psychologist at The Family Institute at Northwestern University. Dr. Pryor is also a Clinical Lecturer in the Department of Psychology and Adjunct Faculty in the School of Education and Social Policy at Northwestern University. Dr. Pryor is a board member of the American Psychological Association’s (APA) Society for Couple and Family Psychology, and also serves on the editorial board for the journal Measurement and Evaluation in Counseling & Development. Dr. Pryor completed her Ph.D. in Counseling Psychology at Arizona State University, and completed her APA-approved internship at the Counseling and Consultation Services at the University of Wisconsin-Madison. Dr. Pryor completed a 1-year academic postdoctoral fellowship at Arizona State University, specializing in Counselor Education and Supervision. She also completed a 2-year postdoctoral fellowship specializing in the treatment of couples and families at The Family Institute at Northwestern University. Dr. Pryor’s scholarly pursuits are diverse in interpersonal scope, but predominantly examine maladaptive expressions and features of perfectionism (e.g., personality, interpersonal style) and their implications for interpersonal functioning (e.g., intimacy, self-disclosure, help-seeking).

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About the Managing Editors

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

Contributors

Jukka Aaltonen Department of Psychology, University of Jyväskylä, Jyväskylä, Finland Rola O. Aamar Texas Tech University, Lubbock, TX, USA East Carolina University, Greenville, NC, USA Dena Abbott Department of Psychology and Behavioral Sciences, Louisiana Tech University, Ruston, LA, USA Jonathan S. Abramowitz Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Britney Acquaire Seton Hall University, South Orange, NJ, USA Michael Adams Brigham Young University, Provo, UT, USA Elizabeth Adedokun Drexel University, Philadelphia, PA, USA Tamara D. Afifi Department of Communication, University of California, Santa Barbara, Santa Barbara, CA, USA Juan Carlos Agundez The Family Institute at Northwestern University, Evanston, IL, USA Michelle Ahmed The Family Institute at Northwestern University, Evanston, IL, USA Christine Aiello The Family Institute at Northwestern University, Evanston, IL, USA Renu Aldrich Virginia Tech University, Blacksburg, VA, USA James F. Alexander Functional Family Therapy LLC, Seattle, WA, USA Robert Allan School of Education and Human Development, University of Colorado Denver, Denver, CO, USA Sage Erickson Allen Brigham Young University, Provo, UT, USA Sarah M. Allen Montana State University, Bozeman, ST, USA Argie J. Allen-Wilson Department of Counseling and Family Therapy, Drexel University, College of Nursing and Health Professions, Philadelphia, PA, USA xxi

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Rhea Almeida The Institute for Family Services, Somerset, NJ, USA Aalaa Alshareef The Family Institute at Northwestern University, Evanston, IL, USA Zahra Amer University of Tennessee, Knoxville, Knoxville, TN, USA Austen R. Anderson University of Miami, Miami, FL, USA Harlene Anderson The Taos Institute, Chagrin Falls, OH, USA Houston Galveston Institute, Houston, TX, USA Jared Anderson Kansas State University, Manhattan, KS, USA Maurizio Andolfi Accademia di Psicoterapia della Famiglia, Rome, Italy Harry Aponte Drexel University, Philadelphia, PA, USA Richard Archambault Rhode Island Hospital, Department of Psychiatry, Providence, RI, USA Jane Ariel The Wright Institute, Berkeley, CA, USA Laura Jimenez Arista Arizona State University, Phoenix, AZ, USA Kiran Arora Long Island University, Brooklyn, NY, USA Jeremy Arzt Windward Way Recovery, Los Angeles, CA, USA Rose Ashraf Southern Methodist University, Dallas, TX, USA Kadie L. Ausherbauer University of Minnesota, Minneapolis, MN, USA Jason P. Austin Marriage and Family Therapy and Counseling Studies, University of Louisiana at Monroe, Monroe, LA, USA Constance Avery-Clark Institute of Sexual and Relationship Therapy and Training, Boca Raton, FL, USA Sarah Avery-Leaf The Informatics Applications Group (tiag), Tacoma, WA, USA Christiana I. Awosan Seton Hall University, South Orange, NJ, USA Michael Baglieri Seton Hall University, South Orange, NJ, USA University of Kansas, Lawrence, KS, USA Richard W. Bailey Lancaster, PA, USA Christina Balderrama-Durbin Binghamton University – State University of New York, Binghamton, NY, USA Michele Baldwin Chicago Center for Family Heath, Chicago, IL, USA Jamie Banker California Lutheran University, Thousand Oaks, CA, USA Donna Baptiste The Family Institute at Northwestern University, Evanston, IL, USA

Contributors

Contributors

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Donna Rosana Baptiste The Family Institute at Northwestern University, Evanston, IL, USA Bogdan de Barbaro Family Therapy Department, Krakow, Poland Department of Psychiatry, Jagiellonian University Medical College, Krakow, Poland Pietro Barbetta Centro Milanese di Terapia della Famiglia, Milan, Italy University of Bergamo, Bergamo, Italy Stephanie Barkley Saint Louis University, Saint Louis, MO, USA Mary Jo Barrett Center for Contextual Change, Chicago, IL, USA Robin A. Barry Department of Psychology, University of Wyoming, Laramie, WY, USA Bente Barstad Family Unit, Modum Bad, Vikersund, Norway Brian R. W. Baucom Department of Psychology, University of Utah, Salt Lake City, UT, USA Donald H. Baucom University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Katherine J. W. Baucom University of Utah, Salt Lake City, UT, USA Irene Bautista Converse College, Spartanburg, SC, USA Saliha Bava Mercy College, New York, NY, USA Houston Galveston Institute, Houston, TX, USA Taos institute, Chagrin Falls, OH, USA Steven R. H. Beach University of Georgia, Athens, GA, USA Austin Beck Kansas State University, Manhattan, KS, USA Carol Becker Therapy Training Boston, Watertown, MA, USA Dorothy Becvar Saint Louis University, Saint Louis, MO, USA Christian Beels New York, NY, USA Ben K. Beitin Seton Hall University, South Orange, NJ, USA Kaitlyn Bellingar The Family Institute at Northwestern University, Evanston, IL, USA Christopher K. Belous Mercer University, Atlanta, GA, USA Elisabeth Bennett Gonzaga University, Spokane, WA, USA Kristin M. Bennion California Institute of Integral Studies, San Francisco, CA, USA Intimate Connections Counseling, Orem, UT, USA

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Billy Benson The Ackerman Institute for the Family, New York City, NY, USA Kristen Benson Appalachian State University, Boone, NC, USA Lisa A. Benson Harbor-UCLA Medical Center, Los Angeles, CA, USA Jean Benward San Ramon, CA, USA Sarah Berland Ackerman Institute for the Family, New York, NY, USA Ellen Berman University of Pennsylvania, Philadelphia, PA, USA Natalie Berry Midwestern University, Downers Grove, IL, USA Bob Bertolino Maryville University, St. Louis, MO, USA Dale E. Bertram Abilene Christian University, Abilene, TX, USA Paolo Bertrando Systemic-Dialogical Psychotherapy School, Bergamo, Italy Mark H. Bird Healing and Recovery, Lewisville, TX, USA Gary H. Bischof Western Michigan University, Lee Honors College, Kalamazoo, MI, USA Richard Bischoff University of Nebraska, Omaha, NE, USA Danielle A. Black Center for Applied Psychological and Family Studies, The Family Institute at Northwestern University, Evanston, IL, USA The Family Institute at Northwestern University, Chicago, IL, USA Stephanie Winkeljohn Black Penn State Harrisburg, Middleton, PA, USA Susana Blanco Thrive Psychological Associates, Miami Lakes, FL, USA Emily Blefeld Wickford, RI, USA Stevie Blum The Ackerman Institute for The Family, New York, NY, USA Elizabeth Boatman Texas Woman’s University, Denton, TX, USA Guy Bodenmann Department of Psychology, University of Zurich, Binzmuehlestrasse, Zurich, Switzerland Rebecca Bokoch Couple and Family Therapy, CSPP Alliant International University, Los Angeles, CA, USA Jacek Bomba Department of Psychiatry, Jagiellonian University Medical College, Krakow, Poland Faith Johnson Bonecutter University of Illinois at Chicago, Chicago, IL, USA Maria Borcsa University of Applied Sciences Nordhausen, Nordhausen, Germany Christine Borst Arizona State University, Phoenix, AZ, USA

Contributors

Contributors

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

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

Contributors

Contributors

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

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

Contributors

Contributors

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

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

Contributors

Contributors

xxxi

Todd M. Edwards Marital and Family Therapy Program, University of San Diego, San Diego, CA, USA Ivan Eisler Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK Kathleen A. Eldridge Graduate School of Education and Psychology, Pepperdine University, Los Angeles, CA, USA Cezanne M. Elias Purdue University, West Lafayette, IN, USA Mony Elkaïm Free University of Brussels, Brussels, Belgium Corinn A. Elmore Walter Reed National Military Medical Center, Bethesda, MD, USA Joanna Elmquist University of Tennessee-Knoxville, Knoxville, TN, USA Justine Encinas Seton Hall University, South Orange, NJ, USA Daniel T. Ennaco California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA Naomi Ennis Ryerson University, Toronto, ON, Canada Christie Eppler Seattle University, Seattle, WA, USA Norman B. Epstein University of Maryland, College Park, MD, USA David Epston Family Therapy Centre, Auckland, New Zealand Christie Erickson Alpharetta, Georgia Valentin Escudero Department Psychology, Universidad de A Coruña, A Coruña, Spain Kamran K. Eshtehardi California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA Sandra Espinoza California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA Benjamin J. Evans Marriage and Family Therapy and Counseling Studies, University of Louisiana at Monroe, Monroe, LA, USA William D. Ewing The Family Institute at Northwestern University, Chicago, IL, USA Katherine A. Fackina Department of Professional Psychology and Family Therapy, Seton Hall University – College of Education and Human Services, South Orange, NJ, USA Mariana K. Falconier Virginia Polytechnic Institute and State University, Falls Church, VA, USA

xxxii

Celia Jaes Falicov University of California, San Diego, San Diego, CA, USA Andrea Leigh Farnham The University of Georgia, Athens, GA, USA Erin Ferenchick Columbia University, New York, NY, USA Elena Fernández Grupo Campos Elíseos, Mexico City, Mexico Nedra Fetterman Imago Relationships International, Washington, DC, USA Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA Cyrille Feybesse Porto, Portugal Barbara H. Fiese University of Illinois, Urbana-Champaign, Urbana, IL, USA Stephen T. Fife University of Nevada, Las Vegas, Las Vegas, NV, USA Texas Tech University, Lubbock, TX, USA K. Finch Texas Tech University, Lubbock, TX, USA Frank D. Fincham Florida State University, Tallahassee, FL, USA Brandi C. Fink The University of New Mexico, Albuquerque, NM, USA Michelle A. Finley Antioch University Seattle, Seattle, WA, USA Hans Rudi Fischer Familiendynamik, Heidelberger Institut für systemische Forschung und Therapie, Heidelberg, Germany Melanie S. Fischer University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Linda Stone Fish Syracuse University, Syracuse, NY, USA Adam R. Fisher The Family Institute at Northwestern University, Evanston, IL, USA Brigham Young University, Provo, UT, USA Lesley Fisher The Family Institute at Northwestern University, Evanston, IL, USA Mary A. Fisher Mary Fisher Psychotherapy, PLLC, Salt Lake City, UT, USA CJ Eubanks Fleming Elon University, Elon, NC, USA Douglas Flemons Nova Southeastern University, Fort Lauderdale, FL, USA Autumn Rae Florimbio University of Tennessee-Knoxville, Knoxville, TN, USA Paul Florsheim University of Wisconsin Milwaukee, Milwaukee, WI, USA Karen Focht The Family Institute at Northwestern University, Evanston, IL, USA

Contributors

Contributors

xxxiii

Sallie Foley University of Michigan, Ann Arbor, MI, USA Roberto Font Multicultural Family Institute, Highland Park, NJ, USA Heather Foran Alpen-Adria-University Klagenfurt, Klagenfurt, Austria Rex L. Forehand The University of Vermont, Burlington, VT, USA Catherine Weigel Foy The Family Institute at Northwestern University, Evanston, IL, USA Peter Fraenkel The City College of New York, New York, NY, USA Cynthia Franklin The Steve Hicks School, The University of Texas at Austin, Austin, TX, USA Steffany J. Fredman The Pennsylvania State University, University Park, PA, USA Jill Freedman Evanston Family Therapy Center, Evanston, IL, USA Laura M. Frey Couple and Family Therapy Program, Kent School of Social Work, University of Louisville, Louisville, KY, USA Myrna L. Friedlander University at Albany/State University of New York, Albany, NY, USA Alan E. Fruzzetti Department of Psychiatry, McLean Hospital/Harvard Medical School, Belmont, MA, USA Ben Furman Helsinki Brief Therapy Institute, Helsinki, Finland James L. Furrow Fuller Graduate School of Psychology, Pasadena, CA, USA Jerry Gale University of Georgia, Athens, GA, USA Kami L. Gallus Oklahoma State University, Stillwater, OK, USA Rashmi Gangamma Syracuse University, Syracuse, NY, USA Molly F. Gasbarrini California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA Bob Geffner Institute on Violence, Abuse, and Trauma, San Diego, CA, USA Diane R. Gehart Department of Educational Psychology and Counseling, California State University, Northridge, CA, USA Emily J. Georgia University of Miami, Miami, FL, USA Kenneth J. Gergen Swarthmore College, Philadelphia, PA, USA Mary Gergen Penn State, Brandywine, PA, USA Armine Gevorkyan California Department of Corrections and Rehabilitation (CDCR), Los Angeles, CA, USA

xxxiv

Shawn V. Giammattei Quest Family Therapy, San Francisco Bay Area, CA, USA The Rockway Institute, California School of Professional Psychology at Alliant International University, San Francisco, CA, USA Valerie Gifford University of Alaska Fairbanks, Fairbanks, AK, USA Eliana Gil Gil Institute for Trauma Recovery and Education, Fairfax, VA, USA Dan Gill The Family Institute at Northwestern University, Evanston, IL, USA Lynn Gilman Indiana University, Bloomington, IN, USA Adriana Gil-Wilkerson Adjunct Faculty, Our Lady of the Lake University, Houston, TX, USA Elizabeth Glaeser The Gender and Family Project, Ackerman Institute for the Family, New York, NY, USA Tatiana Glebova Alliant International University – California School of Professional Psychology, Sacramento, CA, USA Dawn L. Glover California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA Shirley Glynn University of California – Los Angeles, Los Angeles, CA, USA Edith Goldbeter Institut d’Etudes de la Famille et des Systèmes Humains, Brussels and ULB, Brussels, Belgium Marvin R. Goldfried Stony Brook University, Stony Brook, NY, USA Rhonda N. Goldman Illinois School of Professional Psychology at Argosy University, Chicago, IL, USA Virginia Goldner Psychology Department, New York University, New York, NY, USA Jacob Z. Goldsmith The Family Institute at Northwestern University, Evanston, IL, USA Joanna Goldsmith Boston College School of Social Work, Somerville, MA, USA Chris J. Gonzalez Department of Psychology, Counseling, and Family Science, Lipscomb University, Nashville, TN, USA Natali Gonzalez Texas Tech University, Lubbock, TX, USA Vived Gonzalez California School of Professional Psychology, Alliant International University, Sacramento, CA, USA Alliant International University, Irvine, CA, USA Eric T. Goodcase Kansas State University, Manhattan, KS, USA

Contributors

Contributors

xxxv

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

xxxvi

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

Contributors

Contributors

xxxvii

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

xxxviii

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

Contributors

Contributors

xxxix

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

xl

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

Contributors

Contributors

xli

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

xlii

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

Contributors

Contributors

xliii

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

xliv

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

Contributors

Contributors

xlv

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

xlvi

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

Contributors

Contributors

xlvii

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

xlviii

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

Contributors

Contributors

xlix

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

l

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

Contributors

Contributors

li

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

lii

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

Contributors

Contributors

liii

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

liv

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

Contributors

Contributors

lv

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

lvi

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

Contributors

Contributors

lvii

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

lviii

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

Contributors

Contributors

lix

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

lx

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

Flora Tuhaka: deceased.

Contributors

Contributors

lxi

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

lxii

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

Contributors

Contributors

lxiii

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

A

AAMFT Approved Supervisor Training

AAMFT Approved Supervision Designation; AAMFT Approved Supervisor Designation; AAMFT Approved Supervisor Program; AAMFT Approved Supervisors; Approved Supervisor status; Supervisor-in-Training (SIT)

counseling (MFC; Stevens-Smith et al. 1993). In the early beginnings of the field, more specifically in 1949, the accrediting body of the AAMFT, later titled the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), identified and established what constituted a competent MFT/MFC (Kosinski 1982). In 1971, the AAMFT further legitimized and added value to the field by initiating rigorous trainings for the AAMFT Approved Supervisor status* (Lee et al. 2004). At the turn of the century, the field of MFT was one of only two fields requiring additional training to “designate supervisors, define supervisors’ qualifications, and require supervisor training” (Todd and Storm 2002, p. 4). This training process offers professional development options for AAMFT Supervisors-in-Training (SIT)* and future AAMFT Approved Supervisors* at both the masters and doctoral levels. The AAMFT Supervisor Designation* and distinction is a hallmark of COAMFTE accreditation.

Introduction

Description

For more than 75 years, the American Association for Marriage and Family Therapy (AAMFT) voluntarily established its professional identity developing formalized education and training standards and responsibilities for the field of marriage and family therapy (MFT; AAMFT 2016; Kosinski 1982) and marriage and family

Members of the AAMFT, initially the American Association of Marriage and Family Counselors (AAMFC; Kosinski 1982; Stevens-Smith et al. 1993), believed the field of MFT/MFC deserved a distinct professional identity in contrast to mainstream theoretical and clinical fields at the time. In 1974, the AAMFT became the first official body

Sarah K. Samman1 and Gita Seshadri2 1 Alliant International University, San Diego, CA, USA 2 Alliant International University, Sacramento, CA, USA

Name of Entry AAMFT Approved Supervisor Training

Synonyms

© Springer Nature Switzerland AG 2019 J. L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy, https://doi.org/10.1007/978-3-319-49425-8

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that enforced accreditation standards for graduate and post-degree training (Kosinski 1982; StevensSmith et al. 1993) to reflect the autonomous theoretical and clinical discipline of MFT/MFCs. This was possible through the institution of COAMFTE (Stevens-Smith et al. 1993), the establishment of licensure requirements for the profession (Kosinski 1982; West et al. 2013), as well as the development of supervisory standards through the AAMFT Approved Supervisor Program* (Kosinski 1982). Since then, it has become one of a handful of credentialing organizations by which to obtain the education, training, and certification necessary to ensure quality supervisory skills, primarily those around the evaluation of students’ basic as well as advanced professional and clinical competencies to ensure ethical and effective therapeutic care. The AAMFT has evolved and thrived, from tentatively drawing lines in the sand to establishing the gold standard for the field of MFT. The AAMFT succeeded at creating and regulating stringent training and supervision standards to ensure both students and professors were validating a terminal degree. Members of the AAMFT realized that their systemic approach to accreditation processes through COAMFTE, in addition to clinical and supervisory professionals working in collaboration along with licensing boards, professors, and students, would ensure the systemic process could succeed. The following sections expand upon the successes of this process. AAMFT Accreditation Process The AAMFT provides recognition of MFTrelated education through COAMFTE grounded in a 2-year, at minimum, terminal master’s degree in MFT. The degree adheres to AAMFT curricular guidelines for students and clinical training expertise of supervisors (West et al. 2013). Unsurprisingly, the curriculum in COAMFTE programs reflects the foundation of MFT and involves a systemic and interactional lens with consideration to case conceptualization, assessment and evaluation, diagnosis, treatment, and attention to diversity issues facing individuals, couples, and families. These guidelines ensure the most

AAMFT Approved Supervisor Training

comprehensive experience for students beginning their careers in the field and preparing for future autonomous clinical practice (Stevens-Smith et al. 1993). COAMFTE also accredits doctoral-level programs with advanced specialization in curricula and training in the field of MFT. These programs commonly require a COAMFTE accredited master’s degree curriculum as a prerequisite (Stevens-Smith et al. 1993). The doctoral curriculum focuses on “emphasizing research, theory construction, supervision, and advanced clinical skills” (Stevens-Smith et al. 1993, para. 19). Thus, it is unsurprising that obtaining a COAMFTE accredited degree is beneficial for the licensure or certification process at the local and national level. AAMFT and Licensure Licensure is the legal privilege to practice within a particular field (West et al. 2013); it provides the basis for regulatory oversight and reimbursement (AAMFT 2016). A vast majority of MFT professionals believe licensure is the crowning achievement after years of effort and hard work in the field. With regard to licensure, AAMFT state divisions collaborated to establish the Department of Divisional Affairs (West et al. 2013) and, in 1987, provided seed money to establish the Association of Marital and Family Therapy Regulatory Boards (AMFTRB; West et al. 2013). In the early 1990s, the AAMFT, through the AMFTRB, succeeded in obtaining licensure and certification statuses for MFTs nationally (West et al. 2013). While the AAMFT initially took a leadership role in establishing professional standards, state licensure boards began taking on a leadership and regulatory role in all 50 states and the District of Columbia (West et al. 2013). Due to the independent needs of each state, West et al. found that prelicensing requirements for individual states and the AAMFT in comparison data for 2007 and 2012 differed and, at times, would conflict. Despite best efforts to collaborate between the AAMFT and state regulatory boards, the authors found that AAMFT guidelines were commonly more stringent reflecting quality graduate guidelines and providing stronger opportunities for

AAMFT Approved Supervisor Training

licensure at the national level. These ongoing conflicts led in small part to the AAMFT membership passing legislation to restructure the AAMFT and dissolve state divisions in 2018 with the desire to reestablish the AAMFT as the central regulatory organization. The restructure also provided opportunities to create personal interest groups based on the needs of each particular state. In the meantime, California currently is an exception to this rule due in large part to differing regulatory values as well as the concentrated number of MFTs in the state comparable to the combined number of MFTs nationwide. Thus, California maintained the AAMFT professional relationship while withdrawing from the AAMFT as its regulating body for licensure, and the state is not currently included in the national exam. The Board of Behavioral Sciences is currently tasked with regulating MFT licensure in the State of California. Additionally, in 1998, advocates for California licensure regulation established the California Association of Marriage and Family Therapists (CAMFT) to bridge this gap between profession and licensure. AAMFT Membership The AAMFT offers several membership opportunities for individuals specializing in MFT in the USA: student, preclinical fellow, and clinical fellow (AAMFT 2018b). Affiliates may join the AAMFT; however, this category includes professionals licensed in alternative fields/disciplines with specializations/emphases in MFT/MFC (AAMFT 2018b). The AAMFT offers the student category to those enrolled in a graduate or postgraduate certificate program; the preclinical fellow is for master’s graduates working toward licensure in any US state; and the clinical fellow is for those who are fully licensed MFTs in any US state (AAMFT 2018b). AAMFT members in any of the above categories, with the exception of affiliates, are eligible to pursue the AAMFT Approved Supervisor Training process and must be a preclinical fellow or clinical fellow to obtain their AAMFT Approved Supervisor Designation* (AAMFT 2016).

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AAMFT Supervision Todd and Storm (2002) viewed the supervisory experience as a developmental process within a large continuously evolving supervisory system. In other words, supervision is the relationship by which the supervisor monitors and evaluates the quality of the supervisee’s professional and clinical development, competencies, and services (West et al. 2013) within the immediate supervisory relationship as well as the larger practice setting (Todd and Storm 2002). Supervisors then act as gatekeepers by ensuring students graduate with the requisite skills and competencies needed toward licensure (West et al. 2013). Thus, the AAMFT supervisory guidelines are essential components of the training experience working toward higher-quality graduate and postgraduate work in consideration of COAMFTE regulation. AAMFT Approved Supervision Training The field of MFT has considerably evolved. Quality supervision by skilled and proficient clinicians is essential to shape MFT professionals and influence the growing mental health profession in multiple aspects of professional identity. In order to ensure quality and rigor, the AAMFT believed creating a supervision credential would contribute to the growth and development of therapists in both prelicensure (i.e., obtaining supervision during practice and development as a Supervisor-in-Training* [SIT*]) and postlicensure (i.e., providing mentorship supervision for developing clinicians and SITs) experiences. Smith et al. (2002, see also AAMFT 2016) reported that pursuing the SIT* credentialing process allows those wanting to become AAMFT Approved Supervisors* to (1) develop an understanding of the various models of supervision, (2) develop a personal philosophy of supervision, (3) forge relationships with other professionals in the form of supervisor/supervisee relationships, (4) use and review cases (verbal, audio, video, and/or live), and (5) expand the systemic unit of supervision from a dyad to multiple systems (i.e., supervisor of supervision/mentor as well as supervisees). SITs* are simultaneously advocates, witnesses, and participants of multiculturalism (race, ethnicity, etc.) and diversity (e.g., gender, sexual

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orientation, socioeconomic status, religiospiritual identification, ability, etc.) in addition to explicit attention to the AAMFT ethical codes, federal and state regulations, and the values of the AAMFT membership and organization as a part of the contextual supervision process. The SIT* is also available to doctoral students in COAMFTE accredited programs offering supervision courses. Students are required to take 30 h of applicable supervision courses in the form of two classes (i.e., Fundamentals of MFT Supervision and Advanced Supervision in MFT; AAMFT 2016). Doctoral students can then complete all other requirements of the AAMFT Supervision Designation* while completing their degree or thereafter within 5 years of starting the Fundamentals of MFT Supervision course. At the culmination of SIT hours, the AAMFT Approved Supervisor* candidate would have completed the following: (1) a 30-h supervision course; (2) 36 h of supervision, where 18 of the hours are completed within the last 2 years of training; (3) a minimum of 9 months of continuous supervision with at least 2 AAMFT trainees; (4) 180 h of supervision of trainees, with 90 of the hours completed within the last 2 years of training; and (5) a philosophy of supervision paper that is reviewed and approved by the SIT’s supervisor. Candidates must ensure they join the preclinical fellow or clinical fellow category before applying for the SIT* designation. For further requirements, see the most current version of the AAMFT Approved Supervision Designation: Standards Handbook (AAMFT 2016). Challenges with Access to AAMFT Approved Supervisors* While there is strength and backing to the AAMFT Supervisor Designation* credential, there are a few roadblocks. There are tens of thousands of licensed MFTs nationwide; however, only a few are AAMFT qualified supervisors, and fewer are available for trainee and intern supervisory mentorship. This creates a challenge around replicability and reliability. Restrictive graduate programs may assign preapproved practicum sites and supervisors to interns and trainees without consideration for goodness of fit. There may not even be enough AAMFT Approved Supervisors* or AAMFT Approved

AAMFT Approved Supervisor Training

Equivalent Supervisors to go around. Nevertheless, supervisors with an AAMFT Supervisor Designation* have completed all necessary training to comprehensively mentor SITs through the supervisory process. Additional roadblocks include AAMFT’s lessening control over the initial requirements of those pursuing a degree in MFT. The education and training experiences are increasingly difficult to evaluate, both in quality and uniformity, especially in nonCOAMFTE accredited MFT programs (West et al. 2013). This includes differences in practicum and state requirements and the fact that agencies are less likely to be able to provide AAMFT Approved Supervisors* on staff (West et al. 2013). Thus, MFT advocates encourage more support for the AAMFT Supervisor Designation* as well as what it stands for due to its established foundation for quality clinical training and supervision. Significance and Uniqueness of the AAMFT Supervisor Training An area of distinction with the AAMFT Approved Supervisor Designation* is the emphasis on diversity and multiculturalism. The AAMFT Code of Ethics (AAMFT 2018a) and principles has a section on nondiscrimination as follows: “Marriage and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity or relationship status” (p. 3). Designation as an AAMFT Approved Supervisor* inherently emphasizes attention to interactional and contextual influences around diversity. Despite these multicultural emphases and contextual values, Northey (2004) highlighted that MFTs in his study were predominantly Caucasian, and this presence automatically influences supervisory experiences when extended systems do not reflect national representations. Based on this, the encouragement is for supervisors to explore these dynamics and be sensitive to how supervision attends to multicultural and diversity issues and needs. They further emphasized that other forms of diversity need to also be acknowledged (e.g., socioeconomic status, sexual orientation, gender, etc.) as well as power dynamics.

ABCT Couples Research and Treatment Special Interest Group

Lastly, as the field of MFT evolves with the turn of the century, AAMFT has provided more opportunities for technology by including it as an aspect of supervision, i.e., providing the supervision and refresher courses online (AAMFT 2018b). The commitment to technological accessibility is evidenced by AAMFT’s official provider status for online courses since June 2015. They have also added a supervisor directory for both students, clinicians, and supervisors who are AAMFT members as a form of networking and connection. Members can view this link after signing into the AAMFT website: https://www. aamft.org/AAMFT/supervision/AS_Designation. aspx. Other resources for supervisors on the website include samples of informed consent with SIT, ways to structure supervision, and a supervisor’s theoretical orientation.

Cross-References ▶ Multicultural Family Institute

References AAMFT. (2016). Approved supervision designation: Standards handbook. Retrieved from https://www.aamft. org/Documents/Supervision/2016%20Supervision%20 Forms/Jan_2014_AS_Handbook_ver_Oct_%202016. pdf. AAMFT. (2018a). Code of ethics. Retrieved from https:// www.aamft.org/Documents/Legal%20Ethics/AAMFTcode-of-ethics.pdf. AAMFT. (2018b). Join/reinstate/upgrade today! Retrieved from https://www.aamft.org/AAMFT/Mem bership/Join_AAMFT/Shared_Content/Membership/ New_Join_Application/Join_AAMFT.aspx?hkey=b16 a4aa7-0e1e-47d4-b47f-5fb8ebdd28a9. Kosinski, F. A. (1982). Standards, accreditation, and licensure in marital and family therapy. Personnel and Guidance Journal, 60(6), 350–352. Lee, R. E., Nichols, D. P., Nichols, W. C., & Odom, T. (2004). Trends in family therapy supervision: The past 25 years and into the future. Journal of Marital and Family Therapy, 30(1), 61–70. https://doi.org/10.1111/ j.1752-0606.2004.tb01222.x. Northey, W. (2004). Who are marriage and family therapists? Family Therapy Magazine, 3(6), 10–13. Smith, A. L., Smith, G. T., Stephens-West, G., & Gallagher, M. A. (2002). The virtual leap to on-line supervisory education: An examination of distance

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education in marriage and family therapy. Journal of Teaching in Marriage and Family, 2(2), 127–151. Stevens-Smith, P., Hinkle, J. S., & Stahmann, R. F. (1993). A comparison of professional accreditation standards in marriage and family counseling and therapy. Counselor Education and Supervision, 33(2), 116–126. https://doi. org/10.1002/j.1556-6978.1993.tb00274.x. Todd, T. C., & Storm, C. L. (Eds.). (2002). The complete systemic supervisor: Context, philosophy, and pragmatics. Lincoln: Authors Choice Press. West, C., Hinton, W. J., Grames, H., & Adams, M. A. (2013). Marriage and family therapy: Examining the impact of licensure on an evolving profession. Journal of Marital and Family Therapy, 39(1), 112–126. https://doi.org/10.1111/jmft.12010.

ABCT Couples Research and Treatment Special Interest Group Dev Crasta1, Kayla Knopp2, Brian R. W. Baucom3 and Katherine J. W. Baucom4 1 University of Rochester, Rochester, NY, USA 2 University of Denver, Denver, CO, USA 3 Department of Psychology, University of Utah, Salt Lake City, UT, USA 4 University of Utah, Salt Lake City, UT, USA

Name of the Organization or Institution ABCT Couples Research and Treatment Special Interest Group

Synonyms AABT couples SIG; ABCT couples SIG; Couples SIG

Introduction The Couples Research and Treatment Special Interest Group (Couples SIG) of the Association for Behavioral and Cognitive Therapies (ABCT, formerly known as Association for the Advancement of Behavior Therapy, or AABT) is a consortium of researchers and clinicians focused on couples research and practice. The Couples SIG was

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Absent but Implicit in Narrative Couple and Family Therapy

founded by a group of psychology researchers actively developing couples therapies. The Couples SIG is steadily growing in size and productivity and currently has 215 members (Eubanks-Fleming 2015). As a part of the ABCT, the Couples SIG promotes empirically supported treatment of couples and relationship problems both by promoting basic research into relationship functioning and clinical research into the assessment, prevention, and treatment of couple problems.

Contributions The Couples SIG encourages professional networking primarily through programming at the annual ABCT convention, including a preconference workshop focused on current issues in couples research and treatment, a business meeting, and an evening social for the whole SIG as well as a student-only portion. Additionally, members of the SIG are active poster and symposia presenters, clinical training workshop leaders, panelists, and members of clinical roundtables at each convention. During the year, the Couples SIG continues to encourage communication between its members through its website (www.abctcouples.org), a biannual newsletter, and an email list serve. All online forums accommodate both discussion about research issues and clinical support for providers specializing in couples therapy. The Couples SIG also encourages the growth and development of the next generation of couples researchers. At the annual ABCT convention, the Couples SIG sponsors many student presentations at the Friday Night Welcoming Cocktail Party’s SIG Poster Exposition and an all-student symposium at the general convention to help feature student work. Additionally, the Couples SIG has created the Robert L. Weiss Student Poster Award to recognize outstanding student research. The Couples SIG also maintains resources for students looking to specialize in couples work including a list of doctoral programs and APA-approved internships that have a strong couples focus. Finally, the SIG advocates for the visibility of relationship research both within and outside of ABCT and encourages dissemination of empirically

supported best practices. Currently, the interventions supported by research within the Couples SIG include (but are not limited to) behavioral and cognitive-behavioral couple therapy (BCT/CBCT), integrative behavioral couple therapy (IBCT), emotionally focused therapy (EFT), couple relationship education (CRE), and specializations of these approaches focused on couples with concurrent psychological and medical issues such as PTSD, substance use, depression, cardiovascular disease, and cancer. The Couples SIG also contributes to the overall quality and output of ongoing research in the field by emphasizing topics such as research methodology, grant funding, and translational issues in their conference programming as well as advocacy efforts.

Cross-References ▶ Behavioral Couple Therapy ▶ Cognitive Behavioral Couple Therapy ▶ Emotion-Focused Therapy for Couples ▶ Integrative Behavioral Couple Therapy ▶ PREP Enrichment Program

References Eubanks-Fleming, C. J., (2015). ABCT Couples SIG Treasurer’s Update (C. Carrington, A.M. Parsons, & K.Z. Pentel, Eds.). Couples Research & Therapy Newsletter, 21(2), 4.

Absent but Implicit in Narrative Couple and Family Therapy Saviona Cramer Barcai Institute, Tel Aviv, Israel Every expression can be considered to be founded upon its contrast, which I refer to as the ‘Absent But implicit.’ (White 2005)

In narrative therapy, “Absent But Implicit” refers both to an understanding regarding how people ascribe meaning to experiences (values, hopes,

Absent but Implicit in Narrative Couple and Family Therapy

beliefs, purposes) and to a practice of seeking entry points toward developing preferred stories. Inspired by Derrida (1978), White (2000) suggested that people ascribe meanings to experiences in relation to other experiences, by contrasting them with other experiences, by what they are and by what they are not. He described how it can be useful in therapeutic conversations to listen for values, hopes, and purposes that, while absent from the problem story, may be implied by it, as the backdrop on which the explicit problems are given meaning. Using what White calls “double listening,” in addition to listening for explicit “unique outcomes,” the therapist also listens for unmentioned values, beliefs, and intentions that contrast with the problem-saturated story and may imply what is precious to this person, couple, or family. “These implied experiences are a rich source of alternative stories” (Freedman and Combs 2008). Furthermore, based on the narrative premise that no one is a passive recipient of hardship, the therapist looks for acts of resistance that have been performed and the skills that have been used in performing them, which may augment sense of personal agency. White (in workshops in 2006–2008) proposed a “map” of Absent But Implicit practices, which Carey et al. (2009) compiled in a “scaffold”: 1. The Expression – of problems and their influence 2. What the Complaint or Expression is in Relation to – externalization 3. Naming the Response or Actions – discovering acts of resistance 4. Skills or Know-How that are Expressed in the Action 5. Intentions and Purposes – of actions and plans for life 6. What is Given Value To – the “Absent But Implicit” 7. Social and Relational History of What Is Absent But Implicit – connections with people who share the values 8. Connecting Actions Over Time and Into the Future – around the Absent But Implicit

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Clinical Example Anna’s father asked me to meet with her. “She’s become so withdrawn.” However, he explained, “she doesn’t go anywhere alone anymore,” so they would bring her and accompany her in the therapy sessions (one of the fortunate times I didn’t need to persuade the family to participate in therapy). In the first session, Anna (aged 16) sat quietly while her parents told me that she had begun high school 3 months ago “and everything changed.” After school, they said, she stays in her room all day, mostly in bed. She rarely comes to the table for dinner; they bring a tray to her bed. She’s cut herself off from her friends, and when she has to go to the mall, she asks her parents to go with her. After understanding that no recent trauma was involved, I asked Anna about the expressions of the problems in her life and their influences on her relationships and on her “private story” (the story she tells herself about herself). Anna responded in “internalized language” (as most people do), seeing herself and the problem as one: “I’m so needy; I need my parents all the time, I’m afraid to go out alone with my friends, I feel so sad.” Following the narrative map of separating between people and their problems, I began an externalizing conversation with Anna, hoping that in the space created between her and the problem, we would find preferred directions. I asked what name would she give to her problem? And could she imagine how it looks? She said “Blue Dependency; it looks like a big blue monster who looks at me with sad eyes and tells me I won’t succeed alone. It makes me feel blue all the time.” We discussed the ways in which Blue Dependency had recruited her to this lifestyle. As she spoke, tears began rolling down her cheeks. I asked her what the tears meant to her. Anna said that Blue Dependency had such a bad influence on her life. I asked whether Blue Dependency opposed something she treasured – perhaps joyfulness? maybe self-reliance? or something else? She looked at me and said “Yes, Self-Reliance.” She told how she used to be able to do almost anything on her own, how proud she had been of that, how much selfreliance had always meant to her, and how she missed it in her life now.

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I inquired about her acts of resistance against Blue Dependency and her intent in those acts. We discussed how those tears might be a protest against Blue Dependency. We (Anna, her parents, and I) then explored when had Anna begun to value self-reliance. We spoke about stories of self-reliance in her past and how meaningful they were to her. We connected them to her intentions, actions, and dreams in the present and started to think about what her next steps will be if she continues to hold the value of selfreliance close to her heart. I asked about stories of self-reliance in the family and in their social and cultural history. We prepared a genogram with all family members. Her parents told stories of their own selfreliance and of Anna’s independence as a child. We heard that her grandparents were Holocaust survivors who had built a new life out of utter destitution and how the family felt blessed by that. The focus of our conversations moved from the story of Blue Dependency to the preferred story of Sassy Self-Reliance. We developed a family project of telling, retelling, and witnessing – and joint planning and doing. The practice of Absent But Implicit opened new possibilities for Anna and her family to work together to find and thicken preferred stories in their lives.

Cross-References ▶ Deconstructive Listening in Couple and Family Therapy ▶ Dulwich Centre ▶ Externalizing in Narrative Therapy with Couples and Families ▶ Narrative Couple Therapy ▶ Narrative Family Therapy ▶ Problem-Saturated Stories in Narrative Couple and Family Therapy ▶ Re-authoring Teaching ▶ White, Michael ▶ Witnessing in Narrative Couple and Family Therapy

Acceptance in Couple and Family Therapy

References Carey, M., Walther, S., & Russell, S. (2009). The absent but implicit – A map to support therapeutic enquiry. Family Process, 48(3), 319–331. Derrida, J. (1978). Writing and difference. Chicago: University of Chicago Press. Freedman, J., & Combs, G. (2008). In A. S. Gurman (Ed.), Clinical handbook of couple therapy. New York: The Guilford Press. Chap. 8. White, M. (2000). Re-engaging with history: The absent but implicit (chapter 3). In M. White (Ed.), Reflections on narrative practice: Essays & interviews (pp. 35–58). Adelaide: Dulwich Centre Publications. White, M. (2005). The International Journal of Narrative Therapy and Community Work, 3&4, 15.

Acceptance in Couple and Family Therapy Kathryn M. Nowlan, McKenzie K. Roddy and Brian D. Doss University of Miami, Coral Gables, FL, USA

Introduction Acceptance in couple and family therapy refers to the process of individuals becoming more patient and sympathetic when problems arise because the individual recognizes that there are natural and understandable reasons for the way the individual, the partner, and the relationship are. Within an intervention context, acceptance helps individuals soften the impact of relationship aspects and dynamics that are likely unamendable to change, even if the partner makes attempts to change. Through acceptance, individuals relinquish the struggle to change others’ behavior, learn to see differences and problems as opportunities to increase relational closeness and emotional connection, and develop empathy around the seemingly intractable issues that drove the individuals apart (Christensen and Jacobson 2000). In contrast to more traditional behavioral change techniques, acceptance work encourages the complainant to change. The process of acceptance in couple and family therapy reduces relationship

Acceptance in Couple and Family Therapy

distress, facilitates emotional connection, and increases the likelihood that the parties involved are better able to handle future challenges and relationship issues.

Theoretical Context for Concept While there has been some work within the family therapy literature on acceptance, the majority of research has focused on acceptance within couple therapy. Acceptance within couple therapy was first introduced as one of the major tenets of integrative behavioral couple therapy (IBCT; Jacobson et al. 2000) in response to limited long-term efficacy of change-oriented therapy approaches. Indeed, IBCT developed as an attempt to improve upon traditional couple therapy models such as traditional behavioral couple therapy (TBCT; Jacobson and Margolin 1979) which focused on couples making overt behavioral change in order to increase relationship satisfaction (e.g., increasing positive behaviors and decreasing negative behaviors). While changeoriented approaches such as TBCT are effective in helping some couples make changes and see increases in relationship satisfaction, a substantial number of couples do not benefit from therapy and show no clinically meaningful improvement by end of therapy (Jacobson et al. 2000). A few explanations have been offered as to why overemphasizing behavioral change strategies is not always enough to result in meaningful changes for some individuals. One explanation is that approaches like TBCT fail to meet individual needs. Indeed, due to the nature of distress in treatment-seeking individuals, many partners and family members may be unwilling to make the changes requested of them or accommodate behavioral change. Moreover, by the time a family or couple is attending therapy, they have often reached a behavioral impasse due to entrenched problems in their relationships and the lack of a “collaborative set” or a mutual understanding that they are both responsible for the problems in the relationship and, therefore, both need to make change (Jacobson et al. 2000). Additionally, change-oriented treatment approaches often fail

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to take into account the historical context in which problems develop and the emotional hurt developed from repeated relationship problems that often lead to high relationship distress. All these problems, which are often present for treatment-seeking individuals, make it harder to change relationship dynamics. However, the most important reason that an exclusive focus on change is likely to be unsuccessful is that many domains of couple and family life are not modifiable by the couple/family. For example, it is not possible for an individual to will him/herself to feel (or not feel) a certain way. Similarly, personality or other stable traits are not amenable to change. Furthermore, external stresses such as a job loss or foreclosure are often out of the couple or family’s direct control. Thus, behavioral change techniques alone may be ineffective and insufficient without a simultaneous focus on acceptance of the problems at hand. Indeed, it is the combination of acceptance and change strategies that is likely to be most effective for most relational problems. Treatments with a focus on acceptance such as IBCT build upon behavior-focused therapies by integrating acceptance strategies with changeoriented approaches. Indeed, IBCT has a stronger emphasis on creating relationship improvement by targeting the controlling variables that often impact relationships such as individuals’ thoughts, feelings, and desires rather than overt behavioral change alone. Through acceptancebased approaches, individuals come to a level of acceptance whereby they willingly let go of frustration, hurt feelings, and the struggle to change one another. IBCT and other acceptance-based approaches in couple and family therapy remove blame and help individuals see a new perspective on the relationship whereby the other party involved is no longer conceptualized as being deficient, inferior, or at fault.

Description Within all couples and families, there are countless natural differences between individuals. Some people tend to be more emotional,

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outgoing, or organized than others. Some people may be more career driven, and others may be more family or interpersonally oriented. Many, perhaps most, of these natural differences are experienced as just that – differences. The couple or family system is able to adapt to these differences without conflict. Indeed, some differences may be a source of strength for a couple. For example, an introvert may appreciate that his/her partner or family member helps maintain social connections, while the extravert appreciates not having to compete to be the center of attention in social settings. However, other differences create conflict and distress for the couple or family. From an IBCT perspective, distress develops through a three-phase process. Acceptance is key in both avoiding and overcoming this process. In the first phase, when an individual experiences a difference that is unpleasant, that individual pushes the other person to change. For example, if two people differ in their standards for cleanliness, one person will often ask the other to pick up after him/herself, put dishes in the dishwasher rather than piling them in the sink, etc. If these requests for change can be accommodated, then no distress develops. However, if the messier person is unable or unwilling to change, then conflict around cleanliness develops. In the second phase – called polarization – each attempt to change the other person results in the partner not only continuing the behavior but often acting more extreme than he or she otherwise would. For example, the more the individual “nags” his/her partner to be cleaner, the less likely the partner is to be responsive to those requests. Over time, the clean individual becomes more and more upset at even smaller instances of messiness. Polarization makes it hard for the couple to get out of the negative pattern. The repeated requests for change are often met with hard emotional expressions such as anger, yelling, and blame (or just simply walking away without responding), which often increase retaliation or unwillingness to compromise. In the third phase – called the mutual trap – each partner views the other as the sole

Acceptance in Couple and Family Therapy

source of the conflict. Moreover, each partner feels that, if they give in to the other, the problem will only get worse. For example, the individual requesting more cleanliness worries his/her partner would never clean up if he/she didn’t “nag” the partner. In turn, the partner feels that if he/she “gives in” to the demands to clean, it’s only going to increase the “nagging.” Models of acceptance within couple and family therapy posit that acceptance can reduce the initial unpleasantness of the differences, reduce the process of polarization, and offer an escape from the mutual trap by beginning to view the problem as a process that is jointly created. By better understanding and accepting one another’s actions or each other instead of pushing for change, individuals gain emotional distance from the problem. This emotional distance allows them to address the issue without engaging directly or pushing for behavioral change. Indeed, the response to problematic behavior moves from being extremely negative in valence (e.g., anger, vulnerability and pain, contempt) to neutral or positive (e.g., toleration, appreciation, and understanding), which subsequently generates a greater sense of emotional closeness and intimacy. For the individuals on the receiving end of the frequent pushes for change, increased acceptance helps them to be less reactive. As a result, they, too, learn to better accept why the other person is asking for change, become more understanding of how the negative pattern developed, and let go of the aspects of the relationship and other person that they cannot change. They may also learn to accept their contribution to the pattern. Through this process of acceptance, the desired change becomes more likely to occur. This process is consistent with the literature on individual therapy approaches (e.g., acceptance and commitment therapy) which suggests that when individuals are more accepting, do not judge or blame themselves, or try to stop unwanted problems, they move in a direction more consistent with their values, can better take action against the problem, and find more meaning in their lives.

Acceptance in Couple and Family Therapy

Application of Concept in Couple and Family Therapy As mentioned, acceptance within couple and family therapy has arisen largely within the framework of IBCT. IBCT assumes that problems in relationships do not just occur as a result of the negative behaviors of partners but also in the emotional disruption and reactivity caused by these actions. Thus, strategies are implemented in order for couples to not only gain a deeper understanding of how to communicate or interact more healthily (which would be a more skillsbased and change-oriented approach) but to understand what factors in the relationship make relationship problems more likely to occur and what led to the problems initially. Through an acceptance approach, couples become less biased, are better able to reflect on their own behavior, and learn to stop undermining the relationship by using blaming, pushy, or hostile communication. The first intervention used by the IBCT therapist to promote acceptance is unified detachment. Unified detachment helps couples talk about problems rather than engaging in the problematic dynamic. It creates a shift in perspective by labeling the problem as an “it” versus a “you,” teaching couples to no longer think of their partner as the cause of the problem. Instead, unified detachment helps couples develop an objective third party perspective on the major issues in their relationship by removing blame and promoting active communication. Unified detachment begins with an initial feedback session that takes place within the first few weeks of therapy. During the session, the therapist promotes acceptance by beginning to introduce his/her formulation of the couple’s major problems and themes. Additionally, the therapist formulates a DEEP Understanding of the couple’s relationships problems, which is an acronym for the couple’s natural differences, emotional sensitivities, external stress, and patterns of interaction that often escalate conflict. The components of the DEEP Understanding help the couple see a more holistic picture of what is negatively impacting the relationship. Through discussion of the DEEP Understanding,

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the therapist models acceptance by validating both partners’ concerns as understandable and by using nonjudgmental language that removes blame from each member of the couple. Instead, the therapist focuses on the couple’s strength, begins the narrative that each partner is not at fault, and introduces the idea that the couple has developed a pattern of behavior and communication that has been getting them stuck. This approach is essential to the success of couples gaining acceptance and is modeled throughout therapy. Unified detachment interventions continue throughout the course of treatment. In session, couples explore emotionally salient, negative interactions that have recently occurred in order to better understand the context in which the problem developed instead of focusing on who is to blame. Rather than allowing partners to jump into old habits of telling each other why they think the other is at fault, therapists encourage couples to focus on each of their contributions to the recent interaction. By gaining more emotional distance from the issue, couples begin to think of the interaction from an outside perspective and gain insight into the sequence of events. For example, they think through how the components of the DEEP Understanding such as differences, emotional triggers, the impact of stress, and the way they interacted with one another prevented them from better addressing the problem. Through unified detachment, partners formulate a new, more accepting, and less biased narrative of the negative relationship interactions wherein the partner is no longer to blame. In the second acceptance strategy in IBCT – empathic joining – the therapist encourages couples to be more open and provides opportunities for couples to discuss emotional sensitivities and support one another through those emotional disclosures. Problematic relationship dynamics often arise because, as partners feel more hurt or distant from each other over time, they often blame, accuse, or negatively judge their partners. These negative behaviors and cognitions often result in greater separation and defensiveness, which only lead to more relationship distress.

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For example, take an individual who feels emotionally unsupported by his/her partner. Throughout the relationship, this person has likely learned that being vulnerable with emotions only leads to disappointment as his/her partner may not be the best at validating those emotions or expressing his/her own. Over time, the partner who feels unsupported is less likely to share emotional sensitivities and more likely to display harder emotions such as anger or contempt. Additionally, instead of being vulnerable, he/she is more likely to say a hurtful statement such as, “You are totally unfeeling and don’t know how to connect with anyone!” This in turn may hurt the partner’s feelings, which could result in him/her displaying his/her own hard emotional expressions such as yelling or withdrawing. During empathic joining, the therapist instead encourages both partners to share their hidden emotions – the softer, more vulnerable emotions that underlie the reaction that the partner sees (e.g., anger, contempt). After one individual discloses a vulnerable emotion, the therapist works with the partner to appropriately support that disclosure. If the partner has difficulty doing so, the therapist supports the disclosure him/herself (providing a model to the partner) and then explores why it was difficult for the partner to support that disclosure. Through these empathic joining exercises, the partners become less blaming, more empathetic, and more accepting of each other and the pattern in which they have gotten stuck. Empathic joining promotes compassion and emotional intimacy. Through the subsequent increase in emotional connectedness, partners become more open to any subsequent changes that are under their control. In the final IBCT strategy to promote acceptance, therapists help couples with tolerance building. Through tolerance building, couples begin to see the differences that first created the conflict as natural and as part of portions of their partner that they do like. For example, differences that create conflict can be related to traits that they initially found attractive (e.g., a partner that is now viewed as “irresponsible” could have been initially viewed as “spontaneous”). Alternatively, aspects of the partner that an individual currently

Acceptance in Couple and Family Therapy

enjoys (e.g., initiating a spontaneous evening out) could be related to aspects of the partner that create conflict (e.g., lack of follow-through on household tasks). Additionally, partners work to better tolerate situations that are out of their control. By letting these biased perspectives go and learning to tolerate what cannot be changed, couples increase acceptance which in turn removes emotional distance and blame. Throughout this technique, therapists also model empathy so that both partners feel heard and understood. Modeling this air of acceptance is central to partners feeling emotionally safe to be vulnerable, which in turn helps them to let go of hurt and stop blaming their partners. Following IBCT’s model, a few secondary interventions have been developed which also focus on acceptance promotion. One intervention is the marriage checkup, which offers early detection and preventative care for relationship functioning. While the intervention is brief and only consists of two, 8-hour sessions (one assessment and one feedback session), it helps couples create more intimacy and closeness in their relationship. Indeed, the program promotes greater understanding of common relationship issues and differences between partners, which helps build acceptance. Couples who participated in the marriage checkup, compared to those in a control group, were significantly more relationally satisfied 2 years following the intervention (Córdova et al. 2014). Another secondary intervention with a focus on acceptance is the OurRelationship.com program (Doss et al. 2016). As an online adaptation of IBCT, the program’s goals are consistent with those of IBCT. Indeed, through online activities, the program helps couples select the biggest problem in their relationship, develop a DEEP Understanding of the problem, and problem solve solutions tailored to the issue. Throughout the program and through several contacts with study coaches that promote empathic joining and unified detachment, couples gain acceptance and a better understanding of what occurs during emotionally salient, negative interactions. By the end of the 8-hour program, the couples reported significantly increased relationship satisfaction,

Acceptance in Couple and Family Therapy

relationship confidence, and positive relationship qualities as well as reduced negative relationship qualities (Doss et al. 2016). Furthermore, acceptance is a central component of other primary interventions such as the Compassionate and Accepting Relationships through Empathy (CARE) program. CARE encourages couples to use prosocial, empathy-based skills and teaches the importance of acceptance in relationships. Many couples who received CARE reported increased relationship satisfaction, greater affection, and less hostile communications over 3-year follow-up (Rogge et al. 2013). Overall, the literature on acceptance within secondary and tertiary interventions shows that acceptance is a key element in enacting positive change for couples. Indeed, IBCT has been shown to be effective at increasing relationship satisfaction and communication and reducing negative relationship behaviors both short and long term (Christensen et al. 2004, 2006). Moreover, acceptance has been shown to be a mechanism of change of treatment gains across acceptancefocused interventions such as IBCT and the marriage checkup (Doss et al. 2005; Hawrilenko et al. 2016). While most of the research on acceptance has occurred within the couple intervention literature, acceptance has also shown to be important within family therapy in promoting positive changes in negative family dynamics. Specifically, when acceptance is included in a family therapy approach, parents and children learn how to be more value-centered, better accept difficult emotions, and stop repeated measures to prevent unwanted problems. Acceptance within family therapy results in the reduction of parentadolescent conflict and improvements in psychological flexibility and individual functioning (e.g., Coyne et al. 2011; Greco and Eifert 2004).

Clinical Example The case of Steve and Carmen can be used to illustrate the use of acceptance in an IBCT framework. After 20 years of marriage, Steve and Carmen sought couple therapy because of their

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lack of emotional intimacy. Between their responsibilities to their two teenage daughters and their two careers, Steve and Carmen’s relationship had taken a backseat. Steve described that the intimacy in their relationship had degraded to the point where he felt that they were “just roommates.” Although he identified that both he and Carmen were great parents and led fulfilling individual lives, he felt that the romantic spark they once had was gone. Carmen, likewise, reported they were not as close as they used to be and wished they could get back to “being in love.” While both Steve and Carmen agreed that intimacy was lacking in their relationship, each partner had different ideas of what led to the lack of intimacy as well as how it should have been fixed. Steve believed they both became busy with life, jobs, and family and that they failed to prioritize the relationship. He thought that if they spent more time together, the intimacy issue would abate. Carmen, on the other hand, saw the lack of intimacy as resulting from the fact that they rarely talked outside of surface-level conversations or discussing their children. She felt the relationship could not improve without first making the effort to dive deeper into more emotional conversations, such as through sharing their passions, interests, and goals as individuals and as a couple. Her attempts to engage Steve in these conversations were frequently, if not always, a letdown. Both partners’ attempts to solve the intimacy issue – Carmen pushing for deep conversation and Steve wanting to spend more fun time together – ultimately created more discord in the relationship. After a thorough assessment process including standardized measures, an introductory session with the couple, and individual sessions with each person, the therapist initiated the first acceptance intervention – unified detachment – in the feedback session. In this session, the therapist presented the formulation of Steve and Carmen’s relationship problems to the couple. The therapist emphasized that there was a natural difference between Steve and Carmen around emotional expressiveness. For example, more in touch with her emotions and able to describe how she is feeling at any given moment, Carmen became frustrated when Steve could not reciprocate.

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Additionally, the therapist hypothesized that Carmen was sensitive to Steve’s inability to share his feelings partially due to past experiences. Indeed, Carmen’s previous partner had cheated on her and hid his infidelity for over a year by being vague about his whereabouts and feelings. As a result, Carmen frequently tried to initiate meaningful conversations with Steve in order to calm her anxieties that he might also be cheating on her. When he refused to engage because he felt put on the spot and unable to connect to his emotions, Steve often raised his voice and would ultimately storm out of the room. To help Carmen and Steve better understand this negative pattern, the therapist hypothesized that, as a response to Steve’s withdrawal, Carmen felt rejected, hurt, and lonely – much like she did in her previous relationship. After receiving confirmation that Carmen felt this way, the therapist then emphasized that, later, when Steve tried to placate the situation by offering to watch TVor go on a walk with Carmen – a good solution to the intimacy issue in his mind – Carmen felt he was ignoring their earlier fight. Additionally, the therapist helped Steve identify that he often withdrew from Carmen’s attempts to initiate meaningful conversations both because communicating emotions was challenging for him and because he felt like it interfered with his attempts to get them to spend enjoyable, light-hearted times together. During the course of therapy, the therapist created unified detachment by encouraging Carmen to reframe Steve’s inability to share his emotions as a natural difference rather than a malicious attempt to keep her in the dark. Additionally, the therapist helped reframe Steve’s attributions of Carmen’s desire for deeper communication as being related to her past experiences and not ceaseless nagging. By helping the couple to see their problem as “differences in need for intimacy and emotional expressiveness” and as an “it” rather than a “you,” the therapist promoted acceptance in Steve and Carmen’s relationship. Over the course of treatment, the therapist also utilized empathic joining and encouraged Steve and Carmen to share vulnerable emotions with each other, as this was an area in which they both struggled. Indeed, Carmen had not been as open with

Acceptance in Couple and Family Therapy

Steve about her past relationship and had not shared those feelings of fear and loneliness. During session, she began to share her feelings of fear and hurt stemming from her past relationship. Once Carmen opened up, it not only gave Steve a fuller picture, but it allowed him the opportunity to respond to those emotions in a soft, kind, and accepting manner. Additionally, because Steve was not naturally skilled at expressing his emotions, the structure and therapist’s support during empathic joining helped him open up to Carmen in ways that he had not done previously. By increasing acceptance around their emotional sensitivities and the natural differences between them, Steve and Carmen were more effective at healing the relationship. These supportive interactions, repeated over the course of therapy, helped the couple interrupt their previous unproductive pattern of communication, reestablish trust, and build emotional intimacy.

Cross-References ▶ Acceptance Versus Behavior Change in Couple and Family Therapy ▶ Christensen, Andrew ▶ Integrative Behavioral Couple Therapy

References Christensen, A., & Jacobson, N. S. (2000). Reconcilable differences. New York: Guilford Press. Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., Baucom, D. H., & Simpson, L. E. (2004). Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. Journal of Consulting and Clinical Psychology, 72(2), 176–191. https://doi.org/10.1037/0022-006X.72.2.176. Christensen, A., Atkins, D. C., Yi, J., Baucom, D. H., & George, W. H. (2006). Couple and individual adjustment for two years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 74(6), 1180–1191. https://doi.org/ 10.1037/0022-006X.74.6.1180. Córdova, J. V., Fleming, C. J. E., Morrill, M. I., Hawrilenko, M., Sollenberger, J. W., Harp, A. G., . . . Wachs, K. (2014). The marriage checkup: A randomized controlled trial of annual relationship health checkups. Journal of Consulting and Clinical Psychology, 82(4), 592–604. https://doi.org/10.1037/a0037097

Acceptance Versus Behavior Change in Couple and Family Therapy Coyne, L. W., McHugh, L., & Martinez, E. R. (2011). ACT: Advances and applications with children, adolescents, and families. Child & Adolescent Psychiatric Clinics of North America, 20(2), 397–399. Doss, B. D., Thum, Y. M., Sevier, M., Atkins, D. C., & Christensen, A. (2005). Improving relationships: Mechanisms of change in couple therapy. Journal of Consulting and Clinical Psychology, 73, 624–633. https://doi.org/10.1037/0022-006X.73.4.624. Doss, B. D., Cicila, L. N., Georgia, E. J., Roddy, M. R., Nowlan, K. M., Benson, L. A., & Christensen, A. (2016). A randomized controlled trial of the web-based OurRelationship program: Effects on relationship and individual functioning. Journal of Consulting and Clinical Psychology, 84, 285–296. Greco, L. A., & Eifert, G. H. (2004). Treating parentadolescent conflict: Is acceptance the missing link for an integrative family therapy? Cognitive and Behavioral Practice, 11, 305–314. Hawrilenko, M., Gray, T. D., & Córdova, J. V. (2016). The heart of change: Acceptance and intimacy mediate treatment response in a brief couples intervention. Journal of Family Psychology, 30(1), 93–103. https:// doi.org/10.1037/fam0000160. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel. Jacobson, N. S., Christensen, A., Prince, S. E., Córdova, J., & Eldridge, K. (2000). Integrative behavioral couple therapy: An acceptance-based, promising new treatment for couple discord. Journal of Consulting and Clinical Psychology, 68(2), 351–355. Rogge, R. D., Cobb, R. J., Lawrence, E., Johnson, M. D., & Bradbury, T. N. (2013). Is skills training necessary for the primary prevention of marital distress and dissolution? A 3-year experimental study of three interventions. Journal of Consulting and Clinical Psychology, 81(6), 949–961.

Acceptance Versus Behavior Change in Couple and Family Therapy Karen Rothman1, Emily J. Georgia1 and Brian D. Doss2 1 University of Miami, Miami, FL, USA 2 University of Miami, Coral Gables, FL, USA

Name of Concept Acceptance Versus Behavior Change in Couple and Family Therapy

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Introduction At the broadest level, change techniques make direct attempts to modify behavior, while acceptance techniques attempt to modify the understanding, interpretation, or impact of behaviors or events. While change interventions generally solicit changes in the partner, acceptance interventions generally target modifications in the self.

Theoretical Context for Concept Change techniques formed the core of the first behavioral couple therapy interventions, including the first published trial in 1969. Behavioral couple therapy (BCT), as it is often used today, was manualized by Neil S. Jacobson and Gayla Margolin in 1979. Change techniques were adapted in the early 1980s by premarital education and enrichment programs and were delivered to non-distressed couples. In the context of couple interventions, acceptance approaches have their origins in integrative behavioral couple therapy (IBCT). Based on BCT, IBCT was developed by Andrew Christensen and Neil S. Jacobson in 1995 in an attempt to prolong the positive effects of BCT (Dimidjian et al. 2008).

Description There are two common categories of change techniques – communication skills and behavior exchange (Christensen et al. 2014). In the speakerlistener communication skill, therapists help couples develop methods to share emotion-laden information or perspectives. Partners are encouraged to take turns being the speaker and the listener, with specific skills and responsibilities for each role. Using the problem-solving communication skill, couples move through a series of sequential steps to reach a solution or compromise to a problem, which include defining the problem, brainstorming potential solutions, selecting a solution, and setting a time to reevaluate that solution. Finally, behavior exchange teaches couples to identify and implement more frequent or additional positive behaviors that might increase relationship satisfaction.

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Acceptance Versus Behavior Change in Couple and Family Therapy

There are three categories of acceptance techniques – unified detachment, empathic joining, and tolerance. Unified detachment encourages couples to achieve a more comprehensive and less blaming conceptualization of their relationship problems, which allows couples to escape their destructive patterns. In empathic joining, couples are encouraged to disclose their hidden, vulnerable emotions; this disclosure softens the hardened stance of the partner and provides an opportunity to foster emotional closeness. Finally, tolerance interventions help individuals view their partner’s negative behaviors as part of the broader package of the person – sometimes even components of their partner’s traits they like or initially found attractive. Tolerance also promotes increased self-care and self-reliance for each partner.

Application of Concept Research on BCT and IBCT has shown both acceptance and behavioral change techniques to be effective in creating long-term change in couples (Christensen et al. 2010). Clinical experience suggests that acceptance techniques may be more appropriate for presenting problems that are more emotion-laden or that are out of the couple’s control. In contrast, BCT may be an especially good fit for couples who are comfortable with rule-governed behavior or who present to treatment with communication problems. However, it should be noted that these clinical impressions have not been tested empirically.

In the feedback session, the therapist utilized the acceptance technique of unified detachment to help the couple conceptualize the problem as a combination of their natural differences in emotional expressiveness. The couple also learned that their problem is intensified because it triggers vulnerable emotions in each partner and that, over time, their attempts to fix the problem have actually intensified it. Through subsequent empathic joining interventions, Amy began to share the softer emotions (e.g., sadness, rejection) she feels when Manuel is distant, and he was able to comfort her. These interactions helped her feel more emotionally close, and, as a result, she started to reduce her demands and criticisms. The therapist also used behavioral techniques to improve their presenting problems. The therapist taught the couple to utilize the speakerlistener communication skill, which helped Amy be less critical of Manuel while simultaneously helping Manual share his feelings more. Additionally, once the couple began to feel more connected during sessions, the therapist assigned behavioral activation assignments such as date nights to increase the enjoyable moments the couple experienced.

Cross-References ▶ Acceptance in Couple and Family Therapy

References Clinical Example In their first session of couple therapy, Manuel reported feeling criticized by his wife Amy, while Amy complained of a lack of emotional intimacy. She attributed this distance to “Manuel’s inability to open up.” Amy stated that she urges Manuel to talk to her, to tell her how he’s feeling, and to be there for her emotionally. Manuel explained that these requests feel increasingly critical and have resulted in him pulling away even more, which in turn leads Amy to escalate her demands.

Christensen, A., Atkins, D. C., Baucom, B., & Yi, J. (2010). Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 78(2), 225–235. Christensen, A., Wheeler, J. G., Doss, B. D., & Jacobson, N. S. (2014). Couple distress. In D. Barlow (Ed.), Clinical handbook of psychological disorders: A stepby-step treatment manual (5th ed., pp. 704–728). New York: The Guilford Press. Dimidjian, D., Martell, C. R., & Christensen, A. (2008). Integrative behavioral couple therapy. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed., pp. 73–101). New York: The Guilford Press.

Accommodation in Couple and Family Therapy

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Theoretical Context for Concept

Accommodation in Couple and Family Therapy Katherine O’Neil1 and Danielle A. Black1,2 1 Center for Applied Psychological and Family Studies, The Family Institute at Northwestern University, Evanston, IL, USA 2 The Family Institute at Northwestern University, Chicago, IL, USA

Name of Concept Accommodation

Synonyms Adaptation; Adjustment; Joining

Introduction Accommodation broadly refers to the spontaneous way a system instinctively adapts to coordinate functioning (Nichols 2017). Accommodation has two distinct definitions within the field of marriage and family therapy. The first is defined through a structural lens and describes the techniques a therapist uses to make self-adjustments in order to successfully join with and understand a system’s functioning (Minuchin 1974). The purpose of accommodation in this context is to join with the system to create change. The second application of accommodation describes the way family members change or adapt their behavior to decrease another family member’s emotional distress often reinforcing an individual’s maladaptive behavior (Calvocoressi et al. 1995). Within the family system, accommodation maintains maladaptive functioning and/or behaviors often through subliminal patterns of interaction. Family accommodations (FA) often maintain or increase maladaptive symptoms (Lebowitz et al. 2012).

Mapping the origins of accommodation is difficult due to the expansive nature of the term. The first time the concept was theorized was by Howard Giles to describe the phenomenon of changing the way one speaks depending on the person being spoken to (Swann et al. 2004). Although Giles’ accommodation theory is not a common reference of family therapy theory, its designation of the term to define the subconscious way humans adapt to one another serves as a foundation for how accommodation is conceptualized by psychologists and family therapists. The construct of accommodation was first identified and defined by developmental psychologist, Jean Piaget. Piaget (1932) defined accommodation to describe a child’s ability to adapt their internal schemas to the changing world. Piaget’s accommodation similarly describes a type of inherent adaptation. However, Piaget’s theory focuses on the individual context as opposed to a systemic context. Thus, Piaget’s definition of accommodation is useful to understand one origin of the construct albeit an individualistic definition. Other theorists defined the construct within a relational context providing a more useful construct within family therapy. Conversely, Minuchin developed a conceptualization of accommodation originating in his model of Structural Family Therapy. His perspective of accommodation progressed the term to encompass patterns of interaction. Minuchin advanced accommodation from merely linguistic, as suggested by Gilesor internal to interpersonal, as suggested by Piaget (1932) (Swann et al. 2004). Minuchin’s explanation of accommodation describes the way a system develops patterned transactions, or mutually influences ways in which members impact and monitor one other’s behavior (Minuchin 1974). With a systemic perspective, Minuchin applied the concept of accommodation to the therapeutic relationship, thus creating the technique of joining and accommodating.

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Description Accommodation in family therapy refers to two specific concepts: (1) the therapist adjusting to a system’s style while functioning to successfully join and (2) the adapting of a family system by creating mutually influencing patterns to support one another’s functioning. Both applications of accommodation include adjusting behavior, whether intentional or involuntary. The distinction between the ways accommodation is conceptualized is critical to understanding its value to family and couple therapy. In the therapeutic relationship, accommodation is a necessary step in approaching the alliance. In structural therapy (Minuchin 1974), joining and accommodating complement one another and, when used deliberately, can progress and expedite treatment. Minuchin (1974) describes this process of accommodation as a therapist’s adaptation to the family system through maintenance, tracking, and mimesis. Maintenance refers to the accommodation technique of deliberately supporting a family structure to create change; tracking describes the therapist’s accommodating technique of following the content and process of the system by asking clarifying questions, actively listening, and remaining interested in the system’s communication; and mimesis refers to human operations that are implicit and spontaneous such as a therapist adopting the language and style of a system (Minuchin 1974). Each of these accommodating techniques directly applies to family therapy. In Cognitive Behavioral Therapy (CBT), the construct of accommodation is defined as a maintenance factor of child anxiety symptoms. Accommodation is the process by which family members reinforce avoidance behaviors of the anxious child resulting in the increase or maintenance of the child’s anxiety symptoms (Black 2017; Lebowitz et al. 2012). Within the CBT framework, accommodation is defined as maladaptive process as opposed to a therapeutic adaptive process, interaction that maintains and/or amplifies symptoms and family dysfunction. Family accommodation (FA) appears differently across anxiety disorders and ObsessiveCompulsive Disorder (OCD), although it

Accommodation in Couple and Family Therapy

generally originates from a parent’s natural empathy toward their children’s distress. In children with social anxiety, separation anxiety, or other anxiety disorders, FA can take the form of a parent speaking for their child, allowing their child to stay home from school, or sleeping in their child’s bed. Accommodation becomes a problem when it maintains or amplifies a maladaptive symptom of a disorder. This usually means a parent is colluding with their child to avoid situations and/or objects that provoke anxiety. For children with OCD, parents accommodate by helping their child avoid triggering situations, participate in rituals, and provide reassurance, thus maintaining the avoidance behavior (Lebowitz et al. 2012). Overall, accommodation describes a general pattern of sequences that influences the entire system, either the therapeutic system (as defined by Minchin) or the family system (as defined by Lebowitz et al. 2012). Accommodation is natural, inevitable, and typically occurs without much thought. Thus, family therapy aims to bring awareness to accommodation as both a therapeutic technique and a method of acknowledging maladaptive family patterns.

Application of Concept in Couple and Family Therapy Accommodation refers to two different clinical applications: joining the family and identifying a specific maladaptive behavior pattern within a family dynamic. In the first application, refers to the joining process in family therapy, the family therapist adapts or mirrors the communication style and structure of a family. For structural therapists (Minuchin 1974), accommodation is mandatory and intentional. For those practicing a different, systemic model, noticing the way a therapist accommodates to the family system can facilitate joining and bring awareness to the process of building an alliance with each member of a family. Using the structural model, a therapist can join with a family or couple by accommodating, rather than challenging them (Minuchin 1974).

Accommodation in Couple and Family Therapy

Family accommodation (FA) is also highly relevant to couple and family therapy, as it serves to conceptualize patterns of family behavior that maintain the identified patient’s presenting problem. FA can constrain systems either in times of change, such as when a family struggles to adapt to new circumstances, or when a parent colludes with a child’s symptoms of anxiety, OCD, or other diagnoses (Minuchin 1974; Lebowitz et al. 2012). FA exacerbates symptoms of some disorders and contradicts the empirically supported method of treatment for anxiety disorders such as exposure therapy (Merlo et al. 2009). Therefore, a family therapist can use their knowledge of accommodating behaviors to reduce symptom severity by interrupting the constraining pattern of FA. Family therapists can interrupt maladaptive patterns by teaching a family to recognize FA, demonstrating ways in which they can decrease FA such as with exposure techniques, and guiding them to manage symptoms without accommodating behaviors (Merlo et al. 2009).

Clinical Example A therapist works with Chris, the 13-year-old identified patient (IP) with a history of trauma, his new guardians, his biological father, Todd, and Todd’s partner, Joanna. Before the work began, the therapist accommodated through maintenance by validating Todd’s cause for concern and empathizing with Chris’s presenting problem of anger. In addition, the therapist immediately began to take note of the way the new family creates their patterns of interaction. In their third session, the therapist tracks a pattern where Joanna interrupts Todd when he is asked a direct question about Chris. Chris responds by scoffing at Joanna. In tracking this interaction, the therapist can begin to accommodate to the system and notice how the system functions. The therapist continues to accommodate when she notices how the family uses humor to manage discomfort. After Chris’s scoff towards Joanna, Todd makes a joke about the tension in the room, while Joanna and Chris join him in laughter. When the therapist notices this addition of humor, the therapist adapts

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through mimesis by spontaneously mirroring their style of humor and joins in the laughter. An example of the second definition of accommodation is when a family member reinforces or maintains maladaptive symptoms within an individual or the family. For example, a therapist meets with Luisa, a 10-year-old identified patient (IP) experiencing OCD symptoms such as checking her locked doors and rereading homework assignments to a point where she feels out of control. The therapist works with Luisa and her family to understand how she may avoid experiencing distress by engaging in her specific rituals such as checking and rereading. After the therapist discusses this with the family, he notices how Luisa’s mother, Sue, seems unsure in their session. The therapist decides to meet with the parental subsystem separately and reflects his observation to Sue and her husband, John. John begins to nod his head in agreement with the therapist and says, “I think Sue has a hard time when she sees Luisa do her rituals so she helps her [Luisa] so they get done faster.” The therapist watches Sue as John says this and notices a tear roll down Sue’s cheek. John turns to her and says, “Sue, I can imagine it must be really difficult to see your daughter in such distress.” As Sue wipes tears and John rubs a hand on her back, Sue admits that she wants to reduce Luisa’s stress. Sue then goes on to acknowledge how her assistance in Luisa’s rituals reinforces her symptoms, finally seeing how Sue’s actions present as accommodation. Together, John and Sue agree to attempt new actions that reduce accommodation in their system.

Cross-References ▶ Adolescents in Couple and Family Therapy ▶ Anxiety Disorders in Couple and Family Therapy ▶ Cognitive-Behavioral Family Therapy ▶ Communication in Couples and Families ▶ Joining in Couple and Family Therapy ▶ Joining in Structural Family Therapy ▶ Maintenance in Couple and Family Therapy ▶ Minuchin, Salvador

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▶ Obsessive Compulsive Disorder (OCD) in Couple and Family Therapy ▶ Structural Family Therapy

References Black, D. A. (2017). Applying systems to anxiety disorders. In J. A. Russo, J. K. Coker, & J. H. King (Eds.), DSM-5 and family systems. New York: Springer. Calvocoressi, L., Lewis, B., & Harris, M. (1995). Family accommodation in obsessive-compulsive disorder. American Journal of Psychiatry, 152(3), 441–443. https://doi.org/10.1176/ajp.152.3.441. Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., . . . & Leckman, J. F. (2012). Family accommodation in pediatric anxiety disorders. Depression and Anxiety, 30(1), 47–54. https://doi.org/10.1002/da.21998. Merlo, L. J., Lehmkuhl, H. D., Geffken, G. R., & Stroch, E. A. (2009). Decreased family accommodation associated with improved therapy outcome in pediatric obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 77(2), 355–360. https://doi. org/10.1037/a0012652. Minuchin, S. (1974). Families and family therapy. London: Routledge. Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods. Boston: Pearson. Piaget, J. (1932). The moral judgment of the child. London: Routledge & Kegan Paul. Swann, J., Deumert, A., Lillis, T., & Mesthrie, R. ( 2004). A dictionary of sociolinguistics. Edinburgh: Edinburgh University Press.

Ackerman Institute for the Family Lois Braverman Ackerman Institute for the Family, New York, NY, USA

Introduction Founded in 1960 by Nathan Ackerman as a training institute, the Ackerman Institute for the Family was initially known as The Family Institute. Nathan Ackerman, a psychiatrist and psychoanalyst, believed that if one person in the family had a problem, everyone in the family was impacted and that the place to solve that problem was in the

Ackerman Institute for the Family

family. Dr. Ackerman’s idea to position family therapy as the primary therapeutic modality in the treatment of children was revolutionary at the time. Following WWII, he began to experiment with seeing his patients and their families together in therapy. A group of grateful families came together to establish a nonprofit center to support and expand Nathan Ackerman’s’ work in teaching and training. A building was donated for this work, which was located on the Upper East Side of New York City in an old brownstone. Dr. Ackerman published, taught, and even videotaped his new methods. Documenting clinical work with videotapes became the cornerstone in the teaching and training of family therapists at the institute and is the main training modality to this day. Although many family therapy institutes formed in the 1960s in the USA had a distinctive conceptual core or were aligned with the work and thinking of a specific person, Nathan Ackerman was not very interested in establishing a specific school or theory of family therapy. However, he was committed to the invention and development of clinical innovations for some of the most difficult problems facing families and couples. This tradition of developing family therapy techniques and ideas around specific problem areas continues today in the form of special projects at the institute. Since 1960, the leadership of the Ackerman Institute (Don Block, Peter Steinglass, and Lois Braverman), followed Ackerman’s tradition of supporting innovation, of developing new ways to work with specific problem areas facing families and then feeding these ideas into the training program and the clinical services offered to couples and families. In August of 2013, the Ackerman Institute for the Family moved from its original home at 149 East 78th Street to its current location in the heart of the Flatiron District. In this move, a stateof-the-art training institute was built that now houses the training activities and clinical services of the institute.

Location 936 Broadway 2nd floor, New York, NY 10010

Ackerman Institute for the Family

Prominent Associated Figures Since 1960, many people who have developed work in special projects at the Institute. This work resulted in books and articles that have influenced others in the field of family therapy. This list includes but is not limited to: Nathan Ackerman (1966), Don Bloch (1972, 1981), Mary Kim Brewster (Brewster and Sheinberg 2015; Sheinberg and Brewster 2014), Jorge Calipinto (1995), Martha Edwards (2002), Peter Fraenkel (2006, 2011), Aquilla Fredericks (2014), Virginia Goldner (2004; Goldner et al. 1990), Miquel Hernandez (Hernandez et al. 1999), Lynn Hoffman (1990), Evan Imber-Black (1992, 1993, 2011), Laurie Kaplan (Kaplan and Small 2005), Elana Katz (2007), Kitty LaPerriere (1982), Catherine Lewis (2011), Jean Malpas (2011), Peggy Papp (1983, 2000; Papp and Imber-Black 1996; Papp et al. 2013; Walters et al.1991), Peggy Penn (1982), Michele Scheinkman (2005, 2008; Scheinkman and Werneck 2010), Marcia Sheinberg (1992); Sheinberg and Brewster 2014; Sheinberg and True 2008; Sheinberg and Fraenkel 2001; Sheinberg and Penn 1991), Olga Silverstein (Silverstein and Rashbaum 1995), Sippio Small (Kaplan and Small 2005), Peter Steinglass (1987), Marcia Stern (2008), Judy Stern-Peck (2007), Fiona True (Sheinberg and True 2008), Gillian Walker (1991), and thandiwe Dee Watt-Jones (1997, 2004, 2010, 2016; WattsJones et al. 2007).

Contributions In a general sense, the Ackerman Institute for the Family can be described as a “think tank,” where teaching methods and clinical models are continually invented, practiced, and refined. The institute provides (a) direct services to families and couples through an on-site clinic, (b) postgraduate training in couple and family therapy, and (c) clinical research initiatives known as “special projects” that focus on the development of new treatment models and training techniques. Many projects at the institute have led to articles, books, and training tapes. What was learned

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in the projects was fed back into the training program and the clinical services. In addition to workshops and conferences, a program of international training was established with ongoing collaborations with family therapy institutes in Hong Kong, Argentina, Chile, and Mexico. Examples of projects that have been conducted historically at the institute include: • The Family-School Collaboration Project, led by Howard Wiess • The AIDS Project, led by Gillian Walker and John Patten • The Foster Care Project, led by Jorge Colapinto • The Infertility Project, led by Mimi Meyers, Connie Scharf, David Kezur, and Margot Weinshel • The Gender and Violence Project, led by Virginia Goldner, Marcia Sheinberg, Gillian Walker, and Peggy Penn • The Making Families Safe for Children Project, led by Marcia Sheinberg, Fiona True, and Peter Fraenkel • The Depression Project, led by Peggy Papp • The Writing Project, led by Peggy Penn • The Alcohol, Drugs, and the Family Project, led by Peter Steinglass • The Themes and Beliefs Project, led by Evan Imber-Black and Peggy Papp • The Diversity in Social Work Training Program, led by Sippio Small, Laurie Kaplan, and Ruth Mohr • Fresh Start for Families, led by Peter Fraenkel • The Mentoring Group, led by Miguel Hernandez, Sippio Small, and Dee Watts-Jones • The Unique Minds Project, led by Gillian Walker, Marcia Stern, Susan Shimmerlik, and Pat Heller • Competent Kids/Caring Classrooms, led by Marcia Stern Current projects include: • Adolescents and their Families Project led by Peggy Papp, Michael Davidovits, and Courtney Zazzali • Center for the Developing Child and Family, led by Martha Edwards

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• Center for Families and Health, led by Evan Imber-Black • Center for Relational Trauma, led by Marcia Sheinberg and Fiona True • Center for Substance Abuse and the Family, led by Peter Steinglass • Competent Kids/Caring Communities, led by Zina Rutkin • Couples Project led by Michele Scheinkman, Peggy Papp, and Jean Malpas • Diversity in Social Work Training Program, led by Sippio Small and Laurie Kaplan • Divorce Mediation Project, led by Elana Katz • Foster Care and Adoption Project, led by Catherine Lewis and Andrea Blumenthal • Gender and Family Project, led by Jean Malpas • Justice Project, led by Sarah Berland and Courtney Zazzali • Language and Writing Project led by Patricia Booth, Joan DeGregorio, and Sally Write • Latino Youth and Family Immigration Project: Dimelo en Espanol, led by Silvia Espinal and Erika Klein • Money, Values, and Family Life Project, led by Judy Stern Peck • Multiracial Families and Couple Project, led by Dorimar Morales, Keren Ludwig, and Mary Kim Brewster • Resilient Families: Children with Special Needs Project, led by Judy Grossman • Serious Mental Illness and the Family Project, led by Mary Kim Brewster and Lois Braverman • Talk Race Group Project, led by Aquilla Frederick and Frank Wells Over the years, the Ackerman Institute has developed an approach taught in the training program called the Ackerman Relational Approach. The most recent articulation has been in the manual written by Mary Kim Brewster and Marcia Sheinberg (2015). The Ackerman Relational Approach reflects the following ideas about change: • People change from positions of strength and empowerment.

Ackerman Institute for the Family

• People change when they feel understood by the people closest to them. • People change when they feel hopeful. • People change when they expand their capacity to genuinely appreciate the perspectives and lived experiences of others. • People change when the meaning attributed to a problem shifts or becomes more comprehensible within its context. • People change when they are able to mobilize resources and work together (Brewster and Sheinberg 2015). The Ackerman Relational Approach is not a model but a way of thinking and conceptualizing family dilemmas that is non-pathologizing and collaborative, searches for the unique beliefs and meaning each family member attributes to the problem, holds the complexity of the individual as more than their symptoms, and understands how oppressive practices in the larger society impact the interior of couple and family relationships. At the same time, therapists are trained to understand how their own social location impacts their view of the problem and how it may influence their interaction with the family or couple in treatment. The list of key references reflects some of the seminal articles and books written by Ackerman faculty in the last 50 years that have influenced the thinking and practice of family therapy at the institute today.

References Ackerman, N. W. (1966). Treating the troubled family. New York: Basic Books. Bloch, D. A. (1972). Family interaction: A dialogue between family researchers and family therapists. Family Process, 11, 511–512. Bloch, D. A. (1981). Family therapy training: The institutional base. Family Process, 20, 131. Brewster, M. K., & Sheinberg, M. (2015). The Ackerman relational approach: A training manual. Unpublished manuscript. Colapinto, J. (1995). Dilution of family process in social services: Implications for treatment of neglectful families. Family Process, 34, 59–74.

Ackerman Institute for the Family Edwards, M. (2002). Attachment, mastery, and interdependence: A model of parenting processes. Family Process, 41, 389–404. Fraenkel, P. (2006). Engaging families as experts: Collaborative family program development. Family Process, 45, 237–257. Fraenkel, P. (2011). Sync your relationship, save your marriage: Four steps to getting back on track. New York: St Martin’s Press. Frederick, A. (2014). Depression and suicidality among African American females attending elite private schools: Impact of diminished community support. In C. F. Collins (Ed.), Black and adolescent girls: Facing life challenges, (pp. 211–220), Oxford: Praeger. Goldner, V. (2004). The treatment of violence and victimization in intimate relationships. Family Process, 37, 263–286. Goldner, V., Penn, P., Sheinberg, M., & Walker, G. (1990). Love and violence: Gender paradoxes in volatile attachments. Family Process, 29, 343–364. Hernandez, M., Watts-Jones, D., & Small, S. (1999). Velvet revolution: Changing organizations from the inside. Family Therapy Networker. September–October, 21–22. Hoffman, L. (1990). Constructing realities: An art of lenses. Family Process, 29, 1–12. Imber-Black, E. (1992). Rituals for our times: Celebrating, healing, and changing our lives and our relationships (the Master Work Series). New York: Harper Collins. Imber-Black, E. (1993). Secrets in families and family therapy. New York: W. W. Norton. Imber-Black, E. (2011). The evolution of family process: Contexts and transformations. Family Process, 50, 173–195. Kaplan, L., & Small, S. (2005). Multiracial recruitment in the field of family therapy: An innovative training program for people of color. Family Process, 44, 249–265. Katz, E. (2007). A family therapy perspective on mediation. Family Process, 46, 93–107. LaPerriere, K. (1982). Family therapy techniques. Family Process, 21, 129–130. Lewis, C. (2011). Providing therapy to children and families in foster care: A systemic-relational approach. Family Process, 50, 436–452. Malpas, J. (2011). Between pink and blue: A multidimensional family approach to gender nonconforming children and their families. Family Process, 50, 453–470. Papp, P. (1983). The process of change. New York: Guilford. Papp, P. (2000). Couples on the fault line: New directions for therapists. New York: Guilford. Papp, P., & Imber-Black, E. (1996). Family themes: Transmission and transformation. Family Process, 35, 5–20. Papp, P., Scheinkman, M., & Malpas, J. (2013). Breaking the mold: Sculpting impasses in couples’ therapy. Family Process, 52, 33–45. Peck, J. S. (2007). Money and meaning: New ways to have conversations about money with your clients. New York: Wiley.

23 Penn, P. (1982). Circular questioning. Family Process, 21, 267–280. Scheinkman, M. (2005). Beyond the Trauma of betrayal: Reconsidering affairs in couples therapy. Family Process, 44, 227–244. Scheinkman, M. (2008). The multi-level approach: A road map for couples therapy. Family Process, 47, 197–213. Scheinkman, M., & Werneck, D. (2010). Disarming jealousy in couples relationships: A multidimensional approach. Family Process, 49, 486–502. Sheinberg, M. (1992). Navigating treatment impasses at the disclosure of incest: Combining ideas from feminism and social constructionism. Family Process, 31, 201–216. Sheinberg, M., & Brewster, M. K. (2014). Thinking and working relationally: Interviewing and constructing hypotheses to create compassionate understanding. Family Process, 53, 618–639. Sheinberg, M., & Fraenkel, P. (2001). The relational trauma of incest: A family-based approach to treatment. New York: Guilford Press. Sheinberg, M., & Penn, P. (1991). Gender dilemmas, gender questions and the gender mantra. Journal of Marital and Family Therapy, 17, 33–44. Sheinberg, M., & True, F. (2008). Treating family relational trauma: A recursive process using a decision dialog. Family Process, 47, 173–195. Silverstein, O., & Rashbaum, B. (1995). The courage to raise good men. New York: Penguin. Steinglass, P. (1987). The alcoholic family. New York: Basic Books. Stern, M. B. (2008). Child-friendly therapy: Biopsychosocial innovations for children and families. New York: W. W. Norton. Walker, G. (1991). In the midst of winter: Systemic therapy with families, couples, and individuals with AIDS infection. New York: W. W. Norton. Walters, M., Carter, B., Papp, P., & Silverstein, O. (1991). The invisible web: Gender patterns in family relationships. New York: The Guilford Press. Watts-Jones, D. (1997). Toward an African American genogram. Family Process, 316, 375–383. Watts-Jones, D. (2004). The evidence of things seen and not seen: The legacy of race and racism. Family Process, 43, 503–508. Watts-Jones, D. (2010). Location of self: Opening the door to dialogue on intersectionality in the therapy process. Family Process, 49, 405–420. Watts-Jones, D. (2016). Location of self in training and supervision. In K. V. Hardy & T. Bobes (Eds.), Culturally sensitive supervision and training: Diverse perspectives and practical applications (pp. 16–24). New York: Routledge. Watts-Jones, R. A., Alfaro, J., & Frederick, A. (2007). The role of a mentoring group for family therapy trainees and therapists of color. Family Process, 46, 437–450. Whiting, R. (2003, 1988). Rituals in families and family therapy. New York: W. W. Norton.

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Ackerman, Nathan Rajeswari Natrajan-Tyagi Couples and Family Therapy Masters and Doctoral Programs, California School of Professional Psychology at Alliant International University (Irvine), Irvine, CA, USA

Name Ackerman, Nathan

Introduction Nathan Ackerman is widely acknowledged as a pioneer in the field of family therapy and is credited with developing the concept of family psychology. He was born in Bessarabia, Russia, on November 22, 1908. Ackerman and his family came to the United States in 1912 when he was only 4-yearsold. He grew up during the age of anti-Semitism, the great depression, and World War II.

Career He attended the public school system in New York City, earned his Bachelor of Arts degree from Columbia University in 1929 and his Doctor of Medicine degree from Columbia University in 1933. He did his internships at the Menninger Clinic in Topeka, Kansas, and the Montefiore Hospital in the Bronx, New York. At the Menninger Clinic, Ackerman was offered a staff position which he accepted and in 2 years rose to the position of Chief Psychiatrist at that clinic. During World War II, Ackerman lent his services to the Red Cross and by the end of the war he was offered the position of clinical professor of psychiatry at Columbia University.

Contributions to the Profession Ackerman is thought to be one of the pioneers of family psychology. He began his early training as a

Ackerman, Nathan

classical psychoanalyst. His interest in integrating insights related to the psychodynamic perspective into a group therapy session paved the way for what has evolved into modern day family therapy. He faced great struggles in challenging and changing the psychological zeitgeist of his times which was steeped in concepts and terminology of intrapersonal personality theories. Initially, Ackerman followed the Child Guidance Clinic model of having a psychiatrist treat the child while a social worker worked with the mother. However, within his first year of work at the Menninger clinic, Ackerman became a strong advocate of including the entire family when treating a disturbance in one of its members. He believed that the mental or physical health of one family member affected other family members, and that often the best way to treat the individual was to treat the family as a whole. He argued that families acted as a type of social unit and just like individuals go through developmental stages. He was particularly fascinated by intergenerational ties and the role emotions played within the family unit. For this reason, Ackerman insisted on the entire family receiving treatment, utilizing family systems therapy, and traditional psychodynamic therapy into his work as a psychiatrist. He was seen as a phenomenal therapist with a confronting and charismatic therapeutic style. He was seen as a high-affect therapist who can gain quick access to clients’ emotions and make things happen in the room. He founded the Ackerman Institute in 1960, which to this day serves as a base for education, research, and clinical service for families and improving their mental health. Along with his colleague Don Jackson, Ackerman founded the first family therapy journal, Family Process, which is still the leading journal of ideas in the field today. Dr. Ackerman published multiple books such as Family Diagnosis: An Approach to the Preschool Child (1938), The Unity of the Family (1938), The Psychodynamics of Family Life (1958), Treating the Troubled Family (1966), and Family Process (1970). Nathan Ackerman served as the president of the Association of Psychoanalytic Medicine and was awarded the Wilfred Hulse Award and the Rudolph Meyer Award. He died in 1971.

Action as a Stage of Change in Couple and Family Therapy

Cross-References ▶ Ackerman Institute for the Family ▶ Jackson, Donald ▶ Philadelphia Child Guidance Clinic

References Barrows, S. E. (1982). Nathan, W. Ackerman as a therapist and individual: An interview with Donald Bloch and Kitty La Perriere. The American Journal of Family Therapy, 10(4), 63–70. https://doi.org/10.1080/ 01926188208250101. Broderick, C. B., & Schrader, S. S. (1981). The history of professional marriage and family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (pp. 5–35). New York: Brunner/Mazel. Nichols, M. P. (2011). The evolution of family therapy. In The essentials of family therapy (pp. 7–28). Boston: Pearson.

Action as a Stage of Change in Couple and Family Therapy Carlo C. DiClemente and Alicia E. Wiprovnick University of Maryland, Baltimore County, Baltimore, MD, USA

Synonyms Adherence; Coping activities; Engagement; Plan implementation; Taking action

Overview and Theoretical Context Stages of Change represent a series of steps and tasks that assist in understanding the multidimensional nature of intentional behavior change. According to the transtheoretical model (TTM), the process begins with an individual in precontemplation and currently not considering change through contemplation (decision making), preparation (planning and committing), and action (making the change and revising the plan) to reach maintenance where the new behavior is sustained

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and integrated into one’s life (Prochaska and DiClemente 1984). When individuals in couples and family therapy need to make a change in personal or interpersonal behaviors, the stages can be helpful for understanding their readiness and motivation (Prochaska et al. 1994). Thus, assessing stage status enables therapists to match their approaches to meet the needs of clients in different stages of change (see ▶ “Contemplation as a Stage of Change in Couple and Family Therapy” entry). Moreover, stage status is goal and behavior specific so individuals can differ in readiness based on goals (desired amount of contact with in-laws) and behaviors (cutting down or quitting smoking).

Application of Concept in Couple and Family Therapy Action is the stage that most identify with change. The pre-action stages represent tasks that get individuals ready to change. The action stage begins the activities needed to create a new pattern of behavior. The plans and commitment generated in the preparation stage are activated and behavior change is begun; a couple tries a new communication strategy, parents begin to change how they manage temper tantrums, or an abusive spouse stops using verbal abuse to communicate feelings. The tasks of the action stage are to initiate a plan, continue commitment despite difficulties, and revise the plan when it is not working. After successful creation of a new pattern of behavior (often 3–6 months), individuals or families move into the maintenance stage where the new pattern becomes integrated into the couple or family behavioral repertoire (Prochaska and DiClemente 1984). Time is an important consideration during preparation; having a specific time when the change will be implemented and letting others know increase commitment and the probability of an attempt at action. A starting point gives some structure to the change attempt. The action stage also represents an important time to engage clients in learning behavior change strategies and skills needed to successfully implement the plan and act. Examples of skills to be taught during this time are communication skills such as active

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Action as a Stage of Change in Couple and Family Therapy

listening and using “I statements” to express oneself (Jacobson and Christensen 1998). Couples who practice these activities as part of the change plan demonstrate higher readiness to change (Hawrilenko et al. 2016). Another key dimension is whether the plan is working completely. Plans usually have flaws and there are unanticipated challenges in implementation. For example, a parent fails to ignore a problem behavior or use positive reinforcement and gets into a screaming match with their adolescent; or a husband comes home late for dinner without calling as promised. These are labeled as a slip (use of the substance that is time limited) or a relapse (a return to the problem behavior pattern). This distinction is critical. Slips indicate that there is a problem in the plan or commitment of the individual. Relapse indicates that the individual or family has given up on the plan of action (DiClemente and Crisafulli 2017). Both can be remediated, but a relapse usually requires recycling through earlier stages to fix what went wrong with the process of change and to adequately complete earlier tasks leading to greater success next attempt (Prochaska et al. 1992). Slips, however, are instructive in the sense that they uncover flaws in the action tasks. Plans may need to be adjusted or tweaked to accommodate what went wrong. As long as the decisions made in the contemplation stage and the commitment generated in the preparation stage are still operative, the clients can change the plan rather than abandoning the change. Rigid expectations on the part of client or counselor that everything must go smoothly once action is taken or that a failed plan represents complete failure create discouragement and defeat. In couple counseling, this is particularly important because a slip on the part of one person is often interpreted as a lack of commitment, effort, or ability rather than a glitch in the implementation of the action plan (DiClemente 2015).

would have temper tantrums whenever he did not get his way. Shakira refused to go out shopping with Demond because his behavior embarrassed her. At home, she thought that Brad constantly gave in to avoid the tantrums. In the third family counseling session, the counselor explained selective attention and how to ignore the tantrum and reward positive behaviors. The couple found the ideas helpful and agreed to try these strategies. During the week, both of them began praising Demond for good behavior: playing quietly, working together on a puzzle, and helping Mom with a chore. Both were surprised that it seemed to be working. On Friday, however, Demond was throwing his toys around and instead of ignoring it, Brad, who had had a difficult day at work, kept telling him to stop and then yelled at him. The interaction escalated and Shakira started to get angry at Brad, telling him that he was not trying to do what the counselor recommended. The next session both were tense and thought that they were not able to do this since it was creating conflict between them. After assuring them the foolproof management plan had not yet been created, the counselor elicited a recommitment to continue to try the strategies, and problem solved the situation. Brad and Shakira agreed that each of them could call a time out if they were feeling overwhelmed and angry and let the other, less stressed parent manage Demond whenever possible. After several more weeks of working together and implementing the strategies, they saw a noticeable improvement. They were not always able to implement the strategies but were motivated to figure out what went wrong and how to adjust the strategies to fit their situations. Their behavior change and use of these child management strategies continued even as Demond moved out of his “terrible twos.”

Cross-References Case Example Shakira and Brad constantly argued over how to manage their 2-year-old son, Demond. He

▶ Contemplation as a Stage of Change in Couple and Family Therapy ▶ Precontemplation in Couple and Family Therapy

Addictions in Couple and Family Therapy

References DiClemente, C. C. (2015). Change is a process not a product: Reflections on pieces to the puzzle. Substance Use and Misuse, 50, 1–4. https://doi.org/10.3109/ 10826084.2015.1042338. DiClemente, C. C., & Crisafulli, M. (2017). Counting drinks needs a broader view of alcohol Relapse and Change. Alcoholism Clinical and Experimental Research. 41(2), 266–269. Hawrilenko, M., Eubanks-Fleming, C. J., Goldstein, A. S., & Cordova, J. V. (2016). Motivating action and maintaining change: The time-varying role of homework following a brief couples’ intervention. Journal of Marital and Family Therapy, 42, 396–408. https:// doi.org/10.1111/jmft.12142. Jacobson, N. S., & Christensen, A. (1998). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York: Norton. Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Malabar: Krieger Publishing. Prochaska, J. O., DiClemente, C. C., & Norcross, J. (1992). In search of how people change. American Psychologist, 47(9), 1101–1114. Prochaska, J. O., Norcross, J., & DiClemente, C. C. (1994). Changing for good: The revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: William Morrow & Co.

Addictions in Couple and Family Therapy Meagan J. Brem, Autumn Rae Florimbio and Gregory L. Stuart University of Tennessee-Knoxville, Knoxville, TN, USA

Synonyms Behavioral addictions; Impulse control disorders

Introduction Behavioral addictions, sometimes referred to as impulse control disorders, are becoming increasingly recognized as treatable addictions. In 2011, the American Society of Addiction Medicine (ASAM) departed from traditional

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conceptualizations of addiction as being limited to substance dependence and instead referred to addiction as a chronic disease affecting brain reward, motivation, memory, and related circuitry. Though debate continues regarding the nature, etiology, and terms used to describe various behavioral addictions, evidence suggests that these behaviors often involve a natural reward which maintains the behaviors despite the presence of aversive physical, mental, or social consequences. Gambling disorder is the only behavioral addiction recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association 2013). However, a growing body of research has applied the addiction model to a number of behaviors, including sexual intercourse, pornography use, shopping, video gaming, and Internet and computer use. Like substance dependence, these behavioral addictions contribute to a number of emotional, interpersonal, physical, spiritual, and financial difficulties for individuals and their families. Such difficulties pose a significant threat to an individual’s recovery process and to the structure and process of their family system. As such, clinicians and researchers have made efforts to address the impact of behavioral addictions on couples and families. The efficacy of these treatments remains limited.

Sexual and Pornography Addiction Theoretical Context and Description. An increased awareness of sexual addiction among researchers and clinicians developed following Carnes’ (1992) publication. Sexual addiction, also known as hypersexuality and compulsive sexual behavior, refers to compulsive, excessive, out of control, or otherwise problematic sexual behaviors (e.g., sexual desire/drive, sexual intercourse, masturbation, pornography use, sexual chat/video use, and/or engagement in sexual fantasy). According to the behavioral addiction model for sexual addiction, individuals who engage in these behaviors experience craving prior to engagement in sexual activity, impaired

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control over sexual behaviors, and continued engagement in sexual activity despite negative consequences. Sexual addiction affects both men and women of all ages and ethnicities though it is more often reported among men than women. Individuals with sexual addiction often endorse co-addictions, including substance use disorders, which are often intricately intertwined with sexual activity. Application of Concept in Couple and Family Therapy. Individuals with sexual addiction experience a range of consequences including sexually transmitted infections, unwanted pregnancies, abortion, financial loss, marital- and work-related problems, legal issues, and psychiatric comorbidities. Partners of such individuals often share the experience of these consequences in addition to feelings of shame, distrust, betrayal, anger, traumatization, helplessness, poor selfesteem, isolation, and diminished sexual intimacy. As such, a growing number of couples are seeking therapy with sexually based compulsive behaviors as the primary presenting concern. Couple therapy is considered an important method for rebuilding trust, communication, and intimacy among couples affected by sexual addiction. Despite recognition of this importance, limited resources are available for the treatment of sexual addiction within couples. Of the few resources available to clinicians working with this population, the following treatment aims consistently emerge: psychoeducation regarding the nature of sexual addiction, restore trust in the relationship, examine cognitive and emotional effects of addiction on each member of the couple, develop adaptive communication patterns, reorient the addicted partner away from egocentrism and toward relationship responsiveness, address the broad systemic effects of sexual addiction within the family system (e.g., sexuality and withdrawal), facilitate forgiveness, establish healthy boundaries, reduce shame, and increase intimacy within the partnership and family (e.g., increase time together; Zitzman and Butler 2005). Structural and emotionally focused couple therapy demonstrated efficacy in accomplishing many of these aims. Due to the complex relations between the development of sexual addiction,

Addictions in Couple and Family Therapy

the presence of early life traumas, and the role distortions observed in the family of origin for both members of the couple, couple therapy should supplement or follow individual or group therapy. Therapists working with couples in which one or both members are affected by sexual addiction must provide a safe, nonjudgmental environment while promoting good boundaries (Turner 2009). It is important that therapists have well-developed self-awareness of their own beliefs and experiences regarding sexuality and accept the broad range of sexual expression. Identifying with one member of the couple could result in the other feeling alienated, leading to treatment termination. Research in this understudied domain remains limited to primarily white, heterosexual, married couples. Marriage and family therapists should therefore consider the potential limitations of applying existing treatment modalities to diverse populations affected by sexual addiction.

Gambling Disorder Theoretical Context and Description. Gambling disorder, sometimes referred to as problematic gambling, pathological gambling, or compulsive gambling, was reclassified by the DSM-5 (APA 2013) as a substance-related and addictive disorder. Gambling disorder is broadly characterized by difficulty in limiting time and resources spent on gambling and unsuccessful attempts to cut down on gambling despite significant psychological, financial, medical, occupational, or interpersonal consequences. The conceptualization of problematic gambling as an addiction followed after observed similarities between substance use disorders and problematic gambling with regard to symptom presentation, genetic vulnerabilities, neurological mechanisms, cognitive deficits, and motivations (Petry 2007). For instance, gambling is used by many to cope with aversive internal and external events. Gambling disorder often co-occurs with various other psychiatric conditions, including substance use, mood, anxiety, and personality disorders. Though gambling disorder is observed across multiple populations,

Addictions in Couple and Family Therapy

young, nonwhite men with low socioeconomic status who are separated or divorced are at an increased risk (Petry 2007). Application of Concept in Couple and Family Therapy. Couple and familial distress is both a contributor and consequence of problematic gambling. Partners of problematic gamblers often share the burden of financial distress associated with gambling in addition to feelings of guilt, shame, anger, betrayal, and loss of trust and the burden of upholding responsibilities for the family alone. These experiences paired with difficulty in communicating, resolving conflict, and maintaining sexual intimacy further exacerbate relationship dissatisfaction within such couples. Children and other family members of problematic gamblers often report adverse effects of gambling, including neglect, lying, deception, alcohol and drug problems, and family violence (Kalischuk 2010). Alternatively, couple conflicts, partner’s efforts to exert control over the gambler, poor social support, and conflictual attitudes from family members are major elements of relapse for individuals who engage in problematic gambling. Indeed, gambling may be such an integrated component of the family system that eliminating gambling by means of individual treatment alone may disrupt the dynamics within the family, leading to relapse or separation. To address these issues, researchers and clinicians advocate for the inclusion of couple and/or family therapy in the treatment of problematic gambling. There is a paucity of resources for evidencebased, couple-focused treatments for problematic gambling with a majority of resources focusing on individual or group approaches to treatment. Congruence Couple Therapy (CCT), a short-term, integrative, humanistic, and systemic approach, aims to reduce problematic gambling while healing the emotional pain within the couple relationship (Lee and Awosoga 2015). In CCT, gambling is targeted within couples’ broader and deeper concerns. CCT accomplishes these aims during 12, 1-h weekly sessions which span across six phases of treatment: (1) engaging the client, (2) aligning with the couple and assessing couple communication and gambling, (3) facilitating congruence within the couple, (4) deepening

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experiencing, (5) linking the past to the present, and (6) consolidating changes. Similarly, Adapted Couple Therapy (ACT) for pathological gamblers (Bertrand et al. 2008) aims to support and encourage the gambler’s recovery while relieving the distress experienced within the couple. ACT involves two overlapping phases of treatment. In the first phase, management of the gambler’s problems and symptoms occurs (e.g., a functional analysis of gambling behaviors is performed, irrational cognitions are addressed, and emphasis is placed on developing empathy between partners). In the second phase, couple dimensions are addressed (e.g., developing caring behaviors, intimacy, constructive communication, and problemsolving skills). The efficacy of ACT for gambling has yet to be determined.

Other Behavioral Addictions Theoretical Context and Description. Research examining addictions to various technological devices and activities (e.g., gaming, browsing, social networking, etc.), and compulsive buying (sometimes referred to as shopping addiction), remains controversial and limited. These behaviors are oftentimes conceptualized as being more closely associated with impulse control disorders and obsessive-compulsive disorders than with addiction. Nonetheless, terms such as “Internet addiction” and “shopping addiction” have received increased attention among researchers and clinicians who characterize these phenomena as excessive or poorly controlled preoccupations or urges to engage in these behaviors, leading to impairment and distress (Granero et al. 2016; Shaw and Black 2008). The growth of technology and the Internet contribute to significant overlap among these behaviors and other behavioral addictions (e.g., cybersexual addiction, online gambling addiction, and online shopping addiction). As with substance use disorders, neurological evidence suggests individuals with these behavioral addictions have abnormalities in reward-processing regions of the brain. Similarly, both reinforcement and punishment systems appear to contribute to the onset and development of these behavioral addictions. Unlike substance use

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disorders, these behavioral addictions depend on specific cultural mechanisms (e.g., market-based economy and materialistic values). Whereas more women than men endorse compulsive buying behavior, findings on gender differences in computer and Internet addiction are mixed. Application of Concept in Couple and Family Therapy. Excessive use of technological activity (e.g., gaming, browsing, social networking, etc.) interferes with relationship functioning and flexibility within the family system in various ways. Partners’ concerns may include issues with the amount of time an individual spends on a technological device, how the technological activity interferes with familial responsibilities and relationship intimacy, and the extent to which a partner maintains appropriate boundaries with other individuals with whom she/he interacts through technological devices. Consequences of excessive or compulsive technology use may result in disrupted sleep, which may then affect the time and energy an individual puts into relationships. Couples in which one or both partners engage in some form of technology addiction may experience neglect, betrayal, jealousy, and reduced intimacy within their relationship. Similarly, compulsive or excessive buying behaviors may create hostility, lack of trust, and financial difficulties within couples, which may then subsequently and negatively affect buying habits. No research has investigated the efficacy of couple or family therapy for couples in which one or both partners exhibit a technology addiction or compulsive buying. Nonetheless, therapists can work to help couples establish boundaries and rules within their relationship. Exploring couples’ conflicting value systems, motivations for and patterns of engaging in compulsive behaviors, and level of intimacy within the relationship may provide important therapeutic directions. Therapists should work to address couples’ use of disparate leisure activities, perceived neglect, and poor communication skills. In cases in which the entire family system is disrupted by such behaviors, family therapists can work to set boundaries on such behaviors within the family and replace disparate activities with family activities.

Addictions in Couple and Family Therapy

Case Example Steve and Sally have been married for 16 years and have a 12-year-old son. They recently sought couple therapy stating that their relationship was negatively affected by Steve’s pornography use. They viewed pornography together during sexual activities when they first married, which Sally described as a comfortable, intimate experience. However, over the past 10 years, Steve became increasingly secretive about his pornography use and began to use pornography alone on a daily basis. Sally reported she was uncomfortable with the type of pornography Steve used and the extent of his use. As a result, she had asked him to discontinue and Steve promised he would not use pornography anymore. When Sally and Steve’s 12-year-old son stumbled across a secret file on their computer where Steve had saved pornographic material, Sally became suspicious that Steve was continuing his pornography use. Again, Steve promised to quit using pornography. Sally became distrustful of Steve and frequently searched the house, his computer, and his Internet history on his cell phone to monitor his pornography use. When Sally found evidence of Steve’s pornography use, they would get in an argument, causing Steve to become more secretive about his pornography use. This process transpired throughout the last several years of their marriage. Sally stated that she did not trust Steve anymore, they lacked intimacy, and she began to perceive herself as unattractive. She recently threatened to end their marriage over his pornography use. Steve argued that he did not have privacy. He maintained that he found Sally attractive and that his pornography use did not affect his commitment to her. Steve repeatedly promised he would stop using pornography, but was unable to stop and had in fact began using more graphic and novel forms of pornography. Steve was addicted to pornography. Just as many therapists suggest addressing substance use prior to beginning couples’ concerns, Steve and Sally’s therapist chose to address the addiction components prior to working on their relationship concerns. Once the addiction decreased, the couple system was restructured to

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improve marital functioning. Using a structural approach, the therapist focused on reducing the alliance Steve has with pornography in place of an alliance between Steve and Sally against the pornography. The therapist hypothesized that Steve’s relationship with pornography has strengthened over the years, while his relationship with Sally weakened. Steve relied on pornography, instead of Sally, for comfort. As a result, Sally grew to feel rejected from Steve. After providing some psychoeducation regarding pornography addiction, the therapist helped Steve and Sally identify pornography as a third party in their relationship. Sally agreed that Steve’s pornography use felt like he was having an affair with another woman and that trust could be restored by Steve’s pornography discontinuation. The importance of trust and boundaries within the relationship were discussed, and they conceptualized what would constitute betrayal of trust and boundaries. The couple agreed that cheating, lying, and secretive behavior impeded trust, and attempting to cover up pornography use was similar to secretly meeting with an extra-dyadic partner. Sally expressed a desire to discontinue monitoring and detective work as a way to determine Steve’s honesty. Steve developed a realization that his addiction interfered with the type of relationship he wanted with Sally (e.g., one that included trust, open communication, and intimacy). After developing these realizations and goals, Steve agreed to keep all of his pornography (e.g., movies, magazines, websites, etc.) in one clearly identified location so that Sally would no longer feel the need to search for it. Sally was pleased and discontinued searching for evidence of Steve’s use. Steve then agreed that he would only review pornographic materials in the established location with Sally’s permission. This pleased Sally as she began to trust Steve more, and Steve eventually decided to get rid of his materials as trust and intimacy further developed in their relationship. Furthermore, Steve began to feel closer to Sally as he began to receive help and comfort from Sally, as opposed to shame and anger, when he experienced urges. Sally also received comfort and consolidation from Steve as they focused on healing the

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wounds pornography placed upon their marriage. Future sessions focused on maintaining this process and increasing the time spent with one another. Follow-up sessions revealed Steve and Sally experienced increased relationship satisfaction.

Cross-References ▶ Alcohol Use Disorders in Couple and Family Therapy ▶ Substance Use Disorders in Couple and Family Therapy

References American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Bertrand, K., Dufour, M., Wright, J., & Lasnier, B. (2008). Adapted couple therapy (ACT) for pathological gambling: A promising avenue. Journal of Gambling Studies, 24, 393–409. Carnes, P. (1992). Out of the shadows: Understanding sexual addiction (2nd ed.). Minneapolis: CompCare. Granero, R., Fernández-Aranda, F., Mestre-Bach, G., Steward, T., Baño, M., del Pino-Gutiérrez, A., Moragas, L., Mallorqui-Bagué, N., Aymami, N., Gómez-Peño, M., Tárrega, S., Menchón, J. M., & Jiménez-Murcia, S. (2016). Compulsive buying behavior: Clinical comparison with other behavioral addictions. Frontiers in Psychology, 7, 1–9. Kalischuk, R. G. (2010). Cocreating life pathways: Problem gambling and its impact on families. The Family Journal: Counseling and Therapy for Couples and Families, 18(1), 7–17. Lee, B. K., & Awosoga, O. (2015). Congruence couple therapy for pathological gambling: A pilot randomized controlled trial. Journal of Gambling Studies, 31, 1047–1068. Petry, N. M. (2007). Gambling and substance use disorders: Current status and future directions. American Journal on Addictions, 16(1), 1–9. Shaw, M., & Black, D. W. (2008). Internet addiction: Definition, assessment, epidemiology, and clinical management. CNS Drugs, 22(5), 353–365. Turner, M. (2009). Understanding and treating sexual addictions in couples therapy. Journal of Family Psychotherapy, 20, 283–302. Zitzman, S. T., & Butler, M. H. (2005). Attachment, addiction, and recovery: Conjoint marital therapy for recovery from a sexual addiction. Sexual Addiction and Compulsivity, 12(4), 311–337.

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Addressing Racial Trauma in Therapy with Ethnic-Minority Clients

Addressing Racial Trauma in Therapy with Ethnic-Minority Clients Jamila Evans Reynolds Tallahassee, FL, USA

Synonyms Discrimination; Race-based traumatic stress; Racial trauma; Racism; Racist-incident based trauma

Introduction Given the current race-relations in the United States, with racially motivated hate crimes, divisive rhetoric, and political fearmongering occurring almost daily, ethnic-minority families are at an increased risk for the development of negative mental health outcomes. One such outcome that clinicians should be mindful of and assess for is the development of trauma symptoms, such as fear, anxiety, avoidance, and helplessness, as a result of directly experiencing or witnessing racist incidents or discrimination. This is also referred to as racial trauma.

Description Racial trauma has been defined as “an emotional injury motivated by hate or fear of a person or group based on their race or ethnicity; a racially motivated stressor that overwhelms the capacity to cope; a racially motivated, interpersonal stressor that causes harm or threatens one’s life; or a severe interpersonal or institutional stressor motivated by racism that causes fear, hopelessness, or horror” (e.g., BryantDavis 2007, pp. 135–136).

Relevant Research Research on racial trauma suggests that exposure to racist incidents are widespread and can influence the physical, emotional, behavioral, and

cognitive wellbeing of ethnic-minority children and adults (Carter 2007; Bryant-Davis and Ocampo 2006; Utsey et al. 2002). For example, racism and discrimination experiences have been related to lower self-esteem and perceptions of academic success, and greater depression and anxiety (Contrada et al. 2001; Fisher et al. 2000; Utsey and Payne 2000). Similar to other more accepted forms of trauma, such as rape, domestic violence, terrorism, or death of a family member, racial trauma results in posttraumatic stress like symptoms. However, what makes racial trauma unique is that racist incidents tend to be an ongoing source of stress for ethnic-minority individuals (Bryant-Davis 2007). In addition, several scholars have noted that race-based traumatic stress can occur in conjunction with other forms of trauma and provide a multiplicative effect on the trauma survivor (Bryant-Davis 2007; Carter 2007), further emphasizing the importance of identifying racial trauma as its own category of stressor. However, even though there is significant research suggesting that experiences of racism and discrimination are related to negative health outcomes, there has been resistance from professionals to adopt racial trauma as a unique and significant stressor. Studies have suggested that this is potentially due to the inconsistent and inconclusive research, the fact that racial trauma is a relatively new phenomenon in the physical and mental health literature, or that the effects of racist experiences are simply ignored by the public, and some professionals (e.g., Carter 2007). Although there are limitations within the literature, racist incidents can produce stress-like responses that should be addressed by mental health professionals.

Special Consideration for Couple and Family Therapy Even though ethnic-minorities are at risk for both experiencing and witnessing race-based traumatic events daily, very few clinical resources exist to help address the symptoms related to racial trauma. This is primarily due to either clinicians failing to conceptualize the experience of racism,

Adjunctive Psychopharmacology in Couple and Family Therapy

discrimination, and microaggressions, as a traumatic experience, or clients not having the language to describe the intensity of the pain related to racial trauma. Further, because many ethnic-minorities are used to their experiences being dismissed or invalidated, it is possible that ethnic-minority clients may avoid addressing their racial trauma entirely. However, as our field strives to become culturally sensitive, it is imperative that clinicians are aware of, sensitive to, and willing to unmask racial trauma in the therapy room. The ability to conceptualize racist incidents as traumatic will further enhance the mental health treatment of ethnic-minority children and their families. In addition, Lee (2005) suggests that to be effective, power and privilege must be examined within the therapeutic context, and that denying the existence and impact would be irresponsible practice. As such, marriage and family therapists should work to create a safe environment for ethnic-minority clients to process their personal experiences of racial trauma. Further, it is important that MFT’s be attune to brief moments of vulnerability by the client, where healing conversations can take place (Lee 2005). Several scholars such as Bryant-Davis and Ocampo (2006), Carter (2007), and Hardy (2013) have provided guidelines for clinicians to address racial trauma and incorporate the assessment of racial trauma within already established treatment models. Clinicians are encouraged to seek further training so that they are prepared to address all forms of trauma that ethnicminority clients may experience.

References Bryant-Davis, T. (2007). Healing requires recognition: The case for race-based traumatic stress. The Counseling Psychologist, 35(1), 135–143. Bryant-Davis, T., & Ocampo, C. (2006). A therapeutic approach to the treatment of racist-incident-based trauma. Journal of Emotional Abuse, 6, 1–22. Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35, 13–105. Contrada, R. J., Ashmore, R. D., Gary, M. L., Coups, E., Egeth, J. D., Sewell, A., et al. (2001). Measures of ethnicity-related stress: Psychometric properties, ethnic group differences, and associations of well-being. Journal of Applied Psychology, 31, 1775–1820.

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Fisher, C. B., Wallace, S. A., & Fenton, R. E. (2000). Discrimination distress during adolescence. Journal of Youth and Adolescence, 29(6), 679–695. Hardy, K. V. (2013). Healing the hidden wounds of racial trauma. Reclaiming Children and Youth, 22(1), 24–28. Lee, L. J. (2005). Taking off the mask: Breaking the silence – The art of naming racism in the therapy room. In M. Rastogi & E. Wieling (Eds.), Voices of color: First-person accounts of ethnic minority therapists (pp. 91–115). California: Sage. Utsey, S. O., & Payne, Y. A. (2000). Differential psychological and emotional impacts of race-related stress. Journal of African American Men, 5, 56–72. Utsey, S. O., Chae, M. H., Brown, C. F., & Kelly, D. (2002). Effect of ethnic group membership on ethnic identity, race-related stress, and quality of life. Cultural Diversity and Ethnic Minority Psychology, 8, 366–377.

Adjunctive Psychopharmacology in Couple and Family Therapy Dixie Meyer and Stephanie Barkley Saint Louis University, Saint Louis, MO, USA

Introduction This entry reviews five major categories of psychopharmacological medications used to treat mood disorders, anxiety disorders, bipolar disorders, psychotic disorders, and attention-deficit/ hyperactivity disorder. The term adjunctive distinguishes how therapists should approach medication. Medication should be viewed as supplemental. Only one role of the therapist is as medication manager with tasks like identifying target symptoms to treat with medications, assessing medication responsiveness, confirming use as directed, coping with side effects, and working with the prescribing physician.

Theoretical Framework The systemic perspective notes multiple influences on the client. Therapists treat the whole family to use relationships to heal. Working with the family provides the best support for the

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individual using psychotropic medication. Yet, the medical model should be incorporated into therapy to ensure the client is receiving the best standard of care. For example, lithium has a success rate between 48% and53% of clients seeing greater than 50% reduction of bipolar disorder symptoms (Girardi et al. 2016). Anticonvulsants are effective in 41–53% of cases to reduce mania with a long-term effect size of about 10% (Poon et al. 2015). There are similar response rates across antipsychotics. For example, 40–50% of individuals with a psychotic disorder respond to medication, 30–40% of individuals receive some symptom relief, and only 20% do not respond to antipsychotic medications (Smith et al. 2010). Marrying the systemic and medical paradigms provides a framework that supports treating the whole person.

Rationale for Strategy Psychotropic medications are frequently prescribed to treat mental health concerns. They are consumed by all age groups. Approximately 3.5% of children were prescribed stimulant medication in 2008 to treat ADHD (De Sousa & Kalra 2012). Benzodiazepines (e.g., Xanax, Valium), associated with treating anxiety, are popular with 5.2% of adults using them (Olfson et al. 2015). Benzodiazepines are about twice as common among women and, as individuals age, the rate increases with 8.7% of the geriatric population using them. Antidepressants are used by approximately 13% of Americans (National Health and Nutrition Examination Survey 2015). Given the high prevalence of individuals using psychotropic medications, therapists need to understand their responsibilities in helping clients manage their medications.

Description of the Strategy

ADHD Medications used to treat ADHD include stimulants and non-stimulants. Stimulant medications, amphetamine (e.g., Adderall) and

methylphenidate (e.g., Ritalin and Concerta), are a first-line treatment. Stimulant medication treats hyperactivity/impulsivity or the combined type of ADHD. Non-stimulant medications are used as alternative or adjuncts to stimulants. Non-stimulant medications include alpha-2A-adrenoceptor agonist (e.g., Catapres, Intuniv), selective norepinephrine reuptake inhibitors (e.g., Strattera, Vivalan), and norepinephrine–dopamine reuptake inhibitors (e.g., Wellbutrin). Non-stimulant medications treat the inattentive type of ADHD. Non-stimulants are used in combination with a stimulant to treat the ADHD combined type. Some side effects for both stimulants and non-stimulants are typical like decreased appetite and disturbed sleep. Stimulants have black box warning for cardiovascular risks, and Strattera has a black box warning for suicidal thoughts in youth. Even with medication, 10–30% of individuals still meet criteria for ADHD (De Sousa and Kalra 2012). Some concerns that the therapist may address with the client and prescribing physician include selecting medication by symptoms and ADHD type, length of time expected to be on medication, and side effects such a growth concerns. ADHD symptoms may overlap with other disorders (e.g., bipolar). Therapists need to be careful in their differential diagnosis to ensure the client is receiving the correct treatment. If a client has a history of substance use, using a stimulant medication may not be the best option due to abuse potential. Therapists should be aware how family dynamics have shifted to accommodate and adjust to a family member living with ADHD. Examining the familial environmental spaces and how the individual functions across various settings will inform treatment. Including the family in the treatment process shifts the family dynamics. A lack of family therapy may result in patterns and stressors that maintain symptoms. Depression Antidepressants are prescribed for mental health concerns like depression or anxiety and physical health conditions like chronic pain or menopause. There are a variety of antidepressants including monoamine oxidase inhibitors (e.g., Nardil, Marplan), selective norepinephrine reuptake

Adjunctive Psychopharmacology in Couple and Family Therapy

inhibitors, norepinephrine–dopamine reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors (e.g., Effexor, Cymbalta), selective serotonin reuptake inhibitors (e.g., Prozac, Lexapro), serotonin antagonists and reuptake inhibitors (e.g., Serzone, Desyrel), serotonin modulators and stimulators (e.g., Viibryd, Trintellex), tricyclic antidepressants (e.g., Anafranil, Elavil), and tetracyclic antidepressants (e.g., Remeron, Asendin). Other types of medications to treat depression or augment antidepressants include atypical antipsychotics, thyroid medications, bipolar medications, St. John’s wort, and SAMe. Antidepressants face controversy due to effectiveness concerns. Metaanalyses demonstrate antidepressants may not outperform placebo. Other concerns are related to increased risk of suicide among adolescent users and usage of antidepressants in pregnancy being linked to birth defects and autism spectrum disorders. Many side effects are typical of medications like dry mouth, weight gain, or drowsiness. However, some side effects can cause interpersonal problems like sexual side effects or are more serious like serotonin syndrome. Clients considering antidepressants should be informed about benefits and concerns. For example, antidepressants do not outperform psychotherapy for treatment of depression (Weitz et al. 2015). When individuals do not respond to antidepressants, the reason for the lack of remission may be related to the impetus for depression. Research suggests individuals with a history of early life traumas may not respond to traditional antidepressants (Meyer 2014). Clients should be knowledgeable about the likelihood of needing antidepressants in the future. About half of all individuals experiencing depression will not experience another episode. Yet, when individuals go off antidepressants, they are more likely to relapse. Most physicians will prescribe an antidepressant beyond the traditional depressive episode lasting 6 months. For those individuals who may not have another depressive episode, they are potentially using a medication longer than needed and increasing their likelihood of developing another depressive episode. However, for the half of individuals who will experience another

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depressive episode or those with chronic depression, antidepressants can improve the quality of life. Anxiety Disorders Anxiolytics, minor tranquilizers, treat anxiety disorders. These medications target the fight-or-flight response, fear, worry, and rumination associated with anxiety disorders. These medications also treat seizure disorders, insomnia, alcohol withdrawal, or muscle spasms. Other medications that treat anxiety include Buspar, barbiturates (e.g., Amytal, Prominal), antidepressants (e.g., venlafaxine, Remeron), anticonvulsants (e.g., Lyrica, Neurontin), antihypertensives sympatholytics (e.g., clonidine, propranolol), antihistamines (e.g., Atarax, Benadryl), and herbal remedies (e.g., kava, valerian root). Selecting a medication depends on the length of need. Medications like barbiturates are highly addictive and can be lethal, so they are rarely prescribed for anxiety. Benzodiazepines can also be addictive and should only be prescribed for short-term daily use (i.e., 2–4 weeks, McIntosh et al. 2004). Benzodiazepines are best prescribed on an as needed basis (e.g., during a panic attack). Antidepressant medications are beneficial for long-term use to treat anxiety. Benzodiazepines side effects can be typical like dry mouth, headache, or upset stomach. However, these medications are not recommended when individuals need to be alert, use fine motor or cognitive skills. Other troubling conditions are related to long-term memory issues. Benzodiazepines can be habit forming. Therapists need to help clients monitor usage. Individuals may have the urge to use benzodiazepines anytime anxiety arises. However, therapists need to communicate that the symptoms are an adrenalin rush. Helping clients to reframe the feelings as similar to exercise make the symptoms less scary. Benzodiazepines should not be used with alcohol; however, often individuals use alcohol to self-medicate their anxiety. This may be particularly dangerous. Benzodiazepines are not recommended in geriatric population.

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Not only because of genetic predispositions, depression and anxiety can be a mood shared among family members. While this demonstrates empathy, it may be difficult when family members experience stress overload. Unfortunately, family members often only synchronize negative not positive moods (Mancini and Luebbe 2016) making it difficult for family members to help their loved ones recover. For example, Nicolas et al. (2009) found when a family member has depression, other family members are more likely to develop mental health distress. When individuals are depressed, they become less socially responsive and display fewer positive nonverbal behaviors adding strain to relationships. Strained relationships may increase one’s anxiety. As individuals spend more time with others who cause them stress, the stress response may become the homeostatic state. As individuals become more stressed, they become more sensitive to stress and more easily overload from stress. Working with a client and their family may be necessary to teach the system relaxation techniques to create a homeostatic state more tolerant of stress. Bipolar Disorders Bipolar disorders medications include lithium, anticonvulsants, antipsychotics, and in some cases antidepressants. Lithium is a standard treatment for bipolar disorders due to success with mania and reducing suicidality. It is important that the therapist consults with the prescribing physician to ensure blood levels and side effects are monitored. Lithium can have severe side effects including damage to physical health and cognitive impairments such as reduced vigilance, alertness, learning, and short-term memory. Other side effects include thyroid changes, minor cardiovascular changes, rash and acne-like lesions, weight gain, and pregnancy problems. Adherence to medication is difficult when the client is experiencing or fears side effects. Open communication about what to expect can help reduce fears. Anticonvulsants are the second most common form of bipolar medication. Anticonvulsants (e.g., Depakote, Lamictal) are often prescribed to reduce mania and work by calming the hyperactivity in the brain. Possible side effects include weight loss,

cardiovascular risk, sleep disturbances, nausea, vomiting, diarrhea, dizziness, drowsiness, and tremors. Therapists should be aware that each anticonvulsant effects the body differently. For example, Lamictal is often used to reduce recurrences of depression. In consultation with a physician, therapists have a responsibility to assess for medication appropriateness. Antidepressants should be used with caution with bipolar disorder. Antidepressants should not be used with mania or mixed episode, history of rapid cycling, and should be used if clients relapse into depression without an antidepressant. Family members may be the first to notice an individual is relapsing. Family therapy may be a critical component of treatment to address symptom manifestation, increase family cohesiveness, and address how this disorder affects the family. Family therapy may enhance treatment, specifically if the family may be triggering symptoms. For example, clients from families with higher expressed emotion have a greater likelihood of relapse and poorer treatment outcomes. Implementing family therapy to impact change at the familial level can increase the likelihood of success for the client. Psychotic Disorders Antipsychotic medications, known as major tranquilizers or neuroleptics, treat psychotic disorders such as schizophrenia or schizoaffective disorder. Older antipsychotic medications (e.g., Haldol, Thorazin) are often called conventional, typical, or first-generation antipsychotics, and newer medications, atypical antipsychotics, are called second- (e.g., Risperdal, Zyprexa) and thirdgeneration antipsychotics (e.g., Abilify). Older medications treat the positive symptoms of schizophrenia, whereas the newer medications treat the positive and negative symptoms. There are similar response rates across types of antipsychotics. Antipsychotic medications have a range of side effects. Some may be mild (e.g., headaches, dry mouth, fatigue). However, all types of antipsychotics may produce dangerous side effects like

Adjunctive Psychopharmacology in Couple and Family Therapy

extrapyramidal symptoms (movement disorders). Examples include dystonia (muscle spasms), Parkinson-like symptoms (rigidity), tremors, tardive dyskinesia (jerky movements), akathisia (restlessness), and bradykinesia (slowness in movement). Extrapyramidal side effects may be less frequent with atypicals; however, atypicals may increase the risk of developing type 2 diabetes. Other side effects include weight gain, hyperlipidemia, gastrointestinal issues, sexual side effects, cognitive concerns, risk of seizure, and cardiac dysfunction. The side effects may make it difficult for individuals to adhere to treatment, although, most tolerate atypicals more easily than typical antipsychotics. Taking antipsychotic medications may be difficult for individuals as some medications require behavioral changes multiple times per day (i.e., a large caloric intake at ingestion, no smoking). Individuals needing antipsychotics usually require multiple medications to manage symptoms and side effects, thus, contributing to more planning difficulties. Other medication adherence challenges include delusions about the medication, medication affordability, lack of consistent routine, chaotic home life, lack of social support, loss of autonomy, side effects, and substance use. Individuals not compliant with medications risk relapse, poor insight, mental clarity issues, high-risk behaviors, increased aggression, violence, substance use, hospitalization, worse prognosis, and even suicide. Therapy is an opportunity to confront challenges and brainstorm solutions. Despite challenges, most individuals report reduce symptoms and lead a more normal life. Improving quality of life requires the client to have a good relationship with the therapist and physician. The client needs to communicate their concerns with their physician and therapist. The therapist will see the client more frequently than the physician, thus, may recognize an increase in symptoms before they become problematic. Family therapy may help to reduce symptoms, alleviate side effects, improve medication adherence, establish patterns of support, foster relationships, develop routines, recognize relapse, and help individuals stay socially connected. The family may need to take an active

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role in changing their lifestyle to support the client and report concerns. The therapist needs to target building family bonds as individual who feel supported report fewer symptoms and relapse.

Case Example Kim, a 20-year-old, Korean, female was diagnosed with schizophrenia in her first year in college. After the diagnosis, she moved back home with her parents. Kim wants to complete college, but struggles with paranoid delusions. Her delusions are exacerbated when she does not take medication, but she is concerned the medication is poisoning her. Kim’s parents initiated Kim’s therapy to improve medication adherence. In therapy, Kim noted her parents were treating her like a child, stated her goal to live on her own, and indicated how terrible her medication made her feel. The therapist suggested Kim’s parents attend therapy. The parents noted concerns about Kim’s ability to live alone if she will not take her medication. They were concerned Kim would be confused and hurt herself. Kim felt that they did not trust her. The therapist began by rebuilding the relationships between Kim and her parents. The therapist reframed the parental overprotection as concern, provided Kim an outlet to express independence and voice medication concerns. Kim, her parents, and the therapist met with Kim’s psychiatrist to express concerns about treatment adherence, side effects, and Kim’s other medication concerns. The psychiatrist switched Kim to another atypical antipsychotic and used a longlasting injectable to improve adherence. The psychiatrist prescribed a medication to treat side effects and a benzodiazepine for Kim to use when overwhelmed by her thoughts. The therapist started weekly sessions with a medication checkin for Kim to voice concerns and the therapist to assess for medication dependence. Kim moved into an apartment over her parents’ garage. It gave her freedom, but Kim also agreed to have dinner with her parents every night. This ensured her parents could provide support, check for relapses, and confirm Kim was using her medications as directed.

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References DeSousa, A., & Kalra, G. (2012). Drug therapy of attention deficit hyperactivity disorder: Current trends. Mens Sana Monigraphs, 10, 45–69. Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). Lithium in bipolar disorder: Optimizing therapy using prolonged-release formulations. Drugs in R&D, 16, 293–302. Mancini, K., & Luebbe, A. (2016). Dyadic affective flexibility and emotional inertia in relation to youth psychopathology: An integrated model at two timescales. Clinical Child and Family Psychology Review, 19, 117–133. McIntosh, A., Cohen, A., Turnbull, N. et al. (2004). Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder. National Collaborating Centre for Primary Care. Meyer, D. (2014). Candidates for Antidepressants: Assessing a history of early life stressors CounselingVistas. Retrieved from http://www.counseling.org/docs/defaultsource/vistas/article_65.pdf?Sfvrsn=8 Nicolas, G., Desilva, A., Prater, K., & Bronkoski, E. (2009). Empathic family stress as a sign of family connectedness in Haitian immigrants. Family Process, 48, 135–150. Olfson, M., King, M., & Schoenbaum, M. (2015). Benzodiazepine use in the United States. JAMA Psychiatry, 72, 136–142. Poon, S., Sim, K., & Baldessarini, R. (2015). Pharmacological approaches for treatment-resistant bipolar disorder. Current Neuropharmacology, 13, 592–604. Smith, T., Weston, C., & Lieberman, J. (2010). Schizophrenia (maintenance treatment). American Family Physician, 82, 338–339. Weitz, E., Hollon, S., Twisk, J., et al. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs. pharmacotherapy: An individual patient data metaanalysis. JAMA Psychiatry, 72, 1102–1109.

Adlerian Family Therapy Erin J. Schuyler and Paul Rasmussen Adler Institute, Columbia, SC, USA

Adlerian Family Therapy

and the nature of goal-oriented behavior. Adler’s work also underscores the importance of community feeling and the necessity of a cooperative attitude among community members. He recognized that individuals are socially embedded organisms each striving to enhance quality of life while overcoming states of burden and unpleasantness (Adler 1935). Adler recognized the importance of early childhood experiences in setting the foundation of the individual’s style of life, including the establishment of personal convictions, beliefs, feelings, and values. Adler, along with his students and colleagues, established over thirty Child Guidance Clinics throughout the area of Vienna, Austria, during the early decades of the twentieth century (Dreikurs 1958). He welcomed the general public to come for assistance with family matters and to observe the practice of AFT. By 1934, Hitler’s Nazi party had eradicated these clinics (Dreikurs 1958; Christensen 2004) and what was a building movement in Individual Psychology was stalled for many years. To escape the Nazi occupation, Adler and many of his followers left Austria, many immigrating to the United States. Adler himself intended a move to New York City but died of a heart attack while lecturing in Scotland in 1937 prior to his permanent move to the United States.

Prominent Associated Figures Alfred Adler, Rudolf Dreikurs, Ray Lowe, Oscar Christensen, Bronia Grunwald, William and Mim Pew, Don Dinkmeyer, Jane Nelson, Michael Popkin, Frank Walton, Raymond Corsini, Manford Sonstegard, and James Bitter.

Introduction

Theoretical Framework

Alfred Adler (1870–1937) was one of the first psychiatrists to use a systemic approach in psychotherapy (Carich and Willingham 1987). Adler pioneered a holistic approach to therapy highlighting the complexities of family dynamics

Basic principles of AFT were derived from The Individual Psychology of Alfred Adler (Ansbacher and Ansbacher 1956). These assumptions about human nature are reflective of socially embedded individuals whose actions, decisions, and

Adlerian Family Therapy

psychological movement have purpose and meaning (Dinkmeyer et al. 1979). Law of movement. Adler argued that movement is the most important aspect of life; when movement ends, life ends. Movement is reflected in how one strives for feelings of worth and security. Feelings of validation emerge from one’s sense of value, satisfaction, and status. Each individual within a family strives to discover sources of worth and validation by developing strategies for procuring positive outcomes and ways to overcome challenges. Purposive behavior/teleology. Movement is goal-oriented. The term teleology refers to the striving for optimal existence that characterized all living organisms. As each self-determined goal is subjective, behavior is purposeful without necessarily being conscious and intentional. Mistaken beliefs are impacted by this movement and influence an individual’s behavior. Holism. AFT is a holistic approach focusing on the totality of the individual and the totality of the family unit. This includes biological factors, personal perceptions and unique interpretations, and the interactions between the family members, not excluding the impact of influences outside of the family such as their social community. Phenomenology. Reality is shaped by an individual’s interpretation of the world. An individual’s view of life is subjective and beliefs and opinions are not required to match the view of others. Clashes occur when the interpretations and expectations of one conflict with those of another. Family constellation. Each member of a family influences the lives of each other. The constellation of the family includes parents, children, extended family members, and other care providers. Understanding a family’s constellation provides information of each person’s position and role within the family. While we accept the differences as only tendency rather than absolute, Adler pointed out that oldest children tend to be more traditional and conservative and are more inclined to follow established rules and satisfy the expectations of authority figures. Second born children tend to be less concerned with power and tend to be more competitive and ambitious. Middle children often feel lost in their position

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and become concerned with issues of fairness; may feel cheated by the circumstances of life. The youngest tends to be more dependent, sociable, and are often the most pampered while finding their niche apart from older siblings. The only child shares characteristics of the oldest, yet tends to be more pampered and may have difficultly cooperating with others. Because age differences and gender differences can impact the influence of birth order, psychological birth order is thought more important that ordinal birth order. Discipline. Children learn best by way of logical and natural consequences; consequences that are related in no unambiguous or indirect way to the misdeed. The alternative is arbitrary consequence, such as physical discipline, which leads to relationship problems and fails to meet the objective of teaching discipline. Dreikurs (1967) recognized that children, as well as adults, often garner validation and relief from burden via the quest for attention, power, revenge, and via displays of inadequacy. While these motives often lead to some degree of validation and some relief from burden, lack of cooperation and contribution create problems for the individual and too often for the individual’s community (e.g., family and later perhaps school).

Populations in Focus Adlerian-based parent education (child-guidance) and AFT is focused on helping care providers meet the task of raising children who are prepared to meet the demands of living with others in a civilized society. While parents cannot control a child’s behavioral choices, they are leaders responsible for creating a cooperative family atmosphere characterized by encouragement, cooperation, and accountability.

Strategies and Techniques Used in Model AFT is primarily educational, assuming that problems emerge because members of the family are discouraged about their place in that family and

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have embraced strategies that are optimally counterproductive. Forming a relationship. The therapist generally interviews parents without children present. Supporting parents as leaders of the family, family constellation and routines are explored. During the parent interview, rapport is built by demonstrating a relaxed interactional dialogue, a friendly and open demeanor and the display of empathy and understanding concerning the family’s situation. This collaborative approach models respect, optimism, and encouragement among family members. Similarly, children are then interviewed to gain insight on their collective and individual perspectives of the family system. Psychological investigation. The therapist continues to collect pertinent facts among family members and focuses on the current situation. The therapist observes and assesses each individual’s place and role within the family constellation. Psychological birth order (vs. ordinal order), roles adopted within the family, family values, hierarchical patterns, and individual niches are considered. Exploring each family member’s style of movement within and outside the family provides valuable information that guides the next phase of therapy. Disclosure/interpretation. A working hypothesis is derived by examining each member’s style of behavior and contribution to the family system. It is essential to address the hidden goals of both parents and children and identify the misdirected goals, while promoting cooperation among family members. Parents are encouraged to consider the motives behind a child’s behavior, underscoring the child’s desire to belong and feel of value. Through appropriate interpretation and subtle confrontation, family members are able to develop insight concerning their motives and harmony-defeating behaviors. Reorientation. The final phase encourages individuals to take action and apply what they have discovered about themselves. Self-awareness will ultimately improve during therapy; however, actual change occurs outside of sessions as family members engage with each other. They are encouraged to reorient their goals and decision-making process

Adlerian Family Therapy

and move towards fostering positive interactions between one another. Reorientation requires consideration of alternative beliefs, attitudes, behaviors, and goals that are both realistic and effective. Children will learn to take on responsibilities and complete unpleasant tasks while cooperating with others. Parents model respect by allowing children to make choices and face logical and natural consequences of those choices. The parents are encouraged to withhold criticism, ridicule, coercion, and harshness. An effective therapist educates as necessary and continually encourages. The therapist assigns activities that build on the strengths of each family member and reveals the counter-productive motives.

Research About the Model Numerous studies have researched elements of Adlerian theory, including encouragement, birth order, social interest, and early recollections (Carlson et al. 2006; Evans et al. 1997; Phelps et al. 2001; Watkins and Guarnaccia 1999; Watts and Shulman 2003; Wong 2015). Adlerian psychology is grounded in holistic, optimistic, purposeful, and socially embedded theories. These basic assumptions of Adlerian psychology and practice are woven throughout various therapeutic orientations, including cognitive-behavioral, positive psychology, multicultural theory, solutionfocused theory, and attachment theory. Moreover, practitioners who emphasize individual psychology display inherent qualities required throughout the therapeutic process, possess sophisticated set of interpersonal skills, offer adaptive explanation for discouragement, and adjust treatment as needed to fit the client’s goal (Anderson et al. 2009; Duncan et al. 2010; Neukrug 2010; Norcross 2011).

Case Example Tom, Susan, and their three children attend their first session. The therapist meets with parents to get their observations. They express primary

Adlerian Family Therapy

concerns with their middle son, Jonah, who is preforming poorly at school and is antagonistic with his sisters. Tom does most of the talking and describes difficulty managing his time at home and work; typically works 65 h a week and has minimal time to engage with his children. Tom notes that he relies on Susan to mange the children. Susan is responsible for much of the child rearing, and while she loves her role as a mother, she is overwhelmed with juggling family life and her own job. Susan works 35 h a week in addition to “making sure their household runs smoothly.” Parents agree that while their daughters are generally easy to manage, Jonah refuses to do homework, antagonizes his sisters, and talks back to his mother. It is noted by the therapist that Tom did most of the talking, despite being less involved with the children. This suggests a pattern of how men behave (dominant) and how women behave (dutiful and obedient). Interview with the children reveals they are here because their mom told them they were coming – a common response. Stacy, age sixteen, states the problem is not with her, but her brother. Jonah, age twelve, does not respond and is clearly unhappy being there. Beth, age eight, smiles and seems to think the whole endeavor to be entertaining. From this interaction, the therapist saw Stacy as the obedient, compliant child who also tends to be a bit bossy. Jonah, as a second born, has taken a different path to establish his independence; this includes acting dominant and rebuffing schoolwork. Beth has taken on the role of entertainer. The therapist evaluates family values, parenting style, and roles within the family constellation and provides observation/interpretation of the goals of each member. The therapist then offers observations and looks for signs of recognition to confirm or dismiss the observation. For Jonah, the therapist might offer the following observation: “You seem to have taken on the role of the man in the family when your dad is away and like to call your own shots, but I also wonder if you don’t do your homework

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because school work is your sister’s thing.” These observations question Jonah’s effort to assert power and his assumed inadequacy when it comes to school work. His belief as the only son is verbalized as “I should be in charge and should be smarter, but I can’t function at my sister’s level.” The therapist pays attention to each child’s reaction to the interpretation. For Jonah, he discloses feeling more pressure than his sisters to do well in school and makes up for it by acting out. The therapist also comments on the frustration that Stacy is feeling given she does well at school, tries to be helpful at home, and often feels like her efforts are unappreciated. Stacy appreciates that her efforts are finally acknowledged. The therapist also comments on Beth’s curiosity about what all the fuss is about. She smiles. Understanding the motivation behind misbehavior allows opportunities to encourage reorientation. Together, the therapist and family members offer suggestions and realistic goals. The therapist works with Tom and Susan to equalize the power balance within the family and to create logical consequences for Jonah should he not complete homework. Tom agrees to set special time aside for each child throughout the week. Susan is more aware of Stacy’s frustration and gives her some personal time to spend with friends. Goals are now aligned for this family. Until the next session, each member will be encouraged to take on responsibility of meeting their tasks, respecting the differences everyone experiences, cooperating with each other as they navigate new behavioral choices, and to be courageous as their family adapts and reorients to new methods of thinking and behaving.

Cross-References ▶ Family Rules ▶ Family Structure ▶ Modeling in Couple and Family Therapy ▶ Parenting Skills Training in Couple and Family Therapy

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References Adler, A. (1935). Fundamental views of individual psychology. International Journal of Individual Psychology 1(1), 5–8. Retrieved from https://journal-ofindividual-psychology.scholasticahq.com/ Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A. (2009). Therapist effects: Facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology, 65, 755–768. https://doi.org/10.1002/jclp.20583. Ansbacher, H. L., & Ansbacher, R. R. (1956). The individual psychology of Alfred Adler. New York: Basic Books. Carich, M. S., & Willingham, W. (1987). The roots of family systems theory in individual psychology. Individual Psychology, 43(1), 71. Retrieved from https://journal-ofindividual-psychology.scholasticahq.com/ Carlson, J., Watts, R. E., & Maniacci, M. P. (2006). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association. Christensen, O. C. (2004). Adlerian family counseling (3rd ed.). Minneapolis: Educational Media Corp. Dinkmeyer, D., Pew, W., & Dinkmeyer, D. (1979). Adlerian counseling and psychotherapy. Monterey: Brooks. Dreikurs, R. (1958). The challenge of parenthood (rev. ed.). New York: Hawthorn. Dreikurs, R. (1967). Psychodynamics, psychotherapy, and counseling. Chicago: Alfred Adler Institute of Chicago. Duncan, B., Miller, S. D., Hubble, M., & Wampold, B. E. (Eds.). (2010). The heart and soul of change: Delivering what works (2nd ed.). Washington, DC: American Psychological Association. Evans, T. D., Dedrick, R. F., & Epstein, M. J. (1997). Development and initial validation of the encouragement scale (educator form). The Journal of Humanistic Education and Development, 35, 163–174. https://doi. org/10.1002/j.2164-4683.1997.tb00366.x. Neukrug, E. (2010). Counselling theory and practice. Brooks/Cole. Pacific Grove, CA. Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York: Oxford University Press. Phelps, R. E., Tranakos-Howe, S., Dagley, J. C., & Lyn, M. K. (2001). Encouragement and ethnicity in African American college students. Journal of Counseling & Development, 79, 90–97. https://doi.org/10.1002/ j.1556-6676.2001.tb01947.x. Watkins, C. E., & Guarnaccia, C. A. (1999). Introduction: The future of psychotherapy training: Psychodynamic, experiential, and eclectic perspectives. Journal of Clinical Psychology, 55(4), 381–383. https://doi.org/ 10.1002/(SICI)1097-4679(199904)55:43.0.CO;2-I. Watts, R. E., & Shulman, B. H. (2003). Integrating Adlerian and constructive therapies: An Adlerian perspective. New York: Springer. Wong, Y. (2015). The psychology of encouragement: Theory, research, and applications. The Counseling Psychologist, 43(2), 178–216. https://doi.org/10.1177/ 0011000014545091.

Adolescents in Couple and Family Therapy Thomas L. Sexton FFT, Bloomington, IN, USA

Name of Family Form Adolescents in Families

Introduction The systemic approach of couple and family therapy has always viewed adolescents as a central part of how families function, struggle, and are able to ultimately make successful clinical changes. Life cycle models of family development suggest that the stable relational patters established in families can be disrupted as younger children become adolescents. Changing adolescent behavior and the ability of the family relational system to adapt can be critical stress points for families. In some cases, adolescent behavior and the resulting reactions from parents create family conflict, negativity, and withinfamily blame that make it difficult for families to successfully solve daily problems. In some cases, adolescent behavior problems emerge overwhelming the family’s ability to manage. The behavioral expression of a youth’s struggles can result in violence, criminal behavior, and other consequences for not only the youth but also those in the families and community. This makes youth problems a systemic one affecting not only individuals and a likely time for community-based intervention. For adolescents and families, this usually means struggles with the justice system and educational system or involvement in the mental system. Adolescent behavior problems are one of the most difficult and pervasive of those faced by prevention and treatment specialists in the mental health field (Sexton and Alexander 2006). Schools and community-based mental health and counseling services face growing referrals of adolescents

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with a wide range of complex clinical problems. In fact, survey data gathered over the last decade suggest that the range of adolescent behavior problems including drug use/abuse, violence and school-related behavior problems, as well as suicide, depression, and anxiety are widespread in adolescents of all cultures, ethnicities, and from all communities (Sexton and Alexander 2006). Couple and family psychology brings a unique systemic perspective to understanding and helping youth and families (Sexton and Stanton 2016). The systemic theoretical models of CFP bring a unique relational perspective to understanding youth behavior as part of a larger family relational system that serves to both maintain problems and as the most likely place for lasting clinical intervention. The evidencebased family-focused clinical treatment models for adolescents, which are based on systemic theoretical principles, have strong research foundations of community-based studies in diverse real-life settings (Sexton et al. 2012; Sexton and Datachi 2014). As a result, CFP offers a unique platform for understanding adolescent behavior (whether problematic or not) and illuminating a pathway for successfully preventing and intervening to help families overcome struggles related to adolescence.

Description This chapter will briefly focus on the scope of issues facing adolescents and families, a systemic perspective for understanding family and youth clinical problems, and a brief overview of successful ways of clinically intervening with these complex issues. The goal is to illustrate the unique contribution of CFP-based theoretical models and clinical intervention programs that are specifically aimed at understanding and successfully helping families successfully deal with adolescent behavior problems. As such, the focus of this discussion is on the systemic and relational theoretical models understanding problematic youth behavior and the evidence-based treatment prevention and intervention programs for helping youth and families.

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Relevant Research Adolescent Behavior Problems The behavior problems of adolescents are of significant concern in schools, families, and for communities. Conduct problems of adolescents and children are the most common referrals to mental health clinics in the Western hemisphere (Sexton and Alexander 2006). Youth who fall into the broader category of externalizing problems account for between one third and half of all child and adolescent clinic referrals (Kazdin et al. 1992; Sexton et al. 2005). One perspective in understanding problematic adolescent behavior is the individually focused diagnostic approach. From this perspective adolescent behavior problems are often described as adolescent-focused. There are two broad categories: internalizing and externalizing problems. Internalizing disorders are problems internally directed and include clinical symptoms: anxiety, withdrawal, and depression. Internalizing disorders are problems internally directed and include clinical symptoms which are anxiety, withdrawal, and depression. These adolescents are easily overlooked in families, schools, and communities; however, the impact of internalizing problems in adolescents is signification in regard to later mental health adjustment, school success, peer struggles, and even teen suicide. In addition, internalizing problems of adolescent can set a pattern of psychological and behavioral functioning that becomes a lifelong pattern of struggle. Externalizing disorders are those directed to others and the environment. They include oppositional, hyperactive, aggressive, and antisocial behaviors. Numerous psychiatric diagnostic categories encompass these areas including attentiondeficit and disruptive disorders. Youth referred to the mental health and juvenile justice systems are most likely to be ones who fall into the externalizing behavior disorders category (cite the other chapter). Early-onset (childhood onset) problems that begin in early childhood escalate into more violent behavior later. Only about 20–40% of the male adolescent in this category become serious offenders later in life. Later-onset (adolescent onset) problems that are not there in younger life

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are there to appear in adolescent years. Between 60% and 80% of youth these youths are later identified as serious offenders. A third, frequently overlooked group are at risk adolescents. The problems experienced by youth who do not meet the criteria for either internal or externalizing behavior problems may engage in problem behaviors that put them at risk for becoming involved in the mental health or juvenile justice system or to experience future psychiatric problems. These youths might be involved in truancy, vandalism, stealing, drug use, bullying, running away from home, etc. These data led Kazdin (2018) to suggest that prevalence rates for youth behavior problems substantially underestimate the scope of the existing problem. It is important to understand these adolescents because this is the population toward which prevention efforts can be directed to prevent the internalizing and externalizing behavior patterns. Equally troubling are the significant number of adolescents in need of mental health treatment. Epidemiological studies suggest that between 17% and 22% of adolescents suffer from a significant developmental, emotional, and/or behavioral problem (Kazdin and Whitley 2003). High rates of mental disorders also exist among youth involved in the juvenile justice with an estimated 50–80% of delinquent adolescents meeting the criteria for a mental disorder such as conduct- or substance-related disorders (Kazdin 2018). The economic is significant. Each year, an estimated 600,000 youth cycle through detention centers, with more than 70,000 youth in a juvenile correctional setting on any given day. Generally, though, involvement in the juvenile justice system has been shown to have long-term detrimental effects and makes youth more prone to future antisocial behavior or criminal activity. Adolescents in the juvenile justice and mental health systems alone account for billions of dollars in costs to taxpayers and communities (Elliott 1998). Family-Based Treatment Approaches for Adolescent Problems Family therapy plays a central role in the successful treatment family conflict and the resulting youth behavior problems. Probably more than in

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any other area of psychology, the domain of adolescent behavior problems has seen the development, maturation, and growth of a number of successful “evidence-based” treatment programs (Sexton et al. 2011). Of the prevention and treatment programs options currently available the outcomes suggest that, when implemented with model fidelity and clinical competence that youth and families can change drug use and abuse problems, reduce violence, less frequently enter the justice system, and when they do, improve to the degree that they can successfully function in schools, with peers, and in communities (Sexton et al. 2012; Sexton and Datachi 2014). Evidence-based treatment and prevention programs have also been successfully implemented in local communities and some across entire statewide systems of care with impressive results. The evolution of evidence-based prevention and treatment programs for adolescent behavior problems fits within a broader movement of evidence-based model development in medicine, psychology, and other social services (Sexton et al. 2011). There are many different prevention and treatment programs in the professional literature (Elliott 1998 estimates over 1000); however, few have enough external evidence to suggest that they are effective. The most effective are family-based or family therapy intervention programs that are central to CFP.

Special Considerations for Couple and Family Psychology There are two primary implications of the research on adolescents and adolescent problems and effective clinical intervention programs: youth problems are significant, and there are wellestablished intervention programs that work better than nonspecific approaches (Sexton et al. 2012); and to be effective, it is important to take a systemic/relational view of the family functioning and clinical problems. Taking a Multisystemic Perspective It is a challenging task to identify and describe youth behavior problems because to a certain

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extent, externalizing behaviors is part of the normal developmental trajectory of the youth. Oftentimes these children are simply labeled as having “dysfunctional” behavior. However, it should be recognized that they actually have very complex behavioral profiles and are undoubtedly experiencing a wide range of developmental, emotional, and behavioral problems. For example, part of normal adolescent development includes fighting, withdrawing, disagreeing, and standing up to authority figures. While helpful in understanding community prevalence rates, this approach is limited in its individual orientation and lack of help in identifying clinical intervention strategies. They are also limited in their individually focused scope that often misses factors in the large social context, within family factors, or normal family development (Sexton and Alexander 2006). For example, it is not easy to determine if an oppositional youth is going through normal adolescent developmental phases or if those behaviors represent the onset of more significant issues. Does fighting, withdrawing, disagreeing, and standing up to authority figures represent behaviors that are often part of normal adolescent development? Identification is made even more complex by the various systems in which with similar behavior problems are identified and the different labels given by these systems for similar behaviors (e.g., child welfare, juvenile justice, or mental health). What might be considered criminal behavior in the juvenile justice system is often seen as a mental health disorder in the community mental health center. While the acting-out behaviors exhibited by these children appear quite similar, each case is unique in that the behaviors occur at very different times in the biological development of the youth and within very different environmental and family contexts. CFP has offered a unique and comprehensive multisystemic approach to understanding adolescent behaviors that both help identify how problems emerge and where the clinical intervention points may be to successfully help family relational system adjust and adapt. A CFP, multisystemic approach considers the biological, family, and social factors that help explain both

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the origins and the facilitating features of these chronic behavioral problems. In this view, it is the risk and protective factor that operates within and around a core family relational system that serves as the most comprehensive way to understand problematic adolescent behavior. Risk and protective factors. Risk and protective factors approach, based on an established body of etiological research, integrates the epidemiological research into a developmental and multisystemic perspective that enhances successful intervention (Sexton and Turner 2010). Risk and protective patterns describe alterable behavior, rather than “labeling” the youth or family with characteristics that become stable and enduring. This model helps organize the complex information from the multiple systems (individual, family, and social). It is a useful way of thinking about problems because it describes them through a “probability lens” (determining the likelihood of problems), rather than in terms of causal relationships. The risk and protective factors model can be helpful in organizing critical information, such as how the multiple systems function in regard to difficulties as well as strengths. It allows the interventionist to identify which factors to develop, which to work around, and which to attempt to decrease. The risk and protective factor approach helps define the outcomes of prevention and therapy for children with these types of problems. Many risk factors are not changeable (e.g., unemployment, biological predisposition, and relational histories). Thus, successful intervention with adolescent behavior problems involves building protective factors to overcome some of the more static risk factors. In this way, intervention focuses on building the resiliency of the child, parents, and family. A comprehensive risk-and-protective-factor view identifies risk and protective factors in each of the three areas: individual factors, family factors, and social factors. These include (1) child risk variables, including a difficult temperament or high rate of disruptive, impulsive, inattentive, and aggressive behaviors (Campbell and Ewing 1990); (2) parenting variables, including ineffective parenting strategies and negative attitudes (Patterson and Stouthamer-Loeber 1984); and

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(3) family variables, apart from the parent–child relationship, which include parental psychopathology, marital factors, socioeconomic factors, and other stressors (Webster-Stratton 1990). The central role of families. A systemic perspective would suggest that within family, risk and protective factors are critical to understand adolescent behavior (Sexton and Turner 2010). It is well-accepted that families characterized by conflict (anger and aggression), deficient parenting, and family interactions that are cold, unsupportive, or neglectful contribute to childhood psychopathology (Knutson et al. 2004). For example, as youth struggle, in what are many times very normal ways, the relational system around the youth and the family begins to strain the individual’s and family’s capacity to manage outside stressors. The decline of these abilities results in changes in the relational systems that develop around the specific behaviors of the youth. Finally, these stabilized relationships are connected to the chronic nature of the youth’s conduct problems. Furthermore, family dynamics that is unresponsive or rejecting of children likely exacerbates children’s genetic or temperamental diathesis to the development of conduct disorders and aggression (Repetti et al. 2002). Protective parenting factors include the quality of maternal instructions, frequent joint activities, monitoring, structuring the child’s time, and constructive discipline strategies (Hutchings and Lane 2005). Intervention Programs The sections below are intended to be an overview of the range of types of intervention types of family therapy-based interventions for helping with adolescent behavior problems, not a systematic review. As noted above, the goal is to illustrate the central role that CFP models play in the treatment of these difficult issues. For a comprehensive overview, please note the references below. It is also important to note that the lack of research evidence does not mean that a clinical intervention approach does not work. Couple and family therapy has an impressive research foundation demonstrating its effectiveness (Sexton et al. 2012). Common factors, or those core elements of any good therapy, are particularly

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important when working with adolescents. The CFP evidence-based approaches briefly described below illustrate a wide range of reliable, communitytested programs that, when implemented with fidelity, result in positive changes of youth and families. Early prevention approaches. Certain evidence-based prevention programs have repeatedly demonstrated the critical importance of later adolescent behavior on the early family relationship system and parenting activities. These early prevention efforts are remarkable in that they show that changes in the family relational system during the infancy period as well as preschool years have demonstrated a considerable reduction in adolescent behavior problems, particularly for families at greater social risk (e.g., related to low SES and unmarried mothers, weak parental involvement, low educational attainment, marital discord) (Bor 2004; Olds et al. 1998). Two best practices for the prevention of adolescent conduct problems are early childhood home visitation and the Triple P (“Positive Parenting Program”). Nursing Home Visitation Program is designed both to promote maternal health-related behaviors early in the child’s life, as well as to promote maternal long-term self-development through family planning, educational achievement, and participation in the work force. At 15-year followup, child outcomes (in adolescence) of the nurse home visitation program were observable: fewer episodes of running away from home, fewer arrests and convictions (e.g., recurrent truancy, destroying parents property), fewer violations of probation, fewer sexual partners, and less frequent engagement in smoking and alcohol consumption (Olds et al. 1998). Given these clinical outcomes, it is clear that changing the family relational environment early in life can have an impact on later adolescent certain antisocial behaviors. Parent skills training. A second set of categories of clinical interventions focus on helping parents with skills to change the ways in which they work with their adolescents. Hutchings et al. (2004) identified six essential components of parenting interventions for the treatment of conduct disorder: (1) the rehearsal of new parenting skills, (2) the teaching of management principles rather

Adolescents in Couple and Family Therapy

than techniques, (3) the practice of new parenting strategies at home, (4) the teaching of both (nonviolent) sanctions for negative behavior and strategies to build positive relationships, (5) the addressing of difficulties in the parental relationship, and (6) the early delivery of interventions, as later interventions are less effective. Psychoeducational approaches. Psychoeducation treatment use information and education to change youth behaviors with the intent to prevent adolescent behavior problems. For example, the Life Skills Training Program (LST) targets middle- and junior high school youth in the prevention of tobacco, alcohol, and marijuana use and abuse through the development of skills that reduce the risk of engaging in high-risk activity (Botvin and Kantor 2000; Botvin 1998). The program consists of three components: drug-related knowledge and skills, personal self-management, and general social skills. The drug-related knowledge and skills component targets knowledge and attitudes related to drug use through drug education, discussion of norm expectations related to drug use, and the teaching of skills to resist media influences as well as peer and social pressures related to drug use. The personal selfmanagement component targets the development of skills in decision-making, problem-solving, selfcontrol, and self-improvement, and the general social skills component targets the development of skills in communication. Family-Based Treatment Models There are number of family-based and family therapy treatment models that are also central to the successful treatment to adolescent behavior problems. For example, trauma-focused cognitive behavioral therapy is designed for adolescents who experience traumatic events (e.g., child abuse, parental divorce, out-of-home placement, family violence) for they are prone to several mental health problems and to engaging in highrisk behaviors. Specific interventions that target the effects of trauma on the youth and their families are needed to foster resilience and decrease the risk of future mental health problems. TF-CBT that has strong empirical support to its effectiveness in treating children and adolescents (aged

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3–18) and their families overcomes the experience of trauma. TF-CBT consists of 12–16 sessions delivered once a week. Multidimensional family therapy (MDFT ) is a rigorously studied outpatient treatment that integrates family therapy, individual therapy, drug counseling, and multiple systems-oriented intervention approaches to treat adolescent drug abuse and related emotional and behavioral problems (Liddle et al. 2002). MDFT builds on knowledge derived from research on risk and protective factors related to youth substance abuse in formulating its assessment and intervention techniques. It targets multiple aspects of youth presenting problems through four interdependent modules that together form the adolescent’s psychosocial world, each of which contribute to maintaining the problematic behavior. Multisystemic therapy (MST) is systematic, manual-driven, family-based intervention for youths and families facing problems of juvenile delinquency, adolescent conduct disorder, and substance abuse (Henggeler et al. 1999). MST is an approach derived from social-ecological models of behavior, family systems, and social learning theories (Henggeler et al. 1993). Targets of change in MST include individual- and family-level behaviors, as well as outside system dynamics and resources like the adolescent’s social network. Treatment interventions are on an “as-needed” basis, focusing on whatever it takes to alter individual, family, and systems issues that contribute to the problem behavior. The typical treatment course for MST implementation ranges from 2 to 4 months. Multiple-level assessments of family and social systems functioning are embedded within the treatment protocol. Like FFT, MST has demonstrated outcomes with a wide range of adolescent externalizing disorders (conduct disorders, adolescent drug abuse, adolescent mental health issues), with families that represent diverse cultural and ethnic groups, in a number of contexts (Kazdin 1997; Sexton et al. 2012). Functional family therapy (FFT) is a clinical model that has evolved over the last 35 years built on a foundation of integrated theory, clinical experience, and empirical evidence (Alexander

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et al. 2013; Sexton and Turner 2010; Sexton and Stanton 2016). FFT is a well-developed clinical model designed to treat at-risk youth aged 11–18 with a range of maladaptive behaviors including delinquency, violence, substance use, risky sexual behavior, truancy, conduct disorder, oppositional defiant disorder, disruptive behavior disorder, and other externalizing disorders. The primary focus of treatment is on the family relational system with an emphasis on the multiple domains of client experience (cognition, emotion, and behavior) and the multiple perspectives within and around a family system (individual, family, and contextual/multisystemic). As a treatment program, FFT has produced successful outcomes with at-risk youth and their families. FFT is a short-term family therapy intervention that ranges from 8 to 12 1-h sessions for mild to moderate cases and up to 30 h of direct intervention for more serious situations. The program also works as a preventive measure in diverting the path of at-risk adolescents away from the juvenile justice or mental health systems (Alexander et al. 2000; Sexton and Turner 2010; Sexton and Alexander 2002). FFT has demonstrated outcomes with a wide range of adolescent problems, with families that represent diverse cultural and ethnic groups, in a number of contexts.

Conclusion CFP brings a unique multisystemic perspective to understanding adolescent behavior. This perspective is descriptive, relational, and family-based in which individual adolescent behavior is part of a larger relational system. The current treatment programs show remarkable success in successful intervention for substance use problems, behavior problems, and other mental health problems by working with and through families to enact longterm successful change. These approaches range from early prevention models to intense family therapy-based approaches. What each share is a grounding and a multisystemic way of understanding these complex clinical issues.

Adolescents in Couple and Family Therapy

References Alexander, J. F., Pugh, C., & Sexton, T. L. (2000). Functional family therapy. In D. S. Elliott (Ed.), Blueprints for violence prevention (Book 3) (2nd ed.). Boulder: Center for the Study and Prevention of Violence, Institute of Behavioral Science, University of Colorado. Alexander, J. F., Waldron, Robbins, M. & Need, A. (2013). Functional family therapy for adolescent behavior problems. American Psychological Association: Washington, D.C. Bor, W. (2004). Prevention and treatment of childhood and adolescent aggression and antisocial behavior: A selective review. Australian and New Zealand Journal of Psychiatry, 38, 373–380. Botvin, G. J., & Kantor, L. W. (2000). Preventing alcohol and tobacco use through life skills training. Alcohol Research & Health, 24(4), 250–257. Botvin, G. (1998). Preventing adolescent drug abuse through Life Skills Training: Theory, methods, and effectiveness. Social Programs That Work. 225–257. Campbell, S. B., & Ewing, L. J. (1990). Follow-up of hardto-manage preschoolers – adjustment at age 9 and predictors of continuing symptoms. Journal of Child Psychology and Psychiatry and Allied Disciplines, 31(6), 871–889. Elliott, D. S. (Ed.). (1998). Blueprints for violence prevention. Boulder: Blueprints Publications/University of Colorado, Center for the Study and Prevention of Violence. Frick, P. J. (1998). Conduct disorders and severe antisocial behavior. New York: Plenum. Henggeler, S. W., Henggeler, G. B., Melton, L.A. Smith, S. K. & Schoenwald, J. H. (1993). Hanley Family preservation using multisystemic treatment: Long-term follow-up to a clinical trial with serious juvenile offenders. Journal of Child and Family Studies, 2, pp. 283–293. Henggeler, S. W., Henggeler, S. G., Pickrel, M. J. (1999). BrondinoMultisystemic treatment of substance abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability. Mental Health Services Research, 1, 171–184. Hutchings, J., Gardner, F., & Lane, E. (2004). Making evidence-based interventions work. In C. Sutton, D. Utting, & D. Farrington (Eds.), Support from the start: Working with young children and their families to reduce the risks of crime and antisocial behaviour (pp. 69–79). Nottingham: Department for Education and Skills. Collaborative, www.tacinc.org. Hutchings, J., & Lane, E. (2005). Parenting and the development and prevention of child mental health problems. . Current Opinion in Psychiatry, 18(4), 386–391. Kazdin, A. E. (1997). Practitioner review: Psychological treatments for conduct disorder in children. Journal of Child Psychology and Psychiatry, 38, 161–178. Kazdin, A. E. (2004). Psychotherapy for children and adolescents. In M. Lambert (Ed.), Bergin and

Adult Attachment Interview Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 543–589). Hoboken: Wiley. Kazdin, A. E. (2018). Innovations in psychosocial interventions and their delivery: Leveraging cutting-edge science to improve the world's mental health. Oxford University Press. Kazdin, A. E., Siegel, T. C., & Bass, D. (1992). Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. Journal of Consulting and Clinical Psychology, 60(5), 733–747. Kazdin, A. E., & Whitley, M. K. (2003). Treatment of parental stress to enhance therapeutic change among children referred for aggressive and anti- social behavior. Journal of Consulting and Clinical Psychology, 71, 504–515. https://doi.org/10.1037/0022-006x.71.3.504 Knutson, J. F., DeGarmo, D. S., & Reid, J. B. (2004). Social disadvantage and neglectful parenting as precursors to the development of antisocial and aggressive child behavior: Testing a theoretical model. Aggressive Behavior, 30, 187–205. Liddle, H. A., Bray, J. H., Levant, R. F., & Santisteban, D. A. (2002). Family psychology intervention science: An emerging area of science and practice. In H. A. Liddle, D. A. Santisteban, R. F. Levant, & J. H. Bray (Eds.), Family Psychology: Science-Based Interventions (pp. 3–15). Washington, DC: American Psychological Association. Olds, D., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Lucky, D., Pettitt, L., Sidora, K., Morris, P., & Powers, J. (1998). Long-term effects of nurse home visitation on children’s criminal and antisocial behavior: 15 year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280(14), 1238–1244. Patterson, G. R., & Stouthamer-Loeber, M. (1984). The correlation of family management practices and delinquency. Child Development, 55(4), 1299–1307. Repetti, R. L., Taylor, S. E., & Seeman, T. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128(2), 330–366. Sexton, T. L. (2015). Functional family therapy: Evidence based, clinical specific, and creative clinical decision making. In T. L. Sexton & J. Lebow (Eds.), Handbook of family therapy (pp. 250–270). New York: Routledge. Sexton, T. L., & Datachi, C. C. (2014). The development and evolution of family therapy research: Its impact on practice, current status, and future directions. Family Process, 53(3), 415–433. https://doi.org/10.1111/ famp.12084. Sexton, T. L., McEnery, A., & Wilson, L. R. (2011). Family research: understanding families, family-based clinical interventions, and clinically useful outcomes. In J. Thomas & M. Hersen (Eds.), Understanding Research in Clinical and Counseling Psychology. Erlbaum: New Jersey.

49 Sexton, T. L., & Stanton, M. (2016). Systems theories. In J. Norcoross & G. Vandenbos (Eds.), APA handbook of clinical psychology. Washington, DC: APA. Sexton, T. L., Alexander, J. F., & Mease, A. C. (2003). Levels of evidence for the models and mechanisms of therapeutic change in couple and family therapy. In M. Lambert (Ed.), Handbook of psychotherapy and behavior change. New York: Wiley. Sexton, T. L., Gillman, L., & Johnson, C. (2005). Evidence based practices in the prevention and treatment of adolescent behavior problems. In T. P. Gullotta & A. Gerald (Eds.), Handbook of adolescent behavioral problems: Evidence-based approaches to prevention. New York: Springer. Sexton, T. L., & Alexander, J. F. (2002). Family based empirically supported interventions. The Counseling Psychologist, 30(2), 1–8. Sexton, T. L., & Alexander, J. F. (2006). Functional Family Therapy for Externalizing Disorders in Adolescents. In J. Lebow (Ed). Handbook of Clinical Family Therapy (pp. 164–194). New Jersey: John Wiley. Sexton, T. L., Schuster, R., & Peterson, H. (2007). The treatment and prevention of oppositional defiant and conduct disorders in children. In T. P. Gullotta & A. Gerald (Eds.), Handbook of child behavior disorders. New York: Springer. Sexton, T. L. (2012). The challenges, focus, and future potential of systemic thinking in couple and family psychology. Couple and Family Psychology: Research and Practice, 1(1), 61–65. https://doi.org/10.1037/a0027513 Sexton, T. L., & Turner, C. T. (2010). The effectiveness of functional family therapy for youth with behavioral problems in a community practice setting. Journal of family psychology, 24. Sexton, T. L., Datachi-Phillips, C., Evans, L. E., LaFollette, J., & Wright, L. (2013). The effectiveness of couple and family therapy interventions. In M. Lambert (Ed.), Handbook of psychotherapy and behavior change. New York: Wiley. Webster-Stratton, C. (1990). Stress: A potential disruptor of parent perceptions and family interactions. Journal of Clinical Child Psychology, 19, 302–312.

Adult Attachment Interview Mary A. Fisher Mary Fisher Psychotherapy, PLLC, Salt Lake City, UT, USA

Name and Type of Measure Adult Attachment Interview (AAI).

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Adult Attachment Interview

Introduction

Description of Measure

The AAI is a semistructured interview and scoring system developed to assess adult- and adolescent-attachment based on congruence between semantic and episodic memories. To illustrate, the semantic descriptor “loving” about an interviewee’s childhood relationship with his mother is incongruent with the episodic memory of being punished for failing to take out the trash, but is congruent with the memory of being surprised that she comforted the interviewee for failing a history exam. The AAI contains 18 questions that probe autobiographical childhood memories, descriptions of relationships with primary caregivers, and experiences of loss and trauma. Trained coders analyze responses for coherence of discourse, comprised of natural conversational maxims, including veracity, concision, relevance, and order (Grice 1975), resulting in assignment on one of the continuous rating scales of attachment: Secure-Autonomous (F). Transcripts are coherent and collaborative, evincing a valuing of attachment, and offering objective descriptions of experiences, favorable or not. Insecure-Dismissive (Ds). Not coherent, excessively brief, characterized by dismissal of attachment experiences, and semantic descriptors of childhood relationships with parents that are insufficient or contradictory. Insecure-Preoccupied (E). Not coherent, excessively long, entangled speech, wherein the interviewee seems passive, frightened, or angry. Unresolved (U). Superimposed on the aforementioned classifications if the interview contains evidence of unresolved experiences of trauma or loss (Hesse 2008).

The AAI evolved from research applications to a tool for use in clinical work. Particularly relevant to couple and family therapy, the AAI identifies how early relationship patterns inform current relational functioning, both in parenting and romantic relationships. It reveals the existence of important losses and traumatic experiences that might otherwise go unreported. In contrast to self-report measures, the AAI reveals unconscious states of mind. It also may be used to assess therapeutic outcomes. Finally, the AAI informs decisions regarding custody and foster placement (Steele and Steele 2008). There are two scales: Experience and State of Mind. Experience scales include inferred parental behavior during childhood, drawn from semantic descriptors. State-of-Mind scales assess interviewees’ contemporary state of mind, which denotes mental representations of attachmentrelated experiences and are drawn from episodic memories (George et al. 1984, unpublished manuscript).

Developers The Adult Attachment Interview was originally developed by Carol George, Nancy Kaplan, and Mary Main in (1984).

Psychometrics In a meta-analysis of a nonclinical sample of mothers, the classification distribution revealed 58% secure/autonomous, 24% dismissing, 18% preoccupied, with approximately 19% unresolved, with nonclinical fathers similarly distributed. Unresolved and dismissing categories were overrepresented in samples with low socioeconomic backgrounds. Only 8% of clinical samples were secure (van IJzendoorn and BakermansKranenburg 1996), highlighting a link between attachment and mental health. Seventy-eight percent stability (kappa = .63) was found across the three attachment classifications (Bakemans-Kranenburg and van IJzendoorn 1993) and is echoed in studies over 18-month and 4-year spans (Crowell et al. 1996; Ammaniti et al. 1996). In an assessment of discriminant validity, AAI classifications were independent of

Adult Attachment Interview

intelligence, social desirability, and autobiographical memory. Reliability of classifications was high across coders and over time for the three main categories (78%), though less so for the unresolved category (Bakermans-Kranenburg and van IJzendoorn 1993).

Example of Application in Couple and Family Therapy Tania, a successful attorney, presented to therapy stating, “Mothers should like their children. I don’t,” and described 28-month-old Jemma as incompetent. During the initial session, Jemma played quietly alone in the corner, frequently giving wary, sideways glances at her mother. Jemma did not pursue her mother, nor cry, when Tania left to use the restroom, and when Tania returned, Jemma continued her subdued play. Tania’s AAI included notable incongruence between semantic descriptions of childhood relationships with her parents and episodic memories. For example, Tania described her relationship with her surgeon father as adoring. However, when providing illustrative instances of adoring, Tania recalled his refusal to help her with her science fair project, saying he had adult things to do. Tania proudly reported winning first place, stating, “I want Jemma to be successful.” On the AAI, a reliable coder found Tania’s state of mind regarding attachment to be dismissive (Ds). The AAI highlighted Tania’s idealization of her relationship with her father, which the therapist suspected belied disowned pains of rejection, and dismissal of the importance of attachment-related feelings. Initial interventions across four sessions involved asking her to play with Jemma, which she did begrudgingly and in a stilted manner, stating, “Playing isn’t my area of expertise.” These sessions saw Jemma carefully coloring in a coloring book, with Tania impatiently instructing, “Keep the colors inside the lines.” When given the choice, Tania always chose a structured board game. Jemma’s quiet, subdued demeanor persisted

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until session seven, when the coloring books and board games were removed from the office and, the dyad was again invited to play. Jemma was observed anxiously searching the selection of wooden blocks and figurines. When asked what Jemma was feeling, Tania retorted, “I guess playing isn’t her area of expertise, either.” Tania seemed irritated when pressed further to interpret Jemma’s emotions, moreso when asked to offer her own, and she questioned the efficacy of therapy, sighing impatiently, “I have a lot of important work to do.” When Tania was asked to describe her physical sensations, Tania revealed, “This is weird, but my stomach hurts, and my mouth is really dry. My heart is pounding. My joints ache.” The therapist offered, “Something happens for you when you see Jemma struggling to play competently.” Tania choked back tears and said, “I don’t know what’s going on, but I want to get the hell out of here.” Therapy continued productively over the course of 24 months, with Tania moving from the level of somatic complaints and criticism of Jemma, to feelings of anxiety and shame about Jemma’s competence, to finally accessing painful feelings of rejection by her father, and the anxious pressure to perform in order to gain connection with him. As she began to experience tender compassion for herself as a child, she concurrently viewed Jemma’s behavior more sensitively. Play in the dyad became more improvisational, relied less on structured activities, and most notably, included delight. Tania discontinued therapy but returned due to concerns about “repeating patterns” in her new romantic relationship. After 12 sessions and an additional administration of the AAI which was judged secure (F), therapy was terminated.

Cross-References ▶ Attachment Theory ▶ Attachment-Based Family Therapy ▶ Circle of Security: “Understanding Attachment in Couples and Families”

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Adult Child of Alcoholics (ACOA)

References

Synonyms

Ammaniti, M., Speranza, A. M., & Candelori, C. (1996). Stability of attachment in hildren and intergenerational transmission of attachment. Psychiatria dell-Infanzia e dell-Adolscenza, 63, 313–332. Bakermans-Kranenburg, M.J., & Van IJzendoorn, M.H. (1993). A psychometric study of the Adult Attachment Interview: Reliability and discriminant validity. Developmental Psychology, 29(5), 870–879. Crowell, J.A., Waters, E., Treboux, D., O’Connor, E., Colon-Downs, C., Feider, O., Golby, B., & Posada, G. (1996). Discriminant validity of the Adult Attachment Interview. Child Development, 67, 2584–2599. George, C., Kaplan, N., & Main, M. (1984). Adult Attachment Interview protocol. Unpublished manuscript, University of California at Berkeley. Grice, P. (1975). Logic and conversation. In P. Cole & J. Morgan (Eds.), Syntax and semantics. 3: Speech acts (pp. 41–58). New York: Academic. Hesse, E. (2008). The adult attachment interview: Protocol, method of analysis, and empirical studies. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed., pp. 552–598). New York, NY: Guilford Press. Steele, H., & Steele, M. (Eds.). (2008). Clinical applications of the Adult Attachment Interview. New York: The Guilford Press. van IJzendoorn, M.H., & Bakermans-Kranenburg, M. (1993). A psychometric study of the Adult Attachment Interview: Reliability and discriminant validity. Developmental Psychology, 29, 870–879. van IJzendoorn, M. H., & Bakermans-Kranenburg, M. (1996). Attachment representations in mothers, fathers, adolescents and clinical groups: A metaanalytic search for normative data. Journal of Consulting and Clinical Psychology, 64, 8–21.

ACOAs

Introduction Nearly 7.5 million children living in the United States have at least one parent with an alcohol problem (SAMHSA 2012). The impact of alcoholism on the family has been well documented (Vaught et al. 2013; Engels et al. 2004; Peterson et al. 1994), and emerging research continues to highlight the long-term effects on adult children of alcoholics (ACOAs*) (Haverfield and Theiss 2016; Werner and Malterud 2016; Sanchez-Roige et al. 2016). Experiences of children growing up in families with a parent abusing alcohol are subjective, yet research indicates that ACOAs* experience depression, anxiety, low self-esteem, difficulty with interpersonal relationships (Haverfield and Theiss 2014; McCoy and Dunlop 2016; Salvatore et al. 2016), as well as increased risk for intergenerational alcohol addiction (Cutler and Radford 1999). The formation of the Adult Children of Alcoholics (ACA) was in response to an observed need for adult children who were impacted by parental alcohol addiction and also to provide a place for individuals who were looking for support around shared experiences of dysfunction within the family (Adult Children of Alcoholics World Service Organization 2006).

Location

Adult Child of Alcoholics (ACOA) Jessica L. Chou1 and Bertranna A. Muruthi2 1 Queen of Peace Center, St. Louis, MO, USA 2 Marriage and Family Therapy Program, Virginia Tech - Northern Virginia Center, Falls Church, VA, USA

Name of Organization or Institution Adult Children of Alcoholics (ACA)

The ACA holds peer-led 12-step programming in locations throughout communities in the United States and internationally. Members are encouraged to complete the 12-step program, while providing support and discussing shared experiences of family dysfunction. Meetings can be attended in-person, online, and over the telephone (Adult Children of Alcoholics World Service Organization 2006). Individuals interested in finding a meeting can check the Adult Children of Alcoholics World Services Organization website for local meetings in their area.

Adult Child of Alcoholics (ACOA)

Prominent Associated Figures Adult Children of Alcoholics was founded in New York in 1978 by teenagers from AlaTeen (an extension of Al-Anon). Al-Anon is a peerled support group for individuals who are impacted by another person’s (i.e., family, friend, partner) alcohol use (Al-Anon Family Groups 2017). Tony A. is credited as the founder and author of the “laundry list,” comprised of 14 common behaviors of ACOAs. This document is known as the first ACA literature and the impetus for the development of the ACA. Jack E. has been credited with further extending the organization to California (Adult Children of Alcoholics World Service Organization 2006).

Contributions (Including What It Is Known for, Relevance to Couple and Family Therapy, and Mission and Values, Though not Presented in Separate Sections) The ACA organization is a 12-step recovery program adapted from the Alcoholics Anonymous steps [see ▶ “Alcoholics Anonymous, 12-Step Programs” chapter]. In addition to the 12-steps, ACA also adapted the 12 traditions from AA which provide guidelines on how to interact within the support group and with society as a whole. The ACA is built on two guiding characteristics: (1) purpose of the organization is for children who grew up in families with an alcoholic parent and (2) the focus is on the self and the inner child that developed as a result of parental alcohol addiction (Adult Children of Alcoholics World Service Organization 2006). The belief that children’s identity is formed in the context of interpersonal family relationships leads ACA to help adult children separate themselves from the identity of an alcoholic family (Adult Children of Alcoholics World Service Organization 2006). Cutler and Radford (1999) utilize Black’s (1990) conceptualization of four roles that are often filled by children impacted by parental alcohol addiction: (1) the hero, (2) the placater, (3) the adjuster, and (4) the acting

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out child. The hero child is best identified as being “overly responsible” (Cutler and Radford 1999, p. 150) and often taking on the role of the parent. While the placater can be viewed as having qualities consistent with wanting to mediate relationships, the adjuster role is associated with a neutral attitude of the child not caring. The acting out child is viewed as obtaining attention through undesired behaviors. As these roles have been part of the identity development process and reinforced by the family system for years, it is not uncommon that some traits are carried into adulthood (Cutler and Radford 1999). The ACA program can be a vital support systems for these shared experiences as ACOAs* may identify with one or more of the roles (Cutler and Radford 1999). The ACA prioritizes the individual by nurturing the inner child and focuses on the solution which is “to become your own loving parent” (Adult Children of Alcoholics World Service Organization 2006, p. 590). This is accomplished by allowing emotions developed in childhood to be expressed while an individual is working towards love and acceptance of the self (Adult Children of Alcoholics World Service Organization 2006). Intrapersonal introspection used by ACA can be reinforced in the therapeutic setting by clinicians. The whole family system is impacted by parental alcoholism (Haverfield and Theiss 2014; Vaught et al. 2013). Family functioning for ACOAs* has been identified as more destructive compared to nonalcoholic families indicated by passive communication patterns and hostile expressions of anger (Breshears 2015). Children who experience parental alcohol addiction are at high risk for following intergenerational patterns of alcohol use and other maladaptive behaviors (Cutler and Radford 1999). Marriage and family therapists must consider becoming familiar with the ACA and literature in order to ensure clinical work is complementary and not contradictory. Participation in the ACA can assist individuals in unpacking the development of identity within a dysfunctional family system among a peer support group that offers empathy and resources.

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Marriage and family therapists must consider the varied perspectives of addiction and the consequential degrees of relational conflict that are a result of growing up in a family impacted by addiction. For example, some ACOAs* acknowledge that alcoholism is a disease and that has aided in maintaining a relationship with their parent(s), while others have utilized different perspectives and experienced their parents as choosing alcohol over the family and have chosen to cut parental ties (Jarvinen 2015). Historically, literature has focused on childhood experiences and adult characteristics of ACOAs*, omitting emphasis on valuable tools and resources to support this population. In addition to participation in the ACA, the role of forgiveness has been key in reconciliation of some parental relationships among ACOAs* (Breshears 2015). Though forgiveness will not be a tool for every ACOAs*, Breshears (2015) found that forgiveness among ACOAs*: (1) afforded individual person wellbeing, (2) assisted in reframing addiction as a disease, and (3) was supported by the recovery efforts of parents. Forgiveness focuses on interpersonal relationships, while the ACA program allows for intrapersonal discovery.

Cultural Considerations There are a variety of meeting types available for diverse populations (Adult Children of Alcoholics World Service Organization 2006). Yet, limited access or utilization of social services creates disparity within this population. Therapists must consider familial composition and substance use in the context of different cultural groups. For example, African American ACOAs* who had extended family and/or fictive kin support reported the relationship(s) positively impacted their self-esteem, well-being, and ability to solve problems (Hall 2008). Kin and fictive kin relationships can provide emotional support to the child when the parent with alcoholism is unavailable. When working with ACOAs*, marriage and family therapists can utilize ACA in conjunction with therapeutic services while considering contextual factors related to this population.

Adult Child of Alcoholics (ACOA)

Cross-References ▶ Addictions in Couple and Family Therapy ▶ Alcohol Use Disorders in Couple and Family Therapy ▶ Alcoholics Anonymous, 12-Step Programs ▶ Family of Origin ▶ Stages of Change in Couple and Family Therapy

References ACA WSO INC. (2006). Adult children of alcoholics/dysfunctional families world service organization, Inc. Torrance: Sixteenth Printing. Al-Anon Family Groups (2017). Retrieved 26 Jan 2017 from http://www.al-anon.org Breshears, D. (2015). Forgiveness of adult children toward their alcoholic parent. Qualitative Research Reports in Communication, 16(1), 38–45. https://doi.org/10.1080/ 17459432.2015.1086419. Cutler, H. A., & Radford, A. (1999). Adult children of alcoholics: Adjustment to a college environment. The Family Journal: Counseling and Therapy for Couples and Families, 7(2), 148–153. Engels, R. C., Vermulst, A. A., Dubas, J. S., Bot, S. M., & Gerris, J. (2004). Long-term effects of family functioning and child characteristics on problem drinking in young adulthood. European Addiction Research, 11(1), 32–37. Hall, J. C. (2008). The impact of kin and fictive kin relationships on the mental health of black adult children of alcoholics. Health & Social Work, 33(4), 259–266. Haverfield, M.C., & Theiss, J.A. (2014). A theme analysis of experiences reported by adult children of alcholics in online support forums. Journal of Family Studies, 20(2), 166–184. https://doi.org/10.1080/13229400. 2014.11082004. Haverfield, M. C., & Theiss, J. A. (2016). Parent’s alcoholism severity and family topic avoidance about alcohol as predictors of perceived stigma among adult children of alcoholics: Implications for emotional and psychological resilience. Health Communication, 31(5), 606–616. Jarvinen, M. (2015). Understanding addiction: Adult children of alcoholics describing their parents’ drinking problems. Journal of Family Issues, 36(6), 805–825. https://doi.org/10.1177/0192513x13513027. McCoy, T. P., & Dunlop, W. L. (2016). Down on the upside: Redemption, contamination, and agency in the lives of adult children of alcoholics. Memory, 1–9. https://doi.org/10.1080/09658211.2016.1197947. Peterson, P. L., Hawkins, J. D., Abbott, R. D., & Catalano, R. F. (1994). Disentangling the effects of parental drinking, family management, and parental alcohol norms on

Adult Survivors of Sexual Abuse in Couple and Family Therapy current drinking by black and white adolescents. Journal of Research on Adolescence, 4(2), 203–227. Salvatore, J. E., Thomas, N. S., Cho, S. B., Adkins, A., Kendler, K. S., & Dick, D. M. (2016). The role of romantic relationship status in pathways of risk for emerging adult alcohol use. Psychology of Addictive Behaviors, 30(3), 335–344. Sanchez-Roige, S., Stephens, D. N., & Duka, T. (2016). Heightened impulsivity: Associated with family history of alcohol misuse, and a consequence of alcohol intake. Alcoholism: Clinical and Experimental Research, 40(10), 2208–2217. Substance Abuse and Mental Health Services Administration (SAMHSA) (2012). More than 7 million children live with a parent with alcohol problems. Data spotlight. http://www.samhsa.gov/data/ Vaught, E., Wittman, P., & O’Brien, S. (2013). Occupational behaviors and quality of life: A comparison study of individuals who self-identify as adult children of alcoholics and non-adult children of alcoholics. International Journal of Psychosocial Rehabilitation, 18(1), 43–51. Werner, A. & Malterud, K., (2016). Children of parents with alcohol problems performing normality: A qualitative interview study about the unmet needs for professional support. International Journal of Qualitative Studies on Health and Well-being, 11, 1–11. https://doi.org/10.3402/ qhw.v11.30673.

Adult Survivors of Sexual Abuse in Couple and Family Therapy Linda Stone Fish1 and Mary Jo Barrett2 1 Syracuse University, Syracuse, NY, USA 2 Center for Contextual Change, Chicago, IL, USA

Name of Family Form Couple therapy.

Synonyms Incest survivors; Childhood trauma survivors

Introduction Childhood sexual abuse often impacts adult romantic relationships. Adults who have been

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sexually violated as children often carry wounds that are triggered in current relationships which carry similar dynamics to the relationships in which the sexual abuse occurred. Interactional cycles of survival are then activated in the couple relationship which make it difficult for survivors and their partners to feel in control, powerful, and connected. Sometimes, intimate adult relationships retraumatize adult survivors. Therapists who are not trauma informed may unwittingly do the same thing. This chapter will introduce clinicians to the Collaborative Change Model (CCM), a trauma-informed model of couple therapy, which helps couples where one or both partners are survivors.

Description The Collaborative Change Model was first introduced by Trepper and Barrett (1986) to treat incest in a family context. In the last 30 years, the model has been practiced worldwide in a variety of settings and for work with individuals, couples, and families coping with trauma. In its current version, the CCM (Barrett and Stone Fish 2014) is a clinically evaluated model that helps practitioners collaborate with other professionals, and the individuals and families they are involved with, to move from survival mindstates to engaged mindstates. The model is a blueprint for helping professionals engage with each other and their clients. There are three stages to the model. The first stage, Creating a Context for Change, is based on the knowledge that healing begins to occur when people experience safety. The second stage, Challenging Patterns and Expanding Alternatives, is the practice of new behavior that leads away from survival mindstates to engaged mindstates. Individuals acting from engaged mindstates have access to and incorporate tools that regulate their affect, cognitions, behaviors, and relationships. The third stage, Consolidation, integrates new learnings and provides hope. The CCM was developed from many years of working with families whose members had experienced complex trauma. Complex trauma is a pervasive mindset that develops from historical

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Adult Survivors of Sexual Abuse in Couple and Family Therapy

and ongoing abusive and violating relationships and contexts. Many clients who have a history of complex trauma come to therapy stuck in survival mindstates and want help managing their lives. Clients with complex trauma often begin the treatment process having been traumatized in relationships that have similar characteristics to the ones they are entering into when they seek help. Clinicians, on the other hand, come to the relationship with the explicit understanding that they are to be helpful. In most psychotherapy training, trainees are taught to begin therapy after a brief period of “joining,” move quickly into assessment, followed soon after by interventions to challenge unproductive behaviors, thoughts, and feelings. Unfortunately, this rapid movement toward challenge and change can and often does trigger a survival mindstate for clients who have experienced complex trauma. Developing a new relationship with a helping professional is stressful as is the change process. It can be disorienting and threatening. Clients often experience therapy as something that is happening to them. They have no idea what to expect and do not understand the rules. Lacking a detailed blueprint for the process of therapy the therapist’s actions may seem confusing, irrelevant, or critical. This stressful situation triggers survival mindstates in which it is virtually impossible to achieve therapeutic growth. All of the clients’ energies are focused on surviving while in this state and change is not an option. Therapeutic interventions are neutralized and become ineffective at best and re-traumatizing at worst. The essence of a trauma-informed model is the active and transparent use of collaboration. Clients are active members of the treatment team, and are informed consumers throughout treatment. The CCM follows a clear sequence of stages and is at the same time flexible and adaptive to therapist style, theoretical model, clinical setting, and client presenting challenge. Helping others grow and change is a creative and sacred process. The CCM allows each and every client and therapist together to design the creative process of change that fits their strengths and styles. Trauma-centered interventions are incorporated into the blueprint of the CCM in conversation with the needs of clients.

Relevant Research About Family Life It is difficult to accurately estimate the number of adult survivors of childhood sexual abuse who come for couple therapy. If therapists do not take a detailed history, clients may not report past abuse. Even if therapists ask, individuals may not report, for a variety of reasons. They may not have shared their history with their partner, they may not have acknowledged their abuse to themselves, they may experience shame that silences them, they may not trust therapy, or believe it is relevant to their current problems. It is also difficult to accurately estimate how many people are adult survivors of childhood sexual abuse because researchers differ on definition and most believe that sexual abuse itself is underreported (e.g., Briere and Elliott 2003). Studies done by the Crimes Against Children Research Center show that 1 in 5 girls and 1 in 20 boys are victims and self-report studies show that about 20% of adult females and 5–10% of adult males recall at least one incident of childhood sexual abuse (Finklehor 2008). Children who have been sexually abused are more likely to be sexually abused again as adolescents and adults (Russell 1986; Messman-Moore and Long 2003). Since Russell’s (1986) landmark study on incest and Herman’s (1992) groundbreaking book comparing the epidemic of childhood sexual abuse to other forms of trauma, many researchers have studied the effects of sexual abuse while acknowledging that research is limited by the secrecy surrounding abuse, particularly when it is intrafamilial. Reactions to abuse vary widely and there is no single profile that defines specific symptomology related to childhood sexual abuse. There are, however, some common individual and relational themes. At least two decades of reviews of research (e.g., Briere and Elliott 2003) have shown many survivors of childhood sexual abuse suffer low self-esteem and symptoms of anxiety and depression. Some suffer from posttraumatic stress disorder, alcohol and drug abuse, self-mutilation, borderline and bipolar personality disorders, suicidal ideation, aggression, and sexual acting out

Adult Survivors of Sexual Abuse in Couple and Family Therapy

and dysfunction. Furthermore, adult survivors of childhood sexual abuse are more likely to suffer from medical problems than the general population. Childhood sexual abuse also has consequences on adult intimate relationships. Sexual difficulties, from pain to avoidance, to low desire, and risky sexual acting out, have an impact on the survivor and her/his partner. There is also some research, which suggests that severe abuse is correlated with more sexual difficulties (Trickett et al. 2011). Valliancourt-Morel et al. (2016) found that relationship status may impact sexual difficulties, discovering that adult survivors in marital relationships were more likely to avoid sex while single survivors were more likely to act out sexually. Research shows that other symptoms related to childhood sexual abuse also have an impact on intimate relationships, like attachment disorders, affect regulation, a sense of powerlessness, and lack of trust. Some survivors, however, do not experience symptomatology related to the abuse when studied as adults. Collishaw et al. (2007) attribute the survivors’ well-being to their relationships with their parents, adolescent friendships, individual personality characteristics of the survivor, and the quality of their adult relationships.

Special Considerations for Couple and Family Therapy Creating Safety When working with adult survivors of childhood sexual abuse, a trauma-informed lens is invaluable. It appears that most trauma-informed models of couple therapy highlight the importance of safety when working with adult survivors (e.g., Courtois and Ford 2009). This is particularly important when working in conjoint sessions since couples trigger each other into interactional cycles of survival that create dangerous emotional territory and have the potential to explode in the therapy room. In stage one of the Collaborative Change Model (CCM), therapists overtly discuss ways to make the therapeutic environment as safe as possible. They talk with clients about what feels safe and what does not and help couples

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explore the idiosyncratic ways that they can maintain safety in therapy. In the first few sessions with couples, concepts from neuroscience are introduced that are helpful in understanding how traumatic experiences in childhood continue to impact them today. Often the explanation goes something like this: “So we are learning a lot about the brain recently that I find helpful in understanding why we do the things we do and how to change our behavior to cope better. So the three parts of the brain the cortex, the limbic area, and the survival brain all have different functions. The cortex, that part of our brain that pays attention, learns, is thoughtful, processes information, helps us with impulse control, etc., is the part of the brain we want to keep on line all the time in therapy. We will explore ways to do that as part of the therapy process. The limbic area is the expression and mediation of emotions and feelings, including emotions linked to connection with others. It also includes the amygdala, which is our danger signal. Sometimes, when we have had a lot of trauma in our past, the danger signal can be over- or underactive and that is something else we will explore as we work together. The survival brain is the oldest part of the brain and has kept us alive since the beginning of time. It is instinctual and unconscious and reacts to danger by taking action to keep us safe. Fight, flight, freeze, and tend and befriend are the four survival options we have when our survival brain is activated. Adrenalin and cortisol are released, our pupils dilate, our breathing and heart rate go up and we are pumped. We defend ourselves by fighting or running away as fast as we can or taking cover and protecting others or protecting ourselves through eliciting support from safe people. If these three options are not available to us, we can’t fight, we can’t get away, and there is no safe person to tend to us, if we are completely helpless and out of control, the body has a way of shutting down and protecting itself. This is the frozen or dissociated state, almost like we have left the room, or some people talk about being out of body or seeing themselves from afar. The survival brain often kept us alive as children and overfunctions now when it is not necessarily always needed. We will explore many of the

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incidences that occur in your current life that trigger your survival brain.” The CCM is a stage model that works like a fractal. The first stage, creating a context for change, which includes a plan for titrating safety and challenge, is repeated continuously, moment to moment and session after session. When working with adult survivors of childhood sexual abuse in couple therapy, this is an essential part of treatment protocol. Many sexual abuse survivors were perpetrated in relationships with adults who were supposed to protect and care for them. Some of the ways therapists attempt to show curiosity and empathy may trigger clients who were groomed and abused by adults who used similar techniques. When the survival brain is triggered, the CCM trained therapist helps clients pause and ponder the trigger, which activates the cortex and helps to create safety in the therapeutic relationship. Interactional Cycles of Survival Also of special consideration in couple therapy with adult survivors of childhood sexual abuse is mapping the couple’s interactional cycle of survival (see Fig. 1). The cycle is a part of each couple’s dynamic that keeps them from supporting each other in times of struggle. It is mapped in the early stages of

therapy so that both partners can work on understanding their reactions and then work towards changing those reactions. It is a cycle that both partners engage in and both can change. An example of an interactional cycle of survival goes something like this. Often when Theresa’s survival brain is triggered, she becomes convinced that Mattis, her partner of 12 years, is not trustworthy. Theresa was sexually abused by a stepfather who lied constantly, telling her he felt awful about his drunken behavior and would stop the sexual violence, only to repeat it the next time he drank. When Mattis, for example, forgets to call Theresa and let her know he is meeting a friend for a drink, Theresa’s survival brain is triggered. She becomes anxious and mistrusting and convinced he is hiding something from her. She obsessively checks phone records, credit card statements, social media, and follows him to work, and weepily question everything he says. This behavior triggers Mattis’s survival brain. Feeling like a cheating loose when he believes he has done nothing but be forgetful, reminds him of growing up with a mother who would periodically, for no reason that Mattis could understand, trash his bedroom looking

Victim/Survivor Cycle VULNERABILITIES

SURVIVAL

SURVIVAL

VULNERABILITIES M.J. Barrett 1990

Adult Survivors of Sexual Abuse in Couple and Family Therapy, Fig. 1 Victim/Survivor Cycle

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for drugs or weapons or sexual paraphernalia that did not exist. He reacts to Theresa’s behavior by shutting down, stonewalling, leaving the house, which of course, triggers Theresa’s survival behavior. Once the interactional cycle is mapped in stage one of the CCM, the pattern is challenged in stage two. Therapists use various techniques to help explore how partner’s behavior triggers survival behavior. The survival behavior may have been valuable in the past, and that is sometimes explored, but now gets in the way of increased intimacy, feeling valued, connected, and in control. Exploring how the survival behavior made sense in the context of the traumatic abuse of childhood in the presence of an engaged, compassionate partner, helps heal the wounds of the traumatic event. So when Theresa, for example, talked about her stepfather’s abuse and how powerless she was as a teenager, in front of Mattis, as the therapist guided Mattis to witness without taking on Theresa’s anger or trying to fix Theresa’s hurt feelings, he is actually helping Theresa heal. Furthermore, Mattis is calming his own nervous system down as well, a skill he can generalize outside the therapeutic encounter. New interactional cycles are then practiced. These new patterns incorporate all parts of the brain and are practiced with intension. When they are triggered, they can recognize their reactions from an engaged mindstate, and make decisions about how they want to behave. In stage three, both partners have incorporated ways to support each other when one is triggered, preventing interactional cycles of survival, and providing each other a safe haven to cope with life’s ongoing demands.

Cross-References ▶ Attachment Injury Resolution Model in Emotionally Focused Therapy ▶ Child Sexual Abuse in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy and Trauma ▶ Vulnerability Cycle in Couple Therapy

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References Barrett, M. J., & Stone Fish, L. (2014). Treating complex trauma: A relational blueprint for collaboration and change. New York: Routledge Press. Briere, J., & Elliott, D. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse and Neglect, 27, 1205–1222. Collishaw, S., Pickles, A., Messer, J., Rutter, M., Shearer, C., & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse & Neglect, 31(3), 211–229. Courtois, C. A., & Ford, J. D. (2009). Treating complex traumatic stress disorders: An evidence based guide. New York: Guilford Press. Finklehor, D. (2008). Childhood victimization: Violence, crime, and abuse in the lives of young people. Oxford, UK: Oxford University Press. Herman, J. (1992). Trauma and recovery. New York: Basic Books. Messman-Moore, T., & Long, P. (2003). The role of childhood sexual abuse sequelae in the sexual revictimization of women: An empirical review and theoretical reformulation. Clinical Psychology Review, 23, 537–571. Russell, D. (1986). The secret trauma: Incest in the lives of girls and women. New York: Basic Books. Trepper, T., & Barrett, M. J. (1986). Treating incest: A multiple systems perspective. New York: Routledge Press. Trickett, P. K., Noll, J. G., & Putnam, F. W. (2011). The impact of sexual abuse on female development: Lessons from a multigenerational, longitudinal research study. Development and Psychopathology, 23(2), 453–476. Valliancourt-Morel, M. P., Godbut, N., Sabourin, S., Brier, J., Lussier, Y., & Runtz, M. (2016). Adult sexual outcomes of child sexual abuse vary according to relationship status. Journal of Marital and Family Therapy, 42(2), 341–356.

Affect in Couple and Family Therapy Andrew S. Brimhall and David M. Haralson East Carolina University, Greenville, NC, USA

Name of Concept Affect

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Introduction Affect, mood, and emotion are often used interchangeably. However, important distinctions exist. Within modern psychology, affect is usually represented as one of three interconnected domains: affect, behavior, and cognition (Duncan and Barrett 2007). Some theorists believe that affect is a type of instinctual reaction to stimuli that occurs before cognition, while others believe that affective reactions happen both pre- and post-cognition. Although both emotions and moods are generally considered affective states, moods are distinguished by being more diffused, unfocused, and lasting much longer, whereas emotions are typically elicited by something and include the individual assignment meaning to that reaction (Batson et al. 1992).

Theoretical Context for Concept Despite being one of three interconnected domains (affect, behavior, and cognition), the prominence placed on the role of affect varies by theory. Theories who view affect as central to the change process (e.g., emotionally focused therapy) see affect as the window to change and intervene accordingly. Their belief is that behaviors and cognitions change as emotional experiences are reprocessed and reexperienced. Other theories (i.e., behavioral, CBT) may see affect as a supporting cast; something that changes as professionals intervene to alter behaviors and cognitions. Irrespective of whether it is the primary focus of intervention or not, most couple and family theories see affect as one of the three domains that must change for individuals to improve.

Description Affect (both moods and emotions) is generally divided into either positive or negative experiences – positive affect being reserved for emotions such as happy, excited, and enthusiastic and negative affect for feelings such as anger,

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sadness, or nervous. Because affect is a latent variable (an intrapsychic experience), many people rely on emotions (the outward display of affect) in order to understand another person’s affective experience. This outward display of emotion is often described by the range, fluctuation, intensity, appropriateness, and quality of the affect. When attempting to measure affect, care should be taken when choosing an assessment. There are many self-report questionnaires that can be used to measure affect, mood, and emotion (Ekkekakis, 2013). However, since they are not exactly synonymous, researchers and clinicians should be careful to choose a measure that theoretically fits with the concept being measured. If a researcher chooses an instrument designed to measure a specific state/emotion, then global inferences about a person’s mood would not be appropriate. It is important to match the instrument with what is being assessed. For example, the Differential Emotions Scale (DES) could be used reliably to divide an individual’s description of specific emotional experiences into discrete categories like enjoyment and interest, while the Profile of Mood States (POMS) might be used to assess more general mood states like anger/hostility, tension/anxiety, and friendliness. The most widely used scale for measuring individual affect is the Positive and Negative Affect Schedule Expanded (PANAS-X). These scales ask participants to mark any of the feelings they have experienced in the last few weeks and are aimed at measuring affective states.

Application of Concept in Couple and Family Therapy Because affect is an important part of human relationships, most couple and family therapy approaches are either centered upon or place strong emphasis on increasing positive affect while simultaneously decreasing negative affect. Some professionals would go to the extent of arguing that this is a common factor that is unique to couple and family therapy (Sprenkle et al. 2009). In fact, the literature on

Affective Reconstructive Approach to Couple Therapy

marital distress would suggest that distress is not a result of negative affect/conflict but rather the abatement of positive. As a result, clinicians should consider more interventions that help increase the positive affect of individuals within couples and families.

Clinical Example Joe and Sidney sought out therapy because they felt disconnected. Working from an emotionally focused approach, the therapist asked Sidney to describe feeling “disconnected.” She explained that she felt “alone” and “unsupported” when Joe was gone for long hours. The therapist then asked Sidney to turn and tell Joe directly of her feelings. Sidney turned to Joe and said I feel “alone,” and “like a single parent.” Seeing Joe tense, the therapist asked Joe to describe what emotions were elicited as Sidney talked. Looking down, Joe explained that he knew Sidney felt alone and as such he “felt like a failure.” He began to cry and said, “I’m sorry. . .I wish I could have been there for you, but I just couldn’t.” Noticing Sidney’s softened facial expression (an emotional manifestation of inner affect), the therapist then asked Sidney to tell Joe how that changed her experience. Sidney responded that hearing Joe’s feelings helped her feel needed and important, something she typically doesn’t feel (mood). In this scenario, the therapist was able to create an environment that helped change the couple’s overall affect. Sidney moved from feeling disconnected and unimportant to feeling closer to Joe. Joe moved from feeling like a failure to feeling more supported. Learning to read affective displays (i.e., voice changes, facial cues, etc.) helps therapists know how to intervene when working with both positive and negative affect.

Cross-References ▶ Affect in Couple and Family Therapy ▶ Emotion in Couple and Family Therapy

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References Batson, C. D., Shaw, L. L., & Oleson, K. C. (1992). Differentiating affect, mood, and emotion: Toward functionally based conceptual distinctions. In M. S. Clark (Ed.), Emotion (pp. 294–326). Thousand Oaks: Sage. Duncan, S., & Barrett, L. F. (2007). Affect is a form of cognition: A neurobiological analysis. Cognition & Emotion, 21(6), 1184–1211. https://doi.org/10.1080/ 02699930701437931. Ekkekakis, P. (2013). The measurement of affect, mood, and emotion: A guide for health-behavioral research. Cambridge, MA: Cambridge University. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press.

Affective Reconstructive Approach to Couple Therapy Molly F. Gasbarrini1 and Douglas K. Snyder2 1 California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA 2 Texas A&M University, College Station, TX, USA

Name of the Strategy or Intervention Affective reconstruction.

Introduction Affective reconstruction (Snyder 1999) refers to the interpretation of persistent maladaptive relationship patterns having their source in previous developmental experiences. Affective reconstruction reflects an insight-oriented approach to couple therapy and presumes that an important source of couples’ current difficulties frequently includes previous relationship injuries resulting in sustained interpersonal vulnerabilities and related defensive strategies interfering with emotional intimacy. Hence, therapeutic approaches that fail to address developmental experiences giving rise

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to these vulnerabilities and their associated reactivities deprive individuals of a rich resource for understanding both their own and their partner’s behaviors that could help them to depersonalize the hurtful aspects of the couple’s interactions and to adopt an empathic stance.

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each partner consistencies in their interpersonal conflicts and coping styles across relationships. In addition, ways in which previous coping strategies vital to prior relationships represent distortions or inappropriate solutions for emotional intimacy and satisfaction in the current relationship are articulated.

Theoretical Framework Diverse approaches to examining maladaptive relationship patterns can be placed on a continuum from traditional psychoanalytic techniques rooted primarily in object relations theory to schema-based interventions derived from cognitive theory. These approaches vary in the extent to which they emphasize the unconscious nature of individuals’ relational patterns, the developmental period during which these maladaptive patterns are acquired, and the extent to which interpersonal anxieties derive from frustration of innate drives. However, these approaches all share the assumption that maladaptive relationship patterns are likely to continue until they are understood in a developmental context. This new understanding and exploration serve to reduce the couple’s attendant anxiety in current interactions and permit them to develop alternative, healthier relationship patterns. Drawing on earlier psychodynamic formulations, Snyder and Wills (1989) articulated an insight-oriented approach to couple therapy emphasizing affective reconstruction of previous relationship injuries resulting in sustained interpersonal vulnerabilities and related defensive strategies interfering with emotional intimacy. In affective reconstruction, developmental origins of interpersonal themes and their manifestation in a couple’s relationship are explored using techniques roughly akin to traditional interpretive strategies promoting insight, but emphasizing interpersonal schemas and relationship dispositions rather than instinctual impulses or drive derivatives (Snyder 1999; Snyder and Mitchell 2008). Previous relationships, their affective components, and strategies for emotional gratification and anxiety containment are reconstructed with a focus on identifying for

Rationale for the Strategy or Intervention Affective reconstruction builds on strengths of earlier relational models of individual psychotherapy by capitalizing on features unique to conjoint couple therapy. First, in couple therapy data reflecting current expression of persistent dysfunctional patterns of interpersonal relating are not confined to the individual’s interactions with the therapist but extend more visibly and importantly to in vivo observations of the individual and his or her significant other. Thus, core conflictual relationship themes having greatest relevance to each partner are more likely to be apparent than in the context of individual therapy. Second, individuals’ understanding of maladaptive relationship themes and their reformulation of these in less pejorative terms may extend beyond their own dynamics to a more benevolent reinterpretation of their partner’s more hurtful behaviors. That is, both individuals can be helped to understand that, whereas certain relational coping strategies may have been adaptive or even essential in previous relationships, the same interpersonal strategies interfere with emotional intimacy and satisfaction in the present relationship. Finally, in couple therapy the “corrective emotional experience” (Alexander 1956) of disrupting previous pathogenic interpersonal strategies and promoting more functional relational patterns has an opportunity to emerge not only between the individual and therapist, but between the individual and his or her partner. Thus, interpretation of maladaptive interpersonal themes in the context of couple therapy affords unique opportunities for affective reconstruction of these patterns in individuals’ primary emotional relationships.

Affective Reconstructive Approach to Couple Therapy

Description of the Strategy or Intervention An essential prerequisite to affective reconstruction of relational themes is a thorough knowledge of each partner’s relational history. Critical information includes not only the pattern of relationships within the family of origin, but also relational themes in the family extending to prior generations. Beyond the family, intimate relationships with significant others of both genders from adolescence through the current time offer key information regarding such issues as perceived acceptance and valuation by others, trust and disappointment, stability and resilience of relationships to interpersonal injury, levels of attachment and respect for autonomy, and similar relational themes. Some of this information may be gleaned from earlier interventions linked to establishing appropriate boundaries with families of origin, discussion of partners’ expectancies regarding parenting responsibilities acquired during their own childhood and adolescence, or disclosures of traumatic experiences with significant others previous to the current relationship. Alternatively, in anticipating focused work on developmental issues, the therapy may adopt more structured clinical or self-report techniques. For interpretation of maladaptive relationship themes to be effective with couples, the therapist needs to attend carefully to both partners’ preparedness to examine their own enduring relational dispositions. Unlike individual therapy in which clients often accept at least partial responsibility for their own distress, persons entering couple therapy often focus on their partner’s negative behaviors and resist examining their own contributions to relationship difficulties – particularly those linked to more enduring personality characteristics. Distressed couples often suffer from a long history of exchanging pejorative attributions for each other’s behaviors, furthering their initial resistance to clinical interventions emphasizing early maladaptive schemas underlying relationship distress. Consequently, examining developmental sources of relationship distress demands a prerequisite foundation of emotional safety, partners’ trust in the therapeutic process,

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the couple’s ability to respond empathically to feelings of vulnerability exposed by their partner, and an introspective stance initially prompted by examining dysfunctional relationship expectancies and attributions residing at a more conscious level. In affective reconstruction, previous relationships are initially explored without explicit linkage to current relational difficulties, in order to reduce anxiety and resistance during this exploration phase. Often, individuals are readily able to formulate connections between prior relationships and current interpersonal struggles; when this occurs, it is typically useful for the therapist to listen empathically, encouraging the individual to remain “intently curious” about their own relational history but to refrain from premature interpretations that may be incorrect, incomplete, or excessively self-critical. Just as important is for the individual’s partner to adopt an accepting, empathic tone during the other’s developmental exploration, encouraging self-disclosure in a supportive but noninterpretive manner. Provided with relevant developmental history, the therapist encourages each partner to identify significant relational themes, particularly with respect to previous relationship disappointments and injuries. Gradually, as the couple continues to explore tensions and unsatisfying patterns in their own relationship, both partners can be encouraged to examine ways in which exaggerated emotional responses to current situations have at least partial basis in affective dispositions and related coping styles acquired in the developmental context. Developing a shared formulation of core relationship themes is a critical antecedent to subsequent linkage of these themes to current relationship exchanges. Both individuals can be helped to understand that, whereas certain relational coping strategies may have been adaptive or even essential in previous relationships, the same interpersonal strategies interfere with emotional intimacy and satisfaction in the present relationship. In couple therapy, the therapist’s direct access to exchanges between partners affords a unique opportunity for linking enduring relationship themes to current relationship events. Rather than interpreting transferential exchanges

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between either partner and the therapist, the focus is on partners’ own exchanges in the immediate moment. Interpretations emphasize linking each partner’s exaggerated affect and maladaptive responses to his or her own relationship history, emphasizing the repetition of relationship patterns and their maintaining factors in the present context. Guidelines for examining cyclical maladaptive patterns in the context of individual therapy (Binder and Strupp 1991; Luborsky 1984) readily lend themselves to couples work. How does the immediate conflict between partners relate to core relationship themes explored earlier in the therapy? What are each person’s feelings toward the other and their desired response? What impact do they wish to have on the other in this moment? How do their perceptions regarding their partner’s inner experience relate to their attitudes toward themselves? What fantasies do they have regarding their partner’s possible responses? What kinds of responses from their partner would they anticipate being helpful in modifying their core beliefs about their partner, themselves, and this relationship? Specific therapeutic techniques relevant to examining core relationship themes in individual therapy (Luborsky 1984; Strupp and Binder 1984) apply to affective reconstruction in couple therapy as well. For example, it is essential that the therapist recognize each partner’s core relationship themes, that developmental interpretations link relational themes to a current relationship conflict, and that therapy focuses on a few select relationship themes until some degree of resolution and alternative interpersonal strategies are enabled. It is also important that the extent and complexity of interpretations take into account (a) the affective functioning of the individual and his or her ability to make constructive use of the interpretation, (b) the level of insight and how near the individual is to being aware of the content of the proposed interpretation, and (c) the level of relationship functioning and the extent to which developmental interpretations can be incorporated in a mutually supportive manner. From a psychodynamic perspective, cognitive linkage of relational themes from early development to the current context is frequently

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insufficient for reconstructing or modifying these interpersonal patterns. The affective component of interpretation is seen in the reconstruction of these critical emotional experiences in the immediate context; new understanding by both partners often promotes more empathic responses toward both themselves and the other, facilitating more satisfactory resolutions to conflict. Often the individuals must be encouraged to work through previous relationship injuries, grieving losses and unmet needs, expressing ambivalence or anger toward previous critical others in the safety of the conjoint therapy, and acquiring increased differentiation of prior relationships from the present one. Similar to individual therapy adopting a relational model, the therapist serves as an auxiliary processor helping to “detoxify, manage, and digest” the partners’ relationship themes in a manner that promotes interpersonal growth (Messer and Warren 1995, p. 141). Affective reconstruction makes possible but does not inevitably lead to changes in maladaptive relationship patterns. In addition to interpretive strategies, interventions must promote partner interactions that counteract early maladaptive schemas. Thus, the couple therapist allows partners’ maladaptive patterns to be enacted within limits, but then assists both partners in examining exaggerated affective components of their present exchange. Partners’ exaggerated responses are framed as acquired coping strategies that interfere with higher relationship values. Interpretations of the developmental context underlying the current unsatisfactory exchange help both partners to depersonalize the noxious effects of the other’s behavior, to feel less wounded, and consequently to be less reactive in a reciprocally negative manner. Both individuals are encouraged to be less anxious and less condemning of both their own and their partner’s affect, and are helped to explore and then express their own affect in less aggressive or antagonistic fashion. Throughout this process, each individual plays a critical therapeutic role by learning to offer a secure context in facilitating their partner’s affective selfdisclosures in a softened, more vulnerable manner. The couple therapist models empathic

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understanding for both partners and encourages new patterns of responding that enhance relationship intimacy. That is, by facilitating the nonoccurrence of expected traumatic experiences in the couple’s relationship, both individuals are able to challenge assumptions and expectations comprising underlying maladaptive schemas. Thus, therapeutic change results from the experiential learning in which both partners encounter relationship outcomes different from those expected or feared. In response, partners’ interactions become more adaptive and flexible in matching the objective reality of current conflicts and realizing opportunities for satisfying more of each other’s needs. Although affective reconstruction seeks to promote new relationship schemas facilitating more empathic and supportive interactions, couples sometimes need additional assistance in restructuring longstanding patterns of relating outside of therapy. In a pluralistic hierarchical model (Snyder 1999) in which structured interventions for strengthening the relationship have previously been pursued, couples already will have been exposed to communication and behavior-exchange techniques characterizing traditional behavioral approaches. Consequently, alternative relationship behaviors can often be negotiated more readily after schema-related anxieties and resistance to changing enduring interaction patterns have been understood and at least partially resolved. Termination of couple therapy proceeds when the couple has resolved any initial crises potentially precipitating treatment; when partners have acquired information and specific skills essential to maintaining individual as well as relational health; and when partners understand and resolve individual dynamics previously contributing to exaggerated emotional reactivity, and substantially reduce or eliminate distorted responses to their own as well as each other’s dynamics. As evidence of these goals being met evolves, the therapist may suggest terminating or “thinning out” the frequency of sessions – with remaining interventions emphasizing an integrative review and consolidation of therapeutic work that has been accomplished, and preparation for

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anticipated stresses from within or outside the couple relationship that may challenge individual or relationship functioning in the future. Empirical Support for the Efficacy of Affective Reconstruction Snyder and Wills (1989) examined the effectiveness of affective reconstruction as described here, in a study comparing this insight-oriented approach with traditional behavioral therapy in a controlled clinical trial involving 79 distressed couples. The behavioral condition emphasized communication skills training and behavior exchange techniques; the insight-oriented condition emphasized the interpretation and resolution of conflictual emotional processes related to developmental issues, collusive interactions, and maladaptive relationship patterns. At termination after approximately 20 sessions, couples in both treatment modalities showed statistically and clinically significant gains in relationship satisfaction compared to a wait-list control group. Treatment effect sizes at termination for behavioral and insight-oriented conditions were 1.01 and 0.96, respectively, indicating that the average person receiving either couple therapy was better off at termination than approximately 83% of individuals not receiving treatment. Moreover, treatment gains for couples in both therapy conditions were substantially maintained at 6-month follow-up. However, at 4 years following treatment, 38% of the behavioral couples had experienced divorce, in contrast to only 3% of couples treated in the insight-oriented condition (Snyder et al. 1991a). Based on these findings, Snyder and colleagues suggested an important distinction between acquisition of relationship skills through instruction or rehearsal versus interference with implementation of these skills on a motivational or affective basis. They argued that partners’ views toward each other’s behavior “are modified to a greater degree and in a more persistent manner once individuals come to understand and resolve emotional conflicts they bring to the marriage from their own family and relationship histories” (Snyder et al. 1991b, p. 148). Finally, Snyder (1999) has argued that affective reconstruction comprises a critical

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component of couple therapy from a pluralistic perspective. Whereas some couples demonstrate a capacity to implement and maintain important relationship changes without undertaking such reconstructive work, others will remain significantly if not permanently mired in recurrent maladaptive interactions until they understand and resolve the developmental origins of exaggerated or distorted emotional responses to their own concerns or those of their partner. For some couples, affective reconstruction yields rapid and dramatic breakthroughs and resolution of longstanding dysfunctional patterns of interrelating. For others, insights are more gradual and the gains more circumscribed. Affective reconstruction becomes critical to couple therapy when partners’ difficulties arise in part from previous relationship injuries resulting in sustained interpersonal vulnerabilities and related defensive strategies interfering with emotional intimacy. Partners’ ability to benefit from insight into these vulnerabilities and defensive strategies may be optimized when affective reconstruction is embedded within a broader, comprehensive therapeutic strategy building upon structural, behavioral, and cognitive interventions earlier in the therapeutic sequence.

Case Example Bob and Sharon entered couple therapy after 15 years of marriage, reporting increasing emotional detachment and brief but hurtful arguments when either partner felt misunderstood or unappreciated by the other. The couple had two daughters, ages 13 and 11, to whom Sharon felt quite close but Bob often felt estranged. Both partners were successful professionals in the healthcare field and described effective communication strategies with coworkers. In their marriage, however, a pronounced demand-withdraw pattern undermined their efforts to engage and resolve relationship issues. In discussing their families of origin, Sharon reported a family that was emotionally close but highly avoidant of conflict. Tensions with Bob felt threatening to her, and she was unable to

Affective Reconstructive Approach to Couple Therapy

tolerate even his modest expressions of frustration or unhappiness. When Bob expressed discontent with Sharon or their marriage, she felt deeply wounded and unloved, retreating for days into minimal interactions. By contrast, Bob’s family was characterized by recurring high conflict and a dominant, emotionally abusive father. Bob had grown up often feeling marginalized and powerless, with little opportunity to express his own feelings and needs. Sharon’s withdrawal in response to his complaints felt punitive. Exploring these dynamics in couple therapy helped each partner to alter their interpretation of the other’s behaviors, and these new understandings helped them to resist their respective tendencies to withdraw or escalate. Sharon worked hard to expand her tolerance for Bob’s occasional expressions of discontent and he, in turn, worked to regulate more effectively when and how he communicated his concerns or frustrations to Sharon. Understanding Sharon’s retreat as a reflection of her own anxieties rather than a ploy to punish him helped Bob to tolerate her needs to suspend difficult discussions until they could both adopt softened perspectives on their differences and engage these in a less defensive or antagonistic manner. Sharon came to understand the intensity of Bob’s feelings as reflecting deep needs for closeness and his own anxious response to her withdrawal, rather than as a rejection or punishment of her. Bob’s and Sharon’s enduring dispositions to lapse into escalation or withdrawal persisted, but at a much lower frequency and intensity than before the couple therapy. Moreover, their new understanding of this interactional pattern helped them to recognize it earlier in the cycle to dampen its escalation, and to recover more quickly and engage in corrective strategies when old patterns resurfaced.

Cross-References ▶ Behavioral Couple Therapy ▶ Insight-Oriented Couple Therapy ▶ Snyder, Doug

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References

Introduction

Alexander, F. (1956). Psychoanalysis and psychotherapy. New York: Norton. Binder, J. L., & Strupp, H. H. (1991). The Vanderbilt approach to time-limited dynamic psychotherapy. In P. Crits-Christoph & J. P. Barber (Eds.), Handbook of short-term dynamic psychotherapy (pp. 137–165). New York: Basic Books. Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive-expressive treatment. New York: Basic Books. Messer, S. B., & Warren, C. S. (1995). Models of brief psychodynamic therapy: A comparative approach. New York: Guilford Press. Snyder, D. K. (1999). Affective reconstruction in the context of a pluralistic approach to couple therapy. Clinical Psychology: Science and Practice, 6, 348–365. Snyder, D. K., & Mitchell, A. E. (2008). Affectivereconstructive couple therapy: A pluralistic, developmental approach. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed., pp. 353–382). New York: Guilford Press. Snyder, D. K., & Wills, R. M. (1989). Behavioral versus insight-oriented marital therapy: Effects on individual and interspousal functioning. Journal of Consulting and Clinical Psychology, 57, 39–46. Snyder, D. K., Wills, R. M., & Grady-Fletcher, A. (1991a). Long-term effectiveness of behavioral versus insightoriented marital therapy: A four-year follow-up study. Journal of Consulting and Clinical Psychology, 59, 138–141. Snyder, D. K., Wills, R. M., & Grady-Fletcher, A. (1991b). Risks and challenges of long-term psychotherapy outcome research: Reply to Jacobson. Journal of Consulting and Clinical Psychology, 59, 146–149. Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to time-limited dynamic psychotherapy. New York: Basic Books.

African Americans, unlike most ethnic groups who immigrated to America in search of freedom and equality, arrived involuntarily as slaves. Living in the shadow of slavery economically, politically, socially, and psychologically, African Americans often are misunderstood, stigmatized, and racially stereotyped as inferior. Due to a history of racism, discrimination, and lack of cultural understanding, African Americans are wary and underutilize mental health services. Also, disparate and inadequate treatment of African Americans has resulted in a culture of mistrust. As such, it is critically important that couple and family therapists develop knowledge of African American history and culture. Failure to consider the historical trauma of slavery and the impact of race in African American clients’ experiences and presenting problems may cause couple and family therapists to conceptualize cases from the default perspective of the dominant white culture. While accredited couple and family therapy training programs are tasked to attend to context, race continues to be an afterthought. Moreover, the advent of evidence-based models as best practice in couple and family therapy may have the unintended consequence of minimizing or negating the significance of race.

Description

African Americans in Couple and Family Therapy Marlene F. Watson Drexel University, Philadelphia, PA, USA

Name of Family Form African Americans in Couple and Family Therapy

Synonyms Black

The term African American refers to the descendants of those black Africans who were enslaved in the United States of America. According to Billingsley (1992), the African American family often is viewed too narrowly, which, out of the context of black* communities and the larger society, can fuel stereotypical thinking and be counterproductive. Frequently, theoreticians, researchers, and clinicians focus exclusively on single-parent families, the lower class or problem children and youth, falling into the trap of seeing these phenomena as characteristic of African American families. Billingsley proposes a broader and more complex definition of the African

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American family as “an intimate association of persons of African descent who are related to one another by a variety of means, including blood, marriage, formal adoption, informal adoption, or by appropriation; sustained by a history of common residence in America; and deeply embedded in a network of social structures both internal to and external to itself” (p. 28). Throughout history and the changing sociopolitical landscape, the name associated with black* Americans has been fluid, evolving across time periods. A word or name contains power and conveys persuasive ideas that can enlighten or erode people’s minds. In reality, imposing, proposing, accepting, or rejecting names can be used as a political tool. By the end of the first third of the nineteenth century, the N-word, which can be traced to the Latin word niger meaning black, was firmly entrenched in the American psyche. During slavery blacks* largely were referred to as the N-word, conjuring up powerful imagery of black* people as ugly, promiscuous, dangerous, immoral, and animal-like. Thus the imposition of the N-word onto black* Americans was political, dehumanizing blacks* and humanizing whites. The word Colored to describe black* Americans rose to dominance in the mid to late nineteenth century. The rape of black female slaves by white masters resulted in mulatto children, a new group of black* Americans with mixed ancestry that needed classification. Colored was regarded as more encompassing and inclusive (Smith 1992). Negro replaced the word Colored in the late nineteenth century. Notables such as Booker T. Washington and W.E.B. Dubois pioneered the movement to trade Colored for Negro. The media, both black* and white, helped the word Negro to gain acceptance and become the standard through its use of the term (Smith 1992), documenting the role of the media in shaping public discourse and politics. The Civil Rights Movement ushered in the word Black. The late 1950s to early 1960s called into question the word Negro to define black* Americans. A critique of the word Negro found it outdated and reflective of the past and slavery. Negro was thought to stir the white imagination of

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black* Americans as docile, passive, and eager to please – Uncle Tom-ish. Civil rights leaders and organizations, such as Stokely Carmichael of the Student Nonviolent Coordinating Committee, the Black Muslims, and Black Panthers, rallied behind the term Black (Smith 1992). Also, acclaimed singer James Brown made a record in 1968 that became akin to a black* national anthem, “Say it Loud—I’m Black and I’m Proud,” helping to solidify Black as the new identity. Black now stood for racial pride and action – empowerment. Black communicated African Americans’ rejection of second-class citizenship and the status quo (Smith 1992). The word Black, though not accepted by all, remained unchallenged until 1988 when renowned civil rights leader Jesse Jackson declared that members of the black* race preferred the term African American. Seeking parity with white ethnic groups, the African American label was fashioned to express cultural integrity and put black* Americans in the proper historical context (Smith 1992). African American and Black* often are used interchangeably. However racial labels can arouse strong emotions. For example, Zilber and Niven (1995) found that whites, particularly liberal whites, view the label African American negatively in comparison to Black. African American was thought to be indicative of concern with the specific group, not society. Moreover, black* Americans’ concern about racial identity was seen as insignificant. African Americans are not a monolithic group, and therefore therapists should not assume that all embrace a single term. Therapists may be able to facilitate an understanding of the terms Black and African American by helping clients to distinguish between racial and ethnic identities. Approaching identity from a both-and rather than an either-or perspective, black* Americans can accept Black as their racial identity and African American as their ethnic identity. Slavery. Fully comprehending African American couples and families requires understanding slavery. Slavery began in 1619 with the arrival of a Dutch ship in Jamestown, Virginia carrying 20 black Africans. Millions of blacks,

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including royalty, were stolen from their African homes, brought to America in chains, and sold into slavery for the specific purpose of white economic prosperity. Slavery, as a legal practice, ended with the Emancipation Proclamation by President Abraham Lincoln following the Civil War in 1865 (Meltzer 1984). Blacks* were enslaved in the United States of America for over 200 years. African people and cultures were rich and diverse (Meltzer 1984). Slaves were forced into one mass identity, stripped of their rightful names, country, tribal identities, language, religion, customs, and the right to read or write. As chattel, they were worked, raped, bred, whipped, and sold according to the master’s needs and desires (Watson 2013). Perceived as a better fit because their black skin made them more durable, slaves, including infants, were guinea pigs in medical and scientific experimentation (DeGruy 2005; Wyatt 1997). Slavery thus violated the most basic and core sense of self that, as Africans, the slaves had known. Slaves were denied the right to marry and forced to become studs and breeders. Slavery first established patterns of no marriage, out of wedlock children, teenage pregnancy, and absentee fathers. “The white man was the original abandoning father in this country” (Pinderhughes 1998, p. 187). He fathered children with slaves, denied paternity, and rebuffed his children. Slavery dismantled the black* family. The African sense of “we” was disturbed because slaves could be torn apart at any time. Couple and parenting relationships were fragile at best, and group solidarity was difficult to sustain. Direct support from or for the group was virtually nonexistent because of the perils of doing so (Wyatt 1997). Sexuality was altered for the slaves and their descendants, beginning with the rape and impregnation of black* females by white men aboard the slave ship (Wyatt 1997). Most female slaves were sexually assaulted by white men by their 16th birthday (Russell et al. 1992). Marriage and sex were valued and respected as a sacred part of life’s plan in Africa. Deprived of

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their clothing, with potential buyers and strangers touching their most private parts to determine if they were worth the price, the slaves’ destinies as sexual beings were changed on the auction block (Wyatt 1997). Slaves experienced a brutal attack on their bodies and minds. They had no real ability to nurture, care, protect, and support one another as intimate partners and parents. Slave men and women were forced to silently endure the degradation and humiliation of the other and to internalize the shame that comes from fear, powerlessness, defeat, and/or emasculation. Race and Racism. Race is a socially constructed concept, which preserves the myth of white superiority and black inferiority (Watson 2013). The institutionalized belief of white superiority and black inferiority is fundamental to the African American experience. According to Walton and Smith (2008), American founding father and author of the Constitution Thomas Jefferson stated in his Notes on Virginia that blacks were “inferior by nature, not condition” (p. 7). The white/black bifurcation functions to uphold the purity, privilege, beauty, goodness, and moral authority granted to whites at birth. By contrast, black* is targeted as inherently flawed, deficient, and undeserving, paving the way for social discrimination and bias. African Americans thus are likely to experience injustice, criminalization, devaluation, depression, anxiety, relational fractures, attachment ruptures, identity crises, trauma, high blood pressure, and more based on the socially imagined but life-shaping construct of race. Walton and Smith (2008) use Carmichael and Hamilton’s definition to describe racism as “the predication of decisions and policies on considerations of race for the purpose of subordinating a racial group and maintaining control over it” (p. 5). Regardless of one’s ideology or rationale, any policy that has the intent or effect to subordinate a racial group is decidedly racism. For racism to be successful, a group or individual must have the relative power to impose its will onto another group or individual through policies.

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Relevant Research About Family Life Black* family research primarily has emanated from three perspectives: (1) ethnocentric, (2) cultural relative, and (3) class. The ethnocentric view compares African Americans to Eurocentric values, norms, attitudes, and behaviors, resulting in pathology of any deviation. Congressman Daniel P. Moynihan is responsible for decades of research that approached black* families as pathological, affirming that the social is political. The infamous Moynihan Report entitled The Negro Family: The Case for National Action in 1965 resulted from President Lyndon B. Johnson’s request to understand social unrest and poverty in the black* community (Billingsley 1992). Blaming the victims, the Moynihan Report attributed problems in education, employment, and politics to internal black* family weaknesses. Rather than placing racism and injustice at the center, Moynihan placed the dysfunctional black* family at the center; reinforcing the policy perspective that society did not need to change and downplaying the need for civil rights legislation and affirmative action (Billingsley 1992). Emphasized as weak were the matriarchal black* family structure and the absence of black* males as heads of household, not the mandated invisibility of black men, such as that in 1662 requiring black children to take on the status (slave or free black) and name of their mothers regardless of the condition of the father (Russell et al. 1992). The cultural relativist perspective ascended in opposition to comparative studies of black* Americans to white Americans, espousing an Afrocentric worldview (Sudarkasa 2007). For instance, African American couples tend to have more egalitarian relationships, which reflect African values of unity, harmony, cooperation, and interdependence, not the Eurocentric value of head of household. The class perspective de-emphasizes race, seeking to understand the specific needs and concerns of African Americans according to socioeconomic status. Black Identity. Black slaves and white indentured servants worked together in early America, developing friendships and romantic relationships. Race mixing became a major concern,

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particularly black* men and white women. Also, race mixing made it more difficult to justify slavery on the basis of white morality and black immorality. Additionally, the widespread rape of female slaves by white masters presented a problem, namely, whether mixed race children should take on the free status of the white father or the black slave mother. Departing from traditional English law, Virginia enacted legislation, necessitating children to have the same status as the mother (Russell et al. 1992). The rising number of mulattoes required racial classification. The “one drop” rule was decided by legislators to address the problem of race mixing and to maintain the social order. Anyone with a drop of black blood was by definition black*. Mulattoes were forced into the black box no matter how white looking their skin, hair, and features, giving birth to a color caste system (colorism) that is evident today. Colorism positively affects those with lighter skin and negatively impacts those with darker skin, influencing power and privilege. Hence skin color may be the undercurrent in family strife or the basis for mate selection (Russell et al. 1992; Watson 2013). Whiteness as the ideal marker of beauty, education, success, and wealth is the backdrop against which African Americans develop identity, contributing to divisiveness in the African American community. For instance, this author’s lightskinned client Joe and his family considered themselves to be “exceptional” blacks*. Joe railed at worthless black* men and decried being a black* man. Yet everyday he went into his Fortune 500 company, he felt less than all of his white peers, leaving him disconnected from self, other blacks* and white coworkers. As a result, Joe suffered from severe anxiety and depression (Watson 2013). The Nigrescence model of black* identity (Cross 1991) comprises five developmental stages: (1) pre-encounter, (2) encounter, (3) immersion-emersion, (4) internalization, and (5) internalization-commitment. The pre-encounter stage starts with where the person is – the present identity that needs to be changed. Pre-encounter racial attitudes vary from low salience to neutral to

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rejecting. Low salience refers to individuals who accept being black* but do not see blackness as a factor in their daily lives. Some however feel compelled to defend themselves against blackness as a social stigma, having little knowledge of black* history or culture. Neutrality denotes persons who believe they have evolved beyond race. An example of which may be an actress who does not see herself as a black* actress but rather an actress who happens to be black*. Antiblack African Americans blame other blacks*, uphold racist stereotypes, and affirm white culture (Cross 1991). Underlying causes of pre-encounter attitudes may be “miseducation, a Eurocentric cultural frame of reference, spotlight or “race-image” anxiety, a race-conflict resolution model that stresses assimilation-integration objectives, and a value system that gives preference to other than Afrocentric priorities” (Cross 1991, p. 192). Given that the American educational system has not focused on Africa’s role in civilization and the role of blacks* in the making of America, blacks* generally have a distorted view of their own cultural history as well as other histories besides white western history. According to Cross (1991), poor mental health is not necessarily the most damaging outcome of miseducation but a learned world view that inhibits knowledge and weakens the capacity to advocate for one’s best interests. Through miseducation, blacks* are socialized to have a greater appreciation of all things white, leading to a Eurocentric cultural perspective. Thus blacks* in the pre-encounter stage may enjoy black* music and/or art but may see it as counter to being accepted into the white mainstream. The problem for blacks* is not appreciating white culture but seeing it as a measure of “correctness” (Cross 1991). Spotlight or race image anxiety speaks to African Americans being overly sensitive to white people’s belief in negative racial stereotypes, triggering worry about the behavior of other blacks*. On the positive side, spotlight anxiety can lead to a heightened awareness of prejudice and discrimination. However selfhating blacks* are beyond race image. Antiblack blacks* embody their disdain for black skin and see blackness as an imposition that must be discarded. Blacks* with an assimilation-

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integration outlook think it is incumbent upon African Americans to fit into white spaces and structures, not those structures changing to be more racially inclusive (Cross 1991). A person’s identity is shaped by early experiences in family and society. Once formed, identity is difficult to change, no matter the stage. Incoming experiences are expected to match a person’s understanding of self and the world. An encounter must occur that is strong enough to shake a person’s current identity, thrusting the individual toward needed change. The encounter can be a sudden event, such as the murder of nine black* people in a church in Charleston, South Carolina by a self-proclaimed white supremacist or the mass incarceration of blacks* (Cross 1991). The encounter can be positive (e.g., reading the Autobiography of Malcolm X) or negative (e.g., racial profiling) and involves two steps: experiencing and personalizing. Witnessing a dramatic event does not necessarily mean that one is changed by it. For a person’s worldview to be affected, the encounter must be personalized. Feelings of confusion, guilt, anger, anxiety, and depression likely are experienced in this stage, which may be motivational (Cross 1991). In the immersion-emersion stage, an individual is committed to developing a new identity but more familiar with the old identity. Persons in this stage exhibit first-order change, such as wearing natural hairstyles and/or African clothing. Also, either-or thinking is manifested in this stage wherein the old attitude of white is superior and black is inferior is reversed to black is superior and white is inferior. During the immersion phase, an individual is consumed with blackness – a self-liberating experience from whiteness – and tends to be judgmental about others’ blackness, which can become divisive. Anyone who becomes stuck at the immersion level has a pseudo-black* identity because of being more concerned with negating whites than affirming blacks* and dismantling racism (Cross 1991). Emersion signals the emergence from oversimplified dichotomous thinking and reactivity. An individual in the emersion phase is better positioned to develop a black* identity because

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there is a balance between emotion and intellect. Realizing that the commitment to black* issues does not require white hatred or negation, the individual is ready to move toward internalizing a new identity. However it should be remembered that individuals at the immersion-emersion stage might regress because of the warring old and emerging new identities; fixate on white hatred because of pain, anger, and guilt; or become overwhelmed and give up (Cross 1991). The internalization stage “seems to perform three dynamic functions in a person’s everyday life: (1) to defend and protect the person from psychological insults that stem from having to live in a racist society; (2) to provide a sense of belonging and social anchorage; and (3) to provide a foundation or point of departure for carrying out transactions with people, cultures, and situations beyond the world of blackness” (Cross 1991, p. 210). Second-order change occurs at the internalized stage of black* identity development. An individual is concerned with standards of blackness, not outward physical appearances of blackness or black* rhetoric. Uncontrolled anger is redirected away from white people toward racist systems and injustice; and black* pride replaces rigidity and a holier-than-thou black* attitude. Nonetheless, individuals at the end of this stage could develop a monocultural (black nationalist), bicultural (black and American), or multicultural (multiple cultural interests and saliences) orientation. Internalization-commitment, the final stage of the Nigrescence model, is mainly distinguished from internalization by a sustained interest and commitment to black issues (Cross 1991). Black Male-Female Relationships. Marriage is desired and valued by African Americans. Prior to the twentieth century, marriage was quite prevalent among African Americans. Currently, marriage is lower among black* Americans than any other racial or ethnic group. As well, African Americans have the highest rate of divorce and never married. Social scientist bell hooks (1981) posits that black* men adopted a view of black* women as controlling and emasculating from Moynihan’s unfavorable report about the matriarchal black* family. Likewise, black* women may have accepted a view of black* men as inadequate.

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The cognitive dissonance or discomfort between black* men and women may be due to the residual effects of slavery and ongoing racism (Watson 2013). Surviving the horrors of slavery, slaves disconnected emotionally. While emotional disconnection was a protective factor in slavery, it may be limiting black* marriage today. Living with the realities of racism may cause feelings of shame and helplessness in African American men and women that each may try to avoid by disconnecting or projecting onto the other. Finger pointing, African Americans attempt to justify rather than heal from the trauma of slavery. The devaluation of black* womanhood and manhood began in slavery with sexual victimization, objectification, and marginalization. Black* women were seen as hypersexual, and black* men were praised for their sexual prowess. The sexual objectification and victimization of black* men and women severed intimate bonds and created suspicion and distrust. Slavery and its racist aftermath taught black* women two important lessons: black* women were not deserving of the same protections as white women; and black* men could not be counted on to protect and provide. A prevailing message of the strong black* woman thus was born as black* men struggled with the “boy” complex from slavery (Watson 2013). Black Mass Incarceration. The mass incarceration of black people functions as the new Jim Crow, upholding the legacies of slavery in the present day. Imprisonment is profitable and, like slavery, requires bodies to secure the business interests of those that capitalize and benefit from it. Incarceration therefore has become the response to problems of addition, poverty, adolescence, and mental health issues. Blacks* are disproportionately incarcerated and tend to receive higher sentences, generating racial disparities in the criminal justice system that likely are steeped in myths about black inferiority and white superiority originating from slavery (Stevenson 2015). According to Stevenson (2015), the four institutions that have determined the American approach to race and justice are (1) slavery, (2) the reign of terror following slavery, (3) Jim Crow, and (4) mass incarceration. The end of

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slavery announced the beginning of terror for black* people by the police, KKK, or any white person. Black* families were constantly in fear of lynching, bombing, and overall racial violence. Also, blacks* were subject to conviction for nonsensical offenses that then allowed them to be leased (convict leasing) to businesses, effectively forcing them back into slave labor. Jim Crow, which legalized segregation and denied blacks* basic rights, had real consequences for daily psychological functioning of African American families. Similarly, modern-day racial profiling has many of the same characteristics and negative consequences for black* families. On a daily basis, blacks*, regardless of class, experience a variety of indignations and humiliations, whether followed in a store, profiled by the police, or mistaken for the help. Mass incarceration is a weakening burden borne by African American families and communities. Targeted prosecution and draconian laws for drug crimes in poor black* neighborhoods and the collateral damage (e.g., voter disenfranchisement and barriers to reentry) to African American families operate within the American legacy of race relations (Stevenson 2015).

Special Considerations for Couple and Family Therapy African Americans, unlike other ethnic groups, are sometimes seen as having no history and culture to safeguard or defend. Social scientist E. Franklin Frazier believed that the African culture was obliterated by the experience of slavery. Scholars Melville Herskovits and W.E. B. Du Bois opposed Frazier’s view, asserting that important vestiges of African culture survived slavery and that black* family life in the United States is an extension of African heritage (Billingsley 1992). Although ties to African heritage were broken and distorted in slavery, there remain African American cultural values that are submerged in African values. The intergenerational transmission of African values from slavery to the present can be seen in the behavioral and psychological

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functioning of African American families around interdependence, unity, mutual responsibility, reconciliation, cooperation, and religion/spirituality. Dr. Maulana Karenga solidified and, to a great extent, codified the cultural connection between Africa and African Americans when he founded Kwanzaa in 1966. Kwanzaa, an American holiday that commemorates the African cultural heritage of blacks*, is celebrated from December 26 to January 1 and is based on seven fundamental principles known as the Nguzo Saba. These seven principles are (1) Unity (Umoja), (2) Selfdetermination (Kujichagulia), (3) Collective Work and Responsibility (Ujima), (4) Cooperative Economics (Ujamaa), (5) Purpose (Nia), (6) Creativity (Kuumba), and (7) Faith (Imani) (McClester 1994). The cumulative effects of race have resulted in historical trauma or post-traumatic slave syndrome for African Americans as a people (DeGruy 2005). Absorbing the myth of white superiority and black inferiority has created lies and difficulties that manifest themselves today in multiple ways, including racial identity, black* marriage, and mass incarceration. Couple and family therapists must confront myths of racial differences and challenge racial injustice to work effectively with African American clients. Couple and family therapy should be a place where both therapists and African American clients can commit to a process of truth, honesty, and healing. Racial indignations and microaggressions accrue daily for African Americans, taking a serious toll on the mind, body, and spirit. As a result, couple and family therapists may be scratching only the surface with African American clients without a deeper conversation around slavery, race, and racism. African Americans have shown tremendous strength and resilience in the face of adversity. Hope and faith have been two major sustaining factors, allowing African Americans to achieve, accomplish, contribute, and survive despite slavery and racism. Nonetheless, if true healing is to come, African Americans must face the grief, losses, and trauma of their own history. Couple and family therapists must be prepared to help African Americans do so by seeing (own and

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that of client), not avoiding, race. Otherwise, couple and family therapists risk perpetuating racism and oppression in the lives of African American clients. As a cautionary note, couple and family therapists must do their own person of the therapist work, including uncovering racial biases, in order to be able to hold the intensity of engaging in meaningful conversations about race while staying emotionally present and connected in therapy. However the growing interest in evidencebased models of treatment may deter couple and family therapists from attending to race as a crucial dimension of inquiry in therapy. Fundamentally, evidence-based models tend to neglect broader social influences that impinge on black* families daily. Personally, this author believes that evidence-based models may unwittingly distort or mystify race and its impact on black* families. Denying, relabeling, or reframing race could be detrimental to African American clients because it basically robs them of their racial experiences and feelings, which might contribute to the development of a false self. Self-inauthenticity for African Americans, in turn, could reinforce feelings of internalized racism and black inferiority. Admittedly, evidence-based models, such as emotionally focused therapy (EFT) and attachment-based family therapy (ABFT), have not researched their applicability for clients of culturally and racially diverse backgrounds. However, they maintain a universality of human emotions, such as attachment. Nevertheless, attachment in families can be affected by outside social forces, which is well documented by slavery. Despite research demonstrating the effectiveness of evidence-based models across racial and cultural lines, the question of racial equality and healing from slavery and racism remains for African Americans. Families are affected by politics. The early pioneers in the field of couple and family therapy began a revolution that transformed mental health and changed the view of families from adversaries to supporters. Will the field again rise to the occasion and take an active stance against racism and oppression?

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Cross-References ▶ Black Men in Couples and Families ▶ Black Women in Couples and Families ▶ Boyd-Franklin, Nancy ▶ Cultural Competency in Couple and Family Therapy ▶ Cultural Values in Couples and Families ▶ Culture in Couple and Family Therapy ▶ Ethnic Minorities in Couple and Family Therapy ▶ Ethnicity in Couples and Families ▶ Hardy, Kenneth V. ▶ Intercultural Couples and Families in Couple and Family Therapy ▶ McGoldrick, Monica

References Billingsley, A. (1992). Climbing Jacob’s ladder: The enduring legacy of African American families. New York: Simon & Schuster. Cross, W. E. (1991). Shades of black: Diversity in AfricanAmerican identity. Philadelphia: Temple University Press. DeGruy, J. (2005). Post traumatic slave syndrome: America’s legacy of enduring injury and healing. Portland: Joy DeGruy Publications. hooks, b. (1981). Ain’t I a woman? Black women and feminism. Boston: South End Press. McClester, C. (1994). Kwanzaa: Everything you always wanted to know but didn’t know where to ask. New York: Gumbs & Thomas. Meltzer, M. (1984). A history in their own words: The black Americans. New York: HarperCollins. Pinderhughes, E. (1998). Black genealogy revisited: Restorying. In M. McGoldrick (Ed.), Re-visioning family therapy: Race, culture, and gender in clinical practice (pp. 179–199). New York: Guilford. Russell, K., Wilson, M., & Hall, R. (1992). The color complex: The politics of skin color among African Americans. New York: Anchor Books. Smith, T. W. (1992). Changing racial labels: From “Colored” to “Negro” to “Black” to “African American”. Public Opinion Quarterly, 56(4), 496–514. Stevenson, B. (2015). Just mercy. New York: Spiegel & Grau. Sudarkasa, N. (2007). Interpreting the African heritage in African American family organization. In H. P. McAdoo (Ed.), Black families (pp. 29–47). Thousand Oaks: Sage. Walton, H., & Smith, R. C. (2008). American politics and the African American quest for Universal freedom. New York: Pearson Longman.

Ahrons, Constance Watson, M. F. (2013). Facing the black shadow. Author. Wyatt, G. E. (1997). Stolen women: Reclaiming our sexuality, taking back our lives. New York: Wiley. Zilber, J., & Niven, D. (1995). “Black” versus “African American:” Are whites’ political attitudes influenced by the choice of racial labels? Social Science Quarterly, 76(3), 655–664.

Ahrons, Constance Roy H. Rodgers Professor Emeritus, University of British Columbia, Vancouver, BC, Canada

Name Constance R. Ahrons, Ph.D.

Introduction Constance R. Ahrons has been a leading scholar with her contributions to the theory and research on divorced families. She has been a major influence in family therapy education and practice.

Career Ahrons received her Ph.D. from the University of Wisconsin in 1973. She held positions as Assistant and Associate Professor in the School of Social Work at Wisconsin (1974–1984) and Cofounder and Therapist, Wisconsin Family Studies Institute, Madison, Wisconsin (1979–1984). The major portion of her career was spent at the University of Southern California as an Associate Professor in the School of Social Work and Associate Professor and Professor of Sociology (1986–2001). In the latter positions, she was heavily involved in the training of family therapists as the Associate Director and Director of the Marriage and Family Therapy Program. She retired as Professor Emerita in 2001.

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Among her awards are: Distinguished Research Award, Association of Family and Conciliation Courts; Fellow, Radcliffe Institute for Advanced Study, Harvard University; and Distinguished Cumulative Contrtibution to Family Therapy Research, American Family Therapy Academy. She is a Fellow of the American Association for Marriage and Family Therapy and the American Orthopsychiatric Association.

Contributions to Profession Based on her pioneering 5 year longitudinal study of 98 postdivorce couples and her 20 year followup of over 90% of the children of those divorces, she introduced the concepts of “binuclear family” and “the good divorce.” Over thirty articles, book chapters, and three books have resulted in the widespread use of these concepts in the theoretical and research literature on the structure and behavior of divorced families, as well as in clinical practice. By normalizing divorce and its transitions and removing it from a purely pathological view, her work has served to change the culture of divorce in practice, scholarly theory and research, and in public perceptions. Her work has provided a new language for the structural and behavioral dynamics in the family from childless couples, to families with children, to postchild and aging couples. A major contribution to the field has been her numerous presentations nationally and internationally to professional and lay audiences. These appearances have served to stimulate scholarly activity in the field and to invigorate public thinking about the changes in families during the divorce experience. Within the profession Ahrons has been active in bringing her experience to a broad range of organizations. These include: Cofounder, first Chair, and Board Member of the Council on Contemporary Families Guest Editor, Family Process, Special issue on Divorce and Remarriage

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Editorial Boards: Journal of Divorce and Remarriage; Psychotherapy and the Family; Family Process American Family Therapy Association: Charter Member, Executive Board (elected), Member of Research Committee, Chair of the Clinical Research Conference American Association for Marriage and Family Therapy: Fellow, Approved Supervisor, Commission on Supervision Research Committee American Psychological Association, Member International Academy of Collaborative Professionals, Member International Family Therapy Association. Member National Conference on Family Relations, Member, Publications Committee

References Ahrons, C. R. (1979). The binuclear family: Two households, one family. Alternative Lifestyles, 2, 499–515. Ahrons, C. R. (1994). The good divorce: Keeping your family together when your marriage comes apart. New York: Harper Collins Publishers. Ahrons, C. (1996). Making divorce work. Video: San Francisco: Psychotherapy.net. Ahrons, C. R. (1998). Divorce: An unscheduled life cycle transition. In B. Carter & M. McGoldrick (Eds.), The family life cycle. New York: Allyn and Bacon. Ahrons, C. R. (2004). We’re still family: What grown children have to say about their parents’ divorce. New York: Harper Collins Publishers. Ahrons, C. R., & Rodgers, R. H. (1987). Divorced families: A multidisciplinary developmental view. New York: Norton.

Ainsworth, Mary Mary A. Fisher Mary Fisher Psychotherapy, PLLC, Salt Lake City, UT, USA

Name Ainsworth, Mary

Ainsworth, Mary

Introduction Mary Dinsmore Salter Ainsworth was a developmental psychologist whose vanguard empirical methodology and theoretical formulations validated the basic tenets of attachment theory while contributing to the theory itself. Her conscientious, nurturing approach shaped numerous students and colleagues whose work forms much of the substance of contemporary developmental psychology. Ainsworth was born in 1913 in Ohio, to Mary and Charles Salter. The family moved to Toronto, Canada, in 1918 when Charles was transferred and the family adopted Canadian citizenship. Academic achievement was prized in the Ainsworth family, and Mary was precocious; she learned to read at three. At 16, Ainsworth began honor psychology courses at the University of Toronto. Despite her father’s initial suggestion that she become a stenographer before she married, Ainsworth earned a doctorate in developmental psychology at the University of Toronto in 1939 (Ainsworth 1983).

Career Ainsworth’s first postgraduation appointment, as a lecturer at the University of Toronto, was circumvented by World War II. She joined the Canadian Women’s Army Corps in 1942, conducting assessments and counseling, and was promoted to the rank of major within the year. After V-Day, Ainsworth was invited to an administrative position as superintendent of Women’s Rehabilitation in the Department of Veteran’s Affairs. Within a year, she had developed a multidisciplinary clinical vantage, deemed she had accomplished what she could, and had tired of administrative work (Ainsworth 1983). Returning to the University of Toronto, she married Leonard Ainsworth, a veteran who was finishing his master’s degree. Concerned about how it might feel to continue a Ph.D. in the department where she had a faculty assignment, the couple moved to London when Leonard continued as a doctoral student at University College, even though Mary had no work

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arranged for herself. In the interim, she co-authored a book on the Rorschach with Bruno Klopfer, Walter Klopfer (1954). It was at a research position at the Tavistock Clinic, directed by John Bowlby, that she began to formulate the research methodology that she would later employ in her cardinal works. Studying the effect of maternal separation on personality development with James Robertson, she was intrigued by his use of direct, naturalistic observations followed by basic descriptive statistics. As well, Ainsworth’s collaborations with Bowlby, during the early genesis of attachment theory itself, would change the course of her career (Bretherton 1992). Bowlby proposed that the processes of social bonding in infancy were less congruent with both psychoanalytic theory and social learning theory, and more specifically with biology and ethology, in particular Lorenz’ concept of imprinting. Ainsworth remained skeptical, influenced, as much of psychology was, by the operant conditioning zeitgeist (Ainsworth 1983). When her husband finished his doctorate and applied for a position at the East African Institute of Social Research at Kampala, Uganda, Ainsworth, again, accompanied him with no work arranged for herself, though she was able to cobble together funds for a simple, anthropological, observational study. At the same time, she called for empirical validation of Bowlby’s ethological views. Her motivation gave birth to one of two cardinal studies in Ainsworth’s career. From 1954 to 1955, Ainsworth’s field study paid particular attention to “the onset of proximity-promoting signals and behaviors, noting carefully when these signals and behaviors became preferentially directed toward the mother” (Bretherton 1992, p. 7). Significantly, Ainsworth found that secure infants cried less and explored more, while insecure infants cried more and explored less, and that maternal sensitivity to infants’ communications was correlated with infant security. She also found that it was not breastfeeding, per se, but rather the mother’s enjoyment of breastfeeding that is salient to infant security (Ainsworth 1967). These findings contradicted prevailing behavioral notions and resulted in criticism and

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controversy. Nonetheless, her work began to validate Bowlby’s initial suspicions: Infants are genetically predisposed to seek and maintain proximity to adult caregivers, even before they are able to ambulate, by crying, vocalizing, and reaching. Optimally, adult caregivers respond with complementary behaviors involving protection and care. This ethological view proposed that infants become attached to the caregivers who most reliably and substantially relate with them and is its own motivational system distinct from feeding (Bretherton 1992). Ainsworth’s second cardinal project began with a theme that persisted throughout her married life: Leonard found an appointment, and Mary followed, having made no arrangements for herself, though she asserted that career differences were not at the root of their ultimate divorce in 1960 (Ainsworth 1983). The couple settled in Baltimore. Johns Hopkins University eventually created a position for her; responsibilities included providing psychological services, teaching, and the supervision of clinical students. Ainsworth soon found that her clinical appointment left scant time for research, and thus she was released to pursue what she would later write “drew together all the threads of my professional career” (Ainsworth 1983, p. 213). Her Baltimore study combined naturalistic observation in the homes of middle-class families with a laboratory procedure she and Wittig (1969) named the Strange Situation. The Strange Situation, the first of its kind, standardized a means of assessing how infants organize proximityseeking behavior with attachment figures, illuminating normative patterns for how secure and insecure infants respond to stress. Early criticism of Ainsworth’s interpretations of infant behavior in the Strange Situation was countered by the fact that classifications were extensively validated against home observations (Bretherton 1992). For example, some critics viewed what Ainsworth classified as avoidant behavior rather as independence. However, her data showed that those babies had a less congenial relationship with their mothers at home than did the secure infants. Alan Sroufe and Everett Waters later further validated Ainsworth’s classification with their psychophysiological study revealing that the unperturbed demeanor of

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avoidant infants upon separation from caregivers belied their distress, as evidenced by increases in cortisol and heart rate (A. Sroufe, March 30, 2018, personal communication). Collegial collaboration and connection were vital to Ainsworth, in part evidenced by her vibrant correspondence and collaboration with John Bowlby until his death, and the numerous graduate students who were enriched by her mentorship, including Mary Main, co-developer of the Adult Attachment Interview, Robert Marvin, one of the originators of the Circle of Security. In 1975, when developmental psychologists were scant at Johns Hopkins, she accepted a position at the University of Virginia and continued her collaborative efforts. In 1978, along with Blehar, Waters, and Wall, she published Patterns of Attachment: A Psychological Study of the Strange Situation, which is a report of the methodology and results of her Baltimore study. Ainsworth’s contributions and achievements were lauded: the American Psychological Association bestowed her with the G. Stanley Hall Award in 1984, the Award for Distinguished Contributions to Child Development in 1985, and the Distinguished Scientific Contribution Award in 1989. She was elected a Fellow of the American Academy of Arts and Sciences in 1992.

Contributions to Profession of Couple and Family Therapy It is unlikely there exists a singular clinician in the field of couple and family therapy who is unaware of attachment theory, which is the result of a joint effort between both Bowlby and Ainsworth. Bowlby’s contributions were entirely theoretical and would not have had the impact and longevity without Ainsworth’s empirically validating contributions (A. Sroufe, March 30, 2018, personal communication). Her work contributed to a more accurate understanding of infant behavior and emotion, as well as what infants need for security. Because of her work, clinicians may confidently help struggling parents understand that picking up a crying baby will ultimately result in a

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baby who cries less. Because of her scientifically rigorous nurturance, the field of attachment theory continues today, with conceptualizations of attachment across the lifespan, psychopathology, cross-cultural studies, and public policy (Bretherton 1992).

Cross-References ▶ Adult Attachment Interview ▶ Attachment Disorders in Couple and Family Therapy ▶ Attachment Theory ▶ Attachment-Based Family Therapy ▶ Bowlby, John ▶ Children in Couple and Family Therapy ▶ Circle of Security ▶ Circle of Security Parenting Enrichment Program ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Development in Couples and Families ▶ Fathers in Families ▶ Mentalization in Couple and Family Therapy ▶ Mothers in Families ▶ Parenting in Families ▶ Research in Relational Science ▶ Tavistock Clinic

References Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant care and the growth of love. Baltimore: The Johns Hopkins Press. Ainsworth, M. D. S. (1969). Object relations, dependency, and attachment: A theoretical review of infant-mother relationship. Child Development, 40, 969–1025. Ainsworth, M. D. S. (1983). Mary D. Salter Ainsworth. In A. N. O’Connell & N. F. Russo (Eds.), Models of achievement (pp. 200–219). New York: Columbia University Press. Ainsworth, M. D. S., & Wittig, B. A. (1969). Attachment and the exploratory behavior of one-year-olds in a strange situation. In B. M. Foss (Ed.), Determinants of infant behavior (Vol. 4, pp. 113–136). London: Methuen. Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale: Erlbaum.

Alcohol Use Disorders in Couple and Family Therapy Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759–775. Klopfer, B., Ainsworth, M. D., & Klopfer, W. F. (1954). Developments in the Rorschach Technique, vol. 1: Technique and theory. Yonkers-on-Hudson: World Book Company.

Alcohol Use Disorders in Couple and Family Therapy Autumn Rae Florimbio, Meagan J. Brem and Gregory L. Stuart University of Tennessee-Knoxville, Knoxville, TN, USA

Synonyms Hazardous alcohol use; Problematic alcohol use

Introduction Alcohol is one of the most commonly used substances. While some individuals can use alcohol safely, others’ patterns of use result in significant impairment in functioning across various life areas. Such impairment typically occurs when alcohol is used frequently, excessively, and hazardously. Recurrent use of alcohol in this manner that is accompanied by significant impairment is recognized as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA] 2013). Alcohol use disorder (AUD) is characterized by a combination of features, including loss of control over one’s alcohol use and physiological symptoms. Moreover, AUD is associated with a host of shortand long-term consequences such as alcoholrelated accidents, physical and mental health problems, and disturbances in social, occupational, and/or familial functioning. Although a diagnosis of AUD occurs at the individual level, the consequences associated with AUDs extend beyond the individual, affecting partners and family members. Given the impact AUDs can

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have on relationship functioning, it is crucial to understand AUDs in the context of couple and family therapy.

Theoretical Context for Concept Consequences associated with alcohol-related problems can contribute to relationship distress, which in turn can serve as a cue for further alcohol use (Kelly 2009). Within couples, AUDs are associated with relationship conflict, an increased risk for partner violence, reduced intimacy, financial difficulties, and emotional health problems in one or both partners. When working with couples and families, it is important to explore the dynamics of the couple or family from a systemic view. In other words, rather than focusing solely on one individual, the focus should include all members of the family system and the interactions that occur among them. Exploring relationships from a systemic view provides information about each individual within the system and how interactions between individuals contribute to relationship functioning. This notion holds true when addressing AUDs in the context of couple and family therapy. That is, the focus should not be limited to only the individual with the AUD diagnosis but should include all members of the family system and the interactions that occur among members as well. In regard to AUDs, individual and systemic factors have been identified that may contribute to a partner’s alcohol use and, in turn, affect relationship functioning. One area to consider is individual attitudes and beliefs regarding alcohol use and AUDs. Individuals may hold certain beliefs about the origins and explanations of alcohol use and related disorders. For example, one partner may hold the belief that using alcohol is a choice and abstaining from alcohol use is just another choice that should not be difficult. This belief could impact how the partners address alcoholrelated problems and how they interact with one another. Additionally, this belief could interfere with treatment. A clinician aware of such beliefs could provide psychoeducation about current explanations of alcohol use and the intricacies of

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repeated alcohol use on biopsychosocial functioning (Lander et al. 2013). The various functions of alcohol use within the relationship should also be considered. There is evidence suggesting that alcohol use can facilitate intimacy and warmth among couples and may be viewed as a positive component within the relationship (Leonard and Eiden 2007). However, there are often situations in which the function of alcohol within the relationship is not apparent to partners. In some cases, alcohol may be used as a way to cope with relationship distress. One partner may use alcohol as a way to cope with day-to-day arguments occurring within the relationship and be unaware that the arguments are a result of consequences related to the alcohol use (e.g., financial difficulties, not fulfilling responsibilities around the home). This emphasizes the importance of understanding alcohol’s function within a couple and/or family system. Another factor to consider is exploring the interaction between partners’ behaviors and how behaviors may reinforce an individual’s problematic alcohol use. For example, when one partner has an AUD, the other partner may engage in enabling behaviors, behaviors they perceive as caring and helpful, such as making excuses for a partner missing work, when the behaviors may actually maintain problematic alcohol use by reinforcing properties of alcohol use or eliminating negative consequences (Klostermann and O’Farrell 2013; McCrady 2012; Rotunda et al. 2004). It is important to note that such behaviors may be a partner’s method of coping with their partner’s alcohol use. Identifying reinforcing properties of behavior among couples and families is important to understand the reciprocal relationship between AUDs and relationship functioning.

Description Different treatment modalities exist for treating AUDs in couple and family therapy. Behavioral couples therapy (BCT) is one approach to treating AUDs and other risky substance use in couples (O’Farrell and Schein 2011). BCT

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consists of treatment using substance- and relationship-focused methods in conjunction, although substance-focused methods are typically employed first. Substance-focused methods in BCT include a daily recovery discussion or contract around the sobriety of the partner with the AUD. Each day, the partner states their intent of sobriety for the week and plans for their recovery, such as attending self-help meetings. The other partner is encouraged to support their partner’s goals for sobriety and maintaining abstinence. Other substance-focused methods include identifying and reviewing high-risk situations that may trigger an urge to use alcohol and discussing with both partners the role of relapse in recovery. Relationship-focused methods include increasing positive activities and communication within the relationship. A similar approach is alcohol behavioral couples therapy (ABCT), which aims to include both partners in the treatment process and encourage change within both partners. Goals of ABCT include (a) involving both partners in the treatment process, (b) reducing or discontinuing alcohol use, (c) helping both partners develop effective coping skills and responses to apply to drinking situations, (d) increasing relationship satisfaction, and (e) maintaining improvements established in therapy (Kelly 2009; McCrady 2012). Both BCT and ABCT have demonstrated favorable outcomes in terms of reduced drinking and better relationship functioning (McCrady 2012; O’Farrell and Schein 2011).

Application of Concept in Couple and Family Therapy Couples and families may present to treatment already having identified alcohol use as the primary problem. However, there may be situations in which couples and families present to treatment for problems associated with alcohol use such as financial difficulties, domestic violence, or decreased relationship satisfaction. In other words, rather than identifying alcohol use as a culprit for problems within the relationship or family, alcohol-related consequences may be the

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reason for presenting to treatment (Cox et al. 2013). As such, it is critical to routinely assess alcohol use at the onset of treatment, even when it is not the presenting problem. In addition to a thorough assessment, therapists should clarify the impact and function of alcohol use within the couple or family. The impact of having a parent with an AUD on children and adolescents, as well as how AUDs among adolescents can impact the family system, should be considered. When a parent or guardian has an AUD, children may develop reversed roles in which they begin to take on a parental or caregiver role. Taking on a role before it is developmentally appropriate is associated with difficulties setting interpersonal boundaries and regulating emotions (Lander et al. 2013). Children and adolescents with parents who have an AUD are at an increased risk for the later development of psychological disorders, including alcohol and substance use disorders. Adolescents with an AUD can impact the family system as well, and treatment should focus on increasing familial support for abstinence, improving communication, and restoring the family environment and functioning. When working with couples and families in which one or more members have an AUD, it is important to convey that the disorder does not solely affect the diagnosed individual, but both members of the couple or members of the entire family system. Similarly, it should be communicated that behavior change of one partner or family member that will occur during the course of therapy will affect other members (Lander et al. 2013).

Clinical Example Bill and Jane presented for couple therapy after experiencing increased arguments, problems with communication, decreased intimacy, and overall relationship dissatisfaction. The couple had been married for 7 years with one child, a 4-year-old daughter. The couple described their relationship as “good” up until 1 year ago when Jane was let go from her job. The couple revealed that Jane’s alcohol use had escalated significantly since then and seemed to relate to much of their relationship

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discord. The therapist further assessed the role of alcohol in their relationship. After becoming unemployed, Jane applied to several jobs yet was unable to secure employment. This was discouraging to Jane and her evening glass of wine seemed to help with handling her current situation. Her evening glass of wine gradually increased to three to four glasses, and eventually she was drinking nearly two and a half bottles of wine daily. Despite having more time to fulfill obligations at home, Jane’s drinking interfered with her ability to meet her obligations. Bill agreed and indicated that there were several occasions in which he had come home from work to find that Jane did not follow through on tasks she said she would complete (e.g., running errands, grocery shopping, laundry, etc.). At first, Bill would complete the tasks for her; however, Bill had become frustrated with Jane and he began to argue with her about her drinking. Bill admitted that he had become increasingly overwhelmed as a result of working more hours to support their family. Jane’s increased alcohol use was negatively impacting her relationship with Bill. As the turmoil in their relationship increased, Jane’s desire to drink increased as a means to cope with the stress. Following the assessment sessions, the therapist provided feedback based on the information the couple had provided during the assessment. Jane’s use of alcohol functioned as a coping mechanism for negative emotions and relationship distress. Her use also impaired her ability to fulfill responsibilities at home, which contributed to Bill’s stress. Bill’s response (e.g., taking care of her, completing tasks for her) reinforced Jane’s alcohol use, as it removed negative consequences associated with her drinking. While acknowledging that treatment would be challenging, Bill and Jane were both motivated for treatment to increase satisfaction within their relationship and work toward Jane’s goal of achieving abstinence from alcohol. The beginning of therapy focused on reducing Jane’s alcohol use. One strategy utilized was for the couple to engage in a daily conversation that Jane initiated in which she stated her intentions for sobriety that day. The discussion also included Jane’s intent for attending self-help and support groups, such as Alcoholics Anonymous. Bill was

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encouraged to convey his support of Jane’s plan for sobriety. The couple practiced the discussion in session prior to trying it at home on their own. The therapist also provided psychoeducation on various aspects of AUDs. Specific situations that elicited cravings for alcohol and/or triggered Jane’s alcohol use were assessed. Focusing on specific situations increased awareness for both partners regarding situations that would be particularly challenging for Jane. Jane learned alternative, healthy ways to cope with situations, and Bill learned skills to provide support for Jane in responding to situations that might serve as a trigger for her. Eventually the couple applied the positive coping skills they learned to other areas of concern in their relationship (e.g., communication problems, and reduced intimacy). Bill and Jane practiced openness and honesty with each other regarding their feelings on a daily basis. They scheduled time together that did not involve alcohol and worked on increasing positive interactions between them. They identified current problems (e.g., Jane’s unemployment, financial difficulties), and, with the help of the therapist, they developed potential solutions to solve them. Throughout the course of therapy, Jane decreased her drinking and achieved abstinence from alcohol. Bill and Jane were able to effectively communicate with each other which reduced the amount of arguments and increased their overall relationship satisfaction.

Cross-References

Alcoholics Anonymous, 12-Step Programs Kelly, A. B. (2009). Behavioral couples therapy in the treatment of alcohol problems. In P. M. Miller (Ed.), Evidence-based addiction treatment (1st ed., pp. 233–247). Burlington: Elsevier/Academic. Klostermann, K., & O’Farrell, T. J. (2013). Treating substance abuse: Partner and family approaches. Social Work in Public Health, 28, 234–247. https://doi.org/ 10.1080/19371918.2013.759014. Lander, L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families and children: From theory to practice. Social Work Public Health, 28, 194–205. https://doi.org/10.1080/19371918.2013.759005. Leonard, K. E., & Eiden, R. D. (2007). Marital and family processes in the context of alcohol use and alcohol disorders. Annual Review of Clinical Psychology, 3, 285–310. https://doi.org/10.1146/annurev.clinpsy.3.022806.091424. Marital. McCrady, B. S. (2012). Treating alcohol problems with couple therapy. Journal of Clinical Psychology, 68(5), 514–525. https://doi.org/10.1002/jclp.21854. O’Farrell, T. J., & Schein, A. Z. (2011). Behavioral couples therapy for alcoholism and drug abuse. Journal of Family Psychotherapy, 22(3), 193–215. https://doi. org/10.1080/08975353.2011.602615. Rotunda, R. J., West, L., & O’Farrell, T. J. (2004). Enabling behavior in a clinical sample of alcoholdependent clients and their partners. Journal of Substance Abuse Treatment, 26(4), 269–276. https://doi. org/10.1016/j.jsat.2004.01.007.

Alcoholics Anonymous, 12-Step Programs Shannon Cooper-Sadlo1 and Jessica L. Chou2 1 School of Social Work, Saint Louis University, St. Louis, MO, USA 2 Queen of Peace Center, St. Louis, MO, USA

▶ Addictions in Couple and Family Therapy ▶ Behavioral Couple Therapy ▶ Substance Use Disorders in Couple and Family Therapy

Synonyms

References

Introduction

American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Cox, R. B., Ketner, J. S., & Blow, A. J. (2013). Working with couples and substance abuse: Recommendations for clinical practice. The American Journal of Family Therapy, 41, 160–172. https://doi.org/10.1080/01926187. 2012.670608.

Over 17 million individuals suffer from alcohol dependence or abuse, and millions more exhibit risky behaviors that have the potential to become an addiction (ncadd.org). In response to this public health problem, Alcoholics Anonymous (AA)* was created “. . . to carry the message of recovery to the

AA*

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person with alcoholism who is seeking help in achieving sobriety,” (Barnett 2003, p. 469). Since inception in 1935, AA supports individuals and their families in the recovery process through a 12-step program. Often times, various systems of a person’s life are disrupted by alcohol use including social networks (friends, family, coworkers). Through AA a person can begin their journey to recovery and rebuilding their life.

Location Alcoholics Anonymous is the oldest 12-step program and has more than 114,000 groups worldwide and a membership of two million individuals in the USA and Canada (Alcoholics Anonymous World Services 2012). Groups are often held at churches, community centers, and treatment facilities. Individuals are encouraged to contact the regional chapter in order to locate meetings in the area. AA offers groups that are specific to gender, age, demographic, as well as offering groups for members with co-occurring mental health issues.

Prominent Associated Figures Alcoholics Anonymous is a mutual aid group that was developed in 1935 by Bill Wilson and Dr. Bob Smith. AA was influenced by the Oxford Group, an international religious movement in the 1920s and 1930s, which incorporated the early teachings of Christianity and self-improvement that encouraged an examination of the lives of the members, admitting wrongdoing, making amends, praying and meditation, and spreading the work of the group (Fewell and Speigel 2014; Reiter 2015).

Contributions (Including What It Is Known for, Relevance to Couple and Family Therapy, and Mission and Values, Though Not Presented in Separate Sections) AA Overview AA is a strictly peer-led program that requires anonymity in order to ensure that

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members have the freedom to share personal narratives that are the basis of the supportive nature of mutual aid groups. There are three types of meetings, and newcomers are encouraged to attend 90 meetings in 90 days as well as obtaining a sponsor. The three types of meetings include: Speaker meetings, Discussion meetings, and Step meetings. Speaker meetings are personal addiction and recovery narratives by members who have at least 90 days of sobriety. Discussion meetings are open for members to share personal experiences but center around a specific topic. Step meetings focus on the exploration and discussion of a particular step and how members have used that step in their recovery process. Speaker meetings are traditionally open to all who wish to attend, while Discussion meetings and 12-Step meetings can be closed to anyone that is not a part of the fellowship (Alcoholics Anonymous 2016; Fewell and Speigel 2014; Reiter 2015). Ultimately, the 12-Steps were developed and are the guiding principles of AA and the other 12-Step programs that have developed utilizing the prototype of AA. The 12-Steps are: 1. We admitted we were powerless over alcohol – that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

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10. Continued to take personal inventory and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs. (Alcoholics Anonymous 2016).

members of the unit have experienced consequences of alcohol dependence. Alcohol problems within a couple or family can generate marital conflict and have a negative impact on children. As research suggests that family and couple relationships are an integral part of the recovery process for those with alcohol addiction (Navarra 2007), AA can be used as a counterpart to couple and family therapy to treat the whole family system (Walsh 2003). Family is encouraged to attend meetings and help participate in the recovery process (Gurman 2008).

Values Bill W. wrote Alcoholics Anonymous (Bill 1939/1976), which is often referred to as “The Big Book” as a guide to the recovery process. This text describes “The Promises” which are statements that encourage members to accept responsibility for recovery, engage in a spiritual awakening, and use personal experiences to provide guidance and support to others. If members adhere to the 12 Steps, recovery from substance use is possible (Fewell and Speigel 2014). The goals of AA are maintained abstinence from substance use, a sober support community, as well as a guide for psychological and spiritual well-being.

Al-Anon Overview Al-Anon grew out of the AA movement as a support for the families and friends of the members of AA. Lois, the wife of Bill W., was instrumental in the formalization of Al-Anon as a separate self-help group in 1951 (Fewell and Speigel 2014; Reiter 2015). Al-Anon remains the most recognizable and widespread support group for families and friends of loved one with alcohol addictions. According to a 2009 Al-Anon survey, Al-Anon groups are found in the USA, Canada, and 130 countries worldwide (Al-Anon Family Groups 2009; Fewell and Speigel 2014).

Relational Perspective of AA Many who suffer from alcohol addiction have severed personal and professional relationships leaving an individual isolated to manage their disease. Each person participating in the 12-Step program is encouraged to utilize support by seeking out a sponsor. Sponsorship is described as a supportive one-onone relationship with a long-term member of AA (Fewell and Speigel 2014; Reiter 2015). Sponsorship provides an individual in the program a person to turn to in times of question and hardship, as well as someone who will celebrate recovery through shared experience. As alcoholism impacts individuals and their families, a sponsor can assist an individual in exploring different capacities for family involvement. When one member of a family is experiencing alcohol addiction, there is a high likelihood other

The majority of the participants in Al-Anon are the female partner/spouse of men who have an addiction (Fewell and Speigel 2014). The 2009 survey of Al-Anon participants reports that 84 % of the members are women and 60 % are over the age of 56 (Al-Anon 2009). Of the respondents of this survey, 94 % were still involved with the individual whether or not the loved one was sober (Al-Anon 2009). Al-Anon utilizes the 12 steps of AA as the guiding principles with the exception of the final step in which the language is changed to include the education of others (Reiter 2014). The focus of Al-Anon is to provide ongoing support and increase the coping skills for the families and friends of the person with the addiction. Al-anon addresses the issue of codependency through the slogan of the three C’s: “I didn’t cause alcoholism, I can’t control it, and I can’t cure it” (Al-Anon Family Groups 2009). Participants can focus on their recovery

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needs rather than on the person with the addiction. Furthermore the refocusing of attention to the self provides the participant the opportunity to “detach with love” from the loved one’s behaviors while maintaining a positive and loving relationship with the person. Due to the increase of 12-Step groups that address specific drugs, drug-specific and age-specific family support groups have grown as well. These groups are Nar-Anon and Alateen. The groups offer an opportunity for peer support and growth for those who have a loved one with an addiction.

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Alexander, James Douglas Kopp and Michael Robbins Functional Family Therapy LLC, Seattle, WA, USA

Name James F. Alexander.

Introduction Cross-References ▶ Addictions in Couple and Family Therapy ▶ Adult Child of Alcoholics (ACOA) ▶ Alcohol Use Disorders in Couple and Family Therapy ▶ Family of Origin ▶ Stages of Change in Couple and Family Therapy

References Al-Anon Family Groups. (2009, Fall). Al-Anon membership survey. Virginia Beach: Author. www.al-anon.org/ membership-2009-survey Alcoholics Anonymous World Services. (2012). 2011 Membership survey. Retrieved July 26, 2016, from http://www.aa.org Alcoholics Anonymous. (2016). AA.org. Retrieved July 29, 2016, from http://www.aa.org Barnett, M. A. (2003). All in the family: Resources and referrals for alcoholism. Journal of the American Academy of Nurse Practitioners, 10, 467–472. Fewell, C. H., & Speigel, B. R. (2014). 12-Step programs as a treatment modality. In S. L. Straussner (Ed.), Clinical work with substance-abusing clients (3rd ed., pp. 275–300). New York: The Guilford Press. Gurman. A. (Ed.). Clinical handbook of couple therapy (4th ed). New York: Guilford Press. Navarra, R. (2007). Family response to adults and alcohol. Alcoholism Treatment Quarterly, 25, 84–104. Reiter, M. D. (2015). Substance abuse and the family. New York: Routledge Publishing. Walsh, F. (Ed.). (2003). Normal family processes: Growing diversity and complexity (3rd ed.). New York: Guildford Press.

Alexander is the developer of Functional Family Therapy (FFT), one of the most widely disseminated family therapy approaches for young persons with disruptive behavior problems. His contributions to the field span more than four decades with over 100 publications demonstrating the impact of family therapy for one of the most recalcitrant clinical populations. His work has been recognized by the Centers for Disease Control, Office of Juvenile Justice and Delinquency Prevention, and the Surgeon General as one of the most effective treatments for youth with behavior problems.

Career Alexander received his Bachelor of Arts from Duke University before attending graduate school at the California State University and Michigan State University, where he received his Ph.D. For more than 40 years, Alexander was a Professor at the University of Utah in Salt Lake City where he developed FFT. During this time, he served as principal or coprincipal investigator on numerous clinical and research grants and contributed numerous publications to the field of family therapy. Alexander served as President of Division 43 of the American Psychological Association in 1988. Alexander’s contributions to the field have been consistently recognized by his peers,

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including the American Psychological Association where he has received the Presidential Citation for Lifetime Contributions to Psychology, Family Psychologist of the Year, and Distinguished Contribution to Family Psychology Awards.

Contributions to Profession Alexander began to create and research the core elements of Functional Family Therapy (FFT) in 1971 in collaboration with Drs. Cole Barton and Bruce Parsons. The development of the FFT model has now spanned more than four decades and represents one of the most rigorous and clinically compelling programs of research in the field of evidence-based practice. Jim’s body of work has included core experimental family interaction research, in-session change mechanisms research, developing and sequencing clinical model elements, developing training formats, and conducting outcome research evaluating proximal, intermediate, and long-term outcomes. After the first two decades of research and clinical development, primarily led by Dr. Alexander and colleagues at the University of Utah, the FFT model was designated by the Center for the Study and Prevention of Violence as a “Blueprints Program.” FFT has received similar designations as an Exemplary Program, Best Practice, and Evidence-Based Effective program (Center for Substance Abuse Prevention, Centers for Disease Control, Office of Juvenile Justice and Delinquency Prevention, and the American Youth Policy Forum) for the treatment of youth violence, substance abuse, and related behavioral disorders. FFT also has been designated one of only four Level 1 treatment programs in the 2001 US Surgeon General’s Report on Youth Violence (www. ncbi.nlm.gov/pubmed/20669622). Over the past two decades, Alexander has spearheaded efforts to move FFT from research to clinical practice settings. The FFT model is now one of the most widely-disseminated familybased intervention programs for adolescent violence, substance abuse, and related behavioral disorders. The effectiveness of FFT has been replicated across sites, settings, ethnic cultural

Alexander, James

groups, and service providers with diverse backgrounds and training. Moreover, evidence supports the effectiveness of FFT for siblings and parents of problem youth, and for the long-term effectiveness of the intervention. Alexander’s efforts to develop, test, and disseminate the FFT model has had a broad impact on youth, families, and communities, both nationally and internationally. FFT is being implemented systematically in more than 350 accredited sites in USA, Europe, and the Western Pacific/Asia. FFT LLC (www.fftllc. com) trains and supervises/consults with 2000+ therapists treating 40,000+ families per year, with session-by-session tracking for feedback and quality control. Thus, implementation in the real world has been characterized by rigorous evaluation, oversite, and accountability, which has been a hallmark of Alexander’s work for decades. The integrity of implementation has ensured that approximately 500,000 troubled youth and their families have received the highest quality of care over the past 15 years. FFT also represents a framework and implementation vehicle for programs providing treatment for youth and families in diverse settings including mental health, school, child welfare, juvenile justice probation and/or parole, and integrated reentry/ reunification services. The findings from numerous independent research studies provide strong support for the effectiveness of FFT across these settings. Newer specialized applications of the model are undergoing trials in child welfare settings and with gang-involved youth.

Cross-References ▶ Functional Family Therapy

References Alexander, J. F., Barton, C., Schiavo, R. S., & Parsons, B. V. (1976). Systems-behavioral intervention with families of delinquents: Therapist characteristics, family behavior, and outcome. Journal of Consulting and Clinical Psychology, 44(4), 656–664. https://doi. org/10.1037/0022-006X.44.4.656.

Alger, Ian Alexander, J., & Parsons, B. V. (1982). Functional family therapy (pp. 109–112). Monterey, CA: Brooks/Cole Publishing Company. Alexander, J. F., Waldron, H. B., Robbins, M. S., & Neeb, A. A. (2013). Functional family therapy for adolescent behavior problems (p. 261). Washington, DC: American Psychological Association.

Alger, Ian Sarah K. Samman Alliant International University, San Diego, CA, USA

Name Alger, Ian

Introduction Ian E. Alger was born in Oshawa, Canada, in 1926. After earning his medical degree, he immigrated to the United States and pursued psychiatry at Bellevue Hospital-New York University (NYU) School of Medicine. He later trained as a psychoanalyst and established innovative techniques for couples, families, and groups, primarily around the use of video recording in therapy and its use as a catalyst for self-revelation. He was a successful published author spanning four decades on various topics such as the treatment of physical and mental illnesses within their social contexts; modern couple therapy, including roles, rules, and power in relationships; and the use of technology in therapeutic treatment such as utilizing videos in therapy, engaging in virtual reality, and telemedicine. Dr. Alger passed away in 2009 in Manhattan, New York, at the age of 82.

Career Dr. Alger obtained his medical degree from the University of Toronto in 1949 and trained as a psychiatrist at Bellevue Hospital-NYU School of

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Medicine in the United States. He mainly practiced in the state of New York and pursued training in psychoanalysis at the New York Medical College after which he opened a private practice. Dr. Alger established a successful academic and clinical career holding esteemed appointments such as clinical professor of psychiatry at the Albert Einstein College of Medicine, adjunct professor of clinical psychiatry and training and supervising analyst at the Psychoanalytic Institute within the department of psychiatry at the New York Medical College, psychiatrist at the Rusk Institute of Rehabilitation Medicine in New York, and chief psychiatrist at the New York Regional Respiratory Center, in addition to appointments at the Weill Medical College of Cornell, the Letterman Army Hospital in San Francisco, and the New York–Presbyterian Hospital. He was also the president of the American Orthopsychiatric Association from 1979 until 1980 and was an advisory editor for Family Process. His innovative therapeutic interventions landed him a consulting position for a public broadcasting show addressing issues on mental health, titled The Thin Edge.

Contributions to Profession Dr. Alger was one of the first psychoanalysts to pioneer the use of videotaping and playback into couple, family, and group therapy sessions. He intentionally used videotaping with patients as a therapeutic instrument to capture nonverbal cues and gestures which Dr. Alger believed influenced the therapeutic experience as strongly as spoken words. He often showed video recordings to patients to point out nonverbal cues and bring them to patients’ awareness such as nervous tapping and its effect on other members. He believed this process increased patients’ self-awareness and resulted in tangible insights leading to immediate and significant changes in sessions, particularly in family and marital therapy. He also advocated for the use of videos in therapy with children who present as nonverbal or who have experienced trauma. He proposed recording puppets on video and introducing the recordings to young patients to support the therapeutic experience when there are no opportunities to use physical puppets in session.

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Dr. Alger also advocated for the use of teletherapy and virtual reality. Teletherapy involves communication with patients via videoconferencing as opposed to face-to-face in-session interactions. Virtual reality involves the inclusion of live interaction between the therapist and patients in a proposed virtual environment that reflects the patients’ realities. The therapist in this approach joins the interactional process and provides in-session feedback with the goal to exact immediate change. This allows the space for patients to co-create their realities and enact change in their lives. Dr. Alger contributed dozens of publications over the course of his 40-year career. Several book publications included Doctor/patient Communication and Technology, Marriage and Marital Problems, Family Therapy: Full Length Case Studies (co-author), Family Therapy: Models and Techniques (co-author), and The Marriage Relationship: Psychoanalytic Perspectives (co-author). Several article titles include Continuing Education and Training; Creative Media in Psychotherapy; Marital Therapy with Dual Career Couples; Puppetry as a Therapeutic Tool for Hospitalized Children; Stimulus Tapes on Attitudes, Supervision, and Stereotypes; The Social Context in Virtual Realities; Therapeutic Use of Videotape Playback; and Therapy with Schizophrenic Patients.

Cross-References ▶ Emerging Technologies in Couple and Family Therapy ▶ Family Process (Journal) ▶ Psychoanalytic Couple and Family Therapy ▶ Recorded Supervision in Couple and Family Therapy

References Alger, I. (1990). Managing the aggressive patient, plus videotapes on schizophrenia and the homeless. Psychiatric Services, 41(8), 840–842. https://doi.org/10.1176/ ps.41.8.840. Alger, I., & Hogan, P. (1967). The use of videotape recordings in conjoint marital therapy. American Journal of Psychiatry, 123(11), 1425–1430.

Alliance in Family Relationships Alger, I., & Hogan, P. (1969). Enduring effects of videotape playback experience on family and marital relationships. American Journal of Orthopsychiatry, 39(1), 86–98. Alger, I., & Rusk, H. A. (1955). The rejection of help by some disabled people. Archives of Physical Medicine and Rehabilitation, 36(5), 277–281.

Alliance in Family Relationships Jody Russon1, Maliha Ibrahim2 and Guy S. Diamond2 1 Center for Family Intervention Science, Drexel University, Philadelphia, PA, USA 2 Center for Family Intervention, Drexel University, Philadelphia, PA, USA

Name of Concept Alliance in family relationships

Introduction Alliance refers to the factors that allow clients to accept and engage in psychotherapy (Bordin 1979). This construct is the most robust predictor of psychotherapy outcome and has been investigated for several decades (Barber et al. 2000).

Theoretical Context for Concept Early in the history of psychotherapy, Carl Rogers’ (1951) emphasis on unconditional positive regard made the relationship central to the achievement of therapeutic gains. Building off of Rogerian concepts, Bordin (1979) conceptualized alliance as consisting of three components. Specifically, the client and therapist must (a) develop a trusting relationship (bond), (b) establish agreement on what the client wants to change (goals), and (c) obtain agreement on how to go about changing (tasks). Bordin’s framework served as the foundation for decades of theoretical and empirical work on alliance.

Alliance in Family Relationships

Description Alliance in family relationships refers to a trusting relationship as well as agreement upon goals and related tasks in therapy among various dyads (i.e., family member to therapist, and family member to family member, as well as entire system to therapist).

Application of Concept in Couple and Family Therapy Alliance research has focused on treatment outcomes and therapeutic change across a variety of treatment modalities and clinical issues. It is well established that alliance consistently predicts outcome above and beyond therapeutic techniques (Safran and Muran 2000). In the last three decades, couple and family therapy (CFT) researchers and practitioners have expanded the definition of alliance by examining relationships within and between multiple family members and the therapist. According to Pinsof and Catherall (1986), this meant accounting for multiple levels of alliance. At the first level, each client’s alliance with the therapist is determined (e.g., Does the father feel good about his work with the therapist?). At the next level, each client’s perception of other family members’ alliances with the therapist is considered (e.g., Does the mother think that the therapist had a good connection with the reluctant father?). Finally, at the final level, each family members’ perception of the therapeutic relationship with the family system, at large, is evaluated (e.g. Does the son think that the therapist has a strong working relationship with his family?).

Clinical Example The following clinical example illustrates one of many possible ways of joining with a family system. Strategies used to join with families vary according to approach. In this example, the therapist uses an attachment-based family therapy (Diamond et al. 2014) framework to guide alliance-building. Specifically, the therapist bonds with each individual in the

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room while moving the family to agree on joint goals and tasks (Bordin 1979; Pinsof and Catherall 1986): Case. A 15-year-old Caucasian adolescent, Sasha, and her father, Eric, were referred from a local children’s hospital due to Sasha’s intermittent, passive suicidal thoughts (client names have been changed to maintain confidentiality). In an assessment, Sasha disclosed that she has been feeling “down” and had “lost her friends.” Eric stated that Sasha’s paternal grandmother passed away a month ago and expressed his frustration about his daughter’s “inability to communicate.” He complains that Sasha is “too sensitive” to have a mature conversation. Bond. The therapist begins the first session by asking about individual and relational strengths. Specifically, the therapist asks Sasha about her interests at school and, thus, unearths her strengths. The therapist then asks Eric to comment on these strengths (“Did you know your daughter was so good at math?”). As Eric responds positively to his daughter’s attributes, the therapist then highlights this interaction (“It sounds like you are really proud of your daughter’s ability”). In this initial interaction, the therapist’s verbal and nonverbal communication emphasizes that she is interested in each family member. Goal. Once a bond is created, the therapist asks Sasha and her father to discuss why they came to therapy. The therapist continuously reiterates that she wants to hear both Eric’s and Sasha’s perspective on the issue. The therapist notices that Sasha has a tendency to disengage, while Eric does most of the talking. In order to continue to build her alliance with Sasha, the therapist respectfully blocks Eric’s interruptions while Sasha is talking about her experience (e.g., “Hold on one second, I need to make sure I understand your daughter’s perspective too, so I know where you both stand”). This intervention continues to build the bond with Sasha, while the therapist

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gets an individual understanding of the problems. Sasha explains that she has been feeling sad and lonely. She has been missing her grandma and doesn’t feel like her dad understands her. In fact, he keeps bothering her by always being “in my business.” Eric describes how his daughter isn’t giving him the chance to understand her. After helping father and daughter each share their perspective and getting the details, the therapist presents a relational conceptualization of the problem to the family, one that incorporates each individual’s perspective of the problem and the impact on the relationship. In this case the therapist suggests that father and daughter want to have a supportive relationship (“Sasha, you want dad to understand you, and dad, you want your daughter to let you know what to do so you can help her”). The therapist then states a potential goal for the family: “Can we work on communicating in a different way?” Task. The therapist then gets the family’s feedback on the treatment plan and provides structure and information about how future sessions will work. Specifically, she says “I’d like to work with you on your communication by teaching you new ways of interacting with each other. This means that, during each session, I will support you both in talking about your experiences. As you talk, I will help each of you listen and respond in a new way. In order to work on our goal, we will need to meet all together each week. Does this sound okay to you?” In this case, the therapist developed a bond with the family and got an agreement from each individual on the desired goal of treatment as well as on the process of achieving these goals. The therapist made sure to incorporate all individual perspectives into her conceptualization of the relational problem. This therapist has set the groundwork for maintaining a strong working alliance with the individual clients and family system.

Cross-References ▶ Attachment-Based Family Therapy

Alliance Repair in Couple and Family Therapy

References Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2000). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Journal of Consulting and Clinical Psychology, 68(6), 1027. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252. Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014). Attachment-based family therapy for depressed adolescents. Washington, DC: American Psychological Association Press. Pinsof, W. M., & Catherall, D. R. (1986). The integrative psychotherapy alliance: Family, couple and individual therapy scales. Journal of Marital and Family Therapy, 12, 137–151. Rogers, C. R. (1951). Client-centered therapy. Cambridge, MA: Riverside Press. Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press.

Alliance Repair in Couple and Family Therapy Jacob Z. Goldsmith The Family Institute at Northwestern University, Evanston, IL, USA

Synonyms Therapeutic alliance repair; Working alliance repair; Working relationship repair

Introduction The working relationship between client(s) and therapist, called the alliance, is one of the powerful common factors in successful psychotherapy (Friedlander et al. 2006). Problems in the alliance, called ruptures, are common and may occur for a variety of reasons. The process of rectifying such a rupture is called alliance repair. Repairs can take a variety of forms, depending on the rupture, but should be executed quickly according to the general guidelines described below.

Alliance Repair in Couple and Family Therapy

Theoretical Context Psychotherapy alliance is the working relationship between client and therapist. Edward Bordin (1979) defined alliance as agreement between client and therapist on the tasks and goals of therapy, in addition to the presence of an interpersonal bond. Agreement on tasks involves a shared understanding (between client(s) and therapist) of what is occurring in the therapy room (e.g., the choice of interventions or area of focus within a session), whereas agreement on goals involves a shared understanding of the overall objectives or desired outcomes of the therapy. The bond aspect of alliance involves a felt sense of interpersonal connection. This varies greatly across different types of therapy and therapist interpersonal style but typically involves some felt sense of empathy, warmth, or caring. Each different therapy requires a somewhat different configuration of tasks, goals, and bonds, but every therapy requires a strong enough alliance to be successful. Strong alliance is necessary for positive outcome in therapy, and without an alliance therapy falters and cannot continue (Safran and Muran 2000). Some clients enter therapy with a strong alliance and maintain it throughout treatment (Goldsmith and Stiles 2010). Others experience change in the quality of their alliance over the course of treatment. Many (if not most) clients will experience a brief precipitous drop in the quality of alliance, called a rupture (Safran et al. 2011). Alliance ruptures are sudden decrements in an established alliance – in other words they are moments when an otherwise strong clienttherapist alliance falters. Alliance ruptures can have many causes, including client defensiveness or poor fit between clients’ and therapist’s goals, but often involve a misstep by the therapist (e.g., a failure of empathy, or decision to push a client too hard in a given situation). Alliance repair is the act of fixing an alliance rupture, or restoring the alliance to its original strength. The concepts of psychotherapy alliance, and rupture-repair, although initially developed in the context of individual therapy, may be applied to couple and family therapy with some basic changes to accommodate the additional clients and the

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differences in the process and goals of treatment. With multiple clients comes the potential for conflicting needs, goals, and interpersonal styles (Pinsof and Catherall 1986). As a result, in terms of both the theoretical conceptualization and the actual clinical practice, couple and family alliances are more complex. In conjoint treatment alliances exist between each client and the therapist, and each client is aware not only of his or her own alliance but of the other alliances as well (Friedlander et al. 2006; Pinsof and Catherall 1986). Furthermore, working relationships exist between the clients themselves. Therefore, alliance in couple and family therapy must not be thought of as a monolithic entity but rather as a system of interconnected relationships that must be balanced and that can each rupture and require repair. With the added conceptual complexity of multiple relationships in couple and family alliances comes added difficulty in building and maintaining those relationships. Maintaining all alliances at equal strength at all times is not always possible. Some temporary imbalance in the alliance is to be expected and does not necessarily constitute a rupture. A rupture is better thought of as a break than an imbalance, wherein therapy cannot continue without a repair. For example, a teenage daughter in family therapy may experience temporary frustration when her father describes his side of a recent argument. This is not necessarily a rupture. But if the therapist exclusively validated the father’s experience to the point where the daughter no longer felt bonded or invested in therapy, then a rupture has occurred and would require repair.

Description Alliance repair begins when the therapist recognizes a rupture and shifts the focus of therapy to explicitly address the problem (Safran et al. 2011; Friedlander et al. 2006). To make an effective repair, the therapist must remain open and nondefensive throughout the repair process. With the rupture identified and the focus of the session shifted, the therapist may implement a number of different repair strategies including:

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• Clarifying the events of the rupture • Therapist taking responsibility for any mistakes or missteps • Eliciting emotions related to the rupture • Empathically joining with the client • Identifying necessary changes to the tasks or goals of therapy • Connecting the rupture to underlying interpersonal processes • Connecting the rupture to ongoing relational patterns in the client’s life The choice of specific repair techniques depends on the content and process of the rupture. For example, if the therapist has made a clear mistake (e.g., a lapse in empathy), he or she needs to take responsibility. If the client becomes withdrawn or disengaged during the rupture, eliciting emotions may be helpful. If the rupture appears due to misunderstanding of the tasks and goals of therapy, then explicit discussion of these topics is necessary (including, perhaps, psychoeducation about the need to balance conflicting needs within the system). Beyond the obvious goals of allowing the client to work through negative feelings about the relationship and restoring a strong working alliance, repair is an opportunity for client(s) and therapist to build insight into a client’s relational style (or defenses). Repair is also a chance for the therapist to model appropriate, nondefensive conflict resolution, and as a corollary the repair process can be a moment of experiential learning for all clients in the room. Often, only a single client will experience a rupture at once. In that case, the therapist must accomplish the repair while still considering the alliances of the other clients. At other times, multiple clients will rupture at once, sometimes for the same reason and sometimes for different reasons. In all of these cases, the generic repair process is the same, with repair techniques chosen to fit the specific situation. However, whether one client or every client ruptures, the therapist must still consider the system as a whole during repair.

Alliance Repair in Couple and Family Therapy

Application of Concept in CFT The first step in alliance repair is the timely identification of a rupture. With multiple clients in the room, the therapist must attend to multiple alliances and to clients’ perceptions of each other’s alliances. This can make identifying a rupture difficult, simply due to the burden of having more moving parts to monitor at any one time. Further complicating rupture identification, some imbalance between alliances is expected in couple and family work and does not necessarily constitute a rupture. The task for the therapist then is to be aware of whether each interconnected part of the alliance system is strong enough to maintain the work of therapy, or conversely whether one or more parts have become so weak that therapy cannot continue without a repair. When a rupture is identified, the therapist must actively shift the focus of the session toward repairing the rupture. In cases where only one client ruptures, the process of repair requires direct attention to that client’s needs, but still demands consideration of the other clients. Making a shift to address one client may alienate other members of the system. Those clients in turn may feel upset or defensive witnessing the repair process and may even object to the shift in focus. The therapist must therefore be explicit and directive throughout this process, explaining his or her intentions to the group. It may also be necessary to process client reactions to the repair process after the fact. When multiple clients rupture at the same time, the therapist must still pause the ongoing work of therapy to focus on the repair. If all clients rupture for the same reason (e.g., the therapist is at odds with the entire family about the goals of therapy), the therapist can implement a single broad repair. If clients simultaneously rupture for different reasons, it may be necessary to shift the focus of therapy from one client to the next to accomplish multiple sequential repairs. Different repair techniques have different consequences in a systemic context. Take for example

Alliance Repair in Couple and Family Therapy

a rupture caused by the therapist neglecting one client’s viewpoint in family therapy. If the therapist apologizes and gives that client a chance to express frustration, this could lead to the client feeling a sense of pride or vindication. The client is empowered through the rupture. On the other hand, if the therapist takes the opportunity to push deeper, eliciting underlying emotions or connecting the rupture to other instances of neglect or disempowerment in the clients’ life, this could lead to a feeling of exposure – the client’s personal vulnerabilities are now on display. With any repair technique, the therapist should consider the systemic context, including the intersecting needs and goals, differing relational styles and areas of defensiveness, and potential areas of high vulnerability, among all of the clients (not just the client who initially ruptured). Although repair is more complicated in couple and family work, it may also be especially meaningful in this context. Repairs are moments when clients’ interpersonal issues (defenses, areas of need or sensitivity, ways of being in conflict) come into the spotlight in the therapy room. If the goal of therapy is to improve the quality of romantic or family relationships, then the insights gleaned from alliance repair are directly relevant to the overall work. Two repair techniques in particular – connecting the rupture to existing interpersonal processes and to patterns that manifest in relationships beyond the alliance – may be particularly applicable to the ongoing work of conjoint therapy. Therapists may also take particular advantage of repairs as moments of experiential learning. The therapist can use the repair to demonstrate nondefensive, appropriate conflict resolution, which again may be particularly relevant to couple and family work. Of course, in couple and family therapy, repairs happen in the presence of the other clients, allowing the group to observe and learn from the resolution. For a spouses entrenched in their own repetitive conflict cycles, the repair may be crucial evidence that a different way of expressing anger or hurt is possible.

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Clinical Example Parents Alex and Nina seek therapy with 17-year-old son Sam to address Sam’s emotional dysregulation and aggressive behavior. The therapist works with the family to conceptualize Sam’s behavior as part of a broader systemic pattern involving Nina’s anxiety and Alex’s work-related stress. Early alliance is strong. Sam and Nina both readily recognize their contributions to the ongoing issues. Alex generally appears engaged and nominally agrees with the therapist’s assessment, but withdraws somewhat when the focus turns to his role in the family’s problems. In the sixth session, feeling frustrated at Alex’s lack of ownership, the therapist makes an overly directive push to get him to take responsibility, saying “Both your wife and son have shared what they feel they’ve contributed to Sam’s problems. What do you think your role is here?” Alex scowls, physically turns himself away, and clenches his fist; he has never exhibited this level of contempt in session before. Sensing a rupture, the therapist begins by simply noticing out loud Alex’s change in body language and facial expression. Alex responds “Of course I’m angry, you’re blaming me for my son’s problems!” With this acknowledgement, the therapist begins the repair by shifting the focus and eliciting information about Alex’s experience: Therapist:

I think I did a bad job of saying what I was trying to say. I’m sorry. I don’t believe that you caused your son’s problem. I see how that made you angry, and I want to understand what you’re feeling more clearly. I want to switch our focus now and give you time to talk this through. I know I’m asking you to take a risk here. Can you tell me what you were feeling when you got angry?

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Alex:

T:

A:

T: A:

Alliance Scales in Couple and Family Therapy

The thought that happens over and over again is “Its all your fault! It’s all your fault!” Sounds like you felt blamed. Did feeling blamed by me remind you of anything? It actually reminds me of things I’ve said to my dad. I’ve worked so hard not to be like him. And then you said what you said and I just felt like ‘oh well, I guess he thinks I’m just like my dad’. And I felt angry, but I also felt really insulted. Hurt? Yeah, Hurt!

The therapist empathically joins with him in this hurt, reflecting and normalizing it. Alex acknowledges feeling relief and connection and, in this context, is able to begin to take responsibility for letting his work-life intrude into the home. As the repair process concluded, the therapist began to reintegrate Nina and Sam into the work, both as additional sources of information to help Alex and also to check in about both of their experiences of the repair. The repair process here accomplished three main goals. First, it allowed Alex to work through the pain of the rupture and open himself back up to the therapy. Second, it provided insight into a part of Alex that had been hidden throughout treatment. Finally, it provided a model for the whole system to understand an appropriate discussion of personal responsibility, even in the face of unwanted emotions, that the therapist could refer back to throughout the rest of the treatment.

References Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, research & practice, 16(3), 252. Friedlander, M., Escudero, V., & Heatherington, L. (2006). Therapeutic alliances in couple and family therapy: An empirically informed guide to practice. Washington, DC: APA Press. Pinsof, W. M., & Catherall, D. R. (1986). The integrative psychotherapy alliance: Family, couple and individual therapy scales*. Journal of Marital and Family Therapy, 12, 137–151. https://doi.org/10.1111/j.17520606.1986.tb01631. Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80–87. Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford. Stiles, W. B., & Goldsmith, J. Z. (2010). The alliance over time. In J. Muran, J. P. Barber, J. Muran, & J. P. Barber (Eds.), The therapeutic alliance: An evidence-based guide to practice (pp. 44–62). New York: Guilford.

Alliance Scales in Couple and Family Therapy Maliha Ibrahim1, Katherine Vaughan2 and Guy S. Diamond1 1 Center for Family Intervention, Drexel University, Philadelphia, PA, USA 2 Drexel University, Philadelphia, PA, USA

Synonyms Individual, Couple and Family Therapy Alliance Scale (ITAS, CTAS and FTAS); System for Observing Family Therapy Alliances (SOFTA); Vanderbilt Therapeutic Alliance Scale (VTAS); Working Alliance Inventory (WAI); Working Alliance Inventory (WAI-Co)

Cross-References

Introduction

▶ Alliance in Family Relationships ▶ Alliance Scales in Couple and Family Therapy ▶ Split Alliance in Couple and Family Therapy ▶ Therapeutic Alliance in Couple and Family Therapy

For the past 60 years, therapeutic alliance has been considered one of the most important common factors in psychotherapy research. Early on, couple and family therapy (CFT) researchers joined this area of research, wanting to better understand

Alliance Scales in Couple and Family Therapy

how therapeutic alliance could be examined within a family system (Pinsof and Catherall 1986; Rait 2000). Previous measurement tools were developed to evaluate the therapeutic alliance between an individual client and their therapist. CFT researchers questioned if these measurement tools could assess the complexities of a therapist attending to multiple family members simultaneously. Consequently, family therapists sought to develop more complex, multilevel models of alliance and the assessment tools to measure them. Two of the most widely used scales for measuring alliance in individual therapy are reviewed. Additionally, three of the most widely used and psychometrically strong scales for measuring alliance in CFT are reviewed. All of these measures have utility in the context of CFT research and practice. Regardless of the measure used, differential alliance in family therapy has interesting clinical implications. One study with adolescents found that therapist’s alliance with the adolescent predicted outcome but that therapist’s alliance with the parents predicts treatment retention (Shelef and Diamond 2008). Paying attention to the impact of these kinds of split alliances in family therapy may help illuminate some of the unique challenges faced by a family therapist. Additionally, barriers in the development of the therapeutic alliance such as client motivation and the therapy environment may also influence alliance measurement. Cost, complexity, and transportability of alliance measures into clinical settings also need to be considered, as these factors will determine the overall utilization of the measures in the years to come. Before considering which of these measures one might use for clinical or research purposes, one must consider a few methodological issues regarding different sources of data and when to collect it. Alliance has been measured from the client’s perspective, the therapist’s perspective, and from the perspective of trained objective raters. Client report is usually done with a short, self-report questionnaire after the third or fourth session. This gives enough time for the alliance to form, but not so much time to be confounded by symptom reduction. In individual therapy, the

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client rates their view of their relationship with the therapist. In the family systems measurement system, clients can rate not only their own view of the alliance, but they might be asked to rate how they think other family members are feeling toward the therapist. For the therapist’s perspective, the therapist does not rate their own feelings of their alliance with the patient. Instead, the therapist rates how they think the client sees the alliance with them. Observer rating usually involves training raters (often undergraduate students) to watch tapes of therapy. Raters can rate one client or several (e.g., parent and child, husband and wife). Usually one group of raters rates one family member. Interestingly, most studies suggest therapist reports of alliance are not as good at predicting outcome as client self-report. Observer reports of alliance however are consistently the most robust perspective for predicting outcome (Horvath 2001). Working Alliance Inventory* (WAI; Horvath and Greenberg 1989) Introduction. The WAI is the most widely used alliance scale (Martin et al. 2000). Utilizing Bordin’s theory of working alliance (Bordin 1979), the WAI assesses three primary components: tasks, goals, and bonds. Tasks refer to what is done in therapy (e.g., CBT worksheets, family therapy enactments, DBT mindfulness exercises). Goals refer to whether the client and therapist agree on what they are working on, or toward, in therapy. Bonds refer to the general feeling of being liked or respected by the therapist. Developers. Adam O. Horvath and Leslie S. Greenberg developed the WAI. They first described it in a paper titled Development and Validation of the Working Alliance Inventory (Horvath and Greenberg 1989). Description of measure. The WAI has three different versions: client, therapist, and observer. Each version contains 36 items and similar questions, all using a 7-point Likert scale (1 = “Never”; 7 = “Always”). Questions evaluate the agreement on task, goal, and the quality of the strength of the therapist-client bond. The WAIshort version (WAI-S) reduces the number of items to 12, and there are still self-report and

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therapist report types for this version. The scale items for this measure were selected through factor loading the 36 items on the WAI. A 7-point Likert scale (1 = “Never”; 7 = “Always”; Busseri and Tyler 2003) is also used on the WAI-S. Although less well known and used, there is a WAI couples version (WAI-Co*; Symonds 1997). Using the same 7-point Likert scale (1 = “Never”; 7 = “Always”) and 68 items, this self-report scale is made up of three sections. Section 1 asks the client to rate their alliance with the therapist. Section 2 asks the client to rate their partner’s alliance with the therapist. Section 3 asks the client to rate the couple’s joint alliance with the therapist. Psychometrics. WAI has strong reliability (r = 0.85–0.93) and has demonstrated predictive validity in several outcome studies (Ardito and Rabellino 2011; Elvins and Green 2008; Martin et al. 2000). Reliability for the WAI-Co was observed for each partner at the third session and was similar to the reliability found on the WAI (r = 0.95–0.97; Symonds and Horvath 2004). Application. The WAI has been used in numerous research studies, exploring a range of treatment disorders and treatment modalities. With versions in 18 languages, it can be used with a diverse set of clients (Ardito and Rabellino 2011; Elvins and Green 2008; Horvath and Greenberg 1989; Martin et al. 2000). The WAI-Co has been observed primarily with couples described as heterosexual, Caucasian, and married (Symonds and Horvath 2004).

Vanderbilt Therapeutic Alliance Scale* (VTAS; Hartley and Strupp 1983) Introduction. The VTAS was developed from the Vanderbilt Psychotherapy Process Scale (VPPS; Gomes-Schwartz 1978; O’Malley et al. 1983). Multiple theories influenced the VPPS, but Bordin’s theory of working alliance (Bordin 1979) primarily influenced development of the VTAS (Martin et al. 2000). Developers. D. Hartley and H.H. Strupp developed the VTAS. They first described it in a paper titled The therapeutic alliance: Its relationship to outcome in brief psychotherapy (Hartley and Strupp 1983).

Alliance Scales in Couple and Family Therapy

Description of measure. The VTAS is an observer scale only, containing 44 items. It uses a 6-point Likert scale (0 = “none at all”, 5 = “a great deal”) to measure alliance via client contribution (14 items), therapist contributions (18 items), and client-therapist interaction (12 items) (Horvath and Greenberg 1994). Client contribution items are defined as patient resistance, patient motivation, patient responsibility, and patient anxiety. Therapist contribution items are defined as positive therapeutic climate and therapist intrusiveness. Questions are similar to the WAI. For example, client items include “The client agreed to the therapist’s method or process,” “He/she expressed feeling more positive since the initiation of therapy (bond),” and “The therapist and patient together share a common viewpoint about the definition, causes, and alleviation of the patient’s problems? (goal).” A shortened and revised version of the VTAS (VTAS-R Short Form; Shelef and Diamond 2008) was developed due to the time-consuming nature of the longer observer-rater scale that generated burden on staff implementing it (Fenton et al. 2001; Shelef et al. 2005). The scale is a 26-item self-report measure and is on a 5-point Likert scale. Psychometrics. VTAS demonstrated adequate inter-rater reliability, based on interclass correlations as indicated by a coefficient a = 0.95 and internal consistency (0.96–0.82; Elvins and Green 2008). The scale also demonstrated adequate predictive validity in the association between early treatment alliance and outcome. The Vanderbilt scales also depicted the best convergent validity (r = 0.86) with other alliance scales (Elvins and Green 2008). Application. VTAS scales have been used with children, adolescents, and adults with multiple mental health issues like substance use and depression (Faw et al. 2005; Mayorga 2008).

Individual, Couple, and Family Therapy Alliance Scale* (ITAS, CTAS, and FTAS; Pinsof and Catherall 1986) Introduction. The Individual Therapeutic Alliance Scale (ITAS), Couple Therapeutic Alliance Scale (CTAS), and Family Therapy Alliance Scale

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(FTAS) were developed to assess alliance in CFT research. These alliance scales were also influenced by Bordin’s theory of working alliance (Bordin 1979; see WAI). Developers. William M. Pinsof and Donald R. Catherall developed the ITAS, CTAS, and FTAS. They first described it in a paper titled The Integrative Psychotherapy Alliance: Family, Couple and Individual Therapy Scales (Pinsof and Catherall 1986). They, more than any other family therapy researchers, have tried to capture the complex nature of alliance in systemic therapies (Norcross 2011). Description of measure. The ITAS, CTAS, and FTAS are self-report measures for clients. Using a 7-point Likert scale (i.e., 1 = “Completely disagree” to 7 = “Completely agree), the ITAS (26 items), CTAS (29 items), and FTAS (29 items) all examine how each participant views alliance based on Bordin’s tasks, goals, and bonds. While the ITAS evaluates alliance scores between the client and the therapist, the CTAS and FTAS include an evaluation of the client’s view of others’ alliance with the therapist as well as the client’s view of the whole groups’ (i.e., couple or family’s) combined alliance with the therapist. The CTAS and FTAS measure alliance similarly to the WAI-Co (see WAI; Friedlander et al. 2011). Examples of questions are: “The therapist does not understand the relationship between my partner and myself” and “The therapist understands my goals in this therapy” (Pinsof et al. 2008, p. 282). The ITAS-r, CTAS-r, and FTAS-r were recently revised to include more comprehensive questions (i.e., 36, 40, 40; Hamilton and Carr 2016; Pinsof et al. 2008). Psychometrics. The ITAS, CTAS, and FTAS have adequate reliability (r = 0.72–0.83; Elvins and Green 2008) and predictive validity (Heatherington and Friedlander 1990). Application. The ITAS, CTAS, and FTAS were the first alliance scales developed to assess alliance from a more systemic perspective. They are frequently used in couple and family therapy research (Friedlander et al. 2011).

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System for Observing Family Therapy Alliances* (SOFTA; Friedlander et al. 2006) Introduction. The SOFTA scale was developed for both self-report and observational rating. Using Bordin’s theory (Bordin 1979), the SOFTA scales reflect Bordin’s principles of tasks, bonds, and goals as well as systemic elements unique to couple and family therapy (Bordin 1989, 1994; Pinsof and Catherall 1986; Pinsof 1999; Symonds and Horvath 2004). The scale assesses client’s trust in the therapy process and captures features in the therapeutic relationship that could be used to prevent treatment dropout (SOFTA-o; Friedlander et al. 2001, 2004; SOFTA-s; Friedlander and Escudero 2002). Developers. Myrna Friedlander and Valentin Escudero developed and published the SOFTA in a manual (Friedlander et al. 2006). Description of measure. The four major dimensions on the scale are (1) engagement in the therapeutic process, (2) emotional connection to the therapist, (3) safety within the therapeutic system, and (4) shared sense of purpose within the family (Friedlander et al. 2006, p. 56). The engagement in the therapeutic process scale measures the client’s view of how meaningful treatment is to them and how well he or she and the therapist are working together on negotiated goals. Sample items include (a) client’s agreement with therapy and (b) client expressing optimism that positive change is taking place. Reversecoded items include (a) the client feeling stuck or (b) the client showing indifference to the tasks or process of therapy (Friedlander et al. 2006, p. 62). The safety within the therapeutic relationship scale measures the degree to which clients feel they can take risks and process new insights with their therapist. Sample items include (a) client showing vulnerability in session, (b) open and relaxed body posture, and (c) encouraging other family members to speak up. Reverse-coded items include (a) reluctant to respond to the therapist or another family member and (b) anxiety toward camera (Friedlander et al. 2006, p. 62). The emotional connection with the therapist refers to the client feeling that the therapist has

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genuine care and concern for them. Sample items include client sharing a light-hearted moment with the therapist. Reverse-coded items include (a) hostile or sarcastic interactions and (b) commenting on therapist’s lack of training or competency (Friedlander et al. 2006, p. 66). The shared sense of purpose within the family implies that family members work collaboratively and value one another in therapy. Items include family members ask for each other’s perspectives and validate one another. Reverse-coded items include (a) avoiding eye contact and (b) devaluing each other’s opinions and perspectives (Friedlander et al. 2006, p. 68). Psychometrics. The SOFTA has been tested psychometrically in a number of studies. In one study, the 44 items were ordered by 24 different MFT researchers across 3 countries to assess face validity. High internal consistency of items was found via kappa coefficients Ks = 0.81(English) and Ks = 0.71 (Spanish). Client and therapist reports were then developed using the four conceptual SOFTA dimensions with 16 positive and negative items on a 5-point Likert scale (Friedlander et al. 2006). Application. The SOFTA has been especially applicable in the training and supervision of novice CFT therapists, as they can observe a client’s engagement in sessions, emotional connection with the therapist, and ability to work together with family members (Friedlander et al. 2006, p. 44). Being an observational coding system, the SOFTA can also identify moments of client alliance and resistance with the therapist (Friedlander et al. 2006).

References Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 270. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252. Bordin, E. S. (1989). Building therapeutic alliances: The base for integration. In Annual meeting of the Society for Psychotherapy Research, Berkley.

Alliance Scales in Couple and Family Therapy Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In The working alliance: Theory, research, and practice (pp. 13–37). Busseri, M. A., & Tyler, J. D. (2003). Interchangeability of the working alliance inventory and working alliance inventory, short form. Psychological Assessment, 15(2), 193. Elvins, R., & Green, J. (2008). The conceptualization and measurement of therapeutic alliance: An empirical review. Clinical Psychology Review, 28(7), 1167–1187. Faw, L., Hogue, A., Johnson, S., Diamond, G. M., & Liddle, H. A. (2005). The Adolescent Therapeutic Alliance Scale (ATAS): Initial psychometrics and prediction of outcome in family-based substance abuse prevention counseling. Psychotherapy Research, 15(1–2), 141–154. Fenton, L. R., Cecero, J. J., Nich, C., Frankforter, T. L., & Carroll, K. M. (2001). Perspective is everything: The predictive validity of six working alliance instruments. The Journal of Psychotherapy Practice and Research, 10(4), 262. Friedlander, M.L., & Escudero, V. (2002). Self-report version of the System for Observing Family Therapy Alliances. Unpublished instrument. Available from www. softa-soatif. net. Retrieved 16 Nov 2016. Friedlander, M.L., Escudero, V., & Heatherington, L. (2001). SOFTA-o for clients. Unpublished instrument. Available from www.softa-soatif.net. Retrieved 16 Nov 2016. Friedlander, M.L., Escudero, V., Heatherington, L., Deihl, L., Field, N., Lehman, P., ..., Cutting, M. (2004). System for Observing Family Therapy Alliances (SOFTA-o) training manual-revised. Unpublished manuscript. Available from www. softa-soatif. net. Friedlander, M. L., Escudero, V., & Heatherington, L. (2006). Therapeutic alliances in couple and family therapy: An empirically informed guide to practice. Washington, DC: American Psychological Association. Friedlander, M. L., Escudero, V., Heatherington, L., & Diamond, G. M. (2011). Alliance in couple and family therapy. Psychotherapy, 48(1), 25. Gomes-Schwartz, B. (1978). Effective ingredients in psychotherapy: Prediction of outcome from process variables. Journal of Consulting and Clinical Psychology, 46(5), 1023. Hamilton, E., & Carr, A. (2016). Systematic review of self-report family assessment measures. Family process, 55(1), 16–30. Hartley, D. E., & Strupp, H. H. (1983). The therapeutic alliance: Its relationship to outcome in brief psychotherapy. Empirical Studies of Psychoanalytic Theories, 1, 1–37. Heatherington, L., & Friedlander, M. L. (1990). Couple and family therapy alliance scales: Empirical considerations1. Journal of Marital and Family Therapy, 16(3), 299–306. Horvath, A. O. (2001). The alliance. Psychotherapy: Theory, Research, Practice, Training, 38(4), 365. Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223.

Almeida, Rhea Horvath, A. O., & Greenberg, L. S. (1994). The working alliance: Theory, research, and practice (Vol. 173). New York: Wiley. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438. Mayorga, C.C. (2008). Self-reported and observed cultural competence and therapeutic alliance in family therapy. Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Evidence-based responsiveness. New York: Oxford University Press. O’Malley, S. S., Suh, C. S., & Strupp, H. H. (1983). The Vanderbilt Psychotherapy Process Scale: A report on the scale development and a process-outcome study. Journal of Consulting and Clinical Psychology, 51(4), 581. Pinsof, W.M. (1999). Family therapy alliance scale-revised. Unpublished document. Evanston: The Family Institute. Pinsof, W. M., & Catherall, D. R. (1986). The integrative psychotherapy alliance: Family, couple and individual therapy scales. Journal of Marital and Family Therapy, 12(2), 137–151. Pinsof, W. M., Zinbarg, R., & Knobloch-Fedders, L. M. (2008). Factorial and construct validity of the revised short form integrative psychotherapy alliance scales for family, couple, and individual therapy. Family Process, 47(3), 281–301. Rait, D. S. (2000). The therapeutic alliance in couples and family therapy. Journal of Clinical Psychology, 56(2), 211–224. Shelef, K., & Diamond, G. M. (2008). Short form of the revised Vanderbilt Therapeutic Alliance Scale: Development, reliability, and validity. Psychotherapy Research, 18(4), 433–443. Shelef, K., Diamond, G. M., Diamond, G. S., & Liddle, H. A. (2005). Adolescent and parent alliance and treatment outcome in multidimensional family therapy. Journal of Consulting and Clinical Psychology, 73(4), 689. Symonds, D. (1997). The working alliance inventory for couples. Retrieved from http://wai.profhorvath.com/ sites/default/files/upload/waiCo.doc Symonds, D., & Horvath, A. O. (2004). Optimizing the alliance in couple therapy. Family Process, 43(4), 443–455.

Almeida, Rhea Willie Tolliver Silberman School of Social Work at Hunter College, New York, NY, USA

Introduction Rhea Almeida, MS, PhD, is the founder and director of the Institute of Family Services in

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Somerset, NJ, and a former faculty member of Rutgers University School of Social Work. Dr. Almeida is co-founder of the LiberationBased Healing Conference (LBHC) held annually in locations throughout the United States. Almeida is an internationally renowned leader in decolonizing couple and family therapy and developed the cultural context model of family therapy.

Career Rhea Almeida was born and raised in Kampala, Uganda. She moved to the United States to attend Florida State University in Tallahassee for her undergraduate studies. She earned a BA in social work and psychology at Florida State University and an MS in social work at Columbia University in New York. Dr. Almeida completed her PhD in anthropology at Makerere University, in Kampala, Uganda. From 1980 to 1987, Dr. Almeida was on the faculty of Rutgers University School of Social Work and completed her postgraduate training at the Ackerman Institute in New York City. Almeida left her position at Rutgers when it became clear to her that clinical social work was focused primarily on the individual as the therapeutic location for change efforts. She felt there was no systemic analysis of change for practice or the institutions that provided social work services. In 1993 she published “Unexamined Assumptions and Service Delivery Systems.” Dr. Almeida established the Institute of Family Services in 1890 where she began to investigate theories of social and political change and resistance. She found many of these ideas more useful to oppressed peoples than the narrow theories of psychology promoted by social work educators. She and her colleagues developed the cultural context model that sought to bring critical consciousness to client journeys weaving in threads of empowerment and accountability. Connecting people and their context was the focus for therapeutic change.

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Contributions to the Profession Throughout her career, Dr. Almeida has evidenced commitment to decolonizing theory and practice that sustain and reproduce coloniality in couples and family therapy. In 1997, Almeida was named as one of ten innovative healers in the nation (The UTNE Reader – “Cultural Healers: Ten Innovative Therapists Who Do More Than Just Talk,” features Rhea Almeida, February 1997). Her commitment to decolonization extended to pointing out to editorial boards of journals how their processes for selecting articles for publication sustained the status quo. In 1998, she negotiated with the Journal of Feminist Therapy to provide a section in the journal that would not be subject to the “blind process” of review that frequently vanished publications from authors on the margin. This provided the opportunity to many authors outside of whitestream to submit and get published. After 25 years of knowledge building, training, and practice in the Institute for Family Services (IFS), in 2005 Almeida was honored by the American Family Therapy Academy with an Award for Innovative Contributions to Family Therapy. Therapeutic approaches at IFS incorporate an analysis of power, privilege, oppression, and intersectionality into its therapeutic approaches to a wide range of problems presented by couples, families, children, and youth who engage in violence. The programs also encourage healing by embracing life-affirming choices, based on a strong foundation of empowerment and accountability. Mindful of the resilience embodied by those who struggle, the therapeutic process anchors the problems presented within a system of support, care, and action strategies. Dr. Almeida co-founded the Liberation-Based Healing Conference in 2005. Currently, in its 13th year, the LBHC travels the country and Canada hosted by organizations and universities. The vision for the Liberation-Based Healing Conference is embedded within strategies of decoloniality. Strategies of decoloniality call for changing the paradigm, the lens, the language, and the historical journey that upholds the myth of healing through diagnostic codes, individual structures and the rigid bifurcation of

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individuals, their families, their context, and their healing spaces. Liberation-based healing encompasses the multiplicity of personal and social institutional locations that frame identities within historic, economic, and political life. Almeida is the author of several books and numerous journal articles. Her upcoming book, Liberation Based Healing Practices, is due to be released soon! Almeida is also an AAMFT approved supervisor.

Cross-References ▶ Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice

References Almeida, R. (1993). Unexamined assumptions and service delivery systems: Feminist theory and racial exclusions. Journal of Feminist Family Therapy, 5, 3–23. Almeida, R. (2013). Cultural equity and displacement of othering. Article ID: acrefmrw-9780199975839-e-889. https://doi.org/10.1093/acrefmrw/9780199975839.013. 889. Almeida, R. (in press). Liberation based healing practices. Somerset: Institute for Family Services. Almeida, R.V., Melendez, D., & Paéz, J. (2015). Liberation-based healing. Encyclopedia of Social Work. Online Publication Date: December 2015. Hernández, P., Siegel, A., & Almeida, R. (2009). How does the cultural context model facilitate therapeutic change? Journal of Marital and Family Therapy, 35(1), 97–110.

Ambiguous Loss in Couple and Family Therapy Janet Yeats LMFT LLC, Minneapolis, MN, USA

Introduction Ambiguous loss theory was created by Pauline Boss, PhD in the 1970s, from initial research conducted with indigenous women and wives of

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Navy pilots missing in action Boss (2000). Dr. Boss continued her research with families of missing persons and with families living with a loved one with a dementia diagnosis. Researchers and clinicians continue Dr. Boss’s work in ambiguous loss by applying the theory to adoption, GLBTQ communities, hoarding disorder, refugee populations, bereavement, military families, divorce, among many other diagnoses and populations.

Theoretical Context for Concept Dr. Boss began her research first in boundary ambiguity in families. As she continued her work, she noted that what she was finding went beyond boundary ambiguity to a lack of identifying and naming loss. Clinicians and researchers continuing Dr. Boss’s work in ambiguous loss have applied the theory to a variety of individual and family losses. Ambiguous loss theory fills a gap in marriage and family theories and therapies by providing an understanding for how to address grief that lacks definition and defies cultural understandings of how loss is typically identified. Grief and loss work in the therapy context encourages the opportunity for clients to tell their story as a way to begin to understand their loss and how to move into their lives while holding their grief in healthy ways.

Description Ambiguous loss is a psychological or physical loss that is unclear and lacks definition. Lack of definition creates difficulty in obtaining support and movement through the grief process. When the goal of addressing ambiguous loss is to resolve the loss and solve the “problem,” individuals may get stuck in the search for a right or wrong decision. Application of ambiguous loss theory does not provide a solution to a “problem” but rather assists with helping individuals and families to live well with their experiences of ambiguity. There are two types of ambiguous loss:

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Type 1: Leaving Without Goodbye: Physical absence with psychological presence. Although the loved one is not physically present, their presence is felt in ways that reflect their ongoing psychological connection to family and friends. Examples of this type of loss include persons who have disappeared or missing in action. More commonly experienced examples of this type are divorce, adoption, and immigration. Type 2: Goodbye Without Leaving: Psychological absence with physical presence. In this type of loss, loved ones remain physically present to family and friends but absent in their emotional and psychological connections. Examples of this type of loss include persons with a dementia diagnosis, depression, and hoarding disorder. More commonly experienced examples of this type are loss of a dream, or loss of a way of life, e.g., loss of identity due to career transition. Ambiguous losses create complicated grief because the losses have not been identified as such. Lack of understanding that the ambiguous situation is indeed a loss does not give permission to begin the grief process. Without permission to grieve, coping can be blocked and grief gets stuck. Friends and family do not understand the loss as it lacks definition, and questions are raised as to appropriate responses. This lack of understanding is often not intentional, but rather due to misunderstanding ambiguity. The stress of living with ambiguous loss may affect individuals with a variety of emotions such as: • • • • •

Depression, anxiety, guilt, shame Neglect or lack of self-care Somatic illnesses Abuse: substance and other Distress and traumatization

The unknowing that accompanies ambiguous loss can become overwhelming and leave the individual feeling as though they have no way to control the events that are taking place around them, as well as the sense that they are alone and misunderstood. Helping the individual identify their psychological family,

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information, community, and spiritual support is important, as well as encouraging the individual to reach for those experiences, people, and recreation activities that encourage selfcare and much-needed respite. Reaching for a solution to resolve the ambiguous loss does not work and is not helpful to the individual or family. How, then, do we provide the best help and resources to those living with ambiguous loss?

Application of Concept in Couple and Family Therapy: Guidelines for Resilience The therapeutic goal of ambiguous loss theory is to help the individual live well with ambiguity. Living well with ambiguity involves a response of learning to flow with the ambiguity rather than fighting it and demanding solutions. Ambiguous losses are not problems to be solved, but life situations to be explored and lived with. Often there is a belief that closure is possible and individuals living with ambiguity are encouraged to seek that closure to their situation; however, closure is a myth. Attempts to reach closure in ambiguous losses lead to feelings of shame, worthlessness, and failure. These attempts are not a reflection on the individual, but rather a reflection of the situation of ambiguity. Ambiguous loss is difficult and hard to hold. Ambiguous losses are irrational, and rational attempts to address them will not succeed nor provide healthy coping strategies for living with ambiguity. The Guidelines for Resilience provide a framework for understanding what works and what does not work in addressing ambiguous loss. The guidelines are not linear and are best understood as elements that work together to better live with ambiguity. The chart below introduces the six guidelines and provides details related to each guideline (Boss and Yeats 2014; Sampson et al. 2012).

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Finding Meaning

Discovering Hope

Tempering Mastery

Revising Attachment

Reconstructing Identity

Normalizing Ambivalence

Finding Meaning: How do I make sense of my losses? The ability to name a loss “ambiguous” helps to make sense of that which does not make sense. Therapy that applies ambiguous loss theory to individuals and families living with ambiguity focuses on a both/and approach rather than either/or. Both/and approaches allow for paradoxical thinking that helps foster resilience in ambiguity. Spirituality, forgiveness, reshaping family rituals are also helpful resources. Anger, the desire for revenge, and secretkeeping hinder one’s capacity for living well with their loss. Tempering Mastery: How do I learn to accept what I cannot control? Recognizing that the world is not always fair helps to address the feelings of being out of control that can accompany ambiguous losses. Other actions that assist acceptance are: externalizing blame, decreasing selfblame, and mastering one’s internal self by the use of meditation, prayer, etc. Perceptions such as believing that bad things only happen to bad people, and the harder you work, the more you avoid suffering, only increase the belief that solving the ambiguity “problem” is the best solution.

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Reconstructing Identity: How can I know who I am now? Accepting that ambiguous losses will change the way in which individuals view themselves, redefining couple/family boundaries can be helpful. Such redefining helps to clarify who is “in” and who is “out,” as well as who plays what roles in this new way of life. Connections with new acquaintances as well as old friends help with the feelings of sadness. Isolation and disconnecting from social interactions hinders the move to resilience. Normalizing Ambivalence: What can I do with the anger and guilt? Many feelings that are often identified as “negative” are actually normal and to be expected in living with ambiguous loss. Denying that these ambivalent feelings exist about who or what has been lost gets in the way of a healthy life. Understanding and normalizing these conflicted feelings are helpful, with the caution that the harmful actions that may occur with the feelings need to be redirected. Talking with trusted friends and colleagues or mental health professionals can also be helpful. Revising Attachment: How can I let go without the certainty of loss? The uncertainty in an ambiguous loss situation can lead to freezing and lack of decision-making. Forcing oneself to make a decision without knowing the true outcome of this type of loss puts the individual in an impossible situation of expecting clarity and closure. Instead, recognizing the paradox of what or who is ambiguously lost can be both here and gone can help the individual live with resilience. Finding new human connections can also be helpful. Discovering Hope: How can I find new hope when my loss remains ambiguous? Although it may be hard to imagine, it is possible to discover hope in the situation of ambiguity. Developing the capacity to become comfortable with ambiguity requires an individual or family to “float” with the situation. Becoming comfortable does not mean pretending or acting as though all is ok, but rather comfort is not fighting the ambiguity. Finding or exploring existing spirituality, justice, and forgiveness can help this process. The ability to find the humor in the absurdity of the situation

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lightens the heaviness. However, insisting that the suffering end or looking for closure to the ambiguity will create more pain, not less Boss (2006).

Clinical Example Ambiguous losses can create stress in family systems and complicate relationships, due to the fact that ambiguity is difficult to live with. Relationships become immobilized and impact the capacity to make decisions that can create conflict between family members. Therapy may involve family mediation and helping family members (and other systems involved with the couple or family) understand how ambiguous loss impacts each individual and system involved Boss (2011). A family who came to me for help in responding to their growing concerns related to decision-making. Al, 80 years of age, had been diagnosed with Alzheimer’s a year earlier. His social ease had masked symptoms for quite some time, and the family was surprised to learn just how diminished his cognitive capacity had become. Al requested that his family keep his diagnosis a secret and that everyone act as though nothing was wrong. The family complied for a year, and came to me after reporting that the adult children and Al’s wife, Jean, were concerned about their inability to come to agreement as to Al’s treatment moving forward. I met with Jean and her adult children. Al’s health had significantly declined, he was living at home with Jean who was his primary caregiver. Jean reported that she was exhausted and felt guilty for saying so. Jean did not like to ask for help from her children and grandchildren as they were “busy with their own lives.” Al and Jean’s son, Jeff managed his parents’ finances and was self-employed with a business that did not allow him to spend much time with his parents. Jeff and his wife, Susan, lived about 15 min from Al and Jean. Daughter Diane and her son lived approximately 3 h from the rest of the family. Diane

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visited her parents once each month for a few hours and believed that the family needed to move Al to a memory care unit because Jean needed relief and she (Diane) was unable to help. Jeff disagreed with his sister and believed that the family needed to stick to their promise, regardless of the fact that Al no longer had capacity to remember his request. At our first family meeting, the tension in my office was palpable, and it was also clear that this family cared about each other, felt guilty about what to do, and did not feel they had permission to make decisions. After listening to each family member, also clear to me was that none of the family members had grieved the losses they had faced and were facing. Because Al had not yet died, the family was not sure they had anything to grieve. I introduced the concept of ambiguous loss to the family, and we discussed what the losses were that this family had been facing. With this understanding, the family could look at decision-making through a different lens that allowed them to know that the choices they were making were in Al’s best interest and for the good of Jean’s health. In two additional family meetings, we discussed how having freedom of choice, based on loss, not only helped the family make decisions but also gave them the opportunity to grieve what had happened and what was currently happening. Finally, using the Guidelines for Resilience allowed us together to reframe the guilt and shame Jeff and Diane were experiencing related to their limited capacity to help their parents and gave Jean a new way to understand that she could still be taking good care of her husband by making use of trained professionals to help. At the end of our sessions, the family decided to move Al to a memory care unit close in proximity to Jean’s home so she could visit her husband frequently. He received excellent care, Jean was able to sleep through the night and saw a reduction in her stress symptoms. Jeff, Susan, and Diane committed to working out a plan amongst themselves to provide more support for Jean as the primary caregiver. This family will continue to have challenges related to Al’s

Ambiguous Loss in Couple and Family Therapy

diagnosis, as Alzheimer’s is a progressive disease, but by acknowledging their ambiguous losses, they are more able to address those challenges in healthy and connected ways.

Conclusion Ambiguous losses are difficult and painful; however, individuals and families can live well with the ambiguity. The process is not easy and is best managed with support from mental health professionals, friends, and family. Ambiguous loss is a relational condition, and a therapeutic goal is to encourage and support resilience. Paradoxical thinking can be used to increase coping: both/ and approaches (harmony with) rather than either/or approaches (mastery over) help to minimize suffering in the midst of the loss. Supporters can be most helpful when they keep in mind that the person experiencing ambiguity is normal, it is the situation that is abnormal (Boss, personal communication 3/17/12). Understanding how to live well with ambiguous loss will help to create meaning and significance within the loss.

Cross-References ▶ Boss, Pauline ▶ Externalizing in Narrative Therapy with Couples and Families ▶ Family Therapy ▶ Feminism in Couple and Family Therapy ▶ Loss in Couples and Families ▶ Resilience in Couples and Families ▶ Theory of Resilience and Relational Load

References Boss, P. (2000). Ambiguous loss: Learning how to live with unresolved grief. Cambridge, MA: Harvard University. Boss, P. (2006). Loss, Trauma and Resilience: Therapeutic work with ambiguous loss. New York: WW Norton. Boss, P. (2011). Loving someone who has dementia: How to find hope while coping with stress and grief. New York: Jossey-Bass.

American Academy of Couple and Family Psychology Boss, P., & Yeats, J. (2014). Ambiguous loss: A complicated type of grief when loved ones disappear. Bereavement Care, 33(2), 63–69. Sampson, J. M., Yeats, J. R., & Harris, S. M. (2012). An evaluation of an ambiguous loss based psychoeducational support group for family members of people who hoard: A pilot study. Contemporary Family Therapy, 34(4), 566–581.

American Academy of Couple and Family Psychology Bob Geffner Institute on Violence, Abuse, and Trauma, San Diego, CA, USA

Introduction The American Academy of Couple and Family Psychology (AACFP) is the specialty organization for family psychologists that works with the American Board of Professional Psychology (ABPP) with respect to the diplomate process and board certification in the specialization of family psychology. The actual group that issues certifications and diplomates in family psychology is the American Board of Couple and Family Psychology (ABCFP). The AACFP works closely with the ABCFP as well as the Society for Couple and Family Psychology, a division of the American Psychological Association. This report focuses on the AACFP, its origins, structure, and goals with respect to family psychologists. In the late 1950s at the American Psychological Association (APA), the Academy of Psychologists in Marriage Counseling was formed. The 1960s and 1970s saw the growth of theoretical orientations and training institutes in couple and family therapy. In 1984, APA added the Division of Family Psychology (Division 43), now the Society of Couple and Family Psychology noted above. In 1990, the ABPP recognized family psychology as a specialty, and the American Board of Family Psychology (ABFamP) and the Academy of Family Psychology were created. Currently, ABFamP is now called the ABCFP. It is responsible for establishing criteria related to the

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definition, education, training, competencies, and the examination process leading to being a board certified specialist (i.e., a diplomate) in couple and family psychology. The Academy of Family Psychology has evolved into the AACFP, an independent nonprofit professional corporation. The purpose of the AACFP is to advance family psychology as a science, advocate on behalf of family psychologists, and to ensure adequate training for those practicing couple and family therapy and family assessment. In 2002, the APA’s Council for the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP) approved family psychology as a specialty. The AACFP promotes this specialty certification and works to encourage and mentor family psychologists in this certification process. The AACFP has developed and enhanced its infrastructure in recent years, improved and refined its governance, added new board members, including early career psychologists for sustainability and mentoring, and has encouraged early career psychologists and graduate students to become involved even before obtaining their own diplomates. Couple and family psychology also represents a comprehensive application of the science and profession of family psychology with assessment, treatment, and consultation for individuals, families, and family subsystems. Couple and family psychologists stress the centrality of understanding and constructively changing the family unit or subsystems, as well as facilitating change within the individual.

Prominent Associated Figures Robert Geffner Chris Tobey Andy Benjamin Christen Carson Karen Prager Rachael Silverman Anthony Chambers Allison Waterworth Florence Kaslow Terry SooHoo Lenore Walker

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American Association for Marriage and Family Therapy (AAMFT)

Michel Harway John Thoburn Terry Patterson Mark Stanton

Contributions The AACFP coordinates efforts and works cooperatively with the ABCFP and APA’s Division 43 to promote the profession of couple and family psychology nationally and internationally. The AACFP has developed and conducted advanced training workshops in conjunction with other conferences, developed an excellent newsletter that is disseminated to academy members and others, enhanced the mentoring program to help those seeking to become diplomates in couple and family psychology, enhanced its website, and developed a fellows program for active members. How professionals identify themselves is a key to enhancing and uniting the field. Part of this is ensuring that they understand the dynamics of dysfunctional, abusive, traumatized, or conflicted family members and are able to conduct appropriate assessments and treatment. Thus, the AACFP promotes and works to ensure that family psychologists are able to work with such varied situations as marriage therapy, family therapy, child abuse, intimate partner abuse, divorce, parenting, and so forth and are trained in all of these areas. For example, many of the above situations involve trauma, child psychology, family dynamics, family violence, couples’ interactions, attachment, adverse childhood experiences, and possibly forensic issues if they end up in some court. Thus, identifying as a family psychologist if one is working in some area of this specialty is important, as is obtaining the needed training and expertise. It is hoped that these issues will be clarified and emphasized in the coming years, with the AACFP playing a key role. Many training programs that focus on marital therapy, or clinical psychology with a family emphasis, do not necessarily identify themselves as family psychology. It is also important to ensure that those psychologists who do evaluate or treat family members in a variety of settings, including

forensic ones, are indeed trained in family psychology and identify as such. The academy wants to help ensure that such training and identification is more widely recognized so that psychologists and others untrained in these areas would not be chosen to do this type of treatment or evaluation. This raises ethical concerns, especially about mental health professionals working in forensic arenas with situations that involve couples and families but who are not trained nor have expertise in couple or family psychology. This has been most relevant in family courts with respect to child custody evaluations and the role and expertise required to do such family evaluations. There is also a controversy that revolves around ethics and appropriate roles and responsibilities of therapists who happen to have a client or family involved with a court and whether the therapist should be trained and follow forensic guidelines rather than therapeutic or family psychology ones. These issues will be addressed by AACFP in the future in order to set appropriate policies.

American Association for Marriage and Family Therapy (AAMFT) Christopher M. Habben Friends University, Overland Park, KS, USA

Name of Organization American Association for Marriage and Family Therapy

Introduction Founded in 1942, the American Association for Marriage and Family Therapy (AAMFT) is the oldest and largest professional association promoting the common professional interests of marriage and family therapists and the field of marriage and family therapy as a whole (Nichols 1992; AAMFT 2017). Multiple pathways exist for membership in AAMFT with variant categories of

American Association for Marriage and Family Therapy (AAMFT)

membership and related benefits. Membership is open to those licensed or pursuing licensure as a marriage and family therapist as well as students enrolled in a graduate marriage and family therapy program. In addition, AAMFT extends membership to professionals holding or pursuing professional licenses in related mental health fields authorized to provide services to individuals, couples, or families and to students enrolled in acceptable alternative graduate mental health programs. Membership is also available to those professionals in fields related to marriage and family therapy (AAMFT 2017).

Location 112 S. Alfred Street Alexandria, VA 22314

Prominent Associated Figures Dr. Tracy Todd, Chief Executive Officer

Contributions The primary mission of the AAMFT is the advancement of both the profession and the practice of marriage and family therapy (AAMFT 2017). The contributions of AAMFT to couple and family therapy have shaped the development and maturation of the marriage and family therapy profession. AAMFT has long endeavored to represent the professional interests of marriage and family therapy before government and corporate policymakers regarding matters such as licensure, the equitable reimbursement of practitioners, and evidence of the efficacy of systemic and relational therapies. The profession and practice of marriage and family therapy is enhanced through its professional journal, the Journal of Marital and Family Therapy (JMFT). The peer-reviewed JMFT is published quarterly and has earned international respect as a family therapy journal [http:// onlinelibrary.wiley.com/journal/10.1111/(ISSN) 17520606/homepage/ProductInformation.html].

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AAMFT promotes the public trust of marriage and family therapists by developing high standards for ethical and professional behavior as outlined in the AAMFT Code of Ethics and the formal processes for addressing complaints of ethical misconduct (AAMFT 2015). The Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), established by AAMFT, furthers the profession of marriage and family therapy by developing and reviewing rigorous standards of education for marriage and family therapy and by promoting best practices for training (COAMFTE 2016). With a goal to identify and improve the quality of service delivered by all marriage and family therapists, AAMFT commissioned a task force to define core competencies articulating the knowledge and requisite skills necessary for the competent practice of marriage and family therapy (AAMFT 2004). The development of the core competencies further delineates the overlap and distinctiveness of marriage and family therapy relative to other mental health disciplines. The core competencies of AAMFT also pose learning objectives for educational and training programs. The AAMFT Approved Supervisor designation is another example of the dedication of AAMFT to ensure a high standard of practice. AAMFT Approved Supervisors must meet stringent education and training requirements and renewal criteria. These high standards of training and practice assure that supervisees are equipped with the latest innovations and skills for competent practice (AAMFT 2014). Another contribution to the advancement of the profession of marriage and family therapy is the AAMFT Research and Education Foundation which endeavors to fund systemic and relational research, scholarship, and education. The Research and Education Foundation supports the next generation of scholars and clinicians through grants, awards, and a minority fellowship program [http://www.aamftfoundation.org/]. Amid the efforts to advance the profession, AAMFT is equally cognizant of marriage and family therapy practitioners’ needs. AAMFT offers multiple services, publications, and products to members to improve their clinical practices

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and efficacy of client care. The Family Therapy Magazine, continuing education (in-person and online), interest networking, an employment search engine, and various practice tools are a few of the options for members. Legislative advocacy in provinces, states, and federal levels, policy advocacy with policy and research entities, meaningful publications, educational support, professional standards, research opportunities, and the products and services of AAMFT all advance the profession of marriage and family therapy. A vibrant and flourishing association attentive to the relevant needs of a diverse membership in turn provides various resources for the continual advancement of the field. To that end, AAMFT consistently pursues high standards of care and innovation in all of the association efforts to promote systemic and relational therapies in general and marriage and family therapy in particular. The diversity of association membership and the collective possibilities members provide to the field of marriage and family therapy are a precious resource. AAMFT has long served the profession and practice of marriage and family therapy and remains a vivid champion for the interests of all marriage and family therapists.

Cross-References ▶ Journal of Marital and Family Therapy

References American Association for Marriage and Family Therapy. (2004). Marriage and family therapy core competencies. Retrieved from http://www.aamft.org/imis15/doc uments/mft_core_competencie.pdf American Association for Marriage and Family Therapy. (2014). Approved supervisor designation: Standards handbook. Alexandria: American Association for Marriage and Family Therapy. American Association for Marriage and Family Therapy. (2015). Code of ethics. Retrieved from http://www. aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_ of_Ethics.aspx American Association for Marriage and Family Therapy. (2017). AAMFT bylaws: January 2017. Retrieved from

American Board of Couple and Family Psychology http://networks.aamft.org/viewdocument/aamft-bylawseffective-january-2012 Commission on Accreditation for Marriage and Family Therapy. (2016). Accreditation manual: Policies and procedures. Alexandria: Commission on Accreditation for Marriage and Family Therapy. Nichols, W. C. (1992). The AAMFT: Fifty years of marital and family therapy. Washington, DC: American Association for Marriage and Family Therapy.

American Board of Couple and Family Psychology Allison Waterworth American Board of Professional Psychology, Chapel Hill, NC, USA

Introduction The American Board of Couple and Family Psychology (ABCFP) is a specialty credentialing board for the American Board of Professional Psychology (ABPP). A specialty is a defined area in the practice of psychology that connotes special competency acquired through an organized sequence of formal education, training, and experience. In order to qualify as a specialty affiliated with the ABPP, a stable examining board, national in scope, must reflect the current development of the specialty. As a constituent specialty group of ABPP, ABCFP offers certification to psychologists who present the requisite training and experience in couple and family work. One of the most important missions of ABCFP is to increase consumer protection. Board certification assures the public that specialists designated by ABPP have successfully completed the educational, training, and experience requirements of the specialty, including an examination designed to assess the competencies required to provide the highest degree of service. Additionally, board certification through ABPP provides psychologists with increased opportunities for career growth, including employability, mobility, and financial compensation.

American Counseling Association (ACA)

Candidates for board certification in couple and family psychology complete an application, submit credentials, provide a work sample, and sit for an oral examination administered by the ABCFP. Candidates who successfully complete the process earn board certification. Couple and Family Psychology (CFP) is a broad specialty in professional psychology that is founded on a systemic epistemology. It represents a paradigm shift from contemporary individualistic psychology and incorporates an understanding of human behavior, psychological assessment, and intervention based on a systemic perspective and model. The specialty of Couple and Family Psychology conceptualizes human behavior in a matrix of reciprocal interaction among intrapersonal, interpersonal, environmental, and macro-systemic factors. ABCFP-certified psychologists use their awareness of context, diversity, and developmental perspectives to understand, assess, and treat the comprehensive issues of psychological health and pathology. These issues include affective, cognitive, behavioral, and dynamic factors among individuals, couples, families, and larger social systems. ABCFP-certified psychologists depend upon a body of knowledge and evidence-based interventions that require specialty competence (Stanton and Welsh 2011). The ABCFP Board was affiliated in 1990. Before its inception, the only organization representing the interests of psychologists in the family field was the Academy of Psychologists in Marital, Sex, and Family Therapy. In 1983, the academy changed its name to the Academy of Family Psychology, and in 1984, it officially became the Division of Family Psychology of the American Psychological Association. Founders of the ABCFP included Florence Kaslow, Michael Gottlieb, S. Richard Sauber, Gerald Weeks, and George Nixon, Jr.

References Stanton, M., & Welsh, R. (2011). Specialty competencies in couple and family psychology (1st ed.). Oxford: Oxford University Press.

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American Counseling Association (ACA) Thelma Duffey University of Texas at San Antonio, San Antonio, TX, USA

Name of Organization or Institution American Counseling Association (ACA)

Synonyms ACA

Introduction The American Counseling Association is the largest professional membership organization for counselors in the world. With a membership of over 55,000, ACA serves counselors working in diverse settings and across specialties. ACA is dedicated to strengthening professional identity and unity within the counseling profession, promoting clarity within the public about the counseling profession, and advocating for legislation serving the interests of counselors and their clients. ACA also supports the professional development of counseling students and promotes research in counseling. These goals are grounded in ACA’s mission to promote respect for human dignity and diversity.

Location ACA is headquartered in Alexandria, Virginia, and serves counselors in the United States, Latin America, Europe, the Philippines, and the Virgin Islands. There are 4 ACA regions (Midwest, North Atlantic, Southern, and Western) and 56 state- and territorylevel branches of the ACA which support the goals of the ACA and address issues particular to each geographical area. The ACA also maintains a website: www.counseling.org.

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Prominent Associated Figures ACA is a community of professional counselors across specializations, and its growth and foci have been developed through the work of countless members. There are a number of notable figures within ACA, including Thelma T. Daley, 1975–1976 president of the American Personnel and Guidance Association (APGA) – which would later become the ACA. Daley has been a pioneering leader and mentor for many within the profession and beyond. Daley was the first African American president of the American School Counselor Association in 1971 and the first African American and third female president of APGA; Samuel T. Gladding continues to be a leading figure within the ACA. He has written a myriad of textbooks within the field of counseling and served as ACA president in 2004–2005. Patricia Arredondo, well known for her work on multicultural competencies, served as president in 2005–2006. Loretta Bradley, ACA president in 1998–1999 has made seminal contributions in the area of marriage and family counseling and is a board member for the Texas State Board of Examiners of Professional Counselors. These leaders, and others like them, have contributed to ACA’s growth and the professionalization of counseling.

Contributions ACA is structured to include 20 divisions/associations which address distinct areas of specialization in practice or orientation within the counseling profession. Among these are: the Association for Adult Development and Aging (AADA); Association for Assessment and Research in Counseling (AARC); Association for Child and Adolescent Counseling (ACAC); Association for Creativity in Counseling (ACC); American College Counseling Association (ACCA); Association for Counselor Education and Supervision (ACES); Association for Humanistic Counseling (AHC); Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC); Association for Multicultural Counseling and Development (AMCD);

American Counseling Association (ACA)

American Mental Health Counselors Association (AMHCA); American Rehabilitation Counseling Association (ARCA); American School Counselor Association (ASCA); Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC); Association for Specialists in Group Work (ASGW); Counselors for Social Justice (CSJ); International Association of Addictions and Offender Counselors (IAAOC); International Association of Marriage and Family Counselors (IAMFC); Military and Government Counseling Association (MGCA); National Career Development Association (NCDA); and National Employment Counseling Association (NECA). ACA traces its development to 1952, when the National Vocational Guidance Association (NVGA), the National Association of Guidance and Counselor Trainers (NAGCT), the Student Personnel Association for Teacher Education (SPATE), and the American College Personnel Association gathered in Los Angeles, California, to create the American Personnel and Guidance Association (APGA). The APGA was renamed the American Association of Counseling and Development in 1983 and became the American Counseling Association in 1992, a name which best reflected its goals for professional unity. Through the strategic efforts of ACA and its organizational partners and predecessors, the identity and standing of the counseling profession has strengthened steadily over time. Among the recent historical milestones for the profession are the adoption of a unified definition of professional counseling by ACA in 1997, the legal recognition of counselors as mental health specialists within the Veterans Affairs health care system in 2006, the enactment of counselor licensure in all 50 states in 2009, when California adopted licensure legislation, and the promulgation of a consensus definition of counseling by ACA delegates and 30 other professional organizations in 2010. Other milestones include the passing of the 2015–2016 ACA Governing Council’s policy to endorse the Council for Accreditation of Counseling and Related Educational Programs (CACREP) as the accrediting body for counselors, and the 2015–2016 ACA Governing Council’s passage of the ACA Licensure

American Counseling Association (ACA)

Portability Model. ACA continues its advocacy for counselors through this model. ACA was instrumental in supporting statelevel efforts to secure licensing laws for counselors in all 50 states and continues to advocate that licensed counselors be included in governmental insurance systems. In addition, with licensure legislation in place in all 50 states, licensure portability across states has become a primary concern for the ACA. Currently, counselors moving across state lines must satisfy the licensure requirements of the new state in which they intend to practice, regardless of their experience and record. The long and idiosyncratic history of state legislation of counselor licensure inadvertently created a significant burden to the counselor moving across state lines. The 2015–2016 ACA Governing Council made significant strides in addressing educational standards and policies on portability to address these burdens. The council’s position on CACREP as the accrediting body for counselors, and its passage of the ACA Licensure Portability Model, both serve the vision of a unified and standardized counseling license. The ACA Licensure Portability Model provides that fully licensed counselors without disciplinary records would be eligible for licensure without additional requirements after taking a jurisprudence exam in any state or US territory. ACA is dedicated to legislative advocacy at state and federal levels. Its efforts have two foci: advocacy for the professional interests of counselors and advocacy for the mission of the ACA. These involve enhancing the quality of life in society and promoting human respect and dignity. The ACA offers training on legislative advocacy to its members and also employs a Director of Government affairs and legislative representatives that work on Capitol Hill to represent the interests of counselors and their clients. ACA also continues to advocate for counselors’ inclusion as mental health providers within various governmental systems. For example, since 2010, licensed professional counselors who meet standards set by the VA health care system qualify to work as licensed professional mental health counselors for the VA health care system.

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The ACA Code of Ethics (2014) provides a framework for ethical conduct and decisionmaking for professional counselors. It is structured around the core values of the counseling profession and the fundamental ethical principles of autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity. The ACA Code of Ethics has nine sections dealing with the counseling relationship; confidentiality and privacy; professional responsibility; relationships with other professionals; evaluation, assessment and interpretation; supervision, training, and teaching; research publication; distance counseling, technology, and social media; and resolving ethical issues. The ACA Code of Ethics is a living document. Since the approval of the first Code of Ethics in 1961, the code has undergone numerous revisions to stay up-to-date with current thinking and emerging issues. The most recent ACA Code of Ethics was issued in 2014 with a number of updates, including but not limited to the ethics of social media for counselors, clearer language around client referral based on counselor competence rather than personal values, the need to use a decision-making model when considering ethical dilemmas, and the need to rely on relevant laws in deciding whether to disclose a client’s status as a carrier of a life-threatening communicable disease to a person at risk. ACA holds an annual conference which serves to bring together members for collaboration and continuing education. Presenters and participants at the conference travel from all over the world to learn from each other. The conference features keynote speakers, group discussions, plenary sessions, and research presentations. It also provides opportunities for counselors to connect with colleagues and engage in growth-fostering networking. The conference serves as a forum for the expression of a unified professional identity for counselors. Continuing education is a common licensure requirement, and it is also important for counselors’ professional advancement. ACA provides continuing education courses online and offers webinars and podcasts for professional development. ACA is approved by the National Board of

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Certified Counselors, the Association for Play Therapy, the Association for Addiction Professionals, and other related associations and licensure boards as a provider of continuing education units. The Journal of Counseling & Development is the flagship journal of ACA and published quarterly. Research studies published in the Journal of Counseling & Development span many topics and include both quantitative and qualitative studies, as well as pieces on practice and theory. A number of ACA divisions also have their own peerreviewed journals. In addition, Counseling Today is the monthly newsletter of ACA, published since 1958. It includes news, feature stories, and other related information on professional issues in counseling. ACA also publishes books electronically and in print in partnership with John Wiley & Sons publishing company on topics including creativity in counseling, counselor supervision and education, counseling children and adolescents, ethical and legal issues in counseling, multiculturalism and diversity in counseling, counselors’ professional development, school counseling, and substance abuse and addictions counseling. ACA emphasizes the importance of developing a strong research base within the counseling profession. Because empirical work in counseling may be framed to explore some of the issues of particular interest to counselors, including strengths-based work, multiculturalism, innovative and creative practice, and preventive mental health, the ACA sees counseling research as indispensable to the growth of the profession.

Cross-References ▶ Training Counselors in Couple and Family Therapy

References American Counseling Association. (2005). ACA code of ethics: As approved by the ACA Governing Council, 2005. Alexandria: American Counseling Association.

American Family Therapy Academy (AFTA)

American Family Therapy Academy (AFTA) Kiran Arora Long Island University, Brooklyn, NY, USA

Introduction The American Family Therapy Academy was founded in 1978. It is an interdisciplinary community of family therapy and allied-field mental health professionals, researchers, academics, students, policy makers, and program directors. AFTA studies the interaction between psychological, relational, biological, and sociocultural dimensions that contribute to mental health and well-being (AFTA 2016). Members are informed of topics of concern to those in the mental health field. AFTA holds a core commitment to justice and social responsibility while providing acute attention to underserved groups. Emerging leaders in the field are supported through a variety of initiatives.

Location The AFTA office is located in Haverhill, Massachusetts.

Prominent Associated Figures Murray Bowen James L. Framo Kitty La Perriere Lyman C. Wynne Carol M. Anderson Rachel T. Hare-Mustin Froma Walsh Richard Chasin Evan Imber-Black Donald A. Bloch Celia J. Falicov Janine Roberts Lois Braverman Paulette Moore Hines John S. Rolland

American Psychiatric Association

John Sargent Hinda Winawer Gonzalo Bacigalupe Volker Thomas Kiran S. K. Arora

Contributions AFTA envisions a just world by transforming social contexts that promote health, safety, and well-being of all families and communities. AFTA’s mission is developing, researching, teaching, and disseminating progressive, just family therapy, and family-centered practices and policies. An annual conference is held for members and nonmembers where practitioners, educators, and researchers share contributions to the field. Interest groups include online communities that provide AFTA members with opportunities to discuss areas of interest, generate new ideas, and develop community. The AFTA Springer Briefs in Family Therapy, produced in partnership with Springer Science is an official publication of the American Family Therapy Academy. AFTA releases position statements and provides recommendations to current social issues that are relevant to the well-being of families.

References American Family Therapy Academy (2016). Retrieved from https://afta.org/. 1 Aug 2016.

American Psychiatric Association John Sargent Tufts Medical Center, Boston, MA, USA

Description and Contributions The American Psychiatric Association (APA) is the professional organization of psychiatrists in the United States. The APA has over 36,000

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members and holds two annual meetings every year: the Annual Meeting of the APA in May each year and the Institute of Psychiatric Services in October. The APA also owns and operates a publishing company that publishes and markets books and journals on a variety of mental healthcare topics. The American Psychiatric Association Publishing Company also publishes the APA’s Diagnostic and Statistical Manual (DSM) which provides information on diagnostic criteria for and descriptions of all psychiatric diagnoses. The fifth edition (DSM-V) was published in 2013, was several years in creation, and is the standard used for diagnosis and coding for mental health treatment in the United States and is widely used internationally. The American Psychiatric Association was formed in 1844. It was formed by 13 superintendents of psychiatric hospitals and was called the Association of Superintendents of American Institutions for the Insane. Throughout the nineteenth century, the organization was primarily concerned with the funding, building, and operation of longterm care institutions for those with mental illness. Over the first 50 years of its existence, the organization was primarily concerned with ensuring adequate care for those in institutions and defining procedures and indications for admission as well as criteria for a legal definition of insanity. As the twentieth century began, the organization expanded and diversified its focus to outpatient care and appropriate and effective treatments for a range of mental health problems including those that did not require institutional treatment. The name of the organization was officially changed to the American Psychiatric Association in 1921. Through the twentieth century, the organization embraced new forms of treatment including psychoanalysis, group therapy, family therapy, cognitive therapy, and psychopharmacology. One particularly noteworthy event was removing homosexuality from the diagnostic manual in 1973, thus depathologizing that sexual orientation. The scope of attention of the APA currently has expanded to include advocacy, communication – especially with patients, families, and the public – diversity in membership, and leadership

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and research into the causes of and treatments for mental illness. The organization has grown to include 76 district branches across the country and councils addressing major topics in psychiatry. The APA views itself as the professional home for all subspecialties of psychiatry although each subspecialty may have its own focused organization as well (e.g., the American Academy of Child and Adolescent Psychiatry for child and adolescent psychiatrists). Of particular note to marriage and family therapists is the APA component, the Association of Family Psychiatrists, composed of psychiatrists with a strong interest in the treatment of couples and families. DSM-V, while steadfastly only diagnosing individuals with a formal diagnosis, does include a section covering “other conditions that may be a focus of clinical attention” including family problems, relational problems, and problems related to interpersonal violence including child maltreatment. These, indeed, are the focus of couple and family therapy.

Andersen, Tom Elena Fernández Grupo Campos Elíseos, Mexico City, Mexico

Andersen, Tom

Association and the International Family Therapy Association. He was a Board member of the Taos Institute.

Career Tom Andersen started as a psychiatrist, but he was attracted to the ideas of Family Therapy that were critical of orthodox psychiatry. He disliked labels and to treat people as such. He and his colleagues were influenced by the ideas of Gregory Bateson, the physiotherapist Aadel Bülow-Hansen, Jay Haley, Salvador Minuchin, Paul Watzlawick from the MRI in Palo Alto, Peggy Penn from The Ackermann Institute, Luigi Boscolo and Giancarlo Cecchin from the Milan Model of Family Therapy, Phillippa Seligman, and Brian Cade, Harlene Anderson and Harry Goolishan, Lynn Hoffman, and the Chilean biologist Humberto Maturana and FranciscoVarela, among other theorists and practitioners. He was invited around the world to teach his RT, he appreciated the different milieu of human behaviors and the gift of the human spirit to grasp and surmount adversity. Tom dedicated himself to traveling to developing countries where he taught many of his colleagues, donating his time and getting funds and training for therapists in these countries.

Name Contribution to the Profession Tom Andersen Ph.D. (1936–2007)

Introduction Tom Andersen was a Norwegian psychiatrist, Professor of Social Psychiatry at the Institute of Community Medicine, University of Tromsø, Norway, and he is recognized worldwide for the contribution that, with his colleagues, led him to the development of the Reflecting Team (RT). The RT is an approach that offers to the consultant a pluralistic view of meaning by inviting numerous interpretations rather than a correct view of what is happening to them. Tom Andersen was an inspiration both for the Norwegian Family Therapy

Andersen’s innovative manner of working was originally proposed as a therapeutic space consisting of three parts: (1) An interview of one or more therapists with one or more consultants during the first 30–40 min, while a team of several therapists listen quietly, (2) A reflective conversation about the ideas and thoughts that arose during the time of listening to the interview (the RT maintains this conversation with each other for about 10/15 min not including the consultants, who are in a posture of listening), and (3) A final conversation between the team and the consultant about his/her/their reflections on the reflections of the RT. Andersen (Andersen 1987) underscored the tentative way in which members of the team

Anderson, Carol

should present their ideas once they give back their reflections to the clients: As a general rule, everything that is said should be speculative: “I am not sure, “It occurred to me,” “Maybe,” “I had the feeling that, “Maybe this is not appropriate, but,” and so forth. The reflections must have the quality of tentative offerings, not pronouncements, interpretations, or supervisory remarks (p. 419). The RT continues developing around the world. The weight of his work is better explained in his own words: I see two kinds of therapy, the first gives priority to the philosophy of ontology and the second gives priority to the philosophy of ethics. Ontology is occupied with questions like: What is it? For instance, what is a human being? Or what is the problem? One could say questions that call on explanations and understanding of something, “out there”. Ethics are carried by what connects people; that which is between us, for instance, language and conversations. http://www. newtherapist.com/andersen5.html

Andersen’s main contribution, The Reflection Team, characterizes a transformation in the means of delivering ideas to the clients and on “expert knowledge.” When several specialists offer their views tentatively and horizontally, the position of the specialists changes and enhances the relationship with the client. Reflection teams are used in many countries and in a variety of contexts: clinical, educational, and organizational and with different objectives: therapeutic, supervision, or training.

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References Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26, 415–428. http://www.newtherapist.com/andersen5.html. Retrieved 31 July 2017.

References Andersen, T. (Ed.). (1991). The reflecting team, dialogues and dialogues about the dialogues. London: Norton. Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26, 415–428. Andersen, T. (1989). Back and forth and beyond. Australian and New Zealand Journal of Family Therapy, 10, 75–76. Andersen, T. (1992a). Reflections on reflecting with families. In S. McNamee & K. J. Gergen (Eds.), Therapy as a social construction (pp. 54–68). Newbury Park: Sage. Andersen, T. (1992b). Relationship, language and preunderstanding in the reflecting processes. Australian and New Zealand Journal of Family Therapy, 13, 87–91. Andersen, T. (1993). See and hear, and be seen and heard. In S. Friedman (Ed.), The new language of change: Constructive collaboration in psychotherapy (pp. 303–322). New York: Guildford Press.

Anderson, Carol Britney Acquaire, Justine Encinas and Christiana I. Awosan Seton Hall University, South Orange, NJ, USA

Name Cross-References ▶ Anderson, Harlene ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Dialogical Practice in Couple and Family Therapy ▶ Milan Associates ▶ Open Dialogue Family Therapy ▶ Postmodernism in Couple and Family Therapy ▶ Social Constructionism in Couple and Family Therapy ▶ Talk as Action in Couple and Family Therapy

Carol Anderson (11/1/1939–11/20/2014).

Introduction Carol Anderson is most well known for her revolutionary approach to the treatment of schizophrenia. Family psychoeducation is an empirically supported family therapy model that aims to decrease symptoms of schizophrenia and increase social involvement in schizophrenic patients. Carol Anderson proposed that families can

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support their loved ones with schizophrenia if they are given the knowledge to understand the illness and the skills to care for their family member effectively.

Career (Includes Education, Professional Training, Positions) Carol Anderson attended the University of Minnesota where she received a Bachelor’s Degree in Child Development and Psychology in 1961 and a Master’s Degree in Social Work in 1964. She earned her Ph.D. in Interpersonal Communication from the University of Pittsburg in 1981. Early in her career, Carol Anderson served as Chief Psychiatric Social Worker at Yale University’s Psychiatry Department. Carol Anderson joined the faculty at the University of Pittsburg Medical Center (UPMD) in 1973, where she worked as a Professor of psychiatry and social work. She was granted Professor Emerita status in 2010. During her time at UPMD, Carol Anderson helped develop the Family Therapy Clinic at the Western Psychiatric Institute and Clinic (WPIC). Over the span of her career, Carol Anderson also served as Director of the Family Therapy Institute and Clinic, Director of Family Research, Director of Brief Treatment Center for Children and Families, Director of Child and Adolescent Outpatient Services, and Director of Family Studies and Social Work. Carol Anderson was the administrator of WPIC from 1989 to 1994 and then became Vice President for Patient and Family Psychiatric Services at UPMD. Carol Anderson served as the President of the American Family Therapy Academy (AFTA) from 1988 to 1989. She was Editor of the Family Process journal from 1999 to 2003.

Contributions to Profession Carol Anderson developed family psychoeducation, an empirically validated family therapy model used to treat schizophrenia. Developed in 1978, family psychoeducation was among the first family therapy models that

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did not blame families for the development of mental illness. In the 1970s, her approach to treatment was controversial and revolutionary because she accepted the families’ view of the symptom bearer as the identified patient and advocated for the use of medication in conjunction with family therapy. The goal of family psychoeducation is to help families manage symptoms of schizophrenia, cope with the illness, and help the identified patient achieve their highest potential for social engagement. The family psychoeducation model is divided into five stages of treatment. During the beginning stages, therapists provide information to families about schizophrenia. Topics include: symptoms and causes of schizophrenia, medication treatment and side effects, brain functioning of a schizophrenic, and the social response to schizophrenia. During the middle stages of treatment, families use their new knowledge in the context of their everyday lives in order to help the identified patients successfully return to life in the community. During the last stage of treatment, therapists address general family functioning issues that are unrelated to the mental illness. Outcome studies endorsed by the American Psychiatric Association support the use of Carol Anderson’s family psychoeducation model in the treatment of families struggling with schizophrenia. In conjunction with medication, family psychoeducation significantly reduces relapse and unemployment for the individual with schizophrenia. Carol Anderson’s research interests also include: access to mental healthcare, barriers to mental health services, and engaging low-income mothers in mental health treatment. Throughout her career, Carol Anderson wrote and coauthored more than 40 research articles and published several books: Mastering Resistance: A Practical Guide to Family Therapy, Families and Schizophrenia, Schizophrenia and the Family: A Practitioner’s Guide to Psychoeducation and Management, Flying Solo: Single Women in Midlife, and Women in Families. Carol Anderson received multiple acknowledgement for her contributions to the field. In

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1992, Anderson was named a Distinguished Daughter in the State of Pennsylvania, an award grated to renowned individuals affiliated with Pennsylvania who have achieved professional excellence. She was also granted two Distinguished Contribution to Family Therapy awards from AFTA in 1985 and AAMFT in 1987.

Cross-References ▶ Family Psychoeducational Treatments for Schizophrenia in Family Therapy

References Barlow, K. K. (2014, December 4). Obituary: Carol M. Anderson. University Times. http://www.utimes. pitt.edu/?p=33431. Carpeter, M. (2014, November 21). Obituary: Carol Anderson / Psychiatrist social worker helped to develop cutting-edge therapy for children. Pittsburg Post-Gazette. http://www. post-gazette.com/news/obituaries/2014/11/21/Psychiatricsocial-worker-helped-to-develop-cutting-edge-therapyfor-children/stories/20141121008. Singer, J. B. (Host). (2007, October 24). Family psychoeducation: Interview with Carol Anderson, Ph.D. [Episode 27]. Social Work Podcast. Podcast retrieved 3 Aug 2016, from http://socialworkpodcast.com/2007/ 10/family-psychoeducation-interview-with.html.

Anderson, Harlene Sylvia London Grupo Campos Elíseos, Mexico City, Mexico

Introduction Harlene Anderson is recognized internationally as a leader in the development of a postmodern collaborative-dialogic approach to psychotherapy, which she has applied to work in organizations, communities, education, research, and consultation. Her books, translated into several languages, include Conversations, Language and Possibilities: A Postmodern approach to Therapy; she

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coedited Appreciative Organizations, Collaborative Therapy: Relationships and Conversations that Make a Difference and Innovations in the Reflecting Process.

Career Harlene Anderson holds a doctorate in psychology and is a licensed professional counselor and family therapist. She is an advisor for the Taos Institute Doctoral Programs and a member of Silver Fox Advisors. She received the 2008 American Academy of Family Therapy Award for Distinguished Contribution to Family Therapy Theory and Practice, the 2000 American Association for Marriage and Family Therapy award for Outstanding Contributions to Marriage and Family Therapy, and the 1997 Texas Association for Marriage and Family Therapy award for Lifetime Achievement.

Contribution to the Profession In collaboration with Harold Goolishian, Ph.D., she is the creator of postmodern collaborative and dialogic practices, also known as collaborative language systems approach to therapy. The collaborative-dialogic approach draws from postmodern, social construction and hermeneutic traditions of thought to emphasize conversation, collaboration, and language as the main principles to promote transformations and generate possibilities. Dr. Anderson is a cofounder and board member of the Taos Institute, Houston Galveston Institute, and Access Success International; she is the founding editor of the International Journal of Collaborative Practices and cofounder of the International Certificate in Collaborative Practices program. A sought-after speaker, consultant, and trainer, she uses her tools – her insights, her keen interest, her engaging conversational style, and her leadership skills – to help and inspire individuals and organizations to achieve clarity, focus, renewed energy, and often surprising results.

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References Anderson, H. (1997). Conversation, language and possibilities: A postmodern approach to therapy. New York: Basic Books. Anderson, H. (2007). The heart and spirit of collaborative therapy: A way of being. In H. Anderson & D. Gehart (Eds.), Collaborative therapy: Relationships and conversations that make a difference. New York: Taylor & Francis Group 4. Anderson, H. (2009). Collaborative practice: Relationships and conversations that make a difference. In J. Bray & M. Stanton (Eds.), The Wiley handbook of family psychology (pp. 300–313). Malden: Blackwell Publishing Ltd. Anderson, H., & Gehart, D. (2007). Collaborative therapy: Relationships and conversations that make a difference. New York: Taylor & Francis Group. Anderson, H., & Goolishian, H. (1988). Human systems as linguistic systems: Preliminary and evolving ideas about the implications for clinical theory. Family Process, 27(4), 371–393. Anderson, H., Goolishian, H., Pulliam, G., & Winderman, L. (1986). The Galveston Family Institute: A personal and historical perspective. In D. Efron (Ed.), Journeys: Expansions of the strategic-systemic therapies (pp. 97–124). New York: Brunner/Mazel. Anderson, H., Goolishian, H., & Winderman, L. (1986). Problem determined systems: Towards transformation in family therapy. Journal of Strategic and Systemic Therapies, 5, 1–13.

Andolfi, Maurizio Anna Mascellani Accademia di Psicoterapia della Famiglia, Rome, Italy

Name Maurizio Andolfi, M.D. (1942).

Introduction Maurizio Andolfi is a world-renowned family therapist due to his remarkable scientific and methodological contribution to the contemporary family therapy. Over the last 45 years, he developed the Multigenerational Family Therapy, an experiential model of intervention that centers on

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creativity and humanity as the best way to build an alliance and work with a family in crisis. Andolfi has been published widely in English, Italian, and several other languages.

Career After graduating and specializing as child psychiatrist with Giovanni Bollea, in the early 1970s Andolfi moved to New York, where he stayed for a few years and where he established close professional relationships with the most important family therapists, such as Salvador Minuchin, Carl Whitaker, James Framo, and Murray Bowen. He learnt family therapy by personally observing master therapists at work and absorbing their skills and knowledge. Back in Italy, he was Professor in Clinical Psychology at the University La Sapienza, Rome, and cofounder of the European Family Therapy Association. Andolfi is currently Director of the Accademia di Psicoterapia della Famiglia of Rome and is editor of Journal Terapia familiare. Throughout his career he received several awards, among which the AAMFT Award for his Significant Contribution to Marriage and Family Therapy and the Life Achievement award from the American Family Therapy Academy (AFTA).

Contributions to Profession The Multigenerational Family Therapy developed by Andolfi reveals the limits of the medical model in treating mental and relational problems. It instead provides a toolkit for therapists, observing family functioning over the last three generations to explore the developmental history of the family, in order to discover links between past trauma and broken emotional bonds and current problems experienced by family members. Andolfi’s model considers both the structural dimension (Minuchin 1974) and the historical and developmental dimension with which the therapist interacts. In the observation of the family spanning several generations, an important role is given to the

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subsystem of the children, who are engaged in therapy as significant relational bridges in the dialogue of clash between generations. This active role of children and adolescents in therapy, especially when they are the bearers of symptomatic behaviors, is without doubt the most original aspect of Andolfi’s clinical experience and of the model he proposes. Having noticed the limitations and often the damage caused by the widespread pharmacological treatment of many types of child and adolescent psychopathology, over time, he developed the conviction that the family is the best medicine. The cure, therefore, consists of revisiting together the family’s developmental history, stitching up still open wounds and healing broken emotional bonds. The presenting problem becomes an access door to the family’s world and the identified patient a privileged guide in the exploration of family ties. The first concrete result of this therapeutic approach will be the gradual disappearance of symptoms in the person for whom intervention was required, but even more significant, will be to observe the affective and relational transformations between family members, both on the couple dimension and on the intergenerational relationships. The family will thus move from a passive position of delegating to the expert, typical of a medical model, to a leading role in its own destiny, within the kind of therapy that helps it to discover its own resources rather than highlighting its failures. For this to happen, it is necessary for the therapist to keep in mind a multigenerational map of the family that he meets in therapy, a kind of “living genogram,” where he can access active resources and open healing pathways. The therapist needs to adopt the curiosity of an explorer who enters into the private world of each family, while remaining centered. His professional toolkit consists of multiple instruments designed to promote a trusting and cooperative therapeutic relationship with each family member. It is necessary to develop a creative repertoire of relational questions and to listen attentively to each person’s voice, honoring adults as well as children. At the same time, it is important during the session to be able to gasp those nonverbal signals transmitted by the body, the eyes, by

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gestures, and postures that are more eloquent than words, and to appreciate pauses and silences rich in relational meanings. The therapist described by Andolfi should be free from cultural stereotypes and institutional routines, to be able to use himself, his affective resonance and the therapeutic space in an active way, approaching and establishing physical contact with this or that family member, facilitating new connections, and mending the emotional disconnections of the past. His physical and internal presence, besides the professional one, is the most effective therapeutic instrument to make direct and authentic contact with each person, by attuning to the pain and desperation expressed by many families in therapy, as well as to the implicit aspects of vitality and hope, in order to transform them into elements of strength and change.

Cross-References ▶ Children in Couple and Family Therapy ▶ European Family Therapy Association ▶ Multigenerational Households ▶ Parenting in Families ▶ Terapia Familiare (Journal)

References Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

References Andolfi, M. (2017). Multi-generational family therapy. Tools and resources for the therapist. New York: Routledge. Andolfi, M., & Haber, R. (Eds.). (1994). Please help me with this family: Using consultants as resources in family therapy. New York: Brunner/Mazel. Andolfi, M., & Mascellani, A. (2013). Teen voices. Tales from family therapy. San Diego: Wisdom Moon Publishing. Andolfi, M., Angelo, C., Menghi, P., & Nicolò-Corigliano, A. (1983). Behind the family mask: Therapeutic change in rigid family systems. New York: Brunner/Mazel. Andolfi, M., Angelo, C., & De Nichilo, M. (1987). The myth of atlas: Families and the therapeutic story. New York: Brunnel/Mazel.

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Anxiety Disorders in Couple and Family Therapy Lindsay T. Labrecque, Margaret Tobias and Mark A. Whisman Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA

Anxiety disorders encompass a diverse set of psychological disorders. The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013) recognizes seven distinct disorders within the category. These disorders are generally characterized by the presence of fears (defined as perceptions of imminent threat), anxiety (defined as worry regarding future threat), chronic tension, cautiousness, avoidance, and related behavioral disturbance. In addition to these symptoms, anxiety disorders also share mechanisms underlying their etiology and maintenance, although there is considerable heterogeneity in how these disorders present. One implication of these shared mechanisms is that there is relatively high comorbidity among anxiety disorders. Anxiety disorders are also particularly common in the general population, with lifetime prevalence estimates nearing 30% in the United States (Kessler et al. 2005). Due to their high prevalence, many individuals may be relatively familiar with anxiety disorders. However, misunderstandings still abound regarding how best to care for individuals struggling with these disorders. Without being involved in the treatment process, family members and significant others may attempt to reassure and care for their loved one, which may actually undermine the effectiveness of certain treatments, such as exposure therapy. Therefore, it is important for clinicians to consider incorporating a coupleand/or family-based perspective to their approach when treating anxiety disorders. There is evidence to suggest that couple-based approaches are effective in reducing both anxiety symptoms and relationship discord (Whisman and Robustelli 2016). Attending to both anxiety

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symptoms and relationship discord in treatment is important, due to the potential for each to maintain and promote the other. Research suggests that couple-based interventions are effective in treating posttraumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD), which were both included in the anxiety disorder category in previous editions of the DSM. To date, little research has examined couple- or familybased treatment for other anxiety disorders.

Theoretical Context for Concept Anxiety disorders are generally thought to arise when the human capacity for learning and avoidance goes awry. When appropriately matched to the dangers at hand, these learning and avoidance processes can have adaptive functional outcomes (e.g., learning not to touch a hot stove). However, when fear associations and avoidance behavior grow out of proportion with the actual danger posed or generalize inappropriately, the benefits can quickly be outweighed by significant negative life consequences (e.g., becoming fearful of burning the house down to the extent of refusing to turn on the heat in the winter). Avoidance in the face of true dangers can be vital for survival. However, this same process can also drive clinically relevant anxiety by removing opportunities to challenge beliefs upholding fears. Fears are typically based in catastrophic beliefs about the outcome of specific situations (e.g., that a future panic attack will lead to death, as seen in panic disorder; that an individual will be rejected and embarrassed if evaluated by others as seen in social anxiety disorder). Therefore, gaining experience with the feared situation or stimulus and seeing that the fears do not “come true” provide compelling evidence against the belief and form the foundation of effective anxiety disorder treatment. However, individuals with anxiety disorders avoid the perceived dangers and therefore the opportunity to collect evidence against the beliefs underlying their anxiety. In fact, when engaging in avoidance, the fact that the fear does not “come true” is attributed to success of avoidance as a countermeasure.

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Although avoidance is typically considered an individual endeavor, it is also important to consider how interpersonal relationships may help promote avoidance and maintain fear beliefs. It can be difficult to observe a loved one suffering from distressing anxiety symptoms. For example, a spouse may attempt to relieve anxiety symptoms of their partner associated with social anxiety disorder (social phobia) by accommodating the partner’s avoidance of social gatherings or other social situations that create discomfort. It is understandable that family members want to relieve their loved ones of their symptoms of anxiety and make them feel less distressed. Although these behaviors may be intended to be supportive, they do not actually help to eliminate the fears and can serve as interpersonal safety behaviors. Thus, it is important to consider the role of relationship partners and other family members in understanding and treating anxiety disorders.

Description There are several reasons why couple- or familybased treatments may be effective treatments for anxiety disorders. On one hand, relationship or family discord may increase the likelihood of a person experiencing anxiety. For example, conflict between partners may be stressful, thereby increasing the risk of experiencing symptoms such as worry or anxiety about one’s relationship. On the other hand, symptoms of anxiety may increase the likelihood of relationship problems. For example, if a person with social anxiety disorder (social phobia) chooses not to attend social gatherings that their partner wishes to attend, that may strain their relationship, thus increasing the likelihood of poor relationship functioning. Finally, symptoms of anxiety disorders and relationship functioning may exert a bidirectional influence. Therefore, individuals with an anxiety disorder may exhibit behaviors that bring about relationship discord, which in turn perpetuate anxiety about the state of the relationship, which can in turn exacerbate behaviors and symptoms that can strain the relationship. Thus, the interplay of anxiety symptoms with couple and family functioning is likely to be complex.

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Epidemiological studies suggest that marital discord is positively associated with symptoms of anxiety (Leach et al. 2013) and that lower levels of marital adjustment are reported by people with anxiety disorders, including people with generalized anxiety disorder (GAD), PTSD, and social phobia (Whisman 2007). One longitudinal population-based study found that lower marital quality was associated with an increased risk for incidence of social phobia at a 2–3 year follow-up (Overbeek et al. 2006). Much of the research on couple functioning and anxiety has focused on PTSD. PTSD is associated with relationship discord and perpetration of both psychological and physical aggression against an intimate partner (Taft et al. 2011). In addition, lower relationship quality and higher psychological distress are reported by partners of individuals with PTSD (Lambert et al. 2012). With respect to family functioning and anxiety in children, there is a modest association between parenting and childhood anxiety, with parental control more strongly associated with childhood anxiety than parental rejection (McLeod et al. 2007). However, most studies on parenting and childhood anxiety are cross-sectional, so it remains unclear whether negative parenting behaviors precede the development of childhood anxiety, are elicited by childhood anxiety, or are the result of some “third variable.” Taken together, research findings suggest that couple and family problems are likely to be common for people with anxiety disorders. Several theoretical approaches have been developed to involve partners or other family members in the treatment of anxiety disorders (Whisman and Robustelli 2016). Whereas some treatments are indicated for use with specific anxiety disorders, others have broader treatment applicability. Cognitive-behavioral conjoint therapy (CBCT) has shown to be an effective couplebased intervention for the treatment of PTSD. CBCT targets both PTSD symptoms as well as relationship functioning by providing psychoeducation regarding PTSD, communication skill training for improving relationship adjustment, behavioral approach activities to counter avoidance, and cognitive interventions that aim to address beliefs that reinforce sources

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of relationship problems and PTSD symptoms. Including partners or parents in couple- or family-based interventions has also been shown to be effective in treating OCD. This treatment supplements individual cognitive-behavioral therapy with couple- or family-assisted exposure, response prevention for accommodation, and communication training. Emotionally focused couple therapy (EFT) is another couple-based approach with evidence suggesting it may be an effective treatment for couples in which one partner has symptoms of PTSD. In EFCT, couples learn to identify and understand emotions related to trauma and those that are related to relationship discord and work to form a supportive emotional connection. Another couple-based approach to PTSD is strategic approach therapy (SAT), which targets both avoidance symptoms associated with PTSD and enhances communication and healthy relationship skills.

Application of Concept in Couple and Family Therapy The majority of couple- and family-based approaches for anxiety disorders share several key components. In order to develop a treatment plan, it is first necessary to assess the individual’s anxiety symptoms and the impact of these symptoms on the individual’s functioning in multiple domains, including their intimate and family relationships. In addition, it is important to identify behaviors that both individuals and their partners or other family members enact to maintain their anxiety. As previously discussed, by attempting to decrease a person’s distress or to minimize conflict related to a person’s symptoms, partners or family members may inadvertently reinforce anxiety, so a thorough accounting of these maintaining factors is an important component of the assessment phase of treatment. Another common component to couple- and family-based approaches is psychoeducation. Just like individual treatments, couple- and family-based treatments involve general psychoeducation about the nature of anxiety, as well as specific topics of interest such as

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reinforcement learning and avoidance. However, psychoeducation in couple- and family-based approaches is also likely to include a discussion of the ways in which a partner or family member may actually be reinforcing an individual’s anxiety symptoms. Given the bidirectional effect of anxiety and couple and family functioning, psychoeducation also generally includes education regarding the ways that anxiety symptoms can negatively impact and be impacted by couple and family functioning. Other components to couple- and family-based approaches to anxiety disorders include interventions to enhance relationship adjustment. Specifically, couples typically learn ways to enhance their relationship functioning, including ways to improve communication and problem solving and ways to enhance intimacy and feelings of connectedness. These skills help couples become more resistant to relationship distress that may occur due to anxiety-related stressors or anxious cognitions. At this point, treatments may vary in foci. Treatments such as CBCT and SAT rely on partner-assisted exposures in which the partner is taught how to guide exposures and facilitate new learning to extinguish safety behaviors. Other treatments like CBCT utilize cognitive interventions to target maladaptive beliefs that may impact both relationship functioning and PTSD symptoms. EFCT focuses on helping couples identify problematic relationship patterns and understanding how trauma-related emotions contribute to these patterns. Once those are identified and better understood, couples work to enact more positive patterns of interaction.

Clinical Example Caroline presented for therapy for PTSD following a sexual assault she experienced the previous year. Although she originally presented for individual therapy, she and Joshua, her husband of 7 years, were receptive to the therapist’s suggestion to pursue couple therapy (i.e., CBCT for PTSD; Monson and Fredman 2012). The first phase of therapy focused on providing psychoeducation about PTSD and how it was

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impacting the couple’s relationship. In the second phase of therapy, the couple learned and practiced communication skills to identify and share their thoughts and feelings with one another and used these skills to increase emotional intimacy and reduce PTSD-related emotional numbing and avoidance. They also used these communication skills to identify people, places, situations, and feelings they were avoiding as a couple as a result of Caroline’s PTSD. Both partners reported “walking on eggshells” when they were around one another, and they identified a variety of things they were avoiding (e.g., going out in public, physical affection, sexual behavior, talking about the assault). This “avoidance” list became their “approach” list, as each session they identified things they could do during the coming week that would not only reduce behavioral and experiential avoidance but also serve as rewarding activities. They started with the approach activities they thought would be easiest and included other activities over the course of therapy. In the final phase of therapy, in addition to increasing the frequency of approach behaviors, therapy focused on identifying and modifying traumarelated cognitions. In CBCT, cognitions that either partner holds that maintain PTSD or relationship distress are challenged together as a couple. The initial focus of the cognitive work for Caroline and Joshua was on cognitions related to the traumatic event (e.g., Caroline’s recurring thoughts about how she should have been able to “see the assault coming” and how she could have prevented the assault). The therapist helped Caroline and Joshua work together to generate alternative ways of thinking about the assault (e.g., by reviewing how the assault occurred, Caroline came to see that she couldn’t have predicted it in advance or prevented it). Over the course of several sessions, the focus of the cognitive work was expanded to include interpersonal beliefs that were a result of the trauma (e.g., Caroline would never be able to trust Joshua, the couple would never be comfortable having sex again). At the end of therapy, Caroline reported a substantial decline in her PTSD symptoms, and both partners reported an increase in their relationship satisfaction.

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Cross-References ▶ Cognitive Behavioral Couple Therapy ▶ Communication Training in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Exposure in Couple and Family Therapy ▶ Obsessive Compulsive Disorder (OCD) in Couple and Family Therapy ▶ Posttraumatic Stress Disorder (PTSD) in Couple and Family Therapy

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: American Psychiatric Publishing. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602. Lambert, J. E., Engh, R., Hasbun, A., & Holzer, J. (2012). Impact of posttraumatic stress disorder on the relationship quality and psychological distress of intimate partners: A meta-analytic review. Journal of Family Psychology, 26, 729–737. Leach, L. S., Butterworth, P., Olesen, S. C., & Mackinnon, A. (2013). Relationship quality and levels of depression and anxiety in a large population-based survey. Social Psychiatry and Psychiatric Epidemiology, 48, 417–425. McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examining the association between parenting and childhood anxiety: Ameta-analysis.ClinicalPsychology Review,27,155–172. Monson, C. M., & Fredman, S. J. (2012). Cognitivebehavioral conjoint therapy for PTSD: Harnessing the healing power of relationships. New York: Guilford Press. Overbeek, G., Vollebergh, W., de Graaf, R., Scholte, R., de Kemp, R., & Engels, R. (2006). Longitudinal associations of marital quality and marital dissolution with the incidence of DSM-III-R disorders. Journal of Family Psychology, 20, 284–291. Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Monson, C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79, 22–33. Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116, 638–643. Whisman, M. A., & Robustelli, B. L. (2016). Intimate relationship functioning and psychopathology. In K. T. Sullivan & E. Lawrence (Eds.), The Oxford handbook of relationship science and couple interventions (pp. 69–82). Oxford: Oxford University Press.

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Aponte, Harry J. Martha LaRiviere and Janet Robertson Antioch University New England, Keene, NH, USA

Name Harry J. Aponte

Introduction Harry J. Aponte is a licensed clinical social worker and a marriage and family therapist who is widely respected for his development of the person-of-thetherapist training model (POTT). With POTT, therapists explore their inner selves allowing them to be deliberate as they interact with their clients psychologically, culturally, and spiritually. Aponte used the phrase “wounded healer” to signify the power of the therapist’s experiences (Aponte and Kissil 2014). His career began in the early years of systemic marriage and family therapy, and his current contributions affect training in the field internationally. Many of Aponte’s interests are derived from his life in the impoverished Harlem and South Bronx sections of New York City. His childhood in his Catholic Puerto Rican family influenced the development of the concept he termed ecostructuralism, which refers to seeing clients in relation to their own family and social environment (Aponte 1976). As he worked with many poor and minority families, he integrated the family system into the larger communities of school, culture, and faith.

Career After graduating from Maryknoll College in Glen Ellyn, Illinois, Aponte earned his Master of Social Work at Fordham School of Social Science in New York City. Following graduation, he joined the Menninger Clinic as a postgraduate student where he studied psychodynamic psychotherapy and attended presentations of visiting therapists including Salvador Minuchin. Aponte read

Aponte, Harry J.

Minuchin’s Families of the Slums and in return sent Minuchin a manuscript of his own for feedback (Minuchin et al. 1967). In 1968, Aponte responded to an invitation from Minuchin to work with him at the Philadelphia Child Guidance Clinic where he settled into the position of coordinator of clinical services. Aponte served with Minuchin for 11 years, ultimately as the clinic director from 1975 to 1979. In 1980, Aponte became a clinical associate professor at Drexel University’s Couple and Family Therapy Department where he remains today. He also maintains a private practice in Philadelphia, Pennsylvania. He has received two honorary degrees including Doctor of Humane Letters from Drexel University and the degree of Doctor of Public Service from the University of Maryland. Some of Aponte’s awards include Distinguished Contribution to Family Therapy and Practice from the American Family Therapy Academy (1992) and the Outstanding Contribution to the Field of Marriage and Family Therapy from the American Association for Marriage and Family Therapy (2001). Currently Aponte is a Fellow of the American Association of Marriage and Family Therapy and a Board-Certified Diplomate in Clinical Social Work.

Contribution to the Profession Aponte’s best-known contribution to the field of couple and family therapy is the person-of-thetherapist training model, which begins with identifying the therapists’ central psychological issue upon which their emotional functioning is based. This foundational issue is called the signature theme. Therapists are then trained with POTT to incorporate their insight and emotional awareness into therapy. According to Aponte, we are a part of a vulnerable humanity and cannot succeed in completely resolving our own personal issues in this life (Aponte and Kissil 2014). As Aponte worked with Minuchin at the Philadelphia Child Guidance Clinic, he incorporated the topics of poverty, race, and spirituality into structural therapy. Aponte used the term ecostructure as he worked on structural family therapy to embody the socioeconomic context of the family. He worked

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with underorganized families, a term Aponte originated to describe families that were inadequately positioned to cope with their environment. His book, Bread & Spirit: Therapy with the New Poor: Diversity of Race, Culture, and Values, explored the multidimensional context of these families (Aponte 1994). The hardships that underorganized families meet can best be understood by empathic connections to therapists’ responses to their own ordeals.

Cross-References ▶ Person of the Therapist Training Model, The ▶ Spirituality in Couple and Family Therapy ▶ Structural Family Therapy

References Aponte, H. (1976). The family-school interview: An ecostructural approach. Family Process, 15(3), 303–311. Aponte, H. J. (1994). Bread and spirit. Therapy with the new poor. New York: W. W. Norton. Aponte, H. J. (2017). The philosophy of the person-of-thetherapist training model: The underlying premises. Seminare. Learned Investigations, 38(4). (in press). Aponte, H. J., & Kissil, K. (2014). “If I can grapple with this I can truly be of use in the therapy room”: Using the therapist’s own emotional struggles to facilitate effective therapy. Journal of Marital and Family Therapy, 40(2), 152–164. https://doi.org/10.1111/jmft.12011. Aponte, H. J., & Kissil, K. (Eds.). (2016). The person of the therapist training model: Mastering the use of self. New York: Routledge, Taylor & Francis Group. Minuchin, M. B., Guerney, B., Jr., Rosman, B., & Florence, S. (1967). Families of the slums. New York: Basic Books.

Applied Behavior Analysis in Family Therapy Anna Santowski and Ryan M. Earl The Family Institute at Northwestern University, Evanston, IL, USA

Name of the Strategy or Intervention Applied Behavior Analysis in Family Therapy

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Synonyms ABA

Introduction Founded upon the major principles of behaviorists such as Watson and Skinner, applied behavior analysis (ABA) is a therapeutic approach that specifically focuses on increasing quality of life through meaningful and socially relevant behavioral modification. Proponents of ABA posit that problematic behaviors can be changed via a mixture of reinforcement and repetition. ABA is used to treat multiple age groups within a variety of contexts such as education, healthcare, and business management. Due to a considerable body of literature demonstrating its efficacy, ABA is most commonly known as the gold standard approach to working with children with autism (Baer et al. 1968). ABA has been researched extensively since its inception in the 1960s, with the majority of studies being published in the Journal of Applied Behavior Analysis. The journal currently presents the most recent research on ABA techniques and showcases how behavior analysis applies to socially relevant behavioral change and learning. Among the extensive literature in ABA are the findings that it improves cognitive functioning, reduces problematic behavior, and improves academic performance in autistic children. Further studies show that learned behaviors from ABA interventions are maintained over time (Baer et al. 1968; Lovaas et al. 1973; McEachin et al. 1993).

Theoretical Framework “Applied” ABA stems from a group of faculty members and researchers from the University of Washington and the University of Kansas in the 1960s. Members of the group include Donald Baer, Sidney Bijou, Jim Hopkins, Jay Birnbrauer, Todd Risley, Montrose Wolf, and, later, James Sherman. ABA formed as the result of efforts to link interventions to observable

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changes in behavior and to apply behavior analysis techniques to actual social situations (Baer et al. 1968). “Behavior” ABA’s roots lie in behavior analysis, which is a field of study concerned with studying the factors that change or modify human behavior. According to the beliefs of behaviorists, observable behaviors can be learned or modified through techniques involving rewards and punishments. Although ABA initially used punishments in its techniques, it now encourages the use of rewards over punishment as it seeks to drive motivation rather than fear. Reward systems such as token economies paired alongside reinforcement techniques make up the bulk of many of the ABA techniques seen today. “Analysis” ABA therapists study the feedback and outcomes of a behavior change attempt and adjust the approach to the behavior change if needed. Emphasis is placed on the role of the instructor as they work to control environmental factors to produce the target behavior.

Rationale for the Strategy or Intervention Prior to ABA, treatments for autism included separating children with autism from their parents and later, giving them LSD and removing gluten and casein from their diets. Early studies of ABA applied it to children with autism in Ole Ivar Lovaas’s 1987 “Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children” (Lovaas 1987). In this integral study that came to be known as “The Lovaas Method,” 47% of children who were exposed to 40 intensive hours of 1:1 discrete trial training (DTT) no longer qualified for an autism diagnosis by the end of treatment and were considered to have normal intellectual and educational functioning. Over the course of his life, Lovaas would go on to study ABA and publish several studies that found it to be an

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effective treatment for children in classrooms. Ultimately, his research popularized the use of ABA in classrooms and spread international awareness of ABA as a treatment for kids with autism. While the intensive Lovaas method is still used, it is one of several ABA interventions that have been researched and found effective as an autism treatment. ABA is now considered the gold standard for treating children with autism since it has the most research behind it showing its efficacy. ABA works well with children because they respond well to behavioral interventions with interesting external stimuli as opposed to solely verbal interventions. ABA methods teach simple skills such as looking and imitating as well as more complex skills such as reading, conversing, and understanding others’ perspectives. Its safe, effective, and research-backed interventions make ABA the most widely used method for teaching these skills to children with autism. ABA can be used within family therapy sessions for children diagnosed with autism. In family therapy sessions, ABA-certified therapists teach parents techniques for changing problematic behaviors or learning new behaviors. Parents are encouraged to use ABA in the home and in other naturalistic settings throughout the day to teach social and academic skills across contexts.

Description of the Strategy or Intervention: What Happens during ABA? In ABA, interventions are intended to reinforce positive social behaviors such as identifying colors, asking for a toy, maintaining eye contact, etc. Interventions can be done in a variety of settings, including in the therapy room, at school, or in the home. Exact techniques used vary on a case-by-case basis only after a period of observation in which behavioral triggers are assessed by a trained behavior analyst. Typically, an analyst works alongside teachers and parents to equip them with specific techniques that target the behaviors intended to be learned or modified.

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ABA breaks down behaviors into the “Three ABC’s of ABA”: the antecedent, the behavior, and the consequence. These principles are rooted in behaviorism and are applied in various forms across the numerous techniques stemming from ABA. Studying the ABC’s of a behavior of interest in ABA is often one of the first steps in planning its development or change. The antecedent (A) focuses on what happens before the behavior occurs; in other words, what cues and instructions appear to be triggering the behavior? The behavior, (B), is observation of the behavior of interest. Finally, the consequence (C) looks at the events happening immediately after the behavior. Within ABA, consequences typically result in rewards such as food or verbal praise for a correct behavior and a correction if the target behavior is not done. After the behavior is observed through the ABC’s, ABA therapists, teachers, and parents can choose from several techniques to teach the participant the target behavior. Over the years, numerous behavioral techniques have been developed for use in ABA. Two of the more popular evidence-based interventions include discrete trial training (DTT) and pivotal response treatment (PRT). In DTT, whole skills are broken down into smaller sub-steps of (1) antecedent, (2) prompt, (3) response, (4) consequence for response, and (5) interval between trials (Smith 2001). If the client successfully completes the task, they are positively reinforced with a reward. If the task is done incorrectly, the instructor will show the correct way to do the task, and the task will be repeated again in a new trial with the goal of reaching the target behavior. DDT has been found to be most effective with teaching new behaviors to children with autism such as new speech sounds or motor movements. It is also used to teach discriminatory skills such as responding accurately to different requests (Smith 2001). Pivotal response treatment (PRT) focuses on building upon “pivotal” skill areas such as language acquisition, behavior regulation, and social engagement. Created by Koegel et al. (1987), the approach was initially designed to teach language acquisition to nonverbal children with autism. PRT posits that development of these areas will

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improve other aspects of children’s lives across social, behavioral, and academic contexts and settings. Important to PRT is the idea that children must become inherently motivated to engage within these pivotal areas in order to successfully use them in real-life scenarios. Emphasis is placed on children being self-motivated as this drives them to use learned skills in other contexts. Because of this, PRT interventions are shaped by the interests of the participant and ideally take place in naturalistic settings such as parks or regular education classrooms. For example, a therapist can ask a child to pick from a variety of toys to play with in a normal education classroom, and the therapist can teach social engagement skills by requesting the child to ask for the toy before playing with it. If the child is able to do so, he or she is rewarded with the toy, and in turn, the requesting behavior is reinforced.

Case Example Franky is a 5-year-old boy who is diagnosed with severe autism. He is currently in family therapy with his mother Helen and his father Tom. Franky also attends an alternative school with ABAcertified teachers who use ABA techniques in classroom settings with Franky throughout the school day. The family therapist is trained in ABA and is using DTT to teach Franky social skills. The target behavior for today is for Franky to maintain eye contact with someone for 3 s when they say his name. In order to reach the target behavior, Franky’s trials are broken down into successively approximate steps toward the target behavior in a method known as “shaping.” In a family session, the therapist demonstrates and explains DTT to the parents. The therapist first gives Franky a piece of popcorn. This establishes the popcorn as the reward that Franky will be working toward during his trials. Then, the therapist shows Franky another piece of popcorn and says Franky’s name while putting the popcorn behind his own head. Franky looks in the direction of the therapist’s head and is rewarded with the popcorn and verbal praise for doing so as this is a step toward the target behavior. If Franky does

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not look in the direction of the therapist, the popcorn reinforcement will be withheld and he will be guided toward the correct behavior until he is able to look again in the direction of the therapist’s head or display a behavior further along in the behavior sequence such as making eye contact. After a few more trials, Franky briefly makes eye contact with the therapist when his name is said. Again, he is rewarded with both popcorn and verbal praise for doing so. Now that Franky is making eye contact, the therapist works to maintain the contact for a longer amount of time. The popcorn and verbal reinforcement is now withheld until he is able to make eye contact for more than 1 s and then 2 and 3 s. The therapist encourages Helen and Tom to work with their son at home every day to extend Franky’s eye contact to up to 5 s and then gradually phase out the popcorn reinforcement. The therapist explains how the DTT format can be used to teach other social skills as well such as saying “thank you” or “excuse me” and that family participation in this process helps to create lasting change over time.

Cross-References

Areas of Change Questionnaire Applied Behavior Analysis, 6(1), 131–165. https://doi. org/10.1901/jaba.1973.6-131. McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Longterm outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 97(4), 359–372. Smith, T. (2001). Discrete trial training in the treatment of autism. Focus on Autism and Other Developmental Disabilities, 16(2), 86–92. https://doi.org/10.1177/ 108835760101600204.

Areas of Change Questionnaire Cody G. Dodd Department of Psychology, Central Michigan University, Mount Pleasant, MI, USA

Name and Type of Measure The Areas of Change Questionnaire (ACQ) is a two-part measure of: (a) desired change in partner behaviors and (b) changes in one’s own behaviors that are perceived to be pleasing to the partner.

Synonyms

▶ Behavioral Couple Therapy ▶ Behavioral Parent Training in Couple and Family Therapy

In the research literature, the ACQ has also been abbreviated A-C, AC, and AOC.

References

Introduction

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97. https:// doi.org/10.1901/jaba.1968.1-91. Koegel, R. L., O’ Deil, M. C., & Koegel, L. K. (1987). A natural language teaching paradigm for nonverbal autistic children. Journal of Autism and Developmental Disorders, 17, 187–200. Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55(1), 3–9. https://doi.org/10.1037//0022006x.55.1.3. Lovaas, O. I., Koegel, R., Simmons, J. Q., & Long, J. S. (1973). Some generalization and follow-up measures on autistic children in behavior therapy. Journal of

The Areas of Change Questionnaire (ACQ; Margolin et al. 1983) is a 68-item measure of intimate relationship functioning, originally designed to facilitate effectiveness research on behavioral couple therapy (Weiss et al. 1973; as cited in Margolin et al. 1983). The ACQ has two parts: first, the respondent rates the degree of change desired on 34 common partner behaviors; second, the respondent indicates the degree to which his or her own changes on those 34 behaviors is likely to be pleasing to his or her partner. Items are rated on a 7-point scale from “much less” change ( 3) to “no change” (0) to “much more” change (+3). A common

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scoring system for the ACQ produces summative scores for Desired Change (DC) and Perceived Change (PC). A Total Change (TC) score is derived from the number of cross-partner item agreements and disagreements (Margolin et al. 1983).

Developers The ACQ was developed by Robert L. Weiss, Hyman Hops, and Gerald R. Patterson (Weiss et al. 1973).

Description of Measure The ACQ has been used primarily in behavior couple therapy research; however, it has also been used as a prompt in observations of couple interactions (e.g., Halford et al. 1993). Increased scores on the instrument are associated with marital dissatisfaction, and several studies have shown the ACQ to be sensitive to changes in relationship adjustment resulting from treatment. The ACQ has been shown to differentiate distressed and nondistressed heterosexual married couples (e.g., Birchler and Webb 1977; Margolin et al. 1983), and some evidence supports its use to examine parent-child relationships and intimate relationships among adolescents.

Psychometrics The ACQ has not been standardized with a large normative sample, and the data available on its psychometric properties is limited. In several more recent studies, the internal consistency coefficients for ACQ scores have ranged from 0.76 to 0.85 (Cordova et al. 2005; Heyman et al. 2009). However, most studies with the measure have not reported on the internal consistency of all three of its scores. In addition, no information is available on the ACQ’s test-retest reliability, although studies using it as a marital therapy outcome measure have shown it to be sensitive to changes in treatment (e.g., Baucom 1982; Halford et al. 1993; Margolin and Weiss 1978).

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Several studies using the ACQ have shown that women often have slightly higher Desired Change scores compared to their husbands (e.g., Heyman et al. 2009; Margolin et al. 1983). Women also tend to over predict their husbands’ Desired Change (Margolin et al. 1983). These results have primarily come from studies with heterosexual married couples in multi-year relationships. Further research is needed to examine the cultural invariance of the instrument and to validate it with same-sex couples and partners early in relationships. Research validating the ACQ as a predictor of useful clinical outcomes or other phenomena is limited. Many studies have reported high convergence among the ACQ and similar measures, with some studies reporting correlations with self-report indices of relationship problems and marital satisfaction from 0.59 to 0.72 (Heyman et al. 1994). Taken together with other research failing to show consistent prediction of behavioral observation and daily-assessed pleasing and displeasing behavior (e.g., Margolin et al. 1983), these results suggest that the ACQ may be best characterized as an indicator of relationship satisfaction.

Example of Application in Couple and Family Therapy After being married 6 years, Zack and Stefani sought couple therapy to address longstanding conflict important family decisions. The two had considered having children, but had delayed it due to their frequent arguments about finances and Zack’s extended work schedule. Their therapist provided them with feedback informed by their ACQ results, which indicated that they were both in agreement on many areas of concern. Their item-level responses demonstrated that, in addition to their concerns about finances and career, they both shared a strong desire for each other to show greater appreciation and interest in one another. They were surprised and encouraged to see that they both had higher Perceived Change scores than the other’s Desired Change score. Based on these results, their course of treatment focused on increasing quality time spent together, increasing acceptance and

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affirmation of one another, and improving problem solving and communication around money management. After 8 sessions, the readministration of the ACQ showed a reduction in both their Total Change scores and signaled the therapist to initiate the treatment termination process.

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Asen, Eia Rebecca Branda The Family Institute at Northwestern University, Chicago, IL, USA

Name References Asen, Eia (1946 to present) Baucom, D. H. (1982). A comparison of behavioral contracting and problem-solving/communications training in behavioral marital therapy. Behavior Therapy, 13(2), 162–174. https://doi.org/10.1016/s00057894(82)80060-9. Birchler, G. R., & Webb, L. J. (1977). Discriminating interaction behaviors in happy and unhappy marriages. Journal of Consulting and Clinical Psychology, 45(3), 494–495. https://doi.org/10.1037/0022-006x.45.3.494. Cordova, J. V., Scott, R. L., Dorian, M., Mirgain, S., Yaeger, D., & Groot, A. (2005). The marriage checkup: An indicated preventive intervention for treatmentavoidant couples at risk for marital deterioration. Behavior Therapy, 36(4), 301–309. https://doi.org/ 10.1016/s0005-7894(05)80112-1. Halford, W. K., Sanders, M. R., & Behrens, B. C. (1993). A comparison of the generalization of behavioral marital therapy and enhanced behavioral marital therapy. Journal of Consulting and Clinical Psychology, 61(1), 51–60. https://doi.org/10.1037/0022-006x.61.1.51. Heyman, R. E., Sayers, S. L., & Bellack, A. S. (1994). Global marital satisfaction versus marital adjustment: An empirical comparison of three measures. Journal of Family Psychology, 8(4), 432–446. https://doi.org/ 10.1037/0893-3200.8.4.432. Heyman, R. E., Hunt-Martorano, A. N., Malik, J., & Slep, A. M. S. (2009). Desired change in couples: Gender differences and effects on communication. Journal of Family Psychology, 23(4), 474–484. https://doi.org/ 10.1037/a0015980. Margolin, G., & Weiss, R. L. (1978). Comparative evaluation of therapeutic components associated with behavioral marital treatments. Journal of Consulting and Clinical Psychology, 46(6), 1476–1486. https://doi. org/10.1037/0022-006x.46.6.1476. Margolin, G., Talovic, S., & Weinstein, C. D. (1983). Areas of change questionnaire: A practical approach to marital assessment. Journal of Consulting and Clinical Psychology, 51(6), 920–931. https://doi.org/10.1037/ 0022-006x.51.6.920. Weiss, R. L., Hops, H., & Patterson, G. R. (1973). A framework for conceptualizing marital conflict: A technology for altering it, some data for evaluating it. In L. D. Handy & E. L. Mash (Eds.), Behavior change: Methodology concepts and practice (pp. 309–342). Champaign: Research Press.

Introduction Eia Asen is a pioneer of multi-family group therapy. He has been influential in the dissemination of the Marlborough model and the integration of mentalization into multi-family group therapy. He is a world-renowned child and adolescent psychiatrist, consultant, editor, author, and speaker who continues to influence the field of family therapy.

Career Asen received his doctorate in medicine in 1972 from the Free University of Berlin. He completed his foundation program in general medicine followed by a specialization in psychiatry at the Maudsley Hospital in London. During his work at the Maudsley Hospital, Asen received an additional 5 years of training in psychoanalysis and psychotherapy (1974–1979) as well as family therapy (1976–1981) with Salvador Minuchin. These formative training experiences profoundly impacted his contributions to multi-family group therapy. Following the completion of his training, Asen became a member of the Royal College of Psychiatrists. In 2001, Asen was honored with election to the fellowship of the Royal College of Psychiatrists (FrcPsych). In 1979, Asen began his career as a child and adolescent psychiatrist in London at the Marlborough Family Service (previously the Marlborough Day Hospital). Asen was an integral team member and leader over his 34-year tenure at the Marlborough Family Service. Over

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the course of his career, Asen was heavily involved in building the Marlborough model and applying the model for use in the legal system. He assessed over 1000 abused children and families using the Marlborough model to predict whether families could be rehabilitated. In 1989, Asen began consulting for the Maudsley Hospital, and he entered academia that same year as a senior lecturer at the Institute of Psychiatry at King’s College. Asen also became the head of parenting assessment and services on the mother and baby unit at Bethlem Royal Hospital from 1997 to 2002. In the early 2000s, Asen began integrating mentalization into multi-family group therapy and mentalization-based therapy for families (MBT-F). Asen became a visiting professor at University College London and a consultant psychiatrist for children, adolescents, and adults at the Anna Freud Centre in 2009 and 2013. Today, Asen is an internationally renowned psychiatrist and lecturer, with several grants from the European Union to disseminate his research. Asen has numerous book and article publications in English, German, and Italian. He has written seven books in English which include the following: Psychiatry for Beginners (1986); Family Solutions in Family Practice (1992); Family Therapy for Everyone (1995); Systemic Couple Therapy and Depression (with E. Jones, 2000); Multiple Family Therapy: The Marlborough Model and its Wider Applications (with N. Dawson & B. McHugh, 2001); 10 Minutes for the Family: Systemic Practice in Primary Care (with D. Tomson, V. Young & P. Tomson, 2004); and Multi-Family Therapy: Concepts and Techniques (with M. Scholz, 2010).

Contributions to Profession Asen and his colleagues pioneered the Marlborough model, which is a unique model of multi-family group therapy. The Marlborough model was named after the Marlborough Family Service, the hospital where the model was originally formulated and refined over the course of 25 years. The

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Marlborough Family Service was the first publicly funded hospital in South London to create an intensive day unit program treating families 5 days a week for 8 hours a day in a structured multi-family group therapy program (Cooklin et al. 1983). At the Marlborough Family Service, the team based their model on the family systems approach, emphasizing the paramount importance of context and integrating techniques from structural family therapy. The structured therapeutic day program setting created a multifamily milieu and helped families that were previously deemed untreatable. Asen’s notable contributions to the Marlborough model stems from his work with Salvador Minuchin. In 1981, Minuchin came to London for his sabbatical and supervised Asen. Minuchin recommended the use of structural interventions including setting boundaries, challenging hierarchies, and provoking enactments (Cooklin et al. 1983). Asen operationalized the key elements from Minuchin’s supervision and built a formal-structured multi-family program. Asen also had a considerable contribution to the Marlborough model by decreasing the length of treatment from 18 months to 3 months based on influences from Gianfranco Cecchin and Luigi Boscolo. Cecchin and Boscolo helped Asen realize that altering the model to reflect real-world linear relationships benefited the families and decreased their sense of dependence on the clinicians. Additionally, Asen integrated circular questioning and the use of a reflection team into the Marlborough model. The mainstream applicability of the Marlborough model became evident in the 1990s when Asen and his colleagues began working with the legal system to predict a family’s ability to rehabilitate after incidents of abuse. The success of the Marlborough model inspired other programs across the world. For example, clinicians in Germany and the United Kingdom have applied the Marlborough model to help families with adolescents suffering from eating disorder. Asen continues to pioneer multi-family group therapy. Currently, Asen is focusing on integrating mentalization into multi-family group therapy (Asen and Fonagy 2012).

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Cross-References

Introduction

▶ Cecchin, Gianfranco ▶ Circular Questioning in Couple and Family Therapy ▶ Mentalization in Couple and Family Therapy ▶ Minuchin, Salvador ▶ Multifamily Group Therapy ▶ Structural Family Therapy

The Asian Academy of Family Therapy (AAFT) is a charitable and nonprofit organization with a vision to promote family therapy research, training, and practice in Asia. Originally named as Academy of Family Therapy, the same group of visionaries who had established the HKU Family Institute (HKUFI) almost a decade ago started the Asian Academy of Family Therapy in 2012. Through the training effort of the Director of HKUFI, Wai Yung Lee, a collaboration with other Asian regions was formed. As a result, a cross-regional study to compare how couples negotiated their differences among five regions was made possible. This joint venture created a bond among the involving regions. Prominent figures from each region started to meet annually, and in 2015, the Academy officially changed its name to Asian Academy of Family Therapy to reflect the interests and activities of other family therapists in the Asian region. Currently, AAFT is membershipbased. Its membership categories include Fellow, which consist of qualified family therapy practitioners from multidisciplinary backgrounds, as well as members who support the vision of AAFT.

References Asen, E. (2002). Multiple family therapy: An overview. Journal of Family Therapy, 24, 3–16. Asen, E., Dawson, N., & McHugh, B. (2001). Multiple family therapy: The marlborough model and its wider applications. London: Karnac. Asen, E., & Fonagy, P. (2012). Mentalization-based therapeutic interventions for families. Journal of Family Therapy, 34, 347–370. Cooklin, A., Miller, A., & McHugh, B. (1983). An institution for change: Developing a family day unit. Family Process, 22, 453–456. Cooklin, A., Asen, E., Mannings, C., & Costa-Cabellero, M. (2012). Talking heads: Alan Cooklin and Eia Asen reflect on the history of the multi- family model at the Marlborough Family Service in London. Context, 3–7.

Asian Academy of Family Therapy Takeshi Tamura1, Wai Yung Lee2,3 and Viviana Cheng2 1 International Committee, Tokyo, Japan 2 Asian Academy of Family Therapy, Hong Kong, China 3 Aitia Family Institute, Shanghai, China

Name of Organization Asian Academy of Family Therapy

Synonyms AAFT

Location AAFT is based in Hong Kong, with core members from the Asian region, including Hong Kong, Japan, Korea, Taiwan, Mainland China, Singapore, and Malaysia.

Prominent Associated Figures Wai Yung Lee, Ph.D., Ng Man Lun, M.D., William Fan, M.D., Joyce Ma, Ph.D., Takeshi Tamura, M.D., Shin-Ichi Nakamura, M.D., Zhao Xudong, M.D., Du Yasong, M.D., Meng Fu, M.D., Chen Xiang-Yi, M.D., Hao Wei Wang, M.D., Chao Wen-Tao, M.D., Lin Lee-Chun, M.A., Young-Ju Chun, Ph.D., and Sunin Shin, Ph.D.

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Contributions Asia covers a vast geographic area with diverse cultures. Each region has very different family norms and language expressions. However, while there are different social and family structures, we do share aspects that are uniquely Asian, such as an emphasis on collectivism rather than individualism, religious and ethical influences of Buddhism and Confucianism, extended kinship system, and lifelong parent/ child relationship of filial piety. AAFT is established to create a strong collaboration and professional exchange among our counterparts in Asia. It should be noted that although there are many family therapy associations in other parts of the world, AAFT is the first family therapy organization in this region that represents distinctive effort in developing family therapy. As the service system in Asia tends to be more individual-based, we also have a strong mission to draw together systemic thinkers and practitioners in different parts of Asia to reflect the family-oriented culture of this part of the world. Our important research includes: 1. A comparison of how couples negotiate their differences among five regions including Japan, Korea, Taiwan, Shanghai, and Hong Kong. Contrary to popular belief that Asians are all the same, it was found that couples in these five regions have very different styles in negotiating their differences (Lee et al. 2013). 2. Children’s response to parental conflict (Lee et al. 2010). Wai Yung Lee has set up an innovative tool to measure how children respond to their parents’ impasse. This tool shows to be very powerful in activating the parents to change when used for clinical purpose. Clinicians from both within the Asian region and abroad are showing interest for possible cross regional collaborations. Some of AAFT’s activities include professional conferences, which are held in a different region each year. These conferences have been

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very well received and participants also include professionals from the United States of America and Europe. AAFT is aiming to provide accreditation for Asian therapists. Criteria that pertains to the Asian culture is currently being established. Each participating region is also working toward developing their own practice and training model that is relevant to their region. For instance, South Korea has a long history in developing family therapy, with very well-systematized organizations and professional standards within the region. In Taiwan, different therapists have also been developing their therapeutic approaches. Mainland China, in particular, has shown a strong interest in the development of systemic approach. Not only are family therapy programs provided by universities and mental health organizations, private institutes, such as the newly established Aitia Family Institute in Shanghai, is one example of how training, practice, and research can be combined to bridge the work between the East and the West. Different regional training efforts are also taking place, such as Takeshi Tamura and his peer supervision group with members who represent different regions meeting regularly at different parts of Asia to exchange ideas and clinical contributions. Although a strong bond with some Asian regions have been established, AAFT hopes to continue to expand its geographical coverage, to elicit more regional and cultural participation from all over Asia in the near future.

References Asian Academy of Family Therapy. http://www. acafamilytherapy.org Lee, W. Y., Ng, M. L., Cheung, B. K. L., & Yung, J. W. (2010). Capturing children’s response to parental conflict and making use of it. Family Process, 49(1), 43–58. Lee, W. Y., Nakamura, S. I., Chung, M. J., Chun, Y. J., Liang, S. C., Meng, F., & Liu, C. L. (2013). Asian couples in negotiation: A mixed method analysis of cultural variations among couples from five Asian regions. Family Process, 52(3), 499–518.

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Asian Americans in Couple and Family Therapy Terry Soo-Hoo California State University East Bay, Hayward, CA, USA

Introduction The topic of working with Asian American families and couples in psychotherapy is quite complex, and it is difficult to summarize in a very brief article. However, it is possible to discuss a few principles that might serve as a guide to such work. First, it is important to keep in mind that the term “Asian American” is very broad and can include many different people from many different countries, such as China, Japan, Korea, Vietnam, India, etc. The rationale for such a term rests on the assumption that many of these nationalities share similar cultural patterns. This is true despite the diversity in language and other major differences, such as having different histories in the USA and living in different communities, for example. The general recommendation when working with any ethnic or cultural group is to “never assume” the client fits perfectly within expected norms or common cultural patterns or set of beliefs. The therapist should always carefully explore the unique characteristics of each client.

Description Myth of the Successful Minority The general population might view Asian Americans as having achieved great success in America. However, this is not the total story. What might be visible are the successful Asians who have completed their professional college degrees and are doctors, dentists, optometrists, pharmacists, engineers, or accountants. They drive around in their Mercedes and BMWs. However, what is less visible, behind the glitzy façade of the Chinatowns, Japantowns, and Manilatowns in

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San Francisco, Los Angeles, and New York with their restaurants and quaint shops, are “deplorable social conditions” (Sue and Sue 2013). There is much poverty, drug abuse, criminal gang activity, and physical and mental health problems in many Asian American communities. There is also great family distress in these communities. Often, both parents work long hours in low-wage jobs such as waiters, seamstress, or laborers. As a result, children are either left alone until late into the night or older children take care of younger children. It is important to understand the socioeconomic communities in which Asian American clients reside. An Asian American optometrist living in an upper middle class suburb might present quite differently in therapy than a seamstress working long, hard hours in a sewing factory in Chinatown. Economic issues are also related to racism and discrimination. Asian Americans have experienced a long history of racism and discrimination, from the early Chinese immigrants to the present day. In addition, racism and discrimination have a strong impact on mental health. Brenner and Kim (2009) found that many Chinese American adolescents reported facing discrimination in early adolescence. These experiences were associated with depression, alienation, and lower academic performance in middle adolescence. Many Southeast Asian refugees reported experiencing racial discrimination, and this was associated with high rates of depression (Noh et al. 1999). Views of Mental Health and Reluctance to Seek Treatment Another important issue facing many mental health professionals is the reluctance of Asian Americans to come to therapy. It is clear that Asian Americans underutilize counseling and other mental health services (Sue and Sue 2013). Many Asian Americans view psychotherapy or counseling as only for “crazy people.” The more traditional Asian American might prefer to seek help from traditional healers such as herbalists, acupuncturists, shamans, religious leaders such as priests or ministers, or important community leaders. Often Asian Americans are referred to therapy when there is a crisis in which the tradition healers or helpers are ill equipped to handle

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the problem situation. The challenge for therapists is to engage these clients in ways that both acknowledge their cultural beliefs on one hand and also express to them that there are ways of helping that may be different than what they might be used to. It is important to listen to what the client is requesting. Is the client requesting practical, pragmatic, problem-solving type of help or is the client requesting deeper exploration of internal intrapsychic processing? In general, Asian Americans tend to prefer time-limited, problemsolving-oriented therapy approaches. Chen and Davenport (2005) suggest using cognitive behavioral and other solution-focused strategies when working with Asian Americans. However, they also caution that it is important to modify any therapy approach to incorporate a collectivistic rather than an individualistic perspective. For instance, a therapist might encourage the Asian American client to practice assertiveness training. Such training must take into consideration the social cultural context of the client and relationships in which the assertive behavior is to be practiced. A son needs to approach the father with the proper respect and appreciation or the father will be very upset and will not be open to hearing what he has to say! A modified strategic therapy approach might also work effectively with Asian American clients (Soo-Hoo 1999). This approach emphasizes working within a client’s unique world or cultural context. Complexity of Asian American Culture While an individual might operate within the context of a particular cultural group, each individual will interpret and act out the culture in a different way. Therefore, counselors should recognize that each individual shares the context of the group in a unique way and that this is never identical. Furthermore, many people of color are socialized to live not only in their own culture but also in the White culture. Chinese Americans have evolved an interesting mix of traditional Chinese and Western European cultures (Soo-Hoo 1999, 2005a). This is also true for many other Asian American groups. The range of this mix can be quite wide. At one end of the spectrum are Asian Americans who are extremely traditional, while

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those on the other extreme might be highly acculturated to the American culture. In fact, there might be significant differences in the level of acculturation among members within a family. It is clear that Asians in America are evolving their own culture that may be different in many aspects from the traditional Asian cultures found in their country of origin, be it China, Japan, Korea, Vietnam, India, or another country. There is a blending of traditional Asian culture and American culture. However, this blending can be complex and variable, making it difficult to predict how any one Asian American might integrate the two cultures together. For instance, an Asian American male might be rather Americanized and very modern in regards to working in a highly technological field and have liberal political views, yet he can still hold very traditional views of gender roles. He may still expect to marry a traditional wife, who will follow in her traditional role as an Asian wife. Furthermore, this blending of cultures is dynamic and not static, so it is ever evolving and changing. The challenge for family therapists is to assess carefully not only the level of acculturation but also how a particular client has blended the two cultures.

Relevant Research About Family Life Collectivist Culture Asian cultures are very much “collectivistic.” Western cultures in general tend to value independence and individuality, while Asian cultures value interdependence and being part of a collective, whether it is a family, school, or other types of organizations. Being part of a group is very important. In fact, each person is defined and judged by the family and other groups to which he/she belongs. Children are expected to strive for family goals. There is strong emphasis on correct values and behaviors, family harmony, and adapting to the needs of the family, especially elders (Chen 2009). In a traditional Asian family, the father is the head of the household. The mother is responsible for raising the children. The family is a central part of life. Often, extended family members, such as grandparents or uncles, live in

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the same household or close by. There is a strong emphasis on diligence, harmony, taking responsibility, and self-reflection. Individual accomplishment is celebrated by the entire family, and failures reflect negatively on the family. Thus, failure or misdeeds bring “shame” not only to oneself but also to the whole family. Each member of the family has a responsibility and a duty to the family, while one’s individual rights are not emphasized. In family therapy, this collectivist view will influence how each family member behaves. Children are dependent upon their parents for caretaking, and these same parents will eventually become dependent upon their adult children in old age. In general, family members have very structured roles that benefit the family. Often, a family member, such as the eldest daughter, plays the role of caretaker of the younger siblings and is also mother’s assistant. There is conflict when the daughter feels overwhelmed or is resentful of such a role. She comes to therapy complaining that she wants to get relief. A therapist might interpret this request as wanting to separate and individuate from her family. The more accurate interpretation of this type of presentation is that the daughter wants a way to modify her role so that she can both support and help her family but also manage to have some time and space for her own needs. She most likely does not want to separate or abandon her family. It is common for Asian American parents to not only emphasize educational achievement but to also emphasize certain professions, such as becoming a doctor or some other highly prestigious or high-paid profession. Often an Asian American child will feel pressure to take on these goals without truly agreeing with them. The child feels like he or she cannot argue with the parents over choice of careers. Over time, this can result in the child becoming emotionally distressed. The consequences can be the development of somatic complaints or symptoms such as headaches, stomach or digestive disorders, poor concentration, anxiety, back problems, sleep disorders, and many other complaints. In fact, these are quite common presentations in university counseling centers where there are many Asian

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American students (Sue and Kirk 1975). Sue and Sue (2013) recommend that the therapist understand the hierarchical and patriarchal orientation of Asian American families. What is often helpful is to find common ground for a collaborative conversation that focuses on a common goal. The common goal for both parents and children is assisting everyone to be successful in life. Culture Conflict Intergenerational and cultural differences can be a source of difficulty. Young people who have grown up with Western norms often find themselves at odds with parents who have very different values and expectations of them. One such issue revolves around strong parental pressures on the young person to excel. This can become especially problematic when the parents of their non-Asian peers are saying to their children, “just relax. Do what you want.” In traditional Chinese homes, discipline is strongly emphasized, as is the demand to be successful academically and otherwise. One symptom that may emerge is depression, resulting from feelings of failure and inadequacy, engendered by internalized, unrealistic family expectations. Also common is a conflict between independence needs and loyalty to family. Guilt can also result from not completely conforming to family demands. Confucian values emphasize obedience to parents and loyalty. It is common for Asian American immigrant parents to come to therapy complaining that their adolescent children are “too Americanized.” They have been influenced too much by American culture and by their American friends. They want too much freedom and independence. They do not follow the old traditions and show enough respect to their parents. This is particularly the case with Asian American females who feel like their parents are too restrictive and who do not have the ability to date and go out with their friends just like their white friends are able to do. It is important to assist both parents and adolescent to view the positive intentions of each other. The parents want the best for their children, and they are acting out of love and concern. The adolescent wants to explore and learn about life in ways that will enhance his/her future success, but the adolescent

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also wants to honor the family and make them proud. The goal is to bring both sides together cooperatively to work out how both issues can be address effectively. Another possible problem is related to identity confusion from minority status and the impact of discrimination on personality development. Culture conflict can impact Asian American youth and their personality development (Kitano and Maki 1996). Many Asian youths are reluctant to identify with their Asian heritage due to negative stereotypes fostered by the dominant culture. In fact, even fourth and fifth generation Asian Americans have been identified as “foreign” (Sue et al. 2009). Often there is a strong pressure to assimilate to Western ways. Yet there also is still a strong pull from the family to conform to the traditional Asian culture of their parents.

Special Considerations for Couple and Family Therapy The concept of multicultural competence is very important in working with Asian Americans. Meyer et al. (2011) found that agreement on the cause and treatment of the presenting problem is more important than racial match in promoting counselor credibility and the therapeutic alliance. The ability to demonstrate multicultural competence by addressing the cultural beliefs of clients was also viewed as more competent by Asian Americans (Wang and Kim 2010). Another key element is helping Asian American clients to develop culturally appropriate strategies to cope with their problems. In this process the client improves their problem-solving abilities and develops skills for successful interactions within the larger society, including balancing conflicting values. It is important to work within the client’s unique world rather than to force the client to work within the therapist’s world (Soo-Hoo 1999). Any new solutions will be effective only if they fit within the client’s cultural context. As is true for most therapies, it is very important to develop a therapeutic alliance with Asian American families. It is critical to enter their world and to acknowledge and validate their experiences

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and their cultural values. It is important to form a social and cultural connection with the family during the initial stage. In addition, it is also helpful to establish expertise and credibility, build alliance with members who have power, and mobilize the family’s cultural strengths. The therapist must explore potential internal and external resources. In addition, the therapist needs to activate individual strengths within each family member. The therapist needs to validate how much parents care about their children and how they want the best for them, including the important goal of facilitating their children’s success in life (Soo-Hoo 2005). Only after forming this alliance can the therapist explore different ways to open up new perspectives to the problem situation (Soo-Hoo 1998). This is often called reframing, or changing the narrative about the problem situation. Working with Couples When working with couples, it is important to explore cultural and societal conflicts. Often one partner is more acculturated and present with different expectations and views of what is desirable in the relationship (Soo-Hoo 2005). An effective strategy is reframing the problem. Reframing a problem situation requires sensitivity to the client’s cultural context (Soo-Hoo 1999). For instance, a traditional Korean husband balked at a therapist’s suggestion that in order to resolve his relationship problem with his wife, he needed to be less aloof and become more emotionally expressive. He must show her greater tenderness. The therapist further suggested that the husband must show his venerable side to her, as well as sweep her off her feet with expressions of love and affection. He responded by saying that in Korean culture, the traditional husband is supposed to be very strong and quiet and does not express intense emotions directly, especially gentle, tender feelings. He felt that his wife was putting unreasonable demands on him, and that his wife has been influenced too much by American culture. This was his frame of reference which was shaped by his culture. He quickly became dissatisfied with this therapist and decided to go to a different therapist who was more culturally sensitive. This second therapist validated the husband’s love for

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his wife (which he had difficulty expressing directly) and how he wanted the best for her. The new therapist suggested that the wife needed the husband’s help in specific ways. As a strong, competent, and intelligent man, could he “model” for his wife how to be reasonable and teach her by example how to handle difficult situations in the relationship? This framing of the problem and suggestions for new behaviors allowed him to maintain his culturally defined role in the relationship. This also permitted him to collaborate with the therapist to generate new, more effective behaviors that resolved the relationship problems. In fact, with this new framing of the problem, he was able to show more gentle, caring feelings for his wife, but he also understood these behaviors as being a more “effective teacher.” Thus, shifting perceptions helped him attribute different meaning to a problem situation. Helping the wife see the problem situation in a new way was also helpful. However, reframing can be effective only when it is done within a client’s cultural context (Soo-Hoo 1998, 1999). Case Example Jennifer is a 19-year-old Chinese American college freshman. She was born in Hong Kong and immigrated to the USA with her parents when she was 6 years old. She was studying accounting and wanted to be a CPA. On the one hand, she considered herself acculturated to American culture in terms of her preferences for the latest American music, food, clothing, movies, and many other facets of American culture. On the other hand, she had many traditional Chinese cultural values. She was very close to her family and felt a great sense of responsibility for them. Her primary presenting problems were anxiety, insomnia, headaches, and stomach problems. Now in her second semester, she also had difficulty concentrating and focusing on her studies. A physician at the university medical center examined her and found no physical or medical issues. Subsequently she was referred to the counseling center. A Chinese American psychologist saw her for counseling. Initially, Jennifer complained that she was not sure why she was seeing a counselor

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because she did not have any psychological problems. In her culture only “crazy people” needed counseling or therapy. She only had physical problems and what she needed was some type of medicine. The Chinese American psychologist understood that her complaints were symptomatic of psychological distress. In this case, Jennifer was experiencing her psychological distress through somatic symptoms, which is quite common for Asian Americans (Sue and Kirk 1975). The therapist began with a thorough discussion about her physical symptoms. It was important that Jennifer felt heard about her concerns related to her physical complains. She also stated that she had tried many over-the-counter medicines such as aspirin and antacids, but nothing helped. The therapist explored with Jennifer that these physical symptoms are often associated with stress, especially anxiety and nervousness. She was then able to express that her mother was pressuring her to return home to take care of her three younger brothers and sisters. She was caught between her desire to pursue her educational and career goals and the needs of her family. Her father was supportive of her going to college because he believed that she could make good money to support the family when she graduated. However, her mother was reluctant to let Jennifer travel over 130 miles from home to college. Her mother felt overwhelmed with having to work long hours and still find time to take care of the three younger siblings. Her father was working even longer hours and had almost no time for the family. The mother advised Jennifer that since she was such an attractive and capable woman, she should come home and prepare herself to marry a “wealthy husband.” That would solve everything. Jennifer also felt very lonely and isolated at school because she could not relax and make friends. All her time was devoted to studying and working at the library. Her father told her repeatedly that the family was paying her way through school to study, “not” to have “fun.” “Do not waste our money!” On weekends she would go to the library to work or to study. She

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had no one to talk to. Whenever she did talk to someone, she felt guilty that she was diverting her attention away from her studies. The therapist validated her for being a caring and devoted daughter. Her concern for her mother and rest of the family was clearly part of her culture, which she valued highly. She replied that this was the reason she was so conflicted and felt so trapped. Her closest high school friend left home right after graduation and got a job in another city. She told Jennifer on the phone that she should think of herself and not think of her family. “They will be fine without you!” Jennifer told the therapist that her friend did not understand that as the eldest daughter in her family, her role was to take care of her family. She did not want to be selfish and abandon them. The therapist explored with Jennifer the difference between long-term goals and short-term goals. From ancient times it has been common for a Chinese family member to travel long distances to work and earn money or for a family member to go to school far away. When the family member completed the task, she or he returned home and was able to contribute to the family substantially more. The reason for her going to college was not only to pursue her own career but also to be able to make good money to help out her family. This discussion helped her to remember that her original goal was to help the family financially in the future. She also stated that she wanted to support her three younger siblings to go to college. To add to her stress, Jennifer’s mother was experiencing some separation anxiety and was feeling like she was losing her daughter. Jennifer showed the therapist letters from her mother that clearly stated this. Jennifer was encouraged to reassure her mother that she was still thinking of her. She was to call her mother and talk to her briefly once a day for the next few weeks. Also she agreed to come home for a weekend once a month since she was able to get a ride with a female student going to her hometown once a month. These arrangements helped to reassure her mother that her daughter was still attached to her. Going home once a month also helped Jennifer take a break from school, which was

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helpful. Reconnecting with the family once a month was also reassuring for Jennifer and allowed her to make the transition to college a bit smoother and less abrupt. Jennifer also was able to earn a scholarship that paid for all of her college fees as well as her housing expenses. The scholarship, along with working in the library at the university part-time, reduced significantly the financial burden on her family. These financial improvements reduced the financial pressures on her family sufficiently so that her mother was able to reduce her hours at her work. Thus, her mother could spend more time with the three younger children. Within a few months Jennifer reported that her physical symptoms had subsided significantly and she no longer felt as anxious. She had much more energy to pursue her studies and was doing very well in her classes. Whenever some of the old worries about not being home to take care of her family appeared, she would say to herself that she was on a “mission.” This mission was to become a successful CPA so that she would earn enough money to significantly help out her family! In the meantime, it was also important that she finds time to get rest and recuperate. In order for her to excel in her studies, she needed to recharge her batteries periodically. Finding time for rest, relaxation, and socializing were important elements of maintaining optimum academic performance! A few months later, she reported that she was finally feeling “more balanced.” Once she became more relaxed and open to connecting with people, she was able to form connections with a group of friends in her dormitory. They studied together but also had fun together. The social activities actually helped her to reduce some of the stress due to the academic pressures of her classes. In her social group, she discovered that two of the Chinese American students experienced similar pressures from their parents and families. The ability to share common experiences and feeling like she was not alone really helped her feel more “normal” and subsequently able to cope more effectively with the different pressures.

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References Brenner, A. D., & Kim, S. Y. (2009). Experiences of discrimination among Chinese American adolescents and the consequences for socioemotional and academic development. Developmental Psychology, 45, 1682–1694. Chen, P. H. (2009). A counseling model for self-relation coordination for Chinese clients with interpersonal conflicts. Counseling Psychologist, 37, 987–1009. Chen, S. W. H., & Davenport, D. S. (2005). Cognitivebehavioral therapy with Chinese American clients: Cautions and modifications. Psychotherapy: Theory, Research, Practice, Training, 42, 101–110. Kitano, H. H. L., & Maki, M. T. (1996). Continuity, change, and diversity: Counseling Asian Americans. In P. B. Pedersen, J. G. Dragun, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (4th ed., pp. 124–145). Thousand Oaks: Sage. Meyer, O., Zane, N., & Cho, Y. I. (2011). Understanding the psychological processes of racial match effect in Asian Americans. Journal of Counseling Psychology, 58, 335–345. Noh, S., Beiser, M., Kaspar, B., Hou, F., & Rummens, J. (1999). Perceived racial discrimination, depression, and coping: A study of Southeast Asian refugees in Canada. Journal of Health and Social Behavior, 40, 193–207. Soo-Hoo, T. (1998). Applying frame of reference and reframing techniques to improve school consultation in multicultural settings. Journal of Educational and Psychological Consultation, 9(4), 325–345. Soo-Hoo, T. (1999). Brief strategic family therapy with Chinese Americans. American Journal of Family Therapy, 27, 163–179. Soo-Hoo, T. (2005a). Working within the cultural context of Chinese American families. Journal of Family Psychotherapy, 16(4), 45. Soo-Hoo, T. (2005b). Transforming power struggles through shifts in perception in marital therapy. Journal of Family Psychotherapy, 15(3), 19–38. Sue, D. W., & Kirk, B. A. (1975). Asian American: Use of counseling and psychiatric services on a college campus. Journal of Counseling Psychology, 22, 84–86. Sue, D. W., & Sue, D. (2013). Counseling the culturally different: Theory and practice (6th ed.). New York: Wiley. Sue, D. W., Bucceri, J., Lin, A. I., Nadal, K. L., & Torino, G. C. (2009). Racial microaggressions and the Asian American experience. Asian American Journal of Psychology, S(1), 88–101. https://doi.org/10.1037/19481985.S.1.88. Wang, S., & Kim, B. S. K. (2010). Therapist multicultural competence, Asian American participants’ cultural values, and counseling process. Journal of Counseling Psychology, 57, 394–401.

Assertiveness Training in Couple and Family Therapy Sara J. Lee Didi Hirsch Mental Health Services and Alliant International University (CSPP), Los Angeles, CA, USA

Name of the Strategy or Intervention Assertiveness training

Synonyms Assertion training

Introduction The consensus definition of assertiveness is a verbal and nonverbal interpersonal behavior and a direct expression of one’s feelings and wants that is based on the person’s best interest, which respects the person and the other people’s rights (Alberti and Emmons 1974; Wolpe and Lazarus 1966). Assertiveness training (AT) was developed to help people effectively express their feelings, wants, and rights in their relationships with others and in various contexts of their lives (Speed et al. 2017). The purpose of AT has gone through an evolution and has been used in a wide range of population, including both clinical and nonclinical contexts. Peneva and Mavrodiev (2013) noted that in the 1960s, AT was utilized to overcome mental illnesses and to attain personal growth; in the 1970s, to protect individual rights; in the 1980s to 1990s, to attain self-accomplishment and self-approval and to advocate for women’s rights; and in the twenty-first century, to improve communication skills in diverse fields such as medicine, education, politics, business, and sports. Assertion training has shown to be effective in treating anxiety, depression, addictions, and personality disorders and improving self-

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confidence, self-esteem, personal satisfaction, interpersonal communication, and socialization (Lee et al. 2013; Peneva and Mavrodiev 2013). Assertiveness training has a long history. The concept of assertiveness originated from an American psychologist and psychotherapist, Andrew Salter, in 1949 (Lazarus 1968). When Salter was working with clients with depression, his efforts to find the cause of uncertainty/nonassertiveness and to treat its neurotic influence were shown in his theoretical explanation, “Conditioned Reflex Therapy” (Peneva and Mavrodiev 2013). Salter indicated that inhibitory individuals are not able to openly express their feelings, desires, and needs and consequently experience difficulties in their interpersonal relationships (Peneva and Mavrodiev 2013). Salter contrasted inhibition with excitation. Salter described excitation as the outward expression of feelings and emotions that leads to a healthy intra- and interpersonal functioning (Lazarus 1968). Later in 1958, Joseph Wolpe, a psychiatrist, used the term assertiveness and utilized assertiveness training (a) to decrease social fears, which Wolpe identified as the reason people are unassertive, and (b) to maintain a high level of self-esteem (Wolpe 1958). People are either assertive or nonassertive, and those who are nonassertive range from being excessively passive/submissive to being excessively hostile/aggressive (Speed et al. 2017). Caballo (1993) described people who are assertive as those who are satisfied, confident, and able to cope well in their daily social life. Caballo explained that those who are unassertive avoid conflicts, are ignored by others, and lack selfrespect and confidence by not being able to express their thoughts and feelings to others. Lastly, Caballo explained that those who are aggressive break the ethical norms and do not care about others’ rights.

Theoretical Framework Assertive training has its roots in behavior therapy (Speed et al. 2017). However, AT progressed

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from being a unidimensional model to a multidimensional model that incorporates behavioral, cognitive, and affective components (Peneva and Mavrodiev 2013). Although literature has supported the clinical efficacy of AT as a “standalone” intervention in treating diverse clinical problems, AT is typically embedded within large treatment programs currently (Speed et al. 2017). Peneva and Mavrodiev (2013) provided a history of how AT, a behavioral model, gradually integrated the cognitive and affective models. From the behavioral point, Salter and Wolpe addressed that people need to acquire habits to be able to openly express their feelings. Wolpe identified social fear as the source and the cause of nonassertiveness. Wolpe’s examples of social fear were fear of criticism, rejection, bosses, new situations, and fear to ask for help or to provide help. Wolpe stated that the effects of social fear become associated with a certain social situation and become enhanced and self-produced that it eventually becomes an automatic response that is spread out in other daily life situations (Peneva and Mavrodiev 2013). Peneva and Mavrodiev indicated that in 1971, Lazarus combined behavioral therapy with cognitive therapy. Lazarus defined assertive behavior as a social competence and addressed that people need to be able to differentiate assertive and socially acceptable behaviors from aggressive behaviors, which requires people to use cognition to assess their own personal life philosophy. Lastly, Peneva and Mavrodiev explained that the German psychologists Rita and Rüdiger Ullrich identified the feelings of guilt and shame as significant agents of nonassertiveness and therefore affirmed that assertiveness, in addition to behavioral and cognitive components, consists of an emotional component. According to Rita and Rüdiger Ullrich, as a person assesses one’s own personal life philosophy and tries to become assertive, emotions are evoked, which leads to a process of cognitive interpretations and emotions that can in turn be an overwhelming emotional condition that affects one’s self-assessment, selfesteem, and personal significance (Peneva and Mavrodiev 2013).

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Rationale for the Strategy or Intervention Most of the assertive trainings utilize various cognitive behavioral interventions in order to assist people in eliminating maladaptive behaviors (e.g., decreasing anxiety) and gaining new responses (e.g., building social skills and being assertive; Speed et al. 2017). Behavioral skills aim to build social skills, to verbally and nonverbally express oneself, to decrease the level of social fear, and to increase the level of self-esteem (Speed et al. 2017). Consequently, AT utilizes behavioral interventions such as relaxation, role plays, modeling, reinforcement, homework, coaching, guided imagery, desensitization, videotape feedback, exposure, and behavioral rehearsals for communication skills such as making requests, using “I” statements, and practicing to maintain an appropriate eye contact, affect, volume, and posture (Lee et al. 2013; Peneva and Mavrodiev 2013; Speed et al. 2017). On the other hand, cognitive skills aim to restructure negative thoughts about the self and anxious thoughts that lead to unassertiveness and to gain control over the misconceptions about oneself and the world in order to improve self-confidence (Peneva and Mavrodiev 2013; Speed et al. 2017). Consequently, AT utilizes interventions that help objectify misperceptions, identify maladaptive patterns of thoughts (e.g., selective attention, illogical conclusions, overgeneralizations, exaggerations, and underestimation), and evaluate thoughts and behaviors (Peneva and Mavrodiev 2013).

Description of the Strategy or Intervention (Critics and Application) Researchers have criticized AT for defining appropriateness based on the values of a White majority culture and consequently addressed the importance of assessing whether assertive skills are contextually and culturally appropriate for diverse groups or need modification (Lease 2018; Speed et al. 2017; Wood and Mallinckrodt 1990). Culture plays a role in defining what is appropriate and inappropriate. Ethnic minority groups such as Asian-American, Black, Latino, and Native American have different

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values, expectations, and definitions on assertiveness compared to the dominant culture (Wood and Mallinckrodt 1990). This means that a behavior can be viewed as appropriate and assertive in one culture and as inappropriate and aggressive or passive in another culture. Wood and Mallinckrodt (1990) addressed that people from the ethnic minority groups may need to learn to be assertive in the dominant culture in order to effectively interact with the dominant culture and may also need to learn how to respond in an assertively appropriate way in their own cultures in order to cope in their daily lives. Hence, Wood and Mallinckrodt recommended that therapist to be culturally sensitive by exploring and discussing cultural differences in regard to the appropriateness of assertiveness depending on the clients’ sociocultural contexts and by helping clients to make their own choices instead of therapist implying or persuading clients to change or reject their own values. Wood and Mallinckrodt noted the importance of considering the possible consequences of being assertive for the minority groups such as experiencing discrimination, shame, and ostracism from their families and friends. Wood and Mallinckrodt also advised considering acculturation levels of the immigrant families. In addition to the ethnic minority groups, Speed et al. (2017) suggested that women’s assertive behavior in their workplace may lead to negative consequences. Lease (2018) addressed the influence of the microsystem that consists of supervisors, colleagues, and supervisees with whom women directly interact on a daily basis and the influence of the macrosystem that consists of the cultural values, expectations, and norms that the society defines as appropriate. Consequently, Lease warned that if women are assertive, women can become norm violators and therefore be negatively affected. Therefore, it is imperative to broaden perspectives and to consider the clients’ socioecological system when utilizing assertiveness training.

Case Example Kate, a 58-year-old Chinese-American, is seeking individual therapy. Kate stated that she had a

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divorce 12 years ago and is now living with her 30-year-old daughter, Annie. Kate stated that she was happy and content at home and at her previous work until she started working at her current job 8 months ago. Kate stated that she has been feeling “down” for the last 4 months and has been “dragging” herself to go to work every day. Kate reported that she is a “horrible employee” and added that has recently started to think that she is a horrible mother as well. Kate concluded, “I am not good at anything.” Kate reported that her boss does not like her and “picks on” her. Kate stated that her boss always criticizes her for not doing her job on time. Kate reported that she is worried that she may get fired any time soon for being “an incompetent employee.” Kate stated that she cannot afford to lose her job. During the assessment, Kate stated that she would like to talk to her boss and explain her situation, but Kate reported that she cannot do so. Kate’s cultural values and expectations for working with coworkers and communicating with superiors were further explored. While exploring the reason that Kate cannot talk to her boss, Kate reported that she does not want to “backstab” or “shame” her coworker/partner in the group project. Kate explained that she does not want her partner to get into trouble because of her. Kate also reported that she does not want to give excuses or “talk back” to her boss when her boss criticizes her for not doing her work on time. Kate explained that she cannot disrespect her boss. When detailed questions were asked in regard to Kate’s group project, Kate revealed that her partner has not been doing her part of the work and she has been doing her best to cover her partner’s role. Kate reported that she is not good enough and fast enough to complete and turn in the weekly reports on time to her boss. Kate reported that her boss questions and accuses her of not doing her work in a timely manner. When specific questions were asked in regard to Kate’s work context, Kate reported that her boss is a White man who is older than her. Kate also explained that her partner is one of the people who has the longest seniority while Kate she is the newest employee in her department.

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Assertiveness was introduced, explained, and discussed with Kate. Cultural differences in defining appropriateness were explored and discussed, and Kate indicated her willingness to become more assertive at work. Kate’s cultural and the societal expectations were further considered and explored. Therapist and Kate adjusted the assertive skills accordingly. Kate’s worries/concerns that she will “backstab” her coworker and that she will be disrespectful to her boss were further explored, discussed, and differentiated based on the differences in the culture and the context. Kate learned relaxation techniques in order to cope with her feeling of anxiety whenever she tried to be assertive. Therapist and Kate explored, discussed, and modified the appropriateness of being assertive based on Kate’s own beliefs and values. The therapist modeled for Kate on how to be assertive by using “I” statements based on Kate’s level of comfortableness. Appropriate eye contact, voice volume, and physical posture were also discussed, modified, and rehearsed based on Kate’s culture. Kate engaged in role plays with the therapist wherein the therapist played the role of Kate and Kate played the role of being the boss and vice versa to practice being assertive. Kate did her homework by practicing the use of “I” statements and being assertive with her daughter Annie at home. Therapist performed guided imagery with Kate on Kate explaining to her boss about the work situation. In addition, Kate’s maladaptive thoughts of “I am a horrible employee,” “I am not good at anything,” “I am not good enough and fast enough,” and “I am an incompetent employee” were identified, evaluated, and challenged. Eventually, Kate became successful in being assertive by expressing the situation to her boss, and appropriate changes were made in the office. Kate also reported that she was able to be assertive with her coworker/ partner in the group project as well. Kate reported that she is feeling high levels of self-confidence and satisfaction at work, at home, and in her daily life.

Cross-References ▶ Communication Training in Couple and Family Therapy

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References

Synonyms

Alberti, R., & Emmons, M. L. (1974). Your perfect right: A guide to assertive behavior. San Luis Obispo: Impact Press. Caballo, V. (1993). Manual de evaluación y entrenamiento de las habilidades socials [Handbook of social skills assessment and training]. Madrid: Siglo XXl. Lazarus, A. A. (1968). Behavior therapy in groups. In G. M. Gazda (Ed.), Basic approaches to group psychotherapy and group counseling (pp. 149–175). Springfield: Charles C. Thomas. Lease, S. H. (2018). Assertive behavior: A double-edged sword for women at work? Clinical Psychology: Science and Practice, 25(1), 1–4. https://doi.org/ 10.1111/cpsp.12226. Lee, T.-Y., Chang, S.-H., Chu, H., Yang, C.-Y., Ou, K.-L., Chung, M.-H., & Chou, K. R. (2013). The effects of assertiveness training in patients with schizophrenia: A randomized, single-blind, controlled study. Journal of Advanced Nursing, 69(1), 2549–2559. https://doi. org/10.1111/jan.12142. Peneva, I., & Mavrodiev, S. (2013). A historical approach to assertiveness. Psychological Thought, 6(1), 3–26. https://doi.org/10.5964/psyct.v6i1.14. Speed, B. C., Goldstein, B. L., & Goldfried, M. R. (2017). Assertiveness training: A forgotten evidence-based treatment. Clinical Psychology: Science and Practice, 25(1), 1–20. https://doi.org/ 10.1111/cpsp.12216. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford: Stanford University Press. Wolpe, J., & Lazarus, A. A. (1966). Behavior therapy techniques: A guide to the treatment of neuroses. New York: Pergamon Press. Wood, P., & Mallinckrodt, B. (1990). Culturally sensitive assertiveness training for ethnic minority clients. Professional Psychology: Research and Practice, 21(1), 5–11.

Clinical interviews; structured interviews

Assessment in Couple and Family Therapy Lane L. Ritchie, Kayla Knopp and Galena K. Rhoades University of Denver, Denver, CO, USA

Name of the Strategy or Intervention Assessment in Couple and Family Therapy

Questionnaires;

Semi-

Introduction Assessment in couple and family therapy refers to the process by which a therapist evaluates the clients’ individual and dyadic characteristics, and environmental circumstances. Clinical assessment is aimed at evaluating the nature, scope, and severity of the presenting concerns. It also includes collecting relevant information that may assist in selecting an appropriate course of treatment and establishing methods for evaluating progress throughout treatment. Often, assessment is thought of as a first step in treatment, aimed at identifying targets of intervention and guiding treatment planning. However, assessment can be used throughout treatment in order to monitor progress and make decisions about termination; furthermore, assessment itself can be used as a therapeutic intervention.

Theoretical Framework All models of couple and family therapy include some form of assessment, though they vary widely in the role that assessment plays. Approaches to assessment also vary, with some models including only a brief initial assessment and others incorporating ongoing assessment into the treatment throughout. The clinical interview* is certainly the most common form of assessment and is used more or less universally in couple and family therapy. Therapists typically talk with all involved parties together and/or individually about the primary issues currently impacting the couple or family dynamics and what changes or improvements they would like to experience during the course of therapy. Some therapeutic approaches emphasize a semi-structured interview*, such as is used during

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the assessment phase of Integrative Behavioral Couple Therapy (IBCT; Christensen and Jacobson 1996), whereas others gather information in an unstructured, conversational manner. Some models of couple and family therapy also incorporate some form of a screening assessment, often in a questionnaire* format, in order to ensure that couple or family therapy is an appropriate intervention. For example, the presence of severe partner or family violence may be an exclusionary criterion for some couple or family interventions, and clients who endorse this particular problem will usually be referred for anger management or other violence prevention-focused services prior to beginning couple or family therapy. Substance abuse, individual mental health disorders, and ongoing infidelity are other common targets of screening assessments, as they will frequently influence treatment targets and approaches or, in some cases, may preclude couple or family therapy. As mentioned previously, IBCT is perhaps the model of couple therapy with the most formalized initial assessment process (Christensen et al. 2015). The first four sessions of therapy are explicitly dedicated to an assessment and feedback phase of treatment, with one conjoint assessment session, two individual assessment sessions (one with each partner), and a conjoint feedback session. During the assessment phase, a semi-structured interview* is used to discover the relationship, individual, and contextual factors that comprise a DEEP (Differences, Emotional sensitivities, Environmental stressors, and Patterns of interaction) formulation. The DEEP formulation is presented to the couple during a feedback session and is used to focus and anchor the targets of treatment throughout therapy. IBCTemphasizes the functional assessment of behaviors in order to discover how the meaning of problematic behaviors is related to larger themes of dissatisfaction that cause relationship distress. The Integrative Problem-Centered Metaframeworks approach (IPCM; Breunlin et al. 2011) is perhaps the best example of an intervention model that uses assessment therapeutically throughout treatment. IPCM treatment involves an ongoing, systemic assessment that is used to

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create and test hypotheses about the causes and maintenance of couple or family dysfunction. The process of IPCM therapy is explicitly empirical, as therapists use the data collected throughout treatment to adjust treatment approaches and targets as new information is learned. Importantly, assessment in IPCM is done collaboratively with clients: data from assessments are incorporated into therapy in a way that allows clients and therapists to increase their understanding together about the particular couple or family dynamics at play. IPCM has provided the theoretical framework for the development of the Systemic Therapy Inventory of Change (STIC), an assessment tool optimized for both measurement and feedback in a therapeutic context (Pinsof et al. 2015). Other forms of couple and family therapy may incorporate assessment initially and throughout treatment in a way that helps to focus treatment on the most pressing issues and monitors progress toward goals. The focus of assessment typically mirrors the focus of a particular mode of therapy; for example, in Cognitive-Behavioral Couple Therapy (CBCT; Baucom et al. 2015), assessment often probes for specific behaviors and partners’ evaluations of those behaviors that contribute to relationship dissatisfaction, whereas in Emotionally Focused Therapy (EFT; Johnson 2015), assessment frequently aims to elicit the presentmoment emotions that are associated with relationship distress. Information gathered during assessments may be presented to clients in order to increase insight about relational issues and highlight the potential for change to occur. Finally, some models of couple or family therapy focus on the treatment of specific psychological disorders, in addition to alleviating relational distress. For example, Cognitive-Behavioral Conjoint Therapy for PTSD and Behavioral Family Therapy for Bipolar Disorder both utilize the couple or family context to support treatment of individual mental health concerns. In these cases, assessment specific to the relevant disorder is typically included. Assessment at the beginning of therapy may be used to confirm a particular mental health diagnosis and to quantify the severity of impairment or distress, and

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assessment may continue to be incorporated throughout treatment to monitor improvement in symptoms. Importantly, these models of therapy also focus on improving the couple or family relationship, and therefore may include relevant assessment of the couple or family functioning similar to other models of couple or family therapy. Assessment can be and often is used in preventive or psychoeducational programs for couples. When teaching the Prevention and Relationship Education Program (PREP; Markman et al. 2001), for example, many facilitators may use initial assessments to learn about the couples they are serving. PREP also offers several selfassessments as part of the curriculum so that partners can learn about themselves and each other. Some other preventive approaches use assessment and feedback as the basis of the program. Examples of these kinds of programs are PREPARE/ ENRICH (Olson and Olson 1999) and the Marriage Checkup (Cordova 2009).

Rationale for Strategy or Intervention Assessment in couple and family therapy can serve several purposes. First, it can be used to guide treatment planning by identifying specific targets of intervention, and identifying which approach will be best suited to a couple or family’s circumstances. With a rich understanding of a family’s strengths, challenges, and resources, clinicians are better-prepared to select a course of treatment that is most appropriate. However, assessment can do more than guide treatment. Some approaches include ongoing assessment as a core component of the intervention. For example, many couple and family therapists administer assessment measures at several time points during treatment in order to track progress and remaining areas of challenge (e.g., Christensen et al. 2015).

Description of Strategy or Intervention Although models of couple and family therapy vary in the role and method of assessment recommended, many of the general purposes of

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assessment are similar. Most approaches include some assessment of individual, dyadic, and environmental factors. This information is most often collected through a combination of questionnaires*, clinical interviews*, and observations. Although couple and family therapists are primarily focused on addressing challenges at the level of the dyad or larger family group, it is important to assess several characteristics of each individual involved. For example, information about individual psychopathology, trauma history, and previous relationship history may be relevant, depending on the current presenting concerns. In many cases, individuals hold attitudes and beliefs that contribute to the dyadic- or family-level concerns. These characteristics, which often interact with cultural background and previous relationship experiences, are important for a clinician to understand. Another important component of assessment across models is collecting information about the couple or family’s level of distress. In couple and family therapy, assessment includes developmental relationship history (e.g., in couple therapy, how the couple met, how intimacy and commitment changed over the course of the relationship, significant events in the relationship including transitions such as engagement, marriage, or parenthood). Particularly in couple therapy, an assessment of current commitment to the relationship can also inform treatment planning. When assessing current presenting problems, clinicians generally benefit from asking each family member about their own perceptions of the problems, including attributions about why the problems are occurring. Further, clinicians may ask each family member’s opinion about what it would take for the problem to be adequately addressed. Assessment may also include investigating prior efforts that the couple or family has made in order to address relationship problems or enhance relationship strengths. Some common efforts include individual, couple, or family therapy; enrichment programs such as retreats; selfhelp resources including books or blogs; and support from others such as religious leaders. Most approaches also encourage clinicians to ask about strengths of the couple or family relationships. An overly strong emphasis on negative

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qualities can leave a couple or family feeling discouraged about the status of their relationship. Asking couples and family members to generate information about the positive aspects of their relationships can serve at least two purposes: identifying areas of strength to build on during treatment and reminding family members that there are positive characteristics of the relationships even though negative aspects may be more readily accessible during periods of distress. Another important component of assessment is related to the environmental context of each couple or family. Contextual factors include financial resources, social resources, family support, and health-related concerns. Assessing these factors external to the dyad or family allows clinicians to identify areas of strength and challenge that each couple or family faces. The individual, dyadic, and environmental factors reviewed here can be assessed using questionnaires*, clinical interviews*, and observation of interactions. Clinicians are encouraged to make thoughtful decisions about which type of format is likely to yield the most useful information in each domain. Some approaches emphasize the importance of collecting some information by individual clinical interview*, even when a dyad or family presents for treatment. For example, the IBCT protocol includes a conjoint assessment session, followed by individual assessment sessions with each partner. Among other purposes, the individual interviews are meant to provide an opportunity for each partner to speak openly about information that they may be unable or unwilling to discuss fully in the presence of the partner. For example, the individual interviews provide an opportunity for those who do not feel safe in their relationship to express that information without concern for additional danger. Observing family members’ current interaction patterns can be a useful tool. Although each family member can report their perception of how conflict occurs at home, clinicians often find that observing small segments of conflict provides additional information that was not easily gathered from interview. Models emphasizing behavioral change strategies, such as Cognitive Behavioral Couple Therapy (CBCT) and Parent-Child Interaction Therapy

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(PCIT) may particularly benefit from observation of communication or interaction patterns during session. Upon conclusion of the initial assessment period, many clinicians compile the information and share it with the couple or family in some way. Some approaches to therapy encourage smaller, less formal presentations of the information. For example, a clinician may briefly summarize a couple’s history and review mutually agreed-upon goals, ensuring that both partners are in agreement about targets of treatment. Other approaches call for a more formal presentation of the assessment. For example, IBCT consists of a highly-structured assessment phase, with the first four sessions devoted specifically to assessment. There is a feedback session, during which the therapist shares a detailed summary of assessment data and collaboratively reviews the case conceptualization with the couple. Many therapists use this opportunity to orient couples and families to the model of treatment to be used. This may include discussing the role of the therapist and the clients. Importantly, clinicians may address who the client is (e.g., the couple’s relationship? One of the individuals involved?). Assessment can be used throughout treatment in order to assess progress toward therapeutic goals. Interventions can be altered accordingly. For example, interventions can shift toward other areas of focus once a particular goal has been attained.

Case Example José and Ally began couple therapy after two years of marriage due to growing dissatisfaction in their relationship. The partners reported that they generally get along but would like to improve communication, specifically around sensitive topics about which arguments escalate quickly. The couple had no children, though they had been trying to conceive for the duration of their marriage. Conflict often arose when communicating about their difficulty becoming pregnant. Both partners worked and Ally managed the couple’s business. José occasionally helped out with the business, though this frequently became an area of contention due to discrepant expectations about roles and who should

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be in charge of different components of their family and business. Ally considered the two of them to be generally equal partners across contexts, while José drew a distinction between their home life, where they would interact as equals, and their life outside of the home, where Jose was in charge. A packet of questionnaire* measures was administered to each partner at the first session to collect demographic information and some individual characteristics such as psychopathology. Standardized scales measuring relationship quality were also included in this packet. The use of standardized measures allowed for the couple’s scores to be compared to established norms. Further information about relationship history, current presenting concerns, and relationship strengths was collected during a conjoint interview session. Specific individual information (e.g., relevant previous relationship history) and some key pieces of safety-related information (e.g., aggression in their relationship) were collected during individual interview sessions with each partner. Although no specific interaction task was administered, the clinician used several opportunities during the conjoint session to observe interaction patterns that emerged naturally without therapist interjection. A thorough assessment of this couple yielded a great deal of information that was useful in guiding treatment planning. Specifically, after learning that physical safety was not consistently maintained, the clinician was able to prioritize some brief cognitive-behavioral interventions aimed at establishing physical safety within the home. Throughout treatment, a standardized measure was administered regularly in order to monitor ongoing relationship satisfaction. The clinician also conducted regular informal assessments during sessions regarding progress toward goals and working alliance.

Assimilation in Integrative Couple and Family Therapy

References Baucom, D. H., Epstein, N. B., Kirby, J. S., & LaTailade, J. L. (2015). In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 23–59). New York: Guilford Press. Breunlin, D. C., Pinsof, W., & Russell, W. P. (2011). Integrative problem-centered metaframeworks therapy I: Core concepts and hypothesizing. Family Process, 50(3), 293–313. https://doi.org/10.1111/j.15455300.2011.01362.x. Christensen, A., & Jacobson, N. (1996). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York: WW Norton. Christensen, A., Dimidjian, S., & Martel, C. R. (2015). Integrative behavioral couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 61–94). New York: Guilford Press. Cordova, J. V. (2009). The marriage checkup: A scientific program for sustaining and strengthening marital health. New York: Jason Aronson. Johnson, S. (2015). Emotionally focused couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 97–128). New York: Guilford Press. Markman, H. J., Stanley, S. M., & Blumberg, S. L. (2001). Fighting for your marriage. San Francisco: Jossey-Bass, Inc. Olson, D. H., & Olson, A. K. (1999). PREPARE/ENRICH program: Version 2000. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (pp. 196–216). Philadelphia: Brunner/Mazel. Pinsof, W. M., Zinbarg, R. E., Shimokawa, K., Latta, T. A., Goldsmith, J. Z., Knobloch-Fedders, L. M., Chambers, A. L., & Lebow, J. L. (2015). Confirming, validating, and norming the factor structure of systemic therapy inventory of change initial and intersession. Family Process, 54(3), 464–484.

Assimilation in Integrative Couple and Family Therapy George Stricker Argosy University, Arlington, VA, USA

Cross-References Introduction ▶ Cognitive Behavioral Couple Therapy ▶ Emotionally Focused Couple Therapy ▶ Integrative Behavioral Couple Therapy ▶ PREP Enrichment Program ▶ Prepare/Enrich Enrichment Program

Psychotherapy integration has been defined as including various attempts to look beyond the confines of single-school approaches in order to see what can be learned from other perspectives. It

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is characterized by openness to various ways of integrating diverse theories and techniques (Stricker 2010).

Theoretical Context for Concept There are four generally accepted approaches to psychotherapy integration. These include the following: 1. A common factors approach to understanding psychotherapy, which identifies those aspects of psychotherapy that are present in most, if not all, therapeutic system 2. Technical integration, in which a combination of techniques is drawn from different therapeutic systems without regard for any specific theoretical approach 3. Theoretical integration or an attempt to understand the patient by developing a superordinate theoretical framework that draws from a variety of different frameworks 4. Assimilative integration, which combines treatments drawn from different approaches but remains guided by a unitary theoretical understanding

Description Assimilative integration may begin with any of several theoretical approaches. A psychodynamic approach is used by Stricker and Gold (2005) and a cognitive-behavioral approach by Castonguay et al. (2005). When doing couple and family therapy, it is difficult to imagine treatment being carried out without the incorporation of a systems perspective, whether it is the primary orientation or is assimilated into an alternative approach. In assimilative psychodynamic psychotherapy integration, one of several assimilative approaches, the therapist begins with a psychodynamic approach to conceptualizing the clinical situation, uses many psychodynamic techniques, but also integrates cognitivebehavioral, humanistic, and systems techniques. In addition, of necessity, some systems thinking is used in couple and family therapy.

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Application of Concept in Couple and Family Therapy The couple or family is viewed through the preferred lens of the therapist. In the assimilative psychodynamic integrative approach, in order to understand each of the patients as individuals, the lens is psychodynamic, and this is supplemented by a systems lens in order to view the meaning of the interaction between them. Interventions then may be generated from a variety of different approaches to psychotherapy other than the basic psychodynamic approach of the therapist, including cognitivebehavioral, humanistic, and systems. It is important to recognize that theory and technique are separable, so that one theory can be used with multiple techniques, as long as the integration is conducted seamlessly.

Clinical Example Mrs. A. was a 40-year-old woman, married for 10 years, with two children, aged 4 and 2. She came to therapy because of a growing dissatisfaction with her husband, based on a very different set of values and lifestyle. She felt he had not risen to the occasion of their children’s birth and had become increasingly uncommunicative, and they had become more distant from each other physically and emotionally. She didn’t seem to feel that she was getting much from the relationship now and had little romantic interest in him (or anyone else) but acknowledged that he was a good father. He offered to live in the basement and allow her to have a boyfriend, which was not what she wanted, and this also suggested something about his personality to the therapist, who had a psychodynamic orientation. They came together to the next session, and it was obvious that communication was almost absent between them, leaving Mrs. A. frustrated and unhappy and Mr. A. not being bothered very much. This formulation had both psychodynamic and systems components, and the therapist encouraged them to speak to each other without much direction. By the end

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of the session, she became more expressive of her feelings, and he was surprised that she was actively considering separation. At the next session they reported a much better week, a confrontation of sorts in the car, with Mr. A. upset about the mention of divorce and Mrs. A. about his not realizing her concerns. However, the talk went well, and they did a little better after that. The importance of communicating was highlighted by the therapist, as was the need to make time for each other if it was to happen. This more directive approach to a psychodynamic orientation was an early example of assimilation. It also meant that Mr. A., who was laid back, would have to be more assertive and Mrs. A., who was reluctant to make waves, also would have to be more expressive. Because of the value of outcome assessment (Lambert 2007), at the beginning of each session, they were given an outcome form to fill out and, at the end, a scale to assess the session (Duncan et al. 2006). This too was an assimilation of a non-psychodynamic intervention. Interestingly, Mrs. A. rated the sessions very highly, as most patients do, but Mr. A. was much more reserved in his rating. The therapist asked him about this and he said that he never rated anyone highly, as he did not think it was possible to be perfect. The therapist then remarked that his approach must make it very difficult for his wife. Her face lit up, as though she finally felt heard, and he recognized what was being said.

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References Castonguay, L. G., Newman, M. G., Borkovec, T. D., Grosse Holtforth, M., & Maramba, G. G. (2005). Cognitive-behavioral assimilative integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 241–260). New York: Oxford University Press. Duncan, B. L., Sparks, J. A., & Miller, S. D. (2006). Client, not theory, directed: Integrating approaches one client at a time. In G. Stricker & J. Gold (Eds.), A casebook of psychotherapy integration (pp. 225–240). Washington, DC: American Psychological Association. Lambert, M. (2007). Presidential address: What we have learned from a decade of research aimed at improving psychotherapy outcome in routine care. Psychotherapy Research, 17, 1–14. Stricker, G. (2010). Psychotherapy integration. Washington, DC: American Psychological Association. Stricker, G., & Gold, J. (2005). Assimilative psychodynamic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 221–240). New York: Oxford University Press.

Assimilative Family Therapy Patricia Pitta Department of Psychology, St. John’s University, Jamaica, NY, USA

Name of the Strategy or Intervention Assimilative Family Therapy Model

Cross-References

Introduction

▶ Common Factors in Couple and Family Therapy ▶ Eclecticism in Couple and Family Therapy ▶ Integration in Couple and Family Therapy ▶ Integrative Couple Therapy: The Functional Analytic Approach ▶ Integrative Problem-Centered Metaframeworks ▶ Stages of Change in Couple and Family Therapy ▶ Therapeutic Alliance in Couple and Family Therapy

Pitta integrated Bowen Family Systems Therapy with cognitive behavioral, psychodynamic, communications, and other systems therapies into Integrative Healing Family Therapy (Pitta 2005). As her thinking evolved, she began to consider context (Brabender and Fallon 2009) and common factors (Davis et al. 2012). She then labeled this therapy for individuals, couples, and families the Assimilative Family Therapy (AFT) model (Pitta 2014). The home theory of AFT is a systemic theory or family therapy model, and the

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concepts and interventions from other therapies can be from individually oriented treatment therapies and other family therapy models.

Theoretical Framework for the AFT Model Four major models have been identified within the field of integration: technical, theoretical, common factors, and assimilative integration (Norcross and Goldfried 2005). Technical integration uses a systemic reasoning process and integrates techniques from different approaches to meet the needs of the client to attain growth and change. Theoretical integration looks at how different models can be integrated to form a model of treatment that is more powerful than either model separately. Common factors look at how effective treatments result in positive change processes that are not specific to any theory or model, while also measuring the alliance between client(s) and therapist. These factors include: the client viewing the therapist as someone who can help; the client(s) being committed and motivated to do the work of therapy; having hope that their realistic expectations can be reached (Davis et al. 2012). Finally, Assimilative Integration names a home theory as the main theory and then integrates concepts and interventions from other theories to support the goals of the home theory and the goals set out by therapist and clients for the course of their treatment (Messer 2015). Bowen Family Systems Therapy is a theoretical framework that looks at generational patterns, including transmission processes, that addresses why a client may be acting in a certain way. Often, they are repeating the patterns of previous generations. It also looks at triangulation within a system and addresses how a person can get stuck within the family processes and not be able to further differentiate. This therapy also defines concepts such as cutoffs, intergenerational transmission processes, triangulation, fusion, differentiation, pursuit-distance patterns, coaching, and how these concepts defines and help change thoughts, behaviors, and feelings of individuals and family functioning. In addition to identifying

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dysfunction, this framework also looks for health in the system to promote changes. The major goals of Bowen Family Systems work are to lower anxiety and emotional reactivity and increase differentiation (Bowen 1976). Pitta added concepts and interventions from Cognitive Behavioral Therapy, including cognitive relabeling, assertiveness training, relaxation therapy, role-play and modeling, behavioral parent training, contingency contracts, reinforcement, punishment, and mindfulness to integrate with the home theory. Additionally, AFT examines psychodynamic defenses such as repetition compulsion, denial, doing and undoing, repression, distortion, splitting, and projection and projective identification are also integrated. Gottman’s Sound House Theory is utilized within this model (Gottman 1999). Lastly, other systemic theories, concepts, and interventions such as re-parenting parents, drawing boundaries, and exposing family secrets are also integrated with the home theory. Included in the AFT model (Pitta 2014) is a deep respect for context (age, ethnicity, culture and racial backgrounds, sexual identity and relationship status, socioeconomic status, life stage, life cycle, resilience, attachment, emotional regulation, optimism, chronic illness, religion, spiritual affiliation, and spiritual beliefs). Levels of resistance are determined through the use of a resistance questionnaire (Pitta 2014, p. 293). Building on a genogram (McGoldrick et al. 2008) assembled in the initial sessions, the therapist is able to formulate a case conceptualization that holds an important key to help clients and therapist to form their goals of treatment. In Solving Modern Family Dilemmas: An Assimilative Family Therapy Model (Pitta 2014), a case conceptualization questionnaire (p. 295) is presented that enables therapists to create their own conceptualizations about the cases they are treating. Assimilative models, and the AFT model in particular, are generic models; therapists can create their own AFT model by identifying their systemic model as a home theory and then integrating concepts and interventions from other theories.

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Populations in Focus The AFT model can be applied to couples, families, and individuals, because it uses Bowen Family Systems Therapy, a systemic theory, as the home theory. This theory has been applied to all populations throughout the life cycle. Its main goals of lowering anxiety, regulating emotions, and helping individuals differentiate can apply to all systems.

Strategies Used in the Model The process for the model is as follows: Before beginning treatment, each family member fills out a contextual questionnaire to offer the treating therapist essential information about their specific contexts. From this, the therapist draws a contextual diagram that indicates the contexts that this family lives within. This offers the therapist a photo of who the family members are in relation to their ages, culture, ethnicity, and racial backgrounds, sexual identity, marital status, life stage and life cycle, socioeconomic status, levels of resilience, attachment and emotional regulation, optimism, chronic illnesses, religion, spiritual affiliation, and spiritual beliefs. Second, the therapist has the clients fill out a resistance questionnaire that the author created (Pitta 2014) based on the work of Beutler and Harwood (2002). Through the resistance questionnaire, the therapist can determine if clients are demonstrating low or high levels of resistance. Those with low levels can be approached by the therapist in a more direct manner while those who presented as more resistant, the therapist will need to approach in a less directive manner and using questions rather than statements as a means to ascertain information. Third, the therapist meets with the individual, couple, and/or family and ascertains why they are seeking treatment. Fourth, the therapist builds an alliance while meeting with members of family to build a strong bond and provide a safe environment to promote growth and change. Fifth, as the therapist meets with the family, she is constructing a genogram to

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learn further about the patterns of functioning within and between the generations that might be contributing the presenting dilemmas. As the therapist conducts the first few sessions, she is getting the necessary information to create a case conceptualization with the help of the family, where goals are identified and therapist presents ways to solve presenting dilemmas. This gives the family members a sense of control and understanding about the process of treatment and offers them an active role in creating their therapy to help them resolve issues. The major goals of the home theory are always kept in mind when setting goals and creating a treatment plan. Treatment plans can change as clients make changes in contexts, goals, and extra-therapeutic influences. Important to note is that therapist takes temperature checks (Pitta 2014) during sessions asking clients such questions as: Do they feel comfortable with therapist; do they feel their goals for the session are being addressed; Is there anything else that needs to be addressed before the session ends that helps with ensuring the development and maintenance of the alliance between clients and therapist.

Research About the Model Integrative approaches have found to be effective when looking at them through a common factor lens, which consider therapy to be most effective when clients feel comfortable and allied with the therapist, and thus also hopeful that positive change can take place (Davis et al. 2012). Further, research shows that any one method of treatment is far surpassed by using the lens of common factors with an integrative perspective (Wampold and Imel 2015). AFT integrates cognitive behavioral, psychodynamic concepts, and interventions and communications interventions derived from their respective theories. These approaches have been shown to be effective treatments through a number of primary and meta-analytic studies (Babcock et al. 2013; Butler et al. 2006; Shedler 2010). AFT is a model that clearly delineates steps that the therapist adheres to, promoting more effective treatments (Datchi and Sexton 2016).

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Case Application A mother, father, and their teenage daughter presented in therapy because the daughter was being very oppositional at home, despite being an A-student with a flourishing social life. She was particularly disrespectful towards her mother and very demanding of her father for attention and material things. After noticing how both the father and daughter expressed resistance towards therapy, the therapist began focusing not only on the issues with the daughter but in what might be causing those issues from a larger systemic perspective. The therapist discovered the parents’ marriage was fraught with tension because they were repeating the patterns they had witnessed in their own parents’ relationships. The couple’s issues stemmed from around the time they had begun having children. When the wife began dividing her attention among the children and her husband, the husband began to grow angry and distant. To further complicate matters, the wife had become obese as a result of using food as an outlet for her marital anxiety, while her husband smoked cigarettes and pot as a means of coping. The therapist created a case conceptualization to aid in formulating her treatment plan for this case (Pitta 2014). It appeared that disappointment, rage, and anger described the relationship that the husband and wife had created with each other. Family patterns that were learned in their families of origin were repeated in their relationship as a couple and in their nuclear family. Their daughter had learned their patterns and introjected aspects of their personalities and patterns and acted it out within her personal life and within the nuclear family. If the couple would agree to work on changing their thoughts, feelings and behaviors towards each other, it was possible that their daughter would see the change and more than likely, also change. They needed to work on understanding their mutual responsibility for the dysfunction as well as to appreciate what was functional in themselves and their relationship. They needed to: (1) build new behaviors and interactions that could overcome the negative interactions of the past, (2) work on their

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communication so they could learn to demonstrate how they appreciated each other and express their own feelings, (3) differentiate themselves from the patterns of their families of origin to become a true self by identifying their “I” positions on matters within themselves and between themselves, (4) remove their daughter from the triangle that was created to keep their marriage together and to allow her to differentiate her position as a daughter to both parents and as an individual, and (5) lower their mutual and individual levels of anxiety and mutual reactivity so the couple could learn how to interact in a more effective, gentler manner. The couple met with the therapist for a total of 18 sessions. During the third session, the therapist offered the family her conceptualization of how she envisioned the dilemmas they presented and then thanked the daughter for acting out sufficiently to get the parents to look at their relationship. The teen did not want to be in therapy as she clearly stated in the sessions. She said, “I don’t want you to change the way my family functions. I like it just the way it is”. In the middle of the third session, the therapist joined the teen and said that the therapist would work with the parents and she was free for the time being to not be part of the sessions and asked the teen to please wait in the waiting room. The teen was stunned and left the room. This was the first attempt on the part of the treatment to create a boundary that focused on the couple’s functioning and to put power back to parents. The therapist identified for the parents that they allowed the teen to run the family since their behaviors were so conflictual and non-connected and they did not take charge of the family functioning We explored how on some unconscious level the teen was trying to make order in her life, but her adjustments in the home were not functional, but due to her inner strengths, she excelled in school and with friends. The therapist worked with the couple on their anger revolving around their sense of mutual abandonment of each other upon the birth of their child. They worked on learning to express their feelings that they fought about and distanced from. We worked on each taking responsibility for

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their behaviors and feelings. They also were encouraged to identify the dream behind their selfish and childlike behaviors. They then were enabled to mourn and grieve the loss of their childlike fantasies. We also explored how their behaviors were a repetition of their same sex parent in their family of origin and how each needed to differentiate to become their own person. The therapist utilized mindfulness techniques to enable them to relax and become more cognizant of their behaviors. With learning how to communicate more appropriately and developing a more unified stance, the couple experienced a reduction in their anxiety and became more emotionally regulated and differentiated offering each other connection and their daughter a different form of interaction with boundaries, limits and love. These interactions created the family unit with the parents in charge of the family and the daughter allowed to be a teenage who did not have to try and control the family unit.

Cross-References ▶ Assimilation in Integrative Couple and Family Therapy ▶ Coaching in Bowen Family Therapy ▶ Family Therapy ▶ Triangles in Bowen Family Therapy

References Babcock, J., Gottman, J., Ryan, K., & Gottman, J. (2013). A component analysis of a brief psychoeducational couple’s workshop: One year follow-up results. Journal of Family Therapy, 35, 252–280. Beutler, L. E., & Harwood, T. M. (2002). What is and can be attributed to the therapeutic relationship? Journal of Contemporary Psychotherapy, 32(1), 25–33. Bowen, M. (1976). Theory in the practice of psychotherapy. In P. J. Guerin (Ed.), Family therapy: Theory and practice (pp. 42–90). New York: Gardner Press. Brabender, V., & Fallon, A. (2009). Contextual variables requiring further examination. Washington, DC: American Psychological Association. Butler, A., Chapman, J., Forman, E., & Beck, A. (2006). The empirical status of cognitive behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31.

Athenian Institute of Anthropos, The Datchi, C., & Sexton, T. L. (2016). Integrating research and practice through intervention science: New developments in family therapy research. In T. L. Sexton & J. Lebow (Eds.), Handbook of family therapy (pp. 434–453). New York: Routledge/Taylor & Francis Group. Davis, S. D., Lebow, J. L., & Sprenkle, D. H. (2012). Common factors of change in couple therapy. Behavior Therapy, 43(1), 36–48. Gottman, J. (1999). The marriage clinic. New York: W. W. Norton. McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and intervention (3rd ed.). New York: W. W. Norton. Messer, S. B. (2015). In E. Neukrug (Ed.), The Sage encyclopedia of theory in counseling and psychotherapy (Vol. 1, pp. 63–66). Thousand Oaks: Sage. Norcross, J. C., & Goldfried, M. (2005). Handbook of psychotherapy integration (2nd ed.). New York: Basic Books. Pitta, P. (2005). Integrative healing couple’s therapy: A search for the self and each other. In Haraway (Ed.), Handbook of couples therapy (pp. 211–227). New York: Wiley. Pitta, P. (2014). Solving modern family dilemmas: An assimilative therapy model. New York: Routledge. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. New York: Routledge.

Athenian Institute of Anthropos, The Mina Polemi-Todoulou Scientific Council Member, The Athenian Institute of Anthropos, Athens, Greece

Νame The Athenian Institute of Anthropos (AIA).

Introduction The Athenian Institute of Anthropos (AIA) – the first center for family therapy, group therapy, community interventions, and systemic practice in Europe – was founded in 1963 in Greece, by George and Vasso Vassiliou, as a center for

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training, therapy, prevention, consultation, research, and development of systemic applications to the systems of Anthropos (meaning the whole human being, in Greek). The AIA logo, with the image of a lantern, accompanied by the ancient Greek philosopher Diogenes’ quote “For Anthropos I search,” symbolizes the vision of its founders for a world where cooperation and humanness would prevail over antagonism and exploitation. The ΑΙΑ has been functioning for over 50 years as a collective professional coevolving process, as an international interdisciplinary meeting point and incubator of theory development, and as a base for launching collaborative community-oriented projects.

The Scope and Character Developing an Approach Since the beginning, the ongoing contact with innovative movements across the world kept the AIA community constantly fertilized with new ideas. Associates getting their academic training abroad brought back influences and acquaintances from different schools of thought. A strong feeling was generated throughout that of being part of an open process contributing to the creation of a new field. The basic theoretical frame for AIA’s work is the “systemic-dialectic multilevel-multifocal approach”: Anthropos is conceptualized as a bio-psycho-social-economic-cultural, open system, spiraling toward more organized complexity through its interaction with other systems in the wider context. The model addresses the self-leading aspects of the whole system, as it emerges through the interconnectedness, transaction, and coevolution of processes at different levels of complexity – the individual, the family, the group, the community, and the culture. These levels are utilized, in varied ways, in all interventions, training, and family or group therapy. Priority is given to (a) forming and keeping throughout a secure relational context,

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(b) acknowledging the coevolution among the interrelated systems as a primary factor in therapy and learning, (c) fostering the development of dialogue within and among members holding different roles or points of view within or around each system, and (d) appreciatively reflecting the unique contribution of each different viewpoint. The development of this approach and intervention model constitutes a primary contribution of the AIA to the therapeutic community. Along with this are two related techniques introduced by the Vassilious in the late 1950s and extensively applied for five decades by the AIA network of professionals in a wide range of contexts, populations, and enriched variations: the Synallactic (meaning changing together in Greek) Collective Image Technique (SCIT) that utilizes the group or family members’ interaction on a common stimulus and the Sequence Analysis (SA) of their contributions that provides the group or family theme as the frame for therapy (Vassiliou 1968). Developing the Activities: Rationale and Target Groups The AIA therapeutic and health promoting interventions and training programs have been developing around the following axes: 1. Activities encompass the whole family life cycle: children, adolescents, young adults, couples, parents, and families from pregnancy to the “empty nest.” Activities address the needs of the particular developmental phase (e.g., for teens and young adults, programs aim at autopoiesis (i.e., self-forming) and creating viable relationships while for older adults at the road to maturity).They are carried out separately or in combination (e.g., parallel as well as mixed parent-children groups or daughters-mothers-grandmothers). 2. A primary goal has been the sensitization of a wide spectrum of professionals – related directly or indirectly with family functioning – in the systemic approach and applications for the promotion of functioning of the Anthropos systems. Included are all mental

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health practitioners, child carers and educators, as well as family physicians, human resource managers, organizational consultants, cultural mediators or animators, etc. 3. The AIA activities are largely carried outside its murals, within the community, in collaboration with a wide range of institutions relevant to family, welfare, mental health, and the challenges arising from crisis: public and private schools, childcare centers, welfare agencies, universities, hospital clinics, mental health and child psychiatry institutions, community centers, drug addiction institutions, rescue teams, institutions for children from broken homes, professional associations, municipal agencies, and Ministries (Education, Health, Culture, or Work) – the list includes almost every section of the societal structure. The collaboration encompasses staff training, consultation, supervision, and relevant research. 4. Large-scale projects have frequently been the product of these collaborations. For example: (a) In the early days, in collaboration with the University of Illinois, a large-scale research was carried out comparing subjective culture data from different countries (Vassiliou and Vassiliou 1973). (b) In the mid-1990s, responding to an invitation by the Organization Against Drugs (OKANA), the AIA designed and materialized a large-scale community program Preparing Anthropos for the 2000 in six municipalities (population ranging from 28,000 to 85,000). The main goal was to introduce systemic training for parents, teachers, adolescents, young couples, and professionals working in the community, sensitizing them to the changing social realities and the new required skills, thus creating the ground work to be further developed by the newly created public Prevention Centers (Gournas et al. 1995). (c) In 2011, in the context of the Major Foundation Program for Educators of the Ministry of Education, AIA Associates designed and implemented an Experiential

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Training Program on Developing Human Relations in the School Community, addressed to about 16,000 school teachers in various parts of Greece (PolemiTodoulou 2010). Interprofessional consultation programs are regularly offered for the interdisciplinary teams of institutions, such as the drug prevention community centers in various parts of Greece, family therapy or child-guidance clinics, rural community psychiatry programs, substance addiction institutions, mental health centers for immigrants and refugees, welfare programs, and schools, in response to their own requests for help with bullying, substance abuse, or relationship difficulties, often leading to whole school community interventions utilizing the systemic-dialectic multilevelmultifocal methodology. Interventions are tailor-made and interactional: Rather than following a predetermined plan, an attempt is made to acknowledge the needs of the system as they emerge from the interactions unfolding during the course of intervention and to redesign step by step accordingly. Therefore, the outline of the intervention course, rather than existing beforehand, usually emerges as the process develops. Therapy utilizes a combination of different contexts: In order to effect a more holistic approach to a particular family case, for example, the therapists may flexibly combine sessions with the family, group therapy for one member over a period of time, couples group, children’s group, genogram exploration, and family reconstruction, even experiential training addressing role or developmental phase challenges. Likewise, professionals are encouraged to understand in depth more than one system – not only the family but the therapeutic process in a group, the individual’s inner dialogue, the large group process dynamics, and at least one broader system, e.g., a school community or a large organization, in order to better understand complex systems. As a living system, the AIA is actively responding to the changes happening in the wider context, and the prioritization of its

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activities reflects this. For example, in recent years, the activities addressed to adolescents need to take into account the reduced opportunities for autonomous face-to-face peergrouping socialization (Polychronis 2018). The challenges arising from the widespread socioeconomic, political, and cultural crisis have urged the AIA associates to initiate or participate in programs addressing refugees, immigrants, or families with reduced financial viability, as well as school – mental health – or social welfare institutions that need to accommodate members from these populations. New elaboration of the approach and the techniques is necessitated to handle new emerging roles as the cultural mediators or the much needed cooperation among the many institutions (governmental/nongovernmental/private, local/international) that address refugees with different approaches and methods. 9. The AIA has developed its own guiding value system as any organization in the course of its history: commitment to teamwork, meeting the challenges of cooperative over antagonistic orientation, utilizing differences within or among groups through open dialogue, acknowledging what is valuable in every member’s contribution, seeking meaning in life though responsible and creative community membership, responding to changes affecting society, and taking leadership for community welfare. The G. Vassiliou’s motto “Autonomy through and for Interdependence” and the AIA’s logo “For Anthropos I search” reflect these values.

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B. Intermediate cycle: Systemic-dialectic epistemology and personal professional development C. Advanced in-depth training cycle: Family therapy, group therapy, multilevel group process interventions in broader systems D. Supervised practice: On family and group therapy and systemic interventions in and outside the institute Examples of other seminars offered: Systemic diagnostic methodology, children’s animation programs, sequence analysis, systemic applications in education, professional role dynamics, etc. All training is experiential, actualizing the personal experiences of the participants in the context of a developing group process (Polychroni et al. 2008). The course of training for each participant is personalized in collaboration with the Scientific Consultative Committee, and his/her unique professional profile is encouraged, along with cooperative peer relations, leading to lifelong collaborations. Apart from the formal training, the trainee commits to a personal therapeutic process, including didactic group therapy and family of origin exploration and reconstruction. Therapy for the therapist, including family members, is encouraged. With all the above, skills in both autonomy and interdependence and awareness of both self and context are targeted. Yearly, on the average, about 150 professionals participate in the AIA seminars.

Training Program The AIA basic training in family and group therapy and systemic thinking and applications involves four cycles. The first two are offered to a wider body of professionals; for therapists and system process specialists, the completion of all four is required: A. Introductory cycle: Sensitization to the systemic-dialectic multilevel-multifocal approach

Impact The AIA since its inception has had a leading presence in the systemic field of family and group therapy and community interventions for the promotion of mental health in Greece and abroad. It has extensively contributed to the development of systemic theory and applications in therapy, prevention, and training. Over

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300 texts by AIA Associates are presented at the AIA Communication Series: chapters in books, articles in journals, technical reports and presented papers, books, and research monographs. It has provided the context for pioneer discussions on family therapy and systemic ideas through the Delphic Symposia it organized, along with a wide range of international meetings and a rich schedule of visiting and hosting leaders in the field up to current times: Virginia Satir, Paul Watzlawick, Salvador Minuchin, Yvonne Agazarian, Mony Elkaim, Karl Tomm, Kenneth Gergen, Carlos Sluzki, Luigi Boscolo, Maurizio Andolfi, Luigi Onnis, Peter Lang, Elspeth McAdam, and Sue Johnson. The AIA Newsletter was sent quarterly till the mid-1980s to an international network of about 600 professionals in 55 countries (The AIA Newsletters: 1963–1988). AIA Associates have been serving in the editorial board of many journals and book series. Since 2008, the AIA is a joint publisher of Human Systems, the journal of systemic consultation and management, in collaboration with Leeds Family Therapy and Research Centre of the UK (K. Polychroni and P. Stratton (Eds)). Over its 55-year course, more than 500 mental health professionals have completed the Institute’s training cycle, who in turn have expanded the field, founding new systemic therapy and training institutions, disseminating systemic ideas, and widening the spectrum of applications. Many leaders of the systemic and family therapy institutions in Greece and elsewhere, as well as university professors, have been trained or associated with the AIA and continue their collaboration. The AIA Associates have played a leading role in the formation of the professional scene of family therapy and systemic practice by participating as founders, chairs, and board members of many Greek, European, and International associations, e.g., EFTA (European Family Therapy Association), WASP (World Association of Social Psychiatry), MESPA (Mediterranean Sociopsychiatric Association), NORG (National Organization for Psychotherapy in Greece), ETHOS (Hellenic Federation of

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Family and Systemic Therapy), and HELASYTH (Hellenic Association for Systemic Therapy). They have been actively involved in various policy-making committees on social welfare, mental health, educational issues, and professional certification, or in task forces preparing reforms relevant to family functioning (e.g., preschool childcare reform or the process of deinstitutionalization in the 1990s), leaving an impact on important institutions. Locally and internationally, through an extensive involvement in collaborative projects and scientific meetings, the AIA has contributed to an ever-growing network of systemic professionals working and cooperating in a wide spectrum of different fields and sectors of the society, private and public, addressing different populations and challenges in a turbulent society that requires more than ever a holistic, cooperative, process-oriented, dynamic approach. The large community of systemic therapists that practice today in various parts of Greece to a large extent see their roots in the pioneering work of the AIA and its founders. The AIA has been awarded by the World Association of Social Psychiatry (WASP) in 1974, in Athens, for Organizing a Congress Pioneering Structure Content and Spiritwise and by the Mediterranean Sociopsychiatric Association (MESPA) in 1980 in Dubrovnic for its Outstanding Contributions to the Prevention of Malfunctioning and Promotion of Functioning of the Anthropos Systems in the Mediterranean Region and the World Over.

Operation The AIA functions in the frame of the professional, nonprofit, self-financed Society for the Advancement of Human Relations Research (SAHRR), with the goal of catalyzing cooperation in the sciences of Anthropos, both nationally and transnationally. The interdisciplinary body of SAHRR includes prominent figures in the society, who support the shared AIA vision. For many years it has been chaired by Dr

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C. Spinellis, Professor Emeritus of Sociology at Athens University. The AIA has been directed for 38 years by the Vassilious couple; since 2001 it is being operated by a team of long-standing Associates, consisting of Petros Polychronis, Child Psychiatrist, AIA Director, and the AIA Scientific Consultative Committee Members: Giorgos Gournas, Ph.D., Psychiatrist; Mina Polemi-Todoulou, Ph.D., Psychologist; Kyriaki Protopsalti-Polychroni, M.A., Psychologist; and Dionyssis Sakkas, Ph.D., Psychiatrist, all psychotherapists, members of the European Family Therapy Association, certified by the European Association of Psychotherapy and The American Group Psychotherapy Association. Currently, about 20 professionals are regularly involved as AIA trainers, therapists, and supervisors, while the wider AIA project-supporting network includes more than 80 AIA-trained associates. The AIA is an accredited member of the European Family Therapy Association-Training Institutes’ Chamber (EFTA-TIC) of the European Association for Psychotherapy (EAP) and of the National Organization for Psychotherapy of Greece (NOPG).

Cross-References ▶ European Family Therapy Association ▶ Human Systems (Journal) ▶ Systemic-Dialectic Multilevel-Multifocal Approach ▶ Vassiliou, George and Vasso

References Gournas, G., Polemi-Todoulou, M., Polychronis, P., & Vassiliou, V. (1995). Educating the anthropos of 2000: A systemic-dialectic multilevel-multifocal community intervention. . A five-year program subsidized by the organization against drugs (OKANA). Athens: The Athenian Institute of Anthropos. Polemi-Todoulou, M. (2010). Systemic thinking as a key to redesigning training, Metalogos, 18, Thessaloniki. Polychroni, K., Gournas, G., & Sakkas, D. (2008). Actualizing inner voices and the group process: Experiential systemic training in personal development. Human Systems: The Journal of Therapy Consultation and Training, 19(1-3), 26–43.

159 Polychronis, P. (2018). Depriving adolescence from its growing processes. Metalogos, 33, Thessaloniki. (In process). The Athenian Institute of Anthropos. (1963). The AIA Newsletters: 1963–1988. Athens: AIA. Vassiliou, G. (1968). A transactional approach to mental health: An experiment in greece. In B. Riess (Ed.), New directions in mental health. New York: Grune & Stratton. Vassiliou, G., & Vassiliou, V. (1973). Subjective culture and psychotherapy. American Journal of Psychotherapy, 27(1), 42–51.

Atkinson, Brent Jason Nicol The Couples Research Institute, Geneva, IL, USA

Name Brent J. Atkinson, Ph.D. (1956–).

Introduction Brent Atkinson is the principle architect of the Pragmatic/Experiential Method for Improving Relationships (also called the PEX Method), an approach that translates findings from neurobiology and the science of intimate relationships into practical methods for improving relationships. His pioneering work is detailed in the books Emotional Intelligence in Couples Therapy and Developing Habits for Relationship Success, has appeared in leading professional journals, and has been featured in outlets such as the Oprah Magazine, the Washington Post, and the Psychotherapy Networker. He is known for his ability to present complex scientific ideas in compelling and easy-to-understand ways.

Career After completing a Ph.D. in Marriage and Family Therapy from Texas Tech University in 1985, Atkinson accepted a faculty position in Marriage and Family Therapy at Northern Illinois

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University (NIU) where he spent the next 27 years. He served as Director of the Marriage and Family Therapy Program, guiding it through successful AAMFT accreditation renewals in 1995 and 2002. He also served as Chair of the State of Illinois Marriage and Family Therapy Licensing and Disciplinary Board, and President of the Illinois Association for Marriage and Family Therapy. In 1999, he cofounded the Couples Clinic and Research Institute where, drawing on research methods detailed earlier in his career (Atkinson et al. 1991), he began assembling the components of the PEX Method. Atkinson is currently Professor Emeritus at NIU and Director of Post-Graduate Training at the Couples Research Institute.

Contributions to Profession Atkinson’s methods for rewiring automatic emotional processes in the brain are widely recognized. Early in his career, Atkinson noted that the skills needed to successfully navigate relationships can be difficult to execute because people may experience 1) automatic emotional tendencies or inclinations that take them in the wrong direction, and 2) a paucity of naturally occurring feelings that enable attachment and connection. The automatic patterns of emotional activation and suppression that enable successful relationships cannot be generated on demand, but rather develop naturally over time in children who have well-attuned and non-anxious caregivers. But Atkinson saw evidence emerging from neuroscience suggesting that with the right kind of practice, even people who don’t have the benefit of well-attuned caregivers can still develop automatic internal tendencies and inclinations that facilitate relational competence. He incorporated several empirically-verified practices into his treatment method for couples and developed further practices of two different varieties: 1. Practices that strengthen mood-regulation and response-flexibility. Atkinson developed exercises that rewire the way people automatically react in emotionally charged situations. These exercises include methods for

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deliberately restimulating and interrupting old emotional reactions through visualization, relaxation, and mental rehearsal. Like athletes and musicians who learn new movements and skills so thoroughly that they become instinctive, Atkinson asks partners to practice new mental and physical reactions frequently enough so that they became part of their mental muscle memory and begin happening with little or no conscious effort. 2. Practices that increase naturally-occurring feelings of love and connection. Atkinson has been particularly interested in studies suggesting that the brain can be primed so that it naturally generates more of the feelings needed for relationships to thrive. He identified the active ingredient across studies of successful priming as sustained inviting – a process in which subjects invite specific feelings while remembering times when the feelings were present or imagining situations where they would likely have the feelings. Studies suggest that the process of sustained inviting stimulates and strengthens areas of the brain associated with intimacy-related feelings, increasing the degree to which they emerge spontaneously in the course of everyday life. Atkinson developed specific practice protocols that are used by partners to prime their brains for more empathy, attentiveness, warmth, fondness, playfulness, and desire for connection.

Cross-References ▶ Attachment Theory ▶ Gottman, John ▶ Neurobiology in Couples and Families

References Atkinson, B. (2005). Emotional intelligence in couples therapy: Advances from neurobiology and the science of intimate relationships. New York: W.W. Norton. Atkinson, B. (2013). Mindfulness training and the cultivation of secure, satisfying couple relationships. Couple and Family Psychology: Research and Practice, 2(2), 73–94.

Attachment Disorders in Couple and Family Therapy Atkinson, B. (2016). Developing habits for relationship success (version 4.6). Geneva, IL: The Couples Research Institute. Atkinson, B., Heath, A., & Chenail, R. (1991). Qualitative research and the legitimization of knowledge. Journal of Marital and Family Therapy, 17(2), 161–166. Atkinson, B., Atkinson, L., Kutz, P., Lata, J., Szekely, J., Weiss, P., & Wittmann Lata, K. (2005). Rewiring neural states in couples therapy: Advances from affective neuroscience. Journal of Systemic Therapies, 24(3), 3–13.

Attachment Disorders in Couple and Family Therapy Quintin Hunt, Maliha Ibrahim and Guy S. Diamond Center for Family Intervention, Drexel University, Philadelphia, PA, USA

Name of Concept Attachment Disorders in Couple and Family Therapy.

Introduction Attachment disorders have several meanings in the field of couple and family therapy. The first refers to the relatively rare, diagnosable disorders of Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) which are seen exclusively in maltreated children. The second refers to commonly enduring attachment styles of parent-child interactions that were first identified by John Bowlby (1969) and Ainsworth et al. (1978) for children and later expanded to adults (Hazan and Shaver 1987). The third meaning of “attachment disorder” is a pseudo-diagnostic term with criteria ambiguous enough to include most developmentally appropriate child behavior such as lying, persistent questions, or triangulation of caregivers. This entry focuses on RAD and DSED. Both RAD and DSED have particular relevance to field of Couple and Family Therapy as the disorders result

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from severe and persistent neglect, and caregivers often experience intense challenges with raising these children.

Theoretical Context for Concept Attachment theory posits that children are biologically wired to form close, long-term, and dependent relationship with their caregivers from infancy. Four infant styles of attachment (secure, avoidant, resistant-ambivalent, and disorganizeddisoriented) has been identified. Infants that have a secure bond with their caregiver experience distress when the caregiver leaves and seek reunion upon the caregivers return. Infants with an insecure bond either do not attempt reunion with caregiver upon return or do so ineffectively. While insecure attachment styles are related to Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED), the relationship is not causal and the appropriateness of classifying these disorders as attachment disorders is increasingly questioned. There are several major questions that should be considered with the RAD or DSED diagnoses. First, given that RAD and DSED are almost entirely seen with institutionalized children, we must question if the disorders can be generalized to other developmental experiences. The lack of information about their prevalence also severely limits the generalizability of what we do know about the disorders. Second, although RAD and DSED are considered relational disorders, they are primarily defined by the individual symptoms of a child (attachment) rather than the relational dynamics at play. Namely, the role of caregivers failing to bond with RAD/DSED children is essential to the development of the disorders and is absent from literature on the disorders. This leaves the main conceptualization of the disorders as the child’s problematic behaviors as the problem rather than the systemic pattern of neglect in which the child was raised. Although there is question about the caregivers’ role in the development of the disorder that may never be answered due to ethical limitations, some caregivers may be less likely to bond with children

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that are less likely to seek comfort. Third, attachment styles and several of integral aspects of attachment theory, like internal working models, are missing from the discussion of RAD and DSED. In fact, many have suggested that an attachment framework may not be appropriate for these disorders (Allen 2016; Lyons-Ruth 2015). Perhaps most importantly, the disconnect between attachment theory and RAD/DSED is confusing the public and may encourage caregivers that are have exhausted all other options to consider “attachment therapies” that include dangerous and controversial tactics that have no established evidence of efficacy. These “attachment therapies” are typically marketed as treatments designed for attachment disorders.

Description Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) manifest through disturbed and developmentally inappropriate social behaviors. Children that have been severely neglected, maltreated, or abused are more likely to be diagnosed with RAD or DSED, but no epidemiological studies have examined their prevalence. Children at risk for RAD and DSED are those who have been placed in foster care or raised in institutions such as orphanages, hospitals, or long-term care facilities. The development of these attachment disorders is rooted in both biological factors (e.g., temperament) and contextual factors (e.g., parent ability to bond). A stress-diathesis model may be useful to understand the development of these disorders. This model assumes that most people have some level of diathesis (predisposition) for any disorder that is then activated by stress. People with high levels of diathesis require lower levels of stress but no amount of stress can activate the disorder in people with no amount of diathesis. Given that even within extremely maltreated populations few children develop these disorders, it appears be that some biological factor underlies the disorder. Children with RAD demonstrate contradictory or ambivalent social responses at reunions or

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partings with attachment figures. Essentially, this manifests through children rarely turning to an attachment figure for comfort. These children may approach others without making eye contact or stare into the distance while being held or embraced. RAD children respond to social and parenting cues inconsistently – sometimes appearing welcoming or accepting and other times showing avoidance or resistance. When experiencing their own distress or in proximity of others in distress, RAD children are typically unresponsive, withdraw entirely, or sometimes become physically aggressive. They are noted for displaying hypervigilance and fearfulness. For complete diagnostic criteria and further discussion of differential diagnoses (autism spectrum disorder, intellectual disability, and depressive disorders), we recommend consulting the DSM-5; the diagnosis cannot be made before the age of 9 months and should be made with caution after the age of five. The DSED diagnosis was originally a subtype of RAD but is now considered distinct disorder. Given that there are differences in how DSED and RAD symptoms respond to in-home placement after institutionalization, this separation appears to be appropriate. Children with DSED are seen to have inappropriate or overly familiar relationships with people unknown to the child. This manifests through comfortable and intimacy with strangers. These children are often overly clingy as infants but become indiscriminately friendly as older children. Children with DSED are comfortable sitting on the laps of strangers and leaving the presence of caregivers with a stranger. They also have extreme difficulty in creating close relationships with peers and commonly have emotional and behavioral disturbances. Many DSED children also suffer from cognitive delays and developmental delays. Although the prevalence of RAD in the general population is unknown, some literature suggests that approximately 1 out of every 100 children in foster care or other placement outside of a home will be diagnosed with RAD (Gleason et al. 2011); the DSM-5 reports the prevalence of RAD to be about 10% and of DSED to be about

Attachment Disorders in Couple and Family Therapy

20% in extremely neglected populations. Though RAD is more likely to develop in cases of maltreatment, many children are able to subsequently form a stable attachment relationship and only 40% of children diagnosed with RAD spent time in foster homes or orphanages. There is no standard diagnostic protocol for either attachment disorders, though the Disturbances of Attachment Interview has effectively been able to identify both RAD and DSED (Smyke and Zeanah 1999). Children typically do not develop attachment disorders from a mild history of maltreatment or disrupted attachment although there is some connection between mild maltreatment and the RAD/DSED disorders (Lionetti et al. 2015). Most of the foundational research on RAD and DSED has come from or has been inspired by two longitudinal projects which tracked a group of institutionalized children in the United Kingdom and children from Romanian Orphanages. Barbara Tizard et al. (1972) followed a group of children from the UK who were placed outside of a home or in an institution. Tizard and colleagues first identified the emotionally withdrawn and socially disinhibited categories that have been utilized as bases for RAD and DSED, respectively. The other project involved the study of Romanian orphans in the 1990s (O’Connor et al. 2000). O’Connor and colleagues found that some DSED behaviors are likely to persist in-home placement. Fortunately, there has been a sizable increase in research to attachment disorders in the last decade (cf. Zeanah and Gleason 2015). Perhaps the most hopeful and striking finding from recent research is that children placed into homes, and receive care adequate to their needs show significant (or complete) remission of their RAD/DSED symptoms in most cases. However, it appears that DSED symptoms are more persistent post in-home-placement than RAD symptoms; the most important factor predicting reduction of symptoms appears to be the amount of time the child has spent in an institution (Guyon-Harris et al. 2018). Specifically, the less time in an institution, the greater the reduction in symptoms has been found.

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Application of Concept in Couple and Family Therapy The primary interventions RAD and DSED focus on enhancing caregiver sensitivity or finding new caregivers when current caregivers are unable or unwilling to meet the heightened and intense needs of the child (BakermansKranenburg et al. 2003). Enhancing caregiver sensitivity requires observation of a caregiver providing care for their child to accurately assess caregiver sensitivity patterns. The therapeutic target is how the parent and child interact and specifically, how the caregiver responds to the child. Much of this work involves psychoeducation about the development of attachment disorders and the child’s inability to just get over it. This involves building a belief within the caregivers that it is their responsibility to help the child learn to be a more functional and normative adult. This belief fits very well with most family-based interventions that believe that the parent/caregiver plays an integral role in the child’s development. The child’s behaviors are not the focus; rather, treatment focuses on teaching the parent to better understand and be able to respond to the child’s needs. Interventions also aim to help parents and caregivers develop greater empathy for their child through helping caregivers better understand their own attachment history. When parents are able to increase their understanding and empathy of their child, they are then able to comfort and provide care more effectively. Because of the severity and persistence of attachment disorders, when efforts to increase the caregiver’s capacity to be sensitive to the child’s needs and behaviors is not possible – due to unwillingness or inability of the caregiver – it may be appropriate to work on finding a new caregiver that is capable of the increased level of sensitivity needed. Though there is no model that specifically addresses RAD and DSED attachment disorders, both RAD and DSED appear to be responsive to enhanced and stable caregiving (cf. Zeanah and Gleason 2015).

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Clinical Example Maria was 5 years old when her foster parents sought additional help to understand some of the challenges they were facing with Maria. Maria had been severely neglected by her biological parents. She was found alone when she was 12 months old by her parents’ landlord after a neighbor reported a noise disturbance and the parents were not home. This started a process several years long of bouncing between systemsof-care and short-term placements before she was placed in a more stable foster home with her older sister. Maria’s foster parents reported erratic and unpredictable moods with behaviors that would escalate quickly from hugging to biting and yelling. According to the foster parents, Maria had no friends at school. They also reported frequent physical altercations, lying, and a lack of remorse after acting aggressively. Most recently, the foster parents reported an incident in which Maria followed an unknown adult male and tried to get into his car. Many elements of DSED appear present with Maria, particularly the early and sustained neglect, difficulty in mood regulation, and the willingness to wander off with an unfamiliar adult. An integral aspect that distinguishes DSED from RAD is the pattern of overly familiar and inappropriate social behavior with strangers. While Maria’s pattern of indiscriminate behavior of nonselective attachment behavior is a clear indicator of DSED, utilizing the Disturbances of Attachment Interview (Smyke and Zeanah 1999) may be useful during assessment. Perhaps most important in Maria’s treatment is the inclusion of the caregiving system (and parents should reunification ever take place). The development of secure attachment can occur in the foster-care family environment but only if the foster parents also demonstrate more secure attachment patterns for Maria. The mains goals for treatment are to help Maria’s foster-parents (1) learn how to increase their empathy for Maria, (2) increase their ability to be emotionally available and respond sensitively to Maria, and (3) to help them feel confident and capable of

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loving a child that may, at times, be challenging. Perhaps most important is that Maria has a stable and consistent home to live in – good enough but consistent caregivers are key. An integral aspect of both these goals involves psychoeducation with the caregivers regarding the DSED diagnosis and some of the history that Maria, and her sister, has experienced. When the caregivers better understand the context in which Maria has lived, they are more able to forgive the difficulties they are dealing with currently. Given that many DSED children also are developmentally or cognitively delayed, it may be useful help the caregivers learn how to listen and speak with toddlers and young children. This may occur through play-therapy or sandbox treatments due to Maria’s age. Given the increased effort that parenting a DSED child takes, it is likely the caregivers experience frustration and may even wonder if they should continue to try as foster parents. Empathizing with the caregivers about their frustrations will help the caregivers to feel competent and revitalize their efforts to parent a difficult child. Structured sessions in which the therapist helps the caregivers to identify and respond to Maria’s needs may be useful. Most important is that the caregivers find the support, the need, and the belief that they themselves are good enough to provide consistent care. Several changes identify when termination of treatment with Maria and family should be considered: (1) Maria is able to consistently turn to her caregivers (reunited parents or foster parents) when she has questions or difficulties, (2) when Maria’s parents (foster or reunited) are able to consistently be emotionally available and respond to Maria’s concerns rather than their own reactions to her, and (3) Maria’s caregivers feel revitalized and confident in parenting on their own and seeking additional help when they need it. Though treatment duration may vary between cases, what little outcome data does exist on children diagnoses with RAD or DSED suggest that almost all youth that are placed in a home show few differences when compared to non-neglected or institutionalized youth.

Attachment Injury Resolution Model in Emotionally Focused Therapy

Cross-References ▶ Anxiety Disorders in Couple and Family Therapy ▶ Attachment Theory

References Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum. Allen, B. (2016). A RADical idea: A call to eliminate “attachment disorder” and “attachment therapy” from the clinical lexicon. Evidence-Based Practice in Child and Adolescent Mental Health, 1, 60–71. https://doi. org/10.1080/23794925.2016.1172945. Bakermans-Kranenburg, M. J., Van Ijzendoorn, M. H., & Juffer, F. (2003). Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129, 195–215. https://doi.org/ 10.1037/0033-2909.129.2.195. Bowlby, J. (1969). Attachment and loss: Attachment. New York: Basic Books. Guyon-Harris, K. L., Humphreys, K. L., Fox, N. A., Nelson, C. A., & Zeanah, C. H. (2018). Course of disinhibited social engagement disorder from early childhood to early adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 57, 329–335. https://doi.org/10.1016/j. jaac.2018.02.009. Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52, 511–524. https://doi.org/ 10.1037/0022-3514.52.3.511. Lionetti, F., Pastore, M., & Barone, L. (2015). Attachment in institutionalized children: A review and metaanalysis. Child Abuse and Neglect, 42, 135–145. https://doi.org/10.1016/j.chiabu.2015.02.013. Lyons-Ruth, K. (2015). Should we move away from an attachment framework for understanding disinhibited social engagement disorder (DSED)? A commentary on Zeanah and Gleason. Journal of Child Psychology and Psychiatry, 56, 223–227. https://doi.org/10.1111/ jcpp.12373. O’Connor, T. G., Rutter, M., & English and Romanian Adoptees Study Team. (2000). Attachment disorder behavior following early severe deprivation: Extension and longitudinal follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 703–712. https://doi.org/10.1097/00004583-200006000-00008. Prior, V., & Glaser, D. (2006). Understanding attachment and attachment disorders: Theory, evidence and practice. Philadelphia: Jessica Kingsley Publishers. Smyke, A., & Zeanah, C. H. (1999). Disturbances of attachment interview. New Orleans, LA: Tulane University School of Medicine, Department of Psychiatry.

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Tizard, B., Cooperman, O., Joseph, A., & Tizard, J. (1972). Environmental effects on language development: A study of young children in long-stay residential nurseries. Child Development, 43, 337–358. https://doi.org/ 10.2307/1127540. Zeanah, C. H., & Gleason, M. M. (2015). Annual research review: Attachment disorders in early childhood – Clinical presentation, causes, correlates, and treatment. Journal of Child Psychology and Psychiatry, 56, 207–222. https://doi.org/10.1111/jcpp.12347.

Attachment Injury Resolution Model in Emotionally Focused Therapy Lorrie Brubacher University of North Carolina, Greensboro, NC, USA

Synonyms EFT AIRM

Introduction Emotionally focused couple therapy (EFT) is an empirically validated therapy (Wiebe and Johnson 2016) for increasing relationship satisfaction and creating secure bonds in distressed couple relationships. As an attachment-based, systemic, humanistic-experiential therapy, it places emotion in the forefront as the target and agent of change, making it particularly relevant for repairing interpersonal injuries. Johnson et al. (2001) first presented the construct of “attachment injury” to describe a particular type of interpersonal injury and delineated a model for resolving such injuries. Johnson developed a model of forgiveness and resolution to address relationship traumas such as infidelity and other moments of betrayal or abandonment, defining an attachment injury (AI) as a specific relational incident where one partner violates the expectation that she/he will offer comfort and caring at a particular moment of urgent need. Attachment injuries emerge in therapy “in an alive and intensely emotional manner, much like a

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traumatic flashback, and overwhelm the injured partner” (Johnson et al. 2001, p. 145), redefining the safety and trustworthiness of the relationship and blocking relationship repair. From the moment of injury, the specific event continues to be the standard by which one partner measures the dependability of the offending partner (Zuccarini et al. 2013).

Prominent Associated Figures Susan Johnson

Theoretical Framework The theoretical framework of the EFT AIRM includes attachment theory as a theory of romantic love, the empirically validated EFT theory of change, the empirical study of hurt and social pain, and the reparative responses created through the AIRM. Romantic love as an attachment process. Attachment theory holds that the human need for affectional bonds extends throughout the life span. The attachment view of romantic love (see Attachment Theory, Johnson, this volume) – that partners develop emotional bonds of interdependence – is a core concept for understanding the power of a single event to rupture a relationship and redefine its security. According to attachment theory, events in which one partner responds or fails to respond in times of danger and extreme distress are found to influence the quality of an attachment relationship disproportionately (Simpson and Rholes 1994). It is not the content of the event but rather the lifeand-death sense of threat experienced during the event – in the absence of the other partner’s comforting response – that gives it the power to rupture an attachment bond. The EFT theory of change: Working with emotion to shape security. EFT consists of three stages (see Emotionally Focused Couple Therapy, Johnson & Wiebe, this volume). Stage 1 (Steps 1 to 4 of EFT) culminates in de-escalating the negative interaction cycle

between partners, and sets the stage for attachment injury resolution. The second stage of EFT is one of reprocessing underlying emotions to reshape the couple’s relationship. When there has been an attachment injury a couple will reach an impasse in therapy and because of the disproportionate impact of the injury, will be unable to move beyond de-escalation. The AIRM provides an empirically validated 8-step model to use in Stage 2 for resolving attachment injuries and rebuilding trust. In the third stage of EFT partners integrate and consolidate their newly shaped attachment bond. Stage 1 – de-escalation of the couple’s negative interaction pattern – precedes the Stage 2 AIRM forgiveness and resolution process. When the injured partner is the critical pursuer, the AIRM process is followed after withdrawer re-engagement. Without de-escalation and withdrawer re-engagement, the depth of this process could not be tolerated without triggering reactivity. Rationale for a model of forgiveness and resolution. The attachment meaning of an injurious event – that in a moment of urgent need one’s expected source of comfort is unavailable or unresponsive – shatters trust, making the relationship unsafe and catapulting it into ongoing distress. To rebuild trust in a relationship and resolve the injury, the hurt surrounding the injurious event needs to be explored and reprocessed. The AIRM is a blueprint for clinicians (Zuccarini et al. 2013) to do this. Hurt or social pain is distinguished from other emotions as a complex blend of sadness, anger, and fear of rejection or abandonment. It is conceptualized as an experience that devalues the relationship and the injured person (Vangelisti 2007). With the AIRM, partners can transform the hurtful impact of an AI. Injured partners are helped to experience the emotional depth of the hurt and to disclose it in an increasingly vulnerable manner, and offending partners are supported to respond with emotionally engaged empathy and remorse (Zuccarini et al. 2013). In this vulnerable reaching and responding process, the hurt is reprocessed, forgiveness occurs, and trust is restored.

Attachment Injury Resolution Model in Emotionally Focused Therapy

Populations in Focus The AIRM is relevant for couples in distressed relationships for whom the nature of their relationship is linked to one or more attachment injuries in which there was a pivotal injurious event that redefined the relationship and shattered trust.

Strategies and Techniques Used in Model Therapist interventions used in EFT include intrapsychic experiential interventions in combination with interpersonal systemic interventions. Exploring and deepening attachment related fears and needs and facilitating emotionally engaged disclosures and responses between partners are central to successful outcomes in EFT and particularly to the resolution of attachment injuries. Zuccarini et al. (2013) identified particular interventions associated with the resolution of attachment injuries to include empathic reflection and validation, evocative responding, reflecting and tracking process patterns and emotions, heightening softer primary emotions, and structuring enactments. The first four steps of the AIRM de-escalate the cycle related to the injury, preparing the terrain for more explicit processing of the emotional injury. AIRM Steps 5 and 6 are the core of the interpersonal forgiveness and resolution process, wherein new cycles of emotional engagement related to the injury are created. Finally, in AIRM Steps 7 and 8 the newly restored bond is consolidated. The case example below illustrates this process with an injured partner who was a withdrawer in the relationship.

Research About the Model Naaman et al. (2005) published the first report linking the hypothesized model to outcome. In a case study comparing one couple who successfully resolved their attachment injury with a couple who did not, they found that the resolver couple “went through the steps of the AIRM in the expected order. . . [whereas the nonresolved

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couple] deviated significantly from the expected sequence” (Greenman and Johnson 2013, p. 54). The resolver couple also showed “increasing depth of emotional experience in both partners and increasingly more affiliative responses to each other” (p. 54). The first outcome study (Makinen and Johnson 2006) validated the effectiveness of the model as a map for the forgiveness change process. It was conducted with 24 couples who experienced an attachment injury. Sixty-three percent resolved the injury, forgave the injuring partner, and reshaped the attachment bond. A 3-year followup study (Halchuk et al. 2010) showed that increase in relationship satisfaction and forgiveness in the resolver couples was maintained. In 2013, Zuccarini et al. examined the process of change following the steps outlined in the 2006 study. They delineated the specific therapist interventions and client processes that promoted successful attachment injury resolution and further validated the change process identified in the earlier studies.

Case Example of Resolving an Attachment Injury with the AIRM A 5-year-old incident emerges in Stage 2 with Dom and Sofia, illustrating that a seemingly small incident can have as devastating an impact and be as sharp an attachment threat as a recently discovered incident of infidelity. Dom and Sofia, a couple in their mid-forties, have two adolescent children. They entered therapy with a wellentrenched cycle of Sofia pursuing with escalating criticism and hostility and Dom “going cold” and disappearing into his work. Silence would hang heavy between them for days, until Sofia would explode, insisting they “talk about what’s happening.” Their talks – which eventually brought them closer for a while – were filled with accusations from Sofia and admissions and apologies from Dom for being such a “poor recreational partner” and for disappearing into work. Shortly thereafter the pattern would recur. After several months of therapy they successfully de-escalate their negative interactive pattern.

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Dom becomes increasingly engaged and able to share his fears of disappointing Sofia. In EFT Step 5, therapist Casey helps Dom to deepen and disclose his core fear of eventually losing her. Sofia is touched: “I had no idea you had any fears at all!” she says in amazement. “No idea you still want to be close to me!” (EFT Step 6). While Dom is emotionally engaged with his attachment fears and longings, Casey inquires what he needs from Sofia to remain open and engaged (inviting EFT Step 7, withdrawer re-engagement). An injurious memory from the past resurfaces and stops Dom in his tracks. His face goes blank, he drops his head and stares at his shoes. Haltingly he utters, “She wants a strong, active husband, not me. Ever since Disney – it’s been clear – I’m a bother to her.” Sofia is incredulous that he is talking about Disney, 5 years after their trip, and initially becomes defensive about revisiting the event. Casey recognizes the AIRM is needed to help the couple move forward. Using EFT interventions described above, Casey processes the injury and choreographs the forgiveness and resolution process. In AIRM Step 1 Dom repaints the scene of the injury. “We booked a family trip to Disney just before I was placed on a waiting list for a heart procedure and I said, ‘I guess we’ll have to put the trip on hold,’ and she just shrugged and said, ‘Well I’d better learn to do things without you!’ She was angry. She just pushed me away.” Casey validates Dom’s pain. Sofia interrupts (AIRM Step 2), “How could I have done it differently? The pressure was on me! Our kids and nephews were counting on us. And now it’s all about how much I hurt you?” Casey supports Sofia in her defensive reactions, validating that she cannot hear Dom’s pain at feeling rejected – only his anger at her for going to Disney without him. Dom experiences and discloses his core pain of feeling rejected by Sofia (AIRM Step 3). “I just keep going back to the moment you brushed me away. You literally pushed me away, like you didn’t need me in this family anymore and you went off without me!” Sofia begins to grasp the significance of the event (AIRM Step 4). She begins to understand that what

felt like blame and guilt levied at her for going to Disney was Dom’s painful sense that she was rejecting him. When Casey inquires how Sofia could brush Dom off like she did, she tearfully discloses, “You were in a precarious medical condition and I had no idea you’d understand all the obligations tugging at me. I couldn’t burden you with this. I just froze – terrified you might die – and carried on as though I’d already lost you.” After hearing Sofia’s description of how this happened, Dom (AIRM Step 5) deepens his emotional expressions and tells a clear, coherent statement of the painful impact of the event. Sofia listens wide-eyed – never having seen Dom so vulnerable and open. Tears brimming in his eyes, Dom discloses, “I needed you that day and I felt in one moment when you brushed past me that I became useless and insignificant to you. I wouldn’t have tried to stop you from going on the trip – but you didn’t even seem to like me anymore or want me in your life!” Sofia rolls her chair in close to Dom with both hands on his knees, tears streaming down her face (AIRM Step 6), clearly moved by his pain. Her face mirrors his anguish as she says, “I had no idea – five years ago! My heart aches to see how my brushing you off that day hurt you so much!” She feels how important she is to him, and expresses deep remorse and regret for turning away from him in that moment. “I totally need you in my life. I want you to know how much I need you and like you. I am so sorry!” Dom could now receive her empathy and remorse (AIRM Step 7). With Casey’s prompting he asks to have his needs, sparked by this attachment injury, met. “I worry that there are so many ways I’m not quite the partner you want – and now with all my medical concerns I need to know you still want me – to be a full partner in this relationship. That you still need me – as I am.” Sofia replies (AIRM Step 8): “I want you to feel safe and loved – to know I need and want you! You are everything to me! I want you to feel completely safe with me. I want to care for you every way I can!” Casey validates how Dom and Sofia are beginning to create a new attachment bond, redefining their relationship as one of safety and shared support.

Attachment Theory

This AIRM was Dom’s withdrawer re-engagement change event. Following this change event, Casey processes Sofia’s blamer softening where Sofia is helped to reach from a vulnerable position of attachment fears to ask Dom for what she needs to be soothed and comforted, thereby reshaping secure connection between partners. Finally, Stage 3 of EFT marks the integration of the new positive interactive cycle across pragmatic concerns and the consolidation of the new relationship bond.

Conclusion The attachment injury resolution model (AIRM) operationalizes forgiveness and resolution as an interpersonal process, wherein the depth of emotional experiencing and affiliative, vulnerable disclosures and emotionally engaged responses are reparative. The AIRM moves partners beyond forgiveness into rebuilding trust and intimacy.

Cross-References ▶ Attachment Theory ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Clarifying the Negative Cycle in Emotionally Focused Therapy ▶ Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Emotionally Focused Couple Therapy and Physical Health in Couples and Families ▶ Emotionally Focused Couple Therapy and Trauma ▶ Emotionally Focused Family Therapy ▶ Hold Me Tight Enrichment Program ▶ Hold Me Tight/Let Me Go Enrichment Program for Families and Teens ▶ Johnson, Susan ▶ Training Emotionally Focused Couples Therapists

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References Greenman, P. S., & Johnson, S. M. (2013). Process research on emotionally focused therapy (EFT) for couples: Linking theory to practice. Family Process, 52, 46–61. https://doi.org/10.1111/famp.12015 Halchuk, R. E., Makinen, J. A., & Johnson, S. M. (2010). Resolving attachment injuries in couples using emotionally focused therapy: A three-year follow-up. Journal of Couple & Relationship Therapy: Innovations in Clinical and Educational Interventions, 9, 31–47. Johnson, S. M., Makinen, J. A., & Millikin, J. W. (2001). Attachment injuries in couple relationships: A new perspective in impasses in couples therapy. Journal of Marital and Family Therapy, 27, 145–155. Makinen, J. A., & Johnson, S. (2006). Resolving attachment injuries in couples using emotionally focused therapy: Steps toward forgiveness and reconciliation. Journal of Consulting and Clinical Psychology, 74, 1055–1064. Naaman, S., Pappas, J. D., Makinen, J. A., Zuccarini, D., & Johnson, S. (2005). Treating attachment injured couples with emotionally focused therapy: A case study. Psychiatry: Interpersonal and Biological Processes, 68, 55–77. Simpson, J., & Rholes, W. (1994). Stress and secure base relationships in adulthood. In K. Bartholomew & D. Perlman (Eds.), Attachment processes in adulthood (pp. 181–204). London: Jessica Kingsley. Vangelisti, A. (2007). Communicating hurt. In B. H. Spitzberg & W. R. Cupach (Eds.), The dark side of interpersonal communication (2nd ed., pp. 121–142). Mahwah: Lawrence Erlbaum. Wiebe, S. A., & Johnson, S. M. (2016). A review of the research in emotionally focused therapy for couples. Family Process, 55, 390–407. https://doi.org/10.1111/ famp.12229 Zuccarini, D., Johnson, S. M., Dalgleish, T. L., & Makinen, J. A. (2013). Forgiveness and reconciliation in emotionally focused therapy for couples: The client change process and therapist interventions. Journal of Marital and Family Therapy, 39(2), 148–162.

Attachment Theory Sue M. Johnson The International Centre for Excellence in Emotionally Focused Therapy, The University of Ottawa, Ottawa, ON, Canada

Name of Theory Attachment Theory.

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Introduction In the last several decades, attachment theory has provided couple and family therapists and researchers with a map for understanding love and bonding in couple and family relationships. The science of attachment has grown tremendously and now has a large base of research support from the fields of social psychology, development, and neuroscience.

Prominent Figures British psychiatrist John Bowlby (1907–1990) outlined the basic theory of attachment: a developmental understanding of personality with a focus on emotion regulation in his trilogy on Attachment and Loss (1969–1982). Mary Ainsworth helped Bowlby create the Strange Situation research paradigm where a mother leaves a baby alone with a stranger for a few minutes and the babies’ responses are coded on reunion. This allowed the normative and individual differences principles of attachment to be outlined. Since the late 1980s, adult attachment has been outlined by North American researchers such as Mary Main, Phil Shaver, and Mario Mikulincer.

Description John Bowlby was arguably the first family therapist, writing his book Forty-Four Juvenile Thieves in 1944. He crafted the main principles of attachment theory after studying the effects of World War II on orphans and widows, rebelling against the analytic teachings of his time: Bowlby believed his own observations that it was emotional experiences in real relationships – rather than intrapsychic fantasies and conflicts – that shape how we deal with emotions, create our models of self and other, and habitually engage with loved ones. He laid out the theory in his trilogy on attachment and loss (Bowlby 1969, 1973, 1982).

Attachment Theory

Attachment theory has seven basic principles that are now supported by hundreds of studies on child–parent and adult–partner bonding. This theory has already revolutionized understanding of the task of parenting and the emotional needs of children and is now being applied to the field of adult romantic bonds. The first central tenet of attachment theory is that seeking and maintaining contact with significant others is an innate and primary motivating force in human beings at all phases of the lifespan. Dependency is an innate part of being human, not a sign of enmeshed relationships, immaturity, or of lack of differentiation from others. Rejection and emotional isolation are inherently traumatizing and coded as danger cues by a nervous system wired for close connection with trusted others. New research in neuroscience suggests that this connection is the baseline condition for coping and survival assumed by our mammalian brain; human beings are indeed bonding animals (Coan 2016). Attachment research began with infants and mothers but adult bonding research has now grown to more than 500 studies (Mikulincer and Shaver 2007). In adults, the sense of connection with loved ones can be maintained more readily on the cognitive, representational level. For example, one might hear a partner’s reassuring voice in one’s head before going into a challenging interview, but contact is still a primary need. This need appears to be universal across cultures, although it may be expressed somewhat differently in different contexts. The bonds of love are viewed here as an ancient wired-in survival code designed to keep those we depend on close to us, especially at times of vulnerability or perceived danger and to provide a felt sense of expansive safety where we can grow and thrive. The second principle is that a felt sense of secure connection offers a safe haven where one can find comfort and reassurance with trusted others. This sense of safety and support allows humans to find and maintain a sense of emotional balance in the face of challenges and uncertainties. This inner sense of security arises from repeated interactions with key loved ones who respond when called. Houston’s research on predictors of success in newlyweds finds that

Attachment Theory

emotional responsiveness is indeed the best predictor of future relationship satisfaction (Houston et al. 2001). The third principle – based on observations that children who can turn to and take in comfort from their mothers are much more likely later in life to move away, take risks, and explore their universe – is that secure connection with others offers us a secure base from which to take on the world. Constructive dependency makes people stronger. Feeney (2007) found that young career women who could turn to and confide in their partners took more risks, felt more confident, and reached their career goals faster. The evidence that a combination of a safe haven and a secure base fosters resilience in the face of threat and challenge is considerable (summarized in Mikulincer and Shaver 2007). This perspective suggests that members grow and differentiate with each other rather than from each other. A felt sense of secure connection is seen as the best route to confident autonomy – a state that is often a key goal in family therapy, especially with adolescents. The secure base provided by a loving attachment figure encourages a cognitive openness to new information and promotes the confidence necessary to risk, learn, and continually update models of self and others, so that adjustment to new contexts is facilitated. It also strengthens the ability to stand back and reflect on oneself, including one’s behavior and mental states (Fonagy et al. 2016). The fourth principle of attachment defines the core variables that define a secure or less secure bond and therefore the quality of couple and family relationships. It is worth noting that this principle privileges emotion and recognizes that emotional communication – the music of the dance between intimates – organizes key relationship defining interactions. Bowlby always stressed the importance of emotion and that turning to others is the foundational way in which we regulate our own emotions, especially fear. Attachment research suggests that the core question in bonding relationships is, “Are you there for me when I need you”? This question really contains three elements: emotional Accessibility (A), Responsiveness (R), and Engagement (E). This

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finding is invaluable for intervention in that it tells the therapist what has to happen to create significant change in family relationships; emotional disconnection has to be contained and emotional presence in the form described above enhanced to shape more secure supportive bonding interactions. The attachment perspective focuses therapy on issues of connection and disconnection and allows for the active validation of needs and fears concerning attachment. It offers the therapist a language for the emotional starvation that characterizes an insecure relationship. It also helps therapists understand how insecure attachment is such a risk factor for problems such as depression and anxiety (Mikulincer and Shaver 2007). The fifth principle is that a close relationship is a powerful circular feedback loop in the sense outlined in systems theory (Johnson and Best 2003) where patterns of interaction shape the creation of internal working models, sets of if-thisthen-that expectations. These models then set up or maintain patterns of interaction. Such models of self and other may be out of awareness and mostly define the self as lovable or unworthy and others as trustworthy and reliable or not. These are called “working models” in that they can be revised in new relationships by new corrective emotional experiences of secure connection. Self and relational systems are intertwined in these working models. An attachment-oriented clinician would see emotional isolation and loss entwined with a model of self as failing and unlovable as a constant trigger for depression. The sixth principle of attachment is that when we cannot find emotional connection with an attachment figure, a process of separation distress occurs. The person moves into protest at disconnection. This often looks like anger, especially in adult couples, but is triggered by a sense of abandonment or rejection. If this does not elicit responsiveness, a stage of clinging and disorganized pleading and clinging begins. If this does not result in repair and reconnection then despair follows. This process eventually leads to a general sense of grieving and detachment. From an attachment perspective, much acting out in families or angry escalation in adult couples is best seen in

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terms of separation distress rather than simply in terms of disagreement or conflict. Conflict may be seen as inflammation, while emotional disconnection coded as danger is the virus. All of the above are normative principles. The last principle addresses individual differences – what are commonly called attachment styles. Research finds three basic patterns in ways of engaging with others and regulating emotions: secure, anxious or preoccupied, and dismissing or avoidant patterns. For a video illustration of these patterns in infants and in adult partners, see http://www.drsuejohnson.com/videos/. Secure children and adults can generally listen to their emotions, make sense of them, and, when lonely or uncertain, reach for those they are bonded to. When this person responds, they can take in comfort and find emotional balance. They can also tolerate less than optimal responses at any one time because of their basic trust in others responsiveness. Anxiously attached individuals are very sensitive to rejection or abandonment and hyperactivate their emotions and emotional signals to others, often becoming controlling, critical, or demanding, to the point of driving others away. They also have trouble really taking in comfort and tend to stay vigilant rather than find a way to emotional equilibrium. As adults, these partners often end up blaming and demanding, triggering withdrawal in others which then maintains their alarm and insecurity. Avoidant partners have experienced calling to others as futile and see closeness as risky at best. They shut down their own attachment emotions and needs and withdraw at any sign of vulnerability in themselves or others. They offer stonewalling responses to others and do not grasp the impact of their lack of response. Some individuals who have been seriously hurt or abused by those they love – who have experienced violations of human connection – are overwhelmed and cannot organize themselves into anxious or avoidant stances so they flip between the two and this is usually termed disorganized in children and fearfulavoidant in adults. Others are, at one and the same time, a desperately needed form of comfort and a feared source of pain. Attachment science offers a map to the structure of individual’s inner

Attachment Theory

emotional worlds, helping therapists tune into that world and make sense of their client’s realities and interactions. More generally, attachment in adolescents implies that they need – not to separate per se from their parents – but to move into a more reciprocal connection where they can be autonomous and yet securely attached. In adult relationships, attachment is seen as shaping other aspects of the relationship, in particular caregiving (secure connection fosters empathy for others and more attuned responsive caregiving) and sexuality. Securely attached partners can take risks and play in erotic contexts and in general have higher sexual satisfaction.

Relevance to Couple and Family Therapy Attachment theory provides the rich, deep, empirically validated theory of close relationships that has been missing from couple and family therapy. This allows therapists to go to the heart of the matter and target the key variables that define relationship quality rather than being caught in addressing more tangential symptoms or intervening in general ways that have been found not to impact close relationship repair or satisfaction, such as teaching communication skills (Rogge et al. 2013). This theory also allows therapists to address aspects such as nurturance and love itself that have been generally missing in this field. It offers the therapist a guide to the emotional fears and unmet needs of partners that trigger anger and withdrawal in couple relationships, and a map to the creation of powerful new corrective emotional experiences of bonding that have been shown in research (Greenman and Johnson 2013) to significantly transform a relationship. As already outlined in the literature, attachment theory and science now forms the basis for several cutting-edge couple and family interventions including two that have extensive empirical validation, emotionally focused couple and family therapy, or EFT and EFFT (Johnson 2004) and attachment-based family therapy, or ABFT (Diamond 2005). Another approach, less validated but increasingly popular, is dyadic

Attachment Theory

developmental psychotherapy or DDP (Dan Hughes 2004). There are some differences in how these models use the attachment frame. For example, the family interventions offered in ABFT are generally more cognitive and less emotionally focused than in the other two, and family DDP is generally used with young children who have been in foster care, while ABFT and EFFT are used with adolescents and parents or, in the case of EFT, with adult partners. The general implications for the repair of bonded relationships and associated problems can be outlined as: First, the therapy session has to be a safe haven and a secure base for partners and family members, even when they present as living in opposing universes. Therapy tends to be collaborative and egalitarian but parents are, naturally, given more responsibility for redefining a troubled relationship as a more secure bond than are children or adolescents. Bowlby noted that, if attachment is understood, all responses – even those that are apparently very dysfunctional – are in fact “perfectly reasonable.” Like Carl Rogers, Bowlby advocated meeting the client in acceptance and compassion rather than beginning from a pathologizing stance. An attachment-oriented therapist acts as a surrogate attachment figure by actively helping clients regulate emotion, particularly the attachment-related anxiety or panic (Panksepp 1998) that triggers negative emotional flooding or requires avoidant emotional suppression and withdrawal in insecure relationships. The attachment-oriented therapist, especially in EFT, EFFT, and DDP, is emotionally present and engaged and deliberately regulates the emotions of clients with their pacing, voice, repetition, and reflection of emotions. The therapist creates safe emotional engagement with clients and models responsivity which then expands the client’s window of tolerance and encourages exploration. The therapist orders a client’s experience the way a good parent reflects and orders the emotional experience of a child in challenging situations. Second, the goal of therapy is to reduce emotional escalation and interactions that maintain distance and disconnection and create

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in-session moments of increased mutual accessibility, responsiveness, and engagement; that is, corrective bonding moments when attachment fears and needs can be acknowledged and responded to, and new ways of regulating emotions and making connection shaped. These moments then access working models of self and other so they can be revised. This contrasts to the communication skill building, insight provision, cognitive reframing, or role reversals to unbalance negative homeostasis that are typically found in the field of couple and family therapy. At the end of therapy, for example, a 13-year-old boy might be able to say to his stepfather, When I was little, with my first dad, I decided I was a bad kid. That was why he was so mad at me. Now I assume you think I’m bad, and when you get upset with me, I just tell you I don’t care. I’ll never please you anyway. I just give up. Get depressed. Shut you out. But it hurts cause then I don’t have a Dad. His stepfather can now lean close and tell him, “I don’t want you to feel like you’re a bad kid. You are my kid now – my special son. I don’t want you to give up with me. I want us to be close. And I want to learn to be a kinder dad.”

Third, emotional regulation and habitual ways of expressing emotion are viewed as structuring interactions and so being at the heart of the presenting problem, but emotion is also an ally in creating change rather than a problem to be coped with or bypassed. Newly accessed and distilled emotional responses translate into new responses to loved ones and new interactional cycles. Attachment theory provides a guide for understanding and normalizing many of the extreme emotions that accompany distressed relationships. The longing for connection is also a powerful motivator in therapy and facilitates new levels of engagement in the therapy process. Separation distress, indicated by powerful emotions of anger, panic, and hurt; abandonment; and sadness results from the perception that an attachment figure is inaccessible or does not care. Attachment relationships are where our strongest emotions arise. A positive sense of connection with a loved one is a primary emotion-regulation device and family members are “hidden regulators” of each other’s physiological and emotional realities

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(Johnson et al. 2013). The exploration and reprocessing of key emotions and how they are expressed, and a focus on barriers to constructive emotional connection, such as vague or confusing bids for responsiveness, are part of any attachment oriented intervention. Therapists who understand the process of separation distress can look beyond disruptive responses such as hostility or stonewalling and place them in the context of legitimate attachment needs and fears, translating what might appear to be characterological deficits or lack of social skills into context-specific responses to loss of connection – responses that can be restructured. Fourth, the attachment-oriented therapist deliberately choreographs and shapes particular kinds of new interactions in a therapy session that transform distance and disconnection into a dance where vulnerabilities and needs can be shared and heard. The therapist will both offer a meta-perspective on the cycles of disconnection in a relationship, so that partners or family members can see this dance and its emotional consequences, and also, later in therapy, deepen emotions to help clients access and share their triggers, sensitivities, and needs in a way that fosters an empathic response and secure bonding. The relevance of attachment science for this field cannot be exaggerated in that it offers a secure base of empirically supported, developmental relational theory from which to shape on-target intervention in therapy and in relationship educational programs. It is clear that the habitual forms of engagement with one’s own emotions and with key others, as well as mental models of self, can be modified by new or changed relationships (Simpson et al. 2007). The latest outcome study on EFT found that this intervention significantly impacted both anxious and avoidant attachment, moving partners into more secure attachment and this result was stable at 2-year follow-up (Burgess-Moser et al. 2015). Thus, this science not only offers a way to heal relationships but to shape relationships that heal and grow the sense of self in partners and families. Attachment security is associated with greater self-efficacy and a more coherent, articulated, and positive view of self (Mikulincer and Shaver

Attachment Theory

2007). This also offers the promise of relational therapies to effectively address symptoms in individuals such as depression, anxiety, PTSD, and coping with physical illness such as heart attacks, as attachment oriented therapies such as EFT have done.

Clinical Example of Application of Attachment Theory in Couples and Families Laura and Mick come to couples therapy to deal with the escalating fights and days of distance that have taken over their relationship since Mick’s serious heart attack. Laura has been diagnosed with clinical depression and Mick is not complying with his cardiac program, missing appointments and not taking his meds. The pattern of Laura pursuing for closeness and then becoming angry at Mick’s lack of response has always been part of their 35-year relationship but has now completely erased any positive interactions. Laura is enraged and critical and Mick is zoned out and withdrawn. In session three, the therapist draws out the steps in their dance of disconnection and paints this dance as the enemy (rather than one of the partners), linking in the attachment consequences. Laura – I told him – “Why are you drinking that big glass of wine. You know you are not supposed to.” He ignored me of course. (To Mick) You don’t care about how much I worry. You just act like you don’t have any health problems at all. As always – if there is a problem you just put your head in the sand.” Mick – All you do is keep telling me how sick I am. Years ago it was how I was too silent, or worked too much. Maybe I just don’t want to hear it. You are always telling me there is something wrong with me. Shooting me down. Laura – You just don’t want to hear me is all. You never listen. I don’t know why I bother. (Mike looks out the window with a flat face and set mouth) Therapist – Can I stop you for a minute. This is what happens much of the time isn’t it – this dance you are doing now (they nod). And it just keeps going – almost runs by itself and pulls you both along with it. Laura, you are speaking very angrily but I see the teariness in your eyes and maybe this is about the “struggle” you spoke of when you see Mick doing

Attachment Theory something that you see as dangerous – that might have you even lose him to another heart attack (she agrees). So you try to reach him – warn him – poke him to get his attention. But Mick you just hear her criticizing – trying to bring you down (he nods). You poke and tell him to be different and you hear her trying to hurt you – telling you there is something wrong with you, so you shut down. Mick – I leave is what I do – get away from her and then we don’t talk for days. Therapist – That must be pretty hard. To hold up that wall for days (Mick grimaces and agrees). And the more you prod and warn him Laura, the more you see her as putting you down and the more you shut down. The more you withdraw, the more frustrated you get Laura and the more you poke. Poke, then shut down and shut her out, so then she slams you to get a response. That is hard and seems like it leaves you both alone and both upset – and then Mike you forget to take your meds and Laura you give up and get depressed cause you are all alone. Am I getting it? The dance leaves you both lonely. It would be good if you could help each other step out of it so that you could help her with her depression Mike, she could help you stay on you regime – and you guys could be close again.

The therapists tracks and distills the cycle of emotional disconnection in a safe way and invites them to stand together and look at their pattern. They decide to call it the Bang-Slam. She bangs on the door – he sees it as an attack and slams it shut again. The therapist also helps them touch and find words for and share the more vulnerable feelings that trigger these reactive responses and push the other away. Laura is able to say – “I get scared when you do risky stuff like drink a lot and that fear is familiar. I never know if I can reach you, say “Mick, where are you – are you with me” and have you respond. So I ramp up the message. I am all by myself here with the fear of losing you.” Mick is able to find his feelings of loss around his heart attack and his fear that his wife sees him as a failure and a “sicky” who she doesn’t value. He hears her saying he is a “screw up” and that triggers his “hurt’ so he just tries to “get away”. The therapist validates, distills and helps the couple share these emotions, putting the music into the dance of disconnection. In session 11, after this couple have reported that they can stop this dance at home (Mick says – “Heh we are caught in the Bang-Slam again. It’s a

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lonely place. Let’s slow down – scaring each other we are. Want a coffee?”), the therapist moves into shaping positive cycles of connection. Here this couple can share vulnerabilities and ask for comfort and support – that is they can move into safe accessibility, responsiveness, and engagement. The therapist stays with Mike and helps him move into his emotions and needs. Therapist – So Mike, when Laura gets mad, you act like you don’t care, but in fact this is very hard on you. Mike – Well yes, especially since the heart attack. That was a lesson in fragility that was. I do turn away but I get now that she feels like I am gone – like she doesn’t matter. But it’s just too hard to stay there. I run (He waves his hand in the air like he is trying to get away from something). Therapist – And she sees “indifference,” like “Mike is a rock,” but you have to get away – there is something here that is difficult – almost a threat? Mike – Yes. I look calm but inside I am coming apart. I hear that I have failed again and she is mad at me – sees me as a screw up. Therapist – And that hurts Mike – Yes (he tears). I get so stirred up inside – I get so – well – shaky. I just never get it right with her – and now I am less of a man ‘cause I had a heart attack – so – Therapist – Right – I hear that. You look stoic and unaffected but you are “coming apart” – feeling like Laura is disappointed in you and you are failing. Helpless and hopeless and less of a man – that is a very dark, lonely place. Kind of overwhelming – so you try to shut down and shut it all out. You can’t just turn to her for comfort, reassurance that you are still her man. Mike – (Very soft) That would be nice. Comfort. I know my heart attack scared her. It scared me too. Why would she want a sick guy who doesn’t even know how to tell her. . .. . .. . .. . .. . .. . .. . .. Therapist- That is the fear Mike – you won’t meet her standards now – so she will not want you – be there for you? Mike – Well I am fine. I can manage alone (He looks at the therapist’s face). You don’t buy that do you? Right. Neither do I. In the hospital I really knew how much I needed her. THAT is scary! Therapist – She is your life line (Mike nods) and its scary when she gets mad or frustrated with you. But shutting down just leaves you alone (Mike nods again) and none of us can handle that. Can you tell her Mike – I do shut down and shut you out ‘cause

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176 I am so afraid to hear that you might not think I am good enough – strong enough – loving enough. I get shaky and overwhelmed – just because I need you so much. Mike – Yes – all of that (He laughs)

He then turns and tells her his version of this and with the therapists help he shares how intimidated he is about talking about emotions, how ashamed he is of his vulnerability, and how scared he gets when he fear he might be rejected. The therapist helps him say this in a way that evokes tenderness in Laura and she softly reassures him. In fact is amazed to see her husband in a new light and to feel so connected to him after 35 years of conflict. This is a withdrawer re-engagement event in EFT and the therapist will then go on to shape moments where Laura is able to talk about her “panic” around losing Mike, and her fear that he does not need her or need her closeness. She is then able to ask directly and clearly for connection in a way that Mike can hear and respond to. The bonding moments that then occur provide a safe haven bond where this couple can help each other with their fears and form a more satisfying connection. They also craft a secure base where Mike can comfort Laura, countering her depressive fears and thoughts, so her depression remits, and she can help him stay on track with his health regime in a way that builds him up rather than puts him down. A secure bond is the most potent source of resilience, happiness, and health.

Cross-References ▶ Adult Attachment Interview ▶ Ainsworth, Mary ▶ Attachment Disorders in Couple and Family Therapy ▶ Attachment-Based Family Therapy ▶ Bowlby, John ▶ Circle of Security ▶ Circle of Security Parenting Enrichment Program ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Emotionally Focused Couple Therapy

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▶ Emotionally Focused Family Therapy ▶ Hold Me Tight Enrichment Program ▶ Hold Me Tight/Let Me Go Enrichment Program for Families and Teens

References Bowlby, J. (1969). Attachment and loss (Vol. I). New York: Basic Books. Bowlby, J. (1973). Attachment and loss (Vol. 2). New York: Basic Books. Bowlby, J. (1982). Attachment and loss (Vol. 3). New York: Basic Books. Burgess-Moser, M., Johnson, S. M., Dalgleish, T., Lafontaine, M., Wiebe, S., & Tasca, G. (2015). Changes in relationship specific romantic attachment in emotionally focused couple therapy. Journal of Marital and Family Therapy, 42, 231–245. Coan, J. (2016). Towards a neuroscience of attachment. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (3rd ed., pp. 242–272). New York: Guilford. Diamond, G. (2005). Attachment based family therapy for depressed and anxious adolescents. In J. Lebow (Ed.), Handbook of clinical family therapy (pp. 17–41). New York: Wiley. Feeney, B. C. (2007). The dependency paradox in close relationships: Accepting dependence promotes independence. Journal of Personality and Social Psychology, 92, 268–285. Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2016). Reconciling psychoanalytic ideas with attachment theory. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (pp. 805–826). New York: Guilford. Greenman, P., & Johnson, S. M. (2013). Process research on EFT for couples: Linking theory to practice. Family Process, Special Issue: Couple Therapy, 52, 46–61. Houston, T., Caughlin, J., Houts, R., Smith, S., & George, L. (2001). The connubial crucible: Newlywed years as predictors of marital delight, distress and divorce. Journal of Personality and Social Psychology, 80, 237–252. Hughes, D. (2004). An attachment based treatment of maltreated children and young people. Attachment and Human Development, 6, 263–278. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection. New York: Routledge. Johnson, S. M., & Best, M. (2003). A systemic approach to restructuring adult attachment: The EFT model of couples therapy. In P. Erdman & T. Caffery (Eds.), Attachment and family systems (pp. 165–192). New York: Routledge. Johnson, S. M., et al. (2013). Soothing the threatened brain. Leveraging contact comfort with emotionally focused therapy. PLoS One, 8, e79314.

Attachment-Based Family Therapy Mikulincer, M., & Shaver, P. (2007). Attachment in adulthood: Structure, dynamics and change. New York: Guilford. Panksepp, J. (1998). Affective neuroscience: The foundations of animal and human emotions. New York: Oxford University Press. Rogge, R. D., Cobb, R. J., Lawrence, E., Johnson, M. D., & Bradbury, T. N. (2013). Is skills training necessary for the primary prevention of marital distress and dissolution? A three year experimental study of three interventions. Journal of Consulting and Clinical Psychology, 81, 949–961. Simpson, J., Collins, A., Tran, S., & Haydon, K. (2007). Attachment and the experience and expression of emotions in romantic relationships: A developmental perspective. Journal of Personality and Social Psychology, 92, 355–367.

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multidimensional family therapy, emotionally focused therapy, and contextual family therapy. The ABFT manual is interpersonal and processfocused, but offers a structure and roadmap for how to facilitate depth-oriented therapy in a 12 to 16 week period. The model unfolds in five distinct, but interrelated, treatment tasks that focus on critical treatment processes. These tasks serve as a guide for helping the family to repair attachment ruptures and work toward increasing trust and security.

Prominent Associated Figures

Attachment-Based Family Therapy Guy S. Diamond1, Jody Russon2 and Suzanne Levy2 1 Center for Family Intervention, Drexel University, Philadelphia, PA, USA 2 Center for Family Intervention Science, Drexel University, Philadelphia, PA, USA

Name of Model Attachment-Based Family Therapy

Introduction Attachment-based family therapy (ABFT; Diamond et al. 2014) is a trust-based, emotionfocused, empirically supported treatment that aims to repair interpersonal ruptures and rebuild secure, protective caregiver-child relationships. ABFT is designed to improve the family’s capacity for affect regulation, relational organization, and problem solving. This strengthens family cohesion, which can buffer against depression, suicidal thinking, and risk behaviors (Restifo and Bogels 2009). This framework is particularly relevant to adolescents for whom the family context is inescapable (Maccoby and Martin 1983). ABFT is rooted in structural family therapy,

Guy Diamond, Ph.D. Gary Diamond, Ph.D. Suzanne Levy, Ph.D.

Theory ABFT is a brief family-based therapy with a solid grounding in attachment theory (Bowlby 1969). This theory proposes that when children are distressed, they are “hard-wired” to seek support and comfort from their parents. When children experience their parents as responsive and available in the face of distress, they begin to feel that (a) the world is a safe place and (b) they are worthy of being loved protected. Over time, these experiences of protection become internalized as working models (or expectations) of relationships. If a child is treated well, then they seek out similar relationships. When a child is treated poorly, they internalize expectations that their relationships will be unresponsive, if not hurtful. In the face of these untrustworthy relationships, children develop attachment (interpersonal) strategies that will protect them from more harm: dismissive, preoccupied, or disorganized. If internal working models are shaped by real relationships, then these real relationships can revise internal working models and other behavioral changes. ABFT aims to revive the adolescent’s hope for attachment security and promote responsive parenting. Improving the family’s communication, problem-solving, and emotional

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regulation can create the corrective attachment experiences that help adolescents work through past traumas and relational ruptures. This establishes the groundwork for rebuilding secure relationships with parents.

Strategies and Techniques Used in ABFT In ABFT, the “corrective attachment experience,” and subsequent autonomy building, is engineered using five distinct treatment tasks. Tasks are not equated with sessions. Instead, a task is a set of procedures, processes, and goals related to resolving or accomplishing specific aims in therapy (e.g., building alliance). Task I offers a roadmap for establishing an essential and common process inherent to many family therapy models: getting the family members to agree to work on relationship building rather than behavioral management. To achieve this, the therapist focuses on resuscitating the adolescent’s desire for protection and support as well as the caregivers’ longing for love and connection with their child. The therapist promotes the caregivers as “the medicine” to help the adolescent cope with, and recover from, depression and suicidal ideation. Task II consists of individual sessions with the adolescent. The therapist aims to help adolescents identify and articulate their perceived experiences of caregivers’ attachment failures and prepare them to discuss these felt injustices in Task IV. Task III consists of individual sessions with the caregivers. The therapist aims to help each caregiver consider how their own life stressors and intergenerational legacies of attachment ruptures affect their parenting style. This insight helps caregivers develop greater empathy for their adolescent’s experiences. With this insight, caregivers become more motivated to learn new emotion coaching and parenting skills. Next, in Task IV, the therapist brings the adolescent and caregivers back together to discuss and understand how these relational disappointments have damaged trust in the relationship. As adolescents share these thoughts, feelings, and memories and receive acknowledgment and

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empathy from their caregivers, they become more willing to consider their own contributions to family conflicts. As caregivers acknowledge adolescents’ experiences, adolescents become more emotionally regulated and cooperative. Although these conversations may not address or resolve all relational problems, this mutually respectful, and often emotionally profound, dialogue serves as a “corrective attachment experience,” thus revising the adolescent’s internal working model of self and other. In this new emotional climate, caregivers become a resource and secure base for their adolescent. Task V then focuses on using the caregiver to support the adolescent’s exploration of competency and autonomy. Adolescents begin to seek comfort, advice, support, and encouragement from their caregivers while exploring new opportunities and managing life stressors. Table 1 summarizes the treatment targets and expected outcomes for each of these five treatment tasks.

Populations in Focus ABFT is a therapy for adolescent depression and suicide; however, youth with other presenting problems can benefit from the clinical model. ABFT has been useful for clients with histories of trauma, eating disorders, substance use, or victimization due to their sexual identity (see full review in Diamond et al. 2016a). ABFT is flexible enough to incorporate comorbid conditions and has gained empirical support for young adults with unresolved anger toward a caregiver (Diamond et al. 2016b). Low income, minority families have been absent from many of the clinical trials testing psychotherapies for youth depression and suicide (Bernal et al. 2009). ABFT, however, has had a history of success working with diverse families. In general, ABFT is recommended for clients 12 years of age and older and is not limited by treatment context. The model has been used in outpatient, inpatient, home-based, hospital settings, and residential care. ABFT is not recommended as a treatment approach for clients with active psychosis, low-functioning

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Attachment-Based Family Therapy, Table 1 Targeted risk factors, relevant treatment task, and expected outcomes. Adapted from Diamond et al. (2003) Treatment targets Caregiver criticism and blame

Interventions Relational reframe

Adolescent hopelessness about, and disengagement from, caregiver

Alliance building with adolescent

Caregiver stress and abdication

Alliance building with caregivers

Adolescent-caregiver disengagement and conflict

Repairing attachment

Poor adolescent functioning in extra-familial contexts

Promote caregiver support for adolescent competency and autonomy

autism spectrum disorders, borderline intellectual functioning, or severe externalizing behaviors. However, the guiding principles and tasks of ABFT can be applied when working with any family.

Empirical Support ABFT research is conducted at the Center for Family Intervention Science (CFIS) at Drexel University and at partnering sites throughout the world (Diamond et al. 2016a). ABFT research has focused primarily on reducing depression and suicide in adolescents, ages 12 to 18. To date, several studies have been conducted demonstrating the efficacy of ABFT. These studies have shown that ABFT is more effective than waitlist control groups or treatment as usual in reducing depression and suicidal ideation. ABFT has also been adapted for use with suicidal LGB adolescents (Diamond et al. 2012). Secondary data analysis indicates that ABFT is effective for severely depressed adolescents and those with a history of sexual abuse, both

Expected outcomes Caregivers and adolescent become more willing to focus on relationship building instead of behavior management Build treatment bond with adolescent, help them understand their attachment rupture narrative, and prepare them to discuss these stories with their caregivers in task IV Build treatment bonds with caregivers, increase caregiver awareness of adolescent’s attachment needs, and teach parenting skills that will promote attachment-repairing conversations in task IV Increase adolescent’s perceptions of caregivers’ availability and protection, increase adolescent’s confidence in communicating his or her needs, build caregivers’ view of their adolescent as having legitimate concerns (who can express themselves in a direct and emotionally regulated manner), work through memories of loss and abuse, and improve interpersonal and conflict resolution skills Increase adolescent’s use of the caregivers as a secure base for problem solving and identity development

predictors of poor response in treatment with combined medication and cognitive behavioral therapy (Asarnow et al. 2009; Barbe et al. 2004). Also several process studies have explored the proposed mechanisms of change (see Diamond et al. 2016a for a review). A new study comparing ABFT to FamilyEnhanced Non-Directive Supportive Therapy has just been completed. Results are not yet available, but seem very promising. Several effectiveness research projects have been conducted or are currently underway. Israel and Diamond (2013) explored the feasibility of training therapists to conduct ABFT in a hospital setting in Norway. Similar implementation challenges are explored in three recent papers on implementing ABFT in Australia (Diamond et al. 2016c), Belgium (Santens et al. 2016), and Sweden (Ringborg 2016). In the United States, we have recently partnered with an LGBTQI youth center to conduct an implementation study of ABFT in a community counseling center working with this population. This empirical support reviewed above meets the criteria for a promising intervention (Chambless and Hollon 1998) and

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ABFT is currently listed on the National Registry of Evidence-based Programs and Practices (NREPP).

Case Study Brittney was a 17 year old, African American, and Caucasian (biracial) adolescent who lived with her mother, Sharise, and younger brother. The father lived in the home until Brittney was nine; however, he was not involved in her life at the time of this therapy. The family was referred from a local inpatient psychiatric hospital after treatment for severe suicidal ideation. Brittney struggled throughout her life socially and academically. Although very creative, athletic, and intelligent, Brittney reported difficulties “fitting in” and being bullied given her biracial identity. She discussed how she felt “not black enough.” These issues with peers impacted her ability to attend school. Sharise self-identified as African American and came to therapy with concerns about her daughter’s suicidal ideation, depression, anger, and “out of control” sexual behavior. Specifically, Sharise had recently “caught” her daughter kissing “an older guy” outside of her school. Sharise described her daughter as being highly susceptible to peer influence (e.g., cutting class to hang out with friends, provoking fistfights in school, and staying out past curfew). Sharise reported no history of family mental health concerns, but described a history of domestic violence in several of her past romantic relationships and between her own parents in childhood. At the time of treatment, Sharise had a steady job and was single. Brittney and Sharise attended ABFT sessions for 4 months. Sessions were focused on repairing ruptures between mother and daughter. The primary ruptures involved Brittney’s feelings of “being attacked” by her mom when she tried to share feelings about being bullied at school, feeling rejected by her father, and feeling abandoned by her mom during episodes of domestic violence between Sharise and her previous partners. After trust was rebuilt between mother and daughter,

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sessions focused on being bullied, school struggles, career goals, identity development (e.g., what it means to be a biracial woman), and sexuality. Task I: Relational Reframe. Initially the therapist joined with Sharise around her concerns about her daughter’s depression, sexual behavior, and peer relationships. She also joined with Brittney around her depression which resulted from being bullied, feeling rejected by her father, and feeling as though she did not “fit in” given her biracial identity. The primary focus of the Relational Reframe was captured in the following question: “When you feel so bad that you want to hurt yourself, why don’t you go to your mother for help?” In response, Brittney disclosed that she worries about her mom’s negative opinions of her and does not want to stress and burden her mother. Brittney expressed that, in the past, she had felt more comfortable talking to her few close friends and boyfriend; however, with her recent struggles with peers, she felt completely “alone.” At first, Sharise was frustrated with Brittney for not coming to her. The therapist shifted Sharise’s tone by acknowledging her love and concern for Brittney and asking her to share those emotions: “Let your daughter know how sad you are that she does not trust you. Let her know how worried you are that she is all alone.” This softened the mood in the room and shifted the family from anger to sadness. At this point, Brittney and Sharise could focus on interpersonal ruptures instead of problem behavior. Both mother and daughter were able to remember the close relationship they once shared and how distant they had become. The therapist helped them acknowledge that they felt this loss of closeness. With the relational narrative now at the center of the conversation, Sharise agreed to the relational treatment contract: to make relationship repair the initial goal of the treatment. Brittney was more hesitant. She, like many adolescents, had lost hope that family relationships could improve. Brittney was protecting herself from further hurt by no longer wanting attachment security. The therapist validated this concern but also talked about the consequence of being so alone in life: depression and suicide. After the therapist

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explored her resistance and validated her concerns, Brittney agreed to come to the next session and discuss this further with the therapist alone. Task II: Adolescent Alliance. The therapist met with Brittney for her first Task II session to continue building an alliance and to better understand her depression and suicidal ideation. After this initial session, Brittney participated in two more Task II sessions where she discussed what got in the way of going to her mother for help and support (e.g., relational ruptures). Brittney noted two ruptures that were different from those originally identified in Task I. First, rather than being worried about her mother’s opinion of her or feeling like a burden, Brittney actually felt attacked and humiliated by her mother. Specifically, she said that when she shared things with her mother, the mother would then follow her around the house and “yell” at her if she did not keep talking about these things. If she brought up feelings about her father, her mother would “lashout” and reprimand her for wanting a relationship with such a “horrible man.” Brittney also described feeling abandoned by her mother during the scariest moments in her life. Brittney had witnessed episodes of domestic violence that her mother suffered at the hands of multiple romantic partners. This had never been discussed before. In sessions, Brittney talked about the impact that witnessing the violence had on her as well as the consequences of not being able to talk with her mother about these events. These conversations helped Brittney understand how these relational ruptures impacted her sense of safety and security in her relationship with her mother (i.e., her attachment rupture narrative). The therapist spent the fourth session of Task II helping Brittney see the link between her attachment narrative and her depression and suicidal ideation. Understanding this link motivated Brittney to talk to her mom about the ruptures. The therapist then spent time preparing Brittney for these conversations. Task III: Caregiver Alliance. In this task, Sharise was initially very guarded and worried about being judged or blamed for her daughter’s problems. In the first session of Task III, the therapist got to know Sharise better, including

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her work responsibilities, social life, supportive relationships, and current stressors. Sharise was burdened with balancing childcare and her job. She described feeling “stressed,” “exhausted,” and “guilty” on a daily basis. Sharise acknowledged that these stressors impacted her capacity to be present with her children. The therapist also helped her realize that when she felt worried about her daughter (e.g., when Brittney failed to arrive home on time), this would trigger her own feelings of guilt. Sharise actually attributed her daughter’s acting out behavior as a result of her own lack of availability as a mom. When these feelings of guilt were triggered, Sharise tended to lash out verbally at her daughter. Despite this initial work to understand how current stressors impacted her, Sharise remained highly defensive. In the next Task III sessions (sessions two and three), the therapist explored Sharise’s intergenerational history, specifically helping her talk about vulnerable moments as a child. At first, Sharice resisted exploring her own history of attachment ruptures. The therapist worked slowly with Sharise to uncover fears and disappointments resulting from witnessing domestic violence in her own family of origin. The therapist used information gathered in Task II with Brittney to look for similar attachment themes in mom’s life. Sharise struggled to emotionally connect to her own childhood experiences of betrayal and abandonment. In the therapy, Sharise would often distance herself from the emotional intensity of the conversation by flippantly saying, “Oh I just had to get over all this.” Each time Sharise retreated like this, the therapist would gently invite her back into uncovering more vulnerable feelings. To stay in this zone, Sharise’s primary emotions related to abandonment and neglect needed to be identified and validated. Only when Sharise could allow herself access to these more vulnerable feelings could she begin to have more empathy, rather than indifference, for her own painful experiences as a child. Once she was able to acknowledge this, the therapist helped her empathize with her daughter’s experience of witnessing domestic violence and having no one to turn to for support. Sharise

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quickly realized what her daughter needed to resolve these frightening experiences. Brittney needed to have someone help her understand these frightening events and tell her it was not her fault; just what Sharise wished she had gotten from her mother. The therapist spent the fourth session of Task III helping Sharise identify how themes of abandonment permeated her own life and her current approach to parenting. Sharise acknowledged that she was “walking with blinders on.” She admitted that she wanted to deny that the witnessing of domestic violence had an effect on her daughter. She also acknowledged that she attacked her daughter out of guilt. Specifically, when her daughter unknowingly reminded Sharise of her own “failings” as a caregiver, she felt accused and blamed. Sharise now recognized how her daughter must have felt during their times of conflict; Sharise said “I didn’t know how to manage my own hurt when Brittney needed me.” In this task, Sharise developed a new narrative about herself, her childhood, and her parenting – an approach that had more tolerance for painful feelings. In the fifth and final Task III session, the therapist offered Sharise the opportunity to change her relationship with her daughter. Once Sharise agreed, the therapist prepared her for the first Task IV conversation. Task IV: Repairing Attachment. Building on the preparation in Task II and Task III sessions, Brittney and Sharise immediately engaged in an attuned discussion about relational ruptures in Task IV. In the first session of Task IV, they discussed how Brittney felt alienated and attacked by her mother when she tried to talk to her about upsetting experiences. After some discussion of this, Brittney shared her feelings of being rejected by her father and how bad this made her feel about herself. With the help of the therapist, Sharise listened to her daughter’s feelings with empathy, rather than criticism and interrogation. In fact, Sharise was so moved by Brittney’s sadness that she physically moved closer and comforted her daughter as she cried. In this moment, the therapist had the adolescent sharing vulnerable feelings and the parent

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providing comfort and protection: a corrective attachment experience. This conversation also laid the foundation for the more difficult discussions about domestic violence. In the second Task IV session, they talked about Brittney’s experience of fear and abandonment during the episodes of domestic violence. With the support of the therapist, Brittney disclosed feeling abandoned by her mother because she had never asked Brittney about these events. After mom validated, rather than dismissed, Brittney’s feelings, Brittney began to share her memories of the violence. In this conversation, the therapist encouraged Sharice to listen, be curious, ask questions, and not talk too much. The therapist also discouraged her from apologizing too quickly, as this often brings closure to a conversation that the therapist wanted to sustain. When the time was right and Brittney had shared her full story, Sharise gave her daughter an honest apology for not being there for her during those difficult times. Sharise also shared a bit about her own life experiences as a child, but not so much that the mom would become the center of attention. In Task IV sessions, the conversations between Brittney and Sharise were different from those in the past. Mom was softer and Brittney was more willing to share her experiences and emotions openly. At the end of Task IV, the therapist asked the family to reflect a bit on how these conversations had gone. Mom and daughter both acknowledged how different the other one had been: both more open, more receptive, and more honest. They both realized how often they bury their hurt feelings and how much better it was to share them with each other. Mom and daughter only needed two Task IV sessions before moving on to Task V. Task V: Promoting Autonomy. Sharise and Brittney had four Task V sessions to discuss issues contributing to Brittney’s depression (e.g., being bullied, struggling to fit in, school attendance), plans for the future (e.g., work, college), and personal development (e.g., sexuality, romantic relationships, biracial identity). All of these conversations allowed Sharise to practice supporting her daughter on her path

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toward womanhood. The therapist encouraged Sharise to serve as a support for her daughter (i.e., help Brittney express her emotions and make better decisions). By the end of Task V, the family felt like trust was coming back, reducing mom’s worries about her daughter’s “out of control” behaviors and increasing Brittney’s tendency to go to mom for support. Case Review. At the close of the final session, both mom and daughter felt able to continue having conversations together about future difficulties. Brittney began college preparatory courses with her mom’s support and actively visited local community colleges to learn more about business programs. By the end of therapy, Brittney had begun thinking about the possibility of starting a hair styling and braiding service. Suicide was no longer a needed coping strategy, and the family had a plan in place if suicidal thoughts returned. Specifically, Brittney felt like she could go to her mom for care and support. Brittney’s depressive symptoms and suicidal ideations had dropped to a nonclinical level. Brittney and Sharise found ABFT to be successful in helping them regain their closeness. Although not all cases go this smoothly, many families successfully progress through the five tasks in 12 to 16 weeks. ABFT can accomplish this rapid progress because the model focuses directly on the issues that lie at the heart of the matter for families: love, commitment, and trust.

Cross-References ▶ Adolescents in Couple and Family Therapy ▶ Alliance in Family Relationships ▶ Attachment Theory ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Contextual Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Emotion-Focused Therapy for Couples ▶ Enactment in Structural Family Therapy ▶ Multidimensional Family Therapy ▶ Primary Emotions in Emotionally Focused Therapy ▶ Softening in Emotion-Focused Therapy ▶ Structural Family Therapy

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References Asarnow, J. R., Emslie, G., Clarke, G., Wagner, K. D., Spirito, A., Vitiello, B., et al. (2009). Treatment of selective serotonin reuptake inhibitor-resistant depression in adolescents: Predictors and moderators of treatment response. Journal of the American of Child and Adolescent Psychiatry, 48(3), 330–339. Barbe, R. P., Bridge, J., Birmaher, B., Kolko, D., & Brent, D. A. (2004). Suicidality and its relationship to treatment outcome in depressed adolescents. Suicide and Life-threatening Behavior, 34(1), 44–55. https://doi. org/10.1521/suli.34.1.44.27768 Bernal, G., Jimenez-Chafey, M. I., & Rodriguez, M. M. D. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40(4), 361–368. Bowlby, J. (1969). Attachment and loss: Attachment (Vol. 1). New York: Basic Books. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7–18. Diamond, G.S., Siqueland, L., & Diamond, G.M. (2003). Attachment-based family therapy for depressed adolescents: Programmatic treatment development. Clinical Child and Faily Psychology Review, 6(2), 107–127. Diamond, G. M., Diamond, G. S., Levy, S., Closs, C., Ladipo, T., & Siqueland, L. (2012). Attachment-based family therapy for suicidal lesbian, gay, and bisexual adolescents: A treatment development study and open trial with preliminary findings. Psychotherapy, 49(1), 62–71. https://doi.org/10.1037/a0026247 Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014). Attachment-based family therapy for depressed adolescents. Washington, DC: American Psychological Association Press. Diamond, G. S., Russon, J., & Levy, S. (2016a). Attachment- based family therapy: A review of the empirical support. Family Process, 55(3), 595–610. https://doi.org/10.1111/famp.12241 Diamond, G. M., Shahar, B., Sabo, D., & Tsvieli, N. (2016b). Attachment-based family therapy and emotion focused therapy for unresolved anger: The role of productive emotional processing. Psychotherapy, 53(1), 34–44. https://doi.org/10.1037/pst0000025 Diamond, G. S., Wagner, I., & Levy, S. A. (2016c). Attachment-based family therapy in Australia: Introduction to a special issue. Australian & New Zealand Journal of Family Therapy, 37, 143–153. https://doi. org/10.1002/anzf.1148 Israel, P., & Diamond, G. S. (2013). Feasibility of attachment based family therapy for depressed clinic-referred Norwegian adolescents. Clinical Child Psychology and Psychiatry, 18(3), 334 350. https://doi.org/10.1177/ 1359104512455811 Maccoby, E. E., & Martin, J. A. (1983). Socialization in the context of the family: Parent-child interaction. In E. M.

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Hetherington (Ed.), Mussen manual of child psychology (pp. 1–102). New York: Wiley. Restifo, K., & Bogels, S. (2009). Family processes in the development of youth depression: Translating the evidence to treatment. Clinical Psychology Review, 29(4), 294–316. https://doi.org/10.1016/j.cpr.2009.02.005 Ringborg, M. (2016). Dissemination of attachment-based family therapy in Sweden. Journal of Family Therapy, 37(2), 228–239. https://doi.org/10.1002/anzf.1153 Santens, T., Devacht, I., Dewulk, S., Hermans, G., & Bosmans, G. (2016). Attachment-based family therapy between Magritte and Poirot: Dissemination dreams, challenges and solutions in Belgium. Australian and New Zealand Journal of Family Therapy, 37(2), 240–250.

Attention Deficit Hyperactivity Disorder (ADHD) in Couple and Family Therapy Gina Pera1 and Arthur L. Robin2,3 1 Adult ADHD-Focused Couple Therapy, San Francisco Bay Area, CA, USA 2 Children’s Hospital of Michigan, Detroit, MI, USA 3 Dennis, Moye, and Associates, Bloomfield Hills, MI, USA

Synonyms ADHD in couples; ADHD marital therapy; Adult ADHD couple therapy; Counseling couples with ADHD

Introduction Attention deficit hyperactivity disorder (ADHD) is a genetically based, neurobiological disorder that begins in childhood but persists into adulthood at a rate of at least 65–70% (Barkley 2014). It is estimated that only one in ten adults with ADHD in the USA is diagnosed. Many of these adults are currently misdiagnosed with depression, anxiety, or other conditions. Couples wherein one or both partners have ADHD often experience excessive conflict and negative interactions that threaten or even

end their relationships. The ADHD partner often listens poorly, fails to finish tasks or fulfill commitments, manifests inappropriate emotional outbursts, and generally acts in the relationship more like a child than an adult. Compounding the potential for disruption to the couple and the family unit: Adult ADHD itself is associated with sequelae including higher than average rates of undereducation, underemployment, bankruptcy, traffic accidents, and interpersonal violence (Barkley 2014). When ADHD goes long unrecognized or misunderstood – as it has for most adults – domestic problems tend to intensify over time. The partners of these adults misattribute ADHD-related problem behaviors to malicious motives, lack of love, immaturity, or their own deficiencies. The adults with ADHD themselves feel misunderstood and frustrated. Both partners’ negative reactions to the “invisible elephant in the room” of ADHD gradually create a downward spiral in the relationship and for each individual. Traditional marital therapy typically proves unsuccessful because it does not address the special challenges that ADHD poses for the couple (Pera 2014). Snyder et al. (2003) succinctly describe the situation currently facing therapists seeking to help ADHD-challenged couples: Therapists trained primarily in couple or family interventions sometimes feel ill prepared to address significant individual psychopathology contributing to or interacting with relationship concerns— in part because traditional systemic formulations have often marginalized or ignored the etiological role of individual pathology in family system functioning.

Adult ADHD-Focused Couple Therapy (Pera and Robin 2016) is specifically designed to address relationship dysfunction and the full range of issues around domestic cooperation for couples where one or both partners have ADHD.

Theoretical Context for Concept Until recently, ADHD was considered primarily a disorder of attention, impulse control, and

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hyperactivity. Now researchers know that ADHD is fundamentally a disorder of selfregulation of executive functions and that the 18 DSM-5 ADHD symptoms can be considered akin to executive functions (Barkley 2014). Executive functions are higher-order processes of the brain that guide an individual’s behavior over time, analogous to the chief executive officer of a company or the conductor of an orchestra. To use the latter metaphor, the conductor selects the musicians and music, rehearses the orchestra, and leads the musicians during the concert. If the conductor does a good job, the music sounds fine. If not, it sounds mediocre – or even cacophonous. In adult ADHD, the brain is inconsistently “conducting” the person’s daily functioning; core executive functions are not efficiently operating in a purposeful, task-oriented direction. Neuroimaging research has identified deficits in areas of the brain associated with the executive functions of inhibition, attention, distractibility, organization, time, self-awareness, emotional self-control, and motivation in people with ADHD, compared to those without ADHD (Pera and Robin 2016). These areas include the frontal lobe, the basal ganglia, and the cerebellum. Intrinsically interesting tasks such as the Internet and video games produce higher reactivity in these areas of the brain and more task completion for everyone, regardless of the presence of ADHD. Intrinsically less interesting tasks – such as doing chores, listening to another person speak, and paying bills – require more brain stimulation for the person to complete. The neurogenetic brain deficits found in adults with ADHD interfere with such tasks. As a result, many aspects of ADHDchallenged relationships suffer. Adult ADHD-Focused Couple Therapy addresses this situation by blending evidencebased marital therapy with evidence-based treatment for adult ADHD, including a specific cognitive behavior therapy model and medications shown to mitigate ADHD symptoms. This model incorporates five principles derived from more than 40 years of published research and practice on effective couple therapy (Benson

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et al. 2012), imbuing them with ADHD-specific treatment interventions: 1. Alter views of the relationship: Couples are provided with psycho-education regarding ADHD, its causes, how it impacts relationships, and how changing their view of the nature of their relationship’s challenges reduces blame and sets the stage for positive change. 2. Modify dysfunctional interactions: Targeted interventions address dangerous and destructive behaviors that ADHD partners may exhibit (e.g., violence, anger outbursts, abusive remarks, denial). 3. Decrease emotional avoidance: Clinicians employ techniques such as consciousness raising and motivational interviewing to cut through denial and low self-awareness of ADHD as well as the associated tactics around blame and avoidance that some individuals with ADHD have developed as poor coping responses. 4. Improve communication: Direct communication training and the modified Imago Dialogue help couples improve their interpersonal exchanges. 5. Promote relationship strengths: The therapist continually emphasizes the importance of partners praising each other’s efforts, increasing positive activities, using rewarding incentives for habit and behavior change, and rekindling romance. From evidence-based treatment for adult ADHD, the therapist further incorporates these elements: 1. Interventions designed to teach the ADHD partner how to get the most out of medication 2. Cognitive restructuring designed to replace the distorted thinking developed over the years when ADHD had not been identified with more reasonable thinking 3. Behavioral interventions that improve time management, organization, planning, and follow-through

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Description Adult ADHD-Focused Couple Therapy proceeds through seven steps: 1. Educate the Couple about ADHD. The therapist provides the couple with a scientifically based explanation of ADHD as an executive function disorder, summarizes the evidence for its genetic/neurobiological etiology, describes how it impairs individuals and couples, summarizes how a diagnosis is made, and outlines the various treatment strategies available to the couple. Each partner is encouraged to ask questions and to fully process their reactions to the diagnosis in joint or individual sessions. 2. Clarify the Partners’ Cognitions. Prior to learning about ADHD, couples often harbor misattributions or distorted cognitions about each other’s behaviors, responses, and counter-responses. The non-ADHD partner often attributes the ADHD partner’s actions to malicious motives or not caring about the relationship, leading to depressed and angry affect and poor coping behavior. The ADHD partner often views the non-ADHD partner’s actions as over controlling and hypercritical. It is important to remember that sometimes both partners have ADHD, manifesting in perhaps very different ways; these dual-ADHD couples experience patterns similar to the ADHD and “non-ADHD” partner. The therapist uses adult ADHD-focused cognitive restructuring to help the couple identify their dysfunctional coping responses and reframe their challenges through the lens of ADHD as a neurobiological disorder. This new perspective promotes less toxic and more neutral cognitions, establishing a stable foundation for more positive affect and teamwork in learning coping behaviors and improving their ability to problem-solve long after therapy ends. 3. Optimize Medication. Many physicians conduct only brief medication monitoring visits. They do not provide couples with the knowledge or tools to access, much less optimize, the benefits of medication. While respecting

professional boundaries, the knowledgeable therapist can provide critically needed help in informing about medication; guiding the couple to select meaningful, medication-sensitive targets for change (e.g., attentive listening, efficient follow-through, and enhanced emotional self- control); employing a simple system for monitoring medication effects; and helping the couple work as a team in giving feedback to the physician. 4. Acquire New Habits and Improve Coping Behavior. The therapist teaches the couples “nuts and bolts” strategies for behavior change. These include reliably adopting physical supports (e.g., calendar planners, prioritized “todo” lists, and reminder systems) and cognitive strategies around “getting things done” (e.g., managing time, breaking down complex tasks into small steps, overcoming procrastination and distractibility, and utilizing positive incentive systems). The couple learns how to work as a team in applying these techniques to their important household and family projects. In experiencing successful task completion around these projects – typically for the first time – couples gain new optimism in improving other aspects of their life together. 5. Communicate Attentively and Empathically. The couple learns to identify and replace negative communication habits with positive, solution-oriented habits. The result: They can listen to each other without interruption, express their thoughts and feelings with dignity and respect, and mutually problem-solve disagreements. The highly structured Imago Therapy technique called The Dialogue serves as the centerpiece of communication training, chosen because it reduces impulsivity, increases sustained attention, and fosters empathy. 6. Co-parent Effectively. Adults with ADHD typically experience extreme difficulty in consistently implementing the rules, routines, structure, incentives, and punishments needed to parent effectively. This is true whether or not their children also have ADHD. (Given the high heritability of ADHD, however, chances are good that biological children will also have ADHD, which only increases demands around

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creating consistent routines and structure, not to mention regulating tempers.) As a result, their partners perform more than their fair share of the parenting, especially when it comes to discipline. Moreover, they come to consider the ADHD partner to be “like another child to be parented.” The therapist helps the couple “get on the same page” with regard to evidence-based parenting strategies. They also apply to parenting the lessons learned from step 4, Behavior and Habit Change. 7. Address Other Challenges. ADHDchallenged couples grapple with various specific issues around sexual intimacy, money management, cyber addiction, and denial of ADHD. Distinct modules in Adult ADHDFocused Couple Therapy address each of these challenges. The therapist typically goes through these steps in the order described above, but the therapy is flexibly tailored to the needs of each couple. Both partners attend most sessions, but the therapist may at times choose to meet individually with each partner. This can be especially helpful when the adult with ADHD needs to be “brought up to speed” on many basic personal habit-change and cognitive-restructuring techniques before they can be expected to implement cooperative strategies.

Application of Concept and Clinical Example Michael and Rose have been arguing for most of their 26-year marriage, with conflicts centering on spending, chore sharing, and co-parenting. Michael has worked off and on as a carpenter for a home-building company. Rose works as the longtime billing manager in a busy psychiatric clinic. The couple allowed the more intimate aspects of relationship to fall by the wayside years ago, due to the historical futility at improving these areas. Rose earns the more reliable salary, acted as primary caregiver for the children, and, having finally given up on inspiring Michael’s cooperation, performs most household

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chores. After her many tearful breakdowns, Michael would always once again agree to help more with laundry, dinner preparation, or with the kids’ homework. But he never followed through for long, and he cannot explain why. Rose said the reason is clear: He doesn’t care; he does only what he wants to do. Over the years, Rose coped by dreaming of “Plan B” – that is, the time when their children were living on their own, and she could finally make decisions based on her happiness. That “empty nest” time has come. Their youngest just moved out. One day at work, Rose confided to a staff psychologist that she was filing for divorce. The more the psychologist listened, however, the more she perceived “red flags” for ADHD. Rose responded with incredulity. On the drive home, however, she had time to think. The description fit. Michael has his good qualities; they were just so overwhelmed by the problematic behaviors. If it is possible that their long-running conflicts are due to a treatable condition, she decides she owes it to him and their marriage to pursue the possibility. In preparation to deploying “Plan B,” Rose had in recent months turned her attention to sprucing up and then selling their 1960s home. Michael, currently out of work, possesses the “sprucing up” skills but not the follow-through. He has always started renovation projects with great enthusiasm. He eventually loses steam, however, and returns to other more interesting, passive activities, such as watching YouTube videos on random topics. When it came to issues such as the months-long unfinished bathroom tile, Michael minimized with quips such as “Grout is over-rated” and promised “I’ll get to it.” Just last week, Rose declared, “I’m done with your lame excuses.” She accused him of being a “do-nothing who does not care about your marriage, just like your father.” He retorted that she is “a controlling bitch, just like your mother.” That’s when Rose gave up on renovating the house. The next day, she confided in the clinic psychologist her plans for divorce. Now, Rose wants to give their marriage one last try. She presented the possibility of ADHD to Michael and asked him to pursue an evaluation. Initially, he balked. Clearly sensing, however, that

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a refusal would mean the end of his marriage – and being vaguely aware that ADHD might explain his lifelong struggles – he made the appointment. Once evaluated and diagnosed, he half-heartedly agreed to couple therapy. Rose knew that the therapist would need to provide reason for optimism quite quickly, to keep Michael “in the game.” Their one attempt at couple therapy, years ago, failed because the therapist kept delving into Michael’s dysfunctional family of origin without offering any strategies for addressing the couple’s domestic problems, leaving him feeling hopeless and defeated before he got started. ADHD Education. The therapist thoroughly explains what ADHD is, the variable ways in which it can manifest, and how the diagnosis is made. “This explains a lot about my dad,” said Michael, after learning of ADHD’s high heritability. “It explains a lot about Michael’s approach to work, too,” said Rose. One the one hand, Michael could easily sell customers on his plans for remodeling, and they would be impressed with his enthusiastic “blaze of glory” start. But as time went on, they grew frustrated that he would “hyper-focus” on small details and loses focus toward more monotonous tasks, such as measuring and hanging doors. Too many times, he simply stopped showing up, thus forfeiting payment for work completed. Michael was relieved to learn that his lifelong pattern of avoidance was common for late-diagnosis adults with ADHD – and that there was hope for change. Also like many other adults with ADHD, Michael’s attention darts to the new and exciting. Left in the dust: the “daily tasks of living” and nurturing a relationship. To put simply one aspect of ADHD, the associated neurobiology can lead a person to crave the stimulation of exciting or novel tasks but shut down when the task becomes mundane. Michael learns to view his ADHD as a challenge to be coped with, not an excuse. Rose comes to understand that the underlying issues are biomedical in nature, not intentional. Both partners learn that in order to have a more satisfying relationship and smoother-running domestic life, they need to cooperate in implementing ADHD-targeted strategies and altering their mindsets.

Clarify Cognitions. Using the figure detailing the Adult ADHD-Focused Dysfunctional Interaction Cycle (Pera and Robin 2016, p. 66), the therapist explains to Rose and Michael that they aren’t alone. Other couples dealing with unrecognized ADHD predictably develop tightly held and toxic misperceptions about each other’s behaviors, reactions, and counter-reactions. For example, the therapist reframes Michael’s poor follow-through on various promises as a natural consequence of his ADHD brain turning off repetitive or tedious tasks, not laziness or lack of regard. Likewise, Rose’s critical statements become better understood as the natural frustration of a partner who has for years had no viable explanation for her spouse’s repeated failure to finish what he agrees to do and who forgets important agreements – and always finds a way to avoid important discussions. Optimize Medication. Michael expressed a lot of anxiety about “Big Pharma” and the possible negative effects of medication – a bit odd for a person who smokes two packs of cigarettes per day. Nonetheless, the therapist provided him with clearly explained scientific information about stimulant medication and urged him to attend an adult ADHD support group meeting on this topic. After talking there with other adults, including men Michael’s age, who benefitted greatly from medication, Michael reluctantly agreed to try it. The couple chose two medication targets for change: (1) Michael conversing attentively with Rose during dinner and (2) Michael following through on three simple, mutually agreed-upon household tasks each day. After the prescribing physician gradually increased Michael’s dosage of stimulant medication over 3 weeks, the couple concurred in seeing great improvement in both target behaviors. Again, it is emphasized, a team approach helps both partners stay on track and optimistic about making further improvements. As part of the treatment team, the physician agreed that Rose should accompany Michael to his medication follow-up visits. Acquire New Habits and Improve Coping Behavior. Michael acknowledges that he wants to be more actively engaged in his marriage and their “team effort.” He expresses a desire to complete

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the household renovation, one that promises to give their marriage a beautiful “fresh start.” Simultaneously, though, he feels hamstrung by doubts, reinforced by past failures. The list seems overwhelming. He dreads Rose having to endlessly nag him to finish. The therapist explained the importance of acknowledging and problem-solving around those fears, especially around making and completing plans. First, he prompted the couple to list on paper all the steps of the renovation, sequence the steps, break them down into small steps, note them on a calendar spanning several months, and detail how they would carry out the first step. During the next few weeks, the therapist directed the couple to sit down each evening for 10 min, reviewing the day’s work and remaining tasks. They used their smartphones to structure daily and weekly to-do lists, set reminders, and reward their progress. They selected motivating rewards such as dinner out or movies for completing each phase. To their surprise, they steadily accomplished a great deal without deteriorating into “screaming meanies.” Communicate Attentively and Empathically. Michael and Rose called it a “freeing experience.” That is, their gradually learning to reframe their challenges through the neurobiological lens of ADHD rather than Michael being “lazy and never listening” and Rose being “hypercritical and controlling.” This breakthrough led to improved positive regard, further solidified by ongoing progress on shared goals at home. Between these events and Michael’s ongoing medication treatment, he showed more active engagement with Rose – listening, remembering more, and being more thoughtful. For her part, Rose had dropped the incessant inflammatory criticism. With this more positive foundation established, the therapist worked to strengthen the pair’s communication beyond the chore list. Using the structure of the Imago Couple Dialogue, Michael and Rose learned how to have more respectful conversations about intimate issues and practical problemsolving. They practiced sharing appreciations for each other and dealing with grievances. Under their therapist’s direction, the couple had been “checking in” with each other for 10 minutes daily, primarily to note renovation progress and coordinate

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the next day’s goals. Now, the therapist assigned them the task of using part of that time to practice new elements of The Dialogue learned in session. Co-parenting. Because their children were now grown and on their own, this component of the intervention was no longer needed. Yet, given the pileup of years spent arguing about co-parenting, the therapist found it important to review how ADHD, left unrecognized, can present co-parenting challenges. Rose now better understood why Michael was always the “fun” parent, leaving her to be the “heavy.” As the children grew, the constantly changing rules and guidelines were too much for Michael to keep track of. He also did not trust himself with meting out discipline, fearful of repeating his own father’s violent punishments. Address Other Challenges. Michael and Rose had not been sexually intimate for 3 years at the time that they entered therapy. They had grown so angry and distant from each other. Yet, the therapist took no direct steps to help them restart sexual intimacy. After they started attributing their entrenched problems to ADHD as the “elephant in the room,” and found new success in working cooperatively, they naturally rekindled their desire and again enjoyed sexual intimacy. This couple fortunately had no comorbid addictive behaviors that also needed intervention. Other couples of course will need targeted help in improving patterns around managing income and outgo, curbing electronic overuse, tackling ADHD challenges related to sleep, and nurturing physical and emotional intimacy. Throughout, practical strategies typically lay the foundation for success. After all, even physical intimacy typically relies on cooperation in the rest of life, including both partners being in bed at the same time instead of one staying up until the wee hours checking social media.

Conclusion Each couple challenged by adult ADHD is different. ADHD itself is a syndrome, meaning that symptoms are variable individual to individual. Moreover, most adults with ADHD will have a

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second coexisting condition. The poor coping responses to unrecognized ADHD take myriad shapes as well, influenced by socioeconomic backgrounds, culture and ethnicity, educational levels, and other aspects of personality. The partners of these adults might also have ADHD – or any other human foible. Family-of-origin issues always form a part of the picture. Yet, when ADHD is challenging the relationship, predictable patterns can ensnare even the most mutually loving partners and lead to a mistakenly dire prognosis for the more troubled couples. ADHDinformed strategies can provide the all-important foundation for healing ADHD-challenged relationships (Pera and Robin 2016).

References Barkley, R. A. (Ed.). (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford Publications. Benson, L. A., McGinn, M. M., & Christensen, A. (2012). Common principles of couple therapy. Behavior Therapy, 43(1), 25–35. Pera, G. A. (2014). Counseling couples affected by adult ADHD. In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed., pp. 795–825). New York: Guilford Press. Pera, G. A., & Robin, A. L. (2016). Adult ADHD-focused couple therapy: Clinical interventions. New York: Routledge. Snyder, D. K., Schneider, W. J., & Castellani, A. M. (2003). Tailoring couple therapy to individual differences. In D. K. Snyder & M. A. Whisman (Eds.), Treating difficult couples: Helping clients with coexisting mental and relationship disorders (pp. 27–52). New York: Guilford Press.

Attneave, Carolyn L. Heather Colquhoun Couple and Family Therapy, Alliant International University, Sacramento, CA, USA

Attneave, Carolyn L.

Introduction Carloyn L. Attneave was one of the best known American-Indian psychologist due to her contributions in cross-cultural issues and network therapy in the field of family therapy.

Career In 1940, Attneave completed her Bachelor’s degree in English and Theatre at California State University, Chico. Attneave returned to school shortly after graduating to pursue a second baccalaureate in elementary education. Attneave put her teaching career on hold and joined the Coast Guard during World War II, which made her one of the first female officers. While in the Coast Guard, Attneave researched the educational needs of Japanese families. Attneave was inspired to pursue psychology after participating in a mental health training course. After the war was over, Attneave returned to Stanford in 1947 to begin her doctoral work in counseling psychology. In 1952, Attneave received her Ph.D. from Stanford. Attneave spent several years in Texas teaching at various institutions such as Texas Technical College and Texas Woman’s University. Attneave moved to Oklahoma and began a new position as the coordinator of community guidance services for the Oklahoma State Department of Health, which serviced seven different American Indian tribes. In 1968, Attneave moved to Philadelphia, Pennsylvania, to work at the Child Guidance Clinic where she began to focus on network therapy. For the next 6 years, Attneave collaborated with physicians, civic organizations, tribal and federal agencies, tribal leaders, and medicine men and women by providing mental health services. Attneave began her teaching career at Harvard University’s School of Public Health in 1973 then later joined the faculty of the University of Washington for the remaining 15 years of her career.

Contributions to Profession Name Carolyn L. Attneave, Ph.D. (1920–1992)

Attneave developed network therapy when her interest in an individual’s support network

Australian and New Zealand Journal of Family Therapy

beyond one’s family offered an alternative to hospitalization for mental health concerns. Throughout Attneave’s career, she worked with leaders within the health care field to increase mental health services for individuals of variously diverse backgrounds. Attneave strived to gain a better cultural understanding of the cultural contexts of her clients. Attneave developed a stage model for network therapy and created a map for patients and professionals to help identify people and relationships of a network. In 1973, Attneave released her book, Family Networks, coauthored by Ross Speck, which provided a comprehensive guide to using network therapy. A year later, Attneave moved to Boston, Massachusetts, and founded the Boston Indian Council. The Boston Indian Council became known to be one of the largest Indian Centers in North America. Attneave also developed a newsletter to exchange information about services available to Indian communities called the Network of Indian Psychologists. During her time at the Harvard School of Public Health, Attneave produced a nine-volume document on the mental health needs, service networks, and utilization patterns for the Indian Health Service. During the last 15 years of Attneave’s career, she dedicated herself to educating others at the University of Washington as a professor of psychology and director of the American Indian Studies Program while she continued her work in network therapy and involved herself in community services.

Cross-References ▶ Network in Family Systems Theory

References Attneave, C. L. (1976). Family network map. Boston: Boston Family Institute. Attneave, C. L. (1990). Core network intervention: An emerging paradigm. Journal of Strategic and Systematic Therapies, 9, 3–10.

191 LaFromboise, T. D., & Fleming, C. (1990). Keeper of the fire: A profile of Carolyn Attneave. Journal of Counseling & Development, 68(5), 537–548. LaFromboise, T. D., & Trimble, J. E. (1996). Obituary: Carolyn Lewis Attneave (1920–1992). American Psychologist, 51(5), 549. Speck, R. V., & Attneave, C. L. (1973). Family networks: Retribalization and healing. New York: Pantheon.

Australian and New Zealand Journal of Family Therapy Glenn Larner Australian and New Zealand Journal of Family Therapy, Sydney, NSW, Australia

Name of Organisation The Australian and New Zealand Journal of Family Therapy

Introduction Since its foundation in 1979, The Australian and New Zealand Journal of Family Therapy (ANZJFT) has played a central role in the development of family therapy in Australia and New Zealand. The journal is a quarterly peer-reviewed professional journal that publishes relevant, innovative, and original articles on the theory, research, teaching, and practice of family therapy. The journal is overseen by an editorial board under the auspices of the Australian Association of Family Therapy and published by Wiley. The current Editor-inChief is Dr. Glenn Larner with the editorial team including Associate Editors Liz Forbat (research) and Kristof Mikes-Liu (in practice).

Location Sydney, Australia

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Prominent Associated Figures/ Contributions Michael White from Adelaide, well known with David Epston as the originator of narrative therapy, was the foundation editor of ANZJFT from 1979 to 1984. Under Michael’s tutelage, the journal provided a much needed bedrock for the evolving family therapy movement “down under.” From 1985 to 1996, ANZJFT was edited by Max Cornwell with contributions from leading figures in the family therapy field such as Tom Anderson, Karl Tomm, Luigi Boscolo, and Harlene Anderson. The many achievements of this period included a significant contribution to indigenous family therapy from Colleen Brown on the Stolen Generation in Australia (Brown and Larner 1992) and an exploration of social justice in the Just Therapy approach in New Zealand (Waldegrave and Tamasese 1993). From 1997 to 2008, coeditors Hugh and Maureen Crago oversaw the development of a professional journal for the workplace (Crago 1997) with articles on a range of clinical themes. As the Crago and Crago (2007) noted in a snapshot of the journal’s history, ANZJFT offers a practitioner friendly and less academic alternative to other family therapy publications with an appeal to both beginning and experienced family therapists and is “distinguished by its continuing attempt to include humour and provocative ideas, alongside more serious theoretical exploration and research” (p. 11). From 2009 to 2010, coeditors Paul Rhodes, Glenn Larner, and Alistair Campbell introduced a more mainstream journal with a focus on theory, practice, diversity, and innovation. In September 2010, the helm was taken by Glenn Larner, the current editor-in-chief. In this time ANZJFT has become the publication journal for the Australian Association of Family Therapy and developed its current format as a Wiley journal. An exciting regular feature is a series of groundbreaking special issues on contemporary approaches to family therapy compiled by local and international guest editors. For example, in March 2015, Judith Brown and Kristof Mikes-Liu (Sydney) compiled a special issue on Dialogical Practices including contributions from Peter Rober and Jaakko Seikkula. The

Authoritarian Parenting

June 2016 issue by Guy Diamond, Ingrid Wagner, and Suzanne Levy (the USA and Brisbane, Australia) had the theme of Attachment-Based Family Therapy: Adaptation and Dissemination. In summary, ANZJFT has an international reputation for publishing articles on a wide variety of topics in couple and family therapy in the areas of theory, practice, research, pedagogy, and training. It hopes to provide a journal with an appeal to both academics and practitioners.

References Brown, C., & Larner, G. (1992). Every dot has a meaning. Australian and New Zealand Journal of Family Therapy, 13, 175–184. Crago, M. (1997). Editorial: A journal for the workplace. Australian and New Zealand Journal of Family Therapy, 18(2), iii–iiv. Crago, H., & Crago, M. (2007). The ANZJFT: Snapshots from the history of an evolving journal. Australian and New Zealand Journal of Family Therapy, 28(1), 11–20. Waldegrave, C., & Tamasese, K. (1993). Some central ideas in the ‘Just Therapy’ approach. Australia and New Zealand Journal of Family Therapy, 14(1), 1–8.

Further Reading Australian and New Zealand Journal of Family Therapy. Wiley Online Library: http://onlinelibrary.wiley.com/ journal/10.1002/(ISSN)1467-8438

Authoritarian Parenting Jessica L. Chou1, Shannon Cooper-Sadlo2 and Agnes Jos3 1 Queen of Peace Center, St. Louis, MO, USA 2 School of Social Work, Saint Louis University, St. Louis, MO, USA 3 Community Treatment, Inc. (COMTREA), Comprehensive Health Center, St. Louis, MO, USA

Introduction Parents play an integral role in child development over the lifespan (National Center on Parent, Family, and Community Engagement 2013).

Authoritarian Parenting

Parenting style has been a well-studied phenomenon in relation to child outcomes. Through the studies of parenting the authoritarian parenting style has emerged as a more disciplinary style of parenting compared to the authoritative and permissive styles (Woody 2003). To fully understand different parenting styles, developmental and cultural perspectives must be considered.

Theoretical Context for Concept Diana Baumrind (1971) developed one of the most widely used theories of parenting typology. Through her extensive work of observing children from elementary school through adolescents, Baumrind created three parenting styles: authoritarian, authoritative, and permissive (Pellerin 2005). Maccoby and Martin then expanded Baumrind’s theory and provided further detail of different parenting styles (Wang and Fletcher 2016). The different parenting styles are based on intensity of two dimensions, responsiveness and demandingness. The two dimensions are not mutually exclusive rather they interact together and are used to typify each parenting style (Minaie et al. 2015). Parents who are low on demandingness and high on responsiveness are classified as permissive, while parents who are high on responsiveness and high on demandingness are considered authoritative. Parents who are low on responsiveness and high on demandingness are characterized as utilizing the authoritarian style of parenting (Pellerin 2005).

Description Authoritarian parenting favors demandingness over responsiveness. Parents who are low in responsiveness lack empathy and warmth toward their child(ren). While parents who are high in demandingness are able to set boundaries, limits, and age-appropriate expectations tailored toward healthy child developmental trajectories (Pellerin 2005). Thus, an authoritarian parent is generally described as a parent who prioritizes enforcing rules but often lacks a

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warm and nurturing disposition. Parents who utilize authoritarian parenting tend to be more rigid and narrow in rule setting while being more punitive in disciplinary measures (Woody 2003). From a developmental perspective, parenting styles need to be taken into consideration. Since authoritarian parents tend to control the child and expect the child to follow directions, children can have difficulty developing the autonomy needed to formulate their own ideas and beliefs as they get older (Fernandez et al. 2013). Since the child is rarely provided with an explanation for expected behaviors, he or she is unable to understand why behaving a certain way aligns with one’s beliefs. Instead, a child behaves based on an existing power differential and fear of consequences. Goals are not created collaboratively, rather they are dictated. It is not unusual for children in these homes to struggle with poor self-esteem and have behavior concerns. Intrinsic motivation to succeed is rare for a child raised in an authoritarian home and consequently impact academic achievement (Fernandez et al. 2013). Consideration must be given to the fact that parenting styles are culturally driven and the authoritarian parenting style was developed and has been rooted in Western culture (Van Campen and Russell 2010). Though the authoritative parenting style has been observed as yielding the most ideal outcomes for children, the authoritarian parenting style should be understood in the cultural context in which it exists before stigmatizing this style of parenting.

Application of Concept in Couple and Family Therapy The therapist should take time to gain an understanding of the context for which the authoritarian style of parenting developed and was maintained. Understanding cultural influences can provide insight into how parenting styles manifest and can be viewed as beneficial in certain cultures. For example, some cultures may adhere to authoritarian parenting practices as it aligns with cultural values (Kotchick and

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Forehand 2002). Navigating cultural expectations regarding parenting should be done in collaboration with the parent, and the therapist should remain supportive in assisting parents in adapting old parenting styles into new ones that work within the family unit. Communication about authoritarian parenting style is key in gaining insight into how this style of parenting is impacting the child, as well as the parent-child relationship. Children who are subject to harsh disciplinary measures and strict rule enforcement can become rebellious and exhibit other unintended consequences. Therapeutic techniques can be utilized to discuss disciplinary measures and how to adapt a parenting style to achieve the desired behaviors in children. For a parent who uses an authoritarian style this may warrant a discussion on balancing discipline with warmth and flexibility. Additionally, the therapist can explore age-appropriate expectations with the parent and child in an effort to support healthy development. The therapist should be attentive of how the authoritarian style of parenting may present in the session. As this style of parenting focuses more on disciplinary measures and rigid boundaries, a parent may enter therapy wanting to control the flow of the session. Engaging in a power struggle hinders the ability to build rapport and can be an obstacle for engaging the parent. The therapist must remain empathetic towards this style of parenting and focus on validating positive aspects of this parenting style. Consistent discipline and monitoring of behaviors has been linked to buffering against stressors (Kotchick and Forehand 2002). Likewise, the therapist should remember that this style of parenting is a reflection of care and consideration for the child’s well being.

away from the home. If Tracy does not complete the chore list Georgia has created for each day, Tracy loses her phone for 1 week for each day chores are left uncompleted. In addition, Tracy is not allowed to have friends to the home or leave the home when Georgia is at work. Recently, Tracy has begun talking back to Georgia, and Georgia discovered that Tracy has snuck out of the house on more than one occasion. Although Tracy maintains good grades at school, Georgia is concerned about Tracy’s behaviors. Georgia’s reaction to Tracy’s recent behavior is to continue punishment through taking things away from Tracy and limiting interaction with friends at all times. During family therapy, the therapist explores with Georgia and Tracy how the isolation Tracy is experiencing may be contributing to her behaviors. Georgia reports she is not interested in the therapist’s explanations for Tracy’s behaviors and believes that her granddaughter should respect her enough to listen. The therapist continues to validate aspects of Georgia’s parenting style while exploring where it developed. After several sessions, Georgia reveals she wishes she had enforced more rules when Tracy’s mother was growing up and reveals that she was raised in a culture that highly valued discipline and control. This disclosure enables the therapist to understand Georgia’s authoritarian parenting style with Tracy and acknowledge Georgia’s concerns for her granddaughter’s safety as well as her future. The therapist and Georgia discuss alternative ways to address Tracy’s behaviors in order to elicit change such as setting boundaries and limits for sneaking out of the house while still letting Tracy know she cares.

Clinical Example

Cross-References

Georgia is the guardian of her 16-year old granddaughter, Tracy. Georgia has been raising Tracy since Tracy’s mom went to jail 11 years ago. Due to financial struggles, Georgia works long hours and Tracy is often alone. Georgia has firm expectations of Tracy while Georgia is

▶ Authoritative Parenting ▶ Building Strong Families ▶ Children in Couple and Family Therapy ▶ Family of Origin ▶ Nurturing Parenting Enrichment Program ▶ Parenting Wisely Enrichment Program

Authoritative Parenting

References Baumrind, D. (1971). Current patterns of parental authority. Developmental Psychology, 4, 1–103. Fernandez, I. T., Schwartz, J. P., Chun, H., & Dickson, G. (2013). Family resilience and parenting. In D. S. Becvar (Ed.), Handbook of family resilience (pp. 119–136). New York: Springer. Kotchick, B. A., & Forehand, R. (2002). Putting parenting in perspective: A discussion of the contextual factors that shape parenting practices. Journal of Child and Family Studies, 3, 255–269. Minaie, M. G., Hui, K. K., Leung, R. K., Toumbourou, J. W., & King, R. M. (2015). Parenting style and behavior as longitudinal predictors of adolescent alcohol use. Journal of Studies on Alcohol and Drugs, 76, 671–679. National Center on Parent, Family, and Community Engagement. (2013). Understanding family engagement outcomes: Research to practice series. Retrieved from [email protected] Pellerin, L. A. (2005). Applying baumrind’s parenting typology to high schools: Toward a middle-range theory of authoritative socialization. Social Science Research, 34, 283–303. https://doi.org/10.1016/j. ssresearch.2004.02.003. Van Campen, K. S., & Russell, S. T. (2010). Cultural differences in parenting practices: What Asian American families can teach us. Frances McClelland Institute for Children, Youth and Families. ResearchLink, 2, 1–4. The University of Arizona. Wang, D., & Fletcher, A. C. (2016). Parenting style and peer trust in relation to school adjustment in middle childhood. Journal Child Family Studies, 25, 988–998. https://doi.org/10.1007/s10826-015-0264-x. Woody, D. J. (2003). Early childhood. In E. D. Hutchinson (Ed.), Dimensions of human behavior: The changing life course (pp. 159–195). Thousand Oaks: Sage.

Authoritative Parenting Jessica L. Chou1, Shannon Cooper-Sadlo2 and Agnes Jos3 1 Queen of Peace Center, St. Louis, MO, USA 2 School of Social Work, Saint Louis University, St. Louis, MO, USA 3 Community Treatment, Inc. (COMTREA), Comprehensive Health Center, St. Louis, MO, USA

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experience and for many, are influential over the course of a lifetime. More specifically, parentchild relationships can determine various aspects of family functioning. Different parenting styles can promote or hinder child development. Authoritative parenting style has been deemed the ideal parenting style that offers healthy child adjustment (Minaie et al. 2015).

Theoretical Context for Concept Diana Baumrind (1971) developed one of the most widely used theories of parenting typology. Through her extensive work of observing children from elementary school through adolescents, Baumrind created three parenting styles: authoritarian, authoritative, and permissive (Pellerin 2005). Maccoby and Martin then expanded Baumrind’s theory and provided further detail of different parenting styles (Wang and Fletcher 2016). The different parenting styles are based on intensity of two dimensions, responsiveness and demandingness. The two dimensions are not mutually exclusive rather they interact together and are used to typify each parenting style (Minaie et al. 2015). Parents who are low on demandingness and high on responsiveness are classified as permissive, while parents who are low on responsiveness and high on demandingness are considered authoritarian. Parents who are high on responsiveness and high on demandingness are characterized as authoritative parents (Minaie et al. 2015). Authoritative parenting style is identified as having the most optimal outcomes for children. Parents who utilize an authoritative style often have children who are better adjusted socially, academically, (Cowen and Cowen 2003) behaviorally, and psychologically (Minaie et al. 2015), compared to the other two parenting styles.

Description Introduction Family relationships are some of the most rewarding and complex relationships a person can

Authoritative parenting balances the qualities of responsiveness and demandingness. Parents who are high in responsiveness demonstrate the ability

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to exercise empathy, warmth, acceptance, and love toward their child(ren). While parents who are high in demandingness are able to set boundaries, limits, and age-appropriate expectations tailored toward healthy child developmental trajectories (Pellerin 2005). Thus, an authoritative parent has the ability to nurture their child while also enforcing healthy rules. Parents who utilize authoritative parenting are flexible and reasonable with their child(ren). They provide positive reinforcement while enforcing firm expectations that are clearly rationalized and communicated with their child(ren) (Woody 2003). From a developmental perspective, parenting styles need to be taken into consideration. Authoritative parenting is associated with healthy development for children and adolescents. This style of parenting encourages a child to think about their behaviors and reflect on how the behaviors tie to their values (Fernandez et al. 2013). Parents, who are attuned and supportive, are able to create an environment that fosters this type of critical thinking. In turn, behaviors become much more meaningful for the child. Authoritative parenting by its virtue buffers some of the risk factors that are tied to adolescence resulting in more positive outcomes associated with this parenting style than authoritarian or permissive. Child and adolescent outcomes are tied to adjustment and educational success (Fernandez et al. 2013). Consideration must be given to the fact that parenting styles are culturally driven (Van Campen and Russell 2010). Though the authoritative parenting style has been observed as yielding the most ideal outcomes for children, an effort should be made to understand the cultural influences on parenting styles regardless of style in order to ensure best fit for families.

Application of Concept in Couple and Family Therapy When integrating parenting styles into family therapy, therapists must consider communication and education about various parenting styles. The

Authoritative Parenting

discussion of parenting styles can feel accusatory or punitive, thus cognizance about the sensitive nature of parenting is pertinent to building trust and rapport in session. In alignment with authoritative parenting, the therapist should model empathy and warmth toward the parent and the child, while maintaining boundaries with the dyad. The therapist is responsible for utilizing techniques to elicit awareness into current parenting methods as well as parenting expectations. During this process, the therapist can begin a discussion on balancing responsiveness and demandingness; these techniques can also be reinforced in session with a parent and child. The therapist should offer therapeutic interventions consistent with authoritative style of parenting and guide parents in adapting these interventions to work within the family unit. Boundary setting can be difficult for some, and a therapist should assist parents in understanding how to set boundaries among different family processes. The role of the therapist should be one of consideration for the parenting context and cultural influences that shape different parenting styles. Though authoritative parenting style has largely been favored in the Western culture (Woody 2003), the therapist should consider how cultural beliefs shape parenting styles (Kotchick and Forehand 2002). Consideration should also be given to how responsiveness and demandingness are interpreted and applied in different cultures. The therapist needs to be willing to support parents and children when applying concepts of authoritative parenting.

Clinical Example Georgia is the guardian of her 16-year old granddaughter, Tracy. Georgia has been raising Tracy since Tracy’s mom went to jail 11 years ago. Due to financial struggles, Georgia works long hours and Tracy is often alone. Georgia has firm expectations of Tracy while Georgia is away from the home. Recently, Georgia and Tracy entered therapy. Georgia was becoming increasingly concerned about the defiant behaviors she was

Autonomy in Families

seeing from her granddaughter. Although Tracy is the model student she has started “getting an attitude” with Georgia and has become more argumentative. Tracy insists that if Georgia would just “leave me alone” that things would be okay, but Georgia experiences this as Tracy not obeying her rules or respecting her as a parent. Georgia is concerned she is headed down the same path as her mother. The therapist first inquired about the context in which Georgia’s parenting style developed. After several sessions, Georgia finally reveals that she felt she was too permissive with her own daughter and decided to parent her granddaughter the way she was parented. Georgia described her own parents as strict and controlling. In expressing guilt over daughter’s current situation, Georgia acknowledges that her current parenting style may not be effective either. The therapist guides Georgia to reflect on how the two different parenting styles, as varied as they are, may be eliciting similar behaviors. In offering Georgia another perspective, the therapist explained how Georgia can nurture Tracy and at the same time enforce age-appropriate rules. Tracy was present in the session while the parenting discussion was happening, which allowed for Tracy to be an active participant in therapy and gain an understanding of Georgia’s current parenting practices. In the coming weeks, the therapist worked with Georgia and Tracy in session to assist Georgia in utilizing a more flexible and responsive approach to parenting with Tracy. The therapist noted that there was a reduction in conflict and that Tracy was no longer displaying the behaviors that initially brought the family to therapy. The therapist was able to utilize an authoritative parenting approach to create the balance needed to support the needs of both Georgia and Tracy.

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References Baumrind, D. (1971). Current patterns of parental authority. Developmental Psychology, 4, 1–103. Cowen, P. A., & Cowen, C. P. (2003). Normative family transitions, normal family processes, and healthy child development. In F. Walsh (Ed.), Normal family processes: Growing diversity and complexity (3rd ed., pp. 424–459). New York: The Guildford Press. Fernandez, I. T., Schwartz, J. P., Chun, H., & Dickson, G. (2013). Family resilience and parenting. In D. S. Becvar (Ed.), Handbook of family resilience (pp. 119–136). New York: Springer. Minaie, M. G., Hui, K. K., Leung, R. K., Toumbourou, J. W., & King, R. M. (2015). Parenting style and behavior as longitudinal predictors of adolescent alcohol use. Journal of Studies on Alcohol and Drugs, 76, 671–679. Pellerin, L. A. (2005). Applying baumrind’s parenting typology to high schools: Toward a middle-range theory of authoritative socialization. Social Science Research, 34, 283–303. https://doi.org/10.1016/j. ssresearch.2004.02.003. Van Campen, K. S., & Russell, S. T. (2010). Cultural differences in parenting practices: What Asian American families can teach us. Frances McClelland Institute for Children, Youth and Families. ResearchLink, 2, 1–4. The University of Arizona. Wang, D. & Fletcher, A. C. (2016). Parenting style and peer trust in relation to school adjustment in middle childhood. Journal of Child and Family Studies, 25 988-998. https://doi.org/10.1007/s10826-015-0264-x. Woody, D. J. (2003). Early childhood. In E. D. Hutchison (Ed.), Dimensions of human behavior: The changing life course (pp. 159–195). Thousand Oaks: Sage.

Autonomy in Families Brad Sachs Stevens Forest Professional Center, Columbia, MD, USA

Synonyms Independent; Individuation; Self-determination; Self-directed; Self-reliant

Cross-References ▶ Authoritarian Parenting ▶ Children in Couple and Family Therapy ▶ Family of Origin ▶ Nurturing Parenting Enrichment Program

Introduction Autonomy is one of the three cornerstones of a healthy identity, along with competence and

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relatedness, and entails individuals’ capacity to be personally effective in adapting to, and producing changes in, their environment (Deci and Ryan 1985).

Theoretical Context for Concept While autonomous functioning was initially envisioned as a quality inhering within an individual, resulting from a sequential mastery of developmental tasks, contemporary theorists and clinicians find it more useful to view autonomy as bi-directionally connected with the capacity for relatedness (McGoldrick et al. 2011). In other words, the more comfortable one feels about being separate, the better one can connect with others, and vice versa. From a family development standpoint, the process of differentiating from one’s family of origin creates the space for autonomy, leading to an increasingly elective and nimble movement into and out of family ties, as opposed to those ties becoming stagnant, entrapping, or severed (Bowen 1978; Stierlin 1981).

Description Autonomy is distinguished by the establishment of personal intentions, goals, and preferences while taking responsibility for one’s thoughts, feelings, and actions and their ramifications. Evidence of thwarted autonomy is seen when an individual is committed either to a rigid compliance with, and/or a reactive defiance of, the expectations of others. While autonomy is a universal constituent of psychological well-being, the pursuit and definition of autonomy may differ cross-culturally (Minuchin 1974). For example, exerting individual choice with one’s personal priorities primarily in mind might characterize autonomy in an Anglo-American family, but submerging individual choice in the service of collective priorities might characterize autonomy in an East Asian family.

Autonomy in Families

Application of Concept in Couple and Family Therapy The problems bringing clients into treatment usually have to do with either stunted or misguided autonomy on the part of one or more family members, so family therapy often revolves on the axis of facilitating healthy autonomy. The clinician will emphasize the importance of children exploring their environment, becoming aware of their own desires and motivations, and being allowed to make and learn from their own mistakes. Parents will be encouraged to respect interpersonal boundaries, value their children’s unique perspective, and accept them for being who they are rather than who they “should” be. Parents who are overly controlling, permissive, or neglectful, and/or who burden the child with their own unmet needs, unresolved conflicts, and unfulfilled ambitions will be more likely to raise children who struggle to achieve autonomy. Successful couple therapy will also rely on promoting autonomy, being that, as noted above, the capacity for autonomy corresponds closely with the capacity for intimacy. If one of the primary goals of treatment is to promote autonomy within the family crucible, it behooves therapists to simultaneously promote clients’ autonomy within the treatment crucible, too. This requires many of the same autonomysupportive tactics noted above, as well as a careful consideration of clinical presence so that the therapist eventually becomes less necessary to the family.

Clinical Example The Pak’s entered treatment due to the parents’ concerns about their 17-year-old daughter Mi-Sook, who was preparing to enter senior year of high school, and who had begun engaging in sexually promiscuous behavior that was in stark contrast to her family’s moral code. The family immigrated to the United States when Mi-Sook was 2 years old, and their second child, So-Yi, was born 1 year later, with Down’s syndrome. Mi-Sook was recruited to play numerous pseudo-adult roles in the family, such as handling

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business-related phone calls for her parents as a result of her fluency with English and providing childcare for So-Yi, made necessary by the parents’ work schedules. However, while Mi-Sook became quite competent on many levels, her sense of selfdetermination was being compromised by the formidable family responsibilities she was shouldering. This reached crisis proportions when her parents told her she was expected to continue living at home to maintain these responsibilities after she graduated and to attend community college rather than the 4-year residential college she had set her sights on. The clinician hypothesized that Mi-Sook’s promiscuous behavior provided her with a narrow channel for autonomous behavior since no other avenues of independence appeared to be open to her. “I am not allowed to physically and psychologically depart from my family,” she may have reasoned, “but at least I will allow myself to morally depart from my family.” Treatment focused on helping the parents understand how their reliance on Mi-Sook was quashing her efforts to separate in developmentally appropriate ways and contributing to her engaging in a maladaptive form of separation. A parallel component of treatment explored the possibility of creating more autonomy for So-Yi despite her limitations. Assisting the entire family in achieving functional separation yielded a cessation of Mi-Sook’s worrisome behavior and laid the groundwork for all four family members continuing to evolve.

Cross-References ▶ Authoritarian Parenting ▶ Authoritative Parenting

References Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Deci, E., & Ryan, R. (1985). Intrinsic motivation and selfdetermination in human behavior. New York: Plenum Press.

199 McGoldrick, M., Carter, B., & Garcia-Preta, N. (2011). The expanded family life cycle:Individual, family and social perspectives. Boston: Allyn and Bacon. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Stierlin, H. (1981). Separating parents and adolescents. New York: Jason Aronson.

Autopoiesis in Family Systems Theory Michelle A. Finley Antioch University Seattle, Seattle, WA, USA

Name of Concept Autopoiesis

Synonyms Living system; Self-regulating system

Introduction In the early development of family therapy, general systems theory offered a mechanistic view for explaining interactions among family members (Bateson 1972). Early family therapy work also was based on first-order cybernetics, which viewed families as self-stabilizing systems by employing homeostasis and feedback (Jackson 1957; Weiner 1948). These ideas focused on how family systems stabilize and organize. Family therapy underwent further refinement through the inclusion of second cybernetics, which focuses on processes such as positive feedback and deviation-amplification to explain how family systems are dynamic (Maruyama 1963). Autopoiesis originated in biology and was then adapted to other fields including family therapy (Mingers 1995). Family therapy theorists Dell (1982a, b, 1985), Keeney (1982), and Watzlawick (1984) brought the concept of autopoiesis to family therapy, which underscored a core feature of family systems (Mingers 1995). The emergence

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of autopoiesis refined the idea that family systems are self-regulating, autonomous systems and that changes to the system from external sources such as a therapist only occur via perturbations through the therapist’s conversations with the family (Mingers 1995).

Theoretical Context for Concept Autopoiesis has its roots in the work of biologist and cybernetics theorist Humberto Maturana who sought to distinguish between living and nonliving systems with the former being “self-referred” and the latter being “other-referred” (Maturana and Varela 1980; p. xii.). Autopoiesis, which is derived from Greek, literally means “self-making” and can be broken into its constituent parts: auto meaning “self” and poiesis meaning “making” or “creation” (Capra and Luisi 2014). Maturana and Varela (1980) coined the term “autopoiesis” in their pursuit to understand and define what the essential characteristics of a living system are, and they postulated that the main characteristic of life is the ability to achieve self-maintenance through internal processing and networking that continuously reproduces itself within a self-made boundary. The most basic example of a biological autopoietic process would be the cell, which is an autonomous entity that has a cell membrane or boundary enclosing the cell’s various structures and components (e.g., nucleus, mitochondria). Crucially, the cell is able to produce and be produced by nothing other than itself. These qualities comprise an autopoietic process that defines what it means to be a living system (Maturana and Varela 1980). Varela extended Maturana’s work on autopoiesis to include social systems, which he termed “autonomous systems” meaning any system comprised of elements that may or may not themselves be autopoietic (Varela 1979). Many family therapy theorists influenced by constructivism and Maturana’s ideas viewed family systems as autopoietic in the sense that families maintained themselves through rules and patterns formed over time, and families distinguish themselves from

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other systems by their self-made boundaries (Dell 1985; Leyland 1988). Finally, language connects Maturana’s descriptions of autopoiesis and social systems to how autopoiesis is viewed in family systems theory. Maturana and Varela (1980) viewed language as fundamental to being human, and they posited that the outcome of language is determined within the cognitive domain of the listener such that the listener’s behavior is ultimately determined by his or her own structure and organization and not the speaker directly. This concept was expanded to the family system whose response to language is determined by the structure and organization of the family system itself in addition to the corresponding cognitive domains of each family member (Mingers 1995).

Description Autopoiesis is the process where a living system internally responds to messages from all components of itself in order to preserve its organization enabling the system to exist and remain identifiable (Leyland 1988). Any changes living systems make are determined by their own structure and how they are organized rather than due to external triggers, which Maturana refers to as “structural determinism” and “non-instructive interaction.” Structural determinism is the idea that a living system’s structure and organization informs how a living system is configured and responds to perturbations external to the living system. Noninstructive interaction is the notion that living systems respond differently to the same external perturbation because the system itself determines how it will behave, not the external perturbation or information. Maturana further notes that if living systems were instructable, then they would all achieve the same state under the same external perturbations. Maturana recognized that autopoietic systems exist within a medium through which the system interacts with other systems. This process of interaction is called “structural coupling.”

Autopoiesis in Family Systems Theory

Although the autopoietic system’s structure determines how it will respond to a given external perturbation, autopoietic systems interact reciprocally with other entities in their environment (structural coupling), which can also lead to structural change that alters the future behavior of the autpoietic system (Goolishian and Winderman 1988; Leyland 1988; Mingers 1995).

Application of Concept in Couple and Family Therapy Autopoiesis is most relevant to the ideas promulgated within the constructivist schools of family therapy (Goolishian and Winderman 1988) and autopoietic-like concepts can be seen in the Milan School of family therapy (Mingers 1995). The specific framing within the Milan School is to see families as “self-regulating systems” that maintain control via rules and patterns formed over time (Selvini Palazzoli et al. 1978; p. 3). Further, the Milan School, like Maturana and Varela’s view of social systems, sees family systems as noninstructive to external triggers such that perturbations by a therapist do not automatically produce changes in the family system. Leyland (1988) defined the family as a complex system consisting of two or more autopoietic structurally determined individuals who are structurally coupled to one another. In the context of therapy, a therapist would see herself as only triggering a response in the family, not directing one. When a family receives the message that it should be different, it will likely respond by maintaining itself as it is, which is traditionally labeled as “resistance.” However, when considering that a family is autopoietic and structurally determined, this process can be seen instead as the structurally coupled system trying to be itself (Leyland 1988). Autopoiesis offers a framework for understanding the paradox of change and stability among family systems such that a family therapist would see herself as someone who helps facilitate rather than directs change in families.

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The existing structural coupling of the family undergoes change during crisis or at critical junctures such as a birth, death, or divorce leading to a new pattern or view of reality that must emerge as the system evolves (Leyland 1988). This notion is similar to the Milan view that a family presents symptomatically in therapy when its view of reality has become outdated and no longer fits the current system. Thus, the therapist is to facilitate change that allows the family to create a new reality for itself. This facilitation best occurs when the nature of structural coupling between the therapist and the family is such that the therapist enters the family system as though she were an equal member who gains permission to question the family’s current reality and introduces new connections to facilitate the family’s ability to extend its cognitive and behavioral patterns, which is also known as taking a second-order cybernetics stance (Hoffman 1985; Leyland 1988).

Clinical Example A husband, wife, and their 14-year-old daughter enter therapy for help with their daughter’s frequent outbursts and truancy. Both parents feel helpless to change the situation and have “tried everything.” The therapist employs “positive connotation” (therapist offers a positive view of the effects problematic behavior has on family members) to effect change. The therapist states that the teen’s behavior has brought together her parents in a way that has not happened since she was a little girl. The intervention helps the family shift their perspective and frees them to consider alternative paths toward connection apart from the symptomatic behavior (changing their structural coupling). Using positive connotation is likely most effective with the therapist entering the family system as an equal with no urge to directly change anyone because to do so would likely lead the family to double its efforts to maintain itself (structurally determined).

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Aversive Control in Couple and Family Therapy

Cross-References ▶ First Order Cybernetics ▶ Maturana, Humberto ▶ Perturbation in Couple and Family Therapy ▶ Second-Order Cybernetics in Family Systems Theory ▶ Varela, Francisco

Aversive Control in Couple and Family Therapy Kyle C. Horst and Patrick S. Johnson California State University, Chico, Chico, CA, USA Department of Psychology, California State University, Chico, Chico, CA, USA

References Name of Concept Bateson, G. (1972). Steps to an ecology of mind. New York: Jason Aronson. Capra, F., & Luisi, P. L. (2014). The systems view of life: A unifying vision. Cambridge: Cambridge University Press. Dell, P. (1982a). Beyond homeostasis: Towards a concept of coherence. Family Process, 21, 407–414. Dell, P. (1982b). Family theory and epistemology of Humberto Maturana. Family Therapy Networker, 6(4), 26, 39–41. Dell, P. (1985). Understanding Bateson and Maturana: Towards a biological foundation for the social sciences. Journal of Marital and Family Therapy, 11, 1–20. Goolishian, H. A., & Winderman, L. (1988). Constructivism, autopoiesis, and problem determined systems. The Irish Journal of Psychology, 9(1), 130–143. Hoffman, L. (1985). Beyond power and control: Toward and “second order” family systems therapy. Family Systems Medicine, 3(4), 381–396. Jackson, D. (1957). The question of family homeostasis. The Psychiatric Quarterly. Supplement, 31, 79–90. Keeney, B. (1982). What is an epistemology of therapy? Family Process, 21, 153–168. Leyland, M. L. (1988). An introduction to some of the ideas of Humberto Maturana. Journal of Family Therapy, 10, 357–374. Maruyama, M. (1963). The second cybernetics: Deviationamplifying mutual causal processes. American Scientist, 51, 164–179. Maturana, H., & Varela, F. J. (1980). Autopoiesis and cognition: The realization of the living. Dordrecht/ Boston/London: Reidel Publishing. Mingers, J. (1995). Self-producing systems: Implications and applications of autopoiesis. New York: Plenum Press. Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox. New York: Jason Aronson. Varela, F. J. (1979). Principles of biological autonomy. New York: North-Holland Press. Watzlawick, P. (1984). The invented reality. New York: Norton Publishing. Weiner, N. (1948). Cybernetics: Or control and communication in the animal and the machine. New York: Wiley.

Aversive Control in Couple and Family Therapy

Synonyms Coercion; Punishment

Introduction Aversive control refers to the use of aversive events to manipulate another’s behavior. Punishment* is a form of aversive control used to decrease the frequency of unwanted behavior and commonly involves either the presentation of an undesirable consequence (positive punishment*) or the removal of a desirable consequence (negative punishment*). Aversive control may also refer to the use of aversive antecedent stimulation. This process, known as negative reinforcement, typically results in an increase in the frequency of behaviors that allow the individual to avoid or escape from aversive stimulation.

Theoretical Context for Concept An initial conceptualization of aversive control within psychology was the law of effect, which stated that behavior that led to an “annoying state of affairs” was likely to be weakened (Thorndike 1913, pg. 1–4). Behaviorists – most notably the radical behaviorist school founded by B. F. Skinner – subsequently reconceptualized this environment-behavior relation as “punishment*”

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and operationalized it in terms of an observed decrease in behavior resulting from the presentation or withdrawal of a consequence (Skinner 1938). As mentioned previously, aversive control may also occur through antecedent manipulations. Skinner theorized that any behavior that allowed the individual to avoid or escape from an aversive stimulus would increase in frequency through a process known as negative reinforcement. Two primary processes are thought to be involved in aversive control. First, through classical conditioning, the association of a non-aversive or neutral stimulus with an aversive stimulus may lead to conditioned emotional responding in the presence of the newly conditioned stimulus. An example may involve feelings of anxiety or fear in the victim of spousal abuse when in the presence of their abuser. Because conditioned emotional responses in these instances may be incompatible with previously punished responses (e.g., approaching one’s abuser), the latter may be reduced in frequency. Second, through operant conditioning, a stimulus previously associated with an aversive consequence may “set the occasion” for an avoidance or escape response. In the earlier example, the victim of past abuse may leave the room or avoid meeting their abuser entirely. These behaviors are negatively reinforced because they decrease or eliminate the occurrence of aversive consequences and are more likely to occur in the presence of aversive stimuli (e.g., the sight of one’s abuser).

Description Aversive control in couple and family relationships is present when one member of the family attempts to alter another’s behavior through aversive means. Aversive tactics have varied effects but are widely used. For example, most parents use punishments* such as time-out or spanking as a means of child discipline. In couples, one partner might withhold affection or sex as a means of control in the relationship. Although often immediately effective, aversive tactics have many potential side effects that may outweigh potential benefits.

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According to systems theory, the pattern of interaction observed in the use of aversive control is consistent with the concept of “reciprocal influence” in understanding the continuation of aversive control patterns. In the example above, a spouse might withhold affection to control their partner’s behavior, only to find the spouse resentful and further disengaged from the relationship. In the context of relationships, the use of aversive behaviors to control a partner or family member often leads to a decrease in couple or family relationship quality in the long run. Thus, the couple and family therapist is careful to observe the interactions between couples and family members, considering how each member’s use of aversive tactics might be reinforcing unwanted and dysfunctional behavior.

Application of Concept in Couple and Family Therapy Aversive tactics have been used as a means of treatment in therapy. Most notably, electric shock or other unpleasant aversive stimuli are paired with a desirable stimulus or behavior in what is often referred to as “aversion therapy.” Although these techniques have often been used to curb habitual, addictive, or (as seen in Kubrick’s film A Clockwork Orange) violent behavior, there are questions regarding their effectiveness and ethical use. No notable examples exist of aversion therapy being used in the context of family or couple treatment. Therapists considering the use of aversive control in therapy are advised to consider alternate techniques as no evidence suggests their efficacy. Therapists working with parents, however, may find themselves discussing aversive tactics for disciplining their child. Even in these instances, therapists and parents should be made aware of the potential side effects these tactics may have on the parent-child relationships. Aversive Control in Couples In couple relationships, aversive control is typically seen as strategically withholding positive experiences (e.g., positive affect, sexual intimacy) or using aversive antecedent stimuli (e.g.,

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nagging, threats) or consequences (e.g., physical violence) to curb undesired behavior. Within the couple system, more aversive control generally results in more aversive behavior. Both behavioral and systems theories suggest that the use of aversive control in romantic relationships is at best ineffective and at worst toxic to the overall satisfaction and functioning of the relationship. Some have suggested that the use of these tactics may result in the formation of “triangles,” most likely with children, which are further damaging to relationships outside of the couple. Common aversive strategies used in intimate relationships include emotional distancing/withdrawal, withholding affection/sex, nagging, threats, or violence. Behavioral couple therapists have noted that aversive control strategies are often the product of failed conflict resolution (Jacobson and Margolin 1979). More recent research by Gottman (1999) has further supported the potential pitfalls of aversive control. He notes four particularly destructive aversive tactics, which he calls the “four horsemen,” and studies how the presence of these tactics early in a relationship can help to predict the later dissolution of the same relationship. One of the more well-known, documented, and deleterious aversive tactics used in couples is intimate partner violence (IPV). Perhaps an extreme example of aversive control, IPV is unfortunately a common experience for couples, with some data indicating one in four women and one in ten men experiencing relationship violence in their lifetime (Black et al. 2011). IPV includes not only physical violence but many types of behavior aimed at controlling one’s partner through aversive means. For example, a partner may decide to limit or restrict a partner’s access to financial resources in an attempt to keep them from leaving the relationship. The use of aversive tactics to control a partner is also often referred to as coercive control. A hallmark of coercion* is the degree to which one partner controls or manipulates the other partner as an exertion of power. From a behavioral theory perspective, a perpetrator’s use of IPV is reinforced through their partner’s compliance, increasing the likelihood of further coercion* and violence. Many have noted the cyclical pattern that develops in violent

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relationships, where violent acts are usually met with a “honeymoon” phase of immense positive reinforcement. This further entrenches the victim and perpetrator in a cycle where violence is reinforced by both aversive and positive means. Couple therapists are highly encouraged to assess for IPV and coercion* when aversive tactics have been utilized in the relationship. Aversive Control in Families and Children The use of aversive control through punishment* is a common child-rearing practice in the USA. The use of aversive control as a means of discipline for children involves parents presenting some sort of aversive stimulus to either increase wanted behavior or decrease unwanted behavior. Popular aversive tactics include threats/yelling, spanking (corporal punishment), time-out, restriction, or abuse. In order for punishment* through aversive means to be effective, several conditions must apply. The punishment* should be delivered contingently, immediately, consistently, and without strong emotion. Aversive tactics are often considered in contrast to positive reinforcement techniques of child discipline. Aversive tactics (especially positive punishment) are often less advisable, as they are often associated with undesired side effects. For example, spanking a child may decrease their unwanted behavior, but it may also instill fear for the context in which the aversive control was used (referred to as “spread” or stimulus generalization). Furthermore, because punishment* is immediately effective, parents may be inclined to use aversive tactics in other situations. This limits the repertoire of parenting techniques, making aversive tactics more prominent. Some have argued, however, that aversive tactics for behavior change are not necessarily a “bad practice” and unavoidable (Perone 2003). Other evidence suggests, however, that the use of aversive control tactics on children is associated with outcomes such as poor school performance, difficulty with interpersonal relationships, and increased likelihood of depression and anxiety (see Gershoff and Grogan-Kaylor 2016). Much has been written about the use of corporal punishment as a means of child discipline. The

Aversive Control in Couple and Family Therapy

majority of Americans report their parents using spanking as a means of punishment* as a child, and the use of corporal punishment remains a common technique (Watts-English et al. 2006). Although much debate still exists, many behavioral researchers have argued that corporal punishment is a generally ineffective means of discipline. Furthermore, data indicates that the use of corporal punishment may have negative long-term consequences, although much debate about these findings persist (Gershoff and Grogan-Kaylor 2016). Scholars have argued that corporal punishment as a means of aversive control fails to teach the child why their behavior is wrong, elicits a physiological response that prevents the child from constructively learning, and establishes a negative and fearful relationship between the parent-child that will ultimately make other attempts at discipline more difficult. Additionally, some scholars have argued that using this method of aversive control unwittingly models violence as an acceptable means of relating to others.

Clinical Example In order to illustrate the impact of aversive control strategies in a romantic relationship, consider the following fictional case study. Ben and Abby have been married for 3 years and are expecting their first child. Although the couple is excited about the addition, Ben has unfounded concerns that Abby will leave him after the baby is born. He finds himself suspicious of the time Abby spends away from him and is overly critical of anything she does without him. He recently suggested she quit her part-time job to focus on getting the house ready for the baby. Ben’s suspicions, however, are making Abby increasingly uncomfortable. She finds his constant inquiry into her whereabouts as intrusive and unnecessary and has felt less desire to include Ben in her day-to-day experiences. She has even begun to sneak out of the house at times to avoid Ben’s inquisition. This, of course, only further fuels Ben’s suspicions and attempts at control Abby. One evening, Abby gets caught up at work and ends up staying an hour later. Her initial impulse to contact Ben to let him know she is running late is contrasted

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by the thought, “He shouldn’t have to know where I am twenty-four hours a day,” which in turn prevents her from letting him know of her situation. This results in Ben becoming increasingly irate, eventually leading him to drive to Abby’s place of work. Fuming, Ben storms into her work, demanding she leave with him, telling her co-workers, “I can’t believe you would keep a pregnant woman here this long. . .well, you can consider this her resignation!” Abby, embarrassed, leaves quickly and responds “I cannot believe you would do that. I am sick and tired of you trying to control my life. I think I need some space from you right now.” It would be advisable for a therapist working with this couple to consider the aversive control tactics and their impact on the overall relationship dynamic. In particular, the therapist might note Ben’s controlling strategies and follow this up with an assessment for IPV. If violence is not present, the therapist could bring to light the destructive reciprocal pattern of aversive control, paying particular attention to Ben’s suspicions. The couple therapist might want to encourage Ben to find a more positively reinforcing way to elicit reassurance from Abby about their relationship status.

Cross-References ▶ Behavioral Couple Therapy ▶ Couple Violence in Couple and Family Therapy ▶ Family Violence in Couple and Family Therapy ▶ Reciprocity in Couples and Families ▶ Violence in Couples and Families

References Black, M. C., Basile, K. C., Brieding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., et al. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Gershoff, T. E., & Grogan-Kaylor, A. (2016). Spanking and child outcomes: Old controversies and new metaanalyses. Journal of Family Psychology, 30(4), 453–469.

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206 Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. New York: W. W. Norton. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner Mazel. Perone, M. (2003). Negative effects of positive reinforcement. The Behavior Analyst, 26, 1–14 Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. New York: Appleton-CenturyCrofts. Thorndike, E. L. (1913). Educational Psychology. Vol 2. The psychology of learning. New York: Teachers College, Columbia University. Watts-English, T., Fortson, B. L., Gibler, N., Hooper, S. R., & De Bellis, M. D. (2006). The psychobiology of maltreatment in childhood. Journal of Social Issues, 62, 717–736.

Avis, Judith Linda Stone Fish Syracuse University, Syracuse, NY, USA

Introduction Judith Myers Avis, Ph.D., is professor emerita of couple and family therapy at the University of Guelph in Ontario Canada. As an educator, clinician, and researcher, her work has focused on gender, trauma, resilience, and re-storying in couple and family relationships, and draws on narrative, feminist, and mindfulness ideas.

Career Dr. Myers Avis graduated with a Ph.D. from Purdue University in 1986 and taught at the University of Guelph in the Family Relations and Applied Nutrition Department until her retirement in 2004, directing the couple and family therapy program for 2 years. She went on to a productive career as a professor, therapy consultant, supervisor, and practitioner in Guelph. Author or co-author of more than 40 journal articles and book chapters, Dr. Myers Avis has given conference presentations, keynote addresses, and invited workshops throughout the world.

Avis, Judith

Contributions to the Profession Dr. Myers Avis is best known for being one of the pioneers in the family therapy field, introducing feminist concepts into family therapy and family therapy training. In the late 1970s and early 1980s, a handful of woman began to publish and lecture about the absence of critical analysis of the hierarchical imbalance of gender in the family and the role that sexism plays in family and the family therapy field in general. Together they implored the field to re-evaluate and challenge the gender hierarchy in families. Her 1985 publication in the Journal of Marital and Family Therapy entitled, “The politics of functional family therapy: A feminist critique” was a groundbreaking analysis of one of the leading evidence-based therapy models and led to a call for all researchers and practitioners in the field to pay attention to the ways in which sexism permeates our consciousness and has the potential to do real harm to families in our care. The article was provocative enough that the editor asked for a response from functional family therapy’s founding theorists to which Dr. Myers Avis responded. Since that germinal article, Dr. Myers Avis has written over a dozen articles and multiple book chapters with the intent to infuse feminist informed thinking about gender into training and practice in the field. Not afraid to constructively critique founding family therapy theories through a feminist lens, she challenged dichotomous thinking, and urged the field towards a form of activism whose seeds bear fruits today. Her work has been recognized by awards from the American Association for Marriage and Family Therapy for Outstanding Contributions to Family Therapy, the American Family Therapy Academy for Innovative Contributions to Family Therapy, and the Hincks-Dellcrest Institute for Significant Contributions to the Field of Psychotherapy. In 2003, she was made an Honorary Fellow of St. Thomas University in Fredericton, New Brunswick in recognition of her contributions to social work knowledge, education, and practice. During her career, she has been on the editorial board of multiple journals in the field (Contemporary Family Therapy, Journal of

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Feminist Family Therapy, Journal of Marital and Family Therapy) and on the Board of Advisory Editors to Family Process. She has held numerous positions of leadership in the American Family Therapy Academy (AFTA) as well. She currently provides supervision, consultation, and workshop training to therapists and agencies, therapy to individuals and couples, and teaches mindfulness meditation.

Cross-References ▶ American Association for Marriage and Family Therapy (AAMFT) ▶ American Family Therapy Academy (AFTA) ▶ Feminism in Couple and Family Therapy ▶ Functional Family Therapy ▶ Gender in Couple and Family Therapy ▶ Journal of Marital and Family Therapy

References Avis, J. M. (1985a). The politics of functional family therapy: A feminist critique. Journal of Marital and Family Therapy, 11, 127–136.

207 Avis, J. M. (1985b). Through a different lens: A reply to Alexander, Warburton, Waldron and Mas. Journal of Marital and Family Therapy, 11, 145–148. Avis, J. M. (1988). Deepening awareness: A private study guide to feminism and family therapy. In L. Braverman (Ed.), Women, feminism and family therapy. New York: Haworth Press. Avis, J. M. (1991). The politics of empowerment. Journal of Feminist Family Therapy, 3, 141–153. Avis, J. M. (1992). Violence and abuse in families: The problem and family therapy’s response. Journal of Marital and Family Therapy, 18(3), 223–230. Avis, J. M. (1994). Advocates versus researchers – A false dichotomy? A feminist, social constructionist response to Jacobson. Family Process, 33, 87–91. Avis, J. M. (1996a). Deconstructing gender in family therapy. In F. P. Piercy, D. H. Sprenkle, & J. Wetchler (Eds.), A family therapy sourcebook (2nd ed., p. ##). New York: Guilford Press. Avis, J. M. (1996b). Feminist-informed training in family therapy: Approaching the millenium. In K. Weingarten, & M. Bograd (Eds.), Reflections on feminist family therapy training (p. ##). New York: Haworth Press. Avis, J. M. (2006). Escaping narratives of domination: Ideas for clinical practice with women oppressed by relationship violence. In R. Alaggia and C. Vine (Eds.), Cruel but not unusual: Violence in Canadian families – A sourcebook of history, theory & practice (p. ##). Waterloo: Wilfrid Laurier Press. Spitzer, B., & Avis, J. M. (2006). Recounting graphic sexual abuse memories in therapy: Impact on women survivors’ healing. Journal of Family Violence, 21(3), 173–184.

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Bacigalupe, Gonzalo Peter Fraenkel The City College of New York, New York, NY, USA

Name Gonzalo Bacigalupe, Ed.D., M.P.H.

Introduction Gonzalo Bacigalupe is a Chilean-American family psychologist who has made major contributions in the areas of theory, research, and practice, with a focus on utilization of emerging technologies in promoting health, mental health, and resilience for individuals, families, and communities struggling with chronic illness and in disaster response. He is also an innovative leader in the area of online/distance learning, qualitative research, and intimate and political violence.

Career Bacigalupe received a B.S. in Psychology from Pontifical Catholic University of Chile in 1984, an M.Sc. (Equivalent) in Clinical Psychology from Catholic University of Chile in 1986, an Ed.D. in Consulting and Counseling Psychology

and Family Therapy from the School of Education, University of Massachusetts Amherst in 1995, and an MPH in Family and Community Health, Department of Society, Human Development, & Health, Harvard University School of Public Health in 2007. He became a registered psychologist in Chile in 1986, was licensed in Massachusetts as a Marriage and Family Therapist (LMFT) in 1993, and received designation as an AAMFT Approved Supervisor in 1996. He is a member of several professional organizations both in Chile and the USA, including the Red Chilena de Psicología Política and Scientific Psychologist Society of Chile; the Society for Participatory Medicine (Founding Member); the American Psychological Association (Fellow since 2012); AAMFT where he has been a Fellow since 1993; and the American Family Therapy Academy since 1996, serving as a member and chair of several committees and on the Board of Directors, and where he was the first (and only, to date) international and Latino professional to serve as President (2013–2015). Bacigalupe has received numerous awards, research grants (27 in all), and fellowships, including a Career Development Award from the Department of Health & Human Services and Inter-University Programs of Latino Research, 1999–2000; a Fulbright Senior Research Scholar Award in 2004; an NIH P-60 award (2012–2016); and the 2016 Carolyn Attneave Diversity Award from the APA’s Society for Couple and Family Psychology.

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Bacigalupe began his academic career at Nova Southeastern University in 1994 and has been a faculty member since 1996 (Full Professor, 2012) in the Department of Counseling & School Psychology, College of Education and Human Development, University of Massachusetts Boston, where he served as Director of the Family Therapy Program (2005–2010, 2011–2017), as Department Chair (2007–2009), and is Principal Investigator, Communication and Emergent Technologies for Disaster Risk Reduction, Research Center for Integrated Disaster Risk Management (CIGIDEN), in Santiago, Chile. He has been a Visiting Professor in Chile (Doctoral Program, School of Psychology, Catholic University of Valparaiso, 2015–2016; School of Engineering, Catholic University of Santiago, Chile, 2016–2018) and in Spain (Universidad Nacional de Educación a Distancia, Madrid, Spain, 2006–present, and Department of Psychology, University of Deusto, Bilbao, 2010–2014) and has been a Research Collaborator and Program Evaluator on numerous projects in both countries, as well as in the USA, focusing mostly on community mental health. He also serves on several editorial boards for leading journals. Bacigalupe is also in private practice in Boston and Santiago.

Contributions to Profession Bacigalupe has authored or co-authored one book, 62 peer-reviewed articles, 21 book chapters, 4 white papers, 13 research monographs, 33 newsletter articles, and 21 editorials for Spanishand English-language publications, as well as 16 audiovisual products (videos and photography) and has presented world-wide. He has made wide-ranging contributions to the fields of family therapy and public health. He is one of the world’s leading experts in the application of emerging technologies to intervention in community health, emergencies and disaster relief, as well as technological advances in education. Bacigalupe has focused greatly on issues of health disparities for Latino individuals and families, as

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well as other oppressed and marginalized communities. He has documented and advocated for the impact of online communities for chronic illness patients. One special focus has been on the usefulness of emerging technologies in health interventions for adolescents. His stance is that technologies can be vehicles of empowerment for persons and communities to be full participants in their healthcare, and to be active in promoting their resilience and wellbeing. Through his participation and leadership in international research and medical treatment communities outside of family therapy, he has brought a systemic and social justice perspective to collaborative healthcare practice and public policy. He has also influenced emerging practices in the use of technology to aid transnational families in maintaining connection. Through his numerous leadership positions in academia and professional organizations, Bacigalupe has guided the field towards integrating concerns about social justice in research and interventions. He has mentored many colleagues and organizations as they enter the digital, online world of research, treatment, and online/distance learning. He has also made major contributions to qualitative research methodologies, especially in the use of analysis software. In addition to these seminal contributions, Bacigalupe has contributed to the field of intimate and political violence, especially in the Chilean context; the study of masculinity; and critical appraisal of social constructionist family therapy theory and practice. Importantly, he has argued that many so-called natural disasters occur due to sociopolitical conditions that put oppressed communities at greater risk. Bacigalupe has also pioneered the use of film and the arts in family therapy. A talented abstract painter in his own right, he draws upon visual representations of families’ struggles and solutions in his therapeutic work.

Cross-References ▶ Couple and Family Therapy in the Digital Era ▶ Global Mental Health with Couples and Families

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▶ Immigration in Couple and Family Therapy ▶ Latino/Latinas in Couple and Family Therapy ▶ Resilience in Couples and Families

References Bacigalupe, G. (2011). Is there a role for social technologies in collaborative healthcare? Families, Systems & Health, 29(1), 1–14. https://doi.org/10.1037/a0022093. Bacigalupe, G., & Askari, S. (2013). E-health innovations, collaboration, and healthcare disparities: Developing criteria for culturally competent evaluation. Families, Systems & Health, 31(3), 248–263. https://doi.org/ 10.1037/a0033386. Bacigalupe, G., & Lambe, S. (2011). Virtualizing intimacy: Information communication technologies and transnational families in therapy. Family Process, 50(1), 12–26. https://doi.org/10.1111/j.1545-5300.2010.01343.x. Bacigalupe, G., & Plocha, A. (2015). Celiac is a social disease: Family challenges and strategies. Families, Systems & Health, 33(1), 46–54. https://doi.org/10.1037/ fsh0000099. Bacigalupe, G., Velasco, J., Rosenberg, A., & Berríos, P. (2017). Medios sociales en la emergencia: Evidencia y recomendaciones para la gestión de desastres [Social media for emergency: Evidence and recommendations for disaster management] Spanish Edition. Santiago: CIGIDEN. ASIN: B01NAPL2AC.

Bandler, Richard Shalini Lata Middleton Alliant International University, Sacramento, CA, USA

Introduction Richard Bandler is a psychologist, philosopher, and a self-help author who has contributed significantly to the field of neurolinguistics. He is the cofounder of the field of neurolinguistic programming (NLP) and has also helped codevelop other models and techniques, including the metamodel, the Milton model, anchoring, the swish pattern, reframing, the belief change, nesting loops, chaining states, submodality applications, and timelines. Along with his various published books and articles, Bandler continues to contribute to the field through his workshops, seminars, and consulting work.

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Career Bandler attended the University of California (UC), Santa Cruz, where he received his Bachelor of Arts in philosophy and psychology in 1973. Two years later, he earned his Master of Arts in psychology from Lone Mountain College in San Francisco. Earlier in his career, Bandler worked with a number of notable figures including Virginia Satir, Milton Erickson, and Robert Spitzer. His work in the neurolinguistic field began when he met John Grinder who was a professor at the time when Bandler was a student at UC Santa Cruz. In 1974, Grinder and Bandler started creating a model of the language patterns used by Fritz Perls, Virginia Satir, and Milton Erickson. This model was published in their books The Structure of Magic, Volumes I & II (1975a, b) and Patterns of the Hypnotic Techniques of Milton H. Erickson, Volumes I & II (1976; 1977). These co-authored books by Grinder and Bandler served as the foundation of the field of neurolinguistic programming.

Contributions to Profession Bandler has made significant contributions to the field of couple and family therapy through the creation of his models, trainings, and writings, which have all facilitated clinicians’ ability to better understand and help people. Specifically, he is best known for codeveloping NLP, which is comprised of models and methods used to understand human communication and behavior in order to elicit change. Two major models that arose from Bandler and Grinder’s work with NLP include the metamodel and the Milton model. The metamodel documents language patterns through a series of questions that allow the individual to identify thinking patterns in another person. It responds to the distortions, generalizations, and deletions in the speaker’s language. This can be useful to individuals in various roles, including therapists, who are working to identify their clients’ thinking patterns in order to understand, modify, and/or change them. The Milton model is also helpful for therapists, as it can assist in shifting a listener into a more receptive state by using language that guides the clients from detail

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and content to deeper levels of cognition. NLP is widely used as a technique to elicit behavior change in the mental health field. Bandler continues to train individuals and clinicians in NLP and other self-help techniques that he has developed over the years. Bandler has over four decades of work that is available to those in the field of psychology as well as the general public. His work includes published books, articles, audios, and videos. He has developed numerous workshops and seminars which include neurohypnotic repatterning, design human engineering, persuasion engineering, personal enhancement, charisma enhancement, and hypnosis. He has also continued to write books to help progress the work of NLP. Bandler’s book How to Take Charge of Your Life (2014) discusses the importance of self-belief and how to change beliefs, how to control your emotions and negative thinking, and how to create the life you that want in order to create change. In the book, The Ultimate Introduction to NLP (2013), readers are given the tools to change their life by overcoming things such as phobias, depression, habits, psychosomatic illnesses, and learning disorders. Bandler’s book Get the Life You Want (2008) discusses simple NLP exercises the readers can do to transform their lives. Bandler’s work continues to live on through his students and the licensed institutes worldwide.

Cross-References ▶ Erickson, Milton ▶ Hypnosis in Couple and Family Therapy ▶ Metacommunication in Couple and Family Therapy ▶ Reframing in Couple and Family Therapy ▶ Satir, Virginia

References Bandler, R. (2008). Get the life you want: The secrets to quick and life change with neuro-linguistic programming. London: HCi. Bandler, R., & Grinder, J. (1975a). The structure of magic I: A book about language and therapy. Palo Alto: Science & Behavior Books.

Bateson, Gregory Bandler, R., & Grinder, J. (1975b). The structure of magic II: A book about communication and change. Palo Alto: Science & Behavior Books. Bandler, R., & Grinder, J. (1976). Patterns of the hypnotic techniques of Milton H. Erickson, M.D. Volume I. Cupertino: Meta Publications. Bandler, R., Grinder, J., & Delozier, J. (1977). Patterns of the hypnotic techniques of Milton H. Erickson, M.D. Volume II. Cupertino: Meta Publications. Bandler, R., Fitzpatrick, O., & Roberti, A. (2013). The ultimate introduction to NLP: How to build a successful life. London: HarperCollins. Bandler, R., Fitzpatrick, O., & Roberti, A. (2014). How to take charge of your life: The user's guide to NLP. London: HarperCollins.

Bateson, Gregory Douglas C. Breunlin1 and Rajeswari Natrajan-Tyagi2 1 The Family Institute at Northwestern University, Center for Applied Psychological and Family Studies, Northwestern University, Evanston, IL, USA 2 Couples and Family Therapy Masters and Doctoral Programs, California School of Professional Psychology at Alliant International University (Irvine), Irvine, CA, USA

Introduction Gregory Bateson was born into a highly acclaimed academic family in England in 1904. Bateson’s father, William, was the founder of the prestigious Cambridge School of Genetics. Bateson was named “Gregory” by his father after the famous geneticist, Gregor Mendel who is known as the father of genetics. While Bateson received his undergraduate degree in biology, he is also known as an anthropologist, cybernetic theorist, and a philosopher. He was known as a great cross-disciplinary thinker. He had a profound impact on the field of mental health, particularly the incorporation of cybernetic and systemic thinking into the field that led to the birth of family therapy. Bateson died in 1980.

Career Bateson obtained a Bachelor of Arts degree in biology in 1925 from St. John’s College,

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Cambridge. He then went on to teach linguistics at the University of Sydney in 1928. He was recruited by the Anthropology chair at Cambridge to do field work in the South Pacific where he spent several years. There he met and married Margaret Meade in 1936. He then moved to California. He worked at Saybrook University in San Francisco and at the University of California, Santa Cruz. He never settled into a discipline or into a tenured position. When he died, he was a scholar-in-residence at Esalen Institute in California.

Contributions to the Profession Bateson’s work in anthropology led to the publication of an important book, Naven in 1936. This book had a huge impact on the practice of anthropology as it argued that the anthropologist as observer does not report raw data but rather inferences about behavior viewed through the lens of the anthropologist’s theory. The book also proposed ideas about sequences of interaction or vicious cycles, mutual influence or recursiveness, and the mutual roles of the observer and the observed. These were seminal ideas that would later shape the epistemology that Bateson advocated for a paradigm shift in the field of mental health. One of Bateson’s early forays into the field of mental health occurred through his participation in the set of famous Macy conferences devoted to cybernetics (1946–1953). The purpose of these conferences was to establish a foundation for studying how the mind works. A rich multidisciplinary group of giants in their respective fields grappled with this topic. They employed cybernetics, systems theory, mathematics, biology, and anthropology to name a few. The Macy conferences advanced the understanding of cybernetics and systems theory and laid the foundation for the new field of cognitive science. Excited by these ideas and their application to the state of the art of mental health, Bateson did two things. He co-authored a book with Jurgen Ruesch titled: Communication: The Social Matrix of Psychiatry (1951) and he sought funding to study human communication. It is impossible to measure

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the critical impact Bateson’s direction would have on mental health and the yet to exist field of family therapy. Bateson did receive his funding to study communication of schizophrenic patients and began the Palo Alto project in 1952. The research team he assembled included himself, Jay Haley, John Weakland, and Don D. Jackson. It should be noted that only Jackson, a psychiatrist, had any formal training in mental health. The team’s first publication, Toward a Theory of Schizophrenia (1956), would become one of the most influential papers in the field of family therapy. In this paper, the team introduced the concept of the Double Bind which is a form of paradoxical communication. The article suggested that such paradoxical communication accounts for the bizarre communication of schizophrenics. The double bind theory was subsequently investigated in many research studies and found not to be a causal factor in schizophrenia; nevertheless, it remains seminal as a classic example of early theorizing that would evolve into the interactional view and the importance of family context in the formation and maintenance of human problems. The team was highly generative for a decade, publishing dozens of articles, many of them still considered classics. The team disbanded in 1961. Evan though Bateson had deeply touched the field of mental health and the early beginnings of family therapy, he wasn’t interested in therapy. Some of these views affected the relationship between him and Haley who was already writing about therapy. Haley and Weakland would become highly acclaimed in the field of family therapy. Jackson also contributed to the emergence of family therapy. He founded the Mental Research Institute (MRI) in 1958 but suffered an untimely death in 1968. Although Bateson no longer moved in the circles of mental health, he continued to be viewed as a visionary and many in the field of family therapy continued to follow his work closely. Two books by Bateson, widely popular among family therapists, are Steps to an Ecology of Mind (1972) and Mind and Nature: A Necessary Unity (1979). These books captured Bateson’s understanding of the foundational concepts that underpinned the enormous paradigm shift that had taken place during the previous quarter century and gave birth to the field of family therapy.

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Bateson’s writing has always been dense and challenging; hence, some have avoided it. In 2011, his younger daughter, Nora Bateson, produced a wonderful documentary DVD that beautifully captures what she believed were five of his most essential ideas. The first is relationship. All things exist in relationship to each other. The second is cybernetics. Processes exist that regulate the nature of any interaction. The third is ecology of mind. The mind is a network of ideas and not a thing. The fourth is epistemology. We must always be diligent about how we know, what we know. Finally, the fifth is difference. Information is a difference and one should always ask: what is the difference that makes a difference? Many other ideas could be added to this list, including systems theory, context, homeostasis, feedback family rules, circular causality, firstand second-order cybernetics, etc. Bateson was ahead of his times. Today many of the ideas that were radical for his time are a mainstay of how human systems are viewed. His genius changed the course of numerous disciplines including communications, anthropology mental health and its subspecialty, family therapy.

Cross-References ▶ Double Bind Theory of Family System ▶ Haley, Jay ▶ Homeostasis in Family Systems Theory ▶ Jackson, Donald ▶ Palo Alto Group, The ▶ Weakland, John

References Bateson, G. (1936). Naven: A survey of the problems suggested by a composite picture of the culture of a New Guinea tribe drawn from three points of view. Stanford University Press. ISBN 0-8047-0520-8. Bateson, G. (2000) [1972]. Steps to an ecology of mind: Collected essays in anthropology, psychiatry, evolution, and epistemology. Chicago: University of Chicago Press. ISBN 0-226-03905-6. Retrieved 19 Mar 2013.

Baucom, Donald Bateson, G. (1979). Mind and nature: A necessary unity (Advances in systems theory, complexity, and the human sciences). Hampton Press. ISBN 1-57273434-5. Bateson, N. (2011). An ecology of mind: A daughter’s portrait of Gregory Bateson. Oley: Bullfrog Films. Bateson, G., Jackson, D. D., Haley, J., & Weakland, J. H. (1956). Toward a theory of schizophrenia. Behavioral Science, 1, 251–264. Haley, J. (1981). Development of a theory: The history of a research project. In J. Haley (Ed.), Reflections on therapy and other essays. Rockville: The Family Therapy Institute of Washington, DC. Lipset, D. (1980). Gregory Bateson: The legacy of a scientist. Englewood Cliffs: Prentice Hall. Nichols, M. P. (2011). The evolution of family therapy. In The essentials of family therapy (pp. 7–28). Boston: Pearson. Ruesch, J.; Bateson, G. (2009) [1951]. Communication: The social matrix of psychiatry. W.W. Norton & Company. ISBN 978-1-4128-0614-5. Retrieved 19 Mar 2013. Stagoll, B. (2005). Gregory Bateson (1904–1980): A reappraisal. Australian & New Zealand Journal of Psychiatry, 39(11/12), 1036–1045. https://doi.org/ 10.1111/j.1440-1614.2005.01723.x.

Baucom, Donald Steffany J. Fredman1 and Kristina Coop Gordon2 1 The Pennsylvania State University, University Park, PA, USA 2 University of Tennessee, Knoxville, Knoxville, TN, USA

Donald H. Baucom, Ph.D., is the Richard Simpson Distinguished Professor of Psychology and Neuroscience at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) and a licensed clinical psychologist. He is a pioneer in the development and testing of couple-based interventions for the treatment of relationship distress, infidelity, individual psychopathology, and health concerns, as well as in the dissemination of couple therapies on an international scale. Baucom earned his Bachelor of Arts in Psychology (1971) and Doctor of Philosophy in Clinical Psychology (1976) from UNC-Chapel Hill and completed his doctoral internship in clinical

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psychology at the University of Minnesota (1976). He served as Assistant Professor of Psychology at Texas Tech University from 1976 to 1980 prior to joining the Psychology faculty at UNC-Chapel Hill, where he has conducted research, taught, and mentored students since 1980. He is a Professor of Psychology (1990–present) at UNC-Chapel Hill, where he also served as Director of the Clinical Psychology Program (1993–2003; 2004–2006). Baucom’s program of research focuses on optimizing relationship health and individual psychological and physical well-being within a relational context, and his primary contributions center on the translation of basic cognitive-behavioral research to empirically supported couple therapies designed to enhance relational and individual adjustment. His work has resulted in major paradigm shifts with respect to the treatment of relationship distress and infidelity, as well as conceptual and clinical models for the treatment of individual distress (e.g., individual psychopathology and health concerns) within a couple context. His early contributions focused on developing the clinical, theoretical, and empirical basis for behavioral couple therapy to ameliorate relationship distress. In collaboration with Dr. Norman Epstein, this approach was subsequently expanded to elevate cognition and affect to equal importance with behavior in the onset and maintenance of relationship distress, marking a major paradigm shift within the field. This innovation resulted in a seminal text on cognitive-behavioral couple therapy (Epstein and Baucom 2002) that provided both a theoretical and applied clinical model of couple functioning with respect to cognition, affect, and behavior, as well as the importance of considering individual differences in needs, personality, and affect regulation. Baucom’s work on the treatment of couples who have experienced infidelity, conducted in collaboration with Drs. Douglas Snyder and Kristina Coop Gordon (Baucom et al. 2011), marked a major innovation in the treatment of couples in which there has been a history of infidelity. Conceptualizing infidelity as a relational trauma, the work highlighted the

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importance of helping couples form a cogent narrative about the affair by exploring both proximal and distal factors that may have provided a context for the infidelity’s occurrence, considered essential for both partners’ ability to work through the negative impact of the infidelity regardless of whether they remain a couple going forward. Baucom and colleagues’ work on conceptualizing the treatment of individual distress within a couple/family context represented a major conceptual shift in the approach to the treatment of individual psychopathology and health concerns. In the late 1990s, he spearheaded a paper that offered a novel heuristic for thinking about ways to incorporate significant others into treatment when one member of a couple or family has a psychological or medical disorder (Baucom et al. 1998). This framework differentiated between interventions that considered the unit of intervention to be the identified patient versus the couple’s relationship and whether the intervention targeted individual symptoms, the way individual symptoms intersect with relationship adjustment, or the relationship more broadly. The different models for involving family members into care are conceptualized as (a) partner-assisted interventions, in which the primary focus is on the identified patient and the partner functions primarily as a surrogate therapist or coach; (b) disorder-specific interventions, in which the focus is on how the couple (or family) interacts focal to the disorder; or (c) generic couple therapy, in which the focus is on improving the couple or family’s relationship more generally to improve the emotional climate of the home, thereby reducing the identified patient’s subjective sense of environmental stress. Consistent with this conceptual model, Baucom has been at the forefront of the development and testing of disorderspecific couple-based treatments for individual psychopathology and health, resulting in innovative therapies for conditions including obsessivecompulsive disorder, eating disorders, depression, breast cancer, and heart disease. Baucom’s current work includes the dissemination of empirically supported couple therapies in real-world clinical settings both in the United States and abroad, including a national effort to

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disseminate couple therapy for depression to providers within Great Britain through the National Health Service.

References Abramowitz, J. A., Baucom, D. H., Boeding, S., Wheaton, M. G., Pukay-Martin, N. D., Fabricant, L. E., Paprocki, C., & Fischer, M. (2013). Treating obsessivecompulsive disorder in intimate relationships: A pilot study of couple-based cognitive-behavior therapy. Behavior Therapy, 44, 395–407. https://doi.org/ 10.1016/j.beth.2013.02.005. Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., & Stickle, T. R. (1998). Empirically supported couples and family therapies for adult problems. Journal of Consulting and Clinical Psychology, 66, 53–88. https://doi.org/10.1037/0022-006X.66.1.53. Baucom, D. H., Snyder, D. K., & Gordon, K. C. (2011). Helping couples get past the affair: A clinician’s guide. New York: Guilford Press. Baucom, D. H., Worrell, M., Corrie, S., & Fischer, M. S. (in progress). Engaging couples: Improving well-being and reducing distress with cognitive behavioural couple therapy. London: Routledge. Epstein, N., & Baucom, D. H. (2002). Enhanced cognitivebehavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association.

Bava, Saliha Kristen Benson Appalachian State University, Boone, NC, USA

Name Saliha Bava, Ph.D. (1969–)

Introduction Saliha Bava has offered numerous revolutionary, creative, and constructionist contributions to the field of couple and family therapy. She is an innovator of actively engaging the art of exploring play, risk-taking, and improve in clinical work, scholarship, and everyday life. She is a leader in engaging community leaders and nonprofit agencies in organizing collaborative disaster response. Bava addresses identity and social justice through

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collaborative-dialogic practices and hyperlinked identity, developing a concept coined from her doctoral research.

Career Bava graduated with honors from the University of Delhi, India. She earned her M.S. in Social Work from the Tata Institute of Social Sciences, India in 1992 and a post masters certificate in Research Methodology in 1997. She moved to the USA in 1995 to enroll in the Marriage and Family Therapy program at Virginia Polytechnic Institute and State University, where she earned her Ph.D. in Human Development in 2001. She completed the Executive Program for Nonprofit Leaders at Stanford University in 2009. Bava completed a doctoral fellowship at the Houston Galveston Institute (HGI) 1998–2000 and served as HGI’s Associate Director 2001–2009. There, she provided leadership and vision as an administrator, family therapist, clinical supervisor, consultant, and researcher. She worked closely with families referred by Harris County Child Protective Services and with school-based crisis intervention programs. In 2001, she launched improvisation-based, multifamily workshops for divorcing families funded by the Texas Office of the Attorney General. She also served as adjunct faculty in the MSc in Psychology Program at Our Lady of the Lake University. She has been affiliated with the Taos Institute (TI) since 2000 developing their online course offering, serving as faculty in the masters in Relational Leading and doctoral advisor for the Ph.D. program in the Social Sciences and currently their Advisory Board Member. In 2010, she joined the Marriage and Family Therapy Program faculty at Mercy College in Dobbs Ferry, NY, where she continues as a tenured associate professor. At Mercy, she has received grants to focus on equitable practices, play, and design thinking in engaging first-generation college students. Bava directs the Play Lab NYC to explore the generative potential of relational play in everyday living. Bava maintains a private practice in

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New York City as a Licensed Marriage and Family Therapist, supervisor, leadership coach, and consultant.

Contributions to the Profession Saliha Bava is known for her focus on creativity in life, leadership, research, pedagogy, and therapy from a play and performative perspective. She identifies creativity as relationally responsive in actively making/co-creating our identities, our social processes, and the world around us (Bava 2016, 2017, 2019). Bava’s integration of creativity in therapeutic healing is emphasized in her role as a group facilitator for Moving Our Embodied Stories: Creative Resilience Workshops for Survivors of Sexual Assault, which is based in New York City. Her playful approach is evident in the book she co-authored with her husband and partner in life, Mark Greene, titled The Relational Book for Parenting (2018). The book focuses on parenting as an ongoing relational activity of experimentation and improvisation rather than a scripted or prescriptive role through use of comics, games, and articles to engage families in growing their relational intelligence. Bava’s academic contributions emphasizes her questioning of the dominant academic discourses of research methodology, social justice, and identity through use of performative methodologies, socially just dialog, and hyperlinked identities. In this work, she bridges justice and identity and encourages a shift to consider how people live in a world that feels generative while there is subjugation happening. This challenge is reflected in her chapter, Hyperlinked Identity: A Generative Resource in a Divisive World which is published in McGoldrick and Hardy’s (2019) Re-visioning Family Therapy. Bava is pushing for conversation in her stance which acknowledges there is a practice of hegemony happening regarding knowledge and discourse about social justice, and challenges people in socially marginalized groups to refuse the burden of discussing social justice in ways defined by the dominant group by instead telling stories of agency and survival.

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Bava has contributed to revolutionary change in the ways that communities collaboratively respond to trauma and disaster. She served as the Director of Mental Health for Katrina Relief at George R. Brown Convention Center in Houston, TX in 2005. In this role, she led the initiative to respond to people with mental health needs who were displaced following Hurricane Katrina. She developed collaborative mental health response among University of Texas, Mental Health and Mental Retardation Authority of Harris County (MHMRA), City of Houston Disaster Mental Health Crises Response Team, and volunteers. She then served on the Katrina Behavioral Health and Emotional Support (KBHES) Network developing and implementing long-term disaster response. Her leadership and efforts were recognized when she was awarded the Exceptional Leadership and Service for the City of Houston and to the Citizens of the City of New Orleans by City of Houston’s Disaster Mental Health Crisis Response Team in July, 2006. Bava was the Program Director for the Community Partnership for Resiliency at the Houston Galveston Institute May 2006–January 2007 where she worked to connect various communities in an effort to strengthen Houston’s resiliency in response to Hurricanes Katrina and Rita. This led to designing a community-engaged project From Settlement to Community: A Collaborative Mental Health Model for Immigrants and Refugees, a model of emotional wellness using social engagement, collaborative learning and innovative approaches to mental health (trauma treatment) design and delivery. Bava again provided leadership as the Co-Director of Houston’s Ike Behavioral Health Response Team in 2009, following Hurricane Ike. Bava’s extensive experience with collaborative response to disaster and trauma is reflected in her ongoing work, including funded grants, her service as an International trainer and authored publications. In 2010, she was invited to be a faculty and research consultant for the International Trauma Studies Program affiliated with Columbia University, where she has focused on theater and psychosocial programing and served in designing a community engagement program for New York City’s Mental Health Service Corp.

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She has offered notable service to the profession in various ways. Bava is the Co-Founder & Co-Editor of the International Journal of Collaborative-Dialogic Practices. In 2009, she co-founded and serves on the board of International Collaborative-Dialogic Certificate Program. She served on the American Family Therapy Academy board (2012–2017). Bava is an AAMFT approved supervisor and Clinical Fellow.

Beach, Steve trauma: Impact and recovery issues. New York: Nova Science Publishers. Bava, S., Coffey, E., Weingarten, K., & Becker, C. (2010). Lessons in collaboration, four years post-Katrina. Family Process, 49(4), 543–558. Bava, S., Chaveste, R., & Molina, P. (2018). Collaborativedialogic practices: A socially just orientation. In C. Audet & D. Pare (Eds.), Social justice and counseling. New York: Routledge.

Beach, Steve Cross-References ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Creativity in Couple and Family Therapy ▶ Houston Galveston Institute ▶ Play in Couple and Family Therapy ▶ Social Constructionism in Couple and Family Therapy

Frank D. Fincham Florida State University, Tallahassee, FL, USA

Name Steven R. H. Beach

Introduction References Bava, S. (2005). Performance methodology: Constructing discourses and discursive practices in family therapy research. In D. Sprenkle & F. Piercy (Eds.), Research methods in family therapy (2nd ed.). New York: Guilford Press. Bava, S. (2016). Making of a spiritual/religious hyperlinked identity. In D. R. Bidwell (Ed.), Spirituality, social construction and relational processes. Chagrin Falls: Taos Institute Publications. Bava, S. (2017). Creativity in couple and family therapy. In J. L. Lebow, A. L. Chambers, & D. Breunlin (Eds.), Encyclopedia of couple and family therapy. New York: Springer. https://link.springer.com/referenceworkentry/ 10.1007/978-3-319-15877-8_226-1. Bava, S. (2019). Hyperlinked Identity: A generative resource in a divisive world. In M. McGoldrick & K. Hardy (Eds.), Revisioning Family Therapy: Addressing Diversity in Clinical Practice. New York, NY: Guilford Press. Bava, S., & Greene, M. (2018). The relational book for parenting. New York: Think Play Partners. Bava, S., & Levin, S. (2012). Collaborative therapy: Performing reflective and dialogic relationships. In A. Lock & T. Strong (Eds.), Discursive perspectives in therapeutic practice. Oxford: Oxford University Press. Bava, S., & Saul, J. (2012). Implementing collective approaches in mass trauma and loss in western contexts. In K. M. Gow & M. J. Celinski (Eds.), Mass

Steven R. H. Beach is well known in clinical psychology for his extensive contributions to marital therapy and particularly the use of marital therapy in the treatment of depression. His many contributions to the field include elucidation of self-evaluation maintenance processes in relationship contexts; work on forgiveness, gratitude, and religiosity, in marriage; the role of broader family processes, especially parenting, on healthy psychosocial development; and, more recently, examination of the contribution of genetics and epigenetics in combination with family and community factors in predicting inflammatory and health outcomes.

Career Dr. Beach studied under K. Daniel O’Leary at Stony Brook University where he received his Ph.D. degree in 1985. He then relocated to the University of Georgia where he has been ever since. His initial work was in a psychiatric hospital, in a student metal health clinic, and in private practice. He began his academic career as an assistant professor at the

Beach, Steve

University of Georgia in 1987 and became director of the Owens Institute for Behavioral Research in 2003, and Distinguished Research Professor in 2007. Since 2009 he has served as codirector of the Center for Family Research at the University of Georgia.

Contributions Dr. Beach’s early work experiences led him to focus on issues with the potential to advance both the practice of clinical psychology and the prevention of psychological disorder. This led to pioneering work on depression, particularly the way that marital processes covaried with and influenced the course of depressive episodes. Using the large literature on stress and social support, Dr. Beach developed a theoretical framework that both detailed various interpersonal provisions related to depression and underscored the likelihood that spouses could play a central role in recovery from depression. This model, later published in book form (Beach et al. 1990), received many accolades and garnered considerable attention. The treatment model presented in the book, Depression in Marriage, helped to influence the thinking of a generation of researchers and changed the practices of clinicians. Dr. Beach’s success in using marital therapy as a treatment for depression underscored the importance of intimate relationships in understanding this disorder. Over the course of the ensuing decade, his surprising findings were replicated across several laboratories in the USA and across national boundaries. Dr. Beach began to expand the focus of his research using the self-evaluation maintenance tradition as a useful framework for more detailed examination of the way the interpersonal could affect the intrapersonal. The model is experimental and so had the potential to provide a useful counterpoint to intervention-based research by allowing identification of causal mechanisms. In this research Dr. Beach found that married partners tended to divide decision-making in a manner that protects each partner’s self-evaluation. Further, spouses tend to engage more in activities that supported each partner’s self-evaluation and are more likely to recall satisfying relationship memories when

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self-evaluation needs were supported. As this line of research unfolded, it became clearer that selfevaluation was commonly and perhaps continuously influenced by events involving the partner. Indeed, as a subsequent line of investigation showed, romantic partners, particularly marital partners, were especially good at adjusting their selfdefinition to fit with their partner. When outperformed by the partner in a given area, persons in committed relationships showed little negative affect (unlike persons interacting with strangers), instead showing an increased tendency to change the importance of the area to their self-evaluation. Conversely, Dr. Beach discovered that when the opportunity to change self-evaluation was blocked, it resulted in more negative recollections about the couples’ past together and led to more negative problem-solving interactions. Dr. Beach has noted that many apparently intractable marital disputes may be fruitfully conceptualized as resulting from automatic self-defensive processes like those described by the self-evaluation maintenance model. More recently, Dr. Beach has shifted his research again, focusing increasingly on prevention, the role of biological variables, and ways for families and marriages to protect against the stresses of disadvantage, poverty, and racism. Building on his earlier work, he has designed two culturally sensitive programs to enhance couple functioning. These programs are designed to help sustain couple satisfaction over time, to enhance co-parenting, and to provide health protective benefits for both couples and their children. Dr. Beach has provided evidence that parenting-based interventions decrease parental depression and enhance parental health. Results to date indicate that positive, constructive marital and parenting processes can be promoted by both “in-home” and “group-based” intervention programs and that these changes have the potential to promote the health and well-being of parents and offspring. Dr. Beach’s work has provided a conceptual foundation that has inspired many researchers to follow in his footsteps and has placed many clinical practices on a firmer scientific foundation. He published seminal papers on the connection

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between marriage and depression as well as on self-evaluation maintenance in marriage and on the role of epigenetic change in understanding environmental effects on long-term health outcomes. He established a well-described program to help couples dealing with both marital discord and depression. Likewise, he has more recently developed several programs of preventive interventions aimed at couples to help them work together to protect their relationships against the erosive power of external stressors arising from financial strain and from society more broadly. In brief, Dr. Beach’s research has led the marital area in a number of new, productive areas and continues to do so today.

Cross-References ▶ African Americans in Couple and Family Therapy ▶ Behavioral Couple Therapy ▶ Depression in Couple and Family Therapy ▶ Research About Couple and Family Therapy

References Beach, S. R. H., & Sales, J. M. (2016). Refining Prevention: Genetic and Epigenetic Contributions. Retrieved from http://www.frontiersin.org/books/Refining_Pre vention_Genetic_and_Epigenetic_Contributions/846 Beach, S. R. H., Sandeen, E. E., & O’Leary, K. D. (1990). Depression in marriage: A model for etiology and treatment. New York: Guilford. Beach, S. R. H., Wamboldt, M., Kaslow, N., Heyman, R. E., First, M. B., Underwood, L. G., & Reiss, D. (2006). Relational processes and DSM-V: Neuroscience, assessment, prevention & intervention. Washington, DC: American Psychiatric Publishing. Beach, S. R. H., Brody, G. H., Barton, A. W., & Philibert, R. A. (2016a). Exploring genetic moderators and epigenetic mediators of contextual and family effects: From GE to epigenetics. Development and Psychopathology, 28(4pt2), 1333–1346. https://doi.org/ 10.1017/S0954579416000882. Beach, S. R. H., Lei, M. K., Brody, G. H., Kim, S., Barton, A. W., Dogan, M. V., & Philibert, R. A. (2016b). Parenting, SES-risk, and later young adult health: Exploration of opposing indirect effects via DNA methylation. Child Development, 87(1), 111–121. https://doi.org/ 10.1111/cdev.12486. NIHMSID 739989.

Beavers Systems Measures, The

Beavers Systems Measures, The Alan Carr School of Psychology, University College Dublin and Clanwilliam Institute Dublin, Dublin, Ireland

Name and Type of Measure The Beavers Systems Measures assess family functioning from clinician and client perspectives. The Beavers Interactional Scales (BIS) are a set of rating scales for completion by clinicians or researchers observing family interaction. The Self-Report Family Inventory (SFI) is a questionnaire for completion by literate family members over 11 years.

Introduction Family competence and family style are the two main dimensions of the Beavers Systems Model of Family Functioning (Beavers and Hampson 1990, 2000). The competence dimension ranges from optimal through adequate, midrange, and borderline to severely dysfunctional. The style dimension ranges from centripetal to centrifugal. When the two dimensions are combined, they define nine distinct family groupings, three of which are relatively functional and six of which are dysfunctional. A family’s status on the competence and style dimensions may be established with the BIS and SFI.

Developers The BIS and SFI were developed by W. Robert Beavers, M.D. Emeritus Clinical Professor of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

BIS: Description and Psychometric Properties There are two BISs, one of which assesses family competence and the other family style (Beavers and Hampson 1990). Ratings are based on observations

Beavers Systems Measures, The

of families discussing the question, What would you like to see changed in your family?, for 10 min. Each interactional scale is made up of a number of 5- or 10-point subscales. The Beavers Interactional Competence Scale in composed of the following 13 subscales: 1. Structure of the family 1.1 Overt power (from chaotic to egalitarian) 1.2 Parental coalitions (from parent-child coalition to strong parental coalition) 1.3 Closeness (from indistinct boundaries to distinct boundaries) 2. Mythology (from congruent to incongruent) 3. Goal-directed negotiation (from extremely efficient to extremely inefficient) 4. Autonomy 4.1. Clarity of expression (from very clear to unclear) 4.2. Responsibility (from regular to rare acceptance of responsibility for actions) 4.3. Permeability (from very open to unreceptive) 5. Family affect 5.1. Range of feelings (from direct expression of a wide range to little expression) 5.2. Mood and tone (from warm and optimistic to cynical and pessimistic) 5.3. Unresolvable conflict (from severe unresolved conflict to none) 5.4. Empathy (from consistent empathy to none) 6. Global health pathology (from pathological to healthy) The Beavers Interactional Style Scale evaluates family style, which may range from centrifugal to centripetal. Members of centrifugal families look outside the family for their needs to be met, and members of centripetal families look within the family for need fulfillment. The family style scale is composed of eight subscales: 1. Meeting dependency needs (from needs ignored to met alertly) 2. Managing conflict (from open to covert) 3. Use of space (from much space between members to very close)

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4. Appearance to outsiders (from try to make a good impression to unconcerned) 5. Professed closeness (emphasize closeness to deny closeness) 6. Managing assertion (discourage to encourage assertion) 7. Expression of positive and negative feelings (mainly positive to mainly negative) 8. Global style (from centripetal to centrifugal) The Beavers Interactional Competence and Style Scales have good reliability. Kappa inter-rater reliability coefficients for subscales exceed 0.75, and Cronbach alpha internal consistency reliability coefficients exceed 0.88. With respect to validity, the competence scale has been shown to discriminate between families with hospitalized adolescents and nonclinical families and to correlate above r = 0.6 with the SFI and the general functioning subscale of the McMaster Family Assessment Device (FAD, Miller et al. 1985). The family style scale has been found to predict internalizing versus externalizing diagnoses of patients.

SFI: Description and Psychometric Properties The SFI is a 36-item questionnaire which measures five family domains: health/competence, conflict, cohesion, leadership, and emotional expressiveness (Beavers and Hampson 1990). The health/competence subscale includes 19 items involving family affect, parental coalitions, problem-solving abilities, autonomy and individuality, optimistic vs. pessimistic views, and acceptance of family members. The conflict subscale includes 12 items involving overt versus covert conflict. The cohesion subscale includes five items dealing with family togetherness. The leadership subscale includes three items involving parental leadership, directiveness, and rigidity of control. Finally, the emotional expressiveness subscale includes six items dealing with verbal and nonverbal expression of warmth. Responses to items are given on 5-point Likert scales. The SFI has high internal consistency reliability with Cronbach alphas and test-retest reliabilities above 0.8. It also has a good validity with

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correlations above 0.6 with the Beavers Interactional Competence Scale and the general functioning subscale of the FAD.

Example of Application in Couple and Family Therapy The scores of the mother, father, and 14-year-old depressed daughter of the Burke family on the BIS competence scale and the SFI competence scale improved after eight sessions of family therapy. Treatment focused on helping the parents develop a more supportive and less critical relationship with their daughter, who had become withdrawn, depressed, and argumentative in 6 months after the family moved from the UK to Ireland.

Beavers, W. Robert

Introduction W. Robert Beavers was a leading figure in family systems therapy and made significant contributions to the field. Based on his own research he developed the Beavers System Model of Family Functioning, which provides the structure and tools for assessing families. Additionally, he provided treatment and intervention techniques for working with families. Beavers also suggested some insights on using a systems approach in couples’ therapy and supervising from a family systems perspective. Beavers contributed 3 books and over 40 journal articles to the field.

Career Cross-References ▶ Family Assessment Device

References Beavers, W. R., & Hampson, R. B. (1990). Successful families: Assessment and intervention. New York: W.W. Norton. (Contains the BIS and SFI). Beavers, W. R., & Hampson, R. B. (2000). The Beavers Systems Model of family functioning. Journal of Family Therapy, 22(2), 128–143. Miller, I. W., Epstein, N. B., Bishop, D. S., & Keitner, G. I. (1985). The McMaster Family Assessment Devise: Reliability and validity. Journal of Marital & Family Therapy, 11, 345–356.

Beavers, W. Robert Ester Yesayan1 and Armine Gevorkyan2 1 Los Angeles, CA, USA 2 California Department of Corrections and Rehabilitation (CDCR), Los Angeles, CA, USA

Name William Robert “Bob” Beavers, M.D. (born September 27, 1929)

W. Robert Beavers completed medical school at the University of Texas Southwestern Medical Center in 1953. Following graduation he completed an internship at the Wayne County General Hospital in Eloise, Michigan. He then completed a fellowship in pharmacology (1954–1955), after which he spent 2 years in the Air Force in the Arctic, conducting research. He then became an assistant professor of pharmacology for 3 years, during which time he also completed residency in internal medicine, eventually becoming chief resident, in St. Paul Hospital, in Dallas, Texas. W. Robert Beavers completed a residency in psychiatry at the University of Texas Southwestern Medical Center from 1960 to 1963. After completing his residency he joined the faculty of the Medical School once again, this time as an assistant professor of psychiatry. He was also a psychiatry attending at the Parkland Memorial Hospital and conducted psychiatry consultations at the Terrell State Hospital. W. Robert Beavers founded a nonprofit counseling center in 1973, called the FamilyStudies Center of Dallas, which is dedicated to advancing family-based approaches to treating mental disorders, and is also a training center for psychiatry residents, psychology graduate students, and medical students of the University of Texas Southwestern Medical Center of Dallas.

Beavin, Janet

Contributions to Profession W. Robert Beavers has been a prominent contributor to the field of family psychiatry. He developed scientific approaches to family-based therapy and extensively examined family dynamics in his work. Beavers was interested in studying the difference between healthy and disturbed family dynamics and developed a family model that provided a classification system for family therapists. Beavers derived the information for identifying healthy and disturbed families from the research studies of nonlabeled, healthy, “normal,” or functional families and clinically referred families. From this empirical data, he developed the Beavers Systems Model of Family Functioning, which has been extensively used in family assessment. The Beavers Systems Model of Family Functioning provides a crosssectional perspective on family functioning on two dimensions, family competence and family style of interactions. The Beavers Interactional Scales are used by a trained rater to classify a family into one of nine categories or family groupings, including optimal families, adequate families, midrange families, borderline families, and severely dysfunctional families. A Self-Report Family Inventory (SFI) is also included in the Beavers Systems Model, which measures five family domains – health/competence, conflict, cohesion, leadership, and emotional expressiveness. Beavers developed this model with the intention to help promote systems thinking for therapists who were new to family therapy and to provide a structure for guiding assessment and therapy. Beavers also examined families from a variety of different ethnic and socioeconomic backgrounds to examine differences in family interactions. Based on his studies, he was able to determine the two separate characteristics that determined functional families, (1) expressed or implied beliefs and (2) observable patterns. Finally, Beavers emphasized the importance of the functionality of the family system and its relationship to psychological disorders. He was a strong advocate for adequate client care and was devoted to advancing family approaches in treating mental disorders. Thus, in 1973 Beavers founded the Family Studies Center in Dallas,

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which is a non-profit counseling center. The focus of treatment at the Family Studies Center is on the interaction between the clients and their families. The center also provides clinical training in the application of family interventions for future mental health and medical practitioners.

Cross-References ▶ Family Assessment Device

References Beavers, W. R. (1977). Psychotherapy and growth: A family systems perspective. New York: BrunnerMazel. Beavers, W. R. (1981). A systems model of family for family therapists. Journal of Marital and Family Therapy, 7, 299–307. https://doi.org/10.1111/j.17520606.1981.tb01382.x. Beavers, W. R. (1982). Healthy, midrange and severely dysfunctional families. In F. Walsh (Ed.), Normal family processes. New York: Guilford Press. Beavers, W. R., & Hampson, R. B. (1990). Successful families: Assessment and intervention. New York: Norton & Co. Beavers, W. R., & Hampson, R. B. (1993). Measuring family competence: The Beavers systems model. In F. Walsh (Ed.), Normal family processes (2nd ed.). New York: Guilford Press. https://doi.org/10.4324/ 9780203428436_chapter_20. Beavers, W. R., & Hampson, R. B. (2000). The Beavers systems model of family functioning. Journal of Family Therapy, 22, 128–143. https://doi.org/10.1111/ 1467-6427.00143. Lewis, J. M., Beavers, W. R., Gossett, J. T., & Phillips, V. A. (1976). No single thread: Psychological health in family systems. New York: Brunner-Mazel.

Beavin, Janet Jasmine Pickens Alliant University, Sacramento, CA, USA

Name Janet Beavin Bavelas, PhD, F.R.S.C. (February 12, 1940–)

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Introduction Janet Beavin is a pioneer in the field of communication theory and contributed substantially to the field of Marriage and Family Therapy (MFT) through her research regarding therapeutic and interpersonal communication. She authored several books including Personality: Current Theory and Research and has co-authored Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies, and Paradox, as well as the book, Equivocal Communication. She has published nearly one hundred articles in professional journals. Her work has been used to develop solution focused brief therapy (SFBT) as an evidenced-based practice.

Career Beavin began her education at Stanford University in 1961 where she received her Bachelor of Arts in Psychology. Beavin then went on to obtain a Master of Arts in Communication Research in 1968, and a PhD in Psychology in 1970 also from Stanford University. Prior to completing her graduate and doctoral degrees, Beavin was a research assistant (1961–1966) and later a research associate (1966–1970) for the Mental Research Institute of the Palo Alto Medical Research Foundation, commonly referred to as the MRI (Beavin Bavelas 2007). During this time, she co-authored Pragmatics of Human Communication, which remains as a foundational text in the field of Marriage and Family Therapy and communication theory (Watzlawick et al. 2011). In the early 1970s, Beavin moved to Canada where she became an assistant professor at University of Victoria in Victoria, British Colombia (Signorielli 1996). She retired from this institution in 2005 as Professor Emeritus of Psychology. Beavin continues to research and provide lectures regarding the power of interaction and focuses on the study of face-to-face dialogue through microanalysis. She has received several awards for her work as a researcher and educator. Most notably, in

Beavin, Janet

2012, Beavin received the Steve de Shazer award by the Solution Focused Brief Therapy Association for her work as a researcher.

Contributions to the Profession Beavin’s contribution to the field began when she collaborated with Paul Watzlawick and Don Jackson to co-author Pragmatics of Human Communication, a book that challenged traditional communication theory. Prior to the publication, the information-transmission model was used as the primary analysis of communication. The purpose of therapeutic communication was to gather information in the form of monologues between client and therapist. In this format, the therapist influenced the client and the direction of treatment. Beavin and colleagues believed that therapeutic communication should be more of a dialogue where communication is co-constructed between two individuals and involved moment by moment influence (Beavin and Watzlawick 1967). Beavin and fellow authors summarized the findings on interpersonal communication in five axioms: (1) it is impossible to not communicate. Even in silence, communication continues to occur. Anti-behavior does not exist. (2) Communication is not just the words expressed; it also includes how the sender of information wants to be understood and how they understand the receiver. (3) The nature of any relationship is dependent on punctuation. Communication is cyclical. Communicants structure the interaction and are interpreting their own behavior based on their reaction to the other’s behavior. (4) Analog modalities are also involved in human communication. Nonverbal and analog-verbal communication is just as vital as digital communication and one cannot exist without the other. (5) Interactional communication procedures are either symmetric or complimentary, which is based upon the relationship of the communicants (Watzlawick et al. 2011). Beavin views Pragmatics of Communications as the turning point of her career and

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paved the way for her future research in the field of psychology and communication (Beavin Bavelas 2007). Beavin’s focus remains in the study of interactional communication and most notably, her research has continued to develop microanalysis of face to face dialogue (MFD). Beavin defined MFD as a detailed examination of observable communication as it occurs in the moment. Beavin’s communication theory places importance on the here and now interaction which has heavily influenced the practice of SFBT, a major MFT model and is taught in most MFT graduate programs (Bavelas et al. 2016). Her current research team includes prominent practitioners and researchers focused on SFBT who are using microanalysis to expose the power of language in therapy dialogues (Beavin Bavelas 2012). Beavin’s work has been essential in helping to define SFBT as an evidenced-based practice.

Cross-References ▶ Communication Theory ▶ Jackson, Donald ▶ Metacommunication in Couple and Family Therapy ▶ Solution-Focused Couple and Family Therapy ▶ Watzlawick, Paul

References Bavelas, J., Gerwing, J., Healing, S., & Tomori, C. (2016). Microanalysis of face-to-face dialogue. An inductive approach. In C. VanLear & D. Canary (Eds.), Researching interactive communication behavior (pp. 129–157). Thousand Oaks: Sage. Beavin Bavelas, J. (2007). Writings with Paul. Journal of Marital and Family Therapy, 33, 295–297. Beavin Bavelas, J. (2012). Connecting the lab to the therapy room. Microanalysis, co-construction, and solution-focused brief therapy. In C. Franklin, T. Trepper, W. Gingerich, & E. McCollum (Eds.), Solution-focused brief therapy. A handbook of evidenced-based practice (pp. 144–162). New York: Oxford University Press. Beavin, J., & Watzlawick, P. (1967). Some formal aspects of communication. American Behavioral Scientist, 10(8), 4–8. https://doi.org/10.1177/0002764201000802.

225 Signorielli, N. (Ed.). (1996). Women in communication: A biographical sourcebook. Westport: Greenwood Press. Watzlawick, P., Beavin Bavelas, J., & Jackson, D. D. (2011). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York: W. W. Norton & Company.

Becvar, Dorothy Karen Caldwell Appalachian State University, Boone, NC, USA

Introduction Dorothy Becvar is a licensed marriage and family therapist and a licensed clinical social worker whose contributions to the field of family therapy include teaching family therapy to graduate students in university settings and authoring influential texts. Her contributions also include her many presentations to professional organizations, service on editorial boards, and provision of leadership in family therapy associations.

Career Dr. Becvar completed her MSW degree at Saint Louis University in 1980 and a PhD program in Family Studies at Saint Louis University in 1983. Her professional career began in Philadelphia, PA, leading family clusters, enrichment groups for whole families in church settings. She began her academic career at the University of Missouri-St. Louis and subsequently held academic positions at Saint Louis University, Texas Tech University (Lubbock, TX), the George Warren Brown School of Social Work at Washington University (St. Louis, MO), and Radford University (Radford, VA). Her final academic position was as Professor and now Professor Emerita at Saint Louis University. She also has maintained a private practice, either full- or part-time, since 1980, and serves

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as president/CEO of The Haelan Centers ®, a not-for-profit organization dedicated to facilitating growth and wholeness in body, mind, and spirit. Created as a memorial to her son, who was killed in a bicycling accident in 1987, the Haelan Centers help clients regardless of their ability to pay.

Contributions to Profession In addition to her university teaching, she traveled extensively, both nationally and internationally, to give presentations on a range of topics including spirituality, grief, systems theory, resilience, and supervision. Her writings are extensive and include many journal articles, book chapters, and books (Becvar 1997, 2001, 2007, 2013; Becvar & Becvar 1994, 2013; Becvar et al. 1982; Nichols et al. 2000). Relative to service to the profession, she was editor of Contemporary Family Therapy: An International Journal for 5 years. She provided two decades of service to the American Association for Marriage and Family Therapy as a leader in the state association, as a member of the Board of Directors, and as chair of the Standards Committee of the national association. She also provided leadership for a decade to the International Family Therapy Association serving on the Board of Directors and as chair of the International Accreditation Commission on Systemic Therapy Education.

Beels, Christian

References Becvar, D. S. (1997). Soul healing: A spiritual orientation in counseling and therapy. New York: Basic Books. Becvar, D. S. (2001). In the presence of grief: Helping family members resolve death, dying, bereavement and related end of life issues. New York: Guilford Press. Becvar, D. S. (2007). Families that flourish: Facilitating resilience in clinical practice. New York: W. W. Norton. Becvar, D. S. (Ed.). (2013). Handbook of family resilience. New York: Springer. Becvar, D. S., & Becvar, R. (1994). Hot chocolate for a cold winter’s night: Essays for relationship development. Denver: Love Publishing Co. Becvar, D. S., & Becvar, R. J. (2013). Family therapy: A systemic integration (8th ed.). Boston: Allyn & Bacon. Becvar, R. J., Becvar, D. S., & Bender, A. E. (1982). Let us first do no harm. Journal of Marital and Family Therapy, 8(4), 385–391. Nichols, W. C., Nichols, M. A., Becvar, D. S., & Napier, A. Y. (Eds.). (2000). The handbook of family development: Dynamics and interventions. New York: Wiley.

Beels, Christian Marjha Toni Hunt Couple and Family Therapy, Alliant International University, Sacramento, CA, USA

Name C. Christian Beels

Cross-References

Introduction

▶ Ambiguous Loss in Couple and Family Therapy ▶ American Association for Marriage and Family Therapy (AAMFT) ▶ Individual Supervision in Couple and Family Therapy ▶ International Family Therapy Association ▶ Loss in Couples and Families ▶ Resilience in Couples and Families ▶ Spirituality in Couple and Family Therapy ▶ Systems Theory

C. Christian Beels has been called a “Hero in Community Psychiatry.” Beels was a pioneer in training professionals on how to work from a collaborative family perspective in public mental health.

Career Beels earned a B.A from Harvard University in 1953. In 1960, he went on to earn his MD at the University of Rochester School of Medicine and

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Dentistry. Beels entered residency at an AECOM’s teaching facility, Jacobi Hospital. After residency, he began a fellowship at the National Institute for Mental Health and began his work with individuals and families struggling with schizophrenia. Beels later joined the Tremont Crisis Center. He later became the director of both the in-patient and the out-patient services at the Bronx State Psychiatric Center and renamed this program Family Service Bronx State Hospital. In 1980, he received a Master of Science degree in psychiatric epidemiology from Columbia University School of Public Health. In 1981, Beels created the Fellowship in Public Psychiatry at the New York State Psychiatric Institute and served as the director of the program through 1987. Although he left this position upon retiring in 1987, this program is still thriving today. He has held numerous positions in the field from family therapist, various director positions, many assistant and associate professor, as well as part-time teaching positions. He serves as faculty at Ackerman Family Therapy Institute.

Contributions to Profession Beels has been known for his nontraditional psychotherapeutic approach. He has a background and interest in anthropology, which underlies his focus on social connections and historical impact. In creating the Fellowship in Public Psychiatry, he wanted to train early career psychiatrists in remaining cognizant of the patients’ family support systems, multistoried accounts, and their historical context when working with individuals diagnosed with mental illness. Beels was a major moving force in the development of family therapy and the journal Family Process. He brought with him his emphasis in community psychiatry to the field; most especially, in promoting humane family treatments for those with severe mental illness. Later, Beels met and instantly made a personal connection with the developers of narrative therapy, Michael White and David Epston in 1982. Although he didn’t have a name for it at the time, he had similar ways of thinking that aligned with the values that narrative therapy.

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In The Invisible Village, Beels discusses ways in which the culture and the dominant discourse play a role in the trajectory of schizophrenia. He suggests that western cultures views can negatively impact those challenged with this mental illness. Beels emphasizes that in addition to societal expectations of the individual at this specific developmental stage, the person support diminishes; they often loose a sense of themselves and their place in society. Beels’ work had a major effect on psychoeducational treatments of schizophrenia. In Beels’ book A Different Story: The Rise of Narrative in Psychotherapy, he writes to both professionals and nonprofessionals an account of his journey in merging the two – narrative and psychotherapy. He gives personal accounts of his therapeutic work with community members, discusses the works and his encounters with those that influence his views and practices, and presents his ideas of the many challenges experienced in psychotherapy. Included in the latter are conversations about the division of professionals through the adherence of schools of thought and professional isolation. He stresses a collaborative approach not only when working with clients but in working with each other as professionals. Beels has made a major impact through his work in being an educator, a family therapist, and a pioneer in the development of a new way to view and engage in public mental health.

Cross-References ▶ Epston, David ▶ Family Process (Journal) ▶ Narrative Family Therapy ▶ White, Michael

References Beels, C. C. (1989). The invisible village. New Directions for Mental Health Services, 42, 27–40. Beels, C. C. (2001). A different story: The rise of narrative in psychotherapy. Phoenix: Zeig, Tucker & Theisen. Beels, C. C. (2009). Some historical conditions of narrative work. Family Process, 48(3), 363–378.

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Behavior Exchange in Couple and Family Therapy Jennifer Duchschere University of Arizona, Tucson, AZ, USA

Name of the Strategy or Intervention Behavior exchange in couple and family therapy

Synonyms BE; Contingency contract; Social exchange

Introduction Behavior Exchange (BE) is a therapeutic tool which seeks to increase the ratio of positive to negative behaviors that occur within a dyad (Gurman and Jacobson 2002; Jacobson and Christensen 1996; Jacobson and Margolin 1979). A BE model of relationships assumes that each partner holds some amount of control or influence over the other’s behaviors, and thus the dyad is engaged in a continuous cycle of interacting behaviors and responses (Jacobson and Margolin 1979). Partners often respond to positive behaviors with positive behaviors, and respond to negative behaviors with negative behaviors (Gottman et al. 1976).

Theoretical Framework BE is derived from behaviorism and makes the assumption that small shifts in behavior will influence the overall dyadic dynamic. It is thus often incorporated into behavior-based therapies, such as traditional behavioral couple therapy (TBCT) or integrative behavioral couples therapy (IBCT; Jacobson and Christensen 1996).

Behavior Exchange in Couple and Family Therapy

Rationale for the Strategy or Intervention Previous research suggests that distressed couples are less likely to engage in rewarding or positively reinforcing behaviors and are more likely to engage in negative or unwanted behaviors (cf. Birchler et al. 1975). This finding has been demonstrated as a general effect as well as within specific dyadic interactions such as problemsolving (Birchler et al. 1975). Increased negative behaviors have been linked to higher levels of partner avoidance (e.g., engaging in activities without their partner; Birchler et al. 1975) and lower levels of marital satisfaction (as cited by Birchler et al. 1975; Gottman 1993). When behaviors occur without a naturally rewarding context, they may lead to heightened reactivity to a partner’s behaviors (Jacobson and Margolin 1979). This reactivity is illustrated by distressed couples responding more intensely to immediate rewards or consequences as opposed to delayed rewards or consequences, whereas nondistressed couples may not be as significantly affected by immediate responses (Jacobson and Margolin 1979).

Description of the Strategy or Intervention In a therapeutic context, BE seeks to resolve the imbalance of positive and negative behaviors exchanged by distressed couples. In order to do so, reinforcing or rewarding behaviors are identified (with the therapist) that would increase a partner’s relationship satisfaction. It is important to note that these identified behaviors are often unique in that both dyadic and individual differences must be considered. Even within the dyad, each partner may desire seemingly unrelated behaviors. Examples of target behaviors include demonstrations of affection, increased verbal communication, or spending more time together (Jacobson and Christensen 1996; Gurman and Jacobson 2002; Jacobson and Margolin 1979). Chosen behaviors should be ones which partners seek to increase (positive) rather than those they

Behavior Exchange in Couple and Family Therapy

want eliminated (negative), so as not to provide further effort and attention to the negative behaviors within the relationship (Gurman and Jacobson 2002). Additionally, these behaviors should not generate additional conflict; thus, behaviors should feasible (low-cost) for a partner to complete as well as require similar effort across the dyad (Gurman and Jacobson 2002). After rewarding behaviors are generated within the session, therapists often guide the couple to individually choose a behavior to try at home and notice what the responses are to these changed actions. The idea is that if the behaviors chosen are truly rewarding, or have the potential to actually increase relationship satisfaction, their partner will respond positively. For example, a husband may choose to increase his physical affection toward his wife by hugging her each day when he comes home from work. If his wife is indeed seeking increased physical affection, she may respond by smiling or engaging in conversation. These responses are natural and positively reinforcing for the initial act of hugging. Jacobson and Christensen (1996) provided a simple structure for BE. They suggested that in session, each partner generate a list of behaviors they believed their partner would want more or less of (rather than create this list about behaviors they want their partner to change). A behavior is chosen to “try out” during the week without knowing whether their partner would agree that a given behavior would shift their current level of relationship satisfaction. During the next session, the behaviors attempted are explored and each partner may respond. The partners at this time may then review the list and provide feedback as to why or why not a particular action would be something wanted. After this, they may continue in the same fashion as traditional BE. Research on the effects of BE demonstrate that although it generally creates rapid change, it is not sufficient for lasting change (Jacobson and Christensen 1996). Jacobson (1984) examined the components of behavioral marital therapy, including BE and communication/problemsolving training (CPT). He found that BE demonstrated significant increases in marital satisfaction and positive behaviors, while reducing desires for

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behavioral change immediately after the termination of therapy. However, after 6 months couples receiving only BE lost their gained progress, whereas those who received CPT or the combination of CPT and BE were more likely to maintain their gains or continue to improve. It seems that although BE can increase positive behaviors at home short-term, it does not tend to get at underlying relationship issues or help the couple determine how to work through challenges in the future (Jacobson and Christensen 1996). As such, BE is insufficient treatment for a distressed couple. The above describes the use of BE within romantic relationships because there is existing and ongoing literature on this topic; however, BE might also be a successful tactic in other types of relationships in which dyads or families are struggling with the presence of rewarding or reinforcing behaviors. For example, if a parent is seeking behavior change in their child but is using punishment or consequences as the motivation for the child, shifts in their behavior may need to reflect those which are rewarding to the child.

Case Example Karen (30) and Justin (32) have been married for 5 years. They have two young children. They decided to start therapy due to feeling distant from one another in the past year. While they do not argue frequently, they both acknowledged that their relationship currently feels more like “roommates” rather than partners in marriage. Karen expressed that at times she doubts Justin’s feelings for her because his physical affection and intimacy has decreased. She believes this shift has resulted in her seeking any affection. Justin reported feeling stressed from responsibilities related to both work and taking care of their children. He described still being in love with Karen, but simply that he “doesn’t have time to show it.” Karen and Justin were asked to create separate lists of behaviors they could reasonably do during the week in attempt to increase their partner’s relationship satisfaction. These lists were not shown to the other partner. Rather, they were

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asked to try one of the behaviors on this list during the week and take note of their partner’s response. When Karen and Justin came in for their next session, they reported that the task had gone well. Karen reported that one evening during the week, she prepared lunches for Justin and their children for the next day. When Justin discovered that she helped with this task generally designated to him, he responded by smiling and giving her a hug. Justin indicated that his idea was to come home from work, kiss Karen and tell her that he loves her. The first time this behavior occurred, Karen’s mood seemed uplifted and she inquired more about his day at work. Although Justin’s goal was to try this one time, he ultimately did this several times throughout the week stating that they actually felt like they were a couple.

Behavior Exchange Theory Jacobson, N. S. (1984). A component analysis of behavioral marital therapy: The relative effectiveness of behavior exchange and communication/problemsolving training. Journal of Consulting and Clinical Psychology, 52(2), 295–305. Jacobson, N. S., & Christensen, A. (1996). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York: W.W. Norton & Company. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel.

Behavior Exchange Theory Kathleen A. Eldridge Graduate School of Education and Psychology, Pepperdine University, Los Angeles, CA, USA

Cross-References ▶ Behavior Exchange Theory ▶ Behavioral Couple Therapy ▶ Christensen, Andrew ▶ Gottman, John ▶ Gurman, Alan ▶ Integrative Behavioral Couple Therapy ▶ Jacobson, Neil ▶ Problem-Solving Skills Training in Couple and Family Therapy ▶ Social Exchange Theory

Name of Theory

References

Behavior exchange theory is a set of ideas designed to explain the formation, maintenance, and dissolution of close relationships. The basic principles of behavior exchange theory are that (a) close relationships are characterized by interdependent interpersonal transactions (behavioral exchanges) between people, (b) these exchanges provide rewards and costs for each person, and (c) people weigh the ratio of rewards and costs against alternative relationships to determine whether to continue or dissolve the relationship. Based on these ideas, it follows that satisfying and stable relationships will contain behavioral exchanges marked by favorable reward-cost ratios for each member of the relationship. Although behavior exchange theory has been

Birchler, G. R., Weiss, R. L., & Vincent, J. P. (1975). Multimethod analysis of social reinforcement exchange between martially distressed and nondistressed spouse and stranger dyads. Journal of Personality and Social Psychology, 31(2), 349–360. Gottman, J. M. (1993). The roles of conflict engagement, escalation, and avoidance in marital interaction: A longitudinal view of five types of couples. Journal of Consulting and Clinical Psychology, 61, 6–15. Gottman, J., Notarius, C., Markman, H., Bank, S, Yoppi, B., & Rubin, M. E. (1976). Behavior exchange theory and marital decision making. Journal of Personality and Social Psychology, 34(1), 14–23. Gurman, A. S., & Jacobson, N. S. (Eds.). (2002). Clinical handbook of couple therapy (3rd ed.). New York: Guilford Press.

Behavior exchange theory

Synonyms Social Exchange Theory

Introduction

Behavior Exchange Theory

of interest across multiple disciplines, this entry will emphasize the aspects most pertinent to couple and family therapy.

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by Neil Jacobson, Andrew Christensen, and colleagues (Jacobson and Christensen 1998).

Description Prominent Associated Figures John Thibaut and Harold Kelley (1959) are often cited as the social psychologists who proposed behavior exchange theory. Other early works on behavior exchange are those by social psychologist Kenneth Gergen (1969) and by sociologists George Homans (1961) and Peter Michael Blau (1964). After the theory was proposed, it was studied in the context of couples and families throughout the 1970s and 1980s by numerous psychologists associated with cognitive-behavioral approaches. Early examples of these studies include Weiss et al. (1973), Birchler et al. (1975), and Gottman et al. (1976). Their goal was to identify frequencies, correlates, and consequences of rewarding and aversive behavioral exchanges among couple and family dyads experiencing varying levels of distress. Psychologists also developed treatment methods based partly on the ideas of behavior exchange theory, such as operant-interpersonal treatment presented by Richard Stuart (1969), reciprocity counseling for couples introduced by Nathan Azrin and colleagues (1973), and the Gottman Method developed by John Gottman and colleagues (Gottman 1999). Examples of treatment approaches that contain some behavior exchange methods and have been established empirically over decades include the Prevention and Relationship Education Program developed by Howard Markman, Scott Stanley, Susan Blumberg, Galena Rhodes, and colleagues (Markman et al. 2010); Behavioral Parent Training developed by Gerald Patterson and colleagues (Forgatch and Patterson 2010); Behavioral Couple Therapy developed by Neil Jacobson, Gayla Margolin, and colleagues (Jacobson and Margolin 1979); Cognitive Behavioral Couple Therapy developed by Norman Epstein, Donald Baucom, and colleagues (Epstein and Baucom 2002); and Integrative Behavioral Couple Therapy developed

Behavior exchange theory has featured prominently in behavioral conceptualizations of couple and family relationships and treatment methods. Integrating ideas set forth by sociologists, psychologists, and economists, it describes relationships as social exchanges of rewards and costs. In any close relationship, each partner experiences rewards from being together and costs of being in the relationship. Rewards and costs can be tangible or intangible and exist for both the receiver and the producer of the behavior. Examples of rewards include companionship, emotional and instrumental support, pleasant emotions, income, social approval, and physical intimacy. Conversely, costs might include, among others, compromises, disagreements, unpleasant emotions, financial costs, time and energy costs, or social disapproval. Presuming that people are motivated to maximize rewards and minimize costs, behavior exchange theory suggests that relationship decisions around mate selection and relationship maintenance or dissolution are based, in part, on the level of rewards experienced and costs incurred in the relationship. An individual considers the rewards and costs of the current relationship in comparison to the rewards and costs of alternative relationships and to no relationship. If the current relationship offers a better reward-cost profile than the alternatives, the relationship is more likely to continue. Conversely, if alternative relationships or no relationship offers a better profile, the relationship is more likely to end. Some versions of behavior exchange theory emphasize parallels with economic or market forces. As individuals seek to immerse themselves in relationships that offer more advantages than disadvantages, they also consider supply and demand. If supply of a reward is generally low in the population (extreme wealth or attractiveness; excellent listening and deep, meaningful conversation) but provided by one’s partner, that

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reward may be valued more than one that is provided but in high supply elsewhere as well (physical affection). Likewise, costs that are incurred in the current relationship but also likely incurred in other relationships (time and energy; minor disagreements) may be experienced less negatively than costs incurred in the present relationship but unlikely in other relationships (violent behavior). Another economy metaphor offered in the context of behavior exchange theory is the “bank account” model of marriage (Gottman et al. 1976). In this metaphor, positive exchanges are described as investments or “deposits” that maintain a favorable emotional balance and ensure stability and satisfaction of the relationship, while negative exchanges are considered “withdrawals” from that account that disrupt a favorable balance. As the balance declines and tensions rise, couples are more apt to scrutinize the rates of deposit and withdrawal and become increasingly reactive to withdrawals. This increased reactivity creates a higher level of negative reciprocity in behavioral exchanges, in which partners increasingly respond to negative behaviors with subsequent and escalating negativity (Jacobson and Margolin 1979). Early studies of behavior exchange theory examined behavioral exchanges in dyads using questionnaire methods, such as the Spouse Observation Checklist (Wills et al. 1974), or observational methods, using objective coders who observed the recorded conversations of couples and made judgments about what would be considered positive or negative. Later, researchers understood that partners’ subjective perceptions of the level of reward or aversion they experience in response to specific behaviors would represent a more accurate reflection than just behaviors alone or evaluations of behaviors from an outsider’s frame of reference. They discovered a difference between the intended impact of a behavior and the actual impact, particularly for distressed partners who received behaviors more negatively than nondistressed partners. In addition to associations with distress, it is important to note that what each partner regards as a reward or cost is also culturally informed. Hence, those from collectivist cultures may place higher value on the rewards of interdependent behavioral exchanges,

Behavior Exchange Theory

whereas those from more individualist cultures may place a higher value on tangible rewards garnered in exchanges. Similarly, those with collectivist orientations may find the time and energy costs of relationships less burdensome than those from an individualist orientation. Exchange Ratios and Satisfaction Of interest to therapists and clinical researchers is the ratio of rewards to costs in the behavior exchange of relationships. This ratio can be favorable, with high rewards and low costs, or it can be unfavorable, with high costs and low rewards. Psychologists have attempted to understand how this reward-cost ratio relates to satisfaction in the relationship, how an unfavorable ratio develops, and how treatment can improve the ratio. In support of behavior exchange theory, studies have found that a higher ratio of rewards to costs is associated with more relationship satisfaction. In behavioral terms, this is assumed to be due to the high rate of reinforcement experienced in relationships that have a favorable rewards-to-costs ratio, as compared to the low rate of reinforcement experienced when an unfavorable rewards-tocosts ratio exists. John Gottman and colleagues have attempted to determine the specific numeric ratio of benefits to costs necessary during conflict discussions for a relationship to be stable and satisfied. Their work suggests that a 5:1 ratio of positivity to negativity is necessary, even during disagreements. An example of this would be five positive behaviors such as compliments, expressions of empathy, careful listening, appropriate humor, or affection for every one negative behavior such as criticism, withdrawal, or defensiveness. On the other hand, unhappy couples headed for divorce display a ratio closer to 0.8:1, while they are discussing problems in the relationship. Their ratios demonstrate slightly less positivity than negativity (Gottman 2011). Development of Unfavorable Exchange Ratios Early on, dating relationships are often characterized by rewarding behavioral exchanges as partners display their most pleasing behaviors. Rarely are these uniformly positive exchanges sustained throughout the relationship. In behavioral theory,

Behavior Exchange Theory

two processes are thought to contribute to the development of unfavorable behavior exchange ratios over time. One process is reinforcement erosion. In every relationship, partners habituate to the rewarding behaviors each one displays toward the other. Over time, behaviors that were once highly reinforcing gradually become less so as each person becomes accustomed to them. Even though the exchanges are positive, they carry less reinforcement value over time as their impact wears off. If couples aren’t intentional about refreshing these behaviors by adding new ones, or bringing back ones that have fallen away, their relationship begins to have less reinforcement. Another process that contributes to unfavorable behavioral exchanges is skill deficit or decline. Many skills are helpful in the effective functioning of relationships, such as communication, parenting, budgeting, and decision-making. If these skills are not learned, practiced, or used, relationships are likely to have higher rates of negative exchanges and fewer positive ones. Interdependence and Reciprocity Studies of behavior exchange theory have also considered the extent to which behavioral exchanges are reciprocal or interdependent. If reciprocity exists, behaviors are contingent on prior and subsequent behaviors of the partner. For example, one partner is more likely to behave in rewarding ways if the other partner has recently done so. Each person’s behavior is in response to and provokes the partner’s behavior, in a cyclical pattern, so that exchanges that are positive tend to bring about more positive exchanges immediately and over time (positive reciprocity), whereas negative exchanges foster more negativity (negative reciprocity). Research tends to indicate that distressed and nondistressed couples alike tend to engage in positive reciprocity, whereas distressed relationships are uniquely characterized by negative reciprocity, particularly escalating negativity. These patterns hold true for both day-to-day exchanges as well as lengthier time frames (Jacobson and Margolin 1979). When reciprocity exists, suggesting that partners are more reactive to one another, this can be beneficial

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or disadvantageous. Being more responsive to negative exchanges creates a spiral of negative reciprocity between partners, while responsiveness to positive exchanges can lead to a powerful response of positive reciprocity when treatment methods increase positive behaviors. Behavioral Reinforcement in Exchanges In behavior exchange theory, principles of positive and negative reinforcement are an important component in explaining the maintenance and intensification of exchanges. Positive behavioral exchanges are experienced as rewarding and are therefore more likely to continue. Negative behavioral exchanges on the surface would appear to be distressing and non-rewarding and therefore less likely to continue. However, a closer look at the specifics of these exchanges reveals the central role of negative reinforcement in their continuation. For example, when one partner criticizes the other, the responding partner sometimes changes in a favorable way to stop the criticism. Doing so provides intermittent negative reinforcement for both partners. In other words, the criticizing partner gets the criticized partner behavior to stop (negative reinforcement), or gets new positive behavior in its place (positive reinforcement), and is therefore more likely to criticize again in the future. The criticized partner, in making the changes desired by the partner, ends the criticism, at least temporarily (negative reinforcement), and therefore is likely to respond with similar changes upon future criticism. The downside to this behavioral exchange pattern is that problems are not often discussed or resolved in a meaningful or sustainable way. Instead, temporary changes are made to stop the unpleasant behaviors, but ineffective patterns of aversive control or coercion are reinforced and repeated over time. Similarly, if heated exchanges involving both partners yelling and arguing are followed shortly thereafter by declines in intense emotional arousal, these behaviors are negatively reinforced and likely to continue in future exchanges. These types of reinforcement patterns in behavioral exchanges are described further by coercion theory (Patterson and Reid 1970) and escape conditioning theory (Gottman and Levenson 1986).

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Relevance to Couple and Family Therapy The clinical implications of behavior exchange theory are clear in assessment, psychoeducation, and treatment planning. In relying on these ideas, therapists start with careful assessment of the rewards and costs in the relationship, gathering specific details about positive and negative behaviors displayed and their precipitants and consequences. Therapists also ask partners about their perceptions of those behaviors, to ensure their subjective experience is considered, instead of making assumptions about how behaviors are experienced based on one’s own frame of reference. Therapists can use the Spouse Observation Checklist in specific ways that provide both objective and subjective measurement of behavioral exchanges and their impact on partners (Wills et al. 1974; Jacobson and Margolin 1979). Therapists may provide psychoeducation about behavior exchange ratios and processes like reinforcement erosion and skill deficits that bring about unfavorable ratios. For example, the fact that some negative exchanges do exist in the 5:1 ratio of stable and happy marriages indicates that not all negativity is detrimental to relationships, as long as it is not extensive and exists in combination with ample positive exchanges. An overall positive experience in the relationship, termed positive sentiment override, provides a buffer for those negative exchanges. This information may be helpful for partners who believe that all conflict is harmful and seek to avoid it at all costs. It is also helpful for partners to understand the role of reinforcement erosion in reducing the potential for positive behaviors to impact the relationship. For example, in describing the positive behaviors displayed, partners may feel unappreciated for those they have been engaging in, finding them to be fruitless in improving the relationship. Particularly if those positive behaviors have been displayed routinely, they may no longer hold much reinforcement potential. Couples appreciate understanding why their positive behavior attempts are not being met with the anticipated positive outcome, which then reduces their discouragement and hopelessness. Lastly, explaining the utility of skill building for

Behavior Exchange Theory

improving the behavior exchange ratio provides a clear rationale for including skills in the treatment plan. Behavior exchange theory also guides goalsetting and treatment planning. The theory and research suggest that improving the ratio of rewards to costs will improve the quality and stability of the relationship. This provides a clear path for improving relationships by helping couples improve this ratio. Note that improving the ratio involves addressing both elements of the equation, reducing the negatives and increasing the positives. Mathematically speaking, if the goal is a 5:1 ratio or higher, it will clearly be necessary to help distressed couples who are closer to a 0.8:1 ratio to increase their rewarding behavior, especially during attempts to resolve conflict. Behavior exchange methods, such as developing lists of positive behaviors each partner will demonstrate, are intended to escalate rewarding exchanges. In these methods, the goal is to determine behaviors that maximize rewards for the recipient and minimize costs to the giver. Therapists ensure that partners plan to engage in positive behaviors that are new or renewed, instead of routine, so that they will carry ample reinforcement value. Therapists also ensure the behaviors are within the partners’ current abilities, so they can be implemented with ease instead of requiring practice or preparation. Often, couples who have been immersed in problems appreciate the initial focus on building back positivity in the relationship, and this initial focus builds their hope, confidence, and willingness to collaborate as they engage in the more difficult skill-building work of therapy. Treatment methods that strengthen skills in communication and conflict resolution are also designed to improve the behavior exchange ratio. In addition to helping couples constructively work on problems throughout therapy, another benefit is that these skills can continue to be used long after therapy has ended, particularly when difficult problems arise, to maintain a favorable behavior exchange ratio. Generally, research does show that skill acquisition and ratio improvements occur over the course of couple treatments that encourage skill building. In addition, these

Behavior Exchange Theory

improvements in positive behavior and reductions in negative behavior are associated with expected improvements in relationship satisfaction.

Clinical Example of Application of Theory in Couples and Families Jamil and Maya Rehman have been struggling in their relationship for quite some time. They are a dual-career couple with three children ranging in age from 8 to 15. While their initial dating years were characterized by high levels of affection and rare disagreements, their marriage is now marked with occasional heated exchanges followed by days of tense silence and minimal exchanges needed to carry out the functions in their family. Jamil feels ignored by Maya on a daily basis, and Maya sees the relationship more like roommates who co-parent than a marriage based on Jamil’s lack of physical affection and involvement with her. Both have silently considered divorce but have decided to attempt marital therapy before giving up, for the sake of their children. In addition, Maya and the eldest daughter, Amira, report frequently occurring and rapidly escalating behavioral exchanges in which Maya blames and criticizes, while Amira gets defensive and countercriticizes. Maya initiated treatment for the martial relationship and also expressed concern about the quickly deteriorating relationship with her daughter. In early meetings with Jamil and Maya, the therapist attempted to gather specific details about the early behavioral exchanges in their relationship, bringing back pleasant memories and providing some initial hope and encouragement. The therapist also assessed the details of their current behavioral exchanges, asking for specific behaviors and listening carefully for their perceptions of those behaviors. Since Jamil and Maya’s descriptions were mainly negative, the therapist intentionally asked about current positive exchanges. While observing the Rehmans and listening to their descriptions and perceptions, the therapist considered whether processes like reinforcement erosion and skill deficits contributed to the decline in positive exchanges and

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increase in negative ones. The therapist also considered whether the ratio of positive to negative during disagreements was closer to the 0.8 to 1 expected of distressed or divorcing couples or to the 5:1 ratio of stable and satisfied marriages. The therapist discussed the possibility of inviting Amira to sessions, asking the Rehmans if they would like to do this. Together, the therapist and the Rehmans decided to make initial progress in the marriage and then begin to incorporate other members of the family system. They ended up holding three sessions over the course of treatment in which Amira attended with her parents. The behavioral exchanges between Maya and Amira were assessed in the same ways as the parental dyad, asking about both positive and negative exchanges and gathering specific details. Psychoeducation about ratios in satisfied and dissatisfied relationships, the processes of reinforcement erosion, positive and negative reinforcement, skill deficits that contribute to unfavorable ratios, and the methods for improving the ratio was shared with Jamil and Maya and then later with Amira as well. For example, the therapist informed them that the aim would not be to eliminate conflict, since even happy couples and family dyads experience negativity, but to help them respond to it in more constructive ways while also increasing their positive exchanges so that the overall balance was skewed toward rewarding exchanges. In addition, the therapist explained the reinforcement process that gets them stuck in their negative behavioral exchanges. For example, the therapist helped Maya understand that her criticism and blame toward Amira, while unpleasant for both, continues in part because it sometimes gets rewarded by changes in Amira’s behavior. Psychoeducation also helped the Rehmans understand that reinforcement erosion, a natural process, contributes to decline in satisfaction even when positive behavioral exchanges have been maintained for many years. The goal of treatment was straightforward in theory, although not always simple to accomplish, and entailed increasing rewards and decreasing costs through shifts in behavioral exchanges. The first treatment method was closely tied to

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behavior exchange theory and was in fact called behavior exchange. The Rehmans were encouraged to write a list of kind, considerate, affectionate interpersonal behaviors they were willing to do toward their partner. The therapist helped them include items that were worded positively (“I will make eye contact and ask how he is doing each day” instead of “I won’t ignore him”), specific (“I will hug her” instead of “I will show affection”), daily interpersonal behaviors (“I will make her coffee when I make mine” instead of “I will buy a new coffee-maker”), behaviors already in their repertoire (not requiring newly learned skills), and behaviors unrelated to highly sensitive unresolved issues (such as longstanding absence of sexual activity). It was quite helpful to have them make their lists focused on what they were willing to do for their partner, instead of the reverse direction of what they want from their partner. As the Rehmans entered therapy, they were highly focused on what they wanted their partner to do for them and had become less aware of the behaviors they could demonstrate toward their partner to improve the relationship. Early in therapy, partners are often more willing to produce rewarding behaviors that are self-initiated instead of partner imposed. The therapist also considered variations in how to implement these behavioral changes. The Rehmans could be encouraged to initiate the specified behaviors in an unscheduled way by doing them as it occurred to them, or in a prescheduled way by designating specific “love days” or “caring days” when they intensify their number of pleasing behaviors (Stuart 1980). They could also be encouraged to do the behaviors in a non-contingent fashion, regardless of how the partner behaves, or use contingency contracting or quid pro quo agreements in which each behavior is tied to another behavior in the partner, therefore creating reciprocal or interdependent behavioral exchanges between Jamil and Maya (Azrin et al. 1973; Stuart 1969). In collaboration with the Rehmans and based on their input, the therapist encouraged a combination of these methods, allowing them some flexibility in choosing when and how to engage in the behaviors while also specifying

Behavior Exchange Theory

some preplanned contingencies, such as encouraging Jamil to initiate physical affection through hugs each evening, which would then prompt Maya to ask about his day. Initially, the therapist chose to forego specified days, based on the unpredictability of their daily lives with dual careers and three children. Instead the therapist started with approaches that maximized the probability of the Rehmans experiencing early success in treatment while minimizing the potential for disappointment. The therapist also encouraged the Rehmans to notice the behaviors initiated, the impact they have, and the level of pleasure experienced both as receiver and giver. The therapist then began the subsequent session with a review of the behavioral exchanges demonstrated by Jamil and Maya, their experiences doing the behaviors, and the receiving partners’ experiences of them. Over time, as collaboration and satisfaction improved, the Rehmans were encouraged to provide input to their partners’ lists, thereby including the behavioral exchanges that were likely to carry the strongest reinforcement value. Jamil and Maya were also encouraged to brainstorm activities they could partake in together that were mutually rewarding, each making a separate list then comparing to see where there was overlap. Jamil’s list included enjoying the outdoors, and Maya’s list included going on a family picnic, so together they decided to spend Saturday afternoon at the local park, picnicking and enjoying time together and with their children. The therapist also helped them work out the details of food preparation, ageappropriate activities and responsibilities for each of the children, communicating the plan with the children (particularly Amira who they anticipated would express displeasure at the idea), backup plans in case of inclement weather, and methods for maintaining pleasant exchanges during the activity. The therapist also had them design the details of a rewarding time together for just the two of them without the children, involving a short hike and picnic of their favorite foods. As the Rehmans experienced initial success in escalating rewarding exchanges, they were then taught skills for maintaining them with less

Behavior Exchange Theory

involvement of the therapist. They were encouraged to make requests in effective ways that are assertive and non-demanding. For example, they were encouraged to start requests with phrases such as “I would appreciate it if you. . .” or “Would you please. . .” or “I would like you to. . .” followed by specific behaviors, not vague prompts. Jamil was able to change “You should show some interest in my life instead of ignoring me” to “I would like you to ask me about my day and listen with eye contact for 5–10 minutes each evening.” In addition, the therapist encouraged the Rehmans to reinforce rewarding behaviors by expressing interest and appreciation toward their partner in the moment and at later times, such as the end of the day or next morning. This came naturally to the Rehmans, but other couples may need instruction, modeling, and practice in how to provide positive feedback. Although these methods were not designed to reduce negative exchanges, they also had that impact in addition to increasing positive behaviors quite effectively, consistent with research. These methods were then followed by skill building in communication and conflict resolution to reduce the family’s negative exchanges and provide them with methods to address their unresolved problems now and in the future. These methods are described in other entries, such as communication training in couple and family therapy, problem-solving skills training in couple and family therapy, and behavioral couple therapy.

Cross-References ▶ Behavior Exchange in Couple and Family Therapy ▶ Behavioral Couple Therapy ▶ Caring Days in Couple and Family Therapy ▶ Contingency Contracting in Couple and Family Therapy ▶ Cost-Benefit Ratio in Couple and Family Therapy ▶ Negative Reinforcement in Social Learning Theory ▶ Operant Conditioning in Couple and Family Therapy

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▶ Positive Reinforcement in Couples and Families ▶ Quid Pro Quo in Couple and Family Therapy ▶ Quid Pro Quo in Social Exchange Theory ▶ Social Exchange Theory

References Azrin, N. H., Naster, B. J., & Jones, R. (1973). Reciprocity counseling: A rapid learning-based procedure for marital counseling. Behavior Research and Therapy, 11, 365–382. Birchler, G. R., Weiss, R. L., & Vincent, J. P. (1975). Multimethod analysis of social reinforcement exchange between martially distressed and nondistressed spouse and stranger dyads. Journal of Personality and Social Psychology, 31, 349–360. Blau, P. M. (1964). Exchange and power in social life. New York: Wiley. Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples. Washington, DC: American Psychological Association. Forgatch, M. S., & Patterson, G. R. (2010). Parent management training – Oregon model: An intervention for antisocial behavior in children and adolescents. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies or children and adolescents (2nd ed., pp. 159–177). New York: Guildford Press. Gergen, K. (1969). The psychology of behavior exchange. Reading: Addison-Wesley. Gottman, J. M. (1999). The marriage clinic. New York: Norton. Gottman, J. M. (2011). The science of trust: Emotional attunement for couples. New York: W.W. Norton. Gottman, J. M., & Levenson, R. W. (1986). Assessing the role of emotion in marriage. Behavioral Assessment, 8, 31–48. Gottman, J. M., Notarius, C. I., Markman, H. J., Bank, S., Yoppi, B., & Rubin, M. E. (1976). Behavior exchange theory and marital decision-making. Journal of Personality and Social Psychology, 34, 14–23. Homans, G. C. (1961). Social behavior: Its elementary forms. New York: Harcourt, Brace & World. Jacobson, N. D., & Christensen, A. (1998). Acceptance and change in couple therapy. New York: W.W. Norton. Jacobson, N. D., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel. Markman, H., Stanley, S., & Blumberg, S. L. (2010). Fighting for your marriage (3rd ed.). San Francisco: Jossey-Bass. Patterson, G. R., & Reid, J. B. (1970). Reciprocity and coercion: Two facets of social systems. In C. Neuringer & J. L. Michael (Eds.), Behavior modification in clinical psychology (pp. 133–177). New York: AppletonCentury-Crofts.

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238 Stuart, R. (1969). Operant-interpersonal treatment for marital discord. Journal of Consulting and Clinical Psychology, 33, 675–682. Stuart, R. (1980). Helping couples change: A social learning approach to marital therapy. Champaign: Research Press. Thibaut, J. W., & Kelley, H. H. (1959). The social psychology of groups. New York: Wiley. Weiss, R. L., Hops, H., & Patterson, G. R. (1973). A framework for conceptualizing marital conflict, a technology for altering it, some data for evaluating it. In L. A. Hamerlynck, L. C. Handy, & E. J. Mash (Eds.), Behavior change: Methodology, concepts, and practice. Champaign: Research Press. Wills, T. A., Weiss, R. L., & Patterson, G. R. (1974). Spouse observation checklist. Princeton: Educational Testing Service.

Behavioral Couple Therapy Justin A. Lavner University of Georgia, Athens, GA, USA

Name of Model Behavioral couple therapy (BCT)

Synonyms Behavioral marital therapy (BMT); Traditional behavioral couple therapy (TBCT)

Introduction Since its development several decades ago, BCT has grown into one of the most widely used couple therapy modalities and has been the most widely studied form of couple therapy. This treatment also forms the basis for later iterations of behaviorally based couple therapy, including cognitive behavioral couple therapy, enhanced cognitive behavioral couple therapy, and integrative behavioral couple therapy. These later treatments adopt many of the theoretical tenets and therapeutic strategies described here while also expanding on this

Behavioral Couple Therapy

foundational approach to include other domains such as cognition (cognitive behavioral couple therapy) and acceptance (integrative behavioral couple therapy).

Prominent Associated Figures Neil Jacobson; Gayla Margolin; Richard Stuart; Robert Weiss

Theoretical Framework BCT is based on behavioral exchange principles. Drawing from behaviorism, it focuses on the frequency of positive and negative behaviors, how these behaviors get reciprocated between partners, and how partners’ responses either intentionally or unintentionally reinforce these behaviors (Stuart 1969; Jacobson and Margolin 1979). Generally, the model argues that happy marriages can be distinguished from unhappy marriages by the ratio of positives to negatives in the relationship, such that this ratio is favorable in happy relationships and unfavorable in unhappy relationships; that distressed couples are especially likely to reciprocate negative behavior; and that distressed couples are more likely to use punishing behaviors to bring about behavior change in their partners, whereas non-distressed couples use positive reinforcement. The model further assumes that a lack of positives signifies an absence of key skills such as providing empathic and supportive communication and problem-solving/decisionmaking (Weiss 1980). Couples’ inability to utilize the skills needed to promote happier relationships is thought to be due either to couples’ lack of those skills in the first place (i.e., a skill deficit) or an inability to perform certain skills they do have due to other factors (e.g., external stressors such as work or children; Baucom et al. 2008). In keeping with these behavioral principles, BCT emphasizes increasing the frequency of couples’ positive interactions and teaching couples communication and problem-solving skills to decrease the frequency of their negative interactions. The focus is on present interactions and on

Behavioral Couple Therapy

specific interventions in and outside of session to improve couple’s interactional processes. The theory of change is that by changing couples’ behaviors and their reinforcers, these interventions can shift the overall balance of positives and negatives in the couple’s relationship, ultimately resulting in improvements in couples’ satisfaction. The ideas underlying the model – particularly the notion that maladaptive communication patterns distinguish between distressed and non-distressed couples – have been supported by a large body of research spanning several decades. Collectively, this work indicates that the relationships of distressed couples are marked by high levels of negative communication, low levels of positive communication, and more negative reciprocity between partners (Bradbury and Karney 2013). BCT’s focus on increasing positives in couples’ relationships and improving their communication to decrease negatives is thus consistent with this basic research on some of the factors that characterize satisfied and dissatisfied couples. BCT’s sole focus on behavior and how the relationship context serves to shape each partner’s behavior distinguishes it from other behavioral couple approaches with more expansive foci. For example, cognitive behavioral couple therapy addresses how cognitions, values, and beliefs can drive behavior and includes a therapeutic focus on these cognitive elements. Integrative behavioral couple therapy incorporates an emphasis on promoting acceptance in addition to behavior change.

Populations in Focus Behavioral couple therapy is widely used with and appropriate for couples with a range of relationship difficulties. In addition, it has been shown to be particularly effective for couples with relationship distress in which one partner is experiencing clinical depression (Whisman and Beach 2012) as well as for couples in which one partner has an alcohol or drug use disorder (Powers et al. 2008), with adaptations for dealing with the specifics of these conditions.

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Strategies and Techniques Used in Model BCT takes a skills-oriented, present-focused approach to improving couples’ relationships. The therapist plays an active role in treatment as a collaborator, coach, and facilitator. The strategies and techniques used in BCT fall into two general categories that directly target the theoretical framework outlined above: (1) behavior exchange strategies designed to increase the ratio of positive to negatives in the relationship and (2) communication and problem-solving skills training. Behavior Exchange Strategies Behavioral exchange strategies can generally be thought of as interventions designed to increase positivity in couples’ relationships. They are the initial focus of treatment so that couples experience some positive growth and learn that change is possible (Jacobson and Margolin 1979). Given that couples are generally presenting to therapy with some distress – and commonly present with considerable distress – these strategies are aimed at introducing positivity back into couples’ relationships. Therapists can use a variety of strategies to increase positivity in couples’ relationships. Some of these strategies are directed at improving an individual partner’s happiness. Initially, couples are encouraged to monitor their behaviors and how their behavior affects their partner’s satisfaction. This strategy shifts the focus away from what the partner does not do or does “wrong” and toward what each individual does that makes the partner happier. With the therapist’s assistance, each member of the couple is then encouraged to identify behaviors that they can implement in order to increase their partner’s satisfaction. For example, a partner may take over some of the household chores like washing the dishes or tucking the kids in or engage in some pleasurable activity like giving the partner a massage. These types of activities can be enacted on a daily basis, such that partners are assigned a certain number of tasks per day to complete, or they can be implemented in a more targeted manner during

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“love/caring days” in which one partner does several pleasing activities for the other partner during a given day. In addition to helping romantic partners identify things they can do to make their partner happier, therapists also help couples make and respond to specific requests. Here couples learn how to ask for specific things they would like the partner to do and how to respond to these requests. This strategy differs from the previous strategy in that the previous set of activities were developed by Partner A and directed toward Partner B in order to improve Partner B’s satisfaction, whereas specific requests are made by Partner B to Partner A to improve Partner B’s satisfaction. For example, one partner may request that the other partner give them 10 min after arriving home in order to decompress before having to talk about the day. Behavioral exchange strategies also include strategies directed at improving the couple’s happiness. Couples are encouraged to brainstorm activities that they can engage in together that will be pleasurable for both of them, like going to the movies, going out to dinner, going for a walk, or doing arts and crafts. These activities can be particularly beneficial in terms of providing couples with novel activities that boost their mood, repositioning them as a team, and breaking them out of negative routines. Taken together, behavioral exchange strategies increase the frequency and amount of positivity in couples’ relationships. These strategies provide a much-needed boost for distressed couples and in some cases prove sufficient to solve couples’ presenting problems. However, many couples need assistance dealing more directly with their problems, necessitating the next set of therapeutic strategies: communication and problem-solving skills training. Communication and Problem-Solving Skills Training Communication and problem-solving skills training helps couples become more comfortable and adept at sharing their thoughts and feelings and resolving specific challenges in their relationships. Communication training proceeds in a three-part sequential process in which couples

Behavioral Couple Therapy

(1) receive feedback about their current patterns, (2) learn about more adaptive communication (e.g., listening skills, positive and negative feeling expression), and (3) practice the new communication patterns (Jacobson and Margolin 1979). When providing feedback to the couple about their communication, therapists focus on describing specific aspects of the communication as well as their function; doing so helps the couple become more aware of aspects of their communication that are positive and negative and what role this plays in the relationship. With this understanding in place, the couple is then in a better position to learn more adaptive communication patterns. The therapist serves an active role as a coach and model, instructing the couple in new ways of interacting. As a coach, therapists may interrupt a couple when they are speaking, directing them to phrase things a certain way (e.g., “This time tell her what you think, not what you think she is thinking”). As a model, therapists may participate in the interaction by pretending to be one of the partners, allowing the couple to see firsthand what a more adaptive type of communication looks like. With this foundation in place, the couple then focuses on practicing these new skills (behavioral rehearsal). Again the therapist plays an active role in shaping the couple’s communication, providing feedback and instructions throughout. This process is helpful for teaching couples a range of communication skills, including empathy and listening skills, validation, feeling talk, negative feeling expression, positive expressions, and assertiveness (Jacobson and Margolin 1979). Couples may be provided with specific guidelines for speaking and listening skills (e.g., Epstein and Baucom 2002). Problem-solving training is a specific type of communication training. It is aimed at helping couples develop solutions to particular problems in their relationship in a structured way that helps couples avoid some of the maladaptive strategies they have used to resolve conflicts in the past. Couples are provided with specific guidelines and instructions for how they should have these conversations (e.g., see Epstein and Baucom 2002; Jacobson and Margolin 1979). Generally, these guidelines include instructions for helping

Behavioral Couple Therapy

couples better define their problems (e.g., being specific, discussing feelings about the issue, and being brief) as well as for solving problems and developing change agreements (e.g., focusing on solutions, brainstorming, compromising, making a plan). The magnitude of these issues can range from what to do on a Friday night to whether to have children, but the same general guidelines apply. Therapists often assign couples homework to practice these discussions at home and then review these conversations during the following session. Discussions that did not go well can then be reattempted in session under the therapist’s guidance. The therapist may need to play an active role in limiting couples’ angry outbursts or encouraging withdrawn partners to engage, especially early on, but in time, the therapist’s role becomes less directive and more collaborative as couples are better able to self-correct and engage in positive communication on their own.

Research About the Model There is robust research support documenting the effectiveness of behavioral couple therapy. In a meta-analysis and review of different couple therapy models, BCT was the only model considered “efficacious and specific,” the most stringent criteria for empirically supported treatments (Baucom et al. 1998). More than two dozen controlled treatment outcome studies consistently showed that BCT was more effective than waitlist controls or nonspecific treatments. Meta-analyses similarly indicate the effectiveness of BCT compared to no-treatment couples, with an average effect size of 0.59 (Shadish and Baldwin 2005). Recent data on a sample of chronically and severely distressed who received BCT indicated that 46% of couples demonstrated clinically significant improvement 5 years after treatment, and 72% remained married (Christensen et al. 2010).

Case Example Thomas and Lauren Smith presented to a university-based psychology treatment for couple

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therapy. In the initial phone call, Lauren explained that the couple had been arguing more frequently and wanted assistance improving their communication. The therapist met with the couple for several intake sessions, including an initial conjoint session, two individual sessions, and a conjoint feedback session. During these sessions, the couple provided more information about their background and presenting problems. The couple was in their late 20s and had a 6-month-old son, Max. They reported that their communication problems had been an issue before Max’s birth but had increased significantly since then. They reported that they could argue about almost anything. They stated that they had particular difficulty with navigating household roles now that they were a family of three and now that Lauren was taking a leave from her job to stay home to take care of Max. Both partners noted that they did not have good role models for what healthy couple communication looked like: Thomas had been raised by a single mother throughout his entire childhood, and Lauren had been raised in a family who never discussed negative emotions. The couple also noted that they were no longer engaging in positive activities together, which was a drastic shift for them since this was something that had always been a strength of their relationship during the 2 years they’d dated and the 3 years they’d been married. The couple reported a moderate level of marital distress but a high level of commitment to working on their relationship and was pleased to hear that behavioral couple therapy would target increasing positives in their relationship and decreasing negatives. Consistent with the behavioral couple therapy model, treatment began with behavioral exchange strategies. First, the couple was asked to brainstorm positive activities they could engage in together. The couple greatly enjoyed doing so, reporting that it reminded them of when they were dating and more carefree. As the couple completed this activity, the therapist encouraged them to identify a range of activities, including relatively short activities like going for a walk or putting together a puzzle together, longer activities like going to a farmer’s market or cooking a

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special meal together, and extended activities like going out of town on a weekend getaway. The couple understood this distinction and agreed to implement a range of different activities in the upcoming weeks. The therapist then helped the couple identify caring activities they could do for the other person to increase their happiness. Thomas noted several activities he could do around the house to make things easier for Lauren and also offered to spend some one-on-one time with Max at some point during the evening so Lauren could have a break. Lauren stated that she could let Thomas have some decompression time when he got home from work before asking him to engage with her and Max and also suggested giving him a shoulder massage when he had a particularly long day. The couple was able to successfully implement these activities, and in subsequent sessions they reported that these activities had helped remind them of why they became a couple in the first place. Thomas and Lauren were able to quickly implement these behavioral strategies and noted a fairly rapid increase in their positivity. They reported that they continued to argue about a range of topics but their fights seemed to decrease in intensity and they were able to bounce back more quickly, which they attributed to having more overall positivity in their relationship again. Nonetheless, they were eager to learn new communication strategies to improve how they handled difficult situations, so the focus of therapy transitioned toward these topics. However, the therapist still continued to periodically check in about the couple’s use of behavior exchange strategies throughout the remainder of treatment to ensure that these did not dwindle. Communication skills training focused initially on general communication strategies the couple could use for a range of topics. One of the couple’s biggest challenges was in having a conversation after Thomas arrived home. Lauren was often excited to have someone to vent to about her challenges with Max that day, but Thomas often reported feeling overwhelmed by these updates and stated that he did not know how to respond or what he could do to help. With the therapist’s guidance, Thomas was able to learn and implement basic

Behavioral Couple Therapy

listening techniques such as reflecting and validating, which allowed him to focus more on Lauren and demonstrate his care and compassion rather than having to be a problem-solver. Lauren liked having Thomas listen to and validate her feelings after a day at home with their son and reported that their improved conversations made her feel closer to him. She was also able to more clearly express what she needed from these conversations (e.g., “I want to vent about my day”), which served to clue Thomas in to her goals and helped them be on the same page when they started their discussions. The therapist then implemented structured problem-solving training. Initially the couple was hesitant to embrace the more rigid format of this approach, but agreed to try it to break out of their existing patterns. The therapist walked the couple through the various guidelines in the approach outlined by Jacobson and Margolin (1979). The couple struggled at first with the problem definition phase, lacking clear consensus around exactly what their problems were and with defining them within a clear scope. With practice, however, they were able to do so more easily and used the time in therapy to discuss several problems that ranged in difficulty from moderately easy to more challenging. For example, at one point as the holidays were approaching, the couple chose to spend their time in session discussing whose family they would spend the time with. They were surprised at how much more calmly they were able to approach this discussion with the guidelines in mind and how much easier coming to a solution was. In time, the couple was able to add more challenging topics to their agenda, like if and when Lauren should go back to work. The therapist continued to guide the couple during these discussions but took on a less active role as the couple became more comfortable and proficient in using problem-solving skills. Toward the end of treatment, the therapist engaged the couple in several discussions about relapse prevention and the steps they wanted to take to ensure that they would maintain their functioning going forward. Both partners expressed some anxiety about terminating treatment; they recognized that they were functioning well, but were concerned about things going downhill when they did not have weekly therapy to ground them. The

Behavioral Parent Training in Couple and Family Therapy

therapist encouraged the couple to treat this as a problem to solve as well, and they were able to come up with a plan forward involving slowly titrating treatment (biweekly for 1 month and then a 1 month follow-up after that) and scheduling their own weekly time to check in about how things were going. At their final appointment, the couple reported that they had continued to engage in their positive activities and healthy communication even without the therapist’s help. They stated that although they had some minor squabbles during the previous month, they were able to quickly resolve them, making them feel more confident about their ability to do so moving forward. The couple’s scores on measures of marital satisfaction showed significant improvement, and their level of commitment remained high.

Cross-References ▶ Behavior Exchange Theory ▶ Behavior Exchange in Couple and Family Therapy ▶ Caring Days in Couple and Family Therapy ▶ Cognitive Behavioral Couple Therapy ▶ Communication Training in Couple and Family Therapy ▶ Depression in Couple and Family Therapy ▶ Integrative Behavioral Couple Therapy ▶ Jacobson, Neil ▶ Margolin, Gayla ▶ Stuart, Richard ▶ Time Outs in Couple and Family Therapy ▶ Weiss, Robert

References Baucom, D. H., Shoham, V., Mueser, K. T., Daituo, A. D., & Stickle, T. R. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology, 66, 53–88. https://doi.org/ 10.1037/0022-006X.66.1.53. Baucom, D. H., Epstein, N. B., LaTaillade, J. J., & Kirby, J. S. (2008). Cognitive-behavioral couple therapy. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (pp. 31–72). New York: Guilford Press. Bradbury, T. N., & Karney, B. R. (2013). Intimate relationships (2nd ed.). New York: W. W. Norton.

243 Christensen, A., Atkins, D. C., Baucom, B., & Yi, J. (2010). Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 78, 225–235. https://doi.org/10.1037/a0018132. Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel. Powers, M. B., Vedel, E., & Emmelkamp, P. M. (2008). Behavioral couples therapy (BCT) for alcohol and drug use disorders: A meta-analysis. Clinical Psychology Review, 28, 952–962. https://doi.org/10.1016/j. cpr.2008.02.002. Shadish, W. R., & Baldwin, S. A. (2005). Effects of behavioral marital therapy: A meta-analysis of randomized controlled trials. Journal of Consulting and Clinical Psychology, 73, 6–14. https://doi.org/10.1037/0022006X.73.1.6. Stuart, R. B. (1969). Operant interpersonal treatment for marital discord. Journal of Consulting and Clinical Psychology, 33, 675–682. https://doi.org/10.1037/ h0028475. Weiss, R. L. (1980). Strategic behavioral marital therapy: Toward a model for assessment and intervention. In J. P. Vincent (Ed.), Advances in family intervention, assessment and theory (Vol. 1, pp. 229–271). Greenwich: JAI Press. Whisman, M. A., & Beach, S. H. (2012). Couple therapy for depression. Journal of Clinical Psychology, 68, 526–535. https://doi.org/10.1002/jclp.21857.

Behavioral Parent Training in Couple and Family Therapy Hsinlien Tiffany Tsou and Ryan M. Earl The Family Institute at Northwestern University, Evanston, IL, USA

Name of the Strategy or Intervention Behavioral Parent Training

Synonyms Parent management training; Parent training

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Introduction

Behavioral Parent Training in Couple and Family Therapy

BPT is based upon the principles of behavior modification and social learning theory. A central component of BPT focuses on the role of parents and pinpoints how their actions are directly influencing the child’s targeted behavior. With the aid of a therapist, parents are to proceed with behavior modification techniques, oftentimes with rewards and punishments through the principles of operant conditioning during treatments. As illustrated by Chronis et al. (2004), parents are taught to identify and manipulate the antecedents and consequences of child behavior, target and monitor problematic behaviors, reward prosocial behavior through praise (e.g., praising a child for following orders), positive attention, and tangible rewards, and decrease unwanted behavior through planned ignoring (e.g., removing parental attention after child throws a tantrum), time out, and other nonphysical discipline techniques.

mediators for childhood behavior problems. BPT especially emphasizes the role that parents play in the development and maintenance of undesired behaviors in children, and follows the assumptions that: (1) human development serves as a function between reinforcement and punishment, to which humans are constantly interacting with either one with the environment; (2) undesired – most often antisocial – behavior is learned and sustained by the positive and negative reinforcement children receive from social agents, most often parents; (3) the goal of therapy is to strengthen the desired behavior through positive parental reinforcement, while alleviating undesired behavioral through ignorance or parental punishment; (4) maintenance and generalization of treatment gains are heavily reliant on a process of positive reinforcement through a newly acquired interactive pattern based on BPT techniques (Dumas and Lechowicz 1989). Notably, as caretakers, parents are most often the closest attachment figures for a child. Therefore, training an adult who has a greater and more frequent influence on the child to manage the presenting problematic behaviors will ultimately increase the likelihood that a positive change will occur. Furthermore, the involvement of parents is ideal because individual treatment usually does not address parental ability to deal with the child’s undesired behavior, adding additional distress that may be more effectively mitigated through a direct involvement of parental figures. Moreover, taking medication solely as the method of therapy also may not be sufficient enough to mitigate all behavioral problems. Lastly, due to a shortage of mental health practitioners that are thoroughly trained in working with children’s behavioral issues, training parents may be a more attractive option that can be both costeffective and time-saving – a win-win situation for both clinicians and clients alike.

Rationale for the Strategy or Intervention

Description of the Strategy or Intervention

Under the umbrella of the social learning theory, BPT is a proponent of utilizing parents as

BPT treatments usually last for 8 to 12 sessions for 3 to 14 year olds, with the majority of

Since its emerging presence in the late 1960s, behavioral parent training (BPT) has been one of the most widely used behavioral interventions for parents of children with behavioral problems. BPT involves clinicians helping parents to define behavior problems accurately, implementing assessment measures that further define the problem and its intensity, and educating parents in the treatment plans that would be appropriate for the problems within their individualized context (Briesmeister and Schaefer 1998). Although this approach has been applied to a variety of child behavioral problems, it is most commonly focused on antisocial behavior, including but not limited to noncompliance, temper tantrums, defiance, and aggressiveness (Serketich and Dumas 1996).

Theoretical Framework

Behavioral Parent Training in Couple and Family Therapy

treatment utilizing treatment manuals specifically describing the intervention while employing various interventions such as social skills training and school interventions (Chronis et al. 2004). In most cases, the training is delivered by a therapist and is conducted primarily with parents (as opposed with the child); however, the child could be involved in sessions during different periods of treatment. BPT typically starts with a collaborative effort between the clinician and the parent(s) to assess for and provide an overview of the child’s presenting issues. The therapist may use this opportunity to psychoeducate, particularly in regard to concepts such as the social learning theory and the behavioral management principles, and how that could be tied into treatment. After mutually agreed upon treatment goals have been established, the therapist slowly starts to work behaviorally around different aspects of the child’s environment (mostly focusing on school and home). A clear reward system and response cost is then established to reinforce “good” behaviors and diminish “bad” ones. Oftentimes, a progress chart or a checklist of some sort is introduced and acted upon as in-session activities. The chart or list may pertain to identified desired behavior(s) of the child and tracking the progress of such behaviors on a daily basis. Next, parents are trained to attend to appropriate behaviors and ignore inappropriate behaviors during sessions, while having the opportunity to practice and track their own success rates for administering the newly learned BPT at home. The therapist oversees and points out specific areas where parents can improve on (e.g., praising the child in a more effective manner) as parents recapitulate the weekly scenarios reflected back at home. Moreover, the therapist coaches parents to express more effective commands and reprimands to mediate the desired responses from the child. New rules are established, enforced, and continually modified based on the child’s progress, and time-out procedures are often included in this process. Additional rules and planning for unforeseen misbehaviors outside of home may need to take into consideration. Problem solving techniques are introduced and discussed to foster effective communications and interactions between parents and child.

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Oftentimes, BPT treatment programs also collaborate with the child’s teacher to track the child’s performance at school and link it to the reward system administering at home. Before termination, maintenance of progress is addressed to ensure the modified behaviors are continued post-treatment. Unanticipated roadblocks in the future are discussed and planned ahead in hope for parents to refrain from similar pre-treatment situations.

Case Example Angela and Howard brought in Hunter, a 10-yearold soon turning 11 Hispanic boy who has had trouble at home with defiant behaviors and an oppositional attitude. Angela, feeling helpless, mentioned dismally how Hunter’s grades at school had been dropping (from an A and B range student to C’s), and how his behaviors at home had “gotten out of control.” As the therapist continued to inquire what “out of control” entailed for the parents, Angela went about how Hunter constantly yelled and screamed at them whenever he didn’t “get his way.” When things got worse, Hunter would throw around items in the house and physically push and hit his parents (mostly Angela) and then directly go to crying. Hunter’s father, Howard, expressed how often he lost his temper because of Hunter’s unacceptable tantrums and would often scold him harshly which would bring about more crying from Hunter. The therapist laid out a brief overview for the duration of the time the parents (and child) were in treatment and determined whether both parents were on board with the treatment plan. After both parents agreed, treatment officially began and the therapist started with a mixture of psychoeducation and therapeutic strategies, adding in frequent inquiries regarding the child’s specific issue surrounding different techniques assigned for each week. Due to an inflexible working schedule, Howard was sometimes not able to join for the sessions, in which case, Angela would solely work with the therapist with occasional involvement of Hunter. In the beginning, the use of a progress chart was introduced that let Angela and Howard

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document the desired behaviors that Hunter performed (e.g., picking up his trash, read for 20 min before night) through putting “star stickers” next to the ones he successfully completed. The therapist then continued on with coaching the parents for effective ways to diminish Hunter’s screaming and crying. Through many roleplays, planning, and validation, the therapist was able to coach Angela to speak to Hunter in a clear, concise manner to ask him to stop the presenting “bad” behaviors. The therapist taught Angela to be consistent with her answers and to “persist on,” even when she confessed that “it is so easy to give in.” After constant encouragement, the therapist walked Angela through different scenarios in which she was expected to ignore Hunter’s unreasonable tantrums. Moreover, the therapist facilitated discussion between Angela and Howard to establish agreement around Hunter’s punishment. Lastly, Angela and Howard were coached to practice praising in a more natural and direct manner. Through periodic evaluations, the parents were asked to assess their progress and modify or strengthen BPT in certain areas if needed. Overall, throughout the treatment period, both parents expressed seeing slight improvement from Hunter over the course of treatment. Angela noted Hunter became more compliant with her orders and felt there were fewer tantrums of higher severity in the last month or so of treatment. There were still some relapses here and there, but both Howard and Angela were much more confident at handling Howard’s defiant behaviors and better at administering effective communication to Hunter. Before termination, the therapist also provided space for discussion regarding post-treatment and refreshed all the techniques the parents had learned.

Behavioral Rehearsal in Couple and Family Therapy

▶ Premack Principle in Social Learning Theory ▶ Punishment in Social Learning Theory ▶ Social Learning Theory

References Briesmeister, J. M., & Schaefer, C. E. (1998). Handbook of parent training. New York: Wiley. Chronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T., & Pelham, W. E. (2004). Enhancements to the behavioral parent training paradigm for families of children with ADHD: Review and future directions. Clinical Child and Family Psychology Review, 7(1), 1–27. Dumas, J. E., & Lechowicz, J. G. (1989). When do noncompliant children comply? Implications for family behavior therapy. Child and Family Behavior Therapy, 11, 21–38. Serketich, W. J., & Dumas, J. E. (1996). The effectiveness of behavioral parent training to modify antisocial behavior in children: A meta-analysis. Behavior Therapy, 27(2), 171–186.

Behavioral Rehearsal in Couple and Family Therapy Nicole Ortiz Clinical Psychology, California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Introduction Behavioral rehearsal is a technique that emerged from social learning theory and operant conditioning and is used to modify current behaviors or learn new behaviors. This technique is particularly effective in cognitive behavioral models of treatment for couples and families. It is most effective in learning behaviors that require practice.

Cross-References ▶ Cognitive-Behavioral Family Therapy ▶ Negative Reinforcement in Social Learning Theory ▶ Operant Conditioning in Couple and Family Therapy

Description of the Strategy or Intervention This technique involves the clinician modeling behaviors or interactions for the clients, followed

Behavioral Rehearsal in Couple and Family Therapy

by the clients imagining or performing the behaviors and receiving feedback from the clinician. This may be covert or overt, such that the clients can imagine the experience, role plays the experience, or discussing future behaviors with the clinician in preparation for the real experience. These rehearsals are different from typical therapeutic role plays, because they focus on practicing skills rather than evoking emotional responses. This technique can be used to modify or teach responses, behaviors, and social skills in order to improve interpersonal functioning. In couple and family therapy, this process begins with the clinician observing interactions of the partners or group in order to formulate a conceptualization and determine the target behaviors. The target behaviors are those that will require rehearsal. Next the clinician models the chosen behavior for the couple or family and allows them to practice said behaviors and interactions, followed by providing feedback based on their performance. An important aspect of this technique is that the clients practice the new behavior often, in order to develop the knowledge and skills to utilize in real life settings and situations.

Theoretical Framework This behavior therapy technique is most often utilized in cognitive behavioral models of treatment with individuals, groups, couples, and families. In addition to its use for teaching social skills within interpersonal relationships, this technique is also commonly used to foster coping skills that can target anxiety, stress, and other psychological phenomena. Additionally it can be used to increase a client’s self-efficacy, assertiveness, and other social skills that can improve their interpersonal relationships and daily functioning. More specifically, it is utilized within behavior couple therapy (BCT) and cognitive-behavioral family therapy (Masters and Burish 1987; Meichenbaum 1977). In BCT the technique is has been used to target couples’ communication patterns as well as psychological functioning including depression, substance abuse, posttraumatic stress disorder, relationship distress,

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conflict resolution, and relationship satisfaction. In cognitive-behavioral family therapy, the behavioral techniques focus on the parents and helps provide parental training to help target problems of the children or adolescents.

Rationale for the Strategy or Intervention In regard to its efficacy in couple’s therapy, it has been found more effective compared to traditional communication training, likely due to its largely collaborative nature (Fischer and Fink 2014). Empirical evidence also suggests it is more effective in fostering more adaptive relationship functioning compared to individual-based treatments (O’Farrell & Schein 2011). Behavioral rehearsal has also been effective in modifying maladaptive behavioral and communicative patterns within families (Liberman 1970). Specifically, it has been utilized as a component of child-focused behavioral therapy, behavioral parent training, and family skills training. There is also evidence that these therapeutic interventions have been empirically proven to impact outcomes including relationship satisfaction, social skills, depression, substance abuse, posttraumatic stress disorder, obsessive compulsive disorder, anxiety, and eating disorders.

Case Example Matthew and Allison presented to couple therapy in order to address an ongoing conflict they were experiencing in their relationship. The couple had been experiencing conflict, as a result of Allison not feeling supported by Matthew during her new job transition. Allison stated that Matthew would come home late from work and when she talked to him about her day and sought support, she felt that he was not actually engaged in the conversation, which hurt her feelings. As a result, Allison often told him that he does not care about her, and they ended up arguing. There is clearly a lack of communication within this couple regarding each of their needs

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in the relationship. Thus, the therapist’s first goal was to talk to the couple about the importance of open communication and then to demonstrate this with Matthew and Allison. In order to demonstrate this open communication, the therapist acted as Allison and told Matthew to imagine he just came home, tired and stressed, and Allison started talking to him about her day. The therapist, acting as Allison, told Matthew that she felt like he was not really listening to her, and that this hurt. She proceeded to tell him how important it was to her to have his support, and then asked him what they could do to work on this together. Matthew responded that he would like a short amount of time when he got home to unwind from his day so that he could be fully present with her when she tells him about her day. Next, the therapist asked the couple totry having this conversation with each other, communicating their needs and working toward a compromise. Ultimately, following several practices of this open communication about their needs across several sessions, Allison and Matthew were able to resolve this conflict and use those skills to communicate more openly with each other in other situations.

Cross-References ▶ Cognitive Behavioral Couple Therapy ▶ Cognitive-Behavioral Family Therapy

References Fischer, D. J., & Fink, B. C. (2014). Clinical processes in behavioral couples therapy. Psychotherapy, 51(1), 11–14. Liberman, R. (1970). Behavorial approaches to family and couple therapy. American Journal of Orthopsychiatry, 40(1), 106–118. Masters, J. C., & Burish, T. G. (1987). Behavior therapy: Techniques and empirical findings (3rd ed.). San Diego: Harcourt Brace Jovanovich. Meichenbaum, D. (Ed.). (1977). Cognitive-behavior modification: An integrative approach. New York: Plenum Press. O’Farrell, T. J., & Schein, A. Z. (2011). Behavioral couples therapy for alcoholism and drug abuse. Journal of Family Psychotherapy, 22(3), 193–215.

Bell, John

Bell, John Samuel B. Rennebohm Seattle Pacific University, Seattle, WA, USA

Name John Edlerkin Bell, Ed.D. (1913–1995)

Introduction John Bell is recognized as one of the first clinicians in the United States to work systemically with families as the focus of treatment, rather than the individual. His contributions as a scholar and a practitioner helped to launch family therapy as a formal approach to clinical work.

Career After earning a bachelor’s degree from the University of British Columbia and a certificate in theology from Union Theological College in Vancouver, Bell began his career as a parish minister. He served churches in British Columbia for 3 years before making the decision to pursue further education. Bell moved to New York City and enrolled in the graduate program in education at Columbia University. He earned a Master of Arts degree in 1941 and a doctor of education degree in 1942, focusing on educational psychology. He spent the next 2 years as an assistant professor of psychology at Park College in Kansas City, followed by 12 years on the faculty of Clark University in Worcester, Massachusetts. While at Clark, Bell also served as director of the psychological clinic, where he pioneered his approach to working with family groups. It was also during this time that Bell published his most influential texts documenting this approach. Later in his career, Bell held positions as a regional director for the National Institute of Mental Health (1959–1968), Director of the Palo Alto Mental Research Institute (1968–1973), and

Bernal, Guillermo

research psychologist at the Palo Alto Veterans Hospital (1973–1979). He also traveled to 24 countries in the developing world on behalf of NIMH to study family functioning in medical contexts. He also served terms as president of the Society for Projective Techniques and president of the Division of Psychologists in Public Service, and in 1970 was honored with the Distinguished Scientific Contribution Award from the Division of Clinical Psychology.

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insisted that all members of the family be present for each session, and refused to meet with individual members outside of family sessions. While many of these techniques have since become standard practice in the field of family therapy, they represented novel innovations at the time, and were developed through years of trial and error in Bell’s work with families. Much of the technical and theoretical basis for contemporary clinical work with families has thus been derived from Bell’s pioneering work and writings.

Contributions to Profession Cross-References Bell’s efforts to focus treatment on the family as a whole emerged from his work with adolescents experiencing significant behavior problems. Recognizing the limitations of applying adult intervention techniques to adolescents, Bell instead began experimenting with techniques he had learned while doing group therapy. He applied these techniques in sessions attended by the entire family and labeled the emergent approach as Family Group Therapy. In his written text of the same name, Bell described Family Group Therapy as consisting of six phases: (1) orientation, (2) child-centered, (3) parent-child interaction, (4) father-mother interaction, (5) sibling interaction, and (6) family-centered. Consistent with his emphasis on treating entire families rather than individuals, Bell conceptualized psychological problems as the result of disruptions in familial relationships rather than individual-level pathology. Treatment then focused on improving communication and interaction patterns within the family at-large. The role of the therapist, in his view, was to first shift the focus away from individual level pathology and towards a system level analysis, then to facilitate new interactions between members. He structured sessions in such a way as to give each member of the family opportunities to express themselves, particularly the children, in order to create a collaborative environment in which all members shared ownership of the problem-solving process. To help facilitate this, Bell would often meet with the parents beforehand to teach them skills for listening more carefully to their children. He also

▶ Family Therapy ▶ Identified Patient in Family Systems Theory ▶ Therapist Position in Couple and Family Therapy

References Bell, J. (1961). Family group therapy : A method for the psychological treatment of older children, adolescents, and their parents, Public health monograph; No. 64. Washington, DC: United States Government Printing Office. Bell, J. E. (1963). A theoretical position for family group therapy. Family Process, 2(1), 1–14. https://doi.org/ 10.1111/j.1545-5300.1963.00001.x. Bell, J. E. (1964). The family group therapist: An agent of change. International Journal of Group Psychotherapy, 14(1), 72–83. Bell, J. (1975). Family therapy (1st ed.). New York: J. Aronson. Bell, J. (1983). Family group therapy. In B. Wolman & G. Stricker (Eds.), Handbook of family and marital therapy (pp. 231–245). New York: Plenum Press.

Bernal, Guillermo Lorna London Midwestern University, Downers Grove, IL, USA

Name Bernal, Guillermo

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Introduction Dr. Guillermo Bernal is a licensed clinical psychologist and a prolific researcher who has been touted for his contributions to advancing psychological science and practice. He serves as the director of the Institute for Psychological Research at the University of Puerto Rico, Rio Piedras, and remains active in teaching, research and service. Much of his work centers on the impact of the cultural adaptation of psychological treatment intervention with ethnic minority populations.

Career Dr. Bernal graduated cum laude with his A.B.. in psychology from the University of Miami in 1972. He earned his master’s degree in clinical psychology from the University of Massachusetts at Amherst in 1975 and completed his thesis entitled “Vicarious eyelid conditioning in a discrimination learning paradigm.” Bernal continued his education at the University of Massachusetts at Amherst, where he earned his Ph.D. in clinical psychology in 1978 and successfully defended his dissertation entitled “Couple interactions: A study of the punctuation process” (Bernal 2018).

Contributions to Profession A clinician licensed to practice psychology in Puerto Rico and California, Dr. Bernal’s professional work has had him involved in clinical, research, and academic pursuits. Following receipt of his doctorate degree, Dr. Bernal worked as a staff psychologist at the Community Organization for Mental Health and Mental Retardation, Inc., in Philadelphia, PA. He later accepted an appointment as an assistant professor of psychology and the University of California, Department of Psychiatry at San Francisco General Hospital. He was promoted to associate professor, before accepting a position in the Department of Psychology at the University of Puerto Rico, Rio Piedras (UPR-RP). Dr. Bernal continues his

Bernal, Guillermo

work at UPR-RP and has served as the founding director of the University Center for Psychological Services and Research, professor of psychology, and the director for the Institute for Psychological Research at UPR-RP (Bernal 2018). To support his research in the areas of depression with Latino youth, suicide prevention, and training in biopsychosocial research, Dr. Bernal has received grants from the National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In his role in academia, Dr. Bernal has been active as a grant reviewer, serving on panels for various professional agencies, and has also been active on the editorial boards of journals such as the Puerto Rican Journal of Psychology, the Journal of Family Psychology and the Journal of Consulting and Clinical Psychology. A prolific researcher and author, Dr. Bernal has made many contributions to the field of psychology. In particular, he has published widely in the area of empirically supported treatments for ethnic minorities (Bernal et al. 2016). Of mention, he has published articles discussing the importance of the cultural adaptation of existing treatment interventions and the need to establish evidence-based practice for work with individuals and families (Bernal et al. 2012). Within the area of family therapy, Dr. Bernal has collaborated with researchers and published works related to understanding the manifestation of clinical issues among Latino families, and ways in which counseling and psychotherapy may be utilized in a culturally competent way. Of note, he was instrumental in devising the Contextual Therapy Action Index for use by family therapists in their work with culturally diverse clients (Bernal et al. 2016). A member of a number of professional organizations, Dr. Bernal has held positions of leadership including serving as Fellow for the Society for Community Research and Action (1992), President of the American Psychological Association (1996–1997), and Chair of the Research Committee for the American Family Therapy Association (2007–2011).

Berne, Eric

Throughout his lifetime, Dr. Bernal has received numerous accolades for his professional work, including a Lifetime Achievement Award from the Puerto Rican Psychological Association, the Stanley Sue Award from the Society of Clinical Psychology, the APA Presidential Citation and Distinguished Elder Award, and the Distinguished Contribution to Family Systems Research Award presented by the American Family Therapy Academy. Dr. Bernal’s many contributions to the field of psychology have led him to be respected for his vast works which have blended his commitment to the mental health of Latino families and his desire to ensure that family therapy interventions are culturally based and empirically supported.

Cross-References ▶ Cultural Competency in Couple and Family Therapy ▶ Culture in Couple and Family Therapy ▶ Latino/Latinas in Couple and Family Therapy ▶ Research About Couple and Family Therapy

References Bernal, G. (2018, Sept 10). Guillermo Bernal curriculum vitae. Retrieved from http://guillermobernal.net/ Bernal, G., & Domenech Rodriguez, M. M. (Eds.). (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: APA Press. https://doi.org/10.1037/13752-000. Bernal, G., Flores-Ortiz, Y., Rodriguez, C., Sorensen, J. L., & Diamond, G. (1990). Development of contextual family therapy therapist action index. Journal of Family Psychology, 3(3), 322–331. Bernal, G., Jimenez-Chafey, M. I., & Domenech Rodriguez, M. M. (2009). Cultural adaptation treatments: A resource for considering culture in evidencebased practice. Professional Psychology: Research and Practice, 40(4), 361–368. Bernal, G., Morales, J., & Gomez, K. (2016). Family counseling and therapy with diverse ethnocultural groups. In P. B. Pendersen, W. J. Lonner, J. G. Draguns, & J. E. Trimble (Eds.), Counseling across cultures (7th ed., pp. 457–476). Newberry: SAGE.

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Berne, Eric Lindsay Dwelley and Marilisa Z. Raju California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Name Eric Berne (1910–1970)

Introduction Eric Berne is known in the field of psychotherapy for his theory of Transactional Analysis (TA) and his prolific writings, authoring eight books and over 50 publications. Berne’s work, analyzing social transactions and disrupting predictable patterns between individuals, has extended out to group work, families, and couples.

Education/Career Canadian born, Eric Berne attended McGrill University in 1935 where he earned his degrees, Doctor of Medicine and Master of Surgery. Berne then moved to the United States, where he later became a citizen. He did his psychiatric residency at Yale University School of Medicine and later a psychiatric post in New York City at Mt. Zion Hospital. In 1941, Berne attended the New York Psychoanalytic Institute where he began training as a psychoanalyst; he worked with Paul Federn, whose ideas were highly influential and shaped Berne’s personality theory (Stewart 1992). Eric Berne joined the US Army Medical Corps in 1943 during World War II, eventually becoming a Major while serving in several Army hospitals as a psychiatrist. In 1946, he left the Army, moved to the west coast, and resumed his psychoanalytic training. At the San Francisco Psychoanalytic Institute, Berne worked with Erik Erikson for 2 years; his influence illuminates much of Berne’s work (Stewart 1992). Meanwhile, Berne

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became Assistant Psychiatrist at Mt Zion Hospital, San Francisco, in 1950, while also working as a Consultant to the Surgeon General of the US Army. Soon after, Berne joined a Veterans Hospital, serving a third psychiatric post, while concurrently establishing his private practice and maintaining a busy schedule of writing, teaching, and research. In the early 1950s, Eric Berne began hosting regular seminars where he and fellow clinicians presented papers and exchanged ideas focusing on social psychiatry. When he was turned down for a formal membership of the psychoanalytic institute in 1956 for allegedly challenging psychoanalytic orthodoxy in a formal paper, Berne split from psychoanalysis, marking a departure from the classical theory toward the development of new language and thought. Berne continued to work, write, and lecture until his death in 1970.

Contributions to the Profession Eric Berne has several notable contributions to the field, including advancing his theory of Transactional Analysis and publishing his first full-length book devoted to the theory in 1961, Transactional Analysis in Psychotherapy. Berne’s theory of Transactional Analysis (TA), while developed from the thinking of earlier writers like Freud, Federn, and Erikson, was rooted in his real-world observations and clinical experiences (Stewart 1992). In contrast to psychoanalytic theory, Eric Berne was determined to create a new approach to psychotherapy that had practical applications and aimed to make change quickly. The cornerstone of Berne’s theory was that he believed human behavior was systematically observable thereby highlighting transference phenomena and improving the likelihood for intrapsychic change (Stewart 1992). Transactional Analysis is mapped into four main divisions: the structural model of ego-states, transactions, games, and script (Berne 1961). Berne’s ego-states are the basis of TA and

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describe how a person is structured psychologically. The varying ways a person behaves, thinks, and feels may be put into three large categories of ego-states called Parent, Adult, and Child (Berne 1961). Berne’s transactions explains the patterns of communication between people and are analyzed in terms of the ego-states employed. Thus, according to TA, identifying and changing the transactions between people is the path to solving emotional problems (Berne 1964). The games within TA refer to the stereotyped, repetitive sequences of transactions and predictable patterns that lead to painful outcomes. Berne’s theory of games is what he and TA are best known for due to the world-wide fame of his 1964 best-selling book, Games People Play, written and intended for a professional audience, but sold to a mass market and popularized by the media (Stewart 1992). Lastly, the concept of script within TA signifies a person’s wider-life pattern that encompasses the smaller expressions of games and transactions; it is based on a person’s decision in childhood and reinforced by his or her parents and subsequent life events. Finally, Transactional Analysis helps people to succeed in freeing themselves from their script and their predictable relational patterns (Berne 1964). Berne’s therapy model has been used with individuals in psychotherapy as well as with couples and families, where interpersonal disturbances are the focus of treatment. Eric Berne is also known for his professional interest and writings on the psychotherapy of groups and the comparative study of psychiatry, inspired by the different regions where he traveled and wrote about while visiting psychiatric hospitals throughout the world (Berne 1963).

References Berne, E. (1961). Transactional analysis in psychotherapy. New York: Grove Press. Berne, E. (1963). The structure and dynamics of organizations and groups. New York: Lippincot. Berne, E. (1964). Games people play. New York: Grove Press. Stewart, I. (1992). Eric Berne. London: Sage Publications.

Bids and Turning Toward in Gottman Method Couple Therapy

Bids and Turning Toward in Gottman Method Couple Therapy Robert J. Navarra and John M. Gottman The Gottman Institute, Seattle, WA, USA

Name of Concept Bids and Turning Toward in Gottman Method Couples Therapy.

Synonyms Emotional bank account

Introduction Research indicates that a reliable predictor of relationship satisfaction and stability is found in how couples typically respond to each other’s attempts for conversation and connection, referred to as “Bids and Turning Toward” (Gottman 2001). While heart-to-heart conversations create moments of closeness, a more pervasive sense of emotional connection is found in nuanced day-to-day interactions that may not seem particularly significant or even noticeable at the time.

Theoretical Framework Bids are defined as any attempt a partner makes, verbally or nonverbally, to connect with the other partner. The couple’s ability to pay attention to and effectively respond to these immediate needs for connection is defined as “Turning Toward,” which increases positivity and is likened to making a deposit in the “emotional bank account.” An emotional bank account balance in the black is positively correlated with sex, romance, and expressing positive emotions of humor and

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affection during conflict (Gottman 2015). Bids can be understood as the smallest units of intimacy with these moments of emotional connection often brief and seemingly trivial at first glance (Gottman and Gottman 2015). Conversely, a failed bid occurs when the bid is met with either “turning away” by ignoring the bid or by responding negatively or “turning against.” This is akin to a withdrawal from the emotional bank account. For marriages headed for divorce, the bank account is in the red and the chances of the partner re-bidding again and partners risking further rejection is almost zero, while in stable marriages partners re-bid about 20% of the time (Gottman 2001). With continued failed bids, the number of bids drops precipitously, increasing emotional disconnection over time. Relationship distress and core dysfunctional interactions are likely to be found in a pattern of failed bids (Gottman 1999). In a hierarchy of needs, bids can range from low-level to high-level, depending on the amount of emotional vulnerability associated with the bid (Navarra and Gottman 2011). A low-level bid would be “small talk,” including any comment, remark, or observation. Building on low-level bids leads to increased trust – the stepping stone to bids that reflect increased emotional vulnerability. When high-level bids (e.g., for attention, empathy, support, affection, humor, or comfort) are responded to positively, partners feel cared for, important, and that their partner is there for them. The fundamental law of bids and turning toward creates either a positive or negative feedback loop; turning towards leads to more turning toward, and turning away or turning against leads to more turning away or turning against. Gottman Method Couples Therapy integrates the work of affective neuroscientist Jaak Panksepp and his discovery of seven emotional command systems and the subcortical structures found in all mammals that he identified as neuronal circuits hardwired for emotional expression. These emotions (i.e., seeking, rage, fear, lust, care, panic/ grief, play) are circuits built into the brain. Panksepp’s remarkable integration of affective

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Bids and Turning Toward in Gottman Method Couple Therapy

neuroscience and evolution identifies these emotions as our primary affective command systems. They are primary, but they can work together, with emotions from two or more command systems at work at the same time. Turning toward the partner’s core emotion-based needs provides and nurtures connection at fundamental levels (Gottman 2015). Once researchers knew what to look for, patterns emerged that clearly differentiated stable relationships from distressed relationships (e.g., some couples made 200 bids in 10 min while others only made two bids in the same amount of time). The researchers discovered that they could quantify how often partners needed to turn toward bids for a stable relationship. In a study of newlyweds and divorce prediction, couples that were happily married 6 years later turned towards each other’s bids about 86% of the time, while couples who ended up divorced turned toward each other only 33% of the time (Gottman and Gottman 2015).

Rationale Bids and Turning Toward is one of the levels, or building blocks, of the Gottman relationship theory, the Sound Relationship House (SRH), that emerged after combining long-term predictive studies and proximal studies. Turning away or against leads to severe relationship difficulties over time; however, brief interventions can effectively mediate this trajectory and modify couples’ interactions (Gottman and Gottman 2015).

Description of Strategy or Intervention Interventions for strengthening bids and turning toward and increasing the emotional bank account start with informing the couple about these concepts and discussing and exploring how they currently make bids and typically respond to bids. Once couples become more aware of bids and how to respond to them, changes are likely to happen very quickly, as the proximal studies suggest. Couples learn that turning toward the partner needs to occur in all of Panksepp’s seven

emotional command systems. Strategies are developed on initiating and responding to expressed needs, so they are not left to chance. Couples are given tools to have conversations and make agreements for ritualizing activities, like date night, going for walks, or sharing time together, even if briefly. One example of a ritual is the “stress-reducing conversation,” where couples take turns talking about and receiving support for stressful events that are external to the relationship.

Case Example Debby and James had been married for 2 years when they began couples therapy complaining of continual arguments, lack of emotional support, an absence of connection, and increasing withdrawal. They married several years after meeting in a 12-step program. Both had established, longterm recovery from substance use disorders at the time they began therapy, but recovery was the only point of connection for them. Gottman Method Therapy is an affectivebased therapy; emotional connection increases likelihood of more effectively managing conflict (Navarra and Gottman 2011). By defining bids and discussing how they each made bids, the therapist helped them establish new ways to ask for what they needed and how to turn toward each other, deepening emotional attunement and connection. Over the months, they became much more successful in recognizing, then ritualizing bids and turning toward. They made commitments to meet regularly, spending time to talk about the day and hopes for the future. Strengthening their friendship helped put their relationship back on track to manage conflict more effectively.

Cross-References ▶ Four Horsemen in Couple and Family Therapy ▶ Gottman method couples therapy ▶ Negative Sentiment Override in Couples and Families

Biobehavioral Family Model, The

▶ Sound Relationship House in Gottman Method Couples Therapy ▶ Trust in Gottman Method Couples Therapy

References Gottman, J. M. (1999). The marriage clinic: A scientifically-based marital therapy. New York: W. W. Norton. Gottman, J. M. (2001). The relationship cure. New York: Three Rivers Press. Gottman, J. M. (2015). Principia amoris: The new science of love. New York: Routledge. Gottman, J. S., & Gottman, J. M. (2015). 10 principles for doing effective couples therapy. New York: W.W. Norton & Company. Navarra, R. J., & Gottman, J. M. (2011). Gottman method couple therapy: From theory to practice. In D. K. Carson & M. Casado-Kehoe (Eds.), Case studies in couples therapy: Theory-based approaches (pp. 331–343). New York: Routledge.

Biobehavioral Family Model, The Beatrice Wood State University of New York, Buffalo, NY, USA

Synonyms BBFM

Introduction The Biobehavioral Family Model (BBFM) is a multilevel systemic biopsychosocial model, positing reciprocal pathways of effect among family and individual function (Wood et al. 2000, 2008, 2015). This model rests upon assumptions of the interdependence of relational, emotional, and biological processes consistent with the current “social and affective neuroscience” paradigm. The BBFM posits that patterns of family relational process influence one another and collectively either buffer against or potentiate emotional, physiological, and developmental dysfunction in individual family members (see Fig. 1).

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Prominent Associated Figures The Biobehavioral Family Model was developed by Beatrice L. Wood, PhD, who was trained in family therapy at Philadelphia Child Guidance Clinic and has remained active in clinical training and research in family systems. The BBFM was inspired and informed by Salvador Minuchin’s Psychosomatic Family Model (Minuchin et al. 1978).

Description This model is not a model of family dysfunction, but rather a configurational model of seven dimensions of normative family process. Individual emotional and physiological dysregulation mediates the effects of family relational process on the individual’s physical functioning. The dimensional nature of the model provides for consideration of both protective and negative effects of family relations on the individual family member. The seven continua include: (1) interpersonal proximity; (2) generational hierarchy; (3) responsivity; (4) parent-parent relationship quality; (5) family emotional climate; (6) attachment security; and (7) biobehavioral reactivity. Family relational process characterized by the positive ends of each continuum would buffers the effects of stress (internal and external) on the individual, whereas family process characterized by the negative ends of the continua would transmit internal family stress and exacerbate external stress for the individual. This model has been used to guide research on the effects of family relational stress on stressrelated illnesses, to guide treatment, and to guide training in family systems intervention. The Scope of the BBFM: The BBFM model originally focused on the child. However, the model can be applied to patients across the lifespan. In principle the model can address the family and individual processes affecting any family member (adult or child) suffering from physically and/or psychologically manifested disease. This integrated interpretation of “disease” is justified by research developments that increasingly demonstrate the mutual contribution of psychological

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Biobehavioral Family Model, The

Biobehavioral Family Model, The, Fig. 1 The biobehavioral family model 2016

motional Climate Family E FAMILY

Proximity

Generational Hierarchy

Parental Relationship Quality

Responsivity

PARENT-CHILD

Attachment Security Parenting

Biobehavioral Reactivity PATIENT

PSYCHOBIOLOGICAL MECHANISMS Emotional or Physical Disorder

and biological factors to both physically and psychologically manifested disease. Indeed, it could be argued that the dichotomy of psychological versus physical disease is an outmoded dichotomy.

Dimensions of the Biobehavioral Family Model Proximity is defined by who is close to whom based on the extent to which family members share personal space, private information, and emotions (Wood et al. 2000). It is analogous to family cohesion. Generational hierarchy refers to the extent to which caregivers are in charge of children by providing nurturance, guidance, and limit setting through strong parental alliance and absence of cross-generational coalitions (Wood et al. 2000). Responsivity refers to the extent to which family members are behaviorally, emotionally, and physiologically responsive to one another. Responsivity depends, in part, on the biobehavioral (i.e., emotional/physiological and behavioral) reactivity of each family member. Moderate levels of emotional/physiological responsivity allow for empathic response among

family members. Extremely high levels of responsivity can exacerbate maladaptive emotional/physiological resonance in the family, possibly worsening stress-influenced emotional or physical disorders. Extremely low levels of responsivity result in neglect or avoidance, leaving family members unbuffered from internal, familial, or environmental stressors. Family-wide levels of responsivity reflect family-level emotion regulation or dysregulation. Furthermore, familylevel emotion regulation and individual biobehavioral reactivity are inter-related (Wood et al. 2000). Parent-parent relationship quality refers to mutual support, understanding, and adaptive disagreement (respectful and resolving) versus hostility, rejection, and unresolved conflict (Wood et al. 2000). Parent-parent relationship quality is a key component determining family-level emotional climate. Family emotional climate refers to the overall intensity and valence of family emotional exchange. It colors all aspects of family relational process, and therefore it is likely a key factor contributing to emotional status and outcomes in family members (Wood et al. 2008). A negative family emotional climate (NFEC) includes hostility, criticism, verbal attacks, etc., and it is similar

Biobehavioral Family Model, The

to the criticism construct of expressed emotion. Positive aspects include respect, acceptance, caring, warmth, support, affirmation, etc. Family emotional climate is characterized by the intensity and balance of negative and positive emotional exchange among family members. This balance or imbalance can be construed as reflecting one aspect of family-level emotion regulation or dysregulation. Attachment refers to the biologically based, lifelong tendency, of human beings under conditions of stress to seek some form of proximity (physical or emotional) with specific other persons who are perceived as protective or comforting, such that one’s emotional and physiological disequilibrium are restored (Bowlby 1969). Patricia Minuchin (Minuchin 1988) has also elaborated family systems frameworks in which attachment may be studied. There is evidence that secure attachment can buffer a child from difficult life events. In the BBFM, attachment mediates and/or moderates the effect of family relational process on individual family members (Wood et al. 2000). The construct of attachment overlaps with the constructs of proximity and generational hierarchy in the BBFM. However, the constructs are distinct, suggesting potentially independent influence on family member experience and function. Proximity, as conceptualized in the BBFM, refers to the amount and intensity of physical and emotional exchange among all family members. In contrast, the construct of attachment refers to dyadic relations and includes not only an individual family member’s seeking of closeness and soothing, when under threat or stress, but also the attunement (that is, sensitive attentiveness, perception, and response) of one to another family member, which helps the individual modulate his or her emotional/physiological response. Thus attachment involves the notion of dyadic empathic attunement safety and emotion regulation, but proximity, by itself, does not. Proximity is analogous to family cohesion. The constructs are related, however. The degree of family proximity (or lack thereof) may be a reflection of attachment security or insecurity among family dyads, the family proximity or cohesion may

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contribute to ongoing attachment security and empathic attunement. The nurturance aspect of generational hierarchy is also not equivalent to attachment, because nurturance is a broader construct addressing a more general fostering of the child’s well-being. Nurturance and attachment are likely to be closely related, however, because secure attachment interactions are unlikely to occur in the absence of a nurturing relationship. Given the above research findings and theoretical rationale, it seems likely that secure attachment may buffer, and insecure attachment exacerbate, the impact of stressful family process or life events on disease-related psychological and physiological processes in individual family members. Furthermore, the patterns of proximity, generational hierarchy, parental relationship quality, family emotional climate, responsivity, and biobehavioral reactivity are likely to shape and be shaped by attachment configurations in the family. Biobehavioral reactivity is the pivotal construct of the BBFM. It mediates the effect of BBFM family relational processes on physical well-being or illness in the individual. It is conceptualized as the degree or intensity with which an individual family member responds physiologically, emotionally, and behaviorally to emotional stimuli. It is the phenomenological reflection of at least three psychobiological processes: neurobiological aspects of temperament; emotion/affect regulation and dysregulation; and allostasis/allostatic load. Neurobiological aspects of temperament. The neurobiological aspects of temperament are reflected in biobehavioral reactivity. Individual differences in infant and child temperament and stress reactivity have been shown to be related to health outcomes. Infant reactivity and regulation are two constituent parts of Rothbart’s model of temperament (Rothbart and Derryberry 1981). Research has shown robust support for an integration of Rothbart’s behavioral model of temperament with the neurobiological processes underlying the model. Thus temperament constitutes an important component of biobehavioral reactivity.

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Emotion regulation and dysregulation. Biobehavioral reactivity in part reflects emotion regulation and dysregulation, because of the neurobiological processes inherent in emotion/ affect regulation and dysregulation. Emotion dysregulation is influenced both by innate and by external influences, particularly by patterns of caregiving. Insecure attachment can result in specific types of emotion dysregulation: anxiety and depression, which are the aspects of biobehavioral reactivity. Emotion dysregulation is accompanied by neurobiological dysregulation. Thus, emotion/ neurobiological dysregulation has potential influence on physical or psychologically manifested disease by dysregulating neurobiological pathways and mechanisms related to disease. Thus, biobehavioral reactivity reflects, in part, the ability of the individual to regulate emotion, accompanied by the neurobiological underpinnings of this process. Allostasis and allostatic load. Allostasis, which is the body’s physiological response to stress (McEwen 1998), also reflected in biobehavioral reactivity. Several physiological systems and processes underlie and constitute allostasis: cardiovascular functioning, the sympathetic and parasympathetic nervous systems, the hypothalamic pituitary adrenal axis, immune function, lipid/fat metabolism, and glucose metabolism. When activated by stress, these systems respond in ways that support the organism’s adaptive response to stress, while protecting the body’s appropriate function. However, if these systems are repetitively or chronically called upon to respond to stress, their continual activation can damage the body and result in poor health. This is called “allostatic load,” defined as “wear and tear that results from chronic over activity or under activity of allostatic systems” (McEwen 1998, p. 171). Allostasis and allostatic load are important underlying processes contributing to biobehavioral reactivity. These three aspects of biobehavioral reactivity (neurobiological aspects of temperament, emotion regulation, and allostasis and allostatic load) mediate the effects of the BBFM-identified family

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relational process on the physical well-being or disorder in a given family member. Family flexibility is implicit in the BBFM. Family flexibility is a dynamic construct. It is the family’s ability to change its relational patterning according to the demands of the circumstances. Stressful life events, including trauma, developmental changes, illness, and rapid cultural change and/or migration are some of the circumstances in which the family needs to shift its patterns of relational process and make necessary changes in order to successfully adapt (Akyil et al. 2016). Families that lack such flexibility have rigid patterns that prioritize maintaining the status quo, which precludes adapting to the need for change. Families that are too flexible have a chaotic pattern that makes them vulnerable for dissolution.

Relevance to Couple and Family Therapy Examples of BBFM Configurations in Clinical Context Adaptive family configuration: A family that is characterized by positive balance of emotional climate (more warmth than hostility); moderate proximity (i.e., age and dyad appropriate sharing of emotions, personal information, physical space; cohesive but allowing for privacy); moderate parental hierarchy (i.e., parents in alliance, age appropriate guidance and limits, parents nurturing children, no-cross generational coalitions; room for age appropriate autonomy); moderate responsivity (i.e., enough responsivity to share emotions, which promotes bonding, and to soothe, but not reactive in ways that contribute to the stress level); good quality parent-parent relationship (i.e., more positivity than negativity, but negativity permitted); and a secure parentchild attachment with both parents. The children or ill adult can turn to a family member for soothing and support, and this family member or members are attuned and provide what is needed. This family configuration would support moderate biobehavioral reactivity which would be sufficient to

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inform appropriate response to life challenges, but not so extreme as to evoke high levels of psychobiological stress, resulting in vulnerability to physical and emotional illness. Extreme maladaptive configuration A: A family that is characterized by more negative than positive family emotional climate (i.e., more hostility than warmth); very high levels of proximity (i.e., intrusive over involvement) among family members; extremely strong generational hierarchy (i.e., parent(s) overly controlling of child(ren); extreme reactivity (i.e., family members hyper-emotionally reactive to any stressor or challenging family interaction); and insecure parent-child attachment and attachment among family members (i.e., anxious attachment). This configuration would leave an individual family member highly susceptible to family and or environmental and social stress, and likely produce high levels of biobehavioral reactivity and consequent physical or psychologically manifested illness. Extreme maladaptive configuration B: A family that is characterized by flat family emotional climate (i.e., neither positive nor negative emotion expressed); low levels of proximity (i.e., low levels of sharing of feelings, personal information, and personal space among most dyads or between parent and child); weak generational hierarchy (i.e., parents uninvolved or ineffectual, or engage in cross-generational coalitions); low responsivity (i.e., lack of emotional or behavioral response); flat parent-parent emotional climate (i.e., emotionally distant); insecure attachment patterns (i.e., likely avoidant attachment). This family configuration could lead to high levels of biobehavioral reactivity, and perhaps would be more permissive of, or inciting of, behavior disorder. There are many possible BBFM configurations, and patterns may differ by individual family member and dyads. Therefore it is crucial to assess each family individually based on all of the BBFM dimensions and to attend to each dyad type (parent-parent, parent-child, siblings) as well.

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Research Applications of the BBFM Relevant to Family Systems Theory and Practice Children with asthma: The BBFM has been tested in laboratory-based family interaction studies of children with asthma. Findings demonstrated that the chronic stress of negative family emotional climate, parental depression, parent-parent hostility, insecure parent–child relationship, and negative parenting predicted child anxiety and depression, which in turn were associated with increased asthma disease activity (Lim et al. 2011). Other studies indicated that chronic family stress may impact child asthma disease process through asthma-relevant altered immune function and autonomic dysregulation, mediated by child depression. Thus, the results of these studies are suggestive that the BBFM may be useful in specifying family-psycho-biological pathways by which family relational stress impacts child physical well-being and disease. Furthermore, the findings suggest that the BBFM, as a dimensional model, may be used to examine how family function may buffer the impact of social stress on child asthma by examining the effects of the family configurations constituted by family relational patterns at the positive ends of the BBFM dimensions. Adult health: Recently, the BBFM has been extended to test the model’s pathways for adult family members. Research supports the model in explaining the health of underserved primary care patients (Woods and Denton 2014). Further, the model has been validated for use in studying adult health using large, representative, epidemiological samples, incorporating social support as an additional exogenous variable, distinct from family emotional climate (Woods et al. 2014). Emotion dysregulation (anxiety and depression) and allostatic load (two aspects of biobehavioral reactivity) were highlighted as distinct mediating pathways in the model (Priest et al. 2015) Together these studies indicate an indirect pathway from family emotional climate to disease activity, through

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the mediating variable of biobehavioral reactivity, thus supporting the BBFM’s useful application across the lifespan.

Clinical Applications of the BBFM Guiding family system-based intervention: The BBFM can be used to guide family systems intervention in several ways. The BBFM proposes that all families (healthy and maladaptive) have the same basic interactive relational dimensions, as identified in the BBFM. Families that function at the extremes on these dimensions can be problematic. The BBFM has distinct value: (1) The BBFM can be used to identify the extremes of family emotional climate, proximity, hierarchy, responsivity, attachment, and individual biobehavioral reactivity and determine how they are related to an individual patient’s emotional and/or physical disorder. This can guide intervention by targeting specific patterns of relational process that need redirecting; (2) The BBFM can be used as a guide within the context of most family intervention models (Theodoratou et al. 2011; Wood 2001); (3) By focusing on enhancing the positive direction of the dimensions, the BBFM can be used in family-based prevention programs so as to enhance the ability of the family to buffer family members from external stressors; (4) The BBFM has the advantage of being intentionally developed with constructs that are relatively culture-neutral (Akyil et al. 2016; Theodoratou et al. 2011). Teaching family assessment and intervention: The BBFM can be used as a model to organize a trainee’s learning to observe, perceive, and characterize family relational process as it relates to a patient’s presenting problem. A Family Process Assessment Protocol (FPAP) was developed to test the BBFM (Wood et al. 2008). The FPAP has also been used in clinical work to characterize families and to direct family intervention according to the BBFM (Wood 2001). It is currently being used in Child and Adolescent Psychiatry and Family Therapy Training programs. The process of trainee and supervisor observation (from behind a one-way mirror) allows families to

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interact about problems, losses, conflicts, and things they like best about each other, without being distracted by the presence of an interviewer. The trainees learn how to perceive patterns of family relational process, characterize a family’s strengths and weaknesses according to BBFM dimensions, and plan intervention accordingly. This importantly supplements and enhances the more standard interview process, and speeds the course of therapy. Case Example Brian was a white, middle-class, 14-year-old boy for whom assessment and treatment was requested because of seizure-like symptoms and auditory hallucinations, which occurred despite negative neurologic and EEG findings. The Family Process Assessment Protocol (FPAP) was used to assess BBFM patterns of family relational process, and to determine their relevance, if any, to the child’s symptoms. The family consisted of biological mother and father, Brian, and a younger brother and sister. The FPAP assessment involved having the family engage in six different fiveminute discussion tasks designed to evoke a range of emotions and interactive patterns. The family was observed, and BBFM dimensions were characterized by the patterns of interaction and from subsequent interview. The family was characterized by extremely hostile and anxious expression of emotions (negative family climate) and with extreme reactivity to one another’s communications (high responsivity). This responsivity was unmodulated by parental guidance (weak parental hierarchy), because the mother and father could not function in alliance as parents. Mother was especially hostile to father who reacted anxiously to her interactions with him (negative quality of parentalrelations). Mother had established a stable coalition with Brian against father (weak parental hierarchy). The coalition of Brian with mother against father reduced tension between the parents but also resulted in scapegoating of Brian, and in a lack of support and nurturing attitude towards his stress and symptoms (weak generational hierarchy). Inconsistent availability from mother and an emotionally absent father resulted in insecure

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parent-child attachment. Brian’s stress was further fueled by maladaptive levels of proximity (e.g., Brian sleeping with mother “because of his seizures,” being exposed to mother’s suicide attempts and sexual indiscretions). The direct experience of maternal mental disorder, parental conflict (intense proximity) amplified Brian’s stress. The threat of the father leaving mother, and the already unstable and potentially dangerous family context, acutely exacerbated the situation. The insecure attachment between Brian and each parent made the threat of his father’s leaving extremely traumatic. Brian’s anxiety/emotion dysregulation and cognitive fragmentation (biobehavioral reactivity) skyrocketed, culminating in stress-related seizures and auditory hallucinations. The hallucinated voices stated that they were going to “kill his family or Brian, himself.” An initial family intervention alone with the parents achieved a commitment from them not to separate at this time, but to work in therapy on their marriage. This arrangement was accomplished by evoking positive emotional climate in the room and guiding the parents in exchanging positive expressions of support of one another. Hope was instilled by pointing out each of their strengths and parents, individuals, and marital partners. The children were brought into the room, and informed of this plan by their parents. There was great relief. Therapy focused on reorganizing the BBFM patterns to provide a family context that was conducive to healthy functioning and development. Engendering hope and proving a positive emotional “holding environment” in family sessions improved family emotional climate. This allowed family interventions which focused on reducing stressful proximity between Brian and mother, and on increasing soothing proximity with father. The motherBrian cross-generational coalition against father was interrupted, and parents were guided in working together as a team, both guiding and nurturing Brian and their other two children, improving generational hierarchy, reducing negative emotional climate, and improving attachment relations. Brian became less anxious (reduced biobehavioral reactivity) and his seizures and hallucinations ceased. Parents ultimately separated,

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but, with therapeutic assistance, they did so in a way that preserved appropriate BBFM dimensions of functioning. As a result the children remained well connected with both parents, and parents were able to coparent adequately.

Cross-References ▶ Biopsychosocial Model in Couple and Family Therapy ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Health Problems in Couple and Family Therapy ▶ Medical Family Therapy ▶ Medical Model in Couple and Family Therapy ▶ Neurobiology in Couples and Families

References Akyil, Y., Prouty, A., Blanchard, A., & Lyness, K. (2016). Experiences of families transmitting values in a rapidly changing society: Implications for family therapists. Family Process, 55(2), 368–381. Bowlby, J. (1969). Attachment and loss: Vol.1 Attachment. New York: Basic Books. Lim, J., Wood, B. L., Miller, B. D., & Simmens, S. J. (2011). Effects of paternal and maternal depressive symptoms on child internalizing symptoms and asthma disease activity: Mediation by interparental negativity and parenting. Journal of Family Psychology, 25(1), 137–146. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. N Engl J Med, 338, 171–179. Minuchin, P. (1988). Relationships within the family: A systems perspective on development. In R. A. Hinde & J. Stevenson-Hinde (Eds.), Relationships within families (pp. 7–26). New York: Oxford University Press. Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge: Harvard University Press. Priest, J. B., Woods, S. B., Maier, C. A., Parker, E. O., Benoit, J. A., & Roush, T. R. (2015). The biobehavioral family model: Close relationships and allostatic load. Social Science & Medicine, 142, 232–240. Rothbart, M. K., & Derryberry, D. (1981). Development of individual differences in temperament. In M. E. Lamb & A. Brown (Eds.), Advances in developmental psychology (Vol. 1, pp. 37–86). Hillsdale: Erlbaum. Theodoratou, M., Bekos, V., & Wood, B. L. (2011). Applying biobehavioral model in a young asthmatic patient:

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262 Case study. Thessaloniki: 2nd International Congress on Neurobiology, Psychopharmacology and Treatment Guidance. Wood, B. L. (2001). Physically manifested illness in children and adolescents: A biobehavioral family approach. Child and Adolescent Psychiatric Clinics of North America, 10(3), 543–562. viii. Wood, B. L., Klebba, K. B., & Miller, B. D. (2000). Evolving the biobehavioral family model: The fit of attachment. Family Process, 39(3), 319–344. Wood, B. L., Lim, J., Miller, B. D., Cheah, P. A., Zwetsch, T., Ramesh, S., & Simmens, S. J. (2008). Testing the biobehavioral family model in pediatric asthma: Pathways of effect. Family Process, 47(1), 21–40. Wood, B. L., Miller, B. D., & Lehman, H. K. (2015). Review of family relational stress and pediatric asthma: The value of biopsychosocial systemic models. Family Process, 376–389. Woods, S. B., & Denton, W. H. (2014). The biobehavioral family model as a framework for examining the connections between family relationships, mental, and physical health for adult primary care patients. Families, Systems & Health: The Journal of Collaborative Family HealthCare, 32(2), 235–240. https://doi.org/ 10.1037/fsh0000034. Woods, S. B., Priest, J. B., & Roush, T. (2014). The biobehavioral family model: Testing social support as an additional exogenous variable. Family Process, 53(4), 672–685. https://doi.org/10.1111/famp.12086.

Biopsychosocial Model in Couple and Family Therapy Rola O. Aamar1,2 and Irina Kolobova3 1 Texas Tech University, Lubbock, TX, USA 2 East Carolina University, Greenville, NC, USA 3 Center of Excellence for Integrated Care, Cary, NC, USA

Introduction The biopsychosocial (BPS) model was presented as a challenge to the biomedical model in the late 1970s (Engel 1977, 1980). Per Engel, the biomedical model left little room for the social, psychological, and behavioral aspects of illness and reduced all symptoms to physiological or biochemical origin. Engel commented that the human experience of illness is not well captured by laboratory results or diagnostic tests often employed in the biomedical model and hence

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deserved to be viewed from a more comprehensive framework. Engel posited that an individual’s health experience results from the intersection of biological, psychological, and social factors operating on multiple levels of the system (i.e., molecular, individual, interpersonal, cultural, and national levels). Engel encouraged the application of the BPS model with systems theory in an effort to practice medicine from a perspective that includes attending to the multiple levels of the organization present. This perspective is beneficial for understanding a condition and providing treatment to individuals, couples, and families. In the years since Engel proposed the BPS model, there has been debate regarding its application. Some have argued that the BPS model takes away from medicine and could lead providers to miss important biomedical issues because of the attention to psychosocial issues (Herman 1989). However, others have encouraged providers to think of BPS as an orientation rather than a prescribed approach that relies on well-developed interview skills. Borrell-Carrió et al. (2004) recognize the BPS model as a philosophy for clinical care and a practical clinical guide. As a philosophy, it is a way to understand how illness and disease are impacted and impact multiple levels of the patient’s system. As a practical guide, a clinician should aim to understand a client’s subjective experience in order to develop an accurate diagnosis and develop a clientcentered treatment plan. For many the BPS model is seen as a vision of health rather than a manualized guide to practice (e.g., Hepworth and Cushman 2005). As Engel suggested, the BPS model prioritizes understanding the client’s subjective experience of his or her symptoms from a comprehensive and contextual lens rather than focusing on just one factor or dimension of the individual’s health. Successful implementation of the BPS model is dependent on the provider’s perspective of health, interpersonal skills, empathetic curiosity, and diagnostic flexibility. Furthermore, interview skills and the ability to create relationships with clients and other healthcare providers are important to successful implementation. Strong interview skills are important for gathering relevant health information for each domain (e.g.,

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biological, psychological, social) within the context of the client(s)’ story and being able to bring it together in a way that reflect the client’s reality and needs. In conceptualizing the client’s needs, being able to collaborate with other providers (e.g., doctor, psychiatrist, school counselor, case worker) is necessary in order to provide comprehensive and cohesive treatment.

Prominent Associated Figures George Engel is widely recognized as the developer of the current biopsychosocial model. He was also the major proponent of the model through his medical and psychiatric work. While Engel is frequently remembered as a psychiatrist, Engel started his career in the biomedical field and held a dual appointment in the departments of psychiatry and medicine at the University of Rochester Medical Center for the majority of his career. Many propose that this dual appointment reflects his commitment to attending to the biopsychosocial needs of his patients. Engel started his work in medicine as a physician and a researcher. Initially, Engel was a strong proponent of the medical model and advocated for identifying and focusing on physiological causes and treatments, even for psychiatric problems. This is highlighted in his discussion of neuropsychiatric disturbances and complications as originating in the malfunctioning of the central nervous system (Engel and Margolin 1942). However, around this same time in the early 1940s, Engel was exposed to the work of his colleagues in psychoanalysis at the University of Cincinnati. As a result of this exposure, Engel began to slowly accept and explore alternative explanations to the physiological and psychosocial problems of his patients, initially focusing on gastrointestinal disorders (Guillemin and Barnard 2015). This led him to be recognized as one of the foremost experts on psychosomatic illness. Engel’s passion for and work in integrative healthcare that incorporated the multiple domains of health eventually culminated in the proposal of his heavily cited works on the biopsychosocial model for treatment as an alternative to the biomedical model.

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Description Through the use of the BPS model, clinicians and researchers promote the idea that there are three domains of health that need to be collectively attended to in treatment and research. Prior to the BPS model, the biomedical model was the primary tool used to explain and manage health. Per the BPS model, the three domains of health are biological, psychological, and social. The primary premise of the BPS model is that while there are three distinct domains of health, they are inextricably linked, meaning that one domain of health cannot be understood, researched, or treated without examining how the other domains of health are impacting it or being influenced by it. The principal argument made by proponents of the BPS model is that overall health is most clearly understood in the space where the three domains overlap. Biological The biological domain of the BPS model is commonly associated with physiological and biomedical health issues and concerns. Focusing on the biological domain highlights the importance of the physiological experience of an individual’s health. This may include addressing a specific disease or condition and tracking biomarkers, medications, or treatments that change an individual’s physiological response to a disease or to promote health. An important consideration for clinicians is that oftentimes distress in other domains can manifest themselves physiologically, such as stress leading to chronic headaches or ulcers. Conversely, issues with physiological health can also have a negative impact on the other domains such as struggles with mood regulation among individuals with poorly controlled diabetes. Therefore, clinicians should be aware that for some patients the biological domain of health may be the first indicator that something is wrong or the first signal to which they respond to seek treatment or relief. Psychological The focus of the psychological domain of health often refers to addressing mental health issues and disorders. Engel stressed the importance of the

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psychological domain on the patient’s overall health, even drawing the connection between cardiac patients’ psychological health and heart functioning, which continues to be a commonly accepted and heavily studied relationship in healthcare (Moravec and McKee 2011). Therefore, clinically, the focus would be on mental health diagnoses as defined by the DSM 5. Symptoms associated with these diagnoses could be assessed using mental health screeners or through a clinical interview. The psychological domain also encompasses assessing for issues related to mental status functioning including appearance, behavior, attitude, orientation, mood, affect, thought, and speech. These issues are most frequently assessed through a mental status exam. Finally, any testing pertinent to psychological functioning also falls within the scope of this domain. This level of psychological testing is often completed by a psychiatrist or psychologist and includes testing for neurodevelopmental disorders and neurocognitive disorders. Social While the biological and psychological aspects of the BPS model tend be easily identifiable, the social domain of health often seems more ambiguous. This can be attributed in part to the vast number of issues that falls under the purview of the social domain. Clinicians and researchers attend to a myriad of issues including family dynamics, availability of social support, access to resources, employment and financial concerns, substance use histories, housing concerns, the impact of racial and cultural expectations and needs, safety issues, and history of incarceration or oppression (Hodgson et al. 2007). While intake forms and well-constructed questionnaires or screeners may provide some insight into the social health of an individual, addressing the implications of social health often proves to be more challenging. A difficult reality that researchers and clinicians frequently face is that the social aspects of health are oftentimes more difficult to act on and change. For example, there may be few options for changing a patient’s insurance status or financial concerns. Therefore, while the social domain can be used to inform how the patient’s

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social health is impacting the other domains and what factors to consider when proceeding with treatment, there may be some aspects of the domain that cannot be improved. A Final Domain to Consider: Spirituality There is one additional proposed domain of health that some advocates of the BPS model have sought to bring attention to in recent years: spiritual health. Researchers and clinicians argue that the role of the spiritual domain needs to be equally examined in relation to health. Sulmasy (2002) argued that a truly holistic model focused on the value of relationships (including the relationships of each domain of health to the other) should also include spirituality – the domain of health concerned with an individual’s relationship with the transcendent. The distinction between spirituality and religiosity is important here. Rather than emphasizing prayer or belief in a higher power, the spiritual domain is more concerned with identifying an individual’s beliefs and values. These beliefs and values in turn can then be used to inform how a patient understands, explains, and makes sense of their health.

Relevance to Couple and Family Therapy While the BPS model was initially introduced for psychiatrists and other medical providers, its popularity continues to grow with couple and family therapists, particularly medical family therapists (McDaniel et al. 2014). As a vision of health, the BPS model helps couple and family therapists understand a couple’s or family’s functioning from a lens that incorporates biological, psychological, social, and systemic factors. For example, a couple’s frustrations with infrequent sexual intimacy may be partially explained by poorly controlled diabetes. A therapist who does not consider this may struggle to make significant process with improving the couple’s intimacy. With high rates of comorbidity between physical health, mental health, and substance use issues, the BPS model provides a framework for making sense of how these issues are interrelated and build treatment approaches that systemically address multiple

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issues at the same time. As clients’ health is best understood and treated at the intersection of the BPS domains, it is important that the BPS model is applied throughout all components of therapy including during the assessment, conceptualization, and treatment phases. While there are not specific guidelines for the application of the BPS model, there are two sets of biopsychosocial-spiritual interview guidelines available for clinicians’ use in completing a comprehensive assessment (Hodgson et al. 2007, 2016). Examples of questions that may be useful in the assessment are featured below. Biological: • What physical health issues are you and the family most concerned about at this time? How do these issues impact the family? • What goals are you working on with your family doctor? • What does being healthy mean to you? • How do you keep yourself healthy? Psychological: • Have you had any days recently when you have felt hopeless or unhappy? • What happens at home when someone in the family is experiencing stress? • Have you had any days recently when you have felt nervous or spent a lot of worrying? • How do you cope with feeling unhappy, nervous, or feeling stressed out? • How are your energy levels? Social: • Who among your family and friends is the most supportive and how do you let them know when you need support? • What types of activities do you enjoy doing in your free time? • How frequently is it difficult for you to get your medications because of financial issues? • How do you learn about what you need to do to keep yourself healthy? Spiritual: • How do your beliefs guide how you make sense of your health or some of the issues you have reported today? • When you are feeling down, do you find prayer or meditation to be helpful?

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Findings from a comprehensive assessment will help the clinician conceptualize the client’s presenting issues as the intersection of the BPS domains. This is done by integrating all of the information together and understanding how each domain is impacting the client’s function. Once the clinician has conceptualized the case from a BPS lens, the clinician will want to identify long-term and short-term goals that are aimed at improving the client’s functioning. At this phase, it is important for the clinician to find the balance between attending to the client’s pressing concerns and utilizing interventions that target multiple domains. One of the many benefits of the BPS model is that because it is seen as a vision of care, it allows for significant flexibility with regard to the setting of treatment (e.g., community mental health, primary care, school settings), the treatment time (e.g., 15 min, 50 min, 90 min), and the client composition (e.g., individual, couple, family). The BPS model has been successfully implemented in multiple settings, including primary care, community mental health, military settings, pediatric settings, school-based health centers, and independent practice (Hodgson et al. 2014). Therapists have successfully implemented the BPS model in brief sessions within integrated care practices, as well as in traditional 50-min sessions. Without prescribed interventions or a manualized practice guide, clinicians have the flexibility to apply this approach with any client composition including individuals, couples, or families. Clinicians practicing from the BPS model are encouraged to shift away from attending to just psychosocial or relational issues and consider clients’ functioning holistically and systematically. For many clinicians, this will require some additional education about biomedical conditions and their relationship to psychosocial issues. This may feel challenging to some as it means stepping outside of one’s comfort zone and becoming more comfortable talking with clients about topics such as disease progress and medication management. Furthermore, to provide the most holistic care, couple and family therapists are encouraged to collaborate with the patients’ medical team.

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Collaborating with clients’ medical team will help align treatment plans among providers and thus increase adherence to treatment recommendations. This collaboration will also increase the clinician’s knowledge and comfort with medical conditions and medications.

Clinical Example of Application of Theory in Couples and Families Case Vignette 1 Beatrice and Tuck have been married for 28 years. They present to the therapist’s office for couple’s therapy due to increased frequency of arguments and tension between them. During the intake, they report that 6 years ago Tuck was in a devastating car accident and nearly lost his life. The couple reported that Tuck spent three grueling weeks in a medically induced coma, had undergone over a dozen surgeries, and received years of medical intervention and rehabilitation. They explained that Tuck is now back home full time with regular visits to his medical and rehabilitation providers, instead of consistent inpatient treatment. Beatrice tells the therapist that Tuck came out of the accident with a traumatic brain injury (TBI). She also reports that since the accident there has been a significant change in Tuck’s attitude. She has noticed that he is moody, irritable, and less patient. Beatrice explains that recently Tuck has been rude toward her and their children including name calling, being judgmental, and being openly disrespectful of their choices and actions. Beatrice explains that this is not the same Tuck that she married and thinks that the accident is to blame. Tuck sits quietly and looks at the ground while Beatrice shares her frustrations. She also quietly explains that she does not know if she can stay married to him if his behavior does not change. As Tuck begins to talk and explain his side of the story, the therapist notices that he often struggles to find the right words. He appears to be embarrassed when he says the wrong words. Later, his face turns red and he looks away when he lets a curse word slip. He explains that he does not know why it is so hard for him to explain what he is thinking right now. He tries to keep

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explaining, but he appears to be getting flustered. He is visibly anxious. The therapist asks him to pause for a few minutes and try a diaphragmatic breathing technique with her. The therapist encourages him to take his time explaining that she is in no rush and that she wants to hear what he has to say. He is finally able to slow down a bit even though he still fumbles with his words occasionally. Tuck explains that he is easily irritated and endorses being disrespectful at times but then comments that it is because people in the family intentionally push his buttons. Applying the Biopsychosocial Lens. This case is used to highlight how even in the situation where a couple presents to therapy for a relational issue, the impact of medical and psychological factors still needs to be considered. Even when a biological condition is being managed and attended to thoroughly by a medical treatment team, it can continue to impact the other domains of health. In this case, it is evident that even though Tuck’s TBI is being managed and he continues to receive medical care, the side effects of having a TBI, such as irritability and decreased functioning in speech, have negatively impacted his relationship with his family. The pressure of having to function on the same level as he did before his life-altering accident is also having a deep impact on Tuck and his family. This desire to have things be the way they were before may also be connected to Tuck’s increased anxiety and to Beatrice’s frustration with the relationship. This couple would benefit from psychoeducation about the TBI and its impact on the relationship. In addition, the couple would benefit from learning how to identify when members of the family are becoming irritated, as well as developing new ways of relating to each other. Case Vignette 2 Forrest is a 63-year-old male. He has been referred to a well-known, local marriage, and family therapist by his primary care physician for therapy. Forrest’s physician explains to the therapist that Forrest has diabetes and hypertension. He is also on antidepressants, but the physician makes it a point to tell the therapist that Forrest does not like to talk about his depression nor acknowledge his

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depression diagnosis. Forrest is also a longtime smoker and refuses to quit. The physician tells the therapist that in the referral paper work she will document that she is referring Forrest specifically for help managing his medical diabetes and behavioral treatment for smoking cessation, but hopes that the therapist will address the depression as well. When the therapist meets with Forrest, she learns that 2 years ago he divorced his wife of 35 years. He has a tense relationship with his three children, who took their mother’s side in the divorce and blame him for breaking apart the family. Forrest states that he lives alone, but visits his mother in the nursing home often and spends time with his siblings and their families on the weekend. During the week, he works part time at the post office. Toward the end of the session, Forrest mentions that he recently quit taking his depression medication. The therapist inquires about whether he has mentioned this to his physician yet. Forrest tells the therapist that he has not reported this to her and he has no intention to because he does not want to go back on his medication. The therapist completes a brief depression screener and notices that his depression symptoms appear to be quite severe. His depression symptoms include decreased appetite, disrupted sleep cycles, inability to concentrate, and occasional thoughts of being “better off dead.” The therapist inquires more about the suicidal ideations and about making a safety plan that includes a support system with whom he can share these feelings. Forrest appears to become agitated. He tells the therapist that he only has thoughts and will not act on them. He refuses the safety plan and refuses to tell anyone about the thoughts. Forrest tells the therapist that he told God and God will help him take care of it. The therapist tells Forrest that she respects his relationship with God and makes a plan for him to talk to God about his thoughts when they pop up. Forrest agrees to continue returning for therapy. Applying the Biopsychosocial Lens. Many of the clients that could benefit most from applying the BPS lens are those who have unmanaged needs in one or more domains of health (e.g., biological, psychological, social). While it is common for clients to have symptoms and needs in each domain of health, it can be a

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daunting task for therapists to identify and create goals for multiple health concerns. This case highlights the complexity of health when chronic medical illnesses (diabetes and hypertension), a behavioral health risk factor (tobacco use), a mental health diagnosis (depression), and social factors (recent divorce, limited social supports) are comorbid. The spiritual domain in this case serves as both a strength and challenge because while the client can use his faith to cope with his suicidal ideations, it does impede the development of a thorough safety plan. What should be noted is that there is not a singular best way to approach this case; however, starting with behavioral changes for managing the diabetes and hypertension may be a good place to start as that is why the client was referred to therapy. While working on these behavioral changes, this client may also benefit from psychoeducation about the symptoms of depression, motivational interviewing in efforts to increase his collaboration with his medical provider and adherence to the medical treatment plan, and increasing the client’s engagement with social support. It will be incredibly helpful to work collaboratively with the medical provider and available social supports on the client’s health management.

Cross-References ▶ Families with Illness ▶ Health Problems in Couple and Family Therapy ▶ Medical Family Therapy ▶ Medical Model in Couple and Family Therapy

References Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. The Annals of Family Medicine, 2(6), 576–582. https://doi.org/ 10.1370/afm.245. Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. Engel, G. L., & Margolin, S. G. (1942). Neuropsychiatric disturbances in internal disease: Metabolic factors and

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268 electroencephalographic correlations. Archives of Internal Medicine, 70(2), 236–259. Guillemin, M., & Barnard, E. (2015). George Libman Engel: The biopsychosocial model and the construction of medical practice. In The Palgrave handbook of social theory in health, illness and medicine (pp. 236–250). Basingstoke: Palgrave Macmillan. Hepworth, J., & Cushman, R. A. (2005). Biopsychosocial – Essential but not sufficient. Families, Systems & Health, 23(4), 406–409. https://doi.org/ 10.1037/1091-7527.23.4.406. Herman, J. (1989). The need for a transitional model: A challenge for biopsychosocial medicine? Family Systems Medicine, 7(1), 106–111. https://doi.org/10.1037/ h0090019. Hodgson, J., Lamson, A. L., & Reese, L. (2007). The biopsychosocial-spiritual interview method. In D. Linville & K. M. Hertlein (Eds.). (2014). The therapist’s notebook for family health care: Homework, handouts, and activities for individuals, couples, and families coping with illness, loss, and disability. Location: Routledge. Hodgson, J., Lamson, A., Mendenhall, T., & Crane, D. R. (Eds.). (2014). Medical family therapy: Advanced applications. New York: Springer. Hodgson, J. L., Lamson, A. L., & Kolobova, I. (2016). A biopsychosocial-spiritual assessment in brief or extended couple therapy formats. In G. R. Weeks, S. T. Fife, & C. M. Peterson (Eds.), Techniques for the couple therapist: Essential interventions from the experts (pp. 213–217). New York: Routledge. McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2014). Medical family therapy and integrated care. Washington, DC: American Psychological Association. Moravec, C. S., & McKee, M. G. (2011). Biofeedback in the treatment of heart disease. Cleveland Clinic Journal of Medicine, 78, S20–S23. Sulmasy, D. P. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. The Gerontologist, 42(Suppl 3), 24–33.

Bipolar Disorder in Couple and Family Therapy Sheri L. Johnson, Ben Swerdlow, Jennifer Pearlstein and Kaja McMaster University of California, Berkeley, Berkeley, CA, USA

Introduction Bipolar disorder (BD) is a severe psychological disorder characterized by symptoms of mania.

Bipolar Disorder in Couple and Family Therapy

The diagnostic system of the American Psychiatric Association recognizes three major forms of bipolar disorder, all defined by manic symptoms of varying severity and duration (American Psychiatric Association 2013). Bipolar I disorder is defined by at least one lifetime episode of mania and may include episodes of depression. Bipolar II disorder is characterized by both hypomania and major depressive episodes. Cyclothymic disorder is defined by high and low moods that are present at least 50% of the time for more than 2 years but do not fulfill diagnostic criteria for mania or hypomania. Mania and hypomania, in turn, are defined as an elevated or irritable mood accompanied by an increase in energy that involves three of nine additional symptoms, such as decreased need for sleep, increased goaldirected activity, flight of ideas, and pressured speech (American Psychiatric Association 2013). Although the symptoms are similar, mania and hypomania are differentiated by severity and length. Mania causes functional impairment, involves psychosis, or requires hospitalization; hypomanic episodes do not involve this level of functional impairment. Manic episodes must last one week; hypomanic episodes can be defined on the basis of symptoms lasting at least four days. Many with bipolar disorder experience well periods between episodes; others, however, experience mild depressive symptoms between episodes. Across the various forms of bipolar disorder, estimates of prevalence range between 2% and 4% of the US population, with lower rates worldwide (Merikangas et al. 2007). Most people diagnosed with bipolar disorder experience recurrences throughout the life course. Bipolar disorder has been rated as the sixth leading cause of medical disability worldwide (Kleinman et al. 2003). Bipolar disorder has significant repercussions for relationships, and relationship satisfaction, in turn, has significant effect on the outcome of disorder. For more than two decades, research has shown that marital and couples therapy can improve the outcomes for bipolar disorder, as well as reduce the effects of bipolar disorder on family and couples function.

Bipolar Disorder in Couple and Family Therapy

Theoretical Context for Concept Couple and family therapy in bipolar disorder is based on several assumptions. The first assumption is that a stress-diathesis model, integrating biological and social influences, can be applied to understanding bipolar disorder. The second assumption is that misinformation and poor understanding of bipolar disorder can intensify relationship conflict. The third assumption is that the symptoms of bipolar disorder can create burden and stress in families. As with other disorders, the stress-diathesis model in bipolar disorder suggests that an underlying biological vulnerability creates an increased reactivity to stressors. Heritability estimates, which provide an estimate of the extent to which the onset of disorder is attributable to genetic influences, are as high as 85% for bipolar disorder (McGuffin et al. 2003). About 5–10% of first degree relatives of those with bipolar disorder will meet diagnostic criteria for the disorder, a rate that is considerably higher than the general population (Smoller and Finn 2003). Despite the strong biological vulnerability to this disorder, it is well documented that familial and social relationships can influence the course of bipolar disorder, as can psychological variables such as tendencies to be highly sensitive to rewards and life events involving goal attainment, sleep disruption, and impulsivity (Miklowitz and Johnson 2009). One assumption guiding treatment is that the genetic and biological vulnerability to disorder may increase vulnerability to negative environments. Given this, one of the goals of couple and family therapy is to reduce the triggers of episodes. There is also considerable evidence showing that the attitudes and behaviors of family, spouses, and other significant others influence the course of bipolar disorder. Critical attitudes in particular are associated with poorer outcomes. Expressed emotion, or the degree to which a caregiver expresses critical, hostile, and emotionally over involved attitudes toward the person with bipolar disorder, is also a strong risk factor for poorer course of illness. For example, over the course of 9 months, 90% of patients returning from hospitalization to

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live with families characterized by high expressed emotion relapsed compared to 54% of patients returning to live with families characterized by low expressed emotion (Miklowitz et al. 1986). Beliefs of controllability, or that the bipolar symptoms can be attributed to the patient’s choice or temperament, can intensify tendencies for families to engage in expressed emotion. Seventy percent of spouses in one study endorsed beliefs that symptoms were controllable by the patient, and these attitudes were a strong predictor of marital difficulties during manic and depressed phases of the disorder (Lam et al.2005). Data indicate many ways in which the symptoms of bipolar disorder can present challenges for relationships. When the patient is ill, many families experience changes in sexual, social, socioeconomic, household, parenting, occupational, and other functional domains that often put a strain on the people caring for the person with bipolar disorder. Families tend to endorse concerns about how well family interactions are going across a broad range of domains (Young et al. 2013). The challenges this places on those taking care of the person with bipolar disorder have been referred to as caregiver burden. Caregiver burden is consistently found to be elevated among spouses and parents of people with bipolar disorder. For example, more than half of a sample of spouses reported increasing their work hours and childcare responsibilities and decreasing their social interactions when the patient is ill (Lam et al. 2005). Partners of individuals diagnosed with bipolar disorder reported more dissatisfaction with marital and sexual relationships than did those whose partner was not diagnosed with bipolar disorder (Lam et al. 2005). This burden carries with it important consequences, including psychiatric or medical illness in the caregivers or separation and divorce in couples. Given the robust evidence that family and couple concerns are common for those with bipolar disorder and have an important influence on the course of disorder, clinicians and researchers have frequently emphasized the benefits of involving family members and significant others in treatment as an adjunct to pharmacotherapy.

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Description Drawing on the above assumptions, most couple and family treatments of bipolar disorder aim to provide education about the disorder so that family members and partners can better recognize symptoms and be less blaming, emphasize the importance of conflict and stress for poor outcomes within bipolar disorders, diminish family conflict, and address caregiver’s burden and demand. Many treatment approaches also aim to improve adherence with pharmacotherapy and to enhance symptom management. The hope is that reducing stress in the family environment will delay, minimize, or prevent recurrences of BD (e.g., Davenport et al. 1977). To date, Family Focused Therapy (FFT) has been the most carefully researched approach (see the entry in this encyclopedia). Nonetheless, a number of other approaches have been detailed in the literature, including the Problem Centered Systems Therapy of the Family (PCSTF) based on the McMaster Model of Family Functioning. Each of these approaches involve assessment phase, development of a treatment contract with the family that specifies core treatment goals, treatment involving education, skills and communication training, and then a closure period of reviewing gains made and planning for the future. Overall, there is strong evidence that couple and family therapies are helpful for adult and adolescent patients with bipolar disorder, with a two- to threefold reduction in the rate of relapse as compared to control conditions in some studies (Miklowitz et al. 2003), although some studies have shown less positive outcomes for adolescents. Family therapy may be particularly helpful when families endorse more difficulty and distress at baseline (Miller et al. 2008). The finding that family therapies improve treatment and medication compliance is particularly robust.

Application of Concept in Couple and Family Therapy Most family therapy approaches for BD share a number of core components, including psycho

Bipolar Disorder in Couple and Family Therapy

education about the symptoms, course, and treatment of bipolar disorder, the importance of longterm pharmacotherapy, training in communication and problem-solving skills to reduce family conflict, and development of a relapse prevention plan. Most of these treatments are offered conjointly to the patient with their family members. Almost all treatments begin with assessment of the patient and of family concerns. During the assessment phase, therapists are likely to use self-report scales and interviews to understand how families are faring in different domains (e.g., problem-solving, communication, closeness). In early sessions, family members and those with bipolar disorder are taught about the disorder including the expected course of the disorder and the different ways that symptoms of mania and depression may be expressed. After increasing understanding of the disorder, therapists provide more information about available pharmacological and psychological treatments to address current symptoms and to prevent relapse. One of the main goals is to work with the family to improve medication adherence, as this is an important facet of relapse prevention. In the next phase of therapy, most approaches include a more in-depth focus on the problems that the family is facing, ways to problem-solve about those issues, and to consider new solutions that would work well both for the person with bipolar disorder and their family members. This work may involve crisis management, communication training, and a focus on tackling one problem at a time using systematic cognitive and behavioral strategies. Family members may work together on best strategies for communicating and resolving crises that can occur if a patient becomes manic or suicidal. Family treatments for BD vary somewhat in the foci of treatment and formats. Whereas FFT tends to be fairly focused on knowledge of the illness and ways to reduce family conflict and over-intrusiveness, the McMaster Model focuses on six dimensions that have been found to be frequently impaired in treatment settings: problem-solving, communication, roles, affective responsiveness, affective involvement, and behavior control. Family treatment models have been applied with adult

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and adolescent patients and have been implemented with individual families and as multifamily group therapies (e.g., Fristad et al. 2009). When multiple families are seen together, group members often gain coping strategies and social support from the group interaction.

Case Study The case of Nancy illustrates some of the steps and goals in treatment. Nancy and her family sought treatment after her third episode of mania. Nancy was typically a very active contributor to the community and a loving wife and mother to her two children (ages 2 and 3). Nonetheless, when her manic symptoms developed, she would find it hard to stay home to take care of the children – the world enticed her with possibility, and she would wander the neighborhood for long hours, meeting and flirting with strangers, and shopping at a level that challenged the family budget. Several months ago, during one of her high periods, her mother confronted her with the need to stay home to care for the children; major fights ensued. As her mania progressed, she made biting and harsh comments toward family members and close friends, and she remained haunted by guilt over some of those interactions. Within 2 days of those arguments beginning, she began to have terrifying hallucinations, and her husband called the police for help when she became highly agitated and he could not understand her verbalizations. She was hospitalized for the first time in her life, an event that she found deeply painful. As she left the hospital, though, Nancy focused on the early “sparkling” phase of the episode, when her symptoms were less severe. During that phase, she had felt more alluring, engaged, insightful, and alive than at any other period of her life. She missed that experience so much that she did not want to take medications. Nancy and her husband, who typically enjoyed a close and supportive relationship, had been experiencing considerable marital conflict over whether she should engage in treatment.

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The therapist talked with Nancy individually for a session to review her personal reasons for considering treatment. Nancy was able to identify that she felt considerable regret about the fights that had happened and was deeply traumatized by her hospitalization. She was eager to avoid those problems again and with encouragement, could see that medication was one way to gain control over these difficult problems. With Nancy’s commitment to treatment in place, the therapist met with Nancy and her husband jointly. Both had a clear sense of what mania looked like once it was “full-blown” but neither felt like they were sure what the early signs were. This had left Nancy feeling like there was no point in trying to monitor symptoms; in contrast, her husband would notice every small shift in her mood and would get worried if she laughed a little louder, stayed up a little later, or met a new friend. Together, they began to learn more about the early symptoms of mania and how to consider when those might be evolving in a troubling manner. They began to develop a game plan for managing early signs of mania to help prevent the onset of another full-blown episode. During this process, Nancy’s husband often became directive in a way that led to conflict. The therapist helped them understand that although his fear was common, Nancy needed a certain amount of autonomy in planning her treatment and care plan. Nancy’s husband was able to feel reassured when he saw that Nancy was taking on this responsibility and developing skills for checking her own symptoms on a daily basis. They were able to talk about the challenges to her autonomy that the illness had created, and he expressed a deep sense of compassion for her experience. At the same time, they both recognized the need to protect the family and her friendships if relapse were to occur. They worked together to put in place resources to keep the children safe and to help her decide when it might be good to restrict social interaction and find a quiet zone until she felt more calm. By working together, they were able to develop Nancy’s plan for self-care and symptom monitoring, a sense of when and how her husband might be able to constructively note changes he saw in her mood and energy, a plan for quickly obtaining

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medical care in case of relapse, and behavioral strategies to implement to avoid damage to relationships if symptoms did unfold. The process of developing this plan strengthened their relationship and allowed them to begin to think about spending more time together as a couple.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: American Psychiatric Publishing. Davenport, Y. B., Ebert, M. H., Adland, M. L., & Goodwin, F. K. (1977). Couples group therapy as an adjunct to lithium maintenance of the manic patient. American Journal of Orthopsychiatry, 47, 495–502. Fristad, M. A., Verducci, J. S., Walters, K., & Young, M. E. (2009). Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry, 66, 1013–1021. Kleinman, L., et al. (2003). Costs of bipolar disorder. PharmacoEconomics, 21, 601–622. Lam, D., Donaldson, C., Brown, Y., & Malliaris, Y. (2005). Burden and marital and sexual satisfaction in the partners of bipolar patients. Bipolar Disorders, 7, 431–440. https://doi.org/10.1111/j.1399-5618.2005.00240.x. McGuffin, P., Rijsdijk, F., Andrew, M., Sham, P., Katz, R., & Cardno, A. (2003). The heritability of bipolar affective disorder and the genetic relationship to unipolar depression. Archives of General Psychiatry, 60(5), 497–502. https://doi.org/10.1001/archpsyc.60.5.497. Merikangas, K. R., Akiskal, H. S., Angst, J., Greenberg, P. E., Hirschfeld, R. M. A., Petukhova, M., & Kessler, R. C. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Archives of General Psychiatry, 64(5), 543–552. https://doi.org/10.1001/archpsyc.64. 5.543. Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. L. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904–912. Miklowitz, D. J., & Johnson, S. L. (2009). Social and familial factors in the course of bipolar disorder: Basic processes and relevant interventions. Clinical Psychology: Science and Practice, 16(2), 281–296. https://doi.org/10.1111/j.1468-2850.2009.01166.x. Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S., & Doane, J. A. (1986). EE, affective style, lithium compliance, and relapse in recent onset mania. Psychopharmacology Bulletin, 22, 628–632. Miller, I. W., Keitner, G. I., Ryan, C. E., Uebelacker, L. A., Johnson, S. L., & Solomon, D. A. (2008). Family treatment for bipolar disorder: Family impairment by

Birdwhistell, Raymond treatment interactions. Journal of Clinical Psychiatry, 69(5), 732–740. https://doi.org/10.4088/JCP.v69n0506. Smoller, J. W., & Finn, C. T. (2003). Family, twin, and adoption studies of bipolar disorder. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 123C(1), 48–58. https://doi.org/10.1002/ ajmg.c.20013. Young, M. E., Galvan, T., Reidy, B. L., Pescosolido, M. F., Kim, K. L., Seymour, K., & Dickstein, D. P. (2013). Family functioning deficits in bipolar disorder and ADHD in youth. Journal of Affective Disorders, 150(3), 1096–1102.

Birdwhistell, Raymond Armine Gevorkyan1 and Ester Yesayan2 1 California Department of Corrections and Rehabilitation (CDCR), Los Angeles, CA, USA 2 Los Angeles, CA, USA

Name Raymond “Ray” (1918–1994)

L.

Birdwhistell,

Ph.D.

Introduction Raymond “Ray” L. Birdwhistell was an American Anthropologist who was well known internationally for his significant contributions to the field of nonverbal communication or body language. He coined the term kinesics, the part of nonverbal communication that deals with postures of the body and movements of various parts of the body that play a role in communicating. He contributed many writings to the field of nonverbal communication including, 2 books and about 15 papers published in prestigious professional journals such as, Schizophrenia; Group Processes: Transactions of the second conference; and Lectures on Experimental Psychiatry. He was also involved in the making of numerous films, such as Microcultural Incidents in Ten Zoos; TDR-009; and the Lecture on Kinesics by Ray L. Birdwhistell at the Second LinguisticKinesic Conference Nov. 4–7, 1964.

Birdwhistell, Raymond

Career Raymond “Ray” Birdwhistell received a bachelor’s degree in 1940 from Miami University in Oxford, Ohio, followed by his Master’s degree in 1941 from Ohio State University. He then completed his doctoral training and received his Ph.D. in Anthropology in 1951 from the University of Chicago. It was during the time he spent conducting his dissertation fieldwork among the Kutenai Indians of British Columbia (1944–1946) where his interest in nonverbal behavior began. During the time he was completing his dissertation, Raymond Birdwhistell began teaching at the University of Toronto (Ontario). He then went on to teach for 10 years at the University of Louisville, Kentucky, and helped in racial integration of the University. He also taught at the State University of New York at Buffalo from 1956 to 1959 and at Temple University. In 1959, he was appointed as senior research scientist at the Eastern Pennsylvania Psychiatric Institute in Philadelphia. He continued to conduct research and analysis in kinesics for five decades, including studying videos of interactions among family members of individuals who had schizophrenia. He held the position of professor at The Annenberg School of Communication at the University of Pennsylvania from 1969 until he retired in 1988. Throughout his career he taught many influential individuals in the field, including Erving Goffman and Alan Lomax.

Contributions to Profession Raymond “Ray” Birdwhistell, Ph.D. coined the term “kinesics,” which is the nonverbal communication through gestures and body movements or patterns. He studied and wrote extensively about body motion patterns, gestures, and nonverbal aspects of communication within various countries and cultures. Raymond Birdwhistell studied videos of interactions among family members who had someone with schizophrenia in their family to see if there was a different pattern of body motion communication between

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these family members and among those with schizophrenia. Being an anthropologist, he was interested in the study of communication more broadly than just kinesics, including linguistics and anthropology and sometimes film and the arts. Raymond Birdwhistell collaborated with Margaret Mead, Gregory Bateson, Erving Goffman, and Dell Hymes, among many others. Additionally, he was influenced by linguist-anthropologists George L. Trager and Henry Lee Smith Jr. Raymond Birdwhistell introduced a system of annotation meant to assist in the recording, analysis, and interpretation of cross-cultural body motion. In his research he observed that that there were differences in how people expressed themselves through gestures and body movement patterns based on their different cultures, which led him to understand that gestures and body motion patterns are socially learned. Consequently, he concluded that nonverbal communication cannot be analyzed in one universal way across all cultures. Instead, he insisted that body movement patterns be analyzed and viewed within the context of the specific culture in which they are learned. He highlighted that when observing a bilingual speaker as she/he changes languages, the speaker also tends to change patterns of body movement. Raymond Birdwhistell used cameras and slowmotion projectors to compare and analyze detailed behavioral motion patterns with what individuals were verbally communicating as they spoke. He also used these films to analyze patterns of body motion and interaction and to study how such nonverbal communication is learned. Additionally, Raymond Birdwhistell created films with the filmmaker Jacques van Vlack, for the purpose of providing technical training on kinesics: Microcultural Incidents in Ten Zoos; TDR-009; and the Lecture on Kinesics by Ray L. Birdwhistell at the Second Linguistic-Kinesic Conference Nov. 4–7, 1964.

Cross-References ▶ Social Learning Theory

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References Birdwhistell, R. L. (1952). Introduction to kinesics: An annotation system for analysis of body motion and gesture. Washington, DC: Department of State, Foreign Service Institute. Birdwhistell, R. L. (1955). Background to kinesics. ETC: A Review of General Semantics, 13(1), 10–18. Birdwhistell, R. L. (1959). Contribution of linguistic–kinesic studies to the understanding of schizophrenia. In A. Auerback (Ed.), Schizophrenia: An integrated approach (pp. 99–123). New York: Ronald Press. Birdwhistell, R. L. (1963). The kinesic level in the investigation of the emotions. In P. H. Knapp (Ed.), Expression of the emotions in man (pp. 123–139). New York: International University Press. Birdwhistell, R. L. (1970). In E. Goffman, D. Hymes, G. Samkoff, & H. Glassie (Eds.), Kinesics and context: Essays on body motion communication. Philadelphia: University of Pennsylvania Press.

Bisexual Couples Kristin S. Scherrer Department of Social Work, Metropolitan State University of Denver, Denver, CO, USA

Introduction Bisexuality is an often invisible topic even within scholarship on sexual orientation. Yet, for several reasons, bisexuality remains an important topic within the field of couple and family therapy to examine in and of itself. First, bisexual people make up the demographic majority of gay, lesbian, and bisexual populations (Egan et al. 2007; Herbenick et al. 2010; Mosher et al. 2005), making bisexuality an important dimension of sexual diversity that practitioners should be knowledgeable about. Second, bisexual people face unique challenges because of their bisexuality – an experience that can be understood as biphobia. Biphobia is pervasive and can negatively affect bisexual people’s relationships to both heterosexual and gay/lesbian people. Biphobia also has profound effects on interpersonal relationships, such as in intimate relationships or within family

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systems (McLean 2007; Scherrer et al. 2015; Todd et al. 2016). Third, given the unique experiences associated with being bisexual, it is critical that therapeutic practitioners are knowledgeable about bisexual people and their unique experiences in intimate relationships and in families. Biphobia is also pervasive within the therapeutic relationship (Dworkin 2001; Page 2007; Scherrer 2013), a bias that can be mitigated with practitioners’ conscientious intervention. This encyclopedia entry provides an overview of how bisexual identities are relevant in intimate relationships and family systems.

Relevant Research This section provides an overview of scholarship relevant to bisexual people’s intimate and familial relationships. Specifically, this section reviews definitions of bisexuality, conceptualizations of biphobia, research on bisexuality in therapeutic practice, research on bisexual people in relationships, and scholarship on bisexuality in family relationships. The concept of bisexuality is mercurial, and there is no universally agreed upon definition of what it means to be bisexual (Esterberg 2006; Halperin 2009). Some conceptualize bisexuality as a psychological quality, focusing on same- and different-sex attractions. Others conceptualize bisexuality as primarily behavioral, examining previous and current sexual and romantic relationships. Other scholarship examines those who adopt bisexuality as an identity. Self-identification represents a particularly salient classification for therapeutic practitioners as a person’s bisexual identification conveys meaning about the self, internally as well as within a social and cultural context. Practitioners working with clients who indicate bisexual attractions, behaviors, or identities must be careful in making assumptions about other dimensions of clients’ experiences. For instance, a person may identify as bisexual, but may or may not have had behavioral experiences with members of a particular gender category. Similarly, a client may describe same- and different-sex attractions or behaviors, but not identify as bisexual. In other words,

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practitioners should seek to adopt client-focused understandings of their sexual orientation, as the meaning and salience of their identities vary. Despite the variation in definitions of bisexuality, a more general definition of bisexuality can indicate attraction to people of one’s own gender and people of other genders. A discussion of therapeutic practice with bisexual people would be neglect without examining the concept of biphobia. Biphobia describes the stereotypes and negative attitudes that people hold about bisexuality (Israel and Mohr 2004; Ochs 1996; Rodríguez-Rust 2002). One common stereotype about bisexuality is that bisexual people are in transition toward an “authentic” heterosexual or gay/lesbian identity. Bisexual people may be viewed as duplicitous, as they are assumed to be seeking to avoid the stigma of identifying as gay/lesbian, or alternatively seen as at an early stage in their identity development and naïve to their true sexual orientation (Ochs 1996; Rodríguez-Rust 2002). These beliefs stem from the expectation that individuals should only be romantically attracted to people of one gender (Bradford 2004; Rodríguez-Rust 2002) and convey disbelief that bisexuality is a “real” sexual orientation. Another stereotype about bisexuality centers on strong, deviant sexual drives, which are seen as even more hedonistic than lesbian or gay individuals (Israel and Mohr 2004). People who hold this stereotype often express disbelief that a bisexual person could ever be satisfied in a monogamous relationship. Bisexual people are seen as sexually indiscriminate and libel to have sex with “anything that moves” (Ochs 1996). Related to this stereotype is the assumption that bisexual people are carriers of sexually transmitted infections (Eliason 2001; Mohr et al. 2009). As a result of this stereotype, bisexual people often deal with other people’s assumptions about their issues with commitment, fidelity, and trustworthiness (Eliason 2001; Spalding and Peplau 1997). Scholarship about therapeutic practice with bisexual people indicates that practitioners are not exempt from unconsciously adopting biphobic attitudes. Practitioners’ beliefs generally mirror other biphobic stereotypes (Eliason and

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Hughes 2004; Mohr et al. 2001, 2009; Page 2007). Practitioners have more negative beliefs about bisexual people than about lesbian/gay people (Eliason and Hughes 2004). Further, these biphobic beliefs shape practitioners’ work with bisexual clients in problematic ways (Bowers and Bieschke 2005; Mohr et al. 2009, 2001; Murphy et al. 2002). Research with bisexual clients indicates that practitioner bias negatively affects their experiences of psychotherapy. For instance, one of the issues most commonly faced by bisexual people is having their bisexuality invalidated by their therapist (Page 2007). Bisexual people also report that their practitioners lack knowledge about bisexuality and bisexual issues or that their practitioners believe that bisexuality is unhealthy (Page 2007). Additional education and critical self-reflection are a critical need for practitioner competency in working with bisexual clients (Mohr et al. 2001; Murphy et al. 2002). Issues of biphobia also carry into bisexual people’s intimate relationships. In this section, the term intimate relationships is utilized in recognition of the fact that although the majority of the research on bisexual people’s intimate relationships focuses on dyadic relationships, some bisexual people pursue polyamorous or nonmonogamous relationships. The term nonmonogamous is an umbrella concept for relationship statuses that are intentionally not monogamous. Polyamory is a more specific term that describes “having multiple emotionally intimate relationships simultaneously. Often, though not always, these relationships are sexual in nature; the emphasis in polyamory is generally on the presence of multiple romantic partners” (Fierman and Poulsen 2011, p. 17). Not all bisexual people (or gay, lesbian, heterosexual people) are desirous of monogamous dyadic relationships (Kleese 2005; Rodríguez-Rust 2002; Rust 2003). Scholarship indicates that bisexual people may be more likely (than heterosexual or gay/lesbian individuals) to seek out nonmonogamous relationships and less likely to regard monogamy as an idealized relationship form (Rodríguez-Rust 2002; Rust 2003). Forming and maintaining nonmonogamous relationships in a cultural context that privileges monogamy is a likely source of

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stress for bisexual people who engage in nonmonogamous relationships. Misconceptions about bisexuality affect heterosexual, gay, and lesbian people’s interests in forming intimate relationships with bisexual people (Armstrong and Reissing 2014; Eliason 1997; McLean 2007; Rodríguez-Rust 2002; Spalding and Peplau 1997). Spalding and Peplau (1997) found that heterosexual individuals believe bisexual individuals to be nonmonogamous, unfaithful, sexually risky, and more likely to spread sexually transmitted infections. Similarly, heterosexual undergraduate students were reluctant to engage in a relationship with a hypothetical bisexual person to whom they were attracted (Eliason 1997). Other research has found that participants who were asked to pair up profiles of single people were more likely to match a bisexual profile to bisexual profile and less likely to match a bisexual profile to either a lesbian or gay profile or a heterosexual profile (Breno and Galupo 2008), indicating the idea that bisexual people are seen as less desirable intimate partners. Taken together, this research indicates that bisexual people experience challenges in intimate relationships because of their bisexuality. Furthermore, once in a relationship, biphobic stereotypes also affect bisexual people’s experiences in intimate relationships (McLean 2007; RodríguezRust 2002). For example, these stereotypes may manifest as bisexual people may not feel comfortable disclosing their identity to a partner, fearing stigma or rejection (McLean 2007). The stereotype that bisexual people are sexually promiscuous, sexually insatiable, or nonmonogamous may also manifest in an intimate partner’s concerns that a bisexual person may not be able to adhere to monogamous expectations. Stereotypes that bisexual people are confused or unsettled about their sexual orientation may manifest in intimate relationships as the intimate partner may fear that the bisexual person may decide that they are no longer attracted to the romantic partner’s gender identity category. Relatively little literature focuses on the family relationships of bisexual persons. More frequently, scholarly research subsumes bisexual people’s family relationships alongside gay and

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lesbian people. However, a burgeoning body of literature examines bisexual people experiences in families of origin (McLean 2007; Scherrer et al. 2015; Todd et al. 2016; Watson 2014). This research finds that bisexual people may be less likely to disclose their sexual orientation to family members (McLean 2007). Furthermore, bisexual people’s disclosure decisions are mediated by their relationships’ status (Costello 1997; Scherrer et al. 2015). For example, bisexual people in intimate relationship are more likely to disclose their identity (Scherrer et al. 2015). Further, the gender of their significant other also medicates disclosure decisions (Costello 1997; Scherrer et al. 2015). Biphobia also shapes bisexual people’s disclosure experiences with their families of origin, for instance, as it influences how a bisexual person may choose to come out to their families (Scherrer et al. 2015; Watson 2014). Bisexual people often utilize a disclosure strategy that they see as maximizing desirable outcomes in their family relationships (Scherrer et al. 2015), although the desirable outcomes vary from person to person. Scherrer et al. (2015) found that many bisexual people “simplified” their identity when coming out by describing themselves as gay or lesbian, hoping to avoid family members’ negative conceptions about bisexuality. When bisexual people do come out as bisexual to members of their family of origin, they frequently anticipated negative responses based on biphobic stereotypes (Scherrer et al. 2015; Watson 2014). Stereotypes about bisexuality also shape how family members respond to learning about a bisexual family member’s sexual identity (Scherrer et al. 2015; Todd et al. 2016). Family members were (surprisingly) knowledgeable about stereotypes about bisexuality, often as they described bisexuality as a temporary identity on the way to a stable gay/lesbian/heterosexual identity (e.g., “I thought it was a phase”) (Scherrer et al. 2015) or as associated with sexual irresponsibility (Todd et al. 2016). Family members engaged with these stereotypes, both explicitly and implicitly, to try to understand their bisexual family member (Scherrer et al. 2015; Todd

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et al. 2016). Taken together research indicates that the social construction of bisexuality is important for understanding bisexual people’s experiences in families.

Special Considerations for Couple and Family Therapy This section provides an overview of scholarship relevant to therapeutic practice with bisexual people in regard to their intimate and familial relationships. Scholarly research provides a number of insights for therapeutic practitioners. First and foremost, practitioners must pursue ongoing opportunities to improve their knowledge about bisexuality and assess their own unconscious biases about bisexuality. Ongoing clinical supervision and continuing education on issues of bisexuality will be critical to achieving this goal. Practitioner must also keep in mind that while being knowledgeable about bisexuality is necessary to effectively practice with this population, practitioners must also be careful to avoid overly focusing on the client’s sexuality if it is not relevant to the presenting issue. Second, in working with bisexual people in regard to their intimate relationships, practitioners should anticipate that stereotypes about bisexuality may negatively shape relationship quality, for instance, as a bisexual person may not even feel comfortable disclosing their identity to their significant other. Practitioners are advised to talk openly about biphobic social attitudes and then to examine how these stereotypes may shape partners’ expectations of one another. If the client is interested, the practitioner may work with the bisexual about potentially disclosing their identity to their partner. Practitioners may also potentially work with the partner on their stereotypical beliefs about bisexuality. “Because trust and intimacy are usually needed to sustain intimate relationships, these relationships may be particularly difficult for bisexual people partnering with individuals who do not believe in a ‘real’ bisexual identity” (Scherrer 2013, p. 244). Practitioners may wish

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to assist couples in explicitly discussing biphobic stereotypes and in examining how these stereotypes shape their interactions with and expectations of one another. Bisexual individuals who engage in nonmonogamous or polyamorous relationships may also benefit from an in-depth discussion of the challenges and strengths associated with these identities, in consideration of the challenges associated with being embedded in a cultural context that devalues these relationships (Rust 2003). Third, bisexual people in intimate relationships may also experience challenges from their broader family systems. As detailed in the scholarly research on bisexual people’s family relationships, bisexual people often navigate familial disclosure once they are in intimate relationships. Bisexual clients struggling with their relationships with families of origin may benefit from exploring how stereotypes about bisexuality shape their familial relationships. This may provide space for bisexual clients to describe experiences of familial support as well as marginalization and ultimately provide the practitioner with a better understanding of the client’s familial context. Practitioners should affirm that there is no “wrong” or “right” way to come out to one’s family members, nor is there an imperative to disclose one’s identity to one’s family. Rather, clients can examine some of the positive and negative potential outcomes of different disclosure strategies. One strong theme in research on the family relationships of bisexual people concerns the challenge that many bisexual people feel in regard to how to be authentic with their families (Firestein 2007; Scherrer et al. 2015). For those bisexual clients who are interested, practitioners may seek to encourage conversations within the family so that a bisexual person can fully explain their identity and their relationships to their families. In consideration of the fact that intimate relationships are always situated within the broader context of family systems, practitioners should also be prepared to work with families on issues relevant to bisexuality. Practitioners working with the families of bisexual people will potentially benefit from examining stereotypes about bisexuality with their clients. Conceptualizations of bisexual people as

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promiscuous, nonmonogamous, or untrustworthy contradict social expectations of “good” family members. This may strain bisexual people’s abilities to maintain positive family relationships. At the same time, stereotypes about bisexual people as nascent in their sexual identity development or that bisexual people will eventually realize their heterosexuality may lead to more affirming responses from family members. Addressing these stereotypes directly will enable families to better understand how cultural constructions of bisexuality may problematically shape their understandings of their bisexual family member. These expectations will shape familial experiences above and beyond the disclosure moment, including interactions with a partner, decisions around parenting, entering into a marriage relationship, or other familial events. When working with families on issues of bisexuality, family systems approaches have been identified as a potentially fruitful approach (Scherrer et al. 2015), as well as more generally with LGB families (Baptist and Allen 2008; Heatherington and Lavner 2008; Scherrer 2016). Coming out in families may be best understood as an ongoing process, whereby family members disclose their identities, provide support and education for one another, and influence one another’s thoughts and beliefs about having an LGB family member (Baptist and Allen 2008; Heatherington and Lavner 2008; Scherrer 2016; Scherrer et al. 2015). Using a family systems approach in a therapeutic context provides an understanding of coming out as a complex, interdependent process with implications that unfold over time.

References Armstrong, H. L., & Reissing, E. D. (2014). Attitudes toward causal sex, dating, and committed relationships with bisexual partners. Journal of Bisexuality, 14(4), 236–264. Baptist, J. A., & Allen, K. R. (2008). A family’s coming out process: Systemic change and multiple realities. Contemporary Family Therapy, 30(2), 92–110. Bowers, A. M., & Bieschke, K. J. (2005). Psychologists’ clinical evaluations and attitudes: An examination of the influence of gender and sexual orientation.

Bisexual Couples Professional Psychology: Research and Practice, 36, 97–103. Bradford, M. (2004). The bisexual experience: Living in a dichotomous culture. Journal of Bisexuality, 4(1–2), 7–23. Breno, A. L., & Galupo, M. P. (2008). Bias toward bisexual women and men in a marriage-matching task. Journal of Bisexuality, 7(3–4), 217–235. Costello, C. Y. (1997). Conceiving identity: Bisexual, lesbian and gay parents consider their children’s sexual orientations. Journal of Sociology and Social Welfare, 24(3), 63–89. Dworkin, S. H. (2001). Treating the bisexual client. Journal of Clinical Psychology, 57(5), 671–680. Egan, P. J., Edelman, M. S., & Sherrill, K. (2007). Findings from the Hunter College poll of lesbians, gays, and bisexuals: New discoveries about identity, political attitudes, and civic engagement. New York: Hunter College, CUNY. Retrieved July 6, 2012, from http://as.nyu.edu/docs/IO/4819/hunter_col lege_poll.pdf. Eliason, M. (1997). The prevalence and nature of biphobia in heterosexual undergraduate students. Archives of Sexual Behavior, 26(3), 317–326. Eliason, M. (2001). Bi-negativity: The stigma facing bisexual men. Journal of Bisexuality, 19(2–3), 137–154. Eliason, M. J., & Hughes, T. (2004). Treatment counselor’s attitudes about lesbian, gay, bisexual, and transgendered clients: Urban vs. rural settings. Substance Use & Misuse, 39, 625–644. Esterberg, K. (2006). The bisexual menace revisited; or shaking up social categories is hard to do. In S. Seidman, N. Fisher, & C. Meeks (Eds.), Handbook of the new sexuality studies: Original essays and interviews (pp. 169–176). New York: Routledge Press. Fierman, D. M., & Poulsen, S. S. (2011). Open relationships: A culturally and clinically sensitive approach. American Family Therapy Academy Monograph Series, 7, 16–24. Firestein, B. A. (Ed.) (2007). Becoming visible: Counseling bisexuals across the lifespan. New York, NY: Columbia University Press. Halperin, D. (2009). Thirteen ways of looking at a bisexual. Journal of Bisexuality, 9(3–4), 451–455. Heatherington, L., & Lavner, J. A. (2008). Coming to terms with coming out: Review and recommendations for family systems-focused research. Journal of Family Psychology, 22(3), 329–343. Herbenick, D., Reece, M., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, J. D. (2010). Sexual behavior in the United States: Results from a national probability sample of men and women aged 14-94. The Journal of Sexual Medicine, 7(s5), 255–265. Israel, T., & Mohr, J. J. (2004). Attitudes toward bisexual women and men: Current research, future directions. Journal of Bisexuality, 4(1–2), 117–134. Kleese, C. (2005). Bisexual women, non-monogamy and differentialist anti-promiscuity discourses. Sexualities, 8(4), 445–464.

Black Box Concept in Family Systems Theory McLean, K. (2007). Hiding in the closet? Bisexuals, coming out and the disclosure imperative. Journal of Sociology, 43(2), 151–166. Mohr, J., Israel, T., & Sedlacek, W. E. (2001). Counselors’ attitudes regarding bisexuality as predictors of counselors’ clinical responses: An analogue study of a female bisexual client. Journal of Counseling Psychology, 48, 212–222. Mohr, J., Weiner, J. L., Chopp, R. M., & Wong, S. J. (2009). Effects of client bisexuality on clinical judgment: When is bias most likely to occur? Journal of Counseling Psychology, 56, 164–175. Mosher, W. D., Chandra, A., & Jones, J. (2005). Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Murphy, J. A., Rawlings, E. I., & Howe, S. R. (2002). A survey of clinical psychologists on treating lesbian, gay, and bisexual clients. Professional Psychology: Research and Practice, 33, 183–189. Ochs, R. (1996). Biphobia: It goes more than two ways. In B. A. Firestein (Ed.), Bisexuality: The psychology and politics of an invisible minority (pp. 217–239). Thousand Oaks: Sage. Page, E. (2007). Bisexual women’s and men’s experiences of psychotherapy. In B. Firestein (Ed.), Becoming visible: Counseling bisexuals across the lifespan (pp. 52–71). New York: Columbia University Press. Rodríguez-Rust, P. (2002). Bisexuality: The state of the union. Annual Review of Sex Research, 13, 180–240. https://doi.org/10.1080/10532528.2002.10559805. Rust, P. C. R. (2003). Monogamy and polyamory: Relationship issues for bisexuals. In L. Garnets & M. Kimmel (Eds.), Psychological perspectives on lesbian, gay and bisexual experiences (pp. 127–148). New York: Columbia University Press. Scherrer, K. S. (2013). Clinical practice with bisexual identified individuals. Clinical Social Work Journal, 41(3), 238–248. Scherrer, K. S. (2016). Gay, lesbian, bisexual and queer grandchildren’s disclosure process with grandparents. Journal of Family Issues, 37(6), 739–764. Scherrer, K. S., Kazyak, E. A., & Schmitz, R. (2015). Getting ‘bi’ in the family: Bisexual people’s disclosure strategies within the family. Journal of Marriage and Family, 77(3), 680–696. Spalding, L. R., & Peplau, L. (1997). The unfaithful lover: Heterosexuals’ stereotypes of bisexuals and their relationships. Psychology of Women Quarterly, 21(4), 611–625. Todd, M., Oravecz, L., & Vejar, C. (2016). Biphobia in the family context: Experiences and perceptions of bisexual individuals. Journal of Bisexuality, 16(2), 144–162. Watson, J. B. (2014). Bisexuality and family: Narratives of silence, solace, and strength. Journal of GLBT Family Studies, 10, 101–123.

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Black Box Concept in Family Systems Theory Samuel Major1 and Adam R. Fisher1,2 1 The Family Institute at Northwestern University, Evanston, IL, USA 2 Brigham Young University, Provo, UT, USA

Name of Concept Black Box Concept in Family Systems Theory

Introduction As psychotherapy shifted from intrapsychic to more contextual models of therapy in the 1940s and 1950s (Lebow 2014), the black box concept was adapted as an expression of the systemic perspective predominant in marriage and family therapy (Nichols and Davis 2012). The black box is the simplest way of approaching the individual mind within a family system, basing it solely on the outward behavior and communication between family members.

Theoretical Context for Concept The metaphor of the black box has been utilized in a number of fields including computer science, engineering, and biology. A black box represents something whose internal system is unknown; studying the object involves looking at what goes in or comes out rather than trying to look inside and study the inner workings. Two fundamental concepts are key for understanding the black box concept in family systems theory. (1) General systems theory describes living systems as holistic entities whose properties arise from the relationship of individual parts; living systems are then maintained through inputs and outputs from the environment (Nichols and Schwartz 2001). What this means is that families in family therapy are viewed as living systems – individual members are parts of the

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system whose interactions give rise to defining the function of the whole family system. (2) Cybernetics is the study or analysis of the flow of information between feedback mechanisms in a self-regulating system (Nichols and Schwartz 2001). Cybernetics relates to a family’s patterns of communication and behavior and how those patterns either maintain or change the functioning of the family unit. Intervention would then work best through manipulation of patterns in the family system. When general systems theory and cybernetics were introduced, family therapists began to look primarily – if not exclusively – at the interactions between members of a family system rather than at the intrapsychic processes of each individual.

Description With the introduction of general systems theory and cybernetics as a theoretical backdrop for framing problems in therapy, the black box concept marks a radical expression of the systems perspective. The metaphor of the black box – as applied to the mind – states that the inner workings of human beings (e.g., thoughts and emotions) are impossible to truly observe, let alone work with in therapy. Therefore, the best way to analyze how human systems work is through the observable input-output relations of communication and behavior. As Watzlawick et al. (1967) stated, The impossibility of seeing the mind “at work” has in recent years led to the adoption of the Black Box concept from the field of telecommunication. Applied originally to certain types of captured enemy equipment that could not be opened for study because of the possibility of destruction charges inside, the concept is more generally applied to the fact that electronic hardware is by now so complex that it is sometimes more expedient to disregard the internal structure of a device and concentrate on the study of its specific input-output relations. While it is true that these relations may permit inferences into what “really” goes on inside the box, this knowledge is not essential for the study of the function of the device in the greater system of which it is a part. (pp. 43–44)

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In other words, the mind can be most simply understood as a black box whose thoughts, feelings, emotions, and intentions may be inaccessible and are ultimately extraneous to the overall analysis and improvement of the presenting problem in therapy. Rather than working on unraveling intrapsychic conflict, emotions, or thoughts in therapy, the therapeutic focus is on changing the communication and behavior in the client system.

Application of Concept in Couple and Family Therapy Application of the black box concept gives therapists a clinical advantage in terms of simplifying their hypotheses about the presenting problem(s). “No ultimately unverifiable intrapsychic hypotheses need to be invoked” (Watzlawick et al. 1967, p. 25); the therapist can focus solely on communication between spouses or family members. Couple and family therapists can focus initial efforts on the simplest and least invasive methods and only move on to more complex theories when needed to lift constraints in the couple or family system (Pinsof et al. 2017). For example, integrative systemic therapy (IST; Pinsof et al. 2017) posits three “levels of the mind” (M1–M2–M3). The M1 level of mind consists of emotion and meaning drawn from approaches such as CBT or narrative therapy; M2 includes simple structural models of the mind such as object relations or internal family systems; M3 is based on self-psychology, applied when clients are proven to be “too fragile to modify their internal processes” (Pinsof et al., p. 121). Breunlin – one of the IST developers – places the black box concept at an additional level of the mind (“M0”; personal communication, 2017); the black box concept is positioned as an initial level of the mind before M1. The couple and family therapist may thus opt to initially work at the M0 level of mind before moving on to deeper levels as needed.

Clinical Example Morgan and Lamar presented in couple therapy with complaints about frequent fights that

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always seemed to escalate to the point of one leaving the house or threats of ending the marriage even though they would typically begin with ostensibly benign issues. Lamar would often forget to clean up the living room before Morgan returned home from work; Morgan would often spend too much money on exercise classes. The therapist – utilizing the black box concept – initially applied the simplest approach in tracking each partner’s behaviors and overt communications throughout the couple’s problem sequence. Once each partner was engaged in the process of therapy, the therapist implemented behavioral suggestions for the couple to implement at key points in the sequence with the goal of preventing the same escalation – thus making the same negative outcomes less likely – such as one of the partners slowing down the sequence as it was occurring by noting they were both getting caught in their typical negative cycle.

281 with individuals, couples, and families. Washington, DC: American Psychological Association. Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of human connection: A study of interactional patterns, pathologies, and paradoxes. New York: Norton.

Black Men in Couples and Families Adia Gooden1 and Anthony L. Chambers2 1 The University of Chicago, Chicago, IL, USA 2 The Family Institute at Northwestern University, Center for Applied Psychological and Family Studies, Northwestern University, Evanston, IL, USA

Synonyms African American men

Cross-References ▶ Breunlin, Douglas C. ▶ First Order Cybernetics ▶ Integrative Systemic Therapy ▶ Jackson, Donald ▶ Second-Order Cybernetics in Family Systems Theory ▶ Sequences in Couple and Family Therapy ▶ Strategic Family Therapy ▶ Structural Family Therapy ▶ Watzlawick, Paul

References Lebow, J. (2014). Couple and family therapy: An integrative map of the territory. Washington, DC: American Psychological Association. Nichols, M. P., & Davis, S. D. (2012). Family therapy: Concepts and methods (11th ed.). Hoboken: Pearson Education. Nichols, M. P., & Schwartz, R. C. (2001). The essentials of family therapy. Boston: Allyn and Bacon. Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J. L., Rampage, C., & Chambers, A. L. (2017). Integrative systemic therapy: Metaframeworks for problem solving

Introduction Black men in the United States are a unique population, and it is important to understand their social, ecological, and historical experiences in order to effectively support them in therapy. Here, the term Black reflects having some African heritage, and the primary focus of this entry will be on African American men. African American men primarily have ancestors who were brought to the United States to be slaves. While many immigrants from African countries, Europe, and the Caribbean who have African ancestry do not identify as African American, the second and third generations of these immigrants often identify as African American and integrate into the larger Black American community. Therefore, for the sake of inclusivity, the term Black is used in this entry. When assessing Black clients, it is important to ask specifically how they identify. Some prefer the term Black, while others prefer African American, and as mentioned some will disclose their immigrant heritage, which is critical background information for case conceptualization.

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Finally, as with all other populations, there is more heterogeneity within the Black population than between Blacks and other racial groups. The points highlighted in this entry are generalizations and should be used as guides for further assessment.

Description Black men have a long legacy of struggle in the United States dating back to slavery. Black men are often misrepresented and misunderstood. Research has demonstrated that the behavior of Black males is more likely to be interpreted as aggressive than the same behavior by White males. Further, Black men are frequently stereotyped as thugs or people who are lazy and unwilling to work. These stereotypes are inaccurate and contribute to the discrimination that Black men experience in housing, employment, and the legal system. The legacy of unequal education for Black people in the United States has often limited Black men to low-skill, low-wage jobs. With the closing of many manufacturing plants, numerous Black men found themselves out of work with few alternatives. Additionally, the war on drugs, which began in the late 1970s, started mass incarceration in the United States, which has resulted in large proportions of Black men being incarcerated for minor, nonviolent drug crimes (Alexander 2012). Being charged with a felony makes it even more difficult for many Black men to find work. Having difficulty finding work and being able to provide for their families has taken a toll on many Black men emotionally. Even with this legacy of discrimination, many Black men have achieved at high levels of education, business, medicine, politics, and the legal field. Black men have strengths that are often underappreciated by the general public. Black men typically display high levels of resilience and resourcefulness. Black men are faced with constant negative assumptions about who they are, and yet time and again, they persist in jobs, as fathers and as partners. Further, it is important to note that not all Black men come from low-income families; there is a

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significant portion of Black upper- and middleclass families. Coming from a middle- and upperclass background will influence Black men’s experience of their race and the world. Black men have a pervasive consciousness of how they are perceived in the world and are very aware of how they present themselves physically and engage with others. Black men raised in America may have received the consistent message that the expectation for Black men in this country is that they will not succeed. They may feel pressure to avoid being incarcerated or dying early. Experiencing discrimination and the history of Black people being mistreated by institutions may cause Black men to be wary of sharing things about themselves in the context of these institutions and with people who they do not trust. Black masculinity is also an important factor to consider. Often, there is a dynamic of hypermasculinity among Black men. Black men, particularly those reared in impoverished communities, are socialized to be tough and independent as a means of survival. Therefore, Black men are often taught as children not to express emotions other than anger. This impacts Black men’s ability and willingness to process difficult experiences and to enter into spaces such as therapy or romantic relationships where they are asked to be vulnerable. Black men may be navigating the tension between expectations for their behavior based on the norms for men in mainstream society and the norms for Black men. Specifically, Black men must navigate the tension between competing in an individualistic way as proscribed by mainstream American society and supporting members of their family or community as they succeed, which is encouraged by Black cultural values. Research has demonstrated that Black men experience psychological distress when navigating their male gender roles particularly if they have internalized racist stereotypes (Wester et al. 2006).

Relevant Research About Family Life Black Men in Romantic Relationships The racism and oppression that Black men experience in their daily lives may contribute to

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feelings that they must assert more power and control in their romantic relationships in order to make up for emasculating experiences. Black male partners may take their frustrations and disappointments related to experiencing racism out on their partners. This can contribute to more arguments and tension in romantic relationships. Additionally, research has demonstrated that Black men feel they should be the primary financial providers for their family even though many expect their partners to be gainfully employed (Haynes 2000). Black men may feel threatened by their female partner’s success and simultaneously insecure about their own accomplishments (Chambers 2008). They may have experienced stymied careers or fewer opportunities due to the discrimination against Black men. Black men may have difficulty expressing emotions in their romantic relationships. Additionally, they may feel like it is not okay to show vulnerability to their partners, which can create distance in romantic relationships. However, research has demonstrated that Black, middleclass, heterosexual couples tend to be egalitarian and partners tend to work together to navigate the challenges that they face (Cowdery et al. 2009). It is important to note that Black couples are less likely to get married than couples from other racial groups. Chambers and Kravitz (2011) have asserted that the lower marriage rates are in part due to the financial, discrimination, and family stressors that many Black couples face.

authoritarian style of parenting, in order to help prepare their children for the difficult realities of being a Black person in America. Black fathers are also involved in racial socialization, which involves helping Black children to feel positively about themselves and the Black community and helping them navigate the challenging experiences of Black people in America and to buffer them against negative racial stereotypes (Livingston and McAdoo 2007). A combination of systemic racism and fewer job opportunities makes it challenging for Black men to obtain consistent, gainful employment and therefore causes challenges for Black men as they work to be providers for their children. Further, when Black men are employed, they do not earn as much as White men with the same levels of education. Having difficulty providing financially for children can be accompanied by shame for Black men and may contribute to an emotional distancing from children. Black fathers who live in neighborhoods characterized by community violence are concerned about the safety of their children. Starting when they have preschool-aged children, Black fathers play important roles in helping to keep their children safe through supervising their children’s behavior and monitoring what they are doing and being exposed to. Black fathers also teach their children safety strategies to use in and outside of their homes (Letiecq and Koblinsky 2004).

Black Fathers The prevailing stereotypes of uninvolved and disinterested Black fathers are largely inaccurate. Even when Black fathers do not have primary custody of their children they still commonly play an important role in supporting and caring for their children. Black fathers are involved in caring for, nurturing, and socializing their children, and research has demonstrated that they display comparable levels of involvement to White fathers (Smith et al. 2005). Additionally, Black fathers share parenting decisions with their partners and the parenting relationships with the mothers of their children tend to be egalitarian. Black men are more likely to engage in an

Special Considerations for Couple and Family Therapy Alliance Building with Black Male Clients Black men are often apprehensive about engaging in individual, couple, and family therapy, and therapists should account for this and take steps to ensure that their Black male clients feel welcomed and accepted. Therapists should keep in mind that it may take longer to build trust in the therapeutic relationship; being patient with this process will help Black male clients to feel more comfortable opening up in therapy over time. Black people including Black men are often socialized to keep personal matters private (e.g.,

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“don’t air your dirty laundry”) and may be hesitant to share personal information with a therapist who is initially a stranger. To build rapport, it is essential for therapists to show respect for Black male clients. Black men often experience disrespect in their everyday lives when their manhood and personhood are ignored. Therapists should begin by addressing their Black male clients using formal titles. Less formality can be adopted if suggested by a client or if the therapist receives approval from the client to use their first name. Additionally, Black men are often blamed unfairly in a variety of contexts. It is important that therapists are careful not to place inappropriate blame on Black male clients and work sensitively to support them in understanding their role in conflicts. Black people tend to engage in what is referred to as high-context communication; this means that nonverbal cues (e.g., tone, volume, hand gestures) play a large role in communication. Additionally, high-context communication may rely on shared references including slang. Therapists should be aware of potential differences in communication styles with their clients and leave room for their clients to communicate in a way that is most comfortable for them. Therapists are encouraged to ask for clarification if they do not understand what a client is intending to express. It is important for therapists to take into consideration the intersectionality of Black male client’s race, gender, and sexual orientation. As mentioned above, Black men experience their gender in unique ways. Further, Black men who identify as gay, bisexual, queer, or transgender may be navigating challenging gender norms and may experience discrimination within the Black community.

relationship is exactly the thing that can destroy it. Thus, clinicians need to assess a couple’s capacity to be vulnerable as well as help the couple, especially the Black male partner, to understand the function and importance of expressing vulnerability in a marital relationship (Chambers 2008). The issue of gender disparities among Black Americans is a sociological one with interpersonal implications (Chambers & Kravitz 2011). With a disproportionate number of Black men underperforming with regard to employment and income, issues of gender identity and leadership can constrain one’s ability to appropriately express vulnerability. Hence, it is important to understand each person’s conceptualization of gender roles in the context of a romantic relationship and especially how the man has held onto his ideas of masculinity when his female partner is the primary financial provider. Finally, if Black fathers do not initiate therapy for their family or children, it is important for the therapist to actively engage Black fathers in the therapeutic process given the important role that they play in their children’s lives.

Pertinent Clinical Issues In light of the literature delineated above, a critical construct that has significant clinical implications for working with couples and families is vulnerability. In fact, there is a glaring paradox when it comes to vulnerability. As previously stated, Black men are frequently given the message to not show vulnerability if you want to be successful in the world. Although minimizing vulnerabilities in certain contexts can be helpful, the paradox is that trying to manage and hide vulnerabilities in an intimate

References

Cross-References ▶ African Americans in Couple and Family Therapy ▶ Black Women in Couples and Families ▶ Cultural Competency in Couple and Family Therapy ▶ Cultural Values in Couples and Families ▶ Culture in Couple and Family Therapy

Alexander, M. (2012). The new Jim Crow: Mass incarceration in the age of colorblindness. New York: The New Press. Chambers, A. L. (2008). Premarital counseling with middle class African Americans: The forgotten group. In M. Rastogi & V. Thomas (Eds.), Multicultural couple therapy. Thousand Oaks: Sage. Chambers, A. L., & Kravitz, A. (2011). Understanding the disproportionately low marriage rate among African Americans: An amalgam of sociological and psychological constraints. Family Relations, 60(5), 648–660.

Black Women in Couples and Families Cowdery, R. S., Scarborough, N., Knudson-Martin, C., Seshadri, G., Lewis, M. E., & Mahoney, A. R. (2009). Gendered power in cultural contexts: Part II. Middle class African American heterosexual couples with young children. Family Process, 48(1), 25–39. Haynes, F. E. (2000). Gender and family ideals an exploratory study of black middle-class Americans. Journal of Family Issues, 21(7), 811–837. Letiecq, B. L., & Koblinsky, S. A. (2004). Parenting in violent neighborhoods African American fathers share strategies for keeping children safe. Journal of Family Issues, 25(6), 715–734. Livingston, J. N., & McAdoo, H. P. (2007). The roles of African American fathers in the socialization of their children. In McAdoo (Ed.), Black families (4th ed.). Thousand Oaks: Sage. Smith, C. A., Krohn, M. D., Chu, R., & Best, O. (2005). African American fathers myths and realities about their involvement with their firstborn children. Journal of Family Issues, 26(7), 975–1001. Wester, S. R., Vogel, D. L., Wei, M., & McLain, R. (2006). African American men, gender role conflict, and psychological distress: The role of racial identity. Journal of Counseling & Development, 84(4), 419–429.

Black Women in Couples and Families Adia Gooden The University of Chicago, Chicago, IL, USA

Synonyms African American Women

Name of Family Form Black Women in Couples and Families

Introduction Black women in the United States are a unique population, and it is important to understand their social, ecological, and historical experiences in order to effectively support them in therapy. Here, the term Black reflects having some African heritage; the primary focus of this entry will be on

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African American women. African American women are women whose ancestors were brought to the United States to be slaves. Many immigrants from Africa, Europe, and the Caribbean who have African ancestry do not identify as African American. However, the second and third generations of these immigrant families often identify as African American and integrate into the larger Black American community. Therefore, for the sake of inclusivity, the term Black is used in this entry. When assessing Black clients, it is important to ask specifically how they identify in terms of race and ethnicity. Some prefer the term Black, while others prefer African American, and some will disclose their immigrant heritage, which is critical background information for your case conceptualization. Finally, as with all other populations, it is important to remember that there is more variation within the Black population than between Black people as a whole and other racial groups. The points highlighted in this entry are generalizations and should be used as guides for further assessment.

Description Black women have a large number of strengths, which are often overlooked and are important to highlight. Black women are often extremely resilient. Black women attend college and graduate school at high rates and often serve as matriarchs for their families. Black women have a legacy of figuring out how to feed, clothe, and keep their families together and healthy with limited resources. While many Black women are faced with challenges related to racism, sexism, and receiving lower pay and higher unemployment than White women, they continue to work to protect and provide for their families. Further, Black women often take pride in their appearance and the appearance of their children. They may have rituals of regularly going to get their hair styled and nails manicured; they may spend a lot of time and energy making sure that their children look presentable. This is related in part to the belief that if you present yourself well and you

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look respectable, people will treat you better. This comes from a legacy of being judged, discriminated against, and disregarded in the United States because of race and poverty. Black women tend to step up and take responsibility when their families are in need. In addition to caring for their own children, Black women often help to care for grandchildren, nieces, and nephews. Most Black people have a communalism orientation, which involves feeling responsible for loved ones and people in your community. It is important to note that not all Black people are poor or come from low socioeconomic backgrounds. While rates of poverty are higher in Black communities than in White communities, there are significant portions of Black people who were born into or have achieved upper- and middle-class status. Therapists should assess and consider socioeconomic status (SES) in their work with Black female clients. The intersections of race, gender, and SES influence Black women’s personal, professional, and family experiences. Black women are often religious – the majority are Christian – and many draw strength from their religious and spiritual beliefs and their involvement in a church community. Churches often serve as surrogate families for Black people. Black women commonly engage in prayer as a form of religious coping during times of challenge. Additionally, when Black women and their families experience success, this will often be attributed to the grace of God and will be met with high levels of gratitude. While religion and spirituality can serve as an important strength for Black women, some conservative Christian traditions may discourage mental health treatment and assert that mental illness can be prayed away. This can be a hindrance to Black women interested in seeking psychotherapy. As with any population, Black women also face challenges. Black women experience both racism and sexism. These stressors, along with experiencing financial strain and limited access to health care, contribute to a host of medical and psychological concerns that many Black women have to navigate. Black women have higher rates of heart disease, cancer mortality, and HIV than White women. These health

Black Women in Couples and Families

concerns are exacerbated by the fact that Black women often feel like they must take care of everyone else during difficult times and frequently fail to care for themselves. Additionally, many Black women have experienced trauma in their lives. Black women’s symptoms related to anxiety and depression may present differently and often go undetected. Specifically, Black women are more likely to have somatic (physical) symptoms, engage in overeating, and spend too much time and money on physical appearance when experiencing depression and anxiety, which may be overlooked by mental health-care professionals (Jones and ShorterGooden 2003). Further, Black women may continue to function at high levels even when experiencing significant symptoms of depression. Overall, Black women are less likely to receive mental health treatment than White women. There are a number of reasons for these disparities, including lower access to affordable health care, financial limitations, and a historically grounded mistrust of health-care professionals. There is a legacy in the United States of mistreating Black people within the medical system, which has made it less likely for people from these communities to seek help when they need it. Further, research has demonstrated that when Black people reach out to mental health professionals for help, they are less likely to receive return phone calls or engage in therapy than their White, middle-class counterparts (Kugelmass 2016).

Relevant Research About Family Life Black Women in Couples Black women are less likely to be married than White women. It is important to note that eventually the majority of Black women do get married, but they tend to marry later in life than White women (e.g., marriage in mid-to-late 30s vs. mid-to-late 20s). Lower marriage rates among Black women are due to a number of factors. First, a combination of mass incarceration, differences in gender birth rates, and high death rates for young Black men means there are fewer Black men available for women to date and

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marry. Additionally, financial insecurity may keep Black couples from getting married (Karney and Bradbury 2005). Heterosexual Black women are often frustrated by their limited options for Black male partners. Additionally, many Black women want to have a Black family, not a mixed-race family, and therefore may be unwilling to date men from other races or ethnicities. Further, research has demonstrated that Black women are often found to be least desirable and not approached by men of other races or ethnicities for romantic relationships. This combination of factors, along with the loyalty that many Black women feel to Black men, likely contributes to Black women being more likely to marry Black men who are less educated and earn less money than them. Some Black women may experience feelings of anger, resentment, and disappointment related to their relationships with Black men or the limited eligible Black men. Other Black women may stay in relationships with Black male partners longer than is healthy or tolerate disrespectful or insensitive behavior in part due to concerns about the “shortage” of eligible Black men to date. Additionally, Black women who are partnered may feel pulled to downplay their strengths and successes to make Black male partners feel more comfortable. Overall, research has demonstrated that difficulties in relationships with Black men are one of the top concerns for Black women (Jones and Shorter-Gooden 2003). It is important to recognize that the legacy of disrupting Black families in slavery continued into the twentieth century through public housing policies that discouraged two-parent households and is ongoing with mass incarceration. These factors have left many Black women as the heads of their households and matriarchs. This necessarily influences romantic heterosexual relationships between Black men and women. Many Black women have been raised to be selfsufficient; the need to independently care for themselves and their families has been modeled by Black mothers and grandmothers. Additionally, a significant number of Black women have children out of wedlock and experience periods of single parenting. These factors can make it challenging for Black women to transition from being

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independent to being interdependent and vulnerable within a romantic relationship when a partner is available. Black women are socialized to be strong and encouraged to hold the paradoxical space of strength and sensitivity (Jones and Shorter-Gooden 2003). Black women may receive complaints from Black male partners about being too outspoken and independent. Black heterosexual couples tend to be egalitarian (Marks et al. 2008). This is due in part to the fact that in order to take care of financial and family needs, it is important for both partners in Black couples to be employed and to work together inside of the home. Research has demonstrated that partners in egalitarian relationships report higher levels of contentment; this is a strength for Black couples (Marks et al. 2008). Despite this strength, the divorce rate for Black marriages is higher than the divorce rate for White marriages. Black couples contend with stressors related to racism, unemployment, and finances. Additionally, while Black romantic relationships tend to be more egalitarian, Black women may frequently put the needs of their partner and their children ahead of their own, at times neglecting their own health and well-being. Black women may overcompensate to support or fill in the gaps that their Black male partners will not or cannot fill due to difficulties finding employment and stress related to racial discrimination. Black women may over-function and be less likely to express their concerns to Black male partners because they empathize with the discrimination their Black male partners experience outside of the home and do not want to add to that stress (Jones and Shorter-Gooden 2003). It is important to note that some Black women are in same-sex relationships. The dynamics in Black lesbian couples are similar in some respects to heterosexual relationships. Black women in same-sex relationships may be more likely to value economic independence than Black women in heterosexual relationships. Black women in same-sex couples are also likely to endorse egalitarian values related to the division of household responsibilities (Moore 2008).

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Black Mothers Being a mother is a significant and honorable role for Black women. Black mothers often take on the role of primary caregiver for their children while working full time. Many Black grandmothers help to raise their grandchildren or serve as primary caregivers when parents are unable to care for their children. In addition to the common responsibilities that mothers take on related to ensuring that their children are healthy and safe, Black mothers take on additional tasks to help prepare their children to function successfully in a world where Black people are often discriminated against. One key task of Black mothers is racial socialization, which involves helping Black children to feel positively about themselves and the Black community and helping them navigate the racism and discrimination Black people experience. Black mothers attempt to do this while also preventing their children from having overly negative views of White people or mainstream society (Nobles 2007). It is a difficult task that requires a delicate balance. Black mothers are intentional and thoughtful about how they socialize their children in these ways. Additionally, Black mothers may have a strict parenting style (Black parents are more likely to use the authoritarian style of parenting) and low tolerance for talking back or resistance by their children. Teaching children that they cannot talk back and that they must contain their emotions and always follow the instructions of people in authority is a way to help Black children protect themselves when they are out in the world. Black mothers work to prepare their Black children for encounters with police who may be racist and violent. Black mothers often have understandable anxieties about the safety and well-being of their children.

Special Considerations for Couple and Family Therapy Black women may be apprehensive about engaging in therapy and often take a while to feel comfortable and open up. This may be due in part to Black women being socialized to appear

Black Women in Couples and Families

strong, self-sufficient, and unbothered, which can make it hard for them to express their concerns (Watson and Hunter 2015). Therapists should be patient with this process and gently help Black female clients to feel more comfortable sharing more in therapy over time. Black people, including Black women, are often socialized to keep personal matters private (e.g., “don’t air your dirty laundry”) and may be hesitant to share personal information with a therapist who is initially a stranger. As a show of respect, therapists should begin by addressing their middle-aged and older Black female clients using formal titles. Less formality can be adopted if suggested by a client or if the therapist receives approval from the client to use their first name. Black people tend to engage in what is referred to as high-context communication, which means that nonverbal cues (e.g., tone, volume, hand gestures) play a large role in communication. Additionally, high-context communication may rely on shared references including slang. Therapists should be aware of potential differences in communication styles with their clients and leave room for their clients to communicate in a way that is most comfortable for them. Therapists are encouraged to ask for clarification if they do not understand what a client is intending to express. Black women tend to be very connected to their families and spend a lot of time and energy working to care for families, and therapists should be thoughtful about engaging family members in therapy with Black women; this may include looking beyond the nuclear family to include extended family members. Additionally, when family members are not available to participate in the therapy, therapists should consider how familial relationships affect Black women and address these interpersonal concerns in individual therapy. Kelly and BoydFranklin (2005) suggest therapists should use a systems therapy approach that involves doing family therapy with one person if the entire family is not willing or able to engage in therapy. Therapists should also keep in mind that Black women may not show symptoms of depression in

Blamer Stance in Couples and Families

expected ways. Therapists should do thorough evaluations and explore symptoms that might not seem to be obvious manifestations of depression, such as somatic symptoms (Watson and Hunter 2015). It is important for therapists to acknowledge and take into account the external and potentially internalized negative stereotypes that Black women face. Additionally, it is necessary for therapists to make room for Black female clients to process their experiences related to microaggressions, racism, and sexism.

Cross-References ▶ African Americans in Couple and Family Therapy ▶ Black Men in Couples and Families ▶ Cultural Competency in Couple and Family Therapy ▶ Cultural Values in Couples and Families ▶ Culture in Couple and Family Therapy

References Jones, C., & Shorter-Gooden, K. (2003). Shifting: The double lives of Black women in America. New York: Harper Collins. Karney, B. R., & Bradbury, T. N. (2005). Contextual influences on marriage implications for policy and intervention. Current Directions in Psychological Science, 14(4), 171–174. Kelly, S., & Boyd-Franklin, N. (2005). African American women in client, therapist, and supervisory relationships: The parallel processes of race, culture, and family. Voices of color: First-person accounts of ethnic minority therapists. In M. Rastogi & E. Wieling (Eds.), Voices of color: First-person accounts of ethnic minority therapists (pp. 67–89). Thousand Oaks: Sage. Kugelmass, H. (2016). “Sorry, I’m not accepting new patients” An audit study of access to mental health care. Journal of Health and Social Behavior, 57(2), 168–183. Marks, L. D., Hopkins, K., Chaney, C., Monroe, P. A., Nesteruk, O., & Sasser, D. D. (2008). “Together, we are strong”: A qualitative study of happy, enduring African American marriages. Family Relations, 57(2), 172–185. Moore, M. R. (2008). Gendered power relations among women: A study of household decision making in Black, lesbian stepfamilies. American Sociological Review, 73(2), 335–356.

289 Nobles, W. W. (2007). African American family life: An instrument of culture. In H. P. McAdoo (Ed.), Black families (4th ed., pp. 69–79). Thousand Oaks: Sage. Watson, N. N., & Hunter, C. D. (2015). Anxiety and depression among African American women: The costs of strength and negative attitudes towards psychological help-seeking. Cultural Diversity and Ethnic Minority Psychology, 21(4), 604–612.

Blamer Stance in Couples and Families Forogh Rahim, Dara Winley, Elizabeth Adedokun and Jessica Chou Drexel University, Philadelphia, PA, USA

Introduction Blaming is not uncommon among clients and therapists in the therapeutic setting (Paivinen et al. 2016).

Theoretical Context for Concept The blamer stance has captured the attention of theoreticians and practitioners over the years and refers to the shifting of responsibility for conflict that occurs in couple and family relationships. From a communication perspective, blame can be conveyed implicitly or explicitly; but regardless, blame ascribes moral judgment from one person to another (Paivinen et al. 2016).

Description The blamer stance is seen as someone who behaves in a way that implies superiority while deflecting any faults or guilt onto another person (Carlson et al. 2017). Someone taking the blamer stance may indicate disapproval in attempts to influence or at least to protect themselves from others (Bowen et al. 2005). Those who are blamed might become defensive and or lose motivation in therapy, while those who are not blamed may believe they are not responsible for working toward conflict resolution (Sprenkle et al. 2009).

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Application of Concept in Couple and Family Therapy Therapists play an active role in unpacking unmet needs to promote healthy communication (Goldenberg and Goldenberg 2012) that can result in changing the blamer stance. It is important for the therapist to identify the blamer stance and verbalize an understanding of the underlying unmet needs of the person issuing blame in order to create a safe environment for change. The blamer may feel “endangered and [react] by attacking in order to cover up feeling empty, unloved and unworthy” (Goldenberg and Goldenberg 2012, p. 225). It then becomes the therapist’s goal to help the blamer take the risk of being congruent between what they are truly feeling and communicating. Furthermore, blaming communication may have different meanings across cultures. Therapists must practice from a culturally sensitive lens and model culturally appropriate communication in order to reduce blame (Bermudez 2008).

Blamer Stance in Couples and Families

rooted in family of origin relationships. However, what gets communicated to Nina is his anger and frustration rather than how Charles truly feels. Additionally, Charles and Nina’s experiences of the world may be different based on their differences in various cultural factors, such as race and gender. Nina lives with identities that are marginal and may feel alone and misunderstood by Charles in this regard. The therapist can work toward helping this couple better understand their conflict as a result of differing worldviews based on experiences out in the real world. By attending to the underlying judgments, each individual may be more open to taking accountability for their part in the conflict and also practice being more vulnerable with each other.

Cross-References ▶ Fair Fighting in Couple Therapy

Clinical Example

References

Charles and Nina are seeking couple therapy related to increased arguments after moving to Philadelphia. Charles, a 23-year-old Caucasian male, and college graduate, is currently looking for employment. Nina, a 22-year-old African American female, also a recent graduate, is now in graduate school. During session, Nina begins by discussing the stress of starting school and not having close friends and family nearby for support. Charles believes most of the fighting stems from Nina being more invested in her graduate program than the relationship. Charles describes that while he tries to make a concerted effort to prioritize their relationship, he feels that he is the only one working at it. The therapist may promote a systemic view of the problem by bringing the couple’s attention to their relational and communication patterns. Charles may be feeling abandoned by Nina, and this sense of abandonment may be

Bermudez, D. (2008). Adapting Virginia Satir techniques to Hispanic families. The Family Journal, 16(1), 51–57. Bowen, C., Stratton, P., & Madill, A. (2005). Psychological functioning in families that blame: from blaming events to theory integration. Journal of Family Therapy, 27(4), 309–329. Carlson, M. W., Oed, M. M., & Bermudez, J. M. (2017). Satir’s communication stances and pursue–withdraw cycles: An enhanced emotionally focused therapy framework of couple interaction. Journal of Couple & Relationship Therapy, 16(3), 253–270. Goldenberg, H., & Goldenberg, I. (2012). Family therapy: An overview. New York: Cengage Learning. Paivinen, H., Holma, J., Karvonen, A., Kykyri, V. P., Tsatsishvili, V., Kaartinen, J., Penttonen, M., & Seikkula, J. (2016). Affective arousal during blaming in couple therapy combining analyses of verbal discourse and physiological responses in two case studies. Contemporary Family Therapy, 38, 373–384. https://doi.org/10.1007/s10591-0169393-7. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press.

Blended Family

Blended Family Patricia L. Papernow Institute for Stepfamily Education, Hudson, MA, USA

Name of Family Form “Blended Family”

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Stepfamilies take many forms: only one adult may bring children (“simple” stepfamily). Both adults may bring children (“complex” stepfamily). Adult stepcouples may be married or (increasingly) unmarried cohabiting. Previous parenting relationships may have ended with divorce, death, or, in the case of unmarried cohabiting partners, neither. Divorce rates have fallen in the USA, except over age 50 where the rate doubled between 1990 and 2010 (Brown and Lin 2012). Thus, increasing numbers of new stepcouples are over age 50, with adult children and even grandchildren. All of these stepfamily forms face five major challenges to intimate relationships (Papernow 2013):

Stepfamily; “Remarried family”

Introduction “Blended family” is a commonly used term for stepfamily. Although the phrase captures the human longing for closeness and oneness, it is misleading. Becoming a stepfamily proves to be less like blending a smoothie and more like asking a group of Japanese and a group of Italians to live intimately together. “Remarried family” is often used interchangeably with “stepfamily.” However, many stepcouple marriages are a first marriage for one or both adults. Forty-two percent of Americans have a close step relationship (Pew Research Center 2011), making it critically important that all clinicians develop a solid understanding of stepfamily dynamics, the challenges they create, and evidence-based, evidence-informed strategies for meeting those challenges.

Description Stepfamilies differ fundamentally from first-time families. In first-time families, children are born into an already-established adult couple relationship. They generally arrive hardwired for attachment to both of their parents, and vice versa. In a stepfamily, at least one parent-child relationship precedes the adult couple relationship. Parentchild attachment excludes stepparents.

1. Insider/outsider positions are intense and stuck. Strong bonds of attachment, shared history, and shared values lie in parent-child relationships, not in step relationships. This structure makes stepparents “stuck outsiders” to already-established powerful parent-child (and ex-spouse) relationships. Parents become “stuck insiders,” torn between their children’s needs and their partners. Struggling stepcouples can easily become increasingly divided and disconnected. Clinicians must often help hold the intense affect this challenge creates. Stepcouples often need help building empathy and understanding across their insider/outsider divide. 2. Children struggle with losses, loyalty binds, and change. Adults often describe stepchildren as “manipulative,” “resistant,” or “splitting.” In fact, while a new relationship is a wonderful gift for adults, children (even adult children) often experience their stepfamily as yet another set of losses (Cartwright 2008). Stepparents can also engender loyalty binds: “if I care about my stepmother/stepfather, I am disloyal to my mom/dad.” Adults often want to move forward quickly. But, for many children, adjustment to a new stepfamily is more difficult and takes longer than divorce. Stepfamily adjustment is easier for boys and children under eight and seems to be harder for girls, especially preadolescent girls (van Eeden-Moorefield and Pasley 2012). Clinicians often need to help stepcouples to prioritize

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both parent-child relationships and the stepcouple relationship, and to proceed much more slowly. 3. Parenting tasks divide parents and stepparents. Research establishes that children do best in all family forms with “authoritative” parenting that is both loving (warm, responsive) and moderately firm (setting developmentally appropriate expectations and monitoring behavior) (Bray 1992). When this challenge goes badly, stepparents move too quickly into a disciplinary role. Frustrated stepparents become increasingly harsh and authoritarian; parents become increasingly protective and permissive. Neither serves children. Stepparents can often help parents to “firm up,” and parents can help stepparents to “soften up.” The research provides clear guidelines for meeting this challenge: parents need to retain the disciplinary role until and unless stepparents have formed caring trusting relationships with stepchildren. Meanwhile, stepparents have input, and parents have final say about their own children. Across many cultures, authoritarian (harsh and cold) stepparenting is toxic. (For citations and research overview see: Ganong and Coleman 2017; Papernow 2013, pp. 65–84, 200–201.) 4. A new family culture must be forged in the presence of already-established cultures. Shared understandings about noise, mess, holiday rituals, money, etc., lie in parent-child relationships, not step relationships. Differences, large and small, often saturate daily life. Struggling stepfamilies argue over right and wrong. Successful stepfamilies slowly build a new family culture while simultaneously respecting and honoring established family traditions, values, and habits. 5. Ex-spouses (other parents) are part of the family. Children have another parent, dead or alive, nourishing or abusive, outside the nuclear family. Child well-being is highest with low parental conflict, collaborative co-parenting, and when children feel securely connected to all the adults in their lives (Ganong and Coleman 2017; Grych and Fincham 2001; Papernow 2013, pp. 102–125, 202–204).

Blended Family

Relevant Research The unique challenges of stepfamilies first received attention from clinicians (Papernow 1993; Visher and Visher 1979, 1996). No major clinical work appeared again until Browning and Artfelt (2012) and Papernow (2013). Despite the prevalence of this family form, and the need for evidence-informed clinical help, these remain the only two clinical books available. Meanwhile the research has exploded. (For excellent reviews of the research see: Ganong and Coleman 2017; Stewart 2007; van Eeden-Moorefield and Pasley 2012.) Family scholars agree: becoming a stepfamily takes time, with estimates ranging from 3 to 6 years for successful stabilization, and much longer in struggling stepfamilies. (For a summary of these findings, see Papernow 2013, pp. 162–166, 206–207.) Again, stepfamily adjustment is more difficult for children under 8, seems to be harder for girls, and is especially hard for preadolescent girls (van Eeden-Moorefield and Pasley 2012). Parents need to retain the disciplinary role until or unless stepparents form caring and trusting relationships with their stepchildren (Bray 1999; Ganong and Coleman 2017; Hetherington et al. 1998). Stepparents must begin by forging relationships with stepchildren, i.e., with “connection not correction” (Papernow 2013). Authoritarian (harsh and firm, not loving) parenting by stepparents is particularly damaging to stepparentstepchild relationships (Bray 1999; Ganong et al. 2011; Hetherington et al. 1998), including, it appears, in cultures that accept authoritarian parenting (e.g., Nozawa 2015). The field has suffered from what Ganong and Coleman call a “deficit comparison” model that posits never-divorced families as “normal” and stepfamilies as “deviant.” In the last few decades, the field has become more sophisticated. For instance, early research found that children in stepfamilies have slightly lower well-being scores. However, although these findings are significant, effect sizes are small (Ganong and Coleman 2017). A meta-analytic review of the literature found a great majority of stepchildren scoring in the normal

Blended Family

range of development (Jeynes 2007). Another meta-analytic review found 43 % of children in stepfamilies scoring higher than those in never divorced families (Amato 1994). Over the years, as stepfamily scholarship has matured, it has become clearer that differences in well-being are due more to process variables, particularly parenting, conflict, and numbers of transitions, than to family structure (Dunn 2002; Ganong and Coleman 2017; Jeynes 2007).

Special Considerations for Couple and Family Therapy It is vital for clinicians to understand that stepfamily structure places subsystems in competition with each other for secure connection. When parents turn to their children, stepparents are left out. When stepparents have the full attention of their partners, children feel excluded. When the whole family is together, parent-child subsystems easily dominate, eclipsing stepparent-stepchild relationships. Stepfamilies do need time together to create a new family culture. However, stepfamilies also need to meet their competing attachment needs by establishing regular reliable alone time for each subsystem: adult stepcouple, parent-child, and stepparent-stepchild. Likewise, these competing needs make “family therapy” with a whole stepfamily inadvisable. Clinicians must think systemically, but proceed in subsystems (adult couple, parent-child relationship, sibling relationships, ex-spouse relationship), or with individual therapy firmly grounded in a systemic understanding of stepfamily dynamics. Stepparent-stepchild and whole-family therapies come after attachment needs are met in other subsystems (Browning and Artfelt 2012; Papernow 2013). Parents do often ask for family or child therapy to “help children adjust.” However, children are often helped most by helping the adults to develop more realistic expectations, providing psychoeducation about effective strategies for meeting stepfamily challenges, and increasing parent-child attunement and alone time. It is helpful to conceptualize clinical work on three different levels (Papernow 2013):

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(I) psychoeducational (information about what is normal, what works to meet stepfamily challenges, and what does not), (II) interpersonal (building compassion and forging connection in the face of divisive challenges), and (III) intrapsychic family-of-origin work (healing family-of-origin wounds that are intensifying reactivity to stepfamily challenges).

Cross-References ▶ Bray, James ▶ Browning, Scott ▶ Papernow, Patricia ▶ Remarriage in Couple and Family Therapy ▶ Visher, Emily ▶ Visher, John

References Amato, P. R. (1994). The implication of research findings on children in stepfamilies. In A. Booth & J. Dunn (Eds.), Stepfamilies: Who benefits? Who does not? (pp. 81–88). Hillside: Lawrence Erlbaum. Bray, J. (1992). Family relationships and children’s adjustment in clinical and nonclinical stepfather families. Journal of Family Psychology, 6, 60–68. Bray, J. (1999). From marriage to remarriage and beyond: Findings from the developmental issues in stepfamilies research project. In E. M. Hetherington (Ed.), Coping with divorce, single parenting, and remarriage. A risk and resiliency perspective (pp. 263–273). New York: Lawrence Erlbaum. Brown, S. L., & Lin, I. (2012). The gray divorce revolution: Rising divorce among middle-aged and older adults, 1990–2010. Journals of Gerontology: Series B. Psychological Sciences and Social Sciences, 67, 731–741. Browning, S. C., & Artfelt, E. (2012). Stepfamily therapy: A 10-step clinical approach. Washington, DC: American Psychological Association. Cartwright, C. (2008). Resident parent-child relationships in stepfamilies. In J. Pryor (Ed.), International handbook of stepfamilies (pp. 208–230). Hoboken: Wiley. Dunn, J. (2002). The adjustment of children in stepfamilies: Lessons from community studies. Child and Adolescent Mental Health, 7(4), 154–161. Ganong, L., & Coleman, M. (2017). Stepfamily relationships: Development, dynamics, and interventions (2nd ed.). New York: Springer. Ganong, L., Coleman, M., & Jamison, T. (2011). Patterns of stepparent – stepchild relationship development. Journal of Marriage and Family, 73, 396–413.

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294 Grych, J. H., & Fincham, F. D. (Eds.). (2001). Interparental conflict and child development: Theory, research, and application. New York: Cambridge University Press. Hetherington, E. M., Bridges, M., & Insabella, G. M. (1998). What matters, what does not? Five perspectives on the association between marital transitions and children’s adjustment. American Psychologist, 53, 167–184. Jeynes, W. H. (2007). The impact of parental remarriage on children: A meta-analysis. Marriage & Family Review, 40(4), 75–98. Nozawa, S. (2015). Remarriage and stepfamilies. In S. R. Quah (Ed.), The Routledge handbook of families in Asia (pp. 345–358). London: Routledge. Papernow, P. L. (1993). Becoming a stepfamily: Stages of development in remarried families. New York: Taylor & Francis. Papernow, P. L. (2013). Surviving and thriving in stepfamily relationships: What works and what doesn’t. New York: Routledge. Pew Research Center. (2011). A portrait of stepfamilies. Washington, DC: Pew Research Center Social and Demographic Trends. Stewart, S. D. (2007). Brave new stepfamilies. Thousand Oaks: Sage. van Eeden-Moorefield, B., & Pasley, K. (2012). Remarriage and stepfamily life. In G. Petersen & K. Bush (Eds.), Handbook of marriage and the family (3rd ed., pp. 517–548). New York: Springer. Visher, E. B., & Visher, J. (1979). Stepfamilies: A guide to working with stepparents and stepchildren. New York: Taylor & Francis. Visher, E. B., & Visher, J. (1996). Therapy with stepfamilies. New York: Brunner Mazel.

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the Family where he served as Director, and his editorship of family therapy’s flagship journal, Family Process and Family Systems Medicine (Weiner 1996). Always tempered and collaborative, Dr. Bloch is credited with creating a “big tent” under which constructive dialogue took place among the many disparate voices of the pioneers of family therapy. The field of family therapy that ultimately emerged from this dialogue owes him a debt of gratitude. Dr. Bloch was born and raised in New York City in a second-generation Jewish immigrant family. He was described by colleagues as being a very funny, creative, and authentic human being; one of the original family therapists who saw the importance of applying systemic approaches to healthcare. He was trained as a psychoanalyst at the Chestnut Lodge under the supervision of two highly influential psychiatrists, Frieda FrommReichman and Harry Stack Sullivan. It was the Lodge’s understanding of psychosis in interpersonal terms that further swayed Bloch to a more systemic approach to psychotherapy. According to Dr. Bloch, aspects of the Lodge’s approach to treatment captured family healthcare in motion. In the 1950s he abandoned psychoanalysis in favor of systems theory and eventually a family approach to psychotherapy. Dr. Bloch died in 2014 at the age of 91 (Sluzki 2014; Seaburn 2015).

Bloch, Donald Career Diana J. Semmelhack Midwestern University, Downers Grove, IL, USA

Introduction Donald Bloch was a psychiatrist who influenced the development of the field of family therapy primarily through his influential leadership positions (Doherty 2015). This leadership touched family therapy organizations such as the American Family Therapy Academy (AFTA) where he served as president, The Ackerman Institute for

In 1972 Donald Bloch became the Ackerman Institute’s second director. He served in this role until 1990. The world famous Ackerman Institute for the Family was founded in 1960 by Dr. Nathan W. Ackerman (Weiner 1996). Dr. Ackerman also trained as a psychoanalyst and abandoned this approach after WWII and began treating families and groups. A group of families under his care started what was originally a very small not-forprofit institute that mushroomed into the Ackerman Institute for the Family. Under Bloch’s leadership, the institute inaugurated and expanded

Blow, Adrian John

its clinical training program, developed a large family therapy clinic housed in the Institute and developed a series of research projects designed to study special populations, among them the women’s project that included Peggy Papp, Olga Silverstein, Betty Carter, and Mariane Walters. Dr. Bloch’s interest in special populations is highlighted by his first paper, “The Delinquent Integration,” which defined delinquency as an interpersonal pattern rather than an intrinsic characteristic. Today, the Institute’s focus on developing clinical projects to study difficult populations continues to distinguish the Ackerman Institute from others of its kind. During his tenure, Dr. Bloch was instrumental in attracting many prominent family therapists to the Ackerman. Dr. Bloch’s distinguished career is also marked by editorship of Family Process (Peek 2015). He founded the journal, Family Systems Medicine, and had a critical role in the development of the Collaborative Family Healthcare Association. The Association focuses on advocacy of the fair distribution of resources and listening to diverse voices in need of mental healthcare. Dr. Bloch steadfastly drew his systems expertise to help bridge the mind-body gap and pursue a more humane, egalitarian, and interdisciplinary view of healthcare.

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References Doherty, W. J. (2015). Don Bloch’s vision: A commentary. Family Systems & Health, 2, 99. Peek, C. J. (2015). Don Bloch’s vision for collaborative family health care: Progress and next steps. Family Systems & Health, 2, 86–98. Seaburn, D. (2015). Donald A. Bloch, MD: A remembrance. Family Systems, & Health, 1, 3–4. Sluzki, C. (2014). In memoriam. www.iftafamilytherapy. org/docs/DonBloch.pd Weiner, E. L. (1996). An interview with Donald A. Block, MD. Families, Systems, & Health, 14, 95–14.

Blow, Adrian John Tim Welch Human Development and Family Studies, Michigan State University, East Lansing, MI, USA

Name Adrian John Blow Ph.D. (b. 1965)

Introduction Contributions to the Profession Dr. Bloch is a noted pioneer of the field of family therapy. He was not a prolific writer or the creator of one of the models of family therapy. Rather, he was a wise man who brought thoughtfulness and respect to a field still in its adolescence. He was liked and admired and often sought to navigate challenging situations. He was the recipient of many awards commensurate with his contributions to the field of family therapy.

Cross-References ▶ Ackerman Institute for the Family ▶ Family Process (Journal)

Adrian Blow, Ph.D., has made significant contributions to the field of Couple and Family Therapy (CFT) and is known for his work on common factors across CFT theories, resiliency processes in military families, and infidelity in committed relationships.

Career Adrian Blow received his Ph.D. in Marriage and Family Therapy from Purdue University in 1999. He spent 6 years (1999–2005) as a faculty member at Saint Louis University in the department of Counseling and Family Therapy, where he also served as department chair. In 2005, he joined the faculty at Michigan State University in

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the Human Development and Family Studies department where he is currently a full professor. He has served as the program director for the Couple and Family Therapy program since 2011 and was associate chair of the department from 2015 to 2018. He has been involved in several large federally funded grants related to military deployment for over a decade. Blow’s research includes postdeployment adjustment of National Guard couples, studies of interventions to boost resiliency, and other family-based interventions. He has also published on the intersection of spirituality in women coping with breast cancer. In 2017, he received the American Association for Marriage and Family Therapy (AAMFT) training award.

Contributions to Profession Blow is well known for his contribution to research on common factors across theories of Couples and Family Therapy. In particular, Blow (together with Doug Sprenkle) is well known for articulating a “moderate” common factors stance in CFT theories. This approach contends there are few overall differences in treatment outcomes among effective therapies. The approach leaves room that in some circumstance, for some clients, one therapy model may be more well-suited than another. His work argues that common change elements found in diverse models of therapy and the process of therapy itself accounts for a large portion of why CFT works. Additionally, Blow and colleagues have articulated four common factors found in CFT models that are unique to CFT: (a) relational conceptualization of the problem; (b) the expanded direct treatment system; (c) the expanded therapeutic alliance; and (d) interruption of interactions. Relational conceptualization of problems sees human difficulties through a relational lens: it contextualizes problems as occurring within a social network and keeps the whole system in mind even when interacting with a part of the system. The expanded direct treatment system refers to the work of CFTs when they expand the focus of treatment from the identified patient to other relevant members of the system, and to those outside

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of the system (e.g., school teachers or medical professionals). The expanded therapeutic alliance consists of the alliance between the therapist and the individual members of the family as well as the alliance between various sub-systems in the family. Finally, the interruption of sequences occurs when family therapists interrupt negative cycles in families and allow them to adopt more adaptive ways of relating to each other. Blow is also known for recognizing the vital role a therapist plays in treatment outcomes. In writing about the relationship between common factors, therapy models, and therapists, Blow writes that therapy models are the vehicle through which common factors operate. In turn, a therapy model works through a therapist. Thus, it is a therapist who activates important change mechanisms that affect therapy success. Blow contends more research should examine how a therapist effects treatment outcomes and what differentiates effective and ineffective therapists. Blow is also well-regarded for his contributions to infidelity in committed relationships. He has written several journal articles and book chapters on the topic and has presented at state and national conferences. Blow is also a nationally recognized expert on military families and has numerous publications and presentations on resiliency processes in military families as well as issues related to access and mental health treatment for military personnel.

Cross-References ▶ Common Factors in Couple and Family Therapy ▶ Infidelity in Couples ▶ Military Families

References Blow, A. J., & Hartnett, K. (2005a). Infidelity in committed relationships II: A substantive review. Journal of Marital and Family Therapy, 31, 217–234. Blow, A. J., & Hartnett, K. (2005b). Infidelity in committed relationships I: A methodological review. Journal of Marital and Family Therapy, 31, 183–216.

Blueprint for Therapy in Metaframeworks: Transcending the Models of Family Therapy Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298–317. Gorman, L., Blow, A. J., Ames, B., & Reed, P. (2011). National Guard families after combat: Mental health, use of mental health services, and perceived treatment barriers. Psychiatric Services, 62, 28–34. Sprenkle, D., & Blow, A. J. (2004). Common factors and our sacred models. Journal of Marital and Family Therapy, 30, 113–129.

Blueprint for Therapy in Metaframeworks: Transcending the Models of Family Therapy Nancy Burgoyne The Family Institute at Northwestern University, Evanston, IL, USA

Name of Strategy/Intervention Blueprint for Therapy

Introduction The blueprint for therapy is a schema that differentiates the moment-to-moment events that take place in a psychotherapy encounter into a recursive sequence of four elements: hypothesizing, planning, conversing, and reading feedback. These elements define the essential decisionmaking and decision-evaluating process that unfolds in a therapeutic exchange and serves as an organizing tool for managing within and between session planning (Breunlin et al. 2011). The blueprint for therapy was first introduced by Breunlin, Schwartz, and Mac Kune-Karrer in Metaframeworks: Transcending the Models of Family Therapy (1992). It was later woven into Integrative Problem Centered Metaframeworks (Russell et al. 2016; Breunlin et al. 2011; Pinsof et al. 2011). It has been most recently and fully elaborated in Integrative Systemic Therapy (Pinsof et al. 2017). Although the blueprint was

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developed within these approaches, the authors maintain that it is a useful tool for any therapist seeking to be mindful and planful with the process of therapy.

B Theoretical Framework The blueprint for therapy is an essential component of Integrative Systemic Therapy (hereafter IST) and reflects its tenets. IST is a comprehensive therapeutic perspective applicable to individual, couple, and family therapy and useful with most any presenting problem. Although IST has general utility in the field of psychotherapy, it is currently most widely utilized by couple and family therapists and family psychologists. IST is also a basis for teaching systemic, integrative, and empirically informed practice as well as a framework for the lifelong learning and growth of psychotherapists (Pinsof et al. 2017). IST is based on two premises. The first is integration. The authors believe that “the field of psychotherapy has to move beyond specific models (empirically supported or not) to a comprehensive and integrative framework that simultaneously incorporates and transcends those models” (Pinsof et al. 2017, p. ix). This belief is linked to the quest for a common factor approach (Sprenkle et al. 2009). The authors observe that “the movement toward a comprehensive and integrative approach heralds the emergence of psychotherapy as a mature clinical science” (Pinsof et al. 2017, p. ix). The second premise is based on systems theory. IST is grounded within “the systemic beliefs and practices that drove the creation and growth of the field of family therapy” (Pinsof et al. 2017, p. ix). IST posits that all psychotherapy takes places within the biopsychosocial context that includes the individual’s biology and experience of themselves, multiple relationships, community(ies), and the larger society. To consider an individual and their problems apart from these layers of context, while appealing in its simplicity, leads a therapist to incomplete and potentially pathologizing hypotheses. The systemic, integrative approach of IST, within which the blueprint for therapy is nested, provides a framework for simultaneously

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embracing the individual and their context (Pinsof et al. 2017; Russell et al. 2016). The blueprint is an expression of several of IST’s theoretical pillars and therapy guidelines. First, IST’s position that humans can progressively know reality, but can never fully know it, supports the idea of hypothesizing (vs. knowing) and testing hypotheses in the blueprint. Second, IST’s emphasis on collaboration and the therapeutic alliance establishes the importance of client feedback as a primary factor in hypothesizing. Third, the blueprint is IST’s schema for integrating concepts and interventions and helping the therapist and clients determine what to do when what they are doing is not working (Pinsof et al. 2017).

Rationale for Strategy or Intervention The blueprint for therapy guides a therapist’s decision-making, facilitates evaluation of the effects of treatment, and provides the basis for the clinical–scientific method of integrative psychotherapy (Breunlin et al. 2011; Pinsof et al. 2011). The tool breaks down what a therapist does (or is well advised to do) into clearly identifiable steps. This heuristic ensures that therapists are intentional and collaborative about what they are thinking and doing at each juncture. In the context of training and professional development, the blueprint provides a means to evaluate therapists’ skills and choices, as well as the progress of a given course of treatment. The blueprint is a process for deciding how to accomplish any and all of the problem-solving and relational tasks of therapy. In addition to providing a map for decision-making, the blueprint is a tool for treatment planning, as well as a vital resource for reflection and course correction. “It has utility on a moment-to-moment basis within sessions (micro level of therapy) and between sessions as a means of planning therapy (macro level of therapy). In a sense, each therapy is a single case study in which the blueprint is continuously used to intervene and correct the course until the presenting problems are solved. Significantly, the blueprint logic is the tool for

integrating intervention strategies from a variety of models and the basis for the incorporation of feedback, including empirical feedback, into the work” (Pinsof et al., p. 82).

Description of Strategy or Intervention The blueprint, including its four recursive elements (hypothesizing, planning, conversing, and feedback), is most effectively and usefully portrayed graphically as in Fig. 1. The arrows of the diagram depict both the directionality and the recursiveness of the process. This visual allows the therapist to see the recursive pattern that drives the therapeutic encounter and the opportunities the therapist has for focusing on any one component in order to make decisions about their own behavior and/or assess the impact of the current therapeutic strategy. Importantly, the blueprint components also function to contain and organize the knowledge and skills a therapist needs to conduct the aspects of therapy associated with that component. The bodies of knowledge associated with each component of the blueprint are beyond the scope of this entry but can be found in Pinsof et al. (2017). Hypothesizing is a feedback-informed process of understanding the client(s) dilemma(s) and reflects all or part of the therapist’s current formulation of the case. The therapist and client(s) seek explanations for both the presenting problem and various events and processes that occur within the therapy (Breunlin et al. 2011). The blueprint guides the therapist to select a working hypothesis from a vast field of potential explanations (in IST (Hypothesizing)

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(Planning)

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Blueprint for Therapy in Metaframeworks: Transcending the Models of Family Therapy, Fig. 1 Blueprint for therapy

Blueprint for Therapy in Metaframeworks: Transcending the Models of Family Therapy

these are called “hypothesizing metaframeworks”) that focuses exclusively on one or more constraints that block the client from accessing their strengths and resources in order to resolve the presenting problem. When clients have difficulty in the therapy, this feedback prompts further collaborative hypothesizing progressively revealing the factors that prevent change (Breunlin et al. 2011; Pinsof et al. 2017). Planning happens both within and between sessions and reflects the therapist’s intentional decision-making about where and how to focus the treatment. Planning is driven by the hypothesis at play. A therapist must choose strategies to employ to influence the change process (e.g., action-based strategies, meaning- or emotionbased, biobehavioral, or intrapsychic strategies). In IST, these strategies are organized into planning metaframeworks. Planning is intended to move the change process forward and to create and maintain a therapeutic alliance (Pinsof et al. 2011, 2017). Conversing refers to the conversations through which plans are developed and explored. Conversation is a collaborative process where the therapist and client exchange information, develop an understanding of the client(s)’ concerns, manage and advance the therapeutic alliance, and formulate a course of action (Pinsof et al. 2017). Conversation is the vehicle through which interventions are typically delivered in therapy. Lastly, feedback involves careful attending to clients’ verbal and nonverbal communication and the therapist’s intrapsychic experience. “The therapist tracks the content and themes of conversation, observable behavior and interaction, reports of actions and interactions, empirical data regarding progress in therapy, and her or his internal (emotional) reactions” (Pinsof et al. 2017, p. 81). Feedback informs the therapist on every level, including the strength of the alliance, the clients’ responsiveness to the treatment plan, the resonance of the hypotheses being pursued, the success of specific interventions, and the therapist’s use of self. Feedback provides the therapist with data to confirm or revise hypotheses and modify plans or specific conversational elements as needed.

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Case Example The following example illustrates the blueprint in motion. A single father and his three children ages 8, 7, and 5 attend a third session. The father is seeking help “getting my kids to behave.” For the third week in a row, the children are poorly organized and fight with one another, and the therapist is unable to engage the family in a useful way. The therapist observes (reads the feedback) that the father is agitated and seemingly preoccupied, the children alternate between bidding for the father’s attention and acting out, and the therapist feels helpless and is over-functioning in the session. The therapist discusses the case with her supervision team. The team observes that there is a lack of effective leadership in the family and that the therapist is undermining the father by stepping into that void (hypothesizing). The group wonders (expanding the hypothesis) what keeps the father from being a leader to his children. The orgy of ideas that is typical of hypothesizing extends deep into the father’s history and wide into the community within which the family resides. The team decides the most useful hypothesis to pursue first is the one that seems most directly related to the reason the family is seeking help – reorganize the system to support the father in the hierarchy. Given the age of the children, the team decides the therapist should use play (planning). The therapist reconvenes the family and creates an enactment that utilizes a part of the presenting problem (the children’s behavior on the school bus) as raw material. The therapist invites the family to “play school bus” (conversing) and assigned the father the role of the driver. The therapist enters and exits the scene (reads feedback, hypothesizes, recommits to the plan) and playfully encourages the father (conversing) to “run the bus the way he thinks it should be run.” The family enjoys the activity and both the father and therapist appear buoyed (feedback). Based on the feedback, the therapist maintains the treatment strategy (plan) over a series of sessions and varies the in-session and betweensession work to allow the father and children to settle into their new structure.

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Several months into the therapy, the therapist observes (feedback) that the family lacks energy and the father appears withdrawn. The therapist scans her knowledge of the family (hypothesizing) for a possible explanation for the current distress. The therapist has a hypothesis about loss (based on the prior hypothesizing session with her supervision team) but does not have a clear understanding of the affect in the room, though she feels sadness (intrapsychic feedback) and so decides (planning) to ask the family about it by describing the behaviors that she sees: “I notice that no one is smiling today and that Dad is looking at his hands. What do you see?” With this question, the therapist invites the family to share (conversing) their current experience. The therapist observes (feedback) that the father struggles to communicate and that the middle and youngest children begin to fight. The therapist thinks (hypothesizing) that the children are attempting to distract the father from his distress and determines (planning) that the children need an outlet for their discomfort that does not undermine the father’s leadership. The therapist asks the father (conversing) to give his children the paper and crayons on an adjacent table to draw a picture of the family. The children draw pictures, one that includes the absent mother and one that does not (feedback). This leads the therapist to develop a hypothesis regarding the family’s loss and chooses to support the family (plan) to discuss their grief (conversing) over the missing mother and wife. This ongoing and continually evolving therapeutic process invites client participation and welcomes expansion and/or course correction as therapist and clients collaboratively address the layers of constraint that maintain the presenting problem (Pinsof et al. 2017). In this example, the family was constrained in at least two ways, by the father’s difficulty in providing leadership to his children and by the family’s shared grief over the loss of the absent mother and wife. The undeniable interaction between these variables was most effectively addressed by the strategy of pursuing one hypothesis at a time through the blueprint up until the juncture at which additional constraints were revealed. The blueprint for therapy provided the structure necessary to both understand and guide the process.

Bonds in Couple and Family Therapy

Cross-References ▶ Breunlin, Douglas C. ▶ Chambers, Anthony ▶ Integrative Problem-Centered Metaframeworks ▶ Integrative Systemic Therapy ▶ Lebow, Jay L. ▶ Pinsof, William M. ▶ Rampage, Cheryl ▶ Russell, William P. ▶ Web of Human Experience in Couple and Family Therapy

References Breunlin, D. C., Pinsof, W. M., Russell, W. P., & Lebow, J. L. (2011). Integrative problem centered Metaframeworks (IPCM) therapy I: Core concepts and hypothesizing. Family Process, 50(3), 293–313. Pinsof, W. M., Breunlin, D. C., Russell, W. P., & Lebow, J. L. (2011). Integrative problem centered metaframeworks (IPCM) therapy II: Planning, conversing and reading feedback. Family Process, 50(3), 314–336. Pinsof, W., Breunlin, D. C., Russell, W. P., Lebow, J., Rampage, C., & Chambers, A. (2017). Integrative systemic therapy. Washington, DC: APA Books, American Psychological Association. Russell, W. P., Pinsof, W., Breunlin, D. C., & Lebow, J. (2016). Integrative problem centered metaframeworks (IPCM) therapy. In T. L. Sexton & J. Lebow (Eds.), Handbook of family therapy (4th ed., pp. 530–544). New York: Routledge. Sprenkle, D., Davis, S., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press.

Bonds in Couple and Family Therapy Andrew S. Brimhall and David M. Haralson East Carolina University, Greenville, NC, USA

Name of Concept Bond

Bonds in Couple and Family Therapy

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Synonyms

Description

Alliance; Attachment; Link; Tie

As individuals age, attachment bonds are transferred from primary caregivers to pair bonds; romantic partners who replace the asymmetrical bonds developed between parents and children with symmetrical bonds that are mutual. Several methods have been developed to help determine the quality of these bonds, both parent child and romantic partners (Farnfield and Holmes 2014). The original measurement of mother-child attachment was coined the strange situation which observed the reactions of young children when their mothers left the room and returned and when the children confronted someone unknown. Responses to these events help determine how they deal with the four major dimensions (i.e., proximity maintenance, separation distress, safe haven, and secure base). The most extensive assessment for adults is the adult attachment interview (AAI).

Introduction Bond is an emotional attachment between one or more individuals. To be considered an attachment bond, the relationship must have four defining characteristics: proximity maintenance, separation distress, safe haven, and secure base. Relationships may have some of these characteristics (referred to as affiliative bonds) but to be classified as an attachment bond, all four must be present.

Theoretical Context for Concept Psychologist John Bowlby (1958) was one of the first to formally study the concept of an attachment bond. According to Bowlby, children instinctively form emotional attachments to their caregivers in order to obtain a sense of safety. Other theorists have built upon Bowlby’s original ideas by distinguishing between different attachment styles and by applying attachment bonds to adult and professional relationships (i.e., romantic relationships and therapist-client alliance) (Cassidy and Shaver 2008; Davis et al. 2012). According to these theorists, both children and adults form one of four attachment styles: secure, anxious, avoidant, and disorganized attachment (Bartholomew and Horowitz 1991). Individuals with an anxious or preoccupied attachment become demanding of their partner or caregiver’s time and attention, while individuals with an avoidant attachment seek distance. Those with a disorganized attachment style often feel paralyzed, wanting to be close, and yet fearing rejection. According to Bowlby, as children navigate the world around them, they begin forming internal working models – a cognitive map which associates certain people or scenarios as either being safe or dangerous. These internal working models form the basis of how individuals interact in future relationships (Hazan and Shaver 1987).

Application of Concept in Couple and Family Therapy The term “emotional bond” is a hallmark of emotionally focused therapy where emphasis is placed on healing emotional wounds and on restoring the attachment bond between one or more family members (Johnson 2004). When working with parents and children, therapists work to help parents maintain an active presence where they consistently reinforce that the child is lovable and that the world is safe. When working with romantic partners, Susan Johnson developed the A.R.E model to help partners become more accessible, responsive, and engaged three hallmarks of secure attachment. Other therapy models also work with emotional injuries, and couples and families try to restore trust when these bonds have been damaged. In cases where attachments have been damaged, therapists can often serve as temporary attachment figures; people who help reestablish safety and reinforce the message the client are valuable. Perhaps for this reason, common factor literature emphasizes the importance of the therapeutic alliance and list it as the most instrumental in creating change.

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Clinical Example

Cross-References

Charles and JoAnn came into therapy because of “communication problems.” JoAnn complained that Charles often “shut down” and refused to talk about difficult subjects. JoAnn explained that it felt painful for her when he refused to speak, reporting that the silence reminded her of her father who never showed her enough affection. She recalled that she often tried to get her father’s attention, but that he seemed “too busy” with work or other obligations. Charles explained that growing up, he often felt like he was never “good enough,” that he was often criticized in front of others, and that he never felt safe enough to express his true feelings. Charles explained that he coped with this rejection by emotionally distancing himself from others and “shutting down.” In this scenario, JoAnn began forming an internal working model that others were unavailable and unsafe, a model originally developed through her experiences with her father. Charles, on the other hand, began forming an internal working model that told him it was not safe to express emotions or to look weak, especially in front of others. His way of dealing with these messages was to internalize his feelings and distance himself. Because of these internal working models, both of these individuals have formed insecure attachment styles – Charles leaning toward avoidance and JoAnn toward anxious. Both of these models interfere with their ability to form a secure attachment bond. A therapist working from an emotionally focused stance may serve as a temporary attachment figure and help model availability and safety, thus strengthening the therapist-client bond (Davis et al. 2012). This modeling helps provide each client the strength necessary to take that risk with their partner. Specifically, work with Charles would focus on helping him become vulnerable and vocalizing his need for JoAnn while also working with JoAnn to understand that she is loved by Charles and his attempts to shut down are not a reflection of his love for her but rather a way to protect himself.

▶ Adult Attachment Interview ▶ Attachment-Based Family Therapy ▶ Attachment Disorders in Couple and Family Therapy ▶ Attachment Theory ▶ Circle of Security: “Understanding Attachment in Couples and Families”

References Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four category model. Journal of Personality and Social Psychology, 61, 226–244. Bowlby, J. (1958). The nature of the child’s tie to his mother. International Journal of Psychoanalysis, 39, 350–373. Cassidy, J., & Shaver, P. R. (Eds.). (2008). Handbook of attachment theory: Theory, research, and clinical applications. New York: Guilford Press. Davis, S. D., Lebow, J. L., & Sprenkle, D. H. (2012). Common factors of change in couple therapy. Behavior Therapy, 43(1), 36–48. https://doi.org/10.1016/j. beth.2011.01.009. Farnfield, S., & Holmes, P. (2014). The routledge handbook of attachment: Assessment. London: Routledge. Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52(3), 511–524. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed.). New York: Brunner-Routledge.

Borcsa, Maria Valeria Pomini First Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece

Name Maria Borcsa, PhD, Dipl.-Psych., Professor of Clinical Psychology (b. 1967), University of Applied Sciences Nordhausen, Germany

Borcsa, Maria

Introduction Maria Borcsa is a brilliant representative of the “fourth generation” of systemic couple and family psychotherapists in Europe. By promoting a truly European, trans-national perspective, bridging the Eastern and Western European cultures, the Southern and the Northern, she shows a unique capacity in creating synergies among international organizations and their members. She excelled as President of the European Family Therapy Association (EFTA) from 2013 to 2016. During this time, she increased among other things, the scientific production of the association by founding the Springer EFTA Book Series, of which she is co-editor. Her personal academic activities focus on qualitative research in the field of systemic couple and family therapy, with a special interest in multicultural and transnational couples/families as well as the change in relational life through the usage of digital technologies.

Career Maria Borcsa was born in Romania into a Hungarian family and grew up in Germany; she speaks German, English, French, and Hungarian. She studied Psychology, Philosophy, and Sociology at the Universities of Mainz, Freiburg i. Br. (Germany) and Strasbourg (France). In Freiburg, she concluded her PhD (2001) in a research project on identities/alterities with a dissertation on blind-born persons belonging to three different generations. Subsequently, she continued her academic career at the University of Wales, Bangor, UK. In 2004, she joined Nordhausen University of Applied Sciences, Health Care and Social Studies program, Department of Business and Social Sciences, where she is Professor of Clinical Psychology, acting as Dean of the Department (2008–2013). She is a co-founder and board member of the Institute for Social Medicine, Rehabilitation Sciences and Healthcare Research, and founder of the interdisciplinary course Systemic Counseling (Master of Arts), a cooperation between Nordhausen University and a long-established private institute (IF Weinheim) – the first of its kind in Germany.

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During the 1990s, she completed her training in CBT (University of Freiburg) and in Systemic Individual and Family Therapy with a special focus on multicultural systems as well as a further training in Systemic Supervision and Counselling for Institutions (IF Weinheim). She holds a German state license as Psychological Psychotherapist and a certificate of the European Association of Psychotherapy (EAP). Maria Borcsa’s clinical experience developed mainly at the Outpatient Department for Clinical and Rehabilitation Psychology at Freiburg University. She has been acting as psychotherapist in private practice (both CBT and systemic therapy) and as supervisor in different clinical and training institutions. As a trainer, she is renowned internationally.

Contributions to Profession Professor Borcsa’s work focuses on transcultural aspects in the life of individuals, couples, families, and larger systems, with her special interest in this topic enriched by her personal history and experience. “Globalized families” are transnational families maintaining family ties across different countries and languages, the strengthening of their bonds often facilitated by the use of Information Communication Technologies (ICTs) (Borcsa and Hille 2016). She is particularly interested in the influence of ICTs on family relationships as well as their utilization in couple and family therapy, training, and supervision, touching upon ethical and deontological issues. Professor Borcsa has contributed to the application of qualitative methods to couple and family therapy, bringing research closer to the complexity of clinical practice (Borcsa and Rober 2016; Ochs et al. 2019, in prep). More specifically, she introduced Objective Hermeneutics as an investigating method aiming at identifying – through the microanalysis of therapy transcripts – “latent meaning structures” that people are not aware of in their communication. This method serves to reconstruct the specificity of a single clinical case, while dialectically revealing general social configurations. Through this process, the

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researcher/clinician may help the family/couple towards a second-order change, by altering the rules of their structures in addition to their interactional patterns. The societal domain of human interactions remains one of Maria Borcsa’s main concerns: how couple and family therapists can act systemically at different levels, as therapists-citizens, facing difficult issues like conflicts, migration, and poverty prevalent in our post-modern societies, becoming facilitators of change, and promoting the Aristotelian logos, ethos, and techne within the globalized polis. Professor Borcsa has been an organizer of scientific conferences (e.g., EFTA, Athens 2016; QRMH7 – Qualitative Research in Mental Health, Berlin 2018) and developed an extensive editorial activity that includes being founder and co-editor of the EFTA Book Series (Springer International), associate editor of the Encyclopedia of Couple and Family Therapy (Springer International), co-editor of Psychotherapie im Dialog (Thieme Germany), and co-editor of the Austrian-German Journal Systeme. She serves on the Editorial Boards of Testing, Psychometrics, Methodology in Applied Psychology, Contemporary Family Therapy, and Family Process. Her intense professional participation at both national and European levels includes being a board member (2005–2011) of Systemische Gesellschaft (German Association for Systemic Research, Therapy, Supervision, and Counselling) and a board member of EFTA (2007–2016), as well as Chair of the Chamber of National Family Therapy Organizations (NFTO) of EFTA (2010–2013) and President of EFTA (2013–2016). She is Honorary Member of the Hellenic Systemic Thinking & Family Therapy Association (HESTAFTA).

Cross-References ▶ Conversation and Discourse Analysis in Couple and Family Therapy ▶ Couple and Family Therapy in the Digital Era ▶ European Family Therapy Association ▶ Systeme (Journal)

References Borcsa, M., & Hille, J. (2016). Virtual relations and globalized families – The Genogram 4.0 Interview. In M. Borcsa & P. Stratton (Eds.), Origins and originality in family therapy and systemic practice (pp. 215–234). Cham: Springer. Borcsa, M., & Nikendei, C. (Eds.). (2017). Psychotherapie nach Flucht und Vertreibung. Eine praxisorientierte und interprofessionelle Perspektive auf die Hilfe für Flüchtlinge. Stuttgart: Thieme. Borcsa, M., & Rober, P. (Eds.). (2016). Research perspectives in couple therapy. Discursive qualitative methods. Cham: Springer. Borcsa, M., & Stratton, P. (Eds.). (2016). Origins and originality in family therapy and systemic practice (EFTA book series, Vol. 1). Cham: Springer. Ochs, M., Borcsa, M., & Schweitzer, J. (Eds.). (2019, in prep.). Linking systemic research and practice – innovations in paradigms, strategies and methods (EFTA book series, Vol. 4). Cham: Springer.

Borderline Personality Disorder in Couple and Family Therapy Alan E. Fruzzetti1 and Alexandra King2 1 Department of Psychiatry, McLean Hospital/ Harvard Medical School, Belmont, MA, USA 2 University of Nevada – Reno, Reno, NV, USA

Introduction Borderline personality disorder (BPD) is a pernicious disorder in which the vast majority of people struggle with painful emotions and a consequent lack of self-control related to trying to escape from, or alleviate, those emotions, resulting in nearly 10% lifetime suicide rate and a self-harm rate upward of 80–90%. BPD is characterized by pervasive instability across multiple domains: affect/emotion, social and interpersonal functioning, identity/self-image, cognition/problem solving, and overt behavior control (Gunderson et al. 2018). However, although pervasive emotion dysregulation is at the core of BPD, transactions within the individual’s social and family context are essential for the development, maintenance,

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and remediation of problems related to severe and chronic emotion dysregulation. Emotion dysregulation occurs when a person is unable to accept or change different components of the emotion process and thus experiences enough distress, due to high negative emotional arousal, that it interferes with effective self-management and the person’s ability to organize behavior to support long-term goals (Fruzzetti et al. 2008). This includes lacking the skills needed, or using maladaptive strategies, to regulate emotional responses and/or manage painful emotions (Kring and Sloan 2010; Neacsiu et al. 2013), and most often occurs in a social or family context (Fruzzetti and Iverson 2006). It is easy for parents, partners, and other family members to misunderstand the experiences that people with BPD have, frequently invalidating their family member and often exacerbating his or her emotional distress. In addition, about 10% of all outpatients meet full criteria for BPD (many more have significant BPD features), and parents and partners of people with BPD and related problems frequently struggle with their loved ones’ suicidality and selfharm, as well as their intense emotions. Consequently, both people with BPD and their parents, partners, and family members need help, and couple and family therapy specialized for their needs can be very effective.

Theoretical Framework Severe and pervasive emotion dysregulation is commonly understood to develop in a transaction between an individual’s vulnerabilities and an invalidating family and social environment (Fruzzetti et al. 2005; Grove and Crowell 2017; Linehan 1993). These ongoing transactions have both an internal process and an interpersonal component (see Fig. 1). Internal process: Every emotional reaction begins with an event of some kind (internal, such as a memory or thought, or external, such as the behavior of another person), and this initial emotional reaction is a primary emotion, which is both universal and adaptive (Greenberg and Safron 1989). Those who develop BPD may

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have a variety of temperamental vulnerabilities that affect their emotions, including emotion sensitivity (they discriminate or pick up on emotional cues that others frequently miss) and emotion reactivity (they have strong reactions when their emotions are triggered), and once emotionally activated, that person may take a long time to return to emotional baseline (cf. Linehan 1993). Additional vulnerabilities may be transient, but important, such as not having enough sleep, being hungry, or having physical pain, as well as the person’s current baseline emotional arousal. Then, when an event occurs, high vulnerabilities increase the frequency, intensity, and duration of emotional reactions. In addition, the person may become judgmental (about the event, another person, or him/herself), which also increases emotion intensity. When emotional arousal becomes sufficiently high, it may change into a secondary emotion, either through conditioning or judgmental thought processes. For example, if one partner (Aldus) is late coming home, the other partner (Emelia) might understandably be worried (perhaps something bad happened) and disappointed (she was looking forward to seeing Aldus). However, if she becomes judgmental in her thinking (e.g., “he’s an insensitive jerk”), her emotion can quickly morph into something very different (in this case, anger, as a secondary emotion). Once secondary emotions arise, people have difficulty modulating them and begin to express their emotion inaccurately (e.g., blaming, judging), making it difficult for others to understand. External process: Accurate expression is easy to understand. It is descriptive, expresses understandable primary emotions, connects the relevant event to the person’s primary emotion, and puts relatively fewer demands on the other person. However, when people express secondary emotions, others cannot immediately understand them because secondary emotions are not integrally connected to whatever happened. Consequently, others are likely to invalidate the person’s experience. Of course, in some families invalidating responses are common even when a child or partner expresses himself/herself accurately. Evidence is clear that being validated actually soothes emotional arousal and facilitates

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306 Borderline Personality Disorder in Couple and Family Therapy, Fig. 1 Transactional model for emotion dysregulation

Borderline Personality Disorder in Couple and Family Therapy

Emotion Vulnerabilities

Pervasive History of Invalidating Responses Event Judgments

Heightened Emotional Arousal (leading to emotion dysregulation)

Dysregulated Actions

Inaccurate Expression

Invalidating Responses (From Others & Yourself)

cooperation, while, conversely, being invalidated results in sustained or exacerbated negative emotional arousal and less cooperation (cf. Edlund et al. 2015; Shenk and Fruzzetti 2011). Thus, a pervasively invalidating family and/or social environment makes a very significant contribution to chronic emotion dysregulation, the core of BPD. Although psychotherapy can be effective at helping people with BPD learn to modulate and regulate their emotions, couple and family therapy and family skills have been shown to be an effective adjunctive component for BPD, addressing the two key steps highlighted above: accurate expression and validating responses to replace inaccurate expression and invalidating responses (Fruzzetti and Worrall 2010; Fruzzetti 2006, 2018).

Description Strategies and Interventions Although ongoing transactions between emotionally vulnerable individuals and their invalidating social and family environments may be

responsible for the development and maintenance of BPD, these kinds of transactions are also extremely common in more ordinary distressed couples and families. In fact, most of the problems in communication in conflictual or chaotic families can be understood easily within this framework. Because of this transactional pattern, along with high emotional reactivity, not only can there be colossal misunderstanding and conflict in these families, but in-session behavior can sometimes be difficult to manage. We will break these interventions down into two separate sets: (1) the skills that parents and partners need to learn and (2) specific intervention strategies used in couple or family therapy with BPD. For couples, more details may be found in Fruzzetti (2006) or Fruzzetti and Payne (2015), and for parents and families, more details are provided in Fruzzetti (2018). In all cases, the intermediate goals are to increase both accurate expression and validating responses. Family Skills: There are many skills needed to reduce emotion reactivity, improve communication and problem solving, and bring partners and family members together. Skills include (a) emotion self-management, largely drawn from

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Linehan’s DBT skills (2014), mindfulness and relationship mindfulness skills, to help family members slow their reactivity and be able to focus descriptively on the other person and stay connected to their long-term relationship goals (loving each other, wanting a better relationship, etc.); (b) accurate expression; (c) validation, to communicate the legitimacy of the other’s experience; (d) relationship reactivation, to help reintroduce both nonnegative and pleasant activities, decrease reactivity, and build shared positive experiences; and (e) radical acceptance, to let go of residual and reactive negative emotion related to the past and/or to things that can’t be changed, and either parenting skills or closeness skills, depending on the relationship. Treatment Targets: Because there are frequently high levels of distress and self-harm, and suicidality in this population, it is important that family interventions augment individual treatment when one member of the family is actively suicidal or self-harming. That individual will need more help to become safe and stable than family sessions alone can provide. Thus, safety is always the priority target, and even when the suicidal or self-harming individual has an individual treatment provider, the family sessions will start with a focus on safety whenever these risks are present. For example, sessions can explore the role that parents or partners might play vis-à-vis a recent self-harming or suicidal episode (including increased urges) and/or may seek ways that parents and partners can help the individual stay safe without compromising developmental tasks, generational boundaries, or roles (cf. Fruzzetti 2018 for more details). Other targets include emotion selfmanagement and reducing invalidating responses, relationship reactivation, improved communication (accurate expression and validating responses) and problem management, and enhanced closeness (for couples) or improved relationships overall. Treatment Strategies: Treating very distressed and emotionally dysregulated families can be challenging. These strategies can help reduce in-session escalation and create opportunities for

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successful work: (a) blocking dysfunctional reactions early, even prior to their emergence in the session; (b) liking the patient/family members and communicating this via irreverence, staying nonjudgmental, playfulness, etc.; (c) coaching more skillful behavior whenever possible; (d) balance therapist communication (include both warmth, genuineness and irreverence, humor); and (e) use the “revolving door strategy” to send out one family member while working to help the individual still in the room, allowing a bigger push for change (which might be humiliating in front of the other family members) or bigger validation about the situation (which might be embarrassing for the others).

Clinical Example Sam worked late, didn’t feel well, and was grumpy when he got home. Typically, this would be his time to take over some of the child care for his and Terri’s 6-month-old, who Terri had been caring for all day. Anticipating that, Sam felt exhausted, overwhelmed, and guilty as he came into the house, didn’t make eye contact with Terri, and immediately complained that the kitchen was a mess. Terri was tired, also, and really looked forward to Sam coming home, both to get some relief from childcare and because she felt warm and loving feelings toward Sam. She was really disappointed when he greeted her with a complaint, but quickly spun into self-judgments (“I should have cleaned up the kitchen”) and shame, and then judgments about Sam (“what an asshole. . .I’ve been taking care of everything around here, made a nice dinner, and he doesn’t even appreciate it!) and anger. She quickly yelled at him, told him he was a “selfish jerk” and burst into tears. Sam yelled back for her to leave him alone, and “what is wrong with you?” Imagine that instead of complaining about the kitchen, saying “leave me alone” and criticizing her, Sam had said (accurate expression) “Terri, I’m exhausted and getting sick, and I know you must be exhausted, too. . .but

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would you mind taking care of the baby the rest of the night so that I can go to sleep early?” She would have known what Sam was feeling and wanting and could have told him to go get some rest. This argument was typical for this couple. Treatment included slowing down and hearing each step of the transaction for each of them, in the form of a step-by-step (or chain) analysis. When one or the other became highly reactive in the session, the therapist was typically able to block one from attacking the other. On a couple of occasions, the therapist asked one of them to step out to the waiting area for a few minutes, both to validate and coach the one left in the session in the skills noted above, to help that partner practice managing his/her emotions and communication. Then the therapist did the same with the other partner, and then brought them back together to redo the argument (now a conversation) in real time. New skills take a lot of practice to use effectively, particularly for clients who have been in dysfunctional patterns of interpersonal interactions for long periods of time and are highly reactive. But, as family members become more comfortable expressing themselves accurately and providing validation to others, they can use these skills in more and more situations. Family and other relationships can be as challenging as they are necessary for people with BPD and their loved ones, but effective and respectful solutions are available. Working with this population can be easier as well as enjoyable, with meaningful outcomes.

References Edlund, S. M., Carlsson, M. L., Linton, S. J., Fruzzetti, A. E., & Tillfors, M. (2015). I see you’re in pain: The effects of partner validation on emotions in patients with chronic pain. Scandinavian Journal of Pain. https://doi.org/10.1016/j.sjpain.2014.07.003. Fruzzetti, A. E. (2018). DBT with parents, couples and families to augment stage 1 outcomes. In M. Swales (Ed.), Oxford handbook of dialectical behaviour therapy. London: Oxford University Press. Fruzzetti, A. E., & Iverson, K. M. (2006). Intervening with couples and families to treat emotion dysregulation and

psychopathology. In D. K. Snyder, J. Simpson, & J. Hughes (Eds.), Emotion regulation in couples and families: Pathways to dysfunction and health (pp. 249–267). Washington, DC: American Psychological Association. Fruzzetti, A. E., & Payne, L. G. (2015). Couple therapy and the treatment of borderline personality and related disorders. In A. Gurman, D. Snyder, & J. Lebow (Eds.), Clinical handbook of couple therapy (5th ed., pp. 606–634). New York: Guilford Press. Fruzzetti, A. E., & Payne, L. (in press). Assessment of couples, parents and families in dialectical behavior therapy. Cognitive and Behavioral Practice. Fruzzetti, A. E., & Worrall, J. M. (2010). Accurate expression and validation: A transactional model for understanding individual and relationship distress. In K. Sullivan & J. Davila (Eds.), Support processes in intimate relationships (pp. 121–150). New York: Oxford University Press. Fruzzetti, A. E., Shenk, C., & Hoffman, P. D. (2005). Family interaction and the development of borderline personality disorder: A transactional model. Development and Psychopathology, 17, 1007–1030. Fruzzetti, A. E., Crook, W., Erikson, K., Lee, J., & Worrall, J. M. (2008). Emotion regulation. In W. T. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 174–186). New York: Wiley. Fruzzetti, A. E., Gunderson, J. G., & Hoffman, P. D. (2014). Psychoeducation. In J. M. Oldham, A. Skodal, & D. Bender (Eds.), Textbook of personality disorders (2nd ed., pp. 303–320). Washington, DC: The American Psychiatric Publishing. Fruzzetti, A. E., Payne, L., Hoffman, P. D. (in press). Dialectical behavior therapy with families. In L. A. Dimeff, K. Koerner, & S. Rizvi (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders and settings (2nd ed.). New York. Greenberg, L. S., & Safron, J. D. (1989). Emotion in psychotherapy. American Psychologist, 44, 19–29. Grove, & Crowell, S. (2017). Invalidating environments and the development of borderline personality disorder. In M. Swales (Ed.), Oxford handbook of dialectical behaviour therapy. London: Oxford University Press. Gunderson, J. G., Fruzzetti, A. E., Anruh, B., & ChoiCain, L. (2018). Competing theories of borderline personality disorder. Journal of Personality Disor148–167. https://doi.org/10.1521/ ders, 32, pedi.2018.32.2.148. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (2014). DBT skills training manual. New York: The Guilford Press. Shenk, C., & Fruzzetti, A. E. (2011). The impact of validating and invalidating responses on emotional reactivity. Journal of Social and Clinical Psychology, 30, 163–183.

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Midwest in 1997, the ethnic cleansings of Kosovo in the late 1990s, the September 11th attacks on New York City in 2001, the Malaysian Airlines flight 370 disappearance in 2014, and most recently in Fukushima, Japan, and Tbilisi, Georgia. These efforts have informed and evolved (and continue to evolve) in synchrony with other scholars and practitioners worldwide who are aligning what they do in therapy, community engagement, and research with what Boss set into motion.

Biography

Scholarship and Contributions

Pauline Boss is an internationally recognized scholar, educator, and family therapist. She earned her Ph.D. in Child Development and Family Studies from the University of Wisconsin-Madison in 1975, where she then began her academic career as an assistant professor. After achieving tenure 1981, Boss transitioned to the University of Minnesota’s (UMN) Department of Family Social Science. She is a Fellow in the American Psychological Association (APA) and American Association for Marriage and Family Therapy (AAMFT), former president of the National Council on Family Relations (NCFR), and a clinician in private practice. Since retiring from the UMN in 2005, Boss has continued to actively contribute to the field – as Professor Emeritus – through writing, speaking, and training efforts across both national and international forums. Boss’s principal expertise and professional contributions as a scientist practitioner are centered within the theory of ambiguous loss. This work is based on decades of scholarship and clinical practice with individuals and families who have been traumatized by chronic illnesses and disabilities (e.g., alcoholism, head injuries), humancaused atrocities and suffering (e.g., war, terrorism), and national disasters (e.g., tsunamis, earthquakes). It began with Boss’s early work with wives of missing-in-action (MIA) pilots who served in Vietnam and Southeast Asia in the 1970s and continued with her engagement with providers, community leaders, and survivors during the aftermaths of the Armenia earthquake in 1989, the Red River Valley floods in the upper

In its most general sense, “loss” is an experience that all humans endure from time to time (e.g., launching adult children from the home, mourning a lovedone’s memory after death, going through a painful break-up). According to Boss, ambiguous loss represents a unique type of loss that is arguably more stressful and difficult to cope with. Situated within the context(s) of human relationships, it carries no verification of death and/or certainty that the person we are losing will ever return (physically or psychologically). This ambiguity manifests itself in two primary ways: Type 1 ambiguous loss occurs when there is physical absence and psychological presence of a loved one. Losses like this can range from relatively common experiences like those involving absent parents following a divorce or lost contact between family members during immigration, to catastrophic experiences like kidnapping and missing persons in the contexts of war, terrorist attacks, or natural disasters like tsunamis or earthquakes. Type 2 ambiguous loss occurs when there is physical presence and psychological absence. This loss occurs when loved ones become cognitively or emotionally missing, as they do with injuries resulting in head-trauma and/or illnesses like Alzheimer’s disease, alcoholism, and depression. One of the hallmarks that makes ambiguous loss so difficult to endure is that does not fit well into culturally prescribed scripts for coping and grieving. It defies “resolution” and creates longterm confusion about who is “in” (or not in) a family. For example, how does a family decide

Boss, Pauline Tai Mendenhall University of Minnesota, St. Paul, MN, USA

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that a loved one has died when they do not have proof that she/he has really passed away? How do they memorialize a loved one’s death when they do not have a body to conduct a funeral over, cremate, or bury? How does a family say “goodbye” to a person who is still physically alive and present, but not psychologically “there” anymore as a parent, spouse, or child? Informed by decades of research and clinical work, Boss has begun to answer these questions. She and colleagues have done this by challenging the notion of “closure,” Instead, clinical approaches – best advanced within family- and community-formats (not individual therapy) – walk alongside people in finding meaning in their experiences and pain. These approaches endeavor to temper (or adjust, as culturally- and situationallyappropriate) mastery, reconstruct identity, and normalize ambivalence (versus trying to resolve or “fix” it). In healing and growth, they act to revise interpersonal attachments and discover – and indeed, embrace – new hope. Boss has published her work extensively across both professional (e.g., peer-reviewed journals, clinician-oriented book-chapters and books) and lay (e.g., books for general audiences, fact-sheets, and web-resources) arenas. Several of these are listed below. As of this writing, Boss’s energies in informing, inspiring, and facilitating new generations of scholars to continue advancing the theory of ambiguous loss – and its application(s) – across different loss-types, cultures, and disciplines is nothing short of inspiring. Her legacy, already strongly felt, will continue to grow as our field(s) endeavor to better understand, ease suffering, and foster resilience vis-à-vis some of the most stressful kinds of losses that humans can bear.

References and Suggested Readings Boss, P. (1975). Psychological father absence and presence: A theoretical formulation for an investigation into family systems pathology (Doctoral dissertation). Madison: University of Wisconsin-Madison. Boss, P. (1999/2000). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University Press.

Boszormenyi-Nagy, Ivan Boss, P. (2002). Ambiguous loss: Working with families of the missing. Family Process, 41, 14–17. Boss, P. (2004a). Ambiguous loss research, theory, and practice: Reflections after 9/11. Journal of Marriage & Family, 66(3), 551–566. Boss, P. (2004b). Ambiguous loss. In F. Walsh & M. McGoldrick (Eds.), Living beyond loss: Death in the family (2nd ed., pp. 237–246). New York: Norton. Boss, P. (2006). Loss, trauma, and resilience: Therapeutic work with ambiguous loss. New York: Norton. Boss, P. (2007). Ambiguous loss theory: Challenges for scholars and practitioners [Special Issue.]. Family Relations, 56(2), 105–111. Boss, P. (2010). The trauma and complicated grief of ambiguous loss. Pastoral Psychology, 59(2), 137–145. Boss, P. (2011). Loving someone who has dementia: How to find hope while coping with stress and grief. San Francisco: Jossey-Bass. Boss, P. (2015). Coping with the suffering of ambiguous loss. In R. E. Anderson (Ed.), World suffering and the quality of life (pp. 125–134). New York: Springer. Boss, P. (2016a). Ambiguous loss. Retrieved from http:// www.ambiguousloss.com/ Boss, P. (2016b). The context and process of theory development: The story of ambiguous loss. Journal of Family Theory & Review, 8, 269–286. Boss, P., & Carnes, D. (2012). The myth of closure. Family Process, 51(4), 456–460. Boss, P., Doherty, W., LaRossa, R., Schumm, W., & Steinmetz, S. (Eds.). (1993/2009). Sourcebook of family theories and methods: A contextual approach. New York: Plenum. Boss, P., Beaulieu, L., Wieling, E., Turner, W., & LaCruz, S. (2003). Healing loss, ambiguity, and trauma: A community-based intervention with families of union workers missing after the 9/11 attack in New York City. Journal of Marital & Family Therapy, 29(4), 455–467. Boss, P., Bryant, C. M., & Mancini, J. (2016). Family stress management: A contextual approach (3rd ed.). Thousand Oaks: Sage.

Boszormenyi-Nagy, Ivan Grace E. Hazeltine and Molly F. Gasbarrini California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Name of the Person Ivan Boszormenyi-Nagy

Boszormenyi-Nagy, Ivan

Short Introduction Ivan Boszormenyi-Nagy, born in 1920, was a Hungarian American psychiatrist and family therapist who made significant contributions to the field of marriage and family therapy, most notably by pioneering the development and practice of contextual therapy (also known as contextual family therapy) in the 1970s. Through an extensive career as both a scholar and educator, Boszormenyi-Nagy directly and indirectly influenced marriage and family therapists until his death in 2007, and his approach continues to inspire new generations of therapists in the United States and internationally.

Career Boszormenyi-Nagy was born in Budapest, Hungary, where he began his career as a psychiatrist after graduating medical school from the Budapest’s Peter Pazmany University in 1944. During his psychiatric training, BoszormenyiNagy also studied biochemistry and physics. He left Hungary in 1948 and, while a political refugee in Austria, he worked as a physician for the International Refugee Organization. Following this, he migrated to the United States, arriving in Chicago in 1950. After 6 years conducting biochemical research, he returned to clinical work and obtained a U.S. Board Certification in Psychiatry in 1956. In 1957, he accepted a position as the director of a research unit on schizophrenia at the Eastern Pennsylvania Psychiatric Institute (EPPI) in Philadelphia where he worked until the closing of the Institute in 1980. While working at EPPI, Boszormenyi-Nagy taught at several universities throughout the Philadelphia area, including a primary appointment at Hahnemann University, now Drexel University, where he founded a Master of Family Therapy Program in 1978 and from which he retired as Emeritus Professor of Psychiatry in 1999. Also in 1978, he founded The Institute for Contextual Growth, which has served as a private training program for many local and international family therapists. During all his professional life, he simultaneously maintained a private practice of couple and family therapy.

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Boszormenyi-Nagy also became a founding member of two important organizations devoted to the practice of family therapy, the Family Institute of Philadelphia, one of the earliest private training facilities for family therapy in the United States and the American Family Therapy Association, currently known as the American Family Therapy Academy. Throughout his career he won numerous awards including the Hungarian Republic Gold Medal and an honorary doctoral degree in medicine from the University of Bern, Switzerland. He served as a psychiatric research director, educator, and clinical supervisor to developing marriage and family therapists in the United States and internationally; and published 4 books and over 80 papers, some of them translated into many languages.

Contributions to the Profession Upon migrating to the United States as a psychiatrist, Boszormenyi-Nagy began a career in Chicago in 1950 as a biochemical researcher with the goal of identifying biological markers of schizophrenia, which he considered a first step in finding a cure for this disorder. He later left this field to focus on trying to define what constitutes effective therapy and very soon he and his team started to include family members in the treatment for clients suffering from schizophrenia who were hospitalized on his research unit at EPPI. During this period, Boszormenyi-Nagy became one of the pioneers of family therapy, organizing some of the earliest family therapy conferences, and later developing contextual therapy. He later renamed his research unit the Department of Family Psychiatry. His department offered training in family therapy to many professionals in the Philadelphia area and also inspired many early European family therapists. Key among his contributions to the practice and understanding of clinical psychologist is the identified importance of fairness and loyalty in close relationships. His book Invisible Loyalties, coauthored with Geraldine Spark, has influenced generation of therapists throughout the world.

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Cross-References ▶ Contextual Family Therapy ▶ Framo, James ▶ Intergenerational Couple and Family Therapy ▶ Invisible Loyalties in Families ▶ Ledgers in Couple and Family Therapy

Boundaries in Structural Family Therapy

“to protect the differentiation of the system. Every family subsystem has specific functions and makes specific demands on its members, and the development of interpersonal skills achieved in these subsystems is predicated on the subsystems freedom from interferences by other subsystems” (Ibid., pp. 53–54). Boundary permeability will therefore affect family functioning.

References Description Boszormenyi-Nagy, I. (2014). Foundations of contextual therapy: Collected papers of Ivan Boszormenyi-Nagy, M. D. New York: Routledge. (Original work published 1987). Boszormenyi-Nagy, I., & Framo, J. L. (1985). Intensive family therapy: Theoretical and practical aspects. New York: Brunner/Mazel. (Original work published 1965). Boszormenyi-Nagy, I., & Krasner, B. R. (2014). Between give and take: A clinical guide to contextual therapy. New York: Routledge. (Original work published 1986). Boszormenyi-Nagy, I., & Spark, G. M. (2013). Invisible loyalties: Reciprocity in intergenerational family therapy. New York: Routledge. (Original work published 1984).

Boundaries in Structural Family Therapy Richard Holm Minuchin Center for the Family, Woodbury, NJ, USA

Introduction “Boundary Definition” according to Davidson (1983) was one of the most important concepts of General Systems Theory. It provided an inclusive contextual view that was expansive enough to include the significant factors relevant for understanding a particular organism or entity (p. 33). Minuchin (1974) viewed the family and its subsystems as circumscribed by boundaries.

Theoretical Context for Concept Boundaries are the “rules defining who participates and how.” (Ibid., p. 53). Their function is

First described boundaries in the family as enmeshed or disengaged. Later (1974) he applied these terms to two extremes of boundary functioning and stated that “all families can be conceived of as falling somewhere along a continuum whose poles are two extremes of diffuse and rigid boundaries (Ibid., p. 54). Diffuse boundaries between subsystems leads to a heightened “sense of belonging,” (Ibid., p. 55) and family members will respond immediately to any departure from expectations. On the other hand, rigid boundaries and disengagement between subsystems results in a lack of a sense of cohesion and a “tolerance for a wide range of variation in its members” (Ibid., p. 55).

Application of Concept in Couple and Family Therapy Boundary assessment is critically important for understanding the interaction between the family system and larger systems, the interaction among subsystems within the family system, including the couple system, and finally, in the understanding of the therapist as part of the system. Diffuse external boundaries of the family can invite or allow enmeshed entanglements with outside helping systems resulting in a dilution of internal decision-making and boundary definition processes (Minuchin 1984; Colapinto 1995; Minuchin et al. 2007). On the other hand, families may view the outside world as a threat and develop rigid external boundaries as protection against external intrusion.

Boundaries in Structural Family Therapy

Diffuse boundaries between subsystems within the family may be evidenced by over involvement between a parent(s) and a child or children resulting in an inappropriate intrusion into one another’s world (Minuchin et al. 1967, 1978, 2007; Minuchin 1974; Minuchin and Fishman 1981; Minuchin 1984). A rigid boundary contributing to disengagement between the parental subsystem and the child subsystem occasions a neglect of the needs of the children in terms of guidance and nurturance (Colapinto 1995). More recently boundary assessment has been applied to work with couples, utilizing the concepts of Structural Family Therapy that, in the past focused on the couple as a member of the parental subsystem, Simon (2015) directed attention to the couple system itself and the permeability and flexibility of its external and internal boundaries for proper functioning. Directing attention to the therapist as a part of the system, (Minuchin et al. 1996; 1998, 2014) notes that the nature of the boundary between the therapist and the family needs to remain permeable in order for the therapist to effectively position him/herself from a close, median/middle, or disengaged/distant position depending on the intervention need.

Clinical Example A brief clinical example of diffuse boundaries, characterized by hyper-vigilance, is exhibited in the following dialog between parents and their adolescent daughter: Mother: I am not home to watch you! Daughter: Well, that’s what it feels like. Father: You must have a guilty conscience or something. Daughter: No! You do watch me. Your room is right across from mine. I can’t go up, I can’t go down, I can’t go anyplace. Mother: You have to realize you’re only fifteen. You can’t have everything your own way. You have to be guided and supervised by your parents. Daughter: I have nothing my own way! Minuchin (1978, pp. 65). When the child is apart from the family, this occurs:

313 Mother: When you went to Jean’s party, her mother told me what you ate. She told me you ate a fruit cup. Daughter: What did you do, check up on me? Father: Yes. (ibid., p. 65)

In summary, the rules within the system that govern who belongs and how is significant for clinical work as Minchin states, “A therapist often functions as a boundary marker, clarifying diffuse boundaries and opening inappropriate rigid boundaries. His assessment of family subsystems and boundary functioning provides a rapid diagnostic picture of the family which orients his therapeutic intervention” (Minuchin 1974, p. 56).

References Colapinto, J. (1995). Dilution of family process in social services: Implications for treatment of neglectful families. Family Process, 34, 59–74. Davidson, M. (1983). Uncommon sense: The life and thought of Ludwig von Bertalannffy (1901–1972), father of general systems theory. Los Angeles: J. P. Tarcher, Inc. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Minuchin, S. (1984). Family kaleidoscope. Cambridge, MA: Harvard University Press. Minuchin, S., Montalvo, B., Guerney, B. L., & Schumer, F. (1967). Families of the slums. New York: Basic. Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press. Minuchin, S., Simon, G. M., & Lee, W. Y. (1996; 2006, 2nd ed.). Mastering family therapy: Journeys of Growth and Transformation. New York: Wiley. Minuchin, P., Colapinto, J., & Minuchin, S. (1998; 2007, 2nd ed.). Working with families of the poor. New York: Guildford. Minuchin, S., Nichols, M. P., & Lee, W. Y. (2007). Assessing families and couples: From symptom to system. Boston: Allyn and Bacon. Minuchin, S., Reiter, M., & Borda, C. (2014). The craft of family therapy: Challenging certainties. New York: Routledge. Simon, G. M. (2015). Structural couple therapy. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (5th ed., pp. 358–384). New York: Guilford Press.

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Boundary Making in Couple and Family Therapy Lisa Scott, Alexander Julian and Chunyue Tu Brigham Young University, Provo, UT, USA

Name of the Strategy or Intervention Boundary Making in Couple and Family Therapy

Introduction Boundaries are an inherent part of all families and couples. Boundaries determine which roles individuals and family subsystems (e.g., children or parents) play, expectations of each party, and responsibilities of family members. Boundaries can be classified as diffuse, clear, or rigid. For practitioners adhering to a systems theory approach, the goal in therapy is to help clients form clear boundaries that are not too diffuse or too rigid. The more a family or a couple strays from having clear boundaries, the more likely they are to experience dysfunction (Wetchler and Hecker 2015).

Boundary Making in Couple and Family Therapy

such cases, a therapeutic reconstruction of boundaries may be necessary (Minuchin 1985; Minuchin et al. 2014).

Rationale for the Strategy or Intervention Within systems theory, family systems cannot function well if there are not clear boundaries (Minuhcin 1974). Furthermore, in order for boundaries to be effective, they should be adequately permeable. If boundaries are too permeable, the individuals within the system might accept dangerous environmental influences, but if the boundaries are too impermeable, individuals may shut out potentially beneficial influences (Wetchler and Hecker 2015). For example, Minuchin (1974) highlighted the importance of a clear but permeable boundary between the marital and child subsystems. He explained that the boundary between parents and children should be permeable enough that a child feels supported, but clear enough that the child does not take on parental roles (p. 57).

Description of the Strategy or Intervention Theoretical Framework According to Minuchin (1974), boundary making is the “basic principle” in systems theory and therefore crucial in the formation of healthy family systems. Within a family system, each subsystem (e.g., the marital subsystem or the child subsystem) has set boundaries that create separation from other subsystems (Minuchin 1985). The rules and patterns of interaction within and between subsystems are created and maintained by all members of the family (Minuchin and Fishman 1981). It is believed that the family members’ roles are expected to evolve across time for developmental and environmental reasons. Some families have issues with boundary maintenance and change, and in

The therapist facilitates boundary making by aiding the family in clarifying which interactions are open to certain family members but closed to others. Through this process, detouring mechanisms and avoidance patterns are corrected and the development of communication skills is encouraged (Colapinto 1991). During family and individual therapy, family members can be encouraged to find a balance between rigid and diffuse boundaries in order to create clear and healthy boundaries (Wetchler and Hecker 2015). Diffuse boundaries describe cases where two individuals or subsystems do not have clearly established roles. For example, a situation in which one of the children has taken on parental responsibilities (or who has become

Boundary Making in Couple and Family Therapy

parentified) is likely to occur in a family system that has diffuse boundaries between parental and child subsystems. Conversely, a family or couple with rigid boundaries is one in which subsystems or individuals are considered to be too confined, where roles are strictly adhered to, and in which not much interaction or collaboration is allowed. An example of this could be found in a family where the parents rarely speak with the children and hold the belief that “Children are to be seen and not heard” (Wetchler and Hecker 2015).

Case Example Our case example will cover part of a session conducted with a three-person family consisting of a mother (Usha), father (Robert), and adolescent child (Megan). Megan has been exhibiting excessively aggressive behavior and the family has sought therapy as a result. Therapist: Usha:

Therapist:

Robert:

Therapist:

And do each of you take the time to do what you want? Ha! I can’t remember the last time I did anything for myself, perhaps last year when I went out to lunch with my sister. Why don’t you have time to spend on yourself? Surely Megan is old enough that she doesn’t need constant supervision. You would think so, but Usha spends so much time either trying to prevent Megan from getting into trouble or arguing with her that she really doesn’t have time for herself to ever just unwind. Robert, this may be an opportunity for you to support Usha in creating her own “space” for herself within your family’s dynamic. Maybe you can offer to work with Megan at times when Usha is feeling that she needs some personal time?

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Cross-References ▶ Attachment Disorders in Couple and Family Therapy ▶ Attachment Theory ▶ Attachment-Based Family Therapy ▶ Autonomy in Families ▶ Bonds in Couple and Family Therapy ▶ Boundaries in Structural Family Therapy ▶ Closed Systems in Family Systems Theory ▶ Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy ▶ Differentiation of Self in Bowen Family Systems Theory ▶ Enmeshment in Couples and Families ▶ Fusion in Family Systems Theory ▶ Individuation in Family ▶ “I-Thou” in Couple and Family Therapy ▶ Marital Fusion in Couples ▶ Minuchin, Salvador ▶ Open Systems in Family Systems Theory ▶ Parent-Child Interaction Family Therapy ▶ Parentified Child in Family Systems ▶ Restructuring the Bond in Emotion-Focused Therapy ▶ Roles in Couples and Families ▶ Separation-Individuation in Families ▶ System in Family Systems Theory ▶ Systems Theory ▶ Undifferentiated Family Ego Mass in Bowen Therapy

References Colapinto, J. (1991). Structural family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (Vol. 2, pp. 417–443). New York: Routledge. Minuchin, S. (1974). Families & family therapy. Oxford: Harvard University Press. Minuchin, P. (1985). Families and individual development: Provocations from the field of family therapy. Child Development, 56(2), 289–302. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press.

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316 Minuchin, S., Reiter, M. D., & Borda, C. (2014). The craft of family therapy: Challenging certainties. New York: Routledge. Wetchler, J. L., & Hecker, L. L. (Eds.). (2015). An introduction to marriage and family therapy (2nd ed.). New York: Routledge.

Bowen Center for the Study of the Family, The Robert J. Noone Center for Family Consultation, Evanston, IL, USA

Introduction The Georgetown University Family Center was founded in 1975 by Murray Bowen, MD, who, at the time, was a clinical professor in psychiatry and director of Family Programs at the Georgetown University School of Medicine in Washington, DC. Dr. Bowen had moved to Georgetown following his landmark 5-year study of the family at NIMH (1954–1959). Based on this research and further studies, he developed a formal systems theory of the family, which was published in 1966 (Bowen 1978). Initially, he taught psychiatric residents and medical students. A group of graduating residents who participated began the Symposium on Family Theory and Family Psychotherapy in 1965, which has continued to the present day. When a growing number of mental health professionals showed interest in learning more about his theory of family systems, he began a postgraduate training program in 1969. When Dr. Bowen was awarded a grant from NIMH for fellowships in family psychiatry, he founded the Georgetown University Family Center in 1975, which then moved off campus. He remained the director of the Family Center until his death in 1990. An additional postgraduate program was initiated in 1975 for mental health professionals who lived at a distance from Washington. In this program, the trainees met for three days, four times a year. A sliding fee scale family clinic was also added in 1975.

Bowen Center for the Study of the Family, The

Murray Bowen added new faculty and expanded training opportunities. Interest in the training programs by mental health professionals, clergy, organizational, and financial professionals, and other disciplines grew. As out of town trainees returned home, they established a network of centers across the country that sponsored conferences and their own educational programs. Interns and clinical fellows in family therapy and biofeedback staffed the sliding fee scale clinic at the Bowen Center. Research seminars were added for those who had participated for several years in the postgraduate programs. Central to Bowen’s research and the development of his theory was a belief that it was possible one day for a science of human behavior to be developed. The observation that the family functioned as a unit provided a foundation to move in that direction. It provided a step toward a less subjective view of human behavior. Given the prominence of subjectivity in the effort to study human behavior and the strong tendency for a theory to become a belief system, as occurred with Freud’s psychoanalytic theory, Bowen thought it vital that the theory be in contact with the natural sciences. Toward that end, he decided to invite natural scientists to be the principal guest speakers at the annual Georgetown Family Symposium beginning in 1975. Prior to that year, he had invited prominent individuals in the field of family therapy to be the principal guest speakers. A Theory Meeting that Dr. Bowen began in 1963 at Georgetown continues to provide an opportunity for individuals experienced in Bowen Theory to present their work and research on a twice-a-month basis. Another continuing program is the monthly Clinical Conference. The Clinical Conferences began at the Medical College of Virginia, where Bowen conducted a series of videotaped clinical interviews with families to demonstrate the application of his theory in a clinical setting. The meetings were moved to the Georgetown University Medical Center in 1978 and became a formal monthly teaching conference by Dr. Bowen and later by other faculty. These sessions were observed by a professional audience and then discussed with the families present. The videotaped sessions

Bowen Center for the Study of the Family, The

represent the world’s largest collection of recorded family therapy sessions and are currently housed at the National Library of Medicine in Washington, DC. The monthly Clinical Conferences have continued to the present. Each month, a different faculty member is responsible for the program and selects a topic of his or her own professional interest. The format of the day includes a lecture on a particular theme followed by videotaped clinical sessions that illustrate the topic. The long, continuous history and the format of videotaping families who are invited to the clinical day make this conference unique in the world of family theory and family psychotherapy. The Bowen Center also hosts Annual Spring Conferences. These conferences each focus on a single concept related to Bowen Theory. Guest scientists, researchers, and leaders in the study of family systems offer presentations related to the central focus of this two-day conference. Each year at the conference, the Caskie Research Award is given to support an important research effort in Bowen Theory. All programs have continued to the present day (go to www.thebowencenter.org for more details on the Center’s programs). The Bowen Center also offers a clinical internship for professionals with graduate degrees in mental health disciplines and at least 1 year in the Postgraduate Training Program at the Bowen Center. The intern receives referrals from the clinic, ongoing supervision from a faculty member, and continued Bowen Center Postgraduate Program training. Dr. Bowen wrote extensively about the development of his ideas. Family Therapy in Clinical Practice, a compilation of his papers, was published in 1978, permitting a wider exposure and more in depth understanding of the theory. In 1988, Family Evaluation by Dr. Michael Kerr, with an Epilogue by Bowen, was published, and segments were featured in The Atlantic Monthly. Dr. Daniel Papero, faculty at the Georgetown Family Center, published Bowen Family Systems Theory. In 1994, the first issue of Family Systems: A Journal of Natural Systems Thinking in Psychiatry and the

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Sciences, a peer-reviewed journal of articles related to Bowen Theory and the natural sciences, was published and continues to the present. In 2013, Dr. John Butler edited The Origins of Family Psychotherapy, a compilation of Dr. Bowen’s papers written during the NIMH study, many of which had not been previously published. And in 2015, The Family Emotional System: An Integrative Concept for Theory, Science, and Practice, which highlighted the ongoing interchange occurring between natural scientists and Bowen theorists, was edited by Robert Noone and Daniel Papero. Roberta Gilbert has written several books on Bowen Theory, and Peter Titelman has edited several books (e.g., Titelman 2014) on a variety of topics related to the theory and its application. In 1990, The Georgetown Family Center left Georgetown University and became incorporated as a nonprofit organization in the District of Columbia, receiving a 501(c)(3) tax-exempt status. When Dr. Bowen died that year, Michael Kerr, MD, became the next director. Later the Center purchased a condominium suite at 4400 MacArthur Boulevard in Washington, giving the Family Center a permanent address for the first time. Dr. Kerr added new faculty who took on responsibilities such as hosting the clinical conferences, supervising, training, organizing conferences, and speaking at network centers around the country. A videotaped series of interviews, Family Matters, with Bowen Center faculty and others discussing Bowen Theory, was begun and produced by the University of the District of Columbia. An advisory board was appointed and assisted the Center in launching its website and recommending the name change to the Bowen Center for the Study of the Family to recognize Dr. Bowen as its founder. In 2011, Dr. Kerr retired and Dr. Anne McKnight was selected to be the next director of the Bowen Center. The mission of the Center is to lead the continued development of Bowen Family Systems Theory toward a science of human behavior and to assist individuals, families, communities, and organizations in addressing major life challenges through understanding and improving human

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relationships. The Center carries out its mission locally, nationally, and internationally through training and online programs, conferences, research, clinical services, website, and publications. In 2016, Bowen’s book was translated into Spanish and an online program in Spanish was added. The Bowen Center seeks to fulfill this mission by: – Maintaining and developing practices of scientific inquiry through collaboration and interaction with scientists and active participation in scholarly pursuits – Contributing to the development of Bowen Theory in the effort to move toward a science of human behavior through promoting research and writing, fostering thoughtful interchange among Bowen theorists, and maintaining viable contact with the natural sciences – Contributing to the development of leadership of Bowen theorists locally, nationally, and internationally through training and collaboration – Presenting Bowen Theory and its applications as a resource to address major life challenges for individuals, families, organizations, and communities – Financially sustaining and enhancing the Bowen Center and its mission – Engaging with the communities in the Washington/Baltimore area through education and service Bowen Family Systems Theory consists of eight interrelated concepts and was developed as a natural systems theory of human behavior. A new form of psychotherapy, based on the theory, was developed by Bowen, which is applicable for individuals, couples, and families. The family is seen as the client regardless of the number of individuals involved in the therapy sessions. The application of the theory has extended beyond therapy to include organizations, congregations, and societal process.

Bowen Family Systems Therapy with Couples

References Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry, 7, 345–374. Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. New York/London: W.W. Norton. Noone, R. J., & Papero, D. V. (Eds.). (2015). The family emotional system: An integrative concept for theory, science, and practice. Lanham: Lexington Books. Papero, D. V. (1990). Bowen family systems theory. Boston: Allyn and Bacon. Titelman, P. (2014). Differentiation of self: Bowen family systems perspectives. New York: Routledge.

Bowen Family Systems Therapy with Couples Susan Regas1 and Ronda Doonan2 1 California School of Professional Psychology, Los Angeles, CA, USA 2 Community Memorial Health Systems, Ventura, CA, USA

Bowen Couple Therapy is more about the nature of being human than about couples or couple therapy. Murray Bowen conceptualized the couple and the family as an emotional unit and the family members were part of that unit and not just autonomous psychological individuals. Furthermore, there is the assumption that each family member is a product of evolution and that their behavior is regulated by the same processes that regulate behavior in all living systems. He based his theory on observable facts rather than on subjective experiences and feelings. Bowen proposed that any change in the emotional functioning of each family member affects everyone in the system. The emotional functioning of every person impacts the occurrence of health problems or psychological issues in every other member. Feelings move from individual to individual by means of predictable and patterned emotional reactions such as distance, conflict, over functioning, underfunctioning, or triangling.

Bowen Family Systems Therapy with Couples

Bowen did not limit his focus to the couple. Past and present forces mold what makes one partner distance from the relationship and another partner neglect their own personal development and focus on the relationship. This circular or multiple causality thinking replaced cause and effect thinking. According to Bowen, there was not any one person or relationship that caused the couple’s relationship problem. The person or relationships were the receptors, medium, and contributors of larger multigenerational processes. Bowen considered the three-generational emotional process the best way to understand the couples’ presenting problem. Because the system has significant impact on a person’s behavior and emotions, one must see the big picture and assess this context to understand what is going on with the couple. The clinician then helps each partner become aware of how their issues are connected to the multigenerational processes and family dynamics. It is important to see how one couple’s problem fits within the broader fabric of the family systems rather than trying to identify and focus on the individual with the problem. When partners can see and understand the system and at the same time work on self, this can produce a powerful impact on the couple and individual.

Case Conceptualization There are four concepts in Bowen theory along with anxiety that play important roles when working with couples: differentiation, triangles, nuclear family emotional process, and emotional cutoff.

Level of Differentiation and Chronic Anxiety Bowen couple therapy rests on the concept of differentiation of self. Differentiation is the ability to define a self in the context of close relationships. It includes the ability to adapt to life, to cope with life challenges, and reach one’s goals. Differentiation is often referred to as emotional maturity. It is the instinctual force that is

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embedded in all living systems. In fact, it is the natural growth process that moves partners toward individuality. The most fundamental feature of being human is the struggle to balance two basic instinctual forces: the need to be an individual and the need to be connected to others. Differentiation is the ability to balance these two forces which is a lifelong journey. No one is ever fully differentiated. Differentiation is conceptualized on a continuum and is determined by the amount of chronic anxiety in the relationship, the intensity of internal and external life stressors, and the individual’s ability to handle these influences. Therefore, individuals are viewed as more or less differentiated. The instinctual individuality and togetherness forces often exist outside our awareness. They are driven by acute and chronic anxiety. Acute anxiety is the response to real or imagined threat whereas chronic anxiety is an ongoing state of tension after that threat has abated. Anxiety strengthens the togetherness force and diminishes the individuality force in close relationships. The level of differentiation establishes the threshold for the tolerance for anxiety. Below the threshold, a partner can maintain awareness of thinking and feeling and can employ cognitive skills to regulate self and guide behavior. Once the tolerance for anxiety threshold is crossed over, the partner loses the ability to self-regulate, becomes increasingly reactive, and behaves instinctively and automatically. Partners want a deep connection with others, attachment, and benefit from the relationship and, over time, long to be free, to be the captains of their own ships, and to direct their own lives. With less differentiation, partners place greater value on the relationship and fear the discomfort of being alone. They will sacrifice individuality and autonomy to preserve the connection. Compared to more differentiated couples, they depend on the relationship for their stability and sense of wellbeing. Poorly differentiated people are overwhelmed by anxiety. This anxiety gets triggered around issues such as money, parenting, sex and in-laws. The intensity of feelings makes it very

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difficult to think clearly and as a result partners respond with emotionally based actions. As people become more anxious, they pursue contact with important others and become less responsible for oneself in the attempt to fit with others. Immaturity is revealed in partner’s difficulty in establishing and following through on their own goals, insisting that others do things or make decisions for them, requiring partners to soothe their anxiety and boost their self-worth. That dependence becomes evident when partners are expected to be available to them in exactly the way one expects or there is a significant reactivity to perceived mistakes or failings on the part of the partner. In contrast, immaturity can also be reflected in the inability to set limits with others and in the need to take care of others who are capable of taking care of themselves. Less differentiated people depend heavily upon relationships with others to provide direction, soothing, and well-being. Although better differentiated people are subjected to the togetherness pressure, they are able to separate their own thinking from the opinions of other important people. At higher level of differentiation, people are less fused in their close relationships. They are able to accept those close to them thinking, feeling, or behaving different from themselves and yet maintain a connection. More mature partners have well-defined boundaries. A well-developed inner guidance system with thought-out beliefs and values guide them. These values and opinions are not inflexible but the differentiated individual knows what they believe and why. Since they are able to preserve intellectual functioning, they are able to make decision from a place of strength versus a fear of losing the relationship. With an inner guidance system, mature partners care less about what others think of them. Time is not devoted to seeking acceptance. This mitigates the relationship of having the pressure of being responsible for the others’ self-worth and anxiety regulation. In order to have a successful relationship, people need to work at a high level of differentiation.

Bowen Family Systems Therapy with Couples

Differentiation creates a clarity that allows individual and families to reduce the reactivity and anxiety associated with survival in natural systems. Differentiation allows couples to make conscious choices about how to respond. Differentiation of self affects the relationships people form. Couples are attracted to each other because they are at the same basic emotional level of differentiation. An individual with a low level of differentiation needs a partner who is seeking the same level of emotional fusion, one who will sacrifice their own self for the sake of the relationship. Individuals with higher levels of differentiation are not interested in participating in a relationship that would require the loss of self. Consequently, people choose partners at the same level of differentiation as themselves.

Nuclear Family Emotional Systems When there is undifferentiation, the couple’s functioning is more or less chaotic. Emotional and instinctual forces tend to govern people and relationships. Thoughtful communication and problem-solving appear only fleetingly when the anxiety in the system is low and things are calm and disappear into reactivity-driven confusion as anxiety increases. Most adults have unresolved issues with their parents and bring those unresolved issues into their committed relationship. These unresolved cross-generational issues lead to physical, psychological, or social problems in the couple. They also lead to patterns of behavior. Bowen describes patterns that partners use to manage the intensity of the psychological and emotional system oneness. These patterns occur along a continuum. The most intense and dysfunctional patterns exist at the lowest end of the continuum of differentiation. As tension increases, one typical pattern that partners may engage in is conflict, a process that ranges from simple squabbling to domestic violence. Secondly, the couple may also distance from one another. This distance can range from silence to excessive activities like reading or computer use to actual avoidance of one another.

Bowen Family Systems Therapy with Couples

Often conflict and distance occur alternately in the same relationship. A third pattern is over functioning–underfunctioning. In this pattern, one of the partners appears to give up responsibility for oneself to the other. Either partner can take the lead in the process as anxiety and tension mount. The overfunctioning partner can act more convincingly and inflexibly and the other yields to that pressure rather than oppose it. Or the underfunctioning partner can appear increasingly powerless and dependent, requesting that the other take charge. As is the case with the patterns of conflict and distance, this pattern becomes more and less pronounced with increasing and decreasing anxiety. These patterns can be found in all couples varying with the intensity of the fusion and anxiety at play. Bowen noted that most families use a combination of them. As a result, these observable patterns of behavior can shift, reducing the likelihood that any one becomes disabling. The intensity of the process in any nuclear family appears to be governed by the degree of undifferentiating or immaturity, the degree of emotional contact or cut off with the extended families of the partners, and the degree of stress and anxiety in the system.

Emotional Triangles Bowen identified emotional triangles as one of the most important dynamics to assess because they are the basic building blocks of families. It is the smallest viable relationship unit and he saw them as inherently unstable over time as a result of conflict, overly involved connection, or increase in anxiety. The human dyad is so unstable that when two people who are important to each other develop problems, which they invariably do, they automatically look around for a third person, activity, or topic to include into the anxious situation in some way. This alleviates tension in the dyad and rebalances the dyad emotionally. The emotional triangle occurs automatically with increasing or decreasing anxiety along the differentiation continuum. At the lowest end of the continuum, they have the most difficult time

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maintaining a one-to-one relationship and rapidly bring in a third person when conflict or distance occurs in the relationship. In the short term, the triangulation relieves the pressure on the relationship by spreading the anxiety among three people instead of two. Triangulation is a quick-fix solution that only circumvents the anxiety rather than solving a problem. Once the anxiety in the dyad has been reduced to a tolerable level, the entity who is triangulated may be easily villainized or cut off. Some triangles may be difficult for a couple to identify as they may have begun their relationship as a triangle. For example, the relationship that begins as an affair for one or both partners or a relationship founded in a significant other relationship (e.g., best friend’s sibling). Triangulation is a fundamental process in natural systems. Everyone triangulates to some degree. However, when this becomes the primary means for dealing with dyadic tension, the partners of the dyad never actually resolve the tension themselves, and pathological patterns emerge.

Emotional Cutoff Emotional cutoff is a way of distancing from the togetherness in the family of origin. It varies in intensity along the continuum of differentiation and reflects the unresolved issues with the family of origin. Families with high levels of differentiation are able to grow up, leave home, choose their own life partners, form their own families where they are self-supporting individuals while at the same time staying connected to their family of origin. Families with low levels of differentiation have children who feel hampered in moving toward independent adulthood. Depending on the intensity between the generations, they may be dependently connected to the family or cut off with minimal connection. In committed relationships where there has been cut off from other generations, anxiety will usually increase and there are more social, physical, or psychological symptoms in the couple. A pattern or cycle of cutoff/fusion may be observed over the life cycle of a relationship or within families as a way of managing intense anxiety.

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Differentiated individuals are more able to stand on their own and are less enmeshed in the family emotional system. When one does not have emotional dependence, that does not mean there is distance. Just the opposite, if there is less emotional dependence, there is more space for openness and true intimacy in the emotional system.

Two-Person System Bowen theory views relationship difficulties as emerging from a mixture of level of differentiation plus intensity of anxiety in the relationship field. Each person brings reactivity from their own family system and exposes them as anxiety increases in the current relationship. Over time, the love relationship develops its own reactive patterns based on past and present experience. Each partner struggles to be a self and a partner at the same time. The difficulties develop when the effort to be autonomous conflicts either with one’s own or one’s partner’s desires for connection. Under these conditions anxiety increases and problems occur. Bowen believed that people who married or formed long-term intimate relationship selected as partners those who had about the same level of differentiation as themselves. Bowen hypothesized that partners meet and develop relationships because they are similar in the way they function emotionally, in their tolerance of anxiety, and ability to tolerate similar levels of intimacy and distance. Two undifferentiated selves fuse into a twosome that begins to govern behavior. They appear to be so tightly connected and form such intense relationships that they act as one person. In this state of fusion, each reflexively depends on the other for support, direction, and her or his own sense of well-being. Low level of differentiation carries with it anxiety which when conveyed in relationships creates significant difficulties. Their emotional or automatic functioning is fused with their intellectual functioning. The arrival of differences between partners produces pressure on the one perceived as different to adapt and fit more comfortably with the other.

Bowen Family Systems Therapy with Couples

Acquiescence as well as reactivity is often used to keep anxiety away. When anxiety is low, couples may display an acceptance for difference. However, this tolerance for difference disappears as the couple becomes more anxious. Anxiety increases the togetherness pressure which triggers reactivity and the use of distance and avoidance. The less differentiated individual is more dependent on their partner for their sense of satisfaction and well-being. They are willing to trade individual sense of “self” for the perceived security of togetherness. Emotionally, mature relationships entail two people with a high level of differentiation and well-defined boundaries. This means there is less trading away of self in the relationship. As a result, there is greater cooperation and altruism. This teamwork is achieved as a thoughtful choice and guided by inner principles not by automatic accommodation response. Those individuals with greater ability to differentiate between thinking and feeling have more tools to meet relationship challenges competently.

Goal Setting Bowen theory views relationship difficulties emerging from a mixture of level of differentiation of self plus intensity of anxiety in the relationship field. Consequently, there are two basic goals in treatment. The first goal is to increase differentiation which is the ability to stay separate and autonomous while still connected to important others. The clinician helps in raising level of differentiation in both partners as well as in their relationship. With increased differentiation, partners can manage their relationship issues more calmly and thoughtfully and can reduce their reactivity to each other. As a result, there will be less blaming, conflict, and distancing. If each partner takes responsibility for their own part in the relationship problems, they will be able discover a solution together. The second goal is to reduce the anxiety felt by each partner and in the relationship. This follows from the first goal since as differentiation

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increases, anxiety decreases. Both reducing anxiety and reactivity while increasing their differentiation of self in their important relationship is key. When these are realized, they are better able to find balance between self and togetherness and tolerate facing the difficult gridlock issues in their relationship in order to find solutions. It is important that each partner have these goals for themselves. The goal cannot be to change the relationship or the partner. Each partner is asked to observe how their own behavior and reactions contribute to or impair them achieving their goal. Once a goal for self is established, the coach can ask each partner to reflect on what they are doing toward their goal and with what effects.

Assessment Genograms A very important way of assessing couples’ dynamics is through the use of genograms. Genograms are a type of family tree that specifically maps key multigenerational processes. This provides insight for both therapist and the partners regarding the emotional dynamics that contribute to the presenting problem. Genograms are used to identify problematic multigenerational patterns that surround the presenting complaint such as conflict, over functioning, or level of differentiation. The therapist creates the genogram with the couple that includes at least three generations of the family of both partners. It places each individual in a nuclear family but also it charts important facts such as education, achievements, physical and mental illnesses, occupations, where people live, immigration, and health status. It records dates of birth, deaths, divorce, and marriages. It can also include information about how the couple met and how they decided to commit to each other and any separations, previous serious/long-term committed relationships, children, abortions, or mischarges. In addition, emotional facts regarding relationship patterns such as conflict, distance, violence, abuse, cutoff, and fusion are all recorded.

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The genogram allows the coach to get an understanding of the level of differentiation by the way the couple describe their functioning and the functioning of their families of origin. Furthermore, the goal is to help the individual learn about self and understand one’s own patterns. Genogram making is not about rehashing past grudges. Instead, the focus is on self instead of others. The objective is to move to a different level of comfort and responsibility in one’s own family and to become a more mature person in one’s relationship and family of origin. Through the use of the genogram, the couple becomes aware that they are living out patterns and rules long established in their families of origin. This increased awareness allows each partner to consciously choose alternative ways for relating and handling problems that may have previously been unclear or never even considered. Being able to visualize family of origin dynamics may lead to greater willingness to take action. This conscious and intentional approach to relating and problem solving comes from the strength in each partner rather than the weaker and collapsed “that’s just how it is” patterns that have caused chaos in the relationship.

Therapeutic Relationship Coach Bowen referred to the therapist as a coach. A coach is an active expert of both individual players and the team. A coach does not assume responsibility for fixing the presenting problem or for changing the relationship. The coach assumes that the couple can tackle their own problems successfully. The coach takes responsibility for providing a structure that allows the partners to think more objectively. The coach facilitates partners focusing on self rather than on others. The couple talks directly to the coach rather than to each other. They talk with therapist about how to manage themselves less reactively in relationships. As one of them talks to the coach, the other sits back, thinks, and listens.

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The basic principle governing this approach derives from the observation that tension between two can resolve if both can remain in good contact with an emotionally objective and neutral third person or coach. The coach reduces the direct exchange between the partners that results in the emotionally driven chain reaction while urging each partner to witness their own reactivity. As each partner becomes a better observer of the process, anxiety and tension decreases. With the decrease in anxiety, each can observe more of the reactive process in self and in the other.

Differentiation and the Person of the Therapist The primary tool for transforming couples is the therapist’s own personal level of differentiation. In fact, the differentiation of the therapist and the emotional being of the coach is seen as technique. The coach’s ability to embody and live the theory is key. If the therapist works to enhance their level of maturity, they will interact with the clients in a way that will automatically facilitate clients level of differentiation. Murray Bowen believed that individuals can only differentiate as much as the therapist has differentiated. So if the coach is going to assist the couple they must continually work on developing themselves. While what the therapist does is important, how the therapist ‘is’ in relation to the couple is most important. The emotional system of the therapist can be triggered when sitting with the couple’s distress and anxiety. If the coach takes sides or overfunctions, they become part of the problem. But when the therapist focuses on his/her own reactivity and anxiety tolerance, their ability to sit with an emotionally charged couple improves. The therapist’s goal is to get greater clarity and objective thinking during a session as opposed to responding out of an emotional reaction to the couple. Emotional objectivity is the goal. If the coach can relate to each partner as more of a self, they aid in facilitating and encouraging more solid self to emerge in relationship with each other.

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The higher one’s differentiation, the more the therapist can maintain a non-anxious presence with the clients. Non-anxious presence does not mean a cold detached stance but rather an emotionally engaged yet nonreactive stance. The therapist does not react to attacks or take sides. When the therapist can tolerate the anxiety in the room, they do not try and fix the client or rescue them from tough feelings. The therapist does not try and liberate the couple from anxiety when they feel overwhelmed by disappointment anger, fears and other strong emotions. If the therapist is differentiated enough they are able to tolerate the feelings that the couple is trying to avoid and coach them through the arduous process of separating self from others and thoughts from feelings. If the coach soothes and calms the couple anxieties and fear, no growth occurs.

Interventions Encourage Differentiation of Partners Most people tend toward fusion and less differentiation. Encouraging differentiation of self is a technique that encourages people to hold on to their individual opinions and feeling states while in a relationship with their partner. If the partners work on their own level of differentiation, their relationship will get better. Even if one person works to raise their level of maturity, the relationship will do better. A partner cannot change their half of the relationship without changing the relationship. When one partner changes their focus from the faults of their partner to their own functioning in the relationship and their own life goals, differentiation is enhanced. In small steps, one partner begins to change behavior based on their observations about the relationship process and can see more clearly how the partner responds reciprocally to one’s own behavior. In time, the partner begins to convey views based on self-knowledge. These beliefs begin to guide behavior. These are considered to be “I-positions” or “I-statements.” This is what I think, this is what I believe, and this, therefore, is what I am going to do. These statements

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demonstrate a sense of responsibility for self and the ability to act responsibility toward others. The clinician serves as a consultant or coach to this process. Rather than providing an answer, the clinician challenges each partner to manage reactivity more effectively, to take more responsibility for self, to avoid infantilizing others while remaining interested and committed to the welfare of their partner. Provided the clinician has worked on differentiation of self in her/his own family, the coach can outline common challenges and suggest pathways for progress around obstacles. The project, however, is the couple’s challenge not the coach’s. Detriangulation Detriangulation involves the therapist having a collaborative alliance with each partner and does not tolerate being drawn into the couple’s triangle. The therapist declines to be triangulated by refusing to take sides. Although it will relieve one partner’s anxiety to agree with them, validation from the therapist can in fact undermine the client’s autonomy. Instead, the therapist attempts to get the partner to validate their own opinion and take responsibility for what they say and want. Partners must be coached to approve or disapprove of their own thoughts, opinions, and feelings and take action as needed. The coach works to keep himself or herself detriangulated from the emotional system of the relationship. The anxious couple will automatically seek a third person to rebalance the couple relationship. Often this third person is the coach. The coach must be aware to the challenges of being triangulated in to the relationship and maintain the detriangulated position in order to be effective. This requires that the coach remain emotionally detached from the twosome yet in good contact with them. Bowen refers to this process as the magic of family psychotherapy. Bowen believed that the coach’s efforts to stay out of triangles with the couple is a central intervention. Conflict between two people will resolve automatically if both remain in emotional contact with a third person who can be equally involved with both without taking sides.

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Termination The time frame for therapy is specified by the couple. The goal is for them to move as quickly as possible toward their goals. Often the couple begins with weekly meetings. When the presenting problem becomes less of an issue, the anxiety is lower, and/or the relationship runs more smoothly, couple may come less frequently. They move to every other week schedule. Some come monthly or even yearly. The clients are responsible for those decisions. Some couples may drop out of therapy but one partner may continue on to work on self. Many begin to see Bowen therapy as giving them a lifelong project where partners continually work on self. They have learned to have a more solid self and less reactive up close to important people. There is always work to be done both for the therapist as well as the couple since no one ever gets to the idealized level of Bowen’s continuum of differentiation. When the couple does decide to terminate, the therapist often asks to evaluate what changes they have made and how they will handle themselves during the next problem which will inevitably come.

Recommended Reading Brown, J. (2012). Growing yourself up: How to bring your best to all of life’s relationships. Wollombi: Exisle Publishing Pty Ltd. Gilbert, R. M. (1992). Extraordinary relationships: A new way of thinking about human interactions. New York: Wiley. Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. New York: W.W. Norton & Company.

Bowen Family Systems Therapy with Families Heather Katafiasz The University of Akron, Akron, OH, USA

Synonyms Bowen couple theory; Bowen theory

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Bowen Family Systems Therapy with Families

Introduction

Theoretical Framework

Bowen Family Systems Theory fits into the category of Intergenerational Family Theories, with its emphasis on how family of origin experiences impact current individual and relationship functioning. It is a theory that emphasizes personal autonomy, as well as balance. Bowen found inspirations for his theory, not only in the mental health work but also in natural systems. He believed that his theory would be applicable to all human systems and, to a much more limited extent, to all living systems as we are all connected.

Core Concepts Bowen Family Systems Theory is a multi-layered theory comprised of many interconnected concepts. At the core are counterbalancing forces; the interpersonal forces of togetherness and separateness and the intrapersonal forces of thoughts and feelings. These forces exist within a web of interconnection known as the emotional field (Friedman 1991). The process of navigating the togetherness and separateness forces has been labeled distance regulation (Kerr and Bowen 1988). While navigating interactions with others, people experience a pressure known as Chronic Anxiety, which is the pressure to fuse with others (Friedman 1991). Fusion can manifest as increasing physical proximity or aligning one’s own thoughts or feelings to that of others (Bowen 1978). A person experiencing fusion has difficulty separating their thought from their feelings, as well as separating their thoughts and feelings from that of others. This fusion can become so intense that members of the relationship experience a loss of individual identity, creating a dynamic in which any threat toward separation becomes a threat to the individual identities (Bowen 1978). Fusion inevitably leads to cutoff, which can be either an interpersonal or intrapersonal separation from the impact of the other (Kerr and Bowen 1988). Cutoff forms a false sense of independence, as the relationship and impact therein does not cease to exist with the separation. Responses that are solely based on thought or emotion, which lead to fusion or cutoff, are believed to be based on emotional reactivity (Bowen 1978). Vacillating between fusion and cutoff can lead to unstable interactions with others and a sense of mental instability within oneself. Differentiation is the remedy to the struggles created by chronic anxiety (Kerr and Bowen 1988). It is the ability to become aware of the chronic anxiety, allowing a person to choose how to interpersonally and intrapersonally react, rather than being compelled to have an emotional reactive response. Differentiation exists on a continuum, with those with higher differentiation

Prominent Associated Figures Murray Bowen, the founder of Bowen Family Systems Theory, trained initially as a psychiatrist. While working at the Menninger Institute providing therapeutic services to patients diagnosed with Schizophrenia, he began to involve the mothers of the patients in the treatment (Kerr and Bowen 1988). He began to observe how the relationship between mother and adult child impacted the patient’s symptom presentation, beginning to build the foundations of his theory. Bowen then took on a clinical research position at the National Institute of Mental Health (Kerr and Bowen 1988), continuing to explore how family relationships in general impacted individual symptoms. In the 1960s, while at Georgetown University, Bowen established the Georgetown Family Centre. At this point, he transitioned to working with families presenting with less severe psychological symptoms, applying those concepts from earlier in his career to his work with these families. Bowen announced the development of his theory at a presentation at the Family Research Conference in 1967, in which he presented the application of his theory to his own family of origin experiences (Bowen 1978). With this presentation, Bowen demonstrated that this theory needed to not only be utilized by but also lived by the therapist.

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being better able to combat the chronic anxiety, while those with lower differentiation more easily succumbing to the chronic anxiety (Kerr and Bowen 1988). Those with higher differentiation have the ability to maintain a sense of connection to others while also being autonomous, as well as the ability to separate their thoughts from their feelings as they consider how to react in interpersonal interactions. Differentiation is thought to be a life-long endeavor that no one can ever truly achieve, and so must always be practiced. Bowen believed that to a certain extent, all systems experienced symptoms; however, the extent to which a system under stress developed systems depended on differentiation level and access to resources (Kerr and Bowen 1988). Therefore, those with more resources and higher differentiation are the least likely to develop symptoms. Conversely, those with the least resources and lower differentiation more easily succumb to the pressures of chronic anxiety, experience more emotional reactivity, and are the most likely to develop symptoms. Schizophrenia was hypothesized to be linked to the lowest differentiation levels. The primary mechanism through which individuals regulate distance is using the emotional triangle (Bowen 1978). This involves dispersing the chronic anxiety that permeates a two-person relationship into three relationships. The third “leg” of the triangle need not be a person, as it could also be something the other two members have in common, such as a hobby. Emotional triangles are not problematic, as they are an effective way to disperse the chronic anxiety and the most stable form of relationship. However, when they become rigid and inflexible, the process becomes triangulation, which can lead to symptom development (Kerr and Bowen 1988). Often, in triangulation, two of the “legs” of the triangle are able to fuse, while the third “leg” is cutoff. Symptoms fall into one or more of the following categories: relational conflict, symptom development in one member of the couple, or symptom development in a child (Friedman 1991). When symptoms are triangulated, the focus now becomes solving the symptom rather than navigating the underlying problem in the primary dyad.

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Families pass down patterns of interaction, such as differentiation level and ways in which chronic anxiety is managed through generations in a process known as the multigenerational transmission of emotional processes (Friedman 1991). Families with excessive amounts of chronic anxiety, low differentiation, and limited access resources while under stress, such as family life cycle transitions, will develop an undifferentiated ego mass (Kerr and Bowen 1988). Parents in these families then engage in the family projection process by including their children in their own distance regulation patterns through triangulation (Bowen 1978). Not all children become triangulated into the parental system, such that some children experience more projected chronic anxiety than others. Those children triangulated more will develop lower differentiation levels than other children in the system. Often these children develop symptoms as a way to cope with the projected chronic anxiety. Bowen believed that sibling position (Bowen 1978), along with other contextual factors, may be reason for why one child is triangulated more into the parental subsystem than others. Eventually, when these children attempt to leave their families, they may feel that their only course of action will be to cut off because they are unable to separate from their family without their family attempting to fuse again. As adults, these people will use similar distance regulation strategies as their parents (or other relatives) to navigate the pressures of chronic anxiety. Bowen believed that these processes occur similarly in broader levels of the ecological system. The concept of societal emotional processes suggests that civilizations of people must also navigate the balance of separateness and connectedness (Bowen 1978). Attempts at distance regulation under the pressures of chronic anxiety as a society are reflected in the values and rules created by the people. Bowen hypothesized that excessive chronic anxiety and lower differentiation as a whole society could lead to the societal regression process (Bowen 1978).

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Theory of Change Bowen Family Systems Theory is very insight oriented. Therapy is about giving people an opportunity to learn more about themselves and their relationships, so they can assume responsibility for their own problems (Kerr and Bowen 1988). The therapist’s role is to be a coach and facilitator of the client’s understanding, rather than directing or pushing them (Bowen 1978). Regardless of the presenting symptom, the focus of therapy is on helping clients learn to manage their emotional reactivity while under the pressures of chronic anxiety, improving their differentiation, and reducing the need for the symptom in the system.

Populations in Focus Bowen Family Systems Theory was originally designed to explain all emotional systems (Friedman 1991), with emotional referring to the connection between living things, and not to be equated with feelings (Kerr and Bowen 1988). The implication of this original assertion was that the concepts of Bowen’s theory would be universal to all human experiences. Researchers, such as Monica McGolrick, have spent decades examining and expanding the cross-cultural applicability to Bowenian concepts (Erdem and Safi 2018). Additionally, more recent theorists have discussed the cross-cultural applicability of Bowen Family Systems Theory with specific populations and have redefined it as a culturally valid approach (Erdem and Safi 2018).

Strategies and Techniques Used in Model One major technique of Bowen Family Systems Therapy is that the therapist forms a new emotional triangle with the client system, attempting to maintain a differentiated stance, or autonomous I-position, during the session when the chronic anxiety is palpable (Guerin and Guerin 2002; Kerr and Bowen 1988). Bowen believed that maintaining this I-position would model for

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clients a differentiated stance and aid in alleviating the chronic anxiety in the room, allowing clients to learn to react from a differentiated stance, as well. Furthermore, Friedman (1991) suggested that therapists must be able to regulate distance with clients; be connected to them as humans, while also being distant enough to prevent triangulation. To create this new emotional triangle without actually being triangulated into the system, the therapist must have at least a higher level of differentiation than the clients. The therapist’s use of self in the room is key to helping clients become more differentiated; therefore, any technique has the possibility of being an effective intervention during the course of therapy (Friedman 1991). The family diagram, which was later altered and renamed the genogram, is both an assessment tool and an intervention designed to gather information from clients regarding their family of origin. To complete a genogram, the therapists first elicits from the client information regarding their family composition, then adding in contextual and relational information regarding the members of the family. The genogram is designed to garner insight within clients, while aiding therapists in treatment planning (Guerin and Guerin 2002; Kerr and Bowen 1988). Once the patterns of emotional reactivity have been identified, therapists can assign relationship experiments to clients (Guerin and Guerin 2002). As differentiation is a process that must be practice, these are behavioral tasks focused on helping clients practice maintaining a differentiated stance when interacting with others during the time between sessions. The successes and inevitable failures of relationship experiments can then be processed in subsequent therapy sessions.

Research About the Model Bowen Family Systems Theory is used widely by many therapists as their primary theoretical orientation, but there have not been many empirical studies performed supporting the effectiveness of it in clinical practice (Miller et al. 2004). Although there are dearth of empirical studies

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on Bowen Family Systems Theory, a great deal of basic research has been done on specific constructs from the theory. Specifically, differentiation, chronic anxiety, emotional reactivity, triangulation, and the multigenerational transmission of emotional processes have all been studied. Research on differentiation has showed that while the hypothesis that married couples would have similar levels of differentiation was supported by some early research (Miller et al. 2004), it has since been countered by later research (Miller et al. 2004). Furthermore, support has been found for the inverse relationship between differentiation and trait anxiety (Miller et al. 2004). Research has generally supported the hypothesized relationship between low levels of differentiation and psychological symptoms, as well as physical symptoms (the latter only for women; Miller et al. 2004), and the hypothesis that higher levels of differentiation would be associated with better marital quality and less frequent marital conflict (Miller et al. 2004). Emotional reactivity research has shown that one’s emotional reactivity toward one’s parents is related to psychological distress. While research has not supported the hypothesis that triangulation would reduce anxiety for the couple and increase anxiety in the third party has not been supported, mixed results have been found support for the relationship between triangulation and physical, emotional, and social symptoms (Miller et al. 2004). Finally, mixed results have been found for the intergenerational transmission of emotional processes, with some studies showing support for this process and other studies finding contradictory evidence (Miller et al. 2004).

Case Example Joe and Mary are a married couple who have been together for a total of 23 years. They are a White, middle-class couple with two children. They presented to therapy with their eldest daughter, Amelia, who is 20 years old. Mary reported that Amelia may have been deprived of oxygen at birth and was identified as having a borderline IQ but did not provide any additional information

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regarding Amelia’s ability level. Amelia still lives at home, and although Amelia works part time, she does not contribute financially to the household and has no plans to move out. Amelia has expressed a desire to attend college and to individuate from her family. Mary is hesitantly supportive of this, as she expresses frustration that she is never able to spend any time with Joe without Amelia present and believes their couple relationship is suffering. Joe has expressed anxiety regarding Amelia moving out of the home, as he does not believe the world is safe for her. Amelia has a younger brother, who she believes behaves similarly to her, but does not get into trouble because her parents favor him over her. When the therapist inquired about the possibility of the younger brother attending therapy, the parents reported that he refused to attend. Joe and Mary brought Amelia into therapy due to chronic conflict in the home, as they reported Amelia is disobedient and lazy. The therapist spent the first few sessions exploring the history of the family and identifying a timeline of the “problem.” The family reported the problems began approximately 2 years ago, when Amelia graduated from high school. During that same year, Mary had a heart attack, which terrified Amelia, who became Mary’s caretaker while she recovered. When Mary returned to work, Amelia’s behavior problems began, as she became defiant regarding her chores and argumentative. She also requested to know any and all information regarding the house, Mary’s health, and Mary and Joe’s relationship. From a Bowen Family Systems Theory perspective, the family has become stagnant in the launching stage of their family life cycle. Amelia has become triangulated into Mary and Joe’s relationship, as they have been unable to regulate the chronic anxiety triggered by Amelia’s preparation to launch and Mary’s health issues. Mary and Joe projected the chronic anxiety onto Amelia, who has become emotionally reactive, acting out behaviorally and vacillating between fusion and cutoff in her relationships with both of her parents. Amelia was “chosen” as the recipient of the chronic anxiety due to her cognitive delays that precluded her from a typical launching

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experience, as well as her being both the elder and female child. After exploring the timeline of their relationship, the therapist moved to exploring family of origin patterns to identify the origination of these processes via a genogram. Joe is an only child to a single mother. He reported that his parents divorced when he was very young and he did not have a relationship with his father. Joe reported that he lived with his mother until he and Mary married, when they were in their mid20s. He further explained that the entire family was very close with his mother, who had provided respite for Amelia as a younger child. Joe explained that mother died suddenly approximately 2.5 years ago. Mary is the youngest of three children. She has a brother and a sister. She reported that her father was an alcoholic and emotionally and physically abusive, primarily to her older brother, but she and her sister experienced it, as well. She reported that she did not want to use physical punishment on her children due to her own experiences, but wondered if she had used more physical discipline with Amelia, then Amelia would have fewer behavioral issues. She also reported that her parents argued frequently throughout her childhood, although the majority of it had dissipated by the time she was in her teenage years, leaving her parents’ relationship very disconnected. Mary reported moving out when she was 18 and that their relationship was estranged thereafter with only interactions on holidays. From a Bowen Family Systems Theory Perspective, Mary tends more toward cutoff in her family of origin, as demonstrated by the estranged relationship upon launching, while Joe tends more toward fusion in his family of origin, as demonstrated by the maintenance of the close relationship with his mother into adulthood. This may explain Mary’s higher level of comfort with Amelia launching compared to Joe’s hesitancy as they are both attempting to repeat their family of origin patterns surrounding this issue. Further, it may be that Mary’s family experienced an undifferentiated ego mass due to the intensity of the symptom development in her family; however, Mary may have been more protected

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from the family projection process due to her younger age in the family. Mary’s attempts to alter her parenting style from that of her parent by not engaging in physical discipline suggest that she may have developed a higher level of differentiation than that of her parents. Additionally, Mary’s protection of her son may be her attempts to stop the cycle of male child maltreatment, as her brother development mental health struggles as an adult, presumably resulting from his mistreatment as a child. The family’s close relationship with Joe’s mother suggest that she may have been triangled in during times of stress, perhaps in a functional way, as she was able to mitigate some of the chronic anxiety and her presence was experienced in a positive way by all family members. Her death then represented an emotional loss of that relationship to everyone in the family, as well as a loss of their main strategy to mitigate the chronic anxiety in the family. Amelia then was triangulated in to take the place; however, as she did not have the resources to manage the chronic anxiety, she developed symptoms. As they moved into the working phase of therapy, the family therapist focused on improving the differentiation of the family members both in the room, as well as through relationship experiments at home. The therapist further encouraged the participation of Joe and Mary’s son, as he plays an important role in the family as well. After several sessions of encouragement, he finally began attending therapy. The therapist also began processing the grief over the loss of Joe’s mother with the family, allowing them to experience the emotions of that loss in a more differentiated manner. The family was encouraged to identify resources, such as case management, that could provide support for Amelia to experiment with her independence. The therapist encouraged Mary to reestablish contact with her family of origin and experiment with interacting with her parents in a more differentiated manner. Joe and Mary were also encouraged to seek out couple counseling to assist them with improving their ability to manage the chronic anxiety associated with transition of the launching years and help them find a healthier balance between

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separateness and connectedness in their own relationship. During sessions, the therapist attempted to maintain a differentiated stance, remaining a neutral coach throughout the process. As they processed family of origin experiences, as well as the conflict in their relationship, the chronic anxiety became higher in session. The therapist diffused this chronic anxiety by creating a new emotional triangle with the family. The therapist used supervision and their own therapy to process countertransference so that they did not get triangulated during session. Additionally, the therapist used communication skills training to slow down the communication processes between the family members, allowing them to take a differentiated stance and choose how to react to each other. While Amelia’s behavior problems were processed as part of the content in session, the goal for Joe, Mary, Amelia, and her brother was to become more differentiated, allowing them to communicate about stressors, rather than the therapist resolving the issue for them.

Cross-References ▶ Bowen Family Systems Therapy with Couples ▶ Intergenerational Couple and Family Therapy

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Bowen, Murray Tara Schlussel and Molly F. Gasbarrini California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Name Murray Bowen, M.D. (1913–1990)

Introduction Murray Bowen is considered one of the founders of systemic therapy and a pioneer of family psychology. Bowen developed the theory of triangulation and continued to emphasize differentiation of the self throughout his work. His groundbreaking work with patients with schizophrenia changed the way in which the medical and psychological fields perceived the disorder. Bowen authored over 50 book chapters, papers, and monographs founded on his research and clinical work.

Education and Career References Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Erdem, G., & Safi, O. A. (2018). The cultural lens approach to bowen family systems theory: Contributions of family change theory. Journal of Family Theory & Review, 10, 469. https://doi.org/10.1111/jftr.12258. Friedman, E. H. (1991). Bowen theory and therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (Vol. 2, pp. 134–170). Philadelphia: Brunner/Mazel. Guerin, P., & Guerin, K. (2002). Bowenian family therapy. In J. Carlson & D. Kjos (Eds.), Theories and strategies of family therapy. Boston: Allyn and Bacon. Kerr, M., & Bowen, M. (1988). Family evaluation. New York: W. W. Norton & Company, Inc. Miller, R. B., Anderson, S., & Keala, D. K. (2004). Is bowen theory valid? A review of basic research. Journal of Marital and Family Therapy, 30(4), 453–466.

Bowen attended primary and secondary school in his hometown, Waverly, Tennessee. In 1934, he earned a Bachelor in Science from the University of Tennessee, Knoxville. In 1937, he earned an M.D. from the University of Tennessee Medical School, Memphis. He started his professional training as an intern at Bellevue Hospital in New York City in 1938 and later worked as an intern at Grasslands Hospital in Valhalla, New York from 1939 to 1941. After his experience as an intern, Bowen spent 5 years on active duty in the US Army (1941–1946), ranking first Lt. to Major. His experience in the army during World War II forever impacted his career by changing his interest from surgery to psychiatry. Once Bowen’s professional focus changed, he began his fellowship in psychiatry, specifically

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personal psychoanalysis, at the Menninger Foundation in Topeka, Kansas (1946). After completing formal training, Bowen became a staff member at the Menninger Foundation and continued to work there until 1954. While holding a position at the Menninger Foundation, he also worked at the National Institute of Mental Health (NIMH) (1954–1959). After leaving NIMH in 1959, he began working part-time for Georgetown University’s Department of Psychiatry. Bowen became a clinical professor, held the position of director of family programs, and in 1975, founded the Georgetown Family Center. During his time at NIMH, he continued to grow his private practice from his home in Maryland. Among the many awards Bowen has received throughout his career, he has been awarded the Distinguished Alumnus Award from the University of Tennessee, Knoxville, and the Alumnus of the Year from the Menninger Foundation. He held positions on many boards including the American Psychiatric Association, the American Board of Psychiatry and Neurology and, lastly, was named president of the American Family Therapy Association (1961).

Contributions to Profession During his time at NIMH, Bowen began research that would ultimately become the foundation for Bowen Family Systems Theory. During his time at the NIMH, he worked particularly with patients with schizophrenia and their families. His work with these patients and families revolutionized the way in which practitioners viewed schizophrenia. While, once perceived as an isolated and individual diagnosis, Bowen highlighted the impact of family dynamics on the patient’s psychosis. Through his work and research, Bowen claimed that schizophrenia was a result of relationship dysfunction within families, where dysfunction had continued and intensified through generations. Bowen is known for his contribution to family therapy and development of relevant concepts and theories. His work with patients with schizophrenia led to further development of Bowen’s family systems theory and family systems therapy, which

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clinicians continue to integrate into therapy today. Family Systems Theory underlines the strong ties among family members, stating that individuals are united in their network of connections. Family Systems Therapy emphasizes the importance of assessing the structure and behavior of the whole family, when aiming to address an individual’s inner psyche. Bowen conceptualized triangulation as an integral part of Systems Theory. He recognized the formation of triangles or involvement of a third party, when tension between two parties became exceedingly high. Although the inclusion of a third party alleviates tension, it prevents the two original parties from addressing their issues with one another. Triangulation can be found in any two party relationships and was brought to the forefront of family psychology by Bowen. Bowen highlighted differentiation of self as a goal that each member of a family should strive to achieve. Differentiation emphasizes the importance of each member of a family to view themself as independent from their families while maintaining intimate relationships and managing reactions and behaviors. When one attains differentiation, they gain emotional maturity and, consequently, are less likely to internalize conflicts and less likely to struggle emotionally. Bowen further developed his Family Systems Theory by emphasizing the impact of birth order on the family dynamic. He asserted that sibling position, an individual’s birth order in relation to siblings, provided essential information about the individual’s emotional reactions and behavior. While some members of a family may confront their perceived instigator, some members may withdraw from conflict. Emotional cutoff is when an individual distances oneself from their family, in order to avoid potential conflict, discomfort, or pain. Among Bowen’s many contributions to Family Therapy, he developed The Family Projection Process, which explains the way in which parents transfer their emotional difficulties to their child or children. The process of projection abides by three steps: (1) the parent is afraid there may be something wrong with their child and, consequently, aims all focus onto that child; (2) the

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parent perceives the child’s behavior as affirming their fear; (3) the parent then interacts differently with the child believing that, in fact, something is wrong with their child. This process is also viewed as a self-fulfilling prophecy as the parents seek to “fix” a problem they perceive their child has, but they ultimately cause their child to develop such problem(s) they most likely never had. Bowen had an exceptional awareness of parental influence on a child’s emotional and behavioral development. Multigenerational transmission process explains how parental level of differentiation transfers across generations, producing noticeable patterns in differentiation among family members through relationships. It is important to understand one’s level of differentiation since it impacts all facets of an individual’s life: relationships, affect longevity, marital stability, reproduction, health, educational accomplishments, and occupational success. In addition to exploring the process in which differentiation is transmitted by generations, Bowen has also been acknowledged for his conceptualization of Nuclear Family Emotional Process and Societal Emotional Process. Bowen contributed immensely to the field of psychiatry and psychology, through his research, therapy, written works, recorded audio and videotapes, and positions held on numerous boards. Among over 50 works published, Bowen’s contributions can be further studied in The Origins of Family Psychology (2013) and Family Therapy in Clinical Practice (1978).

Cross-References ▶ Differentiation of Self in Bowen Family Systems Theory ▶ Emotional Cutoff in Bowen Family Systems Theory ▶ Family Projection Process ▶ Family Therapy ▶ Multigenerational Transmission Process in Bowen Therapy ▶ Triangles and Triangulation in Family Systems Theory

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References Bowen, M. (1960). A family concept of schizophrenia. In D. D. Jackson & D. D. Jackson (Eds.), The etiology of schizophrenia (pp. 346–372). Oxford: Basic Books. https://doi.org/10.1037/10605-012. Bowen, M. (1972). Family therapy and family group therapy. In H. I. Kaplan & B. J. Sadock (Eds.), Group treatment of mental illness (Vol. 12). New York: E. P. Dutton. Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Bowen, M. (1991). Alcoholism as viewed through family systems theory and family psychotherapy. Family Dynamics of Addiction Quarterly, 1(1), 94–102. Bowen, M., Butler, J., Kerr, M., & Bowen, J. (2013). The origins of family psychotherapy. New York: Jason Aronson.

Bowlby, John Mary A. Fisher Mary Fisher Psychotherapy, PLLC, Salt Lake City, UT, USA

Name Bowlby, John

Introduction The father of attachment theory, John Mostyn Bowlby, was born in 1907 in London to Anthony Alfred Bowlby, a surgeon of renown, whose military service and medical practice frequently separated him from his family, and Mary Bridget Mostyn, whom Bowlby characterized as stable and sensible. The couple married and started their family unusually late in life, but as was customary among middle- and upper-class Edwardians, the rearing of Bowlby and his five siblings was conducted almost entirely by nursemaids. Minnie, the nursemaid who had daily charge of Bowlby, left the household when he was 4 years old, the effects of which may have inspired him to assert that the loss of a “loving nanny” in young childhood “can be almost as

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tragic as the loss of a mother” (Bowlby 1958, p. 7). After being sent to boarding school to avoid the threat of air raids on London, and later naval training as a cadet, Bowlby determined that a military path would offer him little opportunity to fulfill his ambition to improve society. Despite a lack of passion, but believing his father would approve, he enrolled at Trinity College at Cambridge in 1925 to study medicine.

Career Having developed an interest in experimental and developmental psychology, Bowlby diverted from his original plan to carry on with his father’s perceived wish. He found philosophical alignment when he volunteered at Priory Gate, a school for maladjusted children, during which time he interacted with troubled children with unstable parental figures, an experience that evoked the suspicion that problems arise from early experiences of loss and emotional deprivation. Because it was a prerequisite to training in psychiatry, Bowlby begrudgingly completed his medical studies in 1933. He began research and clinical work at the Maudsley Hospital for adults, where he conducted research on the relationship between early loss and psychosis. At the same time, Bowlby began psychoanalytic training at the British Psycho-Analytical Society. In 1936, he became involved in the London Child Guidance Clinic, where he worked with children who had been separated from their parents during the war. The Clinic employed a multidisciplinary approach and no singular theoretical basis, wherein he reported he “learned far more from. . .two social workers than I learned from my psychiatric colleagues” (Senn 1977, p. 9). These two social workers introduced him to the concept that children’s problems are rooted not only in early experiences of loss but in unresolved conflict from their parents’ own childhoods. Despite conflicts with his training analyst, who may have viewed him as depressed and unable to form relationships, and the Society’s reigning Kleinian view that focused on unconscious fantasies to the exclusion of the real life problems of

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individuals in childhood and beyond, Bowlby qualified as an analyst in 1937. He began training in child analysis under Melanie Klein soon after. While he disagreed with her prohibitions against interacting with mothers of the children he was analyzing, he recognized her influence, particularly valuing her belief in infants’ capacity to form relationships. A year later, he met and married Ursula Longstaff, one of the intelligent and cultured daughters of a well-known alpinist. Longstaff would collaborate with him on his biography of Darwin; write articles for popular press on pregnancy, breastfeeding, and parenting; and assume the majority of the care of their four children. Like his father, Bowlby was separated from his family during World War II for service as a military psychologist, though the relationships he developed during this time facilitated a post-war appointment as head of the children’s department of the Tavistock Clinic. There he formed his own research unit, and appointed Mary Ainsworth, developmental psychologist and developer of the Strange Situation procedure. This finally made possible the empirical testing of his ideas.

Contributions to Profession of Couple and Family Therapy During his time at the London Clinic, Bowlby authored several papers describing the effects of maternal deprivation on the personality development of children: the first two using psychoanalytic concepts and the latter two delineating his ideas on how many psychological disorders in childhood are rooted in real world separation and loss, which drew criticism from his psychoanalytic colleagues. From this work, however, Bowlby wrote a report, Maternal Care and Mental Health (1951) by request of the World Health Organization, which was translated into 14 languages (Bretherton 1992) and was published in popular press as Child Care and the Growth of Love (1953). In these papers, Bowlby highlighted psychological concerns over economic, medical, and other such concerns as central to social problems, making recommendations for preventing and ameliorating the effects of parent-child

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separation. These works have influenced policies worldwide, particularly with regard to foster care and child psychotherapy. During his time at the Tavistock Clinic, Bowlby’s documentary film, in collaboration with social worker, analyst, and conscientious objector, James Robertson, A Two Year Old Goes to Hospital (1952) demonstrated a child’s protest, despair, and final detachment at being separated from her mother for 8 days during a minor medical procedure. Criticized by the British PsychoAnalytical Society for its focus on actual experiences, it nonetheless impacted hospital protocols regarding parental visitation and care. Bowlby presented a synthesis of the previous research and thought, including Mary Ainsworth’s work, regarding attachment in a trilogy, Attachment (1969), Separation: Anxiety and Anger (1973), and Loss: Sadness and Depression (1980). Bowlby’s posthumously published biography of Charles Darwin (1991) explored the roots of the naturalist’s illnesses in his early history of maternal deprivation, which drew together both Bowlby’s mother’s love of nature and the essential theme of his career of children’s early experiences with their parents. Bowlby understood that his work had social impact, despite criticism and conflict with psychoanalysis, and believed that deprived children would grow up to be parents who are impaired in their ability to care for their children, and that society could be improved by altering this cycle. His work, collaboration, and mentorship gave rise to new generations of clinicians and researchers who applied attachment theory to the study of adults and adult relationships cross-culturally.

Cross-References ▶ Ainsworth, Mary ▶ Attachment Theory ▶ Attachment-Based Family Therapy ▶ Circle of Security ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Emotionally Focused Couple Therapy ▶ Tavistock Clinic

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References Bowlby, J. (1958). Can I leave my baby? London: The National Association for Mental Health. Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759–775. Holmes, J. (1993). John Bowlby and attachment theory. New York: Routledge. Karen, R. (1994). Becoming attached: First relationships and how they shape our capacity to love. New York: Oxford University Press. Senn, M. E. (1977). Interview with Dr. John Bowlby. Washington, DC: National Library of Medicine. Unpublished manuscript. van Dijken, S. (1998). John Bowlby: His early life: A biographical journey into the roots of attachment theory. London: Free Association Books.

Boyd-Franklin, Nancy Shalonda Kelly Rutgers, the State University of New Jersey, New Brunswick, NJ, USA

Name Nancy Boyd-Franklin, Ph.D.

Introduction Dr. Nancy Boyd-Franklin is an AfricanAmerican family therapist, psychologist, and a Distinguished Professor at Rutgers University in the Graduate School of Applied and Professional Psychology (GSAPP). Her pioneering work on the treatment of African-American and other ethnic minority families has made a significant contribution to the literature on multiculturalism and race within the family therapy field. Prior to the 1980s, race was often ignored in the mental health and family therapy literature and practice. Dr. Boyd-Franklin’s groundbreaking body of work and her innovative Multisystems Model have contributed to a definitive shift in the field to a strength-based and culturally sensitive approach to treatment.

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Career (Includes Education, Professional Training, Positions) Dr. Boyd-Franklin has transformed the field of family therapy over the course of her 40-year career. Dr. Boyd-Franklin received her B.A Cum Laude from Swarthmore College and herM.S. and Ph.D. in Clinical Psychology from Teachers College, Columbia University. She received extensive family therapy training during her internship at the Philadelphia Child Guidance Clinic, training with the renowned Salvador Minuchin, Harry Aponte, and Jay Haley, as well as during her subsequent training in the Family Studies Section, Bronx Psychiatric Center at the Albert Einstein College of Medicine. She has held academic positions at the department of psychiatry at the University of Medicine and Dentistry of New Jersey (UMDNJ) in Newark, and she currently teaches and supervises in the clinical and school psychology doctoral programs at GSAPP. An internationally recognized lecturer and author, Dr. Boyd-Franklin has written numerous articles and book chapters on issues related to treatment approaches with multicultural populations. She has received many awards for her outstanding contributions to the field from professional organizations including: the American Psychological Association, the American Family Therapy Academy, the American Psychiatric Association, the National Council of Schools of Professional Psychology, the Association of Black Social Workers, the Association of Black Psychologists, and the Teachers College Multicultural Roundtable. For example, in recognition of her body of scholarly work on the treatment of African-Americans and other ethnic minority families, the American Family Therapy Academy (AFTA) presented her with the “Pioneering Contribution to the Field of Family Therapy Award” in 1991. As a result of her family-centered approach to families with HIV and AIDS, she was invited by President Bill Clinton to participate in the first White House Conference on AIDS in 1995.

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Contributions to the Profession Her seminal work, Black Families in Therapy: A Multisystems Approach (1989), was one of the most influential books on African-American families to appear in the clinical literature. This comprehensive book provided in depth discussions illustrating cultural and racial issues in therapy including: racism, racial identity, skin color, extended family networks, and informal adoption. This was one of the first books in the field to provide an exploration of the role of religion and spirituality in clinical work with African Americans. The second edition of her book, Black Families in Therapy: Understanding the African American Experience (2003), significantly expanded on the first edition to areas impacting these families in therapy such as welfare reform, child welfare, adoption, managed care, and affirmative action. It focused on the socioeconomic diversity among African-American families with broader chapters on poor, inner city clients, and middle class families in predominantly White communities. Issues such as gender dynamics and couple therapy, racial profiling, violence, and the cultural diversity of the Black community including Caribbean and biracial families were explored. Another major contribution of Dr. Boyd-Franklin’s first book and her impressive list of other publications has been the development of her Multisystems Model. This is an innovative theoretical approach for conceptualizing clinical interventions at multiple ecosystemic levels. Building upon Bronfenbrenner’s (1977) ecostructural framework, Dr. Boyd-Franklin applied this model to the realities of clinical practice with diverse clients. Acknowledging that everyone is embedded within multisystemic contexts (individual, family, community, school, work, etc.), this model accounted for the impact of these systems on poor and ethnic minority families. It clarified the vulnerability of such families to the intrusion of powerful external systems including the health, mental health, school, child welfare, police, juvenile justice, and prison systems. Her work has also documented the punitive effects of racism and poverty on the mental health of families of color.

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A number of her publications have expanded her work on the Multisystems Model to other ethnic minority populations. Her book, Children, Families, and HIV/AIDS: Psychosocial and Therapeutic Interventions (Boyd-Franklin et al. 1995), was the first book to broaden the definition of pediatric AIDS to conceptualize it as a multigenerational family disease and one of the first to argue for a family-centered approach to treatment with African-American, Latino, and Haitian children and families living with HIV and AIDS. Dr. Boyd-Franklin’s Multisystems Model has been widely applied in the treatment of at-risk youth. In 1993, she co-founded with Dr. Brenna Bry the Rutgers/Somerset Counseling Program for at-risk adolescents and their families, which she directed for over 20 years. This work contributed to her book, Reaching Out in Family Therapy: Home-based, School and Community Interventions (Boyd-Franklin and Bry 2000). She has just completed a new book on this topic entitled, Working with At-Risk Adolescents: Home-based Family Therapy and School-based Achievement Mentoring (Boyd-Franklin and Bry in press). Her book, Therapy in the Real World: Effective Treatments for Challenging Problems (BoydFranklin et al. 2013), expands her work to interventions with individuals, families, groups, and multisystemic agencies.

Cross-References ▶ African Americans in Couple and Family Therapy ▶ Cultural Identity in Couples and Families ▶ Culture in Couple and Family Therapy

References Boyd-Franklin, N. (1989). Black families in therapy: A multisystems approach. New York: Guilford Press. Boyd-Franklin, N. (2003). Black families in therapy: Understanding the African American experience (2nd ed.). New York: Guilford Press. Boyd-Franklin, N., & Bry, B. H. (2000). Reaching out in family therapy: Home-based, school, and community interventions. New York: Guilford Press.

337 Boyd-Franklin, N., & Bry, B. H. (in press). Working with at-risk Adolescents: Home-based family therapy and school-based achievement mentoring. New York: Guilford Press. Boyd-Franklin, N., Steiner, G., & Boland, M. (Eds.). (1995). Children, families and HIV/AIDS: Psychosocial and therapeutic issues. New York: Guilford Press. Boyd-Franklin, N., Cleek, E., & Wofsy, M. (2013). Therapy in the real world: Effective treatments for challenging problems. New York: Guilford Press.

Bradbury, Thomas N. Joanne Davila Stony Brook University, Stony Brook, NY, USA

Name Thomas N. Bradbury, Ph.D. (b. 1959)

Introduction Dr. Bradbury is a nationally and internationally renowned clinical scientist who had dedicated his career to the study of intimate relationships. His research focuses on how relationships, especially marriages, develop and change over time, naturally and through intervention. To date, he has over 170 publications, which have been cited widely. He has won numerous prestigious awards, including the Distinguished Scientific Award for Early Career Contributions from the American Psychological Association (APA), and the Reuben Hill Award from National Council on Family Relations, and awards from the International Network on Personal Relationships, the Association for Behavioral and Cognitive Therapies, and APA Division 12 (Clinical Psychology). He was awarded an honorary doctorate, the Laurea Honoris Causa, from Catholic University in Milan in 2013. Dr. Bradbury has mentored numerous graduate and postdoctoral students, most of whom have gone on to faculty positions in the USA and abroad.

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Career Dr. Bradbury received his Ph.D. in clinical psychology in 1990 from the University of Illinois at Urbana-Champaign, where he worked closely with Professor Frank Fincham. Since 1990 he has been a faculty member in the Department of Psychology at UCLA, earning tenure in 1994 and Full Professor in 1998. In 2006, Dr. Bradbury also was appointed as an Affiliated Professor in the Department of Psychology, University of Fribourg, Switzerland, and in 2016 he was appointed Honorary Professor at the Education University of Hong Kong. He has served as a consultant and scientific advisor for numerous national and international organizations fostering marital, relationship, and family health.

Contributions to Profession Dr. Bradbury’s contributions are many. Early in his career, with Fincham, he conducted groundbreaking research on the attributions people make about partners’ behavior and how this impacts marital well-being. Prior to this work, marital research heavily emphasized behavior to the exclusion of cognition. Dr. Bradbury’s work was instrumental in broadening the scope of how marital functioning is understood by drawing attention to the importance of how people view and understand partners’ behavior. Soon thereafter, Dr. Bradbury proposed his highly influential Vulnerability-Stress-Adaption (VSA) model of marital functioning, which provided the field with a guiding paradigm for conceptualizing how multiple factors – including individual characteristics of the partners, environmental stressors, and couple interaction processes – interact to impact relationship satisfaction and stability. Within the context of the VSA model, Dr. Bradbury’s research has shed light on key factors that affect marital satisfaction and outcome, including: individual vulnerabilities, such as attachment insecurity, neuroticism, avoidance, and negative family of origin experiences; stressors, such as discrimination, racism, and financial strain; and interaction processes, such as positive affect, social

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support, and physical aggression. This research has yielded a clear picture of the circumstances under which relationships have the potential to work or fail, and it has provided a continued impetus for ongoing work in the field. Importantly, the vast majority of Dr. Bradbury’s research has been prospective and longitudinal in nature, allowing him to truly examine development and change over time, particularly from the newlywed stage, through the transition to parenthood, and into later marital stages. This has allowed him to identify factors that contribute not only to where people start or end in marriage, but to how they get from one point to the next. Dr. Bradbury’s most recent work involves investigating interventions designed to improve relationship functioning. One of his most important contributions in this area has been to challenge the status quo which contends that communication-based interventions are widely effective in helping couples succeed. Dr. Bradbury’s work has demonstrated that this is not the case. Not only do communication training programs yield small changes in actual communication, those changes do not predict changes in outcome over time, and such training programs are not at all helpful for individuals who are disadvantaged to begin with, such as couples with physical aggression or alcohol use, the very couples who may be most in need of help. This work has significant implications for public policy targeted at marital and family success.

Cross-References ▶ Fincham, Francis

References Bodenmann, G., Meuwly, N., Germann, J., Nussbeck, F. W., Heinrichs, M., & Bradbury, T. N. (2015). Effects of stress on the social support provided by men and women in intimate relationships. Psychological Science, 26, 1584–1594. Bradbury, T. N., & Fincham, F. D. (1990). Attributions in marriage: Review and critique. Psychological Bulletin, 107, 3–33. Bradbury, T. N., Fincham, F. D., & Beach, S. R. H. (2000). Research on the nature and determinants of marital

Braverman, Lois satisfaction: A decade in review. Journal of Marriage and the Family, 62, 964–980. Karney, B. R., & Bradbury, T. N. (1995). The longitudinal course of marriage and marital instability: A review of theory, method, and research. Psychological Bulletin, 118, 3–34. Williamson, H. C., Altman, N., Hsueh, J., & Bradbury, T. N. (2016). Effects of relationship education on couple communication and satisfaction: A randomized controlled trial with low-income couples. Journal of Consulting and Clinical Psychology, 84, 156–166.

Braverman, Lois Ellen Berman University of Pennsylvania, Philadelphia, PA, USA

Introduction Lois Braverman has been a critical voice in the development of feminist family therapy, and in developing the field of family therapy through her superb organizational/leadership skills at the American Family Therapy Academy (AFTA), and leading the Ackerman Institute for the Family.

Career Lois Braverman received her Master’s degree in social work from the University of Iowa in 1976. In 1983 she became the Director of the Des Moines Education Center at the University of Iowa School of Social Work, where she was responsible for the masters of social work program for 124 graduate students and reshaped the clinical curriculum to reflect systemically oriented practice. Along with three colleagues, she founded and became Director of the Des Moines Family Therapy Institute in 1984, a family therapy training institute for post-masters practitioners which brought family therapy training throughout the state of Iowa. After practicing in Iowa for 30 years, she moved to New York City in 2006 to become the President/CEO of the Ackerman Institute for the Family, one of the premier training institutes in the country.

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Contributions to the Profession Lois was a powerful early voice in examining the ways in which gender constructs family life, both in the assumptions that women are responsible for their children’s psychological wellbeing, the ways in which unequal financial power affect personal power in the relationship, and how early theories of family therapy ignore the gendered realities of family life. In 1987, she became the founding editor of the Journal of Feminist Family Therapy and remained its editor until 1992. This journal provided a critical voice for deconstructing and enriching the prevailing therapy models of the time. She was also active on the boards of Family Process, Affilia: Journal of Women and Social Work, and the Journal of Marital and Family Therapy. As a leader, Lois was active in the governing bodies of AFTA from 1991 on, including two terms as Program Chair, and served as President from 2003 to 2005. During this term, she began multiple initiatives including the AFTA monograph series, the early career member program, and the Endowment Initiative. At the Ackerman Institute for the Family, she has been instrumental in developing a new state of the art training facility, increasing the number of clinical research projects that received national and international attention, dramatically increasing the diversity of the faculty, administrative staff, and professional trainees, and developing the next generation of family therapy teachers and trainers. She worked with Ackerman’s faculty to examine how marginalization and racism impacted the relational life of families. She has received numerous awards including: 2011 University of Iowa Distinguished Alumni Award 1994 Innovative Contribution to Family Therapy – American Family Therapy Academy 1990 Distinguished Alumna Award, University of Iowa School of Social Work 1981 Danforth Foundation Associate

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References Braverman, L. (1986a). The depressed woman in context: A feminist family therapist analysis. In M. Ault-Riche (Ed.), The family therapy collections: Women’s issues and family therapy. Rockville: Aspen Systems Corporation. Braverman, L. (1986b). Social casework and strategic therapy. Social Casework: The Journal of Contemporary Social Work, 67, 234–239. Braverman, L. (1986c). Reframing the female client’s profile. Affilia: Journal of Women and Social Work, 1(2), 30–40. Braverman, L. (1986d). Beyond families: Strategic family therapy and the female client. Family Therapy, 13(2), 143–152. Braverman, L. (Ed.). (1988a). Women. Feminism and family therapy. New York: Haworth Press.. Braverman, L. (1988b). Beyond the myth of motherhood. In M. McGoldrick, C. Anderson, & F. Walsh (Eds.), Women in families (pp. 227–243). New York: W.W. Norton Press. Braverman, L. (1989). Mother-guilt. The Family Therapy Networker, 13(5), 46–47. Braverman, L. (1990). Jewish mothers. Journal of Feminist Family Therapy., 2(2), 9–14. Braverman, L. (1991). It’s bigger than both of us. In T. Goodrich (Ed.), Women and power: Perspectives for therapy. New York: W.W. Norton.. Braverman, L. (1992). The magical properties of worrying. Lilith, Spring, 31–32. Braverman, L. (1995). Mothering and motherhood: Clinical implications. In J. Van Lawick & M. Sanders (Eds.), Gender and beyond. Amsterdam: Dutch Associate for Marital and Family Therapy. Renee, R., Braverman, L., & Zuo, M. (2017). Interrogating the Limits of Trauma Language: A conversation on sexual abuse narratives and storytelling. Guernica. July1. https://www.guernicamag.com/interrogatingthe-limits-of-trauma-language.

Bray, James Susan Nash Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA

Name James Houston Bray, Ph.D. (1954–)

Introduction James H. Bray is a distinguished American psychologist who has made major contributions to

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family and health psychology, including divorce, remarriage and stepfamilies, intergenerational family relationships, adolescent substance use, and screening and brief interventions for substance use. He is a pioneer in collaborative healthcare and primary care psychology and several as president of the American Psychological Association in 2009.

Career Bray received his doctorate in clinical psychology from the University of Houston in 1980. Following a postdoctoral fellowship in Family Therapy at the Texas Research Institute of Mental Sciences, he was appointed faculty at Texas Woman’s University (TWU) – Houston Center and remained there for 6 years. In 1987, Bray joined the Department of Family Medicine at Baylor College of Medicine in Houston, Texas, where he continues to engage in research, teaching, and patient services. Bray has received numerous awards including Family Psychologist of the Year from the Society of Family Psychology, election into the National Academies of Practice for Psychology, the Karl F. Heiser Presidential Award for Advocacy on Behalf of Professional Psychology, and the Education Advocacy Distinguished Service Award from the American Psychological Association.

Contributions to the Profession Bray has made numerous contributions through his research, teaching, publications, and leadership. Family System Measurement. At TWU he worked with Donald Williamson researching intergenerational family relationships and personal authority in the family system (PAFS). They developed the Personal Authority in the Family System Questionnaire (PAFS-Q), which has been used in studies across the world. Stepfamily Research. Bray’s “Developmental Issues in Stepfamilies” research project investigated the social, emotional, and behavioral

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development of children in stepfamilies and first marriage families. Funded by the NIH National Institute of Child Health and Human Development, this project was one of the first longitudinal studies on the effects of divorce and remarriage on children and adolescents. This groundbreaking work was subsequently summarized in his book: Stepfamilies: Love, Marriage and Parenting in the First Decade. While at Baylor, Bray completed the “Stepfamily Project” and focused on the collaboration between psychologists and family physicians. Through partnership with John Rogers, MD, they completed one of the first demonstration projects on teaching psychologists to collaborate with primary care physicians. Their “Linkages Project” demonstrated that collaboration between behavioral health professionals and primary care physicians facilitates positive gains and is possible in both rural and urban areas. Bray and his colleagues (Paul Baer, Greg Getz, Gerald Adams, Amy McQueen, Susan Nash) conducted a series of NIAAA funded studies on adolescent alcohol use. The Baylor Adolescent Alcohol Project used measures and methods developed in previous research to investigate how family relationships, peers, and the developmental process of individuation influence adolescent drinking in junior high and high school aged students. The research also examined ethnic differences in adolescent drinking. He continues to apply these findings in his clinical work in community, private, and mental health clinics. Bray has published over 200 articles, tests, book chapters, books, and reviews. He has been on the editorial boards of several leading journals: Family Process, Journal of Family Psychology, Psychotherapy, Families Systems and Health, Monographs of the Society for Research in Child Development. He is the coeditor of Primary Care Psychology (2004) and the Handbook of Family Psychology (2009). Leadership and Service. Active in APA governance since 1988, Bray has been involved in practice, science, education, and state issues. He has served on the Board of Educational Affairs; Rural Health Task Force and Committee on Rural Health; Primary Care Task Force; State

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Leadership Organizing Committee; President of the Texas Psychological Association (2015), President of the American Society for Advancement of Pharmacotherapy (2014); and President of the Division of Professional Practice of the International Association of Applied Psychology. He also served as treasurer for five APA divisions (34, 37, 43, 46, 55); member-at-large, Division of Psychotherapy (29), Media Psychology (46), and Psychopharmacology (55). Bray is a fellow of 12 APA Divisions: 5 – Evaluation, Measurement and Statistics; 7 – Developmental Psychology; 12 – Society of Clinical Psychology; 29 – Division of Psychotherapy; 31 – State, Provincial and Territorial Psychological Association Affairs; 34 – Society for Environmental, Population and Conservation Psychology; 37-Society for Child Family Policy and Practice; 38 – Health Psychology; 42 – Psychologists in Independent Practice; 43 – Society for Family Psychology; 46 – Media Psychology; and 55 – American Society for the Advancement of Pharmacotherapy. Bray is also licensed as a private pilot with an instrument rating and enjoys studying oenology in his spare time. He is married to Elizabeth Mason Bray, the owner of an HR consulting firm. He has three children and two stepchildren.

Cross-References ▶ Stepfamilies in Couple and Family Therapy

References Bray, J. H. (2004). Personal authority in the family system questionnaire manual (2nd ed.). Houston: D-Boy Productions. Bray, J. H. (2010). The future of psychology practice and science. American Psychologist, 65, 355–369. Bray, J. H., & Berger, S. H. (1993). Developmental issues in stepfamilies research project: Family relationships and parent-child interactions. Journal of Family Psychology, 7, 76–90. Bray, J. H., & Kelly, J. (1998). Stepfamilies: Love, marriage, and parenting in the first decade. New York: Broadway Books. Paperback edition, April 1999.

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342 Stiefouder en stiefkinderen (Dutch ed.). Amsterdam: Forum, 1999. Bray, J. H., & Maxwell, S. E. (1985). Multivariate analysis of variance. Thousand Oaks: Sage. Bray, J. H., & Rogers, J. C. (1997). The linkages project: Training behavioral health professionals for collaborative practice with primary care physicians. Families, Systems, & Health, 15, 55–63. Bray, J. H., & Stanton, M. (Eds.). (2009). Handbook of family psychology. London: Wiley-Blackwell. Bray, J. H., Williamson, D. S., & Malone, P. E. (1984). Personal authority in the family system: Development of a questionnaire to measure personal authority in intergenerational family processes. Journal of Marital and Family Therapy, 10, 167–178. Bray, J. H., Adams, G., Getz, J. G., & Baer, P. E. (2001). Developmental, family, and ethnic influences on adolescent alcohol usage: A growth curve approach. Journal of Family Psychology, 15, 301–314. Bray, J. H., Adams, G. A., Getz, J. G., & McQueen, A. (2003). Individuation, peers and adolescent alcohol use: A latent growth analysis. Journal of Consulting and Clinical Psychology, 71, 553–564. Bray, J. H., Kowalchuk, A. K., Waters, V., Laufman, L., & Shilling, E. H. (2012). Baylor SBIRT medical residency training program: Model description and initial evaluation. Substance Abuse, 33, 231–240. Frank, R., McDaniel, S. H., Bray, J. H., & Heldring, M. (Eds.). (2004). Primary care psychology. Washington, DC: American Psychological Association.

Breunlin, Douglas C. William P. Russell The Family Institute at Northwestern University, Evanston, IL, USA

Name Douglas C. Breunlin

Introduction Douglas C. Breunlin is a Clinical Professor of Psychology at the Family Institute at Northwestern University (TFI). He has enjoyed a 42-year career as a marriage and family therapist. He has spent his career working at major centers devoted to family therapy and has published four books

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and over 60 articles and chapters on subjects related to family therapy training, theory development, and the integration of psychotherapies. He continues to practice, teach, write, and conduct research at TFI.

Career Douglas C. Breunlin completed undergraduate work at the University of Notre Dame where he received a BS degree in aeronautical engineering and a BA in Arts and Letters. These studies profoundly impacted his contributions to the field of couple and family therapy, the former through precise thinking about problem solving and the latter through an appreciation of the complexity of the human experience. Following a career as an aeronautical engineer at the National Aeronautics and Space Administration (NASA), he completed graduate training in social work at Case Western Reserve University where he developed a love of systems theory and family therapy. Following graduation, he accepted a position as a family therapist at The Family Institute in Cardiff, Wales, where he later became the Director of Student Unit Training. Living abroad fueled his interest in the impact of culture on family systems. The Institute’s focus on training inspired his commitment to study the training process. Breunlin then returned to the States where, for 12 years, he worked at the Institute for Juvenile Research (IJR) in the Family Systems Program (FSP), first as a family therapy trainer, then as Director of FSP, and finally as the Training Director for IJR. During the FSP years, he was fortunate to work with prominent family therapists Richard Schwartz, Celia Falicov, Howard Liddle, and Betty MacKune-Karrer. This highly creative group did seminal work together for over a decade. The group published in the areas of training and training research, theory development, and integration of family therapy models. In 1990, Breunlin accepted the position of Chief Operating Officer at The Family Institute at Northwestern University (TFI) (formerly the Family Institute of Chicago). He worked closely with William Pinsof, TFI Chief Executive Officer,

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to establish TFI as one of the premier family therapy centers in the world. This work included creating a formal relationship with Northwestern University and building a state-of-the-art facility on the Northwestern campus. He also began a quarter century collaboration with Pinsof to develop a comprehensive integrative perspective on the practice of psychotherapy. Breunlin and Pinsof were later joined by William Russell, Jay Lebow, Cheryl Rampage, and Anthony Chambers in the work to refine and advance the integrative perspective. In 2009, Breunlin became the Program Director for the Master of Science in Marriage and Family Therapy, a program that is jointly operated by TFI and Northwestern University. During his tenure at TFI, Breunlin also created the Peaceable Schools Initiative and served as the director of the Family Business Program. Research studies were published from the products of both programs. Breunlin has served on the editorial boards of Family Process, Journal of Marital and Family Therapy, Journal of Family Therapy, and Couple and Family Psychology. He also served as secretary, treasurer, and board member for the American Family Therapy Academy.

Contribution to the Profession Mr. Breunlin has published extensively on the training and supervision of marriage and family therapists. He is coeditor (with Howard Liddle and Richard Schwartz) of The Handbook of Family Therapy Training and Supervision, the first such text in the field (Liddle et al. 1988). With Richard Schwartz, he developed one of the first instruments to evaluate the outcome of family therapy training (Breunlin et al. 1983). He worked with Howard Liddle, Richard Schwartz, and John Constantine to develop the first formal program to train family therapy supervisors (Liddle et al. 1984). Mr. Breunlin has maintained a strong interest in theory development in the field of marriage and family therapy. He advanced the stage-transition model of development to include the concept of microtransitions and developmental oscillations

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(Breunlin 1988). Drawing on Bateson’s theory of negative explanation, he incorporated and articulated the concept of constraint within family systems theory (Breunlin 1999). He expanded the important concept of interactional sequence by cataloging sequences according to their periodicity (Breunlin and Schwartz 1986). He developed the concept of a metaframework, that is, a framework of frameworks, to enable systemic family therapists to draw ideas about domains of human functioning from the various models of family therapy. While serving as director of the Clinical Externship at The Family Systems Program at IJR, Breunlin recognized the need for students to be able to integrate the models of family therapy being taught. With colleagues Richard Schwartz and Betty MacKune-Karrer, he expanded the concept of a metaframework into an integrative perspective and a book titled: Metaframeworks: Transcending the Models of Family Therapy (Breunlin et al. 1992). Breunlin continued to maintain an interest in integration once he moved to The Family Institute at Northwestern University. In 2009, he, along with William Pinsof, William Russell, and Jay Lebow, formed a task force to explore the metaintegration of Breunlin’s “Metaframeworks Perspective” and Pinsof’s Integrative ProblemCentered Therapy (Pinsof 1995). This work culminated in the publication of two articles in Family Process on a new perspective called “Integrative Problem-Centered Metaframeworks” (Breunlin et al. 2011; Pinsof et al. 2011) and a chapter on this approach in Sexton and Lebow’s Handbook of Family Therapy (Russell et al. 2015). The group added members Cheryl Rampage and Anthony Chambers and further explicated the perspective in a book titled Integrative Systemic Therapy: Metaframeworks for Problem Solving with Individuals, Couples, and Families (Pinsof et al. 2017). Breunlin also coedited (with Jay Lebow and Anthony Chambers) The Encyclopedia of Couple and Family Therapy (Lebow et al. 2017). This online and hardbound encyclopedia has over 1,000 entries authored by prominent figures in the field of couple and family therapy.

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Throughout his career, Breunlin has maintained a substantial clinical practice. Many of the ideas reflected in his writing and teaching derive from his clinical experience.

Cross-References ▶ Family Institute at Northwestern University ▶ Integrative Problem-Centered Metaframeworks ▶ Integrative Systemic Therapy ▶ Pinsof, William M. ▶ Russell, William P. ▶ Schwartz, Richard C. ▶ Theory of Constraints in Couple and Family Therapy

References Breunlin, D. C. (1988). Oscillation theory and family development. In C. J. Falicov (Ed.), Family transitions: Continuity and change over the life cycle (pp. 133–155). New York: Guilford. Breunlin, D. C. (1999). Toward a theory of constraints. Journal of Marital and Family Therapy., 25(3), 365–382. Breunlin, D. C., & Schwartz, R. C. (1986). Sequences, toward a common denominator of family therapy. Family Process, 25, 67–87. Breunlin, D. C., Schwartz, R. C., Krause, M., & Selby, L. (1983). Evaluating family therapy training: The development of an instrument. Journal of Marital and Family Therapy, 9(1), 37–48. Breunlin, D. C., Schwartz, R. C., & Karrer, B. (1992). Metaframeworks: Transcending the models of family therapy. San Francisco: Jossey-Bass. (Paperback edition, 1997, Portuguese edition, 2000, Artmed Editorial). Breunlin, D. C., Pinsof, W., Russell, W., & Lebow, J. (2011). Integrative problem centered metaframeworks (IPCM) therapy I: Core concepts and hypothesizing. Family Process, 50(4), 293–313. Lebow, J., Chambers, A., & Breunlin, D. (Eds.). (2017). Encyclopedia of couple and family therapy. New York: Springer. Liddle, H. A., Breunlin, D. C., Schwartz, R. C., & Constantine, J. A. (1984). Training family therapy supervisors: Issues of content, form and context. Journal of Marital and Family Therapy, 10(2), 139–150. Liddle, H. A., Breunlin, D. C., & Schwartz, R. C. (Eds.). (1988). Handbook of family therapy training and supervision. New York: Guilford.

Brief Relational Couple Therapy Pinsof, W. M. (1995). Integrative problem centered therapy: A synthesis of family, individual, and biological therapies. New York: Basic Books. Pinsof, W., Breunlin, D., Russell, W., & Lebow, J. (2011). Integrative problem centered metaframeworks (IPCM) therapy II: Planning, conversing, and reading feedback. Family Process, 50(4), 314–336. Pinsof, W., Breunlin, D., Russell, W., Lebow, J., Rampage, C., & Chambers, A. (2017). Integrative systemic therapy: Metaframeworks for problem solving with individuals, couples and families. Washington, DC: APA Books. Russell, B., Pinsof, W., Breunlin, D., & Lebow, J. (2015). Integrative problem centered metaframeworks (IPCM) therapy. In T. Sexton & J. Lebow (Eds.), Handbook of family therapy (pp. 530–544). New York: Routledge.

Brief Relational Couple Therapy Douglas Flemons and Shelley K. Green Nova Southeastern University, Fort Lauderdale, FL, USA

In keeping with other brief therapy models – including MRI (developed by the clinicians at the Mental Research Institute, e.g., Watzlawick et al. 1974), Strategic Therapy (Haley 1987), Solution-Focused Brief Therapy (SFBT) (e.g., de Shazer 1985), and the Milan Associates (e.g., Boscolo et al. 1987) – Brief Relational Couple Therapy (BRCT) is a systemic approach significantly influenced by Gregory Bateson’s revolutionary systemic ideas (Bateson 2000) and Milton Erickson’s innovative hypnotherapy and psychotherapy methods (Erickson 1980; Flemons 2002; Flemons and Green 2007, 2018; Haley 1986).

Introduction As brief therapists, BRCT clinicians are committed to working as efficiently as possible (Fisch et al. 1982). Aware that both therapist- and clientexpectancy contribute significantly to therapeutic outcome (Kirsch 1999), they are careful not to assume that long-standing and/or particularly

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distressing problems necessarily require longer durations of treatment (O’Hanlon and Wilk 1987). They search for and highlight the strengths and resources of couples – noting their areas of expertise and any previous successes in solving problems – and they offer possible understandings (or framings – see below) of the problem for clients to consider. They acknowledge their own expertise in helping couples change, but they make clear that they don’t have privileged access to a “correct” view of the clients’ situation. This nonnormative stance means the therapists never take a position on what the clients “should” do, and they don’t advocate for “better” or more “open” communication. Any ideas the therapists offer are posed tentatively and are qualified as provisional. BRCT therapists make suggestions for experiments the clients might undertake (either in the session or back at home) to gather information about consistencies and variations in the problem the clients have identified. However, they avoid offering “first-order” solutions (Watzlawick et al. 1974), that is, ideas for interventions that don’t differ significantly from what the couple has already tried or what others (whether friends, family members, or other therapists) have already suggested. As MRI theorists pointed out long ago, problems are generated and maintained by ineffective solution attempts applied to life difficulties (Watzlawick et al.). Committed to developing an insider’s appreciation of the pattern, the “logic,” of the couple’s interaction, BRCT therapists concur with the MRI emphasis on “speaking the client’s language” and attending to the client’s beliefs, values, and priorities (Fisch et al. 1982). Their goal is to make “contextual sense” of the couple’s fights but also of the stubborn commitments of each partner. Rather than attempting to correctly diagnose pathology in how people think and/or what they do, BRCT therapists go in search of the legitimacy of each partner’s positions and actions, as well as the legitimacy of the couple’s interactive pattern of relating. The therapists operate from the assumption that the fighting and the suffering reflect both partners’ fundamental need for safety and their willingness to do whatever it takes,

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regardless of the consequences, to protect themselves. One or the other (or both) may also feel the need to protect the children, the other person, and/or the relationship. This assumption of the therapists about the necessity of safety is an example of reframing, a therapeutic technique derived from Bateson’s (2000) recognition that the way an item of perception or experience is contextualized or categorized (i.e., “framed”) is integral to its meaning. When the context or category (the frame) is changed, the meaning changes, and this in turn changes the experience itself. For example, when clients’ intransigence on an issue is framed (by themselves, by their partner, and/or by a professional) as petty stubbornness, they can’t change their mind without losing face, without admitting, if only tacitly, that they have been inappropriately and unnecessarily resistant. However, if the importance of safety is underscored and their behavior is reframed as one of many ways of ensuring this safety, then a change of mind is not an admission of blame and it doesn’t have to entail a loss of face. In this way, clients are provided the freedom to safely change from this way of feeling protected to that way. BRCT therapists work to create the conditions for clients to safely experience the vulnerability of interpersonal intimacy. Such intimacy – first, perhaps, with the therapist and then with the partner – is engendered through conversations organized by the therapists’ commitment to empathic knowing. Contrary to what is commonly understood, empathy does not involve therapists asserting that they understand what the clients are describing: Joanne: I can’t take it anymore. I’m ready to leave. If I’m not screaming at Tony, I’m screaming in my head: Enough! Enough already!! Therapist: I hear what you’re saying. I get that you’re upset.

Rather than claiming to understand, BRCT therapists demonstrate it by offering back empathyinformed descriptions of, and hunches about, what they have distilled from the clients’ stories. Joanne: I can’t take it anymore. I’m ready to leave. If I’m not screaming at Tony, I’m screaming in my head: Enough! Enough already!!

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346 Therapist: You’re at your wits’ end! And there’s no respite. Screaming inside, screaming outside – you must be exhausted. Joanne: Yes, but I’m too wired to feel the exhaustion. Therapist: So stressed. Kind of like feeling perpetually charged with an electric current? Joanne: So much. And I’m afraid of a spike taking me out.

Attending carefully to both the content and the emotional complexities of the stories, therapists offer their emerging empathic grasp of what the clients are saying. As clients listen and respond to these comments, agreeing with some and disagreeing with or correcting others, therapists use the feedback to adjust what they are understanding (and thus saying). Through such recursive dialogue, therapists derive a more accurate grasp of the clients’ experience, and clients feel better heard and understood, allowing them to relax into trusting someone who is essentially a stranger. This interactive unfolding of empathic knowing is particularly important when working with couples, as conflict is common. Rather than trying to maintain a neutral position that neither partner would take issue with, BRCT therapists adopt Anderson and Goolishian’s (1986) commitment to “multi-partiality” with couples who are holding divergent views and are telling demonstrably different versions of fights and disagreements. The therapist stays actively engaged at all times, making empathic statements that the one partner can agree with, acknowledging that the other partner views the situation fundamentally differently, empathizing with the second partner’s view and experience, going back and doing the same with the first partner, and so on: Joanne: I race home as soon as I can, but it is often after six. By then Tony, who isn’t working and has no other responsibilities, should at least have dinner on, if not have the girls fed. But nine times out of ten, he hasn’t even figured out what he’s going to cook. Is he at least helping them with their homework? No! He’s in his room on his iPad, drinking his first glass of wine for the evening. Therapist: You arrive home frazzled and exhausted, and it seems only reasonable that Tony would show appreciation for all you do by helping with the kids – with cooking and homework. It sounds like you experience his being in his room as an affront.

Brief Relational Couple Therapy Joanne: I do! Why is it up to me, the one working her butt off and paying the bills, to also have to make dinner?! If he doesn’t care about me, well, whatever, but at least he could do it for the girls – they need to eat! Therapist: It seems to you like a no-brainer. If only for the kids! Joanne: Yes. Exactly. Therapist: (turns to Tony) Do you agree with Joanne that most nights when she gets home she is the one to start in on making dinner? Tony: Such a heroic figure. Fighting the good fight all day at work, only to arrive home and start dishing it out as she walks in the front door. Therapist: Comes in like she’s spoiling for a fight? You must have to gird yourself for her arrival. Tony: You said it! Therapist: I imagine the wine helps with that. Tony: Oh yeah. I hear the car door, and I know the fireworks are about to begin. Therapist: Feels safer in your room? Tony: Let’s just say there’s no “Hello, how was your day?” No “How’d the writing go?” No “How are the girls?” Therapist: You’d like to feel Joanne’s interest in you and the girls be more important than her concern about whether you’re fulfilling your assigned duties. Tony: Yes! Therapist: You want to feel like her husband and co-parent, not her employee. Tony: Exactly. Therapist: And Joanne, I imagine you’d love to walk in the door and encounter a husband who is happy you’re home and invites you to join him in sharing some wine and finishing off dinner preparations. Joanne: That would be wonderful. Therapist: You don’t want to be in the position of assigning duties. Joanne: Not at all. But he doesn’t step up, so what I’m supposed to do? Therapist: It has felt like you’ve had no choice. Joanne: Right. Therapist: Man, it would feel so much better to not feel compelled to ride him. Joanne: You can’t imagine the relief. Therapist: Let’s talk about what the first step in that direction might look like.

Such empathy-infused conversations help each partner to feel understood, and they can facilitate descriptions in positive terms of what each person needs and what he or she might be willing and able to do differently in the service of making change possible. The conversations also provide a foundation for the therapist to introduce subtle shifts in how the problem is understood. The

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therapist framed Tony’s drinking of wine and retreating to his bedroom as methods of protection or coping. Such characterizations are supportive rather than critical, and, as such, they make it possible for Tony to make different choices in the future without losing face. Implied in the therapist’s comments is the idea that if Tony has been protecting himself from Joanne in these ways, perhaps he could find other ways of feeling safe. Perhaps he could shift from protecting himself from her to protecting himself with her. The therapist also described Joanne feeling like she had no other choice than to tell Tony what he needed to do. This is different from describing her as actually not having any other choice. The description implies that there is flexibility available; she just hasn’t recognized it, yet. Thus, the conversation has brought the couple to a place where they can safely explore other possibilities. The relational orientation of BRCT therapists is grounded in Bateson’s (1991) recognition that we “live in a world that’s only made of relationships” (p. 287). Information, the “stuff” of mind, is composed not of things but of differences or distinctions (Bateson 2000; Flemons 1991), and a difference is nothing (a no-thing) other than a relationship – a boundary that separates (and thus identifies) an object from what it isn’t. According to Bateson (2000), mind is not synonymous with brain but is, rather, a systememergent phenomenon, formed and maintained in communicational loops within and between brain and body, and within and between perceiving organisms in an ecosystem: “The individual mind is immanent but not only in the body. It is immanent also in pathways and messages outside the body; and there is a larger Mind of which the individual mind is only a sub-system” (2000, p. 467). For BRCT therapists, the relevant loops of this larger mind are those within and between partners and among the partners and the therapist. The information shared along these circuits is sometimes rational, but it is always relational. Both partners are communicating back and forth – or, more accurately, round and round – within themselves (between brain and body) and with each other, responding to each other’s responses to

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each other’s responses. It doesn’t take long, particularly at times of high stress, for the communications to become fraught – knotted in a way that feels difficult if not impossible to untangle. BRCT therapists thus conceive of themselves as disentanglement consultants. This is an important distinction: When couples localize a problem (usually each partner locates it inside the other person – “We’d be fine if only it weren’t for my partner’s pathology”), they typically come to therapy with a request to have the problem controlled, contained, or cured. But such goals are unattainable, and they lead to solution behaviors that tend to exacerbate the suffering (Watzlawick et al. 1974). All problematic solution attempts stem from a desire to distance from whatever is deemed undesirable; treating the problem as other, clients want to be rid of it. Paying heed to Milton Erickson’s admonition (in Rossi and Ryan 1986) that the clinician’s task is “that of altering, not abolishing” (p. 104; italics in the original), BRCT therapists shift the clients’ goal from wanting to be free of the problem to finding freedom in relation to it. Problems are altered when the clients’ experience has changed – when they are able to do something different in the relationship and in relation to the problem, which then allows them to view the relationship and the problem differently, or when they come to a different view of their partner and the struggle they’ve been having together and this shift in perspective frees them up to engage differently. BRCT therapists have no interest in couples achieving “insight.” This would imply that there exists one “right” understanding of the clients’ situation and their participation in it, and that finding and embracing this understanding would itself be somehow therapeutic. Instead, the focus is on the clients finding it possible to orient differently to themselves and each other, allowing for a shift in their pattern of interaction and/or in the discovery of exceptions to their problem.

Case Study A BRCT therapist began seeing Stephen, a 50-year-old physician, after Stephen’s wife,

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Rachel, also a doctor, discovered his 4-year affair with a drug rep, Sandra, who still often visited his practice. Rachel worked at a hospital serviced by a different rep, so she didn’t know Sandra personally, but when she discovered the texts and emails that confirmed the betrayal, she was able to use social media to familiarize herself with a woman she considered her nemesis. As therapy began, Stephen was still very much involved with Sandra and reluctant to end it, although Rachel was demanding that he do so. The couple had played mixed-doubles tennis for many years, successfully competing nationally when they were younger and, until recently, still actively involved in senior competitions. The revelation of the affair had rocked this world, where both were minor celebrities, as well as the local medical community, where they were respected as a successful dual-career couple. The therapist saw Stephen alone for several sessions as he oscillated between guilt over hurting Rachel and a desperate desire to continue seeing Sandra. After a number of weeks, Stephen announced that he wanted to fix his marriage, and he asked Rachel to join the therapy. They began working towards rebuilding their fractured relationship, but the progress was touch-and-go. Despite his reassurance to Rachel that he would end the affair, Stephen held back from cutting off all contact with Sandra, and, he said, he could do nothing about the fact that his office was still part of her drug-rep responsibilities; he couldn’t stop her from dropping off samples and requesting time with the docs. This devastated Rachel, who would threaten to leave, but she didn’t follow through, as she truly wanted to save the marriage. Rather than urging Stephen to end all contact with Sandra and reclaim his marriage, and rather than urging Rachel to fight harder for her husband or make good on her threats, the therapist, eschewing any position of authority from which to tell them what they should do, instead maintained a stance of deep empathy for both partners. Therapist: Rachel, this is such familiar territory for you, and yet you never give up hope. Even in the midst of your devastation, you reach out to Stephen.

Brief Relational Couple Therapy Rachel (crying): I hate that I still love him. If I could leave him and tell him to go to hell I would. But I still love him. I want this marriage. Therapist: You feel so caught, wanting, but so far unable, to cast him aside. The connection is strong. You just want to be rid of him and you just want him. Rachel: (quietly) Yes, both. Therapist: And (turns to Stephen) as hard as it is to imagine ending your relationship with Sandra, here you are with Rachel, receiving her pain and anger, accepting it. Stephen: I hate hurting you, Rachel. I’m truly sorry. I just can’t promise you right now that I will never see her again. She’s not a bad person. I don’t want to devastate her. Rachel: (yelling) But you’re devastating me! Therapist: (to Stephen) You don’t want to hurt either of them. Stephen: No, I don’t. Therapist: (to Rachel) And you’re caught by the irony that Stephen’s commitment not to be hurtful wounds you to your core. Rachel: It stabs me in my heart. Therapist: . . . So very, very painful. And no easy answers. Rachel, what do you know about yourself, and about Stephen, that gives you hope you can recover from this betrayal, whether or not the marriage itself survives? Rachel: I don’t know (more crying); I am just not willing to give up. Not yet, not after 20 years. I still love the bastard, stupid as that sounds.

While Stephen remained stuck, not knowing how or whether to end his relationship with Sandra or to divorce his wife, the therapist saw Rachel for several sessions, helping her to find her way through the anger and confusion she was experiencing. She remained unconvinced that she and Stephen could ever make the progress necessary to reconcile and rebuild their relationship, and the therapist respected this questioning. Blind-sided by the affair and publically humiliated when it had become known to both the professional and tennis communities, she had, she said, “gone underground,” losing her voice and becoming an invisible passenger in a relationship that felt out of control. Normally a strong and productive person, Rachel felt she had lost her balance, resulting in her acting in ways that she didn’t recognize or respect. She wanted to stop alternating between berating Stephen about the affair and begging him to end it.

Brief Relational Couple Therapy Therapist: It makes sense to me that you would be out of touch with your usual mojo – you are accustomed to being a vibrant part of a dynamic, and very public, relationship. So who is Rachel outside of the Rachel-and-Stephen duo? Rachel: Exactly! I hate it; I feel invisible, and then I hate him. And I have no voice! No vote! The son of a bitch does exactly as he pleases, and I have to accept the fallout. He just gets away with it!

Rachel had been closely monitoring Stephen’s computer and cell-phone communications with Sandra, focusing on that to the exclusion of most everything else, save for her patients. She and the therapist explored expanding the scope of her interests to include activities of her own she cared about. Therapist: Certainly, right now Stephen is calling the shots on what happens with this other relationship. What parts of your life are still yours? What matters to you now in the areas of your life that you are in charge of? Rachel: I’m still a doctor, and I’m still an athlete. I have a professional identity separate from him, but we’ve been tennis partners for forever. I haven’t played singles for as long as I can remember, and I don’t remember the last time I competed with a different partner.

The therapist acknowledged how difficult it would be for Rachel to find anything as arresting as the status of Stephen’s relationship with Sandra; nevertheless, they explored the possibility, however slim, of her experimenting with reclaiming a life that didn’t have Stephen at the center. When she returned a few weeks later, Rachel described an experience much different from what she would have predicted. She’d started thinking a lot about personal agency, and she’d decided to do something about it. She moved fulltime into a nearby condo that she and Stephen owned on the beach, she started playing women’s doubles tennis, and she blocked both Stephen and Sandra on Facebook. She and Stephen had gone to dinner twice, but only when it was convenient for her; a few other times when he’d suggested they meet, she’d been too busy with work or other involvements to agree. She said she’d become much less reactive to him – her anger had transported her into living rather than stewing.

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The couple came in together to the next appointment 3 weeks later. They had spent two weekends together, talking intensely about issues they had not discussed in many years, and Stephen said he had not been in touch with Sandra for several weeks. During this session, the couple described an ongoing challenge that Stephen considered a catalyst for his affair. For several years, sex with Rachel had felt like “an obligation,” and at some point along the way, he’d found himself unable to maintain an erection during intercourse. He’d started avoiding sex with her altogether, and they’d become “like roommates,” and this had compromised not only their physical closeness but also their emotional connection. With Sandra, he’d had “no problems in the penis department.” This had been both exciting and relieving for him, proving that he didn’t have a physical problem. Now that they were having unprecedented intense, intimate dialogues, this topic was on the front burner, and they were concerned it could be a deal breaker, even as they both gained confidence that they could save their marriage. Rachel was not the least bit interested, she said, in staying in a sexless marriage. Turning to Stephen, she was clear and forceful: “You can take your obligation and shove it up your ass!” She was no longer concerned, she said, about whether he considered her sexy enough; she found herself sexually attractive and, if he didn’t, she knew she would find someone else who would. Rachel had found her voice, her strength, and her independence. She was clear that she wouldn’t tolerate any communication between Stephen and his lover, but she also said that she was firing herself as a “private investigator.” If Stephen chose to be with her, he had to be all-in; if he waffled, or if she discovered he was lying, she’d immediately file for divorce. If he wanted to work towards rebuilding trust and to risk reigniting their sexual relationship, she would consider it; otherwise, she was moving forward on her own. Stephen found the difference in Rachel both intriguing and terrifying. Therapist: (to Stephen) What’s it like to have these conversations with Rachel now, and to anticipate being sexual with her? Stephen: Talking to her is incredibly arousing; she’s strong and demanding and sexy. I’ve never

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350 been so attracted to her, intellectually. But I don’t trust that’s going to make the difference for me physically. And the thing is, I know there is nothing wrong with me physically. I can perform, believe me! Rachel: Well, imagine how terrifying that is for me, Stephen! How can I risk making myself vulnerable to you, knowing that if I’m not sexy enough, you’ll just go back to her!

These significant changes in their ways of relating to each other, and in Rachel’s ways of relating to Stephen, to his affair, and to her own sexuality, opened the door to different ways of conceptualizing their past struggles. The therapist acknowledged the differences and offered a reframe of Stephen’s past difficulty in maintaining an erection with Rachel. Therapist: How very difficult for both of you to imagine enjoying sexual encounters together while worrying that if Stephen can’t get it up, this would mean the end of your relationship. These are incredibly high stakes, and a lot of pressure to put on one organ and one experience. Stephen, I have a question for you. Stephen: Shoot. Therapist: You said before that sex with Rachel had starting feeling like an obligation. Stephen: That’s right. Therapist: And then at some point after that, you started having erection difficulties during intercourse. Stephen: Yes. Therapist: Do you remember when that started? Rachel: It didn’t happen all of a sudden, but it got pretty quickly to where it was happening a lot, and then he just avoided sex altogether. Therapist: That sound about right to you, Stephen? Stephen: Pretty close, yeah. Therapist: And when did that start? Rachel: Must have been about four years ago. Therapist: Makes sense. About the time the affair started. Rachel: Son of a bitch! Therapist: Sure, but this is what I’m thinking. It seems to me, Stephen, that while you were involved with Sandra, being sexual with Rachel felt to your penis like “cheating” on Sandra. While obviously disturbing to you both, the one thing your lack of an erection accomplished during your relationship with Sandra was to keep you from betraying her, or from giving false hope to Rachel. Perhaps there was some wisdom in the choice your penis was making at the time. You weren’t being monogamous, but it was. Now, however, much has changed between you two, and, Rachel, you now have begun to embrace your own sexual identity apart from

Brief Relational Couple Therapy Stephen. I’m wondering how your body may respond differently now, Stephen, given that you would no longer be “cheating” when being sexual with Rachel. Rachel: Sweet. My philandering husband has a monogamous dick. Who knew?

By reframing Stephen’s erection difficulties as a sign of his faithfulness, if only to his lover, the therapist offered Stephen and Rachel (and Stephen’s mindful body) a way forward. Given the intimacy and vulnerability generated by their new conversations, and given Stephen’s commitment to direct his faithfulness towards his wife, they could expect his “monogamous penis,” not weighted down by guilt, to rise to the occasion. Therapist: So, what incredible risks you are both taking – finding the freedom to talk about sex when it has been a taboo topic – and act! – for so many years. Rachel: Yes, it’s terrifying, but I’m not going to go back underground. This is our only chance. Therapist: There is tremendous risk for both of you, but what I notice is that you are each finding the strength to embrace risk in new ways. I wonder how you will find desire in that risk, and where that desire will take you both.

The couple continued to attend therapy, sometimes weekly, sometimes sporadically, for the next 3 months. Rachel stayed in the condo until she decided it was emotionally safe to move home, and they started playing tennis together again, though with a different set of interpersonal rules. Stephen had always been a fierce competitor; when one of them would make a mistake, he’d be quick to anger and unrestrained in voicing his criticism. He wouldn’t hold onto his rancor, but his words and tone of voice would ring in Rachel’s ears, and she was no longer willing to be subjected to his temper. She agreed to play again with him in competition, but only if he approached winning – and losing – with more acceptance and kindness. He took up her challenge and worked, mostly successfully, with the therapist on altering his orientation to the game. They also ventured into a sexual relationship, full of apprehension and anticipation, facing their greatest fear – that Stephen would not be able to be fully sexual with Rachel. The results were often

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wonderful, sometimes disappointing, and at one point devastating, but the act of taking the risks together allowed them to find mutual respect and desire, both of which had been absent from their relationship for many years. In their final session, they described their evolving sexual connection, their commitment to saving their marriage, and their success on the courts. The yelling was absent, and, continuing to untangle themselves from the effects of the affair, they were finding joy and rhythm in all facets of their partnership.

Cross-References ▶ Brief Strategic Couple Therapy ▶ Collaborative Couple Therapy ▶ Couple Therapy ▶ Empathy in Couple and Family Therapy ▶ Neutrality of Therapist in Couple and Family Therapy ▶ Reframing in Couple and Family Therapy

References Anderson, H., & Goolishian, H. A. (1986). Problem determined systems: Towards transformation in family therapy. Journal of Strategic & Systemic Therapies, 5(4), 1–13. Bateson, G. (1991). In R. Donaldson (Ed.), Sacred unity: Further steps to an ecology of mind. New York: HarperCollins. Bateson, G. (2000). Steps to an ecology of mind. Chicago: University of Chicago Press. Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy: Conversations in theory and practice. New York: Basic Books. de Shazer, S. (1985). Keys to solution in brief therapy. New York: W. W. Norton. Erickson, M. H. (1980). Further clinical techniques of hypnosis: Utilization techniques. In E. L. Rossi (Ed.), The collected papers of Milton H. Erickson: Vol. 1 (pp. 177–205). New York: Irvington. Fisch, R., Weakland, J. H., & Segal, L. (1982). Tactics of change: Doing therapy briefly. New York: Jossey-Bass. Flemons, D. (1991). Completing distinctions. Boston: Shambhala. Flemons, D. (2002). Of one mind: The logic of hypnosis, the practice of therapy. New York: W. W. Norton. Flemons, D., & Green, S. (2007). Just between us: A relational approach to sex therapy. In S. Green & D. Flemons (Eds.), Quickies: The handbook of brief sex

351 therapy (Rev. ed., pp. 126–170). New York: W. W. Norton. Flemons, D., & Green, S. (2018). Therapeutic quickies: Brief relational therapy for sexual issues. In S. Green & D. Flemons (Eds.), Quickies: The handbook of brief sex therapy (3rd ed., pp. 126–170). New York: W. W. Norton. Haley, J. (1986). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D. New York: Norton. Haley, J. (1987). Problem-solving therapy. New York: Jossey-Bass. Kirsch, I. (Ed.). (1999). How expectancies shape experience. Washington, DC: American Psychological Association. O’Hanlon, B., & Wilk, J. (1987). Shifting contexts: The generation of effective psychotherapy. New York: Guilford. Rossi, E. L., & Ryan, M. O. (Eds.). (1986). Mind-body communication in hypnosis. New York: Irvington. Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York: W. W. Norton.

Brief Strategic Couple Therapy Michael J. Rohrbaugh George Washington University, Washington, DC, USA

Name of Model Brief Strategic Couple Therapy.

Synonyms Brief problem-focused therapy; Brief Therapy Center; MRI model; Palo Alto group; Palo Alto model

Introduction As described here, brief strategic couple therapy is an extension of the “brief problem-focused therapy”* developed over 40 years ago by Richard Fisch, John Weakland, Paul Watzlawick, and their

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colleagues at the Mental Research Institute (MRI) in Palo Alto, CA (Weakland et al. 1974; Watzlawick et al. 1974; Fisch et al. 1982). The hallmark of this approach is conceptual and technical parsimony: Therapy aims to resolve the presenting complaint as quickly and efficiently as possible by interrupting ironic processes, which in couples take the form of interaction cycles centered on well-intentioned but persistently applied “solutions” that keep problems going or make them worse. The approach is “strategic” because the therapist intervenes to interrupt ironic processes deliberately, on the basis of a case specific plan that sometimes includes counterintuitive suggestions (e.g., to “go slow” or engage in behavior a couple wants to eliminate). Referring to “strategic therapy” alone, however, risks confusing the MRI model with a related but substantially different approach to treating couples and families developed by Jay Haley (who coined the term “strategic therapy”) and his associate Cloé Madanes (Haley 1987). More importantly, by emphasizing style and tactics of intervention, the label “strategic” distracts attention from the more fundamental principle of ironic problem maintenance on which the MRI group* based their approach. Although the focus here is couple therapy, this can be an arbitrary delimitation. As a general approach to problem resolution, the MRI model* approaches couple problems in essentially the same way it does to other complaints. Furthermore, because practitioners of this therapy are inevitably concerned with interpersonal problem maintenance, they typically focus on couple and family interaction even when working with “individual” problems such as depression, anxiety, addictions, and various health complaints – yet to optimize cooperation, they may avoid framing intervention as “couple therapy” when working with what clients prefer to view as “individual” complaints (Rohrbaugh and Shoham 2011). Coupled with the predilection of brief strategic therapists to see people in conflict individually as well as conjointly, this makes it difficult to distinguish between what is and is not couple therapy.

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Prominent Associated Figures Richard Fisch, John Weakland, Paul Watzlawick, Don Jackson, Jay Haley, Cloe Madanes, Wendell Ray.

Theoretical Framework Brief strategic couple therapy is the pragmatic embodiment of a systemic “interactional view” that explains behavior – especially problem behavior – in terms of what happens between people rather than within them (Watzlawick and Weakland 1978). The interactional view grew from attempts by members of Gregory Bateson’s seminal research group (which included Weakland, Haley, and MRI founder Don D. Jackson) to apply ideas from cybernetics and systems theory to the study of communication. After the Bateson project ended, Watzlawick et al. (1967) brought many of these ideas together in the landmark book, Pragmatics of Human Communication. Around the same time, Fisch, Weakland, and Watzlawick formed the Brief Therapy Center* (BTC) at MRI to study ways of doing therapy briefly, and over three decades the BTC team treated over 500 unselected cases, representing a broad range of problems, for up to 10 sessions [Rohrbaugh and Shoham 2015]). The Center’s pattern of practice remained remarkably consistent, with the three core members (Fisch, Weakland, and Watzlawick) participating regularly until Weakland’s death in 1995. From this work emerged a model of therapy that focuses on observable interaction in the present, makes no assumptions about healthy or pathological functioning, and remains as close as possible to practice. At the heart of the model are two interlocking assumptions about problems and change: Regardless of their origins and etiology – if, indeed, these can ever be reliably determined – the problems people bring to psychotherapists persist only if they are maintained by ongoing current behavior of the client and others with whom he interacts. Correspondingly, if such problem-maintaining behavior is appropriately changed or eliminated, the problem will be resolved or vanish, regardless of its nature, or origin, or duration. (Weakland et al. 1974, p. 144)

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Together, these assumptions imply that how a problem persists is much more relevant to therapy than how the problem originated, and that problem persistence depends mainly on social interaction, with the behavior of one person both stimulated and shaped by the response of others (Weakland and Fisch 1992). Moreover – and this is the central observation of the Palo Alto group – the continuation of a problem revolves precisely around what people currently and persistently do (or do not do) to control, prevent, or eliminate their complaint. Although Fisch, Weakland, and associates did not themselves use the term “ironic process,” it captures well their assertion that problems persist as a function of people’s well-intentioned attempts to solve them, and that focused interruption of these solution efforts is sufficient to resolve most problems (Shoham and Rohrbaugh 1997). A problem, then, consists of a vicious cycle involving a positive feedback loop between some behavior someone considers undesirable (the complaint) and some other behavior(s) intended to modify or eliminate it (the attempted solution). Given that problems persist because of people’s current attempts to solve them, therapy need consist only of identifying and deliberately interdicting these well-intentioned yet ironic “solutions,” thereby breaking the vicious cycles (positive feedback loops) that maintain the impasse. If these solutions can be interrupted, even in a small way, then virtuous cycles may develop in which less of the solution leads to less of the problem, leading to less of the solution, and so on (Fisch et al. 1982). Importantly, brief strategic couple therapy attaches little importance to goals such as promoting personal growth, working through underlying emotional issues, or teaching couples better problem solving and communication skills. Theory is minimal and nonnormative, guiding therapists to focus narrowly on the presenting complaint and relevant solutions, with no attempt to specify what constitutes a normal or dysfunctional marriage. Regardless of whether the locus of a complaint involves one or several people, ironic processes in couples

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take many forms and are essentially nonnormative. Thus, patterns such as quiet detachment or volatile engagement might be dysfunctional for some couples but adaptive for others. What matters is the extent to which interaction patterns based on attempted solutions keep a complaint going or make it worse – and the topography of relevant problem-solution loops can vary widely from couple to couple. Furthermore, because the “reality” of problems and change is constructed more than discovered, the therapist attends not only to what clients do but also to how they view the problem, themselves, and each other. Especially relevant is clients’ “customership” for change and the possibility that therapy itself may play a role in maintaining (rather than resolving) problems.

Populations in Focus In principle, this therapy is applicable to any couple that presents a clear complaint and at least one customer for change. In practice, however, strategic interventions appear to be more effective, at least relative to straightforward emotion- or skillfocused interventions, when clients are more rather than less reluctant to change (Fisch and Schlanger 1999; Rohrbaugh and Shoham 2015). For example, the ironic process model is central to team-based family consultation for couples coping with health problems, which is indicated when first line medical or behavioral approaches have not been successful (Rohrbaugh and Shoham 2011, 2017). Brief strategic therapy is probably least applicable to couples whose concern is relationship enhancement, prevention of marital distress, or personal growth. This is because problem-focused therapy requires a complaint and would rarely continue more than a few sessions without one. In fact, the ironic process idea sensitizes us to therapeutic excess and the possibility of therapy itself becoming a problem-maintaining solution. In this framework, intervention should be proportionate to the complaint – and as a general rule, less is best.

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Strategies and Techniques Used in Model The basic formula for conducting brief strategic therapy involves the following: (1) define the complaint in specific behavioral terms; (2) clarify minimum goals for change; (3) investigate solutions to the complaint; (4) formulate ironic problem-solution loops (how more-of-the-same solution leads to more of the complaint, etc.); (5) specify what less-of-the-same will look like in particular situations (the strategic objectives); (6) understand clients’ preferred views of themselves, the problem, and each other; (7) use these views to frame suggestions for less-of-the-same solution behavior; and (8) nurture and solidify incipient change. Sessions do not necessarily occur on a weekly basis, but rather reflect a schedule intended to maximize the likelihood that change will be durable. Thus, when the treatment setting formally imposes a session limit (e.g., 10 sessions), the meetings may be spread over months or even a year. A typical pattern is for the first few sessions to be at regular (weekly) intervals and for later meetings to be less frequent once change begins to take hold. Therapy ends when the treatment goals have been attained and change seems reasonably stable. Termination usually occurs without celebration or fanfare, and sometimes clients retain “sessions in the bank” should they want to return or feel apprehensive about discontinuing contact. Whenever possible – particularly in training or research settings – therapy occurs in a team format with a one-way mirror or closed circuit video set-up, allowing team members to phone in suggestions or consult with the therapist during breaks in the session. As a treatment for couples, this approach differs from most others in that the therapist is willing, and sometimes prefers, to see one or both partners individually. The choice of individual versus conjoint sessions is based on three main considerations: customership, maneuverability, and adequate assessment. Thus, a brief strategic therapist would rather address a marital complaint by seeing a motivated partner alone than by struggling to engage a partner who is not a “customer”

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for change. In theory, this practice should not decrease the possibility of successful outcome, since the interactional systems view assumes that problem resolution can follow from a change by any participant in the relevant interactional system. Another reason to see partners separately, even when both are customers, is to preserve maneuverability. If the partners have sharply different views of their situation, for example, separate sessions give the therapist more flexibility in accepting each viewpoint and framing suggestions one way for her and another way for him. The split format also helps the therapist avoid being drawn into the position of referee or possible ally while working to promote change in what happens between the partners. A final reason for seeing spouses separately is to facilitate assessment. For example, many strategic therapists make a point of seeing each partner alone, at least briefly, to inquire about their commitment to the relationship and assess the possibility of spousal abuse or intimidation. The therapist’s main task is to persuade at least one participant in the couple (or most relevant interactional system) to do less of the solution behavior that keeps the complaint going. While this does not require educating clients, helping them resolve emotional issues, or even working with both members of a couple, it does require working with the customer and preserving maneuverability. The customership principle means simply that the therapist works with the person or persons most concerned about the problem (the “sweater” or sweaters). Preserving maneuverability means that the therapist aims to maximize possibilities for therapeutic influence, which in this model is his or her main responsibility. It also means that the therapist avoids taking a firm position or making a premature commitment to what clients should do, so that later, if they do not do what is requested, alternate strategies for achieving less-of-the same will still be accessible. Despite this preoccupation with controlling the course of therapy, good strategic therapists rarely exert control directly in the sense of offering authoritative prescriptions or assuming the role of an expert. Much more characteristic is what Fisch et al. (1982) call taking a one-down

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position, which involves an unassuming, unknowing stance of empathic curiosity when investigating behavioral sequences around the complaint, or soft-selling specific suggestions in order to promote client cooperation and avoid the common countertherapeutic effects of overly direct or prescriptive interventions. Empathic restraint, exemplified by injunctions to go slow, is a related stance strategic therapists use to neutralize apprehension and/or resistance to change. The main goals of assessment are to (1) define a resolvable complaint; (2) identify solution patterns (ironic problem–solution loops) that maintain the complaint; and (3) understand clients’ unique language and preferred views of the problem, themselves, and each other. The first two goals provide a template for where to intervene, while the third is relevant to how. The therapist begins by getting a very specific, behavioral picture of the complaint, including who sees it as a problem, and why it is a problem now. A useful guideline for behavioral description is having enough details to answer the question, “If we had a video of this, what would I see?” Later the therapist also tries to get a clear behavioral picture of what the clients will accept as a minimum change goal. For example, “What would he (or she, or the two of you) be doing differently that will let you know this problem is taking a turn for the better?” The next step requires an equally specific inquiry into the behaviors most closely related to the problem, namely, what the clients (and any other concerned people) are doing to handle, prevent, or resolve the complaint, and what happens in response these attempted solutions. From this should emerge preliminary formulations of problem-solution loops, particularly of the specific solution behaviors that will become the focus of intervention. The therapist (or team) can then develop a picture of what “less of the same” will look like – that is, what behavior, by whom, in what situation, will suffice to reverse the problemmaintaining solutions. Understanding ironic solution patterns also helps the therapist be clear about what positions and suggestions to avoid. For example, if a husband has been persistently exhorting a wife to eat or spend less, the therapist

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would not want to make any direct suggestion that the wife change in these ways. The most relevant ironic patterns are current ones (what one or both partners continue to do about the complaint now), but the therapist investigates solutions tried and discarded in the past as well, because these give hints about what has worked before, and may work again. The final assessment goal – grasping clients’ unique views, or what Fisch et al. (1982) call “patient position” – is crucial to the later task of framing suggestions in ways clients will accept, so that they will behave in less-of-the-same ways that interrupt ironic processes. Assessing these views depends mainly on paying careful attention to what people say. For example, how do they see themselves and want to be seen by others? What do they hold near and dear? How do they see themselves as a couple, in terms of values, flavor, or unique style? When are they at their best, and what do others notice at those times? Brief strategic therapists employ a variety of strategies to interrupt ironic patterns of couple interaction by inducing one or both partners to do less of the same solution behavior. For example, consider variations of the familiar demandwithdraw sequence, where one partner either (a) pushes for change while the other partner refuses to respond; (b) attempts to initiate discussion, which the other avoids; (c) offers criticisms against which the other defends; or (d) accuses the other of thinking or doing something that he or she denies. Each of these variations fits the ironic problem-solution formula because more demand leads to more withdrawal, which leads to more demand, and so on. If the demand side partner is the main customer for change and pursues this by exhorting, reasoning, arguing, or lecturing (a solution pattern that Fisch et al. (1982, pp. 139–152) call “seeking accord through opposition”), achieving less of the same may depend on helping him or her suspend overt attempts to influence the other partner – for example, by declaring helplessness, taking a one-down position, or performing a diagnostic (observational) task to find out “what he’ll do on his own” or “what we’re really up against.” How the therapist frames such suggestions depends on “patient

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position” (what rationale the client will buy). Thus, an extremely religious wife might be amenable to silently praying for her husband rather than exhorting him, or an outraged spouse might accept redefinition of the partner’s stubbornness as motivated by underlying pride. Because proud people need to discover and do things on their own without feeling pressed or that they are giving in, it makes sense to encourage such a person’s partner through discouragement and restraint – which in effect reverses the former solutions to stubborn behavior (Fisch et al. 1982). When interventions such as these succeed in interrupting an ironic pattern, if only temporarily, the therapist is in a position to nurture and solidify incipient change. When the demand–withdraw pattern involves criticism and defense or accusation and denial, both partners are more likely to be customers for change, which can be introduced through either or both of them. One strategy here focuses on getting the defending partner to do something other than defend – for example, by not responding, simply agreeing with the criticism, or helping the criticizer “lighten up” by not taking the criticism seriously (“I guess you’re probably right. Therapy is helping me see I’m not much fun and probably too old to change”). Another is a conjoint intervention the MRI group called “jamming” (Fisch et al. 1982), where the therapist asks the defending party to deliberately engage in some approximation of the censured behavior (e.g., sometimes acting “as if” she is attracted to other people and sometimes not) while the accuser tests his or her perceptiveness about what the defender is “really” experiencing. The effect of such a prescription can be to free the defender from (consistently) defending and the accuser from accusing because verbal exchanges (accusations and denial) in the “jammed” circuit have less information value. When ironic patterns include the paradoxical form of communication Fisch et al. (1982) called “seeking compliance through voluntarism” (e.g., “You should do this only because you really want to”), the therapist may invite the person who is asking for something to do so directly, even if arbitrarily, or persuade the nonrequesting partner to take the edge off the paradoxical “be spontaneous” demand by saying something like, “I’m

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willing to do it and I will, but let’s face it, I don’t enjoy this.” In other complaint-maintaining exchanges, one partner may be domineering or explosive and the other placating or submissive. Here, less of the same usually requires getting the submissive, placating partner to take some assertive action. In contrast, an intervention for combative couples embroiled in symmetrically escalating arguments might involve getting at least one partner to take a one-down position, or prescribing the argument under conditions likely to undermine it. Finally, although interventions for marital complaints usually focus on one or both partners, there are circumstances in which other people – relatives, friends, or even another helper – figure prominently in this approach to couple therapy, especially when the third party is a central customer for change. For example, a mother understandably concerned about her daughter’s marital difficulties may counsel or console the daughter in ways that unwittingly amplify the problem or make the young husband and wife less likely to deal with their differences directly. In this case, brief therapy strategic might focus first on helping the mother reverse her own solution efforts and take up later (if at all) the interaction between the young spouses, which is likely to change when the mother becomes less involved.

Research About the Model Although most research on brief strategic couple therapy has been qualitative, it is noteworthy that the original description of brief, problem-focused therapy by Weakland et al. (1974) included tentative 1-year outcome percentages for the first 97 cases seen at the MRI Brief Therapy Center. A later analysis of 285 BTC cases seen through 1991 found problem resolution rates of 44%, 24%, and 32% for success, partial success, and failure, respectively – figures very similar to those Weakland and colleagues had reported a15 years earlier (Rohrbaugh et al. 1992; Rohrbaugh and Shoham 2015), Thus, at least two-thirds of the BTC cases reportedly improved, and the average length of therapy was six sessions. Interestingly,

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about 40% of these early cases involved some form of couple complaint, and couple cases were more likely to be successful when at least two people (the two partners) participated in treatment. This analysis did not, however, evaluate the potentially confounding role of customership or the possibility that the absent partners were as uncommitted to the relationship as they apparently were to therapy. Other research relevant to this model has focused on the role of ironic processes in problem maintenance and change. For a summary, see Rohrbaugh and Shoham (2011, 2017).

Case Example In a case treated at the MRI Brief Therapy Center, the wife, herself a therapist and the main complainant, would repeatedly encourage her inexpressive husband to get his feelings out, especially when he came home from work “looking miserable.” When the husband responded to this encouragement with distraught silence, the wife would urge him to talk about his feelings toward her and the marriage (thinking that this topic would bring out positive associations on his part and combat his apparent misery). In a typical sequence, the husband would then begin to get angry and tell the wife to back off. She, however, encouraged by his expressiveness, would continue to push for meaningful discussion, in response to which – on more than one occasion – the husband stormed out of the house and disappeared overnight. The intervention that eventually broke the cycle in this case came from Fisch, who entered the therapy room with a suggestion: In the next week, at least once, the husband was to come home, sit at the kitchen table, and pretend to look miserable. The wife’s task, when she saw this look, was to go to the kitchen, prepare chicken soup, and serve it to him silently, with a worried look on her face. The couple came to the next session looking anything but miserable. They reported that their attempt to carry out the assignment had failed because she – and then he – could not keep a straight face, yet they were delighted that the humor so characteristic of the

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early days of their relationship had resurfaced. Whereas the intervention served to interdict the wife’s attempted solution of pursuing discussion, it also interrupted the heaviness and deadly seriousness in the couple’s relationship (Rohrbaugh and Shoham 2015, p. 344).

Cross-References ▶ Bateson, Gregory ▶ Brief Strategic Couple Therapy ▶ De Shazer, Steve ▶ Haley, Jay ▶ Jackson, Donald ▶ Papp, Peggy ▶ Paradoxical Directive in Couple and Family Therapy ▶ Restraining in Couple and Family Therapy ▶ Second-Order Change in Couple and Family Therapy ▶ Symmetrical Relationships in Couples and Families ▶ Watzlawick, Paul ▶ Weakland, John

References Fisch, R., & Schlanger, K. (1999). Brief therapy with intimidating cases: Changing the unchangeable. San Francisco: Jossey-Bass. Fisch, R., Weakland, J. H., & Segal, L. (1982). The tactics of change: Doing therapy briefly. San Francisco: Jossey-Bass. Haley, J. (1987). Problem – Solving therapy: New strategies for effective family therapy (2nd ed.). San Francisco: Jossey-Bass. Rohrbaugh, M. J., & Shoham, V. (2011). Family consultation for couples coping with health problems: A socialcybernetic approach. In H. S. Friedman (Ed.), Oxford handbook of health psychology (pp. 480–501). New York: Oxford University Press. Rohrbaugh, M. J., & Shoham, V. (2015). Brief strategic couple therapy: Toward a family consultation approach. In A. S. Gurman, D. K. Snyder, & J. Lebow (Eds.), Clinical handbook of couple therapy (5th ed., pp. 335–357). New York: Guilford Publications. Rohrbaugh, M. J., & Shoham, V. (2017). Family consultation for change-resistant health and behavior problems: A systemic-strategic approach. In L. E. Beutler, A. J. Consoli, & B. Bongar (Eds.), Comprehensive

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358 textbook of psychotherapy (2nd ed.). New York: Oxford University Press. Rohrbaugh, M.J., Shoham, V., & Schlanger, K. (1992). In the brief therapy archives: A request on the don D, jackson memorial award. Mental Research Institute, Palo Alto, CA. Shoham, V., & Rohrbaugh, M. J. (1997). Interrupting ironic processes. Psychological Science, 8, 151–153. Watzlawick, P., & Weakland, J. H. (Eds.). (1978). The interactional view. New York: Norton. Watzlawick, P., Beavin, J., & Jackson, D. D. (1967). Pragmatics of human communication. New York: Norton. Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York: Norton. Weakland, J. H., Fisch, R., Watzlawick, P., & Bodin, A. (1974). Brief therapy: Focused problem resolution. Family Process, 13, 141–168. Weakland, J. H., Fisch, R., & Watzlawick, P. (1992). Brief therapy–MRI style. In S.H. Budman, M.F. Hoyt, & S. Friedman (Eds.), The first session in brief therapy (pp. 306–323). New york: Guilford press.

Brief Strategic Family Therapy Austen R. Anderson1, Stephen K. Denny1, Joan A. Muir2 and José Szapocznik1 1 University of Miami, Miami, FL, USA 2 Brief Strategic Family Therapy Institute ® (BSFT ®), University of Miami Miller School of Medicine, Miami, FL, USA

Name of Model Brief Strategic Family Therapy

Introduction The Brief Strategic Family Therapy (BSFT) model is an evidence-based intervention used with families of adolescents who are engaging in problematic behaviors (Horigian et al. 2016). It is usually delivered weekly for 12–16 sessions, with each session lasting about 1–1¼ h. It most often occurs at the client’s home, but can also occur at other places that are convenient for the family, including schools or community clinics. The intervention is guided by a clinical manual that outlines the

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model’s theory and techniques (Szapocznik et al. 2003). As described below, the current BSFT intervention emerged from a rich history of treatment development that included theoretical principles, clinical experience and experimentation, empirical treatment research, and implementation science. It should be noted that in the BSFT model, “family” is defined as all individuals who “function” in the role of family members, and “parents” are defined as those adults who function in parenting roles.

Prominent Associated Figures In the 1970s, Szapocznik and colleagues investigated how family intergenerational and cultural conflict in Cuban families in Miami were causing adolescents to develop problem behaviors such as drug use, delinquency, and conduct problems at school and at home (Szapocznik et al. 1978b). To help these families, the BSFT intervention was developed as an integration of Minuchin’s (1974) Structural Family Therapy and Haley’s (1976) Strategic Family Therapy. The model was initially designed to be culturally specific to the preferences of Cuban immigrant families in Miami (Szapocznik et al. 1978a). These families preferred treatments that were focused on the present, were practical in that they focused on fixing presenting problems (i.e., family conflict and adolescent drug use), and involved a therapist who, in accordance with a hierarchical view of relationships, acted as an expert in directing the family to arrive at solutions to their problems. The integrated structural and strategic therapies matched these families’ preferences and resulted in a culturally relevant family-based intervention. The core BSFT intervention has been refined, improved, and more widely disseminated to other cultural groups over the last four decades, always using a consistent theoretical framework.

Theoretical Framework The BSFT theoretical framework builds on an ecological perspective within which the family is understood as the fundamental context for the

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development of children. Specifically, adolescent development is influenced by the interactions that occur within the family and between the family and its context (Szapocznik and Coatsworth 1999). The evidence suggests that when families communicate well and are respectful and nurturing in their interactions; when there is appropriate parental involvement, monitoring, and guidance; when parents collaborate on parenting activities and the implementation of rules, then adolescent substance use and related behavior problems are reduced. Alternatively, when families are unable to resolve their differences (e.g., blaming to change the topic of conversation), when affect is chronically negative, and when family members are unable to communicate directly and with specificity, then adolescents are more likely to engage in problematic behaviors. The overarching goal of BSFT is to improve the functioning of families by changing those patterns of interactions that prevent the family from reaching its own goals – referred to as “maladaptive” interactions – while encouraging supportive and nurturing interactions. As families learn new ways of interacting, they are able to more successfully pursue individual and family goals. The BSFT intervention is based on three main theoretical principles adapted from structural and strategic family therapies: systemic, structural, and strategic. These principles provide the framework for understanding the obstacles that keep the family from achieving its goals (the theory of the problem) and the method for bringing about change in the obstacles that are keeping the family from achieving its goals (the theory of behavior change). Systems theory posits that the parts of the system are interdependent. Families are social systems with interdependent family members. Each family member is affected by the other family members’ actions. For families that are functioning well, this interdependency can lead to the successful attainment of family and individual goals for family functioning and healthy adolescent development. Structural refers to the family’s habitual repetitive patterns of interactions. These repetitive patterns of interactions can be either

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beneficial or problematic. Families served in BSFT treatment are often stuck in maladaptive interpersonal interactions. That is, interactional patterns that do not permit the family to achieve their own goals. Despite their maladaptive nature, these repetitive patterns of interactions are often experienced as a stabilizing force within the family. This tendency toward stable equilibrium (or homeostasis) can explain some families’ willingness to continue to behave in ways that are problematic for the family. The BSFT intervention is also based on a strategic approach to family therapy, meaning that the BSFT therapist makes use of treatment plans that target the families’ presenting problems using practical interventions. Practical means that interventions are selected because they have the greatest likelihood of successfully changing family interactions. One example is reframing. Reframing, as noted below, is emphasizing one aspect of a family’s interaction to encourage more positive interactions among family members. Interactions such as a father being angry with his daughter may comprise a complex reality. However, the therapist might select one aspect of that reality – that the father is worried about the daughter – and highlight it in hopes that it could lead to more positive interactions (in which father shares, “Yes, I am worried that she is in trouble with the law, and I want her to succeed in life”). Through these practical interventions, a BSFT therapist strives to bring about changes in the family’s maladaptive patterns of interaction so that the family can function in a way that will reduce the adolescent’s problem behaviors. Further, a problem-focused approach targets only those repetitive patterns of family interactions that are directly related to the adolescents’ problem behaviors. Such problem-focused approach allows for substantive change in a relatively short period of time. Hence, the strategic aspect of the BSFT model means that interventions are planned and focused on changing those interactions that prevent the family from achieving its goals of eliminating the problem behavior. Strategic also means that interventions are practical, meaning that they are most likely to achieve a desired outcome.

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Taken together, these principles offer a theoretical framework for understanding the development of adolescent problem behaviors (stemming from maladaptive family interactions such as negativity within the family, a lack of warmth, poor boundaries, and a weak executive system) and a framework to bring about change.

Populations in Focus As mentioned, this intervention was originally developed in the early 1970s to help Cuban immigrant families who were experiencing intense intergenerational family conflict related to cultural issues, with the goal of reducing conflicts that gave rise to adolescent problem behaviors such as drug use, delinquency, and conduct problems in school and in the family. After achieving clinical success with Cuban Americans, the model was subsequently tested on other Hispanic cultural groups, White Americans, and Black Americans. As a family-based intervention, the model is best suited to adolescents who can be treated with their family members and is thus targeted toward adolescents who live with at least one parental figure (defined as an adult who functions in the role of a family member). In most cases, the treatment is used for adolescents (12–17 years old) who are using drugs or are engaging in other problematic behaviors such as delinquency and conduct problems at school and home. It has also been used as an after-care intervention for youth released from residential or probationary settings.

BSFT Techniques The BSFT techniques build on the work of Salvador Minuchin (1974) and have been adapted for families with troubled externalizing adolescents. These techniques are organized into four main categories: joining, tracking and diagnosis, reframing, and restructuring. While each of these interventions is important, some are more critical at different periods of the treatment process. Joining interventions are those that allow the

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therapist to build a therapeutic relationship with all members of the family and with the family system itself. Joining is especially important in the early stages on therapy to build the relationship between the therapist and the family. Therapists must show each family member respect and acceptance by validating each person, their concerns, and desired therapy outcomes. Joining allows the therapist to be viewed as a temporary member and leader of the family. Research reveals that joining is critical throughout therapy to ensure successful outcomes (Robbins et al. 2011b). A second set of techniques is tracking and diagnosing. These interventions often involve redirecting the family members to speak directly with each other rather than to the therapist when they are describing their family problems. In this case, a therapist might direct a son to speak directly to his father, rather than allowing the son to tell the therapist his complaint about the father. When the youth speaks directly to his father, the therapist is able to observe how father and son interact, and more generally how other family members may interfere when son and father try to interact directly, hence gaining a better understanding into how the family members might interact with each other on a day to day basis. With this information, the therapist can identify the family’s repetitive patterns of interactions in ways that prevent the family from achieving its goals. In other words, the therapist can diagnose the family’s problematic patterns of interaction which will guide later interventions. Hence it is the diagnosis of these repetitive patterns of interactions that make it possible to plan the course of treatment, contributing to the brevity of BSFT. A common pattern that might be diagnosed is identified patienthood or scapegoating, which occurs when one family member is blamed for all of the family’s problems. This is often the drug using, delinquent, or conduct problem adolescent. Blaming the adolescent allows the family to ignore other problems within the family (e.g., father is depressed, mother is angry). Another common pattern of interaction occurs when, in a two parent-figure family, a parent and child are closer to each other than both parents are together.

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This would lead to interactions wherein one parent is marginalized and the youth becomes uncontrollable because parents who do not work together typically do not have the power to control an acting out adolescent. Having obtained an understanding of the family system, therapists can help reduce overall negativity within the family and improve motivation for change by using reframing techniques. Reframing takes emotionally charged negative interactions and, through careful selection of a transformative frame, offers more positive meanings that are likely to permit more constructive dialogue. For example, after a mother says, “You’re wasting your life by hanging out with friends like yours” to her daughter, a therapist could indicate to the mother that “It sounds to me like you care about your daughter a lot and that you would like her to have a happy, healthy, and productive future.” Hearing an angry criticism – which might normally be met with harsh responses or behavioral acting out – transformed into concern, might reduce the focus on the daughter’s problematic friendships and increase the focus on feelings of love and concern that the mother has for her daughter. Reframing is a powerful way to improve relations in the family, and by creating a motivational context for change, prepares the family to behave in new ways. In BSFT treatment, the actions of the therapist that are intended to create new ways of interacting are called restructuring techniques. Supplemented with a strong therapeutic relationship, an understanding of the current patterns of interaction, decreased negativity, and the creation of a motivation context for change (through reframing), the therapist is now ready to encourage new ways of interacting using restructuring techniques. For example, in the case of a family in which the problem adolescent and one parent are more closely allied than the parents are with each other, it is important to create a stronger bond between the parents, which the therapist can do by giving the parents the task of working together to agree on the rules they would want to develop for their daughter. This intervention to change the alliances from mother–child to mother–father figures is frequently needed in families with acting

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out adolescents. The intention is to create a new experience in the family in which parents work together (which will require much help in conflict resolution, keeping the daughter from sabotaging the parents, etc.) to manage an out-of-control youth. These changes, once consolidated, help the family respond more effectively to other challenges that will emerge in the future.

Research About the Model Research has been conducted on the BSFT intervention across four decades. BSFT Engagement In the 1980s when BSFT Engagement was developed, the challenge of engaging and retaining families of drug-using adolescents in treatment was experienced across the nation by treatment providers who felt that family therapy was appropriate for externalizing adolescents, but could not get families into treatment. There was a groundbreaking observation that made BSFT Engagement possible. As the developers struggled to bring families into treatment, they realized that the kinds of interactional patterns they had observed in therapy were similar, if not identical, to the kind of interactional patterns that were keeping families from entering therapy. It was thus hypothesized that the symptom of “resistance to coming to therapy” resulted from the same repetitive patterns of interactions that were causing other problems in the family such as adolescent drug abuse. To address this challenge, BSFT developers decided to extend the use of three of the BSFT interventions (joining, tracking/diagnosing, and reframing) to the problem of engagement. In other words, from the first contact with the family, the therapist was tasked with using the same systemic, structural, and strategic principles and interventions to help bring the family into treatment and to increase the rate of retention into therapy. To accomplish this, the family’s “resistance” to entering treatment was re-conceptualized and treated in terms of systemic, structural, and strategic principles. The therapist would join with individual family

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members who were initially available to the therapist by validating that individual’s willingness to reach out for therapy, would track and diagnose family interactions, and would reframe negative statements to increase motivation to attend therapy. For example, if the person seeking therapy says that she/he cannot bring another family members in, the therapist determines that that the other family member is more powerful than the person seeking therapy. Then the therapist, with the permission of the person seeking therapy, will directly reach out to that person(s) to overcome their reluctance to entering treatment. Research on the efficacy and effectiveness of this engagement process is described below. A case example is also presented below that demonstrates the use of BSFT Engagement to bring families into treatment. Across three efficacy trials, BSFT Therapy + BSFT Engagement proved to be significantly better at initially engaging families into treatment and retaining them into treatment. This effect was found when comparing BSFT Therapy + BSFT Engagement to BSFT Therapy alone in a university clinic (Szapocznik et al. 1988), to group therapy in a university clinic (Santisteban et al. 1996), and family counseling in a community-based clinic (Coatsworth et al. 2001). BSFT Efficacy Two efficacy trials demonstrated that BSFT was more effective than alternative therapy conditions. In the first study with 6–11-year-old Cuban boys, BSFT treatment was more effective that an individual psychodynamic therapy and a recreation intervention placebo control (Szapocznik et al. 1989). Both therapies, BSFT and individual, showed improved emotional and behavioral problems at post-treatment. However, at the 1-year follow-up, BSFT had significantly improved on blind independently-rated family functioning, while the families whose children were treated with individual therapy had significantly deteriorated in their blind independentlyrated family functioning. A second efficacy trial compared BSFT with an adolescent problem-solving group control intervention (Group; Santisteban et al. 2003). Teens who were in BSFT treatment had significantly

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reduced aggression and conduct problems relative to those in Group. Of those who reported marijuana use, being placed in BSFT treatment resulted in significantly reduced drug use at termination relative to those in Group. Family cohesion also significantly improved in BSFT treatment relative to Group. BSFT Effectiveness A national, multisite BSFT effectiveness trial was conducted by randomizing families within each of eight community-based agencies (Robbins et al. 2011a). BSFT treatment was compared against the treatments usually offered at each clinic (“usual treatment”). The findings presented in this section represent findings across AfricanAmerican, Hispanics, and White American youth and their families. Engagement and Retention

BSFT with BSFT Engagement fully integrated was significantly more effective than the usual treatment at bringing and retaining families in treatment in community-based settings. This increased engagement and retention is especially important because families who need care are not always able to bring themselves into treatment. Drug Use

At 12 months, the BSFT condition, compared to usual treatment, had a lower median number of days of drug use (2 vs. 3.5 days of use in the last 28 days). There was not a difference in the mean trajectory of use between conditions. In part this was the case because drug use values were generally low and stayed low in both conditions throughout the 12 months of the study. Low rates of drug use made it difficult to find significant improvements. Moreover, 72% of the adolescents were referred from juvenile justice systems and thus were often coming from drug-free settings and were often monitored by the juvenile justice system throughout the 12-month period of the study. Subsequent analyses showed that BSFT treatment was dramatically more effective than usual treatment in helping adolescents whose parents used alcohol and drugs at baseline (Horigian et al. 2015a).

Brief Strategic Family Therapy

Family Functioning

Compared to usual treatment, in the BSFT condition, parents rated their family functioning as significantly more improved. Adherence Affects Outcomes

Families treated by therapists who adhered better to the BSFT techniques of joining, tracking and highlighting, and reframing and restructuring had all-around better outcomes. That is, better engagement, better retention, greater reductions in drug use, and more improved family functioning outcomes (Robbins et al. 2011b). Arrests and Incarceration

A follow-up conducted 4–7 years after baseline (3–6 years after treatment) revealed that, compared to usual treatment, BSFT was significantly more effective in reducing self-reported last-year and lifetime arrests and imprisonments (Horigian et al. 2015b). BSFT Implementation We have demonstrated that better adherence to the model predicted good outcomes for the families and adolescents treated with BSFT. The challenge in providing evidence-based interventions, like BSFT, is in implementing the treatment in a way that allows for excellent fidelity (Szapocznik et al. 2015). To accomplish this, the BSFT Institute was created as the implementation team that helps agencies adopt BSFT, deliver BSFT treatment with fidelity, and enhance the likelihood of sustainability. Adoption requires the agency’s readiness to make organizational changes needed to successfully implement BSFT. Fidelity requires that therapists adhere to BSFT theoretical principles and techniques. As part of this process, agencies, rather than therapists, are certified to provide BSFT because therapists need a supportive organizational structure to have good outcomes with the families with whom they work. Finally, sustainability requires that agencies involve funders in observing BSFT outcomes. Thus, for agencies to be licensed to provide BSFT, they must be able to limit the case load of their therapists to 10–14 cases to allow adequate time to travel to families’ homes to deliver

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therapy, prepare treatment plans, and receive continued monitoring, feedback, and coaching on their BSFT cases. One key factor in reducing therapists’ client loads is the agency’s ability to obtain funding based on treating each family (or case) rather than on a fee-for-service model. This is important because when an agency is funded by case, they are evaluated not on the volume of sessions, but rather on the outcome with each of their families. Another important step in BSFT Implementation is the creation of BSFT teams that deliver only BSFT and no other treatments. This has two functions. First, practicing only BSFT allows the therapist to develop more fully their skills in the approach. Second, the team provides a context that supports BSFT knowledge and practice over time. The process of BSFT implementation includes four main steps: identifying and engaging the key agency leaders, assessing agency readiness to adopt BSFT, creating a motivation context for change in the agency, and obtaining a commitment to sustainability. By the time an agency obtains a license to practice BSFT, the agency will typically have a team of four BSFT therapists including an on-site supervisor who has displayed a special aptitude in delivering the BSFT intervention. The on-site supervisor takes on the supervision of the agency’s other BSFT therapists and continues to receive supervision on their supervision from the BSFT Institute. Future research will test the efficacy of the BSFT Implementation model on successful adoption, fidelity and sustainability.

Case Example The Lewis family was referred by the school because the daughter’s school performance had deteriorated, and the daughter had shared with the school counselor that she had frequent fights with her mother. The BSFT therapist received the referral and called the family. The mother answered the call. After speaking with the mother, the therapist scheduled a family session. The therapist learned during this first call that the family consisted of a mother and a father figure, a

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14-year-old son, and an 11-year-old daughter. In BSFT treatment, the sessions can take place at the home if that is more convenient to the family. The mother stated, however, that she did not want therapy in the home, so the therapist scheduled their first session for his office. The therapist made it clear to the mother that she would like to meet with all four members of the family and asked the mother if she thought there would be any problems for the whole family to attend. The mother said, “It will be fine. I’ll get us all to come.” At the first session, only the mother and the 11-year-old daughter arrived for treatment. The therapist inquired about the father and son, and the mother explained that they were not able to come that evening, but they would be available the following week. To explore the obstacles that may have obstructed the son and father to join therapy, the therapist mostly asked relational questions about how things worked in the family, focusing on bringing the father to the session: “Tell me what you said to your husband when you invited him to treatment?” The mother said that she told father that everyone was expected to come to the session. “How did he respond?” the therapist asked. He said he could not do it this week but he would come next week. The therapist out of an abundance of caution said to the mother, “If you don’t mind, I will give a call to your husband. I would personally like to emphasize how important it is for him to come. If he is not able to come at the time of the session, we will change the session for a time that works for him.” The therapist was surprised when mother refused to give him the father’s phone number; she said that father did not want to come to therapy, but that she and her daughter were committed to getting help. It became clear to the therapist at this point that the mother did not want her husband in treatment, and the therapist was well aware that BSFT treatment requires working with whole families. At that point the therapist said that she would like to explore other ways to reach the father, and purposely left it vague. The therapist intentionally did not say what she had in mind because she did not want the mother to block her. The therapist planned to drop by the house in the evening, hoping to find the father.

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Fortunately, when the therapist came to the house, she found the father at home. The therapist was very surprised when the father told him that he wanted to participate, but had been told by the mother that therapy was only going to focus on the mother–daughter relationship. The mother and daughter were not at home, and the therapist worked out a time to come back to the house when everyone would be home. In the next session, the therapist decided not to confront the mother. Rather, she expressed how happy she was that everyone was able to be present at the session. She indicated that she was now ready to begin therapy and told the family that she was here to help them, asked how she could best help them. Mom immediately said that daughter was not doing well at school and had been very rebellious with her. The therapist requested that the mother say this directly to the daughter. Mom said, “I have told her a million times,” but the therapist responded, “If you don’t mind, I would like for you to tell her in my presence.” The daughter responded with considerable anger. The therapist then asked the dad for help. “Dad, what do you think makes your daughter so angry?” to which the father responded that he did not think that his daughter liked sleeping in the same bed with the mother. Apparently, the mother did not want to sleep in the same bed as her husband and had brought the daughter to sleep with her, and the father now slept in the daughter’s bed. It was clear that the mother and daughter had a very strong bond and were overly involved with each other, while at the same time, the mother was trying to marginalize the dad, and that the dad was unhappy with his sleeping arrangement (and more). It did not take much training to know that the mother and father’s marital problems were affecting the daughter who had become triangulated between the mother and father in a very literal sense – she had been forced to take her father’s place in the marital bed. This example demonstrates why it is so critical in BSFT to see the entire family. Only when the whole family is together, is it possible to learn about the patterns of interactions that are linked to the youth’s presenting problems.

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When all family members are not present, the therapist is unable to diagnose the true family interactions.

Cross-References ▶ Adolescents in Couple and Family Therapy ▶ Family Structure ▶ Strategic Family Therapy ▶ Structural Family Therapy ▶ Training in Brief Strategic Family Therapy Acknowledgments This work was funded in part by grants UL1TR000460 and U10DA013720 to José Szapocznik. José Szapocznik is the developer of this method. The University and José Szapocznik have the potential for financial benefit from future commercialization of this method.

References Coatsworth, J. D., Santisteban, D. A., McBride, C. K., & Szapocznik, J. (2001). Brief strategic family therapy versus community control: Engagement, retention, and an exploration of the moderating role of adolescent symptom severity. Family Process, 40(3), 313–332. https://doi.org/10.1111/j.1545-5300.2001.4030100313.x. Haley, J. (1976). Problem-solving therapy. San Francisco: Jossey-Bass. Horigian, V. E., Feaster, D. J., Brincks, A., Robbins, M. S., Perez, M. A., & Szapocznik, J. (2015a). The effects of Brief Strategic Family Therapy (BSFT) on parent substance use and the association between parent and adolescent substance use. Addictive Behaviors, 42, 44–50. https://doi.org/10.1016/j.addbeh.2014.10.024. Horigian, V. E., Feaster, D. J., Robbins, M. S., Brincks, A. M., Ucha, J., Rohrbaugh, M. J., . . . Szapocznik, J. (2015b). A cross-sectional assessment of the long term effects of brief strategic family therapy for adolescent substance use. The American Journal on Addictions, 24(7), 637–645. https://doi.org/ 10.1111/ajad.12278. Horigian, V. E., Anderson, A. R., & Szapocznik, J. (2016). Taking brief strategic family therapy from bench to trench: Evidence generation across translational phases. Family Process, 50(3), 529–442. https://doi. org/10.1111/famp.12233. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Robbins, M. S., Feaster, D. J., Horigian, V. E., Rohrbaugh, M., Shoham, V., Bachrach, K., . . . Szapocznik, J. (2011a). Brief strategic family therapy versus treatment as usual: Results of a multisite randomized trial for substance using adolescents. Journal

365 of Consulting and Clinical Psychology, 79(6), 713–727. https://doi.org/10.1037/a0025477. Robbins, M. S., Feaster, D. J., Horigian, V. E., Puccinelli, M. J., Henderson, C., & Szapocznik, J. (2011b). Therapist adherence in brief strategic family therapy for adolescent drug abusers. Journal of Consulting and Clinical Psychology, 79(1), 43–53. https://doi.org/10.1037/a0022146. Santisteban, D. A., Szapocznik, J., Perez-Vidal, A., Kurtines, W. M., Murray, E. J., & LaPerriere, A. (1996). Efficacy of intervention for engaging youth and families into treatment and some variables that may contribute to differential effectiveness. Journal of Family Psychology, 10(1), 35–44. https://doi.org/ 10.1037/0893-3200.10.1.35. Szapocznik, J., Scopetta, M. A., de los Angeles Aranalde, M., & Kurtines, W. M. (1978a). Cuban value structure: Treatment implications. Journal of Consulting and Clinical Psychology, 46(5), 961–970. https://doi.org/10.1037/0022-006X.46.5.961. Szapocznik, J., Scopetta, M. A., Kurtines, W., & Aranalde, M. D. (1978b). Theory and measurement of acculturation. Revista Interamericana de Psicología, 12(2), 113–130. Szapocznik, J., Perez-Vidal, A., Brickman, A. L., Foote, F. H., Santisteban, D., Hervis, O., & Kurtines, W. M. (1988). Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach. Journal of Consulting and Clinical Psychology, 56(4), 552–557. https://doi. org/10.1037/0022-006X.56.4.552. Szapocznik, J., Rio, A., Murray, E., Cohen, R., Scopetta, M., Rivas-Vazquez, A., . . . Kurtines, W. (1989). Structural family versus psychodynamic child therapy for problematic Hispanic boys. Journal of Consulting and Clinical Psychology, 57(5), 571–578. https://doi.org/10.1037/0022-006X.57.5.571. Szapocznik, J., Hervis, O., & Schwartz, S. J. (2003). Brief strategic family therapy for adolescent drug abuse (NIDA therapy manuals for drug addiction, NIH publication 03–4751). Bethesda: Department of Health and Human Services. Szapocznik, J., Muir, J. A., Duff, J. H., Schwartz, S. J., & Brown, C. H. (2015). Brief strategic family therapy: Implementing evidence-based models in community settings. Psychotherapy Research, 25(1), 121–133. https://doi.org/10.1080/10503307.2013.856044. Szapocznik, J., & Coatsworth, J. D. (1999). An ecodevelopmental framework for organizing the influences on drug abuse: A developmental model of risk and protection. In M. Glanz & C.Hartel (eds.), Drug abuse: Origins and interventions, American Psychological Association, Washington, DC, pp. 331–366. Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A., Kurtines,W. M., Schwartz, S. J., LaPerriere, A., et al. (2003). Efficacy of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use. Journal of Family Psychology,17,121–133.

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Bronfenbrenner, Urie David Hauser and Dan Gill The Family Institute at Northwestern University, Evanston, IL, USA

Introduction Urie Bronfenbrenner was a psychologist and human development theorist. His theory and writing evolved into what became known as “the ecology of human development.” Bronfenbrenner also notably had a significant impact in public policy as it relates child development in the United States, consulting with congress in the 1960s to help design and construct the Head Start program which has provided hundreds of thousands of under-resourced children access to early childhood education.

Career Bronfenbrenner was born in Moscow, but he and his family moved to the United States when he was 6 years old. His father was a neuropathologist, who spent a good deal of his career advocating for under-resourced children in New York City. Bronfenbrenner went on to attend Cornell University for undergraduate study, majoring in music and psychology. He then earned a master’s in education at Harvard University and finally a Ph.D. in developmental psychology from the University of Michigan. He had brief stints as a military psychologist in World War II and as an assistant professor at the University of Michigan. In 1948 he moved back to join the faculty at Cornell University where he spent the remainder of his career, some 50 years, as a professor of human development. In his unique experience having been born in the Soviet Union, but growing up in the United States, Bronfenbrenner penned “Two Worlds of Childhood: U.S. and U.S.S.R.,” a timely crosscultural comparison of child development between these two nations’ different approaches

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for child rearing in 1970, at the height of the Cold War. It was a piece of academic work that foreshadowed two critical elements of what would become Bronfenbrenner’s lasting theoretical contributions: the importance of environment and ecology in shaping human development and a recognition of the myriad of different complicated, systemic, and interacting variables that influence a person’s development. It was his 1978 book “The Ecology of Human Development,” that remains Bronfenbrenner’s lasting legacy, a major contribution to the growing field of family therapy in the 1970s, as well as the fields of psychology and human development.

Contributions to Profession As a theory, The Ecology of Human Development built upon foundations laid by the early pioneers of systems theory like Gregory Bateson and Ludwig von Bertalanffy and groundwork for more modern family systems psychotherapy theories like integrative systems theory (IST, formerly Integrated Problem-Centered Metaframeworks (IPCM)). Bronfrenbrenner used elements of systems theory to suggest that multiple complex and interacting systemic layers shape a child (or person) in their development. Bronfenbrenner posited that humans are shaped by four layers of different systems of influence: most immediately the microsystem (often including influence from family, siblings, peers, school), the mesosystem (the interaction of different microsystem variables upon the individual), the exosystem (slightly more distant shaping variables such as an individual’s neighborhood or parent’s work environment, mass media, or local politics), and lastly the macrosystem (variables such as social conditions, laws, political climate, culture, or the economy). A helpful analogy utilized in understanding and demonstrating Bronfenbrenner’s ecological systems theory is that of the famous “Russian nesting dolls” (the oblong-shaped wooden dolls that usually are grouped in 4–5 dolls, each nesting or sitting inside the larger doll). The idea is that an

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individual lay at the middle of all of the complicated environmental systems around them. Each layer provides some level of influence on an individual’s development. The closer the systemic layer to the individual, the stronger the influence upon the individual’s development. Thus, the microsystem (including family, school, and peers) is a stronger shaping agent in an individual’s development than the exosystem, where influence is still present, but not as strong as a shaping agent. Later in the development of this theory, Bronfenbrenner added another systemic layer of influence upon human development, which he termed the “chronosystem.” The chronosystem accounted more for the role of time and its impact on development, as well as the patterning of environmental events and transitions over the life course. Bronfenbrenner’s ecological theory continues to hold importance in assessment and family therapy models. His theories specifically hold much relevance in family therapy. Similar to the use of biopsychosocial assessments or integrative systems therapy (IST), Bronfenbrenner’s ecological theory offers a systematic framework for synthesizing the seemingly endless number of potential environmental variables that can impact a person’s development, but doing so in a way that can increase understanding of a person, while also respecting the complexity of a human life. John Hopkins sociologist, Melvin L. Kohn, and former Bronfenbrenner student at Cornell put it best, Bronfenbrenner’s work impelled social and behavioral scientists to “realize that interpersonal relationships, even [at] the smallest level of the parent-child relationship, does not exist in a social vacuum but are embedded in the larger social structures of community, society, economics and politics.”

References Bronfenbrenner, U. (1970). Two worlds of childhood: U.S. and U.S.S.R. New York: Simon and Schuster. Bronfenbrenner, U. (1979). The ecology of human development: Experiment by nature and design. Cambridge, MA: Harvard University Press.

367 Fox, M. (2005, September 27). Urie Bronfenbrenner, 88, an authority on child development. New York Times. Woo, E. (2005, September 27). Urie Bronfenbrenner, 88; co-founder of Head Start urged closer family ties. Los Angeles Times.

Browning, Scott Amy Roth Chestnut Hill College, Philadelphia, PA, USA

Introduction Scott Browning is a licensed psychologist, professor, researcher, mentor, and a member of several professional organizations. Browning’s vast contributions to the field of family therapy include the following subject areas: the diverse and changing family, increasing and measuring empathy, children with developmental disorders, therapy outcomes, and the dynamics and treatment of stepfamilies.

Career Browning received his Ph.D. in clinical psychology from the California School of Professional Psychology in 1986, which he followed with a postdoctoral fellowship at the Philadelphia Child Guidance Clinic. He has been a professor in the Chestnut Hill College Clinical Psychology Doctoral Program since 1988 and was chair of the Masters and Doctoral Programs from 1995 to 2001. His clinical experience includes providing therapy in the private practice setting since 1988, where he specializes in family therapy, school-related concerns, remarried families and couples, adult individuals, adolescents and children, and consultation and supervision. Additionally, he was the director of the counseling center at Chestnut Hill College from 1989 to 1997. Browning also has extensive experience supervising and mentoring clinical psychology students and early career psychologists, as well

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as consulting with psychologists in a variety of settings, including the Psychological Services Clinic of Chestnut Hill College, the Counseling Center for Families and Individuals, and with the Anti-Violence Partnership.

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References Browning, S., & Artelt, E. (2011). Stepfamily therapy: A 10-step clinical approach. Washington, DC: APA Books. Browning, S., & Pasley, B. K. (2015). Contemporary families: Translating research into practice. New York: Routledge Press.

Contribution to the Profession Browning received diplomat-awarded fellow status from the American Board of Professional Psychology in Couples and Family Psychology. Further, he is a board member of the Stepfamily Association of America and is considered a national expert on stepfamily therapy. His most prolific work is the coauthored book titled Stepfamily Therapy: A 10-Step Clinical Approach (APA Books, 2011), which created a paradigm shift within the psychological community regarding the treatment of stepfamilies. He has authored numerous articles and chapters on empathy, marriage and family therapy, and stepparenting. He is also a regular presenter at national conferences on these topics. Further, Browning’s contributions to family systems theory include Contemporary families: Translating research into practice (Routledge Press, 2015). To create this book, Browning coordinated several experts of diverse family compositions to write about the research and clinical implications of their respective fields. This publication serves as a reference tool that informs psychologists about the nuances of several specific family types and informs the way psychologists work with these families. Browning has also made international contributions to the field of psychology. During a sabbatical from Chestnut Hill College, he was a visiting senior researcher at the Universita Cattolica del Sacro Cuore, where he taught a 20-hour seminar, conducted two full-day workshops in Napoli and Milano, and sat on the doctoral commission for their Department of Psychology. He also organizes and hosts an annual study abroad program for Italian psychology graduate students at Chestnut Hill College.

Buber, Martin Brittany Salerno1 and Molly F. Gasbarrini2 1 Clinical Psychology, California School of Professional Psychology at Alliant International University, Los Angeles, CA, USA 2 California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Name Martin Buber

Introduction Martin Buber (born February 8, 1878, Vienna, Austria – died June 13, 1965, Talbiya, Jerusalem) was a Jewish philosopher, educator, and political activist. As a philosophical anthropologist, Buber was interested in studying the wholeness of man by first understanding one’s own experiences with solitude and then recognizing one’s self in relation to the world. Buber is mostly known for his work I and Thou (1923).

Career From 1897 to 1899, Buber completed courses in philosophy and art history at University of Leipzig, and he worked in the psychiatric clinics of Wilhelm Wundt and Paul Flecksig. In 1899, he attended the University of Zürich and then studied at the University of Berlin until 1901. Buber also attended the University of Vienna in 1904.

Buber, Martin

He was an editor of the weekly paper Die Welt and became a leader in the Zionist movement, a Jewish nationalist movement that supports the Jewish homeland of Palestine. In addition to editing, he lectured, published journals, and produced an art exhibition centered on the Jewish culture. He continuously wrote dialogues on religious phenomenology, his most famous work being Ich und Du (translated as I and Thou) which was completed in 1923. While he was in Germany he promoted Jewish studies by being appointed the first lecturer in “Jewish Religious Philosophy and Ethics” at the University of Frankfurt in 1923, reopening the Free Jewish House of Learning in 1933, developing the Central Office for Jewish Adult Education in 1934, and establishing the School for the Education of Teachers of the People in 1949. In 1961, he co-translated the Hebrew Bible into German. Buber was Chair of the Department of Sociology of Hebrew University, an advocate of Jewish-Arab unity, and a multiaward winner for many of his works.

Contribution to Profession Buber’s work centered around existentialism. A focus of this is the development of human existence measured by the approach in which individuals engage in dialogue with the world. He is responsible for acknowledging the I-Thou relationship, in which a person perceives his or her own existence (I) separate from external nature (Thou). He believed that to progress away from the disparaged I-It relationship, in which a person develops experiences through the observance of others and perceives others as objects to fulfill his or her needs, a person must acknowledge both oneself and the other person as participants in the relationship. This understanding of existing as a subject in a relationship with an external subject, rather than with a perceived object, encourages dialogue involving each other’s whole being. Although the ideal relationship is I-Thou, Buber noted the importance of I-It relationships, as they provide space to analyze the world. The advantages of

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incorporating the philosophies of I-It and especially I-Thou relationships in a psychotherapy environment were explained by Buber. He believed that a therapist may analyze an impaired client, but doing so may only promote healing to an extent. A more successful technique involves the therapist acknowledging the sum of the client’s qualities, perceiving the client’s wholeness, and building a therapeuticrelationship that is reciprocal. He supported mutual, genuine communication as a way for the client to reconnect with oneself and with others. Buber was first to use “dialogue” as a relational term. His idea of focusing psychotherapy on the I-Thou relationship is valuable for reconciling the dynamic in various relationships, such as families and couples. According to his philosophy of dialogue, love is an expression of each other’s unity of being. Buber acknowledged the essence of confirmation and that there is no unity in a relationship without confirming the other person’s existence and becoming. The term “imagining the real” is used by Buber when a person can understand the other person’s point of view without abandoning one’s own opinions. This act of inclusion to understand both the other’s uniqueness and their unity accomplishes confirmation. In a relationship, such as in the case of love, both persons imagining the other’s feelings without giving up one’s own allow for reflection of similarities and differences in perspectives. Buber put forward the collaboration of inclusion and mutuality as being the source of a genuine dialogue. He shared his dialogical approach in lectures he gave at the Washington School of Psychiatry, and he has continued to influence the psychology world.

Cross-References ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Dialogical Practice in Couple and Family Therapy ▶ “I-Thou” in Couple and Family Therapy

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References Buber, M. (1957). Guilt and guilt feelings. Psychiatry, 20, 114–129. Buber, M. (1958). I and thou. (trans: Smith, R. G.). New York: Charles Scribner’s Sons. (Original work published 1923). Buber, M. (1965a). Between man and man. (trans: Smith, R. G.). New York: Macmillan. (Original work published 1947). Buber, M. (1965b). The knowledge of man: A philosophy of the interhuman. M. Friedman, (Ed.), (trans: Friedman, M., & Smith, R. G.). New York: Harper & Row.

Bug-in-the-Ear Supervision Linda Wark Indiana University – Purdue University, Fort Wayne, IN, USA

Synonyms and Acronyms Audio-cuing; BIE; Bug-in-the-ear technology; BITE*; Earphone; Third ear; Third ear mechanical device; Third mechanical ear

Theoretical Context The intention of the bug-in-the-ear in the clinical professions is to improve the abilities of supervisees. It is part of the evolution of live supervision wherein an intrusion is made by a supervisor during an ongoing therapy session to assist the student therapist. Therapy trainees receive instant help or suggestions which, in turn, can provide clients with immediate help from a more experienced vantage point. Authors have described mutual benefits of this method for both therapy trainee and clients. Benefits for trainees include help with blind spots and instant support from supervisors (DeRoma et al. 2007) as well as minimal disruption (Carmel et al. 2016). Benefits for

Submitted by: Linda Wark, Ph.D., Associate Professor, Indiana Purdue Fort Wayne, Fort Wayne, Indiana.

Bug-in-the-Ear Supervision

clients include an alteration in therapist’s behavior that leads to changes in client behavior (Smith et al. 1998). Some opposition to BITE* supervision also exists. Criticisms of BITE* include (a) the supervisee is forced to listen to a supervisor instead of the clients (Russell 1976); (b) it is a disruption to session processes (Liddle and Halpin 1978); and (c) the range of communication the supervisor can use is limited to terse comments (Berg 1978). The first journal articles on the topic appeared in the early 1970s (Boylston and Tuma 1972; Mathis 1971) and have continued to be published in professional journals every decade since that time (e.g., Kaplan 1987; Smith et al. 1998; DeRoma et al. 2007; Boyle and McDowellBurns 2015). There isn’t a singular theoretical affiliation of BITE* with therapy models. It has been used with supervisees who are employing group therapy (Tauber 1978), psychodynamic psychotherapy (Singer 1990), rational-emotive therapy (Young 1986), and behavioral therapy (Haney et al. 1975).

Description In this particular type of live supervision intrusion, the therapist conducts a therapy session wearing an ear piece similar to those worn by television news reporters. The equipment used includes a wireless radio receiver and fits into the ear. The supervisee hears short comments from a supervisor who attempts to provide helpful guidance during the therapy session.

Applications According to professional literature, the bug-inthe-ear method has been used in training clinics in several clinical professions (Friedberg and Brelsford 2013), in special education classrooms (Alila et al. 2015), in music therapy education (Adamek 1994), in live Internet supervision (Rousmaniere and Frederickson 2013), and as a supervisory method with parents and their children (Mathis 1971).

Bug-in-the-Ear Supervision

Clinical Example The supervisor asks a student therapist if he would be willing to try a different method of live supervision. She explains the history of the bug-in-the ear method and discusses how it can be useful and that, overall, supervisees do not find it disruptive (Champe and Kleist 2003). She believes that any annoyance can be reduced when the method is used properly. For example, sensitivity to the supervisee’s experience with live supervision or to the supervisee’s temperament (Mauzey et al. 2000) may facilitate adjustment to this method. She also explains that, in her experience, clients accept methods of live supervision more often than not (Locke and McCollum 2001). The supervisee agrees to work with the bug-in-the-ear method for two client sessions. After that, they agree to evaluate its continued use. The supervisee becomes acquainted with the equipment in preparation for the client family therapy session. A student friend of the supervisee takes the role of a client so the supervisee can experience listening to his “client” and tuning into a supervisor’s message. The supervisor adjusts her delivery based on feedback from the supervisee. They meet for a session with specified clients and agree that except for urgent situations, the supervisor will speak to the supervisee no more than two times during the session. The session with the clients proceeds.

References Adamek, M. S. (1994). Audio-cueing and immediate feedback to improve group leadership skills: A live supervision model. Journal of Music Therapy, 31(2), 135–164. Alila, S., Määttä, K., & Uusiautti, S. (2015). How does supervision support inclusive teacherhood? International Electronic Journal of Elementary Education, 8(3), 351–362. Berg, B. (1978). Learning family therapy through simulation. Psychotherapy: Theory, Research & Practice, 15(1), 56. Boyle, R., & McDowell-Burns, M. (2015). Modalities of marriage and family therapy supervision. In K. B. Jordan (Ed.), Couple, marriage, and family therapy supervision (pp. 51–70). New York: Springer. Boylston, W. H., & Tuma, J. M. (1972). Training of mental health professionals through the use of the “bug in the

371 ear”. American Journal of Psychiatry, 129(1), 124–126. Carmel, A., Villatte, J. L., Rosenthal, M. Z., Chalker, S., & Comtois, K. A. (2016). Applying technological approaches to clinical supervision in dialectical behavior therapy: A randomized feasibility trial of the bug-inthe-eye (BITE) model. Cognitive and Behavioral Practice, 23(2), 221–229. Champe, J., & Kleist, D. M. (2003). Live supervision: A review of the research. The Family Journal: Counseling and Therapy for Couples and Families, 11(3), 268–275. DeRoma, V. M., Hickey, D. A., & Stanek, K. M. (2007). Methods of supervision in marriage and family therapist training: A brief report. North American Journal of Psychology, 9(3), 415–422. Friedberg, R. D., & Brelsford, G. M. (2013). Training methods in cognitive behavior therapy: Tradition and invention. Journal of Cognitive Psychotherapy, 27(1), 19–29. Haney, J. N., Sewell, W. R., Edelstein, B. A., & Sartin, H. H. (1975). A portable, inexpensive, walkie-talkietype “bug-in-the-ear”. Behavior Research Methods & Instrumentation, 7(1), 19–20. Kaplan, R. (1987). The current use of live supervision within marriage and family therapy. The Clinical Supervisor, 5(3), 43–52. Liddle, H. A., & Halpin, R. J. (1978). Family therapy training and supervision literature: A comparative review. Journal of Marriage and Family Counseling, 4(4), 77–98. Locke, L. D., & McCollum, E. E. (2001). Clients’ views of live supervision and satisfaction with therapy. Journal of Marital and Family Therapy, 27(1), 129–133. Mathis, H. I. (1971). Training a “disturbed” boy using the mother as therapist: A case study. Behavior Therapy, 2(2), 233–239. Mauzey, E., Harris, M. B. C., & Trusty, J. (2000). Comparing the effects of live supervision interventions on novice trainee anxiety and anger. The Clinical Supervisor, 19(2), 109–122. Rousmaniere, T., & Frederickson, J. (2013). Internet-based one way mirror supervision for advanced psychotherapy training. The Clinical Supervisor, 42(1), 40–55. Russell, A. (1976). Contemporary concerns in family therapy. Journal of Marriage and Family Counseling, 2, 243–250. Saba, G. W., & Liddle, H. A. (1986). Perceptions of professional needs, practice patterns and critical issues facing family therapy trainers and supervisors. The American Journal of Family Therapy, 14(2), 109–122. Singer, J. L. (1990). The supervision of graduate students who are conducting psychodynamic psychotherapy. In R. C. Lane (Ed.), Psychoanalytic approaches to supervision (pp. 165–178). New York: Brunner/Mazel. Smith, R. C., Mead, D. E., & Kinsella, J. A. (1998). Direct supervision: Adding computer assisted feedback and data capture to live supervision. Journal of Marital and Family Therapy, 24(1), 113–125.

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372 Tauber, L. E. (1978). Choice point analysis – formulation, strategy, intervention, and result in group process. The International Journal of Group Psychotherapy, 28(2), 163–184. Young, R. A. (1986). The function of supervision and means of accessing interview data. The Clinical Supervisor, 4(3), 25–37.

Building Strong Families Shawndeeia L. Drinkard Alliant International University, Los Angeles, CA, USA

Name of Model Building Strong Families

Building Strong Families

developers and their associated teams were credited with development and ongoing guidance throughout the pilot and evaluation of the BSF project.

Theoretical Framework The model for the BSF project had three components: (1) Individual-Level support from Family Coordinators, (2) Instruction for Healthy Relationships and Marriage, and (3) Assessment and referral to Family Support Services (Dion et al. 2010). The goal of the family coordinators was to help individuals and couples identify and find resources for issues that may impede the couples’ ability to be successful in the BSF project. The BSF project primarily used group-based education to address various topics based on literature that would predict relationship satisfaction and marriage stability (Dion et al. 2010).

Introduction The Building Strong Families project was jointly developed in 2002 by the Office of Planning, Research, and Evaluation, Administration for Children and Families (ACF), and the US Department of Health and Human Services. The project was developed to address the high rates of children in the United States who are born to unmarried parents (Dion et al. 2010). Current and past literature suggests that children born to unmarried parents are at a higher risk for many negative outcomes such as living in poverty and experiencing barriers to quality education than children who are raised by their married biological parents. To address these concerns, the Building Strong Families (BSF) project was initiated to serve unmarried, romantically involved couples who were expecting a baby or had recently had a baby (Dion et al. 2010).

Prominent Associated Figures According to the BSF project report, the developers of the BSF curriculum were: Julie and John Gottman, Bernard Guerney, Mary Ortwein, Pamela Jordan, and Pamela Wilson. These

Populations in Focus As stated earlier, the BSF project was designed for unmarried, romantically involved couples who had recently had or were expecting a baby. Recruitment for participants was primarily in low socioeconomic neighborhoods. The project model required each participating program to link families to community resources to help them be successful (e.g., employment services, additional educational resources, housing resources, and/or child care resources).

Strategies and Techniques Used in Model Eight organizations volunteered to implement the BSF project nationwide. The participating organizations were: (1) Georgia State University, Latin American Association, Atlanta, GA, (2) Center for Urban Families, Baltimore, MD, (3) Family Road of Greater Baton Rouge-Baton Rouge, LA, (4) Healthy Families Florida, Florida: Orange and Broward Counties, (5) Healthy Family Initiatives, Houston, TX, (6) Healthy Families Indiana, Indiana: Allen,

Building Strong Families

Marion, and Lake counties, (7) Public Strategies, Inc., Oklahoma City, Oklahoma, and (8) Healthy Families San Angelo, San Angelo, TX. Each of the partnering organizations complied with a set of research-based project guidelines. Although there were key topics that each program needed to cover in their group sessions, individual programs had the opportunity to develop their own curriculum to address these topics in session. Potential participants were screened to assess their fit for the project (Dion et al. 2010). Couples presenting with evidence of violence were not eligible for BSF and were referred to other services. The BSF project had three main components: (1) group sessions that focused on building and maintaining relationship skills for the couple, (2) individualized support from family coordinators, and (3) assessment for and referrals to outside support services. The project was intended to be intensive, having couples attend 30–42 h of group sessions for the duration of the project. Among the couples whom participated in groups, there was an average of 21 attended group sessions. Overall, 55% of the couples that participated in BSF attended a group session during the project (Dion et al. 2010).

Research About the Model The outcomes of BSF were reviewed after 3 years of project implementation (Dion et al. 2010). The impact of the project was measured on three separate aspects of the family: (1) the status and quality of the couples’ relationship, (2) parenting and father involvement, and (3) child well-being. At the 3 year follow-up for the project, the project had no effect on the quality of the couple relationships or on the likelihood that couples would get married. Additionally, the BSF project had no effect on the couples’ co-parenting relationship and showed a slight negative effect on some aspects of father involvement. Finally, the project had no effect on the family stability or economic well-being of children. Notably, results from the 3-year follow-up suggested that the BSF project may have led to a slight reduction in children’s behavior problems. Interestingly, results from the project implemented by Public Strategies, Inc. in

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Oklahoma City suggested that the project had a positive impact on relationship outcomes (Dion et al. 2010). Some reflections given by the authors of the project report on the outcomes include thoughts about the pressure that may have been felt by fathers participating in the project (Dion et al. 2010). A possible explanation for their deceased involvement in their children’s lives could be that after hearing about the importance of fatherhood and the pressure that comes with the role, they felt it would be best to remove themselves from their children’s lives. Another reflection of the project was that it was geared toward couples with limited economic resources which may have been a barrier to marriage for them. Research suggests that lowincome couples tend to want both partners to be economically stable prior to marriage (Dion et al. 2010). The Building Strong Families project provided information regarding helpful considerations that need to be made when working with minority couples and those couples with limited economic prospects. Some resources that describe the Building Strong Families project include: Dion and Hershey (2010), Hershey and Alan (2006), and Wood et al. (2014). Following the Building Strong Families project, other programs were launched that placed more of an emphasis on offering low-income couples both employment- and relationship-related services. The Building Strong Families project paved the way for future programs to address these issues and support families in new ways.

Cross-References ▶ PREP Enrichment Program

References Dion, M. R., & Hershey, A. M. (2010). Relationship education for unmarried couples with children: Parental responses to the building strong families project. Journal of Couple and Relationship Therapy, 9(2), 161–180. Dion, M. R., Avellar, S., & Clary, E. (2010). The building strong families project: Implementation of eight programs to strengthen unmarried parent families. Washington, DC: Office of Planning, Research, and

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Evaluation, Administration for Children and Families, US Department of Health and Human Services. Hershey, M., & Alan, A. H. H. Z. (2006). Implementing healthy marriage programs for unmarried couples with children early lessons from the building strong families project. Washington, DC: Mathematica Policy Research. Wood, R. G., Moore, Q., Clarkwest, A., & Killewald, A. (2014). The long-term effects of building strong families: A program for unmarried parents. Journal of Marriage and Family, 76(2), 446–463.

Clinic, he was exposed to and strongly influenced by Salvador Minuchin’s approach, when the famous family therapist spent two sabbatical periods of leave from the Philadelphia Child Guidance Clinic at the Tavistock. In addition, he established close collaborative links with another American Mary Main who had developed the Adult Attachment Interview and also visited the Tavistock Clinic on several occasions.

Byng-Hall, John

Contributions to the Profession

Renos K. Papadopoulos University of Essex, Colchester, UK

Essentially, Byng-Hall’s own approach falls within the broadly defined framework of Structural Family Therapy, which he combined with John Bowlby’s attachment theory. He had an enormous respect for Gregory Bateson’s ideas, and he incorporated them in his own unique blend of therapy that emphasized the importance of “rewriting family scripts.” For Byng-Hall, a “family script” is a scenario that develops imperceptibly within families; it provides the context within which meaning is constructed in families and, in turn, dictates relationships, roles, and identities. As such, a family script may either promote development of its members or it may thwart and retard development, fostering dysfunctionality. Byng-Hall, using the Structural Family Therapy tradition of enactment, emphasized the gradual enactment of the re-edited scripts during therapy, introduced in a most sensitive and human way. In clarifying the way he modified Structural Family Therapy, he wrote characteristically that he had to adapt it to his own “personal style,” explaining that “My style is more quiet insistence than of dramatic intervention . . . I like to let things happen more slowly. . . What is more important is that [the parents] . . . feel respected instead of criticized” (Byng-Hall 1995, p. 169). Byng-Hall was able to develop further the concept of “family scripts” and locate it in the wider contexts of narrative approaches that emerged in Family Therapy. With his colleague and collaborator at the Tavistock Clinic, Renos Papadopoulos, they edited a book (“Multiple Voices”) exploring the various applications of

Name John Byng-Hall

Introduction John Byng-Hall is a British family therapist and psychiatrist. Born in Kenya to an old aristocratic English family, he worked for most of his active professional life at the Tavistock Clinic in London, where he was instrumental in developing a systemic clinical service for families, as well as training courses in family therapy. A person of genuine kindness and gentle authority, as a clinician, his work was characterized by authentic engagement with the families, and, as a teacher, he was most inspirational. His role in introducing family therapy in the UK has been considerable.

Career John Byng-Hall’s first encounter with family therapy was during his early work as a psychiatrist with severely disturbed adolescents at the Hill End Adolescent Unit in North London (1969–1972), when he saw adolescents with their families for therapy with his more experienced colleague Dr. Peter Bruggen. Subsequently, when he moved to the Tavistock

Byng-Hall, John

the narrative in systemic thinking. More specifically, they examined how “stories develop and in turn affect the clinical work in relation to four interconnected domains: (a) the therapists’ own personal stories about their background and training, (b) the story of the institutional setting which provides contexts within which they work, (c) the narrative of the actual therapeutic or research material, and (d) in the background, the general theoretical paradigms and sociopolitical stories and myths of the time” (1997, pp. 3–4). In retirement, John Byng-Hall is able to enjoy his serious hobby of painting.

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Cross-References ▶ Schemas in Families ▶ Structural Family Therapy

References Byng-Hall, J. (1995). Rewriting family scripts. Improvisation and systems change. London: The Guildford Press. Papadopoulos, R. K., & Byng-Hall, J. (Eds.). (1997). Multiple voices. Narrative in systemic family psychotherapy. London: Duckworth.

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Cahiers critiques de thérapie familiale et de pratiques de réseaux (Journal) Edith Goldbeter Institut d’Etudes de la Famille et des Systèmes Humains, Brussels and ULB, Brussels, Belgium

Initially 15 issues were published on an annual basis directed by Mony Elkaïm. After an interruption of 2 years, from 1994 to June 1996, a new publisher was found (De Boeck, Brussels), and the journal moved to biennial publication with Edith Goldbeter as editor-in-chief.

Location Name of Journal Cahiers critiques de thérapie familiale et de pratiques de réseaux.

The journal’s editorial office is located in Brussels.

Prominent Associated Figures Introduction The journal Cahiers critiques de thérapie familiale et de pratiques de réseaux (Critical Reviews of Family Therapy and Network Practices) is historically the first international Frenchlanguage family therapy journal. Created in 1979 in Belgium by Mony Elkaïm, who is still its director, it was the official body of the Institute for the Study of the Family and Human Systems – Brussels, Belgium. Organized around specific topics, the Cahiers critiques de thérapie familiale et de pratiques de réseaux is intended for mental health practitioners, teachers, researchers, and students alike. Authors are solicited or submit articles by themselves.

Mony Elkaïm presented his project at the opening of the first issue of the magazine as follows: – to open a theoretical-technical debate on our practices in family therapy, – to extend this debate to all those who, in different ways, question existing institutions and practices in the field of mental health, – to make available international documents in this field to the French-speaking public.

He concluded his presentation by insisting on the fact that the Cahiers critiques de thérapie familiale et de pratiques de réseaux “will only make sense if they solicit and allow the widest possible debate based on our practices, so it is your active participation which will be the decisive element for the future of this journal”

© Springer Nature Switzerland AG 2019 J. L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy, https://doi.org/10.1007/978-3-319-49425-8

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Camberwell Interview for Assessing Expressed Emotion in Families

Edith Goldbeter became editor in chief in 1996, following the line opened by Mony Elkaïm, being still involved in the journal.

Contributions The first issues included articles translated into French of family therapy pioneers such as Carl Whitaker, Carlos Sluzki, Helm Stierlin, Mara Selvini Palazzoli, Paul Watzlawick, Luigi Onnis, Maurizio Andolfi, and others, and also texts of French-speaking authors such as Mony Elkaïm, Philippe Caillé, Elisabeth Fivaz, and Danielle Desmarais. There were also articles of antipsychiatrists and professionals involved in institutional psychiatry as David Cooper, Ronald Laing, Yvonne Bonner, etc. The Cahiers critiques de thérapie familiale et de pratiques de réseaux have also opened their pages to contributors belonging to fields related to family therapy, to practitioners from other disciplines or orientations, as well as to scientists such as Felix Guattari, Francisco Varela, Humberto Maturana, Ilya Prigogine, Martine Gross, trying always to keep up a constructive dialogue. Here are some issue topics: “Adolescence in context” (40, 2008), “Biology and psychotherapy” (43, 2009), “Analytical therapies, systemic therapy: what bridges?” (45, 2010), “Constrained help and psychotherapy” (46, 2011), “Adopting, a challenge?” (56, 2016), “Families, caregivers and critical illness” (57, 2016), “Co-therapy” (58, 2017). A special issue will be dedicated to the “Singularities of the therapist” (60, 2018) and will appear in 2018, crowning the 39 years of life of the Critical Reviews of Family Therapy and Network Practices.

Cross-References ▶ Elkaïm, Mony

References https://www.cairn.info/revue-cahiers-critiques-detherapie-familiale.htm.

Camberwell Interview for Assessing Expressed Emotion in Families Cody G. Dodd and Ciera E. Schoonover Department of Psychology, Central Michigan University, Mount Pleasant, MI, USA

Name and Type of Measure The Camberwell Family Interview (CFI) is a semi-structured interview measuring expressed emotion (EE) in families.

Introduction The Camberwell Family Interview (CFI; Vaughn and Leff 1976) is a semi-structured interview that is considered the gold standard measure of expressed emotion (EE) in families of individuals with mental health problems. Originally designed for patients with schizophrenia, the CFI is conducted with key family members and focuses on the impact of the identified client’s condition on the daily life of the family. High expressed emotion in families is a significant predictor of symptomatic relapse and other negative outcomes for individuals across a range of emotional, behavioral, and thought disorders. The CFI administration takes place without the patient present and is recorded so that it can later be coded on five domains: criticism, hostility, warmth, positive comments, and emotional overinvolvement. An overall high or low-EE designation is derived based on cutoffs from these subscale scores. The typical length of the interview is 1–2 h and coding the interview takes approximately 2 to 3 h. Approved CFI administration requires between 40 and 80 h of formal training (Van Humbeeck et al. 2002).

Developers The CFI was developed by Christine Vaughn and Julian Leff (1976).

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Description of Measure

Psychometrics

The CFI has primarily been used in research on the outcomes of individual diagnosed with schizophrenia and other chronic or severe mental illnesses. CFI scores are indicators of the emotional climate among the patient and key relatives that he or she is in close contact with. A completed and scored CFI produces five subscale scores and an overall EE designation of high or low. The relationship between EE and relapse has often been described as a diathesis-stress model, wherein already-vulnerable patients with highEE families accrue more negative and hostile interactions in their daily life and are thus more likely to experience a relapse. Scores on the CFI are obtained via coding of verbalizations made during an individual interview with a family member. A CFI manual exists that provides trained administrators with detailed guidelines for coding (Vaughn and Leff 1985). The Critical Comments (CC) and Positive Remarks (PR) scales consist of the number of negative and positive statements made about the patient throughout the interview. The three other scales are rated at the end of the interview on Likert-type scales as overall appraisals. Emotional over-involvement (EOI) and Warmth (W) are rated on six-point scales (0–5) and Hostility is rated on a four-point scale (0–3). Emotional over-involvement is rated based on the interviewees’ description of their behavior in terms of protectiveness, emotional reactivity, and devotion in response to the patient. Warmth takes into account vocal aspects of the interviewee, and his or her expressions of interest and empathy directed at the patient. Hostility ratings are based on severe, overly general, and critical comments about the patient. Finally, relatives are classified as high EE if they have: (a) 6 or more critical comments, (b) a hostility score of 1 or more, or (c) an emotional over-involvement score of 3 or more (Van Humbeeck et al. 2002). A large body of evidence indicates that individuals with a range of mental health and other chronic diagnoses have worse outcomes if they have or live with high-EE family members (Hooley 2007).

Of the instruments used to measure EE in research on families of individuals with mental disorders, the CFI is considered to be the most reliable and powerful predictor of symptomatic relapse (Van Humbeeck et al. 2002). Inter-rater reliability estimates for the five CFI scales in published research using approved CFI raters have ranged from fair to good. Reportedly, raters who complete the official CFI training program are required to produce an intraclass correlation (ICC) coefficient of 0.80 or better with an expert rater on all scales (Van Humbeeck et al. 2002). Estimates of the test-retest reliability of the CFI have not been reported. The factor-analytic research on the CFI is limited, although some evidence suggests a three-factor model consisting of criticism, positivity, and emotional over-involvement has the best fit (Van Humbeeck et al. 2002). Hostility and criticism appear to overlap highly, and criticism is also negatively correlated with warmth and positive comments (Vaughn and Leff 1976). The construct validity of EE and its subscales is strong, as CFI scores have been shown to correlate with physiological measures of arousal and coded interactions among patients and family members (Van Humbeeck et al. 2002). Expressed emotion, as measured by the CFI, is predictive of symptom relapse, treatment response, and other negative outcomes in patients with a range of disorders including schizophrenia, affective and eating disorders, and substance abuse (Hooley 2007). The overall EE index appears to be the single best predictor of relapse; however, the number of critical remarks contributes highly to the index’s overall predictive validity (Vaughn and Leff 1976). Research on EE in staff members suggests it as a potential indicator of service quality, and criticism in particular is associated with worsened patient functioning (Berry et al. 2011). In general, patients with chronic and severe conditions seemed to be more vulnerable to the negative effects of high EE. Additionally, research suggests that high-EE relatives report higher levels of burden and are also at greater risk for experiencing depression than low-EE relatives (Safavi et al. 2017), which

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Camberwell Interview for Assessing Expressed Emotion in Families

also may impact their care and contribute to negative interactions with the patient. Surprisingly, meta-analytic results indicate that the CFI may be a better predictor of poorer outcomes in depression and eating disorders than it is for schizophrenia. For example, some evidence suggests that high EE is associated with engagement and worse response to treatment for anxiety disorders (Taylor et al. 2012). It is noted, however, that although early research showed promise for the CFI in terms of treatment sensitivity, reviews of the psycho-education and other family intervention research have not concluded that treatment can reliably produce changes in EE (e.g., Mari and Streiner 1994; Sin et al. 2017). Data on the cross-cultural validity of EE and its facets are mixed, and most of the research on the CFI has been done with US and Western European samples. Published empirical research with the CFI in non-Western samples has produced conflicting results, with studies showing EE to be predictive of symptomatic relapse in some cultures, but not others. Several translations of the CFI have been developed, and the evidence supporting their predictive validity has been mixed. Some studies have shown an association between criticism and worse outcomes in international samples; however, this finding needs replication. Great variability in the EE profiles of families of individuals diagnosed with schizophrenia and other mental disorders across cultures has been noted as a significant limitation of the research on EE and the CFI (Kymalainen and Weisman 2008).

Example of Application in Couple and Family Therapy Malcom Waters is a 26-year-old university student who was recently admitted to an inpatient psychiatric treatment center after a first-episode experience of psychosis. Over the past month, he has received medication treatment in combination with individual and group therapy. He is about to be discharged so that he can return to living with his parents and attending school. During his predischarge evaluation, his parents and teenage brother each participated in an individual

interview conducted according to the CFI format. Malcom’s psychologist, Dr. Pitts, considered information obtained from the CFI alongside other assessment data to provide discharge recommendations to Malcom and his family. During a feedback session with the family, Dr. Pitts reviewed the results from the CFI. Mr. Waters and Malcom’s brother, James, both were classified as low-EE based on their CFI scores; however, Mrs. Waters’s high number of critical comments and level of emotional over-involvement earned her a high-EE rating. Dr. Pitts provided the family with information about the vulnerabilitystress model of relapse in severe and chronic psychiatric conditions. Then, she commented on how all members of the family scored high on the protective indicators of warmth and positivity in their interviews. To reduce the impact of criticism and emotional reactivity observed in Mrs. Waters’s interview, Dr. Pitts recommended a brief course of family therapy and asked that the family attend an educational group provided by the agency for families. Through these two processes, the family could reduce conflict and emotional reactivity in the home and learn other strategies to manage stress and prevent symptom relapse. Based on Dr. Pitts’s recommendations, the family attended several sessions of family therapy aimed at reducing family conflict and stress. After several weeks of group and family treatment, Malcom was discharged and re-enrolled in classes part-time at his university. The increased family cohesiveness and use of strategies learned in the educational group allowed the family to better support him in developing skills to manage his symptoms. This ultimately helped Malcolm function more adaptively in the social and academic domains.

References Berry, K., Barrowclough, C., & Haddock, G. (2011). The role of expressed emotion in relationships between psychiatric staff and people with a diagnosis of psychosis: A review of the literature. Schizophrenia Bulletin, 37(5), 958–972. https://doi.org/10.1093/schbul/sbp 162. Hooley, J. M. (2007). Expressed emotion and relapse of psychopathology. Annual Review of Clinical Psychology, 3(1), 329–352. https://doi.org/10.1146/annu rev.clinpsy.2.022305.095236.

Caring Days in Couple and Family Therapy Kymalainen, J. A., & Weisman, D. M. (2008). Expressed emotion, communication deviance, and culture in families of patients with schizophrenia: A review of the literature. Cultural Diversity and Ethnic Minority Psychology, 14(2), 85–91. https://doi.org/10.1037/10999809.14.2.85. Mari, J. D. J., & Streiner, D. L. (1994). An overview of family interventions and relapse on schizophrenia: Meta-analysis of research findings. Psychological Medicine, 24(3), 565–578. https://doi.org/10.1017/ S0033291700027720. Safavi, R., Berry, K., & Wearden, A. (2017). Expressed emotion in relatives of persons with dementia: A systematic review and meta-analysis. Aging & Mental Health, 21(2), 113–124. https://doi.org/10.1080/ 13607863.2015.1111863. Sin, J., Gillard, S., Spain, D., Cornelius, V., Chen, T., & Henderson, C. (2017). Effectiveness of psychoeducational interventions for family carers of people with psychosis: A systematic review and meta-analysis. Clinical Psychology Review, 56, 13–24. https://doi. org/10.1016/j.cpr.2017.05.002. Taylor, S., Abramowitz, J. S., & McKay, D. (2012). Nonadherence and non-response in the treatment of anxiety disorders. Journal of Anxiety Disorders, 26(5), 583–589. https://doi.org/10.1016/j.janxdis.2012.02.010. Van Humbeeck, G., Van Audenhove, C., De Hert, M., Pieters, G., & Storms, G. (2002). Expressed emotion: A review of assessment instruments. Clinical Psychology Review, 22(3), 321–341. https://doi.org/10.1016/ S0272-7358(01)00098-8. Vaughn, C. E., & Leff, J. P. (1976). The measurement of expressed emotion in the families of psychiatric patients. British Journal of Social and Clinical Psychology, 15(2), 157–165. https://doi.org/10.1111/ j.2044-8260.1976.tb00021.x. Vaughn, C. E., & Leff, J. P. (1985). Expressed emotion in families. New York: The Guilford Press.

Caring Days in Couple and Family Therapy Jennifer M. Lorenzo1 and Robin A. Barry2 1 Department of Psychology, University of Maryland, Baltimore Country, Baltimore, MD, USA 2 Department of Psychology, University of Wyoming, Laramie, WY, USA

Name of Strategy Caring Days

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Introduction Caring Days is a strategy designed to build trust and commitment in the couple relationship by increasing positive behavior exchanges. When couples engage in more positive exchanges, they increase investment and trust in the relationship. Additionally, the procedure increases clients’ attention to caring actions exchanged and decreases attention on negative behaviors (Stuart 1980).

Theoretical Framework Caring Days is rooted in operant behavior, social learning, and social exchange theories. Operant behavior theory maintains behavior increases or decreases over time as a result of whether it is reinforced or punished, respectively. Social learning theory maintains that learning in social contexts can occur through direct instruction and observation of others’ behavior. Finally, social exchange theory purports that the relative costs and rewards exchanged in a relationship determine its relative value to partners. The Caring Days procedure increases noncontingent positive behaviors exchanged in a relationship to increase commitment and positive affect using direct instruction provided by the partner and therapist and positive reinforcement to change partners’ interactions (Stuart 1980). Several models of relationship functioning emphasize the importance of experiencing greater positive relative to negative behavioral exchanges for relationship functioning (Gottman 1993; Stuart 1980). The ratio of positive to negative behavioral exchanges may become less optimal in a relationship overtime due to reinforcement erosion or because negative behaviors tend to be salient. When positive behaviors are not reciprocated or are not reinforced, they occur less frequently. The Caring Days procedure promotes positive behaviors, and thus should increase attraction, trust, and investment in the relationship and a more favorable ratio of positive to negative behavior exchange in the relationship.

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Rationale for the Strategy The Caring Days technique is designed for implementation in the initial stages of therapy. Many couples seek treatment when experiencing a low rate of caring behaviors (Stuart 1980). Couples experiencing low rates of caring behaviors tend to have lower relationship commitment because rewarding aspects of the relationship are absent or diminished. The Caring Days procedure increases noncontingent positive behaviors, increasing reinforcing aspects of the relationship and enhancing commitment. For more committed couples who are already engaging in caring behaviors, implementation of the Caring Days technique reinforces existing relationship strengths and provides opportunities for the couple to practice assertively making requests (Stuart 1980).

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clarifying questions to ensure accurate understanding. The therapist then asks each partner to commit to performing at least one behavior from the list daily, regardless of whether the other partner performs the behaviors. This promotes change by reducing contingencies for performing positive behaviors. Couples are also instructed to take time each day to note whether their partner performed each behavior. This serves to increase attention to and reinforcement of partner’s positive behaviors. Posting the list in a conspicuous place (e.g., on the refrigerator) serves as a reminder of the task for the couple. Therapists should contact the couple between sessions to address concerns and encourage adherence.

Case Example Description of the Strategy or Intervention In introducing the Caring Days technique, couples are told that they may not actually experience caring feelings for one another until their behavior has changed. Thus, they are asked to act “as if” they care for each other. Through this explanation, couples are provided with a rationale to perform positive behaviors for their partner even though they may not feel positively toward their partner (Stuart 1980). Each partner is asked to identify and list behaviors that their partner could enact that would convey care to them. Behaviors must be (1) positive (i.e., it is a behavior the partner can enact rather than a behavior the partner should refrain from), (2) specific, (3) small (i.e., can be performed at least once daily), and (4) unrelated to recent intense conflict. Couples should identify several behaviors so that each couple member will have relevant behaviors to perform daily. They are encouraged to add behaviors to the list each week to reduce stagnation and to allow for partners’ preferences in caring behaviors to shift over time. When behaviors are listed, the spouse making the request should describe what, when, and how the behavior should be performed. The partner receiving the request should ask

Peyton and Jamie entered therapy following the loss of Jamie’s job. They had been married for 7 years and had a daughter aged 2. The couple described a decrease in intimacy since the birth of their daughter and an increase in intense arguments since Jamie was laid off from work a few months ago. During intake the couple struggled to identify positive qualities about one another. Peyton criticized Jamie’s poor housekeeping and not working hard enough to gain employment. Jamie complained that all Peyton did was “work, eat, and sleep.” Jame felt Peyton did not help enough with their daughter. The clinician explained that couples often develop a pattern of focusing on negatives in the relationship until it becomes too difficult to identify positives about their partner. For Peyton and Jamie to develop intimacy, they would need to change their behaviors toward one another which would likely change their feelings about one another. The clinician introduced the Caring Days procedure and asked the couple to identify behaviors they would like their partner to do to show caring. Initially, Peyton identified vague behaviors such as “tidy the house” and sources of conflict such as “get a job.” Jamie negatively framed requests such as “don’t be so tired in the evening.” The clinician helped the couple reframe requests to be positive, specific,

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small, and not the subject of recent conflict. The couple identified and discussed different positive requests and agreed to perform at least one activity daily and to record the dates they saw their partner complete the task. The clinician called the couple 3 days later. The couple reported inconsistently performing tasks because they did not think their partner was doing their tasks. The clinician reminded each partner to complete tasks regardless of their partner’s performance. After about a month, the couple had added several additional tasks to their list. In addition to completing caring tasks, the couple reported fewer arguments and more intimate moments. With enhanced commitment and positive affect, the couple was able to successfully learn conflict resolution skills in therapy.

Cross-References ▶ Behavior Exchange in Couple and Family Therapy ▶ Social Learning Theory ▶ Stuart, Richard

References Gottman, J. M. (1993). The roles of conflict engagement, escalation, and avoidance in marital interaction: A longitudinal view of five types of couples. Journal of Consulting and Clinical Psychology, 61(1), 6–15. https://doi.org/10.1037/0022-006X.61.1.6. Stuart, R. B. (1980). Helping couples change: A social learning approach to marital therapy. New York: Guilford Press.

Carlson, Cindy Shelley Riggs Department of Psychology, University of North Texas, Denton, TX, USA

Name Cindy I. Carlson, Ph.D., A.B..P.P.

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Introduction Dr. Cindy Carlson has contributed to the field of couple and family psychology in many essential roles, including researcher, educator, practitioner, editor, and active professional citizen. Her scholarly and training efforts focus on family assessment and intervention, particularly in the context of the home-school partnership. She has held many governance positions at her home university and more broadly within the American Psychological Association (APA). Among her many notable achievements, Dr. Carlson is a Fellow, Past President, and Distinguished Service Award winner for two APA divisions, namely, the Societies of Family Psychology and School Psychology.

Career Dr. Carlson received a bachelor’s degree from DePauw University and then went on to earn master’s and doctoral degrees in School Psychology with minors in Clinical and Counseling Psychology from Indiana University. She completed her internship training with the Memphis Clinical Psychology Internship Consortium in association with the University of Tennessee College of Medicine. In 1982, Dr. Carlson accepted an academic position at the University of Texas at Austin (UT-Austin), where she has served in multiple capacities, including Director of the School Psychology Program, departmental Graduate Advisor, and A. M. Aikin Regents Chair in Junior and Community College Education Leadership. Currently Dr. Carlson is the Margie Gurley Seay Professor and Chair of the Department of Educational Psychology at UT-Austin.

Contributions to Profession In addition to publishing two influential books, the Handbook of Family-School Intervention: A Systems Perspective (Fine & Carlson, 1991) and Family Assessment: A Guide for Researchers

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and Practitioners (Grotevant & Carlson, 1989), Dr. Carlson has authored or coauthored approximately 60 book chapters and journal articles. She is perhaps best known for her expertise on family assessment (Carlson, Krumholtz, & Snyder, 2013; Grotevant & Carlson, 1989), the family-school interface (Carlson, Funk, & Nguyen, 2009), and best practices for working with single-parent and stepfamily systems (Carlson, 1995). Dr. Carlson has received substantial funding for her research on the influences of family processes on children’s behavior and achievement at school, schoolbased interventions with parents and families, and intergroup relations and academic success among diverse youth (Carlson & Christenson, 2005). Dr. Carlson has been a dedicated educator for over 30 years and was named Outstanding Graduate Advisor by UT-Austin in 2005. She developed an innovative family therapy training program at UT-Austin and has mentored numerous graduate students, who now contribute to the field in academic positions, public schools, nonprofit agencies, community and national service, and private practice settings across the country. Dr. Carlson received two Graduate Psychology Education Program grants for the Integrated Behavioral Health Psychology (IBHP) Program at UT-Austin, which is designed to prepare doctoral-level students to provide culturally and linguistically competent, evidence-based psychological services as part of interprofessional health-care teams serving vulnerable and underserved populations within community health settings. With an extensive service record, Dr. Carlson has made notable contributions to the specialty of couple and family psychology. She has served on the editorial boards for five journals and is currently Associate Editor for Couple and Family Psychology: Research and Practice. Dr. Carlson has held numerous leadership positions in APA Societies of School and Family Psychology and represented the field as Chair for APA’s Commission for Specialties and Proficiencies in Psychology. Most recently, she was a member of the Executive Board for the

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Council of Graduate Departments of Psychology and is now on the APA Commission of Accreditation.

Cross-References ▶ Assessment in Couple and Family Therapy ▶ Couple and Family Psychology (Journal) ▶ Single Parent Families

References Carlson, C. I. (1995). Best practices in working with single parent and stepfamily systems. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology (Vol. III, pp. 1097–1110). Washington, DC: National Association of School Psychologists. Carlson, C.I., & Christenson, S. (Eds.). (2005). Evidence-based parent and family interventions in school psychology [Special Issue]. School Psychology Quarterly, 20, 345–351. Carlson, C. I., Wilson, K. D., & Hargrove, J. L. (2003). The effect of school racial composition on Hispanic intergroup relations. Journal of Social and Personal Relationships, 20, 203–220. Carlson, C. I., Funk, C., & Nguyen, K. (2009). Family-school communication. In J. H. Bray & M. Stanton (Eds.), WileyBlackwell Handbook of family psychology (pp. 515–526). New York, NY: Wiley-Blackwell Publishing. Carlson, C. I., Krumholtz, L. S., & Snyder, D. K. (2013). Assessment in marriage and family counseling. In K. F. Geisinger (Ed.), APA handbook of testing and assessment in psychology (pp. 569–586). Washington, DC: APA Publications. Fine, M. & Carlson, C.I. (Eds.) (1991). Handbook of family-school intervention: A systems perspective. Boston: Allyn & Bacon. Grotevant, H. D., & Carlson, C. I. (1989). Family assessment: A guide for researchers and practitioners. New York: Guilford Press.

Carr, Alan Peter Stratton Leeds Family Therapy and Research Centre, University of Leeds, Leeds, UK

Name Carr, Alan

Carr, Alan

Introduction Alan Carr is best known for his researchinformed, theoretically integrative clinical practice models. He has been awarded many research grants, and is a prolific writer having published over 20 books and 200 articles. He has made keynote addresses and presentations to professional associations of family therapy and clinical psychology around the world. His books have been translated into many languages. His best-selling textbooks are Family therapy: Concepts, process and practice (Wiley, 2000) and the Handbook of clinical child and adolescent psychology: A contextual approach (Routledge, 1999). Second and third editions of both have been published. His research spans a range of topics including evaluation of the effectiveness of systemic interventions, family assessment, psychotraumatology, and positive psychology.

Career Carr received his BA (1977) and MA (1979) in psychology from University College Dublin (UCD). He then travelled to Queens University Kingston in Canada where he graduated with a PhD in clinical psychology in 1984. He was employed as a clinical psychologist at the National Health Service in the UK between 1984 and 1991. He returned to UCD in 1992 where he has worked for over 25 years. At UCD, he founded a doctoral program in clinical psychology which includes systemic practice in the curriculum. Alongside his academic career, Carr has practiced systemic therapy at Clanwilliam Institute, Dublin since 1992. Among his many accolades, in 2011, he received an award from the European Family Therapy Association for his contribution to family therapy research.

Contribution to Profession Professor Carr has made five important contributions to the field of systemic therapy. First, he developed an integrative model of systemic

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therapy, most comprehensively articulated in his book: Family therapy: Concepts, process and practice (Carr 2012). In this model, he proposes that most common problems are embedded in a recursive pattern of interaction involving the identified problem person and members of their social system. The roles adopted by those who participate in this interaction pattern are driven by beliefs and narratives about problems, their resolution, and relationships. These beliefs and narratives, in turn, are underpinned by background factors. These include factors within the wider current social system, developmental experiences, and biological vulnerabilities. In clinical practice, a three-column formulation specifying the problem-maintaining interaction pattern, underlying beliefs, and background factors may be developed, as well as a similar three-column formulation of exceptional episodes where the problem was expected to occur but did not. The process of developing these problem and exception formulations may be used to engage families in therapy and motivate them to cooperatively resolve the presenting problem. These formulations may also guide the development of interventions, and the order in which it may be most helpful to implement these. Interventions that aim to disrupt behavior patterns may be tried before proceeding to those which focus on beliefs, and these may precede those that focus on background factors. Carr’s second main contribution has been documenting the large evidence-base that supports the effectiveness of systemic practice and arguing that couple and family therapy should be informed by this evidence-base. Since his first review in 2000, he has supplied regular updates, the most recent being Carr (2014a, b). He has shown that there is evidence for the effectiveness of systemic interventions with child-focused problems such as sleeping, feeding, and attachment problems in infancy; aspects of child abuse; childhood disruptive behavior disorders; and adolescent eating disorders. There is also evidence for the effectiveness of systemic interventions for adult-focused problems such as relationship distress,

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psychosexual problems, and intimate partner violence. Finally, for both young people and adults, there is evidence for the effectiveness of systemic interventions with alcohol and drug problems, mood disorders, anxiety disorders, psychosis, and adjustment to illness and disability. Carr’s third contribution has been showing how systemic practice may be integrated into clinical psychology. This specialism arises from his successful integration of systemics into the doctoral training of over 100 clinical psychologists. This achievement is encapsulated in his book: The Handbook of child and adolescent clinical psychology: A contextual approach (Carr 2015). His fourth major contribution has been in creating a vibrant research ethos among his doctoral students and his own substantial research contributions particularly of outcome measurement in systemic therapy, and positive psychology. Finally, he has documented the history of family therapy in Ireland, a history in which he has played a dominant role (Carr 2013).

Cross-References ▶ European Family Therapy Association ▶ Integration in Couple and Family Therapy ▶ Research in Relational Science ▶ SCORE

Carter, Betty

Carter, Betty Melinda MacDonald and M. L. Parker Marriage and Family Therapy Program, University of Saint Joseph, West Hartford, CT, USA

Name Betty Carter Elizabeth A. (1929–2012)

(Golden)

“Betty”

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Introduction Betty Carter, MSW, was originally trained as a Bowenian Family Therapist and became well known for her work on the expanded family life cycle. In collaboration with Monica McGoldrick, Carter integrated the concepts of individual human development and the traditional family life cycle to develop an expanded perspective of family development. In addition to the expanded family life cycle, Carter strongly influenced the field of marriage and family therapy by questioning the family systems theory tenets of traditional gender roles, power dynamics, and the narrow view of the female perspective. Carter was also a cofounder of the Women’s Project in Family Therapy, which aimed to amplify the female voice within the field of family therapy.

References Carr, A. (2012). Family therapy: Concepts, process and practice (3rd ed.). Chichester: Wiley. Carr, A. (2013). The development of family therapy in Ireland. Contemporary Family Therapy, 35, 179–199. Carr, A. (2014a). The evidence-base for family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 36, 107–157. Carr, A. (2014b). The evidence-base for couple therapy, family therapy and systemic interventions for adultfocused problems. Journal of Family Therapy, 36, 158–194. Carr, A. (2015). Handbook of child and adolescent clinical psychology: A contextual approach (3rd ed.). London: Routledge.

Career Carter received her undergraduate degree from St. John’s College, NY, and went on to earn her Master of Social Work degree from Hunter College, NY. Carter then met Peggy Papp and Olga Silverstein while attending the Ackerman Institute for the Family, NY, who worked with Marianne Walters to lead the Women’s Project in Family Therapy. Carter eventually became the director and founder of the Family Institute of Westchester in White Plains, NY.

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Contributions to Profession Carter contributed to many writings and trainings that challenged concepts within the field of family therapy using a feminist lens. Notably, Carter worked with McGoldrick to coauthor The Family Life Cycle: A Framework for Family Therapy (1981). Carter continued to collaborate with McGoldrick on works that utilized the feminist critique to reevaluate traditional gender roles and power dynamics that are inherent within the Bowenian concepts of triangles in divorce and remarriage. The pair also examined the struggle between vertical (flow of generational anxiety) and horizontal (familial stress associated with different stages of the life cycle) patterns of convergence. Carter wrote Love, Honor, and Negotiate: Building Partnerships That Last a Lifetime (1996), which focuses on the function of money and power in relationships. Couples are encouraged to explore communication on cultural, social, and historical contexts associated with gender power dynamics that influence their relationship. Carter’s body of work has brought attention to family assessment through a multicontextual lens including acknowledgment of class, race, ethnicity, gender, and sexual orientation. Carter cofounded the Women’s Project in Family Therapy with Marianne Walters, Peggy Papp, and Olga Silverstein to examine the female experience within the family. The project aimed to challenge the idea that men and women share equality in a world where societal roles and rules are organized in favor of men at the disadvantage of women. The Women’s Project hosted a series of international meetings of female therapists to address traditional patriarchal views of gender in families and within the field of family therapy as a whole. As a product of these meetings, Carter and the other founding members of the Women’s Project went on to coauthor The Invisible Web: Gender Patterns in Family Relationships (1988). The aim of The Invisible Web was to challenge traditional gender beliefs and clinical practices in the field of family therapy. The writings further incorporated feminist thinking to explore conflicting sexist messages inherent within systems thinking.

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Lastly, Carter was the director and founder of the Family Institute of Westchester where she was a clinical supervisor and taught students about family systems concepts while coaching clients to create change within their families. Carter is quoted as saying: I would say that, after having been in the field for almost 30 years, of all of the many different things that I did, my most gratifying work was related to gender and culture – especially when we first started recognizing and working with gender issues. It was mind-blowing to me that we hadn’t noticed the most basic of things – the organizing principle of gender. And when I did notice it, nothing was the same.

Cross-References ▶ Family Life Cycle ▶ Feminism in Couple and Family Therapy ▶ Gender in Couple and Family Therapy ▶ Gender Roles ▶ Triangles in Bowen Family Therapy

References Carter, B., & McGoldrick, M. (1981). The family life cycle: A framework for family therapy. New York: Gardner Press. Carter, B., & Peters, J. K. (1996). Love, honor and negotiate: Building partnerships that last a lifetime. New York: Pocket Books. McGoldrick, M. (2013). The multicultural family institute remembers Betty Carter (May 13, 1929–September 11, 2012). Journal of Marital and Family Therapy, 39(1), 2–4. https://doi.org/10.1111/jmft.12009. Walters, M., Carter, B., Papp, P., & Silverstein, O. (1988). The invisible web: Gender patterns in family relationships. New York: The Guilford Press.

Catherall, Donald Katelyn Steele Alliant International University, Los Angeles, CA, USA

Donald Catherall is an important contributor to couple and family therapy and theory. He is well known for introducing the concept of emotional

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safety. Catherall has authored four books and numerous papers in influential journals. Catherall received his Ph.D. in Clinical Psychology from Northwestern University Medical School in 1984 following his honorable discharge from the United States Marine Corps. He began his postgraduate work at the Center for Family Studies/Family Institute of Chicago (1983–1987), transitioning from Team Leader to the Director of Clinical Services in only four years. He went on to be the Executive Director at the Phoenix Institute in Chicago, Illinois (1991–2004). Catherall currently has a private clinical practice and works as a Clinical Associate Professor at Northwestern University. Catherall has presented at numerous professional conferences, including the American Family Therapy Association Annual Conference (1987) and the Fourteenth Annual Family Therapy Conference of the Family Institute Alumni Association (1991). He also received the honor of Distinguished Alumnus of the Year from the Family Institute Alumni Association (1992). Catherall has contributed several important theories to couple and family psychology, most notable of which is the theory of emotional safety. The concept of emotional safety describes the role of shame in relationships and attachment theory, and it explains the connection between adults in an intimate relationship. The partner who perceives a threat to this attachment is bothered, prompting criticism of their intimate other. Based on the concepts of emotion and attachment, emotional safety allows couple therapists to conceptualize client problems and to consider solutions, noting the emotional subtext of their clients’ communication. The emotionally safe relationship will subsist through adversity and hardship as it is grounded in acceptance and understanding. Relationship problems occur when the partners no longer feel safe being open and unguarded with each other; the partners question the sincerity of their relationship and do not consider circumstances at face value. This relationship will struggle through innoxious remarks or situations. However, the emotionally unsafe couple can

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create a healthier mindset and repair their strained relationship. The successful couple is one that can overcome transitory lapses in safety. Catherall developed the therapeutic alliance in couple and family therapy, akin to the wellestablished concept in individual psychotherapy. The alliance applies to two systems – not just two people. The therapist and the couple or family mutually participate in, and collaborate on, the therapy. Catherall – along with William Pinsof, Ph.D. – developed discrete scales to gauge the therapeutic alliance in individual, couple, and family therapy, adjusting for the interpersonal variations in the three therapeutic contexts. The three tiers of this system are: (a) Self-Therapist; (b) Other-Therapist; and (c) Group Therapist. The scales operationalize the therapeutic alliance in couple and family therapy, acknowledging the distinctive quality of this relationship. Catherall also focuses on trauma and its impact on the family system. As a combat veteran, Catherall was recruited to work with traumatized veterans in 1981. He soon expanded this interest to all trauma populations, specifically families. Catherall understood the importance of the family in overcoming trauma. He united his passion for trauma and the family in The Handbook of Stress, Trauma, and the Family. Catherall culled research, theory, and practice, focusing on the effect of traumatic stress on intimate others and how anxiety is buffered or augmented by the family system. As an Associate Professor at Northwestern University, Catherall shares his knowledge with a new generation of therapists and theorists. As a clinician, he guides couples and families through conflict and trauma.

Cross-References ▶ Circle of Security ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Marital Fusion in Couples ▶ Therapeutic Alliance in Couple and Family Therapy

Cecchin, Gianfranco

References Catherall, D. R. (1984). The therapeutic alliance in individual, couple and family therapy. Ann Arbor: University Microfilms International. Catherall, D. R. (1992). Working with projective identification in couples. Family Process, 31(4), 355–367. https://doi.org/10.1111/j.1545-5300.1992.00355.x. Catherall, D. R. (Ed.). (2004). The handbook of stress, trauma, and the family. New York: Brunner-Routledge. Catherall, D. R. (2007). Emotional safety: Viewing couple through the lens of affect. New York: Routledge. Catherall, D.R. (2012). Marriage and the marital relationship. In C.R. Figley Encyclopedia of Trauma (pp. 363–366), Los Angeles: Sage.

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High Point, Portchester. Once in Italy, in 1968, Cecchin joined Mara Selvini Palazzoli and her group – psychoanalysts interested to explore systemic ideas. The group became a foursome in 1971 when Selvini, Boscolo, and Prata joined the efforts. In 1980, the foursome split and Cecchin and Boscolo initiated a training effort to translate the systemic ideas in clinical practice within institutions, hospitals, jails, enterprises, and public wards and services. Cecchin and Boscolo travelled the western world teaching at seminars. The dialogue between them was generative and brought to many interesting ideas that consolidated Milan Systemic Family Therapy.

Cecchin, Gianfranco Contribution to Profession Pietro Barbetta1,2 and Umberta Telfener1 1 Centro Milanese di Terapia della Famiglia, Milan, Italy 2 University of Bergamo, Bergamo, Italy

Name Cecchin, Gianfranco

Introduction Gianfranco Cecchin could listen in silence before intervening with an irreverent comment, a different point of view, something surprising, able to get immediately to the core of each situation. He highlighted a peripheral aspect following the original path he was participating in co-creating, to deconstruct usual scripts. Along with Luigi Boscolo, Cecchin was the co-founder of the Milan Center of Family Therapy, one of the main systemic institutions between the 1980s and present times. He died in February 2004.

Career Cecchin received his degree in medicine in 1959 and completed his fellowship in child psychiatry at Hillside in Long Island, New York, and later at

Systemic thinking was the imprint that gave meaning to everything happening around Cecchin. He would choose which road to take by improvising and using marginal thinking and correlating processes. He did this by following his instinct and using the available stimuli. The three key concepts that constituted his embodied knowledge include epistemology, context, and theory of practice, with essential links between the three layers. From this choice he would build each phrase and then the path, the route, and the process, in order to deconstruct ideas and propose new connections. Cecchin did not follow a script but rather was faithful to the systemic frame, which influenced the choices of the language used, topics, timing, and the use of voice, body, and posture. Cecchin believed that to get distracted is useful in order to refrain focusing on the details of the narratives. Cecchin believed that the unconscious system of the therapist has to be responsive in order to respond naturally to what was happening outside of the dialogue. Levity and improvisation are words to describe Cecchin’s way of thinking and acting: a need of moving from one connection to the other (Cecchin and Apolloni 2003). Cecchin claimed that a large part of psychotherapy is a speculative description of the pathology and an attempt to make sense of it. Cecchin’s position differed in order to learn from clients taking their side, being in a

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References

relationship with them. He passed through irony, irreverence, and respect for transforming subjection in liberation. Cecchin neither criticized his clients nor wished to correct them or teach how to behave in a socially acceptable manner. He had the capacity of deconstructing discursive practices and proposing ironic dialogues as a way of liberating new lines of flight, rhizomes. Cecchin believed that people were considered as responsible subjects who chose their own way of living their lives and believed to be free to choose their path once they realized they are free (Cecchin 1987; Cecchin et al. 2005). For Cecchin, irony was a line of flight to escape from the influence of power. Irony maintains a distance between talking and doing and is the open space in the gap between subjects. Today, the Milan School continues to bring forward his teachings. In the entry Hypothesizing, Circularity and Neutrality Revisited: an Invitation to Curiosity (1987), Cecchin revised what was the big premise of the Milan group: the three main guidelines to make therapy work. He then started proposing some key concepts for the systemic practitioner as the one of irreverence. Irreverence was defined by Cecchin as “the attitude that protects against dependency from something, whichever this ‘something’ might be: food, other people, perfect ideas, heroin, therapy, the need for help, attachment” (Cecchin et al. 1992). The irreverence toward one’s own ideas also meant continually challenging all the possible limits and setting the boundaries always further while inhabiting a marginal positioning. Cecchin often told his students to flirt with their ideas and hypothesis without ever marrying them. As such, Cecchin often flirted with the cybernetic ideas and concepts.

In Structural Family Therapy (SFT), challenge designates the therapist’s questioning of the family’s individualistic certainties creating a relational understanding about the symptom and the transformative possibilities of enhanced individual and family functioning.

Cross-References

Theoretical Framework

▶ Circular Questioning in Couple and Family Therapy ▶ Curiosity in Couple and Family Therapy ▶ Milan Associates ▶ Milan Systemic Family Therapy

In Structural Family Therapy, the therapist’s goal is to cocreate a context that expands the relational rules that bind the narrow certainty of the symptom’s location from occurring “in” the Identified Patient (IP) to what happens between them – the

Cecchin, G. (1987). Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process, 26(4), 405–413. Cecchin, G. F., & Apolloni, T. (2003). Idee perfette: Hybris delle prigioni della mente (Perfect ideas: Hybrid prisons of the mind). Milan: Franco Angeli. Cecchin, L., Ray, K., Lane, G., & Ray, A. W. (1992). Irreverence: A strategy for therapists’ survival (Systemic thinking and practice series). London: Karnac Books. Cecchin, G., Lane, G., & Ray, W. (1993). From strategizing to nonintervention: Towards irreverence in systemic practice. Journal of Marital and Family Therapy, 19(2), 125–136. Cecchin G., Lane G., & Ray, W. (1994). The cybernetics of prejudices in the practice of Psychotherapy (Systemic thinking and practice series). London: Karnac Books. Cecchin, G., Barbetta, P., & Toffanetti, D. (2005). Who was von Foerster, anyway? Kybernetes: The International Journal of Systems & Cybernetics, 34(3/4), 330–342.

Challenge in Structural Family Therapy Jay Lappin Minuchin Center for the Family, Woodbury, NJ, USA

Introduction

Challenge in Structural Family Therapy

context of the family’s relational patterns. Through restructuring relationships, family members can experience different aspects of themselves and others – a liberation of possibility and growth. It is saying, “The concept of what you think about yourself is partial. Your certainty about ‘this is who you are’ is wrong, but it is wrong because you are richer.” (Minuchin and Lappin 2011, p. 29*).

Rationale Change is hard, uncertain, and stressful. It cannot be separated from its relational, developmental, cultural, and biobehavioral contexts. For all families, especially those with a symptomatic member, change presents a dilemma; face the stress of the unknown or stick with what’s known, remain the same, but suffer the limiting consequences of stagnation. Since the plight of the IP affects everyone, the most obvious “greater good” solution would be simply for the IP to change. As the saying goes, “Don’t ask a fish about water,” so too are the rules that govern family’s interactions “invisible” to them (Minuchin et al. 2014, p. 15). They are also homeostatic – that is to say that when they reach a certain level of “affective intensity” (Minuchin et al. 1978, p. 96) change succumbs to habit. In encountering the uncertainty and discomfort of accessing new feelings and behaviors, family members may either escalate their differences, or avoid them. The result is the same – the family patterns that maintain the symptom return to the status quo. Since this protective threshold constrains the adaptive capacity of the family, it must be challenged respectfully. While challenge at the level of content or education may be necessary, neither may be sufficient to take on the family’s collective symptom maintaining patterns. Transformative challenge must reach deeper into process, at the level of affective and physiological experience. As Minuchin, Rosman, and Baker noted in their seminal work with psychosomatic families and the free fatty acid studies (Minuchin 1974, pp. 7–8) that connected mind, body, family

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organization, and stress, “The affective component of the family members’ interactions has to be pushed beyond the usual threshold” (Minuchin et al. 1978, p. 96).

Description Challenge is inseparable from joining and together, they are inseparable from change and hope. To challenge effectively, “. . .you need to find a way of validating who they are, and then say, The way in which you think you are is partial. It is correct, but it is partial. Join me in the trip to expand your alternatives. Join me in the trip to becoming richer” (Minuchin and Lappin 2011). Challenging the family’s homeostasis – their “certainty” about the problem and who is responsible for changing it (Minuchin et al. 2014, p. 4), however, requires the therapist’s correct assessment of the family structure – an interactional “map” of the symptom maintaining patterns (Minuchin 1974). According to Minuchin, “A family diagnosis,. . . involves the therapist’s accommodation to the family to form a therapeutic system. . .” (Minuchin 1974, p. 129). It is an accommodation that Minuchin has likened to a dance – “like a tango” – in which, “. . .it is the response of the family, that will instruct me if I should continue in that way or if I should move, and instead of being challenging, I should be supportive” (Minuchin and Lappin 2011). In SFT, enactment of the family patterns is one of the principal tools used to elevate process from the landscape of content. It is not about the “facts” of what is said, “but rather the family rules that organize their interactions. This process shifts the picture; content becomes background while family dynamics jump into the foreground” (Minuchin et al. 2014, p. 5). Challenge is always sown with the reciprocal concept that, “Each person is the context of the other” (Minuchin and Fishman 1981, p. 196). So when someone declares, “I own my depression,” the response, “Don’t be so sure,” begins to introduce uncertainty (Minuchin and Fishman 1981, p. 196) and starts the transition from the innerpersonal to the inter-personal.

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When challenging, the family’s location of the problem and expanding their world view, the therapist’s use of self is key. Therapists temporarily enter the family by way of the symptom. In that short time, the therapist must be different so that the family can be different. Effective change requires the therapist’s toggling back and forth between different aspects of self – aware, observing, accommodating, insistent, curious, funny, somber, reflective – in order to be able to offer an earnest challenge to the family’s singular vision; “Help the other to change by changing yourself as you relate to him” (Minuchin and Fishman (1981, p. 197).

Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press. Minuchin, S., Reiter, M. D., & Borda, C. Contributions from: Walker, S. A., Pascale, R., & Reynolds, T. M. (2014). The craft of family therapy: Challenging certainties. New York: Routledge.

Case Example

Name

The following excerpt is from a session with Salvador Minuchin (Minuchin and Fishman 1981, pp. 198–199). It is a couple in their 30s with two small children in which the husband has left for the last month to “find himself.” Minuchin is challenging the location of the problem from inside the husband to between the husband and wife.

Anthony L. Chambers, PhD, ABPP

Gregory: I don’t give her that responsibility, you know; I don’t lay that on her. I feel depressed and I felt really depressed for some time in the situation. Minuchin: Hold it! You said you were depressed at home, you left home, and you are less depressed. You are saying that Pat depresses you. Gregory: No, I really take responsibility for being depressed. I can’t put it on her. Minuchin: For a moment, follow me. You are depressed, and Pat does not help you with your depression. Gregory: Right. Minuchin: Why doesn’t Pat help you? Gregory: I guess I feel that a lot of my needs weren’t being met. I felt very frustrated. I felt very deprived.

References Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Minuchin, S., & Lappin, J. (2011). Salvador Minuchin: On family therapy. www.Psychotherapy.net, V. Yalom, Producer. A. Miller, Instructor’s manual.

Chambers, Anthony John W. Thoburn Department of Clinical Psychology, Seattle Pacific University, Seattle, WA, USA

Introduction Anthony Chambers Ph.D., ABPP is co-editor of the Encyclopedia of Couple and Family Therapy. As the Chief Academic Officer at the renowned Family Institute at Northwestern University and immediate past president of the Society for Couple and Family Psychology, Division 43 of the American Psychological Association, Dr. Chambers is one of the rising stars in the field of couple and family psychology.

Career Dr. Chambers received his undergraduate degree in Psychology from Hampton University and completed his M.A. and Ph.D. in Clinical Psychology from the University of Virginia (Department of Psychology). He completed his internship and post-doctoral clinical residency at Harvard Medical School and Massachusetts General Hospital (HMS/MGH), specializing in the treatment of couples. Dr. Chambers continued his training through the Dr. John J.B. Morgan Clinical Research Fellowship at The Family Institute where he specialized in couple therapy and

Chambers, Anthony

honed an expertise in premarital counseling. Dr. Chambers also completed specialized training in Emotion Focused Couple Therapy (ECFT), one of the few empirically validated treatments for couple distress. Dr. Chambers is a Fellow of the American Psychological Association and a diplomate with the American Board of Professional Psychology in Couple & Family Psychology. He was the recipient of the Alumnus of the Year Award by The Family Institute at Northwestern University (2012) and the Outstanding Professional Accomplishment Award by The Family Institute at NU (2011).

Contributions to Profession Dr. Chambers has made numerous contributions to the departments of marriage and family therapy and family psychology at Northwestern University through his work with The Family Institute and the Northwestern University, Center for Applied Psychological and Family Studies. He has been particularly active in leadership roles in national organizations including the Society for Couple and Family Psychology, Division 43 of APA, where he served in a plethora of leadership positions including Program Chair and Secretary of the Board, culminating in his election as President in 2016. He is on the Board of Directors of the Family Process Institute (2013–2019), a member of the Board of Directors of the American Academy of Couple and Family Psychology (2013–2015), a Research Consultant for Hampton University’s research project on African American Marriages, and a Consultant for the Naomi Ruth Cohen Foundation on Mental Health (2006–Present). Dr. Chambers is also an Associate Editor of the influential APA journal Couple and Family Psychology: Research and Practice and he has been an Associate Editor and is currently on the Editorial Board of the Journal of Multicultural Counseling and Development. Dr. Chambers’ work with academic journals reflects a strong history as a clinical researcher and a keen interest in the reciprocal interaction of research and practice. He maintains a thriving full time clinical practice with a particular clinical research interest

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in African American marriages, including the disproportionately low marriage rate and high divorce rate among African American couples; cultural factors responsible for change in therapy, especially for African American couples; intimate partner violence; minority father involvement in family life; and the development of empirically informed couple and family supervision.

Cross-References ▶ African Americans in Couple and Family Therapy ▶ Culture in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy

References Chambers, A. L. (2012). A systemically infused, integrative model for conceptualizing couples’ problems: The four session evaluation. Couple and Family Psychology: Research and Practice, 1(1), 31–47. https://doi. org/10.1037/a0027505. (One of the top downloaded articles in 2012). Chambers, A. L. (in press). The four session evaluation. In J. Lebow, A. L. Chambers, & D. Breunlin (Eds.), Encyclopedia of couple and family therapy. Springer Publishing. Chambers, A. L., Solomon, A., & Gurman, A., (2016). Couple therapy. In J. Norcross (Ed.), Handbook on clinical psychology. Couple therapy. APA books. Gooden, A. & Chambers, A. L. (in press). Black men in couple therapy. In J. Lebow, A. L. Chambers, & D. Breunlin (Eds.), Encyclopedia of couple and family therapy. Springer Publishing. Lebow, J., Chambers, A. L., Christensen, A., & Johnson, S. (2012). Research on the treatment of couple distress. Journal of Marital and Family Therapy, 38(1), 145–168. https://doi.org/10.1111/j.17520606.2011.00249.x. Lebow, J., Chambers, A. L., & Breunlin, D. (Eds.), online 2016; print (2017). Encyclopedia of couple and family therapy. Springer Publishing. Pinsof, W. M., Breunlin, D., Chambers, A. L., Russell, W., & Solomon, A. (2015a). In D. Synder, J. Lebow, & A. Gurman’s, (Eds.), Handbook on couple therapy. IPCM couple therapy. Guilford Press. Pinsof, W., Zinbarg, R. E., Shimokawa, E., Latta, T., Goldsmith, J. Z., Knobloch-Fedders, L., Chambers, A., & Lebow, J. L. (2015b). Confirming, validating, and norming the factor structure of systemic therapy inventory of change initial and intersession. Family Process. https://doi.org/10.1111/famp.12159.

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Chasin, Richard and Laura

Chasin, Richard & Laura

from Harvard University Medical School (1960). His education included training in psychoanalysis at the Boston Psychoanalytic Institute from 1966–1973 and in child psychiatry and family therapy at Family Institute of Cambridge from 1974–1978. In addition to his clinical work with patients, he has worked as associate professor of psychiatry at Harvard University and has served as the president of the American Family Therapy Academy (Chasin 2018).

Introduction

Contributions to Profession

Richard and Laura Chasin were a couple devoted to making the world a better place through their clinical interventions and civic engagements. Their career paths, though slightly different, served as a platform for helping to advocate for those in need. Married in 1971, and the parents of three children and three step-children, Richard and Laura Chasin spent their lives working as clinicians and social advocates, dedicated to the service of others.

Throughout her life, Laura made significant contributions through her volunteer work and philanthropic leadership. She followed in the footsteps of her mother who served on the board of trustees for Spelman College. Not being one to shy away from difficult discussions, she and her husband Richard joined forces with colleagues to moderate challenging conversations about controversial topics (Esalen 2014). Through her work as the founder of the Public Conversations Project, she facilitated discussions for people of differing ideas, identities, and values (Hess 2015). Through her trainings, she was able to promote healthy dialogue between individuals of differing beliefs in areas such as abortion, religious tolerance, gun safety, and sexual orientation. Her work with this nonprofit agency has been recognized by the likes of the New York State Mediators Association, the American Association of Group Psychotherapy and Psychodrama, and the American Family Therapy Association (Boston Globe 2015). Richard has published articles pertaining to the treatment of patients dealing with depression (Chasin and Semrad 1966), along with articles highlighting the use of systemic therapy with couples (Chasin et al. 1989). He may be best known for his collaborations with his wife as a Founding Associate of the Public Conversations Project. Dr. Chasin continues to maintain a private practice in Cambridge, MA, where he provides psychiatric care to individuals and couples. Laura Chasin passed away in 2015 but her legacy for working to unite people and repair relationships continues to live on.

Chasin, Richard and Laura Lorna London Midwestern University, Downers Grove, IL, USA

Name

Career Laura Chasin was born and raised in New York. As a college student at Bryn Mawr College, she earned a bachelor’s degree in art history. Following her undergraduate work, Laura continued her studies at Harvard University where she received a M.A. in government and a M.S.W. from Simmons College (Boston Globe 2015). Laura also completed postgraduate training in the areas of family therapy and psychodrama, which served to guide much of her later work. Laura and her colleagues at the Family Institute of Cambridge in Watertown, MA, borrowed from techniques used in strategic family therapy to help people to delve into polarizing issues and work to express their ideas while also working to come to a respectful understanding of one another (Staff 1992). Richard Chasin graduated Phi Beta Kappa from Yale University with a B.A. in psychology and philosophy in 1956. He was trained as a physician and received his medical education

Cherlin, Andrew

Cross-References ▶ American Family Therapy Academy (AFTA)

References Boston Globe. (2015). From http://www.legacy.com/obitu aries/bostonglobe/obituary.aspx?pid=176574814 Chasin, R. (2018). Curriculum vitae. http://www. richardchasinmd.com/ Chasin, R., Herzig, M., Roth, S., Chasin, L., Becker, C., & Stains, R. (1996). From diatribe to dialogue on divisive public issues: Approaches drawn from family therapy. Mediation Quarterly, 13(4), 323–344. Chasin, R., Roth, S., & Bograd, M. (1989). Action methods in systemic therapy: Dramatizing ideal futures and reformed pasts with couples. Family Process, 28(2), 121–136. https://doi.org/10.1111/j.1545-5300.1989. 00121.x. Chasin, R., & Semrad, E. (1966). Interviewing the depressed patient. Hospital and Community Psychiatry, 17(10), 283–286. Hess, J. (2015). Celebrating a founding mother of American’s dialogue renaissance. Retrieved from https:// www.huffingtonpost.com/living-room-conversations/ celebrating-a-founding-mo_b_8626362.html Esalen. (2014). Retrieved from https://www.esalen.org/ page/ctr-october-2014-participant-biographies Staff. (1992). Lessons for a Stuck Society. Psychology Today, 25(5), Retrieved from https://www.psychologytoday. com/us/articles/199209/lessons-stuck-society

Cherlin, Andrew Jeffrey Goulding and Corinne Datchi Seton Hall University, South Orange, NJ, USA

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recently he has contributed to knowledge about the influence of socioeconomic status and welfare reform on family structure. Throughout his career Dr. Cherlin has actively published in scholarly journals, newspapers, and other reputable media. He has also written books on family structure and the institution of marriage.

Career Andrew Cherlin is the Benjamin H. Griswold III Professor of Sociology and Public Policy at Johns Hopkins University. In 1976, he earned his PhD in sociology from the University of California at Los Angeles, and joined the Sociology Faculty of John Hopkins University where he has been a professor ever since. His research on the sociological characteristics of the American family has documented changes in family structure since the 1980s, including the impact of the law and economic disparities on family life and the well-being of children. Dr. Cherlin has earned many awards and distinctions in his career. In 1993 he received a Merit Award from the National Institute of Child Health and Human Development for his research on family structure and its influence on child development. In 2001, he received the Olivia S. Nordberg Award for Excellence in Writing in the Population Sciences. In 2003, he was the recipient of the Distinguished Career Award granted by the Family Section of the American Sociological Association, and in 2009, he received the Irene B. Taeuber Award from the Population Association of America, in recognition of his outstanding contributions to demographic research.

Name Andrew J. Cherlin, Ph.D. (1948–)

Introduction Andrew Cherlin has been and continues to be a very influential scholar in the field of family demography. Throughout his career he has studied the changing nature of the institution of marriage and the social effects of marriage and marriage dissolution. More

Contributions to the Profession Andrew Cherlin’s contributions to the field of family demography and family sociology include 5 books and more than 90 scholarly articles about family structure, marriage dissolution, family demographics, and family socioeconomic issues. For over three decades, Dr. Cherlin has researched the changing structure of the family as well as the institution of marriage, in various

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countries, cultures, and demographic areas. One of his major contributions to the field has been his work with families that have experienced divorce and remarriage. Dr. Cherlin has pioneered projects to better understand how families and children are impacted by the challenges associated with marriage dissolution and remarriage, namely, how divorce affects the behavior and achievement of children who come from homes where the parents have separated or divorced. Dr. Cherlin has also attempted through his research to destigmatize the dissolution of marriage in an effort to promote consistent support for children by both parents and extended family members throughout the dissolution and remarriage process. Dr. Cherlin’s work has highlighted the changing role of marriage as a societal institution. Marriage used to be a necessary ingredient to achieve maturity and success as an adult; it also was a condition of stability within the family system. In today’s society, marriage is only one option for forming a family. Diverse family structures have developed as viable alternatives to traditional long-term marital relationships. Dr. Cherlin’s research also showed the evolution of marriage from a necessary rite of passage to a symbol of social status that has become less essential for familial and social stability. Lastly, Dr. Cherlin was the principal investigator of the “Three-City Study,” an interdisciplinary, longitudinal study of low-income children and their caregivers in the era of post-welfare reform. The results of this study have increased our understanding of the impact of welfare reform on low-income families and children across the life span. Specifically, low-income families were found to have higher rates of depression and heart disease, reduced earnings, and greater food insecurity or limited access to food necessary for an active and healthy life.

Chicago Center for Family Health

References Cherlin, A. (1978). Remarriage as an incomplete institution. American Journal of Sociology, 84, 634–650. https://doi.org/10.1086/226830. Cherlin, A. (1981). Marriage, divorce, remarriage. Cambridge, MA: Harvard University Press. Revised and Enlarged Edition. 1992. Harvard University Press. Cherlin, A. (2004). The deinstitutionalization of American marriage. Journal of Marriage and Family, 66, 848–861. Cherlin, A. (2009). The marriage-go-round: The state of marriage and the family today. New York: Alfred A. Knopf. Cherlin, A. (2014). Labor’s love lost: The rise and fall of the working-class family in America. New York: Russell Sage Foundation. Cherlin, A., Furstenberg, F., Chase-Lansdale, P., Kiernan, K., Robins, P., Morrison, D., & Teitler, J. (1991). Longitudinal studies of effects of divorce on children in Great Britain and the United States. Science, 252, 1386–1389.

Chicago Center for Family Health John S. Rolland1 and Froma Walsh2 1 The Chicago Center for Family Health, University of Chicago, Chicago, IL, USA 2 Chicago Center for Family Health and Firestone Professor Emerita, The University of Chicago, Chicago, IL, USA

Introduction The Chicago Center for Family Health (CCFH) is an internationally renowned family therapy training institute providing resilience-oriented advanced training, counseling services, and communitybased programs.

Cross-References Location ▶ Blended Family ▶ Divorce in Couple and Family Therapy ▶ Marriage ▶ Nuclear Family ▶ Remarriage in Couple and Family Therapy

The Chicago Center for Family Health (www. ccfhchicago.org) is located in downtown Chicago, Illinois, with faculty offices in city and suburban areas.

Chicago Center for Family Health

Prominent Associated Figures John Rolland, MD, and Froma Walsh, PhD, cofounders and codirectors, are international leaders in the field of family therapy (▶ “Rolland, John”). Other prominent faculty members are Michele Scheinkman, LCSW, and Mona Fishbane, PhD, who developed and directed the Couples Therapy training program; Gene Combs, MD, and Jill Freedman, LCSW; Mary Jo Barrett, MSW; Jay Lebow, PhD, LMFT; and Thomas Todd, PhD. Other CCFH faculty members who have been instrumental in CCFH programs include Bessie Sultan Akuamoah, LCSW; Michele Baldwin, PhD, LCSW; Cheryl Berg, LCSW; Pamela Brand, PsyD, LMFT; Ruth Fuerst, LCSW; Katherine Neill Goldberg, MA; Deane Graham, LMFT, LCPC; Miriam Gutmann, MD; Lynn Carp Jacob, LCSW; Bruce Koff, LCSW; Ronna Lerner, LCSW; William Martin, LCSW; Bonnie Mervis, LCSW; Michelle Adler Morrison, LCSW; David Schwartz, PhD; Nancy Segall, MA, LCSW; Len Sharber, MDiv, LCSW; Robert Sholtes, MD; Susan Sholtes, LCSW; Virginia Simons, LCSW; Sant Singh, MAS, MA, FIC, LCSW; Karen Skerrett, PhD, RN; Kate Sori, PhD, LMFT; Lorena Valles, LCSW; Stevan Weine, MD; and Steven Zuckerman, PhD, LMFT.

Contributions The Chicago Center for Family Health (CCFH; www.ccfhchicago.org) was cofounded in 1991 by codirectors John Rolland, MD, and Froma Walsh, PhD, as a nonprofit advanced training institute affiliated with the University of Chicago. They formed a network of talented clinical faculty members interested in advancing family systems training and practice. The faculty, bringing varied couple and family therapy approaches and areas of expertise, all share a strength-based, collaborative, systems orientation to practice, responsive to family diversity and committed to serve disadvantaged and marginalized populations and to address social justice concerns. CCFH is renowned for its innovative resilience-oriented practice approach to

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strengthen families at risk, in crisis, or facing persistent life challenges (Rolland and Walsh 2005). Through the Center’s clinical services, CCFH fellows and faculty provide counseling/ therapy for families, couples, and individuals, with availability to clients in financial need. State-of-the-art postgraduate training in couple and family therapy and in family systems-based healthcare are guided by a family resilience framework (Walsh 2016b; ▶ ”Resilience in Couples and Families”). For over two decades, the Center offered a 2-year, postmasters, intensive certificate program, with advanced tracks in couple therapy; child, adolescent, and family therapy; and Families, Illness, and Collaborative Healthcare. Currently, the Center offers the following training opportunities: • Workshops and conferences • Brief intensive certificate programs • Families, Illness, and Collaborative Healthcare (FICH) Fellowship • Distance learning and consultation • International training • Community consultation, training, services, and research Building partnerships with community-based organizations and healthcare systems has been at the heart of CCFH’s mission to train and support healthcare, mental health, and human service professionals, particularly those who work with lowincome and minority families, LGBT (gay, lesbian, bisexual, and transgender) clients, persons with disabilities, and other vulnerable groups. CCFH has provided workshops and intensive certificate programs and partnered with local healthcare centers, schools, and human service agencies to provide specialized staff training, organizational consultation, and program development. Our systems approach has also been usefully applied in the fields of pastoral counseling, family law, and family business. Over the years, community-based programs have addressed a wide range of adverse situations (see Walsh 2016a, b), as summarized in Table 1, with faculty coordinators noted. The Center is particularly noted for its innovative Families, Illness, and Collaborative

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398 Chicago Center for Family Health, Table 1 CCFH resilience-oriented, community-based program applications. Chicago Center for Family Health (1991–2017): Family Resilience-Oriented Training, Services, and Partnerships Recover from crisis, trauma, and loss Family adaptation to complicated, traumatic loss (Walsh) Mass trauma events, major disasters (Walsh) Relational trauma (Barrett, Center for Contextual Change) Refugee families (Rolland, Walsh, Weine) War- and conflict-related recovery (Kosovar familyprofessional education collaborative) (Rolland, Weine, Walsh) Navigate disruptive family transitions Divorce, single parent, and stepfamily adaptation (Jacob, Lebow, Graham) Foster care (Engstrom) Job loss, transition, and reemployment strains (Walsh, brand) Overcome challenges of chronic multi-stress conditions Families, illness, and collaborative healthcare (FICH). Serious illness, disabilities, and end-of-life challenges (Rolland, Walsh, R. Sholtes, Zuckerman) Poverty, ongoing complex trauma (faculty) LGBT issues, stigma (Koff) Overcome obstacles to success: At-risk youth Child and adolescent developmental challenges (Lerner, Schwartz, Gutmann, Martin) Family-school partnership program (Fuerst & Team) Gang reduction/youth development (GRYD) (Rolland, Walsh & Team)

Healthcare (FICH) Program, dedicated to advancing family systems and integrated biopsychosocial approaches in healthcare (Rolland and Walsh 2005; John’s other entry ▶ “Families with Illness”). Rolland’s Family Systems Illness Model (Rolland 2018) has guided the design and implementation of numerous projects designed to meet the training and practice needs of health and mental healthcare professionals who work with couples and families facing serious illness, disability, and loss. Training is relevant to diverse professional disciplines, work settings, and levels of experience and adaptable for brief consultation, more intensive therapy, and multifamily group formats. Over the past 20 years, CCFH, in partnership with Advocate

Child Sexual Abuse in Couple and Family Therapy

Illinois Masonic Medical Center Family Practice, has offered yearlong fellowships for postdoctoral mental health professionals and doctoral candidates specializing in medical family therapy. Additionally, CCFH has partnered with a number of healthcare systems and specialty care services to develop and provide family-oriented training and services, including cancer, diabetes, cystic fibrosis, genetic risk screening, multiple sclerosis, rehabilitation, and integrative medicine, palliative care, and hospice.

Cross-References ▶ Families with Illness ▶ Resilience in Couples and Families ▶ Rolland, John ▶ Walsh, Froma

References Rolland, J. S. (2018). Helping couples and families navigate illness and disability: An integrative practice approach. New York: Guilford Press. Rolland, J. S., & Walsh, F. W. (2005). Systemic training for healthcare professionals: The Chicago center for family health approach. Family Process, 44(3), 283–301. Walsh, F. (2016a). Applying a family resilience framework in training, practice, and research: Mastering the art of the possible. Special Section on Family Resilience: Family Process, 55, 616–632. Walsh, F. (2016b). Strengthening family resilience (3rd ed.). New York: Guilford Press.

Child Sexual Abuse in Couple and Family Therapy Katherine Hertlein, Brittany Donaldson and Nicole Walker University of Nevada – Las Vegas, Las Vegas, NV, USA

Synonyms Incest; Molestation; Pedophilia; Sexual Assault

Child Sexual Abuse in Couple and Family Therapy

Introduction Child sexual abuse is a critically important problem in clinical practice. The prevalence of child sexual abuse ranges from study to study, from 0.7% to 17% for men and from 1.8% to 31% for women (Laaksonen et al. 2011; Pereda et al. 2009), with that number being higher in clinical populations. It is a phenomenon that occurs in all cultures and across all socioeconomic statuses. A decline in the prevalence of child sexual abuse in some cultures has been observed in conjunction with a decline in the risk factors, suggesting that the risk factors associated with childhood sexual abuse have a demonstrable impact on its prevalence.

Theoretical Context Treating the trauma and physiological effects experienced by children of abuse requires a long-term therapeutic framework. Because the treatments tend to be long-term, the theoretical constructs behind the treatments are designed to address multiple areas of the child’s emotional well-being. Traumagenic dynamics is a theoretical construct to assist therapists in thinking about how to treat the accompanying traumatic sexualization, betrayal, powerlessness, and stigmatization resultant from childhood sexual abuse. For example, traumatic sexualization can occur through a variety of ways including, but not limited to, exchanges of affection, attention, privileges, and gifts in return for sexual behavior. The degree of traumatic sexualization can be affected by factors such as the child’s age, developmental level, coping skills, and overall emotional and mental health. Betrayal refers to instances when, during the course of abuse, a child may realize someone close to them whom they trusted has lied or misrepresented themselves in a manipulative way (Finkelhor and Browne 1985). Children who have trusted a family member to protect them from these circumstances, who is then unable or unwilling to do so, may be more susceptible to these dynamics of betrayal.

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A child’s sense of powerlessness comes from the process during which their desires, sense of efficacy, continual fear, and self-identification are violated. For example, the child may feel powerless to control their own environment and powerless to control events around them. This can have significant implications for the development of self-efficacy. Further, destructive communications of badness, shame, and guilt are incorporated into the child’s experience and ultimately into their self-image.

Description Child sexual abuse occurs when someone attempts to engage a child in any sexually charged interactions or behaviors, notably to the gratification of the perpetrator (Malhotra and Biswas 2006, p. 17). This may include noncontact abuse such as indecent exposure, contact abuse such as being touched, fondled, or kissed, and/or forced activity (attempted or completed). Certain risk factors such as interpersonal violence (IPV) in families are indicative of higher levels of child sexual abuse. Other well-documented risk factors include the age of the victim, whether the victim has any physical disabilities or incapacities, absence of a father in the home (which doubles the risk for girls but not boys), paternal impairments (i.e., drug and/or alcohol abuse, poor parenting practices, psychopathology), social isolation, and multigenerational transmission of maladaptive coping and family processes. Socioeconomic status also plays a role in child sexual abuse. For example, boys, though not girls, who live in lower socioeconomic areas report higher levels of abuse than boys in higher socioeconomic areas. Lacking the power, knowledge, or necessities to receive the proper resources plays a major role in reporting abuse and the inability to receive the proper services can be very detrimental to the child being abused. Different socioeconomic groups may also be more reluctant to report as well, due to the lack of trust or confidence they have in higher authorities. The determination as to whether one has experienced childhood sexual abuse is complex

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and is often shaped by aspects of one’s life such as individual history, perception of resiliency and normalcy, and belief systems. The terms used to describe child sexual abuse also vary based on cultural and ethnic contexts. Similarly, the beliefs and attitudes behind what constitutes sexual abuse can be culturally bound. Furthermore, different cultures may not have the same views of reporting child abuse that takes place. There may be repercussions that keep certain individuals from reporting in order to avoid embarrassment or disapproval.

Application of Concept in Couple and Family Therapy The way in which a therapist approaches the concept of child sexual abuse in therapy is crucial to the overall treatment process and outcome. Each family system is different from the next and, likewise, each context where child sexual abuse takes place differs. The goal of therapy generally focuses on helping adolescents communicate about the abuse experience, enhance self-esteem, learn about appropriate family roles and boundaries, overcome isolation, and develop healthy peer relationships. There are many approaches to go about accomplishing these goals. A few examples include abuse-focused therapy, trauma-focused CBT, play therapy, education as therapy, individual therapy, and group therapy. Psychotherapy and cognitive-behavioral therapy have been the most utilized and studied approaches in cases of child sexual abuse. These treatments are intended to assist the sexual abuse survivor in identifying and using coping skills, managing the emotional and psychological consequences of the abuse, restructuring the family system for greater protection of all individuals, and reducing a family’s risk for abuse. The modality of therapy can include individual treatment, group treatment, and family therapy (Gil 1991). Therapists need to decide, based on the case before them, what treatment modality would be most appropriate.

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In some cases of childhood sexual abuse, children are removed from their homes and separated from family members. These children tend to experience a greater degree of separation anxiety, concern for the parents, and loyalty issues (Gil 1991). With that being said, if it is safe for the child, inclusion of parent(s) and/or guardian(s) as part of the therapy team can be quite helpful for the child during treatment. Knowing they have a support system can be an intervention in itself for the child. Issues to consider during the treatment process include attention to inappropriate attachment behavior, infant regressive behavior, need for body contact and body awareness, and need for education on feelings. Additionally, a child’s development may make it difficult to receive help and care. Without the proper tools to express how one feels or the ability to relay their emotions, treatment can be difficult. As the therapist, being able to address and prepare for such instances can have a positive effect on the treatment process for everyone involved.

Clinical Example Jack, age 7, was brought to therapy by his mother. She reported that he had been sexually abused by a cousin 3 months ago. She stated that Jack was having nightmares, wetting his bed, and having temper tantrums that were uncharacteristic for him. Jack’s mother stated that when Jack revealed the abuse, she responded by getting the authorities involved to continue to protect Jack as well as other children. When the therapist brought Jack to the play therapy room, he immediately went to hide the toy snakes and sharks in the room before he would engage in any play. In assessment, the therapist evaluated Jack’s coping skills and resiliency as well as his family structure, extant psychopathology within his family-of-origin, circumstances surrounding the abuse, his selfesteem and view of self, and any other traumatic stress symptomology. The therapist used play therapy techniques to address all of these areas. This included games where Jack processed negative cognitions about himself and these cognitions were challenged in

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appropriate ways. Further, the therapist used child-centered therapy as a way to have Jack make his own choices in therapy, thus addressing his sense of powerlessness. The therapist also worked with Jack’s mother to provide opportunities for Jack to have some control over areas of his life toward developing self-efficacy. Treatment also centered on assisting Jack with relieving symptoms of hypervigilance and anxiety. This included participation in art therapy and nondirective play therapy, teaching relaxation skills, and instituting a new bedtime routine to address his nightmares.

References Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55(4), 530–541. Gil, E. (1991). The treatment of abused children. In The healing power of play (pp. 37–82). New York: Guilford. Laaksonen, T., Sariola, H., Johansson, A., Jern, P., Varjonen, M., von der Pahlen, B., . . . Santtila, P. (2011). Changes in the prevalence of child sexual abuse, its risk factors, and their associations as a function of age cohort in a Finnish population sample. Child Abuse and Neglect, 35(7), 480–490. https://doi.org/ 10.1016/j.chiabu.2011.03.004. Malhotra, S., & Biswas, P. (2006). Behavioral and psychological assessment of child sexual abuse in clinical practice. International Journal of Behavioral Consultation and Therapy, 2(1), 17–28. https://doi.org/ 10.1037/h0100764. Pereda, N., Guilera, G., Forns, M., & Gómez-Benito, J. (2009). The prevalence of child sexual abuse in community and student samples: A meta-analysis. Clinical Psychology Review, 29(4), 328–338. https:// doi.org/10.1016/j.cpr.2009.02.007.

Childfree Couples Mudita Rastogi Illinois School of Professional Psychology, Argosy University, Schaumburg, IL, USA

Name of your Entry Childfree Couples

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Synonyms Childfree by choice

Introduction In many cultures couples have traditionally followed the path of meeting, getting married, and raising a family. For some, this is the right choice but for others, factors such as career, prioritizing couple closeness, disinterest in raising children, and financial stability become more significant than choosing to be a parent. While “childless” couples are unable to have children due to biological or psychological reasons, being voluntarily childfree is quite different than grappling with infertility or deciding to become adoptive parents.

Description Many couples feel that family and society expect them to follow a sequence of life stages including growing their family by adding children after they get married. The picture of a nuclear family with two parents and their biological children is widely portrayed in the media; couples desiring not to have children are often underrepresented in popular culture. Couples who temporarily identify as childfree are seen in a more positive light than couples who choose to remain childfree permanently (Koropeckyj-Cox et al. 2007). The latter often experience pressure and/or stigma from society. At the same time a number of demographic changes have been noted in the USA. The number of married couples is slowly decreasing with more individuals cohabiting before marriage or choosing not to marry at all (McGoldrick 2011). College educated individuals are more likely to delay marriage, with few individuals marrying before age 25 (Cherlin 2010). Furthermore, an increasing number of couples have chosen to remain childfree. In 1990, roughly six million childless married couples were under the age of 45 (American Demographics 1993). At present

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couples without children make up about 6.9% of the population in the United States (CDC 2015) with some estimates of voluntary childlessness at 7–8% of the US population (Abma and Martinez 2006).

Relevant Research About Family Life People report that their reasons for choosing to not pursue parenthood includes greater sense of freedom from responsibility in being sans children, prioritizing their couple relationship, career and economic considerations, philanthropic concerns, not liking children, their own early socialization experiences, and concerns about the physical changes of bearing children (Hird and Abshoff 2000). Contemporary marriages in the developed world are less concerned with cultural and family needs and instead individuals focus on personal fulfilment and satisfying partnerships (McGoldrick 2011). Since the 1970s women in these nations have decreased childbearing voluntarily in order to pursue other roles and identities (Hird and Abshoff 2000). Feminism enhanced women’s rights in numerous areas including reproductive freedoms so that choosing motherhood became a choice (Boucai and Karniol 2008; Rittenour and Colaner 2012). Furthermore, in the USA, we saw a trend of emerging adults (individuals in their 20s) completing higher levels of education than previous generations (Merz and Liefbroer 2012), and postponing relational decisions in order to pursue career and personal goals, compared with individuals in earlier times who sought the stability much earlier in life. While individuals who choose to be childfree come from diverse racial, cultural, and socioeconomic backgrounds (Mollen 2006), women hold more favorable attitudes towards being childfree than men, reflecting the higher opportunity costs of motherhood versus fatherhood (Merz and Liefbroer 2012). Individuals who display low religiosity, have civil versus religious wedding ceremonies, and who tend to disagree with traditional

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Biblical beliefs are more likely to decide to remain childfree (Heaton et al. 1992). Very little research exists on the topic of couples’ decision-making on whether to become parents or not. Cowan and Cowan’s (2000) study on reproductive decision-making found that approximately half of the couples take a thoughtful approach in deciding whether or not to have children. Notably, 12% of the couples they observed were categorized as “Yes-No” couples with one partner ready to pursue parenthood while the other did not. By the time the child reached 6 years of age, all of the “Yes-No” couples had divorced (Cowan and Cowan 2000; Massey-Hastings 2011).

Special Considerations for Couple and Family Therapy Clearly, this clinical issue has significant impact on couples and families. One model, Choosing a Childfree or Parenting Lifestyle (CCOPL), uses a psychoeducational approach via ten modules to help couples clarify their own and their partners’ attachment needs. It helps partners explore, communicate, and decide whether to remain childfree or become a parent (MasseyHastings 2011, 2016; Massey-Hastings and Rastogi 2013). The CCOPL is in the process of being turned into an online, self-paced psychoeducational program (Rastogi 2016; Rastogi and Massey-Hastings 2015). Additionally, couple and family therapists working with childfree couples should consider the following: 1. Women who reject motherhood may face more social consequences than men (Mollen 2006). Therapists may wish to discuss with their clients notions of motherhood, femininity, and the gendered cost of nonconformity. 2. Childfree couples are often perceived in less favorable light than those who are parents (Mollen 2006; Kemkes 2008). They may be perceived as lacking the commitment and

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responsibility required to raise children (Hird and Abshoff 2000). These couples may also receive unsolicited advice and pressure from friends, family, and strangers that they might regret the decision later. Therapists can assist these couples in examining their choices in depth. 3. Couples who value their religious traditions that endorse the importance of procreation may face additional pressure to explain their childfree stance (Merz and Liefbroer 2012). These couples may need support in understanding and resolving their conflicting values and desires. 4. Cowan and Cowan (2000) found that a majority of couples fluctuated between wanting/not wanting to have children. Couple and family therapists need to be prepared for their clients’ decisions to shift. Further, it is paramount to help couples negotiate this issue honestly in the case of “Yes-No” couples.

References Abma, J. C., & Martinez, G. M. (2006). Childlessness among older women in the united states: Trends and profiles. Journal of Marriage and Family, 68(4), 1045–1056. Retrieved from http://origin-search.pro quest.com/docview/62110170?accountid=34899. American Demographics. (1993). Childless couples. American Demographics, 15(12), 34. Retrieved from http://origin-search.proquest.com/docview/200607 829? accountid=34899. Boucai, L., & Karniol, R. (2008). Suppressing and priming the motivation for motherhood. Sex Roles, 59(11–12), 851–870. https://doi.org/10.1007/s11199-008-9489-0. Cherlin, A. J. (2010). Demographic trends in the united states: A review of research in the 2000s. Journal of Marriage and Family, 72(3), 403–419. https://doi.org/ 10.1111/j.1741-3737.2010.00710.x. Centers for Disease Control (CDC) (2015). National survey of family growth: childlessness. Retrieved from https://www.cdc.gov/nchs/nsfg/key_statistics/c.htm# childlessness Cowan, C. P., & Cowan, P. A. (2000). When partners become parents: The big life change for couples. Mahwah: Lawrence Erlbaum Associates. Heaton, T. B., Jacobson, C. K., & Fu, S. N. (1992). Religiosity of married couples and childlessness. Review of Religious Research, 33(3), 244–255. Hird, M. J., & Abshoff, K. (2000). Women without children: A contradiction in terms? Journal of Comparative Family Studies, 31(3), 347–366. Retrieved from http://

403 origin-search.proquest.com/docview/232581954?acco untid=34899. Kemkes, A. (2008). Is perceived childlessness a cue for stereotyping? Evolutionary aspects of a social phenomenon. Biodemography and Social Biology, 54(1), 33–46. https://doi.org/10.1080/19485565.2008. 9989130. Koropeckyj-Cox, T., Romano, V., & Moras, A. (2007). Through the lenses of gender, race, and class: Students’ perceptions of childless/childfree individuals and couples. Sex Roles, 56, 415–428. https://doi.org/10.1007/ s11199-006-9172-2. Massey-Hastings, N. (2011). Choosing the parenting lifestyle: A manualized psycho-educational primary intervention for couples regarding reproductive decisions. Doctoral dissertation, American School of Professional Psychology/Argosy University, Schaumburg. Massey-Hastings, N. (2016). CCOPL: Choosing the childfree or parenting lifestyle. Retrieved from http://CCOPL.org. Massey-Hastings, N., & Rastogi, M. (2013, February). Initial pilot study findings: Choosing the childfree or parenting lifestyle-A manualized psycho-educational primary intervention for couples regarding reproductive decisions. Paper presented at the second international conference on cognitive behavioral psychology, Singapore. McGoldrick, M. (2011). Chapter 13: Becoming a couple. In M. McGoldrick, B. Carter, & N. Garcia-Preto (Eds.), The expanded family life cycle: Individual, family, and social perspectives (4th ed., pp. 193–210). Boston: Pearson Allyn & Bacon. Merz, E., & Liefbroer, A. C. (2012). The attitude toward voluntary childlessness in Europe: Cultural and institutional explanations. Journal of Marriage and Family, 74(3), 587–600. Retrieved from http://origin-search.pro quest.com/docview/1023528253?accountid=34899. Mollen, D. (2006). Voluntarily childfree women: Experiences and counseling considerations. Journal of Mental Health Counseling, 28(3), 269–282. Retrieved from http://origin-search.proquest.com/ docview/198712492?accountid=34899. Rastogi, M. (2016, February). Choosing the childfree or parenting lifestyle (CCOPL): Harnessing educational technology for psychoeducation and personal growth. TeachMeet paper presented at the 8th annual 21CL conference, Hong Kong, SAR. Rastogi, M., & Massey-Hastings, N. (2015, March). Adapting a psycho-educational program for couples regarding reproductive decisions: In-Vivo to online models. Paper presented at the international education conference, Clute Institute, San Juan Rittenour, C. E., & Colaner, C. W. (2012). Finding female fulfillment: Intersecitng role-based and morality-based identities of motherhood, feminism, and generativity as predictors of women’s self-satisfaction and life satisfaction. Sex Roles, 67, 351–362. https://doi.org/ 10.1007/s11199-012-0186-7.

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Children in Couple and Family Therapy Robert Taibbi Charlottesville, VA, USA

Introduction So integral are children to couple and family dynamics; it is no surprise that they have been integral part of the therapy process as well, their role and focus evolving alongside the field itself. By definition children are not physically part of the couple therapy, but that doesn’t mean that children are not often the initial focus. Many couple therapists have had the experience of couples presenting with child issues only to shift focus in the third session and talk about the real concern, namely, issues in their intimate relationship; the child’s problems were a comfortable initial focus, allowing the couple time to feel settled and safe before marching into more contentious territory. Other times the couple comes into therapy seeking help with parenting skills or reconciling differences in values and style. In family therapy, children are, by definition, the primary focus, present in the room in various combinations depending on the clinician’s own therapeutic orientation and approach.

Description: Children in Couple Therapy When children are the couple’s primary focus, the parents’ concerns can take several forms. Parents of a 14-year-old may come because they fear their teen may have a budding eating disorder. The teen refuses to come in or even respond to the parent’s concerns, and so the parents are seeking information about the disorder, ideas about when to seek medical consultation, tips about ways to initiate this conversation with their daughter at home. Parents of a newborn are struggling with their own lack of sleep and irritability, but also are unsure how to help their 3-year-old who suddenly feels dethroned and is throwing tantrums.

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Others parents are struggling adapting their parenting styles to those of their growing children. The 5-year-old who could be picked up and placed in time-out when cranky is now a teen taller than his mother; when he quickly becomes defiant when asked to take out the garbage, his mother is at a loss at what to do instead. Often the clinician’s role in such cases is education and skill training, helping the parents understand their child’s changing needs, and how to best communicate and behaviorally respond. But for many parents the presenting issue is the couple’s own differences over parenting styles, differing visions of the role of children in the family and how they should be treated. Often the foundation for their differences is their reactions to the parenting they received as children – the neglected child who now as a parent is forever attentive, the child of abusive parents who now is overly permissive and fears turning into his father. But this can also reflect differing values – one parent believing that children and family time should be the primary everyday focus, while the other feels that couple needs to have more time for themselves. These different values may sometimes reflect conflicting cultural and ethnic foundations. At the most extreme forms, such parents are polarized: One parent is easy because the other is so strict; the other is strict because the other is so easy. Here we can think in terms of Minuchin’s enmeshed and disengaged parents, as well as Bowen’s notion of triangulation, and using the child’s problem as focus that bypasses other couple issues. When seeing such parents together, there is a feeling in the room of an ongoing power struggle, that the couple is playing courtroom and trying to have the clinician play judge to decide who is right and who is not. Obviously this polarization is harmful to children in couple of ways. One is that children learn to split the parents, playing one against the other, and know to make requests of the easy parent when the other is not around, only intensifying the parents’ conflict. The children unfortunately also get a distorted, one-dimensional view of each parent – my dad is accommodating and my mom strict – shaping their own expectations

Children in Couple and Family Therapy

about relationships and providing poor role modeling for their own parenting. The biggest concern, perhaps, is that such children are living at home in a constant state of tension, spawning individual anxiety, or acting out through sibling rivalry. Most couple and family clinicians would agree that the parents need to get on the same page around parenting, work together as a team, and present a unified front around expectations and rules, even if their own individual styles in carrying them out may differ. And because these issues are often just a tip-of-the-iceberg of other issues that the couple cannot talk about and resolve, these too need to be a focus of treatment. These differences become the starting point for treatment – to bypass the playing of courtroom and to move the parents toward developing a unified plan. How to do this will depend on the orientation of the clinician. If psychodynamic or Bowenian, for example, the clinician may explore the couple’s own upbringing and relationship with parents. If structural, the clinician may focus on developing a clear hierarchy; if cognitive behavioral, ask about their own thoughts about parenting, ways they respond when problems arise, and provide behavioral homework assignments that help the couple support, rather than undermine each other. Case Illustration Sara and Jim come to therapy following an explosive argument where Sara allowed their 17-yearold daughter to stay out later on a date than she normally does. Jim felt that Sara was being too lenient, again, and resented that she made this decision without his input. Sara, once again, felt that Jim was being too rigid. Each spent much of the first session describing their points of view and frustrations. The clinician asked about their overall parenting styles and values, and it was clear that the couple was polarized in their approaches. After pointing this out and asking about other aspects of their relationship, it was clear that they differ in many areas but rarely talk about them for fear of having such an argument. The clinician talked about her worry about how these differences may affect their daughter, her perception of each

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of them as role models and individuals, especially that she may see Jim as always punitive, rather than the worried dad. She emphasized the need for the couple to work together as team and said that she would help them work on a unified plan, as well as help them use their sessions as a safe place to improve their communication and resolve some of the other underlying issues they were struggling with. The couple agreed. Utilizing a cognitive behavioral approach, the clinician helped them use sessions to develop a parenting plan they both could agree on, taught them develop better communication skills, and helped them address and resolve their other underlying couple issues.

Description: Children in Family Therapy Many family therapists embrace this total family approach where family sessions include all the children and any important extended family members, such as grandparents. The value of such family sessions is that the clinician can fully observe all the interactional processes as they unfold in the room, can easily gather important assessment information, and has an opportunity to connect with each family member, minimizing the danger of a left-out member from undermining the treatment process. But conceptually family therapy is less about everyone being in the room and more about thinking in terms of family dynamics – patterns and history, projections, and communication – and such total family session can understandably be overwhelming, especially for less experienced clinicians and often not practical. There is not a need, for example, to bring a baby or toddler into a therapy session. They are often more a distraction that allows the parents to focus upon when tension arises. Here it is better to meet with the parents alone if possible. Often their issues around such young children are around parenting skills, or reaching a balance between parenting and couple time. School-age children can engage and benefit from family sessions. They are, in fact, often the presenting problem, the identified patient – Billy

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is getting in trouble at school and Clare and Adam, sister and brother, have been fighting all the time – and your focus, depending on your orientation, is on deconstructing the underlying problem: Do the parents lack skills? Are they projecting their own issues on the children? Are the parents triangulating the children to avoid conflict in their own relationship? The challenge here is incorporating the children into the session. Here the clinician needs to begin by building rapport with each child, matching the content and his voice tone to that of each particular child. Those young and restless may need a table they can sit to draw or color while you talk. Later on in therapy the clinician may incorporate family sculptures as an assessment tool or use family games to observe and shape the family process. For teens, the clinician faces the same initial challenges, but where school-age children are often mystified by the therapy process, teens are often openly reluctant participants. They are pulled into therapy because of parents’ complaints and are likely to see the clinician as another adult trying to get them to change. Here the clinician needs to control the process unfolding in the room, making sure that the teen is not feeling ganged up on, replicating what often happens in the home. If necessary, he wants to ask the parents to leave and focus on helping the teen engage and quickly defining a goal that the teen is willing to work on. This provides a working contract for therapy that you can build upon.

Case Illustration Teresa, 16 years old, comes with her parents to an initial family session. The parents start by railing about her boyfriend and the fact that her grades are going down and that she has an “attitude” at home. Teresa says nothing, stares off into space. After a few minutes of this, the clinician asks Teresa if she would mind talking with her alone. She nods in agreement, and the therapist asks if the parent would mind waiting in the waiting room; they leave. The clinician now wonders aloud, “Is this what they always do?” Teresa rolls her eyes and nods her head.

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The rest of the time is spent drawing Teresa out, building rapport, and helping her see that the therapist is not just another adult who rants at her about her life. The goal is define with Teresa what she would like to change at home, in her family, a goal for therapy. She talks about her parents getting off her back, not treating her like a child and realizing that she, in fact, can make good decisions and is not as oblivious as she seems. The clinician’s challenge now is to connect the parents’ concerns – her grades and attitude – with what Teresa wants – her parents being less micromanaging. This is the focus of therapy, developing a plan that both addresses the parents’ concerns and those of Teresa.

Relevant Research About Family Life While Freud believed in the power of childhood to shape lives, he had little professional contact with children. His protégé, Alfred Adler, however, organized child guidance clinics in Vienna and developed techniques aimed at alleviating children’s feelings of inferiority. His student, Rudolf Dreikers, continued his work and brought it to the United States, advancing the child guidance movement in the 1920s with its focus on preventing and treating emotional disorders in childhood (Nichols 2006). Real strides were made in integrating children in the family dynamics in the early 1940s when attention shifted from individual pathology to the notion that family tensions could contribute to a child’s symptoms. In these early years, however, parents were viewed as the adversaries, the child the victim, culminating in one of the now infamous phases of psychiatric history, namely, the theory of Frieda Fromm-Reichmann (1948) of the schizophrenogenic mother – domineering rejecting woman married to passive men whose parenting produced schizophrenic children. Psychological treatment of children and family during this time was divided, with a psychiatrist or psychologist seeing the individual child, a social worker working with the mother. In the late 1940s and early 1950s parents finally moved out of their villain roles, and

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pathology was seen as inherent in family life. During this time researchers focused more on the intricacies of the parent–child relationship, with Bowlby (1949) investigating the attachment between parent and child; Melanie Klein (Segal 1964) focusing on the dynamic of mother–child separation, leading to the development of object relationship theory; and Nathan Ackerman (Ackerman and Sobel 1950) taking the bold step of seeing the entire family at the same time in the same room. Finally, child and parents were firmly interwoven, opening the door to viewing and treating the family as one unit. With his general systems theory, von Bertalanffy (1968) added momentum to this perspective, looking at families as closed or open dynamic systems and heralding the power of patterns. Bateson (1951) at Palo Alto focused on homeostasis and double-bind communication, helping to shape what was to become the strategic therapy of Jay Haley (1963). Minuchin (1974) studied family structure and made us sensitive to boundaries, the need for hierarchy between parents and children, the workings of enmeshed and disengaged parents. Bowen (1978) looked at differentiation, families of origin, and the important concept of triangulation – creating stability and detouring conflict between parents by involving the children. Carl Whitaker (1958) focused on the experiential, challenging the family to be more flexible. These grandparents of family therapy laid down the foundation that led to second and third waves of approaches – solution focused, cognitive behavioral, multisystemic, narrative, emotionally focused couples therapy – each fusing of individual therapy approaches with family dynamics.

Special Considerations for Couple and Family Therapy There is always the question with children about at what point does the therapist move toward individual child therapy. Often a clinician can start with parenting issues – essentially coaching

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the parents to be therapists – and see if changes in their behavior results in positive change in the child. If they do not or if the therapist suspects that there are deeper individual issues at work – attention deficit/hyperactivity disorder in a young child, cutting in a teen – the clinician would want to make a referral for further assessment, play therapy, or a shift from family to individual therapy. It is helpful in making such decisions for therapists to have their own treatment maps for specific common issues mentally in place before seeing children and families; this allows to not have to reinvent the wheel with each family and allows the clinician to hit the ground running. But it is also important to realize that a large part of good family therapy is creating a safe place for getting issues out in the open, helping everyone to be more honest, and changing patterns so that are more functional. Ultimately it is always the clinician’s own orientation and therapeutic comfort zone that will ultimately shape the process.

Cross-References ▶ Assessment in Couple and Family Therapy ▶ Authoritarian Parenting ▶ Authoritative Parenting ▶ Circular Questioning in Couple and Family Therapy ▶ Cognitive Behavioral Couple Therapy ▶ Common Factors in Couple and Family Therapy ▶ Conjoint Couple and Family Therapy ▶ Detriangulation in Couple and Family Therapy ▶ Disengagement in Couples and Families ▶ Family Rules ▶ Family Structure ▶ Four Horsemen in Couple and Family Therapy ▶ Identified Patient in Family Systems Theory ▶ Listening in Couple and Family Therapy ▶ Parenting in Families ▶ Problem-Solving Family Therapy ▶ Separation-Individuation in Families ▶ Whole Family Therapy

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References Ackerman, N. W., & Sobel, R. (1950). Family diagnosis: An approach to the preschool child. American Journal of Orthopsychiatry, 20(4), 744–753. Bateson, G. (1951). Information and codification: A philosophical approach. In J. Ruesch & G. Bateson (Eds.), Communication: The social matrix of psychiatry. New York: Norton. Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aaronson. Bowlby, J. P. (1949). The study and reduction of group tension in the family. Human Relations, 2(8), 123–138. Fromm-Reichmann, F. (1948). Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry, 11(2), 263–274. Haley, J. (1963). Strategies of psychotherapy. New York: Gruner & Stratton. Minuchin, S. (1974). Families in family therapy. Cambridge, MA: Harvard University Press. Nichols, M. (2006). Family therapy: Concepts and methods. Boston: Pearson. Segal, H. (1964). Introduction to the work of Melanie Klein. New York: Basic Books, 1963. von Bertalanffy, L. (1968). General systems theory. New York: Brailler. Whitaker, C. A. (1958). Psychotherapy with couples. American Journal of Psychotherapy., 12(1), 18–23.

Christensen, Andrew Katherine J. W. Baucom1 and Brian R. W. Baucom2 1 University of Utah, Salt Lake City, UT, USA 2 Department of Psychology, University of Utah, Salt Lake City, UT, USA

Introduction Andrew Christensen’s contributions to couple and family therapy are numerous. He is best known for his research on the demand/withdraw interaction pattern as well as the development, evaluation, and dissemination of Integrative Behavioral Couple Therapy.

Career Andrew Christensen, Ph.D. is a Licensed Clinical Psychologist and Distinguished Research

Christensen, Andrew

Professor of Psychology at University of California, Los Angeles. Christensen obtained his A.A. from Grand View College in Des Moines, Iowa, and his B.A. in Psychology from the University of California, Santa Barbara. After he received his bachelor’s degree, Christensen worked for several years, first as a social worker and then as a psychology instructor at community colleges in Iowa. Following these professional positions, as well as a year traveling in the United States and abroad, Christensen enrolled in the University of Oregon, where he obtained his Ph.D. in Clinical Psychology in 1976. Christensen’s first faculty position was as an Assistant Professor of Psychology at University of California, Los Angeles, where he remains on faculty today.

Contributions to Profession Although Christensen’s contributions to the field of couple and family therapy are numerous, there are two for which he is best known. The first is his pioneering research on the demand/withdraw interaction pattern, an asymmetrical cycle of couple behavior where one partner nags, criticizes, and pressures the other partner while the other partner avoids, withdraws from, or terminates discussion of the change being pursued. This pattern is common in distressed treatment-seeking couples, couples who engage in intimate partner violence and couples who engage in infidelity. Christensen’s most cited and influential finding in this area, which formed the basis of his conflict structure model of demand/ withdraw, was that the behavior an individual partner engages in is highly influenced by whether she/he is seeking change or being asked to create change (Christensen and Heavey 1990). When seeking change, men and women (regardless of whether they are in cross sex or same-sex relationships) are more likely to engage in demanding behavior; likewise, when being asked to create change, both men and women are more likely to engage in withdrawing behavior. Along with the late Neil Jacobson, Christensen also developed Integrative Behavioral Couple Therapy (IBCT; Christensen et al. 2015; Jacobson and

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Christensen 1998) in an attempt to reach those couples who did not respond to Traditional Behavioral Couple Therapy (TBCT) or relapsed following treatment termination. IBCT is considered a “third wave” behavior therapy, in that it incorporates acceptance strategies for aspects of relationships that are unlikely to change (i.e., differences between partners, as well as partners’ emotional experiences). Christensen and Jacobson conducted a pilot trial of IBCT followed by the largest randomized clinical trial (RCT) of behavioral couple therapy to date, in which 134 seriously and stably distressed couples participated in a 26-session protocol of either IBCT or TBCT. Both IBCT and TBCT generally produced improvements in aspects of relationship functioning, although IBCT couples displayed greater maintenance of treatment gains in some outcomes over time (Christensen et al. 2010). Following his RCT, Christensen has focused his professional efforts on dissemination of IBCT. Along with former graduate student Brian D. Doss, he adapted IBCT principles for web delivery (www.ourrelationship.com), as outlined in Christensen et al. (2014). As part of a nationwide “rollout” of evidence-based practices in the US Department of Veteran’s Affairs, Christensen has also provided training in IBCT to hundreds of mental health providers since 2010.

Cross-References ▶ Acceptance in Couple and Family Therapy ▶ Acceptance Versus Behavior Change in Couple and Family Therapy ▶ Integrative Behavioral Couple Therapy ▶ Jacobson, Neil

References Christensen, A., & Heavy, C. L. (1990). Gender and social structure in the demand-withdraw pattern of marital conflict. Journal of Personality and Social Psychology, 59, 73–81. Christensen, A., Atkins, D. C., Baucom, B. R., & Yi, J. (2010). Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 78, 225–235.

409 Christensen, A., Doss, B. D., & Jacobson, N. S. (2014). Reconcilable differences: Rebuild your relationship by rediscovering the partner you love – Without losing yourself (2nd ed.). New York: Guilford. Christensen, A., Dimidjan, S., & Martell, C. R. (2015). Integrative behavioral couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 61–96). New York: Guilford. Jacobson, N. S., & Christensen, A. (1998). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York: Norton.

Chronically Ill People in Couple and Family Therapy Gustavo R. Medrano The Family Institute at Northwestern University, Evanston, IL, USA

Name of Family Form Chronically Ill People in Couple and Family Therapy

Introduction Family caregiving is an important and common role that may become even more common in our society with a growing elderly population and health care trend shifting more of the patient care onto families. Family caregiving is a complex process that bidirectionally affects the caregiver and patient, with serious negative consequences for the caregiver’s own well-being if not properly managed. Given this complexity and increased risk of depression and psychological distress, professional help, including psychotherapy, should be considered for the patient and family caregivers.

Description Chronic health conditions can be defined as a mental or medical health condition that persists for beyond 3 months. Chronic health conditions

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are quite common, with about half of all adults in the United States found to have at least one of the examined chronic health conditions and about 25% of the adult population having two or more (Ward et al. 2014). Notably, about 43% of the nearly 27 million disabled individuals in 2006 had mental disabilities (U.S. Census Bureau 2006), which include disorders such as schizophrenia, bipolar and chronic depression. Although arthritis and musculoskeletal conditions were the leading cause of activity limitations among working age adults, mental disorders were the second leading cause of activity limitations among individuals age 18–44 years old (National Center for Health Statistics 2006). Among children, the prevalence rate for chronic health conditions is about 30% with about 21% of children having two or more conditions (Newacheck and Taylor 1992), and about 7% of them having their daily functioning impaired by the health conditions (National Center for Health Statistics 2006). These common chronic conditions not only affect the patient, but they also affect their caregivers. With current health care trends shifting patient care more towards families for chronic health conditions, including mental disorders, the well-being of caregivers is quite important, especially as the well-being of the patient and their close family members have been shown to be bidirectional (Martire et al. 2004). A family caregiver can be the spouse, parent, adult child, or any close family member of the patient. The manner in which the chronic condition affects the family caregiver depends on illness characteristics as well as family characteristics. Rolland (1994) proposes four dimensions to better understand how an illness can affect patient and family functioning. These four dimensions are onset (i.e., acute or gradual), course (e.g., progressive, constant, relapsing/episodic, predictable/unpredictable), incapacitation (e.g., presence or absence and severity), and outcome (e.g., fatal, shortened lifespan, nonfatal). For example, a fatal cancer that progresses predictably and slowly has a qualitatively different effect on the patient and their family than episodic and unpredictable inflammatory bowel syndrome.

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The influence of the chronic condition also depends on the onset of the condition in relation to when and how the family was formed and how it fits with transitional times in family (i.e., family life cycles), such as young adult leaving childhood home, coupling, pregnancy, and raising young children. For example, a daughter who is in charge of caregiving for her father who was paralyzed from a car accident may have more difficulty coping with this role if her caregiving began once she was married with children rather than during adolescence while living at home. Depending on onset of the condition in relation to family life cycles, the chronic condition may cause shifting family roles (i.e., who takes care of what), requiring that family members manage different coping styles among themselves and isolation for patient and family. There are myriad ways in which the caregiver and family are affected by the chronic condition. The family burden of caregiving can be broken into two types: objective and subjective. Objective forms of family burden are practical problems that arise from caregiving such as financial difficulties due to medical bills and loss income, disruption of family relationships, limits on lifestyle (e.g., work, social, leisure), and negative influence on physical health. Subjective forms of family burden are the psychological reactions family caregivers experience, which include sadness, anxiety, embarrassment, frustration, stress of caretaking, and grief. This grief could be connected to not only the loss of the patient’s lifestyle and identity but also the loss of the caregiver’s lifestyle and identity. Such grief can then lead to unintentional hostility and anger towards the patient, which then often results in caregiver guilt and shame for having such emotions towards their loved one.

Relevant Research About Family Life Given the multiple negative ways in which a family caregiver can be affected, it is perhaps not surprising to see the many effects caregiving has on the individual. Research has shown that one third to one half of family caregivers experience

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significant psychological distress and higher rates of mental health problems than the general population, with partners often having larger burdens of care as compared to other primary caregivers (Shah et al. 2010). In fact, depressive symptoms are twice as common in caregivers as noncaregivers, with some studies showing up to 50% of caregivers meeting criteria for clinical depression. Additionally, researchers have found that patients’ close family members may experience poorer physical health and the diminished quality of the patient relationship (Martire et al. 2004). A number of studies across conditions have found that the quality of life of partners tends to be lower than that of the patient (Rees et al. 2001). Not all effects from family caregiving are negative as researchers have also found that the experience can include pride in fulfilling familial responsibilities, enhanced closeness with the patient, and satisfaction with one’s competence. Notably, these effects are associated with lower levels of depression and the subjective report of caregiver burden. Beyond the severity of the chronic health condition, other factors have been found to be associated with caregiver well-being. For example, women caregivers have been found to be at approximately twofold greater risk of developing clinical depression than male caregivers. Differences by caregiver ethnicity have also been found, with White caregivers reporting greater depression than Black caregivers, and Latino caregivers reporting greater depression than White and Black caregivers. Additionally, whereas positive associations between caregiver age and caregiver burden (i.e., older age, more caregiver burden) have been found in White caregivers, negative associations (i.e., older age, less caregiver burden) have been found in Black caregivers. Of the multiple factors that are associated with caregiver wellbeing, social support is possibly the most important (Shah et al. 2010). Caregiving is typically associated with a decrease in social support and increased withdrawal and isolation; however, strong negative associations have been found between social support and caregiver depression and burden (i.e., more social support, less depression and burden). Notably, religious coping has been found to be

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more often used in Black and Latino caregivers than White caregivers, and such religious involvement is often associated with increased access to social support (Shah et al. 2010). The value of family caregiving is not limited to the immediate needs that are addressed on a daily basis by the caregiver. Close family members can have a significant influence on the patient’s psychological well-being and the management of the illness, which includes treatment adherence and engagement in positive health behaviors (Martire et al. 2004). Additionally, diverse family characteristics and behaviors such as intimacy, emotional support, overprotective behaviors, and criticism have been found to influence patient outcomes across multiple illness groups, including chronic pain, heart disease, and rheumatic disease. For example, multiple studies have found that paternal involvement in the management of pediatric chronic health conditions is positively associated with not just patient outcomes but maternal and family functioning as well. These studies and others show that family caregiving has value that transcends the daily needs being addressed.

Special Considerations for Couple and Family Therapy Given the prevalence and importance of family caregiving with chronic health conditions, many interventions have been developed to help improve the well-being of the caregivers, and subsequently, the patients as well. The manner in which a chronic health condition is addressed in couples or family therapy can vary widely including educational, case management (i.e., matching people’s needs with available programs and resources), and psychological interventions. Specifically for couples therapy, Baucom et al. (1998) distinguished between three types of couplesbased interventions: partner-assisted interventions (i.e., use partner as encouragement or “coach”), disorder specific interventions (i.e., address partner behaviors that contribute to individual problem), and couples therapy (i.e., address relationship distress as it influences individual’s psychopathology or medical problem).

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There have been multiple reviews of these interventions, and commonalities arise in what makes an intervention most helpful for these families. Psychological interventions that address the multiple stressors and risk factors that come with caregiving, rather than just educational interventions that aim to increase knowledge about the illness, have been found to be more effective. In fact, increased knowledge for a caregiver is not correlated with psychological improvement for the caregiver. Rather, interventions that contain cognitivebehavioral strategies that address unhelpful thoughts and encourage seeking social support have been associated with superior outcomes. Outcomes for family interventions include reductions in caregiver burden, anxiety, and depression, and decreased depression, and in some cases, decreased mortality for patients. The effects of the interventions are generally greater for family caregivers, with the effects being greater when these interventions directly address relationship issues as well (Martire et al. 2004). As with family interventions, couples-based interventions that use cognitive-behavioral techniques have also been found to be effective for a variety of chronic psychological and medical conditions. Specifically for couples, Fischer et al. (2016) reported that multiple studies have found that couple-based interventions using cognitive behavioral techniques to be as effective, if not more effective, than individual interventions for a variety of chronic psychological and medical conditions. Couple-based interventions have generally been found to not only significantly improve outcomes related to the psychological and/or medical condition, but unlike individual interventions, simultaneously also address relationship distress. These conditions include depression, alcohol abuse, obsessive-compulsive disorder, posttraumatic stress disorder, and cancer. Other chronic medical conditions (e.g., arthritis, chronic pain, cardiovascular diseases, HIV) have been studied but not as extensively as cancer in this interpersonal context to make definitive statements regarding couple-based interventions efficacy relative to individual therapy (Fischer et al. 2016). In sum, patients and their families appear to be well served when seen in couples or family therapy

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that employ cognitive behavioral techniques to not only address the effects of the chronic condition on the patient and family but also address relationship distress. This systemic approach is consistent with the known and myriad effects of chronic illness on the patient and their families.

Cross-References ▶ Addictions in Couple and Family Therapy ▶ Attention Deficit Hyperactivity Disorder (ADHD) in Couple and Family Therapy ▶ Alcohol Use Disorders in Couple and Family Therapy ▶ Anxiety Disorders in Couple and Family Therapy ▶ Bipolar Disorder in Couple and Family Therapy ▶ Borderline Personality Disorder in Couple and Family Therapy ▶ Cognitive Behavioral Couple Therapy ▶ Cognitive-Behavioral Family Therapy ▶ Depression in Couple and Family Therapy ▶ Family Focused Therapy for Bipolar Disorder ▶ Family Psychoeducational Treatments for Schizophrenia in Family Therapy ▶ Medical Model in Couple and Family Therapy ▶ Obsessive Compulsive Disorder (OCD) in Couple and Family Therapy ▶ Posttraumatic Stress Disorder (PTSD) in Couple and Family Therapy ▶ Schizophrenia in Couple and Family Therapy

References Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., & Stickle, T. R. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology, 66(1), 53–88. Fischer, M. S., Baucom, D. H., & Cohen, M. J. (2016). Cognitive-behavioral couple therapies: Review of the evidence for the treatment of relationship distress, psychopathology, and chronic health conditions. Family Process, 55(3), 423–442. Martire, L. M., Lustig, A. P., Schulz, R., Miller, G. E., & Helgeson, V. S. (2004). Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness. Health Psychology, 23(6), 599–611.

Circle of Security National Center for Health Statistics. (2006). Health United States with chartbook on trends in the health of Americans. Hyattsville: Author. Newacheck, P. W., & Taylor, W. R. (1992). Childhood chronic illness: Prevalence, severity, and impact. American Journal of Public Health, 82(3), 364–371. Rees, J., O’Boyle, C., & MacDonagh, R. (2001). Quality of life: Impact of chronic illness on the partner. Journal of the Royal Society of Medicine, 94, 563–566. Rolland, J. (1994). Illness, families & disabilities. New York: Basic Books. Shah, A. J., Wadoo, O., & Latoo, J. (2010). Psychological distress in carers of people with mental disorders. British Journal of Medical Practitioners, 3(3), 327–334. U.S. Census Bureau. (2006). http://factfinder.census.gov/ servlet/STTable?_bm=y&-geo_id=01000US&-qr_na me=ACS_2006_EST_G00_S1801&-ds_name=ACS _2006_EST_G00_&-_lang=en&-_caller=geoselect &-redoLog=false&-format= Ward, B. W., Schiller, J. S., & Goodman, R. A. (2014). Multiple chronic conditions among US adults: A 2012 update. Preventing Chronic Disease, 11, E62. https:// doi.org/10.5888/pcd11.130389.

Circle of Security Anna Huber1, Erinn Hawkins2 and Glen Cooper3 1 Macquarie University, Sydney, NSW, Australia 2 Griffith University, Gold Coast, QLD, Australia 3 Circle of Security International, Spokane, WA, USA

Name of Model Circle of Security

Synonyms COS; Circle of Security Intensive (COS-I); Circle of Security Parenting (COS-P)

Introduction The Circle of Security (COS*) is both a framework (represented graphically) for understanding attachment relationships, as well as a strengthsbased intervention approach (Powell et al. 2014). It provides concrete guidelines and clinical tools

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for relationship-focused prevention with families of young children in contexts of risk and/or early intervention with families showing caregiverchild relationship problems. The COS* graphic (see COS Original Circle at http://circleofsecurityinternational.com/handouts) distils essential concepts of attachment theory and research, making them easily accessible to parents and practitioners. Of several COS* intervention variants, the two most widely disseminated are Circle of Security Intensive* (COS-I) and Circle of Security Parenting* (COS-P). COS-I* is a psycho-educational and psychotherapeutic early intervention using individualized video-based assessment and treatment to improve attachment relationships. Originally developed as a 20-week group-based approach, COS-I* has also been used individually and in home and more restrictive settings (i.e., prison). COS-P* is a preventative intervention for caregivers of young children using a manual and DVD-based protocol with groups or individuals, in center- or home-based delivery.

Prominent Associated Figures Originally developed by Glen Cooper, Kent Hoffman, and Bert Powell, COS* was further enhanced and tested over time with research partners, Robert Marvin and Jude Cassidy.

Theoretical Framework Grounded in attachment theory and research, COS* interventions also draw heavily on family therapy, object relations, and psychodynamic theories. Supporting research shows that (1) secure attachment is a protective factor for health, social, and emotional development, (2) insecure attachment can increase the risk of problematic developmental outcomes in the context of other risks, (3) disorganized attachment increases the risk of later psychopathology, and (4) attachment can change if the child’s experience of caregiving changes. The model’s core concepts are as follows:

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Child Exploration and Attachment Are Connected to Adult Caregiving The Circle graphic represents three dynamically interlinked behavioral systems (exploration, attachment, and caregiving). It shows that a predictably available and protective caregiver (hands on the circle) is needed for the child to become secure. The caregiver’s job is to serve both as a secure base when the child has exploration (“top of the circle”) needs and a safe haven when the child has attachment (“bottom of the circle”) needs. When a child’s exploration system is activated, the caregiver needs to signal when and if it is safe for the child to follow their innate curiosity and explore (support my exploration); monitor the child (watch over me); provide scaffolding for learning and the acquisition of new skills (help me); give joint attention to, encourage, and enjoy the child’s endeavors (enjoy with me); and share their delight in the child as a person (delight in me). Providing a secure base enables the child to best meet their learning potential, develop skills, and build a sense of their own autonomy. When the child feels fearful, distressed, or emotionally dysregulated, or their interest in exploration wanes, they need caregivers to be open to meet these emotional needs (welcome my coming to you); provide comfort (comfort me), protection (protect me), and co-regulation (organize my feelings); and communicate the fundamental message of the child’s inherent selfworth (delight in me). Providing a safe haven when the child has these “bottom of the circle” needs deactivates the attachment behavioral system, contributing to a smooth balance between the child going out on the top of the circle (exploration) and coming in (attachment) on the bottom, thus supporting healthy social and emotional development. The COS* message is that, as hands on the child’s circle, the caregiver’s role is “Always be bigger, stronger, wiser, and kind. Whenever possible follow my child’s need. Whenever necessary, take charge.” This encompasses several crucial messages for caregivers: (1) caregiving requires predictable emotional availability; (2) as the more capable partner in the relationship, they

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need to provide a balance between warmth and support and appropriate structure, limit setting, and guidance; and (3) they should mostly follow the child’s signals but at times be able to actively intervene (take charge, e.g., to ensure the child’s safety, solve problems, and/or provide behavioral and emotional containment). Behavior as Communication and Co-regulation of Affect Children’s behavior is understood as a form of communication regarding attachment, exploration, or caretaking needs. A child may openly signal (cue) what they need from the caregiver or hide their real need (miscue). By framing child behavior as communication about legitimate developmental needs, caregivers can shift their focus from trying to eliminate a particular behavior to understanding what the behavior is signaling (see below for miscuing). Children develop emotional regulation capacities through caregiver co-regulation by “being with” their child. This involves a caregiver connecting with the child, communicating (nonverbally and/or verbally) their understanding of the child’s internal emotional experience and remaining available to the child while the feeling passes. Intergenerational Influences, Defensive Processes, and Caregiving COS* teaches caregivers that the way they think and feel about their child can be influenced (both positively and negatively) by their own childhood experiences of being cared for. Caregivers’ defensive states of mind (known as “shark music”) may be activated if their child’s need coincides with their own unmet childhood need, limiting perception of and responsiveness to the child’s real needs in the relationship. If caregivers react defensively, over time the child also defensively limits their expression of these needs (miscuing). This is framed as the child adapting to the caregiver’s needs (limited circles, limited hands). Caregivers learn that some of these inadequate caregiving responses regularly evoke fear in children, with negative developmental consequences.

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Each caregiver-child dyad referred for COSI* typically has a core dyadic relational difficulty (linchpin issue), resulting from caregiver defensive responses, which promotes insecurity for that child. The linchpin issue becomes the focus of the intervention for that dyad, taking into account the caregiver’s defensive style or core sensitivity. Increasing Security, Reducing Disorganization, and Relationship Repair Relational ruptures caused by instances of insensitive or frightening caregiving become problematic for child development if they are not repaired. COS* provides caregivers with a framework for interactive repair of these breakdowns, through “time-in.” Time-in is a threestep process. The first step is a time-out for the parent if needed. This allows the parent to regulate their affect enough to be able focus on the needs of the child. The next step is for the parent to support co-regulation of emotion to help the child calm. This is done through a repair routine that includes the parent taking charge to help the child feel safe, helping the child put language to their emotional experience, and providing a sense of connection until the child is calm enough to take the next step. When the parent is calm enough and the child is calm enough, each person takes responsibility for his or her part in the rupture, makes amends, and talks about new ways of dealing with the problem in the future. Theory of Change COS* interventions promote more secure and less disorganized child attachment by focusing on the parent-child relationship and targeting caregiver capacities within the attachment relationship. COS* aims to increase caregivers’ capacity to meet their children’s needs by providing a map of a secure relationship and then videobased practice with relationship-focused observation, reflection, and empathy. By also providing caregivers with a “secure base” and “safe haven,” facilitators enable caregivers to experience what they need to do for their children.

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Populations in Focus COS-I* targets the caregiving-attachment relationship in moderate- to high-risk caregiver-child dyads showing established relationship difficulties. This version has been adapted for use with pregnant women, caregivers of infants, and caregivers of children up to 8 years of age. COS-P* was developed as a universal prevention model introducing and promoting attachment security for all families. It may also be appropriate as a preliminary intervention with moderate- to high-risk families, prior to engaging in the more intensive COS-I*.

Strategies and Techniques Used in the Model Strategy/technique Facilitator training

COS-P 4-day training; no specific prerequisite qualification or posttraining supervision requirements

Use relational processes between the therapist and parent as a vehicle for influencing parallel change in the parentchild relationship: facilitator creates holding environment and serves as a secure base and safe haven for parent/s Group process: over time the group can serve as a secure base and safe haven for parents, support vicarious learning, normalize struggles, and create a group momentum for change

Central aspect of the curriculum

COS-I Qualified therapists undergo 10-day training, must pass the exam, and be supervised for a minimum period and until competent Crucial therapeutic requirement

If group delivered

If group delivered

(continued)

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Psycho-education: theory and research • Attachment, exploration, and caregiving; importance of caregiving relationship • Child development and foundations of healthy/adverse trajectories • Emotional regulation • Defensive processes • Intergenerational transmission of caregiving relational dynamics • Necessity/ opportunities for relational repair Guided use of video to: 1. Develop skills in behavioral observation of caregiver-child relationship dynamics 2. Help caregivers become aware of caregiver and child representations and how these are connected with behavior 3. Promote reflection on current (and

Circle of Security COS-P Caregivers identify own areas of relational difficulty

COS-I Linchpin issue for each caregiver-child AND caregiver defensive style (core sensitivity) identified through videotaped observation of caregiver-child interaction and narrative interview with caregiver Presented and Presented and reflected on reflected on using circle using circle graphic, graphic, animations, animations, handouts, handouts, video clips, video clips, stock video caregivers’ examples own video examples

Stock footage of secure and insecure dyads and actors

Individualized clips and tape reviews tailored to linchpin issue of dyad and caregiver’s core sensitivity

(continued)

Strategy/technique desired) relational patterns once aware of these behaviors, thoughts, and feelings 4. Build empathy for the child Parents invited/ challenged to take action (choosing security) to change problematic relational dynamics they become aware of Delivery mode – adaptations/options available

COS-P

COS-I

✓

✓

Group/ individual Center based/ home

Group/ individual Center based/ home

Research About the Model The majority of research on COS* to date has focused on COS-I* and its adaptations. Several studies of COS-I* found significant reductions in attachment disorganization and increases in attachment security after intervention, compared to either pre-intervention levels or comparison groups. These promising findings were robust across child age groups, including early infancy (Cassidy et al. 2010) and preschool-age children (Hoffman et al. 2006; Huber et al. 2015a), as well as different risk groups, including families attending a US Early Head Start Program (Hoffman et al. 2006), families presenting to a community mental health service in Australia (Huber et al. 2015a, b, 2016), and mothers in a US jail-diversion program for pregnant, nonviolent offenders with substance abuse histories (Cassidy et al. 2010). Caregivers of children aged 1–7 years in the Australian study also showed improvements in their own emotional well-being following COSI* (Huber et al. 2016) and in relationship capacities (perceptions of self, child, and the caregiving relationship and reflective stance) important in the promotion of attachment security (Huber et al. 2015a). The study also found improvements in child behavioral and emotional functioning after COS-I*. The largest improvements were shown by caregivers and children with the least optimal

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capacities and functioning before COS-I* (Huber et al. 2015a, b, 2016). Mothers who completed the jail-diversion program also showed benefits in relational capacities that promote attachment security, with levels of maternal sensitivity at the postintervention assessment being comparable to mothers in a community comparison group (Cassidy et al. 2010). While these studies are limited by their small sample sizes and their lack of randomized control groups, together their findings show promising preliminary evidence that COS-I* improves attachment outcomes for children 11–58 months of age from high-risk families and it appears to benefit caregivers and children who need it the most. Two randomized controlled trials of COS* interventions have also shown promising intervention effects. A randomized controlled trial of a four-session home-visiting version of COS-I* for first-time mothers of irritable infants, aged 6–9 months, found that dyads were differentially susceptible to the intervention depending on infant irritability and maternal attachment style (Cassidy et al. 2011). Specifically, the intervention was efficacious for more secure and dismissing mothers with highly irritable infants, and more preoccupied mothers with moderately irritable infants, with these infants more likely to be secure at 12 months of age compared to controls. A randomized controlled trial of COS-P* found that while there was no change in child attachment following the group intervention, mothers who participated in COS-P* reported greater improvements in relationship capacities that promote attachment security compared with control group mothers (Cassidy et al. 2017). These studies, while promising, require replication to better understand what version of COS* is best suited to specific populations.

Case Example Lucia, a 29-year-old sole parent of 3-year-old Amy, was referred to participate in COS-I* after a year in a residential drug rehabilitation program. Amy had spent a year out of her mother’s care consequent to the substance abuse and

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child protection involvement, but custody had been restored once Lucia was established in the residential program. As a child, Lucia had an alcoholic mother for whom she frequently had to care and been sexually abused by one of her mother’s partners, leading to a brief period in care after disclosing the abuse. Lucia reported that Amy was hard to manage and became bossy, having tantrums if she could not get her own way. Lucia presented as depressed and, though she wanted to look after Amy, reported feeling overwhelmed by parenting challenges. Assessment revealed the linchpin issue for the dyad was Amy needing to be sure her mother’s hands were fully on the circle as the bigger, stronger, wiser, and kind adult in the relationship. Lucia felt overwhelmed and incapable (shark music) and collapsed when the child needed her to take charge. Lucia’s core sensitivity (separation sensitivity) suggested she feared rejection if she selfactivated as the parent. As a result Amy was left to manage situations without adequate adult emotional support. Amy responded by becoming controlling and punitive (indicating disorganized attachment). Amy miscued her need for Lucia to be the hands by acting like she was the adult, but when her mother was not there, her anxiety and insecurity were apparent. Lucia participated in a 20-week group COS-I* intervention, while Amy attended childcare. Through observing her own and other caregivers’ tape reviews, Lucia realized that the past was being repeated, became more empathic toward Amy, and recognized that, contrary to her fears, Amy needed her and was not able to manage without adult support. Lucia also acknowledged she had to let go of excuses and step up to be the parent Amy needed. Lucia began taking charge and providing emotional support even when Amy acted like she did not need it (miscued). By the time they completed the intervention, Lucia was enjoying being with her child and feeling more capable as a parent; Amy appeared less bossy and self-reliant and was using Lucia more for support. Post-intervention assessment showed Amy’s attachment had become secure and prior clinical level behavioral and emotional problems

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were now reported in the normal range. Lucia’s reflective capacities and representations of the caregiving relationship, self, and child had all significantly improved, and parenting stress was also significantly reduced.

Cross-References ▶ Attachment Theory ▶ Bowlby, John ▶ Circle of Security: “Understanding Attachment in Couples and Families”

Circle of Security Parenting Enrichment Program

Circle of Security Parenting Enrichment Program Julie A. Peterson1, Christie Ledbetter2 and Jermaine Thomas3 1 The Family Institute, Northwestern University, Evanston, IL, USA 2 Alabama Psychological Services Center, Madison, AL, USA 3 Cornerstone Counseling Center of Chicago, Chicago, IL, USA

Name of Model References Cassidy, J., Ziv, Y., Stupica, B., Sherman, L., Butler, H., Karfgin, A., et al. (2010). Enhancing attachment security in the infants of women in a jail-diversion program. Attachment & Human Development, 12(4), 333–353. Cassidy, J., Woodhouse, S., Sherman, L., Stupica, B., & Lejuez, C. (2011). Enhancing infant attachment security: An examination of treatment efficacy and differential susceptibility. Development and Psychopathology, 23(1), 131–148. Cassidy, J., Brett, B. E., Gross, J. T., Stern, J. A., Martin, D. R., Mohr, J. J., et al. (2017). Circle of Security-Parenting: A randomized controlled trial in Head Start. Development and Psychopathology, 29, 651–673. https://doi.org/10.1017/S0954579417000244. Hoffman, K., Marvin, R., Cooper, G., & Powell, B. (2006). Changing toddlers’ and preschoolers’ attachment classifications: The Circle of Security intervention. Journal of Consulting and Clinical Psychology, 74(6), 1017–1026. Huber, A., McMahon, C., & Sweller, N. (2015a). Efficacy of the 20-week Circle of Security Intervention: Changes in caregiver reflective functioning, representations, and child attachment in an Australian clinic sample. Infant Mental Health Journal, 36(6), 556–574. Huber, A., McMahon, C., & Sweller, N. (2015b). Improved child behavioural and emotional functioning after Circle of Security 20-week intervention. Attachment and Human Development, 17(6), 547–569. Huber, A., McMahon, C., & Sweller, N. (2016). Improved parental emotional functioning after Circle of Security 20-week parent–child relationship intervention. Journal of Child and Family Studies, 25(8), 2526–2540. Powell, B., Cooper, G., Hoffman, K., & Marvin, R. (2014). The Circle of Security Intervention: Enhancing attachment in early parent-child relationships. New York: Guilford.

Circle of Security Parenting Enrichment Program.

Introduction The impact of the family system – especially parenting – is understood to leave long lasting impressions on children. From being a child’s teacher, mentor, and protector, parents serve in many roles for their children. To optimally prepare for success, parents look for strategies and interventions to assist them in promoting individual and family resiliency. Various studies have found that parent-training courses often aid in decreasing parent stress and increasing perceived competency in ability (Neece et al., 2012; Meirsschaut et al., 2010). Others have described how parents feel more capable in handing difficult parenting challenges when exposed to workshops or direct interventions rather than personal research (Keen et al., 2010). One well-known, evidence-based parenting intervention is called Circle of Security. Circle of Security Parenting Enrichment Program is an evidence-based parenting intervention used to address concerns around attachment and security. Over the course of the last decade, Circle of Security (COS) has grown in research and developed into a widely used model that is available in at least ten languages with ongoing research to continue improving the program. Lindquist and Watkins (2014) reviewed seven

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different parenting training programs to determine common core concepts that impact effectiveness. They found that a majority of parenting programs aim to do the same task by “promoting a better understanding of the basic needs and motivations that underlie a child’s behavior while also improving communication and fostering mutual respect” (Lindquist and Watkins, 2014, p. 161). Where programs differ are with respect to their theoretical roots.

Prominent Associated Figures Developed by Glen Cooper, Kent Hoffman, and Bert Powell, Circle of Security is embedded in family systems, object relations, and attachment theory. Hoffman, Cooper, and Powell have run a clinical practice in Spokane, WA, for more than 30 years working with families and adult clients. They have worked together for the last few decades converting research around attachment styles in early parent-child relationships to develop a treatment model meant to promote healthy attachment.

Theoretical Framework As previously noted, Circle of Security is grounded within object relations and attachment theory. Originated by Bowlby and Ainsworth, object relations and attachment theory reflect on the development of one’s personality by exploring the complex relationship between oneself and others, particularly, how one becomes independent from others while also having a profound attachment to them (Bowlby, 1969). Ainsworth is known for her exploration and identification of attachment styles through her laboratory-based observations of an infants’ response to the brief separation and reunion with a parent called the Strange Situation (Ainsworth et al., 1978). Ainsworth identified four basic attachment styles that have been later linked to the development of adverse mental health issues later in life. The first is a secure attachment, which is characterized by a child’s confidence in that their

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attachment caregiver will be available to their needs (Ainsworth et al., 1978). The second is insecure avoidant attachment. This attachment style is characterized by a child’s physical and emotional independence from the caregiver, as the child does not seek out the caregiver when distressed (Ainsworth et al., 1978). The next is insecure ambivalent or resistant attachment. This style is characterized by a child’s duel dependence and rejection of the caregiver (Ainsworth et al., 1978). The final attachment style is disorganized, which is characterized by fearful, anxious, or inconsistent responses towards the caregiver (Ainsworth et al., 1978). This style is often associated with neglect, abuse, or other adverse relationship with the caregiver. Each attachment style found in children is correlated with parenting response styles that promote the child’s attachment to the caregiver. Using the Circle of Security model, the primary belief around therapeutic change is that once the attachment style has been identified, parents are provided with necessary skills and tools to assist them in breaking adverse patterns that perpetuate insecure attachment styles in order to promote more secure attachments with their children. Hoffman, Marvin, Cooper, and Powell (2006) created their own video-based examples similar to Ainsworth’s Strange Situation intervention. These videos are used for the education of parents on attachment styles to assist with identifying their own interactions with their young children. Circle of Security aims to educate parents through use of video education, individual consultation with clinicians, and group work to not only understand the principles of attachment theory, but also to develop behavioral management strategies to enhance a more secure attachment style. Much of this work is also done through the use of selfreflection steps that allow parents to explore the material and connect their parent-child interactions with attachment styles.

Populations in Focus Previous research indicates that the Circle of Security method mainly focuses on child

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development concerning attachment within the parent or caregiver-child relationship. Majority of studies have focused on examining caregiverchild dyads including children who are at risk for attachment issues because they are insecurely attached to their caregiver (Hoffman et al., 2006; Marvin et al., 2002; Fardoulys and Coyne, 2016; Huber et al., 2016). Psychosocial factors related to insecure attachment have included parent mental health problems, parental divorce or separation, substance abuse by a family member, family violence or abuse, and abuse or neglect of the children (Huber et al., 2016; Horton and Murray, 2015). Since attachments develop early in life between children and caregivers, studies were mainly concerned with toddlers – or preschool-aged children. However, the age range for child participants across the research spanned from as early as 11 months to 10 years of age. Parent and caregiver ages ranged from 16 to 55 years of age (Hoffman et al., 2006; Marvin et al., 2002; Fardoulys and Coyne 2016; Horton and Murray 2015). The Circle of Security-Parenting (COS-P) serves as the only group-based attachment program available in a manualized, multilingual format (Horton and Murray 2015). This program has been implemented in many countries such as the United States, Italy, New Zealand, and Germany, which increases the model’s applicability across cultures (Horton and Murray 2015; Pazzagli et al., 2014; Ramsauer et al., 2014; Fardoulys, and Coyne 2016).

Strategies and Techniques Used in Model The Circle of Security model utilizes a group treatment modality, parent education, and psychotherapy intervention to promote a healthy attachment development process (Marvin et al., 2002; Hoffman et al., 2006; Fardoulys, and Coyne 2016). To achieve this goal, the protocol has several main tenets. First, it is imperative to establish the caregiver as a safe and secure base so that the child can feel comfortable exploring their environment as well as returning to the caregiver when

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distressed or seeking reconnection. As such, the therapist helps increase the caregiver’s level of sensitivity and responsiveness to the child’s signals of need for soothing. An additional goal is to increase caregiver empathy and ability to reflect upon one’s own, as well as the child’s, behavior, thoughts, and feelings concerning attachmentrelated interactions. Lastly, the therapist helps to increase caregiver reflection regarding personal developmental history that may be affecting present caregiving behavior (Marvin et al., 2002; Hoffman et al., 2006). The COS program typically lasts 20 weeks, although a shortened 10-week version is available. As outlined by Marvin et al., (2002), and Fardoulys and Coyne (2016), the program begins with a pre-intervention assessment using the Circle of Security Interview (COSI), which is semi-structured interview designed to assess the caregiver’s internal working models of self and child, developmental attachment history, and to identify individual treatment goals for each dyad. Based on Ainsworth’s infant system (Ainsworth et al., 1978) and the adult classification, each dyad is coded as Secure/ Autonomous, Avoidant/Dismissing, Preoccupied/Ambivalent, Disorganized/Abdicating, or Insecure-Other/Unclassifiable. During the intervention phase, the therapist meets with a group of caregivers, once per week, to review edited video-vignettes of caregiver-child interactions. The meetings focus on caregiver education regarding becoming the safe haven, increasing caregiver sensitivity to meet their child’s attachment needs, and the caregiver’s vulnerabilities within the caregiver-child interactions. Concepts unique to COS include “limited circles of security,” or insecure interactions between the caregiver and child, and “shark music,” or a caregiver’s vulnerabilities. Each week, one dyad’s video interaction becomes the focus of the group to allow for reflective dialogue. Four vignettes are implemented to highlight the parent’s caregiving system, areas of struggle, successful moments with the child, as well as celebrations of the parent-child relationship. At the conclusive sessions, the group reviews changes that have occurred within each

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caregiver-child dyad. A post-intervention assessment, consisting of caregiver rating scales and child and caregiver questionnaire data, is implemented to demonstrate each dyad’s changes from insecure patterns of attachment to secure ones.

Research about the Model Mercer (2015) conducted a literature review of outcome studies and other reports which have examined the effectiveness of the COS program. The researcher reviewed 116 texts, which included books, journal articles, and dissertations. Following the review, Mercer concluded that the COS program is an emerging treatment with much promise. It was reported that the intervention is theoretically sound given that it stands on wellestablished principles of attachment theory, but that it cannot yet be considered an evidencebased intervention, as more empirical studies involving randomized controlled trials need to be conducted, particularly by independent researchers without an allegiance to the development of the model (Mercer 2015). In one study, Hoffman et al., (2006) examined the effectiveness of the COS program with children living within disadvantaged environments that put them at risk for mental health issues later in development. The study consisted of 65 parent-child dyads pooled from Head Start and Early Head Start programs, set in an average sized city in the state of Washington. Approximately 6–8 weeks before the intervention, the participants underwent a pre-assessment phase, in which the participants’ attachment patterns were assessed using the Strange Situation Procedure and the Circle of Security Interview (COSI). The full 20-week COS intervention was implemented with groups of five to six parents. The researchers found that prior to the intervention, 60% of the children fell into one of two of the high risk attachment classification groups: Disorganized-controlling or Insecure-other. However, after the intervention, only 25% of the children fell into these two groups. Additionally, prior to the intervention, 20% of the children were

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identified as securely attached; following the intervention, 54% were classified as securely attached. In sum, such results are encouraging about the value of COS to improve attachment between caregiver and child. Limitations of this study and several others examining the effectiveness of the COS program are that there was no control group and the sample size was small (e.g., Marvin et al., 2002; Hoffman et al., 2006; Huber et al., 2016; Fardoulys and Coyne 2016). More studies are needed to demonstrate COS’s effectiveness compared to other parenting education programs in improving the caregiver-child relationship.

Case Example Karen is a 34-year-old divorced, single mother with an 18-month-old daughter named Jessica. Karen entered into individual therapy due to her struggle with recurrent bouts of depression. She reported that she grew up in a volatile environment in which her mother also struggled with depression, and she characterized the relationship between her and her mother as very distant. Furthermore, she expressed that her mother was emotionally unavailable. Throughout treatment, Karen vowed to be a much better parent than her mother, but she was worried that her daughter presented as withdrawn and shut down, which reminded her of how she presented when she was a young girl. As a result, Karen’s therapist recommended that she and her daughter enter into the COS program being held at a local community center. Karen agreed to participate. At the beginning of the COS program, Karen’s psychosocial history, as well as her internal working model for herself and her child were gathered using the Circle of Security Interview (COSI) (Hoffman et al., 2006). In addition, the interactions between Karen and Jessica were video recorded and assessed using the Strange Situation Procedure (Hoffman et al., 2006). During this procedure, the clinician noticed that Jessica played with the toys in the room while Karen was present in the playroom. Karen was looking through her phone for much of the procedure, and

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Jessica never cued her mother to become involved in her play. A stranger then entered the room, and Karen was asked to leave. When this occurred, Jessica stopped playing and she sobbed silently by the door. Karen then entered back into the room, and Jessica did not seek closeness with her mother, rather she went back to playing, as if using her explorative system to defend against the excitation of her attachment system. Based upon this dynamic, it was determined that Jessica exhibited an Insecure-Avoidant attachment style. To follow, Karen was shown the video recording, and she was provided psychoeducation on attachment theory. In addition, she was informed that Jessica exhibited Insecure-Avoidant attachment characteristics. The clinician explained to Karen that it is important that she show an interest in Jessica’s play activity and praise the creativity exhibited within her play. In addition, Karen was informed that Jessica may often miscue that she does not need her mother by playing or exploring independently when the mother returns to the room following a separation, but that this is often a self-protective behavior due to a concern that she may not receive the emotional responsiveness that she seeks. This explanation resonated with Karen, as she reported often feeling this way with her own mother. By the end of the program, Jessica appeared a lot less withdrawn, evidenced by her tendency to smile more and reach for her mother when there was a separation of some kind. Jessica appeared more securely attached, and Karen exhibited fewer depressive symptoms, as she felt like a more competent parent.

Cross-References ▶ Ainsworth, Mary ▶ Attachment Theory ▶ Attachment-Based Family Therapy ▶ Bowlby, John ▶ Circle of Security ▶ Object Relations Family Therapy ▶ Object Relations Couple Therapy

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References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: Psychological study of the Strange Situation. Hillsdale: Erlbaum. Bowlby, J. (1969) 1982. Attachment and loss, Vol. 1: Attachment. New York: Basic Books. Fardoulys, C., & Coyne, J. (2016). Circle of security intervention for parents of children with autism spectrum disorder. Australian and New Zealand Journal of Family Therapy, 37, 572–584. https://doi.org/10.1002/ anzf.1193. Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B. (2006). Changing toddlers’ and preschoolers’ attachment classifications: The circle of security intervention. Journal of Consulting and Clinical Psychology, 74(6), 1017–1026. https://doi.org/10.1037/0022-006X.74.6. 1017. Horton, E., & Murray, C. (2015). A quantitative exploratory evaluation of the circle of security-parenting program with mothers in residential substance-abuse treatment. Infant Mental Health Journal, 320–336. https://doi.org/10.1002/imhj.21514. Huber, A., McMahon, C., & Sweller, N. (2016). Improved parental emotional functioning after circle of security 20-week parent-child relationship intervention. Journal of Child and Family Studies, 25, 2526–2540. https://doi.org/10.1007/s10826-016-0426-5. Keen, D., Couzens, D., Muspratt, S., & Rodger, S. (2010). The effects of parent-focused intervention for children with a recent diagnosis of autism spectrum disorder on parenting stress and competence. Research in Autism spectrum disorders, 4, 229–241. https://doi.org/ 10.1016/j.rasd.2009.09.009. Lindquist, T. G., & Watkins, K. L. (2014). Modern approaches to modern challenges: A review of widely used parenting programs. The Journal of Individual Psychology, 70(2), 148–165. https://doi.org/10.1353/ jip.2014.0013. Marvin, R., Cooper, G., Hoffman, K., & Powell, B. (2002). The circle of security project: Attachment-based intervention with caregiver-pre-school child dyads. Attachment and Human Development, 4(1), 107–124. https:// doi.org/10.1080/14616730210131635. Meirsschaut, M., Roeyers, H., & Warreyn, P. (2010). Parenting in families with a child with autism spectrum disorder and a typically developing child: Mother’s experiences and cognitions. Research in Autism spectrum disorders, 4(4), 661–669. https://doi.org/10.1016/ j.rasd.2010.01.002. Mercer, J. (2015). Examining circle of security: A review of research and theory. Research on Social Work Practice, 25(3), 1–11. https://doi.org/10.1177/1049731514536620. Neece, C. L., Green, S. A., & Baker, B. L. (2012). Parenting stress and child behavior problems: A transactional relationship across time. American Journal on Intellectual and Developmental Disabilities, 117(1), 48–66. https://doi.org/10.1352/1944-7558-117.1.48.

Circle of Security: “Understanding Attachment in Couples and Families” Pazzagli, C., Laghezza, L., Manaresi, F., Mazzeschi, C., & Powell, B. (2014). The circle of security parenting and parental conflict: A single case study. Frontiers in Psychology, 1–9. https://doi.org/10.3389/fpsyg.2014. 00887. Ramsauer, B., Lotzin, A., Muhlhan, C., Romer, G., Nolte, T., Fonagy, P., & Powell, B. (2014). A randomized controlled trial comparing circle of security intervention and treatment as usual as interventions to increase attachment security in infants of mentally ill others: study protocol. BMC Psychiatry, 1–11. http:// www.biomedcentral.com/1471-244X/14/24.

Circle of Security: “Understanding Attachment in Couples and Families” Deidre Quinlan1, Mary Ann Marchel2, Glen Cooper3, Kent Hoffman3 and Bert Powell3 1 Circle of Security International, Duluth, MN, USA 2 College of St. Scholastica, Duluth, MN, USA 3 Circle of Security International, Spokane, WA, USA

No variables have more far reaching effects on personality development than a child’s experiences within the family. Starting during his first months in his relations to both parents, he builds up internal working models of how attachment figures are likely to behave towards him in any of a variety of situations, and on all those models are based all his expectations, and therefore, all his plans, for the rest of his life. John Bowlby (1973), Attachment and Loss

Name of Concept Attachment and Circle of Security

Introduction Attachment plays a powerful role in shaping families and intimate relationships and in determining the emotional health of the developing child.

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Attachment relationships develop from birth, and these early care experiences with primary caregivers shape one’s responses to important relationships throughout the lifespan. As attachment theorist and clinician John Bowlby (1953) envisioned more than 50 years ago, children create internal working models of themselves and of the people in their closest relationships. Bowlby argued that patterns of attachment in childhood profoundly impacted the psychological development and capacity for intimate relationships from the cradle to the grave. The Circle of Security provides a way to understand the complexity of the attachment system (Powell et al. 2014). The Circle of Security is designed to enhance one’s ability to promote safety and well-being in relationships. This entry describes an approach to understanding and applying attachment theory in couple and family relationships by using the conceptual framework of the Circle of Security including the Circle of Security graphic to understand the attachment system, “being with” as a way to conceptualize co-regulation, and “shark music” to bring into awareness the adult state of mind.

Theoretical Context for Concept Attachment theory combined with research on brain development (Schore and Schore 2008) and trauma (van der Kolk 2005) is now the dominant theory of child development (Schaffer 2004). Through this lens comes understanding about what it means to be a person in relationship. Attachment theory suggests development is linear, directional, and cumulative, that there are sensitive periods in human development, that change becomes increasingly difficult the longer the pathway is followed (Sroufe 2005), and that what comes first builds the foundation for all that comes later. According to Bowlby (1969), attachment is a motivational behavioral system with the purpose of regulating proximity to an attachment figure. The attachment system includes both exploration, where the function is for learning, and protection, where the function is for safety.

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The third part of the attachment system is the parent system. Specifically, the Circle of Security graphic depicts the three main pillars of attachment theory as follows: (a) the hands, which represent the caregiving system (attachment figure); (b) the top of the Circle, which represents the exploratory system; and (c) the bottom of the Circle, which represents the care seeking system (Powell et al. 2014). In Circle of Security, the hands on the graphic represent the parent’s role in providing a secure base from which the child can explore and a safe haven to which the child can return. In other words, the parent is an attachment figure. To be effective as an attachment figure, parents must demonstrate that they possess the strength, wisdom, and care to protect children from the fear of real or imagined dangers. With the hands of the parent providing a secure base, children have a sense that their parent is supporting their exploration and allowing curiosity. This is an important role because parents act as a model for what is safe or dangerous. Children depend on their parents to protect them while they explore; they also watch to see if their parent is paying attention to them for that needed protection. Parents are sometimes surprised to learn that their children need them just as much when they are out exploring as they do when they are in their parent’s lap. As children get older, they can travel farther and stay away longer. The top half of the Circle of Security graphic represents children’s needs when their exploratory system is activated. These needs are met if the parent supports the child’s bid for exploration and watches over, delights, helps, and enjoys the child. Over time, children remember what parents have indicated is safe and what is dangerous. When children have explored long enough and become tired, frightened, or uncomfortable, they have a new set of needs that require a response from the parent. The bottom half of the Circle of Security graphic represents children’s needs when their attachment system is activated. Unless they are very frightened, the first thing children need after this system is triggered is a sign that they are welcome to come back to the parent. These needs are met if the parent both welcomes the child’s bid

for proximity and follows the child’s need for protection, comfort, and delight and/or helps organizing feelings. The components of the Circle of Security graphic are rooted in early attachment-based research (Bowlby 1969) and include the research of Mary Ainsworth. In the 1960s, Ainsworth developed a technique called the strange situation (Ainsworth et al. 1978). The strange situation is used to systematically measure the quality of attachment relationships. This added to the mounting evidence of the importance of the attachment system in understanding child development. While Ainsworth et al.’s (1978) classification system captured secure and insecure attachment strategies in dyads, there remained an unclassified group whose behaviors could not be categorized. Main and Solomon (1986) later classified these outlying cases, further adding to the field of attachment with their work on disorganized attachment and later the Adult Attachment Interview (Main et al. 1985). Main and Solomon (1986) introduced a fourth classification: disorganized. What follows is a description of secure, insecure, and disorganized attachment. Secure Attachment Secure attachment relationships help to carry children along a healthy developmental path and into adulthood (Bowlby 1969). Security is achieved when the parent repeatedly assists the infant in coping constructively with negative emotions, remains engaged during times of need, provides the necessary co-regulation, and transforms the infant’s dysregulated feelings into tolerable emotions (Sroufe 1977). Key caregiver behaviors include sensitivity to the infant’s cues, responsiveness, as well as physical and psychological availability (Ainsworth et al. 1978). In Ainsworth’s strange situation, about 60% of dyads are secure. Over time, the attachment strengthens between parent and infant, creating a connection that is so enduring it can never be circumvented. With this security, the developing child thrives and, using this internal working model, goes on to form secure bonds in other primary relationships later in life. With confidence, secure individuals move through life’s experiences believing that when

Circle of Security: “Understanding Attachment in Couples and Families”

they struggle there is that special someone they can turn to for support. There is a direct and clear path toward resolution of the struggle. Insecure Attachment According to attachment theory, children are likely to develop maladaptive social behaviors when the environment they are raised in deviates from what is considered evolutionarily adaptive, or “normal” (Bowlby 1969). Since infants cannot control the relationship capacities of the parent, they must learn to adapt in order to survive. To that end, human beings either feel secure because they are able to experience secure attachment relationships or insecure/disorganized because of the specific ways needed security in relationship goes unmet. With insecure attachment, there is a direct and clear path toward resolution of the struggle, but it comes at a cost. Children learn to attend to both their need for security and their parent’s tendency to respond to that need (Powell et al. 2014). Children become exquisitely sensitive to which behaviors they can display to their parent and which behaviors they need to limit or avoid showing. Ainsworth et al.’s (1978) classification system contains two categories of insecure attachment: anxious resistant and anxious avoidant. Children with an anxious-resistant attachment style struggle with relationships because they seek separation from the parent when their exploratory system is activated; however, the exploration is distressing to the parent who, in an effort to stay in the relationship, pulls the child too close. Based on a history of inconsistent care, anxious-resistant children show signs of frustration regarding contact when distressed, have difficulty separating, and cannot be reassured by the presence of a parent. When the anxious-avoidant child’s attachment system is activated and the child seeks proximity to the parent, the attachment need in the child signals distress in the parent, and the parent pushes the child away in order to stay in relationship. If the parent’s early experience of needing comfort was rejection, then the parent’s response will be influenced by his/her unconscious procedure for avoiding rejection by denying the need

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for comfort. Based on a history of unresponsive care, anxious-avoidant children struggle to find or seek comfort from relationships when distressed, are unsure about parent availability, and feel unworthy of love or comfort (Ainsworth et al. 1978). Disorganized Attachment Infants form attachments when there is a consistent parent to interact with repeatedly over time, regardless of the quality of the interaction. For both secure and insecure attachment, repeated daily interactions provide memories that organize into an internal working model of predictable relationship strategies to attempt in times of need. These strategies make sense and, for better or for worse, get the job done. For the disorganized child, there is no clear path, and relationships are not predictable. Disorganized attachment is the irresolvable paradox that occurs when the parent is both the source of the child’s fear and the haven for the child’s safety (Main and Solomon 1986). When the disorganized child’s attachment system is activated, the brain signals the attachment system to seek proximity, but if the parent is the source of the fear where does the infant turn? Disorganized infants fear the parent that they rely on for protection and thus face fear without a solution (Cassidy and Mohr 2001). Because infants are biologically wired to seek proximity, fear leaves the attachment system unresolved. Fear short circuits the brain, and the parts of the brain that evaluate situations in a logical way tend to shut down (Perry and Szalavitz 2009). Children with disorganized attachment are chronically afraid, always on the verge of losing emotional and/or behavioral control, and have difficulty using another as a trustworthy resource. Children who experience maltreatment, abuse, or neglect, who are left alone without adequate supervision, whose parents are involved in substance abuse and the criminal justice system, who are mentally ill, or those whose parent faces unresolved loss or trauma are at risk of disorganization (van Ijzendoorn 1999). In addition, parents who experience their infant’s distress as a threat are vulnerable to create disorganized attachments.

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Adult Attachment and State of Mind Bowlby’s attachment work was primarily concentrated on understanding the essence of the infantcaregiver relationship. However, he believed tenets of attachment theory were applicable to the human experience from the cradle to the grave. A central hypothesis of adult attachment theory is that the caregiver’s mental representations (or state of mind) are an important predictor of infant’s quality of attachment (Main et al. 1985). That is, patterns of responsiveness in caregiving are transmitted across generations. The adult measures of attachment focus on state of mind, as examined through structured interviews (the Adult Attachment Interview, George et al. (1984, 1985, 1986); Q-sorts (Kobak 1989); and questionnaires (Hazan and Shaver 1987; Collins and Reed 1990). Study of adult attachment has identified four styles: secure autonomous, dismissive avoidant, anxious preoccupied, and unresolved. These roughly correspond to infant classifications: secure, anxious resistant, anxious avoidant, and disorganized. Similar to Ainsworth’s (1978) infant classification system, adult attachment styles are rooted in the idea that fear is the driving, organizational force behind the search for safety and security. Separation is inherently threatening; hence, in the ideal course of events, threats lead to reunion and a return to normal functioning. In concordance with adult attachment styles schema, there are individual differences with regard to how adults “make meaning” of and navigate relationship. For example, in those relationships considered secure autonomous, there is a held expectation that their partners will be there in times of need. Further, there is an openness to depending upon “the other” and reciprocation of support for their partner. In contrast to secure relationships, some adults appear insecure in their relationships, demonstrating dismissive-avoidant or anxious-preoccupied attachment styles. While both dismissiveavoidant and anxious-preoccupied attachment styles are considered to include “organized” strategies of maintaining the relationship, the inherent efficiency and effectiveness are less than optimal. Hallmarks of the dismissive-avoidant style

include intellectualization or idealization of their early relationships, maintenance of a dismissing stance, and avoidance of closeness when under stress. In a clinical relationship, a dismissive client may “feel” difficult to connect with, evoking little emotional response. Anxious-preoccupied attachment styles are characterized by an intense neediness with a strong orientation toward relationship. Anxiouspreoccupied attachment styles are often marked by strong emotions, but because there is an inefficiency to their use of the relationship experience, they are often misunderstood. Anxious and immature features serve as barriers to full access of the “other” as a relational partner. As stated, dismissive-avoidant and anxious-preoccupied adult attachment styles are considered organized approaches to negotiating relationships with partners. There is observed predictability, though less than optimal, in relational behaviors. This is not the case in the unresolved/disorganized attachment style, an observed orientation emerging from Adult Attachment Interview (AAI; George et al. 1984, 1985, 1986) when a subset of transcripts include narratives that are deemed “unclassifiable” (Hesse 1999). Features of the disorganized attachment style include the speaker’s inability to make sense of their experiences or establish coherence across the interview. Stories are fragmented, and there is difficulty in clarity of expression. As partners or caregivers, those experiencing an unresolved/disorganized attachment style may demonstrate unpredictable, confusing, or erratic behaviors surrounding relationship. State of mind rests on being frightened, constantly operating out a fight, flight, or freeze response in the face of perceived stress. Difficulty in trusting the “other” results in struggles in successful intimate relationships.

Description Attachment in Adult Romantic Relationships The notion of attachment as a lifelong process was extended to adult romantic relationships in the late 1980s. Parallel to infant and caregiver attachment

Circle of Security: “Understanding Attachment in Couples and Families”

relationships, Hazan and Shaver (1987) propose that adults in romantic relationships (a) feel safety when in close proximity to their partner; (b) experience feelings of insecurity when the other is inaccessible; (c) enjoy shared exploration and discovery with one another; (d) seek close, intimate, physical contact; and (e) engage in “baby talk.” When using the Circle of Security graphic to look at adult intimate relationships, the couple shifts roles between being the hands for the other to being on the Circle needing hands, depending on who has the need and who is able to provide the needed support in the moment. Secure adult relationships require both to participate in fulfilling each other’s needs for exploration and for connection. At the heart of secure attachment in couples is the knowledge that partners are emotionally available to each other and will remain emotionally present during times of need. Daniel Stern (1985) calls this “being with” which is a key concept used in Circle of Security. During infancy, people learn how to self-regulate through repeated predictable and consistent experiences of “being with,” or co-regulation, with a parent. Within these repeated secure experiences, infants are learning what it means to be a person in relationship – that they are valued, that they are worthy, and that there is at least one person in the world who understands them and what they need. A partner’s capacity for “being with” is developed in these early foundational experiences of co-regulation.

Application of Concept in Couple and Family Therapy In family therapy, helping parents learn to track their own process by enhancing their power of reflection is at the heart of the Circle of Security (Powell et al. 2014). Much of the success in the relationship depends on the individual’s capacity to reflect on self-held strengths and struggles, to recognize when there is a rupture, and to make repair. Knowing when to support yourself and when to accept help is an essential skill of

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successful close relationships that comes with reflection. Can you think of someone who will only rely on themselves to solve problems or always relies on someone else? Or someone that must always manage feelings on their own or that cannot manage their own feelings and must always look for someone else to take care of their problems? Adults with a history of relationship needs on the Circle that went unmet need supportive hands (like a therapist or partner) who can be with them and provide a secure base/ safe haven. Access to supportive hands promotes exploration and reflection on these childhood struggles that interfere with their current capacity to be in relationship and to parent their children. Couples also need a coherent roadmap to begin to understand relationship struggles. For many adults, knowing that they do not want to replicate their experiences as a child is positive but only tells them what not to do. When someone only knows what they do not want to do, the pendulum tends to swing too far in the other direction. The Circle of Security graphic illustrates children’s needs in primary relationships. Understanding relationship needs helps couples use the graphic to see where they were struggling as children and to reflect on how those struggles manifest in current relationships. With reflection comes choice. In the attachment literature, a secure state of mind is measured by the capacity of the person to hold the good and bad of the story without getting lost in the telling of the story and without getting dismissive of the importance of the impact of the details of the story (Main and Solomon 1986). The Circle of Security is designed to help individuals derive clarity on their state of mind struggles that evoke uncomfortable feelings and are met with a need to self-protect. These struggles are referred to as “shark music” (Powell et al. 2014). Shark music occurs when one’s partner’s need (or your child’s) on the Circle requires a response that is safe but feels uncomfortable (even dangerous). One suddenly feels uncomfortable – lonely, unsafe, rejected, helpless, abandoned, angry, and controlled (Hoffman et al. 2017). Using the Circle of Security graphic, understanding where shark music shows up on the Circle and then having someone “be with” you

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to help reflect on your strengths and struggles can be organized and provide a way to bring clarity to an experience that before had no access to words to describe (Powell et al. 2014). Attachment research shows that as coherence increases, security increases (Main and Solomon 1986). The Circle of Security helps build coherence, as it provides opportunity for the telling of the story in an organized way and brings to the conscious awareness patterns of behavior that before went unknown. When using the Circle of Security, the goal is not to find problems. Rather, it is to discover those places on the Circle where one finds themselves feeling anxious (shark music) or on the way to anxious (Hoffman et al. 2017). Adults with histories of insecure attachment often grow up to struggle as partners and/or parents with the same relationship needs on the Circle that went unmet as a child. Children need to know that adults are in charge and appreciate the sense of safety that comes from knowing this. With partners, however, there is turn-taking being bigger, stronger, wiser, and kind on the Circle which means that whoever is the most able to respond to the needs in the moment must be the hands. But many people struggle here for a variety of reasons. They overemphasize one aspect of being bigger, stronger, wiser, and kind while at the same time underemphasize another aspect. If someone is perceived as mean rather than kind, or weak rather than strong, they become frightening to the partner. Everyone has an innate wisdom to run away from what is frightening and to run to their attachment figure for security. For children, if a parent is the source of both the fear and protection, there is no solution (Cassidy and Mohr 2001). This is true for adults as well and may leave them with a diminished capacity to see their partner as a resource. Not surprisingly, young children who learn that relationships are not trustworthy grow up to struggle with adult relationships. On the top of the Circle, “support for exploration” is often a combination of the partner’s own comfort level with separation, as well as what is happening in the moment. If a partner is inconsistently available, uncomfortable with separation, needs to be needed, or sees the world as too

dangerous, their support for exploration is limited. There are a number of responses depending on their partner’s own relational history, including hiding their need to explore by acting like they need closeness, comfort, or protection; acting passive/aggressive, angry, and hostile; and/or appearing helpless, needy, and clingy. Like support for exploration, a partner’s sense that they are “welcome to come back in” on the bottom of the Circle is a combination of a partner’s own comfort level with closeness as well as what is happening in the moment. If a person expresses a basic need for comfort, and their partner’s early experience of needing comfort was rejection, then the partner’s response will be influenced by their unconscious procedure for avoiding rejection by denying the need for comfort. In these relationships, partners learn that emotional or physical closeness, or needing comfort, is unacceptable, and they may hide their need to seek closeness by acting like they want to explore or be distant; they may distract from their partner’s need for closeness.

Clinical Example: Shondra and Aidan The Circle of Security can be used specifically for couple therapy, while other times therapists can use the Circle to focus on families. The Circle of Security also helps to see the parallel process of attachment relationships. In this case example, the overlap of working with the parent/child relationship and partner relationship is apparent. Family (Parent and Child) Therapy Shondra first came for family therapy because of concerns about the escalating behavior of her 3-year-old daughter. She was biting, refusing to go to bed, having excessive tantrums, and running away from her caregivers at every opportunity. Shondra was afraid to take her anywhere and instead just stayed home. The parents were disagreeing over how to handle the situation. Conflict in the marriage was escalating, and Shondra and the child’s father, Aidan, had recently separated. Aidan is unwilling at this time to participate in the family therapy.

Circle of Security: “Understanding Attachment in Couples and Families”

During the family history intake, Shondra described her own mother as mean and gave an example of how, as a child, every day when she left for school her mom would be angry with her and make her feel awful. The therapist asked Shondra what it would be like for her now if her mom had been more kind to her, if her mom would have been able to “be with” her when she was a little girl. Shondra then began to cry and spoke about how she has always had to hold in her tears, how she always feels like crying, but never acts on it because (as a child) when she cried her mom would get mean. “Mean” meant that her mom would make her get a mirror and look at herself. As she looked into the mirror, her mother would tell her to stop crying and to control her feelings. As she shared this memory, Shondra had a moment of reflection where she realized she is doing this to her own child. She is afraid of any intense feelings that her daughter shows, such as anger, and is afraid her daughter will not love her. In response, she consistently pushes her daughter to show her a “happy face” and to push away other feelings. In the next weekly session, the hands on the Circle are more deeply explored. Shondra is asked to think about bigger and stronger and, when she gets weak, to reflect on what stops her from being bigger and stronger. She returns the following week excited to share that she figured out where she hears shark music around her own fear of being alone. She believes that this gets in her way of being the parent. She shares that this also serves as a barrier to greater intimacy in her relationship with her husband. She describes a fight they once had, which included yelling and calling each other names. It started in the car with their daughter in the back in a car seat. Her husband dragged Shondra out of the car and across the lawn. A neighbor witnessed the incident and called the police. When the police came, Shondra denied it happened to protect her husband. She wonders out loud about why she protected him. She reflects that at the time she was more concerned at that moment that Aidan might leave her. She did not think about her daughter and what it was like for her. She sees how this left her daughter with no hands when she was frightened. She lowers her head and cries silently.

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The next week Shondra begins the session by sharing she has decided that she needs to make changes on her own and quit waiting around for her husband. She has been thinking more about bigger and stronger and being the hands. Her reflection has led her to realize that her fear of being alone has kept her with her husband. She decided to take charge and told Aidan that she wants him to either participate with her in therapy or leave the marriage. She states that she is not acting like “the parent” when she keeps looking for someone else to be in charge. She concludes that she has to be the hands and take charge. She talks more about how she has been scared of her daughter, scared she is “not gonna like me.” She tearfully shares her realization that they are afraid of each other. Shondra returns the next week excited to share another story about taking charge. She had been to the doctor and was told the pacifier had to go because her daughter’s teeth were bucking out. She said, “I knew her having the nook was a me thing, and not a her thing. I was letting her stuff her feelings by offering her a nook when she was stressed or upset, I used it to shut her up so I didn’t have to comfort her and organize her feelings. I would just put the nook in her mouth, but what she really needs is for me to be with her and help her figure it out together.” She shares how she made a plan with her daughter to give the nook to a younger infant at the child care center. After that, her daughter asked a few times to go in and see the baby, but otherwise she is doing okay with the change. The therapist shares that children really want adults to take charge and how her daughter feels safe to know that her mom is in charge. During the next session, Shondra talks about going to a playgroup and problems with her daughter running all around the room acting out of control. When it is time to leave, her daughter takes off and runs around. The therapist talks about her daughter’s emotional cup being empty and her hyperactivity being less about exploration on the top and more about the bottom of the circle and her need to reconnect with her mom. The next week Shondra shares how she has started to enter the playgroup space and sit for a few minutes with her

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daughter before she takes her out to find her shoes. She makes a point to connect with eye contact, a smile, and a hug. She says this has made a huge difference. Her daughter is more calm and cooperative. She reports it takes longer up front, but it is faster than later chasing her all over. Couples (Wife and Husband) Therapy The following week both Shondra and Aidan arrive for family therapy. Shondra starts discussing her fear of abandonment, her worry that he might actually leave her, and how she has struggled for closeness in their relationship. She shares more about her childhood relationships, and how when she was distressed, her mother would embarrass her and try to talk her out of her feelings. She recounts how her mother would tell her that if she could not manage these small struggles, she would never be able to manage the big things that life brings. Shondra reflects further and shares that it really was because her mother could not handle her own feelings and, as a result, neither can she. She learned that struggles had to be really big before her mother would be with her on the bottom of the circle. Shondra starts to see how she is doing the same now in her relationship with her husband. Aidan listens and softens his tone. He realizes how mad he has been at his wife and talks about how Shondra reminds him of his mother, who he experienced as yelling and blaming him for everything. He remembers how he was embarrassed by his mother every time something went wrong. Hence, he learned that he must never make mistakes to avoid feeling ridiculed. No matter how hard he tried, she was never satisfied and always complained. Shondra hears his story and recognizes the familiar pattern they are in together – she gets needy, he takes over, she blames, he ignores, she protests more, he withdraws, she yells louder, he explodes. The therapist asks Aidan how his life might be different today had he been able to turn to his mom when he struggled. He begins to see how his behavior is a form of self-protection as he works to stay away from the painful memories of feeling alone in his pain, away from the bottom of the circle, even if it comes at a high

cost to the relationship with his wife. As a husband, he sees how he responds to his wife with anger – by sometimes criticizing, sometimes blaming, sometimes threatening, but always pushing her away from her need for connection. In turn, he also pushed away his own possibility for connection. They leave the session with newfound empathy for each other and hopeful for change.

Cross-References ▶ Adult Attachment Interview ▶ Attachment Disorders in Couple and Family Therapy ▶ Attachment-Based Family Therapy ▶ Circle of Security ▶ Object Relations Couple Therapy

References Ainsworth, M. D., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale: Lawrence Erlbaum Associates. Bowlby, J. (1953). Child care and the growth of love. London: Penguin Books. Bowlby, J. (1969). Attachment and loss. Vol. 1. Attachment. London: Hogarth. Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation. New York: Basic Books. Cassidy, J., & Mohr, J. (2001). Unsolvable fear, trauma, and psychopathology: theory, research, and clinical considerations related to disorganized attachment across the life span. Clinical Psychology: Science and Practice, 8, 275–298. Collins, N., & Read, S. (1990). Adult attachment relationships, working models and relationship quality in dating couples. Journal of Personality and Social Psychology, 58, 644–683. George, C., Kaplan, N., & Main, M. (1984, 1985, 1996). Adult attachment interview protocol. Unpublished manuscript, University of California at Berkeley. Hazan, C., & Shaver, P. R. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52(3), 511–524. Hesse, E. (1999). The adult attachment interview: Historical and current perspectives. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment (pp. 395–433). New York: Guilford Press. Hoffman, K., Cooper, G., & Powell, B. (2017). Raising a secure child: How circle of security parenting can help

Circular Causality in Family Systems Theory you nurture your child’s attachment, emotional resilience, and freedom to explore. New York: Guilford Press. Kobak, R. (1989). The attachment interview q-sort. University of Delaware: Unpublished manuscript. Main, M., & Solomon, J. (1986). Discovery of an insecure disoriented attachment pattern: Procedures, findings and implications for the classification of behavior. In T. Brazelton & M. Youngman (Eds.), Affective development in infancy. Norwood: Ablex. Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development, 50(1–2., Serial No. 209), 66–104. Perry, B., & Szalavitz, M. (2009). Born for Love: Why empathy is Essential – and Endangered. New York: Harper Collins. Powell, B., Cooper, G., Hoffman, K., & Marvin, B. (2014). Circle of security intervention: Enhancing attachments in early parent child relationships. New York: Guilford Press. Schaffer, H. R. (2004). Introducing child psychology. Oxford: Blackwell. Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36, 9–20. Sroufe, L. A. (1977). Attachment as an organizational construct. Child Development, 48, 1184–1199. Sroufe, L. A. (2005). Attachment and development: A prospective, longitudinal study from birth to adulthood. Attachment and Human Development, 7, 349–367. Stern, D. N. (1985). Interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books. van der Kolk, B. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401–408. van Ijzendoorn, M. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11(2), 225–249.

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Synonyms Circularity; Mutual causality; Pseudo-feedback; Reciprocal causality; Reciprocity; Recursive relationship

C Introduction Circular causality is a concept that creates a shift in how we understand interactions. Traditionally, a linear continuum consisted of a definitive start and end point where family issues were thought to be rooted to a singular cause. The concept of circular causality helps to move away from the traditional way of viewing interactions to a more relational context focusing on the interactions between two events. Circular causality focuses on the reciprocal relationship between two events. The perspective of reciprocal relationships stems from the foundations of cybernetics, which refers to the regulatory action where one part of the system impacts another. A reciprocal perspective moves away from the mechanical way of viewing systems (individualistic) toward a relational viewpoint with a focus on interactional patterns between contextual factors that exist within families. The shift in conceptualization creates a circular process in which one part of the system influences other parts. The purpose of circular thinking is to understand the impact that the internal and external factors have on the family system. The expansion of thinking results in a shift that dramatically influences the conceptualization of presenting problems. The shift from linear to circular thinking resulted in no longer focusing solely on past events to discover root causes. Rather, in conceptualizing through the expanded perspective, it is evident that the regulatory systems are continually evolving, while being impacted by other factors within the family system.

Lisa Kelledy and Brandon Lyons Northcentral University, San Diego, CA, USA

Prominent Associated Figures Name of Theory Circular Causality

The prominent figures associated with circular causality include Gregory Bateson and Norbert Wiener. Wiener was the creator of cybernetics

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from which circular causality was born. Bateson built upon Wiener’s work by introducing the concepts of first- and second-order cybernetics.

Description Circular causality is a central tenet of family systems theory. Family systems thinking has shifted issues within the family system from a distinctive cause-and-effect outcome to one of mutual influence creating an interactional pattern. Circular causality is known as a holistic type of thinking that involves patterns, rules, and interconnections within a system (Sholevar and Schwoeri 2003). Holistic thinking extends beyond a linear cause-and-effect relationship by taking a more in-depth look into the interactional patterns that emerge and how they influence the functioning of the family system. Looking at the functioning of a family system from a systemic point of view, we start with the origin of the theory. The term systems theory is found in the underpinnings of cybernetics, originating from the work of Norbert Wiener and Gregory Bateson. Wiener and Bateson challenged the epistemological view that there is a definitive root cause to any problem. Their objection to the cause-and-effect viewpoint led to what is known today as systems theory or general systems theory. The development of cybernetics challenged the notion of an absolute truth (i.e., A leads to B, which leads to C) and provided an alternative view where conceptualizing the family system is both recursive and reciprocal (Bateson and Donaldson 1991). The recursive action generated the family systems theory that the relationship between two things have mutual influence upon each other rather than a cause-and-effect relationship between two things (Bateson and Donaldson 1991). The systems theory/cybernetics perspective shifted away from thinking about why something happens toward what is happening within the family system (Becvar and Becvar 1982). The shift in epistemology led to the development of a systemic framework known as circular causality. The focus was no longer on the linear causality,

Circular Causality in Family Systems Theory

rather attention was given to the processes that gave meaning to the presented events. By altering the conceptualization of how a system interacts (individualistic to systemic), the focus shifts toward the role of each part of the system. Each person shares in the responsibility for the construction of the relationship, forming a recursive process where each person equally impacts the interactions with the other. Viewing the system alteration in this way, the distinction between cause and effect and mutual influence becomes visible. The distinction assists in helping one understand that patterns are shared and constantly evolving. The evolution of these interactional patterns highlights the distinct differences and eliminates the notion that there is a primary root cause for the relationship disturbance. Instead, relationships become a shared process influenced by both individuals as well as mutually influencing factors.

Relevance to Couple and Family Therapy Circular causality provides a foundation and a framework in couple and family therapy. As a systems therapist adopts the circular causality framework, the underpinnings of relationships and patterns that are simultaneously influenced by one another begin to emerge. For the field of couple and family therapy, the framework of these patterns provides a structure of thinking about clients in a manner that encourages a holistic assessment of the presenting problems. The structure removes the pathology of linear causality and creates space for a relational assessment that considers the entire couple/family system. The notion of circular causation is a recursive formation. No single event is independent of another. When one part of the system is impacted, the influence on another event, or series of events, creates a recursive interaction in which neither event is mutually exclusive. Understanding relationship systems in this manner allows the client’s concerns to be seen as having a relational impact in which all parts of the system are influencing the other.

Circular Causality in Family Systems Theory

Clinical Example of Application of Theory in Couples and Families Circular causality is an important consideration for working with couples and families. The content of what the clients may bring to therapy will not be linear. Consider the two descriptions below to gain an understanding of how linear and circular causality differ from one another. Using an example of a linear perspective, a husband and wife present in therapy with what they identified as “communication issues.” The therapist begins to ask questions that focus on the why the communication pattern persists. These why questions create the structure that points to the cause-and-effect perspective that concern A leads to concern B. Taking the position of why, the therapist is functioning from a linear perspective. In doing so, the structure does not provide a framework for how the couple’s interactions are influencing one another, and therefore the communication patterns have a limited focus. From a circular causality perspective, a husband and wife present in therapy with same concern regarding communication issues. The therapist begins to ask questions that focus on what is happening in the system that makes the communication pattern persist. When changing the focus from why to what, the therapist is functioning from a relational perspective that understands that the events are not mutually exclusive from one another. This position maintains that the functioning of the systems is reliant to understanding the role that each person plays. In addition, the therapist aims to understand both the internal and external factors influencing the functioning of the relationship. From this vantage point, the therapist is able to engage in the system by identifying other factors contributing to the communication pattern. The following example demonstrates an interactional pattern from a circular causality perspective. John and Sara have been married for 20 years and have an 18-year-old daughter. They are coming to therapy to discuss concerns about communication issues. Sara describes John as authoritative and demanding. John is also seen

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by Sara as dismissive of her feelings as evidenced by the way in which John constantly reminds Sara that she is wrong to feel the way that she has expressed. As the interactional pattern emerges, Sara indicates finding it easier to not engage with John by remaining silent. The couple has maintained the same interactive pattern of “demanding” and “dismissiveness” for the majority of their 20-year marriage. However, as their daughter is preparing to transition into college, Sara realizes that she does not want to continue in their relationship in the same manner. Sara’s goal for therapy is to find her voice in the marital relationship. John’s goal is to discover the reasons for Sara’s disconnect from the relationship. From a linear perspective, it would appear that as John uses his authoritative voice, Sara chooses to withdraw and remain silent, demonstrating a cause-and-effect relational pattern. The linear perspective assumes that Sara is not engaging with John because of his authoritative tone. The linear viewpoint does not provide alternative explanations of the impact that other potential factors may be having on the relationship. From a circular causality perspective, John’s actions of using an authoritative voice (event A) are influencing Sara’s actions of withdrawing (event B). In turn, Sara’s actions of withdrawing influence John’s actions by increasing the authoritative tone (event A), and the pattern continues. When viewing interactional patterns from the circular causality framework, a dialogue emerges centering around the interactive cycle. The circular display would be event A leading to even B which then leads back to event A, leading back to event B. The cycle continues to repeat until the cycle is disrupted. As described, the interactional pattern displays a systems perspective that demonstrates the impact each participant’s actions has on the other participant’s actions. From this perspective, the more John is authoritative and outspoken, the more Sara withdraws. The more she withdraws, the more outspoken John becomes. In other words, John’s elevated tone influences Sara’s silence and Sara’s silence influences John’s elevated tone. Viewing

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the couple’s interactions from a circular causality perspective enables the dialogue to shift away from cause-and-effect and toward the interactional dynamics within the relationship. As the interactional shift occurs, the cycle will be interrupted and the parts of the system (i.e., the clients’ belief systems) are altered. The altered system and the members of that system begin to form a relationship through new communication patterns that encourages systems-oriented thinking. The systems-oriented framework provides clients the opportunity to see how their interactions and experiences with others can influence communication patterns. Adopting a systems perspective of circular causality creates an epistemological shift that involves patterns, rules, and interconnections of the system. The shift often results in the reduction of blame and expands the clients’ insight regarding the presence of numerous different variables within the relationship.

Cross-References ▶ Bateson, Gregory ▶ First Order Cybernetics ▶ Linear Causality in Family Systems Theory ▶ Reciprocity in Couples and Families ▶ Second-Order Cybernetics in Family Systems Theory ▶ Systems Theory ▶ Wiener, Norbert

References Bateson, G., & Donaldson, R. (1991). A sacred unity: Further steps to an ecology of mind (1st ed.). New York: HarperCollins. Becvar, R., & Becvar, D. S. (1982). Systems theory and family therapy: A primer. Lanham: University Press of America. Sholevar, G. P., & Schwoeri, L. D. (2003). Textbook of family and couples therapy: Clinical applications (1st ed.). Arlington: American Psychiatric Association Publishing. Wiener, N. (1948). Cybernetics or control and communication in the animal and the machine. Cambridge, MA: MIT Press.

Circular Questioning in Couple and Family Therapy

Circular Questioning in Couple and Family Therapy Chris J. Gonzalez Department of Psychology, Counseling, and Family Science, Lipscomb University, Nashville, TN, USA

Name of the Strategy or Intervention Circular questioning

Introduction Circular questioning is a systemic method of clinical inquiry initially developed by the Milan Associates (Palazzoli Selvini et al. 1980) and later adapted widely within the field of couple and family therapy (Fleuridas et al. 1986). The innovative work of the Milan Associates applied systems theory and cybernetic epistemology to clinical work with family systems which, in part, resulted in an approach to therapy which directed questions toward a relational system rather than an individual (Palazzoli Selvini et al. 1980). Circular questioning is a practical methodology that makes the clinical shift from individual and linear to relational and circular (Fleuridas et al. 1986).

Theoretical Framework Circular questioning emerged amidst the rise of the systemic revolution in mental health treatment in the twentieth century. The emerging systemic theories of Bateson (1972) and Watzlawick et al. (Watzlawick et al. 1967) were so innovative that it amounted to a paradigm shift in thinking and conceptualizing mental health by expanding the way in which mental health disorders were understood. The impact of this emerging theory was so revolutionary that it gave birth to a new way to intervene in mental health problems. This revolutionary theorizing expanded upon current individualistic thinking of the day and began to include

Circular Questioning in Couple and Family Therapy

relational contexts, such as families, as the cause of mental disorders, the maintenance function of mental disorders, or a context changed by the mental disorder – and often all three. In short, from this emerging systemic theory came a collection of systemic hypotheses about mental health disorders, primarily that disorders manifest in an individual were also bound within a relational context laden with rules, roles, and transactions (Palazzoli et al. 1990). These systemic hypotheses carried with them implications for assessment, diagnosis, and treatment. From these hypotheses, circular questioning was developed to serve as a technique whereby these rules, roles, and transactions might be highlighted, explored, and activated in a therapy session – a desired outcome linear and individualistic questioning methodologies were not equipped to perform.

Rationale for the Strategy or Intervention Being rooted in systemic theory and systemic hypothesizing, circular questioning moves the long-standing intervention of the question itself from linear to systemic by asking questions of a system about the system as opposed to asking questions of an individual about themselves. Circular questioning is versatile in that it can be used whenever the therapist addresses any relational system and is therefore not limited to any model of systemic therapy. More specifically, the rationale for using circular questioning emerges when the therapist seeks to build rapport with a client system, when a therapist diagnoses systemic functioning, when a therapist seeks to build empathy in relationships, and as an intervention to invite change in the patterns maintained by the homeostatic function of the system. Building rapport and a therapeutic alliance with a client system requires a nonlinear approach. Circular questioning is a nonlinear approach that allows for rapport and alliance building with client system. Circular questioning enables the therapist to establish rapport with the family itself rather than simply one or more of the individuals or with each

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of the individuals separately. In short, one of the desired outcomes of circular questioning is to develop a meta-level relationship with the family (Palazzoli Selvini et al. 1980). Circular questioning can also serve as a way to assess and diagnose a client system by exploring the accuracy of systemic hypotheses developed by the therapist (Fleuridas et al. 1986). Asking circular questions can help to reveal the roles people take in the client system, what overt and covert rules govern the client and how transactions function in the client system. In short, circular questions are designed to move the client system to become aware of its patterns or even to perform their patterns of interaction in therapy. Circular questioning can also function to help family members understand each other in the context of the roles, rules, and transactions of the system. Circular questioning serves as a sort of forced empathy for individuals as the therapist seeks to discover the extent to which a system is self-aware of its own functioning while assisting the family in viewing itself systemically (Fleuridas et al. 1986). Finally, circular questioning can serve as an intervention that invites the family to change its functioning. Circular questioning invites the family to break the unwritten rule found in many families which is to avoid commenting on relationships between family members while in their presence (Brown 1997). In commenting about relationships in the system while in the presence of the people being commented on, the rules of silence about who can talk about whom are at least challenged, are certainly exposed, and could possibly be amended.

Description of the Strategy or Intervention The variations and innovations within the practice of circular questioning are limited only to the creativity of a therapist or client system (e.g., reflecting team, co-therapists) and how they devise ways to ask these circular questions of a couple, family, or other client system (Tomm 1984). There is therefore no singular description of the circular question. In an effort to help

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students and clinicians grasp the concept and practice of circular questioning as differentiated from linear questioning, Fleuridas et al. (1986) developed a circular questioning taxonomy which serves as a framework for the use of circular questions. In this taxonomy, circular questioning is parsed into four overarching categories across the span of a client case including: definition of the problem, sequence of interactions, comparison and classification, and intervention. Problem definition questions are asked of each member in order to highlight how each member of the family perceives, describes, and explains family functioning in present tense. Sequences of interaction questions are asked of each member of the family to highlight who does what and when they do it. Comparison and classification questions are asked of each member of the family about other members of the family. Intervention questions are asked of each member of the family with an aim for challenging the family system while also examining the systemic response to the challenge. From the four overarching categories of circular questions, Fleuridas et al. (1986) further built out the framework for circular questions using time: past, present, and future / hypothetical. Using circular questions to help the family situate their problem in time can help to provide context that the problem may not have always been present and may not always have to be. There is a present functioning of the system, but there is also an historical aspect to how the system has functioned in the past. Finally, there is a sense of anticipated or hypothetical functioning of the system in the future. Further still, Fleuridas et al. (1986) built out the framework with three different kinds of circular questions: questions of difference, questions of agreement/disagreement, and questions of explanation/meaning. Penn (1982) offers an example of a circular question by asking, “How are relationships different comparing before and after the problem began?” This question asked of each person in the system fits within the taxonomy as a sequence of interaction question, a past, and present question, as well as a difference question.

Circular Questioning in Couple and Family Therapy

Case Example The Groves family presented for therapy with the parents reporting the presenting problem of their daughter’s depression. Darryl (44) is the father/husband who is an Executive Vice President at a finance company. Sheron (43) is the mother/wife and she works as a CEO of the skin care company which she founded 5 years ago. Telly (14), their daughter, is a sophomore in high school and has recently begun wearing all black clothes (the same outfit every day), wearing thick and black eyeliner as well as painting her fingernails black. She spends hours in her bedroom listening to music with dark lyrics and snapchatting with her friends. When the family enters the therapy room and the therapist welcomes them, Telly never looks up from her phone. Sheron orders her to get off her phone in a sharp tone of voice and then turns to the therapist and apologizes with a conciliatory, “I’m so sorry,” and then shakes her head and says, “teens these days.” Telly rolls her eyes and shoves the phone into a her black and white skull purse. Darryl looks for a place to sit trying to appear to be doing something constructive as he avoids conflict. In the first session, the therapist hypothesized that the daughter’s depression reported by the parents as the reason for therapy is a symptom and means by which the daughter could get the family some help for the larger problem they were having. In order to test the hypothesis as well as build rapport with the client system, the therapist asks each individual a problem definition question, “What is happening in this family that makes therapy a good choice?” beginning with Sheron, followed by Darryl, and then Telly. Each of the members of the family agreed that there was a problem in the family. However, each of their descriptions of the problem was different. Sheron and Darryl were surprised that they partially disagreed on the nature of problem as Sheron said the problem was Telly’s depression while Darryl said the problem was Telly’s depression, overall family tension, and his own insomnia. The insomnia was a surprise to Sheron and Telly. Telly insisted she was not depressed, but that her, “faker parents haven’t

Circular Questioning in Milan Systemic Therapy

given a crap for the whole past year.” Her answer and her anger surprised both of her parents and they tried to deflect her answer. The therapist respectfully listened to the parents and then persisted with Telly inviting more from the daughter and she gave more. The therapist followed up asking each family member, “When were things different from how they are now?” Here the therapist uses neutral language in order to maintain rapport and not commit any of the family members to anyone’s definition of the problem. In doing so, the therapist takes the side of the family without privileging or marginalizing anyone’s perspective. This circular question also continues with the definition of the problem category of question but moves it into the past using the difference angle on the question. In a subsequent session, the family had consolidated their ideas about the presenting problem to how the members of the family interact with each other and how they communicate. The parents were still concerned about Telly’s behaviors, but had not mentioned depression for a few weeks. Then the therapist asked this circular question of Telly: “How do you think your mom would respond if I told her that the family is not yet ready for you to change?” This interventive circular question invokes a paradox implying a redistribution of power in the family system. This question invites the family to observe itself differently than it had to this point. Further, it is a question intended to perturb the homeostasis of the system with an invitation to reorganize itself in a healthier manner. The question assigns responsibility for change to the whole family by highlighting mom’s power through the eyes of the daughter but also opening the door for the daughter to change as the change assumption is embedded within the implied, “You are eager to change if the family would ever let you.” Literally, dozens or even hundreds of circular questions could be asked in this case were it be carried over the course of full treatment from intake to termination. Circular questions are a versatile tool of therapy that can be used at any point in therapy and within any model of therapy.

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Cross-references ▶ Bateson, Gregory ▶ Milan Associates ▶ Milan Systemic Family Therapy ▶ Penn, Peggy ▶ Reflecting Team in Couple and Family Therapy ▶ Selvini-Palazzoli, Mara ▶ Tomm, Karl ▶ Watzlawick, Paul

References Bateson, G. (1972). Steps to an ecology of mind. Northvale: Aronson. Brown, J. (1997). Circular questioning: An introductory guide. Australian and New Zealand Journal of Family Therapy, 18(2), 109–114. Fleuridas, C., Nelson, T. S., & Rosenthal, D. M. (1986). The evolution of circular questions: Training family therapists. Journal of Marital and Family Therapy, 12(2), 113–127. Palazzoli Selvini, M., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing – Circularity – Neutrality: Three guidelines for the conductor of the session. Family Process, 19, 3–12. Penn, P. (1982). Circular questioning. Family Process, 21(3), 267–280. Tomm, K. (1984). One perspective on the Milan systemic approach: Part II. Description of session format, interviewing style and interventions. Journal of Marital and Family Therapy, 10, 253–271. Watzlawick, P., Bavelas, J. B., & Jackson, D. (1967). Pragmatics of human communication: A study in interactional patterns, pathologies, and paradoxes. New York: Norton.

Circular Questioning in Milan Systemic Therapy Kelly Kennedy, Amanda Szarzynski and Irene Bautista Converse College, Spartanburg, SC, USA

Synonyms Circular interviewing; Systemic reframing

Nonlinear

questions;

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Introduction Initially developed specifically for Milan Systemic Therapy, circular questioning appears in several systemic therapies to identify patterns and changes in behavior. An overall understanding of the problem emerges through these types of nonlinear questions, which allow the family to reframe their issues by shifting the blame and making beliefs explicit. Circular questioning enables therapy to progress by eliciting new information through process questioning and creating a stronger therapeutic alliance when compared to strategic or lineal questioning. Neutral questioning of the relational conceptualization of issues from each member of the system allows a comprehensive view of circular behavioral maintenance. Different types of circular questions gather information about cyclical patterns, shift or remove blame, find changes in patterns, and assess clients by posing hypothetical scenarios. Circular questions can also be used in conjunction with lineal questions to help gain more information about the system; however, the therapist should be aware of remaining neutral to avoid a defensive response from the clients. Overall, double description questions, such as circular questions, are a useful therapeutic assessment and intervention technique (Selvini et al. 1980).

Theoretical Framework Circular questioning is most commonly associated with Milan Systemic Therapy. Therapists who developed Milan Systemic Therapy believe that therapists should focus on behavioral exchanges between members of a system and help them to develop a deeper understanding of how each member’s behavior influences and is influenced by other members (Brown 1997). Leading developers of Milan Systemic Therapy cite Gregory Bateson as influential in the development of circular questioning and draw from his idea of the double description where causality is reciprocal and circular (Diorinou and Tseliou 2014). An element of time when the pattern changes or the problem develops can be helpful

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for the therapist in determining a healthier pattern of behavior for the family. Circular questioning is also used in other systemic therapies such as strategic and MRI models. All of these models are informed by systems theory, in which the therapist and system move from a more linear processing of systems to a circular one where each member’s behavior is affected by others in a reciprocal manner (Becvar and Becvar 2013). Some therapists suggest that more “interventive” circular questions that are future oriented and hypothetical may steer away from Milan’s neutrality stance. In a study by Scheel and Conoley (1998), they found through observation of interventive versus more descriptive circular questions that clients did not always feel the therapist stayed neutral in interventive questioning. Therefore, therapists adhering to the Milan model must take caution when using circular questioning to stay neutral in their stance.

Rationale Circular questions are helpful to assess and track the overall pattern in systems. Many systems come to therapy with an identified patient as the “problem” behavior. Circular questions are used to help family members understand their part in the process as well as reduce blame for the identified patient. In using circular questioning, the therapist and system work together to make otherwise implicit beliefs explicit in the therapy room (Feinberg 1990). They also may help to indirectly reframe the issue or problem in therapy by dissecting the overall process of the system (Becvar and Becvar 2013). By helping the system point out assumptions, the therapist elicits new information for the family members to use to move toward second-order change. In addition, by asking more general process questions from each member of the system, the therapist helps to avoid getting stuck in content, which may produce a more defensive response from family members (Feinberg 1990). Finally, therapeutic alliance is an important determining factor for change in therapy. Ryan

Circular Questioning in Milan Systemic Therapy

and Carr (2001) studied the effects of questioning styles on therapeutic alliance in 28 families with 84 participants. In comparison to strategic and lineal questioning, circular and reflexive questionings were related to higher ratings of therapeutic alliance.

Description of the Strategy or Intervention Circular questioning is a type of questioning designed to expose the overall interactional pattern of a system. Nelson et al. (1986) offer specific guidelines for a circular interview and emphasize the role of the therapist as remaining neutral. They indicate that therapists should first begin conceptualizing the case in terms of relationships, instead of as individuals. Therapists should ask questions of all family members, with special care not to spend too much time with one individual’s conceptualization. During the interview, the therapist should concentrate on issues related to the presenting problem or circular hypothesis and note any similarities or differences in keywords or phrases to describe the issue. A comprehensive view of the system’s issue should involve a full cycle of behaviors or patterns that maintain the issue. Forms of circular questions include behavioral sequence, behavioral difference, ranking, beforeand-after, and hypothetical circular questions (Selvini et al. 1980). Behavioral sequence questions track an initial cycle or pattern of behavioral, and the therapists prompt the system until a feedback loop is formed (e.g., “When X brings up an issue to you, what happens next?”). When behavioral difference and ranking questions are used, the therapist typically seeks to take the blame off of the identified patient and will sometimes use others as an example (e.g., “What does your partner do that is avoidant?” or “How does your family of origin typically handle that issue?,” followed by “Whose response is the most helpful?”). Before-and-after questions assess for how patterns change before and after an issue (e.g., “How did your communication with your mother change after the divorce?”), and hypothetical

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circular questions assess clients in a less threatening way since the event has not happened (e.g., “If your son were to persuade you to let him spend the night with a friend, who would cave in first?”). Any differences noted over time, between perceptions of the family members, between parts of a person, or between situations, should be noted and highlighted by the therapist. In addition, the therapist should pay close attention to draw out relationships between behaviors, thoughts, feelings, and meanings among members (Brown 1997). If members become defensive when asking questions, the therapist may consider reversing the question to ask about the issue from the opposite direction (e.g., “Who decided your family should come to therapy?” to “Who does not believe the family should be in therapy?”). In addition, the therapist may find linear questions are helpful in some cases but should only be used in leading to information that helps form circular questions (Nelson et al. 1986).

Case Example Jack is the father of four daughters and has recently been widowed. Jack (42), Danielle (16), Stephanie (13), Sarah (9), and Beth (4) have been dealing with their grief the best they can, but after months of distress at home, the family presents in therapy due to Stephanie’s cutting, aggression toward her sisters, and disobedience to her father and older sister. The therapist begins the therapeutic process by building rapport and joining with each member of the family system. Stephanie’s safety is assessed by the therapist, and plans for keeping her safe in the future are discussed collaboratively with Jack. However, this case example will focus on other aspects of family treatment. In an effort to begin shifting the problem and blame from Stephanie, the identified patient, the therapist assesses the family interactional pattern and opens up conversations to a more cyclical process level. The therapist utilizes circular questioning as much as possible from the very beginning of therapy with the family. Some general types of questions might include “Jack, how have you seen the girls cope with the loss of their

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mother?”, “Danielle, what changes have you noticed in the family without your mom around?”, and “Sarah, how have you seen your family come together through this difficult time?” Each of these examples can be asked to each family member in order to get each person’s perspective, build rapport, and elicit engagement in the therapeutic process. Some questions may need to be adapted to more appropriate developmental levels for the younger children. Additionally, using puppets and/or a family talking stick to conduct circular questioning may assist in making the conversation more fun and engaging for all ages in the family system. More specifically, the therapist can utilize different types of circular questions. Behavior sequence questions might include “Jack, what happens first that leads up to an anger outburst from Stephanie?”, “Stephanie, how does your dad usually react when you get angry?”, and “Danielle, what does your dad do if you and Stephanie get into an argument?” Once an interactional pattern is identified, the therapist can then follow up with behavioral difference questions such as “Sarah, how do you respond when your dad asks you to do your chores?”, “Beth, what about you?”, and so forth to see how each child responds differently when their dad asks them to do their chores. These questions begin with understanding one of the presenting problems but quickly shift the blame to a more systemic interactional process level, rather than staying focused on the identified patient. Some ranking questions can be utilized as well, such as “Who usually wins the arguments at your house?”, “Who gets the most upset when the chores don’t get done?”, and “Who gets in the least amount of trouble at home?” These questions can help the therapist learn more about the power dynamics and relational patterns in the family. Some before-and-after change questions might include “What were arguments between siblings like before your mom died compared to now?”, “How have you seen your dad’s role change now that he is the only parent in the house?”, and “Danielle, what is different about your responsibilities as the big sister now versus when your mom was around?” Lastly, the

Circular Questioning in Milan Systemic Therapy

therapist can utilize hypothetical circular questions to ease the family into envisioning potential positive changes. These questions might consist of “Stephanie, what would your sisters do if you were nice to them?”, “Sarah and Beth, what do you think would happen if Stephanie and Danielle got along?”, and “Jack, what would you be able to do as a family if the girls were no longer fighting with one another?” Ideally, the therapist’s use of circular questioning with this family will lead to a more holistic view of the problem and systemically oriented solutions. Stephanie will no longer be perceived as the problem child, but instead, the family will be able to work together to change the interactional patterns that may have contributed to and/or maintained the problem.

Cross-References ▶ Bateson, Gregory ▶ Cecchin, Gianfranco ▶ Milan Associates ▶ Milan Systemic Family Therapy ▶ Prata, Giuliana ▶ Reflecting Team in Couple and Family Therapy ▶ Selvini-Palazzoli, Mara ▶ Tomm, Karl

References Becvar, D. S., & Becvar, R. J. (2013). Milan systemic/ strategic therapy. In Family therapy: A systemic integration (pp. 224–229). Upper Saddle River: Pearson Education. Brown, J. (1997). Circular questioning: An introductory guide. A.N.Z.J. Family Therapy, 18(2), 109–114. Diorinou, M., & Tseliou, E. (2014). Studying circular questioning “in situ” discourse analysis of first systemic family therapy session. Journal of Marital and Family Therapy, 40(1), 106–121. Feinberg, P. H. (1990). Circular questioning: Establishing the relational context. Family Systems Medicine, 8, 273–277. Nelson, T. S., Fleuridas, C., & Rosenthal, D. M. (1986). The evolution of circular questions: Training family therapists. Journal of Marital and Family Therapy, 12(2), 113–127. Ryan, D., & Carr, A. (2001). A study of the differential effects of Tomm’s questioning styles on therapeutic alliance. Family Process, 40(1), 67–77.

Circumplex Model of Marital and Family Systems, The Scheel, M. J., & Conoley, C. W. (1998). Circular questioning and neutrality: An investigation of the process relationship. Contemporary Family Therapy, 20(2), 221–235. Selvini, M. P., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing-circularity, neutrality: Three guidelines for the conductor of the session. Family Process, 19(1), 3–12.

Circumplex Model of Marital and Family Systems, The Jason L. Wilde Dixie State University, St. George, UT, USA

Name of Concept The Circumplex Model of Marital and Family Systems

Synonyms Couple and Family Map (Olson et al. 2014).

Introduction The Circumplex Model of Marital and Family Systems was originally developed by David Olson, Douglas Sprenkle, and Candyce Russell with the goal of bridging the gap they saw existing between theory, research, and practice in family therapy (Olson 1989). The model brings together three important theoretical concepts: Adaptability, Cohesion, and Communication, in a manner useful to both researchers trying to understand family dynamics and interventionists (therapists, educators) trying to help families functionally improve.

Theoretical Context for Concept The term “circumplex” was coined by Louis Guttman to describe a circular relation of correlated variables organized around two orthogonal dimensions (see Strauss 1964, and Schaefer 1959). Olson and colleagues based their

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circumplex model in Family Systems Theory and organized it around the orthogonal dimensions of family Adaptability (i.e., the family’s systemic ability to change when facing situational or developmental stress) and family Cohesion (i.e., the intra-familial system emotional bonding). Further, Olson and colleagues conceptualized Communication as a third key dimension that allows families to move along the axes of Adaptability and Cohesion (Olson et al. 1989).

Description The Circumplex Model of Marital and Family Systems (Circumplex Model) plots the two dimensions of Adaptability and Cohesion orthogonal to each other, each on a continuous scale from low to high. Healthy family functioning is posited to be more likely for families that are balanced on each dimension; that is, for families that function in the central levels of each dimension and avoid the extremes of high or low (Olson et al. 1989). For simplicity in mapping these dimensions, four levels of each are used. The four levels of Adaptability are, from low to high: rigid, structured, flexible, and chaotic. The four levels of Cohesion are, from low to high: disengaged, connected, cohesive, and enmeshed. These two sets of four levels create a grid of sixteen family types (see Fig. 1). The four central family types (neither low nor high on either Adaptability or Cohesion) are considered “balanced” and include Structurally Connected, Structurally Cohesive, Flexibly Connected, and Flexibly Cohesive. The four extreme family types (either high or low on both Adaptability and Cohesion) are considered “unbalanced” and include Chaotically Disengaged, Rigidly Disengaged, Chaotically Enmeshed, and Rigidly Enmeshed. Unbalanced families are posited to be more likely to experience dysfunction, yet clinicians need to be careful to make assessment with cultural expectations and the context of the family in mind. The remaining eight family types are “midrange” (neither unbalanced nor balanced). The family types are also depicted in Fig. 1. Adaptability and Cohesion are assessed for the Circumplex Model using two validated and reliable assessment devices, the Family

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Low -------------------- COHESION --------------------- High

Low ------- ADAPTABILITY ------ High

Circumplex Model of Marital and Family Systems, The, Fig. 1 The Circumplex Model of Marital and Family Systems

Circumplex Model of Marital and Family Systems, The

Disengaged

Connected

Cohesive

Enmeshed

Chaotic

Chaotically Disengaged

Chaotically Connected

Chaotically Cohesive

Chaotically Enmeshed

Flexible

Flexibly Disengaged

Flexibly Connected

Flexibly Cohesive

Flexibly Enmeshed

Structured

Structurally Disengaged

Structurally Connected

Structurally Cohesive

Structurally Enmeshed

Rigid

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Rigidly Connected

Rigidly Cohesive

Rigidly Enmeshed

Adaptability and Cohesion Evaluation Scales, fourth edition (FACES IV) and the Clinical Rating Scale (CRS) (Olson 2011). Family Adaptability consists of processes surrounding leadership, discipline, negotiation, roles, rules, and family change. Family Cohesion consists of processes surrounding separateness vs. togetherness, “I vs. We” orientation, emotional closeness, loyalty, shared/non-shared activities, and dependence vs. independence (Olson et al. 2014). Family Communication processes are used, according to the Circumplex Model, for working out issues on any of the subscales for Adaptability or Cohesion, such as leadership (part of family Adaptability) and amount of shared activities (part of family Cohesion). Family Communication is assessed by looking at listening skills, speaking skills, amount of self-disclosure, clarity of messages, frequency of staying on topic, and amount of respect and regard family members give each other in conversation (Olson et al. 2014).

Application of Concept in Couple and Family Therapy/Education The Circumplex model is the basis for the popular marital intervention program, PREPARE/ ENRICH, run by Life Innovations, Inc. The Circumplex Model graphically depicts a family’s current functioning in terms of core family processes of Adaptability and Cohesion. It gives a common language for families to discuss their

functioning, allowing them to (a) see if such functioning is normative for their current stressors and (b) plan how to alter processes to improve functioning. Further, it can be used to chart progress as a family changes (Olson et al. 2014).

Clinical Example Maryssa and Tyrone have been together for 5 years, married for just over 2 years, and they have a 1-year old daughter. They present with issues surrounding emotional drifting and control. Maryssa says, “We’re just not as tight as we used to be, ya’ know, there is this distance, this emotional wall building that’s hard to break through.” Tyrone states, “I love her and our daughter and I want to work out this relationship, but I don’t seem to be able to do enough., It’s got to be her way and she doesn’t want me hanging with my friends no more—I’m getting stir crazy, I need some freedom.” Using the Circumplex Model, their counselor helps Maryssa and Tyrone each plot out three locations on the grid: one for where they saw their respective family of origin operating, one for where they see themselves operating, and one for where they ideally would like to be as a family. Looking at the family of origin plots, Tyrone notes that they both grew up in the same rough, impoverished neighborhood, just a few streets apart. He plotted his family as operating in a Chaotically Disengaged style and Maryssa plotted her family as operating in a Structurally

Clarifying the Negative Cycle in Emotionally Focused Therapy

Enmeshed style. With some guidance, Tyrone hypothesizes about the difference, “My dad was never around and my mom had alcohol problems and a hard time keeping a job. We never knew what to count on so everyone just had to take care of themselves. Maryssa’s family pulled everyone together to deal with the neighborhood chaos, they had a lot of rules and her parents enforced them strictly. I remember visiting the first time and thinking, ‘Man, this place feels secure,’ and I wanted something like that.” The counselor helps Maryssa add to the insight, “Yeah, and I remember thinking, ‘It would be nice to do what I wanted once in a while, like this free-spirit man I’d met.’ He opened up my world. That’s one reason I put my ideal as Flexibly Cohesive—I mean, I want the family closeness kinda like my family had, just with some greater adaptability. But when he pulls away and acts all independent, like he doesn’t really need me—I mean, I see him sometimes looking like he’s going for a Chaotically Disengaged family, that’s where I really think we are sometimes right now—and I, I get real controlling, like I’m trying to make us be Rigidly Enmeshed. It’s like an emotional tug-of-war with us in separate corners of the map.” “Um-hmm,” Tyrone agrees. “But our ideals aren’t really too far apart. Having greater structure became real important to me. I had some great teachers who took me in and helped me see that I could set goals and use education to get out of the neighborhood and make something of my life. So that’s why I put my ideal at Structurally Connected, I know I need structure in my life, but I never saw how to do it in a family so when she tries to get too close and gets controlling, I just retreat to what I know from growing up. But I really don’t want to be there.” With coaching and some other work to heal past hurts, Maryssa and Tyrone begin changing communication processes to achieve their goals of a family with balanced Adaptability and balanced Cohesion. They work diligently, finding making the change difficult but rewarding. Their new communication processes help them negotiate without becoming extreme and help them pull together as a couple with a shared vision as to where they want their family to be.

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Cross-References ▶ FACES IV ▶ Olson, David ▶ PREPARE/ENRICH ▶ Sprenkle, Douglas

References Olson, D. H. (1989). Circumplex model of family systems VIII: Family assessment and intervention. In D. H. Olson, C. S. Russell, & D. H. Sprenkle (Eds.), Circumplex model: Systemic assessment and treatment of families (pp. 7–50). New York: Routledge. Olson, D. H. (2011). FACES IV and the circumplex model: Validation study. Journal of Marital & Family Therapy, 37, 64–80. Olson, D. H., McCubbin, H. I., Barnes, H. L., Larsen, A. S., Muxen, M., & Wilson, M. A. (1989). Families, what makes them work. Newbury Park, CA: Sage Publications. (updated edition). Olson, D. H., DeFrain, J., & Skogrand, L. (2014). Marriages and families: Intimacy, diversity, and strengths (8th ed.). New York: McGraw-Hill Education. Schaefer, E. S. (1959). A circumplex model for maternal behavior. The Journal of Abnormal and Social Psychology, 59, 226–235. Strauss, M. A. (1964). Power and support structure of the family in relation to socialization. Journal of Marriage and the Family, 26, 318–326.

Clarifying the Negative Cycle in Emotionally Focused Therapy Lorrie Brubacher1 and Sue M. Johnson2 1 University of North Carolina, Greensboro, NC, USA 2 The International Centre for Excellence in Emotionally Focused Therapy, The University of Ottawa, Ottawa, ON, Canada

Introduction The model of emotionally focused therapy can be seen to draw on two overall basic techniques: (1) Clarifying the negative cycle is necessary for the first change event of de-escalation, and

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Clarifying the Negative Cycle in Emotionally Focused Therapy

(2) deepening emotional experience – especially of attachment fears and longings – is needed for the two transformative change events of the second stage of EFT. Clarifying the negative cycle involves assembling the process of emotion as it is triggered between two partners caught in negative cycles of separation distress (Johnson 2004; Johnson and Brubacher 2016). It is a collaborative process of clarifying what each partner does that unwittingly pulls the other partner into the cycle and identifying each partner’s unacknowledged attachment emotions that are pulling him/her repeatedly into this reactive pattern.

The view of attachment theory (Bowlby 1982; Johnson 2013; Mikulincer and Shaver 2016) is that distressed partners become stuck in misattempts at regulating attachment insecurities and seeking secure connection (using strategies of anxious hyperactivating or avoidant suppression) that paradoxically heighten insecurity. Clarifying the repetitive negative interaction cycle as the problem creates a safe base from which to attend to the attachment fears and unmet needs driving the cycle (Johnson 2004) so as to reprocess the attachment emotions into signals of mutual reaching and responding to one another.

Theoretical Framework

Typical Negative Cycles Variations of the basic demand-pursue/withdrawdefend negative cycles of interaction are seen in several typical cycles described below. The descriptions identify the insecure attachment strategies (Mikulincer and Shaver 2016) that make up these cycles. Pursue/withdraw. Critical, demanding pursuits of a more anxious pursuer trigger avoidance and distancing in the other and vice versa. Attack/attack. One partner is likely using a more anxious attachment strategy, hyperactivating his/her attachment needs and relentlessly pursuing connection. The more avoidant partner may be fighting back in self-defense, continuing to minimize his/her own and others’ attachment needs. Withdraw/withdraw. Withdraw/withdraw couples seldom argue, and seldom get close. Some have occasional blow-ups when an emotionally raw spot is touched. Both default to avoidant positions of not counting on or trusting the other.

Clarifying the negative cycle, a process used in the first stage of emotionally focused therapy (EFT), is based on the view that it is neither lack of insight nor conflict that leads to relationship dissolution. Rather, it is attachment partners’ failure to repair and reconnect following relationship ruptures that erodes a relationship (Huston et al. 2001). Since negative self-reinforcing feedback loops block repair and reconnection, clarifying this negative cycle is the first change event on the path toward reshaping a distressed relationship. A Systemic, Experiential, AttachmentOriented Process The technique of clarifying a distressed couples’ negative cycle is rooted in the tripartite systemic, experiential, and attachment orientations of EFT. The systemic view is that self-reinforcing repetitive patterns of demand-pursue/withdraw-defend characterize distressed couple relationships and perpetuate the distress (Gottman 1994; Bertalanffy 1968). The experiential view is that therapeutic change occurs when therapist and clients engage with present-moment emotional experience, to access awareness of the unfolding process of emotion. Emotion clarifies needs, primes action responses, organizes social interaction, and creates meaning (Arnold 1960; Ekman 2003/2007).

Rationale for Clarifying the Negative Cycle Clarifying the negative cycle as the basic problem in relational distress is one of the depathologizing aspects of EFT. Partners in distress are encouraged to discover that their problem is not a deficit in oneself or in the other partner, but is

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the repetitive cycle that they are inadvertently triggering when either partner senses rejection or abandonment. Increasingly Informed by Attachment Clarifying the negative cycle is primarily a systemic process that has been part of EFT since its inception (1985). It is, however, inseparably integrated with attachment-oriented experiential techniques (empathic reflection, validation, evocative responses and questions, and empathic conjectures). As EFT was increasingly shaped by attachment theory, it evolved from the first integration of systemic and experiential approaches (Johnson and Greenberg 1985), to an approach in which each of the systemic and experiential interventions are reflective of attachment themes and reactions to a threat to the attachment bond (Johnson 1996, 2004). Process of Emotion The view that emotion and interaction patterns are both systemic processes (Johnson and Greenberg 1985; Johnson 2004) is an explicit part of EFT. Clarifying the negative cycle essentially consists of ordering the interactive process of emotion as it is triggered between attachment partners and, in doing so, accessing the specific underlying attachment fear of each partner that is propelling the reactive cycle. The EFT therapist helps partners to assemble elements of emotion – cue, cognitive appraisal, bodily arousal, and action tendency – to gain access to the core attachment emotions that are driving the process but are not yet in conscious awareness or formulated in words. For example, to assemble and order a more withdrawn partner’s emotion and access a core primary fear of rejection, an EFT therapist will evoke and validate the different elements of emotion, metaphorically opening doorways of: (1) the cue which is perceived as threatening (such as a partner’s harsh tone of voice); (2) the cognitive appraisal made of that cue (“I’m letting him/her down again.”); (3) the bodily sensation experienced when that cue is perceived (tension in the stomach, as the body prepares for fight or flight); and (4) the

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automatic action tendencies (e.g., defend/withdraw) and reactive secondary emotional expressions (e.g., anger and numbness).

Description of Clarifying the Negative Cycle Clarifying the negative cycle includes identifying the following aspects: 1. Action tendencies: Identifying the steps in the dance of distress: Outlining the behaviors in a couple’s negative cycle from the story they tell and from observing and capturing the cycle as it happens in session. Their typical responses are linked together in a self-perpetuating loop, such as “the more s/he _____, the more s/he_______.” The typical positions of anxious attachment pursuit or avoidant suppression and withdrawal are identified. 2. Danger cues: Naming the specific danger cues to which each partner reacts. Clarifying what it is that one partner does (a behavior, a voice tone, a gesture) that is typically perceived by the other partner as a danger cue or a threat to the attachment bond of secure connection. 3. Linking action tendencies to perceived threats: Helping partners acknowledge and express their steps in the dance (“I do shut down, when I hear a harsh tone.” “I do lash out when I see you shrug.”) and validating how normal and natural these moves are, in the context of perceived threat. 4. Attachment meanings: Helping partners acknowledge and express the meanings they make of the other partner’s self-protective behaviors by evoking and reflecting attachment meanings that trigger or get triggered in the cycle (“What did it say to you Andie, that she was late?” “What does his loud outburst followed by his silence say to you, Bella?”) 5. Secondary emotions: Attuning to, and validating the reactive, secondary emotions of each partner (When pulled into emotional imbalance Bella is angered by Andie’s distance; Andie is briefly frustrated, followed by numbness.)

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6. Safety: Maintaining emotional safety by “catching bullets” when necessary. Reframing aggression with a validating attachment reframe; e.g., “When you don’t know how to tell her how unwanted you feel, it is so easy to slip into frustration and attempts to shut her down.” 7. Primary emotion: Validating the attachment meanings and evoking the underlying attachment emotional music that drives the dance of disconnection and fuels distress. Both partners typically feel lonely. Withdrawers commonly fear rejection and nonacceptance, while pursuers commonly fear abandonment. Withdrawers typically view their partner as unpredictable and feel safer staying distant, whereas pursuers are likely to view self as unlovable and the other as unavailable for closeness. 8. Summarizing the negative cycle, the fears that trigger it and the attachment consequences of this cycle for both partners: “Bella, the more you complain about his distance and try to pull him close, Andie the more hear you’re letting her down and the more you angrily shut her out. When he shuts down, Bella, you become frantic and aggressive. Underneath, Bella you are lonely and afraid you’ll lose him at any moment and Andie, you’re afraid she doesn’t really love and accept you. This cycle takes over, leaving you both feeling alone and unwanted.” 9. Framing the dance of distress as the common enemy and helping couples to step out of it in session. It then becomes something they can contain and move beyond. Simple attachment frames can be offered for different cycles and attachment positions of pursuit or withdrawal. An attachment frame for a pursue/withdraw couple could be: “The more Bella turns up the volume, the more Andie steps farther away.” Both are trapped in pain and isolation.” A withdraw/withdraw couple’s cycle could be reframed as, “The more Cy walks away, looking unhappy (with me, Jess assumes), the more Jess walks away and gets busy (to numb the pain of isolation), and both are trapped in pain and loneliness.”

Case Example Bella and Andie sit in sullen silence, for a few minutes before Andie mumbles a complaint about how Bella can never be ready on time. A plethora of criticisms tumble forth from Bella, while Andie’s eyes turn down and his arms fold across his chest. He disappears into stony silence.

Therapist:

Bella:

Therapist:

Bella: Therapist:

Andie:

This is a very difficult moment – both of you feeling the other one upset with you! (reflection and validation). Right now, Bella you looked at Andie fold his arms and go silent, and you became very agitated. Your voice sped up as you recounted many struggles of the past few days. You sound very frustrated!” What happened for you Bella as you heard Andie’s complaints over your being late?” I heard, “Here we go again!” – I’ve tried for years to tell him he is good enough, that I am so proud of him, that I just want him to open up to me, but he is always on guard, ready to defend himself and put the blame on me – then he won’t talk to me for days. So you hear Andie’s complaint and you hear that you are being shut out, that he is pulling away from you and you become desperately frustrated, trying to tell him he has no reason to shut you out – yes? Exactly! And Andie, just before Bella exploded with her frustration at you, you were saying how angry you are that she was late to come to this appointment. (Andie nods definitively.) Can you tell me what it means to you when she is late? “That I’m not enough for her to care about getting ready on time!”

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Therapist:

Ah, so is this how many of your unhappy times play out? Andie, what you hear that is that Bella is dissatisfied with you (cue). You are on guard for little signs (limbic appraisal) that she cares (attachment meaning), and when she forgets something or is late, your massive concern that you are not measuring up in her eyes (more attachment meaning), rips through your heart (bodily arousal) and before you know it, you fire back in defense (action tendency) and step far, far away from the trigger of your pain (action tendency). And Bella, you live on the edge of fear (limbic appraisal) that he is going to turn away from you, looking for ways to pull him close and grasping for messages that you are precious to him (action tendencies/meaning making), getting annoyed each time you sense even a hint (limbic appraisal) that he is stepping back or going silent – is that it?”

The cycle continues to get triggered in the session. Each time it does, the therapist tracks what is happening, validating their reactions, and reflecting any hints of their underlying fears and attachment distress. By the end of Stage 1, Andie and Bella have clarified their dominant negative cycle and begun to understand how they trigger this cycle in each other. Bella is beginning to grasp, “You shut me out (action tendency/position of withdrawal) because you think I don’t care (attachment meaning). You are looking for signs that I care about you.” Andie is absorbing a new sense of Bella: “You get angry with me (action tendency/position of demand-pursue) because you are afraid I’ll turn away from you and shut you out” (primary fear of abandonment). Clarifying this automatic selfprotective cycle, each partner also touches the underlying attachment fears that leave them each so vulnerable to this negative pattern: Bella fears

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Andie is not available when she needs him – that he could disappear at any time; Andie dreads signals from Bella that he is unimportant to her – fearing he is not measuring up in her eyes. After both partners engage in the process of clarifying the negative cycle, and acknowledge and disclose to each other the underlying attachment fears propelling their reactive moves, the first change event of EFT is complete. Partners have named the basic negative cycle. Through the de-escalation process of clarifying the negative cycle, partners discover new views of one another. Pursuing partners who previously seemed randomly hostile are now recognized as desperately seeking connection and protesting the other partner’s emotional distance. Withdrawn partners who previously appeared nonchalant and uncaring are now understood to be distancing to protect themselves from criticism and rejection. This first event of de-escalation establishes sufficient emotional safety and awareness to begin the transformative change events of Stage 2.

Cross-References ▶ Attachment Injury Resolution Model in Emotionally Focused Therapy ▶ Attachment Theory ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Emotionally Focused Couple Therapy and Physical Health in Couples and Families ▶ Emotionally Focused Couple Therapy and Trauma ▶ Emotionally Focused Family Therapy ▶ Hold Me Tight Enrichment Program ▶ Hold Me Tight/Let Me Go Enrichment Program for Families and Teens ▶ Johnson, Susan ▶ Training Emotionally Focused Couples Therapists

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References Arnold, M. B. (1960). Emotion and personality. New York: Columbia Press. Bertalanffy, L. (1968). General system theory: Foundations, development, applications. New York: George Braziller. Bowlby, J. (1982). Attachment and loss: Vol. 1, attachment (2nd ed.). New York: Basic Books. Ekman, P. (2003/2007). Emotions revealed: Recognizing faces and feelings to improve communication and emotional life. New York: St Martin’s Griffin. Gottman, J. (1994). What predicts divorce? Hillsdale: Erlbaum. Huston, T. L., Caughlin, J. P., Houts, R. M., Smith, S. E., & George, L. J. (2001). The connubial crucible: Newlywed years as predictors of delight, distress, and divorce. Journal of Personality and Social Psychology, 80, 237–252. Johnson, S. M. (2004). Creating connection: The practice of emotionally focused couple therapy (2nd ed.). New York: Brunner/Routledge. Johnson, S. M. (2013). Love sense: The revolutionary new science of romantic relationships. New York: Little Brown. Johnson, S. M., & Brubacher, L. L. (2016). Clarifying the negative cycle in emotionally focused couple therapy (EFT). In G. Weeks, S. Fife, & C. Peterson (Eds.), Techniques for the couple therapist: Essential interventions (pp. 92–96). New York: Routledge. Mikulincer, M., & Shaver, P. R. (2016). Attachment in adulthood: Structure, dynamics, and change (2nd ed.). New York: Guilford Press.

Classification in Couples and Families Heather Foran and Laura Restle Alpen-Adria-University Klagenfurt, Klagenfurt, Austria

Synonyms Assessment in Couples and Families; Diagnosis

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1994; Smith et al. 2012; Gouin et al. 2010; Whisman 2007). Early research documented the effects of emotional neglect and attachment processes on children’s development (e.g., Beckett et al. 2006; Manly et al. 2001) and the link between intimate partner relationship distress and mental health (e.g., Hammen 1991; Whisman 2001). More recent studies have documented some of the biological and behavioral mechanisms through which family relationships and maltreatment can impact lifelong health (e.g., Boeck et al. 2017; KiecoltGlaser and Wilson 2017; Thomas et al. 2008). Based on this accumulated literature and the prevalence of these problems, family problems and family maltreatment are considered important public health problems. An important first step in addressing public health problems is proper detection and assessment of the problems in the international classification systems – the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual for Mental Disorders (DSM). Family problems and maltreatment have not been fully included with reliable definitions in these classifications systems in the past (DSM-IV, ICD-10). However, some progress has been made in the DSM-5 and revisions are underway for the ICD-11. Four main types of relational problems have been the focus of the DSM-5 and ICD-11 revisions and will be reviewed here: intimate partner violence, caregiver-child relational problems, intimate partner relationship distress, and child maltreatment. These four types of relationship problems are prevalent, are associated with negative public health impacts, and have definitions with operationalized criteria and assessment tools to support their inclusion in the DSM-5 and ICD11. Further, identification of these four types of relational problems has clear implications for improving communication between health care providers and in improving treatment planning.

Introduction The relevance of intimate partner and family relationships for overall well-being, mental health, and physical health has been established with numerous studies (e.g., Lissau and Sorensen

History of Classification Systems for Relationship Problems Efforts to improve the classification of relational problems can be dated back to the 1970s but change has been slow. During the DSM-IV and

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ICD-10 revisions, relational problems were listed as psychosocial processes of clinical relevance in the “V codes” and “Z codes,” respectively. The DSM-IValso included relational problems in Axis IV and as part of the Global Assessment of Relationship Functioning (GARF), which could be coded on Axis V. The ICD-10 included family maltreatment in other chapters. Family maltreatment could be coded as a “T code” in the Injury, Poisoning and Certain Other Consequences of External Causes chapter and as a “Y code” in the External Causes of Morbidity and Mortality chapter. Unfortunately, the numerous codes and lack of definitional criteria has led to unreliable coding. Moreover, important types of relational problems were left out completely (e.g., child psychological abuse). Overall, the ICD-10 and DSM-IV codes have been underutilized and are used unreliably, which has resulted in limited public health utility. Based on the problems with DSM-IV and ICD10, there was a clear need to work toward more reliable and valid assessments. A Relationship Processes Working Group was established and three meetings with support from the Fetzer Institute took place. The first meeting in May 2005 focused on evaluating the empirical foundation for relational processes in the DSM (Beach et al. 2006). The second meeting in May 2007 focused on the content of proposed criteria. The third meeting in October of 2010 took place in Switzerland in collaboration with experts from the World Health Organization. It focused on the revisions for the ICD-11 with particular attention to cross-cultural relevance and implementation in high and low-resources regions (Foran et al. 2013). The proposal for the ICD-11 revisions were formally submitted in 2011. Field trials for particular categories in the DSM-5 and ICD-11 were conducted. A modified version of the field-tested criteria for relational problems were accepted in the DSM-5, but some operationalizations of the criteria were not included. All DSM-5 relationship processes are included as Z codes in the section, Other Conditions That May be a Focus of Clinical Attention. A Z code, may be the “focus of clinical attention” or

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“affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder”. The ICD-11 proposed definitions, also described below, are more consistent with the field trial tested criteria than those included in the DSM-5. Also, notably, the ICD is more widely used globally and includes not only mental disorders but all causes of disease and disability. The ICD is especially relevant for the integration of relational problems into health care systems and surveillance systems.

Description: Current Criteria for Relational Assessment in the DSM and ICD Intimate Partner Violence Intimate partner violence includes Partner Physical Abuse, Partner Psychological Abuse, Partner Sexual Abuse, and Partner Neglect. The empirical foundation for the criteria is described in depth elsewhere (Foran et al. 2013). The DSM-5 defines Partner Physical Abuse as “nonaccidental acts of physical force that result, or have reasonable potential to result, in physical harm to an intimate partner or that evoke significant fear in the partner have occurred.” The following criteria are categorized into Acts (e.g. shoving, biting, burning), Impacts (physical harm, significant fear, reasonable potential to result in physical harm), and Exclusion (excluding acts for self-protection or protection of other’s from harm). The DSM-5 incorporates field-tested criteria, but did not include the complete criteria set (Heyman et al. 2015). The ICD-11 proposed definition is similar to the DSM-5, but does not list as many examples of nonaccidental physical acts and includes the further operationalization that there must be at least one act of physical force during the past year. The ICD changes to these criteria and other criteria described below were based on the feedback provided by an international working group with expertise in family problems from diverse cultures, disciplines, and countries. Further, criteria were sometimes simplified to make them more usable in low resource settings across HICs and LMICs.

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In the DSM-5 and proposed ICD-11 definitions, Partner Psychological Abuse is defined as nonaccidental verbal or symbolic acts by one partner that result in significant harm to the other partner. Ten examples of acts such as berating or humiliating the victim and stalking the victim are provided. The major difference between the DSM-5 and ICD-11 proposed definitions for Partner Psychological Abuse is that the ICD-11 version includes a more detailed specification of the Impacts criterion (“acts causing or exacerbating at least one of the following impacts: significant fear, significant psychological distress, somatic symptoms that interfere with normal functioning and fear of the recurrence of emotionally abusive act (s) that cause victim to significantly limit any of these five major life activities – work, education, religion, medical or mental health services, and contact with family/friends”). The definitions for Partner Sexual Abuse in the DSM-5 and ICD-11 overlap in that they both include “forced or coerced sexual acts” or “with an intimate partner who is unable to consent” and “whether or not the act is completed.” In the DSM-5, one of the field trial tested criterion has been removed: “physical contact of a sexual nature (e.g., kissing, fondling) is against the expressed wishes of the partner and that causes considerable distress to the partner”. This raises concerns that the DSM-5 definition may leave out certain forms of sexual assault. In contrast to Partner Physical, Sexual, and Psychological Abuse, the definitions for Partner Neglect have not yet been extensively tested in field trials. The DSM-5 describes Partner Neglect as “egregious act or omission by one partner that deprives a dependent partner of basic needs” and the context is given, including examples. “Basic needs” and other terms are not operationalized, which may impact inter-rater reliability. The ICD-11 definition is “egregious acts or omissions that result in physical harm to a spouse or intimate partner who is incapable of self-care.” It differs from the DSM-5 in that the Impacts criterion only includes physical injury or reasonable potential for injury, but not psychological harm. Further work with vulnerable

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populations (e.g., elderly populations) is needed to evaluate these definitions of Partner Neglect and determine the inter-rater reliability. Intimate Partner Relationship Distress Relationship distress with spouse or intimate partner in the DSM-5 is defined as: “[Problematic] quality of the intimate (spouse or partner) relationship or [problematic] relationship quality is affecting the course, prognosis, or treatment of a mental or other medical disorder.” Further, it defines criteria as “impaired functioning in behavioral, cognitive, or affective domains” and lists examples under the following categories: behavioral problems, cognitive problems, and affective problems. Specific examples were excluded since they can be culturally specific. The ICD-11 proposed definition differs in that it includes text to indicate that the relationship distress is severe and long-lasting, which is absent from the DSM-5 definition. It is also more detailed in describing the areas of functioning that can be disturbed and includes the additional areas of physical health, interpersonal interaction, and major life-role activities. The changes made to the DSM-5 and the ICD-11 proposed definitions are more closely in line with definitions of relationship researchers and enables better correspondence with assessment tools which differentiate clinically significant levels of relationship distress from normative levels (Foran et al. 2015). Child Maltreatment Mirroring partner maltreatment, child maltreatment includes four categories in the DSM-5 and ICD-11 proposal: Child Physical Abuse, Child Psychological Abuse, Child Sexual Abuse, and Child Neglect (Slep et al. 2015). Child Physical Abuse and Psychological Abuse follow the same structure as Partner Physical Abuse and Partner Psychological Abuse in which Acts and Impacts are required to be coded as present. The wording of the criteria and the definition of Impacts differ for the DSM-5 and ICD-11 proposed criteria. In the DSM-5 definition, a case in which a caregiver throws a knife at their child’s head, but misses, would not be coded as Child Physical Abuse since

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it did not cause injuries or death. In the ICD-11 proposed criteria, this would be coded as Child Physical Abuse because the additional Impact criterion of “reasonable potential for significant injury.” The definition for Child Psychological Abuse in the DSM-5 reads: “nonaccidental verbal or symbolic acts by a child’s parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child.” The ICD-11 definition is “confirmed or suspected verbal or symbolic acts with the potential to cause psychological harm to the child.” Examples of Acts are similar across the DSM-5 and ICD-11 proposed definitions, but the ICD-11 examples are more specific and the additional example of “purposeful indoctrinating the child to consider a parent evil, dangerous or not worthy of affection” is included. The DSM-5 Impact criterion includes only “psychological harm,” whereas the ICD-11 proposed criteria is more detailed and also includes “reasonable potential for significant psychological harm” (followed by examples), and “stress-related somatic symptoms that interfere with normal functioning.” The Child Sexual Abuse definitions for the DSM-5 and ICD-11 differ in defining the perpetrator. Child Sexual Abuse in the DSM-5 is defined as “any sexual act involving a child that is intended to provide sexual gratification to: A parent, caregiver, or other individual who has responsibility for the child; OR Others (without direct physical contact between child and [other but involving exploitation by the caregiver])”. The ICD-11 defines Child Sexual Abuse as “sexual acts involving a child that are intended to provide sexual gratification to an adult”. An Impact is not required because the Act is considered sufficient to identify Child Sexual Abuse. Acts are divided into physical contact and noncontact exploitation, which are defined through examples. Child Neglect is defined in the DSM-5 as “confirmed or suspected egregious act or omission by a child’s parent or other caregiver that deprives the child of basic age-appropriate needs and thereby results or has reasonable potential to result, in physical or psychological harm to the

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child.” The ICD-11 proposal defines Child Neglect as “confirmed or suspected egregious act (s) or omission(s) by a child’s parent/caregiver that deprive the child of needed age-appropriate care and that result, or have reasonable potential to result, in physical or psychological harm.” Although both the DSM-5 and ICD-11 proposed definitions include Acts with Impacts, Impacts are only operationalized in the ICD-11 proposed definition. Caregiver-Child Relational Problem There is a rich history of research and theory on parent/caregiver-child relational problems using a plethora of measurement approaches at different ages. A problem with the existing validated systems is that they are quite complex and costly, making implementation in low and middle income countries (LMICs) unrealistic. To address this gap, the Relational Processes Working Group set out to develop and test a concise definition of caregiverchild relational problems that could be used as an assessment in epidemiological research and used in both low- and high-resource clinical settings (see Wamboldt et al. 2015). The definition was developed and revised based on feedback from international experts, tested in the DSM-5 field trials and is currently being tested in ICD-11 field trials. As reviewed in Wamboldt et al. (2015), this is a work in progress and will continue to need further testing. Similar to the other relational problems, the code of a caregiver-child relational problem requires evidence of an Act and Impacts. Acts include “pervasive sense of unhappiness with the relationship, parent or child and thoughts” or “running away that are more than transitory.” Impacts include behavioral, cognitive, and affective symptoms similar to the structure of Intimate Partner Relational Distress. The DSM-5 field trial supported the reliability and clinical utility of the definition (Wamboldt et al. 2015). The version ultimately included in the DSM-5 does not match the DSM-5 field trial tested definition, but was rather modified to be more descriptive and less criterion-focused. The effect that these modifications have in terms of inter-rater reliability and clinical utility is in need of further evaluation.

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Application of Concept in Couple and Family Therapy Scientifically-based changes in the DSM-5 and proposed for the ICD-11 codes for family problems and violence have potential to facilitate communication and lead to improved health care services, if used in a reliable and valid way. Findings from the ICD-11 field trial suggest there may be an impact of the new criteria on in the context of a mental health diagnosis. Clinicians who were presented with the ICD-10 codes for adult relational problems compared to those presented with the ICD-11 proposed codes were more likely to underdetect a relational problem when a mental health disorder was also present (Heyman et al. 2017). If a relational problem, such as intimate partner violence, is not detected in the context of a mental health assessment, this could lead to inappropriate treatment planning as illustrated in the clinical example provided in the next section. Rather than only considering psychiatric disorders as presenting problems, the ICD-11 proposed criteria may result in increased detection of relational problems and referrals to couple and family therapy. The current coding structure of the ICD-9 or ICD-10, which is used to allocate health care expenditures in most countries, including the United States, provides limited information to health care providers and policy makers about relational problems. The new criteria sets have potential to provide more reliable documentation of relational problems across health care facilities around the world. This can facilitate communication and referrals to couple and family therapists from health professionals, who may first see cases of family problems and violence, such as in primary care, emergency rooms, pediatric clinics, or gynecological clinics. Couple and family therapists may have a better mechanism to gauge the health economic benefits of their services within the health care system with the proposed ICD changes. Some preliminary studies that have reviewed health care records over time have shown that couple or family therapy results in

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lower service utilization rates for other types of medical problems (e.g., Law and Crane 2000). This type of evaluation of the health cost benefits of couple and family therapy is crucial for addressing reimbursement issues related to treatment and prevention of relational problems within different countries. However, changes in the DSM-5 and ICD-11 are only relevant for public health if they are used widely and reliably. There are many implementation barriers that need to be addressed for this to occur. This will require programs in diverse health care fields to include training in coding of family problems and family violence as a standardized part of the curricula. Close attention to implementation practices of the codes is also required, including quality assurance, among current practitioners across countries. For example, there are some difficulties with exact translation of “nonaccidental,” which is used for the family maltreatment definitions, and this may require additional clarification and training in some languages and cultures. Further, more continuing education opportunities in the area of classification of family problems and violence are also needed. Moreover, coding processes in the DSM-5 and ICD-11 operate within health care systems and in many countries, relationship codes are not reimbursable, which can negatively influence coding and treatment decisions. Couple and family therapists can play an important role in addressing these barriers by increasing interdisciplinary communication and dissemination activities, as well as by engaging in health care policy decisionmaking processes.

Clinical Example Martha is a 27-year-old woman who has been married to her husband, Phillip, for the last five years. Although the relationship was going really well the first few years, Phillip and Martha now argue frequently. The arguments, especially when Phillip is drinking, often end with them screaming at each other and her crying herself to sleep. Martha has considered getting divorced, but when she

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suggested this to Phillip, he threatened her and said, “If you even think about that, you are going to regret it.” Martha has become increasingly fearful for her safety. She is experiencing frequent headaches and stomach pains. She feels hopeless about her situation and is not sure what to do. Option 1: No diagnosis; Treatment of physical symptoms Martha goes to see her primary care doctor, Dr. Meet, and tells her about her headaches and stomach pains. Dr. Meet does not identify any medical diagnosis and prescribes her some pain medication for her headaches. She returns home to Phillip. Option 2: Diagnosis without considering a relationship problem or violence Martha goes to see her primary care doctor, Dr. Meet, and tells her about her headaches, stomach pains, anxiety, and feelings of hopelessness. Dr. Meet asks Martha to complete a brief screening tool for depression and anxiety disorders; her score on the PHQ was 8 and her score on the GAD-7 was 12. Dr. Meet diagnoses her with generalized anxiety disorder and prescribes her an anxiolytic medication and some pain medication. She returns home to Phillip. Option 3: Diagnosis with consideration of a relational problem and violence (Biopsychosocial approach) Martha goes to see her primary care doctor, Dr. Meet, and tells her about her headaches, stomach pains, anxiety, and feelings of hopelessness. Dr. Meet asks Martha to complete a brief screening instruments for depression and anxiety disorders, as well as relational problems and violence. After noting Martha’s response on the screener for clinically significant psychological abuse and intimate partner relationship distress, Dr. Meet provides a referral to a practitioner, Dr. Smith, who specializes in couple and family problems; she works in the integrated primary care clinic, too. She is able to meet with her 30 min later. The ICD/DSM codes for Intimate Partner

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Relationship Distress and Partner Psychological Abuse are coded as the presenting problems. The initial session focuses on developing an immediate safety plan for Martha as well as conducting a behavioral and family health assessment.

References Beach, S. R. H., Wamboldt, M. Z., Kaslow, N. J., Heyman, R. E., First, M. B., Underwood, L. G., & Reiss, D. (Eds.). (2006). Relational processes and DSMV: Neuroscience, assessment, prevention, and treatment. Washington DC: American Psychiatric Publishing Inc. Beckett, C., Maughan, B., Rutter, M., Castle, J., Colvert, E., Groothues, C., et al. (2006). Do the effects of early severe deprivation on cognition persist into early adolescence? Findings from the English and Romanian adoptees study. Child Development, 77, 696–711. Boeck, C., Koenig, A. M., Schury, M. L., Geiger, M. L., Karabatsiaskis, A., Wilker, S., et al. (2017). The involvement of mitochondria in chronic low-grade inflammation associated with maltreatment experiences during childhood. Brain, Behavior, and Immunity, 66, e9. Foran, H. M., Beach, S. R. H., Slep, A. M. S., Heyman, R. E., Wamboldt, M. Z., Kaslow, N., & Reiss, D. (Eds.). (2013). Family violence and family problems: Reliable assessment and the ICD-11. New York: Springer. Foran, H. M., Whisman, M. A., & Beach, S. R. H. (2015). Intimate partner relationship distress in the DSM-5. Family Process, 54, 48–63. (Special Issue). Gouin, J. P., Carter, C. S., Pournajafi-Nazarloo, H., Glaser, R., Malarkey, W. B., Loving, T. J., et al. (2010). Marital behavior, oxytocin, vasopressin, and wound healing. Psychoneuroendocrinology, 35, 1082–1090. Hammen, C. (1991). Generation of stress in the course of unipolar depression. Journal of Abnormal Psychology, 100, 555–561. Heyman, R. E., Slep, A. M. S., & Foran, H. M. (2015). Enhanced definitions of intimate partner violence for DSM-5 and ICD-11 may promote improved screening and treatment. Family Process, 54, 17–32. Heyman, R. E., Kogan, C. S., Foran, H. M., Burns, S. C., Slep, A. M. S., Wojda, A. K, Keeley, J. W., Rebello, T. J., & Reed, G. M. (2017). A case-controlled field study evaluating ICD-11 proposals for relational problems and family maltreatment. Unpublished manuscript. New York University. Kiecolt-Glaser, J. K., & Wilson, S. J. (2017). Lovesick: How couples’ relationships influence health. Annual Review of Clinical Psychology, 13, 421–443. Law, D., & Crane, D. (2000). The influence of marital and family therapy on health care utilization in a health

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454 maintenance organization. Journal of Marital and Family Therapy, 26, 281–291. Lissau, I., & Sorensen, T. I. (1994). Parental neglect during childhood and increased risk of obesity in young adulthood. Lancet, 343, 324–327. Manly, J. T., Kim, J. E., Rogosch, F. A., & Cicchetti, D. (2001). Dimensions of child maltreatment and children’s adjustment: Contributions of developmental timing and subtype. Development and Psychopathology, 13, 759–782. Slep, A. M. S., Heyman, R. E., & Foran, H. M. (2015). Child maltreatment: Definitions of relational processes in DSM-V and ICD-11. Family Process, 54, 17–32. Smith, T. W., Uchino, B. N., Berg, C. A., & Florsheim, P. (2012). Marital discord and coronary artery disease: A comparison of behaviorally defined discrete groups. Journal of Consulting and Clinical Psychology, 80, 87–92. Thomas, C., Hypponen, E., & Power, C. (2008). Obesity and type 2 diabetes risk in mid-adult life: The role of childhood adversity. Pediatrics, 121, 1240–1249. Wamboldt, M., Cordaro, A., & Clarke, D. (2015). Parentchild relational problem: Field trial results, changes in the DSM-5, and proposed changes for the ICD-11. Family Process, 54, 33–47. Whisman, M. A. (2001). The association between depression and marital dissatisfaction. In S. R. H. Beach (Ed.), Marital and family processes in depression (pp. 3–24). Washington, DC: American Psychological Association. Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116, 638–643.

CLFC Fatherhood Program Ted N. Strader1,2, Christopher Kokoski1, David Collins3, Steven Shamblen3 and Patrick Mckiernan4 1 Council on Prevention and Education: Substances (COPES), Louisville, KY, USA 2 CLFC National Training Center, Resilient Futures Network, LLC, Louisville, KY, USA 3 Pacific Institute for Research and Evaluation (PIRE), Beltsville, MD, USA 4 University of Louisville, Louisville, KY, USA

Name of Model The Creating Lasting Family Connections ® Fatherhood Program: Family Reintegration (CLFCFP)

CLFC Fatherhood Program

Introduction The Creating Lasting Family Connections Fatherhood Program (CLFCFP) is a manualized intervention designed to help men (and women) in paternal roles experiencing (or at risk for) family dissonance through any form of physical or emotional separation who wish to return to their paternal role in their own family and community. Family separation might be due to marital difficulties, military service, mental health or substance use disorder treatment, incarceration, outof-town work assignments, or other challenging circumstances. The CLFCFP consists of three standard modules (parenting and family relationship skills, effective communication/refusal skills and family alcohol and other drug prevention and intervention) delivered in 16 to 18 two-hour sessions. CLFCFP is designed to modify the attitudes of participants and help them to (1) strengthen families and establish strong family harmony, (2) enhance parenting skills for intergenerational prevention, and (3) minimize the likelihood of further personal problems for all family members (e.g., substance use, violence, risky sexual behavior, prison recidivism). The Three Standard CLFCFP Modules Raising Resilient Youth. Participants learn and practice effective communication skills to use with their families, friends, and co-workers, including listening to and validating others’ thoughts and feelings. Participants also enhance their ability to develop and implement expectations and consequences with others, including spouses, coworkers, friends, and children. This training enhances a sense of competence for achieving connectedness and bonding between marriage partners, parents and children, and workplace relationships (Strader and Noe 1998a). Getting Real. Participants examine their responses to the verbal and nonverbal communication they experience with others. In a group setting, participants receive personalized coaching on effective communication skills, including speaking with confidence and

CLFC Fatherhood Program

sensitivity, listening to and validating others, sharing feelings, and matching body language with verbal messages. This promotes the skills of self-awareness and mutual respect while focusing on helping participants combine thoughts, feelings, and behavior in a way that leads them to generate powerful, meaningful, and palatable messages to others (Strader et al. 1998). Developing Positive Parental Influences. Participants develop a greater awareness of facts and feelings about substance use, abuse, and dependency; review effective approaches to prevention; and develop a practical understanding of intervention, referral procedures, and treatment options. This module includes an examination of childhood and family experiences involving alcohol/drugs, personal and group feelings, and attitudes toward alcohol and drug issues, as well as an in-depth look at the dynamics of chemical dependency and its impact on relationships and families (Strader and Noe 1998b). The CLFCFP program also includes an optional module covering HIV prevention (2 to 3 sessions that may include HIV testing) for at-risk populations: The ABC 3(D) Approach to HIV, Hepatitis and Other Sexually Transmitted Diseases Prevention. This optional module is a candid examination of the primary modes of transmission of HIV, hepatitis, and other sexually transmitted diseases. This training concludes with effective preventive measures to reduce or eliminate risk of infection. Healthy sexual expression is recognized, discussed, and supported (Strader 2012). The CLFCFP includes case management and referral capability. A 6- to 9-day CLFCFP Certification Training is required for access to implementation materials. The CLFC Fatherhood Program is one of three programs comprising the Creating Lasting Family Connections (CLFC) Curriculum Series. The Series also includes the Original CLFC Program and the CLFC Marriage Enhancement Program. The CLFC Curriculum Series addresses the intergenerational and chronic nature of addiction and the family’s role in both recovery and

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prevention. The CLFC Series represents the intersection of treatment and prevention services for families (Strader et al. 2013). Each of the three CLFC programs is separately listed on SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP).

Prominent Associated Figures Drawing on earlier works with Dr. Tim Noe and Warrenetta Crawford Mann, the CLFC Fatherhood Program was developed in the early 2000s by Ted N. Strader, M.S., a Certified Chemical Dependency Counselor, a Certified Prevention Specialist and Executive Director of the Council on Prevention and Education: Substances, Inc. Teresa Strader, L.C.S.W, and Christopher Kokoski assisted with the development of support materials. The CLFCFP curriculum has been recognized on the National Registry of Evidence-based Programs and Practices (NREPP) and as a winner of the Exemplary Program Award provided by the National Association of State Alcohol and Drug Abuse Directors, SAMHSA’s Center for Substance Abuse Prevention and the National Prevention Network. In 2013, the John C. Maxwell Leadership Team named Mr. Strader one of the top 10 leaders in the USA serving youth and families.

Theoretical Framework The CLFC Fatherhood Program integrates an eclectic combination of personal, couple, family, and community strengthening theoretical frameworks. These frameworks are translated into a structured series of sequential, developmental, and experiential activities for participants. CLFCFP incorporates Experiential Learning Theory (Kolb 1975) by providing an interactive program with a strategic mix of role plays, games, brainstorms, guided imagery, reflective exercises, demonstrations, and group discussions. Participants are invited to involve themselves in practicing or “experiencing” the ideas, concepts, and skills shared in the sessions and to engage in reflective thought and group discussion (Johnson 1997; Satir 1983).

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Risk and Resiliency Theory (Hawkins et al. 1992) serves as a major underpinning of the program. Specific exercises build resiliency across the domains of self, family, work, and community. Building from strengths, the program focuses on both intra- and interpersonal skill development including verbal and nonverbal communication (with an emphasis on listening and validation), how to say no (refusal skills) and family management practices to help prevent negative outcomes and mitigate known risk factors. Further, CLFCFP combines Social Learning Theory (Bandura 1977) and Therapeutic Alliance (Bordin 1979) through the positive rapport established between staff and participants and through staff modeling of appropriate relationship behaviors. Developing respected interpersonal connections is key in promoting growth in both personal and family behavioral dynamics. For example, in the group “educational sessions,” two program staff serve in roles often perceived more as facilitators of information and role models of new possibilities rather than as “therapists.” A range of nonjudgmental, inclusive, and positive facilitation skills (Strader and Stuecker 2012) result in a Therapeutic Alliance between the CLFCFP trained facilitators and participants. This alliance can be carried into private case management sessions that, when needed, can lead to deeper personal work or other necessary referrals for more specific therapeutic interventions. Key elements of Cognitive Behavioral Therapy (Beck 1993) are incorporated into group exercises. Participants are invited to participate in a process of individualized coaching and personal reflection to examine new possible ways to self-correct unhelpful thinking and behaviors. CLFCFP integrates this system of established theories which are expressed in the program design, exercises, activities, and implementation protocols. Each of these theories relates to the central belief described in Building Healthy Individuals, Families and Communities that “deep healthy connections build strong protective shields to prevent harm and to provide both nurturing and healing support” (Strader et al. 2000, p. 17). The book refers to this concept as “connect-immunity.”

CLFC Fatherhood Program

Populations in Focus The CLFC Fatherhood Program was developed for Caucasian and African American men (and women in paternal roles) from urban, suburban, and rural areas in the US experiencing (or at risk for) family dissonance through any form of physical or emotional separation who wish to return to their paternal role in their own family and community. Family separation might be due to marital difficulties, military service, mental health or substance use disorder treatment, incarceration, outof-town work assignments, or other challenging circumstances. The program is implemented in gender-specific (all male or all female) groups of selective and indicated populations as designated by the Institute of Medicine (IOM) Classification System.

Strategies and Techniques Used in Model The CLFC Fatherhood Program incorporates a rich variety of strategies and techniques to appeal to the full range of adult learning styles, cultural differences, personalities, and preferences. Learning strategies and techniques include brief lectures, role plays, guided imagery, reflections, discussions, brainstorms, facilitator demonstrations, storytelling, and interactive games. CLFCFP facilitators are trained and certified to implement the program. CLFCFP provides facilitators of differing gender, age, race, and experience to relate to the largest number of participants. CLFCFP facilitators role model the skills of the CLFC Fatherhood Program, therefore providing information within a relational and nonjudgmental context. Facilitators listen and validate participant thoughts and feelings, provide clear and sensitive feedback, and express their own emotions as a means to manage group participation and interaction throughout the program sessions. The concept of “influence versus control” is threaded throughout the entire CLFC Fatherhood Program. Facilitators both role model and manage the program under the belief that participants learn best when they can voluntarily choose their

CLFC Fatherhood Program

own preferred level of participation (i.e., active discussion, interactive practice, quiet listening, etc.) for each activity in each program session. Throughout the CLFC Fatherhood Program, facilitators incorporate motivational interviewing and trauma-informed care techniques into interactions with participants (Strader and Stuecker 2012). Culturally sensitive case management and ongoing supports supplement the program content. Facilitators refer participants to appropriate service providers, as needed.

Research About the Model The CLFC Fatherhood Program was implemented in two projects, funded by Substance Abuse and Mental Health Services Administration (SAMHSA) and the Administration for Children and Families (ACF) between 2005 and 2011, with 345 and 500 participants, respectively. Participants had received substance abuse treatment while incarcerated. Both projects included all four CLFCFP modules and case management services. In the SAMHSAfunded project, there were 249 individuals in the intervention group and 96 in a comparison group. Participants were predominately male, in their mid-thirties, of low socioeconomic status, and 53% in both groups were reportedly African-American. A majority had a high school diploma or GED. In the ACF-funded project, there were 387 individuals in the intervention group and 113 individuals in the treatment as usual comparison group. Most were in their mid-thirties. Almost two-thirds (62%) were White and 37% African-American. Less than half were employed at baseline. A majority had a high school diploma or GED. Most reported having a child. For the SAMHSA-funded project, questionnaires completed at three waves included demographic data and measures of substance use and other behaviors, risk, and protective factors. Recidivism data were provided by the KY Department of Corrections for this project. For the ACF-funded project, questionnaires at three waves included measures of nine relationship

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skills (e.g., communication skills, conflict resolution skills, emotional awareness, relationship satisfaction). Recidivism data were provided by the KY Department of Corrections for this project as well. For both projects, the evaluation examined whether the changes in the intervention group were more positive than the changes in the comparison group. Hierarchical Linear Modeling (HLM) was used for nearly all analyses. For recidivism, a simple logistic regression analysis was used. Results for the SAMHSA-funded project showed intervention significant effects on HIV knowledge, spirituality, and intentions to binge drink. Results for the ACF-funded project showed intervention effects on nine separate relationship skills. At follow-up, results showed that for program participants in the first project the odds of recidivating were 3.7 times less likely than for participants in the comparison group. Similarly, for the second project, the odds of recidivating for the program participants were 2.9 times less likely than for the comparison participants (McKiernan et al. 2013). In another SAMHSA-funded project (Collins et al. 2017), the CLFCFP program was implemented with African-American females. The same modules were used as in the standard CLFCFP program, with sensitivity to the African-American female target population. The program was implemented with 175 women and their results were compared to a convenience sample of 44 women who were similar on background characteristics. Results showed significant increases in the proportion of individuals getting HIV tested and getting the results from the tests, a larger decrease in intimate partner abuse over the past 3 months, and larger increases in all three relationship skills measured relative to the comparison group.

Case Example Having been recently released from prison, Austin (fictitious name used here to protect his identity) chose to voluntarily participate in the

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CLFC Fatherhood Program (CLFCFP) from October 2012 to February 2013 as part of his reentry aftercare plan. Even as he answered the questions on the Screening and Program Placement Survey, he began to understand the destructive nature of his relationship with substances. While quietly participating at first, Austin warmed up to the two program facilitators and connected to the entire group that included several other previously incarcerated individuals. In the Developing Positive Parental Influences module, Austin began to understand how powerfully his addiction had affected his relationship with his children. Subsequently, Austin recommitted to attending his Alcoholics Anonymous meetings. Six weeks into the program, Austin voluntarily accepted and completed a referral to an economic stability program on job search and job readiness skills at Goodwill Industries through which he eventually gained part-time employment. As Austin volunteered for several role-plays in the Getting Real module, he made a second discovery. In one of the role plays, he exclaimed, “I never realized how much my tone of voice and the words I use affected other people.” He made a personal and public commitment to the group to “do better” for his children by trying to use a more sensitive tone and choosing words that were less likely to hurt his children’s feelings. Austin had another realization during the Raising Resilient Youth module. He discovered how to manage his feelings by embracing and nurturing them instead of ignoring them or covering them up with episodes of intoxication. He commented: “I can’t wait to share this with my kids.” After finishing the CLFCFP, Austin reported excitement because he acted upon his dream to enroll in college. Subsequently, Austin successfully completed his first year of college while maintaining his part-time position. Later Austin reported that he had obtained a full-time position doing sanitation work, while maintaining his sobriety and continuing to attend his Alcoholics Anonymous meetings. He also completed all requirements of his parole and reported that he now has more time to spend with his two children.

CLFC Fatherhood Program

Cross-References ▶ Creating Lasting Family Connections Program

References Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice Hall. Beck, A. T. (1993). Cognitive therapy of substance abuse. New York: Guilford Press. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. Collins, D. A., Shamblen, S. R., Strader, T. N., & Arnold, B. B. (2017). Evaluation of an evidencebased intervention implemented with African-American women to prevent substance abuse, strengthen relationship skills, and reduce risk for HIV/AIDS. AIDS Care, 29(8), 966–973. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64–105. Johnson, D. W. (1997). Reaching out: Interpersonal effectiveness and self-actualization. Boston: Allyn & Bacon. Kolb, D. A., & Fry, R. (1975). Toward an applied theory of experiential learning. In C. Cooper (Ed.), Theories of group process. London: Wiley. McKiernan, P., Shamblen, S., Collins, D., Strader, T., & Kokoski, C. (2013). Creating lasting family connections: Reducing recidivism with community-based family strengthening model. Criminal Justice Policy Review, 24, 94–122. Satir, V. (1983). Conjoint family therapy. Palo Alto: Science and Behavior Books. Strader, T. N. (2012). ABC 3(D) approach to HIV, hepatitis and other sexually transmitted diseases prevention trainer manual and participant notebook for the creating lasting family connections ® program. Louisville: Resilient Futures Network. Strader, T. N., & Noe, T. (1998a). Raising resilient youth training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., & Noe, T. D. (1998b). Developing positive parental influences training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., & Stuecker, R. (2012). Creating lasting family connections ®: Secrets to successful facilitation. Louisville: Resilient Futures Network, LLC. Strader, T. N., Noe, T. D., & Crawford-Mann, W. (1998). Getting real training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network.

CLFC Marriage Enhancement Program Strader, T. N., Noe, T., & Collins, D. (2000). Building healthy individuals, families, and communities: Creating lasting connections. New York: Kluwer/ Plenum Publishers. Strader, T. N., Kokoski, C., & Shamblen, S. R. (2013, July 25). Intersection of treatment and prevention: Prevention and recovery-informed care. SAMHSA Recovery to Practice E-Newsletter, 14. Retrieved from http://www.npnconference.org/wp-content/uploads/ 2017/09/Strader-Kokoski-Shamblen-ENewsletter.pdf.

CLFC Marriage Enhancement Program Ted N. Strader1,2, Christopher Kokoski1, David Collins3, Steven Shamblen3 and Patrick Mckiernan4 1 Council on Prevention and Education: Substances (COPES), Louisville, KY, USA 2 CLFC National Training Center, Resilient Futures Network, LLC, Louisville, KY, USA 3 Pacific Institute for Research and Evaluation (PIRE), Beltsville, MD, USA 4 University of Louisville, Louisville, KY, USA

Name of Model The Creating Lasting Family Connections ® Marriage Enhancement Program (CLFCMEP)

Introduction The Creating Lasting Family Connections ® Marriage Enhancement Program (CLFCMEP) is a manualized program for couples in which one or both partners have been physically and/or emotionally distanced because of relational difficulties or separation due to military service, mental health, or substance use disorder treatment, incarceration, out-of-town work assignments, or other challenging circumstances. Relying largely on cognitive change and relational skills training, the goal of CLFCMEP is to build and/or strengthen a couple’s relationship skills by providing structured opportunities for

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participants to develop greater self-awareness and an increased capacity for communication, conflict resolution, emotional awareness, emotional expression, commitment, and trust. Two certified trainers implement the modulebased program with a group of 4 to 15 couples through one of the following implementation options: (1) an 8- to 10-session format (with 2-h sessions), (2) a 2- to 3-day weekend retreat format, or (3) an 18- to 20-session format (with 2-h sessions), which includes all modules. A 3- to 5-day CLFCMEP Certification Training is required for access to implementation materials. CLFCMEP includes three instructional, interactive, and stand-alone training modules in the following three skill areas: • The Marriage Enhancement module consists of 12 marriage-focused, facilitator-guided exercises designed to strengthen marriage through the learning of open, nondefensive communication skills. Partners develop a shared vision, review family of origin experiences, recognize the difference between thoughts and feelings and how they are separate but related, recognize both positive and negative traits in each partner, understand partner needs and how to practice active listening and echoing, provide emotional validation and compassion, and learn to use effective strategies for conflict resolution (Strader 2012). • The Getting Real module is designed to enhance marital relationships through clear and honest communication, and the setting of boundaries through guided role plays that involve saying “No” with warmth and firmness coupled with deep sensitivity and compassion (Strader et al. 1998). • The Developing Positive Parental Influences module is intended for couples interested in positively influencing their children or other family members. Participants are expected to develop a greater awareness of facts and feelings about drug use and dependence; to examine childhood and family experiences involving alcohol/drugs; to review effective approaches to prevention; and to develop a practical understanding of intervention,

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referral procedures, and treatment and recovery options. This module also examines attitudes toward alcohol and drug issues, the dynamics of chemical dependence, and its impact on marriages and families (Strader and Noe 1998). Case management is a critical component of CLFCMEP, and program implementers are strongly encouraged to understand how to assess a wide variety of needs of participants and link them to additional support services in the community. The CLFC Marriage Enhancement Program is one of three programs comprising the Creating Lasting Family Connections ® (CLFC) Curriculum Series. The Series also includes the Original CLFC Program and the CLFC Fatherhood Program: Family Reintegration. The CLFC Curriculum Series addresses the intergenerational and chronic nature of addiction and the family’s role in both recovery and prevention. The CLFC Series represents the intersection of treatment and prevention services for families (Strader et al. 2013). Each of the three CLFC programs is separately listed on SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP).

Prominent Associated Figures Drawing on earlier works with Dr. Tim Noe and Warrenetta Crawford Mann, the CLFC Marriage Enhancement Program was developed in the early 2000s by Ted N. Strader, M.S., a Certified Chemical Dependency Counselor, a Certified Prevention Specialist and Executive Director of the Council on Prevention and Education: Substances, Inc. Teresa Strader, L.C.S.W, Brooke Arnold and Christopher Kokoski assisted with the development of support materials. The CLFCMEP curriculum has been recognized on the National Registry of Evidence-based Programs and Practices (NREPP). In 2013, the John C. Maxwell Leadership Team named Mr. Strader one of the top 10 leaders in the USA serving youth and families.

CLFC Marriage Enhancement Program

Theoretical Framework The CLFC Marriage Enhancement Program integrates an eclectic combination of personal, couple, family, and community strengthening theoretical frameworks. These frameworks are translated into a structured series of sequential, developmental, and experiential activities for participating couples. CLFCMEP incorporates Experiential Learning Theory (Kolb 1975) by providing an interactive program with a strategic mix of role plays, games, brainstorms, guided imagery, reflective exercises, demonstrations, and group discussions. Participants are invited to be open-minded in order to involve themselves in practicing or “experiencing” the ideas, concepts, and skills shared in the sessions and to engage in reflective thought and group discussion (Johnson 1997; Rogers 1951). Drawing on the couple and family therapy work of Virginia Satir, Harville Hendrix, and John Bradshaw, the program invites couples to review relational dynamics from early childhood experiences with a specific focus on the effects of a family history of addiction or substance use disorders provided in the Developing Positive Parental Influences module (Bradshaw 1990; Hendrix 1988; Satir 1983). Risk and Resiliency Theory (Hawkins et al. 1992) serves as an underpinning of the program. Specific exercises build resiliency across the domains of self and family. Building from strengths, the program focuses on both intra- and interpersonal skill development including verbal and nonverbal communication (with an emphasis on listening and validation); how to say no (refusal skills); and relationship management practices to help prevent negative outcomes and mitigate known risk factors. Further, CLFCMEP combines Social Learning Theory (Bandura 1977) and Therapeutic Alliance (Bordin 1979) through the positive rapport established between staff and participants and through staff modeling of appropriate relationship behaviors. Developing respected interpersonal connections is key in promoting growth in both personal and family behavioral dynamics. For example, in the group “educational sessions,” two program staff served in roles often perceived more as facilitators of information and role models of new possibilities

CLFC Marriage Enhancement Program

rather than as “therapists.” A range of nonjudgmental, inclusive, and positive facilitation skills (Strader and Stuecker 2012) result in a Therapeutic Alliance between the CLFCMEP trained facilitators and participants. This alliance can be carried into private case management sessions that, when needed, can lead to deeper personal work or other necessary referrals for more specific therapeutic interventions. Key elements of Cognitive Behavioral Therapy (Beck 1993) are incorporated into group exercises. Participants are invited to participate in a process of individualized coaching and personal reflection in order to self-correct unhelpful thinking and behaviors. CLFCMEP integrates this system of established theories, which are expressed in the program design, exercises, activities, and implementation protocols. Each of these theories relates to the central belief described in Building Healthy Individuals, Families and Communities that “deep healthy connections build strong protective shields to prevent harm and to provide both nurturing and healing support” (Strader et al. 2000, p. 17). The book refers to this concept as “connect-immunity.”

Populations in Focus The CLFC Marriage Enhancement Program is designed for married or committed couples in which one or both partners have been physically and/or emotionally distanced because of relational difficulties or separation due to military service, mental health, or substance use disorder treatment, incarceration, out-of-town work assignments, or other challenging circumstances.

Strategies and Techniques Used in Model The CLFC Marriage Enhancement Program incorporates a rich variety of strategies and techniques to appeal to the full range of adult learning styles, cultural differences, personalities, and preferences. Learning strategies and techniques include brief lectures, role plays, guided imagery, reflections, discussions, brainstorms, and

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facilitator demonstrations. CLFCMEP facilitators are trained and certified to implement the program. CLFCMEP provides facilitators of differing gender, age, race, and experience to relate to the largest number of participants. CLFCMEP facilitators role model the skills of the CLFC Marriage Enhancement Program and provide information within a relational and nonjudgmental context. Facilitators listen and validate participant thoughts and feelings, provide clear and sensitive feedback, and express their own emotions as a means to manage group participation and interaction throughout the program sessions. The concept of “influence versus control” is threaded throughout the entire CLFC Marriage Enhancement Program. Facilitators both role model and manage the program under the belief that participants learn best when they can voluntarily choose their own preferred level of participation (i.e., active discussion, interactive practice, quiet listening, etc.) for each activity in each program session. Throughout the CLFC Marriage Enhancement Program, facilitators incorporate motivational interviewing and trauma-informed care techniques into interactions with participants (Strader and Stuecker 2012). Culturally sensitive case management and ongoing support supplements the program content. Facilitators refer participants to appropriate service providers, as needed.

Research About the Model The CLFC Marriage Enhancement Program was implemented through a “Healthy Marriage Initiative” grant from the Administration for Children and Families from 2006 to 2011. Participants were 250 married individuals (with at least one partner who was recently released from either prison or substance abuse treatment, or both) who voluntarily participated in the intervention group (n = 230) or a program typically offered to those being released from prison (n = 20). The individuals were predominately African-American (57%) or Caucasian (40%). 45% lived with their spouse, 83% had children, and about two-thirds reported living with their children and being independently housed. Most had a high school diploma or GED and 54% were employed.

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Questionnaires were completed at each of three waves that included items about nine relationship skills. Analyses examined whether there were changes over time among participants in the intervention group. A convenience sample of comparable husbands being released from prison allowed for an examination of this change for male intervention participants compared to male comparison participants who were receiving treatment as usual aftercare services. Hierarchical Linear Modeling (HLM) was used in nearly all analyses to examine whether there was differential change in relationship skills between 115 husbands in intervention group and 20 husbands in comparison group. Relationship skills remained relatively constant for the comparison group, but improved for the intervention group. Specifically, the targeted skills showed a large increase between pre- and posttest for the intervention group and the level of relationship skills increased slightly between posttest and follow-up. Pattern of changes in relationship skills was nearly identical for husbands and wives (Shamblen et al. 2013).

Case Example At first, Isabell and her spouse Derek (fictitious names are used to protect true identities) were hesitant to participate in the CLFC Marriage Enhancement Program. Derek had a history of past arrests and brief incarceration, and both reported that they were in substance abuse recovery. In the Screening and Program Placement Survey meeting, the couple indicated they had all but given up on their marriage. They agreed that there was probably nothing they could learn that would help them communicate. However, they decided to try something anyway because they had heard about the “Marriage Class” (CLFCMEP) from some friends who were also in recovery. In an early exercise where Derek and Isabell listed their goals for their marriage, both were pleasantly surprised to see how much their personal hopes for their relationship aligned. Isabel noted with excitement that one of Derek’s goals was that their daughter would have two loving

CLFC Marriage Enhancement Program

parents while growing up. Next, the couple made some connections between the hurt and pain they felt growing up in their own families and, in Derek’s case, the frustrations he was feeling in this relationship. This provided Derek and Isabell with deeper insight into themselves, their relationship and how their earlier family life was affecting their expectations, interactions, and responses to each other. As the program progressed, they learned and practiced the skills of active listening and validating each other’s thoughts and feelings with compassion. When they realized that Isabell was trying to “re-parent” Derek by being controlling, they made a powerful, positive shift by working together to uncover and nurture Derek’s past hurts and address some of his unmet needs. This realization gave both Derek and Isabell greater insight and compassion into the ongoing challenges in their relationship. Derek said, “Wow! I think we’re learning how to fight fair.” Near the end of CLFCMEP, they both committed to taking several small actions every day or every week as an expression of love for each other to help rejuvenate the romantic feelings they had experienced in the early stages of their relationship. Ten weeks later they reported that their relationship went from feeling very distant to closer than ever now that Isabell was less controlling and more understanding of Derek’s needs. Isabell stated that Derek was now showing more sensitivity to her emotional needs too. At a 6-month follow-up session, they both reported that they are now able to listen to each other and respect how each other are feeling – something they reported that they could not do before the program. Isabell thanked the CLFCMEP facilitators most of all for showing her that her feelings are real and deserve her and her husband’s attention and nurturance. She also stated that her participation in the sessions changed her outlook on herself-worth. Derek said he felt hopeful and excited because he thought it was important that their young daughter could now have two loving parents for years to come.

Cross-References ▶ Creating Lasting Family Connections Program

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References Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice Hall. Beck, A. T. (1993). Cognitive therapy of substance abuse. New York: Guilford Press. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. Bradshaw, J. E. (1990). Homecoming: Reclaiming and championing your inner child. New York: Bantam Books. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64–105. Hendrix, H. (1988). Getting the love you want: A guide for couples. New York: Henry Holt and Company. Johnson, D. W. (1997). Reaching out: Interpersonal effectiveness and self-actualization. Boston: Allyn & Bacon. Kolb, D. A., & Fry, R. (1975). Toward an applied theory of experiential learning. In C. Cooper (Ed.), Theories of group process. London: Wiley. Rogers, C. (1951). Client-centered therapy: Its current practice, implications and theory. London: Constable. Satir, V. (1983). Conjoint family therapy. Palo Alto: Science and Behavior Books. Shamblen, S., Arnold, B. B., McKiernan, P., Collins, D. A., & Strader, T. N. (2013). Applying the creating lasting family connections marriage enhancement program to high-risk marriages. Family Process, 52(3), 477–498. Strader, T. N. (2012). Marriage enhancement program trainer manual and participant notebook for the creating lasting family connections® program. Louisville: Resilient Futures Network. Strader, T. N., & Noe, T. D. (1998). Developing positive parental influences training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., & Stuecker, R. (2012). Creating lasting family connections ®: Secrets to successful facilitation. Louisville: Resilient Futures Network, LLC. Strader, T. N., Noe, T. D., & Crawford-Mann, W. (1998). Getting real training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., Noe, T., & Collins, D. (2000). Building healthy individuals, families, and communities: Creating lasting connections. New York: Kluwer/Plenum Publishers. Strader, T. N., Kokoski, C., & Shamblen, S. R. (2013, July 25). Intersection of treatment and prevention: Prevention and recovery-informed care. SAMHSA Recovery to Practice E-Newsletter, 14. Retrieved from http://www.npnconference.org/wp-content/uploads/ 2017/09/Strader-Kokoski-Shamblen-ENewsletter.pdf.

Client-Therapist System in Integrative Problem Centered and Integrative Systemic Therapy William M. Pinsof Pinsof Family Systems, LLC, Chicago, IL, USA

Introduction The Integrative Problem Centered (Pinsof 1995) and Integrative Systemic Therapy (Pinsof et al. 2017) perspectives define the therapeutic playing field as consisting of the client system and the therapist system, which together constitute the therapy system. This entry explains the derivation, the meaning, and rationale for these concepts.

The Client System Since the 1970s, as the integrative movement emerged in psychotherapy, the movement’s primary concern has been intra-modality integration – primarily integrating individual psychotherapy models. There have also been intra-modality forays in couple therapy and family therapy (Breunlin et al. 1992, 1997). Pinsof (1983, 1995) was the first integrative theorist to encompass inter-modality as well as intramodality integration, initially bringing together individual and family (including couple) therapies (1983) and later integrating them with biological therapies (1995). Integrating across modalities creates the problem of what to call the target system. Individual therapy targets the client or patient, couple therapy targets the couple, and family therapy targets the family. To resolve this dilemma, Pinsof originally proposed the term “patient system” (Pinsof 1983, 1984) and later “client system” (1995), defining it as all of the people involved in the maintenance and/or resolution of the presenting problem. This definition was problem centered, in that the presenting problem defined the client

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system. For instance, with a conflictual couple, the client system for their conflict includes them, possibly their children, their parents (family of origin), and some close friends. With a depressed adolescent boy, in addition to him, the client system includes his family, close friends, and possibly some of his teachers and other people at school. The boundary between the client system and the rest of the people in the clients’ lives is ineluctably ambiguous. The problem with the client system concept is that it is too broad when it comes to the pragmatic decision-making about which members to include directly in therapy. To deal with that problem, Pinsof (1995) differentiated the client system into two distinct subsystems: the direct and indirect client systems. The direct client system consists of all the members of the client system directly involved in therapy at any particular moment. The indirect client system consists of the members of the client system not directly involved at that particular point. The clinical value of the indirect client system concept is that it forces the therapist to be aware and considerate of the members of the client system who are not in therapy room, but who will be affected by his or her interventions into the client system. For instance, in working with a family with a defiant and conduct disordered 10-year-old, the therapist becomes aware that the mother’s mother provides childcare for the identified patient and his siblings most afternoons during the week. It is also clear that the identified patient’s mother has absented herself from providing any discipline or behavioral consequences for her son, deferring instead to her mother or her husband, when he is home. The mother owns and manages her own beauty parlor, which keeps her away from home a good deal of the time. When she is home, she does not want to be the disciplinarian. As the therapist encourages the mother to take more leadership with her son, she asks what impact that might have on her husband’s and her mother’s roles in the family. The therapist asks that question because she understands that her intervention with the mother not only affects the direct system (husband and other

siblings), but it also impacts the indirect system (grandmother), which may in turn impact the direct system (grandmother feeling hurt and withdrawing her support, etc.). The indirect client system concept helps the therapist never forget that his/her interventions with the people in the room (the direct client system) will impact client system members not in the room (the indirect client system), and that those effects may well generate intra-systemic feedback that affects the outcome of therapy. From the client system perspective, the distinction between therapeutic modalities is not what the therapist does in the session, but who is in the room – where in the client system the therapist draws the boundary between direct and indirect systems. The clinical question becomes what is the difference between a transference interpretation and an interaction stimulation in an individual context, a couple context, or a family context? The intervention is not attached to a modality but to the therapy model.

The Therapist System Although family-oriented therapists apply systems theory to their clients, they seldom apply systems theory to the systems of which they are a part, particularly the therapist system. The therapist system consists of all of the people engaged in providing therapy to the client system (Pinsof 1995; Pinsof et al. 2017). Obviously, it includes the therapist. Additionally, it includes any consultants to the therapist, any clinical supervisors and/or co-supervisees of the therapist, and any other therapists working with the client system. As with the client system, the exact boundary between the therapist system and the rest of the therapist’s colleagues, family, and friends is necessarily ambiguous. Like the client system, the therapist system can and should be differentiated into direct and indirect subsystems. Typically the therapist is the only member of the direct system, unless supervisors, consultants, and team members directly enter the session (as in live supervision/consultation). It can

Client-Therapist System in Integrative Problem Centered and Integrative Systemic Therapy

also be useful for therapists who are working with the same client system but have very different perceptions of a client to do a session together to better coordinate their perspectives. The coordination of different therapists working with different members of a client system (e.g., the couple therapist and the individual therapists of each of the partners) is a very difficult task, but the more at odds their perspectives, the more crucial becomes coordination. Obvious examples in which the therapist system can be problematic occur when the therapist and the supervisor are in conflict about a case or when a supervision team is dysfunctional and unable to provide consistent support and guidance to a therapist-member. At these points, the therapist system needs to become a therapeutic target in itself, turning its therapeutic skills on itself or bringing in an external consultant.

The Therapy System The therapy system is the clinical system, organized around a presenting problem that encompasses both the client and the therapist systems. Their physical (who, what, and where) and conversational (what to whom, where) interaction constitutes the interaction between them. The life of a therapy system is co-terminus with an episode of therapy. In essence, two groups of people come together in order to help one group/person solve a

Client System

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Client-Therapist System in Integrative Problem Centered and Integrative Systemic Therapy, Fig. 1 The Therapy Systems. (Adapted from Integrative ProblemCentered Therapy (p. 6) W. M. Pinsof 1995, New York:

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problem for which they are seeking help. Some of the same people may get together for another episode at future points to address a different problem, constituting a different therapy system. A therapy system is a distinct, open, dynamic, and living system,

Therapy Systems and the Therapeutic Alliance To address therapeutic and working alliances within a therapy system, Pinsof and Catherall (1986) and Pinsof (1994, 1995) delineated the Integrative Therapy Alliance Model and scales to measure the alliance. Structurally, this model views alliances existing between all of the possible subsystems in the therapy system. The most renowned systemic alliance is between the direct client system and the direct therapist system, which usually includes the therapist and at least one of the clients. However, it is important to note that Pinsof (1994) delineated within-systems alliances to address alliances between clients and alliances between therapists. Obviously, when clients are not allied with each other (e.g., husband and wife), the therapy will be in trouble, as it will be when therapists working with the same client system are not allied. The working rule is that there needs to be strong alliances between the most important (key) subsystems of the therapy system for therapy to be successful.

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Basic Books. Copyright 1995 by Basic Books, an imprint of Perseus Books, LLC, a subsidiary of Hachette Book Group, Inc. Adapted with permission)

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Conclusion The concepts of the client, therapist, and therapy systems were created to facilitate the complete integration of family and multisystemic thinking and practice into the broader field of integrative psychotherapy. In concert with the concept of indirect and direct subsystems, they were designed to map the terrain of psychotherapy such that therapists, regardless of who is in the therapy room, never forget that they are intervening into, and are themselves, part of larger systems that impact both the process and outcome of any psychotherapy (Fig. 1).

Cross-References ▶ Breunlin, Douglas C. ▶ Catherall, Donald ▶ Integrative Systemic Therapy ▶ Lebow, Jay L. ▶ MacKune-Karrer, Betty ▶ Pinsof, William M. ▶ Schwartz, Richard C. ▶ Therapeutic Alliance in Couple and Family Therapy

References Breunlin, D. C., Schwartz, R. C., & Mac Kune-Karrer, B. (1992). Metaframeworks: Transcending the models of family therapy. San Francisco: Jossey-Bass. Breunlin, D. C., Schwartz, R. C., & Mac Kune-Karrer, B. (1997). Metaframeworks: Transcending the models of family therapy (Rev. ed.). San Francisco: Jossey-Bass. Pinsof, W. M. (1983). Integrative problem centered therapy: Toward the synthesis of family and individual psychotherapies. Journal of Marital and Family Therapy, 9, 19–35. https://doi.org/10.1111/j.17520606.1983.tb01481.x. Pinsof, W. M. (1994). An integrative systems perspective on the therapeutic alliance: Theoretical, clinical, and research implications. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 173–195). Oxford: Wiley. Pinsof, W. M. (1995). Integrative problem-centered therapy: A synthesis of family, individual, and biological therapies. New York: Basic Books.

Closed Systems in Family Systems Theory Pinsof, W. M., & Catherall, D. R. (1986). The integrative psychotherapy alliance: Family, couple, and individual therapy scales. Journal of Marital and Family Therapy, 12, 137–151. https://doi.org/10.1111/j.17520606.1986.tb01631.x. Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J. L., Rampage, C., & Chambers, A. L. (2017). Integrative systemic therapy: Metraframeworks for problem solving with individuals, couples and families. Washington, DC: American Psychological Association Press.

Closed Systems in Family Systems Theory Dawn M. Wirick and Lee A. Teufel-Prida The Family Institute at Northwestern University, Evanston, IL, USA

Name of Theory Closed Systems in Family Systems Theory

Introduction A closed system refers to a self-contained family system that employs impervious boundaries with the outside world (Simon et al. 1985). Due to its impermeable boundary system with extrafamilial contexts, a closed system resists influences to change. Minimal interactions with the outside environment render the family system unable to accommodate significant social demands from external social institutions (Minuchin 1974). Failing to integrate information external to the closed system demonstrates the system’s challenges with navigating the change/continuity continuum. Due to rigid external boundaries and minimal interaction with the extrafamilial environment, family members navigate change/continuity primarily via an internal channel. Therefore, external information used to balance change and continuity does not figure centrally into a closed system, thereby increasing isolation and familial dysfunction (Minuchin 1974).

Closed Systems in Family Systems Theory

Conversely, an open system possesses functionally flexible boundaries with the outside world (Simon et al. 1985). The presence of more permeable boundaries permits a free exchange of information and resources between the family unit and the larger systems. Individual members in an open system navigate the change/continuity continuum by extending the family outward into the larger community space, and as a result, incorporate the exterior culture, into the family system (Kantor and Lehr 1975). An open system incorporates outside information and resources when navigating the change/continuity continuum, thereby making the open system capable of integrating external stimuli and the benefits of resources into the existent internal system.

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level of dysfunction due to its desire to disregard order and to resist change. Eleanor Wertheim in her article entitled, Family unit therapy and the science and typology of family systems (1973), in the Journal, Family Process, proposed a theoretically derived threedimensional typology of family systems. More specifically, she concluded that two subtypes of closed family systems existed, namely closeddisintegrated family system and closed-pseudointegrated family system. In both types of closed family systems, homeostatic control is established through family rules that do not permit feedback from external sources.

Description Prominent Associated Figures Salvador Minuchin (1974) initially outlined the concept of boundaries, in his book, Families and Family Therapy. Minuchin discussed how some families attempt to solely rely upon themselves, independent from the external world, and as the distance between family members decreases, enmeshed boundaries result. According to Minuchin, due to attempted cut-off from the outside world, a closed system may lack the resources needed to adapt and change under stressful circumstances. David Kantor and William Lehr (1975) in their book, Inside the Family: Toward a Theory of Family Process, conceptualized three family types: (1) open, (2) closed, and (3) random. In the open system, they concluded that order and change result from a balanced interaction between a family system and its outside environment. In the closed system, the family attempts to prevent outside influences from entering the system, thereby, resulting in an imbalance between order and change. According to Kantor and Lehr (1975), a closed system attempts to maintain order, while attempting to thwart change. In the random system, there is a general sense of disorganization in which the family system resists change and order. According to Kantor and Lehr (1975), a random family system possesses a high

A closed system is one in which the boundaries between the system and environment prevent outside information from entering the system (Simon et al. 1985). According to Kantor and Lehr (1975), in a closed system, the mechanism that regulates both incoming and outgoing information is governed by an authority figure such as a parent(s). Examples of a closed system include: parental control over social media; lack of parental permission to attend social excursions, scrutiny on the part of parent(s) related to communication with persons outside of the immediate family system; and messages that persons outside of the family cannot be trusted. Goals of a closed system are centered around privacy, self-protection, and in some family systems, secretiveness. Members who abide by the rules of maintaining privacy and secrets are rewarded, whereas those who attempt to share information with outsiders are punished. Above all, privacy is to be maintained by all members. Likewise, in accordance with preservation of privacy, closed systems employ formal teaching processes centered around maintaining key family themes, traditions, and values as a transgenerational process. Boundaries, as defined by Minuchin (1974), indicate that a closed system employs rigid boundaries with the outside world, while employing enmeshed boundaries within the

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family system. In closed systems, family members may employ overly protective measures to shield a child from the outside world while employing overly submissive behaviors within the system, thereby demonstrating enmeshed intrafamily boundaries. By isolating from the outside world, family members overly rely upon one another for resource management, information, and need gratification. According to Wertheim (1973), a closed family system, homeostatically, is controlled by firmly established family rules with little acceptance for spontaneous feedback either from the individual within or from systems external to the family unit. In addition, Wertheim’s conceptualization of a closed system-disintegrated type highlighted a low level of consensual morphostasis. Consensual morphostasis is derived from an appropriately balanced, intrafamily distribution of power. The term, consensual morphostasis refers to genuine stability of the family system that is consensually validated by its members (Wertheim 1973). Another form of closed system conceptualized by Wertheim (1973) was the closed system-pseudointegrative type. In this type of closed system, there is a high level of forced morphostasis. Forced morphostasis is rooted in intrafamily power imbalance. The term is synonymous with pseudomutuality, as coined by Wynne et al. (1958), and refers to an apparent stability of the family system, when there is an absence of genuine and consensual validation by its members. Forced morphostasis contributes to within-family alienation, individual alienation, and disturbed functioning in the system as a whole (Wertheim 1973).

Relevance to Couple and Family Therapy In order to explain boundaries within closed family systems, Wynne (1970) introduced the term “rubber fence” to describe a process through which a family implements an elastic boundary that helps them to maintain a sense of closeness/ relatedness within the system. The process is designed to thwart the threat of divergence from within and to prevent intrusion from outside of the system. Therefore, the system attempts to act as a

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self-sufficient social system that protects against dangers from external intrusions and divergent points of view within. However, attempts to sustain a behavioral boundary around a family cannot be maintained because a living system must participate in the larger society. To maintain this myth of complete self-sufficiency within the “rubber fence,” family members stretch to incorporate those persons, experiences, and behaviors that fit into the family framework/possess complementarity and contract to exclude those who do not possess complementarity/fit (Simon et al. 1985). Within a family therapy context, persons in a closed system may conclude that the therapist is either to be excluded from the family system or incorporated into the family system. When a nonfamily member, such as a therapist is incorporated into the family system and its rules, one is said to be within in the “rubber fence” (Wynne et al. 1958). Whether a therapist is incorporated or excluded, new experiences perturbate the system, yet the system accommodates to the perturbations without changing its organizing principles.

Clinical Example of Application of Theory in Couples and Families Jerry and Ana have 2 children, their daughter Amy who is 12-years-old and their son John who is 14-years-old. Jerry and Ana have been married for 20-years. Jerry and Ana have entered family therapy because Amy reportedly no longer wants to follow rules set forth by Jerry. Amy has also begun to question the family’s religious orientation and no longer desires to be homeschooled. Jerry indicates that John complies with all rules, looks forward to attending church functions and flourishes in all aspects of the homeschooling curriculum. Jerry states that all interactions within the family were harmonious until Amy turned 12. According to Jerry, when Amy turned 12, Ana began to grant Amy the latitude to express her opinions. Ana appeared to agree with Jerry and became tearful when she shared that she made mistakes with Amy that put the family at-risk of no longer being close-knit. Jerry and Ana state that they share the same ideas around

Coaching in Bowen Family Therapy

parenting, and that children should be “seen and not heard.” Ana shares that she and Jerry agree about parenting. Ana wants to use therapy to correct her parenting mistakes, so that both children know that parents are to be obeyed and not questioned. The family therapist assessed the extent to which this family employed a closed system. The family therapist concluded that this family functioned within a closed model. Both Ana and Jerry shared that they viewed their family unit as highly self-sufficient and wanted to minimize external influences from entering the family system. As both Jerry and Ana incorporated the family therapist into their closed system, the therapist was able to assist the family in naming their system as “closed.” Benefits and costs of employing a closed system were discussed with Jerry and Ana, and the concepts of continuity/change within a closed system as opposed to an open system were discussed. Over the course of therapy, Jerry and Ana were able to see that they had been excluding Amy from the closed system by identifying her as the family member who was bringing in ideals from the outside that were threatening to the system (e.g., norms around being 12 years of age). In addition, Jerry and Ana ultimately recognized that by excluding their children from outside influences, they were, in fact, sheltering them from the realities of life.

Cross-References ▶ Boundaries in Structural Family Therapy ▶ Kantor, David ▶ Minuchin, Salvador ▶ Morphogenesis in Family Systems Theory ▶ Morphostasis in Family Systems Theory ▶ Pseudomutuality in Family Systems

References Kantor, D., & Lehr, W. (1975). Inside the family: Toward a theory of family process. San Francisco: JosseyBass, Inc. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

469 Simon, B. F., Stierlin, H., & Wynne, L. C. (1985). The language of family therapy: A systemic vocabulary and sourcebook. New York: Family Process Press. Wertheim, E. (1973). Family unit therapy and the science and typology of family systems. Family Process, 12(1), 361–376. Wynne, L. C. (1970). Communication disorders and the quest for relatedness in families of schizophrenics. American Journal of Psychoanalysis, 30(1), 100–114. Wynne, L. C., Ryckoff, I. M., Day, J., & Hirsch, S. I. (1958). Pseudo-mutuality in the family relations of schizophrenics. Psychiatry, 21(1), 205–220.

Coaching in Bowen Family Therapy Tara Schlussel and Molly F. Gasbarrini California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Name of the Strategy or Intervention Coaching in Bowen Family Therapy

Introduction Bowen Family Therapy utilizes a multigenerational approach, addressing conflicts that arise when individuals experience severe anxiety (Miller 2010). Coaching in Bowen Family Therapy refers to one technique associated with Bowen Family Therapy, where the clinician works with an individual or couple who is driven, self-aware, and prepared to address relationship patterns and triangles within their family (Miller 2010). A prerequisite for beginning “coaching” is that the individual must demonstrate control over his or her emotional reactivity and a sufficient level of insight about recurring patterns of communication between family members (Miller 2010). Throughout the intervention, the individual expands his or her awareness of self, as well as conflicts that tend to reoccur within the family system (Miller 2010). Subsequently, the clinician challenges the individual to diverge from the daily patterns of interaction that prevent him or her from achieving differentiation.

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Theoretical Framework Bowen Family Therapy is a family systems approach that recognizes the multigenerational patterns of behavior that impact an individual or family’s behavior. Bowenian therapy involves working with an individual, couple, or family to address how problems may be rooted in previous generations. This framework draws from systems thinking in that an individual is viewed as part of a family or emotional unit. The individual is able to identify how his or her behavior follows a pattern, stemming back to the family of origin, and thus gains further insight into patterns of dysfunction that have persisted through generations. There are a wide array of tools and techniques that may be utilized to conduct Bowen Family Therapy, including genograms, process questions, relationship experiments, the neutralization of the symptomatic triangles, coaching, “I-position,” and displacement stories (Miller 2010). During Bowen Family Systems couple coaching, the couple’s relationship is not conceptualized in terms of illness, mental health, or diagnostic categories (Baker 2015). By viewing the couple through an intergenerational framework, each member is understood as intertwined with his or her respective family and is evaluated by his or her position on the continuum of differentiation (Baker 2015).

Rationale for the Strategy or Intervention Bowen sought to find a term that encompassed the therapist’s role in therapy with couples, which ultimately led him to coin the term “coaching” (Baker 2015). Bowen incorporated the term “coach” rather than common terminology, such as clinician or therapist, to prevent pathologizing the couple and refraining from implementing a medical model that may portray the couple as ill and in need of a cure (Baker 2015). Bowen believed the term “coach” accurately reflected neutrality of the therapist while embodying the concept of an active expert who coaches both individual players and the team as a whole with the utmost capability (Baker 2015). While

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coaching couples, the Bowenian therapist maintains communication between each individual, rather than encouraging the dyad to interact with one another (Hoffman 1976). Bowen preferred this form of communication as it reduces anxiety and irrationality, which he presumed to fuel the patterns of reactivity and dysfunction within families (Hoffman 1976). This method also affords the therapist additional authority and influence (Hoffman 1976). As the therapist communicates with one individual at a time, Bowen’s coaching technique allows for two distinct treatments to co-occur for each of two dyads (Hoffman 1976). The ultimate goal of coaching is for each individual to experience a reduction in anxiety and an ability to maintain independence and autonomy while remaining connected to one another (Baker 2015; Goldenberg and Goldenberg 1996).

Description of the Strategy or Intervention During coaching in Bowen Family Therapy, the therapist begins to coach each spouse in order to increase their levels of differentiation and gain awareness about each of their families of origin (Bowen 1978). This requires the individuals to have some degree of insight about the behavior patterns within their families (Miller 2010). In the initial session, the coach works with the couple to explore each member’s family of origin, extended family, and relationship with one another other, by generating a family diagram or genogram (Baker 2015). When couple coaching, it is important to consider the concept of the emotional triangle, as an anxious couple has the tendency to involve a third individual, in order to regain balance in the couple’s relationship (Baker 2015). This third individual may take the shape of a therapist, friend, colleague, relative, child, or coach (Baker 2015). It is essential that the coach is detriangulated and remains aware of the challenge to uphold neutrality throughout the coaching session, thereby allowing the couple to achieve differentiation (Baker 2015). Children under the age of 18 years are not usually involved in a coaching session, although

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they often endure many of the symptoms (Baker 2015). Occasionally, another family member, such as a grandparent or adult daughter or son, may be invited to participate in the couple coaching session, in order to provide the coach with additional perspectives into the family systems issues addressed by the couple (Baker 2015). While incorporating additional family members provides knowledge about the family systems relationships, it is optimal to include no more than three people, including the “coach.” Restricting the number of participants in session to three individuals limits the potential formation of triangles and enables the coach to localize complete attention on the couple (Baker 2015). During the coaching process, couples are generally seen for 1 hour, once a week, during which time the family history is formulated and assessments are conducted (Baker 2015). After the couple’s anxiety begins to decrease, they are seen every other week and eventually on a monthly schedule or less regularly (Baker 2015). The couple’s decision regarding the frequency of coaching sessions will ultimately depend on their management of regular ongoing stressors and reactivity within relationships (Baker 2015). While plans and strategies for change are formulated during sessions, the couple’s real work is viewed as occurring outside of sessions, when daily stressors and events test each individual’s reactivity and level of differentiation (Baker 2015). A goal of couple coaching is for couples to acquire the skills “to work on their relationship more effectively at home” (Baker 2015, p. 255). If symptoms are acute and intense, clients are encouraged to explore potential medication consultations. In addition, the couple is instilled with curiosity about the emergence of symptoms within the broader sense of their family systems relationship or their “multigenerational emotional unit” (Baker 2015). Empirical Support for the Efficacy of Coaching in Bowen Family Therapy Throughout the coaching process, the coach explores and measures the success of the coaching technique for each couple. The coach continues to incorporate aspects that prove beneficial and

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applicable to each member of the couple and their family system and modify less suited elements, depending on the couple’s needs and preferences. While there remains a need for studies examining the effect of couple coaching on individual and overall couple functioning, research utilizing Bowen Family Theory has evaluated couple relationships. Skowron and Friedlander (1998) have developed a scale for measuring differentiation (Baker 2015). In addition, Schnarch and Regas (2008) created the Crucible Differentiation Scale (CDS) which examines differentiation of self. Klever (2001, 2003, 2004, 2005a, b, 2008a, b, 2009) has explored levels of differentiation among couples and the impact on both couple and family systems functioning (Baker 2015). Further research is needed to empirically demonstrate the effects of couple coaching on couple and individual levels of differentiation, anxiety, and reactivity, utilizing a Bowenian Family Systems approach.

Case Example Dan and Julia sought therapy in order to learn to co-parent and to communicate more effectively with one another in their relationship. The couple had grown distant and angry toward one another over the past 5 years, during which Dan had become increasingly disengaged and passiveaggressive with Julia. Julia had begun feeling abandoned by Dan’s “emotional leave of absence” and dismissal of her parenting style with their children (an 8-year-old daughter and a 12-yearold son). Julia’s reaction to Dan’s disengagement involved angry verbal outbursts with frequent threats to divorce him. During the first session, the coach described her role as a Bowenian family therapist to distinguish the work from other types of individual/ couple therapy work that Julia and Dan had completed in the past. In the first few sessions, the coach encouraged the couple to direct their conversations to her in order to reduce the level of reactivity and verbal aggression that was exchanged among them. The coach began by gathering information about the couple’s separate families of origin and individual relationships

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with their parents. Directing the attention toward understanding their families of origin helped to de-escalate the couple’s negative emotional discourse while increasing their capacities toward a curious and introspective stance. Upon creating family genograms, the couple was able to view the transgenerational transmission patterns of behavior that had locked them into highly reactive and repetitive patterns. This process allowed the couple to take responsibility for their individual roles in their relationship and dysfunctional communication patterns as opposed to blaming one another. Through the use of family diagrams, Dan was able to see that he was conflating his wife with his controlling and overpowering mother who made it difficult for him to develop a solid sense of self. Dan’s passive-aggressive behavior with his mother was now transferred to his wife whenever Julia would express a strong need or desire in their dyad. Dan developed insight about his role in triangulating their son into acting oppositional and disrespectfully to his mother. Dan was encouraged to build a healthier and more differentiated relationship with his mother and to demonstrate firmer boundaries with her. He was able to verbalize his frustrations to his mother and, as a result, engaged in fewer passive-aggressive behaviors toward his wife. Julia’s mother died when she was 12 years old, leaving her to be raised by her father. Growing up, Julia felt dismissed and devalued by her father, noting that the only times she felt heard were during moments where she expressed intense bouts of rage, which would successfully incite a reaction in him. In anticipation of the birth of her first child, Julia had asked her father to be present and supportive of her. When her father instead left for Japan with a new and young girlfriend, Julia decided to cease communication with her father, cutting him out of her life. Upon further work, Julia began to start communicating with her father and heal old wounds. Julia’s work to bridge the cutoff with her father allowed room for emotional intimacy with Dan who remained supportive and engaged during this difficult period. The coach helped Julia develop awareness of how she was transferring her early father-daughter pattern of

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relating onto her relationship with her husband. By also encouraging Dan’s involvement in the process of weaving a connection with Julia’s father, Dan became a vital, active force rather than a detached and passive-aggressive partner. Once their levels of anxiety decreased, Julia and Dan learned to become less emotionally reactive and to de-escalate conversations that were potentially combustive. Upon recognition of their modes of relating through triangulation, multigenerational transmission, emotional cutoff, and projection, Julia and Dan were able to lower their anxiety and increase their level of individual and couple’s level of differentiation. This led to improved co-parenting style and enabled them to refrain from using their children for triangulation or projection in order to lower their anxiety and stabilize their relationship.

Cross-References ▶ Bowen, Murray ▶ Couple Therapy ▶ Differentiation of Self in Bowen Family Systems Theory ▶ Emotional Cutoff in Bowen Family Systems Theory ▶ Family Projection Process ▶ Family Therapy ▶ Genogram in Couple and Family Therapy ▶ Multigenerational Transmission Process in Bowen Therapy ▶ Triangles in Bowen Family Therapy

References Baker, K. G. (2015). Bowen family systems couple coaching. In A. S. Gurman, J. L. Lebow, D. K. Snyder, A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 246–267). New York: Guilford Press. Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Goldenberg, I., & Goldenberg, H. (1996). Family therapy an overview (4th ed., pp. 165–186). Pacific Grove Brooks/Cole Publishing Company. Hoffman, L. (1976). Foundations of family therapy. New York: Garner Press.

Coalition in Couple and Family Therapy Klever, P. (2001). The nuclear family functioning scale: Initial development and preliminary validation. Families, Systems, and Health, 19, 397–410. Klever, P. (2003). Intergenerational fusion and nuclear family functioning. Contemporary Family Therapy, 25, 431–451. Klever, P. (2004). The multigenerational transmission of nuclear family processes and symptoms. American Journal of Family Therapy, 32, 337–351. Klever, P. (2005a). Multigenerational stress and nuclear family functioning. Contemporary Family Therapy, 27, 233–250. Klever, P. (2005b). The multigenerational transmission of family unit functioning. American Journal of Family Therapy, 33, 253–264. Klever, P. (2008a). The primary triangle and variation in nuclear family functioning. Contemporary Family Therapy, 31, 140–159. Klever, P. (2008b). Triangles in marriage. In P. Titelman (Ed.), Triangles: Bowen family systems theory perspectives (pp. 245–264). Binghamton: Haworth Press. Klever, P. (2009). Goal direction and effectiveness, emotional maturity, and nuclear family functioning. Journal of Marital and Family Therapy, 35, 308–324. Miller, A. (2010). Instructor’s manual for Bowen family therapy with Philip Guerin, MD. Mill Valley: Psychotherapy.net. Schnarch, D. M., & Regas, S. (2008). The Crucible differentiation scale: Assessing differentiation in human relationships. Unpublished manuscript. Skowron, E. A., & Friedlander, M. L. (1998). The differentiation of self inventory: Development and initial validation. Journal of Counseling Psychology, 45, 235–246.

Coalition in Couple and Family Therapy George M. Simon1 and Heather Katafiasz2 1 The Minuchin Center for the Family, Woodbury, NJ, USA 2 The University of Akron, Akron, OH, USA

Introduction Prominent in the descriptions of family functioning offered by the earliest approaches to family therapy is the notion of the dysfunctional triangle. Versions of this notion can be found in Bowen family systems theory (BFST), in the strategic therapy (ST) developed by Jay Haley and Chloe Madanes, and in structural family therapy (SFT), developed by Salvador Minuchin and his colleagues.

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Triangulation in Bowen Family Systems Theory From a Bowen family systems theory perspective, triangulation is a rigid process that occurs as a result of excess chronic anxiety (Bowen 1978). A primary dyad is not considered to be a stable relationship from this perspective due to the difficulty with which two people manage the chronic anxiety experienced within the relationship. Therefore, creating an emotional triangle by bringing a third member into the primary dyad is thought to stabilize the relationship by allowing the chronic anxiety to have more avenues to disperse and allowing the primary dyad to better regulate the emotional distance within the relationship. Emotional triangles are not problematic provided they remain flexible. Contrarily, triangulation becomes problematic as it is a rigid process in which the third member is chronically brought into the primary dyad as the sole means of dispersing the chronic anxiety. In these circumstances, the relationship between two of the members of the triangle becomes fused, while the other member is cut off from the relationship. The third “member” of an emotional triangle is often a person. However, in triangulation, that third member often becomes a symptom. Three types of symptoms are thought to present: relational conflict, symptom development in one or both members of the primary dyad (couple), or symptom development in a child (Friedman 1991). Little is written regarding the presentation of relational conflict, although intimate partner violence is thought to be an extreme version of relational conflict (Bartle and Rosen 1994). Symptom development in one member of the primary dyad often presents as an individual or relational issue. For instance, an individual issue may be job instability or overworking, mental health diagnoses, or substance use, while a relational issue may be infidelity. More than one symptom may be triangulated depending on the amount of excess chronic anxiety within the relationship, with both members of a couple presenting with symptoms. Often when symptoms develop within the primary dyad, the relational processes within the emotional system evolve,

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co-emerging to form an “overfunctioner” and “underfunctioner” dynamic (Kerr and Bowen 1988). In this dynamic, both members of the couple have similar basic levels of differentiation, but one member develops a higher functional level of differentiation than the other member. The next type of symptom in triangulation is the development of symptoms within a child. The likelihood that a child will be triangulated into the primary dyad is not well understood, but is believed to depend on sibling position (Friedman 1991), family context, and personality characteristics. Symptoms that develop within children allow the primary dyad to communicate to resolve the symptom, while not having to face the issues within their relationship. More frequent triangulation into the primary dyad by children will lead over time to the development of lower differentiation in those children. Serving an important function for their family, launching can be a difficult process for these children, who have not learned how to be independent, yet connected to their family members. Often launching results in cutoff from their family of origin, at least temporarily. The patterns of managing chronic anxiety learned in their family of origin are then brought into future relationships, with those adults now repeating those same patterns with their own significant others and children, in a process known as the family projection process.

Coalition in Structural Family Therapy Like most other early approaches to family therapy, SFT views the family as a system of interacting parts, with the functioning of each part being both caused by and causative of the functioning of the other parts (Minuchin 1974; Minuchin et al. 1978). At any given stage of a family’s development, the way in which its parts interact tends to be stable, with the result that the family can be thought of as having a structure that can be mapped. A family’s structure is deemed functional if it allows the family to execute the tasks associated with its developmental stage. If the structure inhibits the execution of these tasks, it is deemed dysfunctional. A coalition is a

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structural configuration almost invariably seen by SFT to be dysfunctional. As it is understood by SFT, a coalition is the joining of two or more family members of differing generations in conflict against one or more other members of the family (Minuchin 1974). For example, a man may join with his mother in conflict against his wife. Similarly, a woman may join with one of her children in conflict against her partner. A given family might have two coalitions, each opposed to the other: for example, mother and oldest child arrayed against father and youngest child. Coalitions can be stable or shifting. In the former case, the “allies” remain such over time and in varying contexts, so that if one were to eavesdrop at random times on family transactions, one would always see the “allies” arrayed against the common “enemy.” In the case of shifting coalitions, referred to in the SFT literature as “triangulation,” a member of the family shuttles back and forth between two different “camps” within the family (Minuchin 1974). A particular child, for example, might sometimes be arrayed with one parent against the other and, at a later time, join the second parent against the first. It is not the conflict entailed by coalitions that renders them dysfunctional. In the view of SFT, conflict is not only inevitable in family life, it is also necessary in order to activate latent family resources and empower the family to execute the tasks associated with any given stage in its development. Conflict, however, can achieve this adaptive function only if it remains focused. Coalitions muddle the focus of conflict, precisely as a result of the intergenerational enmeshment that lies at their heart. It is because they muddle conflict, depriving it of its adaptive value, that SFT deems coalitions dysfunctional. A simple example will illustrate the kind of muddling produced by coalitions. A husband observes his wife chronically infantilizing their adolescent son in a manner that he finds highly reminiscent of the way she typically relates to him. The husband rarely complains directly to his wife about her stance toward him; however, he loses no opportunity to join his son

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when the latter begins to complain angrily to his mother about her infantilization. The young man invariably welcomes his father’s support, and the two proceed in unison to berate the mother about the inadequacy of her parenting. The ensuing episode of conflict is focused simultaneously on both a parenting issue (overtly) and a spousal issue (covertly). This muddling of the focus of the conflict would, by itself, all but guarantee that the conflict will not resolve itself in any kind of adaptive shift in the way the family members relate to each other. However, the way in which the members behave in the conflictual transaction further fates the conflict to be nonproductive. The son’s dependence on his father to be the spokesman for his cause during the exchange makes him look “young” and immature to his mother, thereby eliciting nothing more from her than an entrenchment in her infantilizing stance toward the son. Meanwhile, the mother’s perception that it is inappropriate for her husband to be supporting their son in opposition to her has no other effect than to elicit from her exactly the kind of one-up posturing toward the husband that he finds so objectionable. Finally, the father and son’s shared experience of the mother as being self-righteously obstinate during the transaction solidifies their coalition and primes them for their next united confrontation of her.

Coalition in Strategic Therapy The variety of ST developed by Jay Haley and Chloe Madanes shares with SFT all of the latter model’s notions of family structure (Haley 1976). However, even as it employs the concepts of family structure, ST is marked by a focus on power that, while certainly not absent from SFT, is nowhere near as prominent in the latter approach as it is in ST. ST views people in relationship as almost invariably devoted to the project of controlling the rules that govern the relationship. Such a project is foolhardy, since the systemic nature of relationships renders it impossible for one participant to unilaterally control the rules of the circular relational system. Nonetheless, some family

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systems become so preoccupied with control that members begin to resort to covert means to attempt to control the system. Symptoms are one such means. Another is what Haley (1977) termed “the perverse triangle.” Recognizable in ST’s description of the perverse triangle is the structural feature referred to in SFT as a coalition: the joining of two persons of different generations, generally a parent and a child, in opposition to a third person, generally the parent’s partner. However, ST’s distinctive preoccupation with power and control can be seen in its focus on an aspect of the intergenerational coalition not adverted to in SFT, namely, the fact that its existence is denied by the members of the family system who are party to it. It is precisely this denial that allows the allies within the coalition to use their alliance as a covert weapon in their struggle to gain relational control within the family system. Inevitably, the coalition involved in the perverse triangle fails to gain for the allies the relational control that they seek. Quite the contrary, in fact, the coalition has no other effect than to elicit more of the particular behavior by the target of the coalition over which the allies were seeking to exercise control in the first place. As a result, the struggle for control within the perverse triangle frequently escalates over time, with the introduction of symptomatic behavior by one or more participants in the triangle serving as the mechanism of escalation. Tragically, symptoms prove to be as ineffective in gaining the symptom-bearer(s) control of the family system as was the coalition. Precisely for that reason, once introduced into the circular interactions within the perverse triangle, symptoms have the effect of further reinforcing and stabilizing the triangle.

Clinical Example While they have much in common, the descriptions of the dysfunctional triangle provided by each of the clinical models discussed in this article are marked by varying emphases that are reflective of the differing underlying assumptions and preoccupations of each of the models. These varying emphases

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result in considerably differing prescriptions offered by the models to undo the deleterious effects that all of them see as resulting from the presence of dysfunctional triangles within families. Since it lies outside the scope of an article such as this to provide clinical examples of how all three of the models respond to triangles, we will close the article with a brief description of how the SFT therapist typically intervenes to restructure a coalition. The reader will recall that SFT identifies coalitions as dysfunctional as a result of the muddling of the focus of conflict that they inevitably produce. Faced with this muddling, SFT responds to the presence of coalitions in client families by endeavoring to mark a boundary between the “allies” in the coalition (Minuchin and Fishman 1981). This boundary marking creates a context in which each of the members of the coalition can fight the fight that is proper to her or him and fight that fight on his or her own. Among the techniques utilized in SFT to undermine coalitions are enactments, unbalancing and challenging. Let us imagine that the family described earlier in the section on SFT presents itself for treatment to an SFT therapist after the adolescent’s school psychologist contacts the parents to inform them that he is adjusting poorly to high school “due to poor social skills.” First-session enactments allow the therapist to map the coalition detailed above, along with the complementarity to which it is recursively linked. Armed with her assessment of the family’s structure, the therapist contemplates three broad interventive strategies that she can utilize to attempt to restructure the family system. First, she can elicit enactments between mother and son, in which the two are asked to negotiate new rules for their relationship that are congruent with the son’s adolescent status. As the two struggle to accomplish this task, the therapist anticipates that she will need repeatedly to block the father from entering the enactments. A second strategy entails the therapist’s probing for possible areas of conflict between the father and son. Should any such areas be identified, the therapist can attempt to utilize unbalancing to elicit and to amplify conflict between the two, in the interest of marking a firmer boundary between them. Finally, the

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therapist can see the husband and wife in couple sessions that are utilized to prompt the husband to express directly to his wife his objections to the way that she typically relates to him. The therapist expects that she will need to devote considerable energy during such sessions to blocking a shift of focus from spouse talk to parenting talk.

Cross-References ▶ Boundary Making in Couple and Family Therapy ▶ Challenge in Structural Family Therapy ▶ Complementarity in Structural Family Therapy ▶ Enactment in Couple and Family Therapy ▶ Family Development in Structural Family Therapy ▶ Family Function and Dysfunction in Structural Family Therapy ▶ Mapping in Structural Family Therapy ▶ Power in Family Systems Theory ▶ Unbalancing

References Bartle, S., & Rosen, K. (1994). Individuation and relationship violence. American Journal of Family Therapy, 22(3), 222–236. Bowen, M. (1978). Family therapy in clinical practice. In Family therapy in clinical practice (pp. 467–528). New York: Aronson, Inc. Friedman, E. H. (1991). Bowen theory and therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (Vol 2) (pp. 134–170). New York: Brunner/Mazel. Haley, J. (1976). Problem-solving therapy: New strategies for effective family therapy. San Francisco: Jossey-Bass. Haley, J. (1977). Toward a theory of pathological systems. In P. Watzlawick & J. Weakland (Eds.), The interactional view (pp. 31–48). New York: Norton. Kerr, M., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. New York: W W Norton & Co. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press.

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Description

Coalition in Structural Family Therapy Jessica M. Moreno1 and Sarah K. Samman2 1 California State University, Sacramento, Sacramento, CA, USA 2 Alliant International University, San Diego, CA, USA

Name of Concept

Coalitions in structural family therapy are dysfunctional alliances between at least two family members against another member. A stable coalition is a fixed and inflexible union, for example, between a mother and daughter that becomes a dominant part of the family’s everyday functioning (Minuchin et al. 1978). A detouring coalition is when the pair hold a third party responsible for their difficulties with one another, whereby decreasing the pair’s relational stress (Minuchin et al. 1978).

Coalition in structural family therapy

Application of Concept in Couple and Family Therapy Introduction Salvador Minuchin developed structural family therapy based on the belief that family is more than a group of individuals with shared biology. Family members relate to one another and create agreements and allyships, i.e., alliances, demonstrated through certain arrangements that govern their relational and interactional patterns. These arrangements, though not always overtly expressed or known by the family, form a structure whereby each family member abides by and behaves accordingly (Minuchin 1974). Structural family therapists believe the way some family members organize can serve a functional or dysfunctional purpose. Structural family therapists view coalitions as a dysfunctional alliance.

Theoretical Context for Concept According to Aponte and Van Deusin (1981), every interaction in a family is a statement about boundaries, alignments, and power. Boundaries dictate the roles, rules, and interactional patterns of a family. Alignments are healthy alliances that demonstrate how supportive or unsupportive a family member is with another. Power is not static or absolute and can depend on each member and situation, and it is largely related to how actively or passively family members combine alliances.

In order to apply the concept of coalition when conducting a couple or family therapy session, the therapist would (1) recognize the coalition in the interactional patterns in the room, (2) bring the coalition to the attention of the couple or family, and (3) discuss the effect of the coalition on the overall functioning of the family.

Clinical Example The Gonzalez family is comprised of Maria, a 36-year-old cisgender female Mexican-American; Carlos, a 37-year-old cisgender male MexicanAmerican; and their two biological children Ileana, their 12-year-old cisgender daughter, and Rodrigo, their 10-year-old transgender son. The Gonzalez’s were referred to family therapy by Rodrigo’s 6th grade teacher who reported that Rodrigo acted disruptively and defiantly in class. During the first session, the therapist asked the family for an enactment by playing a board game to observe family interactional patterns. Within minutes, the therapist noticed that Maria and Ileana were sitting close to one another, with Carlos and Rodrigo sitting on opposite sides of the table. The mother and daughter were whispering to one another, smiling, and seeming to enjoy themselves. Carlos also seemed fully engaged in the game. Meanwhile, Rodrigo appeared consistently more withdrawn as the game progressed as evidenced by lacking eye contact with

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Maria and Ileana, looking down solemnly, and demonstrated general disengagement from the game. Once the therapist noticed the coalition between Maria and Ileana against Rodrigo, she interrupted the game by asking the following questions, “I noticed that you, Maria and Ileana, seemed to have had a really good time playing the game with one another. I also noticed that you may have purposefully ignored Rodrigo. I wonder what it was like for Rodrigo to feel left out and excluded? Rodrigo, what was it like for you to watch your mom and sister connecting and having a good time, while you were over there looking disconnected? Were there other times you felt left out in the family? By whom? Has your father ever noticed? How often does this happen? What does this look like?” After asking openended questions, the therapist engaged the family in a dialogue about what happens in the family when Maria and Ileana exclude Rodrigo.

Cross-References ▶ Alliance in Family Relationships ▶ Boundaries in Structural Family Therapy ▶ Complementarity in Structural Family Therapy ▶ Enactment in Structural Family Therapy ▶ Family Development in Structural Family Therapy ▶ Family Function and Dysfunction in Structural Family Therapy ▶ Joining in Structural Family Therapy ▶ Tracking in Structural Family Therapy ▶ Training Structural Family Therapists ▶ Triangles and Triangulation in Family Systems Theory

References Aponte, H. J., & Van Deusin, J. M. (1981). Structural family therapy. In F. M. Dattillo & L. J. Bevilacqua (Eds.), Comparative treatments for relationship dysfunction (pp. 45–57). New York: Springer. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press.

Code of Ethics in Couple and Family Therapy

Code of Ethics in Couple and Family Therapy Bobbi J. Miller and Rachel Weddle Regis University, Denver, CO, USA

Introduction Practitioners in the field of mental health are consistently faced with complicated and ambiguous situations in therapy which require them to make decisions about the “best option” for protecting the welfare of their clients. The codes of ethics within the multiple disciplines in mental health arose out of a need to quantify some of the agreed-upon boundaries of practice and to give guidance to practitioners as they were navigating decisions without clear-cut answers. Codes of ethics in couple and family therapy are unique in that they are created to address some of the complicated issues that arise from having more than one individual to consider in thinking about one’s “client.”

Theoretical Context for Codes of Ethics in Couple and Family Therapy Purpose of Codes of Ethics Codes of ethics serve three main purposes: first and foremost to protect the public; second, to protect the profession from governmental intrusion; and finally, to protect practitioners from the public (Wilcoxon et al. 2012). They serve to provide guidance to practitioners in determining acceptable boundaries of sound clinical decision in a given mental health field. This provides autonomy for a profession in determining their own best practices. In addition, they provide support for determining when intervention is necessary to remediate concerning therapist behavior. Finally, they provide some direction about what constitutes malpractice, which allows more clarity for all involved when complaints arise from clients.

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Development of Codes of Ethics The development and use of codes of ethics is fairly new to the mental health field as a whole. The first code of ethics specific to the field of couple and family therapy was crafted by the American Association of Marriage and Family Therapy (AAMFT) and accepted by membership in 1962. These codes continue to be updated as the context of therapy evolves and in response to concerns raised about practice in the field. For example, significant changes were made in the January 2015 revision of the AAMFT Code of Ethics to clarify questions specific to the use of technology in practice (Caldwell, 2015). These types of changes have caused some to view codes of ethics as more “reactive than proactive,” which is a common concern noted specific to relying solely on these codes for guidance in sound ethical decisionmaking. As of the 2015 revision, the AAMFT Code of Ethics has been revised ten times since 1962. Overall, codes of ethics in the field of couple and family therapy are based on the underlying ethical principles put forth by Beauchamp and Childress (e.g., Autonomy, Beneficence, Justice, etc.) consistent with the codes of ethics of other mental health disciplines. However, the application of these ideas in the codes specific to couple and family work is different based on the definition of who constitutes the client (Murphy and Hecker 2016).

on compliance into one focused more on understanding and utilizing the ethical principles undergirding the profession as a whole. Codes developed in a discretionary fashion focus on providing practitioners with philosophical guidance to making decisions. These codes are specific to areas where the field has not yet taken a definitive stance on a course of action, but instead are recognized as areas replete with ambiguity (Wilcoxon et al. 2012). One specific example are codes specific to multiple relationships. The AAMFT Code of Ethics allows that situations arise in which multiple relationships cannot be avoided. However, they also provide discussion regarding the concerns embedded in multiple relationships the practitioner needs to take steps to avoid, including “exploiting trust and dependency.” They also instruct the practitioner to document all steps taken to avoid these repercussions when such a relationship is unavoidable (AAMFT 2015). Discussions of the codes within the context of mandatory and discretionary actions can lead to the false assumption that some decisions practitioners make are “cut and dry.” However, even mandatory actions are replete with their own hidden areas of uncertainty. For example, in the case of “duty to warn and protect,” a provider is left with the question of when a client represents an actual threat to the public and invokes this duty on the part of the clinician.

Mandatory Versus Discretionary All of the ethical standards within the codes reflect one or more of the ethical principles and either a mandatory or discretionary stance. A mandatory stance outlines actions a practitioner absolutely should not take (restrictive) or must take (obligatory) in order to stay within the boundaries of the codes. For example, the “duty to warn” and the “duty to protect” are obligatory mandates that necessitate a practitioner warn specific other (s) and/or take steps to protect the public from a client who poses a risk of harm to others (Wilcoxon et al. 2012). A discretionary stance, on the other hand, moves from decision-making based primarily

Codes of Couple and Family Therapy Arguably, the AAMFT Code of Ethics is the most widely recognized code of ethics governing couple and family therapist. However, there are other codes therapists ascribe to that address elements of practice with couples and family or are fully focused on the practice of systemic therapy. These include, but are not limited to: the Association for Family Therapy and Systemic Practice in the UK Code of Ethics (AFT 2013); International Association of Marriage and Family Counselors Ethical Codes (IAMFC 2017); and the European Family Therapy Association Code of Ethics (EFTA 2012).

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Description of Codes of Ethics in Couple and Family Therapy The discussion regarding the impact of treating a systemic unit on the ethical elements of therapy and how they are addressed in codes of ethics could address several areas of consideration. Three of the foundational areas will be discussed below. Definition of the Client Arguably, the most significant difference between codes governing the practice of couple and family therapy compared with those covering other domains of mental health practice is the presence of a systemic unit as the client. The transition of the definition of client from one individual to multiple individuals in relationship to one another changes the foundational questions being asked by the practitioner regarding their work with the “client.” Among these questions are “what does client autonomy in decision-making look like when there is disagreement among members of the system?” Systems and Confidentiality In contrast to codes of ethics focused more specifically on individual practice, codes of ethics in Couple and Family Therapy address nuanced areas of confidentiality specific to having multiple individuals as part of treatment. Specifically, they address the need to protect both the confidences of the system and the confidences of individuals within the system. For example, the AAMFT Code of Ethics specifies how to handle confidentiality within and outside of the treatment unit when providing systemic therapy: “When providing couple, family, or group treatment, the therapist does not disclosure information outside the treatment context without a written authorization from each individual competent to execute a waiver. . . the therapist may not reveal any individual confidences to others in the client unit without the prior written permission of the individual” (AAMFT 2015, Standard 2.2). Providers additionally have to deal with some limits to their control regarding information shared in session because of the presence of others in the room. Ethical codes guide practitioners to inform clients fully about these risks.

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Client Welfare By expanding the definition of client from one individual to many, the responsibility of the therapist to attend to multiple levels of client welfare also expands. The therapist now must balance what is best for each of the individuals in therapy both against one another and against the standard of what is best for the treatment unit as a whole (Wilcoxon et al. 2012). Several conflicts can arise when these elements are in contrast with one another. For example, when the needs of the individual are in stark contrast to the needs of the system. While the ethical codes of couple and family therapy do not address these conflicts directly, they do provide some discretionary codes that have been applied to thinking through situations related to this dilemma. These include codes specific to multiple relationships (AAMFT 2015, Standard 1.3) and conflicts of interest (AAMFT 2015, Standard 3.4). The onus of the responsibility is put on the therapist to be as clear as possible about whom is the client and whose interests are being promoted, along with the need to be circumspect about clinical decisions that would compromise this ability (e.g., seeing both a couple for relational issues and one of the members for individual issues).

Application of Codes of Ethics in Couple and Family Therapy The application of codes of ethics in Couple and Family Therapy is ever present in the professional life of a systemic practitioner. Therapists are obliged to agree to a code of ethics at several points in their careers, including but not limited to: (1) when they begin training; (2) to join many professional organizations; and (3) when they become licensed. As part of this process, they are agreeing to be held accountable to mandates embedded in the statutes and a process by which they are held to expectations commensurate with a professional of their ilk. This essentially means in areas in which discretion is required, they will be held to the standard of what most other practitioners similar to them would do in the same

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situation. These decisions are always held in light of the interpretation of the codes of ethics in Couple and Family Therapy they are accountable to, as interpreted by their peers.

Clinical Example of Codes of Ethics in Couple and Family Therapy Andrew and Grace bring their 18-year-old son Joshua to family therapy. Upon asking the family what brought them to therapy, Joshua informs the therapist that he does not want to be in treatment and is being “forced” by his parents to attend. The parents acknowledge they are forcing him to attend by refusing to pay his car insurance if he does not show up to sessions. In consulting the 2015 AAMFT Code of Ethics, the therapist recognizes she has an issue specific to Standard 1.2(d). This standard within the Code specifies the therapist gain consent from all individuals who are part of the treatment unit and that consent generally necessitates the client “has freely and without undue influence expressed consent” (AAMFT 2015). While Andrew and Grace meet this criterion, Joshua clearly does not. The wording in this code provides a mandatory component the therapist must attend to, including receiving consent from all parties involved and making sure the consent was freely given. The discretionary component of making this decision includes the process she may go through to probe whether it is possible to get Joshua’s freely given consent and to assist the family in making a decision about how to proceed if he will not give it and she, therefore, may not be able to see him as part of family therapy.

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References American Association for Marriage and Family Therapy. (2015). AAMFT code of ethics. Alexandria: Author. Retrieved from http://www.aamft.org/iMIS15/ AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx. Association for Family Therapy and Systemic Practice in the UK. (2013). AFT code of ethics. Warrington: Author. Retrieved from: http://www.aft.org.uk/ SpringboardWebApp/userfiles/aft/file/Ethics/Code% 20of%20Ethics%202013.pdf. Caldwell, B. (Ed.). (2015). User’s guide to the 2015 AAMFT code of ethics. Alexandria: AAMFT. European Family Therapy Association. (2012). Code of ethics of the European Family Therapy Association. Oslo: Author. Retrieved from: http://www.europeanfa milytherapy.eu/code-of-ethics-of-the-european-familytherapy-association/. International Association of Marriage and Family Counselors. (2017). IAMFC code of ethics. Alexandria: Author. Retrieved from: http://www.iamfconline.org/ public/IAMFC-Ethical-Code-Final.pdf. Murphy, M. J., & Hecker, L. (Eds.). (2016). Ethics and professional issues in couple and family therapy (2nd ed.). New York: Taylor & Francis. Wilcoxon, S. A., Remley, T. P., & Gladdin, S. T. (2012). Ethical, legal, and professional issues in the practice of marriage and family therapy (5th ed.). Upper Saddle River: Pearson.

Cognition in Couple and Family Therapy Kathleen A. Eldridge and Caroline Kalai Graduate School of Education and Psychology, Pepperdine University, Los Angeles, CA, USA

Name of Concept Cognition in Couple and Family Therapy.

Introduction Cross-References ▶ Ethics in Couple and Family Therapy ▶ Supervising Ethical Issues in Couple and Family Therapy ▶ Supervising Legal Issues in Couple and Family Therapy

The field of psychology refers to cognition as an individual’s ability to process information in order to perform certain psychological functions and behaviors (Fuchs and Milar 2003). This term is also used in branches like social psychology and social cognition to refer to an individual’s

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attitudes, beliefs, attributions, and interpersonal dynamics (Relvin 2013; Sternberg and Sternberg 2009). Cognition shapes and influences individuals’ interpretations, behaviors, and emotions in interpersonal relationships and is therefore well integrated into couple and family treatment methods. This entry will specifically focus on the psychological concept of cognition within the area of couple and family psychotherapy.

Theoretical Context for Concept Although originally coined to describe a person’s thinking and awareness in the fifteenth century, early Greek philosophers first contemplated cognition before the field of psychology emerged. Interest in human experiences, such as the inner workings of the mind, led one well-known philosopher, Aristotle, to explore cognitive processes that we identify today as memory, perception, and mental imagery. This interest was further explored and expanded by many pioneering scientists who contributed greatly to the study of psychology and cognitive science (Matlin 2013). These scientists included Wilhelm Wundt, who focused on the human cognitive process of introspection and inner feelings, and Hermann Ebbinghaus, who studied various aspects of learning and memory pertaining to language. Thereafter, Mary Whiton Calkins paved the way for cognitive theories, such as the recency effect in human learning and memory (Best 1999). In the mid-late twentieth century, cognitive theories pertaining to treatment of mood disorders emerged through Albert Ellis’ work in rational therapy (later called rational emotive therapy; Ellis 1962, 1982) and Aaron Beck’s cognitive behavioral therapy (Beck 1995; Beck et al. 1979). A psychiatrist regarded as the “father of cognitive therapy,” Aaron Beck sought to help individual clients cope with psychological symptoms through management of emotions, thoughts, and behaviors. Most notably, he introduced the central role of thoughts, specifically negative and maladaptive cognitive distortions, in developing a vulnerability to depression and in maintaining psychological conditions. Beck’s cognitive theory

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of depression postulates that an individual’s mood and behavior are affected by perceptions and interpretations of events throughout life. The theory also involves three levels of thought, including situational automatic thoughts, intermediate beliefs, and deeper core beliefs or schemas, which are absolute beliefs about the self, the world, and the future, developed through life’s experiences. While Beck’s cognitive theory focuses on altering an individual’s cognitions to improve psychological functioning, similar theories also describe how cognitions influence one’s relationships with others (Dattilio 1998, 2010). Appraisals, assumptions, and interpretations of behavior are cognitions that impact relationships between family members and partners. Therefore, Ellis adapted his A-B-C theory of rational emotive therapy to help couples and families in distress. He posited that marital dysfunction results when individuals hold irrational beliefs and extreme negative evaluations of their partners and their relationship. As knowledge evolved about the influence of cognition on relationship functioning, the integration of cognition into therapeutic work with couples and families in distress also expanded. Early studies found that specific methods, such as cognitive restructuring, significantly enhanced the effectiveness of behavioral interventions (Ellis 1962; Mahoney 1974; Margolin and Weiss 1978; Meichenbaum 1977). In the 1980s and 1990s, Donald Baucom and Norman Epstein developed cognitive-behavioral couple therapy (Baucom et al. 2015; Epstein and Baucom 2002), one of the leading methods for treating distressed couples. Their approach includes specific cognitive methods that have now been adapted to treat a broad range of couples and will be discussed further throughout this entry.

Description Aaron Beck’s work describes the most readily accessible cognitions as automatic thoughts, or “stream-of-consciousness” ideas, beliefs, and images that an individual forms, moment-to-

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moment, in daily life situations. Automatic refers to the spontaneous quality of the cognitions that are not carefully deliberated or thoughtfully developed. He described all automatic thoughts that lead to depression as consequences of cognitive distortions. In the context of couple and family therapy, similar types of cognitive distortions about partners or family members are thought to be associated with relationship distress and are therefore helpful to identify: 1. Magnification and minimization. Exaggerating or minimizing the importance of events and the behaviors of others. One might believe a partner or family member’s mistakes are excessively important (“You spent our weekly budget for groceries so now we won’t be able to buy that house!”) or that a partner or family member’s efforts are unimportant (“Using coupons won’t save us any money for that house”). 2. Catastrophizing. Seeing only the worst possible outcomes of a situation. “If she doesn’t want to date me, then no one will ever want to date me and I will die alone.” 3. Overgeneralization. Making broad interpretations from a single or few events. “My partner got angry with me for doing that. He is always angry with me for everything.” 4. Magical thinking. The belief that acts will influence unrelated situations. “We are good people – bad things, problems, and conflicts shouldn’t happen to us.” 5. Personalization. The belief that one is responsible for events outside of one’s own control. “My mom is always upset. She would be fine if I did more to help her.” 6. Jumping to conclusions/arbitrary inference. Interpreting the meaning of a situation with little or no evidence. For example, a husband concludes that his wife is having an affair when she comes home late from work. 7. Mind reading. Interpreting the thoughts and beliefs of others without adequate evidence. “I know exactly what his intentions were. I don’t need to ask.” Although plausible, mind reading goes beyond available evidence to make invalid conclusions.

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8. Fortune telling. The expectation that a situation will turn out badly without adequate evidence. “If I initiate a conversation with him, then he will just walk away.” 9. Emotional reasoning. The assumption that emotions reflect the way things really are. “You make me feel bad; therefore, you must be a bad partner.” “I feel like a bad son; therefore, I am a bad son.” 10. Disqualifying the positive. Recognizing only the negative aspects of a situation while ignoring the positive. One might receive many compliments from a partner but focus on the single piece of negative feedback. 11. “Should” Statements. The belief that things should be a certain way. “I should always be happy around my partner.” 12. All-or-Nothing Thinking. Thinking in absolutes such as “always,” “never,” or “every.” A wife might criticize her husband for buying the wrong item from the store, which leads her husband to believe: “My wife is never happy with anything I do.” The work of Epstein and Baucom provides another description of three types of cognitions that are salient in couples and families: (1) the most surface and situational reactions to specific incidents and behaviors, such as selective attention, attributions, and expectancies; (2) intermediate level beliefs that are less situational but broader in scope, such as assumptions and standards; and (3) an individual’s deepest layer of automatic cognitive processing, such as relationship schemas. Reactions to events. In selective attention, individuals pay closer attention to certain aspects of dialogue, behavior, or interactions with their partners, thereby selecting aspects of events that are either positive or negative. Conflict ensues when partners selectively choose negative aspects of events or select different aspects of events due to unique perspectives. Based upon the attended selection, an individual will then make attributions, or inferences, to interpret and/or explain others’ behaviors. If an individual selectively attends to negative aspects of events in the relationship, then it follows that he/she will make

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negative inferences about the other person. This cognitive trap leads partners to view the other person’s negative behaviors as enduring, characterological traits, which not only causes them to justify their own behaviors as reactions to their partners, but contributes to expectations and predictions about future negative behaviors based on the preceding cognitions. An example of selective attention, disqualifying the positive, was previously described in the list of common cognitive distortions. For instance, if one partner cleaned the house, but then the other partner complains about the laundry not being done, then selectively attending to chores that have not been completed might lead to inferences about one’s partner as behaving in lazy, forgetful, inefficient, or disorganized ways. Not only might this lead to the other partner feeling unappreciated, it can also lead to future conflicts as well if these negative inferences evolve into characterological assumptions in one another (“My partner is a lazy person” or “My partner is so ungrateful and doesn’t notice all the good things I do”). As seen in this example, selective attention can lead to the development of characterological assumptions, which influence attributions and expectancies between partners. Broad beliefs. Reactions to particular events often contribute to more global beliefs made about one’s partner, which in turn influence reactions to events. Assumptions, for instance, are generalized beliefs about others that have developed and then serve as the basis for attributions in specific situations. Therefore, if a husband holds the assumption that his wife is inconsiderate based upon previous reactions to particular events, then his wife’s future behaviors will be assumed to reflect her inconsiderate nature. For example, if he believes his wife to be inconsiderate as a result of selective attention to previous events (e.g., she forgot to include a card in his birthday gift), then he will develop the assumption that she is inconsiderate in other situations as well (“She’s so inconsiderate; she didn’t even offer me some of her snack”). Conversely, if he holds the assumption that she is a thoughtful and considerate person, then he might believe that she forgot to share her snack because she was distracted by the day’s events.

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Standards differ from assumptions because they pertain to beliefs that are not based in specific events or previous reactions to their partners; rather, they are values and personal beliefs about characteristics that one “should” or “should not” have in a relationship or family. These beliefs can develop outside of the current relationship and may be values learned from the family of origin, education, religion, and/or previous relationships. They become problematic when partners or family members hold opposing standards. For example, couples may have different beliefs about how relationships should operate with regard to gender roles, closeness/togetherness vs. separateness, financial standards of living, cultural or religious involvement, sex and intimacy, or parenting. For instance, an individual may have developed a standard that one partner in a relationship should be responsible for caregiving, while the other should handle all the finances. If the other partner holds a different standard, such that both partners share these responsibilities as observed in his/her family of origin, then this couple might face conflict about the division of responsibilities. Automatic cognitive processing. In addition to standards, beliefs, or reactions to specific events, there is the activity of human cognition described as information processing. Because so much of cognitive processing is automatic and out of one’s awareness, it relies heavily on existing core schemas about people and relationships instead of using deliberate and careful processing of each unique situation or event. Cognitive therapists help partners and family members become more aware of their cognitive processing instead of allowing it to remain automatic. Epstein and Baucom also summarize a distinction between relationship schematic processing, in which partners process their daily lives through a relational schema (considering the relationship and how things may impact one’s partner or relationship), and individual schematic processing, in which partners process information through an individual schema (focused on one’s individual functioning and unaware of others). Findings indicate that relationship schematic processing is associated with higher satisfaction in relationships, and improvement in relationship-schematic

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processing among male partners is associated with increased satisfaction of their wives.

Application of Concept in Couple and Family Therapy The application of cognition in couple and family therapy stems from influences from behavioral couple therapy, which aims to change behavioral patterns; cognitive therapy, which aims to change negative cognitions; and cognitive psychology research on information processing. Thus, cognitive-behavioral couple therapy (CBCT; Baucom et al. 2015; Epstein and Baucom 2002), described next, was developed to target all the aforementioned components to treat couples in distress most effectively. The focus of CBCT is on increasing awareness through interventions that target behavioral interactions, emotions, and cognitive processing, as change in one influences the others. Treatment begins with thorough assessment of multiple domains of the relationship through questionnaires, therapist observation, and information gathered during joint and individual sessions. Cognitions and cognitive processing (e.g., selective attention, attributions, expectancies, assumptions, standards) are included in this assessment. Homework assignments are used to keep partners engaged in treatment between sessions and consistently working to improve their insight and apply learned skills outside of the therapy room. Treatment methods that examine individuals’ cognitions in order to help partners gain insight include Socratic questioning and guided discovery. Socratic questioning involves the therapist asking a series of questions to help individuals understand their logic and reevaluate their thinking. This method induces conscious thinking about the logic involved in one’s cognitions and consideration of alternative explanations or information that might support or negate those cognitions. Because questioning individuals in the presence of their partners can be delicate, the therapist must remain empathic and avoid unsuccessful or counterproductive confrontations that might negatively impact the therapeutic alliance.

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While Socratic questioning can help an individual gain insight, guided discovery involves a broader range of techniques to guide partners in their discovery of one another. The therapist encourages partners to be inquisitive and curious about each other to learn more about one another, rather than relying on the therapist to uncover underlying thoughts as in Socratic questioning. This includes helping partners clarify their preexisting standards, expectations, and differences, as well as problem-solving. Other cognitive strategies include psychoeducation on intimate relationships and the role of cognitions, coaching clients to weigh the advantages and disadvantages of their cognitions, and considering the worst possible outcomes of situations in order to challenge negative predictions. In addition, therapists can use a “downward arrow” technique to tap into underlying meanings of partners’ cognitions and uncover the origins of their beliefs by exploring previous situations that led to current negative/ irrational thinking (e.g., unresolved issues). Lastly, identifying patterns in previous relationships that have led to similar negative consequences can motivate partners to interrupt those patterns by altering their cognitions. As couples understand their cognitive patterns (with their partner and as individuals), treatment progresses to then incorporate behavioral interventions, such as communication and decisionmaking skills training, role-taking (i.e., partners switch roles and play different perspectives in order to focus on their partners’ experiences), and behaving as if they had different cognitions (i.e., temporarily acting) in order to discover possible positive responses by their partner. Although most cognitive-based therapies, like CBCT, were developed and are largely practiced with individuals or couples, comparable methods apply in the treatment of families (Patterson 2014). For instance, methods in the practice of family therapy similarly include cognitive restructuring techniques to help family members better monitor the validity of their cognitions (how accurate or true one’s thoughts are in a given situation) and the appropriateness of their cognitions (the utility of one’s beliefs given the

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possibility that family members hold different standards). Other cognitive methods include teaching family members how to actively and consciously assess their cognitions in any given situation through self-monitoring (noticing one’s thoughts) and challenging negative thoughts that arise in order to de-escalate (Dattilio 1998). In general, the structure remains similar (i.e., assessment phase, treatment phase, brief, directive, and collaborative), so that cognitive distortions, dysfunctional thinking, and information processing can be explored with family members as they are with couples.

Clinical Example The case material used to illustrate the application of cognitive methods in couple and family therapy comes from an engaged couple that decided to work through their unresolved conflicts before getting married. They sought treatment at a local community mental health center where they were seen for 25 weekly therapy sessions. Background. Mark and Sarah, an intercultural couple, are engaged and in their mid-twenties. Mark is of Eastern decent and Sarah is Caucasian. They have been together for 4 years and have a 3-year-old son. This couple entered treatment with several complaints, including (1) regaining trust following infidelity, (2) difficulty coping with negative emotions, and (3) decline in quality time together and intimacy. Specifically, Sarah admitted to kissing a friend at a party and, as a result, Mark worries that Sarah has kept other secrets from him and does not feel comfortable setting a wedding date. He wants to understand whether there is a problem in the relationship or something that he may have done wrong to lead Sarah to kiss someone else; however, he also does not want to interrogate her. Sarah also wishes to understand why the indiscretion occurred and learn ways to improve their communication. The couple reported differences in responding to disagreements. Specifically, Sarah tends to yell and curse in front of their son, while Mark tends to withdraw or stonewall in order to avoid escalating arguments. This leads Sarah to storm off. Usually, arguments begin

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when Mark initiates discussion over certain issues or makes certain requests, such as not leaving dishes and bills around the house. He states that Sarah has a tendency to “breakdown over little things” because she doesn’t work through larger issues. He wants to understand why these situations lead to large arguments. Sarah also believes that they argue over petty things such as an unbalanced distribution of chores and her control over tasks like paying the bills, which she does not allow Mark to handle. She states that when she gets angry, “everything turns red” and she feels “rage.” To de-escalate, Sarah reports that she abruptly leaves the scene. Lastly, Mark and Sarah both report not having any time to spend with each other due to their work schedules. They both work in the entertainment industry, alternating work hours in order to manage childcare. After completing work in the morning and afternoon, Sarah comes home to care of their son while Mark works in the evening. When Mark arrives home, Sarah is too tired when he initiates conversation or sexual intimacy. As a result, Mark and Sarah rarely spend quality time together and have sex approximately once a month. Both enjoy the intimacy when it occurs and want to enhance their sexual relationship. History, conceptualization, and treatment goals. At the onset of treatment, a thorough assessment was conducted to gain an understanding of the couple’s current relationship functioning. The therapist met with the couple together for a joint session followed by individual sessions with each partner to gather individual histories. The information presented below is an integration of their histories. Mark and Sarah met at a mutual friend’s party and were immediately attracted to one another. After leaving the party together, they engaged in unprotected sex. When Sarah learned that she was pregnant, she and Mark started dating and then moved in together after their son was born. Both partners come from large families; however, they described their roles very differently. Sarah grew up in a conservative religious home and was the eldest child who was often responsible for the caregiving of her younger siblings. She experienced significant physical and sexual abuse

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and witnessed the abuse of her siblings as well. She also experienced intimate relationship trauma involving drug abuse, physical abuse, and sexual assault. Mark is the youngest of his siblings and reported a history of emotional neglect as well as abandonment by his father. Conflicts were rare as family and cultural values taught him to avoid any emotional expression. He also endured relationship trauma when his previous partner passed away following a major accident. Emotionally, Sarah tends to avoid confrontation/communication and bottle up her emotions until they are expressed in angry outbursts and crying spells. She described “going from 0 to 100.” Mark does not display his emotions and presents as calm and sometimes aloof. He tends to initiate communication, but is often met with rejection by Sarah so his concerns are left unresolved. An assessment of safety revealed no violence in their relationship or toward their child. Initially, both partners were hesitant to speak or glanced over at one another with restraint. Because each partner was able to speak readily and elaborate comfortably about their concerns during individual sessions, it appeared that the feeling of safety was lacking between partners rather than with the therapist. As such, the therapist deemed it necessary to discuss their fears about couple therapy to uncover the cognitions underlying their communication barriers. When the couple returned for their feedback appointment, the therapist facilitated a discussion about this observation: Therapist

Mark Sarah Therapist

I’d like to share an observation with the both of you. It was apparent during our initial meeting that the both of you have a difficult time communicating with one another, and I imagine that this is probably the same obstacle you face at home. Yet both of you have lots to say. . .it just wasn’t spoken with ease in each other’s presence. Yea. . . I guess we aren’t used to talking about it. . . .yea, especially to someone else. It feels like tattle tailing. I understand completely. So it’s difficult to talk about your problems with each other or with me when you are in the presence of one another.

487 (Silence) Mark Therapist

Mark Therapist Mark Therapist

Mark

Therapist Sarah

Therapist

I just don’t want her to feel attacked or make her feel bad. So you believe that Sarah will feel attacked and that she will feel bad if you openly speak about some of your concerns directly to her? Yes. I see. And then what might happen? I don’t know. . . She’ll shut down. And how did you come to this conclusion. . . that she will feel attacked or she will shut down? Well, that’s what usually happens when I try to talk about something at home, and even now I can sense that she isn’t comfortable. Sarah, let’s check in. Is this how you feel? Not exactly. I mean, yes it’s a bit weird and difficult to hear his complaints. I know he’s not trying to make me feel bad because we came here to fix this. So I wonder if some of your communication barriers, like the one we just observed here, somehow relate to assumptions about the other person. . .what each of you believe the other might be thinking or feeling. . . and making predictions about how the other might react, possibly based on previous conflicts. Does this sound accurate?

(Nodding) Mark Therapist

Yes So the work that we will be focusing on in here will be to slowly uncover the thoughts and beliefs that you hold about one another. We can discover some of the negative ways you think about situations, which, in turn, affects your mood and your behavior – including your communication. The focus will be on your thought patterns, as it seems that a lot of the communication is happening in your own minds, rather than directly with each other, and then negatively displayed by your behaviors.

Mark and Sarah’s relationship concerns can be understood through a cognitive conceptualization given that they both harbor maladaptive beliefs and expectations about how their partner might respond to them. Communication is stalled when cognitive distortions either skew the reality of what happened in a given situation or falsely

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explain the other person’s behavior. Much of this is rooted in their individual histories and the way they have learned to process information in their families of origin and prior relationships, as well as in their current relationship. Over time, Mark and Sarah began to function by their own interpretations and expectations rather than actively testing their logic. A combination of their personality differences, their learned approach to emotional expression, their individual and relationship schemas, and their resulting intermediate and situational beliefs has led to significant problems and ineffective coping through withdrawal, infidelity, and emotional outbursts. As strengths, Mark and Sarah are motivated to improve their relationship and move toward marriage. They are in love, eager to work through their problems, committed to therapy, and trust their therapist. They encourage one another to succeed. Additionally, their division of responsibilities in caring for their son illustrates how they cooperate, care, and support one another. They are both hard-working in their careers and respect each other. Mark openly expresses that he is proud of Sarah’s recent promotion. Following introduction to the treatment approach, the therapist shared this conceptualization with the couple in a feedback session. Thereafter, treatment recommendations and goals were discussed. It was important to help Mark and Sarah communicate effectively so that therapy remained an emotionally safe environment. Then, Mark and Sarah’s emotional disconnect and mistrust could be addressed through cognitive methods aimed to uncover relationship fears and schemas. The therapist also explained how their emotions would be targeted by understanding their individual thoughts and learning how to reevaluate them. Helping them regain control of their emotions through cognitive strategies would further facilitate effective and productive communication around more sensitive issues. Treatment began with psychoeducation as this was the couple’s first experience in couple therapy. Second, cognitive methods were used to improve communication. Guided discovery and downward arrow methods elicited each partner’s specific thoughts regarding conflict and communication in

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relationships and the origins of their thought patterns. Initially, Mark discovered how his father leaving him, his ex-girlfriend passing away, and feeling rejected for emotional expression in his family of origin led to an assumption that he would be abandoned/rejected by Sarah if he upset her with dialogue around their issues. Thereafter, with encouragement and practice, Mark was able to share his thoughts and feelings with less fear that Sarah would get upset or leave him. Meanwhile, the downward arrow helped Sarah uncover the underlying beliefs she developed (e.g., “I am unlovable,” “I am unsafe in close relationships”) and how they contribute to feelings of fear and anger when conflict arises with Mark. Through Socratic questioning, the therapist gently asked Sarah a series of questions to explore the logic that has contributed to her believing she is unloved: Therapist

Sarah Therapist Sarah Therapist

Sarah

Therapist

Sarah Therapist

Sarah

Now that we understand how Mark’s requests or desire to talk about any issue leads you to think he might not love you, let me ask you – what are the ways that a person who loves someone might demonstrate that feeling? I’m not really sure. OK, let’s see. . . how did you know earlier in your relationship that he loved you? I guess the way we were was different. We didn’t fight very much. OK, so, according to this logic, arguing might mean there is less love. That would feel pretty threatening. I wonder, could there be any other reason, other than not loving you, that you two might argue or that he might have certain requests you don’t like? We’ll argue when we want different things or when I feel like he is trying to change me or is unhappy. When you think he is trying to change you, or you think that he is unhappy with you. Any other reason? I’m not sure. I wonder, has he told you directly that he is unhappy with you or that he doesn’t love you? No.

As the session continued, Sarah was able to see how her cognitions prevented her from engaging in meaningful and productive dialogue with Mark. Guided discovery helped Sarah obtain a

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new perspective (“I am loved and safe, even during conflict”) that enabled her to engage in new experiences, such as tolerating discomfort in order to maintain longer dialogue. These cognitive changes facilitated better communication, reduced emotional arousal, and enabled experiences of safety between partners, which allowed further work on issues of trust and fidelity.

Cross-References ▶ Baucom, Donald ▶ Cognitive Behavioral Couple Therapy ▶ Cognitive-Behavioral Family Therapy ▶ Epstein, Norman ▶ Schemas in Families

References Baucom, D. H., Epstein, N. B., Kirby, J. D., & LaTaillade, J. (2015). Cognitive-behavioral couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 23–60). New York: The Guilford Press. Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: The Guilford Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press. Best, J. (1999). Cognitive psychology (5th ed.). Hoboken: Wiley. Dattilio, F. M. (Ed.). (1998). Case studies in couple and family therapy: Systemic and cognitive perspectives. New York: The Guilford Press. Dattilio, F. M. (2010). Cognitive-behavioral therapy with couples and families: A comprehensive guide for clinicians. New York: The Guilford Press. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Ellis, A. (1982). Rational-emotive family therapy. In A. M. Home & M. M. Ohlsen (Eds.), Family counseling and therapy (pp. 302–328). Itasca: Peacock. Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples. Washington, DC: American Psychological Association. Fuchs, A. H., & Milar, K. S. (2003). Psychology as a science. In D. K. Freedheim (Ed.), Handbook of psychology (pp. 1–26). Hoboken: John Wiley. Mahoney, M. J. (1974). Cognition and behavior modification. Cambridge: Ballinger.

489 Margolin, G., & Weiss, R. L. (1978). Comparative evaluation of therapeutic components associated with behavioral marital treatments. Journal of Consulting and Clinical Psychology, 46, 1478–1486. Matlin, M. (2013). Cognition (8th ed.). Hoboken: Wiley. Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach. New York: Plenum Press. Patterson, T. (2014). A cognitive behavioral systems approach to family therapy. Journal of Family Psychotherapy, 25(2), 132–144. Relvin, R. (2013). Cognition: Theory and practice. New York: Worth Publishers. Sternberg, R. J., & Sternberg, K. (2009). Cognistive psychology (6th ed.). Belmont: Wadsworth, Cengage Learning.

Cognitive Behavioral Couple Therapy Donald H. Baucom and Melanie S. Fischer University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Name of Model Cognitive-Behavioral Couple Therapy (CBCT).

Synonyms Behavioral couple therapy (BCT); Behavioral marital therapy (BMT); Cognitive-behavioral marital therapy (CBMT)

Introduction Cognitive-behavioral couple therapy (CBCT) evolved during the early 1980s, drawing heavily upon its theoretical foundations from behavioral couple therapy (BCT), individual cognitive therapy (CT), and basic cognitive and social psychology research on information processing. In early formulations of BCT, principles of social learning and social exchange theories were applied to help couples achieve a more satisfying balance of positive to negative behaviors. That is, relationship

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distress was defined largely by an excess of negative and deficit of positive behavioral exchanges between partners. Patterns of reinforcement and punishment of desirable and undesirable behaviors were assessed with systematic functional analyses, and partners were trained in communication and problem-solving skills as well. Communication skills training was deemed to be central in treatment both because (a) it is a major vehicle for reinforcement or punishment between adults and (b) communication serves as a medium through which other important domains of relationship functioning are addressed. However, over time, it became clear that a strictly behavioral approach was limited in addressing the numerous sources of relationship distress that couples might encounter. In particular, a purely behavioral approach ignores the central role of internal experiences, i.e., cognitions and emotions, in relationship functioning as noted below. The integration of cognitive and emotional factors into the theoretical and treatment models denoted the evolution of BCT into CBCT. Still, researchers and clinicians treating relationships from a social learning perspective continue to vary in the relative emphasis they place on behavioral, cognitive, and emotional factors in understanding and treating couples’ relationships. Hence, the current discussion includes a consideration of what some would call behavioral couple therapy and what others would call cognitive-behavioral couple therapy, all under the inclusive name of cognitive-behavioral couple therapy.

Prominent Associated Figures Robert L. Weiss and Richard Stuart were two of the early contributors to conceptualize couples’ relationship functioning from a behavioral perspective in the 1960s. In the 1970s, these conceptualizations were translated into a treatment protocol by Neil Jacobson and Donald Baucom, and the first randomized controlled trial of behavioral couple therapy was conducted with a purely behavioral focus; Jacobson and Gayla Margolin published a book on behavioral couple therapy soon thereafter. At the same time, BCT was

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gaining prominence in other applications and across countries. Within the United States, Howard Markman (along with Elizabeth Allan, Scott Stanley, Galena Rhoades) applied similar behavioral principles to helping healthy couples enhance their relationships through the PREP program, currently described as a relationship education approach, and others have continued similar efforts across a variety of settings and countries (e.g., Guy Bodenmann, James Cordova, Kristina Coop Gordon). In Germany, Kurt Hahlweg conducted large-scale treatment studies of BCT and relationship education, varying different treatment parameters to optimize treatment. Likewise, Kim Halford began demonstrating the efficacy of the interventions in Australia. As the treatment approach evolved, K. Daniel O’Leary, Steven Beach, and their colleagues began exploring the efficacy of BCT for treating couples who experience relationship distress along with depression. As noted above, the theoretical model for BCT broadened, particularly beginning in the 1980s when the role of cognitive and emotional factors began to gain prominence in addressing relationship functioning which led to corresponding treatment evolutions. D. Baucom collaborated with Norman Epstein, who had a strong background in cognitive-behavior therapy, to develop their version of cognitive-behavioral couple therapy which gives strong consideration to cognitive and emotional factors, along with behavioral factors in relationship functioning. Art Freeman, Frank Dattilio, and others applied similar principles from cognitive therapy into their own variations of cognitive-behavioral couple therapy. Likewise, recognizing this restriction of focusing solely on behavioral factors, Jacobson and Andrew Christensen developed integrative behavioral couple therapy (IBCT) which makes a primary distinction between behavior change and acceptance; while IBCT is viewed as a treatment to be differentiated from CBCT, it maintains its behavioral heritage and is part of the ongoing evolution in couple treatment. As described below, the field of CBCT has continued to evolve as specific domains of relationship functioning (e.g., intimate partner violence, O’Leary; Amy Holtzworth-Monroe;

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Gregory Stuart; Epstein; infidelity, Gordon, Douglas Snyder, D. Baucom; David Atkins and Christensen), additional populations such as couples experiencing psychopathology (e.g., Melanie Fischer, Cynthia Bulik, Jennifer Kirby, Brian Baucom, D. Baucom, Michael Worrell, Sarah Corrie, and Jonathan Abramowitz; Steven Sayers; Mark Whisman; Candice Monson and Steffany Fredman; David Miklowitz; Jeremiah Schumm and, Timothy O’Farrell; Barbara McCrady; Diane Chambless) or medical problems (Francis Keefe, Laura Porter, D. Baucom, and Tamara Sher; Katherine Baucom; Halford and Jennifer Scott; Nina Heinrichs and Tanja Zimmermann; Alan Fruzzetti), and new modalities of intervention such as web-based interventions (e.g., Brian Doss) are addressed from a social learning perspective. Others have focused on the adaptation of CBCT and behaviorally based relationship education to specific populations, including ethnic/ racial minorities (primarily Black/AfricanAmerican couples) in the United States (e.g., Shalonda Kelly, Jaslean LaTaillade), LGBTQ couples (Sarah Whitton, Shelby Scott, Brian Buzzella), and non-Western countries/cultures (e.g., Epstein). The above are only representative domains and contributors as the field continues to grow and expand.

Theoretical Framework As noted above, the current theoretical model began with a focus almost entirely on the role of positive and negative behavioral exchanges in relationship distress, including communication as a central form of behavior exchange within intimate relationships. However, theoreticians and clinicians became aware that it was not only how each person behaved that was important. In addition, each person’s perception of those behaviors was central in both their behavioral and emotional response. That is, each member’s idiosyncratic interpretations of relationship events, causal attributions for a partner’s behavior, and enduring cognitive schemas about close relationships have marked influence on their behavioral responses and subjective emotional

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experiences (Baucom and Epstein 1990). Consequently, BCT practitioners gradually incorporated principles and interventions from individual cognitive therapies such as those developed by Beck and colleagues (e.g., Beck et al. 1979) into their work. Broadly speaking, the goal of the cognitive component of CBCT is to help couples monitor their own thinking that influences their relationship, to evaluate the appropriateness and validity of those cognitions, and to revise them as needed. Further, more recent enhancements of CBCT place greater emphasis on assessing and intervening with partners’ emotional processes and experiences rather than relying on changes in cognitions and behaviors to affect emotions indirectly; that is, minimized or exaggerated/ dysregulated emotional responses may warrant intervention in their own right (Epstein and Baucom 2002). CBCT also takes a contextual perspective that emphasizes characteristics of the two individuals, the dyad, and environmental demands or stressors that influence the quality of relationship functioning. Within this framework, (a) a healthy relationship contributes to the growth and well-being of both partners, (b) the couple forms a wellfunctioning team, and (c) the couple responds adaptively to external demands on their relationship by using their individual and relational resources. Consequently, CBCT therapists systematically assess a range of factors regarding couple coping with demands in their life together as it relates to their presenting concerns and relationship distress. Consistent with this contextual perspective, characteristics related to each partner’s identity and cultural background, such as race/ethnicity, gender, sexual orientation, ability status, and SES, are an integral part of case conceptualization.

Populations in Focus CBCT was developed to assist couples who are experiencing relationship distress and has been applied in numerous settings in various countries, primarily the United States, Western Europe, and Australia to assist these couples. Whereas the

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empirical findings noted below indicate that CBCT is efficacious in alleviating relationship distress, most of the applications of the treatment and research findings are based on middle-class white couples, most of whom are legally married. Although there has been some research identifying particular challenges and experiences of couples based on their cultural backgrounds, there have been few empirical studies exploring CBCT adaptations that take specific experiences of diverse populations into account or directly address specific strengths and challenges associated with a wide range of backgrounds and identities. For example, divorce rates tend to be higher among some ethnic/racial minority groups in the United States, which has been attributed to stressors that disproportionally affect minority couples such as economic hardships, exposure to violence, and daily experiences of microagressions and racism. Generally, relationship quality tends to be lower in the presence of such pervasive stressors. Likewise, research on the unique experiences of LGBTQ couples and their impact on relationship functioning is similarly scarce, although there are a number of challenges that are important to consider, such as lack of support from family members and other forms of minority stress. Treatment adaptations for specific populations have been discussed more systematically in recent years. However, couple therapists need to be aware of within-group diversity for any couple entering therapy, regardless of their group membership on any dimension (e.g., race/ethnicity, sexual orientation, gender identity, SES, physical ability, etc.), and adapt the treatment accordingly. There clearly is a need for further research investigating the effects of tailoring couple interventions to the needs of particular minority groups. Researchers and clinicians have come to recognize that although the interventions employed in CBCT were designed to promote behavioral, cognitive, and affective changes among couples experiencing relationship distress, these same strategies can be employed to assist couples living with other concerns as well, such as one partner experiencing individual psychopathology or medical concerns. Whereas such issues typically are

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described as individual problems, psychopathology and medical conditions exist in an interpersonal context where they interact reciprocally with the couple’s relationship. As a result, there has been a burgeoning interest in applying CBCT principles and interventions to couple-based interventions where the focus is the couple working together in treatment to assist with individual psychological difficulties and health concerns. A fuller description of such interventions and their empirical status is provided elsewhere (c.f., Fischer et al. in press).

Strategies and Techniques Employed in CBCT Given the equal emphasis placed on behavior, cognitions, and emotions in CBCT, a brief description of interventions central to CBCT is provided below. A full description of the range of CBCT interventions is provided in Epstein and Baucom (2002). Interventions for Modifying Behavior CBCT has maintained its emphasis on helping partners interact in more constructive ways, with the intent of simultaneously creating positive cognitive and emotional changes. The wide range of behavioral interventions can be viewed as falling into two broader behavior change categories: guided behavior change and skills-based interventions. Guided behavior change. Guided behavior change interventions do not involve developing new skills but rather draw on the couple’s existing skills. For example, if the couple has stopped making efforts to be kind and thoughtful to each other in general, the therapist and couple might decide that every day, each partner will make a specific effort to do something nice for the other individual that does not require extensive time or effort and that might be sustainable over time (e.g., preparing a cup of coffee for the other person or sending a text message). Also, more focal guided behavior changes address specific key issues or important relationship themes, such as intimacy building, social support, or improved

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individual functioning, for example, partners taking turns putting the children to bed so that each person occasionally has predictable individual time to relax at night within their hectic schedules. Thus, without learning any new skills, the couple might be encouraged to engage in a series of behavior changes to respond to one or both partners’ needs and preferences. Skills-based interventions. In other circumstances, a couple might benefit from new skills for more adaptive interactions. The therapist usually introduces skills-based interventions, such as communication training, by providing psychoeducation about the skills and their purpose, followed by coaching the couple in practicing the new skills in session and planning further practice through homework. For example, communication training typically differentiates between two major types of communication: (a) conversations focused on sharing thoughts and feelings which have the goal of understanding each other and feeling understood and (b) decision-making or problem-solving conversations which are more task-oriented and intended to help the couple reach a resolution on some issue. Guidelines for each type of conversation are discussed as recommendations to be adapted by the couple to their unique style, rather than strict rules. These communication skills are then applied to address areas of concerns specific to the couple. Interventions Focused on Cognitions Similar to cognitions that are targeted in individual CBT, partners are likely to hold strong beliefs about their relationship and have well-established patterns of cognitions regarding how a partner should behave, why their partner is behaving the way he or she does, what they predict their relationship will look like in the future, and so on. These cognitions can strongly influence an individual’s behavioral and emotional responses to a partner (e.g., “You agreed to watch the children while I go out so that you don’t have to spend time with me.”) Several types of cognitions that are commonly addressed in CBCT and are discussed more extensively elsewhere (Epstein and Baucom 2002). These cognitive factors

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include selective attention (what each individual notices about the partner and the relationship), attributions (inferences about causes of relationship events and partner behaviors), expectancies (predictions of what will occur in the relationship in the immediate and distant future), assumptions (beliefs about what people and relationships are actually like), and standards (beliefs about what people and relationships should be like). CBCT therapists help the couple to identify and assess their cognitions for appropriateness and validity and work with them to develop more balanced views of themselves, their partners, their relationship, and how they interact with the environment. Many specific strategies used in individual cognitive therapy apply here as well, techniques such as Socratic questioning and the “downward arrow” method, evaluating the logic behind a cognition, or weighing advantages and disadvantages of a cognition, each applied with modifications given that partners may criticize each other for their cognitions. In addition, having an individual’s partner present in the room allows CBCT therapists to use a different type of intervention called guided discovery. These interventions have the goal of creating experiences between partners that allow one or both persons to rethink their point of view and develop a different perspective on the partner or relationship, without directly questioning an individual’s beliefs and minimizing their defensiveness in the presence of the other individual. Interventions Focused on Emotions An important development in CBCT is to address emotional experiences and processes explicitly, rather than relying on changing cognitions and behaviors to affect emotions indirectly. Couples entering therapy often show extreme patterns in the expression of emotions, with one or both partners either displaying restricted or excessive emotional responses. Understanding the processes involved in partners’ difficulties with emotions allows the therapist to select appropriate interventions. First, many individuals have difficulty experiencing specific (or any) emotions or are very uncomfortable if they do. A number of strategies based on emotionally focused couple

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therapy (Johnson and Greenberg 1987) are used in CBCT to help individuals access and heighten their emotions in a safe atmosphere. On the other hand, some partners experience and express a high level of negative emotional intensity, with difficulty regulating strong emotions. Along with in-session therapist strategies to contain intense emotions, the application of interventions from dialectical behavioral therapy (Linehan 1993) in an interpersonal context can be helpful in addressing poorly regulated strong negative emotions in CBCT. For example, teaching the couple how to mindfully focus on the current moment can be helpful in keeping distress from one domain of the relationship from infiltrating other aspects of their life. Conclusions In summary, CBCT addresses relationship distress by applying interventions that address behavioral, cognitive, and emotion-focused interventions, taking individual, couple, and environmental factors of relationship functioning into account. CBCT is not a manualized treatment. Rather, practitioners conduct a thorough assessment of the aforementioned factors and develop an in-depth case conceptualization. Based on this conceptualization and the couple’s treatment goals, a treatment plan with a tailored sequence of intervention is employed.

Empirical Status of CBCT A large number of empirical investigations demonstrate the centrality of various behaviors, cognitions, and emotions in adaptive and maladaptive relationship functioning (see Baucom and Epstein 1990, for a review of these basic research findings). Findings from these investigations have been taken into account in the development of CBCT interventions described above and which have been investigated subsequently in a number of treatment outcome investigations demonstrating the efficacy of CBCT as noted below.

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Efficacy Research CBCT and other behaviorally based couple treatments that are based in social learning theory have been examined in clinical trials for over four decades. Over time, early interventions approaches that more narrowly included only behavioral interventions (BCT) have undergone important changes to address cognitions and emotions more directly as in CBCT. Several metaanalyses and major reviews have examined the efficacy of this broad range of behavioral and cognitive-behavioral couple therapy approaches across trials in the United States, Europe, and Australia. Even though these various reviews have employed differing criteria for inclusion, they reach the same conclusion: behaviorally based couple therapies are efficacious for the treatment of relationship distress, and the findings are similar when these interventions are employed across countries. It also has become clear that a given component of CBCT typically produces change in the targeted domains (e.g., communication skills or cognitive distortions); however, the amount of change in overall relationship satisfaction among behaviorally based couple therapies tends to be equal. It is possible that overall efficacy may be greater when the targeted domains in a given treatment match the domain in which a couple requires the most change, although this question has not been examined systematically in empirical research. In addition, applications to specific issues including infidelity, intimate partner violence, and separation/divorce have been investigated as well. Discussing these applications to specific relationship concerns is beyond the scope of the current discussion, but reviews and treatment descriptions are available elsewhere (Gurman et al. 2015). Since the aforementioned major meta-analyses, there has been only one large randomized controlled trial of behaviorally based couple therapies, comparing the efficacy of traditional behavioral couple therapy (BCT or, as the authors refer to it, TBCT; a version of couple therapy with almost exclusive focus on behavioral change with little emphasis on cognitions or emotions, unlike more modern treatments such as

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CBCT) and integrative behavioral couple therapy (IBCT) (Christensen et al. 2004). Both treatments resulted in similar improvements in relationship satisfaction with a large overall effect size and no differences in overall effects (despite differences in pace of change during treatment) at posttreatment and 5-year follow-up. Effectiveness Research Despite numerous efficacy trials of behaviorally based couple therapies in controlled settings, only four effectiveness studies of couple therapy in real-world settings have been conducted over the last several decades. Of note, three of the four studies employed an eclectic mix of couple therapy approaches that were not necessarily evidence-based nor behavioral/cognitive behavioral in nature. However, given the dearth of effectiveness research, these studies provide the closest estimation of effects in community settings that are available. Two studies were conducted in Germany, one in Norway and one with military veterans in the United States. Broadly, the results of these four studies suggest that while still demonstrating improvement in relationship distress, the effect of the treatment are not as strong as those evidenced in randomized controlled trials conducted with significant supervision and control regarding selection criteria (see Fischer and Baucom in press for a more detailed review of these effectiveness studies). Mechanisms of Change Attempts to isolate the mechanisms of change in CBCT have been mixed. Early studies with small sample sizes made it difficult to detect mechanisms of change and, thus, were unsuccessful in isolating factors that are central to promoting increases in relationship satisfaction. However, more recent efforts indicate that to the extent that couples make behavioral changes in areas targeted for that particular couple in therapy, their relationship satisfaction improves. Likewise, increases in self-reported positive communication and decreases in self-reported

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negative communication both predict improvements in relationship adjustment as would be predicted by CBCT. While these recent findings are promising, additional evidence is needed before researchers and clinicians can be confident that the factors responsible for creating improvements in relationship satisfaction in CBCT have been isolated.

Case Example A brief summary of CBCT with Samantha and Sean is described in order to demonstrate how the broad range of behavioral, cognitive, and emotional intervention strategies available are adapted to the needs of a specific couple. The couple had sought treatment 3 years after the birth of their first child, Emily. During the initial evaluation, both partners reported having been quite happy during the early years of their marriage, spending a lot of time together with their shared love of the outdoors and physical exercise. They also participated in community and environmental organizations together which provided them a sense of common purpose in line with shared values. Before Emily’s birth, they both worked full-time and were financially stable. They agreed that they wanted Samantha to stay home after Emily was born which involved a notable shift in both of their roles. Samantha’s life changed in major ways from having a successful, active professional life to spending most of her day with a 3-year-old and occasional time with other mothers and their children. Sean felt much more pressure as the sole breadwinner and was working hard to get promoted, along with taking a second job to provide extra income for the family. Thus they both had less time and energy at home when they were together. When Sean came home, he reported feeling exhausted and just wanting to relax. Samantha also reported that she was tired by the end of the afternoon and needed Sean’s help when he arrived. In addition, she noted that frequently she was waiting all day to have a conversation with another adult and became

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disappointed when Sean turned to the television or worked on the computer. The nature of their conversations also shifted as Samantha reported that she did not have very interesting things to contribute these days. As a lawyer, she previously had talked to Sean about her interesting and complicated cases, but now she felt she did not have much to say other than describing her and Emily’s activities of the day. She felt that Sean often seemed distracted or exhausted when they did try to talk, resulting in Samantha frequently “blowing up” and Sean, therefore, avoiding conversations all together. The therapist concluded that a major factor in their relationship difficulties involved their transition to parenthood and struggling to adapt to the demands of this new stage of their family life cycle. In particular, with their role overload and frequent arguments, each partner tended to no longer notice the positive aspects of their relationship or the other person’s efforts. Consequently, to counteract this selective attention to negativity, as an early intervention, the therapist asked each partner to write down one positive thing that the other person did each day and to compliment or express appreciation to that individual for these actions. A significant portion of treatment involved helping Samantha and Sean recognize that they were in a new phase of their family life cycle with Emily as a 3-year-old. The therapist taught the partners communication skills, which helped them to share their thoughts and feelings more fully about these new roles and to reach decisions or problem-solve around the many daily decisions needed with a young child. These communication skills also were used in important discussions about the couple’s standards for what their relationship should be like with a 3-year-old child. As they continued with these discussions, they concluded that they had drifted away from their own value system. Whereas financial security remained important to the couple, they concluded that during this phase of their life, they wanted to live a simpler lifestyle and focus on their marriage, each other, and Emily. Samantha also concluded that her role had become too restricted as a mother and that their current roles put her in danger of stifling her personal growth and well-being. They agreed that she would return

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part-time to her law practice; with this increased financial income, Sean would stop moonlighting and spend more time with the family. Sean and Samantha also discussed how to spend more time with each other and agreed that it was easier to have lunches together during the day when they had regular child care, than to arrange evening outings. They also agreed that Sean had spent little time developing his relationship with Emily. Therefore, they agreed that each weekend he would spend one morning or afternoon with Emily, which would also give Samantha time to herself. The stresses of parenthood also highlighted each partner’s typical style of dealing with stress; Samantha was a person who liked to address it directly, whereas Sean tended to withdraw. Sean clarified that it was particularly difficult for him to discuss problematic issues when Samantha became angry and expressed her feelings loudly. With ongoing effort, Samantha learned to express her distress in a more contained way. Sean explained that he feared that when Samantha became loud, there would be “explosions,” as he had witnessed between his parents while growing up. The therapist emphasized the importance of him continuing the conversations so that he could experience his relationship with Samantha as different and noted that discussing difficult issues does not inevitably lead to destructiveness. Overall, couple therapy was quite helpful to Samantha and Sean. Treatment included an emphasis on cognitive factors (shifting negative selective attention in the relationship, standards for this phase of marriage, and Sean’s fear of “explosions” with Samantha), emotional factors (Samantha’s efforts to contain her anger to a greater degree and Sean’s efforts not to withdraw during such interactions when he sensed danger), and behavioral factors (including numerous discussions and problem-solving interactions resulting in significant behavior change). Therapy for Samantha and Sean lasted approximately 6 months, with weekly sessions tapering off over the course of treatment. The demands of family life with a young child continued, but the couple learned effective ways to address these concerns while enjoying the pleasures that came with Emily, along with recommitting to their relationship and giving it a higher priority.

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References

Introduction

Baucom, D. H., & Epstein, N. B. (1990). Cognitivebehavioral marital therapy. New York: Brunner/Mazel. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., Baucom, D. H., & Simpson, L. E. (2004). Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. Journal of Consulting and Clinical Psychology, 72(2), 176–191. https://doi.org/10.1037/0022-006x.72.2.176. Epstein, N., & Baucom, D. H. (2002). Enhanced cognitivebehavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Fischer, M. S., Baucom, D. H., & Cohen, M. J. (in press). Cognitive-behavioral couple therapies: Review of the evidence for the treatment of relationship distress, psychopathology, and chronic health conditions. Family Process. Gurman, A. S., Lebow, J., & Snyder, D. K. (Eds.). (2015). Clinical handbook of couple therapy (5th ed.). New York: Guilford Press. Johnson, S. M., & Greenberg, L. S. (1987). Emotionally focused marital therapy: An overview. special issue: psychotherapy with families. Psychotherapy, 24(3S), 552–560. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Shadish, W. R., & Baldwin, S. A. (2005). Effects of behavioral marital therapy: A meta-analysis of randomized controlled trials. Journal of Consulting and Clinical Psychology, 73(1), 6–14. https://doi.org/10.1037/ 0022-006X.73.1.6.

Cognitive-behavioral family therapy (CBFT) was born as the family therapy correlate to cognitivebehavioral therapy. That is, it integrates behaviorism and cognitive approaches and applies them to family systems. Because of its flexibility and continued evolution, CBFT is able to focus on a variety of problems, from promoting changes within individuals in families to altering family interaction styles. Furthermore, CBFT provides the fundamental principles and techniques to various empirically supported interventions and programs.

Cognitive-Behavioral Family Therapy Jing Lan and Tamara G. Sher The Family Institute, Northwestern University, Evanston, IL, USA

Name of Model Cognitive-Behavioral Family Therapy (CBFT)

Synonyms Behavioral family therapy (BFT)

Prominent Associated Figures Donald Baucom at the University of North Carolina Norman Epstein at the University of Maryland Gerald Patterson at the Oregon Social Learning Center at the University of Oregon Neil Jacobson at the University of Washington Andrew I. Schwebel at the Ohio State University Frank Dattilio at Harvard Medical School and the University of Pennsylvania

Theoretical Framework Core Concepts The main concepts of CBFT are rooted in behaviorism and cognitive-behavioral therapy. First, within the paradigm of behaviorism, operant conditioning is used as the central mechanism of change. Social learning theory is incorporated by interpreting symptoms as learned responses and emphasizing the impact of social reinforcers on shaping behaviors. Social exchange theory is also a primary component of CBFT, asserting that people strive to maximize rewards and minimize costs in relationships. Thus, behaviors can be changed directly by maximizing positive exchanges and minimizing negative exchanges (Lebow 2014; Lebow and Stroud 2016). Second, from the perspectives of cognitive therapy, CBFT posits that an individual’s perceptions and inferences are shaped by relatively

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stable underlying schema, which can be learned early in life from primary sources which then influence an individual’s automatic thoughts and emotional responses in significant relationships. Given the amount of shared experiences within a family, individuals often develop jointly held beliefs that constitute a family schema. If the family schema involves cognitive distortions, it may result in dysfunctional interactions (Dattilio 2009). Theory of Change As an integration of behaviorism, CBT, and system theory, CBFT views thoughts and behaviors as central to the (dys)functioning of the family. Thus, the underlying principle of CBFT is that the behavior of one family member leads to certain behaviors, cognitions, and emotions within the other family members. Those other family members then affect the cognitive and behavioral processes of the original family member in what is known as a feedback loop. Accordingly, the most efficacious pathways to change are seen as those that directly alter dysfunctional thoughts and behavioral patterns in a family system through changes at the individual and relationship levels. Specifically, the basic premise of behaviorism is that behavior is maintained by its consequences. Thus, behavior will change when the contingencies of reinforcement are altered. According to behaviorism, the general intent of therapy is to extinguish undesired behavior and reinforce positive alternatives. Similarly, the central tenet of a cognitive approach is that our interpretation of other people’s behavior affects the way we respond to them. Accordingly, the primary aim of CBFT is to help family members recognize distortions in their thinking, restructure it, and modify their behavior in order to improve their interactional patterns. Furthermore, with the incorporation of systems theory, CBFT maintains the focus on interactive aspects of the family rather than on internal processes of individuals. CBFT therapists take on the roles of experts, teachers, collaborators, and trainers. Therapists help families identify dysfunctional behaviors and thoughts and then work with them to set up behavioral and cognitive-behavioral management

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programs that will assist them in bringing about change. Families then carry out the programs as the therapists monitor the progress and setbacks. Throughout the process, therapists need to take an active role in designing and implementing specific strategies and are required to have persistence, patience, knowledge of learning theory, and specificity in working with families (Gladding 2019). Rationale for the Model As the term implies, CBFT is the deliberate and theory-based integration among cognitive therapy, behavior therapy, and family therapy. As such, its history can be seen as paralleling the history of cognitive-behavioral therapy (CBT) generally. At its most basic, CBFT has its roots in behavior therapy. During the 1960s and early 1970s, behaviorists applied learning theory, with a particular focus on stimulus and response, to family systems in order to train parents in behavior modification. Parallel to the addition of a cognitive component to traditional behavior therapy practices, behavioral family therapy soon transitioned to cognitive-behavioral family therapy with an added emphasis on the need for attitude change to promote behavior modification. Here, the system of the family was the focus of not just behavioral plans to encourage more adaptive responses to stimuli, but also helping family members see how their thinking about themselves and each other in the family can facilitate growth.

Populations in Focus CBFT has been used across diverse presenting problems and forms of psychopathology. With the foci on increasing parenting skills and facilitating positive family interactions, CBFT has proved effective for families with conduct problems, oppositional defiant disorder (ODD), child anxiety, depression, pediatric obsessive-compulsive disorder (OCD), pediatric bipolar disorder, eating disorders, attention deficit/hyperactivity disorder (ADHD), and trauma symptoms. CBFT has also been found to be effective across various cultures and subcultures. For example, research conducted in several countries

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with families from various racial and socioeconomic groups has demonstrated the efficacy of psychoeducational behavioral family therapy in reducing family stress and patient relapse of major mental disorders (Lucksted et al. 2012). This approach is largely based on CBFT principles and procedures. Another example is traumafocused cognitive-behavioral therapy (TF-CBT) which has been applied in multiple cultures and proved to be feasible for treating traumatized children of an Asian population (Kameoka et al. 2015). Although there is limited empirical evidence for the cultural sensitivity of CBFT, some multicultural strengths can be addressed based on its tenets. First, CBFT asserts that each individual is different in his or her own right. Thus, CBFT therapists are taught to be careful in understanding and defining behavioral norms and recognizing that family values and relational interactions differ between families and between cultures. Second, a central tenet of CBFT is that the therapist partners with the family throughout the therapeutic process. As a result, differences in cultures are discussed and brought to light so that all members of the process understand expectations and norms. Last but not least, its fundamental concepts tend to be easily understood across diverse populations.

Strategies and Techniques Used in Model CBFT applies cognitive-behavioral principles and techniques to family systems. In CBT for individuals, assessment and education are basic and important components and a focus across the treatment. The same is true for CBFT. Within CBFT, we can divide the primary interventions into two categories: those that assess and modify behavior patterns and those that assess and modify distorted and extreme cognitions. Assessment and Education In order to intervene with families, several aspects of their functioning have to be understood including how the system functions in different contexts, the unique strengths, and problematic

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characteristics of each family member and the family as a whole and how the interactions between family members maintain or detract from optimal functioning. As a result, the therapist constantly assesses different behavioral and cognitive patterns within and between family members. Although assessment never really ends, it tends to begin with a functional analysis of the behaviors of the family members. The functional analysis derives from three main sources of information: individual and joint interviews with the family members, self-report questionnaires and inventories, and the therapist’s behavioral observation of family interactions (Dattilio 2009). In addition, other methods of assessment can include more formal psychological testing and appraisals, consultation with previous therapists and other mental health providers, genograms, assessing motivation to change, and identifying automatic thoughts, core beliefs, cognitive distortions, and schema. A number of valid and reliable measures have been developed to provide an overview of key areas of family functioning. For example, questionnaires developed to assess general family functioning include the Family Environment Scale (Moos and Moos 1986), the Family Assessment Device (Epstein et al. 1983), and the SelfReport Family Inventory (Beavers et al. 1985). Other, more specialized assessment tools include the Family Adaptability and Cohesion Evaluation Scales-III (Olson et al. 1985), Family Coping Coherence Index (McCubbin et al. 1996), and the Family of Origin Inventory (Stuart 1995). In addition to written measures, CBFT therapists often rely on observational assessment tools such as observing family members’ interacting as they normally would or providing the family with specific topics for discussion in order to obtain a behavioral sample of the family. Once the therapists have completed a functional analysis of family behavior, they move to an instructor role as they teach families about the cognitive-behavioral model. This includes providing a brief didactic overview and periodically referring to specific concepts during the therapy. In this way, the families can better understand the roles their cognitive distortions have played in the

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interactions and how they inadvertently reinforce undesirable behaviors. It is also important for families to understand and buy into the idea that improvements in relationships often happen through deliberate, rule-governed strategies (such as direct instruction and skill training) and that most problems are solvable with constructive skills and actions. Thus, families may be encouraged to attend lectures, read books and watch videos together, and have discussions based on what they have heard, read, or seen (Dattilio 2009; Goldenberg et al. 2017). Intervention Techniques CBFT emphasizes behavior change. The cognitive component of the intervention comes into play when clients’ attitudes and assumptions get in the way of positive behavior changes.

Cognitive-Behavioral Family Therapy Cognitive-Behavioral Family Therapy, Table 1 Some reinforcers in operant conditioning (Gladding 2019) Techniques Classical conditioning

Positive reinforcement

Extinction

Time-out

Grounding

Interventions to Modify Behavior Patterns

The interventions in this category can be summarized into two main sections: operant conditioning and contracting and skills training. They have the common characteristics of being operationally definable, precise, and measurable. They are usually applied in combination so that family members learn individually and collectively how to give recognition and approval for desired behaviors instead of rewarding maladaptive ones. These fundamental behavioral concepts can lead to significant change in a short period of time (Gladding 2019). Operant conditioning is used most effectively in parent-child relationships where the aim is to increase desirable behavior patterns of children by modifying the contingencies of reinforcement coming from the adults (Table 1). There are several examples of operant conditioning interventions. Contingency contracting is a specific, usually written schedule or contract describing the terms for the exchange of behaviors and reinforcers between family members. One action is contingent, or dependent, on another. For example, parents might use a point system or “token economy” to reward children for specific behaviors such as doing chores or speaking nicely. The parents also work with the children to decide which behaviors should be a focus of

Job card grounding

Brief description In families, classical conditioning is used to associate a person with a gratifying behavior, such as a pat on the back or a kind word A positive reinforcer is usually a material (e.g., food or money) or a social action (e.g., a smile or praise) that increases desired behaviors Extinction is the process by which previous reinforcers of an action are withdrawn so that behavior returns to its original level The process of time-out involves removing children from an environment in which they have been reinforced for certain actions for a limited amount of time (approximately 5 min) Grounding is a disciplinary technique used primarily with adolescents. They are removed from stimuli to limit their reinforcement from the environment Job card grounding is a behavior modification technique that is used with adolescents. In this procedure, parents make a list of small jobs that take 15–20 min to complete and are not a part of the adolescent’s regular chores. When a problem behavior begins, the adolescent is given one of the jobs to complete and is grounded until the job is finished successfully

change and which might not be a priority. “Charting” is a skill whereby families are taught to keep an accurate record of the children’s problematic behavior. They are taught how to specially define the behavior and in what quantity it should be recorded such as every day or every time it happens. This can be used when parents want to establish a baseline of the occurrence of targeted behavior before and after the intervention in order to assess it across time. It should be noted here that charting is both a tool of assessment and the intervention because the charting itself often changes behaviors without other intervention being necessary. Another example of an operant behavioral technique is based on the “Premack principle” whereby family members must first do

Cognitive-Behavioral Family Therapy

less pleasant tasks before they are allowed to engage in pleasurable activities. Here, the more pleasant tasks serve as positive reinforcers for the less pleasant ones. Finally, in order to apply these operant techniques to the level of the family, “behavior-change agreements” are used. Here, each family member learns that when they engage in a specific behavior, another family member will be prompted to engage in a different behavior and so on. Rather than setting this up as a “tit for tat” negotiation, it is used to delineate how each person’s behavior affects and is affected by the behaviors of the other members of the family (Gladding 2019; Nichols 2017). The most commonly used skill trainings are communication training, problem-solving training, and parenting skills training. Communication training improves skills for expressing thoughts and emotions, as well as for listening effectively to others. Therapists begin by presenting instructions to family members about specific behaviors involved in each type of expressive and listening skill with the assistance of handouts describing the communication guidelines. They then coach the families during session and often model good skills for them. Session skills are then practiced as homework in order to increase and maintain improvement. In problem-solving training, therapists use verbal and written instructions, modeling, and behavioral rehearsal and coaching to facilitate effective problem-solving with family members. The steps include achieving a clear specific definition of the problem, generating specific behavioral solutions to the problem, evaluating the advantages and disadvantages of each alternative solution, and selecting and agreeing on implementing one solution. Finally, the main aim of parenting skills training is to change parents’ responses to children by educating parents about operant learning principles, developing their ability to observe children’s behavior systematically, and coaching them in using developmentally appropriate skills to set constructive limits on children’s behavior and reinforce positive behaviors. As parents learn better ways to ask for good behavior, children learn better ways of behaving. Parents are also taught that if they give up focusing on less important behaviors (e.g.,

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wearing a coat in colder weather), more important behavioral changes are more likely to be incorporated. Here, the therapist begins by defining a specific problem behavior and monitoring it in regard to its antecedents and consequences. The parents are then trained in social learning theory with verbal and performance training methods. Verbal methods involve didactic instruction, as well as written materials, with the aim of influencing thoughts and messages. Performance training methods may involve role-playing, modeling, engaging in behavioral rehearsal, and prompting, with the focus on improving parent-child interactions that are easily understood by the children, given their current level of development. Regardless of the form of the training, parents are asked to chart the problem behavior over the course of treatment. Successful efforts are rewarded through encouragement and compliments by the therapist (Dattilio and Epstein 2016; Goldenberg et al. 2017). Interventions to Modify Distorted and Extreme Cognitions

Generally speaking, this category of interventions includes (1) cognitive restructuring techniques, which aim to help family members better monitor the validity (how accurate one’s thoughts are) and the appropriateness (the utility of one’s beliefs) of their cognitions, and (2) self-monitoring skills, by which therapists teach family members how to actively and consciously assess and intervene their cognitions in any given situation. Specifically, in order to restructure the cognitions, therapists can teach older family members to identify automatic thoughts and associated emotions and behaviors and identify cognitive distortions and label them. Children can also be taught to identify and express their emotions appropriately. Then, therapists can test and challenge the automatic thoughts and reinterpret them by considering alternative explanations. In this process, some specific techniques are commonly used. For example, “behavioral experiments,” where families are encouraged to test their predictions that particular actions will lead to certain responses from other members, can provide firsthand evidence in order to reduce one’s negative

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expectancies. When family members attempt to identify their thoughts and responses that occurred in past incidents and have difficulty recalling pertinent information, imagery or roleplaying techniques can be helpful to recollect the past interactions. Furthermore, the “downward arrow” technique can be used to track the associations among one’s automatic thoughts and to identify the underlying core beliefs beneath one’s automatic thoughts (Dattilio 2009; Dattilio and Epstein 2016). Self-instructional training is a form of selfmanagement that focuses on people instructing themselves. It is assumed that problems may be based on maladaptive self-statements and selfinstruction affects behavior and behavioral change. In self-instructional training, a selfstatement can serve as a practical clue in recalling a desirable behavioral sequence, or it can interrupt automatic behaviors or thought chains and thereby encourage more adaptive coping strategies. In families, it is more often employed in helping impulsive children modulate their impulsivity through deliberate and task-oriented “selftalk” (Gladding 2019). In conclusion, CBFT uses behavioral and cognitive interventions to both assess behavior across time and change it for more adaptive family interactions. Most commonly, behavioral components play a larger role than cognitive ones, but both categories provide the therapist with a large “tool box” of possible interventions for different families, presenting problems, and pathology. Intervention Models There are a number of specific types of therapy based on the general principles of CBFT. For example, parent-child interaction therapy (PCIT) addresses child behavioral problems with a twostage intervention model including a relationship enhancement phase and a discipline phase (Galanter et al. 2012). Similarly, functional family therapy (FFT) is a family-based, empirically supported treatment for behavioral problems, especially with adolescents (Alexander and Robbins 2018). Perhaps the best known and most adaptable program is the “Triple P (positive parenting program).” Triple P is a parenting and

Cognitive-Behavioral Family Therapy

family support system designed to prevent and treat behavioral and emotional problems in children and teenagers and create family environments that encourage children to realize their potential. The sophistication of this program is that it has been used in a number of different formats including work with individual parents, groups of parents, agencies working with parents, and even government agencies states responsible for the dissemination of parenting guidelines (Sanders and Turner 2017).

Research About the Model Research on the effectiveness of CBFT is extensive in terms of individual outcomes but lean in terms of family outcomes. The outcome studies have focused mostly on the effectiveness of behaviorally oriented family interventions in treatment of major mental disorders in individual members, such as the psychoeducation and training in communication and problem-solving skills (Mueser and Glynn 1999), rather than on alleviating general conflict and distress within the family. For example, some studies have demonstrated the efficacy of training parents in behavioral interventions for conduct disorders (Forgatch and Patterson 2010). Other studies provide empirical support for behavioral family therapy for childhood ADHD (Kaslow et al. 2012). There is also strong evidence for the effectiveness of familybased/family-focused CBT in the treatment of childhood anxiety disorders (Kaslow et al. 2012), adolescent eating disorder (Le Grange et al. 2015), pediatric bipolar disorder (West et al. 2014), pediatric OCD (Selles et al. 2018), trauma symptoms (Kameoka et al. 2015), and prevention of suicide attempts (Asarnow et al. 2017). Little research has been conducted on CBFT for difficulties in the family as a whole, either in adapting to developmental life-stage changes or in coping with external stressors affecting the family (Dattilio and Epstein 2016). However, CBFT principles and methods have been adapted to the treatment of a variety of problems that families

Cognitive-Behavioral Family Therapy

face in coping with forms of dysfunction in individual members and have demonstrated their effectiveness, such as estrangement in family of origin (Dattilio and Nichols 2011). Another example is that, a psychoeducational parenting program, rooted in cognitive-behavioral principles, has been found to be especially effective as an intervention for at-risk parenting behavior, such as child abuse (Nicholson et al. 2002).

Case Example This is an adoptive, multiracial family. Jane is a 51-year-old Caucasian female. She was born in the United States and works as an IT engineer. Davonti is a 49-year-old African-American male who is a stay-at-home father, having been let go from his job as an adjuster for an insurance company. They define themselves as middle class which is important to them, given that Jane was raised in a working/lower-class family that struggled with money, while Davonti comes from an upper middle-class family where his mother was a lawyer and his father was a university professor. The two struggled with infertility for about 10 years before adopting Jenny, a 10-year-old girl from China, 6 years ago. Jane was very insistent on having children and took the lead in both fertility treatment and in the adoption process. Davonti was less sure about adding a child to the family given that they had a history of financial difficulties due to neither of them paying attention to a family budget. They presented for therapy after finding out that Jenny was caught stealing lunches out of lockers at school and lying to her teachers and parents about it. Jane wanted therapy because she wanted to understand why Jenny stole the lunches. Davonti believes that this was a child “being a child” and that Jane and the teachers were overreacting to a minor infraction. The therapy began with the therapist assessing the nonverbal behaviors of the family members. He noted that each person in the family sat apart from the rest, with both Davonti and Jenny appearing sullen. When the therapist then asked

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each person why they were here, only Jane spoke. Both Jenny and Davonti said they had no idea. The therapist then educated the family on how family therapy can be helpful in terms of improving communication and relationships. Davonti indicated that they got along just fine. At this point, Jenny looked at her mother and squirmed in her chair. When the therapist directed a question to Jenny about how she thought they all got along, she said that nobody really talked to each other, but that was fine with her. Jane then interjected that she tries to get Jenny to come out of her room and takes away her screen time when she refuses. The therapist then asked Jane about her feelings about all the separateness at home. She said that she values privacy because she grew up in a house that was very small with her and her two sisters sharing a bedroom and having no personal space or place in the home to keep any possessions. She also noted that Davonti is really the one who spends all of his time in their room, sleeping most of the day. Davonti then was able to interject that he is sick of hearing how poor Jane was growing up. At this point, Jenny pulled out her headphones and put them on. While Davonti seemed indifferent to this behavior, Jane reached over, grabbed the headphones, and told Jenny that the headphones were “going away for a long time.” From this point on, Jenny refused to speak. The therapist asked the family if it would be ok to talk to Jenny alone. All agreed. He asked Jenny when her parents left the room if this family interaction was typical. She said yes, that her father let her do pretty much whatever she wanted and her mother didn’t understand her at all. She also said she was sick of hearing how poor her mother had been and how lucky she should feel now. When the therapist brought everybody back together, he made a few observations. First, he gently wondered aloud if Davonti might be depressed (individual psychopathology). He also asked the parents if they had ever talked to Jenny about her early years (communication). They both indicated that they assumed she would not want to reflect on such a painful time (cognitive distortion). At this point, Jenny burst into tears saying that all they cared about was money and that they

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assumed that she didn’t want to talk about China on the idea that she had been raised in a poor community in China by various foster parents (generalization and assumptions). She also said that her mother complains about her being in her room all the time, but in fact it is her mother who is always on her phone (reinforcers). The therapist at this time knew enough to make a tentative intervention plan. He suggested that he would teach them how to talk about feelings in a way that felt respectful and validating (education) and could help them decrease the assumptions they had been making (cognitive distortions). He also said that he would help each of them identify which behaviors of the others they would want changed and what they were willing to change themselves (contingency contracting). Finally, he told them that he would help them devise a family responsibility chart based on what behaviors the others wanted to see changed and what they each wanted as a reward for making their own changes (reinforcement). Throughout the delivery of the treatment plan, the therapist was careful to ask for understanding and agreement from each family member before proceeding to the next intervention idea (partnering). At the end, he noted that he would like to meet with each person alone over the next few weeks for part of the sessions in order to understand what individual issues might be impacting the family as a whole and the behavior of each such as depression, resentment, or fears about poverty (focus on the individual in order to show how change in one might affect the whole system). The therapy was fairly successful in that the family learned to work together to identify issues that each wanted changed in the other. It also helped Davonti see how individual therapy might be used to supplement the family sessions so that his depression and feelings of low selfworth based on not working might be addressed. Jane was helped to be more “present” when she was home. Finally, they all learned that one possible explanation for the lunch stealing was Jenny’s fear that she would be poor again based on her pre-adoption experience and the emphasis on poverty in the home now.

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Cross-References ▶ Assessment in Couple and Family Therapy ▶ Baucom, Donald ▶ Behavioral Parent Training in Couple and Family Therapy ▶ Cognition in Couple and Family Therapy ▶ Cognitive Behavioral Couple Therapy ▶ Communication Training in Couple and Family Therapy ▶ Contingency Contracting in Couple and Family Therapy ▶ Epstein, Norman ▶ Functional Family Therapy ▶ Homework in Couple and Family Therapy ▶ Jacobson, Neil ▶ Modeling in Couple and Family Therapy ▶ Parent-Child Interaction Family Therapy ▶ Parenting Skills Training in Couple and Family Therapy ▶ Patterson, Gerald ▶ Role Playing in Couple and Family Therapy ▶ Schemas in Families ▶ Token Economy in Couple and Family Therapy ▶ Triple P – Positive Parenting Program System

References Alexander, J., Robbins, M. (2018). Functional Family Therapy. In: Lebow J., Chambers A., Breunlin D. (eds) Encyclopedia of Couple and Family Therapy. Cham: Springer. Asarnow, J. R., Hughes, J. L., Babeva, K. N., & Sugar, C. A. (2017). Cognitive-behavioral family treatment for suicide attempt prevention: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 56(6), 506–514. Beavers, W. R., Hampson, R. B., & Hulgus, Y. F. (1985). The Beavers systems approach to family assessment. Family Process, 24, 398–405. Dattilio, F. M. (2009). Cognitive-behavioral therapy with couples and families: A comprehensive guide for clinicians. New York: Guilford Press. Dattilio, F. M., & Epstein, N. B. (2016). Cognitivebehavioral couple and family therapy. In T. L. Sexton & J. Lebow (Eds.), Handbook of family therapy (pp. 89–119). New York: Routledge. Dattilio, F. M., & Nichols, M. P. (2011). Reuniting estranged family members: A cognitive-behavioralsystemic perspective. American Journal of Family Therapy, 39, 88–99.

Colapinto, Jorge Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The MacMaster Family Assessment Device. Journal of Marital and Family Therapy, 9, 171–180. Forgatch, M. S., & Patterson, G. R. (2010). Parent management training – Oregon model: An intervention for antisocial behavior in children and adolescents. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 159–178). New York: Guildford. Galanter, R., Self-Brown, S., Valente, J. R., Dorsey, S., Whitaker, D. J., Bertuglia, M., & Prieto, M. (2012). Effectiveness of parent-child interaction therapy delivered to at-risk families in home settings. Child and Family Behavior Therapy, 34, 177–196. Gladding, S. T. (2019). Family therapy: History, theory, and practice (7th ed.pp. 243–265). New York: Pearson. Goldenberg, I., Stanton, M., & Goldenberg, H. (2017). Family therapy: An overview (9th ed.). Belmont: Cengage learning. Kameoka, S., Yagi, J., Arai, Y., Nosaka, S., Saito, A., Miyake, W., et al. (2015). Feasibility of trauma-focused cognitive behavioral therapy for traumatized children in Japan: A pilot study. International Journal of Mental Health Systems, 9(1), 26. Kaslow, N. J., Broth, M. R., Smith, C. O., & Collins, M. (2012). Family-based interventions for child and adolescent disorders. Journal of Marital and Family Therapy, 38, 82–100. Le Grange, D., Lock, J., Agras, W. S., Bryson, S. W., & Jo, B. (2015). Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry, 54(11), 886–894. Lebow, J. L. (2014). Couple and family therapy: An integrative map of the territory. Washington, DC: American Psychological Association. Lebow, J. L., & Stroud, C. B. (2016). Family therapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, & R. Krishnamurthy (Eds.), APA handbook of clinical psychology, Vol. 3: Applications and methods (pp. 333–335). Washington, DC: American Psychological Association. Lucksted, A., McFarlane, W., Downing, D., Dixon, L., & Adams, C. (2012). Recent developments in family psychoeducation as an evidence-based practice. Journal of Marital and Family Therapy, 38, 101–121. McCubbin, H. I., Larsen, A., & Olsen, D. (1996). Family coping coherence index (FCCI). In H. I. McCubbin, A. I. Thompson, & M. A. McCubbin (Eds.), Family assessment resiliency coping and adaptation inventories for research and practice (pp. 703–712). Madison: University of Wisconsin. Moos, R. H., & Moos, B. H. (1986). Family environment scale manual (2nd ed.). Palo Alto: Consulting Psychologists Press. Mueser, K. T., & Glynn, S. M. (1999). Behavioral family therapy for psychiatric disorders. Boston: Allyn and Bacon.

505 Nichols, M. P. (2017). Family therapy: Concepts and methods (11th ed.). Boston: Allyn-Bacon (Pearson). Nicholson, B., Anderson, M., Fox, R., & Brenner, V. (2002). One family at a time: A prevention program for at-risk parents. Journal of Counseling and Development, 80, 362–371. Olson, D. H., Portner, J., & Lavee, Y. (1985). FACES-III, Family social sciences. St. Paul: University of Minnesota. Sanders, M. R., Turner, K. M. T. (2017). Triple P – Positive Parenting Program System. In: Lebow J., Chambers A., Breunlin D. (eds) Encyclopedia of Couple and Family Therapy. Cham: Springer. Selles, R. R., Belschner, L., Negreiros, J., Lin, S., Schuberth, D., McKenney, K., et al. (2018). Group family-based cognitive behavioral therapy for pediatric obsessive compulsive disorder: Global outcomes and predictors of improvement. Psychiatry Research, 260, 116–122. Stuart, R. B. (1995). Family of origin inventory. New York: Guilford Press. West, A. E., Weinstein, S. M., Peters, A. T., Katz, A. C., Henry, D. B., Cruz, R. A., & Pavuluri, M. N. (2014). Child-and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: A randomized clinical trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(11), 1168–1178.

Colapinto, Jorge Richard Holm Minuchin Center for the Family, Woodbury, NJ, USA

Introduction Building upon the work of Dr. Salvador Minuchin, Jorge Colapinto has had a unique impact on family systems theory and practice through his application of Structural Family Therapy (SFT) to marginalized families and the larger systems that serve them.

Career Colapinto received his Licentiate in Psychology from the University of Buenos Aires in 1967. He moved to the United States in 1976 to

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train and work with Dr. Salvador Minuchin at the Philadelphia Child Guidance Clinic. There, he served as an outpatient therapist and a faculty member in the Extern Program in SFT. When Dr. Minuchin moved to New York and founded the Family Studies institute in the mid-1980s, Colapinto joined his consulting team. The team applied SFT concepts and techniques in their work with the foster care system. Between 2000 and 2004, Colapinto consulted with the New York Administration for Children Services on a family-focused approach to permanency and between 2005 and 2008, on the implementation of family team conferences for safety decisionmaking. He also served as a member of the New York City Child Welfare Advisory panel between 2002 and 2003. Colapinto taught in the University of Pennsylvania School of Education from 1982 to 1989, and in the Drexel University Couple and Family Therapy program from 2009 to 2015. He has presented frequently on families, family therapy, family therapy training, and interventions with larger systems, at workshops and conferences in the United States and abroad. Currently he is the Coordinator of Training and Supervision for the Minuchin Center for the Family, where he also directs a grant-supported project for the development of an evidence-based Structural Family Therapy model for the prevention of child maltreatment.

Contributions to Profession Colapinto’s writings provide a clear exposition of SFT and its application to supervision, training, and particularly to understanding and intervening on the context of larger systems that impact on families (1988, 2016). Continuing and expanding upon the initiatives of Salvador Minuchin, Colapinto devoted his career to the application of the theory and practice of SFT to the work with families involved with the child welfare system. This is an endeavor to change not only the families but also the policies and procedures that

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affect them. In Working with Families of the Poor (2007), Colapinto and his co-authors Patricia and Salvador Minuchin articulated the application of SFT to the field of child welfare, foster care, protective services, and mental health, and substance abuse treatment. His writings highlight how larger systems, despite their goal of helping children and families, can sometimes dilute the very processes they are attempting to support (1995). This can happen when larger systems assume the decision-making function within families and link individual family members to separate services, thus decreasing the family’s cohesiveness, connectedness, and access to natural resources. Whether as a therapist, supervisor, consultant, or trainer, Colapinto assumes a socially responsible stance towards his work with families that have lost or surrendered autonomy to the larger system (1998). He directs and encourages family members to actualize alternative ways of relating to one another and to the institutions that impact them, with the goal of helping them regain control over their lives. These actions are based on his belief that family members are multifaceted and possess the latent competence and resources they need to function more effectively and autonomously. A nurturer of family processes, Colapinto focuses not on what relational issue contributes to the problem but rather on what latent “missing pattern” within the family can be encouraged and supported to bring about change. As part of a larger effort to transform the service delivery system toward a more family friendly approach, his consultations typically take place on-site in social agencies and institutions where the family is receiving services. In recognition of his contributions, The American Family Therapy Academy honored Colapinto in 2012 with its Distinguished Contribution to Social Justice Award.

Cross-References ▶ Minuchin, Salvador ▶ Structural Family Therapy

Collaboration with Clients in Couple and Family Therapy

References Colapinto, J. (1988). The structural way. In H. Liddle, D. Breulin, & R. Schwartz (Eds.), Handbook of family therapy training and supervision. New York: Guilford Press. Colapinto, J. (1995). Dilution of family process in social services. Implications’ for treatment of neglectful families. Family Process, 34, 59–74. Colapinto, J. (1998). Structural family therapy and social responsibility. In Paper presented at the X world family therapy conference. Dusseldorf. http://colapinto.com/ files/SocialResponsibility.doc. Colapinto, J. (2016). Structural family therapy. In T. Sexton & J. Lebow (Eds.), Handbook of family therapy. New York: Routledge. Minuchin, P., Colapinto, J., & Minuchin, S. (2007). Working with families of the poor (2nd ed.). New York: Guildford.

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Harry Goolishian developed Collaborative therapy, a framework that encourages therapists to cocreate the therapy process with families through dialogue (Anderson 2007). Therapeutic conversations integrate values around therapist-family co-equality, therapist attunement to clients’ worldviews, and reinforcement of clients’ agency in hypothesizing, reframing, and feedback. In collaborative couple therapy, the therapist works with each partner collaboratively to improve the capacity of each to work similarly with each other (Wile 2011). In multisystemic and other empirically-based therapies, as both stance and strategy, collaboration is a common factor linked to client outcomes (Kazantzis and Kellis 2012).

Theoretical Context for Concept

Collaboration with Clients in Couple and Family Therapy Donna Baptiste, Trang Nguyen and Kesha Burch The Family Institute at Northwestern University, Evanston, IL, USA

Name of Concept Collaboration in couple and family therapy

Introduction In psychotherapy, collaboration refers to a philosophical stance or framework as well as a broad range of strategies that therapists use to build alliances, engender trust, converse with clients, and engage them in their recovery (Kazantzis and Kellis 2012). In couple and family therapy, collaboration involves forging alliances with each member of the dyad or family, and with the whole system, while respecting developmental hierarchies and boundaries. Collaboration can be considered to be a framework guiding therapy as well as a common therapeutic factor. For example, postmodern scholars Harlene Anderson and

In collaborative therapy, clinicians regard knowledge and ideas as socially constructed and not universal truths (Anderson 2007). Like family systems, therapy systems generate meaning and solutions through conversations or language – a means to engage the social world and gain insight into problems and solutions. In this approach, language plays a crucial role in improving family outcomes and contributes to therapists’ growth and learning. Clients’ deconstruction of their concerns is also just as valuable as therapists’ expert knowledge. Multisystemic and other evidenced-based family psychotherapists endorse a collaborative approach for problem youth and resistant or disengaged families (Tuerk et al. 2012). Therapist–family partnerships are crucial to work with youth in contexts of their helping systems that affect their everyday lives. Multisystemic therapists engage families through the lens of strengths by helping them to understand the therapy process and to see it as useful. Therapists create partnerships through reflective listening, empathy, authenticity, and flexibility with therapy setbacks. Therapists amplify family inputs as significant and accommodate family expectations and goals in forging solutions.

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In collaborative couple therapy, Wile (2011) suggests that therapists engage partners as consultants to guide the process in which conflicts are reframed as an inability to communicate heartfelt hurts and disappointments. When partners cannot express their exact thoughts and feelings, they use adversarial or avoidant “fallback” strategies that create gridlock. Wile (2011) believed that couple dynamics can be improved by encouraging them to attend to how they communicate around conflicts and how they show compassion for themselves and each other.

Description In collaborative therapy, Anderson (2007) recommends synchronicity with clients through the use of cooperative language, respectful listening, exploratory questions, a capacity to simultaneously hold multiple and competing ideas, and conversing in the family’s style with respect for their sociocultural dynamics and worldviews. In multisystemic family therapy, Tuerk et al. (2012) suggest highlighting family strengths throughout treatment, reflective listening, reframing, empathy, and perspective taking. These strategies convey an understanding of suffering, encourage trust, counteract the family’s negative experiences with larger systems (e.g., child welfare). Therapists must remain hopeful about families and energize them to keep trying towards self-efficacy, even when they feel discouraged. Authenticity in communication with families and flexibility with therapy setbacks are also crucial. Therapists should also advocate for families with larger systems that denigrate and marginalize. In collaborative couple therapy, Wile (2011) encourages therapists to use their triggers or reactions as clues to what partners are thinking and feeling or how they may be using adversarial or avoidant strategies. In a collaborative mode, therapists can amplify the inner struggles of each person in the union and steer dyads towards intimate and authentic relating. This strategy involves exchanging heartfelt concerns and showing compassion for self and the other.

Collaboration with Clients in Couple and Family Therapy

Application of Concept in Couple and Family Therapy Sundet’s (2011) study of what therapists and clients value in collaborating highlights three domains that undergird approaches discussed above. The three domains are conversations, participation, and relationships. Conversation refers to verbal processes that include exploratory and focused questions to understand families’ worldviews, dynamics, and goals. Therapists are encouraged to give both positive and negative feedback, with negative feedback perceived by families as safe and tolerable when the therapy environment is helpful and supportive. Families also value therapists’ hypotheses and reframing, based on their knowledge, to enlarge perspectives, action steps, and experiences. A goal of the conversation is to offer families corrective experiences through respect and support. Participation involves therapists’ application of expert knowledge in ways that do not undermine a family’s sense of their problems, culture, and values. Participation also suggests a deep capacity for therapists to join with families through authentic styles and affect attunement and to bond over everyday life struggles. Sundet (2011) indicated that in collaborating, families do not want to be merely objects of scrutiny, and therapists do not want families to take them for granted. Relationship implies “to be where people are” and “to get a taste of it” (Sundet 2011, p. 240) through listening, taking disclosures seriously, and believing families. It also implies establishing and following the families’ preferred goals and expectations, using expert knowledge as an enhancement. Therapists’ generosity in giving of themselves and willingness to foster human connections strengthens such relationships. Productive working relationships with families may mean mediating with other systems, and this can help families to regain a sense of honor and dignity in accessing resources.

Collaboration with Clients in Couple and Family Therapy

Clinical Example Byron, a 13-year-old teenager, started therapy due to problems at school. He was in the care of a 63-year-old woman with over 20 years of experience raising foster children. She was raising three other foster children and two of her grandchildren when Byron entered the home. Before this, Byron had six failed foster care and there were significant ambiguities and gaps in his clinical records and diagnoses, suggesting his case should be updated. The new family therapist convened a meeting with Byron and his foster mother, and a separate meeting with the caseworker. The therapist encountered an engaging young man, slightly introverted, with interests in social media, music, and acting. However, Byron had a quirky disposition and chaotic personal boundaries, which explained poor school adjustment. He talked out of turn, invaded personal space, and seemed overly inquisitive. His peers liked him, but his unusual manner created arguments and peer rejection in school. Byron’s foster mother was anxious about his potential to be expelled from school. The therapist built rapport with Byron’s foster mother and sensed that she felt unsupported by other systems. The therapist suggested three goals: to clarify Byron’s mental health profile, to work collaboratively with his other systems of care, and to stabilize the current placement. Byron’s diagnoses of schizophrenia, bipolar disorder, psychosis, and autism were ruled out based on a neuropsychological assessment. Byron received a diagnosis of ADHD, was averagely intelligent, and had poor social skills and features of disorganized attachment. The therapist also connected Byron with a psychiatrist to begin stimulant medication. The psychiatrist also collaborated with Byron and the foster family on attunement, attachment, and social skills. Additionally, the psychiatrist worked with the caseworker, foster mother, and school staff to design individual educational and 504 plans for classroom behavior, academic compliance, and school-based group support. The therapist worked

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closely with the psychiatrist and Byron’s foster mother to help them understand medication requirements and regimens. Setbacks during the 3 years of treatment included caseworker changes, family discouragement, and disengagement due to sibling difficulties. Byron had inconsistent academic achievement although behavior at school improved. Byron also ran away to search for his first foster family, requiring crisis services. With each nuance in treatment, the therapist convened parts of the family and helping system as needed. Over 3 years, the family-adolescent attachment improved, and Byron embarked on a vocational track with interest in media production and acting. Five years later, the therapist learned that Byron, now 19, still lived in the same home, worked at a restaurant, had a committed relationship, and was active as usual on social media. He was in therapy and still on stimulant medications. Byron had setbacks, but he seemed to be achieving appropriate developmental milestones. The keys to successful collaboration, in this case, were the therapist’s positive regard for Byron and the foster family, optimism about Byron’s future, advocacy for Byron within systems of care, and resilience with treatment setbacks. Seeing Byron’s strengths created new pathways to clarify his diagnosis and treatment. While Bryon’s needs were paramount, the therapist also conveyed deep empathy for the needs of the foster parent and siblings and tried to address those needs as well.

Cross-References ▶ Alliance in Family Relationships ▶ Alliance Scales in Couple and Family Therapy ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Collaborative Couple Therapy ▶ Postmodernism in Couple and Family Therapy ▶ Split Alliance in Couple and Family Therapy ▶ Therapeutic Alliance in Couple and Family Therapy ▶ Using Collaborative Helping Maps to Organize Therapeutic Conversations with Couples

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References Anderson, H. (2007). The heart and spirit of collaborative therapy: The philosophical stance – “A way of being” in relationship and conversation. In H. Anderson & D. Gehart (Eds.), Collaborative therapy: Relationships and conversations that make a difference (pp. 43–59). New York: Routledge. Kazantzis, N., & Kellis, E. (2012). A special feature on collaboration in psychotherapy. Journal of Clinical Psychology, 68(2), 133–135. Sundet, R. (2011). Collaboration: Family and therapist perspectives of helpful therapy. Journal of Marital and Family Therapy, 37(2), 236–224. Tuerk, E. H., McCart, M. R., & Henggeler, S. W. (2012). Collaboration in family therapy. Journal of Clinical Psychology, 68(2), 168–178. https://doi.org/10.1002/ jclp.21833. Wile, D. B. (2011). Collaborative couple therapy. In D. K. Carson & M. Casado-Kehoe (Eds.), Case studies in couples therapy: Theory-based approaches (pp. 303–316). New York: Routledge.

Collaborative and Dialogic Therapy with Couples and Families Sue Levin1,2 and Adriana Gil-Wilkerson1 1 Adjunct Faculty, Our Lady of the Lake University, Houston, TX, USA 2 The Taos Institute, Chagrin Falls, OH, USA

Synonyms CLS (collaborative language systems); Collaborative; Collaborative practices; Conversational therapy; Dialogical; Not knowing; Problemdetermined system; Postmodern approaches; Relational therapy; Social constructionist theories

Therapy Strategies and Interventions Name of the Strategy or Intervention Collaborative and dialogic therapy does not use particular strategies or interventions; rather, it demonstrates a philosophical stance in the way that therapeutic conversations and dialogues are conducted (Anderson 1997, 2000, 2001). The

therapist, or other helper, using this approach, engages clients from a non-knowing stance or position of a curious and respectful learner; the client(s) is the expert on their own concerns, struggles, goals, and preferred outcomes. Introduction Collaborative and dialogic therapy is used at the Houston Galveston Institute (HGI), a counseling and training center currently located in Houston, TX. The institute was founded in Galveston, Texas, by Harry Goolishian, Harlene Anderson, and several of their contemporaries who had begun to experiment working with the families of their clients in a medical school setting where family therapy was not being practiced (Anderson et al. 1986). They began including more people’s voices in the therapeutic treatment of people who were hospitalized and struggling with chronic mental health. Working with the individual and his or her family members, Goolishian, Anderson, and their colleagues noticed that the perspective offered to them about their clients’ contexts was much broader and often provided valuable interactions creating possibilities for change and opportunities for members of the system to change their perspective or perception of the context in a way that provided relief or a dissolving of a problem. In collaborative and dialogic practices, a client and the therapist are engaged in conversation where they are mutually learning from each other and creating, through dialogue, ways of exploring the topics and concerns the client is identifying or has previously identified. In collaborative and dialogic practices, a therapist and client are conversational partners that equally engage in dialogue about the client’s concerns and then decide together about the direction of therapy. Theoretical Framework (e.g., “This is utilized most in X models and Y theories.”) Collaborative* and dialogic* therapy is a postmodern approach to therapy and has evolved from interdisciplinary studies in hermeneutics, physics, philosophy, linguistics, and poststructural and postpositivist theories that emphasize the subjective and

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socially constructed nature of reality. It is often categorized with other postmodern approaches such as narrative and solution-focused therapies. Rationale for the Strategy or Intervention The collaborative* and dialogic* therapy approach developed out of the modernist, medical model of therapy, including in family therapy, in which the therapist is viewed as the expert in diagnosing the client/family and determining the most effective treatment interventions. Collaborative practices* grew from studies in quantum physics, postmodernism, hermeneutics, and other areas of study that emphasize the subjective nature of reality. This translates into a focus on the clients’ viewpoints, the need to engage the client more fully, and the belief that the clients’ voice (s) and their story must lead in a relational and dialogic exploration of the problem description and the solution. Description of the Strategy or Intervention Collaborative and dialogic therapy is rooted in a philosophical stance and practices that are relational in nature. Collaborative and dialogic therapy is most commonly described as a way of being as opposed to a theoretical framework or orientation (Anderson 1997, 2001, 2007). This implies that each practitioner has expertise in providing a space for the client to explore their reasons for coming to therapy and in conversational skills that are not usually intended to be evaluated or quantified. This idea provides a challenge for a postmodernist – to speak about the active part of our work without identifying and labeling it as a strategy or intervention as we usually identify each context as part of the relational experience that leads to the co-creation of knowledge. Some indicate that our strategy or intervention is the actual conversation while others might venture to say that the interventions or strategies used in collaborative therapy are the questions the therapist asks. Thus a challenge arises in attempting to describe a collaborative therapist’s work, in that using the language of intervention and strategies we unintentionally create standards that are not universal, but were created for a particular client or situation where the ideas and interactions were

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helpful. Rather than create a list of interventions or strategies, our philosophy is grounded in the tenets of providing a respectful, conversational experience for the participants. We begin each client meeting with an intentionality of walking with them and addressing them with the focus of hosting a dialogical conversation in the moment as opposed to the intention of solving a problem. Anderson (2007) describes how to enhance dialogue by means of skills that are integral to being a responsive listener in a conversation and to having a relational presence in a conversation where the speakers are able to have a dialogical exchange back and forth – with the therapist engaged in conversation with genuine curiosity about the client’s thoughts and ideas and whereby the client feels heard and safe to express him or herself. One of the practices we invite clients to work with is reflecting teams (Andersen 1991, 1992; Anderson and Jensen 2007). At HGI, clients are given the option of seeing their therapist with a reflecting team present. The reflecting team consists of other therapists who are at different levels of experience, some are students, some supervisors, and others are newly licensed therapists. The way we organize the therapy session allows for the therapist and client to have a conversation that is at least half of the hour where the reflecting team members are in a listening role and not commenting or asking questions, and when that conversation is at a stopping point, the therapist checks in with the client to find out whether it would be a good time to transition the conversation from the therapist and client to the reflecting team. Once the client and therapist agree that it is a good time for that transition, the reflecting team members are instructed to have a conversation with each other to discuss ideas that they had while listening to the conversation. The team members then ask questions that are intended to expand the conversation and generate possibilities for the clients present. Once the reflecting team has had a conversation about the session conversation, the clients are offered an opportunity to discuss anything that the team brought up or into further conversation with their therapist. The reflecting team then takes on a listening role again and the client chooses to respond, reflect,

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or continue their conversation with the therapist. Sometimes, in the moment, clients do not respond to reflections offered by the team members but come back weeks later to reference an idea or a comment one of the reflecting team members brought up. Case Example At the Houston Galveston Institute, we work with couples of all kinds. When working with couples in collaborative and dialogic practices, we offer to see them with reflecting teams as a way to expand our possibilities, perspectives, and ways of looking at the situation. The therapist or co-therapy team engages the couple in conversations about their experiences, especially those which have led them to seek our help. From the time we have a phone conversation with a potential client until we are having a termination conversation or session, we engage in conversations that are intended to include the client in decisionmaking about their experience in therapy with us. We work together with our clients to arrange the details of their attending therapy. For example, one of our clients that came in as a couple knew they wanted to use a reflecting team due to a previous experience some of their family members had at HGI. Our arrangements with them were made based on their needs. The wife, Shauna*, scheduled a few appointments with one of our therapists and then informed her that she would like to bring her husband, Rick*, in for couple counseling to discuss some of the challenges they had been facing lately. The therapist asked Shauna if she would like to work with a co-therapist and a reflecting team for when her husband was to come. The client indicated that she did not mind that arrangement and that she needed to let her husband know what the sessions were going to look like and what to expect. The therapist agreed to speak with him to provide him with information about how we work. Once the clients had agreed to meet with a reflecting team present, we began our work with the clients. They discussed their relationship of over 18 years. Through several sessions and conversations about Shauna’s struggle to make sense of her role in the family, she was able to discuss her

thoughts and feelings about specific events and relational difficulties she had experienced. Her challenges lately seemed to stem from not knowing what her role was in the family as she had always been the supporting wife/mother figure and her children were now young adults and did not need her as much while her husband was working and thinking about what direction his career would take. The therapist asked questions that were formed from her curiosity about the situation and about the details that were being discussed during the sessions. The clients were able to respond and clarify their points of view during a dialogic process that invited their opinions and ideas about their experience. In our regular meetings, when the therapist and clients had their conversations, the therapist then asked for space/time for the team to have their reflecting conversation. Shauna and Rick listened to the ideas and conversations that happened on the team, and they regularly would indicate that the ideas that were brought up had been helpful, or they would choose one or two comments to continue a conversation from the reflections. Rick once told us that he had been reluctant to attend therapy to begin with. He indicated that in his context, he was taught to not trust outsiders and that he had to be guarded and careful. Rick stated that the reflecting team process and the conversations he and his wife had with the therapist, as a result, usually left him with questions about how he saw and made sense of the world. He also expressed gratitude to the team for bringing questions up in a way that allowed him and Shauna to decline a comment or invited them into a careful conversation about a topic that might be difficult. The therapist’s skills were factors that provided an experience with which the client felt comfortable to have conversations that Rick and Shauna indicated had made a difference. During the process of 3 months during which we worked with this couple, the focus was on providing them with a space for their conversations about the changes that were happening in their life together. We have not provided many details about the content of their situation as they are different for most of our clients. Additionally, this helps us to emphasize that when working with clients, collaborative and

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dialogic therapists focus on the relationship and conversations that are formed with each client, couple, or family. The ways in which we ask a question or the information which we take into account in conversation with a client as well as the negotiation that happens between all the people present in the therapeutic conversation are what allows us to create change with a client, family, or couple. Each time we engage in conversation with the same clients, we arrive at crucial moments when decisions about therapy have to be made and the responsibility about making those decisions is shared by everyone involved, even though the voices of the clients will be the ones to ultimately inform the process in the most significant way as they are the ones who decide whether or not to return to therapy.

513 conversations that make a difference (pp. 7–19). New York: Routledge. Anderson, H., & Jensen, P. (Eds.). (2007). Innovations in the reflecting process: The influence of Tom Andersen. London: Karnac. Anderson, H., Goolishian, H., Pulliam, G., & Winderman, L. (1986). The Galveston family institute: A personal and historical perspective. In D. Efron (Ed.), Journeys: Expansions of the strategic systemic therapies (pp. 97–122). New York: Bruner/Mazel.

Collaborative Couple Therapy Daniel B. Wile Oakland, CA, USA

Name of Model Cross-References ▶ Anderson, Harlene ▶ Andersen, Tom ▶ Gergen, Kenneth ▶ Goolishian, Harry ▶ Houston Galveston Institute ▶ Reflecting Team in Couple and Family Therapy

References Andersen, T. (1991). The reflecting team: Dialogues and dialogues about the dialogues. New York: WW Norton & Co. Andersen, T. (1992). Relationship, language and preunderstanding in the reflecting processes. Australian and New Zealand Journal of Family Therapy, 13(2), 87–91. Anderson, H. (1997). Conversation, language and possibilities: A postmodern approach to therapy. New York: Basic Books. Anderson, H. (2000). Becoming a postmodern collaborative therapist: A clinical and theoretical journey, part I. Journal of the Texas Association for Marriage and Family Therapy, 3(1), 5–12. Anderson, H. (2001). Becoming a postmodern collaborative therapist: A clinical and theoretical journey, part II. Journal of the Texas Association for Marriage and Family Therapy, 6(1), 4–22. Anderson, H. (2007). A postmodern umbrella: Language and knowledge as relational and generative, and inherently transforming. In H. Anderson & D. Gehart (Eds.), Collaborative therapy: Relationships and

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Synonyms Ego Analytic Couple Therapy

Introduction In Collaborative Couple Therapy (CCT; Wile 1981, 1993, 2002, 2008, 2011), the therapist relates to the partners collaboratively with the goal of improving their ability to relate collaboratively with each other. “Relating to the partners collaboratively” means appealing to the couple as consultants in guiding the therapy. “Improving the partners’ ability to relate collaboratively” means recognizing that the particular content of the couple’s conflicts – money, sex, childrearing practices, amount of time spent together, and so on – is only part of the problem. The additional and often more important part is how partners talk – or do not talk – about these conflicts. They fight or withdraw. Collaborative Couple Therapy is founded on the assumption that partners in a problematic exchange are in need of a conversation – a conversation of reconciliation

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in the case of fighting or of reconnection in the case of withdrawal. Once partners are collaborating rather than fighting or withdrawing, they are in a position to work together to come up with whatever solutions, compromises, accommodations, and understandings might be possible.

Prominent Associated Figures Collaborative Couple Therapy, developed by Dan Wile, is built on ego analysis, a form of psychodynamic reasoning developed by Bernard Apfelbaum. In ego analysis, psychological problems are viewed as developing principally out of clients feeling unentitled to their experience (Apfelbaum and Gill 1989; Wile 1985).

Theoretical Framework Collaborative couple therapists attribute couple conflict to loss of voice – the inability by one or both partners to pin down and confide their leading-edge feeling – what is “alive” for them at the moment, to use Marshall Rosenberg’s term. If Betty were to confide what is alive for her at the moment, she would say to her partner, Joyce, “I’m embarrassed to say I got jealous just now seeing you text your ex. I don’t know if I have reason to worry or it’s just my insecurity popping up again.” Few people are able to talk about their feelings in such a fair-minded and nondefensive way. To do so requires what Apfelbaum calls a “sense of entitlement” to these feelings – which means, for Betty, that she feels sufficiently self-accepting regarding her embarrassment, jealousy, and insecurity to be able to talk about them in a straightforward manner and without putting the blame on Joyce. It requires what collaborative couple therapists call “speaking from the platform” – an ability to step back from the intensity of the moment and view oneself in a compassionate way. It requires, in addition, that Betty and Joyce share the belief that confiding vulnerable feelings is a contribution to the relationship and an act of intimacy.

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If Betty were to confide these feelings and Joyce were to experience her confiding as an act of intimacy, Betty would feel an immediate sense of relief and both partners would feel closer. But Betty cannot confide these feelings. She is too ashamed of them. She worries that Joyce will think of her as needy and jealous. She feels unentitled to her experience. She is left, accordingly, without a good way to handle the situation. When people are unable to obtain the relief that can come from bringing their concerns out into the open – rather than leaving them festering within – they resort to fallback measures that typically make matters worse. Fallback measures are substitutes; they are replacements. They are what people are stuck with when they are unable to express what they need to say. This focus on fallback measures gives CCT much of its collaborative feel. If you attribute clients’ symptomatic behavior to such measures – what they resort to because a better alternative is unavailable to them – you will see yourself working collaboratively to help clients express what they need to say (Wile 1984). If, on the other hand, you attribute clients’ symptomatic behavior to primitive impulses, for example, or character defenses, need to control, or to the unconscious gratification clients might be getting out of their symptoms – if some such notion is your central organizing principle – you will see yourself to some extent in an adversarial relationship with clients, whom you see as resisting your efforts to improve their lives. In couple relationships, there are two major types of fallback measures: the adversarial and avoidant shifts of everyday life. In the avoidant shift, partners take a feeling that makes them uneasy and sweep it under the rug. Betty keeps her feelings to herself and talks about something else. Then she escapes to the bedroom to be alone, soothes herself by writing in her diary, and distracts herself by logging onto Facebook. In the adversarial shift, partners take a feeling that makes them uneasy and turn it into something their partners are doing wrong. Betty bursts into the kitchen and blurts out, “If you’re so fascinated with Cecile, why don’t you just go back to her tonight and get it over with!”

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If partners are unable to confide what they need to say – if they lose their voice – they are stuck as a fallback measure attacking (“If you’re so fascinated with Cecile, why don’t you just go back to her tonight and get it over with”) and/or avoiding (talking about something else, leaving the room, and trying to soothe and distract herself), Each of these responses – confiding, attacking, and avoiding – has its own particular effect on the relationship. Attacking can turn partners into enemies and trigger an adversarial cycle. Avoiding can turn partners into strangers and trigger a withdrawn cycle. Confiding can turn partners into allies and trigger a collaborative cycle. In an adversarial cycle, each partner attacks and/or defends in response to the other doing the same: Betty: Make up your mind – it’s Cecile or me. Joyce: What are you talking about? Betty: I saw you texting her a few minutes ago. Joyce: Why is it any of your business who I text? Betty: You’re still in love with her. That’s how it’s my business. Joyce (sarcastically): I’m glad you’re so good at telling me how I feel. Anything else you’d like to clue me in on? Betty: Don’t change the subject. Joyce: Someone needs to. You’re talking crazy. In a withdrawn or avoidant cycle, each partner disengages in response to the other doing the same: Betty (trying to hide her reaction to seeing Joyce text Cecile): How was work today? Since Betty is not engaged in what she’s saying, her tone is flat. Joyce (taking Betty’s hollow tone to mean she’s not really interested): Same as usual. Betty (discouraged by Joyce’s hollow tone): Well, I think I’ll go check my email. In a collaborative cycle, each partner confides or comforts the other in response to the other doing the same. Betty: I’m embarrassed to say I got jealous just now seeing you text your ex. Joyce: Jealous? That’s so sweet. It makes me feel really loved.

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Betty: I get pretty insecure sometimes. Joyce: You wouldn’t if you saw the kind of thing she texts. Her cat didn’t come home at the usual time. I was reassuring her. Betty: Oh, the cat. I should have known it would be something like that. Joyce: You know, I don’t like Cecile’s texting me all the time. I’ve got to talk to her about that. Of course, Betty and Joyce would not have such a sweet conversation if Joyce were still romantically interested in Cecile. Partners typically come to a therapy session in some form of an adversarial or withdrawn state. In some cases, one partner is in adversarial mode and the other in withdrawal mode. The focus in Collaborative Couple Therapy is not on the problem the partners are raising but the manner in which they relate to each other about this problem: they fight or, in an attempt not to fight, they withdraw. The therapeutic task is to turn this fighting or withdrawing into intimate relating: to get the partners on the same team, working together, talking in a more heartfelt way about the problem – which puts them in place to come up with whatever solutions might be possible. The task, in other words, is to solve the moment rather than solve the problem – which is the CCT way ultimately to solve the problem. The quality of life in a relationship depends on the partners’ ability to deal with what comes up moment to moment in the relationship. The ultimate goal of CCT is to improve the partners’ ability to deal with moments: to function as joint experts in turning fights into conversations and problems into opportunities for intimacy. To get in position to help the partners solve the moment – which means helping them shift from an adversarial or withdrawn cycle to a collaborative one – therapists need to be in a collaborative state themselves. Therapists pass through all the states the couples do. At certain moments, they are in a collaborative state, feeling engaged, at times even moved, by what the partners are saying. At other moments, they are in a withdrawn state, feeling unengaged, their minds wandering. At still other moments, they’re in an adversarial state, feeling put off by or disapproving of one or both partners.

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CCT requires an active appreciation of each partner’s inner struggle, an appreciation that is possible only when therapists are in the collaborative mode. It also recognizes that the therapist will frequently become noncollaborative. It is hard to avoid privately siding at times with one of the partners and, at such times, losing the ability to appreciate fully the other partner’s point of view. An important part of the couple therapist’s task, accordingly, is to become skilled in noticing and recovering from these noncollaborative moments. Ideally, therapists can use their reactions as countertransference clues. They can use their feelings of withdrawal as a sign that the partners themselves are disengaged and it is the therapist’s job to revitalize the situation. They can use their feelings of disapproval as a sign that the person toward whom they feel disapproving is doing a poor job representing her or his point of view and it is the therapist’s job to help.

Populations in Focus CCT is designed for working with pairs of people: couples (LGBTQ or straight, married or not), family members (siblings, parent-child, etc.), coworkers, and so on. This approach can also be used in family therapy, group therapy, and mediation.

Strategies and Techniques used in Model To turn fighting or withdrawing into intimate talking, the therapist goes within to uncover what each partner needs to say in this conversation, between to keep it a conversation, and above to raise the partners up on a platform from which they can talk collaboratively about impasses in the conversation. Each of these three – going within, between, and above – can be accomplished through traditional psychotherapeutic methods such as asking questions, reflecting, reframing, interpreting, and externalizing the problem. Two techniques are

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particularly useful for this purpose: “doubling” and the “how much, how much” question. These two can be thought of as the signature methods of CCT. In doubling, which was originated by Jacob Moreno for use in Psychodrama, the therapist speaks as if s/he were one of the partners talking to the other. Doubling allows the therapist to translate a partner’s fight-inducing or withdrawalinducing statement into a conversation-inducing one. Betty: I saw you texting Cecile just now. Joyce: Why is it any of your business who I text? Betty: You’re still in love with her. That’s how it’s my business. Therapist (doubling for Betty): Here, I’ll be you, Betty, talking to Joyce, and for you I’d say, “Joyce, I could be wrong. I hope I am. But when I saw you texting Cecile, I got scared that you might leave me and go back to her. And you know me – my fear comes out as anger.” In an attempt to reshape Betty’s fight-inducing statement into a conversation-inducing one, the therapist replaced Betty’s harsh tone with a gentle one, recast her complaint as a fear, added a temporizing “I could be wrong,” and reported rather than unloaded her anger (“You know me – my fear comes out as anger”). Intimacy can be just a sentence away and the therapist helps the couple come up with that sentence. Turning to Betty, the therapist says, “Where am I right and where am I wrong in my speculation about how you feel?” After speaking for a partner, the collaborative couple therapist checks it out with that partner. If the partner says some version of “You got it wrong,” that’s okay, since the therapist can then go on to say, “How should I have put it?” or “What is the more accurate way to say it?” The “how much, how much” question enables therapists to ask potentially threatening questions by pairing them with benign alternatives. If the therapist were to ask Betty, “Do you see yourself as a jealous person?” or “Has jealousy been an issue in your life?” Betty might be upset at the implication that the problem is her jealousy rather than Joyce’s behavior. The therapist avoids this

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implication by pairing the question with a benign alternative. Therapist: How much do you see yourself as having an issue with jealousy and how much as having a finely tuned ability to scope out dangers that are there? The “how much, how much” question allows therapists to inquire into delicate, sensitive, and vulnerable areas without arousing partners’ defensiveness or sense of shame – to make it safe for Betty to acknowledge that she might be prone to jealousy. And it enables the therapist to explore whether a partner has at least some appreciation of the other partner’s experience. Therapist: Joyce, how much do you see Betty’s distress as coming totally out of nowhere and how much as at least a little bit understandable? The “how much, how much” question enables therapists to peer into a partner’s inner workings, raise difficult issues in a nonthreatening way, explore the nuances of each partner’s thinking, and suggest that it is normal to have simultaneous contradictory feelings about an issue.

Research about the Model There are no known research studies specifically devoted to Collaborative Couple Therapy.

Case Example The CCT task is to take the fight or withdrawal occurring right there in the session, or that the couple reports from the past week (or earlier), and turn it into an intimate conversation. In the following session, a composite, the therapist engages in a long string of interventions in his struggle to create the needed conversation. The couple is Betty and Joyce. Although Joyce doesn’t want to go back to Cecile, she does want to keep Cecile as a good friend. Joyce is reluctant to express this wish, however, in fear that Betty would get upset. Joyce: I’m minding my business, mixing a salad, and you go into your volcano routine.

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Betty: Don’t play the innocent. I saw you texting Cecile. Joyce: You don’t even know what I said. Betty: I don’t need to know. Why do you have to text her anything? Joyce: Why do you always have to get so paranoid? There’s nothing happening. Each partner feels too unheard to listen – which is what propels the fight. Turning the fight into a conversation requires, before anything else, providing each partner a hearing. The collaborative couple therapist typically provides such a hearing by doubling – repeating a version of what each partner says so that person feels heard, at least by the therapist. The therapist’s goal is to reshape each partner’s statement to make it more satisfying to the partner being spoken for and easier for the other partner to hear. Therapist (bringing the partners in on what he is planning to do): Okay, let’s see if I can say something here that might sort things out a little. I’ll be you, Betty, talking to Joyce. The risk in doubling for a partner when tension is high is that the other partner, feeling their point isn’t being represented, will interrupt. In other words, each partner needs to be heard first. A good way to deal with this problem is to speak on behalf of one partner but begin by acknowledging the other partner’s point of view. Therapist: Here I’m you, Betty, speaking to Joyce, and for you, I’d say, “Okay Joyce, I see what you’re saying. You felt attacked out of nowhere by me, just when you were doing something nice by making dinner for us.” Joyce: Exactly! Since Joyce’s point of view is being represented, she relaxes. She’s now in position to listen, at least for a short period. Since Betty’s point of view isn’t being represented, there’s a chance she might interrupt. To prevent this from happening, the therapist has wheeled his chair over next to Betty and is delivering his comments from there, giving physical representation to being on her side. Also, Betty doesn’t have to wait long before the therapist presents her point of view. Therapist (continuing to speak for Betty): “I wish I could get you to see how a person could

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understandably worry about a threat from a previous relationship.” Betty nods her head in agreement, which encourages the therapist to develop the point further, building his statement out of feelings that she expressed in previous sessions. Therapist: “We haven’t been together long, but you’re precious to me. I feel closer to you than I’ve ever felt toward anyone. So I hope you can understand how I might get upset at the thought of losing you.” Betty: Yeah! Betty appreciates how the therapist makes her position sound reasonable. She had worried that the way she had put it sounded too much like a childish tantrum. Her enthusiastic “Yeah” makes it unnecessary for the therapist to add the usual “Where am I right and where am I wrong in what I just said for you?” Joyce is not pleased, however. Joyce (to Betty): Do you expect me to give up all my friends? Betty: I’m not talking about all your friends. Just Cecile. Joyce: Now you’re telling me who can be my friends and who can’t. Betty: No, I’m just— Joyce: Why do you always have to be so insecure and needy? The therapist is put off by Joyce’s harsh judgmental words and demeaning tone. He is reacting, which means that he has temporarily lost the ability to look at the situation from her point of view. He’s momentarily out of position to do CCT – a condition that can occur at various points in any given session. Recognizing that he has shifted out of therapeutic mode and into judgmental mode, the therapist employs the CCT remedial measure, which is to become spokesperson for the partner – here Joyce – whom at the moment he finds himself privately siding against. Becoming a spokesperson requires first finding a way to appreciate that partner’s point of view. The therapist thinks, “What must Joyce be feeling and thinking – what is her inner struggle – that would lead her to say what she just said?” When reacting to Joyce, as he did a moment ago, he temporarily lost the ability to appreciate her struggle, or even recognize that she had one.

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Therapist: Okay, Joyce, let me make up something for you and see what you think. I give it about a 30% chance of capturing how you feel. By acknowledging that he is speculating, the therapist makes his comment easier for Joyce to reject, which emboldens him to speculate more freely. Therapist: Joyce, I’m you talking to Betty and for you, I’d say, “Cecile was part of my life for many years and so I can understand how you might wonder how I feel about her now.” The therapist begins his comment for Joyce by acknowledging Betty’s position. He now goes on to state Joyce’s own position. Therapist: “Still, I’m frustrated with my inability to reassure you that there’s nothing there that threatens our relationship.” Turning to Joyce, the therapist says, “Where am I right and where am I wrong in this statement I just made for you?” Joyce: You were right when you said she was part of my life for many years. (to Betty): Certain roots set in when you’ve known a person a long time. Joyce takes advantage of what she feels is the relative safety of therapy to press her wish to keep Cecile as a good friend. Betty (upset): Roots? What do you mean roots? How deep are these roots? Joyce (immediately sorry she said “roots”): Now don’t get like this. Betty: How did you expect me to get? Joyce: I don’t know – just not like this. Betty: You know I’m not the one who—. Therapist: Okay Betty, so you’re saying, “Joyce, as you can see, the word “roots” really gets to me.” The therapist jumps in to rescue the conversation. He does this by developing what Betty is saying rather than by challenging or countering it. Betty (sarcastically): You could say that. Therapist (continuing to speak as Betty talking to Joyce): “I hope when you say ‘roots’ you mean deep feelings a person has toward, say, a sister or old high school friend. I’m scared, however, that you mean romantic feelings. The therapist is putting words to what appears to be Betty’s fear. He asks, “Where am I right and

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where am I wrong in this guess about how you feel?” Betty (turning the therapist’s comment into ammunition against Joyce): I’ve seen you with your sister. That’s not at all how you are with Cecile. Joyce: I don’t get along with my sister! You know that. It’s not a fair comparison. Betty: It’s not fair, all right. You’re totally enthralled with Cecile. Joyce: Cecile was an important part of my life, but there’s nothing there. I don’t want you to feel bad about it. Betty (upset): Oh, do I have something to feel bad about? Joyce (to the therapist): This isn’t going well. The therapist is reacting to Betty’s tone – he’s put off by it – which he deals with in the usual CCT way by speaking on her behalf. Therapist: I’ll be you, Betty, speaking to Joyce, and for you I’d say, “As you can see, Joyce, I’m terrified that you’re still caught up with Cecile. I’m beside myself. I don’t know what to do.” Turning to Betty, the therapist says, “Or am I stating this too strongly.” Betty: Not strongly enough. Therapist (continuing to double for Betty): “I’m totally devastated. I feel like a lost little child no one wants. I don’t remember the last time I felt this bad.” The therapist wants to ask Betty whether jealousy has been an issue in her life. He fears, however, that she would hear it as, “Your jealousy is irrational. It isn’t about Joyce. It’s about your childhood.” The therapist uses the image of “a lost little child” in hopes that it might lead Betty to bring up any such early experience. It does not. Betty: I’ve never felt this bad. Joyce: Listen, Betty. I’m glad I left Cecile – I should have done it much earlier. I’m just saying that I don’t want to exclude her entirely from my life. Betty: I knew it. I should never have moved in with you. (To the therapist): How can I believe her? You heard what she said about “roots.” Betty is too riled up to pursue her point effectively. Part of the therapist’s job is to help each partner make their point.

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Therapist (to Betty): Yes, let’s ask her about that. (to Joyce): What did you mean about “roots?” Betty (appreciating the therapist’s pressing Joyce on this matter): Yes, how about that? Joyce (appreciating the opportunity to explain herself): I feel better about Cecile now that I don’t have to deal with her morning, noon, and night. I’d never want to go back to her – never. That was a total nightmare. But I’d still like to keep her as a friend. Betty:(suspiciously) What kind of a friend? Joyce: As a kind of sister – one I like. Not like Franny. Betty: Why didn’t you say that in the first place? Joyce: Because I was afraid you’d blow it out of proportion – like you’ve been doing this whole hour. Betty: Only because you didn’t tell me about the sister thing – although, to tell you the truth, I’m not so happy about that either. How do I know that you’re not going to go off to love land with her again? How do I know you’re not doing it already? Joyce: That ship has sailed. Betty: It could sail back. Why do you have to see her at all? Why is it so hard to give her up? This argument is going too fast for the therapist so he shifts to the overview level. Therapist (asking a version of the “how much, how much” question): In what ways is this argument useful and in what ways is it not so useful? The therapist creates a platform from which Betty and Joyce can talk collaboratively about their argument. Betty: I don’t know. Joyce: It’s frustrating. Therapist: Yes, it’s tough to be at odds with the person you most need to feel understands you. So I want to give you an experience of such understanding. I’m going to make up stuff based on what you’ve said today and other times. Betty and Joyce seem intrigued. They wonder what the therapist is going to say. Therapist: In this conversation, Betty, you’d say, “Joyce, it was a great relief to hear about ‘morning, noon, and night’ and about ‘total

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nightmare.’ For a brief moment I felt that maybe you didn’t want to go back to her.” Betty: A very brief moment. Therapist (incorporating Betty’s correction): “Yes, a very brief moment – because then I thought, “Why didn’t you tell me earlier about the sister thing.” Then, Joyce, you’d say, “Well yes, I can see why you might wonder about that. I was worried you’d get upset, which you kind of did.” Then, Betty, you’d say, “I know. I’m an emotional person. But I thought you liked that.” Then, Joyce, you’d say, “Well, I do like that – a lot. I’ve never met anyone like you. You’re the first woman I’ve been with who doesn’t bore me. I have trouble, however, when you’re angry at me. I get afraid to talk.” Therapist (concerned that he’s speculating too wildly): What do you think so far about this exchange I’m making up? Betty (to Joyce, softly): Are you really afraid to talk to me? Joyce: Sometimes. Betty: I don’t want you to be afraid to talk. For a moment, Betty and Joyce are talking collaboratively. It doesn’t last long. Betty (stiffening): That’s how I get sometimes. You should know me well enough by now not to take it so seriously. Therapist (jumping in to rescue the conversation): I want to go back a moment to that sweet exchange you just had – you know, Betty, when you said, “Are you really afraid to talk to me?” It had such a different feel from almost everything else in the session. Do you both see it that way, and how did it feel when you were saying it? The session continues primarily in battle mode with occasional whiffs of a collaborative exchange. The therapist asks the usual CCT end-of-the-session question, “What are you taking away from this session that’s useful, if anything, and what’s been disappointing about it?” Joyce: This is good. We’re able to talk here. Betty: Your interruptions allow a longer discussion than we have at home. Joyce: The way you restate what we say opens my heart. The therapist shows by demonstration a different way to have a relationship, characterized by

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making acknowledgments rather than accusations; reporting anger rather than unloading it; confiding vulnerable feelings and, in particular, replacing complaints with wishes and fears; and stepping back to create a platform from which to talk collaboratively about the couple predicament. The situation would be different if Joyce were to want to return to Cecile. The therapist would, however, proceed in the same way, working with what each partner said in an effort to create the best conversation possible given the situation. In Collaborative Couple Therapy, the therapist solves the moment by turning the struggle of the moment into the best conversation possible. The goal is (1) to enable partners to become better witnesses and reporters of the thoughts and feelings coursing through them and (2) to help couples to become better joint managers of their recurrent adversarial and withdrawn states.

Cross-References ▶ Bids and Turning Toward in Gottman Method Couple Therapy ▶ Collaboration with clients in couple and family therapy ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Countertransference in Couples Therapy ▶ Doubling in couple and family therapy ▶ Emotionally focused couple therapy ▶ Gottman Method Couples Therapy ▶ Psychodrama in Family Therapy ▶ Wile, Daniel

References Apfelbaum, B., & Gill, M. M. (1989). Ego analysis and the relativity of defense: Technical implications of the structural theory. Journal of the American Psychoanalytic Association, 37, 1071–1096. Wile, D. B. (1981). Couples therapy: A nontraditional approach. New York: Wiley. Wile, D. B. (1984). Kohut, Kernberg, and accusatory interpretations. Psychotherapy: Theory, Research, Practice, and Training, 21(3), 353–364. Wile, D. B. (1985). Psychotherapy by precedent: Unexamined legacies from pre-1920 psychoanalysis.

Collusion in Family Systems Theory Psychotherapy: Theory, Research, Practice, and Training, 22(4), 793–802. Wile, D. B. (1993). After the fight: Using your disagreements to build a stronger relationship. New York: Guilford. Wile, D. B. (2002). Collaborative couple therapy. In A. S. Gurman & N. S. Jacobson (Eds.), Clinical handbook of couple therapy (3rd ed., pp. 281–307). New York: Guilford. Wile, D. B. (2008). After the honeymoon: How conflict can improve your relationship, revised edition. Oakland: Collaborative Couple Therapy Books. Wile, D. B. (2011). Collaborative couple therapy. In D. K. Carson & M. Casado-Kehoe (Eds.), Case studies in couples therapy: Theory-based approaches (pp. 303–316). New York: Routledge.

Collusion in Family Systems Theory Dawn M. Wirick and Lee A. Teufel-Prida The Family Institute at Northwestern University, Evanston, IL, USA

Name of Theory Collusion in family systems theory

Introduction In the formation of a dyadic relationship, each partner discovers in the other past and/or repressed parts of self. These aspects of self may be regarded as representations of needs and wishes repressed via defense mechanisms. A partner’s attraction is often based on the extent to which the partner is viewed as embodying the parts of self that have been repressed (Simon et al. 1985). Consequently, the concept of collusion in family systems theory is derived from projective identification. Over the course of the relationship, what was viewed as initially attractive becomes an eventual source of conflict, and interpersonal strife emerges. Choosing a partner permits one the opportunity to complete one’s self, but also sets the stage for renewed conflicting wishes and

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needs (Simon et al. 1985). The new ways of relating to one another over time in the dyadic relationship are experienced as burdensome, and the partners become polarized within the context of jointly repressed conflicts between one another. The repressed needs and wishes that each partner delegated onto the other become increasingly threatening, and the partner, who served as the embodiment, must be vigorously opposed (Simon et al. 1985).

Prominent Associated Figures Melanie Klein (1936) introduced the concept of projective identification in relation to how her patients appeared to project onto other aspects of themselves that were unbearable to face by oneself. This projection process can be extended to relational issues in couples where, in projective identification, one partner carries projected aspects of the other. Therefore, one partner may assume the aggression from the other partner, and the partner, who projects the aggression, assumes pacifistic traits. Henry Dicks (1967) initially outlined the concept of collusion in relation to ego boundaries, in his book, Marital tensions: clinical studies towards a psychological theory of interaction. He described deeper unconscious bonds within the couple’s relationship, which he labeled as joint ego boundaries drawn around the dyad. He further described the unconscious attribution of shared feelings onto one another as a collusive process. Jurg Willi, in his books Couples in Collusion (1982) and Dynamics of couples therapy (1984), described progressive and regressive roles in the dyadic relationship as they relate to collusive dynamics in dyadic relationships. One partner assumes a progressive role, while the other partner assumes a regressive role.

Description Collusion is an unconscious act undertaken by partners in an attempt to master their fears and

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conflicts (Simon et al. 1985). To handle conflicts that originate from the individual’s personal history, the members of the couple assign to one another the task of embodying components of ambivalence that otherwise would be too painful for them to bear as individuals (Simon et al. 1985). The concept of collusion derives from projective identification in that the recipient of the splitoff part of the partner does not disown the projection, but rather acts upon the unconscious message. For example, a need for a more engaged partner to gratify the needs of a less engaged partner requires that both partners agree to the assigned roles (Stewart et al. 1975). One partner receives praise for being engaged, while the less engaged partner receives protection from the more engaged partner. At times, collusion is explicit and may be neither problematic nor pathologic (Stewart et al. 1975). However, when the assigned roles have changed, couples can experience discomfort or symptom formation. Engagement in overfunctioning behaviors, from one partner, determines the extent of underfunctioning behaviors in relation to the part of the other partner. For example, an extremely helpful partner determines the level of helplessness in the other partner. The more helpful one partner becomes, the more helpless the other partner becomes. Similarly, progressive behavior such as overcompensation on the part of one partner leads to regressive behavior such as irresponsibility on the part of the other partner.

Relevance to Couple and Family Therapy The difficulty within the therapeutic context arises when the couple denies collusion, exaggerates differences, and employs multifaceted attempts to prevent the therapist from unveiling collusion (Stewart et al. 1975). These tactics, on the part of the couple, can lead to increasing the level of confusion for the therapist in relation to how the couple can live together and why they remain in the relationship despite the overt disagreement around meeting one another’s needs (Bagarozzi 2011).

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The application of the concept of collusion implies that there is always either conscious or unconscious agreement within the dyadic relationship, despite the presence of apparent irreconcilable differences. The agreement is reinforced through shared fantasy when both partners conclude together that, for example, males are to behave in a detached manner to demonstrate that they are strong. While the male partner denies that he detaches from the female partner, he also indicates, at the same time, that he must detach from time to time to uphold the notion of being strong. Because of his fantasy of what it means to be a strong male (e.g., I am not able to be strong unless detached), in essence, he agrees with the woman’s accusations. As such, both partners in the relationship possess the same fantasy as to what comprises a strong male (Stewart et al. 1975). The therapist must be aware of how gender norms within one’s culture are practiced and if notions of traditional gender norms are upheld or set aside by the couple.

Clinical Example of Theory Maria and Juan are a child-free couple who have been married for 12 years. They entered couples therapy because Juan suddenly resigned at his job after 10 years of employment, and Maria reported not knowing about Juan’s resignation until after it occurred. Maria indicated her concerns about their acute financial crisis. As a result, Maria stated taking on two additional part-time jobs to make up for the loss of Juan’s income and to prevent the loss of their home. Juan countered by stating that Maria wanted to control every item in the household and that he quit his job, because he was certain Maria would immediately react to and see him as a failure she saw him as being. In response, Maria stated seeing Juan as completely helpless, while Juan stated that he saw Maria as being too helpful to everyone in her life, including his needs. Juan reported that he was typically attracted to women who were strong, independent, and willing to take care of his needs. Maria stated that she was attracted to men who needed her help

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and care and recognized her prior patterns in abandoning relationships when she did not feel needed. The couples therapist explored the central themes to highlight the personal mythologies presented by each partner. A central theme in Maria’s personal mythology was her fear that she would be rejected and abandoned by Juan. In reflection about her family of origin, Maria had shared that her biological father left her mother for a paramour when Maria was 6 years of age. As such, Maria had developed a self-image of one who was defective, incomplete, and unworthy of a man’s love. It became apparent that Maria had selected Juan for a husband, because she viewed Juan’s high level of dependence as an assurance that he would never leave her. For Juan, Maria represented a sense of safety. He defined her as force who helped him to stay consistently employed and away from trouble. According to Juan, Maria also urged him to withdraw from those in his past who encouraged him to return to criminal activity. Maria structured Juan’s daily activities, enacted rules designed to decrease his engagement with past persons and places, and consistently enforced the rules that she created without Juan’s consent. Over time, Juan began to resent Maria for taking on more of a “parent role within their dyadic relationship,” while Maria began to resent Juan for “acting like a child.” Maria and Juan acknowledged and agreed that the way their lives had been structured no longer was functional or desired and that a change was necessary. Both agreed with the therapist’s interpretation that Maria’s attempts to assist Juan had become weighty for her and that Juan interpreted her help as intrusive and controlling. The therapeutic issue became how to change the established pattern in a manner that would account for each partner’s unique personal issues (e.g., Maria’s fear of abandonment and feeling unworthy of a man’s love) and Juan’s need for external structure (e.g., Juan being unable to establish his own sense of safety via his own rule construction). The process began by assisting the couple to develop a cooperative strategy that would permit Juan to explore his environment (places and persons) and also permit Maria to participate in the process that was acceptable to her,

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yet in a way that Juan would not experience as intrusive or controlling. To further facilitate the spouse’s independent functioning, the therapist asked Juan to attend a social skills training workshop so that Juan could enhance his job interviewing skills. The rationale offered for this suggestion was that since Juan’s problematic behavior, at his last job, was partially responsible for his departure, social skills training might provide some value. Juan’s involvement in social skills training proved freeing for Maria, and she began to feel less responsible for constantly monitoring and correcting her spouse. Maria’s feelings of low self-worth and the depressive episodes that occurred as a result were rooted in her ambivalent relationship with her father. The therapist helped Maria work through her ambivalent feelings toward her father, and because Maria’s father lived close, the therapist suggested inviting him to a future session. Maria indicated that she believed that she could work through her feelings without her father attending.

Cross-References ▶ Object Relations Couple Therapy ▶ Projective Identification in Psychoanalytic Couple and Family Therapy ▶ Psychoanalytic Couple and Family Therapy

References Bagarozzi, D. A. (2011). A closer look at couple collusion: Protecting the self and preserving the system. The American Journal of Family Therapy, 39(5), 390–403. Dicks, H. V. (1967). Marital tensions: Clinical studies toward a psychological theory of integration. New York: Basic Books. Klein, M. (1936). The psychoanalysis of children. London: Hogarth Press. Simon, B. F., Stierlin, H., & Wynne, L. C. (1985). The language of family therapy: A systemic vocabulary and sourcebook. New York: Family Process Press. Stewart, R. H., Peters, T. C., Marsh, S., & Peters, M. J. (1975). Family Process, 14, 161–178. Willi, J. (1982). Couples in collusion. New York: Jason Aronson. Willi, J. (1984). Dynamics of couple therapy. New York: Jason Aronson.

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Combs, Gene

Gene Combs, MD (1946–)

narrative therapy in the Chicago area, and he is a founding member of the University of Chicago affiliated Chicago Center for Family Health. With his partner Jill Freedman, Gene received the American Family Therapy Academy’s award for Innovative Contribution to Family Therapy in 2009. The American Association for Marriage and Family Therapy awarded him for the Outstanding Contributions and Leadership to the Association in 2004.

Introduction

Contributions to Profession

Gene Combs is internationally recognized for his advances in narrative theory and training. He has been involved for the last quarter century in the development of narrative therapy as a distinct approach to individual therapy, family therapy, and community work. In his current day-to-day work, he is developing ways to help primary care physicians become more skilled at understanding and working with the particular hopes and fears of the people who consult with them. With his partner Jill Freedman, Gene has practiced, studied, taught, and written about narrative therapy for over two decades.

In addition to his writing about and teaching narrative therapy, Gene has served on the Committee on Accreditation in Marriage and Family Therapy Education (COAMFTE) and on the board of the American Family Therapy Academy (AFTA). He is an active member of the editorial review boards for Family Process, the Journal of Marriage and Family Therapy, and the Journal of Systemic Therapy. In his work with young physicians, Gene strives to help them preserve a human, interpersonal, and reflective focus in the face of corporate pressures toward pills, procedures, and “productivity.”

Combs, Gene Irma Rodríguez Grupo Campos Elíseos, Mexico City, Mexico

Name

Career Cross-References Gene received an MD from the University of Kentucky College of Medicine in 1972, which he followed with a Psychiatry Residency, at the same institution. He specialized in Family Therapy through live supervision with Jay Haley and Cloe Madanes, residential workshops and supervisory experiences in Italy with Luigi Boscolo and Gianfranco Cecchin, and live case consultations with Michael White. Gene is an associate professor in the Department of Family Medicine at NorthShore University HealthSystem, where he is Director of Behavioral Science Education for the University of Chicago affiliated Family Medicine Residency Program. He also serves as Codirector of the Evanston Family Therapy Center, an independent postgraduate training center dedicated to teaching

▶ Family Therapy ▶ Narrative Couple Therapy ▶ Narrative Family Therapy

References Books Combs, G., & Freedman, J. (1990). Symbol, story, and ceremony: Using metaphor in individual and family therapy. New York: Norton. Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York: Norton. (Also in Russian, Taiwanese, Korean, Chinese, Czech, and Serbian Translations). Freedman, J., & Combs, G. (2002). Narrative therapy with couples. . . and a whole lot more! Adelaide: Dulwich Centre Publications. (Also in Korean Translation).

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Articles Chang, J., Combs, G., Dolan, Y., Freedman, J., Mitchell, T., & Trepper, T. S. (2012). From Ericksonian roots to postmodern futures. Part I: Finding postmodernism. Journal of Systemic Therapies, 31(4), 63–76. Chang, J., Combs, G., Dolan, Y., Freedman, J., Mitchell, T., & Trepper, T. S. (2013). From Ericksonian roots to postmodern futures. Part II: Shaping the future. Journal of Systemic Therapies, 32(2), 35–45. Combs, G., & Freedman, J. (2002). Relationships not boundaries. Theoretical Medicine and Bioethics, 23(3), 203–217. Combs, G., & Freedman, J. (2012). Narrative, postructuralism, and social justice: Current practices in narrative therapy. Counseling Psychologist, 40(7), 1033–1060. https://doi.org/10.1177/0011000012460662. Combs, G., & Freedman, J. (2016). Narrative therapy’s relational understanding of identity. Family Process, 55(2), 211–224. Freedman, J., & Combs, G. (2000). Therapy relationships that open up possibilities for us all. Dulwich Centre Journal, 1 & 2, 17–20. Freedman, J., & Combs, G. (2001). Facilitating a narrative culture in a school. Journal of Systemic Therapies, 20(3), 49–59. Freedman, J., & Combs, G. (2009). Narrative ideas for consulting with communities and organizations: Ripples from the gatherings. Family Process, 48(3), 347–362.

Common Factors in Couple and Family Therapy Sean D. Davis California School of Professional Psychology, Alliant International University, Sacramento, CA, USA

Introduction The study of common factors focuses on identifying core elements of effective couple and family therapy (CFT). Proponents of common factors claim that once model-specific language is removed, most CFT theories orient the therapist to similar patterns of dysfunction and help them guide the family towards similar patterns of health. Much of what makes therapy effective is also inherent in the structure of therapy itself. For example, the alliance created by confidentially disclosing vulnerabilities to and seeking guidance from a nonjudgmental, caring, empathetic

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therapist is thought to be healing, regardless of the theoretical approach used. Common factors theorists believe that regardless of their source, identifying the core and unifying elements of effective CFT may lead to more efficient training and ultimately better clinical outcomes. As such the common factors paradigm is not a model of therapy per se, but a principle-based meta-model, or “model of models.”

Prominent Associated Figures The common factors paradigm is new to CFT, so the list of prominent scholars is relatively small. Douglas Sprenkle, Adrian Blow, Sean Davis, and Eli Karam are the most prominent CFT common factors scholars. The first article explicitly addressing common factors in CFT was a book chapter written by Sprenkle et al. (1999), followed by an article by Blow and Sprenkle (2001) in the Journal of Marital and Family Therapy (JMFT). Sprenkle and Blow (2004) had an oft-cited debate with Thomas Sexton in the JMFT over the merits of common factors versus a traditional modeldriven paradigm. A few years later Sean Davis and Fred Piercy published two articles identifying common factors in the practices of prominent CFT model developers and their students (Davis and Piercy 2007a, b). Around this time Sprenkle et al. wrote several foundational articles outlining key principles of common factors in CFT (Blow et al. 2007, 2012). Douglas Sprenkle, Sean Davis, and Jay Lebow wrote Common Factors in Couple and Family Therapy: The Overlooked Foundation of Effective Practice, the field’s first text devoted to common factors in CFT (2009). More recently, Eli Karam has applied many common factors principles to training, practice, and supervision (Karam et al. 2014, 2015).

Description Principles of a Moderate Common Factors Approach The contemporary, moderate common factors approach (Sprenkle and Blow 2004; Sprenkle

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et al. 2009) rests on several foundational principles. The first principle states that change is due to common mechanisms that cut across different models. This principle is often misconstrued as meaning that models are not important. To the contrary, common factors proponents believe that a coherent model of CFT is an essential component of therapy, but not because of any unique contributions of one particular model. Rather, models are thought to be useful because they provide an order and structure that allows the therapist and clients to feel calm and confident, and they provide a coherent set of rituals for healing. As long as the model is structured and coherent, is based on sound systemic principles, is credible to the therapist and client, and is a good fit with the client’s worldview, it will likely work. The second principle of a contemporary common factors approach is that qualities “surrounding” treatment (e.g., the therapeutic alliance, therapist credibility, client motivation) are more important than the unique aspects of a particular treatment. Again, that is not to say that these surrounding qualities such as the alliance are both necessary and sufficient for effective therapy, as is sometimes claimed. Rather it is to say that a treatment model is inseparably connected to contextual elements that are every bit as or more important to treatment as the model. The third principle states that the qualities of the therapist offering the treatment are more important than the treatment itself. Indeed, treatment cannot be separated from the therapist delivering the treatment. Though research has failed to show significant differences in effectiveness between treatment models, some of those same studies show significant differences between therapists (Blow et al. 2007). Without the therapist giving them life, models are just words in a book. The treatment either comes alive or dies through the therapist’s manifestation of the treatment model. The fourth principle states that above all else, the client is the primary agent of change. If a person goes to the gym, does it matter whether he or she uses the treadmill or the stair climber, or does it matter that they got themselves off the couch and down to the gym? A therapist can do

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their best to tailor their approach to the client and foster a healthy alliance, but at the end of the day clients either take whatever is given to them and make it work or not. Some clients will take something meaningful from the most average of therapy, whereas other clients will choose to not benefit from the best of therapy. Therapists ultimately only have so much control over the outcome of therapy. Of course there are limits to this – unethical treatment is likely to do harm no matter what. Furthermore, a skilled therapist may be able to motivate a seemingly unmotivated client, and an unskilled therapist may thwart the most proactive of clients. Generally speaking, however, the client is the most important variable in therapy. Generic Common Factors In addition to the principles described above, many common factors of effective CFT are shared with psychotherapy designed for individuals. These include the therapeutic alliance, expectancy/hope, and allegiance effects. The therapeutic alliance (i.e., the clinical relationship between the therapist and client(s)) is the common factor with the most empirical support. A strong alliance has repeatedly been shown to be associated with positive outcomes. This is particularly true in the beginning of therapy, when the clients are deciding whether the therapist is a good fit. A poor initial alliance is positively correlated with treatment dropout, whereas a strong initial alliance is associated with later treatment success (Sprenkle et al. 2009). The therapeutic alliance is a dynamic mix of client and therapist attributes. The client must be at least somewhat willing to engage in therapy. The therapist must have enough emotional intelligence to be able to “read” the client in order to adapt his or her approach. An approach that is too directive will likely unnecessarily offend or overwhelm clients, whereas an approach that is too passive will likely not lead to any meaningful movement. Both stances are likely to lead to dropout, and depend on the therapist’s ability to read clients (and/or get their direct feedback) and moderate his or her approach accordingly.

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The therapeutic alliance has been said to consist of tasks, bonds, and goals. It is important that both the therapist and client agree on the goals of therapy. This becomes more complicated with the competing goals often presented in couple or family therapy, but it is nevertheless usually still possible to find at least some common ground. Once goals are established, it is important that everyone agrees that the tasks (i.e., interventions) being utilized will help the clients reach their goals. “Bonds” refer to the emotional connection, respect, and positive regard between the therapist and clients. It is possible that one or two of these elements can be going well, but the alliance is overall still struggling due to the third element being off. Therapist factors are another important common factor. In general, effective therapists are warm, compassionate, genuine, empathetic, and nonjudgmental. They also are able to walk the fine line between remaining true to themselves and adapting their style to their clients. Each of the above-mentioned traits can look different with different clients. For example, the same therapist may be more assertive and stern with an overbearing husband yet warm and understanding with the exhausted wife. Yet if the therapist manages things well, both clients will likely describe him or her as caring, compassionate, and competent. So much of being a good therapist comes down to being able to read and adapt to the needs of the specific situation. Recent common factors literature proposes a therapist’s “way of being” as a common factor (Fife et al. 2014). A therapist’s way of being refers to his or her in the moment attitude towards his or her clients. A therapist with an “I-thou” attitude towards others views them as having needs that are as legitimate and valuable as those of the therapist. As a result, the therapist will treat his or her clients as real people as deserving of respect as the therapist. Conversely, a therapist with an “I-it” attitude views his or her clients as objects that will either make life easier or more difficult. If the clients will make life easier the therapist likes them, but if they may make life more difficult the therapist

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wants them to be gone and will do things to subtly get them off his or her caseload. Maintaining an I-thou attitude towards clients is viewed as crucial to maintaining positive outcomes. Expectancy and hope are also important common factors. Simply put, therapy is more likely to go well if a client thinks it will. The same can be true for a therapist. It is important that a therapist believes in his or her approach. A therapist that believes in what he or she is doing presents him or herself more convincingly, and his or her passion can spread through the system. Similarly, if a client believes that therapy will go well, he or she is more likely to take what is given to them and make it work. A client’s expectancy is affected by many things, including the referral source, the degree of fit between the therapist and clients in the early stages of therapy, and whether they experience any success, especially early on. If clients are referred to a therapist via a trusted friend or family member, they are more likely to assume that whatever the therapist is doing is helpful. Clients in this situation are often more likely to try things out and be open to therapy. Regardless of the referral source, if the things the therapist says resonates with clients early on, they are likely to be hopeful that change can be achieved. This is especially true if they experience symptom relief early on in therapy. Allegiance effects are similar to hope and expectancy. Allegiance effects occur in research when the researcher believes in one of the variables he or she is studying and that belief alone sways the results of the study. For example, if a researcher loves strategic therapy, it is likely that any studies he or she conducts will show that strategic therapy works well. That may be because strategic therapy does indeed work, but it will be difficult to tell how much of that outcome is due to the researcher wanting it to work. Allegiance effects are problematic in research, but they can be a good thing in therapy. A similar dynamic happens in therapy when a therapist really believes in what he or she is doing. The mere belief alone makes the therapist more likely to be effective.

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CFT Common Factors Research and Training Much of the rationale for common factors came from meta-analytic reviews of comparative efficacy studies. These reviews consistently demonstrate that CFT is effective, but no one theoretical approach is more effective than another (Shadish and Baldwin 2002). This finding is replicated in psychology, and for a time many in that field claimed that there was no more need for more comparative efficacy studies. The contemporary moderate common factors approach, however, claims that comparative efficacy studies are still useful – they just need to include measures of common factors in order to provide a more nuanced view of why therapy works, not just whether therapy works. Common factors researchers are concerned with why therapy works. What makes therapy effective? Consequently, process research methodologies are particularly well suited for the study of common factors. Qualitative process research focuses on inductively discovering specific variables (i.e., processes) that may be common to effective therapy. This is commonly achieved through interviewing therapists and clients regarding what made therapy effective, conducting thematic reviews of videotaped sessions, and so forth. Quantitative process research focuses on deductively testing whether certain processes are indeed related to outcome. Examples include coding videotapes of therapy, determining whether the presence or absence of certain processes correlates with outcomes, and so forth. Common factors research faces several challenges, the biggest of which is that most of the common factors are interrelated. For example, the therapeutic alliance is affected by therapist and client variables, as well as expectancy/hope factors and allegiance effects, and vice versa. Where one begins and the other ends is not clear, so teasing out the effects of only one variable is difficult. The common factors paradigm has several implications for training. Training could be greatly streamlined and focused if a core set of principles were identified for working with different presenting problems. Students could still learn theory (since having a structured approach is a

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common factor in and of itself), but they would learn the theories in terms of their commonalities with each other so they could move smoothly between theories as client needs dictate. This is different from the current approach to training, which typically focuses on having students briefly overview several theories and then pick their “favorite” to learn in depth. Given that therapist attributes are a common factor, training should focus more on the development of certain character traits in a therapist – compassion, empathy, boundaries, and so forth, as future research dictates. A similar shift could occur in terms of focusing on clients, since they are such a major factor. Training could focus on helping therapists learn to help differently motivated clients, how to gauge client satisfaction with therapy progress and the alliance, and so forth.

Relevance to Couple and Family Therapy Several common factors have been proposed as being unique to CFT (Sprenkle and Blow 2004; Sprenkle et al. 2009). These include conceptualizing difficulties in relational terms, disrupting dysfunctional relational patterns, working with an expanded direct treatment system, and managing the complexities of an expanded therapeutic alliance. Conceptualizing difficulties in relational terms is a hallmark of systemic therapy. Many symptoms become understandable responses to untenable circumstances when a therapist steps back and views the broader context in which the symptoms occur. For example, a husband is likely not withdrawing because he is a jerk, but rather because he does not know how to adequately respond to his wife’s nagging. The wife is likely not nagging because she is by nature overbearing, but because she does not know how to get her husband to be more open and accessible. Each person’s response brings about that of the other. Conceptualizing difficulties systemically provides a foundation for successful therapy. Systemic conceptualization allows the therapist to view each partner as trying their best to solve a problem. This can lower client defensiveness, as

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the therapist is not treating one or both of them as inherently problematic. If each person is seen as trying their best, clients typically respond well to having that validated and brought forth in a way that their partner can understand. If the problem is seen as largely between people (i.e., their communication) rather than solely within them (i.e., their personal issues, resistance, etc.), then solutions tend to emerge more readily as opposed to if someone is told the problem is all them. If conceptualizing problems in relational terms is a common factor of systemic therapy, it follows that disrupting those same relational patterns is also a common factor. Clinicians using different systemic models typically focus on changing cognitive, affective, and behavioral aspects of couple’s communication cycles (Davis and Piercy 2007a, b). For example, a wife thinks her husband does not care about her when he watches TV at night rather than help get the kids in bed (cognition), so she gets angry (affect) and calls him a lazy slob (behavior). The husband thinks his wife is too controlling and bossy when he helps her (cognition), so he feels small (affect) and tries to avoid her by watching TV instead (behavior). One spouse’s interactional stance invites the other’s interactional stance. A therapist has six different points of entry into this cycle, each of which could shift the entire dance. For example, if the husband saw his wife as overwhelmed and in need of help, his feelings towards her may soften and he may push past her bossiness to help her anyway. Doing so may invite the wife to see her husband as more involved, which may soften her feelings towards him which may in turn lead her to expressions of gratitude rather than frustration. Any of these changes could bring about the others. Each systemic model focuses on this cycle but emphasizes different points of entry into the cycle. Common factors suggest that the point of entry should be determined by what resonates for the client, not which model the therapist prefers. Working with an expanded direct treatment system – those directly receiving treatment – is another hallmark of systemic therapy. Generally, the more relevant people in the room the better. A therapist is more likely to hold a balanced, complete view of the problem if he or she works

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with as many people as possible. If working with just the husband in the above example, a therapist would likely end up subtly siding with the husband and demonizing the wife. This would, of course, frustrate treatment progress and in some cases may even lead to an otherwise avoidable divorce. Managing the complexities of an expanded therapeutic alliance is another common factor of systemic therapy. The alliance becomes more complicated in systemic therapy, as family members often have varying goals and agendas. A therapist must validate each person without alienating or unnecessarily siding with one family member at the expense of others. This is easier said than done. A therapist must also try to find common ground with goals of therapy – also not an easy task for a family that is likely already divided. The therapeutic alliance can be managed, though, with careful attention to those dynamics.

Clinical Example of Application of Theory in Couples and Families Raul and Sara came to therapy seeking help for their teenage son, Sam, whose grades had recently started to slip around the same time he had been caught smoking marijuana. Raul and Sara’s therapist, Michelle, had come highly recommended by a close friend, so they were optimistic they could be helped. Michelle had a lot of experience working with families in this situation and had gone through similar experiences both as a child and parent, so she was confident she would be able to help as well (hope/expectancy effects). At the first meeting Michelle correctly guessed that Sam would not want to be there, so she would need to build more “emotional capital” with him than with his parents, who already trusted her. As a result, when they all met for the first session (expanded direct treatment system) she intentionally joined with Sam by asking about his interests, etc., prior to asking about the behavioral issues. When asking about his behavioral issues, she focused on what function they might be serving in his life (systemic conceptualization) rather than on lecturing him or trying to get him to

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stop. Once Michelle believed Sam felt validated, she repeated the same process with Sam’s parents, focusing on validating their concerns and fears for Sam (managing the expanded therapeutic alliance). Each family member left having had a new, calmer experience with each other. They were beginning to see each other in ways they had not before. Sam, Raul, and Sara trusted that Michelle would be able to help them (therapist factors, therapeutic alliance, hope/expectancy). As treatment progressed, Michelle highlighted and helped magnify each family member’s strengths and attempts to connect (client factors). There were stark disagreements between Sam and his parents about what was acceptable behavior. Michelle handled this by helping them slow down their interactions and hear each other’s concerns. She helped each person express their concerns directly and in a way that was easier to hear. Several times throughout treatment one of the two dyads (i.e., Sam or his parents) would feel invalidated by Michelle. Since Michelle used a brief three-item questionnaire about client satisfaction that she’d designed to gather feedback after each session, she was able to catch this and address it at the next session. Healing the ruptured alliance in this way modeled crucial attributes such as humility and assertiveness (therapist attributes). Throughout treatment, Michelle used different treatment approaches based on what seemed to resonate with the family’s personality and goals. In the early stages she realized that the hierarchy was out of balance – Sam was running the show at home, and the parents felt helpless. She used structural therapy to help put the parents back in charge of setting rules. Mixed in with this approach were elements of experiential therapy, as she used sculpting to help each of them see how the family was structured and help them clarify how they would like it to be structured (clarifying goals, using different models to the same end). Once that structural shift was achieved, and even while it was being achieved, Michelle relied heavily on narrative therapy dialogue to help each family member understand the larger sociopolitical pressures they were operating under. This dialogue helped each family member have compassion for each other.

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At the end of treatment there was still a fundamental disagreement about what was acceptable behavior, but Sam at least understood that his parents were coming from a place of love and concern rather than vindictiveness. He reluctantly accepted his increased restrictions, and Raul and Sara felt validated in their desire to stick to rules that reflected their family values. At the same time, they had a newfound respect for the emotional complexities of Sam’s life, and they redoubled their efforts to genuinely connect with him and help him find healthy coping mechanisms for his stress. They all felt closer to each other. Everyone had a respect for Michelle’s fairness and commitment to helping each of them be understood. Throughout treatment, Michelle consciously employed several principles of common factors to help ensure the family was successful in therapy.

Cross-References ▶ Blow, Adrian John ▶ Davis, Sean ▶ Integration in Couple and Family Therapy ▶ Sprenkle, Douglas ▶ Therapeutic Alliance in Couple and Family Therapy

References Blow, A. J., & Sprenkle, D. H. (2001). Common factors across theories of marriage and family therapy: A modified Delphi study. Journal of Marital and Family Therapy, 27, 385–401. Blow, A. J., Sprenkle, D. S., & Davis, S. D. (2007). Is who delivers the treatment more important than the treatment itself?: The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298–317. Blow, A. J., Davis, S. D., & Sprenkle, D. H. (2012). Therapist–worldview matching: Not as important as matching to clients. Journal of Marital and Family Therapy, 38, 13–17. https://doi.org/10.1111/j.17520606.2012.00311.x. Davis, S. D., & Piercy, F. P. (2007a). What clients of MFT model developers and their former students say about change, Part I: Model dependent common factors across three models. Journal of Marital and Family Therapy, 33, 318–343.

Communication in Couples and Families Davis, S. D., & Piercy, F. P. (2007b). What clients of MFT model developers and their former students say about change, Part II: Model independent common factors and an integrative framework. Journal of Marital and Family Therapy, 33, 344–363. Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40, 20–33. https://doi. org/10.1111/jmft.12041. Karam, E. A., Sprenkle, D. H., & Davis, S. D. (2014). Targeting threats to the therapeutic alliance: A primer for marriage and family therapy training. Journal of Marital and Family Therapy, 41, 389–400. https://doi. org/10.1111/jmft.12097. Karam, E. A., Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2015). Strengthening the systemic ties that bind: Integrating common factors into marriage and family therapy curricula. Journal of Marital and Family Therapy, 41, 136–149. https://doi.org/ 10.1111/jmft.12096. Shadish, W. R., & Baldwin, S. A. (2002). Meta-analysis of MFT interventions. In D. H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 339–370). Alexandria: American Association of Marriage and Family Therapy. Sprenkle, D. H., & Blow, A. J. (2004). Common factors and our sacred models. Journal of Marital and Family Therapy, 30, 113–130. Sprenkle, D. H., Blow, A. J., & Dickey, M. H. (1999). Common factors and other nontechnique variables in marriage and family therapy. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 329–359). Washington, DC: American Psychological Association. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford.

Communication in Couples and Families Rebecca Bokoch Couple and Family Therapy, CSPP Alliant International University, Los Angeles, CA, USA

Name of Theory Communication in Couples and Families

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Synonyms Interaction; Message

Introduction Communication is the process of sharing information. It goes beyond the content of the information being shared to encompass the way the information is being shared between people. Communication also reveals information about how people connect and the relationships between people. The process of communicating includes thinking, expressing, listening, interpreting, understanding, and responding (Koerner and Fitzpatrick 2002). Almost everything is a form of communication, including spoken words, sounds, body posture, text, and even silence. Even not speaking is a form of communicating, as it can also hold meaning and value and conveys information in itself (Watzlawick et al. 1967). For example, a teenage daughter falls silent and casts her eyes down towards the floor while her parents are fighting. This act of silence might convey some important information about family dynamics and how the daughter is feeling, such as, “Please leave me out of this. It scares me when you fight and I feel like shutting down.” Communication in couples and families is a prominent focus of clinical work. Communication plays a role in the problems couples and families come into therapy with, and a major role in the change process that allows them to terminate therapy successfully. It is important during the initial assessment stage to explore families’ communication styles and to use communication during stages of intervention as a way to create change within the couple or family unit. One way to use communication as a change agent might be to teach and encourage a family to use “I-statements” when speaking to one another. “I-statements” are messages that are about the speaker’s beliefs, feelings, or values. “Istatements” are in contrast to “you-messages,” which are about the person to whom the speaker is speaking. Helping couples and families to use “I-statements” is a practice used by many therapists to create change in communication patterns and to decrease conflict (Gordon 2000).

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Prominent Associated Figures Gregory Bateson, the father of cybernetics, is an important figure in communication in couples and families. Cybernetics is a multidisciplinary field of study regarding communication and control in humans and robotic systems (Bateson 1972). All systemic theories of family therapy originally stemmed from the cybernetic paradigm, as it refers to a growing body of knowledge about systems of information processing. First-order cybernetics provides therapists with the perspective to see families as information processing machines with growing and changing bodies of knowledge. Second-order cybernetics was the second wave of the cybernetic paradigm, which allowed therapists to view themselves as part of an evolving family information processing system and led to a more collaborative and nonpathological approach to family therapy (Freedman and Combs 1996). The idea that families are systems of information processing and interaction supports the idea that change within couples and families can be achieved through communication.

Description Families and couples act as systems of interaction. They have certain internal variables that are somewhat constant, like individuals’ personalities or relational dynamics within the family, and other variables that are always changing around them, like their environments and current life situations. Each communication, message*, or interaction* received by the family system is acted upon and modified within the family system and given feedback from the family system (Watzlawick et al. 1967). Because families are interaction systems, it is important for families to develop functional communication skills and experience healing through the use of effective communication, which can be supported through couple and family therapy. Families and couples tend to remain in a state of homeostasis until some sort of communication or interaction occurs, like feedback loops, forcing

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families to move out of their stable state. Negative feedback loops are communication patterns that maintain stability while minimizing change, and positive feedback loops are communication patterns that facilitate change, moving the family towards making progress or falling apart. Unless an intervention is specifically used to disrupt homeostasis, families will most likely take any interaction and respond to it in a way that will allow them to find their way back to homeostasis. Perpetuating a state of homeostasis can either propagate dysfunctional communication within the system, or maintain equilibrium despite challenges faced (Watzlawick et al. 1967). Understanding theories of communication in couples and families also requires a different lens, where the theorist can balance family members’ expectations, dynamics, relationships, and rules, along with the family structure and context. There are several theories of family communication that highlight different interaction patterns, including the McMaster model of family functioning (Epstein et al. 1982), the family communication theory of cohesion and change (Galvin et al. 2016), and the theory of family communication of conformity and conversation (Koerner and Fitzpatrick 2002). The McMaster model of family functioning operates from an underlying belief that different styles of family functioning can lead to contrasting styles of communication, such as: instrumental fact-based communication vs. affective expression about emotion, clear and easily understood messages vs. masked or unclear communication, and indirect interaction expressed in a roundabout way vs. direct communication delivered to the person for which it was intended (Epstein et al. 1982). The McMaster model suggests that the healthiest and most functional style of communication is when couples and family members can be both clear and direct with one another (Epstein et al. 1982). According to the family communication theory of cohesion and change (Galvin et al. 2016), the two main spectrums of family communication are: cohesion, which allows families to be both independent and interconnected, and adaptability, which allows families to be flexible throughout changes in family relationships, roles, and rules. Strong

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communication skills allow families to express themselves within healthy ranges of the cohesiveness and adaptability spectrums (Galvin et al. 2016). Koerner and Fitzpatrick’s (2002) theory of family communication identifies different family communication patterns, such as conformity orientation, meaning that family members should all have the same values, attitudes, and beliefs, and conversation style, which means family members are open to expressing their own varied thoughts, values, and beliefs. Members of couples and families may have the same or different communication patterns from one another, which may lead to various levels of conflict and relationship satisfaction within the system. This theory suggests that conversational and open families are most capable of functional communication (Koerner and Fitzpatrick 2002). Dysfunctional communication. Despite the theory or model being used to explore communication in couples and families, it is apparent that there are some styles, patterns, and techniques that are functional and others that are dysfunctional. Dysfunctional communication often leads to conflict and dissatisfaction in couples and families and can obstruct therapeutic growth. One of the most common examples of dysfunctional family communication is the double bind. Double binds occur when conflicting messages are received that discount one another, are mutually exclusive, and often lead to emotional distress (Bateson 1972). For example, if a partner says to his significant other, “Be spontaneous, for once!” This statement serves as a double bind for this couple, because if the other partner responds by doing something spontaneous, it is not really spontaneous because she was told to do so, but if the partner responds by doing nothing, she is also not being spontaneous. This double bind allows for two conflicting, mutually exclusive messages to be received, which is difficult for the partner to respond to successfully and will most likely lead to emotional conflict and distress for the couple. Problems also often arise when intentions and perceptions get confused, there is a lack of empathy, there is a mismatch of methods of communication, there is a challenging topic being communicated, verbal and non-verbal

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communication skills are not known or are not being practiced, or negative facial expressions, vocal qualities, and body language are conveyed (Goldberg 2017). In addition, miscommunication occurs when people contradict themselves, there are inconsistencies in conversation, someone changes the subject or goes on a tangent, or information is misunderstood or misinterpreted (Watzlawick et al. 1967). Therapists have also identified that lack of perspective-taking abilities, criticizing, and blaming are among the most detrimental communication problems for couples and families (Galvin et al. 2016). Disagreements over content and the way that things are communicated are also dysfunctional communication patterns that can contribute to conflict in couples and families. For example, if a child went to a friend’s house after school without asking his or her parents, the family could disagree based on the content: the fact that the parent did not approve of the child going to the friend’s house, as they would have preferred that they went home first and finished their homework. However, the family could also be in disagreement based on the way things were communicated: if the child did not consult with the parent first, even though the parent was fine with them going (Watzlawick et al. 1967). Also, couples and families dealing with stressors or crises may resort to dysfunctional communication styles, as they are reacting to a situation that they do not know how to cope with as a family. For example, when a mother is diagnosed with breast cancer, a father may fall silent, and a child may start acting out. This crisis situation shifts family dynamics and communication patterns in a way that is not supportive of close family relationships or therapeutic processing (Galvin et al. 2016). Couples and families may also use their symptom as a method of communication, which is another form of dysfunctional communication. For example, “I want to talk to you, but I’m too anxious right now.” This statement allows clients to give the symptom power over themselves, which can lead to problems in the relationship (Watzlawick et al. 1967). Functional communication. Functional communication is when couples and families are able

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to share information about thoughts, feelings, needs, and wants in a way that others can understand. Couples and families may take a personal approach to improve their communication, or seek therapy. Personal approaches might include seeking education (i.e., reading books or blogs about improving communication skills), negotiating, spending time together, and accessing support. Therapists can also work with couples and families to develop functional communication as a therapeutic strategy across all systemic theories and approaches. Some of the most valuable communication skills include: listening, expressing, and body language (McKay et al. 2009). Listening skills involve more than just hearing what is being said. Active listening involves acknowledging and respecting other peoples’ points of view, even if you do not agree with them. This can be achieved through reflecting statements, which involves restating the speaker’s feelings and words. Reflective statements show the speaker that you are trying to perceive the world as they see it, you are doing your best to understand their messages, and you encourage them to continue talking. Clarifying language is a way to enhance listening skills. Clarifying language might involve asking questions or restating things that were said, in order to make sure that an individual understands the other’s experience and is interpreting his or her message accurately (McKay et al. 2009). Expressing is when individuals share “whole messages” about their experience. Whole messages” include information about observations, thoughts, feelings, and needs. When expressing these “whole messages,” the speaker should be aware of the self, the other person with whom they are communicating, and the environment in which they are communicating, in order to communicate most effectively. “Whole messages” can help couples and families to better understand one another and support functional communication and therapeutic growth within the relationship (McKay et al. 2009). Body language is an important aspect of nonverbal communication, including body movement and spatial relationships. Body movements consist of gestures, facial expressions, and posture.

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Spatial relationships refer to the distance between people when they communicate. It is valuable for couples and families to pay attention to their own and each other’s body language. When body language is congruent with what is being spoken, it enhances the message; however, when body language is incongruent with what is being communicated verbally, it might undermine or alter the message (McKay et al. 2009). For example, one partner might remark to a therapist in couple’s therapy, “Yeah, my partner’s a really considerate person. He’s always looking out for me and my needs.” If the speaker said this with a soft tone and a smile, the message is congruent with the body language, and we can gather that the speaker is sending a positive message about her partner. However, if the speaker said this with a sarcastic tone while rolling her eyes and with a flat expression on her face, the message would be incongruent with the body language, and we might interpret the meaning behind what was being said as a negative description of her partner. Family relationships and communication are closely related to family mental health (Galvin et al. 2016). Building communication skills can be particularly important to improving relationship satisfaction and creating positive change within couples and families. Families that practice functional communication are better at problemsolving and tend to have more relationship satisfaction (Lavner et al. 2016). Research also supports that clear, open, frequent, and direct communication leads to greater relationship satisfaction (Epstein et al. 1982). It is important to note that while research supports the correlational relationship between relationship satisfaction and quality of communication, most studies’ findings do not suggest cause and effect (Lavner et al. 2016); therefore, more research needs to be done to explore this relationship.

Relevance to Couple and Family Therapy Communication is also relevant to couple and family therapy, as it is a focus of several systemic theories, including strategic family therapy, Satir’s human validation process model,

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emotionally focused couple therapy (EFT), the Gottman method of couple therapy, and narrative family therapy. In strategic family therapy, therapists use a directive approach and paradoxical interventions to create second-order change (Hayley and Richeport-Haley 2003). Paradoxical interventions are specific linguistic strategies used by therapists to encourage families to unknowingly create change through prescribing the symptom, ordeals, or restraining, and can be referred to as therapeutic double binds (Watzlawick et al. 1967). In prescribing the symptom, the therapist advises the client to enact the symptom, and may even order the client to enact this behavior during a particular time period, thus removing all spontaneity and allowing the client to see that they actually do have control over their symptoms and the ability to create change (Hayley and Richeport-Haley 2003). For example, if a family complains of disconnect and isolation with no success in previous attempts to spend time together, a therapist might use a paradoxical intervention by suggesting to the family: “Because it seems you all have a desire to be alone, let’s schedule a set time to be alone. Let’s agree to spend time alone in your own rooms for at least 3 hours from 5 to 8 pm each night.” In this example, the therapist used paradoxical language to purposefully put the client in a double bind. The family does not want to be alone, yet the therapist is explaining to them that they do want to be alone based on what they are telling her, and demanding that they spend at least 3 h alone each night. The family may respond in the moment by saying there’s no way they will do such a thing as this is not what they want, or they may come to the next session and share that they were unable to be alone for that long every night. In both scenarios the therapist’s use of paradoxical language in prescribing the symptom ultimately led to a shift in thinking and change in behavior. Virginia Satir’s Human Validation Process Model focuses on communication styles as a way to assess family relationships, roles of each member, and the overall family system. Satir identified four incongruent communication styles that people resort to in times of distress, conflict,

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or discomfort, including the blamer, placater, irrelevant, and super reasonable. These dysfunctional stances prevent families from practicing frequent, open, and clear communication, which negatively impacts self-esteem and relational connection. The blamer blames others for their distressing feelings and family conflict. The placater avoids and hides from uncomfortable situations. The irrelevant communicator deflects and distracts from conflict and stress. Lastly, the supperreasonable relies on logic and discredits emotion. Satir’s theory also suggests a fifth communication stance, congruent communication, where people can share their thoughts and feelings without projecting them onto others or worrying about them being misinterpreted. As theorized, these communication stances suggest that those who can communicate congruently, even through uncertainty and conflict, will have the most effective communication, and thus, the most satisfactory relationships. For example, a couple may present in treatment where the wife acts as the blamer, blaming her husband for their relationship problems, and the husband presents as the placater, avoiding and hiding from the relationship problems. With this case, the therapist might try to move the couple from their incongruent communication styles to a congruent communication style, by supporting them in communicating openly, clearly, and directly through their relational issues (Satir 1972). Communication is also a core aspect of EFT, which suggests that developing healthier interaction patterns is crucial for the change process. In the earlier stages of treatment, Johnson (2004) suggests that the therapist helps couples to identify their negative interaction cycle that reinforces a dysfunctional feedback loop within the relationship. In addition to understanding a couple’s interactional pattern, EFT also supports the couple in accessing and expressing primary emotions to one another, sharing their underlying attachment needs, and creating a new way of interacting based on a new, shared understanding of one another (Johnson 2004). For example, if a couple identifies a negative interaction pattern of pursuing-distancing, the therapist would first guide the couple towards identifying

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and expressing the underlying emotions of the cycle, like feeling scared or inadequate. The Gottman method also highlights the importance of identifying negative communication methods during conflicts, as their research has found that these negative methods of communication can detrimentally impact intimate relationships, lead to couple dissatisfaction, and even predict divorce for couples in the United States (Gottman 1994). Gottman (1994) also identifies the most destructive methods of communication, which he refers to as the “four horsemen of the apocalypse”: criticism, defensiveness, contempt, and stonewalling. Criticism is when a partner implies that there is something wrong with the other partner. Defensiveness is responding to a perceived attack with an attack. Contempt is when one partner perceives himself or herself to be better than the other and expresses this perception verbally or non-verbally. Stonewalling is when one partner withdraws from the conversation and shuts down. The Gottman method suggests that healthy alternatives to these negative communication techniques involve soothing, listening, and validating (Gottman 1994). For example, if a couple struggles with criticism, the therapist would help the couple to learn to express complaints and listen to concerns, without criticizing his or her partner. Narrative family therapy also emphasizes the importance of communication by focusing on and using language as an agent of change, to create and express the subjective meaning of experiences. Narrative therapists embrace the subjectivity of experiences through the use of linguistic techniques that are designed to explore clients’ meaning-making process and create change, including narrative metaphor, externalizing conversations, deconstruction, and relative influence questioning (White 2007). Narrative metaphors are used to help clients re-author their problemsaturated narrative to a preferred narrative, by allowing the therapist to talk about the problem in a specific way that can change the family’s view and relationship with the problem (Freedman and Combs 1996). For example, “How can you turn your back on the problem together?” Externalizing language is used to separate the problem from

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the person. The therapist also attempts to personify the problem, to further externalize it from specific family members, and to empower the family to see that they have power over the problem (White 2007). For example, instead of talking about “mom’s depression,” the family can rename it “the sticky sadness,” and the therapist can ask: “What can you do to get the sticky sadness to become unstuck in the family?” Deconstructive questioning helps clients unpack their stories, with the intent of understanding how they have been constructed and maintained. By unpacking the story, families are able to see the story from a different perspective, free from the obstruction and subjugation of dominant social discourses (White 2007). For example, the therapists can facilitate the meaning-making process by asking: “What is the significance for your family that you are here together talking about this new perspective on the anger?” Relative influence questions enrich the description of the problem by mapping its influence on various domains such as behavioral, emotional, physical, cognitive, relational, and spiritual (Freedman and Combs 1996). For example, to explore the influence of the problem on behavior, a therapist might ask, “What does the anger get you to do that is against your better judgment?”

Clinical Example of Application of Theory in Couples and Families Emotion-focused couple therapy and couple communication. Jada and Theo have been married for 3 years and dating for 7 years. Jada initiated therapy with an emotion-focused couple therapist. Jada’s husband, Theo, was reluctant to attend because he did not feel comfortable discussing their issues with a “stranger.” Jada expressed that she felt as if Theo never supported her or took initiative in planning events for them as a couple or advancing his career. Theo shared that when Jada asked him to do things, he often didn’t follow through, because he felt like she was too demanding. After identifying the main conflict that the couple is struggling with, the therapist helps the

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couple to identify the negative interaction cycle in which their conflict was expressed. Together, the couple and therapist identify and describe the couple’s pattern of pursuing-withdrawing. Jada shares, “Whenever I try to go to him and talk to him about things, I just feel like he pulls away, like he doesn’t want anything to do with me.” Theo adds, “It’s not that I don’t want to be around you, I just feel like I can’t win. I never please you or respond in a way you seem to like, so why even try?” The therapist responds, “It seems like you two are in a common pattern of Jada pursuing and Theo distancing.” “That sounds about right,” replies Jada. “And when does this pattern usually come out?” asks the therapist. “Usually when I get home from work, I get bombarded with all of this,” states Theo. “Well, I’ve been waiting all day to talk to you in person about what needs to get done. And I’m usually annoyed when I get home from work, and nothing we’ve talked about earlier in the day has gotten done,” says Jada. “It sounds like you both want to be what the other person needs and wants, it’s just this negative cycle of pursuing and withdrawing that gets in the way,” states the therapist. “What do you mean?” asks Theo. “Well, for example, when Jada pursues you when you get home from work, and you feel ‘bombarded’ and withdraw from Jada, you’re not able to be the partner that feels secure with himself and takes initiative. Does that make sense? Does that sound right?” asks the therapist. “Yeah,” says Theo, “That makes a lot of sense.” In a later phase of treatment, the therapist attempts to guide the couple towards accessing unacknowledged emotions and underlying needs. “Now that we’ve figured out the common, negative pattern that has been interfering in your relationship, I want to get more information about how you are experiencing this cycle. Jada, when you feel like Theo pulls away, what emotion are you feeling in that moment?” Jada replies, “I’m feeling sad, lonely. I need a partner, not a child that I need to scold or tell what to do. I’m scared that he’s going to leave me when he shuts down like that. It’s like he’s already checked out.” The therapist encourages this identification of underlying needs, “I

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see. So underneath the conflict, where you usually get angry and start to yell, there are other feelings of fear of loss, sadness, loneliness, and a need for an emotionally available partner.” “Yes, exactly,” replies a tearful Jada. “How about for you, Theo? What are you experiencing emotionally when Jada pursues you?” asks the therapist. “Well, I feel annoyed most of the time. Because I feel like I never can get it right with her. I feel bad about myself. Like, I’m not a good husband, or a good man. So, I guess that leads me to feel somewhat hopeless,” Theo shares. The therapist asks: “And when you are feeling that hopelessness, what is it that you need in that moment? Is there any need that isn’t being met?” Theo responds, “Hmm. Yeah, I guess. It makes me wish I had a partner who could build me up instead of always tearing me down,” Theo shares. “It sounds like you are needing some validation, some support, in order to build some confidence in yourself. Does that sound right to you?” asks the therapist. “Yes. I know that’s a need I should work on for myself too. I know I’ve lost a lot of confidence over the years. But I need some support and encouragement from her too. It would help give me a chance to get better,” Theo states. In the next session, moving into the later stage of treatment the therapist promotes change by working with the underlying feelings and needs that have been expressed and promoting partner acceptance and the continued expression of needs and wants. The therapist facilitated the expression and acceptance of partner experiences by working in the here and now and using an enactment to soften the pursuer, Jada, and reengage the withdrawer, Theo. At one point in the session, when Jada sees Theo getting frustrated, she reaches out and squeezes Theo’s hand. The therapist brings attention to this nonverbal interaction. “I notice you just squeezed Theo’s hand. I wonder what you are wanting to express to him now. Can you turn to Theo and tell him what it means when you squeezed his hand?” Jada softly says, “I believe in you. I love you.” Theo smiles at Jada. “And Theo, can you continue looking at Jada, and tell her what it meant to you that she has shared this

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with you?” prompted the therapist. “Yes, that means the world to me. I feel like a worthy person when you say that. I feel like I’m enough. I feel supported. I love you too,” Theo responds sincerely. Jada smiles and leans on Theo, and the couple hugs. The therapist begins termination by continuing to foster new solutions to old problems and solidify new positive interaction patterns. Understanding their dysfunctional communication patterns and working toward more functional communication helped this couple to change their experience and understanding of each other and their relational problems. Their shift in perspective also allowed the couple to create a new, more positive interaction pattern that embodied clear, frequent, and open communication of feelings and needs. Family communication and narrative family therapy. Matthew, an 8-year-old child dealing with anxiety and attention problems, was brought to therapy by his parents based on his teacher’s recommendation. Matthew’s teacher reported that he was very active in the classroom, had a hard time focusing, and sometimes became so overwhelmed that he cried in class. Matthew’s parents, Jan and Gary, reported that he fought with his younger brother Jon (age 6), and was disobedient and violent at home, especially during homework time. “Overall, he’s just a bad boy, and we don’t know what to do with him. Can you help us?” asked Jan. The narrative family therapist first addresses this problem with the family by using linguistic techniques to externalize the problem from Matthew and change the family’s perspective of the problem, so that they could unite as a family system to work against the problem. The therapist responds to the family by stating, “This fighting and being very active, what should we call that?” Gary replies with a chuckle, “Well, sometimes we call it the tornado. Like when he starts to get upset we joke, ‘uh oh, there’s a storm coming.’” With the help of the therapist’s use of externalizing language, the family starts to shift their communication about the problem from Matthew to the problem itself. The therapist also uses relative influence questioning to

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explore the externalized problem in more depth, by asking: “What makes the tornado bigger or smaller?” “School,” says Matthew, “I hate school!” “Oh,” says the therapist, “How does school make the tornado bigger?” Matthew responds: “When I’m at school, I don’t understand what the teacher is saying, and I feel stupid. I feel like all the kids in my class think I’m stupid. So then I get mad when I have to do school at home. And that’s when I start throwing things and pushing people. That’s when the tornado gets bigger.” Matthew’s response helps the family to gain a greater understanding of the problem narrative by mapping the influence of the problem. The therapist also explores the family’s preferred narrative, so that the family can know what they would like to work toward, by asking: “And what is it that you would like your family life to look like, if not this stormy tornado?” “I would just like for our family to have some peace and quiet,” shares the father. “Yes, for our family to be at peace, happy, and calm and getting along,” agrees Jan. “Okay, so it seems like we have a clear picture of moving from an angry, stormy family that does not get along, to a happy, calm family that does get along,” restates the therapist. Next, the therapist aims to identify unique outcomes. “So last week we learned about this tornado problem that keeps coming up in the family and that school makes the tornado bigger. I wonder if you could tell me about times when the tornado is not there at all?” Jan responds, “Well, I think when we have our family time on Friday nights, it’s less likely that a tornado will come. We usually watch a movie, read a book aloud together, or play a board game, and then Matthew, Jon, and everyone really seem to be happy.” “Yes, those are nights we get some peace and quiet,” states the father. “I like family night,” says Jon. “Wow, it sounds like all of you really enjoy family night on Fridays. How do you think we could get that same feeling of peace and happiness to happen more often?” asks the therapist. “Maybe if we could just watch movies more instead of doing homework?” suggests Matthew. “I mean, yes, that would be great if we could just relax,

Communication in Couples and Families

Matthew. But we can’t just watch movies all the time. We have to go to school,” says Jan. The therapist uses questioning to expand on preferred narratives and thicken the plot of the preferred narrative. “What I’m hearing is being able to relax more with family would feel better than having to do homework. I wonder if there’s a way to make homework time feel more like relaxing family time?” says the therapist. “Maybe if mommy and daddy didn’t yell at me when I get upset when I’m trying to do it. . .” suggested Matthew. “Um, yes, sometimes we get frustrated Matthew, because you get so upset,” Gary says. “Maybe if we took breaks? Maybe then it would help us calm down before we get to yelling. I know sometimes that’s helpful for me,” suggests Jan. In the final stage of treatment, the therapist continues to work with the family to solidify the preferred narrative by asking if taking breaks works, and continuing to find unique outcomes and expanding on them, until the family is able to live out their preferred narrative.

Cross-References ▶ Blamer Stance in Couples and Families ▶ Communication Theory ▶ Communication Training in Couple and Family Therapy ▶ Double Bind Theory of Family System ▶ Externalizing in Narrative Therapy with Couples and Families ▶ Feedback in Family Systems Theory ▶ Four Horsemen in Couple and Family Therapy ▶ Gottman Method Couples Therapy ▶ Homeostasis in Family Systems Theory ▶ Listening in Couple and Family Therapy ▶ McMaster Family Therapy ▶ Metacommunication in Couple and Family Therapy ▶ Narrative Family Therapy ▶ Negative Feedback in Family Systems Theory ▶ Paradox in Strategic Couple and Family Therapy ▶ Paradoxical Directive in Couple and Family Therapy

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▶ Positive Feedback in Family Systems Theory ▶ Prescribing the Symptom in Couple and Family Therapy ▶ Satir Model of Transformational Systemic Therapy ▶ Second-Order Cybernetics in Family Systems Theory ▶ Strategic Family Therapy

References Bateson, G. (1972). Steps to an ecology of mind. New York: Jason Aronson. Epstein, N. B., Bishop, D. S., & Baldwin, L. M. (1982). McMaster model of family functioning. In F. Walsh (Ed.), Normal family processes (pp. 115–141). New York: Guilford Press. Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York: Norton. Galvin, K. M., Braithwaite, D. O., & Bylund, C. L. (2016). Family communication: Cohesion and change (9th ed.). New York: Routledge. Goldberg, R. M. (2017). Communication errors/problems in couples and families. In J. Carlson & S. B. Dermer (Eds.), The SAGE encyclopedia of marriage, family, and couples counseling (pp. 300–302). Thousand Oaks: SAGE Publications. Gordon, T. (2000). Parent effectiveness training: The proven program for raising responsible children. Gottman, J. M. (1994). What predicts divorce? Hillsdale: Lawrence Erlbaum Associates. Hayley, J., & Richeport-Haley, M. (2003). The art of strategic therapy. New York: Brunner-Routledge. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection. New York: Brunner-Routledge. Koerner, A. F., & Fitzpatrick, M. A. (2002). Toward a theory of communication. Communication Theory, 12(1), 70–91. https://doi.org/10.1093/ct/12.1.70. Lavner, J. A., Karney, B. R., & Bradbury, T. N. (2016). Does couples’ communication predict marital satisfaction, or does marital satisfaction predict communication? Journal of Marriage and Family, 78(3), 680–694. https://doi.org/10.1111/jomf.12301. McKay, M., Davis, M., & Fanning, P. (2009). Messages: The communication skills book. Oakland: New Harbinger Publications. Satir, V. (1972). Peoplemaking. Palo Alto: Science and Behavior Books. Watzlawick, P., Beavin Bavelas, J., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York: W. W. Norton & Company. White, M. (2007). Maps of narrative practice. New York: Norton.

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Communication Theory

Jason Cencirulo1 and Kathleen A. Eldridge2 1 Los Angeles, CA, USA 2 Graduate School of Education and Psychology, Pepperdine University, Los Angeles, CA, USA

perceptual processes and relational processes. Those theories that fall under the message/perceptual processes emphasize what, how, and why a message is being communicated and the subsequent perceptual processes involved, while relational processes examine how communication begins, sustains, or dissolves a relationship.

Name of Theory

Prominent Associated Figures

Communication theory

Communication theory relies heavily on cognitive science, which, in turn, is influenced by numerous fields, including linguistics, psychology, sociology, and philosophy. This creates a rich multidisciplinary intersection whose contributors are too numerous to thoroughly credit. However, prominent figures for the communication theories covered in this entry include Sandra Petronio, who is credited with fully articulating communication privacy management theory; Chris Kramarae and Robin Lakoff, early feminist theorists who studied gendered communication styles; Rajeswari Sunder Rajan and Audre Lorde, postcolonial feminists who have examined the intersectional influences of gender, class, nation, and colonialism on women and relationships; Howard Giles, who helped establish communication accommodation theory; Dalmas Taylor, Irwin Altman, and others who proposed social penetration theory; Barbara Montgomery and Leslie Baxter who, inspired by Mikhail Bakhtin, developed dialectical theory; and Mary Anne Fitzpatrick, who was prominent in the creation and/or growth of both family communication patterns theory and marital typologies.

Communication Theory

Synonyms Communication privacy management; Communication boundary management

Introduction Communication permeates every dimension of life. Scholars from numerous fields have attempted to examine various aspects of communication, from what is being communicated to how it is being perceived and what impact it has on internal, interpersonal, and system-level variables. Communication is especially integral to the development, maintenance, and dissolution of couples and family systems. As such, numerous frameworks have been created to help practitioners organize and understand the processes involved in communication and the mechanisms of action specific to them. Within each framework, however, there rests an underlying assumption that certain cognitive processes – or mental activities – shape and direct the messages being sent and influence how these messages are understood. This entry is by no means exhaustive, but rather serves as an overview of influential theories that have shaped and continue to impact the field of communication. For the purposes of this entry, the body of knowledge that comprises the discipline of communication will be viewed through two main theoretical categories encompassing both couples and familial foci: message/

Description Message/Perceptual Processes Feminist Theory

Feminist communication theory explores the intersection between gender, class, ethnicity, and race in women’s lives against historical structures and communication styles that have traditionally privileged men (Griffin 2009). Since its inception,

Communication Theory

feminist communication theory has examined a wide body of topics pertaining to ways in which dominant cultural narratives are born and reinforced through language and the ways in which power differentials disproportionately marginalize women. Early theorists, including Chris Kramarae and Robin Lakoff, examined the ways in which women’s communication styles were modified by gender. For example, early feminist communication scholars proposed that gendered communication expectations exist such that women are expected to hedge more frequently while communicating to others, apologize more, and speak less often. Further, when a woman violates these presupposed gendered expectations, she is rebuked. As such, early scholars contended that women subsisted in a doublebind position that dictates communication style and stifles personal, professional, and social advancement. This is manifest in numerous realms, including the realm of politics, where early feminist theory explored oration differences between genders and the notable absence of women’s speeches and speaking styles in historical textbooks. As feminist theory advanced, scholars questioned the prominence of Western-centric views of feminism, particularly regarding power and subjectivity (Mohanty et al. 1991). For example, early inclusion of a binary of power vs. powerlessness when exploring differentials between men and women privileged a Western view of women’s stylistic bind. As such, when exploring women in relation to their counterparts around the world, some early feminist communication theorists were criticized for defining and advancing notions of power for all women as opposed to just those who shared their view of the ideal (Western) power structure. For many scholars, these early theories ignored a greater world lens of women’s issues, which therefore led to a body of postcolonial feminist theory that focused on intersubjectivity and the reconstruction of women’s agency through a multicultural framework, including dialogues of race, class, religion, sex, etc. Prominent contributors to this field include Rajeswari Sunder Rajan and Audre Lorde.

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Feminist communication theory is relevant to couples and families, and the contributions of the theory can be found in numerous relational dynamics. For example, within couples, scholars studying the demand-withdraw pattern of communication, in which one partner criticizes or complains and another partner forecloses conversation or physically exits, have examined the roles of gender and power in determining demanding and withdrawing parties. While researchers first established the pattern as more prominent in female-demand/male-withdraw pairings, emerging research in line with postcolonial feminist theory has demonstrated that the pattern manifests differently cross-culturally and within same-sex dyads, pointing to an intersubjective space that is more prominently influenced by the individual within a couple seeking change. Communication Accommodation Theory

Communication accommodation theory (CAT) is a framework that merges sociolinguistic and sociopsychological dynamics in order to explore the movement of individuals toward and away from one other through adaptations in communication (Gallois et al. 2005; Giles et al. 1991). Championed by Howard Giles and others, CAT delineates numerous forms of accommodation in communication. For example, shifting one’s language toward another’s language is an accommodation of convergence often intended to minimize the social distance between two individuals. Convergence can be upward or downward and reciprocal (symmetrical) or nonreciprocal (asymmetrical) in nature. For instance, what one might call a couch among peers might be called a sofa in the presence of a highly influential person (if one assumes that sofa is a term better understood by the influential person with whom one is seeking to connect). This example would be considered an upward convergence that, if reciprocated, would be symmetrical. However, there are degrees to which accommodations can alienate – as opposed to connect – others, as accommodations that are too sweeping might appear mocking, and accommodations that are too rapid might appear disingenuous.

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Power plays a prominent role in this theory, as researchers have found that those outside relative social power work harder in order to accommodate the norms of the dominant class, whereas this move is not reciprocated by the dominant class as readily. Here, divergence takes place, which can increase social distance and forward pre-existing power structures. Within relationships, divergent accommodations can be found within distressed couples who consciously use the tactic as a means of emotionally distancing themselves from their partner. Conversely, some level of convergent accommodation is normative in the formative stages of a relationship and can be harnessed in therapy in order to build intimacy or understanding. Communication Privacy Management

Communication privacy management (CPM) studies the realm of private disclosure (Petronio 2002). Specifically, CPM explores the relationship between the messages an individual chooses to conceal and the messages an individual chooses to reveal. Privacy is central to this theory because it is the foundation upon which perceived ownership of personal information is derived. As such, privacy protects an individual from the risks inherent in disclosure to others, whether due to the relation of too much private information to another, poor timing of a disclosure, or a disclosure communicated to one who may do harm. However, privacy needs may deny a person of the benefits of disclosure, as disclosure may connect one to one’s shared humanity, relieve one of undo burden, clarify feeling, or increase intimacy within a partnership. Due to the risks and rewards inherent in both privacy and disclosure, CPM advances a rule-based approach that illuminates the ways in which one might balance his/her needs. The theory offers five assumptions, including (1) the focus of a given decision is on private information, (2) private information and public relationships are demarcated through the use of a boundary metaphor, (3) the desire for personal control fuels boundary management, (4) rules aid in the regulation of boundaries, and (5) disclosure and privacy are considered dialectical in nature.

Communication Theory

The rule management process advanced by CPM contends that an individual must coordinate his/her boundaries with others because information is often co-owned with others. To this end, CPM uses the term private disclosure when labeling disclosure, as opposed to self-disclosure, in order to incorporate the numerous domains of disclosure, including through group or community means. Further, CPM posits that the coordination of boundaries is precipitated on a desire to exercise individual or collective control. When an individual is unable to navigate his/her privacy and private disclosure, boundary turbulence occurs, and corrective action is needed. The proliferation of social media and the availability of multiple channels of information that might be used for private discourse present fertile ground for boundary turbulence within couples and families. Concerns about what information is shared, by whom, with whom, when, and for what purpose must therefore be navigated with a greater degree of conscious consideration. Take, for example, what information might be gleaned about a couple’s health, well-being, or expendable income by the distribution of a picture on social channels or the unintended consequence of a “status update” on the trajectory of a relationship. In these cases, CPM provides the therapist with a framework of understanding and action that might help to clarify or resolve concerns about disclosure. Relational Processes Dialectical Theory

Dialectical theory explores the contradictory tensions within relationships and throughout social functioning that help to order experience (Pawlowski 1998). Whereas family systems theory focuses on homeostasis as a state to which the family unit returns, regardless of the relative health of that homeostasis, dialectical theory eschews homeostasis in favor of change and flux. In short, according to dialectical theory, communication never resolves, but rather moves, and in moving, creates meaning. Developed by Barbara Montgomery and Leslie Baxter and influenced by Mikhail Bakhtin, dialectical

Communication Theory

theory’s central tenant is built off a contradiction: a unity of opposites (Baxter and Montgomery 1996; Baxter 2004). It includes three central, symbolic dialectical dimensions that shape interpersonal relating, including stability-change, expression-non-expression, and integrationseparation. These dialectics can occur both internally and externally, for example, between a couple and between a couple and a couple’s greater social sphere. Within a relationship, a partner may one moment desire physical distance, while moments later desire proximity. These opposing desires are not inherently good or bad, as they are common to all relationships and managed throughout a relationship’s unfolding. However, it is through the negotiation of these tensions that the relative health and well-being of a relationship is determined. As relationships change, so too do the dialectics. Work with couples and families, therefore, centers on the identification and relevance of these co-occurring dialectics within a particular place and time. While all three dialectics can co-occur, a therapist might help a couple identify which dialectics have more salience and therefore create a reference point from which to navigate flux. Marital Typology

Typology – or classification based on different types – has played an important role in the formation of many relational communication theories, as it provides an accessible heuristic from which to base human behavior. Mary Anne Fitzpatrick used a typological approach to develop a theory of marital types and refine/popularize a theory of family communication styles (discussed in detail below). Using self-report measures, Fitzpatrick and colleagues categorized couples by five primary orientations based on their interaction patterns: independents, separates, traditionals, separate-traditionals, and traditionalindependents (Fitzpatrick 1988). Each orientation maintains its own position with respect to the degree of freedom desired within a relationship, desired marital ideology, and manner of managing conflict. Those with an independent marital type maintain a system of belief that is outside of

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conventional norms, can operate interdependently (yet maintain relative self-sufficiency), and can manage conflict. Separates, however, maintain conventional norms, operate more independently than interdependently, and desire to circumvent conflict to a greater extent than all other types. Finally, traditionals maintain more conventional norms than all other types, operate interdependently, and can manage conflict, but would prefer to circumvent it if possible. While these typologies describe couples that share a communication style, mixed-couple marital types are also possible, such as separatetraditionals and traditional-independents, and occur in roughly 40% of all couplings. Overall, the theory of marital types provided an important framework from which to understand couples’ communication, but has declined as a focus of research since its inception in lieu of theories that favor emergent, dynamic qualities of couples’ relationships. Family Communication Patterns Theory

Family communication patterns theory (FCPT) frames family functioning as a shared social reality influenced by two primary communication foci – conformity and conversation (Koerner 2009). From these two communication foci, four distinct family types emerge: consensual, pluralistic, protective, and laissez-faire. Popularized by Mary Anne Fitzpatrick, Ascan Koerner, and others, FCPT posits that each unique family style influences the manner by which a family expresses warmth, shares information, and maintains or resolves conflict (Koerner and Fitzpatrick 2004). One communication focus – a focus on conversation between family members – helps parents and children cocreate meaning of shared symbols and understand each other’s social environment. Conversely, another communication focus – conformity – creates a communication pattern between parents and children that is unidirectional, such that parents ascribe meaning to the symbols a family shares. According to FCPT, families that are focused primarily on conversation between members are classified as pluralistic and enjoy a greater degree

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of member autonomy than other family types. Here, parents are clear about their beliefs, but do not mandate that their children maintain the same beliefs. Consensual families, on the other hand, while focused on conversation, equally value conformity. Parents help their children navigate the dialectics of exploration and hierarchy and provide a clear frame in which members operate. Families with a consensual frame have been found to enjoy greater emotional health and well-being than other types. Protective families focus primarily on conformity in lieu of conversation. Obedience is emphasized within this structure, which establishes rules within the family unit, yet stifles children’s ability to understand and trust their own decision-making processes. Finally, a laissez-faire family places little emphasis on both conformity and conversation. Families with this focus maintain infrequent communication with one another and demonstrate a limited interest in a shared emotional processing as compared to other families. As such, children in this family style are prone to place more emphasis on the opinions of others in order to determine the meaning of information or calculate a given course of action. Relationship Development, Maintenance, and Dissolution Theories

Communication plays a pivotal role in the development, maintenance, and dissolution of romantic relationships. For example, the ability to communicate warmth, confidence, or ease through verbal and nonverbal channels has been shown to increase attraction between strangers. Further, similarities in communication styles can result in increases in the attraction between individuals. A number of theories seek to illuminate the process of relationship development through a stepwise model that predicts relationship development. Dalmas Taylor and Irwin Altman proposed a social penetration theory that examined the role of self-disclosure as a means to deepen intimacy among individuals (Taylor and Altman 1987). According to these theorists, as the breadth, depth, and frequency of disclosure increases among individuals, so too does the intimacy of individuals’ shared bond. Borrowing from elements of the social penetration theory, Mark Knapp proposed a stepwise model that included stages of relationship

Communication Theory

development (Knapp and Vangelisti 2005). These stages, which unfold separately, include initiating, experimenting, intensifying, integrating, and bonding. In each stage, partner unification intensifies and deepens. The role that uncertainty plays in relationship development has also been studied, namely, by Charles Berger, Richard Calabrese, and others (Berger 2005). According to these theorists, uncertainty plays a pivotal role in relationship development due to its unique ability to intensify emotions and polarize communication. While some theorists view uncertainty as inherently negative in relationships, others such as Leslie Baxter view it as a vehicle for increased cooperation and an opportunity for couples to experience more surprises that increase needed relational novelty. After the development of a given relationship, certain behaviors contribute to its ideal maintenance. Scholars such as Laura Stafford and Daniel Canary have identified a number of behaviors that help to maintain marital relationships in particular. These behaviors include engaging in a positive manner, remaining open in communication, sending messages of assurance, sharing social networks, and sharing tasks. Other researchers have identified salient behaviors that help to maintain romantic relationships, including a focus on selfenhancing behaviors such as exercise and mediated communication such as frequent phone contact. For each relationship that is developed and maintained, there is a likelihood of dissolution. Just as Mark Knapp described relationship development, he outlined a stepwise relationship dissolution process that includes the following stages: differentiating, circumscribing, stagnation, avoiding, and terminating. Opportunities for intervention exist in each stage, and as such, the dissolution process is just as important to couples work as the development and maintenance stages. For example, intervention in the circumscribing phase might focus on communication boundaries set up by one’s partner in order to limit the frequency and depth of conversation, whereas intervention in the stagnation phase might focus on communication gaps between the couple that promote neglect.

Communication Theory

Relevance to Couple and Family Therapy The field of communication broadly seeks to explore the ways in which messages comprise, organize, or dissolve our personal, familial, and social relationships and the manner by which these messages are transmitted or perceived (Stamp and Shue 2004). As such, communication is central to all aspects of work in both couple and family therapy, from conceptualization of distress to treatment planning and intervention. Some examples of the relevance of communication theory to couple and family therapy are provided in this section, followed by additional case examples in the next section. One example is a therapist who might use a feminist communication theory to understand a couple’s difficulties communicating as related to internalized gender norms that stifle intimacy, regardless of whether the couple is cross sex or same sex. Treatment, then, would focus on raising the couple’s consciousness about the internalization of their gender norms while investigating the exact ways in which these norms have manifest in their daily life. Further work might focus on resocializing the couple in order to liberate them from the oppressive nature of their respective models. However, other conceptualizations might see distress as exclusively resulting from a communication skill and/or process deficit and would target treatment on buttressing these deficits For example, work from a social penetration theory frame might focus on building self-disclosure skills. First, a therapist would help a couple identify their current communication pattern, including disclosures that each partner believes to be personal in nature and superficial in nature. A therapist might do this by, in part, paying attention to nonverbal cues that denote immediacy (forward lean, touching) and relaxation (arm and leg symmetry), two nonverbal behaviors that have been associated with greater intimacy. By first identifying these behaviors based on observations in the therapeutic setting, a therapist might then help each partner to identify these behaviors in one another. Thereafter, a therapist could choose to help the couple understand the interpersonal rewards of increased personal disclosure (increased intimacy), in addition to the costs of an overreliance on

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superficial disclosure (decreased intimacy). Work with the couple would then focus on helping partners develop the practical skills of effective personal disclosure (“I feel” statements, eye contact, etc.). Still other theories offer a typology to explain the impact that certain communication styles might have on a couple and/or family. For example, family communication patterns theory (FCPT) offers an understanding of the intersection between family communication styles and behaviors based on the level of conversation and conformity within a family. A therapist who understands a family to be of a certain typology (e.g., consensual) might be able to better identify behaviors that correspond (e.g., a mandate for family dinners) and help the family to identify how their communication style corresponds to their behaviors. While both communication styles and behaviors can change over time in a family, the focus in therapy is on the multidimensional functions they serve and their contribution to the shared social reality of a family. Essentially, communication styles create meaning for a family, and as meanings change, the therapist must work with the family to bridge the often tumultuous interactions that result. Using a FCPT framework, a therapist might help family members understand the impact their communication style has on their family’s intersubjectivity, or shared meaning, and interactivity, or the interpersonal interactions resulting from their communication style.

Clinical Example of Application of Theory in Couples and Families Jennifer, a 43-year-old African-American female who identifies as agnostic and Daniel, a 41-yearold Caucasian male who identifies as Christian, have one daughter together, a 13-year-old named Shannon. The couple self-referred to therapy in order to alleviate pent-up ill-will stemming from differences in cultural expectations about the role of gender and religion in their relationship, as well as to improve communication. Using self-report measures, the couple’s therapist first develops a marital typology in order to understand the ways in which the

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couple relates to one another. She determines that the couple operates more independently than interdependently and that they desire to circumvent conflict rather than address it headon. She, therefore, believes that the couple falls into the typology of separates and hypothesizes that work will focus, in part, on increasing interdependence. First, however, she seeks to better understand how the couple employs the skill of communication with one another. She finds that the couple is stuck in a communication pattern of demand-withdraw, in which Jennifer is the withdrawing party and Daniel is the demanding party. Utilizing a social penetration frame, she sees this as a de-penetration of intimacy within the relationship that has impacted the couple’s ability and willingness to share their innermost thoughts and beliefs. She learns that these styles of communication have been formed because Daniel seeks change in the relationship that Jennifer is unwilling to accommodate. Daniel desires that Jennifer spends more time at home with their daughter, but Jennifer believes her current time at home is sufficient and hopes that Daniel will be more accepting of their current roles. Using a feminist and postcolonial feminist theoretical framework, the therapist teases out the historical influences impacting Daniel’s desire for – and sense of entitlement to – traditional gender roles, including the intersection of his race and religion. She then helps Jennifer identify the communicative double bind she is placed in that leads to her withdrawing behavior. This understanding helps the couple navigate the dialectic of communication and non-communication that they have struggled to integrate, and the acceptance of this dialectic helps the couple find moments of communicative convergence in line with communication accommodation theory (CAT). Over the course of treatment, Jennifer is diagnosed with stage II breast cancer. The therapist then employs CPM’s rule-based approach to decision-making in order to help the couple first manage their disclosure of private health information to their daughter and subsequently to their

Communication Theory

greater community. The decision-making matrix that Jennifer, the couple, and the family must go through according to CPM takes into consideration Jennifer’s desire for control and her ability to navigate vulnerability and includes a coordination of the family’s shared boundaries. The therapist has a pre-existing idea of the family’s boundaries because she has examined their communication style and behavior over time and has determined that they operate from a pluralistic typology. As such, the couple’s daughter has been told about her parents’ beliefs, but has been free to choose her own beliefs about what and when to communicate regarding her mother’s disease. While this family communication style has benefitted the unit previously, the family’s new context may require more conformity and conversation in order that the family successfully navigate their newfound boundaries. As such, the therapist works to make the family aware of the benefit of a consensual communication pattern. As the needs of the family change over time, so too do the interventions and the conceptualization of distress, but within each change, the underlying therapeutic focus on communication predominates.

Cross-References ▶ Cognition in Couple and Family Therapy ▶ Communication in Couples and Families ▶ Communication Training in Couple and Family Therapy

References Baxter, L. A. (2004). A tale of two voices: Relational dialectics theory. Journal of Family Communication, 4(3), 181–192. Baxter, L. A., & Montgomery, B. M. (1996). Relating: Dialogues and dialectics. New York: Guilford Press. Berger, C. R. (2005). Interpersonal communication: Theoretical perspectives, future prospects. Journal of Communication, 55(3), 415–447. Fitzpatrick, M. A. (1988). Between husbands & wives: Communication in marriage. Newbury Park: Sage. Gallois, C., Ogay, T., & Giles, H. (2005). Communication accommodation theory: A look back and a look

Communication Training in Couple and Family Therapy ahead. In W. Gudykunst (Ed.), Theorizing about intercultural communication (pp. 121–148). Thousand Oaks: Sage. Giles, H., Coupland, N., & Coupland, J. (Eds.). (1991). The contexts of accommodation. New York: Cambridge University Press. Griffin, C. (2009). Feminist communication theories. In S. W. Littlejohn & K. A. Foss (Eds.), Encyclopedia of communication theory (Vol. 2, pp. 391–394). Thousand Oaks: Sage. Knapp, M. L., & Vangelisti, A. L. (2005). Interpersonal communication and human relationships (5th ed.). Boston: Allyn & Bacon. Koerner, A. F. (2009). Family communication theories. In S. W. Littlejohn & K. A. Foss (Eds.), Encyclopedia of communication theory (Vol. 2, pp. 382–385). Thousand Oaks: Sage. Koerner, A. F., & Fitzpatrick, M. A. (2004). Communication in intact families. In A. Vangelisti (Ed.), Handbook of family communication (pp. 177–195). Mahwah: Lawrence Erlbaum. Mohanty, C. T., Russo, A., & Torres, L. (1991). Third World women and the politics of feminism. Bloomington: Indiana University Press. Pawlowski, D. R. (1998). Dialectical tensions in marital partners’ accounts of their relationships. Communication Quarterly, 46(4), 396–416. Petronio, S. S. (2002). Boundaries of privacy: Dialectics of disclosure. Albany: State University of New York Press. Stamp, G., & Shue, C. (2004). Twenty years of family research published in communication journals. In A. Vangelisti (Ed.), Handbook of family communication (pp. 11–28). Mahwah: Lawrence Erlbaum. Taylor, D., & Altman, I. (1987). Communication in interpersonal relationships: Social penetration processes. In M. E. Roloff & G. R. Miller (Eds.), Interpersonal processes: New directions in communication research (pp. 257–277). Newbury Park: Sage.

Communication Training in Couple and Family Therapy Norman B. Epstein1 and Mariana K. Falconier2 1 University of Maryland, College Park, MD, USA 2 Virginia Polytechnic Institute and State University, Falls Church, VA, USA

Name of Intervention Communication training in couple and family therapy

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Introduction Communication skills training is among the most commonly used of the behavioral interventions in couple and family therapy. It is used to improve the clarity with which members of relationships express their thoughts and emotions to each other and the effectiveness with which they listen to and understand each other’s messages. Good communication involves one individual expressing thoughts and emotions in a manner that is easy to understand and another person setting aside personal agendas to try to take the expresser’s perspective, understand the person’s subjective experience, and reflect those thoughts and feelings back to the expresser to demonstrate empathy. Guerney’s (1977) Relationship Enhancement Program emphasized positive outcomes of family members’ psychological and emotional wellbeing derived from the increased intimacy gained from improved expressive and empathic listening skills. Similarly, Markman et al.’s (2010) Prevention and Relationship Enhancement Program (PREP) applies expressive and listening skills, integrated with conflict resolution skills, to help couples weather the stresses of life together and prevent deterioration in the quality of their relationships. For therapeutic interventions with distressed relationships, a core goal of communication skills training is to substitute positive expressive and listening skills for existing negative communication patterns such as criticism, verbal aggression, defensiveness, and withdrawal. Clear, constructive communication also is considered a prerequisite for effective problem-solving skills (Epstein and Baucom 2002; Jacobson and Margolin 1979).

Theoretical Framework Although forms of communication skills training are used in a variety of couple and family therapy theoretical models, they are associated most with behavioral and cognitive-behavioral models based on social learning theory (Epstein and Baucom 2002). Social learning theory proposes that adults who form a couple relationship bring

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personal learning histories that shape how they interact with each other. In their families of origin and other past relationships, they learned skills and styles of communicating and relating to significant others, by observing parents, siblings, etc., and by being reinforced for certain actions and punished for others. These learned behavioral patterns may differ considerably across cultures. Parents model and explicitly teach their children expressive, listening and problem-solving skills. Some parents model constructive skills, whereas others model ineffective and even destructive approaches. In a social learning and cognitivebehavioral theoretical model, it is assumed that individuals develop both positive and negative behavioral responses through these same learning processes; consequently, learning procedures can be used to teach members of couples and families more constructive communication skills.

effectively (e.g., be brief, be specific, describe emotions as well as thoughts, when expressing dissatisfaction with your partner’s behavior, first say something positive or encouraging about the partner) and for active, empathic listening (e.g., use good eye contact, reflect back the expresser’s thoughts and emotions); (b) modeling the expressive and listening skills via demonstration, either live modeling by trainers/therapists or viewing of video recordings such as the video accompanying the Markman et al. (2010) book; (c) clients repeatedly practicing the skills; and (d) trainers/therapists providing the clients with specific feedback on their behavior and coaching to shape more effective skill enactment. Typically, couples or families first are asked to practice using the skills with benign topics that do not elicit strong upset feelings that could interfere with developing the skills. As they exhibit greater ability to communicate about significant upsetting relationship issues, they are guided in using the skills for discussing areas of conflict.

Rationale for Communication Skills Training Research has demonstrated that negative forms of communication are risk factors for relationship distress, deterioration, and divorce (Gottman 1994), and communication training is a key component of cognitive-behavioral couple therapy that reduces relationship distress (Epstein and Baucom 2002). Couples and family members commonly readily grasp the goals and structured methods of communication skills training, so the skills can be taught and practiced easily in a variety of relationship enrichment groups (e.g., Markman et al. 2010) and couple therapy (e.g., Epstein and Baucom 2002).

Description of Communication Skills Training Procedures for teaching communication skills are based on social learning principles, in which the trainer or therapist’s role focuses on teaching and guiding the members of couples or families. The skills training components include (a) educating the members regarding guidelines and methods for expressing one’s thoughts and emotions

Case Example Elizabeth and James sought premarital therapy because they found themselves feeling misunderstood by each other when they discussed their life priorities and their hopes for the future of their relationship. Their therapist assessed the couple’s current communication pattern by listening to their descriptions of past upsetting discussions and also by asking the couple to engage in a discussion of life goals in front of the therapist. Both members of the couple seemed to focus more on stating their own ideas than on listening and understanding the other’s perspective, and when they expressed themselves, their messages tended to be long and jump from one topic to another. The therapist gave the couple feedback about this pattern and suggested that the three of them work together on improving their communication skills. The therapist provided each partner a handout with specific guidelines for the expresser role and the empathic listener role and explained them to the couple. The therapist then demonstrated first the expresser skills and then the listener skills, and

Complementarity in Structural Family Therapy

she answered Elizabeth and James’ questions about them. Next, the couple selected a benign topic to discuss (their reactions to new neighbors who seemed unfriendly). They decided that Elizabeth would take the expresser role first, with James providing empathic listening. Elizabeth initially only described her perceptions of the neighbors, so the therapist coached her in also mentioning her emotional responses to them. She also began to speak at length, so the therapist asked her to stop after a couple of minutes so James could reflect back what he heard her saying, and then she could express herself further. After James did his reflecting, Elizabeth was able to give him feedback that he accurately summarized most of her feelings but overlooked a particular point. He then reflected back his understanding of that point, and Elizabeth confirmed that he had done a good job of showing his empathic listening. The therapist then asked the partners to exchange roles, with James expressing his reactions to the neighbors and Elizabeth taking the empathic listener role.

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Complementarity in Structural Family Therapy Jorge Colapinto1 and Wai Yung Lee2,3 1 Minuchin Center for the Family, Woodbury, NJ, USA 2 Asian Academy of Family Therapy, Hong Kong, China 3 Aitia Family Institute, Shanghai, China

Introduction Complementarity is the concordance of behaviors and roles between family members.

Theoretical Context The concept is central in structural family therapy, underlying both the structural therapist’s challenge to the family’s definition of the problem, and her or his optimistic stance regarding the possibilities of change.

Cross-References ▶ Cognitive Behavioral Couple Therapy ▶ Problem-Solving Family Therapy ▶ Social Learning Theory

References Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Gottman, J. M. (1994). What predicts divorce? The relationship between marital processes and marital outcomes. Hillsdale: Lawrence Erlbaum. Guerney, B. G., Jr. (1977). Relationship enhancement: Skills training programs for therapy, problem prevention, and enrichment. San Francisco: Jossey-Bass. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel. Markman, H. J., Stanley, S. M., & Blumberg, S. L. (2010). Fighting for your marriage: Positive steps for preventing divorce and preserving a lasting love (3rd ed.). San Francisco: Jossey-Bass.

Description Complementarity denotes the fit among the behaviors and roles of individual members or subsystems of a family. Although the notion bears some resemblance to that of circular causality, there is an important difference between the two. Circular causality designates a sequential pattern of behaviors, represented with a series of arrows (girl clings ➔ mother rejects ➔ girl clings), while complementarity looks at the same behaviors as pieces of a puzzle: the girl’s clinginess and the mother’s rejection are “shapes” that fit each other. The difference is not trivial; it accounts for the structural therapist’s preference for addressing spatial arrangements (literal and metaphorical) among family members, rather than sequences of behavior. The visual representation of complementarity is similar to that of the Chinese Yin and Yang, where all things exist as contradictory

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but inseparable opposites. “When people see things as beautiful,” says the Tao Te Ching, “ugliness is created. When people see things as good, evil is created. Being and non-being produce each other. Difficult and easy complement each other. Long and short define each other. High and low oppose each other. Fore and aft follow each other” (Laozi and Mitchell, 1988, p. 2). In Chinese mythology, Yin and Yang’s ever-changing relationship is responsible for the constant flux of the universe and life in general: as one pole increases, the other decreases. When there is too great an imbalance between Yin and Yang, catastrophes can occur; a correct balance between the two halves must be reached to achieve harmony and order. The similarity is not complete. In structural family therapy harmony and order are not absolute values. Complementary patterns may sustain an unhealthy homeostasis through a rigid distribution of roles, conflict avoidance, and excessive mutual loyalty that stifle growth and individuation. Disrupting long established patterns is often the job of the structural therapist. Through years of mutual accommodation, family members develop dyadic complementary patterns that accentuate selected traits of each individual and inhibit others, which subsist in latent form and may manifest in a different context. Thus the notion of complementarity is consistent with that of the individual self as a diversified structure. While the traditional psychodynamic envisions a “core” identity typically originated in early experiences (“this mother cannot nurture her daughter because she herself was not nurtured as a child,”) – the structural perspective regards being “nonnurturant” as only one of many possible ways for the mother to be. She may be nurturant to a different child or with the same daughter when nobody is looking. She is not unidimensional, but a complex individual whose various possible ways of being are activated within different contexts and at different times.

Complementarity in Structural Family Therapy

Application in Couple and Family Therapy By highlighting complementary patterns, the structural therapist challenges the family’s certainty about the location of the problem, from one individual to a relationship: When [a client] starts a family therapy session with his wife by saying, “I am depressed,” the therapist’s first question is not an acknowledgment (“You are depressed?”) but a challenge (“Is Pat depressing you?”). Simplequestions like this challenge the way people experience reality. They introduce uncertainty. (Minuchin and Fishman, 1981, p. 195.

Looking at behaviors as expressions of parts of the self that are activated by specific complementary patterns, rather than as the products of individual psyches, allows the therapist to be optimistic about the possibilities of change. An apparently ineffective (or authoritarian) parent is seen as having an efficient (or flexible) side, hidden from view but potentially accessible. A mother who “loses it” and yells at her son may be described by others and even herself as incapable of selfcontrol, but a structural therapist will assume that her yelling is sustained by the complementary behavior of somebody else – maybe the son himself, or a disqualifying grandmother, or both. The target of therapy will then be the complementary patterns, rather than the psychological makeup of the mother.

Clinical Example A 5-year-old girl runs in circles around the room, followed by her 2-year old sister. The consultant, Salvador Minuchin, does not study the girl’s behavior but her interaction with the mother, who occasionally issues directives without much conviction. He asks a relational question: “Is this how the two of you live your life?.” The mother answers, “Yes, it’s a continuous battle,” and the session becomes an exploration of relationships between the girl, the mother, and the father. It turns out that the 5-year old is “uncontrollable” by the mother, but not by the father; and that the

Concurrent Therapy

mother/daughter relationship is itself complemented by the allegedly super efficient father, who comes to mother’s “rescue” when she is struggling with the daughter. The family’s view is that the father’s intervention is needed because the mother fails to manage the girl. But if the mother’s and father’s contributions are seen as complementary, it is possible to reverse the direction of causality and say that the mother fails to manage the girl because the father intervenes before she can succeed. To test this hypothesis, the consultant asks the mother how she would like the situation in the room to change. She says that the children should play with the toys in one corner, so that the grownups can talk. “Good, make it happen,” says the consultant. The mother resumes her half-hearted efforts to direct the girls. On cue, the father adds his own, more forceful voice. The consultant stops him: “Let your wife do it. She does it when you are not home, right?.” The mother keeps trying, still from her chair, and still unsuccessfully. At times she appears to give up and turn to the consultant, who invariably responds: “It’s not happening. What you wanted to happen is not happening.” After a few minutes of not being “rescued” by her husband nor by the consultant, the mother does get up from her chair, and in a gentle but decisive way organizes the two girls to play in a corner of the room.

Cross-References ▶ Family Development in Structural Family Therapy ▶ Family Function and Dysfunction in Structural Family Therapy ▶ Individual in Structural Family Therapy ▶ Structural Family Therapy

References Laozi, & Mitchell, S. (1988). Tao te ching: A new English version (p. 2). New York: Harper & Row. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press.

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Concurrent Therapy William D. Ewing and Jessica Rohlfing Pryor The Family Institute at Northwestern University, Chicago, IL, USA

Name of Model Concurrent Therapy

Introduction Concurrent therapy refers to when a therapist sees each member of a couple separately, in two different individual sessions. This is contrasted to conjoint therapy, seeing the couple together in the same session. While conjoint therapy is the community standard for couple therapy, concurrent therapy can be feasible and effective in particular situations (Gurman and Burton 2014). Concurrent therapy commonly occurs during intake to learn each partner’s point of view separately or as a mediation tool when couples are not able to be in the same therapy session without fighting. Concurrent therapy is also effective when the couple needs to overcome their intrapersonal challenges in order to improve their relationship (Gurman and Burton 2014; Hefner and Prochaska 1984; Cookerly 1974). Other common prompts for concurrent therapy include one partner refusing to participate in a conjoint session, one partner’s cognitive impairment or substance abuse, or a lack of emotional and physical safety within the relationship (Gurman and Burton 2014). Conversely, conjoint therapy is most effective for couples who are able to maintain order during the session or need to improve their interpersonal skills, such as communication or problem solving. Conjoint therapy is the most common structure of couple therapy as it focuses primarily on the relational skills that are the hallmark of this treatment form, while concurrent therapy is more commonly used secondarily as a mediation tool (Hefner and Prochaska 1984; Cookerly 1973).

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Concurrent therapy, for example, may be used in response to a particular couple therapy session when a topic becomes quite heated. In this instance, the therapist would ask the individuals to meet with the therapist concurrently and then come back together conjointly to create a resolution. Another common use of concurrent therapy is when a couple needed to have several individual concurrent sessions in order to work on intrapersonal skills (e.g., emotion regulation) before joining together again. When concurrent therapy is needed, it often occurs alongside conjoint therapy (a therapist sees the couple together in one session, and also meets with each member of the couple in individual sessions) to promote both individual and family growth. Concurrent therapy has a risk of creating competition between intimate partners. Each partner may compete to develop a closer relationship with the therapist in an attempt to sway the therapist’s opinion or bias them in some way (Gurman et al. 2015). To this point, it is crucial to have an equal number of concurrent sessions with each client and establish which information shared privately is appropriate to share in the conjoint session with both partners present. Concurrent therapy serves as an adjunct supplement to enrich the main focus of the couple’s work, which is addressed most appropriately when the couple is seen together through conjoint therapy (Gurman and Burton 2014).

Prominent Associated Figures No one figure in this field is responsible for defining or creating the therapy.

Theoretical Framework (Including Core Concepts of Model, Theory of Change, and Rationale for the Model) When conjoint therapy is not possible, couples that refer to high-conflict threats, such as abuse or an affair, can be seen concurrently.

Concurrent Therapy

When the couple is separated, they may give more accurate and level-headed information, which subsequently allows the therapist to more fully understand the challenges the couple may face (Gurman et al. 2015). These individual sessions provide a space for each partner to explore parts of their past that they may not be comfortable sharing with their partner and also review content which could not be fully examined in a conjoint session due to high-conflict dynamics. While conjoint sessions tend to address interpersonal relational skills between members of a couple, concurrent therapy provides a space for each partner to work toward a greater understanding of intrapersonal challenges that may be affecting the marriage.

Populations in Focus Concurrent therapy is primarily utilized as a mediation tool for couples and families who would benefit from individual time with the therapist or development of intrapersonal skills. While primarily focused on couples, concurrent therapy can also be used to mediate other relationships, such as family members, business partners, or roommates.

Research About the Model It has been found that couples who participated in concurrent marital therapy had a significant decrease in intrapersonal problems, such as anxiety and depression (Cookerly 1974). A related study suggested that those who took part in conjoint therapy had significant improvement in interpersonal functioning than did participants who did concurrent therapy (Cookerly 1973). However, a study by Hefner and Prochaska (1984) suggested that, while the effectiveness of concurrent and conjoint therapy demonstrate significant therapeutic results, the dropout rate for conjoint therapy in their study was twice that of the dropout rate for concurrent therapy. Hefner et al. postulated that this may have been due to

Conduct Disorders in Couple and Family Therapy

scheduling conflicts between the couple or because the conflict was simply too high in the conjoint sessions. Additionally, Bennun (1985) suggested that there were no significant outcome differences between conjoint therapy and seeing one partner alone; however, they found that couples in conjoint therapy “solved their target problems more rapidly” (Bennun 1985, p. 157). Over a decade later, Bennun (1997) encourages concurrent therapy, much to the criticism of some contemporary scholars. For example, Gurman and Burton (2014) state that conjoint therapy should be the primary mode of couple therapy, as concurrent therapy has several major issues. They suggest that choosing concurrent therapy over conjoint therapy can lead to therapist sidetaking, disruptions in the working therapeutic alliance, inaccurate individual client reports, and many more issues.

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References Bennun, I. (1985). Behavioral marital therapy: An outcome evaluation of conjoint, group and one-spouse treatment. Scandinavian Journal of Behavior Therapy, 14, 157–168. Bennun, I. (1997). Relationship interventions with one partner. In W. K. Halford & H. J. Markman (Eds.), Clinical handbook of marriage and couples intervention (pp. 451–470). New York: Wiley. Cookerly, J. (1973). The outcome of the six major forms of marriage counseling compared: A pilot study. Journal of Marriage and Family, 35(4), 608–611. Cookerly, J. (1974). The reduction of psychopathology as measured by the MMPI clinical scales in three forms of marriage counseling. Journal of Marriage and Family, 36(2), 332–335. Gurman, A. S., & Burton, M. (2014). Individual therapy for couple problems: Perspectives and pitfalls. Journal of Marital & Family Therapy, 40(4), 470–483. Gurman, A. S., Lebow, J., & Snyder, D. K. (2015). Clinical handbook of couple therapy (5th ed.). New York: Guilford Press. Hefner, C., & Prochaska, J. (1984). Concurrent vs. conjoint marital therapy. Social Work, 29(3), 287–291.

Case Example Kevin and Mary came to therapy after 10 years of marriage with concerns of emotional detachment and frequent fights. During intake, conjoint therapy is not possible because the couple is fighting constantly. As a result, the therapist suggests working with the couple concurrently until they are able to collaboratively participate in the same session. The therapist explains that with concurrent therapy, she will see the husband and the wife individually in order to hear both partners, as well as to work on their intrapersonal factors that may be affecting their marriage. Once they are able to attend the same session, Kevin and Mary are able to see the therapist together conjointly in order to work together to address the issues that may be causing their marriage to dysfunction.

Cross-References ▶ Conjoint Couple and Family Therapy ▶ High Conflict Couples

Conduct Disorders in Couple and Family Therapy Scott W. Henggeler Family Services Research Center, Medical University of South Carolina, Charleston, SC, USA

Introduction The primary aims of this chapter are to provide (a) an up-to-date overview of the research literature concluding that several family-based therapies are the most extensively validated treatments of youths with serious conduct problems, (b) brief overviews of the clinical methods used in these

This manuscript was supported by grant R01DA34064 from the National Institute on Drug Abuse. Dr. Henggeler is a board member and stockholder of MST Services LLC, the Medical University of South Carolina-licensed organization that provides training in MST.

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family-based treatments, and (c) a discussion of their commonalities – commonalities that have implications for the effectiveness of family therapy approaches in general. The content of the chapter is based largely on two recent and extensive reviews of the corresponding research literatures. McCart and Sheidow (2016) evaluated 86 published studies over a 48-year period that covered 50 unique treatment protocols. Based on criteria used by the American Psychological Association (APA) Task Force on Psychological Interventions, treatments were classified as either well established (e.g., at least two independent, well-designed studies demonstrating efficacy), probably efficacious (e.g., possibly one welldesigned study or at least two studies, though not independent, demonstrating efficacy), possibly efficacious (e.g., at least one well-designed study demonstrating efficacy), experimental (e.g., not tested with rigorous research), and questionable efficacy (e.g., research shows no beneficial effects). The second review (Henggeler 2016) examined much of the same literature, but was based on the more rigorous evaluation criteria developed by the Blueprints for Violence Prevention at the University of Colorado. Blueprints reviewed more than 1,000 programs that aim to reduce antisocial behavior in youths. Blueprints model programs are well specified, have strong evidence of effectiveness, achieved sustained outcomes for at least a year, and have the capacity to be disseminated to community settings with fidelity.

Theoretical Context During the past several decades, thousands of studies have examined the causes and correlates of conduct problems, and leading researchers have drawn clear and consistent conclusions. Conduct problems in youth are multidetermined from the interplay of key variables at individual (e.g., biological vulnerabilities, basic cognitive processes such as deficits in social information

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processing), family (e.g., poor parental supervision and monitoring, lack of warmth), peer (e.g., association with drug-using friends), school (e.g., lack of commitment to school, iatrogenic school policies), and community (e.g., lack of prosocial activities for youth) levels. These research findings are highly consistent with Bronfenbrenner’s (1979) theory of social ecology where behavior is viewed as largely the product of the reciprocal interplay between individual characteristics and the proximal systems in which the individual is embedded (i.e., family, peer, school, neighborhood) as well as the relations among these systems. Importantly, research on the determinants of conduct problems and the corresponding socialecological theoretical framework have critical implications for the design of effective treatment interventions. First, to optimize the probability of effectiveness, treatments must be comprehensive and have the capacity to address a range of risk factors across the youth’s social network. Second, in light of the many possible targets for intervention, treatments must be individualized to address the key risk factors in a youth and family as well as to build protective factors. As discussed subsequently, the most effective treatments based on APA and Blueprints criteria are both comprehensive and individualized.

Effective Treatments of Conduct Problems Family-based treatments are the only approaches that meet the highest levels of effectiveness based on APA and Blueprints criteria. Multisystemic therapy (MST; Henggeler et al. 2009) and Treatment Foster Care Oregon (TFCO, formerly Multidimensional Treatment Foster Care; Chamberlain 2003) meet APA criteria for well established, and Functional Family Therapy (FFT; Alexander et al. 2013) meets criteria for probably efficacious. Moreover, MST, TFCO, and FFT were the only interventions to meet Blueprints criteria for model programs. It should be noted that two cognitive-

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behavioral therapy approaches, Aggression Replacement Training and Solution-Focused Group Program, also met APA criteria for probably efficacious, but closer review reveals that the effectiveness of these interventions is not well supported by the corresponding research. The former treatment has only one successful evaluation with a very small sample, three failed evaluations, one international replication, and a variation that qualified for the questionable efficacy category; and the latter intervention has only one small international efficacy study. On the other hand, the family-based approaches have overwhelming support for their effectiveness. Together, MST, FFT, and TFCO have been evaluated in more than 30 controlled, published studies with youths presenting conduct problems, often of a very serious nature. Twenty of these studies evaluated MST, and eight of those were conducted by investigators independent of the treatment developers. Likewise FFT has been evaluated in seven controlled studies including four by independent investigators, and TFCO has been evaluated in four controlled studies including one by independent investigators. Moreover, favorable results from each of these models have been replicated in published studies conducted in community settings as well as international sites. Across these outcome studies, numerous favorable results for these family-based treatments have been reported that are consistent with the aforementioned causes and correlates of conduct problems in youth. Studies often showed improvements, relative to comparison youth and families, in key outcomes and risk factors including decreased conduct problems, decreased caregiver symptomatology, improved parenting and family relations, less association with deviant peers, and improved school performance and attendance. Moreover, for example, across clinical trials, MST has achieved median reductions of 39% and 53% in rearrests and out-of-home placements, respectively. Indeed, favorable outcomes have been sustained for more than 20 years post treatment (Sawyer and Borduin 2011), and improved youth and family functioning has produced considerable cost

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savings for community stakeholders. Finally, and importantly, several of the studies have demonstrated the importance of treatment fidelity in achieving desired clinical outcomes. That is, youth and family outcomes improved as therapists adhered more closely to the respective treatment protocols.

Clinical Procedures Although each of the three evidence-based treatments views the family as the primary change agent, variations in clinical procedures are evident. Multisystemic Therapy As noted elsewhere in this encyclopedia, MST is delivered by master’s-level therapists working within programs that are usually located in private provider organizations and funded by public juvenile justice, child welfare, and mental health authorities. Each MST team consists of two to four therapists, a half-time supervisor at minimum, and administrative support. Each therapist carries a caseload of four to six families, and the average duration of treatment is approximately 4 months – with sessions occurring as frequently as needed to achieve desired outcomes. A home-based model of service delivery is used to remove barriers to service access (e.g., transportation, appointments at convenient times) and facilitate family engagement in therapy. Indeed, more than 85% of families complete a full course of MST treatment nationally. The home-based approach also enables the collection of more ecologically valid assessment data from which to design interventions as well as more accurate data reflecting the outcomes of planned interventions. MST interventions are designed to adhere to nine treatment principles (Henggeler et al. 2009). Together, these principles shape the specifics of the interventions to be strength focused, action oriented, ecologically valid, and developmentally appropriate. Interventions are designed to require daily effort by family members, and the outcomes

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of these efforts are monitored continuously, with the therapist being ultimately accountable for achieving desired goals. Consistent with strategic and structural models of family therapy, interventions target sequences of behavior between the various interacting systems (e.g., family, peers, school, and community) that are hypothesized to sustain the identified problems. Importantly, however, evidence-based behavioral and cognitivebehavioral strategies are integrated into the socialecological approach as needed (e.g., teaching caregivers to provide cognitive-behavioral therapy interventions to their child with an anxiety problem, using contingency management to address substance use), and evidence-based pharmacotherapy is incorporated when necessary as well. Ongoing training and quality assurance are critical components of MST programs (Schoenwald 2016). The fundamental aim of the quality assurance system is to surround therapists with the support and resources needed to optimize the probability of achieving desired outcomes with the client families. As noted previously, several studies have demonstrated significant associations between therapist fidelity to MST treatment principles and favorable youth and family outcomes. Hence, the quality assurance system is designed to continuously assess and promote treatment fidelity. Functional Family Therapy FFT programs typically include a team of three to eight master’s-level therapists who carry caseloads of 12–15 families. Services are provided in office, home, school, and community settings; and the duration of treatment is about 3–4 months. As with MST, the implementation of FFT includes strong training and quality assurance protocols, and research has demonstrated an association between treatment fidelity and youth outcomes. Clinically, FFT is based on an integration of family systems theory and behavioral approaches. Conduct problems are viewed as symptoms of dysfunctional family relations, and interventions aim to change patterns of family interactions in ways that lead to symptom change. The implementation of FFT includes five phases. First, the therapist takes a strength-based

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approach to engage and align with each member of the family through active listening and empathetic behaviors. Second, the therapist engenders hope and positive expectations among family members through the use of reframing, avoiding confrontation, and taking a nonblaming stance. Third, the therapist develops an understanding of how the presenting problems are associated with the family’s internal interactions and relations with extrafamilial systems. Here, the therapist analyzes the family’s values and observed interactions to develop a plan for behavior change. Fourth, the primary aim of behavior change is to establish new patterns of family interaction to replace the less functional older patterns. Family interactions are modified through the use of behavioral techniques such as modeling, communication training, teaching, and assigning homework. Finally, the generalization phase of treatment extends favorable gains to the family’s social network and creates plans to address relapse prevention. Treatment Foster Care Oregon TFCO is a foster care program that serves as an alternative to residential placement. Youth are placed in a TFCO foster home for 6–9 months, with one youth per home. The foster parents receive extensive training in behavioral techniques and have continuous access to a TFCO program supervisor. In addition, therapists and skills trainers work with the youth to improve social skills and meet with the biological/adoptive family to facilitate reunification. Clinically, TFCO is more explicitly behavioral than MST and FFT, but the model is clearly ecological in nature and depends on family-based interventions for success. The foster parents implement a highly structured behavioral plan that specifies rewards and consequences for desired and problem behavior at home, in school, and in the community. Youth behavior is closely tracked, and the contingencies are implemented as planned. The overriding purpose is to surround the youth with competent adults who are positive and encouraging and model responsible behavior. Finally, resources are devoted to enhancing the parenting skills of the youth’s biological/adoptive

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family – to generalize the gains made in foster placement to the home context. As with MST and FFT, TFCO includes extensive training and ongoing quality assurance to support favorable youth outcomes.

Commonalties That Form the Bases of Success The three evidence-based treatments of conduct problems have several commonalities that likely contribute to their success in comparison with the numerous interventions that have not proven effective. First and foremost, MST, FFT, and TFCO view the family as the primary change agent. The majority of clinical resources are devoted to empowering the family and modifying family relations in ways that are less conducive to antisocial behavior and more supportive of prosocial behavior. Importantly, several quantitative and qualitative studies have verified that improved family relations, especially increased parenting competence, are the key mediator of favorable youth and family outcomes. Second, consistent with extant knowledge concerning the correlates and causes of conduct problems, these family-based treatments take a social-ecological perspective of behavior. Hence, each devotes considerable attention to key social systems in which the youth is embedded. With caregivers serving as the primary change agent, strategies are often developed to decrease youth association with deviant peers, increase youth involvement in prosocial activities, and enhance school or vocational performance. Third, interventions are delivered where problems occur – in homes, schools, and community settings. This strategy overcomes barriers to service access (i.e., youths with conduct problems and their families have very high dropout rates) and supports the ecological validity of behavior change. Fourth, interventions are behavioral, individualized, and comprehensive. Behavioral and cognitive-behavioral interventions are action and goal oriented, which fits the problem-focused

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perspectives of these family-based treatments. Importantly, however, these linear behavioral interventions are delivered within a systemic social-ecological context that includes the family in all aspects of behavior change across the social ecology. Fifth, MST, FFT, and TFCO implement rigorous quality assurance protocols. The primary aims of these protocols are to promote treatment fidelity and maximize the probability of favorable youth and family outcomes. Therapist and supervisor training are extensive and ongoing. Treatment outcomes and program fidelity are monitored continuously, and expert resources are available to support remediation as difficulties arise. In conclusion, the most effective treatments for conduct problems in youth are family based. The particular family-based approaches that have proven effective include several key similarities that can inform the larger practice community. Interventions should be pragmatic and goal oriented, aim to enhance parenting competence, remove barriers to service access, and address aspects of the larger social ecology (i.e., peers, school, neighborhood) that present challenges in sustaining behavior change as well as opportunities to enhance prosocial functioning.

References Alexander, J. F., Waldron, H. G., Robbins, M. S., & Nebb, A. A. (2013). Functional family therapy for adolescent behavior problems. Washington, DC: American Psychological Association. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by design and nature. Cambridge, MA: Harvard University Press. Chamberlain, P. (2003). Treating chronic juvenile offenders: Advances made through the Oregon multidimensional treatment foster care model. Washington, DC: American Psychological Association. Henggeler, S. W. (2016). Community-based interventions for juvenile offenders. In K. Heilbrun, D. DeMatteo, & N. E. S. Goldstein (Eds.), APA handbook of psychology and juvenile justice (pp. 575–595). Washington, DC: APA Press. Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic therapy for antisocial behavior in children and adolescents (2nd ed.). New York: Guilford Press.

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558 McCart, M. R., & Sheidow, A. J. (2016). Evidence-based psychosocial treatments for adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 45, 529–563. Sawyer, A. M., & Borduin, C. M. (2011). Effects of MST through midlife: A 21.9-year follow up to a randomized clinical trial with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 79, 643–652. Schoenwald, S. K. (2016). The multisystemic therapy ® quality assurance/quality improvement system. In W. O’Donahue & A. Maragakis (Eds.), Quality improvement in behavioral health (pp. 169–192). Switzerland: Springer International Publishing AG Switzerland.

Conflict Tactics Scale-2 Michele Cascardi1, Sarah Avery-Leaf2 and Michelle Rosselli1 1 William Paterson University, Wayne, NJ, USA 2 The Informatics Applications Group (tiag), Tacoma, WA, USA

Name and Type of Measure Conflict Tactics Scale 2 is a self-report survey of positive and negative behaviors used in an intimate relationship.

Synonyms CTS2; Revised Conflict Tactics Scales; Revised Conflict Tactics Scales 2

Introduction Murray Straus published the groundbreaking measure called the Conflict Tactics Scale (CTS) in 1979. The CTS was designed to measure the frequency of specific positive tactics (e.g., negotiation and reasoning) and negative tactics (e.g., psychological and physical aggression) used to resolve conflicts, disagreements, or disputes in family relationships. This entry

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focuses on the CTS as a measure of behaviors between intimate partners, such as married, cohabiting, or dating partners. Assessment using the CTS exposed a startling and unpleasant reality about American family life: husbands and wives engaged in physical aggression against one another at very high rates, with 17.9% of wives and 9.1% of husbands endorsing at least one act of physical aggression, such as pushing, grabbing, or hitting (Straus 1979). This finding contradicted popular wisdom at the time, which held that married individuals did not typically engage in physical aggression against each other, and if they did, they would not disclose these undesirable behaviors on a self-report survey. The high rates of physical aggression by women also contradicted a long-held belief that husbands were the primary perpetrators of violence against wives. Critics of the CTS charged that it lacked important contextual information, such as aggression used in self-defense, injury and fear resulting from aggression, and aggression used to coerce sex (Straus 1987). The basis for these criticisms was that women were more likely to use aggression in selfdefense, to be injured at a higher rate, and to be victimized by sexual aggression more often than men. Thus, females were believed to be erroneously characterized as more aggressive relative to males. In 1996, Straus and his colleagues revised the CTS to address several of these criticisms. Specifically, they developed a new version of the CTS, the Revised Conflict Tactics Scales (CTS2), that increased the number of behaviors representing more serious psychological aggression (e.g., called fat or ugly) and physical assault (e.g., choked) and added scales for sexual coercion and physical injury (Straus et al. 1996). Although this broader coverage of aggressive behaviors and consequences was advantageous, it still did not distinguish aggression used in self-defense from aggression used for other reasons. Straus et al. (1996) defended this decision, arguing that: the CTS is not intended to measure attitudes about conflict or violence nor the causes or consequences of using different tactics. . .. These types of issues are critical, but they must be investigated by including measures of those explanatory, context, or consequence variables. (pp. 284–285)

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That is, they firmly believed that a behavioral measure provided an objective and standardized method for quantifying specific acts taking place in an intimate relationship, which can be supplemented with additional measures of “cause, context, and consequence variables [that] are relevant for the study or the clinical situation” (p. 285). Use of CTS in Family and Couples’ Therapy. The CTS2 is arguably the most widely used assessment of intimate partner violence (IPV), and in the context of family and dyadic treatment, it is used as a screener for physical IPV. Research has also suggested that the CTS2 may be used to evaluate the potential for future physical IPV based on the frequency of psychological IPV (Salis et al. 2014). While there seems to be widespread agreement regarding the use of this instrument (as opposed to alternative measures) for this purpose, appropriate application of the data to intervention has been complicated by disagreements of interpretation, pertaining both to appropriateness of treatment modalities and definitional issues. Treatment appropriateness. Should a couple seeking conjoint therapy be accommodated despite having reported physical IPV at intake, or should they be refused because physical IPV is present? Two types of physical IPV have been identified in the literature as a discriminating factor for treatment modality: situational (reciprocal, low-level violence perpetrated by both partners as a way to manage conflict) and characterological (violence used to induce fear and control partner). Specifically, couples’ treatment is indicated for those engaging in situational IPV, whereas only individual work is deemed appropriate for partners engaged in characterological aggression (Friend et al. 2011; Johnson and Ferraro 2000). Unfortunately, the CTS2 does not provide information about motives, and so making this distinction with the CTS2 alone is not possible. The CTS2 may be used to screen for IPV; and individual interviews with each partner can follow to evaluate the context in which IPV occurs and to assess safety and inform treatment decisions. Definitional debate. An important consideration is how practitioners define and interpret

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endorsement of items on the CTS2. One concern is a potential mismatch between the interpretation of IPV by the practitioner and one or both members of the couple. For example, a therapist might identify one partner as a perpetrator and the other as a victim, even if neither individual self-identifies in this way. Additionally, a therapist may assign victim and perpetrator roles even if both partners endorse both having perpetrated acts of physical aggression against their partner and also been a target of such acts. This role assignment may not align with the couple’s perception. Thus, it may be difficult for a practitioner to maintain an objective, neutral stance when ascribing “perpretrator” and “victim” labels to clients. There may also be discrepancies in interpretation based on CTS2 item endorsement. For example, one tactic, “stomped out of the room or house or yard during a disagreement,” is categorized as “psychological aggression.” A common style difference among couples is observed when one partner prefers to continue any heated or intense interaction, while the other wants a respite (“timeout”). It is unclear whether the act of leaving a marital disagreement reflects an adaptive cooldown method or problematic behavior. In sum, the CTS2 is an effective screening device for intimate partner violence; however, it should be followed by careful and individual follow-up with each partner about the antecedents, consequences, and interpretation of the acts reported on the CTS2.

Developers Murray Straus, Sherry Hamby, Sue BoneyMcCoy, and David Bruce Sugarman developed the CTS between 1979 and 1996.

Description of Measure Like its predecessor, the CTS2 measures the frequency of specific tactics used when differences arise between intimate partners, with a focus on adult (age 18+) relationships. Despite this initial emphasis on adult partners, research has also

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demonstrated that the CTS and CTS2 are appropriate for use with adolescent populations (Cascardi et al. 1999; Exner-Cortens et al. 2016). Respondents endorse the frequency with which they and their partners have engaged in a variety of behaviors in the previous 12 months. Frequency is rated on an 8-point scale from never to more than 20 times, or not in the past year, but it did happen before. Straus et al. (1996) indicate that other reference periods besides the previous 12 months can be used in order to adapt the measure for different needs (e.g., prior 6 months, time since treatment started, since current relationship started). There are 39 item pairs (78 items) which can be completed in 10–15 min. The items are paired so that respondents indicate which behaviors they used against a partner (perpetration) and which behaviors they experienced from a partner (victimization). There are five CTS2 subscales: 1. Negotiation (6 items): explained side of argument, showed partner cared, respected partner’s feelings 2. Psychological aggression (8 items): insulted or swore at partner, threatened to hit or throw something at partner 3. Physical assault (12 items): threw something at partner; pushed, grabbed, or shoved partner; choked partner 4. Sexual coercion (7 items): made partner have sex without a condom, insisted partner have oral or anal sex but did not use physical force, used threats to make partner have sex 5. Injury (6 items): had a sprain, bruise, or small cut because of a fight with partner, went to doctor because of a fight with partner Each of the four aggression-related subscales (psychological, physical, sexual, and injury) were conceptualized to include minor (e.g., insult, push) and severe (e.g., threaten to hit or throw something at partner, choked partner) behaviors. Separate scores can be computed for perpetration and victimization on each of the five subscales in a number of different ways. Each CTS2 subscale can be scored dichotomously, as presence (at least one act occurred) or absence

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(no acts occurred), reflecting whether any act on a subscale occurred. This scoring can be used to examine the prevalence rate of each CTS2 subscale. To compute an index of chronicity for those who engaged in or experienced at least one act on a subscale, the midpoints for each response option (e.g., 3–5 times = 4, 6–10 times = 8) are summed. The same scoring methods for prevalence and chronicity can be applied to create an overall composite that combines information across the four CTS2 aggression subscales; however, this strategy is not recommended because it can obscure important difference in the nature of aggressions reported and their injurious consequences.

Psychometrics The research on psychometric properties of the CTS2 is difficult to summarize without also considering studies using the original CTS, because there are fewer studies on the CTS2 compared to the CTS. In addition, investigators have commonly modified, added, or deleted certain items on the CTS and CTS2, for various reasons. Some reasons were pragmatic (i.e., to shorten the length of the survey), while others were more substantive (i.e., removal of specific sensitive items, such as threaten with a knife or a gun, or subscales, such as sexual coercion). The influence of item additions, deletions, and modifications on the psychometric properties of the CTS and CTS2 has not been systematically studied, so the effects of these changes are largely unknown. Internal consistency. The items on each of the five CTS2 subscales generally relate strongly to each other, as evidenced by acceptable to high Cronbach a values of internal consistency in the development study (Straus et al. 1996): negotiation scale (a = 0.86), psychological aggression (a = 0.79), physical assault (a = 0.86), sexual coercion (a = 0.87), and injury (a = 0.95). Other research has shown that CTS2 subscales demonstrate acceptable to high levels of internal consistency (e.g., Cuenca et al. 2015). Test-retest reliability. One study on test-retest reliability of the CTS2 has been found in the

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literature using a sample of men court mandated to treatment for wife assault (Vega and O’Leary 2007). Over a 9-week interval, men’s reports about the frequency of their own and their partners’ aggressions were generally high, with testretest reliability coefficients ranging from 0.67 (physical assault) to 0.79 (injury). Reports about partners’ behavior were even more consistent over time for physical assault (0.86) and sexual coercion (0.80). Couple agreement. The CTS2 questions respondents about their own and their partners’ behavior; therefore, it is important to understand the degree to which both parties agree about reports of aggression. Studies of couples have consistently found that agreement about the occurrence and frequency of physical aggression on the CTS and CTS2 is low to moderate. This finding has been observed among married couples in the community (Arias and Beach 1987; O’Leary and Williams 2006), newlyweds and clinic-referred samples of couples seeking marital therapy (Heyman and Schlee 1997), and men referred to treatment for wife assault (Browning and Dutton 1986). In general, both spouses tend to report that their partners engaged in more violence than the other reported. In addition, males tend to minimize or discount their aggression compared to females (Browning and Dutton 1986; Simpson and Christensen 2005). Couple disagreement about the occurrence and frequency of aggression underscores the complexity of measuring this phenomenon, and it has led some to suggest that reports about victimization may be more accurate than perpetration. However, others have argued that when information can be collected by both partners, any report of aggression or victimization from either spouse should be counted (O’Leary and Williams 2006). Construct validity. One way to examine construct validity is with factor analysis. This type of study has focused primarily on the psychological aggression and physical assault subscales of the CTS and CTS2, yielding mixed results about the purity of the subscales and distinctions between moderate and severe aggressions (e.g., Barling et al. 1987; Viejo et al. 2014; Yun 2011). In samples of women from various community

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settings, separate subscales for moderate and severe psychological aggression and physical assault have been identified (Calvete et al. 2007). Similarly, Viejo et al. (2014) found support for a two-factor model of physical aggression that differentiated moderate and severe items in a sample of adolescents. In other studies, the distinctions between psychological and physical aggression items are not always clear, and a severe physical aggression factor has not been consistently identified (Barling et al. 1987; Lucente et al. 2001). For instance, items that have face validity for physical or psychological aggression do not always load accordingly in factor analysis. For example, the “threatened to throw something at a partner” item has face validity for psychological aggression, but loads with physical aggression items (Caulfield and Riggs 1992). In addition, in a sample of adolescents, there were not clear distinctions between physical and psychologically aggressive behaviors, such that threats and aggression toward objects aligned more closely with physical assault than psychological aggression (Cascardi et al. 1999). Convergent validity. Research has consistently supported significant associations between psychological aggression, physical assault, injury, and sexual coercion. Psychological aggression and physical assault tend to be moderately to strongly associated for males and females, with correlation coefficients ranging from 0.33 to 0.71 (e.g., Murphy and O’Leary 1989; Straus et al. 1996). In prospective research, psychological aggression also predicts physical assault (Murphy and O’Leary 1989; Salis et al. 2014). Additionally, more severe psychological aggression, such as public insults, nasty name calling, and property destruction, are more strongly associated with severe physical assault, particularly for males, compared to passive or expressive psychological aggression, such as yelling or sulking (Hamby and Sugarman 1999). Sexual coercion is also strongly associated with psychological aggression, physical assault, and injury for males (r’s range 0.66–0.91) but not for females (Straus et al. 1996). Research has also examined risk factors associated with psychological aggression and physical assault to provide evidence of convergent validity.

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As would be expected, both psychological and physical aggression have been consistently related to anger, hostility, and a wide range of emotional distress (e.g., posttraumatic stress disorder, depression; Birkley and Eckhardt 2015; Straus and Mickey 2012).

Applications in Couple and Family Therapy A young couple entered into therapy to seek help with problems in their marriage. They have been married for 5 years and have a 2-year-old son. The wife threatened to end the relationship if they did not seek professional help, and she is concerned about her husband’s potential for aggression toward their son. Consequently, the husband was pressured to enter therapy by his wife to learn how to manage his anger and stop acting in aggressive ways. The wife reports that her husband often criticizes and belittles her and on a few occasions has grabbed her to prevent her from leaving the room during an argument and punched her once. She says he has started to prevent her from spending time with her friends and family. The husband reports that his wife flirts with other men when they socialize, which she then denies and refuses intimacy with him. At the start of treatment, the clinician administered the CTS2 to each spouse. Although the CTS2 does not have norms, it provides useful descriptive information about the frequency of discrete acts of psychological, physical, and sexual aggression, as well as injury. Because prior research has shown that individuals tend to underreport IPV when asked directly, the CTS2 is a helpful means to assess the severity of IPV in a more comprehensive manner that takes both partners’ perspectives into account. It may also indicate areas that would benefit from additional probing with each spouse individually about the context of IPV so that fear and efforts at domination and control can be evaluated more fully. Discrepancies between partners’ reports may also indicate each partner’s level of denial, minimization, and/or selfawareness. In this case, administration of the CTS2 revealed sexual aggression and more frequent acts of physical aggression, which the wife had not

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previously disclosed at intake interview. The husband admitted to some of these acts and also reported that his wife never engaged in aggression toward him. Follow-up interviews with each spouse indicated that the wife was fearful of her husband’s potential for escalating in aggression. Consequently, couples treatment was not recommended for this case, and the wife was provided with legal and community resources aimed to protect her from harm. After careful rapport building, the husband consented to individual treatment to develop more effective ways to manage his anger and reduce aggressive behavior. An unmarried couple of 8 years began couples therapy. During the intake interview, each partner reported experiencing psychological aggression from the other partner, including swearing and insulting one another on a frequent basis. In the past, the girlfriend has threatened to destroy her boyfriend’s property by slashing his car tires. This couple is worried that their behaviors will escalate and thus sought intervention before this occurred. The CTS2 was administered and showed that each partner engaged in a different forms of psychological aggression (e.g., swearing, insulting) more than 20 times in the past year. Based on prior research (Salis et al. 2014), this couple is at high risk for physical aggression with each other. A large component of therapy focused on how the couple should communicate with one another and were encouraged to take the necessary time to resolve the conflict to its entirety. Impulse control and anger management were topics that were also addressed. After 20 sessions of therapy, presence of the items on the psychological aggression scale of the CTS2 decreased for both partners. In addition, both partners engaged in greater negotiation behaviors with one another. These results indicate that improved communication and levels of respect are likely to prevent escalation of aggression.

Cross-References ▶ Assessment in Couple and Family Therapy ▶ Couple Violence in Couple and Family Therapy ▶ Family Conflict in Couple and Family Therapy

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▶ Gottman, John ▶ High Conflict Couples ▶ Jacobson, Neil ▶ O’Leary, Dan ▶ Violence in Couples and Families

References Arias, I., & Beach, S. R. (1987). Validity of self-reports of marital violence. Journal of Family Violence, 2(2), 139–149. https://doi.org/10.1007/BF00977038. Barling, J., O’Leary, K. D., Jouriles, E. N., Vivian, D., & MacEwen, K. E. (1987). Factor similarity of the conflict tactics scales across samples, spouses, and sites: Issues and implications. Journal of Family Violence, 2(1), 37–54. https://doi.org/10.1007/BF00976369. Birkley, E. L., & Eckhardt, C. I. (2015). Anger, hostility, internalizing negative emotions, and intimate partner violence perpetration: A meta-analytic review. Clinical Psychology Review, 37, 3740–3756. https://doi.org/ 10.1016/j.cpr.2015.01.002. Browning, J., & Dutton, D. (1986). Assessment of wife assault with the conflict tactics scale: Using couple data to quantify the differential reporting effect. Journal of Marriage and the Family, 48(2), 375–379. https://doi.org/10.2307/352404. Calvete, E., Corral, S., & Estévez, A. (2007). Factor structure and validity of the revised conflict tactics scales for Spanish women. Violence Against Women, 13(10), 1072–1087. https://doi.org/10.1177/ 1077801207305933. Cascardi, M., Avery-Leaf, S., O’Leary, K. D., & Slep, A. S. (1999). Factor structure and convergent validity of the conflict tactics scale in high school students. Psychological Assessment, 11(4), 546–555. https://doi.org/10.1037/1040-3590.11.4.546. Caulfield, M. B., & Riggs, D. S. (1992). The assessment of dating aggression: Empirical evaluation of the conflict tactics scale. Journal of Interpersonal Violence, 7(4), 549–558. https://doi.org/10.1177/0886260920 07004010. Cuenca, M. L., Graña, J. L., & Redondo, N. (2015). Differences in the prevalence of partner aggression according to the revised conflict tactics scale: Individual and dyadic report. Behavioral Psychology/ Psicología Conductual: Revista Internacional Clínica Y De La Salud, 23(1), 127–140. Exner-Cortens, D., Gill, L., & Eckenrode, J. (2016). Measurement of adolescent dating violence: A comprehensive review (Part 2, attitudes). Aggression and Violent Behavior, 27, 2793–2106. https://doi.org/ 10.1016/j.avb.2016.02.011. Friend, D. J., Bradley, R. P. C., Thatcher, R., & Gottman, J. M. (2011). Typologies of intimate partner violence: Evaluation of a screening instrument for differentiation. Journal of Family Violence, 26(7), 551–563.

563 Hamby, S. L., & Sugarman, D. B. (1999). Acts of psychological aggression against a partner and their relation to physical assault and gender. Journal of Marriage and the Family, 61(4), 959–970. https://doi.org/10.2307/ 354016. Heyman, R. E., & Schlee, K. A. (1997). Toward a better estimate of the prevalence of partner abuse: Adjusting rates based on the sensitivity of the conflict tactics scale. Journal of Family Psychology, 11(3), 332–338. https://doi.org/10.1037/08933200.11.3.332. Johnson, M. P., & Ferraro, K. J. (2000). Research on domestic violence in the 1990s: Making distinctions. Journal of Marriage and Family, 62(4), 948–963. Lucente, S. W., Fals-Stewart, W., Richards, H. J., & Goscha, J. (2001). Factor structure and reliability of the revised conflict tactics scales for incarcerated female substance abusers. Journal of Family Violence, 16(4), 437–450. https://doi.org/10.1023/ A:1012281027999. Murphy, C. M., & O’Leary, K. D. (1989). Psychological aggression predicts physical aggression in early marriage. Journal of Consulting and Clinical Psychology, 57(5), 579–582. https://doi.org/10.1037/0022006X.57.5.579. O’Leary, K. D., & Williams, M. C. (2006). Agreement about acts of aggression in marriage. Journal of Family Psychology, 20(4), 656–662. https://doi.org/10.1037/ 0893-3200.20.4.656. Salis, K. L., Salwen, J., & O’Leary, K. D. (2014). The predictive utility of psychological aggression for intimate partner violence. Partner Abuse, 5(1), 83–97. https://doi.org/10.1891/1946-6560.5.1.83. Simpson, L. E., & Christensen, A. (2005). Spousal agreement regarding relationship aggression on the conflict tactics Scale-2. Psychological Assessment, 17(4), 423–432. https://doi.org/10.1037/1040-3590.17.4.423. Straus, M. A. (1979). Measuring intrafamily conflict and violence: The Conflict Tactics (CT) scales. Journal of Marriage and the Family, 41(1), 75–88. https://doi.org/10.2307/351733. Straus, M. A. (1987). The conflict tactics scales and its critics: An evaluation and new data on validity and reliability. Retrieved from ERIC Number: ED297030. Straus, M. A., & Mickey, E. L. (2012). Reliability, validity, and prevalence of partner violence measured by the conflict tactics scales in male-dominant nations. Aggression and Violent Behavior, 17(5), 463–474. https://doi.org/10.1016/j.avb.2012.06.004. Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The revised conflict tactics scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283–316. https://doi.org/10.1177/019251396017003001. Vega, E. M., & O’Leary, K. D. (2007). Test-retest reliability of the revised conflict tactics scales (CTS2). Journal of Family Violence, 22(8), 703–708. https://doi.org/ 10.1007/s10896-007-9118-7.

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564 Viejo, C., Sanchez, V., & Ortega-Ruiz, R. (2014). Physical dating violence: The potential understating value of a bi-factorial model. Anales de Psicología, 30(1), 172–180. Yun, S. H. (2011). Factor structure and reliability of the revised conflict tactics scales’ (CTS2) 10-factor model in a community-based female sample. Journal of Interpersonal Violence, 26(4), 719–744. https://doi.org/ 10.1177/0886260510365857.

Conjoint Couple and Family Therapy Ronald Chenail Nova Southeastern University, Fort Lauderdale, FL, USA

Introduction Conjoint couple and family therapy refers to couples and families treatment wherein the clinician sees two or more family members in the same session simultaneously. Conjoint treatment differs from collaborative approaches (i.e., different therapists who collaborate on the treatment see individual family members separately) or concomitant approaches (i.e., one therapist sees members of the families separately in individual sessions). All three approaches may be employed in the same case depending on the presenting problem or treatment process.

Prominent Associated Figures In 1959, Donald Jackson first used the term “conjoint family therapy” and Virginia Satir produced the first conjoint family therapy book in 1964 (Olson 1970).

Theoretical Framework Therapists use a conjoint approach when they want to focus on the relationship between a couple or among family members. From a relational perspective, the therapist theorizes the family or

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couple as a system in which individual members interact with each other so an individual’s thoughts and behaviors are understood in relationship with the other family members’ behaviors and thoughts. In conjoint treatment, the therapist, rather than only hearing about family interactions from individuals, can also see the family members directly communicating together allowing conjoint couple and family therapists the opportunity to observe these interactions first-hand and to intervene directly with family members in a session. The rationale for working conjointly is based on the premise the therapist can help an individual and the other members of the family change concurrently. If one member of the couple or family can change behaviors, feelings, or thoughts, then other members may also change actions, beliefs, and views in relationship to the individual. The same relational pattern can also hold that changes among family members can help an individual achieve new insights or ways of acting.

Populations in Focus Conjoint couple and family therapy is used with all types of couples and families. Therapists may also include nonfamily members such as case workers, teachers, and friends in conjoint sessions.

Strategies and Techniques Used in Model Conjoint couple and family therapists may use in-session enactments by asking family members to participate in conversational or behavioral activities to learn directly how the individuals interact with each other, to intervene in interactional patterns of behavior, and to assess possible change. Therapists may also ask participants to attempt tasks together as homework and to report on progress in subsequent sessions.

Research about the Model Researchers have conducted a large volume of outcome, process, and participant experience

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studies on this model with significant evidence indicating effectiveness of conjoint couple and family therapy for a variety of emotional, behavioral, or physical health problems (Sprenkle 2012).

Case Example Javier and Maria entered couple therapy after 5 years of marriage reporting a deterioration in their relationship including a lack of communication. In the first session, the therapist asked the spouses to discuss their treatment goals and to share perspectives on each other’s objectives. Learning communication was their primary goal; the therapist asked each spouse to describe times in their relationship when they communicated better. The therapist encouraged each spouse to reflect on the other’s depiction of those times and to tell each other how those positive times made them feel. The therapist noted times when Javier and Maria listened to and expressed positive comments towards each other. The therapist asked the couple to observe times next week when they communicated well. In the next session, Javier and Maria shared how the previous week had been more positive. The therapist asked them to share how they felt when the other one appreciated them. The therapist asked the clients to evaluate their progress and to discuss things they would see the other one doing that would be a sign of an improved relationship. The therapist asked the couple to continue the between-session observation assignment. Therapy was concluded after three sessions when Javier and Maria reported they were satisfied with their level of communication.

Cross-References ▶ Common Factors in Couple and Family Therapy ▶ Couple Therapy ▶ Family Therapy

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References Olson, D. H. (1970). Marital and family therapy: Integrative review and critique. Journal of Marriage and Family, 32(4), 501–538. Sprenkle, D. H. (2012). Intervention research in couple and family therapy: A methodological and substantive review and an introduction to the special issue. Journal of Marital and Family Therapy, 38(1), 3–29. https:// doi.org/10.1111/j.1752-0606.2011.00271.x.

Conjoint Sex Therapy Darbi M. Miller, Jennifer McComb and Ryan M. Earl The Family Institute, Northwestern University, Evanston, IL, USA

Synonyms Couple’s sex therapy; Couple’s therapy with sexual issues; Systemic sex therapy

Introduction Until recently, psychological and/or medical interventions were the treatment of choice for sexual dysfunction. Psychological treatment often focused on the individual with the sexual concern and included cognitive and/or behavioral techniques to alleviate sexual problems, whereas medical treatment alters an individual’s physiological response (Heiman 2002). More recently, conjoint sex therapy has emerged as a more systemic approach to treating sexual dysfunctions that attends to the role of relationships in the etiology and treatment of sexual concerns. In 1970, Masters and Johnson proposed there was value in including partners as a way of helping the individual with sexual dysfunction. Even with this new approach, Masters and Johnson were criticized for only giving lip service to the idea of working with couples as they did not conceptualize and treat sexual problems systemically. Even still, this view contrasted the typical

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treatment for their era which conceptualized and treated most psychological problems and sexual dysfunction within an individual psychoanalytic framework (Kleinplatz 2015). In 1977, Helen Singer Kaplan critiqued Masters and Johnson’s work for only looking at physiological factors of sexual responses and ignoring subjective aspects such as desire, psychological arousal, and sexual satisfaction (Kaplan 1977). Kaplan’s work expanded the field of sex therapy by moving beyond the focus on behavioral interventions to addressing the individual psychological factors influencing sexuality. In 2002, in response to the advances in the medicalization of sex therapy and the refocus on the individual as the treatment system, the Working Group for a New View of Women’s Sexual Problems postulated that sexual dysfunctions should “be assessed in terms of sociocultural, political, or economic factors; problems relating to partner and relationships; psychological and medical factors” (Tiefer 2002). This statement recognizes the complexity of factors influencing sexual functioning. Furthermore, it highlights the role of partners and relationships in the development, maintenance, and treatment of sexual dysfunctions.

Theoretical Framework There continues to be a lack of theory and theoryinformed research underlying the treatment of sexual disorders (Weeks and Gambescia 2015). Historically, people within the field have focused on treating the symptoms of sexual dysfunctions and disorders without a clear theoretical framework to guide their work (Kleinplatz 2015). This is beginning to change as theory informed sex therapy models begin to emerge such as the Intersystem Approach. This is a meta-framework, which is grounded in systems theory and informed by Sternberg’s Triangular Theory of Love (Sternberg 1986), The Theory of Interaction (Strong and Claiborn 1982), and Attachment Theory and Sexuality (Johnson and Zuccarini 2010). Unlike the historically dominant models of sex therapy which were individually focused and

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either behaviorally or medically driven, the Intersystem Approach (Weeks 1986) attends to the simultaneous influence of the individualbiological/medical, individual – psychological, couple, dyad, family of origin and larger contextual factors (i.e., religion, culture) on sexual problems (Weeks and Gambescia 2015). Furthermore, it emphasizes the importance of including partners in treatment and conceptualizing the couple as the treatment unit.

Rationale for the Strategy or Intervention Due to the prevalence rates of sexual dysfunction which are estimated to be 40–45% for adult women and 20–30% of adult men (Lewis et al. 2010), it is important to develop treatments that address the range of factors that influence sexual functioning. The medicalization of sex therapy and the reliance on drugs such as Viagra and Cialis provided evidence that there are limits to the effectiveness of medications that do not address the individual and relationship dynamics influencing sexual functioning. Klotz et al. (2005) reported that the rate of noncompliance for people using Viagra was 31% and the majority of participants reported that the reason they stopped using the drug was because “they had had no opportunity or desire for sexual intercourse or that their partners had shown no sexual interest” (Klotz et al. 2005, p. 2). Therefore, by treating the symptom only and not working systemically, these patients were still experiencing sexual problems. It is now widely recognized that it is important to look at the context in which the problem is embedded. Usually, a sexual problem is “created within or maintained by the relationship” (Weeks et al. 2016, p. 42). Certain risk factors can predispose a couple to sexual problems including: anger, resentment, fear of intimacy, conflict management styles, and power struggles (Weeks and Gambescia 2015), making it crucial to work systemically when treating a sexual dysfunction.

Conjoint Sex Therapy

The field of sex therapy has changed in notable ways, and conjoint sex therapy is now considered the treatment of choice for many sexual concerns and dysfunctions. This shift is reflected in the American Association for Sex Educators and Counselors (AASECT) new requirement that all sex therapists have training in couple therapy.

Description of Strategy or Intervention Conjoint sex therapy is focused on treating the couple system from the onset of therapy. The inclusion of partners in therapy challenges the idea that the individual experiencing the sexual concern is the focus of treatment by including and attending to the partner’s role in the development, maintenance, and treatment of the problem. The initial couple session is focused on building the alliance with the couple, the therapist modeling comfort and safety discussing sexual issues, eliciting clients’ experience of the presenting problem, attempted solutions, and hopes for the treatment process. It is important that the therapist be mindful that many couples do not discuss their sexual relationship directly, so this initial session can be very challenging for some clients. Many clients feel embarrassed, uncomfortable, ashamed, or pessimistic from previously trying to solve the issue (Weeks et al. 2016). Furthermore, therapists should be mindful that the partners might have very different experiences related to the sexual concern and it is important that therapists acknowledge, validate, and normalize both partners experience. For example, “it makes sense that your worry about losing your erection gets in the way of wanting to have sex and it also makes sense that his lack of interest in sex leaves you feeling undesirable and inadequate.” While details about sexual functioning are important for the therapist to assess the problem, it is sometimes therapeutically wise for therapists to discuss the issue more broadly in the first session and to ease into the more detailed questions in subsequent sessions. The initial couple session is often followed by the therapist meeting individually with each partner to develop a more detailed understanding of

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their family, sexual relationship, and medical history (for a list of detailed assessment questions refer to Weeks et al. 2016). The rationale for this in the context of conjoint sex therapy is that many clients are able to talk more openly and honestly about their sexual and relationship history and their experience of the sexual problem in an individual context. Therapists must be clear with clients about how information shared during the individual sessions will be used in the couple’s context. Many couple therapists have secret policies that can inform this process. All of the information gathered in the individual sessions will inform case conceptualization and treatment planning. The fourth session is typically focused on the therapist sharing their clinical impressions and recommendations for treatment which can include individual therapy, medical intervention, and/or couple therapy. Collaboratively, the clients and therapist create a treatment plan that is congruent with the client’s goals. One of the challenges that often emerges in conjoint sex therapy is the comorbidity of sexual concerns with other psychological, relational, and/or medical conditions. Weeks et al. (2016) developed The Triage Tree to assist clinicians in treatment planning by helping clarify which presenting problem to treat first, treating a comorbid problem and treating multiples sexual dysfunctions in a sequence that makes sense. Also, it is important to note that not all clients presenting for treatment have a partner. In these cases, it is still possible and important to attend to the systemic and relational influences on the presenting problem. For example, asking questions such as: in previous relationships when you experienced vulvar pain, how did you navigate this? How did your partner(s) respond? How did this make you feel? How does this influence your current sexual relationship with yourself and others? If the client is in a relationship but is unwilling to involve their partner in treatment, it is the therapist’s responsibility to be clear with the client about the potential limitations to treatment and to explore their reluctance to include their partner. Sometimes as a client becomes more comfortable

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in sex therapy, trust the therapist and experience the limitations of individual treatment, they reconsider involving their partner in treatment.

Case Example A heterosexual couple in their early 60s present for treatment due to concerns about the male partners erectile functioning. The couple sought treatment after a consultation with an urologist who report no physiological origins for the problem and referred the patient to sex therapy. During the initial call, the therapist asked if his partner would be willing to attend the first session. The client expressed some reluctance which provided an opportunity for the therapist to explain that his partner’s involvement in the process will be critical to the desired outcomes. Clarifying the four session assessment process was reassuring to the client as he felt that it would be important to be able to discuss his experience without his partner due to the conflict that it has created. The couple presented as uncomfortable during the initial session. Both partners acknowledged that it was difficult to talk to a stranger about such a personal aspect of their life. The therapist validated these concerns and modeled that she was willing to work at their pace and invited the clients to let her know if she asks a question that they are not comfortable answering. The first session focused on exploring the onset of the presenting problem, the impact of erectile dysfunction on them individually and on their relationship, and their hopes for treatment. At the end of the session, the therapist created some time to reflect on the process and elicited their experience of the session. This is a helpful way for the therapist to access some insight into client’s experience of the process. In this case, both partners acknowledged that talking directly about their sexual relationship was difficult but that they felt more comfortable than they expected and hopeful about the process. The subsequent individual sessions were focused on developing a more detailed understanding of each partner’s experience of the

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presenting problem and their family, relational, and sexual history. The psychosexual assessment revealed numerous possible contributing factors to the erectile dysfunction including: performance anxiety, relational dynamics, and unrealistic expectations about erectile functioning. Based on the information derived from the assessment, sex therapy was focused on five primary treatment goals: (1) conceptualizing erectile dysfunction as a relational issue rather than the male partner’s problem, (2) psychoeducation about erectile functioning and normative changes as men age, (3) increasing communication about sexual needs and desires, (4) identifying and interrupting relational dynamics that maintain performance anxiety and avoidance of sexual intimacy, and (5) developing mindfulness and relaxation skills. All of the interventions used in treatment were targeted to address one or more of these treatment goals. Four relational interventions were particularly helpful to the couple. First, the therapist helped the couple understand the interactional sequences that contributed to performance anxiety and the avoidance of sexual intimacy. She highlighted how the partners expressed sadness, frustration, and perceived undesirability when her partner loses his erection contributed to the partner feeling inadequate and anxious about his performance which resulted in him avoiding sexual intimacy and the emotional distress that it creates for both partners. The therapist normalized this dynamic as many couples find themselves stuck in some version of this dance. Second, a series of sensate focus exercises helped the couple work through barriers to sexual and emotional intimacy and develop mindfulness skills. Both partners became more comfortable discussing their physical relationship and were able to develop skills to be present with each other sexually. Third, the couples engaged in some wax and wane exercises that helped both partners gain confidence in the male partner’s erections. This was very important for this couple as their typical dynamic was that as soon as the partner’s erection decreased in rigidity the male partner’s anxiety would increase

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and the female partner would become frustrated and give up. Fourth, the partner’s involvement in the treatment process played a critical role in helping the male partner feel supported and trusting that they could navigate his erectile difficulties when they emerged. This helped decrease his performance anxiety and increase his ability to relax which are both necessary for optimal erectile functioning. This case example highlights the value of conjoint sex therapy as an individual approach would fail to address the relational dynamics that both contributed to the maintenance of the problem and were critical to problem resolution.

References Heiman, J. (2002). Sexual dysfunction: Overview of prevalence, etiological factors, and treatments. Journal of Sex Research, 39(1), 73–78. Johnson, S., & Zuccarini, D. (2010). Integrating sex and attachment in emotionally focused couple therapy. Journal of Marital and Family Therapy, 36, 431–445. Kaplan, H. S. (1977). Hypoactive sexual desire. Journal of Sex & Marital Therapy, 3(1), 3–9. Kleinplatz, P. J. (2015). The current profession of sex therapy. In K. M. Hertlein, G. R. Weeks, & N. Gambescia (Eds.), Systemic sex therapy (2nd ed., pp. 17–31). New York: Routledge. Klotz, T., Mathers, M., Klotz, R., & Sommer, F. (2005). Why do patients with erectile dysfunction abandon therapy with sildenafil (Viagra ®)? International Journal of Impotence Research, 17, 2–4. Lewis, R. W., Fugl-Meyer, K. S., Corona, G., Hayes, R. D., Laumann, E. O., Moreira, E. D., Rellini, A. H., & Segraves, T. (2010). Definitions/epidemiology/risk factors for sexual dysfunction. The Journal of Sexual Medicine, 7, 1598–1607. Sternberg, R. (1986). A triangular theory of love. Psychological Review, 93(2), 119–135. Strong, S., & Claiborn, C. (1982). Change through interaction: Social psychological processes of counseling and psychotherapy. New York: Wiley. Tiefer, L. (2002) A new view of women’s sexual problems. Women & Therapy, 24(1), 1–8. Weeks, G. R. (1986). Individual-system dialectic. American Journal of Family Therapy, 14(1), 5–12. Weeks, G. R., & Gambescia, N. (2015). Toward a new paradigm in sex therapy. In K. M. Hertlein, G. R. Weeks, & N. Gambescia (Eds.), Systemic sex therapy (2nd ed., pp. 32–52). New York: Routledge. Weeks, G. R., Gambescia, N., & Hertlein, K. M. (2016). A clinician’s guide to systemic sex therapy (2nd ed.). New York: Routledge.

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Contemplation as a Stage of Change in Couple and Family Therapy Carlo C. DiClemente and Alicia E. Wiprovnick University of Maryland, Baltimore County, Baltimore, MD, USA

Synonyms Ambivalence; Considering Change; Decisionmaking; Decisional balance; Risk reward analysis

Overview and Theoretical Context Stages of change represent a series of steps and tasks that assist in understanding the multidimensional nature of the process of intentional behavior change. According to the transtheoretical model (TTM), the process begins with an individual in precontemplation and not considering change through contemplation (decision-making), preparation (planning and committing), and action (making the change and revising the plan) to reach maintenance where the new behavior is sustained and integrated into one’s life (Prochaska and DiClemente 1984). When individuals in couples and family therapy need to make a change in personal or interpersonal behaviors, the stages can be helpful for understanding their readiness and motivation. Thus, assessing stage status enables therapists to match their approaches to meet the needs of clients in different stages of change. However, motivation often differs for different members of the couple or family system. Often partners and family members disagree on who and what needs to change, as well as why there is a need for change. Applying the stages to couples and family behavior change is challenging since the therapist must understand who needs to make changes, what changes are needed, and how ready individuals are to make changes. To maintain equality within couples or family therapy, it is recommended that all clients

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be requested to make some type of change (Jacobson and Christensen 1998). Moreover, stage status is goal and behavior specific so individuals can differ in the goals (desired amount of contact with in-laws) and behaviors (cutting down or quitting smoking) as well as in their readiness to make the change.

Application of Concept in Couple and Family Therapy Tasks of the contemplation stage of change include serious consideration of the pros and cons of change, overcoming ambivalence, and making a firm decision to change (DiClemente 2003). Usually individuals move on to preparation and action only after having completed either a formal or informal cost-benefit analysis, which results in a decision that this change is in their best interest. Ambivalence, feeling two ways about a specific change or vacillating about whether to take action or not, is a normal part of the decision-making process (Janis and Mann 1977). This is particularly true when interpersonal as well as personal considerations are in play. Contemplation activity in couples and families is complicated because each member of the dyad or family system has their personal decisional considerations that can complement or conflict with the considerations of others. This potential discrepancy among reasons and motives for a behavior change can disrupt decision-making whether it is focused on the behavior change of a single individual or a shared set of changes to be made by multiple members (Bradford 2012). In treatment settings, the role of the intervenor is often to explore the different motivations of the couple or family members to see if there is some common motives or decisional considerations. In other words, the search is for pros and cons for a specific change that could influence the decisionmaking of each member of the dyad or family to make the changes needed for problem solving and optimal functioning. The desired or recommended behavior change could be following through on a therapeutic strategy, like doing the recommended sensate-focusing strategy for overcoming

vaginismus in sex therapy, or taking actions needed to meet a goal, like taking more time to do activities with an adolescent child (Prochaska and DiClemente 1984). Furthermore, an emphasis on shared goals can be helpful when considering behavior changes with couples or families. Goal setting can involve elucidating the behavior changes that will lead to the achievement of larger goals (such as reduced conflict) by considering each family member’s role in the problem and the solution, as well as an exploration about what changes are needed and acceptable to family members (Lebow and Rekart 2007). When exploring reasons for change, it is important to distinguish between change viewed as chosen and change viewed as imposed. The focus of the TTM is on intentional behavior change that is chosen by the individual, driven primarily by intrinsic motivation, and supported by important explicit or implicit values and reasons. A solid decision to change should be based on an individual’s belief that the change will be personally rewarding and worth the effort and risk of making the change. Sometimes, however, a behavior change is primarily made for extrinsic reasons, e.g., “I will do this because you want me to” or “because it is important to you” or “because you will leave or not let me use the car if I do not do this.” Imposed behavior change can be successful so long as the extrinsic motivations are in place, but often fail when these motivations disappear unless the individual finds personal, intrinsic motivations to persist and maintain the change (Stotts et al. 2000). However, in couples and family therapy, making a change for someone else may not represent imposed change. Some of the seemingly extrinsic reasons for change represent important intrinsic values (keeping the marriage, love, or a good parental relationship) and support intrinsic motivation and a personal decision to change. Nevertheless, it is important for the therapist to assess when the behavior change seems more like an imposed change rather than a chosen change. Several examples may help. A wife may agree to spend holidays with the in-laws to “save the marriage” because this is a deal breaker for the husband. However, when she learns that he had an affair, she is no longer motivated to continue

Contemplation as a Stage of Change in Couple and Family Therapy

making this effort and refuses to visit even though they stay together. A child may go along with doing things a certain way under threat of not receiving allowance money but rebel once he gets a job and no longer has this extrinsic reason to compel him. On the other hand, something that is done out of a deep respect or gratitude may represent an intrinsically motivated change that is capable of being sustained. In relationships, there is always a need to compromise and to “go along to get along” to some degree. This usually works as long as there is perceived reciprocity and mutual benefit. Evaluating the Pros and Cons In working with decisional considerations, it is often helpful to construct or discuss the pros and cons for change. In any such conversation, arguments for change consist of negatives about the current status quo (I don’t like all this fighting; I feel like I am missing something if we do not have children) and the pros for the change (I would stop nagging if you stop drinking; a baby would enrich our lives). Arguments against change consist of the positives of the current status quo (drinking with my friends is my only social outlet; I like the freedom I have without children) and the negative aspects of the proposed change (I would lose friends; we would have to give up going to football games). These considerations represent what motivational interviewing (Cordova et al. 2005; Miller and Rollnick 2013) recommends to reflect upon, whether you are hearing change talk (statements supporting change) or sustain talk (arguments against change). It is important in these conversations to focus more so on reasons for change and not on the sustain talk or arguments against change. Concentrating on the cons of change can reinforce ambivalence and undermine decision-making (Miller and Rose 2015). Another key consideration when examining pros and cons is to make sure that you do not mistake numbers for importance. The more important element that tips the decisional balance toward change is not the number of consideration for or against but the value or importance of each of these considerations

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(Velasquez et al. 2015). If one or more of these considerations are critically important, it does not matter how many others are on the other side. So, look for how meaningful each consideration is, and do not focus simply on generating or expanding the list. In couples counseling, for example, there is often a negotiation about reasons for change. Thus, it is important to understand the dimensions of decision-making for each member of the dyad and the importance of solid, intrinsic reasons for change. Often there is a desire for compromise and a negotiation in finding specific behavior changes that can reduce conflict, promote more effective communication, solve problems, or improve intimacy (Jacobson and Christensen 1998). Counselors should make sure that they are not short-circuiting the decision-making process of every individual especially when there is a dominant partner or a more passive-aggressive participant. Moreover, counselors need to be cognizant of their own values and not interject or impose their values into the decision-making process (Heatherington et al. 2005); this is especially important when cultural differences exist between the therapist and clients since many individuals will have values that reflect the culture they identify with and not those of the counselor’s culture. These considerations are particularly critical in the negotiation and discussion of individuals in contemplation for making a change. Consideration of the pros and cons for change can result in several different outcomes. At minimum, the exploration of decisional considerations should lead to every individual in the couple or family system understanding the motives and motivation of the other members. Ideally the discussion leads to a decision to make a change or attempt to make a change. Decisions can be based on personally as well as interpersonally meaningful reasons that can be shared among family members. The important outcome is that each person finds a risk/benefit calculation that supports making a commitment and implementing a plan for change that would represent the action stage of change.

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Example Skylar and Tammy have been married for 5 years. She is 33 and he is 35. They have come to marital therapy to discuss their concerns about the deterioration of their marriage. They are having more arguments about whether to have children right now and have been growing apart with Skylar spending more time with his friends and Tammy at home alone more. They do not seem to do much together anymore and Tammy is frustrated seeing herself as housekeeper and cook and not an equal partner. Both work and have rather satisfying jobs; they are financially stable and own their own home. In this session, the counselor focused on their thoughts about having children and explored their decision-making about this issue. Although Tammy was concerned about how pregnancy and a child would affect her career and whether she would be a good mother, she felt that it was time and many of her college friends already had a family, so she felt behind. Her family was also encouraging her since she was the youngest and her two older siblings each had three children already. Skylar wanted children but was not ready at this point to spend the time and energy to be a father. He was just promoted and much of his going out was to cultivate business connections and to spend time winding down from job pressures. He was an only child and did not see any rush since he did not want to live like her siblings running around trying to keep up with the activities of the children. As the counselor probed the pros and cons, she discovered that both wanted children but had different visions of what a family would look like and the demands of children. As they shared and discussed personal concerns, they began to realize that they still had a number of shared values and goals, as well as a number of different but important concerns about becoming parents. They discussed their differences, and the counselor was able to have each highlight the key risks and benefits. This discussion led them to a better understanding of one another and to developing shared goals. Their first goal was to begin to do more things together

and reconnect, and second, they recommitted to having children at some point but decided to wait and revisit trying to become pregnant in 3 months. Skylar began to agree that he was being a bit selfish as he had some concerns about losing Tammy’s attention once children were in the picture, and Tammy realized that she also was not convinced that they needed three children. Shared and unique decisional consideration allowed for a decision-making process that fostered shared goal setting and negotiation of immediate and longer-term behavior changes. A 2-year follow-up contact with the couple found them with a 1-year-old child. Skylar was still progressing in his job and working long hours but also spending more time doting over his daughter and spending time with the family. Tammy has gone to part-time work to spend more time with their daughter and was considering starting her own business with several of her colleagues so she could be her own boss.

Cross-References ▶ Action as a Stage of Change in Couple and Family Therapy ▶ Precontemplation in Couple and Family Therapy

References Bradford, K. (2012). Assessing readiness for couple therapy: The stages of Relationship Change Questionnaire. Journal of Marital and Family Therapy, 38(3), 486–501. https://doi.org/10.1111/j.1752-0606.2010. 00211.x. Cordova, J. V., Scott, R. L., Dorian, M., Mirgain, S., Yaeger, D., & Groot, A. (2005). The marriage checkup: An indicated preventive intervention for treatmentavoidant couples at risk for marital deterioration. Behavior Therapy, 36(4), 301–309. DiClemente, C. C. (2003). Addiction and change: How addictions develop and addicted people recover. New York: Guilford Press. (Released in paperback in 2006). Heatherington, L., Friedlander, M. L., & Greenberg, L. (2005). Change process research in couple and family therapy: Methodological challenges and opportunities. Journal of Family Psychology, 19, 18–27.

Context in Family Systems Theory Jacobson, N. S., & Christensen, A. (1998). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York: Norton. Janis, I. L., & Mann, L. (1977). Decision making. NYC: The Free Press. Lebow, J., & Rekart, K. N. (2007). Integrative family therapy for high-conflict divorce with disputes over child custody and visitation. Family Process, 46(1), 79–91. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd ed.). New York, NY: Guilford Press. Miller, W. R., & Rose, G. S. (2015). Motivational interviewing and decisional balance: Contrasting procedures for responding to client ambivalence. Behavioural and Cognitive Psychotherapy, 43(2), 129–141. Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Malabar: Krieger. Stotts, A. L., DiClemente, C. C., Carbonari, J. P., & Mullen, P. D. (2000). Postpartum return to smoking: Staging a suspended behavior. Health Psychology, 19(4), 324–332. Velasquez, M., DiClemente, C., Crouch, C., & Stephens, N. (2015). Group treatment for substance abuse: Stages of change therapy manual (2nd ed.). New York: Guilford.

Context in Family Systems Theory Aalaa Alshareef and Emily C. Klear The Family Institute, Northwestern University, Evanston, IL, USA

Synonyms Background; Perspective; Situated cognition; Situated realities

Introduction Family systems theory originated to account for individuals in the context of their family and how the process of interaction between family members impacted the individual members. Historically, psychological theories focused on objects and drives, and identifying behaviors,

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thoughts, and emotions as independent entities; the context was truncated (Mesquita et al. 2010). There were attempts to understand the influence of social surroundings on individuals; for example, Wundt (1894/1998) discussed the impact of social context on an individual’s mental life (Mesquita et al. 2010). Neo-Freudian psychologists developed personality theories based on human interactions within the social and cultural context (Hair et al. 1996). Family systems theory emphasized the importance of context (Breunlin et al. 1997).

Theoretical Framework for Concept Family systems theory from its earliest incarnations has had a major focus on context. It is a central postulate of family systems theory that behavior can only be understood in the context of the system in which it occurs. Family theorists have varied in how radically this stance is held. For some, especially early family therapists, all meaning occurs in context, and thus even the most severe mental illness can be understood in relation to other behaviors occurring in the family. Most subsequent family theorists emphasize context but also hold the notion that there is an objective reality that transcends context and that behavior is influenced by other forces such as biology. Two recent traditions have extended the consideration of the importance of context: social constructionism and feminism. Social constructivism developed in the 1950s aimed to transform the oppressing effects of the meaning-making processes by considering the political and social context, including but not limited to poverty, sexism, and racism (Lock and Strong 2010). Considering sociopolitical context significantly impacts the process of therapy in conceptualizing cases and building therapeutic relationships. Feminist theory highlighted that family systems theory was predominantly developed by heterosexual males and criticized that it could be rigid in its approach to considering the context of gender. Frequently, family therapists took for granted the power dynamic that was transmitted to couples and families through history and

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socially constructed gender roles. Feminist critiques of family systems theory offered explanations as to how the process of creating meanings occurs within context (Taggart 1985). In respect to the collaborative and systemic therapeutic work along with the complexity of human experiences in the changing world, family therapists integrate context into the process of therapy (Wetchler and Hecker 2015). Most human experience can be thoroughly conceptualized only if it is analyzed within the broader context; therefore, it is critical for therapists to consider the multiple layers of context that may impact the therapeutic process.

Description Context is defined as the circumstances and conditions in which a specific situation occurs, including its history and future (BoszormenyiNagy and Krasner 1986). Context can refer to many factors, such as the intrapsychic system that is situated within the mind (patterns of thoughts) and the interpersonal system that happens between individuals and their environment, or between individuals and each other (verbal/ nonverbal exchange) (Boszormenyi-Nagy and Krasner 1986). Context can include but is not limited to: gender, sexual orientation, race, ethnicity, religion, nationality, socioeconomic status, political ideology, and community norms (Wetchler and Hecker 2015). The functionality of context in family therapy mainly lies on conceptualizing experiences and case material within its frames in which it occurs (Boszormenyi-Nagy and Krasner 1986). As Watzlawick et al. (2011) suggested, behavior that looks strange otherwise may make much more sense when considered in context.

Application of Concept in Couple and Family Therapy There are two major ways to integrate context into therapy work: assessment and intervention. To thoroughly assess and intervene, clinicians

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must consider the contexts in which clients’ lives occur (Wetchler and Hecker 2015). Clinicians should consider contexts in which behavior occurs. This includes the meanings of behavior in family and larger systems. Other important contextual variables include gender role and social expectations that are transmitted from each client’s family of origin and cultural background. Clinicians often explore relationship patterns in terms of power dynamics throughout generations and within the sociopolitical context (Wetchler and Hecker 2015). Clinicians also consider cultural factors, such as ethnicity, race, and immigration status (Wetchler and Hecker 2015). Often such understandings can not only inform assessment and intervention but help in increasing empathy as behaviors are reframed in terms of context.

Clinical Example The following is an example of how context is critical when conceptualizing a case. A heterosexual couple is seeking therapy to navigate power dynamic; wife reports that she hates to be the controller, however, she is scared that the world will fall apart if she does not control everything. For her, making mistakes is not acceptable. Wife maintains control over husband, and he responds to her controlling behaviors by following her rules, which in turn upsets the wife because she wants him to advocate for himself. After the initial assessment, it was found that (a) the wife has a history of trauma, that impacts how she perceives the world. Her perfectionism plays a significant role in making her feeling safe and protected (historical context); (b) the husband was the only male child in his family of origin, leaving him feeling isolated. He does not want to reexperience rejection with his wife, so he works very hard to please her, which prevents him from asserting his needs; (c) both clients were emotionally rejected and they have developed anxious attachment styles with their own parents, and therefore, they do not know how to deal with emotions in effective ways. Understanding these contexts helps the therapist grasp what underlies their exchanges and constitutes a crucial part of case formulation and treatment planning.

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Cross-References

Synonyms

▶ Reframing in Couple and Family Therapy ▶ System in Family Systems Theory

Contextual family therapy

References

Introduction

Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between give and take: A clinical guide to contextual therapy. New York: Brunner/Mazel. Breunlin, D. C., Schwartz, R. C., & Kune-Karrer, B. M. (1997). Metaframeworks: Transcending the models of family therapy. San Francisco: Jossey-Bass. Hair, H., Fine, M., & Ryan, B. (1996). Expanding the context of family therapy. American Journal of Family Therapy, 24(4), 291–304. Lock, A., & Strong, T. (2010). Social constructionism: Sources and stirrings in theory and practice. New York: Cambridge University Press. Mesquita, B., Barrett, L. F., & Smith, E. R. (2010). The mind in context. New York: Guilford Press. Taggart, M. (1985). The feminist critique in epistemological perspective: Questions of context in family therapy. Journal of Marital and Family Therapy, 11(2), 113–126. Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (2011). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes (Pbk. ed.). New York: W.W. Norton & Co. Wetchler, J. L., & Hecker, L. L. (Eds.). (2015). An introduction to marriage and family therapy (2nd ed.). New York: Routledge.

Contextual therapy was founded by one of the pioneers of family therapy, Ivan BoszormenyiNagy (1987, first print 1979). It evolved out of intergenerational family therapy, which he had developed with his early associates, and from his seminal work on family loyalties (Boszormenyi-Nagy and Spark 1984, first print 1973). Contextual therapy is based on the postulate that fairness and loyalty play a major role in intergenerational family dynamics. It proposes that relational ethics, an ethics based on mutual respect and reciprocity, not on preexisting moral values, is a core determinant of close relationships. Based on clinical observations, contextual therapists postulate that relational injustices and distributive injustices, which are the result of adverse circumstances, can have an impact on individuals and on families that may affect multiple generations. Conversely, they believe that fair giving and trustworthiness are at the core of healthy relationships, as well as at the core of individual success. Contextual therapy is based on a core strategy, multidirected partiality. It requires that contextual therapists take into account all the people who could be affected by their therapeutic interventions and that they offer their partiality and empathy successively to each and all family members as a means to bring them to offer more consideration to each other and to restore their capacity for a genuine dialogue. Since the approach developed within the general field of family therapy, it is also known as contextual family therapy. But its founder gave a clear preference to the term contextual therapy to indicate that this approach is not constrained to work only with families. It can inform individual therapy and couple therapy as well. It has been used to promote an

Contextual Family Therapy Catherine Ducommun-Nagy Drexel University, Philadelphia, PA, USA The Institute for Contextual Growth, Inc., Glenside, PA, USA

Name of Model Contextual therapy

Note: A full multilingual bibliography on the work of Ivan Boszormenyi-Nagy and on contextual therapy with over a thousand entries has been established by Ilse SiebesmaNiewöhner and is available at http://www.icbnederland.nl.

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interpersonal dialogue between people in various kinds of settings. It can also be used as a guideline to address interethnic conflicts (Boszormenyi-Nagy 2002).

Prominent Associated Figures Here is a list of the main authors who have contributed to the development of the approach or to its visibility: USA: Ivan Boszormenyi-Nagy, Margaret Cotroneo, Catherine Ducommun-Nagy, Peter Goldenthal, Judith Grunebaum, Terry Hargrave, Janet B. Hibbs, Austin Joyce, Barbara Krasner, and Geraldine Spark Europe: Magda Heireman, Jean-François Le Goff, Jean-Marie Lemaire, Hanneke Meulik-Korf, Pierre Michard, May Michielsen, Luc Roegiers, Gérard Salem, Dick Schlüter, Else-Marie van den Eerenbeemt, and Amy van Heusden

Theoretical Framework Rationale for the Model and Core Concepts Contextual therapy contains elements that are common to all models of family therapy. All the pioneers of family therapy share a common realization: individual behaviors are not the sole result of individual factors like biology or psychology, but also the result of complex interactions between these individuals and the systems in which they are embedded. Consequently, health and dysfunctions depend on supra-individual determinants, not just individual ones, and therapy needs to be built on an understanding of the workings of the family system. On the other hand, contextual therapy does not rely just on systems theory to explain family dynamics. Contextual therapists propose that both individual fulfillment and relational health are directly connected to our capacity for fairness and generosity. The approach is based on the clinical observation that people’s expectations of justice and loyalty play a major role in family dynamics. It is assumed that the mutual commitment of family

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members, i.e., their reciprocal loyalty, is a major factor of family or group homeostasis because it defines a boundary between the group of all the people who are bound by mutual loyalty commitments and all the others, the people, who are not the recipients of this commitment. It is also a source of individual resilience because people who can count on reliable relationships have more resources to withstand adversity. Boszormenyi-Nagy proposed that people’s expectation of fairness and reciprocity constitutes a major determinant of close relationships, which he describes as relational ethics. He borrowed the term relational ethics from the vocabulary of the philosopher Martin Buber (1985). He presents relational ethics as a form of ethics, whereby people treat each other in accordance with an understanding of the direct impact of their behavior on others, not in accordance with preset moral or religious guidelines. For contextual therapists, the issue is not to determine what is moral or not but to bring the family members into a dialogue whereby they can learn about their respective needs and expectations. From this perspective, the definition of justice is intersubjective. It results from a dialogue between the involved parties, not from an abstract definition of what is just or unjust. Loyalty belongs to the dimension of relational ethics in as much as it is a special form of relational commitment that individuals offer to people or groups in reciprocity for their care and support. This commitment shows as an inclination to give more weight to their needs and expectations than to the needs and expectations of others. In families, filial loyalty originates from the parents’ commitment to provide care to their children. As a result, in time, the children will be inclined to repay their parents for their commitment by placing their interests before the interests of other people. Family loyalty is not limited to the parent-child relationship. It can be the result of a mutual commitment between siblings or any other relatives. Loyalty can also be based on factors that lay outside the dimension of relational ethics, such as an unconscious internalization of parental expectations, a fear of retaliation, or the need to maintain a relationship with an absent parent.

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The model describes the many ways in which family loyalties can lead to individual and relational pathologies when loyalties get divided, resulting in loyalty conflicts and split loyalties, or when loyalty is expressed in an indirect and invisible way. Loyalty conflicts result from loyalty expectations coming from several parties at the same time. It is exemplified by the difficulties that can occur when people try to balance the loyalty they owe to their family of origin with the loyalty they owe to their spouse. Split loyalties result from an extreme version of loyalty conflict. They occur when parents give signals that the only evidence of loyalty they will accept is an evidence of disloyalty to the other parent (“As long as you still talk to your father, do not even think of sending me a mother’s day card”). This is a common predicament of children whose parents are involved in a contentious divorce. Invisible loyalties are understood as indirect expressions of loyalty that occur when people get blocked in their capacity to express their loyalty in a direct fashion. This is the case of adopted children who often try to maintain a link with their biological parents who have disappeared from their lives. Since they have no idea about what these people would consider as a valid expression of loyalty, they often express their loyalty simply by pushing away their adoptive parents. At the end, nobody benefits from the situation. The adoptive parents get hurt, the children get blamed, and their loyalty to their biological parents remains invisible since these people have no way to hear about their children’s efforts to bring them into their lives. Also, people who reject their parents out of resentment for their shortcomings can rarely afford to become entirely disloyal to them because of the determinants of loyalty that lay outside the dimension of relational ethics. For instance, a person who was determined to cut off a parent from her life out of anger may at the same time sabotage a friendship that could have evolved into a marriage. The end result is that it is her partner who is pushed out of her life, not the parent whom she wanted to cut off.

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The contextual model underlines that unmet expectations of justice in the family lead to many additional negative relational consequences besides invisible loyalties. Injustices can lead to negative reciprocity (“you didn’t do anything for me, so I won’t do anything for you”), revenge (“you hurt me, so I’ll hurt you”), and destructive entitlement. This term is used by contextual therapists to describe the predicament of people who have been the victim of injustices that were not repaired by the wrongdoers and of injustices that were the simple result of unfortunate circumstances. Their legitimate right to seek justice may lead them to turn to the people who are the closest to them to obtain some compensation, which is unfair and destructive. When destructive entitlement leads to a lack of parental accountability and to the exploitation of children, especially in the form of parentification, it results in pathologies that can affect multiple generations (Boszormenyi-Nagy and Krasner 1986). Another element that characterizes contextual therapy is the dialectic theory of the personality proposed by Boszormenyi-Nagy (1987, first print 1965). According to this theory, the Self cannot exist outside of a relationship with its counterpart a Non-Self (an Other) and vice versa. This theory is based on the premises of existential philosophy (Theunissen 1984). In contextual therapy, the dependence of the Self on the Other to exist as a Self is described as an ontic dependence. According to Spielberg (1960), the adjective ontic describes “a structure inherent in being itself.” This means that this ontic dependence is inherent to the dialectical definition of the Self and not the result of any kind of pathology. This fundamental mutual dependence is one of the determinants of close relationships. In this model, individuation can only result from the meeting of the Self with a Non-Self, and autonomy becomes a paradoxical notion since it can only be reached through relating. Therapists have always known that a core ingredient of the therapeutic process comes simply from their presence, not from any specific treatment strategy. Contextual therapists offer an explication for this clinical observation. They go further by proposing that family

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therapy may foster more individual autonomy than individual therapy, which is counterintuitive. Contextual therapists consider a relational context whose span is wider than the family system, a term that usually references only those people who are in direct observable transactions. The relational context is defined as the sum of all the people who are brought into a relationship through giving and receiving and who are connected by accountability and indebtedness, even if they will never have direct interactions. One can be indebted to ancestors who have worked toward securing a successful future for the family long before being born. One can care to provide good circumstances for the children one plans to have even if in the end, one never becomes a parent. The relational context also includes the sum of all the people who are dependent on one another for their self-delineation. Lastly, what distinguishes contextual therapy from other approaches is that it aims to encompass all the major determinants of our behavior in one coherent model of relationships and of therapy. They are presented as the five dimensions of relational reality: (1) the dimension of facts, which is the world of historical determinants, of biology, and of medical sciences; (2) the dimension of psychology, which is the world of individual psychology informed by cognitive sciences and psychoanalysis; (3) the dimension of transactions, which is the world of systemic family therapy informed by systems and communication theories; (4) the dimension of relational ethics, which is the world of justice, loyalties, and reciprocity, the world specific to contextual therapy; and (5) the more recently added ontic dimension (BoszormenyiNagy 2000), a dimension that could also be called the dimension of mutual becoming, which is the world of the relational definition of the Self (Ducommun-Nagy 2002). Theory of Change Since contextual therapists have been able to demonstrate clinically that there is a correlation between the experience of injustices and individual or relational pathologies, they believe that changes and clinical improvement will come from the restoration

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of fair and responsible relating between family members and from direct and non-sacrificial expressions of family loyalty. They also propose that individual fulfillment and relational health result in good part from our capacity for generous giving. Boszormenyi-Nagy proposes that people who are capable of generosity toward others accrue what he calls constructive entitlement. He coined this term to describe the fact that people who show generosity to others make a gain that does not depend on the response of the beneficiary. This gain manifests itself as an increase in self-worth, self-esteem, and inner freedom. Decades later, his clinical impressions have been validated by neuroscientists and other researchers who have become interested in documenting the benefits of compassion and altruism on physical and mental health (Ricard 2015). In contextual therapy, the healing moment is defined relationally. It comes about as the result of intent, the willingness to give, not from an insight about the situation. At the moment of giving generously, the giver makes an indirect gain in the form of constructive entitlement, while the beneficiary of this gesture gains in a direct manner. Contextual therapists see this double gain as the main source of therapeutic optimism and of prevention: generous giving does not require selfless altruism, and people who receive their fair dues are less likely to accumulate destructive entitlement and to hurt subsequent generations. Therapeutic Goals In general, contextual therapy focuses on two broad categories of pathologies: the individual and relational pathologies resulting from problems in the expression of family loyalties and pathologies resulting from the individual and relational consequences of destructive entitlement. As an integrative approach, it also encourages a multidimensional assessment of clinical situations and relational problems. It permits the use of psychopharmacological interventions, psychological interventions promoting individual insight, or systemic interventions to promote changes as long as these interventions don’t contradict the core principles of relational ethics, especially the mandate of parental accountability.

Contextual Family Therapy

In the area of pathologies related to family loyalties, the therapeutic goal is to bring people to find the means to express their loyalties in direct and nondestructive way. In general, contextual therapists prefer to explore issues related to family loyalty with all the parties involved and explore with them what each could accept as a valid expression of loyalty. When this is not possible because the parents cannot be included for any kind of reasons, or when the parents present such a degree of rigidity due to their own pathologies that any dialogue becomes impossible, the therapists choose a different strategy. They encourage the children to work independently on finding ways of expression of loyalty that are compatible with their individual pursuits. When people are willing to care enough about their family legacy to sort out what they have been handed down and by taking the risk of refusing to transmit elements of their family heritage that could be detrimental to subsequent generations, they are not disloyal to their parents because they give a better chance to their posterity. Also, these people will earn constructive entitlement by trying to give a fair chance to the future. When it comes to injustices and destructive entitlement, the main strategy for change consists in helping people to realize that they can gain more by displaying generosity toward other people than from insisting on their dues. Contextual therapists foster a dialogue between family members encouraging them to present their claims and to discuss their expectations. Each moment of the dialogue leads to a bifurcation: one can insist on one’s claims, and refuse to listen to others, or one can open one’s mind to the possibility that others have valid claims too, which will earn them constructive entitlement. When destructive entitlement leads to blocked giving, therapists try to devise situations where the gesture that needs to be made toward the other is small enough to be feasible. This small experience can then bring just enough positive inner rewards to push the destructively entitled person to take the risk of giving a little more at a next occasion. Another source of motivation will come from the positive response of the beneficiaries of these gestures. A more

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permanent change occurs when family members become able to reengage in positive reciprocity without the support of the therapist.

Populations in Focus Contextual therapy applies to a vast array of populations and clinical problems. It can be used in the treatment of people affected by any major mental illness either as patients or as family members. There, one of the key contributions of contextual therapy comes from the view that any mental illness can be the source of injustices both for patients and for family members. In these cases, contextual therapy offers a unique framework that allows for the integration of psychopharmacological intervention with relational therapy. Contextual therapy can offer significant help to populations affected by intergenerational exploitation resulting from the experience of injustices, ensuing destructive entitlement, and the parentification of the next generations. This can include people who have experienced relational injustices in their personal lives. It can also include people or populations victimized by historical events, natural disasters, social injustices, or any kind of discrimination. Because of its understanding of the workings of family loyalties, contextual therapy can be a major resource for populations that have experienced major disruption in parent-child relationships. Disruptions can come from adoption, divorce, or placement in foster families and institutions. Contextual therapy also offers a framework to think about blended families resulting from divorce and remarriage and the new type of blended families formed by couples faced with infertility or by samesex couples, their children, and the third parties involved in their procreation (known or anonymous donors or surrogate mothers).

Strategies and Techniques Used in the Model To reach their treatment goals, contextual therapists use a specific strategy: multidirected partiality.

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The therapist wants to offer each and every member of the family a fair chance to be heard and to present their claims and, very importantly, an equal chance to earn constructive entitlement. If one participates in the treatment session, the therapist needs to offer one time to present one’s position without interference by others. If, for whatever reason, one family member cannot be included in the treatment, at a minimum, the therapist needs to try to understand that family member’s situation based on whatever information is available. The rationale for this multidirected partiality does not come simply from a humanistic attitude and from the belief that all people deserve a fair hearing no matter how well or badly they have behaved. It is part of a specific strategy to bring people out of the vicious circle of negative reciprocity. Once clients receive the caring attention of the therapist, they will lose some of the justifications that they had for refusing to hear others, and they will be more likely to reengage in a dialogue with them. The second rationale for multidirected partiality comes from an understanding of the workings of family loyalty and from the notion that any improvement in one person will benefit all the other family members. It is even true in the case of children who have been the victim of abuse or neglect. These children will be freer to discuss the destructive aspect of their parents’ behaviors without having to worry about disloyalty if the therapist cares about their parents too. During the entire course of therapy, the main tool of the therapist remains multidirected partiality. Here, the timing is crucial. One guideline is that people who are in the most difficult predicaments, who have been treated the most unjustly, who are the most vulnerable, or who are the least likely to present their claims spontaneously should receive the partiality of the therapist first. Therapists also want to reward people who take the risk of speaking and who volunteer helpful comments. Rewarding people for their positive contributions is a powerful strategy to decrease chaos during the sessions. If people see that the therapist gives them more attention when they try to be helpful than when they act out, they will stop creating havoc.

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Since contextual therapists want to keep their focus on relational ethics, they recommend weekly sessions whenever possible. They believe that when there is too much space between sessions, people tend to focus on reporting on what has happened in their life and less on what is happening between them. In general, contextual therapists don’t give their clients direct tasks, and they don’t give them specific directives to follow between the sessions, but sometimes they ask them to go back to their family to gain more information on the life of their parents or their ancestors. Like the vast majority of couple and family therapists, contextual therapists use genograms in their sessions as a tool for recording information about families. More specifically, they use the genogram to explore the dimension of relational ethics. They want to record the direction of giving and receiving between family members and identify the sources of injustices that may have affected family members over the generations. On occasion, they may ask their clients to obtain more information from family members about illnesses, losses, lifechanging events, and sociohistorical circumstances that may have affected their family. This kind of information is especially useful in cases of clients who have been parentified. If they can see that their family was impacted by adverse events, they may be more likely to understand the shortcomings of their parents and to make peace with them. If clients can see that their parents too were seeking redress for past injustice, and not simply acting out of callousness, they will be more likely to forgive them and to move on with their own lives. Contextual therapists have described this process as exoneration, and they believe that it is one of the major sources of clinical improvement. The decision to terminate treatment results from a discussion that involves all family members. Improvements are measured both in terms of symptom relief and in terms of an increased capacity to engage in a fair dialogue with each other without the help of an outsider. Experience has shown that families who have made excellent progress in these regards can still experience problems when they meet new life

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challenges. For this reason, at the time of termination, therapists offer their client the resource of returning for further sessions at a later time if needed.

Research About the Model Most of the relevance and efficacy of contextual therapy has been established empirically, and most research concerning the model is qualitative rather than quantitative. Ivan Boszormenyi-Nagy was among the first family therapists who used objective recording of their sessions, first by recording on audiotapes and later on videotape. In addition, he was one of the first to use the one-way mirror to allow team members to provide their observations about ongoing sessions. Most of the early discoveries leading to the development of contextual therapy were the result of a detailed analysis of recorded therapy sessions. This methodology was used by Boszormenyi-Nagy throughout his life, and his method was also followed to a lesser extent by some of his colleagues. Many of the authors who have written about contextual therapy have included a clinical case in their publications to illustrate the use of the approach. In most cases they start from the initial consultation to the end of the treatment. They discuss their initial hypothesis, their interventions, and the results of their interventions measured in terms of documented clinical improvements. Over the years a large quantity of material has been published that documents the efficacy of the approach for a vast array of clinical problems. However, large quantitative studies evaluating contextual therapy, like those that exist for other therapies such as cognitive and behavioral therapies, are largely absent from the literature.

Case Example This case example comes from a two-session consultation with Boszormenyi-Nagy that is available as a commercial teaching tape (BoszormenyiNagy et al. 1990).

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The family is composed of a father and a mother in their early 50s, a teen daughter still in high school, a boy in his early 20s still living at home, and an older daughter who is attending college. The parents requested professional help because of their concerns about their son’s behavior. He started to display angry outbursts toward his younger sister that were so severe that the parents had concerns about her safety. Over the course of treatment, the situation improved significantly, but the therapist still remained concerned. The father had remained unable to address his past history of alcoholism and its impact on the family. Also he was insisting that the early loss of his own father did not play any role in his adult life. Since there was a risk that these unaddressed issues could impact the family in the future, the therapist offered them the opportunity to meet with Boszormenyi-Nagy for a consultation. The first session included the two parents only. The consultant started with a review of their history. He offered partiality to the wife who had significant medical problems and asked to hear more about that. She reported that she did not feel supported by her husband. He then offered the husband a chance to respond. The husband admitted that she was right, but he insisted that his attitude was not the result of lack of caring but due to a sense of helplessness. He felt that whatever he would have tried to do would be irrelevant. This gave an opening to the consultant to show partiality to the husband. He asked him if his sense of hopelessness could be related to the loss of his father. After all, he was just a little boy when he was taken out of school to be told that his father, who was healthy in the morning, had just died at his job. This must have been extremely distressing. The husband was adamant that this was irrelevant. For him this was just life: one has to accept what it brings. The consultant indicated that he was willing to hear that, but that for him the death of his father was also an injustice. Most children don’t have to face the early loss of a parent. Could he see that? He did not. The consultant did not back off from this idea and raised his question a couple more times. Suddenly the husband broke down, his voice changed, and he started to talk not only about the day of his

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father’s death but about his life as a young man, his early adulthood, the early years of his marriage, and all the way to his drinking years, which he had never done before. He soon mentioned an incident for which he still felt ashamed. His son, who was still a boy, had caught him drinking in the family kitchen in the morning. He remembered that his son’s eyes were full of sadness and disapproval. He reported that this was the moment when he realized that he had failed his child. While he should have been the parent who cared about his child, his son had become the worried parent (parentification). This story was new to his wife. But she had to admit that at the time she was herself too overwhelmed by the situation to be able to offer support to her children. The next session included the entire family. Soon, the father opened up to his son about what he had shared with the consultant in the couple’s session and about his regret for his behavior. The son was very surprised and immediately turned to his younger sister. He told her that indeed he knew that not only he had helped their father but that he had also shielded her from his alcoholism by taking responsibilities beyond his age. He gave a reason for his violent outburst toward her: he was mad because she never showed him the respect that he believed he deserved for having protected her. This revelation took the entire family by surprise. The consultant moved to offer partiality to both children. To the son, he offered his understanding that indeed he was placed in a demanding and unfair position, but he also pointed out that his parents had started to acknowledge the damages they had caused. The consultant then moved to offer partiality to the sister: she too was a victim of the circumstances, and she could not be made responsible for the unfairness of the predicament. The boy started to be able to recognize that. Later in the session, the two siblings were able to talk more openly about their experiences, and slowly a new trust grew between all family members. These two sessions give a good example of the kind of changes that contextual therapists expect to bring to families. Changes are not measured simply by a decrease in individual and relational pathology. They show as an improvement in

Contextual Family Therapy

clients’ capacity to offer fair consideration to others. This results in an improved trust among family members and a better chance to protect the new generations from the impact of past injustices and destructive entitlement.

Cross-References ▶ “I-Thou” in Couple and Family Therapy ▶ Boszormenyi-Nagy, Ivan ▶ Buber, Martin ▶ Family Loyalty ▶ Intergenerational Couple and Family Therapy ▶ Invisible Loyalties in Families ▶ Ledgers in Couple and Family Therapy

References Boszormenyi-Nagy, I. (2002). Foreword. In F. Kaslow (Ed.), comprehensive handbook of psychotherapy (Vol. III, pp. xi–xii). New York: Wiley. Boszormenyi-Nagy, I. (1987). Foundations of contextual therapy: Collected papers of Ivan Boszormenyi-Nagy, M.D. New York: Routledge. Boszormenyi-Nagy, I., & Framo, J. (1985). Intensive family therapy. Theoretical and practical aspects. New York: Routledge. [First print 1965]. Boszormenyi-Nagy, I., & Krasner, B. (1986). Between give and take. A clinical guide to contextual therapy. New York: Routledge. Boszormenyi Nagy, I., & Spark, G. (1984). Invisible loyalties. New York: Routledge. [First print 1973]. Boszormenyi-Nagy, I, et al. (1990). From symptom to dialogue, a clinical consultation with Ivan Boszormenyi-Nagy [VHS], U.S.A., G.-N. Productions. Boszormenyi-Nagy, I. (2000, April 13). General address in the plenary of the annual conference of the Hungarian Family Therapy Association. Szeged. Buber, M. (1985). Between man and man. Trans. New York: MacMillan. Ducommun-Nagy, C. (2002). Contextual therapy. In F. Kaslow (Ed.), Comprehensive Handbook of psychotherapy (Vol. III, pp. 463–487). New York: Wiley. Ricard, M. (2015). Altruism: The power of compassion to change yourself and the world. Boston: Little, Brown, and Company.

Note: A full multilingual bibliography on the work of Ivan Boszormenyi-Nagy and on contextual therapy with over a thousand entries has been established by Ilse SiebesmaNiewöhner and is available at http://www.icbnederland.nl.

Contingency Contracting in Couple and Family Therapy

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Spielberg, H. (1960). The phenomenological movement: a historical introduction. The Hague: Martinus Nijhoff. Theunissen, M. (1984). The other: Studies in the social ontology of Husserl, Heidegger, Sartre, and Buber. Cambridge, MA: The MIT Press.

controlling conditions of behaviors to understand how they can be changed (Bandura 1971). Distressed families and couples tend to use coercion and punishment rather than rewards and cooperation in their interactions to make another family member or romantic partner behave in desired ways (Fatis and Konewko 1983). Contingency contracts change the environmental conditions by promoting cooperation, rewarding or reinforcing desirable changes, and introducing negative consequences to weaken the undesirable behaviors. According to social exchange theory, individuals’ perceptions about the costs and benefits of engaging or not engaging in a behavior govern their decisions (Thibault and Kelley 1959). Family members and partners are more likely to engage in behaviors desired by others if they perceive equity, reciprocity, and fairness in the exchange. By requiring commitment from all parties involved and introducing consequences for maintaining or failing to maintain the promises, contingency contracts can be seen as reestablishing equity, reciprocity, and fairness in the exchange system.

Contingency Contracting in Couple and Family Therapy Mariana K. Falconier1 and Norman B. Epstein2 1 Virginia Polytechnic Institute and State University, Falls Church, VA, USA 2 University of Maryland, College Park, MD, USA

Name of Intervention Contingency contracting in couple and family therapy

Introduction Contingency contracting is a tool based on social learning principles and that has long been used in marital and family therapy, particularly in behavioral, cognitive-behavioral, and systemic therapies. Contingency contracts are written agreements in which partners or family members agree to engage in a behavior identified as desirable by another partner or family member(s) and in which positive consequences for compliance and negative consequences for noncompliance with the contract are specified (Jacobson 1977). These contracts structure reciprocal exchanges with agreements on “who is to do what, for whom, under which circumstances, times, and places” (Liberman et al. 1976, p.392), on the specific rewards for desirable behavior, and on the consequences for undesirable behaviors.

Theoretical Framework Contingency contracting is consistent with social learning principles and the social exchange perspective. Social learning theory focuses on the

Rationale for Contingency Contracts Since the 1970s contingency contracting has been used in couple and family therapy, particularly in treatments with behavioral (e.g., Jacobson 1977) and cognitive-behavioral (e.g., Epstein and Baucom 2002). Contingency contracting is introduced in therapy as a tool that can help couples and families move from aversive control and coercive, negative interactions to cooperative, positive reinforcing exchanges. Having an agreement in writing contributes to making the rules of exchange clearer and more explicit (Fatis and Konewko 1983). Contingency contracts require families and couples to be precise and concrete about expected behaviors, positive reinforcers, and negative consequences in their contracts and to use language that is not harsh, blaming, or accusatory, all of which reduces the likelihood of conflict. But most importantly, the contract in itself can be seen as representing “a pledge of a mutual

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commitment to work on a relationship” (Faits and Knoweko 1983, p. 161). Since all contracts require negotiation among family members or partners, it has been recommended not to use it in isolation but in conjunction with problem-solving training (Jacobson 1977) and communication training (Weathers and Liberman 1975). Both types of trainings allow family partners to be able to empathize, compromise, and negotiate successfully.

introduced parallel or good faith contingency contracts to work with couples. In this type of contract, each partner’s engagement into a desirable behavior is independent from the other partner’s behavior. In good faith contracts, each partner commits to engaging in certain behavioral changes desired by the other partner, and reinforcers or punishers are independent from the other partner’s expected behavioral changes. Some clinicians have developed specific processes to arrive to a contingency contract. For example, Weathers and Liberman (1975) have designed the family contracting exercise to be used in a group format. The exercise helps couples go from identifying personal needs to the negotiation of responsibilities and corresponding privileges and includes communication skills training. Couples are invited to keep records of each partner’s adherence to the contract, which is reviewed in the group meetings. Couples can also refine and renegotiate various aspects of the contract in group meetings. Similarly, Blechman, Olson, Schornagel, Halsdorf, and Turner developed the family contract game (1976) that enables families to resolve problems by themselves and develop contingency contracts. This board game includes card decks (problems, rewards, risks, bonuses), contract forms, tracking forms for positive behaviors and rewards, and play money. The game is only played by the family, who can use it to write new contracts or revise and renegotiate previous ones.

Description of Contingency Contracting Two types of contingency contracts have been identified: quid pro quo and good faith. In quid pro quo contracts, individuals agree to engage in behaviors that are desired by another family member(s) or partner, and this other family member(s) or partner commits to behaviors that will serve as reinforcers or consequences for not complying with the terms of the contract (Weiss et al. 1974). This type of contract is used in both couple’s and family therapy. In family therapy contracts may be developed between a parent and a child, between siblings, or among any other family members. They have been particularly used between parents and their children when parents would like their children to take responsibility for household chores, academic work, social activities, or other aspects in their lives, and children want their parents to provide them with some privileges (e.g., watching a movie, arriving later, etc.). The children’s desired behavior is reinforced by parents granting or withdrawing privileges, which act as reinforcers or punishers of their children’s behavior. Quid quo pro contracts have also been used in the couple’s therapy context in which partners agree to engage in behaviors that are desired by the other partner, and the other partner commits to behaviors that will serve as reinforcers. Consequences for not complying with the terms of the contract are also included. However, Weiss et al. (1974) have argued that in the case of couples’ therapy, this type of contingency contracting creates the “who goes first” problem, particularly for severely distressed couples in which high levels of mistrust may keep partner from making any change. This is the reason why Weiss et al. (1974) have

Case Example A family sought therapy to resolve the increasing level of conflict with their 12-year-old son. The parents were concerned about the increasing amount of time that their son spent on his cell phone and his computer while neglecting his schoolwork and household chores. The son felt that his parents did not trust him and invaded his personal space. When parents considered that the son had spent too many hours on his electronics, they asked the son to do his schoolwork. An hour following the request, the parents would go into the son’s room to check if he was doing what he had been asked to do, which usually triggered

Contracting of Goals in Couple and Family Therapy

arguments that were followed by the parents removing the son’s phone. These escalations left both parents and son feeling angry and exhausted and had strained the relationship between them. The therapist helped them negotiate a contingency contract in which the son agreed to start doing his schoolwork 1 h after returning from school while leaving his cell phone in another room and having no access to video games and TV series in his computer. Once he was able to prove that he had finished his schoolwork, the son would be given the cell phone and would have full access to his video games and TV shows for as much time as he had spent doing his schoolwork. The parents agreed not to get into his room while the son was doing his homework. However, if the son failed to complete his schoolwork or lied about its completion, the access to his electronics would be reduced by 30 min on the first day and 30 more min everyday if the pattern continued. If the parents got into his room to check whether the son was doing his homework, the son would be given 30 extra min of use of electronics. This contingency agreement committed both the son and the parents to make behavioral changes that reinforced each other’s changes and introduced specific consequences for moments in which either party was not following through their commitment.

585 Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Fatis, M., & Konewko, P. J. (1983). Written contracts as adjuncts in family therapy. Social Work, 28, 161–163. Jacobson, N. S. (1977). Problem solving and contingency contracting in the treatment of marital discord. Journal of Consulting and Clinical Psychology, 45, 92–100. Liberman, R. P., Wheeler, E., & Samders, N. (1976). Behavioral therapy for marital disharmony: An educational approach. Journal of Marriage and family counseling, 2, 383–396. Thibault, J. W., & Kelley, H. H. (1959). The social psychology of groups. New York: John Wiley. Weathers, L., & Liberman, R. P. (1975). The family contracting exercise. Journal of Behavior Therapy and Experimental Psychiatry, 6, 208–214. Weiss, R. L., Birchler, G. R., & Vincent, J. P. (1974). Contractual models for negotiation in training marital dyads. Journal of Marriage and the Family, 36, 321–330.

Contracting of Goals in Couple and Family Therapy Katie M. Heiden-Rootes and Rachel L. Hughes Saint Louis University, Saint Louis, MO, USA

Synonyms Therapeutic Alliance

Cross-References ▶ Behavioral Couple Therapy ▶ Cognitive Behavioral Couple Therapy ▶ Cognitive-Behavioral Family Therapy ▶ Communication Training in Couple and Family Therapy ▶ Problem-Solving Family Therapy ▶ Social Learning Theory

Introduction

References

Theoretical Context for Concept

Bandura, A. (1971). Social learning theory. New York: General Learning Press. Blechman, E. A., Olson, D. H. L., Schornagel, C. Y., Halsdorf, M., & Turner, A. J. (1976). The family contract game: Technique and case study. Journal of Consulting and Clinical Psychology, 44, 339–455.

The goals the client establishes are connected to a therapist’s conceptualization of the problem and interventions – derived from the therapist’s theory of change (Sprenkle et al. 2009). For instance, if a couple comes to therapy saying that they want to

Considered a significant portion of the therapeutic alliance*, the process of contracting goals sets the direction therapy is proceeding in order to reduce the presenting problem (Bordin 1979; Escudero et al. 2008).

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increase their “communication about difficult topics,” a Bowenian therapist may conceptualize the problem as resulting from low differentiation of self (e.g., fusion, pseudodifferentiation, or cut-off) in one or both of the partners. The therapist may then proceed to explore the family history of fusion using a genogram to accomplish the Bowenian goal of increasing differentiation of self of the partners and, thereby, increasing open “communication about difficult topics.” Contracting for goals, then, is a joint therapeutic endeavor where the client expresses their expectations or goals for therapy and the therapist utilizes their theory of change for understanding how to accomplish the client’s goals.

Description The process of contracting goals sets the course of therapy and is an integral part of promoting change for clients (Bordin 1979). At the start of therapy, clients share their understanding of the problem. As the clients explain, the therapist collects contextual information related to the problem, the impact of the problem on the client and others (e.g., partner, family, work functioning), and then sets the goals for therapy that would reduce or eliminate the problem (Sprenkle et al. 2009) or perhaps make the problem more manageable. After establishing goals and a mutually respectful and trusting relationship (i.e., bond), the therapist and the client work together to create the steps towards accomplishing the goals (i.e., tasks of therapy). The interdependence of the therapeutic alliance* and the components of goals – tasks and bond – has been well documented in therapy (Bordin 1979). Without a strong therapeutic alliance*, clients and therapists may struggle establishing clear and attainable goals in session.

Application of Concept in Couple and Family Therapy Goals for treatment in couple and family therapy are phrased relationally and in a process form for

Contracting of Goals in Couple and Family Therapy

couple and family therapists (Sprenkle et al. 2009). The phrasing will also depend on their theory of therapy. For example, for couple therapy using Emotionally Focused Therapy a therapist may work with the couple to set the goal of changing the cycle of conflict between the partners. The cycle is then named based on the behavior of each partner (e.g., “pursuedistance”: “attack-attack,” etc.) and then specific goals about how to change the attachment strategies for connection will be set (e.g., soften the attacker; Johnson et al. 2013). Creating shared goals between members in the couple or family is a common factor to successful couple and family therapy (Sprenkle et al. 2009). By establishing common goals, participants create a shared sense of purpose in the therapeutic process. The shared sense of purpose can empower the family or couple for enacting necessary change in therapy but also when facing future problems. The therapist can help facilitate the creation of goals between discordant family members by highlighting potentially unseen shared goals. Additionally, different members of the client system may have individual goals they pursue based on their understanding of the problem.

Clinical Example Jennifer entered therapy with her 13-year-old daughter, Jessica, because of truancy issues. As the Structural Family therapist conducted the assessment interview, she used circular questioning to map the hierarchy and organization of the family relationships. During the conversation the therapist noticed that Jennifer and Jessica were describing a peer-like relationship where Jennifer felt like she had little parenting authority to respond to the truancy issues because of how Jessica’s father (Jennifer’s ex-husband) allowed Jessica to “have no rules” at his home and because Jennifer feared losing her daughter to her father. The therapist and family discussed a goal of allowing Jessica to “be a kid” again. Both agreed this would be a relief for Jessica who frequently carried

Control in Couples and Families

messages between her parents, saying she felt like “their secretary” and would sometimes feel like she was getting in trouble for simply delivering a message. This goal also included increasing Jennifer’s parental communication with her ex-husband and removing Jessica from the middle of her on-going parents’ conflict. The third goal required Jennifer to seek the advice and support of her friends and family instead of relying on Jessica for emotional and social support. These goals, though not directly aimed at the truancy, did address what Jessica said was her biggest stressor – feeling like her parents’ “secretary” – and she was motivated to change this aspect of the family relationships. Increasing hierarchal structure in the family allowed Jennifer to become an authority figure in the home again; Jessica maintained the position of the “kid” in the family and returned to school on a regular basis.

Cross-References ▶ Bonds in Couple and Family Therapy ▶ Goal Setting in Couple and Family Therapy ▶ Goals in Couple and Family Therapy ▶ Tasks in Couple and Family Therapy ▶ Therapeutic Alliance in Couple and Family Therapy

References Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16(3), 252. Escudero, V., Friedlander, M. L., Varela, N., & Abascal, A. (2008). Observing the therapeutic alliance in family therapy: Associations with participants’ perceptions and therapeutic outcomes. Journal of Family Therapy, 30(2), 194–214. Johnson, S. M., Bradley, B., Furrow, J. L., Lee, A., Palmer, G., Tilley, D., & Woolley, S. (2013). Becoming an emotionally focused couple therapist: The workbook. Taylor & Francis. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press.

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Control in Couples and Families Erin Ferenchick and David Rosenthal Columbia University, New York, NY, USA

Name of Concept Control in couple and family therapy.

Introduction A therapist who is in control comfortably guides the couple or family through the therapeutic process. Interruptions, couples arguing, and other behaviors that might illustrate the nature of their relationship can at times seem disruptive. An emphasis on control is an integral part of many different models of therapy. In strategic family therapy, in particular, the therapist identifies with the family issues that need to be worked on or behaviors that they are interested in changing and designs a strategy for each problem, taking responsibility for what happens during therapy. Other models of couple or family therapy may employ different approaches to gain control during the session. Irrespective of the theoretical position, however, evidence suggests that replicating what goes on in the home or simply allowing a couple to vent during the session is not therapeutic (Bushman 2002).

Theoretical Context for Concept Control of the therapeutic process in couple and family therapy differs in its application within the different theoretical models, including strategic, structural, multigenerational, and integrative behavioral. The concept of control, however, is commonly associated with strategic family therapy. This theory emerged in tandem with, and out of, other theories, most importantly structural family therapy in the late 1960s and early 1970s (Haley 1971).

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Jay Haley and Cloé Madanes were the main proponents and creators of the theory of strategic family therapy. Their theory supported exploring how families work on a structural level, but also expanded this thinking by arguing that the therapist should take more initiative and control over the therapeutic process (Haley 1976; Madanes 1981).

Description The therapist is ultimately responsible for controlling the process of therapy. Control is emphasized not to be pushy or manipulative but to render a problem solvable.

Application of Concept in Couple and Family Therapy The theory of strategic family therapy dictates that the therapist controls the session and takes a more active role in changing the behavior of the family. The therapist examines family processes and functions, such as communication or problemsolving patterns, and identifies solvable problems, sets goals, designs interventions to achieve these goals, and examines the responses and outcomes of the therapy (Haley 1976; Madanes 1984). Therapeutic change is enacted when the therapist actively intervenes through tasks and directives and attempts to substitute new behaviors for dysfunctional ones. The therapist focuses on changing problem behavior rather than generating insight. By comparison, using a structural approach, the therapist may decide to raise intensity by unbalancing the couple or family system but still remain in control of the session by guiding the couple or family through that intensity to a new way of relating. A multigenerational couples therapist, on the other hand, might use a genogram to reduce intensity and illustrate previous patterns that might be impacting the relationships, while an integrative behavioral approach might use assignments and other behavioral strategies to structure the sessions.

Control in Couples and Families

Clinical Example As the family or couple demonstrates their home behaviors during a session, the therapist will respond in ways that are consistent with his or her approach to therapy. For example, Karen is 15 years old and has been arguing with her parents about what time she needs to be home in the evening. In addition, her school grades have been poor, and there are reports that she is using drugs. During the family therapy session, Karen deflects attention from her parents by “acting out” and disrupting the therapy session. The therapist can choose to ask the parents to discuss how they want to respond and guide them to gain control of their adolescent. The therapist can also reframe the situation by discussing with Karen her difficulty in getting what she wants and learning how to best negotiate with her parents. During this situation, the therapist might even take some time to “teach” Karen how to negotiate. Similarly, in couple therapy, a husband and wife argue during the session illustrating the intensity of their relationship. As they are seemingly out of “control,” some therapists might become immobilized by the intensity and sit quietly while others might try and “take over” reducing the intensity for the moment but not really using the argument as a teachable moment. By observing the husband and wife interact, the therapist is often in a better position to determine how best to intervene. However, it also important that the situation not escalate such that the couple becomes abusive during the session or the session ends without reaching some type of closure or agreement that there will be no violence at home. In situations where couples have a history of violence, it might be appropriate for the therapist to see each person alone so he or she can determine safety before having sessions together.

Cross-References ▶ Strategic Family Therapy ▶ Structural Family Therapy ▶ Unbalancing

Controlling Sessions in Couple and Family Therapy

References Bushman, B. J. (2002). Does venting anger feed or extinguish the flame? Catharsis, rumination, distraction, anger and aggressive responding. Personality and Social Psychology Bulletin, 28, 724–731. Haley, J. (1971). Changing families. New York: Grune & Stratton, Inc.. Haley, J. (1976). Problem-solving therapy: [new strategies for effective family therapy]. San Francisco: Jossey-Bass. Madanes, C. (1981). Strategic family therapy. San Francisco: Jossey-Bass. Madanes, C. (1984). Behind the one-way mirror: Advances in the practice of strategic therapy. San Francisco: Jossey-Bass.

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are: (1) viewing conflict in relational terms, (2) broadening the system of treatment, (3) interrupting problematic relational patterns, and (4) widening the scope of the therapeutic alliance (Sprenkle et al. 2009). Emphasis remains on the fundamental concept of building the therapeutic alliance and fostering trust among the therapist and clients. Consideration must be placed on the multiple alliances for therapists working with couples and families in order to effectively guide the therapeutic process.

Description

Controlling Sessions in Couple and Family Therapy Agnes Jos1 and Jessica L. Chou2 1 Community Treatment, Inc. (COMTREA), Comprehensive Health Center, St. Louis, MO, USA 2 Queen of Peace Center, St. Louis, MO, USA

Introduction Control refers to guiding the therapeutic process as opposed to the control of individuals, couples, or families (Leader 1983). The therapeutic process can include the structure of therapy, continuous assessment, and collaborative goals. Control begins at initial contact and continues through termination.

Safety is a key component. Guidelines are established to ensure constructive interaction among a couple or family. The therapist is charged with intervening when guidelines are violated and reminds those present of the agreed parameters. Guidelines can be written and therefore referenced easily in instances where counterproductive behaviors need redirection (Gurman 2008). A competent therapist has an understanding of how much structure is needed for clients whose behaviors threaten this safety as well as when less structure is needed for those with more effective communication patterns (Sprenkle et al. 2009). Cultural context helps therapists understand what maintains problems and what types of interventions to employ; this occurs through conversation as well as the therapist’s own observations (Gurman 2008). During this process, the therapist must maintain a balance of not siding with any one person in the couple or family.

Theoretical Context for Concept

Application of Concept in Couple and Family Therapy

Methods for guiding the therapeutic process extend across multiple theoretical formulations and can be contextualized using the common factors approach. The common factors approach posits that change in couple and family therapy can occur via certain variables despite theoretical orientation (Sprenkle et al. 2009). Four elements that are distinctive in couple and family therapy that must be considered when controlling sessions

Controlling sessions hinges on the therapist’s ability to collaborate and be transparent with clients. Reappraisal of goals and on-going negotiation of the therapeutic process ensures the therapist and clients are moving in the direction to reach desired goals. When met with high resistance during various stages of couple and family therapy, a therapist should decrease directives (Sprenkle et al. 2009) and utilize transparency to reassess

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when a change of course is needed that is agreed upon by the therapist and clients. In addition, the therapist can review the agreed upon guidelines when one or more person begins to fall back on behaviors or interactional patterns that have been counterproductive. While the therapist acknowledges the hierarchies that exist in families, they are not looking to level the playing field by eliminating the role of a dominant family member but rather ensure that the established hierarchies are not perpetuating the “problem” or negative interaction patterns.

The therapist invested in learning about cultural influences for Mark and Sienna to understand how those influences might impact their interactions with each other and with the therapist. Over time, the core mechanisms of safety, trust, transparency, and competency all contributed to a strong therapeutic alliance that allowed for the therapist to collaboratively control the sessions in order for Mark and Sienna to improve their interaction cycle and strengthen their relationship.

Cross-References Clinical Example Sienna and Mark entered couple’s therapy for frequent arguments over finances and parenting styles. The couple had been together for 5 years with one daughter, 2, and had a negative pattern of communication in which Sienna would become upset and argumentative with Mark, who would then proceed to walk away or dismiss her concerns. While the couple was working through their dysfunctional pattern of communication, Mark would “shut down” and provide minimal responses to his partner and the therapist; at times of high frustration he would not communicate verbally. The therapist’s attempts to reduce combative communication from Sienna while engaging Mark often ended in Mark becoming disengaged in the session. Ultimately, this would dominate the session. The therapist worked collaboratively with Sienna and Mark to build a therapeutic relationship with the couple in order to bring balance and control back to the therapeutic process. During this process, the therapist was able to build trust and revisit the negative interaction that Mark and Sienna had outside of therapy and the manifestation of that cycle in therapy. Transparency was utilized as the therapist perceived resistance when either partner would resort to old communication patterns between each other or the therapist. This allowed for the therapist and clients to have an open and honest conversation about the dynamics present in the therapeutic process and to ensure everyone was moving towards the same goals.

▶ Control in Couples and Families ▶ Power in Family Systems Theory ▶ Resistance in Couple and Family Therapy

References Gurman, A. S. (2008). A framework for the comparative study of couple therapy: History, models, and applications. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed., pp. 1–26). New York: Guilford Press. Leader, A. (1983). Therapeutic control in family therapy. Human Sciences Press, 11(4), 315–361. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press.

Conversation and Discourse Analysis in Couple and Family Therapy Eleftheria Tseliou Laboratory of Psychology, Department of Early Childhood Education, University of Thessaly, Volos, Greece

Introduction Conversation Analysis (CA) and Discourse Analysis (DA) are two qualitative research methodologies argued as a promising choice for systemic

Conversation and Discourse Analysis in Couple and Family Therapy

couple and family therapy research. CA and DA share the emphasis on language, context, and interpersonal communication for the understanding of human interaction and psychological phenomena that systemic pragmatic and constructionist approaches endorse. They are also part of the hermeneutic/qualitative research methodology tradition, which has incorporated the call for methods attentive to participants’ own understanding of the phenomena under study. This tradition has also attended to the constructionist emphasis on discursive interaction as the locus for the construction of any phenomenon (Wooffitt 2005). Such epistemological proposals have led to the development of naturalistic, observational, and language-based approaches in psychotherapy research. In couple and family therapy research, there have been calls for research methodologies which can attend to the epistemological and theoretical particularities of the field, like the emphasis on recursiveness and interactional patterns. Accordingly, for the last few decades, a growing number of couple and family therapy studies have deployed CA and DA mostly for therapy process research (Tseliou 2013). However, their use still remains marginal, whereas the fragmented and methodologically flawed picture of their deployment necessitates a more thorough and indepth exploration of their potential for couple and family therapy research.

Definition and Historical Evolution CA and DA are part of the hermeneutic/qualitative research tradition which started flourishing in the humanities and social sciences in the 1960s. The variety of qualitative research methods reflects variant choices of epistemological perspectives, i.e., perspectives about the “how” in the quest of knowledge and the relationship between the subject (observer/researcher) with the object (of knowledge). These extend from realist ones adhering to the reality of an objective world existing “out there,” to relativist, constructivist/constructionist proposals. The latter acknowledge the interdependency between the observer and the observed and the

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central role of language for the constitution of every phenomenon, thus approaching knowledge as a historically and sociopolitically situated construction. This turn to discursive, intersubjective practices and the acknowledgement of the importance of understanding them from an insider’s/in situ perspective, links with the development of language-based research methodologies, like CA and DA (Wooffitt 2005).

Conversation Analysis CA was developed in sociology by Harvey Sacks and his associates in the 1960s and 1970s (see Schegloff 2007 for an overview). It incorporated basic premises of the ethnomethodological tradition, like the emphasis on adopting an endogenic, i.e., participants’ own, perspective for the understanding of the social world. CA constitutes a rigorous methodological approach, suitable for the study of naturally occurring, every day or institutional, talk-ininteraction. It offers systematic and sophisticated ways for the detailed, microanalysis of conversations, utterance by utterance, which exemplify the interdependence between them, in the sense that each utterance is shown as dependent upon the previous one and as constitutive of the next one. A basic CA premise is that talk is indexical, i.e., depends upon context and has a reflexive quality, in the sense that it entails markers which indicate how each speaker has interpreted the other’s utterances. CA also adheres to the idea that talk exhibits ordinariness and structure in that there are normative rules for the organization of conversation, which can be identified via analysis. When such rules are breached, then speakers become socially accountable, like when one rejects an invitation by his/her coconversant (Wooffitt 2005). CA allows for the capturing of how the social world is coconstructed by people in conversation. Some of its basic notions are “turn-taking” which denotes the taking of turns by speakers as they alternate between the role of the speaker and the role of the listener, “adjacency-pair” which denotes how utterances are organized in

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interdependent pairs, where when the first part is uttered the second is expected (e.g., questionanswer) and the notion of “preference structure” which denotes that there are socially or normatively preferred responses (e.g., acceptance of an invitation instead of rejection) (Schegloff 2007). CA is an ideal choice for the pursuing of research questions which aim at investigating conversational structures and/or the ways in which social actions are conversationally coconstructed. Further to the extensive body of CA empirical research which has contributed to our knowledge of conversational structures in many settings, CA has also been deployed in psychotherapy research. There is a growing body of CA studies which have investigated various aspects of the therapeutic conversation across models, like the use of formulations by the therapist, i.e., of statements where the therapist offers a version of his/her understanding of client’s previous utterance (Peräkylä et al. 2008).

Discourse Analysis DA is a term denoting a variety of approaches for the study of written or spoken discourse which have an interdisciplinary flavor as they include proposals from linguistics, psychology, education, sociology, etc. (Wooffitt 2005). Most approaches share social constructionist premises in that they acknowledge that language constructs phenomena whereas shapes and is shaped by sociopolitical and historical conditions (Tseliou 2013). In psychology, DA approaches were developed in the 1980s by social psychologists like Jonathan Potter, Margaret Wetherell, Derek Edwards, Michael Billig, and Ian Parker. DA approaches which have been inspired by poststructural thinking (see Parker 2015), like Foucault’s theorizing, emphasize the constitutive and restraining aspects of language. DA approaches, like Discursive Psychology (DPSy) (Potter 2012), which have incorporated the ethnomethodological flair of CA, mostly focus on how people use language to achieve interpersonal aims.

Poststructural DA, like Foucauldian Discourse Analysis (FDA), usually entails a macroanalytic approach, in that it aims at identifying wider sets of historically and discursively constituted meanings/constructs, i.e., Discourses, which are considered as constitutive of subjectivities. It further identifies how dominant institutional and political contexts shape language use and thus our lives. Thus, texts are analyzed with the aim to bring to the fore these subjugating aspects of language. Michael White’s narrative approach is similarly endorsing a poststructuralist perspective by highlighting the oppressing aspects of discourse in respect of psychological distress. DPsy has gone through different phases of development, including Critical DPsy which has incorporated Billig’s theorizing on ideological dilemmas and a recent, more CA affiliated, perspective (see Potter 2012 for an overview). It has contributed a discursive, interactional approach to psychological phenomena like memory, cognition, attributions etc., evidently departing from mainstream psychological theories. For DPsy, language use reveals how speakers construct social actions and attend to interpersonal aims. In that sense, it shares basic premises of pragmatic approaches, like Austin’s or Wittgenstein’s which have equally inspired systemic, communication approaches (Tseliou 2013). DPsy also entails a strong, rhetorical aspect in that it adheres to the idea that we engage into argumentative “language games” trying to construct our version of the world as the “real” one and not a subjective, biased one. DPsy also adheres to the ethnomethodological notion of social accountability, according to which we are held accountable for our talk, concerning both our choices to make certain reports but also their content. DPsy analysis includes a micro, detailed emphasis on both the content but also the structure of discourse which heavily leans on CA methodological contributions. Like CA, DA and DPsy have been deployed for psychotherapy research, illuminating of our understanding of the therapeutic dialogue details but also of the institutional aspects of the psychotherapeutic establishment. Due to

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their potential for both a micro- and a macroanalytic perspective, CA and DA are suitable for the pursuing of research questions aimed to investigate how therapeutic interventions or the therapy process overall get constructed in the minute-by-minute interaction between therapist(s) and family members. They are also a good choice for the pursuing of research questions, which aim at addressing the political and institutional aspects of psychotherapeutic discourse. As concerns quality criteria, CA/DA research adheres to the criteria defined for constructionist, qualitative research which include analytic coherence, the analysis of deviant cases, the grounding of analysis on participants’ orientation, the evaluation of readers on the basis of the provision of transcripts alongside with analysis, etc. (see Potter 2012 for a discussion).

Couple and Family Therapy Research There is a variety of models and approaches clustered under the term “couple and family therapy,” most of which are affiliated with the systemic paradigm in psychotherapy. Systemic couple and family therapy is a constantly evolving field with various proposals for the relief of psychological distress. Like in research methodology, the field has incorporated the constructionist turn to language which gave rise to discursive approaches like the collaborative, the dialogic, etc. The field’s evolution has witnessed a number of tensions, including fervent debates evolving around the most “appropriate” choice of research methodologies for couple and family therapy research. These have culminated in often unfruitful quantitative versus qualitative debates as well as strict divides between process and outcome research. Recently pluralism has been forwarded and more inclusive proposals have argued for a both/and perspective like in the case of suggestions for the study of process as small outcomes or change-process research. In parallel, the need for observational methods attentive to the complexity of the multiactor dialogue in the family therapy setting has been stated emphatically.

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Conversation Analysis, Discourse Analysis, and Couple and Family Therapy Research Couple and family therapy process research has deployed a variety of quantitative but also qualitative research methodologies including languaged-based approaches. In this context, a growing body of CA and DA research of couple and family therapy (see Tseliou 2013 for an overview) has evolved in the context of recent developments in discursive research methodologies (e.g., Borcsa and Rober 2016; Tseliou and Borcsa in press). These studies have explored significant issues like problem talk in initial family therapy sessions in respect of blame allocation/attribution of responsibility for the reported problem(s), collaboration and or alliance, certain therapeutic techniques or notions like circular questioning or neutrality, shifts in agency or subjectivity concerning the identified patient, etc. However, existing CA and DA research of couple and family therapy is fragmented as there seems to be no systematic pursuing of the study of notions which could lead to consistent theory building. Furthermore, it seems to suffer from methodological shortcomings like inconsistencies between the pursued research question(s) and the research design (Tseliou 2013). Also, most of the studies usually lean on the analysis of a very limited sample of data due to the methods’ laborious “nature.” In that sense, CA and DA research of couple and family therapy is still “work in progress.” Nevertheless, the existing examples are revealing of CA and DA potential. These methodologies can facilitate analysis of the therapeutic dialogue in ways attentive to the recursiveness of therapist/couple and family members’ interaction. Furthermore, they can illuminate us – in a very systemic way – on how therapeutic interventions are implemented in the context of therapist and client joint dialogue. In that sense, they can become valuable tools for the development of therapist reflexivity as they can highlight minute by minute the ways in which therapist interventions are delivered and responded by family members (Tseliou 2013). Additionally, they can alert us to the ways in which the institutional

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aspects of couple/family therapy get downplayed in the “here and now” of therapist / family members’ interaction.

Examples of CA, DPsy, and FDA of Couple and Family Therapy The following studies constitute three indicative examples of the deployment of CA, DPsy, and FDA for the study of couple and family therapy. Muntigl and Horvath (2016) aiming to study therapist-family members’ alliance, used CA to analyze the first 5 min of a transcribed, videotaped session of family therapy, conducted by Salvador Minuchin for training purposes. Their analysis highlights in detail the conversational practices by means of which the therapist repairs a rupture in alliance with family members. It also indicates how structural family therapy techniques like joining or accommodating are conversationally constructed and serve to the establishment of positive alliance. Patrika and Tseliou (2016) explored problem talk in nine, initial, Milan – systemic family therapy sessions. Their DPsy analysis exemplified how therapist attempts for relational problem definitions by means of circular questioning or the final teammessage intervention seem entangled within blame sequences, as family members seem to decode such therapist discursive moves as instilling blame on them for the reported problem(s). Sutherland et al. (2016) used FDA to analyze transcripts of three videotaped, systemic/constructionist couple therapy sessions conducted at a family therapy training center by therapy trainees. Their aim was to investigate heterosexual couple partners’ discursive interactions for traces of the ideology of sexism. Their analysis provides exemplars of the operation of gender inequality discourses in participants’ talk, seemingly reproducing gender inequality in partners’ positioning.

Cross-References ▶ Foucault, Michel ▶ Postmodernism in Couple and Family Therapy ▶ Process Research in Couple and Family Therapy

▶ Qualitative Research in Couple and Family Therapy ▶ Research About Couple and Family Therapy ▶ Research in Relational Science ▶ Social construction and Therapeutic Practices ▶ Social Constructionism in Couple and Family Therapy ▶ White, Michael

References Borcsa, M., & Rober, P. (Eds.). (2016). Research perspectives in couple therapy: Discursive qualitative methods. Cham: Springer International. Muntigl, P., & Horvath, A. O. (2016). A conversation analytic study of building and repairing the alliance in family therapy. Journal of Family Therapy, 38, 102–119. https://doi.org/10.1111/14676427.12109. Parker, I. (Ed.). (2015). Critical discursive psychology (2nd ed.). London: Palgrave Macmillan. Patrika, P., & Tseliou, E. (2016). Blame, responsibility and systemic neutrality: A discourse analysis methodology to the study of family therapy problem talk. Journal of Family Therapy, 38(4), 467–490. https://doi.org/ 10.1111/1467-6427.12076. Peräkylä, A., Antaki, C., Vehviläinen, S., & Leudar, I. (Eds.). (2008). Conversation analysis and psychotherapy. Cambridge: Cambridge University Press. Potter, J. (2012). Discourse analysis and discursive psychology. In H. Cooper (Ed-in-Chief), APA handbook of research methods in psychology, (Research Designs, Vol. 2, pp. 119–138). Washington, DC: American Psychological Association. https://doi.org/10.1037/13620008. Schegloff, E. (2007). Sequence organization in interaction. A primer in conversation analysis I. Cambridge: Cambridge University Press. Sutherland, O., Lamarre, A., Rice, C., Hardt, L., & Jeffrey, N. (2016). Gendered patterns of interaction: A Foucauldian discourse analysis of couple therapy. Contemporary Family Therapy, 38, 385–399. https:// doi.org/10.1007/s10591-016-9304-6. Tseliou, E. (2013). A critical methodological review of discourse and conversation analysis studies of family therapy. Family Process, 52(4), 653–672. https://doi. org/10.1111/famp.12043. Tseliou, E., & Borcsa, M. (in press). Discursive methodologies for couple and family therapy research: Editorial to special section. Journal of Marital and Family Therapy. Wooffitt, R. (2005). Conversation analysis and discourse analysis: A comparative and critical introduction. London: Sage.

Co-parenting in Couple and Family Therapy

Co-parenting in Couple and Family Therapy Matthew D. Selekman Partners for Collaborative Solutions, Evanston, IL, USA

Introduction Family therapy pioneers, researchers, and parenting experts alike have found that when there is consistent parental teamwork and unity with providing nurturance to and consistent limits for their children when they misbehave, their kids are more likely to thrive and function well in all areas of their lives (McHale and Lindahl 2011; Minuchin and Fishman 1981; Haley 1976; Minuchin 1974; Satir 1983; Sax 2016; Taffel 2009; DeFrain 2007; Omer 2004). This parenting style described above is well researched and known as authoritative parenting (Baumrind 1966; Larzelere et al. 2013). Additionally, the stronger the parents’ bonds are with their kids, the better they will be able to cope with life’s challenges; selfregulate their moods; are more self-motivated and self-confident; have more self-control; tend to be more resilient; less likely to develop anxiety and depressive symptoms or engage in self-destructive, aggressive, and delinquent behaviors; or join negative peer groups (Selekman 2010, 2017; Selekman and Beyebach 2013; Diamond et al. 2014; Kang 2014; Alexander et al. 2013; Szapocznik et al. 2012; Liddle 2010; Henggeler and Sheidow 2011; Taffel 2009; Seligman et al. 1995). When parents seek couple and family therapy around parenting issues, there often is a lack of parental teamwork and unity due to the following couple dynamics: 1. One parent is too permissive and the other parent tries to be ultra-strict; 2. One parent is overly responsible and protective, while the other parent is peripheral and too emotionally disconnected from their partner and the kids; 3. One parent may have serious mental health, substance abuse, or physical health problems,

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and the other parent feels frustrated, burned out, and all alone managing the majority of the parenting responsibilities; 4. Intense unresolved marital conflicts or irreconcilable differences and the parents being separated or divorced 5. Are having grave difficulty working together as a co-parenting team. Over time, the aforementioned problemmaintaining couple role behaviors described above can fuel vicious cycles of destructive blame-counter-blame interactions between the partners, and one or both partners possibly recruiting their most loyal child, adult sibling, their own parent, or extended family member to join them in a coalition against the other partner. When this couple dynamic occurs, it is not uncommon for one or more of the parents’ children to become the symptomatic family member (s) that brings them to a therapist’s office.

Description Co-parenting in couple and family therapy involves the therapist assessing with the parents the level and quality of their parental teamwork and unity and assisting them with further honing their parenting skills and becoming even more unified as a team in helping them to resolve their symptomatic child’s or children’s behavioral problems. If they contract to work on parenting difficulties, it is most beneficial to first invite the couple to identify any pre-counseling changes they have already made that can be amplified and consolidated; find out what their key individual, couple parenting, family strengths are that can be utilized in problem areas; and explore with them what their past successes as a parental team have been. Any past successful couple-generated problem-solving strategies at resolving past difficulties with their children can be used as blueprints for future success in resolving current difficulties that may be occurring with them. As they become more unified as a parental team and increase their successes with their kids, we want to encourage them to do more of what works.

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Major Couple and Family Change Strategies With some parents rigidly entrenched in longstanding negative interactions with one another, have little or no teamwork, and have grave difficulty identifying any past or present successes or entertaining the possibility of future success as a team, there are three highly effective therapeutic options that can be pursued. They are: 1. Separate the couple partners and establish separate goals and work projects geared toward changing their negative interactions with one another and how they interact with the symptomatic child. The use of the do-something-different experiment or other pattern intervention strategies (De Shazer et al. 2007; Selekman and Beyebach 2013; Selekman 2009, 2010, 2017; Cade and Hudson-O’Hanlon, 1993) is a very effective therapeutic option. The do-somethingdifferent experiment involves having one or both partners respond in surprising and novel ways when triggered by their other partner that he or she has never experienced from him or her before. The experimenting partner(s) are to keep track of what works in disarming or altering the other partner’s negative behaviors. These strategies are particularly helpful with high-conflict couples where conjoint work early in treatment proves to be counterproductive. Once the emotional climate becomes more relaxed and the intensity of the couple conflicts have greatly decreased, we can bring the partners back together and establish a mutual treatment goal. 2. If on a random basis the partners work together or one parent is stuck in the dominant disciplinarian role while the other parent is too underinvolved or laissez-faire, the couple can be given an intervention that has a random component to it, such as: flipping a coin daily and the heads partner is completely in charge of all of the disciplining for that day or on odd days of the week, one partner handles all of the disciplining, and on the even days the other partner takes over this responsibility. With both of these interventions, the day off parent

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is instructed to play detective using his or her imaginary magnifying glass to carefully observe for the times when the other parent is engaging in specific parenting responsibilities that he or she thinks were well managed, creative, and produced positive outcomes with the children, write them down and bring his or her list to the next session. This information can be exchanged and discussed in the next couple or family session to determine together what works and needs to be increased. In many cases well before the next scheduled appointment, the observing parent will have already spontaneously either complimented the other parent at least once or on multiple occasions or even joined in and supported him or her in disciplining one of the children who was testing their limits or acting out. 3. Another therapeutic option that can be pursued with couples that have a long history of being oppressed by specific intergenerational parenting practices and rigid patterns of interactions with each other and their children is to externalize the parenting practice or pattern (Selekman 2017; White 2007). When parents report in our sessions finding themselves falling prey to these practices or patterns and the ways they have been wreaking havoc in their relationships with one another and inadvertently fueling more acting out behaviors from their children, we can ask them the following questions: • “Tell me, when you were growing up, did ‘yelling’ get the best of you and your relationship with your parents?” • “What effect did ‘yelling’ have on you – your thoughts and feelings towards your parents?” • “After ‘yelling’ did its dirty work, did you find yourself being more or less cooperative with your parents’ wishes?” • “In what ways has ‘yelling’ infiltrated and tried to tear apart your relationship with Cindy (daughter)?” • “Has there been any times lately where you could sense ‘yelling’ was tempted to push you and Cindy around but you thwarted it instead?”

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• “What specifically did you do to frustrate it and not cave into its wishes to make you lock horns with Cindy?” • “What did you tell yourself to pull that off?” • “Are there other helpful things you tell yourself or do to outsmart ‘yelling’ at times?” Once parents are onboard with viewing the parenting practice or pattern as the real culprit behind their difficulties, it helps foster more positive interactions and teamwork in both their relationship and their relationships with their kids. To help ensure that the oppressive parenting practice or pattern is conquered for good, we can have them implement a habit control ritual to help foster more teamwork and changes in their family relationships (Selekman 2010, 2017; Selekman and Beyebach 2013; Durrant and Coles 1991). I have the couple or family come up with both a team name for them and a name for the oppressive parenting practice or pattern. As a team, they are to keep track daily of the various things they do to stand up to and achieve victories over the oppressive parenting practice or pattern. They are also to keep track of the parenting practice or pattern’s victories over them. This information can be recorded daily on a chart. Nightly after dinner, they are to get together to discuss how well they are working together as a team and how to further minimize the likelihood of surprise attacks by the sneaky parenting practice or the pattern. We can have them train together through some form of cardio exercise and/or weightlifting in order to have the endurance and physical strength to conquer the longstanding parenting practice or pattern for good.

Relevant Research The research literature on co-parenting is quite extensive. For the sake of brevity, this discussion is limited to ways to enhance co-parenting teamwork and create a positive and nurturing climate ripe for healthy child development in multiple family environments. One of the first pioneering co-parenting researchers was Diana Baumrind

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(1966). In her research, she identified three parenting prototypes or styles of adult control, they are: permissive, authoritarian, and authoritative. Permissive parents tend to adopt a hands-off parenting style where there is a lack of consistent limit setting, or if it is minimal, there is a lack of concern about their children’s impulse control, affective expression, little concern about their children’s poor decision-making and the consequences of their actions, and a strong belief that children should be independent and free of restraint. On the opposite end of the parenting continuum are authoritarian parents. They tend to be very controlling, may squelch their children’s desires for more autonomy, uphold rigid rules and standards, and may dish out harsh, lengthy, and extreme consequences for misbehavior. According to Baumrind (1966), the most ideal style of parenting is authoritative, which combines the best elements of permissive and authoritarian parenting. Authoritative parents work well together as a team in consistently providing a nurturing and positive family environment but, when necessary, set immediate limits and enforce their consequences when their children misbehave. In studying a wide range of families from different cultural and socioeconomic backgrounds, DeFrain (2007) has identified six characteristics of strong families: appreciation and affection for each other, commitment to each other, positive communication, successful management of stress and crisis, enjoyable time together, and spiritual well-being. He and his colleagues developed questionnaires to administer to each family member to gain access to their unique perspectives on the level and quality of how much or little each of these six characteristics exist in their families. This information can prove invaluable to family therapists in that we can learn what their key family strengths are, examples of the use of these strengths in action, and past family or parental successes at problem-solving that can be tapped for resolving their current presenting difficulties. Finally, there may be one or more of these family strengths families may wish to further cultivate or hone that can be incorporated into their treatment plan.

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When it comes to parents in the divorcing process or in the postdivorce transitional phase with their children, family research has indicated that parental conflict can have a deleterious effect on their children’s development and adjustment to the divorce (Pruett and Donsky 2011; Pruett and Pruett 2009; Marquadt 2006; Wallerstein 2004; Isaacs et al. 2000). According to Pruett and Donsky (2011), the co-parenting mantra we need to encourage divorcing and divorced parents to adopt is: “It is all about the kids.” As therapists we have to help parents put aside their past conflicts and issues with one another and strive to support one another’s parenting actions and decisions, make and stick to agreements about how to raise their children, and to the best of their abilities refrain from undermining each other by deviating from these agreements on their own without any warning or discussion.

Special Considerations for Couple and Family Therapy There are two major and common clinical situations that can lead to a breakdown in couple unity and teamwork, they are: parents entering the divorce process with high conflict and/or postdivorce lack of cooperation and parental remarriage and stepfamily adjustment difficulties. Below, I discuss each of these clinical challenges and propose therapeutic strategies for addressing these treatment dilemmas. Parents Entering the Divorce Process with High Conflict and/or Postdivorce Lack of Cooperation When parents either enter the divorce process with high conflict or have already divorced, due to their intense rage and bitterness toward one another, it may prove to be futile to see them together initially. With these clinical situations, it is much more practical to meet with each partner alone, establish separate parenting goals and work projects, and listen carefully for any common ground where there is parental agreement involving their kids’ needs and the management of their

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most challenging behaviors, which can be revisited in a future conjoint parenting session once their anger and conflict levels have greatly decreased. Additionally, the therapist can see each parent separately with the kids to address the latter’s adjustment to the divorce situation and any other day-to-day difficulties they may be experiencing in their relationships with one another or at school (Isaacs et al. 2000). It is important to remind the parents that in order to help their kids in the best way possible to adjust to the divorce process, they need to refrain from bad-mouthing the other parent or recruiting one or more of the kids to take their side against the other parent and treat each other as civilly as possible when they are together in the kids’ company. Wallerstein (2004) observed from her longitudinal research that children adjust well to parental divorce when the parents are civil and respectful toward one another in their company and when they work together as a parenting team, which fosters in the children a strong sense of security, resilience, and higher self-esteem. Once the parents are in a much better emotional place to work together, we can resume conjoint parenting and/or family therapy sessions and address common concerns and other difficulties they may be experiencing with their kids. In some cases, in spite of conducting separate parent and parent-children subsystem sessions, one or more of the children are still experiencing emotional or behavioral difficulties. When this is the case, it can be most advantageous to coach one or both of the parents to abandon their unproductive ways of interacting with the other parent or the children and experiment with the do-something-different change strategy described earlier in this chapter (De Shazer et al. 2007; Selekman 2017). Another challenge that the custodial parent may experience with their kids following a visit with the noncustodial parent is that they come back home agitated or act up. We need to help the custodial parent come up with a few different rituals or activities to engage the children in for easing the transition of their return back home. Finally, in spite of our Herculean efforts to help the divorcing or

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divorced parents work together around the kids and we are unsuccessful, we need to make ourselves available to each parent, provide support, and continue to try separate parent-children subsystem sessions to help each parent and the children better cope and adjust to this challenging family life cycle transition.

lead to a child or children developing symptoms or behavioral difficulties. This will need to be addressed in family therapy.

Parental Remarriage and Stepfamily Adjustment Difficulties When parents divorce and remarry, this can present a whole host of challenges to their newly formed relational bond and test the stability of their relationships with their own biological children and their ability or difficulty with establishing new bonds with their new partner’s children. As a new reconstituted family, what is most critical is the need for the parents to continue to strengthen their relational bond and be very clear with one another about who will have what parenting responsibilities, what the household rules and consequences are going to be for the children, and to be able to work together as a team in enforcing them. Until each parent cultivates stronger relational bonds with their partner’s children, it is important for the partners initially to take the lead in disciplining their own biological children. When stepparents too prematurely become disciplinarians with their partner’s children without having cultivated more solid relationships with them, this can fuel resentment and disrespect toward the stepparents. Another common challenge for stepparents is to try and balance out their time and love for their own children while attempting to strengthen their bonds with their stepchildren. The parents also have to work together in helping both sets of children bond with one another. A final challenge remarried partners face is working together with their ex-partners and their new partners around parenting needs, rules, and expectations for the children. The more consistent both sets of parents are in their teamwork and with their communications, the more smoothly and better the children will adjust to their new reconstituted families. When both sets of parents are unable to work together and the two households operate in opposing ways, this may

Alexander, J. F., Waldron, H. B., Robbins, M. S., & Neeb, R. A. (2013). Functional family therapy for adolescent behavior problems. Washington, DC: American Psychological Association. Baumrind, D. (1966). Effects of authoritative parental control on child behavior. Child Development, 37(4), 887–907. Cade, B., & O’Hanlon, W. H. (1993). A brief guide to brief therapy. New York: Norton. DeFrain, J. (2007). Family treasures: Creating strong families. Lincoln: iUniverse. De Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E., & Berg, I. K. (2007). More than miracles: The state of the art of solution-focused brief therapy. Binghamton: The Haworth Press. Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014). Attachment-based family therapy for depressed adolescents. Washington, DC: American Psychological Association. Durrant, M., & Coles, D. (1991). The Michael White approach. In T. C. Todd & M. D. Selekman (Eds.), Family therapy approaches with adolescent substance abusers (pp. 135–175). Needham Heights: Allyn & Bacon. Haley, J. (1976). Problem solving therapy: New strategies for effective family therapy. San Francisco: JosseyBass. Henggeler, S. W., & Sheidow, A. I. (2011). Empirically supported family-based treatments for conduct disorder and delinquency in adolescents. Journal of Marital and Family Therapy, 38(1), 30–58. Isaacs, M. B., Montalvo, B., & Abelsohn, D. (2000). Therapy of the difficult divorce: Managing crises, reorienting warring couples, working with the children, and expediting court processes. Northvale: Jason Aronson. Kang, S. (2014). The self-motivated kid: How to raise happy, healthy children who know what they want and go for it without being told. New York: Jeremy P. Tarcher. Larzelere, R. E., Morris, A. S., & Harrist, A. W. (2013). Authoritative parenting : Synthesizing nurturance and discipline for optimal child development. Washington, DC: American Psychological Association. Liddle, H. A. (2010). Treating adolescent substance abuse using multidimensional family therapy. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 416–435). New York: Guilford Press.

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600 Marquadt, E. (2006). Between two worlds: The inner lives of children of divorce. New York: Crown Books. McHale, J. P., & Lindahl, K. M. (2011). Introduction: What is co-parenting? In J. P. McHale & K. M. Lindahl (Eds.), Co-parenting: A conceptual and clinical examination of family systems (pp. 3–12). Washington, DC: American Psychological Association. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University. Omer, H. (2004). Nonviolent resistance: A new approach to violent and self-destructive children. Cambridge, UK: Cambridge University Press. Pruett, M. K., & Donsky, T. (2011). Co-parenting after divorce: Paving pathways for parental cooperation, conflict resolution, and redefined family roles. In J. P. McHale & K. M. Lindahl (Eds.), Co-parenting: A conceptual and clinical examination of family systems (pp. 231–267). Washington, DC: American Psychological Association. Pruett, K., & Pruett, M. K. (2009). Partnership parenting: How men and women parent differently – Why it helps kids and can strengthen your marriage. Boston: DaCapo Books. Satir, V. (1983). Conjoint family therapy. Palo Alto: Science & Behavior Books. Sax, L. (2016). The collapse of parenting: How we hurt our kids when we treat them like grown-ups. New York: Basic Books. Selekman, M. D. (2017). Working with high-risk adolescents: An individualized family therapy approach. New York: Guilford Press. Selekman, M. D. (2010). Collaborative brief therapy with children. New York: Guilford Press. Selekman, M. D. (2009). The adolescent and young adult self-harming treatment manual: A collaborative strengths-based brief therapy approach. New York: Norton. Selekman, M. D., & Beyebach, M. (2013). Changing self-destructive habits: Pathways to solutions with couples and families. New York: Routledge. Seligman, M.E.P., Reivich, K., Jaycox, L., & Gilliam, J. (1995). The optimistic child: A revolutionary program that safeguards children against depression and builds lifelong resilience. Boston, MA: Houghton Mifflin. Szapocznik, J., Schwartz, S. J., Muir, J. A., & Brown, C. H. (2012). Brief strategic family Therapy: An intervention to reduce adolescent risk behavior. Couple and Family Psychology, 1(2), 134–145. Taffel, R. (2009). Childhood unbound: Saving our kids’ best selves—confident parenting in the world of change. New York: The Free Press. Wallerstein, J. S. (2004). What about the kids? Raising your children before, during, and after divorce. New York: Hachette Books. White, M. (2007). Maps of narrative practice. New York: Norton.

Coping-Oriented Couple Therapy

Coping-Oriented Couple Therapy Kevin K. H. Lau1, Chun Tao1, Ashley K. Randall1 and Guy Bodenmann2 1 Counseling and Counseling Psychology, Arizona State University, Tempe, AZ, USA 2 Department of Psychology, University of Zurich, Binzmuehlestrasse, Zurich, Switzerland

Introduction Coping-oriented couple therapy (COCT; Bodenmann 2004) is a treatment model that emphasizes the role of stress communication and mutual support in couples. COCT posits that experiences of chronic minor stressors (i.e., inconveniences occurring on a day-to-day basis that may irritate partners over time) often trigger unpleasant behaviors in partners, which can then give rise to relationship tension. Thus, the goal of COCT is to help partners better understand their individual and joint stress reactions and learn to cope with daily stressors more effectively, which can significantly improve their relationship functioning and overall well-being.

Prominent Associated Figures COCT was derived from Dr. Guy Bodenmann’s seminal work on couples’ stress and coping. Specifically, the systemic-transactional model of dyadic coping, which posits that romantic partners can engage in joint coping efforts to mitigate the deleterious effects of stress on their relationship (Bodenmann 1995, 2005), stimulated the creation of this treatment model.

Theoretical Framework The COCT approach has its foundation in behavioral and cognitive-behavioral couples therapies and thus aims to alter partners’ maladaptive behaviors and cognitive processes in their

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relationships. Moreover, it builds upon the classical cognitive-behavioral couples therapy (Baucom et al. 2008) to address the negative impact of stress on relationship functioning by facilitating romantic partners’ communication of stress (i.e., stress-related self-disclosure) and engagement in coping behaviors (i.e., dyadic coping). Specifically, this treatment model aims to train partners to recognize their unique reactions to stress and to enhance their stress communication and dyadic coping abilities. Practitioners adopting this model have three main roles: (1) to supervise and facilitate stress communication and support giving (e.g., establishing speaker and listener rules), (2) to guide both partners in exploration of their emotions and insecurities by asking open-ended questions (e.g., “How was this for you?”; Why did you feel sad?”; “What meaning does it have for you?”), and (3) to provide clear structure in regard to the time frame, setting, and speaker and listener roles (Bodenmann and Randall 2012). It is important for therapists to coach both partners simultaneously and to give each one equal attention. Core Concepts of Model Stress in intimate relationships. Stress is an excessively common experience that can result in relationship discord. Early work in the couples’ stress literature has focused on the impact of internal stress (i.e., stress that originates within the relationship, such as conflicts arising from a difference of opinion between partners) on relationship well-being. While internal stress plays an important role in close relationships, recent studies have found that external stress (i.e., stress that comes from outside of the relationship, such as work and everyday inconveniences; Randall and Bodenmann 2009, 2017) has a stronger negative association with relationship outcomes like communication quality between partners and relationship satisfaction (e.g., Bodenmann 2005; Falconier et al. 2015). For instance, when Partner A experiences a strenuous day at work, he/she may come home in an agitated mood. As Partner A carries his/her stress over into this relationship with his/her agitated mood, he/she may be more likely to initiate or become involved in an

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argument with his/her significant other (Partner B). As stress often triggers presentations of individuals’ negative personality traits (e.g., dominance, rigidity, intolerance, neuroticism; Randall and Bodenmann 2009), understanding how stress and personality traits affect relationship dynamics may allow couples to develop strategies in overcoming conflicts and emotional distance. Indeed, therapists adopting the COCT approach strive to enhance mutual understanding for seemingly dysfunctional stress reactions that often are experienced as bothering and frustrating by the partner. Dyadic coping. The process of dyadic coping originates when the partner experiencing the stress (Partner A) communicates the stress verbally or nonverbally to his/her significant other (Partner B). Partner B will then evaluate Partner A’s stress and respond with a range of actions, varying from offering positive support to negative responses. Positive dyadic coping entails providing support that could alleviate some of the partner’s stress, and there are three types: emotionfocused supportive dyadic coping (i.e., providing emotional support and empathic understanding), problem-focused supportive dyadic coping (i.e., giving practical advice and helping the partner to see situations in a new light), and delegated dyadic coping (i.e., taking on extra responsibilities to lessen the partner’s workload). On the other hand, negative dyadic coping refers to partners’ reactions to each other’s stress in hostile, ambivalent, or superficial ways. In addition, another form of dyadic coping – common dyadic coping – depicts partner’s joint coping efforts (e.g., searching for shared solutions together) in the face of stress that affects both partners directly, such as stress from children or financial burden. By engaging in positive dyadic coping, partners can improve the relationship in two ways: (1) by relieving the stress and (2) fostering intimacy and solidarity between the partners (i.e., we-ness). Notably, COCT places more emphasis on how partners can help each other cope with external stress. Such stress often affects one partner (Partner A) directly and the other partner (Partner B) indirectly due to shared interdependence (Kelley 1979). The partner who is not experiencing the stress directly (Partner B)

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is therefore trained to minimize their negative dyadic coping behaviors (e.g., invalidating Partner A’s feelings) that they may use to respond to their partner and, rather, respond with more emotion-focused (e.g., empathy, encouragement), problem-focused (e.g., reframing the situation), or delegated support (e.g., taking on Partner A’s responsibilities) to help Partner A alleviate stress. Theory of Change COCT assumes that couples experience relationship distress because they do not fully understand the role of stress in their relationship. In therapy sessions, therapists educate partners on the detrimental effects of stress, help partners identify their unique responses to stress, as well as practice communication, problem solving, and support giving. This will allow them to becoming more aware of signs of stress originating from inside or outside their relationship and learn effective communication and coping strategies during times of stress in their daily lives. The more they understand and practice, the more their relationship will improve. Rationale for the Model External stress can have a major negative impact on relationship functioning (Randall and Bodenmann 2009, 2017); therefore, it is important for partners to adopt effective coping strategies to counter against it. However, many existing therapeutic approaches do not explicitly mention stress (e.g., traditional behavioral couple therapy), and the ones that do focus on internal stress (e.g., insight-oriented couple therapy). COCT is one of the first forms of therapy to address issues arising from external stress (as well as internal stress) and emphasize the role of dyadic coping in coping with this type of stress. It builds upon the strengths of previous, well-established models by integrating the focus on personal assumptions and beliefs from cognitive-behavioral couples therapy, the idea of partners accepting and appreciating each other’s differences from integrated behavioral couple therapy, and the attention to teaching partners to learn new aspects about themselves from emotionally focused couple therapy (Bodenmann 2004). COCT allows couples to understand stress

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from a clear perspective and to practice ways of acting against it by using the clear structure provided by psychoeducation and the three-phase method, which are discussed below.

Populations in Focus Couples experiencing relationship or marital distress can benefit from COCT. This form of treatment can also be applied to couples in which one of the partners is depressed (Bodenmann et al. 2008) or suffers from another clinical diagnosis (e.g., anxiety disorder, sexual functioning disorder, eating disorder).

Strategies and Techniques Used in Model Techniques used in COCT are psychoeducation regarding stress and stress reactions and the threephase method. As this form of treatment is derived from behavioral and cognitive-behavioral couple therapy, techniques such as enhancement of reciprocal positivity, communication and problemsolving training, cognitive interventions, and acceptance work are also utilized. These strategies are typically used during the beginning sessions to help partners rebuild their trust and commitment in each other. These conditions must be met before partners begin the three-phase method because there needs to be a high level of trust for partners to be able to disclose emotionally and provide effective support. Psychoeducation. The psychoeducation portion of COCT aims to help partners learn more about themselves and each other, as well as the impact of stress on their relationship. It is critical for couples to understand that chronic minor external stressors can cause the relationship to slowly deteriorate (often by increasing feelings of alienation) and that engaging in positive dyadic coping can mitigate this deleterious effect (Bodenmann 2004). When stress occurs, individuals may have adverse reactions and exhibit some unpleasant behaviors such as stubbornness or

Coping-Oriented Couple Therapy

anxiety. These undesirable behaviors can trigger relationship conflicts and lead to increased dissatisfaction in partners over time. In COCT, couples learn that daily stressors often trigger individual personality traits or personal insecurities thus resulting in negative stress reactions (Bodenmann and Randall 2012). For instance, Partner A may think, “I am only loved when I perform well,” so whenever something happens to threaten his/her performance, he/she will falsely believe to be unloved and will therefore act destructively toward Partner B. These schemata or patterns of thought are unique in everyone. Thus, an integral component of the COCT involves helping partners gain a deeper understanding of their individual differences and personal vulnerabilities in order to build tolerance and acceptance toward each other. Doing so will allow partners to reinterpret each other’s stress reactions as signs of needing support, which would bring them together rather than drive them apart during stressful times. In the case of couples in which one partner is suffering from depression or similar conditions, psychoeducation may also include teaching partners of depressed patients the difference between beneficial support and support that could reinforce depressed symptomatology (Bodenmann et al. 2008). The three-phase method. The purpose of the three-phase method is to provide structure to partners’ stress communication and support giving. Speaker and listener rules are especially important when using this technique to ensure partners are not interrupted as they are disclosing emotional and possibly difficult information. Therapists work with the couple to establish mutual respect, positivity, and commitment in their relationship, critical foundations to assist partners in developing and practicing stress-related communication, and dyadic coping skills via the three-phase method. It is critical to note that the three-phase method takes place in later sessions in the therapy process because an adequate amount of trust and respect between the partners must exist for them to confide in one another about their stressful experiences. In Phase 1, Partner A (the speaker) describes his/her stress for 30 min, while Partner B (the listener), prompted by the therapist, quietly

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listens and summarizes. A Therapist’s role at this stage is to encourage deeper emotional disclosure by asking open-ended questions and to coach the speaker in his/her self-disclosure as well as the listener in his/her active listening and accurate summaries. Phase 2 consists of Partner B providing support specific to the stress that Partner A is experiencing. Typically this involves emotion-focused support (e.g., providing understanding, empathy, encouragement), followed by problem-focused support (e.g., reframing the situation). This phase should last approximately 10 min. Finally, in Phase 3, Partner A offers feedback for 5 min on the support that Partner B just provided regarding his/her satisfaction with the support and its efficacy. After this, the partners will switch roles so both of them get equal amounts of time and attention in each therapy session, which lasts a total of 90 min for both partners in both roles.

Research about the Model Bodenmann and colleagues (2008) compared the effectiveness of COCT with that of cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) in a randomized clinical trial with 60 depressed outpatients. The CBT approach was individual oriented and focused on correcting faulty cognitive assumptions about the self, the world, and the future. The IPT consisted of both individual and couples therapy sessions and incorporated the exploration of affect as well as cognitive-behavioral techniques such as interpersonal analysis and communication training. COCT was solely couple-oriented and highlighted the role of dyadic stress communication. By the end of the study, all patients had attended therapy for a total of 20 hours and were found to experience less depressive symptomatology across all three conditions. Further, there were no significant differences between the decreases in depressive symptomatology between the three treatment groups, indicating that COCT was as effective in treating depression as the well-established, evidence-based CBT and IPT.

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Contrary to the authors’ hypotheses, there were also no differences found in self-reported relationship quality and dyadic coping between the three groups (Bodenmann et al. 2008). This was an unexpected finding because previous literature had indicated that the treatment effect on depression was mediated by relationship well-being (Bodenmann et al. 2008). Bodenmann and colleagues (2008) suggested this could be due to the use of the time-limited version of COCT in this study or because couples recruited for this study were not highly maritally distressed so treatment effects on relationship well-being were less pronounced. However, they found that partners of depressed patients in the COCT condition showed improvements in another aspect of relationship functioning, expressed emotions (i.e., reductions in open criticism of patients), and this effect was not found among those attending CBT or IPT. Another finding was that while the three conditions had similar recovery rates ranging from 37% to 47% at posttest 2 weeks after treatment, relapse rates at the 1.5-year follow-up were the lowest in the COCT group (i.e., 28.6% in COCT as opposed to 42.9% in CBT and 62.5% in IPT), although this difference was not statistically significant. Additional results showed that expressed emotions mediated the association between COCT and relapse rates. In other words, couples that received COCT reported enhanced abilities in expressed emotion, which, in turn, were associated with lower likelihood of experiencing relationship distress 1.5 years after therapy. Taken together, these results suggest that COCT may promote the maintenance of gains even after treatment ends because of improvements in couples’ expressed emotions.

Case Example Mark and Samantha have been married for 3 years and have no children. Mark is a writer and stays at home most of the time, while Samantha works at an accounting firm. For the past several months, both of them have become increasingly dissatisfied with their marriage. Mark has noticed that Samantha would often come home in an irritable mood and as a result he has been timid to approach

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her. This resulted in many nights of them not speaking to each other. At the recommendation of their friends and family, they decided to see Dr. M, a therapist trained in COCT. In the beginning, Dr. M taught the couple about how stress that is external to the relationship can often trigger partners’ personal vulnerabilities, which may drive partners apart. Dr. M also provided communication and problem-solving training. He observed that the partners actually trust and care about each other but have issues with communicating their stress and thus coached them using the three-phase method. In Phase 1, Samantha recounted her stress from work due to employees being laid off and her having to take on more responsibilities. Dr. M and Mark listened and encouraged her to disclose emotionally. She stated that she felt overwhelmed but did not want to burden Mark about it when in reality, she wanted more support from him. Then, in Phase 2, Mark told Samantha that he heard that Samantha had been experiencing a lot of stress from the recent layoff at her work and the increased workload, which must have been overwhelming to her (i.e., empathetic understanding, an approach of emotion-focused supportive dyadic coping). Mark shared that he had misinterpreted her behaviors as signs that she no longer cared and promised to check in with her every night after work. While he may not be able to fix her problems at work, he would try his best to support her emotionally and take on her responsibilities at home (i.e., delegated dyadic coping). Additionally, Mark asked if this could be an opportunity for Samantha and him together to make positive changes in their relationship (i.e., problem-focused dyadic coping). Finally, in Phase 3, Samantha remarked that hearing Mark’s responses made her feel much better and having Mark’s support would indeed be helpful to her and their relationship in the long run. Next, Mark took the speaker role and shared his stress experiences, while Samantha became the listener following the three-phase method. After treatment, although Samantha was still experiencing stress from work she was more willing to confide in Mark and seek his support. In return, Mark listened to her concerns attentively

Cost-Benefit Ratio in Couple and Family Therapy

and completed more chores at home to alleviate her stress. The couple continued to hone their communication and support-giving skills using the 3 phases Dr. M taught them, and they saw improvements in their relationship as well as personal well-being.

605 Kelley, H. H. (1979). Personal relationships: Their structure and processes. Hillsdale: Erlbaum. Randall, A. K., & Bodenmann, G. (2009). The role of stress on close relationships and marital satisfaction. Clinical Psychology Review, 29(2), 105–115. https:// doi.org/10.1016/j.cpr.2008.10.004. Randall, A. K., & Bodenmann, G. (2017). Stress and its associations with relationship satisfaction. Current Opinion in Psychology, 13, 96–106. http://doi.org/10. 1016/j.copsyc.2016.05.010.

Cross-References ▶ Cognitive Behavioral Couple Therapy ▶ Communication Training in Couple and Family Therapy ▶ Couples Coping Enhancement Training Enrichment Program ▶ Psychoeducation in Couple and Family Therapy ▶ Systemic-Transactional Model of Dyadic Coping ▶ We-ness in Couple and Family Therapy

Cost-Benefit Ratio in Couple and Family Therapy Donna Baptiste, David Kitchings and Kelsey Kristensen The Family Institute at Northwestern University, Evanston, IL, USA

Name of Concept References Cost-Benefit Ratio Baucom, D. H., Epstein, N., LaTaillade, J. J., & Kirby, J. S. (2008). Cognitive behavioral couple therapy. In A. S. Gurman & N. S. Jacobson (Eds.), Clinical handbook of couple therapy (4th ed., pp. 31–72). New York: Guilford. Bodenmann, G. (1995). A systemic-transactional conceptualization of stress and coping in couples. Swiss Journal of Psychology, 54, 34–49. Bodenmann, G. (2004). Verhaltenstherapie mit Paaren [Cognitive behavioral therapy with couples: Copingoriented approach]. Bern: Huber. Bodenmann, G. (2005). Dyadic Coping and its significance for marital functioning. In T. A. Revenson, K. Kayser, & G. Bodenmann (Eds.), Couples coping with stress: Emerging perspectives on Dyadic Coping (pp. 33–49). Washington, DC: American Psychological Association. https://doi.org/10.1037/11031-002. Bodenmann, G., & Randall, A. K. (2012). Common factors in the enhancement of dyadic coping. Behavior Therapy, 43, 88–98. https://doi.org/10.1016/j.beth.2011.04.003. Bodenmann, G., Plancherel, B., Beach, S. R. H., Widmer, K., Gabriel, B., Meuwly, N., . . ., Schramm, E. (2008). Effects of coping-oriented couples therapy on depression: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 76(6), 944–954. https://doi. org/10.1037/a0013467. Falconier, M. K., Jackson, J., Hilpert, J., & Bodenmann, G. (2015). Dyadic coping and relationship satisfaction: A meta-analysis. Clinical Psychology Review, 42, 28–46. https://doi.org/10.1016/j.cpr.2015.07.002.

Synonyms Benefit-Cost Ratio

Introduction The cost-benefit ratio (also referred to as the benefit-cost ratio) is a concept borrowed from fields of economics and finance and applied to interpersonal relationships. Economists and finance professionals use the cost-benefit ratio as a numerical indicator of the profitability of an endeavor. The higher the ratio, the better the investment and goals are to maximize benefits (also termed returns or rewards) relative to costs (or inputs). Social Exchange theorists were the first to apply cost-benefit principles to human relationships. In brief, Social Exchange theory suggests that, consciously or subconsciously, people appraise relationships to determine their relative benefits or rewards as well as

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costs (Emerson 1976; Nezu and Nezu 2016). When people view benefits as high, they are apt to be satisfied and to value relationships. Correspondingly, subjective views of relationships as costly or nonrewarding lead to distress and disconnection.

Theoretical Framework Starting in the 1960s, family science sociologists promoted Social Exchange schema to explain patterns in human relationships and made several assumptions about how costs and benefits operate (Chibucos et al. 2005). First, each person in a relationship seeks to meet his/her own needs, in other words, look out for his/her own best interest. Second, each person wants to maximize benefits or rewards and decrease costs. Rewards might be actual or symbolic attitudes or actions that people desire universally (e.g., love or care) or idiosyncratic actions that people prefer (e.g., a certain type of praise). Costs might be punishments (e.g., hostility or nonresponsiveness) or forfeited rewards (e.g., another relationship). Inherently, power and competition shape social exchanges as each person seeks to meet his/her own needs (Chibucos et al. 2005). Third, cost-benefit assessments lead people to value equality and reciprocity, and both are related to relationship satisfaction. People tend to be more satisfied in relationships in which they perceive they are getting as much as they put in. They are also more satisfied in relationships they deem reciprocal, that is, based on give-and-take. In this regard, constant comparing is a natural dynamic in close and intimate relationships, and in such relationships driven by social exchanges, costbenefit appraisals are inevitable. Social Exchange paradigms, as described above, offer a formula to assess and treat issues in couples and families, and a skillful couple or family therapist can utilize cost-benefit principles to improve bonds and in doing so, improve relationship satisfaction and longevity (Chapman and Compton 2003; Chibucos et al. 2005).

Cost-Benefit Ratio in Couple and Family Therapy

Description Cost-benefit principles offer a plausible framework to assess and treat couple dissatisfaction, although there are nuances in applying these ideas across the relationship spectrum. For example, a couple enters a romantic union expecting a reciprocal contract in which each partner holds him/herself and the other accountable for creating an enjoyable and mutually beneficial union (Emerson 1976). Benefits of the relationship may include love, companionship, affection, support, sex, or financial security. Costs of the relationship might include loss of independence, conflict, and asset-sharing. Research suggests that the most costly dynamics may be constant fighting, chores, jealousies, secrets, and tensions with extended family. In monogamous unions, forgone opportunities to romantically pursue others might also be considered as a cost (Emerson 1976; Crosby 1989). Cost-benefit principles suggest that partners will keep investing in the relationship expecting favorable, or at least acceptable, rewards for what they are giving up. Each can maintain a relatively optimistic outlook so long as the cost-benefit balance remains satisfactory to high. This dynamic occurs when partners get their needs met or feel reinforced positively for their contributions. Alternatively, if the relationship becomes too costly or one or both partners feel that their inputs are unappreciated, one or both might disengage which can then lead to a decrease in highly valued benefits such as affection and intimacy. Costbenefit assessments may play out in everyday interactions as couples evaluate and reinforce each other. Cost-benefit appraisals also play out over time in understanding the union’s worth and viability. Such appraisals might explain why some couples stay together, and others disengage or dissolve (Crosby 1989; Schacter et al. 2012). Some have suggested that cost-benefit principles are inadequate to explain a range of couple dynamics, for example, why couples remain in long-term unions although they are deeply hurt. In such high-cost relationships, couples choose to stay together perhaps because the alternative (e.g., dissolution or singleness) seems worst. Likewise,

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cost-benefit principles may not account for external stressors that impact relational stability. Internal couple dynamics may be satisfactory, but an external stressor can alter partners’ understanding of themselves and destabilize the union. Researchers also suggest that predictors of relationship satisfaction and dissatisfaction may operate independently and not as interdependently as cost-benefit principles suggest. Finally, some characterize cost-benefit explanations as mechanistic, ignoring the complex range of factors that inform relational choice (Chapman and Compton 2003; Crosby 1989; Schacter et al. 2012). In parent-child relationships, cost-benefit principles can also explain interaction patterns, still centered on relational benefits or costs. While assessments of costs may rarely lead parents or children to end relationships, per se, such assessments can seed patterns of reactivity, sourness, and disconnection.

Applying the Cost-Benefit Ratio in Couple and Family Therapy In behaviorally focused and other couple therapies, an obvious application of cost-benefit principles is helping dating couples to validate their selection of the current partner (versus another). A therapist might help couples to examine their social exchanges for principles of equity, reciprocity, and personal satisfaction. Couples might also be coached on trading high-value actions that influence long-term commitment. Another obvious application is helping couples on the brink of dissolution to decide if to stay together. This issue often comes up in couple therapy where one partner feels uncertain about the relationship and contemplates separation or divorce, while the other wants to save the union. With such uncertainty, the therapist might suspend treatment-as-usual to lead the couple in a discernment process, typically a cost-benefit assessment, of the historical, cognitive, emotional, behavioral, and spiritual components of the relationship. This process is usually brief, and some therapists use a structured approach such as a cost-benefit inventory (Crosby 1989; Vernon 2012).

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Cost-benefit principles are also useful to couples seeking to invigorate relationships and in premarital counseling. The emphasis is on behavioral exchanges that increase each partner’s positive experience and perceptions of relational value. Techniques might focus on helping each to reinforce desirable behaviors through warm attentiveness and responding and to increase the balance of positive to negative interactions overall. The therapist might especially target negative interactions (high-cost actions) because of their links to relationship deterioration. The therapist might coach a couple in behavior-exchange such as caring days, that is, particular days in which each partner enacts positive behaviors requested by the other. The therapist might facilitate behavioral contracts, for example, “quid pro quo” arrangements where both exchanges desired actions, also “good-faith” contracts where each takes responsibility to treat the other well regardless of reciprocation. The idea is to make small adjustments in which each partner experiences the other pleasantly, altering the affectional climate (Nezu and Nezu 2016; Vernon 2012). The therapist might educate premarital couples on negative or aversive behaviors that lead to poor relationship outcomes. Also, couples should be trained in effective communication, problem-solving and conflict resolution techniques to increase their capacity to avoid gridlock and to repair ruptures. Such techniques help to maintain a high ratio of positive to negative interactions such that partners might assess the relationship as a good investment (Nezu and Nezu 2016). In applying cost-benefit principles to parents and children, family therapists might help parents and youth to increase behaviors that the other considers “high-value” because parents and youth can often see things differently. Parents, in particular, are prone to ignoring how their youngsters view things and while parents may see their own actions as positive and helpful (e.g., guiding and instructing) young people may interpret the same actions negatively (e.g., as intrusive and nagging). The mismatch in perceptions can fuel conflicts and a therapist may need to reframe and reconcile these points of view. Therapists can also

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help parents and youth to commit to high-value attitudes and actions in everyday communication, conflict resolution, and decision-making that increase the overall ratio of positive to negative encounters. Additionally, therapists may help families to uncover relational imbalances, that is, patterns of dependency, unhelpful reinforcements, and punishments that feed a climate of conflict and negativity. For example, most parents accept their unbalanced roles in family life, taking on burdens of providing, care-giving, and decision-making. But as children grow towards adulthood, parents expect to share responsibilities with their children. Persistent dependency in young adults or parental overreach in young adults’ decisions are signs of imbalance that can make one or both devalue relationships. Sibling conflicts can also be driven by imbalance and inequality, for example, parental favoritism of one child. This may be a costly dynamic linked to sibling conflict and therapists may need to promote norms of fairness, reciprocity, and power sharing to restore balance.

Clinical Application In couple therapy a rigorous cost-benefit evaluation of relationship trouble can help partners to decide on an outcome as the following vignette illustrates. Josie and David, married for 12- years, sought therapy to decide if to stay together or divorce. They seemed miserable, exhausted, and stuck. In the past 6 months, they alternated between high tension conversations, disconnection, and passionate make-ups with neither feeling a sense of resolution. Each declared deep love for the other, but David often added a disclaimer that he loved Josie but was not “in love” with her. The couple’s plans to purchase a home and get pregnant also stalled. Two years ago, they were congratulating themselves on their 10-year anniversary, a milestone that many of their friends did not achieve. Six months later, after attending a Men’s weekend retreat, David confessed to being bored and

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unhappy, sentiments he felt beginning 6 years ago. He thought that he would outgrow these feelings, but they persisted. David insisted that he was not interested in any other person and Josie believed him but feared that he would have an affair. Josie wanted the marriage and felt that she was with her life partner, though there were things that bugged her about David. The therapist validated the suffering of each and suggested three to four sessions of discernment therapy with partners in sessions together and also alone. The goal was to undertake a thorough cost-benefit assessment of the relationship. The therapist used a semi-structured tool to help the couple address several questions in sessions and between -session through writing assignments. At the end of this period, it seemed clear that David assessed the “cost” of remaining in the marriage as high and he was more committed to dissolving the relationship. Deeper explorations also revealed that the couple had married young and as their identities evolved, they grew apart. They buried this disconnection in work and routines with extended families. David had deep feelings of guilt and shame but also felt self-compassion and growing resolve. After wrestling with the distress of these insights, the couple made the painful decision to separate and shortly after that to divorce. They committed to having integrity in the process. The therapist also encouraged boundaries that allowed each to find what he/she needed to deal with the loss. In this vignette above, cost-benefit principles offer a plausible framework to understand relationship dissatisfaction that explains why one partner became discontented. In this instance, the couple chose divorce as a resolution. But had they chosen to repair their relationship, cost-benefit principles still apply. The therapist might have used the cost-benefit evaluation as a springboard for behavioral interventions in which both partners take responsibility to increase the value of the relationship to each. One approach may have been to use a variety of techniques and strategies to help the couple to increase the positive to negative ratio of their interactions, and this requires

Countertransference in Couples Therapy

attention to everyday social exchanges (Chapman and Compton 2003; Crosby 1989; Schacter et al. 2012). In sum, most are familiar with the principle of “gaining a high return on investment,” and this metaphor aligns well with cost-benefit principles in couple and family relationships. The costbenefit framework does not account for the complexity of relationship actions, reaction, or decisions which other constructs may better explain. However, an enduring perspective is that people invest in relationships that they find valuable and disinvest when relationships are costly. Helping family members to maintain a low cost-high benefit ratio might then be key to increasing their relational satisfaction long term. (Nezu and Nezu 2016).

Cross-References ▶ Behavioral Couple Therapy ▶ Behavior Exchange Theory ▶ Contingency Contracting in Couple and Family Therapy ▶ Social Exchange Theory

References Chapman, A. L., & Compton, J. S. (2003). From traditional behavioral couple therapy to integrative behavioral couple therapy: New research directions. The Behavior Analyst Today, 4(1), 17–25. Chibucos, T. R., & Leite, R. W., with Weis, D. L. (Eds.). (2005). Readings in family theory. Thousand Oaks: Sage Publications. Crosby, J. F. (1989). When one wants out and the other doesn’t; Doing therapy with polarized couples. Bristol: Brunner/Mazel. Emerson, R. M. (1976). Social exchange theory. Annual Review of Sociology, 2, 335–362. Nezu, C. M., & Nezu, A. M. (2016). The oxford handbook of cognitive and behavioral therapies. New York: Oxford University Press. Schacter, D., Gilbert, D., Wegner, D., & Hood, B. (2012). Psychology: European edition. New York: Palgrave Macmillan. Vernon, A. (2012). Cognitive and rational-emotive behavior therapy with couples. New York: Springer.

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Countertransference in Couples Therapy Florence W. Kaslow Kaslow Associates, Palm Beach Gardens, FL, USA Florida Institute of Technology, Melbourne, FL, USA

Introduction This article explicates various theoretical perspectives in the vast array of couples’ treatment modalities. It presents an historical overview of major schools of thought and highlights the phenomena of transference and countertransference. Several difficult kinds of patient populations where these twin phenomena are apt to occur are discussed illustratively. The intertwined, reciprocal complex dynamics of transference and countertransference are core elements. “Countertransference” is used to denote the clinician’s reactions to patient transferences which arise unexpectedly from the therapist’s own unresolved feelings towards his or her parents and/or siblings. These emotional responses usually encompass unconscious projections of thoughts and feelings connected to one’s own family members onto clients. Such reactions, triggered in the therapist, are attributable to the fact that how a client acts, looks, expresses his thoughts and emotions, or the information the patient provides ignite submerged emotions and memories in the therapist which interfere with remaining neutrally engaged with the couple’s problems and transactions. Such reactions are spontaneous and initially outside of the realm of conscious awareness (Tansey and Burke 1989). Transference and countertransference dynamics are conceptualized as reciprocal and unresolved phenomena that can only be comprehended by considering both mainstreams of this interplay (Kaslow 2001). When one’s countertransference becomes conscious, it can be

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positive or negative. Therapists sometimes decide to share their countertransference reactions by providing candid feedback when they believe disclosing their emotional responses to the material and the behavior of the couple individually and as a system will prove illuminating to them.

Theoretical Context for Concept The terms transference and countertransference do not appear in the conceptual base of some theoretical schools. Practitioners of approaches such as Rational Emotive Therapy (RET) (Ellis et al. 1989), Narrative Therapies (Goolishian and Anderson 1990), and Cognitive-Behavioral Therapies (Lazarus 1981) do not discuss these intangible phenomena as they assume these do not exist or eschew their significance. The following discussion is predicated upon some of the major theories that incorporate these interlocking concepts and one that explains why it is not incorporated.

Psychodynamic and Object Relations Couples Therapy Ackerman (1958), one of the founding fathers of psychodynamic family therapy, posited in Transference and Countertransference (Bloch and Simon 1982, p. 65) how difficult these concepts are to define and that they convey an element of mystery. He formulated a theoretical shift from the one person conceptual model foundational to psychoanalysis to encompass a philosophy of a two person social reality in therapy in which transference and countertransference are perceived as reciprocal and intertwined processes. Herein the therapist observes the interaction of two individuals and two minds when treating the couple conjointly. In such a dyadic system, there is a circular interchange of feelings that provides the potential to recast the therapeutic context into an expanded model that encompasses the dynamics of the several personalities in the relationship. Within this biopsychosocial model, he believed that intrapsychic events had to be viewed in

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comparison to corresponding interpersonal ones, and that the definition of unconscious should be paralleled by one of the conscious roots of experience, the unreal contrasted with the real, and the sequences of past, present, and future acknowledged. Ackerman disagreed with Freud’s practice of isolating the patient from his family and not including the patient’s significant others in treatment when it seemed warranted so the clinician could engage in direct observation of the interactions and not just hear one person’s version of these. He postulated that given that the roots of transference stem from early and repetitive interactions, that the real people involved in the relational conflicts should become part of the therapeutic dialogue. Freud thought such an involvement in psychoanalysis would be a dangerous interference. Conversely, Ackerman came to believe Freud’s position had contributed to creating a schism between the individual and the social, and the conscious and unconscious. Instead he reasoned that the therapist should enable patients to free themselves of symptoms and suffering while also fashioning a process through which each could create a new sense of self conducive to a more fruitful, dynamic bond with one’s family and society. These principles of inclusion of key family members in the live treatment process became the substance of the theoretical foundation which still underlies psychodynamic couple and family therapy. In light of the new knowledge gleaned in the post Freudian years, Ackerman (1974) came to believe that the real issue was not whether the analyst has or exhibits feelings, but which emotions to convey to the patients to facilitate their healing; and that for true healing to eventuate, the comprehension of emotions has to flow in both directions. He also realized that the therapist should sift through his reactions and inject only those emotions that he believes the patient(s) need to hear and experience in order to improve. When Ackerman (1961) was pioneering seeing couples conjointly, his ideas were considered revolutionary. “Clinical analysts believed doing couples therapy would be problematic because of the serious complications caused by multiple

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transference and countertransference issues that would arise” (Kaslow 2001, p. 1031). In the ensuing 50 years practitioners of the psychodynamically oriented branch of couples’ therapy, including approaches predicated on object relations theory, consider transference and countertransference integral dynamics in the therapeutic relationship. Alexander and Van der Heide (1997) posited that few therapeutic situations stir up such disturbing countertransference reactions as patients’ expressions of rage and aggression. When these emotions are exhibited, their great intensity can provoke overwhelmingly strong reactions in and from the therapist. Becoming aware of and processing these responses can provide the clinician with a richer understanding of the pair’s relational dynamics. How the therapist interprets the origin and role of these affects can have a powerful impact on how he responds to them. By sharing the premise with patients that anger and aggression usually stem from early relational patterns and may be reactivated in later intense emotional relationships and observing their reactions, much needed insight may be garnered by all. These can be interpreted to help hostile, embattled couples cope with their destructive, fury-based interactions. It is imperative that clinicians be cognizant of their own wellsprings of anger and how to convert their reactions into feedback in the service of the patient’s growth and healing of relational schisms. Similarly, in his discussion on countertransference in object relations family therapy, Slipp (1988) stated that the therapist should attempt to be aware of his reactions to the patient’s family and that when disconcerting feelings are experienced, realize this usually signals underlying countertransference reactions. These may include hostility, anxiety, boredom, rescue fantasies, an urge to withdraw, or a wish to control. Behaviors on the therapist’s part such as siding with one couple or family member against another, engaging in sadistic or masochistic interactions with a certain family member, dreaming about the family, tampering with the structure of treatment (e.g., shifting from conjoint to concurrent therapy), coming late or missing appointments may

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be manifestations of countertransference. In response, patients, sensing the therapists’ countertransference may act out, regress, unconsciously try to help their therapist – or abruptly terminate. Slipp (1988) believed that a dynamic interplay between the intersubjective worlds of the family and clinician occur in object relations family therapy and that the clinician’s recognition of the family’s processes of splitting and projective identification, which the numerous transferences and countertransferences herald, are necessary. Object relations psychodynamic therapy has been found to be conducive to a greater degree of closeness if the therapist discloses his countertransference reactions. However, if this is done too soon, it can be detrimental, so timing is of the essence. One must be careful to guard against promoting symbiotic closeness, or it’s opposite, narcissistic distancing, which may occur if individuation and autonomy are overemphasized while sensitivity and empathy are minimized. Mendelsohn (2011) attempted to expand the concept of projective identification from its being viewed as a phenomenon seen primarily in those with severe character pathology to one also used to illuminate a frequent process of communication between intimates. He elaborated the term projective identification to refer to a psychological process through which a person attempts to achieve greater emotional balance by engaging in a complex projection that involves an interactive process between two people. One makes assumptions about the beliefs, feelings, and intentions of “the other,” and these often lead to their behaving “as if” these assumptions are true. In couples therapy each projects unwanted thoughts, actions, and emotions onto their partner and ignores the significance and role of this projective blaming; this type of interaction often typifies sessions held with borderline couples. He highlights the importance of the therapist using his countertransference reactions to these antagonistic, provocative behaviors and the inherent demands that the other comply with a particular role expectation, which is often assigned so that the partner represents a replica of a parental or sibling figure from childhood. In dysfunctional marriages these role assignments are rigid and

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may be “contagious” (Mendelsohn 2011, p. 397) in that the therapist may inadvertently engage in projective identification and respond like one of the patients, acting as a stand-in for one of their original condemning parents. When the clinician realizes what is transpiring, he may defend against these intense feelings with a sense of superiority and/or disdain; defensive distancing may be attempted but is unlikely to be effective. But it raises the therapist’s awareness about what “baddisdainful-unloving feelings” each member of the dyad probably experienced as a child and are now reenacting in their marriage. Mendelsohn (2011, p. 238) concludes that using the therapist’s awareness of the countertransference as a source of information is the most effective way to work with these couples; it helps the therapist to avoid the pitfall of blaming and/or taking sides (this is often what each patient’s projective communication is trying to achieve) and enables him to tolerate the intense feelings activated by the interactions. The major focus of this kind of couple’s therapy needs to be the couple’s projective identifications so that they can see how they communicate through inciting. One result of such a focus is that it will prevent each member of the triad (each member of the dyad plus the therapist) from enacting old pathological patterns of relating that can artificially heighten or dampen feelings in therapy. This formulation adds to the earlier literature about the dynamics of borderline couples and the efficacy of utilizing one’s countertransference reactions to illuminate and facilitate the healing process. Object relations and psychodynamic couples therapists use their own reactions to the family’s interaction processes (objective countertransference) to comprehend the shared but unspoken experiences of each family member about these patterns (unconscious family system of object relations) (Kaslow et al. 1999, p. 771). These responses are transformed in such a way that the therapist can interpret to the family how the interpersonal patterns it has created over time to induce one (or several) member to act in a specific, maladaptive manner, (for example, a scapegoated child) continue to have repercussions.

Countertransference in Couples Therapy

Bowenian Systems Therapy A brief mention of Bowen, who like the behaviorists did not believe in transference and countertransference, is in order here because of his prominent position in the first generation of family therapists and the longevity of his body of work promulgated by respected followers. In Bowen’s classic Family Therapy in Clinical Practice (1988), transference and countertransference are not mentioned, nor are these concepts alluded to in other early references on systemic family practice. Bowen dismissed these elusive interactions as if they did not occur. His theory highlighted the family of origin and he focused on coaching patients to deal with the actual family members. He did not perceive transference of unresolved and unconscious remnants of feelings from childhood onto the clinician as significant; therefore, these were not a therapeutic concern. Followers of Bowenian theory and therapy still adhere to the belief that emotions are more apt to be expressed or acted out to the real significant others present in the therapy room, or during a voyage home to visit family of origin members, than to the clinician as a surrogate figure or transferential object.

Experiential Family Therapy A third pioneer in the first generation of family therapists, Whitaker, along with several colleagues, wrote a core treatise on countertransference in family therapy (Whitaker et al. 1965). They stressed that the therapist should be involved emotionally “in” the family, but not “of” the family, and should be able to identify separately with each individual member. To facilitate this process of identification, they recommended that the clinician reflect on experiences they personally had that were similar to those of the family members and ponder “what would I like and need if I were that person?” (Nichols and Schwartz 1995, p. 308). They hypothesized that becoming aware of the answer could help guide the therapeutic interventions.

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Whitaker emphasized that sharing feelings with patient families would help minimize the destructive potential for acting out of countertransference emotions more than if they were kept hidden. He posited that to be able to achieve and maintain the emotional distance necessary to remain objective with the family (or couple), one should work with a co-therapist or use a consultant in vivo to protect himself from becoming too emotionally embroiled. He personally often used a co-therapist, male or female, very effectively – as evidenced in his writings and videotapes (Napier and Whitaker 1978). Experiential family therapists believe that among the best antidotes to countertransference reactions are excellent professional training, experience, and supervision to be immunized against side taking. Another proscribed factor is for the therapist(s) to have a satisfying personal life so as to reduce the probability of trying to gratify his own personal needs through and from clients.

Contextual Therapy The concept of countertransference historically has been interpreted quite differently in contextual therapy than in classical Freudian treatment. Boszormenyi-Nagy, another family therapy pioneer, and colleagues were convinced that countertransference has its source in prior relational contexts (Boszormenyi-Nagy and Framo 1965/ 1985). They taught that it can be “a resource for deepening one’s capacity for engagement in the multilateral process” of contextual therapy as the therapist temporarily sides with the stance of each family member (Boszormenyi-Nagy et al. 1991, p. 231). They purported that since the therapists’ definitions of “justice and fairness” and his values are communicated implicitly and explicitly, “they become part of the overall therapy context.”

Ericksonian Family Therapy A more recently conceptualized theoretical perspective in the orbit of couples (and family) therapy was articulated by Milton Erickson. Herein

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self-disclosure should be engaged in consciously and deliberately when the therapist thinks it will be beneficial for clients. Lankton et al. (1991, p. 259) indicate she thought these disclosures should take the form of therapeutic stories, which are partially designed by borrowing from personal experience or may be ascribed to another, who is spoken about in the third person. This technique helps the therapist maintain appropriate distance and decreases the likelihood that the story will introduce countertransference elements that would be too revealing. Ericksonian therapists magnify the importance of clinicians being aware of what they convey to clients and what conscious and unconscious reactions are evoked (Erickson and Lustig 1976). In Ericksonian therapy, such self-disclosure, incorporated within a therapeutic metaphor or other broader therapeutic interventions, is perceived as a way to focus emotions, attitudes, and actions designed to stimulate clients. Erickson highlighted the criticality of managing one’s own countertransference in order not to direct therapy in a manner geared to serving the needs of the therapist rather than those of clients. There seem to be many similarities about the utilization of one’s awareness of and interpretation of countertransference in the work of Erickson and Whitaker. However, each was considered a unique and often mesmerizing therapist.

Integrative Problem Solving Therapy Pinsof (1995), a second-generation couple and family psychologist, stressed that within the framework of Integrative Problem Solving Therapy, an approach of which he has been a major proponent, the clinician should contain negative alliances with recalcitrant family members, even if he feels “demeaned or abused” by them. He purports that a negative reaction to any member of the patient unit “can critically damage the total alliance” (p. 111), and should be avoided, especially in the first session. One of the few theoretician-therapists who has addressed the possible dilemmas associated with switching from individual to conjoint therapy

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(i.e., changing the structure of the treatment), Pinsof holds that once ten or more individual sessions have been held with a person, that the intensity of the transference portions of the bonds dimension of the therapeutic alliance will be disrupted by adding other family members to the patient system. The original patient is likely to feel “abandoned.” The therapist’s attempts to forge additional alliances often prove deleterious to a patient who is “narcissistically vulnerable.” The possible risk of jeopardizing the initial alliance should be explained to the original patient before the patient unit is expanded. Pinsoff recommends (1995) that whenever possible, if couples’ therapy seems warranted, they should be referred to a different therapist. If conjoint therapy is entered into, with the same or another therapist, it is imperative that these changes be negotiated with the patient before they commence and that boundaries and commitments be clarified. If making a referral for couples’ therapy seems contraindicated when the person conducting the individual therapy deems it important, then the therapist should be cognizant of and vigilant about the positive and negative transferences from each client separately and the couple conjointly to him as well as his own positive and negative transferences to each of them. It is incumbent upon the therapist to process feelings of favoritism, a tendency to side with one party in all arguments or conflicts, and/or of emotions of dislike for them as a couple surface. Pinsof’s work reinforces the belief that having two patients in the therapy unit complicates the transference and countertransference and renders these phenomena harder to fathom and interpret. Whitaker claimed that he found adding a valued, respected colleague as a co-therapist could decrease some of the countertransference feelings, rebalance the therapy system, and facilitate the progress of the treatment.

Some Especially Difficult Types of Patient Couples to Treat Adult Incest and Abuse Survivors When treating a couple and one member is an adult survivor of childhood incest, the patient

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may not perceive the clinician to be strong nor active enough and may experience the fears associated with childhood sexual abuse (Kirschner et al. 1993, p. 90). These clients, often women, sense there is no understanding, supportive “object” available in the treatment situation. If the therapist experiences a negative countertransference to this kind of patient, who usually harbors transferential anticipation that she will be disappointed, she is apt to abandon treatment quickly. Usually such female patients do not disclose that they find the therapist to be similar to their mother, who was neither protective nor available enough. Thus, Kirschner et al. (1993) urge that therapists be ultrasensitive to indications that the patient is experiencing a negative transference reaction. They prefer to treat a female adult incest survivor conjointly with her partner so that her partner’s involvement can reduce her abandonment fears and augment her sense of security during and between sessions, as well as support the therapist’s interventions. The partner’s participation and witnessing what his partner says and feels usually increases his comprehension of the forerunner of the problems she and they are having, and can make her healing journey feel safer. In dealing with incest survivors, countertransference reactions may include avoidance of the topic, blaming the client for not stopping the molestation, becoming overstimulated by the content in a voyeuristic fashion, and expressing rage at the perpetrator and/or other family members prior to the patient being ready to do so (Kaslow et al. 1999, p. 110). It is imperative in these situations that therapists have resolved their own issues regarding incest, sexual abuse, and secondary traumatization or they may subtly block the issues from emerging into the client’s consciousness. When one partner has suffered childhood sexual abuse (CSA), the couple often experience severe difficulties in the areas of physical contact, sexuality, intimacy, trust, and communications. Their relationship dynamics may be fraught with reenactments of traumatic relational patterns which will need to be confronted if healing is to occur.

Countertransference in Couples Therapy

As it is incumbent upon a therapist to confront such behaviors as the patient missing sessions, not doing agreed upon homework, and forgetting about concerns on which therapy is focusing, the clinician must be able to process her own countertransference reactions to such an unresponsive and needy client so as to be able to offer positive reinforcement. She needs to understand that many patients perceive discussing such family affairs as betrayals of loyalty to the family. The therapist eventually must emphasize that love and hate can coexist and perhaps also to elicit positive feelings to the perpetrator, but not until some of the anger and negativity is worked through and the formerly unspeakable horrors expiated. Learning such feelings can coexist also helps the client understand their ambivalence to the perpetrator, i.e., how they can also love him/her. Borderline, Narcissistic, and Histrionic Couples Therapists may find couples in which one or both have moderate to severe personality disorders, to be very challenging patients (APA 2004). For example, the histrionic is excitable and hard to keep focused; their mood swings make it difficult to follow what they are conveying. There is a strong likelihood that an unemotional person may have chosen her because he found the volatility attractive as it is the opposite of his seriousness and lack of emotionalism; conversely, the histrionic member of the couple was attracted to a predictable, steady partner to keep him/her grounded. However, over time each becomes annoyed with the other as what were perceived as virtues become vices and this is partly the conundrum that brings them to therapy. In couples in which one or both are narcissistic (Solomon 1989), each wants the clinician to support their stance and agree with their side of the argument. To be right is more important than to be happy and their extreme narcissism precludes achieving real intimacy. They need the therapist to express ideas which they find ego-syntonic. The more narcissistic someone is, the more they demand this. Such behavior can elicit negative countertransference reactions as the person’s egocentricity and dismissal of the needs of the other

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may be difficult for the therapist to accept and may arouse familiar but suppressed feelings of animosity displaced from one’s own narcissistic parent. Dyads comprised of one or two borderline members are both likely to tug at the therapist for more attention and reassurance. They may swing from idolizing the therapist to denigrating him and each may be functioning near the opposite poles of negative and positive responses to the therapist (Lachkar 1992). Once I have begun therapy with a couple in which either or both are borderline, I will not see them separately as I have found that after the sessions each relates details from their session to their partner to show that the therapist favors them; their rendition of what transpired is often inaccurate. If each needs a period of individual therapy first, then they will be referred to separate therapists, carefully selected for their competence in treating borderlines and not permitting splitting. A recommendation will be made that they return to the original clinician for couple treatment, if needed, after they have resolved some of their most intense issues. Clinical Example Recently I had a couple referred by a young therapist who had been treating the woman for several months. This never-married couple had had a child out of wedlock 13 months prior to the referral. They did not live together. She had a 15 year old child from a prior relationship (whom she did not list on the in-take form) and he had several children from a previous marriage. She was attractive and dressed in a sexy, provocative matter. After they filled in the intake forms I asked her first to clarify some of her sketchy answers. Her responses were terse and given in a hostile manner. When I turned to him to engage in a similar process, she listened about 2 minutes and clearly disliked what he said. She stood up angrily and said “I won’t sit here and let you malign me” (which he had not done). “I’m leaving and since you are in my car, you’ll have to find a way back to work”. I tried to interject that we would alternate hearing each one’s story but she stormed out and quickly drove away. We were both stunned, but he stated that this kind of erratic, punitive, childish behavior when things did not go her

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way was typical. My rapid clinical diagnosis of her of borderline personality with histrionic and narcissistic features was later reiterated based on psychological testing and she was referred to a Dialectic Behavior Therapy Group (Linehan 1993). Couples therapy with these types of couples is often counterindicated. The amount of negative transferences and countertranseferences can be myriad and two individual therapies and/or group therapy are more likely to prove beneficial.

further complicated by the reality that if the most respected and often best known senior therapists refuse to see other therapists who have carefully chosen them because “they want the best,” those who are turned down may experience a tremendous sense of rejection and resentment. Treating one’s own colleagues and their partners is simultaneously a privilege, an honor, and a relationship fraught with potential countertransference challenges (Kaslow 2001).

Therapists and Their Partners Another domain of practice in which the phenomena of countertransference is apt to surface is the treatment of other therapists. Contributing to the complexity of the therapeutic constellation is the reality that all parties may be functioning within intertwined professional systems in which it is not possible to totally avoid multiple relationships, such as small rural communities. Also, therapists are likely to encounter other clinicians whom they are treating at professional meetings or social gatherings. This unique category of patients is more likely to hear gossip or valid personal information about their therapist than other patients are. They sometimes read books and articles their therapist has written and attend lectures they are delivering. The therapist can attempt to minimize this and explain why these additional interactions might interfere with the therapy, but a total demarcation between one’s personal and professional identities is not always possible (Kaslow 1984). The patient therapist may have sought out their treating therapist because of their stellar reputation, having read their work, or attended one of their lectures and been favorably impressed, thus entering therapy with the beginnings of a positive transference. Throughout treatment complex transference and countertransference issues are likely to be evoked by the numerous images that the patients and their therapist glean of each other. The patient may try to emulate the therapist, compare him or herself to the therapist on many dimensions, experience competitive strivings, and/or fear his partner will find their treating therapist better than they think their partner is. This conundrum is

Countertransference in Couples Group Therapy Other transference and countertransference issues arise in couples group therapy. If the group is co-led by a heterosexual co-therapy team, members, as well as the leaders, may struggle with which therapist is the more competent or more powerful. Members may “develop parental transferences reminiscent of family of origin relationships” to the therapists (Kaslow and Suarez 1988). Participants’ conflicts about closeness may be reactivated through testing the boundaries and strengths of the therapeutic alliance by making after-hours phone calls or raising questions with them about the nature of their co-therapy bond. If the group is co-led by a competent male-female co-therapy team who has a strong working alliance, the team can model effective parenting, mutual respect, and a positive partnership. Then the probability that splitting maneuvers attempted by group members will be effective is decreased markedly. If the co-therapy pair consists of two same sex therapists, different issues may arise. When it is a double male team, the female patients may resent being controlled, perhaps as in the past, by men. Conversely, men may experience a similar resentment if the co-therapy pair consists of two strong women. Another potential countertransference stream is that if the leaders are a same sex therapist team, they each may feel competitive with or overidentify with participants of their own gender and/or experience grave concerns about how to equalize power for those members whose gender is not represented in the team. Some patients may

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act seductively toward the therapists if that is their customary way of relating to members of the same or opposite gender, and this can elicit countertransference reactions from other group members as well as from the therapists. In the event both therapists are gay, lesbian, bisexual, or transgender (LGBT), transferences and countertransferenses to and from heterosexual group members will need to be addressed as will the other gender issues already mentioned. At times cross-gender transferences become very combative and nasty. In addition, the dependency within the transferences may escalate when participants sense the possibility of being able to finally get their childhood needs met by one of the two parental figures, especially if both are of the same gender from which they desperately desire approval and nurturance (Kaslow 2001, p. 1036). Given that many group members will experience the culmination of therapy as a reenactment of early childhood losses or desertions, group members should be assisted in processing the anticipated losses that accompany the termination process and other real life current situations so they do not feel abandoned. If the group was commenced utilizing a contract which specified it is structured as a time limited group, (i.e., 10 or 15 sessions) then this can be interpreted as an agreed upon ending point and not abandonment. Members can also be offered the option of returning by joining a different group in the future.

Clinical Recommendations and Conclusions Transference and countertransference are intangible and elusive phenomena that are often present in couples treatment, even if subliminally, and are only perceived by those who are acutely sensitive to them. For those who choose to negate the reality of these unconscious processes and decide to work exclusively with patients’ displayed behaviors and articulated cognitions, or who intervene based on the spoken narrative of the patient’s reality, these intangible thoughts

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and affects are not a conceptual part of their therapeutic scenarios. Nonetheless it appears in the above exposition that when one is engaged in treating a multipatient unit and the interactions are more complex because they occur in vivo in the moment more than when one treats one patient only, the transference and countertransference aspects may be more submerged in the rapidity and intensity of crossfire between patients (Kaslow 2001). Such behavior may emerge in sessions in which, for instance, one partner is suddenly told that the other has been involved in a long-term affair or that an incestuous relationship is still going on. These intertwined transference phenomena cannot be wished away just because a therapist believes they are not inherent in therapeutic relationships. When they do surface, they should be recognized and handled to the benefit of the patient(s) and their healing journey. Some patients respond to their therapist(s) by projecting emotions and thoughts that are mired in their past relationships onto them rather than being aware of the feelings being dealt with in the current therapeutic encounter. The foregoing discussion describes how complex patterns permeate psychoanalytic couple therapy, thus complicating the therapy and the therapeutic relationship. “The interpretive focal point is the couple, not either member but both of them together, their relationship, and their collusion” (Aznar-Martinez et al. 2016, p. 1). A central principle is that at the inception of treatment the presenting problem(s) should be reframed in such a way that the individual goals are transformed into goals for the pair and both partners can experience the therapy as “our therapy.” Some therapists may also mask the basis of their own feelings and attribute them to their current interactions and not childhood relationships. Given the added complexity of treating a two (or more) patient unit, and the frequent competition of each member for the clinician’s attention and approval, it has been posited herein that multiple transferences and countertransferences may happen simultaneously. Sometimes therapists are the target of a combined attack from the dyad, which may abet a

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negative countertransference (Aznar-Martinez et al. 2016, p. 17). These emotions can be perceived as clues to deciphering important clinical data about the self of the therapist as well as the patient’s interpersonal patterns and internal machinations. When the healing process is stymied, it is often advisable to be tuned into one’s own unconscious projections and countertransferences and to work with a trusted, respected co-therapist or outstanding consultant to process these most productively. Using a co-therapist or consultant when treatment is not progressing, or working with a good supervisor, can enlighten and reinvigorate the therapist and mitigate against the disturbing and depleting effects of countertransference.

References Ackerman, N. W. (1961). A dynamic from the clinical approach to family confict. In N. W. Ackerman, F. L. Beatman, & S. N. Sherman (Eds.), Exploring the base for family therapy (pp. 52–67). New York: Family Service Association of America. Ackerman, N. W. (1958). Psych. dynamics of family life: Diagnosis and treatment of family relationships. New York: Basic Books. Ackerman, N. W. (1974). Treating the troubled family. New York: Basic Books. Alexander, R., & Van der Heide, N. P. (1997). In M. F. Solomon & J. P. Siegel (Eds.), Rage and agression in couples therapy: An intersubjective approach. New York: Norton. American Psychiatric Association (APA). (2004). Diagnosis and statistical manual of mental disorder (4th ed.). Washington, DC: American Psychiatric Association. Aznar-Martinez, B., Perez-Testor, C., Davins, M., & Aramburee, I. (2016). Couple psychoanalytic psychotherapy as the treatment of choice: Indications, challenges and benefits. Psychoanalytic Psychology, 1(33), 1–20. Bloch, D., & Simon, R. (1982). The strength of family therapy: Selected papers of Nathan W. Ackerman. New York: Brunner/Mazel. Boszormenyi-Nagy, I., & Framo, J. L. (Eds.). (1965, 1985). Intensive family therapy. New York: Harper & Row. Boszormenyi-Nagy, I., Grunebaun, J., & Ulrich, D. (1991). In Gurman, A. S. & Kniskern, D.P. (Eds.), Handbook of family therapy. Vol II, pp. 200–238. New York: Brunner/Mazel. Bowen, M. (1988). Family therapy in clinical practice. Northvale: Jason Aronson.

Countertransference in Couples Therapy Ellis, A., Sichel, J. L., Yaeger, R. J., & DiGuiseppe, R. A. (1989). Rational-emotive couples therapy. Needham: Allyn and Bacon. Erickson, M. H., & Lustig, H. (1976). The primer of Ericksonian psychotherapy. New York: Irvington. Goolishian, H. A., & Anderson, H. (1990). Understanding the therapeutic process: From individuals and families to systems in language. In F. Kaslow (Ed.), Voices in family psychology (pp. 91–113). Newbury Park: Sage. Kaslow, F. W. (Ed.). (1984). Psychotherapy with psychotherapists. New York: Haworth Press. Kaslow, F. W. (2001). Whither countertransference in couples and family treatment: A systemic persective. Journal of Clinical Psychology: In Session, 57(8), 1029–1040. Kaslow, N. J., & Suarez, A. F. (1988). Treating couples in group therapy. In Couples therapy in a family context: Perspective and retrospective (pp. 3–14). Rockvill: Aspen Publishers. Kaslow, N. J., Kaslow, F. W., & Farber, E. W. (1999). Theories and techniques of marital and family therapy. In M. B. Sussman, S. K. Steinmetz, & G. W. Peterson (Eds.), Handbook of marriage and the family (2nd ed., pp. 767–793). New York: Plenum. Kirschner, S., Kirschner, D. A., & Rappaport, R. L. (1993). Working with adult incest survivors. New York: Brunner/Mazel. Lachkar, J. (1992). The narcissistic/borderline couple. New York: Brunner/Mazel. Lankton, S. R., Lankton, C. H., & Matthews, W. J. (1991). Ericksonian family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (pp. 239–283). New York: Brunner Mazel. Lazarus, A. (1981). The practice of multimodal therapy. New York: McGraw Hill. Linehans, M. (1993). Cognitive-behavioral treatment of borderline personality disorders. New York: Guilford Press. Mendelsohn, R. (2011). Projective indentification and countertransference in borderline couples. Psychoanalytic Review, 98, 375–399. Napier, A. Y., & Whitaker, C. A. (1978). The family crucible. New York: Harper and Row. Nichols, M. P., & Schwartz, R. C. (1995). Family therapy: Concepts and methods (3rd ed.). Boston: Allyn and Bacon. Pinsof, W. M. (1995). Integrative problem centered therapy. New York: Basic Books. Slipp, S. (1988). The technique and practice of object relations family therapy. Northvale: Jason Aronson. Soloman, M. F. (1989). Narcissisn and intimacy. New York: Norton. Tansey, M. J., & Burke, W. F. (1989). Understanding countertransference: From projective identification to empathy. Hillsdale: The Analytic Press. Whitaker, C. A., Felder, R. E., & Warkentin, J. (1965). Countertransference in the family treatment of schizophrenia. In I. Boszormenyi-Nagy & J. L. Framo (Eds.), Intensive family therapy. New York: Harper and Row.

Couple

Couple Katie M. Heiden-Rootes, Dixie Meyer, Kristin McDaniel and Lauren Wilson Saint Louis University, Saint Louis, MO, USA

Name of Family Form Couples

Synonyms Marriage; Partnered; Romantic relationship

Introduction Couples are defined as two or more individuals engaged in a romantic and/or sexual relationship. Couples may live together, live apart, marry, divorce, and raise children together. Generally, couples share life’s many transitions and developmental stages together. Some couples stay together for many years and others stay together for only a brief period of their lives. Couple relationships shift with cultural norms as the acceptance of divorce, gay and lesbian adoption of children, premarital cohabitation and sexual relations, nonmarital childbearing, and same-sex sexual relationships increases over the past 15 years (Daugherty and Copen 2016). The following description and related research will detail coupling and couple relationship as seen in the USA including US-born and immigrant couples, interracial couples, same-sex couples, and significant issues facing couples.

Description Coupling in the USA. Coupling in the USA has changed over the past 50 years. The most recent federal data showed foreign-born, Hispanic women and men are the most likely to be married or

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cohabitating, while Black, non-Hispanic women were the most likely to never marry (Copen et al. 2012). Greater education predicted greater likelihood of being married for women and men, and cohabitation decreased with greater education for women. Men, by contrast, are more likely to never marry if they are US-born Hispanic or black. Asian and foreign-born Hispanic men are most likely to be married (Copen et al. 2012). The mean age of first marriage across all racial groups was 27.4 for women and 29.5 for men, as compared to 20.5 for women and 23.7 for men in 1947 (U.S. Census 2016). Finally, most minor children are being raised in the USA by a couple (U.S. Census 2016). The federal government does not track samesex legal marriage; however, estimates based on the 2014 number of same-sex marriages performed suggest about 1% of legal marriages are same-sex couples and about 25% of same-sex couples legally marry (Fisher et al. 2016). Same-sex married couples tend to be middle to upper class based on tax return income estimates (Fisher et al. 2016). Male same-sex married couples tend to live in densely populated cities (e.g., New York, NY) and be more affluent than female same-sex couples. Female same-sex married couples tend to live in smaller and mid-size cities (e.g., Madison, Wisconsin; Fisher et al. 2016). Differences in geographic location may be connected to childrearing. Same-sex female couples (27.4%) are more likely to be raising children than male couples (10.6%). Approximately 19% of all same-sex couples are also raising children, and same-sex couples are four times more likely to be parenting adopted or foster care child than different-sex couples (Gates 2013). Finally, the last reported divorce rates in the USA were in 2015, putting the rate at 3.1% of the married population, which is down from 4.0% in 2000 (CDC 2015). Estimates suggest that between 25% and 40% of all marriages end in divorce. This rate increases for subsequent second and third marriages. Little is known about the divorce rates and experiences of same-sex couples given the newness of legal marriage at the federal level. Attraction. Romantic coupling continues to evolve. While variety in sexual orientation is not new, recent changes in marriage rights transformed societal recognition marriages that do not

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adhere to traditional different-sex partnering. Sexual orientation or sexual attraction comes in a myriad of types. Sexual orientation may include different-sex (heterosexual), same-sex (gay and lesbian), bisexual (attraction to both males and females), pansexual (sexual attraction not limited by gender or sex), and asexual (lack of attraction and desire) attractions. Yet, a degree of gradation exists for sexual attraction. Fewer individuals are adhering to complete attraction to one sex or one label of sexual orientation as we continue to see sexual development throughout the lifespan. It may be more appropriate to address sexual attraction on the continuum of attraction from exclusive attraction to one sex through equal amount of attraction across sexes or genders. A similar continuum should also exist generically for sexual attraction to others in recognition of asexuality. These continuums should be considered across time with couples. Commitment. Several definitions exist in literature for the term “commitment” in marital or romantic relationships. The Triangular Theory of Love (Sternberg 1986) defined commitment as the “deliberate choice, first in the decision to love someone and then in the decision to maintain that love” (Acker and Davis 1992, p. 22). Some suggest commitment is the “cold” element of intimacy and lacks perceived sex appeal or passion; however, commitment (based on Sternberg’s definition) was shown to be the best predictor of relationship satisfaction (Acker and Davis 1992). In evolutionary studies on relationships, researchers concluded that close, committed relationships “may serve as a fundamental anxiety buffer,” managing existential threats to existence or mortality (Florian et al. 2002, p. 538). In other words, long-term, committed relationships are stabilizing and may be a key element in promoting satisfaction in relationships. Schnarch (1997) argues for the centrality of commitment in intimate relationships, or rather the ongoing recommitment to the process of personal and relational growth toward intimacy. Recommitment is the choice to remain in the process of intimacy with your partner (Schnarch 1997). It requires

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engagement, investment, vulnerability, sacrifice, and play that offers sweet rewards of greater sexual expressiveness and deepens the friendship between partners. Sex may be an expression of (re)commitment, and this recommitment process may be recursive as it moves the relationship into deeper intimacy. Gender. Gender roles and identities are also loosening in our society, changing the social stereotypes of the male-female, masculine-feminine, and traditional couple picture. Gender includes a spectrum of identities as they relate to understanding attraction, roles, and desires across genders. Cisgender individuals identify with their sex assigned at birth. Transgender individuals do not identify with their gender assigned at birth. Nonbinary individuals do not identify exclusively with a gender; rather they may identify as both male and female, neither male nor female, or another gender. Gender individuals do not identify with a gender. Our heteronormative, cisgender society often stigmatizes individuals that do not adhere to traditional norms and challenges the rights of couples who do not follow mainstream societal understanding of attraction and gender identity. Nonheterosexual, non-cisgender individuals and couples are more likely to be victimized and rejected by family and struggle with mental health issues. Monogamy and infidelity. Couple relationships can adhere to monogamous and consensual nonmonogamous boundaries related to sexual and emotional engagements with others. Monogamy is the most common structure for couples in the USA; however, defining the boundaries of monogamy in the present, social media, Internet-driven culture is difficult. Emotional and sexual affairs are usually best defined by a given couple though there is often influence from culture and religion about what constitutes an affair. Consensual nonmonogamous relationships include a multiplicity of relationship structures and boundaries. This could include relationships where a couple consents to both partners seeking outside sexual relationships, swinging where both partners of one couple may have sexual relations or swap partners

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with another couple or group of couples, and polyamory which may include three (triads) or more partners instead of traditional dyadic coupling. Estimates of consensual nonmonogamous relationships range from less than half of a percent to 4% of the US population (Conley et al. 2013). Consensual nonmonogamous relationships are growing in popularity partly due to divorce rates, increasing rates of (known) infidelity, individual desire for outside sexual relationships, and cultural changes, recognizing that not all couples may choose to bond exclusively with one partner. Couples may also recognize that what individuals want from a long-term partner (e.g., personality, stability) may be different from what individuals want from a short-term partner (e.g., attractiveness, sex drive), thus creating challenges to remaining monogamous. Importantly, research supports that regardless of the type of coupling, similar levels of relationship satisfaction are found. Jealousy may, in fact, be less likely to occur in consensual nonmonogamous relationships. However, challenges may arise in these types of relationships regarding legal recognition of relationships, parenting challenges, and discrimination from others. Intercultural couples. People in relationships may present in various dynamics including intercultural couples, interracial couples, interfaith couples, mixed orientation couples, and couples of varying immigrant status. People commonly partner despite differences in culture, race, ethnic identity, socioeconomic status, religious beliefs, sexual orientation, or immigration experiences. The numbers of interracial and intercultural marriages are increasing in the USA (Hsu 2001). Interracial and intercultural relationships offer opportunities to learn and grow with someone from a different background and with differing perspectives. Intercultural couples have both strengths and challenges. Clarification about definitions and meanings of the family and boundaries are important to explore based upon each other’s cultural expectations (Hughes and Dickson 2005). It is important for each partner to proactively examine and negotiate central issues that could potentially arise because if left silent, the conflict may create

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dissonance and the couple might feel unprepared to deal with barriers. Barriers might include different philosophies around money, childrearing, family, gender roles, sex, affection, celebrations, rituals, and spirituality (Hsu 2001). Sometimes cultural norms and beliefs held by each partner may be incompatible and conflictual given familial and societal pressures. For example, two studies suggest that bisexual women in relationships with heterosexual men experience additional stigma and more negative health outcomes compared to bisexual women in same-gender relationships (Dyar et al. 2014; Molina et al. 2015). One study reported interfaith couples experience higher rates of divorce, involvement in different groups, and lesser support from social networks (Hughes and Dickson 2005). Couples of different immigration status may experience societal pressure about possible deportation or where to live if experiencing discrimination (Tien et al. 2017). Language and communication problems are common when partners do not share a common language or native culture. Coping skills and ways to deal with conflict also vary by culture and upbringing. Additional culturally loaded issues may arise including where to live, children’s names, food choices, assimilation or acculturation of children’s cultural identify, and extended families (Hsu 2001). Family structure and dynamics should be closely acknowledged as various cultures identify family as the core nuclear family, and the family unit in other cultures might include the entire extended family. Imbalances in cultural/ racial hierarchies may shift as some individuals may view different groups either superior or inferior to their own. Conflict in this area could result in one partner’s aspiration for a more egalitarian relationship (Hsu 2001). In sum, intercultural or interracial couples may encounter unique challenges, but also have tremendous strengths. These couples should be reminded of their decision to commit to one another and use that strength and determination to confront or solve conflicts that arise. Despite facing an additional array of barriers, these couples need to realize and appreciate positive aspects of their relationship.

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Relevant Research Gottman’s couple research. One of the leading researchers on couples and couple dynamics is John Gottman and colleagues. They studied couples in their “love lab” for over 30 years and found a consistent result – the problem is not that couples have conflict but it’s how they engage in the conflict that predicts marital satisfaction and divorce (Gottman 2011). Gottman and colleagues outlined the Four Horsemen of the Apocalypse and their associated antidotes that show up in couple conflict: (1) criticism (complaining by suggesting there is something defective with the partner’s personality; the antidote is to complain with a statement that doesn’t criticize), (2) contempt (disgust and fault finding of another; the antidote – creating a culture of appreciation), (3) stonewall withdrawal (shutting down or not responding; the antidote – self-soothing, taking productive breaks, and working to stay connected), and (4) defensiveness (reactive responses that do not accept responsibility for any part of the conflict; antidote – accepting responsibility for even part of the problem). Contempt and husband withdrawal in different-sex couples, in particular, were the largest predictors of divorce (Gottman 2011). Gottman and colleagues also found that about 30% of all topics of conflict would go unresolved for a couple, even those who were satisfied in their marriage. Unresolvable conflict was largely due to couples’ ability to handle them without the Four Horseman. Stable and satisfying couple relationships had a 5:1 ratio of positive to negative (e.g., Four Horseman) interactions, were able to repair after negative conflict, and had husbands who accepted the influence of their wives. Adult attachment. The primary tenant of attachment theory is that humans were made to be in relationship. We are social beings. This is evident in the coupling practices of humans across time. Different styles of attaching from one human to another are postulated for children and then are carried over to adult relationships. Ainsworth et al. (1978) conceptualized three attachment styles: anxious avoidant, secure, and anxious resistant with a fourth added later called

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disorganized-disoriented, to describe what they were seeing with highly traumatized children. Attachment theory suggests that the four styles are acquired during infancy and childhood, are dynamic and change over time, and, ultimately, predict our adult attachment style with our romantic partners. Johnson (2013) crystallizes the theory of adult attachment this way: “the good news is that even if we were emotionally starved in our childhood relationships, our adult lovers offer us a second chance to learn new and more effective ways to deal with our emotions and signal our longings to others” (p. 78). In many ways, adulthood is a chance to have a do-over, according to the theory, and couples have a chance to heal from childhood attachment wounds through more secure attachment experiences with their partner. Domestic violence. Intimate partner violence (IPV) is defined as any physical, sexual violence, threats of physical or sexual violence, stalking, or psychological aggression, perpetrated by a current or past intimate partner (Black et al. 2011). Couples who experience IPV can be in same-sex or opposite-sex relationships, cohabiting or noncohabiting. In the USA, 35.6% of women have experienced some form of IPV throughout their lifetime. For men in the USA, 28.5% have experienced IPV in their lifetime. When looking at women who have experienced only one form of IPV, 56.8% of women have experienced physical violence. 92.1% of men in this same category reported experiencing only physical violence (Black et al. 2011). There are two forms of intimate partner violence that are often seen in couple’s therapy. Common couple violence is situational violence, where conflict can escalate to violence. This type of couple’s violence lacks the control aspects of intimate terrorism violence. Why intimate terrorism is defned as the perpetrator with both physical and non-physical violence. Perpetrators of intimate terrorism often utilize control tactics, such as isolation, financial control, threatening other family members even children, and physical violence. Research has found that victims of intimate terrorism are more likely to be injured during these violent interactions when compared to their counterparts who experience situational violence.

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They are also more likely to frequently experience violence and post-traumatic stress disorder and to use pain killers (Johnson and Leone 2005). When looking at gender, there is a relationship between marital satisfaction/discord and intimate partner violence (IPV) for male partners (Stith et al. 2010). This may imply that when marital satisfaction decreases, men may be more likely to use violence. Stith et al. (2010) speculate that these gender differences may be due to socialization of men and women. Men may be socialized with a power imbalance, thus more likely to use violence when unhappy. Similarly, women may look for other problem-solving strategies. For female partners, there is a relationship between being a victim of IPV and marital satisfaction/ discord. Female partners also identify higher discord and lower marital satisfaction as compared to male partners (Stith et al. 2010). Overall, there is a relationship between marital satisfaction/discord and IPV. This relationship may be recursive in nature, where IPV reduces marital satisfaction, and lower marital satisfaction increases the chances of IPV. It could be that IPV produces shame for the partners perpetrating violence and this feeds the cycle of violence. Finances. Sex and money are some of the most common topics brought into therapy by couples. However, many therapists and couples feel uncomfortable bringing up these topics. Nonetheless, sex and finances play a major role in a couple’s life. Research has shown that finances are often a major component for marital distress (Britt and Huston 2012). Couples who argue about finances often experience lower relational satisfaction and increased likelihood of divorce. One of the leading predictors of divorce is frequent arguments related to financial disagreements early in the marriage (Britt and Huston 2012). There appears to be a connection between couples who view their partners spending behaviors negatively and lower relational satisfaction. The more a partner spends without including their partner in the discussion, the more likely they are to experience lowered relational satisfaction. Due to the unclear line between financial planning and couples’ issues, therapist should be aware of the impact that financial difficulties have on couples’

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relational satisfaction and should be addressed in premarital counseling (Britt and Huston 2012). Sexual dysfunction and satisfaction. There are many types of sexual dysfunction for both males and females. The Diagnostic and Statistical Manual Version 5 defines sexual dysfunction as a significant disruption in a person’s ability to perform or experience sexual pleasure (American Psychiatric Association 2013). Thirty-one to 43% of men and women experience some form of sexual dysfunction (Laumann et al. 1999). Often these men and women experience comorbid physical and mental health diagnoses (Laumann et al. 1999). Erectile dysfunction is a common sexual dysfunction for men. Other frequently treated diagnoses include male hypoactive sexual desire disorder, delayed ejaculation, and premature ejaculation disorder. When looking at women, common sexual dysfunctions are often related to pain such as genito-pelvic pain/penetration disorder, vaginismus, and dyspareunia. Other diagnoses for females may include female orgasmic disorder and female sexual interest/arousal disorder. Significant associations exist between common mental and physical health conditions and sexual dysfunction suggesting sexual health is an indicator of overall well-being for adults and couples (Laumann et al. 1999).

Special Considerations for Couple and Family Therapy In couple and family therapy (CFT), a therapist will want to consider several key aspects of couple dynamics that may impact care for individual partners, the couple, and children who enter psychotherapy. Early family therapists recognized the use of an “identified patient,” usually a child, for masking marital and couple issues (Napier and Whitaker 1978). Napier and Whitaker (1978) advocated for assessment and treatment that encompasses the whole family for creating a systemic definition and approach to therapy. The research on couple conflict and domestic violence showing a negative impact on children’s mental health (Cummings and Davies 2002) suggests Napier and Whitaker were right in this assertion.

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As such, therapists will want to consider issues of couple dynamics even when the identified patient is the child of the couple. Feminist theorists and family therapists identified the significant impact of gender, power, and oppression on the couple. Equality in relationship dynamics is a predictor of couple satisfaction and is often thought of as an issue of gender (Knudson-Martin and Rankin Mahoney 2009). Historically, male partners tend to be sanctioned with more social power than women leading to inequalities in different-gendered partner relationships. This is perhaps most notable in the research and theory development related to domestic violence (Stith et al. 2010). Though power differentials can also be a produce of socioeconomic status, racial/ethnic background, immigrant status, and privilege associated with each partner’s family of origin. A power issue that is not often discussed in CFT is money even though economic hardship significantly affects couple relationships (Britt and Huston 2012) and can have a spillover effect onto the well-being of children. In CFT the issue may be economic hardship causing stress on the couple relationship and family dynamic overall, and it could also be the issue of who is paying for therapy. Who pays for therapy between a couple may be an indication of investment in the relationship and/or suggest something about power in the relationship. This can also become an ethical concern for therapists who are working to maintain a continuity of care for clients and couples in the face of conflicts about money. A final issue to consider is assumptions about sexual orientation that often accompanies couples when they are seen in CFT. Different- and samegender partnered couples may create the assumption that the partners share a sexual identity (e.g., gay, lesbian, heterosexual). Often times in research and in therapy, we call these couples a “heterosexual couple” or “gay couple” when really we are talking about different- or same-gender partnering and have not actually inquired about their individual sexual orientations. In either same- or differentgender coupling relationships, an individual partner could additionally be identified as bisexual, pansexual, or queer, indicating the ability to be

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attracted to and partner with many different people, regardless of gender. More recent research has explored this phenomenon and the psychological and minority stress impact on the bisexual partners given the erasure or minimization of their sexual identity (Goldberg et al. 2017).

Cross-References ▶ Divorce in Couple and Family Therapy ▶ Infidelity in Couples ▶ Marriage

References Acker, M., & Davis, M. H. (1992). Intimacy, passion, and commitment in adult romantic relationships: A test of the triangular theory of love. Journal of Social and Personal Relationships, 9, 21–50. Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale: Erlbaum. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: American Psychiatric Publishing. Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., Chen, J., & Stevens, M. R. (2011). The National Intimate Partner and sexual violence survey (NISVS): 2010 summary report. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Britt, S. L., & Huston, S. J. (2012). The role of money arguments in marriage. Journal of Family and Economic Issues, 33(4), 464–476. Center for Disease Control. (2015). National marriage and divorce rates. Retrieved from https://www.cdc.gov/ nchs/data/dvs/national_marriage_divorce_rates_0015.pdf Conley, T., Moors, A., Matsick, J., & Ziegler. (2013). The fewer the merrier?: Assessing stigma surrounding consensually non-monogamous romantic relationships. Analyses of Social Issues and Public Policy, 13(1), 1–30. https://doi.org/10.1111/j.1530-2415.2012. 01286.x. Copen, C. E., Daniels, K., Vespa, J., & Mosher, W. D. (2012). First marriages in the United States: data from the 2006–2010 national survey of family growth. National Health Statistics Reports, 49(1), 1–22. Cummings, E. M., & Davies, P. T. (2002). Effects of marital conflict on children: Recent advances and emerging themes in process-oriented research. Journal of Child Psychology and Psychiatry, 43(1), 31–63. Daugherty, J., & Copen, C. (2016). Trends in attitudes about marriage, childbearing, and sexual behavior:

Couple and Family Psychology (Journal) United States, 2002, 2006–2010, and 2011–2013. National Health Statistics Reports, 92, 1–10. Dyar, C., Feinstein, B. A., & London, B. (2014). Dimensions of sexual identity and minority stress among bisexual women: The role of partner gender. Psychology of Sexual Orientation and Gender Diversity, 1(4), 441. Fisher, R., Gee, G., & Looney, A. (2016). Joint Filing by same-sex couples after winds or: Characteristics of married tax filers in 2013 and 2014. Retrieved from https://www.treasury.gov/resource-center/tax-policy/taxanalysis/Documents/WP-108.pdf Florian, V., Mikulincer, M., & Hirschberger, G. (2002). The anxiety-buffering function of close relationships: evidence that relationship commitment acts as a terror management mechanism. Journal of Personality and Social Psychology, 82(4), 527. Gates, G. J. (2013). LGBT Parenting in the United States. Retrieved from http://williamsinstitute.law.ucla.edu/ wp-content/uploads/LGBT-Parenting.pdf. Goldberg, A. E., Allen, K. R., Ellawala, T., & Ross, L. E. (2017). Male-partnered bisexual women’s perceptions of disclosing sexual orientation to family across the transition to parenthood: Intensifying heteronormativity or queering family?. Journal of Marital and Family Therapy. https://doi.org/10.1111/jmft.12242 Gottman, J. M. (2011). The science of trust: Emotional attunement for couples. New York, NY: WW Norton & Company. Hsu, J. (2001). Marital therapy for intercultural couples. In W.-S. Tseng & J. Streltzer (Eds.), Culture and psychotherapy a guide to clinical practice (pp. 225–242). Washington, DC: American Psychiatric Press, Inc. Hughes, P. C., & Dickson, F. C. (2005). Communication, marital satisfaction, and religious orientation in interfaith marriages. Journal of Family Communication, 5(1), 25. https://doi.org/10.1207/s15327698jfc0501_2. Johnson, S. (2013). Love sense: The revolutionary new science of romantic relationships. New York, NY: Little, Brown. Johnson, M. P., & Leone, J. M. (2005). The differential effects of intimate terrorism and situational couple violence: Findings from the National Violence against Women Survey. Journal of Family Issues, 26(3), 322–349. Knudson-Martin, C., & Mahoney, A. R. (2009). Couples, gender, and power: Creating change in intimate relationships. New York: Springer Publishing Company, LLC. Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. JAMA, 281(6), 537–544. Molina, Y., Marquez, J. H., Logan, D. E., Leeson, C. J., Balsam, K. F., & Kaysen, D. L. (2015). Current intimate relationship status, depression, and alcohol use among bisexual women: The mediating roles of bisexual-specific minority stressors. Sex Roles, 73(1–2), 43–57. Napier, A. Y., & Whitaker, C. A. (1978). The family crucible. New York, NY: Harper Collins. Schnarch, D. (1997). Passionate marriage: Keeping love & intimacy alive in committed relationships. New York: Henry Holt and Company.

625 Sternberg, R. (1986). A triangular theory of love. Psychological Review, 93, 119–135. Stith, S. M., Green, N. M., Smith, D. B., & Ward, D. B. (2010). Marital satisfaction as a risk marker for intimate partner physical violence: A meta-analytic review. Journal of Family Violence, 23(3), 149–160. Tien, N. C., Softas-Nall, L., & Barritt, J. (2017). Intercultural/ multilingual couples. Family Journal, 25(2), 156. U.S. Census (2016). The majority of children live with two parents, Census Bureau Reports. Retrieved from: https://www.census.gov/newsroom/press-releases/ 2016/cb16-192.html

Couple and Family Psychology (Journal) Cindy Carlson1 and Mark Stanton2 1 Department of Educational Psychology, University of Texas at Austin, Austin, TX, USA 2 Azusa Pacific University, Azusa, CA, USA

Synonyms CFP

Introduction Couple and Family Psychology: Research and Practice (CFP) is a quarterly peer-reviewed scholarly journal focused on the intersection of theory, research, and professional practice in the specialty of couple and family psychology. It was founded in 2011 and Volume I commenced with the publication of Issue 1 in March 2012. CFP was launched by the Society for Couple and Family Psychology because of a perceived need for a journal that focused on both research and practice in the specialty. The idea for the journal gestated over several years as the division bulletin The Family Psychologist increasingly featured journal-level articles. After originally proposing to transition the bulletin to a journal, it was decided to keep the bulletin and entitle the new journal CFP to differentiate the two publications and highlight the emphasis of the new journal.

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Location CFP is a joint publication of the Journals Program of the American Psychological Association in Washington, D.C., and the Society for Couple and Family Psychology (APA Division 43). It is included in the PsycINFO and PsycARTICLES databases of the APA with the most frequent index terms being couples, family therapy, couples therapy, family relations, attachment behavior, relationship satisfaction, marital relations, commitment, interpersonal relationships, and intervention. A print copy of the journal is provided to all members of the society.

Prominent Associated Figures Several leaders in the Society for Couple and Family Psychology created the proposal for the journal during the presidency of George Hong in 2010. Susan McDaniel, Marianne Celano, John Thoburn, and Thomas Sexton collaborated with Hong to submit a plan to APA (Stanton 2011). APA publisher Gary R. VandenBos approved the proposal in November 2010. Mark Stanton was the inaugural editor (2011–2014), joined by Cindy Carlson and Thomas L. Sexton as associate editors. Each was a prior president of the Society for Couple and Family Psychology, as well as the author or editor of books and journal articles related to the specialty. They gathered a panel of over 30 consulting editors and principal reviewers who represented a wide spectrum of specialty research and expertise, including Steven R.H. Beach, Myrna Friedlander, Alan Gurman, Michele Harway, Susan Johnson, Florence Kaslow, Susan McDaniel, Timothy O’Farrell, Galena Rhoades, Douglas Snyder, Harlene Anderson, James Bray, Kristina Coop Gordon, Joseph Cervantes, Frank Dattilio, Ivan Eisler, and Froma Walsh. Thomas L. Sexton is the second editor (2014–present), with Anthony Chambers and Cindy Carlson serving as associate editors. Additional consulting editors joined the journal, such as Robert Emery, Celia Falicov, Doug Breunlin, Mona Fishbane, Anne Fishel, Shalonda Kelly, Mudita Rastogi, Shelley Riggs, Tamara Sher, and Howard Liddle.

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Contributions (What It Is Known for and Relevant to CFT, Mission, and Values) CFP is known especially for its focus on the nexus of research and practice in couple and family psychology. Research is broadly defined, including quantitative, qualitative, mixed methods, and evidence-based case studies. Authors of research articles are encouraged to provide practice implications of their findings, and theoretical or practice articles are expected to demonstrate scientific foundations (Stanton 2014) because “it is at that intersection that many new and important ways of thinking and working in couple and family psychology can be found” (Sexton 2014, p. 138). Originally, each issue featured two to four articles on an identified theme in couple and family psychology, such as the systemic epistemology of the specialty, coping with HIV risk and infection, treating depression in couple or family therapy, technological innovations for specialty practice, neuroscience of interpersonal relations, integrated systems of healthcare, and evolving couple or family forms (Stanton 2014). As the journal evolved, it shifted to occasional theme issues, such as relationship uncertainty in couples therapy and obesity in the family, adding a scholarly commentary to provide context and direction across the theme articles, and more general topics in the specialty (Sexton 2014). CFP now highlights change mechanisms and innovative models for “real world” interventions.

Cross-References ▶ Anderson, Harlene ▶ Beach, Steve ▶ Carlson, Cindy ▶ Eisler, Ivan ▶ Emery, Robert ▶ Falicov, Celia ▶ Friedlander, Myrna ▶ Gurman, Alan ▶ Johnson, Susan ▶ Kaslow, Florence ▶ Liddle, Howard ▶ McDaniel, Susan

Couple and Family Therapy in the Digital Era

▶ O’Farrell, Timothy ▶ Rhoades, Galena ▶ Sexton, Thomas ▶ Snyder, Doug ▶ Society for Couple and Family Psychology, American Psychological Association ▶ Stanton, Mark ▶ Walsh, Froma

References Sexton, T. L. (2014). Moving forward: Next steps in the evolution of the Couple and family psychology: Research and practice. Couple and Family Psychology: Research and Practice, 3(3), 137–140. https://doi.org/ 10.1037/cfp0000027. Stanton, M. (2011). Welcome to Couple and family psychology: Research and practice. Couple and Family Psychology: Research and Practice, 1(S), 1–2. https:// doi.org/10.1037/2160-4096.1.S.1. Stanton, M. (2014). Editorial. Couple and Family Psychology: Research and Practice, 3(2), 65–66. https://doi. org/10.1037/cfp0000021.

Couple and Family Therapy in the Digital Era Maria Borcsa1 and Valeria Pomini2 1 University of Applied Sciences Nordhausen, Nordhausen, Germany 2 First Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece

Introduction Information and communication technologies (ICTs) have deeply changed the way people communicate and relate in their personal and professional lives. The use of ICTs influences not only family life and all kind of relationships; it also introduces new interactional modalities in a wide range of social practices, including health services and education. Moreover, ICTs have created new relational models based on a networked society. This article presents some significant topics for couple and family therapists in the digital era:

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ICTs and relationships, e-mental health and couple/family therapy (CFT), online supervision, online training and training on ICT use, as well as ethical and legal issues.

ICTs and Relationships One key research question in the field is whether ICTs are used to sustain preexisting connections or to establish relationships that start online and then move offline (Chambers 2013). Despite the option of being potentially linked with a large number of persons, all kinds of digital media and a “media multiplexity” (communication conducted through more than one medium) are mostly used to connect with a smaller group of intimates (ibid.; Jennings and Wartella 2013; Webb 2015). Even social network sites are mainly activated to maintain or deepen already existing relations or for tracing people already known offline, rather than to initiate new relationships. Most communication is with and about the loved ones like partners, family members and friends; synchronous (compared to asynchronous) and voice communication (compared to written) are looked at as having a higher degree of intimacy. Nevertheless, an increasing number of singles in the industrialized world regard online platforms as the best place to find a partner for their real life. The particularity of intimate relationships established via social media lies in an accelerated self-opening compared to face-to-face situations (“disinhibition effect”), leading to intensified closeness in emerging online relationships but revealing contradictory results concerning the stability of these partnerships (Eichenberg et al. 2017). ICT use in couple relationships can strengthen the relationship by allowing to convey signs of affection, desire, and lust; it can ease all forms of everyday communication, especially in short- or long-term geographical separation. Couple identity work may start with wedsites (web pages created in conjunction with an upcoming wedding), followed by joint Facebook accounts, and continued by viewing sexually explicit online material together. Vulnerability in couple

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relationship is linked to certain forms of online interaction with nonfamily members. If performed in joint couple/family time, the use of ICTs, especially mobile phones, to communicate with nonfamily members (for work-related or private purposes) may be annoying; hours spent alone in front of the computer might create a “computer widow.” Cyber-affairs, cyber-cheating, Internet pornography, and cybersex may have negative effects on relational trust (Webb 2015). On the other hand, the web can be a source in times of uncertainties and crises, through stabilizing the couple/family system: not only information but also online social support communities are available for (expectant) parents on practically any relevant area. These might be particularly important if offline family support is not available or perceived as intimidating. Couples/family members struggling with stress, illness, or loss can locate online venues for social support provision. Family members may seek online help related to family concerns (e.g., medical information) as well as material about the family itself – online genealogical research is becoming increasingly popular (ibid.). Adoption websites and platforms for sperm and egg donations as well as for surrogate mothers all over the world (even if they are not legal in most states) support the pluralization of family formations and create more options for living arrangements; this might happen under the conditions of globalized neoliberal values and gives rise to ethical issues. To complement, online divorce education programs and online mediation seem to be a suitable way for divorcing couples, especially if they do not want to meet each other physically – this is also the case for “online parenting” after divorce (Eichenberg et al. 2017). With regard to family dynamics, the influence of ICTs is manifold, and research results are inconsistent (Jennings and Wartella 2013; Carvalho et al. 2015). ICT use can impact family functioning in both positive and negative ways and is associated with norms, values, and beliefs of the family system. As the use of ICTs increases along with children’s age (through the development of fine motor skills, increased ability to focus

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on one activity, to think logically as well as being able to read), the function of using ICTs changes in the respective family stages (Jennings and Wartella 2013). The child’s growing independence in adolescence goes hand in hand with parents’ need to support and protect the child. Because most children and adolescents use their ICTs for direct and private access to peers, they often perceive attempted parental regulation as privacy invasion, although, interestingly enough, regulatory strategies vary with parenting style and not with adolescents’ time spent online (ibid.; Webb 2015). Parental worries about children’s contact with social media differ according to social class, gender, geographical region, and cultural background (Chambers 2013), while ICTs have different effects depending on whether they are used in families mainly for educational or for entertainment purposes (Carvalho et al. 2015). Particular aspects of family functioning, such as communication (micro-coordination, i.e., managing daily activities), cohesion (e.g., through sharing online activities between parents and children), roles, rules, intergenerational conflicts, and boundaries, are connected to ICT use. However, the particular family’s developmental stage and the geographical distance are powerful mediating factors on the effects ICTs have on family relationships. Especially in geographically separated or transnational couples and families, in empty nest stage of the family life cycle or in crisis conditions, ICTs are significant in maintaining communication and strengthening existing bonds (Carvalho et al. 2015; Webb 2015). The use of ICTs has the potential to influence family roles due to the discrepancy of levels of expertise. As these devices have appeared late in their lives, today’s (grand-) parents act without a reference model in media education, trying to establish rules which might in themselves have a negative impact on the relationship with their descendants (Webb 2015; Eichenberg et al. 2017). Conversely, through unmonitored use of ICTs, family boundaries may be weakened, increasing vulnerability. These may lead families into hazardous situations like threat to privacy and family safety, contact with inappropriate content, “happy slapping,” child grooming, and

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involvement in situations of loss of control over virtual interactions such as cyberbullying or cybersex (Carvalho et al. 2015). Besides, the web may have a twofold role when used by adolescents and young adults presenting mental health problems like eating disorders, depression, or self-harming: on the one hand, reinforcing the risk behaviors and, on the other hand, preventing them or offering support, advice, and experience sharing (Campaioli et al. 2017). Theoretical development toward understanding the role of technology in couple and family life is still scarce in the systemic field. Life course paradigm embeds family structures and family stages within social institutions and historical context (Watt and White 1999). Hertlein and Blumer’s (2014) multi-theoretical model is an integration of a family ecology, structuralfunctional, and interaction-constructionist perspective. The ecological impacts related to technology are described as anonymity, accessibility, affordability, approximation, acceptability, accommodation, and ambiguity. They are interrelated with two types of changes in relationships: changes in the structure of couples and families (in rules, boundaries, and roles) and changes in the process of couple and family relations (intimacy, relationship initiation, formation, and maintenance). The framework, a valuable model for research, helps also clinicians to address technology-related issues in couple and family relationships, such as online dating, online pornography, online infidelity, online video gaming, Internet addiction, cyberbullying, cyberstalking, etc. (ibid.; see also Borcsa and Pomini 2017).

E-Mental Health and CFT The use of ICTs has been widely established by health professionals with a growing acceptance of ICT use in mental health. E-mental health can include videoconferencing, avatar chat, text chat, virtual reality, e-mail, and others. Online practices may offer resources and connections to special populations, such as people living at geographical distance from services, presenting disabilities, or being impaired in reaching the services.

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Teenagers might be more confident with the use of digital means than support offered offline. Online practices may destigmatize mental health issues and facilitate the disclosure of difficult experiences and feelings through anonymity and distance. Among the psychotherapeutic approaches, cognitive-behavioral therapy has a consolidated history of implementing online activities, while up to now a significant delay has been observed in couple and family therapy. One of the best-developed approaches is Integrative Behavioral Couple Therapy (IBCT), which has been transformed to the web-based intervention OurRelationship.com. A randomized control trial of 300 couples showed significant improvement in relationship compared to a waitlist control (see entry ▶ “Integrative Behavioral Couple Therapy”); research was extended to a brief version of the program as well as on couples with specific characteristics such as intimate partner violence (IPV) (Roddy et al. 2017). In case studies, implementation of video teleconferencing into therapeutic work is especially recommended for families in remote and rural areas (Dausch et al. 2009), couples living in long-distance relationships (McCoy et al. 2013), transnational families (Bacigalupe and Lambe 2011), refugees (Mucic et al. 2016), active duty military members stationed in various areas and their families (Hill et al. 2001), as well as for family caregivers in pediatric and geriatric contexts (Chi and Demiris 2015; Comer et al. 2017). Regarding contraindications, the same exclusions as in-person couple/family therapy apply (e.g., severe IPV, untreated substance abuse or psychotic disorders in one or more family members, untreated high suicide risk in one or more family members). The clinician should request in- person sessions or refer to outside providers when it is necessary to ensure safety (Wrape and McGinn 2018; see ibid. for further recommendations). Settings may vary: the therapist sits with one or more family members in the therapy room (in an outpatient or an inpatient context), this system being virtually connected to the spouse or other family members (for case examples see Shoemaker and Hilty 2016). Another option is having

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all members of the session (even other professionals) at one or more screens, whereas the therapist is online at a different place. The respective settings require attention to aspects of multidirectional partiality, especially if one person is regularly physically present with the therapist. Particularly in this case, but also to ensure therapeutic alliance in general, it is recommended to conduct the first one or two sessions conjointly in person if possible (McCoy et al. 2013; Wrape and McGinn 2018). Further, the family home setting during online session could create some complications like the intrusion of other family or nonfamily members during the session or the pull to multitasking – an aspect which should be discussed before online meetings. Connecting virtually to a (co-)therapist while being physically at a different place, e.g., in another country, enables to create a therapeutic system in the language of the family, even if this is not the language of the country where part or the majority of the family lives. This is especially valuable when working with refugees and their families scattered over various countries, as the implementation of translators might be waived (Mucic et al. 2016). In summary, e-Couple and Family Therapy (e-CFT) has to be considered as a new setting, and further conceptualization and research are needed. Discussing ICT issues with couples and families is becoming increasingly important, not only when the presenting problem is related to ICTs, e.g., Internet addiction or online infidelity. Understanding the role ICTs play in the couples’/families’ everyday life is one significant aspect in working with today’s families (Borcsa and Hille 2016). As regards intervention, using websites for assessment or for psychoeducation, pointing out online self-help resources, and giving technologybased homework assignments (Piercy et al. 2015) are examples of how CFTs can utilize digital tools. With regard to couple and family therapists’ usage of ICTs, it has become slightly more of a routine in the last decades, asynchronous means of use being mainstream at present. Distant communication is primarily seen as a way to improve availability in already established therapeutic

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relationships (Hertlein et al. 2014) but not necessarily as a new therapeutic setting per se. Besides age, personal attitudes and cultural values influence the use of ICTs in clinical practice: whereas family clinicians from Canada, Mexico, Spain, and the United States, who used more ICTs themselves, saw more benefits for families in general, a Turkish sample, despite using overall more ICTs for nonclinical purposes than their English- and Spanish-speaking colleagues, turned out to be less in favor of their use in clinical practice (Akyil et al. 2017).

Online Supervision Online supervision has been defined as a supervision activity via digital tools, ranging from the use of cellular phones, texting, instant messaging, and e-mailing to encrypted online sharing of videorecorded material/sessions, videoconferencing, and remote live supervision (RLS). In RLS, a supervisor watches a live psychotherapy session via the Internet and gives guidance to the therapist in real time (Rousmaniere 2014). Online supervision offers chances to clinicians located in rural or remote zones; receiving online supervision in those cases where no supervision would otherwise be available enhances the quality of the services provided to patients and combats the sense of professional isolation (Pomini et al. 2016). Online supervision in the context of training for licensure saves travel costs and time but goes hand in hand with a higher degree of responsibility for the supervisee and his/her client, meaning, e.g., that a local backup supervisor should be identified if possible (Rousmaniere 2014). In order to establish a high-quality online supervision process, preparation is needed: besides goal formulation and clarification about roles and responsibilities, like in all supervisory settings, discussing software affairs and the management of technical problems which might occur during online supervision as well as the agreement on clear shared rules regarding the time and spaces of the meeting (e.g., avoiding intrusiveness by thirds or multitasking) are essential in this context. Moreover, technology-related matters

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are how and where data will be stored and deleted. The monitoring and evaluation of supervision process and results are part of the quality assurance. Issues related to diverse cultures between supervisor and supervisee located in different areas, countries, or even continents have to be taken into account to prevent negative side effects for all the participants in the supervisory system (client, supervisee, supervisor); further, supervisors should learn about local laws and regulations in the supervisee’s location that are pertinent to client care (ibid.). As in the case of online therapy, synchronous types of online supervision, like videoconferencing, are by now less popular among couple and family therapists, who seem to feel more comfortable with offline modalities, though some forms of asynchronous digital communication like e-mailing are more frequently used (Twist et al. 2016). Online supervision is usually preferred as an adjunct to offline supervision; compared to supervisors, supervisees are usually more at ease with supervision conducted solely online (ibid.), probably due to the generational difference between most supervisors being “digital immigrants” and most supervisees being “digital natives.” Nevertheless, professionals’ attention to online supervision seems to be increasing, as couple and family therapists express more interest in learning about its effectiveness in comparison with offline supervision (Blumer et al. 2015). Research on this aspect is still limited, particularly in the CFT field; however, early findings showed that the supervisory working alliance was not impaired by the use of videoconference supervision (reported by Rousmaniere 2014).

Online Training and Training in ICT Use Along with therapy and supervision, training practices have been rapidly changing under the influence of digital technology. Utilization of e-mailing, chat, texting, and similar tools has become a routine; videoconferencing for educational purposes and online lessons is also well established in academic contexts. Accredited

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online marriage and family therapy programs are available in several countries, even though the literature describing these practices is still poor. The advantage of providing e-learning platforms in CFT training programs is in overcoming geographical distance, offering training to professionals settled in zones where there is no availability of similar training or to professionals who prefer to enter a specific training of their choice, e.g., because it is provided in their native language. Distance training saves cost and time and in many cases allows education, which would otherwise be unaffordable (Blackmore et al. 2008). Nowadays, the use of ICTs in CFT training activities varies in frequency and intensity: from sporadic use to adopting ICTs as the main, if not the only, method of providing education. CFT training courses use ICT tools to enhance not only dialogue, circulation, and exchange of information and didactic materials between teachers and students but also peer interaction among students (e.g., ad hoc web social forum, Pomini et al. 2016). Through the web, students can gain access to a plethora of didactic materials and become more autonomous, while teachers should provide assistance in choosing relevant information in a critical way. Digital technology offers support and new instruments for a wide range of CFT training activities, from a simple task, such as constructing genograms to more complex ones, like rating of psychotherapy sessions for training or research purposes and recording and evaluating therapeutic alliance. An online program based on the System for Observing Family Therapy Alliances (e-SOFTA) is used to rate client(s) and therapist working alliance on four conceptual dimensions: engagement in the therapeutic process, emotional connection with the therapist, safety within the therapeutic system, and shared sense of purpose within the family (Escudero et al. 2011). The program is available on the web for research, supervision, training, or self-supervision (http:// softa-soatif.com/). Advantages of the utilization of ICTs in training programs as an adjunct to traditional classroom teaching are generally approved; however,

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the debate regarding the advantages or disadvantages of solely online training programs is still controversial. Despite the fact that online technology allows group interactions, which can enrich classroom communication among trainees and between trainees and teachers (Boe et al. 2017), the lack of “face-to-face” group communication in a solely online setting limits students’ as well as teacher/trainee’s interactions. Nevertheless, group videoconference with trainees from multiple locations and the online sharing of clinical and didactical material facilitate the distance group training (Rousmaniere 2014). With regard to education, the second main topic is to what extent training programs include teaching of the appropriate ICT use in professional and personal life and offer expertise in (clinical) online practice, including the risks and benefits of such practices. Nowadays, the use of social media is common among trainees (Williams et al. 2013). Students as well as trained therapists must be aware that colleagues and clients may potentially view their posts on social networks. Patients searching for online information about their therapists (“therapist-targeted googling” – TTG) and therapists’ searching online about clients (“patient-targeted googling” – PTG) are practices presenting risks not only for the therapeutic process. Thus, it is important to address these topics during training and to provide trainees with education and guidelines on the use of ICTs both for professional and personal purposes. In this given situation, the insufficiency of adequate education offered by CFT training programs to their students has been underlined (Blumer et al. 2015). This is the case particularly regarding (a) the influence of ICTs on human relationships and family life, (b) the management of ICTs misuse by their clients, and (c) the appropriate use of ICTs in therapy and supervision. Core competences on the use of ICTs in therapy and supervision should include the evidencebased effectiveness of CFT online practices, ethical and legal concerns regarding these practices, confidentiality and privacy matters, general information on how to conduct CFT online practices, and measures of security and safety (ibid.).

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Ethical and Legal Issues Ethical concern in providing online psychotherapy or other e-mental health interventions is one of the main worries expressed by mental health professionals regarding the use of ICTs in clinical practice. Questions of professional responsibility like difficulties in conducting a correct assessment or managing crisis intervention online, as well as the delivery of online therapy in case of severe psychiatric disorders, are further pointed out as ethical dilemmas (Hertlein et al. 2014; Wrape and McGinn 2018). Since there is no total data safety in the cyber endeavors, confidentiality is also one of the main concerns among therapists as well as clients. Working with clients, be it with adults or children and adolescents, implies knowledge of the national legislation on online practices; if clients are living in a different state, those might be different or not defined yet (Rousmaniere 2014). Further, a liability insurance appropriate to online practices has to be considered. Several mental health associations released guidelines for working with the Internet (see Mucic and Hilty 2016). According to the American Association for Marriage and Family Therapy Code of Ethics, (Standard VI TechnologyAssisted Professional Services; AAMFT 2015), not only therapists but also supervisors need to be trained in the use of technology before providing any kind of online activities and be aware of national legislation regulating those (i.e., not practicing online therapy outside their legal jurisdiction). In online therapy or supervision, assuring confidentiality is crucial, not only regarding clients’ personal data but also concerning supervisee’s information and the supervisee’s/ supervisor’s professional interaction. Clients and supervisees must be made aware of the risks and responsibilities associated with technologyassisted services in written form and of both the therapist’s and clients’/supervisees’ responsibilities for minimizing such risks (ibid.). The AAMFT guidelines for online practice of couple and family therapy (Caldwell et al. 2017) summarize existing knowledge: (a) what stakeholders need and prefer with regard to online

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practice (e.g., access to qualified and appropriate care, insurance reimbursement) and (b) which are the current realities and evolving dynamics of our environment (e.g., utilization, research, legal recognition, licensing). Ethical implications are discussed, and best practice guidelines for online psychotherapy are suggested regarding (1) compliance, (2) infrastructure, (3) advertising and marketing, (4) informed consent, (5) initial assessment, (6) ongoing services, (7) crisis management, (8) failures and breaches, and (9) accountability and review. In the year 2017, 13 out of 50 state documents of professional organizations’ ethical codes and state licensure laws/rules in the United States failed to include any technology-related key terms (Pennington et al. 2017). Those mentioning them (California scoring highest) focused upon six major themes: supervision, continuing education, advertising, confidentiality, informed consent, and licensing. More recently developed forms of technologies (e.g., blogging, texting, various social media networks) were not addressed in the codes or state documents, and topics were limited to specific clinical domains and/or tasks. Further, the majority of the themes were not related to direct online interactions with clients. Caldwell et al. (2017) point out that most therapists had been using ICTs before professional standards were developed and state regulations were settled; or state regulations might be available, but professionals are not aware of them. Issues of training, licensing, ethical principles, and other crucial aspects are far from being solved, while technology is rapidly evolving and the variety of ICTs makes services more accessible to clients – even crossing state borders and further complicating the legal situation.

Actual Needs and Directions for the Future ICTs have irreversibly changed familial and professional lives, and CFT has to react to these developments on several levels. The need for training on the use of ICTs in therapy and supervision has been widely expressed. Developing

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online therapeutic programs (e-CFT) to help people in need to whom other forms are not available, as well as assessing their effectiveness, is a plea. Sharing knowledge about and evaluating CFT online training programs is another task. Last but not least, the need for education, dissemination of information, and best practices regarding ethical and legal issues linked to the use of ICTs in therapy, supervision, and training is a crucial aspect for the present and future. While national legislations regulating these practices are developing in several countries, the nature of the web and the globalized societies will need transnational regulation and globally acknowledged guidelines, addressing e-mental health, counseling, and psychotherapy practices.

Cross-References ▶ Code of Ethics in Couple and Family Therapy ▶ Ethics in Couple and Family Therapy ▶ Integrative Behavioral Couple Therapy

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634 Boe, J. L., Gale, J. E., Karlsen, A. S., Anderson, L. A., Maxey, V. A., & Lamont, J. L. (2017). Filling in the gaps: Listening through dialogue. Contemporary Family Therapy, 39(4), 337–344. https://doi.org/10.1007/ s10591-017-9432-z. Borcsa, M., & Hille, J. (2016). Virtual relations and globalized families – The genogram 4.0 interview. In M. Borcsa & P. Stratton (Eds.), Origins and originality in family therapy and systemic practice (pp. 215–234). Cham: Springer International. Borcsa, M., & Pomini, V. (2017). Editorial: Virtual relationships and systemic practices in the digital era. Contemporary Family Therapy, 39(4), 239–248. https:// doi.org/10.1007/s10591-017-9446-6. Caldwell, B. E., Bischoff, R. J., Derrig-Palumbo, K. A., & Liebert, J. D. (2017). Best practices in the online practice of couple and family therapy. Report of the online therapy workgroup. American Association for Marriage and Family Therapy (AAMFT). Retrieved 1 Sept 2017 from http://www.aamft.org/iMIS15/ AAMFT/Content/Online_Education/Online_Therapy_ Guidelines_2.aspx Campaioli, G., Sale, E., Simonelli, A., & Pomini, V. (2017). The dual value of the web: Risks and benefits of the use of the internet in disorders with a selfdestructive component. Contemporary Family Therapy, 39(4), 301–313. https://doi.org/10.1007/s10591017-9443-9. Carvalho, J., Francisco, R., & Relvas, A. P. (2015). Family functioning and information and communication technologies: How do they relate? A literature review. Computers in Human Behavior, 45, 99–108. https:// doi.org/10.1016/j.chb.2014.11.037. Chambers, D. (2013). Social media and personal relationships: Online intimacies and networked friendship. Basingstoke: Palgrave Macmillan. Chi, N. C., & Demiris, G. (2015). A systematic review of telehealth tools and interventions to support family caregivers. Journal of Telemedicine and Telecare, 21(1), 37–44. https://doi.org/10.1177/ 1357633X14562734. Comer, J. S., Furr, J. M., Miguel, E. M., Cooper-Vince, C. E., Carpenter, A. L., Elkins, R. M., Kerns, C. E., Cornacchio, D., Chou, T., Coxe, S., DeSerisy, M., Sanchez, A. L., Golik, A., Martin, J., Myers, K. M., & Chase, R. (2017). Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered parent–child interaction therapy (I-PCIT). Journal of Consulting and Clinical Psychology, 85(9), 909–917. http://psycnet.apa.org/doi/10. 1037/ccp0000230. https://doi.org/10.1037/ccp0000230. Dausch, B. M., Miklowitz, D. J., Nagamoto, H. T., Adler, L. E., & Shore, J. H. (2009). Family-focused therapy via videoconferencing. Journal of Telemedicine and Telecare, 15(4), 211–214. https://doi.org/10.1258/ jtt.2008.081001. Eichenberg, C., Huss, J., & Küsel, C. (2017). From online dating to online divorce: An overview of couple and family relationships shaped through digital media. Contemporary Family Therapy, 39(4), 249–260. https://doi.org/10.1007/s10591-017-9434-x.

Couple and Family Therapy in the Digital Era Escudero, V., Friedlander, M. L., & Heatherington, L. (2011). Using the e-SOFTA for video training and research on alliance-related behavior. Psychotherapy, 48(2), 138–147. https://doi.org/10.1037/a0022188. Hertlein, K. M., & Blumer, M. L. C. (2014). The couple and family technology framework: Intimate relationships in a digital age. New York: Routledge. Hertlein, K. M., Blumer, M. L. C., & Smith, J. M. (2014). Marriage and family therapists’ use and comfort with online communication with clients. Contemporary Family Therapy, 36(1), 58–69. https://doi.org/ 10.1007/s10591-013-9284-0. Hill, J. V., Allman, L. R., & Ditzler, T. F. (2001). Conducting family mental health sessions: Two case reports. Telemedicine Journal and e-Health, 7, 55–59. https://doi.org/10.1089/153056201300093930. Jennings, N. A., & Wartella, E. A. (2013). Digital technology and families. In A. L. Vangelisti (Ed.), The Routledge handbook of family communication (2nd ed., pp. 448–462). New York/London: Routledge. McCoy, M., Hjelmstad, L. R., & Stinson, M. (2013). The role of tele-mental health in therapy for couples in longdistance relationships. Journal of Couple & Relationship Therapy, 12(4), 339–358. https://doi.org/10.1080/ 15332691.2013.836053. Mucic, D., & Hilty, D. M. (Eds.). (2016). E-mental health. New York: Springer. Mucic, D., Hilty, D. M., & Yellowlees, P. M. (2016). E-mental health toward cross-cultural populations worldwide. In D. Mucic & D. M. Hilty (Eds.), E-mental health (pp. 77–91). New York: Springer. Pennington, M., Patton, R., Ray, A., & Katafiasz, H. (2017). A brief report on the ethical and legal guides for technology use in marriage and family therapy. Journal of Marital and Family Therapy, 43(4). https:// doi.org/10.1111/jmft.12232. Piercy, F. P., Riger, D., Voskanova, C., Chang, W.-N., Haugen, E., & Sturdivant, L. (2015). What marriage and family therapists tell us about improving couple relationships through technology. In C. J. Bruess (Ed.), Family communication in the age of digital and social media (pp. 207–227). New York: Peter Lang. Pomini, V., Akalestou, M. I., Tomaras, V., & Charalabaki, K. (2016). Systemic training for ‘frontier’ mental health professionals: An experience from Greece, in the face of the financial crisis. Human Systems, 27(1), 21–37. Roddy, M. K., Georgia, E. J., & Doss, B. D. (2017). Couples with intimate partner violence seeking relationship help: Associations and implications for selfhelp and online interventions. Family Process, (online first publication). https://doi.org/10.1111/famp.12291. Rousmaniere, T. (2014). Using technology to enhance clinical supervision and training. In C. E. Watkins Jr. & D. Milne (Eds.), Wiley-Blackwell international handbook of clinical supervision (pp. 204–237). Chichester: Wiley Publishers. Shoemaker, E. Z., & Hilty, D. M. (2016). E-mental health improves access to care, facilitates early intervention, and provides evidence-based treatments at a distance. In D. Mucic & D. M. Hilty (Eds.), E-mental health (pp. 43–58). New York: Springer.

Couple Distress in Couple and Family Therapy Twist, M. L. C., Hertlein, K. M., & Haider, A. (2016). Electronic communication in supervisory relationships: A mixed data survey. Contemporary Family Therapy, 38(4), 424–433. https://doi.org/10.1007/s10591-016-9391-9. Watt, D., & White, J. M. (1999). Computers and family life: A family development perspective. Journal of Comparative Family Studies 30, 1–15. Webb, L. M. (2015). Research on technology and the family. From misconceptions to more accurate understandings. In C. J. Bruess (Ed.), Family communication in the age of digital and social media (pp. 3–31). New York: Peter Lang. Williams, L., Johnson, E., & Patterson, J. E. (2013). The appropriate use and misuse of social media in MFT training programs: Problems and prevention. Contemporary Family Therapy, 35(4), 698–712. https://doi. org/10.1007/s10591-013-9256-4. Wrape, E. R., & McGinn, M. M. (2018). Clinical and ethical considerations for delivering couple and family therapy via telehealth. Journal of Marital and Family Therapy, (online first publication). https://doi.org/10.1111/ jmft.12319.

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• • • • • • • • •

Marital therapy Couple therapy Same-sex couple therapy Premarital therapy Re-marital therapy Divorce therapy Sex therapy Marriage therapy Couple therapy as adjunct to the treatment of major mental illness, substance abuse, and spouse and family abuse

Peer Review Policy Each paper is first briefly reviewed by the editor for adherence to our standards of science and APA style. If the paper fits our content and purposes as a journal, it is sent out for review to a minimum of two reviewers, usually members of our editorial board, consisting of some of the country’s most prestigious scholars and therapists. Upon completion of reviews, the editor makes a decision about publication.

Volker Thomas The University of Iowa, Iowa City, IA, USA

Introduction The Journal of Couple & Relationship Therapy promotes a better understanding of what contributes to healthy adult relationships and how therapy facilitates the process. Experts address key treatment issues for all types of adult relationships. Articles explore couple therapy from the perspectives of theory, research, and practice, as well as issues related to the supervision and personal growth of clinicians. Special thematic issues address a single topic for the entire issue, allowing a more significant focus on that particular topic. Recent thematic issues studied clinical concerns with interracial couples, and research and treatment models addressing trauma in couples.

Couple Distress in Couple and Family Therapy Douglas K. Snyder1, Richard E. Heyman2, Stephen N. Haynes3 and Christina BalderramaDurbin4 1 Texas A&M University, College Station, TX, USA 2 Family Translational Research Group, New York University, New York, NY, USA 3 University of Hawaiʻi at Mānoa, Honolulu, HI, USA 4 Binghamton University – State University of New York, Binghamton, NY, USA

Name of Concept Couple Distress in Couple and Family Therapy

Contributions Synonyms The Journal of Couple & Relationship Therapy discusses important issues from a multiplicity of therapeutic styles including:

Couple distress; Relationship dissatisfaction; Relationship distress

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Introduction Couple distress has a markedly high prevalence, has a strong linkage to emotional and physical health problems in the adult partners and their offspring, and is among the most frequent primary or secondary concerns reported by individuals seeking assistance from mental health professionals. In the United States, the most salient indicator of couple distress remains a divorce rate of 40–50% among married couples, with about half of these occurring within the first 7 years of marriage. Independent of divorce, many, if not most, marriages experience periods of significant turmoil that place partners at risk for dissatisfaction, dissolution, or symptom development (e.g., depression or anxiety); roughly one-third of married persons report being in a distressed relationship. Couple distress covaries with overall life dissatisfaction even more strongly than does distress in other domains such as health, work, or children. Persons in distressed couple relationships are overrepresented among individuals seeking mental health services, regardless of whether or not they report couple distress as their primary complaint. Maritally distressed partners are significantly more likely to have a mood disorder, anxiety disorder, or substance use disorder. Moreover, couple distress – particularly negative communication – has direct adverse effects on cardiovascular, endocrine, immune, neurosensory, and other physiological systems that, in turn, contribute to physical health problems. Nor are the effects of couple distress confined to the adult partners. Couple distress has been related to a wide range of deleterious effects on children, including depression, anxiety, withdrawal, poor social competence, health problems, poor academic performance, and a variety of other concerns (Vaez et al. 2015). This entry reviews empirical findings regarding behavioral, cognitive, and affective components of couple distress. Findings regarding the comorbidity of couple distress with individual emotional and behavioral health disorders are

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briefly summarized. Implications of these findings for the practice of couple and family therapy are offered, along with a clinical case example.

Theoretical Context for Concept Couple distress (also referred to as relationship distress with spouse or intimate partner) is conceptualized within formal diagnostic nomenclatures (e.g., the DSM-5 or ICD-11) as occurring when (a) the major clinical focus is the subjective experience of problematic quality in the relationship, or (b) the problematic quality is affecting the course, prognosis, or treatment of a mental or other medical disorder. Criteria regarding impaired couple functioning include behavioral (e.g., conflict resolution difficulty, withdrawal, aggression), cognitive (e.g., chronic negative attributions or dismissal), or affective (e.g., chronic sadness, apathy, or anger) domains. However, these diagnostic perspectives fail to recognize subthreshold deficiencies that couples often present as a focus of concern, including those that detract from optimal individual or relationship well-being. These include deficits in feelings of security and closeness, shared values, trust, joy, love, physical intimacy, and similar positive emotions that individuals typically value in their intimate relationships. Not all such deficits necessarily culminate in “clinically significant” impaired functioning or emotional and behavioral symptoms as traditionally conceived; yet, frequently, these deficits are experienced as insidious and may culminate in couple distress or partners’ dissolution of their relationship.

Description Understanding couple distress for purposes of couple and family therapy requires extending beyond global sentiment to consider construct domains particularly relevant to couple distress – including relationship behaviors, cognitions, and affect – as well as individual and broader cultural factors.

Couple Distress in Couple and Family Therapy

Relationship Behaviors Research examining behavioral components of couple distress has emphasized two domains: (a) the rates and reciprocity of positive and negative behaviors exchanged between partners and (b) communication behaviors related to both emotional expression and decision-making. Regarding the former, distressed partners, compared with nondistressed partners, (a) are more hostile; (b) start their conversations more hostilely and maintain it during the course of the conversation; (c) are more likely to reciprocate and escalate their partners’ hostility; (d) are less likely to edit their behavior during conflict, resulting in longer negative reciprocity loops; (e) emit less positive behavior; (f) suffer more ill health effects from their conflicts; and (g) are more likely to show demand$withdraw patterns (Heyman 2001). Findings suggest a stronger linkage for negativity, compared with positivity, to overall couple distress. Given the inevitability of disagreements arising in long-term relationships, numerous studies have focused on specific communication behaviors that exacerbate or impede the resolution of couple conflicts. Most notable among these are difficulties in articulating thoughts and feelings related to specific relationship concerns and deficits in decisionmaking strategies for containing, reducing, or eliminating conflict. Expression of criticism and contempt, along with defensiveness and withdrawal, predict long-term distress and risk for relationship dissolution (Gottman 1994). Distressed couples are more likely than nondistressed couples to demonstrate a demand$withdraw pattern in which one person attempts to engage the partner in relationship exchange and that partner withdraws, with respective approach and retreat behaviors progressively intensifying. Relationship Cognitions Social learning models of couple distress have expanded to emphasize the role of cognitive processes in mediating the impact of specific behaviors on relationship functioning. Research in this domain has focused on such factors as selective attention, attributions for positive and negative relationship events, and specific relationship assumptions, standards, and expectancies. For example, findings

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indicate that distressed couples often exhibit a bias toward selectively attending to negative partner behaviors and relationship events and ignoring or minimizing positive events. Compared with nondistressed couples, distressed partners also tend to blame each other for problems and to attribute each other’s negative behaviors to broad and stable traits. Initial negative attributions predict relationship deterioration over the first 4 years of marriage. Distressed couples are also more likely to have unrealistic standards and assumptions about how relationships should work and lower expectancies regarding their partner’s willingness or ability to change their behavior in some desired manner (Epstein and Baucom 2002). Relationship Affect Similar to findings regarding behavior exchange, research indicates that distressed couples are distinguished from nondistressed couples by higher overall rates, duration, and reciprocity of negative relationship affect and, to a lesser extent, by lower rates of positive relationship affect. Nondistressed couples show less reciprocity of positive affect, reflecting partners’ willingness or ability to express positive sentiment spontaneously independent of their partner’s affect. By contrast, partners’ influence on each other’s negative affect has been reported for both proximal and distal outcomes. From a longitudinal perspective, couples who divorce are distinguished from those who remain married by partners’ initial levels of negative affect and by a stronger linkage of initial negativity to the other person’s negative affect over time. Although much of the couple literature emphasizes negative emotions, deficits in positive emotions such as smiling, laughter, expressions of appreciation or respect, comfort or soothing, mutual support or coping, and similar expressions are equally important to consider as elements of couple distress. Comorbid Individual Distress There is growing evidence that couple distress covaries with, contributes to, and results from individual emotional and behavioral disorders. Representative community surveys indicate that

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maritally distressed partners, compared with nondistressed persons, are between two to three times more likely to have a mood disorder, anxiety disorder, or substance use disorder (Whisman 2007). Hence, when considering couple distress, additional assessment should be made of the extent to which either partner exhibits individual emotional or behavioral difficulties potentially contributing to, exacerbating, or resulting in part from couple distress. Cultural Differences in Couple Distress Cultural differences may also influence the development, subjective experience, and overt expression of couple distress. These include not only cross-national differences in couples’ relationships but also cross-cultural differences within nationality and variations in nontraditional relationships including gay and lesbian couples. Important differences among couples may occur as a function of their race/ethnicity, culture, religious orientation, economic level, and age. These dimensions can affect the importance of the couple relationship to a partner’s quality of life, their expectancies regarding marital and parenting roles, typical patterns of verbal and nonverbal communication and decision-making within the family, the behaviors that are considered distressing, sources of relationship conflict, the type of external stressors faced by a family, and the ways that partners respond to couple distress and divorce. Moreover, when partners are from different cultures, cultural differences and conflicts can be a source of couple distress.

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findings across multiple assessment methods including self- and other-report measures as well as interview and observational methods (Snyder et al. in press). Certain domains (communication, aggression, substance use, affective disorders, emotional or physical involvement with an outside person) should always be assessed either because of their robust linkage to relationship difficulties (e.g., communication processes involving emotional expressiveness and decision-making) or because the specific behaviors, if present, have particularly adverse impact on relationship functioning (e.g., physical aggression or substance abuse). Second, because the functional sources of couple distress vary so dramatically, the critical mediators or mechanisms of change should also be expected to vary – as should the therapeutic strategies intended to facilitate positive change. Although substantial evidence affirms that various versions of couple therapy produce moderate, statistically significant, and often clinically significant effects, findings also indicate that nearly a third of couples fail to improve in couple therapy, and up to one-half may lose gains in relationship satisfaction in the first 4–5 years following treatment (Lebow et al. 2012). The diverse patterns of factors contributing to couple distress may be addressed with differential efficacy by different treatment approaches specifically targeting these causal influences. That is, particularly complex or difficult couples may benefit most from a treatment strategy drawing from both conceptual and technical innovations from diverse theoretical models relevant to different components of a couple’s struggles (Snyder and BalderramaDurbin 2012).

Application of Concept in Couple and Family Therapy

Clinical Example

Variations in the multiple sources, expressions, and impacts of couple distress have important implications for both the assessment and treatment of couple and family difficulties. First, because the composition of couple distress includes both subjective elements (e.g., affective and cognitive components) and objective or external elements accessible to direct observation (e.g., communication behaviors), assessment of couple distress should integrate

Karen and David entered couple therapy following Karen’s miscarriage 2 months earlier. The trauma of their loss compounded significant stressors the couple had endured for the prior 2 years related to David’s struggles in graduate school and Karen’s efforts to balance part-time secretarial work with her responsibilities as a mother to their 4-year-old son. They had managed to keep their marriage together despite financial hardships and growing emotional

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distance between them. Karen longed for the emotional closeness she had anticipated her marriage would offer and that she had enjoyed with her sister growing up. Instead of drawing closer over the years, David seemed increasingly distant and aloof. Karen’s efforts to draw him nearer and her complaints about his emotional detachment seemed to drive them further apart. David wished he could be more the kind of husband that Karen wanted, but her unhappiness with him was apparent and his feelings of inadequacy in the marriage compounded the inadequacy he felt across most areas of his life. He had cried only briefly following Karen’s miscarriage. David tried to invest more time and energy with their young son, but his efforts admittedly felt half-hearted. He empathized with Karen’s unhappiness, felt largely to blame, but found it difficult to approach her given the increasing resentments she seemed to harbor toward him. Initial interventions in couple therapy emphasized providing a secure context for both partners to discuss their hurts and disappointments without attacking the other, deriving a formulation of their difficulties that emphasized stressors outside as well as within their marriage, and identifying both individual and relationship strengths that had sustained them through years of struggle and could be mobilized to reverse the growing despair each had experienced in the past few months. David became more willing to hear Karen’s anguish when this was softened by the therapist’s reflections, and gradually he grew able to share his own grief and the immobilization he experienced when he thought about their loss. Both partners became better able to draw on each other for comfort around this tragedy. Their marital tensions diminished as the therapist helped each of them to confront individual and relational challenges – David in managing responsibilities at school and Karen in adjusting her work demands and finding more reliable childcare for their son; and the couple in blocking out one evening each week to engage in an activity outside their home and another evening for discussing mutual aspirations and lowconflict concerns. Similar to most couples entering therapy, Karen and David each demonstrated deficiencies in their communication skills. David’s skill deficits revolved primarily around difficulties in

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emotional expressiveness and in processing and then paraphrasing feelings that Karen disclosed. Although emotionally more astute, Karen frequently felt overwhelmed by her own distress; her desperate needs for soothing often escalated to a demandingness that precluded the very comfort from David that she sought. Learning to regulate her own affect more effectively and to approach David in a less confrontive manner allowed him enough security to risk more emotional engagement from his end. Examining their differences in assumptions and expectancies about relationship intimacy helped Karen and David to label their differences in a less personalized, less blaming manner. Adopting an alternative attributional framework that emphasized cognitive processes rather than deficits in caring or commitment to their marriage helped to reduce the hurt that accompanied their frustrations. As therapy progressed, Karen began to reexamine the criteria by which she judged David’s behaviors as an expression of his caring, recognizing that these were so narrow and so rigid that she ended up dismissing or rejecting many of his efforts to please her or show her that he cared. David also benefitted from examining his own early relationship experiences, coming to recognize that emotional nonexpressiveness was the norm throughout both his parents’ families for the last several generations. As therapy approached its conclusion, both partners reported experiencing greater understanding of themselves and each other, a stronger sense of commitment to their marriage, and less negative reactivity during times of external stress or relationship disagreements.

Cross-References ▶ Affect in Couple and Family Therapy ▶ Four Horsemen in Couple and Family Therapy ▶ High Conflict Couples ▶ Pluralistic Approach to Couple Therapy ▶ Snyder, Doug ▶ Training in Couple Therapy

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References

Introduction

Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Gottman, J. M. (1994). What predicts divorce? The relationship between marital processes and marital outcomes. Hillsdale: Erlbaum. Heyman, R. E. (2001). Observation of couple conflicts: Clinical assessment applications, stubborn truths, and shaky foundations. Psychological Assessment, 13, 5–35. Lebow, J. L., Chambers, A. L., Christensen, A., & Johnson, S. M. (2012). Research on the treatment of couple distress. Journal of Marital and Family Therapy, 38, 145–168. Snyder, D. K., & Balderrama-Durbin, C. (2012). Integrative approaches to couple therapy: Implications for clinical practice and research. Behavior Therapy, 43, 13–24. Snyder, D. K., Heyman, R. E., Haynes, S. N., & Balderrama-Durbin, C. (in press). Couple distress. In J. Hunsley & E. Mash (Eds.), A guide to assessments that work (2nd ed., pp. xxx–xxx). New York: Oxford University Press. Vaez, E., Indran, R., Abdollahi, A., Juhari, R., & Mansor, M. (2015). How marital relations affect child behavior: Review of recent research. Vulnerable Children and Youth Studies, 10, 321–336. Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116, 638–643.

Couple therapy is a concept that has been around since the twentieth century, but the practice of working with couples together in therapy is a much newer concept. Psychotherapy was originally developed to focus on the individual. However, the first notions of couple therapy began in Germany in the 1920s as a part of the Eugenics movement (Kline 2001) – a movement that attempted to improve the genetic qualities of mankind. In the United States, “institutes for marriage counseling” were first seen in the 1930s. The counseling was commonly offered to individuals separately, and treatment consisted of advice and information about values and obligations of marriage (Gurman and Fraenkel 2002). Couple therapy, what was then called marriage counseling, continued with this format of treatment until psychoanalytic therapists began to consider bringing each member of the couple into the therapy room. This went against fundamental analyst beliefs, and the practice never gained popularity (Gurman and Fraenkel 2002). It was not until the 1950s when psychiatrists began experimenting with treating individual pathology within the context of their families. Consequently, therapists began to see the benefits of treating relationships and couple therapy burgeoned. Today, couple therapy has developed into a large body of psychotherapy theories grounded in a variety of theoretical backgrounds (Lebow 2000). Couple therapy is considered a psychotherapy modality that focuses on the relationships between intimate partners and is no longer limited to married couples. Couple counseling theories are considerate of cohort, culture, sexual orientation, gender identity, and relationship style.

Couple Therapy Laura Sudano1,2, Jamie Banker3, Nicole Goren4 and Chloé E. Zessin5 1 University of California, Department of Family Medicine and Public Health, San Diego, CA, USA 2 Winston Salem, NC, USA 3 California Lutheran University, Thousand Oaks, CA, USA 4 University of San Diego, San Diego, CA, USA 5 California Lutheran University, Port Hueneme, CA, USA

Name of Theory Couple therapy

Prominent Figures Neil Jacobson, Andrew Christensen, Robert Weiss, Susan M. Johnson, John Gottman, Julie Gottman, Harville Hendrix, Helen Hunt, Michael Balint, William R. Fairbairn, Harry Guntrip, Donald Winnicott, Melanie Klein, Henry Dick,

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Edith Balint, Michael White, David Epston, Milton Erickson, Steve De Shazier, Insoo Kim Berg, Salvador Minuchin, Murray Bowen, Jay Haley, Cloe Madanes, Milton Erickson, Don Jackson, and Stephen A. Mitchell

Description Couple therapy is more prevalent than ever before. There are a vast number of theoretical orientations, suited to fit many different relationship styles. These theories continuously gain evidence-based research, proving their effectiveness. Marriage and family therapists are more likely to see couples (as opposed to entire families) in counseling, although spiritual counselors and individual psychotherapists continue to become educated in couple therapy (Gurman and Fraenkel 2002). Numerous models informed by multiple theories have been developed to guide the therapeutic work and to help therapists and couples hone specific aspects of the relationship (Gurman 2011). This entry outlines the full range of couple therapy models and the theories that guide them. The models are categorized based on the overarching themes for which these models were developed, and each category uses different theoretical orientations to guide conceptualization and intervention. These couple therapy models include behavioral couple therapies, emotioncentered, psychoanalytic and psychodynamic, social constructionist, and systemic therapies. Specifically, the models include Integrative Behavioral Couple Therapy (IBCT), behavioral couple therapy, emotionally focused couple therapy, Gottman Method Couple Therapy, integrative problem-centered metaframeworks (IPCM), integrative couple therapy, brief relational couple therapy, Object Relations Couple Therapy, psychoanalytic couple therapy, psychodynamic couple therapy, Imago relationship therapy, narrative couple therapy, solution-focused couple therapy (SFCT), Bowen family systems therapy with couples/intergenerational couple therapy, and Brief Strategic Couple Therapy (BSCT).

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Behavioral Couple Therapies Integrative Behavioral Couple Therapy (IBCT). IBCT emerged when there was strong empirical support for traditional Behavioral Couple Therapy, but there was also evidence suggesting its limitations (Jacobson et al. 1984). IBCT focuses less on behavioral change and more on changing the recipients’ views to acceptance (Jacobson and Christensen 1998). Acceptance is not resignation or a sign of weakness, but instead it is the partner’s ability to keep their bond despite their issues. Acceptance comes when partners can understand the deeper meaning behind their behavior, when they look at why it is there, and avoid thinking of the behavior in terms of caring. The therapist must identify a theme for the couple. IBCT also tries to facilitate a DEEP analysis of these themes (Christensen et al. 2015). The therapist helps the couple look at differences, emotional sensitivities, external stressors, and their patterns of interaction. The treatment sessions focus on events that are happening in the couple’s life. The therapist will look at patterns of interactions, events that may trigger conflict, negative events, and positive interactions. There are three main strategies: (1) acceptance strategies such as unified detachment and empathic joining, (2) tolerance strategies, and (3) change strategies. Behavioral couple therapy. Once named behavioral marital therapy (BMT), behavioral couple therapy (BCT) is informed by operant conditioning, positive reinforcement, punishment, negative reinforcement, negative reciprocity, shaping, extinction, functional analysis, discriminative stimuli, social learning (social cognitive), social exchange, and negative reciprocity. As is implied in the name, the theories informing this approach are behavioral therapies. The original model included four processes: (1) communication skills, (2) problemsolving skills, (3) relationship enhancement, and (4) use of contracting to promote behavior exchange. BCT broadened its focus in the 1980s and included cognitions to include covert processes.

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Emotion-Centered Couple Therapies Emotionally Focused Couple Therapy. Emotionally focused couple therapy (EFT) holds that primary emotions underlie vicious cycles that are driven by the need for attachment (Johnson 2005; Johnson 2015). Based on attachment theory (Bowlby 1969), EFT looks at the need for attachment as the driving force behind distress. The therapist encourages couples to access and display their primary emotions. This restructures their interactional pattern and thus reinforces their attachment. Treatment is experiential and includes three stages: (1) cycle de-escalation, (2) change interactional patterns, and (3) consolidation and integration. The nine steps in therapy are (1) identify relational conflict, (2) identify negative cycle, (3) access underlying emotions, (4) reframe problem in cycle terms, (5) identify disowned attachment needs, (6) promote acceptance of other partner’s experience, (7) promote expression of needs, (8) help find new solutions to old problems, and (9) consolidate (Johnson 2015). Gottman Method Couple Therapy. John Gottman’s research lead to the development of Gottman method couple therapy. Gottman found that “masters” of relationships are relatively happy and stable couples and “disasters” of relationships are either unhappy or no longer together (Gottman and Gottman 2015). What separates masters from disasters is the couples’ ability to handle conflict and lack of escalation of mild negative affect. Gottman Method Couple Therapy begins with a systematic assessment: a conjoint interview, relationship history, conflict discussion, individual interviews, and questionnaires. The therapist and the couple come up with agreed upon goals, based on the assessment (Gottman and Gottman 2015). Since Gottman Method Couple Therapy is an experiential approach, the therapist attempts to make sessions as dyadic as possible, validating and aiding in communication (Wile 1993). The five goals of Gottman Method Couple Therapy are to (1) downregulate negative affect during conflict, (2) upregulate positive affect during conflict, (3) build positive affect in nonconflicting times, (4) bridge meta-emotion mismatches, and (5) create and nurture a shared

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meaning system. Gottman and Levenson (2002) found that a 5:1 ratio of positive to negative comments during conflict was predictive of happy couples, and thus, this has become part of the therapy.

Integrative Therapies Integrative Problem-Centered Metaframeworks (IPCM) Couple Therapy. IPCM is an integrative approach that looks to maximize the success from many different models (Lebow 1997). The five main theories that IPCM draws from are (1) partial and progressive knowing, (2) systems theory, (3) theory of constraints, (4) differential causality, and (5) sequential organization (Breunlin et al. 2011). The therapist follows the four phases of hypothesizing, planning, conversing, and feedback (Breunlin et al. 2011; Pinsof et al. 2011). IPCM is an empirically based approach, and thus the Systemic Therapy Inventory of Change (STIC) (Pinsof et al. 2009) aims to bring this research into the room. Overall, IPCM looks to provide a new integrative model with a basis in common factors. Integrative Couple Therapy: The Functional Analytic Approach (FACT). FACT maintains that the ability to improve a couple’s relationship lies within them, and thus conjoint sessions are necessary (Gurman 2001). The therapist looks to the couple to bring up the focus of the session, typically an interpersonal issue, knowing that each topic is most likely interconnected to the couples underlying issue. In early sessions, most conversations are partner to therapist, progressing toward more partner–partner conversations as the couple gets more comfortable with the process. There are three roles for the therapist in FACT: (1) identify maladaptive patterns, (2) teach the couple systemic awareness, and (3) help the couple understand and overcome central “rules” that are keeping the problem (Gurman 2015). FACT focuses on both individual change and couple change (Gurman 2008), because they work both ways. Because FACT relies on context, there are no real techniques that are FACT specific. There are, however, three types of

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clinically relevant behaviors (CRBs) that are critical in FACT: (1) problems in session, (2) improvements in session, and (3) interpretations of behavior. The five rules of FACT are (1) watch for CRBs, (2) evoke CRBs, (3) respond to CRBs, (4) watch for therapist effects on couple, and (5) recognize variables that elicit behavior and generalize (Gurman 2015).

Psychoanalytic and Psychodynamic Therapies Brief Relational Couple Therapy. Brief relational couple therapy originates from object relations theory and is informed by relational psychotherapy. Specifically, brief relational couple therapy is informed by pieces of interpersonal psychoanalysis, object relations theory, self-psychology, feminist and postmodern thinking, infant–mother developmental research, attachment theory, and emotion theory. This approach investigates client relationship patterns that occur inside a couple’s emotional world. The task of therapy is to work collaboratively to recognize the themes of the relationship between the therapist and client and to look for the deeper meaning in everything that arises in therapy (Mitchell and Aron 1999). Techniques include examining responses to interventions and real-time client–therapist interactions. Therapists use rupture and repair as a healing mechanism. Object Relations Couple Therapy. Rooted in Freud’s psychoanalytic theory, object relations couple therapy is a nondirective model in which the therapist utilizes the anxiety in the room to build the therapeutic alliance. The therapist can provide advice depending on the needs of the couple, but also relies on free association and spousal reaction to track the unconscious and explore countertransference (Scharff and Scharff 2004). Therapists explore a couple’s dreams and fantasies, paying special attention to personal interpretation and reaction between spouses. The main technique of object relations couple therapy is for the therapists to use themselves as an object in the room. The therapist should aim to encompass the hurt and anxiety between the couple,

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becoming a transitional object for expression of feeling (Fairbairn 1949). Therapists remain impartial, communicating their feelings only when it is relevant to their experience of the couple – therapist’s do not self-disclose. Goals of treatment are to identify and modify each partner’s unconscious transfer of his or her own desires or emotions to the other person (Scharff and Scharff 2004). Therapists advance the capability of the couple’s ability to provide for one another’s needs with regard to attachment, communication, evidenced by empathy, and intimacy. Therapists promote self-differentiation between partners and assist the couple in resuming their own stage of the couple life cycle with sureness in their abilities (Scharff and Scharff 2004). Object relations couple therapy does not focus on individual client goals. Collaborating with clients on their goals is considered to be obstructive to the healing process, because symptoms are used as guides to underlying anger and anxiety (Scharff and Scharff 2004). Psychoanalytic Couple Therapy. Psychoanalytic couple therapy, rooted in psychoanalytic theory, draws on the therapist’s experience of dealing with relationships in individual, group, and family therapy. Techniques include therapists using themselves as a tool to relate in depth with a couple to advance contact with a couple’s anxieties and defenses – therapists then interpret the anxiety to create change within the couple. Transference and countertransference are used as therapeutic tools. Goals of therapy are for couples to pass through the stages they are stuck in, in order to be authentic with one another and improve their emotional functioning (Dicks 1953). Psychodynamic Couple Therapy. Psychodynamic therapy comes from psychoanalytic theory which is influenced by Freudian theory, ego psychology, object relations, and self-psychology. Psychodynamic couple therapy is insight oriented, concentrating on unconscious processes as they are exhibited in present behavior. Techniques include assessing the unconscious in order to reveal feelings that have been pushed out of awareness, but are keeping people stuck. The goal of therapy is to foster self-awareness and understanding on how the past influences the present.

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Unfulfilled needs of the past shape one or both of the members of the couple’s behavior. Reality becomes inaccurate, and expectancies between the couple become excessive. With the help of a therapist, functional patterns can be explored that encourage positive perception of reality (Scharff and Scharff 2014). Imago Relationship Therapy. Imago relationship therapy grew out of psychoanalytic theory, among many others. Imago relationship therapy comes from the idea that issues in adult relationships are correlated to early childhood experiences and that most human problems stem from a lack of connection (Hendrix and Hunt 2004). The main goal is to have each partner in a couple become more self-aware and create a more empathetic connection. When one can learn to love his/her partner more fully, Imago relationship therapy believes that one can then begin to heal the wounds from childhood (Hendrix and Hunt 2004). The main treatment method used to achieve these goals is “Imago Dialogue.” In this dialogue, couples are taught to lower their defensiveness and to truly listen to each other. This helps foster clearer understanding both of their own needs and the needs of the partner. Couples will explore images of both their partners and their early childhood caretakers. The two techniques used are (1) parent/child dialogue and a (2) holding exercise. After this, Imago relationship therapy moves to behavioral techniques where partners are encouraged to restructure their frustrations to desires. They come up with a list of behaviors that their partner can do to make them feel loved, and they are encouraged to do these. Lastly, partners are asked to develop a shared vision of their ideal marriage. It is important to note that Imago only works if both partners are ready to both give and receive this love (Hendrix and Hunt 2004).

Social Constructionist Therapies Narrative Couple Therapy. Narrative couple therapy originates from narrative therapy, a

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form of postmodern psychotherapy informed by the philosophical work of Michael Foucault. The idea behind narrative/social constructionist therapy is that if you separate a person from his/her problem, he/she is able to externalize and therefore minimize the problems that exist in him/her lives (White 2009). A person’s experience becomes his/her dominant story, and this story gives meaning and shapes identity. Problems occur when negative experiences shape a person’s story. Narrative therapy suggests that people can change their stories, and therapists help them coauthor their new stories based on values that are discovered through the narrative process. A primary technique is to externalize problems from couples which stops blaming behaviors and allows for collaboration between the couple and therapist on how the couple is allowing the problem to flourish and ways in which to stop the outside problem from flooding their relationship. Goals include engaging clients in making sense of their narrative, separating the person from the problem, externalizing, deconstructing problem-saturated stories, and finding exceptions (White 1993). Solution-Focused Couple Therapy (SFCT). Inspired by Milton Erickson’s brief therapy, SFCT searches for what is already working in relationships. Techniques include miracle questioning, scaling questions, and exception question. Therapists assist in finding exceptions to when the relationship problems are occurring and use those occurrences as a foundation for solutions (de Shazer et al. 2007). Therapists are collaborative with their clients and set goals for the couple, as well as the individuals within the dyad. Moreover, therapists view clients as capable of change and focus on strengths rather than deficits. Therapists assist their clients in making goals concrete, manageable, and clear (Berg and De Jong 1996). Small changes make a large impact on the couple by creating a ripple effect. Repetition of a couple’s success is imperative because this builds confidence and reinforces positive coping skills for future problems. Goals include instilling hope, managing change, and “cheerleading” the small successes.

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Because therapists focus on solutions rather than fixing problems, the model is intended to be short term/brief therapy.

Systemic Therapies Bowen Family Systems Therapy with Couples/ Intergenerational Couple Therapy. Bowen family systems theory is a systemic approach that works both for families and couples. The therapy and theory proposes that a person with increased anxiety and inability to separate thoughts from emotions (intra- and interpersonally) within his/her family of origin will have increased levels of anxiety, particularly within future intimate relationships. Differentiation is defined as an ability to distinguish oneself in relation to the family or intimate relationships (Kerr and Bowen 1988). The lack of differentiation can lead to or exacerbate issues within a couple. Every couple has conflict as it is difficult to remain an individual while attaching in an emotionally intense relationship. The therapist functions as a coach to help the individuals and the team achieve higher levels of differentiation (Bowen 1978). This approach views the dyadic issues in the context of their extended families, and thus genograms are often used throughout the treatment. The two main goals are (1) reduce anxiety within the dyad and (2) increase levels of differentiation (Baker 2015). Bowenian therapists focus on process as opposed to content, avoid being triangulated, and expose the underlying emotional processes to help clients think about their problems differently and deepen the understanding of each other. Brief Strategic Couple Therapy (BSCT). BSCT was inspired by strategic family therapy theory, which has its foundation in cybernetics models. BSCT focuses on the theory of paradoxical intervention and problem-maintaining behaviors (Haley 1963). If a couple is using a “solution” that is maintaining a problem (positive feedback loop), the goal of therapy is to interrupt the problem/solution pattern (creating a negative feedback loop). The

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intervention is brief, because when the positive feedback loop is interrupted, the problem behavior stops (Haley 1963). Techniques include reframing, symptom prescription, paradoxes, ordeals, restraining techniques, and double binds. Goals of treatment include identifying feedback loops, discovering the rules that govern the loop, and changing the loop/rules between the couple. Since client and therapist are influencing one another, therapists use enactments, which include the therapist directing the family members to speak as if the therapist was not present, to explore how their clients relate in the world. The enactments are indicative of repetitive relational patterns between couples, which give insight into personal history. The goal is to use these intrapsychic and interpersonal discoveries to assist the client in acknowledging their ways of relating to others. Then the therapist assists in helping the client gain self-reflective skills to become aware and less reactive.

Relevance to Couple and Family Therapy Theories in couple therapy approaches often overlap but vary. The variety of approaches that are informed by similar and differing theories offer varied conceptual understandings of working with couples. Models are created from modern and postmodern theories. That is, modern models are rooted in behavioral therapies, while postmodern theories emphasize intersectionality of the human experience. Despite how a therapist conceptualizes a case, each model’s intervention is informed by theory.

Clinical Example of Application of Theory in Couples and Families Mark and Tom are in their late 40s and present with issues related to infidelity. Mark presents with irritability and notes that he works tirelessly as a litigation lawyer and often brings

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work home where he stays up past when his family is asleep to complete his work-related tasks. Tom, a stay-at-home dad who raises their 13-year-old daughter, Arden, presents symptoms of depression. Tom notes that he had an affair with a family friend, a woman, for the past 8 years. Tom reports that the affair started around the same time that the couple adopted Arden. Tom reports feeling distant from Mark and stressed from raising Arden on his own. Arden does well in school and has friends, but she is withdrawn from both parents. The therapist observes Mark and Tom blaming each other for Tom’s infidelity. Mark notes that he is the one who “wants to talk about everything” as his family often discussed disagreements openly. Tom reports “wanting to get over things” and notes how his father worked hard to support his family of six while his mom was a stay-at-home parent. Tom further discloses that his father abused alcohol and his mother abused substances which caused division within the family that eventually led them to divorce when he was 16 years old. The therapist determines that the couple is struggling with family of origin issues related to emotional processes, triangulation, and the life stressors of being a gay, male couple raising an adolescent child. Therefore, Bowen family systems therapy with couples/intergenerational couple therapy and narrative therapy approach would be ideal to address the couple’s issue related to conflict. Therapy goals include increasing the couple’s level of differentiation and exploring the dominant discourse of homophobia. The therapist will use genograms to highlight intergenerational patterns of triangulation, particularly in Tom’s family of origin, and emotional process of avoidance, in Mark’s family of origin, that will allow the couple to process their different patterns. Furthermore, a genogram will be helpful to identify multigenerational patterns of triangulation to decrease the anxiety in the relationship, particularly for Mark as he consumes himself with work and Tom as he seeks out another partner to decrease anxiety. Lastly, patient in context is important to determine individual and familial stressors. As

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a gay, married male couple raising an adolescent female, there are varying stressors. For example, Mark and Tom may confront their roles associated with life cycle and sexuality differently. That is, Mark may experience what it means to be a gay married, employed, older male raising an adolescent daughter differently from Tom, a gay married, stay-at-home dad, older male raising an adolescent daughter. A psychosocial and postmodern approach to working with this couple may provide fruitful therapeutic experience working within a Bowen family systems and narrative therapy approach. In essence, a patient-centered approach to understanding each partner’s family or origin and contextual experience can strengthen therapeutic alliance and outcomes.

Cross-References ▶ Behavioral Couple Therapy ▶ Bowen Family Systems Therapy with Couples ▶ Bowen Family Systems Therapy with Families ▶ Brief Relational Couple Therapy ▶ Brief Strategic Couple Therapy ▶ Emotionally Focused Couple Therapy ▶ Gottman Method Couples Therapy ▶ Imago Enrichment Program ▶ Integrative Behavioral Couple Therapy ▶ Integrative Couple Therapy: The Functional Analytic Approach ▶ Integrative Problem-Centered Metaframeworks ▶ Narrative Couple Therapy ▶ Object Relations Couple Therapy ▶ Psychoanalytic Couple and Family Therapy ▶ Psychodynamic Couple Therapy ▶ Solution-Focused Couple and Family Therapy

References Baker, K. G. (2015). Integrative behavioral couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 246–267). New York: Guilford Press. Berg, I. K., & De Jong, P. (1996). Solution-building conversations: Co-constructing a sense of competence with clients. Families in Society, 77(6), 376–391. https://doi.org/10.1606/1044-3894.934.

Couple Therapy Bowen, M. (1978). Family therapy in clinical practice. New York: Aronson. Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. Loss. New York: Basic Books. Breunlin, D. C., Pinsof, W. M., Russell, W. P., & Lebow, J. L. (2011). Integrative problem centered metaframeworks (IPCM) therapy: I. Core concepts and hypothesizing. Family Process, 50(3), 293–313. Christensen, A., Dimidjian, S., & Martell, C. R. (2015). Integrative behavioral couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 61–94). New York: Guilford Press. de Shazer, S., Dolan, Y., Korman, H., McCollum, E., Trepper, T., & Berg, I. K. (2007). More than miracles: The state of the art of solution-focused brief therapy. New York: Haworth Press. Dicks, H. V. (1953). Clinical studies in marriage and the family: A symposium on methods. I. Experiences with marital tensions seen in the psychological clinic. British Journal of Medical Psychology, 26181–26196. https:// doi.org/10.1111/j.2044-8341.1953.tb00823.x. Fairbairn, W. R. (1949). Steps in the development of an object-relations theory of the personality. British Journal of Medical Psychology, 22(1–2), 26–31. https://doi.org/10.1111/j.2044-8341.1949.tb02880.x. Gottman, J. M., & Gottman, J. S. (2015). Integrative behavioral couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 129–157). New York: Guilford Press. Gottman, J. M., & Levenson, R. W. (2002). A two-factor model for predicting when a couple will divorce: Exploratory analyses using 14-year longitudinal data. Family Process, 41, 83–96. Gurman, A. S. (2001). Brief therapy and family/couple therapy: An essential redundancy. Clinical Psychology: Science and Practice, 8, 51–65. Gurman, A. S. (2008). Integrative marital therapy: A depth behavioral approach. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed., pp. 383–423). New York: Guilford Press. Gurman, A. S. (2011). Couple therapy research and the practice of couple therapy: Can we talk? Family Process, 50(3), 280–292. https://doi.org/10.1111/j.15455300.2011.01360.x. Gurman, A. S. (2015). Functional analytic couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 192–223). New York: Guilford Press. Gurman, A. S., & Fraenkel, P. (2002). The history of couple therapy: A millennial review. Family Process, 41(2), 199–260. https://doi.org/10.1111/j.15455300.2002.41204.x Haley, J. (1963). Marriage therapy. Archives of General Psychiatry, 8(3), 213–234. https://doi.org/10.1001/ archpsyc.1963.01720090001001. Hendrix, H., & Hunt, H. L. (2004). Receiving love: Transform your relationship by letting yourself be loved. New York: Atria Books.

647 Jacobson, N. S., & Christensen, A. (1998). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York: Norton. Jacobson, N. S., Follette, W. C., Revenstorf, D., Baucom, D. H., Hahlweg, K., & Margolin, G. (1984). Variability in outcome and clinical significance of behavioral marital therapy: A reanalysis of outcome data. Journal of Consulting and Clinical Psychology, 52, 497–504. Johnson, S. M. (2005). Emotion and the repair of close relationships. In W. Pinsoff & J. Lebow (Eds.), Family psychology: The art of the science (pp. 91–113). New York: Oxford University Press. Johnson, S. M. (2015). Integrative behavioral couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 97–128). New York: Guilford Press. Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. New York: Norton. Kline, W. (2001). Building a better race: Gender, sexuality, and eugenics from the turn of the century to the baby boom. Berkeley: University of California Press. Lebow, J. L. (1997). The integrative revolution in couple and family therapy. Family Process, 36(1), 1–17. Lebow, J. L. (2000). What does the research tell us about couple and family therapies? Journal of Clinical Psychology, 56(8), 1083–1094. https://doi.org/10.1002/ 1097-4679(200008)56:83.0.co;2-l. Mitchell, S. A., & Aron, L. (1999). Relational psychoanalysis: The emergence of a tradition. Mahwah: Analytic Press. Pinsof, W. M., Zinbarg, R. E., Lebow, J. L., KnoblochFedders, L. M., Durbin, E., Chambers, A., et al. (2009). Laying the foundation for progress research in family, couple and individual therapy: The development and psychometric features of the initial systemic therapy inventory of change. Psychotherapy Research, 19(2), 143–156. Pinsof, W. M., Breunlin, D. C., Russell, W. P., & Lebow, J. L. (2011). Integrative problem centered metaframeworks (IPCM) therapy: II. Planning, conversing and reading feedback. Family Process, 50(3), 314–336. Scharff, J. S., & Scharff, D. E. (2004). Guest editorial, special issue: Object relations couple and family therapy. International Journal of Applied Psychoanalytic Studies, 1(3), 211–213. https://doi.org/10.1002/aps.72. Scharff, D. E., & Scharff, J. S. (2014). An overview of psychodynamic couple therapy. In D. E. Scharff, J. S. Scharff, D. E. Scharff, & J. S. Scharff (Eds.), Psychoanalytic couple therapy: Foundations of theory and practice (pp. 3–24). London: Karnac Books. White, M. (1993). Deconstruction and therapy. In S. G. Gilligan, R. Price, S. G. Gilligan, & R. Price (Eds.), Therapeutic conversations (pp. 22–61). New York: W W Norton &. White, M. (2009). Narrative practice and conflict dissolution in couples therapy. Clinical Social Work Journal, 37(3), 200–213. https://doi.org/10.1007/s10615-009-0192-6. Wile, D. B. (1993). After the fight. New York: Guilford Press.

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Couple Violence in Couple and Family Therapy Chelsea Spencer, Marcos Mendez and Sandra Stith Kansas State University, Manhattan, KS, USA

Synonyms Domestic violence; Intimate partner violence; IPV; Partner violence

Introduction Approximately 24% of all intimate relationships experience some forms of violence, and between 36% and 58% couples who are seeking therapy have experienced physical violence in their relationships (Jose and O’Leary 2009). However, not all couples who experience violence in their relationships are the same, nor are they all appropriate for couples therapy. Johnson (2008) identified different typologies of violent relationships, two of the most commonly recognized being intimate terrorism and situational couple violence. Intimate terrorism is characterized by asymmetric violence that is used as a means to control one’s partner. Couples experiencing intimate terrorism are generally not considered appropriate for couples treatment (Stith et al. 2011). Situational couple violence is characterized by less severe violence that is often bidirectional in nature and typically a response to a specific situation (Johnson 2008). There is some research evidence that conjoint treatment with couples experiencing situational couple’s violence can be safe and effective in reducing violence (Stith et al. 2012).

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to stay together. Gender-specific approaches to treatment of IPV were introduced in the 1970s when the feminist movement began to challenge dominant social beliefs that male violence in intimate relationships was a private isolated event. At that time, IPV was believed to occur solely in the context of a patriarchal, male-dominated society in which men exerted power and control over women. Since then, four decades of research expanded on the feminist view of the 1970s and integrated this perspective into a more intersectional, multifactorial perspective, which led to treatment alternatives for women and men who experience IPV (George and Stith 2014). In addition to early clinical studies which sampled women in shelters and hospitals, nationally representative studies in the 1980s began to discover that rates of male violence in the context of intimate relationships were similar to rates of female violence (Straus 2005). These findings helped the research community begin to shift the initial views of IPV resulting in almost exclusively of male perpetration and female victimization, to a perspective that recognizes that both men and women can be perpetrators and victims of IPV. Studies on IPV risk factors revealed that relationship factors, such as partner emotional abuse, marital satisfaction, and attachment, are some of the most important predictors of IPV (Stith et al. 2004). Research has also made it clear that some IPV perpetration result from a maladaptive response to conflict in relationships or from couples’ inability to resolve conflict in a non-violent matter (Johnson 2008). Since many couples want to stay together, end the violence, and work on their relationship, researchers have developed and tested couple’s therapy treatment for IPV.

Description of Treatment Approach Theoretical Context for Concepts and Description of Concepts Couples therapy for IPV was developed as an alternative to gender-specific approaches to treatment for carefully screened couples who choose

Systemic treatment of IPV focuses on working with both individuals in the relationship, as opposed to traditional treatments that focused on working solely with the violent offender. A variety of approaches have been developed and tested for working conjointly with couples, including

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behavioral couples therapy (O’Farrell and FalsStewart 2002). However, in this entry, we focus on one particular approach. Domestic violence-focused couples treatment (DVFCT) is a manualized program for treating couples experiencing situational couple violence (Stith et al. 2011). Its development began in 1997 at Virginia Tech using funding from the National Institute of Mental Health; DVFCT can be conducted in a multi-couple group format or with one couple at a time, and treatment is provided by two co-therapists. DVFCT is grounded in solution-focused brief therapy (De Shazer 1985). Therapist using this model seeks to avoid raising emotional intensity (that could possibly trigger violence in the relationship) and promotes building on strengths in the couple’s relationship (Stith et al. 2011). Research examining the effectiveness of DVFCT has found that this treatment for IPV has led to a decrease in both psychological and physical violence in the relationship, as well as an increase in overall marital satisfaction for some couples (Stith et al. 2011).

Application of Concept in Couple and Family Therapy Prior to beginning DVFCT, a thorough assessment is crucial in order to identify whether or not the couple is appropriate for couple’s treatment. Couples who report severe violence, or couples who have major discrepancies in the violence that they do report, are not suited for couples treatment (Stith et al. 2011). These couples should be referred to other forms of treatment. It is also recommended that couples who are appropriate for couples treatment sign a “no violence contract” which places ending violence as the center of therapy. Therapists using DVFCT begin and end each session meeting with each partner separately or with males and females separately if in a group format (Stith et al. 2011). Each week before beginning conjoint treatment, the therapist assesses for potential violence since the previous session and asks about successes. After the presession meeting, the therapists concur to determine if it is safe

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to conduct conjoint therapy that week. If it is not considered to be safe, the co-therapist works with each client (or each group) separately. If it is determined that conjoint therapy is appropriate, all clients and co-therapists meet conjointly. At the end of each session, co-therapists again meet separately with clients to determine if there is work to do before the couple leaves together. DVFCT is designed to be conducted using a solution-focused framework in 18 sessions. In the first 6 weeks, the therapist works primarily with men and women separately and helps them use and practice mindfulness exercises, develops and practices a negotiated time-out, begins to address substance abuse issues (if necessary), and uses psychoeducation to help them understand IPV. Psychoeducation that is important to address in therapy includes the definition of what constitutes IPV and the various types of abuse (i.e., physical, sexual, emotional, social isolation, etc.). In the final 12 weeks of the program, the same gender-specific pre- and post-groups are used, and couples practice mindfulness activities at the beginning of each session, but the issues addressed by the couple or multi-couple group are determined by client needs.

Clinical Example James and Alicia, both in their late 30s, came to therapy wanting to improve their relationship. James and Alicia had been experiencing more and more conflict and reported that their conflicts have escalated to the point where James would shove, push, or slap Alicia. During the first session, the co-therapists separated James and Alicia in order to assess for violence in their relationship. Through this assessment, the therapists learn that the violence in their relationship has not escalated past pushing, shoving, or slapping. James and Alicia both gave congruent accounts of the amount and types of violence in their relationship. The situational nature of the violence in their relationship, as well as the level of congruency in their responses surrounding the type of violence and the extent of the violence in their relationship, makes James and Alicia suitable for couples

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treatment. The therapists continued to assess for violence and the possibility of violence at the beginning of each session. One of the first things that was addressed in treatment (in separate sessions) was each partners’ view of the problem that brought them to therapy. Although DVFCT works from a solution-focused approach, it is important for both partners to talk about the problems that brought them and especially for the victim of violence to express how the violence has impacted her. This gave Alicia the chance to share her experience and to tell the therapists how emotionally hurtful it was for her when the violence occurred. Alicia described the fear and unsafety that she felt when James became angry. James, in a separate session, talked about his own disappointment that he had let himself lose control and become physically violent. He reported that he had grown up in a violent home and had vowed never to become violent in his own marriage. The therapists made sure that Alicia and James felt heard and understood during the first session. The therapists also had James and Alicia agree to a non-violence contract during their time in therapy. It was important for James and Alicia to make this commitment, or they would not be suited for couples treatment if they had declined making this commitment. Therapy also focused on how violence is a choice and that we are responsible for our own behaviors. The therapists highlighted for James and Alicia how James is responsible for acting violently toward his partner, and Alicia is responsible for her own decision on whether or not she stays with James if he does not commit to remaining violence-free. This first phase of treatment involved providing both James and Alicia with psychoeducation about the different types of violence, the cycle of violence, and anger management strategies. Some anger management strategies that the therapists discussed with James and Alicia were recognizing triggers, understanding that anger is a secondary emotion and that there are other emotions underneath that anger, and the understanding that they have a choice as to how to respond to triggers. Mindfulness exercises are also another important part of DVFCT, and the therapists started sessions with mindfulness exercises that the couple were

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encouraged to practice at home, especially if feeling triggered. Another tool that the therapists gave James and Alicia was a negotiated time-out. The negotiated time-out has seven steps that the therapists taught them and asked them to practice. This intervention can be found in detail in Rosen et al.’s article (2003). The therapists taught James and Alicia how to recognize when they are becoming distressed and develop a signal that let the other partner know that a negotiated time-out is needed, separating from one another for a scheduled period of time and then coming back together to resolve the conflict without the conflict escalating. In the session after the negotiated time-out was discussed, Alicia came to session stating that she thought it did not work. When asked to elaborate, Alicia reported that she felt as though James was using the time-out as a means to completely avoid talking about things. The therapists had to reiterate the importance of setting a time to come back to the conflict and that negotiated time-outs could not be indefinite time-outs. After this, Alicia reported that this technique was more useful, and James was able to come back and talk about conflicts at a later time. After James and Alicia were equipped with tools that helped them to de-escalate conflict, the second part of therapy was more client led and focused on what the couple needs from therapy. Continuing to use a solution-focused approach, the therapists helped Alicia and James navigate obstacles that they believe they will continue to face and focus on the strengths Alicia and James currently have in themselves and in their relationships.

References De Shazer, S. (1985). Keys to solution in brief therapy. New York: W.W. Norton. George, J., & Stith, S. M. (2014). An updated feminist view of intimate partner violence. Family Process, 53, 179–193. Johnson, M. P. (2008). A typology of domestic violence: Intimate terrorism, violent resistance, and situational couple violence. Lebanon: Northeastern Press. Jose, A., & O’Leary, K. D. (2009). Prevalence of partner aggression in representative and clinic samples. In

Couples Coping Enhancement Training Enrichment Program K. D. O’Leary & E. M. Woodin (Eds.), Psychological and physical aggression in couples: Causes and interventions (pp. 15–35). Washington, DC: American Psychological Association. O’Farrell, T. J., & Fals-Stewart, W. (2002). Behavioral couples and family therapy for substance abusers. Current Psychiatry Reports, 4, 371–376. Rosen, K. H., Matheson, J. L., Stith, S. M., McCollum, E. E., & Locke, L. D. (2003). Negotiated time-out: A de-escalation tool for couples. Journal of Marital and Family Therapy, 29(3), 291–298. Stith, S. M., Smith, D. B., Penn, C. E., Ward, D. B., & Tritt, D. (2004). Intimate partner physical abuse perpetration and victimization risk factors: A meta-analytic review. Aggression and Violent Behavior, 10(1), 65–98. Stith, S. M., McCollum, E., & Rosen, K., (2011). Couple therapy for domestic violence: Finding safe solutions. American Psychological Association. Washington, DC. Stith, S. M., McCollum, E., Amanor-Boadu, Y., & Smith, D. (2012). Systemic perspectives on intimate partner violence treatment. Journal of Marital and Family Therapy, 38(1), 220–240. https://doi.org/10.1111/j.1752.0606.2011. 00245.x. Straus, M. A. (2005). Women’s violence toward men is a serious social problem. In R. J. Gelles & D. R. Loseke (Eds.), Current controversies on family violence (pp. 55–77). Newbury Park: Sage.

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program for couples that aims to reduce martial distress and increase relationship satisfaction by helping couples improve their understanding of stress and coping, and acquire relationship skills. The program is based both upon stress and coping theory and research on couples. As everyday stressors can have a negative effect on relationship quality and satisfaction (Randall and Bodenmann 2009), and marital communication is especially affected by stress (e.g., Repetti 1989), the CCET focuses on building coping and communication skills with the aim of improving the quality of their relationship (Halford and Bodenmann 2013). In addition to traditional elements of couples programs (e.g., communication and problem-solving skills), CCET also addresses individual and dyadic coping (i.e., couples coping together as a unit) in promoting relationship satisfaction, improving the quality of the couple’s relationship, and reducing marital distress.

Prominent Associated Figures

Couples Coping Enhancement Training Enrichment Program Courtney K. Johnson-Fait1, Ashley K. Randall2 and Guy Bodenmann3 1 Arizona State University, Tempe, AZ, USA 2 Counseling and Counseling Psychology, Arizona State University, Tempe, AZ, USA 3 Department of Psychology, University of Zurich, Binzmuehlestrasse, Zurich, Switzerland

Name of the Model Couples Coping Enhancement Training (CCET) program

Introduction The Couples Coping Enhancement Training (CCET) program is a distress prevention training

The CCET program was developed by Dr. Guy Bodenmann (1997a).

Theoretical Framework The CCET is grounded in social learning theories, humanistic theory, and communication theory and is based upon the knowledge that communication competencies are among the most important predictors of marital success (Karney and Bradbury 1995). In the conceptualization of dyadic coping underlying the CCET approach, dyadic coping refers to a systemic-transactional view of coping in couples in which one partner communicates his or her stress (verbally or nonverbally), and the other partner responds to these signs in one of three ways: the partner becomes affected by stress also (i.e., stress contagion); the partner ignores the signals entirely (i.e., display no coping reaction whatsoever); or the partner demonstrates positive or negative dyadic coping (Bodenmann 1997b). Positive forms of dyadic coping include supportive dyadic coping (e.g., helping with daily

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tasks or providing practical advice, empathic understanding, helping the partner to reframe the situation, communicating a belief in the partner’s capabilities, or expressing solidarity with the partner); common dyadic coping (e.g., joint problem solving, joint information seeking, sharing of feelings, mutual commitment, or relaxing together); and delegated dyadic coping (where one partner is explicitly asked by the other to give support, and as a result, a new division of tasks is established, such as when one partner takes over chores for another). Negative forms of dyadic coping include hostile dyadic coping (support that is accompanied by disparagement, distancing, mocking, sarcasm, open lack of interest, or minimizing the seriousness of the partner’s stress), ambivalent dyadic coping (when one partner supports the other unwillingly or with the attitude that his or her contribution should be unnecessary), and superficial dyadic coping (support that is insincere, such as asking questions about the partner’s feelings without listening, or supporting the partner without empathy; Bodenmann 1997b). The improvement of individual and dyadic coping skills is a major emphasis within the CCET. In learning about dyadic coping, partners learn how to communicate with each other more clearly about their own stress experiences. Through this process and related emotional exploration, they also learn how to offer each other appropriate and matching support, how to promote closeness and intimacy within the relationship, and how to create a synergy in their efforts, so each partner can deal with everyday stress more effectively. Another key element of the CCET addresses fairness, equity, and boundaries within the relationship, as lack of fairness, equity, or the observance of insufficient boundaries can also give rise to stress and distress within the couple and fairness/equity regarding dyadic coping contributions is crucial. The CCET has elements of communication and conflict resolution in common with other programs (e.g., the Prevention and Relationship Enhancement Program [PREP]; Markman et al. 1993) and shares with Compassionate and Accepting Relationships through Empathy (CARE; Sullivan et al. 1998) elements of empathy and conflict resolution. However,

what makes the CCET different from other programs is its emphasis on stress and coping and the use of additional techniques related to the enhancement of individual and dyadic coping.

Populations in Focus CCET is offered to various populations of couples (universal prevention). This includes couples at risk of high stress vulnerability, such as those transitioning into parenthood and dual-career couples (selective prevention), and couples who already realize first damages of continuous stress exposure (indicated prevention). CCET is offered to heterosexual as well as same-sex couples, and couples at all ages and different cultural backgrounds.

Strategies and Techniques Used in the Model The CCET focuses on the importance of communication and ways in which couples can effectively cope with stress by teaching couples (a) how stress can cause their communication to deteriorate, and (b) how they can protect their communication and their relationship from the negative impact of stress by increasing their individual and dyadic coping resources. A high degree of standardization of the program is ensured with a detailed and highly structured manual for trainers (training manual published in German by Bodenmann 2000 and translated to English in 2004) and a thorough instruction program for the trainers delivering the program. Each trainer receives 30 h of training over a 4-day period, 20 h of group supervision and successful licensing before delivering the program. The program is 18 h and consists of modules varying from 1.5 to 5 h in duration. Because of the flexible modular structure, it can be offered in various formats. Typically, the CCET is offered as a weekend workshop that begins Friday evening and ends Sunday evening; although, the program can also be conducted as a series of six weekly sessions,

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lasting 3 h each. Another format allows the program to be embedded into a weeklong couple’s retreat that includes vacation and childcare. The content and effectiveness are identical in all three formats. The CCET typically is conducted in groups of four to eight couples. The CCET consists of six modules: Module one, Knowledge of Stress and Coping, is focused on teaching couples about stress and coping. This module aims to help couples improve their understanding of stress and distinguish between different types of stress. The content of this module includes an overview of the topic of stress – including its causes, forms, and consequences, as well as how couples cope with the stress. Via psychoeducation, couples are taught that stress is a consequence of cognitive appraisals and that emotions (e.g., sadness, anger, anxiety) are shaped by these appraisals. The content in module one also aims to promote enhancement of situation evaluation with exercises where aspects of the situation such as significance or controllability are evaluated. This module also includes assessment of different areas of stress by questionnaire. This module is intended to last 2 h and 30 min. In module two, Improvement of Individual Coping, the objectives include preventing stress by anticipating stressful situations and preparing in advance how to cope with the stressor. This module focuses on improving coping during the stressful event and processing it in retrospect. It focuses on counter stress by building up a repertoire of pleasant events as well as learning to reduce stress physiologically (e.g., progressive muscle relaxation). This module is delivered through short lectures on functionality of different coping strategies and includes a diagnostic exercise on one’s own coping style. Content is also delivered through exercises on different examples on the link between adequate copings according to different stress profiles. Materials are planning sheets for defining one’s own repertoire of pleasant activities

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and how stress can be avoided, analysis of coping reactions in everyday life and what adequate coping looks like, and relaxation techniques such as progressive muscle relaxation. This module is intended to last 3 h. The goals of Module three, Enhancement of Dyadic Coping, include increasing an understanding of the partner’s stress, enhancing stress-related communication, and improving dyadic coping skills. This module provides an introduction into the concept and utility of dyadic coping via a short lecture. Categories of dyadic coping are taught through video examples. Couples complete a questionnaire on how each partner communicates his or her stress and how they display dyadic coping. The core part of this module is the exercise of stress-related self-disclosure and provision of dyadic coping in the three-phase-method (Phase 1: communication of partner’s A stress; Phase 2: provision of dyadic coping by partner B; Phase 3: feedback of partner A to B on satisfaction and effectiveness of his/her support and further wishes). Simultaneously, both partners act in both roles (stress communicator and support provider). In these exercises, the couples are supervised by CCET providers. This module is intended to last 5 h. Module four, Exchange and Fairness in the Relationship, objectives include improving a couple’s awareness of the importance of a fair and mutual exchange within the context of dyadic coping, enhancing the ability to detect inequality and dependence in the relationship, and improve sensitivity towards one’s own needs and the needs of the partner. The content of this module is delivered through short presentation on the meaning of fairness and boundaries in the relationship. This includes diagnostic exercises to help couples understand their views on the exchange and fairness in their relationship; an assessment of personal needs for distance and closeness, as well as supervised communication exercises that allow both partners to explore their needs. This module also focuses on sensitization to the presence of over-

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involvement that may go along with dependence, or selfishness, in relationships. The length of this module is 2 h. Module five, Improvement of Marital Communication, aims to improve speaking and listening skills, detect inadequate communication behavior, and learn to overcome deficits in communication. These skills are taught through a short presentation on the meaning of appropriate communication and a video demonstration of dysfunctional communication (criticism, defensiveness, contempt, belligerence, and withdrawal), according to Gottman (1994). Each partner is asked to assess problematic communication styles in his or her own behavior by means of a short questionnaire. Then the couples are introduced to more effective ways of discussing differences through a widely used speaker-listener technique and are trained in supervised communication where both partners act as speaker and listener in two exercises. This module is intended to last 4 h. Module six, Improvement of Problem Solving Skills, focuses on strengthening the couple’s mutual problem-solving skills. This module includes brief psychoeducation on the usefulness of problem-solving in marriage and the need to resolve problems. It also consists of a supervised, structured, five-step problem-solving approach involving: describing the problem, brainstorming possible solutions, choosing the best solution, planning to solve the problem in everyday life by implementing this solution, and evaluating the solution. This module is intended to last 90 min.

Research About the Model The efficacy of the CCET has been supported in four randomized controlled trials as well as in different studies on effectiveness up to 2 years after participation in the program (Bodenmann and Shantinath 2004; Bodenmann et al. 2001; Cina et al. 2002; Widmer and Bodenmann 2009). Positive effects were found on

communication skills, individual and dyadic coping, psychological well-being, relationship satisfaction, as well as on the well-being of children.

Case Example Susan and Kim have been together for 8 years. They are in their early thirties, fell in love during college, and moved in together 4 years ago. They both work hard in leading positions, and although they earn well, their busy schedules do not allow much time for each other, and the couple suffers from daily stress and its spillover to their relationship. In the evening, both are either still working or are tired and need time for themselves. Joint activities became rare, and Susan and Kim’s sexual life is affected. Susan is unhappy and realizes that they pay a high price for their luxury life standard and that their high workload drives them apart. She feels alienated from Kim, their communication has become superficial or conflictual, and love is fading out. She talks with Kim and proposes to attend a workshop for couples focusing on stress management as a couple. Kim agrees with Susan’s concerns and approves. They look up possibilities and decide to attend a CCET workshop. In the CCET workshop, they meet five other couples, some in similar situations, one newly married couple wanting to keep love alive, one couple transitioning into parenthood, and one lesbian couple. All are eager to learn more about the how stress affects their relationship and how to deal with daily stress more effectively. A trained psychologist, licensed in CCET, delivers the workshop starting with theoretical inputs (psychoeducation), diagnostics (Stress Management: How much stress do I have in various areas?), and explains what stress is and how it influences communication, cohesion, relationship satisfaction and stability. Kim and Susan learn how their love can get buried under daily stress and how alienation can pull them apart. As they learn about the role of individual and dyadic coping in buffering stress, couples engage in discussing examples of their

Couples Coping Enhancement Training Enrichment Program

experiences coping with stress in their lives. Through their own discussion, other couples’ disclosures, and the facilitator’s teaching, Kim and Susan begin to appreciate how they can benefit from shared stress appraisals and joint dyadic coping efforts. They begin understanding what stress-related self-disclosure and dyadic coping look like – learning rules for the speaker and rules for the listener, and practicing effective communication. Via individual supervision, the trainers coach them in the application of rules and communication skills. Through a three-phase-method, Susan and Kim talk about continually upsetting situations and discover why the experiences are so hurtful. Both express a deepened mutual understanding, closeness, and ability to see their partner’s stress reaction in a different light, and therefore an ability to be empathic and supportive. They learn about fairness, effective communication, and problem-solving through instruction and exercises aimed at fostering their skills. Furthermore, they find the individualized attention from trainers particularly helpful in improving dyadic coping, communication, and problem-solving skills. Susan and Kim, like other couples, especially appreciate the different exercises and their coaching by a trainer. At the end of the workshop, Susan and Kim, like the other couples, feel motivated to apply these skills in everyday life. While five couples leave the workshop in a very positive humor and feel energized, one couple seems to have a harder time than before. One trainer talks with this couple discretely and suggests they seek of counseling or couple therapy for additional support. Susan and Kim leave feeling more confident about their ability to recognize the stress affecting the relationship, as well as their ability to communicate, and to cope with the stress in a more effective manner.

Cross-References ▶ Dyadic Coping Inventory ▶ Systemic-Transactional Model Coping

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References Bodenmann, G. (1997a). Can divorce be prevented by enhancing coping skills in couples? Journal of Divorce and Remarriage, 27, 177–194. Bodenmann, G. (1997b). Dyadic coping – A systemictransactional view of stress and coping among couples: Theory and empirical findings. European Review of Applied Psychology, 47, 137–140. Bodenmann, G. (2000). Kompetenzen für die Partnerschaft [Competencies for marriages]. Weinheim: Juventa. Bodenmann, G., & Shantinath, S. D. (2004). The Couples Coping Enhancement Training (CCET): A new approach to prevention of marital distress based upon stress and coping. Family Relations, 53, 477–484. https://doi.org/10.1111/j.0197-6664.2004.00056.x. Bodenmann, G., Charvoz, L., Cina, A., & Widmer, K. (2001). Prevention of marital distress by enhancing the coping skills of couples: 1-year follow-up-study. Swiss Journal of Psychology, 60, 3–10. Cina, A., Widmer, K., & Bodenmann, G. (2002). Die Wirksamkeit des Freiburger Stresspräventionstrainings (FSPT): Zwei Trainingsvarianten. [The effectiveness of two versions of the CCET]. Verhaltenstherapie, 12, 36–45. Gottman, J. M. (1994). What predicts divorce? Hillsdale: Erlbaum. Halford, K., & Bodenmann, G. (2013). Effects of relationship education on maintenance of couple relationship satisfaction. Clinical Psychology Review, 33, 512–525. Karney, B. R., & Bradbury, T. N. (1995). The longitudinal course of marital quality and stability: A review of theory, method, and research. Psychological Bulletin, 118, 3–34. Markman, H. J., Renick, M. J., Floyd, F. J., Stanley, S. M., & Clements, M. (1993). Preventing marital distress through communication and conflict management trainings: A 4- and 5-year follow-up. Journal of Consulting and Clinical Psychology, 61, 70–77. Randall, A. K., & Bodenmann, G. (2009). The role of stress on close relationships and marital satisfaction. Clinical Psychology Review, 29(2), 105–115. Repetti, R. L. (1989). Effects of daily workload on subsequent behavior during marital interaction: The roles of social withdrawal and spouse support. Journal of Personality and Social Psychology, 57, 651–659. Sullivan, K. T., Pasch, L. A., Eldridge, K. A., & Bradbury, T. N. (1998). Social support in marriage: Translating research into practical applications for clinicians. Family Journal: Counseling and Therapy for Couples and Families, 6, 263–271. Widmer, K., & Bodenmann, G. (2009). The Couples Coping Enhancement Training (CCET): A new approach to prevent marital distress based upon stress and coping. In S. Callan & H. Benson (Eds.), What works in relationship education? Lessons from academics and service deliverers in the United States and Europe (pp. 98–107). Doha: Doha International Institute for Family Studies and Development.

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Couples Financial Interview

Couples Financial Interview

and describe financial triggers which can create feelings of stress or anxiety, depression, and relational conflict.

Anne Brennan Malec Symmetry Counseling, Chicago, IL, USA

Theoretical Framework Name of Strategy or Intervention Couples Financial Interview.

Introduction The Couples Financial Interview has been used within the context of Financial Therapy (FT) in order to help a couple ascertain and express their beliefs and values about money. Financial conflicts may stem from fundamental differences between partners. Families of origin often shape one’s meanings of money – forming one’s money preferences and beliefs, or what are known as, money scripts (Klontz et al. 2011; Klontz and Klontz 2009). It is not uncommon for clients engaging in disordered money behaviors to be unaware of their own money scripts. Money scripts are underlying “assumptions or beliefs about money that are typically only partially true, are often developed in childhood, and unconsciously followed throughout adulthood (Klontz et al. 2011). These schemas often derive from an emotionally triggering financial event in one’s childhood that leaves a lasting impression, often until adulthood (Klontz and Klontz 2009). Money scripts are often multi-generational within families and cultures and serve to significantly influence financial behaviors. One clinical intervention for uncovering money scripts or schemas is to engage in a Couples Financial Interview. The interview will provide needed insight into how client(s) views money, and where he or she may develop problematic financial behaviors. Through addressing a series of questions, the clinician and client(s) will be able to understand long-held beliefs that have created the current difficulty, uncover unexpressed financial expectations of a partner,

The Couples Financial Interview is a method used in Financial Therapy of gathering information about a couples’ beliefs about money. Financial Therapy (FT) is an emerging field focused on evaluation and treatment of the “cognitive, emotional, behavioral, relational, and economic aspects of financial health” affecting one’s daily life (Britt et al. 2014). A main objective of FT is to improve one’s relationship with money thereby improving quality of life. The Financial Therapy Association was founded in 2009 in order to provide a forum for financial professionals, mental health professionals, and researchers to coalesce around a shared vision of financial therapy. Financial therapists assist clients with a variety of issues related to money, such as: improving one’s financial knowledge, skills, and relationship with money; exploring, negotiating, and effectively applying financial knowledge to reduce anxiety and conflict; and gain a sense of empowerment over their financial lives. Financial therapists also assist clients in introducing challenging financial conversations with family members. They are professionally trained in the mental health and financial fields. Financial therapists act in the best interests of their clients and respect the confidential nature of the client-service provider relationship (Financial Therapy Association 2017).

Rationale The American Psychological Association reports that since 2007 money has been a top cause of stress for Americans. The most recent survey found 72% of Americans stressed over money during the past month. Thirty-one percent of adults with partners reported money as a major source of conflict in their relationship. Seventyseven percent of couples with children reported

Couples Financial Interview

money as a very significant source of stress in their marriage (APA 2015). Turkel (1988) states that money is “One of the richest fields in which to sow seeds of marital strife” (p. 225–226), as well as, “A symbol of worth, competence, freedom, prestige, masculinity, control, and security, all of which can become areas of conflict” (p. 525). Trachtman (1999) states that in our society an emotional taboo exists around money issues, making Americans “seclusive, embarrassed, and conflicted about discussion of money” (Kreuger 1986, p.vii). As a society we may be comfortable talking about tax rates, health care costs, and social security, but rarely do people discuss their income, level of debt, or thoughts and feelings about money. Financial difficulties have been shown to predict increases in depression, marital conflict, and the likelihood of divorce, with a predicted decrease in marital satisfaction (Dew 2008; Amato and Rogers 1997; Conger et al. 1990; Gudmunson et al. 2007; Stanley et al. 2002). The European Journal of Public Health found that adults in debt were three times more likely than those without debt to suffer from common mental health disorders. A study from Northwestern (Sweet et al. 2013) found that consumers with higher levels of debt had a 13.3% increase in depressive symptoms and an 11.7% increase in perceived stress. For every 10% increase in personal debt, the study found that depressive symptoms worsened by 14%. In terms of financial and human capital, when resources are low, conflict is high. Dew (2007) found that net worth is an important predictor of partner conflict. Specifically, couples with higher debt loads report greater levels of stress and more conflict, as well as those with lower levels of income and education (Dew and Yorgason 2010). Money conflict between partners arises from different financial management strategies (Lawrence et al. 1993), charitable giving preferences (Andreoni et al. 2003), and spending personalities (Rick et al. 2009). A common theme in the literature is that money arguments are related to couples deciding how to allocate resources within the household. Practitioners and

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researchers have found that spending preferences, such as differences in gifting preferences, financial risk tolerance levels, and perceived power differentials can all lead to increased conflict in a relationship (Stolz 2009). Dew and Dakin (2011) found disagreements about financial issues often lead to intense arguments. Britt et al.’s (2010) research suggested that insufficient communication between couples is a bigger predictor of arguments about money than power or available resources. Falconier and Epstein (2011) supported the value of practitioners’ awareness of how financial issues can affect a couple and the importance of understanding each partner’s role with family finances. The authors also stressed the importance of the clinician inquiring about partners’ satisfaction with the current status of their financial roles. Financial issues are different than other relationship issues in that they cannot easily be ignored (Papp et al. 2009). In addition to their frequency and unavoidability, financial issues may be related to visceral emotions that can act as triggers for negative conflict tactics. This is because individuals connect such powerful meanings as, “caring, security, success, and esteem to money” (Shapiro 2007; Jenkins et al. 2002). Disagreements about money may have less to do with the actual financial and spending choices and more to do with the underlying meanings of money (Jenkins et al. 2002). Research and practice have asserted that “Money has symbolic potential unlike almost anything else” (Stanley and Einhorn 2007, p. 294). Financial disagreements are often related to power, gender, and control issues. (Jenkins et al. 2002; Shapiro 2007). Rick et al. (2009) reported evidence of conflict being predicted by differences in spousal preferences in spending behavior, specifically, a pattern of negative assortative mating (partnering based on dissimilar characteristics) when it comes to spending behaviors. Negative assortative mating has been found to be associated with increased conflict. They found the highest levels of conflict when a chronic over-spender was married to a chronic under-spender. The researchers also found that the greatest relationship satisfaction

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developed when spending behaviors were the same. Lawrence et al. (1993) used financial management strategies to predict arguments about money. Couples who reported healthy financial management strategies, such as recordkeeping and goal setting, were less likely to argue in comparison to other couples. These findings suggest that for couples who prioritize seeking agreement on financial matters may have less to argue about. When working with couples in the context of financial therapy, it is recommended that the clinician keep in mind that research findings indicate that there is a gender gap in the levels of financial knowledge demonstrated by men and women (Huston 2010; Lusardi and Mitchell 2008; Woodyard and Robb 2012; Xiao et al. 2011). In particular, as it relates to personal finance, women are less confident, knowledgeable, and interested than are men (Borden et al. 2008; Chen and Volpe 1998, 2002; Lusardi and Mitchell 2007; Robb and James 2009).

Description of Intervention After establishing basic rapport with the couple and discussing the goals and purpose of financial therapy, the clinician can begin the Couples Financial Interview in order to ascertain the beliefs and money scripts of the individuals. It is important to maintain an exploratory and nonjudgmental atmosphere in order to allow for honest and vulnerable answers. When working with couples or individuals around issues related to money or financial management, a therapist may inquire about the following: • Each partner’s financial role in the relationship – is there a main provider, secondary provider, co-provider, only provider? • Is money a frequent source of conflict? If so, what aspects of money lead to conflict? • What are the client’s biggest financial fears? • What money related cognitions shape each partner’s financial concerns and coping strategies?

Couples Financial Interview

• How will the financial situation change if the couple has children? • Will one partner leave the workforce to care for children? If so, is this a temporary or permanent shift? • What are each partner’s expectations for how their family’s finances should work? • Were finances discussed before the couple got married or engaged? If not, why? • How does a partner feel when the other partner questions spending or tries to place limits on spending? • Does one partner dominate financial decisions? • What are the expectations of income, freedom to spend, savings, retirement, etc.? • Does one partner value budgeting more than the other? • Is there any resentment from past financial decisions? • Does either partner have adult children from this or a prior relationship? If so, what does each partner think about supporting children into adulthood? • Has either partner used joint assets without the knowledge of the other? • Has there been an increase in feelings of anxiety, depression, anger, increase in substance use/abuse, increase in arguments, demand/ withdrawal behaviors, psychological or physical aggression, or relationship distress? What role have finances played? • How has the couple been trying to cope with the financial/relational strain? What helps? What hurts? Have there been attempts at problem-solving? Has there been avoidance of the topic? Further information can be gathered by asking the following (adapted from Mumford and Weeks 2003; Furnham et al. 2014): • What is your earliest memory around money? • What is your most joyful money memory? Most painful? • What were you taught about the wealthy/poor? What are your memories of your parents around financial issues? • Was money openly discussed in your home?

Couples Financial Interview

• Do you recall there being financial honesty or were there secrets and hidden spending? • Were your parents’ savers or spenders? • Were your parents anxious about money? • Did they have consistent work? • Were there periods of poverty or feelings of deprivation? • Were there frequent arguments about money? • Who made the financial decisions? • Were there any bankruptcies? Borrowing? Credit card debt? Gambling issues? • If one’s parents divorced, was money a contentious issue? • Did you determine at a young age that you would “never” do certain things, or you would live differently? • How did/are parents faring financially in retirement/older years? • What plans have you made for retirement? • How much money and what lifestyle do you expect to have for retirement? • What resources are available to you in the event of an emergency? • How do your siblings live now? • How do you think your family money history has affected you? • Does your financial situation cause you shame or embarrassment?

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budget considerations and that she resists his attempts to control her spending. He reports feeling extreme frustration that he must be the family financial manager while his wife seems oblivious to family budget constraints. By conducting the Couples Financial Interview, the clinician is able to help the clients identify and express their feelings and beliefs about money and how those beliefs have created the foundation for their current financial distress. The couple is able to talk about their finances without the conversation escalating to attacks or being shut down by a desire to avoid unresolvable conflicts. The wife can explore how and why she came to believe it was her spouse’s responsibility to manage the family finances, and why she has been so resistant to live within a budget. The husband has the opportunity to consider why he chose to hide debts from his spouse and not address the family spending issues sooner. With the help of the clinician, the couple creates a budget and sets goals to alleviate their debt. They meet separately with a financial planner who can provide an overview of their financial challenges and help them chart a course for the future. The couple also learns strategies for engaging in positive and effective communication about money as well as other sensitive topics. Three months later, they report being on track to pay off their debt within a year and that they are experiencing improved satisfaction in their marriage.

Case Example A heterosexual couple presented for financial therapy after losing their home due to the husband’s poor financial management and growing debt. The wife was unaware of the family financial strain in part due to the husband falsifying financial documents. The couple explains that they have difficulty communicating effectively about money because the conversation escalates quickly with mutual blaming, criticism, and defensiveness. As it relates to spending, the wife reports feeling criticized, controlled, “parented” by her husband and micro-managed. The husband reports feeling unappreciated for his financial contributions to the family, and resentful about unexpressed financial expectations. The husband states that his wife acts entitled to spend without

References American Psychological Association Survey Shows Money Stress Weighing on Americans’ Health Nationwide. (2015, February 04). Retrieved 21 April 2017, from http://www.apa.org/news/press/releases/2015/02/ money-stress.aspx. Amato, P. R., & Rogers, S. J. (1997). A longitudinal study of marital problems and subsequent divorce. Journal of Marriage and the Family, 59, 612–624. Andreoni, J., Brown, E., & Rischall, I. (2003). Charitable giving by married couples: Who decides and why does it matter? The Journal of Human Resources, 38(1), 111–133. Borden, L. M., Lee, S., Serido, J., & Collins, D. (2008). Does participation in a financial workshop change financial knowledge, attitudes, and behavior of college students? Journal of Family and Economic Issues, 29, 23–40.

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660 Britt, S. L., Klontz, B. T., & Archuleta, K. L. (2014). In B. T. Britt, S. L. Britt, & K. L. Archuleta (Eds.), Financial therapy: Establishing an emerging field. New York: Springer. Chen, H., & Volpe, R. P. (1998). An analysis of personal financial literacy among college students. Financial Services Review, 7(2), 107–128. Chen, H., & Volpe, R. P. (2002). Gender differences in personal financial literacy among college students. Financial Services Review, 11, 289–307. Conger, R. D., Elder, G. H., Lorenz, F. O., Conger, K. J., Simon, R. L., & Whitbeck, L. B. (1990). Linking economic hardship to marital quality and instability. Journal of Marriage and the Family, 52, 643–656. Dew J. (2007). Two sides of the same coin? The differing roles of assets and consumer debt in marriage. Journal of Family and Economic Issues, 28, 89–104. Dew, J. P. (2008). Marriage and finances. In J. J. Xiao (Ed.), Handbook of consumer finance research (pp. 337–350). New York: Springer. Dew, J., & Dakin, J. (2011). Financial disagreements and marital conflict tactics. Journal of Financial Therapy, 2(1), 7. https://doi.org/10.4148/jft.v2i1.1414. Dew, J. P., & Yorgason, J. (2010). Economic pressure and marital conflict in retirement-aged couples. Journal of Family Issues, 31, 164–188. Falconier, M. K., & Epstein, N. B. (2011). Couples experiencing financial strain: What we know and what we can do. Family Relations, 60, 303–317. Financial Therapy Association. (2017). What is financial therapy? Retrieved 21 April 2017, from https://www. financialtherapyassociation.org/. Furnham, A., von Stumm, S., & Milner, R. (2014). Moneygrams: Recalled childhood memories about money and adult money pathology. Journal of Financial Therapy, 5(1), 4. https://doi.org/10.4148/19449771.1059. Gudmunson, C. G., Beutler, I. V., Israelsen, C. L., McCoy, J. K., & Hill, E. J. (2007). Linking financial strain to marital instability: Examining the roles of emotional distress and marital interaction. Journal of Family and Economic Issues, 28, 357–376. Huston, S. J. (2010). Measuring financial literacy. Journal of Consumer Affairs, 44, 296–316. Jenkins, N. H., Stanley, S. M., Bailey, W. C., & Markman, H. J. (2002). You paid how much for that: How to win at money without losing at love. San Francisco: Jossey-Bass. Klontz, B., & Klontz, T. (2009). Mind over money: Overcoming the money disorders that threaten our financial health. New York: Crown Business. Klontz, B., Britt, S. L., Mentzer, J., & Klontz, T. (2011). Money beliefs and financial behaviors: Development of the Klontz money script inventory. Journal of Financial Therapy, 2(1), 1–22. https://doi.org/10.4148/jft. v2il.451. Klontz, B., Britt, S. L., Archuleta, K. L., & Klontz, T. (2012). Disordered Money Behaviors: Development of the Klontz Money Behavior Inventory. Journal of

Couples Financial Interview Financial Therapy, 3(1), 2. https://doi.org/10.4148/jft. v3i1.1485. Kreuger, D. (Ed.). (1986). The last taboo; money as symbol and reality in psychotherapy and psychoanalysis. New York: Brunner/Mazel. Lawrence, F. C., Thomasson, R. H., Wozniak, P. J., & Prawitz, A. D. (1993). Factors relating to spousal financial arguments. Financial Counseling and Planning, 4, 85–93. Lusardi, A., & Mitchell, O. S. (2007). Financial literacy and retirement preparedness: Evidence and implications for financial education. Business Economics, 42, 35–44. Lusardi, A., & Mitchell, O. S. (2008). Planning and financial literacy: How do women fare? American Economic Review, 98, 413–417. Mumford, D., & Weeks, G. (2003). The money genogram. Journal of Family Psychotherapy, 14, 33–45. Papp, L. M., Cummings, E. M., & Goeke-Morey, M. C. (2009). For richer for poorer: Money as a topic of marital conflict in the home. Family Relations, 91, 91–103. Stanley, S. M., & Einhorn, L. A. (2007). Hitting pay dirt: Comment on “money: A therapeutic tool for couples therapy”. Family Process, 46, 293–299. Rick, S. I., Small, D. A., & Finkel, E. J. (2009, September 30). Fatal (fiscal) attraction: Spendthrifts and tightwads in marriage. Robb, C. A., & James, R. N. (2009). Associations between individual characteristics and financial knowledge among college students. Journal of Personal Finance, 8, 170–184. Shapiro, M. (2007). Money: A therapeutic tool for couples’ therapy. Family Process, 46, 279–291. Stanley, S. M., Markman, H. J., & Whitton, S. W. (2002). Communication, conflict, and commitment: Insights on the foundations of relationship success from a National Survey. Family Process, 41, 659–675. Stolz, R. F. (2009, July). When couples clash over finances. Journal of Financial Planning, 22(7), 20–25. Sweet, E., Nandi, A., Adam, E. K., & TW, M. D. (2013). The high price of debt: Household financial debt and its impact on mental and physical health. Social Science & Medicine, 91, 94–100. Trachtman, R. (1999). Clinical Social Work Journal, 27, 275. https://doi.org/10.1023/A:1022842303387. Turkel, R. A. (1988). Money as a mirror of marriage. Journal of the American Academy of Psycholanalysis, 16, 525–535. Woodyard, A., & Robb, C. (2012). Financial knowledge and the gender gap. Journal of Financial Therapy, 3(1), 1. https://doi.org/10.4148/jft.v3i1.1453. Xiao, J. J., Tang, C., Serido, J., & Shim, S. (2011). Antecedents and consequences of risky credit behavior among college students: Application and extension of the theory of planned behavior. Journal of Public Policy and Marketing, 30(2), 239–245.

Couples Group Therapy

Couples Group Therapy Judith Coché The Coche Center, Philadelphia, PA, USA Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

Introduction Couples group therapy is a treatment modality founded on integrating principles from group dynamics and family therapy. A small group structure employing insight-oriented therapy is used to promote healing and growth for couples. Concepts are drawn from distinct but compatible sectors: family and couples therapy, group therapy, psychological assessment, and psychoeducation. This combination of modalities constitutes a unique approach which emphasizes each individual and the couple as a unit.

Theoretical Framework Couples group therapy has drawn on major contributors to group and marital therapy, including existential work by Irvin Yalom (1985), psychodynamic work by Rutan and Stone (1984), attachment theory by John Bowlby (1969), John Gottman’s communication model (1994), and Yvonne Agazarian’s system model (1981). Conceptual origins in systems theory are drawn from the worlds of biology (Von Bertalanffy 1968) and social psychology (Lewin 1951). An intergenerational frame for couples work (Sullivan1953) is key. Existential base: Three existential principles underlie the work: 1. Clients seek to be more of a person in an intimate context than they have been able to achieve. Carl Whitaker and David Keith (1981) stated that the goals of therapy should be to establish a sense of belonging, to provide

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the freedom for persons to individuate, and to increase personal and systemic creativity. 2. Adult intimacy involves taking responsibility for one’s actions, thoughts, feelings, and behavior in relation to the other person. 3. An emphasis on the positive and constructive handling of human concerns is hope-inducing for clients. An Intergenerational Frame for Couples Work Couples group therapy assumes that both couples and groups form a system and that treatment interventions need to include multi-generation patterns for both marital and family dynamics. A group operates like a family, and a family has the properties of a small group. Both are greater than the sum of their parts, and the subsystems of each can be fully understood only through knowledge of the working whole. Systems Theory Isomorphism states that similar structures and processes occur on several levels in related systems (Coche and Coche 1990). Therapists need to think on several levels simultaneously in order to respond with flexibility to the challenges of the group: 1. Personal level: The group concentrates intensely on one member, and therapy looks somewhat like individual therapy. 2. Couples level: Interventions focus on the verbal and nonverbal internal and interpersonal behaviors, and dimensions of the behaviors, for each member of the couple and for the couple as a whole. Patterns of affection, interest, anger, and withdraw comprise some of the dimensions considered. 3. Interpersonal level: The activity of the group is directed to interpersonal relationships between members and couples in the group. Many of Irvin Yalom’s (1985) curative factors, such as universality and altruism, come to full therapeutic power at the interpersonal therapeutic level.

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Couples Group Therapy

Description of the Strategy

Group size. A number of authors write that the optimal group size is three to five couples. This size creates optimal opportunity to experience the power of the dyadic and subgroup relationships between group members and allows member to identify with one another. Length and frequency of sessions. Clinicians vary in their preferred length and frequency of group meetings. For example, one use of couples therapy is within a medical setting. There, heart attack victims and their partners may come together weekly for 1 h to discuss common concerns and solutions to ongoing problems. In a different scenario, couples who want to optimize intimacy and sexuality may benefit from a monthly group of three or 4 h. This frequency allows couples to travel the distance needed to attend a group with trained coleaders and encourages depth of clinical progress that can only be achieved with a group of this time duration. Although actual time varies, it is crucial to adapt the frequency and length of sessions to meet the needs of members. In an institutional setting, for example, where clients would find it difficult to concentrate for a longer period of time, greater frequency and shorter sessions would be necessary. Clinical success requires a match between needs served and clinical structures.

Structuring an Effective Treatment Package In order to structure an effective treatment package, it is necessary to decide if one is going to do a closed or open group. One must also plan the length of the sessions, set goals and do progress reports, and consider whether to require out of group therapy. Finally, a decision about single or coleadership needs to be made. Closed versus open group therapy. There are two ways of controlling the flow of patients in a group. In a closed group, patients begin and end therapy at the same time. For example, a group begins in September and ends at the end of June. In an open group, patients begin and end as is optimal: one couple may begin in January and end in April, while a different couple remains in the group for a second year.

Group Organization and Functioning A group is organized along time, content, and leadership dimensions. In structuring couples group therapy, leaders consider the length of the group and interventions concerning both content and process levels of change. Optimal group length depends on the goal of the group: support groups may meet for 1 h for 6 weeks, while depth groups may meet for six to 12 months for two to 4 h. Most members seek change relating to difficult topics of being coupled: they want to improve their finances, decide about whether to have children, or manage sexual dissatisfaction. In addition to these content areas of focus, the couple needs to enrich and deepen the emotional communication skills between them because this level of interchange

4. Group-as-a-whole level: At the group-as-awhole level, the leader makes a statement that applies to everyone, such as the group is annoyed. Directional shifts, group decisions, norm enforcement, and explorations of participants’ roles in the group all are topics of discussion that fall into the group-as-a-whole category (Agazarian and Peters 1981). Groupas-a-whole work enables the group to progress developmentally, from dependence on the leader to interdependence between members.

Rationale for the Strategy Couples group therapy applies strengths from group, marriage, and family therapy. From group therapy, strengths include the feedback loop provided by other members and a spirit of group support that lives in each member between sessions. From marriage and family therapy, there is an approach to the couple/family as a working social system designed to protect the life and well-being of each member. Research in couples group therapy (Coche 2010) underscores the finding that intervention using this modality is at least as effective as other therapeutic modalities.

Couples Group Therapy

allows couples to deepen intimacy and sexuality. Interaction between members focuses not only on the content of the concern but on the way of expressing this topic. Pre-training. Most pre-training programs consist of brief informative sessions which occur before a couples group begins. The function of pre-training is to define the therapist’s role and to explain the session format and other important things such as confidentiality, goals, group purpose, contracting, and general group policies. Therapy goals and progress reports. Treatment goals can focus on issues such as improved communication skills; heightened awareness and openness; increased flexibility in intimacy, sexuality, problem solving, clarification of role ambiguities, and conflicts; improvement of the couple’s maladaptive defense styles; and increasing awareness of intergenerational issues. Many types of couples group therapy include goal setting at the beginning of the group. In some models, goal setting is done by the patients themselves: frequently patients are given an assignment to set their goals and be ready to report on them at the next group meeting. In other couples groups, goals may be jointly set by the therapists and the clients. Setting goals helps clients to focus their energies on specific steps in achieving the change that they seek. Facilitating Therapeutic Change Within a Couples Group Setting Two facets of facilitating change within a couples group setting merit brief clinical attention. First, group leaders must be comfortable handling both predictable problems and clinical emergencies in ongoing groups. Predictable problems include ongoing lateness or absence of members, interpersonal difficulties between group members that are hard to resolve, and members who interrupt the flow of the group through extraneous comments. Clinical emergencies involve choices of treatment paradigms for maximal therapeutic progress. In addition to recent developments in relational psychoanalytic thinking and in cognitive-behavioral approaches to therapy, particular attention is devoted to positive psychology as a catalyst of

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change, to the nodal work on attachment theory in couples group therapy, and to the foundation work in the technology of neuropsychological and nonverbal aspects of couples group therapy.

Case Example In the brief vignette that follows, readers can trace the concerns that brought a couple into treatment, how couples group therapy addressed their concerns, and, finally, the benefits they received from the treatment. Donald carries an American passport and is of Italian heritage; Jean is Australian. They married despite concerns about their competitive families. Both families wanted the couple to move to their country of residency and competed for the affection of the grandchildren. After Jean finished graduate training in economics, the couple settled in the United States. Jean found life empty in a society which she found materialistic and preferred Australia’s laid-back lifestyle. A genetic predisposition toward depression exacerbated Jean’s sense of feeling lost in her home. She sought treatment for depression and asked Donald to move “back home” with her. His career was deeply centered in their state residency. When individual and couples treatment proved inadequate, the therapists suggested that the special power of a group to create an environment that fostered change might help Jean become less depressed as well as help Donald be more flexible in meeting her needs. The couple was screened to be members of a general couples therapy group for relatively highfunctioning couples needing to make changes in one or more areas of their lives. The heterogeneity of the age of the members, combined with the high motivation for clinical change, creates an optimal learning environment for couples who need to change levels of intimacy and sexuality, learn to communicate more effectively, and find greater life satisfaction together. This group offered a safe and positive forum to treat issues necessitating treatment. The group met twice a month for 150 min. Coleadership involved a senior therapist skilled in both group therapy and couples therapy

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and a junior therapist training to become a certified group therapist. Explicit confidential contracts were signed by each member and kept on file. The closed group began in the fall and ended 11 months later. The closed group format had the advantage of enabling members to grow trusting of the leader and of each other, facilitating transformational change in a short time period. Groups started on time and ended on time, and members were asked not to miss more than 25% of the sessions during a 12-month contractual period. Members sat on comfortable chairs and couches in a circle. Leaders sat across from one another in order to maximize eye contact. Clinical notes were recorded by the less experienced coleader. Policies by which the group operated were read by all members when they entered the group: each member signed a contract agreeing to the treatment as described in the policies. The group therapy fee was charged monthly and the bulk of the treatment was covered by insurance. In addition to their participation in the group, each group member (including Donald and Jean) participated in either individual or couples therapy. This combination of some targeted individual work and some targeted group work acted as a catalyst enabling a level of change difficult to achieve without the power of a group. The couples group therapy facilitated both personal and interpersonal change for Donald and Jean. Members grew to care about each other’s welfare. This ongoing source of honest feedback and deep caring facilitated necessary and complex changes for each partner. Members of the group served as a hall of mirrors, reflecting the behavior and comments of each member. Feedback from members helped facilitate necessary behavioral and attitudinal changes in the marriage, in Donald and Jean, and in the communication style between them. As treatment for the couple progressed, Jean and Donald began to explore their respective reasons for marrying. Jean, raised in a highly self-contained British family culture, thought that Donald’s high-spirited Italian family often acted in bad taste and had no interest in learning

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to fit into their customs. Because Donald was more flexible and quite excited about the freedom that Australia offered, the couple decided to move with their two sons to Australia, where they remain. They love living near the ocean, they love the freedom of the country, and they find meaning together raising their family in this society. As soon as they were able to agree on what would mean the most, they overcame the daunting task of creating a meaningful culture for themselves and their children. Treatment with the help of other members of the group enabled substantial change: the group acted as a hall of mirrors, creating a microcosm of the world at large much more powerful than therapy for the couple and one therapist. Couples practiced their work outside the group and reported progress to other members. The feedback loop acted as a catalyst to reach treatment goals. Donald and Jean describe their experience in the group as transformational, allowing them to connect with one another more deeply than they would have thought possible.

Cross-References ▶ Hold Me Tight Enrichment Program ▶ Sexuality in Couples ▶ Strategic Family Therapy ▶ Trust in Gottman Method Couples Therapy

References Agazarian, Y., & Peters, R. (1981). The visible and invisible group: Two perspectives on group psychotherapy and group process. London: Routledge & Kegan Paul. Bowlby, J. (1969). Attachment and loss (2nd ed.). New York: Basic Books. Coché, J. (2010). Couples group psychotherapy: A clinical treatment model (2nd ed.). New York: Taylor and Francis. Coché, J., & Coché, E. (1990). Couples group psychotherapy: A clinical practice model. New York: Brunner/ Mazel. Gottman, J. M. (1994). What predicts divorce: The relationship between marital processes and marital outcomes. Hillsdale: Lawrence Erlbaum Associates. Lewin, K. (1951). Field theory in social science: Selected theatrical papers. Chicago: University of Chicago Press.

Crane, D. Russell Rutan, J. S., & Stone, W. N. (1984). Psychodynamic group psychotherapy. New York: Macmillan. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Routledge. Von Bertalanffy, L. (1968). General systems theory: Foundations, development, and applications. New York: George Braziller Inc.. Whitaker, C. A., & Keith, D. V. (1981). Symbolicexperiential family therapy. In A. Gurman & D. Kniskern (Eds.), Handbook of family therapy (pp. 187–225). New York: Brunner/Mazel. Yalom, I. D. (1985). The theory and practice of group psychotherapy (3rd ed.). New York: Basic Books.

Crane, D. Russell Richard B. Miller Brigham Young University, Provo, UT, USA

Name D. Russell Crane (1948–)

Introduction D. Russell Crane was an influential couple and family therapy (CFT) researcher whose groundbreaking research established CFT as a costeffective treatment modality for mental and relational disorders. His research also demonstrated that CFT resulted in decreased healthcare utilization of couples and families seen in therapy.

Career Crane received his Ph.D. in 1979 in marriage and family therapy from Brigham Young University. After spending the first 4 years of his career at Texas Tech University, he was a professor in the MFT program at Brigham Young University for 34 years, before retiring in 2016. Throughout his career, he provided important service to the profession, serving as chair of the Commission on Accreditation for Marriage and Family

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Therapy Education, as well as chair of the Family Therapy Section in the National Council on Family Relations.

Contributions to the Profession He spent the early years of his career conducting research on measurement issues in CFT, but in the middle of the 1990s, he turned his attention to exploring the economic effectiveness of CFT. Although by that time the general effectiveness of CFT had been established by numerous randomized clinical trials, Crane believed that there was a need to demonstrate that CFT was also cost-effective. Recognizing the research that demonstrated that clients who were seen in individual psychotherapy experienced a subsequent decrease in their use of health-care services, Crane sought to see if a similar phenomenon was present in CFT. Termed the “medical offset effect,” the idea was to see if the costs of mental health treatment were offset by a reduction in visits to doctors and hospitals after treatment was terminated. Crane was able to obtain access to the health-care records from a major healthcare organization, and he found that clients who attended couples therapy experienced a 21.5% decrease in health-care utilization over the next year (Law and Crane 2000). In addition, he found that the “identified patient” in family therapy experienced a 9.5% decrease and that other family members participating in family therapy experienced a 30.5% decrease in their use of health-care services. Thus, in addition to demonstrating the applicability of the medical offset effect to CFT, Crane, consistent with family system theory, was able to establish family therapy’s added economic benefit of reducing multiple family member’s health-care utilization within the same episode of treatment. Subsequent research by Crane showed an even larger medical offset effect among high utilizers of health-care services, who account for a disproportionate amount of overall health-care costs. Crane found that high health-care utilizers (defined as patients with at least four health-care visits in a 6-month period)

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who received CFT decreased their overall health-care use by about 50% (Law et al. 2003). More specifically, they experienced subsequent decreases in medical use for urgent care visits (78%), illness visits (38%), and laboratory/X-ray visits (56%) (Crane and Christenson 2008). Following his seminal work on medical offset effects in CFT, Crane continued doing research on the cost-effectiveness of CFT by publishing a series of studies that used nearly one million medical records from CIGNA, a major health-care insurer. He was able to use those records to compare the costs of using conjoint therapy (either couple of family therapy) with the costs of using individual therapy to treat various mental and relational disorders. For example, when examining the costs of treating depression, he found that individual therapy was 58% more costly than conjoint therapy (Crane et al. 2013). In recognition of his groundbreaking research on the cost-effectiveness of CFT, in 2007 Crane was given the Cumulative Contribution to Marriage and Family Therapy Research Award by the American Association for Marriage and Family Therapy.

Creating Lasting Family Connections Program Law, D. D., & Crane, D. R. (2000). The influence of marital and family therapy on health care utilization in a health maintenance organization. Journal of Marital and Family Therapy, 26, 281–291. Law, D. D., Crane, D. R., & Berge, J. (2003). The influence of marital and family therapy on high utilizers of health care. Journal of Marital and Family Therapy, 29, 353–363.

Creating Lasting Family Connections Program Ted N. Strader1,2, Christopher Kokoski1, David Collins3, Steven Shamblen3 and Patrick McKiernan4 1 Council on Prevention and Education: Substances (COPES), Louisville, KY, USA 2 CLFC National Training Center, Resilient Futures Network, LLC, Louisville, KY, USA 3 Pacific Institute for Research and Evaluation (PIRE), Beltsville, MD, USA 4 University of Louisville, Louisville, KY, USA

Name of Model The Creating Lasting Family Connections ® (CLFC) Program

Cross-References ▶ Meta-Analysis of Treatment Outcomes in Couple and Family Therapy ▶ Quantitative Research in Couple and Family Therapy ▶ Research About Couple and Family Therapy

References Crane, D. R., & Christenson, J. C. (2008). The medical offset effect: Patterns in outpatient services reduction for high utilizers of health care. Contemporary Family Therapy, 30, 127–138. Crane, D. R., Christenson, J. D., Dobbs, S. M., Schaalje, G. B., Moore, A. M., Pedal, F. F. C., Ballard, J., & Marshall, E. S. (2013). Costs of treating depression with individual versus family therapy. Journal of Marital and Family Therapy, 39, 457–469.

Introduction Creating Lasting Family Connections (CLFC) is a manualized, family focused program to increase parenting skills and familyrelationship skills to build the resiliency of youths aged 9–17 years, to increase alcohol and drug knowledge and attitudes, to reduce the frequency of alcohol and other drug (AOD) use, and to increase family use of needed community services. CLFC is designed to be implemented through community systems such as mental health centers, churches, schools, recreation centers, and court-referred settings. There are three modules for parents and three separate modules for their children.

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CLFC Program Modules for Adults Raising Resilient Youth. Participants learn and practice effective communication skills with their families, friends, and coworkers, including listening to and validating others’ thoughts and feelings. Participants also enhance their ability to develop and implement expectations and consequences with others, including children, spouses, coworkers, and friends. This training enhances a sense of competence, connectedness, and bonding between parent and children and other meaningful relationships (Strader and Noe 1998a). Developing Positive Parental Influences. This CLFC training component helps participants develop a greater awareness of facts and feelings about substance use, abuse, and dependency; review effective approaches to prevention; and develop a practical understanding of intervention, referral procedures, and treatment options. This module includes an examination of childhood and family experiences involving AOD, personal and group feelings and attitudes toward AOD issues, as well as an in-depth look at the dynamics of chemical dependency and its impact on relationships and families (Strader and Noe 1998b). Getting Real (Same content for both Adult and Youth Modules). The Getting Real training is provided separately to groups of adults and youth. Participants examine their responses to the verbal and nonverbal communication they experience with others. Participants receive personalized coaching on effective communication skills, including speaking with confidence and sensitivity, listening to and validating others, sharing feelings, and matching body language with verbal messages. This promotes the skills of selfawareness and mutual respect while focusing on helping participants combine thoughts, feelings, and behavior in a way that leads them to generate powerful, meaningful, and palatable messages to others (Strader et al. 1998). CLFC Program Modules for Youth Developing Independence and Responsibility. In this component, youth are asked to examine their current level of personal responsibility in their family life, with an eye toward developing

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personal independence and responsibility for adulthood. Youth are asked to visualize themselves in the future role of parents, coworkers, supervisors, or other adults responsible for setting appropriate expectations and consequences for their children or others they may need to supervise in areas of responsibility (Strader and Noe 1998c). Developing A Positive Response. This module helps young people to become aware of their deepest wishes for their own personal health, their relationships with their peers and family members, and their yearning for success. With exercises designed and facilitated with sensitivity to remain inclusive and nonjudgmental, participants examine information, facts, and feelings about alcohol, tobacco, marijuana, and other drug exposure (and possible use) in family, peer groups, community, and media. This module also helps youth develop an appropriate “worldview” of alcohol and other drug issues with a focus on personal and family health (Strader and Noe 1998d). The six modules of the CLFC curriculum are administered to groups of parents/guardians and their children in 18–20 weekly training sessions. While the sessions are typically provided in the same facility at the same time, the parents and youth meet in separate training rooms with different group facilitators. Youth sessions last 1.5 h and parent sessions last 1.5–2.5 h. The curriculum focuses on (1) imparting knowledge about AOD use; (2) improving communication and conflict resolution skills; (3) building coping mechanisms to resist negative social influences; (4) encouraging the use of community services when personal or family problems arise; (5) engendering selfknowledge, personal responsibility, and respect for others; and (6) delaying the onset and reducing the frequency of AOD use among participating parents and youths. The program includes optional individual, couple, and family case management sessions to identify any need for specific therapeutic interventions and specialized referrals to other community services. A 6–9-day CLFC Certification Training for therapists (and other providers) along with all materials necessary for implementation are available from the program developer. The CLFC Program is one of three programs comprising the Creating Lasting Family

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Connections (CLFC) Curriculum Series. The Series also includes the CLFC Fatherhood Program and the CLFC Marriage Enhancement Program. The CLFC Curriculum Series addresses the intergenerational and chronic nature of addiction and the family’s role in both recovery and prevention. The CLFC Series represents the intersection of treatment and prevention services for families (Straderet al. 2013). Each of the three CLFC programs is separately listed on the SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP).

Prominent Associated Figures The Original CLFC Program was developed in the late 1980s by Ted N. Strader, M.S., a Certified Chemical Dependency Counselor, a Certified Prevention Specialist, and Executive Director of the Council on Prevention and Education: Substances, Inc. Dr. Tim Noe and Warrenetta Crawford Mann provided notable assistance in program development. Teresa Strader, L.C.S.W, and Christopher Kokoski assisted with the development of support materials. The CLFC curriculum has been recognized on the National Registry of Evidence-based Programs and Practices (NREPP) as an Exemplary Program by Healthy Canada’s Compendium of Best Practices, and a four-time winner of the Exemplary Program Award provided by the National Association of State Alcohol and Drug Abuse Directors, SAMHSA’s Center for Substance Abuse Prevention, and the National Prevention Network. The John C. Maxwell Leadership Team named Mr. Strader one of the top 10 leaders in the USA serving youth and families.

Theoretical Framework The Creating Lasting Family Connections ® (CLFC) integrates an eclectic combination of personal, couple, family, and community strengthening theoretical frameworks. These frameworks are translated into a structured series of sequential, developmental, and experiential activities for

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participating families (youth and adult modules) and community members. CLFC incorporates Experiential Learning Theory (Kolb 1975) by providing an interactive program with a strategic mix of role plays, games, brainstorms, guided imagery, reflective exercises, demonstrations, and group discussions. Participants are invited to involve themselves in practicing or “experiencing” the ideas, concepts, and skills shared in the sessions and to engage in reflective thought and group discussion (Johnson 1997; Satir 1983). Risk and Resiliency Theory (Hawkins et al. 1992) serves as a major underpinning of the program. Specific exercises are designed to build resiliency across the domains of self, family, school, and community (Benard 1991). Building from strengths, the program focuses on both intraand inter-personal skill development including verbal and nonverbal communication (with an emphasis on listening and validation), how to say no (refusal skills), and family management practices to help prevent negative outcomes and mitigate known risk factors. Further, CLFC combines Social Learning Theory (Bandura 1977) and Therapeutic Alliance (Bordin 1979) through the positive rapport established between staff and participants, and through staff modeling of appropriate relationship behaviors. Developing respected interpersonal connections is key in promoting growth in both personal and family behavioral dynamics. For example, in the group “educational sessions” two program staff served in roles often perceived more as facilitators of information and role models of new possibilities rather than as “therapists.” A range of nonjudgmental, inclusive, and positive facilitation skills (Strader and Stuecker 2012) result in a Therapeutic Alliance between the CLFC trained facilitators and participants. This alliance can be carried into private case management sessions that, when needed, can lead to deeper personal work or other necessary referrals for more specific therapeutic interventions. Key elements of Cognitive Behavioral Therapy (Beck 1993) are incorporated into group exercises. Participants are invited to participate in a process of individualized coaching and personal reflection in order to self-correct unhelpful

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thinking and behaviors. CLFC integrates this system of established theories which are expressed in the program design, exercises, activities, and implementation protocols. Each of these theories relates to the central belief described in Building Healthy Individuals, Families and Communities that “deep healthy connections build strong protective shields to prevent harm and to provide both nurturing and healing support” (Strader et al. 2000, p. 17). The book refers to this concept as “connect-immunity.”

Populations in Focus The Creating Lasting Family Connections ® (CLFC) Program was designed for at-risk Caucasian, African American, and Hispanic/Latino families (parents and youth) from urban, suburban, and rural areas in the USA. The program is implemented with universal, selective, and indicated populations as designated by the Institute of Medicine (IOM) Classification System.

Strategies and Techniques Used in Model The Creating Lasting Family Connections ® (CLFC) Program incorporates a rich variety of strategies and techniques to appeal to the full range of adult and youth learning styles, cultural differences, personalities, and preferences. Learning strategies and techniques include brief lectures, role plays, guided imagery, reflections, discussions, brainstorms, facilitator demonstrations, storytelling, and interactive games. CLFC facilitators are trained and certified to implement the program. CLFC provides facilitators of differing gender, age, race, and experience to relate to the largest number of participants. CLFC facilitators role model the skills of the CLFC Program, therefore providing information within a relational and nonjudgmental context. Facilitators listen and validate participant thoughts and feelings, provide clear and sensitive feedback, and express their own emotions as a means to manage group participation and interaction

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throughout the program sessions. The concept of “influence versus control” is threaded throughout the entire CLFC Program. Facilitators both role model and manage the program under the belief that participants learn best when they can voluntarily choose their own preferred level of participation (i.e., active discussion, interactive practice, quiet listening, etc.) for each activity in each program session. Throughout the CLFC Program, facilitators incorporate motivational interviewing and trauma-informed care techniques into interactions with participants (Strader and Stuecker 2012). Culturally sensitive case management and ongoing support supplements the program content. Facilitators refer participants to appropriate service providers, as needed.

Research About the Model In a large-scale study, the Creating Lasting Family Connections ® (CLFC) Program was implemented in five communities in the Louisville, KY, area (Johnson et al. 1998). A community was defined as a group of people who form a support system based on shared activities and interests. Families were randomly assigned to the intervention group or control group. Participants were 183 high-risk youths, aged 12 through 14, and their families (95 in the intervention group and 88 in the control group). Over half (58%) of the youths were female, with 16% of families identifying as African American. Almost half (47%) had five or more family members, and 30% were in low-to-medium-income groups. There were no statistically significant between-group baseline differences on key family and environmental characteristics (e.g., age, gender, youth access to marijuana, parent smoking behavior, and family participation in other alcohol and other drug programs). Data on youth and family resilience and AOD use outcomes were collected before program initiation, after program services, and 1 year after program initiation. Parents in the intervention group reported statistically significant gains in knowledge about AOD and enhanced beliefs against using these substances, compared with

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parents in the control group (Johnson et al. 1995, 1998). Both parents and youths in the intervention group reported a statistically significant increase in use of community services to help deal with personal or family problems, compared with parents and youths in the control group (Johnson et al. 1995, 1998). The evaluation also found positive moderating effects on delayed onset and frequency of AOD use among youth.

Case Example Doris (fictitious name used to protect her true identity), a single mother with five children, participated in the CLFC Program. During the initial Screening and Program Placement Survey meeting, she reported that she engaged in the program because the children’s fathers were “alcoholics and drug addicts” who had abandoned her and the children. She was frustrated with her constant need to “threaten, spank, and argue with her children.” She particularly wanted to “prevent her male children from turning out like their fathers.” She and three of her children participated in the program. Early in the Raising Resilient Youth module, Doris participated in an exercise to reflect on how her own upbringing might have affected her approach to childrearing. Along with discovering that her parents were not able to meet all of her needs as a child, she further became aware of how she was relying heavily on a series of “power and threat” techniques that were unintentionally triggering defensiveness and rebellion in her children. In another training room, her children were making their own discoveries about kind and compassionate relationships and developing empathy for their mother in the corresponding Developing Independence and Responsibility module. Next, Doris learned and practiced skills of listening and validating her children’s feelings, while establishing clear, fair, and consistent expectations and consequences. While she struggled with expectations and consequences, she also responded to the interactive experience of the Getting Real module. Doris volunteered to receive personal coaching during role plays on integrating

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her thoughts, feelings, and verbal and nonverbal language. With a little practice, Doris began providing more clear and compassionate messages to others, including her children. Her children were practicing similar communication skills of trust, empathy, and saying “no” to others regarding negative behaviors like alcohol and drug use while learning to show respect for the other person in the role play. In the alcohol and other drugs module, Doris realized how deeply and pervasively her father’s alcoholism had affected her and her family. As Doris recognized alcoholism as a disease (rather than her father’s choice to abandon her), she expressed feelings of understanding and forgiveness toward her father. She also recognized how her relationship with her father affected the choices she made for romantic partners. She expressed openness and excitement for the possibility of bringing healing to herself and her children. As her children participated in the youth version of the alcohol and drug module, two of her children expressed recognition of how they played certain roles in the family. The oldest child recognized that he alternated between playing a “hero” role when he did well and a “scapegoat” role when he made mistakes. A second child recognized how she played the “mascot” role by using humor to deflect attention from the family pain. Both of these children seemed to particularly benefit from learning to express their emotions and from the closeness they felt with their mother when she could validate them. The children made a connection that not all hurtful situations needed to turn into angry interactions. This reduced blame and fighting in the family. A year after participating in the program and several case management sessions, she and her children reported less angry and disrespectful behavior in the family and more communication and support. Both Doris and her children were beginning to listen and validate each other more and argue less. Doris stated with pride and satisfaction that her children really improved attendance at school and she reported less family conflict, less school problems, and greater success in schoolwork. She said that her children appeared to have less interest in alcohol and other drugs.

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She reported that she thought the entire program was very interesting and very helpful. She added that it was really hard to be good at everything she learned in the classes. Because of the family’s new way of thinking and talking about alcohol, other drugs, and emotions, Doris said she could see her children doing better and that is what mattered most.

Cross-References ▶ Creating Lasting Family Connections Program

References Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice Hall. Beck, A. T. (1993). Cognitive therapy of substance abuse. New York: Guilford Press. Benard, B. (1991). Fostering resiliency in kids: Protective factors in the family, school, and community. Portland: Western Center for Drug-Free Schools and Communities. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64–105. Johnson, D. W. (1997). Reaching out: Interpersonal effectiveness and self-actualization. Boston: Allyn & Bacon. Johnson, K., Berbaum, M., Bryant, D., & Bucholtz, G. (1995). Evaluation of creating lasting connections: A program to prevent alcohol and other drug use among high risk youth. Final evaluation report. Louisville: Urban Research Institute. Johnson, K., Bryant, D. D., Collins, D. A., Noe, T. D., Strader, T. N., & Berbaum, M. (1998). Preventing and reducing alcohol and other drug use among high-risk youth by increasing family resilience. Social Work, 43(4), 297–308. Kolb, D. A., & Fry, R. (1975). Toward an applied theory of experiential learning. In C. Cooper (Ed.), Theories of group process. London: Wiley. Satir, V. (1983). Conjoint family therapy. Palo Alto: Science and Behavior Books. Strader, T. N., & Noe, T. D. (1998a). Raising resilient youth training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network.

671 Strader, T. N., & Noe, T. D. (1998b). Developing positive parental influences training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., & Noe, T. D. (1998c). Developing independence and responsibility training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., & Noe, T. D. (1998d). Developing a positive response training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., & Stuecker, R. (2012). Creating lasting family connections ®: Secrets to successful facilitation. Louisville: Resilient Futures Network, LLC. Strader, T. N., Noe, T. D., & Crawford-Mann, W. (1998). Getting real training manual and participant notebook for the creating lasting family connections program. Louisville: Resilient Futures Network. Strader, T. N., Noe, T. D., & Collins, D. (2000). Building healthy individuals, families, and communities: Creating lasting connections. New York: Kluwer/Plenum Publishers. Strader, T. N., Kokoski, C., & Shamblen, S. R. (2013, July 25). Intersection of treatment and prevention: Prevention and recovery-informed care. SAMHSA Recovery to Practice E-Newsletter, 14. Retrieved from http://www. npnconference.org/wp-content/uploads/2017/09/StraderKokoski-Shamblen-ENewsletter.pdf.

Creativity in Couple and Family Therapy Saliha Bava Mercy College, New York, NY, USA Houston Galveston Institute, Houston, TX, USA Taos institute, Chagrin Falls, OH, USA

Synonyms Flow; Improvisation; Innovative; Play-oriented; Unique linkage

Introduction Family therapy originated as a creative resistance to the existing dominant discourse of mental health in the early 1950s, which focused primarily on locating problems within the individual

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psyche. In family therapy’s cultural tales, the originators are often referred to as irreverential and creative. The rise of family therapy as a creative activity was a social process in and of itself. Montuori (1992) states “evolving human systems are. . .creative human systems” (p. 193). The importance of creativity for meaningful living has been emphasized by a number of authors across traditions (Allman 1982; Gergen 2009; Keith 2014; Montuori 1992). Though from a modernist epistemological position, Allman (1982) states that “When we help the family see themselves as a system and teach them to play with their meanings, we open each member to his [sic] own poetry and twinke [sic]” (p. 43). Postmodernists view creativity as a social rather than an individual phenomenon (Gergen 2009; Montuori 1992). Northern-American individualistic culture and reductionist methodological approaches have shaped the construct of creativity by limiting it to the study of the creative individual while failing to look at its relational nature – interactions and contexts (Montuori and Purser 2011). Gergen states “one comes into creativity through participation in a history of relationship” (2009, p. 92). Creativity, “born within relationships,” is not “prior to relational life” (Gergen 2009, p.95).

Theoretical Context for Concept Creativity, a relational process that emerges in dialogue and collaboration, is a flexible and adaptable response to living in “liquid times” where lives are more fragmented with increased uncertainty (Bauman 2007). From a social construction (Gergen 1999, 2009) perspective, creativity is defined as co-creating contextually relevant, unique ways of going on together in our ordinary everyday lives that emerges from the activity of relating. Shotter speaks to the notion of emergence when he states “indeed, every response we make to another’s activity is, often, a poetic response, in the sense that it is a uniquely new, creative linking of familiar utterances into unfamiliar” (2011, p.45, emphasis added). Creative linking is the means by which couples, parents and children, and families and communities create

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pathways for going on together in the face of their differences. Creativity is the useful and meaningful unique linkages* between two “points,” where the points can be ideas, values, beliefs, practices, differences between people, etc. The social constructionist approach to creativity as a social, relational process rather than an individual achievement has important implications for how we engage in family therapy. Family therapy’s growing culture of models, theories, and treatment plans (Imber-Black 2014) increases the quest for certainty while not conceptualizing the process of creative engagement within the therapeutic context. The sole reliance on theories and plans potentially reduces the generative possibilities of clients’ and therapist’s creative interactive process. Family therapy historian Lynn Hoffman’s (1998) statement “models are heuristic fairy tales, holders of complex realities” (p. 98) can be interpreted to mean that theories should be held lightly. All plans, like the models they depend on, are possible road maps that should not predetermine the outcome but create space for emergent possibilities yet to be realized. By taking risks and adopting the stance of a curious learner, therapists and clients can cocreate meaningful ways to engage their plans, as required by their intersectional context. Thus, engaging therapeutic plans and relationships require creativity. Creativity in family therapy is being oriented to the theories and models as possibilities for unique creative linkages in people’s lives rather than being predetermined by the “right” outcome as per our theories. The bridge from theory to the discursive activity of therapy is a performative dialogic relationship (Anderson 1997; Levin and Bava 2012) between the therapist and the clients and their words. Bakhtin (1981) notes that “the word in living conversation is directly, blatantly, oriented toward a future answer-word: it provokes an answer, anticipates it and structures itself in the answer’s direction” (Kindle Location 3952). Therapy, one such living conversation, is a process of understanding and meaning-making (Anderson and Goolishian 1988; Anderson 1997) where words take on an anticipatory and future forming act by the interlocutor’s creative

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utterances. It requires coordination and creativity to make meaning. Such anticipatory, future forming conversational utterances are not to be confused with the theoretically predetermined outcomes. The distinction lies in the relational process. By attending to how we are spontaneously relating to each other, to the context, and to what we want to accomplish together, we cocreate a unique, resourceful, performative activity that is defining of the relationship and the conversations. Drawing on social constructionism, communicative action (Anderson 1997; Pearce 2007), and complexity thinking, I have created a play-oriented* approach (not to be confused with play therapy) which fosters creativity in therapy and teaching/ training. The approach consists of relational processes that foster conditions for creative coordination and spontaneous responsiveness as action (Gergen 2009; Shotter 2011). The play-oriented* approach to relationships not only opens up space for creative emergence but also makes one agile and ready to engage with uncertainty and the emergent (that which is being created in the turn-by-turn interactions). In play*, as children we learn how to act, be, and become; preparing for the social interactions of adult life (Brown 2010). Since life is dynamic, as adults we are constantly making up ways of being and becoming. We do not stop playing, yet we stop calling it play. Instead, we may call it being improvisational* or creative in challenging and/or new situations. In play* we create our social worlds (Bava 2016; Pearce 2007).

Description Creativity in therapy emerges when we engage with clients in a collaborative relationship and dialogue focused on generativity. Such a process invites what Anderson (1997) identifies as connecting, collaborating and constructing understanding and possibilities. Creativity is not a technique but a way of being in relationships; it is a relational process of engagement. Creative engagement in therapy increases uncertainty and ambiguity because the future is undetermined, yet to be cocreated. Adopting Anderson’s (1997) stance of curiosity and shared inquiry along with

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the stance of not-knowing helps to engage emergence of that which is being cocreated among the conversational interlocutors.

Application of Concept in Couple and Family Therapy Bava (2016) states that a play-oriented* approach is “a way of being by which we improvisationally act into the situation, attend to our context, relatedness, and what is being created (emergence) while exploring the meaningfulness of what is being created within the relationship without a predetermined outcome leading the way” (p. 13). There is no prescriptive way of improvising into the situation for creative engagement. Rather, it calls for accepting everything as offers (Poynton 2008) and listening curiously while being in synch with the client (Anderson 1997). Through our listening, hearing, and speaking (Anderson 2003), we position ourselves to create space for the spoken and the unspoken, the yet to be spoken, and the unspeakable and in the process creating unique linkages*. Attending to the relatedness (McNamee 2004) is the focus we bring to how we are relating, not just in our roles but to the relationship and context that is being jointly created. As we engage with our spontaneous responsiveness (Shotter 2011), new possibilities emerge, and staying open to the emerging ideas without rushing to categorize and label it requires comfort with uncertainty and adoption of a not-knowing stance. As the process of mutual inquiry continues, it leads to coordination of meaning about the emergent. What gets created between the client and therapist is part of the “circle of meaning” (Gadamer as referred in Anderson 1997, p. 114).

Clinical Example: The Man Who Seeks Pathways for the Unknowable Rafi (to protect client confidentiality a composite case is used) came to therapy because Sheila, the woman he had dated for nine months and wanted

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to marry, had ended their relationship abruptly and had cut-off all contact with him. And though they lived in the same neighborhood, he rarely saw her. Rafi and Sheila were living in New York City. Both were born and raised in Bangladesh where marriages are arranged by family elders. The reason for the breakup of the relationship was ambiguous. Rafi initially thought it was because his family had not responded to the marriage proposal from her family in a timely fashion. But with time, he felt there were other factors at play, and he felt that unless he was able to unearth the reason for the breakup he would not be able to move forward. When Rafi started therapy, he was unsure of how he would move forward with his life. He was sure the relationship was not over and that he could still influence Sheila to change her mind. But after repeated attempts to contact her with no response, he started to feel very sad. He spoke of the possibility that he might not be able to get an answer from her, as she had not only blocked all contact with him but also he couldn’t track her on social media, where she used to be very active. Rafi who saw himself as smart and successful in business, could not fathom the way to move forward in his personal life. In my attempts to cocreate possibilities, I stayed open to his creative solutions to contact her while being curious of how his approaches might be viewed from her perspective (given her history, which he had shared). Our conversations further focused on his attempts to make sense of the situation, especially the abruptness and the lack of response for the breakup. Later, the focus was on how sad he felt and how he had dreams of her. With each turn in therapy, Rafi would identify the steps he would want to take. Some steps would look like he was potentially pursuing her or would only lead to more pain instead of making a clean break and moving on in the face of what was a dead end. But I attended to the unique linkages* he was making rather than the perceived outcomes. We explored those linkages in terms of the possibilities that would be created for the future of their relationship together.

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I adopted a not-knowing stance and stayed curious of each possibility that Rafi would bring to therapy. We would engage in conversation and mutually explore his options from multiple lenses – his, hers, cultural, family (his parents), etc. as he introduced them. As an Indian, I spontaneously used a shared contextual reference point since he liked Bollywood movies, I would make reference to the hero with a jilted heart as a way to introduce lightheartedness into the conversation, and to explore the storyline he wanted to create for his life’s movie. I would enter each session not sure what aspect he would bring to therapy – his broken heart, lack of sleep, nightmares, work performance, a visit to his home country and/or how to face his family, dating and trusting other women, etc. Over the course of six months, he came up with unique creative solutions to his dilemmas. For instance, Rafi was interested in hiring detectives to unravel Sheila’s family life in Bangladesh as a way to make sense. So, he hired a detective and then called it off as there was not much information. He reflected that in spite of the information, the ambiguity of the breakup might still linger. He was not sure if it was the influence of her parents, the delay in his parents confirming the match, or him not pushing his parents to confirm the match or other factors that resulted in the breakup. In the midst of uncertainty and unfinishedness, there was a sense of play (movement) and flow*. As I improvised* my way through our conversations, I continued to listen and check-in with Rafi on how he needed me to listen, how our relationship was working for him, and how the direction of therapy was meaningful for him. As his ideas emerged, I spontaneously explored them from a place of curiosity and with a perspective of learning by doing (play*), and we would discuss each of their potentials in light of Rafi’s hopes. Sometimes, he would go further with some ideas and come back and discuss the results and then decide to drop them while with other ideas he took them further, and they took on a life of their own. For instance, Sheila loved the outdoors, so he decided that the way to move forward was to honor her spirit of outdoors and take to activities

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such as hiking and traveling. We discussed how that would be helpful for him, how would it not make him pine for her or keep hope alive (if that is indeed what he was seeking). At times, there was a contradiction of responses, which I explored not with the intent to resolve but to understand and publicly hold them as paradoxical responses of being human. And I invited him to play, engage, and discover his preferred options. He continued to hike and realized that he loved it, and by the end of the therapy, he was doing it because he liked it rather than for any symbolic meaning. The emergence of such an activity and the final meaning it took on is an illustration of how I held all ideas as possibilities and allowed for the emergence of meaning rather than naming any single idea as denial or (not) letting go, etc. Over the course of hiking, he also met a couple of women and discovered he was not yet ready to date and that opened up the conversations about how to trust women in the future. The role creativity played in this process was how I stayed curious about the context and what was emerging by noting the creative linkages Rafi made for how to go on in the face of an abrupt ending to his romantic relationship. In holding creative uncertainty and curiosity, the conversations had an unfinished quality to them, yet the activity of being spontaneously responsive kept alive the sense of movement via the unique connections that were made within the conversation and relationship.

Cross-References ▶ Anderson, Harlene ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Dialogical Practice in Couple and Family Therapy ▶ Postmodernism in Couple and Family Therapy ▶ Reflexive Processes in Couple and Family Therapy ▶ Social Construction and Therapeutic Practices ▶ Social Constructionism in Couple and Family Therapy

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References Allman, L. (1982). The aesthetic preference: Overcoming the pragmatic error. Family Process, 21(1), 43–56. https://doi.org/10.1111/j.1545-5300.1982.00043.x. Anderson, H. (1997). Conversation, language, and possibilities: A postmodern approach to therapy. New York: Basic Books. Anderson, H. (2003). Some notes on listening, hearing and speaking and the relationship to dialogue. Paper presented at the Eighth Annual Open Dialogue Conference: What is Helpful in Treatment Dialogue? Tornio, Finland. Retrieved from http://harleneanderson.org/arti cles/newbatch/Dialogue-listeningspeakinghearing.pdf Anderson, H., & Goolishian, H. (1988). Human systems as linguistic systems: Evolving ideas about the implications for theory and practice. Family Process, 27, 371–393. Bakhtin, M. M. (1981). The dialogic imagination: Four essays. Austin: University of Texas Press. Kindle Edition. Bauman, Z. (2007). Liquid times: Living in an age of uncertainty. Malden, MA: Polity Press. Kindle Edition. Bava, S. (2016). Play-oriented pedagogy: Liberating emergence and uncertainty in couples and family therapy training. Manuscript submitted for publication. Brown, S. (2010). Play: How it shapes the brain, opens the imagination, and invigorates the soul. New York: Avery, The Penguin Group. Gergen, K. J. (1999). An invitation to social construction. Thousand Oaks: Sage. Gergen, K. (2009). Relational being: Beyond self and community. New York: Oxford University Press. Kindle Edition. Retrieved from amazon.com Hoffman, L. (1998). Setting aside the model in family therapy. Journal of Marital and Family Therapy, 24(2), 145–156. Imber-Black, E. (2014). Eschewing certainties the creation of family therapists in the 21st century. Family Process, 53, 371–379. Keith, D. (2014). Continuing the experiential approach of Carl Whitaker. Phoenix: Zeig, Tucker & Thiesen. Kindle Edition. Retrieved from amazon.com Levin, S., & Bava, S. (2012). Collaborative therapy: Performing reflective and dialogic relationships. In A. Lock & T. Strong (Eds.), Discursive perspectives in therapeutic practice (pp. 127–142). Oxford: Oxford University Press. McNamee, S. (2004). Therapy as social construction. In T. Strong & D. Pare (Eds.), Furthering talk: Advances in the discursive therapies. New York: Kluwer Academic/Plenum Press. Montuori, A. (1992). Creativity, chaos, and self-renewal in human systems. World Futures, 35, 193–209. Montuori, A., & Purser, R. (2011). Social creativity: The challenge of complexity. Retrieved from https://www. researchgate.net/publication/267834184 Pearce, B. (2007). Making social worlds: A communication perspective. Malden: Blackwell Publishing.

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676 Poynton, R. (2008). Everything’s an offer: How to do more with less. Portland: On Your Feet. Shotter, J. (2011). The dance of Rhetoric: Dialogic selves and spontaneously responsive expressions. In C. Meyer & F. Girke (Eds.), The rhetorical emergence of culture (pp. 37–51). New York/London: Berghahn Books.

Cultural Competency in Couple and Family Therapy Christiana I. Awosan1, Yajaira S. Curiel2 and Mudita Rastogi3 1 Seton Hall University, South Orange, NJ, USA 2 Palo Alto University, Palo Alto, CA, USA 3 Illinois School of Professional Psychology, Argosy University, Schaumburg, IL, USA

Name of Entry Cultural Competency in Couple and Family Therapy

Synonyms Contextual factors; Cultural attunement; Cultural awareness; Cultural consciousness; Cultural humility; Cultural literacy; Cultural multidimensionality; Cultural responsiveness; Cultural sensitivity; Diversity; Intersectionality and social justice; Multicultural perspective

Introduction Over the past four decades, the field of Couple and Family Therapy (CFT) has attempted to move from a broader focus of gender and cultural awareness to a more specific emphasis on ways to train clinicians and researchers to focus on particular groupings such as gender (e.g., females), race (The authors distinguish and present the categories of race and ethnicity as separate but related concepts. Race is categorized as the phenotypic presentation of one’s skin color and ethnicity as a cultural heritage of

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one’s ancestry. Although the classification of individuals on the basis of external markers (racial categorization) has been established by scientists as not having a biological basis, and race is widely accepted as being a social construct, the salience of race in individual, social, and political discourse dictates that it be included in this discussion of cultural competency. In everyday conversation, the terms race and ethnicity are often used interchangeably. However, in this document, they are intended to refer to different concepts.) (e.g., Blacks, Whites), ethnicity (e.g., African-American, Latino-American), social class, (e.g., poor and working-class), sexual orientation (e.g., LGB), and religion (e.g., Muslims). Furthermore, in the past two decades there has been a push to train clinicians to not only critique the overall lack of cultural and gender-sensitivity in family therapy theories, but also the awareness of therapists’ own cultural identities, ideologies, and values on their work with their clients (Hardy and Bobes 2016). In recent years, the work of cultural competency in the field of CFT has included the notion and practice of Social Justice* (McDowell and Shelton 2002). The concept of Social Justice within the practice of cultural competency requires awareness and sensitivity from clinicians and researchers regarding the ways in which issues of gender, race, class, sexual orientation, religion, nationality, etc., influence power, privilege, and oppression in the lives of clients and the therapeutic process. It also includes thorough consideration of the negative impact of these issues on their mental, emotional, and relational well-being. Essentially, cultural competency is the ability of the mental health professional to “consider the broader ecology of families, [couples and individuals, and widen their] lens to take history, context and community into account” in their work (McGoldrick and Hardy 2008, p. 7).

Description Cultural competency in the field of CFT includes the ability of a therapist to take into

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account the cultural histories of a client throughout the process of clinical assessment, diagnoses, implementing clinical interventions, as well as research and clinical training. Further, it encompasses therapists’ awareness of their own culture as well as a recognition and acknowledgment of clients’ cultural differences in order to engage in and cultivate therapeutic relationships, processes, and interventions that are culturally sensitive and responsive to the needs of the clients (Sue et al. 1992). Culture is defined as the ways in which gender, race, ethnicity, class, sexual orientation, religion, nationality, etc., shape individuals’, couples’, and families’ ideologies, values, and relationships. Cultural competency points to the need of the therapist to hold the perspective and practice that every family, regardless of its cultural background is like “all other families, some other families and no other families” (Hardy 1989, p. 22). Therapists must take into account the larger contextual issues, such as race, gender, ethnicity, sexual orientation, spirituality/religion, nationality that inevitably impact the therapeutic relationship, process, and treatment. In other words, cultural competency calls therapists to be appreciative, knowledgeable, and attend to the cultural similarities and differences with regards to gender, race, sexual orientation, class, religion, nationality, etc., that exist in all the couples, families, and individuals they work with, and the impact of their own cultural differences and similarities with clients. The ideas of and training in cultural competency in the field of CFT emerged as scholars and clinicians began to critique the Eurocentric, middle class, heterosexual, male, relational standards, and perspectives that were imbedded in all the family therapy models and clinical interventions. Even though the field of CFT prided itself in the ability to view individuals, couples, and families within the context of their social environment and relationships, family therapists were being trained to be objective to the issues of gender, race, class, sexual orientation, religious, etc., in working with families (McGoldrick and Hardy 2008).

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The History of Cultural Competency in the Field of CFT Cultural competency vaguely appeared in the field of CFT in the later 1970s and 1980s when female therapists such as Rachel Hare-Mustin, Betty Carter and Peggy Papp begun to critique the field’s definition of family, the invisibility of women’s lives with regards to lack of power in relationships, and the privilege of two parent, middleclass, patriarchal, heterosexual, White families in many of the family therapy theories (Walters et al. 1991). The era of the 1980s in the field of family therapy was associated with the “feminist critique of family therapy.” However, many noted that this period mainly focused on the voices of White female therapists without privileging the experiences of women of color or those from the Global South. Raising awareness of and sensitivity to gender inequalities and male dominance largely ignored the topic of ethnicity and work with families of color. Simultaneously, from the late 1960s and throughout the 1970s, the invisibility of ethnicity and general attention to race in family therapy theories, writings, and clinical works were highlighted by prominent scholars such as Harry Aponte, Braulio Montalvo, Salvador Minuchin, and Carlos Sluzki. In these family therapist scholars’ work, they emphasized and advocated for the broad understanding of diverse cultures and cultural influences rather than a specific embracement of understanding of a specific cultural group. For instance, in their work as Structural Family therapists, Minuchin and others focused on specific families of color who lived in impoverished neighborhoods (McGoldrick and Hardy 2008). These scholars contended that it was more effective to attend to the broader sociocultural context of families’ class and ethnic backgrounds rather than the specifics of the ways their social class and ethnicity informed their presenting problems and vice versa (Goldenberg and Goldenberg 2013). According to Doherty and Baptiste (1993), widespread interest on the issues of race and ethnicity was generated by the landmark publication, Ethnicity and Family Therapy (McGoldrick et al. 1982).

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In an attempt to focus on the specific family structure and dynamics of ethnic groups and their presenting problems, some scholars described these families in generalized terms. Although the McGoldrick et al. (1982)’s text, Ethnicity and Family Therapy, played a pivotal role in moving the field of CFT forward in cultural awareness training, it was also critiqued for perpetuating a monolithic view of specific ethnic family groups (e.g., the African American family, the Irish family, the Jewish family) (Hardy 1989). Differences between families of color and White families were highlighted at the expense of differences within families with regards to variables such as gender performance, influence of socio-economic status, geography. It is important for couple and family therapists and researchers to have an awareness of the impact of the historical and current sociocultural context of the specific couple and family they serve. Just as questions were raised about the lack of accountability in family therapy theories regarding gender-sensitivity, the issue of training clinicians to be racially aware and sensitive in clinical and research work became a major topic in the field by late 1980s. During the 1990s and 2000s, the topic of race became a critical issue in the training of Couple and Family Therapists. Family therapists such as Kenneth V. Hardy, Marlene F. Watson, Monica McGoldrick, Celia Falicov, Tracey Laszloffy, Elaine Pinderhughes, Nancy Boyd-Franklin highlighted the significance of addressing race when working with families of color (Laszloffy and Hardy 2000). These scholars and others had to contend with the fact that virtually all the major family therapy theories (e.g., Bowen, Strategic, and Symbolic Experiential) did not highlight the influence of race on the lives and problems that clients present in therapy. Nor did the theoreticians emphasize the interplay of race within the therapeutic relationships and processes. In an article, “The Theoretical Myth of Sameness: A Critical Issue in Family Therapy Training and Treatment,” Hardy (1989) emphasized the “neglect of [cultural] context” in both the therapeutic relationships and throughout family therapy training programs. In calling family therapy’s attention to cultural competency, Hardy noted that

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there was a lack of clinical and training focus in working with families of color, particularly with regards to race. According to Hardy, the “neglect of [cultural] context” created and promoted a “theoretical myth of sameness (TMOS)” in working families of color. To challenge the narrow and linear view, which is antithetical to the systems epistemology that “all families are virtually the same,” regardless of their racial background, a definition of TMOS, Hardy called for “training programs to [not only] adopt a view and practice that emphasize the importance of theory comprehension and skill acquisition [but] also punctuate differences that might be attributable to race, culture, ethnicity and/or gender” between the therapist and the client which may impede the therapeutic relationship and process (p. 20). Laszloffy and Hardy (2000) stated that in order to be culturally competent, trainees need to become aware of and sensitive to the ways race and racism influence the lives of clients and the presenting problems they bring to therapy. Further, their need to learn how to address these contextual factors in therapy has been the focus of cultural competency training in the field since 1990s (Hardy and Laszloffy 1992; Laszloffy and Hardy 2000; Hargrave and Pfitzer 2003). Additionally, to develop cultural competency around the issue of race, scholars emphasize the importance of exploring the ways in which the racial differences between the therapist and client inform the therapeutic alliance and process (Awosan et al. 2011; Rastogi and Wieling 2005). This continues to be a critical topic in the training of culturally competent couple and family therapists and researchers (Dee Watts Jones 2016; Watson 2016). Similarly, much work is still needed in training CFTs to be sensitive and competent when it comes to sexual orientation. By the early 2000s, scholars raised questions about the influence of heteronormativity in the theories and training in the field of CFT, and lack of lesbian, gay, and bisexual (LGB) affirmative content in CFT training programs (Hudak and Giammattei 2010; Green 2003). Cultural competency with regards to sexual orientation calls for decentering heteronormative definitions of family and couple

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relationships and the ways in which clinicians and researchers are trained to work with LGB communities. Pivotal writings on sexual orientation awareness and sensitivity such as Stone Fish and Harvey’s (2005) Nurturing queer youth: Family therapy transformed have expanded the cultural consciousness of CFTs. Authors have stressed training CFTs to be aware and understand the lives and societal stressors that LGB individuals experience, as well as increasing consciousness around clinician’s biases, attitudes, and feelings with working with this population* (Bernstein 2000; McGeorge and Stone Carlson 2011). Others have argued that CFTs must engage in and proactively practice LGB affirmative therapy (Rock et al. 2010). Even with the recent advances within the field on sexual orientation awareness and sensitivity, there is a gap in CFTs’ training on cultural competency around transgendered individuals (McGeorge and Stone Carlson 2011). According to Coolhart et al. (2013), there has been less competency training and development in the field of CFT when working with transgender youth and adults. Thus, more writings and research are needed in the field of CFT with regards to cultural awareness and sensitivity in working with this community. The literature on the timeline of cultural competency scholarship indicates a substantive exploration and articulation around contextual factors such as gender, ethnicity, race, and sexual orientation. Albeit, more work in the development of tangible cultural competency clinical and research skills around these factors are gravely needed in the field. In recent years, scholars have highlighted the need for more scholarship on cultural awareness and sensitivity with regards to other diversity* issues such as social class, spirituality/religion, ability, immigration and nationality (Allen-Wilson 2016; Daneshpour 2017; Hardy et al. 2016; Platt and Laszloffy 2013; Seedall et al. 2014). Knowledge of the influences of social class, spirituality/religion, ability, immigration and nationality on the mental health, and emotional and relational well-being of clients are essential to become a culturally attuned* therapist or researcher. Similar to the other contextual factors* mentioned above, it is critical that CFTs are

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trained to be aware of the values, assumptions, and prescriptions that they attach to cultural issues of class, spirituality/religion, ability, immigration, and nationality. Culturally sensitive* professionals in mental health need to be open to the ways in which their lack of awareness of their own values, assumptions, and prescriptions may negatively influence and undermine the therapeutic relationship, process, and treatment outcomes (Hardy and Bobes 2016). A further issue needs attention. Many of the theoretical and empirical writings on cultural competence largely focus on highlighting diverse social identities or contextual factors such as gender, race, ethnicity, sexual orientation, social class, spirituality/religion and immigration, to name a few, rather than on the multidimensionality* and intersectionality* of these social identities. Intersectionality refers to the notion that all of us occupy multiple niches simultaneously and define ourselves via an interweaving of these categories. Further, our identities can be fluid, with different variables being highlighted in different contexts (Rastogi and Thomas 2009). An understanding of the ways in which multidimensional social identities/ selves inform the therapeutic relationship, supervisory relationship, and conceptual as well as executive skills of CFT clinicians is greatly needed (Hardy and Laszloffy 2002; Hardy 2016). Additionally, the above authors argue that contextualizing CFT cultural competency within the framework of social justice,* power, privilege, oppression, and marginalization in the larger society and on the lives of individual clients, the therapeutic relationships, processes, and outcomes needs to be one of the major next steps to further cultural competency in the field. CFT needs to attend to not only “WHO is included (diversity) but also HOW one is included (social justice)” in our therapy models and training programs (Hardy 2016, p. 7). He further argues that one cannot truly be competent (i.e., be an expert) on someone else’s culture, especially if one is not aware and sensitive to the ways in which his or her own multidimensional cultural identities/ selves dictate the relational and power dynamics in interactions with others.

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Thus, cultural competency is not only about training CFTs to be cognitively aware of the cultural similarities and differences between them and their clients or even among their clients. It is also about equipping CFTs in practical ways to become affectively and relationally sensitive to the ways in which their multidimensional identities/selves and those of their clients may trigger issues of power, privilege, oppression, or marginalization that may impede culturally responsive* therapeutic engagement and process. The “How To’s” of Cultural Competency and Its Current Status in CFT The foundational texts pertaining to cultural competency have focused on obtaining content relevant to the “culturally different.” However, an integral aspect of cultural competency is for the therapist, researcher, and/or scholar to also be aware of her/his own cultural context. Thus, the cultural genogram (Hardy and Laszloffy 1995) is an essential tool in the training of culturally competent family therapists. The purpose of the cultural genogram is to raise cultural awareness and increase cultural sensitivity. Through the process of constructing a cultural genogram, family therapists identify and explore their perceptions and feelings toward their cultural identities, encourage candid discussions that reveal and challenge culturally based assumptions and stereotypes, and lastly, discover their culturally based triggers and how these may impact their therapeutic effectiveness (Hardy and Laszloffy 1995). Additionally, numerous authors contend that experiential learning is a critical part of enhancing cultural sensitivity and have identified other strategies to increase cultural sensitivity in clinical training. In order to address accreditation standards relevant to cultural competence, Laszloffy and Habekost (2010) present a model of experiential tasks to help educators promote both cultural awareness and sensitivity. These experiential tasks are designed to help students move beyond cultural awareness and promote meaningful, empathic clinical sensitivity. Esmiol et al. (2012) concur that a combination of theoretical issues alongside students’ exploring and discussion their own stories of privilege and marginalization

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can raise consciousness of larger contextual issues related to race, culture, gender, power, religion, and its impact on clinical work. Moreover, addressing cultural competence within the supervision context has been supported by many family therapy scholars (Christiansen et al. 2011; Hardy 2016; Killian 2001; Lappin and Hardy 2002; Todd and Rastogi 2014). Hardy (2016) espouses a Multicultural Relational Perspective (MRP) to highlight a variety of core competencies that promote culturally sensitive training and supervision. In these core competencies, trainers and supervisors are required to embody several key elements such as recognizing that all relationships are cross-cultural. Trainers and supervisors must be able to engage in a process of critical self-interrogation and selfreflection. A steady gaze inwards would assist in the process of acquainting oneself with our cultural being. Through the process of selfinterrogation and critical self-reflection, one would be better equipped to remain engaged in intense conversations that often arise during conversations of diversity. The ability to highlight, deconstruct, and make visible the persistent experiences of oppression and its effects also promotes an “oppression sensitive lens” to critically understand the interplay between power, privilege subjugation and trauma (Hardy 2016). Hardy also outlines why the prospect of being “culturally sensitive” is not an endpoint that is easily obtained; rather it is a lifelong process that requires time, commitment, intentionality, and effort.

Relevant Research In a content analysis of three family therapy journals between 2004 and 2011, Seedall et al. (2014) indicated that there is far greater theoretical than empirical scholarship on diversity, intersectional and social justice approaches in the field of CFT. In previous years, the research on cultural competency has focused on evaluating training programs and professional organization such as AAMFT incorporation and interaction of diversity issues in their curricula and programs

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(Wieling and Rastogi 2003). Although these empirical studies have been helpful in moving the field forward in terms of emphasizing diversity issues in CFT training programs, little is known as to how the development of cultural acknowledge of trainees is transmitted/translated into cultural and clinical skills and competencies. More research is needed on how issues of diversity, intersectionality, and social justice are taught and integrated in training programs’ curricula and within supervisory environments. Additionally, it is important for the field to have better awareness and understanding of the evaluative methods and processes of determining trainees’ cultural competency. Empirical work is lagging due to the difficulties that the field has in clearly defining and operationalizing concepts and constructs such as cultural competency. More research is needed to aid the field in defining and understanding what constitutes a culturally competent therapist and/or researcher and the outcomes of this training and practice. Several authors have recently proposed that clinicians, researchers, and scholars focus on cultural responsiveness and humility as compared to cultural competency (Bernal and DomenechRodriguez 2009; Seponski et al. 2013). Particularly, within a research paradigm, these authors contend that simply adapting models of CFT that were normed on White heterosexual, patriarchal middle-class families is insufficient for use with families, couples, and individuals who do not hold mainstream Eurocentric values and norms. Seponski et al. (2013) proposed the development of culturally responsive therapy (CRT) and research by using a responsive evaluation (RE) approach. Culturally responsive therapy and research within a responsive evaluation framework allows CFT researchers and clinicians to develop models of therapies that are “theoretically and technically responsive to the needs unique to a certain population” rather than adapt and utilize current therapy models such as Emotionally Focused Therapy to all couples, under the premise of universality of emotional and interactional processes of partners regardless of their cultural identities and coupling context (p. 28). In order to advance CFT research on cultural

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competency, the field’s research development and design needs to move towards studying and understanding the unique experiences of specific cultural groups. This type of empirical work will provide data to build diverse therapy approaches from the ground up. In recent years, CFT researchers have engaged in research studies that focus on the unique experiences of specific cultural groups (Beitin and Allen 2005; ParraCardona et al. 2009; Coolhart et al. 2013). This research endeavors to provide factual and experiential knowledge on the variant cultural identities, values, and experiences of groups within their familial and societal contexts. To move beyond diversity research, the field of CFT needs to incorporate social justice inquires in its empirical agenda. Scholars have indicated that cultural competency within the frame of social justice should be able to address the impact of sociocultural oppression or the trauma of sexism, racism, heterosexism, classism, Islamophobia, and other forms of domination and issues of equity on clients’ mental, emotional, and relational lives (Hardy 2016; McDowell and Shelton 2002). Together, diversity and social justice research will help the field develop better constructs and concepts to aid trainers in assisting trainees to acquire culturally aware and sensitive skills and competencies as family therapists and researchers. Additionally, this research will be beneficial to the field’s development and implementation of clinical interventions that are culturally and socially just for specific groups, thus enhancing trainers and supervisors’ abilities to effectively evaluate trainees’ cultural competency and responsive skills (McGeorge et al. 2006).

Special Considerations for CFT Schmonburg and Prieto (2011) indicated that the recent emphasis in the field of CFT on diversity training has been helpful in terms of enhancing trainees’ knowledge of social cultural issues through didactic training format. A didactic training format may increase trainees’ cognitive understanding and the complexity of the similarities and differences of cultural identities among their

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clients as well as between them and their clients. We also believe that incorporation of experiential training format (exercises) intertwined with didactic training will aid trainees in becoming more culturally aware and sensitive by assisting in ways in which to develop and apply clinical conceptual and execution skills as well as research skills within the framework of cultural competency (Nixon et al. 2010; Esmiol et al. 2012; Hardy and Bobes 2016). Thus, an integration of both didactic and experiential training formats allow for critical self-awareness and attunement, which are major components of being a culturally competent and responsive therapist and researcher.

References Allen-Wilson, A. (2016). Integrating and addressing religion and spirituality in supervision and training. In K. V. Hardy & T. Bobes (Eds.), Culturally sensitive supervision and training: Diverse perspectives and practical applications (pp. 57–64). New York: Routledge. Awosan, C. I., Sandberg, J. G., & Hall, C. A. (2011). Understanding the experience of Black clients in marriage and family therapy. Journal of Marital and Family Therapy, 37(2), 153–168. Beitin, B. K., & Allen, K. R. (2005). Resilience in Arab American couples after September 11, 2001: A systems perspective. Journal of Marital and Family Therapy, 31(3), 251–267. Bernal, G., & Domenech-Rodriguez, M. M. (2009). Advances in Latino family research: Cultural adaptations of evidence based interventions. Family Process, 48(2), 169–178. Bernstein, A. C. (2000). Straight therapists working with lesbians and gays in family therapy. Journal of Marital and Family Therapy, 26, 443–454. Christiansen, A. T., Thomas, V., Kafescioglu, N., Karakurt, G., Lowe, W., Smith, W., & Wittenborn, A. (2011). Multicultural supervision: Lessons learned about an ongoing struggle. Journal of Marital and Family Therapy, 37(1), 109–119. Coolhart, D., Baker, A., Farmer, S., Malaney, M., & Shipman, D. (2013). Therapy with transsexual youth and their families: A clinical tool for assessing youth’s readiness for gender transition. Journal of Marital and Family Therapy, 39(2), 223–243. Daneshpour, M. (2017). Family therapy with Muslims. New York: Routledge. Dee Watts Jones, T. (2016). Location of self in training and supervision. In K. V. Hardy & T. Bobes (Eds.), Culturally sensitive supervision and training: Diverse

Cultural Competency in Couple and Family Therapy perspectives and practical applications (pp. 16–24). New York: Routledge. Doherty, W. J., & Baptiste, D. A. (1993). Theories emerging from family therapy. In P. Boss, W. Doherty, R. LaRossa, W. Schumm, & S. Steinmets (Eds.), Sourcebook of family theories and methods: A contextual approach (pp. 505–524). New York: Plenum. Esmiol, E. E., Knudson-Martin, C., & Delgado, S. (2012). Developing a contextual consciousness: Learning to address gender, societal power, and culture in clinical practice. Journal of Marital and Family Therapy, 38(4), 573–588. Goldenberg, H., & Goldenberg, I. (2013). Family therapy: An overview. California: Cengage Learning. Green, J. R. (2003). When therapists do not want their clients to be homosexual: A response to Rosilk’s article. Journal of Marriage and Family Therapy, 29, 31–40. Hardy, K. V. (1989). The theoretical myth of sameness: A critical issue in family therapy training and treatment. Journal of Psychotherapy & the Family, 6(1-2), 17–33. Hardy, K. V. (2016). Toward the development of a multicultural relational perspective on training and supervision. In K. V. Hardy & T. Bobes (Eds.), Culturally sensitive supervision and training: Diverse perspective and practical applications (pp. 3–10). New York: Routledge. Hardy, K. V., & Bobes, T. (Eds.). (2016). Culturally sensitive supervision and training: Diverse perspectives and practical applications. New York: Routledge. Hardy, K. V., & Laszloffy, T. A. (1992). Training racially sensitive family therapists: Context, content, and contact. Families in Society. The Journal of Contemporary Human Services, 73, 364–370. Hardy, K. V., & Laszloffy, T. A. (1995). The cultural genogram: Key to training culturally competent family therapists. Journal of Marital and Family Therapy, 21(3), 227–237. Hardy, K. V., & Laszloffy, T. A. (2002). Couple therapy using a multicultural perspective. In A. S. Gurman & Jacobson (Eds.), Clinical handbook of couple therapy (pp. 569–593). New York: Guilford Press. Hardy, K. V., Hernandez, A. M., & Awosan, C. I. (2016). Making the invisible visible: A closer look at social class in supervision and training. In K. V. Hardy & T. Bobes (Eds.), Culturally sensitive supervision and training: Diverse perspectives and practical applications (pp. 35–42). New York: Routledge. Hargrave, T. D., & Pfitzer, F. (2003). The new contextual therapy: Guiding the power of give and take. New York: Brunner-Routledge. Hudak, J., & Giammattei, S. V. (2010). Doing family: Decentering heteronormativity in “marriage” and “family” therapy. American Family Therapy Academy, 6, 49–58. Killian, K. D. (2001). Differences making a difference: Cross-cultural interactions in supervisory relationships. Journal of Feminist Family Therapy, 12(2–3), 61–103.

Cultural Competency in Supervision Lappin, J., & Hardy, K. V. (2002). Keeping context in view: The heart of supervision. In T. C. Todd & C. L. Storm (Eds.), The complete systemic supervisor: Context, philosophy, and pragmatics (pp. 41–58). Lincoln: Authors Choice. Laszloffy, T., & Habekost, J. (2010). Using experiential tasks to enhance cultural sensitivity among MFT trainees. Journal of Marital and Family Therapy, 36(3), 333–346. Laszloffy, T. A., & Hardy, K. V. (2000). Uncommon strategies for a common problem: Addressing racism in family therapy. Family Process, 39(1), 35–50. McDowell, T., & Shelton, D. (2002). Valuing ideas of social justice in MFT curricula. Contemporary Family Therapy, 24, 313–331. McGeorge, C., & Stone Carlson, T. (2011). Deconstructing heterosexism: Becoming an LGB affirmative heterosexual couple and family therapist. Journal of Marital and Family Therapy, 37(1), 14–26. McGeorge, C., Stone, C. T., Erickson, M. J., & Guttormson, H. E. (2006). Creating and evaluating a feminist-informed social justice couple and family therapy training model. Journal of Feminist Family Therapy, 18, 1–38. McGoldrick, M., & Hardy, K. V. (Eds.). (2008). Re-visioning family therapy: Race, culture, and gender in clinical practice (2nd ed.). New York: Guilford Press. McGoldrick, M., Pearce, J. K., & Giordano, J. (1982). Ethnicity and family therapy. New York: Guilford Press. Nixon, D. H., Marcelle-Coney, D., Torres-Gregory, M., Huntley, E., Jacques, C., Pasquet, M., & Ravachi, R. (2010). Creating community: Offering a liberation pedagogical model to facilitate diversity conversations in MFT graduate classrooms. Journal of Marital and Family Therapy, 36(2), 197–210. Parra-Cardona, J. R., Holtrop, K., Cordova, D., EscobarChew, A. R., Horsford, S., Tams, L., et al. (2009). “Queremos aprender”: Latino immigrants’ call to integrate cultural adaptation with best practice knowledge in a parenting intervention. Family Process, 48(2), 211–231. Platt, J. J., & Laszloffy, T. A. (2013). Critical patriotism: Incorporating nationality into MFT education and training. Journal of Marital and Family Therapy, 39(4), 441–456. Rastogi, M., & Thomas, V. (2009). Multicultural couple therapy. Thousand Oaks: Sage. Rastogi, M., & Wieling, E. (2005). Voices of color. Thousand Oaks: Sage. Rock, M., Carlson, T. S., & McGeorge, C. R. (2010). Does affirmative training matter? Assessing CFT students’ beliefs about sexual orientation and their level of affirmative training. Journal of Marital and Family Therapy, 36(2), 171–184. Schomburg, A. M., & Prieto, L. R. (2011). Trainee multicultural case conceptualization ability and couple

683 therapy. Journal of Marital and Family Therapy, 37(2), 223–235. Seedall, R. B., Holtrop, K., & Parra-Cardona, J. R. (2014). Diversity, social justice and intersectionality trends in C/MFT: A content analysis of three family therapy journals, 2004-2011. Journal of Marital and Family Therapy, 40(2), 139–151. Seponski, D. M., Bermudez, J. M., & Lewis, D. C. (2013). Creating culturally responsive family therapy models and research: Introducing the use of responsive evaluation as a method. Journal of Marital and Family Therapy, 39(1), 28–42. Stone Fish, L., & Harvey, R. G. (2005). Nurturing queer youth: Family therapy transformed. New York: Norton. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70(4), 477–486. Todd, T. C., & Rastogi, M. (2014). Listening to supervisees about problems in systemic supervision. In T. C. Todd & C. L. Storm (Eds.), The complete systemic supervisor: Philosophy, context and pragmatics (2nd ed., pp. 314–334). Chichester: Wiley. Walters, M., Carter, B., Papp, P., & Silverstein, O. (1991). The invisible web: Gender patterns in family relationships. New York: Guilford Press. Watson, W. F. (2016). Supervision in black and white: Navigating cross-racial interactions in the supervisory process. In K. V. Hardy & T. Bobes (Eds.), Culturally sensitive supervision and training: Diverse perspectives and practical applications (pp. 43–49). New York: Routledge. Wieling, E., & Rastogi, M. (2003). Voices of marriage and family therapists of color: An exploratory survey. Journal of Feminist Family Therapy, 15(1), 1–20.

Cultural Competency in Supervision Lara Davis California School of Professional Psychology, Alliant International University, Sacramento, CA, USA

Name of Concept Supervising cultural competency in couple and family therapy

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Introduction Cultural competency in supervision is not only an embodiment of cultural awareness and understanding but a core competency of a supervisor in the field of marriage and family therapy. Culture competency in supervision encompasses awareness surrounding one’s own values, assumptions, and biases as these serve as the foundation from which one views the world including that of culturally diverse clients. Cultural competency in supervision is imperative to providing allencompassing therapists that not only own their own power, privilege, and oppression but can facilitate this awareness within their clients (Hernández et al. 2005). Cultural competency is a lens which supervisors, supervisees, clients, and the interwoven connections to each can be empowered to own contributions and take action to help alter the larger discourse taking place within therapy and supervision.

Theoretical Context for Concept The current model of cultural competency evolved from a more rigid, singular perspective inclined to compartmentalize people based on gender, race, ethnicity, sexual orientation, class, etc. The focus surrounded the “otherness,” the differences, of the individual and not the interplay between power and privilege and not only of living in general but the role of the therapist, supervisee, supervisor, and other power positions involved in the therapeutic alliance, including the client (Hernandez-Wolfe and McDowell 2014). A subsequent effect is being the belief that one can understand a person and their experiences based merely on a few select descriptives of their identity and that these pieces of identity were static rather than fluid and interwoven with other vast aspects of identity, experience, and a larger societal institution. For example, a supervisor working from the previous model might encourage a supervisee to learn all she could about working with clients that identify as veterans without helping the supervisee conceptualize the impact of having a veteran

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status and the intersectionalities of one’s power differentials, privileges, marginalizations, gender, sexual orientation, race, ethnicity, rank, service location, political climate, etc. The lack of dialogue acknowledging the interplay of privilege, power, and oppression sets a precedence of limited awareness and unwittingly reinforces previously set power and privilege dynamics through defining and stereotyping. The current model aims to shift focus away from the belief that cultural differences are the source of inequities to understanding that it is the meaning a particular culture construct and practice that creates a norm and defines and labels the dominant, the marginalized, the accepted, and the unaccepted (Hernandez-Wolfe and McDowell 2014). This model, to some degree, utilizes isomorphism by calling attention to various dynamics that play out in supervision that parallel the supervisee and client process. The goal of the model is to foster awareness, not only with the supervisee but also their client, surrounding the interconnectedness of power, privilege, and oppression experienced by, and between, the individual, their family, community, cultural group, and global institution. From this need, a foundation for cultural competency within supervision was devised using cultural equity, cultural humility, and intersectionality.

Description Hernandez-Wolfe and McDowell (2014) emphasize the use of cultural equity, cultural humility, and intersectionality to provide a foundation to help supervisees conceptualize their clients in totality. The use of cultural equity ensures that supervisors reflect upon their own privileges, power, and marginalizations and vice versa while also embodying an awareness surrounding the multifaceted interaction between personal, social, and institutional locality that directly or indirectly interface with relationships of power, privilege, and oppression (Hernandez-Wolfe and McDowell 2014). Cultural humility, as defined by Tervalon and Murray-Garcia (1998), is the embodiment of lifelong learning and self-

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reflection which continuously fosters awareness and flexibility instead of becoming complacent with cultural awareness. Through utilizing cultural humility, one stays curious about culture and is able to admit to times of unknowing. Of course, it is gravely important to know as much as possible about various cultures, disabilities, and experiences, but utilizing humility allows for the navigation of times of unawareness through engaging in honest dialogue. The last foundational piece is intersectionality which refers to how each person is positioned in multiple systems of privilege and oppression including race, gender, sexual orientation, religion, and social class (Crenshaw 1989). For example, a person who was born and raised in America and identified as African American may have a very different conceptualization than another who identified as African American but only recently obtained citizenship. Understanding that there are multiple interactional levels based on the various pieces of identity, cultural and systemic interactions and intersections allow for the supervisor to help the supervisee to reflect upon as many dimensions as possible.

Application of Concept in Couple and Family Therapy The framework for providing culturally competent supervision utilizes three components: (a) critical consciousness, (b) empowerment, and (c) accountability (Freire 1971; HernandezWolfe and McDowell 2014). This framework focuses on understanding lived experiences as well as empowering through creating action within one’s own reality; this process allows room to understand and appreciate actions that had previously been taken for granted. To start, supervisors need to maintain reflective questioning and processing to continue enhancing the supervisee’s awareness and raise critical consciousness, since critical consciousness is formed through the use of dialogue, curiosity, and language (Hernandez-Wolfe and McDowell 2014). Critical consciousness is a multifaceted construct in applicability to the client as well

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as the supervisee allowing the supervisee to help their client enhance their power within their context. Part of this process includes the supervisee acknowledging their own contributions toward therapeutic gains as well as their own gain from the therapeutic relationship. In this aspect, the supervisor garners special attention to the growth of the supervisee as well as the growth of the client. Similarly, accountability is the emphasis placed on acceptance of one’s actions and the effect they have on others, particularly when the actions have negative consequences; as well as utilizing reparative action to right wrongs that have been committed. In this process supervisors gently guide supervisees’ awareness surrounding the consequences their own actions have had for their client and the client’s systemic relationship as well as for their self-ofthe-therapist development. Throughout this process the supervisor shares their own accountability and actions that have contributed negatively to the supervisory relationship as well as the therapeutic relationship. This process is also fluid in allowing for owning and accepting actions that have negatively impacted others, as well as accounting for one’s privilege. Lastly, empowerment is utilized to help the supervisee guide their client in gaining power through and within their own lives. The supervisor facilitates this process by helping the supervisee acknowledge their own standing in society as well as their contribution and gains from the therapeutic process. Once the supervisee has foresight over their own experiences, they can help their client be empowered through owning their own positive contributions in their own life and the lives of others.

Clinical Example Amir, an identified Muslim immigrant from Great Britain, came to the United States and is a practicing marriage and family therapist trainee. Recently, Amir started working with Ehsan, an American-born Muslim who was referred for therapy by his college guidance counselor for anger and depression. In supervising Amir shares that he is having a difficult time connecting with his client outside of a shared commonalty of religion.

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Amir told his supervisor that he has attempted to be transparent with his client and shares some of his own experiences and struggles in America as a Muslim in order to connect with him, but this only seems to push Ehsan away. Previous Model Amir’s supervisor advises him to dichotomize Ehsan’s experiences as separate pieces and focus on his experiences of oppression and marginalization as a Muslim American which eventually alienates Ehsan making him feel disempowered and hopeless. Ehsan soon feels therapy is a waste of time as he is not getting the support he needs and subsequently, feeling defeated, quits therapy and has no intention in finding another therapist. New Model Utilizing intersectionality, culture equity, and humility, Amir’s supervisor helps him to foster selfawareness around his own power, privilege, and oppression. Utilizing critical consciousness, the supervisor encourages Amir to examine his own lived experiences in the United States as well as in Britain, including the effects of the various communal, social, and political climates of each and the aspects of his experiences that he has taken for granted. This allows for Amir to recognize where he may have more privilege as a Muslim British immigrant than a Muslim American born and raised in United States post-9/11. This process helps Amir understand that Ehsan’s experiences are heavily shaped by his geographical location, politics, and economics as well as psychological conditioning and oppression. Furthermore, Amir’s supervisor encouraged the use of empowerment as a way to help Amir construct his own awareness of power within his reality and the reality of his client’s life. Through this process the supervisor helps Amir acknowledge his own standing in the world, be it race, gender, ethnicity, class, sexual orientation, and the implications these have on Amir. Amir is also encouraged to acknowledge his contributions to the therapeutic relationship, for instance, he was able to connect with Ehsan through a shared religious experience on how comforting that might be to Ehsan to not have to explain Muslim morals and values to someone.

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Throughout the supervision process, Amir’s supervisor has continuously reflected his own accountability through acknowledging when his own actions have had a negative impact on Amir and has taken action to repair any damage caused to the supervisory relationship. Through the supervisor’s encouragement and role modeling, Amir decides to have a dialogue with his client and holds himself accountable for his inability to find ways to further connect with and understand Ehsan’s experiences. Conceptualizing Ehsan’s life through intersectionality, cultural equity, and humility allows Amir to genuinely connect with Ehsan and foster a space of awareness and understanding. Through this experience Ehsan feels honored and heard and has a sincere desire to continue the therapeutic alliance.

Cross-References ▶ Cultural Competency in Couple and Family Therapy ▶ Culture in Couple and Family Therapy ▶ Supervisor-Supervisee Relationship in Couple and Family Therapy Supervision

References Crenshaw, K. (2018). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics [1989]. In Feminist legal theory (pp. 57–80). Chicago, Routledge. Freire, P. (1971). Pedagogy of the oppressed. New York: Seaview. Hernández, P., Almeida, R., & Vecchio, D. D. (2005). Critical consciousness, accountability, and empowerment: Key processes for helping families heal. Family Process, 44(1), 105–119. Hernandez-Wolfe, P., & McDowell, T. (2014). Bridging complex identities with cultural equity and humility in systemic supervision. In T. C. Todd & C. L. Storm (Eds.), The complete systemic supervisor: Context, philosophy, and pragmatics. New England: IUniverse. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.

Cultural Identity in Couples and Families

Cultural Identity in Couples and Families Shalonda Kelly and Yasmine Omar Rutgers, the State University of New Jersey, New Brunswick, NJ, USA

Name of Theory Cultural identity

Synonyms Cultural dimensions; Diverse; Diversity; Individual and role differences; Minority; Multicultural theory (MCT); Multiculturalism

Introduction Since the colonial era, a predominately Eurocentric Western cultural lens has been imposed widely, with adverse consequences for minority* couples and families. Despite increasing diversity, treatment approaches tend to adhere to Eurocentric cultural values like rationality and individuality, resulting in misperceptions that these values are universal. Similarly, Western treatment research values internal validity provided by randomized controlled trials over external validity that focuses on whether or not findings generalize to couples and families with diverse cultural identities who remain underrepresented in studies. These narrow, rigid definitions of normalcy often do not consider collectivist and extended family values or the varied family structures, gender roles, socialization, discrimination experiences, and environmental influences of diverse* couples and families. Instead, they are marginalized and perceived as culturally and genetically inferior. Correspondingly, minorities are less apt to seek Western mental health services, more likely to drop out before treatment is completed, and receive less quality care than other Americans (USDHHS 2001).

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Recognition of these issues has occurred across disciplines that include couple and family therapy specialties, and they developed guidelines for cultural competence in order to address these disparities in therapy. For example, the American Psychological Association (APA) recognized the importance of multiculturalism*: Multiculturalism, in an absolute sense, recognizes the broad scope of dimensions of race, ethnicity, language, sexual orientation, gender, age, disability, class status, education, religious/spiritual orientation, and other cultural dimensions*. All of these are critical aspects of an individual’s ethnic/racial and personal identity, and psychologists are encouraged to be cognizant of issues related to all of these dimensions of culture. In addition, each cultural dimension has unique issues and concerns. (APA 2002, pp. 9–10)

Similar to other psychological and allied organizations, APA has continued to recognize the importance of understanding cultural identity and multicultural competence (e.g., APA 2002). The APA Ethics Code’s Principle of Respect for People’s Rights and Dignity highlights awareness and respect for all sources of “individual and role differences”* based on age, gender, gender identity, race, ethnicity, culture, and so on. Many APA divisions focus on cultural identity, APA holds an annual multicultural summit, and APA also has developed guidelines around psychologists’ responsibilities to people having diverse cultural identities. In the field, therapists’ multicultural competence has most often been defined as multicultural knowledge, skills, and awareness. This means that they must have the knowledge of the cultural identities and associated experiences and worldviews of the clients that they treat, culturally relevant and sensitive skills to address client concerns, and awareness that their own biases and values, as well as those of the dominant Western culture, impact treatment. The need for therapist cultural competence underscores the need for multicultural theory as a fourth force in psychology to improve the relevance and usefulness of other theoretical paradigms.

Prominent Associated Figures Here is an alphabetized sample of prominent authors who write about therapeutic work with

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diverse couples and families for several of the many important areas of cultural identity. In regard to race, ethnicity, and immigration, Nancy Boyd-Franklin, Celia Falicov, Kenneth Hardy, Shalonda Kelly, Kyle Killian, Monica McGoldrick, and Mudita Rastogi are prominent. Prominent gender and LGBTQI authors include Beverly Greene, Robert-Jay Green, Carmen Knudson-Martin, and Michael Lasala. Those prominent in working with religious families include Froma Walsh and Mark Yarhouse.

Description Multicultural theory* (MCT) has brought a fundamental paradigm shift to the field of psychology by acknowledging and addressing the fact that all psychological phenomena occur and are learned in a highly influential cultural context. Sue et al. (1996) describe MCT as a metatheory that supplements each of the major theoretical orientations, such as psychoanalysis and behaviorism, and they present the six theoretical propositions on which multicultural counseling and therapy are based. First, the multicultural framework clarifies how all theoretical orientations are grounded in a cultural context that is biased in favor of the worldview of the population on which they are developed. Second, the totality, fluidity, and interrelatedness of layers of individual, family, group, cultural, and universal experiences and contexts must be considered in the development and change of identities for both therapists and clients. Third, for therapists and clients, cultural identity development influences attitudes toward their own group, the dominant group, and other groups and the relationships between them. Fourth, therapists can enhance treatment by using modalities, frameworks, and goals consistent with the life experiences and cultural values of their clients. Fifth, multicultural theory encourages the use of multiple useful helping roles developed by many cultural groups that go beyond the therapist-client relationship, such as those involving prevention, traditional healing methods, and community- and system-level resources and interventions. Sixth, in drawing on these other roles and methods,

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multicultural theory legitimizes liberation of consciousness and social justice as therapeutic goals, as they ground people in context and in relation to other groups and empower them to transcend the Western individualist paradigm. Multicultural theory can include a narrow or broad definition of cultural identity, and each aspect of these definitions has its own set of frameworks and associated micro-theories. The narrow definition refers to race, ethnicity, immigrants of different nationalities, and sometimes sexual orientation, while the broad definition adhered to within this entry includes many more aspects of a person’s cultural identity. These approaches are consistent with the second tenet of MCT regarding how the self is experienced within multiple contexts that are important to a client’s cultural identity, including the couple and family, and the fourth tenet of MCT that states the need for multiple frameworks to ensure that these contexts are considered. First, ecological models are examined, which normalize and emphasize the need to consider cultural and other contexts within treatment, without specifying the role of culture. Next, key structural theories about concepts that are essential to the development and expression of cultural identity are identified. Then information and theories about some of the cultural identities that are experienced by many individuals, couples, and families in treatment are presented. Ecological and Structural Models Ecological models such as the biopsychosocial model and Bronfenbrenner’s bioecological model help in understanding the impact of culture on human behavior. Consistent with tenet two of MCT, they identify microlevel influences such as a person’s biological makeup and increasingly distal contexts, such as family and interpersonal contexts, and the dominant cultural values of the society as being influential on behavior. For example, the context of ongoing arguments with family members about cultural identity factors like religious values, LGBT status, or differences in acculturation levels between teens and parents might lead a teen to run away from home or engage in risky behavior. Moreover, contexts that span history and the life span, such as the

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impact of the legacy of slavery and immigration, influence behavior within couples and families, such as with spouses having differing perspectives on their own heritage or a family living in an ethnic enclave. Oppression is a structural system that confers unearned power and privilege on the dominant group and stigmatizes, dehumanizes, and disenfranchises minority groups having nondominant cultural identities and demographic backgrounds. Oppression includes but is not limited to racism and White privilege and supremacy, heterosexism, classism, sexism and patriarchy, and ableism. These “isms” are enacted in widespread policies, practices, and social norms and customs based upon the cultural identities of privileged groups, consistent with the first MCT tenet that therapy is grounded in a biased cultural context. The “isms” form interrelated structural power systems that systematically create and maintain social inequalities. For example, McIntosh’s (1998) seminal primer shows social norms regarding how White privilege is manifest. Another example involves two widely held mainstream values in the United States; the Protestant work ethic states that one should work hard, and meritocracy states that people get ahead in life based upon their own merits, such as intelligence and skills. Both concepts imply a level playing field in which oppression does not exist, and the result is blame of those with diverse cultural identities for their subordinate status. Oppression also can be internalized, wherein those with diverse cultural identities may believe in the negative portrayals of them that are propagated by the dominant group. Overall, the minority stress that results from oppression harms the well-being and relationships of those with diverse cultural identities. Identity Models Identity models refer to the individual differences among people that can be the basis for the development of their cultural identities, which yield value and meaning to their group membership and are associated with their well-being. Such differences include but are not limited to racial and ethnic identity, sexual orientation, gender, religion, and immigrant status. Theories have

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been developed to explain the impact of these individual differences, their intersections, conflicts, and the beneficial aspects of cultural identities. Next, some of the most well-known and influential theories about culturally related individual differences are detailed. Racial and Ethnic Identities and Stage Theories Racial and ethnic identity theories are at the forefront of our understanding of individual differences and cultural identities (e.g., Jernigan et al. 2017). Racial groupings are assigned on the basis of physical characteristics, such as skin color, facial features, and hair texture. Despite refuted claims that there is a biological racial hierarchy, racial group designations change over time and across countries, and biologically there is just as much diversity within as across racial groups. Thus racial groupings are social constructs that become a significant aspect of a person’s identity. Dr. William Cross developed a stage theory of Nigrescence, a French term for becoming black, to describe African Americans’ development of racial identity in the United States under the conditions of oppression. Dr. Janet Helms developed the first scale to measure it. Dr. Robert Sellers developed a multidimensional theory of racial identity and an associated measure that focused on key dimensions of race, such as its salience and centrality. Similar to racial identity, ethnicity refers to the common ancestry and history of a group of people and a shared sense of belonging to the group. Dr. James Marcia developed theory regarding the process of exploration and commitment as important to the development of a personal identity, which Dr. Jean Phinney applied to the development and measurement of one’s ethnic identity, rather than explicitly considering race or racial oppression. Racial and ethnic identity began to be applied to all racial and ethnic groups. While there are notable differences among measures of racial identity across racial groups, and between measures of racial and ethnic identity, they all reveal important associations of a positive racial and ethnic identity with key life outcomes such as mental health, achievement, in-group and out-group interactions, and couple relationship quality.

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The developmental stage theories of racial and ethnic identities have been applied broadly to other aspects of cultural identity. Like the experience of those having a stigmatized racial identity, people with other stigmatized cultural identities are thought to begin their identity development by believing the negative things about their identity that society promulgates. This perspective becomes challenged through their life experiences, and they discard the dominant perspective to immerse themselves in understanding their identity and eventually develop a positive view of their identity and an acceptance of other identities (e.g., Jernigan et al. 2017). As with general and ethnic identity theory, as they develop, people go through a process of exploring and committing to their cultural identity, and the final healthiest stage is committing to a cultural identity after having explored it (Yip et al. 2014). LGBTQI Identities In addition to the applicability of the foregoing racial identity theory stage model to sexual orientation, several key theories and concepts apply to the experiences of those in the lesbian, gay, bisexual, transgender, queer and questioning, and intersex (LGBTQI) community. They all lack societal acceptance where they do not fit the dominant conceptions of gender, gender identity expression or roles, and sexual orientation. The dominant conceptions are that all persons fit a gender binary of male or female, in which men adhere to traditional masculine gender roles and expression, women adhere to traditional feminine gender roles and expressions, men are solely attracted to women, and vice versa. Conversely, it is well documented that these factors all are more accurately conceptualized as fluid continua rather not belonging solely to one gender. The social stigma of homophobia occurs when LGBTQI community members are seen as deficient, and heterosexism occurs when they are expected to fit the dominant conceptions, such as when a girl is regularly asked which boy she likes in school. Moreover, each subgroup of this community has its own uniqueness. For example, bisexual persons sometimes are pushed by gay and heterosexual communities to choose between them. Issues faced by the LGBTQI community

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affect family relationships, such as with partner differences in the level of coming out to others, having to develop supportive “families of choice,” or having children in ways that all family members are not biologically related. Gender Research and theory on gender differences and the lower status of women in society have focused upon evolutionary theory, social constructionist theory, postmodern feminist theory, and biosocial theory (e.g., Wood and Eagly 2002). For example, evolutionary theory states that men compete and experience sexual jealousy to control paternity and yield reproductive advantages. Social constructionist theories suggest that sex differences vary with power relationships within societies, such that in paternalistic societies, men control the context of child-rearing, and there is sex-typed socialization into gender roles. For example, men may step back from parenting roles, and women may step back from career building due to socially constructed societal discourse suggesting that women are the natural caregivers and belong in the home (KnudsonMartin 2017). Postmodern feminist theory also is a type of social constructionist theory. Consistent with tenet six of MCT, it liberates consciousness by deconstructing the dominant paradigms and highlighting how the most prominent discourses are tied to the power structure, such as “traditional” conceptions of gender being supported by laws governing relative pay of men and women, maternity leave, alimony, child support, custody, and minimum income. It also asserts that the dominant discourses about gender and other oppressed groups portray dominant views and values as universal rather than fluid and situated in contexts. Biosocial theories combine evolutionary and social constructivist models; there are influential biological factors like hormones and nursing children that contribute to sex-typed division of labor, and environmental and social circumstances influence the degree of patriarchy in societies. Spirituality and Religion Religion is an integral part of many cultural identities, and it is particularly salient within couples and families. For example,

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religions may vary in their emphasis on individualism prioritizing the individual or collectivism prioritizing the group, such as with Protestant Christianity and Judaism, respectively, which determine priorities and values and moral judgments of couples and families. Many use their religion as a source of moral guidance, strength, and resilience to turn to in times of trouble, such as with the experience of oppression (e.g., Walsh 2016), and they often practice their spirituality and religion with others having the same cultural identity, thus increasing those bonds. In the context of couples and families, many religions view marriage as sacred, and lust and adultery vary in their moral standing and attribution based on religious culture. Immigration and Acculturation Immigration and acculturation are powerful forces that shape cultural identities and impact couples and families. Key factors prior to immigration may include traumas experienced by refugees, or the process of serial migration, in which one person may emigrate first to prepare the way for other family members, resulting in potentially long periods of separation. Once immigrants have arrived, they experience many practical challenges, such as learning English and obtaining legal citizenship. Also, they experience acculturation or the many cultural and psychological changes of living in a culture that can be radically different than the culture from which they came, such as those coming from collectivist cultures to individualist cultures. Moreover, family members may differ in these identifications, particularly across generations, which may cause family strife due to clashes in cultural identities. Intersections of Identities While each of the foregoing cultural identities was discussed separately, it is important to recognize that each person’s own cultural identity includes aspects of most of them (e.g., Jernigan et al. 2017). For example, everyone has a gender, race, ethnicity, national status, perspective on religion and spirituality, etc., and the term intersectionality describes the confluence of multiple identities within each person. Consistent with MCT, each identity has its own influence on an individual’s in-group and out-group attitudes and relationships. Moreover, one’s felt experience of

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intersectionality often is complex (e.g., Schwarzbaum and Thomas 2008), such that identities are neither exclusive nor discrete, and the whole of one’s intersectional identity often is greater than the sum of each individual aspect of cultural identity. In addition, each person tends to have one or more privileged identities, such as being White, male, American, Christian, rich, etc., as well as one or more oppressed identities, such as being part of a visible racial or ethnic group, a woman, an immigrant, adhering to a non-Christian religion or no religion, poor, etc. These privileged and oppressed identities interact with each other, but do not negate each other. Importantly, the most marginalized groups in society tend to have multiple oppressed stigmatized identities, each facing its own stressors. Risk and Resilience Models Risk and resilience models are useful for specifying which factors are helpful and hurtful to individuals, and these models have important implication for cultural identity within diverse couples and families (e.g., Walsh 2016). Protective and resource factors are positively influential, while vulnerability and risk factors are negatively influential. Similarly, resilience models focus upon identifying those individual, family, and school or community factors that help children and families to thrive even in adverse circumstances, such as poverty and stigma. For diverse couples and families, their cultural identities bring strengths of resource and protective factors, such as the parental socialization of a positive racial and ethnic identity, religious coping, and extended family support (e.g., Walsh 2016). It is important for couple and family therapists and researchers to consider the strengths and resilience derived from the cultural identities of diverse couples and families, rather than just their challenges, to avoid deficit models, further stigmatization, and the internalization of negative cultural identities.

Relevance to Couple and Family Therapy Cultural identity and its associated values impact the definition and structure of a couple or family.

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For example, in the United States, the nuclear family is prioritized, consisting of a heterosexual male provider, his wife who stays at home or tailors her career to enable raising children, and their children who are taught traditional gender roles and see this modeling inside and outside of the family. Juxtaposed against this false norm or false social expectation of what a family looks like and how it functions, all other couple and family types have been deemed deficient and have been stigmatized. These include couples who do not have children, LGBTQI couples and families, interracial couples and families, three-generation extended family households, families with different life cycle phases, and more (e.g., McGoldrick and Hardy 2008). Each has undergone extensive legal and social battles to be seen as legitimate, such as the fight for interracial marriage and gay marriage and the fight to overcome some therapists’ confusion and assumption of deficiency when a grandparent and child present for treatment. Couples and families are known to be the conveyors of culture, consistent with the second tenet of MCT, which states that many contexts, such as family, cultural, and universal contexts, shape cultural identities. Couples and families help their members with the issues that all Americans face when establishing their cultural identities and values, including all of the foregoing cultural identities (Kelly 2017). For example, with racial, ethnic, and gender role socialization, parenting styles, and choices of spiritual or religious practices often linked to their cultures, couple and family members interact daily and develop and model shared worldviews, attitudes, and actions toward various cultural identities. Often, couples’ and families’ socialization is consistent with their environmental and social context, but at other times, those with diverse cultural identities provide a buffer against prevailing social attitudes, such as when one or more of the family’s cultural identities are stigmatized (e.g., Kelly 2017). Family members often have the same backgrounds, and thus many share powerful culturally relevant formative experiences that shape their cultural identities and associated worldviews and values in similar ways. These include but are not

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limited to stigma and discrimination, socioeconomic status, and neighborhood context. For example, within neighborhoods, there are prevailing attitudes and tendencies toward corporal punishment, religion, level of violence, attitudes toward immigrants and non-English speakers, and more, which shape the cultural identities of all of the members of the couple or family. Conversely, some couple and family members may not share all of the same identities, and many may not share the same stance toward their own and others’ cultural identities. The same experiences may lead to differing values and coping styles for each member. For example, within the same immigrant family, two children may differ in acculturation levels, including their adherence to traditions, choice of social groups, and preferred languages. Couple and family members’ structures, values, environmental contexts, and cultural identities interact with and shape each other. Consistent with MCT tenet five, which identifies the need for multiple types of helping roles, these variations require therapists to be culturally competent. They need to assess cultural identities, better understand their roles in couple and family members’ lives, and tailor treatment to address the strengths, challenges, and impacts of cultural identity. Couple and family therapists have many practical reasons to attend to cultural identity within couple and family therapy. First, diverse couples and families are one of the fastest-growing populations in the United States. Second, cultural competence is essential in enabling accurate cross-cultural assessment of health and pathology, use of norms related to the specific population being treated, and the ability to efficaciously tailor treatment to the diversity found in most couples and families (e.g., Benish et al. 2011). This involves helping couples and families to address their unique concerns such as structural disparities and discrimination and incorporating their untapped strengths and resilience. Third, attending to diversity is complementary with the role of couple and family therapists, who often adhere to systems principles. They tend to understand that couple and family dynamics play vital roles in individual family members’ lives and shaping

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their identities. Thus, they are uniquely trained and well equipped to begin learning cultural competence toward supporting diverse couples and families.

Clinical Example of Application of Theory in Couples and Families Mark and Tony, an African American gay couple in their mid-twenties, met at school and began seeing each other without overtly agreeing to being a couple. Six months later, Tony found out that Mark was seeing other guys and broke off their romantic relationship. They continued to hang out together, and after a few months, they reunited as an official couple. Soon after that, Mark’s financial hardships led to him losing his apartment, and thus Tony invited him to move in. While the couple is monogamous, they sometimes enjoy threesome sexual encounters with other men. Finding out that one of those men was Mark’s past sexual partner caused Tony to question Mark’s honesty about his romantic history and Mark to feel mistrusted. Also, Tony sometimes wonders if Mark is with him just because of his financial stability, while it bothers Mark that he has to be the “friend” when they attend Tony’s family gatherings. Their strengths are that they really enjoy each other’s company, they admire and respect each other’s values and striving, and they like to host parties and go to bars together. A cultural genogram revealed important similarities and differences between the partners relevant to their cultural identities. Mark grew up in a low SES household, with a family history of drugs, crime, and multiple relationships, and said it led him to rely only on himself and to act tough in order to not feel helpless. At 18, financial pressure led him to criminal behavior resulting in 2 years of incarceration, after which he joined a community reentry program, turned his life around, and entered college. He reported no positive couple role models, other than TV shows. He had two heterosexual relationships as a teenager before dating only men, with one serious relationship that ended with his devastation because his

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partner left him. His mother and sisters know that he is gay and are supportive of it, but he does not talk to his father, and he is out with other family and close friends, but not professionally. Tony’s parents also had a hard life, to the extent that he did not know his father and his mother became addicted to drugs. But his aunt and uncle obtained custody of him at 3 years old and raised him in a solid middle-class, professional home. Still, Tony’s family relationships are strained, and he says they are homophobic. Tony is fairly sure that his family “knows” about his sexual orientation, but they never talk about it. Tony is a serial monogamist, and most of his relationships ended badly due to infidelity and trust issues. In addition, both Mark and Tony share a deep commitment to the African American community and being role models within it. The therapist’s cultural competence was used to tailor treatment to address key aspects of the couple’s cultural identities within a cognitive behavioral and systems approach. The therapist joined with the couple by being authentic and overtly warm, and she oriented them to treatment procedures, given that they never had been in treatment. Because of Mark’s financial status, and Tony’s desire not to be used by Mark, she increased access to treatment by negotiating with them for each to pay half of the fee and advocating with her agency to lower it so that Mark could afford his half. As a cultural broker who labels and negotiates differences in cultural identities, she had them discuss their differing life experiences, with a focus on socioeconomic-related factors and levels of being out with family and community in ways that invoked mutual support, understanding, and labeling of these “isms.” Then she helped them to develop shared standards in their relationship surrounding issues of cultural identity. She had awareness that her clinic’s intake and couple relationship questionnaires were unfairly geared to heterosexual couples, and so she bonded with them over discussing it as one of their regular experiences of oppression and changed the forms accordingly. She had knowledge that threesomes and other aspects of non-monogamy can be healthy choices, particularly with the small circle of those with whom they could feel comfortable

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sharing their sexual orientation. She also drew upon their strength of role flexibility to address their preferences about penetration and who does it and negotiated the boundaries between themselves and their circle, including exclusion of past partners from their threesomes to build trust. The couple reported satisfaction with treatment and a more rewarding and bonded relationship.

Cross-References ▶ African Americans in Couple and Family Therapy ▶ Biopsychosocial Model in Couple and Family Therapy ▶ Cultural Competency in Couple and Family Therapy ▶ Cultural Values in Couples and Families ▶ Culture in Couple and Family Therapy ▶ Ethnic Minorities in Couple and Family Therapy ▶ Ethnicity in Couples and Families ▶ Feminism in Couple and Family Therapy ▶ Gender in Couple and Family Therapy ▶ Oppression in Couple and Family Therapy ▶ Resilience in Couples and Families ▶ Social Constructionism in Couple and Family Therapy ▶ Socialization Processes in Families ▶ Spirituality in Couple and Family Therapy

References American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. Washington, DC: Author. Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology. https://doi.org/10.1037/ a0023626. Advance online publication. Jernigan, M. M., Green, C. E., & Helms, J. E. (2017). Identity models. In S. Kelly (Ed.), Diversity in couple and family therapy: Ethnicities, sexualities, and socioeconomics (pp. 363–392). Santa Barbara: Praeger. Kelly, S. (Ed.). (2017). Diversity in couple and family therapy: Ethnicities, sexualities, and socioeconomics. Santa Barbara: Praeger.

Cultural Values in Couples and Families Knudson-Martin, C. (2017). Gender in couple and family life: Toward inclusiveness and equality. In S. Kelly (Ed.), Diversity in couple and family therapy: Ethnicities, sexualities, and socioeconomics (pp. 153–180). Santa Barbara: Praeger. MinicGoldrick, M., & Hardy, K. V. (Eds.). (2008). Re-visioning family therapy: Race, culture, and gender in clinical practice (2nd ed.). New York: Guilford Press. McIntosh, P. (1998). White Privilege: Unpacking the invisible knapsack. In M. McGoldrick (Ed.), Re-visioning family therapy: Race, culture, and gender in clinical practice (pp. 147–152). New York: The Guilford Press. Schwarzbaum, S. E., & Thomas, A. J. (2008). Dimensions of multicultural counseling: A lifestory approach. Thousand Oaks: Sage. Sue, D. W., Ivey, A. E., & Pedersen, P. B. (1996). A theory of multicultural counseling and therapy. Pacific Grove: Brooks/Cole. U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity: A supplement to Mental Health: A report of the Surgeon General. Rockville, MD: Author. Retrieved from http:// www.surgeongeneral.gov/library/reports. Walsh, F. (2016). Applying a family resilience framework in training, practice, and research: Mastering the art of the possible. Family Process, 55, 616–632. https://doi.org/10.1111/famp.12260. Wood, W., & Eagly, A. H. (2002). A cross-cultural analysis of the behavior of women and men: Implication for the origins of sex differences. Psychological Bulletin, 128, 699–727. Yip, T., Douglass, S., & Sellers, R. M. (2014). Ethnic and racial identity. In F. T. L. Leong, L. Comas-Diaz, G. C. N. Hall, V. C. McLoyd, & J. E. Trimble (Eds.), APA handbook of multicultural psychology, Theory and research (Vol. 1, pp. 179–205). Washington, DC: American Psychological Association. https://doi.org/ 10.1037/14189-010.

Cultural Values in Couples and Families Kiran Arora Long Island University, Brooklyn, NY, USA

Introduction Cultural values play a role in the everyday lives of couples and families. These values reflect a broad context of individual behaviors and are considered expressions of people and communities. Falicov (1995) defines cultural values as shared worldviews and meanings, which develop from

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membership and participation in numerous contexts. These contexts can include but are not limited to religion, gender, race, ethnicity, language, customs, and migration. These values create varied environments for family life. Therapists must be sensitive to values as they have implications for understanding and organizing couple and family life.

Theoretical Context for Concept Culture is a broad based and multidimensional concept (Hardy and Laszloffy 2002). No one value adequately captures the essence of culture in its’ entirety. Cultural values are the components that make up one’s cultural experience. Therefore, examining the various dimensions of cultural values (gender, sexual orientation, class, etc.) is critical in truly understanding the experiences of couples and families. Culture is an influential organizing principle and individuals can simultaneously hold two different positions, one which maybe subjugated and the other privileged (Hardy and Laszloffy 2002). People from the same cultural group may have different cultural experiences depending on their overall participation in all dimensions of culture. For example, two sisters may share cultural values in regards to race, gender and, sexual orientation but may differ on religion, age, and geographical location. Each of these differing cultural variables presents opportunities for uniqueness within their shared cultural groups. An awareness and curiosity of similarity and difference is essential so that therapists can understand the nuances between family members as it relates to cultural values (Hardy and Bobes 2016)

Holding a Cultural Perspective It is recommended that therapists examine couples and families through a cultural lens (Falicov 1995; Hardy and Laszloffy 2002; McGoldrick and Hardy 2008). Hardy and Laszloffy (2002) created a multicultural perspective, which is a

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worldview on how to understand self in relation to another. They list several overarching goals that can help facilitate treatment while considering culture as a thread of understanding with all people. These goals are: (1) To develop an understanding of the specific ways in which clients view the world and their corresponding values and beliefs; (2) To challenge segregated thinking by promoting a fuller understanding of the ways in which all aspects of existence are interconnected. This includes encouraging awareness of the ways in which experiences at the individual, family, and cultural levels are all related; (3) To respectfully challenge beliefs and dynamics that support domination and oppression; (4) To identify and individual wounds of oppression; (5) To rehabilitate each partners (or family member’s) view of the other; (6) To work actively to achieve justice and; (7) To promote intimacy. These goals can assist in uncovering and understanding cultural values that individuals hold in a family, while promoting healing and transformation.

Application of Concept in Couple and Family Therapy When working with couples and families, it is imperative that therapists explore the importance of cultural values with each client by not only identifying the values but also creating space to explore them deeply. Identifying, strengthening, and validating cultural identity is a useful technique in helping family members ward off stress and find sites of resiliency. Becoming familiar with various support systems from a cultural perspective is key in assisting with healing. Many people become disconnected from traditional support systems. Being curious about the ways in which older generations dealt with challenges can uncover values that specific cultures hold in regards moving through difficulties. Therapists can assist in helping couples and families work through cultural based value conflicts or any culture based pride/shame issues (Hardy and Laszloffy 2002). These value conflicts can occur both within a person and interpersonally. Moving

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away from polarizing conversations and towards a both/and position can alleviate any stuckness clients may feel and open conversations for alternate possibilities (Hardy and Laszloffy 2002). Validating multiple perspectives from multiple cultural values and perspectives can encourage a greater tolerance and acceptance of the various cultural values one may hold.

Clinical Example Alex (35) and Sarah (34) entered couple therapy following their engagement. Alex is Black and from Uganda. He moved to the United States 10 years prior on a work visa. Sarah is White and Scottish. She was born and raised in Vermont and moved to New York City 5 years ago where she met Alex. The couple has a history of feeling stalled when communicating their needs to the other person. Specifically, now that they are engaged they are having difficulty deciding where to live after marriage. Alex has a strong desire to move back to Uganda. Sarah is not directly opposed to it yet has hesitations. They have made two trips as a couple to Uganda and frequently travel to Sarah’s parents home to Vermont for the holidays. Initial therapy sessions were focused on assessing the couple both individually and relationally (Taibbi 2015). A cultural genogram was used to assess the couple’s cultural values (Hardy and Laszloffy 1995). Through the exercise, Alex shared that his family values hard work, perseverance, and having an active role in raising children. For Sarah, there was value placed on being independent, standing up for those less fortunate, and staying out of others’ relational business. Through further inquiry the therapist learned that Alex and Sarah had a number of cultural values in common, such as their Christian religion and their families’ middle class status. In an effort to work through the tension of where the couple is going to live after marriage, the therapist focused on looking at the cultural values that might be driving their divergent positions. Sarah valued independence and a nuclear family. Further, she had struggled most

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of her life with her father undermining her abilities. He recently passed away without resolving the tensions he had with his daughter. She was looking forward to having her life with Alex with a fresh start, somewhat away from the tensions her nuclear family has lived with for years. Although Alex understood Sarah’s position, he was thinking ahead about raising a family and wanted his future children to be close to his parents and siblings, so they could grow in an extended family. Over a period of seven sessions, the couple became fluid in each other’s cultural values. Sarah’s initial perceptions of Alex’s stubbornness of wanting to eventually go back to Uganda were now more relatable. She too wanted to raise her future children in community; however, her community consisted of her women friends who had supported her during her challenges with her family. Alex could appreciate Sarah’s sense of community and, his own feelings of isolation and distance from his family were validated by Sarah. Defenses were softened when each partner could listen to the cultural values the other partner held. They each understood that there was a greater contextual backstory to their partner’s positions and that their positions were closer than what first appeared to be the case.

References Falicov, C. J. (1995). Training to think culturally: A multidimensional comparative framework. Family Process, 34, 373–388. Hardy, K. V., & Bobes, T. (Eds.). (2016). Culturally sensitive supervision and training. New York: Routledge. Hardy, K. V., & Laszloffy, T. A. (1995). The cultural genogram: A key to training culturally competent family therapists. Journal of Marital and Family Therapy, 21(3), 227–237. Hardy, K. V., & Laszloffy, T. A. (2002). Couple therapy using a multicultural perspective. In A. S. Gurman & N. S. Jacobson (Eds.), Clinical handbook of couple therapy (3rd ed., pp. 569–593). New York: Guilford. McGoldrick, M., & Hardy, K. V. (Eds.). (2008). Re-visioning family therapy: Race, culture, and gender in clinical practice (2nd ed.). New York: Guilford Publications. Taibbi, R. (2015). Doing family therapy (3rd ed.). New York: The Guildford Press.

Culture in Couple and Family Therapy

Culture in Couple and Family Therapy Laura Sudano1,2 and Rachel M. Carter3 1 University of California, Department of Family Medicine and Public Health, San Diego, CA, USA 2 Winston Salem, NC, USA 3 University of Rochester, Rochester, NY, USA

Name of Theory Culture in Couple and Family Therapy

Introduction Incorporating culture into therapy is integral to work with others. Each individual is influenced by the culture in which they live and the subculture created within their own family. Aspects of culture include religion/spirituality, race, ethnicity, socioeconomic status (SES), gender, sex, sexual orientation, as well as other aspects of identity. These facets are essential in conceptualizing the human experience as it influences individual beliefs about the self and others, and the rules that govern these beliefs.

Prominent Associated Figures John Dewey, Lev Vygotsky, Jean Piaget, Seymour Papert, Harlene Anderson, Peggy Penn, Harry Goolishian

Description The field of Marriage and Family Therapy incorporates culture into models of therapy to help guide therapists to work effectively with individuals, couples, and families through issues for which they present. Often times, therapists attempt to move clients from maladaptive (unhealthy) to adaptive (healthy) patterns that helps the individual, couple, or family living in

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a multicultural society (McGoldrick 2003). Without frameworks or theory guiding culturally sensitive practice, models of therapy may lack essential components to conceptualizing issues and interventions when working with diverse clients. Incorporating such theoretical frameworks is helpful to assess, diagnose, and intervene with individuals, couples, and families. Multicultural competence is essential to inform therapy. Theoretical frameworks that inform Couple and Family Therapy include social constructionism or the presence of multiple realities and the influences that shape them (Papert 1980). Social constructivism also influences this field as it emphasizes meaning making, forming selfidentity and the social connectedness through which individuals interpret their world and experiences and create patterns and order (Mahoney and Granvold 2005). These tenets, then, can guide therapists to explore how contexts, such as race and ethnicity, can affect a person’s thoughts, feelings, behaviors, and construction of reality.

Relevance to Couple and Family Therapy Cultural concepts can be seen in the various approaches used in Marriage and Family Therapy. In Experiential Family Therapy, the natural orders and patterns of families play an integral role in the therapeutic process. Each family member is considered to be an agent of change and that change happens through experiencing the change in the therapy room (Gladding 2015). Specifically, the order and processes within a family can be addressed in the therapy room through a technique called family choreography in which family members show the patterns in their family, the family dance, by placing the family members in a position according to their ways of relating to each other (Gladding 2015). Family dance shaped by culture can explore loss and meaning making (Mitchell 2016). It is evident that the culture of where one grows up, who one grows up with, and how one is raised shapes the meaning of the word family and what one’s relationship with them should look like. This application of family sculpt and dance can

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be used to understand the culture of a family and modified to be culturally sensitive based on family/individual characteristics. Bowen Family Systems Therapy focuses on the patterns in families as well as the boundaries within them that can either lead to or prevent the differentiation of self in the individuals within the family system (Bowen 1978). This approach focuses on how the family members connect and disconnect from one another and how each member can maintain his/her/their individual identity while still being emotionally close to others. Culture plays a prominent role in the formation of boundaries, levels of self-differentiation, and structures within families. For example, a family in the United States may value individualism, while a family in China where the culture is collectivistic may not value self-differentiation as a goal in therapy (Epstein et al. 2014). Research has shown that the goals of family therapy and the therapeutic alliance differ between cultures. Additionally, culture plays a role in the language individuals use to communicate within their families (Epstein et al. 2014). When using therapeutic approaches developed in Western countries with families of other cultures, therapists should consider taking an inventory of the culture and its specific cultural values so as not to impose one’s own cultural values on the family (Epstein et al. 2014). A therapist, then, may need to modify the view of “healthy” levels of differentiation when working with non-Western families. Cognitive-Behavioral Family Therapy (CBFT) focuses on the way the individuals within families make meaning that is built around his/her/their own personal beliefs and how that meaning influences family behavioral patterns which are largely shaped by culture. CBFT encourages the individual members of families to think for themselves about what is going on in their family instead of adopting beliefs that may be maladaptive and unhelpful (Gladding 2015). In other words, the therapist is responsible for eliciting the patient’s/client’s perspective and exploring how these beliefs affect family patterns. Cultural concepts are used within CognitiveBehavioral Family Therapy (CBFT) as the

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approach can address social inequity and its effects on family schemas and behaviors, and, ultimately, the health of the family (Parker and McDowell 2016). CBFT acknowledges each person individually within the family and how his/her/their socialization within their culture developed his/her/their schemas while increasing the family members’ understandings of the schemas that were influencing their dysfunctional behaviors (Parker and McDowell 2016). Family therapists help the family members create healthier alternative schemas that are both functional and beneficial to the health of the family and incorporated social justice (Parker and McDowell 2016). Cognitive-Behavioral Family Therapy demonstrates that therapists can use a cultural lens to explore how individuals understand the world, what he/she/they are taught to believe about their self, their family, and others, all of which is shaped by the culture. Structural Family Therapy (SFT) focuses on the way families interact with each other. Its premise is addressing the structure of families and the relational systems (e.g., the parental and sibling systems), and coalitions that uphold the family’s patterns of interaction (Gladding 2015). Culture plays an important role in SFT as the boundaries, systems, and subsystems that create the structure of families are shaped by culture. For example, since SFT focuses on the executive subsystem, or the generation that is above the sibling subsystem, it is important to consider that executive subsystems can consist of one parent, step-parents, and/or extended family members (e.g., grandparents) which changes the way that subsystems and boundaries look within a family and can require an altered application of Structural Family Therapy. Cultural changes have occurred since the original development of SFT. Family therapists must recognize and address the cultural barriers, oppression, discrimination, socialization, and familial roles that may be affecting nontraditional family systems to ensure that treatment effectively helps build functional and healthy family systems (Williams et al. 2016). Specifically, family therapists who want to unbalance a family system and create change within a family must identify if

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there is oppression and issues of social justice within the community, political, and/or familial environment (Williams et al. 2016). Strategic Family Therapy utilizes cultural concepts in the way that it emphasizes the importance of how order is created and patterns are established, as well as the importance of what upholds them (Gladding 2015). Strategic Family Therapy views family rules and the often-limited interactional patterns of families as sources of family dysfunction (Gladding 2015). Families learn such limited interactional patterns and establish rules largely due to the culture that they are surrounded by and that which they have created together. When using Strategic Family Therapy, it is important to consider the needs and issues of each individual family and how those are informed by culture. For example, a family therapist can consider ways that detrimental gender roles are perpetuated by culture and society and may limit the interactional patterns between family members of different genders and, thus, contribute to family dysfunction. Family rules such as when and how to externalize emotions and what topics are and are not allowed to be addressed in families are also influenced by cultural norms and can contribute to unhealthy family patterns. In order to be relevant when doing strategic family therapy, it is critical that family therapists are aware of the cultural customs, roles, and rules that affect the interactional patterns of families and how they can be used to either help and hinder relational change. Narrative Family Therapy (NFT) is a theoretical approach that focuses on the stories that families, and the individuals within them, construct (Suddeath et al. 2017). Social constructionism plays heavily into this approach as it is centered on the multiple realities that the family members have created and the validation and investigation of those realities (Suddeath et al. 2017). Therapists using this approach help their clients see their “realities” as “internalized stories” (Suddeath et al. 2017, p. 119) that have been shaped by the systems and culture that they are a part of (Suddeath et al. 2017). In this approach, families are encouraged to consider alternative

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and more adaptive stories about themselves and their relationships with each other to enhance family functioning (Suddeath et al. 2017). NFT addresses the ways in which family members interact with one another and their social surroundings, by exploring how they construct meaning together through the language they use and the stories they tell (Suddeath et al. 2017). Cultural concepts play an integral role in this model as the therapist places great emphasis on the way that society, and clients’ personal interactions with it, affect the way that they make meaning and form the beliefs they hold about themselves and others. NFT therapists also address cultural issues by working with clients to gain a greater understanding of how they interpret the stories they are told by society and the contexts they live in. Furthermore, NFT therapists incorporate culture into their approach as they shift the focus of meaning-making with their clients by encouraging them to focus on the strengths within their families and helping co-construct strengths-based narratives (Suddeath et al. 2017). Collaborative Therapies, which involve dialogical conversation or a mutual exchange of ideas and understanding by more than one individual, attempt to generate new meaning and ideas. The family therapist’s role is to facilitate meaning-generating conversation by which the client can make new assumptions and meaning which includes maintaining space for the client to bring their values to the conversation (Anderson 1997). This social constructionist framework aids the client to re-negotiate a client’s reality and “truth.” These “truths” are embedded in the dominant narratives of the culture in which the client grew up and deconstructing, or unpacking, these narratives or “truths” are essential to explore assumptions in therapy.

Clinical Example of Application of Theory in Couples and Families Jen and Marie present to therapy with issues of intimacy. Jen is a 47-year-old white, lesbian, woman who is a manager at a bank. Marie is a 40-year-old African-American, lesbian, woman

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who is a grief counselor for young children. Jen states that she and Marie have been together for 10 years and never had issues related to sexual encounters until 5 years ago, when they were legally married. Jen notes that she pursues Marie and feels like Marie is closed off from Jen. Jen states that she is “fed up” with pursuing Marie and feels like she doesn’t care. Marie states that she is tired from her work and feels like she has no energy to engage with her wife sexually. The therapist observes that Jen is quick to cut Marie off when she starts expressing her levels of energy. When this happens, Marie stops talking about her feelings and explodes, “You always do this! You don’t let me finish at all!” Jen becomes defensive and says that Marie is, “Making excuses.” Marie, then, becomes upset and is inconsolable. The therapist asks if this exchange in the office is similar to at home, which both endorse that it is. The therapist conceptualizes the case as the couple struggling with issues related to power and assumptions. The therapist may utilize an Emotionally Focused Approach (Johnson 2004) to facilitate an enactment. In the traditional EFT enactment, the therapist instructs one partner to turn towards the other partner to describe their primary emotion about the situation. In a culturally sensitive approach using EFT, the therapist may help each partner to access primary emotions about their experience of varying contextual variables which each partner can share with each other. The therapist can use the information to identify the negative cycle where the conflict is expressed, access unacknowledged emotions, and reframe the problem by incorporating the couple’s perspective using facilitative questions of how these experiences have influenced their view of the current problem which started when they were married. The therapist is cognizant of maintaining neutrality and staying close to the individual’s words. That is, the therapist will maintain a two-way exchange of ideas while also respecting the experience of the individual. Final phases of therapy may include promoting acceptance of each other, creating new cycles, and new solutions to issues. This process is similar to early phase which is to maintain a

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curious stance, explore their thoughts/ideas of how they view contextual factors as mentioned in prior sessions.

Cross-References ▶ Bowen Family Systems Therapy with Couples ▶ Bowen Family Systems Therapy with Families ▶ Cognitive-Behavioral Family Therapy ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Collaborative Couple Therapy ▶ Experiential Family Therapy ▶ Narrative Family Therapy ▶ Primary Emotions in Emotionally Focused Therapy ▶ Secondary Emotions in Emotionally Focused Therapy ▶ Structural Family Therapy

References Anderson, H. (1997). Conversations, language, and possibilities: A postmodern approach to therapy. New York: Basic Books. Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Epstein, N. B., Curtis, S. C., Edwards, E., Young, J. L., & Zheng, L. (2014). Therapy with families in China: Cultural factors influencing the therapeutic alliance and therapy goals. Contemporary Family Therapy, 36, 201–212. https://doi.org/10.1007/s10591-014-9302-x. Gladding, S. T. (2015). Family therapy: History, theory and practice (6th ed.). Hoboken: Pearson Education. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed.). New York: Brunner/Routledge. Mahoney, J. M., & Granvold, D. K. (2005). Constructivism and psychotherapy. World Psychiatry, 4, 74–77. McGoldrick, M. (2003). Culture: A challenge to concepts of normality. In F. Walsh (Ed.), Normal family processes (3rd ed.). New York: Guilford Press. Papert, S. (1980). Mindstorms. Children, computers and powerful ideas. New York: Basic Books. Suddeath, E. G., Kerwin, A. K., & Dugger, S. M. (2017). Narrative family therapy: Practical techniques for more effective work with couples and families. Journal of Mental Health Counseling, 39(2), 116–131. Williams, N. D., Foye, A., & Lewis, F. (2016). Applying structural family therapy in the changing context of the modern African American single mother. Journal of Feminist Family Therapy, 28, 30–47. https://doi.org/ 10.1080/08952833.2015.1130547.

Curiosity in Couple and Family Therapy

Curiosity in Couple and Family Therapy Donna Baptiste, Kaitlyn Bellingar and Incia Rachid The Family Institute at Northwestern University, Evanston, IL, USA

Name of the Strategy/Intervention Curiosity.

Introduction Some argue that curiosity is one of humankind’s deepest preoccupation, which leads to exploration about how, when, and why things work. This results in problem-solving and creativity (Kunst 2012). The notion of curiosity as valuable to both therapists and clients is also prominent in psychotherapy. Psychoanalytic therapists were the first to describe therapeutic curiosity. They viewed it as one of three basic human drives or instincts, a striving or preoccupation with discovery, that humans cannot live without (Kunst 2012; Nersessian and Silvan 2007). Psychoanalysts believed that therapists should be adept at using curiosity. This means developing a deep interest in people’s lives and a push to examine experiences and activities in the lifespan, to help clients understand themselves, grow, and make peace with themselves (Nersessian and Silvan 2007). Given the prominence of curiosity in psychoanalytic thought, it is unsurprising that psychoanalytically trained family therapists promoted curiosity as both therapeutic philosophy and technique in family therapy. To fully understand the place of curiosity in systemic thought, one must understand how it became prominent.

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moved from psychoanalytic to systemic perspectives in working with troubled families (Selvini-Palazzoli et al. 1980). Mara SelviniPalazzoli, Giuliana Prata, Luigi Boscolo, and Gianfranco Cecchin were scholars who became known as the Milan Group. The Milan Group advanced three concepts related to therapeutic curiosity. These concepts were neutrality, circularity and hypothesizing (Selvini-Palazzoli et al. 1980). The Milan Group recommended that therapists display curiosity through neutrality, described as a capacity to remain unaligned with any family member’s opinions and positions, as validation of each person’s point of view. Circularity referred to the therapist’s gathering of data on family patterns, including nonverbal feedback read through body-language, and using such data to articulate hypotheses. Hypothesizing was defined as the therapist’s articulation of systemic formulations around family concerns. The Milan Group’s framework required a therapist to adopt a posture of “scientific inquiry” into the family’s situation. Within this framework, the therapist operated as dispassionate expert observer and interventionist. In the late 1980s, an epistemological shift in the Milan Group led to a more vigorous conceptualization of curiosity and related concepts of neutrality, hypothesizing, and circularity. Cecchin and Boscolo broke with their colleagues and critiqued their own work on therapeutic curiosity. In influential publications that are still prominent in systemic training and education, Cecchin, Boscolo, and colleagues recast curiosity as a physiological stance of deep and meaningful collaboration with clients and within this framework; they articulated revised ideas about neutrality, hypothesizing, and circularity (e.g., Boscolo et al. 1987; Cecchin 1987).

Theoretical Framework

Description

An emphasis on curiosity as philosophy and technique in family therapy originated in the 1970s and 1980s in the work of family therapy practitioners in Milan, Italy. These clinicians

Cecchin, Boscolo, and colleagues described the curious therapist as one that co-constructs therapy with families or couples while maintaining an observer position. This stance contrasted with

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the original Milan framework which recommended a somewhat aloof posture in sessions. They also believed that a therapist’s lack of curiosity may be linked to boredom and psychosomatic symptoms. When bored, the therapist might become superficial, leaving family beliefs and patterns unexamined. In addition to boredom, psychosomatic conditions and stifling contexts can also decrease therapeutic curiosity. A strategy to deal with boredom and psychosomatic symptoms is to avoid taking full responsibility for controlling the family’s problem (as earlier ideas on curiosity recommended). Rather, therapeutic responsibility begins with a realistic assessment of one’s position and power in the system, and curiosity can help the therapist to manage these dynamics (Boscolo et al. 1987; Cecchin 1987).

Applying Curiosity in Couple and Family Therapy Cecchin, Boscolo, and colleagues maintained that a therapist’s posture of neutrality is one in which he/she abandons aloofness, noninvolvement, and unstated opinions and instead works actively with family members to question assumptions (Boscolo et al. 1987). Cecchin (1987) described neutrality “as the state of basic curiosity in the mind of a therapist. Curiosity leads to exploration and invention of alternative views and moves .. and [such] views breed curiosity. In this recursive fashion neutrality and curiosity contextualize each other in a commitment to evolving differences with a concomitant nonattachment to any particular position” (p. 405). In adopting this posture, the therapist stays attuned to differences among family members without being aligned to any position. Pedersen et al. (2008) propose a similar understanding of neutrality as a capacity to hold a both-and approach in responding to the complexities of viewpoints and dynamics within individuals, families, and self. The both/and approach is a stance of not-knowing while considering various personal, cultural, and universal issues in play. The therapist’s

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capacity to hold a plurality of descriptions, including his/her own, and sift through the myriad of stories can reveal patterns that incorporate multiple viewpoints. Conducting sessions along these lines keeps the therapist and family or couple in a state of “scientific” curiosity, which can generate useful hypotheses (Nersessian and Silvan 2007). Hypothesizing helps the therapist to maintain a stance of curiosity (Boscolo et al. 1987; Cecchin 1987). In hypothesizing, the therapist encourages family members to tell stories that reveal underlying family beliefs and patterns. The therapist can then challenge the family to abandon unhelpful scripts and adopt ways of functioning that accommodate phases and transitions in the family life cycle. Rober (2002) suggests that constructive hypothesizing unfolds best in collaborative dialogues among the therapist and family members, vacillating between states of knowing and not-knowing. The intent is not to confirm or disconfirm any family member’s views. Rather, the therapist shows that embracing multiple viewpoints can drive practical action focused on having more than one family member adjusting. A therapist unable to hypothesize loses curiosity, which leads to therapist and family becoming stuck. Cecchin, Boscolo, and colleagues also suggest that therapeutic curiosity drives the use of circular techniques. The curious therapist abandons cause-effect or linear questions that stifle dialogue, emphasize causality, and assign blame. Instead, he/she showcases circularity by posing questions that amplify the family’s understanding of itself. Circular questions imply a lens on action-reaction patterns or sequences among family members. For example, “what-if” questions and “future-oriented” (e.g., “If you decided to stop worrying about me, what would you do instead?”). Questions that test underlying belief systems can also stimulate fresh viewpoints that help in constructing a systemic view of behavior, relationships, events, and interpretations as seen through multiple lenses (Boscolo et al. 1987; Cecchin 1987).

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Curiosity has also emerged as an important concept in collaborative-dialogic, solution-focused, and narrative therapies. In collaborative-dialogic therapy, Anderson (2012) described curiosity as a therapist stance that allows him/her to be relationally responsive to and with the family. Through mutual inquiry, therapist and family create twoway curiosity, that is, a reciprocal process of mutual learning and co-exploration of the familiar and co-construction of the new (Anderson 2012). In solution-focused therapy, the therapist displays curiosity through open-ended, conversational questions that explore alternative explanations for problem stories (Selekman 1997). In narrative therapy, curiosity is expressed through therapist’s questions that help a client to uncover and author-preferred narratives buried within problem-saturated storylines (Selekman 1997; White and Epston 1990). Curiosity is also prominent in positive psychology and wellness promotion. Kashdan (2009) believed that as people live curiously, that is, experiment with new and interesting ideas, they grow personally and expand. Kashdan and colleagues examined associations between curiosity and wellness practices (e.g., gratitude), and curiosity was associated with achieving a pleasurable and meaningful life. In examining interpersonal benefits of curiosity, Kashdan found that curiosity contributes to partner attraction and closeness, processes linked to relational intimacy (Kashdan 2009). In sum, therapeutic curiosity emerged as a fundamental concept in psychoanalytic thought and is now well-integrated into contemporary family and couple therapy practice and training. Other forms of psychotherapy and wellness promotion also emphasize curiosity as “a gateway into creating profound intimacy, insights and meaning” (Kashdan, p. 5).

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Cross-References ▶ Cecchin, Gianfranco ▶ Circular Causality in Family Systems Theory ▶ Selvini-Palazzoli, Mara ▶ Milan Systemic Family Therapy

References Anderson, H. (2012). Collaborative relationships and dialogic conversation: Ideas for a relationally responsive practice. Family Process, 51, 8–24. Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy: Conversations in theory and practice. New York: Perseus Book Group. Cecchin, G. (1987). Hypothesising, circularity and neutrality revisited: An invitation to curiosity. Family Process, 26, 405–413. Kashdan, T. (2009). Curious? Discover the missing ingredient to a fulfilling life. New York: HarperCollins. Kunst, J. (2012). Got Curiosity? The drive that everyone is talking about. Psychology Today. Retrieved July 20, 2016, from https://www.psychologytoday.com/blog/ headshrinkers-guide-the-galaxy/201208/got-curiosity Nersessian, E., & Silvan, M. (2007). Neutrality and curiosity: Elements of technique. Psychoanalytic Quarterly, 76, 863–890. Pedersen, P. B., Crethar, H. C., & Carlson, J. (2008). Inclusive cultural empathy: Making relationships central in counseling and psychotherapy. Washington, DC: American Psychological Association. Rober, P. (2002). Constructive hypothesizing, dialogic understanding and the therapist’s inner conversation: Some ideas about knowing and not knowing in the family therapy session. Journal of Marital and Family Therapy, 28, 467–478. Selekman, M. D. (1997). Solution-focused therapy with children: Harnessing family strengths for systemic change. New York: The Guilford Press. Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing-circularity-neutrality: Three guidelines for the conductor of the session. Family Process, 19, 3–12. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.

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Daneshpour, Manijeh Christi R. McGeorge North Dakota State University, Fargo, ND, USA

Introduction Manijeh Daneshpour, PhD, LMFT, is a professor and system-wide director of the Alliant International University Marriage and Family Therapy (MFT) programs. With more than 22 years of academic, research, and clinical experience, Dr. Daneshpour is a recognized leader in multiculturally sensitive therapy, third-wave feminism, and the foremost expert on family therapy with Muslim families.

Career Manijeh Daneshpour was born in Tehran, Iran, to a philosophy professor father and education minded, stay-at-home mother. She has two sisters and one brother. Her sisters continue to reside in Iran pursuing professional careers, while her brother lives in Italy. Dr. Daneshpour began her undergraduate studies in Tehran. In 1984, she made the decision to come to the United States (USA) to continue her education, intending to return to Iran to begin her academic career. Dr. Daneshpour began her undergraduate studies in the USA in 1985 at Weber State University

and later transferred to the University of Utah where she graduated with a bachelor’s degree in child and family development. In 1992, still at the University of Utah, Dr. Daneshpour completed a master’s degree in family ecology. She then moved to the University of Minnesota where she received her doctorate in family social science, with an emphasis in MFT. Highlighting her perseverance and tenacity, Dr. Daneshpour was a single parent for both her master’s and doctoral studies as her husband returned to Iran for a brief visit to check on an ailing parent, and the US government would not allow him to return to the USA for 9 years despite his repeated attempts to get a visa. Dr. Daneshpour planned to return to Iran; however, a series of events surrounding her dissertation research led her to the realization that while she could have a comfortable life back home in Tehran, she had the opportunity to create significant change in the USA by challenging stereotypes about Middle Eastern individuals and relationships. Thus, she began working extensively as an outpatient family therapist serving a diverse population. She was then hired as the coordinator of the MFT Program at St. Mary’s University of Minnesota. After a year of developing and teaching courses to postmaster’s students, Dr. Daneshpour moved to St. Cloud State University where she was the MFT program director for 13 years. While at St. Cloud State University, she rose through the ranks and became a tenured, full professor and, in 2011, the chair of the

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Department of Community Psychology, Counseling, and Family Therapy. During this same time period, Dr. Daneshpour opened the Center for Multicultural Systemic Family Therapy through which she provided individual, family, and couple therapy to diverse clients using cognitive, behavioral, strategic, and supportive approaches. In 2015, Dr. Daneshpour moved to Alliant International University in Irvine, California, to be a professor in the Department of Couple and Family Therapy. She was quickly selected for leadership roles at Alliant. She first became the Irvine site director and currently is the systemwide program director. In her current role, she is responsible for all aspects of the MFT master’s and doctoral programs on the six Alliant International University campuses: San Diego, Irvine, Los Angeles, San Francisco, Sacramento, and the online programs. Throughout her career, Dr. Daneshpour has been very active with her scholarship. Her main areas of research are focused on immigration, multiculturalism, social justice, third-wave feminism, premarital and marital relationships, and Muslim family dynamics. She has spent more than 20 years training therapists to provide multiculturally sensitive therapy and was awarded a 5-year grant focused on training therapists to work with immigrants and refugees. Further, Dr. Daneshpour has worked with and studied Muslim families not as a religious group but as a distinct group within their own societal context. In 2016, she published a book titled Family Therapy with Muslims illustrating how to use classic and contemporary MFT theories with this population.

Contributions to Profession The themes that are central to Dr. Daneshpour’s career have shaped her influence on the MFT field. For example, she has emphasized the importance of MFTs being their authentic selves, being true to who they are, and never forgetting the importance of the person-of-the-therapist (Daneshpour 2009). This commitment to being her authentic self is illustrated by her decision to wear the hijab, which cross-culturally represents a

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deep connection to Islam as a religion. However, for Dr. Daneshpour wearing the hijab is a representation of her sociopolitical agenda, which attempts to challenge both the Eastern and Western notion of how an educated, feminist woman should appear physically. Dr. Daneshpour has attempted to be a bridge between Eastern and Western cultures and has been willing to challenge the assumptions that each group has had about the other. As the majority of her education has occurred within Western cultures, she is perfectly positioned to be an ambassador between two cultures that historically and currently have little understanding of each other. From her important and classic article on Muslim families and family therapy that was published in the Journal of Marital and Family Therapy (Daneshpour 1998) to her more recent book (Daneshpour 2016), she has been the lone voice reminding the MFT field that although we may have cultural differences, at our hearts, we are all people who experience similar life events, transitions, challenges, and trauma. Dr. Daneshpour has worked throughout her career to remind family therapists that Muslim individuals, couples, and families exist and are deserving of our care and services. In her writings, she has provided important insight on working with Muslim couples (Daneshpour 2008) and highlighted how classic and postmodern MFT theories can guide clinical work with Muslim clients (Daneshpour 2011, 2016). Moreover, Dr. Daneshpour has not been afraid to address challenging topics within Muslim families, which is exemplified by an encyclopedia entry she wrote in 2004 focused on Muslim women, gender, and child sexual abuse. Her willingness to continually highlight the similarities between Muslim and Western couples and families is further illustrative of her desire to be a bridge between the two cultures. Her professional career and personal life have certainly built this bridge and significantly enriched the MFT field.

Cross-References ▶ Cultural Competency in Supervision ▶ Cultural Identity in Couples and Families

Davis, Sean

▶ Cultural Values in Couples and Families ▶ Culture in Couple and Family Therapy ▶ Socioculturally Attuned Family Therapy

References Daneshpour, M. (1998). Muslim families and family therapy. Journal of Marital and Family Therapy, 24(3), 287–300. Daneshpour, M (2004). Women, gender and child sexual abuse inside and outside family: Iran. Encyclopedia of Women and Islamic Cultures. Brill Academic Publishers, Inc. Daneshpour, M. (2008). Couple therapy with Muslims: Challenges and opportunities. In M. Rastogi & V. Thomas (Eds.), Multicultural couple therapy (pp. 103–120). Thousand Oaks: Sage. Daneshpour, M. (2009). Steadying the tectonic plates: On being Muslim, feminist academic, and family therapist. In S. A. Lloyd, A. L. Few, & K. R. Allen (Eds.), Handbook of feminist family studies (pp. 340–350). Thousand Oaks: Sage. Daneshpour, M. (2011). Family systems therapy and postmodern approaches. In S. Ahmed & M. M. Amer (Eds.), Counseling Muslims: Handbook of mental health issues and interventions (pp. 119–135). New York: Routledge. Daneshpour, M. (2016). Family therapy with Muslims. New York: Routledge.

Davis, Sean Fred Piercy Virginia Tech University, Blacksburg, VA, USA

Introduction Sean is a professor of family therapy in the Couple and Family Therapy program, California School of Professional Psychology, Alliant International University, Sacramento, California.

Career Sean earned his Bachelor’s of Science in Family Science at Brigham Young University (BYU) in 2000, followed by a Master’s in Marriage and

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Family Therapy at BYU 2 years later. From there, he received his Doctor of Philosophy (PhD) in Human Development with an emphasis in Marriage and Family Therapy (MFT) at Virginia Tech in 2005. He completed his doctoral internship and postdoctoral training as a visiting faculty member in the University of Kentucky’s MFT program from 2004 to 2006. Dr. Davis’ first core assistant professor faculty appointment was in the MFT program at Alliant International University’s Sacramento campus in 2006. He was the Sacramento campus MFT program director from 2008 to 2013, during which time he started their MFT doctoral program. He was promoted to associate professor in 2008 and professor in 2015. He is involved in international MFT education in Mexico and Italy. Sean is also a California licensed marriage and family therapist, an active clinician specializing in couples therapy, and is the owner of The Davis Group Counseling and Wellness Services, a mental health and wellness agency located in Roseville, California.

Contributions to Profession Sean is most known for his work in common factors of marriage and family therapy. His dissertation, chaired by Dr. Fred Piercy, won both the American Association for Marriage and Family Therapy research and dissertation awards (Davis and Piercy 2007a, b). He expanded his research into the book Common factors of couple and family therapy: The overlooked foundation of effective practice (Sprenkle et al. 2009), the field’s first book on the topic. He has coauthored several popular articles and given several professional presentations related to common factors, including three of the five most cited articles in the field’s flagship journal, the Journal of Marital and Family Therapy (JMFT) between 2005 and 2008, as well as the 2014 and 2015 JMFT articles of the year. Sean has also written several other books, including Clinical Supervision Activities for Increasing Competence and SelfAwareness (Bean et al. 2014), The Family Therapy Treatment Planner (Dattilio et al. 2010), and Family Therapy: Concepts and Methods (Nichols and Davis 2016), one of the field’s most widely used textbooks.

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In his work on common factors in MFT, Sean claims that most theoretical approaches focus on similar processes, but use different language to describe these processes. Rigidly sticking to one model can overlook these similarities and lead therapists to lack flexibility when working with clients that may not resonate with the therapist’s preferred theoretical approach. Being able to see the common principles underlying different models may allow therapists to more fluidly change approaches to adapt to the needs of their clients. Teaching theories this way may also help streamline training. To these ends, he attempts to distill MFT model’s core common factors down to simple statements of unifying principles. His best known example of this is the principle that most couple therapy models focus on three essential things: (1) identifying and slowing down interactional cycles, (2) helping each person stand meta to their role in the cycle, and (3) helping each person take responsibility for their role in changing the cycle. Whatever the systemic intervention is, it is thought to be doing one of those three things.

Cross-References ▶ Common Factors in Couple and Family Therapy

References Bean, R. A., Davis, S. D., & Davey, M. P. (Eds.) (2014). Clinical Supervision Activities for Increasing Competence and Self-Awareness, New York: Wiley-Blackwell. Datillio, F. M., Jongsma, A. E., & Davis, S. D. (2010). The Family Therapy Treatment Planner. (2nd ed.). New York: John Wiley & Sons. Davis, S. D., & Piercy, F. P. (2007a). What clients of MFT model developers and their former students say about change, part I: Model dependent common factors across three models. Journal of Marital and Family Therapy, 33, 318–343. Davis, S. D., & Piercy, F. P. (2007b). What clients of MFT model developers and their former students say about change, part II: Model independent common factors and an integrative framework. Journal of Marital and Family Therapy, 33, 344–363.

De Shazer, Steve Nichols, M. P., & Davis, S. D. (2016). Family therapy: Concepts and methods (11th ed.). Columbus: Pearson. Sprenkle, D. H., Davis, S. D., & Lebow, J. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press.

De Shazer, Steve Cheryl Davies Universidad Iberoamericana, Mexico City, Mexico

Born into a musical family in Milwaukee, Steve de Shazer became an accomplished musician and a professional jazz saxophonist before developing his interest in psychotherapy and social work. He completed his undergraduate studies in Fine Arts at the University of Wisconsin in Madison and subsequently did a master’s degree in Social Work at the same university. In 1978 he cofounded the Brief Family Therapy Center in Milwaukee with Insoo Kim Berg, becoming well-known as the pioneer of solutionfocused brief therapy. De Shazer’s early work concentrated, fundamentally, on defining what makes psychotherapy efficient from intellectual and practical standpoints. He borrowed from the work of philosophers and clinicians alike to develop the essence of brief therapy and how it can be effectively employed. Influenced predominantly by the philosophical contributions of Wittgenstein, the sociopsychological position of Milton Erikson, the socio-constructionist epistemology expounded by Kenneth Gergen, the systemic models of therapy of the MRI and the Milan School, and the work of Bandler and Grinder in neurolinguistic programming, a result of these philosophical and academic endeavors was the development of the solution-focused approach to psychotherapy in collaboration with Insoo Kim Berg. He borrowed from Wittgenstein his tenets: “The limits of my language mean the limits of my world” and “The meaning of a word is

De Shazer, Steve

its use in language.” This interest in the social, interactive construction of language and the co-creation of knowledge and meaning forms the basis of de Shazer’s therapeutic work. When a client says something, the meaning depends not only upon what is being said but also on the context in which it is spoken, i.e., the context apportions the meaning. This reflects Gergen’s influence on de Shazer. Gergen explores how the individual explains and gives meaning to the world in which he or she lives. Words, gestures, tones of voice, and expressions only “mean something” within discourse which is the product of collaborative, dynamic interchange. Language and meaning are not objective “realities” but “social artifacts” which are products of social interchange – an active and collaborative enterprise among people in relationships. The solutionfocused perspective focuses on language in this way, concentrating on how a problematic situation can be exacerbated by the language used by the client to describe and give meaning to it. De Shazer aids the client in releasing the problem-focused language and focusing instead on the identification of solutions and the construction of solution talk. Thus solution-focused therapy is not just a series of techniques but a way of thinking about and approaching problematic situations – thus requiring a specific posture on the part of the therapist. De Shazer’s brief, pragmatic, and futureoriented model is based on a number of principles which have influenced subsequent therapeutic advances. They include: • • • • •

If it isn’t broken, don’t try to fix it. If something works, “do” more of it. If it does not work, do something different. Small steps lead to big changes. The solution is not necessarily directly connected to the problem. • Problems do not occur all the time – there are always exceptions. • The future is co-created and negotiable. • Change is constant and inevitable. These principles gave rise to the development of therapeutic interventions which de Shazer termed collectively “Master Keys.” This refers to

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the fact that each one of these techniques can be employed in any clinical situation irrespective of the presenting problem. Their main objective is to facilitate the client’s capacity to envisage a life in which the problem is not a central, controlling factor. The interventions include the Miracle Question, Scaling Questions, Exception-Finding Questions, and Coping Questions. De Shazer is well-known for his prolific writings, and his books have provided a significant contribution to the evolution of psychotherapeutic thought and investigation since the 1980s. His books include the following: Patterns of Brief Family Therapy (1982), Keys to Solution in Brief Therapy (1985), Clues: Investigating Solutions in Brief Therapy (1988), Putting Difference to Work (1991), Words Were Originally Magic (1994), and More than Miracles: The State of the Art of Solution-Focused Brief Therapy (published posthumously in 2007). Steve de Shazer died while on a conference tour in Vienna in 2005. He was survived by his wife, Insoo Kim Berg, who died 16 months later in 2007.

Cross-References ▶ Assimilation in Integrative Couple and Family Therapy ▶ Deconstruction in Narrative Couple and Family Therapy ▶ Postmodernism in Couple and Family Therapy ▶ Questions in Couple and Family Therapy

References De Shazer, S. (1985). Keys to solution in brief therapy. New York: W.W. Norton. De Shazer, S. (1994). Words were originally magic. New York: W.W. Norton. Gergen, K. J. (2001). Social construction in context. London: Sage. Gilligan, S., & Price, R. (1993). Therapeutic conversations. New York: W.W. Norton. Article retrieved from: International Journal of Solution Focused Practices. (2013). Vol. 1. No. 1. pp. 10–17. www.Ijsfp.com.

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Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice

Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice Rhea Almeida1, Lisa Dressner1 and Willie Tolliver2 1 The Institute for Family Services, Somerset, NJ, USA 2 Silberman School of Social Work at Hunter College, New York, NY, USA “There is no thing as a single-issue struggle because we do not live single-issue lives.” Audre Lorde

Conventional wisdom distilled from Western psychology focuses on the emotional connectivity of couples as an indicator of their health. Nevertheless perforations from oppressive forces seriously impact the development and security of couples lives. These lived experiences lacerate the emotional bonding of a couple. Therapeutic attention to the mature and healthy bond of a couple necessitates the process of naming and disrupting oppressive forces that shape the spaces and places in which emotional bonding of a couple occurs.

Coloniality Matrix of Power One of the most powerful weapons of the colonial matrix of power is hiding crimes against indigenous and enslaved peoples and keeping all of those harmed by the crimes “linked” to the sickness of a conquering society. The control of history, knowledge, health, and justice are features of the colonial matrix of power, or coloniality (Mignolo 2011; Quijano 2007). The representation of different social identity groups in any given society is created and controlled by groups that have greater social, economic, and political power. In general, the category of “other” is ascribed to individuals who belong to underrepresented, marginalized, or oppressed social identity groups. This is done to differentiate groups from the more valued, more powerful social groups that set the standard for normative lived experiences in a given society.

These groups install and legitimize the dominant societal norms that are more familiar in a given society. Subjugated knowledge about social values and life experiences of marginalized populations is rendered invisible. The demand of coloniality requires that we live through one mask. The masks of Latinos, Blacks, Asians, Native Americans, workers, students, athletes, elderly, youth, teachers, social workers, psychologists, and family therapists are therapeutically processed through the single knowledge system of emotionality. The matrix of coloniality is a major site for the wounding of couples and families. Coloniality is a phenomenon in the asserted postcolonial era that maintains a dominance of world structures by modern-day colonizers in the form of restricted resources, life opportunities in the lives of disadvantaged groups (Grosfoguel 2011, 2013; MaldonadoTorres 2007), and implicit cultural imperialism. Castro-Goméz (2010) argues that in modern colonialism, or coloniality, domination by force is not the only method of domination. Another method of coloniality is discourse about “the other” embedded within the everyday lives of both colonizers and colonized. For example, whiteness was the first cultural and geographical imaginary of the world system from which the ethnic division of labor and the transfer of capital and raw material were legitimized globally (Battalora 2013). This set the staging for coloniality. Quijano (2000) describes coloniality as manifesting in at least three interconnected and interdependent forms: • Systems of hierarchies: racial division and classification as the organizing principle of White supremacy • Systems of knowledge: privileging of Western or Eurocentric forms of knowledge as universal and objective • Societal systems: reinforcing hierarchies through construction of the state and specific institutions to regulate, segregate, and diminish decolonizing systems of healing and lived experiences Examples of these hierarchies and categorizations are visible in all of the ways our lives are

Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice

compartmentalized into silos. The silos of the social services and the prison industrial complexes, physicians and big pharma, big Agra, and education are shaped by a principle of corporate profits at the cost of human lives. The academic disciplines that produce professionals to populate the silos are cordoned off from one another’s scholarship, and professionals in mental health or health are bifurcated as advocates or clinicians, academics, or activists. The list is endless and constitutes a powerful capitulation to the hierarchies established by coloniality. These hierarchies are directly contiguous with the formation of healthy families and healthy functioning couples, with emotional bonding being but one factor in the analysis and healing of healthy couples (Fig.1). Gathering knowledge about the lived experiences of subjugated identities requires a deep understanding of the powerful structures that create such uneven access to social and cultural

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capital. This knowledge is essential to the formation of pathways for emancipation and liberation, even for couples.

Intersectionality The concept of intersectionality originated from Black and Chicana feminist theory (Anzaldúa 1987, 1999; Collins 2000, 2004, 2009; Crenshaw 1994), as well as developing world feminism and queer theory. It requires the analysis of systemic power, privilege, oppression, and social location/ standpoint to be used in understanding multiple social identities held by human beings (Harding 2003; Hankivsky and Cormier 2011). Intersectionality holds that classifications such as gender, race, class, and other signifiers of identity cannot be examined in isolation from one another. They interact and intersect in individual’s lives,

Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice, Fig. 1 Hierarchy of power, privilege, and oppression (Almeida 2016)

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society, and social systems and are mutually constitutive. It highlights how people with multiple identities can be excluded from certain initiatives meant to “even the playing field,” such as affirmative action, because such efforts focus on only one oppressed identity, rendering other identities invisible. Intersectionality decodes the “colonial matrix of power” and creates a foundation for decolonizing and liberation praxis. Multiple identities coexist and complicate the ways in which we typically think of class, race, gender, and sexuality as social, political, and economic problems. It reflects the complexity and fluidity of lived experiences along multiple trajectories of hierarchies and overcomes the challenge of compartmentalizing the pillars of privilege, domination, and oppression.

Liberation Praxis Liberatory healing practices have distinct foundational strategies that draw from knowledge across academic disciplines to disrupt and dismantle the residuals of colonial structures. The structures impact clients, practitioners, and students who engage in teaching and learning contexts in search of healing for themselves and their communities (Almeida et al. 2015). Relationships are formed and structured inside of established systems that dispense power, privilege, and oppression based on social identities. Strategies of liberatory healing through decolonizing include: • Transparency and the naming of structures of dominance • Redrawing the boundaries of inclusion • Disrupting the hierarchical categories of coloniality around race, class, gender, sexual identity, etc. • Desegregating healing spaces • Being free of living the script of coloniality • Affirming and developing knowledge and practices from border spaces across disciplines and geographic localities • Sharing social and political capital to create pathway toward economic capital

Redrawing the Boundaries of Trauma Trauma can occur with a single event in one’s life like an illness, rape or sexual assault, sudden loss of employment, and death within a normative trajectory of the life cycle. Other forms of trauma are experienced when loss accompanies sudden death that challenges the lived experiences and normalcy of the life cycle like the death of a child and multiple examples of the brutal separation of children from their parents as in foster care or political migration histories. The experience of targeted identities could be a trauma limited to a specific time in the life cycle like bullying; loss of a parent; loss of ableness through illness, accident, or political terrorism; and other similar lifethreatening events. All of these traumas however can be situated within a family or community where there is intergenerational and or historical trauma. Intergenerational trauma transports these experiences from one generation to another (DeGruy 2005; Brave Heart et al. 2011; Doucet and Rovers 2010; Jacobs 2011). Historical trauma has life-altering consequences in current generations as witnessed in the development of illnesses such as PTSD, depression, and type 2 diabetes all disproportionately occurring in Native and African American communities (Walters and Simoni 2009). For these communities healing is particularly complex as the injury and lack of sustained dignity continue on a daily basis. When trauma manifests in persons located within the contours of historical and intergenerational trauma, healing occurs within the knowledge space of these experiences. Trauma that manifests in persons situated within a legacy of entitlement or advantages also necessitates the naming of these legacies that complicate the healing process if left invisible. This type of trauma is evidenced in the current rage and despair of many White poor communities struck by opioid tsunamis. Addressing trauma through a matrix of perforations occurring at the colonial wound involves: • Addressing intergenerational trauma and its insidious wear on the body and soul

Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice

• Focusing on historical trauma and migration loss • Restructuring parenting hierarchies posttrauma in families with children • Paving the sense of hopelessness with inspiration and dignity In practice, operationalizing this analysis requires building critical consciousness accompanied by strategies of empowerment and accountability.

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identities to the larger societal context where the norms of socialization around gender, race, class, sexual orientation, and other lived experiences are incubated.

Application of the Approach in Couples Therapy: The Power of Language “They get on the walls. They get in your wallpaper. They get in your rugs, in your upholstery, and your clothes, and finally in to you.” Maya Angelou.

Building Critical Consciousness Although couples will experience varying emotions based on their own lived experiences and embodiment of the varying social identities constructed by society, building critical consciousness creates a platform for liberation (Du Bois 1903/1994; Freire 1999; Almeida 2003; Almeida et al. 2007a, b). Gathering knowledge that structural forces exist and control all levels of social, economic, and political interaction provides clients with what Mignolo (2009) refers to as strategies of epistemic disobedience. The method used to raise critical consciousness with couples and families is through the use of popular film vignettes, music, social media, and a variety of tools (Almeida et al. 2007; Hierarchy of Power Privilege and Oppression; Appendix I; Appendix II). The tools are intended to detoxify personal issues while simultaneously inviting larger context conversations, for example, conversations about the trajectory of gender identities. From the outset there is a restructuring of therapeutic conversations taking the therapy out of the realm of the personal to the political, from the intrapsychic to the social, and from the interior to the exterior. This process is crucial as it creates a platform from which healing strategies are created. Following an initial consultation, couples are moved into cultural circles for a period of 8 weeks. During these 8 weeks, they are offered language and analysis to name power, privilege, and oppression for the dialogue and inquiry that unfolds. This allows for a linking of internal couple dynamics and their issues and multiple

Samantha and Allen Not uncommon to most couples, Samantha and Allen defined their problem as one of communication difficulties. Samantha in her late thirties identified herself as Japanese and Chilean who grew up in both places before her family relocated to the United States. She speaks both languages fluently. Samantha is the youngest of three siblings with two older brothers born to middle-class parents. She teaches languages at a private high school. Allen identified as African American, an only child also born to middle-class parents, who spent most of his life in New Jersey. After being laid off from a position at a Media Arts Center in NYC, he decided to open a fitness center. While it did well for a brief time, the recession and loss of many customers made it impossible for Allen to sustain the business. He picked up a few hours a week working for another fitness center. During their 5-year marriage, he worked for the first year and has been unemployed since then. What they defined as communication problems centered mostly around her wanting to have a child and his reticence to move into parenthood, as well as what he described as her “nagging” him to a get a job and help around household responsibilities. He claimed his unemployment was the reason for his refusal to consider having a child at this time. When Samantha suggested that she could continue to support the family if he took on the responsibility of raising their child, it was a solution he was uninterested in pursuing. They were moved into the separate gender circles to begin the process of developing critical consciousness.

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This is the juncture at which the narrow boundaried marker of couples as a closed system is challenged. The concept of couples both as an autonomous unit and disconnected from their contexts of socialization is a feature of coloniality. In the circles they watched film vignettes like Pretty Woman, Jungle Fever, Straight out of Brooklyn, Hope Springs, Mississippi Masala, Love Jones, Crash, Girl Fight, and others. These films’ depiction of social, political, and economic markers are used to begin the multiple gendered conversations including masculinities and femininities. The clips of movie dialogues reflect the intersections of class, race, gender fluidity, and sexual orientation, all of which intrude into a couple’s life. In this case Allen’s unemployment, particularly as a Black man, intruded on his masculinity. Similarly the gendered pressure to have a child with age as a compelling barrier was a great concern to Samantha. In assessing the degree of sexual intimacy, they both reported having sex around once or twice every few months. Using the tool called “Money, Sex, and Responsibility” (Ault-Riche 1994) that assesses for both of their responsibilities around the second shift, it was apparent that Samantha did the bulk of household responsibilities that included cooking, cleaning, grocery shopping, and laundry of common items like sheets and towels. They both did their own personal laundry. Allen took on scheduling car maintenance and caring for his dog, which he brought into the marriage. Regarding financial contributions, he paid for his cell phone, gas, and his car servicing. This tool quantifies contributions to the second shift in terms of daily, weekly, monthly, and annual tasks (Almeida et al. 2007). Samantha scored considerably higher than did Tony, which offered them an analysis of part of their relationship in concrete terms. This information is shared by both of them in their respective circles. The focus remains on societal norms that perhaps informing second-shift decisions, resisting the default to explore inner contributing familial patterns, a potentially pathologizing course.

When exploring Allen’s choices to disengage from the second shift especially since he was not fully employed, he reflected on perhaps sharing responsibilities, but would not consider using a mop or cleaning bathrooms, reflecting rigid masculinity. In her circle Samantha saw the graphic pattern of Tony’s nonparticipation in a partnership. She continually offered excuses such as he did not understand what was being communicated to him by the men and the therapists. She believed that things needed to be broken down for him, as it often needs to be done with the teens in her class. She was challenged to interrogate the ways in which she infantilized him by having her reflect on all of the ways he was competent in some aspects of his life. She became painfully aware of the disconnect between them. Not having knowledge about how power in relationships operated, she overemphasized the personal decontextualized dynamics. Perhaps her efforts, unwittingly to balance the power in their relationship, were to assume a level of literacy that kept her stuck in this relationship. During this period Allen informed her that he would be traveling to Hong Kong with a male friend to clear his head. When asked about his affordability for this trip, he remained vague. She learned later that his mother paid for it. Here is a space where interrogation of intergenerational patterns is relevant. While both of Allen’s parents were frustrated and concerned about his refusal to take up any work even if it was not within his projected hopes, it became clear that his mother supported him financially much to the chagrin of his father. Empowerment: Dismantling Subjugation Empowerment first occurred through transparency and the naming of structures that threaded gendered norms into this relationship shaping it in many ways. Redrawing the boundaries of inclusion occurred through embracing this couple within a multiracial, multi-gendered healing circle, ending their isolation. Simultaneously hierarchical categories of coloniality around race, class, gender, and sexual identity were disrupted.

Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice

Accountability: Dismantling Dominance Following his trip to Hong Kong, Allen decided he would take a break from therapy. Samantha was angry and disappointed but still wanted to explore healing for them and their future. The therapists (a team of therapists work with the couple) contacted him, and he indicated he planned to return soon. Shortly afterward Samantha convinced him to join her in a fertility consult. Test results from that consultation showed she was positive for herpes. After fierce denials he acknowledged having a brief affair during their marriage. This new information confirmed for Samantha the fact that they were in fact living single lives in the corridor of couplehood.

Couple Two In the next vignette, we introduce Jeff and Mary and their two sons Jeff Jr. and David. Liberatory strategies, outlined below, were part of their healing experience. Raising critical consciousness, promoting empowerment, and accountability to different members of this system was accomplished through the use of: Movie vignettes that included Gridlocked and When a Man Loves a Woman, two movies shown together, juxtaposing a single, poor person of color trying to access substance abuse treatment with that of a married White upper-class woman. The tools invite clients, families, and communities to create or draw from their ancestral rituals to address generational trauma. Transparency Around Shared Conversations and Strategies for Change Jeff and Mary are a White, working class family in their early forties with sons Jeff Jr., 14, and David, 11. Both parents were in recovery for many years and connected to an AA community. However, like many other couples in AA, sobriety brought a new set of challenges, in their case a dissatisfied marriage. They both expressed frustration with their high school education and limited careers. Jeff was a carpet layer and Mary worked as an office manager at a pharmaceutical company. Mary was very angry and wondered if

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their marriage was salvageable. After participating in the dialogue and inquiry of the critical consciousness process and understanding the multiple dimensions of misuse and abuse of power, she was able to start naming the behaviors that were eroding their relationship. She was better able to understand how her experience of being overburdened in her marriage was linked to Jeff’s lack of participation in second-shift responsibilities, economic abuse through making unilateral decisions about family purchases, and emotional abuse as he derailed most of her efforts to speak with him about her concerns. These experiences coupled with the challenges of raising two sons (one who was beginning to use drugs and alcohol) led Mary to contemplate divorce. Jeff engaged in a similar process of developing critical consciousness in his circle of men and viewed vignettes that focused on the range of male norm socialization, White privilege and power, and control within heterosexual and LGBTQ relationships. This informed his understanding of how he had absorbed patriarchal messages of masculinity that were threatening both the health of his marriage and his relationships with his sons. The cultural circles made it possible to redefine the root of the problem as stemming from influences of a patriarchal society. Patriarchy emphasizes masculinity as individualistic, stoic, and homophobic, therefore making avoiding femininity and characteristics/tasks associated with this socialization of manhood essential. Rather than a problem that is unique to this couple, understanding patriarchy gave them hope that there were possibilities outside of closed couple model. Within their cultural circle that was multiracial and socioeconomically diverse, inclusive of single individuals and LGBTQ couples, Jeff and Mary began to tease out their self-identification as victims signified by their working class status. The obfuscation of whiteness has not provided the language or interrogation for such identities (Pewewardy and Almeida 2013). They were able to claim more of their privilege as White, heterosexual individuals who, in spite of financial strains due to their limited education, were still able to access treatment keeping their addictions

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private from their workplaces. At this juncture they began to explore and redefine their couple and family values, countering much of what they learned in their prior therapy. The prior focus was within the interior of their relationship – lending support for one another’s professional goals, assignments to spend free time with just one another, and listening assignments to offer reflective feedback to each other. They questioned the commercial definition of relationships, which assumed that all love, caring, and connection ought to come from two people in an isolated context – the couple. It is important to note that this limited and harmful delineation of couplehood is a construction of coloniality exported globally as the gold standard. Couple relationships that are supported and embraced within collective family and community circles are not present in much of this discourse on couples. The transparency of a healing circle, where individuals from similar and different and social locations questioned, explored, tried out, and broadened new definitions of couples and family, created possibilities that pushed well beyond the constraints of the initial borders that Jeff and Mary defined for themselves. Empowerment: Dismantling Subjugation Jeff and Mary’s transition from identifying primarily with their locations of oppression had a positive impact not only on their relationship but with that of their sons as well. The circles opened up spaces for Jeff Jr. and David to develop critical consciousness as young White men. As Mary and Jeff created an alternative definition of marital satisfaction, considering their couplehood in a larger community context – where LGBTQ couples, single men and women, couples of color, and those more financially burdened than them worked together on all types of life cycle challenges – their perspective about their marriage and family shifted. Jeff examined his family of origin and the ideas that were passed along around men and second-shift responsibilities, and he began to assume a more equal role in the tasks in his home. He also addressed the trauma he experienced at the hands of his father from humiliation of his masculinity to frequent instances of

physical brutality. Mary spoke of the trauma she experienced growing up at the hands of her father who divorced her mother when she was 9 years old. She is certain that he was some sort of government spy, and it was believed that he murdered one of their female family friends but was never charged. He had numerous guns and often threatened her and her siblings. She left home at the age of 16 and started to abuse substances at that time. Mary also talked about the shame she experienced because of her small family home. In avoiding invitations for guests to visit their home, there was another layer of isolation to their lives. Through unpacking her complicity with a patriarchal notion that her husband should be the ultimate rescuer and provider, she was able to grasp the rage she often directed toward Jeff. Both Jeff and Mary succeeded in their journey to increase their education. Jeff became a realtor and Mary a nurse. This linking of societal influences of capitalism, patriarchy, and White supremacy to generational patterns within a family and the passing on of this legacy to future generations are a hallmark of liberatory healing practices. Accountability: Dismantling Dominance In the community circles, Mary began to observe that Jeff would lead in challenging other men’s misuses of power in relationships. She noted how this witnessing brought her a sense of pride and purpose in their relationship and the legacy they were creating together for their family. As their consciousness developed around their multiple identities, linking sources of oppression and privilege, and their choices around exercising their privilege responsibly both within their relationship and the outside world, they described an increased sense of peace and security. One example of this is when Jeff took his youngest son David to a national conference on White privilege at the suggestion of the therapeutic team and paid for by some members of the healing community that were in a position to invest in this activity. This benefit of social capital in a healing endeavor exemplifies the ways in which the healing community engaged in the process not only to invest in Jeff and David but toward the greater good of

Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice

the larger community. This experience for David became his gateway as a young White man living in a White, blue-collar community to excel in his academics and participate in a summer travel abroad program. Moving this couple from a focus on purely the interior of their lives to broader lived experiences positioned them as both contributing to and benefitting from a larger healing community. This was the impetus for their transformational shift.

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Cross-References ▶ Fairness in Couples and Families ▶ Gender in Couple and Family Therapy ▶ Power in Family Systems Theory ▶ Social Constructionism in Couple and Family Therapy ▶ Socialization Processes in Families ▶ Social Role Theory in Couple and Family Therapy ▶ Torture in Couple and Family Therapy

Conclusion Appendices Human beings derive meaning in social contexts. Rarely do the human beings who call those social contexts home construct the social contexts in which human beings live. Forces much larger than the individuals living within the structures termed couple, family, community, and/or nation shape societies. Societies are not innocuous spaces created to ensure the healthy growth and development of all of its members. Societies are a mix of all that has happened along the trajectories of their existence. In countries whose very existences were achieved through colonization, there are multiple origin narratives; however, the narratives that achieve prominence are those of the conquering society. The conquering society establishes the norms of what constitutes standard behavior. In the United States, the norms for couples, sexuality, success, and status are all based in ideas that have political purposes, yet the ways of being are offered as the gold standard, and as a result people are legally prosecuted and/or randomly murdered for failure to comply. The well-being of a couple is inextricably tied up with the well-being of society. In the absence of a society that nurtures the well-being of all people in ways that are equitable, liberatory practices undertaken in healing communities stand as an alternative to a one-size-fits-all focus on individuals. It is our epistemic right to present this approach to couple therapy to stand alongside the dominant Western psychology that does not critique its White supremacist and patriarchal origins.

Appendix 1: Questioning Binary Norms of Socialization 1. Avoiding historically femininity and behaviors with cisgender women’s role (housework, childcare, gender nonconforming activities and occupations). 2. Seeking stereotypically hypermasculine appearance – large upper-body muscular build – projecting physical strength and shading/avoiding color. Patina of seriousness around sports and not in fashion or makeup. 3. Restrictive emotionality, suppression of range of feelings (except for anger), emotional distance, avoidance of affect in self and others. 4. Seeking social status and self-esteem via achievement, competition primacy of work/ provider role, earning power. 5. Self-reliance, avoidance of dependency on others even on intimates and friends. 6. Aggression (sometimes alternating with avoidance/denial) as a means of conflict resolution. Toughness and leadership in the face of adversity. 7. Striving for inherited patriarchal dominance in relationships and control over others in the family. 8. Non-relational attitudes toward sexuality, and objectification of others, use of pornography rather than erotica as means for arousal. 9. Homophobia and transphobia, fear/anger at members of the LGBTQ* community/gender nonconforming people and rigid adherence to a gender binary.

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Decolonizing Couples and Family Therapy: Social Justice Praxis in Liberatory Healing Community Practice

10. Seeking stereotyped feminine looks and behavior. Thin Barbie dollesque or the sexualized model of a cisgender woman. Choosing historically female roles and over focus on second-shift responsibilities. 11. Comfortable with a range of emotions except anger and adopting the caretaker role. 12. Seeking social status and self-esteem vicariously through heterosexual partnering. 13. “Acquiescing to non-equal sharing in secondshift responsibilities.” 14. Normalization of heterosexual coupling. Appendix 2: Cultivating Spaces for Gender Fluidity and Nonconformity 1. Expanded emotionality: the willingness to express the full range of emotions, including exuberance, joy, love, wonder and awe at things beautiful, fear, sadness, remorse, disappointment, and allowing oneself to express all of the highs and lows of the human experience. 2. Embracing and accepting of expanded gender expressions to be fluid for all. 3. Balancing work and family life: seeking pride through contributing both within the world of work and as an active participant in family and community life. 4. Embracing relatedness over individualism: valuing collaboration with all human beings and with the rest of the natural spiritual world. 5. Valuing shared power of relatedness: striving to create equal partnerships with adults and relationships with children that engender feelings of being loved and respected while also providing appropriate limits and structure. 6. Challenging and resisting cisgender hetero male definitions of sexuality and inviting expressions along the trajectory of gender identity and sexual orientation. 7. Rethinking and embracing positive sexual roles across gender expressions for all individuals, including elders, all sizes, and different experiences of ableness. 8. Interrupting homophobia/transphobia: embracing gender identities and sexual orientation as fluid identities for all.

References Almeida, R. (2003). Creating collectives of liberation. In T. J. Goodrich & L. B. Silverstein (Eds.), Feminist family therapy: Empowerment in social context (pp. 293–305). Washington, DC: American Psychological Association. Almeida, R. V., Dolan Del Vecchio, K., & Parker, L. (2007a). Transformative family therapy: Just families in a just society. Thousand Oaks: Sage. Almeida, R., Vecchio, D.-D., & Parker, L. (2007b). Foundation concepts for social justice based therapy: Critical consciousness, accountability, and empowerment. In E. Aldarondo (Ed.), Promoting social justice through mental health practice. Mahwah: Lawrence Erlbaum Associates. Almeida, R. V., Hernández-Wolfe, P., & Tubbs, C. (2011). Cultural equity: Bridging the complexity of social identities with therapeutic practices. International Journal of Narrative Therapy and Community Work, 3, 43–56. Almeida, R.V., Melendez, D., & Paéz, J. (2015). Liberation-based healing. Encyclopedia of Social Work. Online Publication Date: December 2015. Almeida, R.V., (2016). Hierarchy of Power, Privilege & Oppression Graphic. Somerset NJ: Institute Family Services. Anzaldúa, G. (1987). Borderlands/la frontera: The new mestiza. San Francisco: Aunt Lute Books. Anzaldúa, G. (1999). Borderlands/la frontera: The new mestiza (2nd ed.). San Francisco: Aunt Lute Books. Ault-Riche, M. (1994). Sex, money, and laundry: Sharing responsibilities in intimate relationships. Journal of Feminist Family Therapy, 6(1), 69–87. Boss, P. (2006). Loss, trauma and resilience: Therapeutic work with ambiguous loss. New York: W.W. Norton. Brave Heart, M. Y. H., & DeBruyn, L. M. (1998). The American Indian holocaust: Healing historical unresolved grief. American Indian and Alaska Native Mental Health Research, 8(2), 60–82. Brave Heart, M. Y. H., Chase, J., Elkins, J., & Altschul, D. B. (2011). Historical trauma among indigenous peoples of the Americas: Concepts, research, and clinical considerations. Journal of Psychoactive Drugs, 43(4), 282–290. Battalora, J. (2013). Birth of a White Nation: the invention of white people and its relevance today. Houston TX: Strategic Book Publishing & Rights Co. Castro-Gómez, S. (2010). La hybris del punto cero: ciencia, raza c ilustración en la Nueva Granada, (1750–1816), segunda edición. Bogotá, Colombia: Editorial Pontificia Universidad Javeriana. Collins, P. H. (2000). Black feminist thought: Knowledge, consciousness, and the politics of empowerment (2nd ed.). New York: Routledge. Collins, P. H. (2004). Black sexual politics: African Americans, gender, and the new racism. New York: Routledge. Collins, P. H. (2009). Foreword: Emerging intersections— Building knowledge and transforming institutions. In

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B. T. Dill & R. E. Zambrana (Eds.), Emerging intersections: Race, class, and gender in theory, policy, and practice (pp. vii–xiii). New Brunswick: Rutgers University Press. Crenshaw, K. W. (1994). Mapping the margins: Intersectionality, identity politics, and violence against women of color. In M. A. Fineman & R. Mykitiuk (Eds.), The public nature of private violence: The discovery of domestic abuse (pp. 93–118). New York: Routledge. DeGruy, J. (2005). Posttraumatic slave syndrome: America’s legacy of enduring injury and healing. Portland: Joy Degruy Publications. Doucet, M., & Rovers, M. (2010). Generational trauma, attachment, and spiritual/religious interventions. Journal of Loss & Trauma, 15, 93–105. Du Bois, W. E. B. (1903/1994). The souls of black folks. New York: Dover. Fanon, F. (1963). The wretched of the earth. New York: Grove Press. Freire, P. (1999). Pedagogy of hope: Reliving pedagogy of the oppressed. New York: Continuum. Grosfoguel, R. (2011). Decolonizing post-colonial studies and paradigms of political economy: Transmodernity, decolonial thinking, and global coloniality. Transmodernity, 1(1), 1–36. Grosfoguel, R. (2013). The structure of knowledge in westernized universities: Epistemic racism/sexism and the four genocides/epistemicides of the long 16th century. Human Architecture, 11(1), 73–90. Hankivsky, O., & Cormier, R. (2011). Intersectionality and public policy: Some lessons from existing models. Political Research Quarterly, 64, 217–229. Harding, S. (2003). How standpoint methodology informs philosophy of social science. In S. P. Turner & P. A. Roth (Eds.), The Blackwell guide to the philosophy of the social sciences (pp. 291–310). Oxford: Blackwell. Jacobs, J. (2011). The cross-generational transmission of trauma: Ritual and emotion among survivors of the holocaust. Journal of Contemporary Ethnography, 40(3), 342–361. Maldonado-Torres, N. (2007). On the coloniality of being: Contributions to the development of a concept. Cultural Studies, 21, 240–270. Mignolo, W. D. (2009). Epistemic disobedience, independent thought and decolonial freedom. Theory, Culture & Society, 26(7–8), 159–181. Mignolo, W. (2011). Geopolitics of sensing and knowing: On (de)coloniality, border thinking and epistemic disobedience. Postcolonial Studies, 14(3), 273–285. Pewewardy, N., & Almeida, R. (2013). Articulating the scaffolding of white supremacy: The act of naming in liberation. The Journal of Progressive Human Services, 25(3), 230–253. Quijano, A. (2000a). Colonialidad del poder y clasifcacion social. Journal of World Systems Research, XI(2), 342–386.

Quijano A. (2000b). Coloniality of Power, Eurocentrism, and Latin America. Nepantla, 1(3), 533–580. Quijano, A. (2007). Coloniality and modernity/rationality. Cultural Studies, 21(2–3), 168–178. Walters, K. L., & Simoni, J. M. (2009). Decolonizing strategies for mentoring American Indians and Alaska natives in HIV and mental health research. American Journal of Public Health, 99(1), 71–76.

D Deconstruction in Narrative Couple and Family Therapy David Marsten1 and Laurie Markham2 1 Miracle Mile Community Practice, Los Angeles, CA, USA 2 USC Rossier School of Education, Los Angeles, CA, USA

Name of Concept Deconstruction in Narrative Couple and Family Therapy.

Introduction Narrative therapy draws upon the work of Jacques Derrida and Michel Foucault to question singular truth claims about human experience. While Derrida takes us beyond what is blatant to latent readings of an expressed word or phrase, Foucault destabilizes knowledge by situating taken-forgranted practices of the self in the historical contexts from which they sprang. Any truth claim about personhood has more to do with power than its inviolability. Once exposed as less than bedrock, it becomes possible to play with meaning rather than search for it, as if it were there all along, waiting in pristine form, unsullied by culture and untarnished by time. This does not make dominant truths wrong any more than they are right. Rather, they are to be taken as subjectively useful or useless depending on the user’s inclination. There is no shortage of truth claims for couples and families to live by. In narrative

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therapy a space is reserved for those seeking help to claim their own preferences, even in a field where voices tinged with a professional tenor aim to impress. It is through the critique of expert knowledge that agency and imagination can achieve momentum.

regulating our behavior and circumscribing our imaginations. Foucault describes “the point where power reaches into the very grain of individuals, touches their bodies and inserts itself into their actions and attitudes, their discourses, learning processes and everyday lives” (1980, p. 39). We risk passively receiving our “marching orders” if we fail to interrogate the ideas that masquerade as truth. Multiple strands of meaning are cropped, and one shining filament remains. Variety is rationalized away by the claim to verity. Michael White and David Epston drew upon the work of Derrida and Foucault in developing their thinking and practice with an interest in deconstructing discourse – that is, destabilizing dominant cultural models that have achieved wide circulation as disembodied truth (White 1995). Take, for example, the modes of expression we depend on to convey suffering. We scan the cultural lexicon and landscape in its current configuration only to land upon concepts that are most conspicuous. As a result, we fret along prescribed lines about our addictive personalities, poor boundaries, and low self-esteem. We fault ourselves for our negative outlook and tendency to dwell on the past and for the way we compound our difficulties by unnecessarily drifting into imagined worrisome futures. We resolve to approach life more positively and redouble our efforts to live in the present. In a neoliberal Western culture that promotes individual advancement through competition, it is no surprise that we encounter ourselves as separable subjects stirred to undertake one self-improvement project after another. The corporatization of the state has produced inevitable reverberating effects upon its citizenry. With the privatization of public institutions (e.g., education, infrastructure, prisons, healthcare, etc.) and the unraveling of the social fabric, we have become entangled in the rhetoric of personal opportunity/blame. What we accomplish or fail to achieve is seen as the result of individual effort alone. Critics of neoliberalism point to how such an emphasis aims to optimize the efficiency of workers, ultimately serving corporate interests but doing little to advance civic welfare.

Theoretical Context for Concept The term deconstruction was coined by the French philosopher Jacques Derrida to denote the inherent contradictions and endless trails of meaning that are detectable in any word or phrase. Striving to capture a static definition is an exercise in futility. For starters, the singularity of a concept is challenged by the unavoidable affiliation to its opposite through inexorable reference (e.g., the notion of “good” is made conceivable only by association to “bad”). Attempting to isolate a distinct and self-governing term is further hindered by the interminable “deferral” of meaning (Derrida 2016), since a given expression is made comprehensible, not only in relation to its opposite but by reference to a closely related idea, which in turn is linked to a subsequent neighboring concept and so on. In an ever-expanding web, we may pause for only so long before conceiving of a range of possible next moves. We set our sights, less with a sense of certainty, as if working with compass and datum, and more with an appreciation for creativity. One advances through flights of imagination. The direction chosen in the search for meaning is made plausible, not through a process of reductive reasoning but by its moral and quixotic resonance for the seeker. Michel Foucault, a contemporary of Derrida’s, sported a similar predilection for contesting final readings, particularly with respect to human activity. He cautioned that what we come to accept as truth is anything but stable. He pointed to the indivisibility of power/knowledge in proposing how fashion becomes fact. Rather than possessing transcendent value, any evaluative concept of the self is made indisputable by its rise to prominence at a particular time and place in history. Once something assumes the form of accepted knowledge, it functions as a kind of “normalizing power,”

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On the road to becoming the “sciences” they aspire to be, dominant strains of psychology and psychiatry appear to have fallen in step with privatizing projects as an outgrowth of the political climate of the past 40 years. Encouraged by the professional disciplines to better ourselves as individuals, we consider possible steps toward maximizing our potentials. As social theorist Nicholas Rose explains, “This citizenship is to be manifested not in the receipt of public largesse, but in the energetic pursuit of personal fulfillment and in the incessant calculations that are to enable this to be achieved” (Rose and Miller 2010, p. 298). We take the measure of ourselves and come up wanting. We give thought to starting therapy, trying antidepressant medication, taking a mindfulness class, keeping a journal, reading a self-help book, joining a gym, booking a massage, and – if all else fails – mama needing a new pair of shoes. Such initiatives are meant to help us function more productively as willing and (dis)contented members of society, while diverting our attention from what has gone missing in the way of structural support. And so, we file out of professional offices with 10 min to spare at the end of the 50-min hour, our heads swimming with information about the limitations of our “operating systems” as a result of arrested development, internal conflicts, chemical imbalances, and newly minted diagnostic labels. Instead of perceiving our woes within broad fields of power, we are objectified and left to consider the consequences of our own faulty thinking, genetic predispositions, and flawed neural circuitry. And dare we think we have tamed our unruly impulses, there is always the pesky child within to reason with.

from grief, to get our anger out, and to assert ourselves and individuate. We are warned to heed such advice or risk our own peril. In questioning self-actualization practices, it was never White’s intention to disqualify a given idea but rather to bring it down to size so that it could be seen as culture bound – a “timely” rather than timeless value – as something to take or leave rather than covet as an emblem of normality or moral worth. In the lives of couples, it is sometimes said “it takes two to tango.” Therapy can organize around the premise that each partner has contributed equally to the problem. Not only does this perpetuate blame, but it treats the problem as something that is wholly personal and overlooks the consequences of power/oppression. As one example, with heterosexually identifying couples, there is the tendency to give considerable focus to a woman’s part in her partner’s infidelity (e.g., she is distant, frigid, castrating, etc.) Additionally, women are held to account for the problems that enter their children’s lives. From the appearance of schizophrenia and migraines to stuttering and autism, mothers have taken the brunt of the blame, often by way of elaborate rationalizations, since psychology’s inception (Blum 2007). White and Epston remind us that rather than residing outside of culture, as if there is an “outside” from which to postulate, psychology and psychiatry operate from within (1990). The impact of patriarchy, for example, can be found at the heart of direct practice, revealing more about culture than anything in the way of human nature or truth.

Application of Concept in Couple and Family Therapy In psychotherapy, narrative practitioners have an eye out for “. . .those familiar practices of self and relationship that are subjugating of persons’ lives” (Epston and White 1992, p. 121). We have come to know, beyond question, that we are meant to forgive and to learn to trust, to let go and move on

Clinical Example Narrative therapy strives to maintain awareness of the cultural inclination to blame wives and mothers, in part or in whole, for problems. It resists patriarchal discourse as an a priori organizing force and instead holds problems at a distance where they might be best observed and critiqued. Viewing problems from a separate perspective affords those seeking help a vantage point from which to come to their own decisions whether prodiscourse, con, or otherwise.

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Don and Louise, a white, middle-class couple in their early 30s, had been married for 5 years when they decided it was time to see a therapist. According to Louise, Don never found his way into the marriage wholeheartedly. Don admitted as much, explaining that the decision to marry was more the result of Louise’s unplanned pregnancy than a settled love. While he guessed he would have eventually ended up with Louise, the pregnancy obliged him to “do the right thing.” As a consequence, he felt “cheated” out of other possible experiences of life. Don: The guys at work don’t make it any easier. Therapist: What do they do? Don: They tell me I turned in my player’s card. When they’re making plans to go out after work, they tell me, “Time for you to head home to the Mrs.!” They’re just doing what guys do, but I don’t appreciate it. It makes me feel like I don’t belong, or like I’m missing out. Louise: He resents us. Therapist: Is it true, Don? Does resentment weigh in? Don: Yeah, I guess, in a way. I know it’s not her fault. She didn’t get pregnant by herself, but yeah, I kind of feel like if she hadn’t had the baby, things would be different. Therapist: Different how? Don: I would have had time to. . .to do more. I would have been freer. Therapist: Is that what the guys at work are getting at. Is it the idea that men are meant to be free (The question is posed in a way that allows for the possibility that the problem is not unique to Don.) Don: I guess so. More or less, yeah. Therapist: So what does that make you? Less of a man? Don: I’m still a man. I’m just not one of the guys. Therapist: Is there a difference, though? Are they real men and are you a “domesticated” man – like it’s a real man’s nature to desire freedom? (Wondering if Don is connected to a dominant story about manhood.) Don: In a way, yeah. Louise: I have to keep an eye on him. When he leaves the house I have to remind him what he has at home and what he’d lose if he makes the wrong decision. It’s kind of a joke, but kind of not. (Don’s fidelity may be more a reflection of Louise’s resolve than his own, as if she is to be the moral compass that keeps him on the straight and narrow.) Don: Yeah, she reminds me because she knows me. Therapist: What does she know?

Deconstruction in Narrative Couple and Family Therapy Don: That I’m a man. (They laugh.) Therapist: Have you considered leaving your family and hitting the natural road with the other guys? Don: I have but I wouldn’t feel right about it. Therapist: What wouldn’t feel right? Don: I guess I’d feel guilty if I left. Therapist: Is it Guilt that’s holding you back? (Externalizing guilt) Don: Not just guilt. I want my family – my wife and my family. Therapist: Why did you say it twice? Why did you include your wife the second time around? Was it Guilt reminding you to include her or was it something else? Don: I love my wife. I may not always show it, but I love my wife (He turns to her.) Therapist: (To Louise) What are you reacting to? Louise: (Tearing up) It’s nice to hear him say it. Half the time I feel like I’m keeping him here against his will. . .like he’s just waiting for me to say, “Okay, you can go.” Therapist: Whether Don stays or leaves, it’s on you? Louise: Yes. (She exhales, seeming to feel the weight of it.) Don: It’s not on you. It’s on me. (Stated earnestly) Therapist: What are you getting at Don? Is there something you’re wanting to take on? (Don may be finding his own interest in accountability.) Don: I’ve got to sort it out. It isn’t fair for her to have to deal with all this. Therapist: When you say she shouldn’t have to deal with “all this,” what is the “this” you’re referring to? Don: I have to figure out if I can be happy with my choices – having a family and being married. . .this is the life I’m living and I have to decide if I can accept it. Therapist: Louise, how does that sound to you? How would it be for this to come off your shoulders and for Don to carry it for a while? Louise: Please, be my guest. (Said with considerable relief)

So began a dialogue with Don about the resentment and ambivalence that had shadowed him throughout his marriage. In an unfolding conversation, hegemonic masculinity’s image of a footloose and natural man was exposed, along with its emasculation of the sort of man who would seek fulfillment at home. The therapist was careful not to guide him toward one preference over another. It was more a matter of exposing the discourse and

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leaving it to Don to reach his own conclusions. In the process, Louise was relieved of the responsibility she had previously felt for Don’s behavior and, ultimately, the fate of their marriage. Three years had passed by the time Louise called again. She explained that she and Don were still together and “doing better.” Their current concern was with their 8-year-old daughter, Millie, who had become “highly anxious.” Louise explained by phone that Millie had trouble falling asleep at night, repeatedly calling one of them or the other to her bedside. She also frequently phoned them at work, asking plaintively when they would be returning home. Louise was convinced that if only she had extended her maternity leave before resuming her career, her daughter would be in far better shape. In her search for answers, she had been reading about “separation anxiety” and was guilt ridden over all that she had “gotten wrong.” Both parents were braced for what their research promised would be a long road ahead in trying to help Millie find the confidence she would need to lead an independent life. In league with mother-blaming practices is the cultural propensity to portray children as helpless, prompting parents, under the guidance of professionals, to carry out any and all corrective measures. This starts with adult ways of conceptualizing problems from the moment children enter therapy offices. Though space is made for their feelings, “[c]hildren perhaps more than any other group are prone to having their ‘saying’ capabilities overshadowed by what is ‘said’ by others about them. They are the most easily marginalized segment of society” (Wall 2006, p. 537). In contrast, narrative therapy aims to treat young people as lead agents, turning to them at critical moments and counting on them to act. In doing so, discourses of mother-blame and adult-centrism are implicitly defied. In the following transcript, a space is created for Millie to occupy the role of protagonist rather than passenger through two practices, a wonderfulness interview (Marsten et al. 2016) and the externalization of the problem. With all three family members in attendance, the first meeting began as follows:

Therapist: Before getting to know Millie, according to any problem, I wonder if you would introduce her to me according to her wonderfulnesses – those talents and gifts that show Millie at her best. If you would tell me who she is according to what is wonderful about her, we can all know what she might have going for her to meet the problem with. (This question is meant to challenge the image of the precious but useless child. It also relieves the parents of the unpleasant task of having to introduce their daughter at her worst – according to the problem.) Louise: Oh, that’s easy. (Looking relieved) Well, this is Millie. She is a very special girl. Millie is very loving. She gives the best hugs. She’s sensitive. She an amazing artist for her age. She’s very creative. She’s really smart. . . Don: She also has a mind of her own. She can be very determined. If she is interested in something she can stick with it for hours.

Louise and Don carried on listing Millie’s virtues and, upon request, easily produced stories about her to substantiate their claims. Recognizing Millie for particular talents rather than treating her as a generalizable child was bound to pay off when it came time for problem redress. At the halfway point in the meeting, they turned their attention to the problem. Therapist: Okay, now that we know what Millie might have in hand to meet it with, should we meet the problem? Louise: (Taking a deep breath) Yes. Alright, let’s see. Millie has always been a little anxious. But over the past 6 months or so it’s gotten worse and we’re not sure why. There have been a few changes. We moved to a new house, so that could have something to do with it, but she says she loves it, and she definitely loves her new bedroom. Right honey? Millie: Uh huh. Don: And my commute is longer now so I get home later, but we still manage to have dinner together most nights. Right? Millie: Yeah. Therapist: Millie, I want to get to know if something like Worry is causing problems for you (a first attempt to externalize a problem), but before I ask you about that, would you mind telling me what you love about your new bedroom? Millie: I have a tent in my room with all of my animals and books and other stuff inside, and there are stars on the ceiling. Therapist: Stars on the ceiling? Don: It’s a sound machine that also projects lights that show the constellations.

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724 Therapist: Oh yeah. I’ve seen those. Those are really neat. Millie: And my bed is a. . .(looking to her mother) Louise: A trundle. Millie: Yeah, so I can have a friend sleep over. Therapist: Do you have a friend who’s come for a sleepover? Millie: My best friend April. Therapist: And have you gone for a sleepover at April’s house, or has something like Worry tried to get in the way? Millie: (She looks down.) Louise: I think she’d like to, but Worry’s gotten in the way. Therapist: Isn’t that just like Worry to play a trick like that on a kid who’s minding her own business. (Hoping this sort of lively depiction will bring the problem within a young girl’s range.) Therapist: Millie, would it be okay if I asked you a few more questions about some of the ways Worry has been messing around in your life? Millie: Okay. Therapist: Thanks. Okay, question number 1. Is your mom right? Did you want to go to April’s for a sleepover, and did Worry try to take over before you could imagine how much fun you’d have? Millie: Yeah. Therapist: How did it do it, Millie? How did Worry take a fun idea like a sleepover at your best friend’s house and turn it into a bad idea or a scary one? Millie: (She shrugs.) (The question may need reshaping to bring it within reach.) Therapist: Does Worry try to take your fun imagination and turn it into scary imagination? Millie: It makes me think something bad will happen. Therapist: And when you had your imagination all to yourself before Worry came along, can you think of what you liked to use it for? (Freeman et al. 1997. Millie: For Minecraft. Don: Not just Minecraft. She used her imagination for all sorts of things. She’s always been very creative. Remember the story you made up on our road trip? (Don describes how Millie sat in the backseat and created a story that “went on for days” about a whole world with characters and plotlines.) Therapist: I’m just thinking, Millie. . .If you had a small imagination do you think Worry might have left you alone? Millie: (Thinking) Therapist: Is it because your imagination is so good that Worry thought you’d be the perfect kid to pick on? Millie: Yeah, because my imagination is pretty big. (She seems to be getting in the spirit.)

Deconstruction in Narrative Couple and Family Therapy Therapist: What do you think of a problem like Worry trying to use a young girl’s talent for imagination against her? Millie: I won’t let it! Therapist: But what if Worry decides it wants to use your imagination as its playground a while longer? Millie: It belongs to me! (Said with conviction) Therapist: (To the parents) Is this the girl you introduced me to with a mind of her own? Louise and Don: Yes! Yeah! (Overlapping) Therapist: I’m just curious, has Worry tried to sneak into your imaginations too? Don: It definitely has. Therapist: What’s it like to be reminded just what kind of girl Millie is? Louise: It’s wonderful.

Despite every loving attempt on Louise’s and Don’s part to mitigate Worry and revive Millie’s spirits, it was only when Millie herself took a decisive position that events began to turn in her favor. Young people have the capacity to effect dramatic change. It is a matter of freeing ourselves from common conceptions of childhood so that our imaginations, alongside those of children, can take flight. As people attempt to orient to the problems that enter their lives and those of loved ones, readymade cultural narratives can get out in front and shape what is possible to perceive. Narrative practitioners remain on the lookout for dominant discourses (e.g., patriarchal, mother-blaming, diagnostic, etc.) that can capture our attention and block out other possible images of life. The aim is, if not to flatten power, to at least account for it. In this way people can see it in its operations and find opportunities to strike out in preferred directions.

Cross-References ▶ Deconstructive Listening in Couple and Family Therapy ▶ Micropolitics and Poetics in Couple and Family Therapy ▶ Narrative Couple Therapy ▶ Narrative Family Therapy ▶ Poststructuralism in Couple and Family Therapy ▶ White, Michael

Deconstructive Listening in Couple and Family Therapy

References Blum, L. (2007). Mother-blame in the Prozac nation: Raising kids with invisible disabilities. Gender and Society, 21(2), 202–226. Derrida, J. (2016). Of grammatology. Baltimore: John Hopkins University Press. (Original Amreican work published in English in 1976). Epston, D., & White, M. (1992). Experience, contradiction, narrative and imagination: Selected papers of David Epston and Michael White 189–1991. Adelaide: Dulwich Centre Publications. Foucault, M. (1980). Power/knowledge: Selected interviews & other writings 1972–1977. New York: Pantheon Books. Freeman, J., Epston, D., & Lobovits, D. (1997). Playful approaches to serious problems: Narrative therapy with children and their families. New York: W. W. Norton. Marsten, D., Epston, D., & Markham, L. (2016). Narrative therapy in wonderland: Connecting with children’s imaginative know-how. New York: WW Norton. Rose, N., & Miller, P. (2010). Political power beyond the state: Problematics of government. British Journal of Sociology, 61, 271–303. Wall, J. (2006). Childhood studies, hermeneutics, and theological ethics. The Journal of Religion, 86(4), 523–548. White, M. (1995). Re-authoring lives: Interviews and essays. Adelaide: Dulwich Centre. White, M. (2016). Narrative therapy classics. Adelaide: Dulwich Centre. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: WW Norton.

Deconstructive Listening in Couple and Family Therapy Marcela Polanco Our Lady of the Lake University, San Antonio, TX, USA

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what they listen to and for impact how they, aesthetically, filter information out of unlimited potential possibilities (Hibel and Polanco 2010). It is in the very same aesthetic act of their selection of information that information becomes such, making whatever difference (Bateson 1972) in the therapeutic process. Consequently, that which is not listened to or selected easily gets lost in the conversation. Solution-oriented therapists, for example, would listen to select information that they judge, from their theoretical framework, as exceptions to the presenting problem, constructing them as exceptions in the very same act of selecting them as such. This means that clients do not bring with them exceptions to their problems per se to put forward. Instead, exceptions are constructed in the process of the conversation. Clients bring with them raw material of their lives, or a stock of knowledges – previously constructed in other relationships and contexts, with different meanings – to put forward for therapists and client to construct solutions together from the times when the problem was not present in the client’s life. Therapists who are oriented to listen from a deconstructive perspective are more likely to ascribe to therapies informed by poststructural philosophies. This is the case of a number of family therapies. The most prominent poststructural family therapies are narrative therapy (White and Epston 1990; White 1991) and solution-focused therapy (de Shazer and Berg 1992). This entry provides an overview of poststructuralism, deconstruction, and a deconstructive listening in couple and family therapy.

Poststructuralism Therapeutic conversations provide a context for change in couple and family therapy and are interconnected with the contexts in which they take place, i.e., social, cultural, and historical contexts. Conversations serve as context and are embedded in context. Therapists’ listening orientation contributes as an important factor in setting up a context of response to the concerns that bring clients to therapy. How therapists are oriented to

Poststructuralism is a term that came from scholars in the United States to situate French philosophers’ work during the second half of the twentieth century. It encompasses a critical political, literary, and aesthetic philosophical turn of the structural model to understand texts and language, not to eradicate it but to introduce another order of things. Poststructuralists reevaluated the structuralist perspectives of language of

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Ferdinand de Saussure (1916) and Claude LévisStrauss (1963), who claimed a universal, stable, and complete totality of language and realism that is unchanged by time. The most important representatives of poststructural philosophy in France are Jacques Derrida (1974/1976), Gilles Deleuze (1967/1994), Jean-Francois Lyotard (1984), and Michel Foucault (1980) and in the United States, Richard Rorty (1991) and Judith Butler (1999). Departing from the study of language as a way to understand the meaning of the client’s reality as well as the reality of the therapeutic conversation (in a linguistically forged world, rather than a world of materiality), among some of the differences between the structuralist and poststructuralist proposals, one of critical relevance to couple and family therapists pertains to how they conceive reality in the relationship between the name (e.g., angry person) and the thing named (e.g., the person’s behaviors such as yelling, hitting, cursing, etc.). For structuralists, the relationship is referential. Behind the name is the thing named, the referent; one corresponds directly to the other, both encompassing a totality. The name of the problem “an angry person” represents a stable and actual truth, fixed to the essence of the reality of the identity of the person. The behaviors – yelling, hitting, and cursing – give rise to the name angry person straightforwardly to stand in for them in their absence. Furthermore, meaning is conferred to the name (angry person) linked to the thing named (person’s behaviors), namely, the “sign,” only in contrast with other signs (happy person), e.g., happy/angry, normal/abnormal, presence/ absence, good/bad, etc. In this binary opposition, one has a priority over the other in a hierarchical order mediated by power. Derrida (1976/1967), however, considered that the referential link between the name and what is named is an illusion. It is an illusion of representation. He divorces the straightforward link between the name and the thing named. For Derrida, instead of being a referential relationship, he considered it to be differential. The name is not like the thing named nor represents it in its absence; it is different from it – anger is demarcated by what is not, excluding or subordinating other meanings. The name creates its own

meaning from other meanings, culturally, socially, and historically negotiated; it is self-contained, articulated on its own, apart, rather than linked to or raised from the identity of the thing named. The name, or language clients use in therapy to describe the problem, is the result of their labor or construction in their historical contexts. It is an entirely new creation that bears its own weight in its expression, undetermined by the thing named and determined instead by the cultural, social, historical contexts in which it is constituted. The name, or problem, can take on any sense or meaning on its own, contextually. Hence, anger, for example, is not a representation of a set of dysfunctional behaviors displayed by the person, subsequently diagnosable as an explosive disorder. It is a construct that carries social and cultural negotiated meanings of interaction in this particular historical time when it has come to be named as “anger.” Language, for poststructuralist couple and family therapists, constitutes the client’s realities rather than represents a priori realities. Language creates social and cultural meanings of anger rather than representing a stable, universal truth about the essence of what an angry person is. Therefore, the clients’ language is constitutive according to their function in the context in which they come to be. For structuralist and poststructuralist couple and family therapists, the world is articulated linguistically. For poststructuralists, however, a linguistically articulated world is inevitably bound to society and culture in their historical moment: There is no longer a tripartite division between a field or reality (the world) and a field of representation (the book) and a field of subjectivity (the author). Rather, an assemblage established connections between certain multiplicities drawn from each of these orders, so that a book has no sequel nor the world as its object nor one or several authors as its subject. (Deleuze and Guattari 1991/1994, p. 22)

Couple and family therapists informed by a poststructuralist perspective are then interested in clients’ linguistic assemblages of multiple meanings within the context of their relationships. Now, Derrida’s divorcing of the unity between the name and the thing named, dislocating binaries and locating a historical context in the construction of language instead, results in couple and

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family therapist’s focus on the deconstruction of such assemblage. By this Derrida did not mean destruction but de-sedimentation, disassemblage, decomposition, or undoing of structural truths of reality and binary oppositions in search for new possibilities of multiple meanings.

lived experience of the person’s relationships and out of a binary of normality or abnormality, other meanings become available in the client’s own terms (White 2003). Derrida clarifies that deconstruction is not a method nor can it be transformed into one with the technical or procedural significations that a method would have; nor does it assume a set of rules or procedures that could be repeated from one context to another. Furthermore, he went on to clarify that deconstruction is not even an act or an operation, since this would imply passivity, on one hand, and a person who would take the initiative and apply it to an object or a text, on the other. Deconstruction does not depend on its application by a person. Instead, “deconstruction takes place”; furthermore “it is an event that does not await the deliberation, consciousness, or organization of a subject” (Derrida (1976/1967). Much like any other word, for Derrida, deconstruction is already part of a chain of possible substitutions of meanings or potential alternatives in a context; a word can be substituted, replaced, and determined by other words and supplemented by them. Hence, a therapist does not adopt a deconstruction method to be performed in a conversation. A therapist listens to a client’s narrative of the problem from a deconstructive orientation to language to capitalize from its potential alternative meanings to be assembled from the client’s historical relationships and contexts. A therapeutic conversation unfolds through the happening of the construction and deconstruction of meanings. The conditions of deconstruction exist within the very same systems of that which is to be deconstructed. Deconstruction is at work in the construction of the meaning. That, which can be constructed, can be deconstructed as well when situating and calling into question the contexts within which it was constituted.

Deconstruction A concept constructed by Derrida, deconstruction refers to a reading and analysis of texts or language conceived as a systematic chain or interconnections of previous assemblages or constructions of meanings that can be traced within a cultural and historical context. For Derrida, this chain of texts is organized hierarchically. The text or word has a privileged meaning, while the chain of texts embedded in it is subordinated (White 2003). Deconstruction means the potential dismantling of the hierarchical architecture of the construction of words by undoing and making visible the chain of meanings that constituted them historically, in the first place. As a result, the predominant text is displaced and loses the determination of its words by structures or binaries. In a situation highly determined by a structure (i.e., a fixed reality of the problem as an intrinsic psychopathology of the client), deconstruction serves as an anti-structuralist gesture to make it underterminate and unsedimented, undoing the conditions that constructed the meaning of the problem in the first instance, to construct new words or meanings that will be subject to their further deconstruction. Deconstruction results in the dismantling of the assemblage or architecture of the chain of meanings embedded in the problem the client brings to therapy. It allows for the revision of the surrounding conditions of the word, or problem, that may have turned into a fact or become naturalized by the influence of institutional, cultural, social discourse of mental health. For example, the term “depression” is desedimented or undone from being a taken-for-granted professional discourse of a mental disorder related to the psychological structure of the person. When revising the historical subordinated chain of meanings from the

Deconstructive Listening A therapist informed by a poststructuralist perspective questions the idea that behind or beneath the client’s language is the true essence of who they are, which must be accessed as a

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target for treatment. Poststructuralist-informed couple and family therapists keep from listening to clients’ narratives as if they are a representation of a hidden psychological structure that ought to be discovered, whether these are strengths clients possess or an intrinsic pathology that they are suffering from. A problem in “communication” that brings a same-sex or opposite-sex couple is not listened to in search for a dysfunction in one or both partners. A therapist with a poststructuralist orientation, most prominently a narrative therapist, would assume no essential psychological structures of pathology concealed within the couple’s communication. Instead, the therapist would be oriented by a deconstructive listening to disassemble the couple’s linguistic constructions that privilege a problem of communication as if it was an essential truth about their lives and relationship, in turn neglecting other potential meanings of what the couple judge as important, valuable, and respectworthy for them and about them. Adopting a deconstructive orientation to listening takes couple and family therapists to pay meticulous attention to the client’s language. They pay close attention to the particular words clients adopt to construct their narratives. They do so to trace the chain of meanings that are not explicitly said but which constructed the stated narratives in the first place. This requires for them to listen in between the lines of what was said for what is not said. In a manner of speaking, therapists listen bilingually or listen for different languages – the language of what is said by the client, say, a problem, and what is not said, a counter-problem. Michael White (2003) referred to this kind of listening as “double listening” borrowing from Derrida’s differential perspective to language (vs. referential as in structuralism). Narrative therapists listen doubly to discern differences in the client’s description of the problem. The problem is a problem because it differs from what it infringes on in relation to what the couple gives value to. Implicit in the problem is a chain of meanings about what they have come to give worth throughout their relationship and contexts. The narrative therapists’ deconstructive

listening takes them to adopt a kind of bilingual ear that focuses on various languages, i.e., the language of the problem and the language of that which the problem is infringing on the couple’s lives. Therefore, therapists select that which is absent in the couple’s narrative about the problem, but it is at the same time implicit (White 2003) in the chain of associations of meanings that constructed historically the narrative of the problem as the most prominent one. Within this chain of association of meanings, narrative therapists listen to or select narratives that contradict the privileged account of the problem to assemble, out of underprivileged narratives, aspects that more fairly account to what made them a couple in the first instance. A deconstructive listening orientation leads couple and family therapists to focus their attention to language in context, holding special interest on the historical assemblage of the meanings of the presenting problem in their lives and relationships. It is important to note, however, that history is approached in a particular way. It differs from how it is often adopted in other therapy perspectives that conceive history from a biopsychosocial assessment perspective in search for the cause or root of the problem for its resolution. Borrowing from Foucault’s (1980) concept of genealogy, rather history is understood as context marker for the constitution of knowledge, discourse, etc., within which clients constitute themselves, as well as the problem across the continuity and discontinuity of time. This means that history serves as an organizing feature of the client’s meanings about their lives and relationships, instead than conceiving life as a product of history. From a deconstructive listening orientation, therapists filter information on how the problem was made up historically. And, once these architectural features are no longer taken for granted, the building of new meanings becomes available. According to Foucault (1980), history divides, distributes, orders, arranges, establishes patterns, distinguishes between what is relevant and what is not, discovers elements, defines unities, and describes relations that make up, in this case, the clients’ lives.

Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy

Cross-References ▶ Absent but Implicit in Narrative Couple and Family Therapy ▶ Communication Theory ▶ Deconstruction in Narrative Couple and Family Therapy ▶ Dialogical Practice in Couple and Family Therapy ▶ Externalizing in Narrative Therapy with Couples and Families ▶ Linguistics in Relation to Couple and Family Therapy ▶ Narrative Family Therapy ▶ Problem-Saturated Stories in Narrative Couple and Family Therapy ▶ Social Constructionism in Couple and Family Therapy

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White, M. (1991). Deconstruction and therapy. Dulwich Centre Newsletter, 3, 21–40. White, M. (2003). Narrative practice and community assignments. The International Journal of Narrative Therapy and Community Work, 2, 17–55. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: W. W. Norton.

D Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy Lorrie Brubacher1 and Sue M. Johnson2 1 University of North Carolina, Greensboro, NC, USA 2 The International Centre for Excellence in Emotionally Focused Therapy, The University of Ottawa, Ottawa, ON, Canada

References Bateson, G. (1972). Steps to an ecology of mind. New York: Ballantine Books. Butler, J. (1999). Gender trouble. New York: Routledge Press. de Saussure, F. (1916/1959). Course in general linguistics (R. Harris, Trans.). Chicago: Open Court. de Shazer, S., & Berg, I. K. (1992). Doing therapy: A poststructural re-vision. Journal of Marriage and Family Therapy, 18(1), 71–81. Deleuze, G. (1967/1994). Difference and repetition (P. Patton, Trans.). New York: Columbia University Press. Deleuze, G., & Guattari, F. (1994). What is philosophy [H. Tomlinson & G. Burchell, Trans.]. New York: Columbia University Press Books. (Original work published 1991). Derrida, J. (1976). Of grammatology. (Spivak, G. Ch., Trans). Baltimore: John Hopkins. University Press. (Original work published 1967). Foucault, M. (1980). Power/knowledge: Selected interviews and other writings. New York: Pantheon Hibel, J., & Polanco, M. (2010). Tuning the ear: Listening in narrative therapy. Journal of Systemic Therapies, 29(1), 59–70. Levis-Strauss, C. (1963). Structural anthropology. New York: Basic Books. Lyotard, J. F. (1984). The postmodern condition: A report on knowledge (G. Bennington & B. Massumi, Trans.) Minneapolis: University of Minnesota Press. (Originally published on 1979). Rorty, R. (1991). Objectivity, relativism, and truth. New York: Cambridge University Press.

Introduction Emotionally focused therapy (EFT) is based on the powerful role which emotion plays in intimate relationships. The word emotion is based on the Latin word emovere, “to move.” In the Stage 1 change event of EFT– de-escalation – therapists focus on clarifying how emotion organizes a couple’s typical pattern of interaction (see ▶ Clarifying the Negative Cycle in Emotionally Focused Therapy, Brubacher and Johnson, this volume). In Stage 2 of EFT, therapists deepen emotional experience using the power of emotion to fuel the two transformative change events of withdrawer re-engagement and blamer softening – thereby reshaping the bond to one of safe connection. The goal of EFT – reshaping relational distress and insecure attachment into a secure attachment bond – is achieved through deepening attachment emotion and interacting from within that deepened emotional experience. Support from attachment neuroscience shows that deepening and reprocessing emotion in EFT creates secure bonds that not only have a significant emotion regulation function (Coan

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and Maresh 2014), they actually change how the brain responds to threat (Johnson et al. 2013). Deepening emotional experience can be defined as heightening and expanding the experience of attachment emotions that, unacknowledged, drive partners’ self-protective behaviors in a distressed relationship. It includes helping a partner to get an alive, vivid felt sense of immediately felt primary emotion that is typically quickly obscured by selfprotective secondary emotions such as anger or numbness during attachment threatening moments (Johnson 2004).

Theoretical Framework The practice of deepening attachment emotion is based on research regarding the nature of couple distress and satisfaction showing that it is the quality of emotional engagement and expression of clear emotional messages that shift negative interaction patterns and shape secure bonding interactions (Johnson 2004; ▶ Circle of Security: “Understanding Attachment in Couples and Families”, Johnson and Wiebe, this volume). Nine process of change studies (see www.iceeft.com) validate that the two key processes predicting positive outcome in EFT are deepening emotional engagement – especially exploring attachment fears and longing – and disclosing and responding to this experience in affiliative (warm, caring, self-disclosing, and responsive) interactions (Greenman and Johnson 2013). The initial deepening of attachment emotion occurs in Stage 1 of EFT when a therapist helps each partner to identify and taste the primary emotion underlying his/her reactive moves and secondary emotion in the typical negative cycle. It is in Stage 2, however, that the fundamental therapeutic focus is on deepening and expanding primary attachment fears and longings and accessing and disclosing the needs embedded in that emotion. This forms the core of the transformative change of EFT, where partners’ disclosure of attachment fears and needs pulls for the other partner to respond in new and reassuring ways. Clear, congruent

expressions of deepened emotion evoke new ways of reaching and responding that reshape the attachment bond into one of security and connection (Johnson and Brubacher 2016).

Rationale for Deepening Emotion Emotion is the agent of change as EFT therapists help couples to reshape their despair and disconnection into loving, lasting bonds. Emotion is recognized for priming key responses (Ekman 2003, 2007) in interactions between partners. Attachment theory (Mikulincer and Shaver 2016) delineates how partners in insecure attachment bonds dismiss or exaggerate emotional cues in themselves and others, deny and fragment emotional experience, and send unclear messages in their best attempts to deal with an underlying sense of rejection and abandonment by their partners. Emotion is also recognized for being a reliable source of information about needs (Frijda 1986). Deepening awareness of primary attachment emotion gives a partner access to the need embedded in that emotion and the capacity to send a clear request to the other partner to meet this need, in place of the indirect messages that have been reinforcing cyclical negative interaction patterns. In the de-escalation change event of EFT Stage 1, partners typically discover and name the underlying emotions and attachment fears driving their negative cycles. The withdrawer newly articulates and touches the aching sense that s/he is failing to measure up in his/her lover’s eyes. An angry, critical partner formulates and tastes his/her softer underlying fears of abandonment. After partners de-escalate (identifying the relationship problem as the negative pattern fuelled by underlying emotions), they begin Stage 2, where the EFT therapist deepens the vulnerable attachment emotions that were touched in Stage 1. Deepening engagement with core underlying fears and needs increases mutual sharing and responsivity, restructuring the bond, and creating broaden and build cycles (Mikulincer and Shaver 2016) of security.

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Description Definition “Deepening” means to evoke partners’ present moment experiencing of primary attachment emotions in a vivid and concrete way. Deepening emotion is a process of present-moment engagement with the core underlying attachment fears, linking bodily felt awareness, perceptions, affect, and impulses towards action. Deepening emotional experience makes it possible for a partner to discover and then be guided to disclose the attachment need embedded within the depth of core emotion. Clear signals about needs pull for compassionate, empathic, and bonding responses (Johnson 2004). Core Process for Reshaping the Attachment Bond Reshaping the attachment bond begins with one partner deepening core attachment fears and disclosing these fears to the partner, after which the partner is supported to receive this disclosure. Next, the partner deeply experiencing his/her attachment fear is supported to access the attachment need embedded within that deeply felt emotion. The apex of the change event is when the experiencing partner takes the risk to reach towards the other partner to ask for this need to be met, followed by the other partner’s response to that reach. Deepening attachment emotion is the core of EFT’s Stage 2 bonding events: withdrawer re-engagement (WRE) and blamer-softening (BLS). In WRE, the formerly withdrawn partner shares attachment fears and needs and from an engaged and assertive position, asks for what s/he needs to remain engaged and to have a safe and secure connection with the other partner. In BLS, the anxious, pursuing partner explores attachment fears of the other’s dependability, fears of one’s own worthiness, and fears of reaching to the other and while deeply engaging with these fears, risks reaching to the now engaged partner to ask for what s/he needs to soothe these attachment fears. This Stage 2 change process is focused first on the more withdrawn partner and then on the more anxious, pursuing partner. First the exploring partner is helped to deepen, distill, and disclose his or

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her primary emotion. Then the other partner is supported to acknowledge and accept this “new” spouse. (Disclosures made from newly expanded emotions convey a new and different view of the partner.) Finally, the EFT therapist lingers with the disclosing partner in a felt sense of the fear so as to evoke the attachment needs embedded within that core fear. Choreographing reaching and responding between partners to disclose attachment needs and request the other partner’s help to meet these needs marks the apex of reshaping attachment security. Interventions Primary interventions for deepening emotion (illustrated in the case example below) are empathic reflections, evocative questions that focus on the cue, the bodily arousal, the attachment meanings and the action tendency of the emotion, heightening emotional experience and empathic conjectures, in an attachment frame, of the client’s emotional experience. After emotional experience has been deepened and distilled, the therapist will help the partner to “disclose” this experience to the other partner, as in, “Can you turn and tell your partner, ‘It’s true – I do fire up and get louder (action tendency) when I see you shrug your shoulders and turn away (cue). I just can’t bear this dreadful loneliness (primary emotion) and the sense that I am too much for you’ (attachment meaning)?” After directing the disclosing partner to share this message, the therapist checks first what is was like to share this, and then asks the listening partner about their in-the-moment experience of receiving the message. Each partner’s emotions that emerge are then reflected and heightened, to deepen emotional engagement within and between partners.

Case Example Ben and Tiara had a familiar pattern of pursueattack, defend-withdraw. The more she would push him to help around the house, the more he would defend himself and sullenly retreat to his computer. This rapid-fire cycle began to soften as they recognized how they were unwitting

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triggering a negative cycle. Both deepened their awareness of the more vulnerable emotional music playing in the background. Ben’s deepened engagement with the attachment fears underlying his defensive, withdrawn position, reveals dread that he is doomed to lose her one day, and a daily sensation of his heart dropping into his stomach with this fear. Ben:

Therapist:

Ben:

Therapist (Slow, soft tone):

Ben: Therapist:

Ben:

She gets so upset with me – I am afraid of saying the wrong thing that will fire her up. I hate her being upset – my heart sinks to my gut – and then I fire back at her. You get scared of her firing at you and just before you fire back, your heart sinks to your gut sensing she is upset with you. I wonder if we could just hear a little more about that fear – your heart sinking to your gut, when this powerful, beautiful person that is obviously so important to you, comes out loud and angry? Eeeew! That I’m not good enough for her. I’m not meeting her needs. It makes me feel like I’m screwing up the relationship and I’m doomed to lose her. (Note the emergence of attachment meanings, negative view of self and core fear of losing.) So, it is really very scary. (Heightening the fear.) You’re saying when you hear Tiara angry, (reflecting the trigger for the fear) that you get very, very scared. Your heart sinks to your stomach. You think, “Oh no I’m going to lose her, I’m not good enough. Oh, no I can’t possibly meet her needs,” and you feel you’ve already lost her, yes? I get really tense and anxious (puts his hand on his abdomen). Yeah, right in your gut you feel a tightness. Do you feel any of that now as you are describing it? Totally – it’s rock hard tense. I’m not able to find words to describe it. Just a real tension I guess.

Therapist:

Ben:

Just this big tense place of, “Oh no, I could lose you!” (Heightening with proxy voice conjecture/reflecting what he has said earlier.) That is a very scary place. I’d like you to imagine telling Tiara how very scary this is – to be so certain you’ve already lost her – you feel your heart sink to your stomach and your stomach becomes rock hard – so tense – frozen in fear of losing Tiara. It makes me really nervous that when we are arguing that you are going to decide that this is the end of it and you’re going to decide that I’m just not good enough for you and that you don’t want to be in this relationship anymore.

(Following this disclosure, the therapist processes with each one in turn what it was like to share and what it was like to hear.) Therapist: Ben:

So, what is it like as you are telling her this? I feel a bit of relief. I don’t think I’ve ever told her how get scared I get when we are arguing or when she is upset. It’s a relief to let you know how scared I get– of losing you. (Owning his primary emotion).

When the therapist evokes Tiara’s experience in hearing from Ben, Tiara is clearly moved and expresses her shock and love for Ben. Deepening the present moment experiencing of Ben’s attachment fear, made it possible for him to disclose it clearly to Tiara. The therapist lingers in Ben’s deepened fear of failing and his exhaustion at trying to get Tiara’s approval, until he is able to access his need for assurance and acceptance. Ben steps forward, assertively stating his longings and needs to Tiara. Ben:

Your complaints and criticism are too much for me. I need you to back off and show me you still want to give me a chance. I do want to be close to you.

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I don’t want to fire back to shut you down anymore – I just need to know that I’m enough for you. Please give me a chance!

Tiara is shocked at Ben’s risk of stepping close to her. She responds with a message of clearly wanting him and wanting him to know that. Next, the therapist deepens Tiara’s attachment fears and shapes enactments where she can risk reaching to Ben to ask him to soothe her fears and meet her attachment needs. From within her deepened fears, first that Ben might disappear again and secondly shaking in fear and disgust at her own unworthiness, Tiara accesses her need for Ben to see her vulnerabilities and uncertainties and to assure her he likes what he sees and will not leave. The therapist supports Tiara to stand on that fearful ledge, and to risk leaping off the cliff and to ask Ben to catch her. Therapist:

(voice quivering) Can, can you catch me – want me – when I’m so pathetic?

Deeply moved by her vulnerability and her need for his response, Ben rises to the occasion to solidly affirm he loves her more than ever. Together Ben and Tiara begin to create a new positive cycle of reaching and responding that pulls them close and reinforces their bond. Deepened emotion, disclosed to the partner creates new contact between them. Clear, simple messages of primary attachment needs embedded within deepened primary emotion pulls the other partner into offering a positive response, initiating new positive bonding cycles of reaching and responding.

Cross-References ▶ Attachment Injury Resolution Model in Emotionally Focused Therapy ▶ Attachment Theory

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▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Clarifying the Negative Cycle in Emotionally Focused Therapy ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy and Physical Health in Couples and Families ▶ Emotionally Focused Couple Therapy and Trauma ▶ Emotionally Focused Couple Therapy ▶ Emotionally Focused Family Therapy ▶ Hold Me Tight Enrichment Program ▶ Hold Me Tight/Let Me Go Enrichment Program for Families and Teens ▶ Johnson, Susan ▶ Training Emotionally Focused Couples Therapists

References Coan, J. A., & Maresh, E. L. (2014). Social baseline theory and the social regulation of emotion. In J. J. Gross (Ed.), Handbook of emotion regulation (2nd ed., pp. 22–236). New York: Guilford. Ekman, P. (2003/2007). Emotions revealed: Recognizing faces and feelings to improve communication and emotional life. New York: St Martin’s Griffin. Frijda, N. H. (1986). The emotions. Cambridge: Cambridge University Press. Greenman, P. S., & Johnson, S. M. (2013). Process research on emotionally focused therapy (EFT) for couples: Linking theory to practice. Family Process, 52, 46–61. https://doi.org/10.1111/ famp.12015. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed.). New York: Brunner/Routledge. Johnson, S. M., & Brubacher, L. L. (2016). Deepening attachment emotion in emotionally focused couple therapy (EFT). In G. Weeks, S. Fife, & C. Peterson (Eds.), Techniques for the couple therapist: Essential interventions (pp. 155–160). New York: Routledge. Johnson, S. M., Burgess Moser, M., Beckes, L., Smith, A., Dalgleish, T., Halchuk, R., et al. (2013). Soothing the threatened brain: Leveraging contact comfort with emotionally focused therapy. PLoS One, 8(11), e79314. https://doi.org/10.1371/journal. pone.0079314. Mikulincer, M., & Shaver, P. R. (2016). Attachment in adulthood: Structure, dynamics, and change (2nd ed.). New York: Guilford Press.

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Delayed Ejaculation in Couple and Family Therapy

Delayed Ejaculation in Couple and Family Therapy Michael A. Perelman Department of Psychiatry, Reproductive Medicine and Urology, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA MAP Education and Research Foundation, New York, NY, USA

Name of Concept Delayed ejaculation in couple and family therapy

Synonyms Retarded ejaculation; Inhibited male orgasm

Inhibited

ejaculation;

Introduction Delayed ejaculation (DE) is a type of diminished ejaculation disorder (DED), which includes all subtypes manifesting ejaculatory delay/absence (Perelman et al. 2004). Many clinicians may find DE difficult to treat and may not grasp the psychosocial distress it causes. Assessment requires a thorough sexual history including inquiry into masturbatory methods to ascertain the information needed for proper diagnosis and treatment. This entry describes a transdisciplinary approach to the etiology, diagnosis, and treatment of men with DE based on the Sexual Tipping Point ® model (Perelman 2009, 2016). DE remains an uncommon disorder, with prevalence rates in 1–4% of males (Rowland and Perelman 2006). Rates are increasing due to greater use of pharmacotherapy [5-alpha reductase inhibitors (5aRIs), serotonin reuptake inhibitors (SRIs), etc.] and an aging population’s declining ejaculatory capacity (Perelman 2016). A man with DE usually has intact erectile

capacity but find ejaculating during partnered sex extremely difficult or impossible. Ejaculatory difficulty may occur in all situations (generalized) or be limited to certain experiences (situational). It may be lifelong (primary) or acquired (secondary). A man typically is unable to ejaculate in the presence of a partner (especially during coitus) but is able to orgasm and ejaculate during solo masturbation. Nomenclature confusion arises over ejaculation and orgasm usually occurring simultaneously, despite being separate physiological phenomena. Orgasm is typically coincident with ejaculation but is a central sensory event with significant subjective variation. Men with DE typically report less coital activity, lower subjective arousal, and often report feeling “less of a man.” Some partners enjoy extended intercourse, but eventually many experience some annoyance, pain, and the distressing question: “Does he really find me attractive?” Initially blaming themselves, partners frequently become angry at the perceived rejection. Men with DE may fake orgasm to avoid negative partner reaction. Finally, distress is extreme when conception “fails,” while fear of pregnancy leads other men to avoid sex (Perelman 2016).

Theoretical Context for Concept The Diagnostic and Statistical Manual of Mental Disorders defines DE as marked delay in ejaculation and/or marked infrequency or absence of ejaculation. Five additional factors must be considered during assessment: (1) partner issues, (2) relationship quality, (3) individual vulnerability, (4) cultural/religious influences, and (5) medical diagnoses relevant to prognosis (American Psychiatric Association 2013). “Worldwide” normative studies indicate that heterosexual males in stable relationships have a median coital duration of approximately 5–6 min (Waldinger 2009, p. 2888; Patrick et al. 2005). Influenced by those studies, the International Society of Sexual Medicine’s ejaculation disorder definitions invoke a concept of percentage (0.5% and 2.5%), often used in medicine. The 3rd International

Delayed Ejaculation in Couple and Family Therapy

Consultation On Sexual Medicine defines DE as a threshold beyond 20–25 minutes of coital activity, as well as negative personal consequences such as distress (McCabe et al. 2016). Perelman has recommended that any bilateral deviation from the majority of men’s 4–10 min coital range would meet the temporal criterion. However, a licensed healthcare clinician must also assess for “lack of control” and “distress,” which are the most important determinants when diagnosing either premature or delayed ejaculation (Rowland and Perelman 2006, Perelman 2016a, b). He also recommended qualifying lifelong (primary) or acquired (secondary), global or situational, and then specifying: mild, moderate, or severe. A man’s inability to ejaculate in response to coital stimulation may be due to biological and/or a range of psychosocial and cultural factors. Typically, medical examination, laboratory testing, and sexual history are all used to rule out anatomical, hormonal, and neurological abnormalities as well as pharmaceutical causes. However, clinicians should also be alert to the numerous potential psychological and behavioral causes of DE. These can include ineffective sexual communication, cultural and religious prohibitions, mood disorders, anxiety, fatigue, trauma, and psychodynamic issues such as abandonment/ rejection concerns, emotional intimacy conflicts, and unwanted pregnancy. Additionally, hostility toward the partner and paraphilic inclinations/ interests also may play an etiological role (Masters and Johnson 1970; Rowland and Perelman 2006). Regardless of the degree of organic etiology, DE is exacerbated by insufficient stimulation: an inadequate combination of “friction and fantasy” (Perelman 2016). Fantasy refers to any erotic thought associated with a given sexual experience. High frequency negative thoughts may neutralize/override erotic cognitions (fantasy) and subsequently delay, ameliorate, or completely inhibit ejaculation, while inadequate partner physical stimulation (friction) may lessen response. Perelman identified three masturbatory factors associated with DE: frequency of masturbation, idiosyncratic masturbatory style, and unsettling disparity between masturbatory fantasy and

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reality (Perelman 2005). Although correlated with high frequency masturbation, the primary causative factor for many men was an “idiosyncratic masturbatory style,” as first identified by Perelman was defined as not easily duplicated with the partner’s body, i.e., hand, mouth, or vagina. These men engaged in patterns of selfstimulation notable for one or more of the following idiosyncrasies: speed, pressure, duration, body posture/position, and specificity of focus on a particular “spot” in order to produce orgasm/ejaculation. Disparity between the reality of sex with their partner and their preferred sexual fantasy used during masturbation is another cause. That disparity takes many forms, such as partner attractiveness, body type, sexual orientation, and the sex activity performed (Perelman 2016). A focused sexual history or sex status is critical (Perelman 2003, Perelman 2018a, b). A sex status begins by differentiating DE from other sexual problems and reviewing the conditions under which the man can ejaculate. Perceived partner attractiveness, the use of fantasy during sex, anxiety-surrounding coitus, and masturbatory patterns all require meticulous exploration. Identify important causes of DE by juxtaposing the patient’s cognitions and the sexual stimulation he experiences during masturbation versus a partnered experience.

Application of Concept in Couple and Family Therapy Consider asking clients: “In what way does the stimulation you provide yourself differ from your partner’s stimulation style, in terms of speed, pressure, etc.?” “Have you communicated your preference to your partner and if so, what was their response?” Some patients might balk at these personal questions, but once assured that research has shown such information is critical to successful outcome, refusal to answer is rare. Assess for the degree of immersion and focus on “arousing” thoughts and sensations during masturbation versus partnered sex including: fantasy, watching/reading pornography, sexy versus

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antierotic intrusive thoughts, e.g., “It’s taking too long!” How do his thoughts/feelings during sex with a partner differ from those during solo masturbation? Additional questions will identify other etiological factors that improve or worsen performance. Obtain the disorder’s development history and if orgasm was ever previously possible. Review life events/circumstances temporally related to orgasmic cessation. Investigate previous treatment approaches, including the use of herbal therapies, home remedies, etc., and if there was benefit. Information regarding the partners’ perception of the problem and their satisfaction with the relationship may assist treatment planning. There are no pharmaceuticals proven to treat DE, but numerous techniques can be combined to treat DE including and not limited to sex education, cognitive-behavioral therapy, mindfulness, psychodynamic exploration of underlying conflicts, and/or couples’ therapy. Patient and partner (when present) education should be integrated into the history taking process to the extent it does not interfere with rapport building or obtaining needed information. Before the evaluation concludes, offer the patient a formulation that highlights the immediate cause of his problem and how it can be alleviated. The Sexual Tipping Point® model can provide a useful frame for helping the patient (and partner) understand etiology and treatment planning. Explain how the mental and physical erotic stimulation he is receiving is insufficient for him to ejaculate in the manner he desires. Successful treatment will depend on the patient’s willingness to follow therapeutic recommendations, which will be influenced by the extent of organicity, relational issues, and potentially deeper patient/partner psychodynamic problems. Behavioral masturbatory retraining within a nuanced sex therapy serves as a frequent primary or adjunctive treatment (Apfelbaum 2000; Perelman 2003, 2016). Masturbation can serve as rehearsal for partnered sex. By informing the patient how masturbation conditioned his response, stigma is minimized and partner cooperation is evoked. Masturbation retraining is only a means to an end; the goal of therapy is higher levels of arousal within mutually satisfying experiences. For both primary and secondary DE (when therapeutically possible), obtain an agreement

Delayed Ejaculation in Couple and Family Therapy

from the patient to temporarily refrain from ejaculating alone. If he will not stop, negotiate a reduction in his masturbatory frequency with a minimum commitment of no ejaculation within 72 hours (experience based) of his next partnered experience. The clinician must provide support to ensure adherence to this suspension. The patient who continues to masturbate alone must do so in a manner different from his normal routine. Limit his orgasmic outlet from his easiest current capacity (usually a specific style) and progressively “shaping” it closer to his likely partnered experience. This can vary from changing hands or the position he uses during self-stimulation to masturbating in his partner’s presence. Transitioning from manual to oral and to coital stimulation is typical, each providing progressively less friction. The patient’s coital bodily movements and fantasies should approximate the thoughts and sensations experienced in masturbation. Single men should use condoms during masturbation to rehearse “safe sex” (Perelman 2016). Success rates for treatment by a skilled sex therapist are greater than 75% (Perelman 2016). Yet, not all cases resolve themselves easily. Naturally, more complex cases require more time for treatment. The longest latency a DE patient in this author’s practice who limited masturbation but eventually reached coital orgasm was 8 months. That couple required management of numerous relational problems before he was willing to stop masturbating and be truly motivated to experience a coital orgasm with his wife. Often coital orgasms are obtained but no longer remain the preferred choice. Despite being the patient/partner’s initial preference, coital orgasms may be less pleasurable and intense than masturbatory orgasms. Nonetheless, for many men and their partners, it is often subjectively the most satisfying for a variety of psychosocial-cultural reasons. This potential conundrum is best resolved when the clinician allows the choice of posttreatment orgasmic preference to remain the decision of the man/couple. Sometimes these men will need clinician support to express their preference for noncoital orgasms, especially when their coital orgasms were less satisfactory and only obtained by painstaking effort. However,

Delayed Ejaculation in Couple and Family Therapy

clinicians who readily negotiate compromise with a couple whose female partner prefers noncoital stimulation should recognize the parallel with men suffering from coital DE. Finally, for some men with DE, failure is predetermined secondary to partner psychopathology, values regarding pornography and their relationship issues, etc. Couples’ therapists will readily notice that many partner issues may affect males’ ejaculatory interest and capacity, but two require special attention: fertility and resentment. The pressure of a woman’s “biological clock” is often an initial treatment driver. The women – and often the man – usually resist anything delaying their plan to conceive. However, the clinician suspecting the patient’s DE is related to conception fears should note any disparity during sex with contraception versus “unprotected” sex. If the DE only occurs during “unprotected” sex, the clinician can assume that impregnation reluctance is a primary variable. Resolution typically requires individual work with the man and occasionally with the partner. Fertility related or not, patient/partner anger is an important causational factor and must be ameliorated through individual and/or conjoint consultation. Anger acts as a powerful anti-aphrodisiac. While some men avoid sexual contact entirely when angry, others attempt to perform, only to find themselves modestly aroused and unable to function. The man’s assertiveness should be encouraged, but the clinician should also remain sensitive and responsive to the impact of change on the partner, as well as alterations in the couple’s equilibrium (Perelman 2016). As treatment progresses, interventions may be experienced as mechanistic and insensitive to the partner’s needs and goals. Understandably, partners’ respond negatively to the impression he is essentially masturbating with her body, as opposed to engaging in connected lovemaking. Indeed, some men are disconnected emotionally from their partners. The clinician must empathically help the partner become comfortable with the idea of temporarily postponing desired intimacy. Once the patient is functional, the clinician can encourage a man/couple toward greater intimacy.

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Alternatively, both partners may be disconnected from each other but otherwise in a valued stable relationship. Support the patient’s goals, but do not push the man (couple) toward the clinician’s own preordained concept of a relationship. Instead, embrace McCarthy’s “good enough” sex model (Metz and McCarthy 2007). The more relationship strife, the less likely treatment will succeed. Clinicians should practice to their level of comfort but should not hesitate to refer as needed to an expert sex therapist (Perelman 2016).

Clinical Example David (34) worked as a lawyer and was recently living together with his girlfriend Judy (28), who he has dated for 18 months. They shared values and enjoyed each other’s company. He planned to propose marriage, but she recently indicated her reluctance to commit in light of their sexual difficulties. They were extremely distressed by his coital anorgasmia, causing a crisis as they questioned his attraction toward her despite his assurances of her desirability. Subsequently, he consulted his urologist, who referred to this author. The decision to meet alone with David or meet with them conjointly was left to David when he first called. Be sensitive to patient preference regarding partner participation, as patient and partner cooperation is more critical to successful treatment than partner attendance at all office visits (Perelman 2003). A focused sex history was obtained from David during the first session. He reported that she usually initiated sex, had high desire, and was easily aroused and was orgasmic with manual, oral, and coital stimulation. The critical issue was his ability to orgasm on masturbation, but not during partnered sex. That was lifelong. He described an idiosyncratic masturbation technique, and his masturbation frequency was high. He reported first masturbating using his right hand, but when he broke it at athletic camp at age 15, he switched to lying on his belly and pressing his penis into the bed until he ejaculated. He continued doing so until the present more than four times per week, plus having sex (non-orgasmic)

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with Judy. His current sexual fantasy was, “making love to Judy,” which was not contributing to his delayed ejaculation. Other dynamic issues may have caught a counselor’s attention. For instance, his shyness and passivity contributed to his not communicating to Judy about his sexual preferences or how he pleasured himself. Although that type of character issue could be addressed, a direct symptomatic focus is preferred unless individual or relational dynamics require doing otherwise. David was instructed to stop masturbating and to limit his attempts to reach orgasm during coitus only to those times when he was initiating sex because he wanted it, independent of who initiated. That suggestion which he followed religiously until follow-up 2 weeks later was sufficient for David to experience his first coital orgasm. Both Judy and David were exuberant. Judy and David married and 2 years later had their first child. Their case is not offered to suggest that DE can always be treated so easily and rapidly but to emphasize the importance of a counselor obtaining specific sexual experience data as part of the history taking because of its profound ability to influence both treatment and outcome.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. http://doi.org/10.1176/ appi.books.9780890425596 Apfelbaum, B. (2000). Retarded ejaculation: A muchmisunderstood syndrome. In S. Leiblum & R. Rosen (Eds.), Principles and practice of sex therapy (3rd ed.). Guilford Press NY, USA Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. Boston: Little, Brown & Co.. McCabe, M., Sharlip, I., Atalla, E., Balon, R., Fisher, A., Laumann, E., et al. (2016). Definitions of Sexual Dysfunctions in Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015. Journal of Sexual Medicine, 13(2), 135–143. http://doi.org/10.1016/j.jsxm.2015.12.019 Metz, M. E., & McCarthy, B. W. (2007). The “GoodEnough Sex” model for couple sexual satisfaction. Sexual & Relationship Therapy, 22(3), 351–362. http://doi.org/10.1080/14681990601013492 Patrick, D. L., Althof, S. E., Pryor, J. L., Rosen, R., Rowland, D. L., Ho, K. F., et al. (2005). Premature

Dell, Paul ejaculation: An observational study of men and their partners. The Journal of Sexual Medicine, 2(3), 358–367. http://doi.org/10.1111/j.1743-6109.2005. 20353.x Perelman, M. A. (2003). Sex coaching for physicians: Combination treatment for patient and partner. International Journal of Impotence Research, 15 (Suppl 5), S67–S74. Perelman, M. A. (2005). Idiosyncratic masturbation patterns: A key unexplored variable in the treatment of retarded ejaculation by the practicing urologist. Journal of Urology, 173(4), 340–Abstract 1254. Perelman, M. A. (2009). The sexual tipping point: A mind/body model for sexual medicine. Journal of Sexual Medicine, 6(3), 227–632. http://doi.org/10. 1111/j.1743-6109.2008.01177.x Perelman, M. A. (2016a). Psychosexual therapy for delayed ejaculation based on the Sexual Tipping Point model. Translational Andrology and Urology, 5(4), 563–575. http://doi.org/10.21037/tau.2016.07.05. Perelman, M. A. (2016b). Reexamining the Definitions of PE and DE, Journal of Sex and Marital Therapy. Taylor & Francis Group, (pp 1–12). http://doi.org/10.1080/ 0092623X.2016.1230161 Perelman, M. A. (2018a). Why The Sexual Tipping Point is a Variable Switch Model. Current Sexual Health Reports, 10: 38. Springer Publications. Perelman, M. A. (2018b). Sex Coaching for Non-Sexologist Physicians - How to Use Sexual Tipping Point Model. The Journal of Sexual Medicine, 15(12). Perelman, M. A., McMahon, C., & Barada, J. (2004). Evaluation and treatment of the ejaculatory disorders. In T. Lue (Ed.), Atlas of male sexual dysfunction (pp. 127–157). Philadelphia: Current Medicine, Inc.. Rowland, D. L., & Perelman, M. A. (2006). Retarded ejaculation. World Journal of Urology, 24(6), 645–652. Waldinger, M. D., McIntosh, J., & Schweitzer, D. H. (2009). A five-nation survey to assess the distribution of the intravaginal ejaculatory latency time among the general male population. Journal of Sexual Medicine, 6(10), 2888–2895. http://doi.org/10.1111/j. 1743-6109.2009.01392.x

Dell, Paul Diana J. Semmelhack, Natalie Berry and Dominique Lawson Midwestern University, Downers Grove, IL, USA

Name Paul F. Dell

Dell, Paul

Introduction Paul F. Dell, Ph.D., ABPP is an American clinical psychologist currently specializing in trauma and dissociation. Dr. Dell pursued a Bachelor of Science degree from Penn State University and graduated in 1970. From there, Dr. Dell furthered his education in Clinical Psychology. He graduated from the clinical psychology department of the University of Texas at Austin with his Doctor of Philosophy Degree in 1977. Dr. Dell played an important role in the development of family therapy, particularly with regard to a period of time in the 1980s when the field began to question its theoretical underpinnings. His seminal article, “Beyond Homeostasis,” published in Family Process, created debates about epistemology that would last for a decade. This paper states that the idea of homeostasis is fundamentally inconsistent with systemic epistemology and should be substituted with the more appropriate concept of coherence (Dell 1982).

Career Dr. Dell began his career in academia, climbing the professional ladder as a professor of Psychiatry and Behavioral Sciences at Eastern Virginia Medical School. In his years in academia, Dr. Dell transitioned from being a family therapy specialist to specializing in posttraumatic and dissociative disorders. Dr. Dell achieved the Ernst R. & Josephine R. Hilgard Award for Best Theoretical Paper on Hypnosis in October of 2017 and the Lifetime Achievement Award from the International Society for the Study of Trauma and Dissociation in November of 2011. Currently, Dr. Dell works as a psychotherapist at Churchland Psychological Center in the Norfolk, VA area.

Contributions to Profession As a family therapist, Dr. Dell’s contributions to the field were primarily theoretical. In his seminal article, “Beyond Homeostasis” published in Family Process in 1982, he called into question the

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widely accepted view that family pathology was maintained by a homeostatic mechanism that prevented change from occurring. He not only questioned the theoretical underpinnings of this theory but also called into question why a field such as family therapy dedicated to change would be grounded in a theory of stability. His work spawned a series of theoretical papers that together constituted the “Epistemology Debates” of the 1980s. These debates are credited with clarifying and shifting the theoretical underpinnings of family therapy. Dr. Dell later shifted the focus of his work to dissociation and trauma, working both as an empirical clinician and researcher, with focus on diagnosis and theory. In his 25+ years of working within the field of dissociation and trauma, Dr. Dell developed a diagnostic instrument for dissociation, the Multidimensional Inventory of Dissociation (MID). He also made contributions conceptually and theoretically. Dr. Dell spent 23 years running a training program for individuals suffering from dissociative identity disorder (DID) and other major posttraumatic stress disorders (PTSD). While serving as Director of the Trauma Recovery Center of Norfolk, he simultaneously maintained a role as a clinical psychologist at Psychotherapy Resources of Norfolk (PRN). While at PRN, a trauma-oriented psychotherapy practice, he worked to provide services to patients suffering from DID. Since 2010, Dr. Dell has further developed his professional standing. He served as the President of the International Society for the Study of Trauma and Dissociation (ISSTD) from 2010 to 2011. He also recognized the importance of utilizing technology to spread knowledge about trauma and dissociation. Dr. Dell developed Understanding Dissociation.com as a website where individuals are invited to participate in discussion surrounding dissociative experiences and dissociative disorders. Since its inception, the cite has grown to include participation from clinicians, graduate students, specialists, and other interested parties who desire better understanding of how to treat and work with people suffering from dissociative and trauma-related disorders.

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Depression in Couple and Family Therapy

Cross-References

Theoretical Context for Concept

▶ Family Therapy ▶ Personality in Couple and Family Therapy ▶ Systems Theory

There are many models that have been advanced to understand the onset and course of depression, including genetic and neurobiological vulnerabilities, cognitive characteristics, and environmental risk factors (e.g., early adversity, stress). Because depression is associated with difficulties in a variety of areas, including interpersonal functioning, there has also been a longstanding interest in understanding how couple and family relationships may impact and be impacted by depression. On the one hand, symptoms of depression may increase the likelihood of couple or family problems. For example, a depressed individual may withdraw and be uninterested in engaging in family and household activities, which may increase conflict with other family members. On the other hand, the stress of couple or family problems, such as poor communication, a decline in social support, or an increase in criticism and blame, may increase the likelihood of a person becoming depressed. Although people may become depressed for a variety of reasons, once present, depression is likely to impact couple and family relationship functioning, which may in turn increase the persistence or severity of depression over time. In other words, depression may contribute to couple and family problems, which may increase perceived stress and loss of support, thereby maintaining or exacerbating depressive symptoms (Beach and Whisman 2012). Consequently, couple and family problems are likely to be common among depressed individuals, and, therefore, they are likely to become a focus of clinical attention in a variety of treatment settings. Furthermore, problems in the couple or parenting domain predict poorer response to individual and pharmacological interventions for depression, perhaps because these interventions do not adequately resolve marital, family, or other interpersonal issues, suggesting that such treatments are often incomplete without some attention to couple or family issues (Beach and Whisman 2012).

References Dell, P. F. (1982). Beyond homeostasis: toward a concept of coherence. Family Process, 21, 21–41. Dell, P. F. [Paul]. (n.d.). Posts [LinkedIn page]. Retrieved 29 June 2018 from https://www.linkedin.com/in/paulf-dell-66045223/. Dell, P. F. (2018). About [Blog Post]. Retrieved from: https://understandingdissociation.com/about/.

Depression in Couple and Family Therapy Briana L. Robustelli and Mark A. Whisman Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA

Depression is characterized by a range of symptoms, including depressed mood, loss of interest or pleasure in activities, change in appetite or weight, sleep dysregulation, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, difficulty concentrating or indecisiveness, and thoughts of death or suicide. In the United States, it is estimated that nearly 1 out of every 6 adults (16.6% of the population) will meet criteria for a major depressive disorder sometime in their lifetime (Kessler et al. 2005), whereas general population surveys in 18 countries estimated lifetime prevalence of major depressive disorder to be 14.6% in high-income countries and 11.1% in low- to middle-income countries (Bromet et al. 2011). Therefore, many people are likely to have had personal experience with depression, having been depressed themselves or through having a relationship partner or family member with depression.

Depression in Couple and Family Therapy

Description There is a large literature linking couple and family functioning with depression (Beach and Whisman 2012; Whisman and Baucom 2012). Results from these studies suggest that poorer relationship adjustment is associated with higher levels of depressive symptoms in cross-sectional studies and increases in depressive symptoms over time in longitudinal studies. Poorer relationship adjustment is also associated with depressive disorders in both cross-sectional and longitudinal studies. Compared to couples in which neither partner is depressed, couples with a depressed partner tend to engage in more frequent negative communication behaviors (such as withdrawing, blaming, or being verbally aggressive) and fewer positive communication behaviors (such as smiling, making eye contact, and self-disclosing) (Rehman et al. 2008). Poorer family functioning is correlated with depressive symptoms and depressive disorders and predicts a poorer course and a higher rate of remission of depressive disorders over time (Beach and Whisman 2012). Furthermore, depression has been shown to result in problems with parenting. For example, compared to nondepressed parents, depressed parents display more negative or coercive parenting behavior (e.g., irritability, hostility), are more disengaged from their children, and engage in less positive parenting behavior (e.g., play, affection) (Lovejoy et al. 2000; Wilson and Durbin 2010). In addition, poor parenting has been associated with childhood depression, with larger effects observed for measures of parental rejection relative to measures of parental control (McLeod et al. 2007). Adverse family processes are also associated with adolescent depression. Specifically, depression in adolescents is negatively associated with the level of support, attachment, and approval provided by the family environment, and positively associated with the level of family conflict (Sheeber et al. 2001). For both couples and families, high levels of expressed emotion (EE) and perceived criticism have been associated with greater depressive symptoms and higher rates of relapse (Whisman

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and Robustelli 2016). Expressed emotion refers to the extent to which family members express criticism, hostility, and emotional overinvolvement about a specific family member, whereas perceived criticism refers to the degree to which people view their partner or family members as being critical or judgmental, irrespective of their actual behavior.

Application of Concept in Couple and Family Therapy There are several couple-based approaches that have been developed and evaluated as treatments for depression. The approach that has been most widely studied is based on the cognitive behavior framework (Whisman and Beach 2015). Cognitive behavioral couple therapy for depression generally follows three stages. The first stage involves eliminating major stressors and reestablishing positive activities in the relationship. Therapists first address severe negative behaviors in the relationship, including verbal or physical abuse, threats to leave the relationship, and extramarital affairs; depending on the severity and scope of these issues, therapists may refer one or both partners to additional or alternative treatments to address these issues. Increasing the frequency of caring behaviors, companionship activities, and self-esteem support also occurs during this stage. The second stage of therapy focuses on teaching couples skills to improve communication and their ability to solve problems in their relationship. Through instruction, modeling, practice, and feedback, both in and out of therapy sessions, couples learn effective receptive and expressive communication skills (e.g., use of “I” statements, sharing thoughts and feelings, nonverbal and active listening skills) and problem-solving skills (e.g., defining problems, brainstorming and evaluating pros and cons of solutions, implementing solutions). The final stage of therapy focuses on helping couples solidify the gains made in earlier stages of therapy and learn strategies to prevent relapse of depression and relationship problems (e.g., identify high-

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risk situations, recognize warning signs of depression recurrence). Whereas the cognitive behavioral approach is the most frequently studied couple therapy for depression, other couple-based approaches have also been used to treat depression (Whisman et al. 2012; Whisman and Robustelli 2016). For example, researchers have evaluated emotionally focused couple therapy (which integrates attachment theory with techniques from experiential and family systems approaches) and systemic therapy (which combines strategic and structural concepts and techniques with feminist, narrative, and social constructionist approaches) as treatments of depression. Studies have also evaluated the impact of including the partner or spouse in individual-based treatments, such as including the partner in cognitive behavior therapy or interpersonal psychotherapy. A meta-analysis of studies evaluating the efficacy of couple-based treatments for depression reported that there was no difference between couple therapy and individual psychotherapy (most commonly cognitive behavior therapy) in the treatment of depression; there was insufficient data to examine the comparison between couple therapy and medication (Barbato and D’Avanzo 2008). However, couplebased interventions were significantly more effective than individual psychotherapy in improving relationship discord when discord was present. Whereas most couple-based treatments for depression have focused on couples with co-occurring depression and relationship discord, there is promising preliminary support for the efficacy of couple-based interventions for depressed individuals who are not necessarily experiencing relationship discord (Beach and Whisman 2012; Whisman et al. 2012). Coping-oriented couple therapy includes elements of cognitive behavioral couple therapy but focuses primarily on enhancing understanding of stressful experiences and promoting emotion-focused and problem-focused support. Brief couple therapy for depression provides psychoeducation and uses cognitive and behavioral techniques to improve distress and symptoms in the depressed person and his or her partner.

Depression in Couple and Family Therapy

In addition to these efficacy studies of couplebased treatments for depression evaluated under ideal and highly controlled circumstances, researchers have also examined the impact of couple therapy on depression in community clinics. There are promising findings from such effectiveness studies that couple therapy results in a reduction in depressive symptoms (Whisman et al. 2012). Research has also provided support for the potential efficacy of parent training as a treatment for depression. Parent training programs seek to improve parenting behavior and the quality of the parent-child relationship. Results from several studies have shown that parenting approaches show promising results for alleviating parental depressive symptoms as well as enhancing child outcomes (Beach and Whisman 2012). Family therapy has also been shown to be efficacious for treating adolescents with depression. One promising treatment is attachment-based family therapy (ABFT), which seeks to increase emotional closeness between parents and adolescents, improve the quality of parent-child relationships, facilitate increased communication, and increase adolescents’ autonomy while still receiving support from their parents (Diamond et al. 2016).

Clinical Example Diane presented with a recurrent major depressive disorder, and the current episode was of moderate severity. She and Peter had been living together for 5 years and had a 2-year-old daughter. Both partners were focused on their careers, and what little free time they had was spent with their daughter. The early stage of therapy focused on increasing the frequency of the partners’ caring behaviors, such as texting each other throughout the day, buying small gifts for one another, and devoting more time to taking care of household responsibilities that had piled up and were causing considerable stress for both partners. They also increased the amount of time spent with one another by more frequently going for hikes, eating dinners together, and taking their daughter to the park. They also worked on increasing self-esteem

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support by noticing and complimenting one another for things they typically took for granted. In the second stage of therapy, the therapist worked with Diane and Peter on improving their communication and problem solving. In the initial assessment, both partners complained that because of their busy schedules, they did not spend much time talking and what time they did spend was devoted to brief updates. The therapist worked with the couple on sharing thoughts and feelings about their experiences, rather than just talking about “the facts.” Diane found this to be particularly helpful, as she reported feeling distant from Peter much of the time, which contributed to her general sense of isolation and loneliness. The couple also learned and practiced problemsolving skills and worked through a variety of issues related to time management, lifestyle balance, and child care. In the final stage of therapy, the therapist reviewed with the couple the skills they had learned in therapy, as well as discussed the importance of planning for ongoing and upcoming potential stressors in their lives, including chronic health problems in a close family member and a potential promotion for Diane at work. At the end of treatment, Diane no longer met criteria for major depressive disorder, and both partners’ relationship satisfaction had markedly improved.

Cross-References ▶ Cognitive Behavioral Couple Therapy ▶ Communication Training in Couple and Family Therapy ▶ Expressed Emotion in Families ▶ Problem-Solving Skills Training in Couple and Family Therapy

References Barbato, A., & D’Avanzo, B. (2008). Efficacy of couple therapy as a treatment for depression: A meta-analysis. Psychiatric Quarterly, 79, 121–132. https://doi.org/ 10.1007/s11126-008-9068-0. Beach, S. R. H., & Whisman, M. A. (2012). Affective disorders. Journal of Marital and Family Therapy, 38,

743 201–219. https://doi.org/10.1111/j.1752-0606.2011. 00243.x. Bromet, E., Andrade, L. H., Hwang, I., Sampson, N. A., Alonso, J., de Girolamo, G., . . ., Kessler, R. C. (2011). Cross-national epidemiology of DSM-IV major depressive episode. BMC Medicine, 9, 90. https://doi. org/10.1186/1741-7015-9-90. Diamond, G., Russon, J., & Levy, S. (2016). Attachmentbased family therapy: A review of the empirical support. Family Process, 55, 595–610. https://doi.org/ 10.1111/famp.12241. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSMIV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602. https://doi.org/10.1001/ archpsyc.62.6.593. Lovejoy, M. C., Graczyk, P. A., O'Hare, E., & Neuman, G. (2000). Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review, 20, 561–592. https://doi.org/10.1016/S0272-7358(98) 00100-7. McLeod, B. D., Weisz, J. R., & Wood, J. J. (2007). Examining the association between parenting and childhood depression: A meta-analysis. Clinical Psychology Review, 27, 986–1003. https://doi.org/10.1016/j. cpr.2007.03.001. Rehman, U. S., Gollan, J., & Mortimer, A. R. (2008). The marital context of depression: Research, limitations, and new directions. Clinical Psychology Review, 28, 179–198. https://doi.org/10.1016/j.cpr.2007.04.007. Sheeber, L., Hops, H., & Davis, B. (2001). Family processes in adolescent depression. Clinical Child and Family Psychology Review, 4, 19–35. https://doi.org/ 10.1023/A:1009524626436. Whisman, M. A., & Baucom, D. H. (2012). Intimate relationships and psychopathology. Clinical Child and Family Psychology Review, 15, 4–13. https://doi.org/ 10.1007/s10567-011-0107-2. Whisman, M. A., & Beach, S. R. H. (2015). Couple therapy and depression. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 585–605). New York: Guilford Press. Whisman, M. A., & Robustelli, B. L. (2016). Intimate relationship functioning and psychopathology. In K. T. Sullivan & E. Lawrence (Eds.), The Oxford handbook of relationship science and couple interventions (pp. 69–82). Oxford: Oxford University Press. Whisman, M. A., Johnson, D. P., BE, D., & Li, A. (2012). Couple-based interventions for depression. Couple and Family Psychology: Research and Practice, 1, 185–198. https://doi.org/10.1037/a0029960. Wilson, S., & Durbin, C. E. (2010). Effects of paternal depression on fathers’ parenting behaviors: A meta-analytic review. Clinical Psychology Review, 30, 167–180. https://doi.org/10.1016/j. cpr.2009.10.007.

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Derrida, Jacques

Contributions to Profession

Derrida, Jacques Megan J. Murphy and Kaylyn E. Gyden Purdue University Northwest, Hammond, IN, USA

Introduction Jacques Derrida is associated with poststructuralist, postmodern thought. Derrida was a French philosopher whose ideas shook the philosophical world in the 1970s and 1980s. His influence extended much beyond philosophy into the fields of literature, communication, linguistics, and therapy. He himself was influenced by – and critical of – other philosophers including Michel Foucault, who he studied under early in his career. In the field of family therapy, several contemporary, poststructuralist therapists have cited his work, including Harlene Anderson, Steve de Shazer, and Michael White. Specifically, therapists were drawn to his ideas involving deconstruction, which was intriguing to therapists attracted to postmodern thought. The therapists above drew on Derrida’s ideas and applied them in various ways to the field of family therapy.

Career Jacques Derrida was born in 1930 in French colonial Algeria to a well-to-do Jewish family (Stocker 2006). He attended the highly regarded École Normale Supérieure (ENS), writing his Master’s thesis on Husserl. From 1960 to 1964, he taught at the Sorbonne, after which he was a lecturer at ENS until 1984. In 1983, he became the founding director the Collège International de Philosophie (Stocker 2006). He was a wellknown philosopher in France, whose influence reached into several fields, including literature, cultural studies, and the humanities. He studied under Foucault. Among his most frequently cited works are Of Grammatology (Derrida 1976); Writing and Difference (Derrida 1978); Positions (Derrida 1981); and Margins of Philosophy (Derrida 1982).

Derrida ultimately challenged the idea of rationality and the reliance on reason. “Derrida first views language as a system of differences, a system in which each word is distinct from all others” (Gergen 2015, p. 19). We understand words in terms of binaries – a word is the presence of something, contrasted with the absence of something else. The signifier of a word that is present is necessarily given foreground in relation to the absence inherent in the word. The most frequently cited of Derrida’s writings by family therapists involves the concept of deconstruction. Derrida himself may object to providing a definition of deconstruction; in addition, his work can be difficult to understand. Put simply, deconstruction refers to understanding a word or words in the context that surrounds those words. In so doing, the context is inherently important – in terms of structure of the actual word itself, the evocations that the word brings about in terms of meaning (and anti-meaning), and an awareness of what gives the word meaning. Depending on your position as reader, this “definition” means something different for you than it does for someone else. Moreover, the word deconstruction exists within its own context; it evokes notions of construction, if nothing else. Deconstruction can be viewed as “taking apart,” critically questioning, and drawing forth contrasts and differences between a word and other words. Several authors have cited Derrida’s philosophical work as influential on the development of their ideas (Harlene Anderson, Steve de Shazer, and Michael White). For example, de Shazer heavily cited Derrida in his 1994 text Words Were Originally Magic. He cites Derrida’s critique of the thenprevailing view of structuralism, and the structural view of language. In a sense, de Shazer was citing Derrida’s indeterminacy of language in arguing that there can be no confirmed difference between a signifier and the signified. From this, and informed by Derrida’s idea of deconstruction, de Shazer purported a “text-focused reading” rather than “readerfocused reading.” Text-focused reading involves consideration of the author and reader’s point of

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view, which is a reading of text (or therapeutic conversation) focused from inside the text as opposed to outside the text. Words give meaning to the text that cannot be considered from outside the structure of language. de Shazer’s application of Derrida’s concepts is consistent with solution-focused therapy, in which therapists attend closely to clients’ concerns, and refrain from imposing their own concerns onto the client. de Shazer privileges a close reading of the client’s text. His application of Derrida’s concept of deconstruction differs from Michael White’s, in that White focused on contrasting experiences clients have from other surrounding experiences (White 2007). In narrative therapy, White would intervene in helping clients distinguish one narrative from another, with an eye toward the client’s preferred narrative. White emphasized the larger context in terms of clients’ experiences, whereas de Shazer focused on clients’ textual meanings in a more immediate sense. Harlene Anderson (1997) describes being generally influenced by postmodern thought as developed, in part, by Derrida, and is inspired by postmodern ideas of “uncertainty, unpredictability, and the unknown” (Anderson 1997, p. 36). She cited Derrida when talking about the “not-knowing” position associated with Collaborative Language Systems. Quoting Derrida, she says that “not-knowing” does not mean that one does not know anything, rather the value comes in a collaborative relationship therapists develop with clients, in which therapists do not work to retain their own knowledge; therapists actively work with clients to seek understanding.

▶ Foucault, Michel ▶ Poststructuralism in Couple and Family Therapy ▶ Social Construction and Therapeutic Practices ▶ Social Constructionism in Couple and Family Therapy ▶ Training Narrative Family Therapists ▶ White, Michael

Cross-References

Name of Concept

▶ Anderson, Harlene ▶ de Shazer, Steve ▶ Deconstruction in Narrative Couple and Family Therapy ▶ Dialogical Practice in Couple and Family Therapy ▶ Externalizing in Narrative Therapy with Couples and Families

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References Anderson, A. (1997). Conversation, language, and possibilities: A postmodern approach to therapy. New York: Basic Books. de Shazer, S. (1994). Words were originally magic. New York: Norton. Derrida, J. (1976). Of grammatology. Baltimore: Johns Hopkins University Press. Derrida, J. (1978). Writing and difference. Chicago: The University of Chicago Press. Derrida, J. (1981). Positions. Chicago: The University of Chicago Press. Derrida, J. (1982). Margins of philosophy. Chicago: The University of Chicago Press. Gergen, K. J. (2015). An invitation to social construction (3rd ed.). Los Angeles: Sage. Stocker, B. (2006). Derrida on deconstruction. New York: Routledge. White, M. (2007). Maps of narrative practice. New York: Norton.

Detriangulation in Couple and Family Therapy Kaylyn E. Gyden and Megan J. Murphy Purdue University Northwest, Hammond, IN, USA

Introduction The process of detriangulating is arguably the most important technique in family systems therapy (Kerr and Bowen 1988). However, it is

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important to briefly discuss Murray Bowen’s concept of triangles and triangulating before discussing detriangulation further. Triangle is a term used to describe a three-person system that is formed when an unstable two-person systems begins to experience stress (Landers et al. 2016). The process of triangulating occurs when the two-person system introduces a third party to the system in hopes of stabilizing the relationship and reducing the amount of anxiety being experienced (Kerr and Bowen 1988). Thus, detriangulation is the process in which the third party begins to remove themselves from the unstable two-person system.

Theoretical Context for Concept Detriangulation as a concept was developed by Bowen, the founder of Bowen family systems therapy, an intergenerational approach to family therapy.

Description Developed by Murray Bowen, detriangulation is the clinical technique in which an individual refrains from joining the emotional field of another dysfunctional dyad or system by gradually separating from one or more members in that system. Although detriangulation is viewed as a technique, Kerr and Bowen (1988) argue that detriangulation is “a way of thinking” (p. 150). To expand upon this, it is believed that detriangulation as a way of thinking allows one to be mindful of the emotional process that connects people instead of focusing on the cause of the problem, which in turn makes the act of detriangulating more effective. Keeping this thought, detriangulation then becomes the process in which an individual refrains from joining the emotional field of another system by practicing emotional neutrality. Emotional neutrality is defined as the ability to define self without being emotionally tied to one’s own viewpoint or in changing the viewpoints of others. After one is able to remain emotionally neutral, one must be able to properly communicate this attitude, thus

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completing the process of detriangulation. Kerr and Bowen (1988) suggest that the most effective way to communicate a neutral position in a triangle is to do so by responding to one’s efforts to triangulate by saying and/or doing things that push that person closer to the person they are having a problem with.

Application of Concept in Couple and Family Therapy There are several ways in which detriangulation can take place in therapy. More specifically, there are two concrete ways that emotional neutrality is incredibly relevant to triangles: first, through the ability to see both sides of a relationship process, and second, the ability to refrain from having one’s own thoughts about the process be shaped with opinions of what “should be” (Kerr and Bowen 1988, p. 150). When one is able to meet the aforementioned criteria, the ability to differentiate and detriangulate is increased. Detriangulation can also be applied to therapists working with client systems. When working with couples and families in a therapeutic setting, it is important for the therapist to remain detriangulated from the system under stress. It is equally important for the therapist to address triangulated individuals throughout the system and begin working toward detriangulating them. As mentioned earlier, the most effective way for a therapist to detriangulate triangulated individuals is by continuously pushing the two individuals under stress closer together. Once the level of stress decreases and the two individuals can communicate with one another, the triangulated individual is removed from the triangle and the dyad reappears.

Clinical Example Marcus and Keisha, both in their mid-30s, came to therapy concerned about difficulty communicating with each other. Marcus is a partner at a law firm, and Keisha is studying for her Ph.D. in biology at the local university. They have been

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married for 10 years, and have no children. In their first session, the therapist asks the couple about their communication concerns. Keisha describes being very frustrated that Marcus does not listen to her when she talks, that he does not help out much around the house, and that he spends his weekends out with his colleagues either hunting or golfing. Marcus counters that he works long hours at the law firm and so he deserves time with his friends on the weekend. He seems puzzled by Keisha’s statement that he does not listen to her. He expressed understanding that Keisha was experiencing a great deal of stress from her doctoral work, and that he helps out as much as he can around the house when he is home. Marcus says that Keisha spends a lot of her time with her sister, Tonya. Keisha says that Tonya has been her major support in listening to Keisha’s concerns about her marriage. Keisha says that Tonya agrees with her – that Marcus spends too much time away from the home and should be spending more time with Keisha. A Bowenian therapist would immediately see the triangle that has developed between Marcus, Keisha, and Tonya, in that there is tension or anxiety in Keisha and Marcus’s relationship. In an effort to reduce that tension, Keisha brought Tonya into the relationship (i.e., triangled her in) to help reduce her own anxiety. The therapist would see the need for detriangulation, and would encourage Keisha to talk directly with Marcus about her concerns instead of talking with Tonya. Although initially this may increase anxiety in the couple’s relationship, in the long term, their relationship would be healthier when they develop the ability to talk with each other about their concerns instead of talking with a third person. A Bowenian therapist would also be aware of the possibility of being triangled into the couple’s relationship, and would take steps to detriangulate themselves if needed.

References Kerr, M. E., & Bowen, M. (1988). Family evaluation. New York: Norton. Landers, A. L., Patton, R., & Reynolds, M. (2016). Family therapy glossary. Alexandria: American Association for Marriage and Family Therapy.

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Development in Couples and Families Katharine Ann Buck1 and Marte Ostvik-de Wilde2 1 Department of Human Development and Family Studies, University of Saint Joseph, West Hartford, CT, USA 2 Counseling and Applied Behavioral Studies, University of Saint Joseph, West Hartford, CT, USA

Introduction Theories of human development offer explanations for how couples and families grow, remain stable, and change across time. Growth and change may be gradual, quantitative, and continuous or abrupt, qualitative, and discontinuous. Stage theories such as Piaget’s cognitive developmental theory and Erikson’s psychosocial theory emphasize the discontinuous nature of development. For example, couples in young adulthood who struggle to resolve the developmental crisis of intimacy versus isolation are in a qualitatively different period of development than adolescents who are challenged with resolving the crisis of identity versus identity confusion. Behavioral theories of learning (e.g., Bandura’s social learning theory, Skinner’s operant conditioning theory), on the other hand, characterize development as a gradual, continuous process that is driven by experiences within our social environment. In his social learning theory, for example, Bandura asserts that individuals learn and develop gradually through continual observation of models’ behavior. To understand development in couples and families, it is critical to consider multiple domains of development, including physical, cognitive, emotional, and social. Although specific developmental theories focus primarily on one or two domains (e.g., Piaget’s cognitive developmental theory focuses on cognitive development, Erikson’s psychosocial theory emphasizes social and emotional development), most contemporary theorists recognize the interdependent nature of

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these domains. Moreover, current developmental theorists acknowledge the complex interplay of genes and environment in their influence on human development. Family and couple functioning across these domains is also shaped by broad cultural, historical, and social contexts. Systems theories (e.g., Bronfenbrenner’s ecological systems theory) emphasize these contextual influences on development. Developmentalists consider the impact of early experiences on subsequent development across the life span. Attachment theorists highlight the importance of early experiences within the parent-child relationship. A secure attachment formed in the first few years of life can increase the probability of subsequent adaptive socio-emotional functioning and relationship success during adolescence and adulthood. Relatedly, the timing of life events is a key consideration for the field of human development. Sensitive periods in development reflect times during which couples and families may be particularly susceptible to the effects of certain events. A couple’s divorce, for example, can lead to a range of salient outcomes in children depending on when it occurs. Finally, developmentalists study growth and change in couples and families throughout the life course. Although historically some theories focused primarily on one period of development (e.g., childhood is the focus of Freud’s psychoanalytic theory), essentially all contemporary developmentalists acknowledge that couples and families are not static, but rather evolve in their functioning until death.

Prominent Associated Figures Albert Bandura, John Bowlby, Urie Bronfenbrenner, Erik Erikson, Sigmund Freud, Jean Piaget, B.F. Skinner, Lev Vygotsky, John B. Watson

Description Systems Theories Family Systems Theory. Family systems theorists underscore the interdependence of individuals

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within the family (Broderick 1993). In other words, the family is viewed as one whole unit, which is greater than the sum of the individual parts within the family. The family is comprised of subsystems (e.g., spousal, sibling) that operate with rules, roles, routines, rituals, and interaction patterns, which may evolve across the course of development. Routines around childrearing and rules set for children are adjusted when children reach adolescence, for example. The family system is maintained by boundaries, which are reflected in rules for membership within systems, information transmission, and appropriate conduct. Boundaries range on a continuum from diffuse (i.e., open to outside influence) to rigid (i.e., closed to outside influence). Relatedly, family functioning can be measured by its level of cohesion (i.e., emotional bonding) and flexibility. Enmeshment (i.e., overly involved, little individuation) and disengagement (i.e., underinvolved, distant) represent the extreme poles of cohesion, which are maladaptive for family functioning. Because of the push toward greater autonomy and individuation during adolescence, development may be hindered for teens in families characterized by enmeshment or rigidity. Families manage their separateness and connectedness by balancing centrifugal forces that divide members and centripetal forces that unite members. Flexibility, or the amount of change allowed in leadership roles and relational rules, ranges from chaotic (i.e., excessive change) to rigid (i.e., little change permitted). Feedback loops regulate the family interactional patterns that reflect cohesion, flexibility, and boundaries. Balance in cohesion, flexibility, and boundaries is related to adaptive family functioning across development. Ecological Systems Theory. In his ecological systems theory, Bronfenbrenner proposed that individuals and families can be understood only by examining the nested systems in which they exist. Moving from proximal to distal systems of influence are the microsystem, mesosystem, exosystem, and macrosystem (Bronfenbrenner 1979). The microsystem consists of individuals with whom the individual and family come into direct contact. Spouses, children, siblings, and peers are key figures in the microsystem. The mesosystem

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reflects the interactions that occur between the microsystem elements. A supportive relationship between a child’s school teacher and his or her parents represents a powerful mesosystem influence on the child’s development. The exosystem includes factors that indirectly influence the individual’s and family’s development. A stressintensive workplace environment that induces parental negative reactivity represents an exosystem influence on children’s and couple’s functioning. Finally, the macrosystem consists of cultural beliefs, values, and social norms. Children raised in western parts of the world may be exposed to individualistic ideals, whereas those in eastern areas may be raised to value collectivistic ideals. These values may affect couple and family development as life expectancy increases and families are faced with decisions on how to care for their aging parents. Finally, each of these systems is affected by the chronosystem, which signifies the element of time and related sociohistorical conditions. Family Developmental Theory. Family developmental theorists propose a series of stages that families move through across the family life cycle. Within each stage, family interaction patterns are guided by roles reflecting kinship position and norms regarding cultural expectations for appropriate behavior (Duvall and Miller 1984; Gerson 1995). Common roles within families are caring for children and supporting the family financially. The eight stages guiding family roles and norms are: married without children, childbearing families, families with preschool children, families with school-age children, families with adolescents, families launching children (first child gone, last child still in home), middle years (“empty nest” to retirement), and aging families (retirement to death). These stages can be further condensed into expansion (i.e., family growth due to children) and contraction (i.e., family shrinkage when children leave the home). Developmental tasks accompany each stage of family development. Successful task completion during the family’s current stage bodes well for successful task completion in the following stage. Working with adolescents as they strive for increased autonomy represents a salient

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developmental task for families with adolescents. Key developmental tasks for couples in middle adulthood include a renewed focus on the marriage and maintaining ties with adult children. Failure to complete developmental tasks does not guarantee future maladaptation, but may indicate that families are susceptible to societal disapproval or challenges in subsequent tasks. Social Role Theory. Social role theory stresses the roles that individuals, couples, and families fulfill throughout the life span. Roles refer to a set of behaviors that are carried out through role enactment. Across development, humans are socialized into an increasingly complex and diverse set of roles, and these roles are thought to shape personality (Brim 1966; Parsons and Bales 1955). Each role is associated with culturally driven expectations for appropriate conduct. A large number of roles or an intense level of role involvement can lead to role overload. Parents with four children may experience role overload, for example, from the demands of getting children ready for school, attending the children’s extracurricular activities, and supporting children emotionally. Role conflict also impacts families when the demands or expectations of one role are at odds with another. When a mother is asked to stay late at work and miss her daughter’s birthday, role conflict has occurred. Role spillover threatens families when the demands of one role interfere with the ability to successfully complete tasks required of a separate role. Role spillover may occur when exhaustion from caring for an ill, elderly parent reduces one’s productivity at work. Spousal support for partner’s involvement in work, however, can buffer the negative effects of these role strains and contribute to marital satisfaction (Dreman 1997). Relatedly, couples who share in each other’s personal and economic well-being experience less role overload and higher marital satisfaction (Helms et al. 2010). Family Stress Theory. Family stress theorists emphasize the role that stress plays in family functioning and adaptation. Stress is understood as a source of tension that can deplete family’s resources and result in family crisis. The ABC-X model of family stress and crisis is used to conceptualize the effects of stress on the family (Boss

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2002; Weber 2011). The model’s “A” represents the stressor, which can be a normative, expected life event or nonnormative, unforeseen event. Normative stressors include events such as conflicts over family roles or adjustment to an adolescent’s push for autonomy, whereas nonnormative stressors include the death of a child or a sudden, traumatic disabling accident. Stressors may be internal or external to the family, brief or prolonged, ambiguous or clear. The family’s individual and collective ability to cope with the stressor is represented by the model’s “B.” Coping resources may include economic means, material goods, relational skills, or psychological attributes. The model’s “C” represents the family’s shared understanding or constructed meaning assigned to the stressor. Taken together, the stressor, the family’s perception of the stressful event, and their use of resources to manage the stressor determine the family’s response and level of crisis, which is signified by the model’s X. Stressors are not inherently problematic for family functioning, but can threaten family functioning if accumulation leads to family resource depletion. Psychodynamic Theories Psychoanalytic Theory. Freud’s psychoanalytic or psychosexual theory of development stresses that unconscious processes and innate biological drives are primarily responsible for human behavior and the development of personality (Freud 1920). Personalities are comprised of three major components: the id (i.e., the unconscious, pleasure principle), the ego (i.e., conscious, reality principle), and the superego (i.e., the conscience, perfection principle). Freud proposed that humans derive pleasure or gratification as they progress through a series of four stages across childhood and adolescence: infancy – oral, toddlerhood – anal, childhood – latency, and adolescence – phallic. When these pleasures are not fulfilled, psychological problems may ensue. Threats to one’s personality are dealt with by what Freud termed defense mechanisms. These include repression, displacement, sublimation, denial, regression, projection, reaction formation, and rationalization. Minimal or moderate reliance on defense mechanisms can promote adaptive couple

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and family functioning. Excessive use, however, is thought to promote and reflect pathology. Psychosocial Theory. In his psychosocial theory of development, Erikson argued that development occurs across the life span in a series of eight psychosocial crises (Erikson 1963). Within each developmental period exists a psychosocial crisis, where the, timing is determined by nature and difficulty determined by societal pressures and prior crisis resolution. The crises are the following: infancy – trust vs. mistrust; toddlerhood – autonomy vs. shame and doubt; early childhood – initiative vs. guilt; middle childhood – industry vs. inferiority; adolescence – identity vs. identity confusion; young adulthood – intimacy vs. isolation; middle adulthood – generativity vs. stagnation; and late adulthood – integrity vs. despair. Across childhood, families and teachers are critical for successful crisis resolution. By providing responsive, consistent care, for example, parents support infants in developing a sense of trust. Couples in young adulthood are tasked with achieving commitment and intimacy in order to resolve the crisis of intimacy versus isolation. The resolution of each crisis results in a related virtue (e.g., hope results from resolving trust vs. mistrust) and affects subsequent attempts to resolve future crises across development. Attachment Theory. Attachments represent an enduring emotional tie that persist across time and space and influence subsequent relationships (Bowlby 1969). During the first year of life, infants develop an attachment style, which reflects the pattern of caregiving received. Consistent, responsive, and sensitive parenting promote a secure attachment style (Ainsworth et al. 1978). A secure attachment is reflected in positive affective sharing with the caregiver, using the caregiver as a secure base from which to explore, and drawing on the caregiver as a source of comfort during times of distress. Unresponsive or rejecting caregiving predicts insecure-avoidant attachment styles, which are characterized by little affective sharing and avoidance of the caregiver when distressed. Inconsistent or interfering parenting leads to insecure-resistant or ambivalent attachments, characterized by little exploration of the environment, and both clingy and resistant behavior with

Development in Couples and Families

caregiver when distressed. Dissociative, frightening, or frightened parenting behaviors lead to a disorganized-disoriented attachment style. This attachment is characterized by a breakdown in strategy for seeking support when distressed. The attachment relationship becomes the foundation for the individual’s internal working model or mental representation of the world, others, self, and relationships that guides one’s expectations and behavior during social interactions. Internal working models of securely attached children are characterized by feelings of trust that their needs will be met and that they are worthy of love. Children who are insecurely attached view themselves as unworthy of love and believe that others are unreliable and cannot be trusted (Ainsworth et al. 1978). These internal working models are manifested in adulthood within couples’ attachment representations, which may be secure, dismissing, preoccupied, or unresolved (e.g., Hesse and Main 2006; Jacobvitz et al. 2006). Learning and Cognitive Theories Classical Conditioning. Classical conditioning refers to learning that occurs when associations are formed between a neutral, or unconditioned, stimulus and an conditioned stimulus. Over time, humans react to the neutral, unconditioned stimulus with a conditioned, or learned, response (Watson 1925). This type of learning was first demonstrated in the case of “Little Albert,” a male child who eventually developed a fear of white rats due to repeated, simultaneous presentation of a white rat and a loud noise. Classical conditioning is relevant for couple and family development in a few respects. Such learning is useful in explaining the development of some phobias. Classical conditioning can also be seen through the conditioning of infants that bond with specific caregivers once the caregiver is consistently associated with feelings of positivity. Operant Conditioning. Operant conditioning refers to learning that occurs as a result of reinforcements and punishments. Reinforcements are events or rewards that increase the likelihood of a behavior recurring, whereas punishments are aversive experiences that decrease that likelihood (Skinner 1975). Positive refers to the presentation

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of a stimulus and negative refers to the removal of a stimulus. Negative reinforcement, then, indicates the removal of an aversive stimulus, which then increases the likelihood of a behavior to recur. Daily, children learn from parents through rewards and punishments. Praise and positive attention serve as effective positive reinforcements, while removal of attention and time-out serve as negative punishments. This learning is also evident in couple functioning when bids for attention are met with positive responses, which reinforces contact between partners. Social Cognitive Learning Theory. According to social cognitive learning theorists, development is driven not only by reinforcements and punishments, but also by observational learning (Bandura 1977). For learning to occur, the observer must attend to the model’s behavior, store the behavior in memory, and have the physical or mental capacity to imitate the behavior. Behaviors that are rewarded are particularly likely to be imitated by the observer. Moreover, the probability of imitating behaviors increases when the observer identifies with the model. This type of learning is evident in families as children frequently imitate parents’ words and actions. Exposure to family violence, for example, consistently predicts childhood aggression (e.g., Farver and Frosch 1996). Cognitive Developmental Theory. One of the most influential theories of cognitive development comes from Jean Piaget. Piaget proposed that cognitive development occurs as children move through four stages: sensorimotor, preoperational, concrete operational, and formal operational (Piaget 1952; Piaget and Inhelder 1958). During each stage, individuals make sense of their world by interacting with the environment. In the sensorimotor stage, infants use their developing senses of sight, touch, and hearing in concert with emerging muscular control to interact with objects and learn about their social world. The preoperational period of early childhood can be characterized by the use of symbolic thought or mental representation (e.g., an understanding that words can be used to represent objects and ideas), egocentrism (i.e., failure to recognize other’s thoughts as separate from

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one’s own), and illogical mental processes (e.g., centration or focus on only one aspect of an object or situation). During the concrete operational stage, children ages 7–12 use logical mental operations to solve concrete problems. Finally, in the formal operational stage and beyond, adolescents’ cognitive understanding of their world is reflected in abstract thought and reasoning. In each stage of cognitive development, children’s understanding of the world is organized mentally into schemes. Equilibrium is achieved when children are able to effectively engage their environment with existing mental schemes through the use of assimilation. Accommodation occurs when changes in the environment require modifications to existing schemes. Sociocultural Theory. In his sociocultural theory of development, Vygotsky stressed the critical role of social interaction in learning and development. By interacting with more skilled others (e.g., parents, peers, teachers), elementary mental processes give way to higher mental functioning (Vygotsky 1926). This development occurs when the skilled other works within the child’s zone of proximal development. The zone represents what the child is capable of accomplishing when assisted by the skilled other. The skilled other works within the zone by scaffolding or providing moment-to-moment adjusted support based on the child’s current needs.

Relevance to Couple and Family Therapy As is evident in the previous section, developmental theories offer complex and varied conceptual lenses for understanding and working with couples and families. In order to select a theory to serve as an appropriate framework, therapists must be skilled in recognizing physical, cognitive, and socioemotional developmental patterns in their clients and applying them in conjunction with therapeutic interventions. Life span developmental theories offer therapists an opportunity to gain a rich understanding of clients because they provide important contextual information on each individual, as well as a framework for working with the couple and family at the systemic level. The previously

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mentioned theories in the section above can be used on an individual basis to best serve the needs of each person – child, adolescent, adult, elder – as well as provide context to best conceptualize systemic issues within the family and community. According to Erikson’s psychosocial theory, for example, a couple may be jointly facing a psychosocial crisis of generativity versus stagnation during the middle adulthood stage. While one partner may feel successful balancing productivity at work and giving back to society through raising children, the other partner may struggle and feel stagnant. This conflict between partners who are in the same psychosocial crisis, but tackling it differently, will impact both the relationship and family unit. Furthermore, an early adolescent child in this same family will face a threat of dissociation from the family if he or she is not able to overcome the psychosocial crisis of identity versus identity confusion. Though healthy peer interaction is vital to the adolescent’s developmental process, a stable family life and parents who model connection and personal competence are also critically important. A systems framework, such as Bronfenbrenner’s ecological systems model, can also provide therapists with a more holistic developmental understanding of couples and families. The integrated, multidimensional nested system model can be applied to explain bidirectional interactions between family members, as well as within and among complex systems. While a couple or family operates as its own multifaceted microsystem, it is heavily impacted by the mesosystem and exosystem (e.g., work, neighborhood, mass media, social welfare, and legal systems) as well as the interactions among them. For example, a woman in her late 60s who recently retired from her long-term employment position and moves to a new town faces a multitude of changes. She is navigating a new financial management system, and changes in her work and neighborhood dynamics. Furthermore, the macrosystem gives a therapist an opportunity to examine the attitudes and ideologies of the couple or family’s culture, while also incorporating concepts of systemic power and privilege, and sociopolitical impact. The final system, chronosystem, provides a family with a better sense of generational differences that may exist

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between parents and children. Therapists are uniquely positioned to help couples and families recognize how the complexity of their development over the life span can impact their overall health and well-being.

Clinical Example of Application of Theory in Couples and Families Markus and Jennifer are a late-40s couple who have been married for 18 years. They initially seek therapy for their two children: Nora, a 16-year-old high school student, and Andrew, a 7-year-old elementary school student. Nora presents as a highly anxious, combative adolescent who has recently been suspended from school for assaulting a classmate. Andrew, who was adopted into the family 2 years ago, is exhibiting regressive behavior, including nighttime bed-wetting and frequent temper tantrums. Markus and Jennifer attribute their children’s recent externalizing behaviors to the death of the maternal grandmother who took on a role as an afterschool caregiver while they worked in their respective jobs. Initial assessment with the couple indicates that the parents are struggling to cope with the loss of Jennifer’s mother. Jennifer indicates she is experiencing mild depression and both parents acknowledge distancing in their marriage. Further data is collected from school counselors at Andrew and Nora’s schools, including discipline referrals and behavioral interventions. The therapist determines that whole family therapy is ideal given their immediate concern with their children’s well-being, as well as a belief that recent marital strain is due to acute grief and loss. Therefore, a humanistic person-centered family therapy is most appropriate, coupled with cognitivebehavioral interventions (CBT). Therapy goals include building empathy and family connectedness, treating Nora’s anxiety and Jennifer’s mild depression, processing grief resulting from the loss of the grandmother, and providing CBT strategies and techniques aimed at decreasing disruptive school behaviors. Cognitive, affective, and behavioral coping strategies will give the family the ability to redefine or reappraise situations by positively

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reframing each one, set individual and mutually attainable goals, and build family resilience. Furthermore, social roles within the family will be examined to discover role strain and conflict generated by expectations and competing demands for each family member. For example, Jennifer and Markus face recent additional roles (e.g., additional caregiving requirements), as well as role loss (e.g., loss of previous generation) that may be contributing to the marital disengagement and parenting challenges. Erikson’s psychosocial theory will be used to determine the impact each family member’s developmental stage has on relationships and overall dynamic. Andrew may face the threat of inertia, as evidenced by his externalizing behaviors, due to his sense of inferiority from his adoption transition. Nora’s psychosocial crisis involves a sense of alienation as she struggles to find her identity as an adolescent within a family in flux. Her dissociation from the family is likely resulting in aggressive behaviors toward peers. Jennifer and Markus face a desire to be productive at work, create meaningful change in their community, and contribute to the next generation through parenting. Their role strain is contributing to a sense of stagnation given the multiple challenges and responsibilities they must take on. Though each individual presents with different crises, as a family, they must also confront the consequence of relational interactions stemming from each unique psychosocial stage. Furthermore, the ABC-X model of family stress and crisis can be applied to examine both normative developmental stressors (e.g., adolescent’s search for identity; parents seeking work satisfaction) and nonnormative stressors (e.g., loss of their grandmother and adoption of a child). Though there are many strengths and coping resources within the family, sessions focused on developing healthy perceptions and collaborative working mindsets to the stressors will be necessary. This integrated therapeutic model allows the family to consider developmental factors impacting their individual journeys, as well as the relational impact on the whole family. In conjunction with a supportive, genuine person-centered approach and

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proactive cognitive-behavioral interventions, a developmental framework both supports and strengthens the therapeutic outcomes.

Cross-References ▶ Attachment Theory ▶ Boundary Making in Couple and Family Therapy ▶ Bowlby, John ▶ Bronfenbrenner, Urie ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Exosystem in Family Systems Theory ▶ Family Life Cycle ▶ Family Rules ▶ Feedback in Family Systems Theory ▶ Learning Theory in Couple and Family Therapy ▶ Mesosystems in Family Systems Theory ▶ Modeling in Couple and Family Therapy ▶ Negative Reinforcement in Social Learning Theory ▶ Operant Conditioning in Couple and Family Therapy ▶ Positive Reinforcement in Couples and Families ▶ Psychoanalytic Couple and Family Therapy ▶ Social Learning Theory ▶ System in Family Systems Theory

References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale: Erlbaum. Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice Hall. Boss, P. (2002). Family stress management: A contextual approach (2nd ed.). Thousand Oaks: Sage. Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books. Brim, O. G. (1966). Socialization through the life cycle. In O. G. Brim & S. Wheeler (Eds.), Socialization after childhood: Two essays. New York: Wiley. Broderick, C. B. (1993). Understanding family process: Basics of family systems theory. Newbury Park: Sage. Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press.

Dialogical Practice in Couple and Family Therapy Dreman, S. (1997). The family on the threshold of the 21st century: Trends and implications. Mahwah: Erlbaum. Duvall, E., & Miller, B. (1984). Marriage and family development (6th ed.). New York: Harper Row. Erikson, E. H. (1963). Childhood and society. New York: Norton. Farver, J. M., & Frosch, D. L. (1996). L.A. stories: Aggression is preschoolers’ spontaneous narratives after the riots of 1992. Child Development, 67, 19–32. Freud, S. (1920). A general introduction to psychoanalysis. New York: Horace Liveright. Gerson, R. (1995). The family life cycle: Phases, stages, and crises. In R. H. Mikesell, D. D. Lusterman, & S. H. McDaniel (Eds.), Integrating family therapy: Handbook of family psychology and systems theory. Worcester: American Psychological Association. Helms, H. M., Walls, J. K., Crouter, A. C., & McHale, S. M. (2010). Provider role attitudes, marital satisfaction, role overload, and housework: A dyadic approach. Journal of Family Psychology, 24, 568–577. Hesse, E., & Main, M. (2006). Frightened, threatening, and dissociative parental behavior in low-risk samples: Description, discussion, and interpretations. Development and Psychopathology, 18, 309–343. Jacobvitz, D., Leon, K., & Hazen, N. (2006). Does expectant mothers’ unresolved trauma predict frightened/ frightening maternal behavior? Risk and protective factors. Development and Psychopathology, 18, 363–379. Parsons, T., & Bales, R. F. (Eds.). (1955). Family socialization and interaction process. Glencoe: Free Press. Piaget, J. (1952). The origins of intelligence in children. New York: International Universities Press. Piaget, J., & Inhelder, B. (1958). The growth of logical thinking from childhood to adolescence. In A. Parsons & S. Seagrin (Trans.). New York: Basic Books. Skinner, B. F. (1975). The steep and thorny road to a science of behavior. American Psychologist, 30, 42–49. Vygotsky, L. S. (1926). Educational psychology. Delray Beach: St. Lucie Press. Watson, J. B. (1925). Behaviorism. New York: Norton. Weber, J. B. (2011). Individual and family stress and crisis. Thousand Oaks: Sage.

Dialogical Practice in Couple and Family Therapy Peter Rober KU Leuven, Leuven, Belgium

In recent years interest the concept of dialogue has bloomed in the family therapy field (e.g., Seikkula and Olson 2003; Rober 2005b). Guilfoyle (2003) even identifies a distinct kind of family therapy

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that he calls dialogical therapy. This approach grew out of the collaborative postmodern family therapy (e.g., Anderson 1997) and social constructionist thinking (e.g., Gergen 1999), and came to bloom mostly in Europe where the postmodernist and social constructionist ideas developed further through revolutionary new practices in the mental health field (e.g., Andersen 1987; Seikkula et al. 1995), as well as through Russian/European philosophical inspirations. Especially, the influence of the Russian philosopher Mikhail Bakhtin brought about a new and enriching perspective in the field that especially in Europe became particularly influential.

Dialogue A lot of philosophers have written about dialogue. Maurice Merleau-Ponty’s phenomenological critique of dualism, for instance, positions individuals as body subjects in a dialogical relationship with the surrounding world, with knowledge that is inherent in their actions (Merleau-Ponty 1962). Martin Buber’s philosophy of dialogue (Buber 1923, 1947) is also well known. He distinguished the I–Thou relationship from the more objectifying I–It relationship and described how the growth of a person is not accomplished in relation to oneself, but instead in the dialogical relation between the I and the other. Also other thinkers have devoted part of their work to the theme of dialogue (e.g., Levinas 1969; Gadamer 1988; Derrida 1978; Habermas 1971). The approach of dialogical practice in the field of marital and family therapy leans heavily on the work of the Russian thinkers Bakhtin (1981, 1984, 1986) and Volosinov (1973). Also the work of psychologist John Shotter needs to be mentioned here. He evolved from being one of the originators of social constructionism (e.g., Shotter 1993), through his study of the ideas of Bakhtin and Volosinov to become one of the most influential thinkers in the approach of dialogical practices (e.g., Shotter 2000, 2011, 2015, 2016).

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Bakhtin’s Influence Bakhtin used the concept dialogue in two distinct ways: as a prescriptive concept and as a descriptive concept (Stewart et al. 2004). When dialogue is used as a prescriptive concept the term refers to a particular kind of interaction of a high quality. Dialogue then is the opposite of monologue. As Stewart, Zediker & Black (2004) write, in prescriptive approaches to dialogue ethics is central. In the marital and family therapy (MFT) literature, the concept of dialogue is often used in such a prescriptive way, highlighting the ethical ideal, and defining dialogue as the opposite of monologue. However, Bakhtin did not always describe dialogue as a prescriptive concept. In fact, first and foremost he presented dialogue as a descriptive concept. In that way, the concept focuses on epistemological and existential issues as it highlights the dialogical nature of all human interaction: All language is dialogic. In the context of this descriptive view of dialogue, Stewart et al. (2004) highlight the importance of tensionality in Bakhtin’s work. According to Bakhtin, in an ongoing conversation, there is a continuous dynamic tension between the monological and the dialogical functions, of which Bakhtin scholar Caryl Emerson writes: “Dialogue is by no means a safe or secure relation. Yes, a ‘thou’ is always potentially there, but it is exceptionally fragile; the ‘I’ must create it (and be created by it) in a simultaneously mutual gesture, over and over again, and it comes with no special authority or promise of constancy. . . . Imbalance is the norm” (Emerson 1997, p. 229–230). According to Bakhtin, life is an ongoing, unfinalizable dialogue continually taking place (Morson and Emerson 1990). The word unfinalizable is essential in Bakhtin’s thinking (Bakhtin 1981). He does not characterize dialogue as an endpoint of a process, as something peaceful or at rest. Instead he calls dialogic life “agitated and cacophonous” (Bakhtin 1981, p. 344) and he describes dialogue as a never-ending, tensionfilled process. Besides unfinalizability, also responsivity is an important characteristic of dialogue. Utterances in dialogue are other-oriented (Bakhtin

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1986). Whatever is said is always said in response to what has been said before (Linell 2009). Also, everything that is said is an invitation to the others to respond. In that way, the participants shape the dialogue together. This responsivity is selective (Linell 2009) in the sense that it is impossible to respond to everything, but that there is always a selection in our responses: to some things we respond, while other things we neglect. This responsiveness is also embodied and spontaneous (Shotter 2015): when we are in dialogue we are immersed in an intra-mingling flow of unfolding activities, in which our bodies spontaneously respond to the other, anticipating what will come next, and attuning to the context that we are for each other as we are in dialogue together. In such an attunement, there is no law, no certainty, and no control over what will happen or what will be said or done. In order to characterize what is needed for such an attuned dialogue to unfold, Bakhtin (1993) uses the word “faithfulness,” and he writes that he refers to the word as it is used “in reference to love and marriage” (Bakhtin 1993, p. 38). What he means is that we have to be “in touch with the other” (Shotter 2015), not only in our words but in our being in the moment: we are oriented toward each other, recognizing the other as other and as like-me (“you are unique, but because you are unique you are like me, because I am unique too”). In fact we continually reassure each other that we are not alone, that we will not hurt each other, and that we will take our responsibility (response-ability) in playing our part in the unfolding flow of going on together (Shotter 2011). It is clear that these ethical-philosophical ideas about dialogue inspired by Bakhtin’s thinking come very close to the work of philosophers like Martin Buber, Emmanuel Levinas, and Jacques Derrida. Not surprisingly, these philosophers have had a big impact of the work of dialogical family therapists (e.g., Brown 2015; Larner 2004, 2015; De Haene and Rober 2016; Rober 2017).

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Responsive Understanding According to Shotter (2015), being a dialogical therapist means moving toward a responsive understanding. He refers to Bakhtin (1986), in whose view understanding is essentially an active, responsive process: “. . . all real and integral understanding is actively responsive, and constitutes nothing other that the initial preparatory stage of a response” (Bakhtin 1986, p. 69). In his view, real understanding does not duplicate some knowledge of the speaker in the mind of the listener. Dialogical understanding creates something new. Bakhtin (1986) stresses the importance of outsideness in dialogical understanding. According to him to see the world through the other’s eyes “is a necessary part of the process of understanding,” and then he adds: “but if it were the only aspect of this understanding, it would merely be duplication and would not entail anything new or enriching” (Bakhtin 1986, p. 7). Bakhtin is not satisfied with understanding that is mere duplication, because according to him, the speaker “does not expect passive understanding that, so to speak, only duplicates his own idea in someone else’s mind” (Bakhtin 1986, p. 69). Instead, the speaker is oriented toward a responsive, creative understanding. That is why, “[I]n order to understand, it is immensely important for the person who understands to be located outside the object of his creative understanding” (Bakhtin 1986, p. 7, italics in original). Bakhtin (1986) even calls outsideness “the most powerful factor in understanding” (p. 7), because only outsideness – or a position of difference – creates the possibility for an enriching dialogue.

The Dialogical Self Bakhtin (1984, 1986) has developed a model of selfhood in terms of inner speech. He describes the self as a complex inner dialogue: “often a struggle of discrepant voices with each other, voices (and words) speaking from different

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positions and invested with different degrees and kinds of authority” (Morson and Emerson 1990, p. 218). According to Bakhtin, the self resembles the novel that, like the self, is a complex dialogue of various voices and ways of speaking, each incorporating a special sense of the world (Morson and Emerson 1990). Bakhtin studied novels of Dostoyevski, Tolstoy, Cervantes, and many others. In his book on Dostoyevski (Bakhtin 1984) he, for instance, studied the inner conversation of the student Raskolnikov from Crime and Punishment. Raskolnikov receives a letter from his mother, and he understands that his sister’s marriage is her sacrifice done on his behalf. In his inner speech the voices of his mother, his sister, and other people mentioned in the letter can be heard, as well as the voices of anonymous others. Raskolnikov’s inner speech consists of a polyphonic symphony of replies and reactions to the voices of others that he has recently heard, read, or imagined (Bakhtin 1984). The dialogical self is a concept that refers to the self as a polyphony of discrete inner voices that are positioned in time and space and that are in interaction with each other: one voice evoking a second voice, siding with a third one, and while suppressing a fourth. In the dialogical self, like in a dialogue between persons, besides the multiplicity, the tensionality is a crucial characteristic: without tension, polyphony is impossible, as all meaningful differences would be wiped away and only monologue would remain.

Dialogical Practices in Marital and Family Therapy The ideas of Bakhtin (1981, 1984, 1986) opened new perspectives in the field of family therapy as they have proven to be very useful to catch something of the complexity of multiactor dialogues (Seikkula et al. 2012). Furthermore, his ideas helped to reconceptualize the therapeutic relationship: under the influence of his ideas the emphasis of dialogical therapists moved away from a focus on the client as the expert (Anderson and

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Goolishian 1992), to a focus on the process of embodied attunement of the therapist with the family members (e.g., Seikkula et al., 2015) and on the therapist as an active, responsive partner in that process (e.g., Rober 2005a). While Mikhail Bakhtin is the most important philosophical inspiration for the dialogical approach in family therapy, arguably the Norwegian psychiatrist Tom Andersen is the most important inspiration as practitioner. While he is best known as the pioneer who invented the reflecting team (Andersen 1987), his influence and inspiration is much broader than that (e.g., Andersen 1991, 1992, 1995, 1997). For instance, he stressed the importance of reflecting processes (Andersen, 1991), he was one of the first to talk about inner dialogues (Andersen, 1991), and about the wisdom of feelings, the body and breathing (Andersen, 1995). Open Dialogue Tom Andersen’s ideas about reflective processes are some of the main sources of inspiration for the Open Dialogue approach (Seikkula 2007a, b). The vast influence of Bakhtin on the Open Dialogue approach is evidenced by the Open Dialogue principles: tolerance of uncertainty, dialogism, and polyphony (Seikkula and Olson 2003). Tolerance of uncertainty implies the establishment of a safe and trustworthy therapeutic context, because only in such a context participants to the dialogue can tolerate uncertainty. Dialogism refers to the contribution of the listener: The listener’s active presence is what distinguishes dialogue from monologue (Bakhtin 1986). Polyphony (Bakhtin 1984) means that every conversational participant is invited to enter the dialogue in his/her own way. Listening is encouraged and all voices are given room to exist. The Open Dialogue approach refers to a specific and elaborate way to deal with acute psychotic crises that has been used for years in Kerapudas hospital in Tornio, Western-Lapland. Swift intervention of the team and working with the social network of the patient are central in this

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approach (Seikkula et al. 1995; Seikkula 2002). The Open Dialogue approach is characterized by open meetings with the psychotic patient, the family, the network, and the therapeutic professionals. All present are encouraged to give – in their own language – their perspective on what is happening in the family. These different voices are listened to by the professionals. The questions of the professionals are as open as possible, to give the family maximum opportunity to say what they want to say (Seikkula and Olson 2003). The psychotic patient is involved as much as possible. Psychosis is understood as a language in crisis (Seikkula and Arnkill 2006). A psychotic crisis is an unbearable experience for which one has no words. In dealing with a psychotic crisis, the therapeutic team invites everyone who is involved in the crisis to speak. By listening to everyone, and by exploring the meanings, it is intended to create a common language for the experience embodied otherwise just inside the psychotic voice and in hallucinations. Unlike a traditional medical view that focuses on intervention in order to cure, in an Open Dialogue approach an attempt is made to create a common language that allows to clarify the meanings of one’s suffering in the social network (Seikkula and Olson 2003). The focus in these meetings is not in the first place on assessment or on controlling the symptoms, but rather on strengthening the adult side of the patient, breaking the isolation in the system, and reestablishing network connections (Seikkula and Arnkill 2006). The Therapist’s Inner Dialogue Bakhtin’s ideas about the inner dialogue contribute to a richer understanding of the therapist’s part in the therapeutic dialogue. Already in the 1980s, Anderson and Goolishian (1988) had stated that the therapist maintains a dialogue with him/herself, which is the starting point of his/her questions. Later, this dialogue has been called the therapist’s inner conversation (e.g., Rober 2005a, 2008). The concept of the therapist’s inner conversation refers to Bakhtin’s view of the self as a polyphony of inner voices (Bakhtin 1981, 1984; Voloshinov 1973). This view of the therapist’s self as a polyphony can be seen as an enrichment of

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the concept of not-knowing (Anderson and Goolishian 1992): The therapist takes a notknowing stance in the session, not because of the emptiness of his/her inner conversation, but because of its polyphonic richness. Being notknowing as a therapist, then, means avoiding monological inner conversations and staying in touch with the complexity, the uncertainty, and the unfinalizabilty that is the result of the multiplicity of voices in the therapist’s inner conversations (Rober 2005a). Dialogical Practices in Practice While it is clear that the dialogical approach in family therapy is deeply rooted in philosophical refection (Bakhtin, Buber, etc.); first and foremost it is a practice that has inspired more and more therapists in Europe (e.g., Bertrando 2015; Davolo and Fruggeri 2016), but also in the USA (e.g., Olson 2015), and in Australia (e.g., Hartman and De Courcey 2015; Mikes-Liu 2015). The No Kids in the Middle approach of the Dutch psychologist Justine van Lawick and her team is a good example of the way in which dialogical philosophical ideas can be put to practice. In Holland, like in a lot of Western countries, high-conflict divorces, complicated by endless legal disputes, are very complex challenges for family therapists. The suffering of the children, silenced by the violence between their demonizing parents, is evident for the therapist, while attempts to help the children to deal with their silent suffering often prove to be futile in light of the pervasiveness of the parent’s conflict. This often left the practitioner feeling impotent and exhausted. Inspired by dialogical ideas, as well as by ideas about other family therapy approaches, van Lawick and her team developed a group treatment protocol in which both parents and children are involved (van Lawick and Visser 2015; van Lawick 2016). Keeping the children in mind throughout the whole process, the therapeutic work is done in a group of parents, a group of children and in network meetings, as well as in the dialogues between these groups. While the usual family therapeutic approaches often collide with the distrust, violence, and defensiveness of the parents, seriously complicating the development

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of a safe therapeutic alliance, this approach can sometimes create a context for these families in which the voices of the children are heard and in which the children’s well-being becomes the parents’ first concern again. Dialogical Practices and the Process of Humanization Central to the dialogical orientation in family therapy is the Bakhtin inspired responsiveness to others, and the process of attunement in which therapist and client are immersed. As Wilson (2015) writes “. . .the practitioner is not only curious about another person’s life but openly engages as a human being who is also a professional helper” (p. 7). The practitioner’s focus is on inviting and valuing the contribution of as many voices (inner and outer) as possible in the dialogical flow of the session. In essence, this means that we have to see the others as subjects and try to avoid to see them as objects. This comes close to Buber’s philosophy of the dialogue. According to Buber we are essentially beings-with-others (Buber 1923, 1947). He made a distinction between the I-Thou relationship and the more utilitarian I-It relationship, in which the other is related to as if he/she were an object. Interestingly, for Buber the I is different in the I-Thou relationship than in the I-It relationship: our being depends on the way we relate to others. In recognizing the other as a subject, we become a subject (Buber 1923). If we want to relate with our clients in an I-Thou relationship, this means that we have to meet our clients as suffering persons in search of meaning, compassion, and relief, instead of as malfunctioning machines in need of repair (Frankl 1970). This view, of course, is in tension with the diagnose-and-fix ideology that rules in the mental health field in the USA, as well as in Europe and Australia. For Wilson (2015), inspired by the Brazilian educationalist Paulo Freire, this means that dialogical therapy involves a process of humanization, in which oppressive practices are countered. Furthermore, it means that we as practitioners have the responsibility to question and critique taken for granted practices in our field (e.g.,

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Wilson 2013) and propose alternatives that are more compassionate and humane. It is no surprise that the dialogical approach in family therapy resonates with the Recovery Movement (Mikes-Liu 2015), as well as with voices that are critical toward diagnosis and medication as potentially colonizing and objectifying mental health practices (e.g., Good 2001).

Conclusion The dialogical family therapist can be described as an active, responsive therapist oriented toward the different voices present in the family, as well as toward his/her own inner voices. The therapist – in the midst of complexity and from within the unique never before encountered circumstances (Shotter 2011) – actively explores and tries to develop dialogical contexts in which not only the loud and obvious voices in the family are invited but also the suppressed, the faint, and the brittle voices (e.g., the voices of psychotics, of children, of refugees, of criminals) – often nonverbal or silent – are listened and responded to. Dialogue is not seen as a forum of agreement and serenity, in which kindness and gentleness rule (and suppress other voices). Instead, besides kind and gentle voices, also voices of anger, confusion, fear, doubt and disappointment are invited and welcomed by the therapist. While some of these voices might be challenging or hard to bear, the therapist tries to be open and curious. He/she tolerates his/her confusion (Shotter 2016) and uncertainty (Seikkula and Olson 2003) and dwells in the tension of the session, humanizing each voice through a relationship of being-with or what Shotter calls “withness thinking” (Shotter 2011). In dialogical family therapy, tension between the different voices in the family session is to be expected; rather than avoided. The aim is not to solve the tension between the different voices but rather to find ways in which the family can tolerate their polyphony, their (internal and external) ambivalences and their uncertainty, and in which they can better deal with the tensions and go on together with their lives.

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Cross-References ▶ Andersen, Tom ▶ Anderson, Harlene ▶ Buber, Martin ▶ Open Dialogue Family Therapy ▶ Postmodernism in Couple and Family Therapy ▶ Social Construction and Therapeutic Practices ▶ Social Constructionism in Couple and Family Therapy

References Andersen, T. (1987). The reflecting team. Family Process, 26, 415–428. Andersen, T. (1991). The reflecting team: Dialogues and dialogues about the dialogues. New York: Norton. Andersen, T. (1992). Reflections on reflecting with families. In S. McNamee & K. J. Gergen (Eds.), Therapy as social construction (pp. 54–68). London: Sage. Andersen, T. (1995). Reflecting processes; acts of informing and forming: You can borrow my eyes but you must not take them away from me! In S. Friedman (Ed.), The reflecting team in action: Collaborative practice in family therapy (pp. 11–37). New York: Guilford Press. Andersen, T. (1997). Miserere Nobis: A choir of small and big voices in despair. In C. Smith & D. Nylund (Eds.), Narrative therapies with children and adolescents (pp. 163–173). New York: Guilford Press. Anderson, H. (1997). Conversation, language and possibilities: A postmodern approach to therapy. New York: Basic Books. Anderson, H., & Goolishian, H. (1988). Human systems as linguistic systems. Family Process, 27, 371–393. Anderson, H., & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. Mc Namee & K. J. Gergen (Eds.), Therapy as social construction (pp. 25–39). London: Sage. Bakhtin, M. (1981). The dialogic imagination. Austin: University of Texas Press. Bakhtin, M. (1984). Problems of Dostoevsky’s poetics. Minneapolis: University of Minneapolis Press. Bakhtin, M. (1986). Speech genres and other late essays. Austin: University of Texas Press. Bakhtin, M. (1993). Towards a philosophy of the act. Autstin: Universtiy of Texas Press. Bertrando, P. (2015). Emotions and the therapist: A systemic-dialogical approach. London: Karnac. Brown, J. (2015). Wherefore art ‘thou’ in the dialogical approach: The relevance of Buber’s ideas to family therapy and research. Australian and New Zealand Journal of Family Therapy, 36, 188–203. Buber, M. (1923, 2013). I and thou. London: Bloomsbury. Buber, M. (1947, 2014). Between man and man. Mansfield Center (CT): Martino Publishing.

Dialogical Practice in Couple and Family Therapy Davolo, A., & Fruggeri, L. (2016). A systemic-dialogical perspective for dealing with cultural differences in psychotherapy. In I. McCarthy & G. Simon (Eds.), Systemic therapy as transformative practice (pp. 111–124). Farnhill: Everything is Connected Press. De Haene, L., & Rober, P. (2016). Looking for a home: An exploration of Jacques Derrida’s notion of hospitality in family therapy with refugee families. In I. McCarthy & G. Simon (Eds.), Systemic therapy as transformative practice (pp. 102–118). Farnhill: Everything is Connected Press. Derrida, J. (1978). Writing and difference. Chicago: University of Chicago Press. Emerson, C. (1997). The first hundred years of Mikhail Bakhtin. Princeton: Princeton University Press. Frankl, V. E. (1970). The will to meaning: Foundations and applications of logotherapy. London: Meridian. Gadamer, H. (1988). Truth and method (trans: Weinsheimer, J. & Marshal, D.), 2nd revised edition. New York: Crossroad. Gergen, K. (1999). An invitation to social construction. London: Sage. Good, P. (2001). Language for those who have nothing: Mikhail Bakhtin and the landscape of psychiatry. New York: Kluwer/Plenum. Guilfoyle, M. (2003). Dialogue and power: A critical analysis of power in dialogical therapy. Family Process, 42, 331–343. Hartman, D., & De Courcey, J. (2015). Family therapy in the real world: Dialogical practice in a regional Australian public mental health service. Australian and New Zealand Journal of Family Therapy, 36, 88–102. Larner, G. (2004). Levinas’: Therapy as discourse ethics. In T. Strong & D. Paré (Eds.), Furthering talk: Advances in the discursive therapies (pp. 15–32). New York: Kluwer/Plenum. Larner, G. (2015). Ethical family therapy : Speaking the language of the other. Australian and New Zealand Journal of Family Therapy, 36, 434–449. Levinas, E. (1969). Totality and infinity. Pittsburgh: Duquesne University Press. Linell, P. (2009). Rethinking language, mind, and world dialogically: Interactional and contextual theories of human sense-making. Charlotte: Information Age Publishing. Merleau-Ponty, M. (1962). Phenomenology of perception. New York: The Humanities Press. Mikes-Liu, K. (2015). Is it possible to be a bit dialogical? Exploring how a dialogical perspective might contribute to a psychiatrist’s practices in a child and adolescent mental health setting. Australian and New Zealand Journal of Family Therapy, 36, 122–139. Morson, G. L., & Emerson, C. (1990). Mikhail Bakhtin: Creation of a Prosaics. Stanford: Stanford University Press. Olson, M. (2015). An auto-ethnographic study of “open dialogue”: The illumination of snow. Family Process, 54, 716–729.

Diamond, Guy Rober, P. (1999). The therapist’s inner conversation: Some ideas about the self of the therapist, therapeutic impasse and the process of reflection. Family Process, 38, 209–228. Rober, P. (2002). Constructive hypothesizing, dialogic understanding, and the therapist’s inner conversation: Some ideas about knowing and not knowing in the family therapy session. Journal of Marital and Family Therapy, 28, 467–478. Rober, P. (2005a). The therapist’s self in dialogical family therapy: Some ideas about not knowing and the therapist's inner conversation. Family Process, 44, 477–495. Rober, P. (2005b). Family therapy as a dialogue of living persons. Journal of Marital and Family Therapy, 31, 385–397. Rober, P. (2008). The therapist’s inner conversation in family therapy practice: Struggling with the complexities of therapeutic encounters with families. Person-Centered and Experiential Psychotherapies, 7(4), 245–278. Rober, P. (2017). Together in therapy: Family therapy as a dialogue. London: Palgrave MacMillan. Seikkula, J. (2002). Open dialogues with good and poor outcomes for psychotic crises: Examples from families with violence. Journal of Marital and Family Therapy, 28, 263–274. Seikkula, J. (2007a). Inner and outer voices in the present moment of family and network therapy. Journal of Family Therapy, 30, 478–491. Seikkula, J. (2007b). Networks on networks: Initiating international cooperation for the treatment of psychosis. In H. Anderson & P. Jensen (Eds.), Innovations in the reflecting process (pp. 125–136). London: Karnac. Seikkula, J., & Arnkill, T. (2006). Dialogical meetings in social networks. London: Karnac. Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its micro poetics and politics. Family Process, 42, 403–418. Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keränen, J., & Sutela, M. (1995). Treating psychosis by means of open dialogue. In S. Friedman (Ed.), The reflecting team in action: Collaborative practice in family therapy (pp. 62–80). New York: Guilford Press. Seikkula, J., Laitila, A., & Rober, P. (2012). Making sense of multi-actor dialogues in family therapy and network meetings. Journal of Marital and Family Therapy, 38, 667–687. Seikkula, J., Karvonen, A., Kykyri, V. P., Kaartinen, J., & Penttonen, M. (2015). The embodied attunement of therapists and a couple within dialogical psychotherapy: An introduction to the relational mind research process. Family Process, 54, 703–715. Shotter, J. (1993). Conversational realities. London: Sage. Shotter, J. (2000). From within our lives together: Wittgenstein, Bakhtin, and Voloshinov and the shift to a participatory stance in understanding understanding. In L. Holzman & J. Morss (Eds.), Postmodern psychologies, societal practice and political life (pp. 100–129). London: Routledge.

761 Shotter, J. (2011). Getting it: Withness-thinking and the dialogical . . .in practice. New York: Hampton Press. Shotter, J. (2015). Tom Andersen, fleeting events, the bodily feelings they arouse in us, and the dialogical: Transitory understandings and action guiding anticipations. Australian and New Zealand Journal of Family Therapy, 36, 72–87. Shotter, J. (2016). Speaking, actually: Towards a new ‘fluid’ common-sense understanding of relational becomings. Farnhill: Everything is Connected Press. Stewart, J., Zediker, K. E., & Black, L. (2004). Relationships among philosophies of dialogue. In R. Anderson, L. A. Baxter, & K. N. Cissna (Eds.), Dialogue: Theorizing differences in communication studies (pp. 21–38). Londen: Sage. van Lawick, J. (2016). Restoring communities for children and separated parents caught in demonising fights. In I. McCarthy & G. Simon (Eds.), Systemic therapy as transformative practice (pp. 233–249). Farnhill: Everything is Connected Press. van Lawick, J., & Visser, M. (2015). No kids in the middle: Dialogical and creative work with parents and children in the context of high conflict divorce. Australian and New Zealand Journal of Family Therapy, 36, 33–50. Voloshinov, V. N. (1973). Marxism and the philosophy of language. New York: Seminar Press. Wilson, J. (2013). A social relational critique of the biomedical definition and treatment of ADHD: Ethical, practical and political considerations. Journal of Family Therapy, 35, 198–218. Wilson, J. (2015). Family therapy as a process of humanisation. Australian and New Zealand Journal of Family Therapy, 36, 6–19.

Diamond, Guy Jody Russon and Suzanne Levy Center for Family Intervention Science, Drexel University, Philadelphia, PA, USA

Name Guy Diamond, PhD.

Introduction Dr. Diamond is a Professor Emeritus at the University of Pennsylvania School of Medicine and Associate Professor at Drexel University, with over 75 publications on psychotherapy outcome, process, and dissemination research. He is a

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licensed clinical psychologist in Pennsylvania with a strong, externally funded NIH research track record supporting the family-based treatment of adolescent suicide, depression, and substance abuse with multicultural families.

Career Dr. Diamond received his doctorate in clinical psychology at the California School of Professional Psychology. During graduate school, he laid the foundation of his career in two psychotherapy research programs. First, he worked with Guillermo Bernal on a NIDA-funded study to test the efficacy of Contextual Family Therapy for heroin addicts in a methadone clinic. Then he worked with Howard Liddle for many years, at the UCSF Medical Center. Dr. Diamond was a therapist and researcher on Dr. Liddle’s first NIDA-funded clinical trial to test multidimensional family therapy. He also served as the first editorial assistant, helping to found the Journal of Family Psychology. For his predoctoral internship, Dr. Diamond worked on the inpatient unit, at the Philadelphia Child Guidance Center. He worked under the tutelage of Joe Micucci, Wayne Jones, John Brendler, and Jon Sarget, all second-generation clinicians who had trained with Minuchin, Montalvo, and Haley. Dr. Diamond then procured a two-year postdoctoral position in the Department of Psychiatry at the University of Pennsylvania, one of the great meccas of psychotherapy research. In 1996, he became an assistant professor in psychiatry where he worked for 22 years, and first established the Center for Family Intervention Science (CFIS). The center recently moved to Drexel University.

Contributions CFIS has received funding from the National Institute of Mental Health (NIMH), Substance Abuse and Mental Health Services Administration (SAMSHA), Centers for Disease Control and Prevention (CDC), Center for Substance Abuse

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Treatment (CSAT), and several private foundations. At CFIS, Dr. Diamond has mainly focused on the development, testing, and dissemination of Attachment-Based Family Therapy (ABFT) for depressed and suicidal youth. To assist with recruitment for his psychotherapy research, Dr. Diamond developed the Behavioral health Screen (BHS). The BHS is a web-based screening tool, initially used in primary care settings. Use of this tool has since expanded to emergency rooms, colleges, schools, crisis teams, outpatient mental health programs, and residential treatment facilities. Due to these research efforts, ABFT enjoys the distinction of being an empirically supported treatment on SAMHSA’s NREPP website. In addition, CFIS now hosts the international ABFT Training Program, directed by Dr. Suzanne Levy, PhD. The program has trained over 1000 clinicians in 10 countries and continues to expand and research these dissemination efforts. Based on his life’s professional work, Dr. Diamond recently received the distinguished research career award from the American Foundation for Suicide Prevention. As the director of CFIS, he aims to provide training for the next generation of empirically informed family therapy researchers to bring further support to family therapy practices.

Cross-References ▶ Attachment-Based Family Therapy ▶ Depression in Couple and Family Therapy ▶ Liddle, Howard ▶ Montalvo, Braulio ▶ Multidimensional Family Therapy

References Diamond, G. S., & Josephson, A. (2005). Family-based treatment research: A 10-year update. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9), 872–887. https://doi.org/10.1097/01. chi.0000169010.96783.4e. Diamond, G. S., Levy, S. A., Bevans, K. B., Fein, J. A., Wintersteen, M. B., Tien, A., & Creed, T. A. (2010a). Development, validation, and utility of the web-based behavioral health screen for adolescents in ambulatory care. Pediatrics, 126, 163–170. PMID: 20566613.

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Diamond, G. S., Wintersteen, M. B., Brown, G., Diamond, G. M., Gallop, R., Shelef, K., & Levy, S. (2010b). Attachment-based family therapy for suicidal adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 49(2), 122–131. https://doi.org/10.1097/00004583201002000-00006. Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014). Attachment based family therapy for depressed adolescents. Washington, DC: American Psychological Association. Diamond, G., Russon, J., & Levy, S. (2016). Attachmentbased family therapy: A review of the empirical support. Family Process, 55(3), 595–610. https://doi.org/ 10.1111/famp.12241.

of family therapy. In that brief episode that opened the workshop, clinical and teaching skills came together, drawing workshop participants into significant questions about the relational ethics of our practice. The workshop episode was at a narrative therapy conference, and it is as a narrative therapist, writer, and teacher that Vicki Dickerson has made perhaps her most significant contributions to family therapy. Her teaching encourages therapists to develop fine attunement to the lives and experiences of clients, by demonstrating ways of doing so herself.

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Career

Kathie Crocket Faculty of Education, University of Waikato, Hamilton, Waikato, New Zealand

Vicki Dickerson obtained her master’s degree in counseling psychology from Santa Clara University. She studied family therapy at the Mental Research Institute in Palo Alto and at the University of Calgary, receiving her doctoral degree in clinical psychology from Pacific Graduate School. She has directed two training centers, the Bill Wilson Centre, affiliated with Santa Clara University, and the Bay Area Family Therapy Training Centre, and has held adjunct positions at Santa Clara University, Palo Alto University, University of San Francisco, San Jose State University, Johns Hopkins University, and Mercy College, NY. She teaches professional workshops in the USA and internationally. Growing Narrative Therapy: Shaped by the dominant systems and strategic models of the 1970s–1980s, Vicki Dickerson practiced from a strong interest in relational patterns in couple and family relationships (Zimmerman and Dickerson 1993a, b). She took an early interest in the developments that became known as narrative therapy, learning from the work of antipodeans Michael White and David Epston (1990). In clinical practice, and beyond, Vicki Dickerson drew creatively on narrative therapy developments, for example, in writing a popular book for young women, offering a self-help, deconstructive perspective on the gender stories that shape (young) women’s lives (Dickerson and Fine 2004).

Name Victoria (Vicki) Dickerson, PhD

Introduction A Conference Story: On a very warm summer afternoon in Adelaide, Australia, an audience gathers for a conference workshop. Vicki Dickerson’s co-presenter stands at the lectern and asks, “Has anyone seen Vicki Dickerson?” The audience looks around. Again, he asks, “Has anyone seen . . .?” We look around, a little puzzled. “Who you looking for?” calls a voice – casual, off-hand – from the back of the auditorium. The person comes forward, cap angled down over eyes, hands in pockets, a swaggering slouch – the stance of a young person who knows how to do cool. Catching the audience unawares, the workshop was already under way. Vicki Dickerson, the cool dude with the cap, had indeed showed up, demonstrating – through voice tone, posture, cap, movement, gesture – a refined attunement to the lived experience of a young person, a client

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As narrative therapy evolved in the North American context, Vicki Dickerson shared emerging ideas and practices with others, teaching both new and experienced therapists. She wrote a number of journal articles, along with a co-authored overview book on narrative therapy (Dickerson 2004; Dickerson and Zimmerman 1992, 1996; Zimmerman and Dickerson 1994, 1996a, b). Continuing to engage in and lead professional community, Vicki Dickerson has more recently opened publishing opportunities for other family therapists, for example, in her role as Social Media/Communications Strategist for the Family Process Institute, where she organizes and moderates a Webinar Series with the Ackerman Institute. Through her strong professional networks and committed editorial work, Vicki Dickerson has encouraged other narrative therapists to publish, fostering international connections: for example, in special sections in Family Process (Dickerson 2009; see Lebow 2016) and in an edited Springer Brief (Dickerson 2016). Just as the Adelaide conference workshop episode, re-told above, involved creativity in a demonstration of the clinical skill she was teaching, Vicki Dickerson’s contributions to the professional community live out the ethics and relational emphasis of clinical practice. While she has specialized in narrative practices, Vicki Dickerson has remained multi-lingual, through tracing lines of evolution in the wider context of family therapy (Dickerson 2010, 2014); in leading e-technology developments; and particularly through professional governance. Her many contributions to the American Family Therapy Academy were recognized with the Lifetime Achievement Award in 2012, and she is currently 2017–2019 President. She continues to contribute actively to the Family Process Institute Board. The words Vicki Dickerson chose for the title of a 2007 article – “Remembering the future: Situating oneself in a constantly evolving field” – serve as an apt description of her own contributions to the field of family therapy, over time, through practice, teaching, publication, professional networking, and governance.

Dickerson, Victoria

Cross-References ▶ Absent But Implicit in Narrative Couple and Family Therapy ▶ Combs, Gene ▶ Deconstruction in Narrative Couple and Family Therapy ▶ Deconstructive Listening in Couple and Family Therapy ▶ Epston, David ▶ Externalizing in Narrative Therapy with Couples and Families ▶ Freedman, Jill ▶ Narrative Couple Therapy ▶ Narrative Family Therapy ▶ Poststructuralism in Couple and Family Therapy ▶ Problem-Saturated Stories in Narrative Couple and Family Therapy ▶ Weingarten, Kaethe ▶ White, Michael

References Dickerson, V. (2004). Young women struggling for an identity. Family Process, 43(3), 337–348. Dickerson, V. (2007). Remembering the future: Situating oneself in a constantly evolving field. Journal of Systemic Therapies, 26(1), 23–37. Dickerson, V. (2009). Introduction to the special section. Continuing narrative ideas and practices: Drawing Inspiration from the legacy of Michael White. Family Process, 48(3), 315–318. Dickerson, V. (2010). Positioning oneself within an epistemology: Refining our thinking about integrative approaches. Family Process, 49(3), 349–368. Dickerson, V. (2014). The advance of poststructuralism and its influence on family therapy. Family Process, 53(3), 404–414. Dickerson, V. (Ed.). (2016). Poststructuralism and narrative thinking in family therapy. New York: Springer. Dickerson, V., & Fine, C. (2004). Who cares what you’re supposed to do?: Breaking the rules to get what you want in love, life, and work. New York: Perigee. Dickerson, V., & Zimmerman, J. (1992). Families with adolescents: Escaping problem lifestyles. Family Process, 31(4), 341–353. Dickerson, V., & Zimmerman, J. L. (1996). Myths, misconceptions, and a word or two about politics. Journal of Systemic Therapies, 15(1), 79–88. Lebow, J. (2016). Narrative and poststructural perspectives in couple and family therapy. Family Process, 55(2), 191–194.

Differentiation of Self in Bowen Family Systems Theory White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton. Zimmerman, J., & Dickerson, V. (1993a). Bringing forth the restraining influence of pattern in couples therapy. In S. Gilligan & R. Price (Eds.), Therapeutic conversations (pp. 197–214). New York: Norton. Zimmerman, J., & Dickerson, V. (1993b). Separating couples from restraining patterns and the relationship discourse that supports them. Journal of Marital and Family Therapy, 19(4), 403–413. Zimmerman, J., & Dickerson, V. (1994). Using a narrative metaphor: Implications for theory and clinical practice. Family Process, 33(3), 233–245. Zimmerman, J., & Dickerson, V. (1996a). If problems talked: Narrative therapy in action. New York: Guilford Press. Zimmerman, J., & Dickerson, V. (1996b). Situating this special issue on narrative. Journal of Systemic Therapies, 15(1), 1–4.

Differentiation of Self in Bowen Family Systems Theory Maria Schweer-Collins1, Brianna Mintz2 and Eizabeth A. Skowron3 1 Prevention Science, University of Oregon, Eugene, OR, USA 2 Counseling Psychology, University of Oregon, Eugene, OR, USA 3 Counseling Psychology and Prevention Science, University of Oregon, Prevention Science Institute, Eugene, OR, USA

Introduction Differentiation of self is a fundamental concept in Bowen’s family systems theory. In Bowen theory, families are conceptualized as emotional units and individual functioning is thought to be best understood in the context of relationship processes within nuclear and multigenerational family systems (Bowen 1976, 1978; Titelman 2014). Bowen recognized that human behavior is influenced and shaped by the fundamental need for both autonomy/selfdetermination and connection in relationships, and he conceptualized heterogeneity in the functioning of individuals and systems along a continuum of health in terms of differentiation of self.

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Description Bowen theory is regarded as a comprehensive explanation of psychological health and functioning from a systemic and multigenerational perspective (Titelman 2014). Bowen theory provides a rich foundation for the field of family therapy that renders it distinct from individual theories. Its central construct, differentiation of self, reflects the development of mature and healthy functioning, and is defined as the extent to which one is able to balance (a) intellectual and emotional functioning, and (b) intimacy and autonomy in one’s significant relationships (Bowen 1978). On an intrapsychic level, differentiation refers to the ability to distinguish thoughts from feelings and to choose between being guided by one’s intellect or one’s emotions (Bowen 1976, 1978). Greater differentiation allows one to feel strong affect or engage in logical reasoning when circumstances dictate, and to take “I-Positions” or to maintain a clear sense of self in the midst of turmoil or shifting, uncertain circumstances. Differentiation involves a capacity to manage one’s own anxieties and to resist reacting to anxiety in others. Bowen theorized that more highly differentiated individuals can mindfully engage the thinking and feelings systems that govern behavior. Thus, even under periods of stress or conflict, more differentiated individuals can thoughtfully self-reflect and act in accordance with their own values and convictions while remaining open to the ideas of others. In contrast, less differentiation is characterized by emotional reactivity and the tendency to make snap decisions on the basis of what “feels” right (Bowen 1976, 1978). Less differentiated individuals live in a “feelingdominated world” where autonomic reactivity determines behavior. Thus, undifferentiation is thought to reflect “fusion” of intellect and emotion. On an interpersonal level, Bowen theorized that differentiation reflects a dialectical balance between two fundamental life forces: autonomy/independence and togetherness/connection with others (Bowen 1976, 1978; Titelman 2014). More differentiated persons can be a “self” in their significant relationships without experiencing fears of being

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abandoned or excluded, and can achieve emotional intimacy in relationships without concerns of losing a sense of oneself or of feeling smothered. Thus, greater differentiation permits greater independence while allowing for intimate contact, and enables one to maintain connections with those who disagree or hold different opinions and resist use of emotional distancing to maintain a sense of self (Kerr and Bowen 1988). According to Bowen, as humans evolved to live within larger social groups, we developed increasing sensitivities to social cues such as acceptance, approval, and belonging in order to maintain connection and proximity with the group, and thus survive (Kerr and Bowen 1988; Noone and Papero 2015). However, these evolutionary forces for “togetherness” at times compromise one’s ability to be a self, and lead to fusion or emotional cutoff (Kerr and Bowen 1988). Less differentiated individuals tend to engage in emotional cutoff to calm or stabilize self during periods of high stress or anxiety (Schnarch 1998; Skowron and Friedlander 1998). Individuals who engage in emotional fusion hold few beliefs and convictions, tend to be either dogmatic or compliant, and seek out acceptance, approval, and belonging above all other goals (Bowen 1976, 1978). Energy is spent keeping harmony in relationships or avoiding intimacy altogether, so there is less space to pursue lifedirected goals. In contrast, emotional cutoff is personified by the reactive emotional distancer, who may appear isolated from others and display an exaggerated façade of independence. Note that both the fused person who experiences separation as threatening and the emotionally cutoff person who finds intimacy overwhelming are each poorly differentiated. According to Bowen theory, levels of differentiation are stable across generations and have a number of important health consequences for individual and relationship functioning. Empirical research has found that adults with greater levels of differentiation of self report fewer psychological symptoms and physical health problems (Titelman 2014). Children of more differentiated parents displayed more pro-social behavior, better cognitive functioning, higher self-esteem, and less anxiety and aggression relative to children of less differentiated parents (Titelman 2014).

Further, a growing body of research is supporting the cross-cultural relevance of differentiation of self as a construct that is associated with psychological health and maturity among individuals from diverse ethnic/racial groups in the USA (Titelman 2014). According to Bowen (1976, 1978), individuals are thought to gravitate toward partners functioning at similar levels of differentiation, and enter romantic relationships with differentiation levels that have been laid down in their own families of origin over generations. At the outset of a romantic relationship, each individual typically puts his or her best foot forward, and acts in ways that he or she believes the other would like them to be (Kerr 1988). This type of self-presentation involves what Bowen (1976) termed “pseudoself,” or pretend self, originally developed in the family of origin, and shaped through emotional pressure on individual members to enact roles – as stronger or weaker, boisterous or retiring, more or less capable or attractive – in order to maintain harmony in the family system (Bowen 1978; Kerr and Bowen 1988). Greater prevalence of pseudoself in one’s family of origin, in turn, leads to greater problems in differentiating a self, and more borrowing or trading of “self” in intimate relationships (Bowen 1978). Some borrowing and trading of “self” is typically seen in the early stages of romantic relationships, and it is not necessarily harmful in small doses. In healthy, flexible romantic relationships such exchanges are brief (Kerr 1988). However, when the anxiety in the system exceeds the capacity to bind it, less differentiated couples are thought to rely more heavily on borrowing and trading of self to maintain stability (Kerr and Bowen 1988). Spouses who have experienced greater difficulty differentiating a self in their families of origin tend to pass more “pseudo-self” back and forth between them. This borrowing and trading of self is thought to account for artificial increases and decreases observable in spousal functioning. That is, a more functional-appearing partner may acquire “self” at the expense of the adaptive partner, who gives up “self” (Bowen 1978; Kerr and Bowen 1988).

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assist the client in identifying this predictable change-back response from the system, and to coach the client to utilize strategies to push for growth in spite of homeostatic forces in the system (McGoldrick and Carter 2001). Therapists who elect to work on ‘differentiating a self’ in their own family systems are thought to be more capable of assisting their clients with their differentiation efforts (Kerr and Bowen 1988). More differentiated therapists can maintain emotional objectivity while engaging with a client and their family emotional system. When engaging with members of a couple in conflict, differentiated therapists manage their emotional reactivity in the face of heightened emotional intensity or cutoff in sessions. For a therapist, efforts to raise one’s own level of differentiation are thought to be essential to avoid therapeutic mishaps driven by emotional reactivity to the client system (e.g., seeing villains and victims in the family; jumping in to fix problems or change the topic when anxiety is high; McGoldrick and Carter 2001; Nichols 1987).

According to Bowen family systems theory, differentiation of self is considered fundamental to long-term emotional maturity, and intimacy and mutuality in romantic relationships. Many clients present to therapy with symptoms that they attribute entirely to individual factors (e.g., I am depressed) or environmental factors (e.g., I am unhappy with my job), and Bowen family therapists incorporate information about the client’s level of differentiation and family relational processes to determine how they may contribute to or inadvertently maintain the presenting problem. Couples in committed relationships tend to express differentiation problems in one of four ways: through marital conflict, emotional distancing or cutoff, dysfunction in a spouse, or dysfunction in a child (Bowen 1978; Kerr and Bowen 1988). Each of these mechanisms is thought to bind or manage anxiety in the system. A client might exhibit lower differentiation in subtler ways. Instead of completely cutting off from family members, the client might actively avoid connecting in relationships by engaging in avoidance behaviors. Alternatively, the client might become emotionally overinvolved in the lives of their loved ones. Family therapists informed by Bowen theory will focus on strengthening client differentiation of self by coaching individuals to develop solid self in the context of their nuclear and extended families (McGoldrick and Carter 2001). The first step involves coaching clients to become curious and engaged in understanding the emotional processes within their family system (McGoldrick and Carter 2001). In Bowen therapy, the majority of therapeutic change takes place outside of the therapy room while clients engage with their partner, parents and extended family members, and their children (Kerr 1988; Nichols 1987). Therapists assist their clients in planning authentic, person-to-person contact with family members. Individuals undertaking concerted efforts to change will very often face resistance and a “change-back” response from others to remain in old, predictable role(s) and continue old automatic behaviors (Kerr 1988). It is the therapist’s task to

Clinical Case Example Louisa, a middle-class 34-year-old married woman, presented in therapy with symptoms of depression and stress. She reported that she had recently returned to the workplace full-time after spending the past 3 years at home following the birth of her first child. She expressed feeling easily overwhelmed, and experiencing sadness, tearfulness, and difficulty sleeping. She also felt confused and angry that her partner had not taken on more responsibility in the home during this transition. During the first 3 years of their son’s life, Louisa had assumed a role as the primary caregiver and household manager. Louisa stated that she had taken those roles by choice, and that even when her husband offered to share responsibility, she felt that he was often too tired or too stressed to be both attentive at home with her and their son, and productive at work. She noted feeling ashamed of her struggles in handling the transition from staying home to her new role as a working mother. When the therapist probed, Louisa reported she had not

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shared her struggles with anyone, including her husband, whom she felt was too stressed by a recent increase in his job responsibilities to burden. Initial sessions focused on gathering relevant information about the presenting concerns. The client and therapist discussed other stressful times in Louisa’s marriage, how family responsibilities are shared in the relationship, and their communication patterns. As information was gathered around the couple’s timeline of major life events (births, deaths, illnesses, job transitions, and moves), it became apparent that as Louisa’s husband experienced work-related stressors, Louisa also felt more anxious about her responsibilities and therefore automatically responded to her husband’s stress by feeling a need to protect her husband and over-manage at home. This pattern of emotional reactivity is characteristic of partners with lower levels of differentiation where there is less emotional maturity, and less ability to thoughtfully choose their actions. Information gathered in a family diagram revealed that Louisa’s parents engaged in significant marital conflict marked by volatile verbal fights, sometimes ending with Louisa’s mother leaving the home for a few days. During those times Louisa took care of household responsibilities and “held things together.” As therapy progressed, Louisa developed an awareness of her hesitancy to express herself in her marriage and her fear of conflict. She explored her beliefs about being abandoned as a potential consequence of conflict, which stemmed from family-of-origin patterns of emotional cutoff. The first focus of coaching was to assist Louisa in becoming aware of her automatic tendency to avoid any hint of conflict, and to coach her to take an “I- Position” in her relationship by managing her anxiety, and thoughtfully and calmly sharing her needs and experience with her partner. As Louisa became less emotionally reactive and communicated her needs more directly, she found herself more able to consider her husband’s experience as well, and gained greater understanding of his tendency to withdraw. Louisa noticed, for example, that he often seemed to feel left out of nighttime rituals with their son. Unknowingly, Louisa and her husband had been engaging in the borrowing and trading of self-in-relation. In the early years of

their son’s life, Louisa, an over-functioner, had taken on more responsibility in the home as her husband experienced heightened stress at work. As anxiety in the system heighted, Louisa fell into a pattern of being both primary house manager and parent. Now that Louisa was back at work full-time, the couple was unable to manage in this state of over- and under-functioning. Family therapy that focuses on strengthening differentiation of self levels involves mobilizing clients to accept personal responsibility and make the changes in self that are necessary to bring one’s actions in line with one’s values. Louisa was coached to thoughtfully plan ways to step back from over-functioning in the relationship, and to take more of an “I-position” in sharing her needs and desires in her marriage. These sessions included strategizing new ways for Louisa to make small steps toward becoming more autonomous from and more connected with her husband through open communication and expression of vulnerability. Louisa was able to share her needs with her husband and was clearer in defining what were and were not her responsibilities. She was coached to plan for her own emotional reactions to relinquishing control over household tasks and to the possibility that her husband may also have resistance to new roles and responsibilities. Together, she and her husband created a more equitable division of housework and parenting responsibilities. These changes opened up room for Louisa’s husband to enter the relationship and contribute to both the household and co-parenting. She reported that her husband felt more included and no longer seemed to be pulling away. Louisa felt less overburdened and less anxious as a result.

Cross-References ▶ Bowen Family Systems Therapy with Couples ▶ Bowen Family Systems Therapy with Families ▶ Emotional Cutoff in Bowen Family Systems Theory ▶ Family of Origin ▶ Marital Fusion in Couples ▶ Triangles in Bowen Family Therapy

Directives in Couple and Family Therapy

References Bowen, M. (1976). Theory in the practice of psychotherapy. In P. J. Guerin Jr. (Ed.), Family therapy: Theory and practice (pp. 42–90). New York: Gardner Press. Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Kerr, M. W. (1988, September). Chronic anxiety and defining a self. The Atlantic Monthly, 9, 35–58. Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen Theory. New York: W. W. Norton. McGoldrick, M., & Carter, B. (2001). Advances in coaching: Family therapy with one person. Journal of Marital and Family Therapy, 27, 281–300. Nichols, M. P. (1987). The self in the system: Expanding the limits of family therapy. New York: Brunner/Mazel. Noone, R. J., & Papero, D. V. (Eds.). (2015). The family emotional system: An integrative concept for theory, science, and practice. Lanham: Lexington Books. Schnarch, D. (1998). Passionate Marriage. New York: W. W. Norton. Skowron, E. A., & Friedlander, M. L. (1998). The differentiation of self inventory: Development and initial validation. Journal of Counseling Psychology, 45, 235–256. Titelman, P. (Ed.). (2014). Differentiation of self: Bowen family systems theory perspectives. New York: Routledge.

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natural for a parent to direct a child or a friend to make a suggestion to a friend who is experiencing a problem or concern. It is natural for therapists, at least at times, to do the same – to give a directive. Directives in therapy range from mundane things, like “Why don’t you sit by the table, so you will have a place to put your coffee,” to the structuring of an enactment, such as “Talk with your partner about how you see this,” to the suggestion of what clients do between sessions, for example, “Each time you begin to escalate to raised voices, I would like you to take what we call a time out.” A directive is one of three basic speech acts in therapy. A therapist can ask a question, make a statement, or give a directive (Breunlin et al. 1992). As a class of speech in therapy, a directive is very broadly defined and includes all of the examples provided above. This entry, however, will discuss a more circumscribed definition of directive, excluding in-session directives such as enactments and focusing specifically on directives as suggestions given by therapists for clients to do something between sessions. Directives include both specific things that therapists ask clients to do and plans that are developed more collaboratively within the therapeutic conversation.

Directives in Couple and Family Therapy Theoretical Framework William P. Russell The Family Institute at Northwestern University, Evanston, IL, USA

Name of the Strategy or Intervention Directive

Synonyms Experiment; Homework; Task

Introduction The act of suggesting what someone should do would seem to be as old as the human species. It is

Although asking clients to do something between sessions is currently a common practice in the fields of psychotherapy and couple and family therapy, early psychoanalytic and psychodynamic models were organized primarily around the process of developing insight and not typically focused on prescribing particular changes in behavior. Similarly, nondirective models such as the client-centered approach (Rogers 1951) did not feature directives as a significant part of practice. Behavior therapy (Wolpe 1969), behavioral couples therapy (Jacobson and Margolin 1979), strategic family therapy (Haley 1976), structural family therapy (Minuchin 1974), and taskcentered casework (Reid and Epstein 1972) were largely responsible for the introduction and proliferation of a more directive therapy that includes specific plans that clients implement between

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sessions. Over the years, the practice of directing a client to execute a plan, do “homework,” or try an “experiment” has made its way into eclectic, integrative, and model-specific practice. Thus, no particular theoretical frameworks own the practice of giving directives, though such frameworks may influence both the role of directives in therapy and the form those directives take. Within the field of couple and family therapy, Haley’s (1976) problem-solving approach provided an early articulation of how to formulate and provide directives. Haley distinguished straightforward directives which represented what the therapist wanted the family to do, as well as indirect (paradoxical) directives which prescribed that the family continue the problem in some way, an outcome the therapist did not actually want. The latter approach depends on the family resisting the directive and thus improving or solving the problem. The ultimate goal of both types of interventions was to modify the sequences of behavior and interaction that comprise or maintain the problem. Although influential in its emphasis on changing sequences of interaction to solve problems, Haley’s approach to directives is out of step with current, more collaborative patterns of practice in that it put the therapist in charge of changing families and often fostered a secret therapeutic agenda. Some approaches to couple and family therapy, such as integrative systemic therapy (Pinsof et al. in press), explicitly maintain Haley’s systemic goal of modifying problem sequences but design tasks in a collaborative manner that is sensitive to client feedback and carefully considers the role of cognition and emotion in the targeted sequences. Encouraging behavior change by means of enactment and directive is considered a common factor in couple and family therapy (Sprenkle et al. 2009). Sprenkle (2002) found that empirically validated relational therapies typically intervene to disrupt patterns of interaction. Cognitivebehavioral couple therapy, emotionally focused therapy, and internal family systems therapy all utilize cognitive, affective, and behavioral interventions – including directives – to disrupt relational patterns or cycles. More than half of couple and family therapists have reported using

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directives (homework), and their theoretical orientation (cognitive behavioral, experiential, postmodern, psychodynamic, systemic) has not been found to distinguish the frequency of usage (Datilio et al. 2011). The transtheoretical model and alliance theory inform the current-day approach to using directives. The transtheoretical model specifies stages of change and suggests that clients will not do things that they are not ready to do. Thus, therapists are encouraged to assess readiness to change and intervene to help clients develop motivations for change before expecting clients to take direct action (Prochaska et al. 1992). Alliance theory suggests that the therapeutic alliance is built by aligning tasks (including directives) to fit the goals established by the client (Pinsof 1994). Attempts to get clients to do things they do not want to do will challenge or damage the alliance which, in turn, will limit therapeutic progress and possibly lead clients to drop out of therapy.

Rationale for the Strategy or Intervention Kazantzis and Lampropoulos (2002) in a review and synthesis of the research on homework in individual psychotherapy concluded that there is sufficient evidence that homework assignments improve therapy outcomes and that compliance with homework predicts outcome in therapy. There is limited research on homework (directives) in couple and family therapy, and its effectiveness has not been systematically investigated. Although the use of directives has yet to be shown to improve therapy outcomes, clinical logic provides a compelling rationale for their use. Since relational therapy seeks to understand and modify the patterns of interaction in client’s lives, why not ask clients to observe those patterns and make changes in them? Asking clients to do so extends the influence of therapy to the very realm it purports to influence. Clients do not attend therapy to make changes in the therapy office, they want things to change in their lives. Giving directives links the in-session work with

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the out-of-session work and keeps the therapy alive between sessions, giving the message that clients are expected to actively engage in therapy and assume responsibility for making the changes they seek. Clients’ feedback on their experience with a directive provides important information about their system. For example, clients may report that they did not do the task because it did not feel natural or authentic to them. This helpful feedback invites the therapist to pay more attention to how these clients feel about tasks and to make a greater effort to ensure that the process of developing a directive is sufficiently collaborative. Additionally, clients’ feedback on out-ofsession tasks can provide data that helps the therapist monitor progress toward the goals of therapy. This is illustrated by a therapist who encouraged a divorced father of two adult sons to take more responsibility for initiating time with them. The father agreed, and an action plan was made and then monitored in subsequent sessions. Over the next few months, as the father and sons reported increased time together and increased comfort with that time, the therapist interpreted this as progress toward one of the goals of therapy (improved relationship between father and sons). Given the clinical logic supporting the use of directives and the widespread utilization of them by couple and family therapists (Datilio et al. 2011), it is reasonable to think that wellformulated directives enhance the effectiveness of therapy and it is appropriate to encourage the scientific investigation of this hypothesis.

Description of the Strategy or Intervention Directives may involve an established procedure or be specifically designed to address the particulars of a client situation. As assessment tools, they are used to learn more about clients’ presenting concerns and how these concerns are embedded in the sequences of interactions that occur within the system. As interventions, directives are used to modify the sequences of interaction. These interventions result from therapeutic conversation in

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which the therapist and clients discuss courses of action that may lead to a solution or improvement in the clients’ presenting concerns. Framing a directive as an experiment can reduce the top-down associations with the word “homework” and produce a win-win mindset that sees performance of the task as success and nonperformance as an opportunity to learn more about factors constraining the client system and make decisions about how therapy will proceed. Perhaps the most important preconditions for a directive are that it be clearly related to what clients want to accomplish in therapy and that it be supported by a rationale that indicates the possible gain from its implementation. Why else would clients want to take it on? It should be offered to the clients or co-constructed with them, paying careful attention to the therapeutic alliance and giving due consideration to whether the clients are on board with the task. This includes attention to their cultural context, values and beliefs, financial limits, and fears or concerns they might have about the task. Thus, the therapist collaborates with clients to ascertain that the task is reasonably within their capacity and disposition. As a directive is being designed or offered, particular attention should be paid to establishing clients’ commitment to it. Formulating a clear, specific description of the task gives clients the opportunity to understand what is involved with it. Then the therapist can ask the clients to think ahead about the task. Do they think they can do it? Do they imagine any obstacles to its performance? Do they have ideas about how they deal with the obstacles? Do they anticipate any negative consequences from following the directive? Some directives can be rehearsed during the session. For others a careful description is sufficient. Written instructions can add clarity in some situations. The therapist can ask clients how on board they are with a directive and may ask them to rate how sure they are that they can and will do the task. Formulating a directive, particularly one aimed at producing change, requires careful attention and discussion. Thus, it is important to allow sufficient time in session for design, review, and commitment.

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An essential requirement for the use of directives is the therapist’s follow-up in the next session. Follow-up is associated with compliance in that the clients see that the therapist takes the tasks seriously. In asking about the task, the therapist seeks to build the alliance and learn more about the system. If clients executed the task, the therapist can emphasize their success and look for ways to build on it. If clients partially did the task, the therapist can highlight their good work, identify constraints they encountered, and ask if they would like to go further with it. If clients did not do the task, the therapist maintains a curious, respectful position and asks them what kept them from doing it. It is reasonable for the therapist to ask if they had second thoughts about whether the task was right for them and to emphasize that it is important that the therapy find tasks that fit well for them. Therapist and clients collaborate to decide whether to repeat, refine, or drop the task.

Case Example Kimberly (age 39) and Jason (age 41), a European American, heterosexual, cisgender married couple, initiated therapy with concerns about their escalating conflicts. In the first session, the therapist gathered information about the couple, inquired about the problem and related interactional sequences, determined that there was no history or perceived risk of violence, and communicated concern for their pain and struggle. In the second session the couple fell into a conflictual interaction that escalated. The therapist let it continue briefly in order to observe its pattern and then intervened to stop it, encouraging each party to take a deep breath and calm themselves. Then the therapist asked a series of questions, the answers to which indicated that the conflicts rarely ever led to a resolution and typically left them feeling distant and angry. The therapist stated that conflict can feel irresistible and that it was impressive that they were able to stop it when asked to do so. The therapist then asked if they thought it would be helpful, if they could stop conflicts at home. They agreed that it would be

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helpful, though Kim wondered if stopping the conflict would stop her from having her say. The therapist suggested that there was a procedure that could help them protect their relationship from high conflict and allow them to address their issues and each have their say. Additionally, the therapist committed to make sure their issues were addressed in session, as well. The therapist provided some psychoeducation on the effects of heightened conflict on communication and the need to be calm enough for effective communication to occur. Then the therapist introduced a “time-out” procedure. The procedure was carefully described and discussed, including stages of recognizing when to take a time-out (raised voices, physiological cues), how to request it (acknowledgment that the other has important things to say and respectful expression of own need to calm down), how to calm and self-assess during the time-out, when to return to conversation (agreed on one hour, unless not practical), who initiates the return (the one who requested it), and how to repair and resume the discussion (each owning responsibility for their part in escalating). At the therapist’s request, the couple practiced the procedure in session. The therapist asked whether they anticipated any obstacles to the procedure. None were noted so the therapist asked if they were ready to experiment with it at home. Jason and Kim agreed to do so. In the third session the therapist asked the couple to report on what they learned from the experiment. Kim reported that during an argument Jason stormed out of the room, stating that he was taking a time-out. The therapist acknowledged Kim’s frustration and Jason’s need for the time-out and then respectfully explored what kept Jason from following the procedure. He stated that he waited too long to ask for the time-out. The rest of the session focused on helping them each identify the physiological signs of escalation in order to recognize better when to take a time-out. The whole procedure was reviewed and practiced. Then the therapist reemphasized the benefits of time-out and asked if they would commit to try it again. Kim and Jason agreed to do so.

Discernment Counseling in Couple and Family Therapy

Cross-References ▶ Behavioral Couple Therapy ▶ Cognitive Behavioral Couple Therapy ▶ Cognitive-Behavioral Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Enactment in Couple and Family Therapy ▶ Homework in Couple and Family Therapy ▶ Integrative Problem-Centered Metaframeworks ▶ Integrative Systemic Therapy ▶ Internal Family Systems in Family Therapy ▶ Stages of Change in Couple and Family Therapy ▶ Strategic Family Therapy ▶ Structural Family Therapy ▶ Tasks in Couple and Family Therapy ▶ Therapeutic Alliance in Couple and Family Therapy

References Breunlin, D. C., Schwartz, R., & Mac Kune-Karrer, B. (1992). Metaframeworks: Transcending the models of family therapy. San Francisco: JosseyBass. Datilio, F. M., Kazantzis, N., Shinkfield, G., & Carr, A. G. (2011). A survey of homework use, experience of barriers to homework, and attitudes about homework among couples and family therapists. Journal of Marital and Family Therapy, 37(2), 121–136. Haley, J. (1976). Problem-solving therapy. San Francisco: Jossey-Bass. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles (Wiley series on personality processes). New York: Brunner/Mazel. Kazantzis, N., & Lampropoulus, G. K. (2002). Reflecting on homework in psychotherapy: What can we conclude from research and experience? Journal of Clinical Psychology/In Session: Psychotherapy in Practice, 58(5), 577–585. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Pinsof, W. M. (1994). An integrative systems perspective on the therapeutic alliance: Theoretical, clinical, and research implications. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 173–195). Oxford, UK: Wiley. Pinsof, W., Breunlin, D. C., Russell, W. P., Lebow, J., Rampage, C., & Chambers, A. (in press). Integrative systemic therapy. Washington, DC: American Psychological Association (APA) Books.

773 Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102–1114. Reid, W., & Epstein, L. (1972). Task-centered casework. New York: Columbia University Press. Rogers, C. (1951). Client-centered therapy: Its current practice, implications and theory. Boston: Houghton Mifflin. Sprenkle, D. H. (Ed.). (2002). Effectiveness research in marriage and family therapy. Alexandria: The American Association for Marriage and Family Therapy. Sprenkle, D., Davis, S., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford. Wolpe, J. (1969). The practice of behavioral therapy. New York: Pergamon Press.

Discernment Counseling in Couple and Family Therapy William J. Doherty University of Minnesota, St. Paul, MN, USA

Introduction Discernment counseling is a short-term intervention for “mixed-agenda” couples where one partner is leaning out of the relationship and is ambivalent about doing couples therapy, and the other partner wants to preserve the relationship and start couples therapy. Therapists often struggle with these couples because there is no common commitment to therapy (Crosby 1989). Discernment counseling is a “pre-therapy” protocol in which the goal is to help the spouses develop greater clarity and confidence about a direction for the marriage, based on a deeper understanding of what’s happened to the marriage and each partner’s contributions to the problems. It is intended for couples who are married or have otherwise made a permanent commitment. The focus is not whether to divorce or stay married for life, but whether to divorce or carve out a 6-month period of all-out effort in couples therapy to restore the marriage to health, with divorce off the table during that time.

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Prominent Associated Figures

threat of divorce makes it difficult to hold onto a differentiated self, thereby leading to responses like emotional reactivity, blaming the spouse, and triangulating with third parties. Because in these situations it is quite difficult to take responsibility for one’s own feelings and actions, discernment counseling focuses on selfdifferentiation during an attachment crisis. Discernment counseling challenges each person to accept responsibility for his/her contributions to problems in the relationship and to take responsibility for deciding where to take the relationship.

William Doherty and Steven Harris

Theoretical Framework The rationale for discernment counseling comes out of the clinical observation, backed by research, that in divorce decision-making, couples are generally not in the same place. There is usually an initiator of the divorce idea and a responder who is reluctant to end the marriage (Vaughn 1986). When these mixed-agenda couples present for couples therapy, they create a challenge that current models of couples therapy do not offer a systematic way of addressing. Because each partner is in a different emotional and motivational stance, the major adaptation of discernment counseling is to work with each spouse separately, with orchestrated sharing with their partner, toward a resolution of the impasse. Although discernment counseling developed as a pragmatic strategy to help couples who present a difficult clinical challenge, the approach is informed by adult attachment theory and differentiation theory. Adult attachment theory (Miculincer and Shaver 2012; Rholes and Simpson 2006) offers a framework for understanding human pair-bonding based on infant/ caregiver attachment. The theory helps explain the intense attachment and ambivalence among people approaching divorce, reactions that may be heightened in people with anxious attachment. Although the person not wanting the divorce would presumably have greater attachment loss fears than the initiator of the divorce, adult attachment theory helps explain why it is common for even the initiator to have intense positive and negative feelings about the idea of getting divorced (Weiss 1975). Discernment counseling is a specialized way to work with attachment ambivalence in marriages on the brink of divorce. According to Bowen’s Family Systems theory (Bowen and Kerr 2009), lack of differentiation of self (knowing and being able to asserts one’s thoughts and feelings) leads to emotional reactivity during crises. The anxiety connected to the

Populations in Focus Discernment counseling is for couples where there has been a permanent commitment (married or otherwise) where one spouse is seriously considering divorce and is ambivalent about working on the relationship in couples therapy, and the other spouse does not want to be divorced and is open (or eager) to begin couples therapy. Rule outs for discernment counseling are (a) when the leaning-out spouse has made an irrevocable decision to divorce and just wants a venue to help the other spouse accept that decision or (b) when there is coercion to participate in discernment counseling (such as legal threats) or risk of harm from violence.

Strategies and Techniques The immediate decision to be “discerned” is framed as three alternative paths rather than as a dichotomous decision between staying together or divorcing. Path one is to stay the course – remain married as things have been and not do couples therapy. Path two is separation or divorce. Path three is an all-out commitment to 6 months of couples therapy (and sometimes other services) with divorce off the table, in order to see if the couple can make their relationship work in a healthy way for both of them. (It is important to help clients understand that discernment counseling is not marital treatment; it is designed to help them decide whether to try the treatment. A medical analogy often helps here:

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couples therapy is like an antibiotic to see if an infection can be cured, but the couple have not yet started it in discernment counseling and thus cannot expect to have seen improvement in their problems.) After 6 months, both partners can evaluate whether to make a permanent commitment to the relationship or move toward divorce. If the couple chooses path three, discernment counseling transitions to couples therapy, usually with the same therapist who did the discernment counseling but possibly a referral therapist. Discernment counseling involves one to five sessions with a structure that differs from conjoint couples therapy. As stated, although both partners come together for all sessions, the intensive work occurs in separate individual conversations (with the other spouse out of the room), plus brief, carefully orchestrated sharing of individual learnings when both people are together in the room. There are no couple interventions (e.g., attempts to facilitate connection and intimacy), and couples are encouraged not to expect improvements in their relationship problems during discernment counseling. The reasons for not doing couple therapy interventions are that there is no contract for relationship improvement interventions and that the therapy-ambivalent spouse may declare change attempts a failure if nothing is improving at home. Couples are continually reminded that discernment counseling is not couples therapy. In addition to the three paths, the individual conversations emphasize self-differentiation and self-responsibility as means toward determining the future of the relationship. This focus encourages both partners to take responsibility for their part in the decline of the health of the relationship instead of focusing on the spouse’s failures. This self-focus benefits them whether they decide to do therapy or end the relationship. (One of the sayings in discernment counseling is “You can’t divorce yourself.”) The other emphasis during individual conversations is on helping clients see their joint interactional patterns or “dances.” Understanding how they have co-created their relationship problems helps both partners become more open to seeing their own role and then sometimes become inclined to try path three couples therapy.

The discernment counselor works with each spouse differently. With the leaning-out spouse, the focus is on the decision-making process about the three paths, on personal contributions to the problems, and on the potential benefits of couples therapy. With the leaning-in spouse (who usually comes in wanting path three therapy), the focus is on “getting” the partner’s pain and complaints about the relationship, on eliminating counterproductive behavior such as pursuing or scolding the partner for considering a divorce, and on using this crisis as a wake-up call to learn about self and develop goals for personal change whether or not the marriage survives. If the ultimate decision is to try to reconcile (path three), discernment counseling transitions to couples therapy. If the decision is to divorce (path 2), the discernment counselor offers assistance and referrals for the transition to divorce. If the decision is to stay together without therapy (path one), the discernment counselor offers to be a resource in the future. In the discernment counseling protocol, the first session is 2 h, and the subsequent sessions are an hour and a half each. (The first session is longer because of time needed to get background information.) Both parties decide each time whether to have a subsequent discernment counseling session, up to a limit of five. This approach is designed to invite buy-in from the leaning-out spouse who has to explicitly agree to continue in the discernment counseling process. The flow of the sessions is as follows: couple time at the beginning (very brief after the first session), followed by an individual conversation, a brief summary by each partner to the other of what that individual has learned in the individual time, then a conversation with the other spouse, followed by that person’s summary, and ending with brief remarks by the discernment counselor.

Research about Discernment Counseling Research on discernment counseling is in its early stages. Doherty et al. (2016) followed and evaluated outcomes for 100 consecutive cases in their Minnesota Couples on the Brink

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Project clinic. These were all couples on the brink of divorce, with at least one spouse considering divorce and reluctant to do traditional couples therapy. (Many had prior experience with couples therapy.) They were referred by lawyers (half had seen a lawyer), other therapists, and self-referrals (the largest category). They were a highly distressed group, with marital satisfaction scores well below published averages for clinical couples entering couples therapy research studies. The primary outcome evaluated was the three paths. Findings showed that about half of the couples (47%) chose the reconciliation path, 41% chose separation/divorce, and the remainder opted for the status quo. Longer-term outcomes were assessed an average of 2 years later. About 42% had succeeded in reconciliation or were still working on reconciliation. A similar number (45%) had divorced or were in the divorce process, and a smaller subset (13%) was on hold, neither in crisis nor particularly satisfied with their situation. Summarized differently, a little less than half of the couples who tried to reconcile ended up divorced within an average of 2 years, and most of the rest had reconciled. The authors concluded that a real discernment process had occurred, with couples choosing different paths that suited them based on what they learned in discernment counseling.

worked hard on the relationship either and thought his wife exaggerated the impact of his depression on the marriage. During three sessions of discernment counseling, the discernment counselor worked with Jessica to understand her own pattern of overfunctioning and how she had come to see herself as his teacher (hence, critic). The counselor challenged Robert to acknowledge how his underfunctioning and lack of self-responsibility for his depression (he had refrained from getting treatment for several years) was contributing to the marital problems – and encouraging her to become his caretaker/critic that turned him off. They were both able to share these insights with each other during the summary times in the sessions, each being surprised with the openness of the other to acknowledge personal contributions to the problems. A key moment in this case came when Jessica realized that that she did not want to give up on the marriage without trying couples therapy (which they had never done before) and that even if it did not work out, she could benefit during the therapy from finding her voice and having better boundaries in the marriage. They both developed personal agendas for change (which included Robert returning to treatment for his depression) and embarked on couples therapy, with both on board for that work.

Case Example

Cross-References

Jessica and Robert had been married for 16 years and had three young children. Jessica was considering divorce, she said, because of years of emotional distance related to Robert’s chronic depression. She was burned out from trying to get him to function better as a husband and father. Although she was working on herself in therapy, and believed she was making changes, she was skeptical that couples therapy could improve the marriage. For his part, Robert did not want a divorce and preferred to try couples therapy to see if the marriage could be made healthy again after years of his wife putting all her energy into the kids. He admitted he had not

▶ Attachment Theory ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Differentiation of Self in Bowen Family Systems Theory ▶ Divorce in Couple and Family Therapy

References Bowen, M., & Kerr, M. E. (2009). Family evaluation. New York: W. W. Norton. Crosby, J. F. (Ed.). (1989). When one wants out and the other doesn’t: Doing therapy with polarized couples. New York: Brunner/Mazel.

Disengagement in Couples and Families Doherty, W. J., Harris, S. M., & Wilde, J. L. (2016). Discernment counseling for “mixed-agenda” couples. Journal of Marital and Family Therapy, 42, 246–255. https://doi.org/10.1111/jmft.12132. Miculincer, M., & Shaver, P. R. (2012). Adult attachment orientations and relationship processes. Journal of Family Theory and Review, 4, 259–274. https://doi. org/10.1111/j.1756-2589.2012.00142. Rholes, W. S., & Simpson, W. J. (Eds.). (2006). Adult attachment: Theory, research and clinical applications. New York: Guilford. Vaughn, D. (1986). Uncoupling: How relationships come apart. New York: Oxford University Press. Weiss, R. W. (1975). Marital separation. New York: Basic.

Disengagement in Couples and Families Emily Wilensky1 and Adam R. Fisher1,2 1 The Family Institute at Northwestern University, Evanston, IL, USA 2 Brigham Young University, Provo, UT, USA

Name of Concept Disengagement in Couples and Families

Introduction Disengagement is one of the classifications and dimensions of boundaries and connectedness in a couple or family, and it is exhibited by low connectedness and high autonomy within the system (Olson et al. 1979).

Theoretical Context for Concept In structural family therapy, Salvador Minuchin classified family boundaries on a continuum from disengaged or inappropriately rigid boundaries to enmeshed or diffuse boundaries (Minuchin 1974). David Olson then adapted Minuchin’s classification of boundaries to create a perspective used in assessing and intervening with couple and family systems based on how they interact with one another. The Circumplex Model of Marital and

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Family Systems separates family interactions into three dimensions: family cohesion, flexibility, and communication. Disengagement is rooted in the first dimension – family cohesion or togetherness – which is defined as “the emotional bonding that family members have towards one another” (Olson 2000, p. 145). The Circumplex Model assesses togetherness on a continuum of four subgroups of family cohesion: disengaged (very low), separated (low to moderate), connected (moderate to high), and enmeshed (very high). In addition to dividing family cohesion into four subgroups, Olson et al. (1979) developed various cohesion dimensions that can further evaluate and distinguish the various levels of cohesion within a system. These dimensions include independence, time, coalitions, family boundaries, space, friends, decision-making, and interests and recreation.

Description Disengagement can be problematic – and even pathological – in some couple and family systems (Olson et al. 1979). Members of these systems are highly independent and do not invest time in one another. These systems do not have strong bonds or coalitions, and often one member of the system is scapegoated. Regarding boundaries, disengaged couples and families have open boundaries outside their system, closed boundaries within their system, and rigid boundaries between generations of their system. Similarly, these systems maximize both physical and emotional space between members and often remain distant from one another. Disengaged couples and families interact with friends individually rather than having a shared group of friends. Decisions are also made on an individual basis, and interests and recreation are often pursued without family involvement and support.

Application of Concept in Couple and Family Therapy Disengagement can present in a variety of ways in couple and family therapy. With couples, one

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partner can be disengaged, while the other attempts to connect. In families, one parent, a parent dyad, or a child in the system can all be disengaged. Since disengaged systems are conflict avoidant, the therapist’s job is to encourage dialogue between members to work through differences and communicate each person’s needs rather than isolating from one another (Nichols and Davis 2017).

Clinical Example Alison and Logan started family therapy with their 11-year-old daughter, Ilana, to address Ilana’s problematic behaviors at home and school. When the therapist asked Alison and Logan to describe Ilana’s behaviors, they were both scrolling through emails and texting, while Ilana was off in the corner of the room playing with a toy. After being asked to put their phones away, Alison expressed, “we just want you to teach her how to behave; she is so attention-seeking.” The therapist then asked Ilana what she thought about the way she was behaving, to which she replied, “What do you expect? My parents don’t pay any attention to me; they are always on their phones. If I behaved how they wanted me to, they would pay even less attention to me than they do now.” The therapist then helped facilitate a conversation between the parents and child about their lack of connection and involvement with one another. This allowed the family to work through some of their differences, and articulate their needs, which created a more secure sense of cohesiveness among the system.

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▶ Russell, Candyce ▶ Sprenkle, Douglas ▶ Structural Family Therapy

References Minuchin, S. (1974). Families and family therapy. Cambridge: Harvard University Press. Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods. Boston: Pearson. Olson, D. H. (2000). Circumplex model of marital and family systems. Journal of Family Therapy, 22(2), 144–167. Olson, D. H., Sprenkle, D. H., & Russell, C. S. (1979). Circumplex model of marital and family systems: I. cohesion and adaptability dimensions, family types, and clinical applications. Family Process, 18(1), 3–28.

Divorce Ideation Alan J. Hawkins1, Sage Erickson Allen1, Kelly Roberts2, Steven M. Harris3 and Sarah M. Allen4 1 Brigham Young University, Provo, UT, USA 2 University of North Texas, Denton, TX, USA 3 University of Minnesota, Minneapolis, MN, USA 4 Montana State University, Bozeman, ST, USA

Name of Concept Divorce Ideation.

Synonyms Divorce decision-making; Divorce thinking

Cross-References Introduction ▶ Autonomy in Families ▶ Boundaries in Structural Family Therapy ▶ Circumplex Model of Marital and Family Systems, The ▶ Enmeshment in Couples and Families ▶ Minuchin, Salvador ▶ Nichols, Michael ▶ Olson, David

Demographers estimate that 40–50% of first marriages and 60% of second marriages end in divorce (Kennedy and Ruggles 2014; Kreider and Ellis 2011). But there is a curious research gap on divorce ideation and decisionmaking. What are people thinking when they are thinking about divorce? How many people

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are thinking about divorce? How frequent and serious are their thoughts? How static or stable is their thinking? What do they do to try to repair the relationship? Until recently, there was little research on these questions. But some answers to these questions are available from a recent study with a nationally representative sample of 3,000 married individuals of ages 25–50 (Hawkins et al. 2017b; National Divorce Decision-Making Project 2015). This study also included a 1-year follow-up survey and repeated in-depth interviews with a subsample of 30 individuals thinking about divorce.

Theoretical Context for Concept There is limited theoretical work trying to understand how individuals think about and make difficult decisions about divorce or staying together (Allen and Hawkins 2017). Work grounded in rational frameworks inevitably force-fit messy, emotional, nonlinear processes into tidy, linear, and self-interested ones. Interpretive frameworks are vulnerable to ways in which individuals reframe, reinterpret, and re-tell events in ways that make sense with their current understanding of a situation, reducing ambiguity and inconsistencies and minimizing instances of nonlinearity. There is a need for theoretical frameworks and methodologies that can capture complexity in ways that attend to the many rational elements of divorce ideation but also to the nonrational, nonlinear, and emotional – that is, fully human – ways in which individuals make sense of their lives. Regardless of current theoretical and methodological challenges, divorce ideation needs a mapping of its basic, empirical contours.

Description of Past and Recent Divorce Ideation Thinking about divorce is common. Twenty-eight percent of married individuals of ages 25–50

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report that in the past (but not recently) they thought their marriage was in serious trouble and had thoughts about divorce. Nearly 90% of them, however, report that they are glad they are still married. A noteworthy proportion of the married population goes through periods of marital distress but survives and even thrives with a mixture of patience, promises, perseverance, and perspiration. (Note, however, that those who had already divorced are not captured in these numbers.) In addition, 25% report thinking about divorce in the last 6 months. Forty percent of recent thinkers say they have talked to their spouse about their thoughts about divorce; another 40% say they have not talked to their spouse, while 20% say, “Maybe, we sort of talked about it,” indicating perhaps vague conversations about marital prospects without directly mentioning divorce. Also, divorce ideation rates do not begin to decline until 15 years of marriage. Most current thinkers have been thinking about divorce for more than a year. Demographic differences in divorce ideation are not common and small when they do appear. For most thinkers (70%), their thoughts about divorce are infrequent, and they are generally pretty happy and hopeful about the future of their marriage. So for most thinkers, their thoughts do not seem to indicate impending marital demise. Also, 43% of current thinkers say they do not want a divorce and want to work hard to stay together. About a quarter of thinkers report mixed feelings about a divorce, while another quarter say they would consider working on their marriage and not divorcing if their spouse got serious about making some major changes. Three distinct categories of thinkers can be identified from these specific questions. One group consists of serious thinkers (46%). Half of them are thinking about divorce often. They have high levels of connection problems (e.g., growing apart) in their marriages and modest levels of instrumental problems (e.g., division of domestic labor). Conflict is a large concern for this group (more than 84% reporting a problem), but they report relatively low levels of intense problems (e.g., adultery, abuse). They have the lowest scores of the three groups on relationship hope.

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Still, few say they are done with the marriage (5%). And they are struggling more than the other groups to find clarity in their decision about a divorce. So serious thinkers are feeling a significant loss of connection, experiencing substantial conflict, and are thinking more about divorce and are less committed, on average, to working through their problems, although they are struggling with the divorce decision. The second group is soft thinkers (48%), and they are a strong contrast to the other two groups. More than 90% of this group say they have been thinking about divorce only a few times recently. They have lower levels of reported marital problems of all kinds, with connection issues being the most common problems; few report one of the more intense problems. Also, they are hopeful about the future for their marriage. Seventy percent say they do not want a divorce and are willing to work hard to keep the marriage together, with another 11% saying they would work to save the marriage if their spouse got serious about making changes. Not surprisingly, then, this group reports much more clarity about the divorce decision, likely settled on not pursuing that course for now. So soft thinkers have only occasional thoughts about divorce and are committed to working on the marriage but are experiencing some connection problems. The smallest group is conflicted thinkers (6%). They report the highest level of problems, including several of the more intense problems. And they report the highest levels of conflict and, by far, mental health problems affecting the marriage. About half have been thinking about divorce often. And about one third said they are done with the marriage, by far the highest endorsement of this attitude among the three groups of thinkers. But curiously, another third said they want to work hard to save the marriage and avoid a divorce. Also, this small group has the highest scores among thinkers on relationship hope. They also report feeling like a failure if their marriage were to end. So conflicted thinkers are experiencing the highest levels of serious problems but remain hopeful about overcoming the problems, and they are conflicted about getting a divorce even though are experiencing

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serious problems. This group is the most religious of the three divorce ideation groups. In-depth interviews with 30 thinkers paint a more nuanced portrait of divorce ideation and decision-making than is provided in the quantitative analyses. There is more of a continuum between soft and serious thinkers. And soft thinking does not preclude real, sustained frustration or sense of being stuck. Thinkers struggle with various tensions as they contemplate divorce. Personal happiness versus children’s happiness, love versus financial security, and rational versus emotional thoughts are all things that thinkers thought about extensively. These tensions combined to determine trajectories of relationship growth, entropy, or maintenance of the status quo. In addition, there are core beliefs about marriage and divorce that people use as reference points for their thinking and decision-making. Some of these reference points come from family, friends, past experiences, and relationships, while others come from general societal and cultural messages. And throughout this divorce ideation process, people often struggle with clarity and confidence in a decision about which direction they should take. What happens over a 1-year span? How stable or dynamic is divorce ideation? Ninety-three percent of thinkers are still married to the same person 1 year later; 6% are divorced or separated. While most nonthinkers (64%) still are not thinking about divorce a year later, about one third of them become thinkers and 2% are separated or divorced, indicating that occasionally marital dissolution comes quickly. And while most thinkers are still thinking about divorce 1 year later (69%), nearly a third of them are not thinking about divorce. Still, marital dissolution is more common among thinkers: 11% are divorced or separated 1 year later. Also, personal attitudes about getting a divorce can change a lot over a year. Only one third of thinkers report the same attitude about divorce a year later. For instance, among the thinkers who say they are done with the marriage, just 29% report the same attitude 1 year later, while 53% report different attitudes that suggest more openness to staying married,

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including 18% who say they have not had recent thoughts about divorce. About half of soft thinkers remain soft thinkers 1 year later, with about 10% becoming serious thinkers; a third have transitioned to nonthinkers a year later while only 1% have divorced. Similarly, about half of serious thinkers remain serious thinkers 1 year later, with 20% changing to soft thinkers; 21% have transitioned to nonthinkers, while 5% are divorced within a year. The risk of divorce is higher for conflicted thinkers – 6% divorced within a year. Nevertheless, a quarter transition from conflicted to nonthinkers. Moreover, the in-depth interviews with thinkers suggest even higher levels of fluctuation. Indeed, for about half of thinkers, feelings about the marriage ebb and flow monthly, weekly, and even daily. When people are thinking about divorce, what actions do they take to repair their relationship? Thinkers report relatively low levels of professional help-seeking, consistent with previous research (Doss et al. 2009; Hawkins 2015; Lebow et al. 2012). Only 40% have sought some kind of counseling (25% sought couple counseling). About 11% counsel with a religious leader. Only 10% have taken a marriage-strengthening class together. Also, about a third report talking to others about improving their marriage. And about 40% report seeking help from self-help sources (e.g., books, websites). The most commonly attempted repair behaviors, however, are private or dyadic efforts, such as having a serious talk with a spouse (68%) or just working harder to fix a problem (79%). Generally, it appears that people who are thinking about divorce do not often seek out professional help in a timely manner. Instead, they engage in more private efforts to fix their problems. In summary, current divorce ideation is common. Perhaps, an inevitable feature of modern marriages is that couples must struggle with the possibility of its demise. Within a culture of widespread acceptance of individualism and romanticism, if a marriage is not fully satisfying, then questions about its viability inevitably surface (Baxter 2010). Cultural beliefs about individualism and romantic love (Swidler 2001) shrink the distance between disappointment and divorce

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ideation. However, divorce ideation is not the same as divorce action. Many have thoughts about divorce, but the thoughts dissipate or they do not get to a decision point for years. At the same time, soft thinking does not mean that marital problems are trivial and painless. While thoughts about divorce are fleeting for some and the issues they raise can be straightforwardly addressed, some thinkers are frustrated and in pain even if they are not thinking seriously about getting a divorce right then. Moreover, divorce ideation is dynamic; for many, thoughts fluctuate from month-to-month and even day-to-day. Knowing what someone is thinking about divorce at one time is useful, but it is not a clear indication about the future. Finally, while most do make attempts to repair and strengthen the relationship, most do so privately without engaging professional help.

Application of Concept in Couple and Family Therapy Divorce ideation is common but does not equal divorce action. Many have had thoughts about divorce in the past but not recently and are happy they are still together. Many more have had recent thoughts but are not headed quickly to a divorce. Couples therapists can use these findings to normalize divorce ideation. Moreover, divorce ideation is dynamic, not static. Normalizing this may help thinkers realize that there does not need to be a rush to premature decisionmaking about the future of the marriage. Clients in distressed marriages can be overwhelmed by the current state of a relationship and lose a longterm view. The use of couple counseling can help couples get clarity about the best direction to go (Doherty et al. 2015). Marriage Education. Marriage education programs can deal effectively with the common connection problems that thinkers reported, such as being able to talk together, arguing too much, or growing apart, as well as instrumental problems, such as balancing work and family issues (Hawkins 2015). Marriage education has generally been portrayed as preventative intervention.

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Yet there is good evidence that distressed couples constitute a substantial portion of marriage education participants (Bradford et al. 2015) and that they often benefit more from it than nondistressed couples (Hawkins et al. 2017a). Scholars have stressed the need for prevention work with couples “before [distress] happens, before it gets worse, and before it is too late” (Bradbury and Fincham 1990, p. 376). Moderately distressed couples are an important target audience for marriage educators.

Clinical Example Jerome and Greta married 10 years ago after cohabiting as a committed couple for almost 6 years. They have two children. Having experienced emotional distance for the past 4 years, they described their marriage during an intake for counseling as “distant, exhausting, and increasingly conflicted.” Greta expressed being especially “done” with their marriage after describing several examples of “trying everything she could” to help them reconnect, including several attempts at couples therapy. Jerome was a reluctant participant in these efforts. Greta admits to thinking almost daily about filing for divorce. When prompted, Jerome concedes that he does not think he can change her mind but never imagined being at this particular juncture in his life. Both reference their children as one of “the main reasons they are still together.” As reflected by their counselor during intake, their marriage had experienced increasingly strained couple identity with Jerome expressing varying degrees of ambivalence and Greta clearly “leaning out” of the marriage. The counselor explained how discernment counseling – a special counseling method for working with “mixed-agenda” couples (Doherty et al. 2015) – worked. The counselor explained that the purpose of discernment counseling was not to begin working on solving couple problems but to get some understanding in order to make a decision about three possible paths forward: divorce/separation, stay the course (relationship status quo), or a commitment to 6 months of couple’s therapy, with divorce off the table. The couple first agreed to stay the course for a couple of weeks.

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During that time, both spouses met individually with the discernment counselor. After a few sessions, Greta reported to their counselor that they had mutually agreed to move into couple therapy and would give these efforts 6 months, seeking more understanding of the problems they were facing and working on solutions.

Cross-References ▶ Discernment Counseling in Couple and Family Therapy ▶ Divorce in Couple and Family Therapy ▶ Divorced Families ▶ Integrative Family Therapy for Difficult Divorce ▶ Post-Divorce Families in Couple and Family Therapy

References Allen, S. M., & Hawkins, A. J. (2017). Theorizing about the divorce/reconciliation decision-making process. Journal of Family Theory and Review, 9, 50–68. https://doi.org/10.1111/jftr.12176. Baxter, L. A. (2010). The dialogue of marriage. Journal of Family Theory & Review, 2, 370–387. https://doi.org/10.1111/j.1756-2589.2010.00067.x. Bradbury, T. N., & Fincham, F. D. (1990). Preventing marital dysfunction: Review and analysis. In F. D. Fincham & T. N. Bradbury (Eds.), The psychology of marriage: Basic issues and applications (pp. 375–401). New York: Guilford. Bradford, A., Hawkins, A. J., & Acker, J. (2015). If we build it, they will come: Exploring policy and practice implications of public support for couple and relationship education for lower income and relationally distressed couples. Family Process, 54, 639–654. https://doi.org/10.1111/famp.12151. Doherty, W. J., Harris, S. M., & Wilde, J. L. (2015). Discernment counseling for “mixed-agenda” couples. Journal of Marital and Family Therapy, 42, 246–255. https://doi.org/10.1111/jmft.12132. Doss, B. D., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2009). Marital therapy, retreats, and books: The who, what, when, and why of relationship help-seeking. Journal of Marital and Family Therapy, 35, 18–29. https://doi.org/10.1111/j.17520606.2008.00093.x. Hawkins, A. J. (2015). Does it work? Effectiveness research on relationship and marriage education. In J. Ponzetti

Divorce in Couple and Family Therapy (Ed.), Evidence-based approaches to relationship and marriage education (pp. 66–73). New York: Routledge. Hawkins, A. J., Erickson Allen, S. E., & Yang, C. (2017a). How does couple and relationship education affect relationship hope? An intervention-process study with lower income couples. Family Relations. Advance online publication. https://doi.org/10.1111/fare.12268. Hawkins, A. J., Galovan, A., Harris, S. M., Allen, S. E., Allen, S. M., Roberts, K. M., & Schramm, D. G. (2017b). What are they thinking? A nationalsample study of stability and change in divorce ideation. Family Process. Advance online publication. https://doi. org/10.1111/famp.12299. Kennedy, S., & Ruggles, S. (2014). Breaking up is hard to count: The rise of divorce in the United States, 1980–2010. Demography, 51, 587–598. https://doi. org/10.1007/s13524-013-0270-9. Kreider, R. M., & Ellis, R. (2011). Living arrangements of children: 2009. In Current population reports (pp. 70–126). Washington, DC: U. S. Census Bureau. Lebow, J. L., Chambers, A. L., Christensen, A., & Johnson, S. M. (2012). Research on the treatment of couple distress. Journal of Marital and Family Therapy, 38, 145–168. https://doi.org/10.1111/j.17520606.2011.00249.x. National Divorce Decision-Making Project. (2015). What are they thinking? A national survey of married individuals who are thinking about divorce. Provo: Family Studies Center, Brigham Young University. Swidler, A. (2001). Talk of love: How culture matters. Chicago: University of Chicago Press.

Divorce in Couple and Family Therapy Amy C. Wagner1 and Rachel M. Diamond2 1 The Family Institute at Northwestern University, Evanston, IL, USA 2 University of Saint Joseph, West Hartford, CT, USA

Synonyms Marital and/or Relationship Dissolution and/or Termination

Introduction Issues related to divorce in couple and family therapy are often challenging and complex and are increasingly common presenting problems

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for clients. According to a national survey, the divorce rate remains around 50 % (Copen et al. 2012). Indeed, a legally married, two-parent household with children is no longer representative of the typical American family.

Theoretical Context for Concept Divorce and the transitions and reorganization of family structure that follows have become a normative experience. In the United States, the term “divorce” is used to refer to the termination of legal marriages, but it can also apply to the dissolution of long-term committed relationships. This is of particular importance as more couples are deciding to cohabitate as an alternative to marriage, not as a precursor to it (Cherlin 2004). Therefore, while the legal aspects of divorce are unique to marriages, the discussion presented here also has relevance to relationship dissolution* of long-term committed relationships that involve cohabitation. It is important to understand that divorce is not a single, discrete event. Instead, the most commonly accepted theoretical model of divorce supports a process perspective (Amato 2010). Divorce is an ongoing couple and familial process that increases relational conflict and emotional instability and inevitably involves the dissolution of the partnered relationship and original family that once existed. By holding this perspective of divorce, it is understood that clients can enter therapy at any point during the process. Client needs can vary greatly based on where they present across the transitional continuum: Clients may come to therapy contemplating divorce (e.g., prefiling or separation), others may seek therapy in the midst of the divorce (e.g., in unison with court proceedings), or others may enter therapy as a means to assist with post-divorce adjustment (e.g., post-legal divorce and/or following physical separation). Therapists who understand the typical challenges and adjustments necessary at these various stages can more directly and appropriately respond to both couple and family needs.

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Description Clinicians should consider each individual in the family system, the interparental relationship, and parent–child relationships when working with divorcing families. Before initiating the process of relationship dissolution, one or both parents likely contemplated separation and/or divorce for some time. Typically upon beginning the physical separation, parents inform their child(ren). While legal/court proceedings may move slowly for many, the transitions in the family’s life often do not follow the same timeline. Upon telling the child(ren) of the relationship dissolution,* there is typically a rapid series of transitions as the couple separates and begins any legal proceedings and one parent may leave the family home. During the divorce process, children may experience other losses such as extended family members, their home, neighborhood, friends, and/or school. It is vital to support children in these losses and subsequent transitions. Throughout a divorce, children often are exposed to high parental stress and/or conflict. This may tax parents’ abilities in caretaking and responding to their children’s emotional needs. Parents need support in staying centered and competent in a leadership role in the face of stress, change, and emotional turmoil. The impact of divorce can vary based on a variety of factors (Wagner and Diamond 2017). These include the ages and number of children, the family’s financial situation, the existence of social support systems (e.g., extended family), and the meaning of divorce to family members. These beliefs are often related to culture, religion, and gender. Indeed, parents who divorce may live in a community where they feel stigmatized or judged because of their decision to end a marriage and are concerned it will negatively impact their social standing. Overall, research indicates that children raised in a two-parent family experience better psychological, social, academic, and physical health outcomes compared to those children raised in divorced families, separated families, or nevermarried single-parent households (Clarke-Stewart and Brentano 2006). However, differences between groups are small and decrease over

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time. Therefore, it is not divorce per se, but the family processes such as the increase in parental conflict around relationship dissolution* that are linked to childhood adjustment difficulties. These include both externalizing behavior (e.g., aggression, delinquency, and conduct disorder) and internalizing behavior (e.g., depression and anxiety), as well as physical health problems (Fabricius and Luecken 2007). Children with cooperative parents have better psychological functioning and academic performance compared to children with noncooperative parents (Hetherington et al. 1998). Indeed, the quality of the parental relationship has been linked to both short- and long-term adjustment, regardless of family type (Cummings et al. 2012). Additionally for parents to support children and bolster their resilience post-divorce, the parent–child relationship must remain warm and supportive (Amato 2010; Simons et al. 1999). Parent–child conflict during stressful transitions like divorce is related to children’s abilities to emotionally regulate and feel secure (Davies and Cummings 1994). The more positive the relationship a child has with his/her parents, the better the child will adjust to divorce.

Application of Concept in Couple and Family Therapy There are various models of therapy that can be appropriately applied to working with couples and families of divorce. However, it is advised that in this work a therapist take an integrative approach in order to address the range of distinct tasks across the transitional continuum (Lebow 2015). The major focus of couple and family therapy with this population is on facilitating family reorganization, establishing a new binuclear family structure with clearly defined boundaries and roles, and facilitating healthy communication between co-parents (Wagner and Diamond 2017). Families who seek treatment during divorce frequently experience periods of conflict or turmoil. Often there is a lack of organization during the transition to a new, single-parent family structure. Couple and family therapy focusing on

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divorce is often complex due to these frequent periods of upheaval and transition. Thus, it is imperative that the therapist provide clear structure within the therapeutic setting while also allowing adaptation as the family transitions through the divorce process. One of the most important goals of therapy is to provide the family with stability in a time of often rapid change while also encouraging flexibility and adaptability (Wagner and Diamond 2017). It is essential to clarify legal agreements regarding consent for treatment of minors before beginning treatment, as laws may vary by state. With that being said, having the cooperation and participation of both parents maximizes the likelihood of a positive treatment outcome. When beginning treatment, it is imperative to distinguish the role of the therapist and purpose of therapy from that of couples counseling, custody evaluation, or legal mediation to facilitate the establishment of a positive treatment alliance with both parents with the goal of acting in the best interest of their child/children. While treatment with the most members of the family system is generally the starting point for family therapy, in divorcing families this is contraindicated due to the common presence of high emotional reactivity and conflict between divorcing partners. As divorce is often not a mutual decision by the couple, they each may need to first process their feelings individually with the therapist. Initially meeting with each parent alone or with the parents together prevents children from being further exposed to conflict and creates a safer therapeutic space. As parents may be actively involved in the legal system, a therapist should have a comprehensive therapy contract to clarify agreements around confidentiality for parents and children. There should be a clear expectation that the therapist will only share information from the children that will facilitate family treatment, without withholding essential information. Even though former partners may have negative emotions toward each other, therapists ask parents to resolve, accept, or set aside these feelings in order to be functional, cooperative co-parents. After the parental subsystem is stabilized sufficiently so that shared goals for therapy can be established,

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subsequent sessions can include each parent and their child/children and/or the sibling subsystem. This method of working with each household separately sets a clear boundary and reinforces family organization as a binuclear rather than nuclear family. There may be times when therapists work with the original family together; however, this should be attempted only after emotional negativity has been reduced, and these sessions should focus on specific treatment tasks and goals.

Clinical Example The following case example illustrates how to therapeutically approach a family adjusting to divorce. Since their separation 6 months ago, Cindy and Mike are struggling with their schoolage children’s adjustment to living in two different homes. They entered therapy at the suggestion of the school social worker, who was told by teachers that both their son, Jason, and daughter, Sally, were missing assignments, coming to school late, and having behavior problems not exhibited prior to the parents’ separation. Cindy and Mike met with the therapist together. They reported there was not a consistent schedule and often the kids forgot their homework or books at the other parent’s house. In addition, the couple was going through a difficult divorce that had recently reached an impasse. While they tried to keep their differences from the children, the kids had recently witnessed an argument during a drop off. Additionally, Cindy, the primary custodial parent, felt overwhelmed getting the kids off to school in the morning and getting herself ready for work, and Mike felt he had so little time with the kids he didn’t want to spend it forcing them to do homework and study. Cindy reported their son was defiant with her and missed his dad; Mike reported their daughter often cried at night before bed and wanted to return to Cindy’s house. Facilitating family reorganization. Beginning tasks and goals in therapy involve supporting and facilitating family reorganization (Wagner and Diamond 2017). These include establishing clear boundaries between households and

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clarifying parenting schedules, rules, and other functional logistics. While daily routines may vary in each binuclear household, they should be similar around important issues such as bedtime/ curfew or expectations about homework and school performance. This clarity helps all family members better adjust to the changes in family organization and increases a sense of safety and predictability. For Cindy and Mike, this involved discussing practical issues in therapy, such as coordination of school and extracurricular schedules, appointments, transportation, and exchange of personal possessions during transitions between households. The therapist explained that predictable routines and direct, consistent communication help children feel more in control and less anxious or uncertain in their daily lives. Lastly, while most parenting agreements require siblings to shift between parents homes in unison, given their concerns about the children’s distress and emotional needs, the therapist discussed the importance for each child to also have one-on-one time with each parent. Redefining parental roles. Divorce involves redefining and renegotiating family roles; the adults must transition from being romantic partners and parents to strictly being co-parents. The new logistics of solo parenting can be emotionally overwhelming with multiple responsibilities for childcare, logistics, or finances that had previously been shared. Unresolved issues and a lack of acceptance and closure often interfere with parents’ abilities to establish a cooperative co-parenting relationship. The therapist worked with Cindy and Mike to normalize these common divorce challenges and the inevitable adjustment period of confusion and conflict. The therapist discussed ways they could be supportive co-parents and suggested the parents utilize a software program designed to assist parents of divorce with scheduling and communication (e.g., Our Family Wizard). With time, newly established emotional and physical boundaries between Cindy and Mike became clearer as the “new normal” was established, supporting the goal of having cooperative, competent leaders in each household.

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Developing healthy communication. Research evidence supports that ongoing parental conflict and triangulation of children in parental disputes is related to poor child adjustment. Children whose parents are involved in a highly conflictual divorce or ongoing custody litigation are especially vulnerable. The therapist advocated for Cindy and Mike to protect their children from parental conflict and having to “choose sides” so Jason and Sally could continue to have a loving relationship with both parents. The therapist discussed how the children should not be treated as buffers, mediators, or messengers; instead, parental communication should occur directly between them. Both parents agreed that negative emotions were not only hindering each child’s ability to adjust to the divorce, it was also interfering with their relationships with Cindy and Mike. Therapy also aided Cindy and Mike in making joint parenting decisions and negotiating differences on topics such as healthcare, extracurricular activities, education, and behavioral expectations. They agreed to focus on their children’s needs and that they were both committed to do what was best for them. With this understanding they felt they could use therapy as a safe place to problem solve or resolve conflicts, rather than using attorneys and the legal system to resolve disputes. Often boys and girls handle the stress and transition of divorce differently, and same-sex siblings may have varying reactions based on their age and development. During parent–child (ren) sessions, therapists can help support children in expressing emotions to parents. Once Cindy and Mike were more cooperatively co-parenting, the therapist had family meetings with each parent and the children. In the family sessions Jason and Sally were able to express their sad, scared, and angry feelings about the divorce, while the therapist coached each parent in responding so the children felt accepted and understood. The therapist also helped Cindy and Mike recognize that problematic behavior had underlying emotional meaning. With time, this decreased Jason’s acting out and Sally’s withdrawal and increased Cindy and Mike’s feelings of competency in supporting their children.

Divorced Families

Over the course of treatment, Cindy and Mike reported seeing indications that the children were better able to handle their transition between households and their school performance improved. They reported that although they had conflict over divorce negotiations, they were both committed to protecting the children from their conflict. In addition, the children seemed happier, and while they still wished their parents would get back together, they were adjusting well to their new schedules and routines. In conclusion, most children in divorced families adjust well to a new binuclear family form over time. By understanding the predictable systemic issues and transitional process of divorce, couple and family therapists can better support their clients in successfully negotiating the common developmental challenges associated with this journey of change.

Cross-References ▶ Divorced Families ▶ Post-divorce Families in Couple and Family Therapy

References Amato, P. R. (2010). Research on divorce: Continuing trends and new developments. Journal of Marriage and Family, 72, 650–666. https://doi.org/10.1111/ j.1741-3737.2010.00723.x. Cherlin, A. (2004). The deinstitutionalization of American marriage. Journal of Marriage and Family, 66, 848–861. https://doi.org/10.1111/j.0022-2445.2004.00058.x. Clarke-Stewart, A., & Brentano, C. (2006). Divorce: Causes and consequences. New Haven: Yale University Press. Copen, C. E., Daniels, K., Vespa, J., & Mosher, W. D. (2012). First marriages in the United States: Data from 2006–2010 national survey of family growth. In National health statistics reports (Vol. 49, pp. 1–22). Hyattsville: National Center for Health Statistics. Cummings, E. M., George, M. W., McCoy, K. P., & Davies, P. T. (2012). Interparental conflict in kindergarten and adolescent adjustment: Prospective investigation of emotional security as an explanatory mechanism. Child Development, 83(5), 1703–1715. https://doi.org/10.1111/j.1467-8624.2012.01807.x. Davies, P. T., & Cummings, E. M. (1994). Marital conflict and child adjustment: An emotional security

787 hypothesis. Psychological Bulletin, 116, 387–411. https://doi.org/10.1037/00332909.116.3.387. Fabricius, W. V., & Luecken, L. J. (2007). Postdivorce living arrangements, parent conflict, and long-term physical health correlates for children of divorce. Journal of Family Psychology, 21, 195–205. https://doi.org/ 10.1037/0893-3200.21.2.195. Hetherington, E. M., Bridges, M., & Insabella, G. M. (1998). What matters? What does not? Five perspectives on the association between marital transitions and children’s adjustment. American Psychologist, 53, 167–184. https://doi.org/10.1037/0003-066X.53.2.167. Lebow, J. L. (2015). Separation and divorce issues in couple therapy. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 445–463). New York: The Guilford Press. Simons, R. L., Lin, K. H., Gordon, L. C., Conger, R. D., & Lorenz, F. O. (1999). Explaining the higher incidence of adjustment problems among children of divorce compared with those in two-parent families. Journal of Marriage and the Family, 61, 1020–1033. https:// doi.org/10.2307/354021. Wagner, A. C., & Diamond, R. M. (2017). Families and divorce. In S. Browning & B. Van Eeden-Morrhead (Eds.), Contemporary families: At the nexus of research and practice. New York: Routledge Press.

Divorced Families Lee J. Dixon and Sarah A. Wilhoit University of Dayton, Dayton, OH, USA

Introduction Given the prevalence of divorce in most countries, and the fact that the dissolution of a marriage often involves the entire family, it is important to have an understanding of the potential impact of divorce. Although divorce is usually related to detrimental experiences for both couples and their children, this is not true in all cases. As is outlined below, research in this area has shone a light on for whom divorce has a more negative impact and for whom the opposite may be true. Given the ubiquity of divorce, it is imperative that we understand its causes and influences and develop therapies and interventions that can help to lessen the negative consequences it can have on families. This entry will introduce the reader to each of these three areas of study.

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Description Although divorce rates in the United States peaked in the 1980s, they are still a very frequent occurrence, with the crude rate in 2012 being reported to be nearly three divorces per year per 1000 population (Organization for Economic Cooperation and Development (OECD) 2015). The decline in the rate of divorce over the last few decades can partially be explained by the fact that the rate of marriages during that same time has been decreasing (National Center for Health Statistics (NCHS) 2015). Because crude rates can be difficult to interpret, another way to understand the frequency of divorce is to consider the fact that in 2014 nearly one million divorces occurred in the US (NCHS 2015). Although divorce rates have fallen in the USA during the last decades, the same is not true of many countries included in the OECD report, with the rates of divorce, on average, having risen in these countries during that same time period. Divorce oftentimes involves not only the divorcing partners, but their children as well; it has been estimated that approximately 40% of US children will experience the divorce of their parents before reaching adulthood (Bumpass 1990).

Relevant Research The causes, antecedents, and underlying processes of divorce have long been a focus of research (see Amato and Previti 2003; Rodrigues et al. 2006). Given that marriage until more recently has been a heterosexual institution, most research regarding divorce has focused on heterosexual relationships (but see Oswald and Clausell 2006). Wives have been found to be more likely than husbands to initiate divorce; additionally, former wives more often cite negative qualities of their spouses as the cause for their divorce, whereas former husbands are more likely to blame factors outside the marriage (Kitson 1992). One often-cited predictor of divorce is one’s socioeconomic status (SES; typically defined as level of income and education), with the risk of divorce being negatively related to SES

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(e.g., White 1991). However, it should be noted that Orbuch et al. (2002) found that income alone did not predict divorce after accounting for the effects of race and education. With regard to race, African American couples have been found to be more likely to divorce than their Euro-American counterparts (e.g., Orbuch et al. 2002), although the explanation for this finding is more likely due to the influence of sociodemographic variables associated with race (e.g., premarital birth, cohabitation, etc.), rather than race itself. Amato and Previti (2003) found that the subjective causes of divorce most often reported by former spouses include infidelity, incompatibility, drinking/drug use, and growing apart. Another focus of research related to divorce is the influence that it has on both the partners and/or their children. Divorce has been rated as the most stressful life event one can experience (e.g., Dohrenwend and Dohrenwend 1974). Thus, it is not surprising that the subjective well-being of spouses tends to decrease as they approach divorce and remain relatively low during the years following divorce (Lucas 2005). Along these lines, parents tend to experience detrimental psychological and emotional consequences as a result of divorce, such as higher levels of depression and anxiety (see Braver et al. 2006). Additionally, a family’s income tends to drop as the transition to divorce occurs, as does the time that parents have to spend with their children (Hanson et al. 1997). With regard to children of divorced parents, they too tend to experience negative consequences, including behavioral, social, and psychological difficulties (Amato and Keith 1991), although these effects may not be long lasting (Hetherington and Kelly 2002). Children of divorce are more likely to contemplate divorce as unhappily married adults (Amato and DeBoer 2001) and are more likely to experience divorce themselves (e.g., Glenn and Kramer 1985). However, in some ways divorce may actually improve the lives of some children. For example, Amato (2003) found a post-divorce increase in the wellbeing of children whose parents experienced high levels of conflict prior to divorcing. This finding supports the notion that the quality of parents’ relationship prior to divorcing may be more

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predictive of children’s experience of divorce than the divorce itself (e.g., Sun 2001). It is worth noting that partners and their children are not the only ones who experience the cost of divorce; one study found that taxpayers in Utah spend approximately $30,000 per divorce by way of food stamps, welfare, etc. (Schramm 2006). Having said this, the cost may be worth bearing in some instances, especially when one considers the aforementioned research highlighting the potential benefits of divorce in some children’s lives.

Special Considerations for Couple and Family Therapy One study found that nearly half of the couples in its sample reported seeking marital therapy due to concerns related to either divorce or separation (Doss et al. 2004). Given this finding, it is not surprising that divorce is often a possible outcome of marital therapy (Lebow 2015). However, as Lebow mentions, little attention is paid in the literature to therapies that are focused specifically on divorce. One possible reason for this dearth in therapies focused on divorce is that the goal for most therapies, couple focused or not, is that there be marked improvement in client functioning. When marital therapists view their “client” to be the marriage itself, which is often the case, they tend to focus on improving the functioning of the relationship. However, such a focus can interfere with seeing the possibility that what is best for some marriages, and the individuals affected by the marriage, including spouses and children, is that the marriage cease to exist. It is in these cases that understanding how to best treat couples and families going through a divorce becomes paramount. Lebow (2015) suggests that all couple therapists doing good work must not ignore the wish of either one or both partners to divorce, and they should “work to establish an empathic connection and therapeutic alliance with both parties in the process of working with this issue” (p. 448). Lebow also points out that there seems to be consensus among couple therapists regarding the need to first assess the viability of the marriage in

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light of the commitment level of each partner to the marriage. Indeed, there are times that, regardless of the objective qualities and viability of a marriage, some partners see no alternative to divorce. In those instances, much attention should be paid to the therapeutic alliance in order to not alienate either the couple and/or individual partners by invalidating their point of view. Objective markers that signal the possibility that a marriage may, in fact, not be viable include contempt and/or stonewalling, coupled with low levels of positive connection (Gottman and Notarius 2000). Since there is such a pronounced difference between couples who divorce “well” vs. those that do not, a therapist who can guide a couple effectively through the process of divorce can have a very positive impact on all involved. Three methods for helping couples navigate the divorce process are listed here. (Please see Lebow 2015 for a more thorough description of these methods, as well as their appropriate corresponding references). One method for guiding divorcing couples is through group psychoeducational prevention programs, which focus on educating couples/individuals about the process of divorce, what they can expect, and how to handle difficulties that often arise. These programs are often offered as an extension of the court and have been shown to have an ameliorative effect on the divorce process. Another method often used is mediation, which typically involves formal meetings in which mediators help couples negotiate differences regarding legal issues that are often involved in the process of divorce, such as finances and child support and custody. Lastly, divorce therapy is another mechanism through which couples can be helped through the divorce process. As Lebow (2015) points out, all therapies that focus on divorce must be somewhat integrative in nature due to the “many quite distinct tasks involved that are intrinsic to this territory” (p. 451). Divorce therapists’ approach must take into consideration the problems and/or conflicts between the clients; each partner’s goals; the influence the divorce will have on others, including children; and the therapeutic alliance with the couple as an entity and each partner individually.

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References Amato, P. R. (2003). Reconciling divergent perspectives: Judith Wallerstein, quantitative family research, and children of divorce. Family Relations, 52, 332–339. Amato, P. R., & DeBoer, D. D. (2001). The transmission of marital instability across generations: Relationship skills or commitment to marriage? Journal of Marriage and Family, 63, 1038–1051. Amato, P. R., & Keith, B. (1991). Parental divorce and the well-being of children: A meta-analysis. Psychological Bulletin, 110, 26–46. Amato, P. R., & Previti, D. (2003). People’s reasons for divorcing: Gender, social class, the life course, and adjustment. Journal of Family Issues, 24(5), 602–626. Braver, S. L., Shapiro, J. R., & Goodman, M. (2006). The consequences of divorce for parents. In M. A. Fine & J. H. Harvey (Eds.), Handbook of divorce and relationship dissolution (pp. 313–337). New Jersey: Lawrence Erlbaum. Bumpass, L. (1990). What’s happening to the family? Interactions between demographic and institutional change. Demography, 27(4), 483–498. Dohrenwend, B. S., & Dohrenwend, B. P. (1974). Stressful life events: Their nature and effects. New York: John Wiley. Doss, B. D., Simpson, L. E., & Christensen, A. (2004). Why do couples seek marital therapy? Professional Psychology: Research and Practice, 35, 608–614. Glenn, N. D., & Kramer, K. B. (1985). The psychological well-being of adult children of divorce. Journal of Marriage and the Family, 47, 905–912. Gottman, J. M., & Notarius, C. I. (2000). Decade review: Observing marital interaction. Journal of Marriage And the Family, 62(4), 927–947. Hanson, T. L., McLanahan, S. S., & Thomson, E. (1997). Economic resources, parental practices, and children’s well-being. In G. J. Duncan & J. Brooks-Gunn (Eds.), Consequences of growing up poor (pp. 190–238). New York: Russell Sage Foundation. Hetherington, E. M., & Kelly, J. (2002). For better or worse. New York: Norton. Kitson, G. C. (1992). Portrait of divorce: Adjustment to marital breakdown. New York: Guilford. Lebow, J. L. (2015). Separation and divorce issues in couple therapy. In A. S. Gurman, J. L. Lebow, D. K. Snyder, A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 445–463). New York: Guilford Press. Lucas, R. E. (2005). Time does not heal all wounds: A longitudinal study of reaction and adaptation to divorce. Psychological Science, 16, 945–950. National Center for Health Statistics. (2015). National marriage and divorce rate trends (Retrieved September 3, 2016, from http://www.cdc.gov/nchs/nvss/mar riage_divorce_tables.htm). Orbuch, T. L., Veroff, J., Hassan, H., & Horrocks, J. (2002). Who will divorce: A 14-year longitudinal study of Black couples and White couples. Journal of Social and Personal Relationships, 19(2), 179–202.

Doherty, William Organization for Economic Cooperation and Development. (2015). SF 3.1. Marriage and divorce rates (Retrieved September 3, 2016, from Organization for Economic Cooperation and Development, Directorate of Employment, Labour and Social Affairs: http:// www.oecd.org/social/family/database.htm). Oswald, R. F., & Clausell, E. (2006). Same-sex relationships and their dissolution. In M. A. Fine & J. H. Harvey (Eds.), Handbook of divorce and relationship dissolution (pp. 499–514). Mahwah: Erlbaum. Rodrigues, A. E., Hall, J. H., & Fincham, F. D. (2006). What predicts divorce and relationship dissolution? In M. A. Fine & J. H. Harvey (Eds.), Handbook of divorce and relationship dissolution (pp. 85–112). Mahwah: Erlbaum. Schramm, D. (2006). Individual and social costs of divorce in Utah. Journal of Family and Economic Issues, 27, 133–146. Sun, Y. (2001). Family environment and adolescents’ wellbeing before and after parents’ marital disruption: A longitudinal analysis. Journal of Marriage and Family, 63, 697–713. White, L. (1991). Determinants of divorce: A review of research in the eighties. In A. Booth (Ed.), Contemporary families: Looking forward, looking back (pp. 141–149). Minneapolis: National Council on Family Relations.

Doherty, William Elizabeth Doherty Thomas The Doherty Relationship Institute, Saint Paul, MN, USA

Introduction Doherty has made distinctive contributions in four areas of couple and family therapy: medical family therapy to treat couples and families dealing with medical illness; values-based couples therapy; discernment counseling for couples on the brink of divorce; and community engagement work by couple and family therapists.

Career After a background in a Catholic seminary, Doherty entered graduate school at the University of Connecticut in 1972 and earned his PhD in

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Family Studies in 1978. He took at faculty position in the Department of Family Practice at the University of Iowa, where he taught family practice residents. In 1983 he coauthored, with Macaran Baird, MD, the first book on family therapy and family medicine. Subsequently, he and Baird joined the faculty of the Department of Family and Community Medicine at the University of Oklahoma. There he further developed collaborative work on the family systems dynamics of illness and the relationships between health care professionals and families. In 1986, Doherty decided to focus more on his original field of couple and family therapists by taking a faculty position in the Department of Family Social Science at the University of Minnesota. From 1988 to 2009, he directed the doctoral program in marriage and family therapy and engaged in private practice as a licensed psychologist and licensed marriage and family therapist. In 2009 he founded the Minnesota Couples on the Brink Project and in 2010 the Citizen Professional Center, both at the University of Minnesota.

Contributions Doherty sees his contributions as coming at times when he absorbed new influences from outside the field. First was his experience in primary care medicine where he realized how little family therapy had paid attention to problems of medical illness in families. As one of the pioneers in family-centered health care, he partnered with Susan McDaniel and Jeri Hepworth to launch medical family therapy as a clinical domain in the field McDaniel, Doherty & Hepworth (2014). In the mid-1990s he was one of the founders of the Collaborative Family Health Care Association, a multidisciplinary organization promoting collaborative, family-centered health care. Doherty’s next turning point came from absorbing critiques of the psychotherapy field from scholars such as sociologist Robert Bellah who argued that therapists were unwittingly promoting a form of “expressive individualism” – akin to “economic individualism” – that eroded family and community commitments. Doherty

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began to question the conventional values of neutrality of the couples therapy field on the issue of marital commitment and divorce – a neutrality he came to view not as neutral but an unacknowledged individualistic values stance. This led him to write the book Soul Searching in 1995. He later coined the term “marriage friendly therapy,” a challenge to the field to embrace a balanced procommitment stance rather than a neutral stance toward whether marriages (and other life-long committed relationships) endure, with the therapist’s active help, or end in divorce. A year after Soul Searching was published, Doherty (1995) was searching for a way to expand on what he considered the most incomplete part of the book – the chapter on commitment to community. He encountered the work of political theorist and former Martin Luther King associate Harry Boyte, who mentored him on the idea of the “citizen professional” – a professional engaged in promoting the larger public good and who views fellow citizens not just as consumers of professional services but as cocreators of their communities. Doherty developed the Families and Democracy Model (also termed Citizen Health Care) and launched the Citizen Professional Center to promote the role of the “citizen therapist” in cocreating social change action projects Doherty, Mendenhall & Berge (2010). Another turning point occurred in 2007 when Doherty was approached by family court judge Bruce Peterson to help understand the “divorce ambivalence” the judge was seeing when he met with couples informally about their divorce. The assumption in the fields of couples therapy and divorce practice was that once people filed for divorce, any uncertainty about divorcing was over and the task of professionals was to help with an expeditious, constructive divorce process. Doherty’s research with Judge Peterson and Brian Willoughby showed surprising levels of ambivalence among divorcing spouses and an openness to consider services for their marriage. After 18 months of meetings with a group of Collaborative divorce lawyers who were interested in assessing divorce ambivalence in their practices, Doherty developed an intervention for these couples called “Discernment Counseling,” and he

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began training couples therapists in this approach to working with “mixed agenda” couples (one spouse leaning out of the marriage and the other leaning in). Discernment counseling is a shortterm intervention that aims for clarity and confidence in a decision on whether to divorce or commit to six months of couples therapy with divorce off the table – a decision based on a deeper understanding of what has happened to the marriage and each partner’s contributions to the problems Doherty & Harris (2017). A key feature is that, although couples come to each session together, the bulk of the work is with the leaning-in and leaning-out spouses separately, because they have different needs and agendas. His new work as of 2017 has been in response to the social upheaval from the nomination and election of Donald Trump as President. Seeing ferment among therapists about how to deal with their clients’ stress and about the public role of therapists in troubled political times, he founded an organization called Citizen Therapists for Democracy to promote the work of citizen therapists in helping clients with public and political stress and promoting depolarization in local communities and society at large. And he co-founded Better Angels initiative that extends principles of couple therapy to the work of political depolarization at the community level.

Cross-References ▶ Discernment Counseling in Couple and Family Therapy ▶ Divorce in Couple and Family Therapy ▶ Ethics in Couple and Family Therapy ▶ Health Problems in Couple and Family Therapy ▶ Medical Family Therapy ▶ Values in Couple and Family Therapy

References Doherty, W. J. (1995). Soul searching. New York: Basic Books. Doherty, W. J. (2017). Psychotherapy’s pilgrimage: Shaping the consciousness of our time. Psychotherapy Networker, 41(1), 18.

Dominance and Submission in Family Dynamics Doherty, W. J., & Harris, S. M. (2017). Helping couples on the brink of divorce: Discernment counseling for troubled relationships. Washington, DC: American Psychological Association. Doherty, W. J., Mendenhall, T. J., & Berge, J. M. (2010). The families and democracy and citizen health care project. Journal of Marital and Family Therapy, 36, 389–402. McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2014). Medical family therapy and integrative care (2nd ed.). Washington, DC: American Psychological Association.

Dominance and Submission in Family Dynamics Norah E. Dunbar Department of Communication, University of California Santa Barbara, Santa Barbara, CA, USA

Synonyms Power

Introduction Power* is one of the most important aspects of all interpersonal interactions because it operates “under the surface,” affecting the communication choices we make even if conflict is not overt. Power* is the capacity to produce intended effects and, in particular, the ability to influence the behavior of another person. In contrast to power*, which may be latent and covert, dominance refers to behaviors that are overt and visible (Dunbar 2015). Dominance, or it’s corollary, submission, can be examined nonverbally in a variety of ways including kinesic cues (facial expressions, gestures, and body posture), as well as through the use of personal space, touch, vocalics, and other contextual cues of precedence and leadership (Hall et al. 2005). The aggressiveness of verbal messages that are used as well as psychological or physical intimate partner violence would also be characterized as dominance strategies. In family

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conflicts, a variety of these dominance messages can be used simultaneously. The messages can be coded for the purpose of examining the effect of dominance on therapeutic processes and outcomes.

Theoretical Context for Concept Power* and dominance are featured prominently in several theories relating to interpersonal communication which is relevant to couple and family therapy. Dunbar (2015) reviews several relevant theories including social exchange approaches, interdependence theory, normative resource theory, equity theory, dyadic power theory, necessary convergence communication theory, bilateral deterrence theory, the chilling effect, relational control approaches, and sex role theories. A variety of coding schemes consistent with those theories have been used to examine dominance maneuvers in conflicts such as the relational control coding scheme which has been used to study a variety of settings including abusive couples (Sabourin 1995), a coding scheme of dominance-submission in verbal disagreements developed for television dramas but could be applicable to real-life conflicts (Barbatsis et al. 1983), and coding schemes for nonverbal cues of dominance which have been applied more broadly (Dunbar and Burgoon 2005).

Description While there are many different ways in which dominance can be measured in a family therapy setting such as examining the nonverbal cues, verbal messages, or amount of talk that is uttered by every family member, one way to determine dominance is that used by Vall et al. (2016) in a clinical setting. They measured (a) quantitative dominance (who speaks the most), (b) topical or semantic dominance (having control over the topics of the conversation), and (c) interactional dominance (control over the dialogue flow).

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Similarly, Honeycutt et al. (1997) argue that quantitative dominance is not sufficient because the response from the partner is important to assess dominance-submission dyadically. They define dominance as unilateral (when a given family member’s statements elicit a response from another family member but not the reverse) or bilateral (where a person’s statements predict a second person’s turn-at-talk who in turn also elicits a response from the first person). Therapists and researchers could use a variety of these messages to examine the dominance that they are most interested in theoretically.

Application of Concept in Couple and Family Therapy An example of how dominance coding can be used in a therapeutic sample is provided by Vall et al. (2016). They used an example of four clinical sessions with a couple using two therapists and the Dialogical Investigations of Happenings of Change (DIHC) method. They coded the couple and the therapists for quantitative, topical, or interactional dominance and had the partners rate the session on a variety of assessments afterward. They found female expression of power* was manifested through semantic dominance, whereas the male expression of power* was characterized more by quantitative dominance, and the therapists were responsible for more of the interactional dominance. The therapists’ control of the conversation allowed the therapists to regulate the speech and minimize the couple’s dominance and reduce their reliance on a “power and control game.”

Clinical Example Imagine a hypothetical scenario in which a couple is discussing the possibility of separating and what would happen to the family home if they did. One possibility is for the house to be sold and each partner establish an independent household with the children spending time in each place. Another option is for the couple to maintain the

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family residence for the children with the parents alternating living there with the children. A conversation like this could ensue: Husband:

Wife: H:

Therapist: H: W:

I would like to talk to you about the living situation. I think we should keep the house and basically leave the kids unchanged. We could split our time there or something and each have our chance to be with them. . . We wouldn’t share the same house very well. . . . And have another place. I don’t really want to move the kids out of their neighborhood. . .changing schools would be kind of hard (. . .) And you would share the same second residence too? Yes We wouldn’t share the same apartment well either.

In this example, the husband is referring to a marital separation and a new living arrangement. In Vall et al. (2016) dominance coding scheme, he has quantitative dominance because he speaks more (65 words) than the wife (18 words), and her two speaking turns are essentially the same. However, Vall et al. argue that the wife has semantic dominance because she uses her statements to control the conversational topic by objecting to his suggestion saying that the proposed arrangement would not work. Her statements are declarative and have no hedging language, while the husband’s statements do contain hedges like “basically” or “or something” which make them seem less forceful and dominant than the wife’s. Her use of repetition also gives the impression that her decision is nonnegotiable and therefore more dominant. While we are lacking the nonverbal cues that accompany this particular example, if her statement is said as forcefully as it sounds (e.g., with direct eye contact, eyebrows that come down and together, or a lowered chin, a firm tone of voice, and a downward inflection at the end) and the husbands’ lack of certainty contained more submissive cues (such as gaze avoidance, upward inflection in the voice, long

pauses denoted by . . ., and facial uncertainty), then these could be coded as well to underscore their verbal dominance cues.

Cross-References ▶ Family Conflict in Couple and Family Therapy ▶ Power in Family Systems Theory

References Barbatsis, G. S., Wong, M. R., & Herek, G. M. (1983). A struggle for dominance: Relational communication patterns in television drama. Communication Quarterly, 31(2), 148–155. Dunbar, N. E. (2015). A review of theoretical approaches to interpersonal power. Review of Communication, 15(1), 1–18. Dunbar, N. E., & Burgoon, J. K. (2005). The measurement of nonverbal dominance. In V. Manusov (Ed.), The sourcebook of nonverbal measures: Going beyond words (pp. 361–374). Mahwah: Lawrence Erlbaum Associates. Hall, J. A., Coats, E. J., & LeBeau, L. S. (2005). Nonverbal behavior and the vertical dimension of social relations: A meta-analysis. Psychological Bulletin, 131, 898–924. Honeycutt, J. M., Wellman, L. B., & Larson, M. S. (1997). Beneath family role portrayals: An additional measure of communication influence using time series analyses of turn at talk on a popular television program. Journal of Broadcasting & Electronic Media, 41(1), 40–57. Sabourin, T. C. (1995). The role of negative reciprocity in spouse abuse: A relational control analysis. Journal of Applied Communication Research, 23, 271–283. Vall, B., Seikkula, J., Laitila, A., & Holma, J. (2016). Dominance and dialogue in couple therapy for psychological intimate partner violence. Contemporary Family Therapy, 38(2), 223–232.

Donor Conception in Couple and Family Therapy Jean Benward San Ramon, CA, USA

Introduction With about seven million women or one in eight couples in the United States (USA) experiencing

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difficulty conceiving a child, many will turn to assisted reproductive technology (ART) to have children. Some can become parents only with “third-party reproduction,” using eggs, sperm, or embryos from another person. Using donor sperm to bypass male infertility has a 100-year history, becoming more widely used since the 1960s. Further developments in ART have made possible the use of donor eggs and embryos, increasing the number of people who will use gamete donation for family building. Besides its use by heterosexual couples suffering from male infertility, lesbian couples and single women increasingly use donor sperm, with single mothers and same-sex couples now making up a significant percentage of people who use donor sperm.

Description: Donor-Conceived Families in Couple and Family Therapy The historical advice to keep the gamete donation secret, combined with feelings of shame and stigma, left families isolated from social and emotional support. Professionals presumed that parents would forget about using a donor, and the donor-conceived had no need for information about the donor or their genetic origins. In recent decades, the work of researchers and clinicians along with personal accounts by the adult donorconceived and parents has led to the recognition that family building with gamete donation is complex with long-term psychosocial meaning and impact on the family (Daniels 2015). The decision to use donor gametes is usually difficult. Family building this way can create emotional distress as couples and individuals contend with feelings of loss and lack of social support. Individuals and couples, heterosexual or gay and lesbian, face a multitude of decisions, uncertainties, and expenses. Parents fear insecure bonding between the child and the nongenetic parent; fear that others, including the child, will not see the nongenetic partner as the “real parent”; and fear the stigma associated with gamete donation. Couples can experience conflict in decisionmaking, in different ways of coping with stress, in expectations about sharing feelings, and, most

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commonly, in conflict about disclosure to others, including their children. Becoming a parent through gamete donation, like parenting after adoption, entails acceptance of losing a genetic connection with one’s child and shifting the goal from having a genetic child to creating a family and parenthood.

D Therapy Before Parenthood Counseling patients about the psychosocial implications of gamete donation, now strongly recommended by professional groups, is a central feature of infertility care in most ART programs in the USA (Sachs andToll 2015). Patients undergoing in vitro fertilization (IVF) with egg or embryo donation are usually required to meet with a mental health professional for one pretreatment session (Benward 2015a). Counselors typically address anxieties and provide emotional support, information, and referrals to community resources. Recipients of sperm donation, which generally occurs outside an ART program, are rarely referred to counseling even though professional guidelines now recommend counseling for all donor gamete recipients. The difference reflects the institutional settings (sperm bank vs. ART program), a longer history of secrecy in sperm donation, and a disparity in professional referral for counseling for couples facing male factor infertility.

Information Sharing in Donor Conception As acceptance of ART has increased and the stigma of infertility lessened, donor conception is now more openly discussed in society and within individual families. Changes in legal, policy, and clinical practice have led to support for disclosure of donor conception and in providing information about gamete donors (ASRM 2013). Preconception therapy should include discussion about whether to be open with others about using a donor. Decisions about whether to tell, whom to tell, what information to share, and when,

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especially regarding their children, are emotionally charged issues for parents, especially for the nongenetic parent. Parents respond well to information about outcomes, about strategies, and discussion that recognizes their particular fears, without pressure to follow any particular path or decision. Since decisions to not disclose are often fear based, especially for heterosexual couples, therapy can minimize some of the fear and reduce anxiety, regardless of the parents’ decisions about disclosure. Without an opposite sex partner, parents in lesbian couple families and single-parent families are by default more open about donor gametes. Despite this, lesbian couples and single parents can still struggle with how to share information with their child and others and can benefit from assistance. Many therapists recommend parents share information about donor conception when children are in preschool and school-age years, before puberty, so the child can absorb that information over time and the child “always knows (Daniels 2015; Iliol et al. 2017).” The information sharing focuses on “how we became a family” and is not a single event, but part of an ongoing process. Young children respond neutrally, with curiosity, or pleasure, rather than distress. Parents generally feel positive about having shared the information, although with feelings of sadness. Later disclosure, in adolescence or adulthood, can lead to confusion and anger for the donor-conceived, generally because of parental deception, rather than use of donor gametes itself. Despite the risks with later disclosure, research has found no consistent association between age of disclosure and family or offspring functioning, suggesting that factors other than age at disclosure contribute to well-being (Benward 2015b).

Couple Therapy During and After Family Formation Although donor-conceived families overall function well and couples undergoing medical treatment with donor gametes tend not to differ from the general population, infertility and/or stresses associated with medically assisted reproduction

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can affect the parents’ relationship in both the short and long term. The shared experience of conceiving a child can strengthen a couple’s relationship and increase commitment, but using donor gametes carries a risk of psychological distress and exacerbation of previous problems. During medical treatment, relationship issues often take a backseat to the concrete tasks of selecting a donor and navigating the costs and logistics of inseminations or IVF, leaving unresolved relationship stress. Some couples will seek therapy, although they may not identify use of donor gametes as a source of difficulty. A large body of research confirms that therapy and counseling for persons using medically assisted reproduction provides effective assistance, reduces levels of anxiety and depression, and increases coping (Benward 2015a). Concerns about gamete donation resurface throughout the family’s life cycle. Couple and family therapy can help the parents communicate about unresolved conflict or anxiety from gamete donation especially about secrecy or disclosure. Because parents’ feelings about disclosure can be different over time, those who had not disclosed may change their mind and seek help. Questions from their children and others about “family resemblances” and inherited traits can prompt parents to think about disclosure. It is common in donor-conceived families, especially with heterosexual couples, for parents to manage these “resemblance” questions by avoidance. Their children and young adults however often observe hidden cues, such as facial expressions, changing the subject, and vague or unsatisfactory answers to their questions (Daniels 2015; Paul and Berger 2008). Family therapy can help parents identify and process their fears and increase their confidence in discussing donor conception. Disclosure can be a relief to these families. Parents who originally intended to disclose may continue to postpone it. These couples might seek help when internal conflict intensifies as their children approach adulthood or prepare to leave home. Parents who consider disclosure when their children are adolescents or young adults are usually more worried and ambivalent about it than those who seek help when their children are young.

Donor Conception in Couple and Family Therapy

In non-disclosing families, maintaining the secret about donor conception rests on topic avoidance and withdrawing from a conversation about certain subjects. Topic avoidance can lead to a more general psychological distancing and compromise family communication. Helping couples increase their communication openness is a relief to parents and may be as important to family functioning as specific communication to children of donor conception. Because genetics are central to the cultural definition of family, these families often need help in creating a family narrative in which a genetic tie to a stranger outside the family is acknowledged but balanced, knowing that kinship and family are based on more than genetics. Parents can benefit from guidance in creating a family narrative that describes the desire for children, the need for help from a donor, and the creation of a family with “real parents.” Therapy can help parents accept, and explain, how their family is different but the same as other families (Daniels 2015). Another juncture for family therapy can occur when the donor-conceived child reaches adolescence, sometimes, because of depression or acting out. Therapists should be alert for signs they are working with a family who has not disclosed, but the adolescent has an unconscious awareness of their donor conception. When parents have shared information about donor conception, adolescence can be a time of heightened questioning and exploration. The adolescent may be curious about the person who gave the eggs or sperm, including the donor’s name, what the donor looks like, or if they can meet the donor. This interest in the donor reflects making sense of their identity. Some adolescents are also interested in contacting genetic siblings (i.e., offspring conceived using the same donor) growing up in different families. This interest in meeting genetic siblings commonly reflects a hope for information about the donor through identifying shared characteristics with other offspring. Adolescent questioning and information seeking can create family stress and may be something the parents have feared. Therapy can help parents understand that questioning or searching is normal and does

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not reflect problematic parenting and the adolescent is not looking for the “real parent” but looking to understand him/herself better. Communicative openness about the adolescent’s concerns will have a positive effect, independent of what information is available about the donor.

Relevant Research A large body of research has looked at the wellbeing of parents and children and the quality of their relationships in donor-conceived families. These families typically have stable marriages and good parent–child relationships. Overall, there are few differences between donorconceived families compared with families who conceived naturally. Longitudinal studies have found few differences between donor-conceived children and naturally conceived children on scales of emotional symptoms, conduct problems, or peer relationships. These findings apply to all family types, including heterosexual couples, gay and lesbian couples, and single parents. While openness and acceptance of donor conception have increased, there remains religious, cultural, and social disapproval that can make families choose nondisclosure. Research has found that generally there are no overall differences between disclosing and non-disclosing families in parent–child relationships, child functioning, or marital satisfaction (Iliol and Golombok 2015). Some researchers have reported that within disclosing families, parent–child relationships may have less conflict, less maternal stress, and more satisfaction than in non-disclosing ones.

Special Consideration for Couple and Family Therapy Twenty years of research with donor-conceived families confirms that a genetic link is unnecessary for healthy parent–child relationships or child development. But genetic links can hold psychological significance, an outgrowth of which is that some parents seek other families who used the same donor, some offspring look for donors,

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and/or others conceived with the same donor (Freeman et al. 2014). This trend can be seen in one Internet-based nonprofit organization that has helped connect over 16,000 donor-conceived with genetic siblings and/or donors. Motivations for seeking facilitated or mutually requested contact are primarily psychosocial support and genetic knowledge. Among those who make contact, relationships can be close or distant; like friends or family; or positive or disappointing. Therapy can provide a safe and neutral setting to explore the meaning of these potential contacts, how both genetics and relationships contribute to identity and negotiate new kinship connections. Research findings about contact are small, although growing and available as a resource for therapists who see these families. Historically the vast majority of gamete donors in the USA have been anonymous. The growth of direct-to-consumer genetic testing along with the creation of large genealogy databases has made it possible for the donor-conceived to discover their genetic origins, sometimes as an unwelcome shock. DNA testing potentially allows the donor-conceived and donors to discover information about each other, about others conceived with the same donor, and about other genetic relatives. Eventually, this raises questions about the viability of anonymity and of nondisclosure (Harper 2016).

Conclusion Using donor egg, donor sperm, or donor embryo has made parenthood possible for many who cannot achieve it through natural conception. The positive research findings about donor-assisted families further support the use of donor gametes for family building. Therapy for this population is not about a specific theoretical or methodological approach to treatment. It is more important that a therapist understands the range of issues, unique history, and experiences these couples and families can bring to therapy. Therapy can support these families before conception and throughout the family life cycle.

Donor Conception in Couple and Family Therapy

Cross-References ▶ Infertility and Pregnancy Loss in Couple and Family Therapy

References American Society for Reproductive Medicine. (2013). Informing offspring of their conception by gamete or embryo donation: A committee opinion. Fertility and Sterility, 100, 45–49. Benward, J. (2015a). Disclosure: Helping families talk about assisted reproduction. In S. Covington (Ed.), Fertility counseling: Clinical guide and case studies (pp. 252–263). Cambridge: Cambridge University Press. Benward, J. (2015b). Mandatory Counseling for gamete donor recipients: ethical dilemmas. Fertility and Sterility, 104(3), 507–512. Berger, R., & Paul, M. (2008). Family secrets and family functioning: The case of donor assistance. Family Process, 47, 553–566. Daniels, K. (2015). Understanding and managing relationships in donor assisted families. In K. Fine (Ed.), Donor conception for life: Psychoanalytic reflection on new ways of conceiving the family (pp. 181–208). London: Karnac Books. Freeman, T., Graham, S., Ebtehaj, F., & Richards, M. (2014). Relatedness in assisted reproduction: Families, origins and identities. Cambridge: Cambridge University Press. Golombok, S. (2015). Modern families: Parents and children in new family forms. Cambridge: Cambridge University Press. Harper, J.C., Kennett, D., & Reisel, D. (2016). The end of donor anonymity: how genetic testing is likely to drive anonymous gamete donation out of business. Human Reproduction, 31(6), 1135–1140. Ilioi, E., Blake, L., Vasanti, J., Roman, G., & Golombok, S. (2017). The role of age of disclosure of biological origins in the psychological wellbeing of adolescents conceived by reproductive donation: A longitudinal study from age 1 to age 14. Journal of Child Psychology and Psychiatry, 58(3), 315–324. Ilioi E.C., & Golombok, S. (2015). Psychological Adjustment in adolescents conceived by assisted reproduction techniques: a systematic review. Human Reproduction, 21(1), 84–96. Nordqvist, P., & Smart, C. (2014). Relative strangers: Family life, genes and donor conception. Basingstoke: Palgrave Macmillan. Sachs, P., & Toll, C. (2015). Counseling recipients of anonymous donor gametes. In S. Covington (Ed.), Fertility counseling: Clinical guide and case studies (pp. 97–108). Cambridge: Cambridge University Press.

Double Bind Theory of Family System

Double Bind Theory of Family System Samuel Major1 and Adam R. Fisher1,2 1 The Family Institute at Northwestern University, Evanston, IL, USA 2 Brigham Young University, Provo, UT, USA

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bind, communication patterns are common. Thus, the double bind theory of family systems was created. Although the theory was highly controversial at the time and the idea that double-binds specifically cause schizophrenia has been widely rejected (Wetchler and Hecker 2015), the double bind theory continues to play a role in modern therapy as it points therapists to a common communication pattern in dysfunctional families (Gibney 2006).

Name of Theory Double Bind Theory of Family Systems

Prominent Associated Figures

Synonyms

Gregory Bateson, Jay Haley, Don Jackson, John Weakland

Double bind hypothesis; Double bind theory of paradoxical communication; The double bind theory of schizophrenia

Description

Introduction

The double bind theory of family systems is a culmination of several concepts found in cybernetics that were combined to explain what doublebinds are and how they can play a prominent role in dysfunctional family systems. Gibney (2006) stated:

During the advent of the field of marriage and family therapy in the 1950s, Gregory Bateson assembled the Palo Alto Group – a team of scientists and psychiatrists to further study the nature of communication as it related to self-regulating systems via mechanisms of information, control, and feedback (Gibney 2006). This group from Palo Alto, California, was particularly interested in communication patterns in families where a member had developed schizophrenia, hoping to reject the strictly biological model of schizophrenia that was popular during that time (Nichols and Schwartz 2001). As a result, the group produced the landmark report Toward a Theory of Schizophrenia (Bateson et al. 1956), which offered the hypothesis that schizophrenia was not biologically caused, rather it was “caused and/or promoted by irresolvable communicational conundrums in families” (Gibney 2006, p. 48) known as double-binds. In other words, they understood schizophrenia to make sense in a familial context where paradoxical, or double-

The essential hypothesis of the double bind theory is that the ‘victim’ – the person who becomes psychotically unwell – finds him or herself in a communicational matrix, in which messages contradict each other, the contradiction is not able to be communicated on and the unwell person is not able to leave the field of interaction (p. 50).

Nichols and Davis (2012) summarized the double-bind phenomenon by describing the victim as “[receiving] two related but contradictory messages on different levels but [finding] it difficult to recognize or comment on the inconsistency” (p. 14). Or even more simply put, “families produced schizophrenia by simultaneously calling for two contrary ways of being” (Lebow 2014) for the identified patients. In order to further understand the components and processes that constitute a double-bind, it is important to first understand what is meant by different levels of communication. According to Bateson, all communications between individuals

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had content that was stated (i.e., report) and a second more abstract message that conveyed how the communication was to be taken or understood by the individual receiving the message (i.e., command; Nichols and Schwartz 2001). The simple example of a mother telling her child to clean his room illustrates that there is the report (“please clean your room”) and the command (“I am in charge, therefore do what I say”). When putting forth the double bind theory, Bateson and his colleagues worked from the assumption that all communications in families had these two levels and that contradictions between either the same level or differing levels could create misunderstanding between individuals. However, it is easy to misuse the concept of a double-bind as merely a contradictory message from which an individual is able to freely choose either alternative (e.g., “stand up for yourself” but also “don’t be rude”). To clarify the difference, Bateson and his colleagues enumerated six components that constitute a double-bind (Nichols and Schwartz 2001): 1. Two or more persons in an important relationship. 2. Repeated experience. 3. A primary negative injunction, such as “Don’t do X or I will punish you.” 4. A second injunction at a more abstract level conflicting with the first, also enforced by punishment or perceived threat. 5. A tertiary negative injunction prohibiting escape and demanding a response. Without this restriction, the “victim” won’t feel bound. 6. Finally, the complete set of ingredients is no longer necessary once the victim is conditioned to perceive the world in terms of double binds; any part of the sequence becomes sufficient to trigger panic or rage (p. 13). Highlighting the essentials of a double-bind for clinical application, Piercy et al. (1996) simplified the six components of a double-bind into three primary characteristics. First, a paradoxical message is conveyed between two individuals at different levels of abstraction. Second, the two individuals are in a long-term, emotionally

Double Bind Theory of Family System

important relationship in which trust has been established. Third, the receiver of the message cannot comment on the perceived, though not always understood, paradox of the message in order to escape the double-bind. The double bind theory posits that within a family in which those characteristics are found, it makes sense that the individual caught in the double-bind would develop psychotic symptoms.

Relevance to Couple and Family Therapy The double bind theory is relevant and valuable to the field of marriage and family therapy in regards to its historical, theoretical, and clinical significance (see Gibney 2006 for a more in depth list of its significance). Historically, the double bind theory was one of the first attempts to break free from the primarily biologically based explanations of its day in order to propel the field of marriage and family therapy into a more prominent position in the social sciences (Nichols and Davis 2012). It was also one of the first attempts to conduct a research project that applied cybernetics and systems theory to the study of communication (Wetchler and Hecker 2015). Relatedly on a theoretical level, the double bind theory pointed therapists to look at how many psychiatric symptoms made sense in the context of pathologic family communications (Nichols and Schwartz 2001). In other words, psychiatric problems were no longer conceptualized strictly in terms of individual deficits but could instead be conceptualized in terms of interactional patterns between individuals in the contexts of their families and other social groups. Clinically speaking, the double bind theory created a way of helping therapists to label and understand what was happening intrapsychically during an interaction common in therapy (Gibney 2006). The theory also confirmed the idea of levels of communication which is foundational to understanding the messages and narratives experienced by individuals in their families. In other words, it brought clinical awareness to a systemic perspective that was beneficial to therapy. Double-binds were later found to be clinically useful as a type of intervention common to

Double Bind Theory of Family System

strategic family therapy (Wetchler and Hecker 2015). For example, in order to upset a family’s own paradoxical interactions, a therapist could give a directive that puts that family in a therapeutic double-bind forcing them to solve their interactions. Such as directing the clients to continue on with their symptoms (i.e., a no-change prescription) when clients insist they cannot change, which if followed, paradoxically infers that they are in fact capable of making the choice to change or not change.

Clinical Example Jason and Monica are a heterosexual couple that came into therapy seeking help to prepare them for their intended wedding in a year. They primarily wanted to address communication issues but were most concerned with Jason’s recent increase in anger outbursts over the past couple of months, which had made it difficult for them to discuss serious matters about their intended wedding. The couple told the therapist of their intention to soon be engaged, but that Jason’s anger outbursts made them both feel like they should reconsider the permanence of their relationship. The couple stated that historically they had felt connected with each other and had been able to talk seriously about almost anything, but that over the past couple of months they had been unable to talk due to Jason’s anger. The therapist discussed with the couple their pattern of communication, and if there was a given context when Jason’s anger was most apparent. The couple identified the topic of their engagement was central to the anger outbursts. When asked to enact a discussion about their engagement over several sessions, the therapist observed the following pattern that held similarly across all enactments. First, Monica would tell Jason that he should not tell her when or how he was going to propose to her. However, she would casually remind him that she has panic attacks whenever she has to wait for something to happen. Jason would act confused and ask Monica to stop bugging him so much about the engagement. Monica would then act very hurt and

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tell him that she was not sure she could trust and be in a relationship with him unless they are engaged. Often, the couple did not even have to follow the pattern, and mere mention of the topic of their engagement brought Jason to a point of rage. After observing their interaction, the therapist recognized that Jason was in a double-bind and mapped it into the following injunctions, each with their corresponding report and command: Primary Injunction: “Don’t tell me what you are planning for our proposal, I want it to be a surprise” (Report). “I trust you to surprise me, so you had better not let me down” (Command). Secondary Injunction: “I hate not knowing stuff, it causes me to panic” (Report). “You had better tell me what you are doing or else I’ll blame you for my anxiety” (Command). Tertiary Injunction: “I’m not sure I can trust you until we are engaged” (Report). “Don’t delay the proposal or else I will leave you” (Command). In an individual session with each client, the therapist highlighted the mixed messages that were being given and received. The therapist pointed out that the first message to not reveal the planned proposal was innocent enough on its own (i.e., at the level of report), but that it contradicted the implied message (i.e., the command) of the second statement she was making. The therapist also noted to himself that the command of the primary injunction contradicted the report of the tertiary injunction, potentially creating another double-bind. In order to resolve the double-bind, the therapist worked with Monica on tolerating her anxiety about not knowing, and he worked with Jason on being able to comment on and express his feelings concerning the contradiction in her messages that were now apparent to him. They also worked on helping Jason empathize with Monica’s anxiety about the proposal. Together, the couple worked on more clear and direct communication about their feelings and expectations.

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Cross-References ▶ Bateson, Gregory ▶ First Order Cybernetics ▶ Haley, Jay ▶ Jackson, Donald ▶ Palo Alto Group, The ▶ Schizophrenia in Couple and Family Therapy ▶ Second-Order Cybernetics in Family Systems Theory ▶ Strategic Family Therapy ▶ Systems Theory ▶ Weakland, John

References Bateson, G., Jackson, D., Haley, J., & Weakland, J. (1956). Toward a theory of schizophrenia. Behavioural Science, 1, 251–264. Gibney, P. (2006). The double bind theory: Still crazymaking after all these years. Psychotherapy in Australia, 12(3), 48–55. Lebow, J. (2014). Couple and family therapy: An integrative map of the territory. Washington, DC: American Psychological Association. Nichols, M. P., & Davis, S. D. (2012). Family therapy: Concepts and methods (11th ed.). Hoboken: Pearson Education. Nichols, M. P., & Schwartz, R. C. (2001). The essentials of family therapy. Boston: Allyn and Bacon. Piercy, F. P., Sprenkle, D. H., & Wetchler, J. L. (1996). Family therapy sourcebook (2nd ed.). New York: Guilford Press. Wetchler, J. L., & Hecker, L. L. (2015). An introduction to marriage and family therapy (2nd ed.). New York: Routledge/Taylor & Francis Group.

Doubling in Couple and Family Therapy Daniel B. Wile Oakland, CA, USA

Doubling is a technique developed by Jacob Moreno for use in his group method of psychodrama. A member of the group stands behind the protagonist (the person who defines the dramatic agenda and narrative) and acts as an auxiliary or

Doubling in Couple and Family Therapy

alter ego – a double – expressing what the protagonist might be holding back or unable to say. When adapted for use in couple or family therapy, the therapist does the doubling and takes the role of one partner talking to the other or one family member talking to one or more other family members. Instead of standing behind the partner or family member, however, the therapist typically remains seated in their chair. The therapist says something like, “Okay, so I guess you’re saying___” or “Here, I’ll be you talking to Glen and for you I’ll say, ‘Glen, I____’.” If the therapist wants to increase the dramatic effect of the intervention, they wheel their chair over to the person for whom they are speaking (or kneel or sit in a stool or chair next to this person), looking directly at the other partner (or family member), and deliver their doubling from there.

Theoretical Framework Doubling can be employed in any couple or family therapy approach to interrupt counterproductive partner or family exchanges and to model the kind of relating the therapist adopting that approach seeks to promote: making “I” statements, confiding attachment wishes or fears, taking personal responsibility, turning toward rather than away or against, making repair efforts, establishing boundaries, looking at things from the other person’s point of view, bringing in family-of-origin, externalizing the problem, and so forth. Many therapists use doubling occasionally in their work. Some therapists, such as Gottman and Gottman (2008) and Harville Hendrix, use it more systematically. Doubling is the signature method of my approach, Collaborative Couple Therapy (Wile 1981, 1993, 2002, 2008, 2011), and flows naturally out of the fundamental goal of the approach, which is to increase the couple’s ability to have the conversation needed to deal with what comes up moment to moment in the relationship. The therapist uses doubling to demonstrate how such a conversation might look and feel.

Doubling in Couple and Family Therapy

To simplify presentation, I will talk here only about couples. However, what I say applies equally to families.

Rationale for the Intervention Speaking as one partner talking to the other allows the therapist to enter directly into the couple interaction in order to shift the direction of the conversation, interrupt an escalation, infuse life into a devitalized exchange, or jumpstart an intimate conversation. The therapist shows how it might sound if partners were to find words for what they have been struggling to say and speak from a place of greater vulnerability and generosity of spirit. Taking the role of a partner collapses the space between that partner and the therapist, an effect that is intensified if the therapist moves next to the partner. Doubling – using the first person “I” – can create a mysterious intimacy. The partner softens and, in response, the therapist does also. The partner gains a spokesperson, translator, and advocate. The therapist develops a more palpable sense of the partner’s struggle and helps each partner make her or his point, which often includes figuring out with them what that point is. Doubling – speaking as one partner talking to the other – enables the therapist to enter directly into the couple system. Looked at from a systems point of view, a couple relationship can be seen as consisting of a number of self-reinforcing cycles. When partners are caught in an adversarial cycle – a fight – each attacks and defends in response to the other doing the same. Both feel too unheard to listen, too misunderstood to be understanding, and too provoked by what the other just said to do anything other than resist and retaliate. In this vicious circle, each partner turns the other into an enemy. When partners are caught in a withdrawn cycle, each partner’s silences, monosyllabic replies, distant manner, devitalized tone, avoidance of controversial topics, talking around things, and strained attempts to engage in a conversation stimulate the same in the other much as whispering stimulates whispering. Each partner turns the other into a stranger.

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A third couple cycle – pursuit and withdraw – develops out of the almost inevitable situation in which one partner (the pursuer) has a greater desire than the other (the withdrawer) for sex, time together, intimate conversation, or other type of connection. The more the pursuer presses for what they want, the more the withdrawer feels suffocated and backs away. The more the withdrawer backs away, the more the pursuer feels deprived and lonely and presses. At some point, the pursuer gets frustrated, leading to a fourth vicious circle: attackwithdraw. The pursuer now responds to the other partner’s withdrawal by attacking. The other partner responds to the first partner’s attack by withdrawing.

Description of the Intervention The task in couple therapy is to shift partners out of the particular vicious circle in which they are caught (attack-attack, withdraw-withdraw, pursue-withdraw, or attack-withdraw) and into the virtuous cycle of confide-confide – a collaborative cycle (Wile 2013). In a collaborative cycle, each partner confides heartfelt feelings, makes acknowledgments, reassures, gives the other the benefit of the doubt, and looks at things from the other’s point of view in response to the other doing the same. Each partner turns the other into an ally and confidant. Doubling – taking the role of one partner talking to the other – is a powerful means for jumpstarting a collaborative cycle. The therapist takes the fight-inducing or withdrawal-inducing comment a partner just made and translates it into an intimacy-inducing one. The therapist accomplishes this transformation by: 1. Changing the tone – replacing the partner’s harsh tone of voice with a friendly one or distant tone with an engaged one. 2. Introducing vulnerable feelings – turning the partner’s angry complaint into a wish, fear, or other vulnerable feeling or devitalized comment into a heartfelt one.

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3. Making acknowledgments. A colleague, Dorothy Kaufmann, pointed out the crucial role of acknowledgment in doubling. When partners fight, neither gets the satisfaction of having the other agree with or acknowledge anything – which is what fuels the fight. When partners withdraw, they are, of course, not tuned into each other. As the therapist, I do the agreeing, acknowledging, and tuning in for them. When I double for partners deep in argument, I begin if possible with, “You’re right that. . ..” and then go on to acknowledge what I imagine that person I’m speaking for does agree with. My “You’re right” breaks the spell of the partners’ reflexive rejection of everything the other one says. My upbeat words make them aware, by contrast, of the grim, giving-no-quarter state they’ve been in. If I can’t think of anything that a partner, let’s call her Marianne, agrees with in what her partner, Lynne, is saying, I acknowledge on Marianne’s behalf that she has at least heard what Lynne has said. Speaking as Marianne talking to Lynne, I say something like, “I get what you’re saying, which is____. And what I’m trying to say is_____” or “I’m getting frustrated because I can’t get you to see that____. Of course, you might be equally frustrated because you can’t get me to see that____.” Such even-handed representation of each partner’s message can at times break the logjam. 4. Reporting the couple predicament. When partners fight, they are down in the muck having it out. When they withdraw, they are essentially absenting themselves from the scene. When I double for them, I show how it might look if they were to step up, as if on a platform, and, in the words of Finkle et al. (2013), adopt “the perspective of a neutral third party who wants the best for all involved.” Dan (speaking as Juanita talking to David): We’re stuck again in this painful vicious circle in which you withdraw when I get critical and I get critical when you withdraw. It’s caused us a lot of misery. Dan (speaking as Sid talking to Amelia): It’s heartbreaking. We’ve finally found in each other

Doubling in Couple and Family Therapy someone we could really love. We never thought we would. But because it’s been your lifelong dream to have a baby and I can’t bring myself to having another – I’ve already had three with my ex – we might lose it all.

I try to show how it might look if these partners were to step back from the intensity of the situation, view themselves and their partner compassionately, recognize the “couple predicament,” to use Erik Grabow’s words, and appreciate each partner’s struggle.

Case Example When doubling for a partner, the therapist restates what that partner just said in a way that is more satisfying to that partner and easier for the other partner to hear. Jack (to Anna): You fuss too much with the baby. You –

From what I know of this couple, Anna is almost certain to react angrily, and the two are about to slip into the kind of escalated exchange that they’ve come to therapy to stop. I pre-empt the fight by moving in and replacing Jack’s complaint with a vulnerable feeling, his “you” statement with an “I” statement. Dan: Jack, let me soften that and see what you think. Here, I’ll be you talking to Anna. And for you, I’d say, “Anna, I miss the alone time we used to be able to have before Ella was born.”

Since I’m making a speculation – although an informed one – I quickly add, “Where am I right and where am I wrong in my guess about how you feel?” Anna is almost certain to find my restatement easier to hear. She’s likely to turn to Jack and say something like, “It would make all the difference if you put it that way” or “Is that how you feel?” I prepare for the possibility, however, that she might say to Jack, “He said that, you didn’t!” My task then would be to double for her. “Anna, are you saying, ‘Jack, it’s too good to believe that you might actually feel that way, but it would be wonderful if you did’.” I’d be reshaping

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Anna’s fight-inducing comment into an intimacyinducing one, as I did a moment before for Jack. Again, I’d add, “Anna, where am I right and where am I wrong in my guess about how you feel?” But how does Jack feel about my replacing his “You fuss too much with the baby” with “I miss the alone time we used to be able to have”? He might welcome it, seeing that my translation is more likely to get Anna to listen. He might feel relief in having his tender feelings brought into the open. I’m using an example – missing alone time with Anna – to suggest the range of soft underbelly feelings. I’m saying in essence, “Jack, there’s a whole different angle from which to look at this situation – the angle of vulnerable feelings. For example, maybe you miss the alone time you used to be able to have with Anna. If that doesn’t capture how you feel, is there a vulnerable feeling of another sort that does?” Jack might not want at the moment to talk about vulnerable feelings. He might say, “What I feel is that Anna fusses over the baby too much” or “No, you’ve got it all wrong. It’s what I said, which is. . ..” But let’s say he welcomes the opportunity to confide his softer feelings. Turning to Anna, he says: • • •

“I feel foolish being jealous of my own daughter.” or “I miss the intimacy that you get breast feeding Ella. I feel so left out.” or “I wish my mother had been a fraction as concerned about me as you are about Ella.”

Jack would be confiding feelings in a way that could jumpstart an intimate conversation. This brief exchange demonstrates how in doubling the therapist:

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• Interrupts an escalating exchange (and, in other cases, breathes life into a devitalized one) • Turns what the couple is concerned about or struggling with at the moment into an opportunity for intimacy • Ends each doubling statement by asking in one form or another, “Where am I right and where am I wrong in capturing how you feel?” But is it such a good idea to skip over Jack’s complaint that Anna fusses too much over Ella and to suggest the issue is also within him? Couldn’t he feel embarrassed or undercut? Couldn’t he believe I’m siding with Anna and putting the blame on him? He could. Accordingly, before making my intervention, I ask myself, “Is there a chance that my comment will alienate Jack in a way I can’t easily repair?” If I believe there is, I content myself with a less chancy intervention such as: Dan: Here, I’ll be you, Jack, talking to Anna. And for you, I’d say, “Anna, I know we disagree about Ella, but don’t you wonder sometimes whether there might be at least a little something to my concern?” Or: Dan: “Anna, I wish I had a way to talk with you about Ella that didn’t just lead to an argument – because it’s hard for me to believe I’m entirely wrong about you being overly involved with her.” Or, demonstrating how it might sound if Jack were to acknowledge Anna’s point of view. Dan: “Anna, I get what you’re telling me, which is that how we treat Ella now will greatly affect her whole life. She needs our attention. What I want to tell you is that there’s a possibility of overdoing it.” (To Jack) And you might want to add – you tell me – “If we’re to do our best for Ella, we need to keep things alive in our own relationship.” I made that up, Jack. You tell me if there’s anything to it at all. Or, reporting the couple predicament.

• Provides an in vivo demonstration of intimate talking • Serves as spokesperson, translator, and advocate for each partner • Recasts what each partner says in an effort to make it more satisfying to that partner and easier and/or more positively engaging for the other partner to hear

Dan: “It’s difficult when we disagree about something so important. We each want to do right by Ella and we have such different ideas at the moment what that means. It’s so important that it’s hard not to get upset with each other. This is tough.”

I’m getting behind Jack in what he has been trying to say, but reshaping his angry statement into one that might actually start a conversation. Instead of

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pressing his case, which is what he is doing, I show how it might look if he were able to step back from the intensity of the moment and present what he wants to say in a more disarming and less accusing way. If I stick more closely to what Jack has been saying – if I meet him where he is and pay attention to what he’s trying to express – he may be able to look at his vulnerable feelings, if not immediately, perhaps later in the session or in future sessions. People need to feel heard in order to feel safe enough to confide their vulnerable feelings or even just recognize that they have them. Doubling reveals to partners the problematic aspects of their way of relating. By giving the partners examples of what confiding, acknowledging, and listening look like, the therapist shows by contrast how they have been accusing, dismissing, and not listening. For many couples the experience is enlightening. They enjoy the better conversations the therapist helps them have and, after a while, begin to improve their conversations at home. A few couples never quite get the hang of what the therapist is doing. For some couples, the experience is transformative. They quickly see what they’ve been doing and go on to adopt their own version of this more productive way of relating.

Dulwich Centre handbook of couple therapy (4th ed., pp. 138–164). New York: Guilford Press. Wile, D. B. (1981). Couples therapy: A nontraditional approach. New York: Wiley. Wile, D. B. (1993). After the fight: Using your disagreements to build a stronger relationship. New York: Guilford. Wile, D. B. (2002). Collaborative couple therapy. In A. S. Gurman & N. S. Jacobson (Eds.), Clinical handbook of couple therapy (3rd ed., pp. 281–307). New York: Guilford. Wile, D. B. (2008). After the honeymoon: How conflict can improve your relationship, revised edition. Oakland: Collaborative Couple Therapy Books. Wile, D. B. (2011). Collaborative couple therapy. In D. K. Carson & M. Casado-Kehoe (Eds.), Case studies in couples therapy: Theory-based approaches (pp. 303–316). New York: Routledge. Wile, D. B. (2013). Opening the circle of pursuit and distance. Family Process, 52, 19–32.

Dulwich Centre Cheryl White Dulwich Centre, Adelaide, Australia

Name of Organization or Institution Dulwich Centre

Introduction Cross-References ▶ Collaborative Couple Therapy ▶ Collaborative and Dialogic Therapy with Couples and Families ▶ Emotionally Focused Couple Therapy ▶ Gottman Method Couples Therapy ▶ Psychodrama in Family Therapy

References Finkle, E. J., Slotter, E. B., Luchies, L. B., Walton, F. M., & Gross, J. J. (2013). A brief intervention to promote conflict reappraisal preserves marital quality over time. Psychological Science, 24, 1595–1601. Gottman, J. M., & Gottman, J. S. (2008). Gottman method couple therapy. In A. S. Gurman (Ed.), Clinical

Dulwich Centre in Adelaide, Australia, is one of the key “homes” of narrative practice and is involved in narrative therapy, community work, training, publishing, supporting practitioners in different parts of the world, and cohosting international conferences. Dulwich Centre is a place of innovation and creativity. Throughout the time that Michael White was involved at Dulwich Centre (from 1983 until his untimely death in 2008), he was continually developing new forms of narrative practice to challenge and inspire and to invite the field to think beyond what was already known. Practices such as externalizing conversations (which involve locating personal and family problems in broader social contexts including gender,

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race, class, sexual identity), therapeutic documentation, re-authoring conversations, saying hello again/remembering conversations, and outsiderwitness practice all evolved during Michael White’s time at Dulwich Centre and in collaboration with David Epston (who visited regularly).

Location Dulwich Centre is located at 20 St John Street, Adelaide, South Australia. This is on the lands of the Kaurna (Aboriginal) people. The Dulwich Centre is also located online at www.dulwichcentre.com.au.

Prominent Associated Figures Michael White, cofounder along with David Epston of narrative therapy, was a director at Dulwich Centre from 1983 until his death in 2008. As a family therapist, teacher, community worker, and writer, Michael White’s work transformed conventional notions of therapy. Cheryl White is a codirector of Dulwich Centre, founder of Dulwich Centre Publications and editor and initiator of projects. Cheryl is the author of A Memory Book for the Field of Narrative Practice and Conversations about Gender, Culture, Violence & Narrative Practice: Stories of hope and complexity from women of many cultures. Barbara Wingard is a senior Kaurna (Aboriginal) elder. She is a coauthor, with Jane Lester, of the influential book, Telling our Stories in Ways that make us Stronger, and coauthor, with Carolynanha Johnson and Tileah Drahm-Butler, of the book Aboriginal Narrative Practice: Honouring storylines of pride, strength and creativity. David Denborough is a codirector of Dulwich Centre, community worker, teacher, and writer/ editor. His books include Retelling the stories of our lives: Everyday narrative therapy to draw inspiration and transform experience and Collective narrative practice: Responding to individuals, groups, and communities who have experienced trauma.

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Jane Hales has worked at Dulwich Centre since 1983 as receptionist, administrator, typesetter, and proofreader and is the coeditor of the book, The Personal is Professional: Therapists reflect on their families, lives and work. Dulwich Centre has a long history of partnership with the Just Therapy Team of Aotearoa New Zealand: Charles Waldegrave, Taimalieutu Kiwi Tamasese, Flora Tuhaka and Warihi Campbell. Key current members of the Dulwich Centre national and international faculty include Jill Freedman, David Epston, Carolyn Markey, Chris Dolman, Gaye Stockell, Mark Hayward, Ncazelo Ncube-Mlilo, Tileah Drahm-Butler, Angel Yuen, Ruth Pluznick, Sekneh Beckett, Manja Visschedijk, Loretta Pederson, David Newman, and Poh Lin Lee. Over three decades, there have been so many other people who have contributed to Dulwich Centre in diverse ways. Dulwich Centre has been a foundation or stepping stone for people to train, work, move on, and start their own programs and centers all over the world.

Contributions During the 1990s, collective projects, such as: the Dulwich Centre alternative community mental health project; narrative community gatherings, including those in partnership with Aboriginal communities; and more recently, cross-cultural inventions such as the Tree of Life and Team of Life narrative approaches, continue to push the field of narrative practice in new directions. This commitment at Dulwich Centre to continually extend what is known as narrative practice is now enhanced through the Master of Narrative Therapy and Community Work, which is offered in collaboration with the University of Melbourne. This program requires participants to innovate local forms of culturally respectful forms of narrative practice. The master program is designed so it is accessible to practitioners wherever they are based and has had graduates from Singapore, Canada, Australia, Spain, Hong Kong, Israel, Tanzania, Ireland, Chile,

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South Africa, Denmark, Mexico, New Zealand, and the UK. Dulwich Centre also cohosts longterm training programs in Turkey, Singapore, Greece, Hong Kong, and mainland China. One week intensive workshops, One year programs, and short workshops are also offered locally in Adelaide. As well as seeking to spark innovation, Dulwich Centre has also sought to create forums to sustain conversations between practitioners and build and support a community of ideas. In 1983, Cheryl White initiated a series of free events on Friday afternoons. These “Friday afternoons at Dulwich” would begin at 4.30 pm so that people dropped by on their way home after the working week. They always consisted of a good speaker sharing some aspect of their practice that was currently intriguing and challenging to them and which was then followed by rigorous debate and discussion. Eventually these events became too popular to continue in person, but with the advent of the internet, Friday afternoon forums now take place online. On the last Friday of every month, a free video is streamed on www.dulwichcentre. com.au. A rigorous free introductory course on narrative therapy is also available online, which provides ideas and resources to practitioners who otherwise could not access them. The “community of ideas” associated with narrative practice is now nurtured online as well as through events, trainings, and publications. In the 1980s there was so much energy and interest in the early Friday afternoon presentations that it seemed a good idea to write these down, and a small news-sheet was developed for this purpose. Links were generated between a range of local practitioners and these first news-sheets were simply a way to continue the conversations. Over time, people from other places requested copies of the news-sheet, which gradually turned into a journal. Interest in the ideas continued to grow and, in 1989, Dulwich Centre Publications published its first book, Literate means to therapeutic ends, by David Epston and Michael White (which was then republished as Narrative means to therapeutic ends by W. W. Norton). Fast forward to the present and there is now a substantial

Dulwich Centre

body of work written by narrative therapists and community workers published in different parts of the world. Dulwich Centre Publications has published over 25 books and countless journal articles and stories of practitioners’ work. If a therapist is seeking writing about the use of narrative approaches with someone experiencing a particular difficulty, there is a good chance such a piece of writing now exists (see narrative therapy bibliography: http://www.narrativetherapylibrary.com/bibliography). Dulwich Centre Publications remains an independent, feminist-informed publishing house, headed by Cheryl White, that publishes writings that represent a diversity of cultures and sexual and gender orientations and which stretch and challenge dominant cultural understandings of the worlds in which we live and work. The International Journal of Narrative Therapy and Community Work is a peer-reviewed journal produced by Dulwich Centre Publications. Dulwich Centre Foundation supports workers and communities in different parts of the world who are responding to significant trauma. This involves: • Direct counselling and community work with individuals, groups, and communities • Developing respectful, effective, and culturally appropriate methodologies to respond to community mental health issues and collective trauma • Working in partnership with local communities to engage with children, young people, and adults using these methodologies • Building the capacity of local mental health workers/community members to address mental health issues in a range of contexts. Crucially, this work involves cross-cultural partnerships, processes to avoid or minimize the chance of psychological colonization, and the cross-cultural inventions of new ways of working (such as the Tree of Life and Team of Life narrative approaches). Dulwich Centre Foundation has a history of working in partnership with colleagues and

Dulwich Centre

organizations in Palestine, Rwanda, Uganda, Bosnia, Israel, India, Sri Lanka, Kurdistan (Iraq), and within Australia with asylum seekers, refugees, young people, and Aboriginal communities. Current projects within Australia focus on using narrative practices to facilitate the sharing of stories of “survival skills” and “life-saving tips” between diverse groups of young people. Enabling young people from diverse backgrounds to make contributions to each other is a powerful force for social cohesion. When young people experience that their skills and knowledge can contribute to others who are going through hard times, then their own experiences of negotiating isolation, marginalization, and cultural and/or religious intolerance take on a different meaning. By eliciting, documenting, and sharing “survival skills” between young people, this builds their capacity to respond to hardship in their own lives and enables a sense of inclusion and acknowledgment through making a contribution. Through these social projects, Dulwich Centre Foundation seeks to respond to racism, Islamophobia, sexism, and homophobia. Since 1999, Dulwich Centre has hosted International Narrative Therapy and Community Work Conferences in Adelaide (Australia), Atlanta (USA), Liverpool (UK), Oaxaca (Mexico), Hong Kong (China), Kristiansand (Norway), and Salvador (Brazil). These events seek: • To provide high-quality presentations on the latest thinking and application of narrative ideas and to do so in ways that enable people of differing experience to be both engaged and challenged • To enable people of different cultures, countries, genders, ages, class backgrounds, physical abilities, and sexual identities to come together, enjoy each other’s company, and have a sense that the conference program and processes include their perspectives, hopes, and ideas • To use the conference as a chance to acknowledge and come to terms with the history of the land on which it is held

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• To create an opportunity for participants to build a sense of connectedness and to contribute to the building of a community of ideas • To provide the opportunity and support necessary for individuals and groups who have never presented before at conferences (and indeed may never have told their stories in front of an audience) to present the stories of their lives and their particular knowledges and skills in keynote addresses • To create an atmosphere that is nonhierarchical, with no pronounced difference between presenters and participants • To provide a forum for conversations that are expanding the field (not confirming it or simply reiterating what is already known) • To decenter the conference collective in both the lead-up and during the conference itself so that the focus remains on everyone’s contributions to a community event The Michael White Archive is located at Dulwich Centre. This archive includes Michael’s unpublished papers and video recordings of his teachings and selected therapy sessions. Two books, Narrative Practice: Continuing the Conversations and Narrative Therapy Classics, have already been published from archival material. In the coming years, further material from the archive will be made available to practitioners, students, and scholars. Finally, Dulwich Centre is also a continually evolving team and network of narrative therapists, community workers, teachers, and writers. The Dulwich Centre’s national and international faculty is diverse in terms of cultures, locations, genders, sexual orientations, age, and class backgrounds. In recent years, the Aboriginal Narrative Practice Teaching Team (led by Aunty Barbara Wingard and Tileah Drahm-Butler) has begun to offer workshops on narrative therapy through an Aboriginal lens and on how narrative practices can be used to decolonize identity stories. Dulwich Centre is committed to and energized by collaborations across difference.

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Duncan, Barry Martha Hernández Family Support Services at Ronald McDonald House at Stanford, Palo Alto, CA, USA

Duncan, Barry

Currently, he is the CEO of Better Outcomes Now and the Director at The Heart and Soul of Change Project. In this position, he has been able to continue his interest in research and training others use the PCOMS.

Contributions to Profession Name Barry L Duncan, Psy.D.

Introduction Dr. Barry L. Duncan has been essential in the development of client-centered measures specific to the therapeutic relationship, in an effort to improve the quality of treatment. In addition to his client-centered measures, his research has contributed to various areas including couple and family therapy, integrated behavioral health, pharmaceuticals in pediatrics, and addiction. He has over one hundred publications in these areas of specialty.

Career In 1984, Dr. Duncan obtained his Psy.D. from Wright State University, School of Professional Psychology. In that same year, he began as Clinical Faculty at Wright State University (1984–1994) and in 1985 as Clinical Assistant Professor (1985–1992). As Director at The Dayton Institute for Family Therapy, he developed a training and treatment center (1986–1994). Since then Dr. Duncan has held various adjunct professor positions at different universities. More recently, he was the co-founder and co-director of The Institute of the Study of Therapeutic Change (1997–2009), in which he co-developed the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) family measures. He later utilized the ORS and SRS measures to create the Partners for Change Outcome Management System (PCOMS).

Dr. Duncan has contributed in various ways and topics of interests in the field of psychology. Dr. Duncan was the co-founder and the co-director of The Institute for the Study of Therapeutic Change, alongside colleagues Scott Miller and Mark Hubble. During his time as the co-director, he was responsible for co-developing, with Miller, the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) family of measures. Each scale includes four-items given to clients to complete. The ORS is given at the beginning of a session to assess client progress during treatment. While, the SRS is given at the end of sessions and aims at measuring the therapeutic relationship from the client’s perspective. After many years of research, Duncan and Sparks (2002) jointly developed the Partners for Change Outcome Management System (PCOMS), a clinical system that includes administering both the ORS and SRS for client-centered feedback regarding client progress and therapeutic relationship. This now allowed the measures to inform the quality of care being provided to the client from the client’s perspective. Duncan and Sparks, used the PCOMS to be able to address the problem that many therapists struggle with; being able to rate their own effectiveness with clients and treatment. As director of The Heart and Soul of Change Project, he continues to research the clinical use of PCOMS. Dr. Duncan’s main focus has been the client’s individual world views, as well as to utilize the client’s theory of change to improve outcomes. Multiple studies have found that by just utilizing PCOMS, client outcome increased and the therapeutic relationship improved. Since then, PCOMS has been recognized and listed on the SAMHSA’s National Registry of Evidenced-based Programs and Practices.

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Dr. Duncan continues to provide continuing education training for those wanting to learn how to utilize PCOMS. PCOMS is easily accessible and used in hundreds of organizations throughout the United States and in countries across the world. Dr. Duncan has increased accessibility by creating Better Outcomes Now (BON), along with Bill Wiggins. BON is a web-based version of the PCOMS. It allows for therapists and supervisors to monitor clients’ perception of progress and the therapeutic relationship, as well as the changes in scores for clients or the therapist. More information on the PCOMS is further discussed and included in Dr. Duncan’s most recent book On Becoming a Better Therapist: An Evidence-based Practice One Client at a Time (2010).

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Dyadic Adjustment Scale Adam R. Fisher1,2 and Alice F. Roberts3 1 The Family Institute at Northwestern University, Evanston, IL, USA 2 Brigham Young University, Provo, UT, USA 3 Bountiful, UT, USA

Name and Type of Measure The Dyadic Adjustment Scale* is a pen-and-paper measure of the quality of a marriage or similar relationship.

Synonyms DAS; DAS-7; RDAS

Cross-References ▶ Assessment in Couple and Family Therapy ▶ Therapeutic Alliance in Couple and Family Therapy

References Duncan, B. (2014). On becoming a better therapist: Evidence based practice one client at a time (2nd ed.). Washington, DC: American Psychological Association. Duncan, B., & Sparks, J. (2002). Heroic clients, heroic agencies: Partners for change. Ft. Lauderdale, FL: Nova Southeastern University. Duncan, B., & Sparks, J. A. (2016). Systematic feedback through the Partners for Change Outcome Management System (PCOMS). In M. Cooper & W. Dryden (Eds.), Handbook of pluralistic counselling and psychotherapy (pp. 55–67). London: Sage. Duncan, B., Miller, S., Wampold, B., & Hubble, M. (Eds.). (2010). The heart and soul of change: Delivering what works (2nd ed.). Washington, DC: American Psychological Association. Reese, R., Norsworthy, L., & Rowlands, S. (2009). Does a continuous feedback model improve psychotherapy outcomes? Psychotherapy: Theory, Research, Practice, Training, 46, 418–431. Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19, 122–136.

Introduction Dyadic adjustment is one of the most common constructs utilized for assessing marriages or similar romantic relationships (Spanier 1976) and has been used in relationship research for over 50 years in thousands of studies (Graham et al. 2006). These studies have involved adult relationships or marriages on a variety of topics such as stress, emotional health, relationship problems, and outcome studies for psychotherapy models. Definitions of dyadic adjustment include how much accommodation each partner gives the other or the degree to which a couple has established positive qualities in their relationship – such as resolving disagreements. Perhaps the most common definition conceptualizes dyadic adjustment as the quality of a romantic relationship involving two people (Spanier 1976). This quality may also reflect the degree a couple is able to reach consensus on key issues, how much tension they experience due to their differences, and the general lack of distress in the relationship (Graham et al. 2006).

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Developers The Dyadic Adjustment Scale (DAS) was developed in 1976 by Graham B. Spanier at The Pennsylvania State University as a self-report measure of the quality of a marriage or similar relationship.

Description of Measure The DAS consists of 32 Likert-type items, which were developed based on 300 items from existing measures, and is written at an 8th-grade reading level. The DAS is administered separately to each partner. The DAS includes four subscales that can be separately measured: (1) dyadic satisfaction – the amount of tension and one’s commitment to staying in the relationship (10 items); (2) dyadic cohesion – shared behaviors and interests (five items); (3) dyadic consensus – how much the couple agrees on important issues (13 items); and (4) affectional expression – satisfaction with sex and the level of affection in the relationship (four items). Scoring of the DAS involves adding up the total score of each question – resulting in a range of 0 to 151 – with higher scores representing a higher quality of marriage or relationship. Each subscale can also be separately scored. Other shorter versions of the DAS have also been developed, including the 14-item Revised Dyadic Adjustment Scale (RDAS) and a seven-item version (DAS-7). The DAS can be administered by couple and family therapists, as well as psychologists, counselors, social workers, or other professionals with documented training, such as completion of university-level courses in testing and assessment.

Psychometrics Reliability of the total DAS score is high (a = .96; Corcoran and Fischer 2013); the DAS is a reliable measure of objective relationship characteristics. Multiple studies have confirmed its high reliability and have shown that it is not substantially affected by sample participants’ marital status, ethnicity, sexual orientation, or gender (Graham et al. 2006). The four

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subscales are less reliable than the total score, with the affective expression subscale being notably lower than the others (a = .73; Spanier 1976). Notably, the RDAS removes affectional expression entirely, and the DAS-7 includes only three items assessing consensus, three for cohesion, and one for satisfaction. The DAS-7 is a reliable and valid instrument comparable to the DAS (Hunsley et al. 2001). The DAS has also been evaluated for content validity based on the relevancy of items to relationships, consistency of definitions of satisfaction, cohesion, consensus, and appropriateness of fixedchoice responses (Spanier 1976). Concurrent validity has been demonstrated through a high positive correlation with the Locke-Wallace Marital Adjustment Scale (Spanier 1976). Norms of the DAS are based on a group of 218 married and 94 recently divorced adults (Spanier 1989).

Example of Application in Couple and Family Therapy The DAS can be applied in couple and family therapy as a measure of marital or relationship quality of a couple at the time of the initial intake. A couple therapist can compare each partner’s scores to the averages for people who are married (M = 114.8, SD = 17.8; Spanier 1976) or recently divorced (M = 70.7, SD = 23.8), or to those who are in distress (107). Scores can be used to measure the quality of the couple’s relationship pre- and posttreatment as a more objective measure of progress in couple therapy. A partner’s level of satisfaction in the relationship may change from day to day, but measuring adjustment through the DAS may be seen as less susceptible to daily changes in mood. Responses to specific items may also be used to prompt discussion of treatment goals. For example, Chris and Sarah presented to couple therapy having been married for about two years. Their initial DAS scores prior to the intake strongly suggested some marital distress: Chris scored 96 and Sarah 88. The therapist specifically looked at question 32, which asks about level of commitment in the marriage. Sarah scored a 3 out of 5 and Chris a 4 out of 5 on this question, agreeing with the statements,

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respectively – “I want very much for my relationship to succeed, and will do my fair share to see that it does,” and, “I want very much for my relationship to succeed, and will do all I can to see that it does.” The therapist addressed this with the couple near the end of the intake, noting that both partners were very committed to making changes in the marriage. Scoring lower on this question may be cause for concern regarding beginning couple therapy and may suggest the need for a more appropriate approach such as discernment counseling. The therapist then readministered the DAS about once every five sessions or so to check in on progress, as well as specific areas that were initial concerns during the intake, including demonstrations of affection, household tasks, and the frequency of arguments. The therapist presented the data to the couple each time along with a graph displaying their scores. At the end of therapy – which lasted 15 sessions – Sarah’s DAS had increased to 97, out of the “distressed” range, and Chris scored a 112, close to the average score for a married adult. The therapist and the couple discussed the meaning of these scores, what amounts of change are clinically significant (11 points or more), and where the couple felt like they were still vulnerable or concerned in their marriage. They each reported feeling much more stable in their marriage after the sessions, but noted some continued areas of concern, and the therapist provided them with referrals for after their upcoming move for work. Both partners were also appreciative to see the data from the DAS; it provided them with both confidence and clarity in the process.

Cross-References ▶ Assessment in Couple and Family Therapy ▶ Classification in Couples and Families ▶ Couple Distress in Couple and Family Therapy ▶ Discernment Counseling in Couple and Family Therapy ▶ Marital Satisfaction Inventory: Revised ▶ Norms in Couples and Families ▶ Spanier, Graham ▶ Locke-Wallace Marital Adjustment Test

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References Corcoran, K., & Fischer, J. (2013). Measures for clinical practice and research: A sourcebook: volume 1: Couples, families, and children (5th ed.). New York: Oxford University Press. Graham, J. M., Liu, Y. J., & Jerziorski, J. L. (2006). The Dyadic Adjustment Scale: A reliability generalization meta-analysis. Journal of Marriage and Family, 68, 701–717. https://doi.org/10.1111/j.1741-3737.2006. 00284.x. Hunsley, J., Best, M., Lefebvre, M., & Vito, D. (2001). The seven-item short form of the Dyadic Adjustment Scale: Further evidence for construct validity. American Journal of Family Therapy, 29, 325–335. https://doi. org/10.1080/01926180152588734. Kurdeck, L. A. (1992). Dimensionality of the Dyadic Adjustment Scale: Evidence from heterosexual and homosexual couples. Journal of Family Psychology, 6(22), 22–35. South, S. C., Krueger, R. F., & Iacono, W. G. (2009). Factorial invariance of the Dyadic Adjustment Scale across gender. Psychological Assessment, 21, 622–628. https://doi.org/10.1037/a0017572. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and Family, 38, 15–28. Spanier, G. B. (1989). DAS: Dyadic Adjustment Scale. Retrieved from http://downloads.mhs.com/das/das.pdf Spanier, G. B., & Filsinger, E. E. (1983). Clinical use of the Dyadic Adjustment Scale. In E. E. Filsinger (Ed.), Marriage and family assessment: A sourcebook for family therapy (pp. 156–168). Beverly Hills: Sage.

Dyadic Coping Inventory Guy Bodenmann1, Laura Jimenez Arista2, Kelsey J. Walsh3 and Ashley K. Randall4 1 Department of Psychology, University of Zurich, Binzmuehlestrasse, Zurich, Switzerland 2 Arizona State University, Phoenix, AZ, USA 3 Arizona State University, Tempe, AZ, USA 4 Counseling and Counseling Psychology, Arizona State University, Tempe, AZ, USA

Name and Type of Measure The Dyadic Coping Inventory is a self-report questionnaire that measures stress management in couples.

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Synonyms DCI

Introduction The Dyadic Coping Inventory (DCI*) is a widely used (Falconier et al. 2016) self-report questionnaire developed by Bodenmann (2008) to assess partners’ stress expression and dyadic coping behaviors as conceptualized in the SystemicTransactional Model (STM; Bodenmann 1995, 2005). According to the STM, dyadic coping is viewed as a stress management process within the couple, which goes above and beyond social support received from others, where the communication of one partner’s stress, supportive dyadic coping, delegated dyadic coping, negative dyadic coping, and common or joint dyadic coping are differentiated. Supportive dyadic coping includes behaviors such as showing empathy and understanding, showing solidarity with the partner, helping the partner to reframe the situation, helping the partner to calm down, helping the partner to believe in himself/herself, physical tenderness (neck massage, holding) or helping the partner to resolve a practical problem by assisting him/her, searching for practical solutions with the partner, and giving the partner helpful advice. Delegated dyadic coping means taking over tasks and duties that normally the partner does in order to reduce his/her burden. Common/joint/communal dyadic coping includes joint search for information, joint search for solutions of the problem, mutual engagement in problem-solving, joint relaxation, joint solidarity, joint reframing of the situation, joint spiritual coping, mutual self-disclosure and sharing negative emotions, and mutual tenderness (massages, physical contact). Negative dyadic coping is differentiated as hostile (expressing reluctance to help, blaming the partner for creating the stress, criticizing how the partner has responded to the stress, minimizing the partner’s stress, expression of disparagement, distancing, mocking, sarcasm, open

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disinterest), ambivalent (providing support to the partner but in an unwilling and unmotivated way, making the partner feel that provision of support is not appreciated), and superficial (the partner provides support but with no motivation, no authentic empathy, and no real understanding). The STM provides a strong theoretical framework for empirical studies on examining associations between stress and coping on relationship quality, stability, and wellbeing than other dyadic coping approaches (Bodenmann et al. 2011).

Developer The developer of the scale is Dr. Guy Bodenmann, who published the German version of the DCI in 2008.

Description of the Measure The DCI is a 37-item self-report assessment that measures partners’ stress communication and dyadic coping behaviors (35 items). Two additional items assess the satisfaction and efficacy of the couples’ dyadic coping. Participants respond to the statements using a 5-point Likert scale (1 = never/very rarely, 5 = very often). The DCI yields information of the total dyadic coping (sum or mean score), positive or negative dyadic coping (positive dyadic coping is typically built from the subscales supportive dyadic coping, delegated dyadic coping, and common/joint dyadic coping), and selfperceived or partner-perceived dyadic coping. As mentioned above, indexes (i.e., of reciprocity, congruence, and equity) can also be used and reflect a more cognitive, appraisal-based dimension of dyadic coping, while the subscales represent perceived behaviors. As shown in Fig. 1, the DCI yields information on each partner’s perception of his/her own dyadic coping (self-perception) as well as of the dyadic coping that is perceived from the partner (perception of the partner’s dyadic coping). As usually the DCI is completed by both

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Self-perception

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Perception of partner

partners, the DCI yields four direct behaviororiented evaluations of dyadic coping and three additional appraisal-oriented indexes, such as the reciprocity, the congruence, and the equity index. The reciprocity index reflects one’s own and the partner’s own dyadic coping (reciprocity(own)) and the partner-perceived dyadic coping (reciprocity (partner)), i.e., how much partner A’s and partner B’s dyadic coping match in their self- and partner perception. The congruence index refers to the overlap of perceived dyadic coping from partner A and B (i.e., how much the self-perceived dyadic coping of partner A or B corresponds with the other’s perception of partner A’s or B’s dyadic coping). The equity index depicts each partner’s evaluation of how equal his/her and the partner’s contributions to dyadic coping is. Subscales of the DCI The following subscales were factor analytically reported in the original German version of the DCI (Bodenmann 2008): (a) One’s own stress communication (items 1, 2, 3, and 4) (b) One’s own supportive dyadic coping (items 20, 21, 23, 24, 29) (c) One’s own delegated dyadic coping (items 28, 30) (d) One’s own negative dyadic coping (items 22, 25, 26, 27) (e) Partner’s stress communication (items 16, 17, 18, 19) (f) Partner’s supportive dyadic coping (items 5, 6, 8, 9, 13)

reciprocity (o) congruence A

congruence B

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Partner A

equity A

Dyadic Coping Inventory, Fig. 1 Structure of the DCI (Bodenmann 2008)

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(g) Partner’s delegated dyadic coping (items 12, 14) (h) Partner’s negative dyadic coping (items 7, 10, 11, 15) (i) Common or joint dyadic coping (items 31, 32, 33, 34, 35) (j) Evaluation of couple’s dyadic coping (items 36, 37) In different validation studies, however, this factorial structure was not fully supported. In the US validation study of the English DCI, items 2, 3, 9, 17, 18, and 24 were excluded due to poor model fit (Randall et al. 2016). In the Latino validation study of the Spanish DCI in the USA, items 2, 3, 15, 17, 18, 23, and 26 were excluded due to poor model fit (Falconier et al. 2013). In the English validation study in Canada, items 2, 3, 8, 17, 18, 23, and 25 were excluded due to poor model fit (Levesque et al. 2014). In the French validation study, items 2 and 3 were excluded due to poor model fit (Ledermann et al. 2010). In the Chinese validation study of the DCI with a sample of mainland Chinese couples, items 2, 3, 17, and 18 were excluded due to poor model fit (Xu et al. 2016). In the Romanian validation study of the DCI, items 2, 3, 17, and 18 were excluded due to poor model fit (Rusu et al. 2016). However, in the Italian (Donato et al. 2009), the Portuguese (Vedes et al. 2013), and the Hungarian (Martos et al. 2012) validation studies, all items were included as presented in the German version (Bodenmann 2008). In sum, it seems that items 2, 3, 17, and 18 do not fit in different cultures. Therefore, it is recommended to use the validated versions of the specific country where the

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study is conducted or to run a factor analysis with one’s own data to replicate the factorial structure (see Nussbeck and Jackson 2016 in Falconier et al. 2016). The DCI is used in research as well as in clinical practice. Subjects need 10–15 min to complete the DCI. Its evaluation is easy, but requires a template for practitioners. Norms and cut-off scores according to gender and five age groups (30, 31–40, 41–50, >50) are available for the German DCI. The scale can be used with heterosexual couples as well as with same-sex couples (Meuwly et al. 2013; Randall et al. 2017). The DCI has been translated into 25 languages: Arabic, Chinese, Danish, Dutch, French, German, Greek, English, Indonesian, Italian, Japanese, Hebrew, Hindi, Hungarian, Norwegian, Persian, Polish, Portuguese, Romanian, Russian, Korean, Spanish, Thai, Turkish, and Urdu (Falconier et al. 2016). The questionnaire can be used for free in the different languages, except for the German version, where the publisher Hogrefe Tests requires a fee.

Psychometrics The reliability of the original DCI (Bodenmann 2008) was tested in a validation sample of 2,499 subjects and has been replicated since then in multiple studies all over the world. The questionnaire has a four- or five-factorial structure according to the samples. The five-factorial structure differentiates problem-focused and emotionfocused common/joint dyadic coping, while the four-factorial structure just considers common/ joint dyadic coping as one subscale. Internal consistencies of the different subscales of the DCI vary between a = 0.71 and 0.92. Cronbach’s alpha of the total scale is a = 0.90. The validity of the DCI has been supported on concurrent validity (i.e., relationship satisfaction, dyadic communication; e.g., Falconier et al. 2015), criterion validity (i.e., well-being, depression, and anxiety; e.g., Bodenmann et al. 2011), divergent validity (i.e., individual coping; e.g., Herzberg 2013; Papp and Witt 2010), as well as prognostic validity (Bodenmann and Cina 2006;

Dyadic Coping Inventory

Ruffieux et al. 2014). The scale has been used in couples and family research, clinical studies, as well as health studies (e.g., Rottmann et al. 2015).

Example of Application in Couple Therapy The DCI is administered to each partner at the beginning of therapy, in conjunction with an initial set of questionnaires measuring relationship quality and satisfaction, couple communication, couple’s expectations, areas of problems, and sexuality. By having each partner’s separate assessments, the therapist can then compare each partner’s scores within the couple (e.g., ones’ own views of dyadic coping provided by oneself and the partner compared to the views of the partner’s sights) and between couples, classifying the couple within the norms of nonclinical reference population. Typically, the therapist will discuss the results of the DCI with the couple early in the process of the couple therapy (usually during the treatment-goal-setting process), pointing out strengths and weaknesses in couple’s dyadic coping. This is done based on a graphical illustration of both partners findings, matched in one figure. The therapist specifically focuses on (1) aspects of dyadic coping that could be improved in each partner and (2) congruences or discrepancies between partners (e.g., one provides a great deal of supportive dyadic coping, the other not). The DCI mostly commonly serves as a subjective outcome measure for the effectiveness of couple therapy, as it is applied pre- and posttreatment (i.e., 2 weeks and 6 months post-termination). However, in some cases, the DCI can be utilized during treatment (e.g., after each fifth session). Take the examine of Thomas and Barbara who enter therapy with several marital problems. Thomas and Barbara have been married for 20 years. Although they have been committed for a long time, since the birth of their third child, their relationship quality has consistently decreased. Compounding this issue, Thomas has recently lost his job, which has caused distress for the couple. Barbara complains about Thomas’ lack of emotional support and thinks that Thomas

Dyadic Coping Inventory

could also help her more around the house (e.g., delegated dyadic coping), given that he is not currently working. Thomas, on the other hand, reports that he does not feel understood and is constantly criticized, which are all characteristics of negative dyadic coping. He feels like a loser. In working with Thomas and Barbara, after administering the DCI to both of them, the therapist discusses the results with them as a couple. Specifically, the therapist points out strong deficiencies in stress communication in both partners, low levels of supportive dyadic coping, and extreme low scores in common dyadic coping. Not surprisingly, Thomas reports high levels of negative dyadic coping from Barbara. Scores are above the norms of the reference sample (between couple comparison), and within the couple there is a high congruence in a regret of insufficient dyadic coping. Based on these results and observing the couple, the therapist defines goals regarding dyadic coping and explains how the couples’ current situation (i.e., high level of family strain and current unemployment of Thomas) may impact their general life, as well as dyadic coping. The therapist further explains the importance of dyadic coping as an important resource of mutual support. The therapist also illustrates how Thomas and Barbara can join together to cope with their stresses and how they can improve on their techniques. In several sessions, the therapist works with the couple by means of the three-phase method on their mutual stress communication, listening to each other’s stress-related self-disclosure and provision of dyadic coping, matching the other’s needs. At the end of the therapy, the therapist readministers the DCI. In the posttreatment, all scores of the DCI reached the average scores of non-distressed couples and stayed stable over the follow-up period.

Cross-References ▶ Coping-Oriented Couple Therapy ▶ Couples Coping Enhancement Training Enrichment Program ▶ Systemic-Transactional Model of Dyadic Coping

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References Bodenmann, G. (1995). A systemic-transactional view of stress and coping in couples. Swiss Journal of Psychology, 54, 34–49. Bodenmann, G. (2005). Dyadic coping and its significance for marital functioning. In T. Revenson, K. Kayser, & G. Bodenmann (eds.), Couples coping with stress: Emerging perspectives on dyadic coping (pp. 33–50). Washington, DC: American Psychological Association. Bodenmann, G. (2008). Dyadisches Coping Inventar: Testmanual. [Dyadic coping inventory]. Bern: Huber. Bodenmann, G., & Cina, A. (2006). Stress and coping among stable-satisfied, stable-distressed and separated/divorced Swiss couples: A 5-year prospective longitudinal study. Journal of Divorce and Remarriage, 44, 71–89. Bodenmann, G., Meuwly, N., & Kayser, K. (2011). Two conceptualizations of dyadic coping and their potential for predicting relationship quality and individual wellbeing. European Psychologist, 16, 255–266. Donato, S., Iafrate, R., Barni, D., Bertoni, A., Bodenmann, G., & Gagliardi, S. (2009). Measuring dyadic coping: The factorial structure of Bodenmann’s “Dyadic Coping Questionnaire” in an Italian sample. TPM-Testing, Psychometrics, Methodology in Applied Psychology, 16, 25–47. Falconier, M. K., Nussbeck, F., & Bodenmann, G. (2013). Dyadic coping in Latino couples: Validity of the Spanish version of the dyadic coping inventory. Anxiety, Stress and Coping, 26, 447–466. Falconier, M. K., Jackson, J., Hilpert, J., & Bodenmann, G. (2015). Dyadic coping and relationship satisfaction: A meta-analysis. Clinical Psychology Review, 42, 28–46. Falconier, M., Randall, A., & Bodenmann, G. (2016). Couples coping with stress – A cultural perspective. New York: Routledge. Herzberg, P. Y. (2013). Coping in relationships: The interplay between individual and dyadic coping. Axiety, Stress, & Coping: An International Journal, 26, 136–153. Ledermann, T., Bodenmann, G., Gagliardi, S., Charvoz, L., Verardi, S., Rossier, J., Bertni, A., & Iafrate, R. (2010). Psychometrics of the dyadic coping inventory in three language groups. Swiss Journal of Psychology, 69, 201–212. Levesque, C., Lafontaine, M.-F., Caron, A., & Fitzpatrick, J. (2014). Validation of the English version of the dyadic coping inventory. Measurement and Evaluation in Counseling and Development, 47, 215–225. Martos, T., Sallay, V., Nistor, M., & Jozsa, P. (2012). Dyadic coping and well-being – the Hungarian version of the dyadic coping inventory. Psychiatria Hungarica: A Magyar Pszichiatriai Tarsasag Tudomanyos Folyoirata, 27(6), 446–458. Meuwly, N., Feinstein, B. A., Davila, J., Nunez, D. G., & Bodenmann, G. (2013). Relationship quality among Swiss women in opposite-sex versus same-sex romantic relationships. Swiss Journal of Psychology, 72, 229–234.

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818 Nussbeck, F. N. & Jackson, J. B. (2016). Measuring Dyadic Coping Across Cultures. In M. K. Falconier, A. K. Randall, & G. Bodenmann (eds.), Couples Coping with Stress. A Cross-cultural Perspective (pp. 36–53). New York: Routledge. Papp, L. M., & Witt, N. L. (2010). Romantic partners’ individual coping strategies and dyadic coping: Implications for relationship functioning. Journal of Family Psychology, 24, 551–559. Randall, A. K., Hilpert, P., Jimenez-Arista, L. E., Walsh, K. J., & Bodenmann, G. (2016). Dyadic coping in the U.S.: Psychometric properties and validity for use of the English version of the dyadic coping inventory. Current Psychology, 35, 570–582. Randall, A. K., Totenhagen, C. J., Walsh, K. J., Adams, C. B., & Tao, C. (2017). Coping with workplace minority stress: Associations between dyadic coping and anxiety among women in same-sex relationships. Journal of Lesbian Studies, 21, 70–87. Rottmann, N., Hansen, D. G., Larsen, P. V., Nicolaisen, A., Flyger, H., Johansen, C., & Hagedoorn, M. (2015). Dyadic coping within couples dealing with breast cancer: A longitudinal, population-based study.

Dyadic Coping Inventory Health Psychology., 34, 486. https://doi.org/10.1037/ hea0000218 Ruffieux, M., Nussbeck, F. N., & Bodenmann, G. (2014). Long-term prediction of relationship satisfaction and stability by stress, coping, communication, and wellbeing. Journal of Divorce & Remarriage, 55, 485–501. Rusu, P., Hilpert, P., & Bodenmann, G. (2016). Dyadic coping in an eastern European context: Validity and measurement invariance of the Romanian version of dyadic coping inventory. Measurement and Evaluation in Counseling and Development., 1–12. https://doi.org/ 10.1177/0748175616664009 Vedes, A., Nussbeck, F. W., Bodenmann, G., Lind, W., & Ferreira, A. (2013). Psychometric properties and validity of the dyadic coping inventory in Portuguese. Swiss Journal of Psychology, 72(3), 149–157. Xu, F., Hilpert, P., Randall, A. K., Li, Q., & Bodenmann, G. (2016). Validation of the dyadic coping inventory with Chinese couples: Factorial structure, measurement invariance, and construct validity. Psychological Assessment. Advanced online publication, 28, e127. https://doi.org/10.1037/pas0000329

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Eastern Philosophy in Couple and Family Therapy Wai Yung Lee1,2 and Viviana Cheng1 1 Asian Academy of Family Therapy, Hong Kong, China 2 Aitia Family Institute, Shanghai, China

Name of Theory Eastern Philosophy in Couple and Family Theory

Introduction Psychotherapy is often regarded as the connecting point between the East and West. Many of the core concepts in psychotherapy can be traced back to the key elements within the three main Eastern philosophical schools of thought – Buddhism, Taoism, and Confucianism. In particular, the global movement of mindfulness, which stems from Buddhist thinking, has influenced the development of couple and family therapy in the twenty-first century.

Prominent Key Figures Gautama Siddhartha, Laozi, Zhuangzi, Liezi, Confucius, Jay Haley, Milton Erickson, Gregory Bateson

Description Eastern thought was first formally introduced to Western philosophy and psychology when British scholars began to translate Indian spiritual texts such as Bhagarard Gita in the 1700s (Germer et al. 2013, p. 11). Western philosophy is broadly defined as striving to find and prove the “truth,” while Eastern philosophy accepts the truth as given and is more interested in the state of “being.” The term, “Eastern philosophy” covers a broad spectrum of concepts, thoughts, and philosophies from various regions including India, China, Korea, and Japan. At times, the term includes Persian, Arabic, Babylonian, and Jewish philosophies from across the Middle East. Since the 1700s, ideas from Eastern philosophy have become widespread in psychotherapy literature. Despite its Western origins, the art of psychotherapy often involves addressing elements of the body, mind, and soul, which challenges the logical thinking or “established truth” that Western philosophy is known to embrace. Thus, it could be argued that psychotherapy is a field where East and West are bound to intertwine. Some aspects of Eastern philosophy are found in the theories and practices of almost all of the founders and prominent figures in the family therapy field. Many of the core concepts of family therapy, such as holism, interdependence, circularity, and homeostasis, are conspicuously similar to the essence of the Eastern worldview, where both call for awareness of the unity and mutual

© Springer Nature Switzerland AG 2019 J. L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy, https://doi.org/10.1007/978-3-319-49425-8

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interrelation of all things that are inseparable parts of a cosmic whole (Capra 2010). Although these three mainstream Eastern philosophical schools of thought are quite different from one another, their distinctions are often blurred when applied to clinical discussion. For the sake of clarity, a brief description of each is outlined below: Buddhism Buddhism was founded between 563 BC and 483 BC by an Indian prince named Gautama Siddhartha, later known as Buddha. He lived in the comfort of his palace until the age of 29 years, when he first had a chance to catch a glimpse of the outside world. On the four occasions that Buddha left his palace, all he witnessed was human misery, including giving birth, aging, falling ill, and dying. These experiences of human suffering had such a profound impact on him that he decided to become a monk and devote his life to the pursuit of enlightenment. Buddhism draws heavily from Hindu philosophy, such as the belief in reincarnation and the search for ways to achieve salvation. Buddha himself wrote nothing. After his passing, his immediate disciples began to preserve his teachings through enforced memorization and oral recitations. The Pali Canon is a result of such process that took four centuries, from fifth century BCE to the first century BCE, before it became a complete written version. Buddhism focuses on the quest to enlightenment, which involves four noble truths. The first truth is that life contains inevitable suffering, from birth to aging to death. The second truth is that suffering is caused by desire and the craving for its gratification. The third truth is the elimination of suffering by extinguishing the three fires of greed, delusion, and hatred. This then leads to the fourth truth – the path to the cessation of suffering, a state in which “no passion remains,” and attainment of Nirvana. Buddha believed that people are in a state of endless suffering and the only way to extinguish suffering is to eliminate desires and achieve a state of “no-self.” By rejecting the common notion of the self, one could be free from the suffering associated with it.

Eastern Philosophy in Couple and Family Therapy

Around 100 CE, Buddhism split into two main schools: Theravada, the classic Buddhist teachings as mentioned above, and Mahayana, which focuses on the notion of “emptiness.” The view of Mahayana is that all reality is devoid of any discernable content or description. The Mahayana Heart Sutra maintains that everything about our identities and the ordinary world we reside in is empty and has no true content. It proclaims that even the four noble truths are empty. The Heart Sutra questions the basic Theravada teachings that distinguish between the ordinary realm of life, death, and suffering and the realm of Nirvana, in which suffering is extinguished. It suggests that the two realms are actually the same. Not only is the ordinary realm of life and death empty of descriptive content, even Nirvana, the very solution to our misery, has no descriptive content. To further grasp the notion of emptiness, Zen Buddhism was founded in China in around the fifth century. It is renowned for its paradoxical, meditative puzzles. It focuses on experience, resists verbal coaching, and has no creed. In Zen, enlightenment cannot be attained through rational discourse and doctrine. The experience of enlightenment is transmitted from the mind of a seasoned teacher to the student in training. Zen can be regarded as the most mesmerizing aspect in Buddhism that has captured the fascination of intellects and psychotherapists worldwide. Taoism Taoism emerged in the fourth century BCE, during China’s Warring States period. In Taoism, the way to end social chaos was to return to nature or to the time before the appearance of the feudal system in China. Taoism is taught through three important texts. The first one is the Tao Te Ching or Book of the Way, believed to be written by Laozi around 450 BCE. Tao Te Ching is an anthology of sayings, specifying a “hands-off” policy. It was compiled to instruct kings on government. The second one is Zhuangzi, written by Zhuangzi around 369–286 BCE. Zhuangzi contains vivid stories and parables that are intended for the general public. The third book is the Classic of Complete Emptiness, written by Liezi around 300 CE.

Eastern Philosophy in Couple and Family Therapy

Contrary to the Taoist rejection of desire, Liezi proposed a more carefree attitude, claiming that desires for beautiful things, good food, music, and sex are simply human nature. There is no need to suppress them. The central concept in Taoism is the notion of the Tao, which means “way” or “path.” It refers to the fundamental ordering principle behind nature, society, and individual people, as described in Tao Te Ching: The Tao that can be named is not the eternal and unchanging Tao. The name that can be spoken is not the eternal and unchanging name. The nameless is the source of heaven and earth. The named is the mother of all things. Always be without desires and you will see mystery. Always be with desire, and you will see only its effects. They are both a mystery, and where mystery is the deepest we find the gate of all that is subtle and wonderful (Tao Te Ching).

Tao is seen as an indescribable source of all existence that can only be grasped by mystically experiencing its subtlety. It emphasizes the notion of non-action (wu wei), which proposes that things should flow simply, with spontaneity, and without being contrived. The notion of nonaction goes hand in hand with that of non-mind (wu-hsin). Taoism rejects traditional methods of education, such as learning from a teacher. Accumulated knowledge is seen as hindering creativity and causing one to become inflexible or subject to a false sense of security. Taoism shares many ideas with Buddhism, particularly in the notion of emptiness and the rejection of desires. Its naturalistic attitude is often in contrast to Confucianism, which contains doctrines and rules of governance. Confucianism Confucius (551–479 CE) was a teacher and philosopher who offered his solutions to end the social chaos during the Warring States period in China. He traveled to the various states in China to give advice on good governance for 13 years. It is believed that his disciples recorded his teachings in four major Confucius texts after his death. These texts have had a profound influence in East Asia for almost 3000 years.

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The principle record of Confucius’ teaching was The Analects, written as clusters of conversations between the Master and his students. It emphasizes the importance of virtuous conduct, addressed in four specific themes: ritual conduct, humanity, filial obedience, and good government. Unlike Buddhism and Taoism, which focus more on the attainment of self-actualization, Confucianism is the major school that emphasizes social, political, and family systems. In contrast to the naturalistic characteristics of Taoism, Confucius recommended a strong infrastructure with a clear set of rules and doctrines, governing all aspects of social life in the government and family systems. Confucius maintained that good government begins at home and believed that there is a proper way of behaving for virtually every activity. Rituals and traditions were regarded as the observable glue that binds society together. The family unit is seen as the primary social unit, and family members are expected to actively participate in the learning of ritual conducts, which are seen to refine and elevate the quality of lives and serve as a tool for moral instruction. Filial obedience (hsiao) is the area in which Confucius’ teaching had the most influence in shaping government and family structure. He held that there are five relationships (wulun) that underlie the order of society: father-son, elder brother-younger brother, husband-wife, elder friend-junior friend, and ruler-subject. Within these relationships, the subordinate person is duty bound to show obedience, while the superior person is expected to show kindness. Under this notion, the husband is expected to be more dominant and the wife more obedient in the husbandwife subsystem, much against gender-equality values in modern society. Despite that, Confucianism did offer a more pragmatic approach with clear doctrines to guide interpersonal conducts at all levels of government and social structure. These structures are still heavily referenced in discussions on Asian families today. Viewed separately, these three major schools of thoughts are very different and sometimes

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contradictory. Collectively, they form crucial parts of both historic and current Eastern philosophy. The Mindfulness Movement The Buddhist term “mindfulness” originated from the Pali word sati. It refers to psychological states of awareness through meditation, a discipline whereby one pays attention to thoughts, feelings, and body sensations in the present moment, without having to be altered or avoided (Bishop et al. 2004). In 1930, Freud believed that the mind and body sensations in the present moment are to be essentially regressive. The fact that the University of Massachusetts mindfulness-based stress reduction program (Kabat-Zinn 2013) would turn into a big enterprise 35 years later was unimaginable in 1979. Mindfulness training and other forms of meditation have since been recommended for a wide range of medical conditions. As many as 20 million people were reported to be using meditation for health purposes in the 2007 census report on adults seeking complementary or alternative medicines in the United States. The mindfulnessbased relationship enhancement (MBRE) program for couples (Carson et al. 2004) is one clinical example, which introduced a range of mindfulness exercises to couples, including partner yoga, loving-kindness meditation, and mindful touch, over the course of 8 weeks. Mindfulness research soared in the 2000s following Harvard Professor Herbert Benson’s studies of the physiological responses of the Tibetan monks during meditation in the 1980s. Studies have been conducted on almost every topic that has a remote connection to mindfulness and most of them claimed to have high success rates in using mindfulness as a remedy for treatment. However, in a massive metaanalysis of meditation programs conducted at John Hopkins University, it has been found that mindfulness meditation had only a “small yet consistent benefit in relieving anxiety, depression, and pain.” Depressive symptoms have been found to have improved by roughly 10–20%, which is similar to the effect of antidepressants (Goyal et al. 2014).

Eastern Philosophy in Couple and Family Therapy

The attitude toward mindfulness between the East and the West has been described as being fundamentally different. In the East, meditation is viewed as a lifelong practice within a rich spiritual context. In the West, it is considered a short-term intervention to achieve clear goals (Wylie 2015). However, this does not stop the mindfulness movement from gaining popularity among contemporary couple and family therapists. Many therapists consider the core elements of awareness, acceptance, and staying in the present in mindfulness psychology to be powerful concepts when used in conjunction with traditional clinical processes (Germer et al. 2013). In addition, it is generally agreed that mindfulness has had a positive effect on relationship satisfaction, empathy development, and skillful communication (Gambrel and Keeling 2010). Numerous studies note the benefits of mindfulness practice on various aspects of a couple’s relationship, including an increase of intimate relationship satisfaction and a more secure attachment (Wachs and Cordova 2007). It has also been suggested that Buddhist practices of accommodation to suffering, in particular, could shift the traditional focus in therapy from change to acceptance, within the contexts of couple and family therapy (Gehart and Collum 2007).

Relevance to Couple and Family Various aspects of Buddhism, Confucianism, and Taoism have had an impact on the development of different approaches within the field of family therapy. However, when Zen Buddhism ideas entered the clinical field in the 1950s, the psychodynamic ideology contained premises so opposite from Zen that it was impossible for the two approaches to connect. The focus on insight in psychotherapy was in sharp contrast to the absurdity in Zen, such as its infamous riddle, “What is the sound of one hand clapping?”, which seems to defy any logical responses. Milton Erickson, who also spoke in riddles and paradoxes, was possibly the only therapist whose approach was different from psychodynamic theory at the time. In this regard, he may be considered the first Buddhist therapist in the West. Following that, family

Eastern Philosophy in Couple and Family Therapy

therapists began to develop an interest in the notion of paradox in Zen. The use of rephrasing, an attempt to challenge the meaning of reality, was a popular technique used by early pioneers such as Carl Whitaker and members of the MRI group. In the family therapy development that followed, its systemic perspective fit well with the Eastern philosophy that all things exist as inseparable and contradictory opposites. The symbol of Yin and Yang, the masculine and feminine sides of human relationship, has become universal in addressing any dyadic relationship within the family system. The influence of Zen Buddhism can be seen in the work of Haley, who considered the ideas behind Western psychopathology matched the basic premise of Zen – humans are seen as trapped in the wheel of life and keep repeating distressing behavior. The more a person attempts to escape from this destiny, the more they are caught up in it (Haley 2013). Haley held that once problem-maintaining patterns have been understood, they may be altered through carefully designed direct or paradoxical interventions. He believed that like Zen masters, therapists must be experts at bypassing resistance. The paradoxical nature of Zen can be found to have strongly influenced his strategic and directive Western therapy in promoting change. The continuous questioning of the perception of reality in Zen Buddhism that attracted early family therapy founders was also addressed in the Constructivism movement that followed. Eastern philosophy perceived the entirety of reality as one empty thing that is incapable of distinction or descriptive content. This is similar to the Constructivist view, seeing everything as filtered through the mind of the observer. Constructivists believe that the world can only be experienced subjectively, through the observer’s own unique constructs of the environment. Constructivism emphasizes cognitive meaning and personal interpretation rather than action. Under this model, therapists don’t assume that they know how families should change but would explore the assumptions people have about their problems. However, this seemed to be where the East and the West diverge. Constructivist therapists use words or conversations to change narratives and reconstruct a new reality. Eastern philosophers

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abandon words altogether, focusing on experience, keeping a “non-mind” and “non-self” stance. Aspects of Taoism resemble the cybernetics concept, whereby all systems have their own way to self-regulate and a “don’t touch” approach is highly preferable. Gregory Bateson’s (1972, 1979) theory of the pattern that connects suggests that every family member is connected to everyone else. A change in one person’s behavior leads to a change in all family members. Therapists might use observation and interviewing processes to understand this pattern and describe their insights to family members. However, any attempt to change this pattern through the unilateral exercise of power may lead to unintended consequences, threatening the integrity of the system. Bateson felt strongly that this pattern of organization must be respected. This position clearly matches the “non-action” philosophy that is prominent in Taoism. Later social-constructionist therapists, such as Andersen, Cecchin, Boscolo, and Hoffman, also adopted this position. Confucius teachings, which place great attention on family structure with clear prescriptions of rules and boundaries among each of the subsystems, may be closer to Ludwig von Bertalanffy’s general systems theory, in which interrelationships between elements altogether form the whole and hierarchy and boundaries are considered essential elements in the production of new patterns. Confucius teaching is generally considered to be the backbone to understanding families of the East and has been referenced in almost all of the literature on Asian families. At the same time, his ideas on family and organizational structure share some similarities with those in Salvador Minuchin’s Structural Family Therapy, which also focus on family structure, boundaries, and hierarchy, particularly in working with children and adolescent delinquent problems. Confucius ideas on gender role distribution are certainly dated and feminist critiques may even find them offensive. Yet, his ideas on the importance of family rituals can be observed in the work of contemporary therapists such as Evan ImberBlack (1993). It should be noted that couple-hood is not addressed specifically in any of the three major Eastern schools, other than an emphasis on

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achieving balance between Yin and Yang. Ironically, mindfulness in Buddhism practice, which supposedly addresses one’s inner-balance, is widely used by modern therapists as a way to prepare individuals in couple therapy. Despite their different worldviews and diverse ways of manifestation, the East and the West are constantly in the process of mutual exchange and interactions. It is expected that the different cultures and philosophical ideas will continue to mix and match in various forms, giving new shape to couple and family therapy interventions worldwide.

Clinical Example of Application of Theory in Couple and Family Therapy Emma and Sam are a middle-class couple in their mid-thirties. They have two young children and have been living relatively settled lives until 2 months ago, when Emma found out that Sam has had an extramarital affair. When she confronted him angrily, he dismissed the affair and said that it was “just a fling.” The conflict between the couple escalated and they came for couple therapy to deal with their dilemma. To break the stalemate, the therapist helped them stay in touch with their conflict and learn to live with it by realizing how their circle of reactivity is causing them to be trapped in the entanglement. As a first step, she suggested that they delay their reactions toward each other while paying attention to their own emotional process. Through meditation and concentrating on their own emotions, the therapist guided Emma to get in touch with her feelings of hurt and betrayal from her husband’s extramarital affair. In doing so, her feelings of hurt and anger became more intense, and she began to cry aloud. The therapist then guided her to be aware of the existence of these negative feelings and not to ignore them while helping her separate herself from these feelings so that they would not affect her as much in her reactions to Sam. Through a guided imagery exercise, the therapist guided Emma with, “I know these feelings are there. I don’t like them,

Eastern Philosophy in Couple and Family Therapy

but I don’t need to get rid of them. They are there, but they cannot overwhelm me!” Following the same process, the therapist also guided Sam to acknowledge his intense feeling of guilt and remorse, as well as his inability to respond to Emma in facing her rage and blame. Realizing that these emotions had been blocking him from getting closer to his wife, he began to face Emma’s pain and accusation instead of running away from her as he previously did. Throughout the couple session, the therapist was very mindful in bringing the couple’s attention to the here-and-now moment. After engaging the couple to concentrate on their own emotional reactions, the therapist began to encourage them to relate to each other in a more satisfactory manner, now that their own emotions did not stand in their way of communication. As a result, the couple was able to deal with the hurt and sense of abandonment that they both experienced and work through their interpersonal conflict. Ultimately, Sam begged for forgiveness from Emma, who was finally ready to forgive him. The therapist has helped the couple reestablish intimacy and survive the damage of a nasty extramarital affair. This is one example of how a therapist adopted a mindfulness framework to couple therapy. She worked alternatively between the partner’s internal and interpersonal processes until the couple was able to establish intimate conversation and connection. Mindfulness exercises, including meditation and yoga, were used to assist estranged couples to rediscover one another.

Cross-References ▶ Boundary Making in Couple and Family Therapy ▶ Family Structure ▶ First Order Cybernetics ▶ Second-Order Cybernetics in Family Systems Theory ▶ Strategic Family Therapy ▶ Structural Family Therapy ▶ Meditation in Couple and Family Therapy

Eclecticism in Couple and Family Therapy

References Bateson, G. (2000 reprint. First published 1972). Steps to an ecology of mind: Collected essays in anthropology, psychiatry, evolution, and epistemology. Chicago: University of Chicago Press. ISBN 0-226-03905-6. Retrieved July 29, 2016. Bateson, G. (1979). Mind and nature: A necessary unity, Advances in systems theory, complexity, and the human sciences. Cresskill: Hampton Press. Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z. V., Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology Science and Practice, 11(3), 230–241. https://doi.org/ 10.1093/clipsy.bph077. Capra, F. (2010). The Tao of physics: An exploration of the physics between modern physics and Eastern mysticisim. Boston: Shambhala Publications, Inc. Carr, A. (2012). Family therapy: Concepts, process and practice (3rd ed.). Manchester: Wiley. Carson, J. W., Carson, K. M., Gil, K. M., & Baucom, D. H. (2004). Mindfulness-based relationship enhancement. Behavior Therapy, 35, 471–494. Gambrel, L. E., & Keeling, M. L., (2010). Relational aspects of mindfulness: Implications for the practice of marriage and family therapy. Contemporary Family Therapy, 32, 412–426. https://doi.org/10.1007/s10591-010-9129-z Gehart, D., & Collum, E. E. (2007). Engaging suffering: Towards a mindful re-visioning of family therapy practice. Journal of Marital and Family Therapy, 33(2), 214–226. https://doi.org/10.1111/j.1752-0606.2007.00017.x. Germer, C. K., Siegel, R. D., & Fulton, P. R. (2013). Mindfulness and psychotherapy. New York: The Guilford Press. Goyal, M., Singh, S., Sibinga, E. M. S., Gould, N. F., Rowland-Seymour, A., Sharma, R., Berger, Z., Sleicher, D., Maron, D. D., Shihib, H. M., Ranasinghe, P. P. P. D., Linn, S., Saha, S., Bass, E. B., & Haythornthwaite, J. A. (2014). Meditation programs for psychological stress and well-being: A systematic review and meta-analysis. JAMA Internal Medicine, 174(3), 357–368. https://doi. org/10.1001/jamainternmed.2013.13018. Greenan, D. (2015). Resiliency-focused couple therapy: A multidisciplinary model. AEDP Transformance Journal, 5(1). https://www.aedpinstitute.org/transformance/ resiliency-focused-couple-therapy/. Accessed 3 September 2016. Haley, J. (2013). Jay Haley on Milton J. Erickson. New York: Routledge. Imber-Black, E. (1993). Secrets in families and family therapy. New York: Norton. Kabat-Zinn, J. (2013). Full catastrophe living. New York: Random House LLC. Langer, E. J. (2000). The construct of mindfulness. Journal of Social Issues, 56, 1–9. https://doi.org/10.1111/00224537.00148.

825 Wachs, K., & Cordova, J. V. (2007). Mindful relating: Exploring mindfulness and emotion repertoires in intimate relationships. Journal of Marital and Family Therapy, 33, 464–481. https://doi.org/10.1111/ j.1752–0606.2007.00032.x. Wylie, M. S. (2015). The mindfulness explosion. Psychotherapy networker. Retrieved from https://www. psychotherapynetworker.org/magazine/article/66/themindfulness-explosion

E Eclecticism in Couple and Family Therapy Terence Patterson University of San Francisco, San Francisco, CA, USA

Synonyms Assimilative integration; Eclecticism; Heterogeneity; Synthesis; Theoretical integration

Introduction The term eclectic has been both widely used and misunderstood in the field of psychotherapy. Recently it has come into some disrepute and developed the connotation of indiscriminately drawing from various theories and techniques without a core foundation. Eclecticism has emerged in couple and family therapy (CFT) in particular due to the multiple approaches that do not clearly fit traditional theoretical models and techniques and are not anchored in a comprehensive conceptual base. The term systemic has also been appropriated by some as a defining aspect of CFT, while many others consider systems to be core to the entire field of. The wider realm of psychotherapy has delineated models that distinguish eclecticism from other models such as spiritual orientation, which can be viewed as an aspect of diversity.

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Prominent Associated Figures Arnold Lazarus, John Norcross, Marvin Goldfried, Larry Beutler, and Ray DiGiuseppe

Description Eclecticism in CFT has emerged in the effort to avoid rigid, dogmatic positions and from the general view that no single theoretical orientation or approach is universally applicable to all disorders, settings, or populations. While this may be considered an advancement from the early domination that psychodynamic therapy, for instance, has had on the field, many clinicians have adopted a mixture of concepts and methods that do not logically or pragmatically fit together. Such a mixed, indiscriminate stance contradicts standards of competence that involve the need for a comprehensive approach to assessment, case conceptualization, treatment formulation, and evaluation that is considered essential for effective treatment. Benchmarks such as common factors and evidence-based treatments have been disseminated to establish an epistemological basis for categorizing psychotherapy models, and concepts such as technical eclecticism*, theoretical integration*, assimilative integration*, and pluralism* have emerged as alternatives to eclecticism. Theoretical integration* was first formally explored in 1983 by the Society for Psychotherapy Integration (SEPI), prominently by Goldfried et al. (2005). It is the most developed and anchored model in that it is theory based and presumes that practitioners are competent in each approach. Technical applications are less stressed, although clinical theoretical grounding generally involves a solid awareness of pragmatic aspects. Theoretical integration involves a synthesis of compatible theories into a blend that is different from its constituent parts; a new approach emerges that fits the style and purpose of the clinician and the client and is therefore distinctive in its application. Beutler et al. (2001) focus on the integration of a distinct model, cognitive-behavioral therapy (CBT). With an emphasis on empiricism and common factors, theoretical integration

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eschews personality-based or technique-driven approaches. Snyder and Balderrama-Durbin (2012) propose an integrationist model specifically for couple therapy. Lebow (1997), a seminal thinker who suggests that it is time to end delineating approaches based on theoretical orientation, has described the evolution of integration in CFT as a revolution that is here to stay. The term technical eclecticism* has been widely promoted by Lazarus and Beutler (1993) and forms the basis of multimodal therapy. This approach is anchored in a theoretical model that asserts that techniques from other models can be applied coherently within its framework. Patterson (1997) described a similar model in which diverse techniques (rather than theories) can be coherently integrated into a major comprehensive model. Assimilative integration* combines models that may be seemingly disparate into an amalgam that involves components of other systems, but is mostly characteristic of a singular approach such as psychodynamic (Striker and Gold 2005). Castonguay et al. (2005) describe a CBT model in which the practitioner is competent in both the theories and methods involved. Another interesting paradigm is described by DiGiuseppe and Wilner (1980) who discuss the indications and contraindications for CFT within certain contexts and recommend that other modalities and formats such as individual child therapy might be used collaterally or alternatively. The term pluralism* is a generic term used to refer to the heterogeneity* of the models discussed here, while the term informed pluralism* is used to describe concepts that organize theories and techniques contextually from widely diverse approaches (Safran and Messer 1997). In everyday practice, the overlapping and ambiguous nature of the terms defined in this section is often used haphazardly to accommodate various approaches whose basic tenets defy assimilation into a common framework.

Relevance to Couple and Family Therapy Theories and techniques in CFT have evolved from a combination of rejection of earlier models

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of psychotherapy, personality-based practices based on distinctive pioneers, and an expansion of traditional individual models of psychotherapy (psychodynamic, humanistic, behavioral) to include systemic and contextual factors. Some CFT models are comprehensive in that they specify methods for assessment, treatment formulation, and appraisal, and others involve only philosophical concepts or dramatic techniques. Due to the competence essential for the effective practice of CFT and the complexity involved in highly contextual formulations and interventions, it is vital for clinicians to have a solid grounding in both theories and methods.

Clinical Example of Application of Topic in Couples and Families Malik and Genna are a mid-forties couple who have been married for 10 years and have two children, Basil, 8, and Malia, 6. Basil’s school has contacted them saying he appears restless and is not concentrating on his work and is not getting along with his schoolmates. They have both emigrated from politically unstable countries, where their parents and extended family still reside. Their marriage is satisfactory – 5.5/10 on the Beavers-Timberlawn Family Evaluation Scale (Lewis et al. 1976), which indicates some mild depression, distancing, and mild dissatisfaction with the marriage and the potential for anxiety-related disturbances in the children. Malik and Genna also have chronic anxiety due to traumatic experiences in their countries of origin, as well as work-related and economic problems. Assessment did not indicate the need for individual treatment of the parents, partially because culturally they feared the stigma it would involve, though the suggestion to treat the family as a whole appealed to their more collectivist worldview. Individual sessions with the couple were held initially to determine their priorities, availability, and commitment and to remove some of the obstacles that were creating distance and dissatisfaction between them. Test data was then collected from the

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school on Basil that indicated rumination about being attacked and his drawings depicted violent scenes. Assessment formulations include the following: a dysfunctional marital relationship, chronic trauma secondary to violence in their home countries, and an anxiety and depressive disorder in Basil. The parents’ priority was to stabilize Basil’s school situation rather than to work on their marriage. Rather than follow a psychodynamic model with individual therapy to explore earlier experiences in depth, a family therapy model with a CBT orientation was employed in order to respect their preferences, limited availability, and cultural understanding. From this foundation three individual sessions were held with Malik and Genna, one with Basil, and two with the entire family. Basil’s teacher and counselor were consulted for additional information, and recommendations were made for assisting him in school, and the parents were referred for financial and vocational counseling through a religious organization. Person-centered and trauma-informed techniques were effective in eliciting responses from the parents about their earlier experiences, and they indicated feeling relief. They were also coached to respond to Basil’s anxiety with understanding and reassurance and to steer away from reinforcing it in any way. The model employed with this family can be described as technically eclectic* with a (CBT) foundation guiding the treatment. With family therapy as the primary modality, formats for sessions were flexible, and collateral contacts were made on behalf of family members. The understanding of trauma is viewed as topic specific; accurate empathy and collaboration is based on Rogerian techniques and multicultural competence; the coaching regarding Basil follows a parent-child consultation model; and the contacts with allied professionals are eco-systemic. None of these methods deviates from the basic CBT model as the techniques used were congruent with the objective of behavioral change. It is also consistent with the paradigm proposed by DiGiuseppe and Wilner (1980) above.

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Cross-References ▶ Assimilation in Integrative Couple and Family Therapy ▶ Common Factors in Couple and Family Therapy ▶ Eclecticism in Couple and Family Therapy ▶ Integration in Couple and Family Therapy

Ecosystem in Family Systems Theory Christie Eppler Seattle University, Seattle, WA, USA

Name of Concept References Beutler, L. E., Harwood, T. M., & Caldwell, R. (2001). Cognitive-behavioral therapy and psychotherapy integration. In K. S. Dobson & K. S. Dobson (Eds.), Handbook of cognitive-behavioral therapies (2nd ed., pp. 138–170). New York: Guilford Press. Castonguay, L. G., Newman, M. G., Borkovec, T. D., Holtforth, M. G., & Maramba, G. G. (2005). Cognitive-behavioral assimilative integration. In J. C. Norcross, M. R. Goldfried, J. C. Norcross, & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 241–260). New York: Oxford University Press. DiGiuseppe, R., & Wilner, R. S. (1980). An eclectic view of family therapy: When is family therapy the treatment of choice? When is it not? Journal of Clinical Child Psychology, 9(1), 70–72. Goldfried, M. R., Pachankis, J. E., & Bell, A. C. (2005). A history of psychotherapy integration. In J. C. Norcross, M. R. Goldfried, J. C. Norcross, & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 24–60). New York: Oxford University Press. Lazarus, A. A., & Beutler, L. E. (1993). On technical eclecticism. Journal of Counseling & Development, 71(4), 381–385. https://doi.org/10.1002/j.15566676.1993.tb02652.x. Lebow, J. (1997). The integrative revolution in couple and family therapy. Family Process, 36(1), 1–17. https:// doi.org/10.1111/j.1545-5300.1997.00001.x. Lewis, J. M., Beavers, W. R., Gossett, J. T., & Phillips, V. A. (1976). No single thread. New York: Brunner/Mazel. Patterson, T. (1997). Theoretical unity and technical eclecticism: Pathways to coherence in family therapy. American Journal of Family Therapy, 25(2), 97–109. https:// doi.org/10.1080/01926189708251059. Safran, J. D., & Messer, S. B. (1997). Psychotherapy integration: A postmodern critique. Clinical Psychology: Science and Practice, 4, 140–152. Snyder, D. K., & Balderrama-Durbin, C. (2012). Integrative approaches to couple therapy: Implications for clinical practice and research. Behavior Therapy, 43(1), 13–24. Striker, G., & Gold, J. (2005). Assimilative psychodynamic therapy. In Handbook of psychotherapy integration (pp. 221–240). New York: Oxford University Press.

Ecosystem in Family Systems Theory

Synonyms Context/contextual; Human ecology; Systems/ systemic

Introduction In family systems therapy, ecosystems are broadly defined as interconnected contextual* variables and patterns of functioning. Ecosystems can be a place, culture, or norm that influences clients (e.g., social locations, boundaries, rules, etc.). Considering the ecosystem in therapy changes the perspective from treating individuals and their symptoms to conceptualizing clients and their presenting problems as the interactions of relationships, environments, and larger systems* in symbiotic processes.

Theoretical Context for Concept Although Eastern spiritualities, African traditions, and Indigenous cultures have long considered interconnections and collectivist ways of relating, it was not until the 1950s that Western mental health professionals used an ecosystemic approach to inform family treatment. Multiple ecological perspectives were delineated, an antithesis to the medical model that dominated the field of early psychotherapy. Germinal theorists of ecosystem thinking in systems therapy include Bateson (1979), Bronfenbrenner (1979), and Bubolz and Sontag (1993). Compared to their

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predecessors, who sought to explore humans intrapsychically, ecosystemic-focused family theorists employed concepts from the natural sciences, anthropology, and communication theory to understand people and their relationships. Bateson (1979), an anthropologist, social scientist, and biologist, applied physical world phenomena, such as feedback loops and entropy, to human interactions. This approach focused on the meta, or how human systems learn and reflect on their experiences, believing that it is not what one thinks, but rather how one thinks. Bateson and his research group explored cybernetics (i.e., how systems regulate using structures, constraints, and possibilities). They defined the double-bind hypothesis as unclear communication that fosters mental disorders (Bateson et al. 1956). Their classic study hypothesized that if a mother’s verbal message did not match her nonverbal stance, her child was at increased risk for a diagnosis of schizophrenia. Bronfenbrenner’s (1979) ecological human development model examined how growth and development happen in proximal processes, reciprocal interactions that occur over extended periods of time. Developmental growth systems are interlocking layers with networking parts. The microsystem, the most immediate level and the one with which the client system has direct interaction, may include family, school, work, and places of worship, etc. The mesosystem includes the interactions between and among microsystems; for example, the quality of interaction between a family and the child’s school. Exosystems influence the microsystem, but without direct interaction. Examples of exosystems include the courts, government, and health care companies, all of which affect client functioning, but clients may not be active participants within these systems*. The chronosystem considers the influence of time: family stories, familial lifecycle stages, and cultural narratives of historical trauma. For example, a family (microsystem) that finds connection and support (mesosystem) from a place of worship (microsystem) may have strong ties to each other over time (chronosystem). The family may use resources from their insurance company, an exosystem, to secure therapy in order to mediate problems that arise.

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In a later model, Bubolz and Sontag (1993) introduced the natural and human built worlds as particularly salient factors that affect human functioning. Their framework considers the natural world or environment such as sunny or cloudy regions, human built structures such as apartments with or without lead-based paint, and social or cultural norms such as egalitarian or hierarchical relationship rules. Each system* reciprocally affects the others. Clients who live in brisk and rainy climates may spend most of their time indoors, which can influence how land and energy resources are consumed. A linear view suggests that lack of sun increases the risk of seasonal affect disorder (SAD). An ecological model hypothesizes not only how sunlight affects mental health, but also how families with individuals who have mental health diagnoses impact their natural and created worlds. More recent theorists have used an ecosystemic perspective to explore particular constructs. Walsh (2006) employed an ecosystem approach in her model of family resiliency. Postmodern models, such as liberation psychology in family therapy (Hernández 2002); transformative family therapy (Almeida et al. 2008); and Falicov’s (2014) multidimensional ecosystemic family therapy, expanded earlier paradigms to consider the intersections of social locations (age, gender, sexual identity, immigrant status, etc.), empowerment, and advocacy in systemic* practice.

Description Family therapy and mental health counseling have many similarities (e.g., treating clients, documenting treatment plans, and writing case notes). The crux of their opposing epistemologies lies in the focus on the individual versus an ecological or human ecology* paradigm. Couples and family therapy is rooted in systems thinking* and human ecology* theory (Wetchler and Hecker 2014). Individuals themselves are considered as systems* embedded in larger interconnected systems* (Bronfenbrenner 1979). Psychiatry and mental health counseling examine intrapersonal

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dynamics. Providers consider the cause and effect of cognitions, affects, and behaviors. This linear process in thinking is reductionist where symptoms are classified within clusters to form a given diagnosis. The ecosystem or human ecology* in systemic* therapy is built on an alternative paradigm. The focus shifts from the individual to relationships, the space between family members and larger environmental systems*. The system* is defined as more than the sum of the parts. The holistic practice of family therapy focuses on processes instead of content. The individual is not the sole focus of treatment even when the individual is the only person present in treatment. Treatment explores the meaning behind behaviors instead of the actions themselves. Rather than hypothesizing about what is happening and why, an ecologicallyoriented clinician examines a presenting problem’s manifestation and maintenance from multidimensional, relational perspectives. Systemic* therapists look for reciprocal causality, circularity, patterns, and meanings. A couple may have a reciprocal effect on one another’s behavior, although this does not exonerate an individual of responsibility (e.g., offender of intimate partner violence). Behaviors are understood in context. For example, a child who defecates on the walls in the school’s bathroom may be sent to a therapist to address the child’s negative behavior. When a systemic therapist learns that this child was harassed on multiple occasions when he went to the bathroom alone, the child’s symptom connotes a different, protective meaning rather than being perceived as naughty behavior.

Application of Concept in Couple and Family Therapy Most problems that clients bring to therapy may be seen as first-order problems, or symptoms. An example of a first-order symptom is when caregivers of an adolescent complain about their child’s missed curfew. Although such a complaint may appear to be the caregivers’ pressing presenting issue, after careful observation of the processes associated with these symptoms, the

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ecology-informed therapist holds regard for second-order processes, or the underlying structures that maintain a symptom. For example, the family’s lifecycle stage is a developmental? process that influences both family functioning and the presenting problem. The therapist inquires about what it must be like for this family to encounter transitions as their child moves from adolescence to adulthood; how the process of decision-making differs from an earlier stage of their child’s development. These questions assist the therapist in remaining inquisitive about multigenerational and isomorphic processes such as how previous generations dealt with transitions; what cultural shifts impacted the family lifecycle; the ways in which the family rules and boundaries may have changed over time; the role of socialpolitical factors in creating and maintaining the family’s presenting problems; and the way in which each member of the family has contributed to changing the cultural narrative regarding caretaking and adolescence. Treatment at the ecosystem level is not an independent treatment modality. Therapists synthesize ecosystemic factors with family therapy theories (e.g., structural family theory, narrative family therapy). Consideration of ecological factors starts before the first session. The therapist invites the entire family, rather than each individual member, into the session. Anyone who has significant influence on the relationship is invited to attend therapy. During the clinical intake process, the therapist gathers information related to the client system’s ecosystems. Assessments include genograms, which are utilized to find patterns in the family ecosystem, and ecomaps, which explore community resources and limitations. All parts of the ecosystem affect each other (e.g., the caregiver’s narrative of what it was like for her to be an adolescent affects her parenting style and how her child may perceive her). The clinician avoids overemphasizing one piece of the system. For example, the therapist would not ascribe blame to an individual (e.g., the adolescent is acting out). Assessing and intervening on the ecosystemic level continues throughout each phase of the treatment.

Ecosystem in Family Systems Theory

Clinical Example Opal and Luke presented for couples therapy out of concern for a breakdown in their communication. Opal, a 32-year-old biracial female, has a college degree and works as a home health aide for elderly patients. Her mother immigrated to the US from Ecuador as an adolescent and her father is African-American. Opal expressed frustration over Luke’s passivity, which Opal defines as his disconnection from his feelings, her feelings, and their disagreements. Luke, a 33-year-old Caucasian male who identifies as a Midwesterner, works as a physical therapist. He stated Opal spends too much time with her mother, asks too many questions, and reminds him of tasks incessantly. In the early phase of treatment, the family therapist asked Opal and Luke to talk about what brought the couple together, ways in which each partner feels connected to the other, and how they would like the relationship to be different at the end of therapy. The therapist drew a genogram and an ecomap. The integrated data gathered by the therapist revealed strengths such as similar vocations and differences regarding the couple’s families-of-origins expectations of the amount of time families spent with one another and in the larger community. Luke’s family of origin valued independence and self-reliance; they had fewer connections to social networks, local places, and friends. Conversely, Opal hailed from a bi-cultural family with many links to larger systems (e.g., political groups, art school, neighbors, and Opal’s mother’s connection with the immigrant community from Ecuador). These differences sparked verbal fights, thus leading the couple to a perception of having compromised communication. The therapist used circular questioning to understand how each member of the couple perceived one another. Did Opal think that Luke’s perceived passivity was aloofness or the need for solitude? What were Luke’s ideas about being in a community – that was unhealthily enmeshed or lovingly bonded? The therapist inquired about how Opal’s answers compared with how Luke described his own experiences and vice versa. The therapist and clients created a dialogue

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about their meta-level beliefs in order to explore the meaning of the couple’s time together as well as being apart. Although the therapist treated the couple from a narrative family therapy framework, the focus of the clinical work was attuned to systemic* processes. For Opal and Luke, their firstorder symptom was their communication skills. The process, or the second-order structure that maintained the symptom of ineffective communication, was to achieve a mutually agreeable balance between cohesion and individuality. This balance was influenced by the couple’s interactions among larger systems (e.g., time spent with kin, at work, with one another). The therapist and clients dialogued about ways in which external connections affected the relationship’s cohesion (how the couple felt connected); flexibility (static or dynamic nature of time spent together or alone); adaptability (how the amount of time together has changed since they met). The therapist assisted Opal and Luke to explore what it is like to partner with someone from a different cultural background. In each session, the process, identified as themes and patterns derived from the couple’s responses to the therapist’s inquiries, is linked back to the content, or the presenting problem. Luke and Opal decided to end their treatment when they were able to understand their communication patterns at a deeper level. The improvement in their communication was measured through the number of times they identify feeling heard and supported by one another. Each partner was able to validate the other’s perspective regarding emotions and experiences, even if she or he disagreed with their partner’s perceptions.

Cross-References ▶ Circular Causality in Family Systems Theory ▶ Double Bind Theory of Family System ▶ First-Order Change in Family Systems Theory ▶ First Order Cybernetics ▶ Narrative Couple Therapy ▶ Postmodern Approaches in the Use of Genograms

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▶ Second-Order Change in Couple and Family Therapy ▶ Second-Order Cybernetics in Family Systems Theory

References Almeida, R., Dolan-Del Vecchio, K., & Parker, L. (2008). Transformative family therapy: Just families in a just society. New York: Pearson/Allyn & Bacon. Bateson, G. (1979). Mind and nature: A necessary unity (1st ed.). New York: Dutton. Bateson, G., Jackson, D., Haley, J., & Weakland, J. (1956). Toward a theory of schizophrenia. Behavioral Science, 1, 251–264. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Bubolz, M. M., & Sontag, M. S. (1993). Human ecology theory. In P. G. Boss, W. J. Doherty, R. LaRossa, W. R. Schumm, & S. K. Steinmetz (Eds.), Sourcebook of family theories and methods: A contextual approach (pp. 419–450). New York: Plenum Press. Falicov, C. J. (2014). Latino families in therapy (2nd ed.). New York: Guilford Press. Hernández, P. (2002). Resilience in families and communities: Latin American contributions from the psychology of liberation. The Family Journal, 10, 334–343. https://doi.org/10.1177/10680702010003011. Wetchler, J. L., & Hecker, L. L. (2014). An introduction to marriage and family therapy (2nd ed.). New York: Routledge. Walsh, F. (2006). Strengthening family resilience (2nd ed.). New York: Guilford Press.

Ecosystemic Structural Family Therapy Marion Lindblad-Goldberg and Edward A. Igle Philadelphia Child and Family Therapy Training Center, Philadelphia, PA, USA

Introduction Ecosystemic Structural Family Therapy (ESFT) is an empirically supported treatment/supervision/ training model developed by Marion LindbladGoldberg in the 1970s and further elaborated at Philadelphia Child and Family Therapy Training Center.

Ecosystemic Structural Family Therapy

ESFT trains family therapists to go against the cultural grain by empowering caregivers and nurturing resilient patterns of family and community connection. Family therapists face three key clinical challenges when they are working to strengthen transactional patterns that weaken a family’s ability to nurture its children. These challenges are: (1) to see the family as ensnared in a set of negative interactional patterns fueled by avoidance and abdication; (2) to understand the therapist’s role to help caregivers envision new transactional patterns; (3) to respond to the family through a collaborative partnership with the caregivers and the at-risk child.

Prominent Associated Figures The development of ESFT was influenced by Salvador Minuchin (SFT 1974), John Bowlby (Attachment 1983, 1988), and Bessel van der Kolk (Trauma 1997).

Theoretical Framework ESFT therapists believe that children thrive when the key caregiver relationships in their lives rest solidly on four pillars: a secure caregiver- child attachment, a healthy alliance between and among their caregivers, a predictable and balanced approach to caregiver executive functioning, and the strengthening of each family member’s ability to increase distress tolerance and emotion relation. A breakdown in one or more of these pillars sustains a child’s troubles. ESFT teaches therapists how to: (1) discern and target the cyclical patterns of interaction that sustain the breakdown of key relationship and (2) work collaboratively with the child’s ecosystem to develop new growth-promoting relational patterns. The ESFT model provides a map of these four stages of treatment: 1. Constructing a therapeutic system. In this stage of treatment, the therapist is challenged to determine who constitutes the family and

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must look within and around the household for members of the child’s ecosystem with a view toward recruiting relevant family members, informal support persons, and formal community partners into a therapeutic alliance. The therapist then convenes and collaboratively joins with each participant – including the symptom bearer – and proposes the structure and purpose of family therapy in a way that differentiates it from other formats of care. The therapist notes the transactional patterns that sustain the child’s symptoms, such as problems with conversational boundaries, failing attempts at executive functioning or emotion regulation, conflicts over caregiving, or weaknesses in attachment bonds. 2. Establishing a meaningful therapeutic focus. In this stage of treatment, the goal is to use therapeutic alliances to place the presenting problem in a relational frame. A relational frame is a summary statement that directly links the presenting symptoms to specific changes in key family relationships listed above. It orients family members toward an inter-personal outcome that is within their power to control and galvanizes them to take action. ESFT equips the therapist with assessment tools that focus on the relational stories of family members such as genograms, relational timelines, and eco-maps. In ESFT, assessment is both a process and a product. The process reveals family structure: the invisible set of functional demands that regulates how each family member participates in the family system. The product is a systemic hypothesis: a recursive explanation that identifies the core negative interactional pattern (CNIP) that sustains the presenting problem. The hypothesis will drive all the family therapy interventions in the next stage of treatment, so it is essential that the therapist and the family collaborate on its meaning and the language. The therapist actively helps the family to see and understand how the CNIP is sustaining the family’s pain and to respond to the CNIP by joining with the therapist to reduce its control over the family.

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3. Creating key growth-promoting interpersonal experiences. In this stage of treatment, the family therapist and the family members join together to create in-session scenarios that activate the members of the family to experiment with obscured or untapped resources. This is done through directed enactments that restructure the transactions maintaining the presenting problem and replace them with transactions that confront and defeat the family’s CNIP. These transactional experiments may be aimed at promoting healthy exchanges in the care-giver alliance, strengthening parent executive skills, increasing distress tolerance and emotion regulation, and/or creating age-appropriate parent-child attachment. In this way, ESFT addresses child or family trauma, the legacies of family losses, the cultural marginalization of the family, the transgenerational effects of poverty, and many other relationally disruptive factors in the “here and now.” The emphasis is not on living in the past but on living with the past as a strong and resilient family system. 4. Solidifying change and discharge planning. In ESFT, the experiments of change that restructure family transactions during the third stage of treatment are expanded and extended into the ecology of the family’s complex relationships to the agencies, institutions and resources that orbit the family. Recognizing that so many families have endured chaotic, unplanned, and unexplained relational endings, ESFT therapists carefully plan termination of family therapy in such a way as to (1) process the loss of the therapeutic relationship as an opportunity to use new relational patterns to tackle future relational challenges, and (2) anchor the family in healthy alignments with supportive resources in its community environment. Toward these ends, ESFT therapists often help families develop closing rituals that reinforce feelings of personal agency and family strength.

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Populations in Focus ESFT is designed to treat families in outpatient, inpatient, and in-home settings. Its design is also applicable to families that are seeking to reintegrate a child from residential treatment, as well as families that are accepting a traumatized child into a foster care or adoption arrangement. ESFT has been applied to a wide variety of internalizing and externalizing disorders, including problems with attention and concentration, insecure or anxious attachment, self-injury and depression, disorders in eating, co-occurring disorders, behavioral problems, addictions, and traumas (physical abuse, sexual abuse, and more). ESFT is able to engage and help families resolve these problems because of its traumainformed perspective of child and adolescent mental health. This means that the model itself generates a treatment plan for every client family as though at the heart of the problem there is an attachment-related developmental disruption associated with the child and/or caregiver’s experience of unresolved trauma.

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are keeping the family in misery, and dilute the power of the CNIP by practicing healthier transactional patterns. The development of a relational frame is viewed as a collaborative effort: once the therapist and the family come to a meeting of the minds on which family struggles to target for change, the focus of clinical attention moves toward designing and experimenting with new relational patterns through enactment. Enactment refers to any therapist-initiated activity in which family members are challenged to engage directly with one another about an issue, a conflict, or a task. ESFT uses enactments, attended by boundary-making, circular questioning, tracking, and crisis induction, to provoke the occurrence of the CNIP and to give family members concrete experiences of triumph over it. Enactments provide the therapist with opportunities to punctuate the strengths of family members and give family members new information about their own resilience and their ability to offset the legacies of avoidance and abdication that previously controlled them.

Research About the Model Strategies and Techniques Used in the Model The assessment phase of ESFT organizes the family therapist to see, understand, and respond to the family’s struggle around four important areas of family functioning: the co-caregiver alliance, the security of attachment, executive functioning, and emotion regulation/distress tolerance. However, it is not enough for the therapist to have ideas about what to do about these areas of struggle; somehow the therapist has to language the problem conceptualization in such a way as to help the family see relational change as the key to its resolution of the presenting problem. This is done by reframing, that is, placing the presenting problem and the core negative interactional pattern that sustains it in a relational frame. Reframing the presenting problem in relational terms empowers family members to see the presenting problem as something under their control, to understand how habitual patterns of behavior

The empirical support for the ESFT model targeted over 4000 families in 39 different sites, having youth with severe emotional and behavioral disturbance who were either at risk of out-ofhome placement or who had already spent time in an inpatient or residential setting. The families of these youth tended to be compromised by traumainduced parental substance abuse, conflictual relationships, emotional disturbance, and the absence of emotional or concrete support (LindbladGoldberg et al. 1998; Lindblad-Goldberg and Northey 2013; Lindblad-Goldberg and Igle 2015).

Case Study Betsy, a Caucasian ESFT therapist in outpatient practice, received a call from Sharita, an African American divorced mother of two in late October. Sharita explained that her son, Rainier, age

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11, was about to be expelled from a charter school because he continually talked back to his teachers, disrupted class with crude remarks, and got in fights with peers. Because he was so bright, the school had given him many “second chances,” provided in-school counseling, and even reworking his schedule so that he would not be instructed by particular teachers who, he claimed, did not like him. Sadly, Sharita went on to say, nothing worked, and Rainier would be expelled unless his family could find “outside help” to settle him down. Sharita added that because she had to be called to the school so often, she had missed so many days of work that she was at risk of losing her job as a department manager at a big box store. Betsy scheduled an appointment time that allowed Sharita not to miss more work. She explained to Sharita that in order to fully understand what was going on with Rainier, Betsy wanted to include everyone who lived at home with him in the first interview. Sharita did not think that Rainier’s sister, Ivana, age 13, should have to attend the session because she was an exceptionally cooperative child. Betsy explained to mother that it would be helpful for her to observe Rainer’s relationship with his sister. Betsy also shared with mother that siblings often have ideas about what needs to change in a setting that has become problematic. Betsy met with Sharita, Rainier, and Ivana for the first interview. She joined with Sharita first, remarking on how respectful both children were as she and their mother conversed and attributing that respectfulness to Sharita’s guidance and leadership. Joining with Ivana proceeded in a similar way. However, when it was time to join with Rainier, the façade of civility between Ivana and Rainier crumbled. Betsy observed that Ivana continually challenged the truthfulness of Rainier’s responses, persisting in this behavior even when Sharita redirected her, even to the point where Ivana accused Rainier of “being a liar just like Daddy.” This transactional pattern gave Betsy her first important clue about a core negative interactional pattern that might be sustaining Rainier’s troubles in school. Could it be, Betsy thought, that, when this family attempts to help Rainier

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change his relationship to school, the conversation gets lost in a tangle of post-divorce resentments and disappointments? Betsy found the use of particular assessment tools helpful in both generating a working hypothesis and in creating a relational frame. She constructed the genogram in such a way as to give Rainier the opportunity, not just to identify assorted relatives but also to specify the over-all quality of these relationships. In a similar way, Betsy used the relational time line to help all three family members agree on the key events that brought their relationships into the space wherein family therapy was necessary. The family’s ecomap was also served as a valuable instrument in helping both Betsy and the family assess how this family was managing its connections to the various resources in its social environment. And throughout the assessment period, an observable, predictable interaction would show itself: talk would come dangerously close to discussion of the parents’ divorce, and then talk would be focused on Rainier’s troubles in school. Betsy’s hypothesis was that there was a link between the family’s navigation of divorce and Rainier’s navigation of school. The challenge for Betsy was how to language this connection in such a way as to capture the family’s imagination in a reframe that would empower the family to work toward change so that Rainier could master the emotional and behavioral struggles associated with his parents’ divorce. Betsy met this challenge with a powerful relational reframe: “Rainier is acting out in school because he has convinced himself that it is his job to regulate his family’s shock and grief over its post-divorce reconfiguration; he will do better in school when the family resolves the hurts caused by the divorce.” Betsy’s hypothesis made sense to the family and allowed them to move into the stage of the ESFT model when family therapy sessions are devoted to experiments in relational change that confront and dissolve the power of the core negative interactional pattern over family transactions. Betsy helped the family accomplish this by directing the enactment participants to persist while discussing difficult material despite their

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urge to run away from it. She also helped enactment participants to set and keep boundaries around their dialogues so that conversations that started between two family members could stay between them until both family members could feel heard and understood. These enactments supported Sharita’s competence as the family’s leader in guiding her children in discussing of difficult material and empowered Sharita to reach out to the father, Roman, to join her in meeting with school officials to discuss Rainier’s progress. Toward the end of family therapy, when it became clear that the members of the family could talk plainly and openly about their shared story of family disruption and when Rainier was no longer dragging disruption around with him whenever he entered the school building, Betsy asked whether the family was interested in sharing its progress with Roman. Sharita led Ivana and Rainier in a discussion of the risks and benefits of this idea, and the family decided that it was a good idea. The purpose of the sharing would be to make it clear that this is a family wherein there is no more need to hide from the truth of its own story as a family. The meeting with Roman turned out to be the first of several meetings that proved helpful to Rainier in anchoring the changes he was making in school to important relational changes in his family.

References Bowlby, J. (1983). Attachment and loss (Vol. 1, 2nd ed.). New York: Basic Books. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books. Lindblad-Goldberg, M. (2011). Ecosystemic structural family therapy treatment manual. Philadelphia: Philadelphia Child and Family Therapy Training Center. Lindblad-Goldberg, M., Dore, M., & Stern, L. (1998). Creating competence from chaos: A comprehensive guide to home-based services. New York: Norton. Lindblad-Goldberg, M., & Dore, M. (2004). Effective family-based mental health services for youth with serious emotional disturbance in Pennsylvania. The ecosystemic structural family therapy model. Philadelphia: Philadelphia Child and Family Therapy Training Center.

Eisler, Ivan Lindblad-Goldberg, M., & Northey, W. (2013). Ecosystemic structural family therapy: Theoretical and clinical foundations. In Contempory family therapy (Vol. 35, pp. 147–160). New York: Springer. Lindblad-Goldberg, M., & Igle, E. (2015). Grandparents raising grandchildren: An ecosystemic structural family therapy (ESFT) treatment approach. In S. Browning & K. Pasley (Eds.), Contemporary families: Translating research into practice (pp. 248–266). New York: Routledge. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Van der Kolk, B. A. (1997). The psychobiology of posttraumatic stress disorder. Journal of Clinical Psychiatry, 58, 16–24. Memphis: Physicians Postgraduate Press.

Eisler, Ivan Judith Lask and Liz Dodge London, UK

Name Professor Ivan Eisler Ph.D., OBE

Introduction Eisler has made a unique, international contribution to the field of family therapy and family psychology, and specifically to the field of eating disorders. His contribution covers extensive and highly valued research, training, service development, and national policy formulation and implementation. He has been a major influence on the creation of effective, evidence-based eating disorders services in the UK and internationally. In addition, his focus on evidence-based interventions and his collaborative approach to therapy, focusing on the way the family organize themselves around the problem, and avoiding family blame, has been an important influence on the field of family therapy. His research has ensured that family therapy and other systemic approaches are accepted as key interventions in the treatment of eating disorders.

Eisler, Ivan

Career Eisler was born and grew up in Prague. He studied psychology and philosophy at Oxford University, England, returning to Prague where he gained his Diploma in Psychology. He worked as a clinical psychologist in Prague until he moved to London, England, taking up a research post at the Institute of Psychiatry in London and completing his Ph.D. He joined a team, led by Professor Gerald Russell, which was pioneering research in family treatments for eating disorders. This research was to influence both the treatment of eating disorders and family therapy in general. He progressed his career at the internationally renowned South London and Maudsley Foundation Trust and the Institute of Psychiatry, Psychology and Neuroscience (Kings College London). He has had a distinguished academic career. In 1995, he was appointed assistant head of clinical psychology and in 2009 “Professor of Family Therapy and Family Psychology”; the first UK professor appointed with this title. He has lectured and presented around the world and received a number of awards for his contribution including the Academy for Eating Disorders “Outstanding Clinician Award” (2009), a Lifetime Achievement Award from “Beating Eating Disorders” (2012) and an award from the American Family Therapy Academy for “Distinguished Contribution to Family Systems Research”(2014). His UK contribution to the field was recognized nationally when he was awarded an O.B.E. (Order of the British Empire) in 2016.

Contribution to the Profession Since his first publication in 1985, Eisler has published more than 100 peer reviewed academic papers and contributed to numerous books. He has administered numerous research grants and carried out highly evaluated research, including randomized control trials, service appraisals, and economic evaluation of services. This work was mainly in relation to eating disorders but he has also had an interest in depression and substance abuse.

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Early in his career he became involved in family therapy training, running MSc programs in London at the Institute of Family Therapy, London and later at the Institute of Psychiatry. Many students have benefited from his research teaching and his pragmatic and collaborative approach to working with families in extremely difficult circumstances. He has influenced training standards and curriculum in the UK and Europe through his involvement with the Association for Family Therapy (UK), United Kingdom Council for Psychotherapy, and the European Family Therapy Association. In addition, Ivan Eisler has had a significant involvement with prominent journals in the fields of family therapy and eating disorders including editorship of the “Journal of Family Therapy” from 2002 to 2008 and membership of several advisory boards, including “Family Process.” Eisler has advocated therapeutic interventions built on an evidence base. He has spent a large part of his career gathering that evidence and adapting his thinking in response to the results of research, as well as encouraging younger colleagues, some of whom might be lacking in confidence, or suspicious of research. The strength of his research credentials has made him an essential member of committees, advising government on policy development and implementation, especially in relation to eating disorders. In the last decade, has been invited by NHS England to take a key role in the development of curricula for systemic family practice and eating disorders as part of a major policy initiative (Children and Young Person’s Increased Access to Psychological Therapies). This has also included a significant input into the development of a whole service approach and a well-trained workforce. His development of multifamily approaches and training courses based on this intervention has had a major impact on the field. Not only has this impacted on the eating disorders field, but his approach has influenced family therapy training and practice in general. His emphasis on the importance of good quality broadbased training where family therapists develop a range of approaches and skills, which can be adapted to suit clinical need, has influenced family therapy training across the UK and beyond.

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The bringing together of research on treatment and service development is demonstrated in services such as the one developed at the South London and Maudsley Trust. This is clearly described in a readily available service manual by Ivan Eisler and colleagues. Here the multidisciplinary team has a primary focus on family involvement utilizing both single and multifamily therapy in addition to incorporating other interventions, as and when clinically appropriate.

Cross-References ▶ Family Meals ▶ Maudsley Family Therapy for Eating Disorders ▶ Multifamily Group Therapy

References Eisler, I., Simic, M., Blessitt, E., Dodge, L., & Team. (2016). Maudsley service manual for child and adolescent eating disorders (Revised). London: Child and Adolescent Eating Disorders Service, South London and Maudsley NHS Foundation Trust. Available at: http://www.national.slam.nhs.uk/services/ camhs/camhs-eatingdisorders/resources. Eisler, I. (2005). The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27, 104–131. Eisler, I., Szmukler, G. I., & Dare, C. (1985). Systematic observation and clinical insight – are they compatible? An experiment in recognizing family interactions. Psychological Medicine, 15, 173–188. Russell, G. F. M., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa. Archives of General Psychiatry, 44, 1047–1056.

Elderly in Couple and Family Therapy Dorothy Becvar Saint Louis University, Saint Louis, MO, USA

Synonyms Aging; Later Life

Elderly in Couple and Family Therapy

Introduction The elderly of today differ in many significant ways from those of previous generations. As the baby-boomers, those born between 1946 and 1964, moved into the categories of middle and old age, they brought with them new ways of thinking about and behaving relative to aging. Retirement no longer necessarily indicates the end to productivity and involvement in the outside world but now often signals the beginning of a meaningful second half of life. Rather than consigning themselves to rocking chairs and a slowing down of their faculties and activities, retirees tend to see themselves as younger longer, confident, engaged, and active, as well as excited about what lies ahead. The context within which this shift has occurred is that of our aging* society. That is, between 2003 and 2013, the 65+ population increased from 35.9 million to 44.7 million, a 24% increase. By 2060, this number is expected to reach 98 million, or to double. In 2013, the 85+ population was 6 million. By 2040, this population is predicted to be 14.6 million, or to triple (Administration on Aging 2015). In the following sections, the impact on the elderly of the changes just noted, including descriptions of important concepts, relevant research, and special considerations for marriage and family therapy, are all addressed.

Descriptions In the traditional framework according to which families have long been understood, elderly adults are described in terms of two stages of development, each with its particular tasks and challenges (Becvar and Becvar 2013). According to this framework, the emotional issue for middle age adults involves letting go of children and, as a couple, facing each other again. Their stage critical tasks include rebuilding their marriage, welcoming the spouses of their children and grandchildren into the family, and dealing with their aging* parents. In the final stage, that of the retired adult, the emotional issue is accepting

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retirement and old age. Stage critical tasks include maintaining individual and couple functioning, supporting the middle generation, coping with the death of parents and spouse, and closing or adapting the family home. While the above framework probably was never completely accurate, it provided a useful set of guidelines to consider. What is more, some aspects may continue to be relevant to a portion of today’s elderly individuals and families. However, for the most part new descriptions, especially relative to timing, are in order given the demographic and behavioral changes noted in the introduction. For example, rather than an empty nest, middle age parents often find themselves in a new stage that might be called, “when the kids come back home.” That is, after initially leaving home, perhaps graduating from college and/or for economic reasons, many young adults return to the family home in order to get their feet on the ground financially. In addition, many young adults are choosing to build a career before marrying or having children. For the middle age adults a focus on the spousal relationship thus may be postponed along with the process of welcoming their children’s spouses and grandchildren into the family. Meanwhile, having retired earlier than in a manner consistent with the previous norm, they may be looking forward to what they perceive to be an exciting next chapter. Indeed, older adults generally are staying healthier and living longer than in previous generations. Further, given the lengthened lifespan, adults may be older as they are called upon to support their aging* parents, who also are older. They also may be less available for the caretaking of grandchildren as they continue to explore new opportunities and interests of their own. However, while the timing may be different, the elderly still may continue to face issues around maintaining the functioning of older individuals and couples. The oldest old may continue to be called upon to support the middle generation. Dealing with dying, death, and bereavement issues also is inevitable as is the need to alter living arrangements when appropriate. In addition, although slowly changing, the fact remains that a large segment of elderly clients are

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likely to be female. This situation is the case given that women have a greater life expectancy, women tend to outlive their generally older spouses, and women in any age group tend to be more comfortable with the idea of therapy. For elderly women, particularly those who are widows, an important issue is the loss of financial security and social network that may occur following the death of a spouse. Further, regardless of gender, facilitating connections with a meaningful support system may be important as the loss of friends and family members becomes ever more common the older one gets.

Relevant Research About the Elderly Over the years, the topic of aging* and its related concerns have been the focus of a very small percentage of the family therapy literature. The area that has received the most attention within this realm is that of the role of the family caregiver. From this body of research we are reminded that assuming the role of family caregiver to a physically or emotionally compromised older person represents a major life transition that may have far-reaching consequences for the caregiver’s physical, mental, and social well-being (Ziemba and Lynch-Sauer 2005. Further, emotional closeness as well as similarity of gender and attitudes may be strongly associated with which children mothers identify as probable caregivers. Another study revealed that female caregivers often feel unprepared for the role and experience emotional distress related to both the loss of a parent and the loss of their youth. Additionally, it has been found that the quality of the caregiver’s marital relationship influences the psychological effects of becoming a caregiver for a biological parent or spouse (Choi and Marks 2006). It also has been found that humor used to communicate information about socially taboo or sensitive topics (e.g., bowel movements, loneliness, personal safety, and intimate care) often masks problems and concerns (Bethea et al. 2000). Regarding the implications for future research related to the elderly, it has been suggested that

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studies are needed on the topics of roles and responsibilities and parent–child interactions including patterns of contact, required assistance, and support. Additional research would also do well to focus on individual well-being, relationship quality, and caregiving by adult children (Mancini and Bliesner 1989).

Special Considerations for Couple and Family Therapy Until recently, the elderly have often been reluctant to avail themselves of therapy, and therapists often have had little experience dealing with elderly individuals and their families. However, given the many changes noted above, it is highly likely that therapists will need to educate themselves about this growing cohort of clients. Elderly family members may bring themselves to therapy or younger individuals may seek help regarding elderly family issues. Therapists, therefore, will need to have knowledge about the entire life cycle as well as an ability to work with family members of all ages. They also will need knowledge about medical issues and how to work with other health care providers. Involving as many family members as possible may aid the therapy process, particularly when role transitions are the focus. Regardless of the presenting issue, the use of a genogram may allow the elderly to tell their stories and engage in a kind of life review that increases their comfort level. Indeed, it may be important to support and validate elderly individuals, acknowledging efforts already made to solve problems as well as feelings of being stuck they may be experiencing. Clients also may be commended for coming to therapy given the courage this may have required. Indeed, although their feelings may change, elderly clients may feel shame or worry that their reputation will be tarnished by engaging in therapy. Therefore, it may be appropriate to normalize, emphasizing to clients that they are not crazy, and responding first to questions and concerns. Therapists also need to understand the tendency of older adults to be vague in their descriptions of problems and concerns, to gloss over potentially

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important information, and/or to have more than one complaint. They also need both to understand that health issues and/or medications may have an adverse effect on behavior and to recognize the influence of normal aging processes vs. disease processes. In addition, therapists must be sensitive to their own biases and preconceptions regarding the elderly, possibly fearing the need for special skills or fearing that older adults are fragile and thus not to be confronted (Davey et al. 2000). They also may have unresolved issues with their own parents and grandparents that are in need of attention. Their assumptions about sexual activity among the elderly may be inaccurate and thus need to be checked out. That is, sexual intimacy does not necessarily end at a particular age and may remain a constant throughout life. In addition, therapists may need to overcome their own fears about dying, death, and bereavement, a crucial topic of consideration for the elderly and their families. Early models of bereavement proposed that the grief process occurs in three stages: 2 weeks of intense grief, followed by 2 years in which the survivor was to disconnect from the one who died, and a return to normal thereafter. Failure to follow this agenda was considered to connote pathological grieving. More recent models of grieving, however, suggest that the grieving process may have no fixed endpoint and may even last a lifetime. Further, complete detachment from the deceased is recognized as neither possible nor desirable. Rather, bereaved persons may remain involved and connected to the person who has died, often constructing an inner representation of the deceased. Further, bereavement may take many forms, and the degree to which grief is or is not maladaptive must be decided on an individual basis. In therapy, the goal is to help family members to resolve rather than work through the loss. This may involve helping them to acknowledge and learn to accept and live with grief while at the same time being successful in reclaiming joy as an equally valid part of life; recognizing each experience of loss as unique; allowing the bereaved to tell their stories as often as need be; and understanding that grief may never end, and that this does not

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necessarily indicate pathology or preclude the possibility of reclaiming joy. In addition, at any age two important aspects of the therapy process may include facilitating resilience and supporting healthy aging. With the goal of resilience in mind, the focus is on strengths rather than deficits with the assumption that families have the ability not only to survive difficult times but also to eventually thrive as they emerge from those experiences. For the elderly this may involve encouraging celebrating and having fun, taking advantage of opportunities to experience spontaneity and a sense of humor. Therapists also may suggest the creation of rituals that might fill a void, or the recreation of traditions that no longer fit as individuals grow older and families mature. Also appropriate may be conversations around goals and values and understanding the importance of a sense of meaning and purpose in life, particularly when dealing with end-of-life issues and challenges. It also may be appropriate to consider the role of religion and/or spirituality in clients’ lives, recognizing that this area may be an important source of coping for older adults. Therapists therefore might include questions about religion/spirituality in initial assessments, be curious about various orientations, and access resources from the religious/spiritual realm as appropriate. Encouraging a focus on ways to create an older age that is as enjoyable as possible may involve helping clients revise their self-talk about what lies ahead. Therapists also may provide suggestions derived from recent research on aging, helping them to plan to live a very long life – perhaps 80 or 90 years – and taking steps to guarantee the intellectual and social stimulation that is desirable in later years (Dychtwald 2000). It may be important to help clients avoid getting trapped in yesterday’s linear model of aging. This effort may include adjusting their psychological, social, and financial expectations to support a life plan that is periodically revised to envision new career goals and challenges. Intellectual flexibility and the ability to learn new skills and technologies are likely to be significant in this process. It is important that the elderly maintain or find social connections and

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be open to new ideas. Healthy aging behaviors include caring about others, accepting the past and taking sustenance from previous accomplishments, and cheerfully accepting the “indignities of old age.” Also important is being graceful about dependency issues, taking care of self, and, when ill, becoming a good patient (Vaillant 2002). Working with later life* families involves distinctive issues and challenges (Shields et al. 1995). At the same time, with an approach that is sensitive to the specific needs and concerns of middle-aged and elderly families and their members, the therapist may experience unique opportunities to assist clients in achieving their goals. They thus may succeed in contributing to the enhancement of the quality of life during what is often one of its most stressful phases.

References Administration on Aging. (2015). A profile of older Americans, 2014. http://www.aoa.acl.gov/Aging_Statistics/ Profile/2014/docs/2014-Profile.pdf. Accessed 6 July 2015. Becvar, D. S., & Becvar, R. J. (2013). Family therapy: A systemic integration. Boston: Allyn & Bacon. Bethea, L. S., Travis, S. S., & Pecchioni, L. (2000). Family caregivers’ use of humor in conveying information about caring for dependent older adults. Health Communication, 12(4), 361–376. Choi, J., & Marks, N. (2006). Transition to caregiving, marital disagreement, and psychological well-being. Journal of Family Issues, 27(12), 1701–1722. Davey, A., Murphy, M. J., & Price, S. J. (2000). Againg and the family: Dynamics and therapeutic interventions. In W. C. Nichols, M. A. Pace-Nichols, D. S. Becvar, & A. Y. Napier (Eds.), Handbook of family development and intervention (pp. 235–252). New York: Wiley. Dychtwald, K. (2000). Age power: How the 21st century will be ruled by the new old. New York: Jeremy P. Tarcher/Putnam. Mancini, J. A., & Bliesner, R. (1989). Aging parents and adult children: Themes in relationships between older parents and their adult children. Journal of Marriage and the Family, 51, 275–290. Shields, C. G., King, D., & Wynne, L. C. (1995). Interventions with later life families. In R. H. Mikesell, D. D. Lusterman, & S. H. McDaniel (Eds.), Integrating family therapy: Handbook of family psychology and systems theory (pp. 141–158). Washington, DC: American Psychological Association.

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Elementary Pragmatic Model Piero De Giacomo1 and Jessica L. Chou2 1 University of Bari Aldo Moro, Bari, Italy 2 Queen of Peace Center, St. Louis, MO, USA

Name of Model Elementary pragmatic model

Introduction The elementary pragmatic model (EPM) was developed in the 1960s in order to expand on family systems theory and further explore interpersonal relationships. The theory focuses on a “pragmatic” approach by examining communication of behaviors between two individuals and an “elementary” approach for classifying communicative interactions (De Giacomo 1992; De Giacomo et al. 2013).

Prominent Associated Figures The theory defined as EPM was born in Bari, Italy, from the meeting of Piero De Giacomo, Professor of Psychiatry at University of Bari, and Alberto Silvestri, Professor of Numerical Calculations and President of Economy Faculty at Trento University. This meeting was a result of De Giacomo’s interest in general systems theory, which at the time was an emerging theory. De Giacomo sought to meet an expert in mathematics, physics, and computer science and explore the possibilty of the integration of these fields with general systems theory. From this meeting, EPM was created. Luciano L’Abate from Georgia University also contributed greatly to EPM and coauthored a book with De Giacomo titled Intimate Relationships and How to Improve Them (L’Abate and De Giacomo 2003).

Elementary Pragmatic Model

Theoretical Framework (Including Core Concepts of Model, Theory of Change, and Rationale for the Model) Rooted in work by Gregory Bateson, EPM explores how the world is perceived and exchanged in interpersonal relationships. EPM is based of ideas related to interactions of the mind between two individuals (De Giacomo 1992). These exchanges produce four outcome modalities of interactions: (1) acceptance of other’s world, (2) acceptance of one’s own world, (3) acceptance of what is shared, and (4) acceptance of what is outside the world of the two interacting persons. From these interactions ensued the development of 16 functions and also coined as interactions and relational styles. The interactions between the 16 relationship styles give rise to 256 possibilities of interactions (De Giacomo 1992). EPM also draws from a structural approach to therapy in that the model focuses on subsystems within the family unit and communication styles among dyads. In addition to the family therapy field, there has to be mention of the important development in the field of problem-solving creativity. Problemsolving creativity has extended into the general field of psychotherapy (De Giacomo et al. 1990) as well as in the field of informatics (De Giacomo 1999). The latest development of EPM to include creativity explores metacognition (i.e., thinking about the mind) and how to think differently. Further information can be located in the book titled Creativity Mind (De Giacomo and Fiorini 2015).

Populations in Focus In the field of family therapy, the original EPM interventions were developed for persons diagnosed with anorexia nervosa and schizophrenia. As the model evolved, it has since been expanded and can be used for a myriad of relational dyads, including those with and without clinical diagnoses. EPM has been utilized as short- and long-term therapeutic model (De Giacomo et al. 2012).

Elementary Pragmatic Model

Strategies and Techniques Used in Model The model implements techniques and strategies considered straightforward and direct while also focusing on paradoxical interventions (De Giacomo et al. 1997b). One technique used in EPM is called the empty box. The empty box intervention can be used when a family is deemed “uncooperative” by the therapist. This intervention mobilizes the families’ capacity to change. The therapist tells the family he knows the solution to the problem, however, believes they are not yet ready to hear the solution. Another example of an EPM technique explores using common logic. If a therapist is working with a client who is dissociative and displaying incoherent speech, the therapist will meet the client where he/she is by also using incoherent speech in order to assist the client in developing a cooperative relational style (De Giacomo 1992).

Research About the Model EPM has 40 years of experimentation with normal and pathological subjects that have yielded significant results. De Giacomo et al. (1997) studied EPM in a sample of families in which one person was diagnosed with schizophrenia. The research showed efficacy for EPM when used in conjunction with medication compared to a medication-only population. Specifically, those who participated in EPM and received medication had reduced psychiatric symptoms and increased social improvement compared to those who had medication only.

Case Example EPM can be conceptualized through an adapted case study published in Finite Systems and Infinite Interactions (De Giacomo 1993). Mia and Russel brought their daughter, Aida, to therapy because they were concerned about Aida’s recent eating habits and weight loss that developed over the past 6 months. Aida restricted her calories at all meals and, additionally, had

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begun skipping meals. Though Aida had participated in various sports during high school, she had recently quit her teams and told her parents she did not want to play sports so she could shift her focus to counting calories. At the start of therapy, the therapist arranged the family members according to a structural approach. The therapist sat behind the desk, and Mia and Russel sat laterally in front of the desk with the two chairs facing each other. Aida was placed in a second line in front of the therapist. The therapist established friendly contact with all family members, showing interest in each person’s world, starting with Mia and Russel and then Aida. After joining with the family, the therapist inquired about the problem. In response, Mia took the lead in explaining Aida’s problems. She reported that Aida was not eating and was irritable and emotional. The therapist utilized a direct and paradoxical approach, saying that in fact there was reason to be seriously concerned because when someone exhibits symptoms of anorexia nervosa the danger of death is real. The therapist also reported that he was not sure the problem could be overcome. The family became more anxious and asked what could be done. The therapist asked if the family was willing to do everything possible to solve the problem (this is first asked collectively to the whole family and then to each separate member). Everybody answered in the affirmative. The therapist asked the father and Aida to follow him into the consultation room next door while the mother remained in the original room. In the consultation room, the therapist asked the daughter to step on the scale and the father to check her weight. The situation seemed ridden with anxiety. Russel had increased concern upon seeing his daughter’s weight, and Aida was also visibly uneasy. The therapist, the father, and the daughter then came back into the therapy room. Mia was moved to Aida’s chair, and Aida was moved to her mother’s seat. The therapist asked Russel to inquire about the eating behavior of his daughter: what food she prefers and which she hates, if she vomits or takes laxatives, etc. Then he asked Aida what

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menu she would accept for breakfast, lunch, and dinner. As Aida responded, Russel was instructed to write the information down. The therapist asked again if the family was willing to do everything necessary to solve the problem, reporting that what he was going to ask was something that was very difficult to carry out. The family answered affirmatively in great earnest. The following prescription was given: Russel and Aida were instructed to travel together, by themselves, to a place of their choice where they have no friends or relatives. They were instructed to spend a month there (sometimes 3 weeks) and be together at all times. During this period, Russel was to try to enter Aida’s world by finding out her thoughts, wishes, and aspirations. Additionally, they were instructed to phone home only once a day and were told to not speak about food/eating during these conversations. Before the departure, Mia was instructed to give Russel advice on how to behave toward Aida. At the end of the prescribed period, the first encounter with Mia was to be in the therapist’s office. The therapist acknowledged that the greatest sacrifice is born by Mia, but that this sacrifice was necessary to rescue and protect her daughter. This notion stems from the perspective that there are generally many interactions between mother and daughter and a limited amount of interactions between daughter and father. Building interactions between father and daughter assists in generating new interaction patterns among the family, as a whole. The family met again for their second session after the month departure. The therapist, once again, asked Russel to weigh Aida, at which time they found out her weight increased. The therapist complemented Russel, Aida, and Mia for their dedication to treatment. The therapist then spoke with the parents, giving the prescription of four rules to follow moving forward: (1) from now on close their bedroom door, (2) go out alone three times a week for at least 1 h, keeping what they do and where they go a secret from Aida, (3) demonstrate reciprocal affection when they are in Aida’s presence, and (4) assign Aida a small task demonstrating strong

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agreement when they give it. The therapist warmly said goodbye to the family and invited them to contact again in 6 months.

Cross-References ▶ Family Therapy ▶ First Order Cybernetics ▶ Paradoxical Directive in Couple and Family Therapy ▶ Second-Order Cybernetics in Family Systems Theory ▶ Structural Family Therapy

References De Giacomo, P. (1992). The elementary pragmatic model: From theory to therapeutic practice. Annali Istituto Superiore di Sanità, 28, 169–176. De Giacomo, P. (1993). Finite systems and infinite interactions. Norfolk: Bramble Book. De Giacomo, P. (1999). Mente e Creatività. Milan: Franco Angeli. De Giacomo, P., & Fiorini, R. (2015). Creativity mind. Amazon Ebook Conversion by CICT CORE Group. 1st Digital Edition: August 2015. De Giacomo, P., Pierri, G., Lefons, E., & Mich, L. (1990). A technique to simulate human interaction: Relational styles leading to a schizophrenic communication patterns and back to normal. Acta Psychiatrica Scandinavica, 82, 413–419. De Giacomo, P., Margari, F., & Santoni Rugiu, A. (1997a). A successful one-session treatment of anorexia nervosa: Report of fifteen case. International Journal of Family Psychiatry, 2, 123–132. De Giacomo, P., Pierri, G., Santoni Rugiu, A., Buonsante, M., Vadruccio, F., & Zavoianni, L. (1997b). Schizophrenia: A study comparing a family therapy group following a paradoxical model plus drugs and a group treated by the conventional clinical approach. Acta Psychiatrica Scandinavica, 95, 183–188. De Giacomo, P., L’Abate, L., Margari, F., Santamato, W., Belgiovine, M. T., Craig, F., & De Giacomo, A. (2012). The elementary pragmatic model: A new perspective in psychotherapy. Estratto da Rivista di psichaitria, 47, 1–8. De Giacomo, P., L’Abate, L., Margari, F., Craig, F., & De Giacomo, A. (2013). Diagnostic and therapeutic potential of the elementary pragmatic model. Rivista di Psichiatria, 48, 67–72. L’Abate, L., & De Giacomo, P. (2003). Intimate relationships and how to improve them. Westport: London Praeger.

Elizur, Yoel

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conditions. He was mentored in this work by Dr. Mordecai Kaffman, the medical director of the Kibbutz Child and Family Clinics.

Jane Ariel The Wright Institute, Berkeley, CA, USA

Contributions to the Profession Introduction Yoel Elizur, Ph.D., associate professor, is the director of the Clinical Child and Educational Psychology Program at The Seymour Fox School of Education at the Hebrew University of Jerusalem, Israel (http://education.huji.ac.il/yoelelizur). Dr. Elizur, a clinical, educational, and medical psychologist, is a leading expert in the design, implementation, and research of family-focused care in public human services. Some of the specific areas he has contributed to include (a) the promotion of collaborative family-agency care for young children, adolescents, and young adults, (b) intervention design and research with parents and teachers of young children with conduct problems, and (c) work with stress-related issues of combat soldiers in Israel. In 2010, he was appointed to a 3-year term as chairperson of Israel’s Council of Psychologists and the Minister of Health’s consultant on policy and practice of psychology in Israel.

Career Dr. Elizur was born and raised in Israel and received his academic degrees from the Hebrew University of Jerusalem (Ph.D in 1981). In 1986–1987, he received a Post-Doctoral Fulbright fellowship at New York University and co-authored Institutionalizing Madness: Families, Therapy and Society with Salvador Minuchin. He worked for 18 years in the Kibbutz Clinics in Israel, during which time he headed the Hadera and Yoav clinics and founded the Medical Psychology Center. Under his leadership, the Yoav Clinic became an interdisciplinary mental health center with 30 staff members. Based on his ecosystemic kibbutz work, he developed a life-span family-systems developmental perspective that was applied to a variety of psychopathological

In 1995, Dr. Elizur joined the Hebrew University’s psychology department where he initiated different consultation projects with senior administrators in the Ministry of Social Affairs and Social Services. Following consultation with Israel’s Youth Protection Authority, he formulated the InvolvementCollaboration-Empowerment (ICE) model for the development of family-oriented care. Subsequently, Elizur developed innovative family-collaborative community and day residential care that is currently provided to 17% of out-of-home Israeli children. He also applied the ICE model to advance familycollaborative care in the IDF’s treatment center for combat-related stress disorders. Following the intensification of his scientific work, Elizur accepted a full-time academic position in the Hebrew University’s School of Education. Subsequently, in collaboration with the Ministry of Education’s Chief Psychologist, he designed and researched Hitkashrut, an early intervention program that promotes attachment security, self-regulation, and cooperation in preschoolers with conduct problems. Hitkashrut is a generic cost-efficient program that has been culturally adapted to Israel’s diverse populations. A randomized controlled trial of the parent training component demonstrated clinicallevel success in real-world conditions and indicated dual processes of change at the relational and early personality development levels. Hitkashrut’s teacher training component is under study and preliminary results indicate its effectiveness. These interventions are currently implemented and publically funded in more than 30 municipalities throughout Israel. Hitkashrut’s success demonstrates how the development of an empirically based program together with systems consultation and research can change public policy and create cost-effective services to children and families. In 2010, Dr. Elizur was appointed by the Prime Minister and Minister of Health to head Israel’s Council of Psychologists. During his 3-year term,

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he chaired a group composed of 27 prominent Israeli psychologists who represented different areas of practice and academic work. His facilitation led to far-reaching change in the Psychology Law, to a reform in the basic operating procedures to enhance transparency and fair administrative practices, and to a successful campaign for the authorization of psychologists in ADHD diagnosis and advanced ADHD-related training standards. A further significant achievement was the definition of a core academic curriculum for graduate professional psychology programs. These reforms ended two decades of conflict over professional and science-based standards of training and academic freedom versus public regulation. Besides Dr. Elizur’s numerous consultations to public service and academic institutions, he has received many research grants and a number of awards, such as the Jerusalem Foundation’s Esther Haar Award for an original contribution to social psychiatry in Israel (2005) and the Bahat and Haifa University Press Award for the best original nonfiction manuscript of 2002: Holding their own: Self/ Mutual Help, Therapy, and Society. Dr. Elizur has published four books, edited two others, and written chapters in 12 publications. His more than 50 peerreviewed articles cover such topics as treating familial and individual stress in different situations, the integration of medical and clinical psychology, supervision and training, and the collaboration of organizational systems with therapeutic interventions.

Cross-References ▶ Minuchin, Salvador ▶ Structural Family Therapy

References Elizur, Y. (1996). Involvement, collaboration, and empowerment: A model for consultation with human-service agencies and the development of family-oriented care. Family Process, 35(2), 191–210. Elizur, Y. (2012). Development and dissemination of collaborative family-oriented services: The case of community/day residential care in Israel. Family Process, 51(1), 140–156.

Elkaïm, Mony Elizur, J., & Minuchin, S. (1989). Institutionalizing madness: Families, therapy and society. New York: Basic Books. Elizur, Y., & Perednik, R. S. (2003). Prevalence and description of selective mutism in immigrant and native families: A controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 42(12), 1451–1459. Elizur, Y., & Somech, L. Y. (2018). Callous-unemotional traits and effortful control mediate the effect of parenting intervention on preschool conduct problems. Journal of Abnormal Child Psychology. https://doi. org/10.1007/s10802-018-0412-z. Somech, L. Y., & Elizur, Y. (2012). Promoting selfregulation and cooperation in pre-kindergarten children with conduct problems: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 51(4), 412–422.

Elkaïm, Mony Michel Maestre PSYCOM, Villeneuve d’Ascq, France

Name Mony (Maïmonid) Elkaïm

Introduction Mony Elkaïm is one of the most important psychotherapists to have contributed to the development of family therapy in Europe, and beyond. He is a neuropsychiatrist, Director of the Institute for Family and Human Systems Studies (Brussels) and Honorary Professor at the Free University of Brussels. He is a consultant and medical doctor of the consultation for couples and families at the Department of Psychiatry of the Erasmus University Hospital in Brussels. He is the Founder of the European Family Therapy Association (EFTA), which he presided 11 years, from 1990 until 2001. Since 2001, he is the chairperson of the association’s Chamber of Training Institutes (EFTA-TIC).

Elkaïm, Mony

He was the President of the European Association for Psychotherapy (EAP) from 2007 to 2009, being Honorary President of this association. He is also an “Approved Supervisor under the Founders Track” of the American Association for Marriage and Family Therapy (AAMFT) and the Director of the collection “Couleur Psy” at the Editions du Seuil in Paris. He has published several books and articles in the field of psychotherapies.

Career After a fellowship at the Albert Einstein School of Medicine in New York in the early 1970s, Dr. Elkaïm stayed in New York where he, cumulatively, practiced social and community psychiatry, founded a school to train family therapists, and worked for 2 years as the Director of one of the mental health centers of the Albert Einstein School. Since returning to Europe, Dr. Elkaïm has become a member of the Council of the Brussels Doctors’ Order as well as of the Order of the Departmental Council in Paris and a professor at the Free University of Brussels (ULB). Trainer in family psychotherapy and the systemic approach in France and Switzerland since 1976, he has trained over 500 psychiatrists, child psychiatrists, psychologists, and social workers in the framework of 4-years formation cycles, both in private and public practice (as of 2016), in Paris and in Geneva. On the strength of this experience, he decided, with the support of a number of colleagues, his former students, to set up an organization named “Elkaïm Formations,” aiming at the development of training courses in systemic and family therapy. Since 1979, he has been also the Director of the Journal Cahiers Critiques de Thérapie Familiale et de Pratiques de Réseaux, (Critical Reviews of Family Therapy and Network Practices), De Boeck Editions.

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Contributions to the Profession In the 1970s, Mony Elkaïm developed “Network Practices” in the South-Bronx where he was directing a mental health center. From 1976 to 1981, he coordinated the international network “Alternatives to Psychiatry” with the support of Felix Guattari, Françoise and Robert Castel, Franco Basaglia, David Cooper, and Ronald Laing. In the 1980s, he enlarged the systemic approach to better understand situations of change by introducing the work of Ilya Prigogine (Nobel Prize in Chemistry 1977) on systems far from equilibrium and chance. At the same time, Mony Elkaïm created a new model for couple therapy insisting on reciprocal double binds and on function of conflicts to maintain the homeostasis of the couple’s worldviews. He created the concept of “resonance” to provide a tool to psychotherapists who consider themselves part of the therapeutic system. The function of their feelings for the therapeutic system thus became an asset rather than a handicap.

Cross-References ▶ Cahiers critiques de thérapie familiale et de pratiques de réseaux (Journal) ▶ European Family Therapy Association ▶ Resonance in Couple and Family Therapy

References Elkaïm, M. (1987). Les Pratiques de réseaux: santé mentale et contexte social. Paris: ESF. Elkaïm, M. (1989). Si tu m’aimes, ne m’aime pas. Approche systémique et psychothérapie. Paris: Le Seuil. Elkaïm, M. (1994). La thérapie familiale en changement. Paris: Les Empêcheurs de Penser en Rond. Elkaïm, M. (1995). Panorama des thérapies familiales. Paris: Le Seuil. Elkaïm, M. (2017). Vivre en couple. Plaidoyer pour une stratégie du pire (Coll. Philo. Gener.). Paris: Le Seuil. Elkaïm, M., & Glorion, C. (2006). Comment survivre à sa propre famille? Paris: Le Seuil. Elkaïm, M., Cyrulnik, B., & Maestre, M. (2009). Entre résilience et résonance. A l’écoute de nos émotions. Paris: Fabert.

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Emerging Technologies in Couple and Family Therapy Viviana Ploper The Family Institute at Northwestern University, Evanston, IL, USA

Name of Entry Emerging Technologies in Couple and Family Therapy

Synonyms Computer therapy; Cyber therapy; E-therapy; Information communication technologies (ICT); Internet-based interactions; Internet-based interventions; Mobile health; Telehealth; Telepsychology

Introduction The term “cyber therapy” came from Isaac Marks (Marks et al. 2007) and refers to the use of using a computer to provide, enhance, or facilitate therapy. It can support therapy across the distance and create virtual realities. Telehealth is defined as the use of electronic and communications technology to accomplish health care over distance (Jerome and Zaylor 2000), as the provision of health care by any telecommunication technology, to include telephone, internet, email, video teleconferencing (VTC), smartphones, blogging, social media, and others digital apps (Wrape and McGinn 2018). Technology, which can be defined as the application of science and information to practical areas, such as electronic or digital products and systems, is an ever-expanding part of the therapeutic process and continues to change the way that both clients and MFTs approach treatment (Pennington et al. 2017). Individuals can use their smartphone, computer, or tablet to visit

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clinical professionals. The literature shows that telehealth first was used more broadly with physical health, but it took longer for behavioral health to adopt it (Borcsa and Pomini 2017). According to the 2017 OPEN MINDS Health & Human Services Technology Survey, there has been a substantial increase in the number of behavioral health organizations using telehealth technologies compared to the previous year, less so for smaller practitioners who use technology to support billing and documentation systems but have been slower to embrace the culture shift of providing online therapies, which also involves having the right technology in place. In the past the use of telehealth was less common among marriage and family therapists, but there has been a steady increase of cyber therapy use to treat individuals, couples, and families. In couple and family therapy, information communication technologies (ICT) support clinician-client communication (via texts, emails), and they can challenge clinicians to stay wellinformed and up to date about how to use these for therapeutic purposes. Teletherapy can be done both live (as in video conferencing) and be either “synchronous” (both communicate in real time) or “asynchronous” such as when one person is emailing or texting and the other person responds with a later response. These technologies also challenge state licensure boards and professional associations to modify or maintain their regulations, standards, and codes of ethics to align with the ongoing advances of technology as well as the increasing developments of new apps. Technology has made it easier to reach more clients who otherwise may not be able to benefit from services. For young people, technology is the way they communicate. In areas that lack MFTs, individuals can now receive services through video conferencing (VC); and families who may have a family member in another city can include that family member through VC in their family therapy sessions. As mental health organizations discuss how to improve individuals’ access and engagement in services, telehealth has been mentioned as the

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preferred solution to improving those issues. “Telemedicine” is now part of a much broader category of tech-enabled therapy services, referred as “virtual health” ranging from virtual online provider networks and automated programs like e-CBT and mindfulness apps (Oss 2018). Popular apps include mood trackers, online journals, meditation tools, virtual coaching, education modules, and more. The Anxiety and Depression Society of America has a large catalog of available mental health applications, each with ratings and reviews. There is an increasing amount of evidence indicating that virtual reality (VR) technology can be effective in the treatment for phobias, PTSD (Hughes 2017, May 8), and other mental health conditions (Wolters Kluwer publication of Harvard Review of Psychiatry, May 2017). Although technology use by marriage and family therapists has been less studied, prior research indicates that clinicians communicate with clients through email, texts, answering services, video conferencing, websites, and phones. Increasingly MFTs are using technology to support supervision and for training. The American Association for Marriage and Family Therapy (AAMFT) added a standard about Technology-Assisted Professional Services, which addresses “the basic ethical requirements of offering therapy, supervision, and related professional services using electronic means” (American Association for Marriage and Family Therapy (AAMFT) Code of Ethics 2015). And in September of 2016, the Association of Marital and Family Therapy Regulatory Boards (AMFTRB) developed the Teletherapy Guidelines, which are “to be used by Member Boards when regulating the practice of teletherapy by Licensed Marriage and Family Therapists (LMFTs) across the country.” Several accreditation and certification bodies now offer a telepsychology credential, to insure best practices in using computer-based therapies. There is a lot of interest on the impact of technology in psychotherapy. In 2014 the Coalition for Technology in Behavioral Science

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(CTiBS) was created as a nonprofit, with three main priorities: the development of competencies for behavioral professionals using technologies; the need to organize human, administrative, clinical, research, and other fields’ resources; and the need to provide an interprofessional, international journal to support the scientific development of technology for psychiatry, psychology, social work, counseling, marriage and family therapy, addictions, and other professions. They publish the Journal of Technology in Behavioral Science (JTiBS), which deals with the interface of technology, psychology, medicine, policy, health administration, and behavioral sciences.

Challenges of Telehealth Technologies have raised some ongoing ethical, risk management, and privacy issues raising questions related to informed consent; delivery of services; privacy, confidentiality, and privileged communication; documentation; and practitioners’ relationships with colleagues. States and professional associations are developing new standards of care that are being incorporated into licensing statutes and regulations, professional codes of ethics, and practice guidelines adopted by the professions of psychiatry, psychology, mental health counseling, marriage and family therapy, and clinical social work (Reamer 2018). Other studies suggest concern in terms of best practices in the areas of confidentiality, boundary issues, dual relationships, and crises situations. Furthermore, though individuals use the internet more frequently and regularly to communicate with social media and to research services, the same is not as true for organizations, which appear to communicate infrequently, in one direction. Emerging technology adoption poses new challenges and opportunities to clients, families, clinicians, and accreditation bodies. Research that explores clinicians’ understanding and use of information communication technologies is growing as evidence starts to show improved outcome for accessing consumers.

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850 From the standpoint of systemic therapists, there is an implied relational level even in long-distance communication: written communication and a limited number of characters do not transfer only data, but also implicit emotional and relational elements. Technology can be of great help to clinicians, but therapists should employ with great care and awareness these new communicative devices, being aware of risks which could compromise the setting management and the therapeutic relationship. (Manfrida et al. 2018).

Emery, Robert Virtual Reality for Psychiatric Treatment? Research Shows Promise for VR and Other Technologies in Mental Health Care, May 8, 2017. Retrieved from https:// wolterskluwer.com/company/newsroom/news/2017/ 05/virtual-reality-for-psychiatric-treatment-researchshows-promise-for-vr-and-other-technologies-in-men tal-health-care.html. Wrape, E. R., & McGinn, M. M. (2018). Clinical and ethical considerations for delivering couple and family therapy via telehealth. Journal of Marital and Family Therapy Advance online publication. https://doi.org/ 10.1111/jmft.12319.

Cross-References ▶ Couple and Family Therapy in the Digital Era

Emery, Robert

References

Jenna Rowen The Family Institute at Northwestern University, Evanston, IL, USA

Borcsa, M., & Pomini, V. (2017). Virtual relationships and systemic practices in the digital era. Contemporary Family Therapy, 39(4), 239–248. Hughes, C. (2017, May 8). Virtual reality for psychiatric treatment? Research shows promise for VR and other technologies in mental health care. Retrieved from https://wolterskluwer.com/company/newsroom/news/ 2017/05/virtual-reality-for-psychiatric-treatment-rese arch-shows-promise-for-vr-and-other-technologies-inmental-health-care.html Jerome, L. W., & Zaylor, C. (2000). Cyberspace: Creating a therapeutic environment for telehealth applications. Professional Psychology: Research and Practice, 31, 478–483. Manfrida, G., Albertini, V., & Eisenberg, E. (2018). Psychotherapy and technology: Relational strategies and techniques for online therapeutic activity. In R. Pereira & J. L. Linares (Eds.), Clinical interventions in systemic couple and family therapy (pp. 119–137). https:// doi.org/10.1007/978-3-319-78521-9_9. Marks, I. M., Cavanagh, K., & Gega, L. (2007). Computer aided psychotherapy: Revolution or bubble? British Journal of Psychiatry, 191, 471–473. https://doi.org/ 10.1192/bjp.bp.107.041152. Oss, M. (2018, September). First telehealth – Now virtual health. OPEN MINDS Daily Executive briefing. Retrieved from https://mailchi.mp/openminds/firsttelehealthnow-virtual-health?e=b92fedcb56 Pennington, M., Patton, R., Ray, A., & Katafiasz, H. (2017). A brief report on the ethical and legal guides for technology use in marriage and family therapy. Journal of Marital and Family Therapy, 43(4), 733–742. https://doi.org/10.1111/jmft.12232. Reamer, F. G. (2018). Evolving standards of care in the age of cybertechnology. Behavioral Sciences & the Law, 36(2), 257–269. https://doi.org/10.1002/bsl2336.

Introduction Robert Emery has been one of the leading researchers and authors in the areas of interparental conflict, divorce, and mediation for the past 30 years. He has spent most of his professional career as a professor of psychology at The University of Virginia, teaching, conducting research, and leading a highly productive lab of graduate students. He has authored over 150 scientific publications, and several books, including Marriage, Divorce, and Children’s Adjustment, Renegotiating Family Relationships: Divorce, Child Custody, and Mediation, and his guides for parents, The Truth about Children and Divorce: Dealing with the Emotions So You and Your Children Can Thrive & Two Homes, One Childhood: A parenting Plan to Last a Lifetime. He is also the coauthor of Abnormal Psychology with Dr. Thomas Oltmanns, a text widely used by undergraduate psychology departments. Dr. Emery has lectured extensively on his research across the United States and in numerous countries throughout the world. In addition to his academic pursuits, Dr. Emery maintains a practice as a couple and family therapist and divorce mediator.

Emery, Robert

Career Dr. Emery earned his B.A. from Brown University in 1974 and his M.A. in psychology SUNY at Stony Brook in 1980. After completing a clinical internship at the Psychology Center at SUNY at Stony Brook, Dr. Emery earned his Ph.D. in clinical psychology from SUNY at Sony Brook in 1982. In 1981, Dr. Emery joined the psychology faculty at the University of Virginia as an Assistant Professor and was promoted to Associate Professor in 1986. From 1984 to 1987, Dr. Emery served as the Coordinator of Research in Clinical Psychology within the Institute of Clinical Psychology at the University of Virginia. At that time, he was also appointed an Associate Faculty position within the Institute of Law, Psychiatry, and Public Policy within the Schools of Law and Medicine at the University of Virginia. Since 1996, Dr. Emery has served as professor of psychology and director of the Center for Children, Families, and the Law at the University of Virginia. He currently serves on or has served on the editorial board of 11 professional journals and has been an ad hoc reviewer for nine professional journals, the Judicial Council of California, the National Science Foundation, and the NIHM Grant Review Committee. He is also a beloved advisor, teacher, mentor, and clinical supervisor and is known at the University of Virginia for being an incredibly collaborative colleague and supremely supportive graduate advisor who maintains professional relationships with students well after completing their training.

Contributions to the Profession Over the past 30 years, Dr. Emery’s research has focused on family relationships and children’s mental health, and he has used important findings from this research to examine associated legal and policy issues. Dr. Emery’s most significant and impactful contributions to the field have been his research on the impact of interparental conflict on children’s adjustment, research on best practices in child custody, and his longitudinal research on

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the benefits of mediation over litigation in the context of divorce. Dr. Emery has published extensively on the harmful effects of interparental conflict on children and healthy ways that parents can navigate the divorce process that is in the best interest of their children. His 1982 Psychological Bulletin paper, Interparental conflict and the children of discord and divorce, was among the first published works that specifically examined the relationship between marital discord and problem behaviors in children using a systemic lens. Dr. Emery’s 2016 book, Two Homes, One Childhood: A parenting Plan to Last a Lifetime, is his most recent contribution to the literature, and it provides empirically supported guidance for parents to successfully create child-focused parenting plans. As a practicing mediator himself, Dr. Emery has always been a champion of mediation in juvenile and domestic disputes because of its collaborative process and ability to preserve relationships instead of creating adversaries. Dr. Emery was able to convince judges in Virginia to allow him to randomly assign separating parents attempting to settle child custody disputes to either litigation or mediation as the dispute resolution method. In 1987, he published the first study examining differences in the outcomes, based on the assigned dispute resolutions method. He found that disputes were settled much quicker and families did not end up having to litigate child custody disputes. Dr. Emery followed these 40 families for 12 years and published a study in 2001 that examined the long-term effects of mediation versus litigation. Dr. Emery found that family relationships were significantly better preserved in the mediation group; custody agreements tended to last longer and prove more effective, both parents saw their children more frequently, telephone contact between non-residential parents and children was greater, and parents perceived one another as more effective. This longitudinal examination of the positive impact of mediation is the only study of its kind and provides empirical support for the benefits of mediation over litigation.

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Cross-References

Introduction

▶ Divorce in Couple and Family Therapy ▶ Mediation in Couple and Family Therapy

Our couple and family relationships are characterized by emotional experiencing. When these relationships are going well, we feel joy, interest, and calm. Relationship distress, on the other hand, is characterized by intense negative emotions such as anger and contempt. However, emotional numbing and distancing and lack of emotional responsiveness are even more corrosive for relationships than chronic anger (Gottman et al. 1998). Traditional views of emotion in couple and family therapy, however, have seen intense emotions as a destructive force rather than a positive source of change; interventions have sought to bypass or supplant them with new cognitions or communication skill sequences. However, more recently in the field of couple and family therapy there has been movement toward acknowledging the importance of working with the emotion that arises within the context of couple and family relationship patterns. Developments in the study of attachment and neuroscience have pointed to the centrality of relationships as a context for emotion regulation. This has had a significant role in shaping research and practice toward a focus on the transformative role of emotion in couple and family relationships, that is the use of corrective emotional experiences and interactions to change negative interactional patterns.

References Emery, R. E. (1982). Interparental conflict and the children of discord and divorce. Psychological Bulletin, 92, 310–330. Emery, R.E. (2006). The truth about children and divorce: Dealing with the emotions so you and your children can thrive. New York: Plume. (Paperback edition) Emery, R.E. (2011). Renegotiating family relationships: Divorce, child custody, and mediation (2nd ed.). New York: Guilford. (Chinese translation forthcoming 2016). Emery, R. E. (2016). Two homes, one childhood: A parenting plan to last a lifetime. New York: Avery. Emery, E. E., & Wyer, M. M. (1987). Child custody mediation and litigation: An experimental evaluation of the experience of parents. Journal of Consulting and Clinical Psychology, 55, 179–186. Emery, R. E., Laumann-Billings, L., Waldron, M., Sbarra, D. A., & Dillon, P. (2001). Child custody mediation and litigation: Custody, contact, and co-parenting 12 years after initial dispute resolution. Journal of Consulting and Clinical Psychology, 69, 323–332.

Emotion in Couple and Family Therapy Stephanie A. Wiebe1 and Sue M. Johnson2 1 The Ottawa Hospital, The University of Ottawa, International Centre for Excellence in Emotionally Focused Therapy, Ottawa, ON, Canada 2 The International Centre for Excellence in Emotionally Focused Therapy, The University of Ottawa, Ottawa, ON, Canada

Name of Concept Emotion in couple and family therapy

Synonyms Affect in couple and family therapy

Theoretical Context for Concept Evidence for the role of emotion in shaping patterns in relationships has been studied extensively in the context of attachment theory. From the perspective of attachment theory, emotional responsiveness in relationships fosters attachment security, which sets up effective emotion regulation experiences and interactions in relationships. Bowlby (1969) was attentive to the central role of affect in attachment relationships noting that attachment-related affect is the means by which we evaluate the presence of threat, decide whether proximity seeking is needed, and choose how to deal with our emotional life.

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Insecure attachment – especially the avoidance of attachment vulnerabilities and needs – involves high levels of effortful control of attachment emotions such as anger, sadness, and anxiety. This avoidance is associated with low levels of emotional experience, intensity, and attention to emotion in self and others. Insecure attachment in the form of high attachment anxiety is associated with high attention to and easily triggered emotion, greater emotional intensity, and high levels of expressiveness. In contrast, secure comfort with closeness is associated with less suppression, more emotional balance, and lower emotional control of anger, sadness, and anxiety. Secure attachment is generally related to high levels of expressiveness and low levels of intensity and attention to affect, such that those with a secure attachment style in relationships are better able to regulate and express emotions than those who are insecurely attached. Insecure attachment is associated with greater control, or down-regulation, of positive emotions as well. Attachment is above all a transactional theory of emotional development and regulation. Neuroscience research has shown that even when emotions are controlled, they continue to have a physiological impact. Suppression, for example, tends to increase arousal, and it is clear that even when emotions are bypassed and not addressed, they continue to have an effect. Moreover, when emotions are addressed in the context of close relationships, they serve the function of helping both relationship partners regulate affect. The interchange of affective information in relationships allows us to respond emotionally to one another in a way that registers with each individual neurologically. The ability to read and coregulate emotions can have profound effects for individual affective functioning. Coan and colleagues (2011) developed social baseline theory based on their research showing that neurological signs of stress were greatly reduced when women in happy relationships had their partner holding their hand, whereas the absence of their partners increased the neurological signs of stress. Social baseline theory is the idea that close relationships are neurophysiologically necessary for effective affect regulation and that the absence of or insecurity in close relationships is inherently stressful.

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Whether a source of soothing or stress, emotional signals organize interactions in love relationships; they are the music of the interactional dance. Given the centrality of emotion in organizing relationship dynamics – through the lens of attachment theory and neuroscience – working with emotion appears to be necessary in order to foster significant positive change for couples. Therapeutic approaches for couples and families that use the transformative power of emotions to shape interactions would need to be consistent with our current knowledge of emotion through research in neuroscience and human development, based on knowledge of how emotion is organized in the context of couple and family relationships, and organized by a unifying theory that could provide a map for how to use emotion to transform relationships in terms of cognitive, behavioral, and interactional patterns.

Description The dominant view in western thought is that emotion is to be distrusted in favor of cognition. However, more recently, attention has been given to the necessary and helpful functions of emotion in terms of communicating with others and making decisions. Therefore, it is no surprise that the field of couple and family therapy would have initially focused primarily of restructuring the system over exploring the emotional experiences of individual family members. Indeed, every emotion is associated with a respective action tendency, as when anger triggers assertive approach in the service of need attainment. Gottman and colleagues paved the way in giving attention to emotional experience in the context of couple relationships. Through observing couple interactions they noticed that it was not the presence of intense emotion that was most predictive of divorce, but rather lower levels of positive affect and bids for attention that are not responded to by the other partner. This was the first time that emotion was viewed positively in couple relationships rather than as an instigating force of conflict to be avoided. We now know that emotional accessibility, responsiveness, and engagement are essential

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components of a satisfying relationship. Indeed, close relationships characterized by emotional accessibility, and mutual responsiveness foster feelings of calm, joy and happiness, and relationships with these elements are more likely to be happy and lasting. Affect coregulation is understood to be a core aspect of close relationships throughout the lifespan, first beginning with early experiences between infants and their caregivers. When primary caregivers and infants are emotionally attuned to one another, this creates a state of emotional balance in which the caregiver and infant mutually regulate affect. This balance is upset when the caregiver does not engage in this coregulation of emotion, which leads to high levels of stress for infants, that is, until coregulation is reestablished. Therefore, emotional expression and responsiveness play a key role across couple and family relationships, and ought to be at the center of approaches to couple and family therapy. To repeat the metaphor stated above, changing the emotional music would seem to be a necessary condition of changing the dance in family systems and changing this music potentially has the power to reshape key interactional patterns.

Application of Concept in Couple and Family Therapy Although, the understanding of couples and families as being emotionally bonded was present from the first formulations of couple and family therapy, early approaches that acknowledged the emotional bond between family members tended still to remain focused on the systemic context as the focus of change, as evidenced in Minuchin’s (1974) structural approach and Watzlawick’s (1967) constructivist focus. Virginia Satir (1983) focused on the importance of valuing the unique experiential realities of each individual to produce encounters that foster emotional connection. She believed that individual family members would flourish if given emotional responsiveness and genuine acceptance. At around the same time, couple and family therapists in the humanistic/ existential tradition such as Kempler (1967) and Whitaker (1977) theorized that new kinds of

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dialogue characterized by emotional selfexpression and engagement with one another, would improve adaptive functioning in relationships. Also developed around the same time is the relationship enhancement (RE) psychoeducational model (Guerney 1977), which views couple distress as a lack of relationship skills, and focuses on training empathy and emotional responsiveness. In this model, empathy and emotional responsiveness are taught rather than actively worked with and shaped. Filial family therapy (FFT) is the family therapy version of RE, and teaches parents the relationship skills necessary to be engaged and empathic with their children. This approach is thought to help parents foster in their children an orientation of acceptance and understanding of their emotional selfregulation. The RE model has accumulated a strong evidence base and has been applied across a variety of populations. Filial family therapy has also demonstrated positive results in the research. The main current approach that focuses on emotion and actively using emotion to shape change in couple and family therapy, emotionally focused therapy or EFT (Johnson 2004) integrates systemic and experiential perspectives with attachment science and takes the view that emotional experiencing and signaling in relationships is the main organizing factor of the family or couple system and inseparable from it. Finding new ways to help clients regulate emotion and creating new kinds of corrective emotional experiences and emotional interactions are then considered the primary route to change in this model. The other contemporary approach to family therapy that explicitly acknowledges the role of emotions in change and shapes powerful emotional encounters that specifically promote emotional bonding is dyadic developmental psychotherapy (DDP; Hughes 2007). The behaviorally based integrative behavioral couple therapy (IBCT; Jacobson and Christensen 1996) also incorporates the naming and acceptance of emotions rather than bypassing emotion as in original versions of traditional behavioral couple therapy (TBCT). This more recent approach has demonstrated superior results as compared to TBCT, suggesting the benefits of addressing emotions in

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couple therapy and the limitations of approaches that do not. As emotionally focused couple and family therapy (EFT & EFFT) and dyadic developmental psychotherapy (DDP) appear to be at the cutting edge of the use of emotion to reshape couple and family systems, and as they offer extensive and explicit emotionally oriented interventions these models will be described in more detail. Emotionally Focused Therapy Emotionally focused therapy (EFT) was developed by Sue Johnson to explicitly focus on emotions in couple and family relationships as the locus of clinical change (Johnson 2004). In EFT, the therapist attends to and tracks patterns of emotional experiencing within the couple or family system. From an EFT perspective, emotional experiencing is a natural part of systems theory as it organizes the system within the couple or family relationship. The EFT therapist acts as a process consultant who empathically attunes to and validates each partners’ emotional experiencing, and creates a safe place to allow them to become more engaged in the emotional experiencing of themselves and their partner. Change is thought to occur in EFT through the formulation and sharing of emotional experience that transforms the system. EFT conceptualizes distressed relationships as an insecure attachment bond, and views the intense emotional experiences of partners in the context of attachment theory (Johnson 2004). That is, the couple and family system is organized by attachment related emotions and needs – in distressed relationships, attachment-related emotions arise as fears about the lack of availability and responsiveness of loved ones. The EFT therapist attunes to the “leading edge” of partners’ emotional experience and uses the experiential interventions such as reflection, evocative questions, validation, heightening emotion, and empathic interpretation to explore and deepen that experience (Johnson 2004). This expanded emotional experiencing is then framed within and drawn upon to create shifts in the system of interactions between partners and family members. The three stages of change in EFT

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are: (1) Cycle de-escalation; (2) Restructuring attachment interactions, which involve both the re-engagement of withdrawn partners and the softening of more blaming partners; (3) Consolidation and integration of change. Once the alliance is established, in the first stage of therapy, the goal is to identify and de-escalate negative cycles, and explore the underlying emotions that organize these cycles. At the end of this stage, the couple has a meta-perspective on their interactions and begins to see their negative cycle as the problem that maintains their insecurity and emotional distress rather than blaming each other. The second stage, restructuring interactions, involves the shaping of new emotional experiences and new interactions so that more withdrawn partners re-engage in the relationship and actively express their needs, and more blaming partners can ask for their attachment needs to be met in a softer manner that primes the other’s emotional responsiveness. This latter event has been termed blamer softening, and is associated with recovery from relationship distress in EFT, and a decrease in relationship-specific attachment anxiety (Burgess Moser et al. in press). At the end of this stage, bonding events occur where each partner confides in and seeks comfort from the other, becoming mutually accessible and emotionally responsive. In this stage, the relationship is fundamentally reorganized and redefined as a more secure bond. The last stage of treatment, involves the consolidation of new responses and cycles of interaction and supporting the couple to solve concrete problems that have been destructive to the relationship. These problems are more manageable since they are no longer infused with negative affect or lacking in emotional responsiveness (Johnson 2004). Emotionally focused family therapy (EFFT) is analogous to EFT for couples. The goal of EFFT is to create a secure base for children to grow in and leave from (Johnson and Lee 2005). The more secure the parent-child relationship is, the more tolerance there is of differences and the more confident and autonomous the child and adolescent can be. EFFT involves helping family members explore emotional responses, particularly attachment fears and unmet needs that underlie

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the interactions between the child who is experiencing problems and the parents (Johnson and Lee 2005). The family is seen together at the beginning and end of therapy (10–12 sessions), but the rest of the therapy process most often involves triads or dyads, depending on the needs of the family. Key change events might involve a depressed adolescent first being able to confide her fears of failure and how her father’s disapproval paralyses her and evokes the need to hide and then, asking her father for his approval and respect. Her father might then be able to confide that he harangues her as a response to his own fears that he has failed as a parent and does not belong in the family. In this encounter, new emotions are formulated and shared and rigid interactions such as criticize/withdraw evolve into dialogues where both participants feel more connected and reassured. The father is able, with the support of the therapist using reflection and evocative questions, to express his “terror’ at his sense of “incompetence’ when he realizes that he does not “know how to be a good father.”. He can then tell his daughter, “I am trying to protect you; but I don’t know how and that feels awful.” That is, he is able to express his attachment needs and attachment-related emotions and be emotionally engaged and responsive to the needs and emotions of his daughter. EFT has accumulated a substantial amount of empirical support for the treatment of relationship distress (Wiebe and Johnson 2016). EFT has demonstrated positive outcomes among a variety of at-risk populations including couples facing illness, depression, and posttraumatic stress. Notable, process research in EFT has identified two key elements of change: depth of emotional experiencing and the gradual shaping of interactions to help partners clearly express attachmentrelated affect and to move toward affiliative responding with one another. A key aspect of the therapeutic process in EFT, the blamer-softening event leads to successful outcomes and shifts in negative interaction cycles and attachment change (Burgess-Moser et al. in press). Therapeutic interventions in EFT, that foster a softening event

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include supporting both partners to regulate emotion, and especially helping the blaming partner to formulate and face underlying attachment fears. The therapist strives to help both partners reach and maintain a greater depth of emotional experiencing in these sessions so that the couple can learn to be accessible and responsive to one another and coregulate attachment-related emotions into the future (Wiebe et al. 2017). Dyadic Developmental Psychotherapy Dyadic developmental psychotherapy developed in the 1990s by Dan Hughes and his colleagues to treat children in foster or adoptive homes who have suffered abuse and neglect and manifested severe psychological difficulties associated with complex trauma and difficulties with attachment. It has since developed a broader focus, has grown into a comprehensive model of family therapy, also referred to as attachment-focused family therapy as it is based in attachment theory and affective intersubjectivity (Hughes 2007). The therapy model focuses on the attachment bond as a way to navigate complex emotions and behaviors in parent/child relationships, and understands problematic child behaviors in the context of the emotional effects of past attachment traumas or injuries. The main components of the model include a strong emphasis on the therapist’s use of self in the session and ability to strike a balance between following and guiding the child and family, a focus on connection rather than compliance or problematic behaviors and the coregulation of emotion and meaning making. Dyadic developmental psychotherapy (DDP) for families has developed into a coherent and comprehensive treatment modality for families. DDP is very similar in terms of clinical process to EFFT, given their joint focus on emotion and bonding interactions and removing the blocks to those interactions. In DDP, children are guided to regulate and express their emotions and send emotional messages in ways that foster secure connection with a parent who is supported to respond positively and empathically. DDP is different from EFFT in that it is often used with younger children and their

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parents. The clinical use of EFFT has focused on children over the age of 12, whereas DDP is used with adolescents but also with children as young as 4 or 5. M:

Clinical Example The following clinical example demonstrates the process of emotionally focused couple therapy for Alex and Mia in a blamer-softening session in EFT. M:

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He just curls up on the couch with his video game, and that’s it! I might as well not even exist. I don’t matter. I might as well just pack my bags and leave!! (angry tone, tears) Mia, as you’re talking about how angry you are with Alex, I see sadness and tears in your eyes. You are so angry and also so sad as you talk about needing a response from Alex. I’m SO sad and SO alone. I need a response from him. Anything! (tears, softer tone) Have you ever told Alex this, just how sad you feel when you reach for him and he curls up with his video games without turning to you or talking with you? Have you shared this with him? No. All I can feel right then is angry. I yell at him. Right, you fight so hard to get his attention, so you yell at him, and he doesn’t get to see how sad you are. It would be too hard to share your sadness, too scary? Yes, too scary. He would just keep playing his video game, so what’s the difference? So, you don’t show him this part of you that is so sad and scared and alone? This part of you comes up and says, “don’t trust him, he won’t turn and respond to you, just keep the sadness inside”. (supporting blamer, preparing for reach) *nods, tears continue to fall* Could you tell him that? Tell him that it’s so scary to show him your sadness because

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you’re so afraid he won’t be able to respond? Let him know just how scary this is and how he can be there for you right now? (encouraging blamer reaching) Alex, I’m so scared to tell you when I’m feeling sad and alone. So, I just get mad and yell and nag at you. I would do anything to get you to pay attention to me, but being vulnerable, showing you how sad I am? I am too scared to do that. I’m scared you will just turn away and ignore me. I want so much for you to just look up from your game and listen and tell me that you’re here with me. That was so wonderful Mia. You really clearly told Alex just how you feel and what you need. How are you feeling inside, right now? (supporting blamer reaching) I’m feeling shaky, kind of jittery, like I could get up and leave the room. You just took a big risk here. This is really new, and you’re being so brave to stay here with Alex now that you have been so clear and so honest about your feelings and needs. (supporting blamer). Alex, Mia just turned to you and let you know how scared she is to show you her sadness, and that she shows you her anger instead so often as a way of protecting herself from being so vulnerable with you. What are you feeling right now that you heard Mia take this big risk with you? (supporting engaged withdrawer) I never really saw this side of you before, Mia. I didn’t know you felt scared. Partly it’s hard to believe. When you get angry, it’s just so overwhelming for me, I don’t realize that you are really feeling sad and scared. I see it in your eyes now, though. I see the sadness there. It makes sense, and I think I understand you better. So this is really new for you, it’s almost hard to believe because it’s such a new perspective on what is happening for Mia when she is distressed. I also hear that there’s another part of you that wants to turn to her and say, “I understand now, I see

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the sadness in your eyes and I want to be here for you”. Is that what is going on for you, right now? (supporting engaged withdrawer) Yes, it’s like I understand now, I feel closer to her. I want to support her when she feel sad and scared. I want to hold her. Alex, can you turn to Mia right now and tell her, in your own words, how you understand her experience, and how you want to hold her when she feels sad and scared? (inviting engaged withdrawer to respond) I want to hold you, I want to be there for you when you’re sad and scared. I feel held by you. I feel supported. I feel like I can take a deep breath *sighs*

In this portion of an EFT session, the blamersoftening event, the therapist helps Mia explore and articulate her primary, attachment-related emotions and needs. She is then guided to share these with her partner, Alex in a soft way that invites emotional connection and responsiveness. The EFT therapist then supports the engaged withdrawer to respond in an emotionally attuned way to Mia. In this way, the EFT therapist helps to establish emotional attunement and responsiveness between partner. In the end, Mia allows Alex to soothe her and help her regulate her distressing affect. This opens up the possibility that both partners will be able to turn to one another in times of stress and coregulate affect. With their newly developing attachment security, they should also be more open to experiences of joy, happiness, and playfulness as a couple.

Cross-References ▶ Emotional Cutoff in Bowen Family Systems Theory ▶ Emotion-Focused Family Therapy ▶ Emotion-Focused Therapy for Couples ▶ Emotionally Focused Couple Therapy ▶ Emotionally Focused Family Therapy ▶ Expressed Emotion in Families

▶ Hold Me Tight Enrichment Program ▶ Primary Adaptive Emotions in EmotionFocused Therapy ▶ Primary Maladaptive Emotions in EmotionFocused Therapy

References Bowlby, J. (1969). Attachment and loss: Vol. I. attachment. New York: Basic Books. Burgess Moser, M., Dalgleish, T. L., Johnson, S. M., Wiebe, S. A., & Tasca, G. (2017). The impact of blamer-softening on romantic attachment in Emotionally Focused Couples Therapy. Journal of Marital and Family Therapy. https://doi.org/10.1111/ jmft.12284 Coan, J. A., & Beckes, L. (2011). Our social baseline: The role of social proximity in economy of action. Social and Personality Psychology Compass, 12, 89–104. Gottman, J. M., Coan, J., Carrere, S., & Swanson, C. (1998). Predicting marital happiness and stability from newlywed interactions. Journal of Marriage and Family, 60(1), 5–22. Guerney, E. G., Jr. (1977). Relationship enhancement: Skill training programs for therapy, problem, prevention, and enrichment. San Francisco: Jossey-Bass. Hughes, D. A. (2007). Attachment focused family therapy. New York: Norton. Jacobson, N. S., & Christensen, A. (1996). Integrative couple therapy. New York: Norton. Johnson, S. M. (2004). Creating connection: The practice of emotionally focused couple therapy (2nd ed.). New York: Brunner/Routledge. Johnson, S. M., & Lee, A. (2005). Emotionally focused family therapy: Restructuring attachment. In C. E. Bailey (Ed.), Children in therapy: Using the family as a resource (pp. 112–133). New York: Norton. Kempler, W. (1967). The experiential therapeutic encounter. Psychotherapy: Theory, Research and Practice, 4(4), 166–172. Minuchin, S. (1974). Families and family therapy. Cambridge: Harvard University Press. Satir, V. (1983). Conjoint family therapy. Toronto: Hushion House. Watzlawick, P., Beavin Bavelas, J., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York: Norton. Wiebe, S. A., & Johnson, S. M. (2016). A review of the research in emotionally focused therapy for couples (EFT). Family Process, 55(3), 390–407. https://doi. org/10.1111/famp.12229. Wiebe, S. A., Johnson, S. M., Burgess Moser, M., Dalgleish, T. L., & Tasca, G. (2017). Predictors of follow-up outcomes in Emotionally Focused Couple Therapy. Journal of Marital and Family Therapy, 43(2), 213–226. Whitaker, C. A. (1977). Process techniques of family therapy. Interactions, 1(1), 4–19.

Emotional Cutoff in Bowen Family Systems Theory

Emotional Cutoff in Bowen Family Systems Theory Judy Haefner University of Michigan Flint, Flint, MI, USA

Introduction How does it happen that family members can go years without any communication between them? While an occasional holiday card might be exchanged, person-to-person contact does not occur. In many instances, all contact is lost not only with extended family but nuclear family. In family counseling persons will say, “I haven’t spoken to my father in 20 years. He remarried and moved to Colorado and started a new family.” Growing up, there was no contact with certain aunts or uncles. They were mysterious, never spoken about, and somehow forbidden.

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Emotional fusion describes a person’s reactions within a relationship. People in a fused relationship react emotionally, being unable to think through or talk about choices with the other person without reacting in a heightened emotional state. The level of anxiety a person experiences is determined by external stress. Persons in a highly fused relationship experience significant anxiety due to fear that decisions or actions could potentially cause emotional separateness. A state of chronic anxiety exists if family members do not have the capacity to think through their responses to relationship dilemmas and bring about change but continue to react emotionally to them. Bowen (1978) believed a family that is unable to differentiate but remains fused will respond to a crisis in a “feeling process” and be unable to respond intellectually. A common coping mechanism is to emotionally separate or cut off from family because one is unable to selfdifferentiate and adapt to changes of one’s environment, and thereby experience less emotional stress when interacting with family (Haefner 2014; Brown 1999; Bowen 1978).

Theoretical Context for Concept Emotional cutoff is one concept in Bowen’s family theory, which consists of a system of eight interlocking states that describe the inevitable chronic emotional anxiety present in family relationships and concludes that chronic anxiety is the source of family dysfunction. The emotional dysfunction of an individual disturbs all of that person’s relationship systems, especially the family system (Bowen 1978). Bowen’s family systems theory model provides a framework to view the individual as part of the family. Key concepts of this theory are differentiation of self and emotional fusion which refer to the ability of a person to distinguish him/herself from the family of origin on a personal and intellectual level (Bowen 1978). Differentiation of self is the ability of individuals to function autonomously by making self-directed choices yet remain emotionally connected to important relationships. “A poorly differentiated person is trapped within a feeling world. . . and has a lifelong effort to get the emotional life into livable equilibrium” (Bowen 1976, p. 67).

Description of Concept The concept of emotional cutoff describes people managing their unresolved emotional issues with parents, siblings, and other family members by reducing or totally cutting off emotional contact with them. Emotional contact can be reduced by physically moving away from their families and rarely going home, or it can be reduced by staying in physical contact with their families but avoiding sensitive issues (Bowen 1978). Emotional cutoff is understood as it relates to differentiation of self (the ability to separate from the family of origin on a personal and intellectual level), triangles (using a third person in a relationship for the purpose of decreasing anxiety between two people), and the family emotional system (how a family reacts to stress is influenced by past generations’ reactions to stress, and a pattern will likely emerge and replicate in future generations). Bowen did not develop the concept of emotional cutoff until 1975, when he observed how one generation separated itself from past generations (Harrison 2003).

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Family members unable to reduce or manage their unresolved emotional issues with parents or other family members may totally cut off emotional contact by moving away geographically or rarely going home. These unresolved emotional issues generally center on unresolved attachment and differentiation of self. Bowen (1978) asserts this running away does not indicate emotional independence but rather these persons tend to see the problems being with the parents rather than with themselves. Brown (1999) states Bowen distinguishes between breaking away (emotional cutoff) and growing away (differentiation of self) The unresolved family conflicts will resurface by way of emotional reactivity reflective of past behaviors demonstrated in the nuclear family communication pattern. Bowen (1978) points out that a person who runs away from his/her family is as emotionally dependent as the person who cannot separate. Certain basic patterns between parent and child are replicas from the past and will repeat in the next generations. Persons who cutoff will likely cutoff again when faced with anxiety provoking relationships.

Application of Concept in Couple and Family Therapy Bowen (1978) believed an ideal person-to-person relationship allows family members to dialogue freely about many personal situations. However, this requires significant differentiation of self and a mature respect for each other (Titelman 2003). When anxiety surfaces between two people, they may be able to communicate for a few minutes but as discomfort builds, the conversation will switch to more trivial, superficial and safe topics, lead to silence, or they may bring in a third person to relieve the tension, thus creating a triangle (Bowen 1978). Triangulation occurs when anxiety and tension experienced between two persons is passed onto a third person in the family. The couple is able to communicate safely when they pull in the third person thereby shifting the anxiety away from their relationship and onto the third party. Bowen did not believe triangulation was

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necessarily dysfunctional but became problematic when the third person distracted the dyad from resolving their tension (Bowen (1978). Cutoff may not always be dysfunctional. It can also be in response to child abuse, spousal abuse, and family members with addiction, chronic mental illness, or any other traumatic experience that occurred in the family setting. Bowen maintains, however, that this cutoff must be worked through because this behavior often becomes a coping mechanism for all other stressful relationships. Bowen (1978) uses the phrase “generation gap” as a common theme in our society, where relationships are emotionally distant, with brief superficial visits to the family of origin out of a sense of duty. Emotional distance or closeness to parental families is determined by a combination of physical distance and quality of relationship. For example, (1) a person feels he/she falls back into the child role when home and believes parents make decisions for him/her that the person prefers to make, or (2) a person feels his/her parents are pulling him/her back into a triangle and that he/she must again solve parental or sibling conflicts or distresses, or (3) a person believes his/her parents do not understand or approve of him/her and feels angry about that lack of respect (Bowen Center 2016). These individuals tend to see the problem as being that of his/her parents or siblings, and running away becomes a strategy for gaining independence from the parents or avoiding the siblings (Bowen 1978). Because of poor and stilted communications, family members tend to keep secrets as an attempt to manage the intense chronic and acute anxiety in the family system. Family members may see secrets as useful initially because they ameliorate emotional intensities, but the secrets may actually increase emotional distance between family members. Bowen (1978) asserts that although people are emotionally dependent and need emotional closeness, they seem “allergic” to it (p. 85). Cutoff is a reciprocal process. Relationships are mutually reinforcing. Hoping things will be different this time, people often look forward to going home. But old patterns of interactions generally surface with powerful emotional undercurrents or may even deteriorate and become hostile confrontations. Families become anxious and reactive and are

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relieved when the visit is over. Emotions may further be escalated by siblings of the cutoff member blaming him/her for upsetting the parents (Bowens Center 2016). The unresolved emotional differentiation can be emotional or physical. One can certainly physically run away but one can also “runaway” by emotional isolation while maintaining some degree of physical interaction with their parents or siblings. Those who remain near the parental home and have emotional cutoff by way of intrapsychic mechanisms tend to develop more internalized symptoms when under stress, such as physical illness and depression. The one who runs away geographically is more inclined to impulsive behavior (Bowen 1978).

A Clinical Example Kate is a 69-year-old woman participating in group therapy as part of an alcohol rehabilitation program. She recently moved to Houston from a small town in Louisiana because she needed “access to big city transportation.” She does not have any family or friends in the area or even within several states. She is, however, vague about her decision to choose Houston. She has lived alone, away from family for the past 40 years. She has two daughters; one lives in Utah, and the other daughter and grandson live in New York; Kate’s mother and sister live in Iowa. She has discontinued all contact with her older daughter (partly in response to her daughter’s own emotional cutoff), and has very infrequent phone calls to her second daughter. She calls her mother primarily on “obligation days” such as Mother’s Day and Christmas. She reports these phone calls are generally filled with silence or “safe topics” such as discussion of the children or health matters. She visited her mother once several years ago for the first time in approximately 20 years. When discussing her family, she laughs and says she visited her mother for a week and, “I’m good for another 20 years.” In years past there were more frequent visits, primarily centered on delivering or picking up her daughters following a lengthy visit with grandparents. She reports these visits were usually limited

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to only a few days. Kate moved away from home at age 18 to a distant town and eventually to Minneapolis and then San Francisco, where she lived for about 20 years. She reports a good relationship with her father but a confrontational relationship with her mother. She believes her mother disapproved of her lifestyle choices, her parenting skills, and her choice for a husband. Her husband was convicted of a crime and served 15 years in prison, triggering financial ruin for Kate and losing her home and custody of her older daughter to foster care resulting from Kate’s alcoholism. She was able to retain custody of her younger daughter. Kate experienced significant hardship due to alcohol abuse, and her relationships with her daughters deteriorated. Kate subsequently moved to Louisiana about 5 years ago before moving to Houston. Her older daughter was in foster care as a teenager for 4 years but maintained contact with extended family and her sister. Following a divorce 2 years ago, this daughter ended all contact with her mother and extended family, hence perpetuating the pattern of emotional cutoff. Kate spoke of her upbringing stating there were regular family visits with extended family of her father but there were no family visits with mother’s family. Discussion of mother’s family or siblings was always shrouded in mystery. It is known that mother’s father deserted the family when she was a young girl. After mother’s marriage in the late 1940s, she did not have any contact with her own mother or siblings until shortly before her own mother’s death about 30 years later, when she visited her mother and attended the subsequent funeral. This triggered a limited renewal of the relationship of the mother with her sister. With Kate’s family, the generational pattern of emotional cutoff is seen in four generations: mother’s father, mother’s siblings, Kate, and Kate’s older daughter.

Bridging Cutoff As a family therapist, it is crucial to look for family patterns such as divorce, intensity of relationships, and conflict resolution strategies or

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differences between generations. A major task of the therapist is to create a trusting, objective environment in which the family members are comfortable exploring their own family emotional and relationship systems. Family systems therapy begins with a family evaluation of their emotional processes, closeness, distance, triangles, and tensions that are still unresolved from the family of origin. The ideal method of working with a family using Bowenian theory is to have several generations participating. However, a genogram that serves as a graphic representation of family relationships, physical and mental health, and substance abuse can help identify patterns of interaction and promote insight about development of behaviors. Use of a family genogram will assist the therapist in maintaining a neutral stance while becoming aware of family triangles that identify who is outside of the family circle and possible reasons why. Due to high levels of anxiety, it may be easier (and more beneficial) if the first contact to bridge a cutoff is not with the cutoff member(s) but with another family member who can provide background and insight concerning the estrangement (Haefner 2014). Creating and referencing a genogram will also help the client see the family as a system connected together rather than as disconnected outliers – that the individual belongs to a system and all parties are interconnected. Because all parties are interconnected, it is profitable to consider the whole system as opposed to parts of the system, as change in one party will affect the whole system. It is also helpful for the client to consider that change in one part of the system not only affects the whole system but also impacts who he/she becomes in terms of differentiation of self and level of emotional intelligence. Bowen (1976) encourages practitioners to throw out the “concept of normal . . . because it is not possible to define normal. Think in terms of keeping “their relationships in balance” and therefore avoid “severe stress . . . and never develop symptoms” (p. 66). A useful evaluation tool to quantify emotional cutoff was developed by McCollum (1991) The

Emotional Cutoff in Bowen Family Systems Theory

Emotional Cutoff Scale. The Emotional Cutoff Scale (ECS) measures the sense of cognitive connection to a person’s mother and father. Scores range on a continuum between 10 and 50. Lower scores mean a greater level of connection to parents; higher scores mean a lesser level of connection or more emotional cutoff to parents. The internal consistency and reliability of the ECS is high, with Cronbach’s alpha ranging from 0.82 to 0.90 (McCollum 1991). A clinician applying Bowen theory wants to assess the nature of the cutoff – is it external with little or no contact, or internal with little personal interaction? One can simply ask, “How often do you visit?” But don’t assume that because there is geographical distance, it implies emotional cutoff. Conversely, an adult may never leave home yet have a poor relationship with other family members. Assess for openness in personal relationships. Are they able to discuss personal and family concerns calmly and respectful of opinions? Are there topics to avoid? Assess the relationship with the extended family. Do they participate in important life events of extended family? Births, weddings, funerals, anniversaries, and retirements? Assess for balance between family expectations and personal choice (Klever 2003). Is the expectation to attend all events at the expense of individual choice and risk increased family tensions? When working with others, it is beneficial if the clinician has thought about his/her own emotional cutoff with family and friends. Understanding the patterns of interaction and attachment in oneself will widen the scope and understanding of working with others. Experiencing the discomfort of analyzing one’s own family can provide useful insight.

Cross-References ▶ Bowen, Murray ▶ Family Therapy ▶ Family of Origin ▶ Genogram in Couple and Family Therapy

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References

Introduction

Bowen Center for the Study of the Family Georgetown Family Center. (2016). Emotional cutoff. Retrieved from http://www.thebowencenter.org/theory/eightconcepts/emotional-cutoff/. Bowen, M. (1976). Theory in the practice of psychotherapy. In P. J. Guerin (Ed.), Family therapy. New York: Gardner. Bowen, M. (1978). Family therapy in clinical practice (pp. 337–388). Northvale: Jason Aronson. Brown, J. (1999). Bowen family systems theory and practice: Illustration and critique. Australian New Zealand Journal of Family Therapy, 20, 94–103. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/j. 1467-8438.1999.tb00363.x/pdf. Haefner, J. (2014). An application of Bowen family systems theory. Issues in Mental Health Nursing, 35, 835–841. Harrison, V. (2003). Reproduction and emotional cutoff. In P. Titelman (Ed.), Emotional cutoff (pp. 245–269). New York: The Haworth Press. Klever, P. (2003). Marital functioning and multigenerational fusion and cutoff. In P. Titelman (Ed.), Emotional cutoff (pp. 219–243). New York: The Haworth Press. McCollum, E. E. (1991). A scale to measure Bowen’s concept of emotional cutoff. Contemporary Family Therapy, 13(3), 247–254. https://doi.org/10.1007/BF00891804. Titelman, P. (2003). Emotional cutoff in Bowen family systems theory: An overview. In P. Titelman (Ed.), Emotional cutoff (pp. 9–65). New York: The Haworth Press.

Emotional reactivity can be defined as the strength and duration of an affective response to a stimulus (Rothbart and Derryberry 1981; Shapero et al. 2016). In the context of couples, emotional reactivity can be defined as “the frequency with which affect becomes dysregulated” in couple interactions (Greenberg and Goldman 2008, p. 58). Emotional reactivity may occur in couple therapy when a member of a couple expresses their feelings in a manner that is destructive to the relationship, resulting in the escalation of affect and negative interaction cycles. One goal of emotion-focused couple therapy (EFT-C) is to move partners away from automatic emotional reactivity and to the expression of more adaptive, regulated emotions that aid couple members in meeting their needs (Goldman and Greenberg 2007; Greenberg and Goldman 2008).

Emotional Reactivity in Emotion-Focused Couple Therapy Natasha Seiter1, Amy D. Smith1,2 and Kelley Quirk2 1 Marriage and Family Therapy/Applied Developmental Science Program, Colorado State University, Fort Collins, CO, USA 2 Marriage and Family Therapy Program, Human Development and Family Studies, Colorado State University, Fort Collins, CO, USA

Name of Concept Emotional Reactivity in Emotion-Focused Couple Therapy

Theoretical Context for Concept Emotions may be adaptive or maladaptive, depending in part on the degree of regulation or dysregulation. Most individuals are motivated to feel positive emotions and not experience negative emotions and thus regulate their affect (Goldman and Greenberg 2013; Greenberg and Goldman 2008). When individuals fail to regulate affect in their relationships, emotional reactivity may result in couple conflict (Goldman and Greenberg 2013). Theoretically, EFT-C recognizes three primary motivational systems that drive emotions and interpersonal relationships: attachment, identity, and attraction/liking (Goldman and Greenberg 2013). Individuals are motivated to attach to others and to achieve a positive sense of identity to fulfill interpersonal needs and regulate affect (Goldman and Greenberg 2013; Meneses and Greenberg 2011). When the attachment or identity systems are threatened, or related needs are unmet, individuals may become activated (Greenberg and Goldman 2008), and emotional reactivity may result if emotions are not sufficiently modulated or responded to.

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Description Emotional reactivity involves the expression of dysregulated emotions (Goldman and Greenberg 2013; Greenberg and Goldman 2008). Dysregulated emotions are not adaptive as they are often not context-appropriate (Elliot et al. 2004; Goldman and Greenberg 2013) and thus not effective in helping an individual meet their needs. For example, individuals may become emotionally reactive when they perceive a threat toward their attachment or identity systems, often leading to defensive or protective responses, even if this threat is not consistent with the current context (Greenberg and Goldman 2008). In other words, there may be times when partners respond to one another in the moment based on past experiences or emotional injuries. Emotionally reactive maladaptive emotions are likely to lead to negative interaction cycles in couple relationships (Goldman and Greenberg 2013; Goldman and Greenberg 2007). In an emotionally reactive state, couple members may shout at each other and/or fail to listen to the others’ perspective (Goldman and Greenberg 2007). A common example of this is the demand/withdraw pattern, known to be destructive to relationship stability and satisfaction (e.g., Eldridge and Christensen 2002). Ultimately, emotional reactivity inhibits the connection and safety that may be felt when more regulated, adaptive emotions are expressed.

Application of Concept in Couple and Family Therapy Emotion-focused couple therapy aims to move clients away from harmful emotional reactivity to more effective emotion regulation (Goldman and Greenberg 2007; Greenberg and Goldman 2008). Therapists practicing EFT-C teach clients to soothe their partners as well as to selfsoothe, and these are seen as equally important components of the therapeutic process. Such self- and other soothing strategies are used to enhance affect regulation, thus minimizing emotional reactivity and stopping negative interactional cycles (Greenberg and Goldman

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2008). Partners in EFT-C are guided in transforming their maladaptive emotional reactivity to regulated emotional responses that are context-appropriate and less likely to lead to negative interaction cycles (Goldman and Greenberg 2007; Goldman and Greenberg 2013). This involves identifying the negative interaction cycle and the roles each partner plays in maintaining the cycle, as well as the underlying emotions driving their attachment and identity needs. By appropriately identifying these processes, the couple’s struggle is reframed toward expression of more vulnerable underlying feelings regarding unmet attachment and identity needs (Goldman and Greenberg 2007).

Clinical Example Alex and Mary sought emotion-focused couple therapy to help resolve frequent conflict. In the session, Mary reveals that she feels Alex is controlling her free time and gets angry at her when she expresses wanting to spend time with her female friends. Alex responds with hostility, exclaiming that he doesn’t trust her to go out without him. In response, Mary withdraws from Alex and he becomes even more hostile. Their EFT-C therapist helps them to identify their negative interaction cycle, a demandwithdraw pattern that reinforces itself. She helps them to recognize that when Alex becomes emotionally reactive, Mary becomes overwhelmed and withdraws, and this makes Alex feel abandoned and even more emotionally reactive. The therapist also helps them to identify the origin of Alex’s emotional reactivity, his first wife’s affair. Alex recognizes that when Mary wants to go to a dinner with her female friends, he perceives a threat to their relationship and to his sense of identity as a husband. As his attachment and identity systems are activated, he may respond to his fear of betrayal with maladaptive emotion that is inappropriate for the context and does not help him meet his need for security. His failure to regulate his emotions may result in Mary feeling

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attacked and becoming overwhelmed, leading her to withdraw. The emotion-focused couple therapist teaches them to soothe themselves and each other, enhancing their affect regulation abilities during interactions. Emotional reactivity is transformed to regulated emotional communication, and Alex and Mary are able to effectively listen and talk with one another.

Cross-References ▶ Emotion-Focused Therapy for Couples ▶ Goldman, Rhonda ▶ Greenberg, Leslie ▶ Secondary Reactive Emotions in EmotionFocused Therapy

References Eldridge, K. A., & Christensen, A. (2002). Demandwithdraw communication during couple conflict: A review and analysis. In P. Noller & J. A. Feeney (Eds.), Understanding marriage: Developments in the study of couple interaction (pp. 289–322). Cambridge, MA: Cambridge University Press. Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The process-experiential approach to change. Washington, DC: American Psychological Association. Goldman, R. N., & Greenberg, L. S. (2007). Integrating love and power in emotion-focused couple therapy. European Psychotherapy, 7(1), 117–135. Goldman, R. N., & Greenberg, L. (2013). Working with identity and self-soothing in emotion-focused therapy for couples. Family Process, 52(1), 62–82. Greenberg, L. S., & Goldman, R. N. (2008). Emotionfocused couples therapy: The dynamics of emotion, love, and power. Washington, DC: American Psychological Association. Meneses, C. W., & Greenberg, L. S. (2011). The construction of a model of the process of couples’ forgiveness in emotion-focused therapy for couples. Journal of Marital and Family Therapy, 37(4), 491–502. Rothbart, M. K., & Derryberry, D. (1981). Development of individual differences in temperament. In M. E. Lamb & A. L. Brown (Eds.), Advances in developmental psychology (Vol. 1). Hillsdale: Erlbaum. Shapero, B. G., Abramson, L. Y., & Alloy, L. B. (2016). Emotional reactivity and internalizing symptoms: Moderating role of emotion regulation. Cognitive Therapy and Research, 40(3), 328–340. https://doi.org/ 10.1007/s10608-015-9722-4.

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Emotionally Focused Couple Therapy Stephanie A. Wiebe1 and Sue M. Johnson2 1 The Ottawa Hospital, The University of Ottawa, International Centre for Excellence in Emotionally Focused Therapy, Ottawa, ON, Canada 2 The International Centre for Excellence in Emotionally Focused Therapy, The University of Ottawa, Ottawa, ON, Canada

Name of the Strategy Emotionally focused couple therapy.

Synonyms EFT; Emotionally focused therapy

Introduction Emotionally focused couple therapy (EFT) is an approach to couple therapy that helps create attachment security in relationships by guiding partners to explore and share with one another their core attachment-related emotions and needs. EFT conceptualizes the negative interaction patterns between partners in distressed couple relationships and the associated strong negative emotions as arising from emotional disconnection and an insecure attachment bond. Core, primary attachment-related emotions are often blocked from awareness and expression in distressed couple relationships by protective reactions such as numbing due to the triggering of attachmentrelated fears. In EFT, couples are encouraged to explore core primary attachment-related emotions and needs as they arise in the therapy session and express these to their partner. Partners are then encouraged to tune into their partners’ emotions and needs and respond. As partners tune into one another’s now clarified and explicit emotional realities, they are able to counter one another’s

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attachment fears, establish emotional connection, and create a more secure bond. Since its development in the 1980–1990s, EFT has accumulated a strong evidence base and is practiced by couple therapists internationally.

Prominent Associated Figures Sue Johnson developed EFT as she strove to understand and capture the complexity and intensity of her couples’ experiences in therapy, alongside Les Greenberg. In the first study of EFT, Johnson and Greenberg (1985a) discovered that focusing explicitly on and regulating emotions in couple therapy sessions was beneficial in alleviating relationship distress, and in fact superior to a cognitive-behavioral problem-solving approach. Sue Johnson and colleagues have further developed the model to include a primary emphasis on attachment. Emotionally focused couple therapy developed by Johnson (2004) differs significantly from emotion focused therapy for couples (EFT-C; developed more recently by Greenberg and Goldman 2008) in that it places emphasis on the attachment relationship and views emotions that arise in the relationship as related to the hereand-now attachment interactions between partners. Greenberg and Goldman (2008), in contrast, also place strong emphasis on identity, power, and individual emotional exploration and regulation.

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activated in couple relationships map onto demand/withdraw pattern such that the pursuing partner typically expresses intense distress and anger characterized by blame, criticism, and contempt and hyperactivates attachment signals to protest the distance in the relationship. The withdrawing partner downregulates affects and withdraws emotionally, consistent with deactivating strategies of affect regulation observed with attachment avoidance. Secure attachment relationships, in contrast, involve mutual emotional responsiveness, accessibility, and engagement (Johnson 2004). In the EFT model, the intrapsychic focus of experiential approaches is combined with the interpersonal perspective of systems theory to slow down negative cycles of interaction, as well as increase emotional accessibility and responsiveness in the relationship. Change is thought to occur through the creation of moments of secure bonding as couples increasingly explore and express underlying attachment needs and the vulnerabilities that underlie secondary protective emotional responses (Johnson 2004). As both partners engage in this process of intrapsychic exploration coupled with the direct expression of attachment-related emotions and needs in the relationship, this interrupts the demand/withdraw pattern seen in distressed relationships and allows couples to create new patterns of mutual responsiveness and deeper levels of engagement (Johnson 2004). Secure bonding potentiates effective caretaking and satisfying sexual connection.

Theoretical Framework EFT draws on humanistic and systemic principles within an attachment-based framework (Johnson 2004). In EFT, the negative, rigid interaction patterns and strong negative affect and lack of positive affect – noted by Gottman (1993) to be a central feature of distressed relationships – are seen as constantly triggered attachment insecurity and a felt sense of isolation. Distressed relationships are typically characterized by a demand/ withdraw pattern of interaction in which one partner pursues with criticisms and/or demands and the other partner withdraws (Gottman 1993). The emotions that arise when the attachment system is

Populations in Focus Since attachment and associated emotions are universal in nature, a therapy that helps couples create more secure attachment, such as EFT, is a viable approach across diverse populations of adult couples (Zuccarini and Karos 2011; Liu and Wittenborn 2011). Liu and Wittenborn (2011) outline three principles for working with culturally diverse couples in EFT: (1) give attention to meanings and functions associated with emotional expression and attachment behaviors; (2) seek understanding of the socially constructed meanings

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of emotion; and (3) use words and metaphors to which clients can relate, especially clients’ own words, and explore further to ascertain their intended meaning. As the meanings underlying attachment behaviors are investigated in session, core attachment-related emotions and needs become apparent and are then open to exploration in a way that can be understood by both partners. By remaining receptive to universal attachment emotions, meanings, and functions underlying behaviors – rather than taking responses at face value – therapists can adapt EFT for diverse populations of couples (Greenman et al. 2009). In terms of clinical presentations, EFT is particularly relevant for couples with medical illnesses, depression, and posttraumatic stress. With the focus of EFT on building secure connection, effective affect regulation, and creating supportive interactions with loved ones, it is not surprising that EFT has been found to be effective for these populations (Wiebe and Johnson 2016). EFT has also been tailored and tested for use with couples dealing with attachment injuries such as affairs and other betrayals (Zuccarini et al. 2013). Contraindications to EFT involve situations in which it would not be safe for partners to become emotionally vulnerable with one another through the exploration and expression of core attachment-related emotions and needs. Unsafe situations may include physical violence, substance abuse, or ongoing infidelity.

Strategies and Techniques Used in Model EFT draws on experiential and systemic interventions including empathic reflection of emotions and interactive patterns, validation, evocative responding and questioning, heightening emotional engagement, empathic conjecture, and reframing and restructuring interactions within a process of three stages, as outlined by Johnson (2004). Stage 1 is cycle de-escalation. In this stage, EFT therapists help couples develop an understanding of their negative dance and the distance it creates as the source of distress in their relationship. In this stage, therapists track

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and reflect how this pattern of interaction takes over the relationship and clarify each partner’s core attachment fears, secondary emotions such as chronic anger, and behavioral reactions, such as turning against or away from the other and how these impact each partner. The completion of stage one is marked by the couple creating a meta-perspective and beginning to view their negative cycle as the source of insecurity and distress in the relationship as opposed to viewing their partner as the problem. Stage 2 is restructuring attachment interactions. This involves helping couples shape new positive interactional cycles where deeper primary emotions and attachment needs can be shared in structured enactments. Partners are encouraged to provide emotionally attuned support to one another. When blocks to emotional attunement and engagement arise, these are explored and understood in attachment terms. Partners who previously withdrew in the relationship begin to express their fears of rejection and failure and ask for their attachment needs to be responded to, and become more responsive and engaged. In turn, partners who previously were blaming and critical begin to clearly express their attachment needs for comfort and reassurance in a way that invites the other partner to understand and respond. As the withdrawing partner reengages, and as the blaming partner softens into vulnerable sharing, new positive interactional responses are shaped in bonding moments. There are two key change events that are understood to occur in stage two of EFT: Withdrawer reengagement and blamer-softening. Withdrawer reengagement occurs when the partner who previously avoided open engagement with their partner can express their attachment needs clearly and directly, and becomes more responsive to their partner. Blamer-softening occurs when the partner who previously took a pursing stance in the relationship, approaching their partner with blame and criticism, begins to express their more vulnerable primary emotions (hurt, sadness, fear, or shame) in a soft but clear and direct way. Their partner is then encouraged to listen and respond in an emotionally attuned way. These events generate new, more constructive, cycles of contact and caring, fostering secure attachment.

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Stage 3 is consolidation. This stage involves integration of gains made during therapy into specific situations of conflict. During this stage, couples use their felt sense of more secure connection and increased trust to solve problems in their relationship and everyday lives, creating a story of resilience and mastery in their relationship. In this way, new interactional patterns are consolidated and adaptive attachment behaviors become increasingly frequent in the couple’s daily interactions (Johnson 2004).

Research about the Model Emotionally focused therapy has strong research support in terms of both outcome and process of change studies. Early EFT research established the value of focusing on emotion in couple therapy. In the first EFT studies, Johnson and Greenberg (1985a, b) discovered that exploring emotions and drawing on them to shape new interactions resulted in significant improvements in relationship satisfaction for couples, and that these gains were more favorable as compared to a cognitive-behavioral problem-solving approach (PS). A meta-analysis by Johnson, Hunsley, Greenberg, and Schindler (1999) found a recovery rate from relationship distress of 70–73% with a Cohen’s d effect size of 1.31 using data from four RCT studies of EFT. EFT has also been shown to be effective for couples facing depression, posttraumatic stress, and chronic illness (Wiebe and Johnson 2016). The EFT literature has also outlined specific steps involved in working with couples facing relationship injuries such as affairs and other betrayals in the attachment injury resolution model within EFT (AIRM; Makinen and Johnson 2006; Halchuk et al. 2010). The AIRM model states that it is necessary for the injured partner to express and process feelings of anger, sadness, and fear due to the attachment injury in order to create secure attachment and in order for forgiveness to be possible. In an investigation of this model, Makinen and Johnson (2006) found that 63% of injured partners were able to successfully resolve the injury, forgive their partner, and

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resume the therapeutic process. Resolving the attachment injury was associated with significant improvements in relationship satisfaction and forgiveness. In a 3-year follow-up, couples who were able to resolve the injury continued to demonstrate improved relationship satisfaction and forgiveness (Halchuk et al. 2010). In a study of the process of healing attachment injuries in EFT, Zuccarini et al. (2013) found that couples who resolved their attachment injuries had demonstrated greater depth of emotional engagement in key sessions of therapy, a more reflective stance in processing of emotions around the injury, and greater levels of affiliative responding toward their partner as compared to nonresolvers. In terms of therapeutic interventions, resolved couples’ therapists tended to have increased levels of reflecting primary emotions, evocative questions, and enactments in EFT sessions. Furthermore, EFT has been found to be effective in reducing the neurological threat response to electric shock experienced by female partners when their partner was present holding their hand (Johnson et al. 2013), suggesting that EFT may help couples coregulate threat, which may help explain the effectiveness of EFT for highly stressed couples. Process research has explored the ingredients of change in EFT. The two main elements of the therapeutic process in EFT that have been identified as key ingredients of change are: depth of emotional experiencing and the process of shaping interactions such that partners begin to clearly express attachment needs and emotions and mutual affiliative responding (Greenman and Johnson 2013). In addition, the occurrence of a blamer-softening event – a key therapeutic event characterized by high levels of emotional experiencing and mutual affiliative responding – is associated with positive outcomes in EFT (Johnson and Greenberg 1988). Blamer-softening has been found to predict linear improvements in relationship satisfaction across EFT sessions (Dalgleish et al. 2015). Blamer-softening has also been tied specifically to reductions in attachment anxiety across EFT sessions (Burgess Moser et al. 2017). Research has confirmed that attachment security improves across EFT sessions

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(Burgess Moser et al. 2017) and during follow-up (Wiebe et al. 2016a), and that this change is predictive of continued improvements in the first 2 years after completing EFT (Wiebe et al. 2016b).

Case Example The following is a snapshot of the EFT therapeutic process with Jack and Marie, illustrating a softening session within the context of forgiveness of an attachment injury: Th: How did you enjoy your vacation? Jack: It was good at first. Marie and I went out dancing and we were having a good time. Then we got back to our hotel room and we started kissing and then all of a sudden just like that she started yelling at me again about the affair and then got up and went to bed. The rest of our vacation was shot. She was just withdrawn and sullen the whole time. Th: Jack, it sounds like you were really enjoying being with Marie, and then something happened, and you want to try and understand. Yes? Jack: Yes, I want to hear it, whatever it is (he gazes at Marie intently). Marie: Don’t act so innocent. The whole night you were staring at that other woman, but I know you don’t want me to talk about it so I held it in, and then later when we were kissing I just felt like it wasn’t me you wanted to be with. I’m never enough for you, just like the affair, I’m never enough (Marie speaks angrily, but with tears filling her eyes) Th: Marie, I hear your anger and frustration, and at the same time I see your eyes well with tears. When you saw him glance at that other woman you said to yourself ‘he doesn’t really want me’, and it brought back all the pain of the affair? And you held it in all night until you were back at your hotel room and you were making love, then part of you said, ‘he doesn’t really desire me’ – that terrible fear came up, and you felt all alone with it, is that it? Marie: Yes! So I just exploded, I let him have it.

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Th – So can you stay with that hurt and fear that you are so bravely naming here – can you take a breath and share that fear with Jack, right here? Marie: (She turns to Jack) It hurts so much to think that maybe you don’t really desire me and then you try to make love anyway, I can’t stand it! Th: You really long to know that you are wanted and desired by Jack, and it’s really hard to let him hear these vulnerable feelings and what ends up happening is you explode in anger, is that what happened?. Marie: Of course, I want to be the one you think about, the one you turn to, but when you look at other women I just get scared and feel alone and rejected and so sad (She weeps). Th: Can you turn to Jack and tell him this is how you feel? That you feel sad and scared and alone in those moments? Marie: Jack, when I’m reminded of the affair, I’m just overwhelmed with sadness and feeling alone. I know I explode in anger, but it’s because I just feel so vulnerable and hurt. Th: Jack – can you take that in? Can you help Marie with these vulnerable feelings? Jack: You just seemed so cold and distant all night. Then when I went to kiss you, you exploded. I didn’t know you were hurting. If I could take back the affair I would, in a heartbeat. It hurts me to see you in pain like this. I don’t want you to hurt anymore, Marie you know you are the only one I really want to be with. Marie: You know as I hear you say that it brings up a different sadness for me. What you did caused me a lot of pain, but now it’s like you can feel that pain too and you understand what it is like for me. I don’t want you to hurt anymore either. In this excerpt, the therapist helps Marie stay with and articulate her softer, more vulnerable attachment longings and fears underlying her angry responses to Jack. She is then guided to turn to Jack with her core feelings of pain and sadness around the attachment injury in a way that pulls her partner closer. Jack is then able to turn to Marie and support her,

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and express a deep empathy with her experience and regret for having hurt her. Marie can experience and take in a sense that Jack understands and feels her pain, and this allows her to shift into a more loving and forgiving response.

Cross-References ▶ Attachment Injury Resolution Model in Emotionally Focused Therapy ▶ Attachment Theory ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Clarifying the Negative Cycle in Emotionally Focused Therapy ▶ Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy and Physical Health in Couples and Families ▶ Emotionally Focused Couple Therapy and Trauma ▶ Emotionally Focused Family Therapy ▶ Emotion-Focused Therapy for Couples ▶ Goldman, Rhonda ▶ Gottman, John ▶ Greenberg, Leslie ▶ Hold Me Tight Enrichment Program ▶ Hold Me Tight/Let Me Go Enrichment Program for Families and Teens ▶ Johnson, Susan ▶ Training Emotionally Focused Couples Therapists

References Burgess Moser, M., Dalgleish, T. L., Johnson, S. M., Wiebe, S. A., & Tasca, G. (2017). The impact of blamer-softening on romantic attachment in Emotionally Focused Couples Therapy. Journal of Marital and Family Therapy. https://doi.org/10.1111/jmft.12284. Dalgleish, T. L., Johnson, S. M., Burgess Moser, M., Wiebe, S. A., & Tasca, G. A. (2015). Predicting key change events in emotionally focused couple therapy. Journal of Marital and Family Therapy, 41(3), 260–275.

Emotionally Focused Couple Therapy Gottman, J. M. (1993). A theory of marital dissolution and stability. Journal of Family Psychology, 7(1), 57–75. https://doi.org/10.1037/0893-3200.7.1.57. Greenberg, L. S., & Goldman, R. N. (2008). Emotionfocused couples therapy: The dynamics of emotion, love, and power. Washington, DC: American Psychological Association. Greenman, P., Young, M., & Johnson, S. M. (2009). Emotionally focused therapy with intercultural couples. In M. Rastogi & V. Thomas (Eds.), Multicultural couple therapy (pp. 143–166). Los Angeles: Sage. Greenman, P. S., & Johnson, S. M. (2013). Process research on emotionally focused therapy (EFT) for couples: Linking theory to practice. Family Process, 52(1), 46–61. http://doi.org/10.1111/famp.12015. Halchuk, R. E., Makinen, J. A., & Johnson, S. M. (2010). Resolving attachment injuries in couples using emotionally focused therapy: A three-year follow-up. Journal of Couple Relationship Therapy, pp. 31–47. https://doi.org/10108015332690903473069, 9 SRC-G. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection. New York: Brunner-Routledge. Johnson, S. M., & Greenberg, L. S. (1985a). Differential effects of experiential and problem-solving interventions in resolving marital conflict. Journal of Consulting and Clinical Psychology, 53(2), 175–184. Johnson, S. M., & Greenberg, L. S. (1985b). Emotionally focused couples therapy: An outcome study. Journal of Marital and Family Therapy, 11(3), 313–317. Johnson, S. M., & Greenberg, L. S. (1988). Relating process to outcome in marital therapy. Journal of Marital and Family Therapy, 14(2), 175–183. http://doi.org/ 10.1111/j.1752-0606.1988.tb00733.x. Johnson, S. M., Hunsley, J., Greenberg, L., & Schindler, D. (1999). Emotionally focused couples therapy: Status and challenges. Clinical Psychology: Science and Practice, 6(1), 67–79. Johnson, S. M., Moser, M. B., Beckes, L., Smith, A., Dalgleish, T., Halchuk, R., & Coan, J. A. (2013). Soothing the threatened brain: Leveraging contact comfort with emotionally focused therapy. PLoS ONE, 8(11), 1–10. http://doi.org/10.1371/journal. pone.0079314. Liu, T., & Wittenborn, A. (2011). Emotionally focused therapy with culturally diverse couples. In J. L. Furrow, S. M. Johnson, & B. A. Bradley (Eds.), The emotionally focused casebook: New directions in treating couples (pp. 295–316). Rutledge: New York. Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment injuries in couples using emotionally focused therapy: Steps toward forgiveness and reconciliation. Journal of Consulting and Clinical Psychology, 74(6), 1055–64. http://doi.org/10.1037/0022-006X.74.6.1055. Wiebe, S. A., & Johnson, S. M. (2016). A review of the research in emotionally focused therapy for couples (EFT). Family Process, 55(3), 390–407. Wiebe, S. A., Johnson, S. M., Burgess Moser, M., Dalgleish, T. L., Lafontaine, M., & Tasca, G. (2016a). Two-year follow-up outcomes in emotionally focused

Emotionally Focused Couple Therapy and Physical Health in Couples and Families couple therapy. Journal of Marital and Family Therapy, 43(2), 227–244. Wiebe, S. A., Johnson, S. M., Burgess Moser, M., Dalgleish, T. L., & Tasca, G. (2016b). Predictors of follow-up outcomes in emotionally focused couple therapy. Journal of Marital and Family Therapy, 43(2), 213–226. Zuccarini, D., & Karos, L. (2011). Emotionally focused therapy for gay and lesbian couples: Strong identities, strong bonds. In J. L. Furrow, S. M. Johnson, & B. A. Bradley (Eds.), The emotionally focused casebook: New directions in treating couples (pp. 317–342). New York: Routledge. Zuccarini, D. J., Johnson, S. M., Dalgleish, T. L., & Makinen, J. A. (2013). Forgiveness and reconciliation in emotionally focused therapy for couples: The client change process and therapist interventions. Journal of Marital & Family Therapy, 39(2), 148–162. https://doi. org/10.1111/j.1752-0606.2012.00287.x.

Emotionally Focused Couple Therapy and Physical Health in Couples and Families Paul S. Greenman Université du Québec en Outaouais, Gatineau, QC, Canada Institut du Savior Montfort, Ottawa, ON, Canada Ottawa Couple and Family Institute, Ottawa, ON, Canada

Name of Concept Emotionally Focused Couple Therapy and Physical Health

Synonyms Emotionally focused therapy for couples, EFT

Introduction Emotionally Focused Couple Therapy (EFT) is an experiential, systemic intervention designed to improve relationship quality and satisfaction by creating a secure attachment bond between partners (Johnson 2004). It is recognized as an

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effective, empirically supported treatment for distress in couple relationships (Wiebe and Johnson 2016). There is also a body of process research on EFT, which informs clinicians about what to do in therapy with couples, when, and how (Greenman and Johnson 2013). The results of process research also provide information on the type of client experiences (e.g., emotional reactions, changes in relationship positions) that therapists need to foster in order to effect positive change. Practitioners have recently begun conducting EFT outside of the traditional marriagecounseling context. It has made its way into medical settings and has been applied, for example, to couples facing chronic illnesses such as cancer (Naaman et al. 2011), heart disease (Greenman and Johnson 2012), and diabetes (Greenman et al. 2015). The rationale behind the integration of EFT into mainstream medical care is that improvement in the quality of the couple relationship can play an important role in the effective management of chronic disease.

Theoretical Context for Concept In contrast to “emotion-focused therapy” (Greenberg and Goldman 2008), emotionally focused therapy is based heavily on attachment theory and research, which stipulates that all people have innate, wired-in needs for close emotional connections to significant others (Bowlby 1979; Zeifman and Hazan 2016). According to attachment theory, these needs become particularly salient in times of stress and when people perceive threats to the presence or strength of their emotional ties to important figures in their lives. For example, the diagnosis and management of a chronic illness such as diabetes would most likely activate “attachment needs” for reassurance and support in the patient, along with “attachment fears” of losing the partner to illness in the patient’s spouse. From the EFT perspective, healthy couples are those who are able to send and respond to clear signals of needs for connection and comfort. Therapy helps them learn how to do this effectively. It is important to note that attachment is

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hierarchical; people tend to have stronger bonds to certain beloved individuals, known as “attachment figures,” than to others (Castellano et al. 2014). Spouses or romantic relationship partners tend to be primary attachment figures for many people, which means that these relationships are of paramount importance to them (Castellano et al. 2014).

Description EFT consists of three stages, divided into nine empirically derived steps (Johnson 2004). In Stage I, therapists work to help partners identify their interaction cycle, which is construed as the true enemy of the relationship and usually involves one partner attempting to establish or maintain emotional contact with the other, while the other partner withdraws or disengages emotionally. Both tendencies are framed in emotionally focused therapy, but not always in emotionfocused therapy, as attempts to manage the intense emotions that arise out of perceived threats to the attachment bond. Once both partners understand and accept the cycle as their main problem and they realize that they both play a role in creating and maintaining it, they have achieved “deescalation” and are ready to proceed to Stage II of therapy. Stage I work with couples facing a serious illness such as heart disease, cancer, or diabetes usually involves helping partners recognize how their questions, fears, and concerns related to the illness activate attachment needs and underlying emotions such as fear or sadness. EFT therapists assist couples in the process of becoming more aware of how their typical ways of managing these underlying emotions (e.g., emotional pursuit or emotional withdrawal) affect their interactions and their relationship as a whole. In Stage II of EFT, therapists create change events by heightening and deepening primary, vulnerable emotions that include fear and sadness, which according to attachment theory are usually borne in distressed couples out of longing for emotional connection with the partner and an inability to establish or maintain it. The

heightening of emotion and attachment needs is followed by enactments in which partners express their fears, longings, and needs directly to each other, and in which they respond to clear signals of vulnerability in comforting ways. The repeated expression of and response to emotional vulnerability in Stage II leads to a stronger, more secure bond in the couple. At this stage, couples who are dealing with a chronic illness generally learn to open up to each other about their stress around the illness, the sense of loss it can bring into their lives, their fears for the future, and their need for support and reassurance. They also learn to comfort and reassure each other at this stage. Stage III of EFT involves helping the couple solve practical problems now that they have a secure attachment bond and consolidating the gains that they have made in therapy. Couples coping with the challenges of a chronic illness are encouraged to engage in problem-solving around the disease as a team. This might involve learning to cook healthy meals or exercising together for some couples. For others, the focus might be on adhering to a particular treatment regimen or medication.

Application of Concept in Couple and Family Therapy In the case of a couple facing chronic illness, the partner who does not have the disease often tends to carefully observe, track, and sometimes even nag or control the partner who has the illness, usually out of fear for the sick partner’s wellbeing. In EFT, this is seen as an attachment fear. The partner with the chronic illness often tends to minimize the concerns of his or her spouse, become defensive, or withdraw emotionally. From an attachment perspective, this can lead to feelings of loneliness that compound the stress of having a disease. The emotional withdrawal then feeds into the partner’s fears, and the couple finds itself caught in a negative spiral. This is an example of the pursue-withdraw pattern that is typical in distressed relationships (Gottman 2011). The therapeutic work in Stage I with such a couple would involve helping them recognize how they

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feel about the illness (e.g., afraid, depressed), what they do when they feel that way (nag, criticize – “You’re having ANOTHER beer?!” or minimize – “It’s no big deal”), and how their behavior affects their partner. The goal is for them to identify this interaction pattern or cycle as their primary challenge and to unite against it. Stage II with couples grappling with a physical disease usually involves supporting the more withdrawn partner to open up about his or her anguish, stress, and sadness in the face of the disease and asking for emotional support rather than criticism. This is known as withdrawer reengagement. The Stage II process also involves helping the pursuing partner to soften by expressing his or her fears about the disease and asking for the ill partner’s cooperation and understanding in managing it together. Once the couple has developed a secure attachment bond in Stage II, exemplified by withdrawer reengagement and pursuer softening, they move on to Stage III of EFT. In medical settings this generally entails supporting the couple to engage in effective problem-solving around the disease. They might develop an exercise regimen together, devise a plan for continuing to administer and take medications properly, and decide to share their experiences about the illness with each other more openly. The therapist reflects this new way of interacting and reminds the couple that they combat the disease more effectively as a team.

Clinical Example Jane (age 44) and Daniel (age 46) have been together for 20 years. They have two children: Samantha (age 16) and George (age 13). Jane is a lawyer and Daniel is a family physician. Jane was diagnosed with type II diabetes 2 years prior to the beginning of emotionally focused couple therapy (EFT) and is now an outpatient at the diabetes clinic of a local hospital. She had been having a great deal of difficulty keeping her blood sugar levels under control and she reported feeling depressed and overwhelmed to the nurse diabetes educator that she had been seeing. She also mentioned that she had been having problems in her

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marriage since the diagnosis, which she attributed to her husband Daniel’s excessive “nagging, controlling, and nastiness.” Upon hearing this, the nurse referred Jane and Daniel for couple therapy, which is part of the gamut of outpatient services offered at the hospital. Daniel agreed to attend. Stage I Daniel and Jane met with a staff psychologist who was an experienced EFT therapist. In the initial sessions, the therapist established a strong alliance with both partners, as this is essential to the success of EFT. He also asked questions about how Jane and Daniel had been feeling since Jane’s diabetes diagnosis. It became apparent that the main trigger of their negative interaction cycle was the diabetes and what Daniel perceived to be Jane’s half-hearted attempts to maintain safe blood-sugar levels. Daniel was the pursuing partner and Jane the withdrawn partner in this case. The therapist helped Daniel identify, experience in-session, and talk about his fear of losing Jane, his sadness at the mere thought that she could become debilitatingly ill or die, and his sense of helplessness in this situation, despite all of his medical knowledge. The EFT therapist reflected that these primary emotions and vulnerable experiences tended to be couched in secondary emotions such as anger and frustration when Daniel interacted with Jane. With the help of some empathic conjectures and validation of this frightening experience, the therapist also brought into the open Daniel’s tendencies to try to control Jane’s behavior (e.g., what she could eat, how much, and when) and to criticize her when he thought she was not trying hard enough to stick to her diet and control her blood sugars. The therapist framed these behaviors as attempts to make sure that Jane would stay healthy and alive, driven by powerful fears of losing her (attachment framework). However, he noted that when Daniel behaved in this blaming, critical way without showing Jane any overt signs of his deep concern, it had a negative effect on her and actually contributed to her stress and to her tendency to withdraw from him. The therapist also worked with Jane in Stage I to uncover more about her experiences in the

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relationship. She mentioned feeling ashamed that she had gained weight since her diabetes diagnosis and was having so many problems keeping the disease under control. She was afraid that Daniel would fall out of love with her because of this, which made her feel sad and alone. The therapist heightened these primary emotions and attachment-related experiences in-session and noted that they were similar to Daniel’s, although Jane tended to cope with them differently. Whereas Daniel would become critical, Jane tended to minimize the impact of her health habits on her disease, to defend herself in the face of Daniel’s reproaches, and to distance herself from him emotionally and physically. The therapist pointed out that when Jane withdrew from Daniel in this way, it increased his tendency to pursue her. He presented this interaction cycle as the principal problem and the primary target of therapeutic intervention. After a few sessions, the couple began to perceive the cycle in their daily lives and to recognize their respective roles in creating and maintaining it. They expressed relief at this new understanding of their problems. Stage II The EFT therapist began Stage II by exploring, deepening, and expanding on Jane’s feelings of shame, fear, and sadness in-session. He supported her to talk in more detail than she did in Stage I about how she has always felt unattractive and how the diabetes diagnosis just confirmed that she was, in her words, “a pig.” The therapist explored how this perception of herself fed into her fears that Daniel would ultimately leave her, especially now that she could not effectively control the symptoms of her disease. She talked about feeling defective. The therapist invited Jane, in a series of enactments, to express these fears directly to Daniel. He then immediately supported Daniel to hear and to respond in a comforting, reassuring manner to Jane’s expressions of vulnerability and need for his support. The therapist helped Jane ask Daniel directly for encouragement rather than scorn. The therapist worked with Daniel in a similar fashion in Stage II. He deepened and expanded,

in-session, Daniel’s intense fear of losing Jane to her illness, his loneliness when she pulled away from him, and his sadness at the distance that had come between them. The therapist supported Daniel to express these fears and vulnerabilities directly to Jane, followed by the direction of Jane’s attention to Daniel’s longing for closeness with her and his terror that she might die. Daniel said at one point, “To me, a chocolate bar is like a gun that you’re pointing at your head,” and he started to weep. This emotional experiencing made Daniel appear less threatening to Jane and it helped him ask her, from a place of vulnerability, to work with him to tackle diabetes more effectively as a team. Over the course of a few sessions the couple became more attuned to each other and they learned to speak to each other clearly and directly about their respective fears and needs. Thus, Jane reengaged emotionally and Daniel softened. Stage III Once the bond between partners was secure, the therapist reflected to them their new positions in the relationship and their new ways of interacting with each other. As they spoke about diabetes, the therapist brought their attention to the fact that Daniel now talked more openly about his concerns instead of criticizing Jane, who now moved closer to Daniel and tried to reassure him of her presence and concerted efforts to manage her diabetes. The therapist suggested that the couple develop a systematic plan for diabetes management that they could work on together. Jane and Daniel decided that they would exercise together three times a week and that they would both embark on a healthy diet with the help of a nutritionist. If Jane’s sugars resisted her efforts to control them she asked Daniel to encourage her, which he did. If Daniel became concerned about one aspect or another of Jane’s diabetes he expressed those to her directly instead of criticizing her. In a 6-month check-in following their final session, the couple reported that they felt closer than they ever had. Managing Jane’s diabetes was still a challenge, but her blood sugar levels were more under control than they ever had been in the past, to the relief of both partners.

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Cross-References ▶ Attachment Injury Resolution Model in Emotionally Focused Therapy ▶ Clarifying the Negative Cycle in Emotionally Focused Therapy ▶ Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy ▶ Emotionally Focused Couple Therapy ▶ Emotionally Focused Couple Therapy and Trauma ▶ Emotionally Focused Family Therapy ▶ Health Problems in Couple and Family Therapy ▶ Training Emotionally Focused Couples Therapists

References Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock/Routledge. Castellano, R., Velotti, P., & Zavattini, G. C. (2014). What makes us stay together? Attachment and the outcomes of couple relationships. London: Karnac Books. Gottman, J. M. (2011). The science of trust: Emotional attunement for couples. New York: W. W. Norton. Greenberg, L. S., & Goldman, R. N. (2008). Emotionfocused couples therapy: The dynamics of emotion, love, and power. Washington, DC: American Psychological Association. Greenman, P. S., & Johnson, S. M. (2012). United we stand: Emotionally focused therapy for couples in the treatment of post-traumatic stress disorder. Journal of Clinical Psychology, 68, 561–569. https://doi.org/ 10.1002/jclp.21853. Greenman, P. S., & Johnson, S. M. (2013). Process research on emotionally focused therapy (EFT) for couples: Linking theory to practice. Family Process, 52, 46–61. https://doi.org/10.1111/famp.12015. Greenman, P. S., Tassé, V., & Argibay-Poliquin, E. (2015). Effective management of diabetes and comorbid depression: Contributions of emotionally focused therapy (EFT) for couples and individual Cognitivebehaviour therapy (CBT). Oral presentation at the 76th Annual Convention of the Canadian Psychological Association, Ottawa. Johnson, S. M. (2004). Creating connection: The practice of emotionally focused marital therapy (2nd ed.). New York: Brunner/Routledge. Naaman, S., Radwan, K., & Johnson, S. M. (2011). Emotionally focused couple therapy in chronic medical illness: Working with the aftermath of breast cancer. In J. L. Furrow, S. M. Johnson, & B. A. Bradley (Eds.),

875 The emotionally focused casebook: New directions in treating couples (pp. 141–164). New York: Routledge. Wiebe, S. A., & Johnson, S. M. (2016). A review of the research in emotionally focused therapy for couples. Family Process, 55, 390–407. https://doi.org/10.1111/ famp.12229. Zeifman, D. M., & Hazan, C. (2016). Pair bonds as attachments. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 416–434). New York: Guilford.

E Emotionally Focused Couple Therapy and Trauma Kathryn Rheem1 and T. Leanne Campbell2 1 Washington Baltimore Center for EFT, Falls Church, VA, USA 2 Vancouver Island Center for EFT, Nanaimo, BC, Canada

Name of Strategy or Intervention Emotionally Focused Couple Therapy and Trauma

Synonyms Emotionally Focused Therapy; EFT

Introduction Emotional dysregulation, including numbing, is a primary hallmark of trauma and PTSD. Since emotions are the messenger of love, emotional dysregulation – especially the very understandable but problematic coping strategy of numbing – is particularly damaging in couple and family relationships. Emotionally focused couple therapy (EFT) (Johnson 2004) is particularly relevant in the conjoint treatment of trauma since it is based on adult attachment theory (Bowlby 1969) and prioritizes the processing of emotions so that each partner can send a clear emotional signal, a requirement to strengthen and repair their bond and heal trauma.

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Theoretical Framework EFT, an empirically validated approach, combines an experiential, intrapsychic focus with a systemic emphasis on cyclical interactional responses and patterns (Johnson 2004; see other chapters on EFT in this volume). Key elements of each partner’s experience, such as attachment fears, needs, and longings, are evoked, distilled, and shared (through enactments) in order to restructure the relationship bond. Expanding beyond traditional individual treatment of trauma, EFT is revelatory for treating the echoes of trauma in the context of couple therapy: when partners have a felt sense of security, their relationship contains and antidotes the distress associated with trauma.

Rationale for Strategy or Intervention Emotion is seen as a primary signaling system that organizes relationship patterns. Acting as a GPS, it is impossible to navigate relationships without regularly referencing how we feel. Since emotions are impossible to hide, partners also regularly gather data about each other’s inner worlds which drive behaviors and influence interactions with each other. In attachment terms, a bond refers to an emotional tie, i.e., a set of attachment behaviors to create and manage proximity to attachment figures and regulate emotions. The accessibility and responsiveness of attachment figures are necessary to create a feeling of personal security. Attachment theory (Bowlby 1969, 1988) is a developmental theory of personality and a theory of love, but it is also a theory of psychological trauma and the impact of isolation, neglect, and emotional starvation on the developing personality. Bowlby and others recognized that separation from primary caregivers and lack of human contact over even a short period of time during critical periods of development could have severe personal and relational consequences. A significant body of research has been accumulated over the last half-century. When an attachment figure is perceived as inaccessible or unresponsive, potent fear, anger, and sadness emerge. These emotions often lead to behaviors and interactions that disconnect partners

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just when they need each other the most. Seeking and maintaining closeness with an important other is viewed as the primary motivating principle in humans and an innate survival mechanism, providing us with a safe haven and a secure base in a potentially dangerous world (Bowlby 1988).

Description of Strategy or Intervention The goals of EFT are, firstly, to expand attachment-related affect which, in turns, clarifies each partner’s position in their interactional pattern and, secondly, to help partners access their underlying vulnerable emotions which, when shared, restructure the couple’s bond. When using EFT with couples where one or both partners have endured more than most (our frame for trauma), there are specific goals: (1) regulate affect, particularly containing anger and working with fear; (2) create moments of sharing vulnerabilities so a corrective experience of safe connection is had and new meaning can be attained; and (3) integrate the revised view of self/other (Johnson 2002). The EFT therapist works toward a sense of safe emotional connectedness where the partner becomes an ally or co-regulator of a trauma survivor’s feelings of helplessness. The relationship is used as a source of protection where partners are able to confide in each other and soothing and comfort are provided. EFT provides an ideal opportunity to help couples break the inevitable trap of trauma: relationship escalations increase symptoms of trauma and often lead to more negative coping strategies; increased symptoms coupled with problematic ways of coping intensify the relationship’s distress (Johnson and Faller 2011). Nothing is more relevant than treating the echoes of trauma in the relationships in which they reverberate. Dealing with trauma together creates an environment of recovery between partners. Partners have much more proximity (nearness, immediacy, and closeness in key moments of distress) and, hopefully, longevity in their relationships with survivors. A sense of belonging mitigates the echoes of trauma, and closeness to a loved one

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soothes the nervous system. Helping the survivor learn to reach emotionally and helping the partner learn how to be emotionally responsive decrease helplessness and numbing, other symptoms begin to diminish, and partners are able to use the relationship to cope together (rather than the partner being a bystander or even a target). The foundation of all EFT interventions is empathic responsiveness. When working with traumatized couples, the empathy and safety provided by the EFT clinician allows the client to focus inwardly and touch fears and pain. For trauma survivors, making experiential contact with pain and fear can feel dangerous. The EFT therapist is the trusted guide who safely brings clients into their inner worlds. By using EFT interventions to evoke and heighten vulnerable emotions, by using parts language in order to leverage the fear with the clients’ longings, and by processing the fear and pain experientially with conjectures and evocative responses, each partner’s inner world becomes less dysregulated and less chaotic. As a result, there is more intrapsychic coherence and organization, allowing each partner to feel more competence with their own inner worlds. Once the intrapsychic landscape of each partner is more organized, linking it to the interpersonal is vital. The only way to restructure the couple’s bond (the goal of EFT Stage 2) is to use enactments to bring the fear and pain to the partner, allowing the partners to hold the emotion together. Emotions are the link between the intrapsychic and the interpersonal and the EFT therapist structures, a process where partners share fear and pain with each other through enactments. Small, simple enactments help the trauma survivor build an interpersonal template of safety, perhaps for the first time. Risks are sliced thinly in order to decrease danger; validation is offered frequently by the EFT therapist to resource and hold the client. Slowly and methodically, reaches are made by one partner, and responses are provided by the other, in order to build a bond that is trustworthy and soothing. As a result of completing Stage 2 of EFT, partners will have had many corrective emotional experiences as each has shared pain and fear with the other. They will have confided about the

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echoes of trauma and the isolation endured, offered each other reassurance which comforts and soothes, and built trust that together they can help each other through the dark moments (Johnson 2002). In completing EFT, trauma survivors and their partners have earned their attachment security (Bowlby 1969) which continually contains and provides antidotes for the echoes of trauma. The neurological benefits of love are hidden when pain and fear are not processed or shared. Slowly but purposefully leaning into and loosening the grip of fear and pain allows the comfort of love to soothe a traumatized heart.

Case Example Gary’s voice rose and his tone sharpened as he turned to Lisa, accusing her of not loving him as much as he loves her. “You work late,” he said, “and are always busy with the kids. I seem to come last on your list of priorities. I rush home to see you. I seem to be way more committed to you than you are to me.” At this point, Lisa’s gaze turned down, and she shifted further into the back of her chair. He continued, now more aggressively and loudly, “Forget it! It’s over!” and started to leave the room. The couple had been struggling for months, had a period of separation, and were now working toward reconciliation. Lisa, with a background of trauma characterized by family violence, as well as abandonment by a parent, had little tolerance for such threats and limited capacity to manage them. The therapist interrupted. Her voice soft, and with eyes locked on Gary’s, she invited him to stay. Gary sat down again. With a deep breath, his chest crumpled slightly and he appeared less intimidating. The therapist then turned to Lisa who was by now gazing off into the recesses of the wall. Her face was frozen. Her eyes were blank. “Where are you?” the therapist queried in a soft inviting tone. Lisa quietly replied, “I don’t know.” The therapist gently leaned toward Lisa and invited her to stay with her experience. “What is

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happening inside of you Lisa? Not in your brain, in your body, what happens in your body when you hear Gary reach for you in this way, when you notice his tone change. . .?” Lisa sat quietly for a moment and then said, “I feel numb. I feel empty. I don’t feel anything.” “Okay Lisa, this is good,” the therapist noted encouragingly, “Let’s just stay here . . . this will be good. . ..” Over the course of the next few minutes, and with similar slow, evocative probing and intonation of voice from the therapist, Lisa then was able to access and acknowledge a sense of fear and anxiety – characterized by a tightness in her chest and a lump in her throat that seemed to choke her and leave her speechless. “If that lump could speak Lisa, what would it say?” the therapist asked. With that, Lisa’s face shifted. Her lips softened, her eyes filled with tears, and she turned tentatively toward the therapist. Staring at the therapist now, and with tears streaming down her face, she quietly responded, “scared.” “I’m scared,” the therapist reflected. Now glancing at Gary from the corner of her eye – to ensure and facilitate further engagement – the therapist evocatively and empathically framed Lisa’s experience in the context of her attachment history and the couple’s negative cycle. Specifically, the therapist reflected, “I hear you Lisa . . . does it go something like this? . . .is this what happens? . . . what I hear you saying is . . . (therapist now begins speaking for Lisa, to Gary) ‘when I hear your voice change, even a little tiny bit, or when I see your brows raise, even ever so slightly. . .[what I hear you say is that when you] . . . hear or see any hints of anger, or any threat of abandonment, . . . [what I hear you saying is. . .] I freeze, I go right back to that place I lived as a little girl, the only place that I could feel safe. . .I disappear, I go silent. . .no one can see me, and I lose myself.’” (Here the therapist is setting the stage for an enactment, reflecting the negative cycle, embedding it in an attachment framework, and normalizing their responses based on their relationship and attachment histories in an effort to create increased safety, as well as awareness.)

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(Speaking as therapist again). . .“And when Gary feels you ‘disappear’ [go silent, withdraw, retreat rather than expressing fear] he feels alone and unimportant, he feels like he doesn’t matter, that he’s not important to you . . .but that’s not quite it, is it? To the contrary, you are hyperattuned to him, and that also served you well as a child, it was helpful to be vigilant to danger . . .but what I’ve heard you say is that Gary is not dangerous . . . he has never been violent, but his tone, his look can at times feel dangerous . . .and as a little girl, it was never safe to share your fear . . . it was safer and it was adaptive to go numb and quiet . . . but now that is keeping you away from the person that matters to you most. . ..” Again, with an evocative, rhythmically paced, and empathic voice, and also allowing herself to be openly and tearfully touched by the profound nature of Lisa’s authentic sharing and experiencing of associated childhood memories and pain, the therapist holds the couple in their experience and invites them both to feel compassion for the younger Lisa. Against this backdrop, the therapist then returns to Lisa with the aim of helping her further embody the fear underlying her sense of numbness and withdrawal. Once distilled and heightened, Lisa is directed to share her fear from a position of vulnerability – that is, the therapist now invites Lisa to do the enactment – and Gary is invited to respond from a place of compassion and empathy (e.g., “when Lisa so beautifully shares her fear with you, in your eyes, and you see her beautiful tear-filled eyes, . . . when she looks at you and shares in this way, what are you drawn to do?”). As Gary reaches back, both with his eyes and presence, and Lisa remains present in her vulnerability, a bonding moment occurs that provides both the foundation for a corrective emotional experience as highlighted earlier, and a new template for connection (i.e., model of other), and an experience of herself in relationship as worthy and lovable (i.e., model of self). The excerpt above provides a brief snapshot of a partial session of emotionally focused therapy for couples. The therapist is working with Lisa in particular (in step three, stage 1/de-escalation of the process). By accessing feelings underlying her

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withdrawal (under conditions of stress/threat) in the relationship, Lisa is able to also tap into childhood experiences associated with trauma and loss. As she begins to openly and directly express such emotions in her relationship with Gary, and as Gary is accessible and responsive (is less reactive, less escalated, and more open emotionally), Lisa’s long-standing patterns of avoidance and withdrawal are interrupted, and Lisa’s template for relationships (and her view of herself) is similarly challenged. In turn, as Gary is able to respond to Lisa in a time of need (i.e., as she shares the pain/ fear underlying her numbness and withdrawal), he too is able to begin to view the relationship and himself differently (e.g., as someone who does matter to Lisa, given the importance of the work he has witnessed and the vulnerability she has shown). Stated more simply, as Lisa is able to explore, access, and then share aspects of her pain outside her typical awareness, transformation (as well as healing of past trauma) begins both personally and relationally for both partners.

Cross-References ▶ Adult Survivors of Sexual Abuse in Couple and Family Therapy ▶ Attachment Injury Resolution Model in Emotionally Focused Therapy ▶ Attachment Theory ▶ Bowlby, John ▶ Child Sexual Abuse in Couple and Family Therapy ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Clarifying the Negative Cycle in Emotionally Focused Therapy ▶ Deepening Emotional Experience and Restructuring the Bond in Emotionally Focused Couple Therapy ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Emotionally Focused Couple Therapy and Physical Health in Couples and Families ▶ Empathy in Couple and Family Therapy ▶ Enactment in Structural Family Therapy ▶ Family Violence in Couple and Family Therapy

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▶ Johnson, Susan ▶ Posttraumatic Stress Disorder (PTSD) in Couple and Family Therapy ▶ Violence in Couples and Families

References Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books. Bowlby, J. (1988). A secure base. New York: Basic Books. Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York: Guilford. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed.). New York: Brunner-Routledge. Johnson, S. M., & Faller, G. (2011). Dancing with the dragon of trauma: EFT with couples who stand in harm’s way. In J. L. Furrow, S. M. Johnson, & B. Bradley (Eds.), The emotionally focused casebook: New directions in treating couples (pp. 165–192). New York: Routledge.

Emotionally Focused Family Therapy James L. Furrow1 and Gail Palmer2 1 Fuller Graduate School of Psychology, Pasadena, CA, USA 2 International Centre for Excellence in Emotionally Focused Therapy, Ottawa, ON, Canada

Name of Model Emotionally Focused Family Therapy.

Synonyms EFFT

Introduction Emotionally Focused Family Therapy (EFFT) provides therapists with a process-focused

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approach to restoring attachment bonds in parentchild and sibling relationships through increasing felt security in the family system (Johnson 2004). In EFFT, family distress results from rigid family patterns and persistent negative emotional experiences that block a parent’s ability to effectively address a child’s attachment needs. The therapist guides family members toward a more secure pattern of relating by shifting these negative interactional patterns into positive cycles characterized by greater parental accessibility, responsiveness, and emotional engagement and more effective attachment responses from children. In EFFT, the therapist acts as a process consultant focusing on the emotional blocks and behavioral patterns that interrupt a family’s ability to respond effectively to the needs and concerns of other members. A family’s presenting problem is conceptualized as a rigid pattern of negative interactions that are informed by reactive and rigid responses based in attachment insecurity. As the therapist works through these emotional blocks, parents are guided toward new positions of availability and children are encouraged to share their attachment needs with their emotionally engaged parent. The process of re-establishing bonds of security in parent and child dyads promotes resilience in the face of ordinary developmental needs and stressors common to family life.

Prominent Associated Figures Susan Johnson.

Theoretical Framework Rationale for the Model Emotionally Focused Family Therapy (EFFT) is founded on the principles and practices of Emotionally Focused Couple Therapy (EFCT). Theoretically, EFCT draws from humanisticexperiential (e.g., Rogers 1951) and systemic theories (e.g., Minuchin and Fishman 1981). Susan Johnson (2004) characterized couple relationships as attachment bonds and their disruption as

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separation distress, following John Bowlby’s theory of attachment (Bowlby 1969, 1988). In distress, a couple’s problematic attempts to re-establish their attachment bonds fuel insecurity as partners rely on anxious or avoidant strategies to cope. Similarly, a family’s distress escalates in the face of insecure attachment bonds and resulting separation distress. Family patterns are often more complex than couples given the hierarchical bonds of parents and children and mutual bonds of partners working together as parents. Escalating insecurity in family interactions prompts fear of possible separation, loss, and isolation (Johnson 2004). The inability to relate clear attachment and caregiving communication further amplifies the family distress. Strategies of anxious control, preoccupation, or avoidant withdrawal organize the family’s attachment communication deepening the insecurity felt by family members. The principle goal of EFFT is to re-establish more secure patterns where attachment and caregiving responses are effective and emotional bonds are reassured. Family bonds are adaptive and essential to a natural system that promotes optimal development and environmental mastery for children (Bowlby 1969). When these bonds are secure, parents are more likely to provide children with a “secure base” to foster exploration promoting the development of a child’s potential and uniqueness and a “safe haven” from the uncertainties and difficulties of life. Together these resources inform a network of security that insures the flexibility and cohesion necessary to maintain individual growth and meaningful relationships across the lifespan (Byng-Hall 2001). Core Concepts Four key concepts guide an EFFT therapist’s conceptualization and work with families: Negative Interactional Patterns; Felt Security; Processing Emotional Experience; and Restructuring Interaction. Negative Interactional Patterns

A family’s inability to respond to developmental and situational demands is often evident in rigid patterns of reactive behavior organized by

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negative emotional experience. These negative interaction patterns produce mutually reinforcing reactive patterns of dysregulated affect. These negative absorbing states lock family members into fixed interactional positions informed by underlying anxious or avoidant attachment strategies (Johnson 2004). In EFFT, these patterns are the initial focus of treatment, where specific disruptive and dysregulated interactions offer access to emotions underlying the family’s presenting problem (Johnson et al. 2005). Felt Security

Secure attachment in a family system results from accessible and responsive caregiving to clear attachment-related communication. Felt security is evident in family interactions where positive emotions enable families to effectively respond to developmental needs and relationship change. Felt security offers a child internal confidence in an attachment figure’s support in exploration and availability in the face of personal threat and emotional distress. Parents as caregivers also turn toward one another for mutual support, just as children turn toward parents for care contact and comfort. These positive cycles of security define the family as a “safe haven” and a critical resource for facing ordinary stressors and developmental demands. Emotional Experience

Emotion is central to attachment communication and a key focus in the EFT process of change. Emotion primes attachment responses in family interactions and is a primary resource to felt security. Attachment communication exists first and foremost at an emotional level because attachment bonds are emotional bonds (Johnson 2004). Focusing on the emotional responses of family members enables parents and children to better access their intentions, desires, and needs. Moreover, separation distress is colored by reactive emotional responses. Processing emotional experience is essential in working through maladaptive responses and the EFFT therapist differentiates primary emotions from secondary emotion by actively accessing and exploring the underlying emotions associated with attachment needs in the family (Johnson et al. 2005).

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Restructuring Interaction

The resolution of a family’s attachment-related distress results from transforming negative interactional patterns through corrective emotional experience. Shifts toward greater parental openness set the stage for increased attunement and interest in the child’s attachment-related needs. Parental accessibility provides new opportunities for children to explore their attachment-related needs and concurrently for parents to take new steps to respond to these needs. The shared experience of vulnerability clarifies parental caregiving intentions and provides a basis for more clear expressions of a child’s attachment needs (Johnson et al. 1998). These shifts result in new experiences and family conversations founded in more accurate, affectively engaged, and emotionally corrective responses. New patterns of secure responding are choreographed by the therapist using new experiences of emotion to move family to cycles of felt security. Theory of Change The EFFT stages of change follow the EFCT treatment approach with a unique focus on parent and child interaction patterns (Johnson 2004). The process of change includes the de-escalation of a family’s negative interaction pattern, restructuring parent and child positions, and consolidation of felt security gained through these new positions. In stage 1, de-escalation is premised on a therapist ability to foster a secure base enabling a family to explore their presenting problem and related distress. Individual family members’ experiences are accessed and understood in the context of family pain, fears, and hurt. Through accessing and processing these primary emotions, the therapist reframes problem patterns based on these underlying emotions and elicits more explicit parental caregiving responses to emerging attachment-related emotions and needs. This enables the family to develop a coherent understanding of their pattern and greater freedom to acknowledge each person’s responsibility in the family’s predictable struggle including greater parental openness and engagement. In stage 2, the EFFT therapist focuses on restructuring the family pattern through deepening

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and delineating the child’s underlying attachment affect and then distilling unexpressed or unclear attachment needs. As a child’s primary emotions and needs are made more explicit, the therapist invites the child to share these experiences. The therapist joins a parent in processing and working through her or his response to the child’s newly expressed vulnerability. Parental blocks to caregiving are identified and worked through leading to greater parental empathy and caregiving responses. The therapist then invites the parent and child into an enactment of the child’s attachment bid and the parent’s attuned caregiving response. New family responses tend to reflect clearer definitions of self, more assertive boundary definitions, and more explicit expectations of the relationships desired in the family (Johnson 2004). The third and final stage of EFFT promotes consolidation of the new patterns of security achieved by the family in the preceding stages. The family takes new steps toward enhancing the felt security experienced by the family after working through blocks to emotional engagement and effective caregiving. More secure family interactions demonstrate greater flexibility in responding to developmental demands and are more effective in problem solving (Johnson et al. 1998). New rituals of connection are explored to increase openness and emotional engagement, greater positive affect, and appreciation for their stronger ties as a family.

reformulated within specific relationships and, second, new interaction patterns are formed based on these new emotional responses. The EFFT therapist uses reflection, validation, and evocative questions to access and process the emotional responses associated with stuck family patterns and rigid positions. Reactive responses are reframed in terms of predictable patterns of family distress, and underlying emotions are understood in the context of attachment seeking and caregiver responding. The second strategy focuses on forming new interactional patterns organized around positive cycles of attachment security. Enactments are used to engage primary emotional experience leading to the sharing of attachment-related emotions and needs. EFFT differs from EFT with couples in recognizing the hierarchical role of a parent and the primacy of parental caregiving in response to attachment needs expressed by a child. The EFFT therapist uses heightening interventions and enactments to choreograph change events that foster parental responsiveness and accessibility to a child’s vulnerability.

Research

Internalizing and externalizing disorders in childhood and adolescence, stepfamily adjustment, and family distress.

Johnson et al. (1998) explored the use of EFFT with adolescents with bulimia and their parents in a hospital setting. Results from the small outcome study demonstrated that EFFT was effective in complete remission of binging behaviors for 44% and vomiting behaviors for 67% of the sample. A series of case studies illustrate the use of EFFT with different presenting complaints including depression, nonsuicidal self-injury, conduct disorder, and issues related to divorce and step family adjustment.

Strategies and Techniques

Case Example

EFFT based Two First,

Zane, a 15-year-old boy, was referred to family therapy following a series of school-related problems. Zane’s difficulty concentrating, completing assignments, and truancy were a change from

Populations in Focus

treatment strategies and techniques are on similar interventions used in EFCT. strategies organize EFT interventions. emotional responses are accessed and

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his previous school success. These difficulties followed a period of family instability including his father Mohammed’s death and his mother Irma’s recent engagement. Zane described his family as a “battleground” of constant fighting with his mother and younger brother Yosef who constantly sought his attention. The therapist engaged each person’s experience by exploring, empathizing, and making sense of their responses to the family. The harsh moments of negativity illustrated the separation distress evident in Zane’s protest and his mother’s attempts to regain control. Tracking the negative interactions gave opportunity to explore Zane’s anger, pain, and loss, which he and brother Yosef felt about their father’s death, which was rarely discussed. As different experiences were acknowledged, specific attention was given to these more vulnerable experiences. Individual sessions with the mother and the sons deepened an understanding of Zane’s relationship to his mother and Irma’s ambivalence about her husband’s death and their distant marriage. Irma avoided discussing her late husband’s absence with her sons as both rejected her fiancé whom she relied on for emotional support. Irma’s parental concerns were affirmed and the family’s distress was framed in relation to the father’s absence and the threat of further loss through mother’s remarriage. The therapist highlighted Irma’s underlying care and concern for her sons. Both boys expressed questions about their father’s death and fears about family changes in a sibling session and both were encouraged to share these experiences with their mother in future sessions. Family treatment focused on Zane and Irma as they shared the most distressed family relationship. Zane’s anger quickly escalated when Irma dismissed his thoughts and opinions or criticized his school-related efforts. Irma’s reactive response was validated and understood in terms of her heartfelt concern for Zane and the frustration she felt when he would withdraw defensively. The therapist identified her care and heightened her concern for Zane using an enactment to engage her softened emotions with her son. As she tearfully reached her hand toward him, she explained her struggle to talk with him and show care for

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him particularly when he was missing his father. Zane rejected her initiative lashing out with contempt, calling her a “whore” for her being unfaithful in choosing another man. Zane’s raw anger showed the intensity of his pain, which the therapist accessed in blocking his attack and reframing his harsh protest to the losses in the family which left Zane utterly alone. Zane fought back tears as he shared his despair: “Nothing is the same. Everything has changed. What’s the point?” Irma again struggled to find words to respond to Zane’s grief as she was invited to courageously engage his vulnerability. Zane slowly responded to his mother’s effort to offer her regret and an apology that she had missed what he was going through given she was lost in her own pain. In turn, Zane was asked to express what he needed most from his mother and he shared that he wanted to know what was happening in the family and needed his mother to talk with him, not just about school. Irma took Zane’s hand and reassured him, sharing how proud she was of him and that his father would see the same, that she sees him as a mature young man that has a very young age had to face this loss of his Dad. Through this corrective emotional experience, Zane faced his fears and reached for his mother from a position of vulnerability. Irma responded to her son’s attachment need by seeing him and his pain and in that place and offering love, support, and comfort. Following this work, Yosef was invited back to a family session and shared happiness that there was more caring and less fighting in the home. The family shared plans to honor and remember Mohammad through rituals of visiting the burial ground together and being closer through sharing more family times together.

Cross-References ▶ Attachment Theory ▶ Attachment-Based Family Therapy ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Emotion-Focused Family Therapy

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References

Prominent Associated Figures

Bowlby, J. (1969). Attachment and loss: Attachment. New York: Basic Books. Bowlby, J. (1988). A secure base. New York: Basic Books. Byng-Hall, J. (2001). Attachment as a base for family and couple therapy. Child Psychology & Psychiatry Review, 6, 31–36. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed.). New York: Brunner-Routledge. Johnson, S. M., Maddeaux, C., & Blouin, J. (1998). Emotionally focused family therapy for bulimia: Changing attachment patterns. Psychotherapy, 35, 238–247. Johnson, S. M., Bradley, B., Furrow, J., Lee, A., Palmer, G., Tilley, D., & Wooley, S. (2005). Becoming an emotionally focused couple therapist: The workbook. New York: Brunner-Routledge. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Rogers, C. (1951). Client-centered therapy. Boston: Houghton-Mifflin.

Adele Lafrance Joanne Dolhanty

Emotion-Focused Family Therapy Allen Sabey1 and Adele Lafrance2 1 The Family Institute at Northwestern University, Evanston, IL, USA 2 Laurentian University, Sudbury, ON, Canada

Synonyms EFFT

Introduction Emotion-focused family therapy (EFFT) is an approach to family therapy whereby parents are viewed as essential to their children’s mental health treatment. The primary aim of EFFT is to recruit and empower parents to engage in a primary supportive role in helping their child to cope with and/or recover from their behavioral and emotional challenges. Although empirical research is limited given its relatively brief existence, preliminary outcome and process research show promise among a variety of clinical populations and research is ongoing.

Theoretical Framework Part of the emotion-focused therapy family, EFFT was initially developed as an adjunct to familybased treatment for eating disorders in order to help parents to support their children in dealing with both behavioral symptoms and the emotional processes fueling them. From the EFFT perspective, emotion processing can play a key role in the onset and maintenance of a variety of mental health issues (e.g., depression, anxiety) and associated symptoms. Emotional avoidance (i.e., suppressing or ignoring emotions) is considered a maladaptive coping strategy that drives a variety of mental health conditions such as mood and anxiety disorders, eating disorders, and selfharm. Although there are a host of factors that can contribute to mental health issues (e.g., genetics, culture, trauma), the ways in which individuals and their families attend to and process emotions can be targeted and transformed, and in short order. Thus, helping parents to support their children to manage their emotions in adaptive and productive ways is an overall target for intervention and treatment (Elliott et al. 2004; Greenberg 2008; Greenberg and Pascual-Leone 2006). Parents have been under-utilized as active agents of change in the context of their children’s mental health treatment, particularly among adolescent and adult populations. An infant’s brain develops in concert with their primary caregivers and a powerful connection between parent and child remains throughout life. As such, EFFT also privileges the parent’s role as a primary agent of healing, and even more so than that of the clinician. Influenced by the theory and neuroscience of parent-child bonding, EFFT purports that it is more therapeutically worthwhile to support parents to lead the behavioral and emotional interventions for their children given that they are “wired” together. In other words, the efforts of a

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parent will be more neurologically powerful than those of a stranger (therapist), even if those efforts are imperfect. Thus, the therapist’s main responsibility is to support the parent to become an active agent of change in the home setting. Should the parent present as unmotivated, unwilling, or uncaring, EFFT theory suggests that these clinical presentations are merely symptoms of an unprocessed emotion “block.” Within the model, the most common emotion blocks include fear, shame, helplessness, hopelessness, and resentment. The goal of the therapist is then to support the parent to work through the emotion block driving the parent’s problematic attitude or behavior and resume implementation of home-based interventions. It is important to note that parents can take on these roles regardless of their child’s level of motivation or involvement in formal treatment, creating hope for those families for whom the affected child refuses service. EFFT is a lifespan approach that can be delivered with parents only, parent-child dyads, or entire families.

Populations in Focus EFFT evolved from work with families with a child diagnosed with an eating disorder. Its focus has since expanded across emotion-based disorders, and research is ongoing among families of children across the life span with mood and anxiety disorders, behavioral dysregulation, social problems, as well as somatization disorders.

Strategies and Techniques Used in Model There are five main modules of intervention in EFFT. The first three include supporting parents to (1) interrupt behavioral symptoms and encourage health-focused behaviors, (2) help their child process overt and underlying emotions, and (3) repair their relationship to facilitate healing of relational injuries and self-blame. The fourth module involves the identification and processing of emotions that “block” or interfere with the

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parent’s ability to carry out of the tasks in each of the aforementioned ways or that lead to therapy-interfering parental attitudes or behaviors such as denial, criticism, or enabling behaviors. These emotional blocks can also occur in clinicians as they implement these interventions. As such the model includes a fifth and final module related to the resolution of such blocks in both clinicians and teams. Interrupting Behavioral Symptoms Children’s mental health issues often involve problematic behavioral symptoms. Parents are taught and empowered to take on the tasks of interrupting problematic behavioral symptoms and supporting health-focused and recovery behaviors instead. The ways in which parents can support their specific child will vary according to the child’s behavioral symptoms. For example, parents with a child suffering from an eating disorder will be taught strategies for meal support as well as tools to interrupt related behaviors such as purging and compulsive exercising. A parent with a child suffering from anxiety will be coached to co-develop a fear hierarchy with their child followed by the facilitation of graduated exposures in the home. These interventions can be delivered in person, over the telephone, and even by text or e-mail. Processing Emotions To lay the groundwork for the techniques for parents to help their child process emotions, the EFFT clinician teaches parents about the nature of emotion as well as its role (i.e., emotional avoidance) as one of the factors related to the onset and maintenance of mental health challenges. Parents then learn the steps of emotion coaching, derived from the steps of emotion processing in EFT (Greenberg 2002, 2004) and influenced by Gottman (1997). The five steps of EFFT emotion coaching are: (1) Attend, (2) Label, (3) Validate, (4) Identify and Meet the Need, and (5) ProblemSolve (if necessary). Perhaps the most important step – that of validating the emotional experience – is also the most difficult. The core skill of validation involves replacing the word “but” with “because” when supporting their loved one to

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move through emotion. For example, parents are taught to move from the conditioned response of: “I understand that you feel sad about missing out but there will be other opportunities,” to “I understand that you feel sad because you were really looking forward to going.” These emotion coaching strategies are essential for two main reasons. First, these strategies can help parents to de-escalate their child’s emotional outbursts that often occur in response to their parents/treatment team’s efforts to interrupt symptoms. Second, with repeated exposure, the affected individual will eventually internalize the skills of emotion coaching, increasing their capacity for selfregulation and making symptoms unnecessary to cope with emotional pain. Relationship Repair The relationship repair intervention is a powerful tool to support the healing of pain within the family. The EFFT clinician would use this intervention with parents under three conditions: (1) family members exhibit a pattern of emotion avoidance that seems to maintain behavioral symptoms; (2) parents and/or their children blame themselves for the mental health challenges; or (3) the parent-child relationship is strained (distant or hostile) and thus making it difficult for parents to effectively engage in treatment for their child. The relationship repair involves a specifically constructed apology influenced by emotion-focused therapy for couples in the service of relationship reconciliation. It is also a process that deals head on with the reality that children and parents often blame themselves and involves an opportunity to target and transform these problematic states. In fact, it is our observation that acknowledging family circumstances and emotional style that may have contributed to the child’s current difficulties is as healing for the parent as it is for their child – perhaps more so in some cases. The parent, thus freed from the burden of their own self-blame and shame, is more emotionally available to their child and has improved access to parental instincts and acquired skills. For each of the abovementioned domains, parents are taught the relevant skills through

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psychoeducation via discussion and videos as well as experiential coaching via role-plays. During role-play, the clinician shapes the parent’s approach, for example, by directing their choice of words, tone of voice, and body language. Parent Blocks A parent’s emotions can interfere with effective parenting efforts (Goddard et al. 2011; Lafrance Robinson et al. 2013; Maliken and Katz 2013). In fact, even though the primary aim of EFFT is to support parents to learn the advanced caregiving skills developed to support the behavioral and emotional recovery of their loved one, the EFFT therapist keeps a keen eye for the identification of emotional “blocks” in parent that may interfere with their ability to adopt the skills of behavioral coaching, emotion coaching, and relationship repair in the home environment. The expression of these blocks can manifest in a variety of ways, including refusal to engage in parent-led interventions, criticism of the child or co-parent or treatment team, and even denial of the severity of the problem. These behaviors are seen as efforts to regulate the parent’s own strong negative emotions, specifically fear, shame, helplessness, hopelessness, and resentment. For example, parents may struggle to set limits around their child’s behavior if they fear a breach in the relationship. Thus, this parent will avoid setting limits to regulate their own fears and “protect” the parent-child relationship. The most common fear underlying parent blocks relates to the fear of suicide. Specifically, many parents – and of all walks of life – struggle to support home-based interventions in case the distress associated with the tasks lead their child to become suicidal. As such, these parents may present as disengaged, unmotivated, or even defiant when they are unable or refuse to follow through with treatment recommendations. EFFT clinicians help parents work through these negative emotional states and associated behaviors in several ways. EFFT clinicians can employ the steps of emotion coaching to validate the parents’ fear or self-blame, for example, in the same manner that the clinician will teach the parent to validate those of the child. In some cases, as parents become aware of and feel validated

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about the impact that these emotions have on their parenting behaviors, they feel empowered to follow through with the behavioral coaching and emotional coaching strategies. Parents can also complete various self-assessment questionnaires that help them to identify their emotional blocks as well as any parenting patterns that may be problematic. They are also presented with the New Maudsley’s Animal Models as a nonthreatening way to identify their underdeveloped capacities as well as optimal parenting styles toward which to work (Treasure et al. 2009). If parents continue to struggle to engage in treatment tasks, therapists can work with the parent using an EFFT version of “chair work” (inspired by self-interruptive split in traditional EFT) to identify and work through the parent’s emotional block. The goal of intervening in this way is to loosen the parent from their emotional block in order to get them back on track with supporting their children and resisting the urge to engage in treatment-interfering behaviors. Clinician Blocks Similar to identifying and processing parental emotional blocks, EFFT clinicians identify and work through their own emotional blocks that arise as they provide treatment through “emotion-focused” supervision. For example, well-intentioned therapists may discourage a parents’ active involvement in their child’s treatment if they believed it would interfere with the recovery process. In fact, we have observed that parents of adult children and/or parents who (1) present with high expressed emotion, (2) engage in overt criticism of the child, or (3) display symptoms of a mental health issue or personality disorder are kept on the outskirts of the recovery process. Although there may be valid limitations or concerns about involving parents in treatment, working through the emotions that accompany such cases can open new avenues for working with parents in some fashion. This type of supervision can take place through case discussion, with a focus on the difficult emotions that the clinician is feeling in response to working with the family, completing an emotion-focused questionnaire to identify clinician blocks, and engaging in

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structured “chair work” to regain perspective and empathy for the family as a whole.

Research About the Model Research on EFFT has largely focused on different formats of treatment with parents of children with eating disorders. For example, a two-day EFFT intervention for parents of adolescent and adult children with ED led to healthier attitudes about their children’s emotions and increased parental self-efficacy, a positive shift in parents’ attitudes regarding their role as emotion coach and a reduction in the fears associated with their involvement in treatment, including a decrease in self-blame (Lafrance Robinson et al. 2016). Parents also reported greater intentions to implement strategies to support their child’s recovery that were consistent with the targeted treatment domains. Process research has also been conducted to explore the theoretical underpinnings of EFFT. First, relationships were explored between common emotion blocks and parent outcomes. Specifically, results revealed that both parental fear and self-blame were negatively related to parental self-efficacy and positively related to accommodating and enabling behaviors among parents (Stillar et al. 2016). In other words, the more fear and self-blame that a parent reported, the less empowered they felt about supporting their child in treatment and the more likely they were to engage in accommodating and enabling behaviors. An EFFT process model was then tested in the context of a 2-day EFFT intervention for parents of loved ones with an eating disorder. The results showed that the intervention was effective in decreasing parental fear and self-blame which subsequently led to an increase in parental self-efficacy and an increase in positive intentions to engage in treatment-enhancing behaviors (Strahan et al. 2017). These results underscore the importance of transforming parental fear and low selfefficacy to support parents to become positive and active agents of healing their children’s treatment for mental health challenges.

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A randomized wait-list controlled trial of EFFT for general mental health issues is in progress to examine various parent and child outcomes over time. Preliminary results indicate that the EFFT intervention predicted positive outcomes for both parents and children. The intervention decreased parental fear, increased parental self-efficacy, and led to improvements in children’s emotional and behavioral difficulties. Finally, task analysis research is ongoing to examine the processes through which therapeutic change and resolution occurs via the parental block chair-work intervention.

Case Example Sharon called an EFFT therapist, concerned about her son Jacob, age 16, who had been struggling at school. He had been involved in several fights over the past few weeks. She said that he “probably is depressed” and that she had tried everything to try to motivate him with his school work but nothing was working. She was also worried that he might want to kill himself, even though he denied any suicidal thoughts or urges when questioned directly. Sharon asked the therapist to talk with Jacob and see if he could be helped. The therapist explained that it would be important to meet with her (i.e., mom) as parents can be much more effective in helping their children given the power of the neurological connection between them. Although skeptical at first, Sharon agreed to a trial of six two-hour parent-focused sessions. During the intake session, Sharon shared that she and Jacob’s father, Ryan, had a history of conflict and had recently divorced. Jacob was currently living with his mom and would stay with his dad on most weekends. Sharon listed the many ways she had been trying to help Jacob with his academics (e.g., helping him with his homework; hiring a tutor) but shared that she did not know what to do about him getting into fights. The therapist spent the first session exploring and validating Sharon’s concerns about Jacob’s recent struggles and discussed how his academic and behavioral problems most likely reflected his efforts to cope with emotional distress. The

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therapist introduced to Sharon the concept of the “super-feeler,” and she quickly recognized her son in the description in that he is very concerned about his mother’s well-being and acutely aware of any tension in his environment. The therapist explained to Sharon that children with this profile may consciously or unconsciously suppress their emotional pain, and perhaps out of fear of upsetting their caregivers given that they would then experience both their pain and their parents’ as well. The therapist further explained that due to his age and brain development, it would be very difficult for him to suppress his emotions without eventually acting out in some ways (e.g., outbursts). Upon reflection, Sharon noted that indeed her son reacted in an atypical manner in that he did not cry when informed of the end of his parents’ marriage, and instead acted rather stoically, even asking if he could take on extra chores to help his mother around the house. To further identify systemic variables related to her son’s inclination to deny or suppress emotion, the therapist presented to Sharon the various animal models and she easily identified herself as a jellyfish (emotional) and kangaroo (overprotective). The therapist taught Sharon about the ways in which her own emotional distress might fuel these problematic parenting patterns or styles. The therapist described how it is normal for parents to have concerns and fears when supporting the behavioral and emotional recovery of their children. Sharon completed a self-assessment tool to identify where she might be most vulnerable to these blocks when supporting her son behaviorally and in the processing of his emotions. Not surprising, she scored high on the item “fear of pushing my loved one too far and making symptoms worse.” Sharon then shared that several years ago she had a psychiatric admission for suicidal ideation and that she was terrified that acknowledging her son’s distress would make him feel worse and lead him to feel suicidal as well. She made the connection between these fears and her tendency to back off from talking to him about the family’s challenges. Over the next few sessions, the therapist taught Sharon about the principles and steps of emotion coaching, and they practiced together the

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scenarios she thought would be most challenging (her son’s hopelessness or refusal to share about his anger). Sharon also prepared to deliver a relationship repair intervention regarding the ways in which the divorce was handled, including what she could have done differently, and how she was going to allow for all his feelings – even the unpleasant ones – to the best of her ability. The therapist was sure to explain that the intervention’s objectives were three-fold: (1) validate her child’s experience and strengthen the relationship, (2) prevent the child from blaming himself for the divorce (as so many children do – either unconsciously or consciously), and (3) process and move through her own undeserved selfblame for the path her son’s life had taken. They also discussed how Jacob might respond to the apology and the therapist prepared Sharon to effectively respond to the most common possible reactions: a blast of anger, silence, or a denial. Over the next few weeks, Sharon reported back she had indeed engaged in the planned relationship repair intervention. She said that Jacob first dismissed her apology (i.e., “You didn’t do anything wrong mom! You did the best you could.”), and she was able to recognize his response as denial and respond accordingly by sticking with it and shouldering the burden until he broke down in tears and shared a bit about how much he wanted his parents to “just get along.” He also shared the extent to which he missed his dad but was afraid to share this with his mom in case it hurt her feelings. Sharon felt great about her ability to support her son to open up to her, and she was surprised at how capable she felt to handle all that he shared. She also noted how much more he had shared over those next few days. That being said, Sharon reported that she struggled with setting limits on his behavior. Despite being able to talk to him about the importance of his schoolwork and day-to-day expectations, Sharon described how difficult it was for her to address his inappropriate behavior (e.g., fighting with peers). The therapist took this opportunity to engage Sharon in an emptychair intervention to help Sharon to work through her emotional “block” in raising this

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ongoing issue. In this intervention, Sharon explored and identified her fears of broaching the topic and creating even more conflict between them. She was afraid that if she insisted on discussing the events and the underlying drivers that he feel worse about himself, disengage from the conversation and even the relationship. Her worst fear was that he would run away from home and instead move in with his father. She said that if all of that happened, she would feel like “an absolute failure of a mom.” Through enacting an imagined conversation with her son about these fears, Sharon was able to work through these fears and feel empowered by her love for her son to talk to him about his inappropriate behavior and discuss better ways of dealing with his peers. Sharon reported back several months after therapy had ended that Jacob was again doing well in school and had been getting into very little trouble with his peers. She also reported that she was working much better with her ex-husband as co-parents. And although Jacob still behaved rather typically for a teenage boy when it came to talking about his emotions, she did report that he came to her for advice once in a while and they were able to talk about some of his fears and vulnerabilities. Overall, she felt confident about the way forward.

Cross-References ▶ Adolescents in Couple and Family Therapy ▶ Attachment Theory ▶ Attachment-Based Family Therapy ▶ Bowlby, John ▶ Children in Couple and Family Therapy ▶ Circle of Security ▶ Circle of Security Parenting Enrichment Program ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Family Therapy ▶ Emotion-Focused Therapy for Couples ▶ Empty Chair Technique in Couple and Family Therapy

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▶ Gottman, John ▶ Greenberg, Leslie ▶ Maudsley Family Therapy for Eating Disorders ▶ Primary Adaptive Emotions in EmotionFocused Therapy ▶ Primary Maladaptive Emotions in EmotionFocused Therapy

Emotion-Focused Therapy for Couples Strahan, E. J., Stillar, A., Files, N., Nash, P., Scarborough, J., Connors, L.,. . . Orr, E. S. (2017). Increasing parental self-efficacy with emotion-focused family therapy for eating disorders: A process model. Person-Centered & Experiential Psychotherapies, 16, 256–269. Treasure, J., Schmidt, U., & Macdonald, P. (Eds.). (2009). The clinician’s guide to collaborative caring in eating disorders: The new Maudsley method. London: Routledge.

References Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The process-experiential approach to change. Washington, DC: American Psychological Association. Goddard, E., Macdonald, P., Sepulveda, A. R., Naumann, U., Landau, S., Schmidt, U., & Treasure, J. (2011). Cognitive interpersonal maintenance model of eating disorders: Intervention for carers. The British Journal of Psychiatry, 199, 225–231. Gottman, J. (1997). Raising an emotionally intelligent child. New York: Simon & Schuster Paperbacks. Greenberg, L. S. (2002). Integrating an emotion-focused approach to treatment into psychotherapy integration. Journal of Psychotherapy Integration, 12, 154–189. Greenberg, L. S. (2004). Emotion–focused therapy. Clinical Psychology & Psychotherapy, 11, 3–16. Greenberg, L. S. (2008). Emotion and cognition in psychotherapy: The transforming power of affect. Canadian Psychology, 49, 49–59. Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practice-friendly research review. Journal of Clinical Psychology, 62, 611–630. Lafrance Robinson, A., Dolhanty, J., & Greenberg, L. (2013). Emotion-focused family therapy for eating disorders in children and adolescents. Clinical Psychology & Psychotherapy, 22, 75–82. Lafrance Robinson, A., Dolhanty, J., Stillar, A., Henderson, K., & Mayman, S. (2016). Emotionfocused family therapy for eating disorders across the lifespan: A pilot study of a 2-day transdiagnostic intervention for parents. Clinical Psychology & Psychotherapy, 23, 14–23. Maliken, A. C., & Katz, L. F. (2013). Exploring the impact of parental psychopathology and emotion regulation on evidence-based parenting interventions: A transdiagnostic approach to improving treatment effectiveness. Clinical Child and Family Psychology Review, 16, 173–186. Stillar, A., Strahan, E., Nash, P., Files, N., Scarborough, J., Mayman, S., . . . & Marchand, P. (2016). The influence of carer fear and self-blame when supporting a loved one with an eating disorder. Eating Disorders, 24, 173–185.

Emotion-Focused Therapy for Couples Rhonda N. Goldman1 and Irene C. Wise2 1 Illinois School of Professional Psychology, Argosy University, Chicago, IL, USA 2 Illinois School of Professional Psychology at Argosy University, Schaumburg, IL, USA

Name of Model Emotion-Focused Therapy for Couples

Synonyms EFT-C

Introduction Emotion-focused therapy for couples (EFT-C) is a person-centered and empirically supported treatment model for couples in distress. EFT-C can also be applied with nondistressed couples seeking to deepen intimacy and improve the quality of their interactions. The premise of EFT-C is that affect regulation organizes couple dynamics and is the core motivation for coupling. Using a blend of systemic and experiential concepts and techniques, therapists employing EFT-C enhance affect regulation in the relationship by first helping couples replace their negative relational cycles with positive ones and then fostering each partner’s ability to self-soothe. Problematic interactional cycles are transformed by each partner accessing vulnerable emotions in the presence of

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the other. Guiding the couple to focus on their negative relational patterns also has the advantage of reducing the tendency of blaming the other partner for relational difficulties. When partners are able to receive, support, and validate each other’s primary emotional experiences, transformation can occur. Healing and bonding events occur through the sharing and soothing of each partner’s primary vulnerable emotions. In addition, working through of attachment and identity injuries leads to healing through processing of unprocessed primary vulnerable emotions. Moreover, enhancing each partner’s ability to selfsoothe also leads to healing and can reduce pressure on partner’s to be the sole source of affect regulation. The relationship is thus strengthened, distress lowered, and mutual feelings of connection and closeness increased.

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experience and how they make sense of their world. Emotion schemes are, in essence, internal, learned, and laid down in emotion memory structures. Unlike schemas, emotion schemes are not static or merely conceptual; rather, they can be viewed as an ongoing, moment-to-moment, selforganizational processes that unite emotion with an action tendency (Elliott et al. 2004). These action-oriented processes also encompass immediate awareness, episodic memories, bodily sensations, language symbolizations, and embedded needs and desires. An emotion scheme is activated by its corresponding emotion that arises in response to unmet needs or concerns (Greenberg and Watson 2006). The action tendency embedded in an emotion scheme motivates an individual to pursue the desires and satisfy the needs associated with the emotion scheme. In this way, EFT conceptualizes that emotions are necessary for motivation.

Prominent Associated Figures The original formulation of EFT-C was developed in the mid-1980s by Les Greenberg and Sue Johnson (Greenberg and Johnson 1988). Subsequently, Greenberg and Johnson have independently modified the formulation of EFT-C, resulting in two different, but related, protocols. Johnson’s Emotionally Focused Couple Therapy emphasizes attachment as the organizing principle of couples’ behavior (Johnson 2004). Emotion-Focused Therapy for Couples (EFT-C), further developed by Les Greenberg and Rhonda Goldman, posits that affect regulation drives the relational dynamics of couples and governs motivation through the subsystems of attachment, identity, and attraction (Greenberg and Goldman 2008). In addition, Greenberg and Goldman have further incorporated individual process in the context of couples therapy, recognizing, for example, that while an overall goal may be to promote partners soothing each other, at times, selfsoothing is an important process.

Theoretical Framework Emotion-focused therapy (EFT) posits that “emotion schemes” guide and organize people’s

The Effect of Motivational Dimensions on Relational Dynamics EFT-C posits that affect regulation is the core motivation that leads individuals to seek intimate relationships. Greenberg and Goldman (2008) define affect regulation as the process of increasing desired emotions while simultaneously decreasing unwanted ones. According to EFT-C, affect is regulated with a partner, along one or more of the following dimensions: attachment, identity, and attraction. As such, these dimensions become motivational systems that define the tone and nature of a couple’s relationship. Both attachment and identity systems are considered more fundamental than the attraction system although the attraction system is seen as distinct from the attachment system. Attachment is seen as slightly more fundamental than the identity system, although identity is an important and sometimes neglected system in conceptualization and treatment of couples. A breakdown in any one of these motivational dimensions leads to tension between the partners. In addition to the relational bond providing a means of affect regulation, each partner may also engage in self-regulation of affect. Again, a breakdown in this type of self-regulation may also negatively impact the relationship.

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When both mutual regulation and self-regulation of affect are impaired, couple conflict ensues (Goldman and Greenberg 2013). Marital dissolution occurs when the relationship no longer provides effective affect regulation and the partners no longer express and respond to affect from the other.

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provoke efforts to control or dominate. Therefore, the identity dimension expresses itself in couple dynamics as degree of influence ranging from dominant to submissive. A partner who operates out of the dominance pole may attempt influence or control his or her partner. In contrast, a submissive partner tends to yield, submit, or enmesh with the other partner.

Attachment Dimension

For infants with their caregivers as well as for romantic pairs, attachment bonds are characterized by a person maintaining proximity to her attachment figure, feeling distress when separated from him, and using her attachment figure as a safe haven and base for exploration (Bowlby 1988; Hazan and Shaver 1987). By forming an attachment with another, individuals regulate their affect through finding security in the relationship with their partners. A healthy attachment cycle expressed within a couple is characterized by the expression of fear and anxiety in one partner and the subsequent offer of nurture and comfort in the other. Anxiety, feelings of loneliness, or a sense of abandonment may arise in an individual if his or her partner is not physically or psychologically present. To regulate these distressing emotions via the attachment subsystem, the individual may either approach the partner to experience connection or nurturance, or the individual may temporarily disengage from the partner in order to selfsoothe. These two differing responses to attachment anxiety represent the two opposite poles of the attachment dimension, namely, seeking closeness and distancing. Identity Dimension

The identity or influence subsystem is important for the development of self-esteem, selfcoherence, and mastery. Positive emotions related to identity include interest and pride. A healthy identity system is associated with appropriate assertion, setting boundaries, and feeling recognized. A sense of shame, powerlessness, or anger occurs when identity has been invalidated or diminished. Within a couple, expressions of shame or powerlessness in one partner may elicit a soothing response of empathy and validation in the other partner. Furthermore, threats to identity

Attraction Dimension

The characteristics of the attachment dimension taps into neurological reward pathways. For couples, the attraction dimension fosters positive feelings in each other such as joy and love and expressions of warmth, fondness, liking, and sexual excitement. In addition to promoting bonding, the attraction dimension is necessary for relationships to flourish and maintain longevity. EFT-C therapists can leverage this dimension to regulate the emotions through increased joy and love by encouraging the couple to express warmth and liking to each other. Relational Cycles

Greenberg and Goldman (2008) have developed a model to describe verbal and nonverbal couple interactions based on the motivational systems used to soothe affect. First, the authors observe that each partner in a couple interacts in a reciprocal manner where one partner’s reaction evokes a complementary reaction in the other. Next, Greenberg and Goldman map these reciprocal responses along two dimensions, affiliation and influence. For romantic relationships, the affiliation axis incorporates the motivational dimensions of attachment and attraction, and the influence axis represents the identity motivational subsystem. This model implies that couples develop positive and negative interactive cycles through both the reciprocal nature of their interactions and their drive to regulate affect with each other via the motivational subsystems. A harmonious relationship develops when each partner is aware of his or her emotions, can communicate these feelings and the associated needs to his or her partner, and have the partner respond to these needs in an appropriate manner. For example, if an individual expresses self-doubt

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and shame to his partner (mapped along the influence axis of the model), the expression of empathy and validation from his partner comforts and may boost the self-esteem in that individual. When a partner is unavailable or cannot respond in the hoped for manner, relational harmony is compromised or challenged. Relational harmony disintegrates when partners cannot find ways to soothe their affect, either with each other or by themselves. Because of the reciprocal nature of couple dynamics, a negative interaction cycle can develop in one or more motivational systems as partners reactively attempt to address their unmet attachment or identity needs. Both partners in a couple may feel distress arising from unmet needs in the affiliation dimension of the relationship, or both may experience deficits in the influence dimension. Greenberg and Goldman (2008) have also identified mixed-dimension cycles where one partner operates out of needs from the affiliation dimension and the other from the influence dimension. Another type of mixeddimension cycle occurs when each partner reacts out of mixture of identity and attachment needs. Relational cycles are kept in place by the expression of one of the four types of emotions identified in EFT (Elliott et al. 2004). Primary adaptive emotions are the appropriate and evolutionary adaptive emotional response to a stimulus. For example, fear automatically signals danger and prepares a person to fight or take flight from the situation. In the context of couple interaction, primary adaptive emotions elicit an appropriate response from the partner, and therefore help maintain positive interactional cycles. Primary maladaptive emotions, found at the core of maladaptive emotion schemes, are also automatic but are overlearned responses to formative situations that are no longer adaptive for a particular situation. For example, a frightened child may have learned to hide from a verbally abusive parent in order to feel safe. When the child grows up, she may still have a disproportionate level of fear when her partner argues with her, causing her to withdraw from him physically and emotionally. The third type of emotions – secondary reactive emotions – are reactions to primary emotions, whether adaptive or maladaptive. The function

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of secondary reactive emotions is to replace or obscure difficult primary emotions. For example, an individual may exhibit reactive anger to cover unacceptable feelings of vulnerability when criticized by his partner. Finally, a person uses instrumental emotions to consciously or unconsciously control others. For example, one partner may burst into tears in order to avoid a difficult conversation. Negative relational cycles are maintained by secondary reactive, maladaptive, and instrumental emotions triggered in each partner by the other partner. A common negative interaction cycle along the affiliation dimension is the pursue-distance pattern where partner A’s unmet attachment needs for closeness lead her to pursue her partner through requests, appeals, or demands for more attention or intimacy. Partner A’s bids for closeness may appear to her partner as criticism, blaming, or even condemnation. These negative perceptions in partner B of partner A’s pursuit lead him to withdraw in order to protect himself and regulate his affect. As partner B withdraws, Partner A’s need for closeness becomes even more activated and she increases her attempts to connect with partner B. He then feels even more threatened and therefore withdraws further thereby deepening and perpetuating the pursue-distance cycle. The pursue-distance conflict may be resolved by helping each partner contact his or her underlying attachment related fear, anxiety, or sadness. The partner’s expression of these vulnerable feelings, which are primary emotions, replace the secondary reactive expressions of anger or contempt which fueled the negative cycle. The other partner then continues the development of a positive relational cycle by responding to these vulnerable primary emotions with caring and comfort. Negative interaction cycles along the identity/ influence axis generally fall into a pattern of leadfollow where one partner is dominant and the other is submissive. In this cycle, both partners have maladaptive feelings of fear or shame related to his or her identity. The dominant partner manages her feelings of shame and inefficacy by seizing control and projecting her own sense of weakness onto her partner. By accepting his partner’s dominance, the submissive partner deals

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with his identity-related shame by abdicating responsibility so that he cannot be blamed for any ensuing negative outcomes. Over time, the dominant partner becomes more protective of her position while the submissive partner becomes afraid to make mistakes or decisions and thus ends up feeling discounted and invalidated. The submissive partner may feel unhappy and wish to dissolve the union with his partner. Conflict resolution in such a cycle along the influence axis involves the dominant partner expressing her primary underlying fear and shame rather than her secondary reactive anger or rage. As the dominant partner processes these maladaptive emotions, she will build a sense of adequacy as she uncovers primary emotions such as assertive anger or grief and expresses the needs associated with these emotions. As the urge to control diminishes in the dominant partner, the submissive partner will also process his shame or fear and get in touch with his primary anger or pride, which in turn leads him to gain confidence as he asserts his needs for validation and recognition. His partner’s soothing response of empathy and validation deepens the couple’s new positive relational cycle. Theory of Change

Emotions regulate individual functioning and organize couples’ interactional cycles. Emotionfocused therapy in general (Elliott et al. 2004) and Emotion-focused couple therapy specifically (Greenberg and Goldman 2008; Goldman and Greenberg 2013) describe different types of emotions that seen in therapy. Primary emotions can be either maladaptive or adaptive and are seen as core emotions driving interactional cycles. Examples of adaptive emotions are sadness in relation to loss and anger in relation to boundary violation. Maladaptive emotions are adaptive emotions that have been associated with negative learning experiences. Maladaptive emotions are at the core of maladaptive cycles or patterns that couples engage and that typically bring them to therapy. Examples are many, but typically maladaptive core emotions are shame, fear, and sadness of lonely abandonment. Secondary emotions hide or cover primary emotions and typical ones seen

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in couples are blaming, anger, and withdrawal. Therapists must work to de-escalate cycles by getting underneath secondary emotions to primary emotions. Instrumental emotions are unconsciously learned and expressed but have an interpersonal effect such as crying to garner sympathy or anger to push others away. Instrumental emotions must be brought to awareness and their primary aim understood. In EFT-C, therapeutic change occurs when partners access and express primary emotions to each other. Couples resolve relational conflicts by stepping out of their vicious cycles and truly accepting themselves and their partners. The EFT-C therapist helps couples recognize the maladaptive, secondary reactive, and instrumental emotions that keep their negative interactional cycles in place. The roots of these maladaptive emotions often predate the couples’ union. Empathy and validation is facilitated when partners realize that they are not to blame for the historical origins of their partners’ maladaptive patterns of relating. Negative cycles are interrupted when each partner can express vulnerable primary emotions related to primary attachment and identity needs. Attachment needs include bids for closeness and comfort while expressing abandonment fear or sadness. Identity needs include validation and acceptance by the other partner as the individual expresses shame or powerlessness. These identity needs and the accompanying shame may not be resolved in the context of the couple’s relationship because the core maladaptive emotion scheme is rooted in unmet childhood needs. In such cases, the couple’s relational pattern can be improved by working with the injured partner to address her unmet childhood needs and enhance her capacity to self-soothe.

Populations in Focus EFT-C is ideal for committed couples experiencing relational dissatisfaction, difficulties, or distress. EFT-C may also be successfully applied with couples who have experienced an emotional injury such as infidelity, betrayal, or neglect during time of critical need. EFT-C has also been

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specifically developed for work with such populations (Greenberg et al. 2010). Ethnically diverse partners, LGBTQ couples, as well as those facing a variety of mental health issues including depression, anxiety, or chronic stress have also benefited from this approach. EFT-C should not be employed when there is domestic violence in the relationship.

Stage 1: Validation and Alliance Formation

Strategies and Techniques Used in the Model

Stage 2: Negative Cycle de-Escalation

The primary aim of EFT-C is to restructure the distressed couple’s emotional bond (Goldman and Greenberg 2010). EFT-C has three basic intervention strategies to meet this goal. First, the EFT-C therapist tracks interactional cycles and reflects these patterns back to the couple. Second, as the couple becomes aware of their patterns, the EFT-C therapist reframes the couple’s issues as a problem with the negative cycle. Viewing the cycle as the problems helps couples externalize their issues and reduces the tendency for the partners to blame each other for their problems. Finally, EFT-C utilizes enactments of emotional engagement, bonding, and validating comments to shape and consolidate the couple’s interactions. The second goal in EFT-C treatment is to enhance each partner’s expression and selfregulation of core maladaptive emotions based unmet childhood needs and unfinished business with significant others. Self-soothing, when required, also helps to restructure emotional bonds and stabilize the positive changes in the couple’s interactional cycle. Stages of EFT-C Therapy Greenberg and Johnson have independently modified the original model for EFT-C intervention (Greenberg and Johnson 1988). Greenberg and Goldman (2008) formulated the five stages of EFT-C treatment described below. The first stage, validation and alliance formation, remains relevant throughout the therapy process. Over the course of therapy, stages may overlap, several stages may be revisited, and progress may proceed in a nonlinear fashion.

During this first stage, the therapist fosters a sense of safety and works to establish a collaborative alliance with the couple. She bonds with each partner by validating concerns and empathizing with underlying pain. The therapist also notes the conflict areas and assesses how these problems reflect the unmet attachment or identity needs of each partner.

The goal of the second stage of EFT-C is to reduce the emotional reactivity between the couple. One way of meeting this goal is for the therapist to externalize the couple’s issues onto the negative relational cycle. The therapist also helps each partner explore previously unacknowledged emotions related to unmet attachment or identity needs and points out how these feelings contribute to the couple’s dynamics. Increased understanding is fostered by exploring the historical origins of each partner’s vulnerabilities and sensitivities. The second stage concludes after the couple understands that their problems are attributed to a negative relational cycle triggered by core vulnerable emotions having their roots in unmet attachment and identity needs. Stage 3: Accessing Underlying Feelings

The third stage in EFT-C focuses on each partner accessing, revealing, and experiencing his or her underlying feelings associated with unmet attachment or identity needs. As the partners own and express previously unacknowledged vulnerable feelings to each other, the couple’s relational dynamics change as safety is created between them. This safe atmosphere sparks empathy between the couple, resulting in more freedom to ask the other for help in meeting core needs. To facilitate this process, the therapist also identifies and helps resolve any emotional blocks in either partner by shifting to individual work in the presence of the other. As this stage progresses, the EFT-C therapist continues to help the partners identify and integrate into their interactions any remaining unmet needs or disowned aspects of the self.

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Stage 4: Restructuring the Negative Interaction

In the fourth stage, the therapist helps the couple restructure their negative interactional cycle by helping each partner respond to revealed emotions with validation and acceptance. If one or both partners cannot accept the other, the therapist helps the individual access, explore, and transform these maladaptive emotional blocks. As each partner becomes more open to the other, the therapist guides the couple in enacting new ways of adaptively interacting with each other by restructuring deeper levels of emotional processing. For example, the therapist may work on helping one partner soften her internalized critic. Rather than reacting to her partner with angry attacks, the softened critic allows this partner to reveal her anxiety over her partner’s absence and ask for comfort. Her partner, in turn, no longer feels the need to protect himself by withdrawing from his partner’s anger and therefore can now be more responsive to his partner. Healing or bonding events occur through the sharing and receiving of core primary emotions, and the negative interaction is restructured. By the end of the fourth stage, each partner’s maladaptive emotion schemes are transformed into primary adaptive emotions, out of which each partner can express his or her needs and desires. Once the partners are no longer reactive towards each other, the therapist introduces self-soothing strategies to be used when the other partner is unavailable or unable to respond. Stage 5: Consolidation and Integration

The goal of the fifth and final stage of EFT-C is to consolidate and integrate the couples’ new and positive interaction cycle. The therapist facilitates a discussion with the couple on how to prevent a negative interactional cycle from redeveloping as well has how to strengthen their positive interactions. The therapist also recaps how the negative relational cycle has been transformed and points out growth in each partner and the relationship. The work of EFT-C concludes when the couple creates a revised narrative for their relationship that incorporates their areas of growth and their positive relational cycle.

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Research About the Model Research in EFT-C has generally explored the process of change and investigated treatment efficacy. For example, EFT-C’s premise of revealing underlying feelings to resolve conflict in couples was empirically supported in the treatment of general couple distress (Johnson, Hunsley, Greenberg, and Schindler, as cited in Meneses and Scuka 2015), resolving emotional injuries (Fisher, as cited in Meneses and Scuka 2015), promoting forgiveness via the expression of shame (Meneses and Greenberg 2011), and fostering mutual sharing of needs (Greenberg and Johnson, as cited in Meneses and Scuka 2015). Other studies support EFT-C’s assertion of the importance of self-regulation to improve relational dynamics. For example, research by Greenberg and Johnson (as cited in Meneses and Scuka 2015) revealed that softening a harsh inner critic of one partner led to a more positive relational cycle. Many research studies have provided empirical support for EFT-C being an effective treatment for couple distress. For example, compared to waitlisted controls and standard behavior couple therapy, EFT-C was found to have a large treatment effect and superior outcomes in enhanced intimacy and marital adjustment (Johnson and Greenberg, as cited in Meneses and Scuka 2015). Goldman and Greenberg (1992) found that EFT and integrated systems therapy had similar positive outcomes for severely distressed couples in conflict resolution and goal attainment, but EFT yielded slightly higher relapse rates. Additionally, Greenberg et al. (2010) found that EFT-C was effective in promoting forgiveness and lowering marital distress in couples dealing with infidelity, betrayal, and other emotional injuries. In their meta-analysis, Johnson and her colleagues (1999) found a very large effect size for EFT-C of 1.3 and a 70–73% recovery rate from relational distress.

Case Example Shari and Andy come to therapy saying they want to heal past wounds and stop escalating conflict that seems to be leading to daily fights.

Emotion-Focused Therapy for Couples

The therapist initially works on forming an alliance with the couple and validating each partners’ concerns and underlying pain and distress. She also clarifies that they are committed to healing and working toward change together. The therapist initially gets a sense of what brought the couple together initially and what sustains their relationship. Andy is and continues to be attracted to Shari’s “joie de vivre,” high energy, affection, and warmth. Shari is attracted to Andy’s drive, determination, stability, and certainty. After a few sessions, after hearing much about Andy and Shari’s regular disputes and conflicts and assessing each partner’s role, emotions, and behaviors at the source of them, the therapist has a much stronger understanding of what the negative maladaptive cycles. Essentially, Shari is the one who pursues for closeness and affection and when turned away feels rejected, sad, and lonely. Core sadness of lonely abandonment is triggered and takes over Shari’s world. While Shari experiences sadness of lonely abandonment often and is able to share and express it in therapy, outside of the sessions, and while engaged in escalating conflicts, Shari does not in fact express such primary emotions but rather expresses blame, contempt, and criticism toward Andy, claiming he is robotic, unavailable, incapable of love and affection, and completely inept at taking care of their two children and completing any tasks or chores around the house even when asked repeatedly. Andy in turn, feeling criticized, tends to withdraw, only fueling Shari’s contempt and blaming anger further. This in turn leads Andy to further withdraw. By the end of stage 2, the therapist and the couple both have a sense of the cycle, how it gets started, how it escalates (with blaming, contemptuous anger, and withdrawal and each partner’s part, respectively), and what the underlying emotions are that drive it (Shari’s sadness of lonely abandonment and Andy’s shame). Therapist and the couple have also identified that Shari’s sadness of lonely abandonment has a source in her experience growing up of being lonely and feeling emotionally neglected by both parents and peers. Andy, on the other hand, was continuously criticized and shamed by a critical, harsh father. The source of the core

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maladaptive emotions was understood by therapist and partners. Through the therapy process, the therapist is able to help the couple get to core emotions. This is aided by the use of empathic conjectures and explorations that help each partner explore underneath secondary emotions driving the negative interactional cycles and deepen core primary maladaptive emotions. Through this process needs embedded within primary emotions are also accessed and expressed. “Blocks” were hit in the expression of primary emotions and needs that often got represented as “walls” that had been built for good reasons (based on each partner’s past wounds developed in childhood, and life prior to the relationship, and wounds brought on by each other). The walls were also reframed as “survival strategies” that secured and protected each partner but also contributed to distress and prevented healing and emotional intimacy. When walls were both conceptualized and understood but then breached or to some extent taken down, and primary emotions and needs expressed, the therapist facilitated Shari and Andy to respond to each other’s expression of core primary emotions. This helped create bonding and closeness. Later in therapy, the therapist also engaged in a selfsoothing dialogue with Andy within the session, with Shari present, wherein Andy was able to soothe the inner child who was always seeking approval from his father and coming up short, feeling as a result chronically inadequate. In the inner dialogue, however, a more adult, parental part of Andy was able to soothe the child who missed feeling recognized and loved unconditionally. By the end of therapy, the couple felt much closer and more connected. Negative cycles could be identified and understood and positive cycles could be enacted and expressed. When conflicts or ruptures occurred they were much more able to speak from and express core primary emotions of sadness related to lonely abandonment and shame. Each felt more compassionate and sensitive to the other’s core wounds and able to soothe their partner when necessary and self-soothe when the other was not available.

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Cross-References ▶ Greenberg, Leslie ▶ Instrumental Emotional Response in EmotionFocused Therapy ▶ Primary Adaptive Emotions in EmotionFocused Therapy ▶ Primary Maladaptive Emotions in EmotionFocused Therapy ▶ Restructuring the Bond in Emotion-Focused Therapy ▶ Secondary Reactive Emotions in EmotionFocused Therapy ▶ Softening in Emotion-Focused Therapy ▶ Stabilization in Emotion-Focused Therapy

References Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books. Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The process-experiential approach to change. Washington, DC: American Psychological Association. Goldman, A., & Greenberg, L. (1992). Comparison of integrated systemic and emotionally focused approaches to couples therapy. Journal of Consulting and Clinical Psychology, 60(6), 962–969. Goldman, R. N., & Greenberg, L. S. (2010). Self-soothing and other-soothing in emotion-focused couples therapy. In A. S. Gurman (Ed.), Clinical casebook of couples therapy (pp. 255–280). New York: Guildford Press. Goldman, R. N., & Greenberg, L. S. (2013). Working with identity and self-soothing in emotion-focused therapy or couples. Family Process, 52(1), 62–82. Greenberg, L. S., & Goldman, R. N. (2008). Emotionfocused couples therapy: The dynamics of emotion, love, and power. Washington, DC: American Psychological Association. Greenberg, L. S., & Johnson, S. M. (1988). Emotionally focused therapy for couples. New York: Guilford Press. Greenberg, L., Warwar, S., & Malcolm, W. (2010). Emotion-focused couples therapy and the facilitation of forgiveness. Journal of Marital and Family Therapy, 36(1), 28–42. Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression. Washington, DC: American Psychological Association. Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52(3), 511.

Empathy in Couple and Family Therapy Johnson, S. M., Hunsley, J., Greenberg, L. S., & Schindler, B. (1999). Emotionally focused couples therapy: Status and challenges. Clinical Psychology Science and Practice, 6, 67–79. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed.). New York: Brunner-Routledge. Meneses, C. W., & Greenberg, L. S. (2011). The construction of a model of the process of couples’ forgiveness in emotion-focused therapy for couples. Journal of Marital and Family Therapy, 37(4), 491–502. Meneses, C. W., & Scuka, R. F. (2015). Empirically supported humanistic approaches to working with couples and families. In D. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed., pp. 353–386). Washington, DC: American Psychological Association.

Empathy in Couple and Family Therapy Johanna Strokoff University of Illinois at Chicago, Chicago, IL, USA

Name of Concept Empathy in Couple and Family Therapy

Introduction A pioneer regarding the utilization of empathy in psychotherapy, Carl Rogers (1957) defined empathy as “to sense the client’s private world as if it were your own,” without the clinician’s personal judgments muddling the client’s experience (p. 99). Rogers posited that empathy was an essential driving force for behavior change, and indeed, substantial subsequent research has demonstrated the magnitude of empathy on the therapeutic process. Therapists’ use of empathy has been strongly associated with the therapeutic alliance, which is commonly referred to as one of the most significant contributors to treatment outcomes (Nienhuis et al. 2016). Distinguished from sympathy, which is defined as one’s personal reaction of concern and/or compassion towards another, empathy involves mirroring

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another’s feelings and perspectives (Stueber 2013). While both components are useful agents for therapeutic change, this chapter will focus the power of empathy to propel couples and families towards greater safety, emotional connection, and treatment success.

Theoretical Context for Concept Multiple theories contend that emotional awareness and expression is paramount for our wellbeing and maintaining healthy connections with others. For instance, Affect Phobia (i.e., a shortterm psychodynamic modality; McCullough et al. 2003) highlights how attunement to one’s emotional experience drives behaviors that lead to personal fulfillment. However, when engrossed in environments that discourage emotional expression, painful emotions may be suppressed, often resulting in problematic consequences such as experiencing depression, anxiety, and guardedness within interpersonal relationships. Thus, with relationships lacking empathy and emotional support, individuals may experience an insufficient sense of safety and intimacy required to sustain emotional bonds within families and romantic partners. In contrast, when emotionally supported and accepted by others, people flourish. Emotion-focused theory (EFT; Elliott et al. 2004) emphasizes the importance of feeling understood, particularly when experiencing intense emotions. Feeling listened to and accepted by others allows individuals to in turn internalize more nurturing, accepting self-concepts, while increasing trust that relationships provide stability and comfort. Thus, demonstrating empathetic listening provides clients with an immediate sense of relief, encourages insight surrounding deeper, unrecognized affect, and models a new way of healthy interpersonal relatedness.

Description Utilizing empathetic techniques in psychotherapy requires the therapist to intensely listen to the

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client, being attuned to subtle changes within session (Elliott et al. 2004). The goal is to connect to the client’s internal experiences, reflecting one’s understanding of what the client is expressing. Elliot et al. (2004) recommends that clinicians are to refrain from directly repeating back what they have heard, but rather provide reflections derived from their internal experience as they are connecting to their client’s emotional state. Further, therapists are to resist the urge of attaching their personal opinions or values with empathetic statements and instead relentlessly aim to align with the client’s experience. Empathy can be expressed through one’s tone and word choice, along with nonverbal communication (e.g., body language). Clinicians are encouraged to provide concise interventions, allowing ample time for client’s to speak, and continually provide empathetic statements to build and maintain a sense of stability and safety in the therapeutic dyad (Elliot et al. 2004).

Application of Concept in Couple and Family Therapy Couple Therapy While empathy is recognized as a central component in most clinical approaches (Elliot et al. 2004), it can be especially impactful with couple and family therapy where relatedness and encouragement of emotional expression is highlighted. Emotionally Focused Couple Therapy (Johnson 2004) underscores the importance of secure relational bonds, rooted in attachment theory, to instill a sense of safety and connectedness within the couple. Couples entering therapy commonly demonstrate rigid, negative dynamics that prevent opportunities for emotional vulnerability and understanding. Without couples feeling safe to disclose their longings and needs (e.g., desire for acceptance, wish for love), couples may externalize their hidden needs (e.g., arguing about bills) and respond harshly to each other. Through these negative interpersonal cycles, couples become more polarized with their critical views of each other and continue fostering a dynamic that symbolizes emotional threat (Johnson 2004).

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It is through empathy that therapists can actively accentuate, dismantle, and reorganize a couple’s destructive pattern. Through conveying empathy towards partners, the therapist can experientially model emotional attunement and the bond that forms from being understood, while also instilling trust about the therapeutic process (Johnson 2004). Similarly, through encouraging emotional vulnerability, partners will naturally want to comfort and protect one another, as opposed to inflicting more emotional damage. As couples create a new interactional style of listening, reflecting, and supporting one another, a great sense of connection and intimacy ensues. Indeed, Johnson (2004) described that successful EFT couples therapy allows “each partner becomes a source of security, protection, and contact comfort for the other” (p. 10). Family Therapy Families often enter into therapy with fears about the therapeutic process, with members exhibiting differing levels of engagement, displaying tendencies to remain blinded by their own emotional needs, and lacking awareness of the needs of those around them (Nichols 1987). Families who lack connectedness and safety may keep their emotions hidden from others, defending themselves from loved ones. That type of emotional secrecy prevents family members from understanding each other and, subsequently, supporting each other. Therapists can identify unexpressed, hidden experiences within families, with the ultimate goal of having family members illustrating empathy and understanding toward one another. As family members display empathy toward each other, they convey openness to future dialogue about challenges and acceptance of each other’s experience (Nichols 1987). It is inevitable for families to experience times of turmoil, resulting in feelings of disappointment and potentially unresolved resentment. The path to healing involves emotional awareness regarding these infractions for those who inflicted pain and those who have been injured. Hill (2010) discusses the interplay between empathy and forgiveness as a way to repair emotional ruptures. In particular, prior to forgiving others, family

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members may need to recognize and humanize their loved ones’ missteps in order to understand and align with those who have hurt them. Encouraging family members to explore and connect with each other’s emotional experiences can set a powerful stage for making amends.

Clinical Example Marcos a self-identified, 36-year-old, Latino, gay man and Will a self-identified 38-year-old, African-American, gay man have been dating for 2 years and moved into together 6 months ago. They began couple therapy 2 months ago due to an increase in verbal arguments and emotional distance. The couple commonly discusses difficulties with Marcos’ hectic work schedule and Will’s resentment over being responsible for daily household responsibilities (e.g., cleaning, paying bills). Marcos reports that he often feels that Will nags him, resulting in wanting to “shut down” and walk away. Will states that Marcos avoids discussing his feelings and, consequently, feels responsible to initiate conversations about their relationship. The interaction below illustrates how therapist utilizes empathy to deepen session content and enhance an emotional understanding within the couple. Will: I just don’t understand why it’s so hard to leave the office by 6:30pm. He knows it drives me crazy. We had to reschedule plans twice last week, and I hate doing that to our friends. It’s very inconsiderate, and he doesn’t care! Therapist: Will, I can sense you are very upset about this. Let’s slow down so we can understand how you are feeling. As you are discussing this concern, what feelings are you experiencing? Will: Well, I feel irritated and helpless, like there’s nothing I can do to get through to him. When I’m waiting for him at home, I get more and more angry. And, it’s sad to be waiting all alone. Therapist: I hear you saying that there’s an ache of loneliness when you are waiting for him alone. It sounds very vulnerable to wonder when he’ll be home and feeling like you have no control over that. Will: Yes, very lonely. Even though I know he’ll be home any minute, a part of me can’t help but wonder if he doesn’t want to come home. Doesn’t want to be with me.

Empathy in Couple and Family Therapy Therapist: It’s as though there is a lot of fear and pain that maybe he does not love you, that maybe he will leave you. You so badly want him to stay. Is that right? Will: (responds softly) Yes, that’s it.

As therapist reflects Will’s feelings, Will acknowledges more painful affect hidden under emotions that are easier to access like frustration and anger. The therapist then invites Marcos to share his understanding of Will’s experience, thereby encouraging Marcos to mirror a similar expression of empathy towards Will. Therapist: Marcos, I’m wondering if you could tell Will what you are hearing him say? Marcos: (turns towards Will) I hear you saying that you have a lot of fear and anxiety waiting for me to come home. I had no idea. I just thought you were angry that I wasn’t contributing enough to the relationship. Therapist: Marcos, how did it feel to listening to Will’s experience feeling vulnerable and afraid you may leave him? Marcos: It felt horrible. I would never want him to feel that. I want him to trust our relationship and be able to feel safe with me. Will: I do feel safe, but I guess I need to hear that more often from you.

Marcos and Will intuitively engage in more supportive dialogue once the conversation becomes more vulnerable and emotionally open. Therapist now shifts attention to Marcos utilizing emotion-focused techniques and empathy to encourage further emotional exploration. Therapist: Marcos, can you share more about your experience coming home late and feeling like you aren’t contributing enough to the relationship. Marcos: It’s hard for me when Will is upset. I feel like I can’t do enough to please him, like no matter what, I’m going to get yelled at. So, when that happens, I kind of freeze. Therapist: Sounds like you feel you aren’t good enough, like you keep failing. Does that fit with your experience? Marcos: It does. I want to be a good partner, but I keep messing it up. It’s awful. Therapist: I’m hearing a lot of pain in your voice. It’s like you desperately want to be there for Will, but when you feel like you are disappointing him, you become overwhelmed and feel panicked.

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Through this type of emotional exploration, Will and Marcos gain a better understanding of the emotions underlying their arguments, thereby allowing them to have more meaningful conversations and feel a stronger emotional connection to each other. As safety builds within the therapeutic triad, the therapist can continue to deepen their work, exploring the origins of their fears (e.g., fears of inadequacy, fears of abandonment) and illustrating how they can comfort and help their partner heal with these concerns.

Cross-References ▶ Affect in Couple and Family Therapy ▶ Circle of Security: “Understanding Attachment in Couples and Families” ▶ Emotion in Couple and Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Emotion-focused Therapy for Couples ▶ Family Secrets ▶ Modeling in Couple and Family Therapy

References Elliott, R., Watson, J., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion focused therapy: A process experiential approach to change. Washington, DC: American Psychological Association. Hill, E. W. (2010). Discovering forgiveness through empathy: Implications for couple and family therapy. Journal of Family Therapy, 32, 169–185. Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed.). New York: Brunner-Routledge. McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. L. (2003). Treating affect phobia: A manual for short-term dynamic psychotherapy. New York, NY: Guilford Press. Nichols, M. P. (1987). Self in the system: Expanding the limits of family therapy. New York: Brunner-Routledge. Nienhuis, J. B., Owen, J., Valentine, J. C., Black, S. W., Halford, T. C., Parazak, S. E., . . . Hilsenroth, M. (2016). Therapeutic alliance, empathy, and genuineness in individual adult psychotherapy: A meta-analytic review. Psychotherapy Research, published online 7 July 2016, 1–13. https://doi.org/10.1080/10503307.2016.1204023 Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Stueber, K. R. (2013). Empathy. In Encyclopedia of sciences and religions (pp. 723–727). Dordrecht: Springer.

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Empty Chair Technique in Couple and Family Therapy Amy D. Smith1 and Kelley Quirk2 1 Marriage and Family Therapy/Applied Developmental Science Program, Colorado State University, Fort Collins, CO, USA 2 Marriage and Family Therapy Program, Human Development and Family Studies, Colorado State University, Fort Collins, CO, USA

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2010; Yontef 1999). Field theory refers to the idea that the experience of a client should be examined in the context of their environment or field (Mann 2010; Yontef 1999). Phenomenology refers to focus on the current moment, describing feelings and experiences rather than trying to interpret them (Mann 2010; Yontef 1999). Dialogue refers to the idea that in the context of therapy, two realities exist, one of the therapist and one of the client, and that a third reality is created as a part of the relationship between the therapist and client (Mann 2010; Yontef 1999).

Name of the Strategy or Intervention Empty Chair Technique in Couple and Family Therapy.

Synonyms Two-chair technique

Introduction The empty chair technique – also known as the two-chair technique – originated from the gestalt approach to therapy. Similar to other interventions that were developed from gestalt therapy, this technique was created to help resolve conflict in the present moment through increasing awareness (Fagan et al. 1974, Mann 2010). In this technique, awareness is increased by helping clients discover new aspects of their experience which they may have been avoiding (Greenberg and Rice 1997; Wagner-Moore 2004).

Theoretical Framework The empty chair technique was originally developed as part of gestalt therapy (Perls et al. 1951), which focuses on the present experience to assist clients in understanding what and how they perceive the situation (Mann 2010). This approach is based on what are known as the pillars of gestalt: field theory, phenomenology, and dialogue (Mann

Rationale for the Strategy or Intervention The empty chair intervention was designed to increase clients’ awareness of different aspects of their experience, helping to resolve conflicts that exist in their lives by resolving “splits” or differences in a person’s internal state (Greenberg 1979; Greenberg and Rice 1997; Mann 2010; Wagner-Moore 2004; Fagan et al., 1974). There are multiple types of splits which can occur (Greenberg 1979). In conflict splits, there are two parts which are in opposition to one another (Greenberg 1979). An example of this type of split would be if a client were to say that there was a part of them that wanted to move in with their partner and another part of them that felt hesitant. In subject/object splits, one part of the self does something to another part – the recipient (Greenberg 1979). An example of this type of split would be if a person reported that they were judging themselves, as they are both judging and receiving the judgment. In attribution splits, one believes there is a disagreement between oneself and another person, or feels that something has been done to oneself by another person making oneself passive in the experience (Greenberg 1979). An example of attribution of opposition would be if a person felt that they should have a child because this is what their mother wants even if they are not entirely sure themselves. An example of attribution of agency would be if a client were to report that another individual made them feel a certain way such as

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embarrassed or angry. A meta-analytic study found that the empty chair technique is a successful intervention for conflict splits, indecision, marital conflict, and resolution of unfinished business (Wagner-Moore 2004).

Description of the Strategy or Intervention In the empty chair technique, a client is asked to imagine that someone from the client’s life or a part of the client themselves – such as an angry or depressed part – is sitting in an empty chair in the therapy room (Greenberg 1979; Mann 2010). Five principles guide the effective use of this intervention (Greenberg 1979). First, clear separation needs to exist between the two parts; the separated parts need to be able to speak directly to each other. Second, the client is encouraged to experience this fully and not avoid parts of their experience by talking in the first person and expressing what they feel in the present moment both in terms of needs and resistance. Third, the therapist adopts a role of helping the client become more aware of their experience instead of trying to motivate change by helping the client to become aware of parts of their perspective that they may not have previously been aware, and by helping the client to focus on their internal feelings or sensations. Fourth, the therapist asking the client to exaggerate or repeat certain statements or behaviors in order to heighten the client’s awareness of the moment to moment experience during the intervention. Fifth, the therapist helps the client to become aware of how they express themselves through guiding their attention to the way in which they speak or act during the intervention (Greenberg 1979).

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reported being committed to their relationship. Hailey also reported struggling to trust Matthew and that she was angry at the affair for “ruining her trust.” Matthew reported that he felt guilty for having the affair and frustrated by the lack of connection that existed in his relationship with Hailey. After several sessions, the therapist suggested they try using the empty chair technique in order to help the couple externalize the affair from who they are as a couple. The therapist asked the couple to place the affair in an empty chair in the room, and then asked each partner to speak directly to the affair, allowing them to express their thoughts and feelings. Through this process, both Matthew and Hailey were able to authentically express their emotions to the affair, thus decreasing defensiveness and allowing for responsibility taking. Hailey was able to talk about how she both wanted to forgive Matthew and how a part of her did not want to, a conflict split, and Matthew was able to express how he was judging himself for having the affair, a subject/object split. After the intervention, Matthew and Hailey reported that they felt closer together because they could picture the affair as something separate from their relationship, and both felt relieved being able to express what they were feeling.

Cross-References ▶ Gestalt Experiential Therapy with Couples and Families ▶ Greenberg, Leslie ▶ Phenomenology and Family Therapy

References Case Example Matthew, 29, and Hailey, 28, recently started couple therapy to work on improving trust and communication. The couple decided to seek therapy after Matthew told Hailey about an affair that he had recently ended. Both Matthew and Hailey

Fagan, J., Lauver, D., Smith, S., Deloach, S., Katz, M., & Wood, E. (1974). Critical incidents in the empty chair. The Counseling Psychologist, 4, 33–42. Greenberg, L. S. (1979). Resolving splits: Use of the two chair technique. Psychotherapy: Theory, Research and Practice, 16, 316–324. Greenberg, L. S., & Rice, L. N. (1997). Humanistic approaches to psychotherapy. In P. L. Watchel &

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904 S. B. Messer (Eds.), Theories of psychotherapy: Origins and evolution (pp. 97–129). Washington, DC: American Psychological Association. Mann, D. (2010). Gestalt therapy: 100 key points and techniques. New York: Routledge. Perls, F., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York: Gestalt Journal Press. Wagner-Moore, L. E. (2004). Gestalt therapy: Past, present, theory, and research. Psychotherapy: Theory, Research, Practice, Training, 41, 180–189. Yontef, G. (1999). Awareness, dialogue and process: Preface to the 1998 German edition. The Gestalt Journal, 22, 9–20.

Enactment in Couple and Family Therapy Kareigh Tieppo and Corina Teofilo Mattson The Family Institute at Northwestern University, Evanston, IL, USA

Synonyms Behavioral rehearsals

Introduction Enactments are used as an intervention when the therapist is prepared to target problematic behavior by both assessing and directing the actions and interactions of a client system. Enactments are made for a relational context, as they call for both interaction and recognition of action between clients in the room. In order to better understand what particular problematic processes look like outside of the therapy room, the therapist will impose a structure of conversation in which clients will to talk to one another about a specific topic and the therapist will guide them through it. Participating within this structure, the hope is that the clients may come to find themselves in a new, and perhaps unexpectedly healing, experience as the therapist helps them to interrupt seemingly permanent, problematic sequences. Through practice and repetition, the therapist is able to more directly address the specific points

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and areas of difficulty within a couple or family’s interactions as they work to implement behaviorbased solutions (Butler and Gardner 2003, p. 312). However, enactments do serve a purpose beyond the assessment of behavioral interaction. According to Gottman and Levenson (1999), “. . .[Enactments] should reduce physiological arousal and reactivity; facilitate positive interaction around discussions of disagreements, differences, and problems; increase display of positive behavior affect, together with the other’s ability to recognize those positive displays; reduce defensiveness, stubbornness, withdrawal, anger, and conflict engagement; increase expressed interest in each other and increase ability to step back and see their partner’s point of view” (p. 312). Enactments also give members of a couple or a family the opportunity to express their emotions in a context where negative or defensive reactions are more easily managed and regulated. In moments of high and vulnerable emotion, the therapist can help clients to be aware and intentional about the role they play in interactions with other members of the client system. By increasing self-awareness, client systems are able to learn how to self-regulate, which leads to better selfcare and care for others (Davis and Butler 2004, p. 320). Enactments give clients an opportunity to recognize and experience their emotions in moments of somewhat spontaneous vulnerability, and as those moments happen, the therapist can help the client system to experiment with different choices of active and responsive behaviors. The hope is that eventually, clients will incorporate behaviors that lead to resolution within patterns of interaction that they had perceived to be hopelessly fixed (Sprenkle et al. 2009).

Theoretical Framework Salvador Minuchin served as the prime example of what an active therapist can do when facilitating an enactment. Working within the model of Structural Family Therapy, he both noticed and named problematic patterns of behavior as they were happening. He helped clients understand

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how their words and their actions – even with the best intentions – could be so much more harmful than they were helpful within some of their most important relationships (Butler and Gardner 2003, p. 314). In Emotion-Focused Therapy (EFT), therapists work to restructure interactions, which are often done by having clients participate in an enactment (Sprenkle at el. 2009). However, in EFT, enactments are not used as spontaneously as they are when working within other models of therapy, for emotion-focused therapists intend to use enactments solely for the purpose of “inviting softer responses from the other,” fostering new experiences of intimacy that lead to healing (Sprenkle et al. 2009, pp. 117–118). Johnson herself (2013) says, “One of the finest moments for me is when partners finally disclose their worries and desires and engage with each other tenderly and compassionately,” which is most certainly the ideal result of intervening with an enactment (p. 55). According to Davis and Butler (2004), versions of enactments exist within all of the relational therapy models. For example, in Marital Enrichment, Relational Enhancement, and Behavioral Marital Therapy approaches, enactments are called “behavioral rehearsals*.” In Narrative Therapy, clients who feel stuck may attempt to “re-story” the difficult narratives that they carry with them each day, and in Solution-Focused Therapy, couples are sometimes asked to engage in “couple dialogue” (p. 320).

Rationale for Enactments Minuchin (1974) used enactments to “unleash sequences beyond the family’s control” (p. 78). When members of a couple or family become lost in their sequences, the therapist can take control in order to help the family navigate what they do not yet understand. Minuchin (1974) explained, “Instead of a patient with pathology, the focus is now a family in a dysfunctional situation. Enactment begins the challenge to the family’s idea of what the problem is” (p. 81). The therapist serves as the navigation system by exercising some control over the rules of the interaction that

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the client system is partaking in. For example, the therapist decides who participates, when they participate, and how long they participate for. The therapist is also able to notice what the system can tolerate, what may be pushing the system too hard, when it may be time to slow the process down, and when it may be time to press pause. Therapists use enactments as a means to observe several different parts of a system’s process all at once (e.g., family roles and dynamics, individual/couple/family strengths, problematic and unproductive patterns of interaction, etc.) (Nichols and Davis 2017). Enactments are process-oriented more than they are contentoriented (Butler and Gardner 2003, p. 313). They do often require clients to communicate directly with one another about content that is important, but the therapist is able to guide, manage, and adjust the conversation as is needed for practicality and productivity. The more people that are involved in an enactment, the more difficult it may be to manage, and thus, the therapist must be aware of and prepared for the particular, potential challenges that come with asking a family to participate in an enactment versus asking a couple or dyad to participate in an enactment. The mediation, direction, and topic of discussion introduced by the therapist during an enactment may sometimes catch the clients by surprise. In turn, this may lead clients to produce reactions and responses that are more true to the person they are when the therapist is not present. When this happens, it may become clearer to the therapist what keeps each member of the system from making the more permanent changes they claim to be seeking in their everyday lives. Thus, the therapist is able to develop more realistic expectations and hypotheses about a system’s capabilities to adapt to change at a specific moment in time. This allows the therapist to better understand how to empower clients to open their minds to new, possible solutions for problematic communication and interaction with their loved ones. Again, it must be emphasized that sustaining these kinds of changes takes practice and repetition. Once the therapist interrupts a system’s longtime pattern of interaction and teaches its participants how they can productively and positively go about change –

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all done collaboratively – they must remember that it is unrealistic to expect the lessons learned to immediately become the norm. Enactments may have to be produced again and again in session in order for them to have a chance of being practiced, repeated, and implemented out in the world and in people’s everyday lives (Pinsof et al. 2017).

Description of Enactments Nichols and Davis (2017) describe the three steps the therapist must take when pursuing the inclusion of an enactment in session. First, the therapist must notice a problem within the system’s process of communication that is impairing its functioning. Second, the therapist must initiate the enactment while simultaneously getting all members that are present to agree to participate. The therapist must be clear with clients that an enactment is meant to allow families or couples to interact or communicate directly with each other so that they do not begin by using the therapist as a messenger with indirect and passive aggressive communication. Third, the therapist must remain present to the interactions of the enactment, for they are the person responsible for helping the family to successfully make it through/partake in the interaction. When the system struggles, or things begin to go awry (as is expected), “the therapist intervenes in one of two ways: commenting on what went wrong or pushing them to keep going” (Nichols and Davis 2017, p. 123). The therapist is responsible for keeping track of the emotional reactivity, the emotional intensity, and the amount of direct/indirect interaction between those in the system. There is always a risk that an enactment may result in high emotion and high reactivity, and in an effort to guide, or perhaps disrupt, these particular interactions, the therapist may need to implement fairly blunt directives. This way, the therapist is able to directly suggest new ways for the system to communicate and/or operate (Pinsof et al. 2017). The hope is that eventually, clients will

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successfully be able to make it through these interactions without relying on directives from the therapist (Butler and Gardner 2003).

Case Example In the following example of an enactment, the family involved is coming to therapy to learn how to cope with the parents’ impending divorce and understanding the mother’s depression. The family members in the therapy room for this particular session include the mom (46) and eldest daughter (17). Over the past 10 years or so, the daughter has become somewhat parentified, feeling an incredible amount of responsibility to protect her three younger siblings from the conflict between their parents. The daughter’s perceived responsibility for her mother and younger siblings has led her to feel overwhelmed. Still, the daughter is afraid to tell her mother that she feels this way. The daughter is convinced that telling her mother how she feels about the role she has taken on in their family will make the mother feel even more alone in her struggles. The daughter is terrified that talking about her mother’s depression and being open with her about her fears may result in the mother’s depression spiraling out of control (i.e., suicidality). Having observed this family’s process for several months, the therapist knows that the daughter’s catastrophic fears will not be confirmed. The therapist will ask the mother and daughter to participate in an enactment by asking the daughter to tell the mother what she fears will happen if she takes on less of a caretaker role, thus allowing an opportunity for the daughter to see how the mother will respond to her fears and overburdened sense of responsibility. Once the mother and daughter are informed of the task at hand, it may unfold like this: Therapist:

Lucy, over the past several months, I have come to understand that you are deeply afraid of what could happen if you chose to open up to your mother about how responsible you feel to take care of and protect her. I want to encourage you to take

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Daughter:

Mother: Therapist:

Daughter:

Therapist: Daughter:

Mother:

this opportunity to talk to her about that now. I believe that her response to you will be much, much different than you think it will be. It may even surprise you. I know that this is very difficult. You are safe to speak about this here, and you can begin whenever you are ready. Mom, I have been feeling very overwhelmed lately. . .more than I ever have before. . .and it’s getting in the way of everything more than it usually does. . . Oh, honey. . .What about? What’s going on? Lucy, can you please tell your mom when you feel the most overwhelmed? Mom. . .I really love when we go on walks or talk before bed and our conversations are really good. . .and about deeper stuff. . .but sometimes. . . You can do this, Lucy. . .Keep going. Sometimes, we switch topics away from what’s going on with me so that you can list all the reasons for the divorce. . .or talk about all the things he won’t do. . .or say. . .or talk to you about. . .and I’ve been the person you go to to vent about that stuff for years. . .but I cannot change any of the things you complain about. . .He has to be the one to do it. . .This is between the two of you. . .and I have never said any of this to you because I did not want you to feel like you couldn’t talk to me about it all because I didn’t want you to feel alone in all of it. . .I did not want to hurt you. I don’t want you to feel alone. I am afraid of what will happen if you feel alone in everything. I know that I talk about him more than I should with all of you kids. We both do. And it’s not fair at all to

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you guys. . .I’m so sorry. . .I’m the mom. . .and you’re the kid. . .I never want to bring my children any pain. You are not responsible for protecting me. . .or fixing any of the marital problems. . .I will try to stop putting all of that on you. . .I want you to be able to focus on your own life and responsibilities. . .I do not and will not feel alone in “all of this.” I am going to be okay.

After thanking both mom and daughter for their participation, the therapist may ask the daughter to share with the mom how she thought she would respond to her truth on this topic. Knowing how difficult it will be for the daughter to be honest with her mother about her fear of her mother’s depression and suicidality, the therapist may help the daughter express to the mother where her strong belief in this fear is coming from. The therapist may then help the mother to validate, be curious about, and respond to her daughter’s fears. The therapist will continue to guide the mother and daughter throughout this conversation, offering directives that may help each of them to slow down, pause, or reflect upon what the other has said as they discuss the fear that is related to the role the daughter has taken on in the family and the ways in which that may influence other particularly burdensome family dynamics. As the possibility of change is explored or attempted throughout the enactment, the therapist will encourage patience as she asks the mother and the daughter to express and to understand what it is that they each truly need from the other.

Cross-References ▶ Behavioral Rehearsal in Couple and Family Therapy ▶ Enactment in Structural Family Therapy

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References

Theoretical Framework

Butler, M. H., & Gardner, B. C. (2003). Adapting enactments to couple reactivity: Five developmental stages. Journal of Marital and Family Therapy, 29(3), 311–327. Davis, S. D., & Butler, M. H. (2004). Enacting relationships in marriage and family therapy: A conceptual and operational definition of an enactment. Journal of Marital and Family Therapy, 30(3), 319–333. Gottman, J. M., & Levenson, R. W. (1999). Rebound from marital conflict and divorce prediction. Family Process, 38(3), 287–292. Johnson, S. (2013). Love sense: The revolutionary new science of romantic relationships. New York: Little, Brown, and Company. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods. Hoboken: Pearson Education. Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J. L., Rampage, C., & Chambers, A. L. (2017). Integrative systemic therapy: Metaframeworks for problem solving with individuals, couples, and families. Washington, DC: American Psychological Association. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy. New York: The Guilford Press.

Enactments are an essential component of Structural Family Therapy (Minuchin 1974; Minuchin and Fishman 1981). They are used to explore and change interactional and organizational problems in families: how couples talk to each other, how parents relate to their children, and how relationship triangles influence family dramas. By bringing the actual dynamics of those relationships to life in the consulting room, enactments lend immediacy and authenticity to family therapy. Although enactments are also used in other therapeutic modalities, there is an important distinction. Outside of structural family therapy, the use is generally more directive, with therapists interrupting to coach communication skills, often after almost every client utterance (e.g., Butler and Gardner 2003; Davis and Butler 2004). The familiar tactic of having couples take turns talking and listening is an example of this approach, as is the rehearsal in behavioral marital therapy (Jacobson and Margolin 1979), the directed dialogues in emotionally focused couples therapy (Greenberg and Johnson 1988), and the role-playing and problem-solving practice in couple enrichment programs (L’Abate and Weinstein 1987). By contrast, enactments in Structural Family Therapy are relatively unstructured. The therapist acts as a facilitator rather than a coach. Although he or she may need to be active in setting an enactment up, once underway the therapist intervenes only when necessary to keep it going. Forced to rely on their own devices, some clients will find a way to get through to each other; others may continue to communicate in ways that are counterproductive. When this happens, the therapist points at what the clients are doing that keeps them stuck.

Enactment in Structural Family Therapy Michael P. Nichols1 and Jorge Colapinto2 1 College of William and Mary, Williamsburg, VA, USA 2 Minuchin Center for the Family, Woodbury, NJ, USA

Introduction In an enactment, family members are asked to talk with each other rather than to the therapist. This serves the dual purpose of allowing the therapist to see firsthand how clients interact, instead of relying on their descriptions, and having clients experience different ways of interacting (Nichols and Fellenberg 2000).

Rationale Because family members often describe themselves more as they want to be seen than as they are, structural family therapy works by doing rather than talking. It relies on the observation of

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actual family transactions – the “family dance” – to identify and highlight the dysfunctional patterns that embed the presenting problems; and on the family members’ practice of alternative ways of relating – a new choreography – as the way to develop healthier patterns. The purpose of an enactment is not necessarily that the family members will reach agreements or the solution to their problems, but that they will have the experience of a better relationship. New relational patterns need to be experienced repeatedly until they hold; each successful enactment contributes to the expansion of the family’s repertoire, showing that change is possible and what it may look like.

Description Enactments can be used as an assessment tool or as a therapeutic intervention. When used for assessment, the therapist initiates an enactment and waits to see where communication breaks down. Suppose, for example, that a wife complains that her husband never talks to her. When the therapist asks the man to talk to his wife about a project at his work and she interrupts with frequent criticisms, the husband grows silent and the enactment comes to a close. In this case, the therapist might conclude that the husband doesn’t talk to his wife, because when he does, she criticizes him – and because rather than answer her, he withdraws. When used as a therapeutic intervention, the therapist’s job is to push family members to continue talking until there is a breakthrough in the way they interact. In the previous example, when the husband grows silent in the face of his wife’s criticism, the therapist could simply say “Answer her.” In families with young children, enactments may take the form of action rather than conversation. To see how effectively parents deal with their children, a therapist might ask them to control an unruly child or encourage a shy child to play a game. Are the parents able to get their children to sit quietly in the corner if the therapist asks them to? Can a parent sit and play with his or her child without trying to control the game?

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Using enactments effectively is more complicated than generally assumed (Nichols 1997). Though some clients are all too ready to argue among themselves, most are reluctant to address their conflicts directly with each other in therapy sessions. They’ve tried, but it’s been painful and unproductive. So by the time they get to a therapist’s office, many people are ready to give up on each other and turn to the therapist for understanding. Therefore, it’s useful to carefully prepare the groundwork for an enactment. Before staging it, the therapist gives everyone present a chance to share his or her point of view about the problems that plague them. Unhappy families are often short on mutual understanding, and therefore the first task of a therapist is to give each of them a sympathetic hearing. Once a therapist has acknowledged what each family member has to say, he or she identifies a problematic interaction. Perhaps, for example, a father sits back silently while his wife and son argue fruitlessly. The therapist may probe the flexibility of this arrangement by asking the father to talk with his wife about her concerns. If the father’s conversation with his wife is interrupted by the son, and the father is silenced, this will support the hypothesis that the mother and son are overinvolved and the father is disengaged. After a specific subject of concern to both parties has been identified, the therapist then initiates an enactment, making a production of it: he or she describes a problem, show that it is an important issue for the family, asks the participants if they’d be willing to talk about it, brings them physically closer to each other, and may prescribe who should begin the conversation. Pointing out a relationship problem that the therapist has observed increases the clients’ motivation to engage in enactments. It is important to choose a subject that both participants have something to gain by discussing. Some subjects are a no-win proposition for certain family members. Suppose, for example, a teenager has trouble expressing himself to his mother, and she has trouble listening. Asking them to talk about why

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the boy should stay in school is unlikely to lead anywhere because the boy has nothing to gain in this conversation. This discussion is almost certain to take the familiar form of a parent nagging a recalcitrant adolescent. On the other hand, asking the mother to find out what the boy wants to do after school may give him a better chance to speak up, and her a better chance to listen. To use enactments effectively, a therapist should focus on the process, not the content, of communication. When the Johnsons complained that their teenage son David had frequent outbursts of anger, the therapist asked David if his father understood what made him angry. The boy answered, “No. He never listens to me.” The therapist said, “This sounds like an important issue. If a father can’t talk to his son, and a son can’t talk to his father, how will the boy learn to get along in the world? David, would you be willing to talk to your father about some of the things that make you angry? Mr. Johnson, would you be willing to help David explain why he gets so upset?” They both agreed, and the therapist turned their chairs to face each other. Once an enactment has begun, the therapist sits back to remove himself or herself from the dialogue. By avoiding eye contact with the person speaking, the therapist encourages clients to continue talking to each other and not to her or him. During this phase of an enactment, the therapist should say only enough to block third parties from interrupting, and to redirect or “jump start” the dialogue if necessary. In the case of “A Father’s Rage” (Minuchin and Nichols 1993), Dr. Minuchin asks a father to talk with his 16-year-old son, Keith. Despite the therapist’s best efforts to encourage a supportive connection between father and son, the father begins by criticizing his son’s choice of clothing. “So you’d rather go around wearing rags . . . than wear nice slacks and have them think you’re a nerd. . .” Keith nods. The boy and his father have had run out of lines. To restart the conversation, Minuchin says “You see, this was a perfectly good conversation between two cultures. It happens in this crazy culture in which these kids live, ragged pants are in and dressy pants are out.” (To Keith:) “It is your

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job to explain yourself to your father so he can understand you.” (To the father:) “Your son is a member of an alien culture that thinks knees are beautiful. Who knows?” (To the son:) “Keith, can you explain this to your father?” “Please,” the father says. As the therapist sits back, this stubborn and unhappy father and son begin to open up to each other. They talk about feeling excluded and feeling misunderstood, about needing to belong and not belonging – and what had begun as another failure of communication becomes a genuine breakthrough of understanding. When an enactment comes to a close, the therapist can comment on what the clients are doing that keeps them stuck, or how they were able to get through to each other. If a real conversation has taken place, it is a good time for encouragement and suggestions for improving communication and cooperation to resolve family problems.

Case Example In the process of raising their children, the Diamonds have allowed the spark to go out of their marriage. They work well together as parents, but as a couple they have drifted apart. Tony Diamond complains that his wife is always too busy with the children to spend time with him; she complains that he is always complaining about his job and never seems to care how she feels. After hearing these complaints, the therapist says, “It seems like you’re both feeling neglected.” They nod. “Maybe the problem isn’t that you don’t make time for each other, but that unspoken resentment makes you not want to.” She looks down, he looks away. “This seems like an important issue. Tony, would you be willing to ask Kristina to tell you what she’s feeling about your relationship?” “I guess,” he says, not too convincingly. The therapist turns their chairs to face each other, and says, “Kristina, can you help Tony understand why you’ve been feeling neglected; and, Tony, can you try to understand what she’s feeling?” They both agree, and Kristina talks about how she misses the early years of their marriage when Tony always seemed willing to listen to her concerns. When Tony counters by

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saying that he also needs to be listened to, it seems that they are about to revert to the familiar pattern of complaining back and forth with neither one really listening to the other. So the therapist says, “Kristina, can I ask you a very personal question?” “Sure,” she says, “I’m a very open person.” “Are you sometimes too angry for sex because you feel that Tony doesn’t care what’s going on with you?” “Exactly!” she says. “Whenever Tony listens to me, I just melt.” The therapist takes Tony’s hand and had him take Kristina’s hand and says, “Keep talking. I think this guy really loves you, and he wants to understand how you feel.” That simple gesture and the physical closeness it fosters helps the two of them open up their hearts to each other. They talk about feeling misunderstood, about missing the good times they used to have, and about feeling that the other one no longer cares. It is a good talk, and it goest on for quite a while. After several minutes, the therapist begins to sense that the conversation is winding down, and wanting to punctuate their success, he moves their chairs apart and says, “It seems that you both miss the closeness in your relationship. I’m impressed with how meaningfully you can talk with each other when you take the time to hear what the other one has to say.”

911 Greenberg, L. S., & Johnson, S. M. (1988). Emotionally focused therapy for couples. New York: Guilford Press. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel. L’Abate, L., & Weinstein, S. E. (1987). Structured enrichment programs for couples and families. New York: Brunner/Mazel. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Minuchin, S., & Nichols, M. P. (1993). Family healing Tales of hope and renewal from family therapy. New York: Free Press. Nichols, M. P. (1997). The art of enactment. Family Therapy Networker, 21(6), 23. Nichols, M. P., & Fellenberg, S. (2000). The effective use of enactments in family therapy: A discovery-oriented process study. Journal of Marital and Family Therapy, 26, 143–152.

Enmeshment in Couples and Families Teresa D’Astice and William P. Russell The Family Institute at Northwestern University, Evanston, IL, USA

Name of concept Enmeshment

Cross-References ▶ Boundaries in Structural Family Therapy ▶ Family Function and Dysfunction in Structural Family Therapy ▶ Structural family therapy

References Butler, M. H., & Gardner, H. A. (2003). Adapting enactments to couple reactivity: Five developmental stages. Journal of Marital and Family Therapy, 29, 311–328. Davis, S. D., & Butler, M. H. (2004). Enacting relationship in marriage and family therapy: A conceptual and operational definition of enactment. Journal of Marital and Family Therapy, 30, 319–333.

Synonyms Overinvolvement

Introduction Salvador Minuchin (1974) used the term enmeshment to describe the overinvolved relationships that develop from diffuse boundaries within family systems and between family members and other systems. Enmeshed families or subsystems are characterized by a high level of communication and lesser levels of distance, and differentiation (Minuchin 1974). Structural concepts,

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including enmeshment, were foundational to the field of Marriage and Family Therapy and remain vital tools for systemic assessment and treatment (Fishman 2012; McAdams et al. 2016; Nichols and Davis 2017). Its established position in the field notwithstanding, the concept of enmeshment has been reexamined over the years by various theorists who have suggested adjustments to its usage.

Theoretical Context for Enmeshment The theoretical context for the concept of enmeshment is Structural Family Therapy (SFT), which was developed by Salvator Minuchin. SFT posits that behavior, including the problems brought to therapy, develops within and is maintained by the interactional context of the family, its subsystems, and other systems in the community. SFT identifies various subsystems of the family and focuses on the transactional patterns among them. These patterns are understood in terms of two dimensions (Wood 1985; Colapinto 2015): vertical (the family hierarchy) and horizontal (boundaries of proximity/involvement among members). Boundaries are defined as “rules defining who participates, and how,” (Minuchin 1974, p. 53). Boundaries regulate the level of contact or engagement between the family and other systems and among individuals and subsystems within the family. When the level of engagement is appropriate to the needs and developmental levels of members, the boundaries are said to be clear. Such boundaries allow family members to manage their individual functions while maintaining adequate communication with the rest of the system.

Description Minuchin and Fishman (1981) states that families with clear boundaries maintain a balance between autonomy and relatedness. In such a case, there is enough closeness, support, and involvement to support its members and enough distance to allow individuals and subsystems to develop independent functional capacity. Minuchin also discusses

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boundaries that are too rigid or too diffuse. Disengaged families have rigid boundaries that limit communication between subsystems, such that family members do not find sufficient connection, comfort, or safety within the system. On the other hand, enmeshed families and enmeshed relationships have diffuse or porous boundaries that allow a high level of involvement among members and establish expectations that tend to reduce the autonomy of members. Enmeshment brings a heightened sense of belonging and a high level of sensitivity to departures from expected behaviors and connections. The resulting lack of distance from one another can lead to difficulty maintaining independence and adaptation in stressful situations (Minuchin 1974). Though connectedness within a system is important, enmeshment can diminish “autonomous exploration and problem-solving” (Minuchin 1974, p. 55).

Applications of Enmeshment in Couple and Family Therapy Minuchin (1974) recommended that family assessment include attention to the following factors: description of the presenting problems, direct observation of family interaction including the family’s response to the identified patient, the family’s sources of support and stress, and the developmental stages of the members and the family as a whole. If the presenting problem seems to be maintained by enmeshed relational dynamics in the family, the therapist works to highlight for the family that this is so. The therapist takes the position that in order for the presenting problem to improve, the family will need to allow greater autonomy to particular members or subsystems. Once this is established, the therapist helps the family create new boundaries by physically rearranging family members into different subsystems in the room, restricting some family members from participating in certain conversations, coaching some members to back off in order to let a member function more independently, and encouraging more autonomous functioning of particular members. (Colapinto 2015; Pinsof et al. 2018).

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As SFT is arguably the most influential conceptual model in the field of family therapy (Nichols and Davis 2017), the concept of enmeshment has achieved and maintained prominence over the years. It has also been the subject of continued discussion and, at times, reexamination. The feminist critique in family therapy challenged the usage of this concept. Bograd (1988) cautioned that family systems concepts may reflect male standards of identity and relationship and present a risk of pathologizing the preferred relational styles of women. The concept of enmeshment had been associated with what have traditionally been described as female-typical qualities such as relational closeness, whereas disengagement had represented the more maletypical qualities such as independence or relational distance. Although STF identified both enmeshment and disengagement in their more extreme forms are problematic, Bograd maintained that enmeshment as applied to women evoked stronger negative views than disengagement. She urged that mothers not be pathologized for their relational nature and suggested that family therapy models “blend and value both attachment and separation, productivity and nurturance, rationality and emotion” (Bograd 1988, p. 78). Fishman (2012) highlighted that boundaries are idiosyncratic to every family and that the impact of the boundaries, as reported by the family members, is key to understanding whether a family or relationship is considered enmeshed. This more subjective approach to structural assessment allows the therapist to consider family member’s points of view, cultural context, and special circumstances. Fishman (2012) also upheld the importance of the application of structural concepts, including enmeshment, to the relationship between families and the larger social context. It is important to consider culture and community before labeling a family as enmeshed. In some family systems, diffuse boundaries are not problematic (Pinsof et al. 2018). In collectivist cultures, low-income populations, or neighborhoods with high crime rates, it may be adaptive or necessary for children to be very highly

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involved with parental or other subsystems in order to meet cultural expectancies, promote development, or ensure safety. Pinsof et al. (2018) emphasized that ideas about a family’s structure are best considered hypotheses not facts. This promotes a collaborative approach to exploring “time members spend together, physical closeness, emotional separation, shared general information, confided personal information, and decision making” (Pinsof et al. 2018, p. 104) and joint determination of whether diffuse boundaries are something that constrain problem solving. These authors also reinforce the importance of considering cultural issues and avoiding gender bias in the use of the concept of enmeshment. Lastly, though they recognize the profound importance of structural concepts, their integrative approach asserts that not all presenting problems are most practically and effectively addressed from a structural perspective. After the family’s boundaries have been assessed with awareness and sensitivity to culture and gender, and the therapist and family have collaboratively identified that the family system is constrained by its enmeshment, the task ahead is to create new boundaries that allow greater autonomy for specific members and, perhaps, more relatedness for others (Colapinto 2015).

Clinical Example Robert and Kate sought treatment for their 14-year old son, Jacob, who had been coming home from school mid-mornings due to strong feelings of discomfort. In the first phone call, Kate stated that Jacob was an only child who had been shy and sensitive throughout his life. She shared that they would often leave family parties and other events early because Jacob needed to go home. This was inconvenient and embarrassing at times, but she understood how difficult it was for him. She was especially concerned that since beginning high school 6 weeks earlier, Jacob had rarely been able to stay at school due to feeling very uncomfortable there.

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At the first session, Kate and Jacob sat on the couch next to each other, and Robert sat in the chair. When the therapist asked Jacob a question, Kate answered for him, and Robert remained silent. The therapist asked if this pattern of Kate answering for Jacob was a common occurrence at home and, with some apparent discomfort, Kate admitted that it was. As the therapist explored the family’s concerns, Robert expressed frustration that Kate often gave in to Jacob’s request to leave social situations. He was particularly frustrated that she often picked Jacob up from school mid-morning after he called to say he was unable to stay at school. Kate expressed that she wanted Jacob to attend school, but she also wanted to support and protect him. She stated that she did not want him to suffer. At the end of the session, the therapist asked for permission to contact the school and subsequently had an initial conversation with the school social worker about the school’s way of dealing with Jacob’s discomfort. After two sessions of observing interaction patterns and thinking about the family structure, the therapist hypothesized that Jacob’s autonomous functioning at school was constrained by disengagement of his father, enmeshment with his mother, and a somewhat divided parental subsystem. Consistent with this, the therapist suggested that in order for Jacob to cope better in social situations, he would need to be given more space and responsibility to learn to do so. Jacob said that would be fine with him, but Robert expressed doubts that when the time came Jacob would resist calling for help. The therapist asked Jacob to sit in a chair near his father and talk about what challenges he would face and how he could handle it. The conversation began awkwardly, but Jacob was able to talk about the discomfort he felt at school. The therapist asked the father and son to discuss this further during the week and to find a small way of thanking Kate for always being there for Jacob. When the family system returned for their next session, the therapist immediately rearranged the seating pattern such that Robert and Kate sat together on the couch, and Jacob sat in his own chair. This arrangement represented the therapist’s goal of strengthening the parental subsystem and

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creating more functional boundaries between parents and Jacob. Kate reported that Robert and Jacob had bought her flowers. She also reported that it felt good for Robert to be directly involved in Jacob’s concerns (vs. complaining about them). The therapist asked Kate and Robert to discuss their goals for Jacob moving forward. They agreed that their main goal was to ensure Jacob attended school regularly. The therapist emphasized that this would require the parents to work together to set consistent boundaries for Jacob. Specifically, they would need to require that he stay at school. Kate agreed but expressed concern about how to handle Jacob’s distress calls. The therapist asked the parents to talk about how they were going to respond to Jacob’s calls, keeping the conversation between the parents and, at one point, directing them to ask Jacob to wait until they completed their conversation before he interjected. They decided that for the time being, Jacob could call if he needed to do so, but they would not pick him up. The therapist asked Kate to directly communicate this plan to Jacob. Kate proceeded to tell Jacob that he had to stay in school, and if he calls her to come home from school early, she will speak with him to support him in staying, but she will not pick him up. Jacob indicated he understood this and would try not to call. Robert reinforced that it was okay to call and that he would be open to receiving the call too, but they would not pick him up. The therapist initiated a meeting with Jacob, the parents, and the school social worker to identify what the school staff would do and how they could support the plan. Then the plan was launched. By setting a clear boundary and sticking to it, the parents obligated Jacob to begin to cope with his discomfort rather than involving others in an effort to avoid it. This was an important step in establishing more autonomous functioning for Jacob, reduced enmeshment between him and his mother, more engagement with his father, and a strengthened parental subsystem.

Cross-References ▶ Boundaries in Structural Family Therapy ▶ Disengagement in Couples and Families

Epistemology in Family Systems Theory

▶ Hierarchy in Family Systems Theory ▶ Integrative Systemic Therapy ▶ Structural Family Therapy ▶ Minuchin, Salvador

References Bograd, M. (1988). Enmeshment, fusion or relatedness? Journal of Psychotherapy & The Family, 3(4), 65–80. https://doi.org/10.1300/j287v03n04_05. Colapinto, J. (2015). Structural family therapy. In T. Sexton & J. Lebow (Eds.), Handbook of family therapy (pp. 120–133). New York: Routledge. Fishman, H. C. (2012). Intensive structural therapy: Treating families in their social context. New York: Basic Books. McAdams, C. R., Avadhanam, R., Foster, V. A., Harris, P. N., Javaheri, A., Kim, S., . . . Williams, A. E. (2016). The viability of structural family therapy in the twentyfirst century: An analysis of key indicators. Contemporary Family Therapy, 38(3), 255–261. https://doi.org/ 10.1007/s10591-016-9383-9. Minuchin, S. (1974). Families and family therapy. London: Routledge. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge: Harvard University Press. Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods (11th ed.). Boston: Pearson. Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J., Rampage, C., & Chambers, A. L. (2018). Integrative systemic therapy: Metaframeworks for problem solving with individuals, couples, and families. Washington, DC: American Psychological Association. Wood, B. (1985). Proximity and hierarchy: Orthogonal dimensions of family connectedness. Family Process, 24, 487–507.

Epistemology in Family Systems Theory Bethany Simmons1 and Jana Sutton2 1 California Lutheran University, Thousand Oaks, CA, USA 2 University of Louisiana at Monroe, Monroe, LA, USA

Name of Concept Epistemology in Family Therapy.

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Introduction Epistemology, or the study of how we know what we know (the process of knowing), was first introduced into family therapy ideas and literature by anthropologist Gregory Bateson. Epistemology involves “...certain propositions about the nature of knowing and the nature of the universe in which we live and how we know about it” (Bateson 1972, p. 478). This concept is closely related to and cannot be separated from ontology, the study of what we know (the content of knowing), and often the term epistemology is used to discuss both aspects of knowing (Bateson 1972). Often, the term epistemology is used to indicate a lens, ideology, worldview, perspective, or framework that informs how someone thinks, the perceptions they have, and the meanings they make that influence how they interact in the world and with others. In turn, recursively, the premises and beliefs they hold about the world inform and reinforce or alter their epistemology. Within family therapy, this concept is applied not only to understanding the epistemology of clients and how that may be related to being in therapy and possible solutions, but also to the therapist’s epistemology, which significantly influences how they view therapy, how they perceive and interact with the client (or even view them as such), what utterances or actions they attend to, what they focus on in the session, what they perceive the problem (or not) to be, what direction they will take, their therapy approach, and agenda for therapy, all of which inform the questions they ask and what they do and do not pay attention to in sessions. The therapist’s epistemology colors every utterance, movement, action, reaction, thought, direction, stance, questions, statements, interpretations, conclusions, understandings, meanings, etc. that the therapist makes. This cannot be avoided. Much of this process of knowing can be largely unconscious or outside of a person’s awareness. While a person may be unaware of their epistemology and, to some extent, access to their whole epistemology may be impossible, one cannot not have an epistemology (Keeney 1983). To deny the existence of epistemology, be unaware of, or refuse to see one’s own epistemology still indicates an epistemology of epistemology.

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Theoretical Context for Concept Inherent within an epistemology and ontology are assumptions, presuppositions, beliefs, and propositions that are held or accepted by the holder that become the building blocks of their epistemology. This filtering process filters everything happening in the world around them and is necessary to simplify a vast amount of complex information into understandable and manageable pieces, accepting some and discarding or ignoring others. This process is mainly unconscious to us and we are unaware that we are doing this at all times. Our assumptions guide our perception, and how the stream of events or information perceived is punctuated will in turn suggest how that information is to be construed and understood constructing our experience and view of reality based on our interpretation and meaning of that punctuation. Two people experiencing the same event with two different epistemologies can lead to different punctuations of that same event, which can lead each punctuator to differ in their perception of that event leading to different understandings and realities, and ultimately different decisions, interactions, and outcomes. Later in this chapter, a clinical example will be presented demonstrating how two therapists with the same case would approach it very differently based on their epistemology. From this perspective, punctuations, beliefs, and perceptions filter all experience and thusly determine reality, but taken further, these punctuations can be self-validating. Through this selfvalidation process, beliefs, punctuations, and perceptions become reinforced by and mutually reinforce behavior of self and others in line with those beliefs affecting the outcome in the direction of those beliefs. Watzlawick et al. (1967) termed this the “self-fulfilling” prophecy. Because our understanding, beliefs, and knowledge of the world are filtered through our epistemology and ontology, a “True” representation of reality cannot be known. Since our way of knowing reality, or making sense of the world around us, is always filtered through our epistemology and ontology, which in turn constructs our knowledge about reality and what we believe

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reality is, one can never really know reality without it also being a reflection of ourselves and the limits of our perception and experience. The knower is always actively involved in constructing what it is that they know. This is the concept known as “constructivism” (Watzlawick 1984). Constructivism suggests that reality is only knowable through our constructions of it. Because we cannot escape our own minds, we can never really know a reality outside of our perception of it. Therefore, any attempt at objectivity will fail because we cannot avoid our interpretation and the lenses through which we filter our perceptions. Often, many assumptions and presuppositions go unquestioned and are often unknowingly accepted and perpetuated. Bateson (1979) argued that cultural institutions such as religion, philosophy, art, and science, etc. often dictate fundamental “Truths,” which are accepted without question and many lack knowledge of the presuppositions inherent not only in these “Truths,” but in everyday life. Bradford Keeney, along with Douglas Sprenkle (Keeney and Sprenkle 1982), emphasized the importance of thinking about epistemology in family therapy practice. Keeney (1983) made clear the distinction between a cybernetic or circular epistemology and linear causal epistemology, highlighting the significant paradigm shift a cybernetic epistemology makes in thinking about human interaction and performing therapy. Within family therapy, a focus on epistemology in the late 1970s into the 1980s, along with the ideas of constructivism and second-order cybernetics began shifting the field into the exploration of postmodern philosophy and approaches to therapy.

Description One’s epistemology leads to particular ways of arranging observed data or information and all therapists diagnose and treat based on their epistemology (Keeney 1979). Keeney (1979) distinguished between a linear epistemology informing treatment (such as traditional psychiatric and medical models of conceptualizing human

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behavior) and one emphasizing a focus on ecology, context, interrelation, complexity, patterns, and the relations between. “Cybernetic epistemology indicates a way of discerning and knowing patterns that organize events” (Keeney 1982, p. 154) and refers to punctuating the stream of information into seeing patterns and the relations between. While a distinct way of knowing, cybernetic epistemology is often also discussed in family therapy literature as a “systems/systemic,” “ecological,” “circular,” “nonlineal,” “recursive,” or “ecosystemic” epistemology (that may or may not embody cybernetics in application) (Keeney 1979, 1982, 1983). A cybernetic and systemic epistemology represents the departure from a linear/causal view of psychotherapy to a broader perspective that accounts for interactions, contextual factors, complexity, and recursive interplays between humans, their environment biology, language and meaning systems, culture, symptomatic displays, communicational patterns, cognitive processes, emotions, experiencing of reality, and relational dynamics. From this perspective, the individual is seen as part of a larger whole (a system) in which the focus is widened beyond a single person to the network of relationships and context in which the individual is inseparable. This epistemological distinction is the foundation and hallmark of the development of the field of family therapy, breaking from traditional psychiatric philosophy. This orientation to thinking about humans was (and still is) a radical shift in thinking about people and mental health issues from the dominant discourse and paradigm. Typically, human problems, especially psychiatric, mental or behavioral health problems, are thought about in terms of something wrong inside of the person, without consideration to the larger ecology, context, or the relationships of which that person is a part. This idea jives with a Western way of viewing the world. Western philosophy encourages independence (I am separate from you), a positivist tradition (discovering ultimate truth and reality), strong value-laden orientation (certain things are good and bad, rather than things just are and we place the meaning or value onto them),

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reductionism cause and effect sequences, and either/or dichotomies (black and white thinking that excludes the possibility that it might be both at the same time) (Becvar and Becvar 2013). This shift from thinking in a linear manner to thinking within a systemic framework is often difficult for many because it is so different from the dominant Western philosophy (Ray and Borer 2007), and language systems often contribute to lineal descriptions (Selvini Palazzoli et al. 1978). Keeney (1982) contended that a cybernetic epistemology is more than a holistic view, concerned with parts and wholes (e.g. seeing families rather than individuals), but rather focuses on how parts and wholes are organized and their “patterns of organization. . .that characterize mental and living process” (p. 155). Within cybernetic epistemology, there is a focus on how information is communicated and organizes the system and how that system organizes through their communication and transmission of information. Information is exchanged and fed back into the interactional system through feedback loops, whereby the system either absorbs the information into its existing parameters (epistemological frame) or has to alter the parameters (epistemological frame) to accommodate for the “news of difference” that is different enough to make a difference within their interactions and meanings (Bateson 1972). Similarly, von Bertalanffy’s General Systems Theory offered an alternative way to study and understand complex systems, particularly biological systems that were not within the linear, positivist, reductionist scientific paradigm (Hammond 2003). The epistemological shift from an intrapsychic individualistic perspective to a relational systemic and cybernetic perspective represents a dramatic revolution not only in how one thinks about human beings, but poses significant ramifications for difference in how therapy is approached and conducted (Watzlawick et al. 1967). From this perspective, one cannot separate the person from the relationships of which they are a part. No person exists in a vacuum or lives independently from influencing and being influenced by others. Watzlawick et al. (1967) asserted that all behavior must be understood in the relational

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context of which it is a part and cannot be separated from that context. Therefore, relationships, communication, and interaction are seen as a vital key to understanding human behavior. This view of human relations considers the patterns of interactions and denotes a recursive nature, whereby each mutually participates in the dynamics that arise. Within family therapy, this is referred to as mutual or circular causality (Becvar and Becvar 1999). Typically, from a linear perspective, cause and effect are separated from the larger whole pattern of interaction and does not take into account those interactions that come before or after that particular sequence that has been abstracted. Systemically, linear cause and effect segments are only part of a larger circular whole (Keeney 1983). As Keeney (1982) described, “The fundamental act of epistemology is to draw a distinction . . .All that we know, or can know, rests upon the distinctions we draw” (p. 156), otherwise known as punctuation. A systemic perspective encourages a view of interaction and relationship – seeing that our thoughts, feelings, and behaviors are connected to the thoughts, feelings, and behaviors of another and can only be separated by punctuation or how the sequences are separated and focused upon by the observer (Watzlawick et al. 1967). How both the client and therapist punctuate the world and therapy and each other constructs a shared therapeutic reality (Keeney 1982). Language and “linguistic conditioning” also informs and constrains how we describe, define, and punctuate the stream of events around us – ultimately playing a major role in our epistemological frames and understanding (Selvini Palazzoli et al. 1978). From a systemic and cybernetic framework, the observer is just as important as those being observed. Viewing the observer as interconnected with what they are observing, studying that relationship between observer and observed, and recognizing that observations from the observer will always include the observer’s epistemological premises and subsequent actions based on those premises. This view became known as secondorder cybernetics (Keeney 1983). This means that therapy is also a relational context and could

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be defined as an interactional system within which the participants interact with one another for a given purpose. Keeney (1983) pointed out that operating from a nonlineal, cybernetic position in therapy accounts for and recognizes both the therapist’s and the client’s influence in the therapy system, stating that to focus on only the effect of the therapist on the client is one-sided and lineal. By seeing the therapist and client in a reciprocal relationship, everything that happens in therapy, how each participant thinks, feels, responds, and relates to one another indicates their own epistemology as well as a new shared epistemology about the nature of their relationship. This is a product of, and then in turn, influences the product of, that interaction and context. A systemic and cybernetic epistemology is a way of drawing distinctions about the world and therapy, which makes a significant difference in practice, the meanings that are made, and how therapy progresses. The concepts of epistemology, second-order cybernetics, and constructivism are inextricably linked. Ironically, as these concepts gained momentum, some began to challenge systemic/cybernetic premises that predominantly tied the variety of family therapy models together, calling for a “new epistemology” (e.g., Hoffman 1985; Goolishian and Anderson 1987). These authors summoned for a revisioning of family therapy and promoted a shift into “postmodern” approaches to therapy focused on an epistemology of language and meaning making systems. Yet, the way in which distinctions have been drawn around theory and ideas have spawned epistemological debates that have spanned throughout family therapy history from the very beginning. While the “modern/postmodern” distinction may be a more recent “us/them” divide in the family therapy field, competition and rivalry are no strangers to family therapy. In fact, thinking about epistemology and how we know what we know has been perpetuated through family therapy generations by drawing distinctions through the competition of ideas, models of therapy, and philosophies. Epistemological challenges to psychiatry defined the emergence of the family therapy field and continued through the development of certain “schools” or “camps” of family therapy

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and how they positioned themselves in contrast to others emerging. And, even though the family therapy “originators” often collaborated and co-developed the family therapy movement, the division of the “originators” into “schools” often obscured the common ground and connectivity of these theoreticians. As Minuchin and Nichols (1993) described, each theorist, researcher, “school,” of therapy honed in on and focused on a specific aspect of therapy and human life based on their biases, premises, ideas, perceptions, and clinical work distinguishing themselves from each other. Often these debates emulate a dualistic lineal thinking about ideas, without acknowledgement of the self-referential nature of making those distinctions, and have lacked viewing the systemic dynamics of the larger ecology of family therapy contributors and their philosophies as they evolved over time. In other words, the debates have failed to include a systemic epistemology of epistemology and how we know what we know in family therapy. And it can be argued that through a systemic epistemology of epistemology, one can find the patterns across epistemologies and identify the relationships between even seemingly opposite, dichotomous, or distinct epistemologies, specifically within family therapy. By redrawing the distinctions that have been made about family therapy ideas and how they have been portrayed over time, even reified distinctions can be transcended to a higher epistemological level to include the relationships between and patterns of connection such as the “modern/postmodern” dichotomy in family therapy (Simmons 2010). Keeney (1982) surmised “How we know (and don’t know) is inseparable from how we behave. . .Therapy becomes epistemology” (p. 167). “All description is self-referential” (Keeney 1983, p. 77) – what we say and do says just as much about our epistemology as it informs what we say and do, which informs our epistemology. Applying epistemology to how we think about our thinking, therapy, human behavior and include our participation in that equation may be one of the most significant contributions and distinctions of family therapy in relation to other social sciences and psychological disciplines.

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Application of Concept in Couple and Family Therapy Each approach to therapy has a theory of practice. Every approach is built on an epistemological framework informed by presuppositions and ideas guiding practice and how to interact with another person defined as a “client.” This philosophy will influence what the person will do when they come in contact with said “client.” As Kerr and Bowen (1988) asserted, “. . .a therapist is what his THEORY TELLS HIM TO BE” (p. 366). Moreover, this cannot be escaped. As Whitaker (1989) contended, “all psychotherapy is based upon a set of assumptions” (p. 159). And, Keeney and Sprenkle (1982) described theory as “. . .the relation between one’s epistemology and habits of action. . .” (p. 5). The therapist’s epistemology informs all aspects of their work and how they interact with clients. If a therapist’s epistemology stipulates that problems are the result of an illness, they will look for pathology and medical ways to cure the disease. If their epistemology permits symptoms to be seen in a larger systemic relational context, they may find something very different and develop vastly different strategies to assist that client. What the therapist sees indicates their epistemology – “. . .descriptions reveal properties of the observer” (Keeney 1982, p. 163). If the clinician’s theory of practice says that people are stuck because of the ways they have tried to solve the problem, they will try to help them find ways to solve their problem differently. If their theory of practice says people are in their office because they overlook their own resources, they will most likely try to help them discover their resources. If their theory of practice says that the way a person tells their story overlooks other ways to interpret and experience those events, they might help them find new ways to tell their story or discover/create overlooked hidden assets. If their theory of practice says that people have problems because they have poor boundaries, they most likely will help them have better, clearer boundaries. If their theory of practice says that in order to be helpful they must be creative in the moment, they will go in the room trying to be creative. If their theory of practice says that the

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way people talk about their problems constricts them, they might help open up space in the conversation to create new possibilities or ways of dialoguing about the problem. If their theory of practice says problems derive from a person’s irrational thoughts that drive problematic behavior, the therapist will work toward helping them have more rational thoughts. If their theory of practice says that problems are a result in how people relate to their problems and with each other, they will attempt to help them relate differently to their problems and each other. If the clinician believes symptoms are a result of disease or chemical imbalance, they may refer them to a medical doctor for medication and decide there is nothing they can do to help them. Each philosophy guides how the therapist will view everything, what direction they will take, what questions they ask, who and what they focus on, and how they will use themselves in the therapy room. This view will determine their intentions for their interaction with the client(s). Every therapist is intentional about how they approach clients, enter the room, utilize the session time, and interact with the people they are in the room with. While these may not be concrete steps, some type of organizing thought guides the person’s intentions when entering the therapy room. This too cannot be escaped. Intentionality is built into a therapist’s working philosophy about what they are doing, the purpose for them being there, and what it means to be a therapist. Whether a therapist is trying to provoke change, eliminate symptoms, help the system function better, change the dialogue and conversations people have, help people communicate better, elicit an experience that sparks growth, open up space for new possibilities to emerge, assist with new ways of thinking about things, or interacting with others etc., the therapist has in their mind the purpose of being in that room and charging that person for that session. The therapist has an intention just by being a therapist whether that is to make some money, help people, or sit and have a conversation with someone for an hour, there is purpose and intent implicit within the use of the space and time as well as the role of being a “therapist.”

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One cannot not have a therapeutic epistemology or influence in the therapy room; there is something that is guiding the thought process and behavior of the therapist while with a client. As Minuchin (1974) asserted, “the scope of the family therapist and the techniques he uses to pursue his goals are determined by his theoretical framework” (p. 14). And furthermore, "it must be recognized that techniques are designs or contrivances which implement a rationale of therapy" (Framo 1965, p. 149). And, the therapist’s epistemology is an accumulation of learned ideas that can derive from many places from science to graduate education to culture to personal experience. There are at least two ways this can be potentially detrimental or dangerous: if the therapist cannot, does not, or refuses to recognize the premises and epistemology they enter the room with and/or they rigidly adopt one position without variance. Both of these positions are limiting and can limit the possible avenues and directions a therapist may take. A therapist may not ask a vital question or use a potentially helpful tool because it does not fit within their epistemological framework. Anytime someone is focused in one direction, there are also many things they may not be seeing that fall outside of that epistemological view. And the client’s epistemology is relevant to how they will interpret and respond to the therapist and their approach. This dynamic give-andtake shape therapy, the nature of the therapeutic relationship, how therapy progresses over time or doesn’t, how the client and therapist treat each other and relate to one another and the outcome of therapy. When therapy is successful, the therapist and client have created a shared epistemology that works to meet the needs of that context.

Clinical Example Within this clinical example, we provide a vignette case example and illustrate both a systemic and a lineal epistemology. This example will demonstrate how two different epistemologies can influence the conceptualization of

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therapy, approach to treatment and the client, which can lead therapy in two different directions. Vignette Case Example Jose, a 25-year-old Mexican-American man, finds himself in your therapy office after his 5th DWI. From his intake paperwork, you know that he has previously been diagnosed with bipolar disorder, after being hospitalized a couple years ago, and takes medication on and off for this. He is on the verge of failing out of college, but indicates a desire to finish so he can be the first in his family to earn a college degree. In addition to going to college, he works part-time at a restaurant. He reveals that the latest DWI resulted from taking pills at a “pill party.” Lineal Epistemology You begin your work with Jose by asking him a series of questions to understand the etiology of his substance abuse, with a hunch that it may be related to not taking the medications for his bipolar disorder. This seems to be confirmed when he states that he hates having to take that “awful medication” they prescribed him that makes him “feel like a zombie.” Through your questions, you discover that he copes with pressure and failure by drinking and after he failed a major examination and therefore an important class, he drank too much and got his first DWI. You begin to explore what he is thinking when he is experiencing pressure that leads him to cope by drinking. He says the pressure makes it hard for him to concentrate and then he just knows he’s going to fail because he cannot think clearly. You begin to educate him on the problem with this way of thinking and how that contributes to him failing. You explore with him how he could think different thoughts when he is feeling pressured so that he could see the pressure differently. You also educate him on his substance abuse problem. You tell him that many people use substances to selfmedicate mental illness when they don’t take their medications as prescribed. You begin to reiterate the importance of taking his medication and that should make it less likely he would feel the need to medicate himself through alcohol or abusing pills. You let him know that if he keeps going on

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this path, he could end up a junkie, in jail and is likely to never finish school. You stress the importance of him attending the Alcoholics Anonymous group he was ordered to attend by the court in addition to your therapy so he can get back on the right track. You begin your therapy by setting goals for him to change his people, places, and things. His first homework assignment is to end his friendships with the “friends” getting him into trouble, many of which work at the restaurant where he works. You recommend that he should start looking for another job as well. Systemic Epistemology You begin your work with Jose by trying to learn more about how he views his situation, his attendance in therapy, and his perspective. You listen to the words he uses, how he describes his experiences and how he makes sense of them, in addition to observing any nonverbal communication cues. You begin to wonder how does it make sense that Jose finds himself in this situation? What is happening in Jose’s life and context that he would be hospitalized, receive a diagnosis of Bipolar Disorder, not consistently take the medication prescribed, attend a “pill party,” take pills, have 5 DWI’s, be failing college, but is still attending, is still able to work part-time and still have a goal of finishing his degree? You find out his first DWI was after he failed a final for one of his major courses, had couple of drinks and drove home. This occurred a few months before he was hospitalized for “attempting suicide.” He reveals that he hates having to take that “awful medication” they prescribed him that makes him “feel like a zombie.” As he talks about this, he hangs his head and says that he promised himself he’d never be like his abusive alcoholic father. You probe further and ask him about his relationship with his father. He shares that he comes from a very traditional Mexican family and his father embodies the stereotypical “machismo” role. Jose discloses it would get worse after his father would drink and would often take out his frustrations by yelling and hitting his mom, himself, and younger siblings from having to work two physically laborious jobs. Jose says he set out to attend college and be successful so

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that he wouldn’t have to work two jobs like his father and to help take care of his mom and younger siblings, but now he is failing and can’t deal with the thought of ending up like his father. You ask him more about what was going on in his life that he attempted suicide. He answers by saying the night before his final exam that he failed, he was eating dinner at home with his family and “things blew up.” His father became enraged at Jose saying he needed to help them more and quit school so he could be a man and help provide for his family. Jose says he was so upset by what happened the night before, he couldn’t concentrate and failed a major exam that was in a class he had to pass. He said after the first DWI things have been down-hill ever since. He states he just couldn’t take the pressure from his family, from school, from work and then with the court he’d find anything to feel free from that. Drinking with his buddies seemed to help and then one night his friend offered him a Xanax. This is how he ended up with a second DWI. After the third, he was hospitalized when he took three Xanax and drank too much. When the psychiatrist evaluated him prior to release, she determined that he was attempting suicide due to the amount of substances he had taken and involuntarily hospitalized him. He says the only things keeping him going are his job, knowing he has to work to survive, and the hope that one day he will get his degree so that he could have a better life. He says he’s never talked about any of this with anyone and it feels good to be able share what’s going on him with someone who gets it. You begin to see how much his family means to him and despite the difficulties in their relationships he says it’s important for him to be loyal to them. You begin to have some ideas about the relational context where Jose’s behavior makes sense. Through his story, you see that Jose is doing the best he can in very difficult circumstances. It becomes clear that the concerns for and about his family, his culture, and epistemology have something to do with the situation he finds himself in. You begin to focus your questions and work around the interactional context between Jose and his family, as well as how he

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participates in that dynamic. You also want to help him work toward his goals of being loyal to his family, while not having to be just like them, and finishing school. Together with Jose, you both explore ways to work toward these goals where drugs and alcohol are no longer problematic for him and discuss the possibility of inviting his family to therapy.

Cross-References ▶ Bateson, Gregory ▶ Circular Causality in Family Systems Theory ▶ Communication Theory ▶ Context in Family Systems Theory ▶ Hoffman, Lynn ▶ Keeney, Bradford ▶ Linear Causality in Family Systems Theory ▶ Postmodernism in Couple and Family Therapy ▶ Punctuation in Family Systems Theory ▶ Second-Order Cybernetics in Family Systems Theory

References Bateson, G. (1972). Steps to an ecology of mind. New York: Ballantine. Bateson, G. (1979). Mind and nature. New York: Dutton. Becvar, D. S., & Becvar, R. J. (1999). Systems theory and family therapy: A primer (2nd ed.). Lanham, MD: University Press of America. Becvar, D. S., & Becvar, R. J. (2013). Family therapy: A systemic integration (8th ed.). New York: Pearson. Framo, J. (1965). Rationale and techniques of intensive family therapy. In I. Boszormenyi-Nagy & J. Framo (Eds.), Intensive family therapy: Theoretical and practical aspects (pp. 143–212). New York: Harper & Row. Goolishian, H., & Anderson, H. (1987). Language systems and therapy: An evolving idea. Psychotherapy, 24(35), 529–538. Hammond, D. (2003). The science of synthesis: Exploring the social implications of general systems theory. Boulder: University Press of Colorado. Hoffman, L. (1985). Beyond power and control: Toward a “second-order” family systems therapy. Family Systems Medicine, 3(4), 381–396. Keeney, B. (1979). Ecosystemic epistemology: An alternative paradigm for diagnosis. Family Process, 18(2), 117–129. Keeney, B. (1982). Not pragmatics, not aesthetics. Family Process, 21(4), 429–434.

Epstein, Nathan Keeney, B. (1983). Aesthetics of change. New York: Guilford Press. Keeney, B., & Sprenkle, D. (1982). Ecosystemic epistemology: Critical implications for the aesthetics and pragmatics of family therapy. Family Process, 21, 1–19. Kerr, M., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. New York: W.W. Norton. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Nichols, M. P. (1993). Family healing: Strategies for hope and understanding. New York: Free Press. Ray, W. A., & Borer, M. (2007). Tracking talk in therapy12 useful maps. Journal of Brief, Strategic Therapies, 1(1), 69–84. Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox: A new model in the therapy of the family in schizophrenic transaction. New York: Jason Aronson. Simmons, B. S. (2010). Family therapy legacies and the patterns that connect: Transcending the modern/postmodern dichotomy in family therapy. Retrieved from ProQuest Dissertations & Theses A&I. (3446927). Watzlawick, P., Beavin Bavelas, J. H., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York: W.W. Norton & Company. Watzlawick, P. (Ed.). (1984). The invented reality: How do we know what we believe we know? (contributions to constructivism). New York: W.W. Norton. Whitaker, C. (1989). Midnight musings of a family therapist. New York: W.W. Norton.

Epstein, Nathan Kamran K. Eshtehardi and Molly F. Gasbarrini California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Name of Person Dr. Nathan B. Epstein

Introduction Dr. Nathan B. Epstein is the primary originator of the McMaster model of family functioning (MMFF). The MMFF is a theoretical basis for

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understanding, assessing, and diagnosing family functioning. Using the MMFF as a foundation, Dr. Epstein created a treatment model called the problem-centered systems therapy of the family (PCSTF), a therapeutic approach that focuses primarily on the overall stages of therapy rather than specific interventions and strategies. Together, the MMFF and PCSTF constitute the McMaster approach to family therapy. In addition, Dr. Epstein helped create instruments and a structured interview used in the practice of the McMaster approach.

Career In 1948, Dr. Epstein received his M.D. at the Dalhousie University Faculty of Medicine in Canada. He completed his internship at Boston University Medical Center and residency in psychiatry at the Columbia University School of Public Health. While at Columbia University, Dr. Epstein trained with Dr. Nathan Ackerman, another pioneer in the field of family therapy. Following his training at Columbia University, Dr. Epstein and his colleagues at McGill University in Montreal, Canada, began research in the area of family studies. His research lab was moved to McMaster University in Ontario, Canada, in 1966, where he became a founding chair of the Department of Psychiatry, and held that position until 1975. In 1980, Dr. Epstein and his colleagues, Dr. Duane Bishop and Dr. Gabor Keitner, moved their research to Brown University in Providence, Rhode Island, where he created the Brown University Family Research Program.

Contributions to the Profession Dr. Epstein is recognized as the primary developer of the McMaster model of family functioning (MMFF), a comprehensive and normative family model that integrates validated assessment instruments and an evidence-based family treatment process. Dr. Epstein began development of the model in the mid-1950s at McGill University. During this time, Epstein and his colleagues

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sought to describe various dimensions of family life and developed a classification system called the Family Category Schema. It was after Epstein moved to McMaster University that the Family Category Schema evolved into the MMFF. Subsequently, at Brown University, Epstein and his colleagues continued to refine and build upon the MMFF. In 1981, Drs. Epstein and Bishop published a model for conducting therapy based on the MMFF called the Problem centered systems therapy of the family (PCSTF). The PCSTF approach shifted the focus from subtle interventions and strategies to the overall stages of therapy as the essential components of treatment. By utilizing this structure, the PCSTF sought to facilitate effective treatment by therapists of various styles and levels of experience. Research findings on the efficacy of the PCSTF have shown positive treatment outcomes for patients and families managing depression and bipolar disorders. In 1982, Epstein and his colleagues Dr. Lawrence Baldwin and Dr. Bishop published an instrument based on the MMFF called the McMaster family assessment device (FAD). The FAD, a self-report questionnaire used to gather measureable feedback from family members, assessed family functioning by incorporating each of the family members’ perceptions of the family’s functioning. The FAD has been used in a variety of settings and cultures and has been translated into over 20 different languages. The McMaster clinical rating scale (MCRS) was also developed in 1982 by Epstein and his colleagues. The MCRS evaluated family functioning through a clinical interview conducted by a therapist familiar with the MMFF. The MCRS provided an objective summary of the various dimensions that contributed to a family’s functioning and acted as a guide that enabled a therapist to perform a thorough evaluation of the patient and family members. The MCRS was designed to be flexible in that it could be tailored to the needs of the family and the therapeutic environment, and it correlated moderately with the FAD. The McMaster structured interview of family functioning (McSiff) was developed in 1987 by

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Dr. Epstein and his colleagues as an alternate means of producing an MCRS score in situations where the interviewer is clinically inexperienced or unfamiliar with the McMaster approach. In addition, the McSiff is used by therapists to gain experience in interviewing, to learn therapeutic structure, and as a teaching tool for learning the McMaster approach.

Cross-References ▶ Family Assessment Device ▶ McMaster Clinical Rating Scales ▶ McMaster Family Therapy

References Epstein, N. B., & Bishop, D. S. (1981). Problem centered systems therapy of the family. Journal of Marital and Family Therapy, 7(1), 23–31. Epstein, N. B., Bishop, D. S., & Levin, S. (1978). The McMaster model of family functioning. Journal of Marriage and Family Counseling, 4(4), 19–31. Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The McMaster family assessment device. Journal of Marital and Family Therapy, 9(2), 171–180. Miller, I. W., Kabacoff, R. I., Epstein, N. B., Bishop, D. S., Keitner, G. I., Baldwin, L. M., & Van der Spuy, H. J. (1994). The development of a clinical rating scale for the McMaster model of family functioning. Family Process, 33(1), 53–69. Ryan, C. E., Epstein, N. B., Keitner, G. I., Miller, I. W., & Bishop, D. S. (2005). Evaluation and treating families: The McMaster approach. New York: Routledge/Taylor & Francis Group.

Epstein, Norman Mariana K. Falconier Virginia Polytechnic Institute and State University, Falls Church, VA, USA

Introduction Dr. Norman Epstein is a clinical psychologist and marriage and family therapist, clinical and research supervisor, teacher, and researcher

Epstein, Norman

focusing on cognitive-behavioral theory, assessment, and treatment of couples and families, with a systemic lens and special attention to domestic violence and culturally sensitive treatment models.

Career Dr. Epstein obtained his Bachelor of Arts, Master of Arts, and Doctoral degrees in psychology from the University of California at Los Angeles in 1969, 1970, and 1974, respectively. He was first an assistant professor in the Department of Psychology at the State University of New York at Buffalo and in Psychology in Psychiatry at the School of Medicine at the University of Pennsylvania. In 1983 he joined the Department of Family Science (former Department of Family Studies) at the University of Maryland, College Park as an assistant professor, and was promoted to associate professor in 1986 and professor in 1992. He has been director of the department’s nationally accredited Couple and Family Therapy Program since 2003. He has taught both graduate and undergraduate courses on theory and research on couple and family relationships, couple and family therapy, research methods, and human sexuality, has provided clinical supervision to student therapists, and directed over 85 master’s theses and doctoral dissertations. He has held licenses as both a clinical psychologist and clinical marriage and family therapist in Maryland where he has had a part-time private practice for over 40 years. He has presented 120 research papers as well as 88 training workshops on couple and family therapy at national and international professional meetings. He has also authored 56 book chapters (at least 50 in cognitive theory and cognitive-behavioral family and couple therapy) and 58 peer-reviewed journal articles. He has coauthored two books on cognitivebehavioral therapy for couples and has edited two more books. His work has received media attention through appearances in radio talk shows and published interviews in newspapers of wide circulation such as the New York Times,

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Washington Post, Baltimore Sun, Los Angeles Times, and Wall Street Journal. He is an approved supervisor of the American Association of Marriage and Family Therapy (AAMFT) and is a clinical fellow of AAMFT, a fellow of the American Psychological Association, a member of the Association for Behavioral and Cognitive Therapies, a member of the Groves Conference on Marriage and the Family, a diplomate of the American Board of Assessment Psychology, and a founding fellow of the Academy of Cognitive Therapy. Dr. Epstein has been the recipient of awards for his contributions in community mental health and the prevention of domestic violence, and his research has been funded by NIMH, SAMHSA, and the Henry M. Jackson Foundation for the Advancement of Military Medicine. He has been on the editorial boards of the Journal of Cognitive Psychotherapy, Psychological Assessment, Behavior Therapy, the Journal of Marital and Family Therapy, Family Process, Cognitive and Behavioral Practice, Journal of Sex and Marital Therapy, Journal of Couple and Relationship Therapy, and International Journal of Cognitive Therapy.

Contributions to Profession Dr. Epstein’s main contributions lie in the area of cognitive-behavioral theory, assessment, and treatment of couples and families, including the area of domestic violence. He also has focused on understanding and treating individual psychopathology within the family context. Regarding individual functioning and psychopathology, Dr. Epstein worked with Dr. Aaron Beck at the Center for Cognitive Therapy in Philadelphia and contributed to the development and assessment of the widely used Beck Anxiety Inventory (Beck et al. 1988) and the Beck Self-Concept Test (Beck et al. 1990). However, his research and clinical work increasingly focused on couples and families. He published the first description of cognitive therapy with couples (Epstein 1982) and articles describing the development of the first measure of couple relationship cognitions, the Relationship

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Belief Inventory (Epstein and Eidelson 1981; Eidelson and Epstein 1982). Subsequently he conducted an extensive collaboration with Donald Baucom, investigating the role of cognitions in the functioning of intimate relationships. This work led to their typology of cognitions, including assumptions, attributions, standards, expectancies, and selective attention (Baucom et al. 1989), their development of an instrument to measure relationship standards, the Inventory of Specific Relationship Standards (Baucom et al. (1996), and two groundbreaking books on cognitive-behavioral couple therapy (Baucom and Epstein 1990; Epstein and Baucom 2002). Dr. Epstein also developed the Marital Attitude Survey with James Pretzer and Barbara Fleming (Pretzer et al. 1991) that assesses attributions and expectancies. Dr. Epstein played a major role in incorporating systemic concepts into cognitivebehavioral treatment by emphasizing the interplay among partners’ cognitions, emotions, and behaviors so that problematic patterns of interaction could be better understood and changed. His work has been praised for its integration in assessment and treatment of partners’ individual characteristics and personal histories and their past and present dyadic interactions. Dr. Epstein developed a cognitive-behavioral intervention protocol to safely treat couples experiencing psychological and mild to moderate physical partner aggression and conducted a clinical trial, the Couples Abuse Prevention Program (CAPP), comparing it to other systemic models of couple therapy. In addition to his university teaching and research, Dr. Epstein has disseminated his cognitivebehavioral treatments for couples and families internationally, but he has especially provided extensive training in China regarding couple and family therapy models, contributing to the rapid growth of such treatment approaches there, and has published articles on culturally sensitive adaptations of Western-derived therapy models in China. He has also conducted several studies with colleagues in China advancing knowledge about couple and family relationships. Furthermore, consistent with his focus on psychopathology in the family context, Dr. Epstein has been

Epstein, Norman

involved in the implementation and evaluation of a family psychoeducational intervention program for schizophrenia and an evaluation of effects on family relationships of engaging military service members with posttraumatic stress disorder in training in service dogs for placement with physically disabled service members.

Cross-References ▶ Baucom, Donald ▶ Cognitive Behavioral Couple Therapy

References Baucom, D. H., Epstein, N., Rankin, L. A., & Burnett, C. K. (1996). Assessing relationship standards: The inventory of specific relationship standards. Journal of Family Psychology, 10, 72–88. Baucom, D. H., Epstein, N. B., Sayers, S., & Sher, T. G. (1989). The role of cognitions in marital relationships: Definitional, methodological, and conceptual issues. Journal of Consulting and Clinical Psychology, 57, 31–38. Baucom, D. H., & Epstein, N. (1990). Cognitive behavioral marital therapy. New York: Brunner/Mazel. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–7. Beck, A. T., Steer, R. A., Epstein, N., & Brown, G. (1990). Beck Self-Concept Test. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2(2), 191–197. https://doi.org/10.1037/1040-3590.2.2.191 Eidelson, R. J., & Epstein, N. (l982). Cognitio n and relationship maladjustment: Development of a measure of dysfunctional relationship beliefs. Journal of Consulting and Clinical Psychology, 50, 715–720. Epstein, N., & Eidelson, R. J. (l98l). Unrealistic beliefs of clinical couples: Their relationship to expectations, goals, and satisfaction. American Journal of Family Therapy, 9, 13–22. Epstein, N. (l982). Cognitive therapy with couples. American Journal of Family Therapy, 10, 5–16. Epstein, N., & Baucom, D. H. (2002). Enhanced cognitivebehavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Pretzer, J., Epstein, N., & Fleming, B. (1991). The marital attitude survey: A measure of dysfunctional attributions and expectancies. Journal of Cognitive Psychotherapy: An International Quarterly, 5, 131–148.

Epston, David

Epston, David Peggy Sax1, Kay Ingamells2, Dean Lobovits3 and Sasha McAllum Pilkington4 1 Re-authoring Teaching, Inc, Middlebury, VT, USA 2 Narrative Apprenticeship, Auckland, New Zealand 3 Narrative Approaches, Berkeley, CA, USA 4 Hospice North Shore, Auckland, New Zealand

Name David Epston.

Introduction David Epston is the co-creator of Narrative Therapy – a collaborative and nonpathologizing approach to family therapy, counseling, and community work that centers people as the experts of their own lives and identities. The intellectual partnership between David Epston and Michael White initiated in 1980 founded a narrative family therapy framework infused with a spirit of adventure and invention based on a shared political philosophy. Narrative Therapy views problems as separate from people and engages people in re-authoring the stories of their lives by developing counter storylines that revive and vivify hopeful, preferred ways of living and being in relationships. David has disseminated this approach for 30 years through his teaching and lively collaborations with partners in 19 countries and has authored or co-authored ten books that have been translated into many languages.

Career David Epston was born in 1944 in Peterborough, Ontario, Canada. At 19, he arrived by tramp steamer in New Zealand. After completing a BA degree in

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Sociology & Anthropology at Auckland University (1969), he returned to Canada to study sociology at the University of British Columbia, and then earned a Diploma in Community Development from Edinburgh University in 1971. He spent time in Australia working for the Department of Aboriginal Welfare in the Northern territory before returning in 1973 to New Zealand to work as a medical social worker. In the United Kingdom, he then studied Applied Social Studies and Social Work at the University of Warwick. He rigorously researched the videotapes of legendary family therapists at The Family Institute in Cardiff, Wales. His studies established the influences of anthropology, social constructionism, Foucault, and Milton Erickson. Returning to New Zealand, David worked as a senior social worker in a Child and Adolescent Mental Health Service and as a consultant family therapist at the Leslie Centre in Auckland (1981–1987). With Johnella Bird, he developed a teaching partnership and they became co-directors of The Family Therapy Centre in Auckland. David has lectured extensively at home in New Zealand and through workshops and guest lectures around the world. After Michael’s death, he continued a long-standing association with The Dulwich Centre in Adelaide. From its inception in 1980 until 1990, David was editor of Story Corner in the Australian and New Zealand Journal of Family therapy. From 2006–2017, he was editor of The Story Corner in the Journal of Systemic Therapies. Together with Tom Stone Carlson and Marcela Polanco, he is current co-editor of an online Journal of Narrative Family Therapy. In 1996, David was awarded an honorary Doctor of Humane Letters (D.Litt.) by the Graduate School of Professional Psychology, John F. Kennedy University, in Orinda, California. He received a Special Award for Distinguished Contributions to Family Therapy from the Australian and New Zealand Journal of Family Therapy (2002) and from AFTA (American Association of Family Therapy) in 2007 for Distinguished Contribution to Family Therapy Theory and Practice.

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Epston, David

Contributions to the Profession

Cross-References

David Epston’s collaboration with Michael White was founded on a shared commitment to creating a partnership without competition. Together they co-authored Narrative Means to Therapeutic Ends – and developed much of the theory and practices of narrative therapy. David is known for bringing an ethnographic and auto-ethnographic approach to narrative practice. Collecting a library of videotapes of young people’s “asthma knowledges,” he coined the term “co-research” to signify a collective approach to narrative practice. Additional collective insider knowledge projects include: The Antianorexia League and the internet-based Archive of Resistance: anti-anorexia/anti-bulimia. David pioneered therapeutic letter writing as a narrative therapy practice. He brought radical and inventive approaches to such childhood problems as intractable sibling disputes, chronic bedwetting, extreme temper tantrums, stealing, fears, and responses to trauma. He has developed a significant number of breakthrough books and website collaborations internationally. His innovations include creating and developing: Story and Counter-story, Mapping the Unmapped Practice, Stories as Pedagogy, Internalized Other Interviewing, and Insider Witness Practices. Through his rigorous, careful, and playful attention to therapeutic questions, he has invented genres of questions such as: Haunting from the Future questions, Wonderfulness and Weird Abilities inquiries with children, and Researching a Person’s Moral Character. As Narrative Therapy develops throughout the world, David is fiercely committed to honoring local knowledge and context, resisting the colonization of cultural ideas, and imagining narrative therapy within many cultural contexts and insider communities. In his endeavors to create a history for the future while supporting others to co-invent and re-invent narrative therapy, he actively joins with and supports partners in Mexico, Columbia, Chile, Brazil, Scandinavia, Spain, France, Switzerland, Belgium, the Netherlands, Britain, Canada, the USA, Israel, South Africa, India, Korea, and Japan.

▶ Deconstruction in Narrative Couple and Family Therapy ▶ Deconstructive Listening in Couple and Family Therapy ▶ Externalizing in Narrative Therapy with Couples and Families ▶ Narrative Couple Therapy ▶ Poststructuralism in Couple and Family Therapy ▶ Problem-Saturated Stories in Narrative Couple and Family Therapy ▶ Re-authoring Teaching ▶ White, Michael ▶ Witnessing in Narrative Couple and Family Therapy

References Epston, D. (2008). In B. Bowen (Ed.), Down under and up over: Travels with narrative therapy. London: Karnac Books. Epston, D. (2016). Re-imagining narrative therapy: A history for the future. Journal of Systemic Therapies, 35(1), 79–87. Epston, D., Maisel, R., & Borden, A. (2004). Biting the hand that starves you: Inspiring resistance to anorexia/ bulimia. New York: Norton. Epston, D., Marsten, D., & Markham, L. (2016). Narrative therapy in wonderland: Connecting with Children’s imaginative know-how. New York: Norton. Freeman, J., Epston, D., & Lobovits, D. (1997). Playful approaches to serious problems: Narrative therapy with children and their families. New York: Norton. Niania, W., Bush, A., & Epston, D. (2017). Collaborative and indigenous mental health therapy: Tātaihono – Stories of Maori healing and psychiatry. New York: Routledge. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton. White, M., & Epston, D. (1992). Experience, contradiction, narrative and imagination: Selected papers of David Epston & Michael White, 1989–1991. Adelaide: Dulwich Centre Publications.

Websites http://www.journalnft.com http://www.narrativeapproaches.com http://www.reauthoringteaching.com

Equifinality in Family Systems Theory

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Description

Equifinality in Family Systems Theory Sarah K. Samman1 and Jessica M. Moreno2 1 Alliant International University, San Diego, CA, USA 2 California State University, Sacramento, Sacramento, CA, USA

Equifinality in family systems theory is the belief that the use of different theoretical orientations and interventions often results in a given end state, goal, or outcome. This implies that in open systems, namely, social systems, clinicians have permission to align with any specific theoretical or clinical modality with the understanding that the system will largely effect similar changes and outcomes.

Name of Concept Equifinality in family systems theory

Introduction Equifinality is both a term and concept adopted across various disciplines including archaeology, biology, business, and psychology. Proponents of the concept commonly believe that various means and/or developmental paths lead to similar end states or outcomes. Within the discipline of couple and family therapy, equifinality refers to an open and flexible position and mindset by a therapist. This is based on the belief that different treatment modalities from various theoretical orientations possess the same potential to yield similar results when treating couples and families.

Application of Concept in Couple and Family Therapy According to Kapsali (2009), in order to apply the concept of equifinality to an open or social system such as that of a couple or family, a therapist would (1) recognize there is more than one method to effect change and achieve outcomes, (2) commit to therapeutic flexibility within a chosen therapeutic modality during case conceptualizing and intervention implementation, and (3) consider the match of client factors such as personality traits with different treatment modalities (Luborsky et al. 2002) as well as client strengths, commitment, participation, and alliances.

Clinical Example Theoretical Context for Concept Hans Driesch, a German developmental biologist and philosopher, coined the term equifinality as well as established its meaning and concept from his philosophy of potentials at the beginning of the twentieth Century (Sato 2011). Ludwig von Bertalanffy, the founder of general systems theory, later used and applied the concept of equifinality to open and closed systems such as social systems (Drack and Pouvreau 2015). When describing social systems, Driesch and von Bertalanffy preferred referring to the concept of equifinality rather than focusing on a specific end goal or state.

The Johnson family is a Native-American Sioux family that lives together on a reservation in the United States of America. The family is comprised of Shelley Ska, a 40-year-old cisgender female; Martin Mato, a 38-year-old cisgender male; Curtis Chaska, their biological 16-yearold cisgender son; and Ska’s father and tribe elder, Tom Takoda, a 68-year-old cisgender male. The family reported Chaska’s school counselor referred them to family therapy because Chaska appears to struggle with symptoms of depression and recent suicidal ideation in response to bullying from seniors at his high school. Ska, Mato, and Takoda reported feeling

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blessed to have access to family therapy and experienced positive outcomes for similar mental health symptoms when Chaska was 8-yearsold. The family reported they previously worked with an experiential therapist and Ska and Mato were hopeful, yet cautious, that pursuing family therapy with a solution-focused therapist would not yield similar results. The therapist assured the family that their fears and concerns for the well-being of their family were valid. She also reflected that concerns were warranted considering their sociocultural status as a Sioux family with limited financial and healthcare resources as well as culturally appropriate caution in response to educational and mental health services involvement. The therapist explained that contrary to popular belief and despite therapists’ specialized training in various therapeutic modalities and interventions, different modalities such as experiential and solution focused have major components and elements in common that result in insignificant differences in therapeutic outcomes. The therapist, committed to cultural responsivity, requested permission to address their concerns and reassure them that their contributions significantly affect the therapeutic experience. Once the family agreed, the therapist shared family strengths in responding to their child’s needs and well-being, seeking out mental health services, demonstrating previous and current commitment and participation in therapy, and interest in building alliances with the therapist to effect systemic change. The therapist highlighted that these client factors in addition to the concept of equifinality will most likely result in similar outcomes even when using a different therapeutic modality.

Cross-References ▶ Common Factors in Couple and Family Therapy ▶ Systems Theory ▶ von Bertalanffy, Ludwig

Erectile Disorder in Couple and Family Therapy

References Drack, M., & Pouvreau, D. (2015). On the history of Ludwig von Bertalanffy’s “general systemology”, and on its relationship to cybernetics – part III: Convergences and divergences. International Journal of General Systems, 44(5), 523–571. https://doi.org/10.1080/ 03081079.2014.1000642. Kapsali, M. (2009). Comparing the application of closed and open systems approaches in innovation project management. The Systemist, 33, 31–46. Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P., Berman, J. S., Levitt, J. T., et al. (2002). The dodo bird verdict is alive and well – mostly. Clinical Psychology: Science and Practice, 9(1), 2–12. https://doi.org/ 10.1093/clipsy.9.1.2. Sato, T. (2011). Minding money: How understanding of value is culturally promoted. Integrative Psychological and Behavioral Science, 45(1), 116–131. https://doi. org/10.1007/s12124-010-9142-7.

Erectile Disorder in Couple and Family Therapy Barry McCarthy and Danielle Cohn American University, Washington, DC, USA

Name of Concept Biopsychosocial model of assessment, treatment, and relapse prevention

Introduction When Viagra (sildenafil) was introduced in 1998, it was a common belief that a stand-alone medical intervention would resolve erectile disorder (ED). ED is the major cause of secondary male hypoactive sexual desire disorder (HSDD). The mistaken assumption underlying this belief was that male HSDD would dramatically be reduced with assured erectile function. Rather than solve ED, many men felt like “Viagra failures” and gave up on couple sex, leading to a shockingly high Viagra dropout rate. Some clinicians believe that Viagra

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has caused more nonsexual relationships since 1998 than anything else in history (Metz and McCarthy 2004).

Theoretical Context for Concept The great majority of men learn sexual response in adolescence and young adulthood in an autonomous manner in which he experiences spontaneous erections, transitions to intercourse, and orgasm on his first erection; consequently, sexual function is 100% predictable. A key factor in autonomous sex is that he needs nothing from his partner in order to experience desire, erection, and orgasm. Unfortunately, this conceptualization has become the typical model of male sex in the media as well as among male peers and even physicians. Over time, especially after age 40 and when in an intimate relationship, this model can become oppressive and self-defeating. Erection and intercourse becomes an individual pass-fail performance test. With the introduction of Viagra, the biomedical community, driven by ads and marketing, asserted that solely the “blue pill” would return the man to the sex function of his youth.

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confidence by viewing sexuality as a “couple process” with mutual giving and receiving of pleasure-oriented touch, rather than as an individual pass-fail test of erection and intercourse. This framework involves two core concepts. First, sexuality involves sensual, playful, and erotic touch in addition to intercourse, which runs counter to the “sex equals intercourse” myth, which is commonly believed and needs to be confronted. The second concept is the replacement of the perfect performance model with the Good Enough Sex (GES) model (Metz and McCarthy 2012). GES affirms that couple sexuality is variable and flexible in nature. The majority of sexual encounters (85%) flow from comfort to pleasure to arousal to erotic flow to intercourse and orgasm. When sex does not flow, the man comfortably transitions to a sensual or erotic alternate scenario or asks for a “rain check.” Apologizing or panicking is unnecessary and self-defeating. The healthy sexual cycle is positive anticipation, pleasure-oriented sexuality that flows to intercourse, and a regular rhythm of sexual connection. The negative cycle is anticipatory anxiety, tense performanceoriented intercourse, frustration, embarrassment, and sexual avoidance.

Description

Application of Concept in Couple and Family Therapy

There is a growing consensus among mental health professionals and sex therapists that a biopsychosocial model of assessment and treatment of ED is superior to the biomedical approach (Rosen et al. 2014). McCarthy and Wald (2017) argue that the most important factor in a comprehensive approach to ED is psychological in nature and thus advocate for a biopsychosocial model. They also maintain that it is crucial to expand the definition of sexuality from one in which sex equates to intercourse to one in which sexuality involves sensual, playful, and erotic touch in addition to intercourse. A new model of male sexuality (McCarthy and Metz 2008) emphasizes the importance of building erectile comfort and

A major cause of sexual problems when using Viagra is that the man rushes to intercourse as soon as he gets an erection because he fears losing his erection. Erectile psychosexual skill exercises are utilized to increase erectile self-efficacy. First, the man does not transition to intercourse until subjective arousal is a “7” or “8” on a scale of 1–10, in which “10” is orgasm. During intercourse, he enhances erotic flow by utilizing multiple forms of stimulation, including fantasies as well as giving and receiving erotic touch. Second, the couple uses the “wax and wane” erection exercise. This exercise involves using physical relaxation and self-entrancement arousal for an “easy erection.” Once this is achieved, they stop

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touching so that the erection wanes. The couple remains mindful and open to sensual and playful touch so the erection will wax again. They then allow it to wane a second time, after which they proceed to orgasm on his third erection. Although men do not enjoy this exercise, it increases awareness of the role of relaxation in sexual arousal and teaches them an anti-panic strategy. He learns not to panic when his erection wanes as well as increases his confidence that his erection will return with relaxation and pleasuring. As the physiological process underlying pro-erection medications is the relaxation of penile muscles and subsequent enhancement of blood flow to the penis, this exercise is able to achieve more by comparison. The biopsychosocial model of understanding, assessing, and treating ED is compatible with the couple/family therapy approach. Whether the primary cause of ED is biomedical, psychological, relational, or social, ED has a profound impact on the man and couple. ED is best understood and addressed within the context of the complexity of its meaning to the man, woman, and couple. ED not only affects the man sexually but also the partner; furthermore, it can devitalize their relationship and threaten relational security. Depression, drug and alcohol abuse, shame, and avoidance are all common reactions to ED. Integrating Medical Interventions into the Couple Sexual Style The hope is that medical interventions will become more efficacious and user-friendly in the future. At present, there are three major types of medical interventions for ED: pro-erection medications, penile injections, and testosterone enhancement. The most popular medications are Viagra (sildenafil) and Cialis (tadalafil). Although few men report the miracle cure promised by the ads, these medications are a valuable therapeutic resource. Reports of efficacy vary from 65% to 85% of encounters resulting in successful intercourse. These rates are promising; however, there is a high dropout rate, which is caused by the drug’s inability to return the man to totally predictable, autonomous erections. In choosing Viagra versus Cialis, the core issue is not efficacy

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of the medication, but rather the ease of integrating the medication into the couple style of intimacy, pleasuring, and eroticism; another important issue constitutes side effects. Viagra is especially valuable for procrastinators and those men who prefer structure, since it presents a 1–4 h window of opportunity for sex. For many couples, Cialis is the preferred medication because it presents a window of opportunity that ranges from 30 min to 30 h, which promotes sexual freedom and choice. The daily low-dose Cialis can easily become part of his routine. The popularity of testosterone enhancement is driven by ads about “low T.” There is no doubt that for the man with very little or no testosterone, this form of treatment can be a valuable therapeutic resource to enhance desire. Two major concerns include that it is very difficult to conduct an assessment of testosterone levels, and there is a tendency to overprescribe testosterone in ways that alarm endocrinologists. In addition, the effect of testosterone on erectile dysfunction is unclear and quite complex. Using testosterone as a standalone intervention for ED has little empirical or clinical support. Penile injections are very effective in producing reliable erections. However, they suffer from an extremely high dropout rate. Typically, the more intrusive the medical intervention is, the more efficacious it is and the greater the challenge is to integrate it into the couple sexual style. In using penile injections, one important question is whether the man or the woman will administer the injection. A second question is whether they will start with the injection or engage in sensual and playful touch to enhance subjective arousal before doing the injection. The core issue is learning to integrate the penile injection with the couple style of intimacy, pleasuring, and eroticism. The woman may complain that his penis feels like a dildo. He may have a hard time ejaculating because he is not subjectively aroused. Both may report that it feels strange that he does not lose his erection after ejaculation. Usually, it is men who stop using injections because they feel awkward and antierotic. These problems are similar to complaints about the external penile pumps, the medicated urethral system for erection (MUSE)

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system, and the penile prosthesis. They focus so heavily on erectile performance that they reduce sexual desire, playfulness, subjective arousal, and the couple’s feelings of being an intimate sexual team. In treating ED, the context of desire/pleasure/ eroticism/satisfaction has a central role. The fatal flaw of the medical approach is that it requires the medication or medical procedure to be the only solution. This builds performance anxiety and negates the concept of sexuality as an intimate sexual team process. By its nature, couple sexuality is variable and flexible with a number of roles, meanings, and outcomes. Sexuality is a team process of sharing pleasure. Although the Good Enough Sex (GES) model is a challenge for men to adopt, it is a core element in regaining self-efficacy with erectile function. The essence of GES is that the couple’s approach is desire/pleasure/eroticism/satisfaction. A guideline is that 85% of sexual encounters should flow from pleasure to arousal to erection and then intercourse and orgasm. Rather than panicking or apologizing when that sequence of events does not occur, the couple transitions to a sensual scenario or a synchronous erotic scenario, though it is important to note that asynchronous scenarios are also positive (McCarthy 2015). The core of GES is the recognition that couple sexuality can be positive without erection and intercourse. Whether it occurs once a month, once every ten times, or once a year, it is normal to not have an erection sufficient for intercourse. This is true for the great majority of adult men, especially those ages 50 and older. This is true of both gay and straight men; treatment of ED is of importance to gay couples as well. When the man and couple believe that perfect intercourse performance is the definition of male sex, they always feel vulnerable to ED. Healthy couple sexuality is anti-perfectionistic, and this is important for individuals to keep in mind. Lindau and colleagues (2007) examined sexual function between ages 58 and 85 and found that sexual satisfaction increases with aging. Fundamental to this satisfaction is the recognition of the multiple roles, meanings, and outcomes of

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couple sexuality. If sexuality were about predictable erections and orgasms, men and women would masturbate rather than engage in couple sex. Couple sexuality, by nature, is variable and flexible. GES is relevant when using medical as well as psychosexual interventions. Although penile injections produce more reliable erections, they do not return the man to autonomous, 100% predictable erections. Men who use Viagra or Cialis experience successful intercourse less than 90% of the time. Hoping that the medical intervention will do it all and enable the man to meet unrealistic performance standards is a common trap for physicians and clients alike. For many men, the combination of vascular effects and the placebo effect facilitates erectile confidence; however, this combination also puts the man in a vulnerable position in which he is one erectile failure from feeling hopeless about ED. The Partner’s Role in Promoting GES GES receives little acceptance from male peers, physicians, or the media. In heterosexual couples, the woman’s support is crucial in enabling the man to embrace GES. When practicing GES, a therapist will instruct, “Traditional men stop being sexual between ages 50 and 60, whereas ‘wise men’ can be sexual in their 60s, 70s, and 80s.” Women find GES easier to accept because it is congruent with female sexual socialization and lived female sexual experiences. Men view GES as “settling,” “feminizing,” and “wimpy,” indicating that he is not “man enough.” In fact, “wise men” are the ones who beat the odds and enjoy sexuality with aging. An important psychosexual skill is for the man to learn how to “piggyback” his arousal on his partner’s. With aging, many women find arousal and orgasm easier than her partner does. Men who welcome this experience will continue to enjoy couple sexuality rather than feel intimidated by this change.

Clinical Example To illustrate these concepts, a couple who had been together since adolescence and who had

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now been together for more than 55 years were in therapy. The woman said she enjoyed sex with him more now than she had during their first 20 years. His feelings were initially hurt, leading her to explain, “In the beginning, you had showup erections, and now you have grown-up erections. You need me sexually, and our sex is more human, genuine, and interactive. I love the fact that we are now a genuine sexual team.” Psychobiosocial Model for Assessment, Treatment, and Relapse Prevention of ED The comprehensive couple biopsychosocial model for ED is optimal (Metz et al. 2017). Important messages to convey to the man with ED include: he is not alone; all the pressure does not have to be on him and his penis; his partner wants to understand and help him deal with the ED; she is his intimate and erotic ally; and they will use all appropriate psychological, biomedical, and social-relational resources to build sexual desire, erectile comfort and confidence, and sexual satisfaction. The major strength of the biopsychosocial model is that it honors the complexity of ED and approaches sexuality as a couple issue. The GES model of sexual function and satisfaction aims to be motivating and empowering for the man and couple. Setting positive, realistic goals is key for relapse prevention and decreases the likelihood that the man will be chronically fearful of failure. The realistic perspective is that whether erectile problems occur once a month or once a year, it is normal to not have an erection sufficient for intercourse. This is true whether he uses Viagra, Cialis, penile injections, or testosterone enhancement. GES is compatible with couple sexuality, which is variable and flexible and features a range of roles, meanings, and outcomes. A crucial relationship skill is to stay involved with the partner, whether the sexual experience is great, good, okay, mediocre, or dysfunctional. When sex does not flow to intercourse, the encounter transitions to a sensual or erotic scenario rather than apologizing or panicking. In couple sexuality, desire is the most important dimension, with satisfaction the second most important. This is a completely

Erectile Disorder in Couple and Family Therapy

different model than that which uses medical interventions as a stand-alone approach to return the man to totally predictable erections and intercourse. Summary As the empirical and clinical study of ED continues to evolve, the hope is that the comprehensive couple psychobiosocial model of assessment, treatment, and relapse prevention will receive further empirical and clinical validation. Rather than view sex as an individual performance for erection and intercourse, a positive, realistic approach is variable, flexible male and couple sexuality with a focus on sharing pleasure. The hope is that this formulation will become the dominant therapeutic narrative. Subsequently, the mantra of desire/pleasure/eroticism/satisfaction with desire as the core factor will replace the secondary HSDD caused by ED. Psychologically, the focus is on using all appropriate resources to build erectile self-efficacy with a foundation of comfort and confidence. Biomedically, user-friendly medications and procedures that can be integrated into the couple style of intimacy, pleasuring, and eroticism will be the dominant narrative, rather than the medical intervention as a stand-alone approach. The social-relational breakthrough for the man, woman, couple, and culture is to define sexuality as involving sensual, playful, and erotic touch in addition to intercourse. A core concept is that the man and woman function as intimate and erotic allies. Perhaps the most important factor is the adoption of the Good Enough Sex (GES) model, which encourages the couple to embrace the multiple roles, meanings, and outcomes of couple sexuality.

Cross-References ▶ Delayed Ejaculation in Couple and Family Therapy ▶ Female Sexual Interest/Arousal Disorder in Couple and Family Therapy ▶ Male Hypoactive Sexual Desire Disorder in Couple and Family Therapy ▶ Sexuality in Couples

Erickson, Milton

References Lindau, S., Schumm, L., Laumann, E., Levinson, W., O’Muircheataigh, C., & Waite, L. (2007). A study of sexuality and health among older adults in the United States. New England Journal of Medicine, 357, 762–774. McCarthy, B. (2015). Sex made simple. Eau Claire: Icai Publication. McCarthy, B., & Metz, M. (2008). Men’s sexual health. New York: Routledge. McCarthy, B., & Wald, L. (2017). The psychobiosocial model of couple sex therapy. In Z. Peterson (Ed.), Wiley-Blackwell handbook of sex therapy. New York: Wiley-Blackwell. Metz, M., & McCarthy, B. (2004). Coping with erectile dysfunction. Oakland: New Harbinger. Metz, M., & McCarthy, B. (2012). The Good Enough Sex (GES) model. In P. Kleinplatz (Ed.), New directions in sex therapy (2nd ed., pp. 213–230). New York: Routledge. Metz, M., McCarthy, B., & Epstein, H. (2017). Cognitivebehavioral couple sex therapy. New York: Routledge. Rosen, R., Miner, M., & Wincze, J. (2014). Erectile dysfunction: Integration of medical and psychological approaches. In Y. Binik & K. Hall (Eds.), Principles and practice of sex therapy (5th ed., pp. 61–85). New York: Guilford.

Erickson, Milton Chris J. Gonzalez Department of Psychology, Counseling, and Family Science, Lipscomb University, Nashville, TN, USA

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Madanes, and the Brief-Solution Focused team in Milwaukee as well other prominent solutionoriented clinicians such as Bill O’Hanlon and Michele Weiner-Davis. His indirect influence spans almost everywhere in the field including the Collaborative Language Systems approach of Harlene Anderson and Harry Goolishian in Houston-Galveston and Minuchin’s structural therapy. Echoes of his influence extend even to what is now called the common factors movement and the idea of the empirically validated therapist.

Career Erickson earned a masters degree in psychology and a medical degree from the University of Wisconsin at Madison. He worked as a medical doctor and psychiatrist in multiple hospitals until 1948 when he was appointed Clinical Director at the Arizona State Hospital. He left that assignment after a year in order to focus on writing, teaching, and private practice. Erickson contracted polio at age 17 and endured a paralysis so severe doctors believed he would die. He again experienced symptoms of polio when he was near the age of 50, but it was later determined that he had “post-polio syndrome.” It was Erickson’s illness at an early age that gave him his introduction to hypnosis and the impetus for so much of his inquiry. While recovering from polio as a teenager, he learned how to listen to his own body, listen to and observe others, and to recognize the discrepancies and congruencies between verbal and nonverbal communication.

Name Milton H. Erickson, M.D. (1901 –1980).

Introduction The influence of Milton Erickson spreads wide and deep across mental health professions including: psychiatry, psychology, family therapy, and clinical hypnosis. In the field of couple and family therapy, Erickson’s direct influence is manifest in the work of the MRI group in Palo Alto, the Milan group in Italy, the strategic work of Jay Haley and Cloe

Contributions to Profession Erickson was an innovator on all levels. From the clinical interactions he had with therapy clients through hypnosis, storytelling, and interventions of creative choice to how he taught and framed the field of hypnosis and psychotherapy to larger audiences – his work was an endless source of innovation. Erickson essentially remade the field of hypnosis in his own image. O’Hanlon highlights many of these changes including: shifting from hypnotic suggestion to creative choice while in trance and from a directive and commanding

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posture to a permissive and collaborative engagement. His approach to hypnosis with clients was “with” clients not “applied to” clients. He was the first to highlight the importance and influence of therapists’ words, tone of voice, and actions, thus paving the way for a far more active therapy than afforded within the assumptions of psychoanalysis. Erickson’s unique approach did not resist symptomology so much as leverage acceptance of client symptoms and client resistance as useful information for creating unique and personalized interventions (B. O’Hanlon, personal communication, December 2, 2016). This approach fascinated clinicians such as Jay Haley, who made considerable efforts trying to solve the Erickson formula and served to inspire all manner of paradoxical interventions such as prescribing the symptom. Erickson was also one of the first to disconnect the solution from the problem and thereby providing inspiration to DeShazer, Berg, and colleagues with one of the foundational assumptions of solution-focused therapy. Erickson saw whole families in his office for therapy as early as 1948, a time when such modality was not simply uncommon, but contraindicated due to the dominating assumptions of the prevailing model, psychoanalysis. O’Hanlon reports Erickson being invited in the 1950s by Gregory Bateson to the Macy Conference on cybernetics. At this conference, Erickson reported a clinical case that was the first known time the theory of cybernetics was actually observed as being clinically relevant. In short, Erickson brought cybernetics from theory to practice (B. O’Hanlon, personal communication, December 2, 2016). Erickson assumed the unconscious mind knew more than the conscious mind. His assumption that clients already had what they needed in order to heal was not merely encouraging talk, but rather a foundational assumption that the client’s unconscious mind knew better than anyone, even Erickson, how to heal. Erickson’s goal in therapy was to agree with the client’s unconscious mind. In so doing, Erickson challenged the notion of “client resistance” and inspired what was later to be coined the humbling concept of “therapist resistance.” Erickson desired to make his thinking, his approaches, and his stories available to as many people as possible. Toward this end he was

Erikson, Erik

instrumental in founding the American Society of Clinical Hypnosis and was their first president. He was also instrumental in launching the American Journal of Clinical Hypnosis and invested a decade into being editor. The first International Congress of Ericksonian Approaches and Psychotherapy was planned for December 1980 and he anticipated attending. He never got the chance to attend as he died 8 months prior to the event. The Milton H. Erickson Foundation continues to host conferences decades later for clinicians and researchers to further explore the genius of Milton Erickson.

Cross-References ▶ Hypnosis in Couple and Family Therapy ▶ O’Hanlon, William ▶ Paradoxical Directive in Couple and Family Therapy

References Erickson, M. H., & Rossi, E. L. (1979). Hypnotherapy: An exploratory casebook. New York: Irvington Publishers. Erickson, M. H., Rossi, E. L., & Rossi, S. I. (1977). Hypnotic realities: The induction of clinical hypnosis and forms of indirect suggestion. New York: Irvington Publishers. Haley, J. (1986). Uncommon therapy. New York: Norton. O’Hanlon, W. H., & Hexum, A. L. (2011). An uncommon casebook: The complete clinical work of Milton H. Erickson. New York: Norton. Rosen, S. (1982). My voice will go with you. New York: Norton. Zeig, J. (1994). Ericksonian methods: The essence of story. New York: Brunner/Mazel.

Erikson, Erik Dawn L. Glover California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Name Erik Homburger Erikson.

Erikson, Erik

Introduction Erik H. Erikson was a twentieth-century psychoanalyst. His major contribution to the field was the concept that identity development extends across the lifespan and is rooted in a sociocultural context. He is best known for the eight stages of psychosocial development and the identity crisis.

Career Erikson’s career was molded by multiple cultural influences. In 1902, Erikson was born to Danish parents, a Jewish mother and Protestant father. He was raised by his mother and stepfather in Germany and attended a Jewish school where he did not feel accepted due to his gentile appearance. After wandering through Europe as an artist, in 1927 Erikson moved to Vienna and began teaching children. At this time, he began studying child psychoanalytic theory and practice with Anna Freud at Vienna Psychoanalytic Institute. In 1933, during Hitler’s rise, he fled to the United States with his Canadian-born wife, Joan Serson. Serson collaborated with Erikson to write his works in English. In the United States, Erikson went on to teach at Harvard, Yale, and University of California, Berkley. He published over 14 books and won the Pulitzer Prize and the National Book Award. In studying the role of culture in development, he utilized a comparative cultural approach and spent time studying Yurok and Oglala Sioux tribes in Northern California. He died in 1994.

Contribution to Profession Given Erikson’s translocation and various cultural experiences, it is not surprising that his work centered on the impact of sociocultural influences on identity. His theories included the identity crisis and a stage-based approach to core identity conflicts. The eight stages of psychosocial development, from his book Childhood and Society, was a conceptual departure from Freudian theory in that it grounded the “self” within a social context and expanded personality development throughout adulthood.

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Novel to the field, Erikson’s work theorized that children are not simply shaped by biological forces in isolation and that early childhood issues may be resolved later in life. This framework of identity development was part of the shift in psychoanalytic theory toward ego and selfpsychology. Freud’s drive theory was based on psychosexual stages, whereas Erikson’s theory was broader and based in epigenetics. Erikson’s psychosocial development theory described the dialectical relationships between the individual and cultural influences. Although Erikson focused primarily on individual development, he acknowledged the contribution of the family to development. Caregivers are cultural representatives who mold the child according to cultural values and needs. Cultural leaders are quasiparents. As part of his work, Erikson described not only childhood but also the structure and function of adulthood. He attempted to distinguish between normal, psychopathological, and socially acceptable development. He studied nonmedical populations. Erikson’s legacy, the eight stages of psychosocial development, posited that across the lifespan, individuals face eight identity conflicts. Each stage represents a critical conflict: (1) Trust versus Mistrust takes place during infancy from birth to 12–18 months (oral-sensory stage) when infants are fully dependent on caregivers. (2) Autonomy versus Shame and Doubt takes place from 18 months to 3 years (muscular-anal stage) when children are learning to control their own body, bodily functions, and beginning to make some choices. (3) Initiative versus Guilt, takes places from 3 to 6 years (locomotor period) during a time when children are asserting themselves and taking control of play and social interactions. (4) Industry versus Inferiority takes place during ages 6 to 12 years (latency period) when children are learning new skills, taking risks, and working toward goals. (5) Identity versus Confusion takes place from 12 to 18 years (adolescence) when children use cues from peers and personal exploration to develop a sense of identity around occupation, relationship role, sex role, politics, and religion. (6) Intimacy versus Isolation takes place from 19 years to 40 years (young adulthood) when individuals strive to develop close, committed, and secure relationships.

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(7) Generativity versus Stagnation takes place between 40 years to 65 years when adults work toward having a stable home and helping others, usually the next generation. (8) Integrity versus Despair takes place from 65 years until death (maturity). Resolving the conflict at each stage leads to virtues of hope, will, purpose, competency, fidelity, love, care, and wisdom, respectively. An inability to resolve these conflicts results in stagnation, distress, and feelings of inadequacy.

Cross-References ▶ Children in Couple and Family Therapy ▶ Development in Couples and Families ▶ Personality in Couple and Family Therapy ▶ Social Constructionism in Couple and Family Therapy ▶ Socialization Processes in Families

References Erikson, E. H. (1950). Childhood and society. New York: WW Norton & Co. Erikson, E. H. (1962). Young man Luther: A study in psychoanalysis and history. New York: WW Norton & Co. Erikson, E. H. (1968). Identity: youth and crisis. Oxford: Norton & Co. Erikson, E. H. (1977). Toys and reasons: Stages in the ritualization of experience. WW Norton & Co. Erikson, E. H. (1980). Identity and the life cycle. New York: WW Norton & Co. Erikson, E. H. (1985). The life cycle completed: A review. New York: WW Norton & Co. Erikson, E. H. (1993). Gandhi’s Truth: On the Origins of Militant Nonviolence. WW Norton & Co.

Escudero, Valentin Myrna L. Friedlander University at Albany/State University of New York, Albany, NY, USA

Name Escudero, Valentín

Escudero, Valentin

Introduction Valentín Escudero, Ph.D., is a professor of psychology at the University of A Coruña and director of the Family Intervention and Care Research Unit (UIICF), a family therapy center at the Hospital Naval, where four prestigious programs of family therapy research and family therapy training have been run since 1999. Escudero’s research and practice epitomizes a systemic approach to family therapy founded on solid observational study and careful theoretical conceptualization. His primary area of scholarship concerns the development and maintenance of therapeutic alliances with couples and families, specifically using alliances to empower the therapeutic system (Escudero and Friedlander 2017). Escudero’s work is extraordinary in the field of family therapy in Europe due to his balance in connecting research to therapist training and clinical practice. Escudero has published numerous journal articles and chapters and is the co-author of three books: Relational Communication, Therapeutic Alliances in Couple and Family Therapy: An Empirically-Informed Guide to Practice, and Therapeutic Alliances with Families: Empowering Clients in Challenging Cases.

Career Dr. Escudero obtained his Ph.D. in Psychology at the University of Santiago de Compostela, Spain, and published his doctoral dissertation on relational communication in distressed couples in treatment. After postdoctoral scholarship at the University of Utah, his academic career spans over 25 years at the University of La Coruña, where he began as an assistant professor of psychology in 1990 and is a professor of the Department of Psychology, director of the master’s program in family therapy, and director of the prestigious Family Intervention and Care Research Unit (UIICF). An accredited psychotherapist and family therapist, Escudero is also an adjunct clinical professor at the University at Albany/State University of New York. Additionally, he was a visiting professor for 3 years at Vrije Universiteit, in Brussels, Belgium

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(2007–2011), and a visiting researcher at the Centre for Family Policy and Child Welfare, at the University of Bristol, UK (2006–2007).

Contributions to Profession From the beginning of his career, Escudero’s work focused on exploring the process of change in family systems distinct from more traditional psychopathology, relying instead on the concept of relational communication. His doctoral dissertation used observational techniques for the microanalysis of conflictual interactions of clinical couples. This framework of research and practice led to collaboration on the creation of the SOFTA (System for Observing Family Therapy Alliances; Friedlander et al. 2006), a conceptual model and set of instruments designed to conceptualize, operationalize, and study therapeutic alliances in the context of couple and family therapy. This line of research, in collaboration with Friedlander and Heatherington, now comprises a range of studies on the process of building and maintaining alliances in family therapy and their power to predict therapeutic outcomes. Because of its reliability and systemic assumptions, the SOFTA is one of the major instruments used to evaluate the alliance in couple and family therapy, having been translated into six languages. Aside from his profile as a researcher, Professor Escudero identifies as a “systemic therapist.” Currently, he directs the Therapy Program for Vulnerable Children and Families, which is the primary mental health treatment program for the Child Protective Services of the Galician Regional Government in Spain. The main focus of Escudero’s work – systemic family therapy in the context of social services and child protection – are the contexts in which establishing a strong working alliance is a challenge as well as a critical process. In this line, he trains, supervises, and consults for several public family intervention programs in Spain, Portugal, England, Belgium, and Poland. Professor Escudero is International Associate Editor of the Journal of Family Therapy and has also published his research in numerous other refereed journals, including Family Process, the Journal of Marital and Family Therapy,

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Psychotherapy, Psychotherapy Research, and the Journal of Counseling Psychology. His treatment manuals and intervention guides for allianceempowering mental health care are widely used by social services professionals in Spain and in several other Spanish-speaking countries.

Cross-References ▶ European Family Therapy Association ▶ Therapeutic Alliance in Couple and Family Therapy

References Escudero, V., & Friedlander, M. L. (2017). Therapeutic alliances with families: Empowering clients in challenging cases. New York: Springer. https://doi.org/ 10.1007/978-3-319-59369-2. Escudero, V., Friedlander, M. L., Varela, N., & Abascal, A. (2008). Observing the therapeutic alliance in family therapy: Associations with participants’ perceptions and therapeutic outcomes. Journal of Family Therapy, 30, 194–214. https://doi.org/10.1111/j.14676427.2008.00425.x. Escudero, V., Boogmans, E., Loots, G., & Friedlander, M. L. (2012). Alliance rupture and repair in conjoint family therapy: An exploratory study. Psychotherapy, 49, 26–37. https://doi.org/10.1037/a0026747. Friedlander, M. L., Escudero, V., & Heatherington, L. (2006). Therapeutic alliances with couples and families: An empirically-informed guide to practice (Vol. 53, p. 214). Washington, DC: American Psychological Association. https://doi.org/10.1037/0022-0167.53.2.214.

Ethics in Couple and Family Therapy Colleen M. Peterson1 and Marj Castronova2 1 University of Nevada, Las Vegas, NV, USA 2 Relational Wellness Institute, Las Vegas, NV, USA

Introduction Ethics in couple and family therapy is based on the long-held understanding that the therapeutic

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relationship between client and therapist is one of safety and trust, with therapists bearing the responsibility for ensuring that they are protecting that relationship and acting in the client’s best interest. A successful therapeutic relationship depends on clients being able to openly and honestly discuss things that are very personal and private, putting them in an extremely vulnerable position. The safety and protection of clients engaged in therapy are so vital that very specific expectations and requirements for therapist professional conduct have been developed in the form of professional Codes of Ethics and laws regulating the practice of licensed therapists. Unique to the ethics in couple and family therapy is the notion of the family or couple system; everyone is impacted both individually and relationally. At times this creates ethical dilemmas in that what is best for the individual may not be best for the couple or family system.

Theoretical Context for Ethics in Couple and Family Therapy The expectations for ethical therapist conduct are deeply rooted in ethics and moral principles which are thoroughly reviewed and explored during therapist education and training in ethical and legal issues (Corey et al. 2011; Heckler 2010; Wilcoxon et al. 2012). In addition, ethics and moral principles are often reviewed during continuing education required for licensed therapists. This core knowledge of ethical and legal issues includes the aspects and differences between mandatory and aspirational ethics, with mandatory ethics being the minimal standards of ethics and aspirational ethics being the more lofty and ideal standards for which a therapist should strive. The core ethical knowledge of couple and family therapists includes understanding and applying principle and virtue ethics. Principle ethics focuses on moral issues in solving an ethical dilemma or type of dilemma. Principle ethics involves making choices and taking action in answering the question “What shall I do?” in a way that is historically and socially acceptable. Virtue ethics focuses on the qualities and

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characteristics for which a therapist should aspire rather than on the ethical dilemma per se. Principle ethics asks “Is this situation unethical?” whereas virtue ethics asks “Am I doing what is best for my client?” Ideally, couple and family therapists integrate both principle and virtue ethics. Underlying ethical decision-making are six moral principles: autonomy, nonmaleficence, beneficence, justice, and fidelity. Autonomy is an individual’s right to self-determination and making his/her own choices. Therapists support autonomy by acknowledging and encouraging clients’ freedom of choice and respecting their wishes. Nonmaleficence is avoiding doing harm or the risk of doing harm. Therapists are obligated to practice in ways that prevent harming or the potential of harming clients. Beneficence is promoting the good of others. Therapists act in ways that support clients’ growth, development, and well-being. Justice is being fair through equality. Clients are entitled to equal access to therapy services, regardless of age, sex, race, ethnicity, socioeconomic status, cultural background, religion, sexual orientation, or disability. Fidelity is being true to one’s word – to making and keeping promises. Therapists maintain their responsibility of trust in the therapeutic relationship by keeping their commitments to clients. These moral principles are at the core of all therapeutic relationships – putting client interests first and doing no harm. They are also at the root of expectations for therapists that are spelled out in Ethical Codes (AAMFT 2015) and laws regulating their clinical practices. While there are some things related to the practice of couple and family therapy that are clearly spelled out in black and white (i.e., sexual intimacy with current or former client or known members of the clients’ family system), there are others that are less specific and require that therapists use their best professional judgment to operate within ethical and legal bounds (i.e., not exploiting clients with unavoidable multiple relationships). When therapists encounter ethical dilemmas, it is vital that they engage in an ethical decision-making process that demonstrates the use of sound professional judgment in

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determining a course of action. While some therapists utilize specific models of ethical decision, most include identifying what the ethical dilemma is, consulting pertinent ethical codes and state/ federal laws, exploring the pros and cons of potential actions and corresponding outcomes, consulting with supervisors or colleagues, exploring what would be considered a professional standard of practice, documenting the decision-making process, and then acting on the choice that appears most appropriate given all the considerations. The exploration of pros and cons often encompasses the moral principles discussed above.

Description of Important Aspects of Ethics in Couple and Family Therapy There are several important perspectives and constructs that warrant consideration when working with couples and families. These perspectives and constructs can influence how a therapist works with a case, and when they go unnoticed or unchecked, ethical violations can occur. While the therapist may not have been maleficent in their intention, the standard of care when working with a couple and or family involves a deeper and broader consideration of a plethora of systems. Who Is the Client? The first thing to consider is “who is the client?” The way a therapist answers this question in terms of the couple or the family he/she is working with influences the kinds of legal and ethical considerations the therapist must make. If the therapist sees only one spouse as the client because of his/her diagnosis and the spouse is brought into therapy as a support, the ethical implications may defer to the spouse with the diagnosis. However, if the therapist sees the couple as the client, regardless of the diagnosis, then the ethical implications are considered in terms of the relationship. In a blended family, “who is the client?” is also an important ethical consideration. When a child enters therapy and the biological parents are divorced and have joint legal custody, typically both parents sign the consent and have access to the file; however, when a blended family starts therapy, does the

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other biological parent still have access to the file? If the client is viewed as the family system, the child is no longer an individual client. Person of the Therapist A strong ethical stance in couple and family therapy ethics flows from the person of the therapist. Therapists hold their own values and morals which influence how they view the world. These values and morals are heavily influenced by the social contextual issues that surround them. Therapists also hold implicit bias that influences their preconceived ideas and influences how they respond to their clients. It is incumbent upon therapists to conscientiously maintain self-awareness and self-monitoring so as to avoid negative impacts upon clients. Diversity and Social Contextual Issues When a therapist is working with a family or couple system, there is an acute awareness that several underlying dynamics and other systems are impacting work with couple and families. These can be referred to as the Social GRRAACCEESS (Burnham et al. 2008): gender, race, religion, ability, age, culture, class, education, ethnicity, spirituality, and sexuality. The Code of Ethics that guides couple and family therapy clearly states that therapists are to provide therapy without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity, or relationship status. This requires awareness that each person involved in the therapy process, the client(s), the therapist, and the potential supervisor all are being influenced by their own Social GRRAACCEESS and the values that they hold in reference to each one of them. Client Rights All therapists working with clients are obligated to obtain written client consent prior to initiating therapy and to uphold client confidentiality which is at the core of establishing a safe therapeutic relationship. The therapists working with the couples and families must consider additional information when obtaining informed consent due to multiple people being involved in therapy and/or being present in the therapy

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room. Best practice is for therapists to obtain written consent from each person involved in the treatment prior to seeing them. Having more than one person involved in the therapy also impacts confidentiality and privacy, as the therapist cannot guarantee the confidentiality of what participants may tell others. State laws differ with regard to handling confidentiality in couple and family therapy. Some states may legally require only one person to sign a release of information, whereas other states may clearly require all participants to sign a release of information. Still other state laws are not explicit as to who can release the information when more than one person is in the room. While the legal implications must be considered, the ethical implications are also important, and this goes back to the question of “who is the client?” When therapists are clear about who their client is, they are clearer as to who needs to sign the release. If the client is the family system or the couple system, then all involved parties need to sign; however, if the therapist is viewing the couple and family as individuals, they may determine only one person needs to sign a release (unless prohibited by certain state statutes). Best practice with regard to releases of information is to have each person involved in the therapy sign a release of information. Another challenge often faced by therapists working with families with children is obtaining proper consent. Of course, all therapists should obtain written parental consent prior to treating minors; however, sometimes this can become complicated when parents are separated, divorced, or hold different views/perspectives on child involvement with therapy. State law varies on this, and the couple and family therapists are obligated to know and practice within the regulations of the state in which they are practicing. It is generally accepted that the best practice is to make sure that parents are aware of any child in therapy and to obtain written consent from both parents. It is also advisable that therapists request and review copies of court documents related to child custody and adhere to the conditions for medical treatment specified therein.

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Another aspect of client rights that needs to be considered is how information obtained while seeing one part of the system alone without the other member present will be managed within couples’ therapy. How will the therapist manage confidentiality of what is disclosed in individual sessions if/when it has a significant impact on the couple relationship? For instance, what does a therapist do with the information if one partner discloses having an affair in individual therapy and the partner isn’t present and doesn’t know about the affair? The danger in these situations is the other partner feeling betrayed by the therapist for aligning with the partner in not sharing the information. This kind of triangulation has the potential to impede couple’s therapy work. Unless the therapist has preemptively addressed this kind of situation by informing the couple of a no secrets policy, the therapist’s hands are tied with regard to addressing the affair in the couples’ therapy (maintaining individual confidentiality) until the affair partner discloses it to the partner. Attending to this aspect of confidentiality between the two parties in the system from the onset of the couple, therapy is crucial. Client rights of confidentiality are also impacted by therapists’ legal obligations with regard to their duty to protect and duty to warn. Therapists are required by law to report threats of suicide or threats of physical harm to another to the appropriate authorities. In a couple or family where one of the individuals dealing with a longterm chronical illness decides that they want to stop taking their medications that have been keeping them alive: Is this suicide or is this the right of a patient, as in a living will? How does the therapist work with the couple and family to consider ethical options? When working with a couple, this can become especially complicated when dealing with the issues of intimate partner abuse. States differ in terms of the laws in handling these types of situations. This becomes even more complicated when one considers child abuse and neglect and whether or not a state considers the child witnessing an act of domestic violence as child neglect. In regard to therapists’ duty to report abuse and neglect of a minor, elderly person, or a dependent adult, state law differs surrounding

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these issues with regard to suspicion verses reasonable suspicion. Again, it is incumbent upon therapists to be knowledgeable about and adhere to the state laws that regulate their practice. Central to client rights and safety in the therapeutic relationship is the therapist attending to and keeping her influential position (power) in check. Doing so requires therapists to monitor and maintain boundaries and avoid exploiting client trust and dependency. To this end, therapists are expressly directed in the AAMFT Code of Ethics to avoid conditions and multiple relationships with clients that could impair professional judgment or exploit clients. Perspectives on multiple relationships vary across the continuum from avoiding them at all costs on one end to embracing the complexity of relationships and interacting with clients in a less hierarchical and more equal manner on the other end. It is generally accepted that there are some situations/circumstances in which multiple relationships are unavoidable (rural communities and smaller populations where clients prefer therapists with insider knowledge of their specific population). In those circumstances, therapists bear the responsibility of taking precautions to minimize the risk of impairment or exploitation and of documenting the appropriate precautions taken. Record Keeping Ethically and legally, all therapists are required to document client treatment. When working with couples and families, it is imperative therapist specifies in documentation who is present in sessions. State law typically dictates the length of time that records must be kept after treatment has ended (usually a minimum of 5 years) and most specifically address the keeping of records for minors (usually at least until they reach the age of 18). Therapists are responsible for making sure that those records are kept safe and protect client confidentiality, whether in hard copy or electronic form, in accordance with applicable ethical and legal obligations as set forth in codes of ethics, state law, and federal law (such as the Health Insurance Portability and Accountability Act – HIPAA). This applies to both clinical and financial records.

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Technology-Assisted Therapy With the everincreasing prevalence technology-assisted therapy and research supporting its benefits and effectiveness, it is important that couple and family therapists understand the ethical and legal ramifications of conducting technology-assisted therapy. When providing services through electronic means, therapists are obligated to ensure that they comply with laws that pertain to the delivery of those services. In addition, those engaging in these types of services should only do so after receiving appropriate education, training, and/or supervised experience in the use of such technology to deliver therapy services. Furthermore, it is requisite that therapists give careful consideration to and assessment for the appropriateness of the use of the technologyassisted services, thoroughly advise clients on the potential risks and benefits, obtain written consent, and follow the same ethical and legal obligations of in-person therapy. Laws pertaining to the delivery of technology-assisted therapy vary from state to state, and it is vital that therapists utilizing this delivery method thoroughly investigate and comply with those laws. Professional Competence and Integrity Therapists working with couples and families are obligated to maintain high standards of professional competence and integrity. Inherent in this obligation is therapists obtaining and maintaining competence in therapy through education, training, and/or supervised clinical experience throughout the course of their therapy careers. It also includes staying abreast of new developments in the field as well as pursuing requisite consultation and training as it pertains to pertinent laws, ethics, and professional standards. It is incumbent upon therapists to practice only within the bounds of their competencies and to exercise caution in representing themselves and their competencies and their professional opinions and doing so with integrity and honesty. Therapists are obligated to represent themselves, their background, education, training, affiliations, etc., honestly and accurately and to correct, wherever possible, false misleading or inaccurate information or representations. Therapists who are impaired

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in any way, with regard to work performance or clinical judgment, are expected to seek assistance and take the steps necessary to correct the impairment.

Application of Ethics in Couple and Family Therapy The application of ethics in couple and family therapy are ever present issues in the course of therapy, from the very first session to termination and often times issues that arise later on, such as when one person from a family requests a release of records long after therapy has terminated. States vary in the length of time that therapists need to hold on to their medical records, and often there is an exception when children under 18 are a part of the therapy process. This means that if you worked with a family and the child was 12, you would need to retain these records for a set number of years after the child turned 18. Teenagers and young adults who are exploring careers in the military, law enforcement, or high security clearance-type jobs are often asked if they have had mental health counseling. If the applicant had family counseling due to either a parents divorce or early at-risk adolescent behavior, should these records be released? When the family was the client, the couple and family therapist needs to consider the reality of more than one person signing a release for records. In addition, this means that the job requesting the information has the file for the whole family. It also means that if the records aren’t released, it could jeopardize the former client’s potential employment. When looking at the social graces of sexuality, the values and beliefs regarding premarital sex, casual sex, extramarital sex, open marriages, sexual orientation, heterosexuality, homosexuality, polygamy, and sexuality in adolescence or as older adults create a plethora of potential ethical issues that may come into play with the couple or the family. When one adds culture to the consideration of the social grace of sexuality, the idea of intersectionality creates more complexity. Culture plays out in many ways. We have culture in terms of our ethnicity and race, our religion and

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spirituality, our geography, and our gender norms. The therapist and the couple or family are all influenced in various ways, and the ethical therapist must be cognizant of these intersections. The various Codes of Ethics that clinicians follow emphasize therapists valuing their client’s autonomy, but a therapist working with a couple or family must also consider the ethical considerations of the unit as a whole – what is best for an individual may not be the best for a couple or family and vice versa. For instance, when a family’s system intersects around culture, sexuality, and religion, there are potential life and death consequences that must be considered. An individual may be left with the decision of having to forfeit their family, culture, and religion in order to live out their sexual preference; however, if he/she is living in a country where a person can still be stoned to death for not being heterosexual, the ethical stakes take on a whole new level for the therapist to consider when working with a family system. Working with various multicultural Social GRRAACCEESS of race, ethnicity, culture, and gender also needs ethical consideration. When a therapist is working with a couple of a different race or is working with an interracial marriage, there are many things the therapist may not know or many things the therapist may assume. Therapists need to be aware of their own implicit bias and privilege that may be influencing their work with a couple or family and have the potential to take them down an unethical path.

Clinical Example of Ethics in Couple and Family Therapy Sarah Ahmed is a 17-year-old client who will be turning 18 in 3 months. Her parents have brought her into therapy because she has been withdrawn and her grades have been dropping. Sarah and her parents describe their family as very close. Sarah’s family immigrated to the United States when she was 12 from Yemen. Sarah’s parents had previously lived stateside when her dad was in medical school. During this time, Sarah’s parents had converted from Muslim to Christianity after

Ethics in Couple and Family Therapy

doing medical rotation with a Christian organization that did short-term medical mission work. The Ahmed family moved back to Yemen after the father finished medical school and worked for several years; however, when Sarah turned 12, they were concerned about Islamic law and the possibility that it might be expected that Sarah marry so they immigrated to the states. The majority of the Ahmed extended family is still in Yemen and still is Muslim. The therapist provides the family with paperwork where the parents sign consent for their child under 18 to be seen. The therapist tells Sarah and her parents that the state statutes give Sarah’s parent’s access to her medical records until she is 18 and wants to know if Sarah’s parents are willing to respect the idea of confidentiality and the idea that confidentiality is only broken when there is a threat to life or a reasonable suspicion of abuse to a child, older adult, or a person with a disability. The therapist also tells them that when Sarah turns 18, this will no longer be the case, and they will need to close her file out and open a new one if she is still in therapy. The parents ask to speak with the therapist alone for a few minutes. After Sarah leaves the room, the father tells the therapist that they suspect that their daughter is wrestling with samesex attraction, and if this is the case, they want the therapist to fix this as it is against everything they believe culturally and religiously. In that moment the therapist considers telling the parents that conversion therapy is against the law but changes her mind as she feels this will scare the parents away from having their daughter in therapy. If this is indeed the case for Sarah, the therapist wants her to have a safe place to process what she is thinking and feeling. The therapist makes this decision based on the premise that her client is Sarah. As the therapist works with Sarah, she discovers that Sarah’s family is very strict and sometimes it feels like they are still following Sharia law. For example, she has not been permitted to get her driver’s license. The family has been a part of what would be considered a fundamentalist Christian church and school that has many rules and beliefs about right and wrong. As the therapist is working with Sarah, she considers how the

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Social GRRAACCEESS are impacting her work and wants to know Sarah’s perspectives: how it is different being a female in Yemen verses in the states; what is it like to be Arab in a primarily white school; what does she notice about the differences in her freedom level as a teenager verses her peers; do the cultural customs of Muslim verses Christianity impact things for her at home, etc. When the therapist starts having conversations with Sarah about the differences between American culture and Muslim culture on how she interacts with boys, Sarah expresses that it is a nonissue for her. When the therapist asks her why, Sarah reveals to her that she is attracted to females. The therapist is left with an intersection of a complex ethical dilemma on many levels. First, it is against the law in the state Sarah lives in to do conversion therapy of a minor, and Sarah is still under the age of 18. Her parents also have legal access to the file, so what she puts in her notes and what she doesn’t put in her notes are critical. Sarah and her family still have strong ties back in Yemen with extended family. In researching the therapist discovers that consensual lesbian acts in Yemen are punishable by 3 years in prison. While her family is part of a fundamentalist Christian church and there is an assumption that this would be viewed as a sin, the therapist has also worked with several different evangelical pastors and knows that this belief system is being challenged. Sarah also has limited support systems outside of her immediate family. The therapist considers all of these complexities with the ethical idea of autonomy of the client and also considers the ethical code of helping a client to explore the risks and benefits of decisions. Since Sarah is almost 18, the therapist decides to talk with Sarah about all the complexities and how difficult this must be for her. As the therapist begins to bring up the contradictions, Sarah starts crying and says for the first time she feels like someone finally understands. Sarah and her therapist first consider what it means to have conversations about this while she is still under 18 and her parents have access to her medical records. They intentionally decide to focus on the other contradictions surrounding her sexuality, such as

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what she values in her culture that she wants to embrace and the view of females in her race and religion. Sarah believes this will be a good starting place for her to deal with complexities, and once she is 18, she and the therapist can begin to explore her sexuality.

Ethnic Minorities in Couple and Family Therapy

Synonyms AAPI; African American; Alaskan Natives; Asian; Asian American; Black; Cultural minorities; Hispanic; Latino; Minority communities; Minority populations; Native American; Pacific Islanders; People of color; Race; Racial groups; Racial minorities

Cross-References ▶ Code of Ethics in Couple and Family Therapy ▶ Supervising Ethical Issues in Couple and Family Therapy ▶ Supervising Legal Issues in Couple and Family Therapy

References American Association for Marriage and Family Therapy. (2015). AAMFT code of ethics. Alexandria: Author. Burnham, J., Palma, D. A., & Whitehouse, L. (2008). Learning as a context for differences and differences as a context for learning. Journal of Family Therapy, 30, 529–542. Corey, G., Corey, M. S., & Callanan, P. (2011). Issues and ethics in the helping professions. Belmont: Thomson Brooks/Cole. Hecker, L. (Ed.). (2010). Ethics and professional issues in couple and family therapy. New York: Routledge. Wilcoxon, S. A., Remley, T. P., & Gladdin, S. T. (2012). Ethical, legal, and professional issues in the practice of marriage and family therapy. Upper Saddle River: Pearson.

Ethnic Minorities in Couple and Family Therapy Jessica ChenFeng1 and Mudita Rastogi2 1 California State University – Northridge, Northridge, CA, USA 2 Illinois School of Professional Psychology, Argosy University, Schaumburg, IL, USA

Name of Your Entry Ethnic Minorities in Couple and Family Therapy

Introduction “Ethnicity, the concept of a group’s ‘peoplehood’ refers to a group’s commonality of ancestry and history, through which people have evolved shared values and customs over the centuries” (McGoldrick et al. 2005, p. 2). In every part of the world, some ethnicities make up the majority and other ethnicities are in the minority. It is important to note that while the terms “race” and “ethnicity” are used interchangeably in everyday language, they have distinctly different meanings. The former refers to an erroneous notion of biological differences between subgroups of people based on external appearance. However, this simplified way of classifying and ranking people has little basis in science (McGoldrick et al. 2005, pp. 16–17). In the United States, White Americans constitute the ethnic majority, thereby defining ethnic minorities as people of color. While White Americans have a rich history and ethnic heritage with ancestry from Europe, North Africa, and the Middle East, much of that history has been dissolved into being “American,” since identifying ethnically was seen as a lowering of status. This idea as passing for being “regular” (i.e., White; McGoldrick et al. 2005) was significant, and this created the “other,” or that which was not “regular,” i.e., ethnic minorities. The White ethnic majority was established not only due to it is representing the largest percentage of the population, but also by the way that this majority group influences all other groups and how it sets standards to which all other ethnicities are compared. To recognize diverse ethnic minority experiences is to understand that they are by no means homogeneous (Rastogi and Wieling 2005, p. 2).

Ethnic Minorities in Couple and Family Therapy

Furthermore, the field of mental health is enriched by the multitude of ways in which ethnic minorities interact and respond to a legacy of white supremacy, colonialism, and other dominant discourses while contributing unique histories, immigration stories, religious differences, socioeconomic status, and cultural values. An appreciation of the intersectionality of between and within group differences adds to a more enriched understanding of ethnicity. When we consider ethnic minorities in the field of couple and family therapy, we think about the clients and communities served as well as the therapists, supervisors, and professors who contribute to shaping the field.

Description Discussion around ethnic minorities tends to focus on their otherness, “emphasizing their deficits, rather than their adaptive strengths or their place in the larger society” (McGoldrick et al. 2005, p. 2). This happens because of mistaken but often deeply ingrained views that privilege and value the majority culture over diversity, as well as the assumption that ethnic minority families have unchanging traditional cultural values devoid of contextual influence (Rastogi and Thomas 2009, p. 6). The experience of ethnic minorities and families must be understood with the larger American social context in mind. Ho et al. (2004) offer a helpful framework from which to understand ethnic minority identitites. A few variables from their framework are highlighted here: (a) ethnic minority experiences with racism and oppression, (b) impact of external systems of minority cultures, (c) biculturalism, and (d) ethnic differences in minority status. Racism, poverty, and oppression are foundational to the ethnic minority experience in the USA. The history of the United States is filled with the subjugation of ethnic minorities: African Americans with slavery and second-class citizenship, genocide of indigenous peoples, the Chinese Exclusion Act and “anti-oriental” sentiment, internment of Japanese Americans, Islamophobia in the post-9/11 era, and countless more. These are

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not merely historical occurrences but translate into present systemic injustices with disparities in health, income, home ownership, poverty levels, education, job promotion rates, incarceration rates, and experiences of violence/death. This day-to-day reality of personal and systemic oppression shapes the identities and relationships of ethnic minorities. In addition to racism and oppression, ethnic minorities carry the burden of responding to a society and an environment that is shaped by values held by mainstream White American culture. These values often focus on human control of nature and environment, individual autonomy, future-oriented growth, and capitalism. Many ethnic minorities come from cultures that may not prize such values, but rather they might esteem harmony with nature, collectivism, and being reflective of the past or present-focused (Sue and Sue 2016, p. 42). Many ethnic minorities feel that being conflicted about holding on to one’s own heritage and ethnic values while trying to adapt to dominant middle-class White discourses in the USA adds to their daily stressors. Members of the ethnic minorities frequently develop a bicultural identity because they often participate in two cultural systems, which require two sets of behavior (Ho et al. 2004). Different contexts demand different expectations and so consciously or not, they adapt to the changing environments. This can create spaces where individuals feel a sense of safety and connection in being more authentic and other spaces where they must adapt to the rules and expectations of the dominant culture. There are also differences in status and hierarchy between ethnic minority groups. It is important to understand US history and the relationship within the USA among different ethnic groups to grasp the ways that status is given or taken. Sociopolitical issues, often relegating ethnic minority groups to at least second-class citizenship or worse, the objects of brutality and hate crimes, influence these “statuses” (Ho et al. 2004). The insidious nature of White supremacy has resulted in countless lost lives, and violence towards ethnic (and religious) minorities, including African American, Asian, Latino, Muslim, Sikh,

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and Arab Americans. Indigenous people have to prove and qualify their indigenous identity and refugees from places such as Syria, Africa, or Southeast Asian countries encounter multiple layers of trauma and loss, not to mention outright hostility in some cases, which make it difficult to create a new life in the USA (Mirkin and Kamya 2008).

Relevant Research In the field of CFT European Americans are significantly overrepresented, while only 2% of MFTs are African-American, 4% Hispanic, 1% Asian, and 1% Native American or Alaskan Native (Northey and Harrington 2003). However, we now have more research (Sprenkle 2012) that focuses on or includes ethnic minorities than the previously stated figure of 4.4% minority-focused research articles (Bean and Crane 1996), and important gaps in this regard that were pointed out by Sprenkle (2003). Previously, training in ethnic minority issues primarily focused on clinical interventions specific to minority client populations. We know now that ethnic minority issues go beyond how to treat clients in therapy, to understanding the impact of the larger social context (ChenFeng et al. 2016), as well as the experiences of ethnic minority therapists (Wieling and Rastogi 2003) and students/supervisees (Hernández et al. 2009). While ethnic specific articles based on case studies and specific populations can be helpful for clinical practice, family therapists should use “cultural descriptors as starting points and not definitive descriptors for a specific cultural group” (Bermudez et al. 2010, p. 170). Researchers sought the feedback of Latino participants by asking the degree to which they agree with statements describing Latino families found in marriage and family therapy literature. Participants agreed with statements pertaining to Latino values of familism and personalism; however, there were mixed results in regard to other Latino values presented such as fatalism and spiritualism. This study reminds us that clients are better served when therapists are flexible and curious in their cultural perceptions; articles and research can provide

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beginning cultural descriptors, but it is important to seek out the local and personal knowledge presented by each client/family. This ethnic specific cultural information also needs to be understood in context, otherwise therapists can unintentionally essentialize and further disempower clients. More recent couple and family therapy theories such as Socio-Emotional Relationship Therapy (SERT; Knudson-Martin et al. 2014) explicitly and intentionally integrate the larger sociopolitical and historical context to be able to recognize and interrupt power imbalances in the therapy room. For example, when therapists work with clients of Asian heritage, they may bring in unexamined assumptions about Asian Americans perpetuated by dominant discourses and stereotypes, such as Asian Americans as a model minority, being forever foreigners, or the submissiveness of Asian American women (ChenFeng et al. 2016). Therapists must examine their own biases so that clinical work does not perpetuate the hurtful consequences of systemic issues of oppression, power, and privilege, and supervision of MFT trainees must necessarily encourage the exploration of self-of-therapist issues related to identity development. When therapists critically engage by attuning to clients’ multiple cultural worlds as embedded in sociopolitical realities, empowering clients becomes a possibility. The research reflects growing interest in the experiences of ethnic minority therapists and supervisees; these studies help to shape how CFT training and supervision can be done to better serve students and clients. Some ethnic minority therapists express having inadequate clinical training in teaching, multicultural diversity, and diverse learning environments (Rastogi and Wieling 2005; Wieling and Rastogi 2003). They strongly identify with their ethnic minority identities and see this as having great value while hoping for organizational and educational change so that their experiences become less peripheral in the field. Ethnic minority supervisees have at times also “felt that their supervisors conducted supervision from a Eurocentric perspective that denied their identities and social locations.” Further, there are supervisee reports of supervisors misusing power and engaging in overt

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racism in supervision (Hernández et al. 2009, p. 97). Training across all levels of CFT work can benefit from the decentering of Eurocentric, White-dominant realities.

Special Considerations for Couple and Family Therapy Given this research, the field of couple and family therapy would benefit from responding thoughtfully to ethnic minority experiences. The hope is that in the therapy room, or in supervision/teaching, MFTs are not contributing to more spaces where clients and students feel unsafe and further marginalized. We know that it is important to address issues related to ethnic identity in therapy (Utsey et al. 2002) and in supervision (Hird et al. 2004; Todd and Rastogi 2014). An article by Hird et al. (2004) on supervision that also applies to teaching and clinical work states that the onus of responsibility to initiate such conversations falls on the person who holds power in the relationship, whether this is the therapist, supervisor, or instructor. When dialogue about culture and ethnicity is not part of the process, supervisees (clients or students) are more likely to self-silence because it may not feel safe for them to initiate conversation even if it is on their mind (Hird et al. 2004). When supervisors model attending to issues of power, oppression, and privilege in the supervisory relationship, it enables supervisees to do the same with clients (Glosoff and Durham 2010). Watts-Jones (2010) models how a therapist can initiate conversation about the therapist’s own self-location. It is the therapist’s responsibility to have a sufficient base of knowledge, a conceptual framework around ethnicity, culture, identity, power, and oppression discourses (Pandit et al. 2014), to engage in conversations with clients around the issue of ethnic identity. This contributes to the creation of a safe space in therapy for clients to be able to dialogue about their own ethnic minority or majority identities. This process hopefully leads to greater awareness regarding ethnic minority experiences and issues so that the CFT field can better serve and empower ethnic minority clients, students, and supervisees.

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Cross-References ▶ African Americans in Couple and Family Therapy ▶ Asian Americans in Couple and Family Therapy ▶ Black Men in Couples and Families ▶ Black Women in Couples and Families ▶ Cultural Identity in Couples and Families ▶ Cultural Values in Couples and Families ▶ Latino/Latinas in Couple and Family Therapy

References Bean, R., & Crane, D. R. (1996). Marriage and family therapy research with ethnic minorities: Current status. The American Journal of Family Therapy, 24(1), 3–8. https://doi.org/10.1080/01926189508251011. Bermudez, J., Kirkpatrick, D., Hecker, L., Torres-Robles, C. (2010). Describing Latino families and their helpseeking attitudes: Challenging the family therapy literature. Contemporary Family Therapy, 32(2), 155–172. ChenFeng, J., Kim, L., Wu, Y., & Knudson-Martin, C. (2016). Addressing culture, gender, and power with Asian American couples: Application of socioemotional relationship therapy. Family Process, 56, 558. https://doi.org/10.1111/famp.12251. Glosoff, H. L., & Durham, J. C. (2010). Using supervision to prepare social justice counseling advocates. Counselor Education and Supervision, 50(2), 116–129. https://doi.org/10.1002/j.1556-6978.2010.tb 00113.x. Hernández, P., Taylor, B. A., & McDowell, T. (2009). Listening to ethnic minority AAMFT approved supervisors: Reflections on their experiences as supervisees. Journal of Systemic Therapies, 28(1), 88–100. https:// doi.org/10.1521/jsyt.2009.28.1.88. Hird, J. S., Tao, K. W., & Gloria, A. M. (2004). Examining supervisors’ multicultural competence in racially similar and different supervision dyads. The Clinical Supervisor, 23(2), 107–122. https://doi.org/10.1300/j001v23 n02_07. Ho, M. K., Rasheed, J. M., & Rasheed, M. (2004). Family therapy with ethnic minorities (2nd ed.). Thousand Oaks: Sage. Knudson-Martin, C., Huenergardt, D., Lafontant, K., Bishop, L., Schaepper, J., & Wells, M. (2014). Competencies for addressing gender and power in couple therapy: A socio emotional approach. Journal of Marital and Family Therapy, 41(2), 205–220. McGoldrick, M., Giordano, J., & Garcia-Preto, N. (2005). Ethnicity and family therapy. New York: Guilford Press. Mirkin, M. P., & Kamya, H. (2008). Working with immigrant and refugee families. In M. McGoldrick &

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950 K. V. Hardy (Eds.), Re-visioning family therapy (2nd ed., pp. 311–326). New York: Guilford Press. Northey, W. F., Jr., & Harrington, M. (2003). 2002 AAMFT member survey of clinical practices and approaches to substance abuse. Alexandria: The American Association for Marriage and Family Therapy. Rastogi, M., & Thomas, V. (2009). Multicultural couple therapy. Thousand Oaks: Sage. Rastogi, M., & Wieling, E. (2005). Voices of color. Thousand Oaks: Sage. Sprenkle, D. H. (2003). Effectiveness research in marriage and family therapy: An introduction. Journal of Marital and Family Therapy, 29(1), 85–96. Sprenkle, D. H. (2012). Intervention research in couple and family therapy. Journal of Marital and Family Therapy, 38(1), 3–29. Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse. Hoboken: Wiley. Todd, T. C., & Rastogi, M. (2014). Listening to supervisees about problems in systemic supervision. In T. C. Todd & C. L. Storm (Eds.), The complete systemic supervisor: Philosophy, context and pragmatics (2nd ed., pp. 314–334). Chichester: Wiley. Utsey, S. O., Chae, M. H., Brown, C. F., & Kelly, D. (2002). Effect of ethnic group membership on ethnic identity, race-related stress and quality of life. Cultural Diversity & Ethnic Minority Psychology, 8(4), 366–377. https://doi.org/10.1037/10999809.8.4.367. Watts-Jones, T. D. (2010). Location of self: Opening the door to dialogue on intersectionality in the therapy process. Family Process, 49(3), 405–420. https://doi. org/10.1111/j.1545-5300.2010.01330.x. Wieling, E., & Rastogi, M. (2003). Voices of marriage and family therapists of color. Journal of Feminist Family Therapy, 15(1), 1–20. https://doi.org/10.1300/j086v15 n01_01.

Ethnicity in Couples and Families Nydia Garcia Preto1 and Monica McGoldrick1,2 1 Multicultural Family Institute, Highland Park, NJ, USA 2 Psychiatry Department, Rutgers University, Robert Wood Johnson Medical School, Highland Park, NJ, USA

Synonyms Cultural identity

Ethnicity in Couples and Families

Introduction Ethnicity, the concept of a group’s “peoplehood,” refers to a group’s common ancestry and history, through which people have evolved shared values and customs over the centuries. Based on a combination of race, religion, geography, political, and cultural history, ethnicity is retained, whether or not members realize their commonalities with one another. Its values are transmitted over generations by the family and reinforced by the surrounding community. Ethnicity is a powerful influence in determining identity. It patterns our thinking, feeling, and behavior in both obvious and subtle ways, although generally we are not aware of it. It plays a major role in determining how we eat, work, celebrate, make love, and die (McGoldrick et al. 2005). Ethnicity is not, however, the only dimension of culture, and to understand it, we must pay attention to its intersection with race, social class, gender identity, sexual orientation, religion, geography, immigration, and family dynamics. Such factors affect the way individuals may feel about their cultural heritage, how they relate to others in their cultural group, and their interest in preserving cultural traditions. They also influence people’s social location, their access to resources, their sense of belonging to this society, and the extent to which they are privileged or oppressed. The continuing rise of immigrants to the United States from Asia, Latin America, and the Middle East during recent decades has contributed to high rates of cultural intermarriage. These changes have also brought more attention to the existence of marked disparities in mental health services for racial and ethnic minorities in this country (Sue et al. 2009). The fact that non-dominant ethnic groups face many barriers in accessibility, an use of high-quality care has prompted mental health professionals to give greater consideration to the underlying cultural assumptions in therapeutic models and to question their universality for clinical work with couples and families. Ethnicity offers a lens through which marriage and family therapists can better understand the influence of cultural values and beliefs on clients’ experience of physical and emotional problems and their patterns of help seeking.

Ethnicity in Couples and Families

Description The consciousness of ethnic identity varies greatly within groups and from one group to another. When we ask people to identify themselves ethnically, we are really asking them to oversimplify, to highlight a part of their identity in order to make certain themes of cultural continuity more apparent. Many people in the United States grow up not even knowing their ethnicity or having descended from multiple ethnic backgrounds. But everyone has a culture. Clinical work may often entail helping clients locate themselves culturally so that they can overcome their sense of mystification, invalidation, or alienation that comes from not being able to feel culturally at home in our society. Our clients’ personal contexts are strongly shaped by their ethnic cultures. As therapists, an important part of our work has been to help clients clarify the multiple facets of their identity to increase their flexibility to adapt to the multicultural society in the United States. We help them appreciate and value the complex web of connections within which their identities are formed and which cushion them as they move through life. Ethnically respectful clinical work helps people evolve a sense of who they belong to. Thus therapy involves helping people clarify their selfidentity in relation to family, community, and their ancestors, while also adapting to changing circumstances as they move forward in time. While generalizing about groups has often been used to reinforce prejudices, one cannot discuss ethnic cultures without generalizing, since the very definition of ethnicity or culture pertains to group values, patterns, and traditions. The only alternative to generalizing about culture is deny its relevance and ignore the analysis of group patterns, which is likely to disqualify the experience of groups at the margins, perpetuating mystification and covert negative stereotyping. Our field’s diagnostic scheme, for example, whether the ICD-10 or the DSM V, does not require the slightest reference to any person’s cultural background or location in order to make a diagnosis or to provide treatment (Regier et al. 2013). The dominant culture privileges individual values

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over group values, tending to avoid discussion of group characteristics altogether, in favor of individual characteristics, maintaining, for example, “I prefer to think of each individual as a unique human being rather than pigeonholing individuals in group categories.” Of course we all prefer to be treated as unique human beings, but such assumptions prevent acknowledging the influence of cultural and group history on every person’s experience. Some in our society have the privilege to belong, with access to society’s resources and the ability to trust that society’s institutions will work for them. Others are disqualified at every turn. The values, beliefs, status, and privileges of families in our society are profoundly influenced by their socioeconomic and cultural location, making these issues essential to our clinical assessment and intervention. Discussing cultural generalizations or stereotypes is as important as discussing any other norms of behavior. It is almost impossible to understand the meaning of behavior unless one knows something of the cultural values of a family. Even the definition of “family” differs greatly from group to group. The dominant mainstream definition in the United States (McGill and Pearce 2005) tends to emphasize the intact nuclear family, whereas for Italians (Giordano et al. 2005), there tends to be no such thing as the “nuclear” family. To them, family typically means a strong, tightly knit three- or four-generational kinship network, which also includes godparents and old friends. AfricanAmerican families typically focus on an even wider network of kin and community (Kelly and Hudson 2016; Moore Hines and Boyd-Franklin 2005). And some Asian families include all their ancestors going all the way back to the beginning of time and all descendants, or at least male ancestors and descendants, reflecting a sense of time that is almost inconceivable to most Americans (Suzuki et al. 2016; Lee and Mock 2005). Ethnic groups’ distinctive problems are often the result of cultural traits that are conspicuous strengths in other contexts. For example, the optimism of those of British ancestry may lead to confidence and flexibility in taking initiative. But the same preference for being upbeat may also

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lead to the inability to cope with tragedy or to engage in mourning (McGill and Pearce 2005). Historically, the British have perhaps had much reason to feel fortunate as a people. But optimism often becomes a vulnerability when people must contend with major losses. They may have few philosophical or expressive ways to deal with situations in which optimism, rationality, and belief in individual efficacy are insufficient. Thus they may feel lost when dependence on the group is the only way to ensure survival. Families from different ethnic groups may experience diverse types of intergenerational struggles. British-American (McGill and Pearce 2005) families are likely to feel that they have failed if their children do not move away from the family and become independent, whereas Italians (Giordano et al. 2005) generally believe they have failed if their children do move away. Jewish families often foster a relatively democratic atmosphere in which children are free to challenge parents and discuss their feelings openly (Rosen and Weltman 2005). Greek (Killian and Agathangelou 2005) or Chinese families, in contrast, do not generally expect or desire open communication between generations and would disapprove of a therapist getting everyone together to discuss and “resolve” their conflicts. Children are expected to respect parental authority, which is reinforced by the distance parents maintain from their children (Lee and Mock 2005). Cultural groups vary greatly in the emphasis they place on various life transitions. Irish and African Americans have always considered death the most important life cycle transition (McGoldrick et al. 2004). Italians, Asian Indians, and Poles tend to emphasize weddings, whereas Jews often pay particular attention to the bar or bat mitzvah and Puerto Ricans to the Quinceanera (15th birthday), celebrating transitions from childhood that other groups hardly mark at all. Families’ ways of celebrating these events differ also. The Irish tend to celebrate weddings (and every other occasion) by drinking, Poles by dancing, Italians by eating, and Jews by eating and talking. Mexican Americans (Falicov 2005) may see early and middle childhood as extending longer than

Ethnicity in Couples and Families

the dominant American pattern, while adolescence is shorter and leads more quickly into adulthood than in the dominant American structure, where courtship is generally longer, and middle age extends into what Americans generally think of as older age. Ethnic groups vary in what they view as problematic behavior. Anglos (McGill and Pearce 2005) may be uncomfortable with dependency or emotionality; the Irish are distressed by a family member “making a scene”, Italians about disloyalty to the family (McGoldrick et al. 2005), Greeks (Killian and Agathangelou 2005) about any insult to their pride or filotimo, Jews (Rosen and Weltman 2005) about their children not being “successful”, Puerto Ricans (Garcia Preto 2005) about their children not showing respect, and Arabs (Abudabbeh 2005) about their daughters’ virginity. For Chinese families, harmony is a key dimension (Lee and Mock 2005), while for African Americans, the concept of bearing witness and testifying about their suffering is a central concept (Moore Hines and Boyd-Franklin 2005). Of course, families also vary in how they respond to problems. Anglos (families of British ancestry) may see work, reason, and stoicism as the best response, whereas Jews often consult doctors and therapists to gain understanding and insight. Until recently, the Irish responded to problems by going to the priest for confession, “offering up” their suffering in prayers, or, especially for men, seeking solace through drink (McGoldrick et al. 2005). Italians may prefer to rely on family support, eating, and expressing themselves. West Indians may see hard work, thrift, or consulting with their elders as the solution (Brice-Baker 2005), and Norwegians might prefer fresh air or exercise (Erickson 2005). Asian Indians might focus on sacrifice or purity and the Chinese on food or prayer. Groups also differ in attitudes toward seeking help. In general, Italians rely primarily on the family and turn to an outsider only as a last resort. African Americans have long mistrusted the help they can receive from traditional institutions except the church, the only institution they could consider “theirs.” Puerto Ricans and Chinese may somatize when under stress and seek medical

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rather than mental health services. Norwegians, too, often convert emotional tensions into physical symptoms, which they consider more acceptable, thus, their preference for doctors over psychotherapists. Likewise, Iranians (Jalali 2005) may view medication and vitamins as a necessary part of treating symptoms. And some groups tend to see their problems as the result of their own sin, action, or inadequacy (Irish, African Americans, Norwegians) or someone else’s (Greeks, Iranians, Puerto Ricans). The degree of ethnic intermarriage in the family also plays a role in the evolution of cultural patterns (McGoldrick and Garcia Preto 1984; Crohn 1995; Root 2001; Kennedy 2003; Killian 2013; Karis and Killian 2009; Rastogi and Thomas 2009; Brunsma and Porow 2016). Although as a nation we have a long history of intercultural relationships, until The Loving vs. Virginia court ruling in 1967 (Newbeck and Wolfe 2015), our society explicitly forbade racial intermarriage and discouraged cultural intermarriage. But traditional ethnic and racial categories are now increasingly being challenged by the cultural and racial mixing that has long been a submerged part of our history. Intimate relationships between people of different ethnic, religious, and racial backgrounds offer convincing evidence that Americans’ tolerance of cultural differences may be much higher than most people think (Pew Research Center 2012; Killian 2013; Crohn 1995; McGoldrick and Garcia-Preto 1984). Intermarriage can also complicate issues that most partners face. The greater the cultural difference between spouses, the more trouble they may have in adjusting to marriage. Knowledge about ethnic/ cultural differences can be helpful to spouses who take each other’s behavior too personally. Typically, we tolerate differences when we are not under stress. We may even find them appealing. However, when stress occurs, tolerance for differences diminishes. Not to be understood in ways that conform with our wishes and expectations frustrates us. For example, when upset, Anglos (Americans of British ancestry) tend to move toward stoical isolation to mobilize their powers of reason. In contrast, Jews may seek to analyze their experience by talking things out together.

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Italians may seek solace in food or in emotionally and dramatically expressing their feelings, and Asians may become very silent, fearing loss of face. Members of these groups sometimes perceive each other’s reactions as offensive or insensitive, although, within each group’s ethnic norms, such reactions make perfect sense. Much of therapy involves helping family members recognize each other’s behavior as largely a reaction from a different frame of reference. Consider an Anglo (British American)-Italian couple in which the husband takes literally the dramatic expressiveness of the Italian wife, while she finds his emotional distancing intolerable. The husband may label the Italian “hysterical” or “crazy” and in return be labeled “cold” or “catatonic.” Knowledge about differences in cultural belief systems can help spouses who take each other’s behavior too personally to be less reactive. Couples may experience great relief when they can come to see the spouse’s behavior fitting into a larger ethnic context rather than as a personal attack. Yet cultural traits may also be used as an excuse for not taking responsibility in a relationship: “I’m Italian. I can’t help it” (i.e., the yelling, abusive language, impulsiveness), or “I'm a WASP. It is just the way I am” (the lack of emotional response, rationalization, and workaholism).

Relevant Research Studies on ethnicity in the United States have fluctuated depending on social factors and politics. Sociologists such as Glazer and Moynihan (1963, 1975), and Greeley (1974) made numerous early contributions that raised awareness about the important role families play in groups maintaining their ethnic identity. Glazer and Moynihan (1963) in their influential book Beyond the Melting Pot presented their analysis of five specific ethnic groups in New York City: Irish, Italians, Jewish, African Americans, and Puerto Ricans. They saw the family as the most important factor in keeping ethnic groups from losing their national identities as they struggled to adapt to a new culture and offered some protection from adversity in the dominant culture.

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The US Census tracking of race and ethnic ancestry provides statistics that help researchers to measure growth or decline of certain ethnic groups and to compare many trends in the population. In the 1970s and 1980s, there was a surge of literature and studies that alerted the government and public about the alarming disparities in the provision and quality of services and care that some racial and ethnic minority groups receive. Many of these studies called for the need to integrate cultural awareness particularly in the delivery of health and mental health services (Sue 1998; Sue et al.1982; Sue and Zane 1987, 2006; Kleinman 1980; Hall 1987). Since then, many studies have reported positive results about the efficacy of integrating cultural competent interventions when working with ethnic minorities (Rosello et al. 1999; Bernal and Saez-Santiago 2006; Santisteban et al. 1997, 2003, 2012). However, in the field of marriage and family therapy, there continues to be a lack of such research. Increasingly over the past 25 years, research in the field has been focused more narrowly on developing empirically supported evidencebased treatment models, rather than exploring the vast untapped potential of system concepts to bring about change for the diverse population of our nation. These treatment models have rarely been tested on the diverse populations of our country. Yet increasingly, they are becoming the only models one can teach at Marriage and Family Graduate Schools. Research evidence is primarily based on studies conducted by white middle-class researchers on white European Americans, and the instruments they use reflect the dominant white culture. The lack of research on ethnically, racially, and/or socioeconomically diverse groups raises obvious questions about the general applicability of these models (Bernal and ScharronDel-Rio 2001; Hall 2001; Sue 1998). For example, the Emotionally Focused Couple Therapy model (Weibe and Johnson 2016) has rarely even mentioned cultural dimensions of experience and has conducted no trials with non-dominant cultural groups, yet the data generated tends to be viewed as universally applicable. A few evidence-based models, such as the cognitive behavioral couple therapy model

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(Fischer et al. 2016), the Family Interventions for Schizophrenia and the Psychosis model (McFarland 2016), and the Multidimensional Family Therapy model (Liddle 2016), have given some consideration to the influence of ethnicity in shaping couple and family relationships and have noted that acknowledging cultural beliefs and attitudes of the target population seems to increase the participation of ethnic minorities. But, the only group that has actually acknowledged that their lack of studies on ethnic minority groups is a limitation of their model were the authors of Alcohol-Focused Behavioral Couple Therapy (McCrady et al. 2016). More commonly, if the researchers even refer to culture at all, it is not embedded in their work in any meaningful way. For example, Busby and Holman (2009) refer in a study based on John Gottman’s work, to the importance of understanding background variables including ethnicity and religion in order to understand a couple’s relationship style. However, they give no idea how these issues would be assessed or integrated into clinical understanding. Only two models, The Oregon Model of Parent Management Training (Forgatch and Kjobli 2016; Parra-Cardona et al. 2016) and The Brief Strategic Family Therapy Model (Szapocznik et al. 1978; Santisteban et al. 2006) seem to really understand that cultural perspectives are at the core of human relationships. The Oregon group, following Stanley Sue’s model for cultural competence (Sue 1998), integrates cultural assumptions within the very core of their structure. Impressively, all those involved in the training are encouraged to learn about their own culture as well as other cultures and to increase their cultural competence. The model has been translated and developed in different languages, modifying their examples to be culturally relevant in each version. The Brief Strategic Family Therapy model is unique in having been designed to fit the cultural values of Cuban immigrant families in Miami who presented with adolescent behavioral problems and intergenerational conflicts (Szapocznik et al. 1978). The model has evolved, applying strategies that were initially tailored for engaging Latinos into work with African Americans and

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interventions with white European populations (Santisteban et al. 2006). Overall, the consideration of ethnicity in marriage and family therapy has remained a “special issue,” mostly ignored in research, taught at the periphery of psychotherapy training and rarely written about or recognized as crucial by or for therapists of European origin (Rastogi and Thomas 2009; Murry et al. 2001; Chambless et al. 1996).

Special Considerations for Marriage and Family Therapy In the past few years there has been a greater commitment by professional organizations such as the American Association for Marriage and Family Therapy to integrate requirements for cultural awareness and sensitivity into their professional codes of ethics and into their curricula. For example, The Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) Accreditation Standards (2015) has called for “ Marriage and family training programs to demonstrate a commitment to diversity and inclusion by providing multicultural informed education that addresses diversity in a safe, respectful, and inclusive learning climate, and that offers students experiences with diverse marginalized, and/or undeserved communities.” (Jordan 2016, p. 12). The expectation has been for supervisors and professors to guide students and supervisees to think about their own cultural values and evaluate their prejudices, biases, racism, stereotypes, and personal reactions. A basic assumption is that we learn about culture not so much by evaluating others but by learning about our own cultures (Hardy and Laszloffy 1992, 1995; Green 1998; McGoldrick et al. 2005; Falicov 2014; Knudson and Mahoney 2009; Kelly and Hudson 2016). More than three decades ago, the idea that the most important part of ethnicity training involves the therapist coming to understand his or her own ethnic identity was advocated in the first edition of the book Ethnicity and Family Therapy (1982). Just as clinicians must sort out the relationships in

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their own families of origin, developing cultural competence and cultural responsiveness requires coming to terms with one’s own ethnic identity. Ideally, therapists would no longer be “triggered” by ethnic characteristics they may have regarded negatively or caught in the ethnocentric view that their own cultural values are more “right” or “true” than those of others. Ethnically self-aware therapists achieve a multiethnic perspective, which opens them to understanding values that differ from their own, so that they neither need to convert others to their view nor to give up their own values. David McGill (McGill and Pearce 2005) has suggested that the best training for family therapists might be to live in another culture and learn a foreign language and that experience might best help the clinician achieve the humility necessary for respectful cultural interactions that are based on more than one way of defining normality, truth, and wisdom. Thus, the best cultural training for marriage and family therapists might be to experience what it is like not to be part of the dominant culture.

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Ethnicity in Couples and Families therapists. Journal of Marital and Family Therapy, 21(3), 227–237. Jalali, B. (2005). Iranian families. In M. McGoldrick, J. Giordano, & N. Garcia Preto (Eds.), Ethnicity and family therapy (3rd ed.). New York: Guilford Press. Jordan, K. (Ed.). (2016). Couple, marriage, and family therapy supervision. New York: Springer. Karis, T. A., & Killian, K. D. (Eds.). (2009). Intercultural couples: Exploring diversity in intimate relationships. New York: Routledge Taylor and Francis Group. Kelly, S., & Hudson, B. N. (2016). Diversity in couple and family therapy: Ethnicities, sexualities, and socioeconomics. Santa Barbara: Praeger. Kennedy, R. (2003). Interracial intimacies: Sex, marriage, identity, and adoption. New York: Pantheon. Killian, K. D. (2013). Interracial couples: Intimacy and therapy. New York: Columbia University Press. Killian, K. D., & Agathangelou, A. M. (2005). Greek families. In M. McGoldrick, J. Giordano, & N. Garcia Preto (Eds.), Ethnicity and family therapy (3rd ed.). New York: Guilford Press. Kleinman, A. (1980). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley: University of California Press. Knudson-Martin, C., & Rankin Mahoney, A. (2009). Couples, gender, and power: Creating change in intimate relationships. New York: Springer. Lee, E., & Mock, M. R. (2005). Chinese families. In M. McGoldrick, J. Giordano, & N. Garcia Preto (Eds.), Ethnicity and family therapy (3rd ed.). New York: Guilford Press. Liddle, H. A. (2016). Multidimensional family therapy: Evidence base for transdiagnostic treatment outcomes, change mechanisms, and implementation in community settings. Family Process, 55(3), 558–576. McCrady, B. S., Wilson, A. D., Munoz, R. E., Fink, B. C., Fokas, K., & Borders, A. (2016). Alcohol-focused behavioral couple therapy. Family Process, 55(3), 443–459. McFarland, W. R. (2016). Family interventions for schizophrenia and the psychoses: A review. Family Process, 55(3), 460–482. McGill, D. W., & Pearce, J. K. (2005). American families with English ancestors from the colonial era. In M. McGoldrick, J. Giordano, & N. Garcia Preto (Eds.), Ethnicity and family therapy (3rd ed.). New York: Guilford Press. McGoldrick, M., & Garcia Preto, N. (1984). Ethnic intermarriage: Implications for therapy. Family Process, 23(3), 347–364. McGoldrick, M., Pearce, J. K., & Giordano, J. (Eds.). (1982). Ethnicity and family therapy. New York: Guilford. McGoldrick, M., Marsh Schlesinger, J., Hines, P., Lee, E., Chan, J., Almeida, R., Petkov, B., Garcia Preto, N., & Petry, S. (2004). In F. Walsh & M. McGoldrick (Eds.), Living beyond loss (2nd ed.). New York: Norton. McGoldrick, M., Giordano, J., & Garcia Preto, N. (Eds.). (2005). Ethnicity and family therapy (3rd ed.). New York: Guilford Press.

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Moore Hines, P., & Boyd-Franklin, N. (2005). African American families. In M. McGoldrick, J. Giordano, & N. Garcia Preto (Eds.), Ethnicity and family therapy (3rd ed.). New York: Guilford Press. Murry, V. M., Smith, E. P., & Hill, N. F. (2001). Race, ethnicity, and culture in studies of families in context. Journal of Marriage and the Family, 63(4), 911–914. Newbeck, P., & Wolfe, B. (2015). Loving v. Virginia (1967). In Encyclopedia Virginia. Retrieved from http://www.EncyclopediaVirginia.org/Loving_v_Vir ginia_1967. Parra-Cardona, J. R., López-Zerón, G., Domenech Rodríguez, M. M., Escobar-Chew, A. R., Whitehead, M. R., Sullivan, C. M., & Bernal, G. (2016). A balancing act: Integrating evidence based knowledge and cultural relevance in a program of prevention parenting research Latino/a immigrants. Family Process, 55(2), 321–337. Pew Research Center. (2012). The rise of intermarriage. Washington, D.C. Rastogi, M., & Thomas, V. (2009). Multicultural couple therapy. Los Angeles: Sage. Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM-5: Classification and criteria changes. World Psychiatry. 12(2): 92–98. Retrieved 17 Jan 2017: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3683251/ Root, M. P. P. (2001). Love’s revolution: Interracial marriage. Philadelphia: Temple University Press. Rosello, J., Bernal, G., & Medina, C. (1999). Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms. Cultural Diversity and Ethnic Minority Psychology, 14(3), 317–344. Rosen, E. J., & Weltman, S. (2005). Jewish families: An overview. In M. McGoldrick, J. Giordano, & N. Garcia Preto (Eds.), Ethnicity and family therapy (3rd ed.). New York: Guilford Press. Santisteban, D., Coatsworth, J. D., Perez-Vidal, A., Mitrani, C., Jean-Guilles, M., & Szapocznik, J. (1997). Brief structural strategic family therapy with African Americans and Hispanic high risk youth: A report of outcome. Journal of Community Psychology, 25, 453–471. Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A., Kurtines, W. M., Schwartz, S. J., LaPerriere, A., & Szapocznik, J. (2003). Efficacy of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use. Journal of Family Psychology, 17(1), 121–133. Santisteban, D. A., Suarez-Morales, L., Robbins, M. S., & Szapocznik, J. (2006). Brief strategic family therapy: Lessons learned in efficacy research and challenges to blending research and practice. Family Process, 45(2), 259–267. Santisteban, D. A., Mena, M. P., & Abalo, C. (2012). Bridging diversity and family systems: Culturally informed and flexible based treatment for Hispanic adolescents. Family Psychology, 2(4), 246–263. Sue, S. (1998). In search of cultural 11competence in psychotherapy and counseling. American Psychologist, 53(4), 440–448.

Sue, S., & Zane, N. (1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. American Psychologist, 59(4), 533–540. Sue, S. & Zane, N. (2006). Ethnic minority populations have been neglected by evidence-based practices. In J.C. Norcross, L. E. Beutler, & R. F. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association. 61: 38 345–359. Sue, D. W., Bernier, J. B., Durran, A., Feinberg, L., Pedersen, P. B., Smith, E. J., & Vasquez-Nuttal, E. (1982). Position paper: Cross-cultural counseling competencies. Counseling Psychologist, 10, 45–52. Sue, S., Zane, N., Nagayama-Hall, G. C., & Berger, L. K. (2009). The case for cultural competency in psychotherapeutic interventions. Annual Review Psychologist, 60, 525–548. Suzuki, L. A., Won, G., Masako Mori, M., & Toyama, K. (2016). Asian American couples and families. In S. Kelly & B. N. Hudson (Eds.), Diversity in couple and family therapy: Ethnicities, sexualities, and socioeconomics. Santa Barbara: Praeger. Szapocznik, J., Scopetta, M. A., & King, O. E. (1978). Theory and practice in matching treatment to the special characteristics and problems of Cuban immigrants. Journal of Community Psychology, 6(2), 112–122. Weibe, S. A., & Johnson, S. M. (2016). A review of the research in emotionally focused couple and family therapy. Family Process, 55(3), 390–407.

Ethnography in Relation to Couple and Family Therapy Rini Kaushal and Bahareh Sahebi The Family Institute at Northwestern University, Evanston, IL, USA

Name of Theory Ethnography in Relation to Couple and Family Therapy

Introduction Ethnography is a prevalently used scientific method to collect data in qualitative research with the intent to understand individuals through their

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social and cultural arrangements. Ethnography attempts to define cultural realities by interpreting, analyzing, and documenting detailed descriptions of patterns, events, contexts, and conversations to better comprehend how culture influences human behavior in everyday environment (Tubbs and Burton 2005). Ethnography has been widely used to enhance the understanding of the practical and theoretical domains of family therapy and its applicability in the client’s real world. In the field of couple and family therapy, the use of ethnographic interviews began as an initiative to create more clientbased descriptions of family therapy sessions. This approach was a shift away from the existing literature that primarily focused on the therapist’s perspective. Since then, ethnographic interviews have been continually used to gather feedback from the clients regarding the direction of the therapeutic process. This approach has also been utilized in exploring the therapeutic relationship to determine fit between client and therapist variables, formulating effective treatment plans, and delivering high-quality services. In couple and family therapy, ethnographic debriefing has also been found to significantly benefit in repairing ruptures in the therapeutic alliance and addressing dissatisfaction expressed by the clients regarding the therapeutic process. One of the unique features of ethnographic research is to focus on hypothesis development, rather than testing, based on the analysis of the gathered data. In lieu of forming questions to elicit predetermined responses, ethnography aids in formulating hypotheses based on an individual’s description of their sociocultural experiences.

considered to be the first researchers to use ethnographic methods to assess the experience of clients participating in family therapy. Through their work, these researchers demonstrated how observations of both the client and the therapist can be effectively utilized to improve the therapeutic process. In recent times, Monica McGoldrick, cofounder and director of the Multicultural Family Institute in Highland Park, New Jersey, has contributed significantly through her writings on the inclusion of race, culture, and gender in family therapy practices. Her work has provided recommendations for culturally sensitive and culturally aware assessments, treatment considerations, and clinical training efforts for diverse groups of couple and family therapists.

Prominent Associated Figures Gregory Bateson is noted as one of the pioneers in the field who first introduced ethnographic approaches to incorporate systems into cultural behavior. Bateson fostered cross-cultural understanding of various ethnic groups through his proposed theory – ecology of the mind. Additionally, Bruce Kuehl and his colleagues Neal Newfield and Harvey Joanning, are

Description The validity of ethnographic interviewing can be better understood by expanding on the idea that research concepts can be effectively combined with counseling techniques. The ethnographic interview questions also serve the purpose of pursuing cultural meaning that is translated and understood differently by different people. Thus, it is imperative to become familiar with the different kinds of questions that therapists can ask their clients to better understand their cultural context and how the clients’ cultural upbringing may have influenced their current lifestyles. A further discussion will follow regarding a number of ethnographic questions including, example questions, structural and descriptive questions, native-language questions, and the ethnographic mapping task. Ethnographic descriptive questions (Banister 1996) are a series of questions asked by therapists to elicit details about specific events, people, or behaviors and how it may have impacted the client’s presenting problem and formed the problem sequence. For example, “I see that this was the first time you celebrated Thanksgiving in America. Can you please tell me what exactly happened during the Thanksgiving dinner with your partner’s parents that upset you?”

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A subcategory of descriptive questions is minitour questions (Spradley 1979). which refers to placing the context of the content in practice for the client (Bruner 1990). For example, “if I were to observe you and your son praying at the mosque, what would I see?” Another category of ethnographic questions includes example questions (Banister 1996), which are most commonly used to comprehend the client’s narrative about a particular event, person, or situation. For instance, “can you give me an example of what ‘gets on your nerves’ when you are with your partner?” Therapists can also ask ethnographic structural questions that help in exploring the client’s responses to the descriptive questions and how they organize this information in everyday life. For example, if a client frequently mentions that he feels burned-out when he spends time with his 3year-old child, the therapist can ask different types of structural questions in order to identify if any significant relationship exists between different variables of the presenting problem. This will also serve to assist the therapist in testing the evolving hypotheses. For example, “What are some of the things you do with your child that contribute to you feeling burned-out? Is your partner’s insistence of sending your child to daycare stressing you out? Are there other family members to help you throughout the day? What is the first thought that comes to your mind when you are with your child?” Ethnographic native-language questions (Spradley 1979), are asked when clients use a specific term or phrase (which could be in their native language) to describe their presenting problem, an event, or a person. The important thing for the therapist to do is to use the same term or phrase that the client has used and present it in another context or experience. This in turn may help the client create new meanings and interpretations of the given situation. For example, “What are some other situations that make you want to pass the buck?” Or “can you think of other terms or phrases to describe why you tend to pass the buck in crucial times?” In order to obtain accurate information about the clients’ experiences of their presenting problems, Banister (1996) also suggested an

effective technique called mapping tasks. In using the mapping task technique, clients are asked to map out a particular event, feeling, experience, relationship, or a situation through a diagram. This technique can be helpful in breaking down the event that is being considered and also providing an opportunity to the individual client to fill in the blanks for other significant people involved in the event. This technique is similar to mapping a problem sequence in Integrative Systemic Therapy (IST) that aids in visualizing a typical repetitive and recursive pattern (Pinsof et al., 2018). The different types of ethnographic questioning techniques have also been found to be effective in eliciting details about the client’s history in a way that promotes an organic flow of conversation and maintenance of therapeutic alliance. Different kinds of questions serve different purposes and assist in facilitating a smooth interview. Therefore, the ethnographic questioning technique is relevant to any form of therapy, especially couple and family therapy, as it can be efficiently used by therapists to combine the experiences of each member in the family for a more thorough conceptualization of the presenting problems.

Relevance to Couple and Family Therapy Recent statistics indicate that interracial marriages in the United States have been on the rise – from 3% in 1967 to 17% in 2015 (Pew Research Center, 2017). According to McGoldrick (2006), interracial marriages in the United States have increased as a consequence of sociocultural, political, and economic factors that in turn continually impact marital and familial relationships. As such, the utilization of ethnographic techniques in the context of therapy provides a more in-depth cultural observation, which is crucial in formulating effective solution sequences and identifying potential constraints that may have unknowingly been brought into the relationship by the partners. Consideration of all the given cultural factors helps the therapist to better understand how people preserve their cultural heritage and traditions

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and the ways in which it surfaces in different contexts of their relationships. McGoldrick aptly highlights the importance of observing how cultural groups differ in understanding what is problematic behavior, how they respond to given problems, and how they seek help to address these issues. For example, individuals from West Indies may prefer to consult the elders in their family, while Norwegians may see physical exercise regimens such as running and hiking as a beneficial means to solve distress. Similarly, Iranians, Puerto Ricans, and Chinese individuals may seek medical help rather than mental health services to find solutions for their marital or familial problems. According to McGoldrick (1998), the greater the cultural difference between spouses, the more likely they are to have difficulty in adjusting to the relationship. For example, East Asian tend to become silent during conflict, in part due to the fear of losing their dignity, while Italians may turn toward food or a major dramatic display of emotional venting to comfort themselves. Hence, ethnographic techniques in couple and family therapy can be immensely helpful for partners to gain more knowledge about their ethnic differences. Also, couples in interracial marriages are continuously trying to rebalance their own cultural characteristics by moving away from some of the values from their culture of origin while moving toward cultural values that they are adapting (McGoldrick 2006). This process of identifying one’s own ethnic identity and cultural values may potentially create friction in marriages and blended multiracial families. As such, adopting an ethnographic therapeutic approach to treat families may shed insight, for both the clients and the clinicians, uncovering the complexities in the presenting problems. As elaborated in the previous section, therapists can ask different types of ethnographic questions to understand the implications of the clients’ sociocultural background and resolve deeply embedded negative cultural attitudes as well as conflicts within the family system. Therapists can do this by identifying and choosing the values that the clients wish to retain in the

relationship. Clinicians can also coach family members to differentiate between deeply held beliefs from values that reinforce dysfunction in the relationship. For clinicians to effectively understand their clients’ familial problems in a cultural context, the following basic assumptions have been outlined to guide them through the process (Giordano and Carini-Giordano 1995; McGoldrick 1998): • Assume that no one can completely understand other cultures, but one must have cultural humility, sensitivity, and awareness of one’s own values and biases. • Assume that a person’s awareness about the positive aspects of his or her cultural heritage and family of origin history contributes toward his or her mental health and well-being. • Assume that individuals and families from marginalized cultures have possibly internalized shame and prejudice toward themselves. This internalized shame and prejudice may be due to interactions within the larger society by those from the dominant cultures who may have most likely internalized their superiority and privileges. • Assume that negative cultural attitude, or lack of awareness about one’s own heritage, can be a result of oppression, cutoffs, or traumatic experiences of being suppressed throughout history.

Clinical Example of Application of Theory in Couples and Families Reiko is a 33-year-old Japanese woman who has been married for 2 years to Mateo, a 36-year-old Mexican-American man. The couple met when Mateo traveled to Japan for a work-related conference. They legally married after dating for 2 years. Prior to their union, Mateo lived with his father and stepmother due to financial constraints. When Reiko moved to the United States, she agreed to live with her in-laws for a brief period of time before the couple could afford their own place. The first few months of their marriage were difficult as Reiko was still adjusting to the culture

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of a new country, learning a new language, as well as making efforts to get along with Mateo’s Mexican-American family. During this same time period, Mateo was struggling to find sponsors for his project and he often felt exhausted being the mediator between Reiko and his parents as minor relational conflicts arose. Some of these conflicts came about when Mateo’s parents, who were described by the couple as emotionally expressive, respectively expressed a desire to spend more time with Mateo and Reiko. Mateo’s parents’ emotional expressiveness was described by Reiko as suffocating and she experienced it as crossing boundaries. Upon further questioning about Reiko’s family of origin, Reiko indicated that she was raised in a family that was more stoic in nature, not emotionally expressive, and encouraged independence and personal space. Thus, Reiko was able to explain why the everyday family dinners and outings with Mateo’s parents became overwhelming for her. Mateo indicated understanding Reiko’s concerns, but he expressed not being able to convey Reiko’s needs to his family due to the fear of hurting his parents’ feelings and creating friction by disrespecting their intentions. As such, living with Mateo’s parents while belonging to vastly different cultural backgrounds and having different experiences with their respective families, began to strain Reiko and Mateo’s romantic and sexual relationship. The residual tension further contributed to the dyadic emotional distancing. Reiko and Mateo sought couple therapy to address communication issues, lack of intimacy, and understanding of one another’s needs. For a multiculturally aware therapist, ethnographic questioning techniques can be beneficial in getting familiar with each of the partner’s backgrounds – how they were raised, their family histories, family cultures and traditions, dynamic between different family members, etc. Families belonging to different ethnic groups experience unique intergenerational struggles that shape the future generations (McGoldrick 2006). Therefore, the therapist may benefit from starting the initial assessment by extracting relevant details about each of the partner’s respective families of origin.

It will be crucial to ask direct questions about religious and spiritual beliefs, social class and how it is stratified in their respective societies. Furthermore, it would be necessary to learn about Reiko's migration and how it has impacted them individually and their relationship. Oftentimes sharing their individual views on their personal history, and hearing the narrative of the other partner, brings to light significant insight and creates a safe space to share feelings or concerns that the couple may not have shared before. This therapeutic approach was helpful for the couple as they learned different things about one another and had the opportunity to express curiosity and understanding in the process. With Reiko and Mateo, asking example questions also provided clarity in terms of pinning the exact issues and making suggestions accordingly. Remaining mindful that Reiko is not fluent in the native English language, it is essential for the therapist to provide examples of situations or events as a means to simplify the communication between the couple. In such instances, Banister’s (1996) mapping task techniques can be useful in breaking down an event or behavior. This can be accomplished by drawing a diagram and identifying and tracking each partners’ respective moment-by-moment thoughts and feelings within the session. As their couple therapist, it will be significant to ask questions about how they both cope and process their conflict while identifying the defensive strategies they tend to use. Being mindful of the general cultural context of each partner’s background, the therapist may choose to ask ethnographic structural questions, as a way to explore how they describe and organize information in their daily interactions. Utilizing this method of questioning may expose any underlying inner conflicts for the couple. “Reiko, would you say that Mateo not speaking out to his parents to give you both some space, has contributed to your lack of desire for him in any way?” The therapist must also ask direct questions about the couple’s personal beliefs and values, and if they are willing to accept each other’s differences in this regard. Another critical theme to explore with the couple is understanding what they consider as a workable solution in a given situation.

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Reiko and Mateo’s responses could possibly differ due to their different upbringings. In such situations, the therapist must act as a mediator, helping Reiko and Mateo to identify their own ethnic values and to resolve clashes that grow out of dissimilar opinions and experiences. These ethnographic questioning techniques can be valuable in analyzing the cultural constraints that are contributing to Reiko and Mateo’s problem sequences and in providing a series of adaptive solution sequences, as they explore what is keeping them from successfully moving toward agency. Respectful clinical work in such cases involves assisting clients to understand their ethnic identity better and how to make sense of it in the context of marital and familial relationships.

Cross-References ▶ Bateson, Gregory ▶ Cultural Competency in Couple and Family Therapy ▶ Cultural Identity in Couples and Families ▶ Cultural Values in Couples and Families ▶ Culture in Couple and Family Therapy ▶ Family of Origin ▶ Integrative Systemic Therapy ▶ McGoldrick, Monica ▶ Qualitative Research in Couple and Family Therapy ▶ Socioculturally Attuned Family Therapy

References Banister, E. (1996). Spradley’s ethnographic questioning: An invitation for healing. Journal of Constructivist Psychology, 9(3), 213–224. Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press. Giordano, J., & Carini-Giordano, M. (1995). Ethnic dimensions in family treatment (pp. 347–356). American Psychological Association. McGoldrick, M. (1998). Re-visioning family therapy: Race, culture, and gender in clinical practice. New York: Guilford Press. McGoldrick, M. (2006). In M. McGoldrick, J. Giordano, & N. Garcia-Preto (Eds.), Ethnicity and family therapy (3rd ed.). New York: Guilford Press.

Ethno-systemic Narrative Approach Pew Research Center. (2017). Intermarriage in the US: 50 years after loving v. Virginia. Retrieved from: http://www.pewsocialtrends.org/2017/05/18/1-trendsand-patterns-in-intermarriage/. Pinsof, W., Breunlin, D., Russell, W., Lebow, J., Rampage, C., & Chambers, A. (2018). Integrative systemic therapy: Metaframeworks for problem solving with individuals, couples, and families. Washington, DC: American Psychological Association. Spradley, J. (1979). The ethnographic interview. New York: Holt, Rinehart and Winston. Tubbs, C., & Burton, L. (2005). Bridging research: Using ethnography to inform clinical practice. In D. Sprenkle & F. Piercy (Eds.), Research methods in family therapy (pp. 136–154). New York: Guilford Press.

Ethno-systemic Narrative Approach Natale Losi and Carol Djeddah Ethno-Systemic Narrative School of Psychotherapy, Rome, Italy

Introduction The Ethno-Systemic Narrative (ESN) approach (Losi 2006) has been developed after years of experiences, in conflict and war-affected areas, with displaced persons and refugees enduring severe traumatic experiences. Many of them flee to escape danger or persecution. They have witnessed or directly experienced violence and traumatic events, for example, death or disappearance of family members. ESN therapy focuses on individuals, their families, often divided by the migration and their contexts. It also considers their social memory, key to understanding the causes of their suffering and treats its consequences, thus avoiding medicalization or psychiatrization. Narratives coming from social memory alleviate war-affected trauma and can boost transformations in refugees and their families. The challenge is to construct, enrich, and apply a model that takes into consideration the individual, his/her family, ethnicity, culture, religion, geopolitical context, and co-construct, within a therapeutic setting, a new healing narrative.

Ethno-systemic Narrative Approach

Theoretical Framework The ESN approach builds on strengths of earlier ethno-psychotherapeutic models developed by Tobie Nathan (1993) and by capitalizing on the systemic therapy as well as the narrative therapy. In his therapeutic approach, Nathan adopts a pluricultural approach. His therapeutic group is made up of different therapists of different national or ethnic origins. The presence of many therapists, one of whom is the primary therapist and the others co-therapists, brings the patients into the framework of a group where they can bring their problems and be understood. The ESN approach is the dynamic result of three different components: ethnicity, system, and narrative. The term “ethnicity” originally refers to a community-based human group or to the strong affinity of somatic, cultural, linguistic, historical, and social characters. Among these similar characters, there is the definition of illness, and the ways of interpreting and healing it. The term systemic refers to an integrated model in family or systemic therapy, here in particular the Milan approach (Selvini Palazzoli et al. 1985) and the contextual therapy (Boszormenyi-Nagy and Spark 1984). Within the ESN therapeutic group, the relationship between patient, therapist, co-therapists, and cultural mediator is important, in order to understand the causes of the suffering and co-construct its meaning and its healing process. The introduction of a cultural mediator within the therapeutic group has a decisive value. A cultural mediator translates from the patient’s language and allows the therapeutic group to understand the meaning that a certain thing has within the respective mother tongues. Thus, a situation is created in which the patient links up and can “crystallize” his or her own symptom within one of the meanings proposed within the group, the one that allows the patient to identify him- or herself better and to understand more easily how, why, and what the reason might be for that “thing” that makes him or her feel so badly. The term narrative reinforces the concept of co-construction and is based on four fundamental

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axis through which a therapeutic narrative can be performed: the relationship between generations; the relationship between women and men (or the gender dimension); the relationship between the humble and the powerful; and the relationship between the visible and the invisible world, with a particular focus on the link between the world of living and that of the dead. During the therapeutic sessions, the floating objects and the narrative method in family therapy such as the systemic tale is used (Caillé and Rey 2004). The adoption of the Ethno, Systemic, and Narrative components has important theoretical consequences on the therapeutic interventions: • The Diagnostic and Statistical Manual of Mental Disorders (DSM) interprets symptoms in a linear perspective: from symptoms to individualistic diagnosis. Following the ESN perspective, symptoms are viewed as “texts without context” (Nathan 1988, p. 137). It means that the therapeutic process is the search of contexts/narratives giving sense and meaning to the symptoms. This is especially true when, depending on his/her culture, the patient brings into their story the worlds inhabited by different types of forces and spirits, of gods and of evil. • Linear approaches position the therapist with the power to define the patient as normal or pathologic, whereas in the ESN approach the therapist together with the therapeutic group co-constructs a relationship with the patient and his/her system (second order cybernetics), thus stimulating the patient with an active and conscious position in confronting his or her own suffering.

Rationale for the Strategy or Intervention The psychosocial stress accompanied by traumatic events in the refugees’ country of origin is often labeled by the dominant western approach with a psychiatric diagnosis or as posttraumatic stress disorder (PTSD). These diagnoses are called “narrative of the destiny” as it gives no chance to the patients to exit from their destiny.

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The ESN approach legitimates the narratives of patients coming from different cultural worlds and co-constructs therapeutic stories on the causes, interpretations, and treatment of the patient’s distress. This change of perspective, called also “narrative of the project,” can help the patients to re-organize their lives, often blocked or broken (Losi 2015). The person’s passage from a terrifying destiny to narrative project changes the patient and therapist’s mutual positioning. The latter is no longer the holder of the definition of “normality,” nor a “diagnostic dispenser.”

Description of the Strategy or Intervention In the ESN approach, the healing process draws on the patient/family’s story as well as all the hypotheses brought by the ESN setting within the session. Each of these different narratives presents the four-theme axis of the ESN model (the relationship between generations, gender, the humble and powerful, the visible world, and the invisible world) as constant. The etiology of the distress can be explained by the presence of a fracture of one or more of these axes. The therapist will reconnect the fractures, through the co-construction of new narratives, using other possible meanings of the symptoms to disentangle the patient and his family from a destructive narrative. This will be made possible through an open conversation between the therapist, co-therapists, and cultural mediator, as they will facilitate the passage from the focus on individual experience/ memory, to a social/historical/cultural memory. In this way, the therapy allows for a co-construction of the external causes of violence in the migration path, avoiding the remembering of the traumatic event per se (Losi and Papadopoulos 2004). The therapy allows the patient and his/her family to rethink the uprooting and the consequences of what he or she endured within a secure setting rather than in isolation. The therapeutic process considers the multiple connections of meaning that bind personal and cultural worlds, in the country of arrival and in the country of origin. In this process, the

Ethno-systemic Narrative Approach

injustice suffered and the despair that leads to a self-destructive spiral and victim’s attitudes gradually gives space to the ability to make a consistent and probable story of selves. Furthermore, ESN considers the multiple connections between the patients’ narratives and the visible and invisible worlds. In order to explain the origin of their symptoms, African patients may refer for example to a marabout, a diviner/healer who holds and exercises magical powers on them. The therapeutic process provides the possibility of using ritual as a method to establish a vital narrative within the patient/family social and cultural world. Therapeutic rituals function as a way of “integration,” between a past and a “fractured” present. Another support to connect the family with the therapeutic group, and therefore of their belonging and identity, comes from the use of prescriptions. The prescriptions are done principally to link the patient with important people who have been left behind, in the country of origin, in the village, those who have died and those who are living. Prescriptions are always directed at supporting the patient in moving towards family and relations that are not set and were left on hold in the course of the migration. Finally, links with their family history here and in the country of origin through their genogram allow an exploration of family dynamics and traumatic events endured by the family. ESN therapeutic setting: It refers to the setting and the rules through which the ESN therapy is performed. This implies two rooms audio-visually interconnected. In the first, the patient/family and the therapist, the co-therapists, and the cultural mediator are sitting and conversing. In the second room, a “reflecting team” is observing and giving feedback. During the sessions, the rule to be respected is that only the therapist speaks directly with the patient/family and the co-therapists can talk among them or with the therapist.

Case Example The R. family, an Alevi Turkish family, fled from Southeastern Turkey. The Alevis have a long

Ethno-systemic Narrative Approach

history of persecution, massacres, and marginalization (Issa 2017). Both parents have been diagnosed with depression in Turkey and are under pharmacological treatment. The request for psychotherapy in the clinical ESN Centre in Rome (http://www.etnopsi.it/it/) has been asked for because of the suffering expressed by the whole family and their concern for the imminent appointment with the government commission for the recognition of international protection. Akin and Fatma are both 40 years old. Akin discovered his religious affiliation, when he was 12, and decided to be a good believer, despite the risks of discrimination he was aware of. In Italy he is suffering from insomnia despite the drugs he is taking, his nights are tormented by bad thoughts that make him sweat and tremble. Fatma suffers from “strange” fainting since she was 18 years old, which were aggravated by the birth of Esra, a girl, who is now 10 years old. Fatma sees the dead, three women who are busy sitting by her side during the day and frightening her. Metin, the eldest son is 13 years old, always together with his father in affirming and sustaining their religious affiliation. Just as Akin, in Turkey, he was often attacked and beaten by fundamentalist groups and has been repeatedly subjected to harassment and aggression even at school. Together with his father, he began studying bağlama, a used string instrument in the Cem ceremony, the central Alevi worship service, during which prayers are accompanied by songs and rituals (Samāh) performed by men and women together. Metin cries often during the sessions when discussions touch on painful and distressing episodes from their past such as the Alevis persecutions and Esra suffers from nightmares. Fatma’s fainting is getting worse in Italy, and during the first session Akin and Fatma express their fear that this situation could generate suspicion and compromise the outcome of the asylum application to the government commission. The Therapeutic Path The ESN therapeutic group consisted of a principal therapist, two co-therapists, the psychologist of the refugee center and a Kurdish cultural mediator. The Turkish language was used during the

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sessions. The reflecting team followed the session from the second room. The setting structure, the communication between the participants and their way of presenting the therapeutic group coming from different backgrounds, and the characteristics of the consultation room, that is, colorful and full of objects on the shelves enabled the coming together and the family narration. In the first session, the family looked very scared and worried, tight – even physically – around the mother, designated as the symptomatic member. The therapeutic work at this first stage consisted of the positive connotation of Fatma’s symptoms and its subsequent de-structuring. During the second session, the group highlighted how with her symptoms Fatma activates Akin’s decision to flee. The symptoms became a “smart symptom” that allowed the family to escape from the on-going persecutions of the Alevis. A new narrative was developed and Fatma, the depressed and psychiatric patient, was seen as the “rescuer” of her family. From the body language of the family members, this new narrative was immediately perceived as more vital leading to new perspectives. In that case, she did not need any longer the depression, as they were now safe and protected. The de-construction of the symptom was also possible using symbolic objects. Esra was invited by the therapist to choose an object from the shelves of the consultation room and then to give this to her mother in order that she may start a new path, without the need for symptoms and drugs. Esra chose a mirror and explained, crying, to her mother that she can now take care of herself in a place where she no longer needs to faint and can ask for help and be protected. Likewise, working on the axis of the visible and invisible world, and the vision of the dead that Fatma has experienced for the past 20 years, has revealed the painful family bonds abruptly interrupted by the migration. The work done in this first phase has allowed an important improvement in Fatma’s symptoms and of the whole family, which after few weeks meant they were able to face the asylum seeker commission, successfully.

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Bad thoughts and the maternal symptoms represented the cohesive energy of the family and played an important protective function from fears and terror. However, the objective of the therapy is to move from a destructive narrative to a healing narrative. Therefore, the second phase of therapy has centered on their identity of being Alevis, according to a dynamic vision of culture that recognizes and integrates identity and belonging. The therapeutic space has allowed giving a voice to those hidden aspects of their religion that forced them to practice taqiyya, a precautionary dissimulation of religious belief and practice in the face of persecution. Being able to declare openly the persecutions suffered or witnessed, but also describing the Samāh that accompanied the joyful moments of sharing and prayer, has allowed all members of the family to be recognized and accepted in a protected environment. During the last session Metin was given a bağlama with the prescription of resuming to play for and with his family, with the aim of re-starting from the deep sound of this instrument the interrupted narrative of their story and identity.

References Boszormenyi-Nagy, I., & Spark, G. (1984). Invisible loyalties: Reciprocity in intergenerational family therapy. London: Routledge. Caillé, P., & Rey, Y. (2004). Les objets flottants, méthodologie systémique de la relation d’aide. Paris: Fabert. Issa, T. (2017). Alevis in Europe: Voices of migration, culture and identity. London: Routledge. Losi, N. (2006). Lives elsewhere, migration and psychic malaise. London: Karnac. Losi, N. (2015). Guérir la Guerre. Des récits qui soignent les blessures de l’^ a me. Paris: l’Harmattan. Losi, N., & Papadopoulos, R. (2004). Post-conflict constellations of violence and the psychosocial approach of the International Organization for Migration. In Harvard book of good practices. Rome: Harvard Program in Refugee Trauma. Nathan, T. (1988). Le sperme du diable. Paris: Puf. Nathan, T. (1993). Principes d’ethnopsychanalyse. Grenoble: La Pensée Sauvage. Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1985). Paradox and counterparadox. New York: Aronson.

European Family Therapy Association

European Family Therapy Association Maria Borcsa University of Applied Sciences Nordhausen, Nordhausen, Germany

Introduction The European Family Therapy Association (EFTA) was established in 1990 and is an international association dedicated to scientific purposes. It is an independent and strictly nonprofit-making association. At present (2016), EFTA has members from 32 European nations (plus so called “foreign members” from Canada, Brazil, Chile, Israel, Senegal, and the USA). EFTA has a tripartite structure and is made up of three chambers: • EFTA-CIM: The Chamber of Individual Members (CIM) gathers a wide range of professionals (social workers, nurses, medical doctors, psychiatrists, psychologists, occupational therapists, and other health professionals) who have finished a minimum of 4 years of training in family therapy/systemic approach and are working with families, couples, and larger systems. • EFTA-NFTO: The Chamber of National Family Therapy Organizations (NFTO) unites national associations/federations representing family therapists and/or promoting the systemic approach and family therapy in any country in Europe and Israel. • EFTA-TIC: The Training Institutes Chamber (TIC) connects training institutes and facilitates networking, exchanges, and joint learning between trainers based on the guidelines of minimum training standards (http://efta-tic.eu/ minimum-training-standards). A common code of ethics is binding on every member and should be read in conjunction with the code of ethics of relevant national associations and professional body(s). (http://www.europeanfami lytherapy.eu/code-of-ethics-of-the-european-familytherapy-association)

European Family Therapy Association

Location Brussels, Belgium

Prominent Associated Figures Official founding members (Moniteur Belge 1992):

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Eric Louis, Elspeth McAdam, Jacques Miermont, Luigi Onnis, Renos Papadopoulos, Roberto Pereira, Mina Polemi-Todoulou, Kyriaki Polychroni, Yveline Rey, Jaakko Seikkula, Mara Selvini-Palazzoli, Daniel Stern, Helm Stierlin, Peter Stratton, Vasso Vassiliou, George Vassiliou and Arlene Vetere

Contributions Mony Elkaïm (Belgium) Alia Samara (Greece) Maurizio Andolfi (Italy) Hugh Jenkins (UK) Edith Goldbeter-Merinfeld (Belgium) Elida Romano (France) Paul Igodt (Belgium) Jorma Piha (Finland) Camillo Loriedo (Italy) Esther Wanschura (Austria) Luigi Onnis (Italy) Jacques Pluymaekers (Belgium) Theo Compernolle (Netherlands) Rick Pluut (Netherlands) Gianfranco Cecchin (Italy) EFTA’s honorary presidents: Luigi Onnis (deceased) Jacques Pluymaekers EFTA’s presidents: Rodolfo de Bernart (2016–2019) Maria Borcsa (2013–2016) Kyriaki Polychroni (2010–2013) Arlene Vetere (2004–2010) Juan Luis Linares (2001–2004) Mony Elkaïm (1990–2001) EFTA awardees: Jean-Claude Benoît, Petr Bos, Ivan Böszörmenyi-Nagy, Bela Buda, John Byng-Hall, Philippe Caillé, Luigi Cancrini, Alan Carr, Pat Crittenden, Boris Cyrulnik, Mony Elkaïm, Elisabeth Fivaz, Janos Füredi, Edith Goldbeter, Per Jensen, Barbara Kohnstamm, Miklos Kovacs, Annette Kreuz, Peter Lang, Juan Luis Linares,

• Linking and coordinating European national organizations, institutes, and individuals in the field of family therapy and systemic practice • Promoting the highest level of competence and quality in practice, research, supervision, and teaching in family therapy and allied fields • Enhancing the training of systemic professionals and family therapists at regional, national, and European levels by organizing and facilitating exchanges between individuals as well as professional centers • Implementing committee work related to the aims of EFTA such as research, training standards, ethics, and external relations • Spreading information about family therapy and systemic approaches throughout Europe to individuals, institutions, and organizations concerned with the health and development of families and human systems. Promoting research, conferences, publications, audiovisual tools and other scientific material in this field through: – Annual meetings of NFTOs: updating on the developments of family therapy and systemic practice with regard to legislation and sociopolitical changes influencing the health system in different countries – Annual meetings of trainers: fostering networking among training institutes, exchanging training methods (workshops), and developments in curricula – Triennial international congress for health professionals and trainees with ca. 1000 participants: Sorrento, 1991; Athens, 1994; Barcelona, 1997; Budapest, 2001; Berlin, 2004; Glasgow, 2007; Paris, 2010; Istanbul 2013; Athens 2016

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– Publication of a book series with relevant topics for the field (founding editors: M. Borcsa and P. Stratton) (Borcsa & Stratton 2016, Tilden & Wampold 2017) • Creating links with other organizations having common or compatible aims worldwide

References Borcsa, M. & Stratton, P. (Eds.) (2016). Origins and Originality in Family Therapy and Systemic Practice. EFTA Book Series Volume 1. Springer International. http://www.europeanfamilytherapy.eu/ Tilden, T. & Wampold, B.E. (Eds.) (2017). Routine Outcome Monitoring in Couple and Family Therapy. The Empirically Informed Therapist. EFTA Book Series Volume 2. Springer International.

Exception Question in Couple and Family Therapy Fangzhou Yu Counseling Department, The Family Institute at Northwestern University, Evanston, IL, USA

Name of Strategy or Intervention Exception Question in Couple and Family Therapy

Introduction Exception questions are an intervention used to uncover exceptions to the current problem in the client’s life. These kinds of questions encourage competency-based conversations. They allow the therapist to discover clients’ previous successes and amplify the clients’ strengths (Trepper et al. 2010). If miracle questions help to identify the treatment goals, exception questions provide the possible pathways to achieve these goals.

Exception Question in Couple and Family Therapy

Theoretical Framework Exception questions are among the main techniques of solution-focused brief therapy (SFBT). The SFBT treatment model is supported by over 30 years of theoretical development and empirical research (De Jong and Berg 2012). Built upon the foundation of social constructivism, SFBT emphasizes the collaboration between the therapist and the client. The therapist is interested in listening to what clients want and what is important to them. The therapist pays special attention to clients’ use of words and the meaning behind them. The focus is on understanding the clients’ preferences. Through adopting clients’ language, asking solution-driven questions, the therapist and client co-construct a new desired future. The therapist is viewed as a consultant and facilitator. The client is given full authority in deciding what areas need to be changed (McGee et al. 2005).

Rationale for Using Exception Questions No problem exists all the time (Trepper et al. 2010). For couples and families, there are times when conflicts were prevented or did not happen at all. These exceptions provide valuable resources for the therapist and the clients to co-construct solutions. One of the assumptions that support exception questions is that solution behaviors are already there for couples and families (Trepper et al. 2010). Some couples and families can clearly identify the solutions they tried before and were successful. If a couple or family does not have a previous solution that can be repeated, discussing the situations when the problem did not exist can lead to a solution. In other words, the solution was there but the family was just not aware of it (Berg 1994).

Description of Exception Question Exception questions focus on the conditions that helped the exception happen. The therapist is not interested in knowing why but more focused on

Exception Question in Couple and Family Therapy

the where, when, who, and what of the exception. Here are some examples of exception questions: • Was there a time you were able to calmly express your needs without being aggressive towards your spouse? If so, could you describe it for me? • Tell me about a moment when you and your dad were enjoying each other’s company. • How did you end that argument with your mom without escalating it to the next level like you used to? • How was that experience different from other fights with your spouse?

Case Example Huang and James have been married for 3 years, they don’t have children. Huang is Chinese, a first generation immigrant. James is American, born and raised in the south. Huang and James met in college. They travel to China to visit Huang’s side family at least once a year. They came to therapy for marital issues. Huang: I do not think he understands my loneliness. James: She just tends to be overly dramatic about small things. Therapist: Let’s listen to Huang and let her tell us the details. Huang: It is the Chinese New Year now, the most important festival in my culture. Nobody around here celebrates it. All my family is in China. Even though I do not talk about it all the time, I miss them terribly. There are certain dishes we cook for this celebration. Since we live with his parents, I could not cook them in the kitchen. I am afraid that they may not like the smell. I feel like I have to hide part of my identity in that house. James: You can cook it in the kitchen. My parents would not mind at all. I think that is her own insecurity, which has nothing to do with others. Huang: You just do not understand. I feel like my Chinese heritage is invisible to you, but it is part of me. James: I do understand, but we were talking about cooking the dish. They are two different things. You are exaggerating again. Therapist: James, I think Huang is trying to tell us that they are all connected: food, festival, culture and her. Her concern and discomfort is real, since she is the only Chinese person living in a

969 whole household of people who are not Chinese. Maybe it is not so much about lacking confidence, as it is about her cultural root. Huang: That is exactly right. Whenever he does acknowledge my culture either intentionally or unintentionally, it always makes me feel good, and accepted as a whole. Therapist: Really? Tell me about those times. Huang: Like when we were dating, he learned how to write my name and “I love you” in Mandarin on a birthday card. That was so sweet. I still have the card. James: I did do that. Therapist: Wow, that was so romantic, James! Any other times that he made you feel that way? Huang: I did not tell him this, but my father-in-law got him a Rosetta Stone software to learn Chinese. So whenever he practices, I like to listen. It always gives me very warm and fuzzy feeling. James: That is why you always stop doing what you were doing and curl up next to me when I practice? Huang: Yes, but you do not do it very often now. Therapist: Maybe we should make it happen again. What do you say, James? James: I guess so. I like to make her happy. Learning Chinese is very hard though. My work has kept me really busy lately, but I need to go back to my practice. Maybe I can also take you out to a local Chinese restaurant sometime this week. We have not done that for a while. Huang: We have not done that for months. Yes, it would be great. Therapist: If you and James do these activities often, will you feel less lonely and more accepted? Huang: Yes.

In this case example, the therapist accomplished several tasks. First, she listened carefully about the presenting issues and accurately reflected the wife’s feelings. Second, she seized the moment when one exception was mentioned. The therapist emphasized the importance of the exceptions by repeatedly asking questions and getting more information that can become a resource. Finally, the therapist connected the goal with the exceptions and received positive confirmation from the clients.

Cross-References ▶ Miracle Question in Couple and Family Therapy

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References Berg, I. K. (1994). Family-based services: A solutionfocused approach. New York: Norton. De Jong, P., & Berg, I. K. (2012). Interviewing for solutions (4th ed.). Belmont: Thomson BrooksCole. McGee, D. R., Del Vento, A., & Bavelas, J. B. (2005). An interactional model of questions as therapeutic interventions. Journal of Marital and Family Therapy, 31, 371–384. Trepper, T. S., McCollum, E. E., de Jong, P., Korman, H., Gingerich, W., & Franklin, C. (2010). Solution Focused Therapy Treatment Manual for Working with Individuals. Research Committee of the Solution Focused Brief Therapy Association. Retrieved from http://www.so1ut.ionfocused.net/ treatment manual.

Exiles in Internal Family Systems Therapy Nancy Burgoyne The Family Institute at Northwestern University, Evanston, IL, USA

Name of Concept Exiles

Introduction Exiles is a concept found in the Internal Family System model (IFS), founded by Richard Carroll Schwartz (Schwartz 1987, 1989, 1995, 2001). The Internal Family Systems Model of psychotherapy (IFS) brought family therapy theory and technique to the intrapsychic worlds of clients. IFS has become not only a school of family therapy but also a major form of psychotherapy in general, with an extensive literature and training institutes throughout the world. The premise of the Internal Family Systems model is that an individual’s intrapsychic world is not monolithic. Rather, the internal world is made up of a plurality of “parts.” Parts are

Exiles in Internal Family Systems Therapy

subpersonalities, each is “a discrete and autonomous system that has a range of emotions, style of expression, and a set of abilities, intentions and/or functions” (Schwartz 1987, p. 3). The Internal Family System model posits that the intrapsychic world is governed by systemic principles, and functions best when it is led by the Self. The Self, per Schwartz (2001), is separate from a person’s parts; it is the core of a person, which possesses qualities such as compassion, curiosity, calm, and confidence.

Theoretical Context for Concept Like a family system, the intrapsychic system has an organizing structure. The structure of the Internal Family System is defined by several subsystems, named: managers, firefighters, exiles, and the Self (Schwartz 1995, 2001). Exiles represent a subsystem of parts that have been sequestered within the system for their own protection or to protect the system from them (Schwartz 1992, 1995). The pain the exiles carry, and the meaning the parts (and often culture) assign to their attributes, generates reactivity in managers and firefighters who want to protect the individual from the imagined damage that is assumed would occur if an exile were to surface. The patterned interactions that occur in an effort to keep the exiles off the intrapsychic and interpersonal “playing field” generate significant distress and dysfunction within and between people (Schwartz 1992, 1995).

Description Exiles hold thoughts, feelings, and memories that are considered unacceptable by the rest of the system. Often exiles are young parts that have been isolated in order to protect the individual from overwhelming affect or sensations. Parts who are exiled are deprived of care and may become increasingly desperate to be known. Parts can be

Exiles in Internal Family Systems Therapy

triggered in the present day by experiences or exposure to stimuli that activate a familiar felt experience and set in motion an internal sequence whereby mangers, firefighters, and/or parts of others in the interpersonal system work to banish the exile once again (Schwartz 1995, 2001). In addition to traumatic or intolerable experiences, exiles carry what Schwartz has called our “everyday damage” (Schwartz 2001). The painful and contorting effects of racism, sexism, and homophobia and gender identity norms are examples, as are idiosyncratic, often family of origin experiences and/or repeated shaming attributions from larger systems. These lead an individual to feel unworthy or in some way defective. Schwartz has noted that exiles, given the tenderness of their experience, also possess useful attributes. Sensitivity, vulnerability, and intimacy seeking are examples of resources exiles have that are less accessible to managers and firefighters whose job is to prevent the exiles from being seen or felt (Schwartz 2001).

Application of Concept in Couple and Family Therapy An individual’s parts interact intrapsychically, interpersonally, and with the larger systems they come into contact with. A triggered exile is dysregulating to all levels of the system. Intervention with an exile cannot be effectively pursued until the managers have been collaborated with and the Self has been accessed to some degree. Thereafter, the goal vis-a-vis exiles is threefold. First is to provide a safe interpersonal and intrapsychic context for the exiles to tell their stories and receive care. Second is to release the exiles from the burden of extreme beliefs that cause the individual profound distress and generate reactivity in the internal system. Third is to identify nonextreme roles for these parts to have within the internal system, so that their strengths can be a resource to the individual (Schwartz 1992, 1995, 2008).

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Clinical Example An exiled part may, for example, interpret early neglect from caregivers as evidence of their own unworthiness. The part would then carry both intolerable shame associated with the belief they are unworthy and a profound longing to be redeemed from their unworthy state by being found loveable by another. When, in the present day, the individual risks seeking love or attention from another, the protective parts (managers and firefighters) rally to sequester the part, fearing that the part’s outsized needs expose the person’s deficits and make them vulnerable to shame and rejection. To the extent the protective parts are successful in sequestering the exile, the individual continues to be deprived of care, and their unmet needs, extreme beliefs, and pain grow. “The irony . . .” Schwartz explains, “... is that once you start the exiling process, it reinforces itself” (2001, p. 93).

Cross-References ▶ Firefighters in Internal Family Systems Therapy ▶ Internal Family Systems in Family Therapy ▶ Managers in Internal Family Systems Therapy ▶ Metaframeworks: Transcending the Models of Family Therapy ▶ Schwartz, Richard C.

References Schwartz, R. C. (1987). Our multiple selves. Family Therapy Networker, 11, 24–31 & 80–83. Schwartz, R. C. (1989). The internal family systems model: An expansion of systems thinking into the level of internal process. Family Therapy Case Studies, 3, 61–66. Schwartz, R. C. (1992). Rescuing the exiles. Family Therapy Networker, 16, 33–37. Schwartz, R. C. (1995). Internal family systems therapy. New York: Guilford Publications. Schwartz, R. C. (2001). Introduction to the internal family systems model. Oak Park: Trailheads Publications. Schwartz, R. C. (2008). You are the one you’ve been waiting for: Bringing courageous love to intimate relationships. Oak Park: Trailheads Publications.

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Exosystem in Family Systems Theory Amy D. Smith1,2 and Kelley Quirk2 1 Marriage and Family Therapy/Applied Developmental Science Program, Colorado State University, Fort Collins, CO, USA 2 Marriage and Family Therapy Program, Human Development and Family Studies, Colorado State University, Fort Collins, CO, USA

Name of Concept Exosystem in Family Systems Theory

Introduction The exosystem is one of four primary levels of the environment, or ecosystem, which are described in the bioecological theory of human development (Bronfenbrenner 1986, 1977). Understanding the different levels of the ecosystem, and how they can impact the development and experiences of individuals, can help therapists to better understand underlying causes to presenting problems, thus enabling a more effecting and change-promoting therapeutic process.

Theoretical Context for the Concept Family systems theory assumes that families operate as a system which cannot be fully understood by looking at one individual without also including all of the other individuals which comprise the system, or family (Cox and Paley 1997). The way in which different aspects of families and the environment can influence the development and experiences of the individual can be understood through the bioecological systems theory (Bronfenbrenner 1977), which emphasizes the importance of the environment on development and experiences. In this theory, Bronfenbrenner identifies four different levels of the environment, the microsystem, the mesosystem, the macrosystem, and the exosystem,

Exosystem in Family Systems Theory

which impact an individual’s development and experiences (Bronfenbrenner 1986, 1977).

Description The exosystem is one of the first four levels of the ecosystem (Bronfenbrenner 1977, 1986). This system refers to the parts of the environment which impact an individual’s development, even though they do not directly interact with the individual (Bronfenbrenner 1977, 1986). Examples of the exosystem would include the work life of a parent or partner impacting another member of the family such as a partner or child, even though the work life is not directly experienced by the individual who is being impacted. In this way, the experiences of one family member can have an indirect impact on the experiences of other family members (Bronfenbrenner 1986, 1977).

Application of Concept in Couple and Family Therapy The concept of the exosystem proposes that individuals are not only impacted by the environments that they directly experience but also by the environments that others in their family experience (Bronfenbrenner 1977, 1986; Lerner 2002). With this understanding, it is important for a therapist to explore how the experiences of other family members may be indirectly impacting the presenting symptoms, especially in situations where the origin of the presenting problem does not seem clear. Through this exploration, the therapist may be able to discover triggers for behaviors, thoughts, or emotions, in the extended environment which may in turn be beneficial for progress and change to occur during the process of therapy.

Clinical Example Jason, 35, and Kimberly, 34, recently started family therapy with their daughter, Sarah, 5. The family has decided to seek therapy because Sarah has recently started to demonstrate new anxious behaviors including not being able to sleep without a

Experiential Family Therapy

nightlight, crying when she is dropped off at school, and worrying that her stuffed animals are “feeling scared.” Jason reported that he is on active duty in the Army and that he recently learned that he was leaving in 3 months for his second deployment since Sarah’s birth. In discussing this transition, Kimberly reported that she first noticed Sarah’s changed behaviors shortly after they had told Sarah that “Daddy has to go away again.” While Sarah does not directly experience Jason’s work environment, the time which he had to spend away due to his job seemed to be related to Sarah’s increased anxiety. With this understanding, the family was able to work with the therapist to help ease Sarah’s fears about her father going away and increase her coping strategies for dealing with her anxiety.

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Introduction

Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513–531. Bronfenbrenner, U. (1986). Ecology of the family as context for human development. Research perspectives. Developmental Psychology, 22, 723–742. Cox, M. J., & Paley, B. (1997). Families as systems. Annual Review of Psychology, 48, 243–267. Lerner, R. M. (2002). Concepts and theories of human development (3rd ed.). Mahwah: Lawrence Erlbaum Associates.

Experiential Family Therapy is a humanistic approach to treating a variety of presenting problems within families and couples. It values the “in the moment” experiences of clients and centers on authentic emotional expression. Experiential clinicians use their unique self-of-the-therapist with spontaneity and creativity to help clients experience in real time accurate self-expression (Baldwin and Satir 1987; Napier and Whitaker 1978). The emphasis of clinicians being authentically involved and to use their personhood indicates that there are many different approaches to experiential therapy. Experiential therapy is described as humanistic based on the foundational assumptions that people possess the necessary resources for change and are naturally drawn toward positive growth. Further, experiential therapists believe that change occurs as people experience honest selfexpressions from themselves as well as the therapist. Along with other humanistic therapies, experiential therapists believe in the value of self-actualization, the reaching of human potential, and in the natural ability and tendency of individuals to achieve it (Nichols 2013). Consistent with other systemic approaches, experiential family therapists believe that the family system is the preferred level of intervention. While other models typically focus on intervening with client behaviors, experiential therapists concentrate the majority of their effort in addressing the affective experience of the family (Gehardt 2015).

Experiential Family Therapy

Prominent Associated Figures

Todd Spencer, Trent Call and Nathan Hardy Oklahoma State University, Stillwater, OK, USA

The origins of Experiential Family Therapy can be directly tied to the work of Carl Whitaker (1912–1995) and Virginia Satir (1916–1988). Specifically, Whitaker developed the “symbolicexperiential” approach, which focuses on warmth and confrontation, while Satir developed the experiential communications approach, which centers on expressions of warmth and empathy within families.

Cross-References ▶ Bronfenbrenner, Urie ▶ Ecosystem in Family Systems Theory ▶ Mesosystems in Family Systems Theory

References

Synonyms Satir’s experiential communications approach; Satir human growth model; Symbolic experiential family therapy

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Carl Whitaker. After graduating medical school and working at the University of Louisville College of Medicine and the Oakridge Hospital, Whitaker became interested in Psychiatry and eventually became the Psychiatry department chair at Emory University from 1946 to 1955. Whitaker resigned from Emory University after growing pressure for the department to become more psychoanalytic in nature and formed the Atlanta Psychiatric Clinic. Under this new freedom, Whitaker was able to further develop his symbolic-experiential approach to therapy. Virginia Satir. Satir was trained as a social worker and began her clinical work in 1951. She was invited to establish a training a program at the Illinois State Psychiatric Institute in 1955. Later in 1959 Satir was invited by Don Jackson to join the MRI group in Palo Alto. She left the MRI group in 1966 to work as the director of the Esalen Institute located in the Central Coast of California. Satir combined humanistic characteristics with principles of communication to develop the experiential communication approach to working with families. Other figures. While Whitaker and Satir laid the foundation for experiential therapy, there are also notable contemporary figures that have carried on the humanistic-experiential tradition. Sue Johnson and Les Greenberg’s work on Emotionally Focused Couple Therapy (1985) has received worldwide attention and is one of the leading evidence-based models of couple therapy. Likewise, Richard Schwartz’s Internal Family Systems Model (Schwartz 1995) is a prominent approach for helping people deal with internal conflicting emotions.

Theoretical Framework Assumptions Satir described four core assumptions of her experiential communication approach: (1) People are naturally drawn towards positive growth, (2) people possess resources for growth, (3) circular reciprocity, and (4) therapy is a process of interactions between clients and therapist in which each person is responsible for themselves (Satir

Experiential Family Therapy

et al. 1991). The first two assumptions highlight the humanistic nature of experiential therapy; the last two assumptions highlight the foundation in family systems theory. The Battle for Structure and the Battle for Initiative Whitaker discussed two different battles that clinicians need to be aware of: the battle for structure and the battle for initiative. Whitaker believed that it was crucial for clinicians to win the battle for structure by setting the boundaries and limits of therapy (Whitaker and Bumberry 1988). Furthermore, Whitaker believed that clinicians are responsible to ensure that the structure and program of treatment are in place in order to give clients an opportunity to express themselves. Specifically, Whitaker believed that the therapist was responsible for making sure that the necessary people attended session, therapy was frequent enough to produce change, and session content and processing could produce change (Gehart 2015). Whitaker posited that the battle of initiative must be won by clients. In other words, clients need to take accountability for the motivation to change and are responsible to be invested in the therapeutic process. The assumption surrounding the battle of initiative is frequently summarized as “clinicians should never work harder than their clients” (Gehart 2015); the therapist is not responsible for a client’s motivation or intent to change, except by providing the necessary structure for client growth opportunities. Core Concepts Satir suggested that people protect themselves through “survival stances” when they feel threatened or vulnerable (Satir et al. 1991). She classified five different survival stances an individual can take: placater, blamer, super reasonable, irrelevant, and congruence. With the exception of congruence, these stances are based in low selfworth. Although individuals experience each stance in varying degrees during their life, Satir believed family members tend to select complementary stances to create homeostasis within the family or relationship (Satir et al. 1991).

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Placater. Placaters avoid conflict by putting everyone else’s needs above their own at the expense of their self-worth. They tend to be people pleasers and deal with relational distress by focusing on others. Blamer. Opposite from the Placating stance, Blamers will use their influence and power to shift responsibility to other family members. They identify others as the source of their problems and avoid taking accountability for their own wellbeing. Super Reasonable. Individuals with a Super Reasonable survival stance exhibit overly rational and logical punctuations of the source of the problems with minimal emotional expression. Super Reasonable clients tend to have difficulty with multiple subjective realities and try to focus on what they can objectively measurable. Irrelevant. An individual with an Irrelevant survival stance tries to perpetuate the illusion that everything is okay and that the problems do not affect them. They may use humor as a way to distract others and keep them at a distance. People with an irrelevant stance tend to have difficulty experiencing tension within relationships without providing a distraction away from the core issues. Congruence. Unlike the previous four survival stances, congruence comes from a place of self-worth. Congruence is the process in which people balance the needs of self, others, and the content of their context. Individuals with congruent communication demonstrate synchrony with the emotions they are feeling, the words they use, and their body language. Goals for Treatment According to Satir, there are three overarching goals for treatment: congruent communication, increased self-worth, and personal growth (Satir 1991). Similarly, there are three goals of treatment outlined by Whitaker: increased family cohesion, promotion of personal growth, and expansion of the family’s symbolic world (Whitaker and Bumberry 1988). Congruent communication. Problems often arise as families experience a disconnect between what people are saying, the expressed emotion,

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and body language (Satir 1972). Satir believed that emotional suppression during communication was at the root cause of conflict within relationships. As such, one of the primary goals of treatment is to help families learn to communicate congruently. Congruent communication means that individuals feel safe to authentically express their emotions and to increase the synchrony between what people are saying, feeling, and their body language. Self-worth. A second goal of experiential therapy is to increase family members’ sense of selfworth. This is accomplished through acknowledging and celebrating differences that exist within individual family members. Highlighting the uniqueness of each family member and creating space for their individuality provides opportunities for greater acceptance at the individual and family level. Self-worth is manifest as individuals take accountability and are proactive in making decisions in their life (Gehart and Tuttle 2003). Personal growth. The final goal of experiential therapy is for individuals to experience personal growth. Satir posits that as family members more authentically express their emotions that it opens greater possibility for personal growth (Satir 1991). Likewise, growth occurs as family members acknowledge and accept differences between family members.

Populations in Focus Whitaker began seeing families in the 1940s. Satir was not far behind as she began working with families in 1951 (Gehart 2015). Experiential therapists typically attempt to see families together. While they have similar beliefs as other systemic and intergenerational models about the value of treating systemic patterns, experiential therapists are more likely than other models to give specific attention to individual problems and may treat them without intervening at the relational or systemic level. Satir’s emphasis on congruent communication, authentic emotional expression, and vulnerability has been demonstrated to be effective with most groups of people. However, there are some

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important modifications a clinician may make when working with certain clients. For example, the amount of vulnerability that experiential therapy prompts may not culturally fit ethnic groups who value less dramatic emotional expression (Wang 1994). In terms of gender, nontraditional female clients often report feeling misunderstood because they do not fit into the stereotype of traditional female emotional expression (Gehart and Lyle 2001). As such it is important for the therapist to consider how emotional expression and vulnerability are expressed within the culture of their clients and modify the emotional intensity within session appropriately. However, experiential family therapy has been widely used with LGBTQ clients due to the emphasis of authentic emotional expression and self-actualization (Davies and Neal 2000). Additionally, experiential therapy is often very threatening for mandated clients and may not be the best approach (Gehart 2015).

Strategies and Techniques Used in Model While Carl Whitaker is an influential figure in the development of Experiential Family Therapy, he was not interested in developing calculated interventions and techniques. Rather, he referred to his work as “therapy of the absurd.” Whitaker posits that theory and technique are useful for beginning therapists but that the best clinical stance is for clinicians to be themselves (Whitaker 1975). Similarly, Virginia Satir preferred what she termed “vehicles of change” over developing a set of manualized techniques to be memorized. As such, the majority of the techniques and strategies associated with Experiential Family Therapy stem from Satir’s “vehicles of change” based on her communication approach. Role of the Therapist One of the hallmarks of experiential therapy is the role of the therapist. Experiential therapists use warmth, empathy, and humor as way to join with clients but are also direct and assertive in confronting client’s maladaptive processes.

Experiential Family Therapy

A commonly held belief is that family problems are often rooted in emotional suppression. As such, experiential therapists strive to prompt clients toward emotional expression. This is often accomplished by increasing the emotional intensity in session. Whitaker called this process “emotional goading.” In order to create a new emotional experience for clients, he would challenge in confrontational ways to illicit a different emotional response from clients if it would assist clients to be more honest with themselves. Satir’s approach to increasing the emotional intensity was to be honest in her experience with clients and inviting clients into greater emotional disclosure. Play and Spontaneity A defining strategy and characteristic of experiential therapy is the use of spontaneity and play. Experiential therapists use play as a way to develop the therapeutic relationship that allows them to be honest and challenge clients directly (Whitaker and Bumberry 1988). Additionally, playfulness can be an effective tool in reframing problems that family members have unrealistically magnified (Gehart 2015). Modeling Communication Satir describes how therapists model congruent communication through three techniques: (1) the therapist speaks in first person using I-statements, (2) the therapist expresses their own thoughts and feelings directly and avoids stating what other people are feeling, and (3) the therapist is honest with others (Satir 1967). Modeling congruent communication should be present during each phase of treatment and is part of every intervention. Family Sculpting A family sculpt is accomplished by having family members take turns creating a living sculpture where they get to position family members in a way that represent the family. During this intervention, the members that are being sculpted are not allowed to talk or influence how the sculptor chooses to position them. The sculptor may also include verbal statements representing each member who is sculpted. After the sculpture is

Experiential Family Therapy

complete, the therapist then processes different aspects of the sculpture (e.g., the proximity between family members, sculpted body language). The goal is to identify roles and patterns of communication within the family played out by its members and for families to experience alternative patterns of communication. Self-mandala The self-mandala technique is used to identify clients’ resources, highlight the interconnected nature of our needs, and assess for balance across different life domains. The self-mandala is a circle dived into eight different pieces: physical, intellectual, emotional, sensual, interactional, nutritional, contextual, and spiritual (Satir et al. 1991). Clients identify their needs within each domain and map out their level of wellbeing in each domain. This allows clinicians to intervene in areas that are unfulfilling in the clients’ lives and relationships. Co-therapy Due to the necessity of implementing both warmth and confrontation, Whitaker was an advocate for involving co-therapists when doing Symbolic-Experiential Family Therapy (Napier and Whitaker 1978). He recommended that co-therapists be able to model a collaborative co-parenting relationship for clients. Whitaker further explained that with co-therapy, one therapist is to provide a more supporting role, while the other therapist would challenge the family. He argues that a balanced approach to co-therapy would provide constant support for families as they encounter invitations to change (Napier and Whitaker 1978). Whitaker also believed that co-therapy was a way to safe guard against therapist counter transference (Nichols 2013).

Research About the Model There has, unfortunately, been little outcome research on either Whitaker’s or Satir’s approach to experiential therapy. There is, however, a body of common factor research that indicates that clinician’s humanistic ways of being (e.g., nonjudgmental, warm, and empathic) strengthen the therapeutic

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relationship (Gehart 2015), which is strongly associated with treatment outcomes (Lambert 1992). Furthermore, research supports experiential therapists’ assumptions that emotional expression is associated with wellbeing (Stanton and Low 2012). Other therapeutic models with humanisticexperiential foundations – such as Emotionally Focused Therapy (Johnson 2004) – have undergone significant empirical testing and demonstrated efficacy in producing positive client outcomes.

Case Example Tony (46) and Martha (45) are seeking counseling along with their sons David (9) and Jared (8). Their youngest son Jared has been having behavioral issues both at home and at school with the most recent incident getting him suspended from school for hitting a peer. In session Martha mentioned that everything they have tried has failed and she is worried that if they do not get Jared help now he might get into worse trouble later on. Tony sees that the behavior as a problem but believes it is just a phase and that Jared will grow out of it because he too had behavioral issues that he grew out of it. The therapist has met with the whole family and has identified Tony to have a placating survival stance. Martha has been identified as having a blamer stance where she blames Tony’s absence from the family as the root cause of Jared’s behavior. The therapist decides to do a family sculpt as a means of intervention. The therapist asked Martha to sculpt how she sees each family member. With help from the therapist, Martha positions Tony standing in the middle of the room between her and their two children. She positions him facing the kids with a stern look on his face. She positions the two boys sitting on the couch with their heads down in their hands looking down at the ground. Martha positions herself sitting on a chair across the room because she feels that the three boys have their relationship and she is the odd person out. Before discussing each person’s perspective of Martha’s sculpt, each family member has the opportunity to sculpt the family. Tony positions his oldest son standing in the middle of the room with Jared standing behind the other brother holding his shirt. Tony

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positions Martha sitting on the couch facing away from the family with her phone in her hand. Tony positions himself sitting next to Martha with his arm around her but not touching her. The therapist then processes with the family each person’s perspective on how each of them sculpted their family. The therapist assesses for anything that stood out to the family. The therapist then asks each family member to sculpt how they would like to see their family. One by one each member of the family sculpts their desired outcome. Through the family sculpt the therapist is able to identify in a visual way how each person in the family system views their family. Through this particular sculpt, the therapist is able to identify that David is perceived as the good child and that Jared identifies as the bad child and Martha is often labeled as the bad parent. The therapist assesses what it is like to try openly communicate from each of their identified roles. After processing the therapist invites each family member to communicate from their desired role. The therapist helps the family experience a more meaningful communication interaction.

Cross-References ▶ Emotionally Focused Couple Therapy ▶ Napier, Augustus ▶ Symbolic-Experiential Relationship Therapy ▶ Whitaker, Carl

References Baldwin, M., & Satir, V. (1987). The use of self in therapy. New York: Haworth Press. Davies, D. E., & Neal, C. E. (2000). Therapeutic perspectives on working with lesbian, gay and bisexual clients. Maidenhead, BRK, England: Open University Press. Gehart, D. R., & Lyle, R. R. (2001). Client experience of gender in therapeutic relationships: An interpretive ethnography. Family process, 40(4), 443–458. Gehart, D. R. (2015). Theory and treatment planning in family therapy: A competency-based approach. Boston: Cengage Learning. Gehart, D. R., & Tuttle, A. R. (2003). Theory-based treatment planning for marriage and family therapists: Integrating theory and practice. Belmont: Brooks/ Cole Publishing.

Exposure in Couple and Family Therapy Johnson, S. M. (2004). The practice of emotionally focused marital therapy: Creating connection (2nd ed.). New York: Brunner/Routledge. Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative andeclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94–129). New York: Wiley. Napier, A. Y., & Whitaker, C. A. (1978). The family crucible: The intense experience of family therapy. New York: Harper & Row. Nichols, M. P. (2013). Family therapy: Concepts and methods (10th ed.). Jersey City: Pearson. Satir, V. (1967). Conjoint family therapy. Palo Alto: Science and Behavior Books. Satir, V. (1972). Peoplemaking. Palo Alto: Science and Behavior Books. Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir model: Family therapy and beyond. Palo Alto: Science and Behavior Books. Schwartz, R. C. (1995). Internal family systems theory. New York: Guilford. Stanton, A. L., & Low, C. A. (2012). Expressing emotions in stressful contexts. Current Directions in Psychological Science, 21(2), 124–128. https://doi.org/10.1177/ 0963721411434978. Wang, L. (1994). Marriage and family therapy with people from China. Contemporary Family Therapy, 16(1), 25–37. https://doi.org/10.1007/bf02197600. Whitaker, C. A. (1975). Psychotherapy of the absurd: With a special emphasis on the psychotherapy of aggression. Family Process, 14(1), 1–16. https://doi. org/10.1111/j.1545-5300.1975.00001.x. Whitaker, C. A., & Bumberry, W. M. (1988). Dancing with the family. New York: Brunner/Mazel.

Exposure in Couple and Family Therapy Alexander O. Crenshaw1 and Brian R. W. Baucom2 1 University of Utah, Salt Lake City, UT, USA 2 Department of Psychology, University of Utah, Salt Lake City, UT, USA

Introduction Exposure in couple and family therapy (C&FT) draws on the same principles as exposure used in individual treatment of anxiety disorders. Based on past learning, certain cues (e.g., an emotion expressed by one partner) come to represent

Exposure in Couple and Family Therapy

some feared outcome (e.g., a relationshipthreatening argument). In order to avoid the feared outcome, partners avoid the cues that are thought to precede the feared outcome. Through associative learning, those cues come to represent the feared outcome and are avoided with greater vigilance, growing the fear to be disproportionately larger than the actual likelihood of the event occurring. When fear cues inevitably arise in the course of life, romantic partners may react with intense emotions, often leading to dysfunctional and destructive behaviors toward one another. Exposure in C&FT, like in treatment for anxiety disorders, involves repeatedly facing such fear cues, learning to tolerate the intense emotions as they arise, and learning that the specific cue does not necessarily lead to the feared outcome. A key difference between exposure for anxiety and in C&FT, however, is that exposure in C&FT is typically done through interactions among partners rather than to specific outside stimuli.

Theoretical Framework Exposure in C&FT is utilized in most behaviorally and affectively based models. The unified protocol for couple therapy, a transtheoretical framework for couple therapy (Christensen 2010), suggests that exposure is a key intervention technique because avoidance of relationship content prevents couples from experiencing emotional closeness and support with one another around these difficult issues and prevents the couple from working together toward solutions.

Rationale for the Strategy or Intervention Decades of research support the effectiveness of exposure as an intervention when significant avoidance is present (Foa and Kozak 1986). The principle of exposure first gained support in the treatment of anxiety disorders and serves as the bedrock of cognitive-behavioral interventions for anxiety disorders. Exposure therapy involves systematically confronting situations that elicit fear

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or anxiety, which reliably reduces subsequent fear or anxiety in future encounters with the same stimulus. The use of exposure in couple therapy is supported by research showing the efficacy of couple therapies that utilize the principle (e.g., Baucom et al. 2015). Two prominent theorized cognitive-behavioral mechanisms of change for exposure have been proposed: habituation and inhibitory learning (Craske et al. 2014). The habituation model states that exposure works to reduce anxiety by helping an individual habituate to the feared situation. The inhibitory learning model states that exposure works by learning that the feared situation (e.g., anger of partner) usually does not produce the feared outcome (e.g., end of relationship) through repeated trials.

Description of the Strategy or Intervention Exposure in C&FT, like couple and family therapy in general, takes two forms: partner-assisted exposure therapy and exposure as part of couple therapy. In partner-assisted exposure therapy, a romantic partner assists in helping conduct exposure exercises designed for his or her partner’s individual psychopathology, acting as a coach or source of encouragement. Exposure in C&FT – the focus of this entry – is conducted in order to improve the relationship itself, and it typically involves exposure to frequently avoided relational stimuli, such as intense negative emotions or undisclosed vulnerabilities. Carrying out exposure in C&FT involves primarily eliciting avoided, relationship-relevant content while preventing or interrupting subsequent destructive interaction behaviors, and encouraging constructive communication and mutual disclosure of avoided content. Like exposure therapy for anxiety disorders, in which exposures are carefully planned out based on a hierarchy of intensity, this process involves a great deal of clinical judgment as to when this avoided content is elicited and the depth at which it is discussed. Also like exposure therapy for anxiety disorders, the therapist typically exercises more control over the process at the outset of therapy compared with later.

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Case Example Eric and Cindy presented to therapy reporting conflict related to the frequency of sexual contact they have. Cindy was satisfied, but Eric was not. Due to her history, Cindy was sensitive to feeling that her autonomy was being encroached upon, so she often felt her “walls” go up in response to Eric’s attempts at establishing physical intimacy and rebuffed his advances. Eric strongly wanted his relationship to be more than just an average relationship, and he was vigilant for any sign that the relationship was less than great or in decline. When Cindy had disclosed emotions in the past related to feeling her sense of autonomy was encroached upon, Eric interpreted these emotions as signs that the relationship was in jeopardy and responded with invalidation and anger, which resulted in Cindy disclosing less in the future. Part of therapy for this couple involved eliciting this important but avoided relationship content in a safe, therapeutic context. Exposure to Cindy’s feelings of having her autonomy encroached upon was important both for Cindy to understand and express exactly what it felt like when Eric made sexual advances toward her and for Eric to hear this distressing content and learn over time that her response did not signal the end of the relationship.

Cross-References ▶ Cognitive Behavioral Couple Therapy ▶ Cognitive-Behavioral Family Therapy ▶ Emotionally Focused Couple Therapy ▶ Extinction in Couple and Family Therapy ▶ Integrative Behavioral Couple Therapy

Expressed Emotion in Families Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20.

Expressed Emotion in Families Hannah S. Myung and James L. Furrow Fuller Graduate School of Psychology, Pasadena, CA, USA

Name of Concept Expressed Emotion in Families

Introduction Expressed emotion (EE) was first identified through studies of patients with schizophrenia and their families. Researchers explored various factors contributing to patient relapse given high rates of hospital recidivism and decompensation among patients diagnosed with schizophrenia. A patient’s family environment and emotional ties were identified as key predictors of treatment relapse and treatment outcomes. Over time EE has been more generally recognized as a familyspecific influence effecting the course of treatment for several psychological disorders. Although EE studies initially focused on posttreatment outcomes, a series of family-based interventions have been targeted to influence family environments and to address the core effects of EE.

References Baucom, B. R., Sheng, E., Christensen, A., Georgiou, P. G., Narayanan, S. S., & Atkins, D. (2015). Behaviorally-based couple therapies reduce emotional arousal during couple conflict. Behaviour Research and Therapy, 72, 49–55. Christensen, A. (2010). A unified protocol for couple therapy. In K. Hahlweg, M. Grawe-Gerber, & D. H. Baucom (Eds.), Enhancing couples: The shape of couple therapy to come (pp. 33–46). Hogrefe Publishing: Cambridge, MA.

Theoretical Context for Concept During the 1950s, George Brown was completing his undergraduate study when he was offered a research position at the Maudsley Hospital in London to observe patients with schizophrenia. Increasing incidents involving patient readmission and symptom relapse prompted Brown and his

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colleagues to examine patient experiences after they were discharged from treatment. Researchers identified a link between patient readmission and the quality of the home environments to which they were discharged (Brown 1959; Brown et al. 1958). Patients who returned to their parents or spouses were showing higher readmission rates than those who went on to live with their siblings, distant relatives, or in new lodgings. Furthermore, if both the patient and a close relative, such as the mother, were unemployed and staying at home there was a higher risk for readmission and symptom relapse. This suggested that unavoidable and prolonged contact to a close relative could be problematic and that the close ties between a patient and family members needed further inquiry. Therefore, Brown and his colleagues began examining the relationships between patients and their close relatives focusing on the emotional ties of hostility or affection that were often observed in these home environments. In pursuing this, Brown recognized the need for reliable methods to measure the emotional quality in families and collaborated with Michael Rutter, who was initially interested in examining the emotional impact of neurotic parents on their children. Rutter had developed interview methods to assess the emotional quality of the familial relationships. Eventually, they applied these methodologies to studying parents of patients with schizophrenia (Brown 1985). The focus on the emotional aspect within the family interactions made Brown’s work distinctive. His primary interest in emotional tone and quality provided an innovative approach to examining family environments including family metacommunication and familial interactions. For example, Brown and his colleagues differentiated critical comments from statements of dissatisfaction in the family based on a person’s emotional tone and vocal quality. This distinction became important in determining EE which proved effective in predicting patient relapse. Although the identification of EE was focused on the treatment of schizophrenia and family environments, EE has also been shown to be relevant to the treatment of other psychological disorders and problems overtime. Cognitive

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models of depression suggest that depressed people tend to internally attribute negative situations. Critical relatives who attribute negative events to internal patient factors are likely to reinforce patient sensitivity to these responses especially for depressed patients (Wearden et al. 2000). The potential influence of EE on depression treatment is significant based on theoretical and research grounds pointing to a positive relationship between EE and relapse for both unipolar and bipolar depression (Wearden et al. 2000). Similar questions have been raised regarding EE’s influence on the course of treatment for anorexia nervosa and bulimia nervosa (Duclos et al. 2012), post-traumatic stress disorder (Tarrier et al. 1999), and significant predictor of time until relapse for patients with alcohol abuse problems (Fichter et al. 1997). Summary efforts to establish a general role for EE in predicting treatment outcomes for psychological disorder are challenged by the varied methodological approaches to the assessment and measurements of EE. For example, establishing an agreed upon cutoff for critical comments to be considered as high EE has been problematic. The absence of a consensus criteria result limits the ability to estimate an overall EE effect. Nevertheless, the breadth and scope of findings among various psychological disorders suggests that the influence of EE on course of treatment should be considered well beyond the treatment of schizophrenia.

Description EE is comprised of five components: criticism, hostility, emotional overinvolvement, positive remarks or regard, and warmth. Problematic levels of EE are generally characterized by increased levels of criticism, hostility, or emotional overinvolvement among the patient’s caregivers or close relatives, whereas low levels on these dimensions are representative of low EE in a family setting. Although some studies have incorporated the positive dimensions of EE along with these negative dimensions, the negative EE factors are given greater consideration in predicting treatment outcomes.

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Criticism Disparaging comments expressed in a critical tone of voice is the defining feature of this dimension. Matter of fact statements without the presence of a critical tone would not be identified as criticism. Critical comments are indicative of disapproval or resentment about the patient’s behaviors. A family member often assumes that he or she is helping the patient by being critical and may complain about the patient’s inability to carry out what would be perceived as normal functioning, such as getting out of bed or taking care of personal hygiene. These behaviors are typically seen in patients exhibiting the negative symptoms of schizophrenia or other psychotic disorders.

overinvolved behaviors as parent assumes responsibility for the patient’s condition, and parental self-blame and guilt increase as these efforts fail to abate the patient’s symptoms. Ironically, these parental behaviors often exacerbate the patient’s symptoms and functioning since the patient is continually having to depend on the caregiver’s support. This undermines the patient’s agency as he or she is perceived as incapable of recovery without the parent.

Hostility Evidence of hostility is best characterized by negative attitudes and critical remarks made directly toward the patient. These remarks are not only about the patient’s behavior but specific to the patient’s character as a person. For example, not getting out of bed or refusing to brush teeth by the patient is attributed to laziness rather than manifestations related to the negative symptoms of the patient’s disorder. The caregiver usually believes that the patient has control over his or her mental illness, but is purposely not willfully choosing to a course toward recovery. Thus, the patient is often blamed for not taking control over the disorder, and many family problems are viewed as being caused by the patient and his or her mental illness, although that may not always be the case. The patient remains caught in a bind within the family since the mental illness is concluded to be both the cause and answer to most problems.

Warmth The assessment of warmth in the family environment is characterized by expression of caregiver empathy and compassionate concern for the patient. Similar to criticism, the caregiver’s supportive tone is often the clearest marker for level of warmth for families.

Emotional Overinvolvement This EE component is identified based on a combination of the actions and beliefs of the family, typically observed in a family interview. Parental and caregiving behaviors are markedly beyond those normally expected given the developmental level of the patient. These actions often include a caregiver’s overprotection, intrusion, sacrifice of own needs, and overidentification with the patient. Parental guilt attributed to the patient’s condition can motivate and heighten these

Positive Remarks or Regard These statements are characterized by expressions of approval, support, or appreciation toward the patient’s actions and to his or her character.

EE Measures Different measures have been developed to assess the level of EE in a patient’s family environment. The Camberwell Family Interview (CFI; Leff and Vaughn 1985; Vaughn and Leff 1976) is a well-known conventional measure that is administered to family members without the patient present. It includes semistructured questions to elicit discussions on everyday features of family life and the patient’s condition (e.g., onset of symptoms, worsening of symptoms, recent episodes, and the specific events leading to hospitalization). The familial interactions, levels of tension and irritability, and daily routines are also noted. These discussions are recorded for later analyses and coding which are done using rating scales developed based on the EE dimensions. One drawback of the CFI is that the training, administration, and reliable scoring can be an arduous and time-consuming process. The FiveMinute Speech Sample (FMSS; Magaña et al. 1986) was proposed as a brief measure developed based on the CFI. The FMSS is comprised of the ratings of the EE components, criticism and emotional overinvolvement, and is measured by

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having family members independently discuss their relationship to the patient for 5 min. The relative is asked to talk about his or her feelings and thoughts regarding the patient, and describe the emotional climate in the relationship. These discussions are recorded and later coded based on content and emotional tone. Other methods in assessing EE include selfreport measures. The Level of Expressed Emotion Scale (LEE; Cole and Kazarian 1988) does not require the presence of a close relative as in the CFI and FMSS. The LEE is a 60-item true or false measure, which is used to assess the relationship quality and emotional environment of the patient and close relatives across four dimensions: intrusiveness, attitude toward illness, emotional response, and tolerance and expectations. The LEE, however, has been critiqued for being too extensive for survey research and being limited to patients with schizophrenia. Furthermore, the Family Emotional Involvement and Criticism Scale (FEICS; Shields et al. 1992) sought to extend the EE concept and its measurement to the broader field of family studies, and provide an assessment that better supported survey research. The 14-item self-report FEICS provides an assessment of the levels of familial criticism and emotional overinvolvement consistent with EE. Other measures attempt to approximate important EE dimensions. The Family Attitude Scale (FAS; Kavanagh et al. 1997) was initially developed as an attempt to develop a questionnaire that could be administered to either patients or relatives, would be sensitive in assessing criticism, and would be correlated with the CFI. The FAS is a 30-item scale that mainly focuses on the level of criticism, annoyance, and burden in the family. Patients or close relatives indicate on a scale how often the given statement is true. Sample statements include “I wish he were not here,” “I shout at him,” and “I find myself saying nasty or sarcastic things to him.” Another quick and simple measure concentrated on the level of criticism in EE is the Perceived Criticism (Hooley and Teasdale 1989). On a 10-point scale respondents answer to the question, “How critical do you consider your relative to be of you?” Interviewers

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can also modify the question using the same scale to gather further information. For example, an interviewer may want to know about the patient’s own perceived criticism toward their relatives.

Application of Concept in Family Therapy Research findings pointing to the negative influence of elevated EE and poor patient outcomes led to the development of family-based interventions targeting EE constructs. Psychoeducational family interventions were initially developed with the primary goal of reducing negative components of EE and preventing relapse in patients. The intervention tasks focused on correcting misattributions related to a patient’s illness and in turn help relatives become less critical toward the patient. Although psychoeducational programs have achieved positive effects on outcomes, there has been a lack of consensus when it comes to effects on EE levels. Findings suggest that interventions with the primary goal of reducing EE have achieved only modest effects or limited success, and that targeting EE as a core goal may be necessary, but not sufficient. Also, the EE concept in the past has been criticized for reinforcing views that pathologize and place blame on families. Recommendations to provide family strength-based approaches have drawn more attention as alternative strategies for promoting a family’s strengths and resources in family interventions. Therefore, EE is better conceptualized as an important factor in the treatment process, but not a primary treatment method or outcome. One approach outlined by Barrowclough and Tarrier (1997) is taking on a “needs-led” approach rather than an “EE-reduction” approach for clinical practice. EE concepts and dimensions can be used to guide therapists in their treatment formulation when obtaining clinically relevant information of the family’s needs, evaluating coping strategies, and prioritizing change, but not a sole focus in treatment (Barrowclough and Tarrier 1997).

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Clinical Example Janice (56) and Caleb (25) entered family therapy after Caleb experienced a relapse in depression. He expressed feelings of worthlessness and hopelessness that persist through most of his day. Caleb reported loss of interest and had little energy for daily activities. He described it being an “ordeal” to get out of bed every morning. Caleb reported feeling helpless and incompetent in the everyday tasks he faced and would rather “sleep it through.” His mother, Janice, expressed frustration regarding Caleb’s symptoms as much as she feels guilt for feeling that way. In the beginning, she felt compassion for Caleb and his struggles, but recently she is convinced that his problems are from “laziness” and failing to take responsibility. She believes that he uses his depression as an excuse, since he has been in treatment for depression previously and gained coping strategies, which he should have applied by now. She expressed that much of Caleb’s issues stem from his indecisiveness to get a job, move out of the home, and seek independence. Janice often finds herself having to pick up after Caleb and has taken on the decision-making responsibility for him because she believes he is incapable of making even the most basic decision. At this point Janice is skeptical entering into therapy again with Caleb as she doubts if anything will change, unless Caleb is willing to change. Following a “needs-led” approach, the therapist attuned to caregiver criticism and hostility that is obvious in Janice’s manner and tone. The therapist noted her reactions to Caleb’s behaviors and what things he does or does not do, all the while paying attention to how Janice coped with Caleb’s depression, including the consequences that this recent depressive episode has had upon the family. The therapist asked Caleb about his experiences including the reactions of his mother and other family members. These conversations brought to light the perceived and actual intentions of family members with a special focus given to identifying the family needs related to Caleb, but also to the family in general. These conversations helped to identify the misattributions being made about Caleb’s depression and

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areas where psychoeducation is needed. The therapist kept in mind that Janice’s skepticism about therapy was related to her attitude toward Caleb and his depression. The therapist provided Janice information about depression and what she could expect as a result. At the same time the therapist gave recognition to her frustration that was associated with her underlying desire to help Caleb (since many relatives believe that they are helping the patient by being critical although not beneficial). Additionally, the therapist listened and observed behaviors that involved emotional overinvolvement and how these behaviors impacted Janice and Caleb’s well-being. The therapist assessed the extent to which Janice felt pulled to “pick up” after Caleb and make decisions on his behalf. The impact of Janice’s behaviors was highlighted in relation to how her actions impacted Caleb’s feelings of helplessness and dependence on his mother. Caleb identified how that it was in these moments he stopped trying and withdrew (e.g., sleeping or refraining from making decisions), which in turn activated Janice’s overinvolvement. Identifying this sequence of misattributions and reactions helps the family and the therapist target specific needs of family members and their responses when these needs are unacknowledged or dismissed. The therapist aids Janice and Caleb in finding new strategies for coping. In addition, recognizing positive and successful coping strategies and responses by each family member is pertinent to a strength-based approach to family therapy and in intervention planning as these strengths can be resources. Expressions of warmth and positive regard between family members can also be noted in this process. Although Janice is skeptical about therapy, she and Caleb seem to have a desire to make things better. They both are present in therapy regardless of how they feel and are actively seeking help. This case example illustrates the application of EE concepts as an important element in case formulation and intervention planning. It is worth mentioning that this is done in conjunction with other treatment modalities the therapist may use and does not in and of itself encompass the whole

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treatment process. Other areas for consideration in this case include the history of the problem (onset, duration, course), experiences of past treatment, risk assessment, psychosocial history, and adjunct treatment (e.g., medication). Disorders are not the result of these family environments (e.g., EE), but often impact family distress in ways that prove problematic for the course of treatment. Taking EE into account, the clinician provides additional resources to the family as well as strengthens the resources of the family to better support the effective treatment of a number of psychological disorders.

Cross-References ▶ Anderson, Carol ▶ Camberwell Interview for Assessing Expressed Emotion in Families ▶ Communication in Couples and Families ▶ Communication Training in Couple and Family Therapy ▶ Faloon, Ian ▶ Family Psychoeducational Treatments for Schizophrenia in Family Therapy ▶ Problem-Solving Skills Training in Couple and Family Therapy ▶ Psychoeducation in Couple and Family Therapy ▶ Schizophrenia in Couple and Family Therapy ▶ Shields, Cleveland

References Barrowclough, C., & Tarrier, N. (1997). Families of schizophrenic patients: Cognitive behavioural intervention. Cheltenham: Nelson Thornes. Brown, G. W. (1959). Experiences of discharged chronic schizophrenic patients in various types of living group. The Milbank Memorial Fund Quarterly, 37, 105–131. Brown, G. W. (1985). The discovery of expressed emotion: Induction or deduction? In J. P. Leff & C. Vaughn (Eds.), Expressed emotion in families: Its significance for mental illness (pp. 7–25). New York: The Guilford Press. Brown, G. W., Carstairs, G. M., & Topping, G. (1958). Post hospital adjustment of chronic mental patients. The Lancet, 272, 685–689.

985 Cole, J. D., & Kazarian, S. S. (1988). The level of expressed emotion scale: A new measure of expressed emotion. Journal of Clinical Psychology, 44, 392–397. Duclos, J., Vibert, S., Mattar, L., & Godart, N. (2012). Expressed emotion in families of patients with eating disorders: A review of the literature. Current Psychiatry Reviews, 8, 183–202. Fichter, M. M., Glynn, S. M., Weyerer, S., Liberman, R. P., & Frick, U. (1997). Family climate and expressed emotion in the course of alcoholism. Family Process, 36, 203–221. Hooley, J. M., & Teasdale, J. D. (1989). Predictors of relapse in unipolar depressives: Expressed emotion, marital distress, and perceived criticism. Journal of Abnormal Psychiatry, 98, 229–235. Kavanagh, D. J., O’Halloran, P., Manicavasagar, V., Clark, D., Piatkowska, O., Tennant, C., & Rosen, A. (1997). The family attitude scale: Reliability and validity of a new scale for measuring the emotional climate of families. Psychiatry Research, 70, 185–195. Leff, J. P., & Vaughn, C. (1985). Expressed emotion in families: Its significance for mental illness. New York: Guilford Press. Magaña, A. B., Goldstein, M. J., Karno, M., Miklowitz, D. J., Jenkins, J., & Falloon, I. R. H. (1986). A brief method for assessing expressed emotion in relatives of psychiatric patients. Psychiatry Research, 17, 203–212. Shields, C. G., Franks, P., Harp, J. J., McDaniel, S. H., & Campbell, T. L. (1992). Development of the family emotional involvement and criticism scale (FEICS): A self-report scale to measure expressed emotion. Journal of Marital and Family Therapy, 18, 395–407. Tarrier, N., Sommerfield, C., & Pilgrim, H. (1999). Relatives’ expressed emotion (EE) and PTSD treatment outcome. Psychological Medicine, 29, 801–811. Vaughn, C., & Leff, J. P. (1976). The measurement of expressed emotion in families of psychiatric patients. British Journal of Clinical Psychology, 15, 157–165. Wearden, A. J., Tarrier, N., Barrowclough, C., Zastowny, T. R., & Rahill, A. A. (2000). A review of expressed emotion research in health care. Clinical Psychology Review, 20, 633–666.

Expressive Leader in Families T. Ciochon, Kristy L. Soloski and K. Finch Texas Tech University, Lubbock, TX, USA

Synonyms Emotional leader; Socio-emotional specialist

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Introduction While many factors affect intrafamilial relationships, it is generally agreed that the family is an economic unit as well as a social unit. Thus, it was expected that economic (instrumental) and social (expressive) roles would evolve to preserve the unit. The instrumental leader can be described as the task specialist, whereas the expressive leader can be described as the socio-emotional specialist*.

Theoretical Context for Concept In the mid-twentieth century, sociologists began to question the appropriation of roles among partners within American households. This division of roles was evidenced most poignantly in the heterosexual, middle-class, EuroAmerican family of the time where wives/ mothers tended to the internal affairs of the home (also called the private sphere), while husbands/fathers tended to the external demands (public sphere) of the home. These roles began to take on new, independent meaning for the structural functionalists, leading to the proposition of two family roles: emotionally focused expressive leaders and economically focused instrumental leaders. This division became known as complementarity. Structuralfunctionalist sociologists sought to make sense of the American family’s trend toward differentiated roles as progressive: the family differentiated roles in order to maintain pragmatic function and stability (Parsons and Bales 1955). This division according to gender was known as sex-role complementarity. However over time, differentiation and complementarity as progressive functions were heavily critiqued, as well as the sex-specific breakdown of roles associated with this differentiation. Critics of sex-role complementarity denied the structural-functionalist assumption that role disparity between partners was increasing in the mid-1900s, citing the increasing trend of female and male spouses to share in parenting in the home and employment outside the

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home – reinforcing the minimization of role complementarity (Foote 1956). Further research has challenged the universality of expressive leadership as a sex-specific function as opposed to an integral component of parenting for both spouses. An examination of a 56-society sample size revealed that the sociological trend for complementarity was challenged as too limited in scope (Parsons and Bales 1955). Future research spanning over 180 societies worldwide challenged the permanency and universality of sex-role complementarity indicating an increased expressive function for women during childbearing and infancy, which later returns to a shared position of leadership between male and female partners (Crano and Aranoff 1978). Although the expressive leader role has been documented in heterosexual relationships, insufficient research has been conducted to identify how expressive leadership functions are distributed within same-sex relationships.

Description Expressive or emotional leadership* within the home is focused upon “child training,” emotional nurturance, and undertaking the responsibility of the human caretaking associated with family leadership. As opposed to the task orientation of instrumental leadership, which emphasizes efficiency and productivity, expressive leadership is generally espoused by focusing on the cohesiveness and emotional health of the group members. In egalitarian partnerships, partners can undertake equal expressive leadership in a family system; conversely in more complementary partnerships, one individual tends to focus on expressive functions, while the other partner may focus upon instrumental functions. The delegation of leadership roles can also change across time given family circumstances. Etiology of the traditional sex role of females undertaking the expressive leadership role in the family was proposed to be a direct result of the female’s sex-specific role of bearing and feeding the child post-conception through infancy (Crano and Aranoff 1978).

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Application of Concept in Couple and Family Therapy Satir’s (1988) experiential family therapy model explained that family members undertake different roles within a family. Having a primary role within a family is not problematic; however, the value messages associated with various roles must be uncovered. Consistent with this perspective, expressive leadership as a primary function of a family member is not an issue unless there are negative value messages associated with the role, and flexibility is withheld from members. The freedom of partners to co-create the roles that are best for themselves and the family while making future adjustments is paramount to thriving and dynamic family systems.

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judgment of some friends as it relates to her no longer undertaking the expressive role in the family. Conversely, José has experienced societal push back faced by men in similar situations who have stepped away from the workforce. They are seeking therapy to help during the adjustment period as the transition has created interpersonal strain evidenced by distance between the partners and relational dissatisfaction.

E Cross-References ▶ Complementarity in Structural Family Therapy ▶ Gender Roles

References Clinical Example José and Diane have been married for 10 years and have two young children, an 8-year-old boy and a 5-year-old girl. Prior to both their children entering kindergarten, Diane stayed home to care for the kids, while José was employed full time and took on the primary income earner in the family. The couple assumed traditional sex-role complementarity in their marriage, with Diane undertaking the primary expressive leadership role and José undertaking the instrumental role as the main income provider. Diane took pride in spending time with her children and talking with them. As a result, Diane was often aware when someone in her family was upset and was promptly there for them. José was proud of his professional accomplishments and being able to provide for his family. Recently, since both of the children entered primary school, José has decided to further his education and return to school. This change forced Diane and José to reconcile new roles within the family as José is unable to work in conjunction with his education, but is able to undertake the majority of the parenting and household functions for the family. This has proven to be challenging for the couple as Diane and José are forced to confront the strain of adjusting to new roles within the family system. Diane as the new primary provider for the family is faced with the

Crano, W. D., & Aronoff, J. (1978). A cross-cultural study of expressive and instrumental role complementarity in the family. American Sociological Review, 43(4), 463–471. Foote, N. N. (1956). Parsonian theory of family process: Family, socialization and interaction process. Sociometry, 19(1), 40–46. Parsons, T., & Bales, R. F. (1955). Family, socialization and interaction process. Glencoe: Free Press. Satir, V. (1988). The new peoplemaking. Mountain View: Science and Behavior Books.

Extended Family Bertranna A. Muruthi1, Megan McCoy2 and Andrea Leigh Farnham3 1 Marriage and Family Therapy Program, Virginia Tech - Northern Virginia Center, Falls Church, VA, USA 2 Firm Foundations Counseling, Columbia, SC, USA 3 The University of Georgia, Athens, GA, USA

Synonyms Extended kinships* Psychological family* (this is more for non-biological)

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Fictive kin* (non-blood related friends who are seen as family) (Hall & Green 2003) Secondary family* Family networks* Extrafamilial* Surrogate kin network* Families of choice* (Weston 1991)

Introduction Extended family refers to the extended kinship system outside of the nuclear family. This system can include biological relatives, relatives by marriage, and the functional kinship system of neighbors, friends, and associates (Pattison et al. 1975). According to Nichols and Schwartz (1998), some of the first therapists who take the extended family into consideration were Murray Bowen and Ross Speck. Bowen stressed the role of the extended family in the transmission of family patterns, rules, beliefs, and values, and the role those play in the current problems. Speck mobilized the patient’s network of family and friends to aid in treatment and saw the extended family as a resource that could be accessed (457).

Description According to Pattison et al. (1975), the extended kinship system provides two major resources for individual and family well-being. One resource is affective support, which is emotional involvement, personal interest, and psychological support. Affective support can be seen in instances of transition, crisis, and/or loss where family members look to extended family and kin networks for emotional support. This type of affective support can be elicited and exhibited through various means such as phone calls, acts of kindness, or just physical presence. The other resource is instrumental support, which comes in the form of money or other assistance in living. Instrumental support can be informal such as bringing meals

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and loaning a car, or it can be more formal and contractual such as a grandparent watching children while parents are at work.

Relevant Research African-American and Latino populations are often the focus of research on extended families. This is in part due to these two groups having more collectivistic family orientations which incorporate having associations with larger kin networks. Historically these family relationships have been viewed as “enmeshed” (Minuchin 1974) due to a perceived lack of differentiation from the extended family network. Yet, these close family relationships have been proven to be a valuable source of support and to also promote viability and health in these family systems (Durant et al. 2013). For example, for AfricanAmerican families, extended networks have been proven to support better mental health outcomes (Lincoln 2007) and also to buffer the stresses associated with child-rearing and caregiving (Brummett et al. 2012). Positive outcomes have been noted with other groups when extended family and informal kin networks are involved with children (e.g., Walsh 2015) and adolescents (e.g., McPherson et al. 2013). For example, McPherson et al. (2013) found that positive extended family support can reduce the likelihood of tobacco, alcohol, and drug use in adolescents. They also found that positive family support appeared to have a stronger buffering effect on risk behavior than parental monitoring and control. Extended family research has also explored the positive impact of extended family support on the elderly population (e.g., Sheffler and SachhsEricsson 2015). This population has a higher risk for social isolation including living alone in community residence, living below the poverty level, or residing in a neighborhood/community environment that does not encourage civic participation (Walker and Herbitter 2005). Limited access to support in this population can lead to negative

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physical and mental outcomes. These outcomes range from higher rates of cognitive decline (Seeman et al. 2001) to increased mortality rates (Everard et al. 2000). According to Bell (1962), the families’ ability to utilize their extended family as a social resource is a prerequisite for healthy functioning in the nuclear family system. He continues to posit that when this is not achieved, the extended family can become pathological by (1) reinforcing family defenses, (2) stimulating conflict, (3) becoming a screen for projection of nuclear family conflict, and (4) becoming competing objects for support (Bell 1962). These pathological extended family relationships have been associated with mental illness (Sapin et al. 2016), declines in physical functioning (Seeman and Chen 2002), and chronic illness (Rosland et al. 2012).

Special Considerations for Couple and Family Therapy Therapists working with extended families should explore an individual in the context of his or her social context. Taylor et al. (2014) described four types of extended family networks: (1) high emotional support and high negative interaction (ambivalent), (2) high emotional support and low negative interaction (optimal), (3) low emotional support and low negative interaction (estranged), and (4) low emotional support and high negative interaction (strained). Their findings show that the second type of family support (high emotional support and low negative interaction) is considered the optimal support, and individuals who experience these types of relationships within their life are closer to their families and interacted with them more and thereby would be less likely to experience depressive symptoms. One of the earliest approaches to family therapy, structural family therapy, has strong ties to extended family in the therapy room (Pattison et al. 1975). This theoretical approach is directed toward changing the structure or organization of

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the family to allow each individual’s experience to change (Minuchin 1974). Yet, “a number of pioneering family therapists – Murray Bowen, Ivan Boszormenyi-Nagy, James Framo, Carl Whitaker – incorporated generational issues in their work with families” (Goldenberg and Goldenberg 2012, p.204). For example, Bowen used genograms to explore the network of interlocking relationships (Goldenberg and Goldenberg 2012). Ivan Boszormenyi-Nagy promoted the concept of relational ethics based on two beliefs: family members are committed to meeting the needs of each member and each member will do what is necessary to maintain the family (Boszormenyi-Nagy and Krasner 1986). James Framo broadened Bowen’s work to create intergenerational family therapy sessions, where he would encourage clients’ family of origin into the therapy room, going as far as to cancel or reschedule sessions if any family members did not show up (Framo 1992). Finally, Carl Whitaker invited extended family members to be consultants in family sessions (Goldenberg and Goldenberg 2012). Therapists must also be aware that a client may not have access to an extended family network. In these times, it can be valuable to help a client develop a surrogate kin network, which can be made up of various kinds of supportive kin, friendships, and community networks that serve the function of extended family. For example, extended family networks and surrogate kin can serve as social and economic resources when finances are drained by costly medical bills or in instances of the death of the major breadwinner (Walsh 2015). Clinicians can help in mobilizing these surrogate kin networks by maintaining a connection with the community and compiling possible networking options for their clientele.

Cross-References ▶ Nuclear Family ▶ Structural Family Therapy

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References Bell, N. W. (1962). Extended family relations of disturbed and well families. Family Process, 1(2), 175–193. Böszörményi-Nagy, I., & Krasner, B. (1986). Between give and take. New York: Brunner/Mazel. Brummett, B. H., Siegler, I. C., Williams, R. B., Hilliard, T. S., & Dilworth-Anderson, P. (2012). Associations of social support and 8-year follow-up depressive symptoms: Differences in African American and White caregivers. Clinical Gerontologist, 35(4), 289–302. Durant, R. W., Brown, Q. L., Cherrington, A. L., Andreae, L. J., Hardy, C. M., & Scarinci, I. C. (2013). Social support among African Americans with heart failure: Is there a role for community health advisors? Heart & Lung: The Journal of Acute and Critical Care, 42(1), 19–25. Everard, K. M., Lach, H. W., Fisher, E. B., & Baum, M. C. (2000). Relationship of activity and social support to the functional health of older adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 55(4), S208–S212. Framo, J. L. (1992). Family-of-origin therapy: An intergenerational approach. New York: Psychology Press. Goldenberg, H., & Goldenberg, I. (2012). Family therapy: An overview. Cengage Learning. Lincoln, K. D. (2007). Financial strain, negative interactions, and mastery: Pathways to mental health among older African Americans. Journal of Black Psychology, 33(4), 439–462. McPherson, K. E., Kerr, S., Morgan, A., McGee, E., Cheater, F. M., McLean, J., & Egan, J. (2013). The association between family and community social capital and health risk behaviours in young people: an integrative review. BMC Public Health, 13(1), 971. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Nichols, M. P., & Schwartz, R. C. (1998). Family therapy: Concepts and methods. Boston: Allyn & Bacon. Pattison, E. M., Defrancisco, D., Wood, P., Frazier, H., & Crowder, J. (1975). A psychosocial kinship model for family therapy. American Journal of Psychiatry, 132(12), 1246–1251. Rosland, A. M., Heisler, M., & Piette, J. D. (2012). The impact of family behaviors and communication patterns on chronic illness outcomes: A systematic review. Journal of Behavioral Medicine, 35(2), 221–239. Sapin, M., Widmer, E. D., & Iglesias, K. (2016). From support to overload: Patterns of positive and negative family relationships of adults with mental illness over time. Social Networks, 47, 59–72. Seeman, T., & Chen, X. (2002). Risk and protective factors for physical functioning in older adults with and without chronic conditions MacArthur studies of successful aging. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 57(3), S135–S144. Seeman, T. E., Lusignolo, T. M., Albert, M., & Berkman, L. (2001). Social relationships, social support, and patterns of cognitive aging in healthy, high-functioning

older adults: MacArthur studies of successful aging. Health Psychology, 20(4), 243. Sheffler, J., & Sachs-Ericsson, N. (2015). Racial differences in the effect of stress on health and the moderating role of perceived social support. Journal of Aging and Health, 28, 1362. https://doi.org/10.1177/ 0898264315618923. Taylor, R. J., Forsythe-Brown, I., Taylor, H. O., & Chatters, L. M. (2014). Patterns of emotional social support and negative interactions among African American and Black Caribbean extended families. Journal of African American Studies, 18(2), 147–163. Walker, J., & Herbitter, C. (2005). Aging in the shadows: Social isolation among seniors in New York City. New York: United Neighborhood Houses of New York. Walsh, F. (2015). Strengthening family resilience. New York: Guilford Publications.

Externalizing in Narrative Therapy with Couples and Families Maggie Carey Narrative Practices Adelaide, Adelaide, Australia

Introduction Externalizing is a practice that sits within a Narrative Therapy approach developed by Michael White and David Epston (1990; Epston 1998). A Narrative approach can be useful in working with individuals, couples, families, and communities and can be used in addressing any concern. A Narrative Therapy approach sees life as multistoried (Freedman and Combs 1996). When couples or families come to therapy, they often come with a single “problem” account of their relationships. This is a single story that has taken on a status of “truth” and has become embedded in the identity of the relationship of the family or couple. The stories that each person has about who they are and what life is about for them are the lens through which life is viewed, and these stories serve to shape the experiences that are had of life and relationships. Stories for example of conflict, fighting, blame, betrayal, distance, or disappointment have often become fixed and immutable as the sole understanding of those relationships and have left little room for shared

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understandings that are different to these dominant accounts. When a story takes hold it is experienced as the truth. Rather than collude with this single storied account, a Narrative approach is interested in people experiencing themselves as multistoried and as having more than the problem story through which to be defined. Michael White developed the practice of “externalizing” (White 2007; Morgan 2000) to separate the problem story out from the identities of the couple or family and to see the problem as something that is no longer intrinsic to the relationships. These externalizing lines of enquiry serve to make visible the ways in which a problem story has taken hold of the relationships and how the problem story is having unwarranted influence on the course of things. Through making this visible, it becomes possible for the couple or the family to begin to take back the influence from the problem and to determine which course of events would better fit for them. It becomes possible for alternative and preferred accounts of relationship or of being a family, that were previously cast in a shadow through the influence of the problem, to be brought forward. These preferred stories (White 2007; Russell and Carey 2004) of what is meaningful and precious in each person’s understandings of relationship or family can then be acknowledged and through further enquiry, be more richly described. The skills and know-how that each person brings to the relationship, or to being a family, can be storied and consideration given to how these skills and know-how might contribute to what could become. The Narrative approach is based in an appreciation that the therapist is not the expert on the family or couple’s experience or on the meanings that are being made. Instead the family or couple are seen as the experts and through practices of enquiry and curiosity, this expertise and “knowing what to do” can be brought forward.

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other therapies, the problem is located in the psychologies or characteristics or personalities of each individual. “Family dynamics” is a term that is often used to ascribe the location of the problem as being in the patterns of interaction in a family, or in individual personalities such as the “overprotective mother,” the “peace-keeper,” or the “scapegoat.” Narrative Therapy differs from these ways of thinking in that it locates the problem in the meanings people are making of their experience. These meanings are held and conveyed through the stories that people have about themselves, and essential to Narrative practice, is the understanding that meanings are always constituted relationally, in a context of cultural discourses, beliefs and practices (White and Epston 1990). Dominant and normalizing ideas of being a “couple” or of “family” are interrogated and the expectations and incitements of discourses, for example of being a “perfect” couple or a “perfect” family are examined and the social and cultural pressures and expectations exposed. When it is understood that people’s relationships with problems are shaped by history and culture, it is possible to explore how gender, race, culture, sexuality, class, and other relations of power have influenced the construction of the problem. By giving consideration to the politics involved in the shaping of identity, it becomes possible to enable new understandings of life that are influenced less by what the problem has to say and more by an awareness of how our lives are shaped by broader cultural stories. In this way, externalizing conversations put back into the realm of culture and history what was created in culture and history. This opens up a range of possibilities for action that are not available when problems are located within individuals.

The Practice of Externalizing The Location of the Problem In some therapies, the problem is explained as being located in “patterns” of interaction, for example, the “pursuer/distancer” pattern. In

Naming the Problem We’ve both changed, we’re not the same people we were when we got together, we’ve become distant and closed down. We can’t communicate any more and everything seems to end in an argument. The spark has gone out of the relationship.

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In order to shift the location of the problem from being experienced as internal to the relationship, we create, through language, a separation between the concern and the relationship. We begin to see the problem as something external that is impacting the relationship. Through the use of language the problem is changed from a description of the relationship (“our relationship has become distant, closed down, lacking a spark”) to something that is experienced as external. Rather than using descriptions or adjectives as accounts of the relationship, the practice of externalizing languages the problem as a noun (“This ‘Distance in the relationship’, what has made it possible for it to get so big?” “The closed-downness” of which you speak, are there times when it is not so effective in its efforts to keep you from talking? This “lack of spark” thing, what effect does it have on how you see each other? What does it try to talk you into about your partner?” Descriptions of what is problematic such as being distant, ambiguous, disappointed, betrayed, mistrustful, worried, ashamed, guilty, angry, stressed become externalized as “the distance,” “the ambiguity,” “the disappointment,” “the betrayal,” “the mistrust,” “the worry,” “the shame,” “the guilt,” “the anger,” “the stress.” This is more than a linguistic “trick” or “technique” and relies on the underlying principle of the social construction of meaning through the storying of experience. We are not born with these problem accounts of who we are, but rather they are constructed through social relations. Externalizing involves questioning the internalizing practices that are such a pervasive part of everyday life and that determine the location of the problem within persons and so can seem quite unfamiliar to begin with. It is not necessary for there to be only one externalized definition of the problem. In fact, when working with more than one person, it is quite likely that there will be more than one definition, and it can help in these instances to start with a broader naming of the problem in which each person is able to have their experience included. Families who seek out therapy are often in the grip of conflict, or things have “broken down” between them.

“We are always fighting over what they are allowed to do and what they are not, they argue with us constantly. They want to go out with their friends midweek and when we say no it always end up in tears. It feels like we are always fighting and arguing”.

Talking about the problem as “the conflict” or “the fighting and arguing thing” creates some distance from a sense of “we are the fighting and arguing family” as an account of the identity of the family, and that this is the only story of the family. Mapping the Effects and Consequences of the Problem on Different Areas of Life or Relationship Once problems are externalized, they can then start to be put into story lines through asking questions that reveal the effects and consequences on each of the members of the couple or family, and on the relationship itself (Russell and Carey 2004). “When did this ‘fighting and arguing thing’ get a hold of the family? What might have opened the door for the ‘fighting and arguing thing’ to come in?” Asking how long the problem has been an influence in the life of the relationship, when it took up residence and if there were factors that contributed to its entry is a useful starting point to have persons see that this has not always been the sole defining story of their family. Placing problems like ‘the distance’ or ‘the arguing and fighting thing’ into story lines can begin to throw some light on how the problem has come to have such a big influence on the relationship. It can also begin to provide the couple or the family with a lot of information and richer understandings of how they might be able to reclaim their relationship from the influence of the problem. Revealing the “Operations” or Tricks and Tactics of the Problem

When a problem is externalized, it also becomes possible to identify the particular practices that sustain this problem. For instance, if “the distance” has come to significantly affect a relationship, there is a good chance that particular

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practices such as judgment or criticism or blame have made this possible. Externalizing conversations about these particular practices can lead to increased understanding about their operation. Making visible how the problem operates can provide people with the skills and know-how with which to resist these operations. Taking a Position on the Effects of the Problem Once the problem has been explored in this way and the effects and consequences and operations made visible along with the social relational political context, there can be a chance for the couple or family to take a position on what the problem is doing. They can be asked to evaluate the effects and to decide if allowing the problem to continue in this way is in line with their preferences for relationship. An editorial summary is offered that captures all of the consequences and operations (tricks and tactics) of the problem, and questions are asked along the line of “When you look at all of this, how do you feel about what the distance is doing? Is this ok with you, or not ok, or perhaps a bit of both?” Finding What Is Given Value to That the Problem Is Getting in the Way of Through having some distance from the problem, it becomes possible to see that it is getting in the way of some things that the couple or family would prefer, and to which they give value and importance (White 2007). “What does this fit with or not fit with in terms of what you value in relationships? How does this work or not work for you in regard to what is important to you as a family?” Further enquiry can bring forth the story of these preferred ways of doing relationships or family, and the skills and know-how identified to be able to reclaim the relationship from the problem (Marsten et al. 2016). A sense of collaboration is made possible through this approach and space can be created for each person to make visible their own stories of relationship. Externalizing conversations don’t just focus on problems but can also be used in relation to positive internalized qualities (such as being

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respectful or empathic or open in a relationship). Because it is understood that being respectful and open is also a product of history and culture, questions can be asked about how this “openness and respect” has developed in the life of the relationship. “What are the practices of ‘respect and openness’? How do you go about ‘doing’ ‘respect and openness’? What has each person contributed to it; who are the people are who’d be least surprised to hear about it; what sustains it, and what particular problem-solving skills it may be linked to?” This process can make these qualities of being respectful and open, more meaningful and relevant to people in addressing the effects of problems in their lives. Asking questions about what other things this “respect and openness” stands for in each person’s life, what it means, and how it is linked to certain values and commitments and the histories of these values and commitments, will contribute in to an even richer and so more sustainable and available story. Narrative Therapy is founded on the understanding that it is the rich description of the alternative stories of people’s lives that provides people with more options for action and therefore enables significant changes to occur.

Cross-References ▶ Deconstruction in Narrative Couple and Family Therapy ▶ Deconstructive Listening in Couple and Family Therapy ▶ Narrative Couple Therapy ▶ Narrative Family Therapy ▶ Postmodernism in Couple and Family Therapy ▶ Poststructuralism in Couple and Family Therapy ▶ Problem-Saturated Stories in Narrative Couple and Family Therapy ▶ Re-authoring Teaching ▶ Social Construction and Therapeutic Practices ▶ Social Constructionism in Couple and Family Therapy ▶ Talk as Action in Couple and Family Therapy

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References Epston, D. (1998). Catching up with David Epston: A collection of narrative practice-based papers. Adelaide: Dulwich Centre Publications. Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York: Norton. Marsten, D., Epston, D., & Markham, L. (2016). Narrative therapy in wonderland. Connecting with children’s imaginative know-how. New York: Norton. Morgan, A. (2000). What is narrative therapy? An easy-toread introduction. Adelaide: Dulwich Centre Publications. Russell, S., & Carey, M. (2004). Narrative therapy: Responding to your questions. Adelaide: Dulwich Centre Publications. White, M. (2007). Maps of narrative practice. New York: Norton. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.

Extinction in Couple and Family Therapy Nicole Ortiz Clinical Psychology, California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA

Introduction Extinction is a behavioral technique that originated from principles of classical and operant conditioning. It is utilized in cognitive behavioral models of intervention for couple and families and is a major component of exposure therapy. It is utilized in order to reduce behaviors that have been reinforced by removing the agent that is reinforcing it.

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trails to complete. It is important to note that in the beginning of this process the undesirable behavior may increase, which is referred to as an extinction burst. Another potential temporary outcome of this process is spontaneous recovery, which involves extinction bursts that occur after an extended amount of time in which the undesirable behavior has not occurred (Dunsmoor et al. 2015). Additionally, contextual renewal may occur when the cues that were previously extinguished are encountered outside of the extinction context (Dunsmoor et al. 2015). It is imperative that clinicians remain consistent throughout treatment in order to counteract extinction bursts and to reduce undesirable behaviors should they return via spontaneous recovery. Extinction techniques take three different forms, which all decrease the targeted behavior over time (Lattal et al. 2013). The first is using extinction to target behaviors that have been maintained by positive reinforcement. The second is used to target behaviors that have been maintained by negative reinforcement (Lattal et al. 2013). The third is used to target behaviors maintained by automatic reinforcement (Lattal et al. 2013). In order for this technique to be effective, the clinician or client participating must not respond when the target behavior occurs. For example, in couple therapy, if one partner does not respond to the target behavior of the other partner, eventually the target behavior will decrease until it has become fully extinct. It is often used in family therapy to target disruptive or maladaptive behaviors of children and occurs when the other family members refrain from responding to the child’s behavior until the behavior eventually becomes extinct (Bitter 2014).

Theoretical Framework Description of the Strategy or Intervention This process occurs when a conditioned stimulus (CS) that was paired with an unconditioned stimulus (US) is presented on its own without the US (Lovibond 2004). This process occurs gradually and typically takes practice and multiple

This technique is utilized most in behavior and cognitive behavioral therapies (CBT) (Waters and Pine, 2016) and applied behavior analysis (Lattal, et al. 2013). While it is commonly used in work with children with developmental disabilities, it is also used to target a wide range of behavioral problems. In CBT it is used during exposure therapy, in which the therapist exposes the patient to

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the CS without the US until the behavior, typically a fear response, is extinct. In regard to the potential occurrences of spontaneous recovery and contextual renewal within the extinction process, it has been theorized that these occurrences may be adaptive (Dunsmoor et al. 2015). Thus, the memory of the fear evoked by the stimulus is not fully erased but stored for later in the event that it becomes a threat once again.

Rationale for the Strategy or Intervention Extinction has been empirically proven effective in treating an array of psychological disorders. Specifically, research has shown it is effective in treating obsessive compulsive disorder in adults and children (McGuire et al. 2016), specific phobias, anxiety (Neudeck and Wittchen, 2012), panic disorder (Lovibond 2004) and has also been used in the treatment of autism spectrum disorders (Kelly et al. 2015). In addition, it has been utilized to modify maladaptive or disruptive behaviors within social and interpersonal contexts. The goal in utilizing this technique in couple and family therapies is to guide the partners or family members to a place where they can identify and change their behaviors and ways of interacting and responding to each other in a safe environment.

Case Example Lauren and Adam presented to family therapy with both their children in order to address a behavioral problem they were experiencing with their younger child John. For the past few months, John (age 7) had been having tantrums when he was not allowed to stay up past his bedtime playing video games with his older brother Liam (age 12). When Lauren and Adam told John he needed to go to bed he began to cry and proceeded to have a tantrum until Lauren and Adam allowed him to stay up for an extra hour. Additionally, when this occurred, Liam would ask his parents to let John have a few more minutes to play. Liam’s actions as well as Lauren and Adam’s reinforced John’s behavior.

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Therefore, the goal of the family therapy work was to educate the family about the process of reinforcement of behaviors, and each of their roles in reinforcing John’s behavior. Next, the concept of extinction was introduced and a dialogue was opened with the family about how each of them felt they could effectively work together to help decrease this problem behavior. It was important that they each recognized their role in the extinction process, namely, not providing reinforcement for John’s behavior. Ultimately with the guidance of the therapist, the family was able to help John decrease this behavior and find more effective ways to communicate as a family.

Cross-References ▶ Cognitive Behavioral Couple Therapy ▶ Cognitive-Behavioral Family Therapy

References Bitter, J. R. (2014). Theory and Practice of Family Therapy and Counseling. S.1.: Brooks/Cole Cengage Learning. Dunsmoor, J. E., Niv, Y., Daw, N., & Phelps, E. A. (2015). Rethinking extinction. Neuron, 88(1), 47–63. Kelly, M. P., Leader, G., & Reed, P. (2015). Stimulus overselectivity and extinction-induced recovery of performance as a product of intellectual impairment and autism severity. Journal Of Autism And Developmental Disorders, 45(10), 3098–3106. Lattal, K. A., St. Peter, C., & Escobar, R. (2013). Operant extinction: Elimination and generation of behavior. In APA handbook of behavior analysis, Vol. 2: Translating principles into practice. (pp. 77–107). Washington, DC: American Psychological Association. Lovibond, P. F. (2004). Cognitive processes in extinction. Learning & Memory, 11(5), 495–500. McGuire, J. F., Orr, S. P., Wu, M. S., Lewin, A. B., Small, B. J., Phares, V., . . . Storch, E. A. (2016). Fear Conditioning and Extinction in Youth with Obsessive-Compulsive Disorder. Depression And Anxiety, 33(3), 229–237. Neudeck, P., & Wittchen, H. U. (eds). (2012). Exposure therapy: Rethinking the model – Refining the method. New York: Springer Science + Business Media. Waters, A. M., & Pine, D. S. (2016). Evaluating differences in Pavlovian fear acquisition and extinction as predictors of outcome from cognitive behavioural therapy for anxious children. Journal Of Child Psychology And Psychiatry, And Allied Disciplines, 57(7), 869–876.

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FACES IV David H. Olson Family Social Science, University of Minnesota, St. Paul, MN, USA

Name and Type of Measure The FACES IV is a family self-report measure with 6 scales and 42 items.

Synonyms The Circumplex Model; The Family Adaptability and Cohesion Evaluation Scales

Introduction FACES IV is the latest version of a family selfreport measure designed to assess family cohesion and family flexibility, which are the two central dimensions of the Circumplex Model* of Marital and Family Systems (Olson 2011). Previous selfreport assessments include three versions of the self-report measure called FACES I, II, and III (Family Adaptability and Cohesion Evaluation Scales*) and the observational assessment called the Clinical Rating Scale (CRS) (Olson 2000, Thomas and Olson 1993, Thomas and Lewis

1999). FACES IV is based on major studies by Dean Gorall (2002) and Judy Tiesel (1994) which were designed to improve the adequacy of the assessment and measure the full dimensions of cohesion and flexibility. More than 1200 published articles and dissertations have used a version of FACES and/or the Circumplex Model of Marital and Family System (Kouneski 2002) since the first version of the model was published (Olson et al. 1979). The model has also stimulated discussion and debate regarding family functioning generally and the cohesion and flexibility concepts specifically. The concepts have been defined in various ways, both conceptually and operationally, by researchers and theorists to include various aspects of family functioning (Barber and Buehler 1996; Doherty and Hovander 1990). The one constant across these discussions and debates has been the consensus on the importance of these two concepts in understanding couple and family systems.

Developers David Olson is the primary developer of a variety of assessments including AWARE for individuals, PREPARE-ENRICH for dating to married couples, a self-directed Couple Checkup for couples, and FACES for families. He has revised these and other assessments several times to improve their

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scientific rigor (i.e., reliability, validity, and national norms). These assessments have become popular both nationally and in over 25 other countries.

Description of Measure The FACES measure was developed to tap the full continuum of the cohesion and flexibility dimensions from the Circumplex Model of Marital and Family Systems. Six scales were developed, with two balanced scales and four unbalanced scales designed to tap low and high cohesion (disengaged and enmeshed) and flexibility (rigid and chaotic). The six scales in FACES IV were found to be reliable and valid (Olson 2011). Concurrent and discriminant validity was established (Olson 2008), and new ratio scores measure the balanced and unbalanced level of cohesion and flexibility (Olson 2011). More details on all aspects of FACES IV are contained in the FACES IV Manual (Olson 2008). The goals in developing FACES IV were as follows: 1. To develop self-report scales that tap the full dimensions (balanced and unbalanced) of cohesion and flexibility 2. To develop self-report scales that are reliable, valid, and clinically relevant 3. To develop a family assessment tool that is useful for research and clinical work with families Brief Overview of Circumplex Model. The Circumplex Model is comprised of three key concepts for understanding family functioning. Cohesion is defined as the emotional bonding that family members have toward one another. Family flexibility is defined as the quality and expression of leadership and organization, role relationship, and relationship rules and negotiations. Flexibility, as previously used in the model, was defined as the amount of change in family leadership, role relationships, and relationship rules. Communication is defined as the positive communication skills utilized in the couple or family system. The communication dimension is viewed as a

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facilitating dimension that helps families alter their levels of cohesion and flexibility. There are five levels of cohesion, and the three central ones are called balanced, ranging from “somewhat connected” to “connected” to “very connected.” The two unbalanced extremes on cohesion are “disengaged” (extremely low) and “chaotic” (extremely high). There are also five levels of flexibility, and the three central ones are balanced, ranging from “somewhat flexible” to “flexible” to “very flexible.” The two unbalanced extremes on flexibility are “rigid” (extremely low) and “chaotic” (extremely high) (Fig. 1). By combining the 5 levels of cohesion and 5 levels of flexibility, this creates 25 types of relationships. There are 9 balanced types, 4 unbalanced types, and 12 midrange types – where the relationship has unbalanced types on one dimension and balanced types on the other dimension. The main hypothesis of the Circumplex Model is: Balanced levels of cohesion and flexibility are most conducive to healthy couple and family functioning. Conversely, unbalanced levels of cohesion and flexibility (very low or very high levels) are associated with problematic couple and family functioning. This hypothesis has received strong support using both FACES and the Clinical Rating Scale (Kouneski 2002; Thomas and Lewis 1999). A second hypothesis is: Balanced couples and families will have better communication skills than Unbalanced relationship, and these skills help Balanced relationship maintain balance over time. Furthermore, poor communication skills are often considered part of the reason that unbalanced relationship stay stuck in more dysfunctional behavior. As a result, teaching couples and families more positive communication skills can be a useful first step in helping them develop a more balanced relationship. A third hypothesis is: If the normative expectation of a couple or family support behavior is more extreme on one or both dimensions, they will function well as long as other family members accept these expectations. This hypothesis is very important in applying the Circumplex Model to other cultures that have normative expectations that are more extreme on one or both of the dimensions. This is especially true

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FACES IV, Fig. 1 Circumplex Model and FACES IV

for cultural groups that encourage and support more extreme togetherness (enmeshment) and extremely low flexibility (rigidity). Assessing the Extremes of Cohesion and Flexibility. The cohesion and flexibility scales from FACES II and III have been consistently found to

have a linear relationship with healthy/unhealthy family functioning (Olson 2000). In addition, there were not distinct scales that measured the two unbalanced areas (extremes) areas of cohesion (disengaged and enmeshed) or flexibility (rigid and chaotic).

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Initial attempts with early versions of FACES IV were also not successful in assessing the full dimensions of cohesion and flexibility. One approach used a bipolar response format instead of a Likert response format, based on the suggestions of Pratt and Hansen (1987). The second approach was to use items based on the Clinical Rating Scale and have families rate themselves in much the same way they are rated by outside observers, based on the suggestions of Perosa and Perosa (1990). Both of these attempts yielded measures that were linear in relation to family functioning. A significant step in developing the current FACES IV instrument was a study by Tiesel (1994) in which she developed four unbalanced sub-scales aimed specifically at the low and high extremes of cohesion and flexibility. Items were developed by having 154 clinical members of the American Association for Marriage and Family Therapy (AAMFT) rate the degree to which they felt an item was representative of either cohesion or flexibility. Then they rated the item as falling into one of the four extremes. This work yielded four scales tapping the very low and very high levels of cohesion (disengaged and enmeshed) and flexibility (rigid and chaotic). These four scales were found to be reliable and valid and were able to discriminate between problem and non-problem families.

Using these four unbalanced scales, Craddock (2001) found support for the basic hypothesis that families with higher scores on these scales had higher levels of family stress and lower levels of satisfaction. Franklin et al. (2001) examined these same four scales using factor and correlational analysis, and their findings replicated the four scales. They found some cross-loading of items and a 0.60 correlation between the disengaged and chaotic scales and suggested further work on the independence of these two scales.

Psychometrics Reliability of the Six FACES IV Scales. Using a sample of 489 adults, the alpha reliability of the 6 scales was assessed (Olson 2011). The reliability of the two balanced scales of cohesion (.89) and flexibility (.84). For the four unbalanced scales, the reliability of the scales was disengaged (.87), enmeshed (.77), chaotic (.86), and rigid (.82). Discriminant Analysis of FACES IV Scales. To determine the ability of the FACES IV scales to distinguish between problem and non-problem family systems, a discriminant analysis was run for the FACES IV scales and validation (see Table 1). The

FACES IV, Table 1 Discriminant analysis of problem and non-problem families (Percent accuracy in discriminating groups)

Scale N for each group Unbalanced scales Disengaged Chaos Enmeshed Rigid Balanced scales Cohesion Flexibility Six scales together

Top vs. bottom 50% on SFI and FAD functioning Top = 199 Bottom = 192

Top vs. bottom 40% on SFI and FAD functioning Top = 142 Bottom = 149

Top vs. bottom 50% on family satisfaction Top = 231 Bottom = 228

Top vs. bottom 40% on family satisfaction Top = 211 Bottom =177

86

89

76

82

80 64 54

85 65 55

60 53 51

77 61 52

89 74 94

94 80 99

80 72 84

87 76 89

FACES IV

analysis demonstrates that using the four unbalanced scales, it is possible to discriminant between those high and low on family functioning and family satisfaction with high accuracy with the disengaged scale (.76–89) and chaos scales (.60–85). Less useful were the unbalanced scales of enmeshment (.53–.65) and rigid (.51–.55). The two balanced scales were very predictive: cohesion (.80–.94) and flexibility (.72–.80). The best were based on using all six scales together, and the range was very high (.84–.99). In summary, these analyses demonstrate the high discriminant validity of the FACES IV scales. Creating a Dimension Score for Cohesion and Flexibility from Six Scales. The dimensional scores for cohesion and flexibility are used for plotting the one location of the family onto the updated graphic representation of the Circumplex Model of Couple and Family Systems. In order to create a single score for cohesion and flexibility dimensions, the following formula was created. This dimension score is created by using the balanced score and adjusting it up or down the scale based on whether the difference in the two unbalanced scale is at the high or low of the dimension. Percentile scores are used for each scale, and they are based on the raw scores. The formulas are cohesion = balanced cohesion + (disengaged – enmeshed / 2) and flexibility = balanced flexibility + (rigid – chaotic / 2). So if the enmeshed score is higher than disengaged, then the balanced cohesion score is adjusted upward.

Example of Application in Couple and Family Therapy The FACES IV was implemented with a family where the presenting problem was significant emotional and behavioral problems exhibited by two children. Peggy and Doug are a married couple in their mid-30s who had three children, Alex (age 10), Sam (age 8), and Taylor (age 3). The couple began having trouble with emotional outbursts and oppositional behavior in both of their older children from an early age.

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They tried every different parenting approach they could imagine and read every book on handling difficult children. After being seen by a child psychiatrist, both Alex and Sam were diagnosed with an early onset of bipolar disorder. Medication was prescribed to aid in reducing the turbulence of the emotions and behavioral difficulties experienced by the brothers. In conjunction with psychiatric services, intensive family therapy services were instituted to assist the parents in adapting their parenting styles and approaches. At the same time, couple therapy was initiated when the therapists conducting the family therapy determined that significant couple conflict prevented the parents from cooperatively instituting any of the parenting approaches they had attempted in the past. FACES IV was administered to assess the particular strength and growth areas of the family. The scores on FACES IV from the two parents can be seen in the couple’s scores on the FACES IV profile and on the Circumplex Model (Figs. 2 and 3). Areas of difficulty for the family indicated by the FACES IV profile scores include low levels of “balanced cohesion” and high levels of the disengaged scale. The high levels of disengagement, particularly by the report of Peggy, and low levels of balanced cohesion indicate a lack of emotional closeness she feels in family. There were average scores on “balanced flexibility” but very high levels of chaos. The high level of chaos reported by the husband and wife was an indicator of problems with organization and leadership that the couple could not effectively provide. This was due to a combination of difficulties in their couple relationship and the overwhelming task of parenting two boys who did not seem to respond to any of their attempts at providing structure. Family Treatment and Post Assessment. Therapeutic work with the couple and family was guided by FACES IV results and clinical observations. Intervention focused on increasing the emotional bonding in the couple relationship to enable Doug and Peggy to more effectively function as a co-parenting unit. As the couple relationship improved over time, they also improved at reducing the chaos as they began to work more as a

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team. They implemented specific parenting techniques aimed at increasing structure and consistency in the home for the boys, as well as increasing the positive emotional connections between the parents and children. As illustrated in the FACES IV profile (Fig. 2), there was a moderate increase in balanced flexibility for both members of the couple, reflecting improvement in conflict resolution and negotiation in the couple relationship. There was a dramatic decrease in the chaos scores of both parents. This demonstrated an increase in the discipline and control exercised by the parents. There was also a positive increase in balanced cohesion and a dramatic drop in disengagement scores for both partners. Figure 3 provides a graphic summary of the changes on the dimension scores of cohesion and

flexibility at pre- and post-test for both partners. It clearly demonstrates that while Peggy was disengaged at pretest, she became more emotionally connected and that both described their relationship as more balanced in both cohesion and flexibility. In summary, this intake assessment and posttherapy assessment enables the therapist to see the progress in the therapeutic process. The initial assessment provided information on how the system is functioning and helped the therapist develop a treatment plan. The six scales in the FACES IV profile provide a picture of balanced and unbalanced scales as perceived by each family member. The post assessment demonstrated the progress as perceived by the family members.

100 90

90 87

80 76

74

70 67 65

Percentile

60

55

57 54

52

50

44

45

43

40 30

27

32 28

30

20

34 27

32

20

18 13

10

15

0 COHESION

FLEXIBILITY

DISENGAGED

BALANCED

ENMESHED

RIGID

UNBALANCED

(Higher Scores Healthier)

(Higher Scores Problematic)

Wife Pre

Wife Post

Husband Pre

Husband Post

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

CHAOTIC

FACES IV

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FACES IV, Fig. 3 Pre- and post-test of couple in therapy

Cross-References ▶ Circumplex Model of Marital and Family Systems, The ▶ Olson, David ▶ PREPARE/ENRICH

References Barber, B. K., & Buehler, C. (1996). Family cohesion and enmeshment: Different constructs, different effects. Journal of Marriage and the Family, 58, 433–441. Craddock, A. E. (2001). Relationships between family structure and family functioning: A test of Tiesel and

Olson’s revision of the circumplex model. Journal of Family Studies, 7, 29–39. Doherty, W. J., & Hovander, D. (1990). Why don’t family measures of cohesion and control behave the way they‘re supposed to? The American Journal of Family Therapy, 18, 5–18. Franklin, C., Streeter, C. L., & Springer, D. W. (2001). Validity of the FACES IV family assessment measure. Research on Social Work Practice, 5, 576–596. Gorall, D. M. (2002). FACES IV and the circumplex model of marital and family systems (Doctoral dissertation, University of Michigan). Dissertation Abstracts, 63. Kouneski, E. (2002). Circumplex model and FACES: Review of literature. Available online at: www.faces.IV.com Olson, D. H. (2000). Circumplex model of family system. Journal of Family Therapy, 22(2), 144–167.

1004 Olson, D. H. (2008). FACES IV manual. Roseville: PREPARE-ENRICH, LLC. Olson, D. H. (2011). FACES IV and the circumplex model: Validity study. Journal of Marital and Family Therapy, 3(1), 64–80. Olson, D. H., Sprenkle, D. H., & Russell, C. (1979). Circumplex model of marital and family systems: I. Cohesion and adaptability dimensions, family types, and clinical applications. Family Process, 18, 3–28. Perosa, L., & Perosa, S. (1990). The use of a bipolar item format for FACES IV: A reconsideration. Journal of Marital and Family Therapy, 16, 187–189. Pratt, D. M., & Hansen, J. C. (1987). A test of the curvilinear hypothesis with FACES II and III. Journal of Marital and Family Therapy, 13, 387–392. Thomas, V., & Lewis, R. A. (1999). Observational couple assessment. A cross-model comparison. Journal of Family Therapy, 21, 78–95. Thomas, V., & Olson, D. H. (1993). Problem families and the circumplex model: Observational assessment using the clinical rating scale (CRS). Journal of Marital and Family Therapy, 19, 159–175. Tiesel, J. W. (1994). Capturing family dynamics: The reliability and validity of FACES IV (Doctoral dissertation, University of Minnesota, 1994). Dissertation Abstracts International, 55, 3006.

Fair Fighting in Couple Therapy

Fair Fighting in Couple Therapy

identified a framework that carves out clear roles for the speaker, listener, and partnership in working toward managing conflict. The focus of the speaker-listener framework is to utilize techniques that harness skills to speak to each other in a meaningful and fair way that creates space for fair fighting.

Description Fair fighting includes active listening, gaining perspective, awareness of thoughts/words and body language, and taking a time out (Gottman et al. 1995). Unfair fighting consists of manipulation, abuse, name-calling, avoidance and blaming. Unfair fighting exacerbates and maintains active conflict, whereas fair fighting promotes conflict resolution. It is important to consider that some problems may arise because of cultural differences in styles of negotiating and handling conflict (Morris et al. 1998). Fighting is an acceptable way of getting what you want but most family members do not know how to do this effectively. It is important for the therapist to consider individuals’ expectations in these sessions.

Dara Winley, Elizabeth Adedokun and Jessica Chou Drexel University, Philadelphia, PA, USA

Application of Concept in Couple and Family Therapy Introduction Conflict is inevitable in couple relationships and the ability to do it in a healthy way can yield desired resolution for the partnership (Gurman et al. 2015).

Theoretical Context for Concept A crucial element to fair fighting is the ability to communicate among partners. Oftentimes, when conflict begins among a couple each person spends time attempting to prove their partner wrong (Gottman et al. 1995). Markman et al. (1998) have

Fair fighting is a concept crucial for conflict resolution and to aid couples in better understanding each other. The process of fighting often reveals more than the content of the argument; if done correctly and healthily, fair fighting can strengthen the partnership. Majority of couples attend therapy because of threats to the security and stability of their relationship (Johnson and Denton 2002). Helping couples identify and verbalize their unmet needs is a core change mechanism. A speaker-listener exercise can be employed where safety becomes the primary focus keeping in mind each partner’s vulnerabilities (Stanley et al. 1997). Once partners feel safe, the speaker and listener can create an agreement to treat one another with respect while fighting.

Fairness in Couples and Families

Clinical Example Rob, a 43-year-old Asian male, and Connie, a 41-year-old Asian female, sought couple therapy as they wanted to amicably separate and learn to co-parent their two children, Eric, 5 years old, and Sam, 7 years old. The couple report that they are still living together but plan to live separately in the near future. They tell the therapist that they rarely talk, and when they do, it is only to coordinate schedules for the children via text message. Additionally, Connie feels that Rob is constantly making comments to the children that puts her in a bad light and insists she is a bad mother. When Rob picked up Sam from school unexpectedly one day, Rob made sure to say that his mother “didn’t have the time” to pick him up. During the session, Connie continued to make remarks about Rob’s parenting skills and express that she feels he needs to be in individual therapy to work out his personal issues. The role of the therapist in this case is to guide the couple to feel understood by each other by slowing them down and giving them two roles: one as a listener and one as a speaker. The therapist assists the speaker in this case to speak for themselves, avoid mind reading, and keep conversation brief. For the listener, the therapist carefully guides them in paraphrasing what they heard the speaker say without rebutting. The therapist’s goal is to get the couple comfortable with the skills from this technique and eventually internalize this method in future conversations.

1005 Gurman & N. S. Jacobson (Eds.), Clinical handbook of couple therapy (pp. 221–250). New York: Guilford Press. Markman, H., Stanley, S., & Blumberg, S. L. (1998). Fighting for your marriage: Positive steps for preventing divorce and preserving a lasting love. Family Court Review, 36(1), 95–95. Morris, M. W., Williams, K. Y., Leung, K., Larrick, R., Mendoza, M. T., Bhatnagar, D., Jianfeng, L. M. K., JinLian, L., & Hu, J. C. (1998). Conflict management style: Accounting for cross-national differences. Journal of International Business Studies, 29(4), 729–747. Stanley, S. M., Markman, H. J., & Blumberg, S. L. (1997). The Speaker/listener technique. The Family Journal, 5(1), 82–83.

Fairness in Couples and Families Rashmi Gangamma1, Tatiana Glebova2 and Jennifer Coppola1 1 Syracuse University, Syracuse, NY, USA 2 Alliant International University – California School of Professional Psychology, Sacramento, CA, USA

Name of Concept Fairness

Synonyms Balance of give and take; Relational ethics

Cross-References ▶ Blamer Stance in Couples and Families

References Gottman, J., Gottman, J. M., & Silver, N. (1995). Why marriages succeed or fail: And how you can make yours last. New York: Simon and Schuster. Gurman, A. S., Lebow, J. L., & Snyder, D. K. (Eds.). (2015). Clinical handbook of couple therapy. New York: Guilford Publications. Johnson, S. M., & Denton, W. (2002). Emotionally focused couple therapy: Creating secure connections. In A. S.

Introduction Growing evidence in developmental and neuroscience research suggest that an intuitive sense of fairness and concern for others exists in infancy (e.g., Decety and Howard 2013). Fairness in relationships is an important concept and is sometimes described in terms of equity (e.g., Kuperminc et al. 2013). In this chapter we discuss fairness as a central construct of contextual therapy theory (Boszormenyi-Nagy and Krasner 1986) which is the only one that explicitly puts

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relational fairness or justice as a cornerstone of family relationships and well-being. Contextual therapy theory is an intergenerational, integrative, strengths-based theory whose hallmark feature is relational ethics* or balance of give and take* or fairness in relationships. Emerging research indicates that perceptions of fairness are related to indicators of health and well-being (Grames et al. 2008), as well as symptoms of depression and partner relationship satisfaction (Gangamma et al. 2015). The following sections examine the theoretical underpinnings of the concept and provide an example of application in couples’ therapy.

Theoretical Context for Concept Contextual therapy theory suggests that symptoms of individual and interpersonal ill health are related to unfair relational patterns where there is an imbalance in giving and receiving care and consideration (Boszormenyi-Nagy et al. 1991). The balance of give and take is dynamic and changes across the life span and stages. There are two types of relationships in regard to that balance: symmetrical and asymmetrical (Boszormenyi-Nagy and Krasner 1986). Symmetrical relationships exist among partners or friends and are based on expectations of equitable give and take. The caregiver-child relationship, in contrast, is inherently unequitable (asymmetrical), with the caregiver expected to give more to the child than vice versa. Fairness is an intergenerational concept; that is, experiences of fair relating in one’s family of origin influence experiences, expectations, and perceptions of fairness in partner relationships as well as future generations (Boszormenyi-Nagy and Spark 1984). The lack of due care in early relationships may lead to the development of unfair patterns where individuals either overgive (for instance, in the form of constant caring for another along with denial of one’s own care and needs) or over-receive (for instance, in the form of excessive expectation of being taken care of by another). Typically, as a result of unfair caregiverchild relationship, individuals may become

Fairness in Couples and Families

“parentified” (i.e., they are asked to take on adult-like relational responsibilities before being developmentally ready) and/or experience “loyalty conflicts” (i.e., they may be forced to either consciously or unconsciously choose between competing interests). The lack of due care in early life experience impacts levels of trust and may carry forward to the individual’s adult relationships with difficulties in either giving freely to and caring about the partner or receiving and acknowledging care from the partner. Contextual therapy acknowledges the influence of at least three generations in the experience of fair or balanced relating. However, it is essential to consider the context in which each generation lived in order to adequately assess its impact on current relationships. For instance, the current generation of adolescents, who have carried the burden of global terrorism, may have very different ideas of a “safe” society compared to their parents who probably were not as exposed to it as they are. Another example would be in the differences in gender role expectations over the years and its impact of perceptions of fairness. Societal expectations of what men and women can do in terms of gainful employment and parenting are evolving; this may result in discrepancies in intergenerational conceptions of fairness.

Description In order to comprehensively assess fairness in relationships, contextual therapy theory proposes its conceptualization within five interrelated dimensions (Ducommun-Nagy 2002): (a) facts, (b) individual psychology, (c) systemic transactions, (d) relational ethics, and (e) the ontic dimension. These dimensions provide a framework to understand experiences of fairness and develop interventions in therapy. Facts refer to actual events that occur during the course of one’s life such as birth, death, marriage, or divorce. For instance, parental infidelity could be a fact that influences not just how fairness is perceived in the parental relationship but also between the parent and child. Additionally, aspects of identity such as a person’s age, sex at

Fairness in Couples and Families

birth, national origin, race/ethnicity, ability status, and sexual orientation are considered facts that could influence experiences of fairness. Individuals who belong to traditionally oppressed groups due to their identities may face societal discrimination which may influence how balance in relationships is developed. Thus, processes of power, privilege, and oppression are also facts that impact how fairness is constructed. For instance, in a same-sex couple relationship, one partner may feel that the relationship is unfair if her partner is not as “out” as she is with family and friends. Being closeted may be tied to systemic and family processes of homophobia; however, it influences what may be perceived as fair in the interpersonal relationship. The dimension of individual psychology refers to cognitions, affect, perceptions, and experiences that vary from one individual to another. It is possible to incorporate concepts from other psychotherapy theories here in order to get a more comprehensive understanding of the relational system. For instance, in a couple relationship, we may note that one partner has a tendency to withdraw in the face of conflict, while the other person has a tendency to pursue. These differences could be indicators of coping mechanisms developed over time. These differences, however, impact how the couple perceives balance. In this example, the partner who pursues may believe that they do more in the relationship and that is unfair. It is important to keep in mind, however, that the individual factors are considered within the context of relationships. Thus, the term “individual” does not refer to a person in vacuum but to unique responses of the individual within the context of interpersonal relationships. The dimension of systemic transactions refers to patterns of interactions between members of a relationship and incorporates concepts from family systems theory (Whitchurch and Constantine 1993) such as hierarchies, boundaries, roles, rules, and triangles. For instance, a couple unable to manage anxiety in their relationship directly may pull in their child as a mediator to defuse it. This relational pattern of triangulation may result in the child shouldering the burden of parental anxiety, which can be considered unfair or

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imbalanced. Systemic concepts here help in understanding interactional processes underlying unfairness in relationships. In planning intervention for this relationship, the therapist may work to reduce unfairness for the child by attempting to establish clearer and healthy boundaries between parents and between the parents and child. Thus, family systemic concepts and techniques provide a blueprint for changing interactional patterns. The dimension of relational ethics is considered the hallmark feature of the contextual approach. Relational ethics are founded on the principle of equitability. It refers to concepts of trust, loyalty, and entitlement which influence justice and fairness in relationships and are transmitted through generations. Within the family context, it means every member is entitled to due consideration of their interests by others in the family (Boszormenyi-Nagy and Krasner 1986). A trusting, caring relationship with one’s caregivers lays the foundation for continued trustworthy interactions with others. Early experiences of violations of trust may result in difficulties in developing trustworthy and fair adult relationships (Hargrave and Pfitzer 2003). The difficulties arise not from an intent to cause harm to others but from one’s own lack of access to relational resources. For instance, growing up in an environment of abuse and exploitation, an individual may not develop the resources to be trustworthy in their partner relationship. This in turn may impact how much the individual is able to give to and receive from the partner. It is possible that the individual would demand more of the partner as a way of seeking compensation for something they did not receive in the earlier relationships, which may in turn contribute to an unfair relationship. Early experiences of unfair relationships with caregivers may also include loyalty conflicts. Loyalty refers to a deep sense of commitment that exists between parent and child due to the two legacies of parental accountability and filial indebtedness (Boszormenyi-Nagy et al. 1991). In intimate partner relationships, it refers to the commitment between partners who have merited trust due to their mutual concern and care. Problems may arise when the individual is forced to take sides.

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Loyalty conflicts can be seen in terms of split loyalty (i.e., being torn between two significant people) and/or invisible loyalty (i.e., an indirect allegiance that blocks loyalty in the most current relationship) and can be a major deterrent in interpersonal fairness and impact health and well-being. In some instances, the legacy of filial loyalty and existential debt to parents could set the stage for parentification of the child (Boszormenyi-Nagy and Krasner 1986). Parentification occurs when an individual is expected to take on adult roles prior to the appropriate developmental stage. For instance, when a 10-year-old daughter becomes the sole caregiver of an alcoholic parent, the daughter is taking on a role whose responsibilities far exceed her developmental capabilities. Parentification that is sustained and not adequately acknowledged can result in the daughter’s continued overgiving as a way of being in relationships. Symptoms may also develop due to invisible loyalties. Invisible loyalty is regarded as an indirect and often unintentional attempt to remain connected to the past. For instance, immigrant parents may continue to unconsciously adhere to familial practices from their home country while raising their children in the United States. Conflicts may arise if there is a discrepancy in their traditional familial practices versus those that their children are exposed to growing up in the United States. In this instance, children may experience their parental standards as unfair, while the immigrant parent may feel it is unfair that the children rebel against them despite all that they have sacrificed in their own lives. This sense of what one is owed in relationships is called entitlement, which takes two forms based on the actions of those in relationship (Boszormenyi-Nagy and Krasner 1986). Constructive entitlement is where an individual may expect to receive care in a relationship by actually caring for and giving to another. Constructive entitlement earned through balanced relating promotes fairness and justice. However, individuals could also earn destructive entitlement which perpetuates unjust relational patterns. Destructive entitlement, often a result of one’s experiences with imbalanced relationships, promotes repetitive and harmful behaviors toward themselves or others. For instance, an

Fairness in Couples and Families

individual’s sense of what one is owed in a partner relationship may be influenced by his emotional reactivity to a partner’s demands (individual psychology) or experiences of loyalty conflicts (relational ethics) as well as by processes of triangulation (systemic transaction) catalyzed by a parental divorce (fact). Finally, the fifth dimension, the ontic, refers to the core idea of contextual therapy that the self exists in relationships and existential meaning occurs in relationships with others. Genuine or meaningful connections are free of exploitation and include acknowledgment and validation of the self and other. For instance, a meaningful connection between partners could develop if they are able to see each other and connect with each other genuinely and not if they see each other as mere projections of their parents or others. Ontic care (Boszormenyi-Nagy and Krasner 1986) refers to active consideration of the context of fairness and justice in relationships. This was introduced as a separate dimension after much of the early formulations of the theory were developed (Ducommun-Nagy 2002). It is possible to conceptualize the ontic aspect of the existence of self in relationships as a fundamental assumption of the theory.

Application of Concept in Couple and Family Therapy Contextual therapy interventions and techniques are closely related to its theoretical principles. The idea of family of origin experiences affecting individual symptoms and interpersonal processes in partner relationships is well documented by other intergenerational family therapy theories (Bowen 1976). In contextual therapy, however, the focus of intergenerational work is to ensure the revolving slate of unfairness is stopped and a legacy of fair relating is passed on to the future generation (Hargrave and Pfitzer 2003). Working to exonerate those who have perpetuated unfairness in one’s family of origin could tremendously impact one’s capacity to more freely give and receive in current relationships. Contextual therapists strive to be accountable and fair to

Fairness in Couples and Families

everybody who may be potentially affected by therapeutic interventions through a technique called multidirected partiality or multilateral stance. Acknowledging the context in which unfairness was perpetuated (which may include caregivers’ own experiences of not receiving due care) sets the stage for this stance which allows space for due consideration of multiple, equally valid perspectives (Boszormenyi-Nagy and Krasner 1986; Krasner and Joyce 1995). Thus, the intention of working with one’s family of origin in contextual therapy is to promote rejunction or repair of relationships by viewing them as resources and not as avenues for blame. The therapist’s self is an important tool in contextual therapy. The practice of multidirected partiality and helping move clients toward a place of Martin Buber’s I-Thou stance (Friedman 1998; Fishbane 1998) requires understanding of issues related to fair give and take in the therapist’s own experiences. The I-Thou stance of dialogue is characterized by a willingness to hold both one’s own perspective and another’s and validation of one’s experience as well as acknowledgment of another’s. Boszormenyi-Nagy and Krasner (1986) suggest that a firm conviction in the importance of justice and fairness in relationships and a willingness to examine them in their lives are essential. This, along with the belief that there are multiple, valid perspectives of any situation, is important for a contextual therapist. The contextual therapist, therefore, examines their own entitlements in relationships and is prepared to work toward fair relationships in their lives.

Clinical Example *NOTE: All identifying information have been changed. Background Nancy and Tim are a biracial, heterosexual couple who have been married for 5 years and together for fifteen. Both are in their mid-50s. This is the second marriage for both and neither partner has children. Nancy is currently disabled and unable to work; she copes with chronic pain and other

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physical conditions that make her intensely afraid for her health in the future. Tim was laid off but recently found night shift work, but struggles with an injury that if left untreated may also render him disabled. The couple presented for therapy after arguments had escalated to verbal abuse and destruction of property by both partners. In sessions it was revealed that after an argument, Tim often left the house and did not return until the next morning, while Nancy would lock herself in her bedroom. The couple was not physically intimate and had not been for more than 1 year. Both disclosed drug and alcohol abuse earlier in life. Tim had relapsed 3 months prior to coming to therapy after being sober for 10 years. Most recently, the couple’s arguments centered around Tim’s relationships with his siblings and his “unfair” level of attention to them, as Nancy perceives it. However, both Tim and Nancy were quick to agree that the sisters were “bullies” and frequently devalued Tim by telling him he was “worthless” and “would not amount to anything,” This was reminiscent of messages from his parents who were both deceased. Nancy reported that she too received phone calls from the sisters calling her names and shaming her physical appearance. Nancy expressed intense anger toward Tim for wanting to buy one of the sisters a birthday gift and criticized him for betraying her, choosing his sibling over her and allowing her to be mistreated. Tim expressed defensiveness by explaining that Nancy is constantly attempting to control his interactions with his family and he simply wants the relationships to be peaceful. Nancy admitted to attacking Tim when she is angry, which escalates the argument, and Tim would react by either attacking or pulling away. Tim stated that he feels controlled and Nancy stated she feels abandoned. Additionally, Tim reported chronic physical abuse at the hands of his father who was an alcoholic. Tim’s mother did not intervene to protect him from the abuse, but made excuses for it. The sisters remained protected from the father as well. After years of being subjected to the abuse and effects of alcoholism, Tim described his mother as absent and that he was

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often left to care for his sisters. Nancy revealed emotional neglect and physical abuse by both of her parents and reported being scapegoated, while her older siblings were dubbed the “hero children.” Beginning in her teenage years, Nancy had a string of abusive relationships with men as she attempted to have her emotional needs met. Tim was the only person Nancy felt safe with. Conceptualization A contextual therapist would begin conceptualizing the case by understanding the complexities of the couple’s reality as put forth in the first four dimensions (facts, individual psychology, systemic transactions, and relational ethics). As a result, the therapist would have a sense for the couple’s feeling about what is fair and unfair to each in the relationship based on actions and accountability. In his family of origin, given the emotional and physical absence of his parents, Tim was parentified by being forced to care for his sisters. In overgiving to his sisters as an adult, he continued to participate in the intergenerational parentification that was established by his parents and the pull of invisible loyalty (or sense of obligation to them despite mistreatment by them). Tim was therefore blocked from giving freely to the welfare of the partner relationship, and trust/ trustworthiness eroded. The fear of being unworthy was also a legacy he carried with him in his conflict with Nancy, which precipitated his shutdown. Nancy had experienced chronic abandonment and abuse in her family of origin and as a result also lacked the resources to be trustworthy in the partner relationship. As such, building trust with Tim had been difficult as he too did not have a foundation of trustworthy interactions. As Nancy was not given due consideration in either family of origin or previous partner relationships, her quest for trust and availability in Tim may have been demanding more of him than he was able to give. These patterns from their families of origin influenced development of destructive entitlement where each partner, unable to see beyond their own pain, did not acknowledge and validate the other.

Fairness in Couples and Families

Interventions Using empathy and multidirected partiality, the contextual therapist gave equal weight to each partner as they stated their situation. The overarching treatment goal was to build the ability for crediting and acknowledging for each partner so that they could benefit from an increased sense of trust in each other and a more balanced relational ethics* ledger. To begin this process, the therapist acknowledged the stress that had been generated by the couple’s blocked give and take and the loyalty conflict. The therapist gently held both partners accountable for their destructive actions and for their lack of accountability to each other. Then, the therapist engaged the couple in understanding their respective intergenerational patterns, allowing space in sessions for them to begin the process of exoneration. Nancy was the first able to see her unfair treatment as a child as the result of her parents’ victimization and limited resources. She began to recognize the pattern that had been established in her intimate partnerships, and as the therapist modeled acknowledgment for the unfairness that had occurred, Nancy expressed her true vulnerabilities to Tim, who was able to witness qualities of Nancy’s genuine self. Tim, in turn, acknowledged the unfairness Nancy had experienced as well as his actions that had exploited the relationship. The therapist then gave Tim the opportunity to understand the violations of trust he had experienced with his parents in a different way, which allowed Nancy to understand and witness Tim’s vulnerability – a quality of his true self that was not readily expressed. The therapist highlighted the loyalty conflict that the couple was experiencing, which made it possible to talk about Tim’s need for his relationship with his siblings while at the same time holding Nancy’s perspective of needing an available partner. The therapist noted these actions as an unblocking of relational resources and moved the couple into a process of learning to credit each other for the contributions made to the relationship, including actions of care, trust, loyalty, respect, and love. The couple and therapist

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navigated this process by working through specific current needs where mutual giving and receiving could increase trustworthiness. Over time each partner was able to benefit from an increased sense of freedom to be their true selves with each other, and to enjoy giving and receiving to/from the other, which led to a restored level of trust and fairness.

Kuperminc, G. P., Wilkins, N. J., Jurkovic, G. J., & Perilla, J. L. (2013). Filial responsibility, perceived fairness, and psychological functioning of Latino youth from immigrant families. Journal of Family Psychology, 27(2), 173. https://doi.org/10.1037/a0031880. Whitchurch, G., & Constantine, L. (1993). Systems theory. In P. Boss, W. Doherty, R. LaRossa, W. Schumm, & S. Steinmetz (Eds.), Sourcebook of family theories and methods: A contextual approach (pp. 325–352). New York: Plenum Press.

References

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Boszormenyi-Nagy, I., & Krasner, B. (1986). Between give and take: A clinical guide to contextual therapy. New York: Brunner/Mazel. Boszormenyi-Nagy, I., & Spark, G. M. (1984). Invisible loyalties. New York: Brunner/Mazel. Boszormenyi-Nagy, I., Grunebaum, J., & Ulrich, D. (1991). Contextual therapy. In A. S. Gurman & D. Kniskern (Eds.), Handbook of family therapy: Volume II (pp. 200–238). New York: Brunner/Mazel. Bowen, M. (1976). Theory in the practice of psychotherapy. In P. J. Guerin (Ed.), Family therapy. New York: Gardner. Decety, J., & Howard, L. H. (2013). The role of affect in the neurodevelopment of morality. Child Development Perspectives, 7(1), 49–54. https://doi.org/10.1111/ cdep.12020. Ducommun-Nagy, C. (2002). Contextual therapy. In R. F. Massey & S. D. Massey (Eds.), Comprehensive handbook of psychotherapy (Vol. 3, pp. 463–488). New York: John Wiley & Sons. Fishbane, D. M. (1998). I, Thou, and we: A dialogic approach to couples therapy. Journal of Marital and Family Therapy, 24, 41–58. Friedman, M. (1998). Buber’s philosophy as the basis for dialogical psychotherapy and contextual therapy. Journal of Humanistic Psychology, 38, 25–40. https://doi. org/10.1177/00221678980381004. Gangamma, R., Bartle-Haring, S., Holowacz, E., Hartwell, E. E., & Glebova, T. (2015). Relational ethics, depressive symptoms, and relationship satisfaction in couples in therapy. Journal of Marital and Family Therapy, 41(3), 354–366. https://doi.org/10.1111/ jmft.12070. Grames, A. H., Miller, B. R., Robinson, W. D., Higgins, J. D., & Hinton, J. W. (2008). A test of contextual theory: The relationship among relational ethics, marital satisfaction, health problems, and depression. Contemporary Family Therapy, 30, 183–198. Hargrave, T. D., & Pfitzer, F. (2003). The new contextual therapy: Guiding the power of give and take. New York: Brunner-Routledge. Krasner, B. R., & Joyce, A. J. (1995). Truth, trust, and relationships: Healing interventions in contextual therapy. New York: Brunner/Mazel Publishers.

Froma Walsh Chicago Center for Family Health and Firestone Professor Emerita, The University of Chicago, Chicago, IL, USA

Celia Jaes Falicov, Ph.D., is a leading clinical scholar and trainer in the field of family therapy, at the forefront in addressing cultural aspects of mental health treatment and therapy with immigrant and Latino families. A licensed Clinical Psychologist, Dr. Falicov is Clinical Professor in the Department of Family Medicine and Public Health, University of California, San Diego, where she provides leadership of mental health services at the Baker Student Run Free Clinic. Her community-based work addresses the mental health care needs of underserved families, facilitates empowerment groups for Latino parents, and provides clinical training to integrate issues of migration and culture change in health and mental health risks and strengths in psychotherapy practice. Additionally, a Visiting Professor and Clinical Research Consultant, Cambridge Health Alliance and Health Disparities Unit, Harvard Medical School (2014–2015), she continues ongoing research collaboration. Dr. Falicov is internationally reknown for her MECA model (multisystemic ecological comparative approach), integrating cultural, developmental, and sociopolitical dimensions in work with transnational and immigrant families. She has developed numerous culturally attuned interventions that are used widely in professional training and research settings. Her seminal book Latino

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Families in Therapy (Falicov 2014a) is valued by students and practitioners for its lucid conceptual framework and richly illustrated practice applications. Dr. Falicov was an early pioneer in the integration of cultural and developmental perspectives in family therapy. Her article “Training to Think Culturally: A Multidimensional Approach” (Falicov 1995) became a classic in the field. She has also edited two influential volumes: Cultural Perspectives in Family Therapy (Falicov 1983) and Family Transitions: Continuity and Change over the Life Cycle (Falicov 1988). She also coedited the APA volume Multiculturalism and Diversity in Clinical Supervision: A Competency Based Approach (Falender et al. 2014). Her numerous publications on the topics of family transitions, migration, and cultural perspectives in working with families have received professional recognition, in particular, her widely cited article, “Working with Transnational Immigrants: Expanding Meanings of Family, Community, and Culture” (Falicov 2007). Dr. Falicov is a Past President of the American Family Therapy Academy (AFTA), and an AAMFT Fellow and Approved Supervisor. She has served on the advisory board of several major family therapy organizations and journals. She is a recipient of numerous professional awards for her leadership and distinguished contributions, including: American Psychological Association (APA) Presidential Citation; APA Division 43 Carolyn Attneave Award for Outstanding Work on Latino Family Psychology; American Family Therapy Academy Distinguished Contribution to Family Therapy Theory and Practice; American Association for Marriage and Family Therapy Significant Contribution to Family Therapy; and Groves Conference on Marriage and Family Sussman Award for work on the impact of globalization on family well-being. Celia Jaes Falicov was born and raised in Buenos Aires, Argentina, where she received her Certificate of Undergraduate Studies at the University of Buenos Aires. After immigration to the United States, she received an M.A. in Clinical Psychology at Loyola University in Chicago, Illinois, and her Ph.D. in Human Development at the

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University of Chicago (1971). She received a Postdoctoral Certificate at the Tavistock Clinic, School of Family Psychiatry and Community Psychodynamic Psychotherapy, in London, England. Additionally, she completed intensive training in family therapy at the Institute for Juvenile Research in Chicago and the Mental Research Institute, Brief Therapy Center, Palo Alto; and in Structural Family Therapy at the Philadelphia Child Guidance Center, where she developed a lifelong collegial relationship with Dr. Salvador Minuchin. In Chicago, in 1973, Dr. Falicov joined the clinical staff at the Institute for Juvenile Research, where she co-led development of family therapy training and supervision and became Director of the Family Systems Program in 1978. After moving to San Diego, California, with her family in 1980, she provided family therapy training and consultation in community agencies and joined the faculty at the University of California, San Diego (UCSD) Department of Psychiatry. Currently, in addition to her university position, professional writing, community work, and clinical practice, she is a highly regarded lecturer, trainer, and consultant nationally and worldwide.

References Falender, C. A., Shafranske, E. P., & Falicov, C. J. (2014). Multiculturalism and diversity in clinical supervision: A competency based approach. Washington, DC: American Psychological Association. Falicov, C. J. (Ed.). (1983). Cultural perspectives in family therapy. Rockville: Aspen. Falicov, C. J. (Ed.). (1988). Family transitions: Continuity and change over the life cycle. New York: Guilford Press. Falicov, C. J. (1995). Training to think culturally: A multidimensional comparative framework. Family Process, 34, 373–388. Falicov, C. J. (2007). Working with transnational immigrants: Expanding meanings of family, community and culture. Family Process, 46(2), 157–172. Falicov, C. J. (2014a). Latino families in therapy (2nd ed.). New York: Guilford Press. Falicov, C. J. (2014b). Psychotherapy and supervision as cultural encounters: The MECA framework. In C. A. Falender, E. P. Shafranske, & C. J. Falicov (Eds.), Multiculturalism and diversity in clinical supervision: A competency-based approach. Washington, DC: American Psyc