Textbook of Couples and Family Therapy in Clinical Practice

CONTENTS
Forewords vii–x
Ellen M. Berman, MD
Lloyd I. Sederer, MD
Preface xi
Acknowledgments xv
A Guide for Using the Text xvii
List of T ables xxxv
List of Figures xxxvii
Section I Family Therapy in Context 3
1 The Field of Couples and Family Therapy: Development and Definition 5
Objectives for the Reader 5
Introduction 5
Development of the Family Therapy Field 6
Definition of Couples and Family Therapy 9
Core Concepts 10
General Systems Theory 10
Family Systems Theory and Homeostasis Over Time 15
An Integrative Interpersonal Model 16
Differentiation of Family Therapy From Other Psychotherapies 16
Clinical Practice Implications 18
Suggested Readings 19
References 19
2 Family Life in Historical and Sociological Perspective 20
Objectives for the Reader 20
Introduction 20
The Family in Early Civilizations 21
Structure and Function of the American Family 21
Immigration 22
Ethnicity 22
Examples of Ethnicity versus Race 23
Internalized and Structural Racism 23
Secular View of Marriage 24
Structures of Marriage 25
Divorce 25
The Functional Single-Parent Family 26xx Contents
Stepfamilies 26
Lgbtq (Lesbian, Gay, Bisexual, Transgender, Queer) Couples 27
Polyamory 29
Parenting in Postmodern Relationships 29
Family T ypes 30
Culture and Race 30
Social Class 31
Aging of the Population 31
The Changing Family Life Cycle 32
Clinical Practice Implications 32
Suggested Reading 33
References 33
Section II Functional and Dysfunctional Families 37
3 Understanding the Functional Family 39
Objectives for the Reader 39
Introduction 39
The Family as a System 40
The Couples/Marital and Family Life Cycle 42
The Individual Life Cycle 42
The Couples/Marital Life Cycle 44
Phase of Relationship and Tasks 45
Marital Coalition 46
Sex, Intimacy, and Companionship 47
The Family Life Cycle 47
Family T asks 50
Provision of Basic Needs 51
Rearing and Socialization of Children 51
Family Belief Systems 53
Family Resilience 53
Clinical Practice Implications 53
Suggested Readings 54
References 54
4 Understanding the Functional Family in a Variety of Family Forms 55
Objectives for the Reader 55
Introduction 55
Impact of an Extended Individual Life Cycle 56
Marriage 56
Divorce 57
Marital Separation 57 Contents xxi
Divorce 58
Children and Divorce 58
Binuclear Families 59
Impact of Divorce Based on the Age of the Child 59
The Functional Single-Parent Family 60
Mother-Headed Single-Parent Families 61
Father-Headed Single-Parent Families 61
Remarriage and Blended Families 61
Remarried Couple 62
Stepfamilies (Blended Families) 62
Grandparent-Headed Families 63
Lesbian, Gay, and Transgender Families 63
Parents with a Gender Nonconforming Child 65
Multiple-Partner Fertility Families 65
Adoption and Families 65
Interracial Families 65
Trends in Parenting 66
Clinical Practice Implications 66
Suggested Readings 67
References 67
5 Problems and Dysfunction from an Integrated Family Systems Perspective 68
Objectives for the Reader 68
Introduction: The Dysfunctional Family System 68
A Systems Approach to Problems and Dysfunction 69
Historical Perspectives 69
Current Perspectives 70
Family Resilience Key Processes 71
Structural and Organizational Problems 71
The Solution as the Problem 72
Family Beliefs and Myths 73
The Larger Social System and Dysfunction 75
Implications for Treatment—the Development of Symptoms in a Particular Person 75
Life Cycle Problems and Dysfunction 77
Unresolved Grief 78
Toxic Secrets 78
Task Performance in the Dysfunctional Family 78
Providing for the Family’s Basic Needs 78
Maintaining a Functional Marriage: Issues of Sex, Intimacy, and Commitment 79
Rearing and Socializing of Children 79
Clinical Practice Implications 79
Suggested Reading 80
References 80xxii Contents
Section III Family Evaluation 83
6 The Process of Evaluation 85
Objectives for the Reader 85
Introduction 85
Who to Include in the Family Evaluation 86
Progression of the Family Evaluation Interview 87
Dimensions of Couple and Family Assessment 87
Joining with the Couple or Family 88
Seeing Systemic Patterns 88
Recognizing Family Developmental Stage, History, and Culture 88
Identifying Family Structure 90
Working with a Systemic Model of Change 90
Role of Historical Material 91
Role of Individual and Family Diagnoses 92
Clinical Practice Implications 93
References 93
7 The Content of Evaluation 94
Objectives for the Reader 94
Introduction 94
Dimensions of Family Function 95
Family Evaluation Outline 95
Gathering Identifying Data and Establishing Current Phase of Family
Life Cycle 95
Gathering Explicit Interview Data 96
What Is the Background of the Family Problem? 97
What Is the History of Past Treatment Attempts? 98
What Are the Family’s Goals and Expectations of the Treatment? 100
The Family Genogram 101
Clinical Practice Implications 101
References 101
8 Formulating an Understanding of the Family Problem Areas 102
Objectives for the Reader 102
Introduction 102
Rating Important Dimensions of Family Functioning 103
Communication 103
Problem-Solving 103
Roles and Coalitions 103
Affective Responsiveness and Involvement 104
Operative Family Beliefs and Stories 105
Recent Family Events and Stresses 105 Contents xxiii
Family Classification and Diagnosis 105
Planning the Therapeutic Approach and Establishing the Treatment Contract 108
Case Example Illustrating Evaluation and Case Formulation 109
Suggested Reading 116
References 116
Section IV Family T reatment 1 19
9 Major Family Therapy Schools and Their T reatment Strategies 121
Objectives for the Reader 121
Introduction 121
Insight-Awareness Model 123
Family of Origin Model 123
Systemic-Strategic Model 124
Structural Model 124
Cognitive–Behavioral Model 125
Experiential Model 126
Narrative Model 126
Psychoeducational Model 126
Clinical Practice Implications 127
Suggested Readings 127
References 127
10 Goals 128
Objectives for the Reader 128
Introduction 128
Mediating and Final Goals as They Relate to Schools 129
The Most Common Mediating Goals 129
The Most Common Final Goals 130
Individualizing Goals with the Family 130
Goals and Their Relation to Process and Content Issues 132
Mediating Goals and Their Related Strategies 133
Goals and Related Strategies 133
Common to All Family Therapy Schools 133
Clinical Practice Implications 134
Reference 135
11 Family T reatment: Integrated Strategies and T echniques 136
Objectives for the Reader 136
Introduction 136
General Elements of Psychotherapy and Their Relationship to Family
Therapy 137xxiv Contents
Basic Strategies of Family Intervention 137
Techniques for Supporting Adaptive Mechanisms and Strengths: The
Psychoeducational Approach 138
Techniques for Expanding Emotional Experience 139
Techniques for Developing Interpersonal Skills 140
Techniques for Reorganizing the Family Structure 143
Techniques for Increasing Insight and Conflict Resolution 147
Techniques for a More Effective Construction of Family Reality 149
Treatment Packages 149
Indications For Differential Use of the Basic Strategies 149
Clinical Practice Implications 150
References 150
12 The Course of Family T reatment 151
Objectives for the Reader 151
Introduction 151
Early Phase 152
Identifying Objectives of the Early Phase 152
Choosing Strategies to Get Started 152
Distributing the Available Time 153
Gathering History and Simultaneously Building a Treatment Alliance
with the Family 153
Distinguishing Evaluation from Treatment 154
Middle Phase 155
Termination Phase 156
Conducting Brief Family Therapy: Treatment as It Is Influenced By Time
Constraints 157
Indications for Brief Family or Couples Intervention 157
Course of Brief Therapy 158
Techniques 158
Setting Limited Goals and a Definite End Point 158
Active Focus: Reinforcement of Family Strengths, Reconceptualization 159
Active Exploration of Alternatives: Behavioral and Emotional Rehearsal 160
Homework and Family Tasks 160
The Problem-Oriented School of Brief Therapy 161
Crisis Intervention 161
Clinical Practice Implications 161
Suggested Readings 162
References 162
13 Promoting Change in Family T reatment: Issues of Alliance and Resistance 163
Objectives for the Reader 163
Introduction 163
The Therapeutic Alliance 164 Contents xxv
Models for Dealing with Families That Have Trouble Forming an Alliance 165
Medical Model 165
Coaching Model 166
Conflict Model 166
Strategic Systems Model 166
Problems in Creating Change: Resistance and Disconnection 167
Problems in Creating Change: Emanating from the Family 167
Problems in Creating Change: Emanating from the Therapist 168
Problems in Creating Change: From the Therapist–Family System 168
Problems in Creating Change: Stages of Treatment: At Evaluation and
Early in T reatment 169
Problems in Creating Change: In Ongoing Treatment 171
Problems in Creating Change: At the Termination Phase of Therapy 172
Problems in Creating Change: Family Secrets 172
Techniques to Deal with Resistances or Stalled Therapy 173
Assume Nothing 173
Collaboration 173
Emphasizing Family Responsibility 174
Focus on the Present 174
Clinical Practice Implications 174
Suggested Readings 174
References 174
14 Family Therapy: General Considerations 175
Objectives for the Reader 175
Introduction 175
Family Participants 176
Extended Family and Significant Others 177
Caregivers 178
Including Children and Adolescents in Family Therapy 178
Diagnostic Family Evaluation 179
Treatment 180
Therapist Combinations 181
Co-Therapy 181
Working as a Team 181
Setting 182
Time, Scheduling, and Fees 182
Keeping a Record of Treatment 183
Family Therapy in Combination with Other Psychosocial Therapies 184
Practical Guidelines 185
Effective Family Intervention 186
Comparison of Therapy Formats and Strategies 186
Clinical Practice Implications 186xxvi Contents
Section V Couples Therapy 191
15 Dysfunctional Couples and Couples Therapy 193
Objectives for the Reader 193
Introduction 193
Marriage in Its Historical Context 194
Couples Difficulties, Problems, and Dysfunction 194
From a Dynamic Point of View 195
From a Behavioral Point of View 196
From a Systems Point of View 196
From a Psychiatric Illness Point of View 196
Couples’ Development Dysfunction 197
Couples Therapy 1 97
The Issue of Commitment—The Problem of Affairs 197
Evaluation of Partners 198
Goals 199
Strategies and Techniques of Intervention 199
A Model for Intervention Based on Patterns of Interaction 199
Individual Models 200
Strategies and T ec hniques 201
Clinical Practice Implications 203
References 203
16 Sex, Couples, and Sex Therapy 204
Objectives for the Reader 204
Introduction 204
Diagnosis—Systems Issues 205
Some Parameters of Sexual Function 205
Assessment of Sexual Disorder 206
Treatment 209
Lack of Desire 209
Erectile Disorder 209
Premature (Early) Ejaculation 210
Painful Intercourse/Female Orgasmic Disorder 210
Sex Addiction and Pornography 211
Other Issues Related to Sexuality and Couples 212
The Spectrum of Sexuality 212
Sexual Functioning After Rape or Sexual Abuse 212
Sexual Problems After Medical Illness 213
Sexual Problems in the Elderly 213
Clinical Practice Implications 214
Suggested Readings 214 Contents xxvii
17 Couples and Families Breaking Apart: Separation and Divorce 215
Objectives for the Reader 215
Introduction 215
Separation 215
Separation Leading to Divorce 217
Communicating the Issue of Divorce to Children 218
Immediate Issues 218
Therapy for Families Facing Divorce 219
Divorce and Postdivorce Treatment 220
Single-Parent and Binuclear Families 221
Blended Families (Stepfamilies) 222
Goals 222
Evaluation and T reatment 223
Cohabiting Couples 225
Serial Relationships 226
Clinical Practice Implications 226
Suggested Readings 226
References 226
Section VI
Family T reatment When One Member Has a Psychiatric
Disorder or Other Special Problem 229
18 Family T reatment in the Context of Individual Psychiatric Disorders 231
Objectives for the Reader 231
Introduction 231
The Family Model and Individual Diagnosis 233
Schizophrenia 233
Rationale 233
Treatment Considerations 235
Patients with Schizophrenia Living with or Supported by Families of
Origin 237
Patients with Schizophrenia Who Are Married, with or without Children 238
Mood Disorders: Bipolar Disorder 239
Rationale 239
Treatment Considerations 241
Mood Disorders: Persistent Depressive Disorder and Major Depressive
Disorder 243
Rationale 243
Treatment Considerations 245
Borderline Personality Disorder 246
Rationale 246
Treatment Considerations 247xxviii Contents
Anxiety Disorders 248
Rationale 248
Panic Disorder and Agoraphobia 249
Treatment 249
Obsessive-Compulsive Disorder 250
Rationale 250
Treatment 250
Posttraumatic Stress Disorder 250
Rationale 250
Treatment 251
Dementia, Amnesia, and Other Cognitive Disorders 251
Rationale 251
Treatment Considerations 252
Eating Disorders 253
Rationale 253
Treatment Considerations 253
Substance-Related Disorders 254
Rationale 254
Assessment and Treatment Guidelines 255
Children of Alcoholic Parents 256
Psychiatric Disorders of Childhood 256
Intellectual Disability 256
Treatment 256
Autism Spectrum Disorder 256
Attention-Deficit/Hyperactivity Disorder 257
Oppositional Defiant Disorder and Conduct Disorder 259
Anxiety Disorders 259
Mood Disorders 259
Childhood Obesity 260
Clinical Practice Implications 260
Suggested Readings 260
References 260
19 Family T reatment in the Context of Other Special Problems—Violence
to Self and Others 264
Objectives for the Reader 264
Introduction 264
The Family Model and Violence 265
Description of the Problem 265
How Violent Acts Occur: The Cycle of Violence 269
Assessment of Individual and Family Systems Issues 269
Physical and Psychological Consequences of Violence 271
Treatment 271 Contents xxix
Intrafamilial Child Sexual Abuse 275
Individual Issues 276
Family Issues 276
Larger System Issues 276
Assessment 277
Treatment 277
The Family Model and Child Abuse 278
Incestuous T rauma 279
The Suicidal Patient and the Family 279
Acute Management 280
Evaluating the Family 280
Involving the Family 281
Treating the Family 281
Discharging the Hospitalized Patient 282
Clinical Practice Implications 282
Suggested Reading 282
References 282
20 The Family and T reatment of Acute and Chronic Psychiatric Illness 284
Objectives for the Reader 284
Introduction 284
Background 285
Acute T reatment 286
The Function of the Acute Team for the Family 286
Family Responses to Mental Illness of a Family Member 287
The Family Burden in Psychotic Illness 287
Rationale for Acute Treatment of Families 288
Process of Family Treatment in Acute Care 289
Common Goals of Acute Family Intervention 290
Particular Decisions in Acute Care and Family Intervention 292
Family T ec hniques 293
A Working Model of Acute Family Intervention 294
Guidelines for Recommending Family Intervention in an Acute Care
Setting 294
Empirical Studies 295
Families of the Chronically Ill 296
Expressed Emotion 296
Community-Based Support Groups 298
Controversies in the Treatment of Acute and Chronic
Psychiatric Illness 298
Clinical Practice Implications 299
References 300xxx Contents
21 Working with Families in the Medical Setting 302
Objectives for the Reader 302
Introduction 302
How Family Functioning Impacts Illness 303
Gender Matters 303
Family Health Beliefs 304
Family Adherence 304
How Illness Impacts Family Functioning 304
Family Coping and Adaptation to Illness 304
Learning to Cope and Adapt 306
Providing a Therapeutic Space 306
Caregiving 306
A Family Systems Interview For Families with Medical Illness 307
Problem Solving 307
Communication 308
Roles 308
Affective Responsiveness 309
Affective Involvement 309
Behavior Control 309
Family Interventions 310
Family Support 310
Family Psychoeducation 310
Family Systemic Interventions 310
Multifamily Groups 311
Clinical Practice Implications 311
Suggested Readings 312
References 312
Section VII
Results of and Guidelines for Recommending
Family Therapy 317
22 Indications for and the Sequence of Family Therapy Evaluation and
Treatment 319
Objectives for the Reader 319
Introduction 319
Sequence of Evaluation and Treatment Planning 320
Step 1: Is Family Evaluation Indicated? 320
Step 2: Is Family Treatment Indicated? 322
Family Therapy V ersus Individual Therapy 322
Managed Care 324
Individual, Couples, or Sex Therapy for Sexual Problems 325
Family Crisis Therapy Versus Hospitalization 325 Contents xxxi
Step 3: What Shall Be the Duration and Intensity of Family Therapy? 325
Family Crisis Therapy 326
Brief Family Therapy 326
Long-T erm Family Therapy 326
Step 4: What Model of Family Intervention Is Indicated? 327
Clinical Practice Implications 327
References 328
23 Controversies and Relative Contraindications 329
Objectives for the Reader 329
Introduction 329
Couples Therapy 330
Couples Conflict and Dissatisfaction 330
Sexual Issues 331
Families in the Process of Divorce 331
Unmarried Couples 332
The Child as the Identified Patient 332
The Adolescent as the Identified Patient 333
Family of Origin Issues 333
Situations In Which Family Therapy Is Difficult and Perhaps Contraindicated 334
When Psychopathology in One Family Member Makes Family Therapy
Ineffective 334
When the Family or Therapist Thinks the Risks of Therapy Outweigh the
Advantages 334
When the Family as a Whole Denies Having Family Problems 335
When Cultural or Religious Prejudices Are Present 335
Skills and Attributes of the Therapist as They Affect Family Work 335
Clinical Practice Implications 336
References 336
24 Results: The Outcomes of Couples and Family Therapy 337
Objectives for the Reader 337
Introduction 337
Overview of Psychotherapy Outcome Research 338
1. Specificity 338
2. The Difference between Efficacy and Effectiveness 339
3. The Difference between Qualitative and Quantitative, or Exploratory and
Confirmatory, Research 339
4. The Difference between Process and Outcome Research 339
What The Studies Show? 340
Couples Treatments for Adult Disorders 341
Insight-Oriented Marital Therapy for Marital Distress 341
Integrative Behavioral Couple Therapy for Marital Distress 341
Emotionally Focused Couples Therapy for Marital Distress 341xxxii Contents
Behavioral Marital Therapy for Depression 342
Behavioral Couples Therapy for Alcoholism 342
Couples Therapy for Posttraumatic Stress Disorder 342
Family Treatments for Adult Disorders 343
Schizophrenia and Major Mental Illness 343
Focused Family Therapy for Bipolar Disorder 343
Family Treatments for Child and Adolescent Disorders 344
Brief Strategic Family Therapy for Children and Adolescents with Externalizing
Disorders 344
Functional Family Therapy for Delinquent Adolescents 344
Multidimensional Family Therapy for Adolescent Substance Abuse 344
Multisystemic Therapy for Youth at Risk 345
Functional Family Therapy for Adolescents with Bipolar Disorder 345
Family-Based Treatment for Anorexia Nervosa 345
Family Interventions for Medical Illnesses 345
The Effectiveness of Combining Medication and Family Therapy 346
Limitations of Family Therapy 346
Negative Effects of Family Therapy 347
Inability to Engage and Premature Termination of Family Therapy 350
Clinical Implications of Data From Couples and Family Therapy Outcome
Studies 351
Clinical Practice Implications 352
References 352
Section VIII Ethical, Professional, and T raining Issues 357
25 Ethical and Professional Issues in Couples and Family Therapy 359
Objectives for the Reader 359
Introduction 359
Ethical Issues Inherent in Family Therapy 360
Conflicting Interests of Family Members 360
Understanding HIPAA 361
Secrets and Confidentiality 362
Issues Involving Gender, Gender Roles, and Sexuality 363
Ethics in a Managed Care World 364
Informed Consent 364
Financial Issues 365
Professional Issues 365
The Problem of Boundaries and Dual Relationships 365
Competencies 368
Training Issues 368
Clinical Experiences 370 Contents xxxiii
Training Programs in Family Psychiatry 371
A Multidisciplinary Field 371
Family Therapy Fellowships 372
Training and Licensure 373
Clinical Practice Implications 373
Suggested Readings 373
References 374
Index 375