Handbook of Clinical Family Therapy

By Jay L. Lebow

The latest theory, research, and practice information for family therapy

The last twenty years have seen an explosion of new, innovative, and empirically supported therapeutic approaches for treating families. Mental health professionals working with families today apply a wide range of approaches to a variety of situations and clients using techniques based on their clinically and empirically proven effectiveness, their focus on specific individual and relational disorders, their applicability in various contexts, and their prominence in the field.

In this accessible and comprehensive text, each chapter covers specific problems, the theoretical and practical elements of the treatment approach, recommended intervention strategies, special considerations, supporting research, and clinical examples. The contributors provide step-by-step guidelines for implementing the approaches described and discuss particular issues that arise in different couple, family, and cultural contexts.

Handbook of Clinical Family Therapy covers treatment strategies for the most common problems encountered in family therapy, including:

• Domestic violence
• Adolescent defiance, anxiety, and depression
• Trauma-induced problems
• Stepfamily conflicts
• ADHD disruption
• Substance abuse in adults and adolescents
• Couple conflict and divorce
• Chronic illness

A detailed reference for today's best treatment strategies, the Handbook of Clinical Family Therapy brings together the top practitioners and scholars to produce an innovative and user-friendly guide for clinicians and students alike.

• Language: English
• Publisher: Wiley
• Release date: Jul 5, 2012
• ISBN: 9781118428863

Book preview

Preface

Edited volumes and texts that strive to represent the most prominent methods of family therapy have typically adhered to the same format since the earliest days of the field. Chapters typically each describe a similar core group of therapies: structural, strategic, Bowenian, behavioral, psychoanalytic, experiential, and so on. These ways of organizing the material present a fine historical view of the branches of development in the field of family therapy, yet also reify a structure for the field that reflects its earliest being rather than its evolution. Some of the approaches described in those volumes are almost never encountered today; a few are no longer even followed by their developers.

This volume looks to present approaches to family therapy in a much different manner. First, it presents prominent family therapy approaches without regard to fitting them into a structure of the first generation schools of family therapy. As I describe in the first chapter, today’s approaches typically assume an integrative stance rather than one based on the categorizations of the older schools. A generic core of strategies and interventions derived from the first generation of models serves as the basis for all of these therapies.

Second, the chapters in this volume are organized around the treatment of specific individual and relational difficulties. In recent years, the cutting edge of model development has moved away from universal theories of how families operate to a more limited focus on how to best operate in a more limited sphere. This volume follows that movement in emphasizing how to best use family therapy in the context of specific difficulties.

Yet, paradoxically, given this focus on specificity of approach, what emerges for the reader prepared to digest all of these approaches is the foundation for a generic family therapy (see Chapter 1). As the twenty-first century begins, family therapy is moving to include a widely accepted range of strategies and interventions that are useful across many specific contexts.

The approaches summarized in the chapters in this volume were chosen following a series of criteria. Approaches needed to focus on one or more specific disorders or relational difficulties. Some of these problems are the age-old Diagnostic and Statistical Manual (DSM) individual problems such as depression and Attention-Deficit Disorder, but equally important in this volume is the presentation of methods that aim at relational difficulties, such as couple distress or problems in family connection. Approaches also needed to be prominent and highly regarded. The approaches also needed to have at least some modicum of support through empirical and clinical testing and to be consistent with the emerging literature on families experiencing that type of specific difficulty. Because specific family therapies for many difficulties are still in the early stages of model development, the standard for evidence for the efficacy of approaches has been kept relatively low. The reader can judge the degree of support for each approach from the brief section in each chapter on empirical support.

In pursuing this method for the organization of this volume a few striking observations emerge. There are many well-developed family therapies for treating some difficulties, such as adolescent delinquency and substance abuse, and none for others, such as most of the anxiety disorders. We decided to make this a volume that tracked the best of family therapy, rather than one aimed to be comprehensive at the cost of including what were more preliminary efforts at developing an approach that were based mostly in musings about what might be effective. Therefore, there are four chapters in this volume describing a range of methods for intervening with acting-out adolescents and none dealing with Generalized Anxiety Disorder. In the next edition of this volume, we hope there will be approaches to fill in the gaps.

We included couple therapies as well as family therapies. Couple and family therapies are often intermixed in the treatment of specific difficulties. In some recent categorizations, couple therapy has begun to be split off from family therapy as a separate entity. Yet, the overlap in these methods far exceeds the differences. As the chapters on couple therapy for couple distress in this volume attest, the strategies and interventions utilized bear striking similarity to those in the family therapies.

We did not include special chapters on culture, social class, or sexual orientation. This decision was based on the desire to keep these issues in central focus in each chapter rather than have them segregated to a special section. Each author was asked to speak to issues of culture that have importance in his or her particular domain and how that therapy needs to be adapted in specific contexts.

The authors for this volume were asked to follow a specific outline, with instructions to include:

1. A description of the problem area that includes a brief statement describing the problem, its importance, and what is known about it.

2. The roots of the treatment approach that includes a brief description of the theoretical and practical roots of the treatment approach, with special attention focused on the relevance of couple and family intervention for the problem in focus.

3. Specific intervention strategies for treating this problem that includes providing a step-by-step guide that readers can use as a generic blueprint for treatment: how to utilize assessment, how to formulate treatment goals, what are viewed as curative factors, a specific description of the treatment strategies and how these strategies connect to the special nature of the presenting problem, how decisions are made about which interventions to employ and how to sequence these interventions, and typical issues that need to be addressed in the course of treatment and how to address those issues.

4. Special considerations in the treatment of this problem, including any aspects of the treatment approach that require special attention.

5. Research evidence supporting the approach, including a paragraph or two that provide a sense of how much evidence there is about the efficacy and effectiveness of the approach and any important process data about it.

6. A clinical example, including a brief example of how the treatment is implemented.

And authors were given the following additional directions:

Think of your core reader as a professional in practice or an advanced clinical graduate student or professional.

Describe the special aspects of the problem area on which you are focusing and the unique aspects of couples and families in this domain. What are the key aspects of these relationship systems that need to be addressed?

As you describe the treatment, be sure to accentuate the aspects of your approach that especially are connected to treatment of those with this particular difficulty. For example, establishing a strong therapeutic alliance probably will be an important aspect in every treatment covered in the volume, but it will be more valuable to speak to the special issues in establishing alliances in the domain you are addressing than to describe generic methods of establishing treatment alliances. What special mediating and ultimate goals and methods of accomplishing those goals need to be highlighted in couples/families in the domain you are addressing?

If the method you are describing involves both individual and couple/family therapy interventions, accentuate the couple/family aspects of the treatment, providing a brief summary of the individual-focused methods.

Emphasize what specifically is done in treatment.

Research relevant to the approach should be presented in a brief section in a manner that will be understandable by the typical clinician.

I believe this volume conveys the excitement of the new family therapy that is emerging. This therapy is no longer a radical opponent to other approaches, but instead is a fairly well-established, mature set of intervention strategies that are dependable and effective, and are increasingly simply a well-established part of good practice. In bringing these approaches together in this book, I hope this volume can serve to further the movement to a widely disseminated, evidence-based generic family therapy that families can count on wherever they are located and whoever they see.

Finally, I’d like to thank Patricia Rossi, Jennifer Simon, Isabel Pratt, and Peggy Alexander at John Wiley and Sons and Becca Uhlers, Jane Kinsman, Danielle Shannon, Michelle Factor, and Jennifer Nastasi at the Family Institute at Northwestern University for their help with preparing the manuscript.

Jay Lebow, PhD

Chapter 1

Family Therapy at the Beginning of the Twenty-first Century

Jay L. Lebow

This volume marks a watershed in the development of couple and family therapy. We have entered an era in which the most prominent models of practice no longer primarily accentuate disparate, broad visions of how families operate and how people change, as they did a generation ago, but instead draw from a core set of well-established strategies to create pragmatic, effective ways of working with specific difficulties and life situations. In the newest generation of family therapies, generic family-based strategies of intervention are shaped to most successfully fit and impact on the specific clinical context.

Today’s state-of-the-art methods in couple and family therapy, although diverse in their specific focus and their particular blueprint for intervention, share many core attributes. A number of transcendent core characteristics readily emerge from deconstructing the ingredients of the kinds of twenty-first-century family therapies exemplified in this volume. These core characteristics are summarized in the following sections.

SYSTEMIC FOCUS

Today’s state-of-the-art methods have a systemic focus. Drawing upon the preeminent core concept of the early family therapy movement (Haley, 1963), these approaches accentuate the importance of understanding the family as a system and the core properties of such social systems. Systemic concepts are apparent in the fabric of these approaches, manifested in such aspects as the significance assigned to mutual ongoing influence, the view that the whole is more than the sum of its parts, the importance assigned to feedback in interpersonal process, and the power of the dueling forces moving toward homeostasis and morphogenesis.

However, it is very much a twenty-first-century version of systems theory that is evident in these approaches, rather than earlier variants of systems theory that were more closely linked to the properties of inanimate systems. In this newer view of social systems, families are seen as more than simply the product of inevitable systemic forces. This systems theory allows room for understandings of causal processes, for the differential impact of different individuals on the mutual systemic process, for influences on the system that reside within the inner selves of individuals, and for the impact of the larger system on the family.

Within such a framework, pathways of mutual influence move well beyond the idealized, circular causality that was posited to be at work in an earlier generation of family therapies (Bowen, 1966; Whitaker, 1992). Following the core insight first presented by Virginia Goldner (Goldner, 1998) in the context of examining couple violence, this includes an understanding that sometimes one person’s influence is greater than another’s on their mutual process, even though the action of each has some impact. As Goldner (1998) suggested, patterns of couple violence may show circular arcs of influence, but typically the individual personality of the abuser has much more impact on the initiation and continuation of abuse than that of the abused partner. This viewpoint provides a crucial example of the refinement of the systems theory that has occurred in light of the pragmatic knowledge gained from a half century of clinical experience and research. There are few findings in the social sciences as well demonstrated as the mutual influence of family and individual behavior (Snyder & Whisman; 2003; Pinsof & Lebow, 2005), but this mutual influence is mediated and moderated by numerous factors. The simplistic application of systems theory derived from observations primarily about inanimate objects and animals has been refined in the context of observations and research about the properties of human systems.

BIOBEHAVIORAL-PSYCHOSOCIAL FOUNDATION

These approaches have a biobehavioral-psychosocial underpinning. Social systems exert influence, but are not the only factors in the lives of individuals. Whereas early family-therapy models eschewed individual psychology (the biological basis of behavior, social psychology, and principles of learning), most of the emerging models embrace these sets of ideas.

The last few decades have been a time in which the biological basis of behavior has come to be well established. In the earliest versions of family systems therapies, notions of a biological basis were dismissed for even the most severe problems in individual functioning, such as schizophrenia or Bipolar Disorder (Haley, 1997). In that era, leaders in the field of family therapy mustered strong arguments against the primitive biological theories of the time (which had little basis in evidence) as part of their argument for the supremacy of a systemic viewpoint. These arguments were the systemic equivalent of Watson’s landmark statement of behaviorism, denying biology any significant role in the development of mental health or pathology.

However, a generation of investigation has very much changed this picture. Although biological theories of the origins of behavior are still often grossly overstated and reductionistic, the impact of biology on individual functioning and on family processes is now well established. Biology has been demonstrated to affect the genesis and development of many specific behavioral patterns and disorders (see, for example, the chapters in this volume by McFarland and Wells) and has become incorporated as a factor to assess and deal with in many of today’s state-of-the-art models. The emerging bodies of knowledge in biology, genetics, and neuroscience influence the most recent models of family intervention in a multitude of ways. These include: suggesting risk factors to mitigate through intervention, as in the treatments designed to reduce expressed emotion in the treatment of families with members with severe mental illness (e.g., see the chapter by McFarland in this volume), suggesting solutions such as medication, as in the use of stimulants as part of the treatment of Attention-Deficit Disorder in children (see the chapter by Wells in this volume), suggesting ways of helping families understand syndromes through psychoeducation, such as in the treatment of schizophrenia and Bipolar Disorder (see the chapter by McFarland in this volume), and suggesting ways of coping with problematic states of autonomic arousal in processes such as couple conflict (see the chapters by Wooley, Johnson, and B. Baucom, Christensen, & Yi in this volume). The importance of understanding and responding to the biological basis of behavior is most apparent in those treatments dealing with psychological disorders with the strongest biological bases for disorder (e.g., those dealing with severe mental illness and Attention-Deficit Disorder), but also is apparent across a wide range of difficulties, including medical disorders such as juvenile diabetes and congestive heart failure, and even in everyday normal couple and family process. It’s also notable that when Minuchin and colleagues wrote Psychosomatic Families (Minuchin, Rosman, & Baker, 1978), the focus at that time in the interface between biology and family was on the influence of family on biology; today’s approaches are as likely to work with the important understandings from the biology of such diseases as juvenile diabetes (e.g., see the chapter in this volume by Pisani & McDaniel).

Behavioral and social psychological understandings have also become well established and integrated into the majority of these models. The last 20 years has seen the emergence of a far better grasp of the patterns of learning and of social exchange that occur in families, and how they impact on family process. Classical conditioning, operant conditioning, modeling, covert processes of learning, and social psychological principles of exchange have all clearly emerged as central processes in shaping the lives of family members. And the understandings of the importance of these processes has led to the development of numerous interventions that draw on behavioral and social psychological principles that have been proven to have considerable impact. Technologies for helping with specific interpersonal skill sets in couples and families, such as communication, intimacy, problem solving, and social exchange, that have been part of clinical practice for many years, have been refined and augmented. These intervention strategies stand as key ingredients in almost all of the state-of-the-art methods in family therapy.

Individual psychological process is also a focus for intervention in most of these approaches. Cognition and affect are crucial human processes and powerfully impact on each of the various difficulties addressed in this volume. As a result, cognitive and affect-focused interventions are typically part of today’s state-of-the-art approaches. Numerous approaches accentuate working with cognitions through examining thoughts (e.g., see the chapter in this volume by B. Baucom, Christensen, & Yi) and several prominent approaches (e.g., see the chapters in this volume by Wooley, Johnson, and Diamond) focus on methods centered on processing affect. And whereas traditional psychodynamic viewpoints are encountered less often today than a generation ago, the essential core psychodynamic notions of the importance of working through individual past history and inner conflicts, and of establishing working alliances with all family members, can be found in most approaches (e.g., see the chapter by Fishbane).

Applying Generic Strategies of Change

Although the technology for approaching problems grows and becomes more refined each year, paradoxically most of the state-of-the-art methods in family therapy today draw from the same generic set of methods. Although the theoretical lens focusing across these approaches and the language for describing the methods for intervention may vary, almost all of these approaches include strategies that work with family structure; strategies that are based on behavioral principles of learning, exchange, and task assignment; strategies that work with cognitions, narratives, or attributions; strategies based in psychoeducation; strategies for working with affect; and strategies for working with meaning. The specific interventions utilized to carry out these strategies similarly draw from a generic catalog of interventions.

Accenting Broad Curative Factors

Today’s state-of-the-art approaches don’t simply accentuate technique, but also emphasize the creation of the so-called non-specific conditions for change in psychotherapy. Almost all of these approaches emphasize such factors as enabling client engagement, building alliances with each family member, and the creation of hope and positive expectations for change. Almost without exception, these approaches look to build strong treatment alliances as a key ingredient in treatment. A transcendent understanding has emerged—treatments can only be as effective as they are able to engage clients. Some of these approaches, such as Brief Strategic Family Therapy, described in this volume by Horigian and colleagues, and the Outcome-Informed approach of Miller and colleagues center a considerable part of their methods on alliance building, and have offered significant refinements in creating alliances. Clearly, couple and family therapies can only be effective if alliances can be created and maintained that enable participation in therapy.

Shaping Strategies Relative to Specific Difficulties

Another core characteristic of these approaches is that they shape strategies of change in relation to the core difficulty or life issue that is in focus. Increasingly, family approaches are grounded in the ecological nexus of the problem area to which they are addressed. Although these methods build from a generic set of strategies and techniques, those strategies and techniques are adapted in relation to the knowledge available about the particular problem area. For example, although psychoeducation is an important intervention in many of the therapies described in this volume, the specific focus of psychoeducation and the content of that psychoeducation will vary with the problem. And, so will the expected affective states likely to be encountered, the behavioral skills likely to be deficient and useful to augment, the most typical problems with family structure and the most useful interventions for working with that structure, and the most helpful cognitive formulations, potential narratives, and reframes. The present state-of-the-art methods of intervention have developed following idiosyncratic pathways, but in almost every instance these models have evolved out of some sort of dialectic between a broad conceptual framework and the pragmatics of working with a particular focal problem.

Labeling Problems

In today’s state-of-the-art approaches, problems are labeled as problems, but sensitivity is maintained regarding the social meaning of labels. The early models of family therapy largely took an ideological stand against the existence of individual problems. In the wake of the version of systems theory then popular, clients with difficulties were seen as identified patients, that is, the carrier of the symptoms of the problem for the system (Minuchin, 1974; Whitaker, 1992). Today’s approaches almost never speak of an identified patient. Instead, the individual or individuals who bear problems are viewed as having an individual difficulty, even if there is some basis for that problem in the social system (e.g., see Gupta, Beach, & Coyne’s discussion of depression in the context of marital difficulty in this volume). And yet today’s state-of-the-art approaches strongly emphasize the context for the generation and maintenance of difficulty, and make considerable effort to limit the possibly deleterious effects of the labeling of individual difficulties through a careful use of language and a nonjudgmental and sympathetic view of problems. Thus, diagnosis has a role in these approaches, but it is a kinder, gentler diagnosis.

Building on Empirical Foundations

Today’s state-of-the-art strategies of change are based in empirical knowledge about families and the problem area in focus, and empirically testing the efficacy of the approach to intervention. Today’s state-of-the-art methods are anchored in the empirical knowledge available about family processes, individual development, individual personality and psychopathology, and about the particular life circumstance around which the approach has been honed. These approaches are heir to several decades of research assessing broadly applicable principles of family and individual process and assessing those family and individual processes in the context of specific life circumstances. And, almost all of the state-of-the-art models in family therapy are the product of a honing of these methods through clinical and research testing, and are in the process of being clinically tested.

Perhaps the most prominent finding that serves as the foundation for these methods is the now very well-established relationship between family functioning and individual functioning, cited in almost every chapter of this volume—one of the most replicated findings in psychological research. Yet, the body of findings that provides the basis for these methods moves well beyond those documenting this simple relationship. We are now heir to a great deal of prominent research that describes the complex relationships within families in the context of various relational difficulties, life transitions, and individual disorders. This research has informed today’s approaches about the typical ways problems develop, the ways problems are maintained, and the pathways that distinguish movement toward greater difficulty or resilience. As an example, the various approaches to the treatment of adolescent delinquency, substance use disorder, and other acting out delineated in this volume are the heir to the complex understandings of such processes developed by Paterson and others over three decades (Dishion & Patterson, 1999).

Today’s state-of-the-art approaches are far from simplistic renditions of the old syllogism that all individual problems must be rooted in family difficulty. Instead, reflecting the contemporary understanding of these issues, families are primarily seen as potential resources for helping with problems and developmental challenges, rather than as the cause of these problems. And, the specific mechanisms that have been identified in the basic research on couple and families often have become the focus for intervention, be those mechanisms parental monitoring of child behavior, parental structure, parental depression, couple attachment, or couple communication.

It is also becoming clear that for treatment approaches to make claims for effectiveness, these approaches must be demonstrated to be efficacious through empirical testing. Most of the approaches in this volume have a strong base of empirical testing that not only demonstrates efficacy but has allowed for the rehaping of methods in relation to the data that emerge. In summary, the evidence offered for the impact of couple and family approaches in relation to a wide range of specific individual and relational difficulties points to the considerable evidence for their impact for couple and family therapy (Sprenkle, 2002).

Today’s family therapy can be more scientific because of the emergence of a true science of couple and family relationships. Research now has vital implications for practice, which it did not have a generation ago. Striking developments in the world of research have important implications for methods of practice. The sources of this change include:

1. An increase in the volume of research. The quantity of research in family psychology has vastly expanded over the last 20 years. Whereas earlier there were very few findings in family psychology that were well established enough to affect intervention, there are innumerable, highly usable findings that can help guide clinical practice and public policy.

2. More research on both broad aspects of family process and on specific disorders and/or problems. There is one tradition in family research that begins with the family and another that begins with the individual. In the former, the primary focus is on a family process (for example, cohesion) and its effect in the individual. In the latter, the research is anchored in an individual issue or problem, such as depression, and family variables are examined in relation to that problem. What we see in current research is a coming together of the two approaches. Whether the figure is the individual or the family, the same family processes are now studied, typically utilizing similar methodologies, and the findings about the relationship between the individual and the family are remarkably consistent.

3. A general acceptance of the power of the circular relationship between family process and individual functioning. In every area of investigation, the importance of the relationship between family process and individual functioning has become well established. If there was a clinical trial about whether the family and the individual affect one another powerfully in their ongoing mutual influence, that trial could be stopped, since the findings so consistently point in this direction.

4. Attention to the importance of other systems. Early research in families ignored systems other than the family. Today’s research considers the impact of a range of systems, including peers and aspects of the macrosystem in which the family is situated.

5. Much-improved methodology. Perhaps the most marked change in research relevant to couple and family therapy is the vast improvement in the technology in the research. Family research has now been underway for over 40 years, and with that time span have come the development of the infrastructure of instruments and methods (and, one might add, investigators) that could speak to the complexities involved in this research. Measures take many years to develop and refine. The breadth of investigation in family psychology now provides numerous measures and procedures for assessing complex family processes. And, the technology for studying interpersonal process and for the complex statistical analyses needed for studying sequential processes have vastly improved over that time.

6. Multimethod research. The research in family psychology has moved more and more to a multitrait multimethod matrix. It is no longer unusual for a range of methods to be utilized in a single study with a range of focuses, some on the individual and some on the family. Quantitative and sophisticated qualitative methods are also mixed readily. For example, in Gottman’s landmark research (Gottman, 1994) on couples, complex analyses of couples’ behaviors are derived from ratings of interactions, augmented with physiological measures and a qualitative life history taken from the subjects.

7. Patience. Some aspects of family process can only be studied over time and, unfortunately (unlike fruit flies), generations of families require over 15 years (and sometimes over 40!). Research in family psychology now has the good fortune to begin to benefit from the information from longitudinal studies conducted over generations. Studies like those of the Oregon Social Learning group, led by Gerald Patterson, have now been ongoing for 40 years (Patterson & Fagot, 1967).

8. Increasing links between process research and treatment research. There was a time when the questions about family process bore little relation to the questions asked in treatment research. Today, in contrast, we see far greater linkage. The processes that evolve in research on families become the focus of treatment, and the treatment research informs the family process as well. As an example, Gupta, Beach, and Coyne’s chapter in this volume highlights how research suggesting the linkage between depression and family process has crucial meaning for treatment development, and how treatment research that is conducted feeds back into the base of information about this problematic constellation.

9. Research grounded in theory. Research does not occur in a vacuum. The best research is anchored in relation to theory. Although there have always been theories about the essential processes in families, the development of theories grounded in empirical findings requires the iteration between theory and research that only can occur over time. Early in the history of family therapy, numerous theories were suggested. Some of them have turned out to be entirely wrong, such as the double bind theory of schizophrenia (Bateson, Jackson, Haley, & Weakland, 1956) or the psychosomatic family theory stated by Minuchin and colleagues (Minuchin, Rosman, & Baker, 1978), while others have emerged as remarkably accurate, such as Minuchin’s theory of family structure (Minuchin, 1974). At this time, we are seeing the blossoming of theories grounded in research that can help guide treatment development.

10. An awareness of cultural diversity. The issue of external validity was once the Achilles’ heel in family research. Findings would be presented and conclusions drawn, only to be followed by the belated understanding that the subjects in the research were all middle-class caucasian-Americans, severely truncating the meaning of the conclusions drawn. Issues around the generalizability of findings remain. Funds are often limited for research and study samples are small. But we are at least seeing a broad acknowledgment of the problem, and we are seeing many more efforts to examine processes in diverse populations.

11. A focus on prevention. Research that identifies family processes related to the emergence of difficulties easily translates into mandates for programs designed to ameliorate these processes. We’ve seen the emergence of many such programs, and the research emerging from prevention programs has contributed to the knowledge base about intervention.

Maintaining A Multisystemic Focus

Drawing on the term Henggeller (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) uses to describe his specific approach, today’s state-of-the-art strategies maintain a multisystemic focus. Instead of centering only on the family, these approaches extend their view to other systems as well, and to a range of system levels: individual, couple or other dyad, nuclear family, multigenerational family, and macrosystems, such as schools and community. Intervention typically focuses on multiple levels, and sometimes the family is not the principal focus for intervention. And yet these are family approaches. Family intervention is in the fabric of each method of intervention, and in most cases the family is the principal vehicle for the change process.

Maintaining a Realistic Frame

These approaches build a realistic frame for the change process. Some approaches to psychotherapy are highly optimistic, suggesting that change is a simple, easy process. Other approaches are more pessimistic, emphasizing the difficulties in changing deeply rooted problems. The earliest family therapies were accompanied by strong statements about the power of homeostasis, incumbent in the system, to derail the change process (Haley, 1963). Later versions of systems theory grafted the more optimistic core of humanistic therapy to family treatment. This generation of approaches finds a midpoint, able to both recognize the difficulty in changing some conditions (e.g., marital distress, major mental illness, adolescent substance abuse), yet possess the optimism that change can occur, given an effective approach.

Enhancing the Durability of Change

Today’s state-of-the-art approaches emphasize concern about achieving lasting change. Family approaches have proven to be highly effective, but, like all other approaches in mental health treatment, have been shown to have difficulties in the maintenance of such a change over time (Lebow & Gurman, 1995). The kinds of approaches summarized in this volume typically build on this understanding, looking for ways to actively work to maintain change. Often, processes intended to maintain treatment gains by setting tasks for the time after termination are invoked to reduce recidivism.

Length of Treatment

Almost invariably, today’s state-of-the-art treatments are time limited. As Alan Gurman has noted, family therapy is by its nature a short-term therapy, given the need for multiple family members to make themselves available for treatment over time (Gurman, 2001). Yet, these therapies are also a far cry from the talk of one- or two-session cures of a generation ago. Most of these therapies look to a time frame of 3 to 12 months for intervention. And in the face of severe problems, some therapies, in order to achieve their goals, are enormously intensive (e.g., Multisystemic Therapy), while others look to ways to structure client engagement that promote continuing self-help over longer periods (as in the multifamily groups described in this volume by McFarland).

Stages of Change

Another frequent theme in these approaches is working with some notion of client readiness to change. Clients differ in many ways; one of the most important is where they are in what Prochaska and DiClemente have termed stages of change (Prochaska, Norcross, & DiClemente, 1995). Prochaska and colleagues differentiate those who didn’t realize they had a problem (in precontemplation), those who realized they had a problem but were not yet ready to do something about it (in contemplation), those who were actively trying to change (in action), and those working to keep the changes they had already undergone (in maintenance). Although some of the approaches in this volume explicitly refer to Prochaska and DiClemente’s stages while others do not, most of these approaches share an implicit focus to look to different ways to intervene with people at different points along this continuum.

Mixing Individual, Couple, and Family Session Formats

Today’s cutting-edge methods mix individual, couple, and family session formats. Twenty-first-century approaches are highly pragmatic in defining who is seen in treatment at various points. Whereas earlier generations of therapy reified certain formats for therapy as the most useful therapy format, with some family therapists even refusing to see subsystems when the whole family was not available (Whitaker & Napier, 1977), contemporary approaches mostly mix session formats, accentuating the best use of various formats for various kinds of work. Paired with this mix are both pragmatic and ethical understandings of the meanings of mixing session formats, so as to reduce the likelihood of iatrogenic effects of such blends.

A More Limited Worldview

These approaches, although based solidly on evidence, tend to be more humble than their progenitors and to have a less grandiose worldview. The modernist concept of one solution for all has been replaced with the more limited notion of working at problem areas and life difficulties and achieving growth. The specter of those clients for whom goals remain unmet, despite the best efforts of the therapist, remains omnipresent, leading to a greater awareness of the difficulties in the task at hand.

Understanding and Building on Personal Narratives

Twenty-first-century family therapies have moved beyond the vision of the family as an entity to include a focus on understanding the individual narratives of family members and to ensure that all members of the family can be heard. Some of this thread in family therapy emerges from the strong postmodern influence in the field, but as much can be traced to simple pragmatics; if family members don’t feel heard, they don’t engage in strong alliances, or do as well in achieving treatment goals (see, for example, the chapters in this volume by Fishbane and Becvar).

Utilizing Solution-Oriented Language

Solution-oriented language and reframes that help family members more readily accept directives and that diminish resistance to change are almost universally included in these approaches. The product of generations of research in social psychology and clinical experience with families, such framings help increase client motivation to change and increase the likelihood of treatment success (see, for example, the chapter in this volume by Sexton and Alexander).

Building on Family Strengths

Today’s state-of-the-art family therapies consider strengths as much as liabilities (Walsh, 1998). Whereas an earlier generation of family therapies were predicated on accentuating family difficulties, most of these approaches clearly identify and build on client strengths.

Considering Client Goals

Today’s state-of-the-art approaches accentuate client goals. People enter family therapy for a variety of reasons. Many do so to solve individual problems, such as the behavior of an adolescent. Others do so to resolve a family crisis or negotiate a transition in family development. Some of the chapters in this book emphasize using family therapy to help resolve individual difficulties, often as one method in a multimethod treatment. Other chapters accentuate changing family process. In general, these approaches are highly responsive to client goals.

Tracking Outcomes

Although Miller, Mee-Lee, Plum, and Hubble alone in this volume describe a specific technology for tracking and feeding back outcome information to clients as therapy progresses, explicitly focusing on client outcome is a core ingredient of most of these models. As Miller and his colleagues point out in their chapter, tracking outcomes improves the levels of success in psychotherapy.

Attachment

Attachment is an explicit focus in only a few of the models in this volume—most prominently, Diamond’s approach, aimed at childhood depression, and Wooley and Johnson’s Emotionally Focused Couples Therapy. Yet, working toward stable attachments that support family members is also a generic goal shared by most twenty-first-century approaches. Attachment is the foundation of the relational nexus that makes the family a healing entity rather than a source of stress.

Attending to Culture

One of the major insights of the last 20 years in the field of family therapy has been the vast importance that culture has on the process and outcome of therapy. Families live in different cultures, and the same intervention may have vastly different meanings to families from differing backgrounds. State-of-the-art methods in family therapy are also very much informed by an understanding of culture. Clearly, culture makes for vast differences in what constitutes normal family life and what constitutes health and pathology. In many of these approaches, specific methods have been developed in the context of particular cultures for working with those cultures (e.g., see the chapter by Horrigian et al. in this volume).

Ethical Considerations

Family therapy is by its nature more complex than other forms of intervention. With more people participating, there are additional difficult decisions about who to regard as the client, about confidentiality, about goal setting, and about innumerable other issues (Margolin, 1982). Contemporary family therapies don’t simply describe how to intervene—they think about and offer suggestions about how to deal with these dilemmas. And, while in some instances there are simple answers to questions of ethics (e.g., clients are each entitled to confidentiality), in many instances there are no perfect answers to such complex questions. What is essential is that family therapists understand the ethical issues likely to emerge and be thoughtful about their resolution.

CONCLUSION: TOWARD ONE FAMILY THERAPY

Family therapy is becoming more a single therapy than any time since its beginning. In their early reviews of research on family therapy, Gurman and Kniskern (Gurman & Kniskern, 1992) pointed out that there were family therapies rather than a method that might be called family therapy. They suggested that the striking differences in approach across treatments rendered it less useful to group these treatments together as if they constituted one entity. Although that logic certainly aptly described family therapy as conducted at that time, today’s state-of-the-art family therapy is moving much closer to being a generic therapy with a shared foundation adapted to particular contexts.

With the movement toward the utilization of multimethod strategies for intervention that cross the boundaries of schools of family therapy, the emergence of what now can much better be regarded as a single family therapy, in which there are multiple variants, seems much more appropriate than at any time since the earliest beginnings of family treatment, before there were schools of family therapy. And though the boundaries between couple and family therapy have grown as a product of the ways these methods are presented as separate entities in coursework, workshops, and writing, the methods employed in couple and family therapy show much more resemblance to one another than differences. Clearly, there are aspects of couple and of family therapy that are unique to one of these domains (e.g., sex as an aspect of couple therapy), but the similarities in focus, strategies of intervention, and techniques vastly outweigh differences across most of today’s current methods.

To point out the emerging common ground shared by this new generation of family therapies is not to suggest there aren’t differences between family therapies. For example, in as complex an endeavor as family therapy there will always be outliers who work from very different positions. And a close reading of the approaches in this volume will uncover numerous differences, even among the approaches included here, but the emerging commonalities far outweigh those differences.

This emerging consensus stands in contrast to the family therapies of earlier eras. In that era, there were numerous competing systems for understanding and intervening in couples and families. Each of these systems accentuated a different aspect of family life. Whether the goal was to impact on the structural foundation of the family, to develop a rapier-sharp intervention strategy, to differentiate individual selves from the family, to connect with family, to leave home, to fully experience, to establish fairness in the balance of power, or to explore the inner selves of the psychodynamics of family members depended on the view of the beholder. Strong opinions existed, leading to many acrimonious arguments. Following in the psychoanalytic tradition of dueling institutes, training accentuated how to work according to the model of a particular master therapist rather than how to work with particular kinds of clients. Little research was also brought to bear in relation to these questions. Persuasion and charismatic charm were the major forces in generating a school of approach.

A footnote here; in describing the strengths of the new generation of family therapies, I do not mean to minimize the contribution of that first generation of pioneers of couple and family therapy who created this field of endeavor. It is much easier to bring tools of analysis and assimilation to a method after its central core thesis has become well established. When the first generation of couple and family therapists began to develop their methods, they were heirs to a 100 years of focus on the individual. Almost no one thought in terms of family process, or grasped the vital importance of the social nexus to the inner lives of individuals. Juxtaposing the systemic and cybernetic metaphors from physics and biology to families was nothing short of a paradigm shift, and the resistance to this shift in the world outside of the community of family therapists was powerful. The present generation of the kinds of family therapies described in this volume could only be constructed building on the foundations of the systemic insights of the earlier generations of therapists.

And what ideas! The core systemic understanding was nothing less than one of the brilliant insights of the twentieth century. Thousands of research studies have subsequently confirmed the central wisdom of noticing how people are affected by the social system in which they live, and how the behaviors of individuals have profound effects on the behaviors of others, at least in part influenced by circular causal pathways. And there probably is no single idea, strategy, or intervention in this volume that was not in some shape or form stated in the early writings and presentations of those pioneers. Both the theoretical concepts invoked (for example, the importance of structure in families) and the techniques most frequently described in this volume, such as reframing, communication training, alliance building, and challenging cognitions can all be traced back to an origin in this earlier potpourri of approaches.

What was missing, however, from this early generation of therapies was the ability to borrow from one another, to engage in an iteration with individual personality and psychopathology, and to explore the realm of how approaches work in the context of specific problems. Pride and belief in the ultimate wisdom of their particular approach—and the needs that evolved from trying to build a constituency for a family viewpoint—transcended all else. There was little search for common ground, or testing and shaping of approaches in specific contexts. The transcendent, core belief was that in helping resolve the central aspect of family life that was in focus in a particular approach, all would change around it.

The approaches in this volume have been built on the foundations of those earlier approaches and these current methods are both more comprehensive and more limited. Twenty-first-century family approaches have been able to integrate and sift the powerful ideas and methods offered by their progenitors. And they have had the additional advantage of drawing from the accumulated knowledge of the last quarter century and the empirical testing of methods that could occur over that period of time. It is an exciting time in the field of family therapy, in which we can point to a diversity of successful methods for helping those with range of difficulties, in addition to an underlying set of strategies and techniques and understandings about families that transcend the specific problem or method in focus.

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Part I

Problems in Children and Adolescents

Chapter 2

Attachment-Based Family Therapy for Depressed and Anxious Adolescents

Guy S. Diamond

Case Study

Sally is a 14-year-old, referred by a psychiatrist who in frustration recently changed her diagnosis from Major Depression to Bipolar Disorder and started her on a course of lithium. School failure, family conflict, intense sibling rivalry, and a fascination with death-rock music were increasing. Six months ago the depression had remitted somewhat, so Sally’s psychiatrists recommended that the mother make more behavioral demands about school performance and cooperation at home. Conflict and isolation escalated.

Sally, her 16-year-old sister, and her mother attended the first therapy session. She wore all-black, heavy eye make-up, a metal choker, and several piercings in her ears. For the first 20 minutes she remained silent, only making insinuating gestures and groans of disagreement while the mother compassionately complained about her daughter’s unpredictable behavior, indifference about school, fascination with death, and her own frustration over her failure to help her daughter.

Hoping to redirect the conversation from a focus on Sally to shared family struggles, the therapist asked about the father’s death 10 years ago. Sally immediately asserted that she was glad he died, which raised protests from her sister and mother. Once the therapist showed some sincere interest in Sally’s feelings about her father, Sally revealed that the father had become a depressed alcoholic who physically abused her mother. After some minimizing statements, the mother admitted to the violence and how bad things had been. The therapist pointed out that Sally’s hatred toward her dad also expressed protectiveness toward her mom. Over this, Sally began to cry and express worries about her mom, then and now. The mother seemed uncomfortable with her daughter’s empathy toward her. Perceiving her mother’s discomfort, Sally returned to complaining about the father. The therapist redirected Sally back to her more vulnerable feelings by noting how hard it was to show love and concern for her mom. Sally’s mood softened again and she began to discuss how they had grown apart, and rarely spent time together. Mother said she assumed her daughter was no longer interested in that, to which Sally responded, I will never be too old for that. At this juncture, the therapist complimented Sally’s willingness to discuss difficult issues that others wanted to avoid and punctuated Sally’s feelings of missing her mom. The therapist also empathized with the mother’s confusion about how to be close to her daughter while also establishing expectations. Finally, the therapist suggested that the first goal of treatment focus on getting reconnected with each other. This way, they would understand each other better, not feel so alone, and Sally would have someone to talk to when she was depressed or suicidal. Both the mother and Sally agreed to this initial treatment focus.

This first session embodies many of the principles and goals of attachment-based family therapy (ABFT; Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, & Isaacs, 2002). Depressed adolescents usually come to therapy feeling hopeless, alone, and angry at their parents for misunderstanding their despair. Parents, with their own ambivalence about, and struggle with, attachment and intimacy, feel frustrated over their failure to help their child. However, the generationally-shared wounds caused by attachment failures are often obscured by conflicts over behavioral problems. It is safer to argue about chores or homework than abuse, abandonment, and/or neglect. Even families that display closeness and open communication struggle with maintaining these strengths in the face of a major depressive episode. Identifying and discussing relational ruptures, and the painful emotions associated with them, creates an experience of shared vulnerability and authenticity that can rekindle the natural desire for attachment (adolescent) and caregiving (parent). Empathic, nonaccusatory conversations about attachment failures become the context for teaching and practicing more effective conflict management and affect regulation skills, expressing contrition and forgiveness, and renewing trust between family members.

This chapter provides a brief overview of the ABFT approach. It begins with a description of the theoretical foundations of the model. Then, a detailed description of the five treatment tasks, along with the logic underlying each, is provided. Empirical support for ABFT with depressed adolescents is briefly reviewed. Next, the adaptation of ABFT to working with anxious adolescents is offered, and preliminary pilot data are presented. Because ABFT has been tested primarily with inner-city African American clients, this chapter also provides a brief discussion of some cultural issues that inform the application of the model. We conclude with a brief summary of the next few sessions of the case previously presented.

THE THEORETICAL BASE

Attachment Theory

Attachment Theory (Bowlby, 1969) offers an alternative theory base to general systems or cybernetic theory for understanding the interpersonal dynamics of family life. These models were critical in helping therapists shift their focus from individuals to systems and from symptoms to interaction. While revolutionary at the time, these theories assumed that families functioned as biological or mechanical systems. Family therapists in search of more relationship-based models have turned to attachment theory to better explain human motivations, emotions, and behaviors (Johnson & Whiffen, 2003; Wood, 2002).

Attachment theory rests on the assumption that a child’s sense of security in life depends on parents being available and protective. When a parent appropriately responds to this need, the child generally develops a secure attachment style. This attachment/caregiving system is essential for survival and thus is a hardwired, biological instinct. While much of the attachment research has focused on infants and young children, the importance of appropriate attachment throughout the lifespan has been well-theorized and documented (Ainsworth, 1989; Steinberg, 1990). For adolescents in particular, secure attachment nurtures healthy development, while insecure attachment has repeatedly been associated with depression and other kinds of functional problems (Kobak & Sceery, 1988; Rosenstein & Horowitz, 1996).

For adolescents, attachment is maintained (and possibly revived) when three interpersonal elements exist. Adolescents must feel they have access to caregivers when needed. They must also feel free to openly communicate without the fear of rejection or judgment. And, adolescents must feel that parents can protect them, not just from physical harm, but from emotional harm as well (Kobak, Sudler & Gamble, 1991). When these conditions are met, adolescents are more likely to feel secure and safe. With this foundation in place, adolescents show greater autonomy seeking behavior, positive peer relations, and higher self-esteem (Allen & Land, 1999). They also freely express negative or vulnerable emotions (e.g., fear, anger, distress) with the expectation of acceptance and comfort, rather than criticism and abandonment. In fact, Kobak and Duemmler (1994) found that secure attachment leads to more direct communication, which fosters perspective-taking and problem-solving skills. In this regard, adolescent attachment theory parallels the now empirically supported view that an appropriate balance of connection to and independence from the family is the central task of adolescent development (Allen & Land, 1999).

One challenge in an attachment-based family intervention approach is in building the parents’ capacity for providing security-promoting parenting. Many parents of depressed adolescents were denied adequate parenting as children and consequently have insecure attachment styles themselves. These parents often feel ambivalent, anxious, or incapable of providing comfort, soothing, and reassurance. In these families, the expression of negative, vulnerable feelings is unwelcome and unsafe. When caretakers are unavailable and/or unresponsive, particularly at critical moments, they can become a source of emotional injury rather than a foundation of safety and support (Kobak & Mandelbaum, 2003).

Lacking confidence in the safety of interpersonal relationships, adolescents fail to develop effective problem-solving skills. Instead of addressing conflict and disappointment directly, they protect themselves with conflict avoidance, denial, and other cognitive distortions. Emotional energy becomes preoccupied with preserving fragile and dysfunctional relationships. In fact, depressed adolescents often protect parents from angry or sad feelings, fearing that honesty would overburden their parents or lead to further rejection (Diamond & Siqueland, 1998). Consequently, adolescents express anger about core attachment failures indirectly, through conflicts over day-to-day behavioral problems (e.g., chores, curfew, or other issues). Depressed adolescents also have a tendency to blame themselves for these attachment failures, and view themselves as unworthy of love and affection. This can promote a negative schema of self and others, putting them at greater risk for depression (Cicchetti, Toth & Lynch, 1995).

Repairing Attachment

In contrast to the psychoanalytic tradition, Bowlby posited that internal working models, although persistent, were open to revision across the lifespan (Bowlby, 1969, 1988; Waters, Kondo-Ikemura, Posada & Richters, 1991). Not only can negative life experience damage one’s felt security, but positive life experience can help rebuild it. Several studies have now found that good parenting, a loving marriage, or a positive therapeutic experience increases one’s sense of felt security (Cicchetti & Greenberg, 1991; Weinfeld, Sroufe, & Egelund, 2000). Main and Goldwyn (1988) characterized this process as earned security. Individuals victimized by negative parenting can earn security by working through and coming to terms with these experiences. Interestingly, adults with earned security remain as susceptible to depression as adults with insecure attachment styles, but they have parenting practices similar to adults with secure attachment thereby. Good parenting thus buffers against the negative impact of the parents’ depression (Pearson, Cohn, Cowan & Cowan, 1994). In this way, parents or adolescents who can resolve these attachment failures can develop interpersonal skills and strengths that promote healthier living.

While adult attachment research has primarily focused on the consequences of negative internal working models, how to earn a secure attachment style has not been well spelled out. Research and theory on forgiveness and trauma resolution provide some insight into this process. The process of forgiveness has been characterized as (1) experiencing strong emotions, (2) giving up the need for redress from the perpetrator, (3) seeing the offender as distinct and separate from one’s needs and identity, and (4) developing empathy for the offender (McCullough, Pargament, & Thoresen, 2000). Although ABFT focuses on exoneration rather than forgiveness, these processes characterize many of the therapeutic domains traversed during the attachment task. Herman’s (1992) model of trauma recovery also delineates several steps toward resolving trauma experiences. These steps include (1) restoring a sense of control, (2) establishing safety, (3) telling the trauma story in detail, (4) mourning losses, and (5) reconnecting with self and community. ABFT helps family members collaboratively participate in conversations that achieve similar goals.

Studies on adolescent affect regulation and family interaction also offer insights into the process of earned security (Allen, Hauser, & Borman-Spurrell, 1996). In particular, Kobak and Sceery (1988) suggest that while behavioral interactions between parents and children shape early attachment security, given adolescents’ emerging cognitive capacity, conversation increasingly becomes the mechanism through which attachment security is experienced and negotiated (Kobak & Duemmler, 1994). Thus, the ABFT model proposes that direct conversations about relational failures may be a key vehicle or mechanism through which family members earn or develop a secure attachment style.

Conversations about relational trauma become the enactment within which families have a corrective attachment experience. Children who have been treated unjustly, be it physical or psychological abuse, internalize a model of self as unworthy of love, and of other as untrustworthy (Bartholomew & Horowitz, 1991). Therefore, rather than appropriately seeking redress for interpersonal injustices, they act out destructively toward themselves or others. Alternatively, helping adolescents identify, articulate, and appropriately talk about these relational ruptures challenges their hopelessness and helplessness, increases their tolerance for emotional conflict, and promotes an appropriate sense of entitlement to healthier relationships. For parents, these conversations offer an opportunity to provide effective caregiving (sensitivity, emotional protection, empathic listening). If successful, these intense, emotionally charged encounters offer an opportunity to provide comfort and protective parenting. This helps the adolescent rebuild trust in the parents’ capacity to provide a secure base. In ABFT, like contextual therapy, repairing trust and reestablishing fairness between family members is a primary therapeutic target (Boszormenyi-Nagy & Spark, 1973). These kinds of corrective-attachments, experienced directly with caretakers (and ideally with sustained improvement in parenting behavior), may alter both day-to-day interactions between family members and parents’ and adolescents’ interpersonal schemas about self and other (see Weinfeld, Sroufe & Egelund, 2000).

CLINICAL FOUNDATION

ABFT is rooted in the structural tradition, with some recasting of the basic concepts. For instance, reestablishing hierarchy in the traditional sense (e.g., parental control) is not the driving theme. Rather, promoting authoritative parenting skills, such as warmth, acceptance, demanding behaviors, and clear expectations (Baumrind, 1991), and a more age-appropriate, mutual communication, serves as one primary treatment goal. Reframing and enactment