Couple & Family Therapy : An Integrative Map of the Territory Jay L Lebow

Chapter 4

Introduction

(Lebow, 2014)

Couple and family therapy linked by treatment models

Models Have rich descriptions of theory /

methods Based on vision of what matters in

families and how to help families change

(Lebow, 2014)

Early Models Synonymous with couple / family

therapy

Articulated ideas and methods on which couple / family therapy is based

Very few practiced in original form today Ideas absorbed within other methods

(Lebow, 2014)

Early Models cont... Structural Family Therapy Strategic Approaches Experiential Approaches Bowen Family Systems Therapy and

other Intergenerational Approaches Psychodynamic Approaches

(Lebow, 2014)

Structural Family Therapy Salvador Minuchin Importance of family structure in determining

life of family and members Family structure: regulating codes

manifested in patterns in which people relate to one another to carry out functions

Three elements: Boundary Alliance Power

(Lebow, 2014)

Boundary Rules defining who participates and how

they participate in what aspects of life Regulate amount / quality of contact Continuum:

Rigid – “disengagement” Disconnected

Permeable – “enmeshment” No separation; violations of space

(Lebow, 2014)

Alliance Joining / opposition of one member of

system to another Inevitable Dysfunctional when fixed or unchanging

or cross-generational Triangulation – two people demand a

third join them against the other Goal of structural family therapy is to

create functional stable alliances

(Lebow, 2014)

Power Influence of each member on outcome

of family activities / decisions Functionally distributed Rigidly held by member or coalition Dysfunctional – no one has power Structural family therapy aims to move

families toward distribution of power (strong parental coalition with all members retaining some power)

(Lebow, 2014)

Structural family therapy emphasizes changing aspects of family structure

Restructure the family to promote better functioning

Homeostatic vision of family system: create enactments to trigger shift in organization

Enactments—powerful in-session experiences; create crisis to alter methods of responding / structure

(Lebow, 2014)

Structural family therapy is primary source for many tools used by therapists today

Joining Tracking (adopting symbols of family’s

life) Accommodation (relate congruent to

family pattern of relating) Mimesis (become like family members in

manner or content of communication)

(Lebow, 2014)

Strategic Approaches Most purely systemic of family therapies Brief and focused Change is a “discontinued process of

making a leap into categorically different way of systemic functioning”

Specific intervention techniques Paradoxical interventions Use of team / one-way mirror Therapist maintains cool detached stance

(Lebow, 2014)

Strategic Approaches cont. Mental Research Institute Model (MRI)

aka Palo Alto model General systems theory, cybernetics, and

communications First order change (more or the same) Second order change (alter rules of the

system)

(Lebow, 2014)

MRI cont... Identify ways problems maintained;

explicate rules underlying problems; change rules

Paradoxical prescriptions / interventions Reframing (“seeking independence” vs

“acting out”) Prevent long term attachment to

therapist to facilitate termination

(Lebow, 2014)

Problem-Solving Therapy Jay Haley Combine paradoxical techniques with

focus on family structure Power and distribution are important Focus on function of behaviors within

the system Understand triangles (who supports

whom) and hierarchy (who has power)

(Lebow, 2014)

Problem-Solving Therapy Directives targeted at triggering family

to engage in new and different behaviors to achieve solutions

Promote confusion to increase suggestibility and openness to change

Pretend technique “Identified patients” (manifest

symptoms because of function of symptoms)

(Lebow, 2014)

Milan Systemic Therapy Milan, Italy – Palazzoli, Boscolo, Cecchin,

Prata and colleagues Typical therapy – once a month;

therapist in room; team of therapists behind one-way mirror

Formulation of hypotheses about family Refined over course of therapy Formulation of strategic messages

emphasizing “positive connotation”

(Lebow, 2014)

Positive connotation - Type of reframing focused on assigning positive meaning to what has been described as problematic behaviors

Point out how dysfunctional behavior serves positive goals of system

Exaggerate or challenge rigid family patterns through irony and confusion

Draw attention to patterns; increase awareness of ability to influence / resolve differences

(Lebow, 2014)

Cognitive-Behavioral Approaches Most efficacious pathways to change are

those that directly alter dysfunctional thoughts and behavior patterns

Classical conditioning Operant conditioning Social learning theory (Bandura) Social exchange theory

(Lebow, 2014)

Cognitive Behavioral Approaches Facilitate awareness of how thoughts affect

emotion More similar to one another than any other

group of family therapies Cognitive Behavioral Couple Therapy –

challenge lies in addressing aspects that are not simply about behavior

Schema-focused couple therapy – focus on ingrained beliefs about self, partner, and relationship as key roles in distress

(Lebow, 2014)

Experiential Approaches Attend to felt experience of clients,

emphasizing moments of heightened emotion in therapy

Ultimate goals – improved functioning; reengaging a sense of liveliness and connection

Whitaker and Satir (original) Emotion focused couples therapies

(Greenberg; Johnson)- most prominent

(Lebow, 2014)

Whitaker – provocative techniques to engage families: ironic commentary, verbal confrontation, physically wrestling with clients

Satir – family sculpting

(Lebow, 2014)

Emotion Focused Emphasis on process of getting in touch

with and expressing emotion First expression of emotion is followed by

working through that emotion to access underlying emotional feeling

Johnson – emphasizes attachment Greenberg – emphasizes identity

(Lebow, 2014)

Bowen Family Systems Therapy Bowen – centers on concept of

differentiation of self Differentiation of self – the evolving ability

to consider the world dispassionately and free of the residue of individual and family history

Balanced thought overrides feeling Undifferentiated ego mass of emotion and

belief transmitted across generations through family projection process

(Lebow, 2014)

Bowen Family Systems Therapy Based on active process of clients

interacting with family members and memories of deceased relatives to free self from processes

Disentanglement from triangles Therapy often occurs with only one

client or a couple present Focus on family of origin

(Lebow, 2014)

Other Intergenerational Approaches Imber-Black – emphasis on exploring and

processing family secrets (past / present) Boszormenyi-Nagi – Contextual Approach

Invisible loyalties – multigenerational ledger of what each person has received or not received

People seek to balance ledgers Carry over feelings from family of origin to adult

life Goal of therapy: help client understand ledger

and find constructive rather than destructive ways to balance them

(Lebow, 2014)

Psychodynamic Approaches Long standing tradition of incorporating

psychodynamic concepts in family therapy Emphasis on dynamic internal processes

occurring within and across individuals and inner conflicts

Emphasis on unconscious mental processes and role of early experiences

Transference; countertransference; interpretation

(Lebow, 2014)

Second Generation Therapies Emerged over the past 30 years

Postmodern and Poststructural Therapies

Feminist Therapies Psychoeducational Approaches

(Lebow, 2014)

Postmodern / Poststructural Therapies Who is in the room is less important that what

is the focus Therapists are collaborators rather than

experts Process of treatment is coevolution between

client and therapist Narrative Therapy Collaborative Therapy Witnessing Solution-Focused Therapy Status

(Lebow, 2014)

Narrative Therapy Focus on stories people hold about their lives Personal stories socially constructed and how

these can be collaboratively reconstructed Social constructionism – ensuring voices of

less powerful given greater prominence that dominant culture

Therapy not about treatment strategy but joint exploration

Problems external to client – externalize the problem to see as separate from individual

(Lebow, 2014)

Collaborative Therapy Coequal dialogue between clients and

therapists toward natural end of mutual benefit

Clients are best expert on their lives Therapist work from position of “not

knowing” Shared inquiry Harlene Anderson

(Lebow, 2014)

Witnessing The value of being present for clients as

they share their life stories and helping them find their own constructive voice in relation to their difficulties

Kaethe Weingarten

(Lebow, 2014)

Solution-Focused Therapy Steve de Shazer and Insoo Kim Berg Therapist role is introducing simple

ways of thinking about and dealing with difficulties and help initiate families’ own processes of problem resolution

Major technique: focusing on times when problem has been absent

(Lebow, 2014)

Feminist Therapies Earliest therapies developed by men Based on assumptions associated with

male ways of experiencing world Two types

Goldner – developed specific couple therapy for partner violence informed by feminism and systems theory

Interventions based on relational perspective

(Lebow, 2014)

Psychoeducational Approaches Emphasize increasing the family’s

understanding of the nature of particular disorders and problems and what helps / hinders recovery

Primarily used in context of mental health and health disorders

Crisis management; skills for particular problems

First were developed in context of working with schizophrenia

(Lebow, 2014)

Integrative Models Integrative Problem-Centered Therapy Metaframeworks Integrative Problem-Centered

Metaframeworks Client-Directed Outcome Informed

Clinical Work Internal Systems Therapy Therapeutic Palette

(Lebow, 2014)

Integrative Problem-Centered Therapy (IPCT) William Pinsof Family’s definition of the problem form

which they are seeking help becomes the center of the therapeutic contract

Identification of problem maintenance cycle (promotes / maintains problem; suggests intervention pathway)

Simple strategies first; then complex

(Lebow, 2014)

Metaframeworks “Emphasizes a theory of constraints that

suggests people do what they do, think what they think, or feel what they feel in ways that are dysfunctional when they are prevented from doing, thinking or feelings something else”

Identify and remove constraints Dimensions where constraints occur:

Development, organization, sequences, culture, gender, and mind

(Lebow, 2014)

Integrative Problem-Centered Metaframeworks Integration of IPCT and metaframeworks Strategies are sequenced

Action (behavioral and structural) Meaning (cognitive and narrative) Emotion (experiential) Biology

If all of the above fail, focus on strategies involving family of origin, internal representation, and self

(Lebow, 2014)

Client-Directed Outcome Informed Clinical Work Maximize common factors in psychotherapy

Generation of hope Positive expectancy Therapeutic alliance

Being change focused and tapping client’s world outside of therapy

Learn client’s theory of change and build on it

Outcome Rating Scale

(Lebow, 2014)

Internal Systems Therapy Richard Schwartz Integrates structural family therapy with

experiential and gestalt therapy methods Understand, sort, and change internal

representations of family in mental process

Managers – prevent unpleasant thoughts Exiles – activate bad feelings Firefighters – control exiled feelings

(Lebow, 2014)

Therapeutic Palette Fraenkel Integrative method of couple therapy Organizes intervention around:

Time frame (past, present, future) Directiveness (more vs less) Entry point (behavior, cognition, emotion)

to fit intervention to task at the moment in therapy

ReferenceLebow, J. L. (2014). Couple and family

therapy: An integrative map of the territory. Washington, DC: APA books.