Family Psychotherapy Research Paper

The origins of family therapy can be traced to three roots. The first is the social work, marriage and family life education, and marriage counseling movements that began in the late 1800s and early 1900s (Broderick & Schrader, 1991; Kaslow & Celano, 1995; Kaslow, Kaslow, & Farber, 1999; Thomas, 1992). Toward the end of the nineteenth century, social workers began to provide classes to educate families (primarily women) to help prevent family problems. During such classes, participants often discussed their own problems; a family approach was adopted to view their problems in the context of the family. Many leaders of the marriage and family life education movement eventually became pioneers of the field of marital and family counseling.

The second root of the family therapy movement is clinical psychiatry. Several influential family therapy theoreticians were trained psychoanalytically, and their practices often began by treating individual patients. A common denominator among such psychiatrists was the recognition that certain problems of their individual patients were connected to current and family of origin dynamics. That recognition led the professionals to recognize that interventions at the family level constituted the treatment of choice even for their individual clients (e.g., Bateson, 1972; Bowen, 1988; Lidz, Cornelison, Fleck, & Terry, 1957a, 1957b; Minuchin, 1974). Ackerman, a child psychiatrist and psychoanalyst, arrived at similar conclusions in working with children and argued that the proper unit of diagnosis is the family rather than the child.

The third root of family therapy is that of general systems theory and communications theory and their application in understanding human interactions (e.g., Bateson, 1972). The application of the theory was influential in the famous doublebind explanation of the etiology of schizophrenia (Bateson, Jackson, Haley, & Weakland, 1956). Although double-bind messages are no longer considered the cause of schizophrenia, other constructs of general systems and communication theory continue to inform family therapy practice.

In addition to the aforementioned theoretical roots, the growth of a number of organizations was influential in advancing the family therapy movement (Kaslow et al., 1999). In the 1930s a number of marriage counseling centers were established, and the 1930s and 1940s witnessed the professional growth of the field of marital and family therapy. During that era two professional organizations were established. Family life educators established the National Council of Family Relations (NCFR), and marital counselors organized the American Association of Marriage Counselors (AAMC). During the 1970s the AAMC was renamed the American Association of Marriage and Family Therapy (AAMFT); both organizations remain active.

The field of family therapy has undergone a number of changes and expansions commensurate with cultural changes and technical and scientific advances. First, new theories of family therapy have emerged, and integrative models have expanded understanding of family functioning from multiple perspectives. Second, empirical analyses of family therapy tenets and the efficacy of the methods have advanced the field. Third, since the 1970s family therapy has enjoyed international recognition. In fact, the American family therapy movements both informed and were influenced by family therapy around the world. Fourth, ethical guidelines have been established for both research and practice of family therapy. Fifth, subspecialties of family therapy have emerged(e.g.,sextherapy,divorcemediation).Sixth,thefield has become more sensitive to diversity with regard to family structure, ethnicity and race, gender, social class, and sexual orientation.

In this research paper we provide a broad and comprehensive, albeit not complete, review of the theories and techniques of family therapy. After providing background information on family systems theory and characteristics of individual families, we turn to family intervention approaches. We discuss the major family intervention models and then examine culturally competent and gender-sensitive family therapies. This is followed by a look at specific applications of family therapy (e.g., medical family therapy, substance abuse, family violence). After reviewing the current state of the field of family therapy research, we offer directions for the future practice and research in family therapy.

Family Systems Theory

Theories of family therapy are based on the assumption that an individual’s behavior must be viewed and addressed within the context of the family. The family is seen as an evolving and developing living system whose members are interdependent. Each individual is influenced by the system as a whole and, at the same time, influences the functioning of the system. The family changes and develops over time, moving to different levels of organization and function during the course of the individual’s and the family’s life cycle. The family system struggles to maintain a balance between change and stability or homeostasis.

Systems theory assumes a hierarchical structure within the family based on the higher degree of responsibility and power of the executive subsystem (e.g., parents, mother, and grandmother) in comparison to the child subsystem. This structure is maintained by implicit rules, functional roles of individuals (e.g., primary breadwinner, primary caregiver, parentified child), and family routines. The components of the family structure are called subsystems and are delineated by boundaries. Asubsystem may refer to an individual within the larger system or to a group of individuals connected by a common task or level of power within the family system. The boundary between the subsystems refers to the implied rules, activities, or behaviors that maintain some separation between the subsystems (e.g., parents sharing a bedroom, having routine periods of time away from the children). Avariety of subsystems might be found in the family depending on the family’s composition (e.g., sibships, same-sex family members, executive subsystem).

Most family systems theories acknowledge four aspects of functioning: cohesion, adaptability, communication, and organization. Cohesion refers to the level of interdependence between family members and is usually viewed on a continuum from overinvolvement (i.e., enmeshment) to complete detachment (i.e., disengagement). Healthy families maintain a balance between connectedness and respect for individuality; this balance changes over the life cycle of the family.Adaptability, ranging from chaotic to rigid, indicates the family’s ability to make changes in certain circumstances while maintaining stability in values and rules for behavior. Communication processes in the family may involve verbal expression of content and emotions or nonverbal, less direct expression of feelings and relationships (e.g., silent treatment, physical signs of affection). Organization refers to the structure, rules, and roles of the family system. According to most theories of family therapy, the general goal of therapy is to create changes in family interaction patterns, which will in turn result in more adaptive family functioning and individual change.

Family systems theory also assumes that the family system as a whole interacts with other outside systems (e.g., educational system, community, government, work environment). The family as a whole is influenced by, and may have some influence on, the surrounding systems. A family therapist should always determine the extent to which a family is involved in outside systems and the degree to which family functioning is impacted by these interactions.

Characteristics of Individual Families

Family Development

Theories of family therapy assume that families change and develop, and much has been written about the changing family life cycle (e.g., Carter & McGoldrick, 1989). Family development most often is described in relation to the family’s function of raising children. Stages of traditional family development include the commitment of two adults to a relationship, the decision to raise children and the increased responsibilities therein, boundary changes as children enter school and the outside world, increasing independence of family members as children enter adolescence, and the renegotiation of the parental relationship as the children leave home.

The family life cycle is influenced by family constellation (e.g., single-parent, remarried). For example, the divorce cycle varies depending on the state of the family’s life cycle and includes the separation and divorce process, postdivorce, and the formation of a remarried family (Carter & McGoldrick, 1989). Other factors that impact the family life cycle include culture, ethnicity, immigrant status, chronic illness, death, substance abuse, and psychiatric disorders.

For some families migration is a significant life cycle transition that is often ignored. Immigrant families have myriad responses to this transition, based in part on their reasons for migration. Families who came to the United States for economic or educational reasons may adapt more easily than those seeking refuge or fleeing political persecution (McGoldrick, Giordano, & Pearce, 1996). Families who migrate within the United States for sociopolitical reasons (e.g., African Americans, Native Americans) also are faced with unique challenges. Families who effectively adapt to the migration experience are those with the capacity to alter family’s structure and interactional processes to meet the demands of the new culture while keeping cultural patterns from their countries of origin (Bullrich, 1989).

The different stages of family life require adaptation to the developmental needs of the individuals within the family and to the demands of the outside world. The family system must change in order for individual members and the system as a whole to survive. Each stage of family development presents different tasks for the family and involves fluctuation in responsibilities and dependency needs of family members. Family development does not always follow a smooth path, but is often discontinuous. Periodically, the family must renegotiate implicit rules around behavior (e.g., how much time a child is allowed to spend away from the family with peers). As young family members mature, they are given new responsibilities and freedoms. Roles and relationships must be renegotiated. A child may take on more household responsibilities and in turn will earn age-appropriate freedoms. At this same time, the parent relinquishes some control over the child’s choices and allows the child to differentiate from the family in order to develop as an individual. When the children leave their family of origin, the adults must renegotiate their relationship and develop new routines and goals. The process of development over the life span of a family calls for a certain degree of stability in order to provide for the health and safety of individual members. However, healthy family development requires flexibility within the family structure so that the changing needs of maturing members may be met.

Family Structures and Types

Many theories of family therapy have been based on the model of a traditional nuclear family, consisting of two heterosexual parents and their biological children. Family therapists today, however, are faced with a wide variety of family configurations and living situations. Given the high divorce rate (40–50%; Bramlett & Mosher, 2001), over 20% of families in the United States are blended families including stepchildren or children who live with another parent outside of the home (Gorall & Olson, 1995). Single-parent families present different challenges because there is only one adult to assume parenting and financial responsibilities. Some families have multiple generations living in the home, or they have grandparents as the primary caretakers of children. Other nontraditional family constellations include adoptive and foster families, as well as gay and lesbian families (e.g., Dahlheimer & Feigal, 1994; Matthews & Lease, 2000;

Scrivner & Eldridge, 1995; Settles, 1999). Still other families may have nonbiological relatives living in the home who are a very integral part of the family structure. Given the variability in family constellations, family therapists generally define “families” as natural social systems that function as a unit with common goals, rules, roles, power structure, routines, forms of communication, and strategies for negotiating and problem solving that allow for various tasks to be accomplished (Goldenberg & Goldenberg, 1999). Relationships among family members are significant and multifaceted and are impacted by a common history, shared perceptions and world beliefs, and a common purpose. Family members are connected by attachments and loyalties that persist over time even though the intensity and quality of these relationships may ebb and flow.

Family Normalcy and Health Versus Dysfunction

The family therapy field increasingly has shifted from an emphasis on finding a singular, universal model for family normality and health to developing conceptualizations of normal family processes that take into account the diverse patterns of family functioning associated with differing family structures, sociocultural contexts, and developmental challenges (Walsh, 1993). Although there are varied viewpoints about what constitutes optimal family functioning, there is general agreement that normal family functioning implies cohesion among family members that helps to maintain a clear family structure while at the same time allowing for age-appropriate autonomy. The family is able to adapt to environmental and developmental demands by making shifts in power structure, role relationships, and rules. Communication is clear and effective, and family members are able to negotiate rule changes and solve problems together. Individual and subsystem boundaries are mutually understood and respected.

Family dysfunction occurs when the family is unable to adapt to the demands of normative development or of the environment. Systems theories assume that pathology lies within the system interactions, not within the individual. Family interaction patterns and structure become so rigid that the family system is unable to make the necessary changes to promote the health of the individual members or to allow expected changes in the family life cycle. According to systems theory, the psychological symptoms of any individual serve to maintain a certain balance, or equilibrium, within the family. If change threatens the family’s established structure or pattern of interaction, an individual may develop psychological symptoms that perpetuate old patterns of family functioning. For example, if marital tension increases and the stability of the nuclear family is threatened, a child may begin to display behavioral symptoms that interrupt the marital conflict, focus parents on their roles as caregivers, and reduce the threat of destruction of the family unit.

When determining the relative health of a given family, a number of factors, in addition to the aforementioned constructs associated with theories of healthy family functioning, must be considered. Different phases of the family life cycle call for varying levels of cohesion and adaptability, and the current life cycle phase of a particular family must be taken into account. Patterns of family functioning that may be appropriate in one phase of a family’s development (e.g., after the birth of a child) may impede development at another phase (e.g., adult children leaving home). Stressful life events (e.g., loss of a home, diagnosis of a chronic illness) may require different family interaction patterns, either on a temporary or on a long-term basis. When working with a family, the therapist must consider patterns of interaction in light of family stressors and recent events. In addition, family interaction patterns vary across cultures and ethnic groups. It is important for a family therapist to understand a particular family’s sociocultural context before determining whether interactional patterns are maladaptive (Walsh, 1993).

Historically, definitions of family normalcy or health failed to acknowledge the influences of culture, social class, ethnicity, and race on family structure and process (Walsh, 1993). Family theorists and therapists have begun to understand the social construction of normal family functioning and have highlighted the fact that because definitions of normal behavior vary across cultures, therapists must not characterize certain family patterns as dysfunctional just because they deviate from the norms of the dominant culture or the norms that are held by the therapist or reflected in his or her theoretical view. They have also underscored the fact that culture contributes to how families define the nature, timing, tasks, and rituals related to life cycle phases and transitions (Carter & McGoldrick, 1989).

Meaning, Beliefs, and Rituals

Family members share beliefs, values, and a worldview that are transmitted across generations. These beliefs provide connection with the nuclear family, as well as with the extended family in the past and future. Family beliefs provide a foundation and a lens through which each member filters life experiences and influence the meaning that family members attribute to certain situations, events, and life circumstances (e.g., death, prosperity, loss).

Family beliefs and values often are communicated and maintained through family rituals (Imber-Black, Roberts, & Whiting, 1988). For example, family celebrations highlight the value placed on certain life span events (e.g., birthdays, weddings, funerals). Rituals around holidays emphasize family values through inclusion of family members and repetition over time (e.g., Thanksgiving dinner, religious celebrations). Daily routines can also serve to communicate and perpetuate important values. For example, mealtime routines emphasize the importance of shared family time and nurturing. Family rituals and routines contribute to cohesion and stability within the nuclear family and across generations.

Family Intervention Approaches

Psychodynamically Oriented Family Therapy

Psychodynamically oriented family therapy, the nearest descendant of individual psychoanalytically oriented psychotherapy, is one of the few family models that acknowledges its ties to psychoanalytic thinking. Initially, psychodynamically oriented family therapists espoused a classical psychoanalytic or ego-psychological perspective. Ackerman, an early proponent of psychoanalytic family therapy, integrated psychoanalytic and systems theory (Ackerman, 1938). He viewed dysfunction as a failure in role complementarity between family members, as the product of persistent unresolved conflict within and between individuals in a family, and as a reflection of prejudicial scapegoating. His therapeutic interventions focused on disentangling interlocking pathologies. Framo (1981) postulated that unresolved intrapsychic conflicts, resulting from interactions with one’s family of origin, are projected onto one’s partner and children. Therefore, the goal of therapy is the working through of the negative introjects, which can be accomplished through a sequence of couples therapy, couples group therapy, and then family of origin meetings separately with each partner.

At the present time, the dominant form of psychoanalytic family therapy is object relations family therapy (Gerson, 1996; Leupnitz, 1988; Scharff, 1989; Scharff & Scharff, 1987, 1991; Slipp, 1988). Object relations family therapy, a longterm treatment approach, addresses unresolved intrapsychic conflicts that are reenacted in one’s current life, causing interpersonal and intrapsychic difficulties. Therapy goals include delineating and redefining problems so that they are more accessible to resolution; clarifying boundary issues; explicating individual needs and desires and how these can be fulfilled within the partnership-family system; modifying narcissistic or inappropriate demands; increasing expressive and listening skills; diminishing coercive and blaming statements; facilitating problem solving and conflict resolution; modifying dysfunctional rules and communication patterns; helping family members achieve increased insight; strengthening ego functioning; acknowledging and reworking defensive projective identifications; attaining more mature internal self and object representations; developing more satisfying interpersonal relationships that support one’s needs for attachment, individuation, and psychological growth; reducing interlocking pathologies among family members; and resolving partner and therapist-patient transferences. When these goals are achieved, they make possible the attainment of more ultimate goals including trust and closeness, role flexibility, appreciation of uniqueness, comfort with and enjoyment of one’s sexuality, and an egalitarian power relationship between the couple as parents and partners, a balance between the cognitive and affective realms of living, positive self-image for each and family esteem for all, clear communication, and the resolution of neurotic conflicts.

To accomplish these goals, the therapist provides a holding environment (i.e., time, space, and a structure) that enables family members to feel secure enough to express their feelings and beliefs, feel intimate, and maintain a sense of self. The therapist reparents the family by providing consistent nurturance and a structure to enhance the development of individual members and the family unit. Once a therapeutic alliance is established and a thorough history is obtained, the therapist empathically interprets conflicts, resistances, negative transferences, defenses, and patterns of interaction indicative of unresolved intrapsychic and interpersonal conflicts. Effective interpretations link an individual’s and a family’s history with current feelings, thoughts, behaviors, and transactions, permitting more adaptive family interactional patterns and intrapsychic changes. Object relations family therapists address transference and countertransference dynamics to facilitate this endeavor. They use their own reactions to the family’s interaction patterns (objective countertransference) to understand the shared yet unspoken experiences of each family member regarding family interactional patterns (unconscious family system of object relations). They use their objective countertransference reactions to interpret interpersonal patterns in which one family member is induced to behave in a circumscribed and maladaptive fashion (projective identification). Although there are specific techniques associated with object relations family therapy, techniques are considered secondary to the alliance between therapist and family.

Experiential-Humanistic Family Therapy

Experiential-humanistic family therapy has its roots in individual schools of existential-humanistic therapy: Gestalt therapy, client-centered therapy, psychodrama, logotherapy, and the encounter group and sensitivity training movements (Wetchler & Piercy, 1996). Central tenets of family therapies based on the experiential-humanistic model include the belief in freedom of choice and the potentials for human (family) growth; the emphasis on the here and now (i.e., focus on the present as opposed to the past); the primacy of experience over rational thought (especially intellectualization); the importance of fostering open communication, genuineness, and authenticity in dyadic relationships in the family; and a positive and hopeful model of humanity. These therapies are unique in their emphases on the “person of the therapist” and on the belief that emotional interchanges between therapist and family members are key therapeutic elements.

According to existential-humanistic family therapy, family dysfunction arises from communication and interactional problems and their associated symbolic meaning. Goals of therapy include the development of awareness of experienced emotions; choosing to be honest in expressing genuine emotions with other family members; and the exploration of immediate inner experiences and relational interactions. The goals are achieved through the therapist’s joining with the family; managing (not interpreting) resistance; pointing to and defining symptoms as efforts toward growth; explicating covert conflicts (e.g., battles for structure and initiative); and fostering open communication, genuineness, and authenticity in dyadic relationships in the family. The achievement of those goals is believed to manifest in the gaining of personal fulfillment and the growth of the family as a whole through increased self-awareness and self-esteem, clarity of communications, and the alteration of the meaning that family members attribute to family interactions.

Whitaker, a founder of experiential-humanistic family therapy, purported that his symbolic-experiential approach is atheoretical (e.g., Whitaker, 1976; Whitaker & Bumberry, 1988; Whitaker & Keith, 1981; Whitaker & Ryan, 1989). He believed that theories are hindrances to “being” and to genuine human experiences in therapy. However, a number of therapeutic emphases have been identified to represent his approach, including the importance of symbolic experience, spontaneity and creativity, growth, battles of structure and initiative, and issues related to psychotherapeutic impasse.

Other schools of experiential-humanistic family therapy include Gestalt (Kempler, 1974, 1981), human validation (e.g., Satir, Stachowiak, & Taschman, 1975), and emotion focused (Johnson & Greenberg, 1985, 1994; Johnson, Hunsley, Greenberg, & Schindler, 1999). Gestalt family therapists strive to help each person within the family attain maximum individuation combined with more vital relationships by facilitating self-exploration, risk taking, and spontaneity. In the human validation model, the therapist and family work together to stimulate an inherent health-promoting process within the family system that is characterized by open communication, emotional experience, and positive self-esteem in each member. This often is achieved through the use of such growth-enhancing techniques as family sculpting.

The most empirically supported form of experiential systems therapy is emotionally focused couple therapy. This approach helps couples identify repetitive negative interaction sequences that restrict accessibility to one another and redefine their problems as reflective of emotional blocks. As these rigid patterns are reprocessed and restructured, the partners are more capable of forming secure attachments and a better sense of connection with one another.

Communication Model

The communication model, the dominant model in the 1960s, has contributed substantially to the field of family therapy. Indeed, one can recognize the far-reaching influences of this model in all schools of family therapy. Originally formulated at the Mental Research Institute (MRI) by Bateson, Jackson, Weakland, and Haley in Palo Alto, California, in the 1950s, the model gained prominence by providing a description of the etiology of schizophrenia based on family communication patterns.According to the double-bind formulation of schizophrenia, a form of paradoxical communication takes place in families with a member who has schizophrenia (Bateson et al., 1956). It was argued that in such families, contradictory messages are communicated along with a third message that the receiver of the message should not make the inconsistencies explicit. Such communication was theorized to cause confusion and pave the way for the emergence of symptoms characteristic of schizophrenia. Although double-bind communication is no longer believed to cause schizophrenia, the focus on maladaptive communication remains an influential aspect of the communication model. According to the model, all behavior is communication; the difference between various communications is whether they are at the surface or content level, or at the metacommunication or intent level.

Communications family therapy typically is time limited, with a maximum of 10 sessions. An individual clinician or cotherapy pair conducts the treatment, often with consultants behind a one-way mirror. The approach is problem focused and behaviorally oriented. It is believed that providing insight to the family is not a necessary agent of change. The goal of therapy is the reduction or elimination of suffering through problem resolution. Thus, therapy is focused on replacing repetitive, dysfunctional behaviors and communication patterns with healthier ways of behaving and communicating.

Strategic Family Therapy

Strategic family therapy gained prominence in the 1970s and took center stage in the 1980s. The communication model and Erickson’s strategic therapy heavily influenced this approach. Initially developed by Haley (1973, 1976, 1984) in PaloAlto, this approach was further developed by Haley at the Philadelphia Child Guidance Clinic and by Haley and Madanes at the Family Therapy Institute of Washington, DC (Madanes, 1991). Central in the theoretical formulation of strategic family therapy is the notion that individual and family problems are maintained because of maladaptive familyinteractional sequences that include inappropriate hierarchies within the family, as well as malfunctioning triangles. Failed attempts of family members to resolve problems are viewed as the very behaviors that perpetuate the problem (Haley, 1976). Hence, strategic interventions designed to alter the way family members interact and relate to one another are viewed as curative agents in strategic family therapy. Because family interactions are considered to be circular and nonlinear, it is theorized that fundamental changes in the way family members relate are necessary precursors to individual change.

Strategic family therapy is change rather than growth orientated, and little effort is made to provide the family with insight into their problems. The therapy tends to consist of brief interventions in which either the entire family or one or two family members are present. The therapist is active, authoritative, and directive. Goal setting is a major component of strategic family therapy, and two sets of goals are delineated. First, short-term goals are formulated based on the presenting problem; however, in an attempt to enhance motivation in the family, the goal is defined as an increase in positive behaviors rather than as a decrease in negative behaviors. Second, more long-term goals are set with a focus on altering the interactional sequences that have maintained the problem in the first place. In accordance with the above, Watzlawick has pointed out that successful family therapy would involve not only first-order changes (superficial changes that take place without meaningful alterations in the family structure) but also second-order changes, by which family structures are modified, resulting in long-lasting change (Watzlawick, Weakland, & Fisch, 1974).

Techniques of strategic family therapy include the initial interview, which is divided into five stages: social, problem, interaction, goal setting, and task setting. Once the therapist is able to derive an overall formulation, he or she develops a therapeutic approach involving a series of tactical interventions, called directives. Some such directives, categorized as straight directives, help maintain a cooperative stance between the therapist and the family. Other directives, labeled paradoxical directives, are utilized when the family is resisting change. Strategic family therapy also incorporates interventions designed to modify existing behavioral sequences. These include paradoxical interventions (e.g., therapeutic use of double-bind communication, positioning, restraining, symptom prescription), reframing, positive connotation, ordeals, pretending, and unbalancing. Because strategic family therapy is time limited and has a problem-solving focus, termination is often a natural process (Segal, 1991). When a family resists termination, termination is reframed as a break from therapy so that gains can be consolidated.

Structural Family Therapy

The focus of structural family therapy, pioneered by Minuchin (e.g.,Minuchin,1974;Minuchin&Fishman,1981;Minuchin, Lee, & Simon, 1996), is on family structure, which expresses itself through family interactions. The family experiences transitions to which the family structure must adapt in order to allow for individual growth and a stable environment.Awellfunctioning family has a well-defined, elaborated, flexible, and cohesive structure (Aponte & VanDeusen, 1981), allowing it to make the necessary adjustments. According to structural family therapy, dysfunctional families are marked by impairments in boundaries, inappropriate alignments (i.e., joining of one member with another), and power imbalances. These families become rigid in the face of stressors, unable to shift familiar patterns of interaction.

In structural family therapy, the course of treatment is typically brief, and the participants are usually those family members that interact on a daily basis.The therapist’s role is that of a director who joins with the family and actively evaluates the family structure. This evaluation includes assessment of boundaries, flexibility, subsystems, the role of the symptomatic family member, the ecological context of the family, and the developmental stages of individuals and the family system. The primary goal of therapy is the resolution of the presenting problem. This goal is achieved through altering the family’s conceptualization of the problem and restructuring the family to allow for more adaptive patterns of interaction.

Behavioral and Cognitive-Behavioral Approaches

Approaches that fall within the rubric of behavioral and cognitive-behavioral family therapy include behavioral couple therapy (Gottman, 1999; Jacobson & Christiensen, 1996; Jacobson & Margolin, 1979), cognitive-behavioral family therapy (Dattilio, Epstein, & Baucom, 1998), behavioral parent training (Patterson, 1975), functional family therapy (Alexander & Parson, 1982; Morris, Alexander, & Waldron, 1988), and the conjoint treatment of sexual dysfunction (Heiman, Epps, & Ellis, 1995; Mason, 1991). We focus this section on cognitive-behavioral family therapy, behavioral parent training, functional family therapy, and sex therapy.

Cognitive-behavioral therapy emphasizes both the behaviors and the cognitive processes of family members. Cognitive-behavioral family therapy assumes that people’s cognitiveprocessesinfluencetheirbehaviors,interactionswith other family members, and emotional reactions. Cognitivebehavioral therapy involves the assessment of family members’ beliefs, causal attributions, expectancies regarding the presenting problem, and logical analysis of distorted automatic thoughts. Techniques of therapy include cognitive restructuring aimed at changing dysfunctional interactive patterns and belief systems, communication skill building, problem-solving training, and homework.

Behavioral parent training aims to train parents in behavioral principles of child management. Strategies include teaching families to develop new reinforcement contingencies to increase the probability that new behaviors are learned. Commonly used techniques include skill acquisition, contingency contracting, and the imparting of behavioral principles.

Functional family therapy integrates systems theory, behaviorism, and cognitive therapy. The interactional sequences in which problems are embedded are addressed, and the function of these behaviors is ascertained. Family members’ cognitions about one another and each other’s problem behaviors are evaluated. Functional family therapy facilitates cognitive change and provides education in which specific strategies are provided to bring about behavior change. The goal is to provide new behavior patterns to meet individual functions of each family member.

Transgenerational Family Therapy

Two major schools of transgenerational therapy are family-of-origin therapy and contextual therapy. Family-of-origin therapy is based on the work of Bowen (1988; Friedman, 1991; Kerr & Bowen, 1988), who views the family as an emotional relationship system. Dysfunction occurs when an individual is unable to differentiate from the family of origin and is thus unable to assert his or her feelings or thoughts, resulting in chronic anxiety. The interaction patterns within a family of creation (i.e., partners) are based on each individual’s differentiation from his or her family of origin.

In family-of-origin therapy, the therapist works as a coach who develops a relationship with individual members but avoids becoming entangled in family relationships. The goal of therapy is for each individual to be differentiated within his or her family of origin. Typically, therapy involves the partners, but it can involve multigenerational sessions. One primary technique of therapy is the use of the genogram, a visual map of family history, structure, and relationships, to illustrate historical patterns of family interaction and behavior (Kaslow, 1995; McGoldrick & Gerson, 1985; McGoldrick, Gerson, & Shellenberger, 1999). From the genogram, hypotheses are formulated about the relationship between the presenting problem and family patterns. Key concepts of family-oforigin therapy include differentiation of self, triangulation, and the multigenerational process. Differentiation of self refers to an individual’s ability to keep emotional and intellectual functioning distinct, being able to choose which system influences his or her activity at a given time. Triangulation occurs when two family members become aligned, or join together, in opposition to another family member. The concept of multigenerational process describes how the emotional process of a family can be transmitted across generations, with each successive generation being impacted by the levels of differentiation and relationship patterns of family members in previous generations.

Contextual family therapy is another form of transgenerational family therapy based on the writings of Boszormenyi-Nagy (e.g., Boszormenyi-Nagy & Krasner, 1986; Boszormenyi-Nagy & Spark, 1973). Whereas familyof-origin therapy focuses primarily on past relationships, contextual family therapy focuses more on current relationships with the family of origin. Goals of therapy are to reveal and address invisible loyalties, rebalance actual obligations to repair strained family relationships, and develop more trusting relationships with a balance of give and take among family members. The therapist works toward developing relational fairness in the family and attends to the sense of indebtedness between generations. Although the therapist serves as a catalyst for change, the family does much of the therapeutic work outside of the therapy sessions through homework assignments (e.g., writing letters, making phone calls, visiting the family of origin). Key concepts include relational ethics, family legacies, and family ledger. Relational ethics are concerned with fairness and equality among family members. Family legacy refers to the expectations passed from one generation to the next. The family ledger is the account of what family members have given to one another and what each family member owes.

Psychoeducational Family Therapy

In psychoeducational family therapy, families are helped to remedy individual and family difficulties and to improve family functioning (McFarlane, 1991). The underlying principle of psychoeducational interventions is that family members can be educated to create an optimal environment for their disabled loved ones, an environment that minimizes stresses exacerbating the patient’s illness and enhances the patient’s capacity for adaptive functioning. In the past these approaches have been successfully used with families in which a member has severe psychopathology (e.g., schizophrenia or affective disorders; Anderson, Reiss, & Hogarty, 1986; Falloon, Boyd, & McGill, 1984; Miklowitz & Goldstein, 1997). Other applications of this approach include sexual dysfunction, attention-deficit/hyperactivity disorder (ADHD), marriage enrichment, and family skills training. Generally speaking, psychoeducational interventions represent a variety of theoretical orientations, with no one orientation being predominant.

Psychoeducational approaches can be applied in an individual family format or with multiple families. There are four phases of treatment in the psychoeducational model as applied to work with families with a loved one who has been diagnosed with a schizophrenia spectrum disorder. The first phase coincides with relapse, followed by the education, reentry, and rehabilitation phases. Psychoeducational family therapy includes short-term, intermediate, and long-term goals. Short-term and intermediate goals include stabilizing symptoms, educating the family about the particular condition, educating the individual and family about pharmacology, establishing a treatment team, establishing the importance of continuity of care, identifying coping resources for the family, and developing and using social support. The long-term goals of this approach include relapse prevention and reintegration into the community.

Systemic-Milan Family Therapy

The Milan group developed systemic family therapy in Italy (Boscolo, Cecchin, Hoffman, & Penn, 1987; Prata, 1990; Selvini-Palazzoli, 1974; Selvini-Palazzoli, Boscolo, Cecchin, &Prata,1978;Selvini-Palazzoli,Cirillo,Selvini,&Sorrentino, 1989). The central theme of this approach is that dysfunctional families remain so because they follow belief systems that do not fit their realities. As such, family interactions often are destructive and perpetuate the negative symptoms that sustain the family’s homeostasis. This treatment is process oriented and is viewed as an ecosystem in which each member can affect the psychological well-being of other members.

Family sessions range in number from 3 to 20 and are well spaced so that systemic change can occur. Sessions are led by an individual therapist or by cotherapists with interventions presented by a consulting team seated behind a one-way mirror. Systemic therapists often offer a directive for the family to complete between sessions. These directives include interventions such as circular questioning (one family member comments on the interactions of two other family members), rituals (prescribing an action that alters family roles by addressing spoken and unspoken family rules), counterparadoxical interventions (presenting a double bind that suggests the family not change), and second-order cybernetics (the cybernetics of cybernetics). These techniques highlight repetitive patterns of family behavior (games), introduce new conceptualizations of family problems, and encourage resolution of problems in new ways that result from systemic change. The specific goals of this treatment are determined by the family and are respected by the therapist (unless harm is being done to one of the family members). The general goals of systemic family therapy are to disrupt destructive patterns of family behavior and to enable the family to alter family belief patterns to fit their collective realities.

Evolving Models

In addition to traditional approaches, a number of newer family therapy approaches have been proposed. Those evolving models can be classified under the general umbrella of postmodernist, second-order cybernetics, and social constructionist perspectives in family therapy. The postmodernist, social constructionist perspective differs from the modernist perspective in that the therapist is viewed as a participant observer and not as the agent of cure. Thus, the therapist collaborates with the client system (the partners or the family system) to create a new reality that is free of the presenting problem. Several such evolving models are reviewed below.

Solution-Focused Family Therapy

Solution-focused family therapy, developed by O’Hanlon (O’Hanlon & Weiner-Davis, 1989), rests on the belief that meaning is a subjective experience. As such, the meaning a person, couple, or family attributes to a problem is also subjective, resulting in a problem formulation that is unique to them. At the heart of the solution-focused approach is the belief that reformulating the problem will result in new solutions that are likely to emerge and resolve the problem at hand. The transformation from a problem-focused to a solution-focused approach in therapy comes about through joining, describing the problem, finding exceptions to the problem, normalizing, and setting goals.

Solution-Oriented Family Therapy

Although solution-oriented family therapy, developed by deShazer (deShazer, 1985, 1991), shares many similarities with O’Hanlon’s solution-focused therapy, it differs from O’Hanlon’s model in important ways. This model also espouses a solution approach to therapy, but it takes the position that one does not need to know the nature of the problem in order to work on resolving it, that the presenting problem is not necessarily related to the solution, and that the solution is not necessarily related to the problem. One of deShazer’s more famous interventions, the miracle question, is descriptive of his approach:“Suppose that onenight there is amiracle and while you were sleeping the problem that brought you to therapy is solved: How would you know? What would be different? What will you notice different the next morning that will tell you that there has been a miracle? What will your spouse[partner]notice?”(deShazer,1991,p.113).Suchquestions are useful in redefining the problem and its causes, as well as in moving toward solutions that would resemble ideal outcomes.

The Reflecting Team Approach

The reflecting team approach, developed by Andersen (e.g., 1991, 1992), is similar to the Milan approach in many respects; however, it differs from the Milan approach in important ways. What is similar is the fact that the reflecting team approach also involves a group of consultants who view the family therapy session and make comments regarding both the therapeutic process and family interactions as they unfold. However, unlike the Milan approach, the reflecting team is not considered to be a panel of experts whose suggested interventions should be implemented by the therapist; instead, team members engage in the process as participantobservers. The reflections of the team are shared not only with the therapist but with the family as well. Then the family is free to examine the team’s reflections, deciding whether team members are correct or incorrect in their comments. Reflecting team members engage in true reflections: they do not necessarily arrive at solutions or suggestions; instead, they reflect on the family process and the therapeutic process as it unfolds in front of them. The reflecting team approach is in line with the postmodernist, social constructionist approach in the way therapists try to understand interactions and engage the family in a therapeutic endeavor.

Externalization and Reauthoring Lives and Relationships Approach

Central in the externalization and reauthorizing lives and relationships model, developed by White and Epston (White & Epston, 1990), is the notion of problem externalization, a method of redefining the problem as residing outside the individual or the family so that it can be viewed as an entity that can be looked at and worked on. White and Epston’s approach involves helping the client develop an alternative story to the one that he or she believes to be the “true” story. Such true stories often involve normative societal beliefs that are devoid of the personal experiences of the individual or the family. The individual or family often is troubled by such true stories; hence, developing alternative stories serves as the curative factor.

Therapeutic Conversations Approach

According to the therapeutic conversations approach of Anderson and Goolishian, alternatively called narrative therapy, a collaborative conversation is not possible if the therapist takes the position of the expert (Anderson & Goolishian, 1988). Hence, the family therapist must approach the therapeutic situation from the position of not knowing, or “a kind of deliberate ignorance” (Hoffman, 1993, p. 127). Family members are encouraged to tell their story, and the expertise of both thetherapist and the family members is utilized to resolve the family’s problems.According to this model, the system does not create the problem; instead, the problem defines the system: “the system consists of a conversation or meaning system organized around the problem” (Becvar & Becvar, 1996, p. 287). For other second-order cybernetics models, such as Keeney’s (1990) improvisational therapy and Flemons’s (1991) relational orientation to therapy, see Becvar and Becvar (1996).

Postmodern and Social Constructionist Approaches

Postmodern and social constructionist family therapies are relatively new approaches. These treatments move away from a systems view of the family, emphasizing individual experiences and viewpoints as well as the family’s interactions with larger systems (Gergen, 1985). Language is used to construct subjectively a story that includes the family’s view of reality. Problems are viewed as stories that families agree to tell about themselves.

A major concept underlying these therapies is that there are no fixed truths in the world, only multiple perspectives of reality. As such, the therapist encourages the family to define the goals of treatment. Postmodern therapists assume a collaborative role in the treatment and engage in therapeutic conversation with families to help them construct new meaning and understanding. The therapist helps the family reconstruct its story to include new interpretations of behavior that in turn encourage the development of new behaviors and solutions to problems.

Integrative Models

The family therapy approaches covered so far can be viewed as being of relatively pure form, that is, one theoretical system per approach. More recently, however, integrative approaches have gained prominence (Carlson, Sperry, & Lewis, 1997). Even a cursory review of recent writing and clinical practice reveals how completely transformed the field of family therapy has become by the integrationist movement. This paradigm shift toward integration has evolved from many sources (Lebow, 1997). Integration occurs at the conceptual level, theoretical level, level of strategy or technique, and level of intervention.

Most of the efforts combine systems, psychodynamic, and behavioral conceptualizations (e.g., Feldman, 1992; Kirschner & Kirschner, 1986; Nichols, 1987, 1995; Pinsof, 1995; Wachtel & Wachtel, 1986). Other efforts mix hereand-now, transgenerational, and ecosystemic approaches (Seaburn, Landau-Stanton, & Horwitz, 1995). Narrative and strategic (Eron & Lund, 1993), strategic and behavioral (Duncan & Parks, 1988), experiential and systemic (Greenberg & Johnson, 1988), and structural and strategic (Liddle, 1984) are further examples of integrative models. Other leaders have focused on combination of treatment perspectives in the development of interventions for specific populations, such as intimate partner violence, substance abuse, sexual dysfunction, medical problems in a family member, and various forms of child and adolescent psychopathology (for a review, see Lebow, 1997). In addition, some authors have utilized an integrative approach for working with families from specific cultures (Boyd-Franklin, 1989; Boyd-Franklin & Bry, 2000; Falicov, 1998; Hardy, 1994).

Although the majority of integrative models involve the combination of two systems of marital and family therapy, most truly integrative approaches involve the combination of more than two systems. The following are a few examples of integrative, multisystemic family therapy models that include more than two models.

Feldman (1992) was one of the first to propose a multisystemic, integrative approach that combines psychodynamic, cognitive, behavioral, and family systems perspectives. He offered a model for determining how individual and family therapy can best be utilized in the treatment of a particular individual, couple, or family. Central in his approach is a detailed assessment of interpersonal and intrapsychic processes that involves individual, family, and family subgroup interviews. Based on those interviews, a formulation is derived and shared with the family. The ensuing treatment, which is determined collaboratively with the family, may involve all of psychodynamic, cognitive, behavioral, and family systems interventions.

Walsh’s integrative family therapy approach is goaldirected and structured, typically lasts 10 sessions, and involves actively soliciting the family’s involvement (Walsh, 1991).CentralinWalsh’sapproachisanintegrativeevaluation of family structure, roles, communication patterns, perceptions, themes related to problems, and personality dynamics of key individuals. The integrative aspect of this model is readily recognizable because the family structure factors are based on Minuchin’s work, the communication and perception factor is derived from Satir’s work on communication and information processing, and the individual dynamics factor is influenced by Ackerman’s work. Indeed, Walsh placed a great deal of emphasis on working with individual personality dynamics and recommended that the integrative family therapist espouse both an individual psychotherapeutic and an integrative family therapy model.

Culturally Competent Family Psychotherapy

As the demography of the United States has shifted, a growing body of literature addressing culturally competent family therapy has emerged (e.g., Ariel, 1999; McGoldrick et al., 1996; Piercy, Sprenkle, & Wetchler, 1996). As a result of the shifting demography, family therapists and theorists have directed their attentions to the diverse cultural contexts that their clients represent and have begun to focus on the impact of their own culture and their clients’ culture on therapeutic process and outcome (Celano & Kaslow, 2000; Falicov, 1998; Kaslow, Celano, & Dreelin, 1995; Kaslow, Loundy, & Wood, 1998; McGoldrick, 1998; McGoldrick et al., 1996). Family therapists have come to understand that while family therapy theories reflect the culture in which they were developed, their clients do not always represent the same or even similar culture. As a result, therapists have come to appreciate that understanding the family’s sociocultural and ecological context is essential for interpreting the meaning and function of family members’ behavior and interactional patterns and for developing appropriate interventions (Tharp, 1991). The effectiveness of family therapy is increased when therapists recognize the dynamic interaction of cultural, individual, and family factors, including one’s own ethnicity (actual and selfdefined), the familial culture of origin, the culture in which the family is embedded, and the cultural groups with whom the family interacts (Szapocznik & Kurtines, 1993).

Ideally, the structure of family therapy is codetermined by cultural considerations combined with the therapist’s theoretical orientation.Therapists treating families from culturally diverse backgrounds must incorporate flexibility into their work. Flexibility in therapy structure and format is warranted given the differential help-seeking patterns found among many families from ethnic minority groups (McGoldrick et al., 1996). Additional adaptations include varying the length and frequency of sessions, accepting the changing composition of family and nonfamilial participants in sessions, conducting family sessions in community settings or the family’s home, and offering a gradual or delayed termination. Therapeutic goals are influenced by several cultural variables, including the role of authority (collaborative vs. hierarchical), decisionmaking processes (e.g., by whom and how implemented), perceptions of the cause of the problem (e.g., external, such as society, vs. intrafamilial, such as in-law difficulties, vs. internal, such as hormonal imbalances), meaning attributed to the problem, possible solutions for the problem (e.g., acceptable interventions), and therapist’s and family’s values (Celano & Kaslow, 2000; Kaslow et al., 1995, 1998).

Though there may be techniques and considerations unique to a particular cultural group, there are general guidelines and skills that are useful to incorporate into any culturally competent family therapy treatment. The therapist should endeavor to assess the importance of ethnicity and race to clients and families. This will allow the therapist to validate and empower clients within the appropriate cultural framework. In families where difficulties in cultural adaptation are associated with the presenting problem, the therapist should ensure that cultural concerns are made explicit rather than avoided. Placing a problem within the appropriate cultural context can enable a family to deconstruct problems as contextual rather than internal (Piercy et al., 1996). On the other hand, the therapist should also be aware of the attempts of some families to use culture as a defense against pain or a justification for resistance in the treatment.

Family therapists should work to create an atmosphere in which families feel that their culture is respected (Piercy et al., 1996). Sharing the same cultural background as the family in treatment does not ensure the creation of such an atmosphere, nor does coming from a different cultural background have to interfere with the creation of therapeutic comfort and safety. There are advantages and disadvantages in being in the same ethnic group as the client. Although there may be a natural rapport on which to build, there may also be overidentification with the family.

Another consideration in the conduct of culturally competent family therapy is the development of the therapeutic alliance. The family therapist is most effective in joining with the family if he or she exhibits an awareness of the family’s culturally determined rules, roles, structure, communication, and problem-solving patterns (Sue & Zane, 1987). In addition, the family’s structure and motivation for treatment, the family’s and the therapist’s own cultural contexts, and the cultural context that they cocreate influence the nature of the therapeutic alliance. Attention to joining is particularly important with families from ethnic minority groups given their increased risk for attrition from treatment (e.g., Kazdin, Stolar, & Marciano, 1995).

Gender-Sensitive Approaches to Family Psychotherapy

Gender-sensitive models are relative newcomers to the family therapy field. Although feminist critiques of other disciplines appeared in the 1960s, it was not until the late 1970s to early 1980s that they began to appear in the family therapy literature (e.g., Avis, 1985; Goldner, 1985; Hare-Mustin, 1978). Feminist models became more common in the late 1980s as theorists began developing new models of family therapy that considered gender as a major contextual factor (Ault-Riche, 1986; Avis, 1996; Bograd, 1991; Goodrich, Rampage, Ellman, & Halstead, 1988; Kaslow & Carter, 1991; Levant & Silverstein, 2001; McGoldrick, Anderson, & Walsh, 1988; Walters, Carter, Papp, & Silverstein, 1988). Literature addressing working with men in family therapy began to emerge in the 1990s (Bograd, 1991; Meth & Pasick, 1990).

In general, feminist approaches seek to underscore power imbalances; to highlight gender differences in relation to intimate relationships, parenting, and extended family relationships; and to discontinue social conditions that contribute to the maintenance of gender-prescribed behaviors (Avis, 1996). Such approaches also emphasize egalitarian relationships and the multiplicity of roles that men and women have in relationships. A major focus of male-oriented models of family therapy is the multiple images and roles of men (Bograd, 1990; Levant & Silverstein, 2001; Meth & Pasick, 1990; Philpot, Brooks, Lusterman, & Nutt, 1997). Such treatment seeks to support men as they value feelings related to their partners, children, and families of origin (Meth & Pasick, 1990). Male-oriented family therapy generally deemphasizes power, control, competition, and money in exchange for focus on the aforementioned topics. In general, interventions designed to acknowledge the importance of gender issues in family treatment should focus at least on the following steps: assessing the distribution of responsibility within the relationship, promoting shared responsibility between men and women, and addressing the balance of power within the relationship (Avis, 1996; Meth & Pasick, 1990).

Specific Applications

Medical Family Therapy

Most families will face the challenge of chronic medical illness or disability at some point during the family life cycle. Illness and disability in elderly members may be anticipated but can be disruptive to family routines and relationships. Other families are confronted with illness or disability at unexpected times, such as when a family member is young or has a role of responsibility in the family. Given the demands of caring for an ill family member, a chronic illness can become a central organizing principle in the family. If the family becomes too rigidly organized around maintenance of the chronic illness, transitions in the family’s development may be impeded (Reiss, Steinglass, & Howe, 1993). Nonillness family priorities may be suppressed, and normative family developmental issues can be ignored (Gonzalez, Steinglass, & Reiss, 1989).

Rolland (1994) discussed several aspects of chronic illness to be considered when examining the relation between family functioning and chronic illness: onset, course, outcome, type and degree of incapacitation, and degree of uncertainty. Illnesses with a gradual onset call for more measured alterations in family routines and structure than do those with a sudden onset. Families differ in their ability to mobilize rapidly when faced with sudden changes and to tolerate uncertainty over a prolonged period. The course of an illness can take one of three forms: progressive, constant, or relapsing or episodic. With a progressive illness, demands on the family continue to change over time. When the course is episodic, the demands of the illness require flexibility within the family. A constant course does not call for as many changes in demands on the family, but there is still the potential for exhaustion of resources and emotional strength. The outcome of chronic illnesses differentially affect family functioning due to varying degrees of anticipatory loss. Some illnesses have a more constant course with little chance of shortening an individual’s life, whereas other illnesses follow a progressive course that almost certainly results in death. When faced with a fatal outcome, families experience grief and the expected loss of a family relationship, as they must adapt to the demands of the illness. The degree of incapacitation has a tremendous impact on families due to increased dependency of a family member, role changes within the family, and possibly social stigma. Rolland also emphasized the added difficulty of coping with illnesses that involve a high degree of uncertainty. The demands of constant adaptation and problem solving can exhaust the resources of even the most flexible families.

The family therapist’s role with a family facing chronic medical illness may be to help the family find a place for the illness while working to maintain preillness family goals, routines, and rituals. The therapist must work to understand the demands of an illness and respect the family’s need to be highly focused on illness tasks at certain times. At the same time, the therapist should help the family become aware of how illness demands can interfere with family and individual development. When working with families in which a member has a medical illness, it is recommended that a model of collaborative family health care be adopted in which family therapists collaborate with other professionals, the family, and the patient in order to coordinate care for the benefit of the patient and family (McDaniel, Hepworth, & Doherty, 1992).

Substance Abuse

Given the tremendous negative impact of substance abuse and dependence on the lives of individuals, families, communities, and nations, prevention and intervention efforts have gained prominence on the national agenda. Substance abuse treatments have varied, extending from outpatient drug rehabilitation treatments to outpatient biological interventions (e.g., methadone treatment for heroin abusers) to inpatient therapies. For a number of reasons, delineated later, family therapy is an important and empirically supported therapeutic modality in the treatment of substance abuse (Edwards & Steinglass, 1995; Piercy et al., 1996).

Family therapy can be invaluable in substance abuse treatment because many substance abusers continue to desire a relationship with their families. However, due to behaviors related to substance abuse, family ties may be so strained that the abuser often is left without much remaining social support. In the life of a substance-dependent individual, the inability to go back home or to enjoy the support of family members is often synonymous with poor prognosis. Family therapy can be useful in helping to reconcile strained relationships and reestablishing family support for the patient. In addition to providing general support, the family can encourage the patient in the process of change and address other psychological difficulties such as depression (Piercy et al., 1996). Moreover, a family’s active involvement in therapy is likely to motivate the individual with a substance abuse problem to engage in treatment, reducing the possibility of early termination or relapse.

Family therapy also can be very effective in addressing codependent behaviors that often are present in the families of substance abusers. The abuser uses substances, but his or her family members often engage in behaviors directly related to substance abuse. It is in this way that family members can fall into codependent patterns (Bernheim, 1997). Hence, substance abuse is a systemic mental health problem. Family therapy can help address such systemic issues, which go beyond the identified patient and may prolong or sustain the addictive behavior.

Family Violence

Many family relationships are plagued by family violence, including child maltreatment (e.g., physical, sexual, and emotional abuse and neglect), intimate partner violence, and elder abuse. Given the severity, destructiveness, and pernicious nature of these problems, family therapists should be aware of key treatment issues: recognizing the need for safety within the family, focusing on individual responsibility, and acknowledging the role of culture in encouraging violent and abusive behavior (Carlson et al., 1997). Safety is the primary goal of any treatment where violence is present. When children or elderly family members are involved, mandatory reporting and involvement of the police or the appropriate government agency is the first step.

Although many people, including advocates, argue strongly against the use ofcouples therapy in cases of intimate partner violence, some therapists underscore the value of such anapproach(e.g.,Brooks,1990;Geffner,Barrett,&Rossman, 1995; Hansen & Harway, 1993; Harway & Hansen, 1994; Mantooth, Geffner, Franks, & Patrick, 1987). The basic assumptions of this work are as follows: Each person is responsible for his or her behavior; batterers have the ability to stop the abusiveness; violence and intimidation are unacceptable; the clients have there sources to change their behaviors and the relationship; and the couples therapist can facilitate and motivatethecoupleinthisprocess(Geffneretal.,1995).Treatment involves a thorough assessment of the relationship violence, relational dynamics, a determination of the appropriateness of couples therapy, a no-violence contract, and safety planning. The first stage of the therapy teaches the couple cognitive and behavioral skills to stop the violent behavior or defend against it and to address the emotions accompanying these changes. This includes anger management, behavioral controls, stress and anxiety management, addressing social roots of aggression, and developing plans for problematic substance use. The second stage emphasizes identifying intergenerational and social messages affecting the relationship and the working through of the emotional, cognitive, and behavioral consequences of these messages. Communication training, assertiveness and social skills training, conflict resolution and problem-solving training, skills in affect regulation, cognitive restructuring, and strategies to enhance self-esteem are also focal during this phase. The third stage includes an examination of the relationship and the decision whether to separate without violence or improve the relationship. In either case, couples therapy is used to help with the process. If the choice is to remain together, this work entails an in-depth analysis of power dynamics, expression of feelings with the goal of increased intimacy, and relapse prevention. In the final stage, the resolution stage, the treatment process comes to an end, and a long-term follow-up period begins.

Many therapists are also opposed to family treatment for childhood maltreatment. However, some family therapists have developed family-oriented treatment approaches for child abuse. For example, Barrett, Trepper, and Fish (1990) and Trepper and Barrett (1986) developed a comprehensive approach for the treatment of intrafamilial sexual abuse of children. In this model, the child’s well-being is paramount, and the cessation of abuse is the primary treatment goal. Systemic approaches are used to equalize power in the family. The goal of the offender is to end his or her denial, engage in a nurturing role as a parent, and become actively involved in a sexual relationship with an age-appropriate partner. Their multiple systems model asserts that abuse results from a combination of external, family, and internal systems. They argue that attributing blame is insufficient and that other contributing factors must be examined for long-term change to occur. Although aware of the complexities of a family model for the treatment of intrafamilial sexual abuse, they advocate the use of conjoint treatment in conjunction with individual therapy for each family member, as well as addressing larger social systems. As another example of a family-oriented treatment for child maltreatment, Henggeler and colleagues have found that both multisystemic therapy and parent training are useful in the treatment of child abuse and neglect (Brunk, Henggeler, & Whelan, 1987).

Understanding the role of the cultural context in which families exist is of the utmost importance in cases of family violence (Brooks, 1990; Carlson et al., 1997). Feminist theorists suggest that acknowledging the effects of patriarchal culture on men and women can provide therapists with a more comprehensive understanding of the experiences of the family system (Walker, 1979). Theorists who work with men highlight the importance of understanding the ways that men have been socialized to use violence in their lives (Brooks, 1990).Therapists should pay attention to the myriad factors from the larger social system that contribute to and often exacerbate violence and abuse in couples and families. These factors often intensify and complicate the situations that present in treatment.

Family Therapy Research

Similar to current trends in individual therapy research, advances in family therapy research have focused away from theoretical debates and toward empirical validations. The task of empirically validating family therapy has not been an easy one, and it continues to pose challenges. At the core of the difficulty lie some very basic questions: What constitutes a family? What is the domain of family therapy (Lebow & Gurman, 1995)? Should research focus primarily on traditional systems-focused family therapy, or is it acceptable to include family therapy approaches designed to help an individual client with his or her particular problems within a family therapy context (Baucom, Shohan, Mueser, Daiuto, & Stickle, 1998)? Should claims about the efficacy and effectiveness of family interventions be made when family therapy is the only therapeutic modality, or can such claims be made even in situations where family interventions are a part of a more comprehensive therapeutic approach (Pinsof, Wynne, & Hambright, 1996)? One can see that with such basic questions in setting the stage for research, methodological and statistical difficulties often pose a substantial, but only secondary, set of challenges.

To address some of these challenges, the trend in family therapy research has been to provide definitions up front as to how certain parameters are defined for the particular study. Likewise, review articles and meta-analyses typically explain how the investigators went about setting the stage for their analyses, describing their logic of why certain articles were included and others were excluded. There is often a definition of terms and a description of the criteria used to conduct the review or the meta-analyses (e.g., Pinsof, 1989; Pinsof et al., 1996). Recent methodologically well-designed reviews and meta-analyses of the family therapy research literature conclude that family therapy works (Dunn & Schwebel, 1995; Lebow & Gurman, 1995; Pinsof & Wynne, 1995; Pinsof et al., 1996; Shadish et al., 1993; Shadish, Ragsdale, Glaser, & Montgomery, 1995). The results also indicate that when comparing family therapy to no-treatment control groups, patients receiving family therapy do significantly better (statistically) at termination and follow-up. Pinsof et al. (1996) further delineated that when family therapy is used to treat a particular disorder, research results have revealed that the following disorders consistently responded well to family therapy treatment as compared to no-treatment controls: adult schizophrenia, adult alcoholism, dementia, cardiovascular risk factors in adults, adult and adolescent drug abuse, adolescent conduct disorders, adolescent anorexia of less than 3 years duration, adolescent and childhood obesity, childhood conduct disorders, childhood autism, chronic physical illness in children, and aggressive and noncompliance symptoms associated with ADHD (Pinsof et al., 1996). The investigators also pointed out the efficacy of couples therapy for the following disorders: marital distress and conflict, obesity, hypertension, and depressed women in distressed marriages.

Pinsof et al. (1996) focused next on comparing family therapy to alternative treatments. They concluded that when compared with medication treatment alone or with individual or group therapy, family therapy is a superior therapeutic modality for the following disorders and problems: adult schizophrenia, alcoholism, dementia, cardiovascular risk factors, adult and adolescent drug abuse, adolescent conduct disorder, childhood autism, and aggression and noncompliance in ADHD. The authors also asserted that one of the strongest and most consistent findings about the superiority of any form of family therapy is in the application of psychoeducational family treatment of schizophrenia (Goldstein & Miklowitz, 1995; Pinsof et al., 1996). There is also growing evidence that in the treatment of childhood anxiety disorders, family therapy is superior to alternative treatments (Barrett, Dadds, & Rapee, 1996). Pinsof et al. (1996) also concluded that couples therapy is a superior therapeutic modality for depressed women in distressed relationships and for marital conflict and distress.

There is also a burgeoning and impressive body of research supporting the effectiveness of multisystemic family therapy for various family problems including juvenile offenders, adolescent sexual offenders, and substance abuse (e.g., Henggeler, Melton, Brondino, Scherer, & Hanley, 1997; Pickrel & Henggeler, 1996; Swenson, Henggeler, Schoenwald, Kaufman, & Randall, 1998). In addition, multisystemic family therapy is a more cost-effective treatment modality than individual therapy, hospitalization, incarceration, or standard treatments not involving the family (Hengeller, Melton, & Smith, 1992; Hengeller et al., 1999; Pinsof et al., 1996).

Pinsof et al. (1996) concluded that the available research does not support the notion than any particular family therapy is superior to any other form. Citing meta-analysis findings by Shadishetal.(1995),theauthorsstatedthatShadishetal.“concluded that if all studies were comparably designed and implemented, orientation differences might disappear, suggesting that orientation outcome differences in meta-analyses may well be primarily a function of the quality of the research, as opposed to the quality of the therapies under investigation” (Pinsof et al., 1996, p. 325). Other investigators also point out that while research findings often support the efficacy of one treatmentmodality,thelackofoutcomeresearchorthescarcity of carefully designed studies makes it difficult to form conclusions about the superiority of one approach over another (Baucom et al., 1998; Dunn & Schwebel, 1995). Nonetheless, Pinsof et al. recognized that the failure of research findings to provide evidence in support of particular orientation differences is not proof that such differences do not exist.

Future Directions

Practice

Much of what has been discussed up to now has revolved around the development and evolution of the field of family therapy. However, at the beginning of the twenty-first century it seems important to ask the question, What is the future of family therapy? Goldenberg and Goldenberg (1999) delineated several topics in answering this question. The first involves a discussion of postmodern outlooks in family therapy. Postmodern philosophy challenges the modernist notion of the existence of an absolute reality that can be explained through cause-and-effect terms and measured by a detached observer. Instead, the postmodernist view postulates that truth is relative and that there are a variety of subjective beliefs in how the world really operates. Hence, truth and reality are relative and dynamic as opposed to absolute and static. The implication of the postmodernist approach to family therapy is that the previous beliefs about what constitutes family dysfunction and subsequent treatments are challenged. The role of the therapist is changed from one who has the knowledge to diagnose and treat to one whose job is to help the family recognize how its belief systems have created their own reality. The therapeutic impact of such an approach comes from the family’s realization that the system of beliefs that has helped family members find meaning in their lives and construct their version of reality has also limited their options. The implication of the fact that there are multiple ways of viewing reality is that there are myriad ways of understanding assumptions, interactions, problems, and impasses. Such a realization has the potential of paving the way for adopting behavioral choices different from the ones that have led the family to the current state of problems. Therefore, the postmodernist, social constructionist approach has profound consequences for the practice of family therapy for several reasons: The therapist is permitted to be a nonexpert; there is a tremendous acceptance of eclecticism; there is an increased recognition of the need to recognize and address diversity issues; and family members and therapists are empowered by believing that the situation is changeable.

Future directions in the practice of family therapy will also be impacted by population diversity and multiculturalism. The fact that the population of NorthAmerica is becoming increasingly diverse, both in terms of racial and ethnic makeup as well as socioeconomic and other cultural factors, is likely to force the field to adopt a more diverse and inclusive approach to the definition of family systems, the etiology of family dysfunction, beliefs about what constitutes dysfunction, and appropriate interventions given the diversity of belief systems. The multicultural view emphasizes the importance of the therapist’s learning about the family’s culture, the cultural background of family members, the culture of the agency where the therapist practices, and the dominant culture in which the therapist and the client family are working together. Once again, a multisystemic, integrative, and postmodernist approach is likely to be adopted in addressing those issues.

Gender-sensitive family therapy is another area that is likely to receive more prominence in the future of family therapy practice. Brooks (1996) noted that at the turn of the century, women and men are facing a period of profound gender role strain, putting into question traditional gender formulations. Hence, one challenge for family therapy is to address how client families could be helped to arrive at gender equity. To that end, Brooks encouraged family therapists to move beyond a stance of neutrality because to adopt such a stance is likely to perpetuate the society’s traditional gender messages.

Goldenberg and Goldenberg (1999) also addressed the issue of same-sex coupling as a topic that needs to be addressed in the future of the field. As gay and lesbian partners have become more visible, family therapists, as well as many others, have become more aware of their own views and beliefs about the definition of what constitutes a family. Particular issues faced by same-sex couples and their families will need to be delineated, researched, and understood, and therapeutic approaches that are sensitive and effective in gay and lesbian families need to be recognized and adopted.

As the demographics and family constellations change in the United States, a number of family issues deserve greater attention in the next decade. These include the interface of family and work, family business consultation, the involvement of the family with the legal system, families with a member with a disability, families with adopted children (e.g., intercultural adoptions, same-sex adoptions), couples experiencing infertility, and elderly couples.

Research

The past decade has seen an unprecedented flurry of activity on empirically supported family therapy outcome research, reviews of such research, and meta-analyses evaluating such research (e.g., Baucom et al., 1998; Diamond, Serrano, Dickey, & Sonis, 1996; Dunn & Schwebel, 1995; Estrada & Pinsof, 1995; Hampson & Beavers, 1996; Lebow & Gurman, 1995; Pinsof et al., 1996; Pinsof & Wynne, 1995; Shadish et al., 1993). While there is a tremendous need for further outcome research, there have been substantial advances to date as well. To go forward, it is important to recognize conclusions that can be drawn definitively about the efficacy and effectiveness of family therapy at this point in time; not doing so can amount to the proverbial reinventing of the wheel.

It has been argued that given the available outcome studies, we can conclude that further research comparing any form of family therapy with a no-treatment control condition, in order to show the efficacy of family therapy, is warranted only for disorders and problems that have not been studied so far. That is because we can conclude that for disorders and problems that have been studied up to now, the basic efficacy of family therapy has been proven (Lebow & Gurman, 1995; Pinsof & Wynne, 1995; Pinsof et al., 1996). So where do we go from here? It is time to determine what approaches are most effective in promoting specific types of changes, what approaches are useful to families from specific backgrounds, what processes unfold in each family therapy approach to sessions, and how the various approaches relate to particular outcomes from particular groups of clients who live in particular kinds of family units (Dunn & Schwebel, 1995). In addition, it is imperative that studies examine the efficacy of therapeutic approaches with individuals from other countries, ethnic-minority families within the United States, and sexually diverse families. Further, research must be conducted that focuses both on specific problems and comorbid conditions (e.g., families with a member with a comorbid schizophrenia spectrum disorder and substance abuse problem; Baucom et al., 1998; Pinsof et al., 1996). In addition, more research should be conducted with integrative models, as these are most commonly practiced within the community. Answers to the aforementioned questions and issues may be fruitfully found in effectiveness, efficacy, and dismantling and longitudinal research designs. Qualitative, as well as the traditional quantitative, research designs are important and will yield valuable insights (Lawson & Prevatt, 1999). These studies must better define, operationalize, and measure various forms of family therapy and address the cost effectiveness of family therapy (Pinsof et al., 1996). Further research addressing these recommendations will no doubt advance the field of family therapy in the current decade and beyond.

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