Therapy

COUPLE RELATIONSHIPS Lorelei E. Simpson, Krista S. Gattis, Andrew Christensen

FAMILY RELATIONSHIPS Linda Berg-Cross, Michelle Morales, Christi Moore

PARENT-CHILD RELATIONSHIPS Marian J. Bakermans-Kranenburg, Marinus H. van Ijzendoorn, Femmie Juffer

Models of Couples Therapy

In general, couples therapy has been shown in dozens of studies to be more effective than no treatment (for meta-analyses of these studies, see Baucom et al. 1998 and Shadish et al. 1993). Although most couples are helped by therapy, less than half end up in the nondistressed range (Shadish et al. 1993). At the beginning of the twenty-first century, the therapies with the most support are behavioral couples therapy, cognitive behavioral couples therapy, and emotionally focused therapy (Christensen and Heavey 1999). A new model in the field, integrative behavioral couples therapy ( Jacobson and Christensen 1996; Christensen and Jacobson 2000), also has empirical support. In addition to these, there are several less researched, but promising, models of couples therapy, including family systems therapy and problem-and solution-focused therapies.

Behavioral Couples Therapy

Behavioral couples therapy (BCT) is the most widely researched and well-validated model of couple therapy (Christensen and Heavey 1999). Like individual behavioral therapy, BCT is derived from social learning and social exchange theories, which emphasize the influence of the environment and its behavioral and emotional rewards and costs. Behavioral couples therapy is built upon the idea that couple satisfaction is determined, in large part, by the positive and negative nature of spouses' interactions with each other.

Many distressed couples report feeling unable to communicate with each other or solve problems when they arise, which leads them to feel unhappy and frustrated with each other. According to behavioral theory, these negative interactions decrease the rewards couples gain from their relationship. In response to this reward reduction, BCT focuses on increasing the ratio of positive to negative behaviors for couples in distress and teaching them effective communication behaviors so that they may handle difficulties when they arise.

Several kinds of skills-oriented therapeutic techniques are used in BCT. First, therapists often work with couples to increase the number of positive behaviors that partners do for each other. For example, the therapist may guide partners in generating a list of positive actions that they could do for the other, such as complimenting the other or fixing the other breakfast. The therapist may then encourage partners to enact the behaviors on the list. Norman Epstein, Donald Baucom, and Anthony Daiuto (1997) suggest, however, that these interventions may be most effective if they address an area of concern for the couple. For example, a couple in conflict over parenting might be asked engage in positive behaviors in the domain of parenting, such as sharing diaper-changing duties.

The other main focus of BCT is improving communication skills and teaching problem-solving strategies. Communication skills that therapists may teach couples include the use of "I statements" that express feelings without blaming the partner, the use of verbal and nonverbal cues in listening, moderation of negative statements with the inclusion of positive feelings, and reflecting back of what each partner has said (Epstein, Baucom, and Daiuto 1997). Problem-solving training typically involves helping the couple to define a problem clearly, generate alternative solutions, compromise on a solution, implement it, and evaluate its effectiveness (Christensen and Heavey 1999).

Cognitive Behavioral Couples Therapy

Cognitive behavioral couples therapy (CBCT) includes the ideas and techniques of its predecessor, BCT, with an added cognitive component. In Couples seek counseling for many reasons, ranging from difficulty communicating with each other to disagreements on parenting. Emotional outpouring, as shown here, is a common and expected part of the therapy. PHOTOEDIT CBCT, several kinds of cognitions may be targeted, including assumptions about the partner, relationship standards, attributions of past partner behavior, expectations regarding how partners will behave, and selective attention to some aspects of partner behavior and not others (Epstein, Baucom, and Daiuto 1997). Cognitive behavioral couples therapy intervention techniques involve the use of cognitive restructuring, a process of evaluating cognitions systematically, determining their accuracy, and changing those that are unrealistic or inaccurate. For unrealistic attributions, assumptions, standards, and expectations, the therapist and partners work together to generate alternative explanations that are more accurate and lead to greater positive feelings between partners.

Integrative Behavioral Couples Therapy

Integrative behavioral couples therapy ( Jacobson and Christensen 1996) is an adaptation of BCT that focuses not only on behavioral change, but also includes an emphasis on acceptance of problems that are difficult or impossible to change. In order to promote acceptance, therapists may help couples reformulate problems as differences, rather than deficiencies; promote the expression of the vulnerable feelings that often lie behind aversive behavior; encourage an objective analysis of the problematic patterns couples experience; or engage in reenactment of aversive behavior in ways that promote increased tolerance. Not only are these strategies designed to promote acceptance, but they may indirectly foster change in the problematic behavior and increase emotional closeness between the pair.

Emotionally Focused Therapy

In contrast to more behavioral therapies, emotionally focused therapy (EFT) explains relationship distress in terms of attachment theory, rather than behavioral exchange. Emotionally focused therapy, developed by Leslie Greenberg and Susan Johnson (1988), involves the identification of problematic interaction cycles between partners and the emotions underlying them. Relationship distress is believed to arise when attachment bonds are disrupted or have not been fully formed, leading partners to engage in rigid interactional patterns that prevent emotional closeness (Christensen and Heavey 1999). Emotionally focused therapy works to help couples recognize their emotional experience in the relationship and restructure their interactions in order to create a more satisfying relationship. The therapist and couple work together to reprocess and redefine the relationship in such a way that it provides a more secure attachment base for both partners.

Family Systems

The family systems approach to couple therapy emerged as part of the field of family systems research, with the couple seen as the central and most influential subunit of a larger family system (Fraenkel 1997). The foundation of systemic couple theory is that all problems, including couple problems, occur in a multilevel context, which ranges in specificity from the just the two members of the couple to their immediate environment (i.e., family, work, or school) to their larger society or culture.

For couples, intervention techniques vary widely, as a function of the specific type of systems theory from which they are derived (examples of different types include structural, strategic, and experiental). However, Peter Fraenkel (1997) notes a variety of common goals of systems therapy, including focusing on strengths and resources, attending to the therapeutic environment as a "system," and identifying, stopping, and changing problematic interaction patterns. Family systems therapists may ensure that the therapy is of a brief duration to save time and energy and avoid dependence upon the therapist. The therapist may also model important concepts, including teaching how different family members may emotionally respond to each other and how partners may maintain their separate identities and perspectives while still working together as a couple (Papero 1995).

Problem- and Solution-Focused Therapy

Problem- and solution-focused therapies are approaches that focus on expedient problem resolution for couples, rather than on protracted work toward personal growth, underlying emotional issues, or general communication skills (Shoham, Rohrbaugh, and Patterson 1995). These therapies focus not only on how partners behave in the situation of conflict, but also how they view the problem. The two therapies, problem and solution focused, differ somewhat in their balance of behavioral versus cognitive change and their manner of reinforcing change, but they are quite similar in their focus on parsimonious therapeutic work toward single problem resolution (Shoham, Rohrbaugh, and Patterson 1995).

What Brings Couples to Therapy

Couples seek help from therapists for many reasons, ranging from difficulty communicating and dissatisfaction with their sex life to problems in coparenting or wanting to prevent divorce or separation. Other common reasons include a lack of emotional affection, divorce/separation concerns, infidelity, and domestic violence. Couples may come to therapy for any issue that they must face together, which can also include individual problems, such as mental illness, or family difficulties, such as a child's problems in school. The role of the therapist is to help them cope with these difficulties together, solve them when possible, and, as discussed above, accept them when no solution can be found.

Specific Issues

Couples frequently come to therapy to seek help in dealing with children and parenting. This is particularly true in the case of blended families, in which one partner is a stepparent to the other's child or children. Anne Bernstein (2000) notes that stepchildren are often a source of conflict, as the couple must try to develop their relationship without the freedom to focus solely on their own needs, which newly married couples without children may have. Other issues that can surface in this area include disagreements about parenting, conflicts with a particular child, or marital conflicts expressed through parent-child difficulties. Often, parent-training or family therapy are also appropriate treatments for these difficulties.

Sexual difficulties are one of the more common problems that couples bring to therapy. Couples may disagree on when, where, or how often they have sex, as well as what activities they engage in. This can be complicated by the emotional meaning sex has for each member of the couple, as when one member wants to use sex to make up after a fight and the other can't have sex until they've made up.

Infidelity is one of the most emotionally laden problems that couples bring to therapy. Shirley Glass and Thomas Wright (1997) discuss the many issues infidelity raises, including how and when discovery of an affair is made, how long the affair went on and with whom, and whether the involved spouse is willing to give up the affair. A major issue is whether the couple will remain together. If they stay together they must discuss what information about the affair the betrayed spouse needs or wants to know, how they can understand the affair, and how they can rebuild trust.

Finally, domestic violence is a serious problem in relationships. As Richard Heyman and Peter Neidig (1997) note, all couples therapists treat couples dealing with violence, whether they know it or not. Although couples may fail to identify violence as a problem in their relationship, its effects can still be quite damaging and therapists need to be vigilant in assessing for violence among couples. If violence is present, the therapist must decide whether or not it is appropriate to treat the couple together. Some researchers and clinicians contend that if violence is present, couples therapy should not be attempted, as it may exacerbate conflicts that put the abused partner at risk. Others suggest that, under certain specific conditions, a couples therapy that is designed to treat violence may be appropriate (e.g., Heyman and Neidig 1997).

Specific Groups

Any couple can face some or all of the problems listed above, but some couples bring other specific issues to therapy, such as unmarried couples, same-sex couples, aging couples, couples of lower socioeconomic status, and interracial or intercultural couples.

Unmarried couples range from dating couples to committed cohabiting couples who have either chosen to remain unmarried or are not permitted to marry (such as lesbian and gay couples). These couples may be more likely to bring in issues concerning whether or not to commit to a long-term relationship, or they may want help in resolving certain problems before making such a commitment. They are less likely to have conflicts over childrearing, though they may disagree about whether to have children. They may also need help in dealing with the stigma for cohabiting without marriage or with pressure from family members to get married (or not to marry).

Same-sex couples face many of the same issues that opposite-sex couples do, but may also carry the additional burdens of homophobia and heterosexism. This can manifest in couple difficulties in a number of ways, including stress related to family disapproval, conflicts over how "out" to be, and distress over not being able to legally commit to one another. Same-sex couples may also have difficulties surrounding differences in identity development. One partner may be more comfortable with his/her sexuality and put pressure on the other to be more "out" than he/she can be at their personal stage of development. Conversely, they may feel held back or forced to remain closeted by a partner who is still coming to terms with their sexuality (Okun 1996).

Aging couples face a number of difficulties they may bring to therapy, including the transition to retirement, dealing with adult children and grandchildren, coping with illness, and learning to be alone when their partner dies. As the population ages, couples will have a longer period of time together in the "empty nest" and presumably a greater need for couple therapy (Rosowsky 1999).

Couples of lower socioeconomic status may face a number of financial tensions and stressors as they attempt to support their families on a low income. This may be particularly problematic if one member of the couple comes from a wealthier family, resulting in tensions over "marrying down" (Ross 1995). Low-income couples may also face difficulties over whether they can afford therapy and how severe problems must be to warrant seeking outside help.

Finally, interracial or intercultural couples face a number of specific challenges in their relationships, which can result in relationship distress. These couples must often deal with the racism and prejudices faced by all people of color, but may also have to cope with the merging of two cultures and two sets of expectations about relationships. It is the task of the couples therapist to be sensitive to the cultural differences and needs of each member, and to help each member of the couple understand how these factors might affect them individually and as a couple (Okun 1996).

Couples Therapy and Individual Issues

In addition to being effective for relationship problems, couples therapy has been repeatedly shown to be effective for individual problems. Studies of couples treatment for individual psychopathology have varied in several ways, including the individual disorder studied, the satisfaction of the couple, and the extent to which the therapy focuses on relationship problems versus an individual spouse's difficulties. Therapies with more minimal involvement of one spouse and a strong focus on an individual issue are often termed spouse-aided rather than couple therapy. The three domains in which couples treatment have been most studied (and appear most efficacious) are depression, anxiety, and substance abuse.

Although causal links between depression and marital discord are unknown, the odds of being depressed increase tenfold for both partners if they are distressed in their relationship (O'Leary, Christian, and Mendell 1994). There is growing support in the literature for couples treatment for depression, and marital therapy used to treat individual depression in a maritally distressed couple has been found to be significantly more effective than no treatment both in increasing marital satisfaction and reducing depressive symptoms (Beach, Fincham, and Katz 1998). Furthermore, several studies have found BCT to be as effective as individual cognitive therapy for reducing depressive symptoms and somewhat more effective than individual therapy for improving marital functioning (see Jacobson et al. 1991 and Beach and O'Leary 1992). Not surprisingly, couples therapy does not appear to be as helpful for depression in the absence of marital distress (Gotlib and Hammen 1992; Beach, Fincham, and Katz 1998).

The most efficacious couples treatments for depression seem to focus on enhancing communication and intimacy and improving interpersonal interactions. This focus may help to improve both the relationship and individual symptomology, although this has not been tested on severely depressed or hospitalized patients. (Beach and O'Leary 1992). However, couples therapy may be contraindicated if one partner is so severely depressed that he or she needs to be the sole focus of treatment or the depression is psychotic or bipolar, all of which would limit that person's ability to focus on the relationship.

Spouse-aided treatment for anxiety spectrum disorders also appears to be efficacious, particularly for agoraphobia and generalized anxiety disorder. W. Kim Halford and Ruth Bouma (1997) note that the relationship between marital difficulties and anxiety is moderated by gender, type of anxiety, and whether both spouses have anxiety disorders. As in the case of depression, research suggests that couples treatment for anxiety may be most effective in the presence of marital distress, although if a spouse reinforces or helps to perpetuate anxiety symptoms (for instance, if a spouse facilitates avoidance behavior), then spouse-aided therapy may also be helpful. Some outcome studies suggest that in vivo treatment for agoraphobia including a focus on couple functioning is more effective at follow-up than in vivo treatment without the couple focus (Epstein, Baucom, and Daiuto 1997). However, other studies have found spouse-aided therapy to be neither more nor less effective than individual therapy for agoraphobia (Emmelkamp et al. 1992).

Substance abuse in a marital relationship may be among the most destructive of comorbid disorders due to its many potential relationship and individual consequences, including poor physical health, unemployment, abdication of household and other responsibilities, and potential for violence. Couples therapy for individual substance abuse shows promise, although research on this topic has varied widely in models of substance abuse, methodology, and level of spousal involvement. Most couples therapy research on substance abuse has focused on alcoholism, and therapy goals typically involve eliminating drinking or supporting the drinker's efforts to stop, altering marital interactions to create an environment that encourages sobriety, preventing relapse, and dealing with more general marital issues (O'Farrell and Rotunda 1997).

Interventions are likely to focus on the urge to drink or do drugs, important events in the last week relating to substance use, helping couples identify behaviors in themselves and each other that may trigger substance use, strategies to increase positive nonalcohol-related behaviors between spouses, and teaching communication and problem-solving skills. Timothy O'Farrell and William Fals-Stewart's (2000) application of behavioral couples therapy for alcoholism and drug abuse found that it was more effective than individual treatment for producing abstinence and fewer substance-related problems, higher relationship satisfaction, decreased domestic violence, and lower risk for marital separation.

Culture, Ethnicity, and Couples Therapy

Culture and ethnicity have been increasingly recognized as important factors in therapy. It is also increasingly evident that therapists can make serious mistakes when they fail to recognize cultural explanations for behaviors or problems and then over- or under-pathologize patients on that basis. This can be a problem in couples therapy, as an uninformed therapist may label a behavior that is acceptable and adaptive from the couple's point of view as problematic because it does not fit his/her cultural standards for a healthy relationship. There are several solutions to this potential problem, including obtaining knowledge about the cultural background of the couple, becoming aware of one's own cultural background, and becoming a culturally sensitive therapist.

The first step, obtaining knowledge about the cultural background of the couple, is similar to researching any issue that might affect the effectiveness of therapy. The greater the therapist's understanding of each member's cultural background, the more likely that they will be able offer interpretations and suggestions that fit the couple's schema. The most important and best source of this information is the couple itself. Although obtaining information on specific ethnic or cultural groups might be useful, it is important to remember that such information may not apply to specific individuals. Rather, a culturally sensitive therapist recognizes that the members of the couple are the best experts on how their cultural backgrounds affect their lives and experiences.

According to Monica McGoldrick and Joe Giordano (1996), it is just as important for the therapist to become aware of his/her own cultural background and influences. Culturally sensitive therapists recognize that their own values and expectations, as well as those of their clients, stem from culture, rather than assuming that such ideas are universal. For example, a therapist may think that it is a universal rule that communicating clearly and openly about one's emotions is healthy, failing to recognize that the idea is, in fact, culturally determined, and that there are many cultures in which straightforward communication about emotions is considered immature or rude.

In other words, a culturally sensitive therapist is one who, as defined by Steven Lopez (1997), is able to recognize the different cultural "lenses" that clients and therapists bring to therapy. According to Lopez, every person views the world through the lens of culture, and it is the therapist's job to learn about their client's lens and find a way to work together in a way that is compatible with both views. This is especially important in couples therapy, as each member of the couple brings a separate lens. The lenses may be vastly different in the case of an interracial or intercultural couple, or they may be only slightly discrepant, in the case of a couple in which both members are from the same culture.

It is extremely important to maintain an awareness of the impact of racism, prejudice, and discrimination. Therapists of the dominant culture may have unconscious or unacknowledged negative attitudes towards people of other cultures. These feelings can emerge in subtle ways that denigrate or ignore the cultural needs and characteristics of a couple. Similarly, a therapist who is not of the dominant culture may have to deal with such negative attitudes from clients of the dominant culture. Even when therapists and couples match in ethnicity or culture, they may find that they have different ideas about what it means to be a member of that culture. Couples in which one or both members are not from the dominant culture may face prejudice and discrimination in the society they live in. This experience can place strain on the health of the relationship, as well as that of the individual. Couples may experience conflict over how and when to confront racism and prejudice and over determining the best ways to cope (Okun 1996).

Conclusion

Since its origins in the marriage-counseling movement, couples therapy has grown and diversified. There are many models of couples therapy, which share the goal of improved relationship functioning. These therapies, however, may differ significantly in the techniques they use, from teaching new skills to focusing on emotions and acceptance. Moreover, the couples entering therapy may differ in the problems that bring them to therapy from communication, to sex, to children, to violence between partners. There is increasing evidence indicating that couples therapy may be useful for treating individual problems as well, including depression, anxiety, and substance abuse.

Couples therapists are also becoming more sensitive to their own and their clients' sociocultural backgrounds, needs, and interests. This trend is important, as there is no single type of couple that may benefit from couples therapy, and couples may vary tremendously in their levels of commitment and the relationship issues with which they are dealing. Further research should address how to differentiate between couples who will improve in therapy and those who will not, what kinds of problems couples therapists are best prepared to help, and how to generalize our treatments so that they work for couples of all ages and backgrounds. Fortunately, with the variety of models, approaches, and techniques available as well as the creativity and careful work of researchers and clinicians, the future looks bright for couples therapy.

The First Generation of Family Therapy

Gregory Bateson (an anthropologist) and Don Jackson (a psychiatrist) developed a systemic approach to schizophrenia while working at the Palo Alto Veterans Hospital (Bateson 1973; Jackson, 1961, 1973). The Bateson Project stressed that problems do not exist in any one person—relationship problems and/or dysfunctional interaction styles cause distress in individual family members. The dysfunction resides not in the "identified patient" but in the verbal and non-verbal communications that occur between family members. For example, if a father tells his son (the identified patient) to "be independent" one day and "obey your father" on the next day, he is putting the child in a position where the son will be emotionally conflicted and lose no matter what he does. The child cannot escape the relationship, his desire to please his parent, or his inability to be both "obedient" and "independent" at the same time. Jackson called this a double bind and thought that it was related to the etiology of schizophrenia. While Jackson was wrong in assuming that family communication patterns "cause" schizophrenia, his work on dysfunctional communications in the family was the seed of the second-generation "family systems" therapies.

Nathan Ackerman (1958), a clinician working in New York City, realized that when parents brought their children into the clinic, they were often blind to how their roles as parents and spouses were inciting and exacerbating the children's problems. Ackerman was the leader in reorienting treatment for children referred to child guidance centers to include the entire family. Ackerman came from a psychodynamic background but he understood that individuals are shaped by current family circumstances as well as their intrapsychic issues. He postulated that many problems in adolescence and adulthood are due to family conflicts over how the family should be organized and how it should carry out essential family functions. For example, should the mother work a second job so her children can buy expensive sneakers? Should the children be allowed to determine their own bedtime? Families inevitably confront many such issues due to changes in their children or themselves. As the family matures and changes, all the members must adapt and change. When family members do not want to change or do not know how to change, conflict characterizes family interaction, and individual members start showing psychological symptoms of distress. Ackerman also focused on the complementary interactions between the family and the individual—how each needs the other's affection and protection to survive.

Second-Generation Family Therapies

As the family approach became more popular, the theories and techniques began to multiply. Most could be grouped under one of the following six headings: Psychodynamic, Structural, Strategic, Conjoint/Humanistic, Cognitive/Behavioral, and Solution-Focused (see Figure 1).

Psychodynamic/transgenerational family therapy. This approach was developed by Murray Bowen, Ivan Boszormenyi-Nagy, and James Framo (Bowen 1978; Boszormenyi-Nagy 1973; Framo 1982). Family members who enter psychodynamic Bowian therapy spend a lot of time thinking about the childhood forces that shape their personalities (Papero 1990). Often, a person will be in individual therapy alone. What makes this family therapy instead of psychodynamic therapy is that the emphasis is not uni-directional, analyzing only what parents did to their children, but rather on what clients really want to do in their lives and how the family has made it difficult for them to move towards their desired goals. They then have to confront their parents as adults, whenever possible, so that instead of being emotionally dependent on the parents for approval, they become interdependent with them as adults. Indeed, Framo (1982) has focused on creating family-of-origin sessions, so that adult children can confront their parents and learn to communicate on a more open, adult, and caring level.

Bowen was highly theoretical in his approach, and many of his concepts are so popular and endemic that they are considered to be the core concepts of the entire field. The five major concepts are as follows (Bowen 1978):

• Differentiation of self. This is the ability to distinguish intellectual from emotional needs, desires, and responses. Young adults who feel guilty leaving their parents' homes are not even going to think about applying to a school 1,000 miles away if they have a low level of differentation. With a high level of differentiation, they will be able to consider the pros and cons of schools both near and far.
• Triangles. When two people have difficulty communicating with one another, it becomes much easier for both to focus on a third person and triangulate them into the relationship. Sometimes the third person has divided loyalties and must shift from side to side (as children in many divorce situations do); sometimes the third person simply aligns himself or herself with one person (e.g., when mother and daughter are on one side and father is alone on the other). There are also many triangles where the two parties who are at odds (usually the parents) decide to focus on and micro-manage the problems of a third person (usually one of the children) to have some interactions that do not touch the most explosive areas of the relationship.
• Family projection process. Not all children in the family are treated similarly by the parents. The child who is most emotionally involved with the parents and the least likely to differentiate from them is the object of the family projection process.
• Emotional cutoff. When children have trouble successfully differentiating they sometime resort to avoiding any real psychological intimacy or self-disclosure with their parents. Sometimes, they will physically move to another state or continent to avoid contact.
• Multigenerational transmission process. Family functioning is passed on like many genetic traits. Psychological functioning is passed down through the generations by two mechanisms. First, individuals tend to marry someone at the same level of differentiation as themselves, so that poorly differentiated FIGURE 1 people marry one another and cannot really relate as independent adults. Then, through the family projection process, at least one of the children is pulled into their emotional neediness circle and can function even less as an independent adult.

The goal is to help each person achieve maximum self-differentiation. The therapist stays removed and de-triangulated from the family, acting as a coach to help the family do research into its own family functioning. Remaining emotionally neutral, the therapist helps each person in the family realize the part that he or she is playing in maintaining the problem. Each person talks to the therapist (instead of each other) as each tries to communicate true thoughts and feelings. The therapist builds a mini-relationship with each person in the family, modeling how each should focus on self-disclosure and respectfully listening instead of talking about a third person. Openly expressing one's thoughts is promoted so that the family hears one another's perspectives. The therapist often works with the most psychologically healthy person in the family, with the idea that he or she will be able to differentiate most successfully and serve as a model for the rest of the family.

The most widely used of Bowen's techniques is the family genogram, where the structure and characteristics of family members are mapped over at least three generations to look for multi-generational influences. Other psychodynamic family therapists have focused on how the children become indebted to their parents and help them find ways to "balance the ledger" (Boszormenyi-Nagy 1973).

Structural family therapy. A family who enters structural family therapy, an approach developed by Salvador Minuchin (1974), will talk about the past as well as the present, since the family's current problems are seen as a carry over from earlier transactional patterns. The therapist looks for transactional boundaries defining the communication rules in the family by watching who talks to whom and how the family breaks up into sub-groups for support and problem solving. They look for triangles, where two family members resolve tensions between themselves by focusing on a third person in the family (Minuchin 1974; Minuchin and Fishman 1981).

The therapist's goal is to restructure family interactions between the family members, so they can more effectively solve their problems. Once dysfunctional transaction patterns are replaced with new, adaptive patterns the relationship loses its toxic nature and individuals no longer need to express their distress or dissatisfaction in an aberrant way.

Structural therapists use five hallmark techniques. They actively try to get the family to be comfortable with them as a person—it is said they join with the family. This is accomplished by maintenance (verbally supporting and reinforcing the family's behaviors and verbalizations), tracking (asking for clarification and amplification of statements to show interest), and mimesis (mimicking the affective tone, communication style, and level of formality that the family portrays in an effort to show that the therapist is "one of them"). A second technique is structured mapping, where the therapist diagrams which interactions in the family are healthy and which are characterized by over-involvement, distance, or anger. Entire families can be described as enmeshed (if they are over-involved) or disengaged (if they are too distant from one another). Other assessment techniques used to discern the structure of the family are enactments (where the family is asked to re-enact an everyday routine or the crisis situation) and actualizing family transactional patterns (where the therapist does not engage in the conversation or choose the topic but simply watches the family as they naturally communicate with one another and sees who communicates with whom under what conditions).

The fifth and most important technique involves various forms of restructuring the family. It may involve actively moving the family's seating arrangements within the therapy session, to help facilitate the restructuring of family communication patterns. It may involve assigning tasks so that individuals who usually do not interact with one another are joined in a purposeful activity. The therapist may help the family mark boundaries by setting up new rules or negotiating old rules.

Structural therapists must learn how culture affects family interactions so that they are not simply projecting their own idea of normal functioning onto their clients. For example, Hispanic families often give more authority to the father than Jewish families do. Structural therapists evaluate the family interaction pattern to determine if it is maintaining a specific problem, not simply judging the pattern. Structural family therapy seems to work especially well with families who have out-of-control or over-controlled teenagers.

Strategic family therapy. A family who enters Strategic Family Therapy, developed by Jay Haley (1963, 1987), talks almost exclusively about what is going on in the present. This therapy assumes that problems are the result of the current dysfunctional interactions taking place in the family. The therapist looks at the presenting symptom as a communication towards the other family members. Perhaps the child's morning stomachache is communicating that the child is sick for mother, who is traveling during the week. Perhaps the marijuana abuse of a teenager is a way to communicate to his mother that he feels out-of-touch with a new stepfather in the house (Haley 1963, 1987; Madanes 1981). The therapist's goal is to be the most powerful person in the therapy room so that the suggested interventions will be carried out and help restructure the power relations within the family.

The most well-known technique used by structural family therapists is problem focused prescriptions that are paradoxical. This involves telling the client to continue doing the very behavior that is labeled "the problem." If the problem is bedwetting, for example, the child is told to try to wet the bed every night. If the problem is an angry husband, he is instructed not to smile or act cordially to anyone in the family during the entire next week. If the symptom is communicating something important, when the client engages in the symptomatic behavior to comply with the therapist, it loses its communication value within the family. In the above prescription it is unclear after therapy what the husband is communicating by not smiling. Is he communicating compliance with the therapist or disdain with his home life? One has to be unsure. This opens the possibility that the client will choose a new and healthier way to communicate his or her needs (after all, the symptom by this time has become a habit that has trapped the person into responding to the family in a particular, defensive way). For problem-focused prescriptions to work, they need to be accompanied by a very plausible explanation. For example, the bedwetters might be told that it is bad for their bladder to try to keep dry; it is more important for their bladder to void during the night, and everyone will just have to learn to live with the bedwetting. Whenever possible, the therapist gives the family a chance to do a small version of the task in the session (e.g., instructing the father on how to keep a straight face), in order to make the assignment more likely to be carried out in the home.

Another famous strategic technique is reframing. With reframing, a person learns how to look at the cup of family virtues as "half full" instead of "half empty." A family may learn that the "immaturity" label that they have given to their son's shy behaviors can also be labeled as "social sensitivity."

Strategic family therapy is usually used with families who have not responded to other types of treatment. Empirical research on the effectiveness of strategic techniques is mixed, and some shy away from this technique, in part, because of the ethical issues of deception that surround the technique (paradoxically telling clients to do A when you really want them to do not A).

Conjoint family therapy. Conjoint family therapy was developed by Virginia Satir, the first major female family therapist, and the founder of the first formal training program in family therapy (Satir 1967, 1972). She combined the historical approaches of the psychodynamic theorists with the here-and-now emphasis found in the structural and strategic approaches. Satir believed that each person in the family was trying to keep the system in balance but that the "price" that each person "paid" was often very inequitable. When people in the family show a maladaptive symptom, it is because their growth is being blocked by the family unit's need for balance. The rules that create balance in a family are the result of how parents go about achieving and maintaining self-esteem. What mothers and fathers do to create an atmosphere that says "I am a worthy person" affects the context in which the children develop their own self-esteem.

Here the family experiences a very warm and emotionally involved therapist who stays in the present or goes into history as the case dictates. For conjoint family therapists the goal is always to help each individual family member build self-esteem. An equally important secondary goal is to expose and correct discrepancies in how the family communicates.

Satir found that under stress, problem families take on rigid communication styles. Each person develops a communication front: The placator is always trying to please; the blamer is finding fault with everyone; the super-reasonable person is always trying to intellectually analyze what is happening; and the irrelevant person acts in a distracting way, not wanting to relate to anything going on in the family. Conjoint family therapy tries to teach the congruent style of communication where people are honest, vulnerable, caring, and responsible for sending clear messages.

One of Satir's most famous techniques is the family life chronology, where the therapist initiates treatment by understanding the family's history through the various life stages and how they want to experience their current family life. This is a therapeutic system that greatly respects the rights of children to be heard, to be loved, and to be respected.

Conjoint family therapy works on eight different levels: physical, intellectual, emotional, sensual, interactional, contextual, nutritional, and spiritual. Sometimes a child needs to be hugged in the session (physical/interactional), for example, and sometimes it is best to cry along with a father grieving for his lost son (spiritual/emotional). The art of conjoint family therapy is learning to work on different levels simultaneously in a natural manner that resonates with the family's needs at the time of the session.

Conjoint family therapy is like solution-focused therapy in that both assume that people have the resources within them to flourish. They both encourage people to take risks and take control of their lives in a very direct and open manner. Also, they both stylistically rely on a very down to earth, approachable manner in the therapist.

Cognitive/behavioral family therapy. Cognitive/behavioral family therapy was developed by Gerald Patterson, Robert Liberman and Robert Stuart in the 1970s. It was a natural outgrowth of applying academic principles of learning and behavior change to the family situation (Liberman et al. 1980; Patterson 1971; Stuart 1980).

A family who enters cognitive/behavioral family therapy spends the first few sessions undergoing a careful functional assessment devoted towards defining exactly what the problem behaviors, attitudes, and interactions are in the family and under what conditions these troublesome symptoms appear. Cognitive/behavioral family therapists focus on dyadic interactions (e.g., husband-wife, parent-child) much more than those in other schools of therapy. The therapist's goal is to teach how one's behavior can influence the others in the family and how controlling one's own thoughts can control how one feels.

The range of techniques used in cognitive-behavioral family therapy is multidimensional. The basic learning principles of positive reinforcement, negative reinforcement, extinction, and modeling are used, as well as more complex clinical procedures such as contingency contracting (where each person writes down their obligations in the relationship and the privileges or rewards they expect to get from the relationship). A very popular technique developed by Stuart (1980) in his work with couples is to have caring days. In this technique, each partner writes down what behaviors he or she wants the other to exhibit. Then each partner promises to carry out eight to twenty of the requests made by the other partner during the week. There is no quid pro quo here. Each person engages in the behavior to become a "reinforcing object" for the other.

Cognitive-behavioral family therapy is successful with a very wide range of problems including marital problems, sexual problems, dealing with children who are diagnosed with conduct disorder or oppositional disorder, coping with mental or physical illness in the family, and dealing with children with anxiety disorders. There is more empirical evidence to support the efficaciousness of cognitive-behavioral family therapy than any other modality.

Solution-focused family therapy. A family who enters solution-focused family therapy, developed by Steven deShazer (1982, 1985, 1994), spends their time talking about the present and the future. All of the techniques are driven by the therapist's goal to use minimal interventions to help the family rediscover what will help them solve their problem.

The therapist's goal is to stay in the here and now and help the family re-discover resources that have helped them solve difficult problems in the past. The focus is always on what is possible and changeable. The prior solutions are labeled as the "problem" and the presenting problem is often left backstage as new solutions are highlighted. The therapist is very active and directive, and like the strategic family therapist, accepts responsibility for the family's outcome. The treatment is brief; sometimes it can consist of only one session. The therapist is looking for behavioral changes and when these occur, the case is closed.

The first and most popular technique is geared towards helping the family define what they want to be the goal of therapy. The family is quickly able to supply these goals by asking the miracle question. The question is posed to the family in the following way: "Suppose you were to wake up tomorrow morning and your problems were solved by some miracle. How would you know that a miracle had occurred? What would be different?" For a depressed mother the answer may be, "I would wake and smile at my daughter and fix her a good, nutritious breakfast. After she went off to school, I would spend the morning looking for a job." Once the therapist helps clients achieve these realistic goals, they feel empowered to create additional changes (deShazer 1982, 1985, 1994).

Another popular technique is scaling, where the family members rate the family well-being on a scale of one to ten, with one being the worst and ten being the best. By frequently asking for ratings the therapist gets feedback on the different perceptions of the family members and the effects of the intervention, and can give the family the expectation for change.

There are four types of conversations fostered during the therapy session: (1) competence talk (focusing on the strengths of individual family members and their collective strengths a family); (2) exception talk (searching for instances in the past where they have dealt with the problem or a similar problem in a successful way); (3) context-changing talk (focusing on how they act differently in different situations); and (4) deconstructing the problem (helping the family see how the problem makes changes inevitable and possible).

While solution-focused therapy has many similarities with strategic therapy (they are both brief and centered in the here and now and have active directive therapists), the big difference is that in solution-focused therapy the therapist is looking for clients to come up with new solutions that can work for them, and in strategic therapy the therapist is coming up with directives that seduce the family into trying a new set of behaviors.

Third-Generation Family Therapies

By the mid 1980s, a number of therapists had written books about the need to integrate the different schools of family therapy. Eclectic family therapy became the "buzz." The two hallmarks of eclectic approaches are: (1) they attempt to respect and utilize cultural attitudes, values, rituals, and social structures, and (2) they borrow theory and technique from a variety of schools to assess the family and develop a treatment plan.

Eclectic therapies do not assume that everyone wants to individuate from their families of origin. Indeed, they acknowledge that for many minority cultures in America the greatest value is placed on interdependence of family members and sacrifice of individual goals for the good of the family (Sue and Sue 1990). The eclectic therapist is expected to learn about different cultures and master the art of understanding cultural norms, avoiding stereotypes, and respecting individual differences.

The eclectic therapies often offer a guidebook to help therapists choose from the buffet table of techniques and theories available to them. The essential point is to realize that solution-focused therapy is not for everyone, nor is structural family therapy. The goal of a successful family therapist is to learn to use the right assessment tools to find the right intervention strategy for a particular type of family with a particular type of problem. A depressed eight-year-old female living with her grandmother in the inner city needs a different combination of family assessments and interventions than a depressed sixteen-year-old boy with a twin sister who is being brought up by his mother and her lesbian partner.

The most influential eclectic family therapy approaches are Larry Feldman's (1992) integrative multilevel family therapy, William Walsh's (1991) integrative family therapy, William Nichol's (1988) integrative approach to marital therapy, and David Will and Robert Wrate's (1985) problem-centered psychodynamic family therapy.

Fourth-Generation Family Therapies: Developmental, Positive, and Ethno-Political Approaches

Experience and research with the eclectic approach revealed that certain technique combinations do consistently work with certain populations. Family therapy is becoming specialized according to the presenting problem and the goals of therapy. For example, often therapists dealing with eating disorders start with a core of behavioral/cognitive interventions and then use structural techniques, as needed, on a case-by-case basis. In addition, empirical research has led to at least two new broad portals that define fourth generation family therapies at the beginning of the twenty-first century.

Developmental family therapies are therapies helping families deal with developmental crises that arise at each stage of the family life cycle—e.g., infertility, dual careers, death, disability, chronic illness, stepfamilies. Specific theories about the nature and trauma of each event guide the family therapist in a highly tailored assessment process and intervention strategy (Carter and Mc-Goldrick 1989). These specialized approaches have been around since the early 1960s but their acceptance, popularity, and common philosophy define them as a twenty-first-century force in the field. The most empirically validated therapies in this category include medical family therapy programs (McDaniel, Helpworth, and Doherty 1992), sexual dysfunction therapies (Leiblum and Rosen 2000), and family programs for severe mental illness (Marsh, Dickens, and Torrey 1998).

Ethno-political family therapies take a transcultural perspective and help resolve problems families have interfacing across cultures and different political regimes. These therapists are involved in helping refugees adjust to their new countries, victims of political unrest and war cope with new family demands, and governments and agencies develop programs based on economic and political analyses of family stressors. For example, when working with refugees who migrate to the United States, therapists first need to learn about the premigration stressors. Was the family fleeing from a war or a famine? Were they trying to reunite with family in the United States? Did they have a comfortable life style in their country of origin? Then, therapists need to assess post-migration stressors. Do the refugees know how to speak English well? Are they embarrassed by their accents? Are they able to find a job commensurate with their level of education? What is there visa status? Are they worried about family left behind? Do they have a financial responsibility to send money home? Third, the therapist must assess the social support system. Who are they looking to for help and for emotional support in this country? In which social institutions are they comfortable (e.g., school, church, community center), and which are threatening to them? Finally, do they think of their visit here as "temporary" and wait for the opportunity to return home, or do they want to become U.S. citizens? Interventions then vary by need and cultural considerations. For example, interventions designed to support Hispanic women who are the major breadwinners may help empower their husbands and make the pair comfortable in developing a new, more balanced relationship to fit the new social demands of the situation. Interventions for a Russian Jewish family where the parents feel isolated may concentrate on helping them establish ties with the wider Jewish-American community.

In this portal, therapists are developing approaches for families to deal with racism (Boyd-Franklin 1993), culturally pluralistic environments (Szapocznik et al. 1994), and oppression (Sue 1994). Most ethno-political therapists have followed and elaborated on Minuchin's structural approach, making it more relevant to diverse ethnic groups and cultural milieus.

Family Therapy and Ethics

A wide assortment of mental health professionals practice family therapy including psychologists, psychiatrists, psychiatric social workers, psychiatric nurses, and pastoral counselors. While all family therapists must follow the ethical guidelines established in their discipline, there are ethical issues unique to family therapy. Thus, special ethical guidelines have been established by the American Association of Family Therapists. Two of the thorniest issues concern defining who is the client (Is it the parent who brings the child, the child, or both of them? Is it the wife, the husband, or the couple?) and confidentiality (If the child tells you he is smoking marijuana do you have to keep confidentiality or do you have to break confidentiality and tell the parent?) (Gladding, Remley, and Huber 2000).

Types of Interventions

Byron Egeland and his colleagues (2000) identified three types of intervention: (1) programs directed at the parent's sensitive behavior; (2) programs that focus on the parent's working model (or mental representation) of attachment and parenting; and (3) intervention efforts that attempt to stimulate or provide social support for parents (for a narrative review of the studies, see Juffer, Bakermans-Kranenburg, and Van IJzendoorn, in press).

The first type of intervention, focusing on sensitivity, often starts by teaching parents observational skills in order to make them better perceivers. This goal can be reached in several ways: for example through stimulating parents to complete a workbook about the behavior of their child, or by encouraging parents to engage in "speaking for the baby" through verbalizing their child's behavior (Carter, Osofsky, and Hann 1991). The therapist may also encourage the parent to perceive the child's behavior in a more correct, objective way, in other words, without distortions, by explaining salient issues about the child's development. Many interventions that focus on parental sensitivity concentrate on prompt and adequate responding, for example through discussing parenting brochures or by modeling the desired behaviors. Another strategy to enhance sensitivity is by reinforcing sensitive and responsive behaviors that the parents already show to their child, for example with video feedback (e.g., Bakermans-Kranenburg, Juffer, and Van IJzendoorn 1998; Seifer, Clark, and Sameroff 1991).

In the second type of intervention efforts are directed towards the parent's mental representation, and the focus of change is the parent's working model or representation of his or her own attachment experiences (Bowlby 1982). Many of these intervention programs base their approach on the work of Selma Fraiberg (Fraiberg, Adelson, and Shapiro 1975). Fraiberg realized that parents are apt to "re-enact" or repeat the parenting behavior of their own parents, even unconsciously and involuntarily. Her famous metaphor of "ghosts in the nursery" has inspired interventions that are typically insight-oriented, therapeutic, and lengthy. The idea is that maladaptive parenting behavior may be changed by changing the mental representations or inner working models of the parents. In this type of intervention parents are involved in discussions about their past and present attachment experiences and feelings in child-parent psychotherapy or in psychodynamic therapy. Often these interventions take a long time, for example, fifty sessions, although some interventions attempt to pursue their goal in a shorter period of time, for example, four to ten sessions.

Nancy Cohen and her colleagues (1999) describe two examples of interventions focusing on the parent's representation. One of the two treatments evaluated in this study was Psychodynamic Psychotherapy (PPT), a parent-infant therapy for clinically referred infants. During center-based sessions mother and infant are invited to play. The mother and therapist talk together, but they also try to attend to the infant's activities. In this representational approach the therapist makes use of psychodynamic transference, repetition of the past, reexperiencing of affect, and interpretation. In the second treatment, Watch, Wait, and Wonder (WWW), a representational approach is combined with a behavioral approach. The authors describe WWW as infant-led psychotherapy: Mothers are given the opportunity to explore with the therapist intergenerational (representational) issues, although a specific and ultimate goal of WWW is to enable the mother to follow her infant's lead (behavioral approach). For half of each session the mother is instructed to get down on the floor, to observe her infant, and to interact only at her child's initiative. According to the authors, this method places the mother in the position of being more sensitive and responsive. After about fifteen sessions both PPT and WWW were successful in reducing infant-presenting problems and in reducing maternal intrusiveness. The infants in the WWW group showed a greater shift towards secure attachment, and their emotion regulation improved more than in the PPT group.

The third type of intervention aims at stimulating or providing social support to parents. The importance of practical and emotional support from relatives or friends for the parent's functioning and subsequently the child's developmental outcome has been supported by ample empirical evidence. Several interventions make use of social support primarily, sometimes by giving practical help and advice, by offering individualized services, by providing information about community services, or by stimulating the parents to extend their social network.

Social support may be more influential at particular times in the parent's development. The transition to parenthood, as a period of considerable change in routines, expectations, and behaviors, requires numerous physical and emotional adjustments. In such a transition period parents may not only need more help, but may also be more receptive for support from others. An intervention program that is illustrative of this line of reasoning is the preventive intervention for couples becoming parents. In groups that extend from pregnancy through three months postpartum, expectant parents receive support from the group leaders (a married couple) and from the other group members by sharing hopes, feelings, and worrisome thoughts (Cowan and Cowan 1987).

Other interventions combine the provision or enhancement of support with promoting sensitive parenting. Finally, the provision of social support can be combined with both a behaviorally focused intervention and a representational approach. For example, in project STEEP (Steps Toward Effective and Enjoyable Parenting) (Egeland et al. 2000), mothers not only receive practical support and advice, but also video feedback, in order to increase sensitive parenting, and help to examine and discuss their own childhood experiences.

Effectiveness of Interventions

Are family interventions effective in enhancing parental sensitivity and children's attachment security? A meta-analysis of seventy published papers reporting on eighty-eight interventions with effects on sensitivity (81 studies with a total of 7,636 participants) and/or attachment (29 studies with 1,503 participants) revealed that interventions are significantly but only modestly effective in enhancing maternal sensitivity. The effect on attachment was even smaller. Intervention that focused on sensitivity only showed the largest combined effect on sensitivity, meaning that interventions with a relatively "narrow" focus tend to be more effective than "broadband" interventions (see also Van IJzendoorn, Juffer, and Duyvesteyn 1995). With respect to attachment, interventions that focused solely on enhancing maternal sensitivity also showed a positive effect on infant attachment security, and these interventions were more effective than the others. In fact, it was the only type of intervention yielding a significant combined effect size. Unexpectedly, a large effect on sensitivity was found in a small subset of three studies that did not use personal contact in the intervention, but a soft baby carrier, a videotape, or a parenting brochure. However, because this set of studies was small, this finding does not allow for strong conclusions.

Somewhat puzzling was the finding that studies with fewer intervention sessions were more effective in changing maternal sensitivity than studies with more intervention sessions. Interventions with fewer than five sessions were as effective as interventions with five to sixteen sessions, but both were more effective than interventions with more than sixteen sessions. Jennifer MacLeod and Geoffrey Nelson (2000) came to a similar conclusion in their meta-analysis of the reported effects of programs for the promotion of family wellness and child maltreatment. Contrary to their hypothesis, effect sizes were highest for interventions with one to twelve visits, lowest for those with thirteen to fifty visits, and in-between for those with more than fifty visits. Less seems more, at least in the area of preventive and therapeutic family interventions.

The interventions that were directed at families at risk (e.g., poverty, depression, lack of support, or adolescent mothers) showed as much improvement on attachment security as interventions that approached families without risks. Interventions in samples with a higher percentage of insecure children in the control group reached relatively large effects on attachment. In samples with more security in the group to which the intervention group is compared, it is difficult to reach an even higher percentage of security as an effect of the intervention. Surprisingly, however, at-risk samples were comparable to other samples in their response to different types of interventions, and more intensive interventions do not seem to be more effective in groups with more serious problems.

Conclusion

The study of early intervention in the service of children's socioemotional development involves thousands of families with multiple problems. Enhanced parental sensitivity and a secure attachment relationship are at the heart of the interventions. Other theoretical frameworks have inspired parent-management training programs for parents of children with conduct problems or disruptive behaviors (e.g., Foote, Schuhmann, Jones, and Ey-berg 1998). Huge investments to accomplish these goals are made by intervenors, using a wide array of intervention methods. Nevertheless, interventions appear to have a varying degree of success in reaching their goals. Behaviorally focused interventions with a modest number of sessions appear most efficient. From a population health perspective, society should profit from the insights of successful early intervention programs, as childhood experiences may affect subsequent health status in profound and long-lasting ways.