couple relationshipslorelei e. simpson,krista s. gattis, andrew christensen
family relationshipslinda berg-cross,michelle morales, christi moore
parent-child relationshipsmarian j. bakermans-kranenburg,marinus h. van ijzendoorn, femmie juffer
Contemporary couples therapy has its origins in several counseling movements. According to Carlfred Broderick and Sandra Schrader's (1991) history of marital and family therapy, couples therapy initially grew out of the marriage-counseling and sex therapy movements of the early twentieth century. Social workers recognized the need to work with the family and marital systems, as well as the individual, long before the growing fields of psychology and psychoanalysis. In addition, burgeoning interest in human sexuality and sex therapy, which grew out of the work of Havelock Ellis in Great Britain and Magnus Hirschfeld in Germany shortly after World War I, influenced the growing emphasis on the couple dyad. Marriage counseling, however, was not truly considered a profession until the 1960s and 1970s, when it developed a professional organization, journals, and standards. It was somewhat eclipsed by the more popular family therapy movement in the 1970s, though the two eventually became strongly linked, with shared journals, organizations, and practitioners. Today, although there are distinct theories and practices of marital and family therapy, there continue to be many shared links.
Models of Couples Therapy
In general, couples therapy has been shown in dozens of studies to be more effective than no treatment (for meta-analyses of these studies, see Baucom et al. 1998 and Shadish et al. 1993). Although most couples are helped by therapy, less than half end up in the nondistressed range (Shadish et al. 1993). At the beginning of the twenty-first century, the therapies with the most support are behavioral couples therapy, cognitive behavioral couples therapy, and emotionally focused therapy (Christensen and Heavey 1999). A new model in the field, integrative behavioral couples therapy ( Jacobson and Christensen 1996; Christensen and Jacobson 2000), also has empirical support. In addition to these, there are several less researched, but promising, models of couples therapy, including family systems therapy and problem-and solution-focused therapies.
Behavioral Couples Therapy
Behavioral couples therapy (BCT) is the most widely researched and well-validated model of couple therapy (Christensen and Heavey 1999). Like individual behavioral therapy, BCT is derived from social learning and social exchange theories, which emphasize the influence of the environment and its behavioral and emotional rewards and costs. Behavioral couples therapy is built upon the idea that couple satisfaction is determined, in large part, by the positive and negative nature of spouses' interactions with each other.
Many distressed couples report feeling unable to communicate with each other or solve problems when they arise, which leads them to feel unhappy and frustrated with each other. According to behavioral theory, these negative interactions decrease the rewards couples gain from their relationship. In response to this reward reduction, BCT focuses on increasing the ratio of positive to negative behaviors for couples in distress and teaching them effective communication behaviors so that they may handle difficulties when they arise.
Several kinds of skills-oriented therapeutic techniques are used in BCT. First, therapists often work with couples to increase the number of positive behaviors that partners do for each other. For example, the therapist may guide partners in generating a list of positive actions that they could do for the other, such as complimenting the other or fixing the other breakfast. The therapist may then encourage partners to enact the behaviors on the list. Norman Epstein, Donald Baucom, and Anthony Daiuto (1997) suggest, however, that these interventions may be most effective if they address an area of concern for the couple. For example, a couple in conflict over parenting might be asked engage in positive behaviors in the domain of parenting, such as sharing diaper-changing duties.
The other main focus of BCT is improving communication skills and teaching problem-solving strategies. Communication skills that therapists may teach couples include the use of "I statements" that express feelings without blaming the partner, the use of verbal and nonverbal cues in listening, moderation of negative statements with the inclusion of positive feelings, and reflecting back of what each partner has said (Epstein, Baucom, and Daiuto 1997). Problem-solving training typically involves helping the couple to define a problem clearly, generate alternative solutions, compromise on a solution, implement it, and evaluate its effectiveness (Christensen and Heavey 1999).
Cognitive Behavioral Couples Therapy
Cognitive behavioral couples therapy (CBCT) includes the ideas and techniques of its predecessor, BCT, with an added cognitive component. In CBCT, several kinds of cognitions may be targeted, including assumptions about the partner, relationship standards, attributions of past partner behavior, expectations regarding how partners will behave, and selective attention to some aspects of partner behavior and not others (Epstein, Baucom, and Daiuto 1997). Cognitive behavioral couples therapy intervention techniques involve the use of cognitive restructuring, a process of evaluating cognitions systematically, determining their accuracy, and changing those that are unrealistic or inaccurate. For unrealistic attributions, assumptions, standards, and expectations, the therapist and partners work together to generate alternative explanations that are more accurate and lead to greater positive feelings between partners.
Integrative Behavioral Couples Therapy
Integrative behavioral couples therapy ( Jacobson and Christensen 1996) is an adaptation of BCT that focuses not only on behavioral change, but also includes an emphasis on acceptance of problems that are difficult or impossible to change. In order to promote acceptance, therapists may help couples reformulate problems as differences, rather than deficiencies; promote the expression of the vulnerable feelings that often lie behind aversive behavior; encourage an objective analysis of the problematic patterns couples experience; or engage in reenactment of aversive behavior in ways that promote increased tolerance. Not only are these strategies designed to promote acceptance, but they may indirectly foster change in the problematic behavior and increase emotional closeness between the pair.
Emotionally Focused Therapy
In contrast to more behavioral therapies, emotionally focused therapy (EFT) explains relationship distress in terms of attachment theory, rather than behavioral exchange. Emotionally focused therapy, developed by Leslie Greenberg and Susan Johnson (1988), involves the identification of problematic interaction cycles between partners and the emotions underlying them. Relationship distress is believed to arise when attachment bonds are disrupted or have not been fully formed, leading partners to engage in rigid interactional patterns that prevent emotional closeness (Christensen and Heavey 1999). Emotionally focused therapy works to help couples recognize their emotional experience in the relationship and restructure their interactions in order to create a more satisfying relationship. The therapist and couple work together to reprocess and redefine the relationship in such a way that it provides a more secure attachment base for both partners.
The family systems approach to couple therapy emerged as part of the field of family systems research, with the couple seen as the central and most influential subunit of a larger family system (Fraenkel 1997). The foundation of systemic couple theory is that all problems, including couple problems, occur in a multilevel context, which ranges in specificity from the just the two members of the couple to their immediate environment (i.e., family, work, or school) to their larger society or culture.
For couples, intervention techniques vary widely, as a function of the specific type of systems theory from which they are derived (examples of different types include structural, strategic, and experiental). However, Peter Fraenkel (1997) notes a variety of common goals of systems therapy, including focusing on strengths and resources, attending to the therapeutic environment as a "system," and identifying, stopping, and changing problematic interaction patterns. Family systems therapists may ensure that the therapy is of a brief duration to save time and energy and avoid dependence upon the therapist. The therapist may also model important concepts, including teaching how different family members may emotionally respond to each other and how partners may maintain their separate identities and perspectives while still working together as a couple (Papero 1995).
Problem- and Solution-Focused Therapy
Problem- and solution-focused therapies are approaches that focus on expedient problem resolution for couples, rather than on protracted work toward personal growth, underlying emotional issues, or general communication skills (Shoham, Rohrbaugh, and Patterson 1995). These therapies focus not only on how partners behave in the situation of conflict, but also how they view the problem. The two therapies, problem and solution focused, differ somewhat in their balance of behavioral versus cognitive change and their manner of reinforcing change, but they are quite similar in their focus on parsimonious therapeutic work toward single problem resolution (Shoham, Rohrbaugh, and Patterson 1995).
What Brings Couples to Therapy
Couples seek help from therapists for many reasons, ranging from difficulty communicating and dissatisfaction with their sex life to problems in coparenting or wanting to prevent divorce or separation. Other common reasons include a lack of emotional affection, divorce/separation concerns, infidelity, and domestic violence. Couples may come to therapy for any issue that they must face together, which can also include individual problems, such as mental illness, or family difficulties, such as a child's problems in school. The role of the therapist is to help them cope with these difficulties together, solve them when possible, and, as discussed above, accept them when no solution can be found.
Couples frequently come to therapy to seek help in dealing with children and parenting. This is particularly true in the case of blended families, in which one partner is a stepparent to the other's child or children. Anne Bernstein (2000) notes that stepchildren are often a source of conflict, as the couple must try to develop their relationship without the freedom to focus solely on their own needs, which newly married couples without children may have. Other issues that can surface in this area include disagreements about parenting, conflicts with a particular child, or marital conflicts expressed through parent-child difficulties. Often, parent-training or family therapy are also appropriate treatments for these difficulties.
Sexual difficulties are one of the more common problems that couples bring to therapy. Couples may disagree on when, where, or how often they have sex, as well as what activities they engage in. This can be complicated by the emotional meaning sex has for each member of the couple, as when one member wants to use sex to make up after a fight and the other can't have sex until they've made up.
Infidelity is one of the most emotionally laden problems that couples bring to therapy. Shirley Glass and Thomas Wright (1997) discuss the many issues infidelity raises, including how and when discovery of an affair is made, how long the affair went on and with whom, and whether the involved spouse is willing to give up the affair. A major issue is whether the couple will remain together. If they stay together they must discuss what information about the affair the betrayed spouse needs or wants to know, how they can understand the affair, and how they can rebuild trust.
Finally, domestic violence is a serious problem in relationships. As Richard Heyman and Peter Neidig (1997) note, all couples therapists treat couples dealing with violence, whether they know it or not. Although couples may fail to identify violence as a problem in their relationship, its effects can still be quite damaging and therapists need to be vigilant in assessing for violence among couples. If violence is present, the therapist must decide whether or not it is appropriate to treat the couple together. Some researchers and clinicians contend that if violence is present, couples therapy should not be attempted, as it may exacerbate conflicts that put the abused partner at risk. Others suggest that, under certain specific conditions, a couples therapy that is designed to treat violence may be appropriate (e.g., Heyman and Neidig 1997).
Any couple can face some or all of the problems listed above, but some couples bring other specific issues to therapy, such as unmarried couples, same-sex couples, aging couples, couples of lower socioeconomic status, and interracial or intercultural couples.
Unmarried couples range from dating couples to committed cohabiting couples who have either chosen to remain unmarried or are not permitted to marry (such as lesbian and gay couples). These couples may be more likely to bring in issues concerning whether or not to commit to a long-term relationship, or they may want help in resolving certain problems before making such a commitment. They are less likely to have conflicts over childrearing, though they may disagree about whether to have children. They may also need help in dealing with the stigma for cohabiting without marriage or with pressure from family members to get married (or not to marry).
Same-sex couples face many of the same issues that opposite-sex couples do, but may also carry the additional burdens of homophobia and heterosexism. This can manifest in couple difficulties in a number of ways, including stress related to family disapproval, conflicts over how "out" to be, and distress over not being able to legally commit to one another. Same-sex couples may also have difficulties surrounding differences in identity development. One partner may be more comfortable with his/her sexuality and put pressure on the other to be more "out" than he/she can be at their personal stage of development. Conversely, they may feel held back or forced to remain closeted by a partner who is still coming to terms with their sexuality (Okun 1996).
Aging couples face a number of difficulties they may bring to therapy, including the transition to retirement, dealing with adult children and grandchildren, coping with illness, and learning to be alone when their partner dies. As the population ages, couples will have a longer period of time together in the "empty nest" and presumably a greater need for couple therapy (Rosowsky 1999).
Couples of lower socioeconomic status may face a number of financial tensions and stressors as they attempt to support their families on a low income. This may be particularly problematic if one member of the couple comes from a wealthier family, resulting in tensions over "marrying down" (Ross 1995). Low-income couples may also face difficulties over whether they can afford therapy and how severe problems must be to warrant seeking outside help.
Finally, interracial or intercultural couples face a number of specific challenges in their relationships, which can result in relationship distress. These couples must often deal with the racism and prejudices faced by all people of color, but may also have to cope with the merging of two cultures and two sets of expectations about relationships. It is the task of the couples therapist to be sensitive to the cultural differences and needs of each member, and to help each member of the couple understand how these factors might affect them individually and as a couple (Okun 1996).
Couples Therapy and Individual Issues
In addition to being effective for relationship problems, couples therapy has been repeatedly shown to be effective for individual problems. Studies of couples treatment for individual psychopathology have varied in several ways, including the individual disorder studied, the satisfaction of the couple, and the extent to which the therapy focuses on relationship problems versus an individual spouse's difficulties. Therapies with more minimal involvement of one spouse and a strong focus on an individual issue are often termed spouse-aided rather than couple therapy. The three domains in which couples treatment have been most studied (and appear most efficacious) are depression, anxiety, and substance abuse.
Although causal links between depression and marital discord are unknown, the odds of being depressed increase tenfold for both partners if they are distressed in their relationship (O'Leary, Christian, and Mendell 1994). There is growing support in the literature for couples treatment for depression, and marital therapy used to treat individual depression in a maritally distressed couple has been found to be significantly more effective than no treatment both in increasing marital satisfaction and reducing depressive symptoms (Beach, Fincham, and Katz 1998). Furthermore, several studies have found BCT to be as effective as individual cognitive therapy for reducing depressive symptoms and somewhat more effective than individual therapy for improving marital functioning (see Jacobson et al. 1991 and Beach and O'Leary 1992). Not surprisingly, couples therapy does not appear to be as helpful for depression in the absence of marital distress (Gotlib and Hammen 1992; Beach, Fincham, and Katz 1998).
The most efficacious couples treatments for depression seem to focus on enhancing communication and intimacy and improving interpersonal interactions. This focus may help to improve both the relationship and individual symptomology, although this has not been tested on severely depressed or hospitalized patients. (Beach and O'Leary 1992). However, couples therapy may be contraindicated if one partner is so severely depressed that he or she needs to be the sole focus of treatment or the depression is psychotic or bipolar, all of which would limit that person's ability to focus on the relationship.
Spouse-aided treatment for anxiety spectrum disorders also appears to be efficacious, particularly for agoraphobia and generalized anxiety disorder. W. Kim Halford and Ruth Bouma (1997) note that the relationship between marital difficulties and anxiety is moderated by gender, type of anxiety, and whether both spouses have anxiety disorders. As in the case of depression, research suggests that couples treatment for anxiety may be most effective in the presence of marital distress, although if a spouse reinforces or helps to perpetuate anxiety symptoms (for instance, if a spouse facilitates avoidance behavior), then spouse-aided therapy may also be helpful. Some outcome studies suggest that in vivo treatment for agoraphobia including a focus on couple functioning is more effective at follow-up than in vivo treatment without the couple focus (Epstein, Baucom, and Daiuto 1997). However, other studies have found spouse-aided therapy to be neither more nor less effective than individual therapy for agoraphobia (Emmelkamp et al. 1992).
Substance abuse in a marital relationship may be among the most destructive of comorbid disorders due to its many potential relationship and individual consequences, including poor physical health, unemployment, abdication of household and other responsibilities, and potential for violence. Couples therapy for individual substance abuse shows promise, although research on this topic has varied widely in models of substance abuse, methodology, and level of spousal involvement. Most couples therapy research on substance abuse has focused on alcoholism, and therapy goals typically involve eliminating drinking or supporting the drinker's efforts to stop, altering marital interactions to create an environment that encourages sobriety, preventing relapse, and dealing with more general marital issues (O'Farrell and Rotunda 1997).
Interventions are likely to focus on the urge to drink or do drugs, important events in the last week relating to substance use, helping couples identify behaviors in themselves and each other that may trigger substance use, strategies to increase positive nonalcohol-related behaviors between spouses, and teaching communication and problem-solving skills. Timothy O'Farrell and William Fals-Stewart's (2000) application of behavioral couples therapy for alcoholism and drug abuse found that it was more effective than individual treatment for producing abstinence and fewer substance-related problems, higher relationship satisfaction, decreased domestic violence, and lower risk for marital separation.
Culture, Ethnicity, and Couples Therapy
Culture and ethnicity have been increasingly recognized as important factors in therapy. It is also increasingly evident that therapists can make serious mistakes when they fail to recognize cultural explanations for behaviors or problems and then over- or under-pathologize patients on that basis. This can be a problem in couples therapy, as an uninformed therapist may label a behavior that is acceptable and adaptive from the couple's point of view as problematic because it does not fit his/her cultural standards for a healthy relationship. There are several solutions to this potential problem, including obtaining knowledge about the cultural background of the couple, becoming aware of one's own cultural background, and becoming a culturally sensitive therapist.
The first step, obtaining knowledge about the cultural background of the couple, is similar to researching any issue that might affect the effectiveness of therapy. The greater the therapist's understanding of each member's cultural background, the more likely that they will be able offer interpretations and suggestions that fit the couple's schema. The most important and best source of this information is the couple itself. Although obtaining information on specific ethnic or cultural groups might be useful, it is important to remember that such information may not apply to specific individuals. Rather, a culturally sensitive therapist recognizes that the members of the couple are the best experts on how their cultural backgrounds affect their lives and experiences.
According to Monica McGoldrick and Joe Giordano (1996), it is just as important for the therapist to become aware of his/her own cultural background and influences. Culturally sensitive therapists recognize that their own values and expectations, as well as those of their clients, stem from culture, rather than assuming that such ideas are universal. For example, a therapist may think that it is a universal rule that communicating clearly and openly about one's emotions is healthy, failing to recognize that the idea is, in fact, culturally determined, and that there are many cultures in which straightforward communication about emotions is considered immature or rude.
In other words, a culturally sensitive therapist is one who, as defined by Steven Lopez (1997), is able to recognize the different cultural "lenses" that clients and therapists bring to therapy. According to Lopez, every person views the world through the lens of culture, and it is the therapist's job to learn about their client's lens and find a way to work together in a way that is compatible with both views. This is especially important in couples therapy, as each member of the couple brings a separate lens. The lenses may be vastly different in the case of an interracial or intercultural couple, or they may be only slightly discrepant, in the case of a couple in which both members are from the same culture.
It is extremely important to maintain an awareness of the impact of racism, prejudice, and discrimination. Therapists of the dominant culture may have unconscious or unacknowledged negative attitudes towards people of other cultures. These feelings can emerge in subtle ways that denigrate or ignore the cultural needs and characteristics of a couple. Similarly, a therapist who is not of the dominant culture may have to deal with such negative attitudes from clients of the dominant culture. Even when therapists and couples match in ethnicity or culture, they may find that they have different ideas about what it means to be a member of that culture. Couples in which one or both members are not from the dominant culture may face prejudice and discrimination in the society they live in. This experience can place strain on the health of the relationship, as well as that of the individual. Couples may experience conflict over how and when to confront racism and prejudice and over determining the best ways to cope (Okun 1996).
Since its origins in the marriage-counseling movement, couples therapy has grown and diversified. There are many models of couples therapy, which share the goal of improved relationship functioning. These therapies, however, may differ significantly in the techniques they use, from teaching new skills to focusing on emotions and acceptance. Moreover, the couples entering therapy may differ in the problems that bring them to therapy from communication, to sex, to children, to violence between partners. There is increasing evidence indicating that couples therapy may be useful for treating individual problems as well, including depression, anxiety, and substance abuse.
Couples therapists are also becoming more sensitive to their own and their clients' sociocultural backgrounds, needs, and interests. This trend is important, as there is no single type of couple that may benefit from couples therapy, and couples may vary tremendously in their levels of commitment and the relationship issues with which they are dealing. Further research should address how to differentiate between couples who will improve in therapy and those who will not, what kinds of problems couples therapists are best prepared to help, and how to generalize our treatments so that they work for couples of all ages and backgrounds. Fortunately, with the variety of models, approaches, and techniques available as well as the creativity and careful work of researchers and clinicians, the future looks bright for couples therapy.
See also:Anxiety Disorders; Attachment: Couple Relationships; Attribution in Relationships; Codependency; Communication: Couple Relationships; Conflict: Couple Relationships; Coparenting; Depression: Adults; Family Systems Theory; Forgiveness; Infidelity; Jealousy; Marital Quality; Marital Sex; Marital Typologies; Marriage Enrichment; Power: Marital Relationships; Problem Solving; Sexual Communication: Couple Relationships; Sexual Dysfunction; Therapy: Family Relationships; Social Exchange Theory; Spouse Abuse: Prevalence; Spouse Abuse: Theoretical Explanations; Substance Abuse; Transition to Parenthood
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LORELEI E. SIMPSON
KRISTA S. GATTIS
Models of family therapy were developing in many different countries during the 1950s, but in the United States, it was a twin birth, with one branch of family therapy being developed on the West Coast (with Gregory Bateson and Don Jackson) and another on the East Coast (with Nathan Ackerman). The field has since grown like an onion, one development layering upon another in a way that makes each development independently useful and still part of an increasingly complex system of interventions. Therapists are always reaching back to older techniques and theories as they also evolve new concepts and interventions.
The First Generation of Family Therapy
Gregory Bateson (an anthropologist) and Don Jackson (a psychiatrist) developed a systemic approach to schizophrenia while working at the Palo Alto Veterans Hospital (Bateson 1973; Jackson, 1961, 1973). The Bateson Project stressed that problems do not exist in any one person—relationship problems and/or dysfunctional interaction styles cause distress in individual family members. The dysfunction resides not in the "identified patient" but in the verbal and non-verbal communications that occur between family members. For example, if a father tells his son (the identified patient) to "be independent" one day and "obey your father" on the next day, he is putting the child in a position where the son will be emotionally conflicted and lose no matter what he does. The child cannot escape the relationship, his desire to please his parent, or his inability to be both "obedient" and "independent" at the same time. Jackson called this a double bind and thought that it was related to the etiology of schizophrenia. While Jackson was wrong in assuming that family communication patterns "cause" schizophrenia, his work on dysfunctional communications in the family was the seed of the second-generation "family systems" therapies.
Nathan Ackerman (1958), a clinician working in New York City, realized that when parents brought their children into the clinic, they were often blind to how their roles as parents and spouses were inciting and exacerbating the children's problems. Ackerman was the leader in reorienting treatment for children referred to child guidance centers to include the entire family. Ackerman came from a psychodynamic background but he understood that individuals are shaped by current family circumstances as well as their intrapsychic issues. He postulated that many problems in adolescence and adulthood are due to family conflicts over how the family should be organized and how it should carry out essential family functions. For example, should the mother work a second job so her children can buy expensive sneakers? Should the children be allowed to determine their own bedtime? Families inevitably confront many such issues due to changes in their children or themselves. As the family matures and changes, all the members must adapt and change. When family members do not want to change or do not know how to change, conflict characterizes family interaction, and individual members start showing psychological symptoms of distress. Ackerman also focused on the complementary interactions between the family and the individual—how each needs the other's affection and protection to survive.
Second-Generation Family Therapies
As the family approach became more popular, the theories and techniques began to multiply. Most could be grouped under one of the following six headings: Psychodynamic, Structural, Strategic, Conjoint/Humanistic, Cognitive/Behavioral, and Solution-Focused (see Figure 1).
Psychodynamic/transgenerational family therapy. This approach was developed by Murray Bowen, Ivan Boszormenyi-Nagy, and James Framo (Bowen 1978; Boszormenyi-Nagy 1973; Framo 1982). Family members who enter psychodynamic Bowian therapy spend a lot of time thinking about the childhood forces that shape their personalities (Papero 1990). Often, a person will be in individual therapy alone. What makes this family therapy instead of psychodynamic therapy is that the emphasis is not uni-directional, analyzing only what parents did to their children, but rather on what clients really want to do in their lives and how the family has made it difficult for them to move towards their desired goals. They then have to confront their parents as adults, whenever possible, so that instead of being emotionally dependent on the parents for approval, they become interdependent with them as adults. Indeed, Framo (1982) has focused on creating family-of-origin sessions, so that adult children can confront their parents and learn to communicate on a more open, adult, and caring level.
Bowen was highly theoretical in his approach, and many of his concepts are so popular and endemic that they are considered to be the core concepts of the entire field. The five major concepts are as follows (Bowen 1978):
- Differentiation of self. This is the ability to distinguish intellectual from emotional needs, desires, and responses. Young adults who feel guilty leaving their parents' homes are not even going to think about applying to a school 1,000 miles away if they have a low level of differentation. With a high level of differentiation, they will be able to consider the pros and cons of schools both near and far.
- Triangles. When two people have difficulty communicating with one another, it becomes much easier for both to focus on a third person and triangulate them into the relationship. Sometimes the third person has divided loyalties and must shift from side to side (as children in many divorce situations do); sometimes the third person simply aligns himself or herself with one person (e.g., when mother and daughter are on one side and father is alone on the other). There are also many triangles where the two parties who are at odds (usually the parents) decide to focus on and micro-manage the problems of a third person (usually one of the children) to have some interactions that do not touch the most explosive areas of the relationship.
- Family projection process. Not all children in the family are treated similarly by the parents. The child who is most emotionally involved with the parents and the least likely to differentiate from them is the object of the family projection process.
- Emotional cutoff. When children have trouble successfully differentiating they sometime resort to avoiding any real psychological intimacy or self-disclosure with their parents. Sometimes, they will physically move to another state or continent to avoid contact.
- Multigenerational transmission process. Family functioning is passed on like many genetic traits. Psychological functioning is passed down through the generations by two mechanisms. First, individuals tend to marry someone at the same level of differentiation as themselves, so that poorly differentiated people marry one another and cannot really relate as independent adults. Then, through the family projection process, at least one of the children is pulled into their emotional neediness circle and can function even less as an independent adult.
The goal is to help each person achieve maximum self-differentiation. The therapist stays removed and de-triangulated from the family, acting as a coach to help the family do research into its own family functioning. Remaining emotionally neutral, the therapist helps each person in the family realize the part that he or she is playing in maintaining the problem. Each person talks to the therapist (instead of each other) as each tries to communicate true thoughts and feelings. The therapist builds a mini-relationship with each person in the family, modeling how each should focus on self-disclosure and respectfully listening instead of talking about a third person. Openly expressing one's thoughts is promoted so that the family hears one another's perspectives. The therapist often works with the most psychologically healthy person in the family, with the idea that he or she will be able to differentiate most successfully and serve as a model for the rest of the family.
The most widely used of Bowen's techniques is the family genogram, where the structure and characteristics of family members are mapped over at least three generations to look for multi-generational influences. Other psychodynamic family therapists have focused on how the children become indebted to their parents and help them find ways to "balance the ledger" (Boszormenyi-Nagy 1973).
Structural family therapy. A family who enters structural family therapy, an approach developed by Salvador Minuchin (1974), will talk about the past as well as the present, since the family's current problems are seen as a carry over from earlier transactional patterns. The therapist looks for transactional boundaries defining the communication rules in the family by watching who talks to whom and how the family breaks up into sub-groups for support and problem solving. They look for triangles, where two family members resolve tensions between themselves by focusing on a third person in the family (Minuchin 1974; Minuchin and Fishman 1981).
The therapist's goal is to restructure family interactions between the family members, so they can more effectively solve their problems. Once dysfunctional transaction patterns are replaced with new, adaptive patterns the relationship loses its toxic nature and individuals no longer need to express their distress or dissatisfaction in an aberrant way.
Structural therapists use five hallmark techniques. They actively try to get the family to be comfortable with them as a person—it is said they join with the family. This is accomplished by maintenance (verbally supporting and reinforcing the family's behaviors and verbalizations), tracking (asking for clarification and amplification of statements to show interest), and mimesis (mimicking the affective tone, communication style, and level of formality that the family portrays in an effort to show that the therapist is "one of them"). A second technique is structured mapping, where the therapist diagrams which interactions in the family are healthy and which are characterized by over-involvement, distance, or anger. Entire families can be described as enmeshed (if they are over-involved) or disengaged (if they are too distant from one another). Other assessment techniques used to discern the structure of the family are enactments (where the family is asked to re-enact an everyday routine or the crisis situation) and actualizing family transactional patterns (where the therapist does not engage in the conversation or choose the topic but simply watches the family as they naturally communicate with one another and sees who communicates with whom under what conditions).
The fifth and most important technique involves various forms of restructuring the family. It may involve actively moving the family's seating arrangements within the therapy session, to help facilitate the restructuring of family communication patterns. It may involve assigning tasks so that individuals who usually do not interact with one another are joined in a purposeful activity. The therapist may help the family mark boundaries by setting up new rules or negotiating old rules.
Structural therapists must learn how culture affects family interactions so that they are not simply projecting their own idea of normal functioning onto their clients. For example, Hispanic families often give more authority to the father than Jewish families do. Structural therapists evaluate the family interaction pattern to determine if it is maintaining a specific problem, not simply judging the pattern. Structural family therapy seems to work especially well with families who have out-of-control or over-controlled teenagers.
Strategic family therapy. A family who enters Strategic Family Therapy, developed by Jay Haley (1963, 1987), talks almost exclusively about what is going on in the present. This therapy assumes that problems are the result of the current dysfunctional interactions taking place in the family. The therapist looks at the presenting symptom as a communication towards the other family members. Perhaps the child's morning stomachache is communicating that the child is sick for mother, who is traveling during the week. Perhaps the marijuana abuse of a teenager is a way to communicate to his mother that he feels out-of-touch with a new stepfather in the house (Haley 1963, 1987; Madanes 1981). The therapist's goal is to be the most powerful person in the therapy room so that the suggested interventions will be carried out and help restructure the power relations within the family.
The most well-known technique used by structural family therapists is problem focused prescriptions that are paradoxical. This involves telling the client to continue doing the very behavior that is labeled "the problem." If the problem is bedwetting, for example, the child is told to try to wet the bed every night. If the problem is an angry husband, he is instructed not to smile or act cordially to anyone in the family during the entire next week. If the symptom is communicating something important, when the client engages in the symptomatic behavior to comply with the therapist, it loses its communication value within the family. In the above prescription it is unclear after therapy what the husband is communicating by not smiling. Is he communicating compliance with the therapist or disdain with his home life? One has to be unsure. This opens the possibility that the client will choose a new and healthier way to communicate his or her needs (after all, the symptom by this time has become a habit that has trapped the person into responding to the family in a particular, defensive way). For problem-focused prescriptions to work, they need to be accompanied by a very plausible explanation. For example, the bedwetters might be told that it is bad for their bladder to try to keep dry; it is more important for their bladder to void during the night, and everyone will just have to learn to live with the bedwetting. Whenever possible, the therapist gives the family a chance to do a small version of the task in the session (e.g., instructing the father on how to keep a straight face), in order to make the assignment more likely to be carried out in the home.
Another famous strategic technique is reframing. With reframing, a person learns how to look at the cup of family virtues as "half full" instead of "half empty." A family may learn that the "immaturity" label that they have given to their son's shy behaviors can also be labeled as "social sensitivity."
Strategic family therapy is usually used with families who have not responded to other types of treatment. Empirical research on the effectiveness of strategic techniques is mixed, and some shy away from this technique, in part, because of the ethical issues of deception that surround the technique (paradoxically telling clients to do A when you really want them to do not A).
Conjoint family therapy. Conjoint family therapy was developed by Virginia Satir, the first major female family therapist, and the founder of the first formal training program in family therapy (Satir 1967, 1972). She combined the historical approaches of the psychodynamic theorists with the here-and-now emphasis found in the structural and strategic approaches. Satir believed that each person in the family was trying to keep the system in balance but that the "price" that each person "paid" was often very inequitable. When people in the family show a maladaptive symptom, it is because their growth is being blocked by the family unit's need for balance. The rules that create balance in a family are the result of how parents go about achieving and maintaining self-esteem. What mothers and fathers do to create an atmosphere that says "I am a worthy person" affects the context in which the children develop their own self-esteem.
Here the family experiences a very warm and emotionally involved therapist who stays in the present or goes into history as the case dictates. For conjoint family therapists the goal is always to help each individual family member build self-esteem. An equally important secondary goal is to expose and correct discrepancies in how the family communicates.
Satir found that under stress, problem families take on rigid communication styles. Each person develops a communication front: The placator is always trying to please; the blamer is finding fault with everyone; the super-reasonable person is always trying to intellectually analyze what is happening; and the irrelevant person acts in a distracting way, not wanting to relate to anything going on in the family. Conjoint family therapy tries to teach the congruent style of communication where people are honest, vulnerable, caring, and responsible for sending clear messages.
One of Satir's most famous techniques is the family life chronology, where the therapist initiates treatment by understanding the family's history through the various life stages and how they want to experience their current family life. This is a therapeutic system that greatly respects the rights of children to be heard, to be loved, and to be respected.
Conjoint family therapy works on eight different levels: physical, intellectual, emotional, sensual, interactional, contextual, nutritional, and spiritual. Sometimes a child needs to be hugged in the session (physical/interactional), for example, and sometimes it is best to cry along with a father grieving for his lost son (spiritual/emotional). The art of conjoint family therapy is learning to work on different levels simultaneously in a natural manner that resonates with the family's needs at the time of the session.
Conjoint family therapy is like solution-focused therapy in that both assume that people have the resources within them to flourish. They both encourage people to take risks and take control of their lives in a very direct and open manner. Also, they both stylistically rely on a very down to earth, approachable manner in the therapist.
Cognitive/behavioral family therapy. Cognitive/behavioral family therapy was developed by Gerald Patterson, Robert Liberman and Robert Stuart in the 1970s. It was a natural outgrowth of applying academic principles of learning and behavior change to the family situation (Liberman et al. 1980; Patterson 1971; Stuart 1980).
A family who enters cognitive/behavioral family therapy spends the first few sessions undergoing a careful functional assessment devoted towards defining exactly what the problem behaviors, attitudes, and interactions are in the family and under what conditions these troublesome symptoms appear. Cognitive/behavioral family therapists focus on dyadic interactions (e.g., husband-wife, parent-child) much more than those in other schools of therapy. The therapist's goal is to teach how one's behavior can influence the others in the family and how controlling one's own thoughts can control how one feels.
The range of techniques used in cognitive-behavioral family therapy is multidimensional. The basic learning principles of positive reinforcement, negative reinforcement, extinction, and modeling are used, as well as more complex clinical procedures such as contingency contracting (where each person writes down their obligations in the relationship and the privileges or rewards they expect to get from the relationship). A very popular technique developed by Stuart (1980) in his work with couples is to have caring days. In this technique, each partner writes down what behaviors he or she wants the other to exhibit. Then each partner promises to carry out eight to twenty of the requests made by the other partner during the week. There is no quid pro quo here. Each person engages in the behavior to become a "reinforcing object" for the other.
Cognitive-behavioral family therapy is successful with a very wide range of problems including marital problems, sexual problems, dealing with children who are diagnosed with conduct disorder or oppositional disorder, coping with mental or physical illness in the family, and dealing with children with anxiety disorders. There is more empirical evidence to support the efficaciousness of cognitive-behavioral family therapy than any other modality.
Solution-focused family therapy. A family who enters solution-focused family therapy, developed by Steven deShazer (1982, 1985, 1994), spends their time talking about the present and the future. All of the techniques are driven by the therapist's goal to use minimal interventions to help the family rediscover what will help them solve their problem.
The therapist's goal is to stay in the here and now and help the family re-discover resources that have helped them solve difficult problems in the past. The focus is always on what is possible and changeable. The prior solutions are labeled as the "problem" and the presenting problem is often left backstage as new solutions are highlighted. The therapist is very active and directive, and like the strategic family therapist, accepts responsibility for the family's outcome. The treatment is brief; sometimes it can consist of only one session. The therapist is looking for behavioral changes and when these occur, the case is closed.
The first and most popular technique is geared towards helping the family define what they want to be the goal of therapy. The family is quickly able to supply these goals by asking the miracle question. The question is posed to the family in the following way: "Suppose you were to wake up tomorrow morning and your problems were solved by some miracle. How would you know that a miracle had occurred? What would be different?" For a depressed mother the answer may be, "I would wake and smile at my daughter and fix her a good, nutritious breakfast. After she went off to school, I would spend the morning looking for a job." Once the therapist helps clients achieve these realistic goals, they feel empowered to create additional changes (deShazer 1982, 1985, 1994).
Another popular technique is scaling, where the family members rate the family well-being on a scale of one to ten, with one being the worst and ten being the best. By frequently asking for ratings the therapist gets feedback on the different perceptions of the family members and the effects of the intervention, and can give the family the expectation for change.
There are four types of conversations fostered during the therapy session: (1) competence talk (focusing on the strengths of individual family members and their collective strengths a family); (2) exception talk (searching for instances in the past where they have dealt with the problem or a similar problem in a successful way); (3) context-changing talk (focusing on how they act differently in different situations); and (4) deconstructing the problem (helping the family see how the problem makes changes inevitable and possible).
While solution-focused therapy has many similarities with strategic therapy (they are both brief and centered in the here and now and have active directive therapists), the big difference is that in solution-focused therapy the therapist is looking for clients to come up with new solutions that can work for them, and in strategic therapy the therapist is coming up with directives that seduce the family into trying a new set of behaviors.
Third-Generation Family Therapies
By the mid 1980s, a number of therapists had written books about the need to integrate the different schools of family therapy. Eclectic family therapy became the "buzz." The two hallmarks of eclectic approaches are: (1) they attempt to respect and utilize cultural attitudes, values, rituals, and social structures, and (2) they borrow theory and technique from a variety of schools to assess the family and develop a treatment plan.
Eclectic therapies do not assume that everyone wants to individuate from their families of origin. Indeed, they acknowledge that for many minority cultures in America the greatest value is placed on interdependence of family members and sacrifice of individual goals for the good of the family (Sue and Sue 1990). The eclectic therapist is expected to learn about different cultures and master the art of understanding cultural norms, avoiding stereotypes, and respecting individual differences.
The eclectic therapies often offer a guidebook to help therapists choose from the buffet table of techniques and theories available to them. The essential point is to realize that solution-focused therapy is not for everyone, nor is structural family therapy. The goal of a successful family therapist is to learn to use the right assessment tools to find the right intervention strategy for a particular type of family with a particular type of problem. A depressed eight-year-old female living with her grandmother in the inner city needs a different combination of family assessments and interventions than a depressed sixteen-year-old boy with a twin sister who is being brought up by his mother and her lesbian partner.
The most influential eclectic family therapy approaches are Larry Feldman's (1992) integrative multilevel family therapy, William Walsh's (1991) integrative family therapy, William Nichol's (1988) integrative approach to marital therapy, and David Will and Robert Wrate's (1985) problem-centered psychodynamic family therapy.
Fourth-Generation Family Therapies: Developmental, Positive, and Ethno-Political Approaches
Experience and research with the eclectic approach revealed that certain technique combinations do consistently work with certain populations. Family therapy is becoming specialized according to the presenting problem and the goals of therapy. For example, often therapists dealing with eating disorders start with a core of behavioral/cognitive interventions and then use structural techniques, as needed, on a case-by-case basis. In addition, empirical research has led to at least two new broad portals that define fourth generation family therapies at the beginning of the twenty-first century.
Developmental family therapies are therapies helping families deal with developmental crises that arise at each stage of the family life cycle—e.g., infertility, dual careers, death, disability, chronic illness, stepfamilies. Specific theories about the nature and trauma of each event guide the family therapist in a highly tailored assessment process and intervention strategy (Carter and Mc-Goldrick 1989). These specialized approaches have been around since the early 1960s but their acceptance, popularity, and common philosophy define them as a twenty-first-century force in the field. The most empirically validated therapies in this category include medical family therapy programs (McDaniel, Helpworth, and Doherty 1992), sexual dysfunction therapies (Leiblum and Rosen 2000), and family programs for severe mental illness (Marsh, Dickens, and Torrey 1998).
Ethno-political family therapies take a transcultural perspective and help resolve problems families have interfacing across cultures and different political regimes. These therapists are involved in helping refugees adjust to their new countries, victims of political unrest and war cope with new family demands, and governments and agencies develop programs based on economic and political analyses of family stressors. For example, when working with refugees who migrate to the United States, therapists first need to learn about the premigration stressors. Was the family fleeing from a war or a famine? Were they trying to reunite with family in the United States? Did they have a comfortable life style in their country of origin? Then, therapists need to assess post-migration stressors. Do the refugees know how to speak English well? Are they embarrassed by their accents? Are they able to find a job commensurate with their level of education? What is there visa status? Are they worried about family left behind? Do they have a financial responsibility to send money home? Third, the therapist must assess the social support system. Who are they looking to for help and for emotional support in this country? In which social institutions are they comfortable (e.g., school, church, community center), and which are threatening to them? Finally, do they think of their visit here as "temporary" and wait for the opportunity to return home, or do they want to become U.S. citizens? Interventions then vary by need and cultural considerations. For example, interventions designed to support Hispanic women who are the major breadwinners may help empower their husbands and make the pair comfortable in developing a new, more balanced relationship to fit the new social demands of the situation. Interventions for a Russian Jewish family where the parents feel isolated may concentrate on helping them establish ties with the wider Jewish-American community.
In this portal, therapists are developing approaches for families to deal with racism (Boyd-Franklin 1993), culturally pluralistic environments (Szapocznik et al. 1994), and oppression (Sue 1994). Most ethno-political therapists have followed and elaborated on Minuchin's structural approach, making it more relevant to diverse ethnic groups and cultural milieus.
Family Therapy and Ethics
A wide assortment of mental health professionals practice family therapy including psychologists, psychiatrists, psychiatric social workers, psychiatric nurses, and pastoral counselors. While all family therapists must follow the ethical guidelines established in their discipline, there are ethical issues unique to family therapy. Thus, special ethical guidelines have been established by the American Association of Family Therapists. Two of the thorniest issues concern defining who is the client (Is it the parent who brings the child, the child, or both of them? Is it the wife, the husband, or the couple?) and confidentiality (If the child tells you he is smoking marijuana do you have to keep confidentiality or do you have to break confidentiality and tell the parent?) (Gladding, Remley, and Huber 2000).
See also:Boundary Dissolution; Codependency; Conflict: Family Relationships; Eating Disorders; Family Assessment; Family Diagnosis/DSM-IV; Family Rituals; Family Science; Family Systems Theory; Forgiveness; Munchausen Syndrome by Proxy; Relationship Metaphors; Self-Esteem; Separation Anxiety; Therapy: Couple Relationships; Therapy: Parent-Child Relationships; Triangulation
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Preventive and therapeutic interventions in infancy and early childhood are often directed at the parents' sensitivity. Sensitivity refers to parents' ability to perceive their children's signals and needs accurately and to respond to these signals promptly and adequately (Ainsworth et al. 1978). Enhanced parental sensitivity stimulates the children's socioemotional development, in particular their attachment security. The theory of attachment was developed by John Bowlby (1982, 1988) to explain the nature of a child's emotional tie to his or her parent, and the attachment relationship with the parent is one of the child's first and most important developmental milestones. Children who are securely attached to their parent seek support from their parent in times of stress and distress, and are able to explore the world and mature in a healthy way. If the attachment relationship is insecure, children do not have a sense of a secure base, and the development of normal behaviors such as exploration, play, and social interactions is impaired. Attachment experiences become internalized as a working model of attachment. Long-term research suggests that children who, as infants, were securely attached have more optimal social and emotional functioning. Therefore, preventive and therapeutic interventions often aim at enhancing parental sensitivity and children's attachment security. Although most of these interventions take place in industrialized Western countries, they are based on fundamental research conducted in various parts of the world, which supports the cross-cultural validity of the basic assumptions (van IJzendoorn and Sagi 1999). It should be noted that several intervention studies have been implemented with cultural minority samples.
Types of Interventions
Byron Egeland and his colleagues (2000) identified three types of intervention: (1) programs directed at the parent's sensitive behavior; (2) programs that focus on the parent's working model (or mental representation) of attachment and parenting; and (3) intervention efforts that attempt to stimulate or provide social support for parents (for a narrative review of the studies, see Juffer, Bakermans-Kranenburg, and Van IJzendoorn, in press).
The first type of intervention, focusing on sensitivity, often starts by teaching parents observational skills in order to make them better perceivers. This goal can be reached in several ways: for example through stimulating parents to complete a workbook about the behavior of their child, or by encouraging parents to engage in "speaking for the baby" through verbalizing their child's behavior (Carter, Osofsky, and Hann 1991). The therapist may also encourage the parent to perceive the child's behavior in a more correct, objective way, in other words, without distortions, by explaining salient issues about the child's development. Many interventions that focus on parental sensitivity concentrate on prompt and adequate responding, for example through discussing parenting brochures or by modeling the desired behaviors. Another strategy to enhance sensitivity is by reinforcing sensitive and responsive behaviors that the parents already show to their child, for example with video feedback (e.g., Bakermans-Kranenburg, Juffer, and Van IJzendoorn 1998; Seifer, Clark, and Sameroff 1991).
In the second type of intervention efforts are directed towards the parent's mental representation, and the focus of change is the parent's working model or representation of his or her own attachment experiences (Bowlby 1982). Many of these intervention programs base their approach on the work of Selma Fraiberg (Fraiberg, Adelson, and Shapiro 1975). Fraiberg realized that parents are apt to "re-enact" or repeat the parenting behavior of their own parents, even unconsciously and involuntarily. Her famous metaphor of "ghosts in the nursery" has inspired interventions that are typically insight-oriented, therapeutic, and lengthy. The idea is that maladaptive parenting behavior may be changed by changing the mental representations or inner working models of the parents. In this type of intervention parents are involved in discussions about their past and present attachment experiences and feelings in child-parent psychotherapy or in psychodynamic therapy. Often these interventions take a long time, for example, fifty sessions, although some interventions attempt to pursue their goal in a shorter period of time, for example, four to ten sessions.
Nancy Cohen and her colleagues (1999) describe two examples of interventions focusing on the parent's representation. One of the two treatments evaluated in this study was Psychodynamic Psychotherapy (PPT), a parent-infant therapy for clinically referred infants. During center-based sessions mother and infant are invited to play. The mother and therapist talk together, but they also try to attend to the infant's activities. In this representational approach the therapist makes use of psychodynamic transference, repetition of the past, reexperiencing of affect, and interpretation. In the second treatment, Watch, Wait, and Wonder (WWW), a representational approach is combined with a behavioral approach. The authors describe WWW as infant-led psychotherapy: Mothers are given the opportunity to explore with the therapist intergenerational (representational) issues, although a specific and ultimate goal of WWW is to enable the mother to follow her infant's lead (behavioral approach). For half of each session the mother is instructed to get down on the floor, to observe her infant, and to interact only at her child's initiative. According to the authors, this method places the mother in the position of being more sensitive and responsive. After about fifteen sessions both PPT and WWW were successful in reducing infant-presenting problems and in reducing maternal intrusiveness. The infants in the WWW group showed a greater shift towards secure attachment, and their emotion regulation improved more than in the PPT group.
The third type of intervention aims at stimulating or providing social support to parents. The importance of practical and emotional support from relatives or friends for the parent's functioning and subsequently the child's developmental outcome has been supported by ample empirical evidence. Several interventions make use of social support primarily, sometimes by giving practical help and advice, by offering individualized services, by providing information about community services, or by stimulating the parents to extend their social network.
Social support may be more influential at particular times in the parent's development. The transition to parenthood, as a period of considerable change in routines, expectations, and behaviors, requires numerous physical and emotional adjustments. In such a transition period parents may not only need more help, but may also be more receptive for support from others. An intervention program that is illustrative of this line of reasoning is the preventive intervention for couples becoming parents. In groups that extend from pregnancy through three months postpartum, expectant parents receive support from the group leaders (a married couple) and from the other group members by sharing hopes, feelings, and worrisome thoughts (Cowan and Cowan 1987).
Other interventions combine the provision or enhancement of support with promoting sensitive parenting. Finally, the provision of social support can be combined with both a behaviorally focused intervention and a representational approach. For example, in project STEEP (Steps Toward Effective and Enjoyable Parenting) (Egeland et al. 2000), mothers not only receive practical support and advice, but also video feedback, in order to increase sensitive parenting, and help to examine and discuss their own childhood experiences.
Effectiveness of Interventions
Are family interventions effective in enhancing parental sensitivity and children's attachment security? A meta-analysis of seventy published papers reporting on eighty-eight interventions with effects on sensitivity (81 studies with a total of 7,636 participants) and/or attachment (29 studies with 1,503 participants) revealed that interventions are significantly but only modestly effective in enhancing maternal sensitivity. The effect on attachment was even smaller. Intervention that focused on sensitivity only showed the largest combined effect on sensitivity, meaning that interventions with a relatively "narrow" focus tend to be more effective than "broadband" interventions (see also Van IJzendoorn, Juffer, and Duyvesteyn 1995). With respect to attachment, interventions that focused solely on enhancing maternal sensitivity also showed a positive effect on infant attachment security, and these interventions were more effective than the others. In fact, it was the only type of intervention yielding a significant combined effect size. Unexpectedly, a large effect on sensitivity was found in a small subset of three studies that did not use personal contact in the intervention, but a soft baby carrier, a videotape, or a parenting brochure. However, because this set of studies was small, this finding does not allow for strong conclusions.
Somewhat puzzling was the finding that studies with fewer intervention sessions were more effective in changing maternal sensitivity than studies with more intervention sessions. Interventions with fewer than five sessions were as effective as interventions with five to sixteen sessions, but both were more effective than interventions with more than sixteen sessions. Jennifer MacLeod and Geoffrey Nelson (2000) came to a similar conclusion in their meta-analysis of the reported effects of programs for the promotion of family wellness and child maltreatment. Contrary to their hypothesis, effect sizes were highest for interventions with one to twelve visits, lowest for those with thirteen to fifty visits, and in-between for those with more than fifty visits. Less seems more, at least in the area of preventive and therapeutic family interventions.
The interventions that were directed at families at risk (e.g., poverty, depression, lack of support, or adolescent mothers) showed as much improvement on attachment security as interventions that approached families without risks. Interventions in samples with a higher percentage of insecure children in the control group reached relatively large effects on attachment. In samples with more security in the group to which the intervention group is compared, it is difficult to reach an even higher percentage of security as an effect of the intervention. Surprisingly, however, at-risk samples were comparable to other samples in their response to different types of interventions, and more intensive interventions do not seem to be more effective in groups with more serious problems.
The study of early intervention in the service of children's socioemotional development involves thousands of families with multiple problems. Enhanced parental sensitivity and a secure attachment relationship are at the heart of the interventions. Other theoretical frameworks have inspired parent-management training programs for parents of children with conduct problems or disruptive behaviors (e.g., Foote, Schuhmann, Jones, and Ey-berg 1998). Huge investments to accomplish these goals are made by intervenors, using a wide array of intervention methods. Nevertheless, interventions appear to have a varying degree of success in reaching their goals. Behaviorally focused interventions with a modest number of sessions appear most efficient. From a population health perspective, society should profit from the insights of successful early intervention programs, as childhood experiences may affect subsequent health status in profound and long-lasting ways.
See also:Attachment: Parent-Child Relationships; Boundary Dissolution; Conflict: Parent-Child Relationships; Discipline; Eating Disorders; Family Assessment; Parenting Education; Parenting Styles; Separation Anxiety; Therapy: Family Relationships; Triangulation
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MARIAN J. BAKERMANS-KRANENBURG
MARINUS H. VAN IJZENDOORN
"Therapy." International Encyclopedia of Marriage and Family. 2003. Encyclopedia.com. (July 29, 2016). http://www.encyclopedia.com/doc/1G2-3406900429.html
"Therapy." International Encyclopedia of Marriage and Family. 2003. Retrieved July 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3406900429.html
Therapy is short for the term “psychotherapy.” Psychotherapy uses talking, learning, feeling, and remembering to help people solve mental, emotional, and behavioral problems and change their lives for the better.
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Many people believe that therapy is one of the most effective ways to achieve and maintain good mental and behavioral health. Therapy can help people understand, solve, and prevent problems as well as live more comfortably with problems that cannot be solved or prevented. Therapy also can support people during especially stressful times of their lives. In addition, it can teach people skills and strategies for coping with lifelong stresses, and it can make medications and other treatments work more effectively.
Therapy most often is provided by mental health professionals who have been trained and licensed to offer counseling. Therapists may include psychiatrists, psychologists, marriage and family therapists, social workers, ministers, and school counselors. People who work with therapists often are called patients or clients.
Different types of therapists use different methods of therapy to work with different kinds of problems, but all therapeutic methods involve an active partnership and alliance between the therapist and client. To create a safe and trusting alliance, or relationship, therapists follow several basic principles:
- Therapists protect the privacy and confidentiality of the information their clients share with them during therapy sessions.
- Therapeutic settings provide clients with safe environments and safe boundaries. Clients are not judged, disrespected, or intruded upon.
- Therapists strive to inspire confidence, encourage emotional expression, and increase their clients’ expectations for success in therapy and in the world outside therapy.
- Therapists encourage self-knowledge and self-awareness in their clients so that clients can learn to manage their own thoughts, feelings, and actions after therapy has ended.
Clients and therapists work together to help the client learn to decrease distress, improve health, and increase quality of life.
When a patient develops trust in the relationship with a therapist, the therapy setting may become right for transference to occur. Transference represents the “transfer” of the patient’s feelings onto the therapist. Complex feelings from childhood experiences and from important relationships can transfer to the therapeutic setting. These may include frustration about not getting the expected love or approval from parents and teachers, fear that parents or loved ones will abandon (leave) us, anger that authority figures (teachers, parents) want us to follow rules, and all aspects of love, hate, pride, shame, disappointment, grief, hope, and affection. Because the therapist is not the parent or loved one who was involved in the original relationship, the therapist and client are able to discuss how those earlier hurts might feel in the safe therapy setting. The client might then learn how to change his or her behaviors in current relationships outside therapy.
Individuals, families, and groups
Therapy also can involve different groups of people. In individual therapy, a client works with a therapist in a one-to-one relationship. This often is referred to as a therapeutic “dyad,” from the Greek word that means “two.” In group therapy, several people with similar problems work together with one or two therapists. This form of therapy can be particularly helpful for people whose problems tend to occur when they must function in groups or teams at school or work. In family therapy, a married couple or an entire family attends therapy sessions, with individuals working together as a unit to understand and resolve the problems the family is experiencing. The family therapist helps members of the family feel safe as they learn both to express their own emotions and to listen to and understand the emotions of other family members.
Therapists use many different approaches to create the trusting partnership that allows people to change their thoughts, feelings, and behaviors. No one method is better than the others, and many therapists use “eclectic” approaches that combine techniques from many different methods.
Group therapy sessions help people with similar problems learn to understand themselves, understand each other, and ask for and accept help and support from others whenever necessary. PhotoEdit, Inc.
Psychoanalysis is the original form of “talk therapy.” During psychoanalysis, people talk about their dreams, desires, wishes, and fantasies from early childhood through the present day. Feelings or information of which people are unaware are called unconscious, but they still may affect their behavior. By “making the unconscious conscious,” people can bring this material into awareness and understand how it may be affecting their daily lives. For example, angry feelings about a parent may be affecting a person’s relationship with her boss. Insight and awareness can be used to create change and resolve conflicts. Psychoanalysis is considered a “psychodynamic” therapy because it emphasizes change, growth, and development.
Cognitive behavioral therapy (CBT)
CBT is a form of therapy that helps people learn to understand and change harmful thoughts, habits, and behaviors. It also can help people learn more effective ways to react to mental problems, emotional problems, and stressful situations. For example, people who think negatively about themselves and the world around them can learn to change these pessimistic thought patterns into thoughts that might be more adaptive. CBT often helps people with anxiety disorders, phobias, addictions, attention deficit hyperactivity disorder, and conduct disorders.
Gestalt therapy, based on the German word that means “form” or “pattern,” focuses on the entire shape of a person’s life: body and mind, habits and beliefs, experiences and actions, home and family, school and friends. This holistic approach to change focuses on making small shifts in body and behavior (for example, chewing food a different way or putting on clothing in a different sequence) that eventually may transform many larger aspects of a person’s life. This form of therapy often is associated with the psychologists Frederick “Fritz” Perls (1893–1970) and Paul Goodman (1911–1972).
Play therapy is used with younger children who may not be old enough to put their thoughts and feelings into words. Play therapists use dolls, toy soldiers, building blocks, games, and sand trays that allow children to express their problems in nonverbal ways. By observing the child’s actions and choices during play, the therapist gradually is able to understand what the child cannot say, help the child learn to understand and put words to the problems expressed through play, and work out solutions during play that can be used in the outside world.
Art, music, dance, and pet therapy
These forms of therapy work in much the same way as play therapy. They use sensory experiences, such as drawing, dancing, drumming, or petting dogs and cats, instead of talk therapy or as a supplement to it.
Hypnotherapy, also known as medical hypnosis, uses an altered state of consciousness called a trance that allows the client to relax, concentrate, listen to the therapist’s suggestions, and learn new behaviors. Hypnotherapy is a recognized form of treatment and is not the same as “stage hypnosis,” where the hypnotist “makes” the volunteer act “like a chicken.” Researchers do not yet understand exactly how hypnosis influences the brain, but they have used it successfully to help people stop smoking, manage eating disorders, and control chronic pain.
Eye movement desensitization and reprocessing (EMDR)
EMDR is a newer approach that combines talk therapy with a series of eye movements. The eye movements are believed to “reprogram” the brain’s information processing systems. EMDR is used most often with people who have had a severe emotional experience (for example, witnessing a car accident) and need to “unlearn” the stress responses created by past trauma.
Psychoanalysis and psychodynamic therapy follow a set of psychological theories that emphasize change, growth, and development. Psychoanalysts believe that change and development are achieved by understanding the internal motivations, drives, forces, and impulses that determine behavior.
Sigmund Freud used the ancient Greek drama Oedipus Rex, written by Sophocles, as a metaphor for parent-child relationships. In this complex drama, Oedipus is a king who unknowingly kills his own father and marries his own mother. In Freud’s “Oedipus complex,” a son may be jealous of the attention and love his father gets from his mother. When he grows up, the son may even marry a woman who reminds him of his mother. The Bridgeman Art Library International
The specific focus of psychoanalysis is unconscious mental activity—the experiences and feelings that people are unaware of but may still influence them. People in psychoanalysis are encouraged to talk about their dreams, wishes, desires, and fantasies so that the unconscious forces that shape and control their behavior can be brought into awareness and be understood. This form of therapy allows people to understand emotional conflicts, disappointments, and traumas that they experienced during childhood and to reconstruct them in the present with the therapist’s guidance.
As with other forms of therapy, change is the goal of psychoanalysis. Change can help ease emotional pain, redirect troublesome behaviors, and improve relationships with the important people in an individual’s life. The techniques that psychoanalysts use to create change include:
- Insight: This refers to awareness and understanding. Often it is described as “making the unconscious conscious.”
- Affective expression: This involves expressing feelings, conflicts, and impulses. It sometimes is referred to as “catharsis.”
- Developing an observing ego: This allows people to monitor and control their own emotions and behaviors.
- Transference: This allows people to “transfer” leftover feelings from other relationships to the therapist, who helps them deal more effectively with difficult feelings.
- Conflict resolution: This allows people to create newer and more helpful patterns for dealing with old and new stresses and problems.
Analytic psychology and psychotherapy
Sigmund Freud (1856–1939) was responsible for most of the original concepts of psychoanalysis. Alfred Adler (1887–1937) shifted its focus from sexual issues to issues of power and authority, introducing the term “inferiority complex.” Carl Gustav Jung (1875–1961) expanded analytic psychology to include the “collective unconscious” of entire populations as expressed in their myths, fairy tales, metaphors, and artistic creations. Freud’s daughter, Anna Freud (1895–1982), and one of Freud’s students, Melanie Klein (1882–1960), expanded Freud’s theories and techniques to include drawing and playing, which made analysis more useful in the treatment of young children. Even though therapists disagree on how useful Freud’s theories are today, most modern therapists agree that the basis of all forms of psychotherapy originated with the work of Dr. Sigmund Freud.
Rather than focusing on the unconscious conflicts that are important in psychoanalysis, CBT uses the way people think and interpret their experiences to understand why they sometimes react to stressful situations in harmful ways. CBT helps people understand their troublesome thoughts and behaviors, learn more helpful ways to behave, and practice the new behaviors until they feel comfortable substituting new thought patterns and new behaviors.
Sigmund Freud And The Unconscious Mind
Sigmund Freud (1856–1939), a doctor of neurology, is considered to be the founder of the modern science of psychiatry. Freud developed the technique of psychoanalysis and introduced many important concepts about the human mind and human behavior.
Freud’s theory described the human mind as having three parts, which he called the id, ego, and superego. Freud thought this structure provided the underlying organization for human experience, with each part of the psychic structure performing specific functions:
- The id exists from birth and controls all the basic drives that motivate people to find pleasure and seek satisfaction. Many of these drives are unconscious, meaning that they occur outside the awareness of the individual.
- The superego maintains moral standards, conscience, goals, and ideals. The superego controls feelings such as selfesteem and guilt.
- The ego is the part of the mind that balances the drives of the id and the controls of the superego. The ego represents a person’s sense of self and is the part of the mind that organizes, directs, and synthesizes the personality.
According to Freud’s theory, all three parts of the mind function together, with the ego acting as a brake on both the id and the superego, keeping them functioning at a healthy balance. Freud believed this balance could be achieved through a therapeutic process that he called psychoanalysis.
Freud introduced many other important concepts that are used today to understand how the mind works, including unconscious motivation, transference, and the Oedipus complex. Some of his best known concepts include:
- Defense mechanisms: These are emotional protectors that help the ego or self defend against overwhelming ideas or harmful thoughts.
- Denial: This is a defense mechanism that helps people refuse to believe thoughts or feelings that are intolerable.
- Repression: This is a defense mechanism that helps people forget events that are too painful to remember.
- Libido and psychosexual development: Freud believed that sexuality begins to develop at birth and that children go through phases he called oral, anal, and genital even before they reach puberty.
- Jokes and “Freudian slips”: Freud believed that unconscious thoughts sometimes slipped into conversation as jokes or “accidental” word combinations.
Many of Freud’s ideas and innovations are used in everyday language and communication today. There even is a comic strip called The Wizard of Id. For many people, Freud remains synonymous with the concept of psychotherapy.
Thoughts, beliefs, and assumptions
Cognitive activities keep our brains busy most of the time. We think about ourselves, our friends, our families, our everyday activities, and our futures. Cognitions include core beliefs, automatic thoughts and assumptions, self-talk, self-images, and even behavioral choices, since most of us think before we act. Sometimes, however, our beliefs, assumptions, and thoughts influence or motivate feelings that create behaviors we want to change. “I always mess up when I try something new,” for example, is a thought or cognition that may lead to fear of change, fear of failure, and not taking action when needed. Working with the progression from thoughts to feelings to behaviors, CBT therapists help people learn to change their assumptions, which leads to changes both in emotional reactions and in behaviors. “Sometimes I succeed when I try something new” and “everyone makes mistakes when they try something new” are different cognitions that can lead to new behaviors.
Sigmund Freud is considered to be the founder of the modern science of psychiatry. Corbis
This picture shows the interior of Dr. Freud’s office, on display at the Freud Museum in London. Instead of using a stethoscope or scalpel, Freud treated his psychoanalytic patients by encouraging them to lie on a couch and talk about how their fantasies, dreams, wishes, and desires affected their daily activities. Today, patients sit up in chairs more often than they lie on couches, but psychoanalysis continues to be “talk therapy.” Peter Aprahamian/Corbis
CBT therapists use therapeutic techniques to help people first identify the thoughts and behaviors they want to change, then identify the factors and situations within their environment that create or maintain the targeted thoughts and behaviors. Once people have done this, the next step is to learn new methods for thinking and acting whenever they encounter the situations that trigger the behaviors they want to change. For example, hearing the message “you always mess up when you try something new” from a parent, teacher, or older brother or sister might be the situation that a CBT therapist would help a client work on. Some of the specific techniques of CBT include:
- Assertiveness training: learning how to “stick up” for ourselves and practicing it with the therapist until we can do it on our own.
- Desensitization training: gradually learning how to deal with situations that trigger fear and anxiety by rehearsing similar situations and learning new response patterns in the safety and privacy of the therapist’s office under the therapist’s supervision.
- Token economy: using rewards, such as extra play time or new videos, to strengthen and reinforce new behaviors. The more difficult the new behavior, the more tokens the client is likely to receive from the therapist.
Often, a CBT therapist will choose a combination of techniques, but all of them will focus on step-by-step change in a safe and private environment with a mental health professional who inspires confidence, encourages emotional expression, and has patience while the client learns to succeed.
In marriage and family therapy, the “client” is a married couple or an entire family. The couple or the family is thought of as a complete system in which each member has influence on the system as well as on the other individual members. At the beginning of the process, one member of the family is the patient (often called the “identified patient”) who “brings” the family to therapy. However, during the process of therapy, the family becomes the patient and learns how to improve all of the interactions that affect relationships among members (the system).
Some of the techniques that family therapists use include:
- using family trees (genograms) to help families understand how the family structure works
- encouraging each member of the family to share his or her thoughts and feelings without fearing the reactions of other family members
- training each member of the family to listen to the thoughts and feelings of other family members in a nondefensive manner, without blaming or feeling threatened
- role-playing with the family so that each member learns to understand the family from all other points of view
- role-playing with the family to model new patterns of behavior that involve sharing, communicating, disciplining, caregiving, and adjusting to illnesses or changes in the family structure
- assigning family homework that gives the family practice in using the new skills they have learned during their therapy sessions
Pavlov, Watson, And Skinner
Cognitive behavioral therapy was developed from the science of behaviorism, which originated with the work of the Russian physiologist Ivan Pavlov (1849–1936).
Pavlov used dogs to study the digestive system, focusing on the salivary glands, pancreas, and liver. During his research, Pavlov noticed that the dogs began to salivate whenever they heard a bell. He remembered that the bell always rang before the dogs were fed, and he realized that the bell had become a stimulus for the dogs’ digestive systems, because the dogs had linked the bell to food. This discovery led to the development of the science of classical conditioning (also called Pavlovian conditioning), in which “unconditioned” (natural) stimuli are deliberately linked to other events, turning them into “conditioned” stimuli. Pavlov was awarded the Nobel Prize for medicine or physiology in 1904 for his work on the digestive system in dogs.
John Watson (1878–1958) often is referred to as the founder of behaviorism. Watson’s work focused on the “response” aspect of classical conditioning. Watson knew from Pavlov’s work that conditioned stimuli (such as a bell ringing before feeding) provoked conditioned responses (such as dogs salivating when they heard a bell). But Watson also observed that stimuli similar to the conditioned stimulus could lead to similar conditioned responses. For example, Watson observed that a boy afraid of rabbits might also be afraid of white furry creatures like guinea pigs. This observation was particularly important in the study of phobias. One approach to treating phobias involves slowly approaching the feared object. The further away, the less the fear. Gradually the person becomes used to being close to the object of their phobia.
B. F. Skinner
B. F. Skinner (1904–1990) is the psychologist who elaborated on Watson’s theories and developed a system for behavior change called “operant conditioning.” This system used rewards (“positive reinforcement”) and punishments to increase or decrease specific behaviors. Skinner helped develop much of our understanding about behavior, and his theories formed the foundation of modern behavioral therapy, the forerunner of CBT. The token economy technique in CBT relies on Skinner’s theories of operant conditioning.
Family therapy can be especially effective for families during periods of stressful change or when families are affected by abuse, addictions, or chronic illnesses.
With so many different forms of therapy, how is it possible to choose the right therapist? In fact, most people rely on referrals from a family doctor, school counselor, hospital social worker, or trusted friend who has been helped by a therapist and understands the complexities of the process. Because feelings of safety, trust, privacy, and confidence in the therapist are such key aspects of healing, it is important to discuss any doubts, fears, and dislikes frankly with one’s therapist. If a person feels he or she is not working well with a therapist, it is reasonable to consider changing to a different therapist. But because therapy is about improving relationships, most often, speaking up about one’s doubts will help the therapist adjust his or her behaviors and techniques to make the therapeutic process even more effective.
Murray Bowen And The Family System
In the late 1950s, a Menninger Clinic psychiatrist named Murray Bowen noticed several things in his work with people who had mental illnesses:
- Sometimes hospitalized patients with mental illnesses got worse after visits from their families.
- Sometimes symptoms of mental illness improved in one member of a family but got worse in another member of the same family at the same time.
- Sometimes parents seemed to resist change and improvement in their children with mental illnesses.
Dr. Bowen concluded that an entire family could be responsible for whether an individual family member recovered from illness or got worse. Based on his observations, Dr. Bowen developed methods of working with the entire family system in therapy. While for most therapists the individual is the patient, for family therapists the family is the patient.
American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Avenue Northwest, Washington, DC 20016. This professional organization has a Facts for Families link at its website. Its Glossary of Symptoms and Mental Illnesses Affecting Teenagers and its fact sheet Questions and Answers About Child and Adolescent Psychiatry explain many different aspects of psychiatric illness, evaluation, and treatment. Telephone 800-333-7636 http://www.aacap.org
American Psychiatric Association, 1400 K Street Northwest, Washington, DC 20005. This professional association publishes a series of pamphlets and fact sheets that describe psychiatric illnesses and treatments. Its fact sheets Psychotherapy and Psychiatric Medications and its pamphlet series Let’s Talk About Facts can help people understand the stigma sometimes attached to mental illness and psychiatric treatment. Telephone 888-357-7924 http://www.psych.org
American Psychological Association, 750 First Street Northeast, Washington, DC 20002. This professional association publishes books, brochures, and fact sheets. It provides referrals to local psychologists, and its website includes a good search engine and a KidsPsych feature. Telephone 800-374-2721 http://www.apa.org
U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892. This division of the National Institutes of Health provides current and reliable information about psychotherapy for the public and for professionals. Telephone 301-443-4513 http://www.nimh.nih.gov
"Therapy." Complete Human Diseases and Conditions. 2008. Encyclopedia.com. (July 29, 2016). http://www.encyclopedia.com/doc/1G2-3497700388.html
"Therapy." Complete Human Diseases and Conditions. 2008. Retrieved July 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3497700388.html
ther·a·py / ˈ[unvoicedth]erəpē/ • n. (pl. -pies) treatment intended to relieve or heal a disorder: a course of antibiotic therapy | cancer therapies. ∎ the treatment of mental or psychological disorders by psychological means: he is currently in therapy | [as adj.] therapy sessions. DERIVATIVES: ther·a·pist / -pist/ n.
"therapy." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. (July 29, 2016). http://www.encyclopedia.com/doc/1O999-therapy.html
"therapy." The Oxford Pocket Dictionary of Current English. 2009. Retrieved July 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O999-therapy.html
"therapy." Oxford Dictionary of Rhymes. 2007. Encyclopedia.com. (July 29, 2016). http://www.encyclopedia.com/doc/1O233-therapy.html
"therapy." Oxford Dictionary of Rhymes. 2007. Retrieved July 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O233-therapy.html