Wampler 2020

The Handbook of Systemic Family Therapy
EDITORIAL BOARD
EDITOR‐IN‐CHIEF
Karen S. Wampler
Michigan State University
East Lansing, MI, USA
ASSOCIATE EDITORS
Volume 1
Richard B Miller
Brigham Young University
Provo, UT, USA
Ryan B. Seedall
Utah State University
Logan, UT, USA
Volume 2
Lenore M. McWey
Florida State University
Tallahassee, FL, USA
Volume 3
Adrian J. Blow
Volume 4
Mudita Rastogi
Aspire Consulting and Therapy
Arlington Heights, IL, USA
Reenee Singh
Association for Family Therapy and Systemic Practice and
The Child and Family Practice
London, UK
The Handbook of Systemic
Family Therapy
Volume 1
The Profession of Systemic
Family Therapy
Editor‐in‐Chief
Karen S. Wampler
Volume Editors
Richard B Miller
Provo, UT, USA
Ryan B. Seedall
Logan, UT, USA
This edition first published 2020
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Library of Congress Cataloging‐in‐Publication Data
Names: Wampler, Karen S., editor.
Title: The handbook of systemic family therapy / editor-in-chief, Karen S.
Wampler.
Description: Hoboken, NJ : Wiley, [2020] | Includes index.
Identifiers: LCCN 2019044963 (print) | LCCN 2019044964 (ebook) | ISBN
9781119438557 (cloth) | ISBN 9781119645702 (adobe pdf) | ISBN
9781119645757 (epub)
Subjects: LCSH: Family psychotherapy.
Classification: LCC RC488.5.H3346 2020 (print) | LCC RC488.5 (ebook) |
DDC 616.89/156–dc23
LC record available at https://lccn.loc.gov/2019044963
LC ebook record available at https://lccn.loc.gov/2019044964
Cover Image: © Lava 4 images/Shutterstock
Cover design by Wiley
Set in 10/12pt Galliard by SPi Global, Pondicherry, India
Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY.
10 9 8 7 6 5 4 3 2 1
In memory of Douglas J. Sprenkle
Educator, scholar, colleague, mentor, and friend.
Karen Smith Wampler, PhD, passed away unexpectedly, just weeks before The
Handbook of Systemic Family Therapy went to press. The handbook is dedicated to her
lasting memory.
Karen served as Editor-in-Chief for all four volumes of The Handbook of Systemic
Family Therapy. From the beginning, she had a vision of what our field needed to
know to move into the future. Her work was finished in late November 2019, just in
time for her next adventure in New Zealand and Australia. She was wise in her selec-
tion of Co-Editors for each volume: Rick Miller and Ryan Seedall (Volume 1), Lenore
McWey (Volume 2), Adrian Blow (Volume 3), and Mudita Rastogi and Reenee Singh
(Volume 4). She was grateful for the chance to work with each of these scholars and
with her Assistant Editor, Leah W. Maderal. She was delighted and humbled to see
“the book” grow to 106 chapters and 292 authors and co-authors. It cheered her
heart—there was so much to know and so much to learn about systemic family ther-
apy. She saw this work as her magnum opus, and it is.
Karen had a career as researcher and teacher, mentor, dissertation and thesis advisor,
program director, and department chair that spanned 33 years. Her impact on the
field of systemic family therapy lives on in these volumes, in her many research publi-
cations and chapters, in students she loved and trained, in colleagues who benefited
from her wisdom, enthusiasm, and support, and in the many individuals and groups
she touched with her kindness, generosity, intelligence, humor, and goodwill.
To paraphrase Shakespeare: “We shall not look upon her like again.”
Contents
About the Editors xi

List of Contributors xv
Prefacexxix
Volume 1 Preface xxxii
The Profession of Systemic Family Therapy
Forewordxxxv
Part I Foundations 1
1 The Importance of Family and the Role of Systemic Family Therapy 3
Karen S. Wampler and Jo Ellen Patterson
2 The Evolution and Current Status of Systemic Family Therapy:
A Sociocultural Perspective 33
William J. Doherty
3 Global Contexts for the Profession of Systemic Family Therapy 51
Timothy Sim and Charles Sim
4 Redefining “Family:” Lessons From Multidisciplinary Research
with Marginalized Populations 79
Heather McCauley and Morgan E. PettyJohn
5 Systems Theory and Methodology: Advancing the Science of Systemic
Family Therapy 97
Andrea K. Wittenborn, Niyousha Hosseinichimeh, Jennifer L. Rick,
and Chi‐Fang Tseng
6 Evidence for the Efficacy and Effectiveness of Systemic Family Therapy 119
Alan Carr
7 Common Factors Underlying Systemic Family Therapy 147
Eli A. Karam and Adrian J. Blow
viii Contents
8 The Process of Change in Systemic Family Therapy 171

Nathan R. Hardy, Allen K. Sabey, and
Shayne R. Anderson
9 Physiological Considerations in Systemic Family Therapy:
The Role of Internal Systems in Relational Contexts 205
Angela B. Bradford and Eran Bar‐Kalifa
Part II Social and Cultural Contexts 225

10 Intersectionality: A Liberation‐Based Healing Perspective 227
Rhea V. Almeida and Carolyn Y. Tubbs
11 Sexual Orientation and Gender Identity: Considerations for
Systemic Therapists 251
Christi R. McGeorge, Ashley A. Walsdorf, Lindsay L. Edwards,
Kristen E. Benson, and Katelyn O. Coburn
12 Spiritual and Religious Issues in Systemic Family Therapy 273
Renu K. Aldrich and Sarah A. Crabtree
Part III Theoretical Perspectives 293

13 Theory: The Heart of Systemic Family Therapy 295
Stephen T. Fife
14 Transgenerational Theories and How They Evolved into Current
Research and Practice 317
Terry D. Hargrave and Benjamin J. Houltberg
15 Structural and Strategic Approaches 339
Jeffrey B. Jackson and Ashley L. Landers
16 Behavioral and Cognitive‐Behavioral Approaches in Systemic
Family Therapy 365
Norman B. Epstein and Frank M. Dattilio
17 Attachment and Other Emotion‐Based Systemic Approaches 391
Ryan B. Seedall and Jonathan G. Sandberg
18 Postmodern Family Therapy 417
Ronald J. Chenail, Michael D. Reiter, Maru Torres‐Gregory,
and Dragana Ilic
Part IV Methodological Challenges and Advances 443

19 Innovations in Systemic Family Therapy Effectiveness Research 445
Richard B Miller and Matthew E. Jaurequi
20 Process Research: Methods for Examining Mechanisms of
Change in Systemic Family Therapies 467
Lee N. Johnson, Laura M. Evans, Brian R. W. Baucom,
and Jason B. Whiting
Contents ix
21 Community‐Based Participatory Research (CBPR) for Underserved

Populations 491
Rubén Parra‐Cardona, Hydeen K. Beverly, and Gabriela López‐Zerón
22 Implementing Research into Everyday Systemic Family
Therapy Practice 513
Mathew C. Withers and James Michael Duncan
Part V Training and Practice 531

23 Ethical and Legal Issues Unique to Systemic Family Therapy 533
Megan J. Murphy and Lorna L. Hecker
24 Training and Credentialing in the Profession of Marriage and
Family Therapy 555
Kevin P. Lyness
25 Supervision in Systemic Family Therapy 577
Marj Castronova, Jessica ChenFeng, and Toni Schindler Zimmerman
26 Multilevel Assessment 601
Todd M. Edwards, Lee M. Williams, Jenny Speice, and Jo Ellen Patterson
27 Sociocultural Attunement in Systemic Family Therapy 619
Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez
28 Promoting Innovative Systemic Research through Improved
Graduate Training 639
Jared A. Durtschi, Suzanne Bartle‐Haring, and Amber Vennum
29 Systemic Family Therapy in Medical Settings 659
W. David Robinson, Adam C. Jones, Daniel S. Felix, and Douglas P. McPhee
30 Specialty Settings: Hospital‐Based Behavioral Health, Military, Family
Businesses, Management, and Government 683
Brian Distelberg, Elsie Lobo, and Griselda Lloyd
31 Integration of New Technologies in Assessment, Research,
and Treatment Delivery 705
Richard J. Bischoff, Paul R. Springer, and Nathan C. Taylor
Part VI Future Directions 727

32 The Importance of Policy and Advocacy in Systemic Family Therapy 729
Jennifer Hodgson and Angela L. Lamson
33 The Future of Systemic Family Therapy: What Needs Nurturing and
What Does Not 753
Fred P. Piercy
Index771
About the Editors
Editor‐in‐Chief
Dr. Karen S. Wampler, PhD, retired as Professor with Tenure and Chair of the
Department of Human Development and Family Studies at Michigan State University.
Professor Emerita at Texas Tech University, she served as Department Chair, MFT
Program Director, and the C. R. and Virginia Hutcheson Professor. During her 10
years at the University of Georgia, Dr. Wampler developed the MFT doctoral pro-
gram as well as the Interdisciplinary MFT Certificate Program, a collaboration with
MFT, Social Work, and Counseling. She is past editor of the Journal of Marital and
Family Therapy. Her primary research interests are the application of attachment the-
ory to couple interaction, family therapy process research, and observational measures
of couple and family relationships. She has authored over 50 refereed journal articles
and 10 book chapters and has been funded by NIMH. A licensed marriage and family
therapist, she is a Fellow of AAMFT, past member of the Commission on Accreditation
for Marriage and Family Therapy Education, and recipient of the Outstanding
Contribution to Marriage and Family Therapy Award. The Family Therapy Section of
NCFR has recognized her with the Distinguished Service to Family Therapy and
Kathleen Briggs Mentor awards.
Associate Editors
Volume 1: Richard B Miller and Ryan B. Seedall

Richard B Miller, PhD, is Chair of the Sociology Department, a former Director of
the School of Family Life, and a former Associate Dean in the College of Family,
Home, and Social Science at Brigham Young University (BYU). He is also a professor
in the Marriage and Family Therapy Program at BYU. Prior to teaching at BYU, he
taught at Kansas State University for 11 years, where he served as Director of the
Marriage and Family Therapy Program. He is passionate about facilitating and
enhancing clinical research in the field, and he has worked to introduce more advanced
statistical methods in SFT doctoral programs and among SFT researchers, in general.
xii About the Editors
His personal program of research focuses on therapist effects and therapist behaviors
in couple therapy. He is also involved in working toward the development of the prac-
tice of couple and family therapy in China. He has published over 100 journal articles
and book chapters, and, along with Lee Johnson, he edited the book Advanced
Methods in Marriage and Family Therapy Research. An MFT professor for over 30
years, he loves mentoring and collaborating with graduate students.
Ryan B. Seedall, PhD, is Associate Professor in the Marriage and Family Therapy
Program at Utah State University, having received his SFT training from Brigham
Young University (MS) and Michigan State University (PhD). He completed post-
doctoral training with Dr. James Anthony in the NIDA‐funded Drug Dependence
Epidemiology Fellowship Program. His primary program of research focuses
on understanding and improving relationship and change processes within the couple
relationship and in couple therapy. He aims to improve couple and family relation-
ships through research on couple interaction and support processes, especially within
the context of chronic illness. He is also interested in protective family dynamics and
prevention efforts, including ways to reduce mental health disparities. Lastly, he is
interested in identifying specific interventions that are useful when working with cou-
ples (e.g., enactments) and also client‐related factors that are strongly associated with
process and outcome in therapy (e.g., attachment and social support). Dr. Seedall has
published over 30 peer‐reviewed journal articles and seven book chapters. He lives in
Hyde Park, Utah, with his wife (Ruth) and four children (Spencer, Madelyn, Eliza,
and Benjamin).
Volume 2: Lenore M. McWey

Lenore M. McWey, PhD, is a Professor and the Director of the Marriage and Family
Therapy Program at Florida State University. She is a Licensed Marriage and Family
Therapist and American Association for Marriage and Family Therapy Approved
Supervisor. She has received federal funding from the National Institutes of Health
(NIH) to support her research on children and families involved with the child wel-
fare system, and the results of her work have been published widely in high‐impact,
peer‐reviewed journals. She currently serves as a scientific reviewer for the Health,
Behavior, and Context Subcommittee of the Eunice Kennedy Shriver National
Institute of Child Health and Human Development of NIH. Dr. McWey has been the
recipient of the Florida State University Distinguished Teacher of the Year and the
Outstanding Graduate Faculty Mentor awards.
Volume 3: Adrian J. Blow

Adrian J. Blow, PhD, works as a couple and family therapy intervention researcher
and educator at Michigan State University (MSU). Dr. Blow is a Professor and
Department Chair in the Human Development and Family Studies Department and
faculty member of the Couple and Family Therapy Program. He obtained his PhD
from Purdue University in 1999 where the late Doug Sprenkle served as his primary
mentor. After Purdue, he joined the faculty at Saint Louis University where he worked
for 6 years. He subsequently joined MSU in 2005. His research is focused on families
and trauma, on military families, and on change processes in interventions pertaining
About the Editors xiii
to systemic family therapy. He has acquired over two million dollars in research grants
as principal investigator and published numerous peer‐reviewed publications (60) and
book chapters (12). He has mentored many students and in 2017 was awarded the
American Association for Marriage and Family Therapy (AAMFT) Training Award,
which recognizes excellence in family therapy education. He has served the field of
systemic family therapy in a number of capacities and was the AAMFT Board Secretary
from 2012 to 2014 and Board Treasurer from 2016 to 2019. He is married to Dr.
Tina Timm, Associate Professor in the MSU School of Social work. He has six
children.
Volume 4: Mudita Rastogi and Reenee Singh

Mudita Rastogi, PhD, practices at Aspire Consulting and Therapy as a Licensed
Marriage and Family Therapist, coach, and educational trainer. Dr. Rastogi obtained
her PhD in Marriage and Family Therapy from Texas Tech University, her master’s
degree in psychology from University of Bombay, and her BA (Honors) in Psychology
from University of Delhi. Prior roles include serving as Professor at the Illinois School
of Professional Psychology, Program Director for the SAMHSA‐funded Minority
Fellowship Program at the American Association for Marriage and Family Therapy,
Associate Editor for the Journal of Marital and Family Therapy, editor of the books
Multicultural Couple Therapy and Voices of Color, and Associate Editor for the
Encyclopedia of Couple and Family Therapy. Dr. Rastogi’s publications focus on cul-
ture, gender, and global issues within the context of family and couple therapy. Dr.
Rastogi is a Clinical Fellow and AAMFT Approved Supervisor having practiced in
both India and the United States. She is a founding member of the Indian Association
for Family Therapy. Dr. Rastogi’s clinical and training interests include systemic family
therapy, diversity and inclusion, global mental health, parenting, child‐free couples,
gender, and trauma. Additionally, she maintains an interest in partnering with grass-
roots, not‐for‐profit organizations.
Reenee Singh, DSysPsych, is the Chief Executive of the Association for Family
Therapy and Systemic Practice in the United Kingdom. She is the Founding Director
of the London Intercultural Couples Centre at The Child and Family Practice in
London, where she practices as a Consultant Family and Systemic Psychotherapist.
She is the past editor of the Journal of Family Therapy, co‐director of the Family
Therapy and Systemic Research Centre at the Tavistock and Portman NHS Foundation
Trust, and visiting professor at the University of Bergamo. Dr. Singh is the author of
two books and numerous academic articles on issues of “race,” culture, and qualita-
tive research. Dr. Singh has lived and worked in Singapore, India, and the United
Kingdom. She has taught all over the world and presents her work at national and
international conferences.
List of Contributors
Hana H. Abu‐Hassan, MD, Department of Family and Community Medicine,

School of Medicine, University of Jordan, Amman, Jordan and Department of
Family Medicine and Public Health, University of California, San Diego, La Jolla,
CA, USA
Sheila M. Addison, PhD, LMFT, Margin to Center Consulting, Oakland, CA, USA
Volkmar Aderhold, MD, Institute of Social Psychiatry, Ernst Moritz Arndt University,
Greifswald, Germany
Renu K. Aldrich, PhD, LMFT, Arlington, VA, USA
Rhea V. Almeida, PhD, Institute for Family Services, Somerset, NJ, USA
Jenny Altschuler, PhD, Affiliate, Tavistock Clinic, London, UK
Shayne R. Anderson, PhD, LMFT, School of Family Life, Brigham Young University,
Provo, UT, USA
Louise Anthias, DProf, Bath, Somerset, UK
Christina M. Balderrama‐Durbin, PhD, Department of Psychology, Binghamton
University – State University of New York (SUNY), Binghamton, NY, USA
Alyssa Banford Witting, PhD, LMFT, School of Family Life, Brigham Young
University, Provo, UT, USA
Eran Bar‐Kalifa, PhD, Department of Psychology, Ben‐Gurion University of the
Negev, Beer‐Sheva, Israel
Suzanne Bartle‐Haring, PhD, Human Development and Family Science, The Ohio
State University, Columbus, OH, USA
Brian R. W. Baucom, PhD, Department of Psychology, University of Utah, Salt
Lake City, UT, USA
Julian Baudinet, PsyD, The Maudsley Centre for Child and Adolescent Eating
Disorders, South London and Maudsley NHS Foundation Trust, London, UK
Erin R. Bauer, MS, Human Development and Family Science, University of Central
Missouri, Warrensburg, MO, USA
xvi List of Contributors
Saliha Bava, PhD, LMFT, Marriage and Family Therapy Program, Mercy College,
Dobbs Ferry, NY, USA
Andrew S. Benesh, PhD, LMFT, Psychiatry and Behavioral Sciences, Mercer
University, Macon, GA, USA
Kristen E. Benson, PhD, LMFT, Human Development and Psychological
Counseling, Appalachian State University, Boone, NC, USA
Jerica M. Berge, PhD, MPH, LMFT, Department of Family Medicine and Community
Health, University of Minnesota Medical School, Minneapolis, MN, USA
J. Maria Bermudez, PhD, LMFT, Marriage and Family Therapy, Human Development
and Family Science, University of Georgia, Athens, GA, USA
Hydeen K. Beverly, MSW, Steve Hicks School of Social Work, The University of Texas
at Austin, Austin, TX, USA
Dharam Bhugun, PhD, MSW, MM, Southern Cross University, Gold Coast Campus,
Bilinga, Queensland, Australia
Richard J. Bischoff, PhD, Child, Youth, and Family Studies, University of Nebraska‐
Lincoln, Lincoln, NE, USA
Esther Blessitt, MSc, The Maudsley Centre for Child and Adolescent Eating Disorders,
South London and Maudsley NHS Foundation Trust, London, UK
Adrian J. Blow, PhD, LMFT, Human Development and Family Studies, Michigan
State University, East Lansing, MI, USA
Guy Bodenmann, PhD, Department of Psychology, University of Zurich, Zurich,
Switzerland
Danielle L. Boisvert, MA, Department of Family and Community Medicine, Saint
Louis University, Saint Louis, MO, USA
Ulrike Borst, PhD, Ausbildungsinstitut für systemische Therapie, Zurich, Switzerland
Pauline Boss, PhD, LMFT, Department of Family Social Science, University of
Minnesota, St. Paul, MN, USA
Angela B. Bradford, PhD, LMFT, Marriage and Family Therapy Program, School of
Family Life, Brigham Young University, Provo, UT, USA
Spencer D. Bradshaw, PhD, Community, Family, and Addiction Sciences, Texas Tech
University, Lubbock, TX, USA
Brittany R. Brakenhoff, PhD, Human Development and Family Science, The Ohio
Andrew S. Brimhall, PhD, LMFT, Human Development and Family Science, East
Carolina University, Greenville, NC, USA
Benjamin E. Caldwell, PsyD, Educational Psychology and Counseling, California State
University Northridge, Northridge, CA, USA
Ryan G. Carlson, PhD, LMHC, Counselor Education, Department of Educational
Studies, University of South Carolina, Columbia, SC, USA
List of Contributors xvii
Alan Carr, PhD, School of Psychology, University College Dublin, Dublin, Ireland
Marj Castronova, PhD, LMFT, MEND, Behavioral Health Center, Loma Linda
University Health, Redlands, CA, USA
Laurie L. Charlés, PhD, LMFT, MGH Institute of Health Professions, Boston, MA,
USA
Ronald J. Chenail, PhD, Department of Family Therapy, Nova Southeastern University,
Fort Lauderdale, FL, USA
Jessica ChenFeng, PhD, LMFT, Department of Physician Vitality, School of Medicine,
Loma Linda University Health, Loma Linda, CA, USA
Amy M. Claridge, PhD, LMFT, Department of Family and Consumer Sciences, Central
Washington University, Ellensburg, WA, USA
Kate F. Cobb, MA, LMFT, Couple and Family Therapy, University of Iowa, Iowa
City, IA, USA
Katelyn O. Coburn, MS, School of Family Studies and Human Services, Kansas State
University, Manhattan, KS, USA
Carolyn Pape Cowan, PhD, Department of Psychology, Institute of Human
Development, University of California, Berkeley, Berkeley, CA, USA
Philip A. Cowan, PhD, Department of Psychology, Institute of Human Development,
University of California, Berkeley, Berkeley, CA, USA
Sarah A. Crabtree, PhD, LMFT, The Albert & Jessie Danielsen Institute, Boston
University, Boston, MA, USA
Lauren Cubellis, MA, MPH, Department of Anthropology, Affiliate Tavistock Clinic,
St. Louis, MO, USA
Carla M. Dahl, PhD, Congregational and Community Care, Luther Seminary, St. Paul,
MN, USA
Andrew P. Daire, PhD, Department of Counseling and Special Education, School of
Education, Virginia Commonwealth University, Richmond, VA, USA
Gwyn Daniel, MA, MSW, Visiting Lecturer, Tavistock Clinic, London, UK
Carissa D’Aniello, PhD, Couple, Marriage and Family Therapy Program, Texas Tech
Frank M. Dattilio, PhD, Department of Psychiatry, University of Pennsylvania Perelman
School of Medicine, Philadelphia, PA, USA
Rachel Dekel, PhD, School of Social Work, Bar Ilan University, Ramat Gan, Israel
Tamara Del Vecchio, PhD, Department of Psychology, St. John’s University, Queens,
NY, USA
Melissa M. Denlinger, MS, Human Development and Family Studies, Iowa State
University, Ames, IA, USA
Janet M. Derrick, PhD, Four Winds Wellness and Education Centre, Kamloops, British
Columbia, Canada
xviii List of Contributors
Guy Diamond, PhD, Center for Family Intervention Science, Drexel University,
Philadlephia, PA, USA
Brian Distelberg, PhD, School of Behavioral Health, Behavioral Medicine Center,
Loma Linda University, Loma Linda, CA, USA
William J. Doherty, PhD, Department of Family Social Science, University of Minnesota,
St. Paul, MN, USA
Megan L. Dolbin‐MacNab, PhD, LMFT, Department of Human Development and
Family Science, Virginia Tech, Blacksburg, VA, USA
James Michael Duncan, PhD, School of Human Environmental Science, University of
Arkansas, Fayetteville, AR, USA
Jared A. Durtschi, PhD, School of Family Studies and Human Services, Kansas State
Lekie Dwanyen, MS, Department of Family Social Science, University of Minnesota, St.
Paul, MN, USA
Lindsay L. Edwards, PhD, Division of Counseling and Family Therapy, Regis University,
Thornton, CO, USA
Todd M. Edwards, PhD, LMFT, Marital and Family Therapy Program, University of
San Diego, San Diego, CA, USA
Ivan Eisler, PhD, The Maudsley Centre for Child and Adolescent Eating Disorders,
Norman B. Epstein, PhD, LMFT, Department of Family Science, School of Public
Health, University of Maryland, College Park, MD, USA
Ana Rocío Escobar‐Chew, PhD, LMFT, Psychology Department, Universidad Rafael
Landívar, Guatemala, Guatemala
Laura M. Evans, PhD, Department of Human Development and Family Studies, The
Pennsylvania State University, Brandywine Campus, Media, PA, USA
Mairi Evans, MA, Post Graduate Research School, Bedfordhsire University,
Bedfordshire, UK
Adam M. Farero, MS, Human Development and Family Studies, Michigan State
University, East Lansing, MI, USA
Daniel S. Felix, PhD, LMFT, Sioux Falls Family Medicine Residency, University of
South Dakota, School of Medicine, Sioux Falls, SD, USA
Stephen T. Fife, PhD, LMFT, Community, Family, and Addiction Sciences, Texas Tech
Heather M. Foran, PhD, Institute of Psychology, Alpen‐Adria‐University Klagenfurt,
Klagenfurt, Austria
Liz Forbat, PhD, Faculty of Social Science, University of Stirling, Stirling, UK
Iris Fraude, BSc, Institute of Psychology, Alpen‐Adria‐University Klagenfurt, Klagenfurt,
Austria
List of Contributors xix
Christine A. Fruhauf, PhD, Human Development and Family Studies, Colorado State
University, Fort Collins, CO, USA
Joaquín Gaete-Silva, PhD, Calgary Family Therapy Centre, Calgary, Alberta, Canada
Kami L. Gallus, PhD, LMFT, Human Development and Family Science, Oklahoma
State University, Stillwater, OK, USA
Casey Gamboni, PhD, LMFT, The Family Institute at Northwestern University,
Evanston, IL, USA
Reham F. Gassas, PhD, Department of Mental Health, King Abdulaziz Medical City,
Riyadh, Kingdom of Saudi Arabia
Abigail H. Gewirtz, PhD, Department of Family Social Science, Institute of Child
Development, University of Minnesota, Minneapolis, MN, USA
Jennifer E. Goerke, MA, School of Counseling, The University of Akron, Akron, OH,
USA
Eric T. Goodcase, MS, LMFT, School of Family Studies and Human Services, Kansas
State University, Manhattan, KS, USA
Arthur L. Greil, PhD, Division of Social Sciences, Alfred University, Alfred, NY,
USA
Cadmona A. Hall, PhD, LMFT, Department of Couple and Family Therapy, Adler
University, Chicago, IL, USA
Eugene L. Hall, PhD, LMFT, Department of Family Social Science, University of
Minnesota, Saint Paul, MN, USA
Nathan R. Hardy, PhD, LMFT, Human Development and Family Science, Oklahoma
Terry D. Hargrave, PhD, LMFT, Department of Marriage and Family Therapy, Fuller
Theological Seminary, Pasadena, CA, USA
Steven M. Harris, PhD, LMFT, Department of Family Social Science, University of
Minnesota, Twin Cities, MN, USA
DeAnna Harris‐McKoy, PhD, LMFT, Department of Counseling and Psychology,
Texas A&M University – Central Texas, Killeen, TX, USA
Jaimee L. Hartenstein, PhD, School of Human Services, University of Central
Rebecca Harvey, PhD, Marriage and Family Therapy Program, Southern Connecticut
State University, New Haven, CT, USA
Stephen N. Haynes, PhD, Psychology, University of Hawai‘i at Mānoa, Honolulu,
HI, USA
Arlene Healey, MSc, DipSW, TMR Health Professionals, Belfast, UK
Lorna L. Hecker, PhD, LMFT, Private Practice, Fort Collins, CO, and Marriage and
Family Therapy Program, Department of Behavioral Sciences, Purdue University
Northwest, Hammond, IN, USA
xx List of Contributors
Katie M. Heiden‐Rootes, PhD, LMFT, Medical Family Therapy Program,

Department of Family and Community Medicine, Saint Louis University, St.
Louis, MO, USA
Sarah L. Helps, DClinPsy, Children, Young People and Family Directorate and
Directorate of Education and Training, Tavistock and Portman NHS Foundation
Trust, London, UK
Katherine Hertlein, PhD, LMFT, Department of Psychiatry and Behavioral Health,
University of Nevada, Las Vegas, Las Vegas, NV, USA
Richard E. Heyman, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Christopher J. Hipp, EdS, LPC, Department of Educational Studies, University of
South Carolina, Columbia, SC, USA
Jennifer Hodgson, PhD, LMFT, Human Development and Family Science, East
Kendal Holtrop, PhD, LMFT, Human Development and Family Studies, Michigan
Niyousha Hosseinichimeh, PhD, Department of Industrial and Systems Engineering,
Virginia Tech, Blacksburg, VA, USA
Benjamin J. Houltberg, PhD, LMFT, Performance Science Institute, Marshall School
of Business, University of Southern California, Los Angeles, CA, USA
Patricia Huerta, MS, LMFT, Human Development and Family Studies, Michigan State
Scott C Huff, PhD, LMFT, School of Human Services, University of Central Missouri,
Warrensburg, MO, USA
Ditte Roth Hulgaard, MD, PhD, Child and Adolescent Psychiatry, University of
Southern Denmark, Odense, Denmark
Quintin A. Hunt, MS, Counselor Education, University of Wisconsin‐Superior,
Superior, WI, USA
Sydni A. J. Huxman, School of Family Studies and Human Services, Kansas State
Dragana Ilic, PhD, LMFT, Department of Family Therapy, Nova Southestern University,
Jeffrey B. Jackson, PhD, LMFT, Human Development and Family Science, Virginia
Tech, Falls Church, VA, USA
Matthew E. Jaurequi, MA, Family and Child Sciences, Florida State University,
Lee N. Johnson, PhD, Marriage and Family Therapy Program, School of Family Life,
Brigham Young University, Provo, UT, USA
Adam C. Jones, PhD, LMFTA, Family Therapy Program, Department of Human
Development, Family Studies, and Counseling, Texas Woman’s University, Denton,
TX, USA
List of Contributors xxi
Tessa Jones, LMSW, Silver School of Social Work, New York University, New York,
NY, USA
Eli A. Karam, PhD, LMFT, Couple and Family Therapy Program, Kent School of
Social Work, University of Louisville, Louisville, KY, USA
Heather Katafiasz, PhD, School of Counseling, The University of Akron, Akron, OH,
USA
Kyle D. Killian, PhD, LMFT, Marriage and Family Therapy Program, School of
Counseling and Human Services, Capella University, Minneapolis, MN, USA
Thomas G. Kimball, PhD, LMFT, Center for Collegiate Recovery Communities, Texas
Tech University, Lubbock, TX, USA
Keith Klostermann, PhD, LMFT, LMHC, Department of Counseling and Psychology,
Medaille College, Buffalo, NY, USA
Carmen Knudson‐Martin, PhD, LMFT, Counseling Psychology, Graduate School of
Education and Counseling, Lewis and Clark College, Portland, OR, USA
E. Stephanie Krauthamer Ewing, PhD, MPH, Counseling and Family Therapy, School
of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
Christian Kubb, MSc, Institute of Psychology, Alpen‐Adria‐University Klagenfurt,
Klagenfurt, Austria
E. Megan Lachmar, PhD, LMFT, Marriage and Family Therapy, Human Development
and Family Studies, Utah State University, Logan, UT, USA
Jennifer J. Lambert‐Shute, PhD, LMFT, Department of Human Services, Valdosta
State University, Valdosta, GA, USA
Angela L. Lamson, PhD, LMFT, Human Development and Family Science, East
Ashley L. Landers, PhD, LMFT, Human Development and Family Science, Virginia
Nicole R. Larkin, MS, CADC, Marriage and Family Therapy, Human Development
and Family Science, University of Central Missouri, Warrensburg, MO, USA
Feea R. Leifker, PhD, MPH, Department of Psychology, University of Utah, Salt Lake
City, UT, USA
Paul Levatino, MFT, LMFT, Marriage and Family Therapy Program, Southern
Connecticut State University, New Haven, CT, USA
Deanna Linville, PhD, LMFT, Couples and Family Therapy Program, University of
Oregon, Eugene, OR, USA
Griselda Lloyd, PhD, LMFT, Edith Neumann School of Health and Human Services,
Touro University Worldwide, Los Alamitos, CA, USA
Elsie Lobo, PhD, LMFT, Counseling and Family Sciences, Loma Linda University,
Loma Linda, CA, USA
Sofia Lopez Bilbao, BA, Counselling Psychology, Werklund School of Education,
University of Calgary, Calgary, Alberta, Canada
xxii List of Contributors
Gabriela López‐Zerón, PhD, Human Development and Family Studies, Michigan

David C. Low, MA, MS, LMFT, Family Therapy Training Institute, Family Institute of
Aurora Family Service, Milwaukee, WI, USA
Mallory Lucier‐Greer, PhD, LMFT, Human Development and Family Studies, Auburn
University, Auburn, AL, USA
Kevin P. Lyness, PhD, Department of Applied Psychology, Antioch University, New
England, Keene, NH, USA
Mohammad Marie, PhD, School of Medicine and Health Science, Al-Najah National
University, Nablus, Palestine
Melinda Stafford Markham, PhD, School of Family Studies and Human Services,
Kansas State University, Manhattan, KS, USA
Heather McCauley, ScD, School of Social Work, Michigan State University, East
Lansing, MI, USA
Teresa McDowell, EdD, LMFT, Counseling Psychology, Graduate School of Education
and Counseling, Lewis and Clark College, Portland, OR, USA
Christi R. McGeorge, PhD, Human Development and Family Science, North Dakota
State University, Fargo, ND, USA
Shardé McNeil Smith, PhD, Human Development and Family Studies, University of
Illinois at Urbana‐Champaign, Urbana, IL, USA
Douglas P. McPhee, MS, Community, Family, and Addiction Sciences, Texas Tech
Lenore M. McWey, PhD, LMFT, Marriage and Family Therapy Program, Department
of Family and Child Sciences, Florida State University, Tallahassee, FL, USA
Lisa V. Merchant, PhD, LMFT, Department of Marriage and Family Studies, Abilene
Christian University, Abilene, TX, USA
Carol Pfeiffer Messmore, PhD, LMFT, Marriage and Family Therapy Program, School
of Counseling and Human Services, Capella University, Minneapolis, MN, USA
Debra L. Miller, MSW, Human Development and Family Studies, Michigan State
Richard B Miller, PhD, Department of Sociology, Brigham Young University, Provo,
UT, USA
Erica A. Mitchell, PhD, Department of Psychology, University of Tennessee, Knoxville,
TN, USA
Danielle M. Mitnick, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Mona Mittal, PhD, LMFT, Department of Family Science, School of Public Health,
University of Maryland, College Park, MD, USA
List of Contributors xxiii
Megan J. Murphy, PhD, LMFT, Marriage and Family Therapy Program, Department
of Behavioral Sciences, Purdue University Northwest, Hammond, IN, USA
Briana S. Nelson Goff, PhD, School of Family Studies and Human Services, Kansas
Hoa N. Nguyen, PhD, Department of Human Services, Valdosta State University,
Valdosta, GA, USA
Matthias Ochs, PhD, Department of Social Work, Fulda University of Applied Sciences,
Fulda, Germany
Timothy J. O’Farrell, PhD, VA Boston Healthcare System, Harvard Medical School,
Boston, MA, USA
Paul O. Orieny, PhD, LMFT, Center for Victims of Torture, St. Paul, MN, USA
Christine Anne Palmer, Aboriginal Elder, Canberra, Australian Capital Territory,
Australia
Rubén Parra‐Cardona, PhD, Steve Hicks School of Social Work, The University of
Texas at Austin, Austin, TX, USA
Jo Ellen Patterson, PhD, Marital and Family Therapy Program, University of San
Diego, San Diego, CA, USA
Rikki Patton, PhD, School of Counseling, The University of Akron, Akron, OH, USA
Brennan Peterson, PhD, LMFT, Department of Marriage and Family Therapy, Crean
College of Health and Behavioral Sciences, Chapman University, Orange, CA, USA
J. Douglas Pettinelli, PhD, Medical Family Therapy Program, Department of Family
and Community Medicine, Saint Louis University, Saint Louis, MO, USA
Morgan E. PettyJohn, MS, Human Development and Family Studies, Michigan State
Bernhild Pfautsch, Diplom‐Psychologist (FH), Department of Social Work, Fulda
University of Applied Sciences, Fulda, Germany
Fred P. Piercy, PhD, Human Development and Family Science, Virginia Tech,
Blacksburg, VA, USA
Nicole Piland, PhD, LMFT, Community, Family, and Addiction Sciences, Texas Tech
Shyneice C. Porter, MS, LMFT, Department of Family Science, School of Public
Shruti Singh Poulsen, PhD, Denver, CO, USA
Keeley Jean Pratt, PhD, LMFT, Human Development and Family Science, The Ohio
Jacob B. Priest, PhD, LMFT, Couple and Family Therapy Program, Psychological and
Quantitative Foundations, University of Iowa, Iowa City, IA, USA
xxiv List of Contributors
Hayley A. Rahl‐Brigman, BS, Institute of Child Development, University of Minnesota,

Minneapolis, MN, USA
Julie L Ramisch, PhD, LMFT, Coastal Center for Collaborative Health, Lincoln City,
OR, USA
Ashley K. Randall, PhD, Counseling and Counseling Psychology, Arizona State
University, Tempe, AZ, USA
Mudita Rastogi, PhD, LMFT, Aspire Consulting and Therapy, Arlington Heights, IL,
USA
Kayla Reed‐Fitzke, PhD, LMFT, Couple and Family Therapy Program, Psychological
and Quantitative Foundations, University of Iowa, Iowa City, IA, USA
Michael D. Reiter, PhD, Department of Family Therapy, Nova Southeastern University,
Kimberly A. Rhoades, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Jennifer L. Rick, MS, LMFT, JLR Therapy, Herndon, VA, USA
W. David Robinson, PhD, LMFT, Human Development and Family Studies, Utah
State University, Logan, UT, USA
John S. Rolland, MD, MPH, Psychiatry and Behavioral Sciences, Northwestern
University Feinberg School of Medicine, Chicago, IL, USA
Lauren M. Ruhlmann, PhD, LMFT, Human Development and Family Studies, Auburn
Nicole Sabatini Gutierrez, PsyD, LMFT, Couple and Family Therapy Program,
California School of Professional Psychology, Alliant International University, Irvine,
CA, USA
Allen K. Sabey, PhD, LMFT, The Family Institute, Northwestern University, Evanston,
IL, USA
Inés Sametband, PhD, Department of Psychology, Mount Royal University, Calgary,
Alberta, Canada
Jonathan G. Sandberg, PhD, School of Family Life, Brigham Young University, Provo,
UT, USA
Shaifali Sandhya, PhD, CARE Family Consultation, Chicago, IL, USA
Jochen Schweitzer, PhD, Institute of Medical Psychology, University of
Heidelberg Hospital and Helm Stierlin Institute for Systemic Training,
Heidelberg, Germany
Ryan B. Seedall, PhD, Human Development and Family Studies, Utah State University,
Logan, UT, USA
Desiree M. Seponski, PhD, LMFT, Marriage and Family Therapy, Human Development
List of Contributors xxv
Erin M. Sesemann, PhD, LMFT, Human Development and Family Science, East
Michal Shamai, PhD, School of Social Work, University of Haifa, Haifa, Israel
Tazuko Shibusawa, PhD, LCSW, Silver School of Social Work, New York University,
New York, NY, USA
Karina M. Shreffler, PhD, Human Development and Family Science, Oklahoma State
University, Stillwater, OK, USA
Sterling T. Shumway, PhD, LMFT, Community, Family, and Addiction Sciences, Texas
Charles Sim, SJ, PhD, S.R. Nathan School of Human Development, Singapore
University of Social Sciences, Republic of Singapore
Timothy Sim, PhD, Department of Applied Social Sciences, The Hong Kong
Polytechnic University, Kowloon, Hung Hom, Hong Kong, China
Mima Simic, MD, The Maudsley Centre for Child and Adolescent Eating Disorders,
Gail Simon, DProf, Institute of Applied Social Research, University of Bedfordshire,
Luton, UK
Jonathan B. Singer, PhD, LCSW, Social Work, Loyola University Chicago, Chicago,
IL, USA
Reenee Singh, DSysPsych, Association for Family Therapy and Systemic Practice and
The Child and Family Practice, London, UK
Izidora Skračić, MA, Department of Family Science, School of Public Health, University
of Maryland, College Park, MD, USA
Amy M. Smith Slep, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Natasha Slesnick, PhD, Human Development and Family Science, The Ohio State
University, Columbus, OH, USA
Douglas B. Smith, PhD, LMFT, Community, Family, and Addiction Sciences, Texas
Douglas K. Snyder, PhD, LMFT, Department of Psychological and Brain Sciences,
Texas A&M University, College Station, TX, USA
Kristy L. Soloski, PhD, LMFTA, LCDC, Community, Family, and Addiction Sciences,
Texas Tech University, Lubbock, TX, USA
Jenny Speice, PhD, LMFT, Family Therapy Training Program, Institute for the Family,
Department of Psychiatry, University of Rochester School of Medicine, Rochester,
NY, USA
Chelsea M. Spencer, PhD, LMFT, School of Family Studies and Human Services,
xxvi List of Contributors
Paul R. Springer, PhD, LMFT, Child, Youth, and Family Studies, University of
Nebraska‐Lincoln, Lincoln, NE, USA
Sandra M. Stith, PhD, LMFT, School of Family Studies and Human Services, Kansas
Linda Stone Fish, PhD, MSW, Department of Marriage and Family Therapy, Syracuse
University, Syracuse, NY, USA
Peter Stratton, PhD, Leeds Family Therapy and Research Centre, University of Leeds,
Leeds, UK
Tom Strong, RPsych, Educational Studies, Counselling Psychology Program, Werklund
School of Education, University of Calgary, Calgary, Alberta, Canada
Nathan C. Taylor, MS, School of Applied Human Sciences, University of Northern
Iowa, Cedar Falls, IA, USA
Karlin J. Tichenor, PhD, LMFT, Karlin J & Associates, LLC, Indianapolis, IN,
USA
Tina M. Timm, PhD, LMSW, LMFT, School of Social Work, Michigan State University,
Glade L. Topham, PhD, LCMFT, School of Family Studies and Human Services,
Maru Torres‐Gregory, PhD, JD, LMFT, Marriage and Family Therapy Program, The
Family Institute, Northwestern University, Evanston, IL, USA
Chi‐Fang Tseng, MS, Human Development and Family Studies, Michigan State
Shu‐Tsen Tseng, PhD, Prudence Skynner Family and Couple Therapy Clinic, Springfield
Hospital, London, UK
Carolyn Y. Tubbs, PhD, Marriage and Family Therapy, Department of Counseling and
Human Services, St. Mary’s University, San Antonio, TX, USA
Ileana Ungureanu, MD, PhD, LMFT, Marriage, Couple and Family Counseling,
Division of Psychology and Counseling, Governors State University, University Park,
IL, USA
Francisco Urbistondo Cano, DCounsPsy, Community Learning Disability Team,
NHS Bolton Foundation Trust, Bolton, UK
Damir S. Utržan, PhD, LMFT, Division of Mental Health and Substance Abuse
Treatment Services, Minnesota Department of Human Services, St. Paul, MN, USA
Susanna Vakili, MA, LMFT, Private Practice, San Diego and San Juan Capistrano,
CA, USA
Catherine A. Van Fossen, MS, Human Development and Family Science, The Ohio
Amber Vennum, PhD, LMFT, School of Family Studies and Human Services, Kansas
List of Contributors xxvii
Ingrid Vlam, PhD, MBA, Research Graduate School, Bedfordshire University,

Bedfordshire, UK
Ashley A. Walsdorf, MS, Marriage and Family Therapy, Human Development and
Family Science, University of Georgia, Athens, GA, USA
Marianne Z. Wamboldt, MD, Department of Psychiatry, Helen and Arthur E. Johnson
Depression Center, University of Colorado School of Medicine, Aurora, CO, USA
Karen S. Wampler, PhD, LMFT, Human Development and Family Studies, Michigan
Richard S. Wampler, PhD, MSW, LMFT, Human Development and Family Studies,
Michigan State University, East Lansing, MI, USA
Michael R. Whitehead, PhD, LMFT, Aspen Grove Family Therapy, Twin Falls, ID,
USA
Jason B. Whiting, PhD, LMFT, Marriage and Family Therapy Program, School of
Elizabeth Wieling, PhD, Human Development and Family Science, University of
Georgia, Athens, GA, USA
Lee M. Williams, PhD, Marital and Family Therapy Program, University of San Diego,
San Diego, CA, USA
Dara Winley, MA, Couple and Family Therapy, Drexel University, Philadelphia, PA, USA
Mathew C. Withers, PhD, LMFT, Psychology, California State University, Chico,
Chico, CA, USA
Andrea K. Wittenborn, PhD, LMFT, Human Development and Family Studies,
Armeda Stevenson Wojciak, PhD, Couple and Family Therapy Program, Psychological
Sarah B. Woods, PhD, LMFT, Department of Family and Community Medicine,
University of Texas Southwestern Medical Center, Dallas, TX, USA
Corey E. Yeager, PhD, Department of Family Social Science, University of Minnesota,
St. Paul, MN, USA
Cigdem Yumbul, PhD, Bude Psychotherapy Center, Istanbul, Turkey
Toni Schindler Zimmerman, PhD, LMFT, Marriage and Family Therapy Program,
Department of Human Development and Family Studies, Colorado State University,
Fort Collins, CO, USA
Max Zubatsky, PhD, LMFT, Department of Family and Community Medicine, Saint
Louis University, St. Louis, MO, USA
Preface
The first volume of Gurman and Kniskern’s Handbook of Family Therapy was pub-
lished in 1981, two years after I finished graduate school. I read it from cover to cover
and used favorite chapters over and over again in my courses. The second volume
published in 1991 was equally treasured. Even though 10 years separated the two, it
was published as Volume 2 instead of as a revision because, as Gurman and Kniskern
explained in the preface, so much new information had emerged that both volumes
were needed.
Four volumes were needed in this handbook to capture the breadth and depth of
systemic family therapy theory, research, and practice. Material is organized to maxi-
mize accessibility by creating volumes on the profession, the parent–child relation-
ship, the couple relationship, and the family across the lifespan. Each volume stands
on its own as well as acts as a complement to the others. The three problem‐oriented
volumes are organized to reflect typical reasons clients initially seek treatment: con-
cern about relationships, worry about a problem or disorder with a family member, or
challenging contexts impacting the family. Taken together, the four volumes of The
Handbook of Systemic Family Therapy offer a comprehensive and accessible resource
for clinicians, educators, researchers, and policymakers.
As much as possible, the editorial team wanted to reflect how systemic family thera-
pists actually think about and do their work. For example, instead of providing sepa-
rate chapters on each evidence‐based treatment model, those models are integrated
into the material on relevant treatment topics. The pervasive impacts of culture, diver-
sity, and inequitable treatment are major themes, and several chapters are devoted to
these important topics. The work includes a global perspective on systemic family
therapy. Instead of promoting a specific approach, we asked the authors to describe
what is known about intervention and prevention for each topic and the next steps
needed to determine best practice. We wanted each chapter to stimulate improved
practice as well as to serve as a springboard for further research.
From the beginning, we used a collaborative process to decide on both the struc-
ture and the content of the book. The crucial first step in this process was a two‐day
“think tank” meeting at the American Association for Marriage and Family Therapy
(AAMFT) offices in April 2016 with me, Adrian Blow, Pauline Boss, Rick Miller,
Mudita Rastogi, Liz Wieling, and Tracy Todd in which we began to sketch a vision for
xxx Preface
the handbook. The next step was securing editors for each of the four volumes and,
to my eternal gratitude, six well‐established and highly esteemed scholars agreed to
take on these roles: Rick Miller and Ryan Seedall for Volume 1 on the profession,
Lenore McWey for Volume 2 on children and adolescents, Adrian Blow for Volume 3
on couples, and Mudita Rastogi and Reenee Singh for Volume 4 on global health.
The group worked together over many months to settle on a table of contents and to
write a formal proposal to John Wiley & Sons Publishing. All seven of us worked on
all four volumes. As systems thinkers, we needed to always look at the project as a
whole and never simply as a set of separate volumes.
Close collaboration among the editors continued as we worked to identify, contact,
and secure authors for each chapter. We deliberately sought authors who were both
scholars and clinicians and could speak to the diverse perspectives inherent in work
with families as well as the breadth of the field of systemic family therapy. We worked
together to avoid overlap across chapters, identify missing content, and maintain the
integrity of each volume. Authors submitted outlines for their chapters that were read
by all seven of us. Feedback for each chapter summarized by the primary editor(s)
provided an opportunity for further collaboration with the lead author. This approach
continued through the manuscript submission, revision, and finalization phases with
at least two, and usually three, editors reviewing each chapter.
This project would not have happened without the efforts of Tracy Todd, Chief
Executive Officer of the AAMFT. As part of an AAMFT initiative to develop essential
resources for “those practicing systemic and relational therapies throughout the
world,” he worked with Darren Reed at Wiley to formulate a market rationale for a
multivolume handbook for the field of systemic family therapy. Tracy and AAMFT
continued to support the project with funding for part‐time staff and expenses for
editorial meetings. While providing invaluable support, Tracy and the AAMFT Board
have not been involved in determining the content of the handbook, which has been
completely the responsibility of the editors.
It is impossible to adequately thank the editors and the authors for their efforts—all
of it as volunteers—to make this project possible. It is a humbling experience to ask
so much and see such dedication of so many people to complete this task. The sheer
size and complexity of this project would not have been manageable without our
Assistant Editor, Leah Maderal. She kept the entire project organized and moving
forward, tracking every version of every manuscript as each was submitted and edited.
She obtained and updated contributor information and developed systems for safe
sharing and storage of all material. In addition, Leah developed and maintained the
project website, checked copyright permissions, and worked to get artwork and other
special elements in the correct format for Wiley. Renu Aldrich served as Assistant
Editor in the early months of the project. Sarah Bidigare played an essential role as
Editorial Assistant, double‐ and triple‐checking each manuscript for formatting and
adherence to APA Style. Recognizing the importance of this project for systemic fam-
ily research and the future of the field, Rick Miller obtained funds from Brigham
Young University to help support opportunities for editors and authors to interact
face‐to‐face.
I want to take a moment to acknowledge the mentoring and support given to me
by the late Doug Sprenkle. Doug and I both started at Purdue in 1975, Doug as a
new faculty member and I as a first‐year doctoral student. He was a model teacher,
supervisor, and mentor of graduate students. He was also a role model for me as
Preface xxxi
e ditor of the Journal of Marital and Family Therapy and in his commitment to devel-
oping scholarly resources for the field. Doug was very supportive of the development
of the handbook. I deeply regret that he died before seeing it in print.
It has meant everything to me to work with colleagues who have been passionate,
committed, and engaged in bringing this project to fruition. Thank you, Adrian,
Lenore, Mudita, Reenee, Rick, and Ryan. Throughout this project, I also depended
on the wisdom and encouragement of friends and colleagues. I particularly want to
thank Pauline Boss, Ruben Parra‐Cardona, Liz Wieling, Mudita Rastogi, Jo Ellen
Patterson, and Andrea Wittenborn. I am grateful to my children, Nathan and Leah,
their spouses, extended family, and friends for their patience and forbearance through-
out these last 3 years. Most of all, I thank my husband, Richard Wampler, who has
lived through all of the trials and triumphs of this project with me. From explaining
genetics and writing two chapters to checking references and looking up doi’s for two
authors in challenging situations, Richard has played a major role in ensuring the
timely completion and uniform quality of the handbook and my survival doing it.
Finally, I want to remember the support of my dear friend Carol Parr, who never
failed to ask about “the book” during her long and final illness.
I did not hesitate to say “yes” when Tracy contacted me about this project. I knew
without a doubt that the field of systemic family therapy had developed to new levels
of depth, breadth, impact, and sophistication in practice, theory, and research that
were simply not reflected in available comprehensive scholarly resources. Those we
contacted to participate in the project had the same reaction—a resource like we envi-
sioned for the handbook was needed for our field and needed quickly. Our hope is
that you will find the content as important, compelling, and useful as we have.
Karen S. Wampler
Editor‐in‐Chief, The Handbook of Systemic Family Therapy
References
Gurman, A. S., & Kniskern, D. P. (Eds.) (1981). Handbook of family therapy (Vol. 1). New
York: Brunner/Mazel.
Volume 1 Preface
The Profession of Systemic Family Therapy
Volume 1 of The Handbook of Systemic Family Therapy (SFT) chronicles the compel-
ling development and scope of SFT. From the early efforts of a few imaginative and
innovative pioneers, the practice and profession of SFT has matured. The theoretical
foundation of systems theory still unites the field, but SFT theories have expanded
from a focus on the classic SFT theories to include attachment theory and postmod-
ern social constructionist theories. At the same time, SFT has incorporated perspec-
tives of intersectionality that calls for sensitivity to issues of diversity, discrimination,
and privilege. The narrative of the parallel developments in research and policy tells
the story of the hard‐fought gains in the credibility and legitimacy of SFT as both a
professional mental health field and a modality of clinical practice. And the growth is
global, with SFTs practicing in most countries in the world, increasingly supported by
in‐country training programs and professional SFT associations. Moreover, because
of the value of a systemic perspective, the practice of SFT has expanded from tradi-
tional social agencies and private practices to medical, business, military, and govern-
ment settings. Thus, Volume 1 of the handbook recounts the main storylines and the
many theoretical, training, research, diversity, ethical, and policy subplots that have
led to the development of the effective and vibrant practice and profession of SFT. At
the same time, volume 1 provides a panoramic overview of SFT, leaving for the other
volumes the pleasant task of presenting the rich details about the effective delivery of
SFT services in a variety of settings, to a variety of populations, struggling with a vari-
ety of problems.
While editing the volume, we have been able to observe firsthand the labor of love
this handbook was for each of the members of the editorial team, especially Karen as
the editor‐in‐chief. It has been a pleasure to work with Karen and the other associate
editors. Each editor brought unique expertise, experience, and perspective to the
project, and our interaction with each of them has enriched us.
And then there are the authors! So many authors graciously agreed to participate in
this project and provide their considerable expertise to a wide variety of important
SFT topics. Our vision as an editorial team was that each chapter be cutting edge—
that the authors summarize and synthesize information relevant to their assigned
topic while also identifying gaps and next steps. To put it concisely, the authors were
amazing. We have been consistently impressed with how receptive and gracious the
Volume 1 Preface xxxiii
authors were in writing and revising their chapters. Each one truly helped produce
something that we feel is a significant contribution to our field. The first volume is by
far the largest of the four, with over 70 authors who contributed to 33 chapters in this
volume. For that reason, we are especially grateful to each of them for their work.
Rick Miller
Being a professor of SFT for over 30 years, editing the chapters in this handbook has
almost been a surreal experience because I remember so many of the theoretical,
research, training, and policy developments that are described in Volume 1. As I
edited different chapters, I kept thinking to myself, “Oh, I remember that.” I partici-
pated in the bitter battles to gain MFT licensure and rejoiced with many other SFTs
when the series of state‐by‐state fights were finally won and AAMFT was able to
declare final victory in the war to gain licensure in the United States. I was at the
AAMFT annual conferences when Bill Doherty interviewed Salvador Minuchin, Jay
Haley, and Murray Bowen, when Susan Johnson first spoke there and introduced
EFT to the field, and when Doug Sprenkle spoke about common factors at a plenary
session. I witnessed the theoretical jolt that came from the feminist critique in the
1980s and the subsequent revolution of postmodern theories and treatments. I have
observed the steady accumulation of empirical evidence that SFT treatments are effec-
tive and cost‐effective and, more recently, the expansion of available research strate-
gies to better capture the complex nature of SFT.
Consequently, working on Volume 1 of the handbook has been an unexpected
experience in “life review.” I am proud of the growth that SFT has made since its
humble beginnings not that long ago. More importantly, I am proud to be part of a
movement that has become a respected profession and practice modality, which gives
mental health practitioners across the world the skills to effectively and compassion-
ately treat human suffering, accommodating their work to the myriad contexts in
which they find themselves.
Finally, I want to express my appreciation to my wife, Mary, who has been so sup-
portive of my need to spend extra hours working on the handbook. Mary is also an
SFT, and we have shared together many of the milestones in the development and
maturation of SFT. Our nine children (Marc, Kaylyn, Rob, Janae, Elli, David, Addy,
Oakley, and Katie) have also cheered me along. They have all been terrific!
Ryan Seedall
I remember taking an Introduction to MFT class during the last semester of my bach-
elor’s degree (coincidentally taught by Rick Miller). I was fascinated by systems con-
cepts, especially the power of relationships. Up until that time, I had been a psychology
major but not entirely sure what I wanted to do when I graduated. It was at that time
that I knew I wanted to be involved in this field and do something of value for individu-
als, couples, and families. I moved forward with those goals and have not regretted it.
As I have continued in my career, I have noted a number of important issues that our
field has or is facing. Some of these include demonstrating our efficacy/effectiveness
xxxiv Volume 1 Preface
and legitimacy as a field, moving to more advanced statistics to examine relational

questions, addressing the clinician–researcher gap, and broadening our understanding
of diverse social identities and those who have been marginalized in an effort to
decrease mental health disparities and increase social justice. In April 2018, I was
approached by Karen Wampler and Rick Miller to become a co‐associate editor with
Rick on Volume 1. I had previously agreed to be an author of a chapter, so I knew of
this project and admired the undertaking from afar. Working on Volume 1 has high-
lighted the rich history and global reach of our field but also the mandate to look
forward toward the future to keep improving. There is much to do!
Personally, I am so grateful to have been included in this project. I learned so much
from the editorial team and also from the chapter authors. In addition, I would be
remiss if I did not acknowledge the support of Ruth and my four children (Spencer,
Madelyn, Eliza, and Benjamin) as crucial for me being able to work on this project.
There were tight deadlines and challenges to meet, many of which required work
outside of standard business hours. My family inspires me, and so much of what I am
able to accomplish is because of them. I am also incredibly grateful for the support of
my employer, Utah State University, and my amazing colleagues in my program and
department.
Richard B Miller and Ryan B. Seedall
Associate Co‐Editors
Foreword
This four‐volume handbook captures the breadth, depth, and creative applications
of systemic family therapy today. The editors and chapter authors capture our pro-
fession’s understanding of the healing potential of couple and family systems and
take that basic understanding in many important directions. Clearly, we have come
a long way.
Over my 44 years in the profession, I have described systemic family therapy in
progressively different ways. In the beginning, it was a young, emerging profession
based on systems theory, then an adolescent finding its place in the world. I explained
to doctoral recruits, for a time, that it was the fastest‐growing mental health profes-
sion. I explained that while more than half of the presenting problems of clients in a
typical mental health clinic had systemic features, most therapists have had little or no
training in family therapy. I remember devouring various editions of Gurman and
Kniskern’s Handbook of Family Therapy and books by Haley, Minuchin, Satir,
McGoldrick, Whitaker, deShazer, Johnson, and others the way I read some nov-
els – without coming up for air. I remember for a long time buying into the battle of
the name brands, as Lynn Hoffman called our preoccupation with famous model
developers and their models. I also quoted Doug Sprenkle (to whom this four‐volume
handbook is dedicated) regarding the importance of “the synergetic interplay of the-
ory, research, and practice,” each domain enriching the others.
Doug died recently, but as more than one of his former students explained, he
humanized the field, and I see his keen, big‐picture mind and therapist’s heart in the
chapters of this handbook. He would have been pleased that the authors of this hand-
book address systems in the margins, internationally, across individual, couple, and
family presenting problems, in health care, and in a research‐informed manner. He
would have been pleased that in such a diverse field, we still see commonalities in the
power of family systems to heal and are giving greater attention to common factors
that contribute to that change and to systemic family therapy research that keeps us
honest and grounded in empirical data.
I agree with you, Doug. This handbook marks the fact that systemic family therapy
is indeed a profession that has taken its rightful place among our sister professions,
who are also embracing the power of systemic interventions. This handbook includes
systems interventions that address important issues and problems—child maltreat-
ment, global public health, domestic violence, depression, racial and gender issues,
xxxvi Foreword
sociocultural attunement, policy and advocacy, adolescent substance use, youth sui-
cide, grief and loss, and so much more. The profession and the practice of systemic
family therapy are both given attention, as is multidisciplinarity. So is, as Doug might
say, the synergism of theory, research, practice, and policy. The editors’ coherent
organization includes overarching foundations, practice models of relational treat-
ment for children, adolescents, couples, and families, and research foundations, with
a global perspective and attention to cultural diversity throughout. In short, the
handbook is broad enough to reflect the health and usefulness of systems interven-
tions that meet the very real needs of people today. I also see room to grow, improve,
and address a world yearning for a caring, vibrant, evidence‐based discipline that
employs the best in ourselves and can positively transform the intimate and varied
systems around us.
Fred P. Piercy, PhD, is Professor Emeritus of family therapy at Virginia Tech,
Blacksburg, Virginia, and former editor of the Journal of Marital and Family Therapy.
Fred P. Piercy
Part I
Foundations
1
The Importance of Family
and the Role of Systemic Family
Therapy
Karen S. Wampler and Jo Ellen Patterson
Family is a fundamental organizing structure for human life from birth to death.
There are words for family, sem’ya, mother, eomeoni, and father, alab, in every lan-
guage on Earth. “Family” is often used as a metaphor trusting that people will under-
stand the reference:
As a mother would risk her life to protect her child, her only child, even so should one
cultivate a limitless heart with regard to all beings. So with a boundless heart should one
cherish all living beings; radiating kindness over the entire world.
(Buddha, 2019)
People all over the world reacted when they learned that 12 young soccer players and
a 25‐year‐old assistant coach were trapped in a cave in Thailand with little hope of
rescue. On the 10th day when the rescuers finally reached them, the first concern was
letting their families know that they were alright—that they were alive. Each knew
that his family would be desperate with worry. They had all carried their families into
the cave with them.
Extensive data from multiple sources document the close connections between
family relationships and mental and physical health. Over the past 50 years, effective
interventions have been tested and implemented to help troubled family relation-
ships, and programs have been established to prevent difficulties from developing in
the first place.
The overarching purpose of this handbook is to provide a broad and inclusive view
of the profession and practice of systemic family therapy (SFT). Topics include treat-
ment and prevention approaches for the core difficulties in family relationships that
impact the mental and physical health of individuals, couples, and families across the
life cycle. The goal is to articulate more clearly and consistently the distinguishing
characteristics of SFT as a profession, the theories and research that underlie the
profession and the practice, and the key role families play in improving human health.
The Handbook of Systemic Family Therapy: Volume 1, First Edition. Edited by Karen S. Wampler,
Richard B Miller, and Ryan B. Seedall.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
4 Karen S. Wampler and Jo Ellen Patterson
Systemic Family Therapy
SFT is the mental health profession and practice that focuses on family relationships.
The family is not a collection of individuals, but an organized whole, a system. SFT
has been most influenced by general systems theory (Bertalanffy, 1968), but other
versions of systems theory such as dynamic systems theory (Burns, 2007; Wittenborn,
Hosseinchimeh, Rick, & Tseng, 2020, vol. 1) and developmental systems theory
(Zelazo, 2013) apply as well. Burns (2007) provides a summary of the characteristics
that all systems theories share:
What the various systems theories have in common is a concern with the complex and
varied interconnectedness and interdependencies of social life. Multiple structures, their
interrelationships, and their historical development hold center stage. Systems are also
more than the sum of their parts. Attention is focused on the different parts and levels of
a system and their interrelationships, for instance, between institutions, collective and
individual agents, and interaction processes in multilevel complexes. (p. 569)
“Systemic” provides a conceptual framework for understanding how to define a

collection of individuals as a group, in this case, a family, and for how to use knowl-
edge of interconnections between individuals (the elements) and the purposes or
functions of the system (Meadows & Wright, 2008; Wittenborn et al., 2020, vol.
1) to develop interventions to help improve family system functioning. The family
as a system means that the therapist must work with and within multiple levels of
embedded relationships that provide multiple possible points of entry and leverage
for change (Reiss, 2013).
We are using the term “systemic family therapy” as an inclusive term that
encompasses both the profession and practice (K. S. Wampler, 2019; K. Wampler,
Blow, McWey, Miller, & R. Wampler, 2019). The handbook is intended to
include both. The term SFT allows us to avoid the ideological issues involved
with the words “marriage” or “couple” and is a more general term that can
include specific terms for state licensure laws in the United States and various
terms for training programs. SFT also fits the most common terms used globally.
The term can be applied to different topics, for example, “SFT with individuals”
or “SFT in medical settings,” in a way that fits better than a term like “marriage
and family therapy.” SFT is by definition an interdisciplinary field. The history of
evolution of SFT as a profession is well documented (Doherty, 2020, vol. 1) as is
the role of the American Association for Marriage and Family Therapy (AAMFT,
2015) in gaining recognition for the profession through licensure in all 50 states
in the United States, as well as providing a scholarly journal, accreditation of
education programs, development of legal and ethical standards, and continuing
policy efforts. Other professional organizations have specialized sections or
divisions.
SFTs in programs accredited by the Commission on Accreditation for Marriage and
Family Therapy Education (COAMFTE) receive extensive training in seeing family
members together. A minimum number of contact hours with more than one family
member in the room are required for licensure as a marriage and family therapist
(MFT) (the most common specific title used for licensure of SFTs).
Importance and Role of SFT 5
Family
The focus of SFT is on the family, not just on “interconnections between ele-
ments” or “social relationships.” Even though family is core to the definition of
SFT, “family” is remarkably difficult to define. Indeed, it is easier to find lists of
many possible ways to define what the family is not (cf., Adams & Trost, 2005;
Berardo & Shehan, 2007) than to define when a system is a family system and its
elements are “family members.” There are many reasons why it is difficult to
define family.
Culture and institutional functions

As a social institution, the definition of family varies significantly by culture, legal
structures, and economic systems. Larger global historical trends have meant the
loosening of ties between the family and the institutional functions of reproduction,
economic production, and physical location. Over time, the construct of family has
become less likely to be defined by household, kinship, and biological relationships
(Brown, 2017; Turner, 2005). This does not mean that these institutional functions
are missing, but they are much more varied and that, again, makes it difficult to
define family.
Every aspect of family functioning is impacted by how the family is placed in social
and cultural contexts such as socioeconomic status, poverty, race or ethnicity, religion,
gender, marginalization, oppression, and discrimination (Knudson‐Martin, McDowell,
& Bermudez, 2020, vol. 1). Family members share these characteristics that have a
pervasive impact on the family system itself as well as the individuals in it. The social
determinants of health are well established (Rojas‐Flores, Clements, Hwang Koo, &
London, 2017; Yoshikawa, Aber, & Bearslee, 2012). Because of its focus on the fam-
ily, these social–familial determinants are even more relevant to SFT than to other
mental health professions that focus on individual mental health issues. The family
system is embedded in wider social and cultural systems that have multiple impacts on
family functioning and the choice of appropriate interventions (Rastogi, 2020, vol.
4). In addition to the chapters on different topics, each volume of the handbook con-
tains chapters with a primary focus on how issues of culture and diversity must be
addressed in SFT.
Ideological controversies
Changes or threatened changes in the institutional structure of the family are core
issues grounded in deeply held beliefs about the family and how it is defined. Family
issues are societal issues and a prominent basis for ongoing political, legal, religious,
and cultural controversies. Indeed, “controversies” is much too mild a word for the
issues around gender roles, definition of gender, LGBTQ rights to marry, who can
legally adopt children, who controls reproduction, and what types of relationships can
be considered “family.” Rather than suggesting that the family is no longer important
because of its loss of institutional importance or because of disagreements about the
definition of family, the controversies suggest the opposite. As Turner (2005) states,
“Given the importance of the family to the organization of society as a whole, public
anxieties about social order are often articulated as political anxieties about the stabil-
ity and continuity of the family” (p. 13—in online version).
These definitional issues and “political anxieties” impact SFT much more than they
impact professions based on the individual. People seeking services and those making
referrals wonder about how family is defined by the field in general as well as for the
individual therapist they are contacting. In trying to get help, they might be asking,
“I’m a Muslim. Would this therapist understand our family?” “Is this a liberal thera-
pist who will try to change my values?” “Do we really want to take a chance seeing a
White person?” “This therapist is single with no children. How can she help us with
our family?” “My best friend says I am the only thing keeping him alive. He keeps
wanting to be with me all the time. Would he be considered ‘family?’”
Inevitably, social justice issues such as racial discrimination (Almeida & Tubbs,
2020, vol. 1); displacement of families through war, natural disasters, and societal
unrest (Daniel, Healey, & Mohammad, 2020, vol. 4; Patterson, Abu‐Hassan, Vakili,
& King, 2018; Wieling, Utržan, Witting, & Seponski, 2020, vol. 4); sexual orienta-
tion and gender identity (McGeorge, Walsdorf, Edwards, Benson, & Coburn, 2020,
vol. 1); and separation of family members through processes like incarceration or
immigration policies are highly salient for the profession and practice of SFT. As clini-
cians, SFTs inevitably work with clients who have different views and values than SFTs
hold themselves. We come from diverse backgrounds and are impacted by our own
social position. Like other professions, the majority of SFTs are not representative of
marginalized and oppressed groups. Because of the salience of these differences in
working with families, how to appropriately address them is an important focus of
SFT training and practice (cf., Castronova, ChenFeng, & Zimmerman, 2020, vol. 1;
Heiden‐Rootes, Addison, & Petinelli, 2020, vol. 3; Knudson‐Martin et al., 2020, vol.
1). Of particular interest is a set of “letters to the field” written by nine scholars and
clinicians “whose cultural heritage and work is represented by communities of color,
Indigenous, and international settings” who describe their own experiences of sys-
temic therapy in diverse contexts (Wieling, Derrick, et al., 2020, vol. 4).
What is the family domain for SFT?

Most SFTs would agree that social relationships that are intimate, personal, and long‐
term fit into the domain of SFT and that the couple, parent–child, nuclear family, and
multigenerational subsystems are core areas of concern. The organization of the
handbook (K. S. Wampler, 2020, vols 1–4) reflects that organization with volumes on
the profession, parent–child relationships, the couple, and the family across the lifes-
pan. Most SFTs would also privilege family members’ own definitions of who is and
who is not a family member. SFTs must always address this implicitly or explicitly and
work within their clients’ definitions (cf., McCauley & PettyJohn, 2020, vol. 1).
When is a caregiver a parent? Is a mother’s new husband a stepfather or a father or a
new father or a second father or my mother’s husband? Does cohabiting mean you are
a couple? Can you be a couple—family to each other—and not be living together?
The man who contacts you because of the results of a DNA search, is he a half‐brother
or a stranger? We suspect the reader can readily supply examples of each of these situ-
ations and generate many more.
Help from attachment theory

Most writing about the definition of family comes from those studying family as an
institution. We think that a stronger source for defining family and for understanding
and intervening in family relationships comes from attachment theory. This theory
developed from the study of the parent–child relationship in early childhood and has
been expanded to a lifespan focus, particularly, in the study of the couple romantic
relationship (Seedall & Sandberg, 2020, vol. 1).
The four defining features of an attachment relationship are proximity
maintenance, separation distress, providing a safe haven when distressed, and
providing a secure base for exploring the world (Zeifman & Hazan, 2016, p.
417). These aspects relate to the functions of caregiving and care seeking. Even
though the attachment behavior system is most easily seen in young children,
evidence has accumulated on how the attachment behavior system continues to
run in the background throughout the life course and comes to the foreground
particularly in times of stress at any point in the lifespan. There is extensive evi-
dence for the biological basis of attachment and accumulating evidence on the
applicability of attachment theory across cultures (Mesman, van IJzendoorn, &
Sagi‐Schwartz, 2016).
Attachment theory also helps define who functions like a family member, regard-
less of biological or institutional definitions. It is this type of unique socio‐emo-
tional relationship that is the main focus of SFT. Most individuals have several
attachment figures (“several,” but not “many”). These relationships take time to
develop and are usually long term; however, who is or is not an attachment figure
can change over time. Typically, there is a “hierarchy” of attachment with some
people more central and important than others. Ironically, there has been relatively
little research on who becomes an attachment figure and who does not. Most schol-
ars assume, probably correctly, that the parent of a child and the spouse/partner of
an adult in a committed romantic relationship are the most likely attachment figures
(Cassidy, 2016; Thompson, 2013), as are other family members of both the imme-
diate and extended family.
To define who is an attachment figure, that is, someone who is “family,” it is
helpful to think of the four defining characteristics of an attachment relationship
(proximity maintenance, separation distress, safe haven, and secure base). Is this
person someone you want to see or communicate with regularly or, if they are not
available, someone you think about regularly? Can you get to them if they need
you? Can they get to you? Are you sad or distressed when they leave? If you were
in trouble, would you seek out this person? Do you want to touch base with this
person when you are excited or trying new things or going outside your comfort
zone? If this person were in trouble, would you feel obligated to help and be dis-
tressed if you could not help? If you were in a bad automobile accident, who would
you most want to walk into the hospital room? Think of an event like the World
Trade Center terrorist attack on September 11, 2001 in the United States. Everyone
was walking around with a mobile phone to their ear or calling from home or work.
Who were they calling? Parents, despite their own fears, walked or drove to get
children out of school. Everyone wanted to touch base—especially with their
attachment figures—their family.
Defining Characteristics of Systemic Family Therapy
Family relationships are the primary mechanisms of change

A defining characteristic of SFT is that family relationships are the primary mechanism
of change for desired outcomes. Family relationships are the primary mechanism of
change regardless of who is seen in treatment or whether the focus is on problems in
the family system as a whole, its subsystems, its individual family members, and/or the
family’s relationship to outside systems. The core of SFT is a focus on family interac-
tion as the method of treatment. The focus is not on the structure of the family (kin-
ship, household, composition of the family, economic unit), but on the processes
between family members, between the therapist and family, between the family as a
system and individual members, and between the family and external systems. SFTs
“work across”—across systems and subsystems and life cycle stages. This is very much
like the field of neuroscience that focuses less on the structure of the brain itself and
more on how processes in the brain work—transmitters, synapses, and circuits. Family
interaction must be observed and intuited and described.
The importance of clarity about the centrality of change in family relationships is
demonstrated in a synthesis of research findings from 70 randomized clinical trials on
family interventions to improve outcomes for children with a chronic illness (Knafl,
Leeman, Havill, Crandell, & Sandelowski, 2015; Knafl et al., 2017). Knafl and col-
leagues categorized the studies by focusing on family engagement (enhancing paren-
tal role performance, improved family functioning, and/or managing the health
condition). They also coded the nature of family participation (passive recipient of
knowledge about health condition or active participant in the treatment) and modal-
ity (parent only, parent/child separately, parent–child together). In spite of all 70
studies being labeled “family interventions,” 84% of them involved family members
only to provide information about the health condition or to help parents manage
limited and specific aspects of the treatment regimen. That is, only 16% of these stud-
ies would meet our criteria for a family intervention defined by a focus on improving
family functioning and inclusion of a family member in treatment with the goal, in
this case, of improving family functioning to enhance the treatment of a child with a
chronic illness. Knafl et al. (2017) conclude:
When developing family‐focused interventions, future researchers are encouraged

to ground their interventions in theoretical frameworks that incorporate family system
constructs and expand the psychosocial content of the intervention to address the family
roles and relationships in which the treatment regimen is managed. (p. 713)
Flexibility in who is directly involved in treatment

For other professions, the individual is the unit of treatment for both mental and physi-
cal health. Even a family physician sees and bills for a specific individual, not a family.
Seeing family members together is a particular strength and a defining feature of SFT.
Flexibility in who is seen is another. A systemic view means that change in one part of
the system can leverage change in other parts of the system, including its subsystems
and individual family members. For SFTs, every case is a family case, regardless of who
is seen directly. Even in cases with a settled pattern of who is attending sessions, the
issue of which family members should be in session will still be in the back of the SFT’s
mind. “I wonder if it is time to suggest that x, y, and z come in for the next session?”
Let us say that Mom is on Skype and Dad and three children are in the therapy room
when the therapist senses that the adolescent may be in serious trouble. Should the
therapist arrange for the two much younger siblings to step out? Or, if the clinician is
committed to seeing a couple conjointly at every session, what happens when the hus-
band shows up without his husband?
SFTs receive extensive training in keeping the entire family system in focus,
regardless of who is in the therapy room. Who attends therapy and when are major
therapeutic decisions that the therapist makes as part of ongoing assessment and
treatment. Different patterns of engaging family members are common in SFT.
The decision is a mutual one and negotiated between the therapist and the fam-
ily. SFTs must have experience in working with individuals, dyads, and different
constellations of family members. Providers who only see individuals have to be
clear about who is the patient, limits of confidentiality, and avoiding conflict of
interest. These boundaries are affirmed in writing for legal and billing purposes.
Seeing more than one family member brings additional legal and ethical issues
that must be clarified, understood, and confirmed (Murphy & Hecker, 2020, vol. 1).
Extensive work has been done, primarily by the American Association for
Marriage and Family Therapy, to establish ethical guidelines for engaging multi-
ple family members in therapy (AAMFT, 2015). Consent to treat forms include
issues about conflict of interest, confidentiality, and disclosure to other family
members and to outsiders.
Goals of treatment
Interventions to change family relationships are intended to achieve a wide range of
treatment goals. Baucom, Whisman, and Paprocki (2012) developed a framework for
couple therapy that can be adapted for SFT approaches in general. The goals and
primary foci of SFT treatment can be categorized into four types:
1 Improving problematic relationships in the family and/or its subsystems.

2 Building capacity for families in order to promote the family’s ability to cope with
and minimize potential harm to family functioning due to all types of stressors from
inside the family (e.g., physical illness) or outside the family (e.g., discrimination,
poverty, family dislocation).
3 Supporting an individual to make needed behavior changes to comply with
treatment protocols for a mental or physical disorder.
4 Changing family relationships that could be causing a problem and interfering
with an individual’s recovery.
These broad types of treatment goals are reflected in the organization of each of
the three problem‐centered volumes in this handbook: children and adolescents
(Volume 2), the couple (Volume 3), and global health (Volume 4). In each of these
volumes, sections are focused on threats to the stability and health of the relation-
ship system itself as well as sections on using family relationships to treat individual
disorders.
A useful framework for SFT role: The WHO pyramid

The World Health Organization (WHO, 2007) created the Pyramid of Optimal
Mix of Services for Mental Health to illustrate how the promotion of positive men-
tal health can occur at many levels (Figure 1.1). The pyramid is designed to rein-
force the points that (a) global mental health (GMH) is a very serious issue, (b)
formal provision of mental health care is extremely expensive, (c) there are not
enough trained providers to meet the needs, (d) it is efficient to integrate mental
health‐care services with general health services, and (e) informal systems must be
encouraged and supported to complement the provision of formal mental health
services. The pyramid illustrates these concepts by dividing informal care (bottom
two layers) from formal care provided by professionals in community and hospital
settings (top three layers). It also illustrates the inverse relationship between quan-
tity of services needed and cost.
The GMH movement is a useful framework for the many ways SFTs fit into systems
focused on mental health and physical health care (Patterson, Edwards, & Vakili,
2018; Patterson, Edwards, Vakili, Abu‐Hassan, 2020, vol. 4). The pyramid illustrates
a key concept from the GMH movement, stepped care, that fits well with family‐based
services. A strength of SFTs is their ability to work with all these levels of care (a family
life educator in a school or a family therapist in an eating disorders unit or a dementia
unit in a psychiatric hospital). There are chapters in the handbook that represent every
level of care from prevention (cf., Carlson, Daire, & Hipp, 2020, vol. 3; Holtrop,
Krauthamer Ewing, Topham, & Miller, 2020, vol. 2) to specialist care (cf., Zubatsky,
Low High
Long stay
facilities and
specialist
psychiatric
services
services
Formal
S
Costs
Psychiatric Community E
services in mental
Frequency of need
L
general health F
hospitals services –
C
A
Primary care mental health services R
E
Informal community care

services
Informal
Self-care
High Low
Quantity of services needed
Figure 1.1 WHO service organization pyramid for an optimal mix of services for mental
health. Adapted with permissions from World Health Organization handout Optimal Mix of
Services: WHO Pyramid Framework, World Health Organization (2007).
Rolland, & Boisvert, 2020, vol. 4). SFTs provide services in both community and
health‐care settings (Distelberg, Lobo, & Lloyd, 2020, vol. 1; Robinson, Jones, Felix,
& McPhee, 2020, vol. 1).
Another contribution from the GMH movement is the concepts of task shifting and
task sharing (Patel, 2015; Patterson, Edwards et al., 2018). In most countries, there
are not enough fully qualified mental health providers nor are there resources to train
mental health providers. Thus, GMH has adapted models from public health initia-
tives that train community health workers to deliver care. The GMH model focuses
on self‐care that is defined as “people managing their own mental problems them-
selves or with help from family or friends” (WHO, 2007). Instead of including “fam-
ily” only in the general idea of self‐care, SFTs would identify the family as a distinct
and separate focus for attention. In the depiction of the pyramid, SFTs would add
family care as a layer between self‐care and informal community care (see Figure 1.1).
Most of the family‐based programs identified by Knafl et al. (2015, 2017) are exam-
ples of task shifting and task sharing to families and improving the care of children
with chronic illnesses through the family instead of directly to the child. In addition,
the GMH movement has focused on digital delivery for self‐care and psychoeduca-
tion. SFTs have increasingly used these approaches for assessment, client support, and
treatment packages (Bischoff, Springer, & Taylor, 2020, vol. 1).
SFTs are part of the formal system for the provision of mental and physical health
care, and they have also been leaders in developing informal support of families through
providing leadership, training, and supervision of laypersons (cf., Parra‐Cardona,
Beverly, & Lòpez‐Zerón, 2020, vol. 1). Reinforcing the points made in the Patterson,
Edwards et al. (2018) article, Griffith and Keane (2018) provide a comment arguing
that “The family should move to the forefront of global mental health clinical research,
mental health policy, and human rights advocacy” (p. 144). In general, SFTs will have
to look for opportunities to educate their employers and communities about the value
of family‐focused services, regardless of where they work in the pyramid of services.
Why Does Helping Families Matter?
It is remarkably difficult to keep “family” salient as a level of intervention in mental and

physical health. This is true even in a context where there is general pessimism about
the effectiveness of current approaches to mental health treatment. Social crises like the
opioid epidemic, gun violence, and the increasing suicide rate in the United States sug-
gest that all mental health professions have more work to do. A New York Times articles
asks, “When will we solve mental illness?” The article concludes that risk is conferred
by experiences and the power of social interactions has been underestimated, even
though the word “family” is never mentioned as a specific and crucial type of social
interaction (Carey, 2018). In a TED Talk in 2013, Thomas Insel, Director of the
National Institute of Mental Health from 2002 to 2015, highlighted how treatment
for mental disorders has not progressed as far as treatment of physical health problems.
In a later part of his talk, he makes a statement about possible new directions:
What I’ve been talking to you about so far is mental disorders, diseases of the mind.
That’s actually becoming a rather unpopular term these days, and people feel that, for
whatever reason, it’s politically better to use the term behavioral disorders and to talk
about these as disorders of behavior. Fair enough. They are disorders of behavior, and
they are disorders of the mind. But what I want to suggest to you is that both of those
terms, which have been in play for a century or more, are actually now impediments to
progress, that what we need conceptually to make progress here is to rethink these dis-
orders as brain disorders (emphasis added).
Again, family is not mentioned. Instead of broadening out causes of mental disorder
to family and community in addition to biological factors, Insel takes a reductionist
stance on mental health (Insel & Wang, 2010). It is not that family is a substitute for
other approaches to mental and physical health; it is a complement, and it is important
that SFTs continue to work to educate other professionals, policy makers, and the
public about the cost of continuing to focus on an approach to treatment based
almost entirely on the individual.
Extensive outcome research has demonstrated that conceptualizing and treating
human suffering using a family lens is effective. This research is summarized in over-
view chapters (cf., Carr, 2020, vol. 1; Snyder & Balderrama‐Durbin, 2020, vol. 3; R.
S. Wampler, 2020, vol. 2) as well as in chapters on specific topics. However, it is cru-
cial to understand why SFT’s focus on families is so effective. What would suggest that
a family perspective regarding mental and physical health would be an effective form
of treatment and that SFTs are such an essential part of interdisciplinary treatment
teams? In fact, a considerable research literature provides evidence that functional and
dysfunctional family relationships can have profound effects on both the physical and
psychological well‐being of individuals. The empirical link between past and present
family relationships and individuals’ well‐being provides a compelling rationale for
family‐based interventions and helps explain why SFT is an effective form of therapy.
Relationships influence well‐being in every part of life

Data from the longitudinal Framingham (MA) Study provide convincing evidence
that family relationships predict health and well‐being (Christakis & Fowler, 2011).
Although the data were originally collected to study risk factors for heart disease,
Christakis and Fowler showed how our social ties influence every area of our lives.
Creating diagrams of participants’ social networks demonstrating that behaviors and
emotions are contagious among connected people, Christakis and Fowler (2011)
found that relationships, up to three degrees of separation, influence both health risk
behaviors (e.g., smoking, obesity) and personal characteristics (e.g., happiness).
Having a happy friend increased a participant’s own happiness by 9% and having an
unhappy friend decreased happiness by 7%. These shared characteristics can be attrib-
uted to homophily (“birds of a feather flock together”) and shared environments;
however, there are also potential biological influences, such as mirror neurons in the
brain. “Mirror neurons” means that the neurons fire when a person does something
but also when that same person observes another doing the same act; thus, the brain
can be trained to respond because of another’s behaviors (Christakis & Fowler, 2011;
Corradini & Antonietti, 2013; Gallese, 2001).
Additional evidence comes from the Harvard Study of Adult Development that
began in 1938 with 268 male Harvard undergraduates, adding 456 disadvantaged
boys from inner‐city Boston, family members of both groups, and following multiple
generations over almost 80 years (Waldinger, 2015). Researchers found that emotional
regulation skills were related to the quality of the participants’ early attachments,
e specially the ability to regulate negative emotions. These skills were predictive of the
success of their most important relationships later in life (usually with spouses and
family members). Participants raised in secure family environments had happier and
more satisfying marriages 60 years later (Waldinger & Schulz, 2016). The answer to
the question of the “good life” was, “[G]ood relationships keep us happier and health-
ier. Period …. The people who were the most satisfied with their relationships at 50
were the healthiest at age 80” (Waldinger, 2015).
Childhood experiences predict both physical and mental health outcomes much
later in life (Felitti et al., 1998; Lyons‐Ruth & Jacobvitz, 2016; Stovall‐McClough &
Dozier, 2016). The health benefits of close familial relationships last even beyond the
end of the relationships, such as after a parent dies. Positive family interactions, includ-
ing those within parental dyads and between parent and child, are correlated with
better cardiovascular health. Family relationships are even more important than rela-
tionships with friends in predicting good health (Uchino & Way, 2017). Other
researchers have looked at the influence of happy and hostile marriages on health
outcomes (Kiecolt‐Glaser et al., 2005, 2015; Liu & Waite, 2014).
Lack of close relationships matters: Loneliness and well‐being

While close, supportive relationships predict well‐being, a lack of positive rela-
tionships predicts health decline, unhappiness, and even death. In 2017, the
Journal of the American Medical Association published an editorial summarizing
some of the findings on the impact of loneliness and calling for the United States
to make alleviating loneliness a public health priority (Rubin, 2017). In addition,
the WHO now identifies social support as a key determinant of health (Rubin,
2017). Governments are responding to the idea that loneliness is a public health
epidemic (Holland, 2017; Yeginsu, 2018). Britain appointed its first “Minister of
Loneliness” charged with addressing “the sad reality of modern life” (Kleinberg,
2018). Prominent researchers like Holt‐Lunstad have called for advancing social
connection to be made a public health priority (Holt‐Lunstad, Robles, & Sbarra,
2017). Loneliness may be associated with other social problems that governments
are trying to combat: isolation of the elderly, people with chronic illnesses, the
poor, refugees, the unemployed, and other citizens who experience living on the
fringe of society.
Here is just a sample of the evidence on the negative health and well‐being impacts
of loneliness on people’s lives. In their groundbreaking book, Loneliness: Human
Nature and the Need for Social Connection, social neuroscientists Cacioppo and Patrick
(2008) described research linking loneliness to early death and poorer outcomes for
cardiovascular disease, Alzheimer’s disease, stroke, and other health conditions. A
major series of meta‐analyses by Holt‐Lunstad and colleagues (Holt‐Lunstad, Smith,
& Layton, 2010; Holt‐Lunstad, Smith, Baker, Harris, & Stephenson, 2015) also
demonstrated that weak or negative social ties are associated with early death and that
loneliness, social isolation, and living alone all increase the risk of dying as much as
more well‐known risk factors, such as smoking and obesity. These researchers note
that public health problems are usually identified by the size and seriousness of the
problem and that their findings strongly suggest that loneliness meets criteria to be
identified as a serious public health problem.
Other topics currently being studied are the differences between loneliness and
related issues such as social isolation and social rejection. For example, socially isolated
individuals may not necessarily feel lonely and lonely individuals may not be socially
isolated (Holt‐Lunstad et al., 2015). Slavich and Cole (2013) studied common
experiences of social rejection such as a romantic breakup, not being invited to a social
event, or even being rejected by a stranger and found that all negatively affect
physiological functioning.
Couple relationships
In general, married people have a health advantage compared with single people.
Being married predicts longer lives and healthier lives—“the marriage advantage.”
But recent research suggests a more nuanced understanding. High stress and conflict
in marriage can be worse than never being married. Overall, research suggests that it
is the quality of the marriage that predicts well‐being—especially for women. In addi-
tion, couples who experience hostile, contemptuous conflict have been shown to have
weakened immune systems (Bakalar, 2016, 2018; Haase, Holley, Bloch, Verstaen, &
Levenson, 2016; Kiecolt‐Glaser et al., 2005; Parker‐Pope, 2013). For couples, strong
relationships appear to be protective in terms of health, but hostile relationships are
corrosive in terms of health, and it may be better to never marry or separate. However,
when one partner dies in a happy marriage, the surviving partner is at risk for more
health problems including cardiac disease and an increased risk of death (Rook &
Charles, 2017).
Conflict in marital relationships is particularly predictive of poor health outcomes.
In general, there should be five positive interactions for every one negative interaction
for people to report that they have satisfying marriages (Gottman, 1994, 1999;
Gottman & Levenson, 1999). Gottman’s “Four Horsemen of the Apocalypse”—
criticism, defensiveness, contempt, and stonewalling—are powerful forces in people’s
lives and relationships. The family literature, health research, and the positive psychol-
ogy literature have all shown that hostility and contempt in interpersonal relationships
are harmful to a person’s sense of well‐being and to health (Kiecolt‐Glacer et al.,
2005). Pietromonaco and Collins (2017) provide evidence that hostile interactions
with a close partner are linked to cardiovascular disease, chronic pain, and obesity.
Social rejection is associated with decreased quality of sleep, risky health behavior—
smoking and binge eating—and less physical activity (Cacioppo & Patrick, 2008).
While family scholars have observed these connections for many years, the exact phys-
iological pathways linking relational conflict (such as toxic stress, abuse, or contempt)
to negative health have been delineated only more recently (Sapolsky, 2004, 2017).
The legacy of family relationships in childhood

Adverse childhood experiences (ACEs) The adverse childhood experience (ACE)
research and the research on toxic stress in childhood have had profound effects on
our understanding of the ties between childhood relationships and later life (Felitti
et al., 1998; Shonkoff et al., 2012). These adverse experiences include abuse and
neglect, family violence, parental substance abuse, and parental mental illness.
Research indicates that close to two‐thirds of adults report at least one ACE (Felitti
et al., 1998). There is a correlation between the number of ACEs reported and
egative adult outcomes—e.g., lower educational attainment, depression, smoking,
n
unemployment, heart attacks, stroke, asthma, diabetes (Centers for Disease Control
and Prevention [CDC], 2016), and alcohol and drug abuse (Substance Abuse and
Mental Health Services Administration [SAMHSA], 2017).
Early toxic stress The ACE research is complemented by the findings on toxic stress
examining the impact of stress and trauma on the developing brains of children (e.g.,
Shonkoff et al., 2012). An integral part of child development is learning to cope with
expectable negative experiences (i.e., everyday stressors). In most cases, the negative
effects of a strong stress response can be buffered by a supportive caretaker. However,
in settings where a caretaker does not or cannot soothe the child back to physiological
baseline, the child can experience prolonged stress activation. This stress activation
impacts brain development and structure (Center on the Developing Child, Harvard
University, n.d.; Lyons‐Ruth & Jacobvitz, 2016).
Stressful events that affect a child’s development are not always interactions
between the parent and child. As an example, when parents have been challenged
on immigration status or detained or deported, their children’s sense of well‐being
is weakened; there is an increased risk for posttraumatic stress disorder (PTSD) for
these children versus children of legal permanent residents or whose parents are
undocumented, but have not been contacted by immigration officials (Rojas‐Flores,
Clements, Hwang Koo, & London, 2017). How parents can help deal with their
children’s stress depends on the age of the child (Chen, Brody, & Miller, 2017), but
it is clear that that uncontrollable stressful experiences early in life are likely to have
the most serious impact.
Early infant care Positive attachment behaviors of human mothers have been
shown to be biologically protective, not just socially adaptive. The ecobiodevelop-
mental (ecology + biology + development) model posits that nurturing caretakers
can protect children from the damaging effects of toxic stress (Shonkoff et al.,
2012). There is considerable evidence of the protective effects of early nurturing in
animals and humans. Mother rats that licked and groomed their infants enhanced
their offspring’s biological abilities to cope with stress throughout their lives (Insel
& Quirion, 2005). In infant rhesus monkeys with competent mothers, a gene vari-
ant is not expressed that would limit the production of serotonin (a neurotransmit-
ter) and slow the development of attention, activity, and motor maturity. Baby monkeys
with this variant raised only with peers do show such deficits (Suomi, 2016). Similar
results have been reported in human infants: an infant at risk of emotional dysregu-
lation and disorganized attachment because of a “short allele” (5‐HTTLPR) is
protected when the mother is a sensitive caregiver (Bakermans‐Kranenburg & van
IJzendoorn, 2016). The brains of human infants are primed to achieve optimal
development when the baby is nurtured and protected by the caregiver (Patterson
& Vakili, 2014; Shonkoff et al., 2012).
Epigenetics Epigenetics, epigenetic inheritance, and genetic nurture are terms origi-
nally developed in genetic research to describe biological processes and possibilities
(Patterson & Vakili, 2014). In essence, epigenetic changes (a methylation process that
changes the way a gene functions) suggest that our genes are not destiny. Instead,
genes offer only possibilities—they confer risk for behavioral or mental disorders or
they protect against such disorders. It is our environment that may “turn on” genes
through epigenesis, or these genetic traits might remain dormant throughout an
individual’s life (Ehrlich, Miller, Jones, & Cassidy, 2016). Genetic research has shown
that there are multiple possible pathways to an illness with both biological and envi-
ronmental (toxins, food, nurturing, stress) forces at work. Research has also demon-
strated that several serious mental illnesses (autism, schizophrenia, mood disorders,
and alcoholism) actually have genetic pathways in common (i.e., set of genes is the
same); however, the environment, including family and social experiences, can influ-
ence “gene expression” for these illnesses, pointing to epigenetic changes (Gandal
et al., 2018).
Epigenetic inheritance Another term from genetics that can inform family therapy
practice is epigenetic inheritance (Jirtle & Skinner, 2007; Shonkoff et al., 2012; Weaver
et al., 2004). Research on epigenetic transmission from parent to child is only now
emerging, and specific biological pathways of transmission, especially in humans, are
still unknown (Feinberg & Fallin, 2015; Mukherjee, 2016). However, evidence is
growing that changes in the mother or father’s gene expression (i.e., epigenesis) from
environmental variables can be passed on to their offspring and even to subsequent
generations (Patterson & Vakili, 2014). Although the area remains controversial,
epigenetic inheritance suggests that cumulative life choices and experiences of either
parent can leave biological traces in their children. “There is a growing belief among
scientists that a man’s behaviors and environmental exposures may also shape his
descendants’ development and future health before sperm meets egg …. [The] sperm
contains a memory of a male’s life experiences” (Abbasi, 2017, p. 2049).
Genetics Genetic research also has shown that the foundation for many mental dis-
orders is developmental. While a young adult may have his first manic episode at age
20, the genetic and epigenetic foundations of bipolar disorder began at birth or even
earlier. In fact, research suggests that the etiology of some illnesses such as autism and
schizophrenia may begin in utero, meaning that the stress level of the mother during
pregnancy and her exposure to toxins and illness can have lasting effects on her fetus
(Sapolsky, 2018; Weir, 2012). However, risk does not end at birth; parental expres-
sions of criticism of their at‐risk adolescent markedly increase the risk of developing
schizophrenia (Doane, West, Goldstein, Rodnick, & Jones, 1981). During early
childhood, adversity (e.g., trauma and poverty) has been linked with immune dys-
function, insulin resistance, and brain changes observed in adulthood (Brent &
Silverstein, 2013). These brain changes can also lead to high‐risk behaviors, emo-
tional dysregulation, and chronic mental health problems.
Genetic nurture A term from genetics that may inform family therapy is genetic
nurture (Koellinger & Harden, 2018). This term suggests that a child’s genotype
(i.e., genetic makeup) is mediated, in part, by the genotype of the parents and the
family environment that the parents create. Thus, a parent’s genotype could
influence his child’s behavior indirectly, depending on the environment the parent
creates for the child. These genes are not inherited biologically by the children, but
they influence the children’s environment by influencing a potent environmental
force for the children—their parents. Regardless of such environmental/parental
events, Hartman and Belsky (2016) suggest that children have “differential‐susceptibility”
to environmental influences; that is, some children are more affected by negative and
positive events than others.
Transmission of traits by social and biological stressors

Our ancestors influence the biological capacities with which we were born. Historically,
SFTs identified legacies and multigenerational transmission of relational patterns
(Boszormenyi‐Nagy & Spark, 1984; Kerr & Bowen, 1988). Later, many family thera-
pists recognized the importance of biological forces and adopted the biopsychosocial
model (Engel, 1997). The biopsychosocial model uses general systems theory, and
Engel states that individuals consist of numerous biological systems from a basic cell
to a human body. Engel also notes that humans live in social systems such as families
and communities.
One indication of the transmission of mental illness across generations comes from
studies of Finnish adults whose mothers had been traumatized when evacuated to
Sweden for safety during World War II (WWII) (1939–1945) (Santavirta, Santavirta,
& Gilman, 2018). Female adult children born to these mothers at least 5 years after
WWII (i.e., after 1950) were twice as likely to be hospitalized for a psychiatric illness
as their female cousins whose mothers had not been evacuated. They were also much
more likely to have depression and bipolar disorder. The researchers suggest that
childhood trauma in mothers can be passed on to offspring. Whether this negative
legacy is the result of epigenetic transmission or the behavioral aftereffects of the
mothers’ earlier traumatic evacuation experiences remains an open question.
Another powerful example of possible epigenetic inheritance comes from the
suffering caused by the Dutch Hunger Winter in 1944 when food supplies to the
Netherlands were blocked for a period of time by the Nazis. Women who were preg-
nant during this horrific period had children who are at increased risk for obesity,
diabetes, and schizophrenia in adulthood and have an increased risk of premature
death. Scientists who studied the Dutch Winter Hunger cohort found that certain
genes were silenced in utero and never expressed during the person’s life (Tobi et al.,
2018). Eventually, findings from studies like these might lead to specific information
on how stress can reprogram an individual’s health even before the person is born.
Prevention and early intervention

Early intervention Mental disorders are developmental disorders. But, as the brain
changes, “neurons that fire together, wire together” and an external stimulus is no
longer needed (Hebb, 1949). Kindling theory argues that stressors, such as poverty
or abuse during childhood, may precede the initial episode of symptoms such as
depression or mania (Hlastala et al., 2000; Patterson & Vakili, 2014).
This information about brain development helps explain why many mental
disorders first emerge in childhood and adolescence. In fact, these disorders may
have begun earlier, but symptom expressions of mental disorders—compulsions,
mania, or psychosis—often first appear between late childhood and the mid‐twen-
ties (Patel, Chisholm, Dua, Laxminarayan, & Medina‐Mora, 2016). “[A]lthough
many psychiatric disorders typically have their onset in late adolescence or early
adulthood … the risk of psychopathology continues to rise with age” (Blanco,

Compton, & Grant, 2016, p. 73).
Public health and GMH scholars have argued for a focus on prevention instead
of treatment. Research on stress and brain development offers insights into how
mental illnesses could be prevented. One important area for SFTs is an increased
focus on young families, including pregnant couples. The goal of prevention efforts
should be to strengthen capacities for emotional regulation in the child by sup-
porting attunement to a child’s or pregnant partner’s emotional needs. Efforts to
ameliorate stress and strengthen positive, nurturing family ties should be primary
goals. The ecobiodevelopmental model and differential‐susceptibility hypothesis
suggest that some mental illnesses might be avoided (the genes silenced or not
expressed) by creating nurturing, strong families (Hartman & Belsky, 2016;
Shonkoff et al., 2012).
Intervention with elders Old age is another time of increasing risk of mental
disorders, albeit different ones. Depression, anxiety, and memory struggles become
part of the larger cluster of health concerns (Shibusawa & Jones, 2020, vol. 4;
Zubatsky et al., 2020, vol. 4). Some elderly adults face mental health struggles for
the first time, experiencing multiple losses, social isolation, and loneliness as well as
increased physical illnesses/limitations such as heart disease, chronic pain, and
disabilities.
Childhood and old age are periods of dramatic developmental changes compared
with adulthood. They are also the periods when the individual is most dependent on
the family for care and support. Thus, SFTs will benefit by having expertise in helping
families care for their younger and older dependent family members as they age and
transition through these stages of dramatic changes.
Public policy These findings highlight the important influence that family relation-
ships have on the well‐being of young children and older adults and suggest the need
for timely interventions. From a policy and economic perspective, one might argue
that family therapists should focus their interventions on pregnancy and transition to
parenthood, along with families with an elderly member. While families can be helped
and can change at any point of the family life cycle, the beginning of new families can
be a critical period in individual and family development as can the transition between
mature adulthood and old age. The research illuminating ties between parenting
behaviors and young children’s brain development suggests that prevention works
better than treatment or intervention when the patterns have existed for many years.
In addition, research suggests that most mental disorders have their origins in child-
hood regardless of when the initial visit for help occurs—usually many years later
(Patel et al., 2016; Patel, Flisher, Hetrick, & McGorry, 2007). High‐quality programs
for disadvantaged children from birth to 5 years of age can deliver a 13% per year
return on investment, a cost‐effective way to mitigate the negative consequences of
child poverty (Heckman, Garcia, Ermini, & Prados, 2016; Shonkoff & Phillips,
2000). Thus, spending small sums of money, time, and energy during pregnancy and
early family life may save heartache and money years later because mental illnesses are
prevented. Similarly, using resources to prepare older adults and their families for
likely physical and emotional transitions may make this time of life smoother for the
whole intergenerational family.
Moving Forward: Observations

from “Reading Across” the Chapters
Expanding the conceptual base

Since the publication of the first SFT handbook by Gurman and Kniskern (1981), the
knowledge base of the field has been organized around the classic family therapy theo-
ries. Broad‐based theories like behavioral, attachment, and social constructionist were
added. As research developed, evidence‐based models became an additional way to
define the field. These became and have all remained the common language for SFTs.
They are how we describe ourselves to each other and to our clients.
But it is apparent from reading across the chapters of this handbook that there are
family‐level relational processes at a mid level between the theories and treatment
models that currently organize our field and actual clinical practice. We just do not
talk about them in an explicit, organized way using a common set of terms that would
be widely understood by those in and out of SFT. A next step in developing the theo-
retical infrastructure of SFT would be to identify these relational processes, find a
common language for them, connect them to the existing research underlying each,
and develop validated assessments for these processes. Such relational processes should
have the following characteristics: (a) evoke interpersonal interaction instead of intra-
psychic conditions, (b) focus on interaction between individuals in family relation-
ships (i.e., family members broadly defined), and (c) be applicable to the family as a
whole, different subsystems, family situations, cultures, and stages of the life cycle,
including interactions between therapist and clients. The following are a few examples
of such relational processes.
Use readily understood terms for family constructs Ambiguous loss (Dahl & Boss,
2020, vol. 4) emerges in several chapters as a core relationship process. Attachment
injury (Johnson, Makinen & Millikin, 2001) is another. Both are examples that are
relational, imply interaction, apply specifically to intimate relationships, and have
strong implications for theory, research, and practice. Both are also explicitly con-
nected to rich sources of basic and clinical research. People in and out of SFT readily
understand and can relate to the phenomenon each describes.
Family estrangement is an example of a core relational process that is implied but is
rarely named as a specific construct in the SFT literature. SFTs would be more likely
to use the term “cutoff” from Bowen theory. Yet, “cutoff” does not capture the pain
of living one block away from your son and his children—your grandchildren—and
seeing them only every couple of months. Cutoff does not quite describe your adult
daughter who lives with you and rarely even speaks to you. In their research, Pillemer
and colleagues (Gilligan, Suitor, & Pillemer, 2015; Pillemer & Suitor, 2006) used the
term “family estrangement” in their study of relationships between 561 older women
(65–75) and two of their adult children. They used Bowen’s concept of “cutoff” but
combined it with the theory of ambiguous loss to define and measure the degree of
different types of family estrangement: (a) physical contact but emotional distance,
(b) absence of or notable reduction in physical contact, or (c) both. Using a construct
like “family estrangement” could identify commonalities underlying different SFT
theories and treatment models that could be readily applied to a wide range of painful
family problems. It would also help develop our conceptualization and research on
how estrangement differs from family separation or when limiting contact with a fam-
ily member is a healthy option.
Use family‐level terms SFTs frequently use individual‐level terms assuming that the
application to systemic therapy is clear. It would be helpful to “translate” these individ-
ual‐level terms into family‐level ones. How would one translate commonly used terms
like “mindfulness” into a term more descriptive of family‐level interventions? Many of
the constructs used in SFT are descriptive of dyadic interaction. For example, secure base
evokes the dyadic relationship between a parent and a child. Explicitly using the con-
struct “family as a secure base” could help broaden our thinking about the construct.
Helping families develop and maintain a sense of safety within the family and
between the family and the outside world involves core family relational pro-
cesses—ones that SFTs know a great deal about. Much of the SFT literature focuses
on issues that have an underlying component of fear, lack of trust, and feeling
unsafe (e.g., substance abuse, illness of a parent, depression, family violence). A
major source of the pain from these internal family threats to security is that the
very people who are supposed to keep you safe are the very ones causing you to be
so frightened. Framing family as a secure base as one major issue underlying these
common painful family problems helps identify common impacts and suggests
ways to intervene to increase the family sense of felt security. The construct also
connects the extensive theory and research on the long‐term impact of frightening
parental behavior on children to SFT theory, research, and practice (cf., Lyons‐
Ruth & Jacobvitz, 2016).
The SFT literature has focused more on internal threats to safety than on external
threats, yet there are commonalities across both types. For example, experiencing
chronically unsafe environments is a core issue for many families. Daniel et al. (2020,
vol. 4) analyze the impact of living in unsafe neighborhood environments in Palestine
and Northern Ireland. They describe the impact on families who are unable to main-
tain an “uncontaminated private family space.” They expand the individual construct
of PTSD to a family‐level construct:
The field of trauma still tends to focus on PTSD; it is time to widen the lens of our under-
standing. Complex Trauma and Secondary Trauma need to be considered with their
specific effects on families. We do not have a reference term for “ongoing trauma,” yet
this is the reality for many people. Families here have commented that if only it was
“post” if only it was over, then maybe they could find a way to recover.
After describing the many impacts on family relationships, these authors summarize
their approach to therapy:
“Doing hope” can reside in a number of processes including witnessing accounts of suf-
fering without flinching or disassociating, naming the intentions and processes behind
the infliction of wounds on families and communities and documenting in detail acts of
resilience, resistance and, above all, the maintenance ̶ against all the odds—of the bonds
that matter. These are the processes that we aim to bring into therapy, and these are
relevant to all therapists working in such contexts.
The idea of external threats to the family functioning as a secure base relates to
many of the chapters in the handbook, particularly those that relate to oppression and
discrimination, historically marginalized communities, family dislocation, and forced

family separation (cf., Wieling, Derrick et al., 2020, vol. 4; Wieling, Utržan et al.,
2020, vol. 4).
Identify common relational processes across the life cycle Working across the life cycle
and working across all types of families is a core strength of SFT. Looking across com-
mon impacts on families of individual disorders, conditions, and illnesses across the
life cycle is also advantageous in identifying approaches to treatment. The chapter on
neurological disorders by Zubatsky et al. (2020, vol. 4) is a model for this kind of
thinking. After describing major neurological disorders, the authors describe core
challenges for families, including the impacts of the progression of the disorder, family
adaptability, and shared caregiving, including caregiving by long distance. They then
analyze differences by life cycle stage (young children, middle age, and later life).
Therapists need to focus on how families adapt to an “off‐time” illness, caregiver
stress, and how to promote the age‐appropriate autonomy. Age‐appropriate auton-
omy is relevant at any age, for children, for adults who are not able to take expected
responsibility for their lives and for elderly who need care. Issues of control versus
responsibility are relevant, and an analysis of commonalities across the life cycle is
informative. These same processes identified for neurological disorders also apply in
cases of chronic physical (e.g., cystic fibrosis, diabetes) and mental (e.g., developmen-
tal delays, bipolar disorder) conditions, and connect the concept of age-appropriate
autonomy to the extensive research literature on parenting and caregiving.
Assessment of family‐level relational processes Ambiguous loss, age‐appropriate auton-

omy, family estrangement, family as secure base, attachment injury, and many others
need to become core organizing constructs for SFT, the way constructs like depres-
sion, conduct disorder, or schizophrenia are to clinical fields based on the individual.
The work of the Relational Processes Working Group (Beach et al., 2016; Foran
et al., 2013) is a model for identifying relationship‐level constructs through the essen-
tial steps of summarizing underlying research, developing assessments, conducting
field trials, and engaging in efforts to get these relationship issues incorporated into
the DSM‐V and the forthcoming ICD‐11. The working group has focused on rela-
tional problems in the parent–child and couple dyads. Chapters by Foran, Fraude,
Kubb, and Wamboldt (2020, vol. 2) and Balderrama‐Durbin, Snyder, Heyman, and
Haynes (2020, vol. 3) include descriptions of some of this work. Applying their model
to other family‐level constructs would be of enormous benefit to SFT.
The complexity of SFT research

Rich description of family interaction was the accelerator for the development of SFT.
More accessible ways of recording interaction for later discussion and coding were
essential. Live and recorded family therapy sessions were presented and discussed at
conferences, at workshops, and in training programs. Our model of clinical training is
based on observation of intensive interaction of family members, therapist and family
members, supervisor, and student. Training and supervision are done in individual,
dyadic, and group settings. Opportunities for interaction, observation of sessions, and
review of videotapes are complemented by intensive feedback and discussion, most of
it informal.
Scholars like Mary Ainsworth (parent–young child), John Gottman (couple),

Gerald Patterson (parent–adolescent), and Susan Johnson (couple therapy) based
their work on intensive, systematic analysis of interaction and made recordings avail-
able for viewing, discussion, and training. Social constructionist approaches used
qualitative methods like discursive analysis to do intensive microanalyses of family
interaction and interaction among multiple family members (Strong, Sametband,
Gaete, & Bilbao, 2020, vol. 4). This aspect of our work, intensive observation of
interaction and talking and writing about it, continues both as basic research on fam-
ily interaction and research on clinical processes in SFT.
While extremely valuable, research on interaction has been focused primarily on the
dyadic interaction of couples and of one parent and a child. Social constructionist
analyses of language are a notable exception (Strong et al., 2020, vol. 4). The study
of the more complex system of the family as a whole and the complexity of factors
involved in family therapy need to incorporate additional methods like discursive anal-
ysis (Strong et al., 2020, vol. 4), dynamic systems analysis (Meadows & Wright, 2008;
Wittenborn et al., 2020, vol. 1), and social network analysis (Scott, 2017). Expanded
access to data on interaction in real time, powerful and accessible ways to analyze large
datasets, and computer‐generated graphics offer exciting opportunities to capture the
complexity of family systems beyond the dyad.
Rich description of interaction and analysis of the complexity of the whole system—
intensely observed, discussed, analyzed, and shared—need to play a more prominent
role that complement the role of RCTs in establishing the research base of the field.
It might be useful to model SFT research after that of fields like neuroscience and
astrophysics. Both of these fields study very complex systems, the brain and the uni-
verse, that involve elements organized into systems where the connections among
elements have to be deduced from theory and intensive observation using increas-
ingly large datasets and sophisticated technology. These researchers are cautioned
about rushing too quickly into application. We think that the way Insel (2013)
describes neuroscience is an excellent description of the enterprise of SFT research:
When we talk about the brain, it is anything but unidimensional or simplistic or reduc-
tionistic. It depends, of course, on what scale or what scope you want to think about,
but this is an organ of surreal complexity, and we are just beginning to understand how
to even study it, whether you’re thinking about the 100 billion neurons that are in the
cortex or the 100 trillion synapses that make up all the connections. We have just begun
to try to figure out how do we take this very complex machine that does extraordinary
kinds of information processing and use our own minds to understand this very complex
brain that supports our own minds. It’s actually a kind of cruel trick of evolution that
we simply don’t have a brain that seems to be wired well enough to understand itself. In
a sense, it actually makes you feel that when you’re in the safe zone of studying behavior
or cognition, something you can observe, that in a way feels more simplistic and reduc-
tionistic than trying to engage this very complex, mysterious organ that we’re begin-
ning to try to understand.
Fields like astrophysics and neuroscience do not have to convince others about the
importance of the universe or the brain. SFTs do not need to be convinced of the
importance of the family system, but we may need to be reminded about the com-
plexity of studying it. One of the goals of the handbook is to make room for and
encourage the kind of writing that complements research summaries limited to RCTs
and evidence-based models. Summaries of research are included, but authors have
been encouraged to use an authoritative voice, include descriptions of how they think
about how to go about intervention and research (“stories from the field”), and pro-
vide clinical vignettes to illustrate.
Make modality a more prominent subject

Mental health professions serving only individuals do not need a theory of modality.
Every case is an individual case. In contrast, which family members to see directly and
when are issues underlying every SFT case. It is a given, but the topic itself is not a
focus of theory and research. Modality is addressed most directly in chapters related
to a specific concern such as safety (couple violence, Stith, Spencer, & Mittal, 2020,
vol. 3), secrets (affairs, Timm & Hertlein, 2020, vol. 3), or family separation (divorce
and children, Huff & Hartenstein, 2020, vol. 2; runaway adolescents, Slesnick &
Brakenhoff, 2020, vol. 2).
The handbook is organized in a way to encourage thinking across domains and
topics. Making modality a more explicit topic would benefit practice, encourage
research, and suggest policy changes that would guide reimbursement for services
involving flexible patterns of direct involvement of family members in treatment.
Asking SFTs how they decide what family members should be involved in a particular
type of session, with a particular family configuration, and a particular presenting
complaint elicits a spontaneous, engaged discussion about the principles that underlie
their decisions about who should be present. Overarching principles include the obli-
gation to provide effective treatment, informed consent, ethical practice, and relating
to the family system as a whole, regardless of who is in the room. Principles about
safety, secrets, and family structure were mentioned above. There are many others.
A particular need related to the topic of modality is how to explain how the basic
principles of SFT apply to therapy with individuals. There are some SFT models like
internal family systems (Schwartz, 1995) or Bowenian therapy that primarily focus on
working with individuals in sessions. Regardless of their specific SFT theoretical ori-
entation, however, SFTs routinely see individuals in treatment using a systemic lens.
Yet, it has been difficult to be clear on this important point. For example, in training
programs accredited by the COAMFTE and in many of the 50 US state licensure
laws, client contact hours are designated as “relational” (sessions with more than one
family member present) or as “individual,” directly implying that seeing an individual
is not “relational.” Explaining when SFTs see individuals in treatment and how they
follow the principles of SFT practice is an important area of development.
A core strength of SFT is engaging multiple family members to work on very pain-
ful issues, often with family members in conflict. The decision of who is seen in a
particular session is also a negotiation with the family. In their chapter on runaway or
homeless youth, Slesnick and Brakenhoff (2020, vol. 2) provide an example of the
kind of thinking that goes into these decisions that are routinely made by SFTs:
Adolescents may be vehement about not needing therapy, but most adolescents are open
to the idea of having an advocate or ally who can help them negotiate better communica-
tion and a better relationship with their parents. The therapist empowers the adolescent
by allowing him or her to decide whether to proceed, and by presenting the therapist as
their ally, and at their service.
The parents or primary caretakers of the adolescent have often already experienced
multiple interventions through various agencies. In many cases, the parents report that
these experiences were not positive because they were blamed for the problems in the
family, or they were not helped by the services. Parents might be reluctant to participate
in family therapy given their own alcohol or drug problem which can include fear of
judgment or fear that their child will be removed from their custody by the state, lack of
motivation for change, and marital or financial stressors. Some parents assert that their
child is to blame for the problems, and do not see their role in the therapy process. In
order to overcome these barriers, the therapist must reduce defensiveness by stating that
treatment is non‐blaming and by stressing that his or her child needs and wants help. The
therapist should not challenge parents at the engagement phase, and instead can focus on
the importance of their perspective in the therapy sessions in order to maximize positive
outcomes. If engagement of the parent or adolescent fails, individual meetings with the
adolescent and their family members can provide an opportunity to continue the nego-
tiation process until the family is ready to meet together.
This example also highlights the ethical issues that must be considered in any decisions
on engaging family members in treatment (e.g., assent, safety; Meade & Slesnick, 2002).
Conclusion
The Handbook of Systemic Family Therapy (SFT) is intended to be a comprehensive

resource for both the profession and practice of SFT. In the past, theory and research
on the importance of family relationships, prevention programs to promote positive
parent–child or couple relationships, and models of intervention were developed in
several independent streams. Important bodies of literature focused on different stages
of the life cycle and different parts of the family system. The work occurred in different
academic departments and within different professions. With some exceptions, the
focus was on intact families representing majority cultures in high‐income countries.
The goal of the handbook is to bring these streams together and to incorporate
them into one resource to encourage “thinking across” and stimulate needed devel-
opments in theory, research, and practice. The work is also intended to broaden our
understanding of, sensitivity to, and care of all families, especially those families in the
most desperate circumstances. It is easy to see people as individual physical beings
occupying a specific space. They exist. Our hope is that everyone will begin to recog-
nize that each individual is connected in a systematic way to an unseen network of
family members, past and present, for good or ill, in or out of awareness that is always
there and moves with them. Just like an individual human being, a family is an entity
and a fragile one worthy of our care. Due to extraordinary efforts over 18 days, 13
individuals were rescued from a cave in Thailand. Thirteen families were rescued too.
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2
The Evolution and Current Status
of Systemic Family Therapy
A Sociocultural Perspective
William J. Doherty
Intervening directly in family relationships to treat human problems and promote

well‐being: the idea moved from novel and controversial in the mid‐twentieth century
to utterly mainstream by the end of the century. Practiced first within established
mental health professions such as social work and psychiatry, family therapy eventually
gave rise to a new profession variously called marriage and family therapy, couple or
family therapy, or systemic family therapy—an evolution that historian Ian Dowbiggin
(2014) described as one of the greatest professional success stories of the twentieth
century.
This chapter describes the evolution and current status of systemic family therapy
through the lens of social and cultural forces that influenced the field. Professional
histories are usually presented in terms of the founders, their models, and the subse-
quent challenges and innovations while paying little attention to the larger historical
forces that gave rise to the profession and shaped its development. But new forms of
professional practice only succeed when they respond to emerging societal needs
(Sullivan, 2005). I will document how systemic family therapy was attuned to new
historical currents and, in turn, influenced those currents. I will also argue that because
these currents have changed, future success of the field will depend on being relevant
in new ways. A primary source will be mental health historian Ian Dowbiggin’s (2014)
definitive history of the field. In some cases, I will rely on my first‐hand experiences
and observations.
Because systemic family therapy evolved in two separate traditions—marriage coun-
seling and family therapy—the contexts of their early years will be described sepa-
rately, using the terms common at the time (marriage counseling and family therapy).
And because the field emerged primarily in the United States, albeit with important
international contributions (see Sim & Sim, 2020, vol. 1; Sim & Shamai, 2020, vol.
4), the American sociocultural context will be my focus.
34 William J. Doherty
Sociocultural Origins of Couples Therapy
The early decades of the twentieth century were times of rapid social change affecting
family life in ways that both impressed and concerned professionals and ordinary peo-
ple. On the positive side was the continuing rise of what pioneering family sociologist
Ernest Burgess called “the companionate family” which for many decades had been
replacing the “institutional family” (Burgess & Locke, 1945). The former was based
on mutuality, love, personal satisfaction, sexual fulfillment, and greater gender equal-
ity, whereas the latter was based more on economic support, child rearing, and fixed
gender roles. The family was modernizing for a new world of more educated people
living in a democracy. On the concern side, was a steady rise of divorce and other
problems associated with rapid urbanization of American life: child abuse and neglect,
and the spread of sexually transmitted diseases (Dowbiggin, 2014).
These problems were exacerbated by the Great Depression when American families
faced severe economic and psychological challenges, the birth rate dropped below
replacement levels for the first time, and desertions combined with divorce to threaten
the stability of marriages (Elder, 2018). At this grim time of the 1930s, Emily Mudd,
a biology lab technician turned social worker, created the Marriage Council of
Philadelphia, which launched the marriage counseling movement in the United
States. From its beginnings, the field emphasized not just counseling, but public edu-
cation and outreach. The most rapid expansion, in fact, was not in direct counseling
services, which were not well‐compensated, but in college classrooms and marriage
support events in faith communities (Dowbiggin, 2014).
If the Great Depression sparked the founding of marriage counseling, World War
II gave it a definitive boost. The vast mental health challenges experienced by the
troops gave rise to forms of brief psychiatric treatment that led to greater public sup-
port for psychotherapy, and in the post‐war years, no institution was considered more
endangered by mental health and social issues than the family (May, 2008). When the
divorce rates spiked in an alarming way in 1946 when the troops came home, the
federal government began to invest in research on family relationships and marital
stability. Social historians have noted that the subsequent Cold War with the Soviet
Union was based not just on military might, but on the belief that strong families
were the key to US security (May 2008). This security was thought to be tied into
traditional breadwinner/homemaker roles that were to be challenged in the 1960s.
The 1942 wartime founding of the American Association of Marriage Counselors
(AAMC) marked the first steps in the formation of a distinctive profession and field of
practice for those working with married couples. The founders were an eclectic group
of social scientists, gynecologists (the largest group), pastoral counselors, and psy-
chologists. Although some were influenced by psychoanalytic thinking, they were
careful to distinguish their work with couples from psychotherapy: they were helping
couples solve relationship problems and have more emotionally and sexually satisfying
relationships—not helping spouses resolve deep psychological problems (Nichols,
1992). Particularly influential in the early AAMC was Alfred Kinsey, whose books
challenging sexual norms fascinated and alarmed the American people (Kinsey,
Pomeroy & Martin, 1948). In general, the pioneers of marriage counseling were a
radical group for their time, promoting birth control and mutual sexual fulfillment.
Marriage was less of a duty‐bound relationship than a venue for personal happiness
(Dowbiggin, 2014).
The Evolution and Current Status of Systemic Family Therapy 35
The post‐World War II era brought a new optimism to mainstream American

culture (Halberstam, 1994). (Of course, there were dark sides to this era, which the
social justice movements of the 1960s would bring to light.) Dowbiggin (2014)
argued that marriage counseling, with its emphasis on personal happiness, sexual
satisfaction, and more modern (if not egalitarian) gender roles, both fit with and
contributed to the cultural movement of middle‐class Americans aiming for the
good life of economic and psychological rewards. With psychotherapy (mostly psy-
choanalysis and its offshoots) gaining popularity among the educated classes, mar-
riage counseling gradually began to be recognized as a legitimate form of help for
troubled marriages, and a spate of books and journal articles began to make it a
professional field of practice.
However, as Dowbiggin (2014) observed, a fault line opened in the philosophy of
marriage counseling that lingers today: the tension between marriage as a permanent,
committed relationship and a venue for personal happiness. This tension reflects a
broader cultural ambivalence about marriage, which on the one hand is celebrated as
a permanent union until death do us part, giving stability to family life if there are
children, and on the other hand as a relationship based on two people meeting each
other’s emotional and sexual needs. The early writers in the field, concerned about
being labeled “marriage savers,” consistently maintained that they were not antidi-
vorce but rather aimed to help both partners achieve their personal goals for a satisfy-
ing relationship (Mudd, 1951). On the other hand, they were marriage counselors
and not individual therapists because they believed in the special value of marital
relationships. But an explicit reckoning with the tension between these two ideas—
personal satisfaction and permanent commitment—has eluded the field then and now
(Doherty, 2015).
If the 1950s gave marriage counseling a foothold in the culture, the 1960s (refer-
ring to the mid‐1960s to the mid‐1970s) were the takeoff point. Exciting and unset-
tling changes were occurring rapidly in American family life (and around the
industrialized world). As the divorce rate began a precipitous rise in the late 1960s
(doubling by 1980), cohabitation and serial committed relationships went from stig-
matized to normative (Cherlin, 2010). The feminist movement called traditional gen-
der roles into question. The gay liberation movement raised fundamental questions
about human sexuality and intimate relationships (Steigerwald, 1995).
The growing public interest in marriage, relationships, and self‐help came at a time
when behavioral psychologists became interested in couple relationships. (The field’s
theories prior to the mid‐1970s had been more influenced by psychodynamic mod-
els). Psychologists brought the rigor of behavioral analysis and interventions to the
field (Jacobson & Margolin, 1979) and prompted a movement toward evidence‐
based models of couples therapy, all of which focused on the here‐and‐now rather
than the past, a focus that cultural anthropologists for many decades have noted is an
American sensibility: the past is not as important in US culture as it is in many other
cultures (Kluckhohn & Strodtbeck, 1961). It is not surprising that the most influen-
tial models of couples therapy have a here‐and‐now focus.
Public acceptance of marriage counseling also allowed practitioners to advocate for
state licensure which first began in California in 1963 and was promoted vigorously
in subsequent decades by AAMC, which became the American Association of Marriage
and Family Counselors and then the American Association for Marriage and Family
Therapy (AAMFT) (Nichols, 1992). I will return later to these professional issues.
Sociocultural Origins of Family Therapy
Family therapy is a product of the post‐World War II concerns about mental

health and family life, with pioneers such as Gregory Bateson, Salvador Minuchin,
and Murray Bowen who were intrigued by systems theory ideas emerging from
biology and cybernetics. They were part of a broader wave of professional and
cultural interest in group dynamics as witnessed by the rise of group therapy, psy-
chodrama, and T‐groups (later becoming “encounter groups”) (Leddick, 2011).
In other words, American culture in the post‐War decades was fascinated by
groups and group dynamics, which no doubt fueled openness to family therapy.
Unlike marriage counseling, which had no particular theory of its own, family
therapy pioneers charted a new theoretical course that became known as family
systems theory.
At the same time, there was a growing public and professional frustration with
long‐term therapy models that were not useful to war veterans and were not able to
move people out of state institutions for the mentally ill (Dowbiggin, 2014). There
was also a wave of public concern over the rise of what was called “juvenile delin-
quency”—and those teens were not going to sit still for years of psychoanalysis. The
historical moment was ripe for a fresh new approach.
An illustration of how family therapy mirrored cultural developments can be found
in the 1956 movie “Rebel Without a Cause,” which portrayed the behavioral prob-
lems of a teenager played by James Dean as stemming from negative family dynamics,
including the triangle of the mother, the weak father, and the husband’s mother. In a
scene at the police station, the actor James Dean looks through a door peephole at
this trio squabbling in the adjacent room and announces that they are driving him
crazy. (This occurs just after he has tried to punch the police detective). This was a
cinematic portrayal of triangular family systems dynamics during the same year that
the first family systems theory article was published—the classic “double bind” article
from Bateson and his Palo Alto team (Bateson, Jackson, Haley, & Weakland, 1956).
Professionals often theorize what artists and cultural innovators have already intuited
in the same cultural milieu.
In the 1960s, the United States was atop the world, with a booming economy,
unparalleled military might, cultural exports in art and music, and a growing interest
in self‐improvement (Steigerwald, 1995). Family therapists were rebels with a cause,
overturning Freudian dogma and aiming for rapid cures—a quintessentially American
idea. Family therapy was the first American therapy export to Europe which previ-
ously had sent its psychotherapy models to North America. With systems theory, the
pioneers wanted to change the world: Bateson (1972) was an early ecologist, Minuchin
wanted to solve the problems of the slums (Minuchin, Montalvo, Guerney, Rosman,
& Schumer, 1967), and Bowen (1993) theorized about societal regression. The pio-
neers aimed for something larger than inventing a new therapy tool—they were inter-
ested in solving the problems of their democratic nation in the post‐War decades
(Doherty, Mendenhall, & Berge, 2010).
There was a disconnect, though, between family therapy and the emerging and
enormously influential Human Potential Movement, which challenged what its
leaders (Carl Rogers, Abraham Maslow, Fritz Perls) saw as strictures of psycho-
logical oppression that infected society: rigidity, either/or thinking, and conform-
ity rather than authenticity. (This historical analysis and some of the subsequent
material in this chapter are adapted from Doherty (2017).) Humanistic

sychotherapies and encounter groups captured the cultural lionizing of personal
p
expression via a new image of the self—what I have termed Liberated Self to refer
to the emphasis on freedom from arbitrary social norms (Doherty, 2017). Virginia
Satir was the only family therapy founder who joined the Human Potential
Movement through personal development workshops around the country and in
her best‐selling book People Making (1972). The other family therapy pioneers
largely ignored the Human Potential Movement. While the cultural vanguard was
doing personal growth groups, Minuchin (1974) was working on boundaries and
cross‐generational coalition, Bowen (1993) was working on family of origin
dynamics, and Boszormenyi‐Nagy was exploring intergenerational loyalties
(Boszormenyi‐Nagy & Spark, 1984).
Although family therapy has endured long after the human potential movement
faded, its leaders, by and large, never challenged the cultural norm of the Liberated
Self or articulated an alternative view of the self. The closest was Bowen’s differenti-
ated self, but its relative lack of emotionality left it with little cultural resonance in an
era of self‐expression. I return later to how system family therapists might articulate a
new vision of the self for the current historical moment.
The 1970s (following Watergate, assassinations, and the Vietnam War) brought a
distrust of social institutions, a sustained movement toward personal lifestyle free-
dom, and dramatic changes in family life via cohabitation, divorce, changing gender
roles, and nonmarried parenting (Bailey & Farber, 2004). It also brought greater
public acceptance of therapy and more generous insurance reimbursement for ther-
apy. Marriage counselors (now called marital therapists) and family therapists were
both riding this tide, and during this time many of them (though not all) joined forces
in the AAMFT. There was tremendous cultural interest in family therapy in the late
1970s into the late 1980s. The New York Times covered AAMFT conferences, and
Minuchin was featured in a New York Times Magazine article. Popularized family
systems ideas penetrated the culture through the growing cultural concern about
“dysfunctional families.” The 1970s also marked the international spread of family
therapy through invitations of US leaders to speak in other countries and the develop-
ment of local leaders and training centers (Kaslow, 2000; Sim & Sim, 2020, vol. 1).
In the United States, the still‐living founders of the field were rock stars at workshops
and conferences.
The Culture Strikes Back: Challenges Hit the Field
The winds at the back of systemic family therapy shifted directions in the 1980s
and 1990s. Feminist and ethnic minority critics knocked the founders off their
pedestals (Goodrich, Rampage, Ellman & Halstead, 1988; Hardy, 1989). Suddenly
a movement that saw itself in the progressive vanguard was challenged as too tra-
ditional and even retrograde—patriarchal and ethnocentric. Family systems theory
was seen as lacking recognition of larger forces of power that stigmatize some fami-
lies and family forms. Family therapists were confronted by a legacy of ignoring
violence and sexual abuse in families and were pushed by feminist, ethnic minority,
and postmodernist therapists Michael White and David Epston (1990), to consider
the impact of larger systems of injustice that affect families. With time, the field
adjusted with a new generation of leaders, especially women and therapists of color,
but it continues to struggle with being primarily white in a multicultural world
(McGoldrick & Hardy, 2008).
By the mid‐1980s, there was also a growing sense among practitioners that the
pioneers and their models had promised too much transformation too quickly.
Paradoxical interventions, for example, did not produce the miracles when used in
everyday practice that were seen in demonstration videos. Indeed, family therapy
could no longer avoid the need for outcome research to legitimize its models and
practices, the kind of evidence that its charismatic leaders could not provide but that
a new generation of empirically trained academic therapists embarked on in a world of
tightening economic resources where evidence was increasingly required for health-
care services (Sprenkle, 2002).
In the broader society, the newly ascendant medical model, with its Diagnostic
and Statistical Manual (DSM) editions and culturally popular medications like
Prozac, proved more difficult for systemic family therapists to contend with than
psychoanalysis had been. Faced with the requirement to diagnose individuals in
order to get reimbursed, many family therapists (breaking from the founders who
were strongly against diagnosis) made peace with the medical model. Some, never
comfortable with the challenges of treating whole families, were content to do
individual therapy with children and adolescents. Even couples therapists began to
diagnose one spouse in order to get insurance coverage for clients who may not
have been able to afford couples therapy. Increasingly, the healthcare system, fed
by national concerns about escalating healthcare costs, focused on “medical neces-
sity” defined by individual symptoms and not relational dynamics. (See Doherty,
2020, vol. 3.)
By the 1990s, major family therapy training centers, which had been sources of
clinical innovation since the first one created by Don Jackson in Palo Alto in 1959,
began to retrench or close as insurance reimbursement tightened (Rampage, 2014).
Ending were the days of routine cotherapy, team observation, and video recording of
sessions for group review and study. (These did continue in university training pro-
grams.) It became difficult to practice family therapy with children and adolescents
outside of institutions with support staff and play areas. In the mid‐1990s, members
of the AAMFT were doing more individual therapy than couples therapy and rela-
tively little family therapy—at least in the practice worlds of AAMFT members
(Doherty & Simmons, 1996). In 2014, Rampage reported a similar clinical practice
profile (half of the cases were individuals) for the Family Institute of Chicago, one of
the few remaining major family therapy centers outside university settings. The extent
to which whether systemic family therapists do individual therapy with a systemic lens
is not known.
Ironically, the systemic family therapy movement was losing its steam at the same
time that research evidence was accumulating for its effectiveness with both cou-
ples and childhood and adolescent problems (see Carr, 2020, vol. 1). Again ironi-
cally, this challenging era was also a time of great progress for the profession via
state licensing, a struggle fought state by state and ending in the early 2000s with
every state credentialing marriage and family therapists. (For a discussion of the
split between the profession and the practice of systemic family therapy, see
Doherty, 2020, vol. 3.)
A Resurgence of Innovation
Family therapy has had the advantage of a broad and fertile conceptual framework in
systems theory, which, while applied mainly to family systems at the beginning, can be
expanded to include other systems. (This is not true of most psychological theories
which are more difficult to apply to larger systems.) Over the past 25 years, systemic
family therapists have ventured outside of mental health offices and clinics into other
settings such as homes, medical clinics, and schools where their perspectives and prac-
tices have proved useful and effective (e.g., Laundy, 2015). These developments have
occurred in the context of broader political and public frustration with the limits of
traditional medical and educational methods to deal with complex problems such as
end of life care, escalating healthcare costs, school failure disproportionately affecting
minority communities, and the high costs of placing children outside their homes. If
the issue of cost containment stifled innovation in traditional family therapy office
practice, it opened up vistas in other settings.
A leading edge of systemic family therapy outside of traditional settings is medical
family therapy, developed after family therapists were invited to teach in medical
schools and family medicine residency programs. The term “medical family therapy”
was coined in the early 1990s by McDaniel, Doherty, and Hepworth (2014) to bridge
family therapy ideas and practices with biological systems (especially via chronic medi-
cal illness) and the systems of healthcare teams. They called their conceptual approach
“biopsychosocial systems theory” and developed collaborative teams with physicians
and nurses to treat families where members were facing medical challenges. Medical
family therapy has proved enduring in the new healthcare system which is increasingly
based on collaboration across professional silos and where there is interest in reducing
unnecessary medical care, especially hospitalizations. A second‐generation of medical
family therapist has expanded the framework into a variety of medical problems and
health care settings (Mendenhall, Lamson, Hodgson, & Baird, 2018).
Home‐ and school‐based family therapies are other examples of moving from men-
tal health offices and clinics to a mainstream setting where families live and travel to
in the course of everyday life (Boyd‐Franklin & Bry, 2019; Laundy, 2015). In addi-
tion to having predictable contact with children and better access to parents, these
settings provide opportunities to collaborate with professionals in schools, human
services, and healthcare. Along with medical family therapy, these approaches harness
the healing power of many stakeholders to solve problems and promote family well‐
being—as compared to traditional family therapy which was based on clients showing
up on their own and meeting with a single therapist.
Finally, systemic family therapy has responded to the cultural interest in diverse
family forms and multiculturalism by producing a body of work on gay couples and
their families, and on culturally sensitive interventions (Hardtke, Armstrong, &
Johnson, 2010; McGoldrick & Hardy, 2008). This was an advance over the found-
ers’ models, which mostly tended to see couples and families in universal terms not
tied to contexts such as culture and sexual orientation. An additional element in
much of the contemporary systemic family therapy literature is a social justice orien-
tation which views social identities such as race, culture, and sexual orientation
through the prism of systems of oppression (D’Arrigo‐Patrick, Hoff, Knudson‐
Martin, & Tuttle, 2017). This social justice model, using critical theories focusing on
oppressor and victimized groups, has stimulated the field to pay attention to larger
social forces affecting minority families. In Doherty (2020, vol. 3), I suggest an
alternative approach to policy and social change that uses the systemic/relational
principles that the field of systemic family therapy has pioneered.
Current Situation and Prospects for Systemic Family Therapy
The main theme of this chapter has been the interaction between the field and the
broader culture. Three interrelated societal trends seem to have emerged in the early
decades of the twenty‐first century: atomization, identity politics, and polarization. A
challenge for our field is how to respond and make a difference, and not be caught up
in these trends or exacerbate them. Atomization (or “bowling alone” in the classic
phrase of political scientist Robert Putnam (2001)) refers to the increasing fragmenta-
tion of American society, witnessed by a decline in community ties and social trust.
Putnam and others have documented how people trust their neighbors less and have
fewer close friends and confidants, along with higher rates of loneliness and depres-
sion. Trust in a wide range of social institutions is at a historic low in the United
States. The social glue has weakened.
Identity politics refers to a shift toward identification with a specific group more
than with the nation as a whole. Sometimes referred to as the tribalization of the
nation (Chua, 2018), identity politics is associated with competing claims of victimi-
zation and calls for redressing grievances of one’s group. Some of these claims, of
course, are historically well founded, while others are doubtful but still strongly
believed, such as the case of unmarried young men claiming oppression by women, or
bankers feeling scapegoated for the 2007 banking crisis. A culture of identity group
grievance is currently widespread and augmented by political leaders who pit one
group against another, as well as by the pervasive influence of social media and 24‐
hour cable TV.
Polarization refers to the division of the country along political lines of conserva-
tives and liberals who increasingly occupy different geographical and relational worlds
and have historically high levels of animosity toward each other (Pew Poll, 2016).
Mason (2018) and other political scientists have documented a decades‐long trend
toward both ideological polarization but, more ominously, high levels of social polari-
zation, with Americans occupying diverging social landscapes based on political
groups who mistrust each other and have little social connection. The United States
is disuniting.
In addition to (and perhaps related to) these problematic social trends, a big demo-
graphic change in family has also been occurring outside of the attention of most sys-
temic family therapists (if our clinical literature is an indicator): A stable marriage in
which to raise children is becoming a privilege of the upper‐middle, college‐educated
class—and, that is, who mostly comes to couples therapy. Working class and low‐
income families are more likely to experience family fragmentation (nonmarital births
followed by the parents breakup, divorce, and then churning through multiple step-
family forms). These families are seen by family therapists when the children are in
serious trouble. The result is that the children of educated, married parents grow up to
achieve success in an increasingly competitive society, while the children of lower or
modestly educated, nonmarried or serially married parents face major challenges to
achievement and to the stability of their own future families (Cherlin, 2010; Putnam,
2016). Systemic family therapists have been largely silent about this escalating social
divide, perhaps because we have not developed an approach that simultaneously accepts
the realities of families who come to us for help (whatever their family structure) and
also engages the larger social impact of family fragmentation. See Doherty (2020, vol. 3)
for ideas about how we can find out voice in the larger social sphere of policy and
cultural conflict.
In many ways, the early decades of the twenty‐first century in the United States and
across much of the developed world have seen the dominance of centrifugal forces:
the pulling apart of communities, nations, and the international order, and a return to
tribalism and nationalism. A global, multicultural ideal embodied in open immigra-
tion practices and affirmative action for minorities has led to a backlash as previously
central groups feel their values and way of life threatened—and turn to leaders who
promise to restore their rightful place in the world. These trends affect families and
are in turn affected by how families manage their relational and economic challenges:
societal and political stress and consequent fragmentation affect families, and socially
isolated families experience stress and fragmentation that reverberate back to society
(Doherty, 2017).
At this time of cultural division, what does systemic family therapy have to offer? We
do know something about helping people connect, about how to form a healthy “we”
out of self and others. We also know something about how to depolarize conflict. But
counteracting the emptiness of hyperindividualism and the seduction of tribalism
require more than effective clinical treatment approaches. We need a new image of the
self for this time in history and new ways to directly engage with culture and
community.
The Consumer Self and the Relational Self
Let us go back to the earlier discussion of the Human Potential Movement and its
Liberated Self. What began as an antidote to the post‐World War II era of button‐
down conformity ended up looking out of balance, with too much self‐absorption
and freedom to manipulate others, plus ignoring institutional forms of oppression.
Unfortunately, the therapy world did not replace the Liberated Self with a new model
of the self. Therapists, including systemic family therapists, were trying to survive
economically, learning to work with the medical model, figuring out how to treat
newly recognized problems such as personal trauma, and establishing evidence‐based
legitimacy. All of this was important work, but not on the cutting edge of cultural
change. We surrendered cultural influence to media celebrities and business authors
whose books replaced psychology books on the bestseller lists.
The Consumer Self

Culture marches ever on, and so a new image of the self‐took hold: the Consumer Self.
As documented by sociologist Lizabeth Cohen (2003) in her book Consumer
America, the consumer culture had been growing in influence since the end of World
War II, when the US government asked Americans to spend their way out of the
aftereffects of the Great Depression. It was augmented by the unprecedented

economic boom of that period, when many Americans moved into the middle class.
The psychological “me culture” of the 1970s became of the economic “consumer
culture” of the 1980s and 1990s. Long gone was John F. Kennedy’s call to national
service, replaced on the political right by promises to tax less and on the left by prom-
ises of more government services.
The Consumer Self and its culture of credit cards and advertising are ultimately
empty. The toys lose their meaning, and there is always someone with more goods to
envy and resent, some new group threatening to take away the status and goods that
your group has earned. The Consumer Self is prone to social isolation, insecurity, and
the siren call of tribalism—because loneliness is too much to bear in a mass society.
Relationships inevitably become more fragile because their main source is not lasting
commitment or enduring friendship, but whether they are meeting the current needs
of the individuals involved. And parenting in the middle class becomes caught up in
competition to help children achieve in a more insecure society where economic suc-
cess is the highest form of accomplishment (Doherty, 2000).
As Cohen (2003) argued, the Consumer Culture tends to colonize all spheres of
society. The Human Potential Movement moved from antimaterialism to commercial
jingles, from Carl Rogers to Tony Robbins, from hippie encounter groups to sales
pitches for Erhard Seminars Training (EST) and The Forum. Systemic family thera-
py’s work on family dynamics became fodder for outing one’s dysfunctional family on
high‐rating TV shows.
But in recent years, family therapists and other therapists have been offering anti-
dotes to the isolated Consumer Self: we have been emphasizing attachment and con-
nection. This shift can be seen in work as diverse as couples therapy (with its emphasis
on attachment bonds), trauma therapy (with its emphasis on healing through connec-
tion), mindfulness therapies (in which self‐attunement leads to attunement with oth-
ers), and even interpersonal psychoanalysis (which attends to current relationships as
well as past ones).
For example, Sue Johnson (2013) argues that bonds of connection can strengthen
the individual, rather than diminish or threaten personal freedom. In a world of cen-
trifugal forces, where politicians talk of building walls, our field is developing a mes-
sage of engagement. We are evolving an image of the self in which connection is
central (Steele & Steele, 2017). And interpersonal neurobiology had made major
steps away from the idea of the isolated self (Minton, Ogden, Pain, Siegel, & van der
Kolk, 2015).
But cultural influence is now eluding us, in part because we have not directly
tackled the fault line of the me‐first Consumer Culture and its image of the Self.
(The Human Potential Movement came with a potent critique of the culture of
conformity that it sought to transcend.) This will require systemic family therapists
to be partly cultural anthropologists, looking not just at the clinical problems we
see in our practices but also at the cultural pathologies that underlie them. Although
there is a substantial literature in systemic family therapy on the problems of racism
and poverty (e.g., McGoldrick & Hardy, 2008), I believe that we are missing other
forces at work: a culture that is adrift in anxiety, polarization, and consumer mate-
rialism, which are part of the reason for a recent decline in well‐being in the US
population (Gallup Poll, 2017), and which make it harder to address the problems
of racism and poverty.
But we need more than a critique. We have the ingredients of a new ideal of the
Self. It is there if we look at our best developments over the past couple of decades—
and if we lift our heads out of our immediate professional preoccupations to ask big-
ger questions. It is a vision of the Relational Self, with two core dimensions: connection
and commitment (Doherty, 2017).
The Relational Self

The Relational Self is more than the truism that we all need relationships. It is a con-
ceptual shift to seeing relationships as part of the self, as inherent in the idea of the
self—not self in relationship, but relationships inside the self and the self inside rela-
tionships. Stated more formally, there is no self‐system outside of relational systems.
This was a core principle of family systems theory that got obscured when family
therapy became seen as an intervention approach to treat DSM disorders. And it is at
the heart of interpersonal neurobiology (Siegel, 2015), attachment therapies (Steele
& Steele, 2017), and relational psychoanalysis (Mitchell & Aron, 1999). Recent work
in identity theory in psychology explicitly uses the term “the relational self” (Chen,
Boucher, & Tapias, 2006). The Relational Self resurrects the premodern idea (think
Homer) that the fully separate self does not exist, but with a modern twist that empha-
sizes both the complexity and agency of the individual person (mind, brain, body, and
choice) and the embeddedness of this person in a web of family, friendships, and com-
munity relations, some being chosen but many being given facts of social life. We are
smart bees in a hive.
In many ways, systemic family therapy in the past assumed a strong “we” from
which an individual needed to differentiate. The founding models of family therapy
thus focused on the problem of enmeshment or fusion, which may have been the
modal problems of the mid‐twentieth century. Arguably, a greater concern today is
whether core relational bonds can hold at all. The enmeshed family has given way to
the disengaged family, the stifling community to a neighborhood of disconnected
strangers. At the family level, we need more “gluing” interventions to augment dif-
ferentiation/boundary setting interventions that are, of course, needed as well. And
at the societal level, we need tools to speak to the importance of authentic connec-
tions across difference, because when these connections are not made, people are not
only isolated and in need of therapy, but they are also prone to false tribalism that
takes forms such as gated communities and white nationalism.
Commitment and the Relational Self

But connection alone is not enough to counteract the fragmentation of today’s
world. Without the second dimension—commitment—the Relational Self is easy
pickings in a consumer culture. (The most powerful commercials call on our sense of
relational connection; recall the Coke song “I’d like to teach the world to sing in
perfect harmony.”) Relational connection by itself lacks a call on the self to transcend
self‐interest—an ethical, moral dimension. Commitment means sustained invest-
ments in something outside oneself, to relationships and causes that transcend us,
extend us, challenge us, and require continual struggle to manage and even sacrifice
for (Doherty, 1995; Taylor, 1992). Commitment stems from the reality that we are
born into existing families and communities that call on us to give back; these rela-
tionships come with obligations that we cannot ignore and still be fully human.
Systemic family therapists know that there is no individual outside of a web of recip-
rocal relationships, even if those are cut‐off relationships.
Ethical commitment is antithetical to a Consumer Self that honors no past obliga-
tions unless they promise future rewards. As Law professor Tim Wu (2017) points out
in his book The Attention Merchants, consumer capitalism is the most creative force in
the contemporary world, able to transform any personal or collective ideal into a con-
sumer desire, in this case by encouraging us to feel entitled to the best possible rela-
tionships that require low maintenance and offer high rewards. So commitment must
be an integral part of a new image of the Relational Self in a consumer society.
But systemic family therapy historically has not articulated a sense of what commit-
ment means in family life. It has been implied but not made explicit that parents have
obligations to the children and cannot simply walk away from these obligations
because they are hard (tragic exceptions notwithstanding). In the couples therapy
area, therapists have held a wide range of ideas about divorce, which all agree is a
necessary safety valve for some marriages, but the agreement stopped there in terms
of whether couples therapists should be neutral about divorce or promote marital
commitment when feasible (Doherty, 1995, 2015; Wall, Needham, Browning &
James, 1999).
Fortunately, commitment is now becoming more visible in the field (Stanley, 2005).
Gottman and Gottman (2018) have begun emphasizing the importance of commit-
ment, which they write,
…means believing (and acting on the belief) that your relationship with this person is
completely your lifelong journey, for better or for worse (meaning that if it gets worse,
you will both work to improve it). It implies cherishing and reinforcing your partner’s
positive qualities and cultivating gratitude
(Commitment section, para 1).
Michele Weiner‐Davis’s (2002) work has long emphasized commitment in mar-

riage, often bucking the tide of expressive individualism in the field. Although attach-
ment‐based approaches like Emotionally Focused Therapy do not use the term
commitment as a central concept, they emphasize how secure attachment creates the
possibility of enduring bonds of connection (Johnson, 2013). Attachment is impos-
sible without a sense of commitment, which creates a safe space for vulnerability. And
attachment in turn can lead to deeper commitment and responsibility to repair the
union when it is broken. But without an explicit notion of the ethical dimension of
commitment, we can be left with attachment relationships that last until a potentially
competing attachment relationship comes along.
Community and the public dimensions of the self

There is one more important element in the Relational Self: connection to commu-
nity. Without the idea of the individual as a member of, and contributor, larger com-
munities, the Relational Self is limited to the intimate world (Doherty, 1995, 2017).
Missing in traditional psychological theories is the public dimension of the Self, with-
out which the individual and the individual’s family are not in a position to flourish as
citizens of a larger world and its institutions. This issue is at the heart of concerns by
social scientists who have chronicled the retreat of individuals away from broad social
engagement and commitments in their communities (Bellah, Sullivan, Swidler, &
Tipton, 1985; Putnam, 2016). Marriages and families are left to fulfill all the social
needs of individuals. In this regard, a provocative but necessary question for systemic
family therapy (and other professions) in the twenty‐first century when democracies
are weakening around the world is this: what role do we play in sustaining and pro-
moting democracy? By democracy, I do not mean just elections and government. I
mean collective agency, the ability of people to work together to solve problems and
have an impact on their world. Democracy, in John Dewey’s (1993) terms, is a way of
life, not just a structure of government. It is about ordinary people deliberating across
differences and taking responsibility for their future together—before, during, and
after electing their public officials (Boyte, 2005). In the realities of the twenty‐first
century, we have to talk about “multiracial democracy” that offers liberty, equality,
and justice to all groups, including those not included in the foundations of modern
democracies. An important question in a world where democracy appears to be fragile
is whether systemic family therapists (and other therapists) have a role in promoting
the conditions for healthy, democratic communities. I offer this as an example of pos-
ing a question about the role of the profession at a moment of history, just as our
predecessors posed questions about how about their times.
In sum, if we can find a way to meaningfully put commitment and community into
our historical emphasis on interpersonal connection, we have the makings of a new
cultural ideal—the Relational Self—which the world badly needs. It is an antidote not
only to the Consumer Self, but to the medical model which sees decontextualized
individual patients as the focus of healthcare. Systemic family therapy is needed
because not only it helps individuals but also individual suffering is inextricably bound
with the suffering (and resources) of families and communities. The Relational Self
means that no problem is bound only by the skin of an individual—illness and healing
occur in a hive of interconnecting, committed bonds that are precious themselves and
necessary for healing. As I heard family therapist and Ojibway American Indian healer
Sam Gurnoe once say, “Outside of a culture, a community, and a spirituality, you can
treat but you cannot heal.”
Implications for systemic family therapy

I offer some thoughts for how the idea of the relational self can provide direction for
the field.
For theory: We can build upon the work of Murray Bowen, our only great origi-
nal theorist of the self in relationship (see Kerr’s (2019) updating of Bowen’s
model), and combine this with concepts from interpersonal neurobiologists like
Siegel and recent work from cognitive social psychologists demonstrating how cog-
nition—long conceptualized as an individual activity—is fundamentally social
(Sloman & Fernbach, 2017). Non‐Western communal (and less individualistic) cul-
tural ways of thinking and seeing the world would have much to offer here. And like
Freud (2010) who engaged the great cultural issues of his day (e.g., in Civilization
and Its Discontents), our intellectual leaders can step beyond strictly professional
terrain and pose challenges and pathways for a society that would take seriously the
relational self in its familial and public dimensions. This would inevitably lead to
implications for public policy, where proposals should be grounded in our systemic,
relational perspective rather than on traditional liberal versus conservative perspec-
tives (see Doherty, 2020, vol. 3).
For research: One implication is to resist the pull toward studying systemic family
therapy as mainly a multiperson treatment modality for treating individuals with diag-
nosable disorders. As medical family therapists argue, there are no strictly individual
illnesses or disorders; all exist in a relational field of influences at levels from dyads to
families to society (McDaniel et al., 2014). Even if the funding for a particular study
is focused on outcomes for an individual, systemic family therapy researchers can
simultaneously look for outcomes for other family members and their relationships.
How are other family members and their relations faring after treatment? Is the fam-
ily’s connection to social supports stronger, weaker, or unchanged? Researchers might
also examine their concepts and measures for implicit individualistic bias. For exam-
ple, in couples therapy research, where the gold standard outcome is individual meas-
ure of relationship happiness or satisfaction, what about domains such as enhanced
commitment to the relationship or more investment in extended family and friend-
ship networks? Can we go beyond measuring consumer satisfaction with relationships
and look at good citizenship in relationships and larger communities?
For clinical practice, one implication is to systematically address the historic tension
between promoting individual well‐being (again, often defined in individualistic, con-
sumerist terms) and marital and family commitments. This means developing explicit
theory and practice guidelines for dealing with situations when obligations to self and
others come into conflict, such as decisions about divorce or new caregiving respon-
sibilities for frail parents. (My work on discernment counseling is an attempt to articu-
late a clear way to deal with ambivalence about divorcing or working on the marriage
(Doherty & Harris, 2017).)
Another clinical implication would be to elaborate more fully what a systemic, rela-
tional approach would be to therapy with individuals, since as mentioned, much eve-
ryday clinical practice in our field is with individuals. Holding onto a systemic lens is
quite challenging when individual clients talk about their problems with other family
members, and my personal observation has been that systemic family therapists are
not necessarily more skilled than other kinds of therapists in this area. To repeat: the
pull toward seeing the client’s relational world through the client’s eyes is very strong.
We could contribute greatly to the whole field of psychotherapy if we could develop
and evaluate a clinical approach to working with individual clients in a systemic way.
For one thing, this might address the frequent concern of systemic family therapists
about the negative fallout of individual therapy for couple and family relationships, a
phenomenon documented in a study of side effects of individual therapy (Schermuly‐
Haupt & Linden, 2018).
Conclusion
The field of systemic family therapy has had an amazing journey, all of it within my
lifetime and much of it within the span of my career. We have succeeded when we
have met a societal need, and we will flourish in the future to the extent that we con-
tinue to meet societal needs, which means identifying and responding to cultural
pressure points. This requires looking beyond our offices and classrooms to the larger
world. We are influenced by the larger culture and our time in history, and, in turn,
we influence it, for good or ill. Our task is to be more aware of the cultural rivers we
are swimming in, so that we do not blindly follow their currents and end up enhanc-
ing their worst features, and so that we can be agents of positive change through
deploying the best of what we know as systemic family therapists.
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3
Global Contexts for the Profession
of Systemic Family Therapy
Timothy Sim and Charles Sim
Systemic family therapy (SFT) started developing as early as the 1950s in developing
countries. However, there has been little analysis of its overall development, other
than occasional reports regarding its development in specific locations (e.g., Deng,
Lin, Lan, & Fang, 2013; Good & Ben‐David, 1995; Ng, 2005; Picon, 2012; Sim,
2012). After the developmental process of SFT around the world for almost six
decades, what is the current state of SFT outside Australia, New Zealand, Europe, the
United States, and the United Kingdom? This chapter will begin by telling the histori-
cal story of SFT in different parts of the world, including Africa, Asia, Latin America,
Middle East, and Russia. It will then examine the larger contexts of mental health and
social service systems in these regions, as they provide the required resources and
structures, or the lack of them, for the development of SFT around the world.
Specifically, we look at the salient policies that could help to promote the development
of SFT, including public funding and government recognition of SFT, and the cultural
mores and help‐seeking behaviors of people in these regions. The chapter will then
outline the development of SFT globally by examining the roles of SFT professional
bodies, education and training, practice, and localization.
The History of SFT Outside the West
Contrary to general belief, some developing countries outside the West started
working with families and couples in some form long before SFT was imported from
Western countries. For example, the Catholic Church in Brazil started organizing
counseling for couples and newly formed families, and the Catholic University of São
Paulo, the University of Brasília, and the Catholic University of Rio de Janeiro started
teaching, researching, and serving couples and families even before SFT started to
develop in the West (Bucher & Da Costa, 2005). In India, a psychiatrist, Vidya Sagar,
52 Timothy Sim and Charles Sim
set up an “outpatient” family therapy hospital in Amritsar in 1954. Mental health

patients and their families were housed in tents, where he focused on psychoeducation
and involved family members to care for patients (Rastogi, Natrajan, & Thomas,
2005), which eventually significantly reduced hospital stay, increased acceptance of
the patients by the family, and enhanced family coping skills (Ng, 2005).
Many social service and mental health professionals in developing countries, like
their Western counterparts, turned to SFT for solutions to difficult problems. As early
as the 1950s, Enrique Pichon‐Rivière of Argentina started to see families regularly in
private practice in an attempt to understand the connection between mental illness
and the family using Batesonian ideas (Herscovici, González, Label, Vega, & García,
2013). In the 1960s, social workers in South Africa started to employ SFT approaches
to alleviate the difficult plight of multiproblem families systematically (Mason &
Shuda, 1999). Incidentally, mental health professionals in Israel (Halpern, 1985),
Japan (Tamura, 2003), and Taiwan (Chao, 2011), too, started to come together to
apply SFT in mental health settings in the 1960s (see Table 3.1 for key benchmarks of
SFT development in selected non‐Western countries).
Going abroad to acquire systematic SFT training has been common among
professionals in developing countries since the 1970s. For instance, professionals
from Chile, Peru (Herscovici et al., 2013), and Mexico (Roberts et al., 2014)
started going to England, Germany, France, Italy, and the United States in the
1970s for SFT training. Notably, there were some who have chosen to travel nearby
for systemic training, such as professionals from Chile traveling to Argentina for
SFT training, as Argentina was one of the countries that started SFT as early as the
1950s. With Argentina as a base, SFT subsequently spread to Chile and then to
Brazil and other Latin American countries (Haug, 2003). In the 1980s, Asian pro-
fessionals from Hong Kong (Wong & Ma, 2013) and Singapore (Sim, 2012) visited
the United Kingdom and United States to receive SFT training. Consequently, the
emergence of SFT in these countries was heavily influenced by the West. Nevertheless,
local SFT pioneers were enthusiastic and visionary leaders, who have played vital
roles in the development of SFT in different countries. Their relentless effort to
learn SFT and then introduce it in their countries to solve the challenges plaguing
families and communities in their local countries has been an essential pull factor.
Some of them even took great risks in promoting SFT. In Chile and Argentina, for
example, some psychologists and psychiatrists had to gather privately in view of the
politically sensitive environment (Herscovici et al., 2013).
Another way that SFT spread globally was that SFT teachers went on international
teaching tours to teach SFT. Many master therapists from the West have traveled
around the world since the 1970s. Carlos Sluzki organized the first family therapy
conference in Argentina in 1970 (Herscovici et al., 2013); Margarete Haass Wiesegart
and Ann‐Kathrin Scheerer and a team of German psychotherapists introduced SFT in
China beginning in the 1970s (Sim & Hu, 2009). This trend of SFT master therapists
conducting teaching tours continued into the 1980s and beyond. For instance, Hong
Kong was a city that attracted many SFT pioneers. After Virginia Satir conducted a 2‐
day workshop for some 300 participants in Hong Kong in 1983, Maria Gomori, Jane
Gerber, and John Banmen continued to train social workers, clinical psychologists, and
counselors in the Satir model each year in Hong Kong from 1986 for about 10 years
(Cheung & Chan, 2002). Today, there are a number of trainers and therapists in Hong
Kong trained in this model (Wong & Ma, 2013). The founders of solution‐focused
Table 3.1 Key benchmarks of SFT development in selected non‐Western countries.
Significant SFT pioneering figures and organizations SFT local professionalization
Foreign supporters/ Key local figures/ Conceptual SFT

Year Profession organizations organizations models Professional bodies Function Journal
Africa
South 1960s to 1970s Social work Multiproblem
Africa families
1969–1972 Ginnot &
Hirschowitz
1974 Donald Bloch &
Jessie Turberg,
Ackerman
Institute
1976 Interdisciplinary •• Avner Barcai, Department of Structural
Philadelphia Psychiatry, family
Child Guidance University of therapy
Clinic Cape Town
•• Haifa Univer-
sity
Asia
China 1976 Psychiatry •• Margarete
Haass Wi-
esegart
•• Ann‐Kathrin
Scheerer
1985 Psychology Jane Roberts,
University of
Massachusetts
1995 German‐Chinese Training
Academy for
Psychotherapy
2000 •• Psychiatry •• Salvador
•• Psychology Minuchin
•• Lee Wai Yung
(Continued )
Table 3.1 (Continued)

Hong 1980s Psychiatry •• Luk Siu Luen

Kong •• Wong Chung
Kwong
1980s Social work •• Katherine
Young
•• Hong Kong
Association for
the Promo-
tion of Family
Therapy
1983 Virginia Satir Satir model
1986–1992 Social work •• Steve de Shazer •• The Hong Solution‐
•• Insoo Kim Berg Kong Poly- focused
•• Scott Miller technic Uni- therapy
versity
•• Caritas
•• Hong Kong
Family Welfare
Society
2012 The Asian •• Clinical
Academy of practice
Family Therapy •• Education
(AAFT) •• Research
•• Policy
development
2016 Hong Kong Clinical
Marriage & practice
Family Therapy
Association
India 1950s Psychiatry Vidya Sagar,
Institute of
Mental Health,
Amritsar

1970s Psychiatry Family Psychiatric

Centre at
the National
Institute
of Mental
Health and
Neuroscience
in Bangalore
1970s Psychiatry Mental Health
Center at
Vellore
1994 The Indian Advocate
Association for for the
Family Therapy profession
Japan 1960s Psychiatry Psychiatry and
psychology
1976 Psychiatry •• Koji Suzuki
•• Japanese
Association of
Family Therapy
1980 Japanese Training Japanese Journal of Family
Association of Therapy
Family Therapy
(JAFT) (http://rnavi.ndl.go.jp/
books/2011/03/
000000041701.php)
1984 Japanese Training
Association
of Family
Psychology
(JAFP)
(Continued )

1984 Psychology Salvador Minuchin •• Tetsuo Okado •• Structural

•• Japanese •• Strategic
Association of commu-
Family Psy- nication
chology model
•• International (MRI)
Academy of
Family Psy-
chology, Kyoto
Singapore 1980s Counseling •• Anthony Yeo •• Strategic
•• Juliana Teo FT
•• Goh Choo •• Milan
Woon SFT
•• Counselling &
Care Centre
1995 Association of Training
Family &
Marital Therapy
(AMFT)
South 1970s Academics •• Family
Korea systems
theory
•• Structural
•• Strategic
•• Satir
•• Solution‐
focused
therapy

1988 Korean Biennial Korean Journal of Family

Association of Korean‐ Therapy (since 1993)
Family Therapy Japanese
(KAFT) Case
Conference
since 2002
2002 Korean •• Accreditation
Association •• Training
of Marriage
and Family
Counseling
(KAMFC)
2011 Korean Society Clinical
of Narrative practice
Therapy
(KSNT)
Taiwan 1960s •• Zhu‐zhang
Chen
•• Jiu‐jiu Wu
•• National Tai-
wan University
Hospital
2003 Taiwan •• Accreditation
Association •• Clinical prac-
for Marriage tice
& Family •• Research
Counseling
2006 Association of •• Accredita-
Couple & tion clinical
Family Therapy practice
•• Professional
dialogue
•• Research
(Continued )

Middle East
Iran 2011 The University Semiannual Journal of
of Kurdistan, Family Counseling and
Pasdaran Psychotherapy
(http://fcp.uok.
ac.ir/?lang=en)
Israel 1960s •• Psychiatry •• Mordechai Kaf-
•• Psychology fman
•• Social work •• Avner Barcai
•• Kibbutz Child
& Family
Clinic
•• Kupat Holim
•• Nathan Acker-
man
1977 The Israeli Accreditation Inside the Family
Association •• Annual
for Marital & conference
Family Therapy •• Certification
and Family •• Clinical prac-
Life Education tice
(IAMFT) •• Family life
education
•• International
conferences
•• Journal pub-
lication
•• Mini‐confer-
ences
•• Training
workshops
•• Systemic
consultation
•• Newsletter
•• Supervision

Latin America
Argentina 1950s •• Virginia Satir •• Enrique Pi- •• Batesonian
•• MRI pioneers chon‐Rivière ideas
•• Carlos Sluzki •• Mauricio Gold- •• Satir
enberg •• Structural
•• The Policlínico •• Strategic
Araoz Alfaro
(currently
Hospital Zonal
Evita)
•• J. García Bada-
racco
1976–1983 Center for Studies Clinical
of Families & practice
Couples
1976–1983 Private Center for Clinical
Psychotherapies practice
1984 The Systemic •• Accreditation Sistemas Familiares (1985–)
Association of •• Annual
Buenos Aires meetings
(ASIBA) •• International Other SFT journals
conferences •• Acta
•• Terapia Familiar (1978–
1993)
Brazil 1980s First National
Encounter
of Family
Therapy in
1982
(Continued )

1994 Brazilian Family •• Training Revista Brasileira de Terapia

Therapy •• Deliberate de Família
Association scientific,
(ABRATEF) statutory,
regimental Other SFT journals:
and social
issues Nova Perspectiva Sistêmica
Chile 1970s Interdisciplinary •• Children’s Pub- •• Strategic
lic Hospital •• Structural
•• Psychiatric •• Intergener-
Hospital of ational
Santiago •• Systemic
models
•• Solution
focused
•• Narrative
•• Dialogical
1982 Instituto de Training De Familias y Terapias (of
Terapia Familiar Families and Therapies)
de Santiago
(ITS) (http://terapiafamiliar.cl/
nuevositio/?cod_info=1)
1982 Instituto Chileno
de Terapia
Familiar
(ICHTF)

Ecuador 1982 •• Structural– La Asociacion •• Clinical prac-

strategic latinoamericana tice
•• Milan de •• Training
asesoramiento
y Pastoral
Familiar (Latin
American
Association
of Family
Counseling
and Family
Ministries)
Peru Gillian Walker, Peruvian
Ackerman Society of
Institute Psychotherapy:
1988 •• Instituto
Familiar
Sistemico de
Lima (IFASIL)
•• Universidad
Católica del
Perú
1995–2000 Peruvian Systemic
Association
(ASISPE)
Mexico •• Australia
•• Europe
•• USA
Mexican Council
of Family
Therapy
Mexican
Association of
Family Therapy
(Continued)

Russia
Russian 1970s Psychology The Center for
Psychological
Assistance,
Moscow
1980s Psychology Vladimir Stolin,
Department
of Psychology,
Moscow State
University
•• Virginia Satir Psychodrama
•• Carl Whitaker
Society of Family •• Bimonthly Family Psychology and
Counsellors supervisory Psychotherapy
and Therapists seminars
(http://familypsychology.ru)
(SFCP) •• Develop
systemic
ideas
•• Training
Global Contexts for the Profession of Systemic Family Therapy 63
therapy—Steve de Shazer, Insoo Kim Berg, and Scott Miller—were invited by universities
and nongovernmental organization to provide solution‐focused therapy training in Hong
Kong for social work academic institutes and social service organizations from 1986 to
1992 (Wong & Ma, 2013; Yeung, Chu, & Ho, 1994). Salvador Minuchin traveled to
Hong Kong regularly to supervise local psychiatrists, psychologists, and social workers.
Indeed, the contribution of international teachers traveling around the world has played
a vital role in transmitting SFT to different parts of the world.
Today, a plethora of SFT models are found around the world. Different SFT
approaches became popular in different countries, and this is probably connected to
master SFT therapists visiting different countries frequently. For example, in Russia
there are Milan, solution‐focused therapy, and narrative (Jorniak & Paré, 2007). In
other parts of the world, the approaches of Bowenian, emotion‐focused therapy, nar-
rative therapy, Satir, structural, and solution‐focused are well known, especially in
China (Sim & Hu, 2009), Hong Kong (Wong & Ma, 2013), Korea (Park, Kim, &
Lee, 2014), Israel (Lavee, 2003), Singapore (Sim, 2012), and Taiwan (Chao, 2011).
In sum, the push (master SFT therapists traveling the world) and pull (local SFT
pioneers) factors coupled with the family‐centered, religious, culture, and societal
structure helped flame the growth and development of SFT in non‐Western coun-
tries. There was a need because individual therapy had its limitation, and SFT pro-
vided a new paradigm in the treatment of emotional and relational problems around
the world. It is also important to acknowledge the pioneering spirit of the early lead-
ers, as well as the practical response of the established institutions like the Catholic
Church in promoting and developing family‐centered programs by reading the signs
of the time.
Larger Contexts for SFT Global Development
In order to understand the development of SFT in non‐Western regions of the world,

it is essential to look at the larger contexts. Unlike in developed countries like Australia,
New Zealand, Europe, the United Kingdom, and the United States, medical, mental
health, and social service systems around the world are organized differently. It is
important to understand the way policies are shaped in these regions and examine the
impact of government support and the relevant cultural challenges facing those who
are working to develop SFT in these regions.
Policy impact on SFT development

Relevant policies facilitate SFT development Countries that give credence to the
importance of marriage and the family tend to have in place policies that may be
conducive for SFT to develop. In 1993, the Chilean government created an interdis-
ciplinary commission to study the characteristics and challenges of the “Chilean fam-
ily” with a focus on those that may require protection. A family therapist was one of
the appointed members of this commission (Herscovici et al., 2013). An even more
obvious case would be that of South Korea. The reach of SFT has exponentially
expanded in South Korea because of the enactment of family‐related laws and the
establishment of family welfare services in the public sector (S. H. Lee et al., 2013).
Legally mandated family counseling services were provided at healthy family

support centers, in addition to a range of human services, such as youth counseling
centers, community welfare centers, and family courts. There are about 150 family
support centers in operation nationwide under the supervision of the Ministry of
Gender Equality and Family. These services aim to address the mental health issues
confronting Korean families in crisis (S. H. Lee et al., 2013). In Singapore, where
the government makes overt social policies to strengthening the family, SFT
has been growing since the late 1990s. The government has been increasing its
funding for family service centers, which has created a demand for more trained
SFTs (Sim, 2012; Tan, 2003).
In 2007, marriage and family counselor (MFC) became a qualified occupation
approved by China’s Ministry of Human Resources and Social Security. By 2008,
detailed criteria for becoming an MFC were established, and the first qualification
examination to become a “marriage and family counselor” was held in Beijing in
2009. These policies may have played a vital role in the dramatic increase in family
therapy training courses and workshops since 2009 (Deng et al., 2013). Likewise, in
Malaysia, the Shariah court system is the regulatory body of Muslim law concerning
marriage and divorce. Some judges may go so far as to require the couple to get coun-
seling for at least three months before proceeding further (Ng, 2003).
No policy, little SFT growth It is apparent that SFT cannot germinate and flour-
ish in a country that has no infrastructure for mental health services, in general.
In other words, SFT cannot grow independently of the larger mental health
delivery structure. In many of the less developed countries, the overall mental
health system needs to be in place in order for there to be a “scaffolding” that
will allow SFT to grow. India is a case in point. Until recently, mental health was
given a low priority in Indian public health policy (Mittal & Hardy, 2005). New
initiatives such as the National Mental Health Care Bill (Roberts et al., 2014)
promise to transform the mental health landscape in India. This bill approaches
mental health from a social perspective, as opposed to a strictly medical one, and
makes it incumbent on the government to create, fund, staff, and maintain struc-
tures at the national and state levels to deliver services. These developments bode
well for the development of SFT in the mental health care of India (Roberts
et al., 2014). Another example is Macau, China. One problem that hinders the
development of family services in Macau is a lack of policies for the registration
for social workers and other mental health professional who could provide SFT
services. This lack of professional credentials for mental health professionals in
Macau reduces the credibility of the professionalism of both social workers and
therapists (Chan, 2013).
In addition to the lack of conducive and supportive policies, inconsistent and
unpredictable government policies and funding do not help to sustain the develop-
ment of SFT. Like in the case of Peru, SFT practitioners who work in organizations
that depend on the state often have difficulty sustaining their new or ongoing projects
in the face of changing government policies, especially when new officials come into
power (Roberts et al., 2014). The next section will focus on the funding of govern-
ment for SFT service in health and social service settings, which would directly affect
its development. Nevertheless, the growth and development of SFT often depend on
government funding in the health and social service sectors.
It is not difficult to see that there is an interplay or interconnectivity among govern-

ment policies, cultural, political, social, and religious factors in the development of
SFT. The government needs to have established a viable mental health‐care system in
order for SFT to become established in a country. If there is not an infrastructure for
psychiatrists, psychologists, social workers, and others to attend to mental health
issues, there is little opportunity for SFT to become established and to grow. Hence,
we may need family advocates in government to highlight the plights of families,
which indirectly will drive the growth of SFT.
Government support for SFT practice in health and social service settings
Despite the increasing interest in SFT among many mental health practitioners
globally, lack of investment by governments to incorporate SFT to become a part of
medical or social services has hindered the development of SFT in many parts of
Africa, Latin America (Herscovici et al., 2013), Asia (Carson, Jain, & Ramirez, 2009;
Karim, Saeed, Rana, Mubbashar, & Jenkins, 2004; Mozumder, personal communica-
tion, April 18, 2018; Ng, 2003; Roberts et al., 2014; Sangganjanavanich &
Nolrajsuwat, 2013; Sim, 2012; Tamura, personal communication, June 12, 2018),
Middle East (Hajihasani, personal communication, April 10, 2018), Russia (Varga &
Glebova, personal communication, May 18, 2018), and Central Asia (Hundley &
Hagedorn, 2014). Hence, government investment in promulgating and implementing
mental health policies and providing financial resources are crucial in the development
of SFT in those countries.
As with the development of SFT in the West, the hospital is a major place where
SFT started receiving public funding (Ganc, personal communication, April 30, 2018;
Roberts et al., 2014). However, this is not without challenges, and there is still much
room for the health setting to recognize SFT around the world. For example, in
Ecuador, psychologists and psychiatrists initially received SFT with apprehension
(Haug, 2003; Ng, 2005). The provision of SFT often remains restricted to a particu-
lar group of patients. For instance, family therapy is provided in children’s hospitals or
only if a child is a part of the presenting problem in Argentina (Herscovici et al.,
2013). Moreover, the practice of SFT is often restricted to psychiatrists in hospital
settings. Although interest in working with families and couples has increased in Peru
through the years (Herscovici et al., 2013), SFT treatment teams in public psychiatric
hospitals are usually run by a psychiatrist, who may not have the necessary training in
SFT. In Brazil and Chile, social workers are not allowed to practice SFT in hospitals,
and the right to practice rests mainly with psychiatrists and psychologists (Ganc, per-
sonal communication, April 30, 2018; Herscovici et al., 2013). In Japan, the situation
is even more restricted. First, it should be noted that a hierarchy that places medical
doctors at the top dominates the practice of counseling in Japanese mental health
facilities (Grabosky, Ishii, & Mase, 2013). Although there are around 200 doctors
who are members of Japanese Association of Family Therapy, it is rare that they prac-
tice SFT (Yoshikawa, 2006). The Japanese government has been slow in implement-
ing licensure systems for clinical psychologists and psychotherapists (Tamura, 2003;
Yoshikawa, 2006). In fact, the Japanese government finally implemented a national
licensure for clinical psychologist only in 2017 (Tamura, personal communication,
June 12, 2018). In Taiwan, many psychiatrists received their training overseas and
have generally been exposed to SFT training. But, although the National Health
Insurance system in Taiwan has included “family therapy” as one of the reimbursed
services, most hospitals do not encourage SFT practice because the insurance reim-
bursement of a 50‐min session is less than a 5–10‐min outpatient psychiatric consulta-
tion (Chao & Huang, 2013).
Notably, SFT has established itself in health services in several places around the
world. In Hong Kong, as evidenced by an initiation of a family systems nursing pro-
ject in 2002 and subsequent training on a family‐centered approach, the outcome of
the project and training demonstrated a positive change among psychiatric nurses
toward systemic perspective in working with families suffering from mental illness. In
addition, there were also some positive changes in the hospital system to facilitate the
family nursing practice within the setting (Ma, Yuan, Leung, & Wong, 2017; Simpson,
Yeung, Kwan, & Wah, 2006). As such, SFT approaches have been more widely and
enthusiastically disseminated to mental health professionals and the medical field
(Tse, Ng, Tonsing, & Ran, 2012). The Hong Kong success story may be useful for
the other developing countries to emulate, especially within the hospital setting.
However, such initiatives are scant around the world.
Other than the health sector, SFT has also started to emerge in the social service
and legal sectors. In the last 10 years in Peru, SFT has gradually been applied by gov-
ernment institutions under the Ministry of Women, the Ministry of Justice, and the
National Family Welfare Institute (Herscovici et al., 2013; Roberts et al., 2014). In
Chile, SFT has been relatively successful in extending its work with different institu-
tions that deal with poverty, vulnerability, and social exclusion. In the public system,
systemic practice has attained legitimacy for its work with families and wider contexts
(Herscovici et al., 2013). In Israel, public family therapy clinics are run by the Ministry
of Social Affairs and Social Services, which are staffed primarily by social workers who
are certified family therapists or family therapists in training. In addition to these clin-
ics, family counseling units are included within other public agencies, such as adult
and youth probation services and schools and municipal offices that provide coun-
seling and intervention for families (Lavee, 2003).
However, in other countries, even though SFT is being promoted, there remains an
urgent need to further develop it. For instance, in the case of China, although the
MFC has been certificated for several years, the majority of the counselors are still in
the process of modifying and adapting SFT to meet the local cultural context and
solution–answer‐oriented session, resulting in high burnout rate among the counse-
lors (Deng et al., 2013) This leads to the need to consider the cultural consideration
in the promotion of SFT around the world. Given the various contexts in some of
these countries, there is need to explore religious and cultural beliefs and behaviors
toward SFT.
Cultural beliefs, help‐seeking behaviors, and attitudes toward SFT

Family relationships are deeply rooted in the cultures and religions of many developing
countries (Epstein et al., 2012; Liu et al., 2013; Mittal & Hardy, 2005; Owusu‐Ansah
& Donnir, 2017; Roberts et al., 2014; Sim & Hu, 2009). SFT’s focus on family system
characteristics would be conceptually appealing within cultures that emphasize collec-
tivist ideals and interconnections (connectivity) among people (Epstein et al., 2012).
For instance, SFT in Mexico has entered its fourth decade of development since the
mid‐1970s. It was first accepted by psychiatrists and psychologists and was well received
by clients largely because the family is a cherished and unifying concept in Mexican,
and within its indigenous cultures, at all levels of society (Roberts et al., 2014).
However, while the local culture may be conducive for the development of SFT in
a country, in general, specific aspects of the culture may make it difficult for SFT to
develop. A Chinese adage says, “While water allows a boat to float on it, it can capsize
the boat.” SFT has grown exponentially in China in recent years (Liu et al., 2013; Sim
& Hu, 2009). Coupled with the “family‐centric” aspects of Chinese culture, the rap-
idly rising wealth and expectations of happiness are creating an unprecedented demand
for mental health counseling services, including a decrease in the stigma associated
with professional mental health treatment (Miller & Fang, 2012). On the other hand,
several aspects of the Chinese culture deter Chinese families from seeking SFT.
Historically, the concept of “marriage and family therapy” is foreign in the Chinese
language, and there is no equivalent Chinese term for “therapist” (Miller & Fang,
2012). According to traditional Chinese beliefs, families “do not wash their dirty
linen in public” (jia chou bu ke wai yang), and many believe that “even an upright
official finds it hard to settle a family quarrel” (qing guan nan duan jia wu shi). These
beliefs have led some Chinese families to not seek professional help. Traditionally,
family support and close friends are the two main resources individuals would turn to
for help in resolving family problems. Thus, Chinese family therapists face a great
challenge in engaging more traditional Chinese families (Deng et al., 2013).
In India, there is widespread social stigma associated with mental health counseling/
therapy, similar to China. For example, only women and children would go for coun-
seling in a society that is still generally patriarchal and where family matters are private
matters. But, in addition, there are also other philosophical and religious beliefs that
would deter the development of SFT. Many Indians believe that change does not occur
within people or in family systems but rather things are predestined (a sense of fatal-
ism); therefore, any formal kind of counseling or therapy from someone unknown
would not be considered productive (Carson et al., 2009). When in need, it is cultur-
ally more acceptable for Indians to use traditional healers and healing methods (e.g.,
yoga, gurus, shamans, and temple rituals). This entrenched practice often makes the
introduction of mental health services, including SFT, difficult (Carson et al., 2009).
Current State of SFT Professional Bodies and Practice
The development of SFT in less developed countries has been a pioneering effort, with
many challenges and constraints encountered along the way. The continued develop-
ment of SFT in these countries is accompanied by institutionalized milestones, including
the establishment of SFT professional organizations. Having considered the constraints
and confounding factors within the larger contexts, we review the global development of
SFT by exploring the current state of SFT professional bodies, education and training,
practice, and attempts to contextualize SFT practice around the world.
Professional organizations
The organization of a professional association of like‐minded SFTs has been an impor-
tant milestone in the development of SFT in each country. These associations perform
important functions, such as publishing a regular newsletter, hosting annual conferences,

sponsoring training workshops, and sometimes publishing a professional SFT journal.
The earliest SFT professional body established outside of the West was founded in Israel
in 1977. The Israeli Association for Marital and Family Therapy and Family Life
Education (IAMFT) was an interdisciplinary association from the start, comprising
members from the field of counseling, psychology, social work, family medicine, psychia-
try, law, and other helping professionals who conduct marital and family therapy, divorce
mediation, systemic consultation, and family life education. The IAMFT publishes a
bimonthly newsletter, Inyan Mispachti (Family Matters), and a journal, Ba’Mishpacha
(Inside the Family), as well as certifying family therapists and approved family therapy
supervisors (Lavee, 2003).
Several SFT professional bodies subsequently emerged in the 1980s in Asia (i.e.,
Japan, Korea) and Latin America (i.e., Argentina, Chile, and Ecuador). In the 1990s,
another five countries established their first SFT professional body, respectively,
namely, Brazil (1994), China (1995), India (1994), Peru (1995), and Singapore
(1995). The turn of the millennium witnessed Hong Kong and Taiwan setting up two
SFT professional bodies, respectively, as South Korea set up its second and third SFT
professional bodies. In addition, a regional SFT professional body (Consortium of
Institutes on Family in the Asian Region) was established in 2005 in Hong Kong.
Of the professional bodies found in 15 countries and regions around the world,
most of them focus on clinical practice and training, thus leaving a handful working
on accreditation, supervision, publication of a journal, and research. Currently, there
are no SFT professional bodies in any of the developing regions such as Africa (other
than the Systemic Constellations Association of South Africa, which is a membership
community of Family, Systems and Organizational Constellations Facilitators), small
island developing states (e.g., Antigua and Barbuda, Bahamas, Fiji), and landlocked
developing countries (e.g., Afghanistan, Bhutan, Kazakhstan, Nepal). In addition, it
should be noted that some individual SFTs in non‐Western countries are members of
the American Association of Marital and Family Therapy and the International Family
Therapy Association.
Formal education and training

In‐country training Another milestone in the development of SFT globally is the
establishment of in‐country formal educational and training programs. Instead of
relying on SFT experts from other countries or on native SFT pioneers to provide
training workshops, training becomes more formalized and institutionalized. This
usually begins with private training institutes and expands into curriculum in regular
universities. Formal education and training in SFT have taken root in several Latin
American countries. SFT is taught in 15% of the universities (mainly at a postgraduate
level) and in almost 40 private institutions accredited by the Systemic Association of
Buenos Aires (ASIBA) or sponsored by the abovementioned foreign training centers
(Herscovici et al., 2013) in Argentina. Similarly in Brazil (Picon, 2012), Chile
(Herscovici et al., 2013), Ecuador (Haug, 2003; Ng, 2005), Peru (Herscovici et al.,
2013; Roberts et al., 2014), and Mexico (Roberts et al., 2014), there are numerous
universities and private institutes providing SFT training. In addition, there are
numerous certificate and postgraduate SFT training programs in Asia, particularly in
Korea, Hong Kong, and Taiwan. For instance, there are 16 graduate schools with a
family therapy department in Korea, which began in the 1990s (S. H. Lee et al.,
2013). In Hong Kong, two universities, four nongovernment organizations, and
several seminaries are providing certificate and postgraduate programs in SFT. In
2017, the Singapore University of Social Sciences launched the first Master of
Counseling Specializing in Couple and Family Therapy program with its first group
of 11 experienced counselors and social workers. This promotes the prospect of
training the next generation of systemic family therapists within the university set-
ting in the coming years.
Formal programs In some developing countries, SFT concepts and methods are
built into formal social work or psychology curriculum. Israel is an interesting case in
point. Family therapists are systematically trained in postgraduate programs in social
work (e.g., University of Tel Aviv and University of Haifa) or psychology (e.g.,
Hebrew University of Jerusalem). These programs engage public family therapy clin-
ics for practicum and all students are supervised by approved SFT supervisors (Lavee,
2003; Slonim‐Nevo & Wagner, 1991). Though there are currently no professional
training programs in SFT in Bangladesh, some university psychology departments
actively incorporate SFT concepts and methods into their curriculum (Kamruzzaman,
personal communication, April 18, 2018), as is the case of Africa (Nwoye, 2001) and
Peru (Roberts et al., 2014). The situation is even more optimistic in other countries.
For instance, in China there are an increasing number of ongoing SFT training pro-
grams by government and nongovernment organizations (Deng et al., 2013; Epstein
et al., 2012; Miller & Fang, 2012). In view of the potential of SFT in working with
families in need, the Singapore government commissioned a 2‐year SFT training pro-
gram leading to a postgraduate diploma in family and marital counseling from 1994
to 1995 for a group of 20 trainees, of whom 16 were experienced social workers.
However, this program did not have a second run, as it was an expensive venture
(Sim, 2012).
Formal SFT education and training is a rarity in some parts of the world. There
are no degree programs in SFT in India, and graduate programs in psychology and
social work generally have few, if any, courses in marriage and family counseling or
therapy (Carson et al., 2009). This is similar in Iran (Hajihasani, personal commu-
nication, April 10, 2018), Macau (Chan, 2013), Malaysia (Ng, 2003), and
Uzbekistan (Hundley & Hagedorn, 2014). The lack of financial and human
resources may contribute to the slow growth of SFT formal training in some poorer
regions such as Africa (Nwoye, 2001, 2004). However, where resources are availa-
ble, formal SFT education and training may not necessarily make inroads into those
places. For instance, in Japan there is currently no formal SFT counselor education
or counseling psychology programs because they have not yet been recognized as a
distinct specialty within psychology (Grabosky, Ishii, & Mase, 2012; Watanabe‐
Muraoka, 2007). In contrast, the numbers are on the rise in recent years in some
developing countries: The Pan Africa Christian University in Kenya has a Master of
Arts in Marriage and Family Therapy and even a PhD program in Marriage and
Family Therapy. There has been a Masters in Clinical Psychology with a Specialization
in Marital and Family Therapy in Turkey since 2013, and the National Research
University Higher School of Economics in Russia has offered a 2‐year master’s pro-
gram in SFT since 2014.
Dependence There are two major observations on the existing SFT education and
training in developing countries. First, where SFT is underdeveloped, there is a heavy
dependence on overseas trainers and expertise for support. For example, most African
SFT practitioners received training abroad (Nwoye, 2004). A number of local training
centers have reached agreements with foreign training institutions and offer jointly
accredited SFT training programs in Argentina (Herscovici et al., 2013) and in Peru
(Roberts et al., 2014). The Centro Privado de Psicoterapias (Advanced Family Therapy
Program) in Argentina, the Bilgi University (Masters in Clinical Psychology with a
Specialization in Marriage and Family Therapy) in Turkey, the Pan African Christian
University (Masters in Marriage and Family Therapy) in Kenya, and the Sino‐American
Family Therapy Institute have approached the International Family Therapy Association
for accreditation. The Hong Kong Polytechnic University has applied to the Commission
on Accreditation for Marriage and Family Therapy Education (COAMFTE) of the
American Association of Marital and Family Therapy for program accreditation.
Notably, some institutions are relying on regional expertise in lieu of Western
professionals. Take, for instance, the case of Uzbekistan, where local expertise is lack-
ing. It heavily depends on visits by professionals primarily from the Russian Federation
even though marriage and family therapy is still in an early stage here, too (Hundley &
Hagedorn, 2014). This is similar in the case of Macau, a special administrative region
of China, which relies mainly on professionals from Hong Kong and Taiwan for train-
ing local professionals (Chan, 2013). Some possible reasons are the familiarity of local
culture, language, and family dynamics, which are closer to the host countries.
Diversified field Secondly, SFT education and training in many developing regions
are diversified and fragmented, partly due to the active promotion of specific SFT
models, such as Bowenian, emotionally focused, narrative, Satir, solution‐focused,
and structural. In the case of Taiwan, many local training programs are organized
around one major trainer (Chao & Huang, 2013), and most of the local training
programs conform strictly to a specific approach (Chao & Huang, 2013). In Japan,
very few organized training programs include multiple schools of theories and models
(Ng, 2005; Tamura, 2003). In Korea, fragmentation is evidenced by the founding of
three professional associations with different foci of SFT models: the Satir model, nar-
rative model, and solution‐focused model (S. H. Lee et al., 2013). This situation has
encouraged many Korean SFT trainees to seek membership, education, and a certifi-
cate from at least one of these associations (Chung, 2017).
Training in SFT in non‐Western countries seems to have a developmental trajec-
tory. Following the introduction of SFT through workshops conducted by foreign
master therapists and local SFT pioneers, more formal training programs, or insti-
tutes, are established, often by local SFT pioneers. The inclusion of SFT curriculum
in established training programs in social work and psychology is an important mile-
stone. Finally, some universities in non‐Western countries have established SFT train-
ing programs that are independent of social work and psychology training programs.
Practice issues
This section will attempt to answer two questions: Who are the SFT practitioners in
developing countries? What are the areas that SFT focuses on globally?
Practitioners SFT is still not fully recognized as a profession in many countries

around the world, such as those in Africa (Nwoye, 2004), Bangladesh (Mozumder,
personal communication, April 18, 2018), China (Deng et al., 2013; Miller & Fang,
2012), Hong Kong (Ma et al., 2017), Kyrgyzstan (Molchanova et al., 2013), India
(Mittal & Hardy, 2005), Macau (Chan, 2013), Singapore (Tan, 2003), Thailand
(Molchanova et al., 2013), Uzbekistan (Hundley & Hagedorn, 2014), and most
other countries in the world. In other words, SFT must be practiced in the context of
other mental health professions and by other mental health practitioners; it is not a
stand‐alone profession. There are five main groups of professionals who practice SFT
globally: counselors, psychotherapists, psychiatrists, psychologists, and social workers.
In some countries, only specific professionals can deliver SFT. For instance, only clini-
cal psychologists in Bangladesh (Kamruzzaman, personal communication, April 18,
2018) and only psychologists and psychiatrists in Brazil and Chile can practice SFT
(Ganc, personal communication, April 30, 2018; Herscovici et al., 2013). Medical
professionals, such as family doctors, nurses, and occupational therapists, alongside
psychologists and social workers, practice SFT in Hong Kong (Wong & Ma, 2013),
Japan (Roberts et al., 2014), South Korea (S. H. Lee et al., 2013), Taiwan (Chao,
2011), and several Latin American countries (Ganc, personal communication, April
30, 2018; Herscovici et al., 2013). Academics in South Korea (S. H. Lee et al., 2013)
and Iran (Hajihasani, personal communication, April 10, 2018) are the main practi-
tioners and drivers of SFT practice. In Japan, family court mediators, lawyers, proba-
tion officers, and even teachers are among the ranks of the Japan Association of Family
Therapy (Roberts et al., 2014). Clergy in Africa (Nwoye, 2004), Hong Kong (Wong
& Ma, 2013), and Malaysia (Ng, 2003) practice SFT, as well. In India, where SFT is
less developed, child development workers and special education workers practice
SFT (Mittal & Hardy, 2005). Some practitioners around the world have sought addi-
tional accreditation from international organizations. Interestingly, there are currently
10 AAMFT‐approved supervisors, 8 of whom are based in Hong Kong and 1 is found
in China and another in Singapore. In sum, there is the recognition of the importance
of SFT among various health and mental sectors for the need on how to sustain and
promote growth and better support these professionals who practice SFT.
Practice focus SFTs in countries throughout the world, including Western countries,
provide help with mental health and relationship issues from a systemic perspective.
They treat individual, couples, and families. However, unique cultural and societal
circumstances have created the need for SFTs to provide additional services within
their countries. Take addictions, for instance; SFT has been applied in Asia to address
a diverse range of addiction problems. It has been applied to drug abuse in Hong
Kong (Sim & Wong, 2008; Tse et al., 2012) and Malaysia (Noor, 2014), gambling
addiction in Macau (Chan, 2013) and Singapore (Sim, 2012), and game disorder in
South Korea (Park et al., 2014) and Singapore (Sim, Choo, & Low‐Lim, 2019). In
addition to mental health problems, domestic violence is one of the major issues SFT
has been applied to working with families in India (Mittal & Hardy, 2005), Japan
(Kojima, 2006), Malaysia (Ng, 2003), Singapore (Sim, 2012), Mexico, and Peru
(Roberts et al., 2014), as well as in Russia (Varga & Glebova, personal communica-
tion, May 18, 2018) and Kyrgyzstan (Molchanova et al., 2013). Specifically, SFT has
been applied to rape survivors in Malaysia (Ng, 2003) and South Africa (Kasiram &
Oliphant, 2014), as well as violence against women in India (Mittal & Hardy, 2005).
Notably, it has been applied to working with violence committed by adolescents both
at school toward teachers and at home toward their parents in Japan (Kameguchi &
Murphy‐Shigematsu, 2001) and students who committed violence toward their peers
at school such as group bullying in South Korea (S. H. Lee et al., 2013).
Although SFTs are uniquely qualified to help families in crisis, the type of family
crises in different countries is often unique. For example, SFTs help families cope with
the “disappearance” of family members in Bangladesh (Samarasinghe, 2016) and
Mexico (Roberts et al., 2014). SFT has been applied to working with large natural
disasters, such as in Chile after an earthquake (Herscovici et al., 2013) or human‐
made disasters like civil war and violence in Uganda and Peru (Roberts et al., 2014),
or working with post‐Holocaust trauma or terrorist attacks and wars in Israel (Good
& Ben‐David, 1995; Lavee, 2003). SFT has been applied to working with individuals
and their families affected by HIV/AIDS in South Africa (Kasiram & Oliphant,
2014), Uganda (Roberts et al., 2014), and Thailand (Tuicomepee, Romano, &
Pokaeo, 2012), immigration problems in Chile (Herscovici et al., 2013) and Israel
(Kidron & Landreth, 2010), and elder abuse in Japan (Narabayashi, 2006). SFT’s
greatest potential contributions around the world could be integrating psychosocial
and spiritual dimensions of well‐being and treatment. That is, in many countries and
cultures, building couple and family resilience in disaster situations and promoting
marital and family emotional and well‐being may best be accomplished by drawing
upon their respective religious and spiritual beliefs, especially for those in the East.
There may be a potential for SFT to go upstream in building capacity and resilience
and actualize potentialities of individuals, couples, families, and communities (see Sim
& Shamai, 2020, vol. 4).
Indigenization or localization
The spread of SFT globally primarily involved the exporting of Western SFT con-
cepts, theories, and clinical models to therapists in other countries who were eager to
learn about the ideas of systems theory. The systemic conceptualization of mental
health and relationship problems seemed more consistent with the values in collectiv-
istic societies than the traditional focus on individual pathology. However, the impor-
tation of the Western ideas of SFT was done without a critical view of trying to adapt
SFT ideas to the local cultures. Russia is a case in point:
The so‐called first generation of systemic family therapists in Russia received in‐depth
training in major western schools and approaches both in Russia and abroad in the
1990s. For example, there was a program organized by Hanna Wiener, IFTA ex‐President
in Moscow from 1989 to 1995. Later many of her students … took additional courses in
Germany, UK and other countries. Virginia Satir, Carl Whitaker, Gianfranco Cecchin,
Tom Anderson, Florence Kaslow and many others visited Russia, primarily in Moscow,
to conduct workshops. Many Russian SFTs studied with this first generation of Russian
therapists as well as other family therapists abroad, such as Insoo Kim Berg.
(Glebova & Varga, personal communication, May 18, 2018)
Likewise, family therapy development in Taiwan has imported foreign theories and
techniques that are applied to local families without adequate modification, hence
leaving its applicability and clinical efficacy in doubt (Chao, 2011). There have been
concerns in Korea over the last decade, as well, that Western‐style therapy models may
have limitations in their applicability to a Korean context (S. H. Lee et al., 2013).
However, more recently, efforts have been made to adapt SFT theories and treat-
ments to local sociocultural contexts. Returning to the Russian example, Varga and
Glebova continued their narrative history of the development of SFT in Russia by
stating that:
In the process of this transmission of knowledge, these main approaches became naturally
applied to local realities or integrated together in some type of eclectic or integrative
models that fit the local cultural and professional context, mostly without an explicit
articulation of cultural adaptation.
(personal communication, May 18, 2018)
In Brazil, SFT has incorporated cultural anthropology and critical theory such as
Freire’s work (Ganc, personal communication, April 30, 2018). Israeli family
therapists have responded to the unique needs of families under war‐related stress
by developing specific intervention programs (Lavee, 2003), and Thai family ther-
apists have offered a model that integrates structural family therapy with an under-
standing of six cultural influences (religion, rural and urban considerations, family
relationships, societal values, masculine and feminine roles, and sexuality)
(Pinyuchon & Gray, 1997). A younger generation of family therapists in Japan is
trying to develop models that are more congruent with Japanese culture and soci-
ety since the turn of the millennium (Kameguchi & Murphy‐Shigematsu, 2001).
For example, in the treatment of families with school refusal children, a preventive
model by L’Abate was modified and called the family activation program, which
fits with Japanese culture and families (Kameguchi & Murphy‐Shigematsu, 2001).
However, such efforts are limited, and there is much room for SFT to be applied
and developed around the world in a culturally relevant manner (see Sim &
Shamai, 2020, vol. 4).
While there is beginning to be more attempts to adapt SFT models in different
parts of the world, there is a long road ahead (Nwoye, 2001; Samarasinghe, 2016;
Sim, 2012; Wong & Ma, 2013). While Western‐derived SFT models are generally
relevant to different families in the developing world, they should be adapted to meet
the characteristics of the various cultures, ideologies, and philosophies around the
world (Epstein et al., 2012; Mittal & Hardy, 2005; Tamura, 2003; Yeo, Tan, &
Neihart, 2013). There is little doubt that relevant adaptations would make a diverse
set of SFT models more sensitive and appropriate for families and communities of dif-
ferent cultures (Chung, 2017; Epstein et al., 2012; Grabosky et al., 2012; S. M. Lee
& Yang, 2013; Roberts et al., 2014; Trangkasombat, 2013). Perhaps, the challenge is
to nurture and develop SFT modalities that are truly indigenized, evolving within
diverse contexts and cultures, which are built upon the shoulders of the SFT pioneers
locally and internationally.
Moreover, it is important in the process of adaptation and implementation of SFT
globally that SFT research be conducted in these countries to validate the effective-
ness of SFT treatments in each country. Indeed, the validation of SFT in non‐Western
countries will help with the development of the practice and profession of SFT because
it will provide evidence to governments and other policy‐making groups that SFT
should be promoted and supported in their countries.
Conclusion: A Global Roadmap of SFT
Both Western and local SFT mavericks and enthusiasts have played an instrumental
role in promoting SFT around the world. Through talks, teaching, and clinical
training using specific SFT modalities, early SFT pioneers from the West traveled to
faraway lands and territories to engage local practitioners and families. While these
commendable efforts provided alternatives to those practitioners and their clients,
they had to contend with daunting challenges in varying cultural, social, and political
contexts. Recognition and credit ought to be given also to those early local therapists
who had learned SFT abroad and introduced SFT to their homeland and indigenize
SFT through “trial and error” and painstaking efforts. The cost was often high, given
that SFT was not readily integrated into the health and social welfare system without
the support of government agencies/local advocates, even today. The early SFT
pioneers, both foreign and local, have provided a crucial roadmap for the profession
of SFT to navigate and develop around the world. It is apparent that the varying
contexts have provided the resources, as well as hindered the teaching, learning,
research, and practice of SFT in those countries.
After six decades of promulgating and developing SFT, we have learned many
lessons in implementing SFT in our respective countries. Given the evolving contexts
and changing terrains, we are now more experienced and competent in designing our
own unique roadmap and applying SFT to meet our local needs, while keeping a curi-
ous and “gung‐ho” attitude (adventurous spirit) of the SFT pioneers, to venture into
unexplored terrains and blaze new trails within the local cultures and contexts.
Acknowledgments
The authors would like to thank the following international expert resource persons
for providing invaluable input and insightful comments in preparing the manuscript:
Lia Ganzc, Federal University of Rio de Janeiro, Brazil; Dr. Tatiana Glebova, Alliant
International University, USA; Dr. Anna Varga, the Higher School of Economics,
Russia; Dr. Yochay Nadan, Hebrew University of Jerusalem, Israel; Dr. M.
Kamruzzaman, University of Khaka, Bangladesh; Dr. Mehrdad Hajihasani, Iran; Dr.
Sun Hae LEE, Chung‐Ang University, South Korea; Dr. Takeshi Tamura, Japan; Dr.
Nicole Chen Lee Ping, International Medical University, Malaysia; Dr. Johnben Teik‐
Cheok Loy, Malaysia; and Philip Messent, UK.
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4
Redefining “Family”
Lessons From Multidisciplinary Research
with Marginalized Populations
Heather McCauley and Morgan E. PettyJohn
Families are central to the work of systemic family therapists, yet demographics, laws,
and social and cultural norms have shifted globally over time, challenging traditional
definitions of family. For example, there have been increases in unmarried cohabitat-
ing couples, same‐gender couples, rates of divorce, and individuals or couples choos-
ing to remain child‐free (Teachman, Tedrow, & Kim, 2013). However, these trends
generally reflect shifts in family structure, which may not capture how the common
functions of families (e.g., social support, financial support) have changed over time as
well. Moreover, these findings do not reflect the experiences of youth and adults who
may not consider their families to comprise those related to them by marriage, blood,
or adoption.
To be responsive to the changing needs of clients and their families, therapists may
draw from other disciplines engaged in research with populations who challenge the
traditional definitions of family, including public health‐related disciplines interested
in placing patterns of health and well‐being in context. The goal of this chapter is to
understand how the field of systemic family therapy has conceptualized “family” and
draw from social epidemiological research with marginalized populations (e.g., those
who experience exploitation, inequity, and harm because of discrimination and injus-
tice) to outline the ways that a more comprehensive operationalization of family,
facilitated by multidisciplinary collaborations, may allow for more inclusive research
and practice.
How Do We Define “Family” in Systemic Family Therapy?
Systemic family therapy examines and intervenes in interactional patterns within fami-
lies using the tenets of general systems theory and cybernetics (Bertalanffy, 1969).
These theories assert that all people exist within the context of a greater network of
interactional systems (Laszlo & Clark, 1972). Within these interactional systems, peo-
ple are interrelated in a recursive manner, such that the actions and influences of one
80 Heather McCauley and Morgan E. PettyJohn
member of a system cannot help but impact other members as well. Similarly, people
recursively find meaning and identity (e.g., friend, spouse) through their interactions
with others. Members of systems organize themselves and ascribe meaning to interac-
tions and relationships to maintain the stability and structure of the system, both
internally and within a broader ecological context (Steinglass, 1987). Applying these
systemic concepts to families, Keeney (1983) explains that “a family is organized to
maintain the organization that defines it as a family” (p. 86). Given that families
functionally organize and define themselves, how do systemic family therapists

conceptualize “families” in research and clinical practice?
The concept of “family” within the field of systemic family therapy has primarily
been defined by cultural norms and values, which have notably evolved over the past
60 years. The field emerged in the 1950s, when the ideal definition of family was a
white, middle‐class household, with heterosexual parents (a breadwinner father and a
homemaker mother) (Walsh, 1994). The 1960s and 1970s ushered in the civil rights
and women’s movements, challenging the oppressive power structures that marginal-
ized people of color and relegated women to the home. Changes in traditional gender
roles and the economy have impacted the demography of families by increasing the
number of dual‐income households (Teachman et al., 2013). As marriage and divorce
rates fluctuate, so do singleparent and blended families. The legalization of same‐gen-
der marriage in 2015 shifted America’s archaic legal definition of marriage to be more
inclusive of all forms of romantic partnerships. Despite the heavy influence of these
shifts, the perception of what “family” means at the societal level is not the only factor
that influences our clinical and research work.
In conjunction with cultural norms at any given time, therapist philosophical views
and personal values have a strong influence on how they define families in their prac-
tice and research (Jurich & Johnson, 1999). Therapists who subscribe to modernistic
views aim to identify and study objective truths regarding “healthy” family function-
ing. This requires an essentialist framework in operationalizing families, both in study
and in clinical conceptualizations of presenting problems (Naden, Johns, Ostman, &
Mahan, 2004). Defining families empirically using biological or legal connections is
valuable in quantitative research because it provides clarity and consistency in how to
define variables across time. However, this approach may fail to account for important
members of the system who fall outside the bounds of these narrow constructs. Given
the unique interactional processes that define relationships in systems, conceptualiza-
tions of family based on modernistic ideals may also fail to adequately measure or
explain the functional processes occurring.
In contrast, postmodern therapists tend to rely more on the social construction of
what “family” means to each member of a given system and reject the idea that reali-
ties can be objectively knowable (Naden et al., 2004). They may employ more narra-
tive or language‐based therapeutic models to allow the system to explore and define
their own functional needs. While this may have utility in the therapy room or in
qualitative research, allowing the members of the family to essentially operationalize
their own system presents challenges in empirical research.
In addition to their epistemological stance, the moral values and personal belief
systems of therapists also impact their rigidity or flexibility in defining families. Despite
demographic shifts in society (e.g., an increase in single‐parent households) or legal
changes in the definition of family (e.g., legalizing same‐gender marriage), therapists
with more traditional views may be resistant to acknowledging or integrating this new
Redefining “Family” 81
information within their own practice or research. While it is not necessary or advisable
for systemic family therapists to have a universal moralistic stance on what constitutes a
“family,” establishing a consistent framework for conceptualizing family systems will
help legitimize the field moving forward.
Since its inception, systemic family therapy has faced substantial obstacles in pro-
ducing empirical evidence to demonstrate its clinical effectiveness. Presumably, part of
this struggle stems from the ever‐changing landscape of the variables we are supposed
to be measuring. This process becomes further convoluted when accounting for dif-
ferences in epistemological views and personal values between clinicians. How, then,
do we establish consistent enough operationalization of family systems variables to (a)
make research more applicable to diverse clinical populations and (b) further substan-
tiate the validity of the field? We start by examining research from other disciplines
that have also been challenged to adapt to changes in how “families” are defined and
operationalized.
Epidemiology of the Role of Family Environments in Shaping

Mental and Physical Health
Similar to the field of systemic family therapy, demographic and epidemiologic
research focused on the health and well‐being of families has traditionally been shaped
by Western legal definitions and cultural and social norms that emphasize heterosex-
ual partnerships and patriarchal gender norms (Carr & Springer, 2010). Families have
been characterized by cohabitation, state‐sanctioned marriage (between one man and
one woman), and child‐rearing. In other words, families have been created and
defined by blood, marriage, or adoption, downplaying the experiences of couples that
are not married, as well as same‐gender couples, and erasing the possibility of other
family structures (Olson, 2011).
Despite these limitations, which will subsequently be addressed as we introduce
research with marginalized populations, epidemiologic research has provided a foun-
dation for us to understand the ways family environments are critical influencers of
health and well‐being across the life course. For example, a robust body of literature
has documented the physical and mental health impacts of marriage (Carr & Springer,
2010). Studies from North America, Europe, and Asia have found decreased mortal-
ity among married persons compared with unmarried persons (Gardner & Oswald,
2004; Gulack, Hale, White, Moon, & Bennett‐Guerrero, 2017; Rendall, Weden,
Favreault, & Waldron, 2011; Su, Stimpson, & Wilson, 2014). Marriage has been
associated with decreased ambulatory blood pressure, decreased drug and alcohol
use, lower stress, lower depression, and higher life satisfaction (Duncan, Wilkerson, &
England, 2006; Green, Doherty, Fothergill, & Ensminger, 2012; Holt‐Lunstad,
Birmingham, & Jones, 2008; Uecker, 2012). In addition to the influence of a partner
on health behavior, marriage provides a platform for social support, fosters responsi-
bility, and promotes healthy immune, endocrine, and cardiovascular functions
(Umberson & Montez, 2010). Married people may additionally benefit from greater
economic stability and access to health insurance (Wood, Goesling, & Avellar, 2007).
However, marriage is not universally protective. Evidence suggests that unhappily
married individuals fare worse than their single counterparts (Holt‐Lunstad et al.,
2008), with marital stress resulting in numerous physiological and mental health
outcomes (Umberson & Montez, 2010). A robust body of research has documented
the numerous physical, mental, and sexual/reproductive health impacts of an increased
health‐care seeking associated with intimate partner violence (Breiding, Black, &
Ryan, 2008; Ellsberg, Jansen, Heise, Watts, & Garcia‐Moreno, 2008; Rivara et al.,
2007), which is experienced by one‐third of women globally (Devries et al., 2013).
Moreover, research on marriage has also indicated that the benefit of marriage may
differ for men and women, as well as among racial/ethnic minority couples compared
with white couples (Koball, Moiduddin, Henderson, Goesling, & Besculides, 2010).
Globally, research using the Demographic and Health Survey (DHS) suggests that
marriage itself is not enough to be protective, especially in low‐income countries
where early marriage is common. The DHS is a comparable, nationally representative
household survey that has been conducted in more than 85 countries since 1984
(Corsi, Neuman, Finlay, & Subramanian, 2012). Originally designed to assess fertility
and family planning, the survey allows for researchers to assess population‐level trends
in health and well‐being, with family indicators including household structure, mari-
tal status, fertility, and infant, child, and maternal mortality (Corsi et al., 2012).
Findings from the Bangladesh DHS suggest that early marriage is associated with
stillbirth, miscarriage, and pregnancy termination (Kamal & Hassan, 2015). In
Pakistan, early marriage is associated with decreased likelihood of seeking prenatal
care and infant morbidity (Nasrullah, Zakar, & Krämer, 2013; Nasrullah, Zakar,
Zakar, & Krämer, 2014). Intimate partner violence victimization is also more com-
mon among women who marry before age 18 (Nasrullah, Zakar, & Zakar, 2014).
Epidemiologic research has also shed light on the impact of families on child
health, with a focus on how the structure of the family (e.g., two‐parent, single‐par-
ent, blended) is associated with outcomes among children. For example, findings
from the National Survey of Children’s Health have documented benefits of grow-
ing up in a household with two biological parents, yet this study also found that
children raised by a single father did as well or better than their peers, suggesting
further contextual factors at play that this quantitative study could not capture, such
as the role of gender norms in shaping the socioeconomic status of families or a
selection effect where fathers might be less likely to seek or be granted custody of
children in poor health (Bramlett & Blumberg, 2007). These findings are bolstered
by research from global settings. For example, a UK‐based study of the World
Health Organization Health Behaviour in School‐aged Children survey found that
life satisfaction was lower among boys in single‐parent households, independent of
their relative economic disadvantage, with stepparents modifying the association
only slightly (Levin & Currie, 2010).
Importantly, these studies may not apply to families in other cultural contexts,
including collectivistic societies that promote interdependence and cooperation. In
India, for example, families may include a married couple, unmarried children, and
their married sons and families (D’Cruz & Bharat, 2001). However, research on the
impact of family in collectivistic societies does mirror research in Western societies in
that it has focused on structure versus dynamics and processes within the family envi-
ronment (D’Cruz & Bharat, 2001). This line of research represents an advance in
family studies with the recognition of other family structures beyond the two‐parent
norm (Carr & Springer, 2010), yet this research does not go far enough as it still
defines family in terms of biologically defined, heterosexual partnerships and does not
assess key contextual factors that may influence the development of or changes in
family structure and how children thrive in these various environments. Notably, a
wave of recent studies from Europe and the United States have highlighted that
children of sexual minority (e.g., lesbian, gay, bisexual) parents generally experience
similar or better outcomes than their peers in families with heterosexual parents
(Baiocco, Ioverno, Carone, & Lingiardi, 2017; Bos, Knox, van Rijn‐van Gelderen, &
Gartrell, 2016; Calzo et al., 2017; Richards, Rothblum, Beauchaine, & Balsam,
2017), ushering in a new era in family studies research.
Adverse childhood experiences and adult health

In addition to family structure, epidemiologists have long been interested in
understanding how family dynamics shape later health and well‐being, with specific
attention to how trauma impacts development over the life course. For example, in
the mid‐1990s, researchers, in partnership with the Centers for Disease Control and
Prevention (CDC), launched one of the largest studies of the health impacts of
childhood abuse and neglect. The Adverse Childhood Experiences (ACE) Study
comprised more than 17,000 members of a health maintenance organization in
Southern California who were seeking medical care between 1995 and 1997.
Participants were primarily white (75%) with a mean age of 57 years old. About half
the sample were women, and 75% of the sample had some college education or higher
(Whitfield, Dube, Felitti, & Anda, 2005). Participants completed a one‐time survey
about their health history, including early exposure to adversity. Measures of adverse
childhood experiences included physical or psychological abuse from a “parent or
other adult in the household,” sexual abuse by an “adult or person at least 5 years
older,” and household dysfunction, which was characterized as substance use or men-
tal illness of “someone in the household,” witnessing their mother experience physical
violence, and incarceration of a household member (Felitti et al., 1998). From these
data, they created an ordinal ACE score and assessed the association of these early
experiences on later mental and physical health. In wave I of the study, more than half
of participants reported at least one category of adversity, with more than one‐fifth of
participants reporting childhood sexual abuse (Felitti et al., 1998). It is important to
note here that although ACE scores are useful for researchers to understand the broad
health impacts of trauma, they are not recommended for use as a screening tool in
clinical practice (Finkelhor, 2017).
Nevertheless, studies using these data have found that adults exposed to adverse
experiences within the family as children were more likely to experience autobio-
graphical memory disturbances (Brown et al., 2007), depression (Anda et al., 2002;
Chapman et al., 2004), hallucinations (Whitfield et al., 2005), substance use disorders
(Anda et al., 2002), suicidality (Dube et al., 2001), and report use of psychotropic
medications (Anda et al., 2007). Generally, these studies found a dose–response rela-
tionship, such that the risk for poor mental health increased for every additional expo-
sure in childhood (Edwards, Holden, Felitti, & Anda, 2003). The impact of early
adversity in the family context extends to physical and sexual/reproductive health,
too. Researchers have found elevated risk of autoimmune disease (Dube et al., 2009),
cancer (Brown et al., 2010), chronic obstructive pulmonary disease (Anda et al.,
2008), headaches (Anda, Tietjen, Schulman, Felitti, & Croft, 2010), ischemic heart
disease (Dong et al., 2004), liver disease (Dong, Dube, Felitti, Giles, & Anda, 2003),
sexually transmitted infections (Hillis, Anda, Felitti, Nordenberg, & Marchbanks,

2000), and unintended pregnancy (Dietz et al., 1999) among people who have
experienced early adversity.
The ACE Study is considered a landmark as it provided a framework for public
health researchers to understand development over the life course, emphasizing that
stressful or traumatic childhood experiences, including child abuse and neglect by
caregivers, were associated with later morbidity and mortality. These findings have
been replicated in subsequent studies using nationally representative data; for exam-
ple, the CDC’s Behavioral Risk Factor Surveillance System, a national cross‐sectional
random‐digit‐dial telephone survey of adults, assesses adverse childhood experiences,
with studies finding similar graded relationships between early adversity and poor
health in adulthood (e.g., Gilbert et al., 2015).
Notably, data from the ACE Study and the Behavioral Risk Factor Surveillance
System are cross‐sectional, precluding our ability to understand why and how dysfunc-
tional family contexts, and exposure to trauma specifically, shape health over time.
Researchers hypothesized that early adversity resulted in social, emotional, and cogni-
tive impairments (Anda, Butchart, Felitti, & Brown, 2010), which increased risk for
mental illness and poor physical health over time. These early findings have been
bolstered by advances in neuroscience that illustrate the ways that adverse childhood
experiences shape neurodevelopment (Kaiser et al., 2018; Teicher et al., 2003;
Tottenham & Sheridan, 2010) and, consequently, health outcomes. Importantly,
however, these purely biological hypotheses ignore the social and cultural contexts in
which children develop into adults and how factors like social class, discrimination
because of race, ethnicity, sexual orientation, or gender identity shape outcomes for
trauma survivors over time.
Placing the Impact of Family on Health in Context: Drawing

from Social Epidemiology
Social epidemiology is a public health subdiscipline that recognizes that people are
both biological and social organisms. Social epidemiologists center the social determi-
nants of health, disease, and well‐being in their work rather than considering social
contexts as background to biomedical phenomena (Krieger, 2001). More specifically,
people are a manifestation of the interaction between our biology and our experi-
ences. In public health, this process is called “embodiment” (Krieger, 2005).
Addressing determinants of health means addressing the social, political, and eco-
nomic contexts in which health, disease, and well‐being are shaped and reproduced.
Social epidemiologists consider the intersection of race, class, gender, sexual orienta-
tion, and so forth, as critical to understanding patterns of and mechanisms driving
health, disease, and well‐being, including the impact of families on health.
Similar to systemic family therapy, social epidemiologists consider individuals
within multiple overlapping systems or environments. Specifically, there are several
key theories that underpin this public health discipline: psychosocial, sociopolitical,
and ecosocial determinants of health (Krieger, 2011). Particularly relevant for sys-
temic family therapists, psychosocial theory posits that the “the distribution of
adverse psychological stressors (and their buffers) is socially patterned, as linked to
people’s social position, living conditions (e.g., at home, in their neighborhood),

and, if employed, their workplace conditions” (Krieger, 2011, p. 197). The inclusion
of ecosocial theory places the individual within multiple contexts, introducing
dynamics crossing households, neighborhoods, regions, nations, and the larger
global community. Moreover, ecosocial theory reminds us that health and well‐being
are patterned by racial/ethnic inequality, class inequality, and gender inequality and
shaped over time (Krieger, 2011).
We draw on tenets of social epidemiology to better understand why and how families
shape human development and, specifically, mental health to inform systemic family
therapy research and practice. Centering the nuclear family is problematic as it poten-
tially erases the experiences of marginalized communities—those who are excluded
from mainstream social, economic, cultural, or political life and/or those who experi-
ence exploitation, inequity, and harm because of discrimination and injustice. Moreover,
as demographics shift globally, in conjunction with changes in laws permitting same‐
gender marriage, increases in dual‐earning couples, unmarried cohabitating couples,
rates of divorce, and individuals or couples choosing to remain child‐free, our research
and clinical practice on the impact of families on health must shift accordingly to reflect
the lived realities of our clients. Research with marginalized youth and young adults
has highlighted the ability for us to hold both traditional (e.g., assumptions of state‐
sanctioned marriage) and socially expansive definitions of family simultaneously, rather
than these definitions be in competition with one another (Holtzman, 2008).
Structural versus functional characteristics of families: Lessons from research

with lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities
In countries around the world, many sexual and gender minorities encounter abuse
and stigma from their biological families (Durso & Gates, 2012), fueled by heter-
onormative social norms that emphasize different‐gender, state‐sanctioned marriage
as the only acceptable way to form a family. These norms are bolstered by laws in
many countries that criminalize homosexuality, prohibit same‐gender marriage, pre-
vent same‐gender partners from being involved in medical decision making, and dic-
tate how queer and genderqueer people move through the world (Han & O’Mahoney,
2014; Hatzenbuehler et al., 2012; Ponce, Cochran, Pizer, & Mays, 2010). Likely a
result of the discrimination they face, research has documented that sexual and gender
minorities are overrepresented among homeless and runaway populations (Durso &
Gates, 2012), are disproportionately affected by mental illness (Berg, Mimiaga, &
Safren, 2008; Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013;
Gattis, 2013), and are less likely than their heterosexual and cisgender counterparts to
seek medical care (Grant et al., 2011). First, we attend to the ways sexual and gender
minority families are measured, defined, and represented in survey research; then we
discuss the ways that sexual and gender minority communities shape their own defini-
tions of family to inform clinical practice recommendations for systemic family
therapists.
Identifying sexual and gender minority families in survey research Sexual and gender
minority families are represented in population‐based studies, though measurement
has changed over time, with early survey research focused on marriage, cohabitation,
and child‐rearing becoming more inclusive as cultural and social norms have changed.
In the 1990 US Census, for example, participants indicated their sex category and
marital status, with the government altering the dataset by recoding the sex categories
of married sexual minority participants to reflect different‐sex relationships, which
resulted in the underrepresentation of same‐gender couples in these national esti-
mates (File, 2016). However, a new category of “unmarried partner” was introduced,
allowing for better measurement than had previously been achieved (Gates, 2010). In
both the 2000 and 2010 US Census, participants could again indicate their sex cate-
gory and marital status, with the data of married same‐gender couples altered to
reflect unmarried partnerships instead of changes to the participants’ sex categories,
as had previously been done (File, 2016). Research on the 2010 US Census has
emphasized the ways that varying legal recognition of same‐gender marriage hindered
the collection of accurate information on same‐gender couples in the United States
(Gates, 2010). Therefore, we remain cautious about what these population‐based
studies can suggest about measuring the prevalence, health, and well‐being of queer
families in the United States.
Understanding the function of chosen families among marginalized populations Research

centered on legal definitions of marriage may not be adequate to contextualize families
in lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. Related to the
discrimination and abuse some sexual and gender minorities experience in their biologi-
cal families, research has documented the ways that sexual and gender minorities build
families through supportive friend networks, often called “families of choice” or “chosen
families” (Dewaele, Cox, Van Den Berghe, & Vincke, 2011). As an aside, research on
chosen families has also commonly used “fictive kin” to describe these relationships.
Here, we intentionally use “chosen families” rather than “fictive kin” to avoid stigmatiz-
ing and delegitimizing relationships that are central to the well‐being and development
of marginalized populations, including sexual and gender minorities. Indeed, one study
of 105 lesbian, gay, bisexual, or transgender‐identified (LGBT) individuals found that
participants considered a family to be composed of others who provided support, love,
acceptance, and trust, regardless of a biological connection (Hull & Ortyl, 2018).
Another qualitative study with 23 friendship dyads (including both LGBTQ and hetero-
sexual participants) described their chosen family to perform many of the same roles that
a biological family would, including providing financial support and emotional support,
emphasizing the functional over the structural characteristics of a family (Muraco, 2006).
Research among homeless youth similarly documents the importance of chosen
families or “street families,” who serve as key socializing agents, provide access to
resources (e.g., food, shelter), and provide social support, love, and security (Smith,
2008). In some cases, homeless youth adopt structured, familial identities mirroring
those in traditional nuclear families, such as parent–child and sibling roles. These roles
are often assigned by age, gender, and other factors, such that female‐identified youth
are assigned feminine roles (e.g., mothers, sisters), while male‐identified youth are
assigned masculine roles (e.g., head of household, father, brother) (Smith, 2008).
However, while research on the experiences of marginalized youth lags social norms
change, it is likely that the structures of chosen families are also changing (i.e., less
driven by traditional gender roles) with the increased visibility of transgender and
nonbinary people, again, suggesting that traditional definitions of family are not ade-
quate for understanding the experiences of marginalized youth and adults.
Researchers have also used novel research methods, such as social network mapping,
to better understand the social support systems of homeless youth. Findings suggest
that homeless youth have heterogeneous networks, characterized by biological fami-
lies and families of choice (Johnson, Whitbeck, & Hoyt, 2005). These findings are
bolstered by research that suggests that social support from street‐based peers and
community‐based providers is associated with greater vocational service and mental
health service utilization, respectively, highlighting the role that support plays in the
positive development of homeless youth, regardless of biological connection (Crosby,
Hsu, Jones, & Rice, 2018).
Scholars have offered several qualifications to expanding definitions of family to
include chosen families. First, debate has surrounded notions of family and the words
used to describe these crucial relationships, with scholars arguing that language of
kinship is used in the absence of a way to describe close friendship ties (Hull & Ortyl,
2018). Second, building chosen families is not a phenomenon exclusively in LGBTQ
or homeless youth communities, with a robust literature documenting similar pat-
terns among African American communities, immigrants, and other marginalized
groups (Ebaugh & Curry, 2000; Stewart, 2007; Taylor, Chatters, Woodward, &
Brown, 2013). Third, chosen families may not look the same for all, with personal
networks characterized by a blurring of the boundaries between biological and social
or chosen ties (Hull & Ortyl, 2018; Neville & Henrickson, 2009; Pahl & Spencer,
2004), especially with the emergence of more inclusive laws and policies affecting
LGBTQ communities (e.g., legalization of same‐gender marriage). Nevertheless,
studies have found that sexual minorities and other marginalized youth use chosen
families to cope with discrimination (Blumer & Murphy, 2011) and chosen families
are largely responsible for caregiving responsibilities as LGBTQ people age (Muraco
& Fredriksen‐Goldsen, 2011).
Support and stability: Lessons from research with system‐involved

youth and adults
The power of building relationships to promote well‐being Research with system‐
involved youth also highlights the many ways families are created and defined. Child
welfare policy and practice aim to build stable, permanent living environments for
youth to promote resilience and healthy development over the life course bolstered by
strong attachment bonds (Harden, 2004). A robust body of research has documented
the many long‐term health and educational outcomes associated with instability and
transition among foster youth (Dworsky & Courtney, 2010; Pecora et al., 2006;
Stott, 2012); however, resilience is possible, too. One qualitative study of 22 adults
who identified as former foster youth found that despite feelings of loss from frequent
transition in childhood, participants remembered nurturing relationships with car-
egivers, including foster parents, church families, and others, highlighting the ways in
which foster youth have overlapping networks of both biological kin and chosen fam-
ily members (Unrau, Seita, & Putney, 2008). Indeed, research among foster youth
suggests that trusting relationships with adults (caregivers or otherwise), placement
stability, positive expectations about their future, positive peer influences, and
increased self‐efficacy are protective factors that reduce their risk for poor health
(Drapeau, Saint‐Jacques, Lépine, Bégin, & Bernard, 2007; Edmond, Auslander, Elze,
& Bowland, 2006; Grogan‐Kaylor, Ruffolo, Ortega, & Clarke, 2008; Traube, James,
Zhang, & Landsverk, 2012).
Social epidemiologists, social workers, and other researchers in the area of child
welfare have highlighted the presence and importance of support systems that affect
the developmental trajectories of foster youth. Specifically, research has found that
many foster youth can identify natural mentors or, importantly, youth‐selected non‐
parental adults with whom they have formed significant connections (Ahrens, DuBois,
Richardson, Fan, & Lozano, 2008). Similar to the networks of LGBTQ youth, natu-
ral mentors comprise both biological and social connections, including staff in the
child welfare system, extended family, parents of friends, coaches, teachers, church
members, or family friends (Collins, Spencer, & Ward, 2010).
Mixed methods research on natural mentors The National Longitudinal Study of

Adolescent to Adult Health (known as Add Health) is an example of a nationally rep-
resentative study that has assessed the presence of natural mentors in young people’s
lives, finding that 58% of the general population and 47% of youth in foster care could
identify a natural mentor (Ahrens et al., 2008). Moreover, more than half (53%) of
LGBTQ youth (a population that overlaps considerably with youth in foster care) in
Add Health reported having a natural mentor (Drevon, Almazan, Jacob, & Rhymer,
2016). Importantly, youth with natural mentors have better health and education
outcomes in adulthood, such as fewer depression symptoms, decreased risk for sui-
cidal ideation, greater life satisfaction, and greater likelihood to finish high school
compared with youth without natural mentors (Ahrens et al., 2008; Drevon et al.,
2016; Munson & McMillen, 2009).
Qualitative studies among homeless youth, girls in foster care, and other vulnerable
adolescent populations have documented that natural mentors provide critical social
support for them, impacting socio‐emotional, cognitive, and identity development
(Ahrens et al., 2011; Dang & Miller, 2013; Greeson & Bowen, 2008; Munson,
Smalling, Spencer, Scott, & Tracy, 2010). It is also possible that youth who are able
to identify natural mentors have greater social capital or other resources and supports
to be able to connect with important adults in their lives. In other words, the same
protective factors that enable youth to identify natural mentors may be those related
to positive health outcomes in this population. Understanding the processes of how
these natural mentor relationships emerge may help to elucidate an untapped inter-
vention strategy. Regardless of the mechanisms, the mounting evidence regarding the
benefits of natural mentors for youth is compelling and again calls into question the
more traditional definition of family, especially when working with marginalized
youth.
Recommendations for Redefining Family

from a Multidisciplinary Perspective
Systemic family therapy and public health disciplines share common characteristics
that make multidisciplinary work more than possible, but ideal. While public health
considers population‐level trends in health and well‐being, social epidemiology places
individuals in context, recognizing the overlapping systems that drive such patterns.
Importantly, both systemic family therapy and social epidemiology understand and
prioritize the importance of relationships on people’s well‐being. Moreover, systemic
family therapy and more traditional epidemiology have struggled to move beyond
traditional definitions of what “family” should look like and see the functionality of
relationships in varying contexts that may fall outside these structural constraints. In
order for systemic family therapy to improve client functioning by modifying interac-
tional patterns, we must first start with a realistic understanding of how the client’s
relational systems are constructed.
Research in the field of social epidemiology and with marginalized populations, in
particular, may help therapists understand how families are created, defined, and expe-
rienced in the context of changing demographic patterns and social norms. These find-
ings may spur changes in how we ask about “family” in the therapy room. Do we even
use the word “family?” Do we ask about our clients’ “support systems” or “important
relationships?” Social epidemiological research demonstrates that social support, regard-
less of a biological connection, fosters well‐being (Ahrens et al., 2008). Systemic family
therapists may consider asking clients to draw personal network maps as described by
Sluzki (2010) to help identify important connections. The exercise begins by asking
clients to name intimate connections (e.g., “people ‘close to our heart’ with whom we
can share intimacy or rely on without question” (p. 9)). They next draw an intermediate
circle of social connections without a high degree of intimacy. Finally, an external circle
is built with acquaintances (Sluzki, 2010). Importantly, this exercise allows the client
and the therapist to identify whether the intimate connections comprise biological
families, chosen families, natural mentors, or others, rather than assuming a client’s
innermost circle is solely connections by marriage, blood, or adoption.
For some systemic family therapists, the experiences of marginalized communities
may not reflect the clients they see in their practice if their clients have largely met
legal or biological definitions of family. Many marginalized communities, including
LGBTQ communities, system‐involved communities, and racial/ethnic minority
populations, may not be able to access care or do not seek care because of past experi-
ences of discrimination or the receipt of inappropriate care in the clinical setting
(Benson, 2013; Burgess, Ding, Hargreaves, van Ryn, & Phelan, 2008). Therefore, if
we shift our practice to be more inclusive of a range of family structures and functions,
will we open doors for marginalized communities to feel safe seeking systemic family
therapy? Given demographic shifts globally, multidisciplinary collaborations in
research and practice will be necessary to address the changing needs of our clients.
Querying how we, as researchers and therapists, conceptualize family will be a critical
component of this shift.
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5
Systems Theory and Methodology
Advancing the Science of Systemic
Family Therapy
Andrea K. Wittenborn, Niyousha Hosseinichimeh,
Jennifer L. Rick, and Chi‐Fang Tseng
General systems theory (GST) is a well‐established conceptual framework for under-

standing complex issues. The origins of GST are credited to mathematicians, engi-
neers, physicists, and biologists in the late 1940s and 1950s (Bertalanffy, 1968).
Scholars in diverse disciplines, including systemic family therapy, have continued to
use and expand the theory over time. The underlying premise of GST is that a system
is a unified whole formed by interrelated parts in which a change in one part of the
system affects the rest of the system. As a result, GST encourages a focus on the rela-
tionship between parts of a system in addition to each part that comprises a system.
Resembling current critiques of the scientific community, Bertalanffy (1968)
described his motivation for introducing GST as follows:
Modern science is characterized by its ever‐increasing specialization, necessitated by the

enormous amount of data, the complexity of techniques and of theoretical structures
within every field. Thus science is split into innumerable disciplines continually generat-
ing new subdisciplines. In consequence, the physicist, the biologist, the psychologist and
the social scientist are, so to speak, encapsulated in their private universes, and it is diffi-
cult to get word from one cocoon to the other. (p. 30)
In addition to offering a theoretical framework, scholars proposed that a transdiscipli-

nary field of systems thinkers would offer a stimulating environment for systems
scholars with expertise across traditional disciplinary lines to solve the world’s most
complex problems (Ackoff, 1994). While systems thinking is not commonly viewed
as a distinct discipline today, scholars across nearly every discipline have applied the
theory to a wide range of problems such as couple therapy, depression, obesity, anti-
biotic resistance, and cybersecurity, among others. GST has also informed more
sophisticated methodological approaches to examining complex systems. Methods
such as system dynamics (SD), for example, are capable of addressing phenomena
with interdependencies, nonlinearities, and time‐varying relationships.
98 Andrea K. Wittenborn et al.
In this chapter, we will first define a system. We will then describe the main tenets
of GST and discuss the complementary theory called cybernetics. Next, we will
describe the history of GST and cybernetics in the field of systemic family therapy,
including modern extensions of the theory. We then provide a definition of systemic
therapy—a term that is used in a variety of ways in the literature—and describe appli-
cations of GST to family therapy. We then shift the focus to systems methods. For
decades, the sophistication of systems theory made it challenging to study empirically,
and systems were often reduced to linear relationships to fit available statistical tech-
niques. However, advanced statistical approaches now make it possible to estimate
systemic relationships. Our chapter will, therefore, include a description of such
approaches, including the simulation method of SD. We will then discuss an applica-
tion of SD relevant to systemic family therapy.
What Is a System?
Before we discuss GST in more detail, it is important to have a shared understanding

of the definition of a system. A system is defined as a set of elements that are intercon-
nected (e.g., family members, cells, atoms) and designed to serve a purpose (Meadows,
2009). Thus, a system must include three features: elements, interconnections, and
purpose. A system may consist of living or nonliving things, though in systemic family
therapy we typically focus our attention on family systems and the systems in which
families are embedded (e.g., school, work, neighborhood). It is important to consider
all three parts of a system when trying to understand its behavior. In other words, the
elements are not the only contributors to a system—the interconnections and shared
purpose play a prominent role as well. Hence, family therapists’ objection to focusing
sole attention on an individual or “identified patient.” Each part of a system is con-
nected to multiple other parts, and the relationships between parts occur in many
directions simultaneously. While it is logical to approach relationships between parts
of a system as linear (i.e., a relationship in which one element corresponds with con-
stant change in another element), nonlinear relationships (i.e., relationships between
two elements in which a change in one does not correspond to a constant change in
the other) are inherent in systems.
It is also important to remember that a system may be affected by outside forces
(Meadows, 2009). Health‐care policy can have a direct effect on the resources avail-
able to care for an ill family member, which can affect the individual’s prognosis and
the quality of life of the remaining family members. Systems can also be nested within
other systems, meaning there can also be purposes within purposes. The purpose of
each nested system may work in harmony or be in conflict. For example, the goals of
Latin American families seeking asylum in the US have recently been in conflict with
the goals of current US immigration policy—a conflict among systems that has
resulted in a human rights crisis of detaining unaccompanied minors and forcibly
separating parents and children (Ataiants et al., 2018).
Systemic therapists are often concerned with change within a system. Interventions
designed to change the behavior of a system can be directed to the elements, inter-
relationships, or purposes (Johnston, Matteson, & Finegood, 2014). Change at the
level of the elements, or individual family members, is a logical and easy place to
Systems Theory and Methodology 99
begin; however, it tends to make less of an overall impact. Changing the purpose of a
system is the most effective approach, yet it is the most difficult to implement. Systemic
family therapists often leverage change in the system by using interventions designed
to target interconnections or change the relationships among family members.
Understanding Systems: General Systems Theory (GST)

and Cybernetics
GST, introduced by biologist Ludwig von Bertalanffy (1968), and cybernetics, intro-
duced by mathematician Norbert Wiener (1961), offer a way to conceptualize sys-
tems and underlie many of the theories and models of therapy that form the foundation
of systemic family therapy (Carr, 2016). Indeed, the field itself is predicated on the
then‐revolutionary paradigmatic shift, fueled in part by GST and cybernetics, from an
individual framework for understanding the human world to a relational one (Carr,
2016; Hecker, Mims, & Boughner, 2015). Any comprehensive understanding of sys-
temic therapy must therefore include an examination of GST and cybernetics.
Systemic family therapy constituted a significant paradigm shift from the more indi-
vidually focused models of psychotherapy, such as psychoanalysis, that preceded it.
Many of the preceding models were reductive in nature. Reductionism posits that a
phenomenon may be understood by reducing it to its constituent parts and then
studying those parts (Hecker et al., 2015). This can work quite well for simple sys-
tems. Consider a ballpoint pen. If you break it down into its various parts (e.g., plastic
casing, ink, ink holder, metal ball, and cap) and examine those parts carefully, you will
end up with a relatively thorough understanding of what a ballpoint pen is and how
it works. However, this same procedure is insufficient for understanding more com-
plex systems, such as a couple or parent–child dyad. Even if you felt you had a com-
plete understanding of each individual member of a dyad or family, truly comprehending
the family as a whole—how they relate to one another, how they function together,
and the rules that govern their behaviors—would remain out of reach. The family
cannot be simplified into merely a collection of individual members. It is this quan-
dary that GST and cybernetics sought to resolve.
General systems theory

Bertalanffy described GST as a “general science of wholeness” (Bertalanffy, 1968, p.
37). In GST, a system is understood as a group of interdependent parts that function
together toward a goal (Bertalanffy, 1968), and it is, in part, the importance of how
the system is organized that sets this theory apart from the more classical reduction-
ism that came before it (Bertalanffy, 1972). With this definition in mind, it is easy to
see how GST may be applied to the living systems of Bertalanffy’s own field of biol-
ogy, as well as the physical systems of mechanics and the social systems. Indeed,
Bertalanffy himself conceived of his theory as a way to unify diverse sciences under
one framework (Caws, 2015).
One of the primary tenets of GST is that a system cannot be understood by simply
studying its individual parts. Rather, any understanding must include an examination
of the interactions between these parts. As Bertalanffy (1972) states, “in order to
understand an organized whole we must know both the parts and the relations
between them” (p. 411). This tenet is often described colloquially as “the whole is
greater than the sum of its parts.” As applied to systemic family therapy, a family sys-
tem is more than just its individual members. It is also the interactions and relation-
ships between these members. Without considering these relationships, a complete
understanding of the system is impossible.
GST also laid the groundwork for classifying systems as either open or closed. A
closed system is one that does not interact with its environment in any way—it is
entirely self‐contained. Consider a perpetual motion machine that, once set off,
requires no additional input to maintain a continuous motion. In contrast, an open
system is one that more freely interacts with its environment by exchanging informa-
tion and resources (Kossmann & Bullrich, 1997). Bertalanffy (1972) saw all living
systems as open systems. A family system might be seen to interact with its environ-
ment on a host of variables including socioeconomic status, geographic location, or
religious affiliation.
Another important tenet of GST is that all the parts of a system are necessarily
interdependent (P. Minuchin, 1985). All parts are continually affecting and being
affected by all other parts. A change to one element within the system impacts all
other elements. One example of this in a family system is when a child graduates from
high school and moves away to college. The child experiences changes in gaining
more independence and responsibility, but the parents also experience substantial
change as they adjust to their “empty nest.” The child’s change ripples out to impact
the parents and the parents’ reactions, in turn, will impact the child.
It is this interdependence that leads into another significant epistemological
shift: the shift from linear causality to circular causality. In linear causality, A causes
B, whereas circular causality states that A causes B and B causes A (P. Minuchin,
1985). Linear thinking conceptualizes interactions as discrete, contained events
such as a husband withdrawing to his office because he wants to avoid criticism
from his wife. Circular thinking places this interaction in context. While the hus-
band does go to the office to be removed from his wife (A causes B), the wife has
been critical because he frequently works long hours and rarely spends time with
the family (B causes A). Linear causality harkens back to the oversimplification of
reductionism, while the reciprocal and recursive nature of circular patterns of
interaction (Hecker et al., 2015) acknowledges the full complexity present in liv-
ing systems.
Cybernetics
Circular causality is one example of a feedback loop within a system because A’s out-
put becomes B’s input and vice versa. Cybernetics provides an important companion
to GST as it endeavors to discover how systems use feedback loops. The theory that
is now known as cybernetics was developed by Norbert Wiener during World War II,
initially as a way for the Allies to destroy Nazi bombers (Galison, 1994). Wiener
studied feedback loops to help Allied antiaircraft gunners predict the position of
enemy planes. After the war, he came to see feedback as a way to understand more
than just enemy flight paths. From there, it grew into “the investigation of self‐regu-
lating feedback processes in complex systems” and came to be known as cybernetics
(Carr, 2016, p. 14).
Feedback loops within a system can be described as either positive or negative.

Despite the terms, these do not refer to a value judgment of good or bad. Rather,
positive feedback loops encourage change in the system, while negative feedback
loops discourage change (Meadows, 2009). Regardless of the connotations associated
with positive and negative feedback loops, each of these may be considered good or
bad based on the specific circumstances present in the system. Negative feedback, that
is, feedback that inhibits change, is said to promote homeostasis. Homeostasis refers
to the tendency of a system to maintain constancy within some set of parameters.
Imagine a thermostat set to 72°. It can tolerate a fluctuation of 1° in either direction,
but once the temperature rises above 73° or below 71°, the heating or cooling system
is switched on (negative feedback) in order to bring the system back to a homeostatic
state of 72°. In this way, the system can maintain relative stability. Similarly, if a victim
of intimate partner violence becomes more critical of her partner’s behavior, her part-
ner could become more violent in an attempt to regain power and control in the
relationship. The increased violence may cause the victim to become less critical,
returning the dyad to homeostasis.
Gregory Bateson and the Palo Alto Group

Bertalanffy (1972) recognized the connection between GST and cybernetics, but it
was Gregory Bateson who truly combined the two theories and envisioned how they
might be applied to systemic family therapy (Carr, 2016). Bateson was an anthro-
pologist, and, though he was never a clinician, his influence on the field is hard to
overstate. In the 1950s, in Palo Alto, California, he formed a research team including
Don Jackson, Jay Haley, and John Weakland, among others, which became known
as the Palo Alto Group and which, later, established the Mental Research Institute
(Ray & Simms, 2016). Bateson and his team synthesized GST and cybernetics, along
with Bertrand Russell’s theory of logical types and Milton Erickson’s work with
trance and paradox, into a unified theory of human communication (Bateson,
Jackson, Haley, & Weakland, 1956; Ray & Simms, 2016). If, as posited by GST, a
family system can only be understood by accounting for the individual members as
well as the interactional relationships between them, then communication is the
expression of those relationships.
It is important to note that, for Bateson, communication does not refer only to
what is said verbally, though this is certainly important. Communication also com-
prises all manners of nonverbal expressions including body position, gestures, and
facial expressions. A sullen teenager who crosses her arms, lowers her eyes, and turns
away from the family is just as much a participant in family communication as her
young brother who boisterously recounts the events of his day.
An overarching theme throughout the work of the Palo Alto Group is the assertion
that all behavior—and all communication—makes sense once the context is fully
understood (Ray & Simms, 2016). This is a marked difference from the individual
pathological framework that preceded it where a patient’s behavior was seen as a
problem to be fixed. For the Palo Alto Group, the patient’s behavior is but one com-
ponent to be investigated within the constellation of all other interrelated compo-
nents. If the entire constellation can be elucidated, then the behavior, which at first
seemed incongruous, will now make sense. If the behavior is to be altered, it will have
to be done within the context of an entire system, by shifting the thoughts or behav-
iors of individuals within the system, relationships within the system, or the shared
goals of the system.
When considering how best to study family systems, Don Jackson (1965) identified
various observable truths that must be accounted for. Among these are the concepts
of equifinality and equipotentiality. Equifinality refers to the fact that the same end
state may result from various different interactional causes. For example, a child whose
mother punished him for making noise and a child whose mother was often ill and
resting may both develop into quiet and withdrawn adolescents. Equipotentiality is
the ability of the same interactional cause to lead to different end states. If there are
two children both punished by their parents for making noise, one may develop as
quiet and meek, while the other may become rebellious and loud. Jackson (1965)
asserts that the systems concept of circular, rather than linear, causality considerably
aids the study of family systems.
Extensions of general systems theory

Modern scholars have offered a number of extensions to GST since it was first intro-
duced. While an exhaustive review of theoretical extensions of GST is beyond the
scope of this chapter, we will describe several that are particularly relevant to systemic
family therapists. Those extensions relate to hierarchy, historical time, and personal
choice. Each of the three areas of extension have some relation to power—a concept
upon which members of the Palo Alto Group disagreed. The concepts of historical
time and choice were proposed more recently to better understand the effects that
socially constructed identities such as race and racism have on families (James, Coard,
Fine, & Rudy, 2018).
The concept of hierarchy was an area of debate among early systems thinkers
(Bateson, 1976). Bateson in particular disagreed with the idea that hierarchy existed
within systems, especially as it related to power. Today, most scholars agree
that hierarchies occur within systems and subsystems (Meadows, 2009). Indeed,
self‐organizing systems frequently form hierarchies. For example, a cell organizes
into an organ and then an organism; an individual forms a romantic partnership and
has children. Systems that are stable and efficient are those in which the subsystems
regulate themselves and serve the needs of the larger system, while the larger system
coordinates and enhances the functioning of the subsystems (Meadows, 2009).
Thus, in functional systems, the welfare, freedoms, and responsibilities of the
subsystems and system as a whole remain in balance. Systems can become inefficient
or unstable when a subsystem’s goals are sought at the expense of the system as
a whole.
Family therapists have long described the importance of assessing and maintain-
ing appropriate hierarchy within families and have used interventions to restruc-
ture hierarchy in families as a method of reducing symptoms of conflict and mental
illness (S. Minuchin, 1974). A child may be assuming responsibilities designated to
the parental subsystem, and the child may be relieved of those responsibilities dur-
ing the process of therapy. The impact of race and racism on the social locations of
family systems may be one of the most distinctive present‐day examples of a self‐
organizing system generating hierarchy. As is common in racialized societies such
as the US, racial hierarchies often exist within geographic, workplace, school, and
even family systems (James et al., 2018). Gender is another socially constructed
characteristic that affects hierarchical and power differences in family and work-
place systems, among others.
Recently, James and colleagues (2018) proposed to extend GST by including the
concept of historical time. They argue that while GST is a useful method for under-
standing the dynamics of a phenomenon over time, the historical contextualization
of time as it relates to a system is not well understood through the lens of GST. In
order to understand change in a system, it is necessary to recognize that the system
is embedded in its own historical experiences related to the family and broader
society. James et al. (2018) also proposed to extend GST by incorporating the
concept of personal choice. Here they argue for the importance of considering
whether families had a choice in their formation or interactions both within the
family and with external systems. This proposal is in direct contrast to earlier schol-
ars who indicate that systems are self‐organizing, and order emerges from the
interactions of the elements of a system (Thelen & Smith, 1998), and instead aligns
GST with racial socialization and disparities literature that explains how racial iden-
tities are formed under conditions that were not chosen (Omi & Winant, 2014).
The extension also has clear relevance to multiple generation households, stepfami-
lies, and arranged marriages. A systemic family therapist would assess and intervene
differently with a couple partnered by choice as compared with a couple who first
met on the day of their wedding.
What Is Systemic Family Therapy?
The definition of systemic family therapy has not yet been resolved in the literature.
Some scholars have argued that all models of couple and family therapy are systemic
because they recognize the inherent interconnections among individuals in a family
(e.g., Carr, 2009; Guttman, 1991), while others have argued that systemic family
therapy must contain important theoretical assumptions of GST (Pinquart, Oslejsek,
& Teubert, 2016; Sydow, Beher, Schwitzer, & Retzlaff, 2010). We suggest a defini-
tion of systemic family therapy that derives from Meadows (2009) description of a
system and the methods she and Johnston et al. (2014) suggest for altering the behav-
ior of a system. In this case, we define systemic family therapy as an approach designed
to change the behavior of a system by leveraging change within a system’s parts,
relationships among a system’s parts, and/or the purpose of a system, with considera-
tion of influences from external and internal subsystems. Such a definition implies that
systemic therapy could be conducted with individuals, couples, families, groups, or
multiple couple or family groups. It also suggests that as long as the primary goal of
the intervention is to change the behavior of the family system, the intervention target
may be an individual family member’s symptoms the quality of relationships among
family members, and/or the functional relationship between a family and an outside
system (e.g., school, community).
Our definition of systemic family therapy is similar to the one offered by Sydow and
colleagues (2010). They suggest that systemic therapy is not synonymous with couple
and family therapy. They argue that some couple and family therapies are not approached
from a systemic theoretical orientation (e.g., psychodynamic and cognitive behavioral)
and that systemically oriented therapy can be conducted with individuals, groups, or
multiple family groups. They define systemic therapy as follows:
…a form of psychotherapy that conceives behavior and especially mental symptoms

within the context of the social systems people live in, focusing on interpersonal relations
and interactions, social constructions of realities, and the recursive causality between
symptoms and interactions. (p. 459)
We agree with Sydow et al. (2010) and others (e.g., Pinquart et al., 2016) that sys-
temic therapy should refer to models based on the theoretical underpinnings of sys-
tems theory as opposed to being based on who attends treatment sessions (e.g.,
individuals, couples, and families). We note, however, that graduate‐level curriculum
in the discipline of couple and family therapy in the US has historically focused more
on models of systemic therapy for couples and families. Exceptions of systemic models
for individuals taught in some US graduate programs include Bowen family systems
and internal family systems. Systemic approaches to intervening with individuals is an
underdeveloped area in need of further clinical research. Such research is needed
before graduate programs can effectively enhance evidence‐based training for sys-
temic therapy with individuals.
Early models of systemic family therapy

In the 1950s and 1960s, novel theoretical approaches such as structural, strategic, and
intergenerational, among others, were developed. The systemic interventions were in
stark contrast to the psychoanalytic interventions that were common at that time. The
interventions and their connection to tenets of GST are described below.
Structural family therapy In the 1960s, Salvador Minuchin, the developer of struc-
tural family therapy, identified the importance of including social and familial contexts
into therapy after he worked in New York’s inner‐city ghettos, where most of the
children suffered from poverty. Born out of his work with low‐income families, struc-
tural family therapists focus on problem solving and are behaviorally oriented
(Guttman, 1991). The ultimate goal in structural family therapy is to ensure the fam-
ily structure benefits the entire family (S. Minuchin, 1974). This goal is achieved by
revising dysfunctional hierarchies and developing healthy boundaries between family
subsystems (S. Minuchin, 1974; S. Minuchin & Fishman, 1981). The restructuring
of the family system leads to a change in interactional patterns within the family,
which in turn affects how individuals relate to one another.
Strategic family therapy Influenced largely by his work at the MRI and by the work of
Milton Erickson, Jay Haley was influential in developing the strategic approach (Haley,
1973). The goal of strategic family therapy is to interrupt the covert hierarchical struc-
ture and alliance by identifying and challenging the parental hierarchy and cross‐genera-
tional coalitions (Haley, 1976). By assessing the cycle of family interactions, strategic
family therapists focus on present interactions and then break the interaction cycle
through paradoxical directives (Haley, 1976; Madanes, 1981). The process of prevent-
ing unhealthy sequences of repeated behaviors and actions allows the individual or fam-
ily to grow and proceed to the next stage of family life (Haley, 1973; Madanes, 1981).
Systemic family therapy Similar to strategic family therapy, systemic family therapy,
developed by the Milan group including Mara Selvini Palazzoli, Luigi Boscolo,
Gianfranco Cecchin, and Giuliana Prata, was influenced by the work of Gregory
Bateson. The Milan team asserted that individual symptoms were maintained by fam-
ily homeostasis (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1978). “Game” is often
used as a metaphor to conceptualize problematic family interactions (Selvini Palazzoli,
Cirillo, Selvini, & Sorrentino, 1989, p. 152). The goal of therapy is to maintain family
survival by allowing the family to learn to accommodate new information by “playing
a different game” (Selvini Palazzoli et al., 1989, p. 248). Hypothesizing, circular
questioning, neutrality, and invariant prescription are considered key interventions to
provide new meanings and possible solutions to the problem (Selvini Palazzoli et al.,
1989; Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1980).
Bowen family therapy During his experience working with schizophrenic family
members in psychiatric wards, Bowen began to recognize the importance of parent–
child relationships (Bowen, 1960). He also viewed families as emotional units and
emphasized the influence of the family of origin, proposing that problems were main-
tained over intergenerational patterns (Kerr & Bowen, 1988; McGoldrick, Gerson, &
Shellenberger, 1999). One key concept in Bowen family therapy is the differentiation
of self, an ongoing process of balancing between togetherness and individuality
through the external and internal processes of self‐definition and self‐regulation
(Friedman, 1991). Triangles are also an important concept and are often seen in fami-
lies when a third individual is involved to stabilize the anxiety between two other
family members (Kerr & Bowen, 1988). Goals of Bowen family therapy include
decreasing anxiety among family members and increasing differentiation in one or
more family members (Kerr & Bowen, 1988).
Modern systemic family therapy

The number of systemic family therapy models has grown exponentially since early
models were first introduced, and models have now been developed for a wide range
of problems and populations. In the 1980s and 1990s, models of couple therapy
emerged including emotionally focused therapy (Johnson & Wittenborn, 2012;
Wittenborn et al., 2018) and behavioral approaches like integrative behavioral cou-
ple therapy (Christensen, Atkins, Yi, Baucom, & George, 2006). Examples of evi-
dence‐based family approaches include brief strategic family therapy (Szapocznik,
Muir, Duff, Schwartz, & Brown, 2015), attachment‐based family therapy (Diamond,
Russon, & Levy, 2016), multidimensional family therapy (Liddle, 2016), functional
family therapy (Gottfredson et al., 2018), and multisystemic family therapy
(Henggeler, Clingempeel, Brondino, & Pickrel, 2002). As new approaches have
been developed, they have often been scrutinized for being more linear in perspec-
tive and, in turn, appearing less consistent with systems theory. For example, scholars
debated whether cognitive and behavioral approaches for couples and families were
consistent with GST (Dattilio, 2001). Others have suggested that approaches for
couples and families have drifted away from GST and theory development has not
kept pace with intervention research. Although concerns about the theoretical foun-
dation of systemic family therapy have emerged, meta‐analytic evidence supports the
use of systemic family therapy.
The effectiveness of systemic therapy for adults and children is well established
(e.g., Sprenkle, 2012). Empirical studies of systemic therapy, typically defined as all
couple and family therapy, have been examined in a series of meta‐analyses and
reviewed in special decade review issues of the Journal of Marital and Family Therapy
(Shadish & Baldwin, 2003; Sprenkle, 2012). In 2003, a meta‐analysis of couple and
family interventions for a variety of presenting problems and populations was pub-
lished (Shadish & Baldwin, 2003) and provided further support for systemic family
therapy. Findings showed that the average family was better off than 71% of families
in control conditions at termination and follow‐up. In Pinquart et al. (2016), a meta‐
analysis of systemic family therapy, defined as therapeutic approaches informed by a
systemic theoretical orientation regardless of who is in the room, provided further
support. Findings showed that systemic family therapy has a medium effect size and
lower dropout rates than alternative treatments.
Methodological Advances in the Study of Systems
While GST has informed scholars’ understanding of families and family therapy for
decades, systems were often reduced to linear relationships in research due to a lack of
sophistication in quantifying nonlinear models. These models often have intractable
likelihood functions and their parameters cannot be estimated using conventional
estimation techniques. However, systems science methods now offer a valuable way to
examine complex systems. Advances in mathematical modeling, computational tools,
informatics, image processing, and communication tools have led to successful imple-
mentation of policies that have changed population behaviors and improved health
(Mabry, Olster, Morgan, & Abrams, 2008). Health researchers are increasingly inter-
ested in analytical frameworks that capture multilevel causal networks and social fac-
tors (Anderson & Armstead, 1995; Birckmayer, Holder, Yacoubian, & Friend, 2004;
Candib, 2007; Diez‐Roux, 2000; Glass & McAtee, 2006; Koopman & Weed, 1990;
Krieger, 2001), include multiple outcomes concurrently (Jones et al., 2006), allow
the use of different qualitative and quantitative data sources (Best, Hiatt, & Norman,
2007), and capture delays, nonlinearities, and complex feedback mechanisms
(Sterman, 2006). Simulation‐based systems modeling, such as SD, provides a promis-
ing framework to address the interdependent, time‐varying complexities of many
health problems (Brennan, Chick, & Davies, 2006; Homer & Hirsch, 2006). For
instance, the SD approach has been effectively used to support decision making for
the global eradication of polio, which led to worldwide resolutions that reduced the
response time and size of polio outbreaks (Thompson, Duintjer Tebbens, Pallansch,
Wassilak, & Cochi, 2015). The polio model includes multiple immunity states for dif-
ferent age groups, captures feedback processes, and uses multiple data sources.
Another example is the ReThink Health Dynamics Model, which simulates changes
in population health, health‐care delivery and costs, workforce productivity, and
health equity (Homer, 2016). It is used to test various scenarios in order to improve
the health of communities at the lowest costs.
Systems models integrate into a single quantitative and testable framework the key
social, environmental, behavioral, and biological factors of interest to scholars and
clinicians. They are, therefore, broad in scope (e.g., include multiple sectors or types
of mechanisms) and include time delays (e.g., delays between changes in mental
health and employment), nonlinearities (e.g., saturation effects and tipping points),
and behavioral feedback loops—describing, for example, social contagion or reactions
to adverse events—not easy to include in typical statistical models.
Advantages of systems models

Systems models offer several distinct advantages over more reductionist methods.
First, their detailed representation of relevant mechanisms at the level of the individ-
ual can make these models valuable for designing personalized treatments. For exam-
ple, in an investigation of treatment for chronic kidney disease, Rogers and colleagues
(2011) use a systems model to schedule the administration of erythropoiesis‐stimulat-
ing agents for hemodialysis patients, improving patient stability by 40%, reducing
drug costs by 35%, and lowering health‐care resources (e.g., staff time) by 50%.
Second, systems models are required for policy analysis, where the interactions
among multiple factors must be considered to limit the likelihood of unintended
negative consequences resulting from policy change. For example, current policies
for outbreak response in the case of epidemics is heavily dependent on broad
boundary and dynamically complex systems models that combine the epidemiol-
ogy of infectious diseases with interactions among population members, their
movement and work routines, different interventions (e.g., vaccination, quaran-
tine, and school closure), and the behavioral responses of people to perceived risks
of infection (Eubank et al., 2004; Ferguson et al., 2005; Germann, Kadau,
Longini, & Macken, 2006; Keeling et al., 2001; Rahmandad, Hu, Tebbens, &
Thompson, 2011).
Third, systems models can include interactions among qualitative and quantita-
tive factors, often not integrated in the same mathematical representation. For
example, Hovmand and Ford (2009) used an SD model with multiple qualitative
components to understand the effects of the timing and sequence of three inter-
ventions for domestic violence on community outcomes. A fourth benefit of these
models is their value in identifying potential data shortages and prioritizing data
collection. For example, Hall and his colleagues have used detailed models of
human metabolism and weight gain and loss (Hall, 2010, 2012) to design new
experiments that tease out the impact of macronutrient composition on weight
change and body composition.
Fifth, systems modeling allows researchers to identify gaps in the literature
regarding the core mechanisms that should be better understood to enable the
development of a fully reliable systems model. For example, in developing child-
hood obesity systems models, Rahmandad and Sabounchi (2012) found gaps in
the literature regarding the exact equation describing the age dependence of the
basal metabolic rate in children. This led to a comprehensive review of the litera-
ture to extract the missing relationships from a synthesis of over 40 statistical stud-
ies (Sabounchi, Rahmandad, & Ammerman, 2013). Sixth, systems approaches
provide the opportunity to engage key stakeholders in the process of model devel-
opment and validation (Hosseinichimeh et al., 2017). Specifically, SD group model
building incorporates inputs from policy makers and subject matter experts and
assists in taking into account key actor behaviors that influence a model’s formula-
tion and outcomes.
System dynamics
SD is a method for understanding the structure and analyzing the dynamics of com-
plex systems (Sterman, 2006). Dynamic complexities arise from interactions between
elements of a system (e.g., feedback loops) and accumulations (e.g., people, materials,
or information). The importance of feedback loops and accumulations has been
acknowledged for centuries; however, until the mid‐1950s, there was no method for
quantifying these concepts. Jay Forrester at Massachusetts Institute of Technology
developed the first computational tools for incorporating these concepts in a simula-
tion environment (Forrester, 1958, 1989). Mathematically, an SD model consists of
a set of ordinary differential equations that can be simulated to answer “what‐if”
questions (i.e., “what would happen if” an intervention or policy was implemented?).
In contrast to clinical trials, the use of a virtual environment in SD makes it possible
to simultaneously examine many treatments (e.g., the effect of one treatment can be
“erased” from a virtual patient before switching to another), moderators, and hetero-
geneous patient profiles. Figure 5.1 shows the contrast between traditional statistical
approaches and systems models.
A typical systems modeling project includes the following steps. First, the networks
of causal factors and feedback loops relevant to the problem are identified based on
available literature and qualitative and process data. Second, a dynamic model of bio-
logical, physical, social, cognitive, and behavioral processes that govern the intercon-
nected evolution of the relevant system components over time is built. In this step, we
develop composite variables that integrate findings and similar variables from previous
research into a single framework; this process is also informed by qualitative data
about key mechanisms. The third step involves parameterization of the model based
on all the empirical data available, including parameter estimates from the literature,
expert opinions, and statistical estimation using panel or cross‐sectional datasets. In
the fourth step, model validity is assessed using data not used in the parameterization.
This step, not common in typical statistical analysis, provides additional confidence in
the usefulness of the model in projecting relevant outcomes beyond the calibration
dataset. The final step involves analysis of the model to generate insights about the
most significant causal mechanisms and feedback loops and to design effective inter-
ventions and treatments.
X4
X4 Delay 1
X2 X5 X1 X2 X5
X3 Delay 2 X3
Figure 5.1 The graph highlights the key differences between statistical (left) and systems
(right) models. The causal relationships are shown with solid lines with arrows. Each relation-
ship between two variables can have a linear or nonlinear functional form with requisite param-
eters (not shown). Variables for which data are available are shown in full circles, partial data
availability is shown in dashed circles (X5 on the right), and lack of data is shown with no circle.
Illustrative Example of System Dynamics
In this section, we explain how we applied SD methodology to understand feedback

mechanisms underlying major depressive disorder to develop the first comprehensive
causal loop diagram of depression. The model focuses on the phenomenon of depres-
sion and includes social, environmental, cognitive, and biological mechanisms of dis-
order. The model diagram can be seen in Figure 5.2. We will also discuss the first steps
we have taken to quantify the model, focusing initially on two feedback loops identi-
fied in the first step and simulating it to examine the behavior of depression dynamics
among diverse patient profiles. The goal of this project is to provide a method for
personalizing care for depression based on differences in social, environmental, cogni-
tive, and biological subsystems.
Developing the first broad boundary conceptual model of depression

In order to develop the first causal loop diagram of depression, we first identified the
key mechanisms of disorder or drivers of depression and their relationships by using a
structured, iterative approach informed by a database of 594 articles and interviews
with a purposive sample of five subject matter experts (Wittenborn et al., 2016).
Drawing from the literature helped to comprehensively identify relevant factors, while
interviewing domain experts helped to connect evidence found in separate strands of
research, thus reconstituting the feedback loops in the system. This approach is fre-
quently used to identify feedback loops contributing to complex behaviors, particu-
larly in cases in which bodies of literature have remained separate and relationships
between parts of a system are less clear (Finegood, 2011; Giabbanelli, Torsney‐Weir,
& Mago, 2012). Following the literature review and interviews with domain experts,
we produced a model incorporating the biological, cognitive, social, and environmen-
tal reinforcing mechanisms of depression, including key inertial factors thought to
contribute to its development. We validated the model structure by coding videotapes
of therapeutic interventions for depression from existing data from a randomized
controlled trial (Wittenborn et al., 2018). The final systems model of depression
dynamics depicts relationships among nine major drivers of depression and demon-
strates 13 key reinforcing feedback loops (see Figure 5.2).
Quantifying feedback loops of the conceptual model

While conceptual models are useful, they become more useful in predicting behavior
when they are quantified. Developing a mathematical model as complex as the one
shown in Figure 5.2 requires an iterative approach. Such complex conceptual models
should be divided into multiple sectors and each sector should be quantified sepa-
rately; then all sectors can be reconnected and the performance of the whole model
should be validated. Thus, in the next step, we quantified two specific feedback loops
that capture the relations among rumination, stressful events, and depressive symp-
toms (see Figure 5.3) to examine the dynamics of depressive symptoms and assess
the potential impact of an intervention. First, we developed the structure of the loop
(see Figure 5.3) based on the theoretical and empirical literature (Michl, McLaughlin,
Shepherd, & Nolen‐Hoeksema, 2013; Nolen‐Hoeksema, Wisco, & Lyubomirsky,
Feedback
inhibition of HPA
+ +
Inhibitory effect of
glucocorticoid on
R8 R7
cytokine Effective GR
Exaggerated Elevated cortisol
– – response
immune response Early adverse
–
experiences
– Cortisol +
Cytokine +
+ –
–
+
Chronic medical Monoamines
illness +
–
Early adverse Brain regulatory
experiences Baised attention capacity + +
R13 + + and processing + + Neurodegeneration
Deteriorating Negative +
health + cognitive R1 Perceived stress
representations
Stress stimuli Consolidation of –
+ + –
– negative cognitive R2 Rumination
– – R6
representations + Hippocampal
Rumination
Financial stress + volume
Encoding of
negative thoughts + Negative affect,
Economic
interpretation, and R11 R10
status
processing
R3 Sleep
+ – Hippocampus
Cognitive deficit deprivation
+ – atrophy
R5 + +
R12 Sleep problem
Social isolation Dysfunctional R4 Deficiency of
Disease related working memory
behaviors
stress – Impaired
Interpersonal – – + +
working memory R9
relationship
quality + – Learning, reward
Impaired
processing, and
Cognitive – memory
memory
performance
– +
Physical – Physical
health inactivity
Figure 5.2 Conceptual system dynamics model of the biological, cognitive, social, and environmental feedback regulating depression.
Reprinted with permission from RightsLink/Cambridge University Press (Wittenborn, Rahmandad, Rick, & Hosseinichimeh, 2016).
Past stressors +
kept alive
Ongoing (PSKA) Let it go
stressor (LIG)
(OS)
–
R1
Memory time
Rumination (MT)
+
+ Gender (G)
Indicated + Rumination
rumination (IR) (R)
+
R2 +
Indicated
Symptom
depressive
exacerbation
symtoms (IDS)
Depressive +
Symtoms
(DS)
Figure 5.3 System dynamics model of rumination, stress, and depression. Boxes illustrate
stock (or state) variables and arrows with valves depict flows into/out of stocks. Single‐line
arrows indicate causal relationships among variables. A stock variable is the accumulation of the
difference between its inflows and outflows and is mathematically represented as an integral.
Source: Copyright: © 2018 Hosseinichimeh et al. Reproduced with permission of Plos.
2008). Specifically, we took into account that rumination contributes to depression

by keeping a stressor active (Ruscio et al., 2015) and that rumination and depression
reinforce each other (see Figure 5.3, loop R2). Second, we used previous studies to
operationalize the conceptual model (i.e., designed equations) by prioritizing varia-
bles and capturing their relationships based on their frequency and strength in the
literature. For instance, findings indicate that women are more likely to ruminate
after experiencing a stressful event. As a result, rumination was formulated as a linear
function of gender (Nolen‐Hoeksema, Larson, & Grayson, 1999), past stressors
kept active (Michl et al., 2013), and depressive symptoms (Nolen‐Hoeksema, Stice,
Wade, & Bohon, 2007). Third, using a dataset of 661 adolescents (McLaughlin &
Nolen‐Hoeksema, 2012), we calibrated the model and examined the validity of the
hypothesized pathway by estimating the significance of related parameters. It is
important to note that, in the absence of sufficient data points over time, calibration
could not be performed using a traditional SD protocol. Consequently, we intro-
duced a new c alibration method. This method, named “indirect inference,” is a sim-
ulation‐based estimation method that can be applied to complex models with
intractable likelihood function when available data have few assessments over time
for many units under analysis (Hosseinichimeh, Rahmandad, Jalali, & Wittenborn,
2016). To fully quantify the model shown in Figure 5.2, additional sectors of the
model are being calibrated (e.g., Hosseinichimeh, Rahmandad, & Wittenborn,
2015) and each sector will eventually be reconstituted, and the validity of the full
model will be assessed.
Using the model for testing and designing interventions

After developing a robust model of rumination, stressful events, and depressive
symptoms, we used it on heterogeneous patients to examine (a) the progression of
depressive symptoms and (b) the impact of a cognitive intervention on depressive
symptoms (sample simulations shown in Figure 5.4). Heterogeneous patient profiles
were created by distinguishing high and low values (e.g., mean ± 1 standard devia-
tion) of each free parameter in the model (e.g., rumination, stress), resulting in 32
unique patient profiles (male profiles not shown for brevity). We found that changes
in the initial value of prior stressors and rumination as well as current stressors gener-
ate diverse trends in depressive symptoms and highlight the importance of personal-
ized intervention.
As we proceed with quantifying the model of depression dynamics, an important
next step is to connect the cognitive mechanisms of depression to the social mecha-
nisms, including inertial factors such as marital discord. The iterative development of
the model builds confidence in the validity of the model, including its ability to simu-
late real‐world dynamics. Ultimately, a fully quantified comprehensive simulation
model of depression dynamics could act as a tool for developing personalized treat-
ment plans to help deliver the right treatment to the right person at the right time.
The processes explained above require specialized training that can be time con-
suming and challenging; however, complex problems require methods that are capa-
ble of handling their systemic complexities. Creating a multidisciplinary team with
diverse expertise in systemic family therapy, systems modeling, and statistics, among
other topics, is an important first step in the process. More information about SD can
be found in Meadows (2009) and Sterman (2000) and conferences such as the annual
meetings of the System Dynamics Society.
Conclusion
GST has had a long history in the natural and social sciences. GST promoted the
development of systemic family therapy and formed the foundation of early therapy
models. Modern scholars have helped to extend the theory in meaningful ways in
order to apply it to the understanding and examination of families. Moving forward,
it will be important for systemic family therapists to develop a clear identity. If the
identify is focused on systemic thinking as opposed to who is in the therapy room
(e.g., couples and families), we must consider the alignment of our existing interven-
tions with GST and the extension of interventions for patients seen individually.
Historically our theories have been more sophisticated than available empirical
approaches, yet systems science has developed further over the years and new estima-
tion methods make approaches such as SD valuable to understanding the immense
complexities of families, including issues of poor functioning and mental health within
High prior and ongoing High prior stressors but Low prior stressors but Low prior stressors but
stressors no ongoing stressors no ongoing stressors no ongoing stressors
High
depressive
symptoms
and
rumination
at T = 0
Group 1 Group 2 Group 3 Group 4
High
depressive
symptoms
but low
rumination
at T = 0
Low
depressive
symptoms
but high
rumination
at T = 0
Low
depressive
symptoms
and
rumination
at T = 0
Figure 5.4 Simulations of depressive symptoms for 16 female patient profiles illustrate the variability of response
to treatment between patients. Long‐dash‐dot = baseline; dashed line = include a stressful event at month 20; solid
line = stressful event at month 20 and cognitive intervention at month 30.
family systems. The participatory modeling approach often inherent in SD in which

clinicians, scholars, and other stakeholders develop models side by side in collabora-
tion is well aligned with systemic family therapy. The collaborative methodological
approach makes SD a valuable tool for bridging the long‐standing divide between
clinicians and scholars.
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6
Evidence for the Efficacy
and Effectiveness of Systemic
Family Therapy
Alan Carr
Since the 1970s, reviews and meta‐analyses of treatment outcome studies have con-
sistently and conclusively shown that systemic therapy was as effective as, or in some
cases more effective than, individual therapy in the short and long term in ameliorat-
ing mental health and relationship problems (e.g., Carr, 2018a, 2018b; Gurman &
Kniskern, 1978; Pinquart, Oslejsek, & Teubert, 2016; Riedinger, Pinquart, &
Teubert, 2017; Shadish & Baldwin, 2003). In Gurman & Kniskern, 1978, in the first
major narrative review of systemic therapy outcome research, Gurman and Kniskern
concluded that systemic therapy was an effective intervention for common mental
health and relationship problems. In an updated version of this review in 1986,
Gurman, Kniskern, and Pinsof showed how the evidence base for systemic therapy
had grown and supported the use of different types of systemic therapy for a number
of specific types of problems. Meta‐analyses provide a particularly important type of
evidence to support the effectiveness of systemic therapy because they statistically
synthesize the results of many outcome studies in a relatively unbiased way. The first
meta‐analyses of systemic therapy outcome studies appeared in the late 1980s and
early 1990s (Hazelrigg, Cooper, & Borduin, 1987; Markus, Lange, & Pettigrew,
1990) with the largest and most influential being published by Shadish et al. in
(1993). These showed conclusively that systemic therapy worked for a range of prob-
lems and was as effective as, or in some cases more effective than, individual therapy.
With the exponential growth in outcome research and meta‐analyses, from the mid‐
1990s, special issues of the Journal of Marital and Family Therapy were published in
the United States periodically summarizing research supporting systemic therapy
(Pinsof & Wynne, 1995; Sprenkle, 2002, 2012). From 2000 the Journal of Family
Therapy in the United Kingdom periodically published review papers summarizing
the evidence base for systemic therapy for child‐focused and adult‐focused problems
(Carr, 2000a, 2000b, 2009a, 2009b, 2014a, 2014b, 2018a, 2018b). In 2016 Lebow
edited a special issue of Family Process on empirically supported treatments in couple
120 Alan Carr
and family therapy. This brief history of major publications synthesizing the accumu-
lated evidence for systemic therapy points to one major conclusion. Compared with
waiting‐list control groups, systemic therapy yields medium to large posttreatment
effect sizes, between 0.5 and 0.8. This means that in round numbers, across all types
of common mental health and relationship problems about two out of three cases
improve with systemic therapy. This level of effectiveness is similar to that shown by
individual therapies for both child‐focused (Weisz et al., 2017) and adult‐focused
(Wampold & Imel, 2015) problems. The results of systematic reviews and meta‐
analyses that support the overall efficacy and effectiveness of systemic therapy have
important implications for service development policy. However, systemic therapists
require more specific research results to inform their practice. The remainder of this
chapter will address this issue. Evidence from systematic reviews and meta‐analyses of
studies of the efficacy of specific systemic interventions for specific problems will be
presented. The evidence will be considered under the headings of (a) child‐focused
problems, (b) adult‐focused problems, and (c) difficulties that may occur across the
life cycle in both children and adults.
Child‐Focused Problems
There is evidence for the effectiveness of systemic interventions for the following
child‐focused problems: attachment problems in infancy, aspects of child abuse, child-
hood disruptive behavior disorders, and adolescent eating disorders. All of these types
of problems occur within the context of problematic family relationships or may be
alleviated by the development of more supportive and functional family relationships.
Systemic therapy addresses these child‐focused difficulties by helping families develop
more supportive and functional relationships, and family problem‐solving routines,
roles, rituals, and narratives.
Childhood attachment problems

In a systematic review and meta‐analysis of 16 studies, Facompré, Bernard, and Waters
(2018) found that a range of systemic interventions were effective in reducing rates of
disorganized child–parent attachment in at‐risk families with infants under 4 years of
age. The mean effect size was 0.35, indicating that the average treated case fared bet-
ter than 64% of cases in control groups. Interventions covered in this meta‐analysis
and in a narrative review by Berlin, Zeanah, and Lieberman (2016) included Child–
Parent Psychotherapy (Lieberman & Van Horn, 2005), Attachment and Bio‐behav-
ioral Catch‐up (Dozier, Lindhiem, & Ackerman, 2005), Video‐feedback Intervention
to Promote Positive Parenting (Juffer, Bakermans‐Kranenburg, & van IJzendoorn,
2008), and Circle of Security (Powell, Cooper, Hoffman, & Marvin, 2014). Child–
Parent Psychotherapy involves weekly dyadic sessions with mothers and infants for
about a year. It helps mothers resolve ambivalent feelings about their infants by link-
ing these to their own adverse childhood experiences and current life stresses within
the context of a supportive long‐term therapeutic alliance. This intensive systemic
intervention is probably most appropriate for high‐risk families in which parents have
histories of childhood adversity and whose current families are characterized by high
Evidence for Efficacy and Effectiveness 121
levels of stress, low levels of support, and domestic violence or child abuse. Attachment
and Bio‐behavioral Catch‐up, Video‐feedback Intervention to Promote Positive
Parenting, and Circle of Security are less intensive interventions. In these three pro-
grams across 4–20 sessions, parents receive psychoeducation about attachment and
video feedback and coaching to improve child–parent interactions associated with
attachment security. Parents are also helped to develop strategies for avoiding replicat-
ing problematic family‐of‐origin parenting practices.
Physical child abuse and neglect

Systematic narrative reviews and meta‐analyses concur that for physical child abuse
and neglect, effective therapy is family based and structured, extends over periods of
at least 6 months, is often conducted on a home‐visiting basis, and addresses specific
problems in relevant subsystems including parenting skills deficits, children’s post-
traumatic adjustment problems, and the overall supportiveness of the family and social
network (Henggeler & Schaeffer, 2016; Kennedy, Kim, Tripodi, Brown, & Gowdy,
2016; Levey et al., 2017; Timmer & Urquiza, 2014; Vlahovicova, Melendez‐Torres,
Leijten, Knerr, & Gardner, 2017). Cognitive‐behavioral family therapy (Kolko &
Swenson, 2002; Rynyon & Deblinger, 2013), Parent–Child Interaction Therapy
(Kennedy et al., 2016; McNeil & Hembree‐Kigin, 2011), and multisystemic therapy
for child abuse and neglect (Henggeler & Schaeffer, 2016; Swenson & Schaeffer,
2014) are manualized approaches to family‐based treatment that have been shown in
randomized controlled trials to reduce the risk of further physical child abuse.
In a series of controlled trials, Kolko, Simonich, and Loiterstein (2014) found that
cognitive‐behavioral family therapy was more effective than routine services in reduc-
ing the risk of further abuse in families of school‐aged children and adolescents in
which physical abuse had occurred. The 16‐session Alternatives for Families program
involves helping parents and children develop skills for regulating angry emotions,
communicating and managing conflict, and developing alternatives to physical pun-
ishment as a disciplinary strategy (Kolko & Swenson, 2002). Separate sessions with
parents and children and conjoint family session are used to achieve these aims.
In a meta‐analysis of six controlled trials, Kennedy et al. (2016) found that Parent–
Child Interaction Therapy led to significantly fewer physical abuse recurrences and
greater reductions in parenting stress than routine services or other control condi-
tions for families in which physical abuse had occurred. The effect size was 0.52,
indicating that the average treated case fared better after therapy than 70% of cases in
control groups. Parent–Child Interaction Therapy involves conjoint parent–child ses-
sions in which parents are coached in how to engage in child‐directed interactions to
strengthen parent–child attachment and how to engage in parent‐directed interac-
tions to address oppositional behavior and prevent the development of conduct prob-
lems (McNeil & Hembree‐Kigin, 2011). Coaching is conducted from behind a
one‐way mirror and therapists communicate with parents through a “bug in the ear.”
Typically, therapy spans 14–16 sessions. For parents who are ambivalent about treat-
ment, additional preliminary sessions may be incorporated into the standard protocol
to enhance parents’ motivation to engage in therapy.
In a series of three studies, multisystemic therapy for child abuse and neglect has
been compared with alternative treatments for families where physical abuse or neglect
had occurred (Henggeler & Schaeffer, 2016). After treatment, families who received
122 Alan Carr
multisystemic therapy showed greater improvements in parenting, individual adjust-

ment, and family functioning and a lower rate of out‐of‐home placements. Therapists
designed intervention plans on a per‐case basis in light of family assessment; used
individual, couple, family and network meetings in these plans; received regular super-
vision to facilitate this process; and carried small caseloads of 4–6 families (Swenson &
Schaeffer, 2014).
Child sexual abuse

For child sexual abuse, trauma‐focused cognitive‐behavior therapy for both abused
young people and their non‐abusing parents has been shown to reduce symptoms of
posttraumatic stress disorder and improve overall adjustment (Deblinger, Mannarino,
& Cohen, 2015). In a systematic review of 33 trials, 27 of which evaluated trauma‐
focused cognitive‐behavior therapy, Leenarts, Diehle, Doreleijers, Jansma, and
Lindauer (2013) found that cases treated with this approach fared better than those
who received standard care. The results of this review suggest that trauma‐focused
cognitive‐behavior therapy is the best‐supported treatment for children following
childhood maltreatment. Trauma‐focused cognitive‐behavior therapy involves con-
current sessions for abused children and their non‐abusing parents, in group or indi-
vidual formats, with periodic conjoint parent–child sessions. Where intrafamilial
sexual abuse has occurred, it is essential that offenders live separately from victims
until they have completed a treatment program and been assessed as being at low risk
for re‐offending. The child‐focused component involves exposure to abuse‐related
memories to facilitate habituation to them, relaxation and coping skills training, learn-
ing assertiveness and safety skills, and addressing victimization, sexual development,
and identity issues. Concurrent work with non‐abusing parents and conjoint sessions
with abused children and non‐abusing parents focus on helping parents develop sup-
portive and protective relationships with their children and develop support networks
for themselves.
Child and adolescent disruptive behavior disorders

In a systematic review and meta‐analysis of 17 randomized controlled trials of chil-
dren and adolescents with disruptive behavior disorders, Bakker, Greven, Buitelaar,
and Glennon (2017) found that most studies evaluated systemic interventions, either
parent training or family therapy. Compared to the outcomes for alternative treat-
ments or waiting‐list control groups, systemic interventions led to small but signifi-
cant overall effect sizes. These ranged from 0.26 to 0.36, indicating that the average
treated case fared better than 60–64% of cases in control groups.
For families of preadolescent children with behavior problems, parent training pro-
grams have a particularly strong evidence base. Systematic reviews and meta‐analyses
support the effectiveness of a number of specific evidence‐based parent training pro-
grams including the Oregon model of Parent Management Training (Forgatch &
Kjøbli, 2016), Parent–Child Interaction Therapy (Ward, Theule, & Cheung, 2016),
the Incredible Years Program (Menting, de Castro, & Matthys, 2013), the Triple P
Positive Parenting Program (Sanders, Kirby, Tellegen, & Day, 2014), the Parents Plus
Program (Carr, Hartnett, Brosnan, & Sharry, 2017), and Kazdin’s (2017) Parent
Management Training and Social Problem Solving Skills Programs. In a meta‐analysis

of 77 studies, Kaminski, Valle, Filene, and Boyle (2008) found that active skills train-
ing, teaching parents skills to enhance parent–child relationships, and teaching skills
for managing antisocial behavior were the three components of parent training pro-
grams consistently associated with larger treatment effects.
For families of adolescents with conduct disorder, a number of empirically sup-
ported family therapy programs have been developed. In a meta‐analysis of 24 studies,
Baldwin, Christian, Berkeljon, Shadish, and Bean (2012) evaluated the effectiveness
of brief strategic family therapy (Horigian, Anderson, & Szapocznik, 2016), func-
tional family therapy (Robbins, Alexander, Turner, & Hollimon, 2016), multisys-
temic therapy (Henggeler & Schaeffer, 2016), and multidimensional family therapy
(Liddle, 2016) in the treatment of adolescent conduct disorders and substance mis-
use. They found that all four forms of family therapy were effective compared with
treatment as usual (d = 0.21) or alternative treatments (d = 0.26). In a meta‐analysis
of 28 studies of the same models of family therapy models, Dopp, Borduin, White II,
and Kuppens (2017) found that all of these types of systemic therapy were more effec-
tive than treatment as usual up to 2.5 years after therapy had ended (d = 0.24). The
results of the meta‐analyses by Baldwin et al. and Dopp et al. showed that the average
case treated with family therapy fared better than 58–59% of cases who engaged in
treatment as usual or alternative treatments in terms of a range of outcomes including
recidivism, antisocial behavior, drug use, scholastic achievement, family functioning,
and deviant peer group contact. The family therapy models evaluated in studies
included in the meta‐analyses by Baldwin et al. (2012) and Dopp et al. (2017) hold a
number of features in common. They are based on a systemic conceptualization of the
etiology of adolescent conduct problems and substance misuse. Treatment aims to
increase prosocial behavior and reduce deviant behavior by changing relational pat-
terns involving adolescents and members of their families, peer groups, and wider
social systems that maintain their difficulties. Treatment involves not only conjoint
family therapy sessions but also sessions with various subsystems of the family and
wider network, including adolescents, parents, school staff, and other involved profes-
sionals. Therapists carry relatively small caseloads, are supervised regularly, and match
the structure and intensity of therapy offered to case needs.
Adolescent eating disorders

A series of systematic reviews and meta‐analyses covering over a dozen trials and
implementation studies allow the following conclusions to be drawn about the effec-
tiveness of family therapy for anorexia nervosa in adolescents (Couturier, Kimber, &
Szatmari, 2013; Couturier & Kimber, 2015; Eisler, 2005, Jewell, Blessitt, Stewart,
Simic, & Eisler, 2016; Le Grange & Robin, 2017; Lock, 2015). After treatment,
between a half and two‐thirds of cases achieve a healthy weight. At 6 months to 6 years
follow‐up, 60–90% have fully recovered and no more than 10–15% are seriously ill. In
the long term, the negligible relapse rate following family therapy is superior to the
moderate outcomes for individually oriented therapies. The outcome for family ther-
apy is also far superior to the high relapse rate following inpatient treatment, which is
25–30% following first admission and 55–75% for second and further admissions.
Outpatient family‐based treatment is also more cost‐effective than inpatient treat-
ment. For example, in a randomized controlled trial, Madden et al. (2015) found that
124 Alan Carr
considerable cost savings occurred when weight restoration was conducted as part of
outpatient family therapy, rather than during hospitalization. Evidence‐based family
therapy for anorexia can be effectively disseminated from specialist centers and imple-
mented in community‐based clinical settings. In the Maudsley model for treating
adolescent anorexia, which is the approach with strongest empirical support, family
therapy for adolescent anorexia progresses through four phases (Eisler et al., 2016;
Lock & Le Grange, 2013). In the first phase the focus is on engaging with the family,
conducting a multidisciplinary systemic, medical, and psychiatric assessment and
developing a therapeutic alliance. The second phase involves helping parents work
together to restore their teenager’s weight. The parents are viewed as a resource to
facilitate recovery rather than as a cause of the eating disorder. The eating disorder is
externalized and viewed as a challenging problem that all family members, including
the adolescent with the eating disorder, work together to resolve. This is followed, in
the third phase, with facilitating family support for the youngster in developing an
autonomous, healthy eating pattern and exploration of issues of individual and family
development. In the final phase the focus is on helping the young person develop an
age‐appropriate lifestyle, recovery review, and relapse prevention planning. Treatment
typically involves between 10 and 20 one‐hour sessions over a 6–12‐month period.
In a review of three trials of the Maudsley model of family therapy for bulimia in ado-
lescence, Jewell et al. (2016) concluded that it was more effective than supportive ther-
apy and led to more rapid initial increases in recovery than cognitive‐behavior therapy.
However, family therapy and cognitive‐behavior therapy had similar long‐term out-
comes. At 6–12 months’ follow‐up, binge–purge abstinence rates were 13–44% for those
who engaged in family therapy and 10–36% for those who engaged in individual therapy.
Family therapy for adolescent bulimia spans 15–20 sessions. To motivate young people
to engage in therapy, and create a context that facilitates cooperative conjoint family ses-
sions, separate sessions with adolescents and parents are scheduled prior to conjoint fam-
ily sessions. Therapy involves helping parents work together to supervise the young
person during mealtimes and afterward to break the binge–purge cycle. As with anorexia,
this is followed by helping families support their youngsters in developing autonomous,
healthy eating patterns and age‐appropriate lifestyles (Le Grange & Locke, 2007).
Systematic narrative reviews and meta‐analyses of controlled and uncontrolled trials
of treatments for obesity in children converge on the following conclusions (Janicke
et al., 2014; Jelalian, Wember, Bungeroth, & Birmaher, 2007; Nowicka & Flodmark,
2008; Young, Northern, Lister, Drummond, & O’Brien, 2007). Family‐based behav-
ioral weight reduction programs are more effective than dietary education and other
routine interventions. They lead to a 5–20% reduction in weight after treatment, and
at 10‐year follow‐up, 30% of cases are no longer obese. Childhood obesity is due
predominantly to lifestyle factors including poor diet and lack of exercise, and so fam-
ily‐based behavioral treatment programs focus on lifestyle change. Specific dietary and
exercise goals are agreed and progress toward goals is monitored by parents and chil-
dren. Stimulus control procedures are used so eating cues are only present during
mealtimes and only healthy food is available in the home. Parents model healthy eat-
ing and regular exercise and reinforce young people for adhering to healthy eating
and exercise routines. Better outcome occurs when therapy is offered to individual
families rather than multifamily groups and where therapy is of longer duration.
Therapy may span 1–24 months, with most programs spanning 3–6 months.
Closing comments on systemic therapy for child‐focused problems

Meta‐analyses comparing outcomes of systemic and individual therapy show conclu-
sively that systemic interventions in which both parents and children were included
were more effective (Dowell & Ogles, 2010; McCart, Priester, Davies, & Azen,
2006). For example, in a meta‐analysis of 48 trials comparing outcomes of systemic
and individual interventions for internalizing and externalizing child and adolescent
behavior problems, Dowell and Ogles (2010) found an effect size of 0.27. This indi-
cates that the average case treated with systemic interventions fared better after treat-
ment than 61% of cases treated with individual therapy. For child‐focused problems,
the inclusion of parents in the treatment process adds benefits beyond those achieved
by individual child psychotherapy.
Adult‐Focused Problems
There is evidence for the effectiveness of systemic interventions for relationship dis-
tress, psychosexual problems, and intimate partner violence in adults.
Relationship distress
Many reviews and meta‐analyses conclude that couple therapy is a particularly effec-
tive systemic intervention for relationship distress (Benson & Christensen, 2016;
Fischer, Baucom, & Cohen, 2016; Lebow, Chambers, Christensen, & Johnson,
2012; Rathgeber, Bürkner, Schiller, & Holling, 2018; Roddy, Nowlan, Doss, &
Christensen, 2016; Shadish & Baldwin, 2003; Wiebe & Johnson, 2016). For exam-
ple, in a review of six meta‐analyses of couple therapy, Shadish and Baldwin (2003)
found an average effect size 0.84, which indicates that the average treated couple
fared better than 80% of couples in control groups. In an overview of research on
empirically supported couple therapies, Benson and Christensen (2016) found that
35–70% of couples showed clinically significant improvement, with their scores on
measures of relationship satisfaction being in the normal range at the end of treat-
ment. Most controlled trials of systemic interventions for distressed couples have
evaluated traditional behavioral couple therapy (Jacobson & Margolin, 1979), inte-
grative behavioral couple therapy (Jacobson & Christensen, 1998), cognitive‐
behavioral couple therapy (Epstein & Baucom, 2002), emotionally focused couple
therapy (Johnson, 2004), and insight‐oriented couple therapy (Snyder & Mitchell,
2008), all of which typically involve about 20 sessions over 6 months. Benson,
McGinn, and Christensen (2012) proposed that five principles are common to evi-
dence‐based couple therapies. These are (a) altering the couple’s view of the pre-
senting problem to be more objective, contextualized, and dyadic; (b) decreasing
emotion‐driven, dysfunctional behavior; (c) eliciting emotion‐based, avoided, pri-
vate behavior; (d) increasing constructive communication patterns; and (e) promot-
ing strengths and reinforcing gains. To implement these factors effectively, therapists
typically have a clinical case formulation that explains the couple’s interactional pat-
tern that underpins their distress.
126 Alan Carr
Psychosexual problems
In a meta‐analysis of 20 studies, Frühauf, Gerger, Schmidt, Munder, and Barth (2013)
concluded that psychosocial interventions, which included couple therapy and other
psychosocial interventions, were effective for a proportion of cases with psychosexual
problems. They found an effect size of 0.58 across all disorders, indicating that the
average treated couple fared better after therapy than 73% of cases in waiting‐list con-
trol groups. In this meta‐analysis, therapy was particularly effective for women with
hypoactive sexual desire and orgasmic disorders. Most studies included in this meta‐
analysis evaluated interventions that combined elements of Masters and Johnson’s
(1970) sex therapy with various couple‐based cognitive‐behavioral interventions.
Reviews by Ter Kuile, Both, and van Lankveld (2012) and Segraves (2015) of nine
controlled trials concluded that directed masturbation (LoPiccolo & Lobitz, 1972)
was an effective treatment for primary orgasmic disorder in almost all cases. Directed
masturbation may be offered in range of formats including self‐help bibliotherapy,
individual and group therapy, and couple therapy. When offered within the context of
couple‐based sex therapy, it involves a graded program that begins with psychoeduca-
tion and is followed by a series of exercises that are practiced over a number of weeks
by the female with partner support initially and later with partner full participation.
In a narrative review of outcome studies, Segraves (2015) concluded that cogni-
tive‐behavioral sex therapy was particularly effective for reducing vaginismus. This
may be offered on an individual or couple basis. Effective couple‐based cognitive‐
behavior sex‐therapy programs for vaginismus include psychoeducation, cognitive
therapy to challenge beliefs and expectations underpinning anxiety about painful sex,
and systematic desensitization.
For male erectile disorder, only 40–80% of cases respond to sildenafil (Viagra) and
other phosphodiesterase type 5 (PDE‐5) inhibitors. In a meta‐analysis of eight stud-
ies, Schmidt, Munder, Gerger, Frühauf, and Barth (2014) found that PDE‐5 inhibi-
tors combined with psychosocial interventions, including couple therapy, led to better
outcomes than medication alone.
Narrative reviews of research on the treatment of premature ejaculation converge
on the following conclusions (Althof et al., 2014; Bailey & Trost, 2014; Segraves,
2015). For premature ejaculation, the current treatment of choice is multimodal
intervention that includes couple‐based sex therapy that involves the stop‐start and
squeeze techniques combined with selective serotonin reuptake inhibitors (SSRI).
Multimodal programs are more effective than either pharmacological or psychosocial
interventions alone.
Intimate partner violence

Gender‐specific group therapy is widely viewed as the standard treatment for inti-
mate partner violence. This position is partly informed by the idea that couple ther-
apy is contraindicated because talking about sensitive topics in couple therapy
sessions may increase the risk of further episodes of intimate partner violence
(Karakurt, Whiting, Esch, Bolen, & Calabrese, 2016). Despite this prevailing view,
systematic reviews and meta‐analyses of treatment programs for intimate partner
violence conclude that most traditional gender‐specific group therapy programs for
violent males have small effects and high dropout rates; the most effective programs
for mild‐to‐moderate situational intimate partner violence are couple based; and
effective programs address both violence and substance use, which often contrib-
utes significantly to violence (Armenti & Babcock, 2016; Karakurt et al., 2016;
Murphy & Ting, 2010; O’Farrell & Clements, 2012). In a meta‐analysis of six stud-
ies, Karakurt et al. (2016) found that couple therapy was more effective than alter-
native interventions, such as gender‐specific group therapy or individual therapy, for
mild‐to‐moderate situational intimate partner violence, with an effect size of 0.84.
This indicates that the average case treated with couple therapy fared better after
treatment than 80% of those in alternative treatments. There is empirical support
for behavioral (Fals‐Stewart, Klostermann, & Clinton‐Sherrod, 2009; O’Farrell &
Clements, 2012), cognitive‐behavioral (Epstein, Werlinich, & LaTaillade, 2015),
and solution‐focused (Stith, McCollum, & Rosen, 2011) couple therapy programs
for intimate partner violence. In these types of couple therapy programs, partners
must agree to a no‐harm contract and commit to work together for the duration of
treatment, which is usually about 3–6 months. All programs help couples improve
communication and nonviolent problem solving and solution finding. They also
address alcohol and substance use problems associated with violence and relapse
prevention planning. They are offered in a range of formats including conjoint cou-
ple therapy, conjoint couple therapy combined with individual sessions, and multi-
couple group therapy.
Mental Health and Physical Health Problems That Occur

Across the Lifespan
For both young people and adults, there is evidence for the effectiveness of systemic
interventions with alcohol and drug problems, mood disorders, anxiety disorders,
psychosis, and adjustment to illness and disability.
Drug and alcohol problems

Adolescents In a systematic narrative review of 45 trials of treatments for adoles-
cent drug misuse, Tanner‐Smith, Jo Wilson, and Lipsey (2013) concluded that
family therapy was more effective than other types of treatments including cogni-
tive‐behavior therapy, motivational interviewing, psychoeducation, and various
forms of individual and group counseling. As was mentioned previously in the sec-
tion on adolescent conduct problems, meta‐analyses by Baldwin et al. (2012) and
Dopp et al. (2017) support the effectiveness of brief strategic family therapy, func-
tional family therapy, multisystemic therapy, and multidimensional family therapy
in the treatment of adolescent substance misuse. All of these empirically supported
models of systemic therapy aim to increase prosocial behavior and reduce drug use
by changing relational patterns involving adolescents and members of their fami-
lies, peer groups, and wider social systems that maintain their difficulties. In the
meta‐analyses by Baldwin et al. (2012) and Dopp et al. (2017), effect sizes ranged
from 0.21 to 0.26, indicating that the average case treated with family therapy
fared better than 58–59% of cases who engaged in treatment as usual or alternative
treatments.
128 Alan Carr
Adults In extensive narrative reviews, McCrady et al. (2016) and O’Farrell and
Clements (2012) concluded that for adult alcohol problems, behavioral couple ther-
apy in many circumstances is more effective than other therapies including individual
cognitive‐behavior therapy, individual relapse prevention, and psychoeducation.
Compared with individual approaches, behavioral couple therapy produced greater
abstinence, fewer alcohol‐related problems, greater relationship satisfaction, and bet-
ter adjustment in children of people with alcohol problems. Behavioral couple therapy
also led to greater reductions in domestic violence and periods in jail and hospital, and
this was associated with very significant cost savings. Behavioral couple therapy typi-
cally involves 12–20, 60–90‐minute conjoint sessions. It includes alcohol‐focused
interventions to promote treatment engagement and abstinence and relationship‐
focused interventions to increase positive feelings, shared activities, and constructive
communication within couples. For the person with the alcohol problem, alcohol‐
focused interventions may include strategies to promote abstinence, such as a disulfi-
ram or a sobriety contract, or behavioral strategies to promote controlled drinking,
such as self‐monitoring and self‐management planning. For sober partners, alcohol‐
focused interventions include training in skills for supporting sobriety and self‐care.
Relapse prevention planning is also a central part of behavioral couple therapy for
alcohol problems.
Depression
Children and adolescents Stark, Banneyer, Wang, and Arora (2012) reviewed 25 tri-
als of family‐based treatment programs for child and adolescent depression. In these
studies, a variety of formats was used including conjoint family sessions (e.g., attach-
ment‐based family therapy [Diamond, Russon, & Levy, 2016]), child‐focused cogni-
tive‐behavior therapy (Klein, Jacobs, & Reinecke, 2007) or interpersonal therapy (Pu
et al., 2017) sessions combined with some family or parent sessions, and concurrent
group‐based parent and child training sessions (e.g., the Adolescent Coping with
Depression Program [Rhode, 2017]). Stark et al. (2012) concluded that family‐based
treatments for child and adolescent depression were as effective as well‐established
therapies such as individual cognitive‐behavior therapy or interpersonal therapy, led to
remission in two‐thirds to three quarters of cases at 6‐month follow‐up, and were
more effective than individual therapy in maintaining posttreatment improvement.
Effective family‐based interventions span about 12 sessions, aim to decrease the fam-
ily stress to which youngsters are exposed, and enhance the availability of social sup-
port within the family context. Core features of effective family interventions include
psychoeducation about depression, relational reframing of depression‐maintaining
family interaction patterns, facilitation of clear parent–child communication, promo-
tion of systematic family‐based problem solving, disruption of negative critical par-
ent–child interactions, promotion of secure parent–child attachment, and helping
children develop skills for managing negative mood states and changing pessimistic
belief systems.
Adults Narrative reviews and a meta‐analysis of controlled trials support three

main conclusions about the treatment of depression in adults with systemic therapy
(Barbato & D’Avanzo, 2008; Beach & Whisman, 2012; Stahl et al., 2016;
Whisman, Johnson, Be, & Li, 2012). First, systemic interventions are as effective
as individual approaches, such as cognitive‐behavior therapy, for the treatment of
depression in adults and older adults. Second, for those with relationship distress,
couple therapy leads to greater improvements in relationship satisfaction than indi-
vidual cognitive‐behavior therapy. Third, a range of couple and family‐based inter-
ventions effectively alleviate depression. These include systemic couple therapy
(Leff et al., 2000), emotionally focused couple therapy (Denton, Wittenborn, &
Golden, 2012), behavioral couple therapy (Jacobson, Dobson, Fruzzetti,
Schmaling, & Salusky, 1991), conjoint interpersonal therapy (Foley, Rounsaville,
Weissman, Sholomskas, & Chevron, 1989), family therapy for depression based on
the McMaster model (Miller, Keitner, Ryan, Solomon, & Cardemil, 2005), behav-
ioral family therapy for families of depressed mothers of children with disruptive
behavior disorders (Sanders & McFarland, 2000), and various types individual
family and multifamily therapy for older adults with depression (Stahl et al., 2016).
All of these approaches to systemic therapy require about 20 conjoint therapy ses-
sions and focus on both relationship enhancement and mood management. They
also involve a staged approach to address mood and relationship issues (Beach &
Whisman, 2012). In the initial phase, the focus is on psychoeducation, increasing
the ratio of positive to negative interactions, decreasing demoralization, and gen-
erating hope by showing that change is possible. The second phase focuses on
helping clients make positive behavioral changes by jointly reflecting on positive
and negative recurrent patterns of interaction, related constructive and destructive
belief systems, and underlying relationship themes. Relapse prevention planning is
the main theme of the third phase of therapy.
Bipolar disorder
The primary treatment for bipolar disorder is pharmacological. It involves initial treat-
ment of acute manic or depressive episodes and subsequent prevention of further
episodes with mood‐stabilizing medication such as lithium (Keck & McElroy, 2015).
The main aim of systemic therapy is to reduce relapse and rehospitalization rates and
increase quality of life. This is achieved by improving medication adherence and
enhancing the way individuals with bipolar disorder, and their families manage stress,
family relationships, and vulnerability to relapse. Family therapy for bipolar disorder is
partly based on research that shows that high levels of expressed emotion (especially
criticism, hostility, and overinvolvement) in patients’ families increase their vulnerabil-
ity to relapse (Hooley, 2007). Family therapy aims to delay or prevent relapse by
reducing the level of expressed emotion in patients’ families. Systematic reviews and
meta‐analyses concur that when included in multimodal programs involving mood‐
stabilizing medication, family therapy has significant positive effects on both ado-
lescents and adults with bipolar disorder and members of their families (Goldberg,
Martin, Biernacki, & Rynn, 2015; Miklowitz & Chung, 2016; Muralidharan,
Miklowitz, & Craighead, 2015). For individuals with bipolar disorder, these positive
effects include improved medication adherence, reduced relapse rate, reduced rehos-
pitalization rate, improved quality of life, and improved family relationships. For fam-
ily members with bipolar relatives, positive effects include increased knowledge about
bipolar disorder and decreased carer burden. Miklowitz’s (Milkowitz, 2008) family‐
focused therapy is a systemic intervention with a particularly strong evidence base.
130 Alan Carr
It usually involves 21 conjoint family sessions and includes psychoeducation, com-

munication and problem‐solving skills training, and relapse prevention.
Anxiety disorders
Children and adolescents Family‐based cognitive‐behavior therapy is an effective
intervention for anxiety disorders (Manassis et al., 2014), including obsessive–com-
pulsive disorder (Franklin, Morris, Freeman, & March, 2017; Thompson‐Hollands,
Edson, Tompson, & Comer, 2014), and posttraumatic stress disorder (Lenz &
Hollenbaugh, 2015) in children. In a large study that synthesized individual case data
from 18 separate trials, Manassis et al. (2014) found that cognitive‐behavioral family
therapy in which parents were helped to use contingency management to reinforce
children’s “brave behavior” for coping with exposure to anxiety‐provoking situations
was particularly effective in helping young people maintain gains a year after treat-
ment had ended. This type of cognitive‐behavioral family therapy was significantly
more effective in the treatment of childhood anxiety disorders in the long term than
therapy where parents had limited involvement or where they had extensive involve-
ment that did not involve using contingency management to reinforce children’s
“brave behavior.” For example, in separation anxiety disorder that often presents as
school refusal, parents and teachers are helped to support and reinforce children for
using anxiety management skills and “being brave” as they return to regular school
attendance (Heyne & Sauter, 2013; Kearney & Sheldon, 2017).
Meta‐analyses and narrative reviews have shown that family‐based, cognitive‐behav-
ioral, exposure, and response prevention treatment is effective in alleviating symptoms
in 50–70% of cases of pediatric obsessive–compulsive disorder; that the best treatment
response occurs where such interventions are combined with SSRI; and that family‐
based cognitive‐behavior therapy is more effective than medication alone (Franklin
et al., 2017; Thompson‐Hollands et al., 2014). Family intervention involves psychoe-
ducation about obsessive–compulsive disorder and its treatment through exposure
and response prevention, helping parents and siblings support and reward the child
for completing exposure and response prevention homework exercises, and helping
parents and siblings avoid inadvertent reinforcement of children’s compulsive rituals.
With exposure and response prevention, children construct hierarchies of anxiety‐
providing cues (such as increasingly dirty stimuli) and are exposed to these cues that
elicit anxiety‐provoking obsessions (such as ideas about contamination) commencing
with the least anxiety‐provoking, while not engaging in compulsive rituals (such as
hand washing), until habituation occurs. They also learn anxiety management skills to
help them cope with the exposure process.
Family‐based trauma‐focused cognitive‐behavior therapy is an effective treatment
for posttraumatic stress disorders in children. In a meta‐analysis of 21 trials, Lenz and
Hollenbaugh (2015) found that young people who had experienced multiple types of
trauma including war, terrorism, natural disasters, and maltreatment who engaged in
family‐based trauma‐focused cognitive‐behavior therapy fared better than those who
were on waiting lists (d = 1.48) or who had received alternative treatments (d = 0.28).
Trauma‐focused cognitive‐behavior therapy involves concurrent sessions for trauma-
tized children and their parents, in group or individual formats, with periodic conjoint
parent–child sessions. The child‐focused component involves exposure to traumatic
memories and cues through trauma narration and in vivo exposure, relaxation and
coping skills training, and safety skills training. Concurrent work with parents and
conjoint sessions with children and parents focus on psychoeducation, reframing
trauma experiences, helping parents develop supportive and protective relationships
with their children, and developing support networks for themselves.
Adults Couple‐based therapies are effective interventions for panic disorder with
agoraphobia (Byrne, Carr, & Clark, 2004), obsessive–compulsive disorder (Thompson‐
Hollands et al., 2014), and posttraumatic stress disorder (Monson & Fredman, 2015;
Wiebe & Johnson, 2016) in adults. In a review of 12 studies of couple therapy for
panic disorder for agoraphobia, Byrne et al. (2004) concluded that partner‐assisted,
cognitive‐behavior exposure therapy provided on a per‐case or group basis led to clini-
cally significant improvement in agoraphobia and panic symptoms for 54–86% of cases.
This type of couple therapy was as effective as individually based cognitive‐behavior
therapy, widely considered to be the treatment of choice. Treatment gains were main-
tained at follow‐up. Effective couple‐based programs include communication training,
partner‐assisted graded exposure to anxiety‐provoking situations, enhancement of
coping skills, and cognitive therapy to address problematic beliefs and expectations
that underpin avoidant behavior.
In a meta‐analysis of 29 studies of adults or children with obsessive–compulsive dis-
order, Thompson‐Hollands et al. (2014) found that couple and family treatments led
to a large effect size of 1.45. Thus, after treatment, the average treated case fared better
than 93% of cases in control groups. Gains made after treatment were sustained at fol-
low‐up. Adults and children had similar outcomes. Longer treatments, and individual
family, rather than multifamily therapy led to greater improvement. Effective programs
included exposure and response prevention and family psychoeducation, which specifi-
cally aimed to reduce family accommodation to obsessive–compulsive symptoms.
Narrative reviews of a small number of controlled and uncontrolled trials support
the effectiveness of cognitive‐behavioral couple therapy (Monson & Fredman, 2015)
and emotionally focused couple therapy (Wiebe & Johnson, 2016) in the treatment
of posttraumatic stress disorder. Cognitive‐behavioral couple therapy involved a pre-
liminary phase of psychoeducation about posttraumatic stress disorder and develop-
ment of couple safety routines for managing anger. In the middle phase, key issues
were communication and problem‐solving skills training and facilitating a reduction
in avoidance of trauma‐related cues. In the final phase, couples’ belief systems were
restructured with a focus on a range of themes including acceptance, blame, trust,
control, closeness, and intimacy (Monson & Fredman, 2015). Emotionally focused
couple therapy progressed through three stages. In the initial stage, there was a de‐
escalation of destructive interactional patterns arising from the couples’ difficulty in
managing trust issues associated with prior traumatic experiences. During the middle
phase of therapy, partners’ authentic expression of and response to each other’s attach-
ment needs were facilitated. In the closing phase, more adaptive patterns of attach-
ment behavior were consolidated.
Psychosis
The primary treatment for psychoses including schizophrenia and schizophrenia‐
spectrum disorders is pharmacological. It involves initial treatment of acute psy-
chotic episodes and subsequent prevention of further episodes with antipsychotic
132 Alan Carr
medication (Abbas & Lieberman, 2015). About 30–40% of medicated clients with
psychosis relapse within a year, and relapse rates are higher in unsupportive or stress-
ful family environments, characterized by high levels of expressed emotions, notably
criticism, hostility, or overinvolvement (McFarlane, 2016). Pharmacological inter-
ventions may be combined with psychoeducational family therapy, the aim of which
is to reduce family stress, especially expressed emotion, and enhance family support,
so as to delay or prevent relapse and rehospitalization. In psychoeducational family
therapy, families learn to understand and manage the condition, antipsychotic medi-
cation, related stresses, early warning signs of relapse, and how to access relevant
mental health services. Throughout treatment, emphasis is placed on blame reduc-
tion and the positive role family members can play in the rehabilitation of the family
member with schizophrenia.
Adolescents First episode psychosis typically occurs in late adolescence. Reviews and
meta‐analyses of over a dozen controlled trials of psychoeducational family therapy for
psychosis in adolescence or young people at risk of psychosis lead to the following
conclusions (Bird et al., 2010; Claxton, Onwumere, & Fornells‐Ambrojo, 2017; Ma,
Chien, & Bressington, 2017; McFarlane, 2016; McFarlane, Lynch, & Melton, 2012;
Onwumere, Bebbington, & Kuipers, 2011). Combining antipsychotic medication
with psychoeducational family therapy leads to significantly better outcomes than
routine treatment with antipsychotic medication. For young people, better outcomes
include a reduction in psychotic symptoms and relapse rates. For family members,
better outcomes include improvement in carer well‐being, reduction in carer burden,
and reduction in patient‐directed negative expressed emotion, particularly criticism
and hostility. The reduction in patient‐directed criticism and conflict may lead to
young people experiencing less stress or more support, and this may facilitate recov-
ery. Compared with single‐family therapy, multifamily psychoeducational therapy may
be particularly effective, possibly because it provides families with a forum within
which to experience mutual support, shared learning, and a reduced sense of isolation
and stigmatization.
Adults A series of systematic reviews and meta‐analyses involving over 100 stud-
ies conducted around the world provide robust support for the effectiveness of
psychoeducational family therapy (as one element of a multimodal program that
includes antipsychotic medication) in the treatment of schizophrenia in adults
(Lucksted, McFarlane, Downing, Dixon, & Adams, 2012; McFarlane, 2016;
Pfammatter, Junghan, & Brenner, 2006). Compared with medication alone, mul-
timodal programs that include psychoeducational family therapy and antipsychotic
medication improve medication adherence and lead to lower relapse and rehospi-
talization rates. For example, in a review of meta‐analyses, McFarlane (2016) con-
cluded that psychoeducational family therapy for adults with schizophrenia reduced
relapse rates by 50–60% compared with routine treatment. The relapse rate with
routine treatment is 30–40%, whereas the replace rate when psychoeducational
family therapy is added to routine treatment is about 15%. Systematic reviews and
meta‐analyses also show that family intervention for schizophrenia has positive
effects on the adjustment of non‐symptomatic family members. It reduces carer
burden and negative expressed emotion (Lobban et al., 2013; Ma et al., 2017; Sin
et al., 2017).
Physical illness and somatic complaints

Children and adolescents Systematic reviews and meta‐analyses support the effective-
ness of systemic interventions as an adjunct to medical care for children and adolescents
with asthma (Brinkley, Cullen, & Carr, 2002), diabetes (Hilliard, Powell, & Anderson,
2016) and functional abdominal pain (Sprenger, Gerhards, & Goldbeck, 2011). In a
systematic review of 20 studies, Brinkley et al. (2002) concluded that family‐based
interventions for asthma spanning up to eight sessions were more effective than indi-
vidual therapy. They included psychoeducation to improve understanding of the condi-
tion, medication management, and environmental trigger management; relaxation
training to help young people reduce physiological arousal; skills training to increase
adherence to asthma management programs; and conjoint family therapy sessions to
empower family members to work together to manage asthma effectively. The adaption
of multisystemic therapy for treating high‐risk families of asthmatic adolescents is an
important recent development. In a randomized controlled trial, compared with family
support, multisystemic therapy led to significant improvements in adolescents’ asthma
management and lung function, parental self‐efficacy, and parental beliefs in the value
of asthma‐related positive parenting behaviors (Naar‐King et al., 2014).
Systematic reviews and meta‐analyses of the impact of family‐based programs for
adolescents with type 1 diabetes allow the following conclusions to be drawn (Farrell,
Cullen, & Carr, 2002; Hilliard et al., 2016; Hood, Rohan, Peterson, & Drotar, 2010;
Lohan, Morawska, & Mitchell, 2015; Savage, Farrell, McManus, & Grey, 2010).
Effective family‐based programs spanning 2–6 months led to improvements in a range
of domains including family members knowledge about diabetes and its management,
adherence, glycemic control, hospitalization, quality of family relationships, and well‐
being of children and parents. Different types of programs were appropriate for fami-
lies at different stages of the life cycle. For families of young children newly diagnosed
with diabetes, psychoeducational programs that helped families understand the condi-
tion and its management were particularly effective. Family‐based behavioral pro-
grams, where parents rewarded youngsters for adhering to their diabetic regimes,
were particularly effective with preadolescent children, whereas family‐based commu-
nication and problem‐solving skills training programs were particularly effective for
families with adolescents since these gave families skills for negotiating diabetic man-
agement issues in a manner appropriate for adolescence. Multisystemic therapy
adapted for families of adolescents with type 1 diabetes (Ellis et al., 2012) is particu-
larly well supported.
Narrative reviews and meta‐analyses show that cognitive‐behavioral family therapy is
effective in alleviating recurrent functional abdominal pain, often associated with
repeated school absence, and for which no biomedical cause is evident (Banez &
Gallagher, 2006; Sprenger et al., 2011; Weydert, Ball, & Davis, 2003). Such programs
involve family psychoeducation about functional abdominal pain and its management,
relaxation and coping skills training to help children manage abdominal pain that is
often anxiety based, and contingency management implemented by parents to moti-
vate children to engage in normal daily routines, including school attendance.
Adults Narrative reviews and meta‐analyses support the effectiveness of systemic

interventions as an adjunct to medical care for adults with chronic pain, heart disease,
cancer, diabetes, and caring for aging relatives with dementia (Campbell, 2003;
134 Alan Carr
Hartmann, Bäzner, Wild, Eisler, & Herzog, 2010). For example, in a meta‐analysis of
52 randomized controlled trials involving a range of conditions in adults including
cardiovascular disease, stroke, cancer, and chronic pain conditions such as arthritis,
Hartmann et al. (2010) found that systemic interventions led to significantly better
physical health in patients and better physical and mental health in both patients and
other family members compared with routine care. Effect sizes were small to medium,
ranging from 0.28 to 0.35, indicating that the average case treated with systemic
therapy fared better than 61–64% of cases who received routine care. Effects were
stable over long follow‐up periods. Systemic interventions included psychoeduca-
tional and cognitive‐behavioral couple and family therapy as well as multifamily sup-
port groups and carer support groups. These interventions had some or all of the
following elements. They provided psychoeducation about the affected family mem-
ber’s medical condition and its management. They promoted adherence to medical
regimes, an increase in adaptive “well behavior” and a reduction of “illness behavior.”
They offered a context within which to enhance support for the person with the
chronic illness and other family members. They provided a forum for exploring ways
of coping with the condition and its impact on family relationships.
Cost‐Effectiveness
There is a growing body of evidence that supports the cost‐effectiveness of systemic

therapy. In a series of 22 studies conducted over 20 years, Crane and his team showed
that systemic therapy was more cost‐effective than individual therapy and led to medi-
cal cost offsets (Crane & Christenson, 2014). Medical cost offsets occurred because
people who engaged in family therapy, particularly frequent health service users, used
fewer medical services after family therapy. The medical cost offset associated with
couple and family therapy covered the cost of providing therapy and in many cases led
to overall cost savings. Large US databases involving over 250 000 cases of routine
systemic therapy were used for these studies. Cases included families of people diag-
nosed with schizophrenia, depression, sexual disorders, somatoform disorder, sub-
stance misuse, relationship problems, and other disorders. Reviews of economic
evaluations of psychoeducational family therapy for psychosis (McFarlane, 2016) and
functional family therapy and multisystemic therapy for delinquency (Henggeler &
Sheidow, 2003) show that these empirically supported systemic interventions are
cost‐effective because they lead to decreased use of costly medical, social, and correc-
tional services. Caldwell, Woolley, and Caldwell (2007) estimated that the free provi-
sion of effective couple therapy would lead to significant cost savings because it would
prevent a range of legal and health‐care costs arising from divorce and divorce‐related
health problems.
Future Directions
This and previous reviews (Carr, 2000a, 2000b, 2009a, 2009b, 2014a, 2014b, 2018a,
2018b) show that there is a strong evidence base supporting the efficacy of systemic
interventions for a range of child‐ and adult‐focused problems. However, as I have
argued elsewhere (Carr, 2010), while we have achieved a great deal, the following 10
questions should drive our future research agenda:
1 Is family therapy as effective in community settings as it is in specialist clinics?

2 For what problems is family therapy cost‐effective?
3 Does family therapy work for under‐researched problems and populations?
4 Do social constructionist and narrative approaches to family therapy work?
5 Can family therapy protocols be enhanced for nonresponders?
6 Can family therapy be combined with other psychotherapies to effectively treat
specific problems?
7 Can family therapy be combined with pharmacotherapy to effectively treat
specific problems?
8 What specific factors contribute to the effectiveness of family therapy with
particular problems?
9 What common factors contribute to the effectiveness of family therapy?
10 What therapist and client factors contribute to the effectiveness of family therapy?
Effectiveness research
With regard to question 1, much couple family therapy research has been conducted
under ideal conditions in specialist clinics, in efficacy rather than effectiveness studies.
However, there are exceptions, for example, multisystemic therapy (Henggeler &
Schaeffer, 2016) and functional family therapy (Robbins et al., 2016) for delinquency. A
common finding is that effect sizes from effectiveness studies are smaller than those from
efficacy trials. There are many reasons for this (Halford, Pepping, & Petch, 2016). In
effectiveness studies, cases tend to have more complex problems and goals and less readi-
ness to engage in treatment. Also, therapists have larger caseloads, deliver treatment
programs with less fidelity, receive less intensive supervision, and monitor progress with
psychometric measures less frequently. Effectiveness studies are important because they
let service funders know how well systemic therapy works in “real‐world” settings.
Economic evaluations
With regard to question 2, less research has been conducted on the cost‐effectiveness
than the efficacy or effectiveness of systemic therapy (Crane & Christenson, 2014). It
will be particularly important to conduct economic evaluations of couple and family
therapy for populations such as frequent emergency service users and families of
patients with conditions such as asthma, diabetes, high blood pressure, cancer, and
heart disease, as well as families of people with mental health problems that have a
chronic relapsing course if left untreated such as anxiety disorders, depression, bipolar
disorders, and so forth. These studies will provide policy makers with further eco-
nomic evidence to justify funding family therapy services.
Under‐researched populations
With regard to question 3, under‐researched populations include families of people
with personality disorders, families of those caring for debilitated older adults with
neurological or mental health difficulties, and families of children and adults with
136 Alan Carr
intellectual or pervasive developmental disabilities (including autism spectrum disor-

ders) and comorbid adjustment problems. Research on the effectiveness of family
therapy for these populations should be prioritized for humanitarian and economic
reasons. Family therapy may well be an important intervention for enhancing the
quality of life for these populations. Furthermore, family therapy may entail lower
costs than inpatient or residential care, which are currently commonly used. There is
also a dearth of research on the effectiveness of family therapy (and other types of
psychotherapy) for addressing problems in minority populations including LGBT
groups and ethnic minorities.
Social‐constructionist and narrative approaches

With regard to question 4, most systemic therapy trials have evaluated interventions
that fall broadly within the cognitive‐behavior therapy and structural–strategic tradi-
tions. Solution‐focused therapy is arguably one of the few postmodern approaches to
have been empirically evaluated in sufficient studies to warrant a systematic review
(Corcoran & Pillai, 2009; Gingerich & Eisengart, 2000; Schmit, Schmit, & Lenz,
2016). There is a need for more trials evaluating social constructionist and narrative
approaches that are particularly popular among clinicians.
Nonresponders
With regard to question 5, systemic therapy outcome research shows that a third of
cases do not benefit from treatment. There is a need for controlled trials of enhanced
family therapy protocols specifically designed to meet the unique needs of nonre-
sponders. These protocols may include procedures for engaging families who drop
out of therapy, helping families address complex apparently intractable challenges,
and helping families maintain treatment gains when discharged from treatment.
Multimodal programs
With regard to questions 6 and 7, research in the fields of drug and alcohol problems
(Stanton & Shadish, 1997) and psychosis (McFarlane, 2016) shows that treatment
outcomes can be enhanced by combining systemic interventions with other forms of
psychotherapy or medication. However, for a very wide range of other physical and
mental health problems, there is need for research on the optimal way to combine
systemic therapy with other psychotherapies and with psychotropic medication.
Process research
Questions 8, 9, and 10 are about process research, a detailed consideration of which
is beyond the scope of this chapter. There is only a small body of research on the rela-
tive contribution of common factors (such as the therapeutic alliance) and specific
factors (such as adherence to particular techniques specified in treatment manuals) to
the outcome of couple and family therapy (Friedlander, Heatherington, & Escudero,
2016). Research on specific and common factors is important because it throws light
on the “active ingredients” of systemic therapy. In contrast, research on therapist and
client factors is essential because it identifies particular characteristics of clients and

therapists that constrain or facilitate therapeutic progress. An extensive evidence base
has shown that certain client characteristics (e.g., readiness to change or psychologi-
cal mindedness) and therapist attributes (e.g., competence or engagement in super-
vision) are associated with a positive outcome in individual therapy (Carr, 2009c).
Very few studies have been conducted on participant factors and family therapy out-
come. Because process and outcome research are inextricably linked, there is a need
for research on the way that specific and common factors, and therapist and client
factors contribute to the efficacy and effectiveness of systemic therapy with particular
problems.
Family therapy efficacy and effectiveness research has come a long way since
Gurman and Kniskern’s first review of the field in 1978. Looking to the future, it will
be important to routinely incorporate economic evaluations and process studies into
controlled trials, to prioritize effectiveness over efficacy studies, to enhance systemic
interventions to meet the needs of nonresponders, to target under‐researched popula-
tions, and to conduct outcome research on systemic therapy within the context of
multimodal treatment programs.
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7
Common Factors Underlying
Eli A. Karam and Adrian J. Blow
The formula for systemic family therapy (SFT) effectiveness involves a complex
combination and interaction of interconnected factors and variables. Common factors
are the general mechanisms of change that cut across all effective therapies, rather
than specific ingredients or interventions from particular models. There is evidence
supporting that these common factors account for far more variance in successful
systemic family therapies than the unique contributions of any particular model or
individual approach (see Blow, Sprenkle, & Davis, 2007; Sprenkle, Blow, & Dickey,
1999; Sprenkle & Blow, 2004a, for an extensive review of this work in SFT). This
chapter will provide a more thorough understanding of these factors and how they
can be woven into SFT research, training, and practice. We will provide suggestions
for next steps for incorporating common factors into SFT training and research in
order to move forward this important area.
History of Common Factors
Before a discussion of common factors in SFT takes place, it is helpful first to under-
stand the history of common factors in individual psychotherapy (see Sprenkle, Davis,
& Lebow 2009, for an in‐depth review of the history of common factors). The fol-
lowing section will provide a history of the common factors position, as well as its
status in individual psychotherapy.
Saul Rosenzweig (1936) described “unrecognized factors” in addition to the
“intentionally utilized methods” and added that the unrecognized factors could have
a greater effect than the planned interventions. This claim was largely ignored, how-
ever, until much of the comparative efficacy research began showing little if any dif-
ferences between models. Though originally written by Rosenzweig, it was Luborsky,
Singer, and Luborsky (1975) who are often credited with publishing the dodo bird
verdict, in which they stated that all models have won and must have prizes. Jerome
Frank, in all three editions of Persuasion and Healing (1961, 1973; Frank & Frank,
148 Eli A. Karam and Adrian J. Blow
1993), furthered the common factors hypothesis by searching for links between psy-
chotherapy and other activities designed to bring about healing.
Frank and Frank (1993) went on to identify four features common to all effective
therapies: (a) an emotionally charged confiding relationship with a helping person;
(b) a setting that is judged to be therapeutic, in which the client believes the profes-
sional can be trusted to provide help on his or her behalf; (c) a therapist who offers a
credible rationale or plausible theoretical scheme for understanding the client’s symp-
toms; and (d) a therapist who offers a credible ritual or procedure for addressing the
symptoms. Around this same time period, Michael Lambert (1992) published a
highly influential article in which he proposed the following four pantheoretical fac-
tors as being responsible for the majority of the outcome variance in psychotherapy:
(a) extratherapeutic change, responsible for 40% of the variance; (b) therapeutic rela-
tionship, responsible for 30% of the variance; (c) expectancy or placebo effects,
responsible for 15% of the variance; and (d) model‐specific techniques, responsible for
15% of the variance. Though Lambert’s findings are often regarded as empirically
derived, in reality they are educated estimates.
Wampold (2001) uses the four dimensions proposed by Frank and Frank (1993) as
a framework for what he calls a contextual model of psychotherapy, which he contrasts
with a medical model of doing therapy. His meta‐analytic work stands as one of the
most convincing empirical arguments for common factors, as he demonstrates that
these four variables can explain about 70% of the outcome variance in therapy.
Furthermore, his meta‐analysis suggests that at most, 8% of the outcome variance is
accounted for by the unique contributions of various models (a percentage much
smaller than the previous estimate of 15%; Lambert, 1992). Twenty‐two percent of
the variance of outcome was unexplained. Wampold’s meta‐analysis is particularly
important because he only includes studies that directly compared two bona fide
treatments to each other, rather than the common effectiveness studies in which a
treatment is compared with a less respected treatment as usual condition.
Ever since Rozenzweig coined the term dodo bird verdict, a heated debate has
persisted on the mechanisms that account for the effects of psychotherapy. Although
almost everyone agrees that both common and specific factors are active in psycho-
therapy, advocates of the specific factors model emphasize the specific ingredients of
the different psychotherapies thought to be responsible for their observed effective-
ness, whereas opponents claim that common factors are pivotal. The truth is that both
are important when therapy is delivered through a credible model such as that pro-
posed by Frank and Frank (see Sexton, Ridley, & Kleiner, 2004; Sexton & Ridley,
2004; Sprenkle & Blow, 2004a, 2004b, for an extensive discussion).
The idea of common factors in psychotherapy is not new, with the original idea
attributed to Saul Rosenzweig (Duncan, 2002a, 2002b). Essentially, common factors
question why psychotherapy works and highlight universal change mechanisms that
cut across theories of therapy. There have been volumes written on the topic including
debates and opinion pieces. But the best arguments come from reviews of research
captured in volumes such as The Heart and Soul of Change (two editions) (Hubble,
Duncan, & Miller, 1999; Duncan, Miller, Wampold, & Hubble, 2010) and the two
editions of Bruce Wampold’s book, The Great Psychotherapy Debate (Wampold, 2001;
Wampold & Imel, 2015). These works remind us that psychotherapy works and that
therapy change can be attributed to factors found in all effective models of therapy
(these will be expounded upon in greater detail below). The goal of this work was not
SFT Common Factors 149
to disparage models of therapy, but rather to consider reasons why these models work
and important points of emphasis for clinicians to consider in adopting approaches to
treatment.
The common factors literature is still quite new in the field of SFT. Presentations
and writings on the topic first came about at the end of the 1990s (see Blow & Piercy,
1997; Sprenkle et al., 1999; Wampler, 1997), and several papers have been published
since that time (e.g., Blow & Karam, 2017; Blow et al., 2007; Blow & Sprenkle,
2001; Karam, Blow, Sprenkle, & Davis, 2015; Sprenkle & Blow, 2004a, 2004b,
2007). This work has created considerable discussion in the SFT literature. However,
in‐depth research on the common factors in SFT is still lacking, and many more stud-
ies are needed to understand how these mechanisms work in therapy when one takes
into account multiple members in the therapy room, and many contextual factors
affecting the presenting problem.
Defining General Common Factors
Common factors are universal elements that operate in the therapy room; while they
include the therapist, the therapist is also able to enhance other common factors that
are present in every therapy session. They hold important keys to understanding
change processes in the field of psychotherapy as a whole. Although more research is
needed, almost everything that has been articulated in the individual therapy com-
mon factors literature also holds true for systemic therapies with couples and families.
In addition, systemic family therapies have additional factors, which will be described
below. Michael Lambert (1992) originally proposed the following clusters, which
were later modified by Hubble et al. (1999) and then by Wampold (2001) as pertain-
ing to the field of individual psychotherapy.
Therapist factors
Sometimes the therapist may do precious little in the therapy, but what she or he does
is very precious (Blow et al., 2007)! Although Wampold (2001) contends that thera-
pist contributions to successful therapy are actually greater than contributions from
the model itself, Sprenkle and Blow (2004a) note that there has unfortunately been
even less attention paid to these therapist factors in wake of the empirically supported
treatment (EST) movement of the past several decades. In fact, specific models usually
de‐emphasize therapist factors even in the face of the empirical evidence and the clini-
cal reality that some therapists are more effective than others are. Along the same
lines, randomized controlled trials (RCT) to study the efficacy of models go to great
lengths to control therapist effects in the studies through supervision, fidelity ratings,
and therapist training procedures. In spite of these attempts, evidence still shows that
therapists who participate in clinical trials have different outcomes across their cases
(see Sprenkle & Blow, 2004b, for a discussion of these differences).
Flexibility and cultural sensitivity are key therapist common factors (Blow et al.,
2007). Effective therapists are flexible enough to understand and implement with
varying client systems, therapeutic strategies, and principles of change coming from a
variety of different models in order to adapt to a wide array of clients and presenting
problems. This flexibility of successful therapists also extends to carefully matching

client preferences, expectations, and characteristics. For example, Beutler, Harwood,
Alimohamed, and Malik (2002) provide evidence that therapists do better offering
insight‐oriented procedures to clients who are more self‐reflective, introspective, and
introverted. Conversely, therapists should offer skill‐building and symptom‐focused
methods to clients who are more impulsive and aggressive. There is also growing
evidence that therapists whose work is sensitive to the cultural values and beliefs of
clients get better results (Blow et al., 2007).
Self‐awareness in therapeutic pacing is another important therapist factor. For exam-
ple, Beutler, Consoli, and Lane (2005) offered evidence that therapists should decrease
directiveness when client resistance is high but increase therapeutic control when cli-
ents need structure and order. Furthermore, the therapist should adjust his or her style
to keep the client’s emotional arousal at a moderate level (neither too high nor too
low) since moderate arousal seems to facilitate change (Blow et al., 2007). Predictably,
therapist positivity and friendliness are powerful factors, while criticism and hostility
are unfavorable therapist attributes (Beutler, Malik, & Alimohamed, 2004).
When it comes to the SFT field, therapist skills are needed in order to manage the
complex systems that therapists deal with when they have more than one individual in
the therapy room (Blow & Karam, 2017). These therapists have to be able to connect
with all members of a system, conceptualize their problem in relational terms, and
then intervene in ways that are palatable to all involved. SFT models are complex and
require therapists to assess a number of factors, conceptualize cases, build alliances
with multiple members of a family, and monitor the therapy process over time. In
spite of the skills required of SFTs to work within these complexities, there are few
studies of therapists working from an SFT perspective. While we contend (Blow &
Karam, 2017) that SFT requires more skills than those working with individuals,
more studies are sorely needed. These include variables/processes such as character-
istics of these therapists, training variables, decision‐making factors, alliance‐building
abilities, and the like. However, conducting this research in a credible way is a chal-
lenge, especially when funding agencies prioritize models and where the therapy
movement as a whole is still dominated by evidence‐based practices versus evidence‐
based therapists (Blow & Karam, 2017).
Client
Client common factors encompass both demographic (age, gender, culture) and per-
sonality or inherent trait characteristics that help clients to benefit from the process of
therapy (Blow et al., 2009; Sprenkle et al., 1999). It is certainly advantageous to work
with clients who are motivated, who are self‐aware, and who actively work to achieve
their goals outside of the therapy room. For these clients, what they bring to the
therapy experience is highly instrumental in their change. Another important factor to
consider related to the client is the stage of change they are in at any point of the
therapy (Prochaska, 1999). Prochaska proposed that there are stages to the change
process. They include pre‐contemplation (the client is not aware that there is a prob-
lem), contemplation (the client has begun to reflect on the problem), preparation
(the client has begun to prepare take steps to solve the problem), action (the client has
taken steps to solve the problem), and maintenance (the client is doing things to
maintain the problem that is now resolved or in the process of being resolved). For
example, a client in the preparation or action stage of change is inherently easier to

work with that an unmotivated client (who may not even be aware that a problem
exists) who is usually in the pre‐contemplation stage. Even though Prochaska devel-
oped this model some time ago, little work has been done in SFT to study this topic.
It is of intrigue in that couples and families present in therapy for individually different
reasons and often at very different stages of change. For example, a couple may pre-
sent in therapy where one party is contemplating leaving the relationship and the
other is fairly satisfied with the status quo. Another example is a family mandated to
therapy by the court for the adolescent’s drug use. Each member of such a family is
likely in a different stage of change and is attending therapy with a different level of
motivation. These two examples illustrate how more research is needed to consider
how these stages of change factors play out in SFT.
Tallman and Bohart (1999), in discussing the self‐healing qualities, speculate that
some clients have the innate ability to use whatever is offered by whoever the therapist
is and whatever the approach he or she practices. In other words, successful clients are
able to utilize the therapy for their own purposes. In addition to what they possess
internally, clients may maximize the healing properties of outside people and things,
including the many resources that exist in the expanded system and social network.
Examples of these external supports include family members, a network of friends, or
a religious community. While this may be true for individual therapy, SFT studies have
not occurred, which examine how systems may self‐heal. While we are trained to think
systemically, some systems may be able to self‐correct and arrive at optimal levels of
homeostasis, while other systems may repeat mistakes again and again that perpetuate
problems. Change in some systems may only occur when key members or one key
member is willing to make needed changes. Studies of these processes in couples and
families would be enormously helpful.
While client factors are an important consideration in treatment, especially the moti-
vation and willingness of clients to change, we also need to recognize that there is a
subgroup of clients who do not have the same motivation or inner resilience to change.
While we know that treatment works for many but there are still significant numbers
of individuals who can be considered treatment failures (Lampropoulos, 2011). In
individual psychotherapy (community samples), between 40 and 60% of clients may
not benefit at all from therapy. On average, only 14% of patients recover, 21% improve,
57% show no change, and 8% deteriorate (average treatment length of four sessions)
(Lampropoulos, 2011). These data suggest that for some clients, change is easier to
achieve than others and for clients that need more, therapist and other treatment fac-
tors are important. We were unable to find data on improvement rates and dropout
rates when it comes to work with couples and families. We would suspect that dropout
rates are similar high and that not all couples and families are achieving the outcomes
that they desired to achieve when they enrolled in therapy. More studies are needed
that study the experiences of couples and families in therapy and what variables lead to
longer utilization of therapy along with positive outcomes.
Therapeutic alliance
The relationship between client and therapist, commonly referred to as the therapeutic
alliance, is composed of three elements: bonds (the affective quality of the client–thera-
pist relationship that includes dimensions like trust, caring, and involvement), tasks
(the extent to which the client and therapists are both comfortable with the major
activities in therapy and the client finds them credible), and goals (the extent to which
the client and therapist are working toward compatible goals) (Bordin, 1979).
It is hard to imagine engaging in successful therapy without having a healthy rela-
tionship between the client and therapist. In fact, one view is that relationship factors
are responsible for at least 30% of therapeutic change, including variables such as
warmth, understanding, genuineness, and mutual respect (Lambert, 1992). Wampold
(2001) concludes that the alliance is responsible for up to seven times the variance of
ingredients attributed to different models and that “the relationship accounts for
dramatically more of the variability in outcomes than does the totality of specific
ingredients” (p. 158). In SFT, Sprenkle and Blow (2004a) speculate that the thera-
peutic alliance more than likely accounts for far more of therapeutic change than in
individualized therapy because of the cumulative momentum that is gained through
connecting with important family members and the ripple effect throughout the
entire system. In contrast, failure to connect with these important players in the thera-
peutic system can furthermore be detrimental to both initial engagement and the
overall outcome of therapy. While research on the alliance in SFT has been conducted,
far more is needed given the complexities of this work in SFT.
Formalized feedback: An alliance enhancing factor

Providing organized feedback to clients is yet another common element associated
with successful alliances in therapy (Halford et al., 2012). Multiple studies have docu-
mented significant improvements in both retention in and outcomes from treatment
when therapists have access to formal, real‐time feedback from clients regarding the
process and outcome of therapy (Anker, Duncan, & Sparks, 2009; Harmon et al.,
2007). Michael Lambert’s research (2010a, 2010b) also has demonstrated that utiliz-
ing systematic feedback, potentiating common factors like the therapeutic alliance and
other client variables, consistently improves therapy outcomes and can greatly improve
treatment effectiveness for clients at risk of treatment failure. Given the importance of
these findings, both on initial engagement and on overall therapeutic outcome, it
makes sense for every therapist, no matter what the theoretical orientation, to become
proficient in receiving and processing feedback with clients around these important
common factors in order to strengthen the therapeutic alliance and keep therapy
focused. Formalized feedback is punctuated by therapists obtaining real feedback
from clients as to how therapy is progressing and on the status of the alliance. This
feedback is processed in the here and now with clients, and this processing allows
clients to feel heard by the therapist and allows therapists to demonstrate responsive-
ness to clients in shifting therapy to meet client needs. Two key studies have been
completed of the use of formalized feedback in couple therapy. In a first, a highly
important study for the SFT field, Anker et al. (2009) studied formalized feedback
with couples in a community family counseling clinic. The study had a simple design
comparing treatment as usual with treatment as usual plus formalized feedback.
Impressively, the feedback condition achieved four times the rate of clinically mean-
ingful change when compared with the treatment as usual group. Importantly, these
gains were maintained a six‐month follow up. In a second study by Reese, Toland,
Slone, and Norsworthy (2010), the authors examined how formalized feedback
extends to couple therapy populations. The study design was similar to that of Anker
et al. (2009), although the sample size was smaller. Importantly, their conclusions
were similar showing that clients in the feedback condition improved to a greater
extent and that this improvement was more rapid. Four times as many couples in the
treatment condition (feedback) reported clinically significant improvement at the end
of therapy. The Reese study shows that feedback is also an effective tool to use with
therapy trainees.
These two studies drive home the idea that enhancing common factors like the alli-
ance can produce substantial effects in couple therapy. These effects can be achieved
at a relatively low cost and with minimal interruptions to therapy. Hypothesized
mechanisms are that formalized feedback forces therapists to focus on important alli-
ance variables (e.g., do clients feel understood and respected) and outcome variables
(e.g., how clients are doing in progressing toward their goals). This feedback initiates
conversations about these important therapy processes. In working with couples, it is
clear that the incorporation of formalized feedback is effective. Conversations between
the couple and the therapist about treatment and its progress are able to enhance
treatment. Yet, it is significant that no new studies of couple therapy and feedback
have been published since these two studies were conducted, and we could find no
studies of family therapy using feedback. Given the potential in family therapy for all
members to engage in deeper conversations about their progress and experiences in
therapy, it is indeed surprising that more studies have not occurred. Sparks and
Duncan (2018) did a review of the Partners for Change Outcome Management
System, an approach to systemic client feedback using measures used in the Anker and
Reese studies. They advocate strongly for the use of these measures as providing both
feedback about how clients are progressing in therapy and a mechanism to communi-
cate with clients about therapy progress and process. They describe how both mem-
bers of a couple complete feedback forms at the beginning (outcome rating) and end
of each session (session rating). The therapist then displays the data generated by
these feedback measures on screens and shows them to the clients. This leads to a
conversation about client progress and their experience of therapy.
Given the impressive results of the Anker et al. (2009) and Reese et al. (2010) stud-
ies, we suggest that future couple and family therapy studies using formalized feed-
back are of the highest priority for our field. In addition, more studies using different
types of feedback mechanisms will also be highly useful (the two studies mentioned
used very brief outcome rating and session rating questionnaires). Finally, more stud-
ies are needed to examine the mechanisms of change that occur through the use of
feedback. We conclude that studies of feedback are needed in couple and family ther-
apy, especially due to the presence of multiple members and the unique processing
that occurs about feedback when multiple members are present in therapy (Lappan,
Shamoon, & Blow, 2018).
Hope/expectancy
Clients sometimes enter therapy because they have lost hope or have a depleted
morale. Hope, or helping clients tap into something positive about their selves or
family system, can help open the space necessary for change to occur. Hope may be
understood in terms of whether clients have goals and how they think and feel about
these goals (Snyder, Cheavens, & Michael, 1999). Not only is it important that clients
are able to formulate goals, but they must also believe that there are one or more
workable routes to their goals (pathways thinking) and that they have the ability to
begin and continue movement on selected pathways toward those goals (agency
thinking or self‐efficacy) (Snyder et al., 1999). Hope and expectancy are cognitive
mechanisms that can be enhanced in clients. Howard, Moras, Brill, Martinovich, and
Lutz (1996) stressed the importance of moving a client from demoralization to rem-
oralization through mobilizing hope and positive expectations early in treatment.
In therapy, hope also takes the form of positive expectations and placebo effects
independent of the treatment model or individual skill of the therapist. Lambert
(1992) estimated that these expectancy and placebo factors are responsible for up to
15% of overall change and are the portion of improvement that results from the cli-
ent’s knowledge of being in treatment, becoming hopeful, and believing in the cred-
ibility of the treatment and the therapist. Hubble et al. (1999) suggest that “this class
of therapeutic factors refers to the portion of improvement deriving from clients’
knowledge of being treated and assessment of the credibility of the therapy’s rationale
and related techniques” (pp. 9–10). Although many therapists in a Delphi study by
Blow and Sprenkle (2001) saw hope as being a crucial aspect underlying all SFT mod-
els, these same participants believed that hope was neither clearly articulated in the
theories themselves nor taught explicitly in training programs. While there are not
many studies of hope in SFT, one study by Ward and Wampler (2010) interviewed 15
therapists about the topic of hope in couple therapy. These authors concluded that
hope entails a continuum and couples in therapy are able to move up this continuum
with the help of the therapist. This includes having the therapist create a context that
is hopeful for couples, having the therapist be hopeful that change can occur, and hav-
ing couples interrupt negative interactional cycles that undermine hope. This theory‐
generating study, although helpful, is only one study, and many more studies are
needed that help understand the concept of hope and how it plays out in SFT.
Common Factors Specific to SFT
In one of the first systemic writings on common factors, Snyder et al. (1999) came up
with four common factors unique to SFT theories. These were updated in subsequent
writings (e.g., Sprenkle & Blow, 2004a), but not much research or writing on this
topic has been done since that time. These factors as a whole are distinct in couple and
family therapy theories and as such are reflective of the core identity of the SFT pro-
fession when compared to other helping disciplines such as counseling, psychology,
and social work.
Conceptualizing difficulties in relational terms

First, and in our view most important, is conceptualization of problems in relational
terms. This conceptualization is what makes the SFT field unique from other disci-
plines (see Sprenkle et al., 1999; Wampler, Blow, McWey, Miller, & Wampler, 2019).
Relational conceptualization occurs when the therapist translates human/family dif-
ficulties into relational terms. SFTs attempt to keep the whole system (or systems) in
view, regardless of the number of people present in the therapy room, or the present-
ing problem. Understanding the problem through a systemic lens helps the therapist
to come up with treatment strategies that are best suited to the problem and its
c onceptualization (Pinsof, 1995). Ideally, the therapist and the family work together
to conceptualize the problem as something that is connected to the family and its
context and as something that impacts all in the family. Through careful assessment
strategies along with family therapy techniques such as reframing (which changes the
view of the problem), the therapist shifts the problem from an individual to a family
focus and comes up with a conceptualization of the difficulties that is palatable to all in
the family (Sexton & Alexander, 2003; Sprenkle & Blow, 2004a; Wampler et al., 2019).
One of the ways this conceptualization is achieved is through having families inter-
act around their problem in the present (enactment), and this helps the therapist to
understand how the family interacts together around the problem (Minuchin, 1974).
In this sense, the therapist comes to understand how the symptoms and behaviors can
be understood within the larger family and its context. This has the positive impact of
reducing blame and thereby engaging family members in the resolution of the prob-
lem. Through this conceptualization, the problem becomes something that is con-
nected to the context and that impacts all in the context. Systemic conceptualization
influences how the therapist thinks about a case and how he/she might intervene
(Sprenkle et al., 1999; Wampler et al., 2019). In cases where it is necessary to involve
multiple providers, therapists are still able to keep the systemic conceptualization at
the forefront in that there would be communication among providers and shared
goals. Therapists start out with an initial conceptualization that then is changed
throughout the course of treatment as the therapist implements interventions, as fam-
ily members respond to these interventions, and as new data arise out of this process.
Wampler et al. (2019) contend that a key defining feature of the SFT profession is in
how therapists go about conceptualizing the cases with which they work. They con-
tend that SFT is not as much a modality of intervention (who is in the room), but
rather a conceptualization of a problem in its context, and after careful assessment of
this context, the SFT develops interventions that are delivered in collaboration with
the client(s) and that are congruent with the conceptualization of the problem.
Ultimately, the correct conceptualization of the problem is a therapist factor in
which the onus lies with therapists to correctly assess the role of a presenting problem
and come up with and implement interventions in a family system in collaboration
with the family. Skilled therapists seem to be skilled at bringing members of a couple/
family on board with the systemic conceptualization of the problem. For example, key
evidence‐based family therapy models such as emotionally focused couple therapy (S.
M. Johnson, 2015), functional family therapy (Sexton & Alexander, 2003), and brief
strategic family therapy (Szapocznik & Hervis, 2005) have the therapist spend con-
siderable time in sessions conceptualizing the problem through summarizing and
reframing in relational terms. This conceptualization becomes a motivating force for
the couple or family as they work together to change their situation. Therapists who
are conceptualizing problems in relational terms are concerned about the context in
which a problem is embedded. This includes both the historical context and the con-
text in the moment. As a result, SFT therapists will spend time assessing the presenting
problem and its history, relationship factors related to the problem, extended family his-
tory and context, and the larger life context (neighborhood, culture). The therapist will
also assess ways in which the system discusses together or interacts around
the problem. This informs the therapists thinking about how the problem is related
to the family system dynamics. Once the therapist has a good conceptualization of the
problem and its maintenance structure, he or she, in consultation with the family, will
intervene.
Disrupting dysfunctional relational patterns

Disrupting of sequences or patterns of behavior is another common factor unique to
SFT (see Breunlin, Schwartz, and Kune‐Karrer, 1997, for an in‐depth review of
sequences and their interruption). We see the interruption of sequences as integrally
linked with the conceptualization of the problem. In particular, enactments, both
staged and naturally occurring, help the therapist to figure out redundant patterns
(Breunlin et al., 1997). Once these have been established, the therapist looks to find
ways to interrupt or change these patterns. There are multiple ways to achieve this
effect (Sprenkle & Blow, 2004a). Examples of these include directing communication
between members, setting boundaries, and providing new skills to family members to
use in relating to each other (e.g., increased parental monitoring, boundary setting)
and in helping members talk about what is going on behind their behaviors.
Expanding the direct treatment system

Family therapists seek to involve more than just the patient in treatment (Sprenkle
et al., 1999). As a result, family therapists may find themselves working with a patient
inside of the room and his or her family and then also with systems outside of the
room. The direct treatment system includes the patients who are physically in the
therapy room or who are directly involved in the treatment process in some way
(Pinsof, 1995). As Sprenkle et al. (1999) note, therapists who expand the direct treat-
ment system see the impact of therapy as occurring when the therapist engages with a
live system and the immediacy of that system that plays out in the here and now. This
is only possible when these individuals are present together at the same time and the
therapist is able to intervene in the process that emerges. The direct and indirect treat-
ment systems all come into focus during the systemic conceptualization of the prob-
lem. This conceptualization then directs the therapist on where in the system to
intervene. For therapists working in school settings, for example, it is a challenge, due
to limited time and resources, to effectively help a child. This is because the message
often is that the therapist will see an individual problem student for 30 min and then
send him back to his classroom. However, the systemic therapist seeks to understand
other systems that influence the behavior of the child (Sprenkle & Blow, 2004a).
These systems both can be exacerbating the behaviors and can be used as resources to
treat these behaviors. In the case of the child at school, the therapist will learn about
and intervene in a family and extended family outside of the school, in the classroom
with the teacher(s), and in peer systems (Carr, 2019). Any one of these interventions
can have a significant influence on the eventual outcomes of the case.
Expanding the therapeutic alliance

As described earlier, the therapeutic alliance is a core construct in therapy and is
responsible for a sizeable portion of therapeutic change. Yet, the therapeutic alliance
when working with systems is complex, requiring the therapist to connect with
multiple people/subsystems at once, navigate split alliances, and repair alliances while
keeping others intact. This process can be compared to a game of chess at times. The
alliance is made up of three key variables according to Bordin (1979) and is expanded
when working with couples and families (Pinsof & Catherall, 1986): first, the goals of
the alliance, meaning getting the clients and the therapist on the same page in terms
of the goals of therapy; second, connection between the therapist and clients, mean-
ing that there is a bond between the therapist and each client and this bond is condu-
cive to the work of therapy (i.e. do the clients feel connected enough to the therapist
to engage in therapeutic work); and third, the tasks of therapy including activities
engaged in by the therapist and clients, activities usually initiated by the therapist, and
activities that foster the work of therapy. Pinsof (Pinsof, 1995; Pinsof & Catherall,
1986) spent much of his career writing about the expanded therapeutic alliance. The
expanded alliance in SFT is complex as the therapist negotiates a fine balance between
staying connected to each member of the family while at the same time working on
the goals of the family as a whole. Others have also studied the multifaceted nature of
this systemic alliance in family therapy at length (Friedlander, Escudero, &
Heatherington, 2006).
The split alliance There is a strong potential for a split alliance to occur in family
therapy (Friedlander et al., 2006; Pinsof, 1995; Pinsof & Catherall, 1986). There is
evidence from some research studies that the split alliance is a common phenomenon
in working with couples and families (Heatherington & Friedlander, 1990).
Friedlander and Tuason (2000) state this well when they say that “because most fam-
ily problems involve interpersonal conflict of some kind or another, expressing warmth
toward one client may be interpreted as betrayal by another” (p. 797). This is an
important point. The essence of the alliance involves warmth, genuineness, and empa-
thy. Yet, how can a therapist be warm to family members but not to others. Pinsof
(1994) suggests that split alliances can have devastating effects on the outcome of
therapy. He suggests that their effects on the process depend on two factors. The first
is the strength of the split in comparing the intensity of the negative alliance(s) with
the relative strength and intensities of the positive alliance(s). The second factor to
consider is the amount of power in the individual/subsystem with the positive alli-
ance. Pinsof suggests that the positive alliances need to be always with the more pow-
erful systems in the family. Pinsof states in commenting about this process:
The principle is not an argument justifying a lack of concern about the therapeutic alli-
ance with relatively weak subsystems. The ideal is a positive alliance with all subsystems
and on all levels. However, the therapist system should always attempt to analyze the
patient system sufficiently to assess the relative power of the different subsystems in
determining the total alliance and then prioritize the maintenance of a positive alliance
with the most powerful systems. (p. 181)
Within‐couple alliances One study in the past decade examined what is known as the
within‐couple alliance. Between‐system alliances are those the therapist has with each
individual partner in couple therapy, but within‐system alliances are the alliance part-
ners have with each other. In other words, within‐system alliances examine how the
couple who present to the therapy are doing in terms of the bonds, tasks, and goals
they have with each other. In one study, Anderson and Johnson (2010) looked at the
relationship of between‐system alliances and within‐system alliances on couple distress.
These authors concluded that the strength of the within‐couple alliance is predictive
of positive outcomes by as early as the fourth session in couple therapy. This suggests
that the therapist should work to help the couple develop a strong working alliance
within their relationship. They go on to say that while therapists need to have strong
relationships with each individual, these alliances are not as potent if the within‐cou-
ple alliance is low. In this regard, their work suggests that it is particularly important
to get both partners on the same page in terms of the goals and tasks of therapy. They
also suggest that the therapist needs to carefully monitor his/her alliance with each
partner as well as the alliance they have with each other. This is another type of study
that sheds a light on the complexities of working with multiple members in the room.
The relationship between clinical variables and the alliance Some studies have looked
at how different variables in therapy affect the strength of the alliance. In the first
study Knobloch‐Fedders, Pinsof, and Mann (2004)) examined the formation of the
alliance in couple therapy. They concluded that worse alliances were predicted by
higher marital distress while distressed family of origin experiences were predictive of
split alliances. The authors suggest that therapists consider these types of variables as
they intentionally work to build strong alliances with couples. In a second study
(Knobloch‐Fedders, Pinsof, & Mann, 2007), the same authors studied the aspects of
therapeutic alliance and alliance‐related predictors of treatment progress in couple
therapy. Their study concluded that overall, the alliance accounted for 5–22% of the
variance in improvement in marital distress in the sample. For women, the strength of
the mid‐treatment alliance was a strong predictor of improvement in marital distress.
Interestingly, when men’s alliances were stronger than their spouses at the eighth ses-
sion of treatment, these couples showed higher rates of improvement in marital dis-
tress. These types of studies illustrate the complexities and nuances of the alliance in
working with couples. In another study, Knerr and colleagues studied client factors
(age, differentiation levels, prior stress, and depression) on alliance formation. They
concluded that clients who were more likely to engage in emotional cutoffs were less
likely to bond with the therapist. Older clients were also less likely to bond with the
therapist. Many more similar studies are needed to enhance our understanding of how
variables with the therapy process affect therapy.
Therapist variables and the alliance Some studies have begun to look at therapist
variables in building effective alliances (note, most of these studies look at couple
therapy and not family therapy). In one study, Bartle‐Haring, Shannon, Bowers, and
Holowacz (2016) examined therapist differentiation of self and perceptions of the
alliance by couples in therapy. Even though this study did not find an expected asso-
ciation between higher differentiation and a stronger alliance in couple therapy, it is
the kind of study that begins to shed the light on important therapist variables in alli-
ance building. In another study, Sotero, Cunha, Da Silva, Escudero, and Relvas
(2017) examined therapist behaviors in building alliances with involuntary clients.
They concluded that with these cases, therapists worked harder to engage clients in
therapy and to promote a shared sense of purpose with family members. This study
suggests that when a family is sent to therapy involuntarily, therapists need to produce
behaviors early on that engage clients in therapy. These behaviors include understand-
ing the perspectives of the clients, negotiation of therapy goals, and not imposing
tasks or goals on these systems. In addition, creating a safe space early on is critical. In
another study, Sheehan and Friedlander (2015) explored alliance factors in retaining
clients in therapy when they presented for family therapy. These authors found that
when clients displayed negative behaviors and therapists responded with positive alli-
ance‐related behaviors, clients stayed longer in treatment. In addition, therapists who
retained cases worked more effectively in engaging clients, creating safety, and bring-
ing a shared sense of purpose to the therapy. These studies of therapist attributes and
behaviors and their contributions to the alliance in SFT are incredibly important and
many more are needed (Blow & Karam, 2017).
In SFT, the therapist has to be able to manage alliances with more than one indi-
vidual at the same time. The therapist has to be able to manage the alliance with
multiple individuals in the therapy room, repair the alliance when it develop prob-
lems, and balance the alliance depending on the conceptualization of the presenting
problem and its resolution. It is essential that the therapist be seen as a trusting and
caring ally for all concerned. All members of a system should feel a sense of connec-
tion to the therapist and that he or she is there to help individually and collectively. In
SFT, it is also important that the therapist help the system be united in the goals of
treatment,that is, all members of the system are united in the goals of therapy and in
how they see these goals, and that they have a shared sense of purpose. It is also
important that the therapist is able to utilize tasks that are comfortable for all mem-
bers of the system and that help them to achieve these goals. This is a difficult dynamic
to consider as families have different preferences and needs. This may at times mean
that the therapist becomes a key advocate for the best means possible to help the fam-
ily achieve their goals and provides a plausible rationale to those family members who
may be skeptical. However, the studies we reviewed suggest that these alliance pro-
cesses are complex and that variables can influence this alliance (e.g., family of origin,
age, gender). These findings confirm our contention that SFT requires a great deal of
skill and that we need to know much more about the therapists who deliver SFT
interventions and the skills they have in assessing client systems in a way that leads to
strong and effective alliances.
Training
Despite the research findings above, SFT has historically been resistant to focusing
on similarities rather than differences among models (Sprenkle & Blow, 2004a).
Charismatic model developers drove this emphasis on “difference” in the golden
age of the 1970s, each trying to brand what they did as a unique and pure form of
family therapy. These psychotherapeutic “rock stars” toured the country, looking
for new fans from disparate mental health disciplines that would be recruited to
become the first generation of SFT students (Karam, Blow et al., 2015, Sprenkle &
Blow, 2004a).
Recently, attention to common factors has turned toward their role in clinical train-
ing (e.g., D’Aniello & Perkins, 2016; Fife, Whiting, Bradford, & Davis, 2014; Karam,
Blow, et al., 2015). This movement is a reaction to the predominant “choose your
favorite model” approach that has dominated many SFT training programs over the
past several decades (Blow et al., 2007). Although it is natural that some models will
resonate with students more than others, it is unrealistic to believe that the therapists
will stay with one pure model throughout the duration of their careers, especially as
they work with a wide range of clientele and presenting problems. Jay Lebow (1997)
has labeled this movement away from relying one model in favor of adapting a more
integrative style as the “quiet revolution” in couple and family therapy.
Karam, Blow et al. (2015) present a logic for teaching common factors alongside of
specific models. Their rationale includes (a) the meta‐analytic support for the impor-
tance of common factors’ contribution to successful outcome, (b) the integrative
reality of post‐training practice, (c) alignment with American Association for Marriage
and Family Therapy (AAMFT) core competencies, and (d) the evidence‐based move-
ment in psychotherapy (Karam, Blow et al., 2015).
As opposed to a more extreme view of common factors that would completely
denigrate the value of models, advocates for a moderate stance see merit in learning
specific MFT theories and approaches, as many of these as possible (Blow et al., 2007;
Sprenkle & Blow, 2004a). After all, common factors are not “islands,” but rather they
work through models (Sprenkle & Blow, 2004b). Models provide the beginning fam-
ily therapy student structure, organization, and coherence—a therapeutic blueprint to
guide work with client systems. Only when we learn several models really well can we
see the similarities that exist between them.
Karam, Blow et al. (2015) provide specific examples from recently developed
courses and practical strategies for including common factors in SFT training. They
articulate how common factors may be incorporated into existing curricula, taught as
stand‐alone courses, and included in supervision. These methods include innovative
assignments, self‐reflections, clinical role plays, and reviewing client interviews
through a common factors framework (D’Aniello & Perkins, 2016).
While there is a general dearth of SFT common factors training research available,
some preliminary work is supportive of these aforementioned beliefs. Nearly all par-
ticipants in a study by Fife, D’Aniello, Scott, and Sullivan (2018) reported that study-
ing common factors while in an SFT training program increased their sense of
self‐confidence in their ability to help clients. The majority wished they were exposed
to common factors earlier in their training, before revisiting them later in their gradu-
ate curriculum after a more in‐depth exploration of traditional family therapy theories
and models. Participants also indicated that they enjoyed the readings and discussions
about common factors. In a recent qualitative study describing trainees’ experience of
common factors, participants reported increased flexibility in their therapeutic
approach and ability to respond to pressing client needs. Another reassuring finding
was that common factors eased participants’ anxiety about being an unexperienced
therapist. Knowledge of the common factors reminded them that despite their novice
clinician status, they were activating many curative factors in the therapy (D’Aniello,
Alvarado, Hulbert, Izaguirre, & Miller, 2016).
Educators can utilize several recent articles to facilitate learning about common
factors (e.g., D’Aniello & Perkins, 2016; Duncan et al., 2010; Fife et al., 2014;
Karam, Blow, et al., 2015; Karam, Antle et al. 2015; Sprenkle et al., 2009; Sprenkle &
Blow, 2004a, 2004b; Wampold & Imel, 2015). These resources are particularly
useful for students in clinical training because they reinforce a moderate common
factors approach—proclaiming that common factors work through models, rather
than replacing them.
Therapist enhancement
It is clear that the therapist is an important contributor to change in therapy and that
skilled therapists are needed in order to work effectively with couples and families
(Blow & Karam, 2017). There are several things that therapists can do in order to
maximize their clinical work by just focusing on common factors. This is not to say
that therapists should ignore other training opportunities, but therapists can improve
what they are doing by improving in these areas.
Therapist development using deliberative practice Therapists working in SFT need

ways in which they can improve their skills. One way is through deliberative practice
(DP). DP is a growing area of emphasis in therapist improvement literature
(Rousmaniere, 2016). DP focuses on the development of expert performance in ther-
apist delivery, in the same way that a violinist would seek ways to improve on delivery
of a musical piece to an audience. DP suggests that therapists can improve what they
do and that this expert performance takes specific focus and hard work. In addition,
literature suggests that experience, CEUs acquisition, and additional in‐depth train-
ing are insufficient in improving outcomes of therapists. Rousmaniere (2016) sug-
gests five steps that therapists should adopt in order to improve their work (solitary
DP). First, therapists should get into the habit of observing their own work (video
recordings are easily made of therapy sessions). Second, therapists should get expert
feedback on the work from a coach, consultant, or supervisor. Therapists are not good
at evaluating their own performances and having an external individual provide input
is critical. Third, therapists should set small incremental learning goals that lie just
beyond their ability. In this regard, Rousmaniere suggests that therapists do not want
to set goals that are too lofty or too overwhelming. Rather, therapists should set small
and achievable goals that are also somewhat challenging to achieve. Fourth, therapists
should engage in repetitive behavioral rehearsal of specific skills. In family therapy,
numerous skills are required from therapists as they engage with complex systems.
Therapists should know these skills and feel competent in their delivery. For example,
therapists who wish to master the important family therapy skill of reframing should
learn the steps to reframing, practice them in private, practice them in role play, imple-
ment with clients, watch video tapes of the work, consult a supervisor or coach, and
then practice again until the therapist is completely competent in the skill. Fifth,
therapists should continuously assess their performances through client feedback
mechanisms (Rousmaniere, 2016). While the use of DP is not yet fully embraced in
SFT, we see that enhancement of therapist skills to have high potential in our field
given the complexities of the work we do.
Ease of use of common factors feedback instruments SFTs can enhance their effec-
tiveness by tracking client outcomes and progress and feeding this back into their
work (Lappan et al., 2018). As stated earlier, feedback‐informed treatment is deliv-
ering more effective outcomes than treatment as usual, and therapists would do well
to integrate this into their work. Feedback measures are free and simple to imple-
ment and therapists who use them are enhancing the alliance and the voice of the
clients in the therapy work. Although we have argued about the inclusion of out-
come‐informed, real‐time feedback instruments as a part of a common factors per-
spective, there are several challenges that should be addressed before adding this
component to SFT practice. Despite a growing research base suggesting that col-
lecting client feedback improves therapy outcome (Duncan, 2010), a majority of
clinicians do not routinely utilize outcome measures in clinical practice (Hatfield &
Ogles, 2004), especially after leaving their graduate or training program. In fact, a
survey conducted by Hatfield and Ogles (2004) found that only 37% of surveyed
clinicians routinely used some form of outcome measurement. Multiple reasons

have been reported for why this is the case, including some seeing the task as too
time consuming, adding too much paperwork, or adding additional burden to the
client (Hatfield & Ogles, 2004). Most of these critiques are quickly overcome when
therapists begin to use these measures. Other clinicians have acknowledged that
outcome measurement is not implemented as they do not see it as relevant or help-
ful in clinical practice (Hatfield & Ogles, 2004). Again, the growing body of
research evidence seems to contradict this claim. In order to promote engagement
and counter the argument that these feedback studies are long and take up valuable
therapy time to complete, it has been found that therapists may be more likely to
use feedback instruments if they take no more than five minutes to complete, score,
and interpret (Duncan, 2010).
Ongoing debate within the field of mental health

We practice in a professional landscape that still gives preference to specific ingre-
dients and pure models in the world of psychotherapy (Karam, Blow et al., 2015).
Although we see a moderate common factors view as an inclusive and useful frame-
work for SFT practice integration, we also acknowledge both the history and con-
troversies within the field (Karam & Sprenkle, 2010; Sprenkle & Blow, 2004b).
For instance, Sexton et al. (2004) believe that common factors are too general and
that therapists should use manualized approaches or pure models of change for
guidance and direction. In another example, the contextual model that is in align-
ment with a common factors perspective is contrasted with the medical model
more typically associated with RCT research (Wampold & Imel, 2015). SFTs need
to cultivate their own opinions around this issue by educating themselves on the
common factors debate versus specific ingredients debate by reading updated
resources (such as this Handbook) and attending relevant continuing education
offerings.
Use common factors as framework for personal integration to prevent

professional stagnation
After many years of working in a particular style, therapists may find it more challeng-
ing to remain energized and focused on SFT practice. They may become complacent
doing the similar interventions or implementing the same therapeutic model repeat-
edly. Although practicing a specific approach or model may fulfill many initial thera-
pist needs and structure, over time it is completely developmentally normal for
enthusiasm to wane for a specific way of practicing SFT. A common factors framework
accompanied by applied, practical, and user friendly resources may help to alleviate
these feelings and reinvigorate clinical work.
Some continuing education options advocate that getting better at SFT practice
will require the participant to change their current model(s) or way of working.
Speaking to the contrary, the core of future common factors practice strategies will be
designed to tap into existing therapist strengths and passions through personal inte-
gration, not to make SFTs change the “core” of their current clinical identity and
preferred theoretical orientation.
Develop practical, applied common factors resources

Our field should continue to develop common factors practice resources and materi-
als that are far more interactive and engaging, ones that require the clinician to per-
sonalize the content and respond so that, at the end, they have integrated the
knowledge and skills about therapeutic change processes in an organic way, germane
to their preferred style of practicing couple and family therapy.
Therapists in private practice should use these applied common factors resources,
but they should also be available for counseling centers and mental health organiza-
tions to share with all of their employees to help them re‐energize themselves and
engage in a form of self‐supervision. Although some therapists may be more comfort-
able integrating the common factors on their own by reading a book or experiment-
ing with worksheet, others may wish to process and share what they are doing within
the context of their ongoing supervision sessions, staff case consultations, or other
scheduled interactions with colleagues. It may even be desirable to undertake this
process as part of peer supervision or an ongoing support group so that opportunities
can be created for talking about what is evoked during the course of personal integra-
tion of common factors perspective.
As an example of this common factors feedback for practitioners, the Marriage and
Family Therapy Practice Research Network (MFT‐PRN) was recently created to build
a professional community based on research‐informed practice. Therapists choose
measures from a list that best represent their needs. Clients’ outcomes are assessed
regularly, and therapists receive immediate graphical feedback on how clients are pro-
gressing or digressing. Data are pooled to create a large and diverse database while
improving client outcomes (L. N. Johnson, Miller, Bradford, & Anderson, 2017).
Karam and Blow (2020) have developed a new resource to promote personal inte-
gration of common factors into the practice of SFT. Many of the exercises in the book
help therapists assess and monitor the changes experienced in the therapy room
through a common factors lens. This book transforms the best lessons learned from
both clinical wisdom and psychotherapy research into operationalized and practical
common factors skills and interventions.
Research
It is critical that research on common factors/common mechanisms of change
occurs in the SFT field in order to move this line of thinking to a new level. For
example, much of the research on common factors in SFT to date has consisted of
studies that are survey or perception focused (see Blow & Sprenkle, 2001; D’Aniello,
Alvarado, Hulbert, Izaguirre, & Miller, 2016; Davis & Piercy, 2007). While these
studies have brought the field to this point, they do not connect SFT common fac-
tors to actual clinical outcomes but instead help identify possible common factors or
mechanisms in SFT.
Embed common factors research in traditional outcome studies One of the challenges
in studying common factors is that it is a difficult topic to get funded on its own. For
example, research on the therapist (Blow et al., 2007; Blow & Karam, 2017) is clear
that the therapist plays a crucial role in psychotherapy effectiveness and an even bigger
role when it comes to working with couples and families. It makes sense that there
would be a growing number of studies looking at, for example, who the therapist it,
how they are trained, how they make decisions, and how they grow in their clinical
work, and then connecting these to the actual outcomes of clients. However, we know
of very few funders or funded studies that have looked at these important factors in
clinical trials, especially in SFT. One way to get around this is for those who are doing
funded research to include a study of common factors or common mechanisms of
change in the research design. These studies, in addition to their main outcomes, could
study, for example, therapist differences, alliance variables, and the use of formalized
feedback measures. These secondary outcomes would do a great deal to advance the
role of these critical mechanisms in our understanding of change. However, it would
require funders and principal investigators (PI) to make these outcomes a priority in
how they draft their proposals and in how they connect these to the larger study pur-
poses. PIs could build these outcomes into their studies from the outset allowing the
data to be collected at relatively low cost and with little extra work.
Study interventions that cut across models There are interventions that cut across SFT
models. These have been identified in several places (see Sprenkle & Blow, 2004a).
Some of these are not that difficult to study. We suggest that in particular, the
following interventions be studied. First, it is important to study in larger studies,
core common factors, identified in the therapy literature as a whole, but through a
systemic lens. These would include studies of the alliance, but in work with couples
and families. There have already been several studies on this topic (see earlier discus-
sion on the alliance), but we advocate even more studies of the systemic alliance.
Systemic conceptualization is a core SFT common factor. It is a definitive compo-
nent of the SFT field. However, it is also quite difficult to study. For example, innova-
tive studies could go about studying therapists in this early phase of therapy when the
conceptualization occurs and then how this conceptualization plays out and evolves
through the course of therapy.
As described earlier, feedback mechanisms have been connected to improved cou-
ple therapy outcomes when compared with treatment as usual (Anker et al., 2009).
This groundbreaking study was the first to study the use of formalized measures in
work with couples, and the study findings are impressive in favor of the feedback con-
dition. We believe that mechanisms such as this, which focus on common factors/
mechanisms of change, can be the focus of many more studies and will shed a light on
how these work in therapies.
Finally, research on the therapist in SFT is severely limited. In our recent article
(Blow & Karam, 2017), we argue that the therapist who works with couples and fami-
lies faces many challenges and requires many talents. Not all therapists are suited to or
are competent in this work. It is a priority to study these therapists and to learn more
about what makes them excel in their craft, separate from the models they use.
Increase importance and funding for progress (process + outcome) research Different
kinds of research will also lead to a deeper understanding of some of these important
change mechanisms. Progress research, research that is focused on both the process
and related outcomes, is ideal in this regard. Unfortunately, US funders such as NIH
are not funding these types of studies, which limits the types of research that can be
done. Countries, such as Norway, have different mechanisms of funding leading to
important studies that shape psychotherapy understanding (e.g., Anker et al., 2009).
These types of studies are relatively cheap to conduct and shed light on critical and
effective therapy processes. In order for these shifts to occur, researchers need to be
persistent in their seeking out of funds for these kinds of studies. The more studies
show that these types of interventions are as effective or more effective than interven-
tions studied in RCT, the more likely it is that larger funding agencies such as NIH
will come on board to fund these types of studies.
Conclusion
In outlining the main tenets of a common factors paradigm, we hope to provide a

unifying framework to bind us together professionally as both relational healers and
empirically informed systemic therapists. We believe that it is healthy for the field to
undergo a process of self‐reflection and to strive continually to update what we do
based upon what works. In addition to honoring the strong foundations of family
therapy, we also believe that we need to be in step with changes in our field based
upon theory development, new ideas, and research. While the information presented
in this chapter highlights the importance of common factors, the integration of this
knowledge into the research, training, and practice of SFT is still in its infancy.
Nevertheless, enough data exists in the general psychotherapy literature to make a
strong case for the ideas presented in this chapter; however, as we have noted, much
more research is needed in understanding common factors in SFT.
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8
The Process of Change in Systemic
Family Therapy
Nathan R. Hardy, Allen K. Sabey, and
Shayne R. Anderson
Life is a journey, not a destination.

(Ralph Waldo Emerson)
Scaling a mountain is a difficult but worthwhile activity, and one thing every moun-
tain guide knows is that having a map and following an outlined pathway to the sum-
mit is often critical—even lifesaving. In much the same way, having a map and knowing
the pathways to specific outcomes in systemic family therapy (SFT) is imperative.
Much of the research in SFT, however, has focused on whether SFT is effective (see
Carr, 2020, vol. 1, for a definitive review of the outcome research). Without a doubt,
this is an important question—very few people want to scale a mountain without a
view! But, while knowing that SFT works is vital, knowing how it works is equally so.
These two questions—what works and how it works—may be considered two sides of
an SFT effectiveness coin; we cannot have one without the other. Research into how
therapy works is called process research (Orlinsky, Grawe, & Parks, 1994) where spe-
cific questions about the mechanisms and contexts of change and their subsequent
answers can provide guideposts for desired therapeutic outcomes. Process research has
led to many important advances and clarity in individual psychotherapy (Tompkins &
Swift, 2015); however, SFT is, simply put, a different mountain to climb.
We begin this chapter by describing the challenge and opportunity of clearly defin-
ing systemic process research. We then take a close look at the processes of change
that have been explored among various schools of therapy and empirically supported
treatments (ESTs). Afterward, we make a case for identifying common and specific
systemic process factors that can be drawn upon by all therapists seeking to do sys-
temic work regardless of their professional or model orientation. This synthesis and
integration provides an invaluable resource for a new generation of process‐informed
systemic therapists. Subsequently, we describe how the current process findings can
be integrated into training programs and practice.
172 Nathan R. Hardy, Allen K. Sabey, and Shayne R. Anderson
Defining SFT Process Research
In 1989, William Pinsof provided the first definition of SFT process research as
follows:
Family therapy process research studies the interaction between therapist and family
systems. Its goal is to identify change processes in the interaction between these sys-
tems. Its data include all of the behaviors and experiences of these systems and their
subsystems, within and outside of the treatment sessions, that pertain to changes in the
interaction between family members and in their individual and collective levels of
functioning. (p. 54)
This definition acknowledges various systemic factors that SFT process researchers
should be concerned about. For example, a systemic family therapist must balance
alliances with different family members simultaneously and alter interactions between
them in sessions. This level of process is complex and quite unique to SFT and deserves
particular attention in our research. The above definition also provides a broad view
of what process research entails. Whereas the distinction between process and out-
come provides a helpful dichotomy, it can also be somewhat arbitrary as the two are
mutually influencing and encompass a circular process in which change processes can
represent desired outcomes and desired outcomes may be processes that predict
future change (Pinsof, 1989). Hence process and outcome represent evolving and
circular constructs that inform one another—like a spinning coin. As Pinsof puts it,
“all family therapy research [is] process research.”
Some opt for a narrower definition that emphasizes therapy‐specific processes
including therapist intervention and client responses that occur within treatment ses-
sions, as opposed to investigations of inputs (e.g., pretreatment conditions) and out-
puts (e.g., clinical progress; Oka & Whiting, 2013). Although this definition simplifies
matters, we cannot adequately understand and derive implications from research that
does not place these therapeutic processes in their proper context (i.e., accounting for
the input and output variables). Therefore, in this chapter, while we generally evaluate
the within‐session change processes as our central focus, we also place these within a
larger backdrop of other important contributing factors that define the processes of
change in therapy—which we describe next.
Disentangling process variables

When we investigate outcomes, we are generally looking at what has been termed “big
O” outcomes, or the more distal, end of treatment, outcomes (Kiesler, 2004). These
are usually predefined outcomes representing the main targets (presenting problem/
symptom/disorder) of therapy. This is an important distinction because there are many
proximal, or “little o,” outcomes of therapeutic processes that are related to these
larger targets and should be closely inspected in connection with in‐session change
processes (Kiesler, 2004). For example, some ESTs seek to reduce adolescent sub-
stance abuse (the big O), but what often precedes this reduction are changes in family
functioning (the little o), something systemic therapies specifically target through join-
ing, reframing, and enactments. Thus, “little o” outcomes often represent mediating
change processes. They are important to recognize when evaluating process research,
Processes of Change in SFT 173
because there are many indirect pathways, or mechanisms of change, in which inter-
ventions reach desired outcomes in therapy and are part of the larger map of how
therapy works (they are like the mini‐summits on the way to the major summit of a
mountainous trek). Therapeutic processes (e.g., within‐session events) are also often
considered mechanisms of change, or mediators of outcomes.
On the other hand, moderating variables generally represent relatively static
variables that provide conditions for therapeutic change, such as characteristics of
the client, therapist, and external systems. These not only include contextual
membership factors such as client race, therapist gender, or strength of a neigh-
borhood, but can also include therapy‐centered factors such as client’s pretreat-
ment distress level, therapist treatment adherence (or fidelity), or the number of
family members directly involved in therapy (Heatherington, Friedlander, &
Greenberg, 2005). Before planning for a mountainous trek, it is important to
check the weather first—the conditions have a lot to do with how hazardous or
stable the journey will be.
In sum, there is an important backdrop to the nitty‐gritty work of unpacking how
therapeutic processes make treatment work that cannot be ignored. For simplicity, we
opt for a more therapy‐friendly language that provides two important definitional
points: mechanisms of change (mediators) and contexts of change (moderators) in which
both may encompass in‐session and out‐of‐session characteristics and processes.
Hence, our review that follows will describe and evaluate the mechanisms and con-
texts for systemically oriented therapeutic change that exist in the literature.
Defining systemic processes of change

Process research from general psychotherapy usually considers the characteristics of an
individual client, therapist behaviors directed toward the individual client, and the
individual client response. We have learned much from, and are grateful for, the clini-
cal wisdom and research generated from within individual psychotherapy. SFT, how-
ever, must cast a wider net. Placing a problem between two, three, or more clients
brings the totality of each individual and the relationship between them together into
one “client system.” What’s more, a therapist’s behaviors must be multidirected, and
mixed responses from family members may be apparent from total engagement in one
to total disengagement in another. Individual characteristics, of course, matter in all
of this, but the processes of systemic therapy are more complex. Even when working
with individual clients, there is always a direct and indirect (i.e., there are usually peo-
ple involved in or aware of the problems of the client) client system that SFTs ideally
attend to (Pinsof, 1995). This chapter articulates those systemic processes that exist
in the literature.
Process Research on the General Schools of Family Therapy
Graduates from SFT master’s training programs are usually taught and learn to prac-
tice from the core set of schools of family therapy rather than from manualized treat-
ments typically tested in randomized controlled trials (RCTs). Although this type of
training remains controversial (e.g., Dattilio, Piercy, & Davis, 2014), we have chosen
to comment on the process research from these general schools of therapy so as to

provide research guidance on their use by students and practitioners.
Modern and systemic models

In spite of the modern (“positivist”) epistemological climate of yesteryear, the earliest
traditions of family therapy did not generally pursue research support, and hence
there is little (if any) process research to date. For example, Bowen family systems
therapy and psychoanalytic family therapy have no outcome or process research
(except for some rare case studies) nor have they been well integrated into couple‐ or
family‐focused ESTs (insight‐oriented couple’s therapy is one exception to this;
Snyder & Wills, 1989). Two recent studies (van der Meiden, Noordegraaf, & van
Ewijk, 2018a, 2018b), however, qualitatively explored the process of change in con-
textual family therapy—sometimes categorized among psychoanalytic or intergenera-
tional traditions. Three primary therapist behaviors were used by contemporaries
including eliciting care patterns, exploring the client’s situation, and directing the
process. Other common methods included empathy, acknowledgment, dialogue, and
addressing the past. An analysis of Ivan Boszormenyi‐Nagy’s therapy identified multi-
directed partiality (e.g., balancing alliances), uncovering the balance of give and
receive, and executing a transgenerational maneuver as the most common methods.
The school of cognitive‐behavioral family therapy has greater research support,
though this usually comes in the form of research on ESTs (parent training programs,
functional family therapy, and various behaviorally oriented couple therapies), which
we describe later.1
Strategic, experiential, and structural models have limited process research, but
these models have formed the basis of several of the current adolescent‐focused fam-
ily‐based ESTs where process research has been explored more extensively. No pro-
cess studies have ever been conducted on the three traditional strategic models
(MRI, Haley–Madanes, and Milan) nor on Satir’s experiential (human validation
process) model. Whitaker’s symbolic experiential family therapy was explored only
through one qualitative analysis, which identified several processes of change (Mitten
& Connell, 2004) including shifting focus from the identified patient to the family
system, “joining” the family system, shifting from content to the family’s use of sym-
bolism, using anxiety to trigger growth (especially when therapy is stuck), amplifying
the family’s symbolic experience, and exiting the family system. A qualitative analysis
of structural family therapy (M. Nichols & Tafuri, 2013) identified 25 different ways
therapists moved families from a linear to a systemic understanding of the problem
following a four‐step assessment process: “(1) broadening the definition of the pre-
senting complaint to include its context, (2) identifying problem‐maintaining inter-
actions, (3) a structurally focused exploration of the past, and (4) developing a shared
vision of pathways to change” (p. 207). Minuchin’s “stroke and kick” form of ther-
apy (Minuchin, 1974) received empirical support in that actively eliciting, empathiz-
ing with, and accepting family member’s points of view were important prerequisites
to challenging and restructuring their interactions and led to more successful in‐ses-
sion changes (Hammonds & Nichols, 2008). Further, the elements of successful
versus unsuccessful enactments—an important part of Minuchin’s restructuring pro-
cess—was explored (M. P. Nichols & Fellenberg, 2000), the details of which are
described later.
Postmodern models
In spite of “post‐positivist” sentiments, postmodern models, such as solution‐focused
and narrative therapies, emerged when process research had become more common-
place. Further, although these models came out of SFT, they are widely recognized
for their suitability in individual psychotherapy and have become widely popular.
Hence, these schools of therapy have more process research though much of it often
represents individual therapy processes. For instance, solution‐focused therapy has an
impressive pool of research; a meta‐analysis conducted on 33 process research studies
(Franklin, Zhang, Froerer, & Johnson, 2017) found that the co‐construction of
meaning and strength‐oriented techniques were the most empirically supported
mechanisms of change.
Nine of the 33 studies, however, did deal specifically with couple or family work.
Two case studies demonstrated how therapists push for and maintain a focus on
exceptions and solutions in couple therapy (Franklin, 1996; Gale & Newfield, 1992).
Creating a focus on future‐oriented goals and a context for positives and strengths in
the first session helped families experience more compliance with treatment, clarity of
treatment goals, and improvement in the presenting problem (Adams, Piercy, &
Jurich, 1991), though this was generally not more impactful than a problem‐focused
approach—except on ratings of sessions being more smooth, impactful, positive,
deep, and leading to more optimism about the problem (Jordan & Quinn, 1994).
However, one study found mothers of a child with intellectual disabilities to find the
miracle question irrelevant though SFBT techniques did help facilitate a therapeutic
relationship and increase self‐efficacy (Lloyd & Dallos, 2008); another study found
executive and joining skills to be more predictive of outcome than solution‐focused
interviewing with families (Shields, Sprenkle, & Constantine, 1991); and finally, one
study found the technique of asking about pretreatment changes was not related to
change in outcome and pretreatment changes did not appear to persist (L. N. Johnson,
Nelson, & Allgood, 1998). Needless to say, there are likely some aspects of solution‐
focused therapy that are more effective than others and some of this may depend on
the context. Mainly, this research suggests that an overall focus on positives, strengths,
future‐oriented goals, and solutions can help create a context for hope and optimism
as therapists address problems, provide support, and seek to create change.
We located a total of seven SFT process studies of narrative therapy (we found 12
individual‐focused process studies). A qualitative analysis of eight families’ experience
of narrative therapy highlighted commonly emphasized therapeutic processes includ-
ing externalizing conversations, unique occurrences, personal agency, and reflecting
teams (O’connor, Meakes, Pickering, & Schuman, 1997). A textual analysis of
Michael White doing couple therapy found an overarching theme of “decentering”
the couple’s unfolding narrative and its embeddedness in the larger cultural discourse
by using matching/self‐disclosure, reciprocal editing, turn management to de‐objec-
tify, expansion questions, and reversals (Kogan & Gale, 1997). Another study of eight
families comparing successful and unsuccessful sessions explored a model of practice
and outlined a successful change process: family members express their individual
views, family members experience an affective change as new stories emerge, and hope
and the possibility of change are acknowledged. Noteworthy in this study is that
acknowledging family structure and generational patterns were common to trans-
formative experiences (Coulehan, Friedlander, & Heatherington, 1998).
An intervention was used to help families dialogue about emotional disorders and
found that informal codes/norms about these disorders keep them private, but when
therapists provide a perspective about the importance of dialoguing, it led to new
shared meanings (Focht & Beardslee, 1996). One interesting study on how families
talk about domestic violence found that when families voice hesitation, and therapists
respond by voicing reassurance, families are more likely to tell their stories about it
(Rober, von Eesbeek, & Elliot, 2006). Finally, Ramey and colleagues explored the
new use of scaffolding conversations with children and found that therapists are able
to move children through the process (name, consequences, evaluate, intentions, and
plans) in one session (Ramey, Tarulli, Frijters, & Fisher, 2009; Ramey, Young, &
Tarulli, 2010). Similarly to solution‐focused therapy, these studies suggest that narra-
tive therapy also creates an optimistic context though their methods somewhat differ
with a clear focus on re‐storying clients lives by assisting the family in clarifying and
expanding new narratives that bolster personal agency and new shared meanings.
Summary of the traditional schools of SFT

In spite of polarized traditions (e.g., modern versus postmodern), the process studies
conducted on the traditional schools of SFT illuminate several core methods of prac-
tice that find some common ground in spite of their differences. Building balanced
alliances that emphasize warmth and acceptance of family members while shifting
families focus toward systemic patterns, positives moments, or new stories are com-
mon trends in engaging and motivating family members in the process of change.
Creating change also often involved an emphasis on new dialogue, interactional
change, and personal responsibility/agency – all prompted by the SFT in various dif-
ferent ways.
There may be important differences that leverage change in unique ways—the suc-
cess of which may depend upon context specific variables (e.g., the issue of concern,
the motivation of family members, the worldview of the therapist). At this point,
however, there is insufficient research on which change processes matter more in
which contexts simply by evaluating the traditional schools of SFT. Incidentally, this
research may, in some cases, affirm the prospect of integrating methods (e.g., narra-
tive therapy’s use of intergenerational and structural dynamics; Coulehan et al.,
1998). While some of the schools of SFT have received more process attention than
others, many of them have formed the basis of ESTs that have been more central in
SFT research.
Process Research in Empirically Supported Treatments in SFT
Some argue that the general schools of family therapy are too broad to provide suffi-
cient guidance on SFT practice and research exploring mechanisms and contexts for
change (Sexton & Datchi, 2014). Regardless, the emergence of highly specialized
integrative treatments for specific issues and populations—which incorporate ele-
ments from various schools of therapy—have become the center of research in SFT
(Sexton & Datchi, 2014). What follows is a review of the process research that has
emerged in both family‐focused and couple‐focused contexts. As each model provides
a unique context in which SFT is practiced, we highlight the mechanisms of change

by model followed by a synthesized review of contextual variables.
Mechanisms of change in family therapy models

Multisystemic therapy Multisystemic therapy (MST) is a home‐based family therapy
approach developed to help youth with serious antisocial behavior and a high risk of
out‐of‐home placement. It draws upon a socio‐ecological framework that empowers
caregivers with resources, skills, and support from the community (Henggeler &
Schaeffer, 2016). In several RCTs of MST, improvements in parenting and family
relations and reductions in associations with deviant peers were found to decrease
delinquency (Huey, Henggeler, Brondino, & Pickrel, 2000) and antisocial behaviors
(e.g., Dekovic, Asscher, Manders, Prins, & van der Laan, 2012) in adolescents. These
broader mechanisms have also been identified in uncontrolled studies (e.g., Tiernan,
Foster, Cunningham, Brennan, & Whitmore, 2015) and qualitative investigations
(e.g., Kaur, Pote, Fox, & Paradisopoulos, 2015) where the therapeutic alliance, fam-
ily functioning, parenting skills, and removing negative peer influences have all been
attributed to sustained positive changes. Several therapist behaviors, including teach-
ing, focusing on strengths, reinforcing statements, problem solving, and dealing
with family needs, increased caregiver engagement and/or positive response (Foster
et al., 2009).
Multidimensional family therapy Multidimensional family therapy (MDFT) is a fam-

ily‐based treatment used particularly with youth substance abuse and antisocial behav-
iors that draws upon developmental‐contextual and dynamic systems frameworks
(Liddle, 2016) to reshape family functioning. MDFT improved parental monitoring,
which decreased adolescent drug use, and overall parenting skills, which decreased
youth symptoms (Henderson, Rowe, Dakof, Hawes, & Liddle, 2009). Interventions
focused on changing family interactions were associated with reduction in drug use
and emotional and behavioral problems (Hogue, Liddle, Dauber, & Samuolis, 2004).
In a task analysis (G. S. Diamond & Liddle, 1999), specific therapist behaviors associ-
ated with defusing negative interactions included actively blocking, diverting, or
addressing and working through negative affect; implanting, evoking, and amplifying
thoughts and feelings that promote constructive dialogue; and creating emotional
treaties among family members (through separate and conjoint sessions).
The therapeutic alliance with both adolescent and parents has been associated with
treatment retention and positive outcomes including decreased drug use and treat-
ment completion in several studies (e.g., Robbins et al., 2006). Specific alliance‐form-
ing behaviors associated with improved adolescent engagement included attending to
the adolescent’s experience, formulating personally meaningful goals, and presenting
one’s self as the adolescent’s ally (G. M. Diamond, Liddle, Hogue, & Dakof, 1999).
Functional family therapy Functional family therapy (FFT) combines systemic and
cognitive‐behavioral theories to address several behavioral problems of youth and their
families by focusing on the function or “payoff” of certain behaviors (Robbins,
Alexander, Turner, & Hollimon, 2016). Studies emphasize improvement in several
family functioning variables (supportive communication, positive interactions, positive
perceptions, parent involvement) as key mechanisms of change in positive outcomes
(Robbins et al., 2016). Early findings highlighted the importance of early engagement
and motivation mechanisms, which led to a more active “frontloading” approach to
early treatment sessions (Robbins et al., 2016). For instance, early alliance imbalances
(good alliance with parent but not adolescent) were associated with early dropout
(Robbins, Turner, Alexander, & Perez, 2003). Therapist relational skills were more
important than structuring skills in creating change (Alexander, Barton, Schiavo, &
Parsons, 1976). Whereas early family negativity increased risks for dropout, improve-
ments in communication by the end of treatment were associated with positive out-
comes (Alexander et al., 1976). Further, therapist reframing reduced negative
expressions in early sessions (e.g., Robbins, Alexander, & Turner, 2000).
Brief strategic family therapy Brief strategic family therapy (BSFT) integrates struc-
tural and strategic concepts and strategies to change the patterns of family interactions
that allow or encourage problematic adolescent behavior such as drug and alcohol
use, delinquency, association with antisocial peers, and unsafe sexual behaviors
(Horigian, Anderson, & Szapocznik, 2016). Process research indicated that negativ-
ity in family interactions during the first session led to retention problems (Fernandez
& Eyberg, 2009), but families were more likely to engage in treatment if negativity
was reduced through restructuring (Robbins et al., 2000). Early engagement also
required therapists to maintain a balanced alliance with the parent and adolescent;
imbalance led to early dropout (Robbins et al., 2000). Reframing appears to be the
therapist behavior least likely to damage therapists’ alliance with family members
(Robbins et al., 2006). Robbins, Feaster, Horigian, Puccinelli et al. (2011) examined
therapist’s adherence to the model using data from BSFT’s large effectiveness trial by
analyzing four technique domains: therapist joining, tracking and eliciting enact-
ments, reframing, and restructuring. Each domain predicted higher retention.
Whereas joining behaviors often decreased over time (as expected) and restructuring
increased over time, when joining had smaller declines and restructuring had larger
increases, there were better adolescent drug outcomes. Joining was also key to improv-
ing family functioning.
Attachment‐based family therapy Whereas MST, MDFT, FFT, and BSFT focus on
more systemic‐behavioral theories and externalizing symptoms, attachment‐based
family therapy (ABFT) emphasizes a systemic‐experiential/emotional approach for
internalizing symptoms. In ABFT, attachment theory is applied to the treatment of
adolescent depression and suicidal ideation by healing and strengthening the attach-
ment bond between parents and children (G. Diamond, Russon, & Levy, 2016).
Emotional processing by family members over the course of treatment was related to
decreases in psychological symptoms (G. M. Diamond, Shahar, Sabo, & Tsvieli,
2016). Decreases in parents’ psychological control and increases in autonomy grant-
ing led to some improvement in attachment security and depressive symptoms
(Shpigel, Diamond, & Diamond, 2012).
ABFT is made up of five therapeutic tasks (relational reframe, adolescent alliance,
parent alliance, reattachment task, and autonomy promoting), most of which have
been empirically investigated. The relational reframe redefines the goal of treatment
from “fixing the adolescent’s pathology” to repairing and strengthening family attach-
ment relationships (G. Diamond & Siqueland, 1998). Process studies found that
therapists’ use of relational reframing helped parents see the problem relationally,
maintain that relational frame, and decrease their negativity (e.g., G. Diamond,
Siqueland, & Diamond, 2003). Qualitative interviews also indicated that adolescents’
expressions of strong attachment‐related emotions helped parents view the problems
as relational (G. Diamond et al., 2003).
Although there is no current research on the adolescent alliance task, there was a
task analysis done on the parent alliance: across five stages, the therapist (a) expresses
concern and acknowledges the parents’ efforts, (b) explores and empathizes with the
parent regarding personal challenges faced throughout life, (c) focuses on the par-
ent–adolescent relationship by reframing the problem in relational terms, (d) defines
and works on goals and relevant tasks of therapy, particularly around increasing secu-
rity of the parent–adolescent attachment bond, and (e) highlights the parent’s
strengths and abilities to increase their confidence and motivation to move forward in
addressing the adolescent’s challenges (G. Diamond et al., 2003). The quality of this
parent alliance predicted parents’ positive behavior in the subsequent attachment task
(Feder & Diamond, 2016).
The reattachment task helps parents and children engage in conversation to heal
attachment ruptures and increase attachment security. Preliminary support was found
for three stages: (a) adolescent disclosure of emotions and attributions about relevant
events, (b) parent disclosure of their limitations and experiences to increase the ado-
lescent’s understanding, and (c) parent–child dialogue consisting of mature self‐dis-
closure, reciprocity, and forgiveness (G. Diamond et al., 2003). There is currently no
published research on autonomy promoting (parents supporting children in resolving
concerns external to the family), the final task of ABFT. In sum, the process research
on ABFT highlights how addressing emotional processes within and between parent
and adolescent helps adolescents to express their emotions to parents and parents to
respond to them in attachment‐promoting ways.
Summary of the mechanisms of change Key findings from this review emphasize key
mechanisms between SFT and outcome—changes in the family system, parental func-
tioning, and removing the adolescent from negative peer influences. Of course, sev-
eral therapist behaviors and therapeutic processes appear to be invaluable in making
this process happen: developing a positive relationship with both parents and adoles-
cents and balancing the alliance between them, reframing how families view the prob-
lems and the relationship and focusing on strengths, and restructuring those
relationships in order to decrease negativity and foster hope by blocking negative
behavioral patterns, shifting toward deepened emotional connections, promoting
constructive dialogue, and reinforcing better patterns were all generally consistent
processes in engaging families in the process of change, reducing negativity, improv-
ing parental functioning and family system dynamics, and ultimately reducing prob-
lematic adolescent behaviors and symptoms. It is important to note the stark contrast
between the behaviorally oriented (MST, MDFT, FFT, and BSFT) and emotionally
oriented models (ABFT) in how they approach the change process. Amidst their com-
mon factors (active‐directive, balanced alliances, relational reframes, restructuring,
etc.), their diverse ways of achieving therapeutic change are in harmony with their
differential foci on externalizing (behavioral) and internalizing (emotional) symptoms
and problems. We believe therapists working with parents and adolescents need to be
well versed in treating both types of issues and must develop skills in working within
these common patterns and navigating between their unique differences.
Contexts of change in family therapy models

There are several contextual variables that do influence the likelihood of successful
treatment in adolescent‐focused family therapy. In terms of demographic client fac-
tors, results are mixed. Client race, gender, socioeconomic status, and age generally
did not differentiate successful and unsuccessful cases in MST (Henggeler & Schaeffer,
2016). Both male and female youth responded well to FFT (Baglivio, Jackowski,
Greenwald, & Wolff, 2014). However, communication processes in session were
moderated by family role and therapist gender in FFT (e.g., Newberry, Alexander, &
Turner, 1991). Further, caregiver race, financial hardship, and therapist–caregiver
racial match occasionally moderated the relationship between other therapist and car-
egiver behaviors in MST (Henggeler & Schaeffer, 2016). Indeed, in FFT, alliance
imbalances were found only among Hispanic families, but not white families (Flicker,
Turner, Waldron, Brody, & Ozechowski, 2008), and ethnic match (between therapist
and family) was related to greater reductions in substance use for Hispanic youth only,
not for White youth (Flicker, Waldron, Turner, Brody, & Hops, 2008). Additionally,
addressing cultural and racial/ethnic themes increased adolescent participation in
treatment in MDFT (Jackson‐Gilfort, Liddle, Tejeda, & Dakof, 2001). Hence, in
some cases, differences such as race may be more salient to clients, and therapists who
effectively attend to these contexts may be more successful.
Levels of severity in several factors may also impact the likelihood of success. High
narcissism and callous traits in youth predicted less favorable outcomes in MST
(Manders, Dekovic, Asscher, van der Laan, & Prins, 2013). Families with more severe
conflict and pessimism were the least likely to change in MDFT. Further, negative
peer involvement, such as gang affiliation, was associated with treatment failure (e.g.,
Boxer, Kubik, Ostermann, & Veysey, 2015) and less decline in aggression and delin-
quency (Ryan et al., 2013).
Treatment adherence has also been explored as a contextual variable and was asso-
ciated with better outcomes in internalizing and externalizing symptoms, family
cohesion, and conflict in MDFT (e.g., Hogue, Dauber, Samuolis, & Liddle, 2006)
and higher retention in BSFT (Robbins, Feaster, Horigian, Puccinelli et al., 2011).
Further, a minimal dose of FFT (seven to eight or more sessions) predicted good
clinical outcomes, though quick movement through the process increased the posi-
tive effects (e.g., Robbins et al., 2003). Taken together, when contextual factors are
accounted for in family therapy, they nearly always provide a better understanding of
the conditions in which treatment is successful providing guidance toward those
areas that may need special focus and attention for successful therapy to occur,
including race and ethnicity, gender, individual psychopathology, and severity of
family conflict.
Mechanisms of change in couple therapy models

Behaviorally focused couple therapies Traditional behavioral couple therapy (TBCT)
is rooted in behaviorism and emphasizes reinforcement principles and skill‐building
exercises for couples (Fischer, Baucom, & Cohen, 2016). Integrative behavioral cou-
ple therapy (IBCT) maintained some of TBCT’s skill‐building focus but introduced
“acceptance” in order to address the difficulty couples had changing around polar-
ized issues (Roddy, Nowlan, Doss, & Christensen, 2016). A separate evolution of
behavioral models includes cognitive‐behavioral (Fischer et al., 2016) and mindful-

ness‐based approaches; however, processes of change within these approaches have
never been empirically investigated to our knowledge. While TBCT has substantial
outcome research support, the only substantial research on processes of change was
evaluated as part of a large comparative RCT of TBCT and IBCT—hence we simul-
taneously reviewed the process research on both models as both shared many simi-
larities. It is important to note, however, that while therapist behaviors and change
events were not explored, the pathways of change for particular variables were.
Self‐report measures were first analyzed (Doss, Thum, Sevier, Atkins, & Christensen,
2005). In both TBCT and IBCT, improvements in the frequency of a partner’s self‐
reported target, positive, and negative behaviors during the first half of therapy were
related to early increases in satisfaction. During the second half of therapy, these asso-
ciations washed out and rates of improvement were no different between the models.
Wives’ early acceptance of husband’s positive behaviors lead to early satisfaction and
husband’s early acceptance of wives’ negative behaviors lead to early satisfaction.
Increases in positive communication and decreases in negative communication both
predicted changes in relationship adjustment in the expected directions for both mod-
els. Spouses in TBCT, however, experienced greater changes in their partner’s behav-
ior during the first half of therapy, and the association was stronger between changes
and satisfaction. Spouses in IBCT experienced greater improvements in acceptance of
partner’s target behaviors across the entire course of treatment. Acceptance improve-
ment in IBCT increased relationship satisfaction during the first half of treatment for
husbands and the second half of treatment for wives (Doss et al., 2005).
Observational analyses also assessed how changes in communication were related to
changes in relationship satisfaction (K. J. Baucom, Sevier, Eldridge, Doss, &
Christensen, 2011; Sevier, Eldridge, Jones, Doss, & Christensen, 2008). In both
TBCT and IBCT, increased problem solving and positivity during problem discus-
sions were associated with greater relationship satisfaction for both spouses at post-
treatment and, for wives only, at 2‐ and 5‐year follow‐up, whereas negativity during
discussions was related to lower satisfaction for both spouses at posttreatment.
Withdrawal behavior during conversations about personal problems were related to
decreased satisfaction for wives, but when husbands decreased withdrawal behavior,
wives experienced greater satisfaction at 2‐year follow‐up. IBCT couples experienced
fewer improvements in communication than TBCT couples but demonstrated better
maintenance of their improvements. IBCT and TBCT demonstrated different pat-
terns of change in observed behaviors: IBCT couples had an initial increase in nega-
tive communication and decrease in positive communication in the first half, but
positive and negative communication improved in the second half, whereas TBCT
couples experienced early improvement in both during the first half but deterioration
during the second half of treatment (Sevier, Atkins, Doss, & Christensen, 2015).
In sum, early changes in self‐reported behavior, communication, and acceptance
were important predictors of early increases of relationship satisfaction in both IBCT
and TBCT. Further, observed communication behavior during treatment was important
in understanding relationship adjustment following treatment for both models. While
these changes occurred in both models, several differences between them highlight their
core emphases. TBCT couples experienced more behavioral change early in treat-
ment, and these behavioral changes were more important for TBCT couples. IBCT
couples, on the other hand, experienced more acceptance throughout therapy, which
was also more important for these couples in predicting adjustment. It would almost
appear as if couples “buy in” to the model’s premise and evaluate their adjustment
according to how well they “fall in line” with the model’s posited values. Also note
that while more significant behavioral changes occurred in TBCT, IBCT was better at
maintaining their changes in the long term.
Emotionally focused couple therapies Emotionally focused couple therapy (EFT) is

rooted in attachment theory and draws primarily upon systemic and experiential
principles (Wiebe & Johnson, 2016). EFT was co‐developed by Greenberg and
Johnson (1988) and diverged into two models with theoretical and practical differ-
ences: emotionally focused couple therapy (EFT) S. M. Johnson, 2004) and emo-
tion‐focused therapy for couples (EFT‐C) (Greenberg & Goldman, 2008).
Therapist’s “emotional presence” (i.e., an awareness of and responsiveness to clients’
emotions) and therapist’s ability to access and deepen emotional experiences in EFT
were associated with greater warmth behaviors and emotional experiencing by clients
and successful change events (e.g., Furrow, Edwards, Choi, & Bradley, 2012).
Several studies demonstrated that greater emotional experiencing (i.e., feeling,
exploring, and organizing emotions in session) by couples was strongly associated
with more positive outcomes (e.g., Greenman & Johnson, 2013; S. M. Johnson &
Greenberg, 1988; Makinen & Johnson, 2006). EFT‐C research found client’s
expression of underlying attachment‐related emotions (e.g., fear) related to positive
post‐session ratings and overall treatment outcomes (Greenberg, Ford, Alden, &
Johnson, 1993; McKinnon & Greenberg, 2013).
EFT also works to improve interactions between partners in session through enact-
ments and affiliative responding (disclosure of emotions and sensitive responses;
Greenberg et al., 1993; Tilley & Palmer, 2013). Two specific enactments or “key
change events” are withdrawer reengagement and pursuer softening. Lee, Spengler,
Mitchell, Spengler, and Spiker’s (2017) task analysis of withdrawer reengagement
found several processes that lead the withdrawn partner to become more connected:
(a) aiding the withdrawer to identify and experience their attachment‐related fears
and needs in session, (b) facilitating the expression of those fears and accompanying
needs with their partner, and (c) helping the partner to respond in a supportive man-
ner. Bradley and Furrow’s (2004) task analysis of pursuer softening likewise found
similar processes that lead the pursuer to shift from being overly hostile/critical to
asking for reassurance or comfort from a more vulnerable position (softening): (a)
facilitating the pursuer’s emotional experience of underlying attachment fears and
needs, (b) directing the sharing of those fears and needs to their partner, and (c) sup-
porting the partner to respond with support and reassurance. The pursuer‐softening
event occurred with “successful” couples but not with “unsuccessful” couples (S. M.
Johnson & Greenberg, 1988), and the completion of this change event increased
relationship satisfaction and decreased attachment insecurities for couples (e.g.,
Dalgleish et al., 2015).
Specific interventions used in the pursuer and withdrawer tasks included heighten-
ing emotion, evocative questioning and responding, heightening present and chang-
ing positions, empathic conjecture/interpretation, reframing, validation, and
restructuring and shaping interactions (Bradley & Furrow, 2004; Lee et al., 2017). In
a follow‐up study, Bradley and Furrow (2007) identified common therapist missteps
that interfered with the pursuer‐softening change event: an absence of an attachment
lens when working with emotions, only talking about rather than feeling attachment
emotions, an avoidance of attachment‐related fears, a lack of differentiating internal
view of self and view of other, and not having the pursuer actually “reach” for the
other through disclosing their fears and needs. This softening process for couples
occurs then as therapists intervene in ways to help both partners to experience and
express their attachment‐related emotions and to respond productively to the others’
vulnerable expressions.
EFT also aims to heal attachment‐related emotional injuries, defined as “a per-
ceived abandonment, betrayal, or breach of trust in a critical moment of need for
support expected of attachment figures” (Makinen & Johnson, 2006, p. 1055). The
therapeutic process developed for this healing is referred to as the Attachment Injury
Resolution Model (AIRM) (S. M. Johnson, Makinen, & Millikin, 2001). The most
salient steps of the model have been identified (i.e., injured partner expressing vulner-
able emotions, offending partner acknowledging the impact and expressing remorse,
injured partner accepting the apology and expressing attachment needs, and offend-
ing partner responding in an affiliative manner) and validated through several task
analyses. The AIRM has been shown to effectively discriminate between resolved and
unresolved couples as evidenced by greater emotional experiencing, more affiliative
responding in sessions, and more positive overall outcomes (e.g., improvements in
attachment security), which were sustained over time (e.g., Makinen & Johnson,
2006; Zuccarini, Johnson, Dalgleish, & Makinen, 2013). Interventions for this task
included empathic reflection, validation, empathic conjecture, evocative responding,
and heightening and the systemic interventions of track and reflect, reframe, and
restructuring and shaping interactions. Researchers of EFT‐C also developed a pro-
cess model for resolving emotional injuries with many steps similar to the AIRM
(Meneses & Greenberg, 2011). The model consists of three main markers: the offend-
ing partner’s expression of shame, the injured partner’s acceptance of the shame, and
in‐session expression of forgiveness. Applying the model has promoted forgiveness
and decreases in marital distress (Meneses & Greenberg, 2014).
Lastly, Swank and Wittenborn (2013) examined the process by which an EFT ther-
apist worked to repair a rupture in the therapist–client relationship. They delineated
the process in steps for the therapist: acknowledging the rupture, exploring the cli-
ent’s emotional experience of the rupture, apologizing and owning responsibility for
the rupture, checking in with the other partner and facilitating empathy for the part-
ner’s emotions related to the rupture, addressing any concerns related to the rupture,
and expressing appreciation for the client’s openness and normalizing the process of
rupture and repair.
Contexts of change in couple therapy models

Studies on IBCT and TBCT found more established couples (married more than
18 years) were more likely to improve (satisfaction and stability) than less established
couples (married less than 10 years) at posttreatment and 2‐ and 5‐year follow‐up
(Atkins, Berns et al., 2005; B. R. Baucom, Atkins, Simpson, & Christensen, 2009; B.
R. Baucom, Atkins, Rowe, Doss, & Christensen, 2014). Higher levels of commit-
ment and greater desires for closeness were associated with less separation likelihood.
Early research on TBCT consistently found that more severely distressed couples were
less likely to improve in couple therapy (Snyder, Mangrum, & Wills, 1993)—a finding
also replicated in EFT research (S. M. Johnson & Talitman, 1997). In addition to
couple traits, individual traits matter a great deal. In a study of behavioral and insight‐
oriented therapies, couples with negative marital affect and depressive symptomatol-
ogy at intake were more likely to be distressed at termination and continue to be
distressed or divorced 4 years after treatment (Snyder et al., 1993). Several studies in
EFT found that certain client qualities at intake such as attachment quality, willing-
ness to self‐disclose, emotional control, and emotional awareness were unrelated to
emotional experiencing in sessions and treatment outcomes (e.g., Dalgleish, Johnson,
Burgess Moser, Wiebe, & Tasca, 2015; S. M. Johnson & Talitman, 1997). One con-
trasting study, however, showed that greater attachment anxiety and emotional con-
trol at intake predicted greater improvements in relationship quality (Dalgleish,
Johnson, Burgess Moser, Lafontaine et al., 2015).
The co‐occurrence of and interplay between individual and couple‐related factors
are critical in understanding the process of change in couple therapy, and several natu-
ralistic studies of general couple therapy clearly illuminate this. High rates of coexist-
ing issues (anxiety, depression, and IPV) meant couples would begin treatment with
lower relationship satisfaction; however, contrary to previous findings, these factors
did not seem to inhibit successful outcomes (Rowe, Doss, Hsueh, Libet, & Mitchell,
2011). If anything, couples reporting low rates of relationship satisfaction experi-
enced greater change in therapy (Doss et al., 2012). Further, improvements in com-
munication, closeness, and psychological distress mediated the effect of treatment on
subsequent relationship satisfaction and improvement in relationship satisfaction
mediated the effect of treatment on psychological distress (Doss, Mitchell, Georgia,
Biesen, & Rowe, 2015). Other data indicated that relationship and individual func-
tioning improved most dramatically during the first four sessions of therapy and then
stabilized during the next four sessions and relationship adjustment predicted changes
in individual functioning only for men, but the inverse was not found for either sex
(Knobloch‐Fedders, Pinsof, & Haase, 2015). These results indicate that there are
consistent associations between individual and relationship functioning variables that
influence one another and the change process at pretreatment, during treatment, and
after treatment, but future research is clearly needed to better clarify and contextual-
ize these pathways of change.
The role of special circumstances needs to also be more closely inspected. For
example, those couples who experienced infidelity and revealed the affair (as opposed
to keeping it secret) prior to treatment showed greater acceleration of improvement
than those without an infidelity history (Atkins, Eldridge, Baucom, & Christensen,
2005) and demonstrated no significant differences in outcomes at posttreatment and
5‐year follow‐up (Marin, Christensen, & Atkins, 2014). On the other hand, infidelity
couples fared significantly worse when the secret affair was not disclosed before or
during treatment (Marin et al., 2014). Similar outcomes were also found between
couples with little physical aggression and couples with no aggression prior to treat-
ment (Simpson, Atkins, Gattis, & Christensen, 2008). Therapist characteristics should
also gain more attention in couple therapy as one study on EFT demonstrated that
securely attached novice therapists delivered simulated EFT at higher fidelity than
insecure therapists, particularly with addressing attachment‐related needs and emo-
tions (Wittenborn, 2012).
In essence, when these contextual factors are not taken into account, we can easily
fall into the trap of overextending results about how these models work. The severity
of couple distress, individual symptoms and characteristics, domestic violence, infidel-

ity and therapist characteristics deserve special attention when applying the methods
of these approaches. Finally, other factors clearly deserve more attention in couple
therapy including mixed agendas and divorce proneness as the models heretofore
discussed often work under the assumption that both couples have some desires to
improve their relationships (Doherty, 2011).
Making the Case for Integrative Process Research in SFT
Many now acknowledge the reality that most therapists prefer to practice from an
integrative and client‐centered approach (Lebow, 2014; Norcross, Karpiak, &
Santoro, 2005) that is less rooted in the dogma of various models. Although some
therapists have a home model they work from, they recognize the need for clinical
flexibility and incorporate strategies from other approaches for particular issues. The
movement toward research on integrative practice has been encouraged by a new
focus on identifying key principles of change that reach therapeutic outcomes
(Castonguay & Beutler, 2006; Castonguay, Eubanks, Goldfried, Muran, & Lutz,
2015). This trend is growing in SFT as well (Lebow, 2014). Process research is very
well suited to this approach, but often process findings are model specific. We believe
an analysis of the key mechanisms of change that either cut across the contexts of vari-
ous models (common factors) or may be uniquely suited for specific contexts (unique
factors) provide a more useful map or guide for therapists to apply an integrative and
principle‐based approach to their work. In our view it is useful to explore both unique
and common factors that produce change—in fact, unique and common factors can-
not exist without the other—common elements depend on specific treatments and
unique variables exist in the context of common factors (McAleavey & Castonguay,
2015). While the following review gives attention to those factors that are generally
common across systemic treatments, we acknowledge there may be unique ways in
which these factors are applied, which future research will need to clarify.
Systemic alliance
The single most frequently studied process variable in SFT is the therapeutic alliance.
Bordin (1979) articulated the most widely accepted understanding of the alliance,
describing it as consisting of the bond between the therapist and client as well as the
agreement about the goals and tasks of therapy. Pinsof and others (Friedlander,
Escudero, & Heatherington, 2006; Pinsof, 1994, 1995; Pinsof & Catherall, 1986)
expanded this definition to account for the greater complexity that arises when mul-
tiple clients are participating in therapy. Four unique aspects of this expanded thera-
peutic alliance are particularly salient for understanding this complexity. First, when
working with a system, the therapist must develop an alliance with each member of
the system and with the group as a whole (between‐system alliance). Second, multiple
between‐system alliances (e.g., alliance between parents and therapist and children
and therapist) present the strong possibility for differing strengths or valences of these
alliances (split or unbalanced alliances). Third, while in individual therapy, the rela-
tionship between the client and therapist is paramount, when the couple or family
relationship is considered a primary mechanism of change, the quality of the working

relationship between family members becomes particularly important. This within‐
system alliance (Pinsof, 1994) or shared sense of purpose (Friedlander et al., 2006)
reflects the family members’ agreement on the goals and tasks of therapy as well as
their joint investment in the therapy process. Finally, unlike individual therapy, what
is said in the therapy room is witnessed by other family members and can have signifi-
cant repercussions outside of therapy. Friedlander and colleagues (2006) identified
the relative sense of safety in the system as another unique element of this expanded
therapeutic alliance. The process research on the alliance can be divided into the rela-
tionship between alliance and “big O” outcomes, “little o” outcomes, and research
that examines how the alliance develops over time.
Systemic alliance and “big O” outcomes The alliance is a robust predictor of therapy
outcomes in SFT with effect sizes that are similar to or larger than those found in
individual treatment (d = 0.622, medium effect size; Friedlander, Escudero, Welmers‐
van de Poll, & Heatherington, 2018). In a recent meta‐analysis, Friedlander and col-
leagues (2018) found that the alliance–outcome effect was the same regardless of
client presenting problem or modality (couple vs. family treatment); however, alli-
ance–outcome correlations were higher when the targeted children were younger,
when there were more adult males in the sample, and when clients were in therapy
voluntarily. Additionally, while the alliance–outcome correlation was significant for all
models of therapy, it was strongest for cognitive‐behavioral models and lowest for
structural/functional and multisystemic models of therapy.
Two themes from this meta‐analysis stand out. First, of the various alliance factors,
the within‐system alliance had the strongest association with outcome, suggesting
that the working relationship between partners and family members is particularly
relevant to change in SFT. This is not surprising given the focus most systemic models
give to family relationships in producing change, but highlights the need for systemic
therapies to develop alliance‐building and repair strategies that target this systemic
component of the alliance. Second, men’s alliances in relational therapy were impor-
tant. Studies on the alliance among heterosexual couples consistently demonstrate
that the male partner’s alliance is particularly important in predicting positive out-
comes for both himself and his partner (e.g., Bartle‐Haring, Glebova, Gangamma,
Grafsky, & Delaney, 2012; Glebova et al., 2011). It is unclear why this is, but Anker,
Owen, Duncan, and Sparks (2010) have suggested that a strong alliance with the
male partner is essential to overcome the culturally promoted resistance he may feel
to participate in therapy.
While there are some exceptions (e.g., Flicker, Turner, et al., 2008; Muñiz de la
Peña, Friedlander, & Escudero, 2009), the majority of research has concluded that
the lower the quality of alliance, the greater the likelihood that the couple or family
will end therapy prematurely (e.g., Anderson, Tambling, Yorgason, & Rackham,
2018; Bartle‐Haring et al., 2012; Knobloch‐Fedders, Pinsof, & Mann, 2004; Robbins
et al., 2003). Early alliance development appears to be particularly important for pre-
venting dropout (e.g., Thompson, Bender, Lantry, & Flynn, 2007).
Although the overall quality of the alliance is an important predictor of dropout,
the prevalence and severity of split alliances appear to be just as, if not, more impor-
tant. Split alliances occur in between 32 and 43% of couples in treatment and appear
to grow more common as therapy progresses (e.g., Knobloch‐Fedders et al., 2004).
Friedlander and colleagues (2018) meta‐analysis identified a stronger effect size for
the association between split alliances and outcome than for the general alliance–out-
come relationship. Individual studies have shown that severe split alliances are seen
more often in cases of dropout than in those with positive outcomes (e.g., Friedlander,
Lambert, Escudero, & Cragun, 2008). The relationship between alliance and drop-
out varies, however, depending on how split alliances are operationalized (Bartle‐
Haring et al., 2012) and what relationship the split occurs in (Robbins et al., 2003).
For example, Robbins et al. (2003) found that the greater the difference between the
adolescent and the father’s rating of alliance in therapy, the greater the potential for
dropout. The same was not true for other splits in the system. More needs to be done
to understand which alliances are most important under what circumstances to help
clinicians navigate this complexity.
Systemic alliance and “little o” outcomes Several studies have examined the relation-
ship between the alliance and immediate session outcome. Multiple studies have
found that the alliance, particularly the task and within‐system components, is associ-
ated with greater session depth and smoothness (e.g., Kivlighan, 2007). For example,
Friedlander, Kivlighan, and Shaffer (2012) found that when parents rated the alliance
higher, they were more likely to experience the session as deeper and more valuable.
Parent–therapist alliance has also been associated with parent behaviors that promote
attachment with their depressed adolescent (Feder & Diamond, 2016). The safety
that the family feels in treatment appears to be particularly important, with greater
safety leading to stronger within‐system alliances that, in turn, led to early symptom
improvement (Muñiz de la Peña et al., 2009). Taken together, these studies demon-
strate that there is a relationship between the perceived value of the session and alli-
ance quality and suggest significant complexity that needs to be understood.
Development of the systemic alliance over time A growing body of literature has exam-
ined how the alliance develops over time. At the most simplistic level, research has
identified several pretreatment predictors of a strong alliance. These include differen-
tiation of self (e.g., Knerr et al., 2011), individual distress (e.g., Anderson & Johnson,
2010), relationship satisfaction (e.g., Anderson & Johnson, 2010; S. M. Johnson &
Talitman, 1997; Knerr & Bartle‐Herring, 2010; Knobloch‐Fedders et al., 2004), and
quality of attachment of both client and therapist (e.g., L. N. Johnson, Ketring, &
Espino, 2018; Miller et al., 2015; Wittenborn, 2012; Yusof & Carpenter, 2016).
More complex longitudinal research has also begun examining the trajectory of
the alliance in therapy. While some have found that alliance is fairly stable by session
two and remains stable over the early sessions of therapy (Glebova et al., 2011),
others have found that alliance quality changes over time (e.g., Escudero, Friedlander,
Varela, & Abascal, 2008). This appears to be particularly true of the within‐system
alliance and safety within the system components of the alliance (e.g., Escudero
et al., 2008). As Anker and colleagues (2010) have reported, it is likely that the
development of the alliance is dependent on several moderating variables. Their
sample was characterized by three distinct patterns of alliance development. Those
with the best outcomes had high initial alliances that continued to increase over
therapy. Two additional groups emerged: those with moderate alliances that con-
tinue to increase over time and a group with lower initial alliances that remain flat
throughout treatment (Anker et al., 2010). Future research focusing on moderators
of alliance trajectory will be an important area of further study to first understand

how alliance changes throughout treatment and to then use this information to
provide feedback to therapists to improve outcomes.
In methodological contrast to these multi‐session longitudinal studies, a few
small‐sample studies have begun to examine differences in therapist and client alli-
ance‐promoting behavior within sessions of good and poor outcome cases. Much of
this research has focused on therapy with adolescents and their parents and has
shown that therapists who attend to the adolescent’s experience helped the adoles-
cent establish meaningful goals, oriented the clients to therapy, promoted the ado-
lescent’s autonomy, and rolled with client resistance were able to successful develop
and strengthen alliances over time (G. M. Diamond et al., 1999; Higham,
Friedlander, Escudero, & Diamond, 2012; Muñiz de la Peña, Friedlander, Escudero,
& Heatherington, 2012; Thompson et al., 2007). How clients and therapists
respond to each other in session can either promote or detract from alliance devel-
opment. In successful cases, clients respond with their own alliance behaviors within
3 min of the therapist’s use of an alliance‐promoting behavior (Friedlander et al.,
2008); and when clients exhibit negative behaviors, therapists in successful cases
respond with alliance‐strengthening behaviors more often than in unsuccessful cases
(Sheehan & Friedlander, 2015). How family members respond to each other in
treatment also impacts the alliance, with the limited research showing that partner
negativity inhibits the development of husbands’ alliances (Thomas, Werner‐Wilson,
& Murphy, 2005).
As therapy progresses, particularly with the complexity involved in systemic ther-
apy, ruptures in the alliance are inevitable. Indeed, Pinsof (1995) predicted that
ruptures would be a normal part of treatment and that a stronger overall alliance
would be the natural result of repairing these ruptures. The individual alliance lit-
erature has long recognized the importance of this alliance rupture and repair pro-
cess (Safran, Muran, & Eubanks‐Carter, 2011). While this literature has grown,
little is known in the couple and family therapy field. In part, this is due to the
difficulty operationalizing a rupture. Is the alliance ruptured when the therapist
maintains a strong relationship with the parents but a ruptured alliance with the
adolescent? The defining characteristics of ruptures in systemic therapy appear to
be the same as individual treatment: withdrawal or confrontation (Escudero,
Boogmans, Loots, & Friedlander, 2012); however these ruptures occur not only
with the therapist but between family members as well. While few systemic studies
of the alliance have used the term rupture, some have begun to examine this phe-
nomenon. For example, Friedlander, Heatherington, Johnson, and Skowron
(1994) examined client disengagement among a small sample of clients that subse-
quently reengaged and those that were not able to reengage. In cases that were
able to successfully reengage, five elements were present: being able to gain insight
about the disengagement, communicating about the impasse, acknowledging the
thoughts and feelings of others, and developing a new construction about the
impasse. In an unpublished dissertation, Goldsmith (2012) found that these rup-
tures occur frequently and, as predicted, that their resolution is associated with
improved outcomes. Future research is needed to further elaborate what ruptures
look like in systemic therapy and the therapist and client behaviors that lead to suc-
cessful repairs.
Client system engagement and retention

Highly related to successful alliance building is the process of engagement and reten-
tion. SFT involves encouraging participation of family members who might be
involved in the problem, keeping families a part of the process, and facilitating their
active engagement in sessions (Heatherington, Friedlander, Diamond, Escudero, &
Pinsof, 2015). Engaging whole families has always set SFT apart, but it can be quite
complicated to do so, and there is much debate today about when this is most impor-
tant (Lebow, 2014). Either way, some process research has examined the benefits of
engaging the identified client and family members as well as what leads to successful
engagement and retention.
Client system engagement has been of greater concern in adolescent‐focused ESTs
because of the high‐risk retention difficulty; early treatment engagement was impor-
tant for FFT to be successful (Robbins et al., 2016). Reducing negativity through
restructuring and balanced alliances were important in initial studies of BSFT (Robbins
et al., 2000), and a recent large study of BSFT showed that adherence to the treat-
ment manual, rapport with the family, attention to resistance, and a facilitation of
parent involvement, safety, and discussing the shared contributions of family members
all lead to retention (Robbins, Feaster, Horigian, Puccinelli et al., 2011; Sheehan &
Friedlander, 2015). Attending to the adolescent’s experience, formulating personally
meaningful goals, and presenting one’s self as the adolescent’s ally were all important
in adolescent engagement in MDFT (G. M. Diamond et al., 1999).
One naturalistic study (Higham et al., 2012) explored factors that contributed to a
resistant adolescent either shifting or not shifting from negative to positive engage-
ment during session. Positive shifts were more likely when therapists structured thera-
peutic conversation, fostered autonomy, built systemic awareness, rolled with
resistance, and understood the adolescent’s subjective experience; parental support
was also important. Further, a recent review of the literature on retention processes in
SFT identified six important therapist‐generated conditions for retention of families
in therapy: conveying understanding and support, demonstrating knowledge and
expertise, conveying a genuine desire to help, providing clarity about the family ther-
apy process, conveying hope that problems can be resolved, and creating a safe envi-
ronment (McAdams III et al., 2018). With the difficulty of even initially getting
whole families into therapy (Breunlin & Jacobsen, 2014), it seems that engagement
and retention are incredibly important processes of change to pay attention to in SFT.
Systemic reframing
Reframing is perhaps the most common systemic intervention. It involves helping
families redefine their view of the problem in more systemic terms (i.e., A does not
cause B, but A and B are mutually influencing). Usually couples or families initially
locate a problem within one individual (my spouse is lazy or my child throws tan-
trums). Reframing seeks to alter this view and point the family toward interactional
processes that are involved in the problem. Doing so interrupts blaming, deepens
understanding, and provides new solutions.
There are, however, many ways to activate these shifts in perspective. For instance,
results from a task analysis of a narrative‐constructivist approach (Coulehan et al.,
1998), which generally relies on questioning to help shift perspectives, indicated three
recursive change processes facilitated by the therapist: (a) family members described
their respective viewpoints of the problem, (b) these viewpoints shifted through affec-
tive responses, and (c) felt sense of hope for change. Effective therapist behaviors
included directing the session to keep focus and including each family member, seek-
ing information about interpersonal events and family dynamics, exploring and rein-
terpreting negative attributions, highlighting strengths, redefining the problem, and
inviting the expression of feelings. Other models using a similar, but often more
direct, style of highlighting patterns in the system likewise find good results including
reduced negative expressions early in sessions, more favorable responses by adoles-
cents (FFT; e.g., Robbins et al., 2000), protections to the therapeutic alliance (BSFT;
Robbins et al., 2006), higher retention (BSFT; Robbins, Feaster, Horigian, Rohrbaugh
et al., 2011), and decreases in parental negativity and increases in parents viewing the
problem in more interpersonal terms (ABFT; e.g., G. Diamond et al., 2003). It seems
that all family therapy models, in one way or another (e.g., circular questioning or
direct statements), seek to highlight interactional patterns of one kind or another
(e.g., negative narratives and dialogue or negatively reinforcing behaviors). While
there are different ways of going about this, it seems clear that systemic reframing is
an important part of the pathway to successful outcomes in SFT.
Systemic enactments
Enactments can be broadly defined as therapist‐facilitated interactions between clients
and are commonly used to assess or modify family dynamics. Enactments can be
employed independently and as key interventions in many prominent models of SFT
(e.g., Hogue et al., 2006; Tilley & Palmer, 2013). There is ample empirical support for
enactments as an effective intervention in promoting change, and it has been argued
that they be considered a “best practice” in SFT, representing a necessary ingredient in
effective relational therapy (e.g., Butler & Wampler, 1999; G. M. Diamond, Shahar
et al., 2016; Friedlander, Wildman, Heatherington, & Skowron, 1994; Gardner &
Butler, 2009; Heatherington et al., 2015; Shields et al., 1991).
Several empirical studies investigating enactments identified three stages of thera-
pist behaviors: initiation, facilitation, and closing (Davis & Butler, 2004; M. P. Nichols
& Fellenberg, 2000). At the stage of initiation, therapists introduce goals and roles
(i.e., clients speak directly to one another), specify the topic for the interaction, and
establish the structure of the enactment. For facilitating effective enactments, thera-
pists avoid interrupting family members and encourage continued and productive
dialogue between family members, particularly about attachment‐based emotion. To
close an enactment, therapists recall the goals of the enactment, evaluate the process
and outcome of the interaction, and invite commitments relevant to the enactment.
Family members who were most effective during enactments demonstrated willing-
ness to engage with each other, spoke about their own feelings without attacking or
defending, and experienced a noticeable productive shift in their interactional pattern
by the end of the enactment. Butler, Davis, and Seedall (2008) found that beginning
therapists demonstrated less proficiency around establishing goals, roles, and topics in
the initiation phase, intervening to facilitate emotional and/or attachment expression
and listening in the intervention phase, and evaluating the goals, quality of interac-
tion, and commitments to change in the evaluation phase.
As to specific therapist behaviors associated with productive enactments, the use of

“proxy voice” (therapist speaking for a client) increased the likelihood of softening
(e.g., sharing primary affect) and decreased the likelihood of withdrawal or negativity
(Seedall & Butler, 2006). In addition, a process‐analytic study found that therapist’s
directiveness, structuring, and working with emotion during enactments were related
to both more positive and less negative interactions between partners (Woolley,
Wampler, & Davis, 2012). Examining successful enactments in family therapy,
researchers developed a measure of therapist behaviors, the Family Therapy Enactment
Rating Scale (Allen‐Eckert, Fong, Nichols, Watson, & Liddle, 2001). Their discov-
ery‐oriented study supported certain therapist actions during successful enactments
including directing family members to talk to one another, encouraging family mem-
bers to discuss an affect‐laden topic, promoting continued engagement between fam-
ily members during the enactment, and summarizing the interaction and praising
family members at the conclusion of the enactment. Process studies within EFT,
ABFT, and MDFT also highlight various therapeutic processes within enactments as
previously discussed (G. S. Diamond & Liddle, 1999; G. M. Diamond, Shahar et al.,
2016; Greenman & Johnson, 2013).
Butler and Gardner (2003) proposed a developmental model for facilitating enact-
ments to guide the amount of structure and type of instructions given for an enact-
ment according to the reactivity of a couple and their progress in therapy. Andersson,
Butler, and Seedall (2006) conducted an evaluation study whereby couples at various
stages of therapy experienced two types of enactments—a structured, safe‐guarded
enactment and a free‐form, coached enactment. Through follow‐up interviews with
the couples, they found that adjusting the structure of enactments according to cou-
ples’ presenting problems and level of reactivity improved outcomes. The interviews
also reaffirmed the role of the therapeutic relationship and certain therapist behaviors
in promoting such outcomes.
Given that research on the structure and process of enactments is “reasonably com-
plete” (Gardner & Butler, 2009, p. 321), future research could further test the vari-
ous models of enactments and their specific components among different populations
(e.g., Seedall & Butler, 2008) and through experimental designs.
Other Systemic Change Processes Needed for Future Research
There are several factors that will need greater attention in future change process
research. There are many questions about when certain methods of systemic interven-
tion might be most appropriate. For instance, when should family therapists focus on
creating cognitive, emotional, behavioral, or insight‐oriented shifts between and
within family members. Is this just a preference of style/model and is it irrelevant
which process one uses, or are there moderating factors including the cultural back-
ground of the client system, the personality of each member, or specific issues?
Although some process research exists on some of these variables, they have usually
been investigated only within a model that specifically targets that domain—hence, it
can be quite difficult to examine the differential effects of these modes of practice.
Larger naturalistic studies of therapists of varying styles or orientations may be useful
in beginning to examine how and when these approaches might be most effective.
Therapist characteristics have been given a lot of attention in individual therapy

(Baldwin & Imel, 2013) including observable traits (e.g., age, sex, ethnicity), observ-
able states (e.g., training), inferred traits (e.g., personality style), and inferred states
(e.g., therapeutic relationship). These are also important variables in SFT and there
are likely therapist characteristics that may be uniquely suited for SFT that could be
explored in future research including the therapist’s ability to handle conflict and
emotional intensity, to think systemically and notice patterns, etc. Individual therapy
has moved somewhat away from specific characteristics of therapists in specific studies
and more toward an emphasis on identifying individual therapist’s own effectiveness
following a foundation in feedback informed therapy (Prescott, Maeschalck, & Miller,
2017). It may only be a matter of time before SFT more fully takes up this same trend
and we begin identifying effective systemic therapists and whether deliberate practice
similarly makes them more effective.
There is a greater need to integrate therapist and client characteristics into process
research at individual and systemic levels. Individual client factors include client
demographic variables, pathology, clinical characteristics, perceptions of therapy, and
constructive activity (Bobart & Wade, 2013). SFT process research should keep in
mind the powerful influence of individuals in systemic processes. Nevertheless, we
need greater development of client system characteristics that should be explored. For
instance, we can begin investigating other dyadic processes beyond the classic pur-
suer–withdrawer process including those outlined by Tomm, St. George, Wulff, and
Strong’s (2014) IPscope diagnostic approach. Triadic processes, such as triangulation
or unbalanced parental hierarchies, are also key client system characteristics and pro-
cesses that could be actively explored in SFT process research.
There is a greater need to explore group‐based trajectories in SFT. Many studies in
individual therapy have found different experiences of progress including those who
make change, those who deteriorate, and those who remain stagnant (Bobart &
Wade, 2013). This does not translate so simply into SFT. Do you measure the indi-
vidual change of each partner or family member as well as the combined change of the
entire family? What happens when one individual in the system makes dramatic
changes and the other does not? Although this is certainly complex, it is possible—
and would be extremely beneficial to the field—to identify the characteristics of cli-
ents and therapists that are associated with various trajectories of change in couple and
family therapy.
While a quantitative investigation of client and therapist factors is important, we
should not underestimate the powerful role of qualitative investigations describing
effective change processes. It is important to determine what is most helpful in creat-
ing change from the client’s perspective. Often we rely too heavily on our own theories
and not enough upon the consumer’s point of view in clinical research. As a demon-
stration of how useful this can be, Chenail and colleagues conducted an impressive
qualitative metasynthesis of 49 articles focused on clients’ experiences of SFT (Chenail
et al., 2012). Their findings indicated that clients view therapy positively when they
experience a sense of connection between their preconceptions of therapy and what
they actually experience in therapy, when therapeutic processes are connected to
desired outcomes and changes in their lives, and when therapists create constructive
balances of the needs and goals between family members (Chenail et al., 2012).
Findings such as these can further aid the field delineating the common and unique
factors of effective SFT.
Finally, SFT has progressively moved toward a greater multicultural and sociopoliti-
cal orientation (McDowell, Knudson‐Martin, & Bermudez, 2018) and with that
comes a need for more attention to the social and cultural characteristics of our cli-
ents. Fortunately, many of our models have been used among diverse and vulnerable
populations, and some of our process research has investigated these key contexts. We
believe, however, that more can and must be done as we progressively become even
more diverse and pluralistic and sensitive to the needs of the underserved. Future
research should be hard‐pressed to capture these dimensions and the best practices for
diverse families.
Applying Process Research in SFT Training and Practice
The current emphasis in SFT training privileges teaching the schools of family therapy
alongside common factors (Karam, Blow, Sprenkle, & Davis, 2015) and then encour-
aging students to develop a personal model of change that integrates concepts of the
various schools that are compatible with the student’s own worldviews (Nelson &
Prior, 2003; Simon, 2006). We see some drawbacks to this approach. While there
certainly are common factors that are important to the change process, unique factors
are also an important part of the pathway to change, especially for unique problems
and contexts (McAleavey & Castonguay, 2015). The process research reviewed here
indicates to us a both/and approach that privileges skills around common and unique
processes that may go neglected by model‐ or therapist‐centered training. Clinical
wisdom suggests that for certain populations, there simply are better and worse ways
to proceed. Many in the field of clinical psychology recognize the limitations of sin-
gular treatment models and find burgeoning evidence of the advantages of integrative
approaches that tailor methods to the unique situation of their clients (Castonguay
et al., 2015). A training framework that teaches students to choose a model that
works through common factors does not take the full breadth of process research
findings into account.
We call upon training programs to actively integrate the implications of the pro-
cess research reviewed here into training programs. To be able to address this call,
however, it seems to us that the best course of action will include a major paradigm
shift in training. We believe that our clientele is at the center of practice and train-
ing and that students should develop skills in tailoring treatment to the unique
needs of any given client system. Some in clinical psychology have advocated a
principle‐based approach that draws upon research evidence of the mechanisms
and contexts of change for various problems and populations and trains students in
becoming skilled around those treatment principles rather than in selecting and
becoming good at a specific model (Castonguay & Beutler, 2006; Castonguay
et al., 2015). For instance, in a study of clinical psychology training, clients whose
student‐therapists followed and were supervised according to a principle‐based
approach showed greater therapeutic gains compared with those who received
supervision as usual (Stein, 2017). We have documented several principles of

change throughout that we believe deserve greater privilege and emphasis in train-
ing programs. This does not replace the need for theory—the why behind an
enactment sometimes provides the motive and rationale to leverage it successfully
in therapy. We find that students, however, worry more about whether structural
therapy fits for them or not than whether they have learned effective skills in using
enactments. In essence, we believe a principle‐based approach will be much more
useful for training and practice than a model‐based approach.
Beyond this paradigm shift, there are several ways students can be encouraged to
draw upon current process research findings. First, students should begin collecting
data on their own therapeutic processes by tracking progress among their own client
systems (Lappan, Shamoon, & Blow, 2018). Supervisors can help students process
these data and find implications for how they can improve their skills in developing
systemic alliances and creating systemic change. Second, when teaching the schools of
family therapy, it is important to educate students on the, sometimes, lack of process
research on them as singular models, but the wide breadth of process research on
integrative systematic programs that have used them—pointing out which processes
have been validated in which specific contexts. Third, it is not difficult to assign stu-
dents readings of process research studies. The nice thing about these studies is that
students find them more relevant than other articles they might read during their
training. For example, when teaching students how to develop skills in enactments,
educators should point students to some key articles including structural family ther-
apy’s 25 different ways of doing enactments (M. Nichols & Tafuri, 2013) and what
made some more successful than others (M. P. Nichols & Fellenberg, 2000). This is
a powerful teaching tool. Students can also be encouraged to identify process‐specific
research on their own. Often students will find research that supports an entire model
of therapy, but this gives little guidance on research‐based skills or principles that are
more relevant to integrative and principle‐based training and practice.
Conclusion
The field of SFT research is progressively growing in a direction of identifying core

mechanisms and contexts of change that can explain the effectiveness of this way of
practice. Many of the various schools and programs of practice reviewed here outlined
many of their therapeutic processes that predict outcomes and the conditions for suc-
cessful change. We have identified some of the key mechanisms of change that seem to
cut across most models of SFT and the research that have supported them including a
systemic alliance, systemic engagement and retention, systemic reframing, and systemic
enactments. We have pointed out several areas for future research in SFT including the
need for greater multicultural considerations. Finally, we have identified several training
implications from this breadth of research. When we can begin to integrate and synthe-
size the key findings from process research, we are able to start formulating a useful map
for the successful practice of SFT that practitioners from all walks of life can learn from
and apply to their own practices. While we know that SFT can be quite effective, the
research reviewed in this chapter provides a foundation for ongoing endeavors to clarify
and solidify those mechanisms and contexts for successful work in our field.
Note
1 We did not review parent training programs because they lacked any substantial “process”
research. These programs, however, have received immense research support in the “out-
come” literature.
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9
Physiological Considerations
in Systemic Family Therapy
The Role of Internal Systems
in Relational Contexts
Angela B. Bradford and Eran Bar‐Kalifa
It was an introductory family science course and one book—The Family Crucible
(Napier & Whitaker, 1978)—that awakened me (A.B.) professionally. Intending to
study psychology, I had mistakenly registered for a family science class to fill a general
education requirement. As I read about Carl Whitaker’s approach, it was as though all
the pieces of a universe I hadn’t known was fragmented fell into place. “This is it!” I
thought. “It’s not about the individual; it’s about the system!” From that point for-
ward, I was an adamant disciple of systems theory.
More than 20 years later, I am struck by my own myopic approach to systemic
thinking and work. While I was busying myself studying and treating family systems,
I almost completely ignored a literally vital system of human functioning—that of the
body. Just as we must view so‐called individual functioning in the context of relation-
ships, so too must we view individual and relational functioning in the context of
human physiology.
The mind–body connection, or the link between human physiology and cognition,
emotion, and behavior, makes it highly relevant to our field. Human physiology refers
to the processes and functions of the body and its parts. It encompasses the interrela-
tion of the body’s nerves, organs, genes, chemicals, and hormones—internal systems
that affect individuals’ interactions with their external systems. To some extent, the
relationship between our internal and external systems is common knowledge. Most
are familiar with the fact that getting insufficient sleep is associated with physiological
processes that result in irritability, which may result in relationship conflict. Thus,
poor sleep has behavioral and physiological consequences (Banks & Dinges, 2007;
Rossa, Smith, Allan, & Sullivan, 2014). Another example is the use of psychotropic
drugs to alter specific elements of human physiology (e.g., SSRIs impact serotonin
levels in the brain), which in turn can have significant impact on behaviors that are
expressed within the families and systems of which the user is a part. For systems
206 Angela B. Bradford and Eran Bar‐Kalifa
therapists, an understanding of internal systems as well as external systems is key to

intervening appropriately with clients.
Although many physiological processes are preconscious and therefore beyond our
control, increasing our awareness of their role in family systems gives systemic family
therapists another level from which to understand clients’ experiences and intervene.
Because entire volumes have been dedicated to psychophysiology or the role of physi-
ology in human cognition, emotion, and behavior (Andreassi, 2007; Cacioppo,
Tassinary, & Berntson, 2017), we will not attempt to provide a comprehensive descrip-
tion or analysis of how physiological processes are related to systemic therapy. Instead,
our objective in this chapter is to review the field’s historical understanding of physiol-
ogy, provide a basic overview of the physiological processes most relevant to systemic
family therapy (SFT), highlight the unique role of systemic therapists and therapy in
accessing and utilizing principles of psychophysiology to promote healing, and provide
some initial guidance about physiologically informed interventions for practitioners.
Physiology in Our History
Although physiology’s role in relationships has received increased and substantial

attention only recently, it has resided—sometimes silently—at the core of much SFT
theory and thought. John Bowlby used primate research to help him conceptualize
and theorize that humans require attachment for survival and that our physiology
mediates the process of avoiding or creating safe attachment relationships. (See Seedall
and Sandberg (2020), vol. 1, for further discussion of attachment theory.) Bowlby
described physiological regulation as necessary to a person’s ability to form the
security he called attachment. That attachment then helps the individual maintain a
regulated physiology (Bowlby, 1973). As a central feature of attachment, physiology
was then theorized and examined as core to the self‐regulatory processes that facilitate
human connection.
As systems theory began to take hold among psychoanalysts and SFT as a field
grew, emphasis was placed on communication patterns and interactional cycles.
Individual physiology became somewhat sidelined, with interpersonal physiological
processes almost completely ignored. Eventually psychotherapists began revisiting the
role of the body and self‐regulation (e.g., Greenberg & Pascual‐Leone, 2006;
Levenson & Gottman, 1983), with particular emphasis on the notion that dysregula-
tion and arousal are problematic in the formation and maintenance of healthy rela-
tionships. Since that time, some interest has grown among clinicians and scholars,
who have largely worked to compile and summarize what we know about the brain
and body and their relevance to the field (e.g., Badenoch, 2008; Fishbane, 2013;
Hanna, 2013). Still, although increased emphasis has been placed on the need to
more fully integrate physiologic concepts into our work (e.g., Atkinson, 2005), most
structured and published interventions are limited to suggesting therapists under-
stand physiological processes and then work to intervene in behavioral (rather than
biobehavioral) ways. Expanding our ability to integrate multiple levels of systems (as
in a biopsychosocial approach) will entail sufficiently considering and addressing indi-
vidual physiology and interpersonal physiological processes, including couple and
family processes, therapist–client processes, and physiologically based interventions.
Physiological Systems in SFT 207
Psychophysiological Processes
Because self‐regulation is core to attachment and the skills necessary for developing
and maintaining healthy relationships (e.g., effective conflict management), the physi-
ological processes associated with emotional regulation are among the most relevant
to SFT. These are evidenced in such experiences as outbursts of anger or cowering
away from an argument (i.e., “fight or flight”), feeling emotionally connected or “in
sync” with family members, and having a prolonged stress response after negative
interactions. Such experiences are largely mediated by the balancing of the sympa-
thetic and parasympathetic branches of the autonomic nervous system (ANS) and the
functioning of the endocrine system. Additionally, there are instances in which indica-
tors of these physiological systems come into concordance or synchrony between
family members, suggesting that family members impact each other in unconscious
and automatic ways. For instance, securely attached infants and their mothers have
concordant heart rates when reunified after a brief period of separation (Donovan &
Leavitt, 1985), which allows them to reestablish their bonded relationship and facili-
tates further adaptive functioning. Thus, we review here how the ANS and endocrine
system work and their relevance to SFT.
Autonomic nervous system

Perhaps the most common physiological processes under consideration and investiga-
tion in relational research and practice are those involving the heart and brain.
Although physiological researchers since Darwin have known that the ANS is core to
bidirectional heart–brain interaction, we can largely credit Stephen Porges for focus-
ing the field’s attention on the relationship between the ANS and social behavior.
After writing several papers illuminating the fact that the heart and brain work to
facilitate social engagement and attachment, Porges synthesized his work in his influ-
ential polyvagal theory (Porges, 2011).
Polyvagal theory posits that one of the primary functions of the heart–brain con-
nection is to facilitate connection with others. This is done by unconsciously assessing
for and responding to the relative safety (or, in its absence, danger/threat) of a situa-
tion. If a situation is threatening, the body’s response is to engage protective mecha-
nisms that remove it from the threat. This sympathetic nervous system (SNS) response
includes increased heart rate, diverting blood and energy from smaller to larger mus-
cle groups, and hypervigilance. It is often referred to as the fight‐or‐flight response
because it allows an individual to either resist a threatening situation or escape it. In
circumstances devoid of threat, the heart–brain connection regulates self‐soothing via
the parasympathetic nervous system (PNS). As part of the PNS, a vagal brake serves
to inhibit SNS activation by sending signals along the vagus nerve to the heart, lungs,
and digestive track enabling a rest, digest, and connect state. Because the vagus nerve
innervates the face, throat, and ears as well as the heart, PNS regulation results in
increased eye contact, calm vocal timbre, auditory receptivity, and more open body
posture, all of which facilitate social connection. Thus, active engagement of the PNS
is necessary for life‐sustaining, healthy relationships.
Because social connection is a vital need for humans (Holt‐Lunstad, Smith, &
Layton, 2010), assessment of the safety or danger of a situation includes its relational
components. Consider what occurs when one perceives that another dislikes or is
angry at him. The SNS responds as to any other threat, and he may experience an
increased heart rate, difficulty making eye contact, or sweating. This physiological
experience accompanies the desire to fight back or escape (i.e., fight or flight), which
moves the individual to engage in behaviors that are designed to protect him from the
relationship (e.g., escalating conflict or withdrawing from further interaction). In
contrast, relational safety cues from a partner (expressed as a result of their PNS func-
tioning, such as in the form of an open posture, eye contact, or a calm vocal tone) help
one feel at ease and active his PNS, facilitating connection between the two. This is
evidence for the assertion made in the polyvagal theory that the role of the PNS in
facilitating connection is not unidirectional. A basic illustration of this process is
shown in Figure 9.1, which demonstrates that behaviors and experiences in relation-
ships serve to inform the heart–brain connection and shape individuals’ responses to
future interactions via conscious and unconscious processes.
Consider a child who grows up in a home with an alcoholic mother who gets angry
and physically violent each night after drinking. With repeated experiences over time
Physiology,
person A
Appraisal, Appraisal,
person A person A
Behavior, Behavior,
person B person A
Appraisal, Appraisal,
person B person B
Physiology,
person B
Figure 9.1 Cycle of physiologic processes and behavior. The dotted line between each per-
son’s behavior does not represent an automatic or unconscious process, but rather a conscious
process that acts as a potential intervention point.
signaling to the child (and his body) that he is not safe, his body begins to have a
physiological reaction to triggers, or reminders, of the violent circumstances (e.g., the
smell of a certain alcoholic beverage, angry shouting). In such instances, the vagal
brake is released, suppressing the PNS and allowing the SNS to become the more
dominant system working to keep the child safe. As a child, he may physically hide
himself in his room or elsewhere. As an adult, without a cognitive appraisal (such as
positive sentiment override) to interrupt his physio‐behavioral response, he may
become fearful when his wife becomes angry and will similarly hide or withdraw. This
withdrawal or avoidance serves to protect; however, it also inhibits the ability to
connect and maintain a meaningful relationship.
Conversely, there are those whose PNS effectively inhibits premature acceleration
of the SNS. A child with a secure attachment to her parents, who consistently
experiences relational safety and appropriate repairs after relational ruptures, may, in
adulthood, tolerate a higher level of threat before the vagal brake is released because
her vagus nerve is more adept at maintaining a self‐regulatory state (quantified by
higher vagal tone). Research has demonstrated that those with higher vagal tone (and
therefore a greater propensity to be self‐regulated; see Beauchaine, 2001; Beauchaine,
Gatzke‐Kopp, & Mead, 2007) have higher marital quality or relationship satisfaction
(Helm, Sbarra, & Ferrer, 2014; Smith et al., 2011) and use more positive social
engagement skills (Geisler, Kubiak, Siewert, & Weber, 2013).
Polyvagal theory provides an important lens for understanding how ANS responses
to the relational environment shape human interactions. It also helps us understand
how relational patterns become programmed into the brain and continue to shape
behavior. In clarifying the role of the vagus nerve and its affiliated organs in social
connection and how vagal tone mediates interactions between internal systems and
external systems, polyvagal theory explains how the heart–brain connection influences
areas of the body that enable us to make appraisals about others’ emotional states,
thereby facilitating relationship‐maintaining behaviors. The role of the ANS in assess-
ing for relational safety or threat highlights that human beings are organized in such
a way that connection is a central feature of lived experience. This further underscores
the importance of clinicians recognizing what is happening within themselves and
clients in order to intervene appropriately.
Common clinical measures of ANS functioning are heart rate, pulse oximetry
(measuring oxygen levels), and electrodermal activity (EDA). These, together with
others such as respiratory sinus arrhythmia (RSA) and cardiac impedance, are also
used in couple and family research. Sympathetic activation can be identified by an
increased heart rate, irregular breathing (i.e., drop in oxygen saturation in blood), a
drop in RSA, an increase in EDA, and a drop in cardiac impedance. Parasympathetic
activation is usually accompanied by an increase in RSA, with stable levels (reflecting
baseline) of blood oxygenation, EDA, and heart rate.
Hormones and neurochemicals of the endocrine system

The ANS and affiliated organs are only one part of the psychophysiological system
affecting relational processes, however. Hormones of the endocrine system also medi-
ate social interactions. The nervous and endocrine systems are linked in the brain by
the hypothalamus via the pituitary gland. The hypothalamus maintains homeostasis in
the body by producing and directing the release of certain hormones such as oxytocin
and vasopressin. These hormones are stored in and released by the pituitary gland,
which also produces hormones including cortisol. Among their other functions,
oxytocin, vasopressin, and cortisol facilitate affect and behaviors that either promote
or inhibit social connection. As systemic therapists seek to understand the internal
systems and the processes by which those systems influence social interactions, it is
beneficial to be aware of these hormones and their roles.
Oxytocin is positively correlated with increased trust, trustworthiness, ability to
decode positive facial cues, empathy, increased eye gaze, more positive communication
between couples, and bonding to parents (see Bachner‐Melman & Ebstein, 2014). It
is robustly implicated in the process of falling in love, bonding, and maintaining bonds
through gaze, touch, and affect (see Algoe, Kurtz, & Grewen, 2017; Feldman, 2012;
Szymanska, Schneider, Chateau‐Smith, Nezelof, & Vulliez‐Coady, 2017). Oxytocin
plays a vital role in parent–infant and couple bonding. Higher oxytocin facilitates
mothers’ ability to respond positively to their infants; it is associated with greater
reward‐system activity (i.e. dopamine response) during interactions and longer
episodes of shared social gaze (see Feldman, 2012). Higher oxytocin in fathers is
associated with greater stimulatory play (e.g., encouraging object exploration and posi-
tive arousal such as moving the child’s limbs), more frequent touch, and higher vagal
tone, indicating greater physiological readiness to engage with their children (see
Feldman, 2012). In couples, oxytocin appears to promote positive perceptions of the
other partner, bonding behaviors, and social receptivity (Algoe, Kurtz, & Grewen,
2017; Feldman, 2012). Thus, oxytocin provides an important biological foundation
for the relationship couples develop with each other and with their young children.
In contrast, emerging evidence suggests vasopressin may be positively associated
with behaviors that impede connection in romantic relationships. There is some indi-
cation that higher levels of vasopressin are associated with aggression, increased stress
in social contexts, and decreased cognitive empathy among men (see Bachner‐Melman
& Ebstein, 2014). Additionally, higher vasopressin levels are associated with nega-
tively biased perceptions of neutral or friendly faces among men, and studies imply
that these associations influence marital satisfaction (see Heinrichs, von Dawans, &
Domes, 2009). However, the research paints more than simply a bleak picture of
vasopressin. There is some evidence that higher vasopressin is associated with more
stimulatory play with infants among mothers and fathers (Apter‐Levi, Zagoory‐
Sharon, & Feldman, 2014). Thus, it appears that vasopressin plays a role in somewhat
excitatory or aroused interactions, which may be developmentally necessary in par-
ent–child interactions, though less beneficial in romantic relationships.
Cortisol has also received significant empirical attention, elucidating its role in rela-
tionship processes. Cortisol is produced as part of the hypothalamic–pituitary–adrenal
(HPA) axis, the body’s central stress response system. Essentially, when an individual
is under stress, the HPA axis releases cortisol. Because the HPA axis is sensitive to the
individual’s social experiences, cortisol studies have been able to identify the effects of
relationship distress on the individual. Research has shown that when partners experi-
ence conflict or marital relationships are distressed, the HPA axis is activated and
cortisol release increases (Burke, Davis, Otte, & Mohr, 2005; Ditzen et al., 2007;
Kiecolt‐Glaser et al., 1997; Saxbe, Repetti, & Nishina, 2008). Low support from a
romantic partner is also associated with a heightened cortisol response (Seeman,
McEwen, Singer, Albert, & Rowe, 1997; Uchino, Cacioppo, & Kiecolt‐Glaser,
1996). Because high or dysregulated cortisol levels are related to serious health issues
including cardiovascular disease and poor immune system functioning, it is important

for SFTs to be aware of how relational distress may manifest in physical ways. Also, as
relationship distress is usually experienced by both partners, it is not surprising that
Saxbe and Repetti (2010) found that spouses’ cortisol patterns are linked over several
days. This association is moderated by marital satisfaction, indicating that co‐regula-
tion of some physiological systems may depend on relational dynamics.
Synchrony/co‐regulation
In understanding the psychophysiological systems that affect social interaction, an
awareness of both the components and the processes is important. Not only are the
ANS and endocrine systems linked, as previously noted, but individuals’ internal
systems affect each other. The synchronization of family members’ physiological

markers is an important phenomenon when considering SFT processes. Most research
has focused on mother–infant co‐regulation and has established that heart rhythms
and oxytocin levels synchronize during interactions (Feldman, 2012; Feldman,
Magori‐Cohen, Galili, Singer, & Louzoun, 2011), upregulating in moments of stim-
ulatory or object‐focused play and downregulating in times of soothing, gazing, and
nurturing interaction. These co‐regulatory processes are considered foundational to
the child’s ability to form and maintain relationships into childhood and throughout
life (Feldman, 2007a).
A comprehensive review on physiological linkage between couples (Timmons,
Margolin, & Saxbe, 2015) adeptly highlights when such synchrony may be helpful
versus problematic in romantic relationships. Evidence indicates that co‐activation of
the HPA axis (i.e., stress response) is generally problematic because it is related to
poorer relationship functioning. This is also often true for co‐activation of the SNS,
which can indicate a pattern of negative affect reciprocity or conflict escalation
(Gottman, Coan, Carrere, & Swanson, 1998; Levenson & Gottman, 1983). However,
synchrony in the SNS is a nuanced phenomenon because there is some indication that
co‐regulation is also associated with increased empathy (see Timmons et al., 2015).
Indeed, Sbarra and Hazan (2008) suggest that co‐regulation is an important feature
of adult romantic attachment, and research has found some evidence to suggest that
greater SNS co‐regulation is associated with greater marital satisfaction (Helm, Sbarra,
& Ferrer, 2014). Thus, the relationship between synchrony in SNS and relationship
outcomes is likely linked to the emotional contexts and processes wherein the SNS is
activated.
Therapist–Client Physiologic Synchrony
One phenomenon that has been receiving growing attention in adult individual psy-
chotherapy over the last decade, but has yet to be adequately addressed in SFT litera-
ture, is the process through which therapists’ and clients’ physiology often become
interlocked and synchronized, thus creating a shared system that involves feedback
loops among the interactants’ physiology. Therapy is at its heart an interpersonal
encounter in which therapists and their clients become cognitively and emotionally
involved with each other. Thus, fundamental phenomena that dominate interpersonal
processes in general, such as synchrony, are of high relevance to the therapeutic context
(Koole & Tschacher, 2016). Indeed, when involved in an interpersonal interaction,
people tend to involuntarily synchronize their perceptual, affective, physiological, and
behavioral responses with each other (Wheatley, Kang, Parkinson, & Looser, 2012).
Moreover, it has been argued that such multimodal synchrony facilitates effective
and coordinated social interactions, as it allows people to obtain partial access to the
internal states of those they interact with and through this process to get “on the same
page” (Semin & Cacioppo, 2008). Consistent with this idea, synchrony was found to
be associated with trust (Bernieri, 1988), relationship satisfaction (Julien, Brault,
Chartrand, & Bégin, 2000), cooperation (Wiltermuth & Heath, 2009), and altruistic
pro‐social behaviors (Valdesolo & DeSteno, 2011).
Drawing upon such findings, Koole and Tschacher (2016) have recently intro-
duced the interpersonal synchrony model of psychotherapy, which postulates that the
therapeutic alliance is grounded on the synchronization of client’s and therapist’s
behavior and physiology. Specifically, the model suggests that such client–therapist
synchrony allows the dyad to construct mutual understanding and shared emotional
experience, which consequently deepen the client–therapist bond. Support for this
idea can be found, for example, in a study that monitored in‐session clients’ and
therapists’ EDA, an index of the SNS (Marci et al., 2007); in this study, clients from
dyads who exhibited higher EDA synchrony during the session reported that their
therapists were more empathically understanding. Moreover, in moments of high syn-
chrony, both clients and therapists demonstrated more positive behaviors toward each
other (e.g., showed positive regard).
Koole and Tschacher’s (2016) model goes one step further to suggest that client–
therapist synchrony has a central role in improving clients’ regulatory capacities and,
thus, in reducing clients’ psychological distress. Specifically, the model argues that cli-
ents’ experience of having a therapist who is synchronized with their affective and physi-
ological arousal, but at the same time is capable of regulating both parties’ arousal,
keeping it within an optimal arousal zone, provides clients the valuable opportunity to
process their emotional hardship in a safe environment. Over the course of treatment,
such recurrent interpersonal experiences of co‐regulation (Butler, 2011) are internal-
ized, thus ultimately facilitating the development of clients’ own regulatory capacities.
No study to date has explicitly examined the suggested association between client–
therapist synchrony and improvement in clients’ emotional regulation capacities; how-
ever, indirect evidence can be drawn from the mother–infant primary attachment bond
in which the beneficial effects of synchrony on infants’ development are widely docu-
mented (e.g., Davis, Bilms, & Suveg, 2017; Granat, Gadassi, Gilboa‐Schechtman, &
Feldman, 2017; Moore & Calkins, 2004). Specifically, it was found that mother–infant
behavioral and physiological synchrony helps to regulate children’s emotional distress;
furthermore, mother–infant synchrony was found to predict children’s capacity for emo-
tional regulation even in the absence of their mothers (for review see Feldman, 2007b).
Importantly, in all effective SFTs, emotional regulatory processes are key. For exam-
ple, therapists often find themselves working with family members on de‐escalating
maladaptive emotional cycles, reestablishing emotional bonds, and facilitating posi-
tive emotional experiences (Gottman, 2002; Harway, 2005; Johnson & Greenberg,
1985). Such therapeutic tasks are most frequently emotionally and physiologically
engaging for therapists as well. It is assumed that skillful therapists are equipped with
the ability to notice both their own and the family members’ physiological and
e motional reactions and to use this information to navigate the therapeutic interac-
tion into a more regulated and constructive one (e.g., helping family members be in
touch with their own as well as with each other’s emotions).
In light of these theoretical assumptions, it is quite surprising that the role of therapists’
emotions and physiology in the therapeutic endeavor is hardly examined. In fact, to our
knowledge, only one research group has directly examined the therapists’ physiology
effects in couple therapy (Seikkula, Karvonen, Kykyri, Kaartinen, & Penttonen, 2015).
Their work elucidates how complex and multifaceted the interpersonal physiological
dynamics that occur in the context of SFT are, as these dynamics involve at least two cli-
ents and sometimes more than one therapist. For example, in one study (Karvonen,
Kykyri, Kaartinen, Penttonen, & Seikkula, 2016), the EDA synchrony between 10 cou-
ples and their therapists at the beginning of therapy was examined; in this study two thera-
pists worked together with each couple, and, thus, the existence and effects of the six
unique dyads’ synchrony could be examined. Interestingly, their results indicated that 85%
of all dyads showed a significant EDA synchrony; however, among all three possible sets
of dyads (therapist–therapist, therapist–client, and client–client), therapist–therapist dyads
displayed the strongest synchrony, whereas client–client dyads displayed the weakest one.
These results trigger intriguing questions, such as the following: (a) Do family
members who become more synchronous over the course of treatment also become
more attuned to each other and thus benefit more from treatment? (b) Should
moments of therapist–client synchrony be equally distributed among the family mem-
bers to facilitate alliance and engagement of all parties? (c) What is the role of thera-
pist–therapist synchrony? Does it model collaborative interactions and dyadic
attunement? These questions, and others, still await an empirical examination; in our
view, answering them can provide valuable insights for SFT therapists into the best
ways to attend, understand, and make constructive use of their own and their clients’
embodied physiological reactions.
One direct implication of the interpersonal synchrony model of psychotherapy is
that SFT therapists should continuously attend to and if needed try to improve the
physiological synchrony with their clients. Notably, there is consistent variability in
therapists’ effectiveness (Baldwin & Imel, 2013), some of which is attributed to thera-
pists’ interpersonal skills (e.g., Anderson, Ogles, Patterson, Lambert, & Vermeersch,
2009). Based on the documented beneficial effects of therapist–client synchrony, it is
quite possible that finding ways to improve such synchrony may improve the ultimate
outcome of therapy. For example, with current technological advancement, it becomes
more and more feasible to use noninvasive monitoring devices. Such monitoring can
be useful in providing therapists with feedback regarding the changing levels of syn-
chrony with their clients throughout the session, as well as in identifying moments of
heightened (dis)connection. Integrated with video recording, this feedback can help
sensitize therapists to the shared embodied experience with their clients and thus
facilitate beneficial verbal and nonverbal communication patterns.
Intervention
Considering the inseparable link between physiology and relationship functioning,

together with the evidence that therapist–client physiological processes are an impor-
tant consideration, it becomes important to identify ways therapists can integrate a
physiological perspective into their work. Here, we address three approaches thera-
pists can take: (a) use assessment to learn their clients’ key/relevant physiological
markers so they can create more physiologically informed treatment plans and inter-
vene where necessary; (b) promote awareness and educate clients about physiological
processes; and (c) work to change client physiology using in‐ and out‐of‐session inter-
ventions to promote psychosocial change.
Assessment
Because there are physiologic indicators of poor relationship functioning (e.g., low
vagal tone, heightened cortisol functioning), therapists can benefit from gaining a
clearer picture of their clients’ physiologic profiles and functioning. This is especially
important because there is great variability between people in their physiologic pro-
files (i.e., baseline levels of physiologic functioning), which should be accounted for
in all assessment and intervention. Establishing healthy collaborative care networks
will be beneficial for therapists routinely seeking this kind of information because
primary care physicians can help provide necessary data. When a medical record is
only sparsely notated or little history exists, therapists can recommend or request cli-
ents complete a physical examination that will provide relevant information. For
instance, a therapist working with a high‐conflict couple may be interested in know-
ing more about the biological bases for their escalation. Referring the couple to a
physician who can provide RSA (i.e., an indicator of vagal tone) levels, basic arousal
patterns (e.g., how long before heart rate increases significantly under stress), and
diurnal cortisol patterns for each spouse would provide the therapist practical infor-
mation to use when planning interventions to interrupt the physiologic arousal that
accompanies behavioral escalation. Most of these tests can be conducted in physician’s
offices (e.g., the heart’s stress response) or ordered from qualified labs (e.g., that
perform cortisol assays).
Some therapists may choose to invest in equipment that provides this kind of basic
information for in‐session assessment and use. In fact, many individual and some SFT
therapists are already using this approach successfully. Although those biofeedback
devices and software that provide moment‐to‐moment readings and the possibility of
user‐controlled settings represent more of a significant financial investment (e.g.,
NeXus biofeedback system; www.mindmedia.com) than those devices usually ori-
ented toward clinical work (e.g., HeartMath system; www.heartmath.com), they
allow clinicians to efficiently assess baseline physiologic functioning, providing perti-
nent information for treatment planning. For example, if a client’s baseline skin con-
ductance level (signifying SNS activation and behavioral inhibition) is elevated, this
indicates that the client “at rest” is more aroused or “on edge,” which suggests he/
she may avoid emotional stimuli. The therapist can then incorporate that insight into
his/her approach.
When collaborative care or acquiring a biofeedback device is not feasible, therapists
may also use in‐session techniques to have clients describe their own physiology.
Facilitating interoception—or awareness of the body and its sensations—serves the
dual purpose of identifying what is happening physiologically and beginning physio‐
related intervention. This can be as simple as the therapist asking clients to sit quietly
and identify physical sensations. Gottman recommends having clients find their own
pulse and count beats per minute at baseline as well as after a conflict discussion,
which provides a picture of their physiologic functioning and tendency toward arousal
(Gottman, 1999). For some (such as in the case of play with children), having clients
describe physical experiences through art can be helpful. This is because art expression
is a sensory activity, which taps into the limbic system and right hemisphere, both of
which are areas of the brain associated with intense emotional processing and the
physiology of emotions (Malchiodi, 2012).
Promoting awareness
Promoting client’s awareness of their own physiology is a basic first step in integrating
physiological principles in an SFT context. Often, clients are so unaware of what is
happening internally that they may adamantly deny feeling or being influenced by
internal processes. One example is the husband who denies being angry while he is
red in the face and scowling. Another example may be a wife who denies being upset
while refusing to make eye contact, maintaining a closed posture, and repeatedly pro-
fessing “It doesn’t matter” in response to strong emotions her husband has expressed.
Helping clients own their internal state and the implications it has in their relation-
ships puts physiology on the table as meaningful in therapy.
In SFT, helping members of a family system become aware of each other’s physiol-
ogy is another valuable precursor to change. Parents can learn to recognize, for
instance, that criticism suppresses children’s parasympathetic activity (Skowron et al.,
2011) and can send a child into a defensive “fight‐or‐flight” mode and inhibit logic.
Spouses can recognize receptive vs. closed states in each other and use this informa-
tion to inform their decision about when to bring up a difficult subject. As awareness
increases, family members can also tune into how their own physiology affects their
family members. A wife might learn to recognize that her anger and “fight” physiol-
ogy is perceived as unsafe and activates her husband’s “flight” mode, which under-
mines her ability to engage with him. Increasing awareness of client physiology sets
the stage for other physiologically informed interventions.
Psychoeducation Once clients and therapist have an awareness of what is happening

physiologically for themselves and others in their systems, interpreting their experi-
ence using psychoeducation is helpful. The psychoeducation offered by therapists can
normalize client experiences and help them externalize problematic relational pat-
terns. Touching on the basics that were explained earlier in this chapter is a good place
to start. Recognizing that the body has physiological processes to ensure survival and
that relational danger is interpreted as a threat the same way a tiger would be is core
to understanding how the internal and external systems interact. Giving further expla-
nations of what various physiological states (e.g., “fight or flight,” “rest, digest, con-
nect”) mean in terms of brain functioning can further elucidate common interactions.
Most people recognize the experience of becoming irrational when highly angry or
stressed and of “shutting down” in the face of what feels like an insurmountable
obstacle. Tying in endocrine system functioning and the emotionally positive experi-
ences of connection or the emotional disconnect that comes with stress can also be
helpful and further set the stage for effective intervention.
Psychoeducation is most effective when a system is not in immediate crisis. When
emotions are high, as noted, the brain is not capable of processing information the
way it is when the environment feels safe. Once psychoeducation has happened, how-
ever, it can be used in crisis moments to diffuse conflict. Pointing out what is happen-
ing physiologically for a client, and why, validates their experience and promotes a
feeling of safety. For example, when a couple starts yelling at each other in session, the
therapist can step in, slow the process, point out their current “fight‐or‐flight” physi-
ology, and note the relational pattern that is in process. In a parent–child interaction,
helping the child recognize his physiology and how it is manifesting in his behavior
can be calming and informative to both parent and child. Therapists can also provide
psychoeducation about how clients’ biological and experiential differences inform
their physiologic profiles and consequently their psychosocial functioning. For
instance, when a family has one child who is typically calm and another child who is
often reactive, it can be useful to teach parents the potential effects different parenting
behaviors (e.g., shouting, intensity of physical play/contact, gaze) have on each child
(Slagt, Dubas, Deković, & van Aken, 2016). This can serve to destigmatize some
“problematic” child behaviors that occur due to automatic, nonconscious biological
factors. It can also help the parents tailor their approaches to better complement each
child’s temperament.
Intervention to change physiology

Just as using interoceptive techniques provides the clinician with information about
physiological factors that influence relationship functioning, it can be key to clients’
change process. Specifically, therapists can use mindfulness techniques to promote
client self‐awareness of physiologic processes (Siegel, 2011). That awareness can act
as the impetus for behavioral changes to help the client engage in more constructive
relationship processes (e.g., sharing baseline physiological state information with
family members, who are then more informed and enabled to be other‐aware or
empathic).
Considering that some physiologic states are associated with better social connec-
tion and relationship functioning than others (Feldman, 2012; Porges, 2011), it
behooves SFT therapists to promote physiology that is conducive to healthy interac-
tions and relationships. These are interventions that access multiple parts of the brain,
rather than being localized to one, enabling the ANS and endocrine systems to func-
tion more holistically. Such interventions utilize the frontal cortex (associated with
rational decision making) as well as the limbic system (associated with emotional reac-
tivity). There are options for both in‐session and out‐of‐session, therapist‐directed
interventions.
In‐session therapeutic interventions As touched upon in the assessment section,

therapists can use psychoeducation about physiology to help clients shift their own
physiological states (Siegel, 2011). Simply teaching clients how their bodies work,
how they respond to threat or safety, and what their bodies are doing in moments
of emotional intensity or calm can help normalize processes, facilitate cognitive or
behavioral attempts to calm/self‐soothe, and encourage healthier habits that will
result in more regulated physiology.
In addition to psychoeducation, therapists can use in‐session techniques to help
clients self‐regulate. Techniques range from expensive technological options like
biofeedback to simpler but less researched options like body scans and progressive
muscle relaxation. Biofeedback may be particularly appropriate for clients who

favor objectivity or who struggle with self‐awareness. Biofeedback devices can be
used to improve client awareness of and ability to change muscle tension, respira-
tion patterns, cardiac reactivity, and other physiological factors that influence social
behaviors. The Association for Applied Psychophysiology and Biofeedback, Inc.
(aapb.org), is a good resource and network for those interested in incorporating
biofeedback into their practices. Alternatively, therapists can incorporate body
scans, guided imagery, or progressive muscle relaxation, all of which serve the pur-
pose of regulating physiology (Sheehan, 2012), so that clients are in a better state
to engage with each other. These techniques can be practiced out of session as well
and are easy to learn.
Relational interventions to help clients regulate physiology are particularly appro-
priate for SFT. Therapists may encourage partners to make physical contact during
session (e.g., holding hands) as there is evidence that touch changes physiology and
promotes physiological synchrony between couples (Chatel‐Goldman, Congedo,
Jutten, & Schwartz, 2014). Touch has also been shown to stimulate the release of
oxytocin and endorphins, which are associated with anxiety reduction and increased
calm and trust, making it a potentially powerful intervention when used in therapy
(Marcher, Jarlnaes, Münster, & van Dijke, 2007). Therapist discretion is essential,
however, because touch can be perceived as intrusive when a relationship feels par-
ticularly unsafe and may, therefore, further activate the SNS.
There are additional relationally oriented physiological regulatory interventions
therapists can use in session. These include gratitude expression, which can
increase parasympathetic activity (McCraty, Atkinson, Tiller, Rein, & Watkins,
1995); use of music, which has been shown to increase autonomic activity associ-
ated with immunity (McCraty, Atkins, Rein, & Watkins, 1996) or (when singing
together) synchronize cardiac patterns (Müller & Lindenberger, 2011); and help-
ing family members forgive. Research has shown that simply visualizing granting
forgiveness is associated with a lower physiological stress response than harboring
a grudge (vanOyen Witvliet, Ludwig, & Vander Laan, 2001). In appropriate
instances, therapists can encourage conciliatory behavior (such as offering com-
fort), as this has been associated with lower blood pressure in both spouses—the
person extending forgiveness and the person receiving it (Hannon, Finkel,
Kumashiro, & Rusbult, 2012).
Lastly, considering the emerging literature on therapist–client physiological pro-
cesses, therapists can consider their own effect in therapy. At the most basic level,
therapists can cultivate their own “therapeutic presence” by working on their own
regulation and incorporating a person‐centered approach, which then sends the mes-
sage that clients are safe and allows them to become more regulated and primed for
connection (Geller & Porges, 2014). Additionally, there is a strong tradition of
encouraging mimesis in SFT (e.g., Minuchin, 1974), which has received empirical
support in recent years. Namely, the more therapists and clients engage in synchro-
nized movements, the better the client’s assessment of the relationship and the better
the therapeutic outcomes (Ramseyer & Tschacher, 2011). Because behavioral m imicry
is associated with greater self‐regulation (see Chartrand & Lakin, 2013), therapists
can both engage in mimesis and coordinate activities between clients that would facili-
tate such synchrony for them (e.g., an experiential sculpting activity) (see behavioral
correlation in Figure 9.1).
Out‐of‐session interventions SFTs can also use the field’s strong tradition of assigning
homework to facilitate physiological changes. In fact, out‐of‐session work is likely
necessary given the complex interplay of myriad factors influencing how our bodies
function. One of the most influential activities therapists can assign clients is regular
aerobic exercise. Aerobic exercise is consistently associated with decreased self‐
reported anxiety and physiological correlates thereof (Petruzzello, Landers, Hatfield,
Kubitz, & Salazar, 1991) and decreased depression, stress, and negative affect (see
Penedo & Dahn, 2005). Because of the robust relationship between exercise and
improved mental health, it has been recommended that clinicians integrate exercise
interventions into their work with clients (Stathopoulou, Powers, Berry, Smits, &
Otto, 2006).
One of the hypothesized mechanisms by which exercise helps improve psychologi-
cal health is through its regulatory effect on the sleep cycle. With more consistent,
healthier sleep patterns, individuals tend to function better. For instance, research has
found that men who report better sleep efficiency also have less negative interactions
in their marriage the following day. The same study found that greater discrepancy in
bed‐ and wake‐time between husbands and wives was associated with wife reports of
more negative interactions and fewer positive interactions the next day (Hasler &
Troxel, 2010). It is hypothesized that the association between sleep and marital qual-
ity is in part due to a secure relationship’s ability to help individuals be more regulated
and improve HPA functioning (see Troxel, 2010; Troxel, Robles, Hall, & Buysse,
2007). Thus, educating clients about good sleep hygiene and assigning healthy sleep
routines is another way to help clients’ physiology adjust and increase self‐regulation,
thereby facilitating improved relationship functioning.
A growing and popular approach to improving physiological regulation is
through mindfulness practices. Mindfulness, like meditation, is thought to pro-
mote psychophysiological regulation, reducing arousal and reactive responses. This
is accomplished through awareness of the present experience and nonjudgment,
reducing reactivity. Growing evidence links mindfulness with self‐regulation
(Siegel, 2011), greater relationship satisfaction (Barnes, Brown, Krusemark,
Campbell, & Rogge, 2007), and enhancement of non‐distressed relationships
(Carson, Carson, Gil, & Baucom, 2004) and has been suggested as a healthy par-
enting model (Duncan, Coatsworth, & Greenberg, 2009). SFTs can teach mind-
fulness skills and encourage continued use of such techniques outside of session.
Indeed, couples who continue to use mindfulness‐based techniques over time show
better relationship functioning in the long term than those who do not (Carson,
Carson, Gil, & Baucom, 2004).
Other Considerations and Future Directions
The study of psychophysiology in SFT processes is an exciting and intriguing area of

the field. Because the mind–body connection is so clearly relevant to our understand-
ing and work with relationships, it can appear to be a crystal ball that holds a multi-
tude of answers, drawing us as scholars and practitioners in. Although there certainly
are answers to be found in considering how physiology relates to SFT processes, we
encourage some caution in this area.
It is important that we take care not to submit to reductionist explanations of com-

plex internal systems. For instance, research has implicated a specific area of the
brain—the insular cortex, especially the anterior insula—as responsible for visceral
processes associated with emotional experiences (see Critchley & Harrison, 2013). It
may be tempting, therefore, for researchers to hone in on this region of the brain
when trying to understand why a child reacts the way she does to perceived disap-
proval from her parents. Perhaps, however, the child’s emotional response is influ-
enced by a synchronous process with her protective older sibling, in which it would
be prudent to additionally examine the sibling’s physiological/neural response and
other systems known for synchronous responding. Emotional experiencing, like so
many processes, is multifaceted and nuanced and only becomes more so in the con-
text of dyads, triads, and more complex family systems. Although an in‐depth exami-
nation of singular processes can be informative, they should exist in the context of
systemic theory and investigation.
The psychophysiology literature dealing with family systems is usually based on
sound theory, most often polyvagal theory (Porges, 2011), although other estab-
lished human science theories are also integrated or otherwise foundational for such
studies (e.g., attachment theory; Seedall & Wampler, 2012). The use of these theories
notwithstanding, much of the literature still only gives a snapshot of singular physio-
logical processes in the context of small subsystems (e.g., examining RSA in the con-
text of couple interactions; Smith et al., 2011). Because the internal human system
comprises many processes, the interrelation of which affect and are affected by exter-
nal processes and behaviors, such limited examinations and their implications are akin
to describing a complex, dynamic rain forest based on examining a single tree. What
is needed is a more comprehensive investigation of psychophysiological processes and
their association with myriad relational systems. For example, research has found that
EDA, which indicates SNS activation, is higher among anxiously attached spouses
during a conflict discussion when their spouse is more avoidantly attached (Taylor,
Seedall, Robinson, & Bradford, 2018); however, perhaps this SNS response is contin-
gent on the individual’s propensity for a heightened stress response, which would be
evident in his HPA axis functioning. Or, perhaps the SNS response during that con-
flict is different based on whether the couple has a crying infant in the room, which
has been shown to lower the mother’s heart rate (see Hane & Fox, 2016). Further,
whether (or how) these system responses vary in or out of therapy sessions is unknown.
Multifaceted studies are needed to truly understand the interplay of intra‐ and inter-
individual systems.
One reason such studies do not exist in the SFT literature is that they require a lot
of resources, in terms of both financial cost and time. Additionally, this kind of work
is intrusive and demands a lot from research participants. This then raises the ethical
question of whether we are asking too much of research participants who are also
therapy clients. Even with good compensation, asking this much of clients may
amount to compulsion. As a result, the psychophysiology literature related to SFT is
still in its infancy. This is further evident in the fact that the vast majority of studies are
correlational and cross‐sectional in nature. A manageable first step would be to dis-
tribute the burden asked of research participants and use a planned missingness
design, wherein each research participant is randomly assigned to provide a subset of
the overall items used in the study (Little & Rhemtulla, 2013).
This would allow for multiple measures of internal and interpersonal functioning
without taxing any one person. Of course, the sample size needed for this would be
higher; for this, we recommend establishing collaborations with like‐minded research-
ers and practitioners so data may be aggregated across sites, thereby facilitating larger
and more diverse datasets.
Conclusion
Just as I (A.B.) was surprised to realize how constricted my view of systemic thinking
and work has been, SFT as a field is awakening to the broader reality that internal
systems shape the external systems we have been studying and vice versa. Our bodies,
how they function, and how they subconsciously interact are integral to relational
processes. As our understanding of these phenomena deepens, we are presented with
more holistic intervention opportunities, including in‐ and out‐of‐session techniques.
Even our physiological roles as therapists are an important consideration, suggesting
that physiologically informed systemic thinking will influence our being as much as
our practice. We encourage researchers and practitioners to attend to physiology as a
pathway toward more effective therapy and greater integration and collaboration with
those in other helping professions.
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Part II
Social and Cultural Contexts
10
Intersectionality
A Liberation‐Based Healing Perspective
Rhea V. Almeida and Carolyn Y. Tubbs
Why the question of intersectional identities in formulating contemporary pedagogy

in the space of families and their communities? Intersectionality argues that classifica-
tions such as gender, race, class, and other signifiers of identity cannot be examined in
isolation from one another (Crenshaw, 1989). They interact and intersect in individu-
als’ lives, society, and social systems and are mutually constitutive. It is no longer
helpful to situate a person’s identity within a single stratum of identifying markers like
black, white, Asian, wealthy, or poor, but rather people should be identified along a
plethora of markers that compound and embrace their multiple identities.
The complexities around identities—the multiplicity of personal, social,
economic, political, and institutional locations that frame identities by locating
them within a societal matrix that shapes relationships of power, privilege, and
oppression—inherently exist in all institutions, places of learning, and therapeu-
tic practices, shaping a society’s understanding of its members and its members
understanding of themselves. An intersectional framework allows us to dismantle
and decolonize the matrix of coloniality. A matrix of power, privilege, and
oppression is quietly recessed and often unchallenged in daily life. The following
examples illustrate this point.
For example, Christian Picciolini, a former neo‐Nazi member and US citizen, is
a white‐identified cisgender male radicalized at the age of 14. The term “cisgen-
der” is an increasingly recognized term that refers to a person whose gender iden-
tity corresponds with the sex the person adopted at birth. Cisgender is no longer
unmarked, universal, or assumed. In conversation and fluidity with trans identi-
ties, cisgender and heterosexuality are part of this trajectory (Picciolini, 2017).
He was alone, unsupervised, and without dreams or life goals. The platform of
white supremacy offered him an identity, space, inspiration, and hope for a future
life. His participation in years of hate and violence cost him his extended family as
well as his wife and two sons. Loss of family initiated his departure from the
white supremacist organization he called home. He chose a different life to correct
the foundation of hate and violence and reconstruct and recreate a life of accountability,
forgiveness, and moral discourse.
228 Rhea V. Almeida and Carolyn Y. Tubbs
Another example would be Mahatma Gandhi, a Hindu man renowned for his
peaceful resistance to the subjugation of British colonialists. Through his stirring
speeches and persistence on peace and freedom through nonviolence, Gandhi
desperately wanted his sons to continue his legacy. His son Harilal originally
shared his father’s dreams, particularly following his father’s path to England for
a law degree. His father, however, was unconvinced of a Western education’s
helpfulness in the struggle against the British Raj and firmly opposed Harilal’s
pursuit. Gandhi’s opposition to the ways of the Raj not only destroyed his son’s
professional dreams but also imposed an austere lifestyle on the entire family and
required everyone to live in simplicity eschewing the accouterments of their prior
middle‐class lifestyle. In response, Harilal vehemently rejected his father’s
demands, became a perpetrator of violence against his wife and child, and drank
his way into oblivion. He died as a homeless man in Delhi (Kapoor, 2017). Gandhi
did not recognize the privilege inherent in his “option” of being part of the ruling
class or an ascetic, and therefore, through the patriarchal context of the Indian
culture, he denied his son the same types of freedoms he hoped to secure for his
country (Kapoor, 2017). It is common for therapists to be in awe of someone like
Gandhi and to be less questioning and curious about the simultaneous role he
plays in truncating life choices for his son. This type of patriarchal domination is
much less challenged than someone who is overtly abusive and dismissive of his
children’s dreams that may not coincide with his own.
Finally, the experiences of Phiona, a young African girl living in the Katwe slums
outside of Kampala, Uganda, were featured in the biographical movie Queen of Katwe
(Carls, Pilcher, & Nair, 2016). Phiona sold corn on the streets of Katwe to help her
single mother make ends meet. Phiona’s world rapidly changed when a chess coach
introduced her and other poor kids of the slums to the game and recruited them to
participate in children’s chess tournaments on the international stage. When the coach
presented this opportunity to the principal of a wealthy city school, the principal balked
at the prospect of an activity mixing students from different economic classes; as a
result, the coach chose to work primarily with the poor children from the slums. The
support Phiona received from her coach, family, and community, built her confidence
and determination needed to pursue her dream of becoming an international chess
champion (Crothers, 2012). Phiona’s unusual rise to success was a particularly poignant
story as it reflected the hierarchical structures inherent in a global space where race is
not the defining marker. There are many sources of knowledge systemic family therapy
(SFT) can learn from this story. If Phiona and her family presented themselves in
therapy, how would the therapist best engage with a disadvantaged family within a
highly disadvantaged community? Would they assist the mother in obtaining higher
wage employment so Phiona could focus on her studies? Would that be considered
close to impossible given the communal poverty? Perhaps assisting Phiona to structure
her day differently might be an option although that too might collide with the hours
she needed to be available to her customers in support of the family income.
Foreshadowing liberation‐based healing (LBH) strategies requires the following.
First, LBH interrupts the conventional wisdom of creating change solely within the
interior of the family. Second, it reaches into a community with greater resources find-
ing paths that connect Phiona to these options highlighting aspects of her identity
that potentiate success and travel into unintended spaces. Third, LBH disrupts the
Intersectionality 229
boundaries of conventional family systems and linking clients across the class divide
speak to intersectional identities, spaces and liberatory healing.
Even in these exceptional lives, each aspect of their identities, although located in
different social spaces, created an intersectional experience with embedded aspects of
advantage, disadvantage, and nuance along the trajectories reflected in the above nar-
ratives. Intersectionality shifts away from the cultural competence framework that
fosters siloed, either/or approaches to understanding the impact of varied, yet over-
lapping, cultural contexts shaping clients’ beliefs, values, behaviors, and motivations
when they present to therapy. When couples and families seek therapy, their differen-
tial locations within the social structure may afford implicit or unacknowledged
advantages or disadvantages directly impacting the presenting problem.
Chapter Overview
A crack is the perfectly ordinary creation of a space or moment in which we assert a dif-
ferent type of doing. Holloway (2010, p. 21)
Based upon our own epistemic rights, this chapter seeks to coexist and stand with
other ways of knowing in SFT consistent with a decolonial paradigm, yet it departs
from the historic colonial path of family therapy. That path, distilled from Western
psychological constructs, weighs heavily on emotional processes, individuality as a
scaffolding for maturity, and siloed connections with little to no attention to the
oppressive forces of the social order that perforate the lived experiences of many indi-
viduals, families, and communities (Pillay, 2017). It aligns with Martín‐Baró’s (1994,
1996) argument that psychology has created a fictionalized and ideologized image of
what it means to be human based on an ahistoricism and bias toward individualism:
There is no person without a family, no learning without culture, no madness without social
order, and therefore neither can there be an I without a We, a knowing without a symbolic
knowing, a disorder that does not have reference to moral and social norms. (p. 41)
While family therapy was radical in its inception, it currently trudges backward
embracing cognitive‐behavioral therapy (CBT) or eye movement desensitization
reprocessing (EMDR), as dominant paradigms, rather than ancillaries for systemic
change. While trauma‐informed care is the new gold standard, it enters one’s identity
at the time of the trauma rather than embracing identities of resistance and resource-
fulness while attending to the traumatic event within a systemic context (Ginwright,
2018). American Indian practitioners in their healing endeavors with their communi-
ties stress the absolute significance of emphasizing and acknowledging the Native
American genocide and its historic, intergenerational, and current impact (Brave
Heart, Chase, Elkins, & Altschul, 2011; Duran & Duran, 1995; K. L. Walters et al.,
2011). Through this lens, a family’s experience of serious health, mental health,
domestic violence, substance use, and school failure resides within the family’s multi-
generational history of violent colonization. Liberation becomes available by situating
current live experiences within their historical social, political and economic contexts
even when clients do not bring this consciousness with them.
Based on theories of coloniality, global feminism, and intersectionality, this chapter

outlines the relationship between intersectionality and LBH in three sections. First, it
presents the hierarchy of power, privilege, and oppression and its role in maintaining
coloniality. Then, it builds on intersectionality as an essential component of LBH,
specifically focusing on its ability to disrupt coloniality‐informed therapeutic concep-
tualization. Finally, it focuses on LBH in therapeutic practice and closes with narra-
tives that emphasize the very tangible outcomes of LBH. Stories from healing circles
as well as from lived experiences of people across various settings create contiguity
between families we serve and families that live their lives in multiple spaces. All stories
represent composites of characteristics and concerns of multiple families and individu-
als and are not attributable to a specific individual, couple, or family.
Hierarchy of Power, Privilege, and Oppression
Examples of these hierarchies and categorizations are visible in all of the ways our lives
are compartmentalized into silos (see Figure 10.1). The principle of corporate profits
at the cost of human lives shapes the silos of social services, prison industrial com-
plexes, physicians and large pharmaceutical groups, agricultural corporations, and the
health and education industries. The academic disciplines that produce professionals
to populate the silos are cordoned off from one another’s scholarship, and professionals
Hierarchy of
line
ro
power, privilege and

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Hete
lth
scu
White
ea
Male
a
Cis-
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W
Defined by intersecting influence of:

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-Capitalism
-Coloniality
-Religion
ion
on
tat
ssi
ir en
pre
o
ntity
al
e x
xu
sex
ide
er
S e
nd
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Gen
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Poor on conf
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color er/g
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G end
Figure 10.1 Hierarchy of power, privilege, and oppression. Reprinted with permission of
Almeida (2016). This figure graphically depicts the structure of social locations in the United
States.
in mental health or health are bifurcated as advocates or clinicians, academics, or activists.

The list is endless and constitutes a powerful capitulation to the hierarchies estab-
lished by coloniality. Disrupting these hierarchies begins when a client/family enters
an SFT’s office wherein conversations that customarily begin at the client’s presenting
concern ought to parallel conversations about historical legacies of lived experiences,
be they from oppressed or privileged communities. For the few SFT thinkers and cli-
nicians who advocate inquiring about historical legacies of oppression, the conven-
tional wisdom trends toward focusing more on singular forms of oppression rather
than nuances of disadvantage coupled with advantage originating within legacies of
power and privilege based on white supremacy and those who benefit from it (Seedall,
Holtrop, & Parra‐Cardona, 2014). Even within families, experiences of segregation
exist, for instance, around issues such as skin color, hair, economic, LGBTQ identi-
ties, and other target markers.
Gathering knowledge about the lived experiences of subjugated identities requires
a deep understanding of the powerful structures that create such uneven access to
social and cultural capital. This asymmetry of positionality is relevant to all families
regardless of their current social location. This knowledge is essential to the formation
of pathways for emancipation and liberation.
Coloniality: Matrix of power, privilege, and oppression

Mignolo (2011) and Quijano (2007) suggest that the strength of colonization lies
in the ability to control (a) the institutional narratives informing history and educa-
tion and (b) the resources that privilege some, oppress others, and guarantee their
power. This colonial matrix of power establishes beneficiaries of economic, political,
and social power by privileging those possessing valued characteristics. Privileging
may at first occur by force; later, it is bestowed through favor, resources, and inclu-
sion by the most powerful or resourced. Those found wanting—the marginalized or
“other”—become mostly invisible unless they intrude on the boundaries of safe
spaces or declared rights of the privileged. As Almeida, Dressner, and Tolliver
(2017) note, “The demand of coloniality requires that we live through one mask.”
Transgressing this mandate occurs by (a) failing to uphold or endorse the rules and
roles of privilege, (b) making public those needs (physical, mental, or relational)
misaligned with those of the privileged (homelessness, mental illness, substance
abuse, being transgender), or (c) being a member of a marginalized group whose
value within the social structure trends opposite of the valued norm. All of these
expressions violate implicit social boundaries and render the invisible more visible
and often problematic. Muting the perspectives and knowledge of the marginalized,
by both the colonizer and the colonized, maintains the power dynamics of the social
structure.
The matrix of coloniality is a major site for the wounding of lived experiences.
Coloniality is a phenomenon in the asserted postcolonial era that maintains domi-
nance of world structures by modern‐day colonizers in the form of restricted resources,
life opportunities in the lives of disadvantaged groups (Grosfoguel, 2011, 2013;
Maldonado‐Torres, 2007), and implicit cultural imperialism. Castro‐Gomez (2010)
argues that in modern colonialism, or coloniality, domination by force is not the only
method of domination. Another method of coloniality is discourse about “the other”
embedded within the everyday lives of both colonizers and colonized. For example,
whiteness was the first cultural and geographical imagery of the world system from
which the ethnic division of labor and the transfer of capital and raw material was
legitimized globally (Battalora, 2015). Privileging of whiteness set the staging for
coloniality.
Using Quijano’s work on coloniality (Quijano, 2000, 2007), Almeida (2018;
Almeida, Melendez, & Paéz, 2015) identifies three systems active in establishing
power, privilege, and oppression:
1 Systems of hierarchies: Racial division and classification as the organizing principle

of white supremacy.
2 Systems of knowledge: Privileging of Western or Eurocentric forms of knowledge
as universal and objective.
3 Societal systems: Reinforcing hierarchies through the construction of the state
and specific institutions to regulate, segregate, and diminish decolonizing systems
of healing and lived experiences.
Intersectionality
The question of replacing traditional conceptualizations of assessment from cherished

theories and practice of SFT can be daunting. The calibration of an intersectional
framework is to decode the matrix of power, privilege, and oppression. It operational-
izes the matrix and offers us a view of all of these possible combinations of privilege
and vulnerability, rather than to create a static impermeable boundary around an
individual or family. Consider Amna, a South Asian lesbian in her 40s, economically
and educationally privileged, but vulnerable as a woman, a gay woman, and a woman
of color over 25. Another could be Chinua, a successful, Nigerian cisgender business-
man, who speaks English fluently, with all privileged identities, but the color of his
skin and his accent create identities of vulnerability. Cisgender is no longer unmarked,
universal, or assumed. In conversation and fluidity with trans identities, cisgender and
heterosexuality are part of this trajectory. Similarly, a white cisgender woman in her
60s, upper class, a successful journalist, and married with grandchildren may experi-
ence vulnerable identities around aging and disability.
The therapeutic opportunity in liberation healing practices is to address presenting
issues within the context of dismantling and reinscribing specific configurations of
power, privilege, and oppression connected to the social context and fabric from
which they emerge and draw sustenance. The interplay and tenacity of power, privi-
lege, and oppression within and across groups help to develop a foundation for under-
standing the multiple identities that everyone holds. These configurations also help to
interrogate the system about which identities receive explicit acknowledgment when
addressing issues in familial or community life. Power, privilege, and oppression are a
part of the human fabric and are present in all relationships.
Power
Power has both positive and negative aspects, and individuals constantly exercise
it by a myriad of agents at the individual, group, and institutional levels whether
intentionally or unintentionally. Since power is always in play in one way or

another, it is also easy to intentionally or unintentionally misuse it and, therefore,
harm others at the individual or group level without necessarily controlling or
having direct access to the institutional agents of power and control. Power has
the ability and capacity to fulfill or obstruct personal, relational, and collective
needs. For example, the story of Flint, Michigan, is but one of thousands of exam-
ples of the abuse of power (Hanna‐Attisha, LaChance, Casey Sadler, & Champney
Schnepp, 2016; Lubrano, 2017). The deliberate choice of the Flint governing
class was to route clean water through lead pipes to save the state money with no
regard for damage to the health of poor residents. The federal government refused
to honor the treaty (one of the hundreds) of sacred lands and water to prioritize
the needs of the indigenous people in the Dakotas when routing the oil pipeline
(Pewewardy, 2000, 2003).
Privilege
Privilege refers to identity markers (white skin, racial heritage, heterosexuality,
maleness, able‐bodiedness, age, class, religion, language) that give individuals and
certain groups unearned advantages when possessed (Almeida, Parker, & Dolan‐
Delvecchio, 2007). Since power and privilege both embody variants of class, some
analysis is required here. Multiple factors including wealth, education, income, and
social status, and prestige determine class. Allen (2009) and Bourdieu (1987)
highlight three types of capital within the construction of social class: economic
capital, which includes financial property (wealth, income, and assets); cultural
capital, which includes specialized skills and knowledge, such as language and cul-
tural heritage passed down intergenerationally or through institutions like prestig-
ious universities; and lastly, social capital, which consists of webs of connections
(Bourdieu, 1987).
Oppression
Oppression, in contemporary discourse, refers to one group’s unjust exercise of
authority and power over another group, including the distribution of rights and
resources (Young, 1990). Oppression is the enforcement of barriers at multiple
levels that leads to the immobilization of some groups by others, stabilized by
largely unquestioned norms, that is, creating structural barriers. Young describes
five faces of oppression: exploitation, marginalization, powerlessness, cultural
imperialism, and violence. While the presence of any of these five conditions is
sufficient to identify a group or individual as oppressed, the application of these
criteria allows for analysis of different and compounding oppressions while also
understanding the virulence and sustained harm inflicted by certain dominant
groups. Frequent sexual assault of Indigenous women by white men on reserva-
tions without prosecutorial protection coupled with limited educational resources
for young native people are further evidence of the total violation of human rights.
This patterned oppression parallels a long history of broken treaties with and
genocidal practices targeting Indigenous peoples (Amnesty International, 2008;
Dunbar‐Ortiz, 2014; Mihesuah, 2013).
Intersectionality and identity

Prior to the late 1980s, social science and legal thought struggled to move forward
from perspectives limiting individual’s multifaceted social identities (i.e., gender, class,
sexual orientation, race). Orienting to individuals based on singular identities failed to
capture the personal realities of navigating social and institutional structures, both for
marginalized and for privileged populations. At the start of the twentieth century
cultural pluralism invited conversations about multiple identities at the macro level
(Political Affairs, 2009); however, in the 1980s, black and Chicana feminists raised
the issue of individual identity being profoundly informed by the nexus of one’s mul-
tiple social identities within any social structure (Anzaldúa, 1987, 1999; Collins,
1993, 2000, 2004, 2009; Crenshaw, 1994). The concept of intersectionality emerged
from their work and provided a cogent perspective for examining within‐group differ-
ences of individuals representing any one social identity (Traister, 2018). SFT has not
fully caught up with this social, economic, and political analysis of lived experiences
across family life nor has the study of human behavior (Seedall et al., 2014).
Intersectionality contends that signifiers of identity inextricably intertwine so that
no one signifier can capture or denote individuals’ experiences within the social struc-
ture, nor can one signifier be understood outside a system where these identities
mutually construct one another (Almeida, 2018; Almeida et al., 2017; Crenshaw,
1994). It is a conceptual acknowledgment of and strategy for triangulating individu-
als’ location on the power, privilege, and oppression map governing the inherent
structure of a society or group.
When the Women’s Project in Family Therapy (Carter, 1993; M. Walters, Carter,
Papp, & Silverstein, 1991) first introduced the construct of gender/woman, in addi-
tion to hierarchy within the interior of the family, it was a homogeneous representa-
tion. It reflected on the white woman’s experience without further elaborating on the
specifics of class, color, or sexual orientation. The naming of women of color and their
experiences appeared later (Almeida, 1998a, 1998b; Almeida et al., 2007; Bograd,
2007; Goodrich & Silverstein, 2005).
From an intersectional standpoint, the experience of women in the therapeutic
space must include a wider gaze for women of color who may use multiple identifiers
like race and class compared with white women. A middle‐class woman of color seek-
ing a divorce might face entirely different challenges than her white middle‐class
counterpart. For the woman of color, her income and that of her partner’s might be
the only wealth they have. In contrast, her white counterpart may also have limited
income, but her family may have inherited wealth that she can access. Similarly, for
white women, the range of their intersectional identities is significant to the healing
endeavor. Intersectionality provides a foundation for decolonizing mental health and
family theory informing clinical practice.
The structure of individual, family, and community development is built on a blue-
print taken from patriarchy, which enforces binaries of gender identities designed to
preserve cisgender heterosexual dominance (Almeida, 2018; Almeida et al., 2017;
Almeida, Hernández‐Wolfe, & Tubbs, 2011). It is important to note that these cate-
gories are limited in that the continuums do not represent those outside of these spaces
or those who might choose no identity within this configuration. Figure 10.2 reflects
the complexity and circularity of sexuality, gender identity gender expression, and sex-
ual orientation. It is a close‐up of the gender matrix path depicted in Figure 10.1.
Dismantling the social construct of gender
Patriarchy Patriarchy
Biological sex
Intersex
Gender identity
Male Female
er Third gender
Genderque Two spirit
Gender nonconform Transgender

Cis ing Cis
man Gender expression woman
ous Transvestite
Androgen
Masculine Butch Femme Feminine

Sexual orientation
gay Lesbian
Asexual
ing
Hetero- form
Poor Bisexual com
nonHetero-
sexualpeop Pansexual der
le of co uee r/gen sexual
lor der q
Gen
*This tool is not meant to capture all of the categories and language of the dimensions of gender. it is intended to be the starting point of a dialogue that
expands the rigid binary definitions which are reinforced through traditional partriarchal systems.
Figure 10.2 Dismantling the social construct of gender. Reprinted with permission of Al-
meida (2017). This figure invites multiple points from which to engage in dialogues about
constructions of gender in all of its fluidity along the hierarchies of race and class.
The introduction of healing circles within this overlay is a strategy for dismantling
the gender hierarchy and Western mental health practices that isolate individuals,
families, and couples. Practitioners can no longer embrace the belief that the struc-
tures of individual, family, and community development rests on a patriarchal blue-
print that enforces binaries of gender identities designed to preserve cisgender
heterosexual dominance. Healing circles, as a strategy for LBH praxis, disrupts the
conventional wisdom of gender binaries. By dismantling the hierarchy, healing circles
promote the decolonizing strategy that mental health or health concerns should not
be viewed as the unfortunate circumstances of the otherized or unlucky isolated
individual(s), but as legitimate concerns and pain of those with differing intersectional
identities. In the case of gender, clients from all levels of the hierarchy engage to dis-
cuss, embrace, and challenge one another on experiences of power, privilege, and
oppression.
Liberation‐Based Praxis
Liberation‐based praxis is the philosophical and theoretical foundation for decoloniz-

ing current platforms of SFT and creating LBH practices. Praxis is the act of doing
and being. This theoretical foundation addresses the established social order of power,
privilege, and oppression and acknowledges the constructs of gender, race, ethnicity,
sexual orientation, class, and other markers of identities that exist within family and
community life (Almeida, 2018; Almeida et al., 2015). LBH is the doing or practicing
from this epistemology.
Decolonizing strategies necessary to create LBH practices call for changing the lens
and the language1 and debunking the myth of healing through diagnostic codes, indi-
vidual structures, and the rigid bifurcation of individuals, their families, their context,
and their healing spaces. The strategies encompass a multiplicity of personal and pub-
lic institutional locations that frame identities within historical, colonial, economic,
and political life. A range of broad and nuanced descriptors—which may or may not
include indigenous hosts, nationality, ethnicity, class, gender, sexual orientation, abil-
ity, or religious preference or language—unwittingly situate local and global individu-
als within a social structure. Combinations of these personal, economic, social, and
political intersections remain largely unacknowledged by current Western models of
clinical practice across disciplines. LBH locates these complexities within a societal
matrix that shapes relationships in the context of power, privilege, and oppression and
builds on the foundations of critical consciousness, empowerment, and accountability.
Intersectionality offers possibilities to decolonize the economic, political, and insti-
tutional aspects of social location and standpoints (Harding, 2003; Holloway, 2010)
present in people’s lived experiences across multiple contexts. Building the platform
for liberation praxis requires three pillars: critical consciousness, empowerment, and
accountability.
Critical consciousness
Approaching the development of critical consciousness for clients from a non‐prob-
lematized agenda is crucial. While people come in with problems, a simultaneous
focus on their multiple lived experiences that reflect hope and inspiration should be
drawn and cataloged. Freire (1978, 1999) called for interacting dialogues between
educators and students as a method to embrace students as subjects of their own
destinies—a direct segue to building critical consciousness with clients. He posed the
idea that critical consciousness is “daring to perceive social, political, and economic
contradictions and to take action against the oppressive elements of reality” (p. 35).
Although individuals’ experiences will vary based on their lived experiences and
embodiment of the varying social identities constructed by society, this knowledge is
the beginning of undoing the matrix of coloniality and laying the foundation for lib-
eration. The context for building critical consciousness occurs within the circle of a
community rather than the imagined protections of the individual in siloed isolation
(Hernández, Almeida, & Del‐Vecchio, 2005).
Grappling with the matrix of coloniality is critical. Understanding that structural
forces affect consciousness is about knowing, recognizing, and controlling all lev-
els of social, economic, and political interaction. Lived consequences are the opus
of this endeavor. It is an awareness of both culpability and accountability coupled
with a critical sense of how to use individual and systemic agency to intervene in
inequitable systems—whether the actor benefits from it. Du Bois (1903/1994),
before Freire, in addressing racialized images of the oppressor, first espoused the
need to free oneself from an “oppressed consciousness” or “double consciousness”
to reach a critical consciousness. Du Bois interrogated consciousness as it related
to racial identity and Freire and Macedo (2000) addressed this phenomenon as it
related to class. Almeida (1998a, 1998b) and Almeida et al. (2011) embraced the
inclusivity of race and gender, and sexual orientation in all its trajectories in acquir-
ing consciousness.
Scaffolding the legitimacy of alternate and border products of knowledge is essen-

tial to the process of decolonizing. The foundational system of critical consciousness
is one vehicle to that end. An analysis of oppressors and oppression or dominators and
dominance is not achievable without an understanding of coloniality, with its embrace
of white supremacy and gender oppression, class, and race (Almeida, 2018; Grosfoguel,
2011, 2013; Hernández‐Wolfe, 2013; Mignolo, 2009, 2011; Quijano, 2000).
Historically, some global societies scrambled gender markers and embraced gender
fluidity, such as the Hijras of India, Two‐Spirit people in indigenous North American
societies, and Japanese men and women who are more androgynous (defined by class
and age), until the influence of Western norms in the late 1800s (Williams & Best,
1996). Still, some parts of the world (Cape Town, South Africa) continue to chal-
lenge traditional Eurocentric constructions of gender (Meslani, 2018).
Empowerment
LBH promotes empowerment “power with” rather than “power over” between
members of a community, group, or family. It does not mean a void of leadership;
rather it espouses the view that power is fluid and varies. For example, would thera-
pists support empowerment if treatment for an 8‐year‐old child experiencing discom-
fort with hiding their transgender identity might run counter to the preferred
treatment of the parental hierarchies? Parents could empower their children by
respecting their evolving gender expression and supporting options like permitting
them to wear clothes, hairstyles, and other forms of expression aligning with their
desired identity, without immediately going to the question of transitioning.
Similarly, negotiating an opportunity to pursue higher education before marriage
rather than resentfully capitulating to parental demands that she immediately marries
and have children to fulfill familial and cultural obligations could empower a single
religious woman. Perhaps a man, neglectful of his wife and children, fosters their
empowerment through an accountability letter acknowledging their concerns, fol-
lowed by subsequent reparative actions. He, too, is empowered through just action as
he articulates his oppressive behavior and engages reparation. This definition initially
confuses some practitioners, whose patriarchal vision presumes that when a man takes
responsibility for his actions, he experiences shame rather than empowerment. The
humility he experiences through this process is a gift that acknowledges his embrace
of connections. The creation of corrective actions within spaces of liberatory healing
originates within these more discrete and larger global assaults of wrongdoing, dehu-
manization, and human decimation (Almeida, 2018; Hernández et al., 2005).
Accountability
Accountability begins with acceptance of responsibility for one’s actions and the
impact of those actions upon others; however, accountability moves beyond blame
and guilt. It results in reparative action that demonstrates empathic concern for others
by making changes that enhance the quality of life for all involved parties (Almeida,
2018; Hernández et al., 2005). The accountability process calls for a spoken or writ-
ten letter/document that is read publicly to a circle of observers and memory holders.
It usually accompanies some form of reparations for the harm done. Collective
accountability with regard to legacies of power, privilege, and oppression are also a
part of this process.
Because corrective actions serve to restore equity after the commission of injustices,
reparations become essential to the accountability process. Reparations at the family/
community level might include the gift of services (like prepared meals, using one’s
abilities to trade services for monetary assets; such services that might go on for a
particular length of time based on the harm done, currency, property, or other assets).
LBH includes these corrective exchanges as a means for rebalancing damaged rela-
tionships in a way that facilitates healing. Coates (2014) speaks to reparations at the
societal level that embrace families and communities in The Case for Reparations. He
writes, “Two hundred fifty years of slavery. Ninety years of Jim Crow. Sixty years of
separate but equal. Thirty‐five years of racist housing policy.” He argues that the lack
of white–non‐white racial healing in the United States stems from the lack of national
accountability for the injustices of slavery (unlike South Africa, Australia, and Canada),
as well as no attempt at reparation. The lack of accountability for stealing the land of
indigenous peoples of the Americas and decimating their cultures too also fuels racial
tensions and white nationalists’ concerns about becoming minorities.
The United States could take its cues from South Africa and the European coun-
tries that have heeded the call for reparations in healing their histories of colonization
and enslavement. Today’s South Africa, although vibrant and booming, bears scars of
subjugation created by decades of racial apartheid borne of European countries’ hun-
ger to (a) colonize and claim valuable resources and (b) establish white supremacy.
Corrupt South African dictators continued the oppressive behavior by reinforcing the
strictures of white supremacy, further limiting black South Africans’ economic and life
prospects. To acknowledge these generational, collective hurts of colonization and
apartheid, South Africa engaged reparative activities, such as personal and community
financial compensations, as well as the Truth and Reconciliation Commission, given
the charge by Dullah Omar, to utilize a restorative justice format to “enable South
Africans to come to terms with their past on a morally accepted basis and to advance
the cause of reconciliation” (Department of Justice and Constitutional Development,
South Africa, 2018; Truth and Reconciliation Commission, 1995). Reparations
memorialize the retributive act(s) and facilitate enduring reconciliation.
Four principles of liberatory praxis

Four principles guide the work of those clinicians utilizing LBH in their practice to
interrogate intersectional identities and transform the therapeutic process: (a) trans-
parency and the naming of hierarchical structures; (b) disrupting the hierarchical
categories of coloniality around race, class, patriarchy/gender, and sexual orienta-
tion; (c) epistemic disobedience; and (d) desegregating and redrawing the bounda-
ries of inclusion. LBH encodes intersectionality as a framework that highlights
coexistence instead of binaries and oppositions where one view must dominate the
other. The voices that are present in the liberatory healing process must include the
individual, their biological or assumed families, together with their embracing com-
munities. These four principles, guided by foundational platforms of critical con-
sciousness, empowerment, and accountability, structure the case illustrations that
follow; they offer a template for bringing these LBH ideas into therapeutic practice
(see Table 10.1).
Table 10.1 Intersectionality and liberatory‐based healing.
These guidelines assist with decoding and redrawing intersectionality through foundational
pillars of critical consciousness, empowerment, and accountability
Conversationally Conversationally and structurally
Transparency and the naming of Redrawing the boundaries of inclusion

structures of dominance and
subjugation
Disrupting the hierarchical categories of Desegregating healing spaces through use
coloniality around race, class, gender, of spoken word, film, music, dance, and
sexual identity and/or orientation, art. ALL simultaneous venues that speak
ableness, immigrant status, and other to different learning styles and different
markers platforms of liberatory healing
Being free of living the script of Sharing social and political capital to create
coloniality pathway toward economic capital
Affirming and developing knowledge •• Bring power and privilege back into the
and practices from border spaces analysis
across disciplines and geographic •• Expand the therapeutic space to build a
localities community with critical consciousness
•• Define empowerment in collective rather
than individual terms
•• Encourage and build social activism into the
healing space
•• Build accountability for all participants,
including therapists and students
•• Help people think about ways to connect
past, present, and future legacies within the
matrix of critical consciousness, empower-
ment, and accountability
Transparency and the naming of hierarchical structures The goals of healing circles,
regardless of clients’ ages, are to raise critical consciousness and the contours of gen-
der, race, class, and sexual orientation. What follows is a healing circle involving five
children, ages 6–12, along with their 14‐year‐old mentor. Four of the children are
Latina—two undocumented and two legal residents. The fifth child is white, as is the
14‐year‐old mentor. The children live in single‐parent and two‐parent families whose
parents have brought the family to therapy for various reasons. The sample dialogue
provides a snapshot of the circle session during which the children discuss news clips
of migrant children being separated from their parents at the border and put in cages.
The children, having already been introduced to hierarchical structures and intersec-
tionality, move from general comments to critically reflecting on the role of white
supremacist policies in shaping the US response to immigrant border crossings.
The italicized text is the dialogue following the viewing:
Two of the undocumented children speak to their parents’ fear of being taken out of their
homes to these places on the US border. The 9‐year‐old shares a story of her mother’s friend who
was asked to show up to a local site for work opportunities. When she showed up, she was
arrested and deported and her children, US citizens, had to be cared for by friends. They
spoke about the fact that not many people in their school were aware of what was happening
to some families and certainly not many in their classrooms (this is a low‐property tax school).
The 12‐year‐old white teen said that her language arts teacher did a presentation on what
was happening to some classmates under the president’s policies and they had to write a jour-
nal about it (this is a high‐property tax school). The mentor shared her experience of how
many students and her parents were talking about these events (empowerment).
Both white children were able to respond to questions and inquiry regarding white
supremacist practices that harmed children and families. These dialogues are intended to
bring dimensions of accountability and empowerment into the healing circles of building
critical consciousness.
The movie Akeelah and the Bee (Fishburne et al., 2006) provides a fictional account
of the very real ways in which power, privilege, and oppression play out in the gen-
dered lives of racially class‐advantaged and disadvantaged children:
With Akeelah and the Bee, there was a conversation about where to place Akeelah in her class-
room and school. Then they were asked to place the characters including her family, her brother,
and his friends and her coach on the hierarchy. This exercise activated a lively dialogue with
some being clear of social location and its implications and others presenting differing nuances.
This process is intended to bring young people into the fold of healing circles with
questions and reflections of trajectories of empowerment and accountability. During
the same healing circle, the children also view clips from the movie.
Disrupting the hierarchical categories of coloniality and installing epistemic disobedi-

ence This example provides storied reflections of how domestic violence and white
supremacy represent ongoing wounds of patriarchy and coloniality (Walker, 1997).
Heraldo’s story highlights three people in a circle with numerous participants. The
participants include clients who are critically consciousness and have engaged in the
process of empowerment and accountability as it relates to their own healing experi-
ences. New clients may attend healing circles after several weeks of raising critical
consciousness.
Conventional structures for family therapy engagement include meeting with fami-
lies one at a time, threading families through the pay‐for‐care system that separates
public‐funded families from private insurance families. Families are further divided by
language proficiency. Desegregating spaces of healing require disrupting these bor-
ders of capitalism around reimbursement and the class protection embedded within
these tiered systems be disabled. Following the work of Guadalupe Valdéz on dual‐
language immersion in the classroom, we have introduced that scholarship into libera-
tion healing practices. Rather than separating Spanish‐speaking from English‐speaking
clients, we invite them into a shared space with therapists and allies as translators lev-
eling the quality of care. This process offers a rich tapestry of Spanish‐speaking clients
offering knowledge in shared spaces and English‐only clients learning to embrace
those from segregated spaces. Continuing with epistemic disobedience, the process of
de‐siloing clients expands the boundaries to include Heraldo, Glenn, and Carolina:
This strategy is intended to challenge Heraldo, a cisgender Latino male, in his 30s, and
Glenn, a white man in his 20s for repeated acts of violence against their partners (account-
ability) and provide a space to speak truth to power for Carolina (empowerment). It also
intentionally provides a space for Carolina, a Latino Spanish‐speaking, undocumented sin-

gle parent to tell her story of working long hours to provide for her two daughters (empower-
ment). Heraldo’s minimization of his intimate violence is challenged by Carolina who says
that no man has the right to harm his partner or his family no matter what the reasons. He
responds that in his family, his dad’s advice was a little violence was necessary to keep women
in line. Others in the circle raise questions around rigid masculinity and de‐link it from
within family legacies. Glenn explained that his reason for battering his partner was tied to
his lack of work and financial independence. Upon being separated from his partner and
their child, he lives with his parents.
Many of the white participants in the circle interrogate his current living situation. They
further inquire and offer reflections about Glenn’s lack of employment for close to two years.
They continued to raise concerns about his follow through with work options previously
offered. He blames the food business and many restaurants, like Chipotle, that have people of
color in management and who Glenn believes discriminate against white-identified men.
Several white members of various genders suggest that he reflect upon his white privilege. One
white woman, a mother of adult sons, suggests it is shocking that he has been unable to secure
employment for two years. She opines that perhaps his comfortable middle-class lifestyle in his
parents’ home, offers him the privilege of deliberating on the type of employment he chooses.
Carolina closes this conversation by stating that if he were in her shoes, he would be willing
to take whatever work was available. He does not have to concern himself about whether his
child will be fed or whether he will have a place to sleep or even have access to transportation
as he uses his parents’ car. She must use community taxis and public transportation for travel.
Desegregating and redrawing the boundaries of inclusion Accountability around sub-

stance use and parenting create a safe space for Meghan to honor her ongoing sobri-
ety and be simultaneously accountable for her absent and abusive parenting to her
now two grown adult sons:
Meghan came from an upper‐class white family with intergenerational patterns of parental,
spousal abuse, and addictions. She entered therapy around her plans to divorce Clinton, her
husband of 20 years. She was primarily concerned about her sons: Peter, her older son, who
dropped out of community college and was in special education due to his ADHD and John
who was academically proficient, had much emotional anxiety over his parents’ divorce and
concern over how his father would survive postdivorce. His father, a scientist, was in an auto-
mobile accident that left him brain injured. He was on disability benefits and addicted to
several pain medications. Meghan had a long history of addictions to alcohol and opioids and
had a long recovery history with AA but re-engaged with the 12‐step program following her
hospitalization for opioids.
Following her consultation, the IFS team invited her husband and sons to be a part of the
healing process. Her husband participated in four sessions and left after the IFS team
requested consent to contact his pain management physician. Soon after he pulled the sons out
of treatment as well. Meghan had over 15 years in recovery but was not required to engage
in accountability work with her adult sons. As part of the liberation‐based healing circle
process, some of her peers in the circle requested that she do this important piece of accounta-
bility and the team supported it.
Meghan wrote a letter that detailed all of the ways and events she derailed their path
toward launching and adulthood. She specifically spoke to ways in which she repeatedly sabo-
taged Peter’s attempts at succeeding in high school and then in community college. She often
showed up high and absent for many of their critical milestones. She planned to offer repara-
tions in financial support for Peter to continue his education and for John to use the money
for whatever he desired. Peter and John were invited to a session to witness and decide for
themselves whether they chose to accept the reparations. Peter voiced concerns about being
offered reparations in the form of money. Members of the circle affirmed his participation,
with his brother, in the healing process occurring through the monthly dinners and phone
connection with his mother. The money they suggested was a way to repair some of his life that
was truncated by his mother’s addiction during a critical time of his life.
Adult children from abusive and compromised homes are often left to find their
own journeys through adulthood. While SFTs invite adult children into sessions with
their parent(s) to clear up and differentiate various hurts through their child and teen-
age lives, rarely do they create and endorse a system of accountability from parents to
adult children. Adults as parents are more likely to hold on to their status as parents
and minimize the hurt emblazoned in their children’s lives. Being a part of a LBH
circle offers pathways for this particular path when parents receive support from par-
ents representing various intersectional experiences. Highlighting these principles as
they apply to cases does not negate fluidity with other cases.
Healing circles
As suggested in the examples, healing circles provide a space where people can come
together to talk about their cruel bosses, get strategies for embracing the dreams of
their children in unforgiving schools, mourn losses, repair relationships, heal from
abusive parenting, and get sober all in a space that redraws the boundaries of segrega-
tion and hierarchical ruptures. Healing circles as a strategy for LBH praxis flatten the
hierarchies legitimized along trajectories of gender, race, class, sexual orientation, and
other markers that offer nuances of power, privilege, and oppression (see Figure 10.3).
Countering the tradition of serving individuals or families who seek therapeutic
help in isolated spaces mirroring the segregation of individual lifestyles, these circles
invite people with different presenting issues from different social locations and iden-
tity markers into once space. Unlike traditional indigenous circles where there is not
a naming or claiming of different identities of power, privilege, and oppression, heal-
ing circles in this context intentionally do not collude with neutrality.
Intersectionality and liberatory‐based healing Miriam’s lived experience best captures

a majority of the guidelines critical to decoding coloniality and redrawing intersec-
tionality through foundational pillars of critical consciousness, empowerment, and
accountability:
Miriam, an 18‐year‐old African American female, attended sessions with a friend.

Both of her parents were incarcerated, and she was without relatives from her immediate
family. She lived with a guardian who could barely provide for her. She joined a healing
circle and became invested in the deep analyses into how categories such as race, class,
gender, sexual orientation, ability, religion, and other markers largely shape her life and
those of others and how these markers overlap. She saw the connections between her chal-
lenges and those of others in ways that she could simultaneously see their similarities and
differences (critical consciousness). She spoke to the fact that she did not realize that
therapy could provide a space to bring alive her experiences from the hood especially in
the context of many others in the circle who had their challenges but lived in more racially
homogeneous communities within the safety of their families and communities. Miriam
knew about the status of her community as a never‐ending space of poorly performing
Healing circles
Affluent
White
men
Upper
middle class
White men and women

LGBTQ+
Middle class
White men and women
Men and women of color
LGBTQ+
Working class
White men and women
LGBTQ+
Poor
LGBTQ+
Youth of color
Figure 10.3 Leveling power and privilege between clients. Reprinted with permission of
Almeida (2018). This figure depicts the hierarchical composition of a culture or healing circle
including individuals from many social locations.
schools, unsafe and boarded buildings and homes, gun violence, lack of jobs, grocery stores
with limited inventories, excessive numbers of alcohol stores, and an omnipresent, men-
acing police force (coloniality). She also accepted patriarchy and sexist masculine norms
but did not have a consciousness of their origin. Through the power of language to name
the intersecting influences of power, privilege, and oppression and a reflection on the
definitional boundaries that intentionally separated communities like hers from other
safe white communities, she was able to gather a critical understanding of the
larger social order and her forced lived experience in a subjugated space (critical
consciousness).
As the process of healing progressed, Miriam considered attending college and a local
university accepted her (empowerment). However, her dream of college entrance came with
newly discovered barriers. She learned that entry into college did not entitle her to secure
financial aid because, in the United States, student loans—state and federal—require a
cosigner. Allies from a local African American church offered to cosign on her behalf, with
the condition that she attend a few church gatherings. Miriam was Muslim and unwilling
to accept an offer that involved worshiping another god (oppression, privilege).
The Alliance for Racial and Social Justice (ARSJ), the resident activist organization
with the Institute for Family Services (the majority of whom are white), agreed to research
the situation using their social and cultural capital to contact the school and find out if there
were options available to someone like Miriam. In return, Miriam began engaging with
ARSJ projects, such as becoming a co‐trainer on dismantling white privilege and creating
communities of resistance.
The week she left for college, ARSJ and the Institute for Family Services (where the healing
circles occurred) planned a celebratory ritual of her launching. During the celebration, a
circle of mentors, community allies, a broad intersection of clients (youth and adults), and
therapists embraced Miriam. Struggling to hold back tears, she stated, “I never had any fam-
ily, and you are not even my family, but I see what family looks like.”
The African American allies, from the local church, initially struggled with the fact that
Miriam turned down their offer to attend a few Sunday gatherings in exchange for the
funding the church could offer her. They failed to recognize the African American revolu-
tionary connection with Islam during the civil rights era—a crucial intersect of black life.
Instead, they focused on a singular view of black Christian identity, one often represented in
the multicultural/cultural competency scholarship.
Intersectionality as stated above departs from this single identity analysis. When prac-
titioners engage liberation‐based practices, stories like this and the ones above are
poignant outcomes in the liberatory trajectory of those served. Authentic connections
are created between people who account for their power and privilege and those from
marginalized spaces. Hierarchies are markedly redefined through desegregated
boundaries to offer people with privilege—whether privilege of gender, race, or
class—the opportunity to account for and heal by allying with those persons who
come from spaces of oppression and subjugation.
For many youths in intentionally fractured communities, they have lost all
knowledge and memory to ancestral histories. Therefore, centering through
sociopolitical, economic, and educational discourse is critical to their healing.
School curriculums leave craters of historical omission. Miriam learned for the
first time about the struggles of MLK to create a platform that was inclusive of
antipoverty and antiwar, the divisions within the civil rights movement between
MLK and Malcolm X, and the origins of the black Muslim conversion. She is a
black Muslim but had no idea of its origins. She was exposed to a few of MLK’s
speeches without context and history. Healing circles can bring in the sociopo-
litical, economic, and educational knowledge that flow from acknowledging the
intersectionality of one’s life.
Miriam’s journey invites reflection on the healing experiences possible through
interruptions of the traditional boundaries of isolating Eurocentric therapeutic
canons. It also highlights the power of a circle of critically conscious members,
from multiple social locations of privilege and oppression, whose awareness and
lived experience of intersectional identities facilitated ready embrace of Miriam and
her situation, as well as invited a number of justice‐oriented action strategies. The
actions of this community challenged various forms of structural and interpersonal
privilege proving transformative not only for her but for many others embraced by
this circle.
Conclusion
This linking and decolonizing of capitalism, patriarchy, white supremacy, and anti‐
Semitism to generational patterns within a family and the passing on of this legacy to
future generations is a hallmark of liberatory healing practices. Intersectionality is a
coherent analysis that names and dismantles the matrix of coloniality. An intersectional
framework is the foundation from which to create LBH and to redraw the boundaries
of individuals, families, and communities with the intent to unpack unspoken, spoken,
and erased histories that perforate lived experiences. LBH is a framework that high-
lights coexistence and fluidity both in lived experiences and in therapeutic practice
instead of binaries and oppositions where important aspects of social, political, and
personal identity go unacknowledged and unchallenged in the familial and social
spaces. Multiple identities matter as they translate into perspective and experience.
This intersectional platform, as a guiding methodology for SFTs, builds the con-
nective tissue between theories of intersectionality and grounded practice. The voices
that are present in the liberatory healing circle include the individuals, their families
of origin or choice, and their embracing communities. While we embrace concepts
from some SFTs models, they are used mostly as micro strategies for change within an
LBH platform. Although recent perspectives speak to the socio‐emotional processes
outside of the family context, they rely solely on internal family process theory and
lack an operational stance. The family is a fluid unit that is constantly susceptible to
outside forces be they to oppress, empower, or thread into the status quo. Theories
and assumptions that situate the family as an autonomous unit unabashedly collude
with the status quo of white stream that continue to privilege some individual, fami-
lies, and communities over others. So, the question to SFTs who view this perspective
as a social justice approach is, can you identify those families that require a social jus-
tice approach and those that do not? What are the values and assumptions that guide
this binary view of healing families? What lies underneath that worldview and how is
it related to an ethical and moral positionality in the practice of SFT?
Certainly, the current political, economic, and social forces have punctured families
and communities in multiple ways. These ugly forces puncture families in ways that
family members do not speak to one another and neighbors keep to themselves. While
this image appears more grotesque than prior times, it is fair to say that these forces
have always played in the dark from the periphery to center depending on the station
and social location of any family and community. Reticence on the issues of intersec-
tional, privilege, and power and oppression and the insidious ways in which they per-
meate the lived experiences of couples and families is no longer a choice of modalities.
Relationships within families (hierarchical social circles, houses of worship, schools,
and the workplace) now call to account sacrosanct spheres of unchecked privilege,
oppression, and abuse. Outcome data by way of transformative stories emerging from
over 20 years working alongside those we serve communicates powerful endorsement
for dismantling concepts of traditional SFT and re‐charting perspectives of LBH. SFT
is historically distinctively separate from traditional models of psychotherapy. It should
scaffold and celebrate this leadership instead of acquiescing to what could become an
increasingly more capitalist, white supremacist, and vibrant arm of coloniality.
There’s really no such thing as the “voiceless.” There are only the deliberately silenced, or the
preferably unheard. (Arundhati Roy, 2004)
Note
1 Language is power. In the interest of developing new language to synchronize with the
power of healing, we have chosen to disconnect from language like “clinical,” which m
irrors
medical pathology, and “intervention,” which is mired in war. To the best of our ability, we
have attempted to represent language that is rooted in peace and liberation.
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11
Sexual Orientation and Gender
Identity
Considerations for Systemic Therapists
Christi R. McGeorge, Ashley A. Walsdorf, Lindsay L.
Edwards, Kristen E. Benson, and Katelyn O. Coburn
In this chapter, we explain the important identity markers of sexual orientation and
gender identity and discuss considerations of these identities for systemic family thera-
pists (SFTs). Sexual orientation reflects who (if anyone) people are sexually attracted
to, who they feel emotionally connected to, and who they love. Gender identity
reflects individuals’ deeply held sense of themselves as gendered beings, regardless of
what sex they were assigned at birth. Historically, the literature in family therapy has
largely neglected both sexual orientation and gender identity (Serovich et al., 2008).
However, sexual orientation has been given slightly more attention (Blumer, Green,
Knowles, & Williams, 2012). This is concerning as research suggests that lesbian, gay,
and bisexual (LGB) individuals seek therapy services at a rate of 25–77%, which is two
to four times the rate of heterosexual individuals (Cochran, Sullivan, & Mays, 2003).
Rates for transgender individuals are even higher; the 2015 National Transgender
Discrimination Survey found that 58% of transgender and nonbinary participants had
been to therapy and 77% reported a desire for therapy services (James et al., 2016).
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience
increased rates of depression, suicidal ideation, and substance misuse as a result of
historical and present‐day oppression (Lewis, Derlega, Griffin, & Krowinski, 2003;
NIDA, 2017). Specifically, the increased likelihood of LGBTQ mental health and
substance use concerns is due to the added stress LGBTQ individuals experience liv-
ing in a heterosexist and cissexist society, known as minority‐related stress (Lewis
et al., 2003). Minority stress can also manifest dyadically and within families, affecting
relationship quality (Gamarel, Laurenceau, Reisner, Nemoto, & Operario, 2014).
Experiences of minority‐related stress are connected both to macro‐level societal dis-
crimination and to more localized experiences of family and/or peer rejection. SFTs
must be aware of these issues to provide competent clinical services to LGBTQ indi-
viduals, relationships, and families (McGeorge, Kellerman, & Carlson, 2018).
252 Christi R. McGeorge et al.
Although LGBTQ individuals seek therapeutic services for many of the same reasons
as non‐LGBTQ clients, it is important that therapists understand how the presenting
problems LGBTQ clients bring to therapy might be created or exacerbated by con-
tinual experiences of discrimination and rejection on both familial and societal levels.
Historical and Social Context
Experiences of discrimination and oppression are grounded in a historical fight by

LGBTQ communities for basic civil rights, including the right to freely and openly
exist; educational access; housing and employment protections; marital, relationship,
and parental rights; and access to competent and affirmative health services. Although
this is by no means an exhaustive review, we hope to provide a glimpse into the soci-
etal context for LGBTQ individuals, relationships, and families by providing an over-
view of some of the historical and present‐day civil rights struggles.
At its most basic level, the LGBTQ civil rights movement has been a pursuit of the
right to exist openly and freely. For many, the right to existence is taken for granted,
but this is often not the case for LGBTQ communities. Examples of efforts to prevent
the mere existence of LGBTQ individuals are numerous and include government‐
sanctioned efforts by law enforcement officials in Chechnya, Russia, to arrest, detain,
and torture gay men (Lokshina, 2017). Laws banning sexual contact between men
have also been used to justify violence against all members of LGBTQ communities
in Ghana and other countries (Isaack, 2018). Along with government‐sanctioned
efforts to eradicate LGBTQ communities, there are many other ways LGBTQ indi-
viduals’ rights to freely and openly exist are challenged, including efforts to prevent
bathroom access to transgender individuals, forced sterilization programs targeting
lesbian women and gay men, and the killings of transwomen of color in the United
States (Human Rights Campaign, 2018c).
LGBTQ communities also continue to struggle for basic education rights, which
involve pursuing safe learning environments. In the United States, researchers asso-
ciated with the Gay, Lesbian, and Straight Education Network (GLSEN) found that
the majority of LGBTQ students surveyed reported experiencing discrimination and
harassment at school, with 56% reporting homophobic comments by teachers and
staff and 64% reporting transphobic remarks (Kosciw, Greytak, Giga, Villenas, &
Danischewski, 2016). A comprehensive study in the Philippines found that verbal
harassment was the most common form of bullying for LGBTQ youth and that
teachers and administrators often failed to intervene, leading to decreased attend-
ance and poorer educational outcomes (Thoreson & Lee, 2017). In the United
States, transgender students have faced disregard for their preferred or self‐desig-
nated names on student identification cards, transcripts, and registration records
(Goldberg, 2017). Higher education has only recently begun to adopt policies
allowing transgender students to live in campus housing that aligns with their gender
identities (Goldberg, 2017).
Globally, LGBTQ individuals, couples, and families have struggled for the right to
have their relationships and families legally recognized. In January 2014, the Nigerian
Same‐Sex Marriage (Prohibition) Bill (SSMPA) made it illegal for individuals of the
same sex to marry (Isaack, 2016). In 1996, the US Defense of Marriage Act (DOMA)
Sexual Orientation and Gender Identity 253
denied federal recognition of same‐sex unions and allowed states to refuse recognition
of marriages that occurred in other jurisdictions (US Congress, 1996). Despite these
efforts, a number of countries have reversed laws banning same‐sex marriage and have
legalized same‐sex marriage equality, including Argentina (2010), Australia (2017),
Belgium (2003), Brazil (2013), Canada (nationwide: 2005), Denmark (2012),
Finland (2017), France (2013), Greenland (2015), Iceland (2010), Luxembourg
(2015), Netherlands (2001), New Zealand (2013), Norway (2009), Portugal (2010),
South Africa (2006), Spain (2005), Sweden (2009), Uruguay (2013), the United
Kingdom (England and Wales, 2014), and the United States (nationwide: 2015; Pew
Research Center, 2017). As political climates change, there is growing concern that
the progress represented by marriage equality may be reversed completely. Less than
1 year after legalizing same‐sex marriage, Bermuda has become the first national gov-
ernment to repeal marriage equality (Human Rights Campaign, 2018a).
Another basic right that LGBTQ communities have been denied is the right to
competent and affirmative mental health services. For heterosexual and/or cisgender
individuals, the right to competent clinical services is assumed to be the basic standard
of care. However, the therapeutic community has regularly failed to provide such
services for LGBTQ individuals, couples, and families. For example, until the 1980s,
therapists conflated “homosexuality” with pathology and developed methods of cor-
recting so‐called sexual transgressions (Giammattei & Green, 2012). Thus, just as
LGBTQ families have been pushed to the margins by societal systems, both explicitly
and implicitly, family therapy has replicated and reproduced this system of inequity.
Understanding how the field has and continues to participate in the reification of
inequity is an important step for SFTs looking to practice affirmatively.
Mental health professions have historically focused on diagnosing LGBTQ indi-
viduals rather than providing competent services. For example, gender identity disor-
der (GID) was added to the DSM‐III in 1980 (American Psychiatric Association
[APA], 1980). More recently, GID was removed and replaced with gender dysphoria
in the DSM‐V (APA, 2013), thus representing a positive shift from diagnosing iden-
tity to diagnosing the distress experienced by some transgender people. Despite this
improvement, the gender dysphoria diagnosis continues to place the onus of pathol-
ogy on the individual rather than on a society that stigmatizes transgender ways of
being. Furthermore, “homosexuality” was viewed as a psychological disorder by the
APA until 1973 and was “treated” with practices such as electroconvulsive therapy
(APA, 2000). In 2001, the Chinese Society of Psychiatry also removed the diagnosis
of “homosexuality” from the official list of mental disorders (Tcheng, 2017). Slowly,
the trend of no longer labeling “homosexuality” as a mental health disorder has
spread across mental health disciplines. Yet, attempts to alter or change sexual orienta-
tion, known as conversion, reparative, or change “therapies,” continue despite
research documenting the harm they cause (Serovich et al., 2008; Tcheng, 2017).
In 2015, as a response to ongoing clinical practices to alter the sexual orientation
of LGB individuals, 12 United Nations agencies, including the World Health
Organization, labeled these so‐called clinical practices both tremendously harmful
and unethical (Tcheng, 2017). The World Psychiatric Association, which is composed
of psychiatrists from 118 countries, echoed similar concerns in 2016, calling repara-
tive “therapies” unethical, unnecessary, and unsupported by evidence (Tcheng,
2017). While several countries have introduced legislation to ban conversion therapy,
at this time Malta is the only country to ban these “therapies” on a nationwide level.
In the United States, 18 states and the District of Columbia have passed laws or
executive orders that prohibit the practice of conversion therapy with minors
(Movement Advancement Project, 2019).
Introduction to LGBTQ Affirmative Therapy
A review of the historical and present‐day struggle for basic civil rights illustrates the
clear need for SFTs to provide competent and affirmative therapy. LGBTQ Affirmative
Therapy is defined as “an approach to therapy that embraces a positive view of LGBTQ
identities and relationships and addresses the negative influences that homophobia
and heterosexism” as well as transphobia and cissexism “have on the lives of LGB[TQ]
clients” (Rock, Carlson, & McGeorge, 2010, p. 175). This definition highlights the
two major components of LGBTQ Affirmative Therapy. First, LGBTQ Affirmative
Therapy requires more than simply tolerating or accepting LGBTQ individuals and
families; it necessitates embracing and celebrating LGBTQ lives and relationships.
The second yet equally important component of LGBTQ Affirmative Therapy is that
therapists are mindful of how societal biases influence their LGBTQ clients, the ther-
apy process, and themselves.
Theoretical Underpinnings of LGBTQ Affirmative Therapy
Many of the practices associated with LGBTQ Affirmative Therapy have been shaped
by critical theories, such as feminism and queer theory. LGBTQ Affirmative Therapy
is positioned within intersectional feminism (hooks, 2000), as a movement toward
competent and just therapy services for all families. Here, we focus on three ways
feminism has informed LGBTQ Affirmative Therapy: (1) the recognition of power,
privilege, and oppression; (2) self‐reflectivity; and (3) activism. Feminists noted that
the power structures underlying all systems, including the discipline of family therapy,
grant privilege to some through the oppression of others (hooks, 2000). Following
this, LGBTQ Affirmative Therapy recognizes the power and privileges granted to
heterosexual and cisgender individuals and relationships while simultaneously disen-
franchising members of LGBTQ communities (McGeorge & Carlson, 2011).
Secondly, LGBTQ Affirmative Therapy necessitates a critical reflection of therapists’
social locations, biases, and assumptions (McGeorge & Carlson, 2011), a process
known as self‐reflexivity. Finally, clinical services must move beyond the four walls of
the therapy room through public participation and advocacy efforts (Toporek, Lewis,
& Crethar, 2009).
Queer theory also informs LGBTQ Affirmative Therapy by undermining the essen-
tialist assumptions that restrict who is characterized as a woman, a man, heterosexual,
or “normal” (Butler, 1990). Queer theory critiques the linguistically constructed
binaries operating implicitly in our interactions and poses alternative ways of viewing
self and relationships (Oswald, Blume, & Marks, 2005). Thus, awareness of the power
of language is fundamental to providing affirmative and competent services to
LGBTQ clients. Further, queer theory highlights the history of identity‐authorship
being given to so‐called experts (e.g., physicians, clinicians). LGBTQ Affirmative
Therapy acknowledges that all clients do family, gender, and sexual orientation differ-
ently and should have the right to decide for themselves what constitutes healthy
relationships (Oswald et al., 2005).
To be truly feminist and queer‐informed, LGBTQ Affirmative Therapy must be
intersectional. Intersectionality describes the interlocking influence of racism, sex-
ism, heterosexism, colonialism, and other systems of structural inequality (Crenshaw,
1991; hooks, 2000). LGBTQ persons are of all races, genders, and religions and
have differential access to privileges, as well as marginalized identities. These identity
points are not additive, but rather interconnected in how they organize life experi-
ences and experiences of oppression. For example, those closest to what is socially
sanctioned as “normal” (e.g., heterosexuality, whiteness, maleness) often have the
most power and access to resources (Oswald et al., 2005). This does not suggest that
therapists should make assumptions about clients’ identities, but rather demonstrate
openness to learning about intersecting identities. Thus, LGBTQ Affirmative
Therapy addresses inequality related not only to sexual orientation and gender iden-
tity but also to all systems of structural inequality that affect clients’ lives. The crux
of competent LGBTQ Affirmative Therapy is its focus on “destroying the cultural
basis for…domination,” such that all “other liberation struggles” are strengthened
through dismantling the power structures that subordinate LGBTQ identities and
ways of being (hooks, 2000, p. 40).
Sexual Orientation
In this section, we discuss (a) important terms related to sexual orientation, (b) bar-
riers to working affirmatively with LGB clients, (c) the impact of these barriers on the
mental health of LGB individuals, and (d) the effects of family acceptance and
rejection.
Defining important terms

There are a number of central terms that may aid SFTs in providing affirmative clinical
services to LGB clients, including terms related to (a) identity labels and (b) oppres-
sion (see Table 11.1). Terminology and language are living and evolving systems;
therefore, language is not definitive and shifts over time (Iantaffi & Benson, 2018).
In an effort to honor people’s identities, SFTs need to connect with marginalized
communities and scholarly literature to stay apprised of current linguistic trends.
Terms related to identity labels The following terms describe identity labels applied
to or used by LGB individuals. The first, sexual minority, refers to those whose sexual
orientation differs from the dominant group (i.e., heterosexual). Although by defini-
tion minority suggests that numerically fewer people identify as LGB, it is important
to note that marginalization occurs regardless of population size. Thus, some believe
the term marginalized sexualities is more accurate, as subordination based on sexual
orientation is not simply about numbers, but rather social stratification.
Lesbian, gay, and bisexual identities are often shortened to the initialism LGB,
although other initialisms such as LGBTQ or even LGBTQQIP2SAA (lesbian, gay,
Table 11.1 Terms related to sexual orientation.
Term Definition
Identity labels
Sexual minority Any sexual orientation that differs from the dominant group (i.e.,
heterosexual)
Marginalized Any sexuality or sexual orientation that is socially subordinated or
sexualities oppressed
Queer A historically derogatory label reclaimed by LGBTQ communities
to embrace the fluidity and expansiveness of gender and sexuality
Oppression
Homophobia Irrational fear of LGB people
Sexual minority Discrimination or oppression based on sexual orientation
prejudice
Bisexual Denial of the existence of bisexuality by reinforcing a false
erasure dichotomy that individuals are either gay or heterosexual
bisexual, transgender, queer, questioning, intersex, pansexual, Two‐Spirit, asexual,

allies) have been proposed to be more comprehensive. Throughout this chapter, we
use the initialism LGBTQ, and we use LGB when discussing sexual orientation
specifically. Another identity label gaining recognition is the term queer, which means
different. Although historically used as a derogatory term that was placed upon LGB
people, “queer” has since been reclaimed by members of LGBTQ communities as a
celebrated identity. Some queer‐identified individuals may prefer this term as a
rejection of fixed identity categories and “normality,” embracing the fluidity and
expansiveness of sexuality (Tilsen, 2013). Because of the discriminatory history, there
are still LGBTQ individuals who perceive “queer” to be a derogatory label. It is
important that therapists ask, rather than assume, how clients identify.
Since the development of the Kinsey Scale in 1948, sexual orientation has been seen
as existing on a continuum whereby individuals fall more toward heterosexual or
same‐sex attraction and anywhere in between (Kinsey, Pomeroy, & Martin, 1948).
Furthermore, scholars have conceptualized sexual orientation as fluid rather than
static, as it may evolve across the lifespan (van Anders, 2015). It is widely accepted
that people do not choose their sexual orientation; yet some queer scholars have cri-
tiqued the “born this way” paradigm for its assumption that, if given the choice, no
one would choose to be LGBTQ, which further stigmatizes queer identities and ways
of being (Tilsen, 2013).
Terms related to oppression based on sexual orientation The following terms relate to
negative beliefs or prejudice surrounding sexual orientation and the subsequent
effects of these beliefs. Homophobia refers to the irrational fear of LGB people and has
been the impetus for hate crimes such as the brutal murder of Matthew Shepard in
Laramie, Wyoming, in 1998. Some scholars have proposed sexual minority prejudice
as a more accurate term to reflect societal practices due to homophobia’s focus on
prejudice that is fear based (Herek, 2004). A specific form of sexual minority preju-
dice is bisexual erasure, which reinforces the dichotomous belief that individuals are
either gay or heterosexual, thus denying the existence of bisexuality and subjugating
bisexual people (Barker & Langdridge, 2008). Sexual minority prejudice and antigay
sentiment have many harmful effects, including that LGB individuals may internalize
harmful messages about their worth from society (Herek, 2004).
Barriers to working competently and affirmatively with LGB clients

There are a number of barriers SFTs may encounter when providing affirmative clini-
cal services to LGB clients, including (a) heteronormative assumptions, (b) institu-
tional heterosexism, and (c) heterosexual privilege. By discussing heterosexual
privilege as a barrier to LGBTQ Affirmative Therapy, we are not assuming that all
SFTs identify as heterosexual, but for those who do, heterosexual privilege is an
important barrier to explore.
Heteronormative assumptions The first barrier, heteronormative assumptions, is

“automatic unconscious beliefs and expectations that reinforce heterosexuality and
heterosexual relationships as the ideal norm” (McGeorge & Carlson, 2011, p. 15). In
particular, heteronormative assumptions construct a reality or unconscious worldview
where heterosexuality is the sole option, and only heterosexual relationships are visi-
ble and acknowledged (Oswald et al., 2005). Heteronormative assumptions lead all
therapists, regardless of sexual orientation, to be blind to the needs and experiences of
LGBTQ individuals and relationships. A common heteronormative assumption that
influences SFTs is the implicit belief that all clients who seek clinical services identify
as heterosexual and, if partnered, are in heterosexual relationships (McGeorge &
Carlson, 2011). For example, a therapist who learns a female client is partnered may
automatically ask about her partner using male pronouns.
Institutional heterosexism Institutional heterosexism, another common barrier to

providing LGBTQ Affirmative Therapy, is defined as societal or governmental poli-
cies and institutional practices within systems (e.g., health care, governments) that
endorse and celebrate heterosexual individuals and relationships above all others
(Hodges & Parkes, 2005). This occurs both explicitly through discriminatory laws
and policies and implicitly through differential access and recognition. Institutional
heterosexism grants unearned privileges to heterosexuals while at the same time dis-
criminating against LGBTQ individuals and relationships (Hodges & Parkes, 2005).
Spaulding (1999) notes that institutional heterosexism is “a form of social control”
that maintains heterosexual dominance (p. 13). Examples of explicit institutional het-
erosexism include laws passed by US states that prohibit LGBTQ couples from adopt-
ing children. Awareness of the pervasive impact institutional heterosexism has on
LGBTQ clients is an important component of LGBTQ Affirmative Therapy.
Heterosexual privilege For heterosexual SFTs, unexamined heterosexual privilege

can become a significant barrier to providing competent and affirmative therapy to
LGBTQ clients and can negatively impact work with all clients. Heterosexual privi-
lege is “unearned civil rights, societal benefits, and advantages granted to individuals
based solely on their sexual orientation” (McGeorge & Carlson, 2011, p. 15). These
privileges are experienced throughout daily life, often unconsciously, and include hav-
ing one’s sexual orientation perpetually affirmed by positive media images, being able
to safely walk down the street holding a partner’s hand, and being able to locate a
mental health or medical provider with a similar identity. In addition to these daily
privileges, there is also an important global privilege all heterosexual individuals expe-
rience, namely, an increased sense of self‐worth, referred to as internalized uncon-
scious superiority, resulting from membership in the dominant, socially sanctioned
group (McGeorge & Carlson, 2011; Worthington, Savoy, Dillon, & Vernaglia, 2002).
Impact of barriers on the mental health of LGB individuals

The described barriers also have harmful effects on LGB individuals’ mental health.
Specifically, LGB individuals experience increased risk of mental health disorders, sui-
cidal ideation and completion, and substance use and misuse (Medley et al., 2016;
NIDA, 2017). For example, the National Survey on Drug Use and Health (NSDUH)
found that 32.2% of LGB individuals surveyed reported smoking cigarettes compared
with only 20.6% of heterosexual individuals (Medley et al., 2016). Further, 36.1% of
LGB individuals surveyed reported binge drinking compared with 26.7% of hetero-
sexual individuals.
When exploring rates of mental health diagnoses, the NSDUH found that 37.4% of
LGB individuals met the criteria for at least one mental health diagnosis in the DSM‐
IV (excluding substance disorders and developmental disorders), compared with
17.1% of heterosexuals (Medley et al., 2016). Additionally, LGB youth in the United
States and across the world report higher levels of anxiety, mood disorders, and sui-
cidal ideation than their heterosexual counterparts (Russell & Fish, 2016). SFTs seek-
ing to practice LGBTQ Affirmative Therapy must understand these trends and risks
as resulting from living in a heterosexist society.
Family acceptance and rejection

Research suggests that acceptance or rejection from families of origin has significant
implications for LGB individuals’ adjustment, functioning, and mental health.
Rejection may involve not being accepted or included in the family, hurtful com-
ments, or even disownment, which has been associated with homelessness for LGB
youth and young adults (Ryan, Huebner, Diaz, & Sanchez, 2009; Schmitz & Tyler,
2017). The effects of rejection are far reaching. In one study, LGB youth who were
rejected by their families were eight times more likely to have attempted suicide, six
times more likely to report high levels of depression, and three times more likely to
use alcohol and drugs (Ryan et al., 2009).
Conversely, family acceptance is the extent to which a family embraces, supports,
and celebrates LGB members. LGB youth who are accepted by their parents report
closer familial relationships, greater life satisfaction, increased hope for the future, and
higher levels of self‐esteem (Ryan et al., 2009). Acceptance from other family mem-
bers (e.g., grandparents, siblings) can contribute to stronger networks of social sup-
port in the lives of LGB young adults (Schmitz & Tyler, 2017). Family acceptance has
also been linked to increased satisfaction and support in LGB adults’ own romantic
relationships (Fuller & Rutter, 2017), suggesting that the influence of acceptance
spans multiple systems.
Therapeutic strategies are often focused on helping parents develop acceptance for
their LGB children; yet it is also important for therapists to acknowledge the common
struggles parents may experience when their child comes out. These struggles can
include fears about long‐term well‐being and safety for their child, worries about dis-
crimination, religious concerns surrounding acceptance and salvation, and parents’
own sense of shame and blame. Because these fears often manifest outwardly as anger
or rejection, it is important to help parents identify what they are truly experiencing.
By attending to parents’ fears and concerns, therapists can play a key role in helping
families work through their struggles and increase their acceptance of their LGB fam-
ily members.
Gender Identity
In this section, we discuss (a) important terms related to gender identity, (b) barriers
to working affirmatively with transgender and nonbinary clients, (c) the impact of
these barriers on the mental health of transgender and nonbinary individuals, and (d)
the effects of family acceptance and rejection.
Defining important terms

There are a number of terms whose understanding is fundamental to affirmative ther-
apy with transgender and nonbinary individuals, couples, and families, including
terms related to (a) sex and gender, (b) gender transition, and (c) transphobia (see
Table 11.2).
Table 11.2 Terms related to gender identity.
Term Definition
Sex and gender

Sex Based on chromosomes, hormones, primary and secondary
sex characteristics, and genitalia
Gender Cultural ideas, roles, identities, and expressions of masculinity,
femininity, and androgyny
Gender expression A person’s embodiment of masculine, feminine, and/or
androgynous characteristics reflected in physical appearance
Transgender When a person’s sex‐assigned‐at‐birth and gender identity are
not in alignment
Cisgender When a person’s sex‐assigned‐at‐birth and gender identity are
in alignment
Gender transition
Social transition The experience of disclosing gender identity to other people
and inviting them to honor one’s gender identity
Physical transition The choice to physically represent one’s gender through
changes in personal attire and/or through the use of
hormonal and/or surgical procedures
Gender affirmation/ Surgeries to physically affirm one’s gender, which may include
confirmation surgeries mastectomy or breast augmentation and/or genital surgery
Oppression
Transphobia Fear or hatred of people who do not conform to social
gender norms
Terms related to sex and gender Although sex and gender are often conflated, these
terms refer to distinct dimensions of personhood and identity. Sex is based on chro-
mosomes, hormones, primary and secondary sex characteristics, and genitalia. Gender
refers to cultural ideas, roles, identities, and expressions of masculinity, femininity, and
androgyny. As such, gender identity refers to the way people experience themselves as
gendered beings, which includes but is not limited to identities such as woman, man,
genderqueer, nonbinary, Two‐Spirit, trans woman, trans man, trans feminine, and
trans masculine. Gender expression refers to a person’s embodiment of masculine, fem-
inine, and/or androgynous characteristics. This is often reflected in physical appear-
ance, such as clothing, makeup, and hairstyle choices, mannerisms, and body
movement (Iantaffi & Benson, 2018). Transgender refers to a range of gender identi-
ties and expressions based on one’s gendered sense of self being different than one’s
sex‐assigned‐at‐birth. When a person’s sex‐assigned‐at‐birth and gender identity are
in alignment, that person is referred to as cisgender.
Gender essentialism is the assumption that masculine and feminine gender stereo-
types are innate and result from biological predisposition. Gender essentialism serves
to reinforce the gender binary, which is the belief that a person can be only one of two
discrete sex and gender options: either female/woman or male/man (England,
2010). A direct challenge to gender essentialism and the gender binary, however, is
the existence of intersex people. Intersex refers to a number of chromosomal varia-
tions that lead to atypical development of physical sex characteristics and, subse-
quently, prevent infants from being classified as biologically female or male. People
whose identity and expression do not fit within or subscribe to the gender binary may
identify as gender expansive or nonbinary. A critical awareness for LGBTQ Affirmative
Therapists is knowing that some transgender people experience their gender as dis-
tinctly woman or man (i.e., within the binary), whereas others experience their gender
on a spectrum (i.e., outside of the binary).
Gender transition terms Another set of important terms for LGBTQ Affirmative
Therapists is related to gender transition. Social transition is the experience of disclos-
ing a marginalized gender identity to other people and inviting them to honor one’s
gender identity. Honoring someone’s gender identity includes using their self‐desig-
nated name and pronouns, which may include non‐gender specific pronouns such as
they, their, and them. Social transition may also include legally changing one’s name
on documents like a birth certificate, driver’s license, passport, and/or school records.
Although not all transgender and nonbinary people choose to make a physical transi-
tion, such a transition can be accomplished with changes in personal attire and/or
through the use of hormonal and/or surgical procedures. Examples include the use
of hormone blockers to delay the development of secondary sex characteristics for
preadolescents; hormone therapy to shift already developed secondary sex character-
istics; and gender affirmation/confirmation surgeries (GAS or GCS), including mas-
tectomy or breast augmentation (i.e., top surgery), facial feminization procedures,
and/or genital surgery (i.e., bottom surgery).
Transphobia Transphobia is a form of gender‐based discrimination rooted in fear or

hatred of people who do not conform to social gender norms (Association of Lesbian,
Gay, Bisexual, and Transgender Issues in Counseling, 2009). Participants in the US
Transgender Survey (2015) reported many experiences of transphobia including
verbal attacks (46%), physical attacks (9%), and sexual assault (47%; James et al.,
2016). Transgender people of color face increased risks for transphobic violence and
discrimination in all aspects of life. Specifically, incidences of sexual assault increased
for Latinx (48%), Black (53%), and American Indian/Alaskan Native (65%) partici-
pants (James et al., 2016). Societal messages favoring cisgender identities can also be
internalized and, thus, believed to be true by transgender and gender nonbinary indi-
viduals. LGBTQ Affirmative Therapists need to be aware of transphobia and its effects
within both majority group and LGBTQ communities. For example, although mem-
bers of a marginalized group, LGB‐identified therapists may still be unfamiliar with
the complexities of gender and gender identity.
Barriers to working affirmatively with transgender and nonbinary clients

SFTs are likely to encounter barriers to providing affirmative services to transgender
and nonbinary clients, including (a) cisnormative assumptions, (b) institutionalized
cissexism, and (c) cisgender privilege. These barriers are not comprehensive and may
be less relevant for transgender‐ or nonbinary‐identified therapists who do not experi-
ence cisgender privilege.
Cisnormative assumptions Cisnormative assumptions are inferences made about a

person’s gender identity, gender history, and chromosomal makeup that result from
implicit beliefs that all people are cisgender and that gender is biologically deter-
mined. These assumptions may lead SFTs to believe they know how clients identify,
what their family and relationship structures are like, and what clients’ gender histo-
ries have been, thus affecting clients’ sense of being engaged, understood, and safe
in therapy. SFTs operating under cisnormative assumptions might also presume that
all transgender clients want and/or require hormonal and surgical transition to con-
solidate gender identity, as well as that relationships formed before the disclosure or
discovery of a partner’s transgender or nonbinary identity will likely end, an assump-
tion not supported by existing research (Meier, Sharp, Michonski, Babcock, &
Fitzgerald, 2013).
Institutionalized cissexism Cissexism is a “set of beliefs and resulting actions that

privilege, validate, and essentialize cis identities to the exclusion of trans identities,”
and thus frame “trans identities and trans bodies as less real, valid, and desirable than
cis identities or bodies” (Bauer & Hammond, 2015, p. 2). When cissexist beliefs
organize institutions like state and federal governments or mental health clinics,
transgender and nonbinary individuals receive never‐ending messages that their exist-
ence is less valid. Examples of institutionalized cissexism include rules requiring that
gender markers on insurance policies match gender markers on driver licenses or that
a diagnosis like gender dysphoria be given, in addition to two psychological assess-
ments from “qualified behavioral health providers,” to receive surgical transition ser-
vices (Human Rights Campaign, 2018b; United Healthcare, 2017, p. 2). These
policies are problematic because they pathologize and medicalize the experiences of
those wanting to physically transition by situating transition‐related services as a treat-
ment for a “disorder” and position SFTs as gatekeepers to these medical services.
Thus, LGBTQ Affirmative Therapists must be cognizant of the effects of institutional
cissexism on transgender people’s daily lives as well as the therapy process.
Cisgender privilege Cisgender privilege is unearned “benefits individuals receive

from having an assigned identity that matches their perceived gender identity” (Walker
& Hernandez, 2014, p. 240). By virtue of living in a culture that reinforces cisnorma-
tive assumptions, the experiences of cisgender people become the standard by which
all other experiences of gender are compared. Examples of cisgender privilege are
never having to question the validity of one’s internal understanding of oneself, not
having to educate others about one’s lived experiences, and never having to justify
clothing or pronouns. Cisgender privilege also manifests as widespread advantage for
those embodying cisgender identities in access to power, resources, and opportuni-
ties, as well as simply being treated respectfully by others. Although cisgender privi-
lege is a central organizing aspect of daily life, it is often unseen and used unconsciously.
Unexplored cisgender privilege can lead SFTs to burden transgender clients with the
task of educating therapists about gender identity‐related issues, to avoid discussions
of gender identity altogether, and to overemphasize the gatekeeper role (Mizock &
Lundquist, 2016). Cisgender SFTs will want to understand their own experiences of
privilege, as well as how these privileges organize experiences and structure power in
therapy with transgender and nonbinary clients.
Impact of barriers on the mental health of transgender and

nonbinary individuals
The aforementioned barriers also have harmful effects on transgender and nonbinary
individuals’ mental health. Specifically, 39% of transgender individuals reported expe-
riencing “serious psychological distress in the month prior to completing the survey,
compared with only 5% of the U.S. population” (James et al., 2016, p. 5). Moreover,
40% of the transgender individuals in the US Transgender Survey reported that they
had attempted suicide in the course of their lifetimes, which is almost nine times that
of the general population (James et al., 2016).
Research also found that 13% of the transgender individuals surveyed had experi-
enced having a mental health professional try to “stop them from being transgender”
(James et al., 2016, p. 109). These harmful therapeutic encounters may lead transgen-
der clients to feel objectified, ignored, or stigmatized, and this is coupled with the fact
that the concerns leading them to seek therapy remain unaddressed (Mizock &
Lundquist, 2016). Despite the clear need for services, barriers such as these further
contribute to a reluctance to seek help or worse to an internalization of stigma, con-
tributing to negative self‐beliefs.
Family acceptance and rejection

Research on families with transgender and nonbinary members suggests that there is
significant variation in family support and rejection (Koken, Bimbi, & Parson, 2009).
Family responses range from actively advocating on behalf of and/or with a transgen-
der family member (Kuvalanka, Weiner, & Mahan, 2014) to rejection in the form of
neglect, discrimination, and violence (Grossman, D’Augelli, Howell, & Hubbard,
2005; Koken et al., 2009). Research clearly documents the significant impact family
acceptance and rejection have on the well‐being of transgender and nonbinary indi-
viduals (Nealy, 2017). For example, transgender and nonbinary individuals rejected
by their family are more likely to have attempted suicide than those who are not
(James et al., 2016). Conversely, family acceptance is linked to higher rates of employ-
ment and stable housing, as well as decreased psychological distress. SFTs can work
with families to facilitate greater acceptance for transgender and nonbinary members
by hearing and validating fears or worries family members may have, encouraging the
communication of love and support, and helping cultivate the belief that transgender
and/or nonbinary family members can live meaningful lives (Nealy, 2017).
Emergent research has begun to document the positive effects that transgender or
nonbinary family members have on their family systems. Kuvalanka et al.’s (2014)
qualitative interviews of mothers with transgender daughters documented the posi-
tive transformations these mothers experienced by virtue of raising their daughters,
namely, moving from having no knowledge of gender identity issues to being com-
munity‐deemed experts. Considering the importance of family support, SFTs are
uniquely positioned to work with families who have transgender and/or nonbinary
members in order to increase acceptance and foster resilience (Nealy, 2017).
Self‐of‐the‐Therapist
When first learning to work with LGBTQ clients, therapists may focus on learning the
“unique” skills necessary to work with this population. However, scholars have argued
that the first step toward providing LGBTQ Affirmative Therapy is self‐of‐the‐thera-
pist work to address the unconscious biases that negatively influence SFTs and the
therapy process (Long, 1996; Phillips & Fischer, 1998). In this section, we share an
adapted version of a three‐step critical self‐exploration process that was originally
developed by McGeorge and Carlson (2011) to help heterosexual therapists examine
the influence of heterosexism on a personal and professional level. Specifically, this
process has been adapted to include critical self‐reflection for cisgender therapists to
explore the effects of cisnormativity on their lives and practice. Although aspects of
this three‐step process are relevant to all SFTs, LGBTQ therapists may experience this
process differently due to their social location, level of outness, and possible internal-
ized stigma.
Exploring heteronormative and cisnormative assumptions

The first step of this self‐of‐the‐therapist process invites therapists to critically
explore the conscious and unconscious heteronormative and cisnormative assump-
tions about the superiority of cisgender identities and heterosexual orientations that
they have been taught over their lifetimes (Green & Mitchell, 2002; McGeorge &
Carlson, 2011). SFTs are invited to acknowledge and work to make conscious the
ways they may pathologize LGBTQ identities (Green, 1996). To do this, therapists
need to fully explore the familial and societal messages they have been socialized in
since childhood, regarding “healthy” and “normal” gender expressions and rela-
tionship practices (Green & Mitchell, 2002). Through this critical self‐of‐the‐thera-
pist process, clinicians increase their awareness of the beliefs they hold about gender,
gender identity, gender expression, sexual orientation, sexuality, and romantic
relationships.
One way for therapists to shift their assumptions from unconscious to conscious is
to use a series of self‐reflection questions including “What did my family of origin
teach me about sexual orientation, bisexuality, and same‐sex relationships?”
(McGeorge & Carlson, 2011, p. 17). We have adapted questions on heteronormative
assumptions to assist in an exploration of cisnormative assumptions. For example, if
applicable, what did/does my faith community teach me about gender identity and
gender expression? SFTs could create a list of relevant questions to guide a self‐reflec-
tive journaling process (Long & Serovich, 2003). These questions could also be used
by those with majority identities to create accountability conversations with others of
similar social locations to increase responsibility for heteronormative and/or cisnor-
mative assumptions (McGeorge & Carlson, 2011). These accountability conversa-
tions shift the burden of explanation from members of marginalized communities to
members of dominant communities, who can then work together to identify their
own prejudicial behaviors and attitudes. Training programs can integrate these con-
versations into supervision groups or require that students discuss how heteronorma-
tive and cisnormative assumptions may be influencing their work (Carlson &
McGeorge, 2012; Green, 1996). Additionally, hiring supervisors with training and
expertise in LGBTQ could help facilitate this critical supervision work (Green &
Mitchell, 2002).
Exploring heterosexual and cisgender privileges

The second step of this self‐of‐the‐therapist process invites therapists with dominant
identities to critically explore their heterosexual and/or cisgender privileges. For SFTs
who benefit from living and working in a cissexist and heterosexist society, it is crucial
to work toward dismantling the daily privileges and unearned benefits they receive.
For many clinicians, this is a challenging step, as it is more comfortable to focus on
the oppression experienced by LGBTQ communities than to self‐reflect on how one
directly benefits from and perpetuates this oppression. To explore these innumerable
privileges, heterosexual SFTs can engage with self‐reflection questions, such as “How
has your involvement in heterosexual relationships been encouraged, rewarded,
acknowledged, and supported by your family, friends, and society?” (McGeorge &
Carlson, 2011, p. 19). A question that cisgender therapists could ask themselves is,
have you ever worried that you might be “outed” as a cisgender person? Why not?
To further this exploration, cisgender and heterosexual therapists could maintain an
ongoing log or journal of privileges that they experience daily, such as “I can wear
clothes that reflect my gender identity without fear people will stare at me or question
my clothing choices.” By recording these privileges, they become more conscious or
explicit, creating opportunities to engage in dialogue about the changes needed on a
local and societal level to dismantle systems of power and oppression and create
greater social equity (hooks, 2000). In training programs, students could record their
experiences of privilege and share them in supervision groups.
Heterosexual and cisgender identity development

The final step of this self‐of‐the‐therapist process involves critical exploration by SFTs
with dominant identities to ask how they came to hold heterosexual and/or cisgender
identities. This exploration of heterosexual and cisgender identity development is
similar to work that was done to assist White individuals in acknowledging and “own-
ing” their racial identity (Hardy & Lazloffy, 1998). Scholars have argued that increas-
ing dominant groups’ awareness of their identity development decreases the influence
of assumptions and privileges on the therapy process (Worthington et al., 2002).
Models of sexual orientation and gender identity development have historically
focused on examining the development of marginalized identities. Conversely, “this
approach appropriately shifts the focus from exclusively examining the identity devel-
opment of the marginalized group to examining the identity development of the
dominant socially sanctioned group” (McGeorge & Carlson, 2011, p. 19). Thus, in
order to develop as an LGBTQ Affirmative Therapist, clinicians with dominant iden-
tities must not simply learn about LGBTQ topics; they must also develop an under-
standing of how they came to hold their heterosexual and/or cisgender identities.
Increasing awareness of identity development can be reinforced by engaging with
self‐reflection questions, including “How do you explain how you came to identify as
a heterosexual?” (McGeorge & Carlson, 2011, p. 20). A question cisgender therapists
can ask themselves is: As a child, what did you learn about gender from your parents,
siblings, peers, teachers, or religious leaders? These questions help heterosexual and/
or cisgender therapists identify a developmental process they have likely not been
asked to consider, but that their LGBTQ colleagues and clients are continually
required to justify (Worthington et al., 2002). In summary, this three‐step self‐of
the‐therapist model is not a means to an end, but rather a recursive, ongoing process
that LGBTQ Affirmative Therapists must continuously participate in to provide com-
petent services to LGBTQ clients.
Strategies for working affirmatively and competently with LGBTQ clients

In addition to committing to regular self‐of‐the‐therapist exploration, there are prac-
tices SFTs can use to more consistently provide LGBTQ Affirmative Therapy. In this
section, we will focus on two groups of strategies, namely, (a) claiming an identity as
an LGBTQ Affirmative Therapist and (b) intentionally communicating an LGBTQ
affirmative stance (McGeorge & Carlson, 2011). It is important to note that for
LGBTQ clinicians there may be an increased risk of safety and employment repercus-
sions when choosing to practice these strategies.
Claiming an LGBTQ Affirmative Therapist identity

Like self‐of‐the‐therapist work, claiming an identity as an LGBTQ Affirmative
Therapist is an ongoing, recursive process. Too often, well‐intended individuals
decide to commit themselves to supporting a marginalized group by engaging in a
single action or simply declaring an identity as an ally, but such an approach always
falls short. Instead of focusing on the “identity” component of this strategy, the focus
needs to be on the act of “claiming” and reclaiming as an ongoing and continuous
action. In line with the work of anti‐racism activists and scholars (Hardy & Lazloffy,
1998), SFTs need to embrace a dual identity as simultaneously heterosexist and anti‐
heterosexist as well as cissexist and anti‐cissexist. This often involves acknowledging
an inability to escape the heteronormative and cisnormative assumptions one has been
deeply socialized in while also committing to continual appraisal of these biases and
their effects.
To further claim an identity as an LGBTQ Affirmative Therapist, SFTs can engage

in (a) personal actions, (b) professional actions, and (c) political actions. Personal
actions include standing up to antigay jokes and stereotypes made by friends and fam-
ily as well as using gender‐neutral language (e.g., partner) when referring to intimate
relationships in private and public settings (McGeorge & Carlson, 2011). Another
personal action that therapists can take is educating themselves by reading trusted
sources, such as LGBTQ affirmative organizations’ websites (e.g., GLSEN, Human
Rights Campaign), books, and peer‐reviewed journal articles.
One key difference between personal and professional actions is that whereas per-
sonal actions center around relationships with family, friends, and oneself, professional
actions include ways of being in the workplace. Therapists might consider claiming a
workplace identity as LGBTQ affirmative by participating in applicable trainings and
sharing what they learn with colleagues (McGeorge & Carlson, 2011). Educating
colleagues can be as informal as expressing appreciation for the importance of work-
ing affirmatively or as formal as scheduling agency‐wide trainings with LGBTQ advo-
cacy groups. Finally, because working affirmatively cannot be done in isolation,
therapists might consider partnering with local PRIDE centers and other LGBTQ
organizations; this type of partnership can serve as a bidirectional resource for refer-
rals (Green & Mitchell, 2002).
Political action refers to public participation in advocating for LGBTQ rights and poli-
cies that support these rights (McGeorge & Carlson, 2011). For example, LGBTQ
Affirmative Therapists might leverage their political voice by petitioning lawmakers to
support affirmative policies (e.g., adoption rights, anti‐discrimination laws, reparative
therapy bans) and voting for candidates who actively support LGBTQ individuals and
families. Other actions include speaking out through letters to the editor or attending
rallies and events in support of LGBTQ rights. It is crucial that LGBTQ Affirmative
Therapists remember that advocacy does not always mean acting on behalf of clients;
oftentimes, it means acting with (Toporek et al., 2009). Thus, being an LGBTQ
Affirmative Therapist includes speaking out in public spaces, networking and finding out
what resources are available for clients, or supporting clients’ own fights for equality.
Intentionally communicating an LGBTQ affirmative stance

Steps that SFTs can take to intentionally communicate an LGBTQ affirmative stance
include (a) expressing commitment, (b) making intentional language choices, (c) estab-
lishing inclusive paperwork, (d) creating an LGBTQ affirmative clinic climate, and (e)
committing to transparency surrounding the impact of biases on the therapy process.
For example, SFTs could begin each intake by clearly stating verbally, and/or in writing
in their consent forms, that they are committed to providing LGBTQ Affirmative
Therapy (McGeorge & Carlson, 2011). Making such a declaration in the first session
communicates to LGBTQ clients that it may be safe to share their sexual and/or gender
identities with their therapist. We recommend therapists not wait for clients to disclose
a marginalized identity before expressing their commitment to being affirmative, as
clients may never feel safe to reveal this important part of themselves. It is essential to
note that communicating a commitment to LGBTQ Affirmative Therapy is not synony-
mous with the disclosure of personal marginalized identities for LGBTQ‐identified
therapists, as there may be implications for safety that need to be considered.
SFTs also need to be conscientious about using non‐heteronormative and non‐cis-

normative language. For example, therapists might ask clients about their desired
pronouns rather than making assumptions based on an interpretation of the client’s
gender presentation. Additionally, formatting intake paperwork with open‐ended
questions allows clients to describe their current gender identity and sexual orienta-
tion, rather than using fixed‐response options (e.g., woman or man). Creating an
LGBTQ Affirmative Therapy environment includes careful attention to waiting room
materials, wall artwork, and bathroom signage (Benson, 2013). This is also an impor-
tant consideration for training clinics in order to model an affirmative and welcoming
environment for students. SFTs and training programs might also consider asking
members of LGBTQ communities to review the inclusiveness of their space. Finally,
SFTs can create space for accountability and making amends when they are transpar-
ent with LGBTQ clients about the reality that heterosexist and cissexist biases may
impact the therapy process.
Conclusion
In this chapter, we explained the major constructs and practices related to working
affirmatively and competently with clients of diverse and marginalized sexual orienta-
tions and gender identities. SFTs need to be knowledgeable about the historic and
current societal structures that negatively impact LGBTQ individuals and relation-
ships, the therapy process, and therapists themselves. Thus, we highlighted critical
self‐of‐the‐therapist work necessary to move unconscious assumptions, biases, and
privileges to individual and collective consciousnesses. We hope SFTs will engage in
intentional conversations with their LGBTQ clients about their preferences for iden-
tity labels, the focus of therapy, and needed support as they navigate living in a cissex-
ist and heterosexist world. The process of becoming an LGBTQ Affirmative Therapist
is recursive, lifelong, and an essential journey toward providing the competent and
ethical clinical services that LGBTQ individuals, relationships, and families deserve.
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12
Spiritual and Religious Issues
Renu K. Aldrich and Sarah A. Crabtree
Manu and Sita1 are middle‐class Muslims in New Delhi who send their 16‐year‐old daugh-
ter, Madhu, to therapy saying she is so preoccupied with boys that she is not performing well
academically. Madhu says she feels conflicted because she loves her faith and family but feels
suffocated by the outdated rules and plans to have sex with her secret Hindu boyfriend.
Is this presenting problem related to religion, generational conflict, acculturation

issues, life cycle transitions, or parent–child interaction? The complicated reality is all
of the above, but what might confound many clinicians is the religious context.
Important aspects to understand about this case would be the forbidden nature of
premarital relationships in the Islamic faith (Adamczyk & Hayes, 2012) and historic
violence with Hindus (Mosher & Das, 2017). But how would a systemic family thera-
pist (SFT) competently help this family? This chapter provides clinicians with a foun-
dation to competently and ethically incorporate the spiritual/religious with clients,
especially when they have a different faith or non‐belief system themselves.
Most of the world is religious, with Christianity the largest faith followed by Islam
and Hinduism (Pew Research Center, 2014). However, most Western‐based thera-
pists do not include spirituality/religion in treatment out of respect for different
client beliefs or through limited awareness of its importance because of their own
lack of spirituality (Delaney, Miller, & Bisonó, 2013; Errington, 2017). Psychology
has a history of being antireligious as it fought to carve itself as a scientific field
(Drobin, 2014). However, worldviews inevitably involve spiritual beliefs, impacting
family therapy conceptualizations implicitly or explicitly (Rivett & Street, 2001). In
addition, clinicians need to become even more comfortable integrating the spiritual/
religious domain given that the current global trend is away from organized religion,
resulting in isolation from typical sources of social support and community ties
(Hodge, 2004; Lake, 2012). Therapists do not have to be spiritual to incorporate it
as a resource into treatment or to address related issues (T. A. Kelly & Strupp, 1992).
Since graduate therapy programs rarely offer specific content with how to do so
274 Renu K. Aldrich and Sarah A. Crabtree
adequately, most clinicians need to augment training to have basic spiritual compe-
tency (T. S. Carlson, McGeorge, & Anderson, 2011; Marterella & Brock, 2008).
Important definitions
The following represents the chapter’s conceptual framework:
Spirituality Spirituality is a person’s search for meaning—their being and experienc-

ing connection to aspects of reality seen as sacred, transcendent, or deeply profound
either as an individual or in a group (Elkins, Hedstrom, Hughes, Leaf, & Saunders,
1988; Starnino, 2016).
Religion As part of spirituality’s umbrella, religions are institutionalized systems of

shared beliefs, doctrines, rituals, practices, and forms of worship (Gall, Malette, &
Guirguis‐Younger, 2011; Starnino, 2016), but followers may not all practice the same
way (Hackney & Sanders, 2003). Buddhists, for example, can vary in belief from
nontheistic to polytheistic.
Religiosity Adherence to the values, beliefs, and practices of a religious system com-
prises religiosity, but measuring it is controversial especially across faiths (Moreira‐
Almeida, Lotufo Neto, & Koenig, 2006; Spiegel, 2013). Traditional measures are
typically from Western perspectives such as worship attendance and prayer (Haynes
et al., 2017; Mencken, 2011; Pardini, Plante, Sherman, & Stump, 2000; Weisman de
Mamani, Tuchman, & Duarte, 2010), while some studies ask for self‐identification.
More helpful distinctions can be made between intrinsic religiosity, which relates to
private activities, and extrinsic religiosity, which relates to overt behavior to study
their impact on mental health (Shreve‐Neiger & Edelstein, 2004).
Higher power/God While God is the most common term for a divine being, the
concept of a Higher Power is more relevant to those who believe in a nonspecific
entity greater than oneself (Cashwell et al., 2016). For example, many indigenous
religions and other spiritualities are animist, experiencing natural objects as imbued
with divinity such as the Hopi Sun Spirit, Tawa, who created the world. An under-
standing of the concept of God must incorporate diversity of belief ranging from a
specific monotheistic Christian, Judaic, or Islamic deity to one of numerous polythe-
istic gods. Some belief systems, such as Judaism, find it offensive to use the word God
in writing because it can be defaced. While there is no wish to offend, it is used in this
chapter for clarity.
Spirituality and mental health

A strong body of literature indicates that spiritual/religious beliefs and practices buffer
mental health issues, particularly depression, substance abuse, suicide, dementia, and
stress‐related disorders as well as severe health issues (Agorastos, Demiralay, & Huber,
2014; Bonelli & Koenig, 2013; Levin, 2010). Social support and faith‐based coping
are main protective factors (Koenig, 2008; Moreira‐Almeida et al., 2006; Webb,
Charbonneau, McCann, & Gayle, 2011). In addition, intrinsic religiosity and positive
Spirituality and Religion in SFT 275
views of God have been correlated with reduced risk for internalizing disorders such as
anxiety, depression, phobia, and panic as well as externalizing disorders such as sub-
stance use and antisocial behavior (Kendler et al., 2003; Reutter & Bigatti, 2014;
Shreve‐Neiger & Edelstein, 2004). Integrating religion/spirituality is common in sub-
stance abuse treatment as a pivotal and essential mechanism for change in recovery
programs, particularly in Alcoholics Anonymous and other 12‐step programs
(Alcoholics Anonymous, 2016). A decade‐long systematic review (Chitwood, Weiss,
& Leukefeld, 2008) supported the association of higher levels of religiosity/spirituality
with lower levels of alcohol and marijuana.
There is also compelling literature (Beach, Fincham, Hurt, McNair, & Stanley,
2008; Fincham & May, 2017; Hayward & Krause, 2013; Lambert & Dollahite,
2006; Mahoney, 2010; Marks, 2006; Vaaler, Ellison, & Powers, 2009; Wendel,
2003) that validate the adage, “the family that prays together, stays together.” More
involvement in religious activities has been related to successfully negotiating mari-
tal conflict (Lambert & Dollahite, 2006) as well as higher levels of marital satisfac-
tion and lower divorce rates (Mahoney, 2010), including low‐income couples with
minor children (Lichter & Carmalt, 2009). Attendance at worship services also has
been associated with a decreased likelihood of infidelity (Atkins & Kessel, 2008;
Vaaler et al., 2009).
Despite this evidence, assumptions cannot be generalized because higher levels of
religiosity also have been associated with pathological outcomes such as traits of
obsessive–compulsive disorder (OCD) (Agorastos et al., 2014). In addition, young
LGBTQ+ youth have increased risk for difficulty establishing a positive sense of self
and for psychological distress when their family’s religion is intolerant (Page, Lindahl,
& Malik, 2013). However, this does not mean those clients cannot use spirituality to
work through these issues. Regardless of affiliation or belief, the potentially severe
impact of spirituality/religion must be treated.
Viewing spirituality from a relational perspective can enable clinicians to assess posi-
tive and negative influences. Conceptualizing clients’ spirituality through “ways of
relating to the sacred” (e.g., high power[s], sacred texts or objects, spiritual practices;
Shults & Sandage, 2006, p. 161), therapists can connect with how spirituality can be
a resource or barrier in treatment. Individuals and family systems can develop emo-
tional bonds with divine figures (e.g., Jesus, Buddha, ancestor spirits) on the attach-
ment spectrum (Kirkpatrick, 1997). Much like a caregiver, God may serve as a secure
base for exploration and a safe haven in times of distress (Beck, 2006). Secure divine
attachment is characterized by low anxiety and avoidance and has been associated
with more effective coping (M. M. Kelly & Chan, 2012) and less psychological dis-
tress (Bradshaw, Ellison, & Marcum, 2010). Rather than positive or negative views,
anxiety swells when the relationship with God is inconsistent (Aldrich, 2018).
Client Spirituality
Kelvin, 22, came to therapy with his sister Keisha, 25, in rural Georgia. Kelvin has been
depressed since they lost their parents in a car accident 4 years ago. Their uncle discouraged
bringing in professionals, worried Kelvin would get worse, be locked away, or become addicted
to antidepressants. Their strong African American Southern Baptist community has urged
them to pray harder instead.
Clients may never bring up their own spirituality or religious views even when they
brave barriers to participate in therapy. However, it is an essential dimension of prac-
tice for clinicians to acknowledge and attend to because it “is interwoven in multiple
threads of family life at the heart of our earliest and most intimate bonds” (Walsh,
2009, p. 334).
Shifting sands
Christianity is the world’s largest religion with 2.5 billion adherents, but forecasts
show that Islam at 1.8 billion will catch up by 2050 and eclipse all other faiths by year
2070 (Pew Research Center, 2017a). In addition to the combination of a decrease in
births and an increase in deaths of adherents, this reflects the global trend away from
organized religion, particularly Christianity in the United States, Europe, Australia,
and New Zealand (Pew Research Center, 2017a; Sahgal, 2018; US Public, 2015).
While the spiritual/religious landscape is changing, it remains an important facet of
everyday life (Newport, 2009). Judeo‐Christian spirituality is entrenched in the
United States, for example, because of its historical foundation as a sanctuary from
religious persecution. Fifty‐five percent of Americans say they pray every day, includ-
ing 20% of the religiously unaffiliated (Pew Research Center, 2017b). Dissatisfaction
is high with religious organizations, which may benefit society by strengthening com-
munity bonds and aiding the poor but are too concerned with money, power, strict
rules, and politics (Pew Research Center, 2012).
Another global shift is occurring in the forms of spirituality that immigrant popula-
tions are bringing with them to new homelands. For example, rates of Islam,
Hinduism, and Buddhism are increasing within countries worldwide, while immi-
grants from Central and South America are exporting distinctive styles of Catholicism
and Protestantism (Yang & Ebaugh, 2001).
Client spiritual needs in therapy

In addition to spirituality/religion as a resource, it can also be the presenting prob-
lem. Half of the clinical psychologists in a study by Shafranske and Malony (1990)
said at least one in six of their clients present with spiritual/religious issues. More than
60% said clients express themselves through religious language even when religion
was not a primary aspect of their presenting problem. Perhaps most importantly, cli-
ents prefer their therapist bring up spirituality/religion because of fears around being
judged or not being appropriate in secular treatment (Oxhandler, Polson, Moffatt, &
Achenbaum, 2017; Reutter & Bigatti, 2014). Religious clients report feeling dissatis-
fied when therapists are not respectful of their beliefs or avoid spiritual/religious top-
ics (Cragun & Friedlander, 2012).
Adapting treatment to include spiritual/religious factors such as prayer and tenets
of specific faiths has been shown to be effective especially when clients desire them. A
meta‐review of 16 clinical trials using faith‐based treatment for depression and anxiety
found significance for using variations of religious cognitive‐behavioral therapy
(CBT), although individual studies’ methodological concerns limit the generalizabil-
ity of the findings (Anderson et al., 2015). Similarly, a meta‐analysis (Worthington,
Hook, Davis, & McDaniel, 2011) of 46 studies found that treatment using religious
teachings and coping mechanisms were more effective. These findings indicate a need
for greater integration of spiritual/religious factors in psychotherapy.
Therapist Spirituality and Training

Jesse, 28, a Protestant man, presented for therapy with anxiety because of community pressure
to leave his agnostic girlfriend. When his therapist, a lapsed Catholic, focused on differentia-
tion and boundaries, Jesse became frustrated, saying, “I can learn to tolerate other people
disapproving of my relationship with Susan, but if God disapproves? I don’t think I can
handle that.”
Religious‐based psychotherapists use faith as a natural part of their work, but lay or
secular practitioners typically steer away from even discussing the topic. While some
studies (Brown, Elkonin, & Naircker, 2013; Oxhandler, Parrish, Torres, &
Achenbaum, 2015) show therapists have positive attitudes toward spirituality/reli-
gion in psychotherapy, a major barrier to spiritual literacy is therapist reluctance and
lack of training (Bonelli & Koenig, 2013; T. D. Carlson, Kirkpatrick, Hecker, &
Killmer, 2002; Khalaf, Hebborn, Dal, & Naja, 2015; Walsh, 2010). The majority of
licensed therapists are less spiritual compared with the general public, and 27%
become disaffiliated with their religion of birth compared with 4% of the general
population (Delaney et al., 2013) so they may not want to force their values onto
clients or even be mindful of it (Marterella & Brock, 2008). Some therapists believe
it is a topic that is required as part of treatment for trauma because clients need to
make meaning of their suffering, but is not relevant for other presenting problems
(Zenkert, Brabender, & Slater, 2014). For others, the topic does not seem salient
enough when there are many other aspects to consider in a short, weekly 45–50‐min
session (Errington, 2017).
Given the lack of inclusion in graduate training programs and the many different
definitions of spirituality in Western culture, some are worried about incompetence
and with encouraging unhealthy coping (Hodge, 2004; Lake, 2012). According to
Drobin (2014), 51% of therapists have an antireligious and anti‐spirituality bias. This
goes back to the roots of the psychology field, which historically has considered spir-
itual matters as “poison” in Freud’s words (Marks, 2006, p. 603). The mental health
field has viewed “religion as either a form of pathology to treat or something that was
best left outside the therapeutic process” (Wendel, 2003, p. 165).
Therapists continue to doubt the “power of prayer.” This is despite literature
(Beach et al., 2008; Fincham & May, 2017; Hayward & Krause, 2013; Lambert &
Dollahite, 2006; Mahoney, 2010; Marks, 2006; Vaaler et al., 2009; Wendel, 2003)
that shows an impressive impact of religious systems on couples and families and evi-
dence that shared spiritual activities are associated with stronger relationships.
In contrast to other types of non‐faith‐based clinicians, SFTs have been found to be
as religious as the general public and believe spirituality is important to address in
treatment and training (T. D. Carlson et al., 2002; Hodge, 2004; Oxhandler et al.,
2017). However, personal faith does not imply spiritual competence, which requires
positive attitudes, adequate knowledge about the roles that religion/spirituality can
play in various aspects of clinical practice, and skills to integrate it into treatment
(Vieten et al., 2016). In addition, therapists who are religious are mostly affiliated
with Christianity (Oxhandler et al., 2017), but there is substantial diversity in even
how Christianity is practiced. For example, in a study of Christian refugees in Sudan,
a crucial aspect of healing pathologized by Western therapists was their prayers to
ancestors and the animist powers of the natural and spirit worlds (Walsh, 2010).
Training must focus on therapists’ own beliefs and comfort with spiritual topics and
interventions since this can impact therapy itself (Hoogestraat & Trammel, 2003).
Incorporating the Spiritual Into Treatment

Raven and Richard, a middle‐age couple who own a travel agency in Texas, bring their two
children, 12‐year‐old Mistle and 9‐year‐old Spring, to therapy because they were mandated
by family court. Spring told his teacher about a Wiccan circle at their house, and she called
child protective services. Mistle is angry with her brother because none of her friends, all
Christians, will talk to her and she is being called a demon lover. Raven is angry with
Richard because she wants to stay to educate their local community, but he wants to move
somewhere safer where they can stay in the broom closet.
Spiritual/religious competence requires a new level of “cultural humility” regarding

clients’ intersectionality and a framework for incorporating all types of faiths/non‐belief
systems into treatment. Cultural humility is the “ability to maintain an interpersonal
stance that is other‐oriented (or open to the other) in relation to aspects of cultural
identity that are most important to the [client]” (Hook, Davis, Owen, Worthington, &
Utsey, 2013, p. 354). Because the combination of culture and religiosity can directly
cause mental health dysfunction as well as interact with personality to cause specific
individual responses, intersectionality is crucial to assess (Agorastos et al., 2014).
Case conceptualization
Some systemic orientations have natural mechanisms for attending to spirituality/
religion and the meaning clients ascribe to it (Errington, 2017).
Biopsychosocial–spiritual model In response to criticism that medicine does not treat

the whole person, the biopsychosocial–spiritual model of health care seeks to heal the
patient in their nexus of connected relationships (Sulmasy, 2002). This model pro-
vides clinicians with direct ways to understand and employ the impact and influence
of spirituality. Medical family therapists, who work within collaborative health‐care
systems, have adopted this inherently systemic lens in which problems are understood
as dimensions of physical, psychological, social, and spiritual health and well‐being
(Delbridge, Taylor, & Hanson, 2014).
Symbolic interactionism Tenets of symbolic interactionism underlie many therapeu-

tic orientations as it emphasizes meaning‐making, identity, and role development
through interaction with others (LaRossa & Reitzers, 1993). Spiritual/religious
beliefs and practices, which are frequently situated in communities, can help clients
make meaning of their life experiences. For example, Satir (1987) saw human beings
as sacred, needing a harmonious balance between intrapsychic, interpersonal, and
universal–spiritual levels of the self (Lee, 2002; Wretman, 2016).
Collaborative language and narrative therapies A postmodern social constructionist

clinical framework provides mechanisms through language to operationalize spiritual-
ity into therapeutic practice. Reality is subjective because meaning is created socially,
often through relationships with spiritual communities and the divine (White &
Morgan, 2006; White & Epston, 1990). Narrative therapy techniques can help
deconstruct limiting perspectives such as a dichotomy between science and God
(Larner, 2017). Therapists can employ spiritual dialogues as part of collaborative lan-
guage strategies to help clients transcend and augment their thin stories, including
their reason for being.
Existential psychotherapy Existential therapy seeks to help clients find meaning and
purpose to manage stress, suffering, grief and loss, and other hopeless situations
(Jang, 2016). In contrast to Freud, depth psychologists Otto Rank, Carl Jung, and
Rollo May as well as psychiatrist Viktor Frankl saw religion as a core issue for clients,
especially those disillusioned with or rejecting of organizations. They sought to help
clients develop a personal spirituality as an essential psychological need. Beliefs pro-
vide context for living and seek to answer the complex existential questions often
addressed in mental health treatment (Temple & Gall, 2018). Clinicians can help
clients explore coping strategies as well as working through confusion and conflict
regarding spiritual issues. This focus may particularly benefit atheists, who do not
believe in God, and agnostics, who doubt God’s existence.
Other models The field of transpersonal psychology including theorists such as

Maslow integrates transcendent experiences into Western mental health, viewing self‐
actualization as the ultimate goal of human development (Guest, 1989). Experiences
are understood through a sacred lens, enabling clients to make meaning particularly
from adverse situations. Spiritual exploration can be facilitated through other systemic
concepts such as Bowen’s theory (Errington, 2017) or solution‐focused strategies
that focus on client resources (Marterella & Brock, 2008). Simulating the need for
communal approval and support, group therapy can be an effective way to allow for
the acceptance of uncertainty and anger toward God as well as work through spiritual
issues related to mental illnesses (O’Rourke, 1997; Phillips, Lakin, & Pargament,
2002; Webb et al., 2011).
Regardless of model, several spiritual assessment strategies should be considered.
Case assessment and treatment

Spiritual history and relevance Spiritual competence begins with paperwork. Invite
clients to share affiliations in intake forms and include scaling questions about impor-
tance to find a starting place for taking religious/spiritual histories. Once basic infor-
mation is obtained, Hoogestraat and Trammel (2003) recommend three areas of
focus: (a) religion/spirituality as a resource, (b) related concerns or frustrations, and
(c) experiences of spiritual/religious abuse.
Broader inquiries concern what informs clients’ meaning‐making processes or
value systems (Delbridge et al., 2014). Therapists may also inquire about clients’
rituals or traditions, influence on daily life and the importance of faith‐based com-
munities as well as specific beliefs (Pearson, 2017). Obtaining narratives about past
spiritual/religious commitments and experiences can also be insightful. A client’s
current spirituality may be different from how they were raised or they may have
had experiences that resulted in change.
Religious coping strategies Religious coping mechanisms are “efforts to understand

and deal with life stressors in ways related to the sacred” (Pargament, Feuille, &
Burdzy, 2011, p. 52). Positive methods, such as seeking spiritual support and offering
forgiveness, tend to reflect security with a sacred figure, meaning‐making, and higher
levels of benevolence; negative methods, such as spiritual discontent and defining the
problem as an act of an evil force (e.g., the devil), reflect more spiritual struggle and
less felt security with a sacred figure (Pargament, Smith, Koenig, & Perez, 1998).
Cultural differences are important to note. Racial minorities from collectivist cul-
tures, for example, do not see having spiritual doubts as negative (Kim, Kendall, &
Webb, 2015). Developing effective coping strategies for those with high anxiety from
ambiguous relationships with God is vital (Aldrich, 2018). Knowing what a client
believes might not be enough, so asking how someone experiences and relates with
the sacred may provide more insight.
Genograms and ecomaps Given the importance of faith traditions and changes to
family systems, symbolic assessment and treatment tools such as genograms and spir-
itual ecomaps/ecograms are especially useful in understanding spiritual legacies and
the impact of communities (Marterella & Brock, 2008). These can be used in therapy
to better assess minority cultural values, such as for Native Americans whose spiritual-
ity is immersive of daily life (Limb & Hodge, 2011).
Adapting spiritual techniques Many SFTs have already heavily adapted the Eastern
spiritual techniques of mindfulness and yoga into Western‐based therapy and can use
this as a framework for including other aspects. Clinicians also can use poetry and
bibliotherapy strategies (Hynes & Hynes‐Berry, 1994), bringing in prayer and reli-
gious texts as symbolic material for therapeutic connection. An example would be
using a couple’s wedding vows to reconnect them with not only their past but also any
deeper meaning they may ascribe to their union through their faith. This can work
across cultures and faiths. For example, in a qualitative study (Anand, 2009) of four
Indian women who survived tragedy, the Hindu doctrine of karma provided them
with a way to make coherent meaning of their suffering that was socially and culturally
endorsed and that allowed them to restore their faith in a just God.
Specific SFT Treatment Considerations

Josie, 37, recently married her longtime partner, Rachel, 34, and described her wedding to her
therapist as simultaneously the most beautiful and traumatic day of her life. She feels grateful
to have been able to marry her best friend, but the memories are marred by profound grief
from being ignored by her family because of their religious opposition to their marriage.
Understanding how spirituality is woven into clients’ lives is an essential part of

assessment and treatment. While spiritual/religious concerns emerge around almost
any topic, we present a few key issues of significance for SFTs.
Life cycle transitions

Culture defines normative transitions, which are often imbued with religious signifi-
cance such as coupling, divorce, aging, or becoming parents (McGoldrick &
Shibusawa, 2012). Many are marked by rituals like weddings, christenings, funerals,
or burial ceremonies (Imber‐Black, 2009). Therapists can help clients uncover spirit-
ual meaning related to new life stages and work with managing related stress such as
Josie feeling abandoned by her family. Clients also can be encouraged to develop new
family rituals. For example, Josie’s therapist could help her evaluate whether in her
father’s absence having someone walk her down the aisle would be meaningful and
who she could ask.
Guidance for family life

Many traditions promote the “sanctification” of relationships, a “psychological pro-
cess through which aspects of life are perceived as having spiritual character and sig-
nificance” (Mahoney, Pargament, Murray‐Swank, & Murray‐Swank, 2003, p. 221).
Many Christian sects believe God has an integral role in their marriages, potentially
impacting treatment (Rivett & Street, 2001). Faiths have major influence on families
as socialization agents, imparting values and norms from the legitimacy of family
structures to division of household labor (Mahoney, 2010). For example, Christian
conservatism has been found to positively correlate with endorsement of corporal
punishment (Mahoney, Pargament, Tarakeshwar, & Swank, 2001).
Sexual control
Other couple and family issues may be tightly wound around religious beliefs such as
whether pornography is considered infidelity, permissible sexuality, and acceptance of
gender and sexual minority identities. For example, sexual shame is prominent in
conservative Protestant communities, for whom sexual desires, thoughts, and actions
outside heteronormative marriage are sinful (Schermer‐Sellers, 2017). Childhood
messages can internalize and contribute to sexual difficulty later in life. Several studies
(e.g., Harris, Cook, & Kashubeck‐West, 2008; Sherry, Adelman, Whilde, & Quick,
2010) have demonstrated greater risk for heightened shame, feelings of guilt, inter-
nalized homophobia, and mental health concerns for gender/sexual minorities who
grow up in conservative religious communities. Lack of acceptance from their religion
makes them at higher risk for identity conflicts, anxiety, depression, and suicidality
(Wood & Conley, 2014). These minorities also struggle with fear of divine retribution
when in non‐affirming contexts (Jaspal & Cinnirella, 2010).
Spiritual bypass
Spiritual bypass is a potentially unhealthy coping mechanism with “a tendency to
privilege or exaggerate spiritual beliefs, emotions, or experiences over and against
psychological needs creating a means of avoiding or bypassing difficult emotions or
experiences” (Fox, Cashwell, & Picciotto, 2017, p. 275). Some may abdicate personal
responsibility in favor of waiting for divine intervention. A defense mechanism across
the spiritual spectrum, spiritual bypass could leave clients feeling powerless, justified
in continuing harmful behaviors, and unsupported by others. Without dismissing the

family’s beliefs, this could be an opportunity to help them identify areas of personal
agency and invite acceptance of responsibility.
Toxic faith
Therapists need to assess for beliefs that harm oneself or damage marital and family
relationships through extreme behaviors and views (Marks, 2006, p. 609). For
instance, the religiosity of some female survivors of interpersonal violence leads them
to tolerate abuse and may contribute to ongoing victimization. In addition, Miller
(1997) recounts numerous circumstances of the Christian Fourth Commandment to
“honor thy mother and father” being used as immunity for abuse.
Oppressive spiritual convictions and rituals and abuse done in the name of God can
lead people to turn from faith (Gannon, 2014). In addition to effects on their physi-
cal, emotional, and mental well‐being, spiritual abuse victims often suffer from feeling
disconnected, abandoned, or punished by God (McLaughlin, 1994). Abuse by clergy
has additional ramifications because religious communities can be like family systems
with illusions of perfection, treating leaders as infallible proxies for God (Benyei,
1998). This can cause internal and external pressure on survivors, while community
members may feel betrayed and need to differentiate their personal relationship with
God (Kline, McMackin, & Lezotte, 2008).
Survivors may be able to use private devotional activities to develop a close personal
relationship with God as a reparative relationship. Non‐organizational religious
involvement such as prayer, meditation, and reading scripture may be linked to better
mental well‐being (Henderson, 2016).
Special populations
Vulnerable populations such as the elderly and racial minorities often turn to religion
rather than professional treatment (Ault‐Brutus, 2012; Lake, 2012). Clinicians can
meet clients where they are by tapping into faith‐based resources, but may need to
develop creative ways to resolve barriers.
Elders Adults become more religious as they get older and often use spirituality
instead of mental health care at a time when their social relationships and physical
needs are changing (Hayward & Krause, 2013; Shreve‐Neiger & Edelstein, 2004).
For example, 70% of adults aged 55 years and older with mood and anxiety disorders
do not use mental health services though they need more support (Byers, Arean, &
Yaffe, 2012). Clinicians may suggest researching local elder and transportation pro-
grams as well as online connections for those socially isolated by physical, mental, or
cognitive issues.
Racial minorities Spirituality is of such significance to racial minorities and low‐

income groups that it provides an opportunity for the mental health field to improve
treatment for marginalized clients (Abu‐Raiya & Pargament, 2015; Fenelon &
Danielsen, 2016; Hamilton, Moore, Johnson, & Koenig, 2013). African Americans,
Asians, and Hispanics often use faith‐based interventions such as prayer and devotional
materials to cope with their symptoms instead of seeking professional help (Lake,
2012; McCauley, Tarpley, Haaz, & Bartlett, 2008; Taylor, Chatters, & Joe, 2011).
Barriers include conflicts with personal beliefs and cultural values, overt and systemic
racism, myths, and discomfort with exposing personal problems outside family and
clergy (McCauley et al., 2008; Taylor et al., 2011). For example, African American
and Latinx clients tend not to use psychotropic medication like antidepressants
because of beliefs that they are ineffective and addictive (Ault‐Brutus, 2012; Lake,
2012). Clinicians can adopt a not‐knowing, nonjudgmental stance as they provide
psychoeducation and a safe space to explore options that may run counter to clients’
cultural norms.
Immigrants Immigrants face acculturation stressors such as discrimination and cul-

ture shock that can cause or exacerbate mental health problems, but they are less likely
to obtain help (Derr, 2016). For example, immigrants to the United States from Asia,
Latin America, and Africa have far less access to services than the general population.
Other issues to assess include access to faith‐based communities and language and
transportation barriers. This can be a major issue because social support is an impor-
tant way immigrants buffer stress and they seek help from family, friends, and religious
leaders (Ebaugh & Chafetz, 2000). Religion is a way to retain ties to their original
culture and family (Ebaugh, 2004) as well as to adapt to the new culture and its chal-
lenging environment (Yang & Ebaugh, 2001). Some may have faced forced conver-
sions or other traumas, while many will have intergenerational conflicts if their children
and subsequent generations disaffiliate in the absence of the continuity of family tradi-
tions. Clinicians can help them focus on positive aspects of cross‐cultural experiences
such as developing competence, personal growth, and resiliency (Rudmin, 2009).
Spiritual minorities The dominance of major faiths causes many smaller ones to be
“invisible religions” that “exist outside of formal, organized, and institutionalized
religions and that are informed by beliefs drawn from sources outside of even uncon-
ventional categories of faith traditions” (Levin, 2008, p. 109). Some esoteric healing
systems such as shamanistic paths go beyond established concepts understood by
practitioners of the traditional medical model of care because of their low visibility
and acceptability in society. Some adherents of alternative spiritualities hide their dif-
ferences out of fear of persecution (Frame, 2004). Those disaffiliated from the reli-
gion of their birth may suffer from different levels of loss.
Advancing Spiritual Competence in Clinical Practice
The act of therapy itself is a spiritual endeavor when the goal is transformation (Rivett
& Street, 2001). Family therapy extends deeper into this realm because of its nature
to go “beyond the bounded individual or self to contemplate the ‘pattern that con-
nects’ us to the world and all of life” (Larner, 2017, p. 126). There is always potential
for therapists’ values and belief systems to run counter to those of their clients, and
these differences are sometimes rooted in spiritual/religious commitments. For exam-
ple, therapists and clients may hold different beliefs about monogamy, gender roles,
abortion and the use of contraception, or effective parenting practices. While clients
sometimes prefer therapists who share beliefs, respect and openness can help tran-
scend differences (Hines, 2008).
Self‐of‐the‐therapist
Therapists do not need to be spiritual to engage a client within this domain, but those
who cannot articulate their beliefs may be more likely triggered by differing values.
Consider the following: How do you identify? What is your own spiritual/religious
history? What do you believe is the purpose of life and the goal of daily living? Have
you had negative spiritual/religious experiences yourself? How do your values influ-
ence your use of spiritualty as a therapeutic resource?
Supervision
Spiritual issues should be raised in supervision as a key place for therapists to engage in
discussions about ethical and self‐of‐therapist challenges (Errington, 2017), but it is
important for supervisors and SFT faculty to do their own self‐development work as
well (T. S. Carlson et al., 2011). The discrepancy between SFT personal spirituality and
lack of inclusion in therapy may be a reflection of a fear regarding how far to go with
spiritual strategies and discussions in the room. Supervisors can help alleviate therapist
discomfort with client spirituality and their lack of attention to the possibility of its cru-
cial role while addressing questions such as when to use self‐disclosure and how their
own spiritual values may influence care (Balmer, Van Asselt, Walker, & Kennedy, 2012;
Pearson, 2017). Clinical training groups oriented around spiritual, existential, religious,
and theological themes may also be helpful (Rupert, Moon, & Sandage, 2018).
Spiritual consultations
Sometimes clients prefer therapists not of their community to provide a safe place to
explore spiritual cognitive dissonance and to be honest about their actual practice.
Therapists can seek opportunities to learn about different spiritual traditions and col-
laborate with local clergy in person or online. Referrals to non‐secular counselors
should be given for more theologically driven issues.
Next steps…
Cultural humility calls for clinicians to adopt a not‐knowing but openly curious and
relational lens regarding client spirituality. Rather than viewing it as a separate domain,
SFTs with a wide range of personal beliefs can explore this area with clients as poten-
tial sources of strength and resiliency as well as pain and loss with interconnected
facets of identity such as race/ethnicity and personal geography. While undergoing
their own introspection, supervisors and faculty could incorporate this domain more
deeply in training and supervision from both self‐of‐the‐therapist and client perspec-
tives. In addition, more research is needed to improve upon the current literature’s
limitations in methodology and generalizability (Baumsteiger & Chenneville, 2015;
Khalaf et al., 2015; Turner, 2015), so we can link theory about the intersection of
spirituality/religion and mental health with how to help clients in the room.
Note
1 To preserve client confidentiality, names and other information have been altered for all
the vignettes in this chapter.
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Part III
Theoretical Perspectives
13
Theory
The Heart of Systemic Family Therapy
Stephen T. Fife
Over the years, I discovered one of the fastest ways to get a reaction out of graduate
students is to talk about theory. Although some are enthusiastic when I bring up my
affinity for theory, others frequently fall into one of four categories: (a) the eye‐rollers,
(b) the sleepers, (c) the protestors, and (d) the avoiders. The eye‐rollers and sleepers
express their aversion by either rolling their eyes or simply closing them as if preparing
for a long nap. Perhaps when they hear “theory” they think “philosophy,” and it puts
them to sleep. As the discussion begins, the protestors may rise up to save their class-
mates proclaiming, “We want to learn how to do therapy, not theory.” When that does
not dissuade me, the avoiders disengage from the conversation, perhaps checking
their social media accounts or email.
Although some may dislike theory, my goal is to help students and therapists
recognize that theory is interwoven into all aspects of systemic family therapy (SFT)
and that being mindful of theory will enhance their work as clinicians. Whether we are
conscious of it or not, theorizing is something that all therapists do, especially given
our interest in the interpersonal and intrapsychic workings of human beings. Theory
performs important conceptual, descriptive, sensitizing, explanatory, and instructive
functions regarding individuals and relationships (Knapp, 2009). It provides ways of
understanding human behavior, cognition, and emotions; individuals, couples, and
families; interpersonal processes; and therapy. It guides the work of therapists, includ-
ing conceptualizations, treatment plans, and interventions. Theory touches every part
of the history, models, training, research, and practice of SFT. As students and clini-
cians gain a greater appreciation of theory and its significance in the field of SFT, my
hope is that a new generation of “theory enthusiasts” will emerge who embrace the
value and power of theory as the lifeblood of the discipline.
The purpose of this chapter is to highlight the importance of theory in the practice
of SFT and to discuss the process of critically studying and evaluating SFT models.
This includes not only learning the application of models and their interventions, but
it also involves learning the theoretical foundations of the models and their implica-
tions for the process of therapy and client change. This chapter is organized in six
sections: (a) defining theory and its relevance to clinical practice, (b) theoretical
296 Stephen T. Fife
history and foundations of SFT, (c) the process of studying and evaluating SFT the-
ory and models, (d) theory development and construction, (e) moving the field for-
ward, and (f) implications for SFT research and training.
Definitions and Terms: Theory, Paradigm, and Model
At its most basic level, a theory is “a systematic collection of concepts or relations”

(White, Klein, & Martin, 2015, p. 2), or simply “an attempt to explain” (Bengston,
Acock, Allen, Dilworth‐Anderson, & Klein, 2005, p. 6). Some theories have more
depth and are more formalized; others are less defined and informal. There are numer-
ous definitions of theory across multiple behavioral science disciplines, each with its
own embedded assumptions about the nature of reality and human beings, what can
be known, and how one knows.
A majority of definitions suggest that theories are constructed of interrelated con-
cepts that aid in understanding the world in which we live and provide explanations
as to why certain things occur (White, 2005). For example, White (2005) asserts that
a scientific theory is a group of logically and systematically related conceptual proposi-
tions that can be empirically tested. However, others consider theory to be an edu-
cated guess that is held tentatively until confirmed by science (Slife & Williams, 1995).
Those who adopt this perspective view science as the way to move theory from
thoughtful speculation to legitimate knowledge.
Theories of family systems are best viewed as active and evolving collections of ideas
about families. Bengston et al. (2005) emphasize the active dimension of theories,
which involves ongoing reflections about our observations and experiences with the
world. They call this theorizing, “a process of developing ideas that allow us to under-
stand and explain our data” by going beyond the what about individuals, couples, and
families to an understanding of the why and how (Bengston et al., 2005, pp. 4–5).
Theorizing is an attempt to explain or make sense out of what we observe, something
therapists do on a regular basis.
All theories of human behavior, including SFT theories, are grounded in funda-
mental assumptions about the nature of the world and human beings (Slife & Williams,
1995). These assumptions include beliefs or views about the nature of reality (ontol-
ogy), how reality can be known (epistemology), and what approach is used to gain
knowledge (methodology). Philosophically related groups of assumptions are often
referred to as worldviews or paradigms. These influence SFT clinicians’ conceptualiza-
tions and interventions with clients. Some examples of paradigms include positivism,
post‐positivism, modernism, structuralism, pragmatism, postmodernism, and social
constructionism (see Slife & Williams, 1995; Daly, 2007 for overviews of common
paradigms).
Theories can also be classified in different ways and have different scopes. There are
formal, middle‐range, or substantive theories (Corbin & Strauss, 2008; White et al.,
2015). Formal theories tend to be broad and apply to a wider range of people, con-
texts, and problems (Corbin & Strauss, 2008). Attachment theory, for example, can
be applied to a broad group of topics and conditions. A middle‐range theory (e.g.,
mate selection) focuses on a narrower phenomenon and the conditions that influence
it. Substantive theories focus on specific topics of interest and are more restricted to
Theory: The Heart of Systemic Family Therapy 297
particular groups, presenting problems, or contexts. One example would be a

grounded theory about the process of change in family therapy with a child who has
ADHD. An SFT theory, or model, is the systematic application of formal and mid-
dle‐range theories with clients seeking treatment for a variety of individual and inter-
personal challenges. For example, emotionally focused therapy is the clinical application
of attachment theory, humanistic theory, and systems theory to the treatment of rela-
tionship problems (Greenman & Johnson, 2013).
Function of theory
Theories serve a number of purposes. Theories may facilitate understanding and the
generation of knowledge. They can be used can be used to “predict, interpret, explain,
formulate questions, integrate research, make deductions, and lead us into novel areas
of research” (White et al., 2015, p. 285). Knapp (2009) describes five essential func-
tions of theory. Theories may perform a descriptive function, as they help scholars
make sense of what they study. They help therapists understand and organize what
they observe in the individuals, couples, and families they treat. In concert with their
descriptive function, theories also serve a sensitizing function, as they focus our atten-
tion on certain aspects of human behaviors and interactions. Theory may also have an
integrative function; theoretical ideas can help scholars and therapists bring together
seemingly disparate ideas or events and see how they might be interrelated. Theories
are perhaps best known for their explanatory function, or their potential for providing
understanding of why people and systems do what they do and offering predictions
that can be evaluated through empirical or rational examination. Finally, theories per-
form a value function, meaning that they embody or promote certain values about
human beings, such as those associated with individualism or collectivism (Fife &
Whiting, 2007). In practice, theories relevant to SFT significantly influence the con-
ceptual work and interventions of family therapists.
Theoretical History and Foundations of SFT
SFT has a rich history of in‐depth theoretical development grounded in revolutionary

ideas by scholars such as Gregory Bateson, Ludwig von Bertalanffy, Don Jackson,
Virginia Satir, Paul Watzlawick, and others. Family therapy began as a reaction to the
individualistic perspective of traditional psychotherapy and its emphasis on intrapsy-
chic processes. The field of SFT emerged with the development of systems theory and
has continued to evolve over the past 60 years through the influence of therapists and
scholars who view the world through a relational lens and value the interconnected-
ness of human beings.
Bertalanffy and Bateson, in particular, made significant contributions to the theo-
retical foundations of SFT. They are considered by many to be the founders of systems
theory. Bertalanffy’s (1950) general systems theory represented a radical shift from
the thinking of his time in which the scientific study of biological systems followed
a reductionist philosophy of studying parts of biological systems in isolation.
Instead, he hypothesized an organismic holism that applied to all living systems.
Rather than investigating parts of living organisms in isolation, he proposed understanding
298 Stephen T. Fife
different aspects in the context of the whole system. About a decade later, anthro-
pologist and social scientist Gregory Bateson (1972) studied the systemic nature of
individuals, cultures, and ecologically connected systems and saw how these ideas
related to human communication processes and social systems. His ideas contributed
to the foundational principles of systems theory and many family therapy models.
The work of Bateson and Bertalanffy led to the development of family systems the-
ory, a theoretical framework for understanding the interpersonal dynamics of families.
The clinical application of systems theory began in the late 1950s and early 1960s
through the work of several dedicated therapist‐scholars. The Mental Research
Institute (MRI), established in 1959 in Palo Alto, California, was the first formalized
training program in family therapy. MRI included family therapy pioneers such as
Jackson, Satir, Weakland, Haley, Watzlawick, and Fisch. Although previously trained
in individual psychotherapy, these influential thinkers found serious limitations in the
predominant clinical models’ ability to conceptualize and treat mental health and
behavioral problems (Bateson, Jackson, Haley, & Weakland, 1956; Watzlawick,
Beavin, & Jackson, 1967). They hypothesized that the pathological behavior of a
family member may be a manifestation of dysfunctional interpersonal processes within
the family system.
SFT’s strong theoretical beginnings provided a foundation for the development of
early therapy models. More than simply another treatment approach, family therapy
was a new way of understanding human behavior, conceptualizing problems, and
facilitating change. Others such as Bowen, Minuchin, and the Milan group furthered
the clinical application of systems theory. In spite of the diversity of family therapy
approaches developed in the 1960s and 1970s, SFT scholars and clinicians shared a
conviction that human behavior is fundamentally influenced by its social context and
an individual’s interpersonal relationships within the family system play a major role
in health and dysfunction (Nichols & Davis, 2017). These scholars believed that
addressing both structural and process issues with families was a better way of solving
problems than intrapsychic examination alone.
Theoretical development in the field continued with the efforts of postmodern and
feminist scholars who recognized the limitations of prevailing SFT models grounded
in assumptions and frameworks that failed to account for the social, cultural, histori-
cal, economic, and political contexts, as well as the influence of gender and power in
family relationships. Recent theoretical efforts come from scholars challenging the
idea of normative social and family structures and advocating for social justice and the
experiences of marginalized populations (McGoldrick, Preto, & Carter, 2016).
Further theoretical development has come from common factors scholars who argue
that the clinical outcomes are better accounted for by therapeutic factors shared across
therapy models, rather than factors that are specific to individual models (D’Aniello
& Fife, 2017; Davis, Lebow, & Sprenkle, 2012).
Theoretical dilution
In spite of its rich theoretical history and tradition, the field of family therapy has
struggled to maintain the same theoretical richness and evolution as its dynamic
beginning. The theoretical momentum of SFT’s early period and the resurgence of
theoretical energy brought by postmodern and feminist scholars have waned. Similar
to other mental health disciplines, various contextual factors and trends in SFT have
shifted attention away from theoretical development and training, resulting in a
diminished attention to theory in SFT education, research, and practice. Two trends
have contributed to this theoretical dilution: practical/professional forces and techni-
cal eclecticism.
A significant part of SFT’s national and international growth and recognition relates
to its expanding empirical literature. The discipline recognized the need to move
beyond reliance on clinical experts and authority figures to establish validity and legit-
imacy through empirical research. Additional motivation came from external pres-
sures, such as the need to justify SFT services in order to be reimbursed by third‐party
payers. Thus, SFT scholars have invested considerable effort into empirical research
and methodological and statistical sophistication in order to demonstrate the effec-
tiveness of couple and family therapy. Although the sophistication of research meth-
ods and statistical analyses has increased, there has not been a parallel improvement in
theoretical sophistication and development in the discipline. The result is students
and clinicians who miss or ignore the theoretical underpinnings of SFT models.
Because of this, the field has become less theoretically robust.
A second theoretically diluting influence associated with the pragmatic pressures
described above is technical eclecticism. Generally, eclecticism in psychotherapy refers
to the blending of various techniques and/or therapy models. Eclecticism is the dom-
inant clinical orientation in psychotherapy, with over two‐thirds of therapists and
counselors identifying themselves as eclectic (Slife & Reber, 2001). Its attractiveness
stems from idea that no single therapy approach can effectively treat all problems or
clients who seek therapy; thus, combining approaches must be better.
Although eclecticism can be defined in different ways, the most common form of
eclecticism is technical eclecticism. In contrast to theoretical eclecticism, which
involves the difficult work of theoretical integration, technical eclecticism entails the
combing of clinical techniques, independent of theoretical grounding. Technical
eclecticism was originally introduced by Lazarus (1967), who argued that therapists
should use any effective techniques, particularly those with empirical support, regard-
less of theoretical origins. Although having a coherent theory of treatment is a “cher-
ished ideal,” he acknowledged, “it is well for the practicing psychotherapist to be
content in the role of a technician than that of a scientist” (Lazarus, 1967, p. 416).
Although therapy techniques are rooted in theory‐based models, technical eclectics
assume that the techniques can be severed from their theoretical roots and applied to
clients atheoretically (Slife & Reber, 2001).
However, technical eclecticism is unable to deliver on its promise of theoretical inde-
pendence and neutrality, resulting in theoretically weakened therapy. First, clinical tech-
niques are grounded in theoretical roots, and therapists practicing technical eclecticism
may unwittingly combine techniques arising from theories with incompatible ideas and
assumptions about clients and the process of change. Second, without a guiding theo-
retical framework to inform the blending of techniques, eclectic therapists are at risk of
haphazardly blending techniques, which is not in the best interests of clients, nor is it
likely to be better than treatment guided by a coherent theory and model of treatment.
Even eclecticism proponents admit that random or haphazard therapy is irresponsible
and unethical (Lazarus, Beutler, & Norcross, 1992). Third, eclectic approaches lack
empirical support—combining one or more empirically tested treatment models or
techniques does not mean that this combination is empirically supported.
300 Stephen T. Fife
Ethical obligation
In a general sense, SFTs are in the business of helping people. Those who go into the
field typically have a desire to be of service to persons seeking help for mental, emo-
tional, and relational problems. Given the human and personal nature of treatment,
as well as the real consequences of the service clinicians provide, therapy is fundamen-
tally a moral endeavor. Clients are seeking help and are often paying for services, and
therapists have an ethical obligation to provide the best possible treatment. What
constitutes the best possible treatment? Therapy involves not only what therapists do
but who they are and how well they think about and understand what they are doing.
Ethically responsible therapists not only know what to do, but they also know why
they are doing it. They are technically knowledgeable and proficient, and they under-
stand the theoretical foundations of the models they use in therapy. Most therapists
intuitively understand that “therapy is a human relational endeavor, not an impersonal
application of techniques to fix a broken machine” (Fife, D’Aniello, Scott, & Sullivan,
2018, p. 11). Yet some clinicians practice primarily at the level of techniques, without
much thought for theoretical influences behind the interventions. Therapists have an
ethical obligation to understand thoroughly the models they use—not only how to
implement the models but also how and why they may be helpful; otherwise, they are
practicing in a negligent and irresponsible manner.
Studying and Evaluating SFT Models
Critical thinking about theories and models of therapy

Theory forms the basis upon which therapists conceptualize client problems and for-
mulate treatment plans and interventions. Therefore, therapists must think critically
about the clinical models they use. One method of thinking critically about SFT mod-
els is to examine carefully their underlying theoretical assumptions and their implica-
tions. All theories of human behavior, including SFT theories, have both theoretical
assumptions and accompanying implications. Theoretical assumptions include (a) the
historical and intellectual roots of a theory and (b) implicit ideas about the nature of
the world that are essential for the theory to be correct. (Slife & Williams, 1995;
White et al., 2015). For example, within each theory, there are implicit explanations
of human behavior. These may include the environment, personality, genetics, family
of origin, agency, and so forth. Each SFT model has assumptions about why people
and systems have problems; why certain behaviors, thoughts, and emotions occur;
how the past is related to the present; whether change is possible; how change occurs;
what are the goals for therapy; and what is the role of the therapist. In order to com-
prehend a therapy model fully, we must understand what it says about these topics.
Therapists might also consider the following questions: Do the assumptions make
sense? Do they fit with my experience? Is there evidence to support them? What con-
tradictory evidence is there?
Along with assumptions, all theories carry with them implications. These are the
consequences that logically follow from the application of a theory (Slife & Williams,
1995). Whether hidden or explicit, every theory in the social sciences carries with it
costs and consequences. Like the underlying assumptions, therapists should carefully
examine and evaluate the implications of the ideas underlying clinical models. What
do the assumptions logically indicate about human beings? What are the consequences
for relationships? What do the assumptions indicate about therapy, the possibility of
client change, the role of the therapist, and how to facilitate change?
Common obstructions and reasons for avoiding theory

Family therapy students and clinicians learn about many therapy models, but their
training is rarely enhanced by careful examination of the assumptions and implications
inherent in these models. Understanding the assumptions and implications is essential
if we are to make informed decisions about how to treat individuals, couples, and
families. This requires SFT scholars and clinicians to take theory seriously. Nevertheless,
some try to avoid theory, and theory may be concealed by certain ideological
traditions. Slife and Williams (1995) discuss four common obstructions and reasons
for avoiding theory: the scientific method, scientific facts, practical motives, and
avoidance of theory.
The scientific method SFT scholars often use science to gain knowledge about
human beings, relationships, interpersonal processes, and so forth. A scientific
approach is commonly embodied in the scientific method, which is seen as a way
of identifying facts or establishing truth about the world. Given this view of sci-
ence, “many have accepted the premise that research is a ‘good’ and that, almost
without question, the conclusions drawn from research must also be good”
(Wampler, 2002, p. 1).
However, science itself is a theory—an idea of how we should observe and study
the world, including humans (White et al., 2015). Thus, it does not escape theory.
The scientific method is a theory about generating knowledge that rests upon several
positivistic assumptions such as empiricism, objectivity, linear time, causality, deter-
minism, and reductionism. Many scholars have critiqued the idea of objective science,
pointing out that the scientific method rests upon theoretical assumptions about the
nature of the world and human behavior, and these underlying assumptions have sig-
nificant implications for research questions, methods, data, results, and conclusions
(Fife & Whiting, 2007).
Scientific facts Similar to the scientific methods, scientific facts (i.e., data and
results) are also theory laden (White et al., 2015). As described above, science is
not objective, nor are scientists objective observers (Knapp, 2002). Research
results require a person to make sense of them or give them meaning, and theory
influences the analysis and interpretation of data. Thus, scientific facts and research
results do not escape theory or human influence. On the positive side, human
interpretation of data and results is what brings meaning to scientific data (Slife &
Williams, 1995).
Practical motives Given the clinical focus of therapy and therapists’ desire to
help, many clinicians naturally focus on learning clinical models and techniques.
When presented with the task of learning the philosophical foundations of the
discipline and the theoretical assumptions behind family therapy models, many
302 Stephen T. Fife
therapists object, “I’m training to be a therapist, not a philosopher,” or “I do

therapy, not theory. Just tell me what to do!” Many therapists simply want to
know what technique or intervention they should use in session. However, it is
important to consider whether the discipline should have technicians who merely
apply techniques without understanding them (Slife & Williams, 1995). Systemic
family therapists work with human beings and important relationships, and the
work done in therapy has real consequences.
Avoidance of theories In addition to attempts to avoid theory by relying on s cience

or practical motives, some simply claim they do not use or need theories. Those
who adopt this stance often believe adherence to a theory leads to close‐minded-
ness and rigidity. To prevent a close‐minded approach, some therapists attempt to
remain open‐minded by avoiding theory altogether. However, open‐mindedness
cannot be achieved by avoiding theories. Even the idea that one should practice
without a theory is itself a theory. Rather than trying to be open‐minded by
eschewing theories, “a safer type of open‐mindedness is based on professionals
knowing what ideas are hidden in their theories, including their costs and benefits,
and then being theoretically skillful enough to discern what alternate ideas are
needed” (Slife & Williams, 1995, p. 9).
Whether therapists are aware of it or not, theory is at the heart of therapy. It is not
a question of whether theory is involved in treatment, but whether therapists are con-
scious of this or not and whether the theories utilized are sound or flawed. Rather
than attempting to avoid theory or practice in a fly‐by‐the‐seat‐of‐their‐pants manner,
responsible therapists take theory seriously. They carefully study the theoretical foun-
dations of SFT models and are able to articulate a coherent theory of change for their
clients. This allows them to practice in a more focused and deliberate manner to the
benefit of their clients.
Evaluation of SFT theories and models

Although there are many useful theories that inform the work of family therapists, not
all are equally valid or reliable. Klein (1994) surveyed more than 100 family scientists
regarding the most important characteristics in determining the quality of a theory.
The following list summarizes some of the most frequently endorsed criteria (see
White et al., 2015, p. 19)). This list can be helpful when thinking critically about SFT
theories:
1 Internal consistency: A theory is cogent and does not contain logically contradic-
tory assertions.
2 Clarity of explicitness: The ideas in a theory are defined and expressed in such a
way that they are unambiguous.
3 Explanatory power: A theory explains well what it is intended to explain.
4 Coherence: The key ideas in a theory are integrated or interconnected.
5 Understanding: A theory provides a comprehensible sense of the whole
phenomenon being examined.
6 Groundedness: A theory has been built up from detailed information about events
and processes observable in the world.
7 Empirical fit and testability: It is possible for a theory to be empirically support-

ed or refuted, and a large portion of the tests of a theory have been confirmatory
or at least have not been disconfirming.
8 Contextualization: A theory gives serious consideration to the social and histor-
ical contexts affecting or affected by its key ideas.
9 Predictive power: A theory can successfully predict relevant phenomena.
10 Practical utility: A theory can be readily applied to social problems, policies, and
programs of action (i.e., therapy).
As described above, all SFT models rest upon underlying theoretical ideas about
human beings. Slife and Williams (1995) present a critical evaluation of the principal
paradigms and theories informing the major approaches of psychotherapy, including
SFT models (see Table 13.1). Although these descriptions are by no means exhaus-
tive, they illustrate the point that each SFT model is grounded in key theoretical
assumptions, with accompanying implications. Responsible therapists will take these
seriously and determine which SFT models are good for their clients.
The practice of SFT

Good therapists are committed to helping clients make important changes, experi-
ence healing, and achieve their goals for therapy. Yet many clinicians become so caught
up in learning and applying techniques and interventions; they fail to think about the
assumptions and implications behind the models and techniques they are using. MFT
training programs place particular emphasis on teaching students various MFT mod-
els (D’Aniello & Fife, 2017; Karam, Blow, Sprenkle, & Davis, 2015). Each model
serves as a lens through which therapists view and understand clients. By emphasizing
certain aspects of human behavior and relationships, each model minimizes other
aspects. Like polarized lenses, which block certain wavelengths of light while others
pass through, therapy models highlight certain facets of families and obscure others.
Different models will accentuate different things: behavior, cognitions, emotions,
environmental or cultural influences, gender, structure, family of origin, and so forth.
None is perfect. All have strengths as well as limitations.
Thoughtful clinicians recognize that understanding SFT theories, including their
underlying assumptions and implications, is critical to making informed clinical deci-
sions. Effective treatment requires a good conceptualization of client issues, and the
philosophical groundings and theoretical concepts of a model provide the means for
conceptualizing client problems. The theoretical groundings of a model also guide
the development of treatment plans, the choice of what interventions to use, and the
decision when to use them. To be faithful to their clients, they should give appropriate
time and energy to the ideas upon which models and techniques rest. Doing so will
enhance, not detract, from the quality of their clinical work.
Theory Development and Construction
Over the past few decades, significant effort has been given to empirically investigate
the effectiveness of SFT models and interventions. In addition to establishing a strong
304 Stephen T. Fife
Table 13.1 Assumptions and implications of major theories and paradigms.
Theory/paradigm Assumptions Implications SFT models
Psychodynamic Humans have an There is little we can do Object

theory unconscious mind that about the unconscious relations
influences a person’s influences on our
behavior. We are behavior. We are
ultimately driven by a determined and self‐
desire for pleasure serving
Behaviorist theory Behavior is automatic We are not responsible Behavioral
based on for our actions. They couple/
environmental stimuli are determined. No family
and a history of original or creative therapy
stimulus–response human activity.
Integrative
bonds. Behavior is Change is not
behavioral
learned and determined volitional; it is only
couple
by conditioning changed by modifying
therapy
reinforcement
Cognitive theory Virtually all human Because the cognitive Cognitive
behavior is seen as processes work only family
being the product of from information put therapy
cognitive processes. into the mind, human
Cognitive‐
Cognitive processes behavior is controlled
behavioral
are based on sensory by the information.
family
experience from Human beings are
therapy
the environment or logical/rational.
inherent cognitive Does not account for
structures creative or original
human activity
Humanistic Humans are basically We should all strive to fulfill Experiential
theory good. Each person our unique needs and family
is unique with an become self‐actualized. therapy
innate potential for Our inborn potential and
Emotionally
self‐actualization and a needs exert considerable
focused
drive to have our needs influence over us. If
therapy
fulfilled and to become these are rooted outside
self‐actualized our conscious control,
then human behavior is
determined. Only I can
know what is good for
me (subjective relativism)
Structuralism Structure is fundamental. Strong forces outside Bowenian
(the paradigm Human behaviors our awareness and family
upon which arise from underlying ability to influence therapy
systems theory structures. These operate to direct
Structural
rests) structures are powerful our lives. Ultimately
family
in directing the parts deterministic.
therapy
of the system. Family Therapists are also
structures and societal products of the
structures influence structure itself, and
individuals and families their efforts arise from
the structure
Theory/paradigm Assumptions Implications SFT models

Postmodernism Human beings are not Postmodern assumptions Solution
and social caused or determined lead to relativism. If focused
constructionism by independent forces truth or knowledge brief
such as instincts, laws, cannot be established, therapy
needs, or systems that it is difficult to
Narrative
operate independent decide the morality
therapy
of them. Humans are of behavior (i.e.,
seen as being involved moral relativism). It Collaborative
in the creation and becomes difficult to language
interpretation of acknowledge that the systems
their own lives and world we live in is therapy
meanings. Truth and important and that it
knowledge are created affects our behaviors
by groups of people without making the
and are constantly environment the cause
open to revision and of our behaviors
even negotiation
Note. Adapted with permission from Slife and Williams (1995).
empirical base, scholars have devoted considerable attention to improving the

methodological and statistical sophistication of SFT research (Sprenkle, 2002;
Sprenkle & Piercy, 2005). SFT training demonstrates this shift, with many doctoral
programs requiring students to prepare portfolios that emphasize empirical research.
However, in comparison to the improvements in research methods and analysis, the
theoretical rigor and sophistication of SFT scholarship has fallen short, with emerging
scholars and therapists knowing less about how to think about theory.
Advancement of the discipline cannot rely on methodological or statistical rigor
alone. Although establishing empirical support for SFT models is important, there is
a need to improve SFT scholarship through theory development and construction. In
order to move beyond current research and therapy models and strengthen the disci-
pline, scholars must improve upon existing theories, move beyond existing frame-
works, and explore alternative ideas and new perspectives.
Monological theorizing and research: A barrier to theoretical development

Theoretical development is facilitated by critically analyzing existing theory, utilizing
research to improve theory, and engaging with novel frameworks outside traditional
SFT thinking. Without this, we risk creating a culture of scholarship that merely
engages in a circular process of internal validation of current ideas and existing mod-
els, thus inhibiting meaningful theoretical development. Knapp (2009) calls this mon-
ological theorizing. He warns that “an approach that engages in theory and research
exclusively within the confines of its own logic, assumptions, language, and so forth,
limits what we can know,” resulting in “at best, premature understandings of phe-
nomena and, at worst, incorrect or inadequate knowledge claims” (pp. 135–136).
306 Stephen T. Fife
Historically, SFT scholars and clinicians have held tightly, even religiously, to their
favorite theories and hallowed models (Sprenkle & Blow, 2004a). Therapists tend to
rely on existing theories to explain family problems, as well as providing direction for
treatment. “Even with the recent shift toward evidence‐based practices,” argue
Sprenkle and Blow (2004a), “the field is still too model‐focused when it comes to
understanding the why of therapeutic change” (p. 114). This devotion to current SFT
theories limits understanding of family dynamics, change, and treatment. Although
existing theories may be useful, they can also desensitize, mislead, and create errors
that constrain or distort our understanding of human phenomena (Knapp, 2009).
Monological theorizing and research lead scholars and clinicians to uncritically,
prematurely, or incorrectly draw conclusions regarding individuals and families.
Scholars may give exclusive attention to a particular theory of human behavior, estab-
lish rigorous methods of examining and testing the theory, produce supporting data,
and conclude the theory provides a true understanding of the phenomenon—all with-
out giving serious consideration to alternative ideas or explanations. Within the disci-
pline of SFT, the problem with a monological approach is that the examination of
therapy models and interventions takes place within the context of SFT’s own assump-
tions, language, methods, and ideas about individuals and families. This may con-
strain scholars’ ability to consider alternative ideas or explanations, thus inhibiting the
development of new theories that have the potential to address limitations of current
models.
Critical theorizing and dialogical engagement

As discussed above, different family therapy approaches vary significantly in the way
they conceptualize individual and family behaviors and problems. This variety should
lead researchers and clinicians to critically examine the theoretical foundations and
diverse applications of SFT models (Fife, 2015). Knapp (2009) calls this critical theo-
rizing, a process of analysis and questioning that pushes scholars to theorize more
deeply and broadly than merely learning about the ideas, research, and applications of
clinical models. Critical theorizing includes a joint process of (a) critically examining
the explicit and implicit assumptions and knowledge claims inherent in theory and
research and (b) using dialogical theoretical practices to further theoretical develop-
ment. By dialogical practices, he means carefully evaluating how a discipline’s theo-
ries, methods, and conceptualizations of phenomena relate to other ways of theorizing,
conceptualizing, and studying these phenomena. Increased critical theorizing will
strengthen the discipline by significantly enhancing the theoretical and scientific rigor
of family therapy scholarship.
Building on Knapp’s ideas about critical theorizing and dialogical practices, I dis-
cuss three frameworks that enhance critical thinking and facilitate theory construction
and development: deduction, induction, and abduction.
Deduction
Deduction or deductive reasoning is an approach to thinking or investigation by
which one moves from general premises to specific inferences or conclusions.
Deductive reasoning is commonly associated with quantitative research and the scientific
method. It is a top‐down approach in which hypotheses are generated from existing

knowledge/theories and then empirically examined by collecting data that either sup-
ports or refutes the theory (Southern & Devlin, 2010). Over time, knowledge and
understanding are advanced through replication and generalization of research.
From a positivist perspective, theory development is generally associated with hypoth-
esis testing to provide empirical support for existing theories. However, some critics view
this approach as stifling the generation of new knowledge and new theories (Daly, 2007;
Kuhn, 1970; Mill, 2002). Philosophers of science argue that the verificationist approach
is fallible because exceptions can always be found in reality that contradict a theory
(Popper, 1959). Furthermore, researchers who adopt this approach to theory testing run
the risk of affirming the consequent, a type of logical fallacy in which one takes a true
statement (e.g., “if therapy model A is effective, then clients will make progress”) and
concludes its converse (e.g., “clients show progress; thus therapy A is effective”), even
though the converse may be false or client progress may be due to other factors.
Nevertheless, deductive reasoning can facilitate theoretical development when
research is used to test, refine, or refute a theory in order to create a better theory
(Gilgun, 2005a). Unfortunately, results from empirical research on SFT models are
rarely used to revise or improve existing models. One exception is integrative behav-
ioral couple therapy (Jacobsen & Christensen, 1996). When research on traditional
behavioral couple therapy revealed limitations in terms of clinical effectiveness and
long‐term effects, the model developers utilized these results as a means of revising
the model of treatment.
Induction
In contrast to a deductive approach to theorizing, induction moves from the specific to
the general. Inductive reasoning involves considering what is observed, comparing it to
previously collected data or existing knowledge of an event or phenomenon, and coming
to an understanding or conclusion about the phenomenon. With an inductive approach,
theory is constructed through repeated observation of a phenomena, which helps distill
key aspects of the phenomena and critical processes associated with it. Southern and
Devlin (2010) explain that theory development through inductive reasoning involves six
steps: (a) observing specific cases or events, (b) describing these “particulars,” (c) assert-
ing a hypothesis, (d) testing the hypothesis by comparing new data/cases with previous
data/cases, (e) compiling results, and (f) building models and theories.
In terms of empirical research, an inductive approach to theory development is
commonly associated with qualitative research. Qualitative methods may be used for
theory building, in‐depth descriptions of human experiences, model and hypothesis
testing, developing items for surveys and measurement tools, and answering ques-
tions that quantitative research cannot (Gilgun, 2005b). There are a number of dif-
ferent qualitative methods, including narrative inquiry, phenomenology, grounded
theory, ethnography, and case studies (Creswell & Poth, 2018; Daly, 2007). Although
not all are specifically intended for the purpose of theory development, they share
certain characteristics of inductive reasoning that are facilitative of theory construc-
tion. They guide researchers to carefully analyze the data, identify central theoretical
concepts and hypotheses, test these against additional data or cases, and develop
refined theoretical constructs related to the topic of interest.
308 Stephen T. Fife
Inductive reasoning is also relevant to the clinical practice of SFT in two important
ways. First, many MFT models were initially developed through processes that
included inductive reasoning. In such cases, clinicians (informally) observed what
they and their clients did when therapy was successful. Over time, these observations
were formalized into a theory of therapy. For example, the solution‐focused approach
of Kim Berg (2008) was developed as they observed the resourcefulness in their cli-
ents and noted what facilitated change in their sessions.
Second, clinicians utilize inductive reasoning in much of their work with clients.
Clinicians observe specific aspects of clients’ lives, develop hypotheses about these, test the
hypotheses by comparing new information from clients with previous data (from these
clients, previous cases, and knowledge of therapy models), and develop a theory (i.e., a
treatment plan) of how to help facilitate change. Therapists continue utilizing induction
to evaluate the results of their interventions and modify their approach as necessary.
Abduction
In addition to the deductive and inductive approaches, abductive reasoning is another
process of theory construction and development. Although there are various defini-
tions, abduction is generally understood as a rational and generative process whereby
one considers plausible explanations for a phenomenon based on observation, data,
theory, and original thought. Abduction involves both induction and deduction,
moving beyond data and theory that are immediately available in order to generate
new ideas and possible explanations or reconceptualizations of a phenomenon of
interest (Daly, 2007). Using abductive reasoning, a scholar will compare existing data
and theory with alternative ideas from other theories, disciplines, or knowledge
domains “in order to envision new possibilities for theoretical explanation… [or]
plausible interpretations of data in relation to theory” (Daly, 2007, p. 52).
Abductive inference is a generative process that enhances the quality of theorizing
and addresses many of the limitations of monological theorizing. It opens the door for
novel understandings and innovative theories about human behavior and family systems
by looking at all possible theoretical causes for observed phenomena, creating hypoth-
eses for each cause, and critically examining the hypotheses by analyzing available data
to develop the most likely explanation (Charmaz, 2014). With an abductive approach
to knowledge and theory development, researchers do not predetermine their methods
before developing their research questions. Rather, they let the research question or
topic of interest guide their inquiry such that their methods will best answer the research
questions. This often involves using multiple methods and sources of data collection. In
addition to empirical investigation, scholars also draw upon reason, reflection, creativity,
and intuition in order to generate ideas and new understandings (White et al., 2015).
An abductive approach is often employed when existing data or ideas fail to account
for observed phenomenon or when current theories are deemed inadequate and in
need of revision (Douven, 2017). Researchers will question empirical observations,
existing theories, and accepted facts or “truths.” They embrace uncertainty and ques-
tions, knowing this may lead to new discoveries, connections, or ideas that did not
occur to them before (Locke, Golden‐Biddle, & Feldman, 2008).
Abductive reasoning can be found in the theoretical work of Albert Einstein, the diag-
nostic procedures of medical doctors, and even the analytical exploits of the fictional
detective Sherlock Holmes. Abduction is also the primary mode of reasoning used by
clinicians when diagnosing patients (Douven, 2017). Drawing upon their clinical train-
ing and theory, professional experience, and the information given to them by patients,
therapists determine the diagnosis that best explains the symptoms of the patient.
Another example of abduction directly related to theory development is the work of
common factors scholars in SFT. Historically, the field emphasized the distinctiveness of
therapy models, rather than what they share in common (Fife, 2016; Sprenkle, Davis,
& Lebow, 2009). Claims by SFT model developers and an emphasis on clinical models
in training suggest that therapy models and techniques are the key ingredients of thera-
peutic change. However, in spite of research efforts to determine which approach was
most effective, the results of several meta‐analytic studies found no significant difference
in clinical effectiveness across treatment models, with therapy models accounting for
only a small portion of clinical outcomes (Lambert & Ogles, 2004; Shadish & Baldwin,
2003). Reflecting on these findings, some scholars considered whether there might be
a better way to account for client change and positive therapy outcomes. Rather than
attributing change to the unique aspects of therapy models, these scholars proposed
that common factors shared across models are the primary facilitators of change in
therapy (Hubble, Duncan, & Miller, 1999; Sprenkle et al., 2009; Sprenkle & Blow,
2004a, 2004b). A number of empirical studies and meta‐analyses of individual, couple,
and family therapy provide considerable support for this idea (Ahn & Wampold, 2001;
Davis & Piercy, 2007a, 2007b; Frank & Frank, 1991; Wampold & Imel, 2015).
The common factors perspective may be the most significant theoretical develop-
ment in SFT over the past few decades (Weeks & Fife, 2014). Although it represents
a major shift in thinking about the process of change in SFT, it is still a work in pro-
gress and is not without criticism (Sexton & Ridley, 2004). In response to various
critiques, Sprenkle and Blow (2004b) presented a moderate common factors perspec-
tive, which affirmed the importance of models and techniques and clarified that com-
mon factors work through models. Recognizing that common factors are often
researched independently, Fife, Whiting, Davis, and Bradford (2014) furthered the
theoretical development by creating a meta‐model that describes the relationship
between important common factors. Future work is necessary to develop empirical
support and refine the theory of common factors.
In order to move the discipline forward, both theoretically and clinically, there must
be better utilization of inductive, deductive, and abductive reasoning, as well as diverse
research methods that facilitate moving from theory to data and back to theory—theory
informing research and research informing theory. Through this process, SFT scholars
and clinicians can take the best of SFT theory, therapy models, clinical practices, and
research and further strengthen the theoretical foundation, clinical models, and research
methods of the field in order to provide better treatment for clients.
Future Theoretical Development and Construction:

Moving the Field Forward
In order to move the field forward theoretically, SFT research, models, and practices
should be subjected to rigorous theoretical and empirical examination. A careful
review of SFT history shows that advances with the greatest impact often occur as a
result of theoretical analysis or breakthroughs, rather than through empirical research.
310 Stephen T. Fife
For example, systemic thinkers challenged the status quo of individual psychological
theory and practice by questioning the assumptions of individual psychology, thus
paving the way for SFT. Additional examples of theoretical shifts in SFT include post-
modern scholars questioning the assumptions of clinical models grounded in modern
assumptions, feminists challenging the field to account for gender and power in rela-
tionships, common factors researchers questioning the centrality of therapy models,
and social justice advocates calling for the field to attend to the intersectional contexts
of therapists and clients. In each of these cases, scholars thoughtfully, yet boldly,
reached beyond existing ideas and traditions to consider new perspectives.
Systemic therapists and scholars clearly recognize the benefit of rigorous scientific
methods. Yet the field may not appreciate the importance of rigorous theorizing to
enhance the conceptual, empirical, and clinical strength and health of the discipline.
In order to maintain a vibrant and influential discipline, we must continue to improve
upon current theories and develop new ones. As discussed above, theory development
in SFT began with careful thinking about prevailing views of human beings and rela-
tionships, recognizing their limitations, and exploring alternative ideas. It also
involved discussion, debate, and critique of the predominant ideas and theories and
consideration of concepts from outside mainstream psychological paradigms. Future
theoretical development in our field will likely follow a similar path in combination
with empirical testing of emerging theories.
In order to refine and improve SFT, scholars must seek out and engage with alter-
native perspectives. Knapp (2009) states:
The alternative perspectives provided through dialogical theorizing are precious because
it may be that only through such perspectives will we see the features of the phenomena
our monological practices overlooked and see what a more adequate knowledge of the
phenomena requires. (p. 139)
However, critical theorizing does not necessarily mean existing theory will be rejected.
When scholars rigorously engage with alternative perspectives, the quality of theory
and scholarship will improve, as previously inadequate or incomplete theories will be
either refined and improved or discarded.
In the past, SFT has suffered from the acceptance of dogmatic knowledge claims by
charismatic and talented clinicians. After recognizing the problems with unexamined
acceptance of therapy models, many scholars pushed to elevate the discipline by estab-
lishing a strong scientific base for what we do. Nevertheless, the unexpected side
effect of this effort may have been an internal stagnation and stifling of theoretical
development—primarily because one set of unexamined knowledge claims (i.e., ther-
apy models touted by model developers) was replaced by another (i.e., knowledge
produced through empirical research). However, critical theorizing requires careful
evaluation of theories and methods, as well as sincere consideration of alternative
perspectives from within and outside SFT.
Although moving the discipline forward theoretically is needed, some therapists are
apprehensive about in‐depth scrutiny of existing models and traditions and the explo-
ration of new paradigms and theories. Embracing new ideas can be challenging, and
giving up cherished identities may be even more difficult. Theoretical development
requires a willingness to consider alternative ideas about individuals, couples, and
families. It also requires patience and compassion by those who propose alternative
perspectives and push the theoretical envelope. Unbridled criticism of existing ideas
and models, without acknowledging their good qualities or contributions, will not
invite serious consideration of new ideas.
Considering new theoretical perspectives will help create the open environment
needed for MFT scholars to engage in critical theorizing. This vitalized engagement
will enhance the field by providing alternative viewpoints from which to evaluate SFT
models. A sure way to enhance theoretical rigor and development in our field is to
increase the dialogue between scholars of different theoretical, research, and clinical
traditions (Knapp, 2009). Rather than perpetuating the arms race between competing
therapy models over whose model is best (Weeks & Fife, 2014), engaging in collabo-
rative dialogue between scholars with diverse viewpoints, theories, and disciplines will
move the field forward toward more effective therapy with individuals, couples, and
families. One example of this is the theoretical, clinical, and research efforts of medical
family therapists and scholars, which demonstrates the generative effects of interdisci-
plinary collaboration and theoretical integration (Hodgson, Lamson, Mendenhall, &
Crane, 2014; McDaniel, Doherty, & Hepworth, 2014).
Another way to enhance knowledge and theory development is to intentionally
seek out alternative or innovative theories of human behavior and relationships and
consider their application to family therapy. Scholars can utilize novel theoretical
lenses to evaluate existing SFT models and develop new ones. For example, the rela-
tional framework of Martin Buber may be used to evaluate existing SFT models ther-
apy processes and outcomes (Fife, 2015). Another theory of relationships that may be
applied to SFT is the ethical phenomenology of Emmanuel Levinas, whose work
emphasizes how family life is grounded in an ethical relationality and responsiveness,
as opposed to laws of behavioral reinforcement and social exchange (Galovan &
Schramm, 2018; Knapp, 2015). Similar to the application of attachment theory in
couples therapy (Greenman & Johnson, 2013; Seedall & Wampler, 2013) and the
aforementioned common factors perspective, serious consideration of alternative
viewpoints can help facilitate theoretical and clinical innovations in SFT.
Theory construction can also be facilitated by discovery‐oriented empirical research.
Qualitative research methods are particularly suited for enhancing existing theory and
developing new theory (Gilgun, 2005b, 2012; Zvonkovic, Sharp, & Radina, 2012).
They are also useful for studying complex human phenomena, as they seek in‐depth
understanding by investigating the perspectives and experiences of participants.
Qualitative research has a long and rich tradition in family studies (Gilgun, 2012), and
qualitative research has increased in SFT training programs and academic journals
over the past few decades. Scholars desiring to increase the depth of existing theories
and explore new ones can utilize qualitative methods to understand better the process
of change in SFT.
Implications for SFT Research, Training, and Continuing

Professional Development
In order for the discipline of marriage, couple, and family therapy to keep pace with
other mental health fields, it must continue to improve the research, theoretical, and
clinical skills of students and licensed therapists. Theory development will play a
312 Stephen T. Fife
critical role in the advancement of SFT over the coming decades. The discussions
about theory in this chapter have several implications for SFT research, training pro-
grams, and continuing education and professional development.
SFT research
Researchers must be more aware of the theoretical assumptions and implications of
the methods they utilize and the theoretical frameworks that inform their studies. As
described above, theory plays a central role in the questions, methods, and reporting
of empirical research. Although many scholars are reflective about the influence of
theory on their research, a significant portion of empirical articles fail to identify the
theoretical grounding of their studies. The field needs more theory‐driven research,
as well as better alignment between theories, research methods, and results (White
et al., 2015). Utilizing research as a means of refining and developing theory will
further strengthen the SFT field.
SFT training and continuing education

Thorough training and continuing education are fundamental expectations for
licensed marriage and family therapists. Early family therapy training centers typi-
cally focused on training students in specific models, with training often overseen
by the model developers themselves. However, the focus of training gradually
shifted to the current model of most SFT training programs, which exposes stu-
dents to a wide range of SFT models. However, one drawback is that therapists
may not get in‐depth exposure and training in any of the models, which includes
learning and understanding the theoretical foundations that undergird the clinical
interventions and techniques. Most training programs cover the primary models of
family therapy in only one or two semesters, providing students with perhaps
1–2 weeks to learn about each of the different approaches. Given the limited time
frame, a thorough study of the theoretical foundations of the models is impossible.
A perusal of common textbooks used in training programs also suggests that cer-
tain models are given even less time and attention, as several are often grouped
together under one chapter heading (see Gladding, 2014; Nichols & Davis, 2017).
If students and training programs rely on such survey textbooks as the primary
source of information/training in SFT models, it is relatively certain that students
will learn them without much theoretical depth.
SFT educators have an important responsibility to help students learn therapy mod-
els—both how they are applied and the philosophical foundations they rest upon.
SFT training is enhanced when it includes deliberate attention to the theoretical foun-
dations, assumptions, and implications associated with family therapy models. In
addition to the characteristics for determining the quality of a theory described above
(see White et al., 2015), SFT models can be evaluated on the following dimensions:
(a) the degree to which they are tied to principles of systems theory; (b) whether they
are grounded in modern or postmodern philosophical assumptions; (c) the extent
they emphasize insight and action in the process of change; (d) their emphasis on
concepts such as behavior, cognitions, emotions, structure, process, and contextual
influences; and (e) relevant empirical support.
Table 13.2 Reflection questions to guide the study of SFT models.

Part 1: Assumptions Discuss the assumptions that the model has about the following:
What is the basis for individual and family problems? Why do
problems occur?
What relationship does the past and/or family of origin have
with the present for individuals and family relationships?
According to this model, how does change occur?
According to this model, describe healthy individuals and families.
How does the model take into account contextual factors,
power, gender, and so forth?
Part 2: Clinical Application Discuss the clinical application of the model about the following:
What are the treatment goals for this approach? What
outcomes are anticipated?
What is the role of the therapist, and how does a therapist
engage with the family?
What does assessment focus on?
What are the preferred interventions? What is the intent of
each intervention?
What are the strengths and limitations of this approach?
Given the central role of theory in the practice of SFT, it behooves therapists, stu-
dents, and educators to give sufficient attention to the study of the theoretical foun-
dations of the discipline and the theoretical ideas undergirding common family
therapy approaches. Instructors can stimulate critical thinking by having students
concentrate on the following questions about the assumptions and implications of
each therapy model (see Table 13.2).
Conclusion
From its revolutionary beginnings to the present, pioneering scholars and ground-
breaking theories have fueled the discipline of family therapy. Although the field can
boast of brilliant clinicians, effective models and techniques, and an ever‐expanding
research base, theory remains the heart of the discipline. However, a neglect of theory
could weaken its foundation and reduce credibility with other scholars and the public
(White et al., 2015). SFT needs clinicians and scholars who take theory seriously and
recognize its influence on all aspects of family therapy research, training, and practice.
A renewed commitment to theoretical development and innovation will keep the
discipline vibrant and strong for the next generation of therapists and the individuals,
couples, and families who seek treatment from them.
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14
Transgenerational Theories
and How They Evolved into
Current Research and Practice
Terry D. Hargrave and Benjamin J. Houltberg
As therapists, we see and hear almost a predictable cadence come out of the voices of
our clients, couples, and families. Whether it is in the effort to describe the problem,
where they are stuck in life, or how they describe their personhoods and relationships,
we hear and see the patterns of the past and how the people we seek to help came to
know and understand themselves and relationships. As we listen, we may call the nar-
rative or story different things such as the problem saturated story, the attachment
history, or the nuclear family emotional process. The fact remains, however, most of
us in the therapeutic context will begin to ask companioning questions about the
people we help and their pasts and how they were raised as well as the essential rela-
tionships that formed and shaped identities and senses of safety. We are still curious to
know how the past and the history of relationships came to impute meaning to the
interpretations of self as well as the beliefs that shaped behaviors in relationships. It
seems fundamental to our systemic family therapy (SFT) DNA to ask questions like
“What experiences or relationships were the most important in your life?”; “Where
did you learn the beliefs you are talking about?”; and “How did you learn about being
a woman or a man in the context of your culture and family?” We are still interested
after all these years to therapeutically chase down the origins of pain, misunderstand-
ings, and impacts of behavior and relationships with our clients. We are, in other
words, all doing at least some of the work we learned in our field’s beginnings through
the transgenerational theories of family therapy.
This does not mean, however, we all do the therapy as it was first identified in the
transgenerational theories. From our viewpoint, we see how the transgenerational
theories were primarily involved in the beginnings of our family systems thinking but
then evolved into more orientations that were experiential in nature. As the impact of
neuroscience and mindfulness has grown in our field, there has been a further evolu-
tion of how to efficiently make sense of the past, capsulate the understanding through
systemic patterns, and then move clients to the work of mindfulness and practice in
order to make the changes they deem necessary and useful to solve problems and
318 Terry D. Hargrave and Benjamin J. Houltberg
create better relationships. In this chapter, our goal is to not only create a scaffold of
three major transgenerational theories but also trace how the experiential theories
evolved from this rich beginning and provided a further scaffolding to the more
recent evolution of current models utilizing emotional regulation, mindfulness, and
practice of new behaviors into habituation.
Transgenerational Theories
It is essential to remember that transgenerational theories themselves did not develop

in a vacuum but instead evolved themselves from the context and influence of psycho-
analytic theory. This was due to two primary factors. First, psychoanalytic theory was
by far the dominant force in psychiatry and psychology through at least the first
50 years of the twentieth century (Sander, 1998). Second, and perhaps more impor-
tantly, the founders of the transgenerational theories described here were trained and
likely influenced by psychoanalytic thinking (Framo, 1981; Goldenberg & Goldenberg,
2013). Even though these family therapy founders emerged from psychoanalytic
thinking to make their own contributions to SFT, they were influenced by certain
aspects of psychoanalysis. For instance, both Boszormenyi‐Nagy and Framo were
heavily influenced by the dynamics expressed in object relations theory (Boszormenyi‐
Nagy & Ulrich, 1981; Fairbairn, 1952; Framo, 1982).
From our observation, as the transgenerational theories evolved, there were important
aspects of psychoanalytic influences that persisted in their work. First and foremost, there
was a clear focus on the fact that early relationships—particularly with the mother and
father—were the dominant force in shaping personality as well as relational dynamics
(i.e., Erikson, 1963; Fairbairn, 1952; Freud, 1940; Giovacchini, 1987; Spitz & Wolf,
1946; Sullivan, 1953). The transgenerational theories clearly accepted as fact that the
family of origin was the essential factor in shaping and driving human behavior in rela-
tionships (Bowen, 1978), as well as having a dual effect of shaping the individual psyche
and interactions with others (Boszormenyi‐Nagy & Framo, 1965; Framo, 1981).
Second, there was a focus of these theories that these influences on the individual psyche
and relationships were the root of much of the anxiety experienced in both the individual
and the family relationships (Boszormenyi‐Nagy & Spark, 1973; Bowen, 1966; Framo,
1992). Although these theories referred to this anxiety utilizing different names such as
merging projections, irrational role assignments, or family projection process, it is clear
that these theorists were picking up the thread that psychoanalytic conflict resulted from
the unconscious forces (Freud, 1959) and the flight of fear from object relations (Klein,
1946). Finally, transgenerational approaches were influenced by the psychoanalytic per-
spective that uncovering unconscious or unrecognized influences on the individuals
could produce client insight and perhaps even change (Goldenberg & Goldenberg,
2013). Whether it was by the practice of coaching and bringing family dynamics to the
attention of the client of family (Bowen, 1978), using multidirected partiality to identify
generational loyalties and relational entitlements (Boszormenyi‐Nagy & Krasner, 1986),
or utilizing the use of insight to loosen past relational introjects to resolve current rela-
tional issues (Framo, 1992), the transgenerational theories very much carried on an
evolved belief that interpretations and insights into the family of origin produced not
only some relief for the individual psyche but also relational resolution.
Transgenerational Theories and Current Practice 319
Bowen family systems theory

Murray Bowen was the leading and most influential person in the cadre of transgen-
erational theories and perhaps the most important founder to the field of SFT. So
much of the language and vocabulary family therapists use on regular occasions—par-
ticularly in assessment and understanding of relationships—was developed or articu-
lated by Bowen (Kerr & Bowen, 1988). Although there are many contributions of
Bowen to the field, the crux of his influence of understanding the individual in con-
text of the family is found in the eight interlocking concepts (Goldenberg & Goldenberg,
2013). Bowen believed, like Freud, anxiety was an unavoidable aspect of human exist-
ence and expressed itself in the context of family relationships as members struggle to
(a) balance togetherness forces of the family and individual autonomy drives and (b)
express thoughts with rational clarity versus being swept away by emotional irrational-
ity (Bowen, 1978). This anxiety is either dealt with in a healthier manner or results in
family dysfunction. For Bowen, the eight concepts were interlocking because they
were mutually influential on one another.
Differentiation of self is the first interlocking concept and the key measure in family
assessment of the health of the individual and family. As an individual becomes more
differentiated, he or she is able to be clearly rational and make flexible and good
choices when balancing the obligations of togetherness with the autonomy drive of
individuality (Bowen, 1978). Individuals who experience a state of fusion are very
much in a state that is opposite of differentiation in that his or her emotions contami-
nate rational thinking and therefore lead to imbalance and leaning to either too much
autonomy in individuality or too much togetherness in relational demands. To lean
too much one way or another in this balance will either result in the individual being
unable to connect with important others relationally or make it difficult to maintain a
more autonomous sense of self and choice. True differentiation always means to be
able to hold the anxiety in a reasonable way and be able to connect with others with-
out fear of losing a sense of self. Bowen (1978) maintained a descriptive differentia-
tion of self scale from 0 to 100 where 0 represented a person totally fused emotionally
and rationally and unable to separate self from family influence and 100 represented a
person who was completely differentiated and able to make relational choices without
fear of losing self.
Lack of differentiation breeds confusion and emotional reactivity not only in the
family‐of‐origin system but also in the intergenerational and societal systems of rela-
tionships. Emotional triangles are largely a result of this lack of differentiation and are
the second of the interlocking concepts (Kerr & Bowen, 1988). In a two‐person sys-
tem such as a spousal relationship, two undifferentiated or emotionally fused indi-
viduals have difficulty finding balance in the relationship and therefore increase anxiety
and discomfort with one another. There is a need to diffuse the anxiety caused by this
relationship, and this fact is highly common in dyadic relationships (Bowen, 1978).
The result is often to triangulate another individual into the situation so one of the
dyadic partners has another who is “teamed” with his or her anxiety against the other
partner. A triangle most often splits the dyad and spins off a situation where there are
two insiders and one outsider. Destructive triangles tend to focus the anxiety and
problems on the outsider and away from the dyadic conflict. Triangles are common
not only in families but also occur intergenerationally and where ever there are sys-
temic relationships at work that produce anxiety. When undifferentiated parents
t riangulate a child into their emotional reactivity, the child is subject to the emotional
impairment and is likely to have difficulty maintaining any sense of differentiation in
the future (Bowen, 1978). Bowen (1972) saw clearly how he was triangulated into his
own parents’ relationship and was insightful enough to develop interventions and
clarity on how to de‐triangulate himself.
Another consequence of differentiation is the third interlocking concept called the
nuclear family emotional process. Bowen (1978) believed dyadic partners sought out
or were only able to attract others who were somewhat at equal levels of differentia-
tion. Of course, when highly differentiated partners create family, they raise children
in an environment where there is clarity of thought, flexibility in meeting relational
and individual needs, and a propensity to produce stability in the family. As a result,
the emotional process and patterns of the partners are replicated in the children to
produce adults who are differentiated individuals. When the partners, however, are
undifferentiated and have a high degree of emotional fusion, they produce the same
type of characteristics and patterns with their children. The lower the level of differ-
entiation in the dyad, the greater the likelihood that there will be family instability
through perpetual conflict, distancing, or blaming. Kerr and Bowen (1988) identified
three symptomatic patterns that often develop when partners are emotionally fused,
which include physical or emotional impairment of one of the partners, resulting in
the rest of the family being absorbed into the symptomatic behavior as the focus of all
relationships; chronic conflict in the marital dyad where partners are locked into cycles
of distanced and enmeshed behavior over the emotional anxiety that then dominates
the entire family; and emotional impairment of a child where the undifferentiated
partners band together to blame the child for the anxiety in the family.
Family projection process is the fourth interlocking concept in Bowen’s model.
Bowen (1978) believed there to be an uneven distribution of the parents’ anxiety to
children, and therefore some children would have an opportunity to be more differ-
entiated than siblings. In other words, all children are exposed to the same nuclear
family process and patterns, but not all children are triangulated or impaired in the
same way in the family. For the unlucky or only child of undifferentiated parents, the
projected on child receives an inordinate amount of focus or blame for the anxiety
that exists between the partners or the family. As a result, the overfocus on the child
puts him or her in a position of having more emotional instability and will grow up
with likely even less differentiation from the parents as he or she learns that the only
way to relate and survive is to be emotionally fused, demanding, and perpetually
immature in the same way the parents are immature (Papero, 1995).
The fifth interlocking concept is recognized as emotional cutoff and is one of the
processes that crosses clearly from the family into the intergenerational context as well
as other relationships individuals have in society. In the family projection process,
children who are unable to achieve some type of differentiation from their families
often try various strategies to exert or put forth their adulthood or autonomy. From
an undifferentiated position, however, the adult child will often make this autonomy
play by moving further away from the family of origin, creating barriers to make com-
munication with the family difficult or pretending as if everything in the family is okay
and attention is never again required. Although this may have an appearance of indi-
vidual autonomy, Bowen (1978) would consider it an emotional cutoff. This has the
unfortunate effect of creating a pseudo‐self of autonomy or pseudo‐maturity by phys-
ical or emotional distancing but does not alleviate the emotional fusion or the lack of
differentiation. As one of my professors used to say, “an emotional cutoff is like drag-
ging the family emotional umbilical cord around with you across any distance.” In
other words, the distancing leaves intact all the emotional anxiety without much pos-
sibility of resolving such lack of differentiation. Even more damaging, however, the
distancing techniques learned in this methodology are perpetuated in partner and
other relationships and makes triangulation and the family projection process even
more likely (Kerr & Bowen, 1988).
It makes sense that as a family with undifferentiated or fused parents raise children
who were triangulated, patterned in the nuclear family process, and subjected to the
family projection process, several of those children will likely be even less differenti-
ated than the original parents. These grown children will seek out partners with
equally low levels of differentiation and perpetuate the same unfortunate triangula-
tion, family process, and impairment of their own children through family projection.
The result, generation after generation, is a further deterioration of the multigenera-
tional family and the levels of differentiation among the members. Papero (1995)
reports that although the multigenerational family may stabilize for one or two gen-
erations, there is a tendency when anxiety rises in the family to return to these long‐
standing emotionally fused reactions that spiral the family into dysfunction. This
interlocking concept is called the multigenerational transmission process.
The last two interlocking concepts in the Bowen family systems theory are sibling
position and societal regression. Bowen (1978) recognized that sibling position not
only came into play as the learned interactive patterns between marital partners were
influenced by their sibling positions of being eldest, middle, or youngest but also how
lesser differentiated parents would select potential children in terms of position in the
family projection process. In societal regression, Bowen put forth the belief that
societies—just like families—faced forces of autonomy and undifferentiation. He pos-
tulated that as societal forces produced more stressful and anxiety‐producing conse-
quences, there would be more global deterioration in terms of differentiation and
clarity of thinking (Bowen, 1978).
Like psychoanalysis, Bowen family systems theory is not as interested in problem
solving or change as much as it is in helping individuals recognize and be thoughtful
about their own differentiation and relationships. Therefore, the primary goal of the
work is to improve differentiation through helping people decrease their emotional
reactive patterns and extricate themselves from the dysfunctional patterns revealed in
the eight interlocking concepts that were present in their families of origin (Kerr &
Bowen, 1988).
Although Bowen did not focus on therapeutic techniques, there are identifiable
methods the theory utilized. First and foremost, Bowen (1978) believed the thera-
peutic posture of a therapist should be one of a coach. In this manner, the therapist is
able to give direction and inform individuals about more differentiated positions and
de‐triangulating the self from the family of origin. Although Bowen would work with
families and couples occasionally, he very much preferred that the family members
learn in conversation with him directly and not by speaking directly to one another in
the beginning stages of therapy. In this way, he believed he minimized the opportu-
nity for family members to emotionally fuse and at the same time maximized his influ-
ence in coaching the family toward more differentiated behavior (Bowen, 1978). In
recognizing the family emotional process, the projection process, emotional cutoffs,
and the multigenerational transmission process becomes evident in the technique of
genograms used by many Bowen systems therapists (McGoldrick, Gerson, & Petry,
2008). Also, Bowen (1978) utilized the coaching position in helping clients practice
more differentiated behavior through improving rational thinking and communica-
tion through taking “I‐positions” and engaging in relational experiments. All of these
methods were clearly designed to help the family members and clients become
thoughtful about their processes and improve their growth by more differentiated
behaviors.
There has been some current research that has explored Bowenian concepts. For
example, Miller, Anderson, and Keals (2004) found that lower levels of differentiation
were significantly correlated with higher levels of anxiety and lower levels of marital
satisfaction. Also, Bartle‐Haring, Ferriby, and Day (2018) found that the level of dif-
ferentiation mediated the association between depressive symptoms and relationship
satisfaction. Higher levels of differentiation of self are also correlated positively with
sense of well‐being (Ross & Murdock, 2014) consistent with Bowen’s perspective of
individual and relational balance.
Contextual family therapy

Ivan Boszormenyi‐Nagy was a Hungarian psychiatrist who immigrated to the United
States after World War II. He was a leading figure in the early development of family
therapy in the 1960s, working with families and schizophrenia (Boszormenyi‐Nagy &
Framo, 1965). As his understanding of families grew, he and his colleagues directed
their work more toward transgenerational issues in the family. Contextual family therapy
was the eventual result. It is a comprehensive approach to therapy that is integrative of
several psychological and developmental theories (Boszormenyi‐Nagy & Krasner,
1986). In essence, contextual family therapy emphasizes relational healing through
growth in family commitment and trustworthiness, primarily developed through the
process of loyalty, fairness, and reciprocity. Although there have been modifications to
his theory since his death in 2006, his systemic therapy is best conceptualized by the
four dimensions of relational reality (Boszormenyi‐Nagy & Krasner, 1986):
1 Facts are the relational influences that are primarily due to existing environmen-
tal, relational, and individual realities that are objectifiable. For example, genetic
heritage, physical health, historical facts, and specific events in the family life cycle
would be a part of this dimension.
2 Individual psychology. Individual psychology is the relational dimension that
accounts for a person’s experiences and motivations. These subjective influences
are internalized to individuals as he or she strives for recognition, love, power, and
pleasure and are motivated by the forces of aggression, mastery, or ambivalence.
3 Family or systemic interactions. This dimension is delineated by relational trans-
actions, communication, and interactions. These interactions produce a family or
systemic pattern of organization that defines power, alignments, structure, and
belief systems.
4 Relational ethics. This dimension deals with the subjective balance of trustworthi-
ness, justice, loyalty, merit, and entitlement between members of relationships. As
relational members interact, they are interdependent and relational ethics requires
them to take responsibility for actions and consequences as well as to strive for
fairness in the process of relational giving and taking.
Although all four dimensions are interdependent on each other and have mutual
influence, it is the dimension of relational ethics that is the strongest and overarching
concept in the theory. Simply stated, it is the balance of fairness in the family relation-
ships between the obligations and entitlements of each member of the family. This is
instinctual to family members based on the trust that the family is committed to meet
the individual’s needs and the individual will do what it takes to perpetuate and give for
the good of the family (Boszormenyi‐Nagy & Krasner, 1986; Boszormenyi‐Nagy &
Ulrich, 1981).
When family members take part in this mutual investment of give and take—both
giving for the good of individual members and the members in turn seeking and giv-
ing to help the family survive or become stronger—a sense of trustworthiness is devel-
oped in the relationships. Trustworthiness in relationships is consistently pointed out
as the essential element in building family health and intergenerational stability
(Boszormenyi‐Nagy, Grunebaum, & Ulrich, 1991). Trust in the family process of
give and take is powerful because it allows family members to contribute and give to
one another in freedom without fear of others threatening, manipulating, or with-
drawing from them. In short, they give to each other because they trust that other
family members will give to them and meet their individual needs (Hargrave &
Pfitzer, 2003).
When there is an imbalance in this family ledger of give and take or merits and obli-
gations between family members, it is experienced by members as a violation of jus-
tice. If the injustice persists over a period of time, trustworthiness begins to deteriorate
and so does the individual freedom to give to others (Hargrave & Pfitzer, 2003). As
a result, individual members decrease or stop giving to other family members, and it
then triggers a further deterioration of trust in the family. Soon, individuals in the
family start seeking destructive ways to gain their justified entitlements that have been
neglected or ignored. Because no one in family relationships give to one another,
members begin threatening others to “make” them give what is needed, manipulating
relationships to meet their own needs, or withdrawing and giving up on the relation-
ships with the belief that people will be unable or permanently unwilling to meet their
needs. This tragic loss of trustworthiness and movement of family members to take
what they need through threat, manipulation, or withdrawal is called destructive enti-
tlement (Boszormenyi‐Nagy & Krasner, 1986).
Boszormenyi‐Nagy, of all the family‐of‐origin therapists and theorists, was most
true to the idea of a comprehensive transgenerational theory. He believed sincerely in
the idea that deficits of injustice and trustworthiness were passed along in the destruc-
tive entitlement of one generation to the next forming a revolving slate of the genera-
tional ledger (Hargrave & Pfitzer, 2003). It was this concept of the revolving slate of
the generational ledger that led Boszormenyi‐Nagy and Spark (1973) to identify the
concept of invisible loyalty. When an individual is raised in a family where there is an
unjust system where he or she is deprived of fair entitlement, the individual is likely to
carry a dysfunctional and sometimes pathological drive into the existing relationships
that can be quite destructive to both the individual and intergenerational family
(Boszormenyi‐Nagy & Krasner, 1986). For instance, as children grow in a family,
they are a part of a vertical relationship where giving from the previous generation is
asymmetrical in nature. In other words, parents give to children not because they
expect to receive giving back from the child, but because the child is fulfilled and
emotionally healthy by the love and trustworthiness given by the parents. As the child
grows up and has children of his or her own, he or she then is raising a child in this
vertical, asymmetrical relationship. This adult child now gives to his or her own chil-
dren love and trustworthiness out of the resource provided by his or her parents in the
previous generation. This healthy generational giving also raises children who are
then able to engage in sound horizontal relationships or relationships where partners
engaged in balanced give and take with one another such as siblings, friends, or
spouses (Hargrave & Pfitzer, 2003).
The unpleasant rub comes when a child is raised in a situation where he or she
does not receive the just entitlement from the previous generation. The denial of
what the child needs to be loving and trustworthy sets him or her on a destructive
entitlement drive to fulfill what is needed and will include the threatening, manipu-
lating, and withdrawing from others. Further, he or she will be indiscriminate in this
destructive entitlement expecting innocent parties such as his/her own spouse, chil-
dren, or friends to make up for the entitlement lost in the vertical relationship. The
invisible loyalty to family of origin, and more importantly the generational revolving
slate, makes the behavior of the destructive and dysfunctional person most profound
as he or she desperately tries to fulfill their own quest for entitlement. Worse still, the
partners and children of this person are impaired and cheated out of their fair love
and trustworthiness. Thus, the drumbeat of dysfunctional families proceeds in a
downward spiral through the generations (Boszormenyi‐Nagy & Krasner, 1986;
Hargrave & Pfitzer, 2003).
The crux of the therapeutic effort in contextual family therapy is multidirected par-
tiality. As Boszormenyi‐Nagy and Krasner (1986) point out, it is not simply a thera-
peutic methodology or intervention strategy, but instead is a central theme for the
therapist as he or she seeks to understand the story of all those who have a genera-
tional ledger stake in the family and be partial and trustworthy in holding parties
accountable and responsible (Hargrave & Pfitzer, 2003).
There are four primary methods used in the process of multidirected partiality
(Goldenthal, 1996). The first is empathy, and it is perhaps the most well‐recognized
methodology in the therapeutic field. When the therapist reflects empathy while lis-
tening to the client story, he or she expresses connections to the client’s loss, fear, and
pain (Goldenthal, 1996). The second methodology in multidirected partiality is cred-
iting and involves the therapist openly acknowledging the unfair violations and rela-
tional insults the client has experienced in the family. In addition, the therapist credits
the client efforts to be loving and trustworthy amidst receiving insufficient resource
from the family. In other words, recognizing the client for giving when he or she has
not received fair and just entitlement. When this is done in conjunction with empathy,
it further builds a trustworthy alliance between the therapist and the client
(Boszormenyi‐Nagy et al., 1991). Acknowledgment of efforts is the next aspect of
multidirected partiality and involves the therapist recognizing the successful loving
and trustworthy efforts not only of the client but also of the family that might have
been well meaning, but went awry because of destructive coping (Goldenthal, 1996).
For example, many times family members get angry or manipulative in relationships
in an effort to force more responsible or just behavior from others. Finally, multidi-
rected partiality involves accountability. This aspect involves the therapist holding the
client as well as the other relational parties—both present and not present in the
room—responsible for the actions and behaviors that caused damage to relationships
and resulted in violations of love and trustworthiness (Hargrave & Pfitzer, 2003).
The practice of multidirected partiality in the therapy room provides an initial infu-
sion of trustworthiness and insight to the family member or members. As this trust-
worthiness grows, members are then able to acknowledge not only the pain in other’s
stories but increasingly take responsibility for their own destructive actions. In short,
family members start making efforts toward giving to one another amidst the atmos-
phere of understanding and trustworthiness. This action creates an equally powerful
inclining spiral of love and trustworthiness as giving results in more family trustwor-
thiness and more family trustworthiness begets even more giving. The way out of
family and individual dysfunction, therefore, is utilizing multidirected partiality in
order to create ample trustworthiness to start building a legacy of health and giving
(Hargrave & Pfitzer, 2003). As such, contextual family therapy clearly acknowledges
the power of the past in shaping the inter‐ and intrapsyche of the individual and family
and builds a methodology of insight and understanding in order to promote healthier
individuals and family relationships.
Contextual therapy has less research that is not associated specifically with examples
and case studies, but there has been encouraging work in terms of identifying core
practices of the approach from observations of both Boszormenyi‐Nagy and current
practitioners (Meiden, Noordegraaf, & Ewijk, 2017, 2018). Also, Hargrave, Jennings,
and Anderson (1991) developed a Relational Ethics Scale to validate constructs in the
theory. This scale was then used to identify a positive correlation between trust and
justice in relationships and marital satisfaction (Hargrave & Bomba, 1993). Likewise,
the Relational Ethics Scale was used and was significant as a predictor of marital satis-
faction, and in turn, marital satisfaction was significantly associated with depression
and health problems (Grames, Miller, Robinson, Higgins, & Hinton, 2008). Finally,
the same scale was used in a study to measure a sense of fairness and relationship sat-
isfaction, which revealed that lower sense of fairness was correlated significantly with
lower relational satisfaction (Gangamma, Bartle‐Haring, & Glebova, 2012). All of
these findings are supportive of the constructs of contextual therapy.
Framo’s object relations/family‐of‐origin therapy

James Framo was a founder in family therapy who was hesitant to jettison what he saw
as the benefits of the psychoanalytic understanding of client intrapsychic issues. He
focused instead on efforts to balance his understanding of object relations with overt
understanding and direct interventions with individuals and couples and their families
of origin (Framo, 1981). His uniqueness in the field of SFT is his direct application
and intervention with individuals and families confronting their pasts in their families
of origins and pioneering conjoint and group meetings with family‐of‐origin
members.
Out of his work in object relations, Framo (1982) believed the bulk of anxiety and
conflict experienced by individuals spawned in the family of origin and it was these
influences that then led individuals to act out and replicate the conflict and anxiety in
current relationships. Framo (1981) was most heavily influenced by the work of
Fairbairn (1952) and believed that as a child interprets and experiences a parent who
is inattentive, rejecting, or even abandoning, the child is caught in a terrible bind. The
child is dependent upon the parent as the only one who can provide the love and care
he or she needs and therefore cannot give the parent up or reject the parent, but, at
the same time, hates the parent who has failed him or her. This love/hate r epresentation
of the child’s feelings toward the parent results in the intrapsychic conflict of splitting
(Framo, 1981).
Key to the object relations analytic perspective, these splits of the object (the par-
ent) are held by the child as introjects, or internalized objects and beliefs about the
objects held in the psyche. In the internalized psychic world of the child, the child
learns to control and deal with the conflicting splits of the internalized parent or
object (Fairbairn, 1952). Framo (1981) believed these parental introjects were among
the toughest to change in therapy, and the greater the parental neglect or rejection of
the child, the more resistant the internalized object and splits would be to change as
the child grows into an adult. Further, as the child turns to an adult and seeks a mate,
he or she does not select a partner that is desired as much as a partner that matches
the internalized objects and splits that which already exists in the psyche. In this way,
the individual seeks a pair bond that holds out the hope of the love represented in the
best of the internalized parent, but also a partner who holds some of the same reject-
ing or neglecting attitudes of the worst part of the internalized parent. The individual,
therefore, recreates their own split‐internalized representation in their current family
relationships in an effort to work out, albeit unconsciously, the desired love of the
internalized best parent and resolve or eliminate the worst characteristics of object or
parent in the context of the current relationship (Framo, 1992).
The most damaging part of this process in producing conflictual marriages is the
process of projective identification, wherein the partners project their expectations and
resentments of their internalized object parents, or the disowned part of themselves
that are much like the hated part of the internalized parent. Although this process is
evident with partners first, children of the partners are particularly vulnerable as
objects of this projections. As a result, children cannot get the projecting parent to
love him or her because the parent has projected a “bad” introject onto the child and
expects the child to somehow work this out on his or her own to provide the parent
with unconditional love. In this way, partners and children become substitutes for the
rigid introjects of the individuals past family of origin (Framo, 1981). In turn, it is
easy to see how this process is then replicated from generation to generation as inad-
equate parents produce splitting of the internalized parental object in their children
where the process is then repeated.
Therapeutically, it was not unusual for Framo to meet with the entire family first in
order to free children from carrying symptoms or responsibilities caused by the pro-
jections of the parents. Once this was achieved, the clear focus of the therapy became
about undoing the projections of the past in the partnering or marital relationship of
the parents (Framo, 1982). Framo (1992) would most often meet with partners in
conjoint sessions first to help the partners articulate and understand their frustrations
and internalizations of their objects. But very quickly in the process, Framo would
move these partners into the context of group marital therapy, most often consisting
of three couples. In addition to hearing and understanding the influences of the past
from each member and the subsequent introjects, splitting, and projections, group
members would learn from seeing the interactional patterns acted out by other cou-
ples. As a result, members would also see how the same or similar dynamics or pat-
terns were at work in their own relationship as well as seeing the insights and new
possibilities brought to light by the therapist. Couples were also encouraged to give
each other positive feedback as well as insight into certain issues the couple might be
experiencing. Besides the positive aspects of any group experience, Framo also believed
that the couple marital group then set the stage and reduced resistance in preparation
for the final stage of the treatment: the meeting of the individual with the family of
origin (Framo, 1992).
Framo (1981, 1992) clearly felt that the most powerful way to loosen the bonds
of the good/bad introjects and projections was not through the insight, understand-
ing, and comments from the therapist or others, but to deal directly with one’s family
of origin in a session with as many original family members as possible. As such,
Framo serves as an important bridge from the insight‐based transgenerational theo-
ries into more of the experience‐based approach that evolved into the experiential
therapies. In the family‐of‐origin meetings, the therapist (or co‐therapists) would
meet with one of the individuals with the couple and his or her family of origin for
usually two two‐hour sessions. The goals of the sessions were to explore how the
beliefs or perceptions formulated in the family of origin found their way into the
projections in current relationships and to have corrective experiences with the fam-
ily of origin. In many cases, individuals had misunderstandings or misperceptions of
the problems in the family of origin, and these could be addressed through the clari-
fications and explanations of the family members. Rather than being a platform for
blame, the meetings would often be a place where misunderstandings could be
cleared up overtly and messages of love and care could be expressed. But even when
this was not the case, individuals had the positive outcomes of talking out their past
beliefs and projections and came to a better understanding that the issues clearly
belonged in the relational realm of the family of origin instead of the intrapsychic
aspect of the individual (Framo, 1992).
In working with the family of origin directly, the individual had the grip of the
internalized objects loosened. As a result, the individual can then see more clearly the
reality of the family‐of‐origin parents and realize that these objects were never totally
the rigid splits that were internalized, but rather real people who are imperfect but still
able to love and connect. With this revision of the introject, the individual is finally
able to release a good part of the old projections and is free to behave and act in a
more beneficial manner toward the partner and the children (Framo, 1981). In this
way, the individual, partnering relationship, and children can have a changed experi-
ence without the unconscious introjects of the past. For the individual, the anxiety of
the split is resolved by both the insight and understanding gained in therapy and the
new liberating experiences gained in the family‐of‐origin sessions. Although imperfect
in many cases, the process of interacting in the conjoint therapy, group marital ther-
apy, and family‐of‐origin sessions is restorative and healing for the intergenerational
family (Framo, 1992).
Experiential Theories
The early transgenerational theories definitely made an impact in the psychotherapy

field as they opened up the possibilities of working in a relational way, instead of
strictly an intrapsychic manner. The experiential theories discussed here were develop-
ing along with these transgenerational approaches and shared much common ground
with those founders. First, both Whitaker and Satir felt that the best context for indi-
vidual fulfillment would come to fruition in the context of healthy relationships (Satir,
Banmen, Gerber, & Gomori, 1991; Whitaker & Bumberry, 1988). This fundamental
concept is very close to and was likely influenced by the outlook that the d
ifferentiation
of self results in the ability to practice not only autonomy but also togetherness in a
family context (Bowen, 1978). Second, there was a high stock put into clarity of
expression in the here and now among the experiential founders (Satir, 1964). Again,
this goal is consistent with the transgenerational theories to root out past loyalties and
projections in order to make more informed and clearer choices in relating. Finally,
the experiential founders placed a premium on growth and individual freedom (Satir
et al., 1991; Whitaker & Bumberry, 1988). Clearly, although the transgenerational
founders did not express it in the exact language, the therapeutic goal was to direct
change into a less dysfunctional system where healthy individuals could flourish
(Boszormenyi‐Nagy & Ulrich, 1981; Framo, 1981; Kerr & Bowen, 1988).
The experiential founders, however, expanded the framework of family therapy
from decreasing the focus on conflict and anxiety to the focus of human growth and
freedom (Satir et al., 1991; Whitaker & Keith, 1981). This was a natural outgrowth
of their phenomenological influence from focusing more on the aspects of humanistic
psychology in the tradition of Gestalt and person‐centered therapies instead of the
more traditional psychoanalytic approach (Goldenberg & Goldenberg, 2013). Still,
both Whitaker and Satir put the family of origin as the primary block to overcome in
the work to growth (Satir et al., 1991; Whitaker & Keith, 1981). As such, the family
dynamic of the past plays a central role in the systemic nature of these experiential
theories. The primary evolution of the experiential theories, therefore, was not so
much the focus of the goal of therapy but rather the way these therapists worked to
produce change and growth. Traditional transgenerational theories focused on
thought processes, understanding, and insight to interpret and clarify family‐of‐origin
dynamics to produce change. In the experiential iteration of the evolution, these
models emphasized the actual emotional experience in the therapy room as the pri-
mary methodology of change, thereby opening the opportunity for freedom and
growth in the individual (Satir, 1982). Indeed, Whitaker and Bumberry (1988)
almost held the practice of theoretically driven techniques and rational thinking as an
avenue to change in contempt and much preferred the practice of being and doing in
the room. As Whitaker said many times in a variety of settings, “Anything worth
knowing cannot be taught; therefore, anything worth knowing must be learned” (C.
Whitaker, personal communication, August 23, 1991). Clearly, the experiential evo-
lution of dealing with family of origin was driven by doing and trying new experiences
rather than clinical interpretation.
Symbolic experiential family therapy

Carl Whitaker was one of the founders of the family therapy movement who took an
extraordinary path in his therapeutic development. Initially influenced in psychoana-
lytic thought, Whitaker took on unique and daring treatment for schizophrenic
patients at the Department of Psychiatry at Emory University early in his career. He
focused on a type of play therapy with influence of therapists who acted as co‐parents
and experimented with regressive and symbolic techniques in order to reduce the
infantile effects of schizophrenia (Whitaker & Keith, 1981). After his tenure ended in
Atlanta, Whitaker eventually went to Madison, Wisconsin, to do training in psychiatry
and further adapt his model of therapy.
Symbolic experiential therapy always values the freedom and choice of the individ-
ual, and growth is seen as developing in healthy groups as a natural process of crisis
due to developmental changes. Issues of individual and family health such as clear
generational boundaries, the flexible distribution of power among members, the free-
dom to express individual beliefs and differences, and the ability to problem solve are
negotiated via the pathway of actual experiences of going through these challenges
together (Whitaker & Keith, 1981). On the other hand, family dysfunction often
presents itself when parents struggle over which family of origin of the partners is
going to govern or influence the family more, a rigid structure of rules that must be
obeyed by all members and an inability to operate outside of the homeostatic expecta-
tions. Further, all members of the family are equally affected in a pathological or
dysfunctional family. Particular members may be scapegoated, but the entire group
bears the marks of the problem behavior (Whitaker & Bumberry, 1988).
Specific issues may bring the family to therapy, but the symbolic experiential thera-
pist most often sees the symptom only in the context of helping the individuals and
family negotiate to a larger goal of freedom and growth. As such, each experience
between therapist and family is essential in formulating new opportunities for choice
and growth (Keith, 2000). The first stage of the symbolic experiential therapy process
is the battle for structure in which the family must capitulate its role to operate the way
it likes and is used to in favor of the therapist’s mode of operating. The next stage is
the battle for initiative in which the therapist is nondirective toward the family in get-
ting information or story concerning their issues. The therapist in this model makes it
clear that he or she is committed to his or her own growth in the therapy process.
While this serves as a model of responsibility, the family members are left on their own
to reveal their own processes and thoughts (Whitaker & Keith, 1981).
Experiential therapists in general, but particularly symbolic experiential therapists,
do not structure interactions or tasks or even endeavor to gain much content or his-
tory concerning the family. The focus of the therapy is clearly to confront the process
that is happening in front of the therapists during the session. Once the family mem-
bers show part of this process, symbolic experiential therapists will engage the process
using metaphor, teasing, humor, free association, fantasy, and confrontation in order to
increase the family confusion, prompting the family members to find a different way
to resolve the stress (Whitaker & Keith, 1981). For example, when a client in a family
states, “I am the black sheep of the family,” a therapist might respond, “Well, that is
fortunate for you that you don’t shear off your black wool just to become another
mindless sheep following your family. Isn’t there something about that makes you the
special one in the family?” Such a challenge forces the family into disequilibrium as
they now will likely attribute forming a coalition against the “black sheep” as being
mindlessly influenced and the “black sheep” having to reckon with the advantages of
having more freedom of choice. The point is that the family is actively challenged
through their discussions and interactions with the therapist to have to modify their
processes and move more toward family health, boundaries between generations,
adapting and balancing new ways of expressing and connecting to one another and
growing (Keith, 2000).
Although research evidence for outcomes in this approach are scant, clinically sym-
bolic experiential therapists believe that this process, experience‐based approach, has
the power to change any family with virtually any diagnosis. They maintain systemi-
cally that since causation is circular, change has the same characteristic (Whitaker &
Keith, 1981). Many times, Whitaker referred to his work as the “therapy of the
absurd” because he saw the entire family as his client and would go to any lengths—
stretching the bounds of accepted therapeutic practice—in order to invade the normal
but dysfunctional family process to produce new growth and adaptations (C. Whitaker,
personal communication August 23, 1991). He saw symptoms and anxiety as oppor-
tunities for growth and would model fantasy alternatives in order to get the family
unstuck (Whitaker & Keith, 1981). Like the transgenerational theories, Whitaker
would use the anxiety as a force to bring about change. From our perspective, he was
part shaman and part stand‐up comedian, but he certainly created experiences wherein
families and individuals were prompted to change and grow.
The Satir model

Virginia Satir was one of the founders of the family therapy movement who was an
experience in evolution herself. Through her work as a social worker, she was perhaps
the first founder to meet with families as a whole. She was attracted to the Palo Alto
Group that eventually became the Mental Research Institute in the late 1950s and
worked in the research of understanding behavioral communication and its connec-
tions with mental health. Satir (1964) published one of the first works in family ther-
apy. As she began to train therapists more, she became more influenced by humanistic
theories and began working to clarify her early communication work and combining
it with growth enhancing methodology (Satir, 1982).
Like Whitaker, Satir believed that being a part of the family as a homeostatic system
required members to take on certain roles, limitations, behaviors, and sometimes
symptoms in order to keep the family functioning the same. She interpreted these
limitations and symptoms as blocks to individual growth and well‐being. She also
believed, like Whitaker, that the experience in the therapeutic process offered the best
opportunity for family members to remake their limits and remove the blocks to the
growth and healthy functioning. Unlike Whitaker, however, who took great care to
guard against being absorbed into the family (Whitaker & Bumberry, 1988), Satir
used her charisma as a nurturing and loving mother figure to involve herself com-
pletely with the family learning experience, creating new possibilities for not only love
but also growth (Satir & Baldwin, 1983).
Satir et al. (1991) pointed to three factors as essential to therapeutic understanding
in human development. The first of these is genetic endowment. Like Boszormenyi‐
Nagy’s account of the dimension of facts in contextual family therapy, Satir also saw
how genetics play into our physical as well as some of our emotional endowment.
The second factor is that of longitudinal influences, and for many, this is the most
essential construct in determining how identity, self‐worth, and self‐esteem shape
behavior, as well as the development of blocks to growth. Satir pointed to the primary
survival triad consisting of mother, father, and the child as the main context of the
family of origin where the child experiences love and encouragement as well as poten-
tially neglect and discouragement. The elements of touch, care, tone, and nurturing
are key in the child’s development, not only in direct experience but also as the child
sees and experiences the mother and father expressing these qualities toward one
another (Satir & Baldwin, 1983). As the child experiences both constructive and
destructive messages from parents, the child learns to interpret the parental messages
and grows or declines in identity and health accordingly (Satir et al., 1991).
The final factor that plays into the Satir model is the mind–body interaction and was
represented in her work by the mind–body–feeling triad. Satir felt mind, body, and feel-
ings take on meaning to the individual, and the person either overemphasizes certain
elements of the triad because it feels comfortable or de‐emphasizes other elements
because it is neglected and disliked (Satir et al., 1991). For instance, a person who is
very strong intellectually may have a tendency to put down their body’s value or attrac-
tiveness and/or pay little attention to the emotional self. Satir would call attention to
these various parts in almost a Gestalt manner with an emphasis on encouragement and
nurturing to help individuals embrace and integrate their whole selves and recognize
the growth that occurs because of such balance (Satir & Baldwin, 1983).
One additional element that played an essential role in the Satir model was the
communication styles. Satir (1972) believes that interaction styles that individuals
take on in relationships are good representations of their feelings and identities. She
identified these styles by paying attention to the way the clients attended to them-
selves (self), the other person (others), and the situation and circumstances in the
environment (context). In turn, Satir had a sculpting stance for each style that she
would utilize in therapy to promote awareness and growth. A person well in tune with
self, others, and context would be identified as a congruent style. Individuals in touch
with others and context but not with self would likely be a placating style and be
prone to be weak, self‐condemning, and apologizing for self. Those who are in touch
with self and context but not others would have a blamer style and likely display
behaviors that were dominating, angry, and self‐justifying. Individuals only in touch
with context at the expense of self and others would be identified as having a super‐
reasonable style and would likely be out of touch with emotions while acting distant
and uninvolved. Finally, those who are out of touch with others, self, and context
would likely display a style that is irrelevant and would represent behavior that is
unable to relate and distracting in relationship (Satir, 1972).
Satir was a master therapist and extremely nurturing in the room. Her focus in ther-
apy was constantly in propelling the individuals and family members into growth of
identity and self in the here‐and‐now experience with her. Some of the techniques she
used were pointing out incongruence in the mind–body connection of the client—
often using body parts as metaphors of communication—as well as making overt family‐
of‐origin rules, power alignments, and threats people felt. She would help individuals
confront these issues with therapeutic touch and support while encouraging new behav-
iors, relational experiments, and evaluation that represented clarity and strength of self
(Satir et al., 1991). In addition, she would often utilize family sculpting and family
reconstruction in her work. In a profoundly effective family‐of‐origin application that
was experiential, she would represent the primary survival triad utilizing communica-
tion stances and styles illustrating roles of family members. She would then teach, illus-
trate, experiment, suggest, and give feedback to members to create additional possibilities
within the here‐and‐now experience and promote growth (Satir & Baldwin, 1983).
There has been very little research on the experiential approaches of Whitaker and
Satir. Outside of case studies and examples, core variables in the symbolic experiential
theory have been identified (Mitten & Connell, 2004), but little progress has been
made how these are utilized in therapy or produce change. In the Satir model, there
has been a scale developed reflecting the theory’s idea of congruence (Lee, 2002) as
well as a study that reported significant improvement in family roles and relationships
after participation in a group focused on the model (Pan, 2000).
Current state of transgenerational and experiential theories

The current discussion in the field toward evidence‐based models can highlight cur-
rent approaches and ignore the contribution of the aforementioned SFTs. This is in
part due to the lack of research that has been conducted within these transgenera-
tional and experiential theories. It is always important to remember that through
these first two iterations of theory, founders in the field were most interested in model
development, techniques, and observations of interventions that produced change in
individuals and relationships. Most written research on these approaches, therefore,
has been anecdotal and focused on case studies or examples of practices. This type of
research, albeit informal, is often quickly disregarded because it lacks the rigor of
more randomized controlled trials that are often touted as the gold standard of the
field. Ironically, there has been a push for more process research in SFTs because of
the noted challenges of conducting randomized controlled trials when trying to oper-
ationalize and measure systemic change over time (Heatherington, Friedlander, &
Greenberg, 2005). Generally, SFTs have been shown to be effective (Shadish &
Baldwin, 2003), and controlled studies comparing effectiveness between models have
yielded very little differences on outcomes (Wampold, 2001). Although evidence‐
based practices provide valuable information about the types of modalities that work
for particular clients, or diagnoses, under a particular circumstances (Patterson, Miller,
Carnes, & Wilson, 2007), there is a need for understanding how therapies work rather
than knowing what works (Heatherington et al., 2005).
However, the modest amount of research within these models beg the question: Are
the transgenerational and experiential models still being used? There is no way to know
the popularity of these models, but it seems reasonable that some of the main assump-
tions of these theories—differentiation of self, triangulation, trustworthiness, justice,
loyalty, and anxiety resulting in growth and individual congruence—are still essential to
SFT and have widespread familiarity. As we have stated before, therapists are still very
much interested in how the past issues experienced in the family‐of‐origin and essential
relationships has shown up in current individual behaviors and relationships. Perhaps it
is reasonable, however, to assume that the popularity and exclusive practice of these
theories and models have decreased with the passing of these founders. We feel, how-
ever, that the familiarity of these theories and models is still present in SFT. We also
believe that emphasizing more process‐oriented research would allow for more in‐depth
research that takes into account “local practice experience and systemic wisdom to apply
relevant therapy techniques in a relational and narrative context” (Larner, 2004, p. 33).
The Third Iteration of Theories
It is our belief that theory development is still evolving from the transgenerational and
experiential theories that represent much of our heritage in SFT. The increased focus
of contemporary research on the physiological and neurobiological aspects of emotion
regulation and benefits of mindfulness have expanded the understanding of how family
processes can shape emotions in patterned ways and introduces new possibilities for
intervention. Emotion regulation involves the modulation of the occurrence, duration,
and intensity of internal states of feeling (positive and negative) as well as physiological
processes and is critical for emotional and relational health (Morris, Criss, Silk, &
Houltberg, 2017). Much of what people learn about emotions and emotion regula-
tion derives from their family of origin and become the emotional scripts for how they
interact in current relationships. Although definitions of mindfulness may vary, there
has been mounting empirical support for the importance of cultivating practices of a
nonjudgmental, present‐moment awareness of physiological, emotional, and bodily
experiences (Shapiro & Carlson, 2009). Mindful practice increases a person’s aware-
ness of their own emotional reactivity and allows them the opportunity to respond
more intentionally rather than automatically out of patterned behaviors.
Emotionally focused therapy (EFT) (Johnson, 2004) and restoration therapy (RT)
(Hargrave & Pfitzer, 2011) are two theories that represent the evolution of transgenera-
tional and experiential theories that integrate current research from neuroscience on
understanding how the brain is shaped by systemic relationships and also has patterned
itself into preferred predictable reactions in dealing with emotional pain (Hanna, 2014).
Both of these theories are rooted in the tradition of transgenerational therapies main-
taining that the past and early attachments are key in understanding current emotions
and behaviors. Also, both theories carry on the experiential tradition of working with
these past influences in the here and now as evidenced with the therapist encouraging
relational partners interacting, using interactions and empathy to produce change, and
engaging in role play and imagery for the purpose of fostering client growth and change.
Both theories identify emotion regulation processes of pain as being the key to
break up old patterns and move into new possibilities of change (Baumeister &
Tierney, 2012; Siegel, 2015). Further, both cultivate a mindfulness practice to pro-
duce emotion awareness, flexibility, and regulation that are critical to consolidating
changes and growth both inside the therapy session and eventual habituation when
therapy ceases. In this way, both of these theories maintain insight, understanding,
and connection as part of the therapeutic practice, but explicitly identify emotion
regulation and mindful practice as being the key elements for behavioral and thera-
peutic change (Hanna, 2014; Hargrave & Pfitzer, 2011; Johnson, 2004).
EFT and RT are heavily influenced by attachment theory (Ainsworth, 1967; Bowlby,
1969) and are appreciated much in SFT in understanding how past family‐of‐origin
and attachment relationships play out in current relationships. People and especially
young children are in need of secure attachment figures that provide emotional sup-
port, encouragement, love, and predictability. When these qualities are absent in par-
ents of young children, the result leaves emotional pain in the child, resulting in
detachment, disconnection, frustration, anger, and depression (Ainsworth, 1967;
Bowlby, 1969). Without this emotionally secure base to be fostered by parents, people
grow into adults who carry this same emotional pain or attachment styles as well as
negative reactions into partnering and family relationships negatively affecting con-
nections and relational satisfaction (Johnson, 2004).
Emotion‐focused therapy and emotionally focused couple therapy

Greenberg and Johnson (1988) are key figures in recognizing that the attachment inju-
ries of the past can change as relational partners engage in new and emotionally meaning-
ful experiences in therapy. Greenberg (2002) has been particularly important in the
development of emotion‐focused therapy promoting human growth and change through
individual and couple emotional awareness through experiential opportunities in therapy.
His approach creates opportunities and a therapeutic atmosphere where there is greater
emotional expression, regulation, and understanding. Further, the approach works to

transform emotions and develop empathy as a pathway toward change. One of the most
important contributions of Greenberg has been developing an evidence‐based approach
that focuses on immediate process changes that occur in therapy in order to not only
distinguish the effectiveness of therapy but also track how intermediate and long‐term
changes with individuals and couples occur (Greenberg, 1986).
Johnson (2004) has been the leading advocate and developer of the application of
the emotion‐focused therapy to marital therapy culminating in her work on emotion-
ally focused couple therapy (EFCT). Also, she and colleagues have produced impres-
sive research on the approach not only in effectiveness of marital therapy but also with
issues of trauma and mental health. EFCT is experientially driven, meaning that
insight and healing are produced as the clients experience emotional connection,
become more secure attachment partners, and change their ways of relating (Johnson,
2004). Work is not accomplished by assignments, but rather the practice in the room.
This process is achieved through the therapist initially, but then is broadened to
include the partners in becoming more attached in their relationship as they experi-
ence safe haven with one another.
EFT identifies nine steps in the process of working the experiential process with a
couple (Johnson, 2004). First, the therapist delineates conflict issues in the core of the
struggle by joining, assessing, and being a safe haven. Second, the work turns to iden-
tifying the negative interaction with the couple. Key to EFCT is the observation of
enactment in order to find pursuer–withdrawer patterns as well as tendencies to
under‐ or overregulate emotions. Assessing the unacknowledged emotions underlying
the interactional positions is the third step in EFCT. Much of this work involves the
therapist probing the couple to not only identify the secondary emotions, which most
often have a reactive and behavioral component, but also the primary emotions, which
are more representative of the true feelings. Fourth, the therapist helps the couple by
reframing the problems in terms of negative cycles, underlying emotions, and attachment
needs. Fifth, the therapist helps the couple by making identification of disowned attach-
ment emotions, needs, and aspects of self and integrating these into relationship interac-
tions. This often involves helping the couple recognize how earlier attachment injuries
have affected the senses of identity as well as making needs and wants better known
relationally. As this discovery takes place and is shared, partners may have difficulty
with acknowledging and accepting these emotions of a spouse and move toward
established relational patterns. Therefore, the sixth step in EFCT is to promote accept-
ance of the partner’s experience and new interactional responses. Seventh, the therapist
helps the couple express needs and wants to each other and create emotional engage-
ment. Helping the couple create new solutions to old relational issues is the eighth step
in EFCT. Finally, the therapist works with the couple to consolidate new positions and
new cycles of attachment behaviors in their relationship.
Restoration therapy
RT is a relatively new model of systemic marriage and family therapy developed by
Terry Hargrave and Franz Pfitzer and is heavily influenced by contextual family ther-
apy, attachment theory, cognitive therapy, and mindfulness research. In RT, the thera-
pist sees the primary emotions as relating to identity, which is developed in the context
of how the individual was loved in relationship, and safety, which is developed by the
patterns of trustworthiness found through predictability, openness, and justice

(Hargrave & Pfitzer, 2011).
In RT approach, the therapist is careful to evaluate and assess the client in terms of
identity and safety. Because of the nature of brain function, many dis‐regulated pri-
mary emotions develop a pattern of being likely to occur frequently from childhood
into adulthood. Also, these primary emotions illicit predictable patterns of reactivity
of actions such as blame, shame, control, and escape/chaos. Although this reactivity is
rooted in behavioral actions, they do have secondary emotional artifacts (Hargrave &
Hammer, 2016). Using this framework of predictable primary emotions and resulting
reactivity during emotional dis‐regulation, the RT therapist is able to construct a cog-
nitive map for the client delineating the pain cycle (Hargrave & Pfitzer, 2011). The
focus of therapy then takes the direction of helping clients focus on a self‐regulating
emotional “truth,” or primary reality individuals feel will regulate the previously trig-
gered emotion. This focus goes beyond simple cognitive‐behavioral focus, but also
includes experiential activities, imagery, repetition of regulating emotions, and role
play demonstration with other family members (Hargrave & Pfitzer, 2011). The
intent of such work is to help individuals self‐regulate emotions associated with attach-
ment injuries and emotional pain and not to conflate vertical relationship attachment
issues into horizontal relationship. This does not mean family members or partners do
not engage in emotional and experiential intimacy in therapy; rather RT maintains
that intimacy is most likely to occur when relational partners are regulated and
engaged versus emotional co‐regulation (Hargrave & Hammer, 2016).
RT then focuses the therapy on the relational interactions using the regulating
emotions of the “truth” to promote the individuals to make choices of actions that are
not governed by reactivity, but rather a sense of peaceful choice. This process is also
delineated in a cognitive map called the peace cycle (Hargrave & Pfitzer, 2011). The
RT therapist is then able to utilize both the pain and peace cycles in a mindfulness
practice process called the four steps. In this process, first the clients are taught expe-
rientially to observe when they are emotionally dis‐regulated to slow down the pro-
cess by saying what they feel related to the pain cycle. Second, the clients will say out
loud what they normally do in terms of reactivity when they are triggered by their pain.
Third, clients are encouraged to say their self‐regulating truth out loud to gain the
benefits of previous experiential processing and emotionally regulate themselves
(Hargrave & Hammer, 2016). Finally, clients then integrate the experience by saying
and doing what they want different in terms of actions. These four steps are the mind-
fulness practice piece of RT, which occurs both in therapy and eventually into rela-
tionships and being outside of therapy (Hargrave & Pfitzer, 2011).
Conclusion
From the beginning of therapeutic processes, there has been a focus on early family‐
of‐origin relationships and how the dynamics of interactions and emotions have
shaped individuals in the transgenerational process. Here, we have tried to clearly
articulate how those processes in the transgenerational theories are indeed still alive in
present in therapy, albeit evolved through the experiential therapies and more cur-
rently in the therapies that also integrate the physical and neurobiological dimensions.
We are still focusing on the past in SFT and will do so for a long time to come.
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15
Structural and Strategic
Approaches
Jeffrey B. Jackson and Ashley L. Landers
The structural family therapy and the strategic family therapy approaches are founda-
tional in the field of systemic family therapy due to their emphasis on systemic process
over content and altering family interaction patterns that create, maintain, or exacer-
bate problems. Both approaches offer innovative systemic frameworks for conceptual-
izing how family processes and organization can be both the source of problems and
the solution to them. Despite differences, such as structural family therapy being more
focused on changing problematic family structures through in‐session interventions
and strategic family therapy being more focused on changing problematic perceptions
and associated maladaptive behavioral patterns through between‐session prescriptions
for one or more family members, both approaches are brief and directive in nature and
emphasize joining with family members, assessing family interaction patterns around
problems, and considering contextual factors including life cycle stage. Both also focus
on the present over the past and seek to modify problematic behavioral sequences and
problematic family rules through reframes, paradox, and directives.
In this chapter, we provide the history, development, and the core theoretical and
conceptual constructs associated with problem development and the process of
change for structural family therapy and strategic family therapy. We also summarize
more contemporary developments and applications of each approach. In addition, we
present critiques of each approach, including issues of diversity and sociocultural fac-
tors, and discuss future directions for these approaches.
Structural Family Therapy
Structural family therapy was developed in the late 1960s and early 1970s by Salvador
Minuchin. Through his groundbreaking book, Families of the Slums, Salvador Minuchin
(1967) provided the theoretical framework for what became known as structural family
therapy. A number of key figures have contributed to the advancement of the
theory of structural family therapy including Charles Fishman, Maryanne Walters,
Nancy Boyd‐Franklin, and Harry Aponte, just to name a few. Structural family therapy
340 Jeffrey B. Jackson and Ashley L. Landers
grew from family systems theory as an approach that focuses on the individual within
their social context (Minuchin, 1974). The theory offers a lens from which to assess
families by first understanding and then subsequently changing their organization
(Minuchin, 1974). The theory suggests that when the structure of a family is altered,
the positions of individual family members are shifted accordingly (Minuchin, 1974).
Assumptions
An individual is not an isolate Structural family therapy theory was founded on the
assumption that each individual does not exist in isolation, but rather acts and reacts
as a member of certain social groups, the primary of which is family (Minuchin, 1974).
Individual experiences cannot be separated from the context in which they occur. The
functioning of individual family members differs across their social contexts (Minuchin,
Reiter, & Borda, 2014). All individual experience occurs in interaction with that indi-
vidual’s environment (Minuchin, 1974). The interaction between an individual and
their environment is mutually influential—the individual shapes their environment
and the environment shapes the individual. Minuchin (1974) argued that individuals
must be approached and understood within their familial context (Minuchin, 1974).
Minuchin (1974) suggests that problems attributed to an individual are actually the
problems of the family.
Dysfunctional family structure Minuchin was known to distribute problems among

members of a family rather than allowing any one individual to be scapegoated as the
symptom bearer. Such problems include dysfunctional hierarchy and organization, as
well as poor functioning within subsystems (Minuchin, 1974), for example, reframing
individual psychopathology into a problem of dysfunctional family structure and
poorly functioning subsystems (Minuchin, 1974). While problems are seen as a symp-
tom of the system rather than the individual, their solutions (i.e., change) are also
systemic. The therapeutic goal is to reorganize the structure of the family (Minuchin,
1974). When failed attempts to change an individual are made, turning toward their
family system often proves more fruitful. Structural family therapy offers hope to
families in their efforts to break free from symptoms by helping family members rec-
ognize their part in symptom maintenance. Family members who once felt powerless
over problems ascribed to individuals (e.g., a parent who feels powerless about a
child’s behavioral problems) can be mobilized to adapt their part in the relational
sequence that maintains the problem (e.g., parents altering their parenting and pro-
viding the child with time and attention without the child having to act out).
At the time structural family therapy was born, the systemic notion of viewing the
individual within their context was not necessarily novel. General systems theory had
been used by other disciplines (Minuchin, 1974). However, conceptualizing individual
psychopathology within the family context was a radical shift for the mental health field
(Minuchin, 1974). While many traditional models of mental health treatment grew from
individualistic and linear approaches, structural family therapy brought forth the notion
that an individual’s family plays a significant role in their treatment (Minuchin, 1974).
Internal processes are influenced by their external context A number of central assump-
tions laid the foundation for what became structural family therapy, the first of which
was that an individual’s external context impacts their internal processes (Minuchin,
1974). The context of an individual’s environment, specifically their family, influences
Structural and Strategic Approaches 341
their individual intrapsychic processes (e.g., the development of psychiatric illnesses).

Family plays a significant role in shaping individual development. For example, children
are fed, protected, and taught by their parents (Minuchin, 1974), as infants do not raise
themselves. Along similar lines of thinking, childhood psychosomatic illnesses have been
found to be influenced by the child’s family of origin (Minuchin et al., 1975).
Individuals attend to and enact family stress Building on the notion that an individu-
al’s context influences their internal processes, the second central assumption of struc-
tural family therapy is that often the individual attends to and even enacts their family’s
stress (Minuchin, 1974). For example, a young child may act out in anger reflecting
underlying dysfunction within the family. Individualistic theories might conceptualize
the boy’s anger as temperament or pathology, whereas structural family therapy would
seek to understand the boy’s behavior in the family context. The theory shifts focus
from individual to that individual’s family and societal context, as well as to the feedback
processes that exist between the individual and their context (Minuchin et al., 1975).
Structural family therapy suggests that patterns of a family can serve to trigger or
buffer psychological and physiological processes, and in some instances both
(Minuchin et al., 1975). Minuchin et al. (1975) add that an individual’s psychoso-
matic symptoms serve to maintain homeostasis. At its core, structural family therapy
is directed toward changing family process, specifically those processes that invite or
maintain symptoms (Minuchin et al., 1975). In accordance with this assumption, psy-
chiatric conditions are seen as having been developed or maintained by family struc-
ture, rather than individual psychopathology. It is not that an individual’s family needs
or causes their symptoms, but that psychopathology happens to not only an individual
but also to their family (Minuchin, Lee, & Simon, 2006). In turn, family therapy is
employed to assist the family in coping with what has become their circumstances
(Minuchin et al., 2006).
Family is the vehicle for change production Since family plays a significant role in shap-
ing individual development, in structural family therapy, the family is seen as a vehicle
for producing individual change. This leads directly into the third major theoretical
assumption of structural family therapy, in which changes within the family result in
changes within family members (Minuchin, 1974). Structural family therapy offers a
framework for systemic family therapists that calls attention to the structure and purpose
of family transactions (Nichols & Davis, 2017, p. 111). Grounded in the assumption
that family structure is observed through patterns of interaction between family mem-
bers, structural family therapy offers an accessible “blueprint” of the family by helping
family therapists make sense of “previously puzzling interactions” (Nichols & Davis,
2017, p. 128). Structural family therapy recognizes that the organization of a family
regulates its interactions and that therapy presents the family therapist with an opportu-
nity to observe and modify a family’s relational patterns (Nichols & Davis, 2017).
Major concepts
Structural family therapy has a number of major concepts. Family structure is con-
structed through patterned interactions (Minuchin et al., 2006). In other words, fam-
ily systems operate through transactional patterns (Minuchin, 1974). Families have
rules, roles, and functions (Minuchin et al., 2006). Family rules and roles are at times
unspoken. A workable form of family structure is needed for a family to support its
individual members while also creating bonding and belonging (Minuchin & Fishman,
1981). In order to achieve optimal functioning, families need to take into account each
individual’s developmental changes, deal with cultural expectations, and adapt to their
changing circumstances (Minuchin et al., 2014). Problems occur when families are
unable to adapt to each individual family member’s developmental needs or are unable
to adapt to their external and environmental circumstances. Therapeutic change occurs
when family structure is adapted in response to changing circumstances.
Family structure Patterns of interaction comprise what Minuchin defined as family

structure. Just as a physical building has a structure, so too do families, although family
structure can often be invisible (Nichols & Davis, 2017). As Minuchin (1967) put it,
“family structure can be observed through interactional patterns” (p. 216). Family
structure dictates individual family member functioning by defining what is within the
acceptable range of behavior for that individual and how they interact with other family
members (Minuchin & Fishman, 1981). In this way, family structure is defined as “the
invisible set of functional demands that organizes the ways in which family members
interact” (Minuchin, 1974, p. 51). As Minuchin (1974) suggested, “repeated transac-
tional patterns of how, when, and to whom to relate … underpin the system” (p. 51).
For example, when a parent tells his/her child to engage in a behavior (e.g., brush
your teeth) and the child obeys, that is a transactional pattern that defines their par-
ent–child relationship (Minuchin, 1974). Transactional patterns, including communi-
cation, help to regulate the behavior of individual family members (Minuchin, 1974).
Hierarchy, power, and alliance Family structure is expressed through action and
observed in interactional patterns (Minuchin, 1967). Family structure can be observed
in the patterns of transactions between family members, which include hierarchy,
power, and alliances (Minuchin, 1967). Hierarchy is another important aspect of fam-
ily organization (Minuchin et al., 2006). Depending on the circumstances, hierarchy
can be both necessary and useful to families (Minuchin et al., 2006). When family
members find themselves in disagreement with one another, hierarchy can be used to
settle issues (Minuchin et al., 2006). Hierarchy has to do with which subsystems exer-
cise power over others, the ways or style in which power is exercised, and how it is
received within the family (Minuchin et al., 2006). Power has been described as
“influence” or “force” (Aponte, 1976; Aponte & VanDeusen, 1981; Boyd‐Franklin,
2003). Aponte (1976) explains that power is “the relative influence of each member
on the outcome of an activity” (p. 434).
Subsystems Family systems are composed of various subsystems (Minuchin et al., 2006).
Each individual is “a subsystem” of the family. Subsystems can be formed by gender
(e.g., mother and daughter, father and son; Minuchin, 1974; Minuchin et al., 2014).
Subsystems can be formed by generation (e.g., children versus adults), interest, or
function (Minuchin, 1974). For example, siblings have been described as having “their
own world,” which often excludes their parents (Minuchin et al., 2014, p. 50). Even
older siblings may exclude younger siblings (Minuchin et al., 2014). Subsystems can
also be formed by blood and history (e.g., your children versus our children; Minuchin
et al., 2006). Families have a number of subsystems including those that are spousal,
parental, sibling, and extended. While subsystems can be viewed as a strength, they can
also be a source of stress for families (Minuchin et al., 2014).
Boundaries Subsystems can be “thought of as being surrounded by boundaries of

varying permeability” (Minuchin et al., 2006, p. 35). Boundaries are the rules that
define “who participates, and how” (Minuchin, 1974, p. 53). They can be thought of
as ranging from diffuse to rigid. For illustration, if a parent is particularly close to their
child, the boundary between them is permeable or diffuse. In contrast, if a parent
lacks closeness and connection to their child, the boundary between them is rigid.
Boundaries exist along a continuum ranging from enmeshed to disengaged (Boyd‐
Franklin, 2003). Enmeshed relationships are typically characterized by diffuse bounda-
ries (Minuchin, 1974). Enmeshment is typically thought of as an entangled
relationship. It involves closeness to the point of being overly involved. In contrast,
disengaged relationships are defined by rigid boundaries (Minuchin, 1974) that
restrict family members from connecting. Building on Minuchin’s ideas, the
circumplex model introduced the concept of cohesion. Cohesion is defined as the
sense of togetherness within a relationship. It reflects the bonds between family
members (Olson, 2000).
Alignment In addition to boundaries, other aspects of family structure such as align-

ment is brought forth by structural family theory. Alignment is defined as the “joining
or opposition of one member of a system to another in carrying out an operation”
(Aponte, 1976, p. 434). Aponte and VanDeusen (1981) suggest that some of the
dimensions of alignment include alliance and coalition. Alliance refers to “the patterns
of family members working together on something of shared interest” (Boyd‐Franklin,
2003, p. 207). At times, the affiliations of different subsystems develop into coalitions
wherein members of a family join in an effort against another family member
(Minuchin et al., 2014). Coalition is the process wherein members of a family join
together to take action against another family member (Aponte & VanDeusen, 1981;
Boyd‐Franklin, 2003). Coalitions are also known as triangles. For example, when one
parent unites with a child in coalition against the other parent, this is called a cross‐gen-
erational coalition (Minuchin, 1974). Cross‐generational coalition or triangulation is
a sign of dysfunctional family structure, often reflecting discord or a rift within the
parental subsystem that has been invaded by a child. Also cross‐generational coalitions
reflect some level of weakness within the parental subsystem and are not functional to
children (e.g., who may be fighting their parent’s battles, rather than getting to be a
child). Minuchin (1974) warns therapists to pay attention to instances of cross‐gen-
erational coalitions where children enter into the parental subsystem even though
they do not belong. Structural family therapy provides a window into a family’s struc-
ture, by inviting therapists to assess for alliances, coalitions, or triangles, and the types
of boundaries that exist between family members (Minuchin, 1974).
Theoretical updates
One of the greatest expansions of structural family therapy has been offered by Boyd‐
Franklin (1989, 2003) in her work with black families. Boyd‐Franklin (2003) sug-
gests that structural family therapy helps to assess family structure and identify areas
of difficulty or dysfunction and then moves to restructure the family in ways that
bring about change (Boyd‐Franklin, 2003). Boyd‐Franklin (2003) indicates that
structural family therapy is somewhat unique in that it was developed rather than
adapted to work with diverse minority families. Through helping families “clarify and
prioritize” their problems (Boyd‐Franklin, 2003, p. 205), structural family therapy

empowers families. As a family’s problems are solved, they are restructured (Boyd‐
Franklin, 2003).
Structural family therapy was developed for underserved minority families. At its
core, the theory was built for diverse families from varying racial, ethnic, and cultural
backgrounds, socioeconomic statuses, gender identities, and sexual orientations.
Minuchin and Fishman (1981) defined couples in a broad and inclusive manner, high-
lighting that couple relationships need not be legal to be significant—as family therapy
concepts are applicable to families that identify as sexual minorities (Luepnitz, 1988).
Structural family therapy is applicable to all families, not just heterosexual families
(Luepnitz, 1988). Although Minuchin was much more interested in what was happen-
ing inside of families, he never neglected what happened outside. He called attention
to society, culture, and context. Minuchin (1974) argued that studying the family also
required study of their relationship to their surrounding societal context. Furthermore,
Minuchin (1974) claimed, “the family will change as society changes” (p. 49). One of
the strengths of structural family therapy is its interest and attention to the sociopoliti-
cal context of the family (Luepnitz, 1988). In this way, structural family therapy has
international merit in its application across countries and contexts.
Structural family therapy is primarily grounded in the notion of problem solving
(Boyd‐Franklin, 2003). It is a “clear, concrete, and directive” approach to working
with families (Boyd‐Franklin, 2003, p. 205). It is through its present and future focus
that structural family therapy shifts families away from hashing through the past and
getting stuck in cycles of shame (Boyd‐Franklin, 2003). Boyd‐Franklin (2003) sug-
gests that through problem solving, structural family therapy offers systemic family
therapists a way to initially engage black families in the therapeutic process. Boyd‐
Franklin (2003) also goes on to suggest that structural family therapy is helpful for
families with complex multiple problems, many of whom may present as overwhelmed
with managing a cascade of life’s problems.
Boyd‐Franklin (1989) expanded upon Minuchin’s earlier explanations of the par-
entified child. Through the application of a cultural lens, Boyd‐Franklin suggests that
the parental child is of common occurrence in black communities. Older children are
invited, and even expected, to carry out parental responsibilities for their younger
siblings (Boyd‐Franklin & Bry, 2000). In other words, older children are often paren-
tified and expected to function at sometimes advanced levels, which may be similar to
adults. Such children often caretake for the younger members of their family (Boyd‐
Franklin & Bry, 2000). Parental children are often the advent of “working mothers,”
“latchkey children,” and the “economic instability” of minority families (Boyd‐
Franklin, 1989, p. 76). She goes on to say, “the need for all members of the house-
hold to contribute in some way to the family’s support is and always has been a very
pressing reality” for many minority families (Boyd‐Franklin, 1989, p. 76). Structural
family therapy lends a way to understand the function or dysfunction of parentified
children. Boyd‐Franklin (1989) suggests that a parentified child only becomes a dys-
functional family structure when the parents relinquish their parental responsibilities
by placing excessive demands on the child. She explains how overburdened parents
may tend to overburden their children, as a result of need. The dynamic of the paren-
tified child runs the risk of robbing the child of age‐appropriate responsibilities, by
alienating the child from their younger siblings, and putting too much distance
between the parent(s) and their other children (Boyd‐Franklin, 1989).
While Boyd‐Franklin offers a critical update to structural family therapy, this is not
enough. As structural family therapy evolves, so too should its writings. While
Minuchin’s more recent texts (Minuchin et al., 2006, 2014) offer additional applica-
tions of structural family therapy, his original writings (Minuchin, 1967, 1974) offer
the clearest indications of the theory’s assumptions and concepts. It is imperative that
today’s structural family therapists continue to broaden and update Minuchin’s writ-
ings. While some scholars have implied that the model applies to diverse families (e.g.,
Boyd‐Franklin; Luepnitz), few have written explicit applications of the model to fami-
lies across countries and continents in more recent years (e.g., in the age of technol-
ogy, immigration, widening life cycle, etc.).
Structural family therapy critiques

Structural family therapy came to be a new way of treating psychiatric conditions
(Minuchin et al., 2006). It was radical in depathologizing psychiatric illnesses
(Minuchin et al., 2006). The initial thinking was that “Schizophrenics were not crazy
… they were simply adapted to a crazy interpersonal context” (Minuchin et al., 2006,
p. 62). However, while such thinking depathologizes the identified patient, it runs
the risk of pathologizing or blaming the family (Minuchin et al., 2006). While the
notion that psychiatric conditions are developed or maintained by family structure, as
opposed to individual psychopathology, frees many individuals from self‐blame and
stigma, it also runs the risk of redirecting blame toward the family of origin. Part of
the theory’s application involves reframing the problem in relational rather than indi-
vidual terms. Such reframes are not expected to be initially well received, but when
done well they can remove or reduce blame from being placed on any one individual
to identify how problems are maintained relationally. As with many of the founda-
tional theories of family therapy, over time, structural family therapy has moved away
from language that suggested that families cause individual psychopathology into lan-
guage that allows family members to see how psychopathology is at the very least
maintained by family structure.
Structural family therapy has been critiqued for the therapist assuming responsibil-
ity for change, therefore, giving too much authority, directedness, and responsibility
to the therapist (James & MacKinnon, 1986). While, at times, structural family ther-
apy has appeared to clash with postmodern approaches (e.g., narrative family ther-
apy), such models are not mutually exclusive. It is possible to employ a directive
stance of attending to the structure of a family while also recognizing that family
members are the experts of their own experience. When structural family therapy
encourages the therapist to be active in the therapy session, this has been critiqued for
making the therapist too centered in the therapeutic process.
Research on structural family therapy theory

Research studies exploring the theory of structural family therapy have been con-
ducted, many of which suggest the important role of the family in the onset and
maintenance of psychosomatic illnesses. Minuchin and colleagues (1975) developed
an interdisciplinary research project to explore the aspects of family structure and fam-
ily functioning that were associated with children’s psychosomatic illnesses (e.g.,
a norexia nervosa, superlabile diabetes, intractable asthma). The majority of children

who received pediatric family therapy demonstrated improvements or remission of
their psychosomatic symptoms. Minuchin et al. (1975) suggested that the systems
model of psychosomatic illness allowed the therapists to conceptualize the illness
within the context in which it was initiated and maintained. In this work, Minuchin
et al. (1975) illuminated how children’s choice of symptoms, their precipitating event,
and maintenance were all connected to family structure and functioning. They found
that structural family therapy modified the family and the life context of the child
appeared to achieve and sustain remission faster than individual treatment (Minuchin
et al., 1975). They conclude that family structure, organization, and functioning can
predispose children to particular psychosomatic illnesses, which can be successfully
addressed through pediatric systemic family therapy. Since the outset of structural
family therapy, the theory has found to be effective in the treatment of psychosomatic
disorders, conduct disorders, substance abuse, eating disorders, and chronic illnesses
(Sandberg et al., 1997).
In addition, basic research supports the validity of the assumptions of the theory of
structural family therapy, specific to family coalitions or triangles and hierarchy.
Minuchin (1974) suggested that triads or triangles require restructuring. He pro-
vided an illustration in Families and Family Therapy (1974) wherein he suggested that
triangles often occur when one parent joins their child in a coalition against the other
parent. Structural family therapy suggests that triangles serve a dysfunctional role for
many families. This notion is supported by research that suggests that in triangulated
families, parents report increased marital conflict and dissatisfaction, whereas their
children report more interparental conflict and overall negative family affect com-
pared with non‐triangulated families (Kerig, 1995). Falicov (1998) explains that
“symptoms of family distress” have historically been linked to triangles (p. 37).
Research supports Minuchin’s ideas. While triangulation diminishes the parent–child
relationship (Fosco & Grych, 2010), it also places youth at greater risk for internal-
izing problems (Buehler & Welsh, 2009), particularly depression (Wang & Crane,
2001). Some scholars have even found that triangulation mediates the relationship
between parental conflict and internalizing and externalizing behavior problems
(Grych, Raynor, & Fosco, 2004).
Research suggests that the families of individuals addicted to heroin were more
likely to display issues related to family hierarchy; in particular, in such families, the
children were considered equal in hierarchy to their parents (Madanes, Dukes, &
Harbin, 1980). Correspondingly, research has shown a connection between chil-
dren’s psychopathology and family hierarchy reversals, in which assaultive adolescents
were more likely to come from families with a reversal of generational hierarchy
(Madden & Harbin, 1983). Along similar lines, boys with conduct disorder were
more likely to come from families with dysfunctional hierarchy reversals (i.e., where
the child is either equal or higher in hierarchy than their parent(s); S. M. Green,
Loeber, & Lahey, 1992). More recently, family structure (specifically hierarchy) has
been associated with children’s eating behaviors (Hasenboehler, Munsch, Meyer,
Kappler, & Vögele, 2009).
The Circumplex Model is a graphical representation of structural family theory.
The Circumplex Model focuses on three dimensions of the family system, specifi-
cally cohesion, flexibility, and communication (Olson, 2000; Olson, Russell, &
Sprenkle, 1989). The model suggests that a balanced level of cohesion and adapt-
ability is essential to family functioning (Olson, Sprenkle, & Russell, 1979). The
model allows for relational assessment (Olson, 2000) of many of the core compo-
nents of structural family therapy. The model suggests that healthy or functional
families have balanced levels of cohesion and flexibility (Olson, 2000). While Olson
(2000) suggests that families with balanced structure will display more functional
or adaptive communication, such findings are supported by research (Barnes &
Olson, 1985; Rodick, Henggeler, & Hanson, 1986). In contrast, unbalanced fami-
lies are more likely to have members exhibiting psychopathology (Carnes, 1989;
Clarke, 1984).
The future of structural family therapy

The future of structural family therapy is at an unprecedented crossroads given
Minuchin’s passing in 2017. Although the theory is more than its creator, it is hard
to envision the future of structural family therapy without Minuchin at the helm, and
his imprint on systemic family therapy leaves no small space to fill. We take comfort in
thinking that his legacy will continue to bring forward new ideas in the years and
decades to come, and we would like to think that the continued evolution of struc-
tural family therapy would make Minuchin proud.
The field of systemic family therapy has expanded, and many, if not all, of the sys-
temic approaches have continued to be developed and advanced by the next genera-
tion of key proponents. As the volume and quality of systemic family therapy research
continues to improve, many of our foundational models, particularly structural family
therapy, would benefit from additional theoretical testing. The results of clinical out-
come research suggest that structural family therapy may be an effective treatment for
anorexia nervosa (Eisler et al., 1997; Eisler, Simic, Russell, & Dare, 2007) and bulimia
nervosa (le Grange, Crosby, Rathouz, & Leventhal, 2007; Schmidt, Lee, Beecham,
et al., 2007), as well as children who suffer from asthma (Gustafsson, Kjellman, &
Cederblad, 1986; Lask & Matthew, 1979) and attention deficit hyperactivity disorder
(Barkley, Guevremont, Anastopoulos, & Fletcher, 1992). Although many empirically
validated systemic family therapy approaches use structural family therapy concepts
and interventions (e.g., ecosystemic structural family therapy, emotionally focused
therapy, functional family therapy, multisystemic family therapy, multidimensional
family therapy, structural–strategic family therapy), clinical treatment outcome
research is needed for identifying when structural family therapy works, and clinical
process research is needed for identifying what is “at work” within the model. Will
structural family therapy become more manualized and tested across contexts? Only
time will tell.
Strategic Family Therapy
Strategic family therapy is a brief approach designed to help families extricate them-
selves from distressing entrenched interactional patterns through targeted strategies
that change thoughts, behaviors, or both. Strategic family therapy has its genesis in
the pioneering work that started coming out of the Mental Research Institute (MRI)
in Palo Alto, California, in the 1950s. Don Jackson, the founder of MRI, assembled
a team of scholars and researchers including Paul Watzlawick, John Weakland, Jay
Haley, William Fry, Virginia Satir, Richard Fisch, Arthur Bodin, and Jules Riskin
(www.mri.org). Their efforts to integrate (a) Ludwig von Bertalanffy’s groundbreak-
ing work on general systems theory, (b) Gregory Bateson’s approach to cybernetics
(e.g., homeostasis, feedback loops, circular causality), (c) Milton Erickson’s clinical
applications of indirect hypnosis (i.e., hypnotic induction without trance), (d) com-
munication theory, and (e) constructivism led to the development of interactional
theory and conjoint family therapy, also commonly referred to as MRI brief therapy
and more generally as strategic therapy (Ray, 2007). In turn, this novel approach to
therapy led to the formation of other strategic approaches developed by the Milan
group (i.e., Luigi Boscolo, Gianfranco Cecchin, Giuliana Prata, and Mara Selvini‐
Palazzoli; Milan systemic) and Giorgio Nardone (Brief Strategic), the integrated
structural‐strategic approaches developed by Jay Haley (strategic), Cloé Madanes
(humanistic strategic), Duncan Stanton (structural‐strategic), and José Szapocznik
and colleagues (brief strategic family therapy), as well as the human validation process
model developed by Virginia Satir and solution‐focused brief therapy developed by
Steve de Shazer and Insoo Kim Berg.
Although all of the strategic approaches (i.e., MRI, Milan group, Haley, Madanes,
Nardone, Stanton, and Szapocznik) differ from one another on varying levels, they all
share commonalties in terms of core theoretical concepts and principles. In an effort
to provide an overview of strategic family therapy, the following sections focus on the
commonalities across the strategic approaches, with more weight given to more con-
temporary strategic approaches. A brief summary of the unique aspects of each strate-
gic family therapy approach is provided toward the end of the chapter.
Strategic therapy concepts

Knowing through changing Whereas most psychotherapy approaches operate on the
assumption that insight leads to change (changing through knowing), strategic therapy
operates on the assumptions that (a) change precedes insight (knowing through chang-
ing), (b) insight may or may not occur as a result of change, and (c) insight is not
necessary for change (Nardone & Portelli, 2005). Instead, having corrective emotional
experiences (i.e., inductive breakthroughs producing an illumination that short‐cir-
cuits the entrenched cognitive and behavioral patterns maintaining the problem, and
produces affective responses that disconfirm the effectiveness of those patterns) that
chip away at the perceived problem is what facilitates change (Nardone & Salvini,
2007). Relatedly, in most approaches, problem etiology assessment is determined
before treatment (changing through knowing); in strategic therapy, however, client
response to interventions facilitates the assessment of the problem and how it func-
tions (knowing through changing; Nardone & Balbi, 2015).
Consequently, instead of helping clients change through increased insight or psy-
choeducation as is the case in most psychotherapy approaches, strategic therapy
intervention is aimed at interrupting the mechanisms maintaining the problem to
provide corrective emotional experiences, overcoming ambivalence about change
typical among clients, and increasing self‐confidence in self‐competence (Nardone,
Milanese, & Verbitz, 2005). As such, the focus of strategic therapy is on identifying
what maintains the problem, not the underlying causes of the problem (Nardone &
Portelli, 2005).
Attempted solutions Strategic therapy takes a strengths‐based approach to viewing

clients as competent people who generally have the skills necessary to manage prob-
lems they encounter. Occasionally, people mishandle problems by employing skills
with limited variation (i.e., first‐order change, or a change in behavior within a narrow
set of related behaviors) to manage problems that inadvertently maintain or even
exacerbate the problem (i.e., doing more of the same makes the problem worse;
Watzlawick, Weakland, & Fisch, 1974). These attempted solutions people use to
manage their problems may actually become the more serious problem if they main-
tain or exacerbate the original problem (Nardone & Balbi, 2015), such as parents
trying to manage a disrespectful and disobedient teenager by criticizing, yelling, or
resorting to physical violence.
Attempted solutions are the reactions (typically behaviors) people use to manage
internal and interpersonal difficulties that tend to result in rigid repetitious dysfunc-
tional patterns that complicate, rather than solve, the problem (Nardone & Salvini,
2007; Watzlawick, & Weakland, 1977). By the time families seek therapy, the
attempted solutions have often become the problem: the cure becoming the disease
(Fisch, Weakland, & Segal, 1982). Consequently, assessing what clients have tried so
far to solve the problem (what the attempted solutions are) is critical in the strategic
approach (Nardone & Watzlawick, 2005).
In families presenting for therapy, the rules governing the system tend to be overly
rigid, and the range of acceptable behaviors too limited (Selvini Palazzoli, Boscolo,
Cecchin, & Prata, 1978). Nonverbal behaviors such as interactional patterns and
behavioral transaction sequences provide information about the attempted solutions
and the rules that govern the system. Family members’ attempted solutions often
serve to maintain systemic homeostasis (i.e., tendency toward equilibrium and stability
and resistance to change) and can also serve as indicators of problematic implicit rules
governing the system (Boscolo, Cecchin, Hoffman, & Penn, 1987). In these instances,
shifts in perceived reality, system rules, and family interactional patterns are likely nec-
essary to facilitate lasting desired change, referred to as second‐order change (i.e., sub-
stantive changes in the function, organization, rules, and contextual orientation of a
family system that produce stable modifications in interactional patterns between fam-
ily members), which is typically the long‐term goal of therapy (Haley, 1987; Selvini
Palazzoli, Cirillo, Selvini, & Sorrentino, 1989). For additional information on sys-
tems theory concepts and their contemporary application, see Chapter 5 (vol. 1), of
this handbook by Wittenborn, Hosseinchimeh, Rick, and Tseng (2020).
Perceptive–reactive system One of the underlying assumptions that set strategic ther-
apy apart from other approaches at the time of its inception was the constructivist
position that reality is perception based: “All purposeful human behavior depends
greatly on the views or premises people hold, which govern their interpretations of
situations, events, and relationships” (Fisch et al., 1982, p. 5). Additionally, from the
outset, strategic therapists also believed that our “ideas of reality are delusions which
we [repeatedly confirm by] trying to force facts to fit our definition of reality instead
of vice versa. And the most dangerous delusion of all is that there is only one reality”
(Watzlawick, 1976, p. xi). In fact, strategic therapy, particularly the Milan systemic
approach, is often viewed as the approach that bridged the modern approaches (i.e.,
truth is objective, reality is observable, and the therapist is positioned as the expert)
to the postmodern approaches (i.e., there are coexisting multiple truths, reality is
constructed, and clients are the experts on their experiences) by proposing that thera-
pists are experts in facilitating change and clients are experts on their experience and
perceptions (Mills & Sprenkle, 1995). Endorsing a stance that there are no right or
wrong ways of behaving allows for different people to have differing reactions to simi-
lar situations, such as a parent experiencing relief that their teenager does not get
invited to parties hosted by peers perceived as troublemakers while the teenager feels
sad about being excluded from the parties because the same peers are perceived as
popular. Furthermore, in strategic therapy, only behaviors that are distressing to cli-
ents are targeted (Watzlawick et al., 1974).
Our perception of reality, to which we react through our behavior, is constructed
based on our observations and the language we use to communicate our perception
of reality (Nardone & Balbi, 2015). The perceptive–reactive system is the recursive
reinforcing interplay between our perceptions of and our reactions to our own reality
(Watzlawick, & Weakland, 1977). It is important for strategic therapists to determine
the perceptive–reactive system maintaining the problem, in which the perception of
reality is typically based on self‐deceptive non‐ordinary logic to which the reactive
response is typically the attempted solution (Nardone & Watzlawick, 2005):
A person who has the illusion of fighting a problem with a functional solution and, pre-
cisely because it is good, persists in applying it until it becomes a permanent scenario. A
person suffering from OCD performs his ritual because he believes that in doing so he is
reducing his anxiety and that the ritual works, and he is considering it as the solution to
his fear; but repeated over time, the ritual becomes the real problem. (Nardone & Balbi,
2015, p. 74)
For example, the more people perceive something or someone as anxiety‐provoking

(e.g., social situations, test taking, a boss at work, a critical family member), the more
likely the reaction (attempted solution) will be to avoid or to ask for help; the more
people avoid or ask for help in an effort to manage the thing or person they fear, the
more the fear tends to increase as opposed to decrease; the greater the fear, the greater
the perceived need to avoid or ask for help; the greater the perceived need to avoid or
ask for help, the greater the fear; and so on and so forth. Therefore, attempted solu-
tion of avoiding or asking for help has become the problem because it has a paradoxi-
cal effect of augmenting the fear instead of reducing it. Figure 15.1 provides a visual
representation of the perceptive–reactive system.
A perceptive–reactive system based on non‐ordinary logic tends to result in self‐
fulfilling prophecy outcomes that reinforce the use of the attempted solution. For
Family
Perception member Reaction
A
Figure 15.1 The interaction of the perceptive–reactive system of one family member.
instance, a woman who is worried her boss thinks she is incompetent because she has
made some mistakes on important things at work (perception) avoids asking her boss for
clarification on an assignment in an effort to prove her competency (reaction and
attempted solution) that results in several mistakes because she did not get clarification,
increasing the likelihood that her boss thinks she is incompetent. Furthermore, given the
nonlinear premises of non‐ordinary logic, the paradox (see section on prescriptions) that
incorporates similar non‐ordinary logic premises (i.e., fighting fire with fire) tends to be
more effective than trying to use logic to convince clients to abandon their perception of
reality. An example of using paradox that incorporates similar non‐ordinary logic prem-
ises of the woman who worries her boss thinks she is incompetent would be to prescribe
the following: In the morning while you are getting ready for work, I want you to think
about the day ahead of you and I want you to imagine everything that you might mess up,
every mistake you might make. Then write them down. Then in the evening before you go to
bed, review your list and see which mistakes you made (Nardone & Balbi, 2015).
In addition to understanding the perceptive–reactive system of individual family
members, it is also important for systemic family therapists to understand how those
systems are interconnected (Nardone, Giannotti, & Rocchi, 2007). Figure 15.2 pro-
vides a visual representation of the interaction that occurs between the perceptive and
reactive systems of individual family members, such that family members’ reactions to
internal perceptions influence the internal perceptions of other family members.
Families are rule‐governed systems best understood in context. Because family mem-
bers react to information in the context of relationships and social interaction, it is
important to take clients’ contexts (i.e., age, class, culture, disability, ethnicity, gender,
nationality, race, religion, spirituality, sexual orientation, and current situation), as
well as relationship interaction patterns, into consideration when assessing the percep-
tive–reactive systems of each family member (Madanes, 1981).
In addition, a central tenet of communication theory that informs strategic therapy
is that family members cannot not communicate, suggesting that all behaviors, even
silence and withdrawal, communicate something in the context of family relationships
(Watzlawick, Bavelas, & Jackson, 1967). Communication is conceptualized as having
two core elements: digital communication consisting of verbalized words (content)
and analogic communication consisting of nonverbal symbolism and meaning through
behaviors such as facial expressions, inflections, and tone of voice (process) that
Family Family
Perception member Reaction Perception member Reaction
A B
Figure 15.2 The interaction of the perceptive–reactive systems of two family members.
rovide interpretation for the content (Haley, 1987). For example, an exchange
p
between family members with one person saying “Thanks a lot!” and the other person
responding “You’re welcome!” may communicate very different messages if the tone
of voice is warm and inviting versus harsh and sarcastic. As such, it is important to
evaluate communication patterns between family members when assessing for the
interactions between the perceptive–reactive systems of individual family members
(Nardone et al., 2007; see Figure 15.2).
Consider the following example of the self‐fulfilling prophecy nature of the percep-
tive–reactive system in a straight couple in which the husband is obese and struggles
with binge eating. The husband perceives binging as the problem; his associated reac-
tion is the attempted solution of restricting to compensate for binging (Nardone
et al., 2005). The wife also perceives binging as her husband’s problem; her associated
reaction is the attempted solution of trying to help her husband avoid binging by say-
ing things like “Don’t you think you’ve already had enough to eat?” “What you’re
eating isn’t a part of your diet.” “You need to take better care of yourself and your
health.” Paradoxically, (a) the more the husband tries to avoid binging by restricting,
the more he binges, and (b) the more he tries to maintain control over binging, the
more he loses control over binging (Nardone et al., 2005). Similarly, the more the
wife tells her husband to stop binging, (a) the more he perceives her as controlling
and continues binging to resist feeling controlled by her, and (b) the worse he feels
about himself, and the worse he feels, the more he comforts himself through binging.
Thus, the wife’s attempted solution creates a lose‐lose situation for the husband:
either he allows himself to be controlled by his wife or continues binging. Consequently,
the perceptive–reactive system of both the husband and the wife actually maintain the
problem, despite their efforts to ameliorate the problem.
Resistance Perhaps what sets strategic therapy apart from other psychotherapy
approaches the most is the conceptualization and utilization of resistance. Instead of
viewing resistance negatively, in strategic therapy, resistance is seen as a primary key to
unlocking the barred doors to more effective solutions (Fisch et al., 1982). The very
resistance that maintains the problem and holds clients hostage can be redirected to
set clients free by reducing the problem or eliminating it altogether (Watzlawick et al.,
1974). Therefore, to some extent, strategic therapy is a kind of therapeutic jujutsu (a
Japanese form of martial arts that uses opponents’ strength and force against them)
that uses strategies to harnesses the resistant nature of problems (homeostasis) against
themselves to shift away from rigid and entrenched perceptive–reactive systems.
Strategic therapy strategies

Thinking outside the box is a key strategy for changing the self‐imposed problematic rules
that influence the perceptive–reactive system. It is typically challenging to think outside
the boxes of our own lives: “One cannot obtain full visual perception of one’s own body
(at least not directly), because the eyes, as the perceiving organs, are themselves part of
the totality to be perceived” (Watzlawick et al., 1974, p. 25, footnote). Consequently, as
one who is more removed from the lives of the clients, the role of the therapist is to pro-
vide strategies that are outside the box that will help clients move outside the box.
In strategic therapy, not only is the therapist an expert and a consultant, but the thera-
pist is also responsible for developing strategies to help clients resolve their p roblems
(Madanes, 1981). Strategies are designed and prescribed to lower distress by helping
clients (a) view their situation differently (changing the perceptive portion of the percep-
tive–reactive system) and (b) find different solutions (changing the reactive portion of
the perceptive–reactive system). It is important that therapists assess for the attempted
solutions and their efficacy and avoid using more of the same type of solutions with the
clients; relatedly, therapists should similarly avoid doing more of the same attempted
solution behaviors in which family members and friends have engaged to try to shift
problem behaviors. To provide clients with emotionally corrective experiences that help
unblock faulty perceptive–reactive systems, therapists can intervene either (a) on the
faulty perception aspect of the perceptive–reactive system using reframes to help clients
think differently or (b) on the problematic reaction aspect of the perceptive–reactive
system (i.e., the attempted solution) using prescriptions to help clients behave differently.
Reframing Reframing is one strategy for shifting the perceptive–reactive system

maintaining the problem and promoting second‐order change:
To reframe, then, means to change the conceptual and/or emotional setting or view-
point in relation to which a situation is experienced and to place it in another frame
which fits the “facts” of the same concrete situation equally well or even better, and
thereby changes its entire meaning. (Watzlawick et al., 1974, p. 95)
Fostering reinterpretations that yield different feelings, behaviors, or understand-

ing, including problematic views of self and others, can alter the perceptions in the
perception–reaction system. Furthermore, providing new interpretation to entrenched
problematic behaviors can result in new behaviors that fit the new interpretation.
Reframing problems from negative to positive through strategies such as authorizing
the retention of problems as helpful or necessary (dangers of improvement), or exag-
gerating the importance or seriousness of problems through hyperbole, can have a
paradoxical effect that leads to the reduction or elimination of the problem (Fisch
et al., 1982; Madanes, 1981; Mozdzierz, Macchitelli, & Lisiecki, 1976).
A common type of reframe strategy for families is to reframe the motivations behind
family members’ behaviors. Returning to the example of the husband who struggles
with obesity and binge eating, one way to disrupt the husband’s perceptive–reactive
system (i.e., perception = binging is the problem; reaction = attempted solution of
restricting to compensate for binging) is to shift his perception of binging as the prob-
lem and restricting as the solution by reframing restricting behavior as the problem to
be feared since it precipitates losing control and binging behavior: Every time you diet
or fast, you are preparing your next binge and your next loss of control (Jackson, Pietrabissa,
Rossi, Manzoni, & Castelnuovo, 2018). In addition, positively reframing the problem
can help family members establish a more positive atmosphere in session and at home,
as well as adopt new perspectives and new possibilities (Sherman & Fredman, 1986).
Prescriptions Another set of strategies associated with strategic therapy are prescrip-
tions. Prescriptions are therapist‐created directives that, if followed precisely by clients
outside of session, generally lead to solutions that are different from the attempted
solutions. In turn, these different solutions create corrective emotional experiences
that disrupt the perceptive–reactive system. There are three types of prescriptions:
direct, indirect, and paradoxical.
Direct prescriptions tend to be effective in circumstances of minimal resistance (the

minority of cases), indirect prescriptions tend to be effective in circumstances of mod-
erate resistance, and paradoxical prescriptions tend to be effective in circumstances of
high resistance (Nardone & Watzlawick, 2005). Direct prescriptions are instructions
to perform specific logical behaviors to reduce the problem or the stress related to the
problem in instances in which the problem may be difficult to resolve. Indirect pre-
scriptions are instructions with covert objectives that yield results that differ from what
is specified, often by shifting focus from the presenting problem to a secondary prob-
lem, thereby bypassing defenses and resistance. Instead of bypassing resistance, para-
doxical prescriptions harness resistance to create corrective emotional experiences.
Paradox is “a contradiction that follows correct deduction from consistent premises”
(Sherman & Fredman, 1986). The more resistant the perceptive–reactive system is, the
more helpful paradox can be in creating corrective emotional experiences. Paradoxical
prescriptions are instructions that help clients perform voluntary actions that they view
as involuntary; to be effective, these prescriptions need to be carefully formulated and
presented repeatedly through hypnotic language (Nardone & Watzlawick, 2005).
Win‐win outcomes are a benchmark that can be helpful in crafting paradoxical pre-
scriptions. For example, prescribing the problem sets up the following win‐win out-
comes: following the prescription shows some level of control over the problem as it
was enacted intentionally, and a willingness to comply with the therapist; not follow-
ing the prescription also shows control over the problem and results in a reduction in
the problem. Common paradoxical prescriptions are presented in Table 15.1.
Engaging in behavior that is 180° different from attempted solutions is another
common paradoxical prescription. For instance, take the case of a mother and daugh-
ter who come to therapy because they have tried everything they can think of to have
a closer, more meaningful relationship, but still feel distant from and conflictual
toward one another. If the therapist were to ascertain that the attempted solution was
trying to figure out ways to improve the relationship, instead of using a host of com-
mon relational interventions to help the clients improve their relationship (more of
the same), the therapist could prescribe that the clients generate a list of things that
they could do to intentionally worsen their relationship: In the morning when you
wake up, think to yourselves, “If I wanted to voluntarily worsen my relationship with my
mother/daughter today, what could I do or not do, think or not think, say or not say?”
Write them down and then go about your day (Nardone & Portelli, 2005). Creating
Table 15.1 Common paradoxical prescriptions.

Practicing the problem to improve problem proficiency
Worsening the problem
Doing more of the same
Pretending to have the problem
Forbidding what is already not being done
Restraining change if there are signs of changing (go slow to go fast)
Encouraging postponement or inaction
Acting as if the problem no longer existed by doing one thing that would be different
Predicting the return of the problem
Note. Summarized paradoxical interventions are based on the work of Fisch et al. (1982), Madanes (1981),
Mozdzierz et al. (1976), and Nardone and Watzlawick (2005). The terms symptom and attempted solution
can often be used interchangeably with the term problem.
such a list can help clients realize that things could be worse (and by extension, that
things are better than they thought) and that they have more control over things than
they thought (they are not doing many of the things that could make their relation-
ship worse), which can be empowering. In addition, this list may generate new ideas
of things they could do to improve their relationship (e.g., doing the opposite of
something on the list) that they had not previously considered. Returning again to
the example of the wife whose husband struggles with obesity and binge eating, one
way to disrupt the wife’s perceptive–reactive system (i.e., perception = the problem is
the husband’s binging behavior; reaction = supporting her husband by telling him to
eat less) is through a paradoxical prescription that she encourage or insist that her
husband eat more; this way, he can avoid feeling controlled by her by choosing to eat
less as opposed to eating more in response to her requesting that he eat less to avoid
feeling controlled by her.
Another common paradoxical prescription is the smallest change possible. Often one
small change is enough to start a chain reaction or ripple effect that can disrupt the
perceptive–reactive system, leading to eventual larger changes (go slow to go fast;
Nardone & Portelli, 2005). Because emotions, cognitions, and behaviors are all inter-
related, a change in one area increases the likelihood that there will be changes in the
other areas (Haley, 1987). Something small is easier, reduces feeling overwhelmed
and powerless, and makes a successful experience more likely. Prescribing that clients
change only aspect of the attempted solution behavioral sequence that maintains the
problem can also have a paradoxical effect. Changing sequences of behavior can be
accomplished by prescribing an alteration to one of the following: who (role; which
person does what), what (change a behavior in the sequence via omitting or substitut-
ing), when (time of day, length of time), where (location), or how (order). Other para-
doxical prescriptions include adding in order to reduce (e.g., add pleasurable activities
to reduce substance abuse; Nardone & Portelli, 2005), ordeals (prescribing construc-
tive yet aversive activities to the problem; Haley, 1987; Madanes, 1981), and thera-
peutic rituals (an experiment in which family members are prescribed behaviors that
replicate and clarify systemic interaction patterns, often exaggerating problematic
family rules; Selvini Palazzoli et al., 1978).
Paradoxical prescriptions have been identified as having several benefits (Sherman
& Fredman, 1986). Paradoxical prescriptions validate the perceptive–reactive systems
in the family and make implicit rules explicit, helping family members feel under-
stood. Prescribing the problem with a rationale of the important role the problem
plays for the family system can ease feelings of shame, blame, and guilt. In addition,
they can help clients replace feeling helpless with feeling empowered as they discover
control over a problem that seemed out of control and beyond control. Paradoxical
prescriptions tend to be highly effective with highly rigid and resistant perceptive–
reactive systems. Finally, they also help family members feel appropriately responsible
for the change process instead of placing that responsibility on the therapist.
Strategic family therapy approaches

MRI The research activities conducted at MRI resulted in the development of stra-
tegic family therapy, which broke from traditional psychodynamic therapies by empha-
sizing a constructivist view of reality, cybernetics, change as preceding and independent
of insight, the how over the why, first‐order and second‐order change, and viewing
attempted solutions to the problem as the problem (Watzlawick et al., 1974). MRI
indelibly influenced the theoretical frameworks of the other strategic family therapy
approaches. MRI continues to provide clinical training and clinical services to families
and individuals. In addition, MRI research fellows like Wendel Ray help maintain vis-
ibility of the MRI. Although clinical research has long been a tradition of MRI, only
one randomized clinical trial on the effectiveness of this approach has been published
in a peer‐reviewed journal (suggesting reduced behavior problems and depression in
children; Steinberg, Sayger, & Szykula, 1997). Despite providing the genesis for all of
the strategic family therapy approaches, MRI seems to have a limited and waning
influence on the current and future developments in strategic family therapy.
Brief strategic therapy In sharp contrast to the diminished impact of MRI, Nardone,
a protégé of Watzlawick who studied at MRI, and his colleagues at the Center for
Strategic Therapy (Centro di Terapia Strategica) in Arezzo, Italy, have further
advanced the MRI approach through the development of innovative protocols for
specific clinical problems. Using an iterative process of testing strategy sequences,
assessing client outcomes, and revising strategy sequences, Nardone has created pro-
tocols for the following clinical issues (grouped by classification) ranging in efficacy
(i.e., resolution or considerable improvement) from 77 to 95% one year after treat-
ment for over 3,000 cases (Nardone & Portelli, 2005; Nardone & Watzlawick, 2005):
anxiety disorders (i.e., agoraphobia, panic disorder, phobias, obsessive–compulsive
disorder), eating disorders (i.e., anorexia, bulimia, binge eating disorder), mood dis-
orders (depression), psychoses (i.e., paranoia, somatic symptom disorder, illness anxi-
ety disorder), female sexual dysfunctions (i.e., genito‐pelvic pain/penetration disorder,
orgasmic disorder, and sexual interest/arousal disorder), male sexual dysfunctions
(i.e., erectile disorder, hypoactive sexual desire disorder, and premature ejaculation),
and relational problems (i.e., marital distress and parent–child relational problems,
including those associated with child behavioral problems). It is impressive that these
treatment protocols have demonstrated high levels of treatment efficiency (i.e., cost‐
effectiveness), with clients attending no more than 10 therapy sessions in 83% of
cases, as shorter lengths of treatment are associated with decreased financial and emo-
tional costs and increased quality of life (Nardone & Watzlawick, 2005). Furthermore,
results of a randomized clinical trial indicated that brief strategic therapy was superior
to cognitive‐behavioral therapy for treating binge eating disorder and comorbid
obesity (Jackson et al., 2018).
The protocols developed by Nardone provide templates for treatment with specific
interventions. Therapists can then tailor the interventions based on the nuances of
their clients’ attempted solutions, situations, and contexts. One of the major obstacles
to using strategic therapy that therapists often encounter is the difficulty in coming up
with effective strategic interventions, particularly paradoxical ones; correspondingly,
one of the major advantages to these protocols is that they can help therapists over-
come reticence to use strategic therapy with couples and families because the treat-
ment, including the interventions, is laid out step by step.
Milan systemic family therapy Boscolo, Cecchin, Prata, and Selvini Palazzoli devel-
oped a strategic therapy approach that is sometimes credited as being the most sys-
temic of all family therapy approaches (Griffin & Greene, 1999). This is likely due to
the focus on identifying each family member’s contribution(s) to homeostasis around
the presenting problem. For example, a teenage daughter may unconsciously perceive
that she needs to sacrifice herself by getting into trouble at school to protect her father
by distracting him from his conflictual marriage with her mother; the father over‐par-
ents his daughter to thank her for her willingness to throw her future away by getting
into trouble to distract him from his conflictual marriage; the mother criticizes her
daughter and husband so that they will stay banded together such that the father will
not want to abandon his daughter to be a husband to his wife (Nichols & Davis,
2017). Positive connotations such as these that reframe motivations behind behaviors
and the problem as having an important helpful function to the family system are
provided to the family along with warnings about changing for paradoxical effect and
to promote second‐order change (Bergman, 1985; Jones, 1993).
In the Milan systems approach, rigid family rules are seen as limiting the range of
acceptable behaviors in which family members can engage (Selvini Palazzoli et al.,
1989). The goal of therapy is to shift the purpose of the problem by interjecting infor-
mation into the family system that moves rigid rules toward more flexible ones (Selvini
Palazzoli et al., 1978). Circular questioning is used as to feed information about the
relationships between family members into the system, creating a positive feedback
loop that amplifies differences in perceptions between family members, encouraging
second‐order change (Boscolo et al., 1987).
Results of research suggest the Milan systemic approach may be helpful for alcohol
dependence, depression, schizophrenia, chronic problems, and child behavioral prob-
lems (Bennun, 1986, 1988; Bertrando et al., 2006; R. J. Green & Herget, 1991;
Simpson, 1990). Although this approach was once popular and influential, frequent
changes and developments to the approach coupled with disagreements and divisions
between the originators have contributed to this approach becoming more obscure
(Griffin & Greene, 1999).
Strategic family therapy critiques

One of the primary controversies surrounding strategic therapy is that it is manipula-
tive and raises related ethical concerns, especially with regard to paradoxical interven-
tions being deceitful and outside of client awareness (Solovey & Duncan, 1992).
Strategic therapists typically take the position that all therapy is manipulative; the
difference from other approaches is that the manipulation tends to be acknowledged
in strategic therapy more so than in other approaches (Haley, 1987, pp. 218–243).
For instance, it is not common practice in narrative therapy to explicitly inform clients
of the clinical mechanisms behind the externalization of a problem before external-
izing it. Similarly, a hallmark of collaborative language systems therapy is transpar-
ency; yet therapists subscribing to this approach would not likely explain to clients
that they are intentionally using the term sadness instead of depression in an effort to
co‐construct a new shared reality in which what they originally perceived as depres-
sion is seen as more manageable.
In short, all therapy approaches likely propagate some form of non‐transparency
about the mechanisms of change at play behind interventions, which could arguably
be described as intentionally deceiving clients and operating outside of clients’
awareness—the essence of the manipulation criticisms typically aimed at strategic
therapy. Notwithstanding, it is important for therapists to balance (a) helping clients
change in ways requested and agreed upon by the clients and (b) treating clients
respectfully and appropriately managing therapist power and influence (Golann,

1988; Held, 1992; Simon, 1992).
The constructivist underpinnings in strategic therapy promote conceptualizing and
intervening within clients’ paradigm, beliefs, values, and language systems; therefore,
strategic therapy lends itself to working with a wide range of clients and problems
(Gehart, 2018). Strategic family therapy has been specifically adapted for Latinx cou-
ples (Schlanger, 2011), Latinx families (Anger‐Díaz, Schlanger, Rincon, & Mendoza,
2004), Italian families (Nardone & Watzlawick, 2005), and black, Latinx, and
Germanic adolescents engaging in high‐risk behaviors such as bullying and substance
use (Nickel, Luley, et al., 2006; Nickel, Muehlbacher, et al., 2006; Robbins, Horigian,
Szapocznik, & Ucha, 2010; Santisteban et al., 1997; Santisteban & Mena, 2009).
Although substantive body of clinical treatment outcome research points to the
effectiveness of strategic family therapy, much of the published outcome research on
strategic family therapy efficacy lacks peer review and is either noncomparative in
nature or nonspecific with regard to population or both. Moreover, although most of
the peer‐reviewed comparative research employed randomized clinical trial designs,
some of the studies were likely underpowered due to small samples, and all of the
studies lacked independent replication. In addition to more high quality clinical out-
come research, research is needed to validate strategic concepts such as perceptive–
reactive systems and attempted solutions worsening the problem and becoming the
problem.
The future of strategic family therapy

Strategic family therapy is a related set of brief problem‐focused pragmatic systemic
approaches to helping family members shift problematic perceptions and behavioral
patterns that sustain or intensify symptoms and problems. As an integration of general
systems theory, communication theory, cybernetics, constructivism, and Ericksonian
hypnotherapy, strategic family therapy emphasizes change over insight and facilitates
change by disrupting resistant perceptive–reactive systems through reframes and pre-
scriptions. Despite empirical indications of the effectiveness of the strategic family
therapy approaches, these approaches do not seem to be as widely used as other psy-
chotherapy approaches, such as cognitive‐behavioral, psychodynamic, and postmod-
ern, perhaps in part because of the criticisms relating to manipulation toward the close
of the previous century and perhaps in part due to insufficient training to effectively
use strategic interventions, especially paradoxical prescriptions.
To ensure the proliferation of these approaches, additional efforts are needed to
provide training and provide more concrete protocols and manuals to make these
innovative systemic approaches more readily available and accessible to clinicians. The
following organizations are a few examples of the types of available strategic family
therapy training: MRI (www.mri.org), Giorgio Nardone’s Strategic Therapy Center
(www.giorgionardone.com; www.centroditerapiastrategica.com), Mara Selvini School
(www.scuolamaraselvini.it), Milan Center for Family Therapy (www.cmtf.it), Systemic
Dialogical School (www.scuoladialogica.it), Cloé Madanes (www.cloemadanes.com;
www.madanesstrategiccoaching.com), and Brief Strategic Family Therapy (www.bsft.
org). Likewise, given the increasing importance of empirically validating approaches
for the treatment of specific populations (e.g., clinical issues, psychiatric disorders,
relational problems), additional clinical outcome research is needed to not only
further evaluate the effectiveness of strategic family therapy but to also increase its
relevance and prevalence in the field of systemic family therapy.
Integrated Structural–Strategic Family Therapy Approaches
Given the many similarities between structural family therapy and strategic family ther-
apy (see beginning of the chapter), it is not surprising that these therapy models are
often integrated with one another. In many ways, the strategic approaches developed
by Haley and Madanes can be seen as an integration of strategic family therapy and
structural family therapy. After a decade at MRI, Haley studied with Minuchin at the
Philadelphia Child Guidance Clinic, which resulted in Haley integrating the structural
family therapy concepts of family hierarchy, power, and system boundaries into the
MRI approach (Griffin & Greene, 1999). Madanes (1981) and Stanton (1981) also
studied with Minuchin at the Philadelphia Child Guidance Clinic and incorporated
similar structural family therapy concepts into their respective approaches. The strate-
gic approaches developed by Haley and Madanes are brief in nature, process focused,
directive, and problem solving focused and emphasize behavioral sequences, family
organization, and developmental stages (Haley, 1987). The objectives of these
approaches are the resolution of presenting problems through therapist‐designed strat-
egies such as reframing, and paradoxical directives (especially ordeals in which clients
are asked to engage in an aversive yet beneficial behavior when the problematic behav-
ior occurs) are the focus of strategic family therapy (Haley, 1986; Madanes, 1981).
Madanes’ approach differs somewhat from that of Haley in that she incorporates
humanistic theoretical constructs such as power, control, and respect (Madanes,
1981) and has developed strategies specifically for improving family relationships
(Madanes, 2018) and decreasing family violence (Madanes, 1990). Notwithstanding
the integration of a few structural family therapy concepts, the strategic approaches of
Haley and Madanes are predominantly strategic in nature, whereas Stanton’s struc-
tural–strategic approach (Stanton, 1981) is a more balanced integration of both
approaches that has been predominantly applied to families affected by substance
abuse (Joanning, Quinn, Thomas, & Mullen, 1992; Stanton & Todd, 1982; Yandoli,
Eisler, Robbins, Mulleady, & Dare, 2002).
By contrast, brief strategic family therapy, the substantially researched approach
developed by Szapocznik and his colleagues that integrates Minuchin’s, Haley’s, and
Mandanes’ approaches, focuses more on structural conceptualizations from both
structural and strategic interventions to facilitate changes in family structures.
Szapocznik’s approach for working with the families of adolescents struggling with
behavioral problems, substance abuse, or both focuses on the family structures acti-
vated in response to the adolescents’ behaviors (Szapocznik, Schwartz, Muir, &
Brown, 2012). This approach systemically conceptualizes the family structures (i.e.,
interactional patterns such as coalitions and detouring) that maintain problematic
adolescent behaviors as being the very family structures that impede family engage-
ment in the therapy process (Szapocznik & Williams, 2000). Strategic interventions
are used to shift these problematic family structures by altering the behavioral
sequences associated with the targeted problematic family structures, as well as inter-
face problems with other relevant systems such as schools, neighbors, peers, extended
family, and community (Szapocznik, Hervis, & Schwartz, 2003). It is also important
to note that yet another integration of structural family therapy and strategic family
therapy has also been found to be effective in reducing marital distress (Goldman &
Greenberg, 1992).
Conclusion
Structural family therapy and strategic family therapy are among the most systemic of
the family therapy approaches given their grounding in general systems theory and
cybernetics. Because of the many similarities across these approaches, they have been
integrated into several differing structural–strategic models that have been found to
be effective for treating substance abuse, adolescent high‐risk behaviors, and marital
distress, begging the question if integrated structural–strategic approaches are the way
of the future. Because clinical outcome research has demonstrated that structural fam-
ily therapy and strategic family therapy are also both independently effective for treat-
ing several populations, it would be beneficial to conduct research to determine if one
approach is more effective, including integrated approaches, for specific populations.
Future steps for ensuring the longevity and value of these models should also
include conducting process research to identify effective mechanisms of change.
Additionally, research is needed to determine if the brief nature of both structural
family therapy and strategic family therapy is more efficient and cost‐effective com-
pared with other treatment approaches to better serve families who have limited
resources and potentially reduce family therapy dropout rates. Finally, taking into
account that Minuchin passed away in 2017 and the fact that almost all of the origina-
tors of strategic family therapy approaches have also passed away, the futures of these
models might be aided by the development of organized networks that could facilitate
a unifying sense of cohesion across the proponents of the many variants of these
approaches by coordinating training, research, and dissemination efforts.
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16
Behavioral and Cognitive‐
Behavioral Approaches in Systemic
Family Therapy
Norman B. Epstein and Frank M. Dattilio
Behavioral and cognitive‐behavioral models for understanding and treating problems

in couple and family relationships are well supported empirically (Baucom, Epstein,
Kirby, & LaTaillade, 2015; Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998;
Fischer, Baucom, & Cohen, 2016). These have also been widely used among practic-
ing clinicians for decades (Northey, 2002) and are routinely included in couple and
family therapy textbooks (e.g., Gurman, Lebow, & Snyder, 2015; Nichols & Davis,
2016). Although the models that have been applied over the years vary in the degrees
to which they emphasize the cognitive and behavioral aspects of relationship function-
ing, as well as the emotional responses of family members, upon close examination,
they all address all three domains. Furthermore, rather than focusing on cognitions,
emotions, and behaviors independently in a parallel manner, behavioral and cog-
nitive‐behavioral models uniquely focus on complex mutual influences among those
domains. Consequently, in this chapter, we use the title Cognitive‐Behavioral Couple
and Family Therapy (CBCFT) to encompass all of the approaches prominent in the
field and describe the theoretical roots that have converged to produce this multifac-
eted theoretical approach to intimate relationships.
The popularity of CBCFT approaches has been largely due to their comprehensive-
ness in addressing the major realms of intimate relationships (individuals’ internal
cognitions and emotions regarding their experiences with significant others and the
overt behavioral interactions among the family members) and their “user‐friendly”
procedures for assessment and intervention (e.g., identifying thoughts that fuel part-
ners’ aggressive acts; teaching communication skills). The flexibility of the overall
model also derives from its development over time as an integrative theoretical frame-
work representing the merging of several key components that capture intrapsychic
processes, intergenerational influences, interpersonal interactional processes, and eco-
logical contextual influences (Dattilio, 1998). Intrapsychic processes involving
thought and emotion have always been core aspects of CBT, as are interactions among
family members that constitute some of the most significant stressors in people’s lives.
In addition, intergenerational influences are prominent in CBT through the develop-
ment of individuals’ schemas via interactions with the environment, especially during
366 Norman B. Epstein and Frank M. Dattilio
childhood (Scher, Segal, & Ingram, 2004). The ecological contextual aspect of the
enhanced CBCFT model is consistent with a traditional CBT model that considers a
wide range of sources of stressful life events (e.g., jobs, extended family, friendships)
that individuals appraise subjectively; i.e., a variety of life events activate the individu-
al’s underlying vulnerabilities that are based on long‐standing schemas (Scher et al.,
2004). In the enhanced CBCFT model, clinicians conduct more comprehensive
assessment and treatment planning with those systemic influences than tended to be
the case in earlier forms of behavioral and CBT programs for couples (Epstein &
Baucom, 2002).
Roots of CBCFT were in the use of simple behavioral contracts designed to increase
pleasing behaviors exchanged by members of couples and families (Jacobson &
Margolin, 1979; Stuart, 1980). However, CBCFT has steadily developed in its con-
ceptual richness and clinical sophistication, such that it now is employed with severe
and complex relational problems such as couples experiencing infidelity or partner
aggression, as well as with couples and families who are coping with severe physical
and mental health problems of individual members (Epstein, 2018; Fischer et al.,
2016). This chapter is intended to provide an overview of the theoretical roots of
CBCFT, identifying how its integrative concepts provide a strong foundation for clin-
ical assessment and treatment of a wide variety of human problems within a relational
systems context.
Theoretical Foundations of Cognitive‐Behavioral Couple

and Family Therapy
CBCFT as an integrative model based on common factors

Therapy outcome studies that have compared efficacy of major couple and family
therapy models have on the whole found that they have comparable impacts on help-
ing clients in distressed relationships (Sprenkle, Davis, & Lebow, 2009). As described
in Karam and Blow (2020, vol. 1), a significant response to findings of equivalent
outcomes from diverse therapy models has been a growing interest in common factors
in couple and family therapy regarding the characteristics of therapists, clients, and the
therapist–client alliance that account for positive effects of treatment. However, com-
parable effectiveness of approaches does not negate the importance of the concepts
and interventions from each model that guide assessment and treatment planning,
leading to improved functioning of distressed couples and families (Gehart, 2016;
Sprenkle & Blow, 2004). For example, cycles of damaging aversive behavior between
members of distressed couples can be interrupted and replaced by more positive inter-
actions through interventions from structural, emotion‐focused, solution‐focused,
cognitive‐behavioral, and other models.
Benson, McGinn, and Christensen (2012) identified principles or processes that are
common to evidence‐based couple therapies: altering partners’ views of presenting
problems to be more objective and dyadic, decreasing emotion‐driven dysfunctional
behaviors, uncovering emotion‐based avoided behavior, increasing constructive com-
munication, and emphasizing relationship strengths. Those processes correspond
closely to the three core CBCFT foci on cognitions, affect, and behavioral interactions
Behavioral and Cognitive Behavioral Theories 367
that contribute to relationship problems and are targeted in treatment. Thus, we

believe that CBCFT has substantial potential for integration with other therapy mod-
els based on its balance in addressing the cognitive, affective, and behavioral compo-
nents of close relationships, with clearly articulated theoretical concepts, assessment
methods, and interventions. Those three foci also match the three major realms of
cognitive mastery, affective experiencing, and behavioral regulation that Karasu
(1986) proposed are addressed by all therapies. Our purposes in this chapter are to
identify the roots of this integrative CBCFT framework and describe how the theo-
retical concepts have led to the development of treatments for a wide range of pre-
senting problems concerning close relationships and their individual members.
Because the major goals and concepts of CBCFT are consistent with the principles
identified by Benson et al. (2012), CBCFT methods can be integrated with those
from other models and used by practitioners from diverse theoretical backgrounds
(Dattilio, 1998).
Social Learning Theory
One of the major and earliest roots of the development of CBCFT was the application
of basic learning principles in understanding and treating problems in couple and
family relationships. At a broad level, learning theory concepts focus on processes
through which both constructive and problematic human behaviors are acquired and
controlled through individuals’ interactions with their environment, and in particular
their experiences with other people. Furthermore, even though learned behavioral
patterns may become fairly persistent, it is assumed that they can be modified through
the same types of experiences with the environment (Bandura, 1969; Weiss, 1978).
The learning principles that were applied to understanding individuals’ actions within
couple and family relationships were derived from basic laboratory research, much of
it with animals. Pavlov’s (1932) studies of classical conditioning demonstrated how an
emotional and/or behavioral response (e.g., a dog’s salivation) can be conditioned to
be elicited by a neutral stimulus (e.g., the sound of a bell) by pairing the neutral
stimulus with an existing reflexive response (e.g., salivation to the sight and aroma of
food). Although this fairly primitive form of learning does not account for much of
the complexity of couple and family relationships, any individual who experiences a
sudden wave of anxiety when a partner simply enters the room based on a history of
that partner’s presence being paired with abusive behavior can attest to its power.
Furthermore, a classically conditioned response can become generalized to stimuli
that are similar to the original conditions, as when an individual whose former partner
escalated from yelling to hitting now experiences anxiety in response to a current
partner’s raised voice.
The efficiency of operant conditioning in human learning

Skinner’s (1953, 1971) concepts and methods of operant conditioning expanded the
utility of learning principles in understanding the development of response patterns in
animals, including complex learned behaviors in humans. Operant conditioning
involves increasing or decreasing an individual’s specific action by controlling the
consequences of the action. Thus, a rat in a “Skinner box” could be taught to press a
bar repeatedly if that behavior dispensed a food pellet; i.e., the rat received positive
reinforcement and learned to work for more of it. Another form of consequence that
can increase a response is the removal of an aversive condition, referred to as negative
reinforcement. A common human example of negative reinforcement occurs when a
child whines until a parent gives her or him a desired treat and then stops the
aversive behavior, leading to an increase in the parent’s compliant behavior. In
contrast to reinforcement processes, a behavior can be decreased by a consequence
assumed to be aversive (punishment) or by discontinuing the reinforcement
(extinction) (Weiss, 1978).
Another key concept in operant conditioning is that of discriminant stimuli (Weiss,
1978). This term refers to stimulus conditions that are cues to the individual that
reinforcement or punishment is likely to occur, and both rats and humans are adept at
learning to tailor their response patterns to such cues. Thus, through trial‐and‐error
experience, a rat learns that pressing a bar when a light is on is likely to result in food
pellets, but pressing when the light is off is likely to be futile. Similarly, members of a
couple learn as they get to know each other through many interactions that particular
nonverbal cues signal the other person’s receptivity to affectionate behavior, whereas
other cues indicate that approach behavior is less likely to be reciprocated. Discriminative
stimuli contribute to more efficient operant conditioning of behaviors, and members
of relationships at times intentionally use them in the process of stimulus control,
systematically providing particular cues to each other that certain behaviors (e.g.,
assistance with a task) are desired and will be reinforced. In fact, some arguments occur
when the intended recipient of a stimulus control cue fails to notice and respond to it.
Mutual operant conditioning in couple and family relationships Operant conditioning

principles appear to represent a primarily linear view of causality, in which a
discriminative stimulus leads an individual to emit a particular type of behavior that is
then reinforced by particular consequences. Such a linear model would seem to have
limited applicability for understanding mutual influence processes that occur in couple
and family relationships. However, in interpersonal relationships, the members
mutually provide each other cues that serve as discriminative stimuli and provide
consequences for each other’s actions. An example of such a process can occur when
a parent reports great difficulty getting a baby to go to sleep by herself, even though
the child is sufficiently old to reasonably develop a self‐soothing routine. The parent
describes holding and rocking the child until she seems soothed and then putting her
in her crib to sleep. However, the baby soon begins to cry and continues until the
parent takes her from the crib and spends time soothing her again. This process can
continue for a long period, and its strength may be attributed to a mutual reinforce-
ment process in which the parent receives negative reinforcement (termination of the
child’s aversive crying) for picking up and soothing the child, while the child receives
positive reinforcement (parental attention) for crying. Over time, the members of a
relationship (parent–child, couple) shape each other’s responses through the discrimi-
native stimuli and consequences that they provide each other, whether or not they
explicitly express their preferences for each other’s behavior. This is similar to the
process of mutual accommodation in which a couple develops repetitive patterned
interactions over time described by Minuchin (1974) in his model of structural family
therapy. Thus, even though learning through operant conditioning is inefficient and
cannot easily account for many complex interaction patterns in family relationships,
the processes truly are relevant for understanding some problematic family patterns
and planning interventions to modify them.
Integration of social exchange theory The learning model of couple relationships that
emphasized mutual operant conditioning also includes concepts from social exchange
theory (Thibaut & Kelley, 1959), in which each individual’s level of satisfaction with a
relationship depends on the ratio of benefits (reinforcement) to costs (punishment or lack
of reinforcement) that he or she experiences in the relationship (Jacobson, 1981; Jacobson
& Margolin, 1979). An individual would be relatively dissatisfied with a relationship that
he experienced as providing a poor benefit‐to‐cost ratio, with his evaluation potentially
influenced by a process of comparing that ratio with a more favorable ratio that he believes
he would receive in an alternative relationship.
Because human behavior tends to be very complex (e.g., language acquisition,
communication skills, skills for particular jobs), learning the vast repertoires of actions
that are required for the average individual to function adequately in the world neces-
sarily requires more efficient processes than classical and operant conditioning pro-
vide. Social learning theorists (Bandura, 1977; Bandura & Walters, 1963; Rotter,
1954) focused on how a child or older individual can observe a complex behavior
demonstrated by another person and then imitate it, a highly efficient form of learn-
ing. The imitation is more likely to occur if the observer sees that the model has high
status or has received reinforcement for the behavior (Bandura, 1977).
Behavioral model of communication and problem‐solving skills In the process of the

early development of the field of marital and family therapy, behaviorally oriented
theorists and clinicians shared a common emphasis with proponents of other sys-
temic models (e.g., Lederer & Jackson, 1968; Minuchin, 1974; Satir, 1967;
Watzlawick, Beavin, & Jackson, 1967) on how the quality of the communication
among family members influences their overall functioning as a system and ability to
cope with life stressors. Although the models conceptualized communication
processes in somewhat diverse ways, there was a common goal of clarifying meanings
and functions of family members’ verbal and nonverbal messages to each other.
Behaviorally oriented theorists focused on the adequacy of family members’ skills for
expressing their thoughts and emotions clearly and constructively (e.g., in a collabo-
rative manner rather than blaming or verbally attacking other members) and skills for
listening empathically to other members and conveying that understanding
(Jacobson, 1981; Jacobson & Margolin, 1979; Stuart, 1980). Such skills were viewed
as vehicles for maintaining favorable benefit‐to‐cost ratios in behavior exchanges. In
addition, members’ skills for collaborative problem solving were viewed as essential
for couples and families to cope effectively with life stressors and experience reward-
ing interactions with each other. Problem‐solving skills include agreeing on a clear
definition of a problem in observable behavioral terms, generating a creative and
diverse list of potential behavioral solutions to the problem (specifying each partner’s
or family member’s role in carrying out each solution), evaluating the costs and
benefits of each potential solution, selecting a solution to try that is feasible and
palatable to all parties, testing the solution during a trial period, evaluating its s uccess,
and revising the solution if necessary (Baucom & Epstein, 1990; Jacobson &
Margolin, 1979; Stuart, 1980).
Empiricism in behavioral models

An empirical tradition was established early in the development of behaviorally ori-
ented models of couple and family functioning, in which basic research was con-
ducted to identify specific forms of constructive and destructive communication and
problem solving (Gottman, 1979; Patterson, 1982; Revenstorf, Hahlweg, Schindler,
& Vogel, 1984; Weiss, Hops, & Patterson, 1973). Typically, the researchers obtained
samples of couple or family interaction by asking the members to have a discussion
regarding an area of conflict in their relationship or focused on making a joint deci-
sion and had trained coders apply structured coding systems to categorize specific
types of their positive and negative behavior. Couple researchers (e.g., Gottman,
1979, 1994; Revenstorf et al., 1984; Weiss et al., 1973) identified particular interac-
tion patterns (e.g., escalating reciprocal exchanges of negative behavior, demand–
withdraw patterns) that differentiated distressed from relatively happy couples and
that predicted dissolution of relationships over time. Analyses of sequences of behav-
iors among members as they interacted demonstrated how the individuals influenced
each other’s responses.
Regarding family interactions, Patterson and his colleagues (Patterson, 1982) con-
ducted observational coding studies of families of children referred for conduct prob-
lems and identified mutual exchanges of aversive behavior among parents and children,
leading the investigators to describe them as coercive family systems. The parents use
criticism, threats, and types of punishment to try to control the children’s behavior,
whereas the children use aversive behavior to punish and resist the parents, a pattern
of retaliatory negative reciprocity. A major contributor to the aversive exchanges is a
common lack of skills for problem solving and child management on the parents’ part
(Robin & Foster, 1989). Similarly, Robinson and Eyberg (1981) developed a system
for coding parent–child dyadic interaction that focuses on effective and ineffective
forms of parental attempts to direct a child’s behavior. This body of research on the
process of couple and family interactions has provided strong support for an integra-
tion of family systems and social learning frameworks for understanding, assessing,
and intervening with members’ negative behavior.
Early focus on cognition in behavioral models

Although the primary focus of learning approaches to couple and family problems
tended to be on observable behavior, Bandura’s (1977) social learning model included
a key cognitive component involving the expectancies that individuals develop regarding
the probability that a particular action on their part would lead to particular
consequences. Thus, a child who observes that his whining initially results in parental
yelling but eventually to the parent’s compliance with the child’s request develops an
expectancy that persistent aversive behavior pays off. Conversely, in couple therapy, as
a therapist models positive communication and problem‐solving skills for a couple and
coaches them in using the skills to produce mutually satisfying results, there is “cognitive
restructuring” occurring (Epstein & Baucom, 2002). Those experiences in the sessions
potentially shift the partners from expectancies that discussions will lead to aversive
conflict to positive predictions that discussions can be productive and satisfying.
Thus, learning within this model is cognitively mediated, and understanding an
entrenched negative pattern in a family’s interaction is enhanced by taking such
cognitive processes into account. However, social learning theory in itself did not
provide an in‐depth conception of the complex forms of cognition that influence
couple and family patterns. Consequently, the development of CBCFT depended on
integration of other theoretical models that identified forms of cognition and their
influence on interpersonal relationships.
Implications of social learning theory for CBCFT

The social learning theory roots of CBCFT provide a strong foundation for under-
standing how members of a couple or family mutually influence each other and how
interventions focused on the eliciting stimuli and consequences that are exchanged by
members can produce significant changes in the quality of their relationships. Because
the behavioral patterns tend to involve contributions from both members of a couple
or from both parents and children, the case conceptualization takes into account each
person’s responses that could be modified to affect the overall behavioral system.
However, this systemic view of patterns does not hold victims responsible for abusive
behavior they receive; rather, each member of a relationship is considered responsible
for the behavioral choices that he or she makes.
A corollary of the core assumption that excesses in negative behavior and deficits in
constructive behavior in couple and family relationships are the result of learning pro-
cesses is the view that learning processes can be used in a therapeutic manner to
improve existing behavioral patterns. Consequently, behaviorally oriented couple and
family therapists have designed interventions that reduce negative actions and increase
positive ones via learning principles, and those interventions have become core com-
ponents of CBCFT. Behavioral marital therapists (Jacobson & Margolin, 1979;
Liberman, 1970; O’Leary & Turkewitz, 1978; Stuart, 1980; Weiss et al., 1973) inter-
vened jointly with the members of distressed couples, applying social exchange con-
cepts (Thibaut & Kelley, 1959) and operant learning principles to guide them in
devising behavioral “contracts” in which each partner agreed to perform particular
behaviors that the other desired in return for receiving reinforcements from the part-
ner. In addition, they used behavioral skill‐building methods to shape couples’ con-
structive communication and problem‐solving skills: describing specific skills in a
psychoeducational manner, modeling desired behavior, coaching partners in practic-
ing skills, and providing feedback and reinforcement to partners.
Couple relationship education and enhancement programs

An outgrowth of the behavioral skills approach to couple relationships has been the
development of relationship education and enhancement programs, which are
designed to enhance relationships that already are relatively satisfying and prevent the
development of future relationship problems. They emphasize psychoeducation
regarding factors that differentiate between satisfying versus distressing relationships
and the direct practice of communication and problem‐solving skills (Halford &
Moore, 2002). Programs vary in content but commonly include psychoeducation and
skill training regarding intimacy building, communication skills for expression and
listening, and skills for problem solving and conflict resolution. Examples of skills‐
based programs are Guerney Jr.’s (1977) Relationship Enhancement (RE) Program,
Markman, Stanley, and Blumberg’s (2010) Prevention and Relationship Enhancement

Program (PREP), Miller, Wackman, and Nunnally’s (1976) Minnesota Couples
Communication Program (MCCP), and Rogge, Cobb, Johnson, Lawrence, and
Bradbury’s (2002) CARE program.
Behavioral interventions for families

Similar to the approaches with couples, behaviorally oriented family therapists devel-
oped behavioral interventions for families with children who exhibited aggressive and
other problematic behavior, primarily based on social learning principles (Patterson,
1971). These behavioral family therapy programs have proliferated, commonly focus-
ing on developing parents’ skills for decreasing their children’s problematic behaviors
and increasing their desirable behaviors, including reducing parents’ unwitting mod-
eling of verbal and physical aggression for a child when they use those types of behav-
ior in disciplining the child (Barkley & Benton, 1998; Blechman, 1985; Chronis,
Chacko, Fabiano, Wymbs, & Pelham Jr., 2004; Eyberg et al., 2001; Forgatch &
Patterson, 2010; Kazdin, 2005; Sanders, Cann, & Markie‐Dadds, 2003; Webster‐
Stratton & Herbert, 1994). Although parents commonly become engaged in these
programs in order to improve their children’s behavior, the interventions actually
result in major positive changes in the parents’ own behavior; i.e., the interventions
are systemic and influence the whole family.
Social Cognition Research
Behavioral models of couple and family functioning included some concepts involving
members’ cognition. As we noted previously, in Bandura’s (1977) social learning
theory, individuals develop expectancies or predictions about probabilities of particu-
lar consequences for their actions. Consequently, if a therapist attempts to motivate an
individual to stop using verbally aggressive behavior in order to try to influence a
partner and replace it with positive requests, the client may resist the change if he or
she holds an expectancy that the partner will ignore simple requests and is more likely
to pay attention and comply in response to aggression.
Biased perceptions and attributions in initial behavioral models

Behaviorally oriented couple and family theorists and therapists also described
perceptual biases that influenced behavioral responses. Jacobson and Margolin (1979)
labeled partners’ tendency to notice each other’s negative behavior and overlook posi-
tive behaviors as negative tracking. Similarly, effective parenting includes reinforcing
a child’s positive behavior, but parents often are so focused on a child’s negative
behavior that they either fail to notice the child’s good behavior or fail to provide
reinforcement such as praise for it (Forgatch & Patterson, 2010; Kazdin, 2005). In
turn, children may attend selectively to parental behavior that they experience as aver-
sive and overlook positive actions by their parents (“You never let me do anything
fun!”). The tendency for members of couples and families to engage in negative track-
ing can be due to a normal tendency to be vigilant regarding threats and problems
and to particular assumptions (schemas that we discuss in the next section) that giving
another person positive feedback decreases the person’s motivation to improve.
Behaviorally oriented writers noted the influence of attributions that members of
couples and families made about causes of other members’ actions. For example,
Jacobson and Margolin (1979) noted that if a member of a couple intends to behave
positively toward a partner but the partner makes an attribution that the individual
had negative motives, the partner will respond negatively to the other’s actions,
whether or not the inference is accurate. Similarly, Morton, Twentyman, and Azar
(1988) reported that parents who behave abusively toward their children commonly
attribute their children’s misbehavior to intentional efforts to be annoying and spite-
ful, responding with negative emotion (especially anger) and behavior (e.g., punitive
actions).
Integration of social cognition findings into behavioral models

In spite of the recognition within the behavioral model that cognitive factors influence
couple and family interactions, theorists and clinicians needed to look beyond social
learning theory for concepts and methods to address cognition adequately. One key
source of concepts about forms of cognition that influence relationships has been
basic research on social cognition. Fletcher, Overall, Friesen, and Nicolls (2018) note
that the study of social cognition within romantic relationships has become a major
focus in social psychology and related fields because humans initially learn how to
think via their relationships with parents and other caretakers and continue to be
influenced by experiences in later intimate relationships. Within social psychology,
Thibaut and Kelley’s (1959) concept that an individual’s level of satisfaction with a
relationship depends on the person’s comparison with alternatives and the develop-
ment of attribution theory that focuses on consequences of causal inferences that
people make for events in their lives (e.g., whether a success was due to effort or
chance) were applied to close relationships. In fact, the majority of studies on cogni-
tions that influence romantic partners’ emotional and behavioral responses to each
other have focused on attributions (e.g., attributing blame to one’s partner for prob-
lems in the relationship is associated with greater unhappiness and negative commu-
nication toward the partner) (Fletcher et al., 2018).
Types of social cognition Overall, social cognition research has focused on two major
categories of thinking—knowledge structures regarding relationships and moment‐
to‐moment “online” processing of information (Fletcher et al., 2018)—and it is notable
that those two categories correspond to the two major categories of cognition in
Beck’s cognitive therapy model (A. T. Beck, Rush, Shaw, & Emery, 1979): schemas
and automatic thoughts. Fletcher et al. (2018) note that a variety of terms have been
used to denote knowledge structures, or relatively stable internalized constructs, such
as schemas, scripts, prototypes, working models, and mental models. There are three
functions of these constructs that individuals develop through experiences with others
beginning after birth and “carry with them” over time. They provide the individual
with explanations for current experiences (e.g., “I am uncomfortable with people
who express anger because of my violent father”), they help one predict outcomes
(e.g., “If I express my opinions, I will be ignored”), and they increase one’s ability to
exert control over particular aspects of relationships (e.g., “After you compliment
a person, he or she is more likely to comply with a request you make”) (Fletcher
et al., 2018).
These knowledge structures or personal theories vary from global views of rela-
tionships with people in general (e.g., how trustworthy people tend to be) to con-
cepts regarding romantic relationships in particular, to specific concepts about a
past or current personal romantic relationship (Fletcher et al., 2018). An individu-
al’s knowledge structures or theories about a current relationship become more
complex as he or she accumulates more experiences with the partner, and the level
of satisfaction with the relationship depends on how closely experiences with the
partner match the individual’s standards for a close relationship (Baucom, Epstein,
Rankin, & Burnett, 1996; Campbell & Fletcher, 2015). Research indicates that
established knowledge structures tend to be resistant to change, and individuals
selectively attend to information that is consistent with their existing beliefs
(Meichenbaum, 1985), but the knowledge structures have potential to be modified
through new life experiences that disconfirm them (Fiske & Taylor, 1991). An
example of knowledge structures that exhibit significant stability in adulthood is
the attachment working models, or beliefs, that individuals have regarding their
own lovability and of the emotional availability of an attachment figure such as a
parent or romantic partner, although research also indicates that adults’ working
models commonly show change over time (Fletcher et al., 2018; Fletcher, Simpson,
Campbell, & Overall, 2013).
Automatic processing of cognition Fletcher et al. (2018) point out that individuals
commonly access their relationship theories unconsciously and automatically
rather than intentionally thinking about them when evaluating current experi-
ences with a partner. The automatic processing poses a challenge for clinicians in
guiding members of distressed couples in exploring the appropriateness of their
standards. More deliberate conscious analysis tends to occur when individuals
experience negative and unexpected events (Fletcher et al., 2018), a process that
therapists often observe when couples enter therapy in a crisis state after a very
upsetting event such as discovery of a partner’s infidelity (Baucom, Snyder, &
Gordon, 2009).
Cognitive Therapy Model
During the same period when behavioral models of couple and family therapy were
developing and captured complex behavioral interaction patterns in intimate relation-
ships, cognitive models of individual psychopathology and therapy (A. T. Beck, 1976;
A. T. Beck & Emery, 1985; Ellis, 1962; Meichenbaum, 1977) were gaining major
recognition. Whereas Ellis’ model emphasized stable core irrational beliefs or knowl-
edge structures that produced distress and dysfunction because real life failed to match
the individual’s unrealistic standards, Beck’s model differentiated stable underlying
schemas or knowledge structures regarding characteristics of the self and world from
much more transitory automatic thoughts regarding one’s immediate experiences.
The model also includes a variety of cognitive distortions or information processing
errors (e.g., all‐or‐nothing thinking, arbitrary inference, overgeneralization) that con-

tribute to distressing automatic thoughts. In the Beck model, events in an individual’s
daily life activate relevant schemas, resulting in stream‐of‐consciousness automatic
thoughts. Meichenbaum’s (1985) approach to understanding stress responses and
assisting individuals in developing skills for “stress inoculation” takes into account
forms of cognition similar to those in the Beck model, including relatively stable sche-
mas, “cognitive events” or stream‐of‐consciousness automatic thoughts, and cogni-
tive processing involving information processing such as drawing inferences. All of the
models underlying the rapidly developing cognitive therapies had in common an
assumption that individuals’ negative emotional and behavioral responses to life
events are influenced by negative cognition. For example, an employee’s emotional
distress upon receiving some criticism from the boss may be due to the individual’s
schema involving a personal standard that one should perform perfectly in all one
does, distorted information processing in which no instances of praise from the boss
are remembered, and automatic thoughts involving an expectancy that the boss is
going to fire the individual.
Application of cognitive therapy models to significant relationships

Although cognitive models initially were developed primarily to address problems
with individuals’ personal functioning such as depression and anxiety (A. T. Beck
et al., 1979), they were applied increasingly to understand and treat couple and
family relationship problems (A. T. Beck, 1988; Dattilio & Padesky, 1990; Ellis,
Sichel, Yeager, DiMattia, & DiGiuseppe, 1989; Epstein, 1982; Epstein, Schlesinger,
& Dryden, 1988). In the relationship context, each member serves as a source of
life events that the others interpret and appraise cognitively, leading to the
individual’s emotional and behavioral responses to the other(s). The interpretations
and appraisals are automatic thoughts that are shaped by preexisting schemas such
as beliefs or standards regarding the characteristics that a caring family member
“should” possess (Baucom & Epstein, 1990; Epstein & Baucom, 2002). Although
some of the literature on these cognitive‐behavioral concepts was primarily an
extension of the individually based Ellis and Beck models that emphasized each
individual’s distorted or unrealistic cognitions, other publications (e.g., Epstein
et al., 1988) presented a more integrative model that simultaneously attends to
behavioral interactions among members and individuals’ subjective cognitions
about them. Thus, assessment and understanding of a couple that presents with a
demand–withdraw behavioral pattern when dealing with areas of conflict in their
relationship would include inquiry about a withdrawing individual’s thoughts
(e.g., “He wants to control me”) and emotional responses (e.g., anger) to the
partner’s demand/pursuit behavior, as well as inquiry about the demanding
individual’s thoughts (e.g., “I can’t stand it if we don’t talk and settle this issue!”)
and emotional responses (e.g., anxiety) to the other’s withdrawal behavior. The
emphasis is on circular processes involving both external actions and subjective
internal cognition and affect (Baucom & Epstein, 1990; Epstein & Baucom,
2002). In CBCFT, the therapist emphasizes collaboration with the couple or family
in identifying the cognitive, affective, and behavioral aspects of their distressing
interactions and engaging them in joint efforts to make constructive changes.
Types of relationship cognitions

The research and clinical literature on relationship cognitions has extended beyond the
basic dichotomy between schemas and automatic thoughts, differentiating several
types of cognitions that influence close relationships. Baucom and Epstein (1990);
Baucom, Epstein, Sayers, & Sher, 1989) developed a typology of relationship cognitions
that have been found to be associated with couple relationship satisfaction and
communication quality, and they also apply to family relationships. Two of them
(assumptions and standards) are relatively long‐standing, stable schemas. More research
has been conducted on assumptions and standards about couple relationships (Epstein
& Baucom, 2002) than about family relations (Roehling & Robin, 1986).
Assumptions Assumptions are beliefs about the characteristics of individuals and

close relationships (e.g., a man’s assumption that women like to control men; a
parent’s assumption that young children lack the cognitive capacity to be aware of
tension in their parents’ relationship). Regarding close relationships, the “working
model” schemas involved in individuals’ attachment styles (which are assumptions
regarding one’s own lovability and regarding significant others’ emotional availability)
develop early in life with caretakers, also develop with adult romantic partners, and
influence one’s sense of security in relationships (Hazan & Shaver, 1987). As
emphasized in emotionally focused couple therapy (Greenberg & Goldman, 2008;
Johnson, 1996), when an individual perceives a partner as unavailable based on the
partner’s current behavior but also based on longstanding insecure attachment, the
individual is likely to become anxious (a “primary emotion”) but often expresses
anger toward the partner (a “secondary emotion”) in a potentially misguided
attempt to cope with the insecurity. Consequently, CBCFT takes a developmental
perspective on the origins of family members’ assumptions and collects information
about partners’ attachment relationships from childhood to adulthood (e.g., with
genograms).
Although assumptions generally can be helpful to individuals in organizing and
making sense of their experiences in daily life, they can be sources of distress in couple
and family relationships when they are inaccurate (Dattilio, 2010). For example, an
individual who holds an assumption that behaving aggressively is an effective way of
being taken seriously by others is likely to use verbal (and perhaps also physical)
aggression when in conflict with family members, causing them significant distress.
Standards In contrast to assumptions, standards are schemas involving beliefs

about characteristics that individuals and relationships “should” have. For example,
an adult may hold a standard that members of a couple should want to spend all
of their leisure time together rather than pursuing individual interests. Within a
family, an adolescent may hold a standard that his parents should allow him all the
freedom he wants to manage his own time. Personal standards are not inherently
dysfunctional; for example, individuals commonly have moral standards that guide
their prosocial behavior toward others. However, risks for relationship dissatisfaction
exist when an individual’s standards are unrealistic (e.g., expecting that one’s
partner should be receptive to sexual overtures even after an upsetting argument)
or when partners’ standards are so discrepant that they are difficult to reconcile
(Epstein & Baucom, 2002).
Identification of relationship schemas The original broad conception of schemas in

Beck’s model (A. T. Beck et al., 1979) was expanded by Young (Young, Klosko, &
Weishaar, 2003) to identify and treat entrenched schemas with core themes (e.g., that
one is unlovable, defective, vulnerable to harm, incompetent) that were developed
through family of origin and other early life experiences and developed into chronic
personality disorders. Schwebel and Fine (1994) and Dattilio (2010) focus on how
the schema therapy model can be applied to couple and family relationships, identify-
ing members’ core schema themes that contribute to dysfunctional interaction
patterns and conflict. Some attention is paid to individually oriented schemas that
influence a person’s reactions to the broader world (e.g., a parent with a schema “I
must perform at an excellent level in all that I do, or I am a failure in life” becomes
frustrated, angry, and punitive when her attempts at disciplining her child are ineffec-
tive). However, in CBCFT, the emphasis is on schemas regarding the self within
intimate relationships and how they are activated during family interactions and
influence members’ responses to each other. For example, a parent who has a schema
(in this case, an assumption) that children are naturally willful, are disrespectful, and
need to be taught to respect parents may emphasize aggressive discipline methods
to show the child who is in control. Such a schema also may lead the parent to
attend selectively to instances when the child is noncompliant, overlooking positive
child behavior.
Dattilio (1993, 2010) and Schwebel and Fine (1994) refer to family schemas as
long‐standing beliefs regarding one’s own family and about family life in general. The
family schemas regarding natural characteristics of family life in general develop over
a lifetime, from family of origin experiences, observation of other families, and media
portrayals of families. They include assumptions about characteristics of adults and
children (some tied to assumed correlates of gender), standards for a successful family,
and standards for role enactment of parents, spouses/partners, and children. In addi-
tion to portrayals of characteristics of families, the schemas include scripts, concep-
tions of sequences of events, such as how a couple or family interacts to make decisions.
Scripts guide members of families as they interact in particular situations, and mem-
bers may become upset when others’ actions are inconsistent with those expectations.
Dattilio (2010) describes family schemas that are beliefs shared by members of a fam-
ily, based on many years of interacting with each other. Those may include beliefs
passed down from parents to children, such as “The women have always been the
ones to keep the family together during difficult times,” “We are a ‘bad luck’ family
and just can’t get a break in life,” and “Jimmy takes after his father; you can’t count
on him.” Such shared beliefs limit the options that members perceive for interacting
with each other and the outside world.
Selective attention, attributions, and expectancies Three other types of relationship

cognitions (selective attention, attributions, and expectancies) can be considered
forms of automatic thoughts, because they occur in the moment and become the
individual’s experience of reality that she or he commonly does not evaluate. Selective
attention (commonly labeled selective abstraction in the cognitive therapy literature)
involves noticing some aspects of available information in situations and overlooking
others (J. S. Beck, 2011; Epstein & Baucom, 2002). The negative tracking that
behavioral couple and family therapists (e.g., Jacobson & Margolin, 1979) identified
is a common example of this biased perception. As we described earlier, attributions are
inferences that individuals make about the factors influencing observed events (e.g., a
man’s partner failed to phone him about her late arrival home from work, and he
attributed it to her not caring about his feelings), and expectancies are inferences
involving predictions of probabilities that particular events will occur in the future
(e.g., the man whose partner failed to call has an expectancy that if he tells her he was
upset about it, she will become defensive and complain that he is too sensitive). Just
as selective perceptions are susceptible to bias, attributions and expectancies can vary
in their accuracy, but, similar to other automatic thoughts, they arise in the individu-
al’s mind quickly, and people generally accept them as valid rather than engaging in
self‐reflection about other possible interpretations of events (Baucom & Epstein,
1990; Epstein & Baucom, 2002).
Implications of social cognition research and the cognitive

therapy model for CBCFT
The research findings on social cognition and concepts have described how people
store and retrieve information from their experiences, and on ways in which informa-
tion processing is subject to distortion, and have contributed to CBCFT assessment
and treatment methods. In terms of assessment, CBCFT clinicians collect information
from couples and families regarding the aspects of each other’s behavior that are
noticed most and those that may be overlooked, as well as each person’s attributions
and expectancies about events in their relationships. Therapists also interview mem-
bers about assumptions and standards that they hold regarding relationships in gen-
eral and about their relationships in particular. Inquiring about family of origin
relationships also is valued as a means of identifying sources of current members’
schemas (which can be used as feedback to help members evaluate their beliefs).
Constructing a genogram with members of a couple or family commonly aids in iden-
tifying intergenerational family patterns that contributed to members’ core beliefs
about family relationships and beginning the process of members considering ways in
which they need not perpetuate problematic patterns (Dattilio, 2010). For example,
the genogram may reveal an intergenerational pattern in which male family members
commonly behaved in irresponsible ways and female members took on over‐function-
ing roles, creating a shared family schema about inequitable gender roles. In addition
to interviews, clinicians monitor couple and family interactions during sessions and
probe for cognitions when verbal or nonverbal cues suggest that an individual has
reacted to another member’s actions (Epstein & Baucom, 2002).
Cognitive interventions
In terms of treatment, CBCFT has borrowed from Aaron Beck’s cognitive therapy
(A. T. Beck, 1976; A. T. Beck et al., 1979; J. S. Beck, 2011; Leahy, 1996) helping
individuals learn to identify aspects of their thinking that contribute to their negative
emotional and behavioral responses within their relationships, test the validity of their
cognitions, and replace distorted thoughts with more realistic or appropriate ones.
CBCFT interventions involve collaborating with family members to track the occur-
rence of particular cognitions during family interactions, identify thought processes
that contribute to negative patterns, examine their validity or appropriateness, and
experiment with substituting alternative attributions, standards, etc. (Baucom et al.,

2015; Dattilio, 2010; Epstein & Baucom, 2002). For example, a Socratic approach
often is used to guide an individual in considering the validity of a negative attribution
about another member’s motivation for behaving in an upsetting way. The therapist
may state, “You have described your inference that your son failed to complete his
chores because he wants to challenge your authority, which is very upsetting to you.
Although you may be correct about his motives, it is important to check on how
accurate that upsetting thought is. What other reasons can you think of that might
explain your son’s not doing his chores?” In addition, the therapist might suggest that
the parent review memories of the son’s past behavior, considering other information
that was either consistent or inconsistent with the inference that the son is engaging
in a power struggle. The goal is for the family members to achieve reasonable views of
each other, based on logic and evidence.
In addition to the Socratic methods used to guide members in examining and modifying
their thinking, therapists provide brief psychoeducational descriptions to family members
that help them evaluate the appropriateness of their cognitions. For example, a therapist
can give parents who appear to be applying age‐inappropriate standards for a child’s
cognitive, emotional, or behavioral development brief readings or brief educational oral
presentations regarding normative child development. Thus, parents who believe that a
young child should be able to understand lectures on the importance of altruism among
siblings can be told about normative moral development for a child of that age and guided
in designing more age‐appropriate strategies for managing their child’s behavior. Such
psychoeducation interventions are used commonly in CBCFT‐based programs for parents
dealing with a child’s symptoms of attention deficit hyperactivity disorder (ADHD)
(Barkley, 1998) and families coping with a member’s symptoms of a major mental disorder
such as schizophrenia (Mueser & Gingrich, 2006).
Similarly, therapists acknowledge to clients the value of holding standards that
guide one’s behavior toward others in life, including personal standards for ethical
actions, but the importance of examining how reasonable and appropriate one’s
standards are is emphasized. Rather than telling clients how to think, CBCFT clini-
cians focus on broadening the scope of their cognitions, with family members ulti-
mately drawing their own conclusions about their views of their relationships. One
common intervention for facilitating clients’ evaluations of their relationship stand-
ards involves asking them to list in detail the advantages and disadvantages of a par-
ticular standard and to consider a revised standard that still captures their core values
but perhaps is more reasonable. Thus, an individual who adheres to a standard that a
caring partner should be able to “mind‐read” the other person’s thoughts and emo-
tions might list advantages of the standard such as “It makes you consistently pay a lot
of attention to your partner, which shows that you care,” and “A person who is upset
doesn’t have to go to the trouble of explaining it to their partner.” However, a list of
disadvantages might include “It may encourage partners to be lax in communicating
clearly to each other about their feelings,” and “People may stand on ceremony wait-
ing for their partner to ‘get it right’ in identifying their feelings.” With a therapist’s
guidance, the individual may devise a more reasonable standard such as “Caring indi-
viduals pay attention to cues of each other’s feelings, learn from past experiences
about particular cues that the other person is experiencing feelings, and inquire about
them. However, because humans cannot actually read each other’s mind, partners
should help each other by revealing feelings that the other person may not notice.”
Models of Emotion in Intimate Relationships
Forms of cognitive‐behavioral therapy including CBCFT have long been somewhat

handicapped in a “public relations” way by the absence of the term “emotion” in their
title, leading members of mental health professions as well as the lay public to assume
that the concepts and methods of the treatments pay little attention to people’s affect.
Groundbreaking publications by Beck, Ellis, Meichenbaum, and others described
links between dysfunctional forms of cognition and heavily affective psychological
disorders such as depression and anxiety disorders, in which stressful life experiences
(e.g., loss of a job) activated an individual’s long‐standing personal schema (e.g., “I
am not as smart as other people”), eliciting negative automatic thoughts (e.g., “I blew
it. I can’t keep a job”) and negative emotions (e.g., anxiety, shame) (Dobson, Poole,
& Beck, 2018). That emphasis on cognition influencing emotion has led some read-
ers to interpret the model as simplistically linear.
The role of emotion in the cognitive therapy model

A linear view of cognition producing emotion partly fails to capture the complexity of
the original cognitive therapy model. For example, one of the common cognitive
distortions identified by Beck and colleagues is emotional reasoning, in which an indi-
vidual focuses on cues of his or her emotion to understand circumstances, such as an
individual who has noticed a decrease in affectionate feelings for a partner and con-
cludes, “I’m falling out of love” (Dobson et al., 2018). In addition, theoretical devel-
opments over the past few decades have refined and strengthened the affective
components of cognitive therapy models. For example, writers have described how
individuals’ awareness and catastrophic interpretation of physical symptoms of anxiety
(e.g., an individual with panic disorder interpreting shortness of breath as the danger-
ous beginning of suffocation), labeled anxiety sensitivity, exacerbate the emotional
arousal and lead the individual to engage in counterproductive coping strategies such
as attempts to escape (Clark, 2018). Emotional schema therapy (Leahy, 2018) posits
that individuals routinely interpret the meaning of their emotions, and those who
have long‐standing schemas that particular emotions are abnormal, dangerous,
uncontrollable, shameful, and intolerable engage in dysfunctional coping responses
such as substance abuse, cognitive avoidance/dissociation, rumination, avoidance,
blaming others, and other forms of unregulated negative behavior.
Current conceptions of emotion in CBCFT

A number of theoretical and empirical developments regarding affect in interpersonal
relationships by researchers and clinical writers have helped shape the current role of
emotion in CBCFT. There is substantial evidence that emotions convey important
information both for the individual who experiences them and for others who interact
with that person. Clinical writers such as A. T. Beck (1976), from a cognitive therapy
perspective, and Goldman and Greenberg (2006) and Johnson (1996, 2015), from
an emotionally focused therapy (EFT) perspective, have noted the associations
between particular emotions and cognitive themes, such as sadness and depression
linked to perceived loss, anxiety or fear linked with threat and danger, and anger associated
with violation of one’s rights and autonomy. They stress that overall emotions occur
in response to events (commonly interpersonal ones), real or imagined by the
individual, which are interpreted as facilitating or interfering with the gratification of
the person’s goals or needs. Thus, emotional responses serve core functions in alerting
individuals to their unmet needs and motivating them to take action to attempt to
induce others to help them fulfill their needs. Cognitive therapists note that clients
often notice their emotional states in response to circumstances before they become
aware of their thoughts about the situation, so emotions are viewed as a gateway to
understanding the individual’s subjective world and what matters to her or him.
In addition, proponents of EFT (Greenberg & Goldman, 2008; Johnson, 1996,
2015) emphasize that the members of a couple or family are connected through an
emotional system and continuously regulate each other’s emotions. Cues of emotion
from one member are signals to other members about the individual’s needs and how
the individual is likely to respond to their actions, thereby influencing the others’
actions. Goldman and Greenberg (2006) stress that better emotion regulation is
needed both in cases of too little recognition and expression of emotions and in cases
of excessive emotional responses. The CBCFT model includes a conception of the
role that emotional responses play in relationships that overlaps with that of EFT, in
that both deficits and excesses in emotional awareness and expression are considered
problematic, and goals of therapy include increasing family members’ awareness of
their subjective emotions and developing their skills for communicating their feelings
constructively to significant others (Baucom & Epstein, 1990; Dattilio, 2010; Epstein
& Baucom, 2002; Rathus & Sanderson, 1999).
Research regarding the role of emotion in couple and family relationships

Clinical writers’ observations about the function of emotions in couple and family
relationships are consistent with basic research findings. In their review of research on
roles of emotion in relationships, Planalp, Fitness, and Fehr (2018) describe how
beginning in childhood individuals develop “emotional knowledge” that includes the
ability to recognize and differentiate types of emotional experiences, how particular
emotions are linked to particular causes and consequences, and how to regulate one’s
emotional states. They note that cognitive appraisals influence emotions and that a
shift in cognition can result in a change in emotion. For example, an individual who
felt angry due to attributing a partner’s late arrival home as due to a lack of caring
shifted to warmer feelings upon learning that the partner’s boss detained her at work
and that she left her cell phone in her office when rushing to leave for home. Planalp
et al. (2018) also summarize findings that emotional expressions help members of a
relationship know each other’s needs, goals, and subjective experiences, allowing the
parties to coordinate and collaborate with each other.
Research has indicated that positive and negative emotions are relatively independent
rather than poles of a single dimension, so reducing negativity does not automatically
result in an increase in positivity (Planalp et al., 2018). Those research findings are
consistent with Epstein and Baucom’s (2002) emphasis on balancing CBT
interventions for decreasing negative couple interactions with other interventions to
increase positive interactions. Planalp et al. (2018) stress the importance of couples
having or developing strategies to upregulate shared positive emotional experiences,
and Gottman (1999) advocates a CBT‐like emphasis on repair attempts for couples to
counteract negative experiences with positives (e.g., taking responsibility for a prob-
lem, agreeing with one’s partner, expressing affection).
The bottom line from the research findings is that emotion is the lifeblood of cou-
ple and family relationships, the essence of the quality of life within those bonds.
Although some couples can have emotionally volatile but stable relationships if both
partners value and accept the intense expressiveness or can tolerate a “devitalized
relationship devoid of emotional connection” (Gottman, 1994, 1999), the distressing
emotions (contempt, anxiety, depression) that commonly drive dysfunctional patterns
such as demand–withdraw, mutual escalation of aggression, and mutual avoidance
take a major toll on the physical and mental health of the partners (Goldman &
Greenberg, 2006).
Implications of models of emotion for CBCFT

The important communicative function of emotions for understanding oneself and
other family members has key implications for CBCFT assessment and intervention.
Therapists need to be adept at tracking cues of family members’ emotional experi-
ences, drawing the signals to the clients’ attention, and enhancing the members’ skills
for self‐monitoring, expressing emotions constructively, and responding empathically
to others’ emotional messages (Epstein & Baucom, 2002). Clinicians need to identify
patterns in which members of a couple or family mutually regulate each other’s emo-
tional states, intervene to increase members’ awareness of those impacts, and engage
the members in a collaborative effort to all make behavioral changes to shift the emo-
tional processes. Psychoeducational presentations can focus on the variety of possible
human emotions and be followed by coaching in differentiating among emotional
responses of the self and others (Epstein & Baucom, 2002). Using initial awareness of
one’s emotional state to explore associated needs and fostering an appreciation for
curiosity about the inner experiences of other family members, CBCFT therapists can
present themselves as joining with the clients in “detective work” to uncover basic,
common human needs that have been overlooked and can be tapped to make the
members happier in their relationships. Furthermore, the assessment of and interven-
tion with behavioral patterns that generate or perpetuate negative affect, along with
interventions to “upregulate” joint positive interactions and associated emotions, are
core aspects of the behavioral components of CBCFT. Simultaneously, cognitions
that contribute to negative emotions such as unrealistic standards that breed discon-
tent and negative attributions about other family members’ motives and level of car-
ing are important foci of assessment and treatment in CBCFT. With particular
presenting problems such as partner aggression, cognitions such as beliefs that fuel
anger and justify punitive behavior toward a partner are key targets for intervention.
Teaching family members anger management skills including self‐soothing tech-
niques, anger‐regulating self‐talk, and use of “time‐outs” to reduce dangerous levels
of anger are commonly used approaches for domestic violence (Epstein, Werlinich, &
LaTaillade, 2015). Similar CBCFT interventions can be used with couples coping
with strong anger and anxiety from disclosure of infidelity, fears associated with a
cancer diagnosis and stressful medical treatments, and other major life stressors.
Rather than overlooking emotion in close relationships, CBCFT brings a wealth of
concepts and methods to the treatment of emotional aspects of relationship problems.
Family Systems Theory
Proponents of family systems theory, which emphasizes recursive patterns of mutual

influence among members of a family, initially were not receptive to behavioral and
cognitive models of relationship functioning (Dattilio, 2010). The resistance stemmed
from their viewing those models as linear (i.e., stimulus leads to behavioral response,
which is controlled by consequences; stimulus–response link is mediated by cognitive
interpretation). Even though behavioral and cognitive‐behavioral models actually
focused on circular causal processes, as in Patterson’s (1982) portrayal of coercive
family systems of adolescents with conduct disorders, some systems‐oriented thera-
pists perceived them as focusing on superficial explanations for symptoms rather than
more symbolic meanings. For example, a systems theory interpretation of a child’s
negative behavior might emphasize the function the behavior had in distracting par-
ents from their marital problems.
However, a behavioral functional analysis of such a family in which antecedent
conditions to a particular behavior (likely eliciting events) and consequences that
reinforce or punish the behavior (Epstein & Baucom, 2002) actually might identify a
pattern in which the child was most likely to misbehave when the parents began to
argue, which would implicate parental conflict as a factor affecting the child’s problematic
behavior. In a CBCFT framework, it would not be assumed that the child was consciously
or unconsciously sacrificing herself to save the parents’ relationship, as there is substantial
research evidence of links between marital conflict and child psychopathology via a
pathway through compromised parenting behavior (Cummings & Davies, 2002). A
systemic CBCFT assessment of the interaction patterns among parents and children in
such a family is likely to identify behavioral responses (e.g., couple problem‐solving and
parenting skill deficits), cognitions (e.g., parental automatic thoughts such as “I am
overwhelmed and can’t handle the children”), and emotional responses (e.g., poorly
regulated parental anxiety and anger) that can be addressed with CBCFT interventions.
The interventions would not be limited to a linear focus on the parents, because child
strategies for coping with parental marital conflict also have been found to affect child
psychological adjustment (Nicolotti, Whitson, & El‐Sheikh, 2003).
The systems concept of feedback processes also is consistent with a CBCFT model.
For example, the concept of positive feedback describes a process in which family
members’ responses to each other amplify a pattern, as when parents and adolescents
in a “coercive family system” reciprocate and escalate aversive actions (Patterson,
1982). Similarly, CBCFT addresses systems theory concepts of family structure,
including boundaries and hierarchy. Boundaries are defined by who interacts with
whom, and in what roles, which involves both overt behavioral patterns and the fam-
ily members’ internal cognitions about what is appropriate. When a parent shares
intimate information about the couple’s marriage with a child and courts the child’s
support, this violates an appropriate boundary between generations and weakens the
parent–child hierarchy. In CBCFT terms, interventions may require modification of
the parent’s beliefs about what children should know about adult issues, coaching the
parent in limiting the content of discussions with the child, and encouraging the cou-
ple to work on their marital conflict apart from their children.
Epstein and Baucom (2002) added another dimension to the systemic approach
that CBCFT brings to couple and family relationships, namely, contextual factors
associated with an ecological framework. Consistent with ecological theory
(Bronfenbrenner, 1979), there are multiple levels of contextual influences on a rela-

tionship with which the members must cope, for example, extended family, friends,
neighbors, schools, jobs, characteristics of the local community such as crowding and
crime, and broader societal and worldwide factors such as economic conditions and
culture. CBCFT takes these contextual factors into account as demands or stressors
on the couple or family (as well as possible sources of resources potentially helpful to
them). Applying a stress and coping framework, Epstein and Baucom (2002) examine
how the family members’ cognitive appraisals of the demands/stressors influence the
level of stress and disruption that they experience, what individual and joint skills and
other resources the members have for coping, and how much emotional turmoil and
disequilibrium they experience from the demands. A CBCFT model is directly appli-
cable to addressing those cognitive, behavioral, and emotional aspects of stress and
coping. Thus, family systems theory and an ecological framework are important parts
of the foundation of CBCFT, providing core concepts regarding couple and family
structure and processes that clinicians can use in assessing and treating intimate
relationships.
Implications of family systems theory for CBCFT

As we noted, the early applications of social learning theory to couple and family
relationships focused on increasing members’ exchanges of positive behavior and
decreasing negatives via behavioral contracts and teaching communication and
problem‐solving skills. Those methods were systemic to the extent that they
focused on all parties’ contributions to the quality of relationships. Since Gurman
and Kniskern (1978) documented that individual therapy for marital problems had
a poor prognosis in comparison with conjoint therapy, substantial research evidence
has accrued regarding the effectiveness of direct treatment of the couple or family
relationship as a system for relationship problems (e.g., conflict, infidelity, partner
aggression) and individual psychological and physical health problems such as
depression, anxiety disorders, obsessive–compulsive disorder, eating disorders, and
couple coping with cancer (Fischer et al., 2016). CBCFT methods allow the
clinician to assess dysfunctional interaction patterns, especially directly through
observation of the couple or family, and engage the members in more constructive
ways of relating. Systems theory concepts regarding circular process, reciprocity,
feedback loops, boundaries, etc., guide the CBCFT clinician in identifying
problematic patterns and planning treatments.
The clinician’s goal is to track pathways through which the cognitions, the emotional
responses, and the behaviors of each member of a couple or family influence each of
the other domains (e.g., behavior influences cognition and emotion, emotion
influences cognition and behavior, etc.) within the same individual and within the
other members. In addition, an ecological perspective guides the clinician in looking
beyond the family system itself to various contextual factors that may be influencing
the family’s functioning. Identifying those paths and evaluating which paths provide
the most feasible “entry points” for therapeutic interventions provides information
for treatment planning. This is a complex task, but as therapists well know, couples
and families exhibit repetitive patterns, so the clinician will have repeated opportuni-
ties to observe links among cognitions, emotions, and behavioral interactions.
Conclusion
CBCFT devotes significant attention to understanding the cognitive, emotional, and

behavioral domains of couple and family relationships. As a systemic and integrative
model, it attends to complex links among the three domains and uses interventions
that commonly have simultaneous effects on members’ thinking, feelings, and behav-
ioral interactions. Clinical texts on CBCFT (e.g., Baucom et al., 2015; Dattilio, 2010;
Dattilio & Epstein, 2016; Epstein & Baucom, 2002; Epstein, Schlesinger, & Kim,
2018) detail the multidimensional assessment and treatment planning involved in this
flexible and uniquely effective treatment model.
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17
Attachment and Other
Emotion‐Based Systemic
Approaches
Ryan B. Seedall and Jonathan G. Sandberg
In the 1970s, researchers developed a fascinating experiment called the still‐face

paradigm (SFP) (Tronick, Als, Adamson, Wise, & Brazelton, 1978). The SFP was
originally designed to examine the role of infants in social interaction with a parent
(Mesman, van IJzendoorn, & Bakermans‐Kranenburg, 2009). Although consisting
of several steps, perhaps the most telling is when the parent ceases interacting with the
infant and maintains a neutral facial expression. Doing this often leads to confusion in
the infant, followed by a redoubling of efforts to engage the parent in interaction.
A continued lack of response from the parent, even with the infant’s exaggerated
attempts to interact, leads to sizeable distress in the infant. Although there are a num-
ber of individual and relationship factors associated with infant responses during the
SFP, these findings—along with many others—highlight the interactional nature of
humans and the salience of emotional experience. Put simply, we are wired to connect
with others and form close, mutually beneficial relationships. Threats to these
relationships are inherently distressing.
However, this predisposition toward connection and relationships does not mean it
is simple. We all have different family of origin, relationship, and cultural experiences
that inform how we view ourselves and others as well as the function of emotions
in our relationships. We see the varied results in therapy. There are clients who are
super‐reasonable, cover up emotions with humor, or have walled themselves off emo-
tionally. Others become overwhelmed by emotion and have difficulty expressing their
hurt without attacking and criticizing, or they justify hurtful comments because they
want to make sure their partner understands what they “really feel.” Then, when
considering that some of these vastly different people become romantic partners, it
highlights how different relationships, interactional patterns, and therapy experiences
can be. For this reason, it can be so challenging for SFTs because there are so many
unique and customizable elements to the change process.
To illustrate, I (R.S.) once worked with a severely distressed couple that had a wide
array of complex strategies (both conscious and unconscious) to keep them from
expressing vulnerable emotions (e.g., humor, alcohol, etc.). After many sessions,
392 Ryan B. Seedall and Jonathan G. Sandberg
we had what I would call a breakthrough. I was able to get them to a place of vulner-
ability where they both became emotional and expressed how scared they were to try
and make things work. I left the session feeling rejuvenated. I could not wait for the
next session to build on the progress of the previous one. So, what happened? They did
not come back for six months! I am sure there are a variety of therapeutic and contex-
tual factors for this. However, I have often wondered if the emotions they experienced
were too raw, too vulnerable, and too unsafe for them to return the next week.
What can we learn from this example? Although principles of change may be con-
sistent across a wide variety of people and presenting problems, what clients need to
catalyze change and how the therapist should go about facilitating that change can be
very different. Something that has been a crucial organizing feature for both authors
to conceptualize client experiences and inform what we do in therapy is attachment
theory (Bowlby, 1969/1982). Attachment theory is both intrapsychic and relational,
meaning it informs how individuals process and regulate their emotions as well as the
type of interactional patterns that are most common in their relationships. This chap-
ter will provide an overview of attachment theory, including those aspects of greatest
relevance to SFTs. We will also highlight where SFT is in terms of attachment‐based
intervention and the important next steps.
Attachment Theory Foundations
John Bowlby and Mary Ainsworth

In the 1940s and 1950s, when the SFT pioneers like Nathan Ackerman, Lyman
Wynne, Murray Bowen, Carl Whitaker, Jay Haley, and Virginia Satir were exploring
the benefits of a systemic approach to treating psychopathology in the United States,
a British psychoanalyst was receiving a great deal of opposition for his ideas about a
child’s tie to her/his mother and the negative effects arising from separation and dis-
connection. Unlike Freud, who described the tie as sexual (libido), Bowlby conceptu-
alized the affectional bond as relational, instinctive, and driven by evolutionary
biology. He noted that infants display goal‐directed behavior designed to maximize
caregiver proximity (Bowlby, 1969/1982; Dozier, Bernard, & Roben, 2017) and
that close physical contact and responsive, nurturing behavior from caregiver to child
was related to healthy development. Attachment theory was born out of clinical expe-
rience (in Bowlby’s case, working in a home for maladjusted boys) and is well suited
as a guide for clinicians (Bowlby, 1988). At a basic level, attachment theory arose
from a need to understand and explain patterns of connection and separation in
human relationships, a pursuit familiar to most SFTs. Bowlby also used interdiscipli-
nary collaboration to build his theory. For example, he often used ethological princi-
ples and findings from researchers such as Konrad Lorenz and Harry Harlow to
support his ideas. Overall, his observations and descriptions of behavior using clear
theoretical constructs has made his readings relevant for researchers and clinicians for
nearly 75 years (see Cassidy (2016), for a more detailed review).
Mary Salter Ainsworth was exposed to the concept of security in parent–child
relationships during her undergraduate work at the University of Toronto; she
went on to develop two different measures of security for her dissertation
(Ainsworth & Bowlby, 1991). After a productive and fascinating stint working
Attachment-Based Approaches 393
with Bowlby in the early 1950s, Ainsworth conducted a groundbreaking study of

infants and their mothers in Uganda. Importantly, her painstaking observational
study found that contrary to the tenets of behaviorism, infants whose mothers were
more responsive to their crying ended up crying less and being less clingy
(Ainsworth, 1967). This study was expanded and replicated in the Baltimore area,
and findings led to Ainsworth’s development of the Strange Situation procedure,
which consists of 8 episodes lasting approximately 20 min and is designed to exam-
ine infant exploration as well as proximity‐seeking behavior when the infant
becomes distressed (Ainsworth, Blehar, Waters, & Wall, 1978). The Strange
Situation represents the gold standard of attachment measurement, with most
other measures of attachment linking to it either conceptually or empirically.
Overall, Ainsworth’s efforts laid the groundwork for most attachment research
over the last 50 years.
Attachment models of self and other

Bowlby introduced the idea that attachment theory outlines a normative process that
is central to human life. The concept of a behavioral system allowed him to describe
“a species‐universal, biologically evolved neural program that organizes behavior in a
way that increases an individual’s chance for survival” (Mikulincer & Shaver, 2016,
p. 9). This hardwired, innate behavioral system is purposeful, with the primary goals
being protection and safety. The attachment behavioral system is activated or trig-
gered when threats to security are present. Both Bowlby and Ainsworth described
how children seek proximity, connection, and comfort in their interactions with
attachment figures to manage stress and uncertainty. The caregiver’s responses to the
child when activated, over time, contribute to a “prototype of…emotional regulation
and interpersonal closeness” (Mikulincer & Shaver, 2016, p. 13).
This prototype is established through a process of repeated interaction early in life
and is often referred to as an internal working model (Bowlby, 1988) of self (“Am I
lovable?”) and other (“Can I trust you?”). Although the first year of life represents a
critical period for establishing these internal models (Bowlby, 1973), they are refined
over thousands of small moments that occur within close relationships. They inform
how we make sense of the world, including whether attachment figures can be
counted on as secure bases from which to explore and to return to when needing
reassurances of safety and comfort (Bowlby, 1973). Ultimately, our internal working
models form patterned responses for responding to stress and dysregulation, predict-
ing what kind of proximity‐seeking and co‐regulation strategies we employ
(Ainsworth et al., 1978).
Organized attachment patterns Ainsworth’s Strange Situation procedure (Ainsworth

et al., 1978) was designed to highlight the varying coping strategies that young chil-
dren develop. Of particular importance are the child’s behaviors during reunion epi-
sodes when the caregiver returns after being separated from the infant. If the young
child—who is inherently distressed by separation—demonstrates clear proximity‐
seeking behaviors (e.g., moving toward the parent, reaching for the parent, etc.) and
is comforted by the parent’s presence, those are indicators that the child has developed
secure and autonomous ways of relating with the caregiver. Ainsworth also found that
those behaviors were linked to parent behaviors outside of the laboratory setting.
Specifically, these caregivers consistently displayed “attunement, sensitivity, and

responsiveness” (Seedall & Wampler, 2013, p. 429) when their children became dis-
tressed, threatened, or overwhelmed.
Ainsworth (Ainsworth et al., 1978) also identified two typologies of behaviors in
the Strange Situation reunions that reflect less secure patterns of relating. Some chil-
dren mask their distress through distancing and distraction behaviors. They might
begin proximity seeking but then veer away from the caregiver, or they might ignore
the caregiver altogether. This deactivation of attachment needs (coded in the Strange
Situation as avoidance) typically arises from consistent rejection of attachment needs.
Other children demonstrated intense emotional output (through anger or passive/
helpless distress) and even preoccupation with caregiver availability. As with the young
children with secure strategies, many of these children demonstrate proximity‐seeking
behaviors and an intense effort to connect (pursuit behaviors). However, the primary
difference is that they cannot regulate and comfort themselves, even when the car-
egiver is present and providing comfort. Rather, these children might arch their backs
when picked up by the caregiver, or they might even hit the caregiver. Ainsworth
found that these hyperactivating strategies (often labeled ambivalent/resistant) typi-
cally developed in response to inconsistent and unpredictable caregiver behaviors
(R.R. Kobak, Cole, Ferenz‐Gillies, Fleming, & Gamble, 1993). Both deactivating
and hyperactivating attachment strategies are unclear expressions of attachment needs
that are typically developed to manage distress when caregivers are not consistently
available and responsive (Dozier, Lomax, Tyrrell, & Lee, 2001). Because these behav-
iors lack clarity, they do not inherently invite a sensitive, loving response from the
caregiver, further perpetuating a disruptive cycle. Although indicators of insecurity,
these behaviors are organized responses, meaning that individuals consistently manifest
one or the other behavior in response to threats to the attachment system.
Disorganized attachment pattern Later, scholars identified the need for a category of
attachment disorganization when they recognized that some children during the
reunion episodes of the Strange Situation did not demonstrate organized responses.
These children seemed to experience irresolvable conflict when their attachment
behavioral system was activated (Main & Hesse, 1990). This internal conflict mani-
fested itself through behaviors that were contradictory, odd, incomplete, or disori-
ented (Duschinsky, 2018). More specifically, these children seemed dysregulated and
overwhelmed, unable to manage their emotions in any coherent way. Even though
they were clearly distressed and the caregiver represented a potential source of com-
fort, there was also a fear and apprehension regarding the caregiver, who offered little
reassurance and often demonstrated frightened/frightening or dissociative behavior
(Hesse & Main, 2006). As a result, the children wanted to simultaneously approach
and run away from their caregiver (approach–flight paradox; Duschinsky, 2018).
Scholars called this “fright without solution” (Hesse & Main, 1999, p. 483). These
behaviors in children have been linked to maltreatment (Cyr, Euser, Bakermans‐
Kranenburg, & Van IJzendoorn, 2010), caregiver psychopathology (Hobson, Patrick,
Crandell, Garcia‐Perez, & Lee, 2005; Toth, Rogosch, Manly, & Cicchetti, 2006),
nonmaternal care exceeding 60 hours per week (Hazen, Allen, Umemura, Heaton, &
Jacobvitz, 2015), and unresolved parental loss and/or trauma (van IJzendoorn,
Schuengel, & Bakermans‐Kranenburg, 1999).
Attachment Theory Critiques
Having just provided a conceptual foundation for attachment theory, we believe it is

appropriate to acknowledge some potential critiques of attachment theory prior to
explaining the application of attachment theory in adult romantic relationships.
Rather than provide a full explanation of each critique, we will provide a conceptual
sampling of the ideas that undergird them. One of the largest concerns in the past has
been with its primary focus on nurturance, which can be perceived as mother blaming
(Birns, 1999). It is true that past empirical research has linked insecure and disorgan-
ized strategies and behaviors to caregiver (most often maternal) insensitivity, neglect,
or maltreatment. The major question is whether attachment theory allows for other
(non‐caregiver) factors (e.g., child temperament, social class and overall access to
resources, etc.) to contribute to these interpersonal strategies and patterns. We believe
it does and that acknowledging the primacy of infant–caregiver relationships does not
dismiss the other factors that might also play a role.
Another critique that may be especially relevant to SFTs is whether attachment
theory is inherently systemic. Conceptually, we believe there are some important areas
of convergence related to conceptualizing how family members interact with one
another and the patterns involved (Byng‐Hall, 1990; G. S. Diamond, Diamond, &
Levy, 2014; Rothbaum, Rosen, Ujiie, & Uchida, 2002). Because attachment theory
is inherently relational, we believe it is also naturally systemic. Nonetheless, we
acknowledge that empirically, attachment theory has been primarily intrapsychic or
dyadic in nature. In other words, most research either focuses on identifying the pri-
mary attachment strategy that governs an individual’s self‐concept and relationship
interactions, or it focuses on a dyadic relationship (e.g., mother–child, father–child,
romantic partners, etc.). Although these are extremely important areas of research,
they neglect the richness of the family system. Nonetheless, with richness comes
complexity, and sometimes it is difficult to address multiple attachment relationships
at the same time, especially when there remains unknown about the interplay between
generalized and relationship‐specific attachment strategies.
The final critique we would like to highlight regarding attachment theory is whether
it is appropriate to conceptualize attachment in the same way across cultures. We
acknowledge, with Rothbaum and colleagues (2002), that attachment theory, in
many ways, reflects “Western ways of thinking and Western patterns of relatedness”
(p. 328). That is not to say that the tenets of attachment theory are not globally
relevant. van IJzendoorn, M. H. (1990) originally suggested four hypotheses related
to attachment theory across cultures: (a) the universality hypothesis, that infants
across cultures are primed to attach to one or more caregivers; (b) the normativity
hypothesis, that secure attachment is the norm for infants whose health and survival
are not inherently threatened; (c) the sensitivity hypothesis, that sensitivity and
responsiveness are important for child development; and (d) the competence hypoth-
esis, that having secure attachments are associated with positive child outcomes.
A review of the literature (Mesman, van IJzendoorn, & Sagi‐Schwartz, 2016) empha-
sizes that substantial cross‐cultural evidence exists for each of these hypotheses (with
slightly less support for the competence hypothesis). Nonetheless, there are likely
nuances between what are adaptive and maladaptive patterns of relatedness in various
cultures. More research is needed to fully understand those nuances.
Attachment in Adulthood
Although Bowlby (1969/1982) had proposed that attachment theory described

human experiences with connection and disconnection “from the cradle to the grave”
(p. 208), it was not until the late 1980s that consistent theoretical work and research
began to emerge on attachment in adulthood (see the pioneering work of Hazan and
Shaver (1987) as a primary example). Thirty years of extensive research now confirms
the core attachment constructs proposed for understanding parent–child relation-
ships apply to adult relationships as well, particularly to pair bonds (Zeifman & Hazan,
2016). In other words, even in adulthood, people exhibit various (secure and inse-
cure) proximity‐seeking strategies when they are distressed and presented with attach-
ment threat, and they respond similarly to the distress of others.
Research has overwhelmingly shown that insecure strategies disrupt and “destabi-
lize relationships by lowering satisfaction, aggravating relationship problems, and cur-
tailing positive experiences” (Simpson & Overall, 2014, p. 55), while secure strategies
provide increased stability and enrich relationships (J. A. Feeney & Karantzas, 2017).
That is not to say that people with secure strategies do not have problems (parent–
child or romantic relationship) for which they may seek therapy. Rather, secure strate-
gies make it more likely for individuals to work through their distress by more clearly
expressing their needs and being responsive to the needs of others. Thus, it is crucial
for SFTs to understand what secure or insecure attachment dynamics are evident in
clients’ lives as well as in the therapy process, whether presenting problems center
around individual mental health issues (Slade, 2016), couple level problems (Brassard
& Johnson, 2016), or parent–child relationship problems. However, to adequately
understand adult attachment dynamics, it is necessary to understand the complex and
varied measurement approaches involved.
Attachment measurement in adulthood

Ainsworth’s Strange Situation (Ainsworth et al., 1978) became the standard proce-
dure for measuring attachment in infancy and early childhood (see Solomon and
George (2016)) for a review of additional measures that have since been developed).
In adulthood, two primary measurement strategies have emerged over time, both
anchored to the theoretical tradition established by Ainsworth and conceptually
aligned to her classifications of secure, avoidant, and resistant/ambivalent.
Developmental psychology has focused more on narratives and interviews to uncover
unconscious representations of attachment strategies. Within the social psychological
tradition, the focus has been on self‐reported, conscious representations of comfort
with intimacy and closeness in relationships.
Unconscious representations of attachment strategies One of the earliest attempts to

create a bridge between Ainsworth’s work with infant styles and adult classifications
of attachment was proposed using the Adult Attachment Interview (AAI) (Main,
Kaplan, & Cassidy, 1985). The AAI is relationally focused, asking participants about
early childhood (ages 5–12) experiences with attachment figures and focusing on the
meaning adult interviewees attribute to these experiences. Interviews are recorded,
transcribed, and coded into groupings like Ainsworth’s: secure for those who exhibit
a clear, coherent discourse around their early childhood experiences, dismissing for
those who exhibit deactivating strategies through discourse that is incomplete or

inconsistent, and preoccupied for those who manifest hyperactivating strategies by
becoming angry, confused, or lost during their discourse (see Hesse (2016) for a full
description). Unresolved attachment is coded when discourse monitoring and flow
change suddenly when discussing loss or abuse (Hesse & Main, 2006). AAI coding
provides categorical results; however, there are two scales within the AAI that have
been used to provide a continuous measure of linguistic coherence. In addition, alter-
native models of scoring the AAI have been developed, and the interview continues
to be widely used in research.
Although relationally focused, the AAI is a generalized measure of coherence when
discussing attachment experiences and does not focus on the couple‐specific relation-
ship. Rather, a major focus of AAI scholarship has been on linking attachment strate-
gies demonstrated in the AAI with parenting behaviors, the parent–child relationship,
and subsequent child attachment strategies (see Hesse (2016) for a review). As a
result, several scholars have used the AAI as a guide to develop marital or couple
attachment interviews (see Alexandrov, Cowan, & Cowan, 2005, for a review).
Pioneering research on couple level attachment interviews led to the development
and standardization of a continuous scoring method for the original Couple
Attachment Interview (CAI) (Silver & Cohn, 1992) based on both partners’ attach-
ment ratings (P. A. Cowan, Cowan, & Mehta, 2009; Mehta, Cowan, & Cowan,
2009). Although more research is needed in this area, these findings suggest that
there are potentially important distinctions between a person’s discourse about his/
her romantic relationship (CAI) and his/her early childhood relationship with
caregivers (AAI), with the CAI providing nuanced insight into adult romantic

relationship quality and emotional expression.
Conscious representations of attachment strategies Although self‐report attachment

focuses more on a conscious self‐assessment of relational comfort rather than access-
ing “implicit, unconscious aspects of attachment‐system functioning” (Mikulincer &
Shaver, 2016, p. 103), it is still widely used by many attachment researchers. The most
commonly used self‐report measures are based on Ainsworth’s original typologies and
can be divided into two groups: categorical or continuous. Categorical assessments
attempt to access participants’ conscious awareness of their own internal working
models and focus on “feelings, tendencies, and behaviors” typical of the three major
attachment categories (Mikulincer & Shaver, 2016, p. 79).
Continuous self‐report measures of attachment built upon the early work categori-
cal work of Hazan and Shaver (1987, 1990) by allowing for variation among people
within style typology, whether measuring generalized or relationship‐specific attach-
ment in adulthood. Most of these measures focus on two dimensions: attachment
avoidance and attachment anxiety. The Experiences in Close Relationships Scale
(ECR) (Brennan, Clark, & Shaver, 1998) is perhaps the most commonly used and
rigorously tested self‐report measure of attachment. The original ECR and/or its
subsequent versions (Revised, Short, Situational and Relationship Specific) have been
included in over 500 studies, with highly reliable versions available in 17 languages
(Mikulincer & Shaver, 2016).
A sizeable body of literature exists supporting the validity of both measurement
traditions. Nonetheless, they represent “two distinct methodological cultures”
(Roisman et al., 2007, p. 678) with very modest empirical overlap, suggesting that
they may “tap different aspects of security that may not have similar correlates”
(Roisman et al., 2007, p. 679). This suggests that clinicians be cautious when inter-
preting attachment findings from multiple studies using a variety of measurement
techniques. From a clinical standpoint, the dimensional nature of self‐report attach-
ment assessments and ease of administration make them more practically useful for
clinicians to use. Use of narrative assessments like the AAI requires extensive training,
which involves time and monetary commitment. In addition, the administration of
these narrative measures is more labor intensive, making them less practical for clini-
cians. Nonetheless, there is an inherent value in this type of measure that may justify
the added effort, as insights about unconscious attachment strategies have some
important implications for the therapeutic process. Scholars are beginning to suggest
ways for adapting of measures such as the AAI to be more easily incorporated into
clinical work (see Solomon & Tatkin, 2011 for an example).
Attachment‐based behaviors Although the two measurement traditions mentioned

above focus on strategies and/or styles of attachment (unconscious or conscious
representations), another potential focus of particular relevance for SFTs is on
attachment behaviors. Regardless of the intrapsychic strategies involved, and
regardless of whether they can be changed (which will be further discussed below),
the fact is that these strategies lead to behaviors that either foster or impede
relationship connection. For this reason, focusing on attachment behaviors is an
important first step to being able to facilitate more secure responding between
partners. Although scholars within developmental psychology have examined
attachment behaviors as they pertain to parent–child relationships (see B. C. Feeney
& Woodhouse, 2016 for a review), much less has been done to examine attachment
behaviors within adult romantic relationships. Rather, much of the scholarly work
within SFT has focused on understanding the relationship between attachment
strategies and couple conflict behaviors (see J. A. Feeney & Karantzas, 2017 for a
review). This has been an important undertaking, confirming that insecure attach-
ment strategies are typically more disruptive during conflict interactions and to
relationship functioning generally. However, there is much more to understand
about how attachment strategies relate to a variety of interactional behaviors
outside of the context of couple conflict. Our focus in this section is to provide a
brief overview of two research avenues within SFT that have examined attachment
behaviors in couple relationships.
Any focus on behaviors and interaction naturally lends itself to observational
research. The Adult Attachment Behavior Q‐Set (AABQ) (Wampler, Riggs, &
Kimball, 2004) was developed to help “ ‘translate’ attachment theory into observable
behaviors between adults who are attachment figures to each other” (Wampler et al.,
2004, p. 316). The AABQ began with 100 different attachment‐related behaviors.
Nine experts completed prototype sorts for secure, dismissing, and preoccupied
attachment behaviors, allowing later q‐sorts to be compared against these prototypes.
Based on this process and later analysis, the AABQ was revised to include 80 items,
representing a variety of themes: intimacy/closeness, intensity and nature of expressed
emotions, responsibility versus blame, self‐concept, emotional self‐ and other‐
awareness and responsiveness, engagement, expectations of support, and interactional
quality/coherence.
Work is currently underway to shorten the AABQ‐R to a more manageable set of
items that could be utilized in session. In addition, there is a need to understand how the
disorganized features related to unresolved loss and trauma are manifested interaction-
ally. Research has identified that disorganized infants are likely to exhibit various
controlling behaviors to caregivers and friends during preschool and school ages (see
Lyons‐Ruth & Jacobvitz, 2016 for a review). However, no research has examined what
these disorganized behaviors might look like interactionally during adulthood.
Attachment behaviors may also be measured via self‐report. The Brief Accessibility,
Responsiveness, and Engagement Scale (BARE) (Sandberg, Busby, Johnson, &
Yoshida, 2012) is a 12‐item self‐report measure designed to assess key behaviors in
the couple attachment system. Research with both community and clinical samples
using the BARE suggests that behaviors demonstrating accessibility, responsiveness,
and engagement are related to secure attachment and relationship quality (Sandberg
et al., 2012; see Sandberg, Novak, Davis, & Busby, 2016 for a description of how to
use the BARE in clinical settings). Additional research suggests that attachment
behaviors, as measured by the BARE, are also related to couple communication and
conflict resolution, depression, relational aggression and violence, family‐of‐origin
issues, self‐regulation, physical activity levels, and dietary habits (Alder, Yorgason,
Sandberg, & Davis, 2018; Davis, Sandberg, Bradford, & Larson, 2016; Knapp,
Sandberg, Novak, & Larson, 2015; Novak, Sandberg, & Davis, 2017; Oka, Sandberg,
Bradford, & Brown, 2014; Rackham, Larson, Willoughby, Sandberg, & Shafer, 2017;
Sandberg, Meservy, Bradford, & Anderson, 2018).
Attachment and Change
An understanding of attachment strategies, their accompanying behaviors, and the

measurement options involved is crucial for SFTs because they provide a framework
for understanding how clients process and regulate their emotions, express their
needs, and respond to the needs of their partner. In this manner, a therapist can
deliver the same intervention to several different clients (or even to the same couple/
family), but the experience of that intervention could be vastly different for each per-
son. Going back to the couple mentioned at the beginning of this chapter, their
potential tendency toward attachment deactivation may be one reason why they did
not return the next week. The high emotionality and vulnerability may have been too
much, too soon for them. Although the principle of expressing more vulnerable,
primary emotions is an important one that can facilitate change, perhaps the process
needed to be more gradual. Regardless, discussion of the various strategies associated
with attachment and our field’s inherent focus on facilitating change leads us to con-
sider the nature of attachment stability and change, which we will summarize in the
remainder of this section.
Attachment continuity
Because Bowlby (1973) considered attachment formation something that happened
within a critical period early in life, there is a certain amount of stability expected
across the lifespan. Despite this salience of early relationship experience,
Bowlby (1969/1982) also recognized that attachment representations were subject
to revision. Two general approaches exist to explain this dynamic of stability versus
change (Mikulincer & Shaver, 2016). A prototype approach conceptualizes attach-

ment as a balance between a prototype, formed based on relationship experiences, and
the attachment‐related experiences we have had throughout life that form a current
relationship model. Although the current relationship model can vary and be quite
fluid, the prototypes formed in infancy “continue to exist and exert a shaping influ-
ence on attachment patterns” (Mikulincer & Shaver, 2016, p. 111). Conversely, a
revisionist approach (Fraley, 2002) takes a more continuous view of change, with the
most recent attachment experiences being the most salient. Older experiences are not
necessarily forgotten, but they are not necessarily more strongly entrenched than
more recent experiences.
Longitudinal findings seem to support the prototype hypothesis. However, the
findings regarding the overall stability of attachment across the lifespan have been
quite divergent. One of the largest studies of its kind (Groh et al., 2014) used a
normative sample (n = 857) to examine the continuity of attachment from infancy
(measured using the Strange Situation) to late adolescence (measured using the AAI)
and found weak stability of attachment (r = 0.12), a similar finding to a previous study
of a higher‐risk sample (Sroufe, Egeland, Carlson, & Collins, 2005). A meta‐analysis
(Fraley, 2002) found more moderate stability (r = 0.27; n = 218) when comparing
security with insecurity in a high‐risk sample between ages 1 and 19 (using a variety
of measures of attachment). Stability was even higher in low‐risk samples (r = 0.48).
Fraley and Brumbaugh (2004) conducted another meta‐analysis of studies examining
attachment styles (i.e., self‐report attachment) in adulthood and also found higher
stability (r = 0.54). Overall, results across a variety of studies demonstrate at least
some stability of attachment, although there is also evidence of discontinuity, due
likely to a variety of life events.
Negative attachment change

Because it can be expected that some individuals fluctuate in their attachment strate-
gies based on their experiences, research has sought to examine potential lawful
discontinuity (Weinfield, Sroufe, & Egeland, 2000). Research examining shifts from
security toward insecurity (i.e., negative attachment change) have identified that indi-
viduals experiencing highly stressful life events are most at risk (J. Crowell & Waters,
2005). Although findings have been somewhat mixed, the most robust of these risk
factors include parental death, illness (parental or child), high maternal stress, or dis-
ruptive family patterns (Hamilton, 2000; Lewis, Feiring, & Rosenthal, 2000; Van
Ryzin, Carlson, & Sroufe, 2011; Waters, Merrick, Treboux, Crowell, & Albersheim,
2000; Weinfield et al., 2000; Weinfield, Whaley, & Egeland, 2004). A more recent
longitudinal study of 857 participants from infancy to adolescence found that those
who experienced negative attachment change were more likely to be girls and experi-
ence decreases in maternal sensitivity, a higher likelihood of father absence, and more
negative life events (Booth‐LaForce et al., 2014).
Positive attachment change

Earned security Although understanding potential risk factors for negative shifts in
attachment can be valuable, of potentially greater interest to SFTs are factors that
contribute to shifts from insecurity to security. Unfortunately, less is known about
how to bring about positive attachment change. Although prospective studies of

attachment change are the ideal, some scholars have sought to use the AAI to retro-
spectively examine positive attachment change. They found that individuals reported
negative caregiving experiences growing up but were able to discourse about them in
a coherent way indicative of attachment security. For this reason, the term earned
secure (as opposed to continuously secure) was created (Pearson, Cohn, Cowan, &
Cowan, 1994). Later scholarly work found that these individuals had actually
experienced average or better care, but their mood was biasing their recall of earlier
relationship events (Roisman, Fortuna, & Holland, 2006; Roisman, Padron, Sroufe, &
Egeland, 2002). A recent prospective longitudinal study of 857 participants did reveal
some stressful life events (less family income, more father absence, higher levels of
parental depressive symptoms) but not any behavioral differences in observed
caregiving (Roisman, Haltigan, Haydon, & Booth‐LaForce, 2014). Overall, findings
regarding earned security should be interpreted with caution.
Partner buffering Because there is some unknown as to whether generalized

attachment strategies can change, some scholars have suggested that it would be more
valuable for clinical research to focus on enhancing the security of interactions (Bick
& Dozier, 2008). For that reason, scholars have examined whether security in one
partner can buffer against some of the potentially negative effects of insecurity in
another. Thus far, no definitive research findings have emerged. A few studies found
that couples did shift from insecure to secure on the AAI, but were not able to iden-
tify any specific factors that predicted that positive shift (J. A. Crowell et al., 2002;
J. Crowell & Waters, 2005). Researchers seem to have moved away from identifying
factors that predict a categorical change from security to insecurity to examine buffer-
ing from an interactional perspective. One study found no evidence of a buffering
effect during couple interaction (Wampler, Shi, Nelson, & Kimball, 2003). Conversely,
C. P. Cowan and Cowan (2005) found that dyads with a secure male and an insecure
female were similar in their marital or parent‐child relationships to those with two
secure parents. Another study (Salvatore, Kuo, Steele, Simpson, & Collins, 2011)
found that secure individuals paired with insecure partners recovered as quickly from
couple conflict and had relationships of similar quality at two‐year follow‐up as cou-
ples where both partners were secure. As a result, there seems to be more possibility
in examining partner buffering from an interactional approach.
Even more recently, the issue of partner buffering has been examined using self‐
report attachment. Simpson and Overall (2014) developed the dyadic regulation
model of insecurity buffering. The idea is that attachment insecurity often leads to
dysregulation of emotion. However, the more secure partner can (deliberately or
automatically) help the other person downregulate using a variety of buffering behav-
iors. “These partner buffering attempts must be carefully tailored to meet the specific
attachment‐relevant needs, concerns, and worries of highly avoidant and highly anx-
ious partners” (Simpson & Rholes, 2017, p. 23). As a result, scholars have begun to
examine specific behaviors that effectively buffer against insecure responses. For
example, in one study (Tran & Simpson, 2009), attachment anxiety was related to
more negative emotion and fewer accommodation behaviors. However, anxious part-
ners reported more acceptance and positive emotions if their partner reported higher
commitment and displayed more accommodating behaviors. With respect to buffer-
ing against the potential anger and withdrawal of attachment avoidance, more sof-
tened partner behaviors like acknowledging one’s sacrifices and expressing confidence
led to more positive outcomes (Farrell, Simpson, Overall, & Shallcross, 2016; Overall,
Simpson, & Struthers, 2013). Although more work is needed, these are useful f indings
with potential clinical relevance.
Therapeutic attachment change The discussion of the nature of attachment change

naturally leads to the question of whether attachment can change in SFT. Although
this is a complex question that we cannot comprehensively cover in this chapter, we
will highlight an important point. One of the first studies (Makinen & Johnson, 2006)
of emotionally focused therapy (EFT) to examine categorical, self‐reported attachment
change did not find any attachment‐related effects. They provided several potential
explanations: (a) the enduring nature of attachment; (b) the relatively short, 12‐session
time frame did not allow for enough corrective experiences; or (c) the self‐report
measurement (ECR) was not sensitive enough. However, more recently, researchers
(Moser et al., 2015) found significant decreases in both self‐reported attachment
avoidance and anxiety following a variable amount of sessions (13–35) of EFT.
As another example, researchers examined self‐reported attachment change across
the beginning stages (six sessions) of therapy and found different change trajectories
related to avoidance and attachment (Seedall, Butler, Zamora, & Yang, 2016).
Nonetheless, they did find that attachment avoidance and/or anxiety was able to
decrease for many clients. However, L. N. Johnson and colleagues (2016) found rela-
tive stability in attachment across eight sessions of therapy. What sense can be made of
the divergent findings? There may be additional explanations, but one important factor
deserves mentioning here. Those studies that found no attachment change examined
generalized attachment strategies, while those that did identify change had been adapted
to examine relationship‐specific attachment change. Because there remains some
unknown as to whether generalized attachment strategies change categorically, we
encourage SFTs (clinicians and researchers) to focus more on either relationship‐specific
attachment change or change in the security of interactions (Bick & Dozier, 2008).
Attachment and Intervention
In previous sections, we provided an overview of attachment theory, including its

potential role in helping clinicians understand relationship processes such as establish-
ing a secure connection and the co‐regulation of emotion. We also addressed attach-
ment continuity and the nature of attachment change, including within the context of
therapy. We now turn our attention to further highlighting the relevance of attach-
ment within SFT. In particular, we will highlight how attachment theory may be used
by SFTs to help repair relationships. To do this, we will summarize the following: (a)
the relationship between attachment and psychopathology and (b) attachment‐based
SFT intervention models.
Attachment and the development of psychopathology

Attachment theory highlights both adaptive and maladaptive responses to distress and
seeking to meet our needs within relationships. In this manner, “attachment theory
was a theory of psychopathology from the start” (Mikulincer & Shaver, 2016, p. 395).
Whether in childhood or adulthood, the consistent emotionally attuned and nurtur-

ing responsiveness of a caregiver or partner leads to secure attachment, which can play
a protective role in buffering against negative outcomes. “The research evidence
underscores the soothing, healing, therapeutic effects of actual support … and the
comfort and safety offered by mental representations of supportive experiences and
loving and caring attachment figures” (Mikulincer & Shaver, 2012, p. 14). Conversely,
repeated attachment disruptions or injuries lead to defensive processes, which can
then result in individual and relational distress, including psychopathology (S. M.
Johnson, Makinen, & Millikin, 2001; R. Kobak, Zajac, & Madsen, 2016; Mikulincer
& Shaver, 2012). Initial attempts to repair and reestablish safe and secure connections
are predictable and take many forms: protest (anger), despair (sadness), and defensive
detachment. Attempts to reconnect “may become dysfunctional when they no longer
serve a reparative function” or make a soothing response from a loved one less likely
(p. 29). In this manner, many presenting problems, whether individually or relation-
ally focused (e.g., depression, marital conflict, child acting out, parental rejection or
over‐involvement, etc.) can be understood as failed attempts at connection.
Across literally thousands of studies of adults, in numerous nations and in both
community and clinical settings, attachment insecurity “predisposes people to psy-
chological disorders” (Mikulincer & Shaver, 2016, p. 442; see also Stovall‐McClough
& Dozier, 2016). Specifically, and relevant for SFTs, across numerous studies indi-
viduals diagnosed with major depression or anxiety disorders report higher levels of
attachment insecurities than control group counterparts. In addition, attachment
anxiety has been linked to obsessive–compulsive symptoms in clinical and nonclinical
samples, even when controlling for depression and anxiety (Doron, Moulding, Kyrios,
Nedeljkovic, & Mickulincer, 2009). Furthermore, increased levels of attachment anx-
iety and avoidance have been linked with increased suicidal thoughts and attempts for
community teens and young adults (Sheftall, Schoope‐Sullivan, & Bridge, 2014).
Research also suggests anxiety and avoidance scores are higher for women with eating
disorders (Zachrisson & Skarderud, 2010). Similar studies can be cited for individuals
with conduct disordered behavior, substance abuse, behavioral addiction, personality
and dissociative disorders, and schizophrenia. In short, there is overwhelming scien-
tific evidence that attachment insecurity is related to psychopathology in adulthood
(see Mikulincer & Shaver, 2016 for a more complete summary).
Attachment‐based SFT intervention models

Emotionally focused therapy Although the early development of attachment theory
in the United Kingdom coincided with the development of SFT in the United States,
they were in somewhat parallel universes for many years, with little intermingling.
That changed somewhat in the late 1980s and early 1990s, when John Byng‐Hall
suggested that family therapy and attachment theory might be a good match (Byng‐
Hall, 1990) and Leslie Greenberg and Susan Johnson began writing about a newly
developed experiential systemic model for treating couples: EFT. Although the first
published journal article on EFT (S. M. Johnson & Greenberg, 1985) did not men-
tion attachment, later publications began to conceptually link the couple’s emotional
bond to attachment behaviors (Greenberg & Johnson, 1988; S. M. Johnson &
Greenberg, 1987). Johnson and colleagues (2001) coined the term attachment
injuries, “characterized by an abandonment or by a betrayal of trust during a critical
moment of need” (p. 145). Over time, attachment theory principles have become an
integral part of understanding and practicing EFT for couples (S. M. Johnson, 2004),
and this is a large reason why attachment theory is a commonly discussed theory in
SFT. Importantly, EFT has gradually been expanded to include the concept of the
family as a safe haven and the process of fostering secure family connections (Furrow,
Palmer, Johnson, Faller, & Olsen, 2019; Stavrianopoulos, Faller, & Furrow, 2014).
Within EFT, therapists first assess the negative interaction cycle while working to
de‐escalate the couple’s level of conflict. They then work to restructure the couple’s
interactional positions by (a) helping partners identify and access underlying emotions
and needs; (b) promoting greater acceptance, accessibility, and responsiveness of their
own and their partner’s experiences; and (c) facilitating more softened, conciliatory
interactions (S. M. Johnson, 1996, 2004). Finally, they help couples consolidate
and integrate new solutions and new cycles into multiple contexts within their
relationship.
Years of process research in EFT have highlighted the pursue–withdraw pattern in
couple relationships and the importance of engaging the withdrawer and softening
the blamer to facilitate secure bonding moments (Bradley & Furrow, 2004; Lee,
Spengler, Mitchell, Spengler, & Spiker, 2017). These are the key elements of change
and occur when partners reach out to and find comfort with and from each other
(Furrow, Edwards, Choi, & Bradley, 2012). This “reach‐for and reach‐back exchange”
between partners around core attachment needs is central to EFT theory and research
(Bradley & Furrow, 2004; Tilley & Palmer, 2013; Moser, Johnson, Dalgleish, Wiebe,
& Tasca, 2018). Such bonding moments are the micro‐interactions that form the
foundation of a secure attachment.
SFTs continue to be drawn to EFT because of (a) its clear focus on working with
emotions from an attachment perspective, (b) its rigorous empirical testing and
evidence base (see Wiebe & Johnson, 2016 for a review of EFT outcome and process
research), (c) the clear positive change it generates in the lives of clients and thera-
pists (Sandberg & Knestel, 2011), (d) its demonstrated utility within a variety of
cultures around the globe (Solymani Ahmadi, Zarei, & Fallahchai, 2014; Wong,
Greenman, & Beaudoin, 2017), and (e) the availability of training in multiple
languages (www.eft.ca).
Attachment‐based family therapy Another attachment‐based SFT model was devel-

oped in the late 1990s and early 2000s by Guy Diamond: attachment‐based family
therapy (ABFT). ABFT is an integrative, empirically supported model of family
therapy focused on helping depressed and suicidal youth form secure and safe

relationships with parents or other primary attachment figures (G. S. Diamond et al.,
2014). A major purpose of ABFT is to “rebuild the original parent‐child attachment”
bond through fostering “intimate, emotionally laden, genuine moments of conversa-
tion about core attachment needs and themes” where parents can act in trustworthy
ways (G. S. Diamond et al., 2014, pp. 24–25).
ABFT has been developed as a 12‐ to 16‐week intervention organized around five
clear, clinically intuitive tasks (G. S. Diamond et al., 2014): (a) the relational reframe,
where the family shifts focus from the presenting issue (depression/suicidality) to
the parent–child relationship (attachment); (b) the adolescent alliance task, where
therapists create a shared vision with the adolescent around the goal of repairing the
attachment bond with the parent; (c) the parental alliance task, where therapists
“resuscitate parental empathy for the adolescent and get parents committed to and
prepared for [attachment repair]” (p. 129); (d) the attachment task, where parents
and children directly address specific attachment injuries, working to help the parent
respond in attuned and safe ways; and (e) the promoting‐autonomy task, where the
family discusses challenges the adolescent faces outside of the parent–adolescent rela-
tionship. Completion of these tasks fosters a safe and secure parent–adolescent
relationship, where attachment injuries can be addressed and repaired as parents learn
to respond appropriately their adolescent’s attachment needs while also respecting
her/his developmental need for autonomy.
SFTs who work with depressed and/or suicidal adolescents will find this model
particularly appealing. It is integrative using attachment theory as a framework for
family‐based interventions developed from the influence of structural family therapy,
contextual family therapy, EFT, and multidimensional family therapy. It consists of
clear and succinct tasks, with excellent and clear transcripts that provide practical
guidance for each task (see G. S. Diamond et al., 2014). It also has strong empirical
support (see G. Diamond, Russon, & Levy, 2016 for a review) demonstrating that it
is effective at reducing both depression and suicidality for adolescents, particularly
those who have experienced trauma and face the daily adversities related to poverty
and minority status.
Next Steps in SFT for Attachment‐Based Intervention
As highlighted throughout this chapter, attachment theory represents a rich concep-

tual framework for understanding and intervening in relationships. Although Bowlby
(1988) recognized a need for attachment theory to be more fully integrated into
clinical practice over 30 years ago, there remain important clinical and research ave-
nues for utilizing attachment theory to enhance clinical practice and ultimately
improve outcomes. Because attachment theory is simultaneously intrapsychic and
relational, SFTs have a unique opportunity to use our training to access the full utility
of attachment theory. We will now identify some additional implications of attach-
ment theory for SFT while also discussing next steps.
Deepening our understanding and application

of attachment‐based intervention
Expanding our views of attachment‐based intervention EFT and ABFT have demon-
strated how to use attachment as a unifying framework to inform clinical intervention.
As such, they have provided important attachment‐based contributions to the field of
SFT. Yet, there are times when SFTs may be guilty of thinking that those two models
represent the extent of attachment‐based intervention. We encourage SFTs to access
the many invaluable resources that can help us expand our understanding of attach-
ment theory and how to apply it clinically. Many of these opportunities exist in the
attachment‐based parent–child intervention literature, from which important princi-
ples can be drawn for other attachment relationships. These interventions have a rich
conceptual background and a strong empirical base that we cannot adequately address
here (see Steele and Steele (2017) for a summary of attachment‐based interventions
for children and adolescents). However, we would like to illustrate this by summariz-
ing a caregiver–child intervention that has informed the first author’s (R.S.) attach-
ment‐based practice.
Attachment and biobehavioral catch‐up (ABC) (Dozier and the Infant Caregiver
Project, 2013) is a 10‐session at‐home intervention with caregivers and children
under three that has a strong evidence base (see Dozier et al., 2017 for an overview).
ABC is designed to promote sensitive and nurturing responses from caregivers when
children are distressed (whether signals are clear or not) by (a) resisting the urge to
respond, “in kind” (i.e., meeting child avoidance behaviors with more rejection or
child anger with increasing frustration; Stovall‐McClough & Dozier, 2004); (b) rec-
ognizing the need to override some of their less adaptive inclinations (often anchored
in their own past adverse attachment experiences) to provide nurturance to their
children (Dozier et al., 2017); (c) increasing caregiver commitment and relational
synchrony by following their child’s lead with delight (rather than mechanically;
Bernard & Dozier, 2011); and (d) recognizing frightening behaviors (even seemingly
innocent behaviors like tickling and puppet play that can be both fun and scary) that
may be undermining the secure base.
A variety of content and process elements within the ABC intervention may be of
use for SFTs. Specifically, the ABC intervention highlights a signal‐response dynamic
(Seedall & Wampler, 2019) that is also common in other dyadic relationships (e.g.,
parents and children older than three, adult romantic relationships, etc.). Much of
what we do as SFTs aligns with the idea of helping clients signal their needs clearly
while also being responsive when their partners express attachment‐related needs.
The idea of helping partners avoid responding “in kind” and being responsive even
when signals are not clear is also relevant. Clients also can benefit from understanding
their predisposed responses to others’ distress and how previous experiences may play
a role. Therapists can help couples follow one another’s lead with delight by enhanc-
ing behaviors that reflect that the other person is a source of interest, support, and
inspiration. Therapists can also be aware of more subtle behaviors that may be associ-
ated with psychological abuse, including intimidation, gaslighting, etc. (Hurless &
Cottone, 2018). From a process standpoint, the ABC intervention uses psychoeduca-
tion, experiential activities, in‐the‐moment coaching (Meade & Dozier, 2012),
strengths‐based feedback, and video review to accomplish its goals. We highly recom-
mend further attachment‐based scholarly work in these areas by SFTs.
Treating attachment as a therapeutic input In addition to a tendency to only con-

sider attachment‐based dynamics within the context of EFT and ABFT, some SFTs
also demonstrate a more cursory understanding of attachment in their research. A
casual review of SFT literature highlights the fact that many studies include self‐
reported attachment strategies (usually avoidance and anxiety) as variables in their
models, whether attachment theory is the underlying theoretical framework or not.
In this manner, attachment variables are being treated more like couple satisfaction
and conflict—good relationship variables that can be used across a variety of concep-
tual frameworks as covariates. We strongly support the expanded attention to attach-
ment theory and believe that there is much to learn about attachment that can benefit
our field. Nonetheless, we caution against the haphazard use of attachment as a
variable in studies without a strong theoretical rationale, depth, and/or direct clinical
relevance.
Greater depth and meaning can be achieved by focusing more on therapeutic

rocess studies that examine how attachment strategies relate to client experience in
p
therapy. To illustrate, a researcher may want to examine the relationship between an
experiential intervention and in‐session emotional experiencing (Klein, Mathieu‐
Coughlan, & Kiesler, 1986). Yet, the optimal experience of emotions is likely to be
vastly different for clients with deactivating strategies as opposed to those with hyper-
activating strategies. There is also evidence of an important systemic interaction if
partners have alternate strategies (Taylor, Seedall, Robinson, & Bradford, 2018). It is
crucial for researchers to use this theoretical understanding of attachment to inform
their analyses, rather than simply using attachment variables as atheoretical covariates.
We believe this deeper understanding of how generalized attachment strategies relate
to therapy process will make it possible for therapists to learn how to adapt interven-
tions to varying attachment strategies. Some of this work has been done within indi-
vidual psychotherapy (e.g., Wallin, 2007), but much more is needed to understand
these dynamics within relationships and especially within SFT process.
Focusing on attachment behaviors Although we suggest above an increasing focus on

attachment as a therapeutic input in clinically oriented research, we acknowledge the
inherent interest within SFT to examine change in attachment strategies (see Seedall
et al. (2016) and L. N. Johnson et al. (2016) for some examples of studies examining
self‐reported change). When doing this, attachment measurement is an important
consideration. Most measures (self‐report or narrative) have focused on identifying
generalized attachment strategies. Self‐report attachment scales that focus on rela-
tionship‐specific attachment are also an option for therapists to track attachment‐
related progress. Yet there are some aspects of attachment theory (e.g., the AAI) that
have potentially valuable clinical utilizations but are more difficult to apply in day‐to‐
day clinical practice. As a result, the practical question remains of how SFTs can use
an understanding of attachment in what they do within their daily clinical work.
We propose that a greater focus on attachment behaviors is an important direction
for attachment research generally and something that would be of interest to SFTs
because of its inherent clinical relevance (Wampler et al., 2004). A growing body of
research, both in community and in clinical settings, has shown that self‐reported
attachment behaviors can mediate and moderate the relationship between relation-
ship stressors and relationship outcomes (Alder et al., 2017; Novak et al., 2017; Oka
et al., 2014; Rackham et al., 2017; Sandberg et al., 2018). In light of this research,
MFTs may wish to focus on fostering attachment security in general and attachment
behaviors specifically, when working with individuals, couples, and families facing
common struggles in relationships, as attachment security appears to be both a
protective and healing factor.
More specifically, focusing on attachment behaviors will help SFTs more readily
identify “specific attachment‐relevant patterns of interaction as they are played out in
the therapy room” (Wampler et al., 2004, p. 316). Then therapists can more deliber-
ately intervene to enhance the security of interactions by increasing those behaviors
that facilitate bonding. This can be done by developing client awareness of their pat-
terned responses and how those responses relate to them expressing their own or
responding to another’s attachment needs (Bick & Dozier, 2008; Seedall & Wampler,
2013). Therapeutic intervention may not fully change how clients are wired—their
biology as well as their experiences might predispose them to deactivation or
yperactivation when coping with their own or another’s distress. Yet, SFTs can help
h
clients learn to override these propensities and behave in more secure ways.
Enhance our understanding of cultural adaptations One final way to be more sys-
temic in our attachment‐related work is to improve our cultural adaptations of attach-
ment intervention. Importantly, a sizeable body of research has examined cross‐cultural
attachment patterns (see Mesman et al., 2016 for a review). Findings have shown a
great deal of continuity of attachment‐related relational dynamics across cultures,
including “the universality of attachment, the normativity of secure attachment, the
link between sensitive caregiving and attachment security, and the competent child
outcomes of secure attachment” (p. 809). Nonetheless, Mesman and colleagues
(2016) still emphasize that there is much to be done in various parts of the world
(e.g., India and parts of Africa, Asia, and Latin America). This need for more clinically
focused attachment research is especially clear within the field of SFT. Although EFT
studies have increasingly examined its effectiveness internationally (e.g., Solymani
Ahmadi et al., 2014; Wong et al., 2017), we know much less about how culture and
varying social identities may manifest themselves in different attachment‐related
dynamics in therapy. In order to more fully apply the potential benefits of attachment
theory in SFT, work is urgently needed in this area.
Conclusion
In this chapter, we have offered a brief historical overview as well as attachment‐

related principles and constructs that can help SFTs understand the growing global
appeal of attachment theory in understanding individuals and interactions. We also
highlighted the attachment‐anchored, evidence‐based interventions within SFT (EFT
and ABFT). Finally, we offered a variety of next steps—both clinically and in terms of
research—for the field of SFT to continue advancing in the delivery of attachment‐
related interventions. Overall, we hope that SFTs recognize that attachment theory
offers a valuable theoretical understanding of how relationships work in addition to
important principles for how to strengthen and repair relationships.
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18
Postmodern Family Therapy
Ronald J. Chenail, Michael D. Reiter,
Maru Torres‐Gregory, and Dragana Ilic
Postmodern family therapy is one of the newer overarching frameworks for therapeutic
practice. It marks a shift from the cybernetic and mechanical metaphors used at the
start of the profession to text‐based constructions (Mills & Sprenkle, 1995).
Modernism posits that people progress by being able to access legitimate knowledge.
Postmodernism, on the other hand, holds that there is no absolute truth. As Anderson
and Levin (1998) explained, “Modern and postmodern are umbrella epistemological
and philosophical positions that inform the culture of therapy” (p. 47). This chapter
presents some of the core philosophical underpinnings of postmodernism and post-
modern family therapy and how these ideas inform the practice of therapy.
Influential Postmodern Ideas
Although it is challenging to summarize the rich world of postmodern ideas championed

by writers such as Lacan, Foucault, Lyotard, and Derrida (Hicks, 2011), by reflecting
on what has emerged as postmodern family therapies, it is easier to highlight what
postmodern ideas have been more influential. Four of these prominent influences are
(a) language, the self, and society; (b) instability of language, meaning, and knowledge;
(c) rejection of global theories; and (d) shifting from the philosophical to the political.
Language, self, and society

Human beings become social with language, and through this circular and reciprocal
relationship, the distinctions between the self and society become blurred. In a
postmodern world, the family, like other social institutions, becomes less like bricks‐
and‐mortar buildings with finite borders as in distinct historical family roles and
generational boundaries and more like virtual portals with infinite channels through
which language can empower, liberate, disrupt, and marginalize (Jencks, 2011). In
such a world, family therapists shifted their theoretical foundations from social and
418 Ronald J. Chenail et al.
biological systems theories to social construction theories to better position their

work within this flow of words. This move helped postmodern family therapists to
understand that language (a) can saturate families with harmful discourse and (b) is
also a way to unframe problematic framing to help families generate healthier
possibilities in their lives (Hoffman, 2002).
Instability of language, meaning, and knowledge

In a postmodern world, meaning and knowledge are constructed through language,
yet relationships between the words we use and the ideas we are trying to convey
are fluid, unstable, and open to interpretation, translation, and change (Malpas,
2005). Family therapists have long appreciated the role language plays in their
work. Circular questioning is just one way family therapists have embraced how
asking families to talk about what they are talking, but to do so from shifts in
personal and temporal perspectives can be helpful and healthy (Tomm, 1984); but
accepting this postmodern instability of language, meaning, and knowledge also
helped postmodern family therapists to realize that their ideas were no more stable
or central than those of their clients. This challenge of the authority of words over
ideas encouraged postmodern family therapists to shift from being the sole
privileged expert of language, meaning, and knowledge in the therapy room to
becoming a facilitator of dialogue and reflection among all the experts in the room
(Anderson, 1997).
Rejection of global theories

If there is such a thing as a universal tenet of postmodern thinking, then skepticism
of modernist ideas world be it (Hicks, 2011). From this speculative perspective,
postmodern scholars reject the possibilities one theory can describe, explain,
interpret, and predict all human behavior and in its place suggest a plurality of
possible descriptions, explanations, interpretations, and predictions (Malpas,
2005). This notion of skepticism of global theories helped postmodern family
therapists to reject dominant normative systems of diagnosis and pathologizing of
individuals and families, or at least treated these theories as just one way of socially
constructing a family (Hoffman, 2002). This rejection of the global also helped
postmodern family therapists to focus on the local theories of the family members
themselves and to centralize the idea that family members are the best experts on
themselves (Anderson, 1997).
Shifting from the philosophical to the political

Postmodern thinkers suggested shifting from seeking foundational truths to
advocating for marginalized groups oppressed by these traditional truths (Hicks,
2011). These thoughts helped postmodern family therapists to not only question
their own foundational ideas as to what constitutes a family, a couple, marriage, and
parenthood and how these restrictive assumptions limited their inclusiveness but also
become more socially active to fight marginalization and oppression while supporting
and championing respect, love, and opportunity for all (Doherty & Carroll, 2002).
Postmodern Family Therapy 419
Postmodern Family Therapy
Postmodern therapies tend to have some common characteristics (Tarragona, 2008).

These include a transdisciplinary inspiration, a social or interpersonal view of knowl-
edge and identity, attention to context, language as a central concept in therapy,
therapy as a partnership, valuing multiplicity of perspectives or voices, valuing local
knowledge, viewing the client as the star, being public or transparent, interest in what
works well, and the notion of personal agency.
Postmodern‐minded family therapists encountering dominant distinctions of expert
therapist positions, social system structuring, and patriarchal‐oriented language and
practices began to question critically these assumptions and practices resulting in new
ways of conceptualizing therapists, clients, and their relationships and how family
therapy is conducted and appreciated (Anderson, 1997; Hoffman, 2002). The fol-
lowing are some of these postmodern questions and responses in family therapy.
How do they do it? Postmodern family therapy models

There is not enough space to do justice to all of the various approaches/models that
are based on postmodern principles, but we wanted to take a few moments to highlight
three of the most common models: solution‐focused brief therapy (SFBT), narrative
therapy, and collaborative therapy. While we present a general understanding of the
development and current state of these models, the postmodern approach holds that
these understandings are in continual flux as a multitude of voices add to the
understandings of the models. While practiced differently, these approaches hold
several commonalities including skepticism of universal truths, promotion of local
knowledge, belief in co‐construction of meanings, appreciation for polyphony, non‐
pathologizing stance, utilization of client resources, and use of story/narrative
metaphors and are nonhierarchical (Anderson, 2016a).
Solution‐focused brief therapy SFBT was developed by Steve de Shazer and Insoo
Kim Berg and colleagues in Milwaukee, Wisconsin, at the Brief Therapy Family
Center in the early 1980s. This husband and wife team was influenced by the
strategic therapy of the Mental Research Institute (MRI) brief therapy team (see
Watzlawick, Weakland, & Fisch, 1974; Weakland, Fisch, Watzlawick, & Bodin,
1974) as well as the therapeutic work of Milton Erickson, perhaps the most
influential hypnotherapist of the twentieth century. However, whereas MRI therapy
focuses on the problem‐maintaining failed solution attempts, SFBT highlights the
past successful actions of people (de Shazer et al., 1986). That is, instead of paying
attention to what is not working in people’s lives, SFBT privileges those times that
were working and that people want more of. This can be seen in solution‐focused
therapy’s three primary rules: (a) if it is not broke, do not fix it; (b) if it does not
work, do not do it again, do something different; and (c) once you know what
works, do more of it (Berg, 1994). In the late 1980s, de Shazer (1988, 1994)
began to talk about therapy as conversation using the works of Wittgenstein,
Lacan, and Derrida as theoretical constructs to base the model upon. This led
to SFBT becoming more of a postmodern approach where solutions are co‐constructed
in the language games of the therapeutic conversation (Berg & DeJong, 1996; de
Shazer, 1991; Shazer & Berg, 1992).
SFBT is premised in a present and future focus, helping clients to do more of what
works, and an exploration of previous solutions and exceptions, usually through the
use of questions (de Shazer et al., 2007). While there has been an evolution in the
core principles and therapeutic techniques of SFBT, what has always been evidenced
is that solution‐focused therapists believe that clients come to therapy with all of the
necessary strengths and resources needed for change. The therapist helps to bring
these previously unfocused aspects of the client’s life to the forefront, whereas previ-
ously the client had the various complaints and problems of life in the forefront.
Through this language game of taking what was background (i.e., strengths and pre-
vious solutions) and bringing them to the foreground, problems then move to the
background (Reiter & Chenail, 2016). These various strengths and resources become
the pathways toward the client’s goals. The process of focusing on the client’s pre-
ferred future and goals as well as the strengths and resources they have to make that
happen is called solution building (Froerer & Connie, 2016).
SFBT therapists tend to ask many questions during therapy, usually leading from
one step behind. The primary questions include presession change, scaling, exception,
miracle, and coping questions (de Shazer et al., 2007). Presession change questions
take into account that clients, on their own, make changes even before therapy begins
that are useful to them (Weiner‐Davis, de Shazer, & Gingerich, 1987). Scaling ques-
tions ask clients to make abstract concepts more concrete by placing them on a scale,
usually from 1 to 10 where 10 is the attainment of that concept (Berg & de Shazer,
1993). Exception questions focus on times when the problem could have happened
but did not, since problems do not always happen or do not happen to the same sever-
ity (Berg, 1994). The miracle question, perhaps the most iconic SFBT question, asks
the client to imagine that a miracle happened in which all the concerns that brought
them to therapy were gone (Berg, 1994; de Shazer, 1991). This question helps bring
forth the client’s goals. Coping questions explore how, even in extremely difficult
situations, clients have engaged in personal agency to ensure the situation did not get
worse (Berg, 1994). Whatever question or experiment is used in SFBT, they are based
on promoting hope and expectancy of change for the client (Reiter, 2007, 2010).
Both the techniques/questions used and the co‐construction process are empirically
supported change agents, especially those that are strength and future focused
(Franklin, Zhang, Froerer, & Johnson, 2017). This focus on client strengths and past
exceptions helps promote client resiliencies, leading to increased motivation and path-
ways to change (Bolton, Hall, Blundo, & Lehmann, 2017). Furthermore, solution‐
focused rather than problem‐focused questions help to increase self‐efficacy, goal
approach, and action steps (Grant, 2012; Neipp, Beyebach, Nuñez, & Martínez‐
González, 2016).
SFBT has become manualized (Bavelas et al., 2013), is widely researched, and is
considered an evidence‐based approach (Franklin, Trepper, Gingerich, & McCollum,
2011). A recent development in SFBT is engaging in a microanalysis of the process
of therapy, where there is a moment‐by‐moment analysis of the therapeutic dialogue.
While the notion of co‐construction was primarily a theoretical concept, recent
researchers have engaged in microanalysis to codify the practical application of co‐
construction (Bavelas, 2012; De Jong, Bavelas, & Korman, 2013; Froerer & Jordan,
2013). This line of research explores how SFBT therapists work the model to co‐
construct the language of solutions. For instance, SFBT researchers have focused on
the process of grounding (Clark & Schaefer, 1989), which is the in‐the‐moment
process of speaker and addressee making sure they understand one another.
Grounding has become a fundamental mechanism in the particulars of SFBT practice
(Bavelas et al., 2013).
Narrative therapy Narrative therapy was developed by Michael White and David
Epston in Australia and New Zealand beginning in the 1980s. Originally being
informed by the cybernetic ideas of Gregory Bateson, White and Epston began to
incorporate ideas from a variety of fields, including literary theory, notions of
power practices located within dominant discourse espoused by Michel Foucault,
and text metaphors and feminist philosophical constructs (White & Epston, 1990).
Other prominent theorists that influence narrative therapists include Lev Vygotsky,
the Russian psychologist who introduced the metaphor of “construction” that
undergirds the scaffolding metaphor (White, 2012); Jerome Bruner, who contrib-
uted to the narrative construction of reality; and Jacques Derrida, who promoted
concepts of deconstruction. Narrative therapists tend to pay special attention to
how dominant discourses utilize power relations that marginalize people and
attempt to empower people to utilize their local knowledge to move past restrictive
worldviews.
Narrative therapists hold that people story their lives and that these stories of who
they are intertwined with the dominant social and cultural discourses of their time
(Madigan, 2011; White, 2007; White & Epston, 1990). As people internalize these
discourses, they self‐police themselves, leading to the dominant stories of who they
are becoming oppressive and limiting. Using a variety of maps of therapeutic conver-
sations, which are not set in stone, but available possibilities of conversational endeav-
ors, therapists help deconstruct these internalized discourses and help bring forth
alternative plotlines of people’s lives and identities (White, 2007). These maps include
externalizing conversations, reauthoring conversations, remembering conversations,
definitional ceremonies, unique outcome conversations, and scaffolding conversa-
tions. Perhaps the most famous of these maps is that of externalizing, where the thera-
pist attempts to separate the person from the problem (White & Epston, 1990). This
has led to the saying “The problem is the problem” as narrative therapists attempt to
promote alternative views of who people think they are, increasing their sense of per-
sonal agency. Unique outcome conversations focus on plotlines and views of self that
fall outside of the dominant story of who someone is (White & Epston, 1990).
Narrative therapists attempt to explore the absent yet implicit; the preferred aspect of
what people say is the problem (Chang et al., 2013; White, 2011). This can occur
through double listening—hearing what they find problematic and what they pre-
fer—and by asking clients about what they treasure.
Narrative therapists view therapy, and the process of identity enhancement, as being
larger than the one‐to‐one relationship between therapist and client. White (2007)
utilized definitional ceremonies where clients tell their stories to not only the therapist
but others (called outsider witnesses) who have likely had some relation to the prob-
lem. In this process, therapists, with the client’s permission, invite people who have
previously dealt with the problem to listen to the therapeutic conversation. The
therapist then interviews these outsider witnesses in a retelling of the therapeutic talk,
primarily those aspects they were drawn to. This retelling adds richer description to
the therapeutic conversation. The client is then interviewed in a retelling of the
conversation with the outsider witnesses. Through this process, alternative knowledges
tend to come to the forefront of the therapeutic talk. Narrative therapists also include
more people into the alternative stories developed during the therapeutic conversation
through the use of counter documents (White & Epston, 1990). These are certifi-
cates, letters, diplomas, and other written documents that support the newly devel-
oped alternative story. This goes counter to the problem‐saturated documents that
have likely followed the client such as psychological assessments, police reports, and
court documents. Counter documents may be written by the therapist, by the client,
or by others outside of the therapy sessions. For instance, in working with a family
where a child has been suspended from school for fighting several times, the therapist
might focus on separating the child from an identity of a troubled kid who is a fighter.
This deconstruction of identity could happen in many ways. Once fighting is no
longer a part of the child and family’s experience, the therapist might present them
with a Fight Fighting Award. The therapist might also write a letter on behalf of the
family, discussing the child’s new relationship with fighting. This letter could be pre-
sented to the school principal and/or teachers to help widen the readership of the
story of the child as proactive in a rebellion against fighting.
Power has been a prominent ethic in narrative therapy (Haugaard, 2016). However,
narrative therapists attempt to change the normal institutional power practices so that
problems rather than people are objectified, the cultural context rather than individ-
ual psyche is examined, privileging client knowledge over therapist knowledge, and
shifting from an individualistic viewpoint to a relational sense of self. To reduce the
power imbalance between therapist and client, narrative therapists take a position of
being decentered yet influential (Gaddis, 2016). This means therapists help clients be
the primary author of their preferred story. Furthermore, narrative therapists are
influential in that they engage in a conversation that opens space for clients to think
about, express, and ultimately live their hopes, dreams, beliefs, and values (White,
2007). This occurs through a process of scaffolding where the therapist helps create a
context where people can separate from what is known and familiar to themselves and
move toward what might be possible for how they think about themselves and act in
their lives (White, 2012). Narrative therapists, based on a view that identity is rela-
tional and fluid, focus on how people’s identities are in a process of becoming rather
than are set (Combs & Freedman, 2016).
Some narrative therapists have moved outside of the therapy room and are working
with groups, organizations, and communities (Freedman & Combs, 2009), especially
those who have experienced trauma (Denborough et al., 2006; Madigan, 2011). This
work, known as collective narrative practices, helps communities to map their history,
collect narrative documentation, discuss social and psychological resistance, and
develop alternative meanings around trauma. Recent work in narrative therapy has
also explored the connection between the practice of narrative therapy and neurosci-
ence (Beaudoin & Duvall, 2017; Young, Hibel, Tartar, & Fernandez, 2017;
Zimmerman, 2017; Zimmerman & Beaudoin, 2015; Zimmerman & Tomm, 2018).
For instance, Young et al. (2017) found empirical support of neurophysiological
effects of single‐session scaffolding conversations, which demonstrates the social
engagement of brief therapy practices. This social engagement is housed within thera-
pist positions of curiosity, enthusiasm, and collaboration. However, one of the impor-
tant points of narrative practice is that it is not set in stone. While there may be maps
of practice, these maps help get to the unmapped—ways of working narratively that
have not yet been explained or even explored yet (Epston, 2016).
Collaborative therapy Collaborative therapy was developed by Harry Goolishian

and Harlene Anderson in Galveston, Texas, in the 1980s. Based originally on
multiple impact therapy and then the brief therapy of the MRI (Anderson, 2007a),
these clinicians shifted their work from the mechanical cybernetic systems metaphor
and introduced a language systems metaphor to working with people (Anderson &
Goolishian, 1988). Further evolvement of the ideas of this approach led to Anderson
(2012) discussing six interconnected perspective‐orienting assumptions. These
include the following: (a) metanarratives and knowledge are not fundamental and
definitive; (b) generalizing dominant discourses, metanarratives, and universal
truths is seductive and risky; (c) knowledge and language are relational, generative
social processes; (d) local knowledge is privileged; (e) dialogue, knowledge, and
language are inherently transforming; and (f) self is a relational–dialogical concept
(pp. 9–11).
Unlike most other approaches, there are not techniques in collaborative therapy.
Instead, the therapist adopts a position of not‐knowing wherein the therapist privi-
leges the client’s perception of self‐meaning over the therapist thinking he or she
knows what the client thinks (Anderson, 1997, 2005; Anderson & Goolishian, 1988).
From this attitude, the client becomes the expert of his or her own meaning‐making
while the therapist is an expert on helping to create a conversation—a dialogic con-
versation—that brings the client’s meanings to the forefront. The dialogic conversa-
tion is a generative process, where new meanings are able to emerge (Anderson,
2007b). The therapist privileges the client’s viewpoint of which meanings are most
useful in their lives.
Based on concepts proposed by Mikhail Bakhtin, where humans are linked dialogi-
cally, collaborative therapy views what happens in the therapy room, the therapy con-
versation, as the medium in which change happens (Anderson, 2012). This goes
counter to developing specific goals with specific interventions that many other thera-
peutic approaches utilize. Collaborative therapy, like narrative therapy, has found its
way outside of the therapy room to be used in alternative settings such as prisons
(Wagner, 2007), educational institutions (Anderson, 2013; London & Rodríguez‐
Jazcilevich, 2007; McNamee, 2007), coaching (Anderson, 2016b), and business and
organizations (Anderson, 2012). Regardless of setting, collaborative practitioners
have moved toward an ethic of responsiveness (Doyle, 2017). From this view thera-
pists are encouraged to conceptualize outside of the therapy room to encompass sys-
tems, institutions, and cultures that contextualize human interactions.
What is the truth? Skepticism toward grand narratives

For much of the history of psychotherapy, therapists operated from a position of
objectivism, a belief that there is an independent reality from the observer. This realist
position holds that environmental determinism occurs separate from the observer’s
constructions (Rosen, 1996). Postmodernists, in general, abandon the notion of
universal truth. In some ways, this is a paradoxical notion since stating that there is no
absolute truth seemingly makes a truth claim. However, social constructionists—those
who believe that reality is a linguistic event where people co‐create understanding—
tend to hold that they do not make truth assumptions. Instead, they engage in dialogue
(or multilogue) where ideas, metaphors, arguments, and propositions are put forth
and examined (Gergen, 1994). Thus, there is not a claim about objectivity of ideas.
This movement from grand narratives that are definitive, objective, and empirical
to those that are more fluid provides the space for more alternatives in how people
think and what they might do based on their viewpoints (Gergen, 1994). That is,
“what is” is not a fixed entity. The understandings that people have are, instead,
based in a communal environment of fluid discourse. These understandings differ
depending on the cultural, linguistic, and relational contexts in which they occur
(Tarragona, 2008).
Instead of viewing one discourse as truth, postmodernists hold that there is a
multiplicity of perspectives (Tarragona, 2008). This is a shift from a realist to an
antirealist position, where people create reality rather than discovering it (Held,
1995). Instead of experiencing an objective reality, people can only know through
their own experience (Raskin, 2002; von Glasersfeld, 1984). This process of
knowing occurs in language and interactions with others. Furthermore, there is
not a set and true narrative of who a person is as the identity of the individual is
fluid and shifts based on the current discourses that are being used to describe the
self (Pilgrim, 2000).
What do we know? The construction of knowledge

Many postmodern therapists consider themselves either constructivists or social
constructionists. While there are overlaps between these two viewpoints, the main
difference is that constructivists view meaning as being created within the individual
(Raskin, 2002; Rosen & Kuehlwein, 1996; von Glasersfeld, 1984), while construc-
tionists view meaning as being created between people via language (Gergen, 2009;
Rosen, 1996). However, both positions hold that meaning and truth are constructed
rather than inherent and set in stone (Mills & Sprenkle, 1995).
In many ways, people “bring forth” what they know through the process of making
distinctions (Moules, 2000). As we make certain distinctions, we see differently. From
constructivism came the idea of radical constructivism, which holds that people can
only know through their own experience (von Glasersfeld, 1984, 1995). The founda-
tion of much of radical constructivism in family therapy came from the biological
ideas of Maturana and Varela (1980, 1992). These authors introduced the term
autopoiesis, which refers to systems as being self‐referential. Given the system’s
organization, it will self‐regulate. For Maturana, change for the organism cannot
come from outside, but rather only internally. This led family therapists to shift from
developing interventions designed to target specific areas of the family’s functioning
and, instead, to attempt to perturb the system. Perturbations are based on the con-
cept that therapists cannot control the impact of their intervention and thus rely on
the system to change in the way that fits with its organization.
It is the individual, through language, who creates the meaning of actions, which
counters the notion that there is an objective truth to be known. As such, Maturana
(1988) differentiated between two kinds of objectivity. The first is objectivity‐with-
out‐parentheses, which holds that there is an objective reality that can be known by
the person. The second, objectivity‐in‐parentheses, describes that the knower makes
distinctions that lead to what is known. Modernists tend to function from the position
of objectivity‐without‐parentheses, while postmodernists operate from the position of
objectivity‐in‐parentheses, where what is “known” is not understood as Truth with a
capital T, but as “truth” with a small t. This is a significant distinction as “truth”
becomes a notion that what is known is an agreed‐upon construction, which can be

understood differently upon subsequent iterations of conversation around that topic.
What does it mean? Discourse and interpretation

The shift from a modernist to postmodernist perspective includes a move from
accessing reality to an understanding that “truth” happens through interaction.
Wittgenstein (1958, 2003) discussed knowledge and communication in terms of
language games, which are the created ways of communication between people.
People develop a system of language that allows them to negotiate meaning between
them. de Shazer (1991), borrowing from Wittgenstein, explained, “The therapy
system can be seen as a set of ‘language games,’ a self‐contained linguistic system that
creates meanings through negotiation between therapist and client” (p. 68). Therapy,
when seen through the process of a language game, becomes a continuous process of
development of what words signify and mean.
People are able to share understandings through various social discourses about
how people should be. Many postmodern family therapists borrow ideas from Michel
Foucault (1980), who posited that knowledge is power. The social discourses that
entwine people’s lives are associated with power relations (Drewery & Winslade,
1997). That is, the constructed knowledges of the many lead individuals to internalize
the expected norms. These knowledges then become the “truth” of who people are
and how they should be, which lead them to self‐police themselves based on these
dominant discourses (White & Epston, 1990).
Postmodern therapists view therapy as a process of coordination between people
who are engaged in languaging, where they use a shared means of communication to
one another (Maturana, 1991). In the postmodern tradition, language shifts from
being just a communicational tool to an action. de Shazer (1991, 1994) called this
process of language creating reality “poststructuralism.” In essence, the words that
people use create their understandings. Whereas modernist‐based family therapists
primarily focus on families’ interactional processes, the focal points of postmodern
family therapy are people’s understandings and meanings. These meanings are housed
within language, which becomes the performance of meaning (Raskin & Neimeyer,
2003). That is, what we say becomes a current truth of who we are, which leads us to
behave in ways that support that view.
Postmodern therapists borrowed ideas from hermeneutics and applied them to
their view of people and the therapeutic context. Hermeneutics is the interpretation
of texts, so with this perspective, postmodern therapists view client narratives as a text
that can be understood and interpreted by many people (Worsley, 2012). In therapy,
the hermeneutic perspective leads to therapist and client attempting to bring new
meanings to the client’s story. Rather than attempting to decipher the truth of the
story, the therapeutic use of hermeneutical ideas is based on bringing forth multiple
meanings. While the client comes to therapy with a primary understanding of their
own story, in therapy, there is an alternative reading of the story (Bruner, 1986).
There may be continual alternative readings, leading to an interpretation of the cli-
ent’s story that better fits within the client’s preferred way of understanding self.
There is thus a deconstruction and subsequent reconstruction of the meaning of
the story. Deconstruction is based on the perspective that people shape their lives
based on how they prescribe meaning to their experience, which is housed within
language and cultural practices (White, 1993). These language and cultural practices
are societal discourses. In therapy, deconstruction happens through a language game
of therapist and client separating the client’s position of self from those of the cultural
discourses.
Once the client’s current narrative is deconstructed, therapists help in the process
of reconstruction where alternative meanings are developed that highlight new aspects
of self (White, 2011). These aspects are not viewed as Truth but rather alternative
readings of the client’s text (i.e., their story of who they are as a person). These alter-
native knowledges lead to additional possibilities for people to think about them-
selves, usually being more in line with their preferred view of self.
Who is it about? Reflexivity and subjectivity

Modernist therapists tend to place their focus on what is happening for the client,
at times losing sight of the person making those observations, themselves.
Postmodern therapists expand this focus and understand that the observed is
invariably intertwined with the observer. Heinz von Foerster (2002) described this
as second‐order cybernetics, which requires the therapist to become self‐reflexive.
Reflexivity refers to the ability to make the self the object of one’s observations
(Lax, 1992). This is important in therapy since the client is able to get out of the
initial problematic story and view self from a different perspective. When they do
so, they are able to expand their current meanings (Berg & DeJong, 1996), which
leads to the possibility of a new perspective being developed. In therapy, this
reflexive process can be seen in the use of reflecting conversations, reflexive
questions, and reflecting teams.
As an example of reflexivity, Tom Andersen (1991, 1992) developed a process of
consulting clients known as the reflecting team. While a therapist interviews a client,
a team of therapists watch behind a one‐way mirror or sit quietly in the therapy room.
Some time during the conversation, the therapist and client will stop and listen to the
conversation of the reflecting team, who talk about what they were drawn to in the
therapeutic conversation. Rather than analyzing the client from an expert position,
the reflecting team operates from a position of uncertainty, usually focusing on the
not‐yet‐said of the conversation. When finished, the reflecting team moves back to
their original position, and the therapist and client talk about what they heard in the
reflecting team’s talk. This process brings the possibility of new ideas and meanings
into the conversation. No idea is truth, but all ideas are equally valid and potentially
meaningful.
Reflexivity and subjectivity are interrelated, leading to the perceiver understanding
self differently based on one’s perception of truth. For those coming from an
objectivist position, where there is a single reality, the self is a distinct and
unassailable entity (Gergen, 1991). However, as one shifts to a subjective view of
truth, a truth developed in coordination with others, the view of self becomes
multiple. This allows the development of multiple perspectives, from multiple
people and even multiple perspectives from the same individual. This is also a shift
from an either/or to a both/and perspective, where objectivity holds that a person
is either this way or that way while a subjective position holds that a person is both
this way and that way.
Postmodern therapists have also shifted from viewing only the client’s cultural con-
text to a more self‐reflexive stance of viewing the therapist’s culture and the intersec-
tion between therapist and client cultural experiences (Addison, 2017). This process,
called location of self, leads to therapist and client having a conversation about how
the similarities and differences of their race, religion, sexual orientation, class, gender,
and ethnicity may impact the therapeutic conversation (Watts‐Jones, 2010).
Postmodern therapists have become reflective to the variety of identities that both
client and therapist hold, especially those of being marginalized (McGoldrick &
Hardy, 2008).
Reflexivity in family therapy leads to a process of mutual influence rather than the
traditional power imbalance of therapist being in a higher hierarchical position based
on an expert position (Hoffman, 1992). This more egalitarian therapeutic relation-
ship is supported when both therapist and client can determine the focus of the rela-
tionship (O’Hanlon, 1993). However, therapists cannot help but be in a position of
power and privilege over clients. For instance, therapists are mandated reporters,
which means they must act in some manner of social control based on the information
they are exposed to.
The shift from the therapeutic relationship being based on a hierarchical to
egalitarian dynamic changes the process of therapy. In modernist approaches, the
initial stages of therapy might be used so that the therapist can conduct an
assessment of the client, such as personality tests, gleaning the empirical truth as to
who the client is and what is going wrong for the person. Postmodern therapists
tend to eschew assessments and instead enter into collaborative relationships.
These collaborative relationships focus on the uniqueness of each person (Anderson,
2012). Modernist approaches tend to categorize individuals, such as assessing for
whether the client fits into a specific diagnostic category using standards such as
the Diagnostic and Statistical Manual (DSM) or the International Classification of
Diseases (ICD), which both have criteria for various mental disorders. Postmodern
approaches help unfold the individual’s unique views, as the client is the person
that knows himself/herself best. Ironically, this position can mean postmodern
therapists may have clients who include DSM and ICD as part of their unique views
so diagnostic discourse can become one of many ways to speak collaboratively with
clients (Chenail, 2002).
While family therapy began with first‐order thinking, with the therapist being able
to observe and assess a family, it quickly moved to second‐order thinking, which
included the notion of the therapist’s influence based on his/her viewpoints. However,
family therapy may be moving toward third‐order thinking, with a focus on systems
of systems—the interactions between and within society systems (McDowell,
Knudson‐Martin, & Bermudez, 2018). Third‐order thinking expands the scope of
therapy to include client, therapist, societal processes, and power dynamics. These
authors explained:
Facilitating third‐order change requires us to do the following; (1) take a metaview of

ourselves and the families with whom we work as acting within systems of systems, (2)
integrate our understanding of societal systems and power into treatment models, and
(3) invite clients to view their own lives from metaperspectives that assist them in solving
problems and expanding possibilities for organizing relationships (p. 6).
Who is the expert? The importance of the client

Expertise in psychotherapy was once the purview of only the therapist, who was able
to assess, diagnose, and then treat based on their own understanding of what needs to
happen for the client. Currently, for postmodernists, the client’s expertise is now con-
sidered of paramount importance. This view of the client as the expert of his/her own
life, meanings, and problem definitions (Anderson, 2012; Berg, 1994; Furman &
Ahola, 1994) privileges the client’s worldview over that of the therapist or any other
social discourse. This is important since clients have had experiences of feeling subju-
gated by social discourses that are associated with power dynamics of who and how a
person should be. This problematic process could be replicated in therapy if therapists
impose their own viewpoints on how the client should be.
In practical terms, the shift from therapist as expert to client as expert has led thera-
pists to take a “not‐knowing” stance (Anderson, 1997; Anderson & Goolishian,
1988, 1992). This position holds that the therapist cannot know the meanings of the
client, which leads the therapist to engage the client from a perpetual position of curi-
osity. Not‐knowing is more than a technique; it is an attitude and belief that the thera-
pist does not have privileged information (Anderson, 1997). Through this
conceptualization, clients are the expert of their own experiences and meanings. The
therapist is an expert on helping to create a space for that exploration—a dialogic
conversation (Anderson, 2012). This is a process of mutual inquiry in which two or
more people engage in conversation around a topic and mutually influence one
another. Developing the therapeutic dialogue can be difficult for the therapist as fam-
ily members tend to engage in antagonism with one another (Rober, 2015). Instead,
the therapist needs to open a space and create an agonism, where the tension is
accepted and discussed, but that the parties are not enemies. Rober (2017) views fam-
ily therapy as being “in therapy together” (p. 49). This occurs through a process of
attunement where family members, as well as the therapist, are able to engage in
dialogue where they are able to talk about their worries in a useful way. When this
occurs, family members are able to speak about the not‐yet‐said—aspects of their lives
they had not previously.
Postmodern therapists believe that clients are the best person to enact change,
rather than the therapist needing to teach or change the client, since clients have all of
the resources they need to live the type of lives they want (Berg, 1994). Most clients
enter therapy with a sense that they are deficient in some way(s). They have become
victims to the subjugating narratives that are dominating their lives. In many ways,
they have a reduced sense of personal agency, where they do not believe they can
shape their own life (White, 2007). Postmodern therapy helps people engage in per-
sonal agency where they are living their preferred lives through the resources they
already have available to them.
What is the problem? From deficits to strengths

Postmodern therapists tend to highlight portions of the client’s story that focus on
strengths and resources rather than deficits and problems. This is in contrast to a dis-
course of deficit that is at the base of many modernist approaches (Gergen, 1994,
2001). Postmodern therapy is a language game where therapist and client enter into
discourse that brings forth the existing strengths and resources of the client
(de Shazer, 1991). These strengths, talents, skills, and resources might be previous
behaviors, thoughts, and feelings that were useful to the person. These ways of being
that had previously been useful are known as exceptions (Berg, 1994; de Shazer,
1991) and unique outcomes (White, 2007; White & Epston, 1990). They then become
the foundation of a therapeutic conversation focusing on how the clients can do more
of what has worked in the past or bring forth alternative plotlines of their lives.
Berg and de Shazer (1993) expressed this conversational movement from deficits
to strengths, or what the client does not want to what he or she wants, as the shift
from “problem talk” to “solution talk.” The more talk there is in the therapy room
about what is not working and what people do not want, the more these problems
grow a life. Thus, postmodern therapists try to quickly shift the therapy conversation
from problem talk to solution talk. However, not all postmodern therapists utilize the
same terms. Postmodern therapists practicing solution‐focused or solution‐oriented
therapies are more likely to talk about client strengths in terms of solution talk and
exceptions—times when the problem could have happened but did not (Berg, 1994;
de Shazer, 1991). Narrative‐based therapists might use terms such as alternative plot-
lines and unique outcomes (White & Epston, 1990). However, postmodern theories
share a focus on client strengths that inform their work. Whatever it might be called,
therapy then becomes about developing a generative discourse (Gergen, 2009), where
the focus is on solutions, strengths, and possibilities rather than problems. This occurs
since problems are not inherent in people.
Postmodernists do not believe that people have a set or core personality. This allows
therapists to view people as separate from problems. Since problems develop in how
people language their experience, problems can also be languaged away (Anderson,
2012). This is related to the concept of poststructuralism, which holds that language
is reality (de Shazer, 1991, 1994). Anderson and Goolishian (1992) viewed therapy
as a problem‐dis‐solving system where therapist and client engage in a discourse
where new meanings are generated that lead to problems not being viewed and
expressed as problems. Thus, postmodern therapy conversations are usually language
games that highlight strengths, creating a reality and “truth” that is more empower-
ing for the client.
Given that the therapist’s viewpoints are not “more right” than the client’s, post-
modern therapists have shifted from an either/or position to a both/and position.
When people view their situation from an either/or perspective, they tend to feel
stuck, as if they have limited options (Lipchik, 1993). One way of enacting this change
is to refrain from using “instead of” and use “in addition to” (Andersen, 1993). This
linguistic practice highlights that whatever the client has tried to solve the problem is
a possibility while there are many other possibilities that may also be useful.
Postmodern family therapists believe that people are not problematic, but rather
they have relationships to problems. This can be seen in narrative therapists’ use of
externalizing. Externalization is the process of separating the person from the prob-
lem (White, 2007, 2011; White & Epston, 1990). During this linguistic process, the
problem is referred to as its own entity rather than of who the person is. For instance,
the therapist would not refer to someone as being “depressed” but that “depression”
has entered into the person’s life. An externalizing conversation then explores how
the problem has influenced the person as well as how the person has demonstrated
personal agency over the problem. The person’s influence over the problem may then
become the focus of therapy as it helps to thicken the alternative story wherein the
client is exerting more personal agency and enacting more preferred relationships
with problems (Roth & Epston, 1996). This may happen through a reauthoring
(Madigan, 2011; White & Epston, 1990) where the therapist helps the client discuss
some of the neglected but preferred areas of their lives.
Postmodern therapists help the client to enhance their sense of personal agency
when the therapeutic conversation focuses on how the client has not let the problem
take over their lives. White (2007) explained that personal agency is the bridge
between what is known to them and familiar and what might be possible for people
to know about themselves. Personal agency highlights the strengths and resources
that people bring with them, such as their resiliencies, even during times of duress.
This can come through coping questions (Berg, 1994)—such as “Given how difficult
it has been for you, how were you able to prevent it from getting worse?”—or focus-
ing on alternative understandings of self that are more in line with the client’s pre-
ferred identity.
What can we measure? Postmodernism, diagnosis, and research

Postmodern therapists, with their concerns about truth claims, tend to not diagnose
individuals as diagnosing promotes a cultural discourse of enfeeblement (Gergen,
1994). However, the majority of psychotherapists and health‐care institutions func-
tion through the use of diagnostic categories. This poses an ethical dilemma for post-
modern family therapists who think systemically but may have to work in a medicalized
context (Strong & Busch, 2013). Gorman (2001) explained that family therapists in
the twenty‐first century need to be able to use the language of the DSM while also
holding multiple views of codification of the dilemmas people experience. This tends
to be a shift from deficits to resilience and possibilities.
Nobbs (2013) provided several ethical and moral issues when diagnosing a client
using the DSM. These include potential administrative misuse, privacy issues, data
about clients being misused or used out of context, and that diagnoses change over
time. Simblett (2013) explained that DSM discourse limits the possibilities for thera-
pists in their identities with clients. He suggested increasing the positions postmodern
therapists take in relation to the DSM to help open space so multiple views can be
heard and respected. Sutherland et al. (2016) concurred, stating that postmodern
therapists who are focused on issues of social justice can have a discursive perspective
of diagnostic discussions where a multiplicity of perspectives are discussed in the same
conversation in which the therapy participants’ voices are privileged.
A further tension for postmodern family therapists is the recent push for evidence‐
based treatments (EBTs), which are usually tied to DSM diagnoses (Strong & Busch,
2013). These authors expressed concern that EBTs privilege the individualizing and
medicalizing language of the DSM and fail to take into consideration the social con-
texts of clients. As an alternative to EBTs, some therapists have focused on practice‐
based evidence (PBE). PBE occurs when clients are able to provide feedback about
what has been helpful in therapy. This line of research and evidence in therapy has led
to client feedback being seen as a common factor (Halford et al., 2012). Out of this
exploration of client feedback emerged feedback‐informed therapy (Prescott,
Maeschalck, & Miller, 2017), which helps merge evidence‐based practice and social
constructionism (Tilsen & McNamee, 2015), as well as the Partners for Change
Outcome Management System (PCOMS) (Duncan & Miller, 2004; Miller, Duncan,
Sorrell, & Brown, 2005). PCOMS has been proposed as an alternative paradigm to
psychiatric diagnoses (Duncan, Sparks, & Timimi, 2018).
Karl Tomm (2014), in an attempt to move away from the individualizing typology
of the DSM, developed the IPscope. Based on social constructionist ideas, the IPscope
is a cognitive instrument that helps to identify relational patterns, such as Pathologizing
Interpersonal Patterns (PIPs), Wellness Interpersonal Patterns (WIPs), Healing
Interpersonal Patterns (HIPs), Deteriorating Interpersonal Patterns (DIPs),
Transforming Interpersonal Patterns (TIPs), and Socio‐Cultural Interpersonal
Patterns (SCIPs). The IPscope helps to relationally name problems, track therapeutic
progress (through the reduction in PIPs), and an alternative or conjoint instrument
than the DSM (Eeson & Strong, 2016).
From a postmodern perspective, there is a convergence between research and ther-
apy (De Haene, 2010; Strong & Gale, 2013). At their core, postmodern research and
therapy are dialogical processes where there is shared inquiry between at least two
people (researcher/interviewee; therapist/client). Change is seen as a natural out-
come of dialogue and thus is present in activities of communication. The process of
engaging in narrative discussions leads to a possibility of increased story development
where new meanings may emerge, even if the intention of the dialogue was not to be
interventive. Postmodern research is a process of identifying subordinated and mar-
ginalized meanings (Strong & Gale, 2013). This entails a process of co‐research where
the researcher and/or therapist focuses on the insider knowledges of the person he or
she is in conversation with (Epston, 2014). One aspect of this is hermeneutic inquiry—
the interpretation of texts (whether it be written or spoken), which leads to multiple
interpretations of the text and is quite useful for postmodern therapists to look at their
therapeutic work (Chang, 2010). Thus, there is a blurring between description and
intervention. De Haene explained that postmodern research and family therapy both
have experienced a challenge to a hierarchical process where the researcher or thera-
pist is not seen as expert, but become collaborative partners who need to self‐reflex-
ively represent themselves in their engagement in the dialogue. However, Helps
(2017) cautions that there are ethical challenges to postmodern qualitative practi-
tioner research, which can be overcome by using a dynamic relational ethics of care—
one where the therapeutic and research aspects are always in the service of the client
while the therapist/researcher maintains awareness of his or her power and position.
Anderson (2014) proposed that a collaborative‐dialogue discourse also helps to
bridge research and practice, where there is movement toward the unfamiliar. In this
way there is a shared inquiry instead of a researcher attempting to determine the
truths and facts of what is being explored. As Anderson explained, “It [collaborative‐
dialogue practice‐based research] flips learning about to learning with” (p. 70).
Research in this manner leads to therapist and client being co‐researchers. However,
while postmodern therapist/researchers have been hesitant to embrace research
(especially quantitative) methodologies and the push for EBT, there is a growing
movement toward integrating research as it relates to practice (Lebow, 2016). This
integration of utilizing evidence to inform practice can also be seen in postmodern
supervision (Sutherland, Fine, & Ashbourne, 2013). The American Association for
Marriage and Family Therapy developed core competencies for family therapists
(Nelson et al., 2007), which on the surface may seem to go against postmodern
sensibilities. However, Sutherland et al. explained that postmodern supervisors can
utilize these competencies to help inform supervisory conversations while the
supervisor is also being reflexive, paying attention to power dynamics, promoting

polyphony, being collaborative, and focusing on the resourcefulness of the client.
What happens in therapy? From techniques to questions

Since therapists are not the experts on how the client “should be,” postmodern therapists
attempt to bring forth what clients want for their own lives. Rather than trying to have
answers, therapists take a stance of wondering and questioning (Dickerson, 2014). This
process happens through a dialogic conversation where the therapist asks questions to
bring forth clients’ further understandings of self (Anderson, 2012). These questions
focus on what works well for people (Tarragona, 2008) and invite clients to develop
new understandings of their own meanings (Neimeyer, 2009) and to perform their
meanings (Strong, 2002). This is the language game of psychotherapy.
Based on the notion that therapists cannot control the outcome for a family,
postmodern therapists shifted from developing targeted interventions and instead
view their interactions with families as perturbations. Because therapists cannot be an
expert that controls the system, the best they can do is to engage the family system
through curiosity. Thus, the therapist’s questions are sometimes asked not to be
answered, but instead to be generative (Doyle, 2017). The therapist’s perturbations
need to be within the realm of meaning of the client or the client will not include
them in their construction of reality (Andersen, 1992). Postmodern therapists tend to
engage clients from a stance of curiosity, which leads to the possibility of new inter-
pretations (Cecchin, 1992). This is a shift from viewing therapy as an attempt to
determine what is happening and instead to explore what might be, as postmodern
family therapy tends to privilege the present and future more than the past.
Postmodern therapists also tend to ask strength‐based instead of deficit‐based ques-
tions focusing on what has been useful rather than not useful for people (Reiter,
2019). One such form of question is conversational questions. Conversational ques-
tions come from within the conversation rather than outside (Anderson, 1997).
Instead of trying to assess and diagnose, which would privilege the therapist’s expert
viewpoint, conversational questions follow up on client’s current meanings and
attempt to richen their talk. Other questions utilized by many postmodern therapists
utilize presupposition (O’Hanlon & Weiner‐Davis, 1989) as well as temporality
(Reiter, 2018) where the therapist asks the client to make distinctions between past,
present, and future while also shifting from an either/or to a both/and perspective.
Since meaning is constructed in language, the conversation in therapy—the dis-
course—is the focus of change. The postmodern therapist expects that the therapeutic
conversation will continue to move toward multiple possibilities, but does not know
a priori to meeting the client what those possibilities will be (Hoffman, 1992).
Whereas modernist therapists might have a picture of how the client should be, which
would privilege the therapist’s position and expertise, postmodern therapists privilege
the client’s experience. This leads to the therapist asking questions centering on how
clients make meaning of their own experience. A postmodern social constructionist
therapy leads a therapist to engage in multiple orders of ethics (Gergen, 2015). First‐
order ethics are those common in everyday life. However, second‐order ethics focus
on the relational process and bring together multiple voices, even when they are in
conflict with one another. McNamee (2015) further argued that these relational
ethics build conversations around curiosity and lead to an ethic of discursive potential,
which promotes diversity, reflexivity, and a challenge to claims about truth.
What happens outside therapy? The inclusion of social justice

Since people come to know themselves based upon the larger social discourses,
therapy shifts from being local—only happening in the therapy room—to social and
global. Family therapists embrace contextual issues of culture, gender, and socioeco-
nomic equity in order to increase their focus on issues of diversity, social inclusion,
well‐being, and social justice (Audet & Paré, 2018; Kosutic & McDowell, 2008;
Waldegrave, 2009). Whereas diversity used to refer to only a person’s gender or eth-
nicity, it now has at least two meanings. The first includes a focus on culture, eco-
nomic status, class, age, gender, disability, sexual orientation, and other aspects of
differences in people. The second aspect of diversity issues includes the areas of cul-
tural competence and social justice (Waldegrave, 2009; Waldegrave, Tamasese,
Tuhaka, & Campbell, 2003). Social justice has been called a “fifth force” in psycho-
therapy, with a push for social justice principles and practices being infused into psy-
chotherapy research, training, and practice (Audet & Paré, 2018). Owing to the
trailblazing work of feminist family therapists (see Walters, Carter, Papp, & Silverstein,
1988; Hare‐Mustin, 1978), postmodern therapists hold that the awareness of social
justice takes into consideration aspects of power differentials and systems of oppres-
sion that impact families (Combs & Freedman, 2012; Kosutic & McDowell, 2008).
Family therapists began to realize that if they only addressed families’ problems with-
out recognizing the ongoing circumstances of poverty, marginalization, and racist
and sexist experiences, they were ignoring these dire contexts and, even worse, help-
ing clients to adjust to these harsh societal factors contributing to the families’ prob-
lems in the first place (Waldegrave et al., 2003). This recent push for diversity and
social justice leads the therapist to advocate activism, multiple perspectives, or both
(D’Arrigo‐Patrick, Hoff, Knudson‐Martin, & Tuttle, 2017).
One approach based on social justice principles is Just Therapy (Waldegrave et al.,
2003). The process starts with therapists’ self‐examination to consider their own cul-
tural, gender, and economic biases and privileges to raise self‐awareness, to diversify,
and to create stronger community connections. Adopting principles of accountability
(i.e., being accountable for one’s own actions and accountable to others), belonging
(i.e., a sense of belonging to one’s own history, place, and people), sacredness (i.e.,
the sacredness of human life), and liberation (i.e., honoring difference and facilitating
new and transformative meanings that inspire hope and reconciliation), Just Therapy
practitioners focus not only on helping families achieve self‐determination but also
enabling policy change and community healing.
Postmodern therapists tend to utilize an intersectional approach to understand how
multiple social inequalities operate together to impact people on a variety of levels
(Seedall, Holtrop, & Parra‐Cardona, 2014). This is a position of viewing people of
“multiply cultured” (Paré, 2013). The various power dynamics of larger social dis-
courses lead people to internalize a sense of who and how people should be. This
might come in the form of body type, sociability, and ability. For a family where an
adolescent female is diagnosed as anorexic, therapists utilizing an intersectional
approach would consider how social views on weight, teen acceptance, culture, and
gender (besides many other dominant discourses) are leading the members of the
family to view their experience in the current way. Therapy would then involve
deconstructing these larger discourses and reconstructing alternative and more local
knowledges of who each family member is. In approaches such as Transformative
Family Therapy (Almeida, Parker, & Dolan‐Del Vecchio, 2007), therapists adopt an
integrated cultural context approach to individual, family, and social problems such as
poverty, racism, sexism, and homophobia by developing therapeutic interventions
that not only address personal and family lives but also foster community building and
social justice.
Where Is It Going? Future Directions of Postmodernism
One irony of both postmodernism and postmodern family therapy is that what
started as an outsider, critical view of mainstream, orthodoxy, modernist thought
and practice appears to have become an orthodoxy itself. If, indeed, postmodernism
and postmodern family therapy have become grand narratives themselves, then
maybe family therapy has entered into a new era some have called metamodernism
(van den Akker, Gibbons, & Vermeulen, 2017)—a consideration of both modern
and postmodern positions championing oscillations among construction and
deconstruction, sincerity and irony, and apathy and affect to obtain possible grand
transcendent positions of informed naivety, pragmatic idealism, and moderate
fanaticism (Turner, 2015).
In these possible metamodern times, family therapists might work toward
championing what Hassan (2015, p. 13) has called “planetary civility” by reestablishing
concepts of trust and truth. For Hassan, trust is a precondition of mutual respect of
difference in society, and truth is not necessarily a universal one, but rather we adopt
a pragmatist notion of truth. With these notions of trust and truth, metamodern fam-
ily therapists might be able to “uphold shared values such as human rights” (p. 13)
and work together to make individuals, families, and communities healthier and
peaceful. Writings such as those of Hardy (2001), Doherty (Doherty & Beaton,
2000; Doherty & Carroll, 2002), and others (e.g., Wieling & Mittal, 2002) suggest
that a metamodern family therapy might have already risen helping family therapists
to move beyond their recent identity crises as marginalized postmodern practitioners
in a dominant modernist world.
From this both/and perspective, with a foundation of postmodernism and social
constructionist framework, Seikkula and colleagues developed the Open Dialogue
used with psychiatric clients (e.g., Seikkula, 2002; Seikkula & Olson, 2003; Seikkula
et al., 2006). Open Dialogue is a network‐based language approach where, instead
of having formal family therapy sessions, there is a treatment meeting that is
organized by a mobile crisis team, usually occurring in the home of the person in
acute distress and including all relevant individuals. This same network continues to
work together toward resolution of the crisis. Research into Open Dialogue can be
seen as a glimpse into a metamodern family therapy world where randomized clinical
trials are utilized to study collaborative, generative, social constructionist practices
with hospitalized psychiatric patients and their families, friends, neighbors, doctors,
and case managers (Rhodes, 2011). To accomplish these types of caring conversations,
modernist and postmodernist researchers and therapists can build trusting and
respectful relationships predicated on metamodernism informed naivety, pragmatic

idealism, and moderate fanaticism with a shared value of client inclusion and
collaboration.
Linares (2001, 2006, 2016) proposed movement away from modernism and
postmodernism to an ultramodern family therapy perspective, in many ways similar to
Larner’s (1994) notion of para‐modern family therapy. This is an integration of
aspects of modernism, such as the therapist having expertise and knowledge, with
postmodern positions, such as the therapist not imposing on the client. Collaborative
conversation is the foundation of ultramodernism, but with the therapist having road
maps based on therapeutic knowledge. In this view, dual epistemologies are able to
work together enabling the therapist to engage in relational diagnosis as a guiding
metaphor, integrate linearity with circularity, balance the therapist’s role of expert
with responsibility, have collaborative conversations while also introducing intelligent
interventions, and view the construction of reality through the lenses of the individ-
ual, family, and society.
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Part IV
Methodological Challenges
and Advances
19
Innovations in Systemic Family
Therapy Effectiveness Research
Richard B Miller and Matthew E. Jaurequi
Establishing a strong research foundation of efficacy and effectiveness of systemic

family therapy (SFT) has been crucial in the development of the practice and profes-
sion of SFT (Wampler, Blow, McWey, Miller, & Wampler, 2019). Based on the
research standards that had been established in the fields of medicine and mental
health, SFT researchers have used randomized clinical trials (RCTs) as the primary,
preferred research design for evaluating SFT efficacy and effectiveness (Sprenkle,
2012). SFT represents a theoretical perspective to conceptualize and treat individual
and relationship problems, where family relationships that are embedded in larger
societal systems are viewed as the mechanism of change, regardless of whether the
client is an individual or a family (Wampler & Patterson, 2020, vol. 1). Consequently,
SFT outcome research using RCTs is not confined to research involving SFT with
couples and families; rather, it tests the effectiveness of SFT treatments, regardless of
who is in the therapy room (Wampler et al., 2019).
The use of RCTs in the health field began in the middle of the twentieth century,
replacing case studies as the dominant method to report clinical effectiveness. The
impetus for their use was spurred by concerns that pharmaceutical companies were
using expert testimonials and case studies as the only evidence to tout the effective-
ness of a new drug. Physicians and government regulators wanted more rigorous and
robust evidence, which led to the introduction of RCTs as an important method in
validating a new drug’s effectiveness. By 1970, the US government developed regula-
tions that required RCTs for the approval of new drugs. The position that RCTs
provided more valid and compelling evidence of treatment effectiveness led to the use
of RCTs to test the effectiveness of nonpharmaceutical medical treatments, and by the
1980s, RCTs had become seen as the “gold standard” in medical research (Bothwell,
Greene, Podolsky, & Jones, 2016).
While the mental health fields have also designated RCTs as the gold standard of
treatment effectiveness (Gold, 2015), RCT methods have evolved over the years, as
researchers have sought to adapt the pharmaceutical‐based RCT standards to better
fit the realities of conducting psychotherapy outcome research. For example, the
446 Richard B Miller and Matthew E. Jaurequi
standard of using double blind designs makes perfect sense when testing drugs
because of the ease in concealing to both the patient and the person administering the
drug whether the pill is actually the drug or the placebo. However, in SFT outcome
research, therapists and clients are very aware if they are in the treatment group or the
control group, making the standard of double blind design impractical. As a result,
most governing and scientific bodies do not expect SFT RCTs to include the double
blind design (Ochs et al., 2020, vol. 4). On the other hand, because of the variable
ways that therapists can administer an SFT treatment, treatment manuals and the
monitoring of therapists’ fidelity to the treatment approach are now expected stand-
ards of SFT RCTs as a way to minimize therapist variability in the delivery of treat-
ment (Denton, 2014).
RCT methods continue to evolve. One of the most significant changes is that the
standard analytical strategy for outcome studies has changed from the family of statistics
related to analysis of variance (ANOVA) to multilevel modeling (Atkins, 2005). Another
important innovation is the increasingly common use of propensity score analysis that
enables community‐based nonrandomized treatment studies to mimic RCTs and pro-
duce unbiased causal estimates of treatment effects (S. G. West et al., 2014).
In addition to innovations regarding RCT methods, recent years have seen the
introduction of an entirely new clinical research paradigm that is client and therapist
based, rather than researcher based. Called practice‐based research, the goal is to pro-
duce practice‐based evidence, where evidence of therapy effectiveness comes from
clients and therapists, in contrast to the dominant clinical research paradigm of evi-
dence‐based practice, where researchers use randomized RCTs to identify empirically
supported treatments and provide clinical guidelines to therapists (Castonguay,
Barkham, Lutz, & McAleavey, 2013).
Practice‐based research is seen as a complementary paradigm to evidence‐based
practice, rather than a competing way to view clinical research. Indeed, both para-
digms enable researchers to address important, yet different, clinical questions. For
example, while the goal of RCTs is usually to minimize therapist variation in order to
focus on treatment model efficacy (Denton, 2014), a common goal of practice‐based
research is to examine the characteristics of effective therapists in natural, uncon-
trolled settings (Castonguay et al., 2013).
Thus, the purpose of this chapter is not to present a typical review of standard clini-
cal research methods. Rather, the goal is to introduce important recent developments
in clinical research methods that hold the promise of enhancing SFT researchers’ abil-
ity to further establish the efficacy and effectiveness of SFT. As will become apparent
in the chapter, these innovative methods are already being used by a few SFT research-
ers; the goal is to make them better known among the larger community of SFT
researchers so that they begin to be more widely used and become the new standards
for SFT research methods.
Innovations in RCT Methods
Multilevel modeling
The problems with ANOVA Outcome research has traditionally used statistical tests
that are associated with ANOVA analytical methods. ANOVA techniques compare
the means of the treatment and comparison group(s) at posttreatment and follow‐up
Innovations in SFT Effectiveness Research 447
to test for statistically significant differences in the means (Tasca & Gallop, 2009).
The basic ANOVA strategy has been expanded over the years to include analysis
of covariance (ANCOVA), which includes the pretreatment score; multiple analysis of
variance (MANOVA), which appropriately accounts for the simultaneous analysis
of multiple dependent variables; and repeated measures ANOVA, which analyzes
change in an outcome variable over multiple points of data collection.
Despite the almost universal use of ANOVA‐related statistics to analyze outcome
studies, scholars in recent years have reported serious liabilities in the use of ANOVA
techniques in RCT designs. One important liability is ANOVA’s inability to account
for the nested data that are inherent in clinical outcome research. In outcome studies,
multiple clients are seen by the same therapist, and multiple family members represent
different study participants in the same clinical case. Consequently, individuals in the
study are not independent; rather, they are embedded, or nested, in larger systems,
such as a family and a therapist’s caseload, where they share experiences in therapy
that are more similar than clients being seen by another therapist or who are members
of a different family (Kenny & Hoyt, 2009). Unfortunately, researchers have largely
employed statistical analyses, such as ANOVA, at the level of the individual and
ignored the fact that individuals are members of groups, even though ANOVA
assumes independence of observations (Baldwin, Murray, & Shadish, 2005).
The failure to address the nonindependent nature of nested data can dramatically
increase the risk for type I error (Kenny & Hoyt, 2009), which refers to a statistical
test falsely being considered significant. Baldwin and colleagues (Baldwin et al., 2005)
examined the results of 33 clinical outcome studies that included clients who were
either in group therapy or in family therapy. The authors reported that none of the 33
studies appropriately accounted for the nonindependence of the study participants.
After making statistical corrections for the nonindependence of the participants, they
found that between 18 and 58% of the studies were no longer statistically significant,
depending on the assumptions they made about the amount of the dependency
among participants.
Another deficiency in using ANOVA‐related statistics is its inability to effectively
account for missing data. ANOVA analyses require that data be balanced, meaning that
there is the same number of data points for each participant. When a study participant
fails to complete an assessment, or drops out of the study, the statistical program will
use listwise deletion to remove all data for that participant (Atkins, 2009), thus reduc-
ing the size of the sample and decreasing the amount of information in the dataset.
The revolution of multilevel modeling In response to the problems with the tradi-
tional ANOVA approach in analyzing RCTs in outcome studies, multilevel models
have become the “standard method for analyzing psychotherapy outcome data”
(Baldwin, Imel, Braithwaite, & Atkins, 2014, p. 920). It should be noted that multi-
level modeling is also known as hierarchical linear model, random effects model, and
mixed effects model approaches.
Multilevel modeling is an analytic approach designed to evaluate hierarchical or
nested data. Multilevel modeling reduces bias in hypothesis testing by extending
regression analysis through partitioning the error terms across individual and group
levels (Kahn, 2011). Consequently, multilevel modeling accounts for the fact that
individuals belong to groups, such as caseloads or families, when estimating
the regression parameters (Kahn, 2011). The evaluation of the intraclass correlation
coefficient (ICC) helps determine whether the magnitude of dependence in scores
may be attributable to a nested factor (Kenny & Hoyt, 2009). The ICC identifies the
proportion of the total variance in an outcome variable that is attributable to a nested
factor (Kenny & Hoyt, 2009).
Multilevel modeling takes the analytical approach of examining the trajectory, or
slope, of each participant’s scores over the course of therapy. For example, assuming
that an increase in scores represents an improvement in relationship functioning, a
statistically significant positive trajectory would indicate improvement during therapy,
a nonsignificant trajectory would indicate no change, and a significant negative trajec-
tory would indicate a decline in functioning. These individual trajectories are then
combined to create an average trajectory. This examination of individual trajectories
over the course of therapy is considered the level 1 analysis. Level 2 analysis might
include membership in the family group, for example, whether the participant is a
child or a parent in the family. Level 3 might assess the effect of the treatment by
comparing the results of the treatment and the comparison group.
In recent years, SFT researchers have demonstrated the utility of multilevel mode-
ling to analyze data from RCTs (Cohen, O’Leary, & Foran, 2010; Nowlan, Roddy, &
Doss, 2017). For example, Doss and colleagues (Doss et al., 2016) used multilevel
modeling to evaluate the results of an RCT that examined the effectiveness of the web‐
based “OurRelationship” program, which is an online adaptation of integrative behav-
ioral couple therapy. In their analysis, the authors modeled time, or changes in
functioning over the course of the therapy for each participant, as the sole predictor of
level 1. Gender was modeled as the level 2 predictor, and condition, or membership in
the treatment or waitlist control group, was modeled as the level 3 predictor. Results
indicated that those who participated in the OurRelationship program experienced
significantly greater improvements in relationship satisfaction, relationship confidence,
and negative relationship quality than those who were in the control group.
Missing data Missing data is common in clinical RCTs, despite researchers’ best
efforts to reduce the number of participants failing to complete an assessment or
completely dropping out of the study (Comer & Kendall, 2013). A meta‐analysis of
669 treatment studies in individual therapy found that an average of 19.7% of clients
prematurely dropped out of treatment (Swift & Greenberg, 2012). Dropout from
treatment in RCTs is similarly common in SFT research (Denton, Burleson, Clark,
Rodriguez, & Hobbs, 2000; Nowlan et al., 2017). Although random assignment to
either the treatment or comparison group theoretically assures equivalence between
groups, sporadic attendance or dropping out the study is often nonrandom, with
more distressed clients more likely to not complete treatment (Anderson, Tambling,
Yorgason, & Rackham, 2018). This is especially true when conducting RCTs with
couples and families because of the greater complexity and challenges they face in
coordinating schedules, arranging transportation, and cooperating to the level that
they can attend therapy together (Masi, Miller, & Olson, 2003). Thus, couples and
families who complete treatment and provide complete data for an RCT are likely to
be higher functioning than those who attend only sporadically or drop out of treat-
ment. This bias in the sample would lead to inflated effectiveness results because the
analysis is only considering the effect of treatment on higher functioning individuals,
couples, and families (Comer & Kendall, 2013).
In contrast to ANOVA, which uses listwise deletion to eliminate all participants in
the study with missing data (Atkins, 2009), multilevel modeling offers the ability to
address missing data in ways that do not reduce the sample size or bias the results.
Because multilevel modeling does not require data to be balanced, it can handle data
where an assessment is missed or where assessments are taken at different times (Atkins,
2009). In contrast to ANOVA using listwise deletion because it calculates group
means, the purpose of multilevel modeling is to create a trajectory, or line, of progress
or deterioration for each participant. In the case of a linear trajectory, it only takes two
data points to create the line. Thus, multilevel modeling is able to calculate a partici-
pant’s trajectory with only minimal data. In addition, multilevel modeling reduces bias
from dropout because it uses all data points in the dataset (Atkins, 2005). Thus, if a
family in an RCT drops out after only two sessions, their data is still included in the
analysis. This leads to a more accurate assessment of treatment effects because informa-
tion from both dropout and “completer” families are included in the analysis.
However, “all missing data are not created equal” (Atkins, 2005, p. 106), and mul-
tilevel modeling is only able to handle acceptable types of missing data. Statisticians
have identified three types of missing data, missing completely at random (MCAR),
missing at random (MAR), and not missing at random (NMAR) (Kahn, 2011).
MCAR suggests missing data are the result of a completely random process, such as
participants going on vacation or missing an appointment because of a sick child. Data
that are MAR, on the other hand, assume data are not missing completely at random.
In a way, using the term MAR is a bit confusing because the missingness of the data
is not random. Instead, there are patterns in the missingness, such as couples who
drop out of an RCT of couple therapy being more likely at the beginning of therapy
to be at a higher level of relationship distress. In this case of MAR, there is a variable
in the dataset that can be used to account for the missingness (e.g., pretreatment
relationship distress).
NMAR data refer to patterns of missingness where the cause of the missingness is
not included in the multilevel model because the predictor variable is unknown or not
available. For example, some couples might discontinue treatment because they lack
reliable transportation to the clinic or they cannot afford a babysitter. If income was
not measured in the study, the missing data would be considered NMAR because
there is nothing in the model that predicts their status as missing (Atkins, 2005).
Missing data that are MCAR or MAR are considered ignorable, meaning that the
missing data can be ignored because multilevel modeling statistical programs are able
to automatically handle these types of missing data (Atkins, 2005; Kahn, 2011; Little
et al., 2012; Schafer & Graham, 2002). In the case of MCAR data, the missingness is
entirely random, which means that there is no bias in the data from missingness. In
the case of MAR, the data are biased, or skewed, because the missingness is not ran-
dom (e.g., couples with higher pretreatment distress are more likely to drop out of
the study and produce missing data). However, in multilevel modeling, the variable
or variables that predict the missingness are included in the model to correct for the
bias caused by the nonrandom missing data, which allows it to produce unbiased
results. NMAR data, on the other hand, are not ignorable. Because the missingness is
not random and its cause is not included in the statistical model, either because the
cause is unknown or was not measured, there is no way to statistically correct for
the skewed data. Consequently, the results will be biased.
In summary, multilevel modeling has replaced the family of ANOVA statistics as the
standard for analyzing data from RCTs (Baldwin et al., 2014). Multilevel modeling is
able to handle nested data that are inherent in RCTs, especially ones involving couples
and families, and it allows researchers to analyze imperfect data caused by either
MCAR or MAR missingness. Atkins states that “multilevel models are incredibly
powerful and flexible tools to analyze couple and family treatment data” (2005, p. 109).
However, multilevel modeling is a sophisticated statistical approach that requires
advanced training. Nontechnical resources that can be used to learn the approach
include Atkins (2005), Kahn (2011), Robson and Pevalin (2016) (whose book has
the encouraging title of Multilevel Modeling in Plain Language), and Heck and
Thomas (2015). In addition to graduate statistical classes that are available at many
universities, researchers can also learn multilevel modeling by attending workshops
hosted by professional statistical training companies.
Propensity score analysis

SFT researchers have long called for an increase in effectiveness research (Lebow,
2018; Pinsof & Wynne, 1995). Efficacy research, which demonstrates that a treatment
approach works using an RCT in a carefully controlled setting, is able to maximize
internal validity by minimizing therapist factors and other sources of variability. In
contrast, effectiveness research evaluates the effects of a treatment in real‐world
settings, such as a community clinic or social agency (Pinsof & Wynne, 1995). Thus,
effectiveness research addresses the greatest weakness of efficacy research, a lack of
external validity, by testing the generalizability of the treatment’s effectiveness in
natural clinical settings, where client, therapist, and environmental factors can vary
substantially.
An RCT is the ideal research design by which to test the effectiveness of a treatment
in a real‐world setting. However, there are times when randomly assigning couples
and families to no treatment or waitlist control groups in community settings
is unethical or unfeasible (Baucom, Hahlweg, & Kuschel, 2003; Shadish, 2011).
Quasi‐experimental research designs, where clients naturally select into treatment and
nontreatment groups, offer ethical and feasible approaches to assessing treatment
effects. However, quasi‐experimental designs, because they do not randomly assign
clients into treatment and comparison groups, have long been considered flawed
because they are not able to assure equivalence in sample characteristics across groups.
In the absence of established equivalence across groups, it is impossible to attribute
group differences in clinical outcome to treatment effects. However, propensity score
analysis has been developed, which enables researchers to statistically create equiva-
lency between nonrandomized groups in order to calculate valid estimates of causal
treatment effects (Austin, 2011).
Propensity score analysis is used in nonrandomized studies to address the potential
threats of selection bias otherwise accounted for by random assignment in experimen-
tal studies (Rosenbaum, 2005). It reduces bias in nonrandomized studies by balanc-
ing the distributions of covariates, or sample characteristics, between treatment and
comparison groups (Lee & Little, 2017). The propensity score is defined as the prob-
ability participants ended up in the treatment or control condition as the result of a
set of observed covariates, or sample characteristics, measured at baseline. Shadish and
colleagues conducted a series of studies that compared the results of an RCT with a
parallel quasi‐experimental study, where the participants self‐selected their group
membership (Shadish, Clark, & Steiner, 2008). Using propensity scoring analysis,
they were able to demonstrate that the results from the quasi‐experiment were essen-
tially equivalent to the results from the RCT.
A basic overview suggests that there are four main steps involved in examining
causal treatment effects in nonrandomized studies using propensity scoring. The first
is the compilation of sample characteristics, or covariates, which may distinguish
members of the treatment and comparison groups. For example, researchers (Barth
et al., 2007) used propensity score analysis to compare the effectiveness of treatment
in intensive, in‐home multisystemic therapy with residential treatment centers. The
outcomes of youth were examined who had received services from a large agency that
made nonrandom referrals for over a thousand youth to either in‐home therapy or
residential treatment centers. Because of evidence that youth assigned to residential
treatment centers had greater problems than those assigned to in‐home therapy,
propensity scoring was used to create equivalency between the two groups.
Research has shown that including only a few demographic characteristics (e.g.,
only using age, gender, marital status, and race) is not sufficient to create equivalency
between groups and leads to biased results (Shadish et al., 2008). Variables need to be
carefully selected from past research and theory that might predict a person’s mem-
bership in one group instead of the other, as well as variables that might predict
treatment outcome (Lee & Little, 2017). In the in‐home therapy study (Barth et al.,
2007), researchers included 25 different covariates, including race, gender, age,
presenting problem of delinquency, presenting problem of mental health issues, pre-
senting problem of maltreatment, presenting problem of substance abuse, committed
a sex offense, past mental health treatment, receipt of special education services, and
youth’s prior legal charges.
The second step is to use the selected covariates to create a propensity score for
each participant. A propensity score for each study participant is typically estimated
using logistic regression models where the treatment status (e.g., treatment or com-
parison) is regressed on observed baseline characteristics (Austin, 2011). Thus, the
propensity score for each participant represents the probability, or propensity, of them
being in the treatment group. The equivalency, or balance, of the two groups can then
be examined, with the possibility that multiple logistic regression runs be conducted
with variations in the composition of the covariates in the model in order to maximize
the amount of equivalency (Lee & Little, 2017).
The third step is to create a revised sample that uses the propensity scores to create
balanced groups. Several methods have been developed to create the balanced groups,
but a popular approach, and one that is easy to understand, is propensity one‐to‐one
matching (Austin, 2011). In this approach, matched sets are created of treated and
untreated participants who share a similar value on the propensity score. This is typi-
cally done using the nearest neighbor approach, where a participant in the treatment
group is matched with the participant in the comparison group who has the most
similar propensity score (Lee & Little, 2017). In the in‐home therapy study, one‐to‐
one matching was done, which resulted in 393 matches out of an original 937 youth
in the in‐home therapy group and 432 in the residential treatment group. Those
participants who were not successfully matched were dropped from subsequent
analyses (Barth et al., 2007).
The fourth step is to use the matched sample containing the treatment and com-
parison groups to calculate the effect of the treatment. Results of the in‐home study
found that 61.5% of those who received in‐home therapy were evaluated 1 year later
as having a desirable outcome. In comparison, 55.8% of those who were in the resi-
dential treatment group were evaluated as having a desirable outcome 1 year later,
which was statistically equivalent to those in the in‐home therapy group. Although
the results found no differences in treatment type, the authors argued that the in‐home
therapy treatment was substantially less restrictive for the youth and over four times
less expensive than residential treatment. Thus, in‐home multisystemic therapy offers
a favorable alternative to residential treatment for troubled youth (Barth et al., 2007).
Propensity score analysis can be done using either prospective quasi‐experimental
designs or archived clinical treatment data. Similar to multilevel modeling, propensity
score analysis represents a sophisticated level of statistics that requires advanced train-
ing. Accessible resources include a book called Propensity Score Analysis: Statistical
Methods and Applications (Guo & Fraser, 2014), as well as excellent introductory
articles (Austin, 2011; Lee & Little, 2017; S. G. West et al., 2014).
Practice‐Based Research
Limitations of RCTs and evidence‐based practice

The use of RCTs to validate the efficacy and effectiveness of SFT treatments has been
crucial in the establishment of SFT as an effective approach for treating individual and
relationship disorders (Carr, 2020, vol. 1; Sprenkle, 2012). This evidence has allowed
SFT to qualify for a seat at the table in the integrated health‐care system (Wampler
et al., 2019). The reliance on RCTs to demonstrate clinical effectiveness is based on
the dominant research paradigm of evidence‐based practice, where clinical researchers
use the gold standard of RCTs to identify empirically supported treatments (APA,
2006). These findings are then communicated to therapists in the form of practice
guidelines to inform their clinical work.
However, in the past two decades, scholars have increasingly questioned the validity
of relying solely on RCTs to establish the effectiveness of treatments and inform clini-
cal practice (Castonguay et al., 2013; Kazdin, 2008). From this perspective, RCTs are
considered an important source of evidence, especially for establishing treatment effi-
cacy, but they are not the only valid source of establishing that a treatment is effective,
particularly for specific individuals, couples, and families (Rubel & Lutz, 2017).
Scholars point out that, while RCT designs are best able to establish high internal
validity by controlling for extraneous factors, they lack external validity or the ability
for the results to be generalized to natural clinical settings (Lutz, Stulz, Martinovich,
Leon, & Saunders, 2014). Consequently, researchers have argued that the exclusive
reliance on RCTs to provide evidence of clinical effectiveness is too narrow, leading
policy makers, researchers, and clinicians to ignore other valuable sources of evidence.
They argue that there needs to be broader definition of what methods can credibly
add to the evidence base (Barkham, 2016).
Khagram and Thomas (2010) have suggested a “platinum standard” for clinical
evidence. The platinum standard recognizes the importance of RCTs, the gold stand-
ard, in establishing efficacy and effectiveness, but the standard is upgraded to include
other forms of evidence, including quasi‐experimental designs, rigorous case studies,
and qualitative approaches. The authors argue that additional methods increase the
robustness of the evidence of effectiveness by providing important information about
the mechanisms of change, for example, which strengthens the validity of the theo-
retical basis of the treatment model. This perspective is shared by the American
Psychological Association’s Presidential Task Force on Evidence‐Based Practice,
which concluded that sufficient evidence of treatment effectiveness “requires an

appreciation of the value of multiple sources of scientific evidence” (APA, 2006,
p. 280) and that the evidence necessary to establish the effectiveness of a treatment
“must be drawn from a variety of research designs and methodologies” (p. 284).
A major criticism of the evidence‐based practice paradigm that relies almost exclu-
sively on RCTs is that the process of dissemination of scientific knowledge is based on
a top‐down approach, where researchers, based on evidence from carefully controlled
clinical trials, dictate treatment guidelines to therapists working in natural clinical set-
tings (Castonguay et al., 2013). From an evidence‐based practice perspective,
researchers are the creators of evidence, and clinicians are the consumers of the
evidence produced by researchers (Spring, 2007). Clinicians often view the pattern
of researchers handing down practice guidelines to them as “empirical imperialism”
because they do not have a voice in what is determined to be best practice (Lutz
et al., 2014).
In an influential article, Howard and associates (Howard, Moras, Brill, Martinovich,
& Lutz, 1996) argued that there are three questions that should be asked about any
therapy treatment modality. First, is it efficacious, meaning that it has been validated
in carefully controlled experimental conditions? Second, is it effective, meaning that it
has been tested in naturalistic clinical conditions? And third, is it working for this
specific client? The third question has been the one least explored, but it is of most
interest to clinicians. They state:
It is not sufficient for the practitioner to know that a particular treatment can work
(efficacy) or does work (effectiveness) on average…The practitioner needs to know what
treatment is likely to work for a particular individual and then whether the selected treat-
ment is working for this patient. Thus, from the clinician’s evaluative perspective, one
critically important task of research is to provide valid methods for systemically evaluating
a patient’s condition in terms of ongoing response of that condition over the course of
treatment… the clinician is interested in the… assessment of progress during the course
of treatment, not the assessment of outcome after the termination of treatment. (p. 1060,
emphasis added)
In response to Howard and colleagues’ (1996) call for the need for therapists to
assess the ongoing effectiveness of treatment for each client, a new research paradigm,
called practice‐based research, has been developed as an additional way to establish
empirical evidence about therapy effectiveness and improve therapy outcome.
Practice‐based research is the process of systematically assessing client progress
throughout the process of treatment and providing “real‐time” feedback of the infor-
mation to therapists (Rubel & Lutz, 2017). In contrast to the evidence‐based practice
approach’s focus on the average effects of a treatment that are derived from RCTs,
practice‐based research focuses on monitoring the progress of each client’s treatment,
which facilitates clinicians’ ability to make treatment decisions during the course of
therapy (Newnham & Page, 2007).
Moreover, while evidence‐based practice takes a top‐down approach, practice‐
based research takes a bottom‐up approach to produce practice‐based evidence, where
therapy evidence comes from therapists in practice settings (Holmqvist, Philips, &
Barkham, 2013). Kazdin (2008) has lamented the evidence‐based practice approach’s
dismissal of knowledge that can be obtained from clinical practice. He asserts that
“Clinical work can contribute directly to the scientific knowledge base…, [but] we are
letting knowledge from practice drip through the holes of a colander” (p. 155).
He advocates filling the holes of the colander by using practice‐based information to
help build the knowledge base of therapeutic effectiveness and, thereby, reduce the
research‐practitioner gap. Indeed, practice‐based research privileges the important
role of therapists, rather than the treatment approach, as a focus in the research
process (Castonguay et al., 2013) and allows therapists to have an active role in the
development of therapy evidence. Research is gathered not only for clinicians but also
by clinicians (Lutz et al., 2014).
Advocates of practice‐based research do not claim that their approach is superior to
the evidence‐based practice approach. They acknowledge the importance of RCTs in
contributing to the evidence base of therapy efficacy and effectiveness. However, they
argue that the additional evidence that is gathered by practice‐based research is also
valuable. Thus, rather than an either‐or dichotomy, evidence‐based practice and prac-
tice‐based research are best viewed as representing different research paradigms that
complement each other because they have the ability to ask different research ques-
tions (Newnham & Page, 2007). For example, although evidence‐based practice has
focused on validating the effectiveness of treatments (APA, 2006), increasing evidence
suggests that the role of the therapist plays a significantly larger role in therapy out-
comes than the treatment model that is used (Baldwin & Imel, 2013). Indeed, Blow
and Karam (2017) have suggested that research attention should shift from identify-
ing evidence‐based treatments to evidence‐based therapists. RCTs of effective treat-
ments, which are designed to minimize therapist variability, are ill‐suited to examine
therapist effects. Instead, research designs associated with practice‐based evidence are
better able to examine therapist effects and the characteristics of effective therapists.
Practice‐based research primarily consists of three main components. These are (a)
the formal assessments of therapeutic progress, (b) the development of practice‐based
evidence, (c) and the use of practice research networks (PRNs) to coordinate the col-
lection of data across clinical sites that can be compiled into large clinical datasets
(Castonguay et al., 2013).
Formal assessment of therapeutic progress

Effects of formal assessment A signature feature of practice‐based research is the
ongoing, formal assessment of clients, including individuals, couples, and families.
Instead of the traditional practice of administering assessments only at pretest and
posttest (in the minority of cases where assessments are actually administered), prac-
tice‐based research methodology consists of the formal assessment of client progress
throughout the course of therapy, typically at every session.
Based on research done in individual therapy, there is considerable evidence that
formally assessing progress throughout the course of individual therapy increases the
therapeutic alliance, decreases dropout rates, and improves outcome (Lappan,
Shamoon, & Blow, 2017). For example, a meta‐analysis of six large RCTs with a
combined sample of over 6,000 individuals in therapy that compared therapists who
monitored client clinical progress with those that did not found that individuals who
were regularly assessed during the course of therapy and whose therapist received
formal feedback about their clients’ progress had significantly better therapy out-
comes (Shimokawa, Lambert, & Smart, 2010).
There is also evidence that formal assessment enhances couple therapy.

(Unfortunately, no research has yet been conducted on the effects of formal assess-
ment in family therapy.) One study (Anker, Duncan, & Sparks, 2009) randomly
assigned 205 couples seeking therapy at a family counseling agency in Norway into
either a condition where couples were formally assessed or a condition where there
was no formal assessment. All aspects of the therapy experience, including the SFT
approach used by the therapists in the study, were allowed to vary; only the assign-
ment to condition was controlled. Multilevel modeling was used to account for the
interdependence of partners who were in therapy together, as well as for missing data
when one or both partners were unable to complete an assessment. Results indicated
that couples in the assessment group experienced twice as much improvement, on
average. Moreover, they were four times more likely to reach clinically significant
levels of change, and they were less likely to separate or divorce following treatment.
These results were subsequently replicated with similar significantly positive results for
those who were in the feedback group (Reese, Toland, Slone, & Norsworthy, 2010).
After reviewing the research on formal assessment feedback, SFT researchers Lappan
and colleagues (2017) concluded that “It is crucial and ethical for couple and family
therapists to use formalized feedback mechanisms as a standard part of their clinical
work…. The use of formalized feedback should be considered best practice, and an
ethical way of working” (pp. 467, 481).
The success of formal client feedback to improve therapy outcome is probably due
to two reasons. First, research on individual therapy has found therapists to have
dramatically inaccurate perceptions of individuals’ progress or deterioration, in most
cases being too optimistic (D. Hatfield, McCullough, Frantz, & Krieger, 2010). For
example, one study found that among 40 therapists who were asked to predict which
of their clients in their caseloads would experience negative outcomes in therapy, only
one of the 40 individuals who eventually deteriorated was identified (Hannan et al.,
2005). In contrast, the formal assessment system that was used in the study was fairly
accurate in identifying individuals who eventually deteriorated. Second, the formal
assessment of client progress includes a feedback mechanism where therapists receive
their clients’ assessment scores each week so that they are able to track their clients’
progress. For example, if the assessment package includes a measure on the therapeu-
tic alliance, assessment scores may alert the therapist of a rupture in the alliance with
a family member, which gives the therapist the opportunity to repair the rupture.
Without receiving feedback from the family member’s assessment, it is unlikely that
the therapist would have become aware of the alliance rupture. With this information
from formal assessment, therapists are able to identify family members whose
symptoms are getting worse or whose progress has stalled, giving the therapists the
opportunity to assess for new stressors or modify their treatment approach.
Expected treatment response Assessment scores fed back to therapists have little clini-
cal meaning when viewed in isolation. Excluding clear patterns of deterioration, how
does a therapist determine if clients are making sufficient progress? In order to address
this issue, researchers have developed the concept of expected treatment response.
The expected treatment response is a series of session‐by‐session scores that are
derived from scores of past clients who had similar presenting problems and charac-
teristics (Lutz et al., 2014). For example, a middle‐aged, white, college‐educated het-
erosexual couple who comes to therapy to resolve relationship distress because one of
them had an affair will be matched with similar couples who have previously been seen
in therapy. The session‐by‐session assessment scores of the previously seen couples
who share a similar profile with the current couple in therapy are averaged to create
the expected treatment response, often displayed as a curve on a line graph. The new
couple’s progress is compared to the expected treatment response, and the therapist
is continuously updated about the couple’s progress in therapy as compared to the
expected treatment response.
Therapist reluctance Despite the evidence that therapists formally assessing their cli-
ents’ progress improves therapy outcome, many therapists are hesitant to use these
procedures in their own clinical work (Lappan et al., 2017). A survey of nearly 1,000
clinicians found that the four most common reasons given for not formally assessing
clients were as follows (in order): adds too much paperwork, takes too much time,
creates extra burden on the clients, and they do not feel that it is helpful (D. R.
Hatfield & Ogles, 2004). One study in Australia found that 44% of clinicians reported
that conducting formal client feedback was a waste of time (Aoun, Pennebaker, &
Janca, 2002). However, when asked what could be done to make it more likely for
clinicians to routinely use the feedback system, many of the participants in the
Australian study responded it would be useful to be trained in the usefulness of the
assessment and how they benefit the therapist and clinic.
Consistent with that recommendation, results of a specific training program on
formalized client assessment indicated that clinicians’ attitudes significantly improved
after they completed the training (Willis, Deane, & Combs, 2011). In addition, thera-
pists’ fears that formally assessing client progress will place a burden on clients seem
unfounded considering that a study of nearly 600 clients in Germany found that
92.2% of the clients liked the idea of monitoring the quality of psychotherapy and
95.9% thought it was important to monitor the progress of treatment (Castonguay
et al., 2013). After reviewing the obstacles to implementing formalized client feed-
back in clinical practice, scholars have recommended that the data collection process
must be simple and time efficient, with the goal of minimizing burden to clients and
therapists (Boswell, Kraus, Miller, & Lambert, 2015; Koerner & Castonguay, 2015).
Practice‐based evidence
Measurement and monitoring systems The accumulation of practice‐based evidence
depends upon the development and utilization of a measurement and monitoring
system that is used as part of routine clinical practice (Castonguay et al., 2013). Several
measurement and monitoring systems have been developed and are available to
clinicians (Lappan et al., 2017). These include the Clinical Outcomes in Routine
Evaluation system (CORE) (Barkham, Mellor‐Clark, & Stiles, 2015); the OQ
Psychotherapy Quality Management System, which uses the Outcome
Questionnaire‐45 (OQ‐45) (Lambert, Hansen, & Harmon, 2010); and the Partners
for Change Outcome Management System (PCOMS), which uses the Outcome
Rating Scale (ORS) and the Session Rating Scale (SRS) (Miller, Duncan, Sorrell, &
Brown, 2005). These systems each use validated clinical outcome measures, and they
come with an internet‐based software package that allows clients to take the measures
electronically on a digital tablet or computer, with therapists given the results in an
easily interpretable format. These user‐friendly features have addressed some of the
concerns that therapists have expressed about formally assessing clients, such as being
a burden on clients and therapists, creating too much paperwork, and taking too
much time (Boswell et al., 2015; D. R. Hatfield & Ogles, 2004). These assessment
systems are commercial products, and therapists and clinics must pay a fee to use
them. However, none of them offers measures for couple or family functioning;
consequently, their clinical utility for SFTs is greatly limited.
In addition to the lack of appropriate outcome measures of couple and relationship
functioning, the lack of other relational measures in these existing assessment systems
limits their usefulness for SFTs who work with individuals. Because SFTs use a sys-
temic lens to conceptualize their work with individuals (Wampler & Patterson, 2020,
vol. 1), they want to know the relational context of their individual clients, regardless
of their presenting problems, in order to appropriately assess and treat them (Wampler
et al., 2019). For example, SFTs may want to understand the level of satisfaction and
conflict in their romantic relationship, the quality of their relationships with their
family of origin, or the quality of the parental alliance with their partner. Consequently,
SFTs need a measurement and monitoring system that includes measures of relation-
ship dynamics and functioning.
Indeed, SFTs have been significantly limited in their ability to conduct practice‐
based research because of a lack of necessary tools to assess therapy from a systemic
perspective. It is no wonder, then, that most of the research that has examined the
effectiveness of formally monitoring client progress has been done in the context of
individual therapy. Even the two RCTs that examined the effect of formal feedback on
couples’ improvement in therapy used the ORS, a measure of individual functioning,
to assess outcome (Anker et al., 2009; Reese et al., 2010).
However, a new measurement and monitoring system designed for SFTs has
recently been developed. Discussed in more detail below, the MFT Practice Research
Network (MFT‐PRN) is a flexible internet‐based system that includes a wide range of
validated individual, couple, and family measures, with clinics being able to choose
which ones they want to include in their own assessment package (Johnson, Miller,
Bradford, & Anderson, 2017). Individual therapists and clinics can use the system free
of charge.
Benchmarking Benchmarking is a method that provides evidence that the clinical

work done by a therapist, clinic, or social agency in natural settings is effective. This is
done by comparing the therapist’s or clinic’s clinical outcome scores with an estab-
lished standard of effectiveness. In most cases, the standard of effectiveness is the
effect sizes found in published RCTs or meta‐analyses (Lueger & Barkham, 2010).
A credible benchmark derived from respected sources is considered a valid compari-
son of therapy effectiveness, making the use of control or comparison group research
design unnecessary (Castonguay et al., 2013). This gives therapists and clinics a prac-
tical way to provide evidence that their clinical work is effective.
At a broader level, benchmarking can provide evidence that a new therapy model is
effective or that a validated model is effective with a new population or with a new
presenting problem. Indeed, what clinical research methodologists call the bench-
marking equivalency design is considered a variant and extension of the traditional
RCT research design (Kendall, Comer, & Chow, 2013). In addition, as mental health
services become more global, benchmarking can be used to evaluate the effectiveness
of treatments that are transported and adapted in other countries, especially
eveloping countries that lack the resources to conduct RCTs (Spilka & Dobson,
d
2015). For example, evidence for the effectiveness of multisystemic therapy in New
Zealand was provided by using a benchmark design that found equivalency between
the therapy outcomes in New Zealand and the benchmarks derived from multiple
RCTs conducted on multisystemic therapy in the United States (Curtis, Ronan,
Heiblum, & Crellin, 2009). Benchmarking is becoming increasingly common in
effectiveness research (Castonguay et al., 2013). In Great Britain, for example, bench-
mark statistics for various disorders and populations have been published, providing a
standard of comparison for researchers to use to determine the effectiveness of clinical
practices and treatments (Barkham et al., 2015).
In addition to the multisystemic therapy study in New Zealand (Curtis et al., 2009),
benchmarking has been used in other SFT research as a way to document the effec-
tiveness of treatments. For example, Baucom and colleagues (2017) examined the
effectiveness cognitive‐behavioral couple therapy for the treatment of depression in
London. He on used benchmarks in two ways to compare the results of his study with
established standards of effectiveness. First, he compared the proportion of the clients
who met the criteria for recovery and compared it with the published benchmark of
recovery from depression in the United Kingdom. Second, he compared the effect
size of the difference between the pre‐ and posttest scores with published effect sizes.
In both cases, the average improvement experienced by the clients in the Baucom
and associates (Baucom et al., 2017) study were greater than the benchmarks;
consequently, these findings provided evidence that the treatment was effective.
What are the specific methods used when comparing practice‐based clinical data
with published benchmark standards? When effect sizes from RCTs are used, Minami
and colleagues (Minami, Serlin, Wampold, Kircher, & Brown, 2008) recommend a
series of accepted and standardized steps that first includes the identification and
aggregation of the results of high quality RCTs. Because the focus of benchmarking
studies is on the change from pre‐ to posttreatment, effect sizes of the change from
the beginning to the end treatment in the RCTs are calculated, with the aggregated
effect size serving as the benchmark. An effect size of pre‐ and posttreatment change
of the treatment being evaluated is also calculated. Seidel, Miller, and Chow (2014)
offer an excellent description on how therapists can calculate effect sizes on their
clients. After the two effect sizes have been calculated, they are compared. Because
clinical data gathered in natural settings often have large sample sizes, a simple statisti-
cal comparison using a t‐test, for example, would yield inaccurate results because even
a trivial difference between the two effect sizes would be statistically significant.
Consequently, Minami and associates (2008) recommend that Cohen’s interpretation
of effect sizes be used to determine the equivalence of the two effect sizes. Because
Cohen argued that an effect size of 0.20 is considered small, Minami et al. (2008)
determined that a difference of less than 0.20 in the two effect sizes should be con-
sidered trivial and, therefore, equivalent. If the benchmark effect size is more than
0.20 greater than the treatment being investigated, researchers conclude that the
treatment is less effective than the benchmark, and a treatment effect size that is more
than 0.20 greater than the benchmark would lead to a conclusion that the treatment
is more effective than the benchmark.
In addition to effect sizes of clinical outcome measures, other benchmarks can be
used to assess effectiveness in practice‐based research. For example, the percentage of
clients who reach clinically significant change, as well as functional measures such as
school attendance, relapse rates, and recidivism rates, can be used in studies to assess
equivalence with benchmarked studies (Baucom et al., 2017; Curtis et al., 2009).
Practice research networks

A significant feature of practice‐based research is the use of PRNs (Barkham, 2014),
where a group of clinicians and researchers collaborate using common assessments
and protocols to address clinical questions by pooling data from a large number of
clinical settings. PRNs facilitate the development of a community of clinicians and
researchers who share the goal of creating practice‐based evidence that can be used to
improve client care. When using commercially based measurement and monitoring
systems, such as the OQ Psychotherapy Quality Management System (Lambert et al.,
2010) and the PCOMS (Miller et al., 2005), therapists pay a fee to access a clinical
service, and the compiled data gathered by therapists is owned by the assessment
companies. In contrast, a key characteristic of PRNs is the sense of shared ownership
among members of the network, including both clinicians and researchers (McAleavey,
Lockard, Castonguay, Hayes, & Locke, 2015). As “part owners” of the PRN, thera-
pists are directly involved in data collection (Castonguay et al., 2013) and are able to
access PRN data to address specific research questions. For example, a psychological
PRN in England includes as its mission the generation of “practice‐based evidence
that will influence psychological services in England” and the development of “a
research culture within its constituent services. It will do so through a ‘bottom‐up’
process of research carried out in the front line of mental healthcare” (Lucock et al.,
2017, p. 922). In most cases, participation in a PRN is free or has a minimal cost
(Johnson et al., 2017).
PRNs are prevalent throughout professions that provide health care. They began
in the medical field among family practitioners in the late 1970s (Lanier, 2005).
By 1994, 28 primary care PRNs were active in North America (Niebaur & Nutting,
1994), and in 2011 there were 143 PRNs among primary care physicians and
researchers in the United States (Peterson, Lipman, Lange, Cohen, & Durako,
2012). PRNs have also developed within the mental health field. For example, since
1993, the American Psychiatric Association has sponsored a PRN (J. C. West et al.,
2015), and multiple PRNs are active in the field of psychology (Castonguay, Pincus,
& McAleavey, 2014; Fernández‐Alvarez, Gómez, & García, 2014). A network of
over 240 university and college counseling centers in the United States have collabo-
rated to form the Center for Collegiate Mental Health as a way to share common
clinical assessment protocols, combine clinical datasets from different sites, and col-
laborate on research efforts (McAleavey et al., 2015). The assessment measures and
procedures used by each PRN vary according to each network’s specific goals, but
they share the important core commonality of a community of researchers and
therapists who collaboratively gather clinical data in a variety of clinical settings to
produce practice‐based evidence that has a direct impact on clinicians’ practice
(Barkham, 2014; Castonguay et al., 2013).
MFT‐PRN Despite the proliferation of PRNs in the delivery of mental health ser-
vices, the existing PRNs have assessed individual functioning, with no measurement
tools available to assess couple or family functioning. Consequently, SFT practice‐
based research has lagged behind other mental health professions. Recently, a PRN
has been developed by SFT researchers at Brigham Young University in the United
States with a specific focus on SFTs who see individuals, couples, and families (Johnson
et al., 2017). A menu of validated, widely used measures for individual adult, indi-
vidual child (ages 5–18), couple, and family functioning is available for clinics to cre-
ate an individualized set of assessments they wish to use at their site. In addition to
basic individual and relationship outcome measures, such as relationship satisfaction
among couples using the Couples Satisfaction Index (Funk & Rogge, 2007) and fam-
ily functioning using the SCORE‐15 (Stratton & Low, 2020, vol. 4), other relational
measures are available to assist SFTs in their clinical work using a systemic perspective.
These relational measures assess more nuanced aspects of relationships, including
attachment behaviors, co‐parental alliance, emotional regulation, communication
patterns, emotional abuse, parenting styles, perceived criticism, relationship power,
sexual problems, and domestic violence. Because relational and individual dynamics
are often interrelated, measures are also available to assess intrapsychic factors, such as
depression, anxiety, stress, and hopelessness (Johnson et al., 2017). Thus, regardless
of how many people are in the therapy room, SFTs can use the MFT‐PRN to assess
and monitor therapy from a systemic perspective.
Similar to other measurement and monitoring systems, the MFT‐PRN is an inter-
net‐based system in which clients complete assessments on electronic tablets before
each session. Recognizing the importance of minimizing additional demands on thera-
pists (Koerner & Castonguay, 2015), clinic receptionists can administer the assess-
ments to clients when they check in for their session, thus eliminating any extra work
by therapists. The results of the completed assessments are immediately available to the
clients’ therapist, who can review their progress before the start of the session. Because
the MFT‐PRN was developed and is being maintained by funding from Brigham
Young University, therapists and clinics can join the MFT‐PRN free of charge.
Utility of PRNs The clinical data that are gathered at each clinical site are combined
into a common dataset. The result is a large dataset that is gathered by therapists
working in an assortment of clinic settings. The large, diverse datasets that are created
from PRNs are used in two practical ways, one that has primarily a clinical purpose
and one that has primarily a research purpose. The data are used to calculate expected
treatment responses (discussed above), which are then used to inform therapists
whether their client’s progress is matching the progress experienced by a group of
similar clients (Lutz et al., 2014). A large dataset provides enough cases for a robust
expected treatment response curve to be calculated for each specific presenting prob-
lem and set of client characteristics that are being seen in therapy. A large, diverse
dataset is needed in order to provide robust expected treatment response data for all
types of clients, such as non‐white, low‐income families or LGBTQ couples. Thus,
data collected by individual therapists and clinics that are combined into a large PRN
database are used to provide feedback to therapists as a way to improve client care.
The large datasets generated by PRNs also enable researchers to use data from
natural clinical settings to conduct high quality clinical research. SFT researchers have
historically been plagued by a lack of high quality data. Data collected from individual
clinics, most commonly university‐based SFT training clinics, typically lead to small
datasets that have fairly homogeneous client populations, as well as students as the
therapists. Large, diverse SFT datasets would significantly enhance the ability of SFT
researchers to do high quality clinical research.
Many research questions asked by researchers who work from a practice‐based

research perspective require large datasets in order to reach valid statistical results. For
example, the study of the variability of therapists’ success rates, called therapist effects
(Baldwin & Imel, 2013), requires large datasets. Researchers recommend that studies
on therapist effects should include at least 100 therapists, with each them having at
least 10 cases in the dataset (Barkham, Lutz, Lambert, & Saxon, 2017). For example,
a recent study of therapist effects in individual therapy used a dataset that included
5,828 clients who were seen by 158 different therapists for a total of 50,048 sessions
(Goldberg, Hoyt, Nissen‐Lie, Nielsen, & Wampold, 2018). These large datasets also
give researchers the capacity to extend the research on therapist effects to studying the
characteristics and behaviors of effective therapists (Barkham et al., 2017), the results
of which can be communicated to therapists to help improve the quality of their
clinical work.
Conclusion
In recent years, SFT clinical outcome research has experienced significant innova-
tions. The revolution from the use of ANOVA‐based statistics to multilevel modeling
to analyze RCTs (Atkins, 2005) offers researchers analytical tools to derive more valid
statistical conclusions. In addition, propensity score analysis allows researchers to con-
duct effectiveness studies in real‐world settings without needing to randomly assign
couples and families to control or comparison groups.
Practice‐based research provides a new research paradigm that complements the
dominant paradigm of evidence‐based practice. This new paradigm promises the
potential of bridging the ongoing researcher–practitioner gap by encouraging mean-
ingful collaboration that offer benefits to both researchers and practitioners. Therapists
can have active involvement in the clinical research process and improve the quality of
treatment that they provide to their clients, and researchers can use the data gathered
through practice‐based research to conduct high quality, impactful clinical research.
Overall, these innovations are welcome news among both SFT researchers and
therapists. Although RCTs were a perfect solution 70 years ago for providing more
compelling evidence than testimonials and case studies for the effectiveness of new
drugs (Bothwell et al., 2016), their gold standard designation has never represented
an entirely sufficient form of evidence for psychotherapy effectiveness. This is
especially true for SFTs, whose work involves multiple, complex “moving parts” that
can influence the validity of an RCT. The introduction of propensity score analysis
and practice‐based research represents opportunities for SFT researchers to build
upon the foundation of RCTs to pursue a wider range of acceptable methodological
strategies to demonstrate SFT effectiveness.
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20
Process Research
Methods for Examining Mechanisms of
Change in Systemic Family Therapies
Lee N. Johnson, Laura M. Evans, Brian R. W.
Baucom, and Jason B. Whiting
Systemic family therapy (SFT) process research has been conducted over the history
of the profession, and researchers have consistently called for more (Sprenkle, 2012).
Outcome research has consistently shown that couple and family therapy works with
clients who participate in therapy being better off that no treatment controls or other
comparison groups (cf. Henggeler & Schaeffer, 2016; Wiebe & Johnson, 2016).
Currently, there is less information on “How does couple and family therapy work”
or “When ______ happens in a session or in clients’ lives what does, or what should,
happen next?” (Heatherington, Friedlander, & Greenberg, 2005). As a field, SFT has
made progress in answering the “how” change happens question (see Chapter 8, this
volume). To make further advances in understanding change in SFT, we need a defi-
nition of process research that goes beyond the stereotype of observational coding
segments of therapy sessions.
Multiple authors have defined process research as the study of interactions between
clients and the therapist in sessions (Woolley, Butler, & Wampler, 2000). Building on
in‐session interactions, Liddle (1991) and Oka and Whiting (2013) advocated for the
inclusion of context in SFT process research. Oka and Whiting (2013) further recom-
mended the inclusion of physiology from clients and therapists, which can be contex-
tual or within‐session variables. Heatherington et al. (2005) recommend that
mediators and moderators be a part of SFT process research, which can include
research that goes across multiple sessions. Further, they add that what occurs inside
and outside of therapy sessions should be included in SFT process research. Lastly,
Greenberg (1986) states that process research includes pretreatment changes,
immediate changes, intermediate changes, and changes at termination or posttreat-
ment, which expands process research to include time points throughout the change
process. Scholars have also emphasized theory as guiding process research (Baucom,
Leo, Adamo, Georgiou, & Baucom, 2017) to include key variables related to change
and influence the choice of analyses related to processes.
468 Lee N. Johnson et al.
Building on previous literature, we propose that process research in SFT be defined

using the following criteria. SFT process research (a) is guided by theory to define
study variables and relationships among variables, or focused on theory development
(e.g., grounded theory, intervention development); (b) is focused on how client vari-
ables (individual and relational), therapist variables (skills, interventions, demograph-
ics), and contextual variables (treatment setting, demographics, intake variables)
relate to change processes both in and out of the therapy room; and (c) is focused on
change processes at any stage of treatment (pretreatment to follow‐up).
This definition expands process research questions to enhance our understanding
of change. While not an exhaustive list, examples of such studies include research on
the formation and effects of the therapy alliance within sessions, alliance growth, and
the relationship between the alliance and therapy outcome (Anker, Owen, Duncan, &
Sparks, 2010; Bartle‐Haring, Shannon, Bowers, & Holowacz, 2016) along with
research on alliance ruptures and repairs (Safran & Kraus, 2014). Further, research
that explores both mediators and moderators of change (Fournier, Brassard, & Shaver,
2011; L. N. Johnson & Ketring, 2006) will help us understand under what circum-
stances change occurs. Since relationships are a key part of SFT, we need more research
to untangle the mutual influence of family members on each other throughout the
treatment process (Anderson & Johnson, 2010; Baucom et al., 2011). Additionally,
research on therapist effects, while not prevalent in SFT, is sorely needed (Blow,
Sprenkle, & Davis, 2007) to better understand therapist’s role in the change process.
This definition also includes research to understand how clinical couples and
families function in daily situations and how therapy influences their daily life (Johnson,
Mennenga, Oka, Tambling, Anderson, & Yorgason (2017)).
Systemic process research methodologies are improving what we know about why
and how SFT works. However, there are competing ideas about how our understand-
ing of change can be improved. Some advocate for a stage‐focused approach first
identifying therapeutic tasks associated with change, then observing and measuring
these tasks, and then connecting these tasks to clinical outcomes (Diamond &
Diamond, 2002). Others focus on deciding where the focus of process research
should be—on behaviors that occur within or outside of treatment, the exploration of
specific moments or events in therapy, or an exploration of the relationship between
predictor and outcome variables (Oka & Whiting, 2013). Finally, some researchers
focus on the development of conceptual models (Fife, Whiting, Bradford, & Davis,
2014) that generate process questions regarding how the therapist perceives and then
responds to clients. We feel that all these various avenues should be pursued. Thus,
this chapter will focus on key methods, procedures, and analysis strategies that hold
promise to advance our understanding of change in SFT.
Process Research Methods
Event designs
When considering options for studying events that occur during SFT, it is important
to consider the nature of the events themselves. One particular aspect that warrants
careful consideration is the continuity with which the event occurs. Is the event
something that occurs sporadically with a clearly defined beginning and ending? Or is
Process Research for Systemic Family Therapies 469
the event something that occurs continuously throughout a session with a beginning
and ending, that is, defined by the start and end of the session? Additionally, it is
important to determine if the research question is focused on studying an event
related to change or studying a change that happened and understanding what
occurred that contributed to the change. We will cover two types of event analysis
methods that can be use in these situations—specific event designs and change event
designs.
Specific event designs Specific event designs focus on studying events of interest that
occur at particular moments, but not continuously, throughout a therapy session or
across sessions. Both client behaviors (e.g., expressing a specific kind of cognitive
distortion) and therapist behaviors (e.g., making a reflection, using a particular inter-
vention strategy) or events between clients and therapists (e.g., alliance ruptures and
repairs) can be studied from this perspective. Specific events can be studied in relation
to outcome or in relation to previous and future events. These kinds of questions
could be asked with regard to other specific events (i.e., does a particular kind of client
behavior tend to elicit a particular kind of therapist behavior?) or to other events that
happen during treatment. The main key to conducting specific event designs is to
make sure the event can be recognized and isolated. Depending on the research ques-
tions, it is important to collect data prior to the event and after the event. While these
designs are for specific discrete events, change event designs focus on things that
change within and across sessions.
Change event designs Research questions focused on how continuous events change
over the course of a session are studied using change event analysis methods. For
example, this type of design could be used to study client physiological markers over
time in therapy. The operationalization of change can vary widely from research ques-
tions focused on smooth, linear growth in mean levels to more complex forms of
smooth change modeled using polynomial models to sudden change in mean levels
and/or smooth growth to associations between relative change in one or more events
(i.e., when X is above the mean for the session, is Y also above the mean for the ses-
sion?). Though the specifics of the research question being asked can vary widely, all
change event analysis studies share the common methodological element that they
focus on at least one event that occurs continuously throughout a psychotherapy ses-
sion, that is, most often either interval or ratio scale in nature. Examples include vari-
ables such as therapist and client emotional expression, psychophysiology, bodily
movement, and body posture. Change event designs can be used with ordinal scale
variables. However, the computational requirements of statistical models commonly
used in change event analysis research (e.g., substantial amounts of within‐person
variance, frequent occurrence of all levels of the ordinal scale, etc.) are often unrealis-
tic for ordinal scale variables.
One aspect of variables that makes them well suited to change event designs is that
the “signal” for these events is measurable at all points in time during a psychotherapy
session. This quality of measurement allows for these variables to be measured at
whatever level of granularity is most appropriate for the phenomenon of interest.
Other variables that can only be measured during some periods of a psychotherapy
session (e.g., those that can only be measured while a client or therapist is speaking
like semantic content or vocal prosody) can be used in change event designs, but
change is operationalized in terms of variability from one segment to the next rather
than variability that unfolds continuously over time.
To analyze data from specific event designs and change event designs, two statistical
strategies are generally used. Log‐linear sequential analysis (Bakeman & Gottman,
1997) is used to compute the conditional probability of event A following event B
while adjusting for the base rates of occurrence for events A and B. For example,
sequential analysis is helpful to understand the likelihood of understanding what
happens after the therapist tries a specific intervention such as an enactment. When
research questions focus on how the occurrence of a specific event is associated with
change other events, piecewise regression (interrupted time series analysis; Singer &
Willett, 1993) is used to model how the occurrence of the specific event is associated
with a sudden change in value and rate of change of the other event. Both sequential
analysis and time series analysis are discussed later.
Intensive longitudinal designs

The change process in SFT is much more complex than what occurs in 50‐min
sessions across multiple weeks of therapy. In fact, scholars have called for research on
what occurs in clients’ relationships outside of therapy (Heatherington et al., 2005;
L. N. Johnson, Mennenga, et al., 2017). One method for understanding what occurs
outside of therapy sessions that are part of intensive longitudinal designs is daily diary
designs (Bolger & Laurenceau, 2013). The use of daily diary methods has been used
regularly in family studies and somewhat in individual psychotherapy. However,
these methods have recently been used to understand change in SFT (cf. L. N.
Johnson et al., 2018; L. N. Johnson, Mennenga, et al., 2017; L. N. Johnson, Selland
et al., 2017).
Daily diary designs have clients respond to a short questionnaire or a group of
questions on a daily basis or more frequent interval. The time between assessments
is determined by theory and previous research on how quickly the variable may
change as a result of participation in therapy (Yorgason, Johnson, & Hardy, 2014)
or on a daily basis (Affleck, Zautra, Tennen, & Armeli, 1999). For example, asking
participants about their personality on a daily basis is not likely to yield data that
demonstrates change. However, asking clients if they did their assigned homework
and the effects of that homework on change is more likely to provide insight into
the change process of client’s lives. Other variables that can be asked about on a
more frequent basis include daily stress and relational behaviors toward family
members.
The ease of conducting intensive longitudinal daily diary studies has been facilitated
by using online survey programs. Most programs (e.g., Qualtrics, Survey Monkey)
allow researchers to have the program email a unique link to participants on a daily
basis (or other interval), with instructions on when to complete the survey. These
programs will also track when the survey is completed and allow links to expire after
a certain time, say, 48 hr, for example, so that participants do not go back and com-
plete multiple links on the same day. For more information on daily diary methods,
see Bolger and Laurenceau (2013), Gunthert and Wenze (2012), and Yorgason et al.
(2014). Analysis of daily dairy design data can use multilevel models (MLM), actor–
partner interdependence models (APIM), and dynamic systems modeling depending
on the specific questions.
Motion energy designs

A new method of process research that has been used in individual psychotherapy is
motion energy designs, which examine synchrony (Ramseyer & Tschacher, 2011).
This research looks at nonverbal behavior during sessions and the influence of the
level of synchrony or nonverbal behaviors between the client and therapist and how
synchrony and non‐synchrony are related to various within‐session outcomes or over-
all therapy outcomes. Results have shown that higher levels of synchrony are related
to better symptom reduction (Ramseyer & Tschacher, 2011), a stronger therapy
alliance, and lower synchrony related to non‐improvement and dropout (Paulick
et al., 2017). While these methods have only been linked to outcome in individual
psychotherapy, researchers have shown that synchrony may occur in couple therapy
(Karvonen, Kykyri, Kaartinen, Penttonen, & Seikkula, 2016).
Almost all SFT models are grounded in systems theory and focus to some degree
on patterns, circular causality, and nonverbal behaviors. However, these aspects
are difficult to quantify and observe in an SFT session. Motion energy designs can be
used to measure nonverbal behavior in relational therapy sessions to better under-
stand alliance development, relational patterns, and if/how patterns are changing
from therapy interventions across sessions. The Motion Energy Analysis software is
free and is available from http://www.psync.ch. A test of the video analysis proce-
dures showed that they are valid (Paulick et al., 2017). The requirements for using the
software are to have a static camera to digitally record therapy sessions and stable
lighting in the therapy room. The digital video is fed through the software that calcu-
lates the level of synchrony. Prior to analysis you select what part of each person you
want to be included in the analysis, for example, you can select someone’s whole body
or just their face.
The main problem with using this method in SFT is that the program analyzes data
from a dyad, such as an individual therapist and individual client. This can be over-
come by treating any SFT session as multiple dyads. For example, in a couple therapy
session, you have three people. Using the Motion Energy Analysis software to analyze
synchrony between the couple, the therapist and partner 1, and the therapist and
partner 2, gives you the level of synchrony within all relationships in the session.
While this is not ideal, it provides information on behavioral patterns in SFT. These
methods can also be used in conjunction with other methods such as specific event
analysis or change event analysis described earlier. For example, a researcher could
identify a softening event in EFT and see if the softening event helped change the
pattern in the session by comparing synchrony before and after the event.
Grounded theory
Grounded theory methods are designed to articulate concepts and the relationships
between them, thus helping show change processes. Using grounded theory results
in a theoretical articulation of relationships between categories, not just a collection
of descriptive themes.
Grounded theory was developed in the 1960s by Glaser and Strauss (1967) who
developed a set of structured tools to gather data and analyze it with the goal of
developing inductive theory. “Grounded theory methods consist of systematic, yet
flexible guidelines for collecting and analyzing qualitative data to construct theories
from the data themselves. Thus, researchers construct a theory ‘grounded’ in their
data” (Charmaz, 2014, p. 1).
Originally, grounded theory procedures were based on positivist assumptions (e.g.,
that researchers were neutral in their choices of how to gather data, analyze it, and
present an “objective” theory), later versions of grounded theory were more flexible,
and many current grounded theorists operate from constructivist epistemological
assumptions and assume an active co‐constructing role of the researcher who makes
choices of what to ask and how to analyze and interpret in the data (e.g., Charmaz,
2014; Corbin & Strauss, 2014. Regardless, in terms of studying process, most
grounded theorists follow similar procedures that include variations on initial coding,
focused coding, and theoretical coding. These processes include close examination
of the data to generate explanatory categories and ultimately create a model with
theoretical utility.
Like all research, grounded theory is conducted by humans with preconceived
notions who make interpretations and choices about how to analyze and present data.
Although it is always important to be aware of researcher presence in systemic research
(Knapp, 2002), it is an essential part of grounded theory. As the research instrument,
the scholar must track decisions in memos and take the time needed with the data to
feel confident with what is being examined. For example, grounded theory methods
have been used to understand the process of how abusers blame their victims, and
how this results in victim’s self‐blame and confusion (Whiting, Oka, & Fife, 2012),
and have also been used to understand the changes that occur in client’s perceptions
and behaviors during an intimate partner violence intervention (Whiting, Smith,
Lovell & Pettigrew, 2018). Grounded theory is “a dynamic process of interpretation”
and is more of a “practice of inquiry” than a rigid empirical method (Gergen, 2015,
p. 51). The flexible nature of grounded theory can feel challenging, but for those who
persist, it can provide an in‐depth way to understand systemic processes.
Experimental designs
One limitation of most process research is lower internal validity because most process
methods focus on understanding rather than on causal relationships. However, there
are process research designs that increase internal validity. We recommend using sin-
gle‐case research methods and ABAB designs across multiple cases to show more
causal relationships in process research (for more detailed information, see Kazdin,
2011; Mennenga & Johnson, 2014).
Single‐case research is set up so that each case and individual within a case are their
own controls. Following a baseline “A” phase, a condition is introduced—the “B”
phase. This condition is followed by the removal of the condition—another “A”—fol-
lowed by another “B” phase. The conditions in these designs are generally specific
interventions or changes in context and can also be used to examine change processes.
For example, some models of therapy advocate clients talking to each other (Minuchin
& Fishman, 1981), while others favor clients speaking more to the therapist (Kerr &
Bowen, 1988). Both communication patterns have benefits, but how do these differ-
ent processes change the therapy session? This type of design could examine flow of
the session, therapy alliance, or in‐session relational sentiment as a dependent variable.
Testing this question requires an expansion of the ABAB design: an ABCBC design,
where A is the baseline, B is clients talking to the therapist, and C is clients talking to
each other, each phase being a specified amount of time—such as 10 min (Anderson,
Templeton, Johnson, Childs, & Peterson, 2006). An important requirement of these
designs is to make sure that the condition can be withdrawn from the setting. The
example above works because the flow of communication can be withdrawn from the
setting. Psychoeducation is an example of a condition that researchers are less able to
withdraw, depending on the variable of interest, because once you have taught some-
thing it cannot be untaught. However, you could use this design to test clients’ emo-
tional reactions to receiving psychoeducation with the therapist alternating between
periods of providing education and periods of a different condition. The data from
these designs can be analyzed using dynamic systems modeling, MLM, or an ANOVA
with each condition being a different group.
General Process Methodological Considerations
Participant recruitment and retention

Recruitment Little has been written about participant recruitment, that is, specific
to process research. Thus, we recommend following recommendations for other clini-
cal research by Olson and Miller (2014). We do, however, make one addition that,
due to the ongoing nature of most process studies, we recommend having an intake
coordinator introduce the study so that participants have the study explained to them
and are able to ask questions (Pinsof, Goldsmith, & Latta, 2012).
Retention of participants There are several recommendations to retain participants

in process research. First, it is important to compensate participants for their time,
which in process research can be longer than completing questionnaires. We recom-
mend that researchers determine how much time participants will be giving to the
project and set the compensation amount based on a fair amount per hour. Additionally,
as part of compensation, researchers may reduce or waive fees. This will balance
compensation by not providing too much compensation, which raises ethical consid-
erations about voluntary participation (Olson & Miller, 2014).
Second, we recommend that process researchers establish a researcher–participant
alliance. This can be done by explaining the benefits of the research to improving
therapy for subsequent participants in person so participants can ask questions and
feel that they are a part of the process of helping others. This can also help to foster a
safe environment and supportive environment for participants (McAdams et al.,
2018). Finally, to maintain this alliance, we recommend that researchers ask clients
about their participation and if they have any questions at regular intervals during
the study.
Sample size and unit of analysis

There is wide variability in the sample size and the unit of analysis in process research,
and due to the intense time involved, the number of couples or families is generally
lower than outcome research. While more participants are almost always better, more
may not be feasible given the complexity and time intensity of process research.
However, it is important to remember within process research that the unit of analysis
is an important factor in analysis techniques and adequacy of sample size. For exam-
ple, in process research, the unit of analysis may be a talk turn within a session, a
therapy session, a segment of a session, or a day. Thus, a study with a small number of
participants may have a larger sample size than the 10 participating couples. Therefore,
by carefully defining the unit of analysis, process researchers can remedy many of the
sample size issues associated with process research.
Measurement issues
When considering the reliability and validity of process measures, we must appreciate
the complexity and difficulty of operationalizing process constructs. For example, one
of the authors on this chapter (LE) developed a coding mechanism designed to iden-
tify therapist common factor behaviors. Although most clinicians have a clear idea of
what “therapist warmth” is, it is difficult to construct a measurable definition of this
construct. Given that our studies can only be as valid as our variables, we need to
continue working to improve the validity of our measures. Thus, we need to work
more collaboratively to define constructs of interest, critique existing measures, and
design new measures that accurately assess variables of interest. When assessing pro-
cesses in SFT, researchers generally use a combination of observational measures,
self‐report measures, or more “objective” measures (e.g., accelerometers, in‐session
physiology data).
Observational measures A thorough review of observational measurement of pro-

cess‐relevant behaviors and emotions is beyond the scope of this chapter; interested
readers are directed to Heyman (2001), Kerig and Baucom, D. H. (2004), Baucom
et al. (2017), and Kerig and Lindahl (2000) for reviews of observational measures
used in SFT. In this section we focus on selecting an observational coding system and
choosing and training coders. At times a coding system may not be available, and you
will need to develop one. The developing of a coding system is a long process, and, if
needed, we recommend the following resources: Alexander, Newell, Robbins, and
Turner (1995) and Bakeman and Gottman (1997).
Selecting a coding system There are many rating systems to choose from all with
varying strengths, weaknesses, and potential applications (Alexander et al., 1995). It
is important to select a rating system that matches the researcher’s needs and theoreti-
cal orientation of the study (Baucom et al., 2017). Rating schemes must operationally
define behaviors and interactions so that observers can rate them reliably. Selecting a
coding scheme also involves balancing several issues. First, there needs to be a strong
match between the theory used in the process research and the theory underpinning
the observational coding system. For example, many existing coding systems can be
used to measure positive and negative behavior, but the specific behaviors included in
a composite measure of positive or negative behavior vary widely across coding sys-
tems. Second, observational coding systems vary in terms of whether they produce
one summary score that characterizes the frequency and/or intensity of that code
over the entire interaction (i.e., global coding systems) or many measurements for a
code generated at set intervals or for each instance of the behavior (i.e., microanalytic
coding systems). If the research question involves analyzing change in a behavior or
sequences of behavior, a microanalytic system that allows for establishing temporal

ordering is likely necessary. If the research question involves analysis of processes that
happen over the entirety of the interaction, either a microanalytic or a global coding
system can be used.
An additional important decision in selecting observational measures is who will
generate the behavioral ratings. Ratings can be made by participants themselves (i.e.,
video recall designs) or by coders. When a team of coders are used, it is important to
remember that coders are part of the construct validity of the measure and demo-
graphics of the coders and detailed information on coder training need to be reported.
Finally, when selecting a coding system, it is important to be mindful of current
research related to coding. Current research shows that there are some variables such
as relationship quality that can be validly coded by untrained raters (Baucom et al.,
2017). Adding these variables to process studies will increase understanding of the
context in which SFT processes occur.
Choosing and training coders Since coders are part of construct validity, how they
are chosen and trained is important. When selecting raters, researchers have to deter-
mine the level of expertise raters need. Some coding systems require coders to have a
certain level of expertise. For example, if the coding system is on the fidelity of a par-
ticular therapy model, it is important for coders to have experience with that model
to be able to determine the quality with which therapy was delivered. This would
require hiring expert coders. Most coding systems require coders to determine if cer-
tain defined behaviors occurred, which requires training but not in‐depth experience.
Since most process research occurs in university settings, students are often selected as
coders (see Margola, Donato, Accordini, Emery, & Snyder, 2017; Zuccarini, Johnson,
Dalgleish, & Makinen, 2013). In our experience coders are more invested when they
are paid or enrolled in a class. Also, when recruiting coders, we recommend explain-
ing the time commitment and sometimes tedious nature of coding. More important
is selecting raters who have the maturity to respect the sensitive nature of the SFT
sessions and the ability to maintain confidentiality.
Once selected, coders need to be trained to reliably apply the coding system. This
takes varying amounts of time depending on the specificity of the coding scheme and
can range from 3 hr (Dalgleish et al., 2015) to several months (Castonguay et al.,
2010). No matter the coding system or the amount of training the coders receive, it
is important to document all training procedures. After training, researches need to
assess inter‐rater reliability. We recommend using an intraclass correlation or Cohen’s
kappa depending on if codes are continuous or categorical (Hallgren, 2012; Seedall,
2014). Much has been written on how the use of percentage of agreement over
inflates the estimate of inter‐rater reliability. Another form of percent agreement is
consensus coding where coders work to come to a consensus around the coded
behavior. While consensus coding can be used to achieve maximum agreement, it may
inflate the level of agreement and does not account for chance. In practice it may be
best to assess reliability using and intraclass correlation or Cohen’s kappa and report
this information in any research publications, prior to getting a consensus code to use
in the final analyses.
Finally, it is important to remember that training is not a once‐and‐done process;
coders will drift over time. Training procedures need to plan to consistently check
reliability and retrain coders as needed. Using a model of regular meetings between
researchers, research assistants, and coders allow check‐ins on areas of confusion,

provide raters an opportunity to ask questions about the sessions they are observing,
and focus on correcting areas of low reliability (Evans, 2011; Sevier, Atkins, Doss, &
Christensen, 2013).
Self‐report measures Self‐report questionnaires are commonly used to assess clients’

and therapists’ internal experiences, their perceptions of one another, and the shared
therapeutic environment. For example, process‐related constructs commonly assessed
using self‐report measures may include subjective emotional experience (e.g., Sloan &
Kring, 2007), working alliance (e.g., Horvath & Greenberg, 1989), readiness to
change (e.g., Tambling & Johnson, 2008), and satisfaction with a session. As exem-
plified by these measures, self‐report instruments are frequently administered imme-
diately after a session to assess a therapist’s/client’s retrospective report of their
experience of the session. Because of the retrospective nature of these measurements,
self‐report instruments are viewed as providing a global assessment of process over the
entirety of the preceding session. Self‐report instruments can also be used to assess
other aspects of a session such as the highest level of emotion experienced or what
intervention technique felt least helpful (D’Aniello & Tambling, 2017; Helmeke &
Sprenkle, 2000; Stiles, 1980). One notable exception to this general trend is self‐
report instruments of process‐related constructs that are naturally administered dur-
ing sessions as standard practice. An example of this type of instrument is the Subjective
Units of Distress Scale (SUDS). An SUDS is commonly administered verbally by
asking a client to provide a 1–10 verbal rating of his/her current level of distress
where 1 is little to no distress and 10 is an extremely high level of distress. The sim-
plicity of this scale makes it well suited to administration during therapy sessions to
get a self‐report of distress across the session. It is also important to note that self‐
report measures can also be used outside of sessions in intensive longitudinal designs.
More “objective” process measures There are times when process research questions
require researchers to measure variables in more “objective” ways to answer research
questions. For example, questions that require this level of measurement may be
focused on the interaction of client and therapist physiological responses during a
session or the relationship of client sleep hygiene on therapy processes. With the
exponential growth of technology, there are always new uses for technology in

research. We will present two commonly used measures.
Physiological measures Psychophysiological assessment associated with therapeu-

tic processes is being introduced into SFT research (Butner et al., 2017). Mainly, SFT
physiological process research focuses on the measurement of emotional‐related
responding in the autonomic nervous system (Gregson & Ketring, 2014). The reason
for this emphasis is both conceptual and methodological—the autonomic nervous
system responds to task demands and environmental changes over short enough peri-
ods that can be related to changes that occur during therapy sessions. Additional
discussion of physiology and SFT is in Chapter 10 in this volume.
Accelerometers and other technology There are many devices that can be used
to facilitate process research such as smart phones, electronically activated recorders,
computer programs and hardware applications, and accelerometers, to name a few. A
review of all the ways to use technology is not possible, but we will discuss accelerom-
eters as an example of how technology may be used in process research.
Accelerometers are small devices that track movement. With some additions they
can also track sleep duration and quality, exercise, body position (standing vs. sitting),
and heart rate (https://www.actigraphcorp.com). They are generally the size of a
wristwatch and worn on the wrist or ankle. However, with advances in technology,
there are some that are the size of a ring worn on a finger. With the reduction in size
and the reduction in cost, many of these features are available on most smart phones
or smart phone apps. While the features found on smart phones are good enough for
personal application, they may not be of sufficient quality and accuracy to be used in
research. Most technology, that is, used for research may cost more, but it has been
tested to be more accurate and uses algorithms that have been validated by research.
The best advice is to do your homework; see what other researchers and peer‐reviewed
articles use and talk with researchers who are using the technology.
Research setting
Many process studies are conducted at SFT graduate programs (Helmeke & Sprenkle,
2000; Knobloch‐Fedders, Pinsof, & Haase, 2015; Pinsof et al., 2009; Seedall &
Butler, 2006). These studies typically explore therapy process when therapists are in
training, but some do include assessments of therapists at varying levels of experience
(Pinsof et al., 2009). Other systemic process studies are conducted at training clinics
and hospitals (Heatherington & Friedlander, 1990; S. M. Johnson & Talitman, 1997;
Karvonen et al., 2016). Increasingly, systemic process studies are being conducted at
community mental health and outpatient clinics by a variety of mental health practi-
tioners (Dalgleish et al., 2015; Friedlander, Heatherington, Johnson, & Skowron,
1994; Rynes, Rohrbaugh, Lebensohn‐Chialvo, & Shoham, 2014), some even using
process research instruments developed in training clinics (like the eSOFTA;
Friedlander, Bernardi, & Lee, 2010). Few systemic process studies are conducted in
private practice settings (Sevier et al., 2013). To further understand the change pro-
cess, future systemic process research should include therapists with varying levels of
clinical experience who work in a variety of practice settings. Multi‐site process
research collaborations will strengthen our understanding of which interventions are
effective or which clients need increased intervention and move us toward general
improvements in clinical care (Lambert, 2001). Multi‐site collaborations also allow
process researchers to use similar measures across locations and populations that will
allow for much needed comparisons (Heatherington et al., 2005). Emerging pro-
grams like the Marriage and Family Therapy Practice Research Network (MFT‐PRN)
(L. N. Johnson, Miller, Bradford, & Anderson, 2017) that provides assessment tools
can be used at a variety of clinical practice sites and then centrally pool data for multi‐
site systemic process research. The MFT‐PRN will allow further exploration of media-
tors and moderators of the change processes, which is a key area of need among
process findings. Further, another key process variable is understanding context, and
the variety of participating clinics from areas around the world will further our under-
standing of contextual variables related to change. Finally, the MFT‐PRN is set up to
build collaborations among researchers with shared interests to collaborate on obser-
vational research outside the structure of the MFT‐PRN.
Process Research Analysis Strategies
Strategies for analyzing data have grown over the past few decades. However, many
of these analysis strategies such as structural equation modeling (SEM) require large
sample sizes. Given the nature of process research, the intensity of data collection, and
the volume of data some projects yield, different analysis strategies are necessary to
capture what is occurring.
Bayesian data analysis

We propose that process researchers working with couple and family data examining
the complexity of change look at using Bayesian estimation as a plausible solution.
Bayesian estimation is more likely to produce unbiased results with smaller sample
sizes, especially when taking prior information into account (Baldwin & Fellingham,
2013; Ozechowski, 2014; van de Schoot, Broere, Perryck, Zondervan‐Zwijnenburg,
& van Loey, 2015). Bayesian estimation is becoming more popular in many applied
mental health fields (van de Schoot, Kaplan, et al., 2013) and is available in most com-
monly used statistical packages such as Stata, R, Mplus, AMOS, and WinBUGS
(which is a free easy‐to‐use software package).
Bayesian approaches have been around for over 250 years, but since the advent of
frequentist methods, those methods have dominated statistics in social sciences (van
de Schoot, Winter, Ryan, Zondervan‐Zwijnenburg, & Depaoli, 2017). Frequentist
methods are based on testing the null hypothesis “nothing is going on,” and the
results of this test simply tell us if we can reject the null hypothesis but still not
answer the question of if our results are correct. Further, the way in which most
social scientists interpret statistical findings is Bayesian, even though it is not based
on Bayesian assumptions. Additionally, most SFT researchers spend time building a
logical case for their current research. This justification is based on past research,
theory, and expert experience. However, when we use frequentist methods, all this
previous information is ignored (van de Schoot, Verhoeven, & Hoijtink, 2013). In
a Bayesian approach, researchers are able to use prior knowledge to inform hypoth-
esis and see if current results deviate from past research. Due to the nature and
complexity of SFT process research, we advocate for the use of Bayesian statistics for
the four reasons delineated by van de Schoot (2014): “(1) complex models can
sometimes not be estimated using conventional methods, (2) one might prefer the
definition of probability, (3) background knowledge can be incorporated into the
analyses, and (4) the method does not depend on large samples” (p. 79). Many of
the analysis strategies described in this chapter can be conducted in a Bayesian
framework, such as multilevel modeling, APIM, and structural equation models. An
understanding of Bayesian statistics will also open up additional analysis possibilities
such as dynamic SEM, which is based on Bayesian statistics and can also be useful
with smaller samples (Asparouhov, Hamaker, & Muthen, 2017). To gain an under-
standing of Bayesian estimation and how to conduct these analyses, we recommend
the following articles: van de Schoot, Verhoeven, et al. (2013), van de Schoot,
Kaplan, et al. (2013), and van de Schoot (2014). Each of these articles also contains
sample studies that illustrate Bayesian estimation.
Multilevel modeling
MLM are an increasingly popular analysis strategy in SFT and can be used to answer
process research questions (L. N. Johnson, Mennenga et al., 2017; Bartle‐Haring
et al., 2012; L. N. Johnson, Tambling, & Anderson, 2014; Sevier et al., 2013). These
models are also referred to as hierarchical linear models, random effects models, and
random coefficient models. MLM is generally used with a single outcome variable
(Ledermann & Kenny, 2017) but have been expanding to include multiple outcome
variables in the same model (Baldwin, Imel, Braithwaite, & Atkins, 2014), which
make MLM even more useful in analyzing couple and family process data.
MLM is useful for data that are nested or hierarchical data. For example, in SFT
process, research data have individuals nested within couples and families, couples and
families nested within therapists, and depending on the methods of data collection,
you have measurements nested within individuals. If data are analyzed without
accounting for the nonindependence of nested data, it leads to “biased p values, incor-
rect confidence intervals, and inflated effect sizes” (Baldwin et al., 2014, p. 921).
Nested data are accounted for by modeling the different levels; for example, in couple
process research, the project may be organized as specific repeated assessments for
individuals (level 1) nested within couples (level 2). These data could also be nested
in a 3‐level model: repeated measures across time (level 1) within individuals (level 2)
within couples (level 3). The way you organized the model will depend on the focus
of the study with the two‐level model being more ideal if you are interested in
modeling differences between partners or family members (Atkins, 2005).
Finally, another advantage of MLM is that it allows for the modeling of within‐
person effects and between‐person effects. Most research is focused on finding the
overall mean or change trend (slope) of participants—these findings are the between‐
person findings. However, as therapists and clinical researchers, we are also interested
in results related to individuals that are part of couples and families—within‐person
findings. MLM provides results for both (Affleck et al., 1999), allowing important
results when between‐person findings mask or run counter to within‐person results
(Yorgason et al., 2014). Other advantages of MLM are that these models do not
require the large samples required by structural equation models, are able to handle
data with a larger number of time points, and do not require the assessment times to
be uniform across participants (Ledermann & Kenny, 2017).
Time series analysis

Time series analysis was developed and is commonly applied in fields such as econom-
ics, where intensive measurement of a single variable or a small number of variables
for one group is common. As high frequency, long duration measurement is being
increasingly common in social sciences, time series approaches are becoming increas-
ingly common. For example, process researchers may be interested in how specific
therapist behaviors during psychotherapy sessions, such as expressions of empathy, are
associated with changes in clients’ physiological activity. Time series analysis would
allow researchers to ask these questions in a single psychotherapy session for a single
couple or family as well as for multiple sessions for the same clients. However, it does
not require the larger number of clients that would be needed to analyze similar ques-
tions using other analytic techniques like multilevel modeling or SEM. It is important
to note that time series analysis and analysis of a time series of data are not one and
the same. Time series analysis refers to a specific set of analytic techniques (see Wei
(2006) for a detailed discussion), whereas a time series of data refers to having a large
number of measurements of a variable.
Time series analysis is a class of regression‐based techniques for analyzing one, or a
small number, of client–therapist groups at a time. In contrast to classic regression
models where the emphasis is on characterizing statistical associations between varia-
bles that represent population‐level associations, the emphasis in time series analysis is
on characterizing temporal associations for one or more variables for the population
of all possible measurements for a given group, in this case the therapist–client dyad
or triad (e.g., Wei, 2006). Because of this emphasis, time series analyses typically
involve the analysis of large numbers of observations collected for the same group.
Actor–partner interdependence models

The APIM (Cook & Kenny, 2005) has grown in popularity among SFT researchers
and has been used to analyze process research data. Since many SFT researchers are
familiar with this model, we will not provide an extensive review, but refer readers to
existing articles (cf. Cook & Kenny, 2005; Cook & Snyder, 2005; Ledermann,
Macho, & Kenny, 2011). Since APIM are usually done in an SEM framework, they
usually require larger sample sizes. However, the models can be estimated with smaller
samples sizes using Bayesian estimation or MLM or following the recommendations
of Tambling, Johnson, and Johnson (2011).
In addition to modeling the nonindependence of data, an APIM can be used to
analyze process research questions and change patterns. Kenny and Ledermann
(2010) state that three important change patterns that are important to test are if the
model has equal partner and actor effects, if a model has similar but different direc-
tional effects, and if partners do not influence each other—a model with only actor
effects. In this article, the authors also advocate the calculation of a new parameter
they call k, where k is “the ratio of the partner effect to the actor effect” (p. 160). This
will allow for patterns between dyads to be assessed in terms of their relationships. For
example, if k is equal to 1, then there is an equal actor and partner effect pattern.
Further, if k is equal to 0.5, then we can say that that actor effect is twice as big as the
partner effect. The use of this new ratio allows for a measure of the size of the partner
effects, for the testing of hypotheses related to specific relational patterns, for a direct
comparison between males and females in studies where dyads are distinguishable,
and for a comparison of this ratio across studies (Kenny & Ledermann, 2010) to build
on previous research.
These ideas become more important when we think of an APIM as a way to analyze
process data across time, allowing for the analysis of how one partner may or may not
influence the second partner across talk turns in therapy, for example.
Dynamic systems modeling

Dynamic systems modeling focuses on patterns of behavior between therapist and
clients and how they emerge over time. Dynamic systems analysis is rooted in dynami-
cal systems theory (such as understanding the behavior of a flock of birds); as applied
to process research, dynamical systems theory suggests that therapist and clients are
constantly responding to one another and that each person’s behavior in any given
moment is linked to the other person’s behavior in that moment, as well as each of
their behaviors in the preceding moment (e.g., Butner et al., 2017). Dynamical sys-
tems theory, furthermore, suggests that the behavior of therapist and clients jointly
represents a combined therapeutic system and that it is not possible to understand one
person’s behavior without consideration of the others. Dynamic systems analysis is
carried out as a cross‐lagged APIM that models the influence of participants in a
therapy session across time and helps us answer the question of “what happens when
individuals in a multiple‐person system interact?” These analyses are especially helpful
in estimating potential for change and how stable changes are based on where each
system starts (Butner et al., 2017).
State‐space grids are a part of dynamic systems analysis and are a way to visually
represent these emergent patterns of behavior as coordinates on a grid, where one
person’s behavior is on the horizontal axis and the other person’s behavior is on the
vertical axis (e.g., Hollenstein, 2007). Each axis is further delineated into a set of
discrete behaviors that each person can engage in. When the set of behaviors is the
same for therapist and client, the axes are ordered so that the diagonal represents the
co‐occurrence of the same behavior for both therapist and client. The sequence of
therapist–client behaviors over the course of a session is depicted by beginning in the
cell corresponding to therapist’s and client’s first behaviors and connecting that cell
to therapist’s and client’s subsequent behaviors. This process is repeated for all meas-
urement periods of the therapy session, and separate state‐space grids are created for
each therapist–client grouping.
The resultant state‐space grids can be used to describe process‐related phenome-
non in multiple ways. When analyzing one or a small number of therapist–client
groupings, interpretation may focus on the behavioral coordinates where therapist
and client repeated return (i.e., attractors) and where they avoid (i.e., repellers).
When analyzing a larger number of therapist–client groups, summary statistics that
characterize the dynamics of the therapy session (e.g., entropy, an index of how pre-
dictable the behavioral sequence is) can be extracted and used in standard inferential
statistical models.
Discrete time survival analysis

Discrete time survival analysis is a form of regression used to predict the incidence and
timing of an event. For example, discrete time survival analysis could be used to test
whether working alliance after the first session is associated with the timing of sudden
gains in symptomatology from one session to the next even though not all clients will
experience sudden gains. It shares some properties with other forms of regression,
such as logistic regression and logistic multilevel regression that predict the likelihood
of an event occurring at a particular moment during a psychotherapy session. Although
these three forms of regression analyze the likelihood of an event occurring over some
period of time, they make very different assumptions about the nature of the event
and the way that time is related to the likelihood of the event occurring (e.g., Singer
& Willett, 1993).
Discrete time survival analysis assumes that (a) at the start of a psychotherapy
session, the event has not happened for any client, (b) the event can happen at any
point in time during the psychotherapy session for all clients, and (c) if the event does
not happen by the end of a psychotherapy session, that does not mean it will not
happen in the future; it just did not happen by the end of the session (e.g., Singer &
Willett, 1993). Additionally, discrete time survival analysis assumes that the likelihood
of the event occurring for a larger number of clients increases at later stages of the
session relative to earlier states of the session. However, it does not assume that this
increase in likelihood occurs in a smooth, continuous fashion (as would be the case in
a logistic multilevel growth model), but rather allows for increases in likelihood to
occur in a nonlinear fashion.
Discrete time survey analysis can be conducted either as a between‐person analysis
or as a within‐person analysis. The between‐person form of discrete time survey analy-
sis allows for the event to happen once and only once for each client. This aspect of
discrete time survey analysis is similar to logistic regression in that in both types of
analysis, the event either does or does not happen for each person. The major thing
that distinguishes the two types of models is that discrete time survey analysis addi-
tionally provides information about the timing of the event (i.e., how does the likeli-
hood of the event occurring in later stages of the session covary with other individual
different variables). The within‐person form of discrete time survival analysis allows
for the event to happen more than once for each client; logistic multilevel growth
models also allow for the event to happen once for each client. The primary difference
between the two types of models is that in discrete time survival analysis, when the
event happens, the time to the event happening again is reset. For example, if the
event happens in minute 32 of a 50‐min session for a given client, this client would
have two occurrences in a discrete time survival analysis. The first is the event occur-
ring at 32 min, and the second is the event not occurring after the following 18 min.
In a logistic multilevel growth model, the time to the event happening is based on the
start of the session and simply increases over the course of the session. In sum, discrete
time survival analysis, logistic regression, and logistic multilevel regression can all be
used to analyze specific event occurrence process questions, and careful consideration
is warranted in selecting among the three models. Interested readers are directed to
Singer and Willett (2003).
Sequential analysis
Sequential analysis describes how prior specific behaviors are related to subsequent
specific behaviors. Sequential analysis operationalizes behavior as temporal patterns
that unfold over time, and that behavior is dyadic in nature. This theoretical under-
pinning leads to an emphasis on computing conditional probabilities of two‐ or three‐
turn cross‐partner chains of behavior in sequential analysis (e.g., Bakeman & Gottman,
1997), as opposed to a continuous chain of behavior in state‐space grids.
These conditional probabilities are used to answer variants of: “Given how often
therapist engages in Behavior A and client engages in Behavior B in general, how
likely is client to engage in Behavior B following therapist engaging in Behavior A?”
As can be seen in this example, one of the strengths of sequential analysis is that it
allows for the examination of specific behavioral sequences of that are of interest a
priori. This quality allows sequential analysis to be viewed as a hypothesis testing
approach, whereas state‐space grids are an exploratory/descriptive approach.
One important consideration in sequential analysis studies is the base rates of all the
behaviors in the analysis. The test statistic for the conditional probability with which
one behavior follows another is a variant of chi square. Similar to chi square, it is dif-
ficult, and at times not possible, to compute conditional probabilities for very low
base rate behaviors (i.e., those that occur fewer than five times during a psychotherapy
session). Exact statistics can be used to improve the precision of conditional probabil-
ity estimates for low base rate behaviors. Interested readers are directed to Agresti
(2007) for additional discussion of rare outcomes.
Future Directions and Recommendations
As can be surmised from reading this chapter, process research is time intensive and
complex with results that are valuable to clinicians and researchers. However, due to
the time commitment required of process research and value of findings to improving
client care, we believe that the SFT field needs many more process researchers con-
ducting high quality process research. This can be difficult as the demands necessary
for investigation and peer‐reviewed publication come at the price of difficulty in dis-
semination. With this difficulty in mind, we wish to provide some recommendations
for future process researchers.
Process research needs to follow established methodological procedures. Due to
the complexity, researchers are encouraged to document every step of the research
process. Take time to leave a paper trail for yourself and colleagues so that you do
not have to redo work what was already done. A documentation trail will allow you
to further examine where exceptions to established procedures were made, and the
documentation can be used as the basis for developing new methodologies. Finally,
given the time it takes to conduct process research, expect future generations of
researchers to continue projects you started. They will need to understand the steps
you took.
Remember that starting small is acceptable. Due to the time involved in these pro-
jects, the tendency is to maximize time use in gathering every variable related to a
particular research question. Have too many variables can complicate a project. Also,
it is important to remember that no study can investigate all aspects of process.
We can make strides in understanding the change process in SFT by investigating
small pieces of the puzzle.
Researchers should also be comfortable taking risks, within established research
practices. Process research involves thinking about the why or how change occurs.
As we try to describe our thoughts on change, we run the risk of presenting ideas
that appear overly simplistic or challenging to long‐held beliefs about change. It is by
taking risks and challenging long‐held beliefs that we will move our understanding of
change in SFT forward.
Next, and related to taking risks, is talk often with colleagues about your thoughts
and ideas related to change processes. Many researchers wonder if their ideas are good
and hesitate to present them to others to avoid sound silly or uneducated. While dis-
cussing ideas early in the process can be unnerving, it will improve your ideas. Process
research is about asking meaningful questions—some of them will be good and others
will require modification.
Finally, we believe that for process research to be truly meaningful, scholars need to
make it relevant to clinicians. Meaningful findings on how to better help improve
couple and family relationships need to be disseminated to frontline clinicians.

Presenting findings at conferences or peer‐reviewed publications will always be an
outlet for dissemination. We recommend going one step further by involving clini-
cians at the development phase of research studies.
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21
Community‐Based Participatory
Research (CBPR) for Underserved
Populations
Rubén Parra‐Cardona, Hydeen K. Beverly,
and Gabriela López‐Zerón
Community‐based participatory research (CBPR) is a research methodology and

approach to scientific inquiry characterized by shared leadership among researchers,
key community stakeholders, and the ultimate beneficiaries of research (Minkler,
Blackwell, Thompson, & Tamir, 2003). CBPR has been implemented in a wide vari-
ety of contexts and disciplines with multiple research objectives. Examples of target
outcomes include the development of programs to address food insecurity, preserva-
tion of ecological resources, community development, reduction of health disparities,
and promotion of family well‐being (Cacari‐Stone, Wallerstein, Garcia, & Minkler,
2014; Carney et al., 2012). Because the ultimate goal is to address inequalities at
multiple levels, CBPR approaches are characterized by an overt focus on social justice
(de Sayu & Sparks, 2017). Furthermore, CBPR has become a core research method-
ology in the family therapy field, particularly as it refers to multiple initiatives aimed
at addressing unmet mental health needs of underserved populations. We refer the
reader to an excellent source that provides a comprehensive description of the origins
of the approach, its influence on the family therapy field, and a detailed explanation of
the methodology (see Robinson, Olson, Bischoff, Springer, & Geske, 2014).
The CBPR methodology has important similarities with core processes of family
therapy practice and research. For example, just as the quality of the therapeutic rela-
tionship is critical for any therapeutic process, the foundation of CBPR is grounded in
establishing strong and collaborative relationships among all agents of change. This
characteristic is essential in CBPR studies, as not a single actor is considered “the
ultimate expert.” Instead, all collaborators are considered experts on specific areas of
knowledge and life experiences (Minkler, Garcia, Williams, LoPresti, & Lilly, 2010).
This approach to collaboration is one that closely resembles the therapeutic relation-
ship. That is, although therapists are experts on addressing interpersonal conflict,
families are the ultimate experts of their own lives.
492 Rubén Parra‐Cardona, Hydeen K. Beverly, and Gabriela López‐Zerón
Thus, a common element across various CBPR definitions consists of highlighting

the role of community members as co‐leaders in research initiatives impacting their
communities. That is, community members have an active voice to effectively influence
all phases of the research process, including the definition of the problem, research
design, implementation, analyses and interpretation of findings, and identification of
specific action plans in response to identified needs (Betancourt, Frounfelker, Mishra,
Hussein, & Falzarano, 2015; Kirk, Johnson‐Hakim, Anglin, & Connelly, 2017).
CBPR: research grounded in social justice

The origins of CBPR can be traced back to the voices of marginalized members of
society that have been historically excluded from the generation of knowledge through
empirical research. Thus, initial CBPR programs of research were focused on histori-
cally oppressed and disenfranchised groups such as populations with limited or no
access to health and mental health services, neighborhoods impacted by lack of basic
services (e.g., water, sanitation), and communities affected by widespread violence,
among others (Israel et al., 2010; Robinson et al., 2014).
For this reason, CBPR is political in nature. That is, if adequately implemented, CBPR
initiatives should lead to transformative change in oppressed communities (Minkler,
2004). As a result, CBPR has been associated with political movements in the scientific
community, such as action research (Holkup, Tripp‐Reimer, Salois, & Weinert, 2004).
According to its political nature, the CBPR process naturally aims at addressing power
imbalances by giving prominence to the voices of populations that have been historically
overlooked or disregarded in the generation of scientific knowledge (Hall, 1992).
CBPR has also been associated with Paulo Freire’s pedagogy of the oppressed,
which indicates that any meaningful transformation in society is rooted in the knowl-
edge and expertise of the people, which must be honored through authentic dialogue
as a precursor for changing oppressive structures (Minkler, 2004). Within this frame-
work, any scientific and academic initiative must always remain focused on addressing
the needs of vulnerable communities (Small & Uttal, 2005).
The social justice foundation of CBPR must be demonstrated according to specific
processes and outcomes. First, CBPR must lead to more resourceful communities as a
result of genuine partnerships among multiple agents of change in targeted popula-
tions (Minkler, Vásquez, Tajik, & Petersen, 2008). CBPR must also be characterized
by equitable knowledge sharing, rooted in a profound understanding of community
challenges and strengths. Third, CBPR should prioritize focusing on populations
whose voices and experiences have been overlooked, silenced, or disregarded, with the
ultimate goal of fostering community empowerment, equity, and respect (Cacari‐Stone
et al., 2014; de Sayu & Sparks, 2017). In essence, CBPR should facilitate a redefinition
of power relationships in communities by integrating multiple perspectives of lived
experience, knowledge, and expertise (Betancourt et al., 2015; Minkler et al., 2010).
CBPR: Critical Concepts
Cultural diversity and recognition of historical inequity

CBPR initiatives are frequently focused on minority populations whose diversity has
led them to experience oppression, injustice, and exclusion. Examples of these groups
CBPR Methods in the Systemic Family Therapy Field 493
include ethnic minority populations, sexual minorities, people with disabilities, low‐
income immigrants, religious minorities, and other diverse groups with limited power
and privilege in society (Cacari‐Stone et al., 2014). Based on its inclusive approach,
CBPR offers an opportunity to incorporate what Gutiérrez and Rogoff (2003) have
identified as a cultural‐historical approach, which “assumes that individual (commu-
nity) development and disposition must be understood in (not separate from) cultural
and historical context” (p. 22).
Therefore, and to effectively promote social change, it is essential for researchers to
understand the broader historical, socioeconomic, and political factors that have led
to power imbalances and inequity in society across time (Hacker et al., 2012). By
understanding how culturally diverse populations have been historically impacted by
various disparities, a key goal in research is to address some of these inequities with
the ultimate objective of increasing community capacity by various stakeholders hav-
ing an active role in the process of change (Freudenberg, 2004).
Communities as leaders and experts: acknowledging and

addressing power differentials
CBPR approaches should result in an empowering experience for community mem-
bers by fully recognizing their expertise and leadership in the process of change. That
is, community stakeholders are engaged as experts of their realities and are co‐leaders
in developing programs of research aimed at benefiting their communities
(Winterbauer, Bekemeier, VanRaemdonck, & Hoover, 2016). As a result, CBPR ini-
tiatives are characterized by an emphasis on building trust and a collaborative deci-
sion‐making process that is responsive to the cultural values and perspectives of target
populations.
Such a trust‐building and shared decision‐making process must be guided by
ethical guidelines to prevent instances of exploitation. As Minkler (2004) has
affirmed, “it becomes imperative to underscore the key elements of the authentic
partnership approaches characterized by CBPR and to explore the many ethical
challenges that such work may entail” (p. 686). Thus, Minkler (2004) proposes the
following five ethical markers that should be achieved in any CBPR initiative:
(a) developing a community‐driven agenda, (b) understanding the history of
insider‐outsider tensions in research agendas, (c) raising awareness of cultural
diversity issues associated with historical injustice in the target community,
(d) understanding the limitations of participation by community members and
leaders, and (e) designing a strategy for dissemination of findings and their utiliza-
tion for the benefit of communities.
Shared leadership, co‐learning, and exchange of knowledge

Researchers engaged in CBPR initiatives are guided by a commitment to generate
knowledge and change according to shared leadership, experiences of mutual learn-
ing, and continuous exchange of knowledge. Holkup et al. (2004) highlight the need
to emphasize “bottom‐up” approaches to correct for the historical domination of
“top‐down” approaches driven by academia and other scientific institutions. To clar-
ify, “top‐down” approaches are characterized by decision‐making processes in which
the individuals with higher levels of power ultimately engage in actions led by their
own perspectives, with little input from individuals with lesser levels of power. In
c ontrast, a “bottom‐up” approach is characterized by a decision‐making process that

is guided by direct input from individuals who traditionally do not have a voice in
critical decision making impacting their communities. According to Holkup et al.
(2004), an emphasis on bottom‐up approaches is necessary to ensure that the needs
of communities are fully identified and understood, particularly if such communities
are represented by populations exposed to historical oppression and exclusion.
However, although it is necessary to always consider the potential for oppressive
practices by those in positions of power and leadership, it is also essential to highlight
that scientific discovery and evidence‐based knowledge have a critical role in CBPR.
Thus, whereas researchers must always remain attentive to the risk of overlooking or
abusing their power and privilege, the expert contributions by members of the scien-
tific community constitute a key component of any CBPR program of research aimed
at benefiting underserved populations, as long as the research collaborations remain
fully informed according to ethical and social justice principles (Minkler, 2004).
Action‐oriented research and advocacy

Action‐oriented research is designed to ensure that the creation of knowledge leads to
concrete changes at various levels of society. According to Small and Uttal (2005),
action‐oriented research aligns with emancipatory research strategies that produce
knowledge that is created by and shared with communities to impact social change.
This principle closely aligns with advocacy principles, which highlight the impor-
tance of facilitating resources to individuals, families, and communities with the
potential to change their immediate realities (Israel et al., 2010). For example, CBPR
has been at the core of social policy initiatives aimed at addressing disparities in educa-
tion, health, and food insecurity (Carney et al., 2012). According to family therapy
researchers, action research and advocacy approaches are “still not widely practiced in
marriage and family therapy circles” (Mendenhall & Doherty, 2005, p. 100). In
essence, advocacy‐focused interventions should extend beyond therapeutic goals
aimed at improving family interactions and often times require active interactions with
external systems. Examples of such goals refer to ensuring that the basic needs of dis-
advantaged families are met and that their rights are protected. To illustrate, in our
work with immigrant families with mixed‐immigration status, we engage in advocacy
efforts with immigration defense attorneys whenever families request our help to pre-
pare affidavits detailing the psychological and emotional damages that will be inflicted
on US citizen children should their immigrant parents be deported. This type of
advocacy intervention is not explicitly addressed in the original premises of traditional
family models; rather, they constitute a response to scholars who have increasingly
exhorted mental health practitioners to engage in actions that are necessary to address
experiences of oppression and discrimination that negatively impact the lives of diverse
populations (Cardoso, Scott, Faulkner, & Lane, 2018; Unger, 2015).
Reduction of mental health disparities

The Centers for Disease Control and Prevention (CDC) has defined health and men-
tal health disparities as “preventable differences in the burden of disease, injury, vio-
lence, or opportunities to achieve optimal health that are experienced by socially
disadvantaged populations” (CDC, 2018). Reducing these disparities has proven to
be an extremely difficult goal to achieve in the United States as inequity is historical

and closely related to unequal allocation of resources and discriminatory practices
(Ginossar & Nelson, 2010; Safran et al., 2009). This problem is particularly complex
at the international level. For instance, according to Cluver et al. (2016), estimates
from the World Health Organization indicate that one billion children experience
abuse each year with the highest rates being observed in low‐ and middle‐income
countries. However, the vast majority of prevention research and evidence‐based child
abuse prevention initiatives remain concentrated in high‐income countries.
Furthermore, even though the United States is a leading nation in the world with
regard to per capita income, health and mental health disparities impacting low‐
income and diverse populations in the nation continue to be persistent and deeply
rooted in discriminatory practices. For example, the decision by states to not expand
Medicaid coverage under the Affordable Care Act (ACA) has significantly impacted
low‐income individuals who are below the federal poverty level, but who also remain
ineligible for Medicaid and cannot afford marketplace coverage (Garfield, Damico, &
Orgera, 2018). Although thoroughly addressing health disparities requires effective
legislation at federal and state levels, CBPR approaches can offer unique contributions
to address these gaps such as offering free community‐based prevention programs
aimed at promoting health and mental health.
Sustainability
A core premise of CBPR refers to strengthening communities with the ultimate objec-
tive of achieving long‐term change. This is a relevant but difficult goal to accomplish
as it assumes that permanent resources will be secured to ensure the sustainability of
specific initiatives aimed at benefiting target communities. Current federal policies in
the United States serve as clear reminders that the sustainability of programs for under-
served diverse populations remains as one of the most difficult goals to achieve in this
country, particularly if disadvantaged minority populations are identified by those in
power as a “burden to the state and society.” More than ever, CBPR approaches have
a critical goal in the pursuit of sustainability efforts as it refers to the formation of com-
munity‐based alliances to ensure the permanency of long‐term initiatives and programs
aimed at benefiting underserved populations (Belone et al., 2016).
Conceptual Model
Figure 21.1 describes a proposed CBPR model consisting of four major phases, which
expand the focus of a previously published model aimed at describing cultural adapta-
tion and services research in community‐based interventions (see Parra‐Cardona,
Lappan, Escobar‐Chew, Whitehead, 2015). Thus, the expanded model is fully focused
on key processes and outcomes that we consider should characterize CBPR initiatives
with underserved populations.
The first phase refers to a qualitative formative stage, in which researchers from
outside the community immerse themselves in the lives of the target population. This
is achieved by listening and learning from the life experiences of the potential benefi-
ciaries of interventions, as well as community expectations associated with the
Long-term sustainability
- Grounded in local intervention

delivery expertise
Evaluation
- Grounded in local support and
- Mixed methods resources
- Rigorous statistical approaches - Responsive to realities of target

Implementation phase to determine efficacy according to population (e.g. insurance
contextual characteristics of affordability, poverty)
- Adapting intervention manuals research design
- Training - In-depth qualitative approaches

to fully capture issues associated
Qualitative formative phase
- Intervention delivery with oppression and adversity
- Learning from the target
population - Advocacy
ledge:
- Establishing a trusting now
of k
relationship h a nge
x c
nd e
g, a perts rts rts
- Setting the foundation for arnin ex xpe
ip , co-le ents as rs as e as expe
adapting and refining e rsh P a r a de hers
lea d ity le c
interventions red mun ear
Sha -res
Com rapists
e
a m ily th
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Figure 21.1 CBPR conceptual model: Detroit case example. Expanded from “Risk and Resilience Among Latino Immigrant Families,” by
Parra‐Cardona, Lappan, Escobar‐Chew, and Whitehead (2015).
roposed initiative. This phase is critical for developing mutual knowledge and estab-
p
lishing trust among all parties involved. Next, the implementation phase integrates all
the necessary activities associated with adapting interventions, training, intervention
delivery, and advocacy. A third phase refers to evaluation of activities, which we con-
sider should always consist of mixed methods approaches to fully capture the multiple
dimensions of experience to be reported by the beneficiaries of interventions. The
final phase, long‐term sustainability, refers to the critical goal of permanently ground-
ing interventions or initiatives in the community. Three foundational processes are
identified in the model, which must be thoroughly inform all phases of CBPR initia-
tives: shared leadership, co‐learning, and exchange of knowledge. The connecting
arrow at the bottom of the figure illustrates the circular process of CBPR, as well as
the fact that once sustainability is achieved for the original research objective, collabo-
rators and communities may decide to initiate a new process to address additional
outcomes. We propose this CBPR model as informed by a long‐term program of
prevention research in a low‐income Latino/a immigrant community. However,
because the proposed model closely adheres to our unique experiences in this context,
it must be tailored according to alternative contexts and populations, CBPR objec-
tives, and proposed outcomes.
Case Study: The Detroit Experience
Qualitative formative phase

Learning from the target population Our community‐based program of prevention
research dates back to 2004. As an assistant professor at a research‐intensive univer-
sity, I (RPC) experienced the drastic change from being a doctoral student to seeing
myself as a young researcher facing the institutional expectations of developing an
externally funded program of research, as well as the need to publish in high quality
refereed journals. Thus, after weeks of being completely consumed by fear stemming
from internalized narratives of inadequacy and impostor syndrome, I resorted to what
any novice therapist must do: focus on the basic skills that set the foundation for a
strong therapeutic alliance. Thus, I decided to apply this principle to my work in com-
munities as a young independent investigator.
As background, my clinical training consisted of providing therapy to ethnic minor-
ities involved in the justice system, which led me to constantly witness the realities of
disproportionate minority contact and confinement of ethnic minority youth in the
juvenile justice system. By focusing on preventive parenting as my primary area of
research, my hope was to support low‐income Latino/a immigrant families who are
forced to battle years of oppression and discrimination, which ultimately undermine
their capacity to offer nurturing and nonpunitive parenting experiences to their chil-
dren. As I confirmed in multiple years of practicing family therapy, if parents are sup-
ported in their child‐rearing efforts, there is a high likelihood that their children will
not engage in risky behaviors, which could ultimately reduce the risk of Latino/a
youth interacting with the juvenile justice system.
Motivated by this dream, our team set out to conduct focus groups in two Latino/a
communities in Michigan, targeting US‐ and foreign‐born Latino/a populations. As
we implemented focus groups, we were presented with clear and contrasting realities.
Briefly, US‐born Latinos/as in central Michigan were more economically stable; most
of them were US citizens and had access to basic resources such as health care and
education. In contrast, foreign‐born Latinos/as in Detroit were living in poverty,
were often times exposed to work exploitation and intense immigration challenges,
had very low rates of health insurance, and had living conditions that continuously
exposed them to community violence and various forms of discrimination.
We published a qualitative article (Parra‐Cardona, Córdova, Holtrop, Villarruel, &
Wieling, 2008) in which we reported common and contrasting life experiences of
US‐born versus foreign‐born Latinos/as. Research findings indicated that whereas
both Latino/a subgroups had experienced adversity and discrimination, the nature of
oppression and adversity experienced by foreign‐born Latinos/as was much more
pronounced than the life challenges reported by US‐born Latinos/as.
Focus group interviews also focused on exploring issues associated with parenting
experiences, cultural values informing parenting practices, and the need for support
with regard to parenting practices. Parents consistently emphasized the need for par-
enting interventions to be characterized by cultural sensitivity and awareness of their
life challenges (Parra‐Cardona et al., 2009). For example, parents highlighted the
importance of intervention being informed according to the intense challenges expe-
rienced by low‐income Latino/a immigrants in the United States, including instances
of discrimination in various settings, immigration challenges, oppressive and exploita-
tive work conditions, and the lack of accessibility to programs and services (e.g.,
health care) to help them address their basic needs.
In essence, the focus group phase of our program of research was essential to reach
a better understanding of the Latino/a community in Detroit, their life experiences,
their parenting expectations, and the characteristics of parenting programs that would
increase likelihood of participation. As stated by Robinson and colleagues (2014), the
initial methodological steps of CBPR initiatives must be grounded in methods aimed
at ensuring that projects are “community driven and useful to participants” (p. 285).
Establishing a trusting relationship and setting the research foundation The focus
group phase of our program of research was essential to help us establish a collabora-
tive and trusting relationship with community leaders. This goal was critical as com-
munity leaders were worried about our team being primarily focused on “completing
a research project, collecting data, and then leaving.” Thus, several conversations
were essential to establish a working relationship characterized by honesty and trans-
parency. Community leaders associated with one of the leading mental health service
organizations in Detroit (i.e., Southwest Solutions) were comfortable with the pro-
posed research goals, as long as we would commit to providing free training and
supervision to their practitioners on the evidence‐based parenting intervention that
we planned to disseminate.
An additional key collaboration was established with the largest faith‐based organi-
zation in Detroit (i.e., Holy Redeemer), known for its strong advocacy in support of
Latino/a immigrant populations. This church was also identified by parents in the
focus groups as the safest delivery site for the parenting program. In resemblance to
the request expressed by Southwest Solutions, the leaders of this organization also
expressed a strong desire for free training of the staff to be involved in the project.
This formative phase lasted 6 months, and in accordance with Robinson et al.
(2014), we confirmed the importance of focusing initial methodological steps on
establishing a solid collaborative foundation for proposed CBPR initiatives.

Specifically, researchers must engage in multiple activities such as individual and
group meetings with community leaders, as well as other key constituents, with the
ultimate goal of promoting active collaborations. The result of these efforts should
ideally reflect that “community members, who are normally the passive subjects of
research investigation, are brought together as co‐investigators and team members”
(p. 285).
Implementation phase
Culturally adapting intervention manuals Our parenting program of research cent-
ers in the intervention known as GenerationPMTO®, a parenting intervention with
established effectiveness in numerous randomized controlled prevention and clinical
trials (Forgatch, Patterson, DeGarmo, & Beldavs, 2009). We selected GenerationPMTO
for our program of research as the principles of the intervention and method of deliv-
ery are highly syntonic with the Latino/a culture as confirmed in empirical research
with Latino/a populations in the United States (see Parra‐Cardona et al., 2008,
2016) and Mexico (see Parra‐Cardona, Aguilar, Wieling, Domenech Rodríguez, &
Fitzgerald, 2015; Parra‐Cardona, López‐Zerón et al., 2018). The GenerationPMTO
intervention is delivered primarily to parents as according to a mediational model,
parents are the primary agents of change in the lives of their children. Thus, by
strengthening the caregivers’ parenting practices, children and youth will experience
positive developmental outcomes (Forgatch et al., 2009).
The first cultural adaptation of GenerationPMTO for Latino immigrant popula-
tions was conducted by the research team led by Domenech Rodríguez, Baumann,
and Schwartz (2011). This GenerationPMTO manual was titled “CAPAS: Criando
con Amor, Promoviendo Armonía y Superación” (Raising Children with Love,
Promoting Harmony and Self‐Improvement). The title was suggested by the parents
who were exposed to the original adaptation of GenerationPMTO in the study led by
Domenech Rodríguez et al. (2011). The cultural adaptation process followed the
guidelines of the ecological validity model (EVM) of cultural adaptation, which indi-
cates to researchers key dimensions for adapting efficacious interventions such as lan-
guage, method of delivery, and content of materials, among others (Bernal, Bonilla,
& Bellido, 1995). Following key premises of the EVM cultural adaptation model, the
development of the CAPAS intervention involved continuous conversations with the
original developers to ensure that adaptations did not alter the core components of
the intervention while also ensuring that the adapted intervention thoroughly
addressed contextual and cultural experiences of high relevance to the target
population.
The original CAPAS intervention was adapted for Latino/a immigrant families
with children ages 4–11 and consisted exclusively of the core parenting components
of the GenerationPMTO intervention. Our program of research expanded the scope
of CAPAS by developing adapted interventions with an explicit focus on Latino/a
cultural values, adversity and discrimination, and promotion of biculturalism. This
intervention known as CAPAS‐Enhanced has been empirically tested in two rand-
omized controlled trials. The first one focused on Latino/a immigrant families with
children ages 4–11 and the second on families with adolescents, ages 12–14 (see
Parra‐Cardona et al., 2017, Parra‐Cardona, Leijten et al., 2018).
Adapting the intervention according to the voices of parents The CAPAS inter-
vention has a solid cultural adaptation foundation focused on linguistic appropriate-
ness and relevant Latino/a cultural meanings, primarily used to culturally frame the
core GenerationPMTO components. However, our empirical studies indicated the
need to overtly address issues of contextual oppression and discrimination, as well as
biculturalism, impacting the lives of Latino/a immigrant families. Thus, the CAPAS‐
Enhanced intervention includes components in which parents are encouraged to
share their experiences as immigrants, immigration‐related challenges, and the ways in
which they have learned to cope with such challenges. As expressed by Unger (2015),
failure to overtly address discrimination in prevention interventions constitutes a
major flaw of prevention studies with populations exposed to significant adversity and
various forms of structural oppression. According to this author, researchers should
consider the overt identification of discrimination as a critical methodological deci-
sion that should inform all phases of applied programs of research aimed at benefiting
underserved populations.
In addition to addressing contextual oppression, the focus on biculturalism is par-
ticularly relevant in the CAPAS‐Enhanced intervention for families with adolescents
as research indicates that within‐family cultural conflicts can increase the risk for US‐
born citizen youth to engage in risky behaviors such a drug use, particularly if they
feel that the cultural values and preferences of their foreign‐born parents conflict with
those of their own (Smokowski, David‐Ferdon, & Bacallao, 2009). Overall, adhering
to rigorous adaptation standards has been key to the success of our program of
research as we have implemented strategies identified as best practices in cultural
adaptation research. We refer the reader to an excellent source on cultural adaptation
that addresses in great detail the science of cultural adaptation as applied to health and
mental health interventions (see Bernal & Domenech Rodríguez, 2012).
Training of interventionists: A bidirectional growth experience A critical process asso-

ciated with CBPR refers to promoting a mutual learning experience, aimed at impact-
ing all research collaborators. Two examples illustrate the dynamic process of this
mutual learning experience. The first instance refers to the struggle that represented
for the interventionists affiliated with Holy Redeemer to be exposed to a highly struc-
tured manualized intervention with a strong focus on promoting positive involve-
ment with children. Due to very adverse childhood backgrounds, both male
interventionists had never been exposed to a parenting program with a strong empha-
sis on promoting a nurturing parent–child relationship. Thus, the intervention drasti-
cally contrasted with family‐of‐origin experiences that were characterized by parenting
through intimidation and minimal praise of children’s positive behaviors. Both pro-
fessionals expressed a normal attitude of suspicion toward the intervention, particu-
larly in the initial phase of training. In response, we validated such reactions and
highlighted to them their individual strengths as they were courageous by expressing
that they would not commit to delivering a parenting program until confirming their
usefulness and impact. Thus, we invited both professionals to engage in the training
process with a “tentative and experimental” attitude and to let the intervention skills
indicate the usefulness of the program or lack thereof. Fortunately, the
GenerationPMTO is highly experiential in nature and focuses on skills that usually
have an immediate positive impact on the parent–child relationship. Thus, both pro-
fessionals reported by the end of the first week of training noticeable changes in the
relationship with their own children, which represented a critical factor for both men
to embrace the intervention.
The training experience for Southwest Solutions professionals was informed by
their clinical professional backgrounds and experience. As clinical social workers, their
training had exposed them to various clinical and preventative mental health interven-
tions. Thus, they viewed the training phase as a protected period of time that would
allow them to be fully focused on learning the GenerationPMTO model, as well as to
carefully examine its applicability according to their vast clinical experience.
When reflecting on major lessons associated with this foundational phase, we con-
tinue to be profoundly inspired by the courage and honesty of Holy Redeemer profes-
sionals as they served as shields for their community, particularly because both
professionals had witnessed examples of abuse from researchers who had engaged in
unethical research practices in this community. Further, the initial anxiety that we
experienced as we interacted with both interventionists in this initial phase of training
proved to be a powerful training opportunity to help us manage future situations,
particularly when delivering the intervention to parents who were reluctant to accept
the premises of the intervention due to intense trauma backgrounds or severe experi-
ences of childhood adversity. With regard to Southwest Solutions interventionists,
their expertise helped us understand the critical interaction between the intense con-
textual adversity experienced by families in Detroit and its influence on the etiology
of mental health problems that were commonly experienced by local Latino/a
residents.
Intervention delivery and shared leadership and expertise Parents have been leaders in
helping us understand how adaptations to the interventions must be done according
to key cultural and contextual considerations that have great relevance in their lives.
For example, one of my (RPC) most critical mistakes as a leader in this program of
research consisted of assuming that I fully understood the priorities of parents who
participated in the parenting groups for families with young children (ages 4–11).
Specifically, due to the intense levels of adversity impacting Latino/a immigrants in
Detroit, I assumed that parents would be primarily concerned about addressing expe-
riences associated with oppression and discrimination, prior to fully engaging in the
content of the parenting program. Thus, I (RPC) made the decision to focus the
initial two sessions of the parenting program for families with young children (ages
4–11), on issues associated with contextual adversity as reported by Latino/a parents
in the qualitative studies. However, when we conducted the qualitative evaluation of
the first parenting program according to this format, parents expressed frustration
because they had to wait until the third session to start addressing parenting issues. A
courageous mother clearly explained the nature of their frustration:
We know you mean well by planning the initial sessions so we can talk about the many chal-
lenges we experience as Latino/a immigrants. However, we have learned ways to deal with
this reality over many years. It’s not that it is not relevant to us, but many of us talked
amongst ourselves after the second session and were frustrated because we signed up for a
parenting program with the hopes of stop hitting or yelling at our children, as we don’t know
better ways to raise them. However, we had to wait until the third session to start talking
about parenting issues we are concerned about. We want to talk about the challenges we live
as immigrants, but let’s start with the parenting … We need a lot of help with our
parenting.1
This powerful disclosure represents a clear example of the need for researchers and
members of the community to continuously engage in productive and honest conver-
sations. Interestingly, when we implemented the pilot study with CAPAS‐Enhanced
for families with adolescents, parents expressed their desire to address culture and
context in the initial sessions as parent–youth cultural conflicts were among their pri-
mary concerns. Thus, both interventions have been tailored according to the needs of
each group of families.
Community leaders as parenting experts The interventionists in our program of

research are also identified by the local Latino/a community as trusted leaders based
on their important roles in local mental health agencies and faith‐based organizations.
This positioning has been critical for promoting a fruitful process of shared expertise.
Two examples can illustrate this critical issue.
When we launched our first parenting group, I (RPC) was worried about power
differentials with parents. Particularly because I was co‐leading all parenting sessions,
I was concerned about parents feeling distant from me as I represented a university
setting in which there is a small representation of Latino/a faculty and students,
which drastically contrasts with the Latino/a community in Detroit. Thus, when I
introduced myself to the group, I encouraged parents to call me by my name rather
than “Doctor.” To clarify, in Mexico and many Latin American countries, the term
“doctor” equally applies to MDs and PhDs. As soon as we had the first break in the
session, one of the interventionists pulled me to the side and expressed:
I understand your desire to be respectful, but you need to know that many of these par-
ents are here tonight because a Ph.D. specialized in parenting issues is leading the group.
For many of these parents, this will be the only opportunity in their lives to interact over
a long period of time with a professional with your credentials. So, you have to be OK
with them referring to you as an expert and Ph.D. Present yourself like this and in future
sessions, you can tell one by one that you prefer to be called Ruben, but let them take
that lead. Tonight, you are the doctor that many of them have been waiting to meet for
a long time.
Just as this colleague predicted, some parents started asking me by the second session
if they could refer to me as “Ruben,” while others expressed at the end of the parenting
program that it was a very meaningful experience to them to share many classes with a
“Ph.D. with expertise in parenting” and that out of respect, they would always refer to
me as “Doctor.” Up until this day, I (RPC) continue to struggle with this process as my
strengths pale in comparison with those of the parents we serve. However, as my col-
league expressed to me, it is essential to respect and follow the guide of the parents we
serve, as we mutually define the nature of the collaborative relationship.
Community leaders giving voice to shared legacies of oppression The role of

community leaders is essential when identifying shared legacies of oppression, as well
as their deleterious consequences across generations. A clear example of this refers to
the need to clearly address risky parenting practices with group participants. Specifically,
a majority of parents who have participated in our groups have reported significant
traumatic childhood backgrounds associated with child maltreatment or parental
neglect. Thus, they have developed an adaptive “hardiness” in life that has allowed
them to adapt to such backgrounds as well as survive in the midst of adversity as

immigrants. However, this shield can also constitute a barrier when promoting par-
enting interventions that are grounded in the need to promote positive involvement
and emotional intimacy with children. For example, when presented with the prem-
ises of positive involvement, parents frequently express, “Why are we going to be soft
with our children if the world is so tough? We are just setting them up for failure!”
As university‐based professionals, many of us are removed from the day‐to‐day reali-
ties of severe contextual adversity that characterizes the lives of the families we serve.
However, it is precisely community‐based leaders who can close this gap by embracing
a unique voice of shared experiences with parents. For example, the initial component
of the GenerationPMTO intervention refers to fostering positive involvement between
parents and children. However, this component is usually challenging for many of the
parents we serve as they are presented with a type of nurturing parenting that they did
not receive growing up in their families. To address this issue, the interventionists pro-
posed a minor adaptation to the manual by offering an introduction that directly
addresses these barriers. The following narrative summarizes the way in which our
interventionists introduce the positive involvement component to parents:
We are about to start one of the most important components of this parenting program, but
you need to know that it is also one of the components that will be most challenging for many
of you. Let’s be honest, many of us share similar backgrounds and we know how it was like for
our parents to not recognize what we did right as children, but rather, to always be punished
for mistakes. For many of us, that was our childhood and because we have not learned a new
way of being parents, that is a legacy that we continue to replicate with our kids. So, as we
engage in these lessons, we want you to be open to these ideas about how to raise children,
which will be challenging for some of you. However, we also tell you this: this parenting pro-
gram changed our lives and that of our kids. We just need to accept our past, forgive our
parents if they hurt us, and focus on the future of our kids. We will be here to walk with you
through this new learning experience. You won’t be alone and you will remember our words
when you see the smiles in your children.
In retrospect, as Mendenhall and Doherty (2005) have affirmed when referring to

methodological principles of action research, the active co‐leadership of community
representatives at multiple levels is critical for promoting sustainable changes in CBPR
initiatives. In our case, we have utilized qualitative interviews and various debriefing
modalities (e.g., with parents in sessions, with interventionists between sessions) to
ensure that a circular and continuous loop of communication exists for all key mem-
bers involved in a CBPR process. In addition, selecting interventionists who are mem-
bers of the target community constitutes a critical methodological decision, particularly
because these professionals are members of the population they serve and bring a
unique moral voice that represents the values and aspirations of the community.
Family therapists‐researchers as experts The expertise of family therapists‐

researchers is essential to promote growth. As Satir, Banmen, Gerber, and Gomori
(1991) once expressed, therapy is similar to embarking in a journey in the open sea,
without the possibility for new travelers to identify the nearest shore. However, thera-
pists are expected to be experts in helping families navigate new waters. Thus, the
process of change is predictable if therapists can support families as they face their
challenges and develop new skills to cope with them and grow.
For example, it is common for parents to express frustration or confusion when

they learn that the limit‐setting component is addressed toward the end of the parent-
ing program. Openly communicating to parents the rationale for this sequence is
essential as empirical evidence indicates that effective changes in parenting practices
must be grounded in a new redefinition of the parent–child relationship. We com-
municate this to parents by using an introduction such as the following:
You are attending this parenting program because you deeply love your children and you
want what is best for them. We hear your concerns about your desire to primarily focus on the
need to change their misbehavior. However, based on our experience in helping families for
many years, we need you to trust us in this process. If we were to focus on discipline right
away, we would only make things worse for you and your family. We are committed to help
you get there and develop those skills but today, we need you to trust us and slow down by
focusing on the practices that we know are essential prior to focusing on discipline. We know
this may challenge your hopes for how this program was going to start, but please know that
your happiness and your children’s happiness is our top priority and you have our full com-
mitment to help you get there.
In essence, a delicate balance between collaboration and the engagement of thera-

pists‐researchers as experts in the process of change constitutes a primary precursor
for sustainable change. As Robinson et al. (2014) have indicated, CBPR integrates at
a minimum two major groups of co‐leaders: researchers and key community mem-
bers. Thus, facilitating continuous exchanges between these two groups of experts
constitutes a key methodological characteristic of CBPR as expertise is multifaceted in
nature and must be integrated by multiple perspectives.
Advocacy In line with CBPR principles, it is essential to maintain a commitment with

families that extends beyond the immediate goals of specific interventions and pro-
grams, particularly if those programs do not directly address their basic needs. In our
case, and due to the multiplicity of challenges faced by low‐income Latino/a immigrant
populations, all families enrolled in the parenting program are offered advocacy services
to help them address various contextual challenges. Specifically, one of the intervention-
ists conducts an assessment with each family at the outset of the program to help them
address urgent needs, which can range from referrals to immigration legal services to
specialized mental health services. According to feedback provided by parents, embrac-
ing an advocacy approach provides a reassurance to families that not only their parent-
ing needs are relevant, but equally important, their overall well‐being. Because advocacy
approaches are not explicitly included in original family therapy models (Mendenhall &
Doherty, 2005), there is a great opportunity for family therapists to expand current
frameworks of intervention by including advocacy components, which will necessarily
expand the ultimate goals of preventative and clinical interventions.
Evaluation
Achieving a delicate balance A critical lesson we have learned as a result of implement-
ing CBPR projects with underserved communities refers to the balance that must be
achieved by simultaneously responding to the needs of research‐intensive institutions
and the communities we serve. In our experience, we consider that an equivalent p rocess
to multidirected partiality has been key to help us accomplish this goal. According to
Boszormenyi‐Nagy and Krasner (1986), developers of contextual family therapy,

multidirected partiality refers to retaining “a concern for the psychological realities of
each family member” (p. 52). Applying this key family intervention principle to the
realities of CBPR follows a similar logic. That is, it is essential for CBPR leaders to fully
understand and remain responsive to the priorities and needs of each constituent. For
example, public research universities are committed to the generation of knowledge and
service to the community. However, they are also faced with tremendous financial
challenges as the majority of these institutions have experienced dramatic reductions
from government funding in the last couple of decades. Therefore, the responsibility
falls on researchers affiliated with these institutions to master grantsmanship skills to
sustain service‐oriented programs of research. Rather than being reminded about this
need by administrators, we consider that researchers must be proactive in responding to
this reality by securing sources of funding for their programs of research as it is not
feasible for public universities to fund all initiatives aimed at benefiting underserved
communities.
Furthermore, the pursuit of knowledge through empirical research and extramural
funding support should always be informed by remaining unequivocally responsive to
the needs and priorities of communities. Such a goal can be accomplished in multiple
ways. In our own work, we have always implemented qualitative studies with target
populations to ensure that our adapted interventions and methods of delivery are fully
responsive to the life experiences of the beneficiaries of parenting programs (see
Parra‐Cardona et al., 2008, 2009). In addition, all the phases of our studies are imple-
mented in close consultation with community leaders. This level of collaboration is
vital to ensure that CBPR projects remain responsive to the contextual and cultural
realities of the families and communities we serve. Although some phases require less
involvement from community partners (e.g., data analyses), the dissemination of find-
ings through presentations and co‐authored publications is fully informed by the
input from our collaborators and their interpretations of research results (see Parra‐
Cardona et al., 2017, Parra‐Cardona, Leijten et al., 2018).
The relevance of mixed methods: Integrating rigorous statistical and q ualitative

methodologies We strongly advocate for implementing CBPR studies according to
rigorous mixed methods evaluation protocols. As Dolbin‐MacNab, Parra‐Cardona,
and Gale (2014) have stated, mixed methods refers to “combining quantitative and
qualitative research methods for the purpose of answering a given research question”
(p. 267). Such an integrative approach provides valuable data at multiple levels. For
example, to measure satisfaction with the adapted GenerationPMTO interventions,
we utilize individual session satisfaction surveys, complemented by focus groups eval-
uations at the end of each wave of parenting groups, to fully understand the strengths
and limitations of the intervention (Parra‐Cardona et al., 2008, 2016).
With regard to determining efficacy and effectiveness, multi‐agent (e.g., parent,
teacher) and multi‐method approaches (e.g., self‐reports on parent practices, parent–
child video interactions) continue to be considered ideal methodologies to reduce
bias. In addition, randomized controlled trials remain the gold standard for determin-
ing efficacy and effectiveness outcomes. However, sophisticated methods are chal-
lenging to implement in underserved communities with scarce resources. Thus, we
have pursued approaches that are rigorous but feasible to implement. Specifically, our
efficacy studies have consisted of randomized controlled trials. In the NIMH trial
with families with young children (ages 4–11), we were able to include 6‐month fol-
low‐up measurements to examine long‐term intervention effects. However, we
recently completed a NIDA trial that only consisted of pre–post measurements. This
design was acceptable to funders as we included relevant outcomes such as youth’s
likelihood of substance use and youth’s reports of key family‐level outcomes (e.g.,
family emotional closeness). Finally, in both trials, we have used multilevel statistical
models to empirically test efficacy outcomes as this rigorous statistical approach has
multiple benefits that can accommodate for the challenges commonly experienced in
community‐based trials (Keiley, Martin, Liu, & Dolbin‐MacNab, 2015), which
include wide variation of measurement time points and nesting of the data.
Furthermore, research designs embedded within CBPR initiatives must thoroughly
address issues of internal and external validity, as well as reliability, when referring to
the quantitative components of studies. With regard to qualitative components, it is
essential to thoroughly describe the methodological steps that were taken to address
trustworthiness of the data. Addressing these issues in detail is beyond the scope of
this chapter, and we refer the reader to an excellent source that addresses in detail
these methodological considerations (see Miller & Johnson, 2014). We have also
reported in our original research reports details associated with key quantitative and
qualitative methodological issues associated with our program of research (see Parra‐
Cardona et al., 2012, 2016, 2017, Parra‐Cardona, Leijten et al., 2018).
Long‐term sustainability
As illustrated in the proposed model, an essential methodological component of
CBPR approaches refers to identifying long‐term sustainability strategies (Robinson
et al., 2014).
However, the feasibility of achieving this goal is highly dependent on contextual
realities.
Specifically, although we have met the original objective established by our funders,
which referred to training community‐based leaders and mental health professionals in
an evidence‐based parenting intervention, we serve a population that faces extraordi-
nary challenges. For example, the health rate coverage of parents in the families we serve
continues to be seriously limited. Similarly, the percentage of parents with the capacity
to cost‐share services and even with sliding‐scale formats remains minimal. Most
recently, revised federal immigration policies have resulted in increased prosecutorial
activities leading to deportations of immigrants who are faced with the dilemma of leav-
ing behind their US citizen children or taking them to their countries and communities
of origin to face uncertain futures. This reality has resulted in a permanent state of fear
across low‐income immigrant communities (Cardoso et al., 2018). Overall, achieving
long‐term sustainability in our program of research has been an extremely challenging
goal to accomplish as we are embedded in a national political climate that identifies
low‐income immigrants as a burden to society, rather than pillars of the US economy.
Implications for the Field
The proposed model constitutes a general guide for implementing applied programs
of research deeply rooted in CBPR principles. Thus, the model should only be used
as a general guide with implementation details to be fully defined by the leaders of
each initiative. In closing, we offer general implications to assist family therapy

researchers in the implementation of the proposed framework.
Always draw parallels between the therapeutic process and CBPR

By its very nature, CBPR approaches strongly parallel the nature of the therapeutic
relationship. Specifically, a continuous dialogue among all agents of change is essential
with the understanding that challenges in the collaborative relationship will constantly
need to be addressed, just as in any therapeutic relationship.
In fact, the goal of the first author to describe in detail several examples of mistakes
and growth experiences is to highlight that the essence of CBPR does not consist of
implementing flawless processes of collaboration. Instead, the main characteristic of
CBPR is to perfect flawed designs, which can only be improved once they are tested
in real practice and in the midst of the realities of the families we serve. Thus, when
faced with challenges of accommodation inherent to every CBPR initiative, the use of
our therapeutic skills as relationship experts is critical to ensure the formation of
authentic and collaborative relationships.
Redefining our approach to service delivery

As described in the case example, our success with the implementation of CBPR
approaches in our program of research refers to our commitment to consistently inte-
grate science, culture, context, and advocacy. This is a challenging goal to accomplish
in prevention and clinical practice as current therapeutic models in the family therapy
field do not fully integrate these dimensions.
This issue requires us to consider “out‐of‐the‐box” initiatives. For example, we could
not have implemented our program of research by expecting families to come to our uni-
versity‐based clinic due to historical mistrust toward Euro‐American‐dominated institu-
tions. In addition, we did not have the option of financing these programs according to
sliding‐scale approaches commonly used in family therapy clinics based in university set-
tings. As CBPR scholars have expressed (Robinson et al., 2014), offering mental health
services in underserved communities should carefully consider the economic burden to
families. With regard to low‐income immigrant communities, offering services according
to sliding‐scale approaches is not feasible as these populations experience intense poverty
and extreme contextual adversity. Thus, it cannot be expected that a proportion of families
will offset the costs of families who cannot offer any payment for services. Furthermore,
because the majority of families we serve have mixed‐immigration status, parents are often
uninsured and do not have access to federally sponsored programs such as Medicaid.
Assuming therapy as a political act

Family therapy leaders have assumed strong political stances throughout the history
of our field. However, although the political battles in the past referred to challenging
oppressive mental health paradigms, the need to embrace a new wave of political
advocacy is more urgent than ever. Specifically, we are living times in the United
States characterized by policies that target and damage underserved and diverse popu-
lations in profound ways. For example, Cardoso and colleagues (2018) have e xtensively
documented the challenges experienced by Latino/a immigrant families at risk of
deportation, as well as the ways in which mental health services for this population
should be informed according to the realities of such permanent threat.
In the international context, widespread efforts are being implemented to address
the gap of limited availability of mental health services in low‐ and middle‐income
countries. We have recently published a report detailing multinational research col-
laborations aimed at disseminating low‐cost and efficacious preventive parenting
interventions in various regions of the world (i.e., México, Central America, South
and sub‐Saharan Africa, and Asia). Each case study included in this report illustrates
the multiple challenges associated with addressing extensive mental health needs in
low‐resource contexts, including the need to engage in political advocacy at multiple
levels and with various constituents (Parra‐Cardona, López‐Zerón et al., 2018).
We consider that many of the current challenges experienced by families extend beyond
relational issues. In our view, family therapists in this generation are presented with a wide
variety of challenges that demand creativity and application of systemic thinking beyond
the therapy room. Ideally, even for family therapists not directly involved in research,
CBPR and social justice principles should be at the core of prevention and clinical practice.
In fact, a silver lining in the midst of the current human rights crisis that we are experienc-
ing as a country refers to the fact that we may be at the dawn of a new generation of family
therapists—a generation characterized by active political advocacy in family therapy prac-
tice and research, aimed at overtly embracing the fight against the oppression that contin-
ues to impact in profound ways the most vulnerable members of our society.
Acknowledgment
The first author would like to express his deep gratitude to all the community collabo-
rators, co‐investigators, project managers, and research staff. We express special grati-
tude to Marion Forgatch, ISII Executive Director, and Laura Rains, ISII Director of
Implementation and Training, for their extraordinary and continuous support as we
have disseminated GenerationPMTO with low‐income Latino/a populations. We are
also deeply grateful to Drs. Karen and Richard S. Wampler who always inspired us as
role models for social justice. The studies were supported by funds from the National
Institute of Mental Health (R34MH087678) and the National Institute on Drug
Abuse (K01DA036747), as well as complementary funds from the HDFS Department
at Michigan State University. The content is solely the responsibility of the authors
and does not necessarily represent the official views of the National Institute of Mental
Health, the National Institute on Drug Abuse, or the National Institutes of Health.
Note
1 The confidentiality of the participants was protected by disguising all potential family iden-
tifiers (including demographic details of the individual participants), limiting descriptions
of the presenting problem, and adding extraneous material to reduce risk of identification.
The participants were informed of these revisions and were supportive of the final descrip-
tion of the vignette.
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2158244016679211
22
Implementing Research into
Everyday Systemic Family
Therapy Practice
Mathew C. Withers and James Michael Duncan
Evidence‐based treatments (EBTs) have impacted the mental health field and sys-
temic family therapy (SFT). However, despite this momentum, EBTs have made little
effect on the everyday practice of SFT clinicians (Dattilio, Piercy, & Davis, 2014).
This research–practice divide is a result of many systemic factors, including researchers
not seeking input from clinicians, clinicians not viewing EBTs as applicable to their
practice, and a lack of effective communication channels between these groups
(Dattilio et al., 2014; Sprenkle, 2003). There has been a considerable debate in the
mental health field regarding the usefulness of clinical research on everyday practice
(e.g., Gambrill, 2006; Gurman, 2011; Hunsley, 2007). As policy makers, third‐party
payers, and regulators explicitly encourage the use of EBTs, others have argued that
requiring the use of EBTs is likely to result in unsustainable implementation and poor
fidelity to the EBT (Raghavan, Bright, & Shadoin, 2008). Clinicians have expressed
that research does not translate to everyday clinical practice due to the unrealistic
nature and unfeasibility of manualized treatment (Dattilio et al., 2014; Gambrill,
2006). In addition, most public mental health agencies in the community, especially
those that focus on underserved populations, do not have access to funding to cover
the cost of training or access to the training needed for cultural adaptation of EBTs
(Parra‐Cardona, Parra, Wieling, Rodriquez, & Fitzgerald, 2014). As a result of this
divide, the water tends to never reach the end of the row, or if it does, the research
takes a significant amount of time to impact everyday practice (Green, Ottoson,
Garcia, & Hiatt, 2009), resulting in an overall failure of EBTs to reach clinicians and
health‐promotion programs (Spoth et al., 2013).
Dissemination and implementation (D&I) research is an important opportunity for
clinical research and EBTs to reach the everyday practice of mental health practition-
ers. The primary goal of D&I research is bridging the divide between researchers and
clinicians by making the clinical knowledge generated by researchers available, acces-
sible, and helpful to practitioners (Baumbusch et al., 2008; Glasgow et al., 2012;
Powell et al., 2013; Spoth et al., 2013; Withers, Reynolds, Reed, & Holtrop, 2017).
D&I research is the process of distributing and integrating research findings into
514 Mathew C. Withers and James Michael Duncan
e veryday clinical practice (National Institutes of Health [NIH], 2017). This research
emphasizes that researchers and practitioners should work collaboratively in a way
that promotes sharing knowledge in a reciprocal manner and holds each other
accountable (e.g., Baumbusch et al., 2008). An important part of this collaborative
and reciprocal relationship includes adapting EBTs to different cultures (Parra‐
Cardona, Whitehead, et al. 2014), which has begun to take place in the field of SFT
in recent years (Parra‐Cardona, Beverly, & Lopez‐Zeron, 2020, vol. 1; Parra‐Cardona,
Parra et al., 2014). In addition, D&I research promotes cost‐effective interventions
due to its emphasis on impacting public mental and physical health (Glasgow et al.,
2012; Spoth et al., 2013). Finally, because D&I research focuses on systems thinking
(Wandersman et al., 2008), D&I research strongly encourages public policy at differ-
ent levels, including provider organizations, governmental regulatory agencies, and
the societal and political culture (Raghavan et al., 2008).
The purpose of this chapter is to discuss the importance of D&I research within the
SFT field, introduce theories that can be utilized in SFT implementation research, and
describe methods and strategies that could prove useful for researchers and clinicians
interested in engaging in implementation research. Reviewing all of the D&I litera-
ture within the field of SFT is beyond the scope of this chapter. However, when
appropriate, SFT research examples will be discussed throughout the chapter as
examples.
Defining dissemination and implementation research

D&I research investigates the types of strategies for sharing information about an
EBT that lead to faster uptake or better integration of an EBT within a clinical context
(Landsverk et al., 2012). Implementation research’s main objective is bridging the
gap between research and everyday clinical practice through building a knowledge
base about how interventions, guidelines, and policies are transmitted for the use in
public health‐care services (NIH, 2017).
Within the literature, there remains a large variation between the use of the terms
dissemination and implementation. Therefore, it is important to clarify each defini-
tion for the use of SFTs and how it will be used in this chapter. For the purposes of
SFT clinicians and researchers, the working definition of dissemination is “the inten-
tional, targeted distribution of empirical knowledge regarding couple and family
relationships, and systemic interventions to [systemic] clinicians and social service
agencies” (Withers et al., 2017, p. 186). Therefore, dissemination focuses on distrib-
uting knowledge from clinical research to SFT clinicians.
For SFT researchers, dissemination should include intentional effort to spread
knowledge to SFT clinicians whom are meant to receive and use it. These types of
efforts would begin in master’s degree training programs in order to train clinicians in
using EBTs and how to culturally adapt EBTs for marginalized populations (Karam &
Sprenkle, 2010; Parra‐Cardona, Whitehead et al., 2014; Seedall, Holtrop, & Parra‐
Cardona, 2014; Withers et al., 2017). In addition, dissemination efforts should be
systematic efforts that would include, but are not limited to, publishing research in
systemic and non‐systemic journals, presenting research at national and local confer-
ences where clinicians have the opportunity to receive knowledge, advocating to local
and national representatives, writing for magazines frequently read by clinicians, such
Implementing Research into Everyday Systemic Family Therapy Practice 515
as the Family Therapy Magazine and The Therapist, and interacting with clinicians and
the general public in less formal platforms such as through blogs or social media
(Withers et al., 2017).
In comparison, the working definition for implementation for SFT clinicians and
researchers is “the process of integrating evidence‐based couple and family treatments
into [systemic] agencies, clinics, and organizations by systematically incorporating a
unique set of strategies or activities” (Withers et al., 2017, p. 190). Implementation
research encompasses methodical and purposeful strategies where the main purpose is
the improvement of uptake and sustainability of specific treatment interventions
(Proctor et al., 2009). In essence, implementation research is focused on the actual
use of EBTs in everyday clinical practice. This includes identifying specific strategies
that increase or decrease the likelihood of clinicians, organizations, agencies, etc.
adopting an EBT in the short and long term.
Due to the purpose of this chapter being the implementation of research into eve-
ryday practice, we will focus the remainder of this chapter on implementation research.
It should be noted that as part of a larger D&I study, there can be a lot of overlap
between these terms and approaches. Researchers may need to start with disseminat-
ing their research in order to draw participants into training and thus an implementa-
tion study. We will discuss these examples as needed, but the majority of this discussion
will be on how SFT researchers and clinicians can work together to implement EBTs
into everyday practice.
Significance of implementation research for SFTs

SFTs are uniquely equipped to conduct and benefit from implementation research
(Withers et al., 2017). First, implementation is systemic and interactional. Specifically,
implementation science moves across and within multilevel systems, and only when
these systems work together will the result be successful implementation (Landsverk
et al., 2012). Implementation researchers emphasize the use of systems thinking due
to the complexity of implementation processes that are not well addressed using linear
causality traditionally found in research (Holmes, Finegood, Riley, & Best, 2012).
This systemic approach is potentially an essential component to bridging the gap
between research and practice.
Another important reason SFT researchers should be conducting implementation
research is the access to funding streams. As funding becomes more difficult to obtain,
there is an increased interest in funding for implementation research. One of the goals
in the US Department of Health and Human Services strategic plan includes efforts
to implement EBTs into community service systems in an effort to solve specific pub-
lic health problems (Glasgow et al., 2012). This is particularly promising because SFT
research has a long history of EBT conducting community‐based research (Wittenborn,
Blow, Holtrop, & Parra‐Cardona, 2018). The NIH continues to renew its funding
opportunities for implementation studies (see NIH, 2017) in addition to the NIH
annual conference on implementation science.
How can SFT clinicians benefit from implementation research? First, implemen-
tation research promotes clinician‐to‐researcher feedback loops, which allow
clinicians to provide feedback to researchers that will improve EBTs (Baumbusch
et al., 2008; Spoth et al., 2013; Withers et al., 2017). While this is a benefit for
researchers, going through the process of feedback also supports better clinical prac-
tice as clinicians often times must adapt to multiple problems. Problems can be both
planned (such as knowing that there is a strong likelihood of identifying multiple
family problems beyond the specific problem a funding agency is looking to solve)
and unforeseen (such as family members attending interventions sporadically; e.g.,
Eubanks‐Carter, Burkell, & Goldfried, 2010). These problems are ones that are not
necessarily dealt with in research due to the sometimes narrow focus of implementa-
tion research. Next, clinicians that tend to be resistant to the use of EBTs because
they perceive that the research does not translate to everyday practice (Dattilio
et al., 2014; Gambrill, 2006) can gain practical strategies for implementing research
findings into everyday clinical practice (Holmes et al., 2012; NIH, 2017). An
important aspect of implementation research is adaptability of the treatment to fit
the culture and practice (Parra‐Cardona, Whitehead et al., 2014). Therefore, the
results of this type of research can be easily translated to everyday practice. Lastly,
being a consumer and user of implementation research allows SFT clinicians to be
research‐informed clinicians who understand, analyze, and integrate existing
research into their clinical practice, which will further close the research–practice
divide (Karam & Sprenkle, 2010).
Finally, SFT training programs can benefit from implementation research by train-
ing students to value and utilize research (Dattilio et al., 2014; Withers et al., 2017),
similar to being a research‐informed clinician (Karam & Sprenkle, 2010). Becoming
a research‐informed clinician begins in graduate training programs, and family ther-
apy faculty can facilitate this through demonstrating the importance of research and
requiring students to utilize research (Dattilio et al., 2014; Karam & Sprenkle, 2010).
Finally, training programs show students how to research their own practice and use
their own practice‐based evidence to improve their client’s outcomes (Duncan &
Miller, 2000; Withers & Nelson, 2015).
Implementation Research Designs
Implementation research designs are quite distinct from efficacy and effectiveness
research. Efficacy research focuses on the overall impact of an intervention on a tightly
controlled, homogeneous sample. Effectiveness research is conducted in more realis-
tic settings that focuses on which types of clients benefit from the intervention and for
how long (Glasgow et al., 2012; Landsverk et al., 2012). Comparatively, implementa-
tion research is primarily focused on the specific strategies used during the implemen-
tation process that increases the speed of implementation, the quality of the
intervention once adopted, and the quantity of clinicians adopting the intervention
(Landsverk et al., 2012). Essentially, efficacy and effectiveness research identify a
potential treatment that can improve a specific public mental health concern.
Implementation research is interested in how the intervention is transferred from
researchers to practitioners, with the end goal of improving public mental health. The
desired outcomes of implementation research can be considered a mediation, or
mechanism, through which more distal outcomes are the overall focus, such as
improvement of public mental health (Proctor & Brownson, 2012). Therefore,
implementation research is considered the final stage of research that bridges the gap
between science and practice (Landsverk et al., 2012; NIH, 2017). Some studies use
a combination of designs within one overall study so that implementation research
and effectiveness research can be evaluated simultaneously (e.g., Brown et al., 2009;
Glisson et al., 2010). However, the purpose of this chapter will primarily be on the
implementation aspect of research.
Although this discussion is in terms of phases, the methods and evaluation of imple-
mentation research are an ongoing process (Gaglio & Glasgow, 2012). Utilizing a
specific theory, such as the theory described later in this chapter, in combination with
the four phases of implementation research, will generate testable hypotheses regarding
the speed, quality, or quantity of implementation (Grol, Bosch, Hulscher, Eccles, &
Wensing, 2007). Implementation research designs combine a specific theory or model
with the phase of implementation needed for the researcher’s identified purpose.
Typically, a large implementation study will begin in the first phase and include all
subsequent phases as a continuous process. However, for smaller implementation
studies, the need of each individual, organization, or policy can dictate which phase a
researcher should begin with, and the theory will help identify the research questions
and design of the study. The following discussion will utilize aspects of the descrip-
tions of specific implementation theories, similar to the theory discussed later in the
chapter, to identify research questions and designs that SFTs can use when conduct-
ing implementation research.
Phases of implementation research

Implementation research consists of four interrelated phases: exploration, adoption/
preparation, active implementation, and sustainability (see Figure 22.1; Aarons,
Hurlburt, & Horwitz, 2011; Landsverk et al., 2012). Within each of these phases, a
researcher, stakeholder, and/or clinician interested in conducting implementation
research can examine aspects of external systems (e.g., public policy, legislators, fund-
ing sources, national and local organizations, etc.) and internal systems (e.g., the
agency, organizations, individuals, etc.) that would be implementing the EBT (Aarons
et al., 2011). These ideas are similar to those used in the Taxonomy of Implementation
Outcomes (TIO) framework (Proctor et al., 2011) described later.
Exploration or pre‐adoption phase The first phase of implementing an EBT into

practice is the exploration or pre‐adoption phase, which focuses on the awareness of
either an issue that needs attention or improving the current approach to an organiza-
tion challenge (Aarons et al., 2011; Grol et al., 2007). From the standpoint of an
implementation researcher, this phase may focus on identifying organizations or
communities that express interest in using or making available a particular EBT
(Landsverk et al., 2012). From the clinician side, this phase would consist of identify-
ing a need for the practice, clientele, or presenting problem that would be of interest
in using or making available a specific EBT to other stakeholders.
An example research question focused on exploration would be: Are there organiza-
tions or agencies that would be interested in implementing a specific EBT? This can be
the beginning part of a larger study focused on implementing an EBT. For example,
Wang, Saldana, Brown, and Chamberlain (2010) sent invitation letters to directors of
child welfare, mental health, and juvenile justice systems in 40 counties in California
Exploration or pre-adoption phase

Researchers: identify communities interested in EBT
Clinicians: identify need for clients or practice
Adoption/preparation phase
Researchers: what factors influence the formal adoption of EBT?
Clinicians: what is the utility of EBT on clientele?
Active implementation phase

Researchers: identify how to increase EBT fidelity in the
community
Clinicians: does the EBT fit practice and clientele?
Sustainment phase
Researchers: what factors lead to extended use of EBT?
Clinicians: is the EBT worth maintaining fidelity, stop using, or

integrate with other approaches?
Figure 22.1 Phases of implementation research.
to participate in a large implementation study of Multidimensional Treatment Foster

Care (MTFC). The invitations explained the study protocol in addition to the evi-
dence base of MTFC. The primary outcomes of this study were to identify consent to
participate and characteristics of the county organizations that were associated with
consent to participate (Wang et al., 2010).
Using the Consolidated Framework for Implementation Research (CFIR) model
(Damschroder et al., 2009), a researcher or clinician could examine the individual,
agency, or community characteristics that would influence implementation of an EBT.
Important areas to consider that will influence implementation are the culture and
climate of the community and agency, readiness for change, preexisting knowledge/
skills, support, values and goals, and the perceived need for change (Aarons et al.,
2011). For example, Glisson and Schoenwald (2005) have used aspects of the CFIR
to create a community intervention model, entitled Availability, Responsiveness, and
Continuity (ARC), that aimed to improve implementation of multisystemic therapy
(MST) for rural Appalachian Mountain communities.
Adoption/preparation phase The second phase of implementation research is the

adoption/preparation phase, which is the beginning process of trying out an EBT on
a smaller scale before deciding on implementation in the larger system (Aarons et al.,
2011). Researchers in this phase would be interested in factors related to the formal
decision to implement in a larger scale or strategies to increase the adoption of the
intervention (Landsverk et al., 2012). For SFT clinicians in this phase, the focus
would be on the overall utility of the EBT to individual clinicians, to the agency or
organization, and to clients.
An important factor in the adoption decision is the quality of collaborative relation-
ship between researchers and clinician (Baumbusch et al., 2008). This relationship
should include characteristics of reciprocity, accountability, and respect for each other
(Baumbusch et al., 2008). Thus, researchers should continuously receive and imple-
ment feedback from clinicians into the research design (Holmes et al., 2012; Withers
et al., 2017). Qualitative research and mixed methods research designs are an impor-
tant aspect of using feedback within implementation research. Qualitative methods
add an examination of context, which is important within implementation research
because, unlike efficacy studies, context cannot be controlled (Landsverk et al., 2012).
In implementation research, mixed methods designs can be used either simultane-
ously or sequentially. When using a sequential design, qualitative interviews can be
used to answer questions that arise from quantitative measures (Landsverk et al.,
2012). Within mixed methods implementation research, one method tends to be the
primary (usually quantitative; Palinkas et al., 2011) and the other is secondary.
Qualitative methods can be used to answer specific research questions, such as
What factors increase the probability of adoption of the EBT? For example, Palinkas et al.
(2008) used qualitative methods to develop a heuristic framework in order to under-
stand the factors that contribute to a clinician’s initial use of EBT and long‐term
intent of adoption of said EBT. The methods used were observation of clinicians,
semi‐structured interviews of supervisors and clinicians, and reviewing meeting’s min-
utes between supervisors, trainers, and researchers (Palinkas et al., 2008). The rela-
tionship between clinicians and researchers during the project was a common factor
associated with initial use of the EBT. Conversely, reports of extended gaps in time
between the acquirement of cases and when training occurred were a common nega-
tive theme that emerged (Palinkas et al., 2008).
Active implementation phase The active implementation phase includes the imple-
mentation efforts for long‐term efforts and sustained use of an EBT (Aarons et al.,
2011). For researchers, this phase involves strategies for improving program fidelity
in the field (Landsverk et al., 2012). For clinicians, this phase includes fit with the
EBT, additional work demands, and client outcomes using EBT (Aarons et al., 2011).
Because this phase involves the majority of implementation efforts, much more
research is found during this phase, as compared with the other three phases (e.g.,
Palinkas et al., 2008).
This phase can also be termed “implementation fidelity” because a large focus of
this phase is the effective implementation of the core elements of the EBT (Allen,
Linnan, & Emmons, 2012). Implementation fidelity is defined as “the degree to
which an intervention is delivered as intended and is critical to successful translation
of EBT into practice” (Breitenstein et al., 2010, p. 164). An important distinction in
the use of fidelity between implementation research and efficacy research is the ability
for aspects of the EBT to be adaptive to the cultural context and within SFT practice.
Cultural adaptation of EBTs is greatly needed in the SFT field, and implementation
research provides an opportunity for such work to be completed (see Parra‐Cardona
et al., 2020, vol. 1; Parra‐Cardona, Whitehead et al., 2014; Seedall et al., 2014;
Withers et al., 2017).
An example research question that could be used to examine implementation
fidelity in this phase is: Is an intervention being implemented in the way it was intended?
An SFT researcher could use the taxonomy of implementation outcomes as the model
in this design and focus on the sixth outcome of fidelity (Proctor et al., 2011). The
most accurate ways that researchers could examine fidelity is by creating a fidelity
checklist and reviewing audio or videotapes or hiring independent raters (Allen et al.,
2012; Breitenstein et al., 2010). In addition, researchers could ask clinicians to keep
intervention logs, diaries, self‐report checklists, or self‐report from clients through
exit interviews or surveys (Allen et al., 2012; Breitenstein et al., 2010). For example,
in a study examining multidimensional family therapy (MDFT) fidelity and client
outcomes, therapist adherence to MDFT predicted a decrease in externalizing behav-
iors in a sample of urban adolescents in substance abuse treatment (Hogue et al.,
2008). Additionally, intermediate levels of adherence predicted the largest decline of
internalizing behavior (Hogue et al., 2008). Therefore, it appears that allowing clini-
cians to adapt while also maintaining fidelity to the core elements of MDFT resulted
in greater outcomes to clients.
Another example research question within this phase is: What factors influence
implementation fidelity? For example, Glisson et al. (2010) compared therapists from
counties that received the ARC intervention and therapists from counties that did not
receive the intervention. The ARC organizational intervention is designed to increase
the implementation of an EBT through the development of community and organi-
zational support systems for clinicians and clients (Glisson et al., 2010). All clinicians
were trained in MST. Two different forms of measurement of implementation fidelity
were used. First, independent raters coded randomly selected sessions; second, clients
reported on a measure regarding the previous week’s session (Glisson et al., 2010).
Results indicated that there was no difference in terms of fidelity between groups;
however, ARC therapists used knowledge gained in the training to focus less time on
specific subsystems, resulting in a significant difference in problem behaviors (Glisson
et al., 2010). Importantly, in both studies reviewed in this section, fidelity to the EBT
was met, but clients improved the most when therapists adapted the treatment.
Sustainment phase The sustainment phase is focused on the continued use of an

EBT in clinical practice (Aarons et al., 2011). Researchers in this phase are interested
in strategies to maintain delivery of the intervention or extend its use in communities
or organizations (Landsverk et al., 2012). Clinicians in this phase are interested in
decisions regarding maintaining fidelity of the EBT. Implementation theorists and
researchers agree that sustainment is the desired outcome (Damschroder et al., 2009).
Unfortunately, much less research has focused on this area of implementation (Aarons
et al., 2011; Lewis et al., 2015). Therefore, there is limited knowledge of factors that
increase or decrease sustainment of an EBT in a clinical practice (Aarons et al., 2011).
Once the sustainment phase has been reached, feedback of the lessons learned can be
used in other phases and impact future research (Aarons et al., 2011).
An example research question in this phase could ask: What factors influence SFT
clinicians to continue to use an EBT following implementation? A mixed methods study
would be appropriate for this research question that could include interviews with
clinicians or surveys at varying time points following active implementation. Some
research in the implementation literature suggests that culture and climate of the
organization/agency surrounding the individual clinician during this phase is a strong
predictor for sustainment (Glisson et al., 2008). In addition, continued monitoring of
EBT fidelity and supervision support may be critical for continued EBT effectiveness
(Schoenwald et al., 2011).
In the SFT literature, Zazzali et al. (2008) interviewed organizations that decided
to adopt functional family therapy (FFT) following two years of training in order to
understand the drivers for adoption and barriers and facilitators to implementation.
The results indicated that organization culture was an important factor in the decision
to adopt FFT and for sustained implementation (Zazzali et al., 2008). More specifi-
cally, it was important that FFT fit with the organization mission, interest in EBTs,
fostered innovation, organizational resources fit the need, characteristics of FFT, and
the cost‐effectiveness of FFT treatment (Zazzali et al., 2008). The authors noted that
this information would be important for the development of future FFT implementa-
tion practices and research (Zazzali et al., 2008).
Use of Theory in Implementation Research
The use of theory, or combination of theories, within the field of implementation

science is an important tool that can provide a foundation to guide the design of
future SFT implementation research (Tabak, Khoong, Chambers, & Brownson,
2012). A large number of theories have been created for the use of implementation
research (see Tabak et al. (2012) for a more thorough review of the multitude of
theories). When considering what theories/frameworks are attempting to achieve a
common purpose of simplifying and facilitating consistent SFT definitions and con-
structs in implementation research, the most prevalent frameworks include the CFIR
(Damschroder et al., 2009), the Theoretical Domains Framework (TDF) (Michie
et al., 2005), and the TIO (Proctor et al., 2011). The CFIR and TDF use in SFT
research has previously been described in detail elsewhere (see Withers et al., 2017),
and both the CFIR and TDF have had in‐depth reviews of their tenets and their use
within the field of SFT (see Birken et al., 2017). For the purposes of this chapter, the
TIO framework will be reviewed because of its ease of use in SFT research and it was
created in order to encourage implementation researchers to develop and strengthen
the implementation process (Proctor et al., 2011).
Taxonomy of implementation outcomes

The TIO focuses on several domains associated with implementation outcomes:
individual client, the service provider, the organization as a whole, and the
environment in which they are all nested in (Proctor et al., 2009; Proctor et al., 2011).
All domains of the TIO are considered to be interrelated playing an important role
in the implementation process, carrying with them the following assumptions

(Proctor et al., 2009; Shortell, 2004). First, it is critical to recognize that the indi-
vidual client is the couple or family receiving the intervention and thus building their
knowledge, skills, and expertise is central to intervention upkeep. Next, understand-
ing that the service provider consists of multiple practitioners who are not always from
the same field or background is important to promoting teamwork that can improve
interdisciplinary knowledge and improve intervention processes. Furthermore, keep-
ing in mind that the organization can provide feedback can help with successful
implementation through the utilization of preexisting strategies in conjunction with
new strategies being implemented. Finally, it is important to note that the environ-
ment is considered a setting in which political forces, economic conditions, and gov-
ernment regulations can impact interventions for the organization, the practitioners,
and the family client (Proctor et al., 2009; Shortell, 2004).
Implementation outcomes Each domain within the TIO is important, but it is equally
important to acknowledge that these domains are interrelated, meaning that each is
connected in such a way that implementation outcomes cannot be successful without
considering how all domains influence the implementation process. Subsequently, the
TIO highlights this interrelatedness through the identification of eight key compo-
nents within the implementation process that are considered necessary for creating
successful implementation outcomes (Proctor et al., 2011). The first component
includes acceptability in the individual client domain. Whether or not the practitioner
is satisfied with the implementation process is just one consideration. The other
consideration is whether the clients perceive the implementation process to be an
acceptable method of treatment and they are also satisfied with the process. The sec-
ond component to consider is adoption within the service provider’s domain, organi-
zation domain, and even the broader environmental domain. Specifically, do the
practitioners, organizations, and surrounding environments have an initial intention
to try (or adopt) the intervention? For example, an organization may have an initial
intention to try an intervention based on community demand. Additionally, do the
stakeholders within all domains perceive the intervention process to be appropriate?
In this third component, the clients, the practitioners, the organizations, and the
environments have a general view about a proposed intervention, and the question
here entails whether or not there is perception of appropriateness of the intervention
and whether or not it will be useful.
The next three components to consider in the implementation processes include
costs, feasibility, and fidelity (Proctor et al., 2011). The fourth component is embedded
within the service provider domain and involves a thorough breakdown of the costs of
intervention to ensure that practitioners understand the costs versus the p erceived
benefit in terms of economic resources. Subsequently, after costs have been factored,
multiple domains must come together and determine feasibility of implementation of
an intervention. In this fifth component, the practitioners, the organizations, and the
environments come to a conclusion of intervention fit after trialability to determine if
the intervention will be feasible for long‐term use. Additionally, when considering
long‐term effectiveness of an intervention, it is also important to consider fidelity.
In general, the sixth component again is set within the service provider domain and
concerns several aspects of the implementation processes, namely, evaluating fidelity in
terms of quality, adherence, and integrity of the EBT being implemented.
The final two components of implementation outcomes are penetration and sus-
tainability. These two components are concerned with dissemination and long‐term
use of an intervention within the general public and are usually handled within the
two larger domains of the TIO framework (the organization and the environment;
Proctor et al., 2011). Specifically, penetration focuses on dissemination of the
intervention; in other words, this seventh component works to get the intervention
“out in the wild” to reach (or penetrate) as many communities as possible. After the
intervention has been successfully disseminated, efforts then shift to sustainability of
the intervention. Within this eighth component, multiple organizations and environ-
ments must make an effort to sustain continued use of an intervention. Examples of
efforts include advocating for continued policy updates or requesting funding for
continued research efforts.
Examining the use of the taxonomy of implementation outcomes (TIO)

in the field
The overarching goal of the TIO is to encourage implementation researchers to
strengthen the implementation process through the use of key variables important
to the field of SFT that can be organized in a taxonomy that researchers can use to
further implementation science and improve evidence‐based interventions (Proctor
et al., 2011). With this goal in mind, it is useful to examine the TIO in the context of
a real‐world setting to investigate whether the TIO is meeting the goal it set out to
achieve.
MacPherson, Leffler, and Fristad (2014) designed a study to investigate the imple-
mentation of Multi‐Family Psychoeducational Psychotherapy in two outpatient clin-
ics. This particular psychotherapy is an 8‐session EBT focused on children with
depression and bipolar disorder that takes place in a group‐based setting (Fristad,
Arnold, and Leffler (2011) as cited in MacPherson et al. (2014)). The authors used
the TIO framework to determine if community‐based therapists were successfully
implementing this intervention according to six components of the TIO (adoption,
appropriateness, feasibility, cost, penetration, and sustainability). In an effort to study
the effectiveness of this intervention, a mixed methods approach was utilized involv-
ing the use of quantitative multiple‐choice questions, qualitative open‐ended ques-
tionnaires, and review of agency‐level observations. Specifically, clinician self‐report
instruments (e.g., clinician–parent improvement reports), client self‐report measures
(e.g., parent group evaluation forms), and agency‐level observations (e.g., recruit-
ment/completion rate reports) were analyzed.
From these three methods of data collection, several insights regarding implemen-
tation outcomes according to TIO were discovered (MacPherson et al., 2014). Clinics
identified interest in intervention adoption and began work on program uptake.
Multiple clinicians agreed with the intervention goals and endorsed it as an appropri-
ate intervention to implement in their communities. Intervention instructions were
endorsed as easy to understand and clearly outlined, making the intervention feasible
to implement. Clinics perceived the intervention to be cost‐effective dependent on the
therapist to family group ratio (approximately three therapists and seven families per
group). Penetration was deemed successful, such that all clinicians trained in the
intervention procedures reported administering the intervention at least one time.
Furthermore, future sustainability was highlighted through reports of clinicians

claiming interest in continued facilitation of the intervention and reportedly provid-
ing family referrals.
It should be noted that MacPherson et al. (2014) also identified some barriers to
the implementation of the intervention. For example, feasibility issues were identified
by clinicians with some of the physical activities outlined for use with the children
within the intervention. Additionally, cost issues were identified, such as high initial
training costs and material costs. Ultimately, the TIO framework and findings identi-
fied by MacPherson et al. (2014) provided information on what elements of the
intervention were successful as well as allowed the authors to make recommendations
for possible improvements to promote sustained uptake of the intervention. From
this example, it is clear to see that the TIO framework can provide an organized
classification of information relevant to SFT implementation research and aid in
improving evidence‐based interventions for use in the general public.
Final thoughts on theory use in implementation research

There are several theories associated with implementation research and the most prev-
alent frameworks include CFIR, TDF, and TIO. While only the TIO was described in
detail here, it should be reiterated that all three of these frameworks were created in
order to encourage implementation researchers to develop and strengthen the imple-
mentation process in order to improve uptake in EBTs. There is overlap between
frameworks (Birken et al., 2017), for example, both the CFIR and the TDF include a
large discussion on the construct of self‐efficacy. Additionally, the CFIR, TDF, and
TIO all include discussions of trialability of an intervention. However, research indi-
cates that there are also notable differences between these frameworks (Birken et al.,
2017). First, the CFIR provides a larger emphasis on the organization domain.
Subsequently, the TDF provides a larger emphasis on the individual client domain.
And still the TIO provides greater emphasis on multiple domains (individual client,
service provider, organization, and environment).
Although it has been noted that using multiple theories/frameworks concurrently
may create added complexity to studies (Birken et al., 2017), using an integration of
these theories may prove beneficial by providing an in‐depth overview of multiple
domains important to implementation research. Ultimately, due to the potential for
unnecessary overlap, it is recommended that researchers clearly articulate how each
framework contributes to their study to ensure that the theories are being used to
meaningfully aid in continued theory development and the theories are being used
to better clarify what constructs are/are not facilitating successful implementation of
interventions (Birken et al., 2017; Tabak et al., 2012).
Conclusion and Future Directions
There remains a divide between SFT research and practice. Implementation research
has the potential to be the final step toward closing the divide. Implementation
research is a process of integrating research findings into everyday practice and
involves specific strategies focused on increasing speed, quality, and quantity of
clinicians implementing EBTs (Landsverk et al., 2012; NIH, 2017). SFT researchers
and clinicians are uniquely equipped to use implementation research because of the
reciprocal relationship focus and systems thinking inherent in implementation research
(Baumbusch et al., 2008; Wandersman et al., 2008). Implementation research has the
capacity to tackle the debate regarding the usefulness of research on everyday practice
because the implementation research is conducted in everyday practice.
In order for implementation research to have this level of impact in the SFT field, a
number of issues must be addressed. First, researchers need to commit to developing
systemic‐based EBTs and be willing to go through the process of efficacy, effective-
ness, and D&I research. This is especially important because recent scholars have
indicated that current SFT researchers may focus less on advancing EBTs through
implementation as compared to in the past (Wittenborn et al., 2018). As this may be
due to the lack of knowledge and training regarding implementation research, this
chapter hopes to facilitate further discussion for the need of implementation research
and promote its use in the SFT field.
Additionally, SFT researchers need to be an active participant in the cultural adapta-
tion of their EBT to fit the culture and context of the agency, therapists, and clients
(Parra‐Cardona, Whitehead et al., 2014). Collaboration between researchers and cli-
nicians can greatly improve this process. Training programs and clinicians can help
bridge the divide by being responsive to research and EBTs (Withers et al., 2017).
The development of skills necessary to become research‐informed clinicians in order
to use research in their clinical practice is vital. Similarly, researchers should produce
person‐centered research and practice‐based evidence for the limitations of evidence‐
based interventions (Miller & Jaurequi, 2020, vol. 1; Withers et al., 2017). SFT prac-
titioners can begin this process on their own by utilizing a practice‐based evidence
approach to examining their own clinical work. This approach would identify strengths
and weaknesses of their practice and theoretical approach, in addition to the extent to
which their work is benefiting their clients (Withers & Nelson, 2015).
Finally, there must be a continued push to use SFT implementation research to
influence policy. In order for the SFT field to continue to grow and for family‐based
EBTs to be more recognized as quality treatments, we must focus on influencing
public policy. Legislators at the state and federal level are critically important in this
process but may be a neglected audience in the dissemination of EBTs (Purtle,
Brownson, & Proctor, 2017).
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Part V
Training and Practice
23
Ethical and Legal Issues Unique
to Systemic Family Therapy
Megan J. Murphy and Lorna L. Hecker
All forms of therapy should consider ethics as a foundational part of practice. This
statement in itself may be common sense, yet how we attend to and enact ethics when
balancing the needs of two or more family members can be extremely challenging,
with multiple potential paths forward. As practitioners, we have much to consider
when contemplating those paths beyond theory: ethical principles, our profession’s
Code of Ethics, applicable laws, the context in which therapy takes place, and the
agency of involved stakeholders, especially clients themselves (Hecker & Murphy,
2015).
Ethical principles that guide our work are taught in ethics courses required of all
clinicians, so they are discussed briefly here (Beauchamp & Childress, 2013). First,
autonomy refers to the individual’s ability to make decisions for themselves, which
includes being fully informed about the benefits and risks of therapy prior to engaging
in the therapeutic relationship. Second, beneficence indicates that the practitioner will
practice to the best of their ability to benefit the client; from this comes the edict to
do good. Third, nonmaleficence is the idea that the clinician will do no harm to the
client in the course of providing services. Fourth, veracity refers to the clinician being
truthful to the clients and providing a level of honesty in their work with others. Fifth,
justice refers to fairness in therapy and providing services without discrimination.
Sixth, fidelity refers to honoring commitments and promoting trust. These basic prin-
ciples are seen as integral to ethical work across professional disciplines and therefore
applicable to therapeutic practice in any country and culture around the world.
Moreover, these ethical principles are enshrined in every counseling profession’s
Code of Ethics. For example, the American Association for Marriage and Family
Therapy (AAMFT, 2015) Code of Ethics reflects autonomy in Standard 1.2, Informed
Consent, in that clients need to be informed of risks and benefits to treatment in
order to make an informed decision about engaging in therapy. Justice can be found
in Standard 1.1, Nondiscrimination, in that all clients need to be treated fairly in
therapy. In the United States, other counseling professions’ Codes of Ethics reflect
these principles, although they may be worded differently (e.g., American Counseling
534 Megan J. Murphy and Lorna L. Hecker
Association, 2014; American Psychological Association, 2017). These ethical princi-

ples are found in Codes of Ethics around the world as well; for example, the UK
Council for Psychotherapy (2009) addresses autonomy with a clear statement that
“The psychotherapist undertakes to respect their client’s autonomy” (1.7). The
Turkish Psychological Association’s Ethics Code (2004) has an entire standard on
beneficence and maleficence (Standard 2). Ethics also becomes entwined with the law,
which is reflected in numerous cautions in the Code to adhere to “applicable laws,
ethics, and professional standards” (AAMFT, 2015). Practitioners need to stay abreast
of laws at multiple levels, including but not limited to local, state, province, and
federal laws that impact therapy and are ever changing.
Common ethical decision‐making models walk practitioners through the steps of
factors to consider when faced with ethical dilemmas. Oftentimes, these steps include
having an awareness that an ethical dilemma is present, identifying facts related to the
dilemma, consideration of relevant ethical principles and the profession’s code of
ethics, consideration of applicable laws, consultation with peers, consideration of cul-
ture and context, decision making, and follow‐up evaluation of the process (e.g.,
Kitchener, 1986). Embedded in traditional decision‐making models are cultural
assumptions reflective of linear decision making and ethical dilemmas that appear to
develop independent of the typical therapeutic relationship (Shaw, 2017). As it is,
current ethical decision‐making models can be helpful to some extent, especially when
applied to work with an individual in therapy. The drawback to most decision‐making
models such as those proposed by Kitchener (1986) and Keith‐Spiegel and Koocher
(1998) is that they assume clinicians will have time to think through the multistep
decision‐making process, when in reality ethical decisions need to be made in the
moment. These models also separate actions and decisions from relationships; the
concern is that if a situation is not seen in terms of ethics, then the entire ethical deci-
sion‐making process will not happen. If, instead, we frame ethics as inherent in all
relationships, then we may be more likely to be aware of and enacting ethics in our
relationships (Shaw, 2017).
The complexity of working ethically increases exponentially when working with
two or more members of a system, such as a couple or family. Systemic family therapy
necessitates a shift from focusing on the individual to focusing on the system; it
involves a paradigm shift from the individual to the relational. This change in focus
has implications for ethical practice. The difficulty in using common ethical decision‐
making models is further highlighted when considering two or more people involved
in a relationship with each other, as these two (or more) people reflect different
cultures, customs, and values, not to mention those the therapist brings to the rela-
tionship (Hendricks, Bradley, & Robertson, 2015). Ethical decision making from a
systemic perspective should include a recursive process reflective of systems theory
itself. A systemic model of ethical decision making proposed by Scott (2009) utilizing
the acronym “SLEEP” was developed specifically to include a systems approach to
clinical professional decision making (see Figure 23.1). The emphasis on this model is
the feedback loop, in which the practitioner must continually reevaluate, at each step,
feedback received from clients. “S” refers to sociocultural considerations, including
gender, race, sexual preference, class, religion, and ability to the problem, issue, or
dilemma. “L” refers to legal implications of the ethical issue. “E” refers to ethical
imperatives, including professional codes of ethics, ethical principles, and the practi-
tioner’s personal morals and values. The second “E” refers to the economic impact of
Ethical Issues Unique to Systemic Therapy 535
Problem, issue, or
dilemma
Systemic Analysis of
Aituation (SLEEPP)
-Sociocultural
Use any corrective -Legal
feedback from system -Ethical
-Economic
-Political
-Power
Implement a course of
action
Gather necessary
information from
appropriate stakeholders
Figure 23.1 SLEEPP model of systemic ethical decision making. Adapted from Scott (2009,
p. 41). Copyright 2009 by Elsevier.
the dilemma or issue. “P” refers to political ramifications of the ethical decision or
broader impact or consequences for relationships. We like the consideration of socio-
cultural factors in this model, as well as the economic and political ramifications.
Therapists using this model are to apply the principle of symmetry, meaning that they
examine the decision from opposing points of view to ensure that multiple perspec-
tives are considered. We would add a second “P” to this model to include analysis of
power—both the power the therapist has by virtue of their personhood and identity
(including privileged identities), the power by virtue of their role as therapists, and
power within the system with which they are working. This systemic model attends to
both the individual and the relational, thereby addressing the complexities therapists
working with couples and families inevitably face. The critiques made of the Kitchener
(1986) and the Keith‐Spiegel and Koocher (1998) models can be applied to the
SLEEPP model in that, even though the SLEEPP model is more systemic, it relies on
recognition of an ethical dilemma separate from relationships and assumes time to
think through decisions logical order.
A common criticism of systems theory is that gender and power inequities are over-
looked (Goldner, 1989). Some exciting developments in relational ethics (distinct
from relational ethics as used in contextual family therapy) have been written by Gergen
(2015), Haslebo and Haslebo (2012), McNamee (2015), and Shaw (2017), which
give systemic family therapists (SFTs) a different way to address ethical decision mak-
ing. Relational ethics suggests a move from a focus on self and other to a focus on the
“we” of a relationship (Gergen, 2015). Gergen discusses a second‐order morality,
replacing individual responsibility with relational responsibility. Indeed, how we deter-
mine what is “good” or “bad” is co‐constructed and is relationally and contextually
situated. A focus on relational ethics involves a move from the therapist thinking “I am
an ethical therapist” to “What am I doing to be relationally ethical?” McNamee (2015)
suggests that we all think of ourselves as ethical therapists, yet this does not help us act
ethically; being ethical is a state of being, not a fixed identity (which itself is individually
focused). We have to be in continuous dialogue with others in constructing the “good”
and the “bad” and know that these definitions are ever changing and contextually
dependent. Relational ethics involves asking questions about who decides what is
ethical and exploring how our actions impact others. McNamee states, “We must focus
on the process of constructing worldviews (moral orders) as opposed to searching for
universal techniques, answers, and ethics” (2015, p. 424). Being ethical becomes a
process instead of a fixed identity. For some, not having clear answers to ethical dilem-
mas is frightening; it is our hope instead that relational ethics opens up doors, conver-
sations, and possibilities that considers all members of the involved therapeutic system
… and beyond to include the community and larger culture in which we are
embedded.
With these considerations in mind, we discuss ethical situations that may present
themselves in the course of work with family systems—specifically couples and fami-
lies. All of us live in ever‐shifting times. We discuss ethical situations that are common
to clinical work with couples and families, including working with triangles, consider-
ing who is the client, safety concerns, managing boundaries, therapist positionality,
and confidentiality, which includes Health Insurance Portability and Accountability
Act (HIPAA) elements of privacy and security. We provide brief vignettes that may be
common in practice with couples and families and apply, where appropriate, elements
of relational ethics and the SLEEPP model.
Working with Triangles
The systemic concept of triangulation distinguishes systemic therapy from other forms
of therapy in that therapy is focused around triangular relationships (Dallos & Vetere,
2011). Indeed, the genesis of couple’s therapy itself is that it is a process of triangula-
tion when a couple draws a third person into their relationship hoping to right insta-
bility in the system. This conceptual shift includes understanding how dyads will
involve the most vulnerable other person to become a triangle when anxiety increases
(Bowen, 1976). Working with triangles allows the therapist to open powerful sources
of influence into relationships; triangles can be used to stabilize or destabilize
relationships. Working with the power of triangles must be done while managing the
therapeutic alliance, including (a) engagement in the therapeutic process, (b) emo-
tional connection with the SFT, (c) safety within the therapeutic system, and (d) a
shared sense of purpose within the couple or family (Friedlander, Escudero, &
Heatherington, 2006).
Consider the following scenario:
Lee and Jan1 are seeing Tammy, an SFT who is a seasoned therapist. The couple are career
professionals who have been married for seven years and present to therapy with communica-
tion issues. Tammy soon noticed a pattern that while Lee and Jan would come to compromises
in therapy, neither would follow through on what they agreed to do to change the relationship
dynamics. Further, Tammy suspected Jan was having an affair. She asked them about
external relationships, but they denied engaging in any affairs. Tammy was left with the
uneasy feeling that neither partner was being candid in therapy.
Triangles in marital and other long‐term relationships are extremely common, and
as stated, therapy itself is a triangle and hopefully one that intervenes in relationships
in a positive way. But what should Tammy do about her feelings about undercurrents
of triangles and deception in this relationship? How can she maintain her alliance with
Lee and Jan while exploring the unstated aspects of their relational presentation? We
need a bit more information; there are many potential sociocultural factors at play in
Lee and Jan’s relationship. We have yet to understand much about Lee and Jan’s cul-
tural background, which may impact the directness of their communication (or lack
thereof). We also don’t know how gender roles play out in their relationship; both
work outside the home, but Lee appears to be the primary breadwinner with more
economic power than Jan, though both are established professionals. In therapy, the
process of triangulation can occur if ground rules are not set. Tammy must have in
place a “secrets policy” of how she will handle confidential information she receives
from the partners (Kuo, 2009). However, the AAMFT Code of Ethics (2015) defines
confidentiality from an individual basis. Unless Tammy has a written agreement to the
contrary, she must honor individual confidentiality. If she does obtain individual
information that a partner does not want shared with the other, then she is now in
alliance with the revealing partner, with possibly the start of a coalition. She must then
work to “de‐triangle” from the unstable triangling process. Likewise, if she sets a strict
secrets policy, she may not have all the relational dynamics on the table, potentially
truncating her understanding of the marital relationship. The decision to see the cou-
ple separately brings with it the ethical issue of confidentiality. The AAMFT Code of
Ethics (2015) notes that “When providing couple, family or group treatment, the
therapist does not disclose information outside the treatment context without a writ-
ten authorization from each individual competent to execute a waiver. In the context
of couple, family or group treatment, the therapist may not reveal any individual’s
confidences to others in the client unit without the prior written permission of that
individual.” Thus, Tammy must either have had to address this in her informed con-
sent with the couple, or she will need to address this issue prior to seeing the couple
individually. If she does not, and an affair is revealed, she must keep that secret and
the therapeutic dynamics will then include an unproductive alliance at best and a
potential coalition at worst. Additionally, potential secrets bring with it ethical issues
of justice (fairness), beneficence (doing good), nonmaleficence (not doing harm), and
fidelity (trust). As with all couple’s therapy, Tammy must decide how to handle secrets
within the relationship should she decide to separate the couple to gain more clarity
on relational dynamics, but this must be done considering each individual’s legal right
to confidentiality.
Tammy appears to hold the belief that an affair is detrimental for this couple’s rela-
tionship, and she wants to address her feeling that there is something more going on
for Lee and Jan. Her expert power as the therapist allows her to take this stance, but
she may at some point need to consider whether an affair triangle is a viable option for
relationships, rather than allow her personal values to dictate therapy. The couple can
make this decision for their relationship.
Who Is the Client?
When children are brought to therapy, issues of power burst into the therapy room
along with them. Are they in therapy of their own free will, or are they mandated
clients? Have they given informed consent? Can they decide to not attend therapy
despite parental wishes for them to participate? Consider the following scenario:
Roberta and Alex Johnson bring their 12‐year‐old daughter Emma to therapy concerned
that she has been acting out at school. She gets into minor scrapes but claims that she has been
defending herself against bullies. However, she has had several detentions because of these
scrapes. Alex is also concerned that Emma has been falling away from the teachings of their
fundamentalist church and is concerned about Emma’s lack of respect for authority. The
therapist, Mike, notes that Emma is extremely quiet and that both parents seem to talk for
Emma in the absence of her own speech. Emma seems very uncomfortable being in the therapy
office.
The Johnson family provides interesting ethical and legal issues for examination.
There are many sociocultural factors in this family’s presentation to therapy. There are
potential gender issues within the context of the family’s culture (unknown at this
time) as well as gender issues brought forward by the relational context of a funda-
mentalist religious embeddedness. There are hints of traditional gender roles that may
put Emma at odds with her parents if, as part of her development, she is learning
about alternatives to a constrained role of what it means to be female. Her school and
religion may be teaching her conflicting messages. There may or may not be sexual
orientation issues at hand, and Mike may be unsure of how to support Emma’s devel-
opmental independence on this issue while also supporting the parents’ right to raise
their daughter according to their cultural and religious values.
Legally speaking, depending upon the state or province, Emma may or may not
need to give her legal consent to be part of the therapy process. What happens if she
does not want to be part of therapy? In some states, Emma must go along with what
her parents dictate; in others she will have legal options about whether or not she
consents to therapy. Her parents have the right to bring her to therapy, but do they
have the right to force her to attend against her will? This legal issue will bring forward
ethical issues that follow. Would it be ethical for Mike to see Emma against her will?
Whenever a minor presents to therapy, there is always the ethical issue of autonomy
(Hecker & Sori, 2017). Have they made an informed decision to consent to therapy,
or are they “mandated clients?” Emma appears uncomfortable with therapy, but we
are unsure whether it is due to her mandated status, discomfort with her parent(s), or
discomfort with the therapist. Should Mike see her separately to gain her confidence,
and if so, how should her confidentiality be handled?
With minors there are also economic and political factors. The parents are paying
Mike for therapy, targeting Emma’s behavior. There is an economic contract with the
parents that could impact how Mike treats Emma; he will need to remain cognizant
of this inherent unequal status in the therapeutic relationship.
There are power issues playing out in the therapy room by the nature of therapy
itself (bringing a minor to therapy) and the parents talking for Emma. While they may
actually be attempting to help Emma express herself, their efforts may thwart her own
development. The therapist’s expert role on understanding adolescent human
evelopment may collide with the parent’s authority in raising their daughter.
d
Additionally, based on his training, Mike may hold a different view on sexual orienta-
tion development than what Emma’s parents may have. His scholarly training in this
area may bump up against the parents’ religious teachings, putting Emma potentially
sitting on an uncomfortable point in that triangle!
Therapists have to decide how they are going to act based on ethical principles. In
this case, principles of autonomy, nonmaleficence, veracity, and justice seem to be the
primary principles in conflict. Even in ranking these principles, values come into play.
Therapists may consider prioritizing justice and veracity first by having a conversation
with the family about their values and the therapist’s values so that family members
can exercise autonomy in making treatment decisions (i.e., whether to stay in therapy
or to seek therapy elsewhere). If there are safety issues, then nonmaleficence may be
prioritized by the therapist above cultural values expressed by the family. If immediate
safety issues are not present, then the therapist may have more time to engage in con-
versation about values, including the importance of psychoeducation on adolescents’
sexual and identity development. As with any ethical situation, it is difficult to point
to a clear pathway forward, because many other factors may be at play (state laws
guiding minors’ autonomy and confidentiality, for example).
Safety
Therapist concern for client safety is essential in clinical work. One could argue that it
is easier to explore client safety when working with an individual; the picture gets
complicated quickly when the therapist works with two or more people, especially
when they are in different places when it comes to safety. This type of situation arises
most commonly in reference to relationships in which there is risk to physical or
emotional safety to one or both members of a couple. Ideally, therapists conduct suc-
cessful screening for abuse prior to seeing members of a couple together. Research
suggests that conjoint couples therapy can be effective with couples who demonstrate
a mild level of violence and who can cease dangerous behaviors while in therapy
(Stith, McCollum, Amanor‐Boadu, & Smith, 2012). The possibility of domestic
violence (which includes physical and emotional abuse) occurring in the clinical popu-
lation is quite high, leading to the likelihood that even the most diligent of therapists
will not catch couples in which violence is actively occurring or in which one or both
members of a couple is not safe (Harway & Hansen, 1993). Some level of safety must
be assured prior to the start of couple’s therapy so that couples can explore difficult
emotional issues and interactions. Inevitably, in working with couples, therapists will
encounter—after a course of several sessions—that abuse is currently occurring or has
recommenced, posing ethical dilemmas for the therapist. It is now considered ethical
practice to routinely screen couples for domestic violence early in the treatment
process (Bograd & Mederos, 1999).
A common yet extreme example occurs when a client (typically the victim) makes a
therapist aware that abuse has happened and does not want the partner to know that
they have expressed a fear for their safety, out of concern that they will experience
further abuse and harm. Assuming that the ethical principle of nonmaleficence is
applied, the therapist would not want to see either partner harmed or placed at risk
for further abuse. The dilemma for the therapist may start with sociocultural consid-
erations; the couple unit may, for example, cite religious reasons for one partner to
harm another. The therapist then must decide whether to uphold this belief or
challenge it. The therapist—at all times—must be aware of their power to make deci-
sions that impact the couple and whether the therapist supports the adherence to or
challenging of cultural discourses.
The therapist must be aware of any laws that mandate reporting of harm to others;
laws vary widely state to state and country to country. Even if it is decided that a
report needs to be made, the therapist must consider how to (or whether to) share
that information with clients, as well as what happens to the future course of therapy.
Yet before the therapist makes these decisions, they must decide whether to act on the
client’s report of the incident or whether to explore further while keeping in mind
that it is not the therapist’s job to investigate. Believing (or not believing) a client will
have an impact not only on the therapeutic relationship but on the relationship
between partners as well.
If the victim does not want their partner to know that they have reported abuse to
the therapist, the therapist needs to decide whether nonmaleficence in relation to the
victim outweighs the autonomy of the perpetrator in deciding the course of therapy.
The therapist may decide to split the couple for safety concerns but will need to
decide what to tell both clients about this decision. This may include being clear
about treatment goals in seeing the couple individually before deciding to bring them
back together as a couple, presumably after safety of both parties has been
established.
Luisa and Ramone have been together for 8 years. Luisa’s parents immigrated to the United
States from Mexico before she was born; she is a housekeeper at a local hotel. Ramone is an
undocumented immigrant from Mexico who works at a meatpacking plant. They have two
children together, who are 2 and 5 years old. They have been in couple’s therapy for 4 weeks.
Two days before the 5th session, Luisa calls the therapist to cancel the session, saying that
Ramone beat her severely over the weekend and she is too bruised, sore, and embarrassed to
come to therapy.
The therapist faces an immediate dilemma: whether to reschedule the session and
decide later who to see and how (i.e., to continue to see the couple together or to split
them up to talk with them individually). The therapist, of course, has other options
available, including calling the police, calling for a wellness check, or providing a
referral.
Let us assume the therapist has an opportunity to talk with Luisa, either over the
phone or in an individual session. Luisa tearfully admits that Ramone has beat her
throughout her relationship, that she doesn’t know what to do, and that she fears for
the safety of herself and her children. She says that she doesn’t want to call the police
because she is fearful that Ramone will be deported and that she wants him to stop
harming her but does not want him to be punished to the extent that he is deported.
She also worries about being able to support herself and her children on her meager
earnings as a housekeeper.
Given the SLEEPP model, the therapist at this point needs to weigh several consid-
erations, including safety of the children and possible legal requirements to report
suspected child abuse. Laws vary in relation to reporting—whether the children are
present or not during the beatings is relevant, as well as whether the children them-
selves have been physically abused by Ramone. The therapist must consider the politi-
cal climate of the area in which the family lives and therapy takes place, which may be
such that Luisa is valid in her fears that Ramone will be deported if he comes to the
attention of the authorities. If Luisa is isolated from family and friends, she may indeed
not have a home to live in, which may lead to (further) involvement by the state if
child protective services is called. Unfortunately, the therapist cannot reassure Luisa
that Ramone will not be deported. Ultimately, it is possible that the family will experi-
ence further harm in ways generated by the system upon report of abuse by the
therapist.
Managing Boundaries
Therapists working with more than one person have always had to manage bounda-
ries. Any therapist who works with couples knows that a lot of important information
can be communicated to the therapist by one partner on the phone or in the waiting
room while waiting for the other partner to arrive. The quick communication meth-
ods offered by texting or email speeds up the pace at which information is delivered
and opens doors to positive as well as negative communication with members of a
family system (Bradley & Hendricks, 2009). As prepared as therapists may try to be
via having comprehensive and thorough informed consent documents, it is impossible
to anticipate all situations in which boundaries may be challenged by clients.
Maria and Gina are coming to therapy to work on conflict and communication in their
marriage. Between sessions, the therapist receives an email from Maria saying that she is
furious that she found a dating profile on http://Match.com that Gina had set up.
According to Maria’s email, Gina has been dating two other people off and on for the past
3 years. Maria says she is no longer coming to therapy and plans to file for divorce.
The therapist had been proactive by saying that email was not an acceptable form
of communication and that both Maria and Gina agreed to this statement when they
signed the Informed Consent for Treatment. Still, the therapist now must decide how
to respond to the email—Is it better to contact Maria to ask for clarification? Is it the
therapist’s responsibility to contact Gina to cancel the session? Does she call them
both and offer individual therapy? The therapist does not know what communications
have occurred between Maria and Gina about this issue. Ethical dilemmas may
continue in this case, if the therapist is unable to reach Gina about canceling or
rescheduling the appointment; indeed, Gina may show up for the next session as
scheduled, unaware of Maria’s email and communications with the therapist.
Use of cell phones in therapy can pose other sets of ethical dilemmas for the thera-
pist. Clients can and do get out their phones to show the therapist “proof” of a part-
ner’s indiscretions, or they may show the therapist texts of their underage child
“sexting” another student in their high school. Likewise, clients can feel compelled to
check their phone, text in session, or otherwise be protective of their phone in relation
to their partner or a parent. In these situations, as with others in therapy, therapists
need to decide which boundaries to enforce when in session; sometimes enforcing
“no cell phone” boundaries may result in damage to or loss of the therapeutic
relationship. In regard to cell phones, ethical principles of autonomy and veracity may
be in conflict. Partners in a couple relationship may disagree, with one favoring auton-
omy, or the ability to decide what to share, and the other partner favoring veracity, or
truth in the relationship. The therapist must seek justice or fairness in helping the
couple decide what to share with each other, as well as what can and cannot be shared
in therapy. The therapist can decide that, in keeping with the ethical principles of
veracity and justice in therapy, that the therapist believes she should facilitate a con-
versation about what each partner’s values are in relation to sharing and truth telling
in their relationship and explore the implications of these values for each partner as
well as for their relationship.
Social media such as Facebook or LinkedIn accounts can also pose boundary chal-
lenges for therapists (Wilcoxon, 2015).
Sharon has worked with Vanessa, a 15‐year‐old girl, and her parents for nearly a year in
therapy. Vanessa’s parents initially brought her in due to concerns about her depression. After
working to alleviate Vanessa’s depressive symptoms, family therapy turned to focus on
Vanessa’s live‐in grandmother’s sudden death due to a stroke. The family and Sharon agreed
to end therapy after working through these issues. Six weeks after therapy ended, Sharon
received a Facebook message from Vanessa, in which Vanessa said she was cutting herself and
thinking of running away with her friend Becky (who Sharon remembers had not been a posi-
tive person in Vanessa’s life).
The therapist faces legal and ethical dilemmas in how to react: whether she responds
to Vanessa via Facebook, whether to contact the parents, and if so, when (how imme-
diate is the concern)? Also, another option may be to call the police. Local, state, and
federal laws may play a role in the extent to which confidentiality is assured in this
situation. Questions arise about Sharon’s privacy settings on Facebook—Is the thera-
pist expected to have strict privacy settings on Facebook? Must the therapist include
Facebook privacy issues in her informed consent (Jordan et al., 2014)?
The proliferation and use of Facebook and LinkedIn allows for connections with
friends, as well as friends of friends. Depending on others’ privacy settings, a therapist
may be able to see a client’s activities indirectly through their own network of friends.
Less than a week before Vanessa messaged her, Sharon discovered that Vanessa was hanging
out with the “wrong crowd” in high school, through her friend’s daughter’s (Evelyn) Facebook
posts, which showed pictures of Vanessa, Becky, and Evelyn at what appeared to be a party
with a beer keg.
Whether looking for information about clients or not, therapists can more easily
come across information about clients through social media sites (Kellen, Schoenherr,
Turns, Madhusudan, & Hecker, 2014). The therapist needs to consider how to
respond, based on ethics, laws, and sociocultural context, as well as other considera-
tions. Oftentimes, therapists may be put in a position to “hold” information—that is,
not share information they may have come across while living their lives (on social
media sites). Or the therapist may decide that it may be of most benefit for the client
to share information with them or with the parents, as in this case with Vanessa,
particularly in relation to receiving a message about running away and self‐harm.
The therapist risks damaging the therapeutic relationship depending upon the avenue
she chooses. In this case, safety is paramount, so the therapist needs to determine the
possible level of risk experienced by Vanessa in order to maximize benefit for the client
(beneficence) and minimize harm (nonmaleficence). The therapist may decide that
she has a commitment (fidelity) to ensure the safety of this former client that out-
weighs the minor client’s right to decide (autonomy) what information should be
shared with her parents. Therapists can always consider connecting with colleagues—
if they have the luxury of time and an immediate response is not needed—to inquire
about ethical decision making. In this case, Sharon may need to consult with colleagues
to learn how to change her Facebook privacy settings.
Electronic Therapy
Over the past decade, there has been an increase in and demand for electronic therapy
(e‐therapy), which raises legal and ethical issues for SFTs. Foremost are confidentiality
and privacy concerns. Best practices suggest that therapists inform clients of the risk
to confidentiality and privacy concerns in their informed consent document (Twist &
Hertlein, 2017). Therapists need to take steps to ensure that information transmitted
electronically is secure. Practicing e‐therapy raises the obvious potential of practicing
across state lines, bringing with it concerns about practicing in another state without
a license (Twist & Hertlein, 2017). Yet it is possible to practice across national lines
as well, raising a more complicated set of ethical and legal issues. Lustgarten and
Colbow (2017) discuss risks of governmental surveillance, citing the National Security
Agency’s attempts to intercept protected data worldwide, including emails and video
conferences. Ethically, it is the therapist’s responsibility to ensure that client informa-
tion is kept secure, private, and confidential.
The benefit (beneficence) to clients is apparent in the provision of e‐therapy. It may
be more affordable, more accessible, and convenient for clients, particularly those in
rural locales. However, boundaries are another concern with e‐therapy. SFTs must
clearly describe when they are available and clarify expectations for their availability to
clients via electronic means in the informed consent document. Twist and Hertlein
(2017) describe challenges in assessing for risk issues in e‐therapy, including client
self‐harm and suicidal ideation. Child abuse reporting requirements vary widely from
state to state, necessitating therapist’s knowledge of the laws of the state in which the
client resides. These types of emergency situations are further complicated when
practicing e‐therapy across national lines. As a field, we are in our infancy in sorting
out these important legal and ethical issues as related to provision of e‐therapy.
Therapist Positionality
The therapist is always in relationship with the clients who are being seen in therapy.
In systemic practice, this means that there is a relationship between the therapist and
each member of the couple or each member of the family. Therefore, the therapist is
a crucial member of these relationships; in many ways, the therapist has the most
power in the system by virtue of their role as therapist and expert on relationships.
Therapist positionality is a concept drawn from feminism, intersectionality, and social
constructionist thought; it suggests (a) that we are inherently in relationship with
others; (b) that our identities are shaped by the relationships we are a part of, and
therefore our identities are ever shifting; and (c) that our identities carry power via
privileges we have connected to our identities in relation to others (Gergen, 2015;
Murphy & Hecker, 2017; Watts‐Jones, 2010). The concept of therapist positionality
inherently challenges previous writings on the desirability of neutrality by the thera-
pist in systemic therapy with more than one client. Therapist neutrality has been
widely critiqued in the family therapy field by feminists (Knudson‐Martin, 1997). Yet
true neutrality is not possible, nor is it desirable for the therapy in relation to clients.
Some therapists suggest taking a stance of curiosity or multidirected partiality; both
concepts have also been recently critiqued for their lack of attention to larger socio-
cultural issues (Stancombe & White, 2005). According to the SLEEPP model, one
has to consider sociocultural factors that are present in ethical dilemmas; there are
inherent cultural differences in all relationships therapists have with clients (and that
clients have with each other). Therapists need to consider power differences that will
result from these sociocultural differences between people in relationships and act
ethically in relation to them.
In relational ethics, therapist positionality involves transparency, engaging in ongo-
ing conversations with clients, and the therapist being aware of the power they hold
by virtue of the helper role, as well as power connected to privileged identities in rela-
tion to clients (Murphy & Hecker, 2017). From a relational ethics frame, therapists
continually work to listen to the narratives generated in the therapy room and listen
for what is made possible by such narratives and what is made less possible. There is a
value in balance, fluidity, and collaboration with clients that exists within the narrative
constructed by society that therapists have an ability to shape reality. Ethics, then,
become a part of the conversations therapists have with clients, instead of a separate
entity to consider when a clear ethical violation has occurred.
In the United States—and perhaps to an extent—worldwide, there is increased
polarization between political groups or parties, which of course impact families and
couples and the relationships they have with each other. Therapists are not immune
to or separate from these ideological divisions. Indeed, they cannot be neutral.
Consider the following scenario:
Gene and Lily have been married for 5 years. They both report that their relationship has been
plagued with conflict. However, since the most recent elections, their differences seemed to
have become even starker. Lily’s experiences of sexual abuse were triggered by one candidate’s
statements about abusing women. Lily cannot understand how Gene could have voted for
this candidate, given his knowledge of Lily’s history of abuse. Gene says that he voted for who
he thought was the best candidate. The therapist, Monique, also has experienced a wide range
of emotions after the election, feeling shocked that a person who has made disparaging state-
ments about women was elected to be the nation’s leader.
Therapists are not neutral people; they have values, morals, and biases that are
shaped by their lived experiences and that they bring with them into the therapy room.
This is true in regard to this scenario and all other relationships therapists have with
clients. Given that it is inhuman to be neutral, therapists can embrace transparency as
a way of providing clients with autonomy to decide whether to continue in the thera-
peutic relationship. Watts‐Jones (2010) suggests that therapists situate themselves and
their identities in relation to clients, thereby opening up conversations about how simi-
larities and differences may impact therapy and the relationships within the therapy
room. Therapists and clients together can decide what will benefit the couple in ther-
apy, what goals they want to work toward, and how they will know when therapy is
completed. Considerations of power are crucial in this scenario—for the key question
may come down to justice and what is fair for each member of the couple. It could be
argued that the therapist has the power—by virtue of her role—to raise issues of justice
and fairness in therapy and to help the couple to be in conversation about justice in
relation to their values and political views.
Confidentiality in Systemic Therapy
There are three distinct issues that affect confidentiality in the therapeutic relation-
ship: confidentiality, privacy, and security. Confidentiality is the foundation of all types
of counseling and therapy (Kaplan & Culkin, 1995). Confidentiality is about the
relationship between the SFT and their clients; there is an expectation that SFTs will
hold the confidences of their clients. Confidentiality is our ethical obligation to keep
client information private, which builds the foundation of the relationship between
the SFT and their client(s). This expectation is typically codified into state professional
statutes and is also reflected in the Code of Ethics (AAMFT, 2015). Privacy relates to
an individual’s right to control their personal information (Siegel, 1979). Before we
reveal confidential information, we respect the client’s privacy and obtain the neces-
sary authorizations. Privacy in the United States has also evolved into privacy regula-
tions and laws, such as the HIPAA Privacy Rule, and state statutes that proscribe
privacy practices. Security is the newest partner to confidentiality. With the advent of
electronic health records, and private information kept digitally in other methods,
security of electronic health information has become a third prong to confidentiality
(Sabin, 1997). Like privacy, security of electronic health information is now in the
purview of federal law, specifically the HIPAA Security Rule. Other countries have
global privacy and security laws as well, and most have now passed security breach
notification laws (Hecker, 2016). The United States also has a federal breach notifica-
tion requirement, and states also have breach notification statutes for various types of
personal information. Privacy and security concerns affect the trust inherent in the
confidential relationship between the therapist and client. In this section, confidenti-
ality issues are explored from these three important lenses (see Figure 23.2). First,
however, the shifting nature of professional confidentiality is explored.
Confidentiality
Keeping confidentiality in the therapist–client relationship has fundamentally changed
with the advent of digital technology and our use of it in therapy. From electronic
health records and other electronic storage of client data to online therapy modalities
to texting and social media, the avenues for potential breaches of confidentiality have
multiplied exponentially. What does this mean for the average SFT? How we think
Confidentiality
(Ethical obligation
Privacy (HIPAA of therapist to keep
Privacy Rule) client information
indicates individuals private)
have the right to
control one's
Protected Health
Information)
Security (HIPAA
Security Rule)
indicates therapist
must safeguard
electronic Protected
Health Information
Figure 23.2 Confidentiality considerations in systemic therapy.
about protecting confidentiality must change; it is no longer about the “trusted rela-
tionship,” but has moved to include the integral areas of consumer privacy and secu-
rity. What is at stake has changed: within our fiduciary relationship with clients, we
now must think about risks to them such as identity theft, medical identity theft, and
a potential loss of trust in the SFT. Practitioners must also think about the ramifica-
tions to their practices for poor security practices, such as state and federal fines and
penalties, civil liabilities, and loss of business due to reputational damage (Hecker,
2016). We have previously discussed many ways confidentiality considerations occur
in all forms of relational therapy; in this section we will discuss privacy and security
considerations as we expand our notion of confidentiality.
Privacy considerations
Privacy revolves around the client’s right to control their personal information. Within
the therapeutic relationship, what is considered private? The HIPAA Privacy Rule helps
us understand what health information should be kept private, by both defining Protected
Health Information and describing specific identifiers that make individually identifiable
information Protected Health Information. Protected Health Information is:
Individually identifiable health information, including demographic data, that relates to:
1) the individual’s past, present or future physical or mental health or condition; 2) the
provision of health care to the individual; or 3) the past, present, or future payment for
the provision of health care to the individual, and that identifies the individual or for
which there is a reasonable basis to believe it can be used to identify the individual. (45
C.F.R. §160.103)
There are 18 Protected Health Information identifiers identified by the Privacy

Rule that give us guidance to understand what information we should be guard-
ing, including but not limited to names, certain geographic units such as zip
codes, elements of dates, telephone numbers, electronic mail addresses, social
security numbers, account numbers, Internet protocol (IP) address numbers, and
full‐face photographic images and any comparable images. If these 18 identifiers
are stripped from client data, it is considered “de‐identified” and is no longer
information that needs protection. This information by itself (the 18 identifiers)
is not enough to be considered Protected Health Information; it must be paired
with health data (for example, diagnosis, treatment plant, prognosis, and so forth;
Hecker, 2016). More information about de‐identifying data can be found in
Hecker (2016).
Notice of privacy practices A father brought his minor daughter for an evaluation to a
family‐focused agency when the daughter had been heard making suicidal threats at
school. The teenage daughter read the Notice of Privacy Practices and started to shout
that there was “no way” she would ever share anything with the therapist, citing the
multiple items in the Notice that indicated the therapist was free to share information
with outside entities. Frightened that her personal information might be shared with
others without her consent, she stood up to leave; the father was unsure what to do.
This young client was rightfully scared that her therapy information might be
shared with others. What happened was that the agency had adopted a Notice of
Privacy Practices template from a professional association but failed to integrate more
strict state mental health law into the Notice. And while most persons may not mind
having their X‐rays freely shared with another provider, sharing more sensitive infor-
mation would probably give most people pause.
How a therapist intends to share Protected Health Information must be detailed in
the HIPAA required Notice of Privacy Practices (45 C.F.R. §164.520). This docu-
ment is given to clients at service delivery, and the therapist is required to put forth a
“good faith effort” to get written acknowledgement that the client has received the
Notice of Privacy Practices (and document client refusal if they do not wish to sign
the acknowledgement). However, services may not be denied if the client refuses to
sign the acknowledgement; the law is the law and how therapists may share Protected
Health Information does not change even if clients do not sign that they have received
this notice of how their information may be legally used or disclosed. Each family
member should receive the Notice of Privacy Practices, including minors (although
whether a parent or guardian should sign for the child is often a matter of state law);
it is to be written in “plain language” for ease of understanding, though the laws
themselves make this task challenging. Further making the Notice of Privacy Practices
a challenge, clients should be informed of stricter state law that protects their Protected
Health Information. Often therapists copy template Notice of Privacy Practices and
shortchange clients by not informing them of these additional protections to their
data. This can affect the confidential relationship between a therapist and client if the
client believes that their private therapeutic information may be freely shared in the
same way as their physical information. Most information protected under HIPAA
can be freely shared for Treatment, Payment, and Health Care Operations (TPO)
without an authorization. State law typically curtails this about mental health infor-
mation, and clients should be correctly informed of their rights. It is the ethical obli-
gation of the SFT to get a clear picture of how patient Protected Health Information
is protected within their state and adequately communicate that to their clients so that
clients can understand their specific privacy rights when it comes to the information
they divulge in therapy. Note that the Notice of Privacy Practices requirements
changed in 2013 with the passage of the HIPAA Omnibus Final Rule, adding addi-
tional requirements such as breach notification. It is up to the SFT to stay abreast of
regulatory changes; clinicians should sign up for updates.2 More information about
Notice of Privacy Practices and Protected Health Information can be found in
Hecker (2016).
Personal representatives A family therapy agency located in Illinois was seeing

12‐year‐old Christopher unbeknownst to his mother, Emily. When his mother found
out that he was attending therapy behind her back, she contacted the therapist asking
for access to his treatment information. Emily has legal custody of Christopher.
When seeing clients, generally a therapist must allow a client’s “personal repre-
sentative” to inspect and receive a copy of Protected Health Information. The per-
sonal representative may be a health‐care power of attorney. For children, the personal
representative is usually the child’s parent or legal guardian; state laws may be more
proscriptive regarding who has access to Protected Health Information of a minor. In
cases where a custody decree exists, the personal representative is the parent(s) who
can make health‐care decision under the custody decree. Because Christopher is being
seen in Illinois, minors are afforded considerable rights to privacy, which must be
evaluated as well. In Christopher’s case, Emily’s request for records brings forward
ethical issues of autonomy (Christopher’s) and beneficence (Emily’s rights as his
mother to protect him), as well as the interplay of state and federal laws and our pro-
fessional code of ethics.
Minimum necessary standard Mary is a receptionist at a small family therapy prac-

tice. Mary has access to the electronic records system both to help with billing and to
schedule clients. Mary notices that her neighbor is bringing her daughter in for treat-
ment. Concerned due to a spate of suicides at the local school, Mary looks at the
intake assessment for the daughter to ensure herself the girl is OK.
While SFTs are typically cognizant of minimizing sharing of Protected Health
Information, federal HIPAA law expounds upon this notion in what is referred to as
the minimum necessary standard (45 C.F.R. §164.502(b), 45 C.F.R. §164.514(d)).
The minimum necessary standard dictates that Protected Health Information may
not be used or disclosed when it is not necessary to satisfy a particular purpose or carry
out a function. This means that each SFT must evaluate their practice and enhance
safeguards to limit unnecessary or inappropriate access to and disclosure of Protected
Health Information. The minimum necessary standard does not apply when uses or
disclosures are for treatment purposes, to the individual client themselves, informa-
tion pursuant to an authorization, or required by HIPAA or other law, or for enforce-
ment purposes by the Department of Health and Human Services. In this case
scenario, Mary has overstepped her boundaries to the point that her situation is a
reportable HIPAA breach for the practice. The practice must act to limit Protected
Health Information available to those who do not need access to it.
Security considerations
Confidentiality considerations have changed with the explosion of the digital era.
Electronic security goes hand in hand with our ethical and legal obligation to keep
our clients’ information confidential. With the advent of electronic health records
and private information kept digitally by other methods, security of electronic
health information has become an important confidentiality consideration. Security
of electronic health information is now in the purview of US federal law, specifi-
cally the HIPAA Security Rule, as well as data protection laws in other countries
such as the much more encompassing General Data Protection Regulation (GDPR)
of the European Union (EU). The HIPAA Security Rule aims to ensure the confi-
dentiality, integrity, and availability of Protected Health Information. The United
States also has a federal breach notification requirement, and within the United
States all states now have some form of breach notification. The GDPR also
requires breach notification. Consider how confidentiality concerns have changed
in the following scenario:
A therapist wished to be able to see when her clients arrive in her lobby, so she put a security
camera in her waiting room, which broadcasts only to her office for her convenience.
Unbeknownst to the therapist, the installer did not change the default password, allowing a
Russian website access to her video feed and broadcasting her therapy office to a website called
http://insecam.org.
Fact or fiction? Thus far, fiction, but this did happen to a dentist in Toronto who had
their office broadcast on this site; they had their entire office broadcast for all to see
until someone tipped them off about this intrusion (Russell, 2017).
In a study of patient concerns about their private information, Software Advice
(2015) found that 45% of patients were “significantly concerned” about a data breach
involving their Protected Health Information; furthermore, 21% said they actually
withhold information from providers out of their concern for data security. What they
withheld is of import to SFTs: they said they withhold personal health information
including their own (or their family’s) prescription information, mental illness, and
substance abuse history! SFTs need to be thinking about these concerns that trouble
our clients.
HIPAA Compliance Process
Creating a robust privacy and security program can be a daunting task. The HIPAA
Security Rule gives baseline guidance for how to establish this process. This includes
completing a security risk analysis, producing a remediation plan, assigning a chief
privacy officer and chief security officer, developing policies and procedures to
adequately protect client Protected Health Information and meet regulatory

requirements, training workforce on policies and procedures needed to do their job,
and auditing and monitoring compliance with the therapist’s HIPAA privacy and
security program. Additionally, with the advent of the Health Information Technology
for Economic and Clinical Health (HITECH) Act of 2013, therapists must also con-
sider their business associate relationships (Hecker, 2016). What follows is a cursory
look at HIPAA security requirements; this is a compliance o verview—there are addi-
tional requirements to consider that are outside of the purview of this chapter.
Security risk analysis

The cornerstone of HIPAA compliance lies in the security risk analysis and is a require-
ment under the HIPAA Security Rule (HIPAA, §164.308(a)(1)(ii)(A)). The security
risk analysis is a comprehensive analysis of all of the threats and vulnerabilities to client
Protected Health Information. The results inform an organization’s HIPAA policies
and procedures. The industry standard (in the United States) is to use the NIST
800‐30 protocol (NIST is a US organization called the National Institute of Standards
and Technology). The risk analysis is a required component of HIPAA; for each vul-
nerability to a practitioner’s electronic Protected Health Information, the threat that
can exploit that vulnerability is examined, along with the likelihood that threat will
occur and the impact it would have on one’s practice and one’s clients should the
threat come to pass. A “vulnerability” is a cybersecurity term that refers to a flaw in a
system that can leave it open to attack (Techopedia, n.d.). A “threat” is a potential
danger that might exploit a vulnerability to breach security and therefore cause pos-
sible harm. A threat can be either “intentional” or “accidental” (e.g., the possibility
of a computer malfunctioning or the possibility of a natural disaster such as an earth-
quake, a fire, or a tornado; Wikipedia, n.d.). Unencrypted laptops and other unen-
crypted mobile devices are a very common source of loss or theft; the lack of encryption
would be the vulnerability, and the potential for loss or theft is the threat. Within the
security risk analysis, a risk score gets assigned to each vulnerability, and a practitioner
can learn what the strongest risks are to their practice, so an action plan is in place to
address those vulnerabilities.
Remediation plan
Once the security risk analysis is in place, the practitioner is required by HIPAA regula-
tion to generate a remediation plan (risk management) (HIPAA, §164.308(a)(1)(ii)(B)).
The remediation plan is a time‐stamped plan whereby each vulnerability is addressed
with a plan to decrease the vulnerability to within an acceptable level of risk. The plan
details how the practitioner will do this, who will do the assigned tasks, and by when they
are to be accomplished. In the event of an audit or complaint, SFTs can show that they
are making strides to become compliant with the regulations and protect client data.
Chief privacy officer and chief security officer

Each entity must designate a chief privacy officer and chief security officer (Hecker,
2016). In smaller organizations this may be the same person, but need not be. These
individuals are in charge of development, implementation, and dissemination of p rivacy
and security policies, respectively, along with monitoring compliance with the policies.
Policies and procedures

HIPAA policies and procedures are put in place to protect client data. HIPAA requires
both privacy and security policies and procedures. The security policies and proce-
dures specifically address the issues in the remediation plan and are broken into safe-
guards of data: administrative, physical, and technical safeguards. While the policies
and procedures requirements are too expansive to discuss here, there are 54 security
regulations that must be addressed within the therapist’s policies and procedures,
which specifically target safeguarding client data (Hecker, 2016).
Training of workforce
A compliance program is only as good as the people involved with client data.
Workforce must be adequately trained on the therapist’s HIPAA privacy policies and
procedures (HIPAA, 45 C.F.R. 45 C.F.R. §164.530), as well as the therapist’s HIPAA
security policies and procedures (HIPAA, 45 C.F.R. §164.308(a)(5)(i)) for them to
be able to do their job.
Audit and monitoring of the HIPAA compliance program

The security regulations have a requirement designated “evaluation” whereby the
practitioner is required to audit and monitor their HIPAA compliance program to be
sure that the practitioner is doing what their policies and procedures dictate (HIPAA,
§164.308(a)(8)). An overall audit is typically done on a yearly basis or if there is a
significant security incident. Audits of program components, such as training compli-
ance, can be run on a quarterly basis to be sure workforce are complying with this
aspect of the regulations.
Due diligence on business associates

Business associates are those entities that a practitioner subcontracts for services who
have access to client Protected Health Information. This may be the practitioner’s
attorney, shredding service, electronic records vendor, billing service, and so forth, if
they have access to Protected Health Information. If a practitioner who is a covered
entity
knows of a material breach or violation by the business associate of the contract or

agreement, the covered entity is required to take reasonable steps to cure the breach or
end the violation, and if such steps are unsuccessful, to terminate the contract or
arrangement. If termination of the contract or agreement is not feasible. (HIPAA,
§164.504(e))
Thus, it is not enough to be HIPAA compliant oneself; if client data is entrusted to

others, the therapist must ensure that they are compliant with the regulations and
enter into a “business associate agreement” with that entity. The contents of these
agreements are set by regulation and ensure that the therapist’s business associate will
guard the clients’ Protected Health Information, as well as notify the therapist if there
is a breach of client Protected Health Information.
Conclusion
As SFTs, ethics moves past linear decision making and includes the challenge to con-
sider the recursive process when evaluating ethical decisions. We presented the
SLEEPP model of ethical decision making adapted from Scott (2009) as one way to
conceptualize how to move forward in making ethical decision consistent with sys-
tems theory. Additionally, we invite readers to learn more about relational ethics as a
way to bridge gaps posed in systemic ethical decision making. Systemic therapy ethical
issues include managing triangles constructively, reflecting upon who the client is
when seeing multiple members in therapy, especially those with less power such as
minors, and addressing the therapist’s positionality in relation to clients and what this
means for treating clients ethically.
We also noted that confidentiality considerations have shifted considerably with the
advent of digital technology. Although confidentiality has long been the foundation
of therapy, with the trust of the SFT as a paramount consideration, confidentiality
considerations have shifted to include both privacy considerations (client’s rights to
share or not to share their Protected Health Information) and digital security consid-
erations. Digital security means SFTs must consider the technology we are using in
our daily practice and how we need to guard this electronic information as we would
any information clients reveal to us. We suggested that HIPAA privacy and security
regulations provide a baseline for tackling this challenge; all SFTs must engage in
HIPAA (or similar data protection laws such as the EU GDPR) in order to best main-
tain client confidentiality in this modern era.
Notes
1 We have protected the confidentiality of those described in the vignette by disguising

material, limiting specific descriptions, and using composites. This holds true for all
vignettes in this chapter.
2 Sign up for the Office for Civil Rights Privacy and Security Listservs at https://www.hhs.
gov/hipaa/for‐professionals/list‐serve/index.html
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24
Training and Credentialing
in the Profession of Marriage
and Family Therapy
Kevin P. Lyness
Marriage and family therapy (MFT) is widely recognized as a distinct profession.

Although clinicians from various professions often engage in the practice of MFT,
there are several characteristics of the field of MFT that set it apart as a profession,
though there is some disagreement outside of the field about this. There are a couple
of different ways to think about what makes MFT a profession; one is to think about
what sets our field apart from other mental health disciplines, while the other is to
examine how MFT has met criteria that are commonly viewed as necessary to become
established as a distinct profession. Although MFT has not reached the status of a
distinct profession in most other countries, the journey and accomplishments of
the development of MFT in the United States can serve as a roadmap for other
countries.
A note about usage: because this chapter is about the profession, the terms
“marriage and family therapy” and “marriage and family therapist” will be used rather
than couple/marriage and family therapy or systemic family therapy. The primary
driver of this language usage is in the licensure laws that regulate the credentialing of
the profession in the United States and Canada.
This chapter will look at how the field has become the profession of MFT, and the
role of accreditation, education (and different types of educational programs), and
training in MFT. The chapter will also explore the role of licensure for marriage and
family therapists with a broader look at professional regulation. Next steps and future
directions are also explored.
Training in systemic family therapy (SFT) takes place in a number of contexts and
settings. These include (a) formal graduate education programs in the United States
and other countries specifically focused on SFT, (b) SFT as a specialty of subspecialty
in other mental health professions (medicine/psychiatry/SFT, psychology/clinical
psychology/SFT, social work/clinical social work/SFT), and (c) training in SFT for
mental health professionals through workshops and other events outside of formal
education programs. It is the first of these that is most related to the development of
556 Kevin P. Lyness
the profession, and while the others may be more common, they do not typically lead
to a professional identity as an MFT or SFT.
Further, what sets our field apart is not the modality of couple or family treatment,
but the way we conceptualize what we do in the therapy room (Wampler, Blow,
McWey, Miller, & Wampler, 2017). Much of this handbook deals with this distinction
and with enumerating the many ways that interpersonal focus, systems thinking, and
relational and contextual work permeate the field. As Shields, McDaniel, Wynne, and
Gawinkski (1994) say, “It is not systems theory that makes family therapy a distinctive
mental health discipline; more crucially, the difference is that family therapy examines
interpersonal relationships first—rather than biological, intrapsychic, or societal
processes—when attempting to understand human distress” (p. 118, italics in original).
There is broad consensus that a systemic way of thinking (regardless of who is in the
room) is what sets MFT apart from other mental health disciplines (see Brown
Standridge, 1986; Crane et al., 2010; Everett, 1979; Hardy & Keller, 1991; Lebow,
2014; McGeorge, Carlson, & Wetchler, 2015; Nichols, 1979a; Rambo & Hibel,
2013; Wampler et al., 2017). However, the professional identity of MFT also includes
profession‐specific education and regulation such as licensure. For example, Franknoi
(2005) spells out some of the common criteria for a developing professional field:
The practitioners usually begin by organizing themselves into one or more professional
organizations…, publishing journals and magazines to keep in touch, and formulating
entry requirements for the profession. These may involve formal education, apprentice-
ships, examinations, continuing professional development, boards that certify compe-
tence… Eventually, the practitioners lobby state and federal legislatures to have laws
passed that formalize the entry requirements into their profession and keep out people
who don’t meet those requirements… As times and professions evolve, the entrance rules
may change and become more formal. (p. 23)
Hardy (1994) also discusses certain characteristics in the development of a profes-

sion, applying them to the field of MFT, including developing a technical base, assert-
ing exclusive jurisdiction, linking skills and jurisdiction to training, and convincing the
public that the services are trustworthy. Claiborn (2000) offers a perspective on
professionalism based on the functions of professional organizations, which includes
education, accrediting educational programs, developing training standards, recog-
nizing and accrediting training programs, holding conferences, publishing journals,
holding public meetings, sponsoring research, providing ethical training, and holding
membership accountable to ethical and quality standards. The American Association
for Marriage and Family Therapy (AAMFT), as the professional organization for the
field, has clearly provided all of these organizational functions at one point or another,
though one shift has been away from AAMFT as a credentialing organization (e.g., via
Clinical Member status, which has been replaced with licensure as the standard for
practice—Kosinski, 1982; Sturkie & Bergen, 2001).
As early as 1953, Harper was calling for “marriage counseling” (p. 338) to become
a “full‐fledged specialty” (p. 338), and many writers have taken on the task of discuss-
ing the history of the profession (e.g., Broderick & Schrader, 1991; Brown Standridge,
1986; Jordan & Fisher, 2016; McGeorge, Carlson, & Wetchler, 2015; Northey,
2009), and several others have focused specifically on the issue of licensure during our
history (most notably Caldwell, Kunker, Brown, & Saiki, 2011; Crespi, 1997;
Training and Credentialing in MFT 557
Kosinski, 1982; Lee, 1998; Lee & Sturkie, 1997; Sporakowski, 1982; Sturkie &
Bergen, 2001; Sturkie & Johnson, 1994; West, 2013; West, Hinton, Grames, &
Adams, 2013). Note that many of these authors also weave into the history the role
of education and of accreditation of educational programs (e.g., Jordan & Fisher,
2016; Kosinski, 1982; Nichols, 1979a; Northey, 2009; Sturkie & Bergen, 2001).
Some of the highlights of this history include the founding of the original profes-
sional association—the American Association of Marriage Counselors—in 1942 (later
to become the American Association for Marriage and Family Therapy in 1979) and
the first publication of the journal of the association in 1975 (as the Journal of
Marriage and Family Counseling, which became the Journal of Marital and Family
Therapy in 1979). In 1992, regulations were published in the Federal Register grant-
ing MFTs status as the fifth core mental health profession, together with psychiatrists,
psychologists, social workers, and psychiatric nurses (Shields, Wynne, McDaniel, &
Gawinski, 1994).
Going back to Franknoi’s (2005) definition of a profession, we have several profes-
sional associations, mostly notably AAMFT and the California Association of Marriage
and Family Therapists (CAMFT) as well as the American Family Therapy Academy
(AFTA) (see Northey, 2009 for a discussion of the various professional associations
representing MFTs); we have multiple journals in the field, including the flagship
Journal of Marital and Family Therapy but also Family Therapy Magazine, for AAMFT
members to “keep in touch” as Franknoi puts it (p. 23); we have entry requirements
for the profession (the primary entry requirement now is formalized as professional
licensure as an licensed MFT [LMFT], which also includes licensure boards and an
examination [Lee, 1998; Sturkie & Bergen, 2001]); and we have continuing profes-
sional development (in the form of the Annual AAMFT Conference and innumerable
regional and local conferences and trainings), plus the vast majority of states require
continuing professional education to maintain licensure (“AMFTRB Continuing
Competency,” 2015). It is important to note that the legitimization of the profession
holds primarily in the United States and to some extent in Canada (where the
Commission on Accreditation for Marriage and Family Therapy Education
[COAMFTE] accredits educational programs and where one province has a registry
for MFTs—see Beaton, Deinhart, Schmidt, and Turner (2009) for a discussion of the
Canadian context and practice patterns) but less so in other parts of the world (see
Northey (2009) for a discussion of implications for international recognition). This is
a growing edge for the field and important future steps will involve adapting the
North American model of SFT or developing new models that fit other cultural
contexts.
Accreditation, education, and training

Accreditation has long been a strength of MFT education in North America and has
been one of the key ways that MFT is distinguished from other mental health disci-
plines. One of the keys to the development of the profession in North America has
been the rise in accreditation of education programs and the formalization of SFT
education. The COAMFTE began with the publication of the first standards for
approving training programs in 1971 and the publication of the first Manual on
Accreditation in 1975 (“The Commission on Accreditation,” 2016). The initial
558 Kevin P. Lyness
accreditation standards for education programs originally came from the AAMFT
standards for clinical membership. In 1978, the Committee on Accreditation was
recognized by the US Office of Education, Department of Health, Education, and
Welfare “as the official body for accrediting educational and training programs in the
field of marital and family therapy” (Kosinski, 1982, p. 351). At the time, this was a
very important marker for the profession to be recognized in this way. COAMFTE is
now recognized by the Council for Higher Education Accreditation (CHEA). CHEA
accredits accrediting bodies and our current CHEA recognition is important for our
programs.
Accreditation standards and the professional regulation of the field via licensure are
greatly intertwined (Kosinski, 1982; Sturkie & Bergen, 2001). For example, in the
Guiding Principles section of the current standards, the COAMFTE says: “The stand-
ards stress the development of competency that accomplishes this goal (preparing students
for licensure/certification) and include steps towards aligning accreditation and regu-
latory efforts to support reciprocity in the recognition of MFT credentials” (“Accreditation
Standards,” 2017, p. 4, italics in original). At times, the COAMFTE standards have
served as the basis for licensure laws, especially around educational and practice
standards.
The current mission of the COAMFTE is as follows: “to promote best practices
for Marriage and Family Therapy educational programs through the establishment,
review and revision of accreditation standards and policies, and the accreditation
of graduate and post‐graduate educational programs” (“The Commission on
Accreditation,” 2016, p. 18). The standards for accreditation are currently (in
2018) in Version 12, indicating that these are the 12th major version of the stand-
ards and there have been several minor revisions as well (“Accreditation Standards,”
2017).
COAMFTE accredits three types of programs (which will be described in further
detail below): master’s degree programs, doctoral degree programs, and postgraduate
degree clinical training programs. There are currently (as of the fall of 2018) 96
master’s degree programs or sites (including MCFT, MMFT, MA, MS, and MSSW
degrees), 26 doctoral programs or sites (including PsyD, DMT, and PhD degrees),
and 7 postgraduate degree training programs. The number of accredited degree
programs continues to grow and shift—in 1999, for example, there were 67 master’s
programs, 18 doctoral programs, and 23 post‐degree programs (Nelson & Johnson,
1999). The shift away from post‐degree programs is very likely tied to licensure and
the requirement of having a master’s degree in MFT as the standard educational
requirement.
COAMFTE standards have evolved in many ways since the first standards were
established. By far the biggest shift has been the move to an outcome‐based educa-
tion (OBE) model (“Accreditation Standards,” 2017; Gehart, 2011; Miller,
Todahl, & Platt, 2010; Nelson & Smock, 2005; Perosa & Perosa, 2010). Version
11 of the accreditation standards was the first version where the Commission
adopted an OBE model, where the focus is on measuring what students are able to
do as a result of their learning, rather than focusing on the content of the courses.
In Version 12, the Commission reinstituted a more detailed foundational curricu-
lum for master’s degree programs and clinically focused postgraduate degree
programs, and this also serves as a prerequisite curriculum for doctoral programs
accredited by COAMFTE.
The competency movement Nelson and Smock (2005) were among the first to write
about the role of OBE in MFT education. As they note, “Education is shifting from
a perspective of what is taught to one of what is learned” (p. 356, italics in original).
Gehart (2011) says, “Accredited programs no longer demonstrate effectiveness by
simply conforming to specific supervision ratios or total hours of experience; instead
they must demonstrate student mastery of a well‐defined set of competencies” (p. 345).
The current (Version 12) accreditation standards say this about OBE:
The primary focus of assessment is evaluating programs’ outcomes, based on specific

measures of student and graduate competency. However, to ensure excellence in
programs, accreditation includes a combination of input‐based standards and outcome‐
based standards. Input‐based standards provide consistency across programs, contribute
to a common understanding of minimum standards with accredited programs, and facili-
tate portability of education for licensure. This approach is all done within a broader
focus on outcomes that establishes the effectiveness of the programs. (“Accreditation
Standards,” 2017, p. 5)
One of the key challenges for the OBE movement remains the lack of valid and
clear measures of outcomes in MFT, though the development of the AAMFT Core
Competencies (CCs) (“Marriage and Family Therapy Core Competencies” Marriage
and Family Therapy Core Competencies, 2004; Miller et al., 2010; Nelson & Graves,
2011; Nelson et al., 2007) was one step in this direction. However, the competencies
have a number of weaknesses. The first is simply that there are too many of them
(there are 128 competencies in 6 primary domains with 5 subsidiary domains in each
of the primary areas). Second, the competencies are not easily measurable and there
are no standardized measures to do so. Finally, they are difficult to adapt to education
programs because they are written to define the level of competency for independent
practice, but this is not the end goal of education programs, and the CCs are not used
to measure competence by regulatory bodies. The only other widely used MFT com-
petency measure we have is the licensure exam (“The Commission on Accreditation,”
2016; Crane et al., 2010; Lee, 1998; Lee & Sturkie, 1997; Sturkie & Bergen, 2001),
which has its own challenges, as will be explored later in the chapter.
Miller et al. (2010) address additional challenges in adopting a competency‐based
approach in MFT, including defining competency by expertise. They note that com-
petence may be a middle level in the move from novice to expert, and they argue that
mere competence may not be the best goal (though some would argue that a master’s
degree is an entry‐level degree and that the development of expertise is not the goal).
Rousmaniere, Goodyear, Miller, and Wampold (2017a, 2017b) discuss the role of
deliberate practice in the development of excellence (moving beyond mere compe-
tence). An important movement in training that is just beginning to have an effect in
SFT training programs is a focus on client outcomes of student therapists. Baldwin
and Imel (2013) and Rousmaniere et al. (2017b) focus on the importance of ongoing
tracking of client outcomes and deliberate practice in improving those outcomes, and
Rousmaniere et al. (2017a, 2017b) link this to the development of expertise. Baldwin
and Imel (2013) particularly focus on therapist effects, and Rousmaniere et al.
(2017b) look at the role that training programs and regulatory boards can play in
helping us move toward developing excellence. This focus on professional develop-
ment is an important direction for our field that moves us beyond legitimation, but
560 Kevin P. Lyness
there is still a great deal of work to be done in understanding what makes for effective
therapists and how to best train to achieve those outcomes.
Both Gehart (2011) and Miller et al. (2010) lay out typical pathways or steps to
competence that apply to MFT education. For example, the steps that Miller et al.
(2010) suggest include a period of supervised practice and a final step of demonstrat-
ing competence through a capstone event. The accreditation standards of the field
have long required direct observation of clinical work by a trained supervisor (Nichols,
1979a), and in Version 12 of the standards, programs are expected to have targets and
benchmarks for specific learning outcomes (though these are left to the program to
identify), as well as a specific capstone experience (“Accreditation Standards,” 2017).
Still needed are valid and reliable measures of competence (Gehart, 2011; Miller et al,
2010; Perosa & Perosa, 2010).
OBE and the competency movement have also had a significant effect on the super-
vision of MFT, including in educational programs (Storm, Brooks, & Lyness, 2014).
Because supervisors are in key positions to evaluate supervisees’ competencies (Perosa
& Perosa, 2010), supervision is viewed as “the most essential avenue to competency”
(Miller et al., 2010, p. 66). Supervisors are typically expected to evaluate supervisees’
systemic practice abilities and play a key role in competency evaluation, as they are the
primary people observing therapists’ work. Other chapters in this handbook cover
MFT supervision, so refer to those for greater details about this intersection.
Research on accreditation There has been little research on issues of accreditation in

MFT education, though what has been done helps us understand the effectiveness of
accreditation in MFT. Keller, Huber, and Hardy (1988) surveyed program directors
of MFT programs (including both COAMFTE‐accredited and nonaccredited) and
clinical members of AAMFT about accreditation and training issues. Although this
research is now over 30 years old and well out of date, it does provide an early snapshot
of some of the thinking regarding accreditation issues and showed general agreement
with the appropriateness of the standards at the time.
Hines (1996) reports on another research project looking at accreditation, report-
ing on follow‐up surveys of graduates of MFT programs from 1980, 1983, and 1986.
Again, this data is outdated, but provides another initial look into the effectiveness of
COAMFTE accreditation, and one of the first looks into the professional lives of
graduates of these programs. For example, Hines found that the majority of work that
graduates did was systemic in nature (including systemically oriented individual work)
and showed the range of presenting problems that MFT graduates were treating (top
issues included marital/couple problems, depression, and parent–adolescent conflict).
Graduates felt particularly well prepared to provide marital/couple therapy, family
therapy, and individual therapy with adults and less well prepared for working with
multifamily groups and for working with children (Hines, 1996).
Although there has been more recent research on aspects of MFT training in
accredited programs, little research has explored the outcomes of COAMFTE accred-
itation. One exception is the work of Caldwell et al. (2011), who looked at COAMFTE
accreditation and MFT licensing exam success in California. The primary finding was
that students from COAMFTE‐accredited programs did significantly better on the
two California licensing exams (the Standard Written Exam and the Written Clinical
Vignette exam) than did students from Western Association of Schools and Colleges
(WASC)‐accredited or state‐approved schools. As Caldwell et al. (2011) note, while

California is unique in using its own exam for licensure, there is a great deal of overlap
with the national exam.
COAMFTE (J. Fogolin, personal communication, May 25, 2018) shared cohort‐
level data gathered in their annual reporting process, reported as a percentage of each
cohort who had taken and passed the licensing exam (either the national exam or the
California exam). This data shows that the average pass rates for full‐time cohorts (for
those cohorts where a percentage was reported) including 122 accredited programs
ranged from 93% (for the 2015–2016 cohort) to 98% (for the 2007–2008 cohort).
Master’s, doctoral, and post‐degree programs were very similar. The overall average
across full‐time and part‐time cohorts across all program types was over 95% (from
2007 to 2016). These data indicate that COAMFTE‐accredited programs are doing a
very good job of training graduates for success on the licensure exam, though this data
is limited in that it is based on program reports of graduate surveys rather than based
on data from the examining bodies (and it is quite difficult to get data on overall pass
rates and not possible to get this data aggregated by program accreditation type).
COAMFTE also tracks two other outcomes for programs: graduation rates and job
placement rates (though only master’s degree programs are required to report licen-
sure exam pass rates and job placement rates). Each program also develops and assesses
specific student learning outcomes, but these are not uniform across programs and this
data is not typically published nor reported beyond the accreditation self‐study.
Hertlein and Lambert‐Shute (2007) took another approach to studying accredited
MFT programs by surveying students about their reasons for selecting MFT pro-
grams. They asked about specific factors that influenced their choices and asked about
satisfaction with their programs. Master’s students were very satisfied with their pro-
grams, with 41% reporting that the program was exceeding their expectations while
only 6% said the program was “just falling short” and none saying the program was
not meeting their expectations. Students in doctoral programs were less satisfied, with
31% saying the program was either just falling short (27%) or not meeting their
expectations (4%). One factor in this may be that there are so few accredited doctoral
programs that it may be harder to find a good fit. It may also be that doctoral pro-
grams are generally more demanding and this may affect student satisfaction.
Nevertheless, these results show that COAMFTE‐accredited programs are generally
meeting student expectations, particularly in master’s degree programs.
Another early study compared some characteristics of COAMFTE‐accredited and
nonaccredited programs (Touliatos, Lindholm, & Nichols, 1997). Although again
this research is quite out of date, it does provide a glimpse at the field at the time.
They found that accredited programs (compared with nonaccredited ones) had fewer
students and more faculty (and the mix of faculty in master’s and doctoral programs
differed) and approved supervisors. The other major difference was that accredited
programs required more practicum semester hours than nonaccredited programs,
and there were some differences in course content implying greater emphasis on the
profession of MFT in accredited programs. COAMFTE’s accreditation standards
have clearly been important in defining the field. It will also be helpful to explore the
evolution and current status of each of the program types accredited by COAMFTE,
what makes for an MFT‐specific degree, and the role these programs play in the
profession.
562 Kevin P. Lyness
The master’s degree Everett (1979) and Nichols (1979a) were among the first to
write about the importance of the master’s degree to the field of MFT and saw the
growth of the master’s degree as a sign of the maturing of the field. Everett also
referred to the master’s as the “terminal clinical degree with the responsibility of pre-
paring practitioners for entry into the field” (p. 12). Everett highlighted that one of
the goals of the master’s degree is in “educating for a new profession and not simply
supplementing traditional clinical skills with new techniques” (p. 8). Everett went on
to describe several characteristics of master’s‐level MFT education that are still quite
relevant today, including the process of intensive selection of potential students
(revisited by Parker, Tatum, Shook, and Alexander (2003)), the requirement for a
12‐month clinical practicum, and a theoretically based graduate curriculum. Nichols
(1979a) provided more detail in the curriculum, and many of the requirements are
still reflected in accreditation and in licensure laws. Christensen, Brown, Rickert, and
Turner (1989) make the case that MFT‐specific master’s degree programs, in com-
parison with programs in other disciplines that allow a specialization in MFT, provide
more training in the relational and systemic foundation that defines the profession.
This relational and systemic focus is what has long set apart MFT training from other
that in other disciplines.
So, what else in the curriculum sets MFT education apart? The core curriculum
described by Nichols (1979a) included the following: human development (including
personality theory, human sexuality, psychopathology, and individual psychotherapy),
marital studies and therapy (including social psychological studies of marriage as well
as marital therapies), family studies and therapy (including studies of family develop-
ment and interactions as well as the theories and models of family therapy), profes-
sional studies (ethics and professional orientation to the field, with MFT programs
focusing on training in the AAMFT Code of Ethics [“Code of Ethics,” 2015]), super-
vised clinical work, and research methodology. All of these topics are still included in
the current foundational curriculum (“Accreditation Standards,” 2017). The biggest
change, other than more specificity, is the addition of content on diversity and working
with marginalized and underserved populations (note that Hardy and Keller (1991)
foreshadowed this, suggesting that emerging trends in MFT education included
“cultural diversity and minority students” [p. 306] and “gender sensitivity” [p. 307]).
Another recent shift has been from training master’s students in research methods in
such a way that they would be engaged in research production to training MFTs to be
research‐informed clinicians (Hoff & Distelberg, 2017; Karam & Sprenkle, 2010;
Williams, Patterson, & Edwards, 2014). This is in contrast to the scientist–practitioner
model (Karam & Sprenkle, 2010) that influenced the development of research training
in MFT programs. The majority of master’s degree programs in MFT are practitioner
focused, with very few requiring students to be engaged in research or produce a the-
sis. The shift in language in the accreditation standards reflects this change in emphasis
as well (i.e., “becoming an informed consumer of couple, marriage, and family therapy
research”; “Accreditation Standards,” 2017, p. 30). One challenge in this shift is that
many students coming into doctoral programs are less prepared in research methods
than in the past, and those students from master’s programs that require a thesis are at
an advantage in research‐oriented doctoral programs.
The master’s‐level curriculum in MFT emphasizes a relational and systemic
approach to each area in the curriculum and includes significant content on MFT
theories and models. The other distinguishing factor in MFT training is the emphasis
on practicum and internship experiences that include a significant percentage of rela-

tional hours (i.e., face‐to‐face client contact with couples and families). Edwards and
Patterson (2012) believe that the clinical practicum/internship is the most significant
part of MFT students’ training. The current standard is that programs should require
500 hours of client contact and that least 200 of those should be relational hours, with
the following qualification: “Alternatively, the program may demonstrate that gradu-
ating students achieve a competency level equivalent to the 500 client contact hours.
The program must define this competency level and document how students are
evaluated and achieve the defined level” (“Accreditation Standards,” 2017, p. 33).
The hours requirement has undergone a couple of notable shifts in the last two
revisions to the accreditation standards. Version 10.3 of the standards required 500
total client contact hours and 250 relational hours, while in Version 11 the hours
requirement appeared in the Educational Guidelines and included a similar qualifica-
tion as found in Version 12 regarding demonstrating alternative competency (“MFT
Educational Guidelines,” 2005; sec. 201.02).
Currently (“State Practicum Requirements,” 2017), only 12 state licensure boards
require 500 hours, 1 state requires 360 hours, 23 states require at least 300 hours, and
4 states require less than 300 (ranging from 150 to 280). Ten states either don’t
specify any practicum requirements or they specify by length (9–12 months) or credit
hours (e.g., nine semester credits). There is no research that has explored the compe-
tency of therapists at different numbers of hours; thus there is no evidence that
500 hours is better than 300. The field will benefit from clearly defined competency
levels that might be able to be tied to number of hours of practice.
However, a case can be made for requiring 500 hours of clinical practice in the
master’s degree. One of the strengths of MFT training has historically been the high
threshold of hours needed, and there has been widespread belief that 500 hours of
clinical training is preferable to a lesser standard. If nothing else, the increase in hours
provides exposure to a wider variety of cases and presenting problems and to a wider
variety of clients and personalities and provides more opportunities for deliberate
practice and supervision (Rousmaniere et al., 2017b). In addition, requiring 500 hours
ensures maximum portability of the degree (clearly meeting qualifications for clinical
requirements in every state in the United States).
As our accreditation standards and training affect licensure laws, we can see this
influence in the requirements for relational and systemic training (Crane et al., 2010).
Crane and colleagues looked at the licensure requirements for six mental health
disciplines and conclude:
A marriage and family therapist is required to have three times more family therapy
coursework than any other professional mental health discipline. Also, before becoming
licensed a marriage and family therapist, [sic] must complete 16 times more face‐to‐face
family therapy hours than a mental health professional from any other discipline. (p. 357)
While other fields may include some content on MFT theories or systemic practice,
MFT programs infuse this content throughout the degree and apply a relational and
systemic focus across the curriculum.
The doctoral degree While the master’s degree is the primary professional degree and
terminal clinical degree (Chen, Austin, & Hughes, 2018; Karam & Sprenkle, 2010),
564 Kevin P. Lyness
the doctoral degree has seemed to lack a clear purpose (Wampler, 2010), though Lee
and Nichols (2010) do spell out three goals for the doctoral education of “profes-
sional marriage and family therapists” (p. 259), which include “sophistication of
family systems scholarship, socialization into the profession of MFT, and cultivation
of professional maturity” (p. 259), and it may be that each program has a clear p urpose
but the purposes are not uniform. For all of the history of MFT education, there have
been many more COAMFTE‐accredited master’s programs than doctoral programs,
and today there are only 22 universities offering accredited doctoral programs in the
United States (two universities offer either multiple degrees or degrees at multiple
sites for a total of 26 programs). Because the master’s degree is the level required for
licensure, it is likely to continue to be the case that the vast majority of those trained
as MFTs will do so in master’s degree programs, though Nichols (1979b) notes that
prior to the advent of licensure, the expectation was that MFT training would take
place post‐master’s degree, both in doctoral programs and in post‐degree institutes
that were more numerous at that time.
For many years the doctoral degree has seemed to be an extension of the master’s
degree (Lee & Nichols, 2010). In Version 11 of the COAMFTE standards, the cur-
riculum standard for doctoral programs said, in part “The doctoral curriculum builds
upon the foundation of the master’s curriculum” (“Accreditation Standards,” 2005a,
p. 10), and the Educational Guidelines note that doctoral curricular areas are a
continuation of the master’s‐level curriculum areas “at a doctoral level of sophistica-
tion” (“MFT Educational Guidelines,” 2005b, sec. 300.01). Prior to 1995 there was
no clear description of the doctoral curriculum beyond noting that it should be devel-
opmentally advanced over the master’s curriculum (Lee & Nichols, 2010).
It is clear that doctoral programs should be at an advanced level, and should include
significant research content, but not all doctoral degrees in MFT are PhDs—there are
accredited DMFT and PsyD programs (which are professional doctorates rather than
research doctorates), and there are different models of doctoral education based on
university setting (Wampler, 2010). In the institutional model (Wampler, 2010),
doctoral programs are housed in tuition‐driven institutions and in departments that
are more clinically focused. All of the accredited DMFT and PsyD programs and some
of the PhD programs fit this model, and the focus is often less on research than on
advanced clinical, teaching, and supervision training. The majority of PhD programs
take a more balanced approach that Wampler calls the Community of Scholars model
and reside in Human Development and Family Studies (HDFS) (or similar) depart-
ments at higher ranked universities. The Community of Scholars programs focus on
balancing research and clinical training and emphasize collaboration between students
and faculty on research and clinical work (Wampler, 2010), and Wampler includes
most of the research‐oriented doctoral MFT programs in this model. Only a few
doctoral programs follow what Wampler calls the Star Researcher model that empha-
sizes grant funding with highly focused programs of research.
One of the greatest shifts in accreditation standards that has come about in the age
of OBE is that the doctoral curriculum has become much more defined in terms of
competencies, so each area of the COAMFTE Advanced Curriculum describes com-
petencies to be developed rather than specifying courses to be taken. The move away
from input‐based standards has also led to no longer requiring a doctoral internship
(which had been a large part of the doctoral training model—see Ivey and Wampler
(2000)). Version 12 refers only to “advanced practical experience” (“Accreditation
Standards,” 2017, p. 34), which may include “any of the following: advanced research,
grant‐writing, teaching, supervision, consultation, advanced clinical theory, clinical
practice/innovation, program development, leadership, or policy” and “The advanced
experiences offered by doctoral degree programs must address a minimum of two of
the areas noted above and combined be over a minimum of 9 months” (p. 34).
The most consistent call in recent writing about doctoral education has been to
improve the research training and research output of such programs, and to do so by
adopting a scientist–practitioner model (Crane, Wampler, Sprenkle, Sandberg, &
Hovestadt, 2002; Hodgson, Johnson, Ketring, Wampler, & Lamson, 2005; Lee &
Nichols, 2010; Sprenkle, 2002, 2010; Stith, 2014; Wampler, 2010; Woolley, 2010).
McWey et al. (2002) surveyed COAMFTE programs about their clinic‐based research
and provided suggestions based on their findings, including (among other things)
creating a culture of research in the program (which is a theme in the other works
noted above). Almost all of these authors agree on the need for more research
productivity from MFTs as a way to further the professionalization of MFT, rather
than the current situation where those with other professional identities carry out
much of the research on the practice of MFT.
One recommendation has been to create practice research networks (PRNs) for
pooling research data across programs (Johnson, Miller, Bradford, & Anderson,
2017; Wampler & Bartle‐Haring, 2016). Johnson et al. provide this definition:
A Practice Research Network (PRN) is a collaborative effort among researchers, clinical

agencies, and private practices to share common assessment measures and protocols to
create high quality data sets and provide feedback for clinical and research purposes.
PRNs facilitate evidence‐based practice, as clinicians can use methodologically sound
assessments to inform their clinical work. (p. 563)
The use of PRNs also facilitates the clinical outcome assessments highlighted by
Baldwin and Imel (2013) and Rousmaniere et al. (2017a, 2017b) by facilitating
deliberate practice via client feedback and monitoring of client outcomes. Wampler
(2010) also suggests more generally that research collaboration across programs is
needed to strengthen the research culture. Version 12 of the standards takes steps to
address this need for more research training. Version 12 includes an Advanced
Curriculum Area on Advanced Research and explicitly lists advanced research in the
advanced practical experience component (“Accreditation Standards,” 2017). While
the PhD is a research degree, because there are also professional doctorates in MFT
and because some programs emphasize different aspects of doctoral training (includ-
ing advanced clinical training and training in teaching and clinical supervision), the
current accreditation standards are broad enough to encompass this diversity.
One of the goals of many MFT doctoral programs, especially PhD programs, is to
train the next generation of academic faculty in MFT training programs. The current
COAMFTE standards require that the majority of core faculty members in accredited
programs have the professional identity of MFT, and one way to demonstrate that, in
part, is through graduation from a COAMFTE‐accredited degree program. Several
master’s programs have set up doctoral internships specifically designed to train future
academics, based on the model presented by Miller, Todahl, Platt, Lambert‐Shute,
and Eppler (2010). Miller and Lambert‐Shute (2009), in a survey of doctoral stu-
dents in COAMFTE‐accredited programs, found that those students wished for more
566 Kevin P. Lyness
training to prepare them for academia. There are many challenges in preparing stu-
dents for academia, including limited opportunities for teaching, limited grant‐writ-
ing opportunities, and limited time available to both students and faculty for
mentoring. In addition, many doctoral students do not wish to pursue academic posi-
tions (the average cohort size in doctoral programs is around 6 students, and the
average graduation rate seems to be around 50%, meaning that there could be over 60
graduates of doctoral programs or more per year and there are many fewer academic
openings each year).
While the primary goal of master’s programs seems clear—preparing clinicians for
practice—doctoral programs have multiple goals, including preparing future research-
ers and faculty members, but also preparing advanced clinicians in professional
doctorates. This diversity makes the job of describing doctoral programs more d
ifficult
but ultimately serves our field.
Post‐degree programs In accreditation there has been a clear shift away from post‐
degree programs, as their numbers have dwindled to just seven accredited programs.
The majority of these programs (six of seven) are in institute or agency settings rather
than traditional academic settings. Before licensure and the professionalization of
MFT, many people were trained in another discipline and sought out post‐degree
training in MFT to gain this specialized skill (rather than to adopt the professional
identity). Now the primary pathway to MFT practice (and credentialing) is via a mas-
ter’s degree in couple or marriage and family therapy.
One of the major challenges for accrediting these post‐degree programs has been
that they often lack the infrastructure to gather and maintain the data necessary for
OBE‐based models of accreditation, and OBE has not been a good fit for the training
models in these programs, and the value of accreditation for these programs has dwin-
dled. The remaining programs have been committed to accreditation and have worked
with COAMFTE to develop the skills needed to gather the data they need. Version
12 of the COAMFTE standards did work to address the needs of post‐degree
programs (which were not even mentioned in the standards in Version 11), and
COAMFTE recognizes that the primary goal of most post‐degree programs is
advanced relational/systemic clinical training, though Storm et al. (2014) note that
some postgraduate programs also focus on supervision training. Very little is written
in the literature about post‐degree programs (though see Herz and Carter (1988) for
an outdated look at these programs).
Additional trends in MFT education There are a few other recent trends in MFT
education that are worth noting, as they show where the field is moving. One is in the
incorporation of common factors in education (e.g., D’Aniello & Fife, 2017; Karam,
Blow, Sprenkle, & Davis, 2015) and looking at therapist factors in MFT (e.g., Blow
& Karam, 2017). There have also been recent studies looking at student learning and
supervision experiences in MFT programs (e.g., Piercy et al., 2005, 2016), explora-
tions of students’ experiences of and training in specific gender and diversity issues
(e.g., McDowell, Brown, Cullen, & Duyn, 2013; McDowell, Storm, & York, 2007;
McGeorge, Carlson, Erickson, & Guttormson, 2006; Quek, Eppler, & Morgan,
2016; Winston & Piercy, 2010), and examination of content areas like human sexuality
(e.g., Zamboni & Zaid, 2017) and sexual orientation (Carlson, McGeorge, &
Toomey, 2013; Henke, Carlson, & McGeorge, 2009; McGeorge, Carlson, & Toomey,
2015), to specialty areas like MFT (e.g., Hodgson, Lamson, Mendenhall, & Crane,
2014; Zubatski, Harris, & Mendenhall, 2016). There are many others who are not
listed here doing excellent work in expanding the field of education in MFT, but
space constraints limit how many can be mentioned.
Licensure and the regulation of the profession

Establishing licensure for MFTs has been another important milestone in the devel-
opment of the profession. California became the first state to license MFTs in 1963,
and they have now been joined by all 50 states and the District of Columbia (Caldwell
et al., 2011; Kosinski, 1982; Northey, 2009; West et al., 2013). In each state, the
basic educational requirement is a master’s degree in MFT or a related degree with
specific educational requirements that include specific MFT course content (“State
Licensure Comparison,” 2018). The Association of Marriage and Family Therapy
Regulatory Boards (AMFTRB) provides updated charts and tables on their website
(www.amftrb.org) with details about the educational, practicum, and post‐degree
practice requirements for each state, along with links to each state’s licensure board.
The AMFTRB is the organization that supports state licensure boards by “providing
a clearinghouse for information and research, producing and maintaining the Marriage
and Family Therapy National exam, crafting model law, and facilitating communica-
tion among our stakeholders” (AMFTRB, n.d.).
The rationale for regulation of MFTs includes establishing legitimate credentials for
practice, based on appropriate education and training from legitimate sources, estab-
lishing and holding professionals accountable to ethical standards, and defining the
boundaries of practice, including who can practice and what is the scope of that
practice, as well as protection for the public (Sporakowski, 1982). Sturkie and Bergen
(2001) also highlight these rationales in their book on the professional regulation of
MFT. Sturkie and Johnson (1994) provided a good early look at the process of regu-
lating MFTs and clearly described distinctions among types of credentialing, includ-
ing registration, certification, and licensure, with licensure being the most restrictive
form. At this time, licensure is the norm in all 50 states, but in Canada there is only
registration and only in two provinces (Ontario and Québec; see https://camft.ca/
regulation), and other countries do not regulate the profession.
West et al. (2013) explore the shift that has taken place in the field with the advent
of licensure across the United States. As they note, “The responsibility for regulating
the profession, which historically has been one function of the AAMFT, is now carried
out by state regulatory board with the assistance of the AMFTRB” (p. 116). West
et al. (2013) also found that fewer than one‐third of LMFTs are members of AAMFT,
so while AAMFT and COAMFTE have influenced licensure laws and educational
requirements, this role continues to shift to the states and their licensure boards. The
move away from input‐based accreditation standards with Version 11 also put pressure
on this relationship, as many states had relied on COAMFTE for providing curricu-
lum standards. The foundational curriculum in Version 12 is one attempt to regain
the place of COAMFTE in state regulation. Another shift in state regulations has
been a move to requiring a 60‐semester‐credit master’s degree (rather than relying
solely on COAMFTE accreditation). One result of this shift to state regulation is
inconsistency of training and background for MFTs, though West and colleagues did
find increasing consistency in comparing 2007–2012 requirements.
As was discussed earlier in this chapter, the licensure exam is one of the primary
mechanisms we have to establish the competence of MFTs in practice, and there is
568 Kevin P. Lyness
quite a bit of information available about the exam (e.g., Coombs, 2015; “Handbook
for Candidates,” 2018; Lee, 1998; Lee & Sturkie, 1997; Sturkie, 2005; Sturkie &
Johnson, 1994; Sturkie & Bergen, 2001; West, 2013). What sets the MFT licensure
exams apart from other licensing exams is content on MFT theories and models and
the application of these to relational clinical practice.
Research on the exam and the profession There has been little published research on
the MFT exam and licensure, but there has been some, and it fits with more general
research about the profession, including cost‐effectiveness and practice pattern
research. The work of Caldwell et al. (2011) was detailed earlier in this chapter (and
showed that graduates of COAMFTE‐accredited programs in California did better on
the exams in California than graduates from nonaccredited programs). Lee (1998)
also reported on a survey of over 1,000 participants on the exam from the mid‐1990s.
Lee found that graduates of COAMFTE‐accredited doctoral programs did signifi-
cantly better on the exam than did psychologists. In addition, those who reported less
than 10% of their therapist practice was with families scored significantly lower on the
exam (helping to make the case for requiring a percentage of relational practice in
degree programs and post‐degree clinical experience). Given that this data is now over
20 years old, it would be very helpful to replicate this study. There is a larger question
as to whether the exam correlates with effective practice or measures actual compe-
tency, and the exam seems to focus on traditional MFT theories rather than on newer
approaches, which again may be a disconnect from actual current practice.
One study has shown a link between licensure type and outcome. A recent study by
Moore, Hamilton, Crane, and Fawcett (2011) looked at the role of license type on
outcomes of family therapy. Moore et al. used CIGNA data from 2001 to 2004 to
examine treatment dropout, recidivism, and cost‐effectiveness, comparing LMFTs to
MDs, nurses, psychologists, social workers, and professional counselors. They found
that LMFTs had the lowest dropout rates and lowest recidivism and that they were
more cost‐effective than psychologists, MDs, and nurses in providing family therapy.
There is also research on the practice patterns of MFTs (Northey, 2002; Simmons
& Doherty, 1995, 1998). In 1998, Simmons and Doherty looked at the academic
backgrounds of clinical members of AAMFT and compared various practice variables
and client outcomes across groups. In this study there were few differences across
academic backgrounds, though as all were clinical members of AAMFT, they all had
an orientation to MFT and at least some common training. Northey (2002) and
Simmons and Doherty (1995) explored practice patterns of MFTs, again using clini-
cal membership in AAMFT as a selection criterion. Both of these studies show that
MFTs treat a wide range of clinical problems using different treatment modalities
(including individual work from a relational perspective as well as relational work with
multiple members present in the room).
Conclusions and Recommendations
This chapter has examined the profession of MFT and many of the characteristics that
make it a profession. Specifically, the chapter has explored professional regulation of
the field, and the roles of the professional association (AAMFT), the Commission on
Accreditation and the role of accreditation in shaping the field, specific issues in the
education of MFTs and what makes our education unique, and the role of licensure
and what we know about MFTs in practice. MFT is a vibrant and growing profession
with demonstrated effectiveness and cost‐effectiveness, a healthy and dynamic set of
educational programs, and mature professional regulation.
So, what is next for the profession? First, we do not have very good data on many
aspects of the profession. We need more research on a whole range of important ques-
tions: How does accreditation affect student outcomes (including their own compe-
tencies and also their outcomes with clients)? How do we measure competency? How
do we measure expertise? What accounts for differences between therapists in SFT
work and how to do we train students to be better SFTs? Are there really differences
in competency level depending on the number of hours of clinical experience in a
graduate program? Does the licensure exam really measure competence in SFT
practice? There are many more questions that we do not have data on either, but these
are perhaps among the most important.
A second area involves inclusion and nomenclature. Throughout this chapter the
term MFT has been used because in North America licensure and regulation use this
title. But the title of the field is exclusionary and does not capture the range of s ystemic
practice that we engage in. This will likely be a long battle, and there is often pushback
in the field to any attempt to address this (as evidenced by a very public battle within
the Association over language in the drafting of Version 12 of the Accreditation
Standards).
Third, in North America, we will need to grapple with how the field has changed
with the advent of master’s‐level licensure and the increased role of state and provin-
cial regulatory boards in defining the training standards and competency measures
(such as the licensure exam). What role does accreditation play in this new climate?
And how can we create more consistency across jurisdictions and potentially increase
the portability of licensure?
Fourth, another challenge for the field lies in the need to diversify and better under-
stand the barriers and opportunities in the field related to diversity. While there have
been a few studies that have focused on the minority experiences in educational
programs, and we have made strides organizationally with things like funded minority
fellowship programs, we are just beginning to think differently about the inclusion of
minority and underrepresented groups in SFT training and credentialing. We need
data on outcomes for students and trainees on whether our models of training work
and what alternatives there might be and data on other outcomes (like licensure exam
pass rates) across diverse populations. One idea that has come up several times is
working to have a COAMFTE‐accredited training program in a historically black
college or university.
Finally, looking beyond North America, what will be the role of the profession?
What role will the International Accreditation Commission for Systemic Therapy
Education (IACSTE) play in the expansion of SFT internationally? The International
Family Therapy Association created the IACSTE several years ago for “development
and implementation of quality standards for programs around the world that provide
systemic therapy education and training” (International Family Therapy Association,
n.d.), and to date very little attention has been paid to this organization (with
COAMFTE seeing it as a potential rival, though the scope of COAMFTE limits their
ability to accredit programs internationally to date). But SFT training is expanding
beyond North America in many places (just one example is that there are two SFT
570 Kevin P. Lyness
programs in Turkey that are accredited by IACSTE: Bilgi University and Ozyegin
University). Overall, IACSTE accredits 13 programs, though only 5 are not located
in the United States. There are a great many questions to be answered here as well:
How do we measure competency cross‐culturally? What are educational best practices
cross‐culturally? What does it mean to be an SFT in other parts of the world?
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25
Supervision in Systemic
Family Therapy
Marj Castronova, Jessica ChenFeng, and
Toni Schindler Zimmerman
The profession of systemic family therapy (SFT) is well regarded for the breadth and
depth of its supervision. Supervision is a distinct area within SFT with a designation,
a body of literature, and requirements to meet high standards. The requirements to
become an American Association for Marriage and Family Therapy (AAMFT)
Approved Supervisor (AS) include the ability to develop and articulate a personal
philosophy of supervision. This philosophy must include the following learning objec-
tives: evidence of systems thinking; clarity of purpose and goals; roles and responsibili-
ties; preferred processes of supervision; evidence of sensitivity to contextual factors;
ethics and legal issues; awareness of personal and professional experiences that impact
supervision; supervision models; and connection between one’s own therapy model
and supervision model (AAMFT, 2016). Approved supervisors must demonstrate
competency in all the areas to meet the designation requirements. This chapter is
organized by these learning objectives. We will begin with the sensitivity to contextual
factors learning objective as we regard this objective as foundational to all the others.
To be an effective SFT supervisor, we must be intentional in addressing issues related
to oppression, racism, privilege, power, marginalization, and a global context. These
are essential and will also be integrated into the other learning objectives covered in
this chapter.
Learning Objective: Sensitivity to Contextual Factors
The SFT supervisor is responsible for understanding and being sensitive to contextual
factors including but not limited to race, gender, ethnicity, religion, age, ability, socio-
economic status, sexual orientation, and the intersectionality of these. Sensitivity to
the personal (i.e., stereotypes, implicit, and explicit bias) and institutional (i.e., judi-
cial, economic, education, health care) oppression that those from marginalized pop-
ulations face is essential if we are to engage in meaningful relationships in therapy and
supervision. We know cultural differences influence feedback in supervision. For
instance, supervisors of European descent are more inclined to give feedback about
578 Marj Castronova et al.
specific counseling skills, whereas supervisors of non‐European descent address aware-

ness of cultural sensitivity (Burkard, Knox, Clarke, Phelps, & Inman, 2012). When an
SFT supervisor lacks cultural awareness (the ability to recognize difference) and/or
cultural sensitivity (the ability to attune to difference), we know that cultural context,
power, and intersectionality are rarely considered or discussed (Gutierrez, 2018).
Quality multicultural supervision involves the following: recognizing cultural systems
and multiple cultural interactions; maintaining a strong alliance with an open and safe
space; examining personal worldviews, power, privileges, and biases; questioning
one’s own cultural sensitivity; working with supervisees to identify prejudices; enhanc-
ing non‐stereotyped cultural knowledge bases; and developing an ongoing openness
to difference (Gutierrez, 2018). Supervisors must commit to ongoing learning related
to self‐awareness, examining and managing privilege, and understanding how the
experiences of oppression influence the lives of people in profound ways. Continued
learning can include relevant shared readings and TED Talks to increase knowledge
and understanding. It also can include experiential activities to increase attunement of
power differentials (Zimmerman, Castronova, & ChenFeng, 2016).
For example, fill out a Supervision Social Location Map Form (see Figure 25.1)
for each client discussed in supervision and include the location of the trainee and
supervisor. The visual of who is located where for multiple social locations areas are
useful in keeping power differentials central throughout the supervision discussion.
To move from writing on the map to an experience, try the following. Put 8–10
chairs in line all facing forward one behind the other like a bus. Alternatively, use
pieces of paper placed in a line on the floor to stand on. Think of the chairs (or
papers) as the human race where those in the back have more barriers in their lives,
an unfair start, and can become invisible to those facing forward in front of them.
Work with the trainee to determine (roughly) where the client, the trainee, and the
supervisor might sit (or stand) if represented in the Supervision Social Location
Map. For instance, a trainee may sit or stand where their elderly, transgender, black
client might be given the intersection of multiple oppressed identities. The supervi-
sor and trainee must be attuned to the racism, bias, trauma, oppression, and maybe
even violence that the client has and continues to face. Staying attuned and sensitive
to context is essential to do no harm. Harm can be done when the supervisor and the
trainee confuse what we wish were true; an equal and just world with what is true;
significant historical and current disparities. We are not sitting side by side all in a
row as some are located in the back of the row and some are in the front. These
power differentials cannot be ignored or minimized as we cannot be sensitive to
context if we are colorblind or simply see all races as equal, rather than understand
racism and its profound impact. To not recognize oppression or to minimize it is to
contribute to it and do harm.
The CARE model (ChenFeng, Castronova, & Zimmerman, 2017) is a way to stay
attuned to power differentials in supervision (see Figure 25.2). In this chapter, we
have added an “i” to represent intersectionality. The iCARE lens is a way for the
supervisor to walk through cultural complexities using a framework (see Figure 25.3).
iCARE lens
In considering cultural complexities in a way that creates safety for trainees and clients,
two critical elements are needed: intersectionality and cultural humility. Intersectionality
Social location map form
Client(s) Therapist Supervisor
Most privileged Less privileged
Gender Men That is, Women, transgender, genderqueer, nonbinary,
gender fluid
Race White That is, Black, Asian, native American, multiracial (lighter
tones tend to have more privilege)
Religion Mainstream Christianity That is, Jewish, Muslim
Age Middle age and young That is, Elderly, teens

adults
Ability Fully able That is, Disability physical, mental, or cognitive
Cognitive and physical
Class Upper and middle income That is, Homeless, poor, lower income
Culture Western culture – That is, Collectivism, Tribalism, Jewish, Muslim

individualism
Ethnicity European American African American, Nigerian,
Asian American, Hmong Hispanic American,
Latinx, indigenous
Education College education That is, Trade school, military, high school, GED
Sexuality Heterosexual That is, Bisexual, gay, lesbian, asexual, queer
Spirituality Moderate expression That is, High or low expression
In each category write how the client(s), therapist, and supervisor identify themselves and along the privilege continuums add an x to indicate
the degree of lived experiences with institutional disparities, discrimination,and oppression. Consider identifiers and the way in which they
intersect to inform privilege. Other identifiers can be added, such as language, appearance, family structure, geographical background, etc.
Privileged categories vary in different global context.
Figure 25.1 Social Location Map Form.

Connecting with supervisees through sharing backgrounds/context
A ppreciating privilege, power, and biases
R atifying a cultural knowledge base with cultural humility
Embracing our role as social justice agents
Figure 25.2 CARE Model.
Intersectionality
• I–low • I–high
• C–high • C–high
Connecting Appreciating
Cultural humility
Sharing Privilege, power, bias
backgrounds/context
Ratifying Embracing
Cultural Social justice role
humility/knowledge
• I–low • I–low
• C–low • C–high
Figure 25.3 iCARE lens.
is a critical element in the iCARE lens as it addresses “the interaction between gender,
race, and other categories of difference in individual lives, social practices, institutional
arrangements, and cultural ideologies and the outcomes of these interactions in terms
of power” (Davis, 2008, p. 68). When the supervisor or trainee has lived in the major-
ity population with majority rules and norms, it is difficult for them to recognize or
understand the complexities of intersectionality and how they have impacted marginal-
ized communities. This lack of awareness can lead a supervisor and trainee to ignore
and marginalize the complexities of cultural influences (Gutierrez, 2018). This can
happen in the therapy room from a client, a peer therapist, or even a supervisor. It is
the supervisor’s responsibility to attend to working with the trainee by validating and
processing through their experience and then working to create accountability and
Supervision 581
empowerment for the trainee (Hernandez & McDowell, 2010). Intersectionality in

the iCARE lens is considered on a continuum of low to high.
Cultural humility is the second essential concept in the iCARE lens and it is also
considered on a continuum from low to high. It is the “ability to maintain an inter-
personal stance that is other‐oriented (open to the other) in relation to aspects of
cultural identity that are most important to the client” (Hook, Davis, Owen,
Worthington, & Utsey, 2013, p. 354). SFT supervisors and trainees all have their own
beliefs, values, and worldviews that are heavily influenced by their own experiences.
Cultural humility is best expressed when supervisors do not assume their own compe-
tence in culture knowledge; rather they remain humble and curious and express
respect with cultural differences and unique variations within cultural differences. The
variations of cultural humility and intersectionality are briefly described in Figure 25.3.
High in cultural humility and high in intersectionality We know that when supervi-
sors are high in cultural humility and in intersectionality, strong alliances are built with
supervisees. This is critical to quality supervision and essential to working with train-
ees of different social demographics (Inman, 2006). The acknowledgment of the role
of power, privilege, and bias is important to the development of a trainee’s ability to
be multicultural (Hird, Cavalieri, Dulko, Felice, & Ho, 2001), and multicultural
supervision is a critical factor to the development of the trainee’s self‐efficacy
(Constantine, 2001).
Low in cultural humility and high in intersectionality When supervisors are low in
cultural humility and high in intersectionality, there is a tendency to make assump-
tions based on privilege, power, and biases. While the supervisor sees intersections,
they may see all oppressions as equal and conflicting intersections may be ignored or
missed. Rather than maintaining a curious and culturally humble stance, the supervi-
sor may make assumptions about their cultural knowledge being accurate and thus
lacks in respectful openness and collaborative supervision. Supervisors who are low
in cultural humility may also struggle with emotionally attuning to cultural differ-
ences and examining their own worldviews, privileges, and biases. A lack of cultural
humility weakens the supervisor–supervisee relationship and alliance may be
threatened.
High in cultural humility and low in intersectionality When the SFT supervisor’s
cultural humility is high and intersectionality is low, there is a curiosity about power,
privilege, and biases; however they are blinded by their own bias of “the way things
should be.” It is hard for them to tolerate incongruence or experiences of oppres-
sions in supervisees, including the ability to reconciling differences that conflict
with their own worldviews, power, privilege, and biases. For instance, if a supervisor
focuses on just one dimension of diversity, such as gender, the socially constructed
intersects of gender within socioeconomic class, sexual orientation, nation of origin,
ethnicity, and sexual orientation that organize family forms and various dimensions
of social inequality will be missed. Furthermore, if a supervisor does not consider
spirituality, especially when working with marginalized populations, they are miss-
ing an important dimension that influences every aspect of life, including sociocul-
tural beliefs, family traditions, everyday practices, and personal belief systems
(Aponte, 1994).
Low in cultural humility and low in intersectionality When supervisors are low in
both cultural humility and intersectionality, social context may rarely be discussed and
the potential for experiences of marginalization increase. Hardy (2008) makes this
point when he uses irony to give tips to minority trainees when their supervisor lacks
in cultural humility and or intersectionality. He advises them to “develop comfort
with being judged by others’ standards” as the dominant group often views themselves
as knowledgeable enough to criticize the minority trainee for being “too abrasive,”
“too emotional,” or “too passive” (Hardy, 2008, p. 468). When supervisors are una-
ware of the complexity and oppressions within intersectionality, they have limited
awareness that it is a prominent factor in marginalized communities.
Other mental health professions and the future of social context

Since contextual factors and systemic influences are viewed as distinguishing elements
of SFT supervision, we want to consider what other mental health professions are
contributing to our understanding of diversity. A significant amount of multicultural
supervision literature is being developed, and there are professional journals dedicated
to multiculturalism, such as the Journal of Multicultural Counseling and Development.
Other mental health professions have adopted multicultural competencies (American
Counseling Association [ACA], 2015a, 2015b; American Psychological Association
[APA], 2017) and developed assessments in diversity to guide supervisors and clini-
cians (Pope‐Davis, Toporek, & Ortega‐Villalobos, 2003; Wong & Wong, 2000). The
Multicultural Supervision Scale (MSS) (Sangganjanavanich & Black, 2011) assesses
the “supervisors’ multicultural competencies in a variety of personal dimensions
including ethnicity, cultural heritage, gender, sexual orientation, age, spiritual belief,
socioeconomic status, body image, and disabilities” (pp. 20–21). The Cultural
Humility Scale (CHS) (Hook et al., 2013) measures the client’s perception of the
therapist’s cultural humility. Closer to home, Inman (2005, 2006) developed the
Supervisor Multicultural Competence Inventory (SMCI) to assess a supervisor’s
multicultural competence in five areas of supervision: “supervisor–supervisee personal
development, case conceptualization, interventions, process, and outcome/evaluations”
(Inman, 2006, p. 77).
Learning Objective: Evidence of Systems Thinking
Traditional approaches to therapy and supervision were linear and causal. As sys-
temic thinking influenced the development of marriage and family therapy (MFT)
theories, new models of supervision were needed to teach the complexities of
working with systems. The premise of the systemic perspective, “the whole is
greater than the sum” (Aristotle, Metaphysics, Book VIII, 1045a, pp. 8–10; von
Bertanlanffy, 1968), came out of multiple epistemologies including cybernetics,
anthropology, mathematics, communication, and biology. Central to the develop-
ment of early systemic thinking in therapy was the revolutionary idea of working
with the family and the identified patient. For a broad overview, Jordan and Fisher
(2016) provide a “historical supervision genogram” that demonstrates the evolu-
tion of SFT supervision (pp. 6–7).
Supervision 583
In considering issues of diversity in our history, Hardy and McGoldrick (2008)

remind us that while the originators of family therapy were white, they were interested
in cultural impact: Bateson was a cultural anthropologist, Weakland studied anthro-
pology, and Watzlawick was a linguist who had lived in a multitude of cultures.
Walters, Carter, Papp, and Silverstein (1988) brought the contexts of power, inequal-
ity, and gender as critical elements needing attending in systemic thinking. Aponte
(1994) has unswervingly reminded us of the cultural ties of spirituality and ecology.
Boyd‐Franklin (2003) and Falicov (1995) have specifically addressed culture and its
impact on family systems for decades.
Underlying tenets to systemic thinking

The underlying principles of systemic thinking include the idea of recursion, feedback,
homeostasis, openness/closedness, morphostasis/morphogenesis, rules and bounda-
ries, entropy/negentropy, and equifinality/equipotentiality. We are intentionally con-
sidering these core systemic tenets through a social contextual lens to demonstrate the
fluidity of their integration.
Recursion or reciprocal causality Supervisors need to consider and attend to their

own culpability to reciprocal causality discrimination in therapy. There is little research
on trainee’s experiences of racism in the therapy room and supervision (Ali et al.,
2005); however there is evidence that it does occur (Sue et al., 2007). Hardy (2008)
reminds us that while the SFT profession claims to value diversity, it still remains
largely homogenetic and paradoxically recommends the following to shift the hidden
recursion patterns of racism in our field:
Never discuss race. Remaining mute regarding race and racial issues is extremely impor-
tant. Discussing race might review that you are hypersensitive about skin color or that
you have unresolved racial issues that warrant resolution. If you must discuss race during
a moment of weakness, use acceptable code words, such as “minority,” “ethnicity,”
“cultural diversity,” or “others” to deemphasize race. Discussing race makes everyone
tense and should be avoided, even if it makes matters worse for you personally. (Hardy,
2008, p. 464)
Supervisors must take the lead and have conversations about race. In order to do this
effectively, they must work to understand oppression, both the experiences of it and
the data about it. An example of this is being informed about mass incarceration. The
documentaries by Ava DuVernay’s (2016) 13th Amendment and Michelle Alexander’s
(2012) The New Jim Crow: Mass Incarceration in the Age of Colorblindness are power-
ful depictions of racial inequality in the prison system.
Feedback, homeostasis, morphostasis, and morphogenesis Supervisors attend to and

teach supervisees to recognize and work with the various feedback sources that influ-
ence the relational system as the systemic theory of change says that when one part of
a system changes, the other parts are impacted. Anything that has the potential to
change the relational system is feedback, including the very processes of therapy and
supervision. The system itself strives for maintaining its level of functioning prior to
the feedback and this is known as homeostasis. The SFT supervisor is working with
the supervisee to recognize when a client’s relational system is in a state of morphos-

tasis (stability turned stagnant) or morphogenesis (change turned to chaos). Finding
a balance between these two states can be complicated. Derrick (2005) notes that
when she attended an AAMFT AS course, she was asked to define what the word
supervisor meant to her:
I immediately found a huge lump in my throat and rage swelling throughout my body. I
had images of the supervisor of many small boys who had sexually, physically, and psy-
chologically harmed them for years in the residential school in the community. (p. 48)
The word supervisor connected her to images and emotions of harm and genocide
in her own Native American relational system, and as Derrick (2005) steps into her
role of supervising and training non‐Native people, she often finds herself breathing
slowly, praying, and forgiving. She strives for morphogenesis, yet encounters mor-
phostasis when white therapists say, “Stop being dramatic or political” or “It’s time to
move forward and to forget the past” (Derrick, 2005, p. 48). Occasionally Derrick
experiences a morphogenetic response when someone acknowledges they did not
know and want to figure out how to work together.
Rules and boundaries Rules and boundaries can vary greatly when attending to cul-
tural uniqueness. For instance, a trainee from an individualistic culture may initially
view a client from a collectivist culture as having an extended family with “too much”
influence, rather than considering how the rules and boundaries may be different in a
collectivistic culture. SFTs are trained to value difference in their clients, but their
own biases show up in the therapy room. It is the SFT supervisor’s role to work with
the trainee in helping them to see difference in cultural values and to not misinterpret
them or see them as wrong (Gutierrez, 2018). Helping the supervisee remain curious
about how the client’s culture may have influenced the rules and boundaries and
consider how their own culture has influenced their own ideas, relational rules, and
boundaries is essential.
Openness/closedness Each relational system has a continuum of openness to clos-

edness that allows for information to flow into and out of the system. A variety of
factors determine openness or closedness of a system. The supervisor is attending
to this continuum given the presenting problem, the needs of the client’s rela-
tional system, and the various contextual influences on and in the system. For
instance, when working with first‐ and second‐generation minority immigrants
where the presenting problem is parental conflict between the generations, it is
important to note how social location can affect one’s view of the problem. If a
trainee is a first‐generation immigrant, she/he may inadvertently try to guide a
second‐generation immigrant client toward respecting their elders and all the sac-
rifices that were made on his/her behalf, whereas a white trainee born in the
United States may not be aware of how the parent–child conflict is due to
acculturation and the openness or closedness of the second generation. When
supervisors are working from a model‐specific supervision process, such as
Bowenian, the integration of theory and cultural values may vary the openness or
closedness of the system when considering constructs like differentiation, chronic
anxiety, and togetherness and separation.
Supervision 585
Equifinality/equipotentiality The premise of equifinality is that regardless of where

the relational system starts, the end result is the same. SFT supervisors work with
trainees to see problems as interactional patterns between people and/or social con-
texts. These interactional dynamics occur within, between, and among subsystems.
The supervisor is guiding the supervisee to develop the ability to create different end
states. This is called equipotentiality and it is here that the SFT supervisor works with
the supervisee to understand the difference between process and content. Process is
who says what, to whom, in what way, with what outcome, whereas content is the
words that are actually said. SFT supervisors who are considering social contexts
might need to take more time to consider content (cultural knowledge) in order to
consider the processes of power, privilege, and bias.
The heart of systemic supervision looks through the lenses of recursion, feedback,
homeostasis, morphogenesis, morphostasis, rules, boundaries, openness, closedness,
equifinality, and equipotentiality. Learning systems is akin to learning a new language
and a new way of viewing problems through deeply ingrained, redundant patterns. It
takes time to move from a linear, individualist way of looking at problems, and when
we do, we also must begin to look at the larger systemic contexts. Hardy (2008) para-
doxically states: “But when working with minorities, you must ignore these concepts.
Thinking too systemically could force you to challenge many traditionally held beliefs
regarding therapy with minorities” (p. 467). If our supervision is truly systemic, we
will indeed be confronted with how racism and marginalization are deeply embedded
in the minority experience. All SFT supervisors come from at least one position of
power and privilege (i.e., educational), and we must be aware that our privilege can
cause us to miss systemic influences in marginalized populations. Remaining culturally
humble and learning to tolerate the ambiguity in conflicting intersectionalities is
essential to SFT supervision.
Learning Objective: Clarity of Purpose and Goals for Supervision
The purpose and goals for supervision can include meeting required hours for intern-
ship or licensure, learning more about a specific theoretical orientation, or focusing
on specific core competencies. Ideally, the supervisor and supervisee will negotiate the
goals together and they will align with the purpose of supervision. The essence of all
supervision goals is to develop confident, competent relational (systemic), and con-
textual therapists. Effective supervision contributes to the development of supervisees
who are confident in their own authentic style and is successful, effective, and ethical
in their work with clients. Foundational to reaching these goals is a quality supervisor–
supervisee relationship.
The strength of the supervisor–supervisee relationship is a major contributor to
successful supervision. It predicts supervisee satisfaction (Ladany, Ellis, & Friedlander,
1999). It is directly related to the supervisee outcomes (Ellis & Ladany, 1997). The
supervisor–supervisee alliance also mediates burnout, secondary traumatization, vital-
ity for the supervisee (Deihl & Ellis, 2009), and the relationship between supervisor’s
multicultural competence and supervision satisfaction (Inman, 2006). Therefore,
building a trusting alliance between supervisor and trainee is foundational to meeting
the purpose and goals of supervision. Attending to self‐of‐the‐supervisee including
setting goals related to exploring their own social location and identity and that of
their clients is also essential.
In considering clarity of SFT purposes and goals, the AAMFT core competencies
provide the standard. Couple and family therapy programs accredited by Commission
on Accreditation for Marriage and Family Therapy Education (COAMFTE, 2017)
are required to have mechanisms in place to assess the development of student’s com-
petencies. When supervising postgraduate, pre‐licensing level supervisees, the core
competencies can continue to be a mechanism for assessing progress while accounting
for where the supervisee is developmentally.
Learning Objective: Clarity of Supervision

Roles and Responsibilities
Roles and responsibilities identified in supervision include teacher, coach, educator,
mentor, colleague, monitor, administrator, client care manager, guide, model, gate-
keeper, supporter, consultant, and so forth (Lee & Nelson, 2014; Morgan & Sprenkle,
2007; Taibbi, 1990). These roles and responsibilities must be managed carefully as
they often involve dual relationships such as thesis advisor, agency administrator in
charge of raises and evaluations, and clinical supervisor. For example, a faculty member
may be the trainee’s supervisor and their thesis advisor. If the student is missing
deadlines related to their thesis work, it is not appropriate to bring that into the super-
vision relationship. These are separate roles that have different competencies for the
trainee to meet.
Some trainees may come from backgrounds where speaking up or questioning
someone in authority may be against their cultural value system. Other supervisees
may take up more talking turns in a group supervision setting and struggle to fully
listen to others. Supervisors need to be clear with supervisees that it is the responsibility
of all involved to listen with an open mind, share thoughts and ideas, suspended judg-
ment, embrace humility, and respect differences. The supervisor is responsible for
ensuring these responsibilities are embraced and followed in order to create a safe
working environment.
Learning Objective: Evidence of Awareness of Personal

and Professional Experiences That Impact Supervision
Relationship building involves knowing one’s self and knowing the other. In the
supervisory relationship, this involves both personal and professional knowing.
Ammirati and Kaslow (2017) have posed that “all supervisors are capable of deliver-
ing harmful supervision, and may have, in fact, harmed a supervisee at some point in
their career; this is a disquieting and sobering fact” (McNamara, Kangos, Corp, Ellis,
& Englann, 2017, p. 136). Reviewing what we know about the best and worst super-
vision experiences can help us to minimize harm. There are two key studies that guide
SFT supervisors in understanding the best and worst supervision experiences
(Anderson, Schlossberg, & Rigazio‐DiGilio, 2000; Piercy et al., 2016). Anderson
Supervision 587
et al. (2000) used two dimensions of supervision, communication and respect, in

understanding quality supervision. The first dimension, communication, is strong
when supervisors are warm, friendly, trustworthy, and straightforward in feedback,
accepting of mistakes, encouraging experimentation, and providing experiences that
are safe and open to feedback. The second dimension, respect, is strong when super-
visees feel like they are respected and treated like a colleague, differences are valued,
new ideas are allowed, and there is an understanding of their personal time demands
(Anderson et al., 2000). In Piercy et al.’s (2016) qualitative analysis of the most
meaningful experiences in SFT training, supervision was more effective when it
included: theoretical foundation and practice, supervisor–supervisee relationships,
collaborative environment, client progress, self‐of‐therapist experiences, and
vulnerability.
In contrast, the least meaningful experiences were lack of personal connection, no
connection between theory and practice, negative experiences with clients, and lack of
diverse perspectives (Piercy et al., 2016). In considering the communication dimen-
sion, supervisees describe their worst supervision experiences as closed, rigid, critical,
“indirect and avoidant communication, emphasizing supervisees’ shortcomings, and
supervisors’ preoccupation with their own problems” (Anderson et al., 2000, p. 86).
Negative experiences in the second dimension, respect, are felt when supervisors are
“assuming authoritarian or demeaning stances, encouraging unthinking conformity,
failing to accept divergent viewpoints, and subtly devaluing supervisees on the basis of
gender” (Anderson et al., 2000, p. 86).
When considering supervisees’ impression of the quality of their supervision across
disciplines, the following was discovered: 57% of supervisees said that their supervi-
sion was outstanding; 65% of supervisees noted that their supervisors had specific
training in supervision; 51.5% of supervisees stated that they had received harmful
supervision at some point in their training; 25% indicated that they currently were
receiving inadequate supervision and that one‐third of these supervisees felt their
clients were harmed by this; and 75.2% felt that they were experiencing or had expe-
rienced inadequate supervision (Ellis, 2010). These are sobering statistics.
In order for a supervisee to be open and share their anxieties, triggers, implicit
bias, personal background, and mistakes, the supervisor must also be vulnerable.
Mutual sharing contributes to a solid and safe foundation in the supervision relation-
ship (Rigazio‐DiGilio, 2016). Attention to person‐of‐the‐supervisor means being
aware of your own triggers, how your own background influences you, and recog-
nizing your own implicit bias. Supervisors that share self with trainees, while attend-
ing to professional boundaries, create an alliance that is more authentic. Sharing self
can include admitting your mistakes as a supervisor, willingness to repair versus being
defensive when you are challenged by a supervisee, sharing your own triggers and
how you manage them, and being more aware and attuned to issues of oppression
and marginalization. In quality supervision, Marovic and Snyders (2010) note that
the person‐of‐the‐supervisor is attentive to second‐order cybernetics where the
supervisor is reflective and recognizes the supervisor self as a professional self that is
subjective and limited in personal knowledge.
Supervision is one of the major contributors to a supervisee’s ongoing growth and
development, including learning to use self‐of‐therapist therapeutically (Aponte &
Ingram, 2018). Important to self‐of‐therapist work is the supervisee’s ability to use
their social locations, “lifestyle, values, and life experiences in forming working
relationships, achieving insightful assessment, and implementing effective interven-

tions with their clients” (Aponte & Ingram, 2018, p. 45). While supervisors must
have boundaries to avoid doing therapy with their supervisees, it is still imperative that
the supervisee feel safe to talk about their personal experiences in relationship to how
they are impacting the therapy process. For instance, if a supervisee is going through
a divorce, they may need extra support to avoid transference with clients in similar
circumstances.
Hernandez and McDowell (2010) proposed that supervisors and supervisees need
to “acknowledge histories of oppression and be accountable for legacies of privilege
within local and global contexts” (p. 29) in their journey of self‐of‐the‐therapist.
When trainees are able to reach into their own painful history and recognize themes
attached to it, such as powerlessness and rejection, the trainee is better able to connect
and empathize with the client’s pain (Aponte & Nelson, 2018). The supervisee is
then able to provide the client with an experience where they are “heard by a society
that could be deaf and immovable, especially to people from relatively powerless sec-
tors of society” (Aponte & Nelson, 2018, p. 41). Conversations of difference can be
complicated. Supervisors must be aware of their own power and privilege in order to
authentically and with sensitivity engage in these discussions, ensuring that supervi-
sees are not silenced or, worse, experience oppression and marginalization similar to
what they experience in their everyday life.
Learning Objective: Preferred Supervision Models and the

Connections Between Personal Therapy and Supervision Model
A continuing discourse in SFT supervision is whether we should or should not have
an agreed‐upon, research‐supported, systemic model (Morgan & Sprenkle, 2007;
Storm, Todd, Sprenkle, & Morgan, 2001; White & Russell, 1997). Early supervisors
had little formal training in supervision and relied on their particular theory to pro-
vide direction for training new clinicians. Today we know that the supervision rela-
tionship is different than the therapy relationship, the emphasis is different, and the
skills are different. When supervising from a specific model, the supervisor may
approach competencies through a specific theoretical lens. For instance, a strategic
supervisor may focus on developing skills of naming problems in ways that are solva-
ble, breaking redundant patterns, and learning to develop direct and indirect inter-
ventions. Many supervisors are broader in their supervision, and, while guided by
preferred theoretical models, they are also working from other frameworks. One such
framework is attention to the supervisee’s development (Morgan & Sprenkle, 2007;
Rigazio‐DiGilio, 1997). When supervising a trainee in their first semester of seeing
clients, the emphasis is different than supervising someone who has almost met all the
requirements for licensure. With a new trainee, a supervisor may coach the trainee on
how to greet a new client in the waiting room, for instance, say the client(s) name
rather than walking up to who you think your client is. This can help avoid assump-
tions based on the client’s name, referral source, presenting problem, or sexual
orientation.
White and Russell (1997) note that social role model is a useful framework for
supervision in that it addresses many dimensions similar to systemic thinking as it
Supervision 589
considers supervisor variables, supervisee variables, relationship variables, supervision

process variables, and contextual variables. This framework also invites the supervisor
to stay attuned to their various roles (i.e., teacher, consultant, mentor) and to be
intentional about these roles. Roles can also include conceptual considerations, such
as monitoring, evaluating, instructing, advising, modeling, consulting, and self‐
evaluating (Holloway, 1995). Feminist supervision models focus on five common
concerns: gender issues, power inequities, diversity issues, the role of emotion, and
process of socialization (Prouty, 2001). The supervision literature includes what
constitutes good supervision, including skill‐based objectives like the AAMFT core
competencies (Nelson et al., 2007). Rather than looking for the “the systemic model”
of supervision, Morgan and Sprenkle (2007) proposed a common factors approach to
supervision looking for commonality across all supervision models and processes.
They proposed three dimensions: emphasis dimension (clinical and professional com-
petence), specificity dimension (supervisee, idiosyncratic and profession, nomothetic),
and relationship dimension (collaborative and directive). They also created a map of
four primary roles in supervision: coach, teacher, mentor, and administrator.
While we still have not created a unified systemic model of supervision that can be
tested and evaluated, supervision models such as a common factors or social justice
emphasis are present in our literature (ChenFeng et al., 2017; Karam, 2016; Sprenkle,
Davis, & Lebow, 2009; Zimmerman et al., 2016). Regardless of the model or
approach, supervisors need to make sure their style of supervision is congruent with
their own approach to therapy. A good fit between the supervisor’s theoretical clinical
goals and approach to therapy and to supervision is imperative.
Learning Objective: Clarity of Preferred Process of Supervision
Quality systemic supervision takes place using many formats: individual, dyad, and
group; live, audio, video, or technology assisted; frequency; and contracting and
evaluating. Systemic supervisors strive to use a combination of formats with their SFT
trainees, thus having the ability to provide feedback and case supervision from multiple
experiences.
Organization of supervision
In both the individual and group supervision formats, there are multiple formats that
can be used to enhance learning, such as co‐therapy, live, video, reflecting teams, or
case notes. The individual format of supervision is either one supervisee or a dyad of
supervisees and has consistently been the primary source of supervision in the SFT
field (Lee, Nichols, Nichols, & Odom, 2004). This type of supervision is intimate in
its format and allows for richer, relational development in order to build trust, take
more time to review cases, and maximize attention on the trainee’s development.
One‐on‐one time also provides a supervisee a private space for self‐of‐the‐therapist
work (Aponte & Carlsen, 2009).
The group supervision format includes a supervisor and three or more trainees up
to six or eight trainees depending on the ratio allowed by accreditation and governing
bodies. This format of supervision provides supervisees with multiple perspectives,
social support, direct and indirect learning, group process (which must be monitored
carefully), and agreed‐upon goals and strategies for effectiveness and efficiency.
Additional group formats like reflecting teams and case presentation can enhance the
process.
In any setting, individual, dyad, or group, the supervisor establishes the level of
safety for the supervisee(s). In individual supervision the supervisor can focus on cre-
ating an alliance with the supervisee and attending to self‐of‐the‐therapist issues. In
group supervision there is a complex matrix of social locations in the room, including
power differentials, privilege differences, bias, and conflicting intersections, in and
between the supervisees and the supervisor. It is the responsibility of the supervisor to
be attentive to the interactions between the supervisees to create a safe space where
one voice is not privileged over any other voice/perspective (attending to power
dynamics). There is limited research on individual and group supervision; and our
premises about the effectiveness of individual and group supervision are based on
assumptions, rather than solid measures of effectiveness. Research is needing to learn
about the complexities of how power, privilege, and social location impact the dynam-
ics in group supervision. We know that trainees do experience marginalization in the
supervision process, and it is imperative that we understand when this happens and
learn to create safer environments and experiences for all trainees.
Formats of supervision
Observational (or direct) approaches to therapy such as live, video, and audio are
recognized as the strongest forms of supervising despite the lack of evidence
(Silverthorn, Bartle‐Haring, Meyer, & Toviessi, 2009). Some of the real issues influ-
encing the access to these types of supervision are coordination, ethical/legal issues
and liabilities, equipment/technology, the costs of people’s time (DeRoma, Hickey,
& Stanek, 2007), the trainee’s level of anxiety, and the client’s concerns. Essential to
the live and video formats are a positive, validating, and growing experience for the
trainee.
Live supervision is in real time and is one of the hallmarks of SFT supervision
(Storm et al., 2001). A one‐way mirror and/or technology that is ethical and legal
allows the supervisor to observe and work with the trainee while they are doing ther-
apy. We know that live supervision has a significant impact on the trainee’s perception
of the progress of therapy (Silverthorn et al., 2009); however we do not know if it
influences the effectiveness of therapy and trainee growth. The live format provides
the supervisor with an opportunity to provide instant feedback by using the call‐in
method or taking a mid‐session break.
The format of reviewing video or audio segments of sessions is a useful format for
observing micro as well as macro aspects of a session. This format provides opportuni-
ties for stopping and starting the video/audio of the session in order to discuss what
is happening and what the supervisee was thinking during that session. It is important
to consider how the supervisor–supervisee alliance, social locations, privilege, and
power might be playing into the type of video clips the supervisee is showing or not
showing. Questions to consider as follows: are they from a culture where it is impor-
tant to please someone in power; what does it mean culturally for the supervisee to be
vulnerable to a person of power; when the supervisor has more privilege, how does
Supervision 591
this impact the supervision dynamic of the trainee showing a video clip of success with
a case verses being stuck with a case?
Case consultation is the highest used form of supervision (DeRoma et al., 2007)
where cases are discussed by reviewing case notes or a written case presentation where
trainees share their view of how they are conceptualizing the case, defining the
presenting problem is, mapping the redundant pattern, generating the hypothesis,
creating the goals, and discussing possible intervention. The majority of supervision
occurs postgraduate and is done via case notes/case presentations. If SFT supervisors
are only doing case note supervision, they are deferring to the supervisee’s perspec-
tive. When assessing attunement to power and context, seeing sessions live or by video
can facilitate evaluating the process and content in this area. Not all supervisors have
access to a one‐way mirror, but this does not need to limit live and recorded formats.
Many HIPAA compliant platforms are available for recording and watching live
sessions. Before you utilize this option, check with your state board to ensure you are
using state‐sanctioned platforms and formats. This can vary greatly from state to state.
Also consult with AAMFT for guidance at the national level regarding what is
recommended.
Technology has rapidly changed and enhanced our abilities to supervise, but the
laws and ethical codes have struggled to keep pace. Changing statutes that regulate
the profession take time, money, and lobbying. For instance, many states allow for
some continuing education credits to be “distance education,” but they do not allow
for online “real‐time” supervision. Technology that meets the ethical and legal stand-
ards can provide supervision that is live (real time), but online supervision is still in the
process of being recognized by licensing bodies. Another consideration is the laws
governing geographic regions; when supervisors live in different licensing regions,
these hours are rarely if ever counted for licensure. Some governing regions may allow
supervisors to watch a postgraduate trainee via an online live format, while other
states may only allow for an on‐site live supervision through a one‐way mirror.
Caldwell, Bischoff, Derrig‐Palumbo, and Liebert (2017) provide best practice guide-
lines and recommendations in regard to online couple and family therapy, and while
these are not specific to the supervision process, these best online practices can provide
guidelines for online supervision.
Bringing recorded therapy sessions to supervision is accessible given that the major-
ity of computers/laptops have recording capabilities and encrypted devices such as
USB flash drive can easily and affordably store the session. We know that monitored
and recorded sessions help the supervisee in their professional development; however,
Ellis (2010) noted that “When there was a bad working relationship, anxiety was
high; in a good working relationship, anxiety was low” (Ellis, 2010, p. 102).
Contracting and frequency

Supervision by nature is an agreement to provide certain services. A formal, clearly
written supervision contract with expectations is an important starting place for a suc-
cessful supervision experience. In order to develop an effective contract, the supervi-
sor should be clear about the frequency of supervision and the evaluation process that
will help both the trainee and the supervisor track progress toward goals that are
stated in the contract. Bernard and Goodyear (2009) have created a list of the basic
essentials of a solid supervision agreement including supervisor’s background, meth-

ods, supervisor’s responsibilities, trainee’s responsibilities, confidentiality and risk
management policies, financial agreement (including fees, cancelations, frequency of
supervision), goals of supervision, evaluation of supervisee, expectations about state
laws and ethical codes, duration and termination of contract, and so forth. Supervisors
should check the literature, consult with colleagues, consider the state licensing laws
(required frequency and ratio of supervision), and AAFMT Code of Ethics (2015) in
terms of creating an inclusive supervision contract (Lee & Nelson, 2014). The super-
visory contract should clearly state how the supervisor expects the trainee to manage
the laws related to the limits of confidentiality including duty to warn, minors in
therapy, maintenance of records, ethical and legal compliance, suicide and homicide
ideations, child and elder abuse, and threats to national security.
Evaluation
Perosa and Perosa (2010) note that the vast majority of evaluations in supervising
SFTs are informal and this has come with great risks to the advancement of the SFT
profession. Accredited SFT training programs are required to document their success
in training clinicians and in doing so have developed evaluation tools. Evaluations in
the post‐master’s/pre‐licensure supervision process may be less formal or nonexist-
ent. Regardless of the type of evaluation process, we highly encourage SFT supervi-
sors to consider the AAMFT core competencies with the supervisees. These core
competencies provide a guide on specific skills needed for quality therapy and provide
supervisors with a guide to self‐reflect on their supervision process. Supervisors can
ask themselves questions such as “is the trainee showing competence in this area,” “is
my reaction more about a difference in therapy style or is this a competency issue,” or
“would I give this feedback if my trainee was male or white?” Engaging in self of
supervisor is important when giving feedback and evaluating. The core competencies
can also provide a way to give feedback when a trainee is struggling in an area. If a
trainee is missing documentation deadlines, review together the core competencies
that address this as part of creating an improvement plan. If a trainee is struggling
with implicit bias related to an identity of their client, review together the core com-
petencies that address this and create a treatment plan (i.e., readings, interviews,
meeting with persons from this identity who are in the profession). When a trainee is
impervious to change, the supervisor’s role as gatekeepers of the profession may be
necessary.
The supervisor can create a Likert scale and evaluate the supervisee on the AAMFT
core competencies that are related to the goals for supervision. Supervisors can also
use evaluation tools such as Gehart’s (2010) three rubrics for evaluating systemic case
conceptualization, clinical assessment, and treatment planning. D’Aniello and
Hertlein (2017) created an evaluation tool based on AAMFT core competencies.
Miller, Duncan, and Johnson (2002) developed the Outcome Rating Scale (ORS) to
assess where the client’s progress and the Session Rating Scale (SRS) to gain feedback
from the clients on how the therapist is doing. Assessing the supervisor’s working alli-
ance and the trainee’s working alliance using the Working Alliance‐Trainee Version
(WAI‐T) (Bahrick, 1990) and the Working Alliance‐Supervisor Version (WAI‐S)
(Bahrick, 1990; Bordin, 1983) are also useful tools in evaluating the supervision
process. Self‐of‐the‐therapist can be assessed using Aponte and Carlsen’s (2009)
Supervision 593
Person‐of‐the‐Therapist Supervision Instrument and Post‐Supervision Questionnaire.

Avila et al. (2018) have developed a measure to assess the systemic dynamic in the
supervisory relationship. Being intentional in finding ways to evaluate the various
components of supervision is an important tool for the successful supervision.
Learning Objective: Evidence of Sensitivity to

Ethics and Legal Issues
The SFT license is continuing to expand in its scope of practice and globally. It is
incumbent on the supervisor and the supervisee to know the laws that regulate the
professional field in the geographic location where they practice as these statues stipu-
late scope of practice, licensure requirements, confidentiality and/or privilege, man-
dated reporting, and who can use the SFT professional title. The scope of practice
(the kind of therapy services) the SFT can practice is stated in the laws and may differ
by jurisdiction. For instance, some US states allow MFTs to do psychological testing
while others do not. Diagnosing is permissible in some states and is not in others.
Globally, countries such as Russia are working toward creating common standards in
training and certification (Bebtschuk, Smirnova, & Khayretdinov, 2012). It is the
supervisor’s responsibility to guide the trainee through these complexities and to
assure they stay within their legal scope of practice.
Supervisors also need to be aware of how the governing body defines the type of
training, coursework, and supervision that an SFT trainee needs to become licensed.
The purpose of licensure and regulations is to protect consumers from harm and the
supervisor is often guiding the supervisee in this process. Governing bodies also have
specifics in terms of hours, such as how they are accumulated during graduate school
or how many can be counted toward the license. Reciprocity is another issue a super-
visee must consider, as it still is not a guarantee that an SFT license is 100% transport-
able between US states or other countries. Supervisors are responsible to be familiar
with the requirements of their governing body specifically in terms of laws that regu-
late the training and supervising of SFT trainees.
Knowing the laws and ensuring that they are followed is a collaborative process
between the supervisee and supervisor. When dilemmas and concerns come out in
supervision, it is the supervisor who guides the supervisee in doing the right thing
legally while teaching the supervisee how they came to that conclusion and what laws
guided those decisions and actions. It is important for the supervisor to have a clear
understanding of their governing laws in terms of reporting abuse (children, elderly,
and dependents), reporting threat to life, responding to subpoenas, limits of confi-
dentiality, and privilege. Laws vary in terms of reporting abuse, such as in “reasona-
ble” or “suspicion” as well as the length of time a therapist has to report. Confidentiality
can vary in different governing regions as some laws clearly describe the client as the
relational system and other laws are less clear and allow for one person in the system
to legally break confidentiality. Supervisors need to assure that trainees are providing
clarity to their clients as to the scope and limits of confidentiality in their disclosures
statements as part of informed consent for therapy.
Learning the process for ethical decision making is an important part of the devel-
opment of a competent SFT. Supervisors become the guide in assisting the supervisee
to recognizing ethical situations and developing an ethical decision‐making process.

This includes knowing the scholarly literature, laws, ethical codes, when to consult
others, and so forth. Many ethical decision‐making models are in the literature and
can be useful when supervisors are guiding supervisees (Kitchener, 1985; Mowery,
2009; Vivian‐Byrne & Hunt, 2014; Zygmond & Borrhem, 1989).
The SFT profession is continually navigating technology, ethics, and law. While the
technology is available to do supervision online, the majority of governing bodies
have not made provisions for it, nor do they allow for supervisees to work with super-
visors from other states. The following states currently have laws allowing for online
supervision: Arizona, Colorado, Florida, Kansas, New Jersey, Utah, and Wyoming
(Caldwell et al., 2017). Models like emotionally focused therapy (EFT) (Johnson,
2000) have taken advantage of online supervision for certification; however, most
SFT state laws will only recognize supervision toward licensure that is done by a
licensed and approved supervisor in their own state. We have yet to realize the impact
and potential our SFT supervision can have globally in training and working with
families as we navigate through the complicated legal and ethical aspects. We as super-
visors, our trainees, and their clients are bombarded with information, and it has
created new relational dilemmas for our clients and for us in how we practice, train,
and supervise.
Learning Objective: Awareness of Requirements for AAMFT

Membership, Regulatory Requirements, and Standards
for the Approved Supervisor Designation
The SFT field is highly invested in supervisors being specifically trained in systemic
supervision and offering outstanding and meaningful experience to supervisees. As
previously discussed, the AAMFT has developed the AAMFT AS designation, which
is a separate and specific designation requiring additional education and training. We
know that supervisors who have specific training in supervision had lower reports of
harm by their supervisees (Ellis, 2010). Requirements for becoming an AAMFT AS
can be found in the AAMFT AS Handbook available at www.aamft.org as well as what
is needed to maintain the AAMFT AS.
One of the biggest challenges to the AAMFT AS is the concept of intersectionality.
As we strive for more diversity in our supervision, we will be confronted with complexi-
ties and contradictions. We will need to learn “acknowledgement of differences and
related systems of oppression, domination, or discrimination that stem from a position
of power and privilege in society” (Gutierrez, 2018, p. 15). We are extremely limited
in our awareness and understanding of how this impacts our supervision process (Cho,
Crenshaw, & McCall, 2013; Hernandez & McDowell, 2010). If we really understand
that intersectionality demands our awareness and involves acknowledging oppression,
domination, and discrimination; what kind of changes might we make in how we
mentor in the AAMFT AS? Is it possible that our expectations as a supervisor are filled
with the very essence of power, privilege, and bias? There are significant costs involved
in becoming an AAMFT AS, whether it is through a doctoral program or a master’s‐
level clinician pursuing the designation on their own. While the minority fellowship
scholarships have created financial incentives for training clinicians while they are in
graduate school, we have not made similar strides in the supervision training process.
Supervision 595
In considering the contextual issues around the AAMFT AS designation, some

readers considering the designation may wonder if it is worth getting the designation,
and some trainees may wonder if it is worthwhile to find an approved supervisor
versus a licensed professional to supervise them. We believe it is worth it for SFTs who
supervise. The commitment and emphasis on supervision is a testament to the welfare
of the clients and to the advancement of the trainee and the SFT field. The SFT field
believes that being an effective supervisor is a specialization beyond being a therapist.
It provides a solid framework through excellent training and mentoring and a solid
standard of care. SFT training and/or licensure is becoming more global and the
emphasis on supervision is central to this. We also believe it is worth it for supervisees
whenever possible, to work with a supervisor that is not only licensed, but also has
supervision training and preferably the AS destination.
We also know that supervision is the essential element for international students as
they report having a difficult time transferring US‐based MFT training (Guvensel,
Dixon, Parker, McDonald, & O’Harra, 2015; McDowell, Fang, Kosutic, & Griggs,
2012; Mittal & Wieling, 2006); international supervisees noted that supervisors
“guided and supported them to gain self‐awareness” and helped to “develop clinical
competency by focusing on the ‘self‐of‐the‐therapist’ rather than on how to apply a
specific approach or a set of techniques on a clients’ presenting issues”; mentorship;
and “positive impact of the strength of the supervisory relationship on their develop-
ment as an MFT” (Guvensel et al., 2015, pp. 434–435). The students also felt it
would be important to “maintain a connection with their U.S. supervisor” upon
returning to their home country (Guvensel et al., 2015, p. 435). Globally there is a
call for a supervision standard. For instance, in Russia, there is a call for the develop-
ment of “common standards in training, certification and supervision” for systemic
family therapists as there is not a consistent common standard for supervision and it
is typically done as a part of “direct work with families in the training group under the
observation of experienced teachers and creates a unique opportunity for directional
formation of professional consciousness, skills and identification” (Bebtschuk et al.,
2012, p. 125).
Concluding Comments
Researching SFT supervision is difficult for a number of reasons: a lack of funding

sources and difficulty in attaining participants especially in the postgraduate arena;
however, it is “imperative that we conduct studies to examine the satisfaction and
outcome of supervision, for supervision is one part of what distinguishes SFTs from
other mental health professionals” (Cheon, Blumer, Shih, Murphy, & Sato, 2009, p.
63). In the last few years, our personal and professional worlds have expanded beyond
the imaginable. We are no longer restricted to a worldview that is in our immediate
vicinity; rather we have instant access to a global view and global exchange. Social
media has created simple connections to long lost friends and family members as well
as invited virtual strangers into our lives. Quick texts, acronyms, and emojis are forms
of communication. Search engines like Google and Alexa have given us instantaneous
access to information (some accurate and some not so accurate). No longer is there
waiting for the evening news—it is immediate. The images we see are no longer
filtered or edited; rather they are real time and can be violent and graphic. It is hard
to imagine what the early founders of the MFT field would say about how technology
has changed our world and influenced our relationships. Would Whitaker be doing
online therapy so every family member could be in the room? How would Bowen
posture emotional cutoffs with unfriending or ghosting someone on Facebook?
Would Satir create family groups on Facebook and have individuals do self‐reflective
blogs?
In considering the future of SFT supervision, technology is a vehicle that we need
to consider. It is the mechanism that lets us consider supervising globally. A supervisor
in the United States could work with an MFT trainee in Rwanda, and this could even
include live supervision. The use of technology will challenge our supervision process,
roles, goals, and models. Another area of consideration is the nature of the supervi-
sion relationship and the strength of the alliance. While we know alliance is essential,
we do not know the essential components of building the alliance. The vast majority
of our supervision research is housed in SFT graduate programs; given this, we know
little about supervision in the postgraduate, pre‐licensure setting. This limits our
understanding of what helps a trainee develop in supervision. In moving globally, we
also need to further our culturally sensitivity and be able to adapt as new information
enters the supervision process. How will our supervision change when we are working
in collectivist cultures? How will our supervision change when we are working in
contexts with ongoing war? Are there ethical challenges that we are unaware of?
Facebook saw a rapid explosion globally and encountered ethical situations they never
imagined. While the very beginning of the SFT field includes global perspectives (i.e.,
Milan), we are still working on translating our systems thinking (Bebtschuk et al.,
2012; Ellis, Creaner, Hutman, & Timulak, 2015; Guvensel et al., 2015; Son, Ellis, &
Yoo, 2007). The AAMFT AS designation has been in existence for almost 50 years.
This is less than one lifetime, and given all the changes in our world and the explosion
of technology, we have accomplished more than one might imagine. How do we keep
improving the quality of SFT supervision and manage the change that is inevitable?
SFT supervisors are continually exposed to new and ever‐changing flows of informa-
tion, and since this is the essence of our systemic thinking, we have the ability to
continue to grow and change.
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26
Multilevel Assessment
Todd M. Edwards, Lee M. Williams, Jenny Speice,
and Jo Ellen Patterson
A glimpse into a contemporary session would reveal a family therapist assessing rela-
tionships, cognitions, emotions, and behaviors of individuals, couples, and families.
The days of identifying as a purist have given way to more integrative thinking, partly
due to the demands placed on family therapists by clients presenting with multiple,
complex problems, and practice settings that are multidisciplinary, which require fam-
ily therapists to communicate with diverse audiences (e.g., physicians, mental health
funding sources). Although the distinction between family therapists and other men-
tal health professionals may have diminished over the years, family therapists continue
to bring a unique approach to assessment. A traditional family system’s view means
that the family is the unit of understanding and care, no matter who comes to therapy.
Even when working with individuals, family therapists understand their clients’
relational and cultural contexts and recognize that there are multiple perspectives to
any problem. Family therapists prioritize relationships in assessment by opening their
doors to family members and other caregivers.
Engel’s biopsychosocial (BPS) model can help family therapists organize and
understand assessment data (Engel, 1977). The BPS model describes an expansive,
layered hierarchy of systems that are in constant interaction over time. Although the
BPS model was developed to train physicians, it is compatible with systemic family
therapy (SFT) by emphasizing the linkages between systems. Therapists cannot fully
understand a system (or part of a system) without understanding its relevant con-
text. Whereas Engel was trying to help physicians understand the psychosocial
aspects of their medical concerns, proponents of a BPS model within SFT aim to
help family therapists understand biological, psychosocial, and spiritual influences,
particularly in situations where clients are coping with serious physical and/or men-
tal illness (McDaniel, Doherty, & Hepworth, 2014; Shields, Wynne, McDaniel, &
Gawinski, 1994).
Since Engel’s seminal article was published in 1977, research has found significant
connections between biological, psychological, and family functioning. Family
therapists have known for years that high expressed emotion in families can worsen
602 Todd M. Edwards et al.
schizophrenic symptoms (McFarlane, Dixon, Lukens, & Lucksted, 2003). Children

who experience multiple traumatic events in their upbringing are particularly vulner-
able to both mental and physical health problems. The longitudinal Adverse Childhood
Experiences (ACEs) Study indicates the strong association between household
dysfunction and later life problems. For example, an ACE score above 6 is associated
with a 30‐fold increase in attempted suicide (Felitti et al., 1998). Research on bipolar
illness and other affective disorders suggests that while individual symptoms can be
recognized and perhaps treated with medication or by other means, the symptomatic
person may experience fewer relapses if they feel the support and love of family (Beach
and Gupta, 2006; Clarkin & Glick, 1992; Fredman, Baucom, Boeding, & Miklowitz,
2015; Miklowitz, 2008). Research on health and illness suggests that loneliness,
together with lack of social support, is one of the strongest predictors of decline and
further suffering, regardless of the problem (Holt‐Lunstad, Smith, Baker, Harris, &
Stephenson, 2015). In addition, the individual can be either hurt or helped by familial
responses. Family therapy’s strength is its recognition of the importance of these
relationships, regardless of the other mental health problems that an individual

experiences.
Today, health‐care professionals from many disciplines are interested in how the
family can ameliorate or worsen the risk of mental illness (van der Kolk, 1997).
Evidence suggests that health services should focus on prevention and early interven-
tion. Research at the Harvard Center on the Developing Child suggests that toxic
stress can permanently damage children’s developing brains and that families can
buffer their children from the destructive effects of toxic stress (Patterson & Vakili,
2014; Shonkoff & Garner, 2012). Early experiences and environmental influences,
such as good parenting, can have lasting effects on a person’s capacity to respond to
stress throughout his or her life, including his or her risk of developing mental illness.
A BPS perspective allows us to embrace human beings as biological, cognitive, and
emotional systems nested in intimate relationships and residing in larger social s ystems.
An assessment of each interrelated system—individual, family, and larger system—is
part of any comprehensive treatment plan.
Assessing Individuals Within a Context of Interacting Systems
Regardless of one’s theoretical orientation and assessment techniques, every individ-

ual assessment begins and continues with a relationship as its foundation. A family
therapist and client are introduced, and a process of joining commences that will
hopefully lead to a trusting partnership. Family therapists rely on clients to be moti-
vated and honest in sharing information. Effectively joining with clients can facilitate
both communication and honesty. For example, an adolescent who has been forced
to come to therapy may be reluctant to talk until a relationship with the therapist has
been established. Likewise, clients will be more open to sharing sensitive information
once they feel safe and connected to their therapist.
When clients present to therapy, they describe challenges that highlight deficits in
thoughts, emotions, actions, and/or relationships. A hallmark of SFT is its focus on
strengths and resilience (de Shazer, 1988; Walsh, 2016): When is the problem
stronger, weaker, and absent, and how has the client effectively coped with c hallenges?
Multilevel Assessment 603
Noting and observing strengths instill hope and facilitate joining. Assessing strengths
may also give important clues about resources that can be leveraged for change.
The inclusion of mental illness and individual diagnosis has generated much debate
within and outside the field of SFT. Two questions that have challenged SFT are as
follows: (a) Is attention to individual psychopathology an abandonment of systems
theory? (b) Are family therapists trained and qualified to diagnose mental disorders,
which has historically been the domain of other mental health professions? While
most family therapists are trained in individual diagnosis (Denton, Patterson, & Van
Meir, 1997; Patterson, Albala, McCahill, & Edwards, 2009), they may initially disre-
gard individual symptom assessment in order to obtain a more holistic understanding
of the client and his or her family’s problems and to briefly enter the client’s world
with as few distractions as possible (Beach & Gupta, 2005). The discomfort with
diagnosis may be linked to family therapy’s early years, particularly the conceptualiza-
tion of schizophrenia (e.g., double‐bind, family homeostasis) that placed families at
the center of treatment (Nichols & Everett, 1986). Later generations of family thera-
pists were likely influenced by the postmodern movement and its concern that a
diagnosis objectified and marginalized a client’s narrative.
Regardless of how one feels about diagnosing a client, the field of SFT resides in a
health‐care world organized around diagnosis. Family therapists often work in set-
tings where they are required to make a formal diagnosis of their clients. Other mental
health professionals use diagnostic terminology to talk about clients, and having a
shared language facilitates treatment planning. A final reason to know how to make a
diagnosis is because psychotropic medication referrals are often made with a diagnosis
to help inform the psychiatric consultation (Patterson et al., 2009).
The Diagnostic and Statistical Manual for Mental Disorders (DSM) (American
Psychiatric Association, 2013b) has been a bedrock of the American health‐care sys-
tem for decades. In its earliest versions, the DSM was a manual created by the military
to describe the mental health problems of returning veterans. The DSM‐I was pub-
lished in 1952 and had a subsequent revision in 1968. However, the DSM‐III, which
was published in 1980, is probably the earliest version of the current DSM. Gone were
Freudian explanations about hidden conflicts and poor mothering. Instead, the
editors focused on signs (what the therapist observes), symptoms (what the client
describes), syndromes (a clustering of signs and symptoms), and events. The focus on
events reflects the view that “functioning” (whether someone can complete normal
daily tasks) has to be impaired for payers to reimburse mental health care.
In recent years, another classification system has gained prominence in the health‐
care world—the International Classification of Diseases (ICD) (World Health
Organization [WHO], 1992). The World Health Organization (WHO), an agency of
the United Nations located in Switzerland, publishes the ICD, which is used in
Europe and other countries. Family therapists need to be familiar with the current
version of the ICD—the ICD‐10, for several reasons. First, since 2015, mental health
professionals seeking insurance reimbursement must now provide a diagnosis using
ICD codes instead of DSM codes. Second, therapists who want to work in global
mental health must be familiar with the ICD because it is the most commonly used
classification system outside the United States (Patterson & Edwards, 2018; Patterson,
Edwards, & Vakili, 2018). Finally, leaders in the WHO and the American Psychiatric
Association have been working to synchronize the DSM and the ICD. At present,
there are few differences between the two documents except for more codes for
s ubstance use disorders in the ICD and some differences in how dementia is coded.
In the future, the ICD and DSM will probably become even more similar, and thera-
pists will code their clients’ diagnoses using the ICD.
The ICD has different goals than the DSM; it is a multidisciplinary document that
is published in numerous languages. It is focused on public health and is used by the
193 countries that are members of the WHO. The primary focus of the ICD is to
reduce the overall burden of disease, so the ICD includes illnesses from body systems
besides the brain including respiratory, circulatory, musculoskeletal, and so forth.
Consistent with its mission of reducing global illness, the ICD is free and can be
downloaded from the Internet.
A final evolving change in diagnosis is the growing recognition of the importance
of biological factors that influence the etiology and course of mental illnesses. The
Research Domain Criteria or RDoC framework created by the National Institute of
Mental Health (NIMH) suggests that assessment should involve multiple units of
analysis, with a particular focus on the developing brain and underlying genetics
(Cuthbert, 2014). The RDoC framework was initially proposed by Thomas Insel, the
Director of the NIMH around the time that the DSM‐V was being published.
Research had already shown that most mental disorders are brain disorders and often
have their origins in genetic risk factors. The RDoC framework rejects the DSM/ICD
focus on signs and symptoms. By viewing mental disorders as developmental disorders
influenced by environmental inputs (exposure to stress, toxins, food, or attachment
behaviors), the NIMH suggests that nosology should include a dimensional approach
that includes the full range of variation from normal to abnormal. Six domains of
cognition, motivation, and behavior have been identified—working memory, nega-
tive valence systems (threat, loss, fear, anxiety, etc.), positive valence systems (anticipa-
tion, reward, learning, etc.), cognitive systems, systems for social processes, and
regulatory systems. The RDoC literature also reflects an awareness of environmental
and epigenetic influences including the impact of human relationships on gene expres-
sion and the developing brain. In the future, the evolving RDoC framework will influ-
ence both research and clinical work in mental health.
In many ways, the BPS model foreshadowed the current issues surrounding diag-
nostic systems. Based on the BPS model, family therapists can glean useful therapeutic
tools from the world of individual diagnosis and simultaneously incorporate the
strengths of family therapy. Therapists do not need to choose one ideological position
to the exclusion of all other perspectives. A family therapist can successfully combine
the basic tenets of systemic thinking with careful attention to individual problems
and biology, drawing upon clinical literature from both systemic and individual
perspectives.
Assessment of mental illness

Epidemiological research suggests that more than 50% of the population will have a
mental disorder at some time in their lives (Kessler et al., 2005). The frequency of
mental health problems suggests the need for careful assessment of mental illness. The
most common disorders are mood disorders (e.g., depression), anxiety disorders, and
substance abuse problems. Frequently, a client suffers from two or more of these dis-
orders simultaneously. While everyone suffers from depression or anxiety at some
time in his or her life, illness does not refer to these everyday problems but to known,
recognizable syndromes. Specificity of symptoms, duration, and intensity distinguish

a syndrome from the common problems of living.
Complicating assessment is the fact that people often have mental health problems
that do not meet DSM diagnostic criteria. The individual diagnostician who closely
follows DSM diagnostic outlines risks overlooking serious problems that do not fit
neatly into a category. This poses a more serious risk for children and adolescents
because their problems fit DSM criteria less frequently than adult disorders and can be
strongly influenced by developmental issues that might be overlooked by the diagnos-
tician. A contextual, holistic approach to mental health problems can correct for many
of these weaknesses.
Clearly, the therapist must pay attention to the symptoms of the identified client as
well as to the characteristics and symptoms of other family members. Questions to
think about include the following: “Does this person have a known, recognizable
cluster of symptoms that meet specific diagnostic criteria?” “Should this individual
receive treatment for these symptoms, in addition to any other therapeutic goals?”
“Do I, as the therapist, have the skills and knowledge to diagnose or treat this prob-
lem, or should I consider referral to someone else?”
While a therapist may never become proficient in the subtleties of making a DSM
diagnosis, family therapists are expected to become skilled in using the DSM and ICD
for the most commonly seen problems. Family therapists also need to know about the
disorders most commonly found in children such as disruptive behavior problems,
childhood depression and anxiety, learning disorders such as attention deficit disor-
der, and autism spectrum disorders. Even if family therapists are not experts on these
diagnoses, they can learn enough information to identify a client who might have one
or more of these problems. If a client exhibits symptoms that are completely unfamil-
iar, a family therapist can consider a referral to a psychiatrist.
A complete diagnosis looks at additional factors in the individual system. The thera-
pist might ask about current or past medical problems that could be influencing the
client’s problems. Is the client currently taking any medications—prescribed or not?
Does any physical event (e.g., car accident, head injury, illness) coincide with the
onset of symptoms? The therapist might also want to do a brief mental status exam to
ascertain whether or not there are cognitive problems. Asking about family history of
mental health problems can help the therapist consider genetics as an underlying eti-
ology. While a family therapist is seldom an expert in these areas, he or she should at
least have screening skills and know when to refer the client to another mental health
professional.
A few final issues that the therapist wants to consider are duration, intensity, and
functioning. How long has the problem been going on? How much is the problem
affecting the client’s daily living? Has the client missed work or school because of the
problem? Are other family members significantly affected by the problem or having to
compensate for the client’s deficits? Even when therapists recognize the key concepts
of individual diagnosis and family process, it can still be overwhelming to sort out the
distinctions during assessment. Below is an example of a diagnostic challenge when a
couple came for therapy because they were fighting.
The wife’s complaints included the husband’s1 disorganization, inability to be on time,

inability to keep a job, and explosive anger. While the therapist started working on conflict
resolution and communication skills with the couple, he also noted the husband’s chaotic life.
The husband was never on time to the sessions and on several occasions forgot the session
entirely, even when the wife reminded him the day before. After a while, the therapist began
to wonder if the husband had ADHD. While maintaining a focus on the couple, the thera-
pist gently explored the husband’s learning history more carefully. Ultimately, a diagnosis of
adult ADHD resulted in dramatic changes in the husband’s life, the wife’s life, and the
marriage.
In cases such as this, family therapists can consider psychiatric consultation for the
family member with mental illness. The consultation can provide information that the
therapist can integrate into the overall treatment plan. In addition, the psychiatrist
might recommend psychotropic medication to treat the symptoms of the individual’s
mental disorder.
Psychometric instruments
Psychometric instruments are a standard part of initial individual assessment and can
provide useful data throughout treatment in order to track change. These instruments
help ensure that the therapist does not miss important symptoms and can sometimes
help the client feel hope when he or she realizes that there is a name and description
for what he or she has been feeling. Common psychometric instruments include the
PHQ‐9 for depression (Spitzer, Kroenke, & Williams, 1999), the GAD‐2 for anxiety
(Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007), CRAFFT for adolescent
substance abuse (Knight et al., 1999), and ACEs for adverse childhood events

(Felitti et al., 1998).
Assessment instruments offer family therapists a number of advantages (Corcoran
& Fischer, 2013; Williams, Edwards, Patterson, & Chamow, 2011). First, informa-
tion can be collected in a quicker and more efficient manner rather than the therapist
asking clients each of the questions and having them verbally respond. Second, assess-
ment instruments provide quantifiable data that may aid clinical decision making if
norms for the instrument are available. For example, the PHQ‐9 will yield a score
indicating the severity of depression, which may inform the therapist’s decision as to
whether to refer the client for a psychiatric consultation and possible medication.
Third, the standardization of assessment instruments allows the clinician to compare
the client’s scores to others or observe how the scores change over time. A therapist
can see how a couple’s score on a measure of marital quality compares to other cou-
ples, or a therapist can administer the instrument over time to see if the couple is
improving. Fourth, assessment instruments can facilitate a thorough assessment of an
issue. A therapist might conclude after asking a few questions about mood that the
client is depressed and not see the need to ask further questions. However, the instru-
ment will ask about all the possible symptoms of depression, providing a more com-
prehensive picture. For example, the therapist may not have thought to ask about low
sexual drive, which can be an important symptom of depression that also impacts the
individual’s relationship. Finally, assessment instruments may facilitate a client disclos-
ing sensitive information (e.g., sexual issues, relationship aggression) that they may
not volunteer in the beginning with a therapist.
Therapists need to exercise caution when using assessment instruments because
some instruments are meant solely for screening—not for comprehensive assessment.
Screening instruments can be used to identify clients who need additional assessment
by using more thorough questionnaires or interview protocols. For example, the
PHQ‐9 and the GAD are commonly used instruments in community mental health
and primary care clinics to screen for depression or anxiety but are not meant to deter-
mine a diagnosis that might lead to treatments, such as psychotropic medications.
However, they can be given periodically to track changes in depression and anxiety
over the course of treatment.
Therapists should also be cautious about relying exclusively on a package of assess-
ment instruments and not considering additional problems or diagnoses. Comorbidity
frequently occurs between mental illnesses and physical illnesses. For example, clients
frequently meet the criteria for both depression and anxiety. Likewise, a client with
dementia might initially present with irritability. While he may be diagnosed
with depression based on the clinic’s protocol, his dementia symptoms might be
overlooked because there is no screening instrument used to assess memory issues.
Thus, screening and assessment instruments should be viewed as part of a more
comprehensive assessment.
Assessment instruments have additional limitations (Williams et al., 2011).
Completing instruments is an impersonal experience, although clients are often
cooperative if a clear rationale for using instruments is provided. Also, assessment
instruments are good at describing what the client is experiencing but may not offer
as much insight as to why the client is experiencing problems. A depression inven-
tory may give a clear picture of the client’s symptoms but will not offer insight as to
why the client is depressed. Finally, the clinician must weigh the potential monetary
cost and time spent scoring the instrument with the potential value of the informa-
tion it offers.
When considering which assessment instruments to use, family therapists must con-
sider a number of factors (Williams et al., 2011). Obviously, the clinical utility of
information is essential. Family therapists may find that responses to individual items
may be as helpful as the total score. For example, if a couple notes problems about sex
on a marital quality inventory, then the therapist will know that this needs further
exploration.
Family therapists should also evaluate an instrument’s psychometric properties
(Corcoran & Fischer, 2013; Groth‐Marnat & Wright, 2016). Instruments should be
evaluated for internal reliability, which is typically reported as a Cronbach’s alpha.
There should also be evidence for the instrument’s validity, which indicates whether
the instrument is actually measuring what it says it is measuring.
Practical considerations also inform a clinician’s decision to use a particular instru-
ment. Does using the instrument require special training or qualifications to use?
How easy is the instrument to score? What does it cost? The therapist also needs to be
mindful of the instrument’s length and the potential burden this puts on the client’s
time. Fortunately, brief instruments are often available for issues that family therapists
frequently assess. If the therapist makes a judicious use of brief instruments, the time
commitment required for clients to complete the assessment instruments is reasona-
ble. Finally, the clinician needs to ask whether an instrument is a good fit with a
specific client. The appropriateness of an instrument may depend upon a number of
factors, including the client’s language, reading comprehension, relationship status,
and whether the instrument has been tested on a population similar to the client.
Assessing the Multigenerational Family System
During assessment, family therapists are collecting and organizing information on

multiple levels within a BPS framework, most notably family relationships and larger
systems (e.g., schools, medical settings). An exploration of each level assists the
therapist in conceptualizing a case and determining an appropriate treatment plan.
Depending on a therapist’s theoretical orientation, a specific level may receive more
attention than others. However, the field of SFT has gradually moved toward more
integrative thinking, resulting in a synthesis of concepts. Family assessment occurs
regardless of who presents for therapy, partly because family therapists focus on
relationships to treat mental health concerns and partly because family members may
be added to the therapy at some point. Genograms are synonymous with SFT and are
often a starting point to learn about a client’s family system.
Genograms
The construction of a genogram is frequently part of a comprehensive family assess-
ment, helping us better understand a client’s challenges and strengths. In its simplest
form, a genogram is a visual map to identify members of a family, including gender,
generation, and age (McGoldrick, Gerson, & Petry, 2008; Pendegast & Sherman,
1977). Over time, the genogram reveals relationship patterns and themes that have an
impact on current functioning.
The first phase in the construction of a genogram is breadth:
• Gather the gender, ages, and names of each family member, starting with the
youngest family members and moving up.
• For family members who have died, list the person’s age at the time of death,
along with an X to indicate the loss. Also, indicate how the person died.
• Connect the family members with lines indicating biological or legal relationships.
• On the relationship lines, make a note of the beginning and, if needed, ending
dates of relationships.
The second phase in the construction of a genogram is depth:
• Descriptions of each relevant family member. “Let’s start with your father. Tell
me a little bit about him” or “What are five words that describe your father?”
• A description of how family members might describe the client or clients. “If your
parents and siblings were here, how would they describe you?” or “What are five
words your parents and siblings would use to describe you?”
• Descriptions of dyadic relationships. “Tell me about the relationship between
you and your father? What about the relationship between you and your sister?
What about the relationship between your parents? How have these relationships
changed over time?”
• Description of family time together. “What was a typical day in the life of your
family? What did your family do for fun together?”
• Description of the family emotional climate. “How were anger, sadness, and
joy expressed in your family? If you had a problem, who did you go talk to?
If your parents were unhappy with your behavior, how did they discipline
you?” These descriptions can capture rules in a family—rules that are explicit
(e.g., “no dating until you’re 16”) and implicit (e.g., “We don’t talk about a
family member after they’ve died.”).
• Family belief systems and mantras. “What were some of the core beliefs in your
family?” For example, families may carry beliefs related to gender (e.g., men
should not be vulnerable or show emotions other than anger) and what is normal
or abnormal (“We have a great relationship; we never argue.”) (Rolland, 2018).
Below is an example of multigenerational themes being uncovered through a
genogram:
A mother and her 15‐year‐old daughter came to therapy due to the mother’s concerns about
her daughter’s “lying,” which has resulted in a lack of trust. The mother also recently learned
that her daughter is having sex with her boyfriend, which left her so concerned that she
considered moving her daughter to another state to live with her father. A genogram was
started in the first session and brought to the second session. The mother’s new husband
attended the second session and was asked to comment on the relationship between his wife
and stepdaughter. He explained that the lack of trust went “deeper” than just their parent–
child relationship: his wife had a distant relationship with her mother, partly due to conflict
and a lack of support in her early teens when she became pregnant. His wife became tearful
as he shared his perspective, which led to a discussion about her fears of repeating the pattern
with her daughter.
In a case such as this, the genogram provided needed context to better understand the
current challenges between a mother and her daughter.
Family structure
A genogram often produces information about a client’s family structure and process.
A typical structural assessment will examine communication (who talks to whom?
who speaks for who?), hierarchy (who has power?), roles and responsibilities (e.g.,
scapegoat, parentified child, peacemaker), and boundaries (Minuchin, 1974). When
assessing boundaries, family therapists determine the permeability of boundaries—
diffuse, closed, and open—and their appropriateness for the family’s stage of develop-
ment. Open boundaries allow for a balance of individual autonomy and intimacy
between family members.
Family assessment includes an understanding of subsystems: couple/marital, sib-
ling, and parent–child. The couple/marital subsystem is of particular interest because
it links three generations: the couple, their children, and each partner’s family of
origin. Effecting change in children is often facilitated through change in the couple/
marital subsystem and change in the couple/marital subsystem commonly comes
from addressing issues (e.g., differentiation) with their parents and other family mem-
bers (Nichols & Everett, 1986). For a detailed discussion of couple/marital assess-
ment, see the chapter by Williams (2020, vol. 3).
Family process
Assessment of family structure is facilitated by an assessment of a family’s flexibility
and cohesion. Flexibility refers to the family’s ability to adapt to change, which is
intimately related to the family’s leadership and organization. Flexibility has two
primary ingredients. First, how does the family mold and reshape its structure to
accommodate change? Some families will make the necessary adjustments in roles,
responsibilities, and expectations to cope effectively with change; others will resist
such change. For example, a father is diagnosed with a debilitating chronic illness and
is unable to perform the functions normally expected of him. If the family fails to
restructure their roles and responsibilities and pretends as if nothing has changed, it is
highly likely that stress will increase and the family’s functioning will suffer. One can
see similar dynamics in family’s coping with life cycle transitions: How will a family
cope with their child transitioning to adolescence and her effort to gain more
autonomy?
A second ingredient of flexibility is continuity: How is stability maintained in the
face of change? When a family is in the midst of change, they are ideally preserving
some familiarity, such as daily routines and rituals. For example, divorce is filled with
many stressful changes for parents and children, but research has shown that too
much stressful change is harmful for children (Clarke‐Stewart, 2006). Children need
parents who can minimize the disruptions associated with divorce and restore some
semblance of predictability, such as rules, roles, and patterns of interaction. Achieving
flexibility means striking a delicate balance between continuity and change.
While flexibility relates to control in families, cohesion relates to connection and
support in families—what is the amount of caring, closeness, and affection in the
family (Olson & Gorall, 2003)? Family members need to feel secure and safe in their
environment, particularly when adversity and stress are high. During times of crisis,
family members are ideally turning toward one another to listen and share concerns
and offer any assistance that facilitates healing and recovery. When cohesion is
lacking, family members may feel disconnected and isolated and look outside the
family for needed support. Although high cohesion is usually a strength in families,
too much cohesion as evidence by diffuse or weak boundaries can block family
members’ efforts to express individual differences and threatens physical and
emotional privacy.
Family development
The degree of family cohesion and adaptability is intimately related to a family’s life
cycle stage and history (Bowen, 1978; McGoldrick, Garcia Preto, & Carter, 2016).
The family life cycle describes the typical stages that a multigenerational family experi-
ences over time. Family cohesion and flexibility change through the life cycle to
hopefully accommodate individual development and normal family transitions.

For example, one might expect that families with small children will lean toward more
enmeshment and rigidity than families with adolescents, which is appropriate consid-
ering the efforts of adolescents to develop more autonomy and freedom.
In addition to family life cycle transitions, families also experience unexpected
transitions that can create more chaos or rigidity and push a family toward more
togetherness or separateness. Nichols and Everett (1986) referred to these additional
systemic developmental disruptions as systemic shifts and systemic traumas. Systemic
shifts refer to subtle changes in the family. For example, a grandparent moving into
the family home may disrupt or exacerbate particular patterns. A systemic trauma
refers to unpredictable life events, such as a death or illness, which shakes the
foundation of a family as it attempts to survive in the face of tremendous stress.
The ability of a family to work together and accommodate these changes is central to
their functioning as a family.
Mr. Smith is a 48‐year‐old male with a 16‐year history of multiple sclerosis. He has been
wheelchair confined for the past 3 years. He has increasing fatigue and lethargy that does not
appear to be related to multiple sclerosis. His wife, age 46, is experiencing depressive symp-
toms, including fatigue, hopelessness, and difficulty managing her responsibilities at home.
Their daughter, age 18, recently quit the volleyball team, presumably to spend more time at
home caring for her father. Mr. and Mrs. Smith have a distant relationship and often com-
municate through the daughter.
A common pattern is evident in this family: the daughter is triangulated by the par-
ents. The daughter occasionally makes efforts to exert her independence but feels
guilty and returns to her role of caregiver to both her father and mother. Her caregiv-
ing role is increasing at a time when she is considering leaving home for college. Her
plans are now unclear as she worries about her parents and their marriage if she leaves,
as well as who will advocate for her father in the health‐care system.
Assessing Larger Systems
Family therapists have long incorporated a contextual view of families embedded in

larger systems. Families move through daily life connected to schools, health care,
community resources, and religious institutions. They also rely on or are mandated to
connections with social service and public welfare systems, child protective services,
juvenile justice or other legal systems, disability services, nursing or institutional set-
tings, and immigration or refugee services, among others. Some families engage with
other mental health and substance use treatment providers, requiring interdisciplinary
collaboration (Hodgson, Lamson, Mendenhall, & Crane, 2014). Individual family
members may have varying relationships with the larger systems, some conflictual,
problematic or even toxic, and others viewing them as beneficial, supportive, and
essential to their survival.
Imber‐Black (1988) provided influential guidance for assessing and connecting
with larger systems, in which she described the “necessity for discerning and assessing
the meaningful system, or that configuration of relationships and beliefs in which any
given family’s problems and issues make sense” (p. 45). Akin to other attempted solu-
tions, larger systems can also perpetuate problems they were designed to solve. A
comprehensive assessment begins with identifying which systems are involved, for
how long (recent or intergenerational), with what frequency, who initiated the con-
tact, and a description of what is provided and expected. This can be guided with an
ecomap (Hartman and Laird, 1983), a sociogram (Sherman & Fredman, 1986), or
simply adding participants in an extended systems genogram (McGoldrick et al.,
2008). Based on their work with gay and lesbian couples, Green and Mitchell (2008)
draw the sociogram as five concentric circles, which are labeled as follows: the couple
(the innermost circle); very close/supportive ties; close supportive ties; instrumental
ties/acquaintances; and others (the outmost circle).
Once the involved larger systems are identified and mapped, the relationship pat-
terns between various family members and care providers are assessed to determine
appropriate entry points into the system to avoid replicating past failed attempts or
negative outcomes; identify how various participants and systems define the prob-
lems, solutions, and available resources; and look for potential dyadic or triadic rela-
tionships across systems, as well as the permeability of boundaries between the family
and larger systems. Family members and professionals might each bring beliefs and
myths about each other and the possibility for change (Rolland, 2018). These can
arise from intergenerational legacies, implicit biases, outright discrimination, or the
narrative already constructed by previous care providers and their historical documen-
tation. The goal is to create a new and different relationship when entering and mov-
ing forward, which can only be accomplished by respecting each member of the
system as true collaborators or partners. Understanding a family’s attempted solutions
rather than pathologizing behavior and appreciating that larger systems also engage in
their own attempted solutions (being expert, ignoring, overprotecting or patronizing,
overstepping roles, adding more helpers) helps to generate this spirit. Even well‐
intentioned families and larger systems can find themselves enacting common binds
such as larger systems mandating families to treatment and expecting that families
want or should want the help; similarly, families can communicate a bind of “help us
without changing us” (Imber‐Black, 1988).
A full larger systems assessment acknowledges the systemic constraints that are
unchangeable regardless of intervention (e.g., structural racism, immigration laws,
foster care policy, financial or insurance limits). Transitions in care providers, case-
workers, employees in agencies, or public welfare systems, as well as at the policy
level, need to be anticipated and incorporated as part of the process moving forward.
Additionally, Imber‐Black (1988) notes the fluid nature that many of these
relationships have.
The Role of Cultural Factors in Assessment
Understanding a client’s intersectionality of multiple cultural identities is an essential

part of a comprehensive assessment and treatment (McGoldrick & Hardy, 2008).
Different identities for a person may be represented, enhanced, or diminished in dif-
ferent circumstances or settings and might influence how a problem is constructed
or understood even within the same family. Perspectives can be influenced by identi-
ties such as age, race, class, gender identity and expression, sexual orientation,
ethnicity, ability/disability, citizenship, immigration or refugee status, language use,
spirituality or religious community, geographic location (rural, urban, suburban,
transnational), economic resources, education, employment, health insurance status,
and health‐care access.
A growing literature acknowledges the effects of oppression (David & Derthick,
2018) and intergenerational trauma (DeGruy Leary, 2005), and client stories them-
selves represent the daily complexities of navigating privilege and subjugation. Within
a Multicultural Relational Perspective (Hardy & Laszloffy, 2002), culture is simulta-
neously considered dynamic, fluid, and static given its many facets and multidimen-
sions. In addition, culture is understood to serve many functions in families’ lives
(rootedness, identity development, coping, providing rules, pride, and shame) and is
timeless in that it connects to our past, present, and future (Hardy & Bobes, 2018).
Examining cultural influences can be done in a myriad of ways. Hayes (2013)

developed the ADDRESSING framework to examine the influence of power and
privilege or oppression and subjugation that impacts a person’s experience, which
includes Age and generational influences, Developmental disabilities and other
disabilities, Religion and spirituality, Ethnic and Racial identity, Socioeconomic sta-
tus, Sexual orientation, Indigenous heritage, National origin, and Gender. DSM‐V
introduced the Cultural Formulation Interview as an aid for exploring a client’s
understanding of cultural influences on their health or mental health symptoms,
beliefs, experiences, and engagement in treatment (American Psychiatric Association,
2013a). The interview is meant to better understand the person’s cultural definition
of the problem, cultural perceptions of cause, context, and support, as well as cultural
factors affecting current help seeking, self‐coping, and past help seeking.
In addition to understanding how cultural identities might influence a family’s pre-
senting concerns, strengths, and resources, therapists must also be sensitive to how
cultural identities may influence the client’s engagement in treatment systems, experi-
ence barriers to care, or even have difficulty developing a therapeutic alliance with the
therapist. Language, transportation, lack of reliable childcare, insurance status, liter-
acy, institutional racism, or previous experiences of discrimination in a treatment or
health‐care setting might all be silently present in a new client encounter. The thera-
pist’s courage to address potential cultural differences with humility and the ability to
demonstrate care, respect, and openness to the client’s experience are essential first
steps (Falicov, 2015).
Legal and Ethical Issues in Assessment: Ensuring Safety
Family therapists routinely encounter dangerous situations. Violence, abuse, suicide

risk, substance abuse, and duty to warn (another person about the client threatening
his or her life) are all examples of potentially dangerous situations. Often, the client
will not bring up these issues initially. Family therapists listen for hints or warning
signs of these situations. For example, the client may appear quite depressed or angry,
which may lead to assessment of suicide or violence. A child might appear afraid of his
parent, which may lead to assessment of physical or sexual abuse. A full discussion of
all the relevant safety issues, including child abuse, elder and dependent abuse, and
domestic violence, is beyond the scope of this paper. We will focus on harm to self
and harm to others.
Harm to self
According to the most recent data available, nearly 45,000 people in the United
States died by suicide in 2016, and suicide rates increased in almost every state since
1999, including by more than 30% in half of states (Centers for Disease Control, Vital
Signs, 2018). Many factors contribute to suicide among those with and without diag-
nosed mental health concerns (e.g., relationship problems, recent crises or anticipated
crises, substance misuse, physical health concerns, job/financial problem, legal
problems, and housing instability) (Center for Disease Control, Vital Signs, 2018).
Common suicide risk assessment questions typically center around thoughts of death
or suicide ideation, planning, intention to act, access to methods or lethal means, and
steps taken to prepare. In addition, understanding a person’s history of past ideation
and attempts adds important assessment information about potential increased risk
for a future attempt. The two most common screening tools are the Columbia Suicide
Severity Rating Scale (C‐SSRS) (Posner et al., 2011) and the Suicide Assessment
Five‐step Evaluation and Triage (SAFE‐T) (Jacobs, 2009).
Flemons and Gralnik (2013) developed a Relational Suicide Assessment rubric that
uses four categories of present and past intrapersonal and interpersonal risks and
resources: disruptions and demands, suffering, troubling behaviors, and desperation.
Within the category of disruptions and demands, a therapist inquires about relation-
ship loss, overwhelming expectations, loss of social position/financial status, legal/
disciplinary trouble, and abuse/bullying/peril as risks to the client while assessing
effective problem solving and positive personal/spiritual connections. Adding a rela-
tional perspective, the therapist inquires about the client’s significant others’ perspec-
tive and role in the risks and available resources. Health and mental health concerns
are noted under suffering, with the significant other’s view of the client as flawed/a
burden or offering unhelpful responses increasing risks, and empathic responses or
supporting treatment as relational resources. Troubling behaviors such as withdraw-
ing from activities, substance use, impulsivity, and harm to self or others are assessed.
Reasons for living and active participation in developing and implementing a safety
plan are highlighted as important client resources, as well as significant others’ com-
passionate response and participation in the safety plan. Desperation, which is some-
times communicated through a client’s hopelessness and others’ dismissiveness, is
considered to increase risk.
Pisani and colleagues (2016) propose suicide risk formulations that incorporate the
traditional risk status (e.g., demographics such as older white male), as well as risk
state (compared to one’s own baseline or another time point), available resources to
draw upon in a crisis, and foreseeable changes that may exacerbate risk. This creates a
conceptual shift from prediction with a low, moderate, or high risk to thinking more
fluidly about the client and risk over time with a hope for prevention. While also
incorporating traditional strength and protective factors, impulsivity and past history,
and current symptoms and stressors, this assessment model considers the person rela-
tive to themselves (state) rather than others (status) and helps to build a relational
connection to available resources, incorporating any foreseeable changes for safety
planning.
Family therapists routinely work to incorporate family members and important oth-
ers in assessing risk and developing safety plans. Ideally, a family therapist has already
begun developing therapeutic alliances with multiple members of the system, or at
least has the skills for quickly creating rapport while navigating the challenging task of
evaluating the risk. This can be more concerning if the family member is also acting
violently or threatening others.
Harm to others
Although more than twice as many people took their own lives, nearly 20,000 people
died by homicide in the United States (Center for Disease Control, and Prevention,
Vital Signs, 2018). Similar to suicide risk assessment, evaluating risk for harm to
thers requires therapist skill and a relationship foundation for clients to share scary
o
imagery, fantasies, and past behaviors that may or may not be alarming to the clients
themselves. The HCR‐20 (Douglas, Hart, Webster, & Belfrage, 2013) identifies
common risk factors including previous violence, young age at first violent incident,
relationship instability, employment problems, substance misuse, major mental illness,
psychopathy, early maladjustment, current lack of insight, impulsivity, lack of sup-
ports, and unresponsiveness to treatment. Protective factors include intelligence,
secure attachment in childhood, empathy, coping, self‐control, work, leisure activi-
ties, motivation for treatment, life goals, social network, and intimate relationships
(de Vogel, de Ruiter, Bouman, & DeVries Robb, 2012). A relational assessment
incorporates the family and significant others’ perspectives on past behavior, current
levels of worry or fear, patterns or factors that exacerbate and escalate, as well as
resources, potential protective factors, and safety planning for all.
Children and teens are also vulnerable to acting violently through fights, bullying,
threats with weapons, cruelty to animals, fire setting, intentional destruction of prop-
erty, and gang‐related violence (American Academy of Child and Adolescent
Psychiatry, 2015; Center for Disease Control, Preventing Youth Violence, 2018).
Even preschool children exhibit violent behavior. Although the hope may be that the
child will “grow out of it,” violent behavior in a child at any age requires a careful risk
assessment with parents, teachers, health professionals, and other involved adults.
Risk assessment includes assessing for previous aggressive or violent behavior, ACEs,
being the victim of bullying, genetic factors, exposure to media violence, substance
use, presence of firearms in home, socioeconomic stressors, as well as brain damage
from head injury (American Academy of Child and Adolescent Psychiatry, 2015). All
children should receive a basic screening for violence as victims, witnesses, or perpe-
trators. This includes school‐related incidents such as bullying or cyberbullying, as
well as dating violence for teens and relationships, which can increase risk for sex
trafficking or gang membership.
Conclusion
Assessing clients with complex, sometimes life‐threatening problems can feel daunt-
ing, even for advanced family therapists. How does one structure enough time to
inquire about the many influences on a presenting problem and simultaneously join
and build a therapeutic relationship? The multilevel assessment described in this chap-
ter is meant to be tailored to the unique presentation of each client: one or two levels
will likely play a more prominent role in the treatment plan. Culture is a constant.
Every assessment must consider the ethnic, racial, class, gender, and sexual identity
and expression of our clients and their concerns.
Note
1 The names of clients have been omitted or changed, and some biographical details have
been altered in order to protect their identities.
References
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27
Sociocultural Attunement
Carmen Knudson‐Martin, Teresa McDowell, and
J. Maria Bermudez
Family therapists have long held that to effectively work with diverse clients, we must
learn about and be sensitive to the experience of those different from ourselves. The
initial focus across mental health disciplines during the mid‐ to late twentieth century
was on cultural competence, which reflected a tendency in the modern era to classify,
categorize, and define “others.” It was essentially up to the therapist to learn about
and bridge the gap between themselves and the “other” with whom they worked.
Though this view of cultural competence has been heavily critiqued, the multicultural
movement raised expectations of cultural awareness in training, supervision, and
practice (e.g., Falicov, 1988; Hardy, 1989) and stimulated questions regarding how
the field may be structured in ways that, intentionally or not, support dominant cul-
ture norms and values, pathologize people at the margins of society, and rationalize
results of inequity as “differences” without attention to sociopolitical contexts
(Almeida, 1993; Laszloffy & Hardy, 2000; McGoldrick, 1998).
Family therapists today are charged with responsibility to understand and help fam-
ilies navigate complex sociocultural realities (e.g., American Association for Marriage
and Family Therapy core competencies, Commission on Accreditation for Marriage
and Family Therapy Education accreditation standards, version 12). There is a call for
more equitable, relational, fluid, and process‐oriented ways to address culture and
diversity (Allan & Poulsen, 2017; Almeida, Hernández‐Wolfe, & Tubbs, 2011; Elias‐
Juarez & Knudson‐Martin, 2016; Falicov, 2009, 2014; Hardy, 2016). Rather than
stereotyping people based on their backgrounds or centering therapist skills and
knowledge, such a view would apply systems/relational practices to attune to and
engage with clients’ unique experiences within an inequitable world. In this chapter
we suggest a socioculturally attuned approach that integrates sensitivity to cultural
differences with issues of equity and power and expands the clinical lens to consider
systems of systems (i.e., third‐order thinking), bringing larger issues of global and
cultural equity together with intimate relationship processes and the moment by
moment of practice. We conclude with practice guidelines and implications for ethics,
self‐of‐the‐therapist, research, and training.
620 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez
From Cultural Competence to Sociocultural Attunement
Family therapy’s early roots in systems theory provided pathways for understanding
the impact of multiple societal forces and social structures on clients and therapists
alike. Critiques from feminist and critical multicultural scholars drove home the idea
that our intersecting identities (e.g., race, class, gender, sexual orientation, etc.) shape
not only how we see the world but how the world sees (and treats) us (Dolan‐del
Vecchio & Lockhart, 2004; Hernández‐Wolfe & McDowell, 2014). As a field, we
challenged monolithic group descriptions and began to look more carefully at dynam-
ics of privilege, oppression, and marginalization (e.g., Hare‐Mustin, 1978; McDowell
& Fang, 2007; Silverstein & Goodrich, 2003; Walsh & Scheinkman, 1989). This
included our own power as therapists to maintain or challenge inequity (Hardy, 1989;
Knudson‐Martin, 1997). Attention shifted to unveiling the liberating and/or oppres-
sive nature of our therapeutic practices, requiring therapists to take broader meta‐per-
spectives of self and clients in context, turning the spotlight away from a simple
understanding of “other” to the nature of our clinical roles in light of systems of
power and privilege (Aldarondo, 2007; Almeida, Dolan‐Del Vecchio, & Parker, 2008;
Leslie & Southard, 2009; Seedall, Holtrop, & Parra‐Cardona, 2014).
Social constructionists further expanded our view of culture and diversity by chal-
lenging the basic concept of difference and drawing attention to the role of power in
the inherent meaning‐making of the therapeutic process (McNamee & Gergen, 1992;
Monk, Winslade, & Sinclair, 2008; J. L. Zimmerman & Dickerson, 1994): that how
differences are described is not innate to the characteristics of a particular group, but
arise within the act of defining and who has the power to determine what is real or
good (Gergen, 1997). We also learned that what it means to be part of a culture is
fluid, not fixed; it changes over time and depends on where one is and with whom
(Paré, 1996). Not all members of a group enact culture in the same ways (Laird,
1999). While feminists challenged the idea that therapists could ever be neutral, social
constructionists made us rethink the notion of objectivity and reminded us that
therapists need to be accountable for their roles in defining what is perceived to be
real, true, or normal.
What was once called cultural competence is giving way to terms such as cultural
equity, social justice, cultural humility, cultural safety, and cultural democracy (Allan
& Poulsen, 2017; Almeida et al., 2011; Falender, Sharfranske, & Falicov, 2014;
Gallardo, 2014; Hernández‐Wolfe & McDowell, 2014). These shifts are indicators of
the changing nature of what it means to be culturally sensitive, socially aware, and
equity minded—what we call socioculturally attuned (McDowell, Knudson‐Martin,
& Bermudez, 2018). This includes recognizing the connection between social and
relational power dynamics and the effects of these dynamics on emotional, physical,
psychological, spiritual, and relational health. When family therapists are sociocultur-
ally attuned, they are not only aware of the interplay between societal systems, cul-
ture, identity, and power, but willing and able to pay close attention and be responsive
to the impact of these forces on individual, relational, and community well‐being
(Falicov, 2009; McDowell et al., 2018).
Training and practice from a socioculturally attuned position involves four elements
not always addressed in conventional models of cultural competence. These include:
(a) a relational focus, (b) third‐order thinking, (c) responsibility toward equity, and
(d) nuanced attention to context.
Sociocultural Attunement in SFT 621
Relational focus
Socioculturally attuned practice is a process of engagement, of seeking to know and be
“with” the experience of all clients (D’Aniello, Nguyen, & Piercy, 2016), a worldview
that recognizes and seeks to discover how culture and societal contexts are connected
to every aspect of life, and discerns our role in it (Falicov, 2014; Hardy, 2016). Rather
than an add‐on or adjustment to practice “as usual,” socioculturally attuned practice
is at the center of every aspect of therapy. It is not an end to be achieved; it is an ongo-
ing relationship in which therapists are “other‐oriented,” aware of their own social
locations, attentive to hidden biases, and accountable to justice in their roles as agents
of change (T. Zimmerman, Castronova, & ChenFeng, 2015).
Third‐order thinking
Third‐order thinking provides a framework for linking awareness of sociocultural
issues with how we practice. Family therapists have long emphasized the difference
between first‐order change in which the basic understanding of the problem and the
system remain unchanged and second‐order change in patterns and processes within
the organization of the relationship itself. Third‐order thinking is more recent to
family therapy (McDowell, 2015; McDowell, Knudson‐Martin, & Bermudez, 2019).
Based on Bateson’s (1972) levels of learning, it involves understanding the system we
are in as part of a system of systems and taking a meta‐perspective of the complex
interactions among societal systems (e.g., economic, political, social). Third‐order
thinking helps link sociocultural issues with client concerns and enables envisioning
alternatives.
Imagine you are working with Cori and Justin, a white cisgender heterosexual cou-
ple in their 30s.1 They live with Justin’s three children from a previous relationship.
Cori is the primary breadwinner. They present with conflict around time and house-
hold management. Justin is frustrated that Cori is untidy and gets upset when he
expresses these concerns. Each also reports previous diagnoses of anxiety. What would
third‐order thinking mean here? Most therapists would probably recognize gender as
a potential influence and be interested in how their nontraditional gender roles might
connect to the couple’s conflict. This would be an important start, but there are many
more interrelated systems at play. Among others, third‐order thinking would consider
the intersections among (a) how Cori and Justin’s relational patterns are linked to
economic structures and societal reward systems that sustain it, (b) how dominant
culture assumptions connect to their identities as white co‐parents and how these
relate to give and take between partners, (c) how they perceive themselves in relation
to the dominant white heterosexual patriarchal culture and their efforts—or not—to
enact alternative patterns, and (d) how all of these relate to your social location and
how you perceive your role as the therapist. It would consider how all of these inter-
locking inequalities operate together in Cori and Justin’s life (Seedall et al., 2014).
When applying third‐order thinking, therapists automatically expand the lens to
connect intimate and family patterns to larger societal systems. This guides how they
go about knowing their clients and what they are curious about. As clients begin to
share their stories and experiences through conversation informed by a broader lens,
they begin to see themselves and each other more compassionately, with less blame.
Alternatives among and within systems are more able to present themselves.
As illustrated by this example, third‐order thinking applies to all cases, not only those
sometimes defined as minorities or “other” by the dominant culture.
Responsibility toward equity

Hardy (2016) suggested that diversity is about who our practice includes, while equity
is about how they are treated. According to Almeida et al. (2011), practice must pro-
mote cultural equity; that is, value and respect all cultures and actively seek to avoid
privileging dominant culture standards, ideals, and practices. Responsibility toward
equity means that socioculturally attuned practice must incorporate an analysis of
power processes that includes the therapist and treatment systems. Whose values and
interests are reflected in the clinical models we employ? Are the concepts that guide
our practice models socioculturally attuned or do they represent the dominant culture
(see McDowell et al., 2018)? The analysis must also take into account how societal
power processes are reflected in clients’ relationship patterns, identities, and beliefs
about their own worth and value (Knudson‐Martin, 2013).
Responsibility toward equity means that therapists recognize that dominant culture
standards and practices are not equitable; they tend to serve groups with more social
power (i.e., white, male, heterosexual, high SES, physically able, etc.). Therapists
need to intentionally orient their work to counter the effects of societal inequities and
help couples and families develop just relationships (McGeorge, Carlson, Erickson, &
Guttormson, 2006). This intentionality is important because social power operates
through communication and relational processes such that persons with powerful
social identities (male, straight, white, affluent) have more ability to influence what
happens and what is believed. What they say is presumed more credible. Fricker
(2007) calls this epistemic injustice. It is not just that individual voices are less credi-
ble, but that these injustices pattern social meaning so that shared collective meanings
invalidate or minimize the experience of the subordinate (female, LGBTQ, persons of
color, persons with low income or disabilities, etc.). Living with persistent societal
invalidation affects self‐worth and beliefs about what one can do and what is possible,
making these important relational and clinical issues.
Let us return to Justin and Cori. Even though Justin does not currently earn money,
like most white men, he has learned to expect that his opinions matter: that the way
he sees a situation is correct. This is an example of epistemic injustice (Fricker, 2007).
Justin does not himself have much power, but both he and Cori draw on “collective
conceptions of what it means to be a man, and what it is to be a woman” (Fricker,
2007, p. 15) and these give male voice more authority, even when women make more
money (Tichenor, 2005). Justin feels much more entitled to question Cori’s perspec-
tive and behavior than she does his. When he criticizes her tidiness, she feels shame
because societal gender expectations tell her that pleasing her partner and maintaining
a tidy, organized home reflect her worth as a woman. This creates an inequitable bal-
ance of power in their emotional exchange (Knudson‐Martin & Huenergardt, 2010;
Knudson‐Martin et al. 2015).
Socioculturally attuned therapists would recognize the imbalance and promote
equity by helping Justin attune to Cori’s experience. This may sound obvious,
something that all therapists would do, but there is considerable evidence that unless
therapists intentionally track how societal‐based power is part of relational processes
and respond in ways that counteract the injustice, they most likely end up following
and reinforcing the dominant societal perspectives (in this case, male) without
realizing they are doing so (ChenFeng & Galick, 2015; Sutherland, LaMarre, &
Rice, 2017).
Other equity issues in this case relate to the interconnections between economic,
educational, family, religious, and political systems. For example, each partner experi-
ences symptoms of anxiety (headaches, panic attacks, self‐doubt, social fear, etc.) that
can be considered reactions to their devalued positions in the dominant social order
or signs of their resistance to dominant social structures (Garcia, Košutic, & McDowell,
2015). Justin, who dropped out of high school, lives with being viewed “less than” by
“the mainstream.” He actively seeks to resist societal measures of success (male pro-
vider role, economic worth, conformity to external standards) while trying to be a
“good” father. Cori, college‐educated with a professional job, must deal with social
judgment that she is a second‐class mother and partner. The couple’s attraction, com-
mitment to each other, and family structure are devalued in the larger society.
Understanding their experience will require attention to the complexities of their
unique niche in the sociocultural context, including the nuanced power processes
involved (Falicov, 2014).
Nuanced attention to context

It is important to avoid stereotyping clients based on their social identities. Therapists
must be both “knowing and not‐knowing” (Falicov, 2014, p. 42). We have an
obligation to be knowledgeable regarding how larger societal systems work and to
recognize possibilities to learn about/consider. We also need to recognize that many
contextual factors influence a case and seek to understand each person’s particular
experience. For example, let us imagine that Cori’s mother immigrated to the main-
land United States from Puerto Rico when she was a young adult. You know a little
about Puerto Rico’s history and culture and recently had another client for whom her
Puerto Rican heritage was very important. You become curious about how Cori’s
ideas/experience of parenthood, marriage, and religion may be connected to this
heritage. What you know may stimulate questions such as “What do you think your
mother learned about what it means to be a woman who grew up in Puerto Rico?”
You know religion may also be important, but do not presume what religion may or
may not mean to Cori or her mother.
Falicov’s (2014) Multidimensional Ecological Comparative Approach (MECA) can
be a helpful guide. It explores four domains that come together to personalize clients’
experiences with social justice (racism, discrimination) and cultural diversity (values,
beliefs) as they are incorporated within family maps. Therapists must also consider
how client experiences compare with their own on each domain: (a) ecological con-
text (community, work, school, religion), (b) migration/acculturation (separations
and reunions, trauma, disorienting anxieties, cultural identities), (c) family life cycle
(ideals, meanings, timings, transitions), and (d) family organization (nuclear/
extended family, connectedness, hierarchies, communication styles). These intercon-
nected aspects of family life are inherently sociopolitical as well as cultural. According
to Falicov (2014), “without a lens that includes social inequities, cultural preferences
may be used as explanations for economic failure, domestic violence, or poor school
performance, whereas the larger negative effects of poverty and social discrimination
are downplayed” (pp. 45–46).
It is also important to not see culture as fixed or applying in the same ways to broad
groups of people. Understanding complexity and nuance means exploring change
over time and the intersecting elements that inform meaning. In Cori’s case, being
Puerto Rican was an unexplored part of her identity. She never really thought about
why she wanted to shorten her name, Corinda, to Cori. Understanding how her
mother had escaped a harsh male‐dominated, violent family and tried to erase her
Puerto Rican history helped Cori negotiate mixed messages regarding what it means
to be a woman/mother and confront dominant discourses that framed her relation-
ship with Justin as “less than” at work, at school, and in the community. This enabled
her (and her mother) to update and personalize Puerto Rican culture with an empha-
sis on relational values. As Justin and Cori became more aware of the workings of
social and economic systems in their lives, they were more able to uphold their desire
to prioritize relational goals over economic status. Because most people do not see the
connections between their struggles and larger systems, the therapist needed to
actively facilitate this awareness as illustrated at the end of the chapter and detailed
more fully elsewhere (see Knudson‐Martin, McDowell, & Bermudez, 2017;
McDowell et al., 2018).
The Role of Place in Conceptualizing Health and Well‐Being
Socioculturally attuned practice extends to how therapists conceptualize clinical issues

and requires understanding how health and relational well‐being are connected to the
material realities of life, including places families inhabit on local and global levels.
Significant attention has been paid to the practice of family therapy internationally
(e.g., Ng, 2005; Roberts et al., 2014) as well as to the distress families experience
when countries are in conflict with each other (e.g., Charlés, 2010; Hakak, 2016).
In general, however, attention to diversity and social equity has tended to focus on
societal systems and power dynamics within national boundaries. Conceptualizing
clients’ experiences within a broader global context can enhance our ability to be
socioculturally attuned to the most intimate context of families and develop sociocul-
turally responsive treatment approaches (Falicov, 2009).
Let us return to Cori and Justin. Cori was able to claim her Puerto Rican heritage
and integrate into her life aspects of Puerto Rican culture that had been previously
unavailable to her. Taking a meta‐view at a global level would expand the therapist’s
ability to socioculturally attune to Cori and Justin’s relationship as informed by an
even larger context. In many ways, their relationship is isomorphic to contemporary
and historical power dynamics related to Puerto Rico as a US territory. While Puerto
Ricans are American citizens, they have limited rights and are largely disenfranchised
in the United States. The history of being colonized by Spain and “ownership” being
transferred to the United States after the Spanish–American War is part of past and
present US expansionism, militarism, and drive for global power. Anti‐Latino senti-
ment in the US mainland and the view of Puerto Ricans as less than full citizens
was evident in failure to provide adequate support after Hurricane Maria in 2017.
This broader view contributes to understanding why Cori’s mother might seek to
erase her Puerto Rican identity and support Cori’s identification as white. Relational
dynamics on a global level in some ways reflect what is happening within Cori and
Justin’s relationship, that is, identities associated with more powerful countries
(and identity groups) are centered and dominant.
Decolonizing practice
An important part of socioculturally attuned practice is recognizing and being respon-
sible to how our practices may serve as a colonizing force through the unexamined
use of Eurocentric practice models that privilege individuality, independence, per-
sonal achievement, and relationship with self. Colonizing occurs when dominant
group cultural values, beliefs, and practices are centered as preferable, normal, and
right. This is not simply a matter of “different” beliefs; dominant cultural practices
determine cultural capital (e.g., language, traditions), social capital (e.g., who you
know, social influence), and even symbolic capital (e.g., skin tone, country of origin,
education). All of these are connected to economic capital (Bourdieu, 1986) and
power to dominate and control a populous. Colonizing processes at an international
level tend to conflate what is determined as right and true with a country’s level of
technological development, material wealth, and military might. A similar dynamic
occurs within societal systems (e.g., education, government, business) including fam-
ily science (Bermúdez, Muruthi, & Jordan, 2016) and mental health service delivery.
The therapist’s expertise and assessment models can have a dominating, colonizing
effect as mental health practices expect therapists to determine what is normal and
what is not.
Decolonizing requires third‐order thinking to inspect our own positionality, cul-
tural norms, beliefs, values, field knowledge, and practices in relationship to those that
are centered and dominant. This decolonization of the mind is a collective process
and helps us put into sociocultural context what we hold as true about how families
are and should be. Decolonizing practice involves helping individuals, couples, and
families do the same, that is, take a meta‐view of systems of systems that shape their
lives. In the example above, helping the couple resolve issues around Cori’s messiness
might reflect an unexamined colonizing expectation that we are to control ourselves
in ways that maintain order even in the most private aspects of our lives and/or that
work and duty supersede relaxation and pleasure. Euro‐American cultures also tend
to prioritize time and efficiency over harmony. Thinking in these broader terms, the
therapists might invite Cori and Justin to examine the value of order and its impact on
relational connection, as well as the role of space and place in which these relationship
events occur.
Assessing space and place

Mental health and relational dynamics are understood in socioculturally attuned ther-
apy as situated within the space or geography of where families live, work, and spend
time in their communities. Space refers not only to the natural environment but what
we construct within environments (e.g., institutions, homes, shopping malls, modes
of transportation, parks, industrial plants) (Soja, 2010). Access to resources (e.g.,
employment, medical care, education, healthy food) compounds our advantages
and/or disadvantages. Geographies, and the distribution of goods and services within
them, are far from equal, privileging some families over others: enhancing choice and
opportunity for some while limiting possibilities for others. Issues related to environ-
mental justice include access to clean air and water, freedom from sound pollution,
protection from harm, and equal participation in making collective decisions about
what happens in one’s community. It is important for therapists to ask questions and
consider the impact of space and place on mental health and relational well‐being, for
example, how safe and comfortable is a family’s environment? What privacy is afforded
to each family member and the unit as a whole? What access do they have to quality
education, healthy food, and medical care?
According to Bourdieu (1986), we tend to share space with others who have similar
social, cultural, symbolic, and economic capital. A socioculturally attuned assessment
might consider things like what parks families visit, the transportation systems they use,
where they buy food, and the schools their children are expected to attend. Bourdieu
suggested that it is within these spaces, or what he termed habitus, that we internalize
shared knowledge of the world including values and beliefs. In these ways, spatially
locating families is core to understanding their worldviews as well as physical resources.
The concept of place focuses on the sense of being within a space. Expectations for
negotiating space vary across cultures, however, tend to universally include needs for
personal space, privacy, safety, and social interactions (Fitzpatrick & LaGory, 2000).
Many cultures are place based and place has various meanings across cultures. Think
of where you feel safe, emotionally moved, spiritually awake, and/or “at home.” How
is access to these places determined? Are you able to live in or near these places? Do
you have the means to visit them? How do these places contribute to your mental
health and relational well‐being? Access to these places is typically associated with
privilege, influence, and/or economic resources.
Mobility, that is, the ability to move or travel from one place to another, is included
in the privilege matrix and impacts access to resources and freedom of interactions. The
privilege of privacy is often reflected in dynamics of mobility (e.g., who can move from
place to place and who is restricted by others) as well as surveillance (e.g., who has the
privilege or right to gaze upon whom). Finally, processes of privilege and oppression
that are interconnected across global and local contexts are reflected in all places,
including the intimate territory of home. For example, the most powerful members of
families often dictate the emotional climate and have greater influence over how inter-
actions unfold in shared spaces determining the relative sense of place for all.
Creating a family cartography (McDowell, 2015) is one way to highlight the rela-
tionship between space and place and dynamics of privilege and oppression. Family
cartographies are topological maps that can be creatively drawn without attention to
scale. Therapists ask questions that reflect attention to power, privacy, personal space,
social interactions, safety, mobility, oppression, resistance, and resilience as they or the
clients map their physical context including client’s communities, neighborhood, and
home. For example, when working with Cori and Justin, you would ask them to
describe the setting in which they live (e.g., physical environment, neighborhood,
town), explore their social interactions within these contexts (e.g., where in the con-
text is safe/unsafe; what privacy is available), and analyze the effects of social location
and power dynamics (e.g., race, class, gender, sexual orientation, nation of origin,
abilities). You could ask them to draw the floor plan of their home and space directly
surrounding their home within the community and neighborhood they are describ-
ing. An emotion map (Gabb & Singh, 2014) can be incorporated to visualize how
embodied sociocultural emotions are experienced in everyday spatial interactions.
As you discuss their social interactions within and around the home, you learn that
the family is living in the small two‐bedroom apartment Justin lived in before Cori
joined the family. It is all they can afford in a neighborhood selected for proximity to
a public “magnet” school they accessed via lottery. Cori reports no private space for
items meaningful to her or personal breathing room. Justin appears to control the
emotional climate and relational interactions in the home, stating that it is “common
sense” (i.e., dominant culture sense) that “mature people” keep an orderly home.
The apartment is a long commute from Cori’s work. The couple spends much time at
the children’s school and sports activities, even though they feel like “second‐class
parents” in this school/community environment, which Justin sought to create
opportunities for the children (i.e., social and cultural capital that he could not him-
self provide). Conversation about space and place generates openings to talk about
the nuances of oppression, privilege, resistance, and resilience within the spaces Cori,
Justin, and their children inhabit. It helps highlight the connections between equity,
culture, and health.
The role of equity, culture, and health

Sociocultural attunement includes attention to how symptoms and presenting issues
are connected to inequities directly related to one’s place in the social hierarchy. The
detrimental effects of discrimination and oppression on health are well documented
(Center for Disease Control Health Disparities and Inequalities Report, 2013). In
fact, there is a plethora of research on health disparities and the negative physical and
psychological effects of discrimination and oppression. We know, for example, that
race is a determining factor in the likelihood of being incarcerated, developing an
addiction, suffering physical illnesses, and determining longevity (Jones, 2000). We
also know that women are more likely to suffer anxiety and depression than men
(National Institute of Health, 2014). Youth who identify as LGBTQ+ are at greater
risk for suicide and homelessness (Garofalo, Wolf, Wissow, Woods, & Goodman,
1999; Kruks, 1991). Being in a lower socioeconomic class increases chances of strug-
gling with mental health issues, among other problems (McCulloch, 2001). There is
also ample research that considers the negative effects of inequity and the positive
effects of equity on intimate relationships. Equity has been clearly linked to relational
satisfaction in a number of studies (Gottman, 2011; Knudson‐Martin & Mahoney,
2009; Lutrell, 2016). Research on couple therapy has also highlighted the impor-
tance of attuning to relational and social equity (Knudson‐Martin et al., 2015,
Knudson‐Martin, Wells, & Samman, 2015).
The idea that therapists can or even should be neutral is becoming outdated as we
become increasingly aware of the connection between power dynamics and present-
ing problems. Being neutral, or attempting to not take an equity stance, often results
in supporting the status quo of unjust relationships, which in turn fails to fully address
presenting problems. Even emotions and ability to attune to other’s emotions are
impacted by relational power dynamics, that is, those with greater privilege and ability
to influence others typically experience more positive emotion than those who are
disenfranchised (Turner, 2007). Likewise, those who hold more power in relation-
ships are typically less attuned to those with less power, and vice versa.
Furthermore, socioculturally attuned therapists do not question that symptoms are
real or that diagnosing symptoms is not helpful to designing treatment. Rather, they
consider the relationship between symptoms and power to assess in what ways, if any,
presenting problems are a result of inequitable relational dynamics and/or serve as
forms of resistance to them. For example, those suffering intimate partner violence,
sexual abuse, homophobia, sexism, or racism may use a variety of resistance strategies
including yielding, emotionally or physically withdrawing, attempting to understand
and navigate power dynamics, and/or anger/speaking out (McDowell, 2004).
Directly challenging oppressive individuals and systems can be treacherous. Speaking
out can lead to more oppression unless there is certainty that one will be believed, not
be punished or seen as the problem, and there is a real possibility of change (McDowell,
2004). Yet, many ways to resist subjugation can also become problematic.
Consider an upper‐middle class, white woman in her early 60s, Rhonda, who
requests therapy for depression. Her husband, Phil, refuses to come to sessions with
her. When Rhonda arrives, it is clear that she meets all the criteria for DSM‐5 Major
Depressive Disorder, Single Episode, Moderate (296.22). The socioculturally attuned
family therapist takes steps to address Rhonda’s immediate needs, including complet-
ing a risk assessment, making sure social support is in place, encouraging physical
movement, making a referral for possible antidepressants, and instilling hope. At the
same time, the therapist is considering the impact of relational dynamics, societal
systems, and power on her depression.
It becomes clear that Rhonda has little influence with Phil, is isolated in her beauti-
ful home, and is angry with herself for not a being more grateful for all she has. She
reports feeling empty and without purpose. Rhonda’s economic dependence on Phil
and expectation that it is up to her to keep the family together freeze her options.
Rhonda began withdrawing from her husband years before her symptoms escalated to
depression. Once their two children left home, she reclaimed one of their bedrooms
as her writing room and began spending most of her time there. Phil often called her
out of the room to provide a meal or watch a television show with him, but she would
retreat to her space whenever possible. Rhonda’s withdrawal increasingly became her
solution for not having voice in her relationship. As therapy progressed, Rhonda was
able to place her experience within a sociocultural framework that included analysis of
both her white and social class privilege as well as her lived experience of gender
oppression and economic dependence. Rhonda decided to continue her relationship
with Phil, however changed the nature of how she withdrew. By the end of therapy,
in her terms, she had “reinvented herself” and was taking weekends away to write
creatively, visiting friends, and spending time with their grown children. Her symp-
toms of depression lifted.
Common factors
Sociocultural attunement enhances common factors in the therapeutic process
(D’Aniello et al., 2016; McDowell et al., 2018). Understanding clients’ social and
physical contexts, cultural practices, and collective legacies helps therapists explore
extratherapeutic factors, including available social support and sources of resilience.
Being socioculturally attuned to clients enhances therapeutic alliance as therapists
are able to accurately empathize with clients’ social situations and provides insights
into clients’ worldviews and preferred ways of being. Within family alliance can be
enhanced by helping family members better understand each other’s positionality and
sociocultural experience. Sociocultural attunement also supports clients’ expectancy

for change. As therapists help clients recognize the impact of societal systems in their
lives, clients begin to see potential opportunities for change. This is empowering and
makes change feel more possible. Third‐order thinking widens options by inviting
clients to step beyond the systems in which their lives are embedded to entertain new
frameworks for organizing their relationships. As we have illustrated in depth else-
where (McDowell et al., 2018), sociocultural attunement can be integrated into all
family therapy models to enhance their effectiveness in working across social contexts
and cultural groups. In the next section we suggest guidelines that help clinicians
translate commitment to sociocultural attunement into practice.
ANVIET: Guidelines for Socioculturally Attuned Practice
The acronym ANVIET (attune, name, value, intervene, envision, and transform)
describes a set of practical guidelines that can be applied across family therapy
approaches (Knudson‐Martin et al., 2017; McDowell et al., 2018). We illustrate
each of these with the case of the Williams family. The mother, Bernadine (34),
called because James (14) was referred following a fight at school. Bernadine
describes herself as an African American single parent “at the end of her rope.” She
reports that until recently, James has always been a “good boy,” who helped with
his younger siblings, Gregory (11) and Ruby (9), both of whom have previously
received multiple diagnoses, including attention deficit hyperactivity disorder
(ADHD) and oppositional defiant disorder (ODD). Bernadine has been separated
from their European American father, Stan (36), for 3 years. The therapy is con-
ducted by Alicia (26), a Latina family therapy intern supported by an observation
team. Alicia applies the ANVIET guidelines to an approach that integrates struc-
tural and attachment perspectives. She asks Bernadine to bring all three children to
the first session.
Attune to client experience within societal contexts

Socioculturally attuned therapists begin by expanding the lens. As a structural thera-
pist, Alicia seeks to join the family by apprehending the multiple systems within
which they live and resonating with their experience. Bernadine and the children
appear to be a close unit. When Gregory starts to become agitated in session, James
quietly strokes him to calm him down. Alicia wants to understand their close family
system in context of the many systems affecting them. After learning a bit about the
incident that resulted in the referral, she asks about the school and their neighbor-
hood. She learns that the school is multiracial and James says he has learned to
“float” in multiple groups. Alicia is also interested in Stan’s apparent disengagement
from the children’s lives and wonders aloud how it happens that fathers often end up
more outside their families than they want to be. From an attachment perspective,
Alicia expands her focus to include each family member’s experience of belonging
within larger sociocultural communities. In the second session, she engages them in
creating a family cartography to help form a systemic framework for considering
child behavioral problems.
Name what is unjust or overlooked

Alicia looks for and identifies what is unjust or overlooked in the dominant culture.
She is intentional in bringing forth and amplifying silenced voices. For example, she
asks James if he thought his experience would be different if he were white. This
produces a spirited conversation about racial inequity that has previously not been
named. Alicia helps the family name the safety they feel in the privacy of their own
home and how this contrasts with the vigilance they must keep in the broader com-
munity. They name how long work hours, tight space, and tensions in the commu-
nity contribute to stress that exacerbates ADHD and invites oppositional behavior.
They discuss what it means to have a white father and name both the loss he likely
experiences as an uninvolved father and the unfair burden that appears to be falling
on Bernadine.
As they further explore the comfort and belonging of each family member at home,
at school, and in the community, James becomes very quiet. Bernadine says he has
been keeping to his room and not wanting to be with the rest of the family. Alicia
suggests individual sessions for James with another team member. In this private
setting, he discloses that he may be gay or perhaps transgender. Naming confusion
about “not knowing where he fits” and lack of safety for LGBTQ+ students at school
as context for his recent fights helps reduce James’ self‐blame and guilt and opens
conversation about the effects of homophobia. They discuss how James wants to
handle this information with his family.
Value what is minimized or devalued in the larger society

As a Latina woman with a close family herself, Alicia is aware that close relational
bonds tend to be devalued in the dominant culture. Rather than thinking of the
Williams family as enmeshed, she values their ability to stick together and recognizes
this as an important survival tactic in face of racism and limited economic resources.
Though one of the first reactions of the observing team is to think of James as “par-
entified” because of his history of looking out for his siblings, they rethink this pattern
and credit James with willingness to share the family work. Alicia also assumes that
Stan (father) has relationship interests that have been devalued in constructions of
white masculinity and dominant culture models of success.
Intervene to support equity and disrupt power dynamics

Socioculturally attuned therapists intervene in societal‐based power dynamics using
in‐session process to make power inequities visible and interrupt them. Many power
inequities are present in the Williams family. James’ silence, withdrawal, and anger
are a response to cisgender and heterosexual dominance that interferes with his abil-
ity to credit and value his own experience or be valued by others. The therapists
intervene by making room for multiple gender and sexual expressions in the session
using questions and reflections that support James in resisting social pressure for a
quick binary, either/or answer. Similarly, since Bernadine is carrying a much greater
share of parenting responsibilities than Stan, Alicia’s interventions support Bernadine
rather than placing blame or additional burden on her. She suggests inviting Stan to
some sessions.
Envision just relational alternatives

Identifying injustice is not enough. Therapists must create space to imagine just
relational alternatives. Though Stan wants to be engaged, male socialization limits his
relational options. His advice to “not take shit” does not take into account Bernadine
or the children’s experience of racial injustice. Alicia invited the family to imagine
what it would look like if Stan were more involved:
Alicia: [to children] Why don’t you tell your father what it would mean to you to be more
connected with him?
The children describe many ways they would like to share time with Stan and do
things together. Alicia expands the conversation to directly address gender and race:
Alicia: Stan, you’ve described learning that men have to stand up for themselves and fight,
but not how to connect with your children. Why don’t you talk with them about your ideas for
a different way of being a father?
Transform by making what is imagined real

Making the imagined real takes practice. This requires persistence on the part of the
therapist, bringing clients back to the goals they have envisioned.
Alicia: [to Stan]. What do you think would help you tune into them—to get the ways racism
and homophobia affect what it’s like at school?
Bernadine and Stan work to create a just co‐parenting relationship that explicitly
values relational bonds and openly addresses what it means to be a biracial family and
how to join together to negotiate the societal stressors they face. They not only
“accept” James’ evolving gender and sexual identities; they seek to know him as a
person. To do this work, therapists must know themselves and consider how their
practices are positioned in relation to equity within systems of systems. This is an
ethical process.
Ethics and Self‐of‐the‐Therapist
Socioculturally attuned practice is only possible through self‐reflexivity, critical social

awareness, and ethical positioning. If therapists do not reflectively counter societal
inequities and dominant discourses through practices such as ANVIET, their diagno-
ses and interventions replicate injustice (ChenFeng & Galick, 2015; Dolan‐del
Vecchio & Lockhart, 2004). Clients may see themselves as “deficient” and/or be
further oppressed (Hernández‐Wolfe & McDowell, 2014). Those already carrying an
unfair burden of responsibility may be asked to take on more (Knudson‐Martin,
2013). Rather than an empowering experience, therapy can become a colonizing one.
Ethical practice requires therapists hold themselves accountable for the effects of their
actions so that clients are more able to deal with present and future injustices and
make changes that begin to transform them (Almeida et al., 2011; Falicov, 2014).
Attention to self and ethical accountability are especially important for those in
structurally ascribed positions of power, including family therapists. Arguably, those
who have the most social capital and ability to influence are most responsible for and
often least likely to facilitate necessary and important changes that lead to equitable
and just practices (Almeida et al., 2008; McDowell & Hernández, 2010). It is impor-
tant for us to find ways to develop accountability systems that identify when we are
actively or passively oppressive in our clinical practice, teaching, supervision, and
research. This includes awareness and self‐reflexivity in the process of therapy as we
implement our clinical models.
Ethical decision making as socioculturally attuned therapists involves recognizing
that how we conceptualize and intervene—the words we use and what we do—are
not neutral. It is not a simple, good/bad dichotomous process. Therapists often grap-
ple with ethical tensions relative to cultural sensitivity and equity, for example, (a) how
to encourage personal empowerment while also recognizing societal constraints that
limit personal choices, (b) helping clients challenge injustice while honoring and rec-
ognizing potential costs of resistance, (c) respecting cultural values and perspectives
while challenging oppression, and (d) using therapist power to counter inequities
while also being collaborative. Solutions to these dilemmas are not the same for all
clients and contexts, and they are often complex, representing a both/and perspec-
tive. Engaging in this work invites us as therapists to “rigorously examine our own
assumptions” and find cultural strengths that may have been minimized or overlooked
(McDowell et al., 2018, p. 36). It is grounded in a broader paradigm shift in how we
think and how we know what we know and has implications for training and research
as well as practice.
Future Directions
Despite growing commitment in systemic family therapy to socioculturally attuned

practice based on a relational focus, third‐order thinking, responsibility toward equity,
and nuanced attention to context, training and research remain heavily organized by
dominant Eurocentric ideals and practices that privilege individualism and place
researchers and practitioners in detached observer positions (Bermúdez et al., 2016;
Hernández‐Wolfe & McDowell, 2014). Research and curricula still often essentialize
whole groups of persons into monolithic categories, view them from a position of
“other,” and address contextual variables (e.g., race, class, gender, sexuality, ethnicity,
nationality, religion, abilities, etc.) as separate variables rather than exploring how they
intersect (Seedall et al., 2014).
Family systems researchers, educators, and supervisors need to better acknowledge
and embrace subjectivity, examining the sources of knowledge and discourses that
influence our work (Bermúdez et al., 2016; Falicov, 2014). We need to reflect upon
the types of questions asked in research, who asks them, what methods are deemed
legitimate, who benefits from them, and how these affect training and practice
(Bermúdez et al., 2016). Family therapy curricula need frameworks such as queer
theory (McDowell, Emerick, & Garcia, 2014) and nepantla (Hernández‐Wolfe,
2013) that help students, faculty, and supervisors embrace social complexity and the
tensions of contradiction, as well as ability to work among multiple and overlapping
spaces and ways of knowing.
Most family systems therapists know that sociocultural context matters, but lack
guidelines for how to translate this knowledge into practice (Knudson‐Martin et al.,
2017). There is a need for process research that expands the small body of practice‐
based evidence (St. George, Wulff, & Tomm, 2015) that informs family systems’
supervisors and clinicians about what helps couples and families become more aware
of their internalized sociocultural values and discourses and the workings of societal
power processes in their lives and able to envision and make transformative change
(e.g., D’Arrigo‐Patrick, Hoff, Knudson‐Martin, & Tuttle, 2016; Elias‐Juarez &
Knudson‐Martin, 2016; Pandit, Kang, Chen, Knudson‐Martin, & Huenergardt,
2014; St. George & Wulff, 2016).
We have observed a disconnect between training and research around best practices
(e.g., good therapy) and socioculturally attuned practice, in which attention to culture
or equity is often an add‐on, rather than a beginning point (Falicov, 2009). Our hope
is that the ideas in this chapter will stimulate third‐order thinking in the field itself so
that collectively we can expand systemic family therapy training, research, and practice
in ways that actively support equitable relationships and just societal systems.
Note
1
Identifying information and some circumstances have been modified to protect client
confidentiality in all case examples in this chapter.
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28
Promoting Innovative Systemic
Research through Improved
Graduate Training
Jared A. Durtschi, Suzanne Bartle‐Haring, and
Amber Vennum
New graduate students in graduate clinical training programs are typically very eager
to develop clinical skills and talents; however, there is usually a less enthusiastic a ttitude
toward learning research. Frequently, and unfortunately, this attitude is reciprocated
by the faculty within these training programs. We believe that this attitude toward
research is bred from misconceptions about the multiple types of research and the lack
of overt connection between research and our clinical values. We further assert that
research is an essential aspect of the systemic family therapy (SFT) field, and, in order
for the field to move forward, we need to overcome barriers SFTs may encounter to
engaging in research. We also need to train passionate researcher‐clinicians who ask
and seek to answer questions that improve our ability to effectively promote positive
mental health and relationships. Because we care so deeply about clinical work, it is
critical for us as a field to learn what works, how it works, for whom it works, and in
what contexts it works. Further, it is critical to bridge any gaps between practice and
research in order to improve the relevance of the research that is being conducted and
to make sure clinicians have the most up‐to‐date information and resources to best
help their clients and themselves grow. Put most directly, our SFT field is not doing
enough quality or quantity of research at either the MS or PhD level, and we are fall-
ing behind our academic peers. There are a host of negative consequences for our
profession, programs, and clients if we do not rectify this. Now is the time for each of
us, and for our programs, to take a few steps forward in elevating our research skills
and the priority with which relationally informed clinicians incorporate, value, and
produce research in their daily practices.
Why we need SFT research

Why should MS students, PhD students, or faculty members in a clinically focused or
research‐focused SFT program be concerned about research? Often, many in
our fields in various capacities feel like research is not necessarily relevant for us.
640 Jared A. Durtschi, Suzanne Bartle‐Haring, and Amber Vennum
For MS‐level training programs, developing a foundation in research methods can

help us become better consumers of research and be able to read and adapt research
into clinically relevant information that can facilitate clinical growth throughout an
entire career. In many of the research journals targeted to clinicians, the research
methods are relatively advanced, and the MS‐level coursework should include suffi-
cient training to read, critique, and make clinical implications from the results of an
actor–partner interdependence model, growth curve, or structural equation model,
just as easily as the results from a qualitative paper using grounded theory. Without
this foundation at the MS level, the terminal degree for clinical practice, it would be
nearly impossible for clinicians to stay abreast of the research that should inform their
clinical practice. Doctoral students and their faculty in SFT programs need a high level
of sophistication in their research training, as the research questions we have in our
field are too complex to be answered with simplistic statistics (e.g., t‐tests, regression,
and analysis of variance). In order for doctoral students to contribute in a meaningful
way to the research in our field, they must learn how to use the research tools that are
critical to advancing the field.
We use the term “research” to refer to a broad spectrum of discovery activities,
including, but not limited to, practice‐based evidence gathering, qualitative research,
focus groups, case studies, mixed methods approaches, process research, research on
treatment failures, community‐engaged research, and basic quantitative research
(Dattilio, Piercy, & Davis, 2014). All of these modes of research have the potential to
elevate our clinical work and make a positive impact in our communities. To engage
in high‐quality research, we need to ask relevant research questions, gather and use
high‐quality data, use sophisticated data analytical approaches, publish our research in
strong journals, aim to make a meaningful difference with our research, seek external
funding to further our understanding, test interventions designed from research, and
disseminate knowledge gained in helpful ways to fellow clinicians and the broader
public. We hope that students, clinicians, and faculty will think big in terms of the
research questions we ask and use this curiosity and drive to advance the SFT field.
Sprenkle (2003) suggested that there were several stakeholders of SFT research,
which included not only other researchers but also clinicians, teachers and trainers,
professional associations like the American Association for Marriage and Family
Therapy (AAMFT), mass media, policy makers, and insurers. The latter two make
research in SFT incredibly important for the future viability of the field and emphasize
the importance of SFTs being trained in consuming, conducting, and communicating
SFT research. Additionally, clinicians need to be clear about their models and tech-
niques and what evidence there is that provides support for their use. Teachers and
trainers need to be aware of the latest evidence that supports the use of family therapy
models and techniques. Finally, professional associations, like AAMFT, need to have
at their fingertips the research that supports the use and practice of marriage and fam-
ily therapy in order to promote and advocate for our field. Additionally, the clients
and communities we serve deserve effective and quality clinical services that can pro-
mote growth and healing. This requires research.
Crane, Wampler, Sprenkle, Sandberg, and Hovestadt (2002) suggested that the
common culture of specialized SFT programs and other degree programs that offer a
specialty in SFT often does not support research and, unfortunately, it is common-
place to develop a model of family therapy and “take it on the road” with books and
workshops without offering evidence for its efficacy beyond anecdotal. If you attend
Graduate Research Training 641
a professional conference around the world that includes clinical work with couples
and families, research presentations are often relegated to quick 15‐min simultaneous
presentations during breaks from the “real” clinical workshops that often do not
include information about the research that informs the theory or intervention, let
alone data on its effectiveness or relevance. Unfortunately, lack of understanding of
the importance of research and how it supports the use and practice of SFT continues
to impede our development as a field. Another unfortunate outcome of neglecting
research at the master’s training level is not learning how to become good consumers
of research and not being able to research their own clinical effectiveness.
As researcher‐clinicians in programs where the students are being trained to do
research, the authors of this chapter believe that the solution to the researcher–clini-
cian gap could begin to be resolved by talking about why researchers choose the
research they do and talking about why clinicians choose the work they do. We imag-
ine that the answers to these questions would be quite similar. The fact is, we do
research about topics for which we are curious and passionate, and our clinical work
is also, in part, driven by our passion for making a difference and our curiosity about
people and relationships. As clinicians develop, hopefully, they begin to see what it is
that attracted them to SFT and identify areas of specialization. Those same things can
attract the researcher‐clinician to research topics of interest, creating a synergy
between clinical work and research. Although there are many stakeholders of SFT
research, hopefully, it is our questions and curiosity that motivate the research we do.
Developing a research passion

We define passion as an intense emotion that drives people to act. Prior to helping
students develop research skills, we believe it is critical for students to first identify the
passion that drives the work they do across all areas of their SFT professional lives.
Once identified, that passion then provides direction and motivation for the integra-
tion of the development of a researcher‐clinician identity. Thought questions to guide
this identity development may include the following: (a) What specific issues do you
care most strongly about? (b) What populations or contexts do these issues dispropor-
tionately affect or occur in? (c) What change do you want to see in the world related
to these issues? (d) What clinical models or nonclinical theories inform how you
understand this issue and potential solutions? (e) What do you need to know and
what communities do you need to involve to develop potential solutions for this issue?
(f) How would you best be able to discern if those potential solutions were effective
(e.g., outcomes, research design)? (g) How might you create a broader impact with
knowledge that is gained (i.e., how do you share it with fellow SFTs, policy makers,
and communities in useful ways)?
Over the years, we have observed that students who have a strong passion for a
specific problem accelerate in their research and clinical skills far faster than those
students who are just going through the motions. Research practitioners who feel
personally compelled to make a difference in a specific area strive to improve their
research abilities and their clinical abilities in this area simultaneously—clinical work
and research inform each other. They continually seek additional resources to improve
their ability to have the impact they desire to have through engaging affected and
invested communities, pursuing external funding, increasing their ability to answer
diverse questions with additional research methods training, seeking opportunities to
build their clinical experience and knowledge relevant to that area, networking with
others who share their passion or have expertise in related areas, and attending train-
ings outside their field to expand how they think about their issue or equip themselves
with new tools for making a difference. These researcher‐clinicians demonstrate
resilience in the face of setbacks because they are concerned about a serious problem,
are hell‐bent on doing something about it, and can clearly articulate and demonstrate
the synergy between their research and clinical work.
What should SFTs research?

Although our belief is that SFTs should research whatever is needed to be answered
in order to effectively address the issue they are passionate about, there is debate
about what types of research SFTs should engage in (cf. Sprenkle, 2010). First, there
is the question of should faculty encourage their students to research something of
interest to the student, or to research something of interest to the faculty. Allowing
students to follow their own passion, while being supported by the faculty, probably
fosters the most passion and a stronger internalized drive to do research for most
students when it is an area they are invested in. However, pragmatics of some environ-
ments dictate a student working on the faculty member’s research, due to available
resources and expertise of the faculty member. Thankfully, often the research interests
of both the student and faculty are aligned, or they share enough common overlap in
interest to have a mutually beneficial relationship.
Second, an area of debate is around “family science” research versus clinically
focused research. For example, at Texas Tech’s PhD SFT program—and this is likely
similar at many programs—61% of the dissertations were focused on family science, as
opposed to SFT (Morris, 2013). In our opinion, it is critical to first understand what
makes a family “healthy,” or resilient, and what issues challenge that health and resil-
iency in order to understand what areas to focus on in clinical interventions. Given the
great variation in pathways to family (defined broadly) formation (e.g., Payne, 2011),
it is critical to continue to enhance our basic understanding of the experiences of peo-
ple in diverse relationships and contexts in order to be effective clinicians with diverse
populations. It seems to us that any topic relevant to family science is relevant to clini-
cians and vice versa. However, there is a case to be made that clinically applicable
research, such as clinical trials, where the findings may be generalizable more broadly
to clinicians have the potential to move the field forward at a more accelerated pace
than a typical family science study might. Also, research with a more direct clinical
focus may be more beneficial to SFT stakeholders, such as insurers, policy makers,
professional associations, and government regulatory boards.
A third area of debate is around comparing models in clinical trials research versus
common factors research. In our opinion, both can inform our practice, and both are
legitimate. What becomes problematic for bridging the researcher–clinician gap is
making claims that because some models have a body of evidence that supports their
effectiveness and other models do not, those that do are better and should be the only
models that clinicians are using. Given the plethora of models available, along with
the plethora of constructs between models that seem to mean the same thing, we
agree with others (Dattilio et al., 2014) that it is premature to suggest that any model
is better than any other. Model may not be as important as other factors, perhaps
common among several theories, in the process of therapy that lead to positive
utcomes (Sprenkle & Blow, 2004). Many questions remain unanswered about how
o
our models contribute to effective outcomes to prematurely close doors to potentially
helpful research areas.
Asking good research questions

As stated earlier, it should be our curiosities about relationships and families and
about what makes therapy work that motivates our research. It is an acquired compe-
tency for students to learn to ask good research questions. In our experience, most
students start out with simplistic questions that are already well documented. Students
often need mentoring in learning to ask questions that can move the needle forward
in a given research area. In addition to passion and curiosity, good questions come
from a thorough knowledge of relevant research literature and theory. The theories
that guide our clinical work can also be used to guide our research questions. As stu-
dents develop a theory of change, they learn to think in systemic ways, which will also
enable them to think about potentially important research areas in systemic ways.
As that happens, they can begin to ask great research questions. One of the things
we have noticed as faculty in SFT programs is that students tend to ask questions that
are guided by research and analysis methods they have already learned or feel com-
fortable with, rather than letting the research question guide the research method
being used. It is important to ask big questions that might not be able to be answered
with traditional statistical methods (i.e., regression, analysis of variance [ANOVA]).
When we limit our questions to more simple and linear models of statistics, for exam-
ple, we limit the relevance of the research we conduct to practitioners working from
a systemic orientation (Dolbin‐MacNab & Keiley, 2013; Oka & Whiting, 2013). A
regression equation that predicts a single dependent variable (some outcome from
one individual) cannot answer questions that reflect human interconnectedness and
the role of context as other statistical techniques might be able to (i.e., dyadic data
analysis, multilevel modeling, etc.). The bigger the question, the easier it is to break
down into smaller questions that can lead to a meaningful program of research. An
SFT’s passion and curiosity to positively impact an issue drives the research questions,
which drives them to adopt a growth mindset and continually seek to improve their
skills in research and clinical practice to better affect change in their communities.
We also propose that our field will not move forward if we allow our students’
research questions to be limited to issues about their own training (e.g., whether
training programs offer courses in diversity, or sexuality, or incorporate spirituality) or
clinicians’ own opinions about what is best to do in a given situation with clients.
Although these topics may be important, we do not have evidence to suggest that
incorporating them makes for better clinicians. That seems to be the question that
should be asked, not whether we have the courses or are exposed to the topic areas,
but whether being exposed to those topics leads to more confidence as a clinician, or
better outcomes for clients. We hope we will redirect our research time and efforts to
bigger issues than what clinicians think about a range of given topics (also referred
to in the field as navel gazing). At times, this may require an assertive major professor
to help guide a student’s research question into something more meaningful.
Considering how many questions we do not yet know about relationships, problem
development, and change, it seems a higher priority to focus on research efforts tar-
geted toward testing what is working, how it works, and for whom it works.
Systemic Tools of Research
We live in the greatest time in history to be researchers. Numerous data management

and analysis programs exist to help researchers quickly organize, analyze, and sum-
marize both quantitative and qualitative data (e.g., Mplus, NVivo, Stata, MAXQDA,
AMOS). We can do literature searches from our phone or laptop from anywhere in
the world, without needing to go to a physical library. We can gather our own data
online using Amazon Turk and have hundreds of participants in a couple of days while
only paying $0.25 to $1 per participant. We have online survey tools, such as Qualtrics,
Axio, and SurveyMonkey. We can recruit and engage with diverse communities across
the country or world using the Internet and social media. We can use online video-
conferencing to run focus groups and qualitative interviews and meet with commu-
nity partners engaged in collaborative research projects from anywhere. Cloud‐based
collaboration platforms make it possible to collaborate with others anywhere they are.
Perhaps most astonishingly, there are dozens of datasets with thousands of couples
and families, with data from each family member, across many years (and in some
cases generations) that can be freely downloaded from the Internet by anyone (see
ICPSR website [https://www.icpsr.umich.edu/icpsrweb]). In addition, we have
seen the rise of research methods and statistical tools that think in much the same way
as SFTs do, opening up new possibilities for testing questions that were not possible
just 10 or 20 years ago.
It is essential that students and practitioners understand important aspects of how
to do research, how to read research, and how to apply research to clinical work.
Unfortunately, we believe many people in our field struggle with an unusual fear of
and a tendency to avoid statistics, research, and writing. This fear and avoidance
shared by many SFT‐oriented people limits the number of statistics and research
courses faculty want to teach and students want to attend. This tendency also results
in a weaker educational foundation in research and lower competence for students in
independently being able to read research and create research. We attribute some of
the blame for these afflictions to teaching of research methods and statistics in a way
that does not align with the needs of our field. For example, many graduate‐level
statistics courses are taught in statistics departments outside of the student’s academic
program, contributing to a sense that my field does not need this. Often, these classes
in other programs focus on formulas rather than application. It is possible to do sta-
tistical analyses by understanding them conceptually, without having to decipher
Greek letters and understanding higher‐level math. We believe that part of helping
students overcome their fear or distaste of research and statistics is to train SFTs in
approaches to research and analysis that are in sync with their systemic clinical training
and are clearly connected to practical application. The research process and advanced
statistics can become demystified by helping students gain mastery experience of how
to use research tools to monitor their own clinical effectiveness, read existing research,
or independently publish new research.
Systemic approaches to research

Bringing together multiple perspectives Although the traditional wisdom was that
basic research (to expand knowledge of a phenomenon) and applied research (research
to find solutions to practical problems) were distinct categories of research conducted
by distinct categories of researchers, this dichotomy is being challenged as a model

that is inefficient and detrimental to the development of innovative and realistic solu-
tions to complex societal problems (Narayanamurti & Odumosu, 2016). Rather, it is
recommended that the process of discovery and application be iterative and involve
combined teams of researchers and practitioners from diverse fields (referred to as
interdisciplinary, multidisciplinary, and transdisciplinary teams; Choi & Pak, 2006)
through all stages of research to increase the relevance of evidence‐based interven-
tions to real‐world settings (e.g., Czajkowski et al., 2016; Gottfredson et al., 2015).
Similar to the family systems SFTs’ clinical work, in order for the interdisciplinary
team to optimally function, team members need to come to a common understanding
of language, how resources will be shared, goals, and methods for achieving those
goals (Lustig et al., 2015). Getting everyone on the same page and checking for mis-
understandings is a well‐honed SFT skill, which, combined with an understanding
of human change processed in diverse contexts, makes SFTs highly effective team
members.
Accordingly, SFTs who have been provided opportunities to develop fluency in the
languages of both research and practice have the potential to offer meaningful contri-
butions to diverse research and treatment teams. Due to the positive outcomes for the
public when health‐care professionals collaborate (see Darlow et al. (2015) for a sum-
mary) and the need to systemically research the multitude of factors that influence
health (e.g., Bachrach & Robert, 2015), graduate programs in diverse health fields
have begun providing their students with cross‐disciplinary collaborative opportuni-
ties for interprofessional practice and research (ranging from specific class‐based pro-
jects to entirely integrated graduate programs) in order to build the interdisciplinary
skills needed to effectively work together toward a common goal. These opportunities
not only prepare students to practice clinically in the increasingly interdisciplinary
health‐care field (Darlow et al., 2015) but also to be competitive in a research funding
environment, which favors the wisdom of collaborative interdisciplinary teams over
siloed experts (see Czajkowski et al. (2016) for overview of current transdisciplinary
funding landscape in behavioral research). Many SFT programs have small research
groups made up of both interdisciplinary research teams (e.g., a substance abuse team
including a couple and family clinician, psychologist, nurse, and high school principal)
and research teams within a faculty’s advisees (e.g., a group of undergraduate, MS,
and PhD students working together to research intimate partner violence). Students
and faculty are encouraged to intentionally form interdisciplinary research teams with
experts in various areas of the shared research interests.
These same skills make SFTs primed to succeed at community‐engaged research
methodologies, which encourage the establishment of bidirectional trusting relation-
ships between academic and community partners in order to find relevant and ethical
solutions to issues affecting their well‐being (Centers for Disease Control and
Prevention [CDCP], 2011). Community‐engaged methodologies are viewed by
health‐focused federal agencies as critical to effectively finding ways to reduce health
disparities and access to care (see Pearson et al., 2015). This family of research meth-
ods aligns with assumptions common in SFT postmodern models including that com-
munity members have wisdom about what will work for them and have a right to be
able to determine what is happening in their community and how to sustain it (e.g.,
Pavao, 2012; Wallerstein & Duran, 2006). Additionally, in line with SFTs’ ongoing
training in honoring diverse experiences and attending to contextual stressors,
e ffective implementation of community‐engaged research methods requires ongoing

attention to and overt discussion of power imbalances and contextual disparities in
access to knowledge and services in underserved communities (Hardy et al., 2016;
Muhammad et al., 2015). Accordingly, SFT graduate students could be provided
opportunities to identify and reach out to the multiple small and large communities
and organizations that would be invested in addressing the issue they are passionate
about to listen to their concerns and ideas about change. From there, students could
be guided through recommendations about what to consider when embarking on
community‐engaged work and different community‐engaged research models
(e.g., Belone et al., 2016) to begin conceptualizing what next steps may look like.
Keeping research relevant An advantage of the theories learned in SFT programs is

that they take into account the important influence of a person’s sociocultural context
on health and well‐being outcomes. Accordingly, SFTs are well positioned to concep-
tualize complex models of change as intervention research shifts from linear models
(e.g., basic to applied research and efficacy to effectiveness trials) into more integrated
feedback designs where issues of applicability to real‐world contexts are considered
through all stages of research (e.g., Gottfredson et al., 2015). For example, in adap-
tive interventions, components that are thought to be universally effective may be
provided to everyone, but in cases where the effects of an intervention are expected
to vary significantly for individuals who differ on certain characteristics or circum-
stances, adaptive components may greatly increase effectiveness (Collins, Murphy, &
Bierman, 2004). These adaptive components include identifying tailoring variables
and decision rules that will lead to optimal outcomes for groups of diverse individuals
and require evaluation designs that can assess which combinations of components
(e.g., expanded factorial designs), as well as which sequences and intensities of com-
ponents (e.g., SMART designs; see Nahum‐Shani et al., 2012, for an overview), are
most effective given specific situations. In comparison to one‐size‐fits‐all interven-
tions (e.g., standard clinical trials), adaptive approaches to intervention and evalua-
tion more closely align with SFT’s focus on people in context.
In addition to training SFT students to be mindful of the real‐world application of
their research and use research approaches that fit their systemic orientation, it is also
important to help them learn how to effectively share these real‐world implications
with practitioners and the public. The National Science Foundation refers to Broader
Impacts as the societal benefit of research; researchers applying for funding must
design a plan to maximize the positive societal impact of each research project
(Adetunji & Renoe, 2017). Additionally, universities and institutions are increasingly
promoting public engagement and the communication of science to the public by
scientists in order to improve public understanding of and trust in research and
increase the relevance of research to public concerns (e.g., Roll, 2017). Accordingly,
both undergraduate and graduate programs in diverse disciplines are building science
communication training into their curricula (e.g., Brownell, Price, & Steinman, 2013;
Kuene et al., 2014; Mercer‐Mapstone & Kuchel, 2015). For SFTs, being able to
articulate complex ideas to nonspecialists is a critical skill for developing both effective
clinicians and researchers. Whether using their ability as informed consumers of
research or conductors of research, all graduate students in SFT can learn to commu-
nicate the research and theory of our field to the public. Not only may training SFTs
to effectively communicate family science have positive societal benefits, but also it
provides connection to one’s community, avenues for public feedback that can increase
the relevance of one’s work, an opportunity to reduce power hierarchies that are
reinforced when knowledge is not shared or co‐created, and potential mental health
benefits for stressed‐out graduate students (Shor, 2017).
Communicating science with the public can occur through diverse mechanisms
such as social media, articles and blogs, infographics, community talks and roundta-
bles, engaged community events, political activism, and so forth. Although measuring
the societal impact of these activities is complex (e.g., altmetrics, funding accrued for
projects, number of online views, in‐person attendees, reported changes on issues
by community members, citations in policy documents), building opportunities to
develop skills in these areas into curricula is more straightforward and can be assisted
by connecting with local and national resources like university communications
offices, local media outlets, related community organizations, online science commu-
nication platforms (e.g., The Conversation), and national organizations (e.g., the
Alan Alda Center for Communicating Science, the National Alliance for Broader
Impacts, NPR’s Friends of Joe’s Big Idea). These activities can easily be linked to cur-
ricula on community engagement, working with larger systems, cultural competency,
research methods, social justice, family policy, and so forth, and included in evaluated
student professional or research competencies. The abovementioned methods for
linking research to SFT students’ passions and systemic orientations are not an exhaus-
tive list, but hopefully stimulate some ideas about how SFT skills can be bridged
across research and practice to create students who feel efficacious in making larger
societal change.
Systemic approaches to data analysis

Qualitative and quantitative approaches can be helpful tools in answering these ques-
tions. Qualitative research allows researcher‐clinicians to ask questions directly to peo-
ple within populations of interest, who can respond in their own words about any
clinically relevant topic of interest to the researcher. This has obvious and powerful
implications for clinicians to be able to learn at a deeper level about the experiences,
feelings, and process of people in relation to mental health, relationships, change, and
growth. Much can be gained from analyzing and coding transcripts of such discus-
sions that can inform the therapy we provide.
Clinicians need to know not only about problems and desired outcomes but also
about how problems develop and how to help people take steps to reach a desired
goal. Any clinician can discuss these issues at length and with great sophistication that
includes a host of factors, contexts, and various people involved. When we think in a
complex manner about people and then learn about simple statistics that cannot begin
to be used to answer such questions, we believe many clinicians become disenfran-
chised with statistics, as traditional statistical methods are no match for their complex
theoretical and clinical thinking. Accordingly, we do not think it is acceptable for a
PhD student or a faculty member to only know how to run a correlation, t‐test, or
simple regression. Further, when faculty limits students’ learning of advanced research
analysis and methods due to their own unfamiliarity, it further hinders the meaning-
fulness of the research our field can produce. For example, the first author helped a
PhD student in an SFT program at another university identify a way to test a very
sophisticated systemic research question. Unfortunately, this student’s dissertation
committee said it was too complicated and she ended up running a correlation
between two variables as her final dissertation instead. Research in graduate school
should be more than just an academic exercise of jumping through a hoop; rather,
graduate school research should be geared toward dissemination and advancing the
collective field. As a field, we hope we are empowering our students to ask meaningful
and sophisticated research questions and to learn to test those questions with the cor-
rect research methods and statistics (or at least find others who can advise our stu-
dents in using the correct statistical tools and research methods). The software
programs available today make more sophisticated analyses highly accessible. Below
we briefly outline several new statistical developments that have the potential to be
meaningful tools to advance the types of research questions we are able to answer.
Measuring systems using latent variables/common fate models (Ledermann & Kenny,
2012) Structural equation modeling (SEM) allows us to approximate a systems per-
spective. Within SEM, multiple perspectives from the client system can be used to
create latent variables (simply meaning that these are not observable, i.e., like a sys-
tem). These latent variables can then be used to predict other latent variables. Complex
constructs of interest, such as love, attachment, differentiation, and others, can be
more accurately measured as latent variables, and complex associations among those
variables tested.
Testing change across time using growth models (e.g., Ruff, Durtschi, & Day,
2017) Perhaps no other concept in clinical practice, supervision, and research in our
field is more discussed than change. Why are some people improving whereas others
are staying the same or even declining? Change is really at the heart of the matter for
what most SFTs are interested in. Although traditional methods of investigating
change (i.e., t‐tests, repeated measures ANOVAs, regressions) can tell us that change
has occurred, they lack the ability to really capture what that change looks like over
time. A growth curve model, in contrast, models trajectories of change, variation in
trajectories across the sample, and incorporates what predicts that variation. Peoples’
initial level and rate of change can also serve as predictors of other outcomes.
Essentially all we are trying to say is if we are trying to assess and predict change in
clients’ outcomes, growth curves are a great tool for this. A question like this can be
answered relatively easily and quickly by predicting how each therapy session is related
to variations in the clients’ change trajectories (this is called a time‐varying covariate
growth curve; e.g., Morgan, Durtschi, & Kimmes, 2018). Growth curves also allow us
to understand how change in one member influences change in another member of
the client system by using the rate of change for each person to predict the rate of
change of the other family members. This is referred to as interlocked growth models,
as the rates of change are interlocked.
Testing complex family processes using moderation and mediation (Anderson, Durtschi,
Soloski, & Johnson, 2014) Statistical models that take into account variability in con-
text (e.g., moderation; e.g., Durtschi, Soloski, & Kimmes, 2017) as well as model
complex processes (e.g., mediation; e.g., Kimmes & Durtschi, 2016) can help eluci-
date the underlying mechanisms and pathways involved in change and what contexts
might change these expected effects. For example, clinicians demonstrating more
warmth toward their clients could be linked with greater client vulnerability in couples’
therapy, which may lead to partners’ increased understanding of each other, leading
partners to feel closer to each other, which may increase their desire to stay together.
This proposed process toward improving a couple relationship is an example of indi-
rect effects, often referred to as mediation. In helping to understand what mediation
is, think of mediation as stepping stones that lead from point A to point B that help
us understand how something unfolds and can include mutual influences between
partners or family members.
However, as any good clinician knows, the expected stepping stones of progression
in couples therapy vary tremendously based on a number of risk or protective factors
such as clients’ motivation to change, if there has been an affair, their relationship his-
tory, each partners’ commitment to working on the relationship, if the couple has
children, and a multitude of environmental and contextual stressors. Any factor that
alters the association between any of the stepping stones in a client’s paths to change
is called a moderator and modeling mediation and moderation at the same time is
called moderated mediation. Clinicians have very sophisticated personal theories
about how to help a client in a challenging situation, and these steps of the growth
process are moderated by the various contexts of the client. This wealth of clinical
knowledge should be tested so others can benefit from learning what steps might lead
to change and what diverse risk and protective factors might alter this expected
pathway.
Testing clinical interventions across multiple clinics, clinicians, and clients using multi-
level modeling (Atkins, 2005) Many SFT programs have been gathering their own
clinical data from clients and clinicians, and many other clinics are also working
together to combine their clinical data among multiple clinics as has been suggested
by Wampler and Bartle‐Haring (2015). For example, Rick Miller and Lee Johnson
have created practice research networks (PRN) (Johnson, Miller, Bradford, &
Anderson, 2017) where at least a dozen programs are now gathering data from clini-
cians and clients systematically in a way where the same measures are given across
clinics. This newly developing dataset includes individuals nested in families and client
cases and clinicians nested within various clinics across the country, collected across
multiple sessions. To use this kind of data, researchers will need to be competent in
using multilevel modeling that allows us to examine factors at different levels of nested
data (clinics, clinicians, clients, time). For example, when examining the average
length of sessions families attend a family therapy, at the client level, you may want to
look at how family structure and presenting problem are associated with retention,
and at the clinician level you may want to look at how therapeutic model used is
linked with retention, and at the clinic level, you may want to look at whether the
clinic takes insurance or not is related to client retention. Multilevel modeling allows
for a better understanding of how characteristics of different levels of a system impact
outcomes.
Propensity score matching (Austin, 2011) Propensity score matching allows us to

approximate an experimental design without having to force people into unethical
situations in a randomly controlled trial (i.e., to understand the association between
child abuse and later relationship processes, we would have to make someone be
abused as a child). It is a relatively new statistical tool that allows us to match people
on a wide variety of characteristics to account for variability on those characteristics
and more accurately test what is actually different between participants. For example,
some results of propensity score matching analyses that have compared race as a pre-
dictor tend to find that differences thought to be due to race are actually eliminated
when the broader contextual variables are more fully included.
Mixture modeling (Masyn, 2013; e.g., Kimmes, Durtschi, & Fincham, 2017) Many
people in our field lament that quantitative analysis just boils people down to some
kind of “average,” which does not really represent any individual’s experience.
Whereas many types of statistics (e.g., t‐tests, ANOVA, regression, SEM, MLM,
growth curves) are variable‐centered approaches that look at overall trends in a sam-
ple as a whole, mixture modeling is a person‐centered data analytical approach that
identifies classes or profiles of people who are similar to one another (e.g., shared
characteristics, beliefs, or patterns of behavior). This is always how clinicians have
thought of people and our clients—as unique and distinct from others, not on one
continuum of variation from a mean. Precision medicine is an approach to treatment
that is based on providing treatment based on an individual’s unique genes, environ-
ment, and lifestyle that is being adopted as a best practice in medicine (Hodson,
2016). For our field, mixture modeling is going to be one of our primary statistical
tools to advance what we know about “precision therapy.” Mixture modeling enables
us to identify unique subgroups of people and identify individually tailored strengths,
risk factors, and potential treatments that may be most beneficial for each subgroup.
Latent class analysis and latent profile analysis help to identify groupings of similar
people at one time point, whereas latent transition analysis and growth mixture mod-
eling allow for studying longitudinal changes by groupings of similar people.
Other useful statistics There are, of course, many other unique types of statistics that
can be helpful for our field that are not widely used. For example, frequently we are
interested in issues that affect maybe a smaller number of people or manifest in spe-
cific ways (such as intimate partner violence or substance use) that make it hard to
quantitatively evaluate. In the ADD Health data, for example, most adolescents report
using marijuana zero times in the past month, whereas one committed adolescent
reported smoking marijuana 800 times in the past month. Data on these variables
would not follow a normal distribution (an assumption of most types of statistical
analyses), so special analytical methods such as Poisson, zero‐inflated Poisson, and
negative binomial are all tailored to model these types of unique distributions.
If we are interested in predicting the date at which a client will drop out of therapy,
or successfully finish therapy, or the date a marriage will dissolve, we can use survival
analysis to predict how long a person’s relationship can last, based on a set of predic-
tor variables, in much the same way cancer researchers have studied a set of predictors
to understand how long until a patient is expected to die. We recognize that the
meanings of many of the abstract concepts we study (like satisfaction or connection or
conflict) are culturally bound. It is important to test whether the assessments we use
are applicable across different groups (e.g., by gender, race, sexual orientation, symp-
tomology) and whether the associations between these variables vary across groups.
We can do this by using invariance testing as part of a multiple‐sample SEM. Preventative
fractions and attributable risk ratios are simple to compute and transform odds ratios
(e.g., from a logistic regression or multinomial regression predicting the odds of a
categorical outcome) to identify how many divorces are preventable, based on a set of
predictors (Durtschi, Love, Brown, Beck, & Morgan, 2017).
Core Research Competencies for MS and PhD

Training Programs
Given weaknesses in research in our field, it seems prudent to revisit the issue of what
research skills should be taught in MS and PhD training programs and how it con-
nects to SFT’s clinical effectiveness. The field of marriage and family therapy has
developed core competencies that have been helpful for training programs (Nelson
et al., 2007). It is promising that among these core competencies, several research‐
focused core competencies are stated. However, in a recent study, 135 AAMFT‐
approved supervisors reported that weakness in research training was commonly the
greatest deficiency in students from accredited programs (Nelson & Graves, 2011).
Specifically, among the 10 competencies supervisors considered least mastered (out of
the 128 total), 6 dealt with research and program evaluation, with average scores
ranging from 2.80 to 2.08 (on a scale from 1 to 5), including (a) understanding reli-
ability and validity, (b) being able to critique research literature, (c) understanding
how to conduct clinical research and program evaluation, (d) administering and inter-
preting assessments, (e) recognizing opportunities to participate in research, and (f)
contributing to the development of new knowledge. Perhaps even more discourag-
ing, Nelson and Graves (2011) found that supervisors scored the research domain as
the least important domain of competencies.
Making mandates regarding what all programs should do in reference to research
training is fraught with challenges and is not likely to be widely adopted. This is true
because there are many different kinds of master’s programs, which focus their pro-
grams somewhat differently. For example, some programs have a required thesis,
some have a thesis option, whereas others have no expectation for a thesis or any
research involvement during an MS degree. Despite these differences, however, it
should be expected that all students receiving a master’s‐level clinical training in SFT
should have several core competencies. Thus, below are our recommendations for
what should be required in all MS and PhD research training programs and what
additional preferred training would also occur in our MS and PhD programs.
Core competencies of research training needed in all MS programs

We propose that all CMF master’s students are taught and can demonstrate the
following.
The value of research to practice Master’s students should be able to articulate the
relevance of research to ethical practice of SFT, including the importance of consist-
ent progress monitoring and evidence‐based or research‐informed interventions.
Progress monitoring Progress monitoring is when clinicians assess the change or lack
of change in their clients using a variety of assessment strategies. All master’s students
should demonstrate competency in administering and scoring progress monitoring
assessments. Similarly, clinicians should be able to gauge when clinically significant
change has occurred and value progress monitoring as an important part of their
treatment (Wampler & Bartle‐Haring, 2015). Progress monitoring, also called con-
tinuous assessment, is described in more detail elsewhere, with details on how to
competently incorporate this into clinical practice (Johnson et al., 2017).
Reviewing existing literature All clinicians should frequently look up articles on best
practices and clinical suggestions when working with challenging presenting concerns
(see Johnson, Sandberg, & Miller, 1999). No matter how long we have been practic-
ing, there is so much we do not yet know. This understanding should drive all clini-
cians to frequently look up new information and know how to critique the veracity
and quality of this information. Clinicians should know how to interpret the quality
of research. Too often, students either blindly accept ideas because they are published
or go to the other extreme and believe all research is so flawed that none of it is reli-
able or valid. As MS students read research, they should be able to read the article and
identify the research question, what the major findings were, and what the clinical
implications were. For example, students should be able to read results from an actor–
partner interdependence model or a meta‐analysis and understand the clinical applica-
tion from the obtained actor and partner effects, or the general effect sizes, respectively.
To become competent consumers of research, MS students should be able to allow
the research they read to inform and change the way they do clinical work. Perhaps
what is most surprising to faculty and students about doing this is how quickly and
readily our intelligent students can grasp the meaning of quantitative results in a table
or figure, or in a results section. Interpreting betas or correlation coefficients, effect
sizes, mean differences, trajectories, and variation explained are concepts that can be
understood by most anyone in the general public after explaining the idea for a
few minutes. We need to make sure we take the time to explain these to the next gen-
eration of clinicians to empower them to keep learning after graduation.
Core competencies of research training in all PhD programs

All the suggested required core research competencies in an MS program should be
understood and applied for a PhD student, but at a more sophisticated level. Although
the focus of our unique PhD clinical training programs varies (e.g., Sprenkle, 2010;
Wampler, 2010; Woolley, 2010), the focus of a PhD in any field is on developing
skills to engage in the discovery and dissemination of new knowledge in that field
(excluding the few PsyD‐type doctoral programs). The standards for research skills
and training at the doctoral level should be high, considering research is the focus of
training for 3–5 years. The quality of the articles published in the leading journals of
our field requires highly sophisticated skills in advanced statistical methods and schol-
arly writing. Likewise, obtaining external research funding requires advanced statisti-
cal skills and strong writing skills. Thus, it is important that PhD students learn to ask
meaningful systemic questions using advanced methodological skills required for
publishing in leading journals and obtaining external research funding.
Research design All PhD students should be able to ask meaningful research ques-
tions and design studies to test those questions using a variety of methods, based on
what would be a best fit for their question. Potential methods to test their questions
could be any of the statistics listed above, other statistics, mixed methods, qualitative
methods, Delphi methods, observational, and so forth. We hope that graduating PhD
students will know how to ask a research question and know how to test a research
question fairly independently from their major professor. Likewise, we hope that
major professors will mentor their students early on to develop research proficiency.
This is an area we can and must collectively improve in for PhD training programs.
Research tools Consider the following metaphor, comparing research training pro-
grams with an apprenticeship training program to make kitchen tables. If we spent
3 years in a training program to learn how to make wooden tables, at the end of those
3 years, we would expect all graduates to know how to independently make tables. We
would be severely disappointed if most of the graduating students could not make a
table on their own, did not learn anything more about table‐making at the end of the
program than they knew prior to starting the program, or never learned how to use any
tools other than a hand saw and a hammer. It would be odd if a graduating student
from table‐making had a set of faculty afraid or unable to use power tools or computer
programs to design a table. Similarly, it would be odd if the students believed that
using more advanced tools were just too hard for them. It would also be weird if the
only time a student made a table was at the very end of their 3‐year degree. Instead, we
propose an excellent table‐making student should learn the most advanced tools avail-
able to make tables from the very first semester of training. When graduation comes
around, this student should be able to make their own table with only minimal assis-
tance from a mentor, because they are so experienced and skilled at it by this point and
they are now ready to mentor others in making tables. In short, this is the kind of PhD
training programs we want for our doctoral students: training that starts early, uses the
most cutting‐edge tools available, and fosters a growth mindset of students and faculty
excited to embrace new skills and better ways of doing research. In extending this
metaphor to SFT PhD training, and based on publications in the leading journals and
the common presentations in our national conferences, we suggest that PhD‐level
students learn how to use advanced statistics, such as multilevel modeling, growth
modeling, mixture modeling in its various forms, propensity score matching, survival
analysis, ways to work with unusually distributed data, and gain skills in psychometrics,
such as using item response theory. PhD students should also develop expertise in a
specific research area, ask research questions to expand this area, know how to work
with data to answer their questions, and write their results in published manuscripts.
They should also be able to present their results to academics and the general public in
a clear and engaging manner. They should be capable of independently using most of
these kinds of research skills, long before they approach graduation. Just as a table
building program would not want to produce students who cannot make or sell a table
at a leading furniture store, we do not want to graduate doctoral students who cannot
independently use advanced research skills to publish in the best journals and obtain
external research funding within their own area of expertise.
Writing In our experience, it is rather easy and straightforward to teach research

methods and quantitative and qualitative research skills to doctoral students. What
takes more time and where students vary more is in their scholarly writing ability. A
PhD student, upon graduation, should be able to independently conduct their own
research and write every part of a manuscript at a high enough quality that this paper
would be published in the best journals in the field. A PhD student who successfully
mastered the core competency of scholarly writing skills should be able to demon-
strate (a) the ability to synthesize existing research, theories, and ideas into a publish-
able paper; (b) success in publishing their own quantitative and qualitative articles as
the lead author within the most discerning and respected research journals; (c) how
to write a strong and fundable research grant proposal; and (d) publish and d isseminate
their clinical ideas to both clinicians and the general public.
Restructuring our programs to integrate research

If we value competency in research as a field, how can we build it into the structure
of our programs through supervision, teaching, professional development opportuni-
ties, and so forth? We suggest several steps that programs can take to integrate oppor-
tunities for developing research competencies at MS and PhD training programs.
First, training programs need to measure research output, report on research output,
and reward research output. This can happen in our annual review process that faculty
do with each student, or as part of accreditation tracking and reporting, or as part of
supervision evaluations at the end of each semester. Second, a way to integrate research
into the structure of our programs is for clinicians to collect clinical data in our clinics.
This allows students practice in using assessments, monitoring client progress, and
benefiting from seeing these results and sharing these results with their clients. This
can serve to help improve the general attitude of students toward research.
Third, and perhaps the biggest issue, is faculty and program resources. One of the
authors has learned that even among the accredited PhD training programs, some do
not have statistical software for their use anywhere on campus (e.g., no SPSS, AMOS,
Mplus, HLM, etc.). Other programs are housed in a university where the IRB approval
process can take 9 months or longer. Many faculty themselves are unfamiliar with
quantitative and qualitative research methods and would find it a challenge to publish
in a high‐impact research journal or have no desire to attempt such work. Each of
these contexts poses certain obstacles toward the advancement of our field. The most
ubiquitous challenge, however, is a lack of time. Most faculty are overly busy, are
stressed, and do not believe they have enough time to do what is already required of
them—doing more research may seem impossible given time constraints. However,
what we prioritize, what we value, and what gets recorded tend to get done. All of us,
the current authors included, have room for growth in prioritizing our research to a
greater extent than we do and being more efficient with our given time at work.
MS programs Master’s students should be taught in an environment where faculty and

supervisors clearly value research‐derived knowledge and evidence in our courses and
student interactions. For example, an instructor of an MS‐level course could spend a few
minutes in class talking about the methods used in the article for that day’s reading and
spend a few minutes to explain in straightforward language—no jargon—how to inter-
pret the statistical results from that particular article. This can make the article more
accessible to students and over time help the student learn to interpret a wide variety of
empirical articles. In clinical supervision, we hope that supervisees are frequently asked
about potential research that might inform their clinical work and that they are encour-
aged to seek out that information and apply it in their work. MS students need to be
trained in how to apply and score a variety of clinical assessments and how to monitor
their clients’ progress. This progress monitoring should also be discussed in clinical
supervision meetings. Some programs are even using clients’ growth based on their
assessments as part of their students’ practicum grades. MS students should begin to
cultivate a curiosity for what remains unknown in relation to mental health, relation-
ships, and providing therapy. In many cases, MS students should be mentored to com-
plete a thesis or thesis equivalent to study topics of interest to them clinically. We hope
that an interest in research can begin to develop in MS programs that encourage MS
students to seek out additional research training in their newly developed passion areas.
PhD programs If the focus of our PhD training programs is really on research,
most of our course work and graduation requirements should be helping students
develop a researcher‐clinician passion, hone systemic research methods and analysis
skills, and write publishable papers. For example, at Kansas State University, newly
admitted doctoral students take a 3‐credit course their first fall semester where they
learn how to work with large, longitudinal dyadic datasets, run a variety of sophis-
ticated statistical models, and start and finish a publishable manuscript from the
results of their analyses. Learning research skills to work with data, run analyses, and
write a complete manuscript in the first semester get them started off with the skills
they need to continue developing their research skills and build a program of
research within their passion area. Other courses follow a similar pattern of having
students produce a new publishable paper each semester. Also, doctoral students
need to be taught how to apply for external funding for research and the application
of clinical programs in our communities. Additionally, at a number of PhD training
programs, preliminary exams (large essays that are usually not publishable) prior to
becoming a doctoral candidate have been thrown out in favor of a portfolio system.
Having detailed requirements for the portfolio (e.g., two publications that demon-
strates their ability to use statistics, theory, and clinical application; two research
presentations at conferences; teaching two classes with favorable student evalua-
tions; passing the clinical licensure exam; and documenting professional member-
ship and service to the program and university) help students work toward applicable
skills and outcomes. Likewise, PhD programs can restructure dissertation require-
ments to be one or multiple manuscript length papers that are easily published
instead of one giant dissertation.
Conclusion
Research matters for clients, for clinicians, and for our field. We can all learn more and
do more in relation to research. We can ask new questions, learn how to learn new
research tools, strive to become a better writer, and foster a passion for research
growth in ourselves and others. Small changes can be made to how we structure our
programs and our time to include more opportunities for research. Future directions
for graduate research training that can move us forward include (a) faculty and PhD
students being trained in a variety of new research skills and statistics they are unfamil-
iar with, for example, meta‐analysis, multilevel modeling, or gathering dyadic daily
diary data; (b) faculty starting to mentor their PhD students in research from the first
week of beginning their programs; (c) faculty mentoring students in asking good
research questions; (d) MS and PhD programs incorporating empirical articles into
the required reading lists and explaining how to interpret those quantitative and qual-
itative results; (e) MS and PhD programs assigning students to read empirical articles
and apply those results to their clinical work; and (f) MS and PhD students incorpo-
rating progress monitoring as part of their clinical practice. We look forward to learn-
ing new ideas ourselves that can push us and our programs forward in the quality and
quantity of research we do. We look forward to improving as researchers, and we look
forward to learning from those in our field who can help us provide even better
therapy to our next client.
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29
in Medical Settings
W. David Robinson*, Adam C. Jones*, Daniel S.
Felix, and Douglas P. McPhee
*W. David Robinson and Adam C. Jones are Equal authors.
The practice of systemic therapy in medical settings has been pioneered by the work
of physicians and therapists who believe that integrated care provides added benefits
to patients. These practitioners held that accounting for the biological, psychological,
social, and spiritual factors that influence patient health is essential to improving well‐
being. The 1977 essay by George Engel laid a vital cornerstone for the incorporation
of systemic therapy in medical settings by challenging the biomedical model of medi-
cine. Engel claimed that the reductionist view of the prevailing medical paradigm
ignored the influence of other psychosocial determinants of patient health (Engel,
1977). This proposed new medical paradigm fit nicely with tenets of systems theory,
which also proposed the need for a broader conceptualization of contextual factors of
mental health (Bateson, 1971). Soon thereafter, a multidisciplinary effort to integrate
health care and offer patients more holistic treatment began.
Many therapists immediately responded to the paradigm shift, that is, often attrib-
uted to Engel’s work. In 1992, Susan McDaniel, William Doherty, and Jeri Hepworth
launched the clinical application of Engel’s theory to systemic family therapists
through their groundbreaking book, Medical Family Therapy, outlining how family
therapists could provide patients and families with psychosocial treatment in medical
settings (McDaniel, Hepworth, & Doherty, 1992). At about this same time, John
Rolland (1994) helped pioneer the practice of integrative medical teams. He also
advanced the theoretical conceptualization of the impact that illness and disability
have on the entire family system (Rolland, 1994). The efforts of these pioneers have
provided a practical and theoretical foundation that has allowed researchers and clini-
cians to stake their claim in collaborative health‐care frameworks.
Over the past few decades, medical family therapy (MedFT) has developed as a
burgeoning subspecialty among systemic therapists; in this chapter, we use MedFT to
describe any systems therapist in medical settings. Presently there are many systemic
660 W. David Robinson et al.
therapists working at varying levels of collaboration across primary, secondary, and

tertiary care systems. This movement into medical settings is primarily due to the fact
that primary care providers have been recognized as the “de facto mental health care
system” since the late 1970s because the majority of individuals with mental health con-
cerns are seen in primary care, not in specialty care (psychiatry, psychology, therapy)
(Kessler & Stafford, 2008; Regier, Goldberg, & Taube, 1978). Some systemic therapists
work in private practice settings while collaborating distantly with health professionals.
Others work in in‐ or outpatient settings with other health professionals to enhance
client care. Where possible, systemic therapists may also be fully integrated into the
medical treatment team, receiving patients at the same time as the medical providers and
completing psychiatric, social, systemic, and behavioral assessments. Meeting patients
where they are, in medical settings, has been a goal of medical family therapists.
While systemic therapists have found employment opportunities in a variety of dif-
ferent medical settings, our biggest task ahead is clarifying and establishing our posi-
tion within the health‐care system. Other behavioral health professions have
concomitantly endeavored to integrate care with medical professionals. Medical social
workers, health/medical psychologists, psychiatric nurses, child and family life spe-
cialists, and other professions have experienced steady growth in the health‐care field.
These professions assist in providing psychoeducation, collaborate on treatment
teams, prepare patients for discharge, connect patients to outside resources, and
deliver counseling (McCoyd & Kerson, 2016; McDaniel, Doherty, & Hepworth,
2014). Because MedFTs have overlapping responsibilities with each of these profes-
sions, MedFTs have had difficulty forming a consistent role in patient care.
Systemic family therapists, however, are uniquely prepared to work effectively in
medical settings for a variety of reasons. Systemic family therapies (SFTs) are trained to
work with people from across the lifespan. This provides significant benefit to medical
providers as they do not have to consider whether or not the patient fits within the age
parameters of the mental health provider. We are also trained to work with individuals,
couples, and families. This also is very beneficial for medical providers as SFTs are able to
diagnose mental health conditions but also investigate the health of the family relation-
ships and the complex interpersonal concerns that play a role in the overall health of each
individual and the family as a whole (Gehart, 2018). In our experience, this makes it
easier for medical providers because they do not have to assess and address the medical,
mental health, and relational factors of each of their patients. They can leave it to the SFT
to assess and address the psychosocial concerns of the patient and family so that they can
focus on the medical issues at hand. For example, we have had multiple medical providers
expressing their gratitude for our assistance in dealing with a patient’s mental health/
family concerns so they could really focus on the diabetes or heart disease care.
SFTs are also extremely effective in working in a health‐care setting because of their
expertise in working with systems. There are multiple systems that have to be negoti-
ated. It begins with the individual’s body systems. Here SFTs focus on the common
concerns that plague clients (e.g., diet, exercise, sleep, depression, anxiety, disease
process, stress) (McDaniel et al., 2014). Here we can also address with the patient key
strategies to effectively improve these concerns. We then focus on the common social
systems in which the patient exists (e.g., family, friends, vocational, educational, and
societal) (Bronfenbrenner, 1979). With this focus, we help to identify social resources
and stressors that exist in the patient’s life. It is then appropriate to address the medi-
cal context in which the patient exists. Here we help the patient understand and
Systemic Family Therapy in Medical Settings 661
avigate the complex system of the medical field. This starts with the basics of who
n
does what (e.g., you do not need a psychiatrist to get antidepressant medication) to
how to effectively advocate for themselves and their family member. Another key role
that the SFT plays in the health‐care system is to utilize their systems training to navi-
gate the complex medical system to effectively interact with each of the key players
and assist with interdisciplinary collaboration among providers. SFTs also assist the
providers to effectively collaborate with the patient and family.
Medical Family Therapy Education and Training
The interest in advancing the practice of systemic therapy into medical settings has
also led to the development of several graduate degrees and certificates that focus on
advanced training in health‐care collaboration. While collaborative health‐care prac-
tices are not uncommon outside of the United States, systemic training programs that
focus on medical integration are mostly limited to the United States. Many clinical
master’s programs in the United States are adding an MedFT emphasis and providing
training within hospital settings. There are presently a few post‐degree certificate pro-
grams, a few doctoral programs, and several masters and doctoral internships that
provide advanced practical experience and training in MedFT. The number of gradu-
ate programs and internship opportunities in MedFT are continuing to propagate.
The future of MedFT will be largely determined by the work done by clinicians and
researchers of this generation.
Integrating systems therapy into medical settings requires advanced training in the-
oretical, financial, and practical knowledge related to the field. Training in systemic
therapy models, ethical standards, and research alone does not provide adequate qual-
ification for practice in medical settings. Presently there are no certifying boards or
licenses that limit any licensed therapist from advertising, practicing, or promoting
themselves as a medical family therapist. Furthermore, any licensed mental health
practitioner, provided that they can bill for services, is not prohibited by law from
working in medical settings. Therefore, it is left to those who teach and train MedFTs
to develop core competencies and standards for practice.
Some important efforts have been made to identify what competencies and skills
should be required of systemic therapists who practice in medical settings. Tyndall,
Hodgson, Lamson, White, and Knight (2012) conducted a Delphi study of 37
experts to help identify core competencies for the practice of MedFT. They recom-
mended that all MedFTs develop competencies in the following areas: clinical skills,
medical culture and collaboration, treatment planning, theoretical base, knowledge
of health/relationships, knowledge of diseases, teaching, evidence base, administra-
tion, self‐care, DSM knowledge, family systems knowledge, and the biopsychoso-
cial–spiritual (BPSS) model (Tyndall et al., 2012). Susan McDaniel also assembled
a team of collaborative professionals to assemble competencies for psychology prac-
tice in primary care (McDaniel, Doherty, & Hepworth, 2014). They proposed six
broad domains for competency that included science, systems, professionalism, rela-
tionships, application, and education. It is hoped that those who are integrating
MedFT education into their clinical training would ensure that these competencies
are being met.
Theoretical Foundations of Medical Family Therapy
It is important for SFTs to master the theoretical models that guide their treatment in
medical settings. It may be important to note that several systemic treatment models
were developed in hospital settings (e.g., Minuchin, 1974; Whitaker & Ryan, 1989).
However, while these models did much to advance the contextual therapy paradigm,
collaboration with other health‐care professionals was not the focus. As systems thera-
pies developed out of a rejection of the medical model, reintegrating a systems para-
digm with the medical paradigm has required MedFTs to redefine and advance the
theoretical foundation for the field. The theoretical advancements within MedFT
guide therapists in working specifically with families in the health‐care system. While
some theoretical approaches have been validated with diverse populations (e.g.,
Woods & Denton, 2014), little guidance for improving treatment and reducing
health disparities across cultures has been given.
Biopsychosocial–spiritual perspective
Systemic therapists working in a medical setting typically work from a BPSS perspec-
tive. Dr. George Engel (1977), an internal medicine physician, was the first to discuss
the need for medicine to address each patient from a more holistic perspective. He
saw several potential issues caused by the reductionistic biomedical model such as
mental illness being considered a myth because it does not “conform [to] the accepted
concept of disease” (p. 129). From these ideas he developed the biopsychosocial
(BPS) model. From this perspective, he expressed the need to move from a focus on
the patient’s biology (e.g., health status, biochemical, illness, nutrition, genetics,
sleep, substances) and look at the complex interplay between biology, psychological,
and social components of patient health. Key aspects of the psychological component
are the focus on concepts such as personality, mood, mental health, behavior, and
stressors. The social component addresses the patient’s social network (e.g., family,
friends/associates, community, sociopolitical environment, culture).
Engel described the need for a new way of providing medical care as the need for
medical providers and researchers to look at the complex interaction of these three
aspects in their patient’s lives. This has led to a change from the reductionist perspec-
tive of medicine to an acknowledgment that a person’s health is determined by more
than biomedical factors. For example, an individual who suffered a myocardial infarc-
tion will need to be treated in all of the three areas. Biologically, they will need medi-
cal interventions to solve the issue with the heart (e.g., medicine, surgery, diet,
exercise, etc.). Psychologically, they may need assistance in coping with the event and
addressing their reaction to the event (overreaction, abreaction, under‐reaction). The
patient may also have a preexisting mental health condition, that is, worsened by the
heart attack or they may develop one because of it. Social components related to pro-
fessional, interpersonal, and family roles (permanently or temporarily) may need to be
addressed. Some examples of the social aspect include decreased ability to work,
potential changes in household duties, and possible concerns about premorbid and
illness created relational and sexual difficulties.
Since Engel introduced the BPS model, a variety of individuals have expressed the
need to add spirituality to the model (Phelps et al., 2009; Wright, Watson, & Bell,
1996). The addition of spirituality to the model allows for professionals to address the
existential aspects of the human experience. This component of the BPSS model is
used to help professionals ascertain the beliefs and meanings people develop as they
deal with health and illness. This ranges from religious beliefs to spiritual practices to
meaning‐making and connection to something greater (e.g., higher power, humanity,
nature). Individuals often use spirituality to make sense of their current situation or
identify sources of hope (Dyson, Cobb, & Forman, 2007). In the case of the indi-
vidual who suffers a myocardial infarction, this component of the BPSS model would
be used to help the professionals and the individual and her/his family to address the
meanings associated with the experience. Patients’ reactions to a disability or diagno-
sis may vary. The patient’s spiritual beliefs and assumptions may influence their experi-
ence of assigning meaning, finding hope, or mourning a loss, that is, either anticipatory
or ambiguous (Boss, 2000; Rolland, 1994).
The BPSS model (see Figure 29.1), effectively used in a medical setting, can help
systemic therapists address the key aspects of the health and illness experience of their
clients. It is essential that therapists in medical settings understand the systemic BPSS
model in order to provide effective treatment for what are often very complex and
difficult‐to‐treat conditions. For example, many patients with depressive symptoms
first seek help not from a therapist, but from their primary care doctor. Although
depression is a chronic medical condition, it is so much more than just unbalanced
brain chemistry; hence more than just a physician’s prescription pen may be needed
to treat it. Depression is a biological, psychological, social, spiritual condition. It
affects a person’s body, mind, relationships, and soul and is also affected by each of
these as well (Jones & Robinson, 2016; Katon, 2009). The BPSS model informs
clinicians of all types that their set of tools alone may not be enough because of the
• Current health • Mental health conditions

• Past health • Degree of hope/pessimism
• Family health history • Current stressors
• Health behaviors • Previous stressors
• Diet • Personality
• Excercise • Mood
• Sleep Bio Psycho
• Substances
• Spirituality
• Family Social Spiritual • Spiritual practices
• Friends/associates • Meaning-making
• Intimate relationships • Religious practices
• Colleagues/coworkers • Connection with society
• Community connections • Sense of awe and wonder
• Sociopolitical environment • Centering and mindfulness
• Culture practices
Figure 29.1 Component parts of the biopsychosocial–spiritual model. Reprinted from

Robinson and Taylor (2016) with permission of SAGE.
multisystemic interaction between a person’s biological systems (e.g., endocrine, res-

piratory, reproductive, etc.), psychological systems (e.g., thoughts, emotions, behav-
iors), social systems, (e.g., family system, peers, community), and even spiritual
systems (e.g., a belief system). Taking a BPSS perspective can allow systemic therapists
the ability to systematically review and intervene, as a member of a treatment team,
on behalf of their clients in a more holistic way.
Agency and communion

The concepts of agency and communion provide the theoretical foundation for the
treatment aims of MedFTs (Hodgson et al., 2014; McDaniel et al., 1992). Agency
and communion are not unique to MedFT, but have roots in the disciplines of theol-
ogy and philosophy. Bakan (1966) first coined the terms in an essay on psychology
and religion. He discussed the two drivers as forces present in every individual: agency
for the existence of the individual and communion for the participation of the indi-
vidual (Abele, Cuddy, Judd, & Yzerbyt, 2008).
Early MedFTs adopted the terms agency and communion into their vernacular as
the two guiding treatment aims that provided a theoretical stance for helping patients
navigate the medical system: agency for activating individuals to meet their health‐care
needs and communion for attending to the emotional bonds within the system
(McDaniel et al., 1992). MedFTs help patients to increase their level of agency by
communicating available treatment options, overcoming obstacles for health mainte-
nance, and ensuring that patient beliefs and desires are heard and respected. Addressing
the emotional bonds of family members allows family members to respond more
appropriately to their medical needs and demands. On a broader level, the level of
support from friends, community members, and health professionals are also essential
to the conceptualization of communion. The many layers of psychosocial communi-
ties should be observed closely for their influence on health and treatment. The pri-
mary treatment aim of MedFTs is to help families balance their needs for agency and
communion through the course of their interaction with the health‐care system.
Navigating the illness experience

It is essential that systemic therapists in medical settings understand the basics of fam-
ily adjustment and adaptation. MedFTs help patients and their families navigate the
challenging landscape of adjusting to illness or injury. Most families tend to find a
balance between demand and capabilities over time. However, the new demands of
the disability or illness tend to exceed the family’s capabilities or resources at various
times in their journey. Once the family learns how to increase their capabilities,
decrease the demands of the illness, and adjust how they make meaning of their situ-
ation, they are able to better adapt to their new situation; some families, however, are
not as adept at effectively navigating illness (Patterson & Garwick, 1994).
Another aspect of coping with the illness experience is to help families learn how to
adapt to the fact that their family is often unlike other families with whom they associ-
ate. It is essential that systemic therapists help these families learn that the world view
they had (sociocultural reality—knowledge, beliefs, values and expectations) may not
ever be the same as it once was. Their biographical reality (behaviors, routines, events,
and relationships) is often unique and makes these families feel different from the
“rest of the world” (Cohen, 1993).
There are often three outlooks on illness that individuals within families employ to
cope with the illness experience. The first outlook has been referred to as the Old
World View (Robinson, Carroll, & Watson, 1999). In the face of uncertainty that
accompanies an illness or disability, some clients employ drastic movements toward
avoidance and minimization, in an effort to just continue to try to live their life as if
the illness did not exist. While this can be an effective temporary coping strategy, it
does not work very well in the long term. This outlook can cause significant problems
with other family members who want the patient to get specific treatments (if that
person has the illness) or want to talk about the impact of the illness on the individual
and the family. The job of the therapist with this person is to gently work with them
to at least address major decisions that must be made and start a dialogue among fam-
ily members.
On the other side of the spectrum are those individuals who become engulfed in the
illness completely. They stop doing things they used to like to do and cannot find an
escape from focusing on or discussing the illness. This outlook is called an Illness‐
Dominated New World View (Robinson et al., 1999). Systemic therapists working with
individuals/families experiencing this outlook need to help them to put back things in
their lives that they once loved. They need to help them learn how to find joy in eve-
ryday life and to take a break from the impact of the illness whenever they can.
The individuals and families that tend to do the best are the ones who have been
able to find the Balanced World View (Robinson et al., 1999). For systemic therapists,
this is the ideal treatment goal for families navigating the health‐care system. The
therapists help the individuals and family members be able to put the illness in its place
and reclaim any losses that were taken from the family through the initial adjustment
period. In this Balanced World View, the individuals within the family are able to also
deal with the reality of the illness (and potential loss) without letting it take them over
completely. One way this can be done is for the family to work together to appreciate
the individual, unique experiences of each member while also bonding over the family
experience as a whole.
Witness of personal suffering and the family’s experience

One aspect of traditional systemic therapy is the focus on assessing problems with the
individual/family and finding a way to change the underlying processes that support
the problem. One distinct difference with systemic collaborative health care is that
many of the families struggling with the impact of a significant illness are reacting in
expected and normal ways. There is less focus on addressing dysfunction and more
focus on enhancing coping. Sometimes there is not anything specific that the therapist
can do but be a witness of the personal suffering and provide a safe environment for
individuals and families to share their story with us and with each other. This is an
aspect of most therapy experiences but plays a much larger role when working with
these families confronted by a significant illness experience.
These experiences have been referred to as the Family Crucible of Illness (Robinson
et al., 1999). Crucible experiences are intense as they are brought about by the family’s
everyday encounter with the illness. Just as heat and pressure creates hardened steel out
of weaker materials, for many families, the crucible experience brings about growth,
connection, meaning‐making, and other positive aspects as the experience refines them.
For other families, their crucible experience creates hurt, animosity, irritation, and dys-
function just as the heat and pressure rids steel of weaker materials. MedFTs can play an
important role in alleviating the confusion, frustration, and anxiety that come with an
illness or injury by providing psychosocial support for these patients and their families.
Requisite Health‐Related Knowledge When Working

in Health‐Care Settings
The demands of working in medical settings require therapists to regularly look
beyond the psychosocial aspects of health and integrate biology into their conceptu-
alization, diagnosis, and treatment. MedFTs should have a working knowledge of
anatomy, common diseases, conditions, and pharmacology (especially psychopharma-
cology; see additional information in this section below). McDaniel, Doherty, and
Hepworth (2014) recommend that MedFTs each have a working knowledge of the
biomedical facts of major chronic illnesses, including “diabetes, heart disease, hyper-
tension, … asthma and emphysema, the major cancers, the most common degenera-
tive diseases such as Alzheimer’s disease, multiple sclerosis, and muscular dystrophies”
(p. 15). Knowing the biomedical facts related to major illnesses and injuries gives
MedFTs the needed ability to relay crucial information to patients and help them
understand the common psychosocial impacts of each illness.
Family systems illness model

Having biomedical knowledge is necessary for practice, but it does not sufficiently
prepare MedFTs to address the myriad of psychosocial components related to patient
health. Rolland (1994) made significant contributions to providing a conceptual inte-
gration of medical and systemic treatments. His Family Systems Illness Model high-
lights the need for therapists to be aware of the psychosocial impacts of various illness
types, family life cycle events, and time phases of illness. Rolland created a typology
for understanding the relationship between psychosocial factors and illness by looking
at the onset, course, outcome, level of incapacitation, and the level of uncertainty of
various illnesses (Rolland, 1994, 2005).
Onset Some health problems come on gradually, others all at once. Pain, for example,
can be the immediate result of an accident, injury, surgery, or another incidental
cause, or it can be the result of damaged nerves, causing the pain to grow over time.
Chronic pain affects a person very differently than acute pain, often shaping lifestyles
and daily routines. Quick onsets such as with strokes, heart attacks, and injuries often
constitute a crisis and require family systems and health‐care systems to mobilize
quickly and rally around a cause. With gradual onsets, such as with arthritis, lung
disease, and some cancers, the diagnosis can be a long and confusing process.
A family system’s ability to manage stress from gradual onset diagnoses is often more
a marathon than a sprint, testing the family and health‐care system’s endurance and
tolerance.
Course The course of an illness, disability, or other health‐care problem is typically

one of three types: progressive, constant, or episodic. A progressive course is one that,
regardless the onset, the symptomology gradually increases over time. For example,
cancer is often a progressive course. With this course, family and health‐care systems
are more apt to predict and prepare based on prognosis; hence, a systemic therapist in
a medical setting can help not only the family gradually adjust and adapt to the increas-
ing stressors but can also help members of the health‐care team transition through the
stages of an illness more easily. A medical family therapist might help the family rec-
ognize increasing stress on a wife caring for a terminally diagnosed husband, helping
mobilize the health‐care system to adjust levels of care and set in place hospice ser-
vices or other stress relieving measures for the family.
A constant course is one that does not increase or decrease. Despite the degree of
incapacitation, it remains minimally unchanging over time. Many developmental and
intellectual disabilities have this course (e.g., autism or diabetes), whereas an episodic
course has periods of time where symptoms impacting the family may disappear
altogether (e.g., asthma). A systemic therapist in medicine is aware that even though
symptoms may be gone, their influence remains whether in shared memories, in
relational dynamics, or in behavioral expectations and roles in the system. For example,
even though a brother has been sober for many months, his sister remains aware and
on guard against relapse by refusing to loan him money, calling him to see that he got
home on time each night, and not inviting him to her daughter’s graduation party to
avoid exposing him to alcohol.
Outcome Diagnoses vary in outcomes ranging from a full recovery, shortened

lifespan, or death. The ability of a family or health‐care system to predict the future
for a patient can be a therapeutic advantage. For example, even when a prognosis is
terminal, knowing the likely outcome can offer a sense of control over the time
remaining. Unfortunately, many families of patients with a terminal diagnosis report
not being informed or updated on the patient’s prognosis and life expectancy
(Enzinger, Zhang, Schrag, & Prigerson, 2015). A therapist who collaborates closely
with medical professionals, who understands a likely health prognosis, can better
help a patient and family members make meaning of, prepare for, and grieve the loss
of the loved one.
Incapacitation The degree of incapacitation of a health problem varies across

illnesses and even within illnesses across the full length of the problem from
onset to outcome. Some illnesses, while not having a significant or fatal biologi-
cal outcome, may be socially incapacitating. Visible skin conditions, depression,
burns, and attention deficit hyperactive disorder (ADHD) are examples of this.
A systemic therapist treating patients with any degree of incapacitation, no mat-
ter the diagnosis, recognizes the incapacitation across biological, psychological,
and social areas of functioning. Incapacitation can also be due to self‐imposed
limits and being student in a previous stage (e.g., post‐stroke patient refusing to
try to walk).
Predictability Finally, the degree of uncertainty that comes with certain health prob-
lems itself can be problematic. It is difficult for a therapist to help a family adapt and
know what to expect when even the medical doctors struggle to define a clear course
and prognosis. Even if the outcome is certain, the path to it can be drastically different
from one patient to the next. Systemic therapists can help patients develop resilience,
frustration tolerance, and flexibility to help cope with the uncertainty of conditions
such as multiple sclerosis, hypertension, or lung cancer.
Incorporating the family systems illness model in clinical practice Systemic therapists
should utilize Rolland’s typology (Rolland, 1994, 2018) to tailor treatment of those
experiencing illness or disability by being sensitive to the unique psychosocial demands
on the individual and the entire family system. Families will only accept help and hope
from therapists at the same level to which they feel understood.
The Family Systems Illness Model also conceptualizes each type of illness within
the broader time phases of illness and family development (Rolland, 1994, 2018).
Family needs and tasks will change as they move through the crisis, chronic, and
terminal phases of illness or disability. The adrenaline, energy, fear, and confusion
associated with the crisis phase may require treatment, that is. more focused on
immediate adjustments that are crucial to survival and family functioning. The
chronic phase requires families to develop a lasting homeostasis, that is. adaptable
to the qualities of the illness. Lastly, the terminal phase may focus on preparation
and mourning of death. Each phase places distinctive demands on families.
Although a family’s unique strengths may provide for adaptability in the crisis
phase, it may cause significant disruption when transitioning into the chronic or
terminal phases.
Medical family therapists must develop the capacity to suspend their evaluation of
family dynamics as “functional” or “dysfunctional” when working with those in
health‐care settings (Wright et al., 1996). Medical problems exaggerate the best
and worst dynamics of any family because they are thrust out of their homeostatic
balance and forced to grapple with anticipatory losses, financial burden, and shifts in
family roles (Rolland, 1994, 2018). Recognizing non‐normative disruptions in the
patient’s family life cycle can also add further understanding of a disease’s impact
(Rolland, 2005).
Pharmacology
MedFTs should be familiar with the purpose, contraindications, side effects, and com-
mon concerns of common medications. There are numerous benefits to client treat-
ment when the therapist and the physician work collaboratively to treat issues. There
is increasing evidence that collaborating in this effort can improve adherence to medi-
cation regimen, increase likelihood for appointment keeping and reduced treatment
time, and increase patient satisfaction (Blount et al., 2007; Katon et al., 2009; M. van
Orden, Hoffman, Haffmans, Spinhoven, & Hoencamp, 2009). SFTs with no under-
standing of pharmacology will not even know the questions to ask their clients so that
they can appropriately refer them back to their medical provider or when to refer
them there in the first place. Furthermore, incorporating patients’ family members in
the treatment process also seems to enhance pharmacological treatment outcomes
(dosReis & Myers, 2009). Medication compliance has been shown to be associated
with family supportiveness and family involvement (Kelly & Scott, 1990; Olfson
et al., 2000). Taking a systemic approach to pharmacology by including patients’
family members in the pharmacological treatment process seems to provide patients

and their family members with greater clarity and enhanced motivation to comply
with treatment recommendations.
Unfortunately, systemic therapists typically receive very little psychopharmacology
training. One study found that only 17% of MFTs reported having received little, if
any, training on the topic (Springer & Harris, 2010). Furthermore, despite almost
half (47.8%) of their clientele taking some sort of psychopharmacological medication,
nearly 80% of clinicians felt inadequately trained in this area (Springer & Harris,
2010). Therapists who know more about pharmacology are more likely to refer to
physicians and benefit from recognizing the role that psychopharmacological treat-
ments can play in patients’ physical and mental health.
Systemic therapists in medical settings must be competent diagnosticians when col-
laborating about medication use. Providing an accurate diagnostic assessment of
patients can help physicians improve their pharmacological assessment (Katon &
Unützer, 2006). This must include looking beyond the psychological irregularities
and assessing the biological components of diagnosis. For example, a clinician may
identify high levels of anxiety in a client and recommend them for psychotropic evalu-
ation while ignoring that the client drinks eight cups of coffee per day. Contrastingly,
one study showed that for every 10 correctly diagnosed patients with depression in
primary care, 15 are misdiagnosed (false positives) and 10 are missed (false negatives)
(Michell, Vaze, & Rao, 2009). The diagnostic accuracy of bipolar disorder is even
worse with 7 out of 10 receiving at least one misdiagnosis, resulting in inaccurate
treatment and poorer patient outcomes (Nasrallah, 2015). How to address physi-
cians’ over‐ and underdiagnosis of mental health problems primary care is a hotly
debated topic within the medical field (e.g., Alduhishy, 2018; Simon et al., 2015).
Because therapists have more face‐to‐face time with patients than most physicians, the
therapist can play an essential role in accurately diagnosing, providing information
regarding treatment effects, monitoring compliance, and tracking outcomes of phar-
macological treatments (Trudeau‐Hern, Mendenhall, & Wong, 2014).
Too often SFTs hide behind the “scope of practice” argument and try to stay far
away from anything related to pharmacology. It is our conviction that SFT must be
knowledgeable about, at least, the basic aspects of pharmacology. Practicing within
our scope of practice means that we are able to accurately and effectively assess our
clients. Part of that would include a basic understanding of potential functions and
side effects of medications. A few examples of this are understanding that clients
might feel nauseated for the first few weeks after starting an antidepressant but these
symptoms are usually transient and that the client should not stop their medications
without talking with their medical provider; understanding that antidepressants take
at least 4–6 weeks to be beneficial; understanding that antidepressants are often used
for many anxiety disorders and that they will tend to make the anxiety worse before it
gets better, but medical providers have additional strategies they can use to help with
the transition; understanding that while benzodiazepines are potentially addictive,
they can be an essential, temporary part of treatment for people with significant anxi-
ety disorders; understanding that for moderate to severe depression, combination
therapy is recommended (medication and therapy) (American Psychiatric Association
[APA], 2010); understanding that most of the medications used for mania and psy-
chosis do have significant side effects and MFTs can help listen to their clients’ con-
cerns and encourage adherence to the treatment plan; and understanding that many
health conditions mimic common psychiatric conditions (e.g., thyroid disorders, dia-
betes, heart disease).
We believe that complete ignorance of psychopharmacology can be a clinical issue
as we are not practicing within our scope of practice, namely, helping our clients
negotiate the complexities of their lives. One quick example of this is working with a
severely depressed client for a period of time and never letting the client know that an
antidepressant might be warranted. Our belief systems about medications should
never be used to make decisions for our clients. In the end, our clients must make an
informed decision about their desired treatment options. If we do not let them know
there are other treatment options, we are opening up potential liability issues for our-
selves and, more importantly, prolonging their suffering.
Required Practical Knowledge When Working

in Health‐Care Settings
Any health‐care system with interaction between its parts (medical providers, thera-
pists, nurses, lab techs, social workers, etc.) follows the same basic systemic principles
as other systems. For example, positive and negative feedback loops, homeostatic
response, equifinality, entropy, boundary setting, hierarchies and structures, and other
systems principles exist in health‐care systems just as in family systems (Yank, Barber,
& Spradlin, 1994). Systemic family therapists will benefit by recognizing these princi-
ples while practicing in medical settings. For example, suppose a family is struggling
with a recent diagnosis of leukemia in their youngest daughter. They may have trou-
ble in their family system (e.g., husband and wife arguing over family stresses and
changes at home), but they will also likely experience trouble in the health‐care sys-
tem (e.g., medical providers disagreeing over the best course of treatment, rebalanc-
ing the hierarchy of power in the system with physicians as shared decision makers).
Systemic family therapists can successfully help families navigate change in their family
system as well as in the health‐care system.
The success of a medical family therapist partly stems from their ability to apply to
medical systems the same systemic conceptualization to patient family systems. He or
she needs to know how to help families, but also how to recognize themselves as part
of a larger “family” of health‐care providers, communicating with medical providers,
nurses, and other members of the health‐care system in a healthy way. Collaborative
health care, by its very nature, is systemic, which is one reason why medical family
therapists are naturally adapted to thrive in medical settings.
Degrees of systemic collaboration

Consider a family with clearly defined boundaries and roles, low levels of emotional
enmeshment, and ample psychological space for individual differentiation. Such sys-
tems struggle far less often with communication problems, competition between
members, oppressive hierarchies, and any other number of problems that family ther-
apists typically identify as dysfunctional. Similarly, highly collaborative health‐care sys-
tems, especially those who have fully integrated behavioral health into their daily
practice, are more likely to communicate openly, understand each other’s’ roles, and
allow each to contribute according to their skills and training.
Not all health‐care systems are this collaborative in nature, however. It is important
to note that collaboration is not a category, but a continuum. So rather than ask “Are
these health‐care systems collaborative: yes or no?,” it makes more sense to find out
what degree of collaboration they currently have. For example, the Tamarack Institute
(2017) describes collaboration in seven levels from “competitive” on one side to
“integrated” on the other. “Competitive” systems compete for patients, resources,
partners, and the attention of the public. Without that competition the health systems
simply “coexist.” As the systems move toward integration, they progress through the
increasingly collaborative stages of “communication” (they begin to share informa-
tion, but have different goals), “cooperation” (they share a focus/vision, but have no
shared processes or structures), “coordination” (they now have shared processes and
structures but maintain separate missions), and “collaboration” (they share missions
and resources as part of a true relationship between them, but are still distinct and
separate systems) to finally become “integrated” (they become one system).
Those health‐care systems that have fully integrated behavioral/mental health care
in their primary care clinics typically offer better outcomes for patients, especially
when it comes to chronic and BPS health conditions (Reiss‐Brennan et al., 2016);
however, any degree of collaboration is valuable.
Perhaps one of the best signs of truly collaborative care is when health‐care provid-
ers hand off patients to each other. Unlike a traditional consult, a “warm handoff”
happens when more than just patient and provider are in the room. When a physician,
for example, introduces their patient to a therapist or other behavioral health‐care
provider, that patient is much more likely to consent to receive, and follow through
on, behavioral health‐care services such as therapy or counseling (Apostoleris, 2000).
The patient on the collaborative care team

In the past, a patient had to go to unaffiliated health‐care providers at different loca-
tions to obtain treatment for her or his various biological, psychological, social, and
other health problems. Those providers often did not share information to help
inform each other’s decision making. Thankfully health‐care systems are changing to
allow all health‐care providers, even behavioral and mental health‐care providers, to
work more collaboratively to address patient needs (Reitz, Whistler, & Fifield, 2011).
Despite these advances, many health‐care systems still fail to collaborate with one of
the most potentially influential members of a given health‐care team—the patient
and family.
Systemic therapists know that collaborating with patients as members of the health‐
care team is essential but is also not without difficulty. Often patients are already part
of a system of people who have a lot of influence over the health decisions they make.
Namely, patients’ family members play an essential role in the health of patients
(Schilling et al., 2002). For example, what good is prescribing a good diabetes medi-
cation, discovering the correct dose, finding a way to pay for it, and getting agree-
ment from the patient to take it, if he then goes home to a partner who does not
believe he even has diabetes and is unwilling to adjust the family diet or spend money
on “those black magic pills.” Having the skills to partner with patients’ family
embers, in their unique family culture, benefits not only the patient and family
m
members but also the health‐care providers who are treating the patient.
Systemic therapists must have skills in facilitating effective partnerships between
family systems and health‐care systems. Therapists in private practice or agency set-
tings who continually foster relationships with physicians find that all parties (physi-
cians, therapists, patients, and families) benefit from the synergy of holistic care. This
is especially true in the context of chronic illness, substance abuse, and mental health
care and also during health‐related family transitions such as pregnancy, children’s
health care, and end‐of‐life care.
Challenges Working in Medical Settings
Time constraints
MedFTs find that effective collaboration relationships are built by respecting the work
culture and environment of those with whom they collaborate. The worlds of medical
health care and mental/behavioral health care operate at much different paces. A
systemic therapist should not expect a medical provider to spend lengthy times dis-
cussing with him or her the full depth of a patient’s case. They often only have time
for the very basics; hence collaborating with medical professionals can feel very differ-
ent than discussing clients with a supervisor or other therapists. MedFTs should rec-
ognize their role in treatment collaboration and also find space for collegial consultation
with other therapists or supervisors.
Usually the 50‐min hr, which has dominated the psychotherapy world for decades,
needs to be shortened to fit in the pace of medical settings. A therapist who typically
sits down on a comfortable couch with soft lighting and wanders with the patient into
whatever conversational paths the session may take might struggle at first in a medical
setting, which often only allows for a brief 20‐min consultation in an exam room.
Working in a medical setting requires therapists to adapt to sitting on exam tables and
stools instead of couches, while nurses interrupt to give a flu shot or draw blood.
Therapists in medical settings must be flexible and efficient (in diagnostic and treat-
ment planning skills) and adapt their methods to their medical setting. They have to
be prepared to redirect the conversation frequently to maintain efficiency and report
back to the collaborating physicians on their assessment, treatment, and progress.
In addition to differences in treatment times (i.e., 8‐ to 20‐min primary care
appointment versus the traditional 50‐min hr of psychotherapy), there is also a differ-
ent expectation of depth of information that comes with these time constraints. For
example, physicians focus heavily on the what and often do not have time for the full
why. What is going on in a patient’s body comes first using a variety of tools to diag-
nose and relieve symptoms. Many traditional therapists, on the other hand, spend
their greater amount of time not only assessing what is going on but also trying to
discover why. These therapists look for reasons why and potential relief from symp-
toms using talk as their primary diagnostic and treatment tool. This cultural differ-
ence of the value of time is important for therapists to note.
Therapists trained to “dive deep” with patients in a traditional 50‐min hr may feel
uncomfortable at first in the more pressed‐for‐time environment of medicine.
Strategies for adjusting to this new environment can be both behavioral and cognitive.
For example, you may be seeing patients in an exam room instead of your office, so
“bring your office with you” by having pamphlets, worksheets, and other commonly
used educational materials easily accessible. Become familiar reading doctors notes in
the electronic health record, and learn to write your notes with an audience in mind of
not only yourself but also of the medical clinicians you are collaborating with. Be flex-
ible with your schedule. Be flexible in your therapeutic methods by reframing your
definition of therapeutic success. Although systemic therapists typically aim for sec-
ond‐order change, when time or other obstacles limit our ability to intervene, we must
be okay with first‐order change or any change we can help our patients achieve.
Confidentiality
Confidentiality expectations are another difference between medical settings and tra-
ditional therapy offices. A traditional therapist or counselor recognizes that others
might read their progress notes at some point, but this is not typically the norm.
Therapists typically write notes with themselves as the primary audience in mind;
however, medical providers and other health‐care providers are trained to write notes
under the assumption and expectation that others will review them. A therapist work-
ing in a medical setting needs to write for the audience of those with whom he or she
is collaborating. To maintain confidentially, especially with highly sensitive therapy
material, he or she may need to purposefully be less descriptive in progress notes or
keep the details separate from the shared electronic medical record keeping system
that nearly all medical settings use.
Identifying a patient
Systemic therapists are trained to see problems as larger than just residing in one indi-
vidual, but medical settings are not used to categorizing or coding problems as “fam-
ily” or “couple” problems. As a result, most of the medical record keeping systems
require an “identified patient.” This can be challenging when seeing a couple for
relationship counseling or treating a whole family. Whose chart do the notes go into?
Which spouse is the identified patient? For example, suppose a systemic therapist is
treating a family with loose structural boundaries, inconsistent disciplining tech-
niques, and minimal room for expressing emotion. As a result, the young boy in the
family is struggling to learn to control his impulsive behavior and manage his anxiety.
Also, the boy’s school teacher is pressuring his parents to take him to see his physician
to be assessed for ADHD. In consulting with a physician, an MedFT may see the
problem as systemic, not just a dysfunction in the child’s brain, and may wonder
about how to document it appropriately. The notes will likely go in the boy’s medical
chart, the billing code under his diagnosis, and the rest falls to MedFTs to educate
those with whom they collaborate about the systemic nature of the problem.
Language
Language is another challenge facing therapists working in medical settings. In the
same way that it is essential for therapists to understand the culture and “language” of
the families they treat, it is equally important for therapists in medical settings to
understand the culture and “language” of medicine. For example, when a patient is
“febrile,” he or she has a fever. A patient with “emesis x3” has vomited three times.
Instead of “pain,” a therapist might hear “radiculopathy.” Medical providers use many
abbreviations, such as PRN, HgA1c, and CBC. Of course, a full understanding of all
medical terminology is not necessary; however, beyond just the difference in words
used, there is a difference in the way words are used. For example, “comfort cares” is
often a euphemism for “we’re stopping treatment because the patient’s life is end-
ing.” MedFTs will enjoy their work more and be better at it as they come to learn the
culture and language of medical settings.
Divergent treatment goals

Medical provider characteristics and openness to collaborate vary widely across care
levels and specializations. Yet some patients, and even some therapists, do not see the
differences between types of specialists simply because they are not yet familiar with
these differences. Unfamiliarity with health‐care settings leads to the belief that all
medical providers are uniformly mechanistic. MedFTs should work to inform both
themselves and their patients to build familiarity of medical provider differences and
encourage confidence in identifying and addressing divergent treatment goals.
Of course, this type of generalized thinking can be applied to therapists as well. We
clearly recognize that not all therapists are the same, yet many health‐care providers
believe that psychologists, counselors, family therapists, and social workers essentially
do the same work. They may refer to each of these unique clinicians simply as “behav-
ioral healthcare providers,” assuming unanimity across specializations, coverage, and
utility. Behavioral health is a catch‐all phrase that dominates medical specialties. It is
up to each MedFT to educate health‐care providers about their unique contributions
and rally around a shared philosophy of systemically focused treatment.
One simple way to make this practical is to bring it into the language of the body
and medicine. For example, a person’s physical body is not simply a set of organs that
operate individually alongside one another; rather, a body is a network of organs that
influence each other as a system of individual parts. This analogy can be used to edu-
cate medical clinicians that a family is also not just a set of individuals who live along-
side one another, but a family system has rules, boundaries, roles, and patterns, and
the relational dynamics between the individuals are as much a part of the family as the
individuals themselves. A systemically oriented or “family” therapist is different than
other behavioral health‐care providers in the sense that we assess and treat not only
the individual parts but also the interactions between them.
It is difficult to collaborate with health‐care providers when goals are divergent. A
shared belief system is an essential part of true collaboration; it does not make as much
sense to have a systemically focused therapist collaborating with health‐care providers
that are not also systemically oriented and family focused. For example, sometimes
physicians are concerned only with prolonging life and maintaining health. Yet some-
times family members of patients, and patients themselves, may have different or com-
peting goals for the treatment. This is often the case toward the end of life when
quality of life remaining becomes more important than quantity of life remaining.
Systemic therapists help families identify their own goals and develop ways of reaching
them. This information is then coordinated with the medical providers. Many health‐
care providers have not been trained in family‐centric methodologies and may not
immediately value the goals and input of the patient’s family system. Inasmuch as
patients benefit from therapies that are whole‐person centric and systemically focused,
therapists will also benefit from practicing and helping to create collaborative health‐
care settings that are systemically focused as well.
Co‐training is beneficial in bridging this interdisciplinary gap. This usually occurs
when medical residents are trained alongside medical family therapists, exposing both
disciplines to the benefits of the other’s work. Thankfully interprofessional education
is an increasingly popular methodology. But even if therapists were not trained along-
side physicians, and even if physicians were not trained along therapists in systemic
treatment philosophies, the nature of systems is adaptive and malleable. Just as fami-
lies can learn to be more collaborative, so can a health‐care system with the help of an
expert in motivating behavior change and relationship improvement according to
systemic theory—namely, a systemic therapist.
Successes in the Advancement of Systemic

Family Therapy in Medical Settings
As health care evolves in the twenty‐first century, many systemically trained therapists
are finding success bridging the divide between biomedical and psychosocial health
care (Marlowe, Capobianco, & Greenberg, 2014). Finding a stable role in health‐care
treatment is an ongoing effort with pathways of integration being forged across the
country and throughout the world. More and more behavioral health‐care providers
each year are being fully integrated into primary care, specialist health‐care clinics, and
hospitals and as part of other health‐care teams (Hodgson et al., 2014; McDaniel,
Doherty, & Hepworth, 2014). Furthermore, there is a growing trend among US
graduate programs in systemic therapy to provide specialized training in behavioral
health‐care collaboration. Systemic therapists bring with them to these positions a
valuable skill set given the nature of medicine and working in multiple systems (e.g.,
biological systems, social systems, health‐care systems). Once they become part of the
health‐care team, they are able to contribute value at all levels (e.g., patient, family,
other providers).
Empirical evidence of benefit and cost‐effectiveness

Research has provided significant evidence that collaboration between medical doc-
tors and behavioral health‐care providers improves the quality of care and is cost‐
effective (Blount et al., 2007; M. van Orden et al., 2009). By combining the funding
streams of medical and mental health services, there is clear evidence of the benefit of
collaboration in the clinical, operational, and financial aspects of care (Blount et al.,
2007). Repeated evidence has shown that patients with psychiatric problems present
to physicians with physical symptoms long before consulting psychiatric services
(Blount et al., 2007). Furthermore, those with psychiatric symptoms incur much
higher treatment costs over time than counterparts without psychiatric symptoms
(Unützer, Schoenbaum, Druss, & Katon, 2006). Other studies have identified that by
enhancing collaboration between doctors and behavioral health‐care providers,
patients who need psychiatric services require half as many visits as those who receive
psychiatric services separately (Unützer et al., 2008; M. L. van Orden, Deen,

Spinhoven, Haffmans, & Hoencamp, 2015). The evidence has shown that collabora-
tion can increase physician satisfaction, decrease the length of treatment, and reduce
health‐care utilization, hence reducing health‐care costs (Blount et al., 2007; M. van
Orden et al., 2009; M. L. van Orden et al., 2015).
Although the medical literature has shown increasing support for the importance of
greater psychosocial integration, demonstrating the financial gains of integration has
proven to be more complicated, limiting the amount of available research. One area
of research, though, has focused on medical cost offset, which is focused on the idea
that integrating mental health with medical treatments can offset medical costs
enough to compensate for the services provided. A meta‐analysis of 91 studies found
that the provision of mental health services reduced medical care utilization by an
average of 20% (Chiles, Lambert, & Hatch, 1999). For example, Cummings, Dorken,
Pallak, and Henke (1990) conducted a large‐scale study on the island of Oahu where
patients with psychiatric symptoms were referred for mental health services, even if
they were not requested. The results of the study showed cost reductions of 18% for
chronically ill Medicaid patients and 38% for non‐chronically ill Medicaid patients
(Cummings et al., 1990).
Research has been done that has similarly demonstrated the medical cost offset of
systemic therapies. In a series of studies, Crane and colleagues found that couples and
families who experienced systemic therapy had subsequent significantly lower medical
care utilization rates (Crane & Christenson, 2014). For example, Law and Crane
(2000) found that couples who participated in couple therapy reduced their health‐
care utilization by an average of 21% in the year following therapy. Additional analyses
show an even larger medical offset effect among high utilizers of health‐care services,
with those receiving either marital or family therapy experiencing a decrease in their
health‐care use by about 50% (Law, Crane, & Berge, 2003). Crane and Christenson
(2008) examined types of health‐care utilization among high utilizers, more specifi-
cally, and found that those receiving couple therapy experienced subsequent decreases
in medical use for health screenings (68%), illness visits (38%), urgent care visits (78%),
and laboratory/X‐ray visits (56%).
In addition to the benefits from medical cost offset, systemic therapy results in
lower dropout rates (Moore, Hamilton, Crane, & Fawcett, 2011), lower recidivism
rates and treatment costs (Crane et al., 2013; Moore & Crane, 2014), and fewer ses-
sions billed to insurances (Morgan, Crane, Moore, & Eggett, 2013). However, it is
important to note that these general benefits of family therapy have not been applied
to family therapy that occurs specifically in medical settings. Despite this limitation,
Crane’s research creates a promising foundation for future research on the combined
benefits of family therapy and the established benefits of collaborative health care.
In order for systemic therapists to develop a greater presence in medical settings,
MedFTs will be required to provide evidence how the services they provide produce
cost benefits to the organization. There are several methods that systemic therapists
can use demonstrate both indirect and direct financial benefits to the hospital or clinic
where they are employed. Indirect approaches focus on providing benefit to hospitals
through many non‐billable services. These services may include improving organiza-
tional efficiency (e.g., providing emotional support to a patient so the physician can
move to other billable services) (Marlowe et al., 2014). More direct approaches focus
on services that can be billed by the therapist. Beyond the billable services for
sychotherapy treatment, systemic therapists in many states are allowed to bill for
p
brief screening interventions such as collaborative consultations or Screening, Brief
Intervention, and Referral for Treatment (SBIRT) codes (Marlowe et al., 2014).
Furthering the Practice of Systemic Therapy in Medical Settings
Early medical family therapists have faced an uphill climb in showing how our field
can be integrated into medical treatment. The work of these pioneers has paved the
way for increased visibility and influence, which has uniquely positioned MedFTs for
future expansion. However, one of the next steps for the expansion of systemic ther-
apy in medical settings is to provide specific adaptations for how systemic therapy can
be integrated into various health‐care settings. Mendenhall, Lamson, Hodgson, and
Baird’s (2018) recent book entitled Clinical Methods in Medical Family Therapy pro-
vides practical adaptations for collaborative systemic therapy across a broad range of
treatment settings (i.e., primary care, secondary care, tertiary care, and other unique
care contexts). The book provides practical ideas for applying systemic therapy into
medical settings and furthering future collaboration and research.
There may be many ways for systemic therapists to enlarge their collaborative foot-
print; however, MedFTs are significantly limited by their lack of access to Medicare in
the United States, which limits their ability to work with the expanding older adult
population. With the ever‐changing landscape of health‐care reimbursement, it is dif-
ficult to predict the future of integrated health‐care and mental health coverage.
However, in the United States, there have been recent changes in federally run health‐
care programs that have incentivized the development of billing approaches that pro-
mote greater provision processes and patient education (Marlowe et al., 2014). As
discussed, systemic therapists working in medical settings can meet each of these aims
by increasing efficiency and enhancing patient interaction. This change reflects the
possibility for MedFTs to expand and solidify a position in medical treatment in the
coming years. It is important to continue lobbying for Medicare in the United States
in order to increase the number of billable services that MedFTs can offer. Providing
more examples of fiscal and treatment integration practices will surely benefit the next
generation of MedFTs.
MedFT research
The future of MedFT practice will depend on our field’s ability to clearly define our
role in treatment and identify the financial and psychosocial benefits to current treat-
ment modalities. Additionally, more research is needed to show effectiveness of treat-
ment, impact on medical provider satisfaction, decreased burnout, cost offset, and
financial viability of having an MedFT on the treatment team. Researchers should also
continue researching the interrelatedness of psychosocial determinants on health out-
comes as this provides important implications for treating the family as a unit.
With the definition of MedFT that we have provided, future researchers in this field
should expand cost‐effectiveness research in collaborative health care by adding a
systemic paradigm. Solidifying the benefits of MedFT will require identifying the fam-
ily as the unit of analysis. Because the MedFTs are especially trained in family therapy,
the cost offset and cost‐effectiveness benefits potentially far exceed that of other
behavioral science professions. Researchers may also begin by expanding their effec-
tiveness research in systemic therapy on different treatment settings, presenting prob-
lems, or at‐risk demographics to also include both psychosocial and medical benefits
of collaborative treatment.
Education and training

There is a great need to expand the provision of more advanced training in systemic
treatment in health care at both the medical and family therapy arenas. While a few
programs exist throughout the nation, we are beginning to see the impact as these
trained therapists are emerging in many different roles (e.g., program directors,
behavioral health faculty, treatment team members, department chairs, deans, facility
directors, health‐care policy members). There is a great need for this small group of
individuals to continue to make an impact and continue to extend their outreach.
Slowly, there are more and more training programs that offer medical family training,
and this will, and needs to, continue to grow.
But the efforts to provide useful guidelines for promoting competency and the
maintenance of these standards are left to educators and supervisors alone. The use-
fulness of these core competencies will be determined by how future systemic thera-
pists who work in medical settings ultimately decide to view their profession. As noted
above, SFTs who become MedFTs possess the requisite training, vision, abilities, and
talents to fill the void that exists in much of medical care.
Conclusion
Medical family therapists continue to expand their reach and show their impact on
individuals, couples, and families and also on the health‐care team and system as a
whole. There continues to be a need for additional research and greater outreach to
show the utility of their services. As systemically trained individuals, the major focus
of MedFT is to provide aid and relief to all aspects of the health‐care system. This
starts at the patient level and expands to the health‐care system as a whole. As the core
group of MedFT trained individuals continues to grow, their visibility and impact will
continue to be identified throughout the health‐care system and truly patient‐ and
family‐centered care will expand.
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30
Specialty Settings
Hospital‐Based Behavioral Health,
Military, Family Businesses, Management,
and Government
Brian Distelberg, Elsie Lobo, and Griselda Lloyd
A majority of (72–78%) systemic family therapists (SFTs) work in traditional outpatient

practices (Rasmussen, 2015). Because of this, SFT training, clinical internships, and
supervision are focused almost singularly on this type of practice. Even the Commission
on Accreditation for Marriage and Family Therapy Education (COAMFTE) standards
and required hours of clinical training assume this type of practice (COAMFTE, 2018),
as do state‐level licensure rules. While this type of practice is common for SFTs, as well
as all mental health professionals, it is by no means the boundary of the SFT field or the
limits of the current SFT field training, skills, and strengths.
In reality, major theories within the SFT field demand that therapists break through
this standard business model in an effort to effect change at larger systems levels. In
addition, clinicians come to the field with their own life experiences and population
interest areas. These students carry these life experiences into their training and are at
the same time taught and encouraged to use their self and experiences as part of their
clinical work. Therefore, it is not surprising to see that over time, SFT as a field is
expanding into specialty settings.
Although this trend is becoming more pronounced over time (Bureau of Labor
Statistics [BLS], 2018), it is still a micro‐trend (e.g., there are fewer less than 1–5% of
SFTs practicing in each specialty area). Therefore we can assume that these specialty
settings are currently occupied by the most entrepreneurial of SFTs, as well as SFTs
with passion for a specific type of population or way of practicing. These SFTs are will-
ing to advocate for the field in these new arenas and therefore are carving out SFT
spaces for future generations. They are educating their sites and organizations on what
the profession of SFT is and how it can be of value to the existing ways of practice.
Although these specialty activities are still a very small percentages of the total field,
we believe these are growing areas of practice, and in some cases, there are large‐scale
efforts focused on encouraging this growth. For example, the American Association
for Marriage and Family Therapy (AAMFT) has been actively lobbying to widen the
doors for SFTs in military settings (American Association for Marriage and Family
Therapy [AAMFT], 2018). Also, US regulatory changes in insurance and behavioral
684 Brian Distelberg, Elsie Lobo, and Griselda Lloyd
health care are providing greater opportunities for SFTs (which will be discussed in
greater detail below). Therefore it is likely that these specialty settings will continue to
grow and more SFTs will likely engage in them in the future.
With this assumption in mind, we highlight five areas where SFT practice is present
and growing. We provide a brief description of each area in terms of the type of setting,
common practice activities carried out by SFTs, and the current level of SFT activity
within each area. We also briefly discuss how the current SFT standard of training sup-
ports these practice areas but then highlight areas where additional education, training,
or experience might be useful. Finally, we present a few thoughts regarding the current
level of training within COAMFTE programs and how modifications within these cur-
rent standards could support the expansion of these and other practices in the future.
Specialty Areas
Hospital‐based behavioral health settings

Although hospital‐based care is not new for the larger field of behavioral health, SFTs
have yet to fully integrate into these settings. To this end, there are over 7,000 facili-
ties within North America that offer hospital‐based behavioral health care (Commission
on Accreditation of Rehabilitation Facilities [CARF], 2018). These facilities are con-
nected either physically or through organizational ties with a full‐service hospital.
These settings offer varying continuums of services from inpatient psychiatric services
to partial hospitalization programs (PHP) and intensive outpatient programs (IOP).
Inpatient hospitalization serves high acuity or high‐risk situations (e.g., danger of
injury to self or others). PHP services are a common first step down for inpatients.
These programs can last 2–8 weeks (or longer). In these programs, regulatory bodies
and insurance companies (e.g., the Centers for Medicare and Medicaid Services as
well as Medicaid, Medi‐Cal) dictate the organizational structure and culture of the
setting. Because of this, patients will likely receive at least 6 hrs of services, 5 days a
week (Medicaid, 2018). Each day of service usually includes group process, therapy,
psychoeducation, occupational therapy, family therapy, etc. A next level of service
down from PHP is the IOP level of care. IOP require 3 days of services per week with
3 hrs of service each day. The 3 hrs of services are usually group‐based services,
whether that is three separate hours of process group work or two 90‐min progress
groups per day. Many IOP also include additional individual or family therapy as part
of the total care plan.
Regardless of the level of care, these hospital‐based services share common cultures
and practices that are unique to hospital settings. Firstly, these sites handle most men-
tal health diagnoses (e.g., self‐injury, psychosis, schizophrenia, severe major depres-
sion, etc.). Similarly, significant levels of drug and alcohol addiction are often treated
in hospital‐based settings due to the high level of risk for the patient and the potential
need for detoxification interventions. Secondly, these services require multidiscipli-
nary teams, often exemplified by the inclusion of a psychiatrist, residents, nursing
staff, case managers, and therapists. Thirdly, these sites are embedded in complex
systems of care. These systems include the larger hospital system’s operational and
administrative systems, state and national regulatory systems, and complex billing
systems for sites that depend on third‐party payers. These complex and hierarchical
Specialty Settings 685
systems are interdependent, and minor changes in one system create ripple effects
throughout the other systems. Finally, the industry of health care is rapidly changing
(Substance Abuse and Mental Health Services Association [SAMSHA], 2014). The
most significant changes on the horizon include the integration of mental health into
primary care, greater movements toward universal health care, and the rapid expan-
sion of mental health as an industry. All of these changes will be complex and take
years to settle into, but they are also providing SFTs with avenues into these systems
and in administrative roles that were previously blocked to SFTs.
Current activity The exact prevalence of SFTs working in these sites is not
completely clear, other than to say it is a very small proportion of the total field. For
example, a 2011 survey of AAMFT members reported that 4% of AAMFT members
worked in hospital or outpatient treatment centers (American Association for
Marriage and Family Therapy [AAMFT], 2012). Because “outpatient treatment”
may or may not be in a hospital setting, the exact prevalence is not clear here.
According to the BLS, less than 1% of SFTs (n = 380; 0.89%) work in psychiatric
mental health or substance abuse settings, and an additional 4% of SFTs work in
residential, PHP, or IOP (BLS, 2018). Again, none of these statistics give an exact
estimate. For example, residential care is rarely hospital based, whereas IOP and
PHP can be either hospital based or not hospital based. Therefore, as a rough
estimate, it would be fair to assume that somewhere between 1 and 4% of practicing
SFTs work in a hospital‐based behavioral health setting. This is a shockingly low
estimate as these settings are ripe for SFT influence and they serve a significant
proportion of the total mental health market worldwide.
Within these sites, SFTs are finding a greater level of acceptance and inclusion.
In part this is due to recent regulatory changes that pushed organizations to
achieve greater levels of family involvement within the total patient care plan (Joint
Commission, 2017: CTS.03.01.05). As mentioned before, PHP and IOP rely
heavily on group work and indirectly on individual and family therapy, all things
that SFTs are trained in and can do. Yet these types of interventions may not be
appealing to the most ardent of SFTs as many sites keep an individual‐level focus
and use individually focused theories (e.g., CBT). Now with the new emphasis on
family involvement, SFTs will find that these sites are more aligned with their
trained way of practice, not to mention that these sites may not be internally
equipped to handle these changes and might be exceptionally happy to see SFTs
come on board and help them achieve these new standards. Therefore, although
SFTs are needed to facilitate process groups, lead psychoeducation programing,
and run therapy sessions, these practitioners are critical in helping maintain these
traditional interventions while also integrating a higher level of family involve-
ment. Furthermore, SFTs with higher levels of practice or management experience
may also find avenues to become program directors or even higher administrative
levels of the system.
Current training and strengths The typical level of SFT training (e.g., master’s
degree) is sufficient for direct patient care employment positions (e.g., therapists). In
many ways, these sites are ideal for SFTs, as most operate through direct contracts with
third‐party payers, reducing the challenges some SFTs face in regard to licensure,
insurance panels, and reimbursement when practicing individually or in the traditional
therapy model. The only limitation to this situation will be the organization’s own
policies and job descriptions.
Also, as part of a multidisciplinary team, SFTs will likely draw heavily from their
clinical training in an effort to work effectively as an integrated team member. In addi-
tion to the clinical work, SFTs will find that their systemic training lends well to man-
agement positions in these facilities. Those with a doctoral degree might also be
afforded with opportunities to create or modify existing programing.
Furthermore, two major regulatory changes have been implemented in 2018
within the United States, these being the emphasis on greater inclusion of the
family system (Joint Commission, 2017: CTS 03.01.05) mentioned above, but
there are also new regulatory standards requiring the use of outcome measures
(Joint Commission, 2017: CTS 03.01.09). These same standards also suggest
(but do not yet require) the application of evidenced‐based models. Specific to
the inclusion of outcome measures, these measures will need to assess not just the
patient but also be informed by the patient’s caregiving system (e.g., the family).
With these new standards, SFTs are well positioned to help these established
organizations shift into the new world of systemic work. For example, planning
and managing family education and multifamily groups will become a common
element of these programs as they adapt into the new emphases. Furthermore,
although assessments have been a common feature for decades, the new stand-
ards require the adaptation of assessments for the inclusion of the family system,
something SFTs are well prepared to do. In a very similar way, instituting meas-
urement systems in a complex hospital system is difficult. But SFTs with program
development, implementation, and evaluation training would be valuable, as all
of these systems begin to move into a culture of evidence and e vidence‐based
practice.
Additional training and skills Although SFTs are well positioned for these settings,
there are experiences and skills that are not commonly taught in SFT training centers.
Because of this, SFTs with prior experience in behavioral health hospital settings will
be highly valued at this moment in history. If the field of SFT desires to have a larger
impact on this setting, there are a number of additional factors that should be considered
in the student’s training experience.
First and foremost, SFT training sites will need to work harder at accessing and
utilizing hospital‐based training sites for the SFT students. The best way to learn these
sites is through immersion in an internship or practicum setting. Given that (as men-
tioned above) less than 4% of SFTs work in these sites currently, SFT program direc-
tors and clinical placement coordinators more than likely do not have existing
knowledge or experience with local sites. These directors will need to take on the
responsibility of seeking out these opportunities. They will also need to help create
new bridges for students and ultimately be responsible for maintaining the relation-
ship between the hospital and training worlds.
In addition, as noted above, hospital‐based sites are complex and hierarchical medi-
cal systems, often fast pace and rigid. These sites are very similar to the cultures and
experiences discussed in medical family therapy (MedFT) literature (Tyndall,
Hodgson, Lamson, White, & Knight, 2014). SFTs will need to be trained on how to
function as a team member in these systems. For example, weekly treatment team
meetings are common in these sites. In these meetings the total care team will come
together for an hour to discuss and make critical decisions on 10–20+ patients. SFTs
will need to learn how to quickly input their information in this hierarchical process.
In these cases, the team as a whole may not value an in‐depth discussion of the
patient’s illness narrative, or how third‐generation norms in the patient’s family sys-
tem are creating differentiation challenges for the patient. Although these are impor-
tant considerations for the therapist and the patient, in these meetings, the focus
tends to stay on whether the total care is working, or, conversely, if significant changes
to the larger plan are needed. From personal experience, most SFT interns struggle
with this as their academic clinical classes and internal practicum training teach them
to process cases at length, not to work toward a short and concise summation.
Additionally, in these settings, there is no sense of “my patient.” This can be a cul-
ture shock for a therapist that is used to seeing their clients one‐on‐one and behind
closed doors. In these sites an individual’s work is out in the open and discussed and
critiqued regularly, sometimes by individuals with little to no therapy training and
often by individuals with no systemic training. Therefore, it is critical that the SFT
becomes comfortable working in this environment. It is also imperative that the SFT
learns how to articulate their portion of the total work and argue for their unique
insights and foci. To do this well in the multidisciplinary team, SFTs will have to
understand their relationship within the larger team and how to use their position in
the team to provide the best possible care for the patient.
Also, it is likely that few SFT training programs directly teach their SFT students
how to effectively use electronic medical records or how to use daily charting within
a multidisciplinary team or for the purposes of billing. SFTs wishing to work in these
sites will have a steep learning curve in these areas if they do not have some familiarity
with these systems prior to entering as an employee.
Additionally, regulations are a significant challenge for these sites. SFTs are not
trained in hospital care regulations. This is problematic as outside regulatory laws and
norms can at times be at odds with systemic logic. A very common example is the fact
that SFTs consider the entire family as the identified patient. In most hospital settings,
the individual is the patient, and there will be significant regulatory and billing process
barriers that will need to be addressed before a therapist can function completely in a
systemic way. SFT students will need to receive training and guidance from their aca-
demic trainers as well as systemic supervisors if they hope to effectively navigate these
contradictions. Also, these regulations create a practice setting where 50% or more of
an SFT’s time could be dedicated to paperwork and policy adherence exercises rather
than direct patient care. This needs to be clear to the student on the front end, as this
will not be a comfortable working environment for all SFTs.
Finally, as noted before, these sites receive the most severe mental health cases, from
schizophrenia, self‐injury, eating disorders, drug/alcohol addiction, etc. Many of the
issues that are treated in these sites have significant bodies of literature identifying evi-
denced‐based practice. Much of this evidence in any one of these areas would point to
a family systems informed evidence‐based approach or at least the necessity to work at
the family systems level. For example, adolescent oppositional defiance disorder is often
seen in partial hospitalization levels of care, and multiple family systems approaches
have achieved evidence‐based practice levels and are used in these sites (e.g.,
Multisystemic Therapy [Henggeler, Schoenwald, Borduin, Rowland, & Cunningham,
1998] and Multidimensional Family Therapy [Liddle, 2009]). The same is true for
addiction and eating disorders. Yet, these evidence‐based approaches are not fully
taught in SFT training programs. SFT students typically have to undergo additional
training through their employment site, when in fact the training that they receive is
likely to have a home in their academic world. Furthermore, as new specialty programs
are developed, SFTs should be on the front end of developing and testing these pro-
grams in these multidimensional hospital sites so that new evidence‐based approaches
are informed by systems theories and inclusive of the larger patient system.
Military settings
SFTs have a passion for helping individuals, couples, and families find solutions
to their concerns. Also, military personnel with combat exposure have significant
mental health needs in the areas of PTSD, major depression, substance abuse, and
anxiety disorders, as well as suffering from functional impairments in social, occupa-
tional, and physical functioning (Hoge, Auchterlonic, & Miilliken, 2006). Therefore,
it makes great sense as to why SFTs might consider working directly with this popu-
lation. However, to effectively work with military service members and their families,
it is important to understand the military culture (Coll, Weiss, & Yarvis, 2011;
Karney & Crown, 2007). To this end, the individuals and families living within
the military culture are uniquely different from the civilian world and must be
understood as such. Military families experience unique challenges when compared
with civilian families, such as frequent geographical relocations, extended separations
due to trainings or deployments, the stress of reestablishing emotional connects after
prolonged separation, and the possibility of injury and death, a few examples of the
unique contextual issues that must be considered when working with this population
(Lloyd et al., 2015).
Beyond the military soldier, these individual’s families are also unique. These fami-
lies also have the additional concern that the service member might be suffering from
PTSD or the possibility that a family member might develop secondary trauma or
compassion fatigue because of living with or caring for a family member with PTSD
(Nash & Litz, 2013). For example, Klarić and colleagues (2012) reported that 40.3%
of the wives of PTSD‐diagnosed veterans also met the criteria for PTSD, pointing to
the interdependence of contextual symptomologies and needs for these families. With
these additional challenges, SFTs wanting to work with military personnel and fami-
lies must develop military specific cultural competencies if they hope to succeed in the
work (Tanielian et al., 2014).
Current activity In 2004, Congress enacted Public Law 108‐375 (US Congress,
2004), Section 717 (a), allowing SFTs to be employed by the Department of Defense
(DoD) in clinical positions. Currently, SFTs are working in various capacities throughout
all branches of the military (military and family life counselors [MFLACs], civil
contractors, chaplains, and clinicians) and within the Department of Veterans Affairs
(VA) as clinicians. In addition, SFTs are also conducting various research studies with
active‐duty and reserved service members (Blow et al., 2013; Blow, Curtis, Wittenborn,
& Gorman, 2015; Gorman, Blow, Ames, & Reed, 2011; Lloyd et al., 2015; Nash &
Litz, 2013; Pfeiffer et al., 2012).
According to AAMFT, the VA employs 21,000 mental health professionals, of
which 150 are SFTs (AAMFT, 2018). SFTs will often find themselves delivering
services related to PTSD, traumatic brain injuries, deployment and reintegration
adjustment, and premarital and marital enrichment programing through the different
service branches. For example, SFTs can also be employed as MFLACs (Military One
Source, 2018). As an MFLAC, the SFTs work with active‐duty service members and
their immediate or surviving family members. These positions engage in individual,
couple, or group counseling, but can also work with deployment adjustment, stress
management, permanent change of station preparations and settling, relationship
building, work problems, and grief work.
Additionally, SFTs are also employed within the US VA, a federal agency that mainly
provides health‐care services to eligible military veterans. SFT positions within the VA
hospitals offer nonmedical individual, marital, and family therapy services. Licensed
SFTs can also serve military personnel in the civilian sector by receiving reimburse-
ment through Tricare. Tricare provides civilian health benefits for US Armed Forces
military personnel, military retirees, and their dependents. It is important to note the
differences of working as an SFT within the military culture and as a civilian contrac-
tor working with military personnel. SFTs working in a military installation follow the
military regulations in addition to the SFT legal and ethical standards. With this, they
attend military specific trainings to maintain their competencies. Civilian contractors
do not have to attend military specific trainings but are encouraged to do so (Karney
& Crown, 2007; Tanielian et al., 2014).
SFTs are also involved in research with the military, studying interventions that are
adapted for personnel and their families. One group of researchers has formed an
academic–military partnership with the Army National Guard to study the well‐being
of their soldiers returning from deployments (Dalack et al., 2010). Through this part-
nership, there have been numerous studies completed using an SFT lens to under-
stand various aspects of the mental well‐being and treatment of National Guard
soldiers (e.g., Gorman, Blow, Ames, & Reed, 2011Blow et al., 2013; Pfeiffer et al.,
2012). Additionally, studies have been done connecting SFT theories and models for
use in the military (e.g., Blow et al., 2015).
As of now, there are no real distinctions between SFTs with a master’s or doctoral
degree when working in these settings. The US DoD does not distinguish between
SFTs and other behavioral health fields in their job or position descriptions and
classifications (AAMFT, 2018). They do recognize SFTs as behavioral health

professional, and therefore SFTs are eligible for all behavioral health positions within
the DoD and VA. Therefore, SFTs are employable within the DoD, but the DoD
does not fully utilize the unique skill sets of SFTs yet. To this end, since SFTs fall
under the existing job classifications within the VA and DoD system, the experience
level of the professional is a greater differentiator than the actual behavioral health
field. In other words, SFTs can be employed in military settings, but the DoD uses
a grade‐level system ranging from entry level, full performance level nonsupervisory
position, supervisor, program coordinator, and program manager. These grades
are based on years of experience and the ability to fulfill the requirements of the
previous job level. SFTs entering these systems will likely begin at the bottom or
entry level. The longer the SFT maintains an employment or contractual relationship
with the military, the higher up in the grade system they will go. In addition, the VA
will only hire SFTs that have graduated from a COAMFTE‐accredited program
(Veterans Affairs, 2018).
Current training strengths The systemic and ecological worldview of the SFT field
allows SFTs to serve military families within their larger context of military culture.
Through this worldview, SFTs offer standard SFT theories and therapy in the context
of the unique military culture. Also, the relationship orientation SFTs have not only
in their clinical work but also in their relationship to colleagues will help them develop
partnerships with chaplains and higher ups to help service members and their families
receive a greater, more systemic range of care. This skill can also be useful in the devel-
opment of new services and programs. For example, Lloyd and colleagues (2015)
have partnered up with several Navy chaplains to develop the iRelate program. This
premarital and marital enrichment program is a demonstration of the benefits SFTs
can bring to these military settings.
Additional training and skills SFTs with prior military experience, whether it was
short or long term, through marriage, or as a family member would have an advan-
tage in these settings. This personal experience would aid in providing culturally
sensitive services that are truly valued in military settings (Tanielian et al., 2014).
SFTs without this direct experience, as well as those with personal experience,
need to develop a cultural awareness of military and veteran life if they hope to be
effective in these settings. This awareness would allow them to develop a deeper
understanding of the unique family and health experiences. For example, service
members often marry younger, have a higher divorce rate (Lloyd et al., 2015), and
experience higher levels of stress because of frequent relocation and long s eparation
due to trainings or deployments than their civilian counterparts (Karney & Crown,
2007). These factors are unique to the military and require contextual sensitivity.
Furthermore, research indicates that currently 87% of civilian clinicians are not
equipped to meet the unique needs that service members and their families face
(Tanielian et al., 2014).
One way to strengthen one’s cultural awareness is through educational materials
provided by AAMFT. AAMFT has teamed up with the Joining Forces program to
increase resources and training for SFTs working with a military population. These
resources can be found on the Joining Forces AAMFT website (AAMFT, 2018). This
would be a great first step, but also additional coursework and training should be con-
sidered. There are several universities that offer additional courses that pertain to work-
ing directly with military families. These courses add to the SFT’s understanding of the
unique military culture and would enhance the delivery of culturally sensitive care.
Family business settings

Most businesses in the United States and around the world are family owned (FBs).
Nearly 62% of all employees in North America work for an FB (Astrachan & Shanker,
2003). From a household perspective, 10% of all US households own an FB (Heck &
Trent, 1999). Additionally, FBs are subject to heightened levels of relational conflict.
For example, it has been noted that FBs are at a heightened risk for family system
stress and often develop symptoms such as addiction or even physical health problems
(Sund & Smyrnios, 2005), as well as relational conflict (Danes, Reuter, Kwon, &
Doherty, 2002). The unique challenge for FBs comes from three distinct systems
merging together.
FBs can be thought of as three separate systems (the business, family, and owner-
ship systems; Gersick, Davis, Hampton, & Lansberg, 1997) that are interdependent,
making the normal developmental processes of each system more complex. For exam-
ple, first‐generation FBs, led by an entrepreneurial founder, often struggle to have
their business survive on to the second and successive generations (Galvin, Astrachan,
& Green, 2007). From a developmental perspective, this challenge comes from the
misalignment of the family’s development and the business’ development (Gersick
et al., 1997). From a structural point of view, one might question the adaptability and
cohesion of the business and family systems (Tagiuri & Davis, 1982). Or, from an
ecological perspective, the failure to continue through multiple generations might be
due to maladaptive rules and values placed on resources and transfers of resources
across system boundaries (Whiteside & Herz‐Brown, 1991). Regardless, a systemic
understanding of FBs quickly leads to a complex interdependence of multiple systems.
This level of insight is very important and valuable to FB systems as they understand
that their challenges are unique, and as such, they do not often seek out advice from
standard business consultants or family therapist (Distelberg & Castanos, 2012).
Rather they want advice from people they trust, which inherently means that the indi-
vidual understands the unique struggles of operating across the business and family
spheres of life (Distelberg & Schwarz, 2015). In total, a summation of the current FB
research clearly suggests that the largest challenges facing FBs are the challenges that
come from managing the interrelationships between family and business concerns
(Pounder, 2014).
Current activity There has never been a study of the prevalence of SFTs working
with FBs. In addition, SFT work in this area spans many levels of intervention,
making it difficult to measure SFT involvement. Having said this, given the preva-
lence of FBs, it is highly likely that all practicing therapists have encountered indi-
viduals from FBs within their daily practice (Distelberg & Castanos, 2012). Also, as
explained in Distelberg and Castanos (2012), SFTs are also aptly positioned to, and
do, offer services beyond the 50‐min therapy practice. Therefore, they can be seen
providing family conflict resolution, family consultation, developing and facilitating
family meetings or councils, offering business consultation, strategic planning, and
psychoeducational services for family and nonfamily employees. Furthermore, there
is a strong history of SFT involvement in FB research. Since the late 1990s, there
has been a significant growth in the writing and research around FBs. For example,
today there are three dedicated academic journals (e.g., Family Business Review,
Journal of Family Business Management, and Journal of Family Business Strategy).
These are multidisciplinary journals that publish only FB‐related empirical studies
and critical reviews. For the most part these voices and reviews are coming from
business and management fields, although seminal voices from the SFT field can be
found in these publications from time to time (e.g., Danes et al., 2002; Distelberg
& Sorenson, 2009; Stafford, Duncan, Danes, & Winter, 1999; Whiteside & Herz‐
Brown, 1991; Zody, Sprenkle, MacDermid, & Schrank, 2006). In all these cases the
SFT theorist/researcher is attempting to highlight the interdependence of the fam-
ily systems within the larger business systems through an application of a general
systems theory.
Conversely, there has been a more robust discussion of clinical implications of FBs
from the SFT perspective in non‐FB specific journals. Specific to the field of SFT, the
Journal of Marital and Family Therapy (JMFT) dedicated a special issue for FB work
in May of 2012. Including this issue, JMFT has published over six FB specific articles
and dozens of related empirical studies. Similarly, the journal Contemporary Family
Therapy has published a few FB specific articles. No other SFT specific journals have
published family business‐related articles that we know of. Of these articles, most
center on translating the FB experience to the clinical realm. For example, Danes and
Morgan (2004) wrote about how FBs can be seen and treated through the lens of
emotion‐focused therapy. Rarely do these articles focus in a detailed way on a specific
issue and the recommended course of therapeutic action. This is interesting as there
is likely a significant overlap between FBs and typical issues seen in the therapy room.
For example, Sund and Smyrnios (2005) suggest that addiction and marital dissolu-
tion are likely high in FB populations. Distelberg and Castanos (2012) also hint
toward a relationship between addiction and FB stress. Yet, these specific therapy
issues are never illuminated in distinct articles, and as such, the connection between a
therapy population and FBs may go unnoticed by the therapist and the larger field.
Current training and strengths Currently SFTs receive little to no direct train-
ing for this work. In Castanos’s (2009) Delphi study of SFTs engaged in FB
work, there is no direct FB training happening within SFT institutes or schools.
Yet, as noted by Distelberg and Castanos (2012), the typical general systems
training within SFT schools can be a great starting point. This is a commonly
echoed point made by many SFTs, as well as other general systems grounded
family practitioners (Benningfield & Davis, 2005; Borwick, 1986; Boverie, 1991;
Danes & Morgan, 2004).
Although core elements of general systems do transfer to this work, the level and
type of training and knowledge required follows directly with the level of intervention
and focus of the work. For example, Distelberg and Castanos (2012) use the Levels
of Family Influence model developed by Doherty (1985) to illustrate the varying
types of skills and trainings that would be necessary for SFTs. In this article the levels
of FB work are organized on a continuum from therapist–consultant–expert. At the
family therapy level, it is suggested that the standard general systems training will suf-
fice, as long as the therapist works from an expanded direct treatment lens. In other
words, the therapist assesses for and brings in other family members, specifically indi-
viduals as well as interdependent patterns or processes that expand beyond the indi-
vidual present in the therapy room.
SFTs possess a unique ability to meet the needs with FB systems as they are complex
interdependent and nested systems (Whiteside & Herz‐Brown, 1991). The FB field
itself is explicitly asking for more help from skilled professionals that understand the
family system in relationship to extra‐interdependent ecosystems (Dyer & Dyer,
2009).
Several SFT authors have illustrated the multidimensional benefit of SFT with FBs
(Boverie, 1991). For example, Borwick (1986) states: “The family therapist utilizing
a systems approach has a reservoir of knowledge and skills that is greatly needed and
can add immeasurably to the effectiveness of business organizations” (p. 440). Also,
many of the SFT founding leaders came from FB backgrounds. For example, Salvador
Minuchin is the most notable FB protégé and suggests his structural functional theory
was greatly influenced by his upbringing (Lansberg, 1992). SFT systems theorists have
also been adapted to FB work. For example, the concepts of flexibility, adaptation,
cohesion, and interdependence were quickly presented and integrated into the FB
field (Tagiuri & Davis, 1982). Multidimensional and ecologically nested supra‐systems
were also fully embraced by the FB field (Whiteside & Herz‐Brown, 1991). More
recently, scholars have begun to integrate existing SFT theories such as Bowen, struc-
tural functional theory, family lifespan development, and emotion‐focused therapy
(Distelberg & Castanos, 2012).
Additional training and skills While it is possible for all SFTs to work with FB
systems, certain unique skills and experiences will likely give some SFTs an advantage.
For example, SFTs that come from FB systems themselves will likely have an advan-
tage due to the shared culture of FBs and the level of trust that will be afforded to
this therapist. FBs are notoriously private when it comes to family issues and chal-
lenges. Similarly, there is a larger portion of FBs that prefer to ignore or at least
downplay their status as a “family” business, choosing rather to look like a traditional
or professional business (Distelberg & Blow, 2011; Distelberg & Sorenson, 2009).
Because of this they often do not easily accept “outsiders” into the larger FB system,
especially those that want to work across the family–business boundaries. To be
afforded this possibility, the key stakeholders in the family and business will have
to trust the SFT. This relationship building is a strength of SFT training, but the
uniqueness of the business system should be understood by the SFT if they hope to
achieve this level of trust.
Additionally, experience in business management is a valuable resource. For much of
the same reasons noted above, this level of shared experience can gain trust with the
powerful stakeholders in the FB system. But this is also because FB owners respect and
value SFTs who understand the need for the business to maintain certain types and
percentages of ownership, as well as financial and operational processes common with
all businesses. This level of multidimensional understanding will help expedite the rela-
tionship and therefore the change that the SFT can achieve within the larger system.
Moving beyond the traditional forms of clinical practice, as one moves up the levels
of influence, extra training becomes more important. For example, Castanos (2009)
notes the importance of multiple supervisors (not just an SFT supervisor but also
supervisors with FB or business experience). In addition, it is helpful to learn and
acculturate into the worlds of business and organizational systems. Specifically, it is
helpful to be aware of legal issues associated with business ownership and structure, as
well as norms and laws regarding succession and transfers of ownership, even if the
SFT is not working toward succession planning. For example, over 10 years ago, it
became apparent that there was a succession dilemma for FB owners. At that time, it
was noted that less than 30% of FBs survive into a second generation and less than 3%
survive into a fourth generation (Galvin et al., 2007). Given the common value of
transferring wealth within the family generations (Gersick et al., 1997), this “succes-
sion problem” was commonly talked about not only in the empirical literature but
also within the FB networking group worldwide. To date, many FBs not only discuss
succession at length, but these discussions (and processes surrounding the discussion)
are difficult. They often involve lawyers and certified public accountants, bringing in
outside individuals to talk about deeply personal family issues. SFTs can be of help
here, but they would need to enter the conversation with some understanding of
business, wealth ownership, and succession. Specifically, the SFT would benefit from
a familiarity of the language, concepts, and cultures used within business when dis-
cussing ownership and succession. In general, the more the SFT can learn about the
ownership, financial, and operational sides of business, the better.
This extra training might seem daunting due to the fact that there is not, to date, a
singular resource to achieve this level of training and acculturation for SFTs. Yet, it
can be done. For example, reviewing empirical articles within the FB specific and fam-
ily therapy journals is a great starting place to increase one’s understanding regarding
how process, language, and dynamics develop in FB systems. If this step is taken, the
SFT will quickly see parallels to this work and theories they rely on. In addition, many
communities have small business associations, and some even have FB networking or
membership groups. These are great resources to acculturate one’s self into the FB
world. An SFT with business experience (either experience at a managerial level or
higher or a master’s in business administration) will be well served by an integration
of their business and SFT trainings.
Management and administration settings

Management and administration refers to managerial positions in which one would
take on roles such as supervising employees, budgeting, strategic planning, develop-
ing organization policy and procedures, etc. Within the field of SFT, these positions
could be a clinic director, behavioral health manager, or director of clinical services in
various settings such as a community‐based agency, large medical center, school sys-
tem, or residential treatment center. Even in academia, management and administra-
tion roles include a long list of department chairs from the SFT field as well as
researchers who manage large grants. SFTs may also take on management and admin-
istration positions in organizations not directly related to the field as well, including
in government, corporations, or nonprofit organizations.
Recent research looking at effective business leadership, management, and
administration highlights the importance of relational skills in these roles. These
skills, often referred to as soft skills, include interpersonal skills such as teamwork,
communication, conflict management, and the concept of emotional intelligence
(Marques, 2013; Mccallum & O’Connell, 2009; Ritter, Small, Mortimer, & Doll,
2017). Having awareness and being able to recognize and respond to one’s own
emotions and the emotions of others have been found to improve leadership effec-
tiveness, retain employees, increase employee self‐esteem, and quality of employ-
ees (Dust, Rode, Arthaud‐Day, Howes, & Ramaswami, 2018; Edelman & van
Kippenberg, 2018; Miao, Humphrey, & Qian, 2018). Given the importance of
relational skills and emotional knowledge to management and administration
roles, SFTs are well equipped with an important set of skills to be successful in
these roles.
Current activity Although there are no clear reports on the number of SFTs w orking
in management or administrative positions, it is estimated that roughly 10% of
nonstudent SFTs may have managerial or administrative roles (AAMFT, 2012; Harris,
Samford, Mehus, & Zubatsky, 2013). These range from management roles in clinical
organizations and nonclinical organizations. They also include multiple SFTs working
as department heads of academic institutions and within hospital settings. It seems
that as time goes on, the management settings occupied by SFTs become more diverse
and varied (Harris et al., 2013).
Current training and strengths Management and administration roles are

well suited to SFTs with a doctoral‐level degree, especially those whose doctoral
program focused on developing leadership skills in clinical practice (Woolley,
2010). Skills developed in these types of programs include program evaluation,
grant writing, clinic leadership skills (budgeting, management skills, and business
planning skills), organizational assessments, advanced supervision, outcome
evaluations, etc. (Woolley, 2010). Specific COAMFTE‐accredited programs that
seek to teach these types of skills include Alliant’s PsyD in MFT program, Loma
Linda University’s DMFT (Doctorate of Marriage and Family Therapy) program
(Woolley, 2010), and Argosy University. In addition, Nova Southeastern
University and Northcentral University currently offer DMFT programs (e.g.,
not currently COAMFTE accredited, but these schools offer COAMFTE‐accred-
ited family therapy programs and a current non‐COAMFTE‐accredited DMFT
program).
There are a number of strengths that SFTs have that are important in managerial
and administrative roles. Firstly, systems theory is readily translatable to organizations
and useful in understanding relational dynamics among colleagues or departments
and the effects of these dynamics on the overall functioning of the organization.
Secondly, the clinical training of SFTs allows for the development of strong relation-
ships with all parts of a system and the ability to navigate differences and bring oppos-
ing parties together toward a solution. Clinical skills also translate to being comfortable
with assertive communication with employees. Lastly, many SFTs, especially those
trained at the doctoral level, have some training in research, evaluation, or systemic
assessments. Experience in this type of scholarship provides the background needed
to evaluate needs and outcomes, obtain grants, etc., which play a role in determining
which direction to steer an organization.
Additional training and skills Positions in management and administration in any

area require organizational skills, social skills, and a range of leadership skills.
Additionally, obtaining a managerial or administrative position in a behavioral health
setting often requires the experience of a clinical background, advanced supervision
skills, and program development and evaluation skills. Previous experience in manage-
ment and administration would be a strong asset to moving into this type of a posi-
tion, as SFTs are not traditionally trained in business and managerial skills in programs.
Skills such as managing a budget and finances, knowing laws, government policies
and human resources regulations pertaining to having employees, strategic planning,
etc. are all areas where previous experience or additional training would benefit an
SFT. Most shocking is the fact that SFTs typically receive no training in budgets and
human resource policies and laws. This is shocking when we consider that many SFTs
operate their own private practice. In this case we must assume that these SFTs reach
out to their own community for support in developing the legal, financial, and opera-
tional foundations of these practices. It would be very useful for future training pro-
grams to provide access to these knowledge areas.
Although SFTs have many characteristics that are a good fit with managerial and
administrative positions, there are a number of skills needed outside of traditional SFT
training. Master’s‐level SFTs may consider taking a doctoral program or additional
training in program development and evaluation, grant writing, or research to be able
to evaluate outcomes of treatment programs. Additionally, any SFT should consider

additional training in areas of business management such as budgeting, strategic plan-
ning, organizational policies and procedures, supervision, and employee manage-
ment. Although some of these skills may be learned through mentorship from a
colleague, many may require specific training to learn comprehensively.
Government and policy settings (research, practice,

and community programing)
There are several roles that SFTs are qualified for within a government setting.
Positions range from traditional clinical work to research and policy work, and set-
tings can range from working at a county level to federal level. Positions relevant to
SFTs are also housed in a range of government departments or agencies, such as the
Department of Education, Department of Health and Human Services, Department
of Housing and Urban Development, or the Department of Justice. Clinical positions
may include SFT in the title, but are also often inclusive of other psychotherapy pro-
fessions. Other positions, especially research‐based positions well suited to SFTs, are
not labeled as such. These positions have titles such as research analyst, research coor-
dinator, or policy analyst. In addition to working directly for the government or in
policy, there are numerous possibilities for forming partnerships with government
agencies or being able to participate in advocacy efforts related to the populations we
work with or the profession.
Current activity Currently 6,370 SFTs (15.8% of all SFTs) work as a government
employee in the United States (Bureau of Labor Statistics [BLS], 2017). The vast
majority of these positions are at the state government level (73.0%), followed by local
government positions (22.1%). Additionally, these government employment posi-
tions are among the higher paying positions for SFTs (e.g., M = $67,930). These
positions not only include conducting traditional therapy with various populations
but also include roles in management and administration within behavioral health
departments. Also, a small portion of SFTs work in government‐operated hospitals
(n = 200, 0.4% of SFTs nationally).
The majority of work SFTs engage in within the government is squarely within the
standard SFT training, such as providing or supervising therapy and mental health
services. Yet, only a very small percentage of SFTs are engaged in policy and advocacy
(as part of their career and professional work). This is surprising, as AAMFT has pub-
licly stated for years that policy and advocacy is an important aspect of the SFT field
(Rasmussen, 2015). This type of SFT work is increasing, and this is evidenced by a
surge of articles calling SFTs to continue political advocacy work on behalf of clients
and the profession (Goodman, Morgan, Hodgson, & Caldwell, 2018; Jordan &
Seponski, 2017). This work can look like consultation to policy creators or through
policy‐focused research.
Current training and strengths Given the many different roles that SFTs can play
in government and policy, there are different levels of education and training
required. Traditional clinical roles within government behavioral health programs/
departments require the standard SFT training. There are also possibilities at the
master’s level for involvement through political advocacy and participation (Goodman
et al., 2018; Jordan & Seponski, 2017). These political or policy‐oriented positions
demand more extensive training in research and potentially fit SFTs with doctoral
degree training.
SFTs have a unique expertise that can contribute significantly to both clinical
work and policy work in government. Training in systemic thinking, family
systems, and change processes allows for importance consideration for the many
factors and systems involved in providing government services and in the policies
and programs that affect families and individuals. For those involved in policy
work, having a clinical background supports a comprehensive examination of the
policies and systems that impact families. It also allows for practical and relevant
recommendations to be made to policy makers and considers the effects of the
changes on families.
Additional training and skills Working in government, whether in a clinical, policy,

or research role, requires strong interdisciplinary collaboration skills. Being able to
remain grounded in a systemic approach and communicate various aspects of this
worldview is important in doing effective work and having an influence. Additionally,
being open to cross‐disciplinary trainings, communications, and collaborators is criti-
cal to an SFT’s success in these areas. Strong research skills are necessary to working
in an area related to policy. This includes both the ability to conduct research and to
communicate the meaning of the results to mixed audiences. Additionally, any previ-
ous experience in government or policy development would be an asset to being suc-
cessful in a position with government. Especially pertinent would be previous
knowledge and experience with existing policies, their histories, and purpose in the
particular area of interest.
Because working in government and policy is a broad area, different types of addi-
tional training may be needed for particular positions or areas of work. Within clinical
settings, particular departments may offer or recommend training in certain approaches
that they are committed to using with their client populations. These agencies may
also offer trainings in paperwork procedures or policies relevant to their specific area.
To take on research roles or positions related to policy, specific training and an under-
standing of particular policies and programs in the area of interest may be important.
This could include attending various trainings or workshops, consulting with col-
leagues, or an independent study of policies, programs, and laws in the particular area
of interest.
Discussion
Part of the draw to the field of SFT is its’ entrepreneurial history. In the first days of
the field, even before there was an SFT field, a handful of psychiatrists across the
world found a common connection in their desire to expand the practice of psychiatry
beyond the medical model of their training. They desired to explore the role of the
family and larger systems impacting their patients. This entrepreneurial gene is still
part of the SFT field’s identity as evidenced in the exploration and current expansion
of what has now become accepted branches of the SFT field. For example, MedFT
was once a thought held by a few SFTs, and now it boosts entire master’s and doctoral
training programs dedicated to this specific type of practice. The specialty settings
discussed in this chapter have the same characteristics. Each is an area practiced by
relatively few SFTs currently. These SFTs have taken an uncharted pathway in an
effort to live out what SFT theories espouse: to work at systems change within multi-
ple ecological levels and not to be bound to one type of practice, which over time
could feel like a rigid and cut off system in and of itself.
The SFT training, especially training that exhibits the core characteristics of SFT
work, is key to the expanded specialty areas noted above. Therefore, the future of
SFT expansion is dependent on keeping healthy the core elements of SFT training,
specifically the training SFTs receive in regard to ecology. A key element to each
of the past and current expansions is the ecological understanding of the SFT. In
each case, the SFT must understand that the individual (or issues) is interdepend-
ent not only with their immediate family system but also with the systems where
services are received. Similarly, this ecological viewpoint helps the SFT understand
their role in systems that are much larger than an individual service provider. In
this case, SFTs working in military, hospital, and government settings will have to
work as a member of a larger team. They must understand how to not only effect
change in their patients or clients but also effect change in their employment
systems.
SFTs that truly understand this ecological viewpoint will be able to balance their
values for social justice with effective change. SFTs entering any one of the settings
noted above will likely run up against professionals in these systems that do not share
their same values for strength‐based or systemic approaches. For example, in a hospi-
tal setting, it is still common for the medical professionals within these teams to take
a medical view only of a patient, suggesting more or less medication to solve the
problem. These same individuals within the team might also be quick to label patients
as “treatment” resistant when they miss a session or two. This worldview runs counter
to standard training of SFTs. An SFT that truly understands that their role, in part, is
to change the system in which they work will approach these issues with longer‐term
systemic change in mind rather than getting discouraged or believing that these things
within the system are not changeable.
Not unrelated, SFTs are taught to approach their work at the relational level. This
will serve the SFT well in all of the settings mentioned above. It will allow the SFT
to see solutions to problems that have plagued the setting. For example, in hospital
settings, the unique viewpoint of an SFT can help reveal solutions to a case that have
otherwise been unsuccessful, possibly due to familial or social influences surrounding
the cases that had been overlooked up until this point, or in the same setting, finding
and adapting systemically oriented assessment measures to help the hospital system
achieve new regulatory requirements. Over time, these environments will learn the
value of the SFT expanded systems view, but in the beginning this expanded view
might be seen as irrelevant or even ignorant. SFTs entering these systems (as the first
SFT in the system) will have to advocate for these viewpoints. It will take time for the
organization to see the benefits of a general systems orientation. During these transi-
tional times, the SFT will likely be responsible to lead this change. The most effective
way to do this is through a relational approach. The same relational techniques
learned for the therapy room can be useful in creating the larger systems change in
these settings.
Future growth areas for SFT

Although there are many skills and assets that exist within the current SFT training, all
of which are critical to the success of the SFT in these expanded practice areas, there are
skill sets that are not commonly taught to SFTs that would be extremely useful in these
expanded practice areas. First, in each of the areas noted above, the success of the work
is highly reliant on a team and not a singular therapist. This is a major shift for SFTs, as
the majority of SFT training assumes that the therapist will be alone in the therapy room
and will be singularly responsible for the total course of therapy for a given client. This
is not the norm in the areas discussed above. Rather the therapist will need to negotiate
their interventions within a multidisciplinary team. They will need to consider their plan
for change in relationship to the plans that other team members have. The therapist will
also need to be able to explain and argue for their plan of action. More can be done to
train SFT to argue for their theory of change, especially in light of a multidisciplinary
audience. For example, medicine, psychology, nursing, business, etc., all have their own
professional foci. These areas each have their own language and culture. If the SFT can
understand these cultural differences, and differentiate their own work in relationship
to the other professional foci, they will be more effective in their new team.
Furthermore, given that most of these areas are new for SFTs, and there are likely only
a hundred or fewer SFTs practicing in any one of these settings nationally, SFTs will likely
be put in a position where they have to be the face and voice for the entire profession.
This is obviously an unfair position for a new therapist, but a reality. If the individual is
not prepared to explain and present the SFT field identity, and even their own unique
identity or way of practice from this larger imagine, they will likely feel intimidated by this
positioning. If the field can prepare SFTs for this situation, it can be a significant oppor-
tunity for future of the field. For example, this individual SFT will have carved a pathway
in this new setting, which will allow future SFTs an easier road to follow. Teaching SFTs
about their identity and the field’s identity prior to going off into these areas will help
support this situation. Conversely, these first‐generations SFTs most hold this identity
with humility. Oftentimes we are taught that not only is our systemic training different
from other fields but also superior. This is a dangerous message to carry into a multidis-
ciplinary team. Rather, we should be able to identity our unique strengths in relationship
to the other field’s strengths and ultimately help other fields see the benefits of systemic
training from a collaborative position and not one of superiority.
Additionally, as noted before, these settings carry unique cultures, inclusive of
unique norms, language, and traditions. If an SFT can be exposed to, or even master,
these cultures prior to entering these areas, not only they will be able to communi-
cate more effectively, but they will also be able to overcome entrance barriers quicker.
For example, in a hospital‐based setting, SFTs will quickly be confronted with a fast
paced and hierarchical culture. If the SFT is not prepared for this, they might feel
intimidated or even inferior to other team members. In this same system, there are
norms such as charting, electronic medical records, and pathways of communication
and decision processes. All of these cultural artifacts take time to learn and can be
significant barriers to the work until mastered. The same is true for working in mili-
tary settings such as the VA where there are language norms and hierarchies need to
be understood. If these norms and cultures are not mastered, the individual can
encounter embarrassing missteps. The same is true in working as a consultant to an
FB or working in government settings.
Regardless of the setting, there is a great need to help SFTs understand the finan-
cial, legal, and operational issues associated with the business side of SFT practice.
Regardless of whether we are talking about SFTs that engage in private practice or
those that go into these specialty settings, it is fair to say that the standard SFT train-
ing model lacks significantly in teaching SFTs the business side of our work. At the
very least, master’s‐level SFTs should be exposed to knowledge sources for finance,
operations, human resources, and legal resources related to the creation of a practice
or in regard to larger organizations in which they might work and someday raise to
the level of management. For doctoral‐level training, there should be even greater
emphasis on these issues. These trainings should be inclusive of managing or leader-
ship in a business/organization, as well as focused on learning how to financially and
operationally manage grants. Without this training our next generation of SFT will be
at a significant disadvantage to their competitors.
Finally, none of these settings operate like what is assumed in regulatory training
requirements (e.g., COAMFTE or state licensure clinical hour requirement stand-
ards). Therefore, students in these settings usually have to do additional work to meet
their school or licensing requirements. In all reality, an SFT in these settings might far
exceed the spirit of regulatory hours requirements, but because the work is not always
structured in the definition of “direct client contact hours,” the individual might not
be able to count these experiences toward their training or licensure goals. Given the
current passion and entrepreneurial nature of the current wave of SFTs within these
specialty settings, they are likely to take on the challenge of this additional work and
training. But as time goes on, and more cohorts of students engage in these settings,
these students will begin to see that the clinical hour ratios and definitions do not fit
their work well. When this happens, these second‐ and third‐generation cohorts are
likely to demand some modification to the standard assumption of a 50‐min hr with
10 min of documentation used at the school and licensure levels.
In conclusion, SFTs have always looked for ways to expand SFT practice beyond
one definable job class or description. SFT by nature seeks to have a systemic impact
in multiple ways and at multiple ecological levels of a system. Therefore it is not sur-
prising to see SFTs continuing to find new ways to work as an SFT. SFT as a discipline
and worldview offer many important core strengths, which allow SFTs to thrive in
these new ventures. Therefore, this is not a new trend but one that has been a core
component of the field and should be fostered. In addition, this trend should be con-
sidered within training programs. Within these programs students should be encour-
aged to seek out innovative ways of practice. Over time, these areas may coalesce into
specialty practice much like MedFT has done to date. If the SFT supports these
growths into specialty settings, we will see an expansion of the field in regard to the
number of student training as SFTs as well as the field’s impact on the larger world.
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31
Integration of New Technologies
in Assessment, Research,
and Treatment Delivery
Richard J. Bischoff, Paul R. Springer, and
Nathan C. Taylor
Technology has become part and parcel of mental health‐care practice. Technology
facilitates client intake procedures and assessment and is used throughout treatment
to provide both therapists and clients with feedback about progress. It allows clients
and therapists to monitor relational, biological, emotional, and psychological
functioning. It supports record keeping and collaboration. It facilitates provider–
client communication, and in some cases, it is the delivery medium of assessment,
treatment, training, and supervision. Technology can be, and often is, integrated into
every aspect of mental health‐care practice.
Technology, at least in developed countries, is ubiquitous. Because it is integrated
into every aspect of our lives, and the lives of our clients, the potential for its use in
mental health care is unlimited. It may be that it is used by many therapists who do not
even realize that in using it they are doing something nontraditional. The examples of
how technology can be integrated into mental health treatment are many and varied,
so much so that it would be impossible to create an exhaustive list. Limiting this list to
technologies that have been documented in the scholarly literature or subjected to
research scrutiny is more manageable. However, limiting the list to only those that
have documented use in systemic family therapy would make for a very brief chapter.
But limiting our discussion to only those technologies that have been documented
would not allow us to dream and to be creative and innovative. When it comes to using
technology in systemic family therapy, what is needed is creativity and innovation.
Acceptance and Effectiveness of Integrating

Technology in Practice
Researchers have looked at both the acceptability of the use of technology in mental
health practice and the effectiveness of its use. In case you want to skip to the next
section, essentially the research indicates that the use of technology is associated with
706 Richard J. Bischoff, Paul R. Springer, and Nathan C. Taylor
favorable treatment outcomes, and the use of technology is generally well received.
About the latter, acceptability of technology is usually higher among clients than it
is among providers, a nuance that has implications for advancements in treatment
delivery because, generally, it is the therapist, not the client, who decides how and
when technology is integrated into treatment.
Acceptability of the use of technology in treatment

Whereas effectiveness has to do with whether or not an intervention is helpful,
acceptability has to do with whether or not it will be used. An effective intervention
does little good if providers and clients reject it or otherwise will not use it because
they do not see it as acceptable (Todd, Jones, & Lobban, 2013). Acceptability is
influenced by the degree of fit the intervention has with what is expected, familiar, or
customary, or what is thought to be reasonable, or best practice, or what fits within
cultural or religious mores.
Research has found various technologies acceptable by both clients and therapists
in mental health treatment (e.g., Naslund, Marsh, McHugo & Bartels, 2015). In
general, clients report high levels of satisfaction and acceptance for the use of advanced
technology, such as videoconferencing, in mental health practice (Backhaus et al.,
2012). Providers also deem the use of technology as acceptable, but, in general, not
to the same degree as clients. For example, Ertelt et al. (2011) found that therapists
reported that the use of videoconferencing negatively affected their ability to provide
treatment. This was true for their perceived ability to use therapeutic techniques,
achieve therapeutic rapport, and achieve therapeutic goals. Their clients, however,
reported no such concerns. It could be that the reduced ratings were due to unfamili-
arity with the use of the technology as a way of delivering treatment, for these same
researchers found that provider acceptance improved with greater experience.
While research finds that the use of technology, in general, is more acceptable to
clients than to therapists, some clients find the use of technology in psychotherapy
unacceptable. The lead author remembers one client who, when he learned of the
integration of technology in treatment, responded, “No. That’s bizarre.” When inte-
grating technology into treatment, it is important to meet the client where they are at.
In our own work (Bischoff, Springer, & Taylor, 2017), we have found that one of
the challenges to acceptability has to do with the reliability that the technology will
work as expected. We are confident that most, if not all, of us have attended a work-
shop or presentation that started late or was interrupted because the presenter could
not get the technology to work as expected. In some cases this is a minor inconven-
ience for the participants and presenter. In other cases, it is something that causes
distress for the presenter and interrupts the learning for the participants. This happens
in therapy as well. We have been in situations where videoconferencing therapy ses-
sions started late because of connectivity problems, or, where the technology just
stopped working sometime in the session, interrupting the flow of treatment. Some
of these problems are the result of human error (e.g., clients not knowing how to turn
on the video or audio) or the result of the technology not functioning as expected
(e.g., poor bandwidth). One or two instances like this are bearable. But when it
becomes a repeated occurrence, frustration sets in. We have had clients drop out, and
therapists pine for non‐technology‐aided options.
Integration of New Technologies 707
We have also found that concerns about confidentiality are barriers to the acceptability
of delivering psychotherapy via videoconferencing. As hardware and Internet connec-
tivity became more sophisticated, we resisted transitioning from our cable‐connected
system because we did not see affordable software options that would provide enough
security to be able to protect the confidentiality of transmitted audio and visual data.
Skype was (and still is not) a secure enough platform to be able to protect client
confidentiality. Other software options either were too expensive or had similar problems
with security. Consequently, we resisted until secure and affordable options became
available. We brought a level of knowledge to bear that allowed us to ask informed
questions and eventually alleviate concerns. Clients, however, may not know what

questions to ask and, consequently, may be left with concerns about whether or not
someone may be able to tap into their conversations with their therapist or access
information about what they are addressing in therapy.
On the same note, we are also concerned that therapists and supervisors often lack
the knowledge to ensure the security of the technology they are using. Too often,
therapists and supervisors may assume that this data is secure, because the platform is
popular or other therapists are using it in their practice. As we talk to therapists around
the world about this at conferences and workshops, many disclose utilizing Skype,
Google Hangout, and other popular platforms for therapy and supervision despite the
fact that these are not secure platforms. This is not just an anecdotal claim; research
conducted by Gassova and Werner‐Wilson (2018) found that 42% of marriage and
family therapists (MFTs) conducting tele‐mental health utilize a software that does
not meet official US standards for data security.
Effectiveness of the use of technology in treatment

The use of technology has been found to be effective in improving mental health
outcomes for a variety of disorders and populations (Backhaus et al., 2012; Hilty
et al., 2013). The effectiveness of technologies such as biofeedback, videoconferenc-
ing, mobile technologies, self‐help applications and web‐based interventions, physical
movement tracking devices, virtual reality, and video games are discussed in greater
detail later in the chapter.
The rapid growth in technological advancements poses a bit of a challenge for
researchers attempting to study effectiveness. It takes so long to conduct a high‐qual-
ity investigation of the effectiveness of a technology that newer, more sophisticated
versions of the technology are typically available before the results of the study are
published. The “cutting‐edge” technology that we are reading about in the research
literature is likely not cutting edge when we are reading about it. An example of this
is the use of videoconferencing as a treatment delivery medium, which is referred to
as telehealth. Telehealth is far from novel or cutting edge. Videoconferencing has
been used as a mental health‐care treatment delivery medium since the 1950s.
However, research on its effectiveness has only been published recently, and much of
that research is about the effectiveness of variations in this technology that is consid-
ered antiquated today. However, we can still draw conclusions and assume that
advancements in the technology would only result in increased effectiveness. About
telehealth, it has been found to be effective in the treatment of disorders such as
depression (Fortney et al., 2013), obsessive–compulsive disorder (Himle et al., 2006),
panic disorders (Bouchard et al., 2004), eating disorders (Mitchell et al., 2008), and
posttraumatic stress disorders (Yuen et al., 2015). Many therapists are using it to work
with couples and families (Gassova & Werner‐Wilson, 2018); however literature
reporting research on its effectiveness in treating couple and family problems is scant
to nonexistent.
Using Technology in Systemic Family Therapy
We acknowledge, again, that we are not providing an exhaustive list of the technolo-
gies that are, or can be, used in systemic family therapy. We may not even be provid-
ing an exhaustive list of those that have been documented in the literature. We have
prioritized those technologies that have been subjected to research scrutiny and to
those that we think have the most promise for being integrated in practical and
impactful ways.
We also acknowledge that technology is expensive. Even inexpensive movement
tracking devices (e.g., Fitbit) and smartphones run in the hundreds of dollars.
Computers, videoconferencing equipment, and biofeedback systems, to name a few,
can be very expensive and as a result limit its utilization in clinical practices. Many of
these costs are shouldered by providers or cash‐strapped mental health‐care agencies
that may not be able to afford the latest technologies. Many of the examples we
present below require clients to possess a technological device or a technology‐related
service (e.g., Internet access) that they often cannot afford or otherwise have access
to. This is particularly true for cutting‐edge technologies. It could be that integrating
technology into treatment to the point where the provider or the treatment relies on
it could increase the gap in access to high‐quality mental health care between the
resource rich and the resource poor. We think that technology’s greatest potential is
in reducing mental health‐care disparities, but we also recognize that, depending on
how it is integrated into treatment, it could actually increase them. Clinicians should
balance the cost and benefit of integrating technology into practice. However, learn-
ing about the potential of even the least accessible technology options can stimulate
ideas for less expensive options that could achieve similar results, thus reducing the
widening gaps in mental health‐care disparities.
Videoconferencing
Of all the advanced technologies, the one that has gotten the most attention in the
literature is videoconferencing. Videoconferencing can be the medium of treatment
delivery or an adjunct to traditional face‐to‐face treatment delivery options. Its ben-
efits include increasing access to care, cost efficiency, and the ability to provide conti-
nuity in follow‐up care (Lexcen, Hawk, Herrick, & Blank, 2006; Ruskin et al., 2004).
It has been found to be equally effective as face‐to‐face‐provided treatments for anxi-
ety, depression, posttraumatic stress disorder (PTSD), and anger problems (Dunstan
& Tooth, 2012; Greene et al., 2010). We have not been able to find research attesting
to its effectiveness in systemic family therapy.
The first mention of using videoconferencing in the literature is in 1961 (Wittson,
Affleck, & Johnson, 1961). Psychiatrists from the University of Nebraska Medical
Center described their use of videoconferencing to provide mental health treatment

to individuals in rural and remote areas of the state of Nebraska. The system that they
were using at the time was unreliable and very expensive, and consequently, continu-
ing to use the treatment medium was unsustainable. It was not until the late 1990s/
early 2000s that the technology and connectivity became sophisticated enough that it
could be reliably used as a mental health treatment medium. The technology has
continued to get more sophisticated, easier to use, less expensive, and more accessible.
We are at a point now where anyone with a computer or smartphone could have
access to sophisticated, secure, easy‐to‐use videoconferencing options.
As a practical example, family therapy clinicians and researchers at the University of
Nebraska–Lincoln have been using videoconferencing as a primary mental health
treatment delivery medium since 2001, when, like those at the University of Nebraska
Medical Center in the late 1950s, we recognized that a technology existed that would
allow us to address mental health‐care disparities for those living in rural and remote
areas of Nebraska. At that time, our end‐user sites were rural high schools. Widespread
Internet access did not exist at that time, and we had so many concerns about being
able to protect the confidentiality of our work with clients, that we used the secure
fiber network that was maintained by Nebraska Public Television and the network of
Educational Service Units throughout the state. While we were able to provide treat-
ment to residents in the far reaches of the state with confidence that we were able to
have a secure connection that would protect client confidentiality, scheduling was
problematic because we had to avoid times when the system was being used by others
at the end‐user sites (the places where our clients were located when they received a
treatment session through videoconferencing).
In 2008, we received a grant from the US Department of Agriculture/National
Institute of Food and Agriculture (USDA/NIFA) that allowed us to upgrade to the
newest technology and to develop a model of tele‐mental health that partners with
local medical providers. Our end‐user sites shifted to rural medical clinics, and because
software that could protect the confidentiality of our work with clients had become
more affordable, we began using the Internet to support videoconferencing. We are
currently working with colleagues in Brazil, where our treatment delivery model is
being used with great success (Springer et al., 2018). Like in the United States, our
end‐user sites in Brazil are rural medical clinics. Through our first 10 completed client
cases, there has not been a single dropout and all 10 have reported satisfaction with
the treatment delivery medium and achievement of therapeutic goals.
We have found that videoconferencing is an acceptable treatment delivery medium
for clients, therapists, and collaborating medical providers. Clients and collaborating
medical providers see it as an indispensable resource for their rural communities. We
have also found it to be effective in that the rate of premature termination of treat-
ment is low and the treatment outcomes are good, although we have not yet com-
pared videoconferencing outcomes to face‐to‐face treatment outcomes.
Mobile technologies
Advances in computing power are accelerating at breakneck speeds. The computing
power that is now contained in a handheld device is greater than that of early com-
puters costing millions of dollars and that were big enough to fill a room. Even 15,
10, or 5 years ago, the most powerful personal computers did not have as much
computing power as can be packed into a modern smartphone. Combining these

portable computing devices, advances in battery technology, and widespread mobile
connectivity has resulted in a transformation of how people around the world engage
with technology, access information, and communicate with one another.
Mobile technologies are the most widely available advanced technology worldwide.
The iPhone is the most popular smartphone worldwide. It is sobering to recognize
that while the first smartphone was developed by IBM in 1992, the first iPhone was
not released for purchase until June 2007, slightly more than just 10 years ago! Just
10 years after the release of the iPhone, in June of 2017, the worldwide mobile indus-
try signed up its 5 billionth user (GSMA, June 13, 2017). This is particularly impres-
sive given that the worldwide population is currently slightly more than 7.5 billion
(US Census Bureau, 2018). In North America, about 80% of the population are
mobile subscribers, which is slightly behind the worldwide leader, Europe, with a
subscriber rate equaling 86% of the population (GSMA, 2017).
Because of the proliferation of mobile technology, these technologies are well
positioned to support health and mental health care. The use of mobile technology to
support health care is referred to as mobile health or “mHealth” (Tucker, 2015). The
purpose of mHealth is to provide medical and mental health patients with wireless
access to medical and mental health information and the ability to transmit, aggregate,
and store information about their health and mental health status. It also allows them
to share real‐time and aggregated information about their health and mental health
with others, including providers and family members. mHealth is currently the most
promising technology strategy for overcoming care disparities and improving health/
mental health outcomes (World Health Organization, 2011). Reflecting the promising
nature of this technology to health care, mHealth is currently a primary funding
priority area in every US federal agency providing funding for health and mental
health research.
To be considered mHealth, the device must be portable and allow the user to access
and/or transmit information wirelessly. mHealth technology includes smartphones,
smart clothing, physical movement tracking devices (e.g., Fitbit, Garmin, Jawbone,
Nike), and other devices that track information about health status (e.g., continuous
blood pressure tracking, handheld EEG, pulse oximeter, smart hearing aids). As is
true for other technologies, mHealth is far more advanced in the physical health arena
than in the mental health arena; however, that need not be the case.
Because mHealth may provide the opportunity to share data about one’s status
with family members, it could be that mHealth has particular utility in systemic family
therapy. Whether it be steps, sleep, exercise, food intake, weight loss, blood pressure,
or stress reactivity, personal data can be made available to family members and provid-
ers in a way that can be used to support family treatment.
mHealth could also be used in systemic family therapy to provide just‐in‐time
information to family members as they are dealing with tasks or activities between
treatment sessions. Or it could be used to provide information about skills and
strategies that could be implemented or practiced at home. Our team at the
University of Nebraska–Lincoln is working with medical and mental health pro-
viders in Brazil to develop an mHealth initiative in which community health
workers will receive guidance about how to address mental health issues in those
they are working with. This guidance will be provided through a web‐based appli-
cation that can be downloaded onto their mobile device and accessed while they
are meeting with families within their jurisdiction. Through this mHealth
intervention, community health workers will be able to effectively screen and
assess patients for common mental health problems such as depression and anxi-
ety and direct them to evidenced‐based interventions. Depending on severity of
the problem and capabilities of the patient, these interventions (such as CBT or
mindfulness interventions) can be delivered face‐to‐face or through a mobile
device such as a smart phone. The community health workers will be trained to
explain and assist patients in practicing the interventions, and they can also be
“dropped” into the patient’s personal mobile devices for them to practice and
implement while in their home.
Biofeedback
John Gottman (1999) identified three important parameters for intervention when
working with couples: perceptual framing and attitudes, interactive behavior,
and physiology. While he was specifically discussing work with couples, these three
parameters apply to any relational context, including work with families and individu-
als. Attention to the first two, interactive behavior and perceptual framing and
attitudes, are the special sauce of systemic family therapy. Systemic therapists assess for
these dynamics and they are the targets of intervention. This is what sets the systemic
therapist apart from every other mental health‐care provider. However, physiology—
the biological processes involved in relational functioning—is less well understood
among systemic therapists and less likely to be assessed or targeted in intervention
(Kassel & LeMay, 2015).
Technology has made it easier to assess biological process and to incorporate this
feedback into treatment in ways that improve mental health outcomes. The word
biofeedback refers to the process of using technology to monitor physiology in a way
that clients are able to receive real‐time feedback about their physiological state. The
feedback helps clients make adjustments in real time about what they are doing or
thinking that will result in changes in their physiological experience (Frank, Khorshid,
Kiffer, Moravec, & McKee, 2010). Biofeedback is based on the assumption, verified
through research, that there is an inexorable multidirectional influence between one’s
physiological, emotional, cognitive, behavioral, and interactional experiences.
Physiological experience influences our thinking, feeling, behaving, and interacting
states and is influenced by these states.
Some may remember the mood rings that were popular in the 1970s. These are
essentially unsophisticated (and unreliable) biofeedback tools. Fortunately, more
sophisticated and practical technologies exist that provide both direct and indirect
feedback on physiological functioning. Modern biofeedback technologies are
more valid (i.e., they measure what we want them to measure), reliable (i.e., they
are consistent), accessible (e.g., cost‐effective, intuitive), and acceptable (e.g.,
worn outside of session without detection, paired with smartphones) than ever
before.
Biofeedback is effective. It is most often used in the treatment of anxiety‐related
disorders, such as general anxiety disorder, PTSD, panic disorder, and phobia
(Schoenberg & David, 2014). It is also effective for a myriad of other mental
health problems, such as depression (Beckham, Greene, & Meltzer‐Brody, 2013),
eating disorders (Teufel et al., 2013), and attention deficit with hyperactive
isorder (Gonzales‐Castro, Cueli, Rodriguez, Garcia, & Alvarez, 2016). Because

d
physiological functioning and management of one’s physiological reactivity is
associated with relationship functioning (Seedall & Wampler, 2012; Taylor,
Seedall, Robinson, & Bradford, 2017), there is great potential for the use of bio-
feedback to contribute to positive and sustainable client outcomes in systemic
family therapy, and it is already being used regularly in couple therapy (J. M.
Gottman, 1999).
One of the benefits of biofeedback is it can help clients recognize and manage
physiological reactivity in difficult interpersonal situations (Yucha & Montgomery,
2008). For example, inexpensive pulse oximeters, fitted with alarms, have been used
with couples to signal “emotional flooding” when the heart rate exceeds 80 beats per
minute (J. Gottman & Gottman, 2017). This threshold has been identified as a point
in which physiological functioning affects one’s ability to stay engaged in emotional
problem solving. The alarm signals the need to take a break and regulate emotions
before reengaging in discussion and problem solving. Similar but more expensive uses
of biofeedback include the use of heart rate monitors applied to children in family
treatment settings to help them recognize internal physiological states and to aid
parents and providers in making connections between behavior and physiological
arousal (McHugh, Dawson, Scrafton, & Asen, 2010).
Biofeedback need not be limited to the therapy room. There are devices that can
be worn as clients go about their daily activities, allowing them to receive feedback
in real time and practice monitoring and regulation behaviors. For example, product
development researchers at Microsoft, in collaboration with researchers at Stanford
University, developed a prototype of a wearable biofeedback device, called
MoodWings, that would provide real‐time stress‐level feedback to the wearer
(MacLean, Roseway, & Czerwinski, 2013). It is activated by using inexpensive
wearable sensors that monitor electrodermal activity and is monitored by the user
through something that looks like a butterfly worn on the wrist. The device was
found to help wearers perform better during stressful situations than non‐wearers.
Other similar wearable devices are also in development or are being marketed (e.g.,
smart garments). While using many of these devices may be impractical in anything
but controlled situations, the implications of this technology to systemic family
therapy are great. Having a device that would allow one to be able to monitor one’s
physiological responses during stressful interpersonal situations may not result in
one’s ability to diffuse the stress or even the physiological reaction to the stress, but
may allow the person to respond with greater interpersonal competence, thus avoid-
ing the likelihood of attachment injury.
Cost of biofeedback devices vary greatly from the very inexpensive (e.g., biodots or
stress dots, which are small stickers that can be placed on the skin to provide feedback
about physiological reactivity to stress) to the very expensive (e.g., an electrocardio-
gram that measures heart beats). Smart garments, clothing that includes embedded
sensors and an onboard computer processor that can provide biofeedback, is a tech-
nology that is currently being used to improve athletic performance. It is possible that
this technology could be used in mental health care as well. This technology could
provide clients with an unobtrusive mechanism for ongoing feedback about their
physiological functioning. With biofeedback devices becoming cost‐effective and
increasing evidence base supporting its use, biofeedback is a valuable technological
tool with vast clinical implications to systemic family therapy.
Self‐help applications and web‐based interventions

There is clearly a desire for online self‐help resources among both the clinical and
nonclinical populations. The number of self‐help health applications focused on
mental health has rapidly increased. These include sophisticated applications that
provide comprehensive structured programs that teach skills and provide self‐help
interventions along with feedback about progress (Georgia & Doss, 2013). These
are prepackaged, automated self‐help programs that are not provider directed. They
are mobile application and web‐based self‐help programs designed to target a broad
range of psychological disorders and vary in design and functionality. They span
prevention, diagnosis, self‐ and provider‐assisted treatment, and posttreatment
follow‐up care (Chandrashekar, 2018). Studies show that they are considered

acceptable by users and effective for the self‐help treatment of mild‐to‐moderate
depression, anxiety, relational distress, and intimate partner violence (Braithwaite &
Fincham, 2011; Christensen, Batterham, & Calear, 2014).
Self‐help apps and web‐based programs are appealing because they are inexpensive,
accessible, and self‐administered and can be done without anyone other than the user
knowing it (Cicila, Georgia, & Doss, 2014). Although self‐help, they can be more
engaging and interactive than a book, providing automated prompts and information
that can be tailored to the person’s condition, frequency of use, and progress. Like
mHealth tools, the technology allows for information to be synced and shared
with other users, so it is well positioned to be able to address couple and relationship
problems in systemic ways.
Examples of automated programs online or in app form that address relationships
include Prevention and Relationship Enhancement (PREP) (www.prepinc.com),
Power of Two Online (www.poweroftwomarriage.com), and OurRelationship
(https://www.ourrelationship.com). These online programs provide interactive
videos and activities to assist clients in improving their relationship. They are well
designed, educational, and entertaining. Other automated web‐based apps or
programs are also focused on specific topics such as interventions aimed at reducing
anxiety and increasing social support for spouses of alcoholics (Osilla, Trail, Pedersen,
Gore, Tolpadi, & Rodriquez, 2018) or emphasizing principles of cognitive‐behavior
therapy to manage depression, generalized anxiety, and seasonal affective disorder
(Titov et al., 2015).
Given the popularity of self‐help and the accessibility of web‐based and mobile app
self‐help programs, systemic therapists could capitalize on the existence of these tech-
nologies to extend the impact of the mental health treatment they provide. Doss et al.
(2017) refer to this as a blended intervention, one that pairs a web‐ or app‐based
automated resource with traditional mental health treatment. Systemic therapists
would do well to familiarize themselves with the apps and web‐based treatments that
can be utilized in a blended way. These could include any of a number of apps or
online meditation, mindfulness, activity tracking, relationship enhancement, or other
resources that are readily accessible to clients. Because of the popularity of these tech-
nologies and the self‐help movement, therapists may want to make it part of their
standard assessment protocol to ask clients if they have downloaded apps, visited
websites, or done online programs to help with self or relationship improvement. Be
aware that clients may not associate all web‐ or app‐based self‐improvement programs
with the problems that are causing them to seek therapy, so asking them about all
self‐help apps or web‐based programs they may have used will allow the therapist to
make connections to capitalize on client self‐help efforts.
Physical movement tracking devices

An area receiving more attention, especially among behaviorally based therapists, is
the use of physical movement tracking technology. These wearable devices marketed
by companies such as Fitbit, Apple, Garmin, Jawbone, and Nike are now available
through smartphone apps. While these devices can be considered mobile technology,
they deserve separate consideration because they can easily be integrated into mental
health treatment and have great potential for systemic family therapy in particular. For
example, these technologies can be used for mental and behavioral health assessment
such as tracking sleep and daily physical exercise. Clients can use the apps and web‐
based programs that are used for tracking movement to also track daily food intake.
Physical movement tracking can also encourage more physical activity among indi-
viduals and families, enhance accountability, increase family communication, and
encourage connection. Studies have shown that when mental health patients use
movement tracking devices in intentional and therapeutic ways, the user benefits from
increased social support, self‐awareness, accountability, and physical activity (Naslund,
Aschbrenner, & Bartels, 2016; Ng, Reddy, Zalta, & Schueller, 2018). Therapists
practicing systemic family therapy can encourage the use of these devices to enhance
the social connectivity among families that can lead to improved relationships. It can
also provide families with opportunities to develop shared interests and to stay
connected throughout the day. Clinicians can more effectively integrate the use of
wearable devices in treatment by clearly describing the purpose of the device, aiding
clients in interpreting the data, and maintaining a strong therapeutic relationship
(Ng et al. 2018).
On the Horizon
Some technologies are, as yet, underdeveloped for use in psychotherapy in general

and systemic family therapy in particular. However, we think that there is promise for
these technologies to be developed in a way that their use in therapy will help achieve
goals of greater access, higher‐quality treatment, and improved client outcomes.
Video games
Present in the literature are examples of how to use client interest in video games to
strengthen family relationships (Curtis, Phenix, Munoz, & Hertlein, 2017), recre-
ate home situations similar to an enactment (Jordan, 2014), and explore clients’
views of themselves (Earl, 2018). While not a nascent technology, there have not
been many video games developed specifically for mental health treatment. However,
in recent years, entrepreneuring researchers and game developers at Griffith
University in Australia have partnered to develop prototypes of a game called
Rumble’s Quest (Realwell, 2018) to assess childhood psychosocial well‐being (Taylor
et al., 2018). They have tested the game’s ability to measure psychosocial well‐being
in two samples, totaling over 8000 school‐age children, and have found the game
to be both reliable and valid. The game assesses psychosocial well‐being through
measures of attachment to schools, emotional and behavioral self‐regulation, social
confidence, supportive relationships, and executive skills. While the game is designed
to be used in schools, it shows the potential for using this or similar video games in
mental and behavioral health treatment.
An example of how a video game has been used in therapy is provided by Brezinka
(2014), who used a video game called Treasure Hunt to support cognitive‐behavioral
therapy in children. The author found that therapists who used this game found it
helpful to explain therapy concepts, enhance child motivation, structure therapy
sessions, strengthen the therapeutic relationship, and reinforce concepts addressed in
therapy.
Because of their interactive quality and appeal, video games have great potential to
be used to accomplish therapeutic outcomes with children and adolescents (Curtis
et al., 2017). But can they be used in family treatment? The answer is yes. Parents and
siblings could utilize gaming as a tool or intervention to encourage more involvement
from a disengaged family member (Earl, 2018). While we are not aware of multiplayer
psychotherapeutic video games, the potential for developing this kind of games is
great. Already there exist video games on the market that could be adapted and used
in systemic family therapy. While many popular video games are competitive, there are
also many popular multiplayer cooperative games on the market, games in which
multiple players need to work together to win or accomplish the purposes of the
game. For example, the popular League of Legends is an online game in which multiple
players take on characters with unique abilities or powers and unique weaknesses.
Players must rely on other characters’ strengths to compensate for their weaknesses
and must work together to survive. It is easy to see how these kinds of games could
facilitate communication and problem solving and how therapists could help translate
the experience with cooperative action in the video game to non‐video game interac-
tions that family members have with one another.
Virtual reality
While virtual reality (referred to in the virtual reality industry as “VR”) technology
has been around since before the invention of digital technology, virtual reality has
exploded in the past decade. The most advanced virtual reality technology today can
create sensations in the user that so closely matches what the person would have in the
physical world that users are unable to distinguish the virtual from the physical
(Freeman et al., 2017). Virtual reality works by blocking out visual stimuli from the
natural world and stimulating our vision with video presented at an incredibly high
frame rate, a comparable refresh rate, and a 100° to 180° field of view (https://www.
khanacademy.org/partner‐content/mit‐k12/eng‐and‐electronics/v/mit‐explains‐
how‐does‐virtual‐reality‐work). This simulates senses in a way that tricks the user’s
mind into interpreting the virtual stimuli as though it is physical stimuli. High‐quality
virtual reality feels just like the real thing.
Over the past two decades, advances in virtual reality technology have allowed it
to be used in the assessment and treatment of medical and mental health disorders
(Srivastava, Das, & Chaudhury, 2014). Virtual reality in the mental health field has
been used to assess and treat anxiety disorders, schizophrenia, substance‐related
disorders, psychosis, and eating disorders (Bidaki & Mousavi, 2018; L. Valmaggia,
2017; L. R. Valmaggia, Latif, Kempton, & Rus‐Calafell, 2016). That said, the
technology is new enough and expensive enough that it is not yet widely used in
clinical settings. When it is used, it is most commonly used to treat anxiety disor-
ders. In these cases, clinicians use virtual environments to expose patients to stress-
ors so that they can assess and implement cognitive‐based interventions to minimize
the reaction to the stressor. This is an in vivo treatment in a virtual world.
Recently, virtual reality has been used to treat PTSD in military personnel or veter-
ans. One example of this is “Bravemind,” which was developed by the Institute for
Creative Technologies at the University of Southern California and funded by the
Department of Defense in 2005 (see http://medvr.ict.usc.edu/projects/bravemind).
Bravemind accurately recreated a war zone to activate “extinction learning,” which
can deactivate deep‐seated fight‐or‐flight responses (Rizzo, Hartholt, Grimani, Leeds,
& Liewer, 2014). With advances in technology over the past decade, Bravemind is
now sophisticated enough to insert minute details of the patient’s incident, and the
therapist can go replay specific scenes that are more likely to activate the client in par-
ticular ways and intervene at those times when the client’s PTSD symptoms are being
activated by virtual reality sensations.
Virtual reality has also been used to treat addiction by helping addicts in recovery
to develop coping strategies as they role‐play scenarios in virtual reality bars, crack
houses, and shooting galleries. These types of virtual situations can help clients learn
to resist and to develop coping skills. Research has found that virtual reality scenarios
can induce cravings in patients so that the therapists can work with them to identify
their triggers and prepare them for when these situations arise in reality (Hone‐
Blanchet, Wensing, & Fecteau, 2014).
As is true with other forms of technology, recent cost‐effective smartphone appli-
cations with virtual reality technology has increased the access to and utility of this
technology. However, to date, virtual reality is mostly about the individual experi-
ence and not about the interactions among family members or couples. With contin-
ued development, this technology has promise for impact on the practice of systemic
family therapy. For example, we can envision a future in which individuals are placed
in a virtual reality simulation of couple or family interactions that triggers physiologi-
cal and emotional reactivity that sets the person on a pathway leading to either a
negative or positive outcome. Given this is happening in a controlled environment
but feeling as though it is really happening, therapists could use these scenarios to
help clients manage their emotional and cognitive functioning to self soothe. Pairing
virtual reality with biofeedback could make for a very powerful intervention. Virtual
reality could be used to address anger, domestic violence, parenting, and couple
conflict, to name a few.
Voice assistant and smart speaker technology

While voice assistant technology dates back to the 1960s, it was not until June of 2015
that Amazon introduced the Amazon Echo, making it possible for the voice assistant/
smart speaker to be mass‐produced for home use. As we entered the calendar year
2018, slightly two and a half years later, 47.3 million adults living in the United States
had access to a smart speaker in their home (https://techcrunch.com/2018/03/07/47‐3‐
million‐u‐s‐adults‐have‐access‐to‐a‐smart‐speaker‐report‐says). That is about 20% of
the US population! Interestingly, when nonowners are polled, it is not the cost that is
being identified as the primary reason why they do not have one; it is concerns about
privacy (https://www.businessinsider.com/amazon‐google‐apple‐major‐hurdle‐grow‐
smart‐speaker‐market‐2018‐7). With the Amazon Echo and the Google Home devices
leading the way and Apple now getting into the market, smart speakers are getting
smarter and more capable. We are confident that proliferation will continue to increase
as these, and similar devices, become more integrated into homes and lifestyles.
We do not know of anyone who is using smart speakers to accomplish therapeutic
goals. However, we can envision a time, in the not‐too‐distant future, when smart
speakers will be able to be used in a way that extends the impact of treatment. Users
can already create lists or set reminders or access health and mental health information
or other material that could help with meditation and encouragement. Could there
come a time where these devices could be tailored to the individual’s preferences
enough that they could access mental, behavioral, and relational health information
and programming? We think so.
Artificial intelligence
Artificial intelligence (AI) is a branch of computer science in which machines
(e.g., computers) can function intelligently and independently. Sophisticated AI is
effective at image and pattern recognition, memory function, and problem
solving. When paired with robotics, AI can learn to perform physical tasks with
precision, accuracy, and reliability.
A common example is the speech recognition software that is empowered through
AI technology. This software learns a person’s voice and is able to differentiate it from
others. AI is why there can be multiple users of a smart speaker and one of those users
can ask for help finding their phone or in creating a shopping list without having to
state their name. Another common example is the face recognition software that is
installed on many photo management/editing programs.
Currently, AI is one of the most rapidly advancing technologies. In the medical
field, AI technology is increasing accuracy and efficiency of diagnosis and improving
treatment planning. It is also reducing health‐care disparities. For example, AI‐
empowered imaging programs are being used in developing countries, where there
are few radiologists, to read chest X‐rays to screen for tuberculosis and are doing so
with comparable accuracy to human counterparts. We do not know of comparable
uses in of AI in the mental health fields. However, with advancements in AI, it is
possible that in the near future we could see applications of this technology that
could improve mental, behavioral, and relational health assessment, diagnosis, and
treatment.
Borrowing from other disciplines

Many of the technologies that are used in mental health care have been developed
for or were first used in other disciplines. If we look only inside of the mental health
disciplines, we will be missing potential opportunities for technologies that can
have potential to improve mental health practice and client outcomes. Let us not
overlook education as one of those disciplines where there have been quite a few
advancements in how technology can be used for more desirable educational
utcomes. Many of these advances are transferable to the mental health field in
o
general and systemic family therapy in particular. For example, Swivl (www.swivl.
com) markets a device that facilitates teacher reflective practice through video
recording and playback of their teaching and software that allows the teacher and
others to insert reflective comments into the recording. The device is a tabletop
cradle for smartphones or t ablets through which the teacher can record audio and
video of their teaching. The device tracks the movement within the classroom and
moves the smartphone or tablet so that the video capture follows the teacher (the
movement).
We think that there are implications for the use of this or similar devices for experi-
ential systemic family therapies that have clients move throughout the room. Our
experience of using stationary cameras in these situations frequently results in action
within the therapy room happening outside the view of the camera. The device pairs
with software that allows for the insertion of reflective comments (voice and written)
that are time‐stamped to the point in the video that correspond to the comment.
Multiple viewers can insert comments, thereby commenting on both the video and
one another’s comments. This technology has obvious implications for training and
supervision. It also has implications for practice. For example, therapists could video
record client experiential interactions using this device and then could allow them to
watch the video and record their reflections on their experience of themselves and one
another directly to the video. This could be used in place of or in addition to the
standard practice of debriefing with clients immediately after the experiential activity.
Using this technology in ways similar to this could likely enhance the impact of the
experiential intervention.
Technological Innovations in Training and Supervision
Technological innovations have enhanced clinical training and supervision. Historically,

audio–video recording of couple and family interactions facilitated the development
of couple and family therapy (Liddle & Halpin, 1978; Perlmutter, Loeb, Gumpert,
O’Hara, & Higbie, 1967). Coding of couple and family interactions is now a com-
mon research practice and has led to important breakthroughs in knowledge related
to family interactions patterns (e.g., J. M. Gottman & Tabares, 2018; Oka, Whiting,
& Reifman, 2015). Audio and video recording of sessions is a long‐standing best
practice strategy for training and supervision in systemic family therapy (Nichols,
Nichols, & Hardy, 1990), and in many cases it has also been used as an important
intervention in therapy, the effectiveness of which has been documented through
research. For example, Wiener (2015) found that showing video clips of sessions to
parents, couples, and families helped individuals see their role in parent–child interac-
tions or maladaptive relational patterns.
Today, the technological development with the greatest impact on student training
and clinical supervision is the increasing accessibility of videoconferencing
(Rousmaniere, 2014). Videoconferencing software has been used for both “synchro-
nous e‐learning” and “online supervision” (Rousmaniere, Abbass, Frederickson,
Henning, &Taubner, 2014; Weingardt, Cucciare, Bellotti, & Lai, 2009) and has
transformed both the educational system and the way people receive supervision.
With advancements in technology that allow for the distance delivery of coursework
and supervision, there has been a proliferation of online clinical training programs.
Students can now choose from well over 100 online clinical training programs. Many
of these provide training in systemic family therapy, although only a very small num-
ber are accredited by the Commission on Accreditation for Marriage and Family
Therapy.
Synchronous e‐learning includes tools that can be used to deliver educational pro-
grams in real time. These include tools such as videoconferencing, conference calls,
and instant messaging. These tools allow students and teachers to participate in class
“in real time” by asking and answering questions and in facilitating group conversa-
tions despite the fact that students may be participating in another location. The
benefit of synchronous learning is that it enables students to avoid feelings of isolation
and helps them receive many of the same benefits of traditional on‐campus learning
environments. Asynchronous e‐learning includes tools that allow students to engage
with material, their instructors, and one another as their schedules allow. These
include coursework, activities, and communications that are delivered via web‐based
classroom learning environments. Many programs blend both synchronous and
asynchronous technologies and strategies. Using technology to deliver clinical train-
ing online has opened the door for clinical training to individuals who otherwise
would not be able to complete a qualifying degree, thereby expanding the mental
health workforce.
Advances in Internet connectivity and hardware have also resulted in greater access
to continuing education programming. This is good news for those wanting to
promote and use best practices in systemic family therapy. The reality is systemic
family therapy skills need to be refreshed with information about current develop-
ments in the field and training opportunities. Many therapists live at a distance from
post‐degree trainers and those providing continuing education. The use of technol-
ogy to deliver this programming saves therapists and trainers time and expense.
Research suggests that high‐quality education delivered online is just as effective as
high‐quality education delivered face‐to‐face (Weingardt et al., 2009; Weingardt,
Villafranca, & Levin, 2006). While research about the effectiveness of online clinical
training is currently underdeveloped, we believe that high‐quality training can be
provided online.
Simulation‐based to virtual simulation‐based learning

Simulation‐based learning has been the gold standard for assessing student out-
comes and has been applied to many different disciplines and trainees. These expe-
riences are often immersive in nature and evoke or replicate real‐world experiences.
For example, in the medical field, full‐body mannequin simulators have been used
since the 1960s to train medical professionals in how to treat patients. Other simu-
lation‐based learning followed the model of the Objective Structured Clinical
Examination (OSCE) where actors are hired to present specific medical or mental
health conditions, allowing the trainee to demonstrate effective use of clinical skills.
We have used OSCEs in our master’s degree marriage and family therapy program
and how they can be used in systemic family therapy training has been documented
(Miller, 2010).
While simulation‐based experiential learning is a technique and not a technology

(Lateef, 2010), advances in technology are allowing simulations to appear closer to
what one might experience in real‐life practice. Advances in technology have now
expanded ways in which technology‐assisted software can facilitate student learning
and skill development. When technology is used in this way, it is referred to as vir-
tual simulation‐based learning. For example, in medicine, virtual patient simulations
are increasingly preferred for teaching medical procedures over the use of actors,
because the technology is so advanced that it can be done in a way that creates a
sense of realism for the learner without the complications of using a living subject
(Meakim et al., 2013). Studies have shown that virtual patient simulations are com-
parable or superior to other simulation methods for teaching diagnostic reasoning
and assessment skills (Duff, Miller, & Bruce, 2016). It also allows students to prac-
tice and repeat procedures as needed at their own pace while receiving timely and
immediate feedback (Gesundheit et al., 2009). This can increase provider confi-
dence and proficiency.
While we are not aware of any virtual simulation‐based learning being used in sys-
temic family therapy, there is potential for this to happen. For example, advances in
technology that have resulted in more realistic‐appearing avatars and game characters
and virtual reality technology, to name just two, could be used to create virtual simu-
lations to aid training and assessment of clinical skills.
Clinical supervision
Many of the technologies mentioned above could be or are used in supervision. We
will discuss only the role of videoconferencing here. Videoconferencing in supervision
was originally adopted to increase accessibility for clinicians living in rural areas
(Pomini, Akalestou, Thomaras, & Charalabaki, 2016). This allowed provisionally
licensed individuals practicing in rural and remote areas to continue to receive quality
supervision. It also helped to guard against professional isolation. We have continued
to see a significant increase in the use of videoconferencing for supervision in the rural
and urban regions of the United States and around the world. Whether the motiva-
tion is to increase access, bridge distance, increase convenience, or receive specialized
training by an expert living in another geographical location (Abbass et al., 2011),
what is clear is that this medium is becoming a common form of supervision
practice.
The body of research on videoconferencing and supervision has for the most part
been positive. In one of the earliest studies on videoconferencing and supervision,
Sorlie, Gammon, Bergvik, and Sexton (1999) found that videoconferencing was
equally effective as in‐person sessions for communication and maintaining the super-
visory working alliance. What was most interesting is that while this modality initially
caused more anxiety for supervisees, it also forced them to prepare for supervision
better. More recent research has shown that a mixed in‐person and videoconferencing
sessions, called blended training, had better outcomes than those who just received
in‐person training (Conn, Roberts, & Powell, 2009). Additional studies (Panos,
2005; Reese et al., 2009; Xavier, Shepherd, & Goldstein, 2007) have found strong
support for videoconferencing‐based supervision on ratings of supervisory working
alliance, trainee satisfaction, and trainee self‐efficacy, compared with in‐person group
supervision formats.
A promising innovation is remote live supervision (RLS) in which supervisors watch

live sessions remotely (Rousmaniere, 2014). RLS opens the door for how and when
supervision can be offered. It provides the supervisor, the therapist, and the clients
more flexibility in scheduling and makes it easier to track clinical progress. Rousmaniere
and Frederickson (2013) found RLS to be effective for advanced postgraduate training
in a very specific short‐term therapy approach.
Conclusion
Throughout this chapter we have highlighted the limitless potential technology has in
the application of the mental health field and with SFT specifically. Technology
will continue to play a more central role in our clinical practice, and systemic family
therapists would do well to develop greater competencies in the technologies that are
available. We have seen that often problems arise in the application of technology
because troubleshooting knowledge extends beyond the skill set of the practitioner.
The integration of technology into training programs can mitigate some of these chal-
lenges and would be an important step in facilitating greater acceptance of technology
among systemic family therapists. This is particularly important as technological skills
need to be adapted as new technologies emerge and existing technologies change.
It is equally important that systemic family therapists demand more technological
innovations that can improve research and clinical practice for couples and family
therapy. Too often innovations are developed with only the “individual” end user in
mind. This has led to a dearth of systemic technologies created with the specific inten-
tion of increasing couple or familial communication and connection in a therapeutic
context. Despite this, there is much to be excited about, as new innovations in tech-
nologies are transforming the ways in which we assess, research, and deliver systemic
family therapy. To harness the potential of these technologies, we must continue to
have an eye on the technology horizon and be innovative and creative in how we
utilize technology into practice.
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Part VI
Future Directions
32
The Importance of Policy
and Advocacy in Systemic
Family Therapy
Jennifer Hodgson and Angela L. Lamson*
*Equal authors.
Policies are a series of plans used as a basis for decision making that can either
cohere or divide communities; they have the capacity to set a society onto a
beneficial or sometimes alarming trajectory. Regardless of individual opinions on
policies, they are essential to stimulating change, enforcing boundaries to protect
and define, and allocating rights and privileges. The field of systemic family therapy
is no stranger to the benefits and challenges of policy. For years, systemic family
therapists have been arguing for their right to care for populations insured through
Medicare, establish and protect their licenses, and advance family‐centered policies
(Goodman, Morgan, Hodgson, & Caldwell, 2018). As a result, changes in policies
at the governmental levels have led to important changes advancing and protecting
our profession. This chapter will discuss some of these advancements as well as (a)
highlight the significant role that policy and advocacy play in our profession, (b)
offer specific examples of advocacy successes, (c) punctuate areas where future
growth in the profession is needed, and (d) identify how policy and advocacy can
help. However, before one can start to think about ways to be a better advocate
and initiate policies where needed, it is important that they appreciate the four
worlds that drive change in one’s profession: clinical, operational, financial, and
training.
The four‐world view

In 2008, C.J. Peek designed a conceptual understanding of four worlds for successfully
integrating behavioral health into any healthcare context: (a) clinical, (b) operational,
(c) financial, and (d) training. He argued that each was critical and necessary to attend
to when initiating any changes in healthcare practices. If not executed systemically,
change is not likely sustainable. He went so far as to say that if any one of these
“worlds” takes precedence over the others, the entire system will fail. While Peek
primarily focused on behavioral health providers in healthcare practices, Hodgson,
730 Jennifer Hodgson and Angela L. Lamson
Lamson, Mendenhall, and Crane (2014) assert that these worlds are meaningful for
systemic family therapists in any work context.
The clinical world is where direct client care takes place. It is where providers,
such as family therapists, creatively design models and approaches that help
promote change with individuals, couples, families, and other larger systems.
However, the best clinical protocols are only as successful as the operational systems
that support them. Without a strong front and back of house staff, health records
system, workflow pattern, set of office procedures, and administrative structure,
most operational systems will fade and fold. Operational systems provide the
structure and support that allow clinical and financial processes to succeed.
The third world is one that commonly promotes the most stress for practice
settings, the financial world. This is the world where therapists are asked to convert
what their heart and mind do freely into something that is financially sustainable.
One may have the greatest clinical idea on how to treat a biological, psychological,
social, and/or spiritual issue; however, if one does not understand how to make it
reimbursable and sustainable, the greatest idea will not survive. This world is ever
changing, based on billing codes according to workplace contexts (e.g., private
practice, versus agency or healthcare setting) and target populations (e.g., severe
mental illness versus dual diagnosis), but is also influenced by state and federal
decisions on the value of mental health screening, diagnoses, and treatment. Peek
also introduced a hidden fourth world: training. He recognized that the fourth
world is important in educational settings, but we argue that it is important
anywhere change is being introduced. This world is where family therapists spend
important time taking courses, attending continuing education classes or
conferences, receiving supervision and mentorship, and gaining professional
competency. Globally, bodies have been working to establish core competencies for
general setting systemic therapists (e.g., American Association for Marriage and
Family Therapy [AAMFT], 2004; Stratton, Reibstein, Lask, Singh, & Asen, 2011),
as well as systemic therapists practicing in specialized settings (e.g., healthcare;
American Association for Marriage and Family Therapy [AAMFT], 2018).
The awareness and inclusion of all four worlds, simultaneously, leads to the
greatest gains and most efficient processes for the future of systemic family
therapy. In particular, these four worlds offer an essential interweaving that
should guide the writing and implementation of policy changes for the profession.
Writing policy or advocating for a change in one world affects the other worlds,
so it is best to consider, plan for, and be prepared to answer questions about
those effects.
To learn the art and science behind policy creation, implementation, and
dissemination, systemic family therapists will need to first understand that policy
making does not have to be an intimidating process and that one voice can
make a difference. No matter if the policy is for a specific work context or
whether it is a necessar y change at the local, state, federal/provincial, or
other governmental level, systemic family therapists must rise up as advocates,
ambassadors, and champions for larger systems change. Their work may include
advocating for specific policy change(s) on behalf of the profession, client
population(s), licensure entitlements, job opportunities, and/or billing/
reimbursement capacity.
Family Therapy Advocacy 731
Role of systems theory

Systems thinking is central to the field of family therapy and pivotal to the success of
policy and advocacy. Imber‐Black (1988) argued that family therapists have invaluable
systemic skills when intervening in the therapy room, but struggle with applying it
outside the “therapy walls.” Perhaps fearful to make a misstep, be at a loss for words,
or deal with the rejection from politicians and people with different points of view,
family therapists may feel that they have less control over the dynamics outside of their
offices and defer to others they perceive as possessing these skills. However, no one
possesses greater skills and has more convincing stories than those in the trenches
doing the work. Politicians appreciate stories—not stories that break confidentiality or
that are filled with references to pithy research, but stories that capture the heart of
change while also promoting the importance of family‐centered policies and
treatments.
According to Goodman et al. (2018), advocacy is broadly defined as “working
with larger systems to promote the interests of the family therapy profession, and
the clients and communities we serve” (p. 33). Through this definition, they
endorsed that family therapists have the ability not only to advocate for their
profession but also to engage in policy advocacy, public system advocacy, social
activism, and social justice. Systemic family therapists must take any advocacy
opportunities they are given to elevate the health of all people and not just those
who can afford services. Entities such as the US‐based National Quality Forum’s
National Priorities Partnership (NPP) exist to advance family‐centered and socially
responsible care by “honoring each individual patient and family, offering voice,
control, choice, skills in self‐care, and total transparency, and adapting readily to
individual and family circumstances, as well as differing cultures, languages, and
social backgrounds” (National Priorities Partnership [NPP], 2010). A policy
change reflecting socially responsible systemic values might involve establishing
Medicare‐funded family therapy clinics in underserved areas that would not only
elevate the health of marginalized families but would also change the way the
referral system operates, the allocation of funds disseminated, and the training
necessary for serving these populations clinically, as well as submitting claims and
documenting services accurately.
As noted previously with the four‐world view (Peek, 2008), when there is a
recommended change in one part of the system, the other parts should be evaluated
and supported with adequate adjustments and adaptations. Applying systemic thinking
to policy would include asking and answering questions such as the following: Whose
job duties would change if this intervention was implemented? How would family
therapists be trained to provide the intervention? What would reimbursement look
like for this intervention? What evidence supports that this is a culturally relevant
intervention for the population served? These questions are often left unasked or
unanswered unless someone trained in family therapy with strong systemic thinking
skills steps up to advocate. A lexicon is provided below to assist with the first steps
toward understanding the language associated with policy making and advocacy.
While the examples below are common to US systems, it is important to note that
every country/government has its own unique policies and lexicon associated with
policy making and advocacy.
Policy and advocacy lexicon

Entering into the arena of policy and advocacy requires one to become familiar with
a different language. Knowledge of keywords and communication tools will help pre-
pare family therapists for disseminating critical policy‐related research and facts at the
clinical, operational, financial, and training levels. The main tools include policy briefs,
white papers, and fact sheets. However, policy think tanks or public advocacy groups
may also use full policy reports, letters to the editor/opinion pieces, and weekly or
daily policy news updates to help disseminate knowledge about a specific and desired
legislative action (DeRigne, 2011).
What is a policy brief? Policy briefs are one vehicle for communicating policy
information to a nonacademic audience, such as advocates and legislators (Shin &
Jones, 2014). They are written to create a sense of urgency, so the reader is engaged
and propelled into action on an issue (Patton, Sawiki, & Clark, 2012). Generally
1–2 pages (700–1500 words maximum), they contain critical facts written to
communicate a position on a specific issue. They may include one or more graphics
and often have an engaging design. According to DeRigne (2011), policy briefs
typically include “title of legislation, background on the social problem the policy
is directed at, s ponsors of the bill, summary of the legislation, status of the bill, and
the preparer’s recommendations for what the outcome should be (e.g., passage,
amendments)” (p. 229).
There are two types of policy briefs: advocacy and objective (Food and Agriculture
Organization of the United Nations [FAO], 2011). An advocacy brief argues in favor
of a particular course of action, whereas an objective brief presents a balanced argu-
ment addressing all positions, so the reader can decide for themselves. Regardless of
type, it is important that policy briefs are concisely written and help readers to under-
stand the clinical, operational, financial, and/or training issues enough to make a
decision about it. They must include facts grounded in valid and reliable research
from reputable sources. Ultimately, they are written to suggest a course of action or
key policy options (Young & Quinn, 2017).
Writers of policy briefs want to steer clear of using professional jargon and special-
ized terminology that only one’s profession will understand. The words used should
be relatable to the nonspecialized audience; in fact, the most cited obstacle for imple-
menting policies is the lack of scientific understanding by policy makers (Jones &
Walsh, 2008). Synthesizing empirical findings into translatable information is a skill.
The writer wants to demonstrate how to apply the research outcomes rather than
present them in their raw form (i.e., this is not a research manuscript), leaving the
reader to infer what they mean. Graphs, charts, and other visual aids are strongly sug-
gested as they aid the reader in quickly reviewing the information and forming an
opinion. The “Women’s and Children’s Health Policy Center” hosts a wealth of
material and tips for effectively constructing a policy brief: https://www.jhsph.edu/
research/centers‐and‐institutes/womens‐and‐childrens‐health‐policy‐center/de/
policy_brief/index.html. For a variety of examples related to health, policy briefs are
consistently posted through Health Affairs at https://www.healthaffairs.org/briefs.
Oftentimes, after a legislator has read one’s policy brief, they will request a full policy
report. This is a more in‐depth report containing more information and a detailed
description of the issue/proposed legislation. Important to note, policy briefs may
also incorporate other sources of information, such as white papers and grey litera-
ture. According to Shin and Jones (2014), this helps to fill in the gaps from the aca-
demic research and in some instances provides more current and relevant
information.
What are white papers and grey/green literature? White papers, designated by the US
government, received their name to be identifiable as written for public access. They
range in length from 2 to 100 pages, but average 6 to 8 pages in length. They are
non‐peer‐reviewed papers, typically written by US government officials, businesses, or
organizations to offer innovative solutions to a problem (Shin & Jones, 2014).
Audience members would likely seek out a white paper because they need solutions to
address a specific therapy problem or concern for a target population. An effective
white paper may be published and disseminated and then revised (as needed in future
months or years) in order to refresh the content to support the most present
concerns. Unlike policy briefs, white papers are not commonly vibrant with color, but
instead fact‐filled with the intent to persuade the audience through innovative statis-
tics that support the usefulness of a solution, service, or methodology. Some readers
may wonder how a white paper differs from a peer‐reviewed journal article; one dif-
ference may be in the primary audience of the white paper (e.g., systemic family
therapy advocates, decision makers, managers, and financial recommenders) versus a
journal article (e.g., academics, students, practitioners, and researchers). Furthermore,
unlike articles that reside in respected journals, white papers are typically disseminated
through websites and emails, mentioned in blogs or press releases, and given to influ-
ential decision makers. All in all, systemic family therapists can create white papers to
highlight expertise in the field that can then influence policy makers, managers,
and executive‐level champions by offering research‐informed solutions to complex
relational and health issues.
Examples of white papers may be found widely. A few healthcare‐related sites
that publish white papers include Humana (https://www.humana.com/about/
innovation/healthcare‐white‐papers), Agency for Healthcare Research and Quality
(https://www.ahrq.gov/professionals/systems/primary‐care/workforce‐financing/
white‐paper.html), and the Institute for Healthcare Improvement (http://www.ihi.
org/resources/Pages/IHIWhitePapers/default.aspx). Commonalities across exam-
ples involve leading with an executive summary, presenting study findings in nonspe-
cialized language, knowing the intended audience, being brief and concise,
highlighting problems and suited solutions, focusing on benefits of taking action, and
being realistic about potential outcomes.
Grey literature, or green papers in the United Kingdom, refers to unpublished or
informally published studies and reports that are thought to be less methodologically
rigorous (e.g., Pappas & Williams, 2011; Roth, 2010; Seymour, 2010). However,
Bellefontaine and Lee (2014) found in their meta‐analysis that there were no signifi-
cant differences between published and unpublished studies in terms of methodologi-
cal quality. Grey literature documents tend to be brief and the content’s shelf life is
commonly short‐lived. These types of documents may include a report on preliminary
findings, a discussion paper, or conference proceedings. A systemic family therapist
may choose to construct and disseminate grey literature if current surveys or pilot
data offered compelling information that may influence a policy maker, financial
officer, or administrator. Systemic family therapists can learn more about grey litera-
ture through an international organization known as GreyNet International (http://

www.greynet.org/home.html).
What is a fact sheet? A fact sheet is a one‐ to two‐page document that is written to
inform, persuade, and/or educate for a particular course of action. Writers should
refrain from using technical language, long sentences, or paragraphs. Information is
more often presented in bulleted form guiding the reader’s eyes from basic facts to
logical conclusions and a call to action. According to the Colorado Nonprofit
Association (2018), well‐written fact sheets include four key components: (a) basic
definition(s), (b) basic statistics, (c) basic information, and (d) an organized conclusion
encouraging the reader toward a specific action. Examples of fact sheets may be found
by visiting the following: the American Association for Marriage and Family Therapy
(https://www.aamft.org/AAMFT/ADVANCE_the_Profession/Federal/Advocacy/
Federal.aspx?hkey=096a44cc‐f107‐4166‐b588‐f121ed5131aa), American Public Health
Association (https://www.apha.org/publications‐and‐periodicals/fact‐sheets), and
Agency for Healthcare Research and Quality (https://www.ahrq.gov/research/
findings/factsheets/index.html).
Systemic family therapists may use fact sheets both for educating policy makers and
for providing current information to clients, collaborators, and champions of the pro-
fession. For example, systemic family therapists may develop a fact sheet in relation to
a targeted diagnosis and describe key facts related to the diagnosis, who is most at risk
for the diagnosis, risk factors, symptoms, prevention, and treatment options. A fact
sheet then affords an opportunity to display emerging priorities related to the area of
focus. This segment can help systemic family therapists in punctuating the key role of
relationships, relational health, and relational therapy.
What is the role of social media? Letters to the editor, opinion pieces, and weekly/
daily updates via social media outlets are other effective methods for disseminating
information and mobilizing larger groups of people. These written options are
commonly placed in respected journals, on organizational websites, or in commu-
nity newspapers or submitted to widely viewed social or news media sites. Social
media has changed the way information is distributed. Using social media can be a
great way to mobilize constituents quickly when critical legislation is appearing
before a legislative committee. For example, North Carolina led a massive public
school education rally of 19 000 constituents outside the legislative building on
May 16, 2018. In 1 week, they secured a day off for teachers and students to be
able to attend; designed, printed, and distributed T‐shirts; and arranged paid buses
to transport advocates to the event. It was orchestrated mainly through social
media. This demonstrates how a well‐timed and promoted event can reach the
masses in a short period of time using social media.
Systemic family therapists can tune into or seek to join think tanks such as the
RAND Corporation (https://www.rand.org), Brookings Institution (https://www.
brookings.edu), and the Urban Institute (https://www.urban.org), which provide
valuable tools, resources, and examples for policy and advocacy work geared toward
influencing public opinion and policy. These think tanks offer examples of policies and
documents from reputable sources that demonstrate the use of effective and persua-
sive communication tools. While some systemic family therapists may feel intimidated
by writing a policy brief or white paper, following the work published through a think
tank should be a reasonable way to engage in current policy trends and advocacy. An
important aim is that every systemic family therapist finds a place in the advocacy
continuum.
Advocacy continuum
How systemic family therapists engage in advocacy work may differ according to
one’s strengths, interests, experience, and subject matter expertise. The “advocacy
continuum for family therapists” was designed by Goodman et al. (2018) and features
the various ways that engagement can occur, ranging from activism to litigation (see
Figure 32.1). Typically, those starting out will begin on the left of the continuum with
activism. They first will get involved in their communities/professional interest groups
and learn more about the issues that are of a personal and/or professional interest.
This is oftentimes where one may establish their political identity, join relevant organi-
zations, attend information sessions, offer to speak formally or informally about a
topic of interest, and write for blogs or newsletters.
Next is the advocacy level. Here, one may choose to write letters, make phone calls,
and make speeches at local, state, national, and/or international levels. It may include
contributing funds to a person/organization that is advancing the cause and/or pre-
paring policy briefs, white papers, and fact sheets. Family therapists may want to join
the AAMFT Family TEAM (https://networks.aamft.org/familyteam/home) and
engage in advocacy efforts through this collective community of diverse AAMFT
members. Family TEAM represents the interests of marriage and family therapists
related to federal and state/provincial legislative activities.
The third level is lobbying. There are two main forms of lobbying associated with
the advocacy level, inside and outside lobbying. Inside lobbying may take place where
local, state, and federal government offices are located. Meetings may be scheduled in
advance with the legislators, legislative assistants, or the legislator’s chief of staff to
discuss critical issues and present well‐written policy briefs, white papers, and/or fact
sheets. After these meetings, some legislators and staffers may request a full policy
report if it is an issue that they are particularly interested in supporting. Larger organi-
zations will have lobbyists employed with them or on retainer. These lobbyists help
monitor the state registrar and any legislative actions that other interest groups are
taking that may impact one’s field. They will then meet with the legislators and advise
the membership on how to address the issues of concern. Outside lobbying may
include mobilizing citizens to take action on an issue, as well as holding meetings
and/or publishing in all sorts of venues so a diverse network of citizens is educated
about issues that impact their health and well‐being.
Lastly, advocacy may include litigation. The litigation level is designed to stop insti-
tutions, oppressive policies, and individuals from causing intended or unintended
harm. Litigation is typically initiated when all other advocacy steps have failed to affect
the desired change. One instance where litigation was instrumental occurred in 2017.
The Texas Association for Marriage and Family Therapy (TAMFT) defeated the Texas
Medical Association’s attempt to halt MFTs rights to diagnose (American Association
for Marriage and Family Therapy [AAMFT], 2017; Appeal from the 53rd Judicial
District Court of Travis County, Texas, 2013). The legal battle was fought for 8 years
and ended when the Texas Supreme Court overturned a lower court decision. There
were many collaborators who helped the TAMFT along the way, setting a precedent
Activism–action taken to determine and let others know your position about a cause
Advocacy – disseminating information about a cause with the intent to influence or persuade
others
Lobbying – advocacy work that targets specific
*Establish political identity legislation
*Be open to and engage in Litigation – lawsuits filed
*Write letters and make phone against institutions and others
reading and learning about the
calls/speeches to local, state,
issues on all sides, not just *Inside/direct lobbying–visit
national, and global
yours your state and national
leaders/groups *Typically used when all other
*Search out local and online legislators and/or their staffers
*Contribute funds to previously attempted
groups that are working on to share your thoughts and
organizations that are working advocacy methods fail
similar issues or concerns and ideas
to advance your political and
volunteer your time: *Outside lobbying–mobilizing
professional interests
*Hand out informational citizens to pressure public
*Identify an issue and join
flyers officials to adopt, change, or
forces with others to bring vote down policies
*Speak at community
awareness to it
gathering places *Hold meetings to educate
*Write white papers or policy
*Initiate and/or attend people about policies and
briefs to help disseminate
events political agendas that could
accurate information help or harm an interest group,
*Post on an online forum
*Start a blog; share/initiate or to notify others about
social media discussion on opportunities to effect change
the issue around an issue or concern
*Join organizations that are *Publish articles where
supporting your political and readers across all social
professional passions locations can be educated
*Engage in a verbal and/or about issues/policies of public
written dialogue with someone interest
about your professional and
political passions
Figure 32.1 Continuum of advocacy. One can start anywhere on the continuum and be in multiple places on the continuum at the same time.
Source: Goodman, Morgan, Hodgson, and Caldwell (2018) © American Association of Marriage and Family Therapy.
that will help others who find themselves in a similar legal predicament (Goodman
et al., 2018). In truth, even though activism is the entry point for most into advocacy,
one can get involved anywhere along the continuum and be in multiple places at any
one time (see Figure 32.1).
How to advocate for families through the clinical world

Family therapists have a tremendous opportunity to break out beyond the walls
of the therapy room and advocate for families with their knowledge and research
(e.g., Carr, 2014, 2018; Carr et al. 2017). Yet, many do not bridge their iden-
tity from relational therapist to relational advocate (Jordan & Seponski, 2018).
Careful review of healthcare policies and practices that impact the clinical world
(Peek, 2008) reveals opportunities for legislative and social policy changes that
allow us to better engage the client and family/support persons into the care
experience. Those who are advocates for policies around client and family
engagement define client and family engagement as “patients, families, their
representatives, and health professionals working in active partnership at vari-
ous levels across the health care system direct care, organizational design and
governance, and policy making to improve health and health care” (Carman
et al. 2013, p. 223). One policy that links the clinical, operational, and financial
worlds is under the Medicare Access and CHIP Reauthorization Act (MACRA).
Under this policy (operational world), a proportion of physician pay (financial
world) is linked to patient and caregiver experience and to patient‐reported out-
comes (clinical world) (Medicare Access and CHIP Reauthorization Act
[MACRA] 2015).
Family‐centered care invites shared decision making while also honoring and
witnessing the shifting roles of family members as they become more involved in
their loved one’s care (Shields, Pratt, & Hunter, 2006). Organizations such as the
Institute for Patient and Family‐Centered Care advocate for an approach to
healthcare that is grounded in mutually beneficial partnerships among healthcare
providers, clients, and families. They believe that “Patient and family‐centered
care is working ‘with’ patients and families, rather than just doing ‘to’ or ‘for’
them” (www.ipfcc.org). Likewise, the Collaborative Family Healthcare Association
(www.cfha.net), Association for Family Therapy and Systemic Practice (www.aft.
org.uk), American Association for Marriage and Family Therapy (www.aamft.
org), along with the International Family Therapy Association (http://www.ifta‐
familytherapy.org), and European Family Therapy Association (www.
europeanfamilytherapy.eu) share similar visions for what care should look like if it
is systemic and relational. Imagine if these entities would form one powerful
alliance to craft, draft, and advocate for policies that advance their shared interests
in family health. Advocating for families in treatment would mean joining forces
and reviewing policies that govern how clients are treated for mental health
conditions in school systems, discharged from the hospital, involved in who gets
to make healthcare decisions, included in who can communicate with providers
(and other collaborators) who are part of the care, and informed about exchanges
between diverse systems (i.e., workplace, school, healthcare) that are critical to
safe and culturally relevant decision making.
How to advocate for policies/procedural changes

through the operational world
Advocacy can take place closer to home or on a broader level. Advocacy for things
happening closer to home may include procedural changes in one’s work setting, such as
opening up opportunities for families to play a more central role in a loved one’s care.
Another option may be to endorse policies that require support persons to be included
in a certain number of therapy sessions. Use research to support this evidence‐based
practice, if it is challenged (e.g., Crane & Christensen, 2014). Regardless of work setting,
advocate for a policy where patients are invited to bring a support person with them to
all appointments. This policy may be especially important when clients receive a new
diagnosis or complex treatment plan instructions. Support persons can help ensure that
the client hears the treatment plan correctly and encourages the client in making necessary
health‐related changes. Lastly, advocate for standard yet culturally sensitive intake
questions that inquire about the clients’ family and support system (e.g., the Four C’s;
Galanti, 2015). Ensure that the client feels safe (emotionally, physically, culturally,
relationally, and financially). Ask beyond the client’s symptoms to better understand how
the diagnosis has impacted the family. Also ask what parts of the client’s culture make it
easier or more challenging to manage one’s physical, emotional, relational, and/or
spiritual health and well‐being. Left up to their own devices, collaborators of systemic
family therapists may not ask about the things they are least comfortable in discussing or
treating. However, it may be the missing link to understanding a physical, psychological,
relational, or spiritual symptom, diagnosis, or chronic condition.
Ways systemic family therapists may advocate on a broader level include (a) joining
AAMFT’s TEAM Family or the equivalent professional body in other countries; (b)
joining a listserv where information about local, state, and national policies that
impact the profession and care of families are addressed; (c) donating funds to an
organization’s advocacy and activism efforts; (d) hosting and/or attending meetings
to advocate for things you believe in and value; (e) monitoring bills being proposed
in legislative committees; and (f) engaging in conversations with people who share
similar or different beliefs. All of these methods are options for family therapists who
are looking to engage purposefully in initiating change. As stated earlier in the chap-
ter, systemic family therapists should not wait until a lobbyist or organizational leader
invites action. It is everyone’s responsibility to remain active and not be lulled into
complacency or a place of apathy believing that nothing will change or that one voice
does not matter.
An example of where advocacy is important is when job announcements exclude
systemic family therapists as a qualified professional. In these cases, it is important to
respectfully contact those who posted the announcement with curiosity. Start with
polite introductions and reference the specific posting. Inquire if the agency has ever
thought about hiring a systemic family therapist for the position. If no, then take the
time to briefly educate the contact about how systemic family therapists are: (a)
trained to assess, diagnose (within state parameters), and treat individuals, couples,
and families, (b) licensed in all 50 states, and (c) evidence based in their practice.
Many times, the person who put out the position announcement is a human resource
professional and is recycling an old position announcement. They will oftentimes
accept applications from other disciplines, but we need to go the extra step to educate
all persons involved so that the future postings include family therapists. In one recent
situation, systemic family therapists were not considered an eligible provider for a
posted position. A systemic family therapist applied anyway. They were so well quali-
fied for this position that the workplace went back to human resources to have the
entire job announcement rewritten so that future systemic family therapists could be
considered. Oftentimes, the representative of the agency will ask about reimburse-
ment mechanisms as depending on the policies that govern, they may differ across
professions. That takes us into the next section of advocacy: financial benefits of fam-
ily therapists in the workforce.
How to advocate for family therapists through the financial world

If someone challenges the reimbursement of a systemic family therapist, make sure to
know the facts before responding. Government policies and reimbursement regula-
tions are apt to change quickly, and sometimes quietly, so it is important to continu-
ously review published policy and guidelines. It is also beneficial to be aware of the
successes and challenges previously encountered by others. If another state, province,
country, etc., has had success advocating for change, there may be precedent that can
be used to argue a case. Lastly, it is important to know the payer mix for the setting
(i.e., percent of uninsured, publicly insured, privately insured). These percentages will
help to discern how to build a model that increases the likelihood for fiscal sustainabil-
ity of the systemic family therapist.
Systemic family therapists need to advocate for themselves and prepare proformas on
how they can be sustainable. A proforma is a tool for calculating one’s return on
investment based on items such as patient panel size, volume of patient encounters, payer
mix, standard salary for a behavioral health provider in that context, average screener
reimbursement per administration, average treatment reimbursement per visit, program
costs, and projected revenue. Whereas quantifying one’s work may fly in the face of why
many opted into this profession, it is critical to the advocacy conversation and relevance
of how the financial and clinical worlds interface (see Crane & Christensen, 2014).
One recommendation while engaging in discussions about the financial merits of
one’s profession is to not simultaneously devalue or discredit another’s professions.
While other professions may do this to our field, family therapists do not need to
participate in that same strategy. Building research, understanding how to apply it,
and pursuing policies that improve reimbursement for services should be the ultimate
goal. The verification of systemic family therapy’s worth is in the evidence of thera-
pist’s practice, research, supervision, and training, not simply in what skills others may
or may not have in the workplace.
Collaborative partnerships are also a way to gain momentum with policy and advo-
cacy. For example, in the United States, the Collaborative Family Healthcare
Association has written several letters supporting reimbursement for systemic family
therapists under Medicare (i.e., public insurance mechanism). This non‐guild organi-
zation understands and recognizes the value of systemic family therapy as a profession
and endorses policies as well that strengthen the role that the family plays in healthcare.
When others are espousing the cost savings, offset, and increased patient‐and‐family
outcomes, it only strengthens our position. Join forces with people who are trying to
unify and integrate behavioral health services in healthcare, school, military, and
justice/legal systems.
How to advocate for training in policy construction and dissemination

through the training world
The fourth world involves training, and this is an important component of advocacy
for the profession. While systemic family therapists receive a rich training and
continuing education in the clinical world, more emphasis on the operational and
financial worlds must be embedded into therapy programs, in conferences, and in
family therapy journals. Even though most systemic family therapy programs are
packed with essential content, there may be unique ways to incorporate the
operational and financial worlds into course assignments or discussions. For
example, in a required theories course, students could learn how to write a fact
sheet in relation to their chosen theory of change/profession. In an ethics course,
students could be asked to explore publications on the ethics of business practices.
Oftentimes, screeners, assessments, or interventions are implemented at a site
without consideration for whether they were indicated for the population(s) served.
These are instances whereby policy can influence practice in a negative way, perhaps
something to consider in a diversity course (e.g., systemic family therapists should
be attuned to policies that add more paperwork for patients, require prior
authorizations for care, or increase costs that further oppress populations with
fewer resources). Furthermore, financial sustainability formulas could be built into
a research method or statistics class in order to determine the number of sessions
in a day or week that would be needed in order for a systemic family therapist to
maintain a salaried position (based on a predetermined payer panel by Medicaid,
Medicare, private insurance, or sliding fee scale).
Beyond what can be introduced into therapy programs, family‐focused policy
makers must have a stronger presence as plenary and workshop speakers at family
therapy conferences. It is concerning to hear colleagues share their uncertainty
about how to talk to legislators, remain dormant when requests come out in emails
to engage in conversations about a policy change, and state that they are unaware
of what a policy brief, white or green paper is, let alone know how to write one.
Conferences are a great way to train larger numbers of the workforce on these and
other advocacy methods. Perhaps this chapter will also inspire systemic family
therapists to write policy‐focused articles for systemic therapy journals. The more
that policy and advocacy papers appear in the professional literature, the more it
may be recognized as a valued skill set shared by many and not just designated for
a few.
Therapists must recognize that policies and decisions related to reimbursement
have an incredible influence on clinical practice, job opportunities, perceived exper-
tise, and contributions aligned with family therapists. Systemic family therapists need
opportunities to learn how to better advocate for their self as well as for their profes-
sion. Let this chapter be a call to action to find a place on the advocacy continuum and
seek out collaborators who help in the climb toward a greater presence of therapists
at the seat of the policy table.
Example of advocacy success in the profession

While policy changes occur regularly, some advocates do an especially great job of
incorporating all four worlds into the process. Below is just one example of an
advocacy success that relied on clinical, financial, policy, and training experts’
deep understanding about how a proposed legislative change could have major
systemic outcomes. A change designed to lighten the workload of state legislators
could have systemically threatened the existence of over 50 occupational boards,
including systemic family therapists. This proposed bill afforded the opportunity
for systemic family therapists to attend trainings and learn more about how an
action item could influence their livelihood and impact their communities. This
opportunity also provided a way for the therapists to learn about how advocacy
could address the issue. Legislative outreach efforts, led by therapists, also took
place so they could directly articulate the clinical, operational, and financial
challenges associated with the proposed legislation with legislators and
communities of interest. This example has a good outcome, but only because of
the quick mobilization of systemic family therapists and well‐constructed advocacy
efforts to stop policy changes that could have resulted in harm to the profession
and communities served by it.
North Carolina occupational boards threat of 2016 In 2016, several North Carolina
state legislators were trying to pass a bill that would shrink the number of occupa-
tional boards by over 50. This bill was a shock to the North Carolina Marriage and
Family Therapy Licensure Board (NCMFTLB) who found themselves on the list. The
board quickly notified some of its licensees to design a response and also contacted
the North Carolina Marriage and Family Therapy Association (NCAMFT) to
collaborate on an advocacy strategy. Several steps were quickly taken to stop this bill
from making it out of committee. First, members of the NCAMFT were asked to see
if any of the committee members discussing the bill were in their district. If so, they
wanted members to call their legislators and educate them on concerns related to a
multi‐license consolidation. NCAMFT members were encouraged to not speak as
academicians, but as people with a direct threat to their livelihood as practitioners.
Numerous phone calls were made to legislators, legislative assistants, and chiefs of
staff. Some systemic family therapists called on those from their district, but others
called on any committee member, senator, or representative who would answer their
calls. Family therapists were prompted to share potential clinical, operational, and/or
financial implications from the consolidation. Since systemic family therapists were
not the only ones calling, the phone lines stayed busy from members of the other 50
plus occupational boards who were also helping with the cause. The collective goal
was to create enough doubt about the utility of the bill that the committee would not
pass it as written.
A month later, the committee held a public meeting to hear out representatives of the
boards who were included on their “list.” The committee underestimated the number
of people who would be present for it and, as a result, limited each board to just 2
minutes of talk time. The room was filled with anxiety and passion as each person spoke
for their professional livelihoods. The chair of the committee appeared unflappable and
would later attempt to quietly put the bill in another committee’s hands to see if it
would move better through that venue. Knowledge of this action just empowered the
family therapists, and all other occupational boards impacted, to call their legislators
again. This time, the legislators were more familiar and many expressed frustration
about the necessity of the bill. The mobilization of family therapists worked. Systemic
family therapists created enough noise alongside the other occupational boards impacted
that the proposed legislation failed to pass. While the experience was tremendously
stressful, the lessons learned were priceless. The advocacy team learned to:
• Have white papers and fact sheets ready and up to date. Creating those on the
fly was stressful and time consuming, but AAMFT’s lobby team was incredibly
helpful sharing what they could in a condensed time frame.
• Talk to colleagues in other states who had gone through a similar challenge. Ask
to see what had been printed and shared in speeches to advocate for their cause.
There was no need to recreate the wheel.
• Create written and spoken scripts to help people know what to write or say to
their politicians as inexperience oftentimes leads to inaction. This made it easier
on people to know what to say and increased participation.
• Speak calmly and slowly as emotions can be a distraction to legislators or staffers.
It is hard not to get excited about things that are so important, so practice the
speech first (before calling/talking) to work out those important emotions and
get out the critical points.
• Never get complacent. Continuously monitor the state register for any legislative
activity that could impact the profession. It is ideal if a lobbyist is hired to do this,
but in some cases, there is just not enough of a budget to hire someone. In such
instances, assign a systemic family therapist who is an active ambassador/cham-
pion to the role. Select someone who can mobilize the membership into action.
• Maintain active relationships with local legislators and not just contacting them
when in a crisis. It is important to never assume that legislators know about the
skills or profession of a couple/marriage and family therapist, so create a 30–60‐
second speech that captures a concise description and core skill set of couple/
marriage and family therapists.
Integrating advocacy into one’s professional identity

There are many reasons why a systemic family therapist may become activated to
engage in advocacy efforts. For example, a proposed bill may trigger a challenge or
alignment to one’s personal or professional ethics, beliefs on social justice, research or
funding potential, and opportunities or sustainability as a trainer or supervisor. Below
are descriptions of ways in which systemic family therapists can consider the position-
ing of their professional identity, abilities, and strengths in each of the four arenas
mentioned above.
Personal and professional ethics around advocacy Oftentimes, actions are taken because
they are in direct support of or in direct contrast to our belief system. As couple/
marriage and family therapists, advocacy (when activated by virtue or professional
ethics) should come to fruition in ways that motivate others toward sustaining and
protecting the profession, license, and job openings that are and should be filled by
couple/marriage and family therapists. One way that family therapists can engage in
advocacy that strengthens one’s professional identity and the future of the profession
is to learn more about the ethical standards and decision making of other professions.
Taking time to do this affords a way to better interact with other professions and
professionals. Opportunities like this can then open the gates for collaboration at a
more local level and result in the culmination of a greater force of diverse providers
who can align through interprofessional commonalities and policies at the state or
federal/provincial levels. These collaborations are especially important when bring-
ing ethical recognition to interventions that do harm, lack of parity in financial
reimbursement, policies that propel health disparities, or in decisions that deter
adequate, practice‐based, and research‐informed training (Hodgson, Mendenhall,
& Lamson, 2013).
Systemic family therapists may grapple with policy changes or advocacy that
bend their ethical values or push against ethical boundaries. For example, to get
reimbursed through insurance mechanisms for clinical services, a policy requires
that someone in the family system must be identified as the “client” and receive
a diagnosis. This may put the therapist in a position of violating their ethical
and theoretical beliefs (i.e., that problems are maintained in the family and not
attributable to one person). In these instances, one may consider constructing
local forums to identify and examine ethical concerns, propose solutions that
may close the gap on potential policy missteps, assume leadership positions,
empower others to fulfill roles that can make a difference, or rely on the strengths
of one’s systemic training to address the issue via a broader lens. Systemic family
therapists are persuasive champions for ethical and systemic change, and this
should be reflected through a stronger presence in policy making, implementation,
and dissemination.
Social justice and advocacy Closely aligned to personal values and ethics is the invest-
ment in social justice by many systemic family therapists. Rawls defined social justice
in 1971 as the maintenance of equal rights and fundamental liberties at the individual
justice level, as well as the equitable distribution of resources, profits, and opportuni-
ties to those with the greatest need, considered the distributive justice level. Current
policy think tanks such as the Center for Economic and Social Justice (2018) host
timeless and systemic descriptions of social justice, by stating that:
any act of social justice is a recognition that improving the social order of an institution
is a never‐ending task. This is because human beings and human creations (including
laws and institutions) are inherently imperfect. Hence, while we can never expect to
achieve perfection, we have a moral responsibility to pursue justice. (“Social Justice, Not
Utopia,” para 7)
Thus, one’s personal identity when activated through social justice becomes more
concentrated in a personal responsibility for one’s own perceptions and actions, as
well as intentionality about improving institutions and social order.
Systemic family therapists are poised to identify challenges and oppression associ-
ated with human rights and as such are well suited to advocate for improvements in
social policy. McDowell, Libal, and Brown (2012) stated that through systemic family
therapy skills in emotional, intellectual, relational, and cultural work can draw on the
centrality of human rights to influence social change (e.g., attending to institutional
racism and discrimination or lack of indicated treatment for underserved popula-
tions). These researchers offered examples through the Cultural Context Model
(Almeida, Wood, Messineo, & Font, 1998) as a way for systemic family therapists to
navigate the awareness needed from advocacy at the (a) clinical level, (b) through the
hierarchies, power, and privileges that can exist at the community levels, and (c)
toward collective social action. It is essential that systemic family therapists model
professionalism through timely and culturally humble activism, such as the inclusion
of a full range of social locations, responsiveness to community needs, and recogni-
tion of competing social and global issues. These skills can be strengthened through
continuous engagement in genuine relationships throughout one’s community that
include recognizing and reflecting on the continuums within social locations and the
intersectionality that cut across social locations. These experiences should then help to
further anchor the meaning and purpose of social justice within one’s professional
identity and advocacy actions.
Research, scholarship, and advocacy The role of researchers in policy development is

essential to the credibility of the results and data shared in policy papers and discus-
sions. High‐level statistics are not visibly present on most types of policy writing;
however, the use of frequencies, statistical findings, data‐informed outcomes, health
informatics, and economic analytics can be beneficial to include, particularly when
analyzed by those who are savvy in policy dissemination and implementation science.
Clinical researchers such as those trained in systemic family therapy have an even
stronger contribution to policy, because they are able to offer samples of identity‐
stripped stories or anecdotes that coincide with and bring to life the personal
experiences behind the numbers showcased through graphs, charts, and/or summaries
of evidence‐based outcomes.
Systemic family therapists should learn through research method courses during
their training program, as well as through professional development conferences, on
how to communicate evidence‐based findings to stakeholders who can advance sys-
temic and relational health. Davey and Watson (2008) stated that a separation exists
between public policy and systemic family therapy mental health research and, as
such, created a model that integrated policy with research for a targeted underserved
population. Examples do exist in systemic family therapy literature on how to attend
to public and social policy. However, the lack of courses offered and publications
available to address the systemic family therapy policy–research chasm suggests that
not enough progress has been made to help close this gap. While master’s training
programs have a full and defined curriculum, advocacy and policy skills could be
woven into assignments and lectures so students learn to apply it at a relatable level.
For example, you could have students look at the paperwork used to establish care in
their clinical sites for literacy challenges, lack of respect for culture and diversity,
scheduling and financial penalty policies that further oppress underserved (e.g.,
minority and lower‐income) families.
To strengthen the momentum in closing the gap, systemic family therapy research-
ers could reach out to and collaborate with leaders who have a contributing role in
influencing policy, publishing policy‐focused research/clinical articles, healthcare
reform, and family‐centered care. Researchers may have a unique skill set in securing
grants that result in findings that could influence policy makers. On the opposite side
of this coin, policy topics and trends at the federal/provincial level may influence the
focus of requests for future proposals and announcements. Thus, if systemic family
therapists are not contributing to research and policy, they are likely to be left out of
funding opportunities and experiences that can strengthen the care provided to
patients, billing options for treatment, and learning potential for future generations.
These decisions undoubtedly influence systemic family therapy researchers in ways

that they may not even realize; however, staying in tune with advocacy movements
and policy shifts can only help researchers to gain momentum in reinforcing the need
for relational health research and funding that can further cement one’s professional
identity in the field.
Training and supervision models for advocacy skill building Accrediting bodies such
as the Commission on Accreditation for Marriage and Family Therapy Education
(COAMFTE) use policy to ensure that graduates of their accredited programs are
getting the education and competencies they need to succeed in their field. They hold
programs accountable for demonstrating that their method of training is working and
that there is a set of measurable outcomes anchoring each program. Currently, neither
the American Association for Marriage and Family Therapy (AAMFT) (2015) nor the
Commission on Accreditation for Marriage and Family Therapy Education
[COAMFTE] standards (2018) require advocacy to be a part of one’s professional
duty or a required competency to be demonstrated prior to graduation. However,
this should not discourage programs from teaching about the importance of policy
initiatives, the advocacy continuum (Goodman et al., 2018), and how to write
fact sheets, white papers, and policy briefs (suggestions are given below in how to
construct select forms of policy papers).
A strong recommendation for trainers and supervisors is to invest in one’s own
training in policy efforts prior to encouraging students to engage in program‐directed
actions or advocacy efforts. AAMFT supervisors do not have to show evidence of
experience in any given practice setting that a supervisee is affiliated with in order for
supervision to occur. This may present ethical and practice challenges in contexts such
as healthcare, school, or military settings and with special populations (e.g., Hodgson,
Boyd, Koehler, Lamson, & Rambo, 2014; Lamson, Pratt, Hodgson & Koehler,
2014). Advocating for workforce development that includes retraining supervisors to
be up to date on new applications of family therapy is imperative such that opportuni-
ties to champion for systemic family therapy can be maximized.
As a starting point, trainers in the field should emphasize through presentations,
publications, courses taught, and supervision the importance of relational expertise
among those who identify as or are in the process of becoming a systemic family thera-
pist so that external communities of interest recognize the unique contributions and
value of the profession and coinciding professionals. Faculty, trainers, and supervisors
should help learners gain the ability to identify key stakeholders in the community or
at the state or federal/provincial levels that can champion for necessary causes. This
includes training students to initiate relationships with potential community partners
that can provide narratives or data that support the need for systemic family therapists.
These experiences should be mutually beneficial so that trainees work with the com-
munities to co‐construct programs and initiatives that can better serve the indicated
needs. Such contributions may then be replicated in a way that influences local, gov-
ernmental, or global policies. These are beneficial ways to ensure that learners are
collaborating with the best interests of the community in mind and are working in
tandem with communities of interest as they seek policy change and engage in advo-
cacy efforts. For example, working with underserved communities and countries
alongside nongovernmental organizations and community‐based think tanks may be
significant ways of impacting policy.
Putting it to paper
There may not be much that is more intimidating to a systemic family therapist than
the invitation to speak with a policy maker, politician, or state/nationally recognized
ambassador. Below are some tips to consider when having a conversation with an
influencer and recommendations on how to begin putting policy to paper through
fact sheets, policy briefs, and white papers.
Preparing for the conversation First and foremost, remember the importance of
relational expertise and remember that underlying every politician or ambassador is a
human who understands and likely honors human connection. Always have a story
readily available that moves the heartstrings of the listener in a way that is tightly
connected to the bill or policy concern that is on the table. Systemic family therapists
commonly have less than 5 minutes to drive home initial points and thus should have
a strong elevator speech on the tip of the tongue, which includes a brief introduction
of the couple/marriage and family therapist, a description of the profession, the name
of the bill, the bill number, highlighting a known and compelling statistic, and a story
that brings the message home about the importance of the bill, if passed. Systemic
family therapists ought to enter into the meeting prepared to ask for what they want
the politician or ambassador to do with the shared information (e.g., sponsor the bill,
co‐sponsor the bill, vote for the bill) and be ready to ask if their vote or sponsorship
can be counted on. The conversation is best to conclude with a message of gratitude
and a fact sheet related to the bill (with coinciding contact information in case fol-
low‐up is needed). Furthermore, systemic family therapists should send a follow‐up
email within 1 week of meeting with a politician or ambassador, including contents
from the conversation related to the specified bill or call to action, a thank you for the
individual’s time in discussing the important matter, and willingness to answer any
further questions regarding systemic family therapy.
Preparing a fact sheet The point of a fact sheet (in relation to advocacy) is to get
the reader motivated to respond through action or support.1 Make the fact
sheet as easy to read as possible. If the fact sheet is intended to raise awareness or
support, make sure any relevant contact information is provided to connect the
reader to the resources needed. If the fact sheet is to encourage a legislator to
vote yes on a bill, ensure that the accurate bill number and title are listed boldly
on the sheet.
A fact sheet is typically one page (and no more than one‐page front and back). The
content should be eye catching, easily readable at most literacy levels, large font, with
very limited text. Bullet points can be used but a vivid pie chart or eye‐catching statis-
tic is often more likely to be remembered than a paragraph of important details. An
important fact to remember for all types of policy papers is to make sure that your
opening lines are the most powerful sentences in the entire document. Most people
will not read past the first few sentences, so make those sentences or facts scream out
a very big “so what” factor. While a fact sheet does not resemble a research paper in
any way, it is still important to cite the work. In this case, footnotes may be used with
superscript numbers placed by any content within the fact sheet that corresponds to
research or literature belonging to other intellectual property.
More recently, fact sheets are being sent by email that include updates on social
determinants of health or updates on health outcomes from private insurance compa-
nies. When sharing a fact sheet that will be disseminated electronically, links can be
embedded that may take the reader to more details related to the bill, or perhaps to
actions that have been taken that would warrant more attention to be given to legisla-
tor’s decision making. If the fact sheet is being sent to supporters, it would be benefi-
cial to list senators or representatives that are relevant to the supporter’s district, along
with up‐to‐date phone numbers. Finally, oftentimes a helpful option on an electronic
fact sheet is to add a link to a template letter that can easily be adapted and then sent
to legislators.
Preparing a policy brief A policy brief has some commonalities with both a fact
sheet and a white paper, but also functions that are unique to this format of advo-
cacy. First and foremost, a policy brief should have a very eye‐catching title and it
should be clear from the title that it is a policy brief. A brief then offers a concise
scope of the problem also known as an executive summary (two to three sentences).
Bolded statistics in the text may draw the reader into the significance of the issue. It
should also be clear from this portion of the brief who or what has been most
impacted by the issue.
Under a second subheading such as systemic implications or rationale for action, a
description can be provided that would offer what could happen if the issue is not
attended to or resolved. Here is where realistic yet devastating outcomes could emerge
if attention is not given to the presenting issue. These outcomes can be placed into
shadow boxes, sidebars, or bullets to help the reader glance quickly at the punctuated
concerns that currently exist or could exacerbate if left unattended.
Next is commonly a list of possible solutions that could improve current
conditions. Here is where citations may be helpful in providing sound and just
rationalizations for each solution. A list of key points may also benefit the reader
by envisioning the solutions with the most potential that may become most
helpful when discussing the issue at hand with other stakeholders who are

unfamiliar with the issue.
Finally, a very clear call to action must be presented. The reader must know very
specific and realistic steps that need to be taken in order to attend to the solutions
proposed. This is where specificity is critical; the name and bill number of proposed
bills or steps needed in order to activate change should be included under this sub-
heading. The call to action must communicate a sense of urgency and offer a perspec-
tive that affirms that the activists have done their homework on the issue (i.e., includes
named legislators who are already sponsoring the bill or that multiple communities of
interest are already engaged in the charge). The overall policy brief is commonly four
to eight pages in length when covering all of the details described above (more in‐
depth details can be found at International Centre for Policy Advocacy at http://
www.icpolicyadvocacy.org).
Preparing a white paper For the most extensive approach to policy writing, systemic
family therapists may turn to writing a white paper or policy report. These docu-
ments are constructed with greater depth in written narrative and are a less flashy
document than a policy brief. As previously mentioned, it is important to have a title
that offers specificity and a significant “so what” factor so that readers are drawn to
the document. Once a reader has seen the title, the summary is the next big hurdle
to grab the audience’s attention. After all, it is suggested that only 5% of readers will
give attention to content beyond the abstract or initial executive summary (Graf,
2008). For example, family therapists are one of the five core mental health profes-
sions recognized by the federal government and are licensed in all 50 states. Their
practices are backed by solid research supporting their effectiveness with individuals,
couples, and families. Unfortunately, because of the recency of their profession
(1950s), they have been excluded from state and federal laws and/or rules restricting
their ability to obtain employment via positions funded primarily by Medicare. A
white paper then should offer a statement of the issue (two pages, i.e., key elements
of the issue, points of interest, and directed to indicated key stakeholders) and back-
ground of the issue (three pages; why the issue deserves attention, what the status
quo is on this issue, what the concerns are in relation to the issue, and what the broad
systemic implications are that coincide with the issue).
Beyond adding length to the descriptors that up to this point look similar to a
policy brief, a white paper does incorporate a review of the literature‐including meth-
odology and data analysis results that are unique to the focus of the white paper (7–20
pages). Similar to the policy brief, but with less brevity, solutions to address the issue
are provided along with the optimal response to the issue, including how the optimal
response would improve patient outcomes, workflow or practice procedures, reim-
bursement, and training of current and future professionals are also provided. A white
paper commonly concludes with a summary, including recommendations and exhib-
its/appendices. Unlike with policy briefs and fact sheets, exhibits are not typically
integrated into the text, but rather reflected as appendices. Rotarius and Rotarius
(2016) offer a specific structural framework that may be useful for novice writers of a
white paper. These authors make a distinction between empirical and conceptual
white papers, particularly within the realm of healthcare. This framework, along with
key points to creating new knowledge, may provide additional support for systemic
family therapists who are seeking probing points that could be included throughout a
thought‐provoking white paper.
Conclusion
This chapter focused on highlights that are most relevant to the significant roles
that policy and advocacy play in the lives of systemic family therapists. Throughout
this chapter, the aim was to compel systemic family therapists to (a) learn more
about the value of a four‐world view; (b) understand the lexicon associated with
policy and advocacy; (c) align with a level on the advocacy continuum; (d) recognize
how advocacy flourishes through the four worlds and thereby activating personal
identity through virtue and professional ethics, social justice, research, and
training/supervision; (e) identify with a success story associated with systemic
family therapy advocacy; and (f) learn how to write fact sheets, policy briefs, and
white papers that can influence policy makers and stakeholders. This chapter will
forever serve as a call to action for systemic family therapists to gain the confidence
and competence to engage in some way as an advocate, ambassador, champion,
and/or policy maker.
Note
1 Fact sheets can also be created for office use with clients so that they may be informed of
specific symptoms that are often associated with a diagnosis, risk factors of the diagnosis,
what to do when the symptoms worsen, and treatment options for the diagnosis. Pictures
are commonly used to reflect the message communicated on the fact sheet.
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33
The Future of Systemic Family
Therapy
What Needs Nurturing and What Does Not
Fred P. Piercy
Recently my wife and I bought a home in the mountains. The previous owner planted
a large English flower garden just outside our back door. It includes beautiful flowers,
most of which we could not name. Each day this past summer was a surprise when one
or another sprouted and bloomed. The problem was that we had trouble weeding.
We couldn’t figure out if an emerging plant was a flower or a weed, and consequently
we felt guilty whenever we weeded. Do we pull up this plant or water it? I hope we
did not pull up too many flowers.
Similarly, systemic family therapy1 is growing, and some of this growth is destined
to become beautiful flowers, but not all of it. How do we tell the flowers from the
weeds? Which do we dig up and which do we water? That is, what I will reflect on in
this chapter.
My opinions are informed by my 45 years in the field, the last seven as editor of the
Journal of Marital and Family Therapy. I have directed several marriage and family
therapy programs. In writing this chapter, I also have relied on the opinions of people
I trust—former editors of the Journal of Marital and Family Therapy—and a sprin-
kling of other wise, creative professionals.
One weed I never pulled up in our garden was poke weed. As a kid, my dad, a
mountain man himself, my mom, and I would explore the woods near our home
looking for poke weed. We would pick it in the spring and bring it home and double
boil it with bacon. I still love poke and search for it each spring. I mention this
because what some people consider weeds may not be weeds for others. Consequently,
I have shared a few unexpected or against‐the‐grain ideas here and there. Also, some
of what I envision is aspirational and undoubtedly tempered by both my love of the
field and my optimism. So, in this chapter, I describe a future professional English
garden, including what about systemic family therapy I believe we should nurture and
what we should consider weeds.
754 Fred P. Piercy
The Big Picture: What Should We Stand for?
I tire of definitional issues that create false dichotomies. For some, systems therapy is
a modality, one tool among many, and for others, it is an overarching way of thinking
and acting. For some, it is a practice that mental health professionals from many dis-
ciplines embrace and employ. For others, it is a profession, quite unique in its own
right. Some support theoretical purity and others look for commonalities across theo-
ries or ways to integrate various theories. For me, systemic therapy can be all of these
things, and one does not diminish the other.
I see great wisdom in the fact that systemic therapists appreciate how relationships
can help us understand and address human problems. No matter how a problem
develops—genetics, family, or culture—often an individual’s close relationships hold
the key to understanding what maintains the problem and what we can do to address
it (Wampler, Blow, McWey, Miller, & Wampler, 2017).
Systemic interventions—interventions based on an appreciation of the power of
relationships—can be applied at various systems levels: friends, couples, families, com-
munities, workplaces, environments, and even cultures. So, the big picture is that
those engaged in systems thinking and intervention appreciate interconnected sys-
tems at a variety of levels. When we skillfully tap into the resources of social relation-
ships, we can and do make a difference. There is a certain integrity and logic to this
work that can cut across our professional differences. The influence of relationships is
self‐evident and immediately understood when I discuss family therapy with interna-
tional audiences. The power of family is indeed an international language. The rele-
vance and strength of systemic therapy is also reflected in the massive amount of
research supporting systems therapy (e.g., Carr, 2014a, 2014b; Sexton & Datchi,
2014; Sprenkle, 2012).
The questions for the future have less to do with “are systemic interventions effec-
tive?” and much more to do with what about systems therapy makes a difference and
how best to teach and employ systemic mechanisms of change. Such thinking is impor-
tant, particularly in a world, that is, becoming increasingly individualistic, fragmented,
and isolated.
Integration of Family Therapy into the Larger

Health‐Care System
Since thinking and intervening relationally are so powerful, a lot of our future will
involve how to best apply systems therapy concepts to existing systems and, in so
doing, to improve them. Health care is an important example. One challenge is the
apparent disconnect between systems thinking and the health‐care system, where
many professionals use the individual as the primary unit of diagnosis and treatment.
It is not an insurmountable goal, though.
Already the medical family therapy field is training systems therapists to work
within the broad field of health care. It will be important for systems therapists to be
trained to understand how to access, intervene, and collaborate with health‐care
teams using biological, psychological, social, and spiritual approaches to care.
Presently, the field of health care is interested in helping the whole person in ways
Future of Systemic Family Therapy 755
that are evidence based and effective. The American Association for Marriage and
Family Therapy (AAMFT) has launched a report entitled “Competencies for Family
Therapists in Healthcare Settings,” which will help guide systems therapists in this
important direction (American Association for Marriage and Family Therapy [AAMFT],
2018). The report states:
Family therapists are well‐suited for working in primary, secondary, and tertiary health-
care settings because of their skills in psychological and relational assessment, diagnosis,
and treatment. They are valuable members of healthcare teams because they understand
the ways that systems best form and function, and they have a wide range of skills for
working with one or more people in the room. (p.1)
It will be important for biopsychosocial and spiritual (BPSS) research and policy to
follow. Clearly, we need relationally based care in the health‐care system, but we also
need systemic providers who are well trained to intervene at this level.
The emphasis on applying systems models in health care also will involve some
adaption. For example, J. Hodgson (personal communication, January 4, 2018)
states that new models and interventions will emerge that professionals can apply
effectively in briefer health‐care visit formats (e.g., integrated behavioral health
care).
I am not as swayed as some about the traditionally individual assumptions associ-
ated with the medical model (such as all disease residing within the individual, cur-
rently reflected in most DSM and ICD diagnosis, and the subsequent assumption that
individual treatment is the preferred methodology). I will respond to this apparent
individual bias of health care through both experience and logic.
Years ago, a local physician, a general practitioner, invited me into her practice
because she was seeing so many people who were depressed. She could see that these
patients were dealing with difficult marriage and family issues. She told me, “I can
probably keep you quite busy.” She “got it.” Many health‐care workers today “get it”
because relationship issues that surround presenting problems are hard to miss. Beach
and Weissman (2012), for example, point to compelling findings that a person in a
distressed marriage is considerably more likely to be depressed than one in a non‐dis-
tressed marriage. Indeed, at least 50% of patients come to primary care offices with
what are actually psychosocial needs (Ansseau et al., 2004; Serrano‐Blanco et al.,
2010; Toft et al., 2005).
Sir John Polkinghorne, a renowned physicist, talks about the various levels of scien-
tific knowledge. For example, in quantum field theory, he states that, “If you ask a
wave‐like question, it gives you a wave‐like answer. You ask a particle‐like question, it
gives you a particle‐like answer” (Tippett, 2010, p. 261). The same goes with medi-
cine. If you ask an individual question (e.g., “How do you experience depression?”),
you get an individual answer. If you ask a systemic question (e.g., “How does your
marriage relate to your depression?” “Is your husband able to help you when you are
depressed?” “How?”), you get a systemic answer. Each of these questions is valuable,
and one does not contradict the other. They are simply different levels of focus. Thus,
systems thinking is not antithetical to medicine. On the contrary, it is critical to under-
standing and helping patients who face a wide range of what may or may not be physi-
cal problems. Creative systems thinkers are making this case, and consequently systems
thinking is becoming more and more a part of the health‐care landscape.
756 Fred P. Piercy
Diversity, Culture, Global Perspective, and Just Practice
We live in an increasingly diverse world, a fact that has great relevance for therapy,
now and into the future. Our practices, for example, need to be responsive to couples
and families of all contemporary forms (LGBT couples, families with disabilities, refu-
gee and immigrant families). Systemic therapies also must be responsive to the inter-
sectional influence of, for example, culture, race, gender and gender identity, class,
and ability. Such practice must also challenge oppression, subtle and obvious, in cou-
ple and family systems. McDowell, Knudson‐Martin, and Bermudez (2017) provide
a good example of one way to do this and, in doing so, provide one useful template
for the field (cf. Knudson‐Martin, McDowell, & Bermudez, 2017). They offer tran-
stheoretical guidelines that cut across specific models to understand and address soci-
ocultural factors that unconsciously promote and maintain unearned privilege and
misuses of power. In their approach, the therapist addresses uneven societal influences
based on, for example, social class, gender, race, ethnicity, languages, sexual orienta-
tion, age, nation of origin, ability, and appearance. The authors show systems thera-
pists how they can integrate cultural attunement within a wide range of existing
systemic theories.
So, therapy with a sensitivity to difference and oppression should be a top priority
for our field. Developing such therapies can take several routes. I can imagine a future
where there is less adapting existing therapies to various cultural groups and more
working collaboratively with those groups themselves to develop therapeutic inter-
ventions based on the groups’ own strengths, mores, beliefs, and practices (e.g.,
Charlés & Samarasinghe, 2019; Doherty, Mendenhall, & Burge, 2010). This will be
particularly important as systems therapy continues to expand internationally. We
must refrain from “colonizing” our therapies elsewhere. Instead, we should employ
participatory practices that help create systemic therapies that are co‐developed and
owned by cultural groups, both within the United States and internationally (cf.
Roberts et al., 2014).
Sean Davis (personal communication, January 31, 2018) hopes that our field will
become not only more diverse in terms of colleagues and clientele but also in terms of
openness to other cultures’ ideas around healing. How do other cultures approach
healing? What can we learn from indigenous practices (e.g., shamans, healing rituals)?
How can we respectfully work with stakeholders in different contexts and countries to
craft systemic interventions that truly fit those contexts? Cultural brokers/consultants
(insiders who are part of and consequently know well a particular group or culture)
can help tremendously in the process of crafting and evaluating culturally meaningful
systemic therapies by and for target groups (e.g., Bermudez et al., 2018).
As systems therapists, we also need to see the importance of change at multiple
levels and to be aware of unintended consequences when we work with marginalized
groups. For example, shortly before his assassination, Martin Luther King Jr. cau-
tioned against only helping people adjust to injustice (King, 1963), to function better
within oppressive conditions. If we do not also look for ways to improve these condi-
tions, we inadvertently help maintain them. Howard Zinn (2002) reminds us in his
book by the same name, “You can’t be neutral on a moving train.” Jacqueline Sparks
(personal communication, January 16, 2018) explains:
… doing nothing, or being silent, masks and perpetuates injustice. Amplifying clients’
voices above expert procedures, helping clients have greater voice in their interpersonal
and broader relationships, and actively challenging injustice in our communities and
nation, are ethical stances and actions …
What does this mean practically? We must talk more about empowerment and sys-
temic changes in an imperfect world. Our conversations and actions have the poten-
tial to help us become more aware, just and affirming in our clinical work.
Systems Therapy Research in the Future

There is convincing evidence for the effectiveness of systems therapies for individuals,
families, and couples with a wide range of presenting problems (Carr, 2014a, 2014b;
Sexton & Datchi, 2014; Sexton, Datchi, Evans, Lafollette, & Wright, 2013; Sprenkle,
2012). In fact, according to Sexton and Datchi (2014), “Family therapy is now rec-
ognized as a treatment of choice for the prevention and reduction of youth violence
and problem sexual behaviors, youth and adult drug use, adolescent depression,
mania and anxiety, and the management of schizophrenia” (p. 419). Similarly, Dowell
and Ogles (2010) reviewed 48 outcome studies that directly compared individual
child therapy with family therapy (or parent‐involved therapy) and found that treat-
ment that included parents was significantly more effective than individual therapy.
Another research improvement is the sophistication of statistical procedures, such
as dyadic analysis and growth modeling, both of which examine dyadic and family
processes in a manner that better fits family processes themselves (Oka & Whiting,
2013; Wittenborn, Dolbin‐MacNab, & Keiley, 2013). Similarly, researchers examin-
ing synchronicity among family members and between family members and their
therapist are beginning to develop methods that capture interactional processes more
elaborately and directly using physiological measures (Karvonen, Kykyri, Kaartinen,
Penttonen, & Seikkula, 2016). Also, statistical methods are being applied to multiple
single‐case designs in interesting ways (e.g., Cornett & Bratton, 2014). I anticipate
an increase in a range of process research methods that better capture relational
behavioral change.
Future systems research could improve in several ways. For one thing, while there
is good evidence for the efficacy of systemic treatments, we have little in the way of
relative efficacy of two or more credible treatments going head to head. Much of the
treatment on models is done by the model developers themselves who are under-
standably committed to their particular models. With few exceptions, such as the
efficacy study that compared integrative behavior couple therapy with traditional
behavior couple therapy (Christensen et al., 2004), the comparison group is usually
“treatment as usual” or some (often devalued) alternative treatment, but not another
strong empirically supported model. What we need are more randomized clinical tri-
als of two or more equally supported and credible treatments (e.g., equal commit-
ment to the treatment by both the researchers and therapists, equally clear and
complete training manuals, equivalent doses, equivalent adherence methods). Also, as
D. Sprenkle (personal communication, January 8, 2018) suggests, it may make sense
for future clinical trials in systems therapy to have their studies “registered” in advance
by an independent body so that no unfavorable outcomes could be withheld. This
would prevent what has happened with the leaders of some drug and tobacco compa-
nies, who have withheld unfavorable outcomes of their products from the public
(Landman & Glanz, 2009).
758 Fred P. Piercy
Also, future researchers need to go beyond comparing the effectiveness of systems‐

oriented treatment programs with one another and look more closely at the mecha-
nisms of change. That is, what about their models bring about change? For example,
Greenman and Johnson (2013) discuss the results of nine studies that have examined
specific processes of change in emotionally focused therapy. Therapist effects repre-
sent another factor to consider. While current research suggests that most theoretical
approaches produce similar results, specific therapists within those studies produce
vastly different results (S. Davis, personal communication, January 31, 2018). One
reason for this may be therapist alliance. Quirk, Owen, Inch, France, and Bergen
(2013), for example, found that couple relationship education leaders who engen-
dered the strongest alliance with participants had the best outcomes.
Such findings suggest the need for more of a focus on the common factors that
make up good therapy (cf. Davis & Piercy, 2007a, 2007b). What factors make some
therapists more effective than others? What interventions relate to positive outcomes
across models? And for whom? Similarly, other common factors that need more
research attention include client factors (e.g., motivation, hope, resilience), dimen-
sions of the therapeutic relationship (e.g., alliance), and expectancy, to name a few
(Sprenkle, Davis, & Lebow, 2009). Indeed, our field has generally been engaged in
examining the effectiveness of “name brands” and not what goes into them. And all
of the above should be examined with an eye for special populations, that is, those
differing in culture, presenting problem, family circumstances (e.g., refugees), and
family configuration.
Future researchers also need to develop collaborative practice research networks
(PRNs) of family therapy programs and a range of clinical sites. These cooperating
sites will employ common instruments, pool data, develop common data‐sharing pol-
icies, and address clinical research questions that require more subjects and larger
datasets than one clinic can provide by itself. Therapists also benefit from being able
to track client progress and consequently improve the care they give. Johnson, Miller,
Bradford, and Anderson (2017) provide an extensive description of one such PRN
and discuss both the advantages and disadvantages for clients, therapists, researchers,
and clinic directors. As these authors suggest, the field of systemic therapy needs to
move beyond its own training programs and expand PRNs to include a wider range
of licensed practitioners and researchers with similar clinical interests.
One particular topic that will be a major focus of study in the future will include the
effects of technology on couples and families. For example, we need to know more
about the effects of texting, sexting, cyberbullying, Facebook, computer gaming, and
whatever new technology trends emerge on the relationships of couples and families
and what to do about problems emerging from these technologies. Likewise, there
will be a lot of research on how best to use technology to address such issues and to
improve relationships (e.g., Piercy et al., 2015).
Of course, one main purpose of clinical research is to address interventions that
therapists will apply and that improve the lives of clients. Unfortunately, many practic-
ing family therapists do not see a great deal of usefulness in current empirical research.
In fact, many practitioners rely more on what they have found effective in their own
practices than treatments based on scientific evidence (Dattilio, Piercy, & Davis, 2014;
Gurman, 2011). This may be because of what they see as rigid treatment protocols,
the less‐than‐accessible nature of many clinical research articles, excessive emphasis on
technique, and what many clinicians perceive as the difficulty in applying clinical
research to their particular professional practices. Also, they trust their own clinical
experience and innovation, practices they have found helpful.
So, how can we reduce the divide between researcher and clinician? For one thing,
the field can expand what is commonly considered effective evidence‐based research
and practice. There are a number of ways to assess effectiveness beyond randomized
clinical trials (Dattilio et al., 2014; Karam & Sprenkle, 2010), and multiple methods
are critical in assessing and providing the kind of useful, nuanced information that
systems therapists actually value and use (Gurman, 2011).
Duncan and Miller (2000) distinguish between evidence‐based practice (which
most commonly relies on randomized clinical trials) and practice‐based evidence.
They explain that in practice‐based evidence, the therapist uses client feedback to bet-
ter understand what is working and what is not. These authors have developed short
instruments to identify goals clients consider important and whether they experience
change from session to session. Therapists then use this feedback to inform what they
do in future sessions. Other client feedback methods have been developed as well
(e.g., Lambert, 2012; Pinsof, Goldsmith, & Latta, 2012). Indeed, research has shown
that relational therapists who monitor client progress have significantly better out-
comes than those therapists who do not (Anker, Duncan, & Sparks, 2009; Reese,
Toland, Slone, & Norsworthy, 2010). Future systemic researchers will do well to
provide multiple ways for therapists to monitor treatment and collect data—like client
feedback—that clients consider useful and therapists find helpful in planning for
future sessions.
Also, it is likely that qualitative research methods will continue to evolve as impor-
tant complements to quantitative research, particularly because of the utility of appro-
priately chosen qualitative methods to help researchers better understand the nuanced
dimensions of therapy. Qualitative assessments also can help therapists understand
and facilitate their clients’ progress and gauge the short‐ and long‐term effectiveness
of therapy (e.g., Deacon & Piercy, 2001).
Specific forms of qualitative research that have therapeutic implications include case
studies, focus groups, clinician‐to‐researcher feedback mechanisms, and qualitative
investigation of treatment failures (Dattilio et al., 2014). In broadening further the
usefulness and understanding of research findings, I would also like to see more use
of aesthetic forms of qualitative data collection and representation in the future. By
this, I mean the use of, for example, creative writing, art, story, music, performance,
and poetry both to capture and communicate relational and therapy processes and as
a way to bring more esoteric, statistic‐laden findings to life (Piercy & Benson, 2005).
These methods capture research findings in a manner that the public can understand
and appreciate. Examples of research‐inspired creative offerings include the film
Dunkirk (Nolan, 2017) and the play The Vagina Monologues (Ensler, 2001). Creative
methods, if used to capture an impact of therapy, have an experiential validity that
addresses both the heart and head of the consumers of research, such as therapists and
the general public, and potentially funders (Piercy & Benson, 2005). After all, why
should our field be not employing methods already used by playwrights, musicians,
and writers to capture the effectiveness of therapy in a manner we can both under-
stand and feel? Aesthetic data are not substitutes for more number‐driven research
methods, but can supplement them and convey them to the public in a compelling
manner, one that may be useful for policy advocacy and public action. Along this line,
researchers must learn to write in a manner that engages clinicians, and journal editors
760 Fred P. Piercy
must encourage a wider range of articles, as well as research methods that help us
better understand the impact of systems therapy. Creative qualitative methods with
their diverse structures support systems research that one can present in ways that will
support greater understanding and buy‐in by potential consumers and advocates of
systems therapy.
Systems Therapy Education
There has been a sea change in how family therapy educators organize their training
programs over the past several decades. Initially, the major focus was on therapeutic
models and related topics. Then, due to the increased focus on outcome‐based educa-
tion in many professions (Nelson & Smock, 2005), the training focus shifted from what
was being taught (inputs) to what students actually learned (outcomes). One of the
major contributors to this movement in systemic therapy was the AAMFT list of “core
competencies,” released in 2005 (Gehart, 2011, Gehart, 2013). These core competen-
cies are minimum skills that clinicians should possess to provide safe and effective care.
Nelson and her colleagues (2007) believed that these skills would provide consistency
across training programs. The idea of competencies and outcomes also has been
embraced by the Commission on Accreditation for Marriage and Family Therapy
Education (COAMFTE), the accrediting body for AAMFT, and by many educators.
While educational outcomes—demonstrated skills and knowledge—are important
in the accountability they bring to the field, we need more detail in what specifically
a graduate student should do to become competent and how an educator can facili-
tate that competence. That is, what more should be taught in systemic therapy pro-
grams (beyond lists of existing competencies) and how should this “something more”
be taught?
For one thing, it would be wise for family therapy graduate students to have a
more comprehensive sense of the philosophy of science and how it connects with
systems theory and therapy. We will know better where we are going if we have a
better sense of where we have been and how this connects to systems therapy.
According to J. Whiting (personal communication, March 8, 2018), other profes-
sions seem to be doing a better job of including philosophy of science in their cur-
riculum. For example, there is an American Psychological Association section on
theoretical and philosophical psychology, and some sociology and social work pro-
grams emphasize these issues at the doctoral level.
Consistent with more research emphases on cross‐model change mechanisms men-
tioned in the research section above, there will be similar training goals around ther-
apy skills that cut across models. Karam, Blow, Sprenkle, and Davis (2015) give us a
sense of how family therapy educators might go about training their students in com-
mon therapeutic factors (such as enhancing the therapeutic alliance and fostering
hope in clients). I suspect many other such efforts will follow.
Also, I expect much more attention to active methods of learning, including prac-
tice simulations such as those used in medical schools and other settings that employ
simulated patients (e.g., Miller, 2010). Hodgson, Lamson, and Feldhousen (2007),
for example, used simulated patient modules related to how to manage suicidal, hom-
icidal, child maltreatment, and domestic violence situations. With the technological
advantages coming in the future, there will be more and more ways to see, practice,
and discuss therapeutic skills.
As for content, I hope there will be more on how to advocate for our field, run a
private practice, and partner with health‐care institutions, schools, businesses, and
managed care. And certainly, with its increased empirical support and the promise
that relationship education has for reaching more people, I would hope that students
wishing to learn about and practice relationship education would have the opportu-
nity to do so. Also, I would like to see opportunities to integrate mindfulness and
positive psychology into family therapy training. (Perhaps students could declare sub‐
interests such as these that they can pursue. The dissertation is also a way to focus in
more depth on certain topics.)
I also can imagine innovative training in some important interpersonal skills we
now simply take for granted. For example, M. Falconier (personal communication,
January 10, 2018) suggests that since the therapeutic alliance is so predictive of posi-
tive outcome, we should focus more on interpersonal skills that largely have been
ignored. For example, we can draw from other fields, like drama, to learn more about
how to use our bodies and voices in the therapy room, that is, how to have a “pres-
ence.” Falconier spends time teaching students how to compellingly convey impor-
tant messages to increase the likelihood that the client will hear and act on them. She
notes that literature from the communication sciences is relevant to this: slowing
down, lowering your tone of voice, looking your client in the eye, leaning forward,
and so forth. In focusing more on such micro‐skills, I believe that a therapist can
improve his or her homework assignment compliance. (Years ago, one of my doctoral
students remarked that in listening to seasoned and beginning private practitioners,
the seasoned practitioners seemed to speak more confidently and in a manner that
increased the likelihood that they would be taken seriously. I have often wondered if
we can research and teach such “presence.” I think we can.)
Of course, technology is and will remain a major influence on our lives. More fam-
ily therapy education will focus on how to better use technology in therapy (cf.
Piercy et al., 2015) and training. For example, D. Gehart (personal communication,
January 18, 2018) uses a virtual reality simulator that she states, “has dramatically
improved our ability to teach first‐year (pre‐practicum) students how to actively
intervene with clients by allowing them to interact with a live avatar.” This and other
such technological innovations will, undoubtedly, become commonplace in family
therapy education.
Educators also will focus more on online therapy and telemental health. While our
field is beginning to examine how to use online therapy in a manner that complies
with state rules and ethical practice, I see online therapy becoming much more
accepted in the future. While compliance to rules will be important to address, so will
innovations in how best to use technology to enhance therapy.
One way to make sure that each faculty member’s particular area of expertise is
taught within programs is to develop a revolving‐subject seminar that focuses on one
or two different topics each semester that it is offered. For example, mindfulness and
positive psychology could be offered one semester, and another popular topic could
be offered the next semester. Such versatility is important to keep systems curriculum
growing and fresh and to make the best use of faculty members’ specific areas of
expertise. It is also a good way for faculty who want to know more about a particular
topic to gain expertise by researching and teaching it.
762 Fred P. Piercy
A few recent studies identify the bedrock of good family therapy education from
the vantage point of both students and award‐winning teachers (Earl & Piercy, 2019;
Piercy et al., 2016). This information about good teaching needs to be integrated
into future systems therapy education, regardless of what technical innovations we
develop in the future.
It is amazing how much commonality there was between survey results of 68 grad-
uate students or recent graduates from 21 different COAMFTE‐accredited programs
(Piercy et al., 2016) and interviews from 12 award‐winning family therapy educators
(Earl & Piercy, 2019). Both, for example, emphasized the relationship between the
teacher/supervisor and student as meaningful. Both favored a warm, caring relation-
ship in which the teacher encourages the student in his or her work. Good teachers
were identified as enthusiastic about what they teach, interested in learning, and open
to both give and receive honest feedback. Collaboration was also identified as impor-
tant, both between the instructor and the student and among the students them-
selves. Also, good teachers, according to both groups, are likely to use active learning
methods—demonstrations, role‐playing, debates, simulation, and other learning
activities—to breathe life into the learning experience. Good teachers were also good
at both connecting theory to practice and to teaching about theories in a way that
graduate students could relate to their own experiences. Good teachers were not
blank slates, but willing to share their own experiences while teaching. Similarly, grad-
uate students and good teachers value self‐of‐therapist activities that allowed students
to explore their own personal experiences in a way that helps them both be vulnerable
and make use of self‐knowledge in therapy.
When both the students and the award‐winning teachers talked about poor teach-
ing, they often talked about the lack of some of the positive qualities above. For
example, poor teaching often lacked both personal connection and the connection of
theory to practice. Students did not feel valued and the teacher did not invite diverse
perspectives. Finally, when student‐led presentations were poorly planned, with little
support from the teacher, they were not enthusiastically received.
Hopefully, family therapy educators in the future will also build into their programs
feedback loops to identify and address what is not working and opportunities for
graduate students to become accomplished teachers themselves. This could be
through training in good pedagogy, teaching assistantships, and opportunities to
observe and learn from excellent teachers.
Some of what has been written about good teaching also relates specifically to how
research methods can be taught, nurtured, and prized. For example, creating a mean-
ingful, rigorous, engaging research culture involves some of these elements. Dattilio
et al. (2014) state:
What would a more supportive, collaborative, collegial research environment look like? It
would undoubtedly be one in which family therapy educators are research savvy and
reflect enthusiasm for their own, their colleagues, and their students research. It would be
a program in which research training and mentoring result in the same spirit de corps and
sense of mission that often characterizes the clinical aspects of programs. This may take
the form of research as well as clinical practica and research teams as well as therapy teams.
It would include listserv discussions of promising research methods, regular prosems
where faculty and students present on research topics, regular congratulatory (“way to go
…”) emails, and even program rituals such as picnics, parties, and faculty roasts that
involve safe ways to flatten the hierarchy and build a supportive community of scholars …
The critical issue is to create a generative team mentality around research. (p.13)
Beyond this, future research training will have at its core students and faculty collabo-
rating in research, articles, grant writing, and conference presentations. We should
also help students find research outlets for their professional passions. For example,
those students with a passion for social justice can integrate this passion into their
research, perhaps through the questions they ask and/or through research methods
that support grassroots action such as participatory action research and evaluation
(Piercy & Thomas, 1998; Piercy et al., 2005).
Other useful literature exists as a template for excellent research training. For
example, Karam and Sprenkle (2010) advocate a clear model to help master’s stu-
dents become “research informed.” Also, Williams, Patterson, and Miller (2006)
describe a six‐step model to help students become more conversant with the research
literature. Such models represent useful templates for future family therapy research
education.
Infrastructure
For our field to survive and thrive, it is essential that we address infrastructure (K.
Wampler, personal conversation, January 25, 2018). Programs are too overloaded
with requirements, and faculty and graduate students often feel overwhelmed. As
chair of my department, I used to say to my faculty, “These are great ideas to add to
our program, but what are we going to do less of to make room for them?” Our field
needs to ask the same question.
As Adrian Blow sees it, “we have too many ‘denominations’ (organizational struc-
tures) in our field” (A. Blow, personal communication, January 2018). Also, there is
a good deal of overlap across organizations. Is it possible for the AAMFT, the American
Family Therapy Academy (AFTA), and the International Family Therapy Association
(IFTA) to align under one umbrella, as Blow suggests? Or perhaps we can develop
disciplinary connections with allied professional associations such as the National
Council on Family Relations or the National Association for the Education of Young
Children. Also, how can we benefit from synergistic partnerships with allied fields
such as family sociology, family studies, family psychology, cultural anthropology,
public health, epidemiology, and/or family medicine? What does it mean to be mul-
tidisciplinary and what form should that take? These are hard questions, because we
also benefit from a firm identification with marriage and family therapy as a profession
in and of itself.
One area to look at for what “to do less of” is accreditation. As Karen Wampler
states, “I would change accreditation into a much simpler, less legalistic, more mean-
ingful, and less onerous process. The current approach is very costly in terms of
morale and faculty time” (K. Wampler, personal communication, January 25, 2018).
Some believe that on‐campus clinics could be cut, allowing graduates more com-
munity experience and freeing up faculty for their academic and research responsibili-
ties. The downside of doing away with on‐campus clinics is that students have less
opportunities to work with faculty on therapeutic teams, less live supervision with
764 Fred P. Piercy
program faculty, and probably less opportunity to see program faculty do clinical
work themselves. But programs cannot do everything. Trade‐offs are difficult but
necessary.
Every program’s graduate faculty needs to discuss the identity they want for their
program and make program changes accordingly. If a doctoral program’s faculty
wants to encourage graduate student publications, for example, the program faculty
need to plan ways to facilitate for this to happen within the programs. Such opportu-
nities might include class requirements such as publishable papers, faculty–student
research projects, and writing groups, dissertation formats that require, say, two pub-
lishable papers and a review of literature on a particular topic. On the other hand, the
goal of a program is to produce excellent practitioners, clinical professional seminars
and hands‐on live supervision opportunities, and clinical guest speakers should be
emphasized. And perhaps both masters and doctoral programs can develop a defining
theme or themes such as social justice, self‐of‐the‐therapist, therapy for LGBT indi-
viduals and couples, narrative therapy, and so on.
A final infrastructure question is how doctoral program faculty and the profession
can encourage the development of a steady stream of qualified doctoral applicants
who are prepared for a research‐oriented doctoral program that prepares them to
eventually conduct fundable, rigorous research (M. Bermudez, personal communica-
tion, January 28, 2018). It is not fair or logical to expect non‐thesis, clinically focused
MFT master’s programs to be the primary supply for all PhD applicants. Such issues
should be discussed in appropriate forums, such as yearly meetings of doctoral pro-
gram directors, ideally with the support of their university and one or more national
family therapy associations.
Weeds and Caveats: Directions to Avoid
To return to the weed metaphor I began this paper with, what professional weeds
should we either pull up or not water? Perhaps one is the pyramid versions of systems
therapy training that has sprung up in recent years. That is, some model originators
teach their approach to only a chosen few who attend expensive workshops and pay
for the “clinical secrets” of experts and the right to teach (for a fee) these secrets to
others. This business model of “certified trainers” makes systems therapy less likely to
be accessible to colleagues and clients, particularly in remote, economically challenged
locations. Systems therapy needs to be democratized, with all professionals being able
to learn clinically effective skills and models. So, let us pull any weeds that stand in the
way of equal access to treatment models and skills.
A related weed involves centering our training too exclusively on “big names in the
field” and their therapies, particularly if they are taken at face value without empirical
testing. And even evidence‐based models should be evolving entities and not static
and hermetically sealed. I would hope that we have evolved from the era of guru
models of family therapy—the battle of the name brands. Such hero worship does not
suit either our future best interests or the well‐being of our clients.
Let me put forward a model I favor more. I recently took part in a four‐day “expert
meeting” in Vienna, Austria, that included family therapy and other professionals
from around the world and also included a lot of the originators of evidence‐based
family therapy for adolescents with substance abuse disorders. It was sponsored by the
Office of Drugs and Crime of the United Nations (UN) in Vienna. The workshop
would not have occurred if the founders of the family therapy models had not rigor-
ously determined the efficacy of their models under controlled conditions. The pur-
pose of the meeting and subsequent development of an integrative United Nations
Family Therapy (UNFT) for adolescents with drug use disorders was to take common
elements of the evidence‐based models tested in Western countries and make them
widely available in low‐income countries without the kind of restricted training model
(mentioned above) that often occurs in the United States. A good deal of effort was
also put into making the model sensitive and responsive to cultural differences. I
would like to see more of this kind of approach that identifies common elements in
empirically based models and makes them accessible to trainers and clients across the
world that need them, regardless of their financial means. At this writing, the UN is
pilot testing this integrative family therapy in several low‐income countries. The pro-
cess behind this program could serve as a template for other efforts to democratize
other evidence‐based therapies.
I have spoken about the need to connect with other professions as an advocate for
systemic therapy. There is a fine line here, though. We should have strong and articu-
late voices advocating the advantages of systemic therapy, but we need to do so in a
way that avoids hubris or suggests that we know what is best. Paradoxically, our power
increases as we appreciate the way other professionals see the world. I advocate a
both/and approach that acknowledges the usefulness of a systemic lens to understand
and help others, but an attitude that allows us to see and appreciate the strengths of
other helping professions. Collaboration with health‐care systems, schools, and other
allied professionals requires us to understand and work within existing systems, but
without giving up what we ourselves have to offer. The specifics of how to go about
doing this has begun (e.g., AAMFT, 2018) but should also be at the forefront of the
development of systems therapy into the future.
A trend reported by some systems therapy educators is for fewer couples and fami-
lies to be seen in the family therapy clinics used to train our graduate students in sys-
tems therapy. This is a red flag. While systems therapy is about “thinking systems” and
not necessarily defined by who is in the room, still there is power in engaging a client’s
social constellation in the therapy process. It can be scary for a graduate student to
have more than one person in the therapy room, but good things can happen when
family members are included in the therapy process. When Minuchin brought this
issue up for debate two decades ago, and constructionists provided alternative ration-
ales, Minuchin’s case is the one that resonated most with me, and it should remain a
cautionary tale for the field (Minuchin, 1998).
Another way to think about this issue is that whether one person is in the room or
many, family therapists and educators should think about how to bring interaction
into the room (role‐play, empty chair) or out of the room (planned interactions with
family members, as Bowenian therapists do). Also, it remains important to be flexible
in whom one sees in therapy, always keeping whole system in mind and weaving in
different family constellations across sessions.
We should also avoid one‐size‐fits‐all treatments, where the myth of “the right
treatment for each particular problem” spurs insurance companies to only reimburse
one type of systemic treatment for a particular problem. Standardization also has the
risk of stifling creativity. Our field began as a response to the dominant thinking and
766 Fred P. Piercy
orthodoxy of previous generations. What a shame if we were to create an orthodoxy

ourselves. We need to stay fresh and maintain our edge. If we stay responsive to cul-
tural variation and collaborative and participatory in our methods, we will help more
people and facilitate a diverse, internationally applicable family therapy. As Jason Platt
recently told me (J. Platt, personal communication, January 2018), “while we know
that the map is not the territory, we keep standardizing and exporting our maps all
over the world.” Hopefully, more attention to effective change mechanisms across
treatments will prevent us from going down this path. But because of the existing
medical paradigm that drives third‐party providers, this is a risk we should take seri-
ously and be ready to confront.
My Thoughts on Optimism and Pessimism
A few days ago, one of my mentees, who had just returned from a family therapy
conference, told me that she had heard both positive and negative things about the
field of family therapy and its future. She wanted to know what I thought. I told her
that, back in 1976, when I was a new assistant professor, I also had heard woe‐is‐me
comments. At that time, only two or three states had marriage and family therapy
licensure, and we had little good research on the effectiveness of systemic therapy,
even fewer legislative victories, and practically no third‐party reimbursement. Today,
all states have MFT licensure or certification laws, a steadily increasing number of
third‐party payers support the reimbursement of family therapy, compelling research
now exists supporting family therapy with a range of populations, and we are seeing
more and more legislative victories. So, we are on firm ground. Of course, we can
always do better, and I have tried in this paper to underline a few ways we can improve.
For my mentee and others who wonder how to respond to doom and gloom com-
ments, I suggest that you see them as the way some people see the world and some-
thing that will always be with us. But do not disregard them either. Ben Franklin once
said, “Love your enemies, for they tell you your faults” (2012, p. 38), so listen to
those who have concerns and learn from them. In truth, they are not your enemies.
However, I suggest that you do not twist yourself into a pretzel when someone criti-
cizes the field. As in most things, there will always be good and bad. The big picture,
in my opinion, is that systemic thinking and practice are critical to mental health treat-
ment and that there is no problem that our field cannot positively address.
Conclusion
A word about predicting the future: I was recently reminded of the “hobo heaven”
envisioned in the predepression song Big Rock Candy Mountains recorded in 1968
(McClintock & Eskin, 1968). Here are a few lines:
In the Big Rock Candy Mountains,

There’s a land that’s fair and bright,
Where the handouts grow on bushes
And you sleep out every night
Where the boxcars all are empty

And the sun shines every day
On the birds and the bees
And the cigarette trees
The lemonade springs
Where the bluebird sings
In the Big Rock Candy Mountains …
On some level, predicting any future—hobo paradise, the NCAA final four, sys-
temic therapy, or otherwise—is risky business and may say more about one’s own
biases than actual reality. Still, it is both natural and healthy to picture a better future
for us and our field. Growing plants and pulling weeds—and getting our hands dirty
in the process—is an active venture, that is, good for body and soul and for our field.
As we nurture what is good about our field, we also nurture our own creativity and
vision for a better world. Remember that we are indeed engaged in noble work: we
tap into the wonder and strength of the interconnectedness of life and help others in
the process. We make a difference. Happy gardening.
Note
1 The editors of this book favor the term “systems therapy” or “systemic therapy” over
terms such as marriage and family therapy, couples and family therapy, or family therapy. I
do not distinguish among these terms, so occasionally I will use one or another of them
interchangeably and consider them essentially the same.
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Index
AABQ see Adult Attachment Behavior Q‐Set ACEs see adverse childhood experiences
AAI see Adult Attachment Interview acknowledgment, of efforts 324
AAMC see American Association of Marriage action‐oriented research 494
Counselors actions, advocacy 735–736
AAMFT see American Association for action stage 150
Marriage and Family Therapy active implementation phase, implementation
ABAB designs 472–473 research 519–520
ABC see attachment and biobehavioral actor–partner interdependence models,
catch‐up process research 480
ABCBC designs 472–473 adaptation
abduction 308–309 cultural
abuse 126–127 community‐based participatory research
ethical considerations 539–540 499–500
see also adverse childhood experiences see also cultural attunement;
ACA see Affordable Care Act indigenization
accelerometers, process research 476–477 addiction 127–128, 716
acceptability, implementation outcomes 522 adding in order to reduce 355
acceptance, of sexual orientation 258–259 ADDRESSING framework 613
accountability administration settings 694–696
liberation‐based healing 237–238 adolescents
transgenerational 324 anorexia nervosa 123–124
accreditation 557–568 anxiety disorders 130–131
approved supervisor designation 594–595 bulimia 124
COAMFTE standards 557–558 depression 128
competency movement 559–560 disruptive behavior disorders
doctoral degrees 563–566 122–123
licensure 567–568 drug and alcohol problems 127
master’s degrees 562–563 eating disorders 123–124
post‐degree programs 566 physical and somatic conditions 133
research 560–561, 568 psychosis 132
acculturation, and religion 281, 283 violent behavior 615
772 Index
adoption Africa 53
implementation outcomes 522, 523 agency 664
implementation research 519 aging
Adult Attachment Behavior Q‐Set interventions 18
(AABQ) 398–399 treatment effectiveness 133–134
Adult Attachment Interview (AAI) 396–398 see also elderly clients
adult health AI see artificial intelligence
and adverse childhood experiences 83–84 Ainsworth, M.S. 392–393
anxiety disorders 130–131 AIRM see Attachment Injury Resolution Model
and attachment 396–399 alcohol problems 127–128
depression 128–129 alignment, structural family therapy 343
drug and alcohol problems 128 alliances, family structure 342
intimate partner violence 126–127 ambiguous loss 19
physical and somatic conditions 133–134 American Association of Marriage
psychosis 132 Counselors (AAMC) 34–35
relationship distress 125–126 American Association for Marriage and
treatment effectiveness 125–127 Family Therapy (AAMFT) 35, 37
Advanced Curriculum, approved supervisor designation 594–595
COAMFTE 564–565 Code of Ethics (2015) 537
adverse childhood experiences (ACEs) entry requirements 557
effects of 14–17, 83–84 analogic communication 351–352
treatment effectiveness 120–125 analysis
advocacy 729–751 actor–partner interdependence models 480
actions 735–736 Bayesian, process research 478
in clinical world 737 discrete time survival 481–482
community‐based participatory dynamic systems models 480–481
research 494, 504 of gaps in literature 107
continuum 735–737 multilevel modeling
conversations 746–748 process research 479
ethics 742–743 randomized clinical trials 446–450
fact sheets 734, 746–747 process research studies 473–474,
in finance 739 478–483
four‐world view 729–730 actor–partner interdependence 480
litigation 735–736 Bayesian 478
lobbying 735–736 discrete time survival analysis 481–482
in operational world 738–739 dynamic systems models 480–481
policy briefs 733, 747 multilevel modeling 479
and professional identity 742–746 sequential 482–483
research and scholarship 744–745 time series 479–480
social justice 743–744 units of 473–474
successes 740–742 sequential, process research studies 482–483
supervision 745 time series, process research 479–480
systems theory, role of 731–735 see also assessment; evaluation
in training 740 analysis of covariance (ANCOVA) 447
white papers 733–734, 747–748 analysis of variance (ANOVA), issues
aerobic exercise 218 with 446–447
affiliative responding 182 Anderson, T. 426
Affirmative Therapy anorexia nervosa, adolescents 123–124
LGBTQ 254–267 ANOVA see analysis of variance
self‐of‐the‐therapist 263–267 antidepressants 669
theoretical underpinnings 254–255 ANVIET guidelines 629–631
Affordable Care Act (ACA) 495 anxiety disorders 130–131, 669
Index 773
appropriateness, implementation conscious representations 397–398

outcomes 522, 523 continuity 399–400
Argentina 52, 59 and culture 395, 408
artificial intelligence (AI) 717 disorganized 394
Asia 53–57, 63–67 emotionally focused therapy 182–185,
assessment 333–334, 403–404
attachment, in adults 396–399 and emotional regulation 333
autonomic nervous responses 209, and families 7, 15–17, 207–209, 333,
214–215 393–395
common factors feedback family therapy 178–179, 180, 404–405
instruments 161–162 future directions 405–408
cultural factors 612–613 injury 19, 334, 403–404
deliberative practice 161 interventions 402–405, 406–408
family cartographies 626–627 measurement, in adulthood 396–399
family‐level models 393–394
genograms 608–609 negative changes 400
relational processes 21, 609–610 organized 393–394
structure 609 physiological responses 207–211
harms positive changes 400–402
to others 614–615 process research 178–179, 180, 182–185
to self 613–614 and psychopathology 402–403
individuals and relational self 43–44
clinical classification 603–604 theory 7, 392–402
harms risk assessment 613–615 in adulthood 396–399
mental illness 604–606 and change 399–402
psychometric instruments 606–607 critiques 395
meaningful systems 611–612 models 393–394
missing data 448–450 as a therapeutic input 406–407
multilevel 601–618 treatment effectiveness 120–121
cultural factors 612–613 unconscious representations 396–397
ethical issues 613–615 attachment‐based family therapy
individuals 602–607 (ABFT) 178–179, 180, 404–405
larger systems 611–612 attachment and biobehavioral catch‐up
legal issues 613–615 (ABC) 406
multigenerational families 608–611 Attachment Injury Resolution Model
postmodern therapy 427–428, 430–432 (AIRM) 183
space and place 625–627 attachment strategies
spiritual considerations 279–280 behaviors 398–399
see also evaluation conscious representations 397–398
assumptions unconscious representations 396–397
cognitive therapy, of clients 376 attempted solutions 349
of major theories 304–305 attributable risk ratios 650
in models 300, 304–305 attributions, cognitive therapy 372–373,
and paradigms 296 377–378
questions for 313 audio recording 590–591
structural family therapy 340–343 auditing, HIPAA compliance 551
asthma 133 automatic processing 374
attachment 391–416 autonomic nervous system (ANS) 207–209
in adults 396–399 assessment 209, 214–215
autonomic nervous responses 207–209 co‐regulation 211
behaviors 398–399, 407–408 synchrony 211–213
and change 399–402 autonomy 533–534
774 Index
average success rates of therapy 151 biofeedback 214, 216–217, 711–712

avoidance biological stressors 17
of future pitfalls 764–765 biopsychosocial (BPS) systems theory 39
of theory 302 assessment
cultural factors 612–613
balanced world view 665 ethical issues 613–615
BARE see Brief Accessibility, Responsiveness, individuals 602–607
and Engagement Scale larger systems 611–612
Bateson, G. 101–102, 297–298 legal issues 613–615
battle for structure 329 multigenerational families 608–611
Bayesian analysis 478 cultural effects 612–613
behavior medical family therapy 662–666
advocacy actions 735–736 multilevel assessment 601–618
attachment strategies 398–399, 407–408 and spirituality 278
biased perceptions 372–373 biopsychosocial–spiritual (BPSS)
and cognition 370–374 perspective 662–666
communication models 369 bipolar disorder 129–130, 669
family interventions 372 bisexual erasure 256
harm assessment 613–614 bisexuality, see also lesbian, gay, bisexual,
to others 614–615 transgender and queer
to self 613–614 blamer style 321
paradigms Boszormenyi‐Nagy, I. 322–325
cybernetics 100–101 boundaries
Palo Alto Group 101–102 ethical considerations 541–543
systems theory 99–102 of inclusion 241–242
polyvagal theory 207–209 structural family therapy 343
problem solving models 369 in supervision 584
relationship education and enhancement Bowen family therapy 105, 319–322
371–372 differentiation of the self 319
violent 614–615 eight interlocking concepts 319–322
see also disruptive behavior disorders transgenerational theories 319–322
behaviorally‐focused therapies Bowlby, J. 392–393
Cognitive‐Behavioral Couple and Family Boyd‐Franklin, N. 343–345
Therapy 365–389 BPS see biopsychosocial
process research 180–182 BPSS see biopsychosocial–spiritual perspective
behavioral models Bravemind 716
biased perceptions 372–373 Brazil 51–52, 59–60, 73
and cognition 370–371 Brief Accessibility, Responsiveness, and
communication 369 Engagement Scale (BARE) 399
social cognition integration 373–374 brief strategic family therapy (BSFT) 178,
behaviorist theory 304 180, 356
benchmarking BSFT see brief strategic family therapy
medical family therapy 675–677 bulimia 124
practice‐based research 457–459 business associates 551
beneficence 533 businesses 690–694
benzodiazepines 669
Bertalanffy, Ludvig von 297–298 CAI see Couple Attachment Interview
best practice 19–24 Canada, COAMFTE standards 557–558
bias CAPAS (Criando con Amor, Promoviendo
perceptual 372–373 Armoníay Superación) see Raising
propensity score analysis 450–452 Children with Love, Promoting
bi‐directional learning 500–501 Harmony and Self‐Improvement study
big O’s see outcome... cardiovascular diseases 134
Index 775
CARE model 578–581 disruptive behavior disorders 122–123, 615

care teams, collaborative 670–672 ethics 538–539
case consultation 591 physical abuse and neglect 121–122
case studies, Detroit 497–506 physical and somatic conditions 133
causality, reciprocal 583 Protected Health Information 548
CBCFT see Cognitive‐Behavioral Couple and psychosomatic illnesses 345–347
Family Therapy sexual abuse 122
CBPR see community‐based participatory violent behavior 615
research Chile 52, 60, 63, 66
cell phones 541–542, 709–711 China 53, 64, 67
CFIR see Consolidated Framework for chosen families 86–87
Implementation Research Christianity 276
challenges, medical family therapy 672–675 see also see also religion
change circular causality 100, 100–101
and attachment 399–402 Circumplex Model 346–347
growth models 648 cisgender
change event designs 469–470 definition of 260
change processes 171–204 identity development 264–265
attachment‐based family therapy privilege 262, 264
178–179, 180 cisnormative assumptions 261, 263–264
behaviorally focused couple civil rights
therapies 180–182 LGBTQ 251–271
brief strategic family therapy 178, 180 see also social justice
client system engagement 189 classifications, of theories 296–297
couple therapy 180–185 clients
direct 173 biopsychosocial assessment 602–612
emotionally focused couple common factors 150–154, 157–158
therapy 182–185 cultural factors 612–613
family therapy 177–180 ethical considerations 538–539
functional family therapy 177–178, 180 individuals 602–607
future research 191–193 in larger systems 611–612
indirect 173 medical presentations 675–676
integrative 185–191 multigenerational families 608–611
multidimensional family therapy 177, 180 physiologic syncrony 211–213
multisystemic therapy 177, 180 process research 189
retention 189 spirituality of 275–277
strategic family therapy 341 therapeutic alliances 151–153, 156–158
systemic 173 clinical classifications 38, 603–604
systemic alliances 185–191 clinical practice
systemic enactments 190–191 common factors 147–149
systemic reframing 189–190 community‐based participatory
variables 172–173 research 506–508
see also process research critical thinking 313, 577–582, 586–588
changing through knowing 348 deliberative practice 161
CHEA see Council for Higher Education family, definitions of 79–81
Accreditation global contexts 70–73
chief privacy officers 550 indigenization 72–73
chief security officers 550 infrastructure development 763–764
children localization 72–73
adverse experiences 11–17, 120–125 and relational self 45–46
anxiety disorders 130–131 self‐evaluation 577–581
attachment problems 120–121 sociocultural attunement 619–637
depression 128 strategic family therapy 355–357
776 Index
clinical practice (cont’d) selective attention 377

supervision 577–600 social cognition 373–374
systems thinking 582–585 standards 376
and theory 303 see also Cognitive‐Behavioral Couple and
clinical variables and therapeutic alliances 158 Family Therapy
closed systems cohesion, family assessment 609–610
definition 100 Cold War, the 34–35
in supervision 584 co‐learning, community‐based participatory
coalition 343 research 493–494
COAMFTE see Commission on Accreditation for collaboration, medical family therapy 670–672
Marriage and Family Therapy Education Collaborative Family Healthcare
Code of Ethics (2015), American Association Association 739
for Marriage and Family Therapy 537 collaborative language, and spirituality 279
coder training 475–476 collaborative therapy 423
coding systems 474–476 coloniality 231–232
cognition decolonizing practice 625
assumptions 376 epistemic disobedience 240–241
automatic processing 374 Commission on Accreditation for Marriage and
behavioral models 370–371 Family Therapy Education (COAMFTE)
operant conditioning 367–370 Advanced Curriculum 564–565
social learning theory 367–372 research 560–561
standards 376 standards 557–558
Cognitive‐Behavioral Couple and Family commitment, and relational self 43–44
Therapy (CBCFT) 365–389 common factors 147–169
assumptions, of clients 376 clients effects 150–154, 157–158
attributions 372–373, 377–378 conceptual difficulties 154–155
cognitive interventions 378–379 direct treatment expansion 156
cognitive therapy model 374–380 dysfunctional relational patterns 156
emotion models 380–382 expectancy 153–154
expectancies 370–371, 377–378 feedback instruments 161–162
family behavioral interventions 372 formalized feedback 152–153
family systems theory 383–384 frameworks 148
negative tracking 372–373, 377–378 history of 147–149
operant conditioning 367–370 hope 153–154
perceptual biases 372–373, 376–377 personal integration usage 162
relationship education and enhancement place and space 628–629
371–372 research 163–165
schemas 376–377 resource development 163
selective attention 377 therapeutic alliance 151–153, 156–159,
social cognition research 372–374 185–191
social learning theory 367–372 therapists effects 149–150, 152–153,
standards 376 158–165
theory 366–372 training 159–162
cognitive theory 304 common fate models 648
cognitive therapy common relational processes 21
assumptions of clients 376 communication
attributions 372–373, 377–378 advocacy 735–736, 746–748
model 374–379 analogic 351–352
perceptual bias 372–373, 376–377 behavioral model 369
relationship schema identification 377 digital 351
role of emotion 380 Palo Alto Group 101–102
schemas 376–377 strategic family therapy 351–352
Index 777
communion 664 remediation plans 550

communities risk analysis 550
leaders as experts 493–494, 502–503 conceptualizing, as a common factor 154–155
participatory research 493–494 conduct disorders 122–123
public dimensions of self 44–45 confidentiality
community‐based participatory research AAMFT Code of Ethics 537–538
(CBPR) 491–511 ethics 537–538, 545–549
action‐oriented 494 medical settings 673
advocacy 494, 504 conflict
concepts 492–495 in marriage 14
cultural diversity 492–493 treatment outcomes 674–675
Detroit case study 497–506 congruent style 321
evaluation 504–506 conscious representations, attachment
implementation 499–504 strategies 397–398
qualitative formative phase Consolidated Framework for Implementation
497–499 Research (CFIR) model 518
sustainability 506 construction
expertise 493–494, 501–504 biopsychosocial–spiritual model 662–666
implications for the field 506–508 of knowledge 417–418, 424–425
leadership 493–494, 501–504 of policy 740, 746–748
mental health disparities 494–495 consumer self 41–43
models 495–497 contemplation stage 150–151
power relationships 493–494 context
social justice 492 and internal processes 340–341
sustainability 495, 506 meaningful systems 611–612
training 500–501 nuanced attention to 623–624
Community of Scholars model 564 process research 477
companionate family 34 sociocultural attunement 619–637
competency and supervision 577–582
administration and management contexts of change 173
settings 694–696 couple therapy models 183–185
cultural 620–624 family therapy models 180
family business settings 692–694 therapeutic alliances 187
gender identity 261–262, 263–267 contextual family therapy 322–325
government and policy settings 696–697 continuity, of attachment 399–400
graduate research training 651–655 contracting, of supervision 591–592
health‐related knowledge 666–670 controversies
hospital‐based behavioral health 686–688 defining families 5–6
medical settings 666–672 family therapy, historical 37–38
military settings 690 see also critiques
outcome‐based education 558–560 conversion therapy 253–254
practical, medical settings 670–672 co‐regulation, physiological 211
relational focus 621 corrective emotional experiences 348
in respect to religions and spirituality cortisol 210–211
283–284 cost‐effectiveness 134, 135, 676–677
responsibility toward equity 622–623 costs, implementation outcomes 522, 523
sexual orientation 257–258, 263–267 Council for Higher Education Accreditation
sociocultural attunement 619–637 (CHEA) 558
third‐order thinking 621–622 Couple Attachment Interview (CAI) 397
compliance couple relationships
HIPAA 549–551 benefits of 14
officers 550 mutual operant conditioning 368–369
778 Index
couple therapy the Great Depression 34

emotionally focused 182–185, 333–334, iCARE lens 578–581
403–404 Multidimensional Ecological Comparative
ethics 537 Approach 623–624
process research 180–185 polarization 40
relationship education and role of 627–628
enhancement 371–372 and SFT acceptance 66–67, 70–73
sociocultural origins 34–35 see also indigenization
traditional behavioral 180–182, 183–184 current models of systemic family
credentialing 555–575 therapy 105–106
approved supervisor designation 594–595 cybernetics 100–101
COAMFTE standards 557–558 second‐order 426
competency movement 559–560
doctoral degrees 563–566 daily diaries, process research 470
licensure 567–568 data
master’s degrees 562–563 de‐identifying 547–548
post‐degree programs 566 missing 107, 448–450
research 560–561, 568 systemic analysis tools 647–650
crediting, contextual family therapy 324 decolonizing practice 625
critical consciousness 236–237 deduction 306–307
critical theorizing 306 deficits, postmodern family
critical thinking therapy 428–429
in clinical practice 313, 577–582, defining characteristics of SFT 8–11
586–588 degrees
model evaluation 300–303 doctoral 563–566
critiques master’s level 562–563
of attachment theory 395 deliberative practice (DP) 161
of strategic family therapy 357–358 democracy, concepts 45
of structural family therapy 345 demographic changes in families 40–41
see also controversies depression
cross‐generational coalition 343 stress and rumination 111–113
cultural adaptation system dynamics model 109–113
community‐based participatory treatment effectiveness 128–129
research 499–500 designs
ecological validity model 499 implementation research 516–521
see also indigenization see also models
cultural competence 620–624 destructive entitlement 323–324
see also cultural humility; social justice Detroit case study 497–506
cultural diversity, community‐based evaluation 504–506
participatory research 492–493 implementation phase 499–504
cultural‐historical approach, community‐ qualitative formative phase 497–499
based participatory research 492–493 sustainability 506
cultural humility 577–582 development 309–311
evaluation 581–582 attachment theory 7, 15–17
culture epigenetics 15–17
and assessment effects 612–613 global contexts 51–77
and attachment 395, 408 of infrastructure 763–764
attunement 619–637 multigenerational families 610–611
the Cold War 34–35 and public policy 63–66, 70–72
consumer self 41–43 of SFT 33–40, 51–77
and family 5, 79–81 of theories 303–309
future perspectives 756 and well‐being 12–17
Index 779
diabetes 133 education see training

diagnosis of illnesses 667 effectiveness and efficacy
Diagnostic and Statistical Manual (DSM) adult‐focused problems 125–127
changes to 603 anxiety disorders 130–131
rise of 38 attachment problems 120–121
dialogical engagement 306 average success rates 151
differentiation of the self 319 bipolar disorder 129–130
digital communication 351 child‐focused problems 120–125
direct change processes 173 cost‐effectiveness 134
directions to avoidance 764–765 depression 128–129
direct supervision 590 disruptive behavior disorders 122–123
direct treatment, expansion of 156 drug and alcohol problems 127–128
discourse, postmodern family eating disorders 123–124
therapy 425–426 evidence of 119–146
discrete time survival analysis 481–482 future research needs 134–137
discriminant stimuli 368 intimate partner violence 126–127
disengaged relationships 343 physical child abuse and neglect 121–122
disorganized attachment patterns 394 physical and somatic conditions 133–134
disruptive behavior disorders 122–123, 615 process research 171–204
dissemination of research 514–515 psychosis 131–132
diversity randomized clinical trials 446–454
community‐based participatory relationship distress 125–126
research 492–493 research innovations 445–465
future perspectives 756–757 sexual child abuse 122
doctoral degrees 563–566 technology in treatment 707–708
domestic violence 126–127, 539–541 effort, acknowledgment of 324
DP see deliberative practice EFT see emotionally focused therapy
drug problems 127–128 eight interlocking concepts, Bowen family
DSM see Diagnostic and Statistical Manual therapy 319–322
due diligence 551 elderly clients
dyads, feedback loops 101 interventions 18
dynamic systems models, process and spirituality 282
research 480–481 treatment effectiveness 133–134
dysfunctional family structures 85–87, 340 e‐learning 718–719
dysfunctional relational patterns as common electronic therapy, ethical considerations 543
factors 156 elements, of a system 98
emotional cutoff 320
early infant care, effects 15 emotional experiences, corrective 348
early intervention 17–18 emotional fusion 319–320
early models of systemic family emotionally focused therapy (EFT)
therapy 104–105 403–404
early toxic stress 15 change processes 182–185
earned security 400–401 transgenerational issues 333–334
eating disorders 123–124 emotional regulation
eclecticism 299 and attachment 12–13, 15, 332–335
ecological validity model (EVM) 499 and early infant care 15
ecomaps, and spirituality 280 and family of origin 332–333
economic evaluation, of therapeutic restoration therapy 334–335
interventions 134, 135 emotional triangles 319–320
ECR see Experiences in Close Relationships emotion‐focused therapy 333–334
Scale emotion models, Cognitive‐Behavioral
Ecuador 61 Couple and Family Therapy 380–382
780 Index
empirically supported treatments (ESTs) principles 533–536

limitations 452–454 privacy 537–538, 546–549
process research 176–185 Protected Health Information 546–549
and theoretical dilution 299 relational 535–536
see also evidence‐based practice remediation plans 550
empowerment 237 risk analysis 550
enactment safety 539–541
of family stress 341 security 545, 549
systemic 190–191 SLEEP model 534–536
endocrine system 209–211 sociocultural attunement 631–632
co‐regulation 211 of supervision 593–594
enmeshed relationships 343 triangles 536–537
entitlement, destructive 323–324 European Union, General Data Protection
epidemiology Regulation 549
adverse childhood experiences 83–84 evaluation
family environment effects 81–88 Detroit CBPR case study 504–506
social 84–88 of models 302–303
system dynamics 106–107 of supervision 592–593
epigenetic inheritance 15–17 see also assessment
epistemic disobedience 240–241 event designs, process research 468–470
equifinality and equipotentiality evidence, practice‐based 453–454
definition 102 evidence‐based practice 119–146
in supervision 585 adult‐focused problems 125–127
equity anxiety disorders 130–131
place, role of 627–628 attachment problems 120–121
responsibility toward 622–623 bipolar disorder 129–130
estrangement 19–20 child‐focused problems 120–125
ESTs see empirically supported treatments cost‐effectiveness 134
ethical commitment depression 128–129
and consumerism 44 disruptive behavior disorders 122–123
of theoretical development 300 drug and alcohol problems 127–128
ethics 533–554 eating disorders 123–124
AAMFT Code (2015) 537 future research needs 134–137
abuse reporting 539–540 intimate partner violence 126–127
advocacy 742–743 limitations 452–454
auditing 551 physical child abuse and neglect
boundaries 541–543 121–122
clients 538–539 physical and somatic conditions
confidentiality 537–538, 545–549 133–134
decision‐making models 534–536 process research 176–185
due diligence 551 psychosis 131–132
electronic therapy 543 relationship distress 125–126
HIPAA sexual child abuse 122
compliance 549–551 and theoretical dilution 299
Privacy Rule 545–549 evolution
Security Rule 545, 549 of SFT 33–40
minors 538–539 see also development
monitoring 551 exchanges of knowledge, community‐based
multilevel assessment 613–615 participatory research 493–494
official roles 550 exercise 218
policies and procedures 551 existential psychotherapy 279
positionality 543–545 expansion, of direct treatment 156
Index 781
expectancies operant conditioning 368–369

and change 153–154 projection process 321
cognitive therapy 377–378 redefining concepts of 79–95
social learning theory 370–371 relational processes assessment 21,
expected treatment responses 455–456 609–610
Experiences in Close Relationships Scale schemas 377
(ECR) 397 and sexual orientation 258–259
experiential theories 327–332 social epidemiology 84–88
Framo’s object relations/family‐of‐origin and spirituality 281
theory 325–327 and stress 341
Satir 330–331 subsystems 342
symbolic 328–329 synchrony, physiological 211–213
experimental designs, process research 472–473 therapeutic concepts 79–81
expertise 428, 493–494, 501–504 transgenerational theories 317–338
exploration phase, implementation and well‐being 12–17, 81–84
research 517–518 witnessing of suffering 665–666
extensions of general systems theory 102–103 family ledgers 323
family‐level terms 20–21
fact sheets 734, 746–747 family‐of‐origin/object relations
faith theory 325–327
toxic 282 family projection process 320
see also religion; spirituality family schemas 377
family businesses (FB) 690–694 family structure
family care 11 dysfunctional 85–87, 340
family cartographies 626–627 multilevel assessment 609
family crucible of illness 665–666 structural therapy 340–342
family/families family systems theory 298
and attachment 7, 12–13, 333, 393–395 Bowen 105, 319–322
behavioral interventions 372 Cognitive‐Behavioral Couple and Family
of choice 86–87 Therapy 383–384
companionate 34 illness model 666–668
contextual therapy 322–325 strategic therapy 347–364
co‐regulation, physiological 211 structural therapy 339–347, 359–364
and culture 5 family therapy
demographic changes 40–41 attachment‐based 178–179, 180,
development 610–611 404–405
domain of SFT 6 Bowen 105
and emotional regulation 332–333 brief strategic 178, 180, 356
epidemiology of 81–88 collaborative 423
estrangement 19–20 contextual 322–325
flexibility of involvement 8–9 discourse 425–426
hierarchies 102–103, 340, 342 ethics 537–539
ideological controversies 5–6 Framo’s object relations/family‐of‐origin
importance of 3, 5–7 theory 325–327
importance of therapy 11–18 functional 117–118, 180
institutional functions 5 historical challenges 37–38
mechanisms of change 8 integrated structural–strategic 359–360
multilevel assessment 608–611 mechanisms of change 177–179
development 610–611 medical 39–40, 659–681
family structure 609 challenges 672–675
genograms 608–609 education and training 661, 678
natural mentors 88 future research 677–678
782 Index
family therapy (cont’d) frameworks

health‐related knowledge 666–670 ADDRESSING 613
practical knowledge 670–672 ANVIET 629–631
successes 675–677 common factors 148
theory 662–666 iCARE lens 578–581
multidimensional 177, 180 Multidimensional Ecological Comparative
narrative 421–422 Approach 623–624
postmodern 417–442 suicide risk assessment 613–614
process research 177–180 WHO pyramid 10–11
reflexivity 426–427 Framo’s object relations/family‐of‐origin
Satir 330–331 theory 325–327
sociocultural origins 36–37 frequency of supervision 591–592
solution‐focused brief 419–421 fright without solution 394
strategic 104, 347–364 functional family therapy (FFT) 177–178, 180
structural 104, 339–347, 359–364 functional issues in families 85–87, 340
symbolic experiential 328–330 functions of attachment figures 7
transgenerational 317–338 fusion 319–321
FB see family businesses
feasibility, implementation outcomes gay see lesbian, gay, bisexual, transgender
522, 523 and queer
feedback GDPR see General Data Protection Regulation
common factors instruments 161–162 gender
formalized 152–153 definition of 260
in supervision 583–584 social construction 235
feedback loops gender dysphoria 253
Cognitive‐Behavioral Couple and Family gender essentialism 260
Therapy 383–384 gender expansive, definition of 260
concepts 100–101 gender expression, definition of 260
depression modeling 109–112 gender identity 251–271
FFT see functional family therapy competency barriers 261–262, 263–267
fidelity definition of 260
ethical 533 family acceptance and rejection 262–263
family therapy 180 important terms 259–261
implementation research 519–520, 522 and mental health 262
process research 173 gender identity disorder (GID) 253
see also treatment adherence ** same as gender transition, important terms 260
fight‐or‐flight response 207 General Data Protection Regulation
flexibility (GDPR) 549
family assessment 609–610 general systems theory (GST) 97–118
of therapists 149–150 advantages of 107
in therapy 8–9 core concepts 99–100
Foerster, H. von 426 cybernetics 100–101
formal assessment definitions 98–99
effects of 454–455 extensions 102–103
expected treatment responses 455–456 hierarchy 102–103
practice‐based research 454–456 historical time 103
formal education, global contexts 68–70 methodological advances 106–108
formalized feedback 152–153 motivation for 97
formal programs, SFT training 69–70 Palo Alto Group 101–102
formal theories, definition 296 personal choice 103
formats, for supervision 590–591 and SFT 103–106
four‐world view 729–730 system dynamics 106–112
Index 783
advantages 107 multilevel assessment

core concepts 108 to others 614–615
depression model 109–113 to self 613–614
rumination, stress and depression HCR‐20 615
111–113 healing circles 242–244
Generation PMTO 499–501 health‐care settings
genes, epigenetic modification 15–17 health‐related knowledge 666–670
genetic endowment 330 integration into 754–755
genetic nurture 16–17 practical knowledge 670–672
genograms Health Insurance Portability and
multilevel assessment 608–609 Accountability Act (1996) (HIPAA)
and spirituality 280 compliance 549–551
transgenerational theories 322 Privacy Rule 545–549
GID see gender identity disorder Security Rule 545, 549
global contexts 51–77 health modeling, system dynamics 106–107
formal education 68–70 health‐related knowledge, medical family
indigenization 72–73 therapy 666–670
localization 72–73 hermeneutics 425–426, 431
practice issues 70–73 heteronormative assumptions 257, 263–264
professional bodies 67–68 heterosexuals
public policy 63–66, 70–72 identity development 264–265
SFT development milestones 51–63 privilege 257–258, 264
global mental health (GMH) movement, hierarchies
WHO pyramid 10–11 and coloniality 231–232
global theories, postmodern family therapy 418 community‐based participatory
GMH see global mental health research 493–494
goals disrupting 240–241
divergent 674–675 families 102–103, 340, 342
of treatment 9, 585–586 general systems theory 102–103
God, definitions 274 naming of 239–241
government 696–697 place, role of 627–628
graduate research training 639–658 of power, privilege and oppression 230–232
core competencies 651–655 higher power, definition 274
data analysis 647–650 historical time, concept of 103
development of passion 641–642 history
focus 642–643 of common factors 147–149
mediation and moderation 648–649 community‐based participatory
need for 639–641 research 492–493
relevance 646–647 development of SFT 33–40, 297–300
research questions 643 family therapy challenges 37–38
systemic tools 644–650 LGBTQ experiences 251–271
grand narratives, postmodern family non‐western SFT 51–67
therapy 423–424 physiology systems usage 206
Great Depression, the 34 homeostasis
Greenberg, L.S. 333–334 concepts 101
green papers 733–734 in supervision 583–584
grey literature 733–734 systemic 349
grounded theory 471–472 homophobia 252–253, 256
growth models 648 homosexuality
civil rights 252–254
Hargrave, T. 334–335 see also lesbian, gay, bisexual, transgender
harm and queer; sexual orientation
784 Index
Hong Kong 54, 63, 66 implications

hope and change 153–154 of community‐based participatory
horizontal relationships 323–324 research 506–508
hormones 209–211, 211 of models 300–301
hospital‐based behavioral health importance of therapy 11–18
684–688 incapacitation 667
HPA see hypothalamic–pituitary–adrenal axis inclusion, redrawing boundaries 241–242
humanist theory 304 in‐country training 68–69
Human Potential Movement 36–37 India, SFT development 54–55, 64, 67
humility, cultural 577–582 indigenization
hypothalamic–pituitary–adrenal (HPA) community‐based participatory
axis 209–211, 218 research 499–500
of practice 72–73
IBCT see integrative behavioral couple therapy indirect change processes 173
iCARE lens 578–581 individuals
identification harms risk assessment 613–615
of medical patients 673 multilevel assessment 602–607
projective 326–327 clinical classification 603–604
identity harms 613–615
critical consciousness 236–237 mental illness 604–606
development 264–265 psychometric instruments 606–607
important terms 255–256, 259–261 structural family therapy 340
intersectionality 234–235, 621–624 induction 307–308
politics 40 infant care, early 15
sexual orientation 255–256 infrastructure development 763–764
ideologies of family relationships 5–6 inheritance, epigenetic 16
illness experiences innovations
diagnoses 667 effectiveness research 445–465
during course of 667 randomized clinical trials 446–452
initial presentation 675–676 in‐session interventions,
medical family history 664–665 physiological 216–217
onset 666 institutional functions, of families 5
pharmacology 668–670 institutional heterosexism 257
immigrants, and spirituality 283 institutionalized cissexism 261
impacts of therapists in interventions 577–582, integrated structural–strategic family
586–588 therapy 359–360
implementation, Detroit CBPR case integration
study 499–504 advocacy and professional identity
implementation fidelity 519–520 742–746
implementation research 513–529 into health‐care system 754–755
active implementation phase 519–520 new technologies 705–725
adoption/preparation phase 519 see also technological measures,
Consolidated Framework 518 integration
definitions 514–515 integrative behavioral couple therapy (IBCT),
designs 516–521 change processes 180–182, 183–184
dissemination 514–515 integrative process research 185–191
future directions 524–525 intensive longitudinal designs, process
phases 517–521 research methods 470
pre‐adoption phase 517–518 intentional communication
significance 515–516 advocacy 746–748
sustainment phase 520–521 LGBTQ affirmative 266–267
theory 521–524 interconnections of a system 98
Index 785
interdependence, general systems theory 100 justice 533–534, 756–757

internal processes, structural family see also social justice
therapy 340–341
International Classification of Diseases Kinsey Scale 256
(ICD) 603–604 knowing through changing 348
interpersonal synchrony 211–213 knowledge
interpretation, postmodern family construction of, postmodernism 417–418,
therapy 425–426 424–425
intersectionality 227–249, 255 exchanges of, community‐based
accountability 237–238 participatory research 493–494
biopsychosocial assessment 612–613 health‐related, medical family therapy
clinical practice 238–244 666–670
coloniality 231–232 instability of 418
critical consciousness 236–237 social cognition 373–374
cultural humility 577–582
decolonizing practice 625 language
empowerment 237 games 425
equity, responsibility toward 622–623 instability 418
gender, social construction 235 and knowledge construction 424–425
healing circles 242–244 medical family therapy 673–674
hierarchies 230–235 self and society 417–418
iCARE model 578–581 and truth 423–424
and identity 234–235, 621–624 latent variables 648
Multidimensional Ecological Comparative Latin America, SFT development 51–52,
Approach 623–624 59–61, 64–65
nuanced attention to context 623–624 LBH see liberation‐based healing
oppression 233–235 leadership, shared 493–494, 501–504
and place 624–629 learning
postmodern family therapy 433–434 community‐based participatory
power 232–233 research 500–501
privilege 233 deliberative practice 161
sociocultural attunement 619–637 operant conditioning 367–370
and supervision 577–582 see also training
therapist evaluation 577–582 legal issues 533–554
third‐order thinking 621–622 abuse reporting 539–540
see also community‐based participatory auditing 551
research boundaries 541–543
intersex, definition of 260 client identification 538–539
intimate partner violence 126–127, 539–541 confidentiality 537–538, 545–549
intimate relationships, emotion models decision‐making, ethical 534–536
380–384 due diligence 551
introjects 326–327 electronic therapy 543
invisible loyalty 323 ethical principles 533–536
invisible religions 283 HIPAA
Iran 58 compliance 549–551
irrelevant style 321 Privacy Rule 545–549
Israel 58, 68 Security Rule 545, 549
minors 538–539
Jackson, D. 102 monitoring 551
Japan 55–56, 65, 73 multilevel assessment 613–615
Johnson, S.M. 182–185, 333–334 official roles 550
Judeo‐Christian spirituality 276 policies and procedures 551
786 Index
legal issues (cont’d) localization, of practice 72–73

positionality 543–545 logic, non‐ordinary 350
privacy 537–538, 546–549 loneliness 13–14
Protected Health Information 546–549 longitudinal influences,
relational 535–536 transgenerational 330
remediation plans 550 longitudinal research
risk analysis 550 process research methods 470
safety 539–541 systemic alliances 187–188
security 545, 549 loyalty, invisible 323
in supervision 593–594
see also accreditation maintenance stage 150
lesbian, gay, bisexual, transgender and queer management settings 694–696
(LGBTQ) 251–271 MANOVA see multiple analysis of variance
Affirmative Therapy 254–267 MAR see missing at random
self‐of‐the‐therapist 263–267 marginalized populations
theoretical underpinnings 254–255 chosen families 86–87
civil rights 252–254 community‐based participatory
competency barriers 257–258, 263–267 research 491–511
families of choice 86–87 social justice 492–493
family acceptance and rejection 258–259, natural mentors 88
262–263 social epidemiology 85–88
historical and social context 252–254 social justice 492–493
impacts of barriers 258 see also intersectionality; lesbian, gay,
important terms 255–257, 259–261 bisexual, transgender and queer
intentionally affirmative marginalized sexualities 255–256
communication 266–267 marriage advantage 14
as a label 255–256 marriage counseling
and mental health 258, 262 development of 34–35
natural mentors 88 see also couple therapy
social epidemiology 85–88 Marriage and Family Therapy Practice
see also gender identity; sexual orientation Research Network (MFT‐PRN) 457,
liberated self 37 459–460, 477
liberation‐based healing (LBH) 227–249 marriage and well‐being 14, 81–82
accountability 237–238 master’s degrees 562–563
clinical practice 238–244 research training 639–658
concepts 230–235 core competencies 651–652, 654
critical consciousness 236–237 data analysis 647–650
empowerment 237 development of passion 641–642
healing circles 242–244 focus 642–643
praxis 235–244 need for 639–641
licensure, professional 567–568 relevance 646–647
life cycles research questions 643
common relational processes 21 systemic tools 644–650
family development 610–611 matrix of coloniality 231–232
and spirituality 281 MCAR see missing completely at random
Likert scales, supervision evaluation 592–593 MDFT see multidimensional family therapy
limitations of evidence‐based practice 452–454 meaning, instability of 418
literature, finding gaps 107 meaningful systems 611–612
litigation, advocacy 735–736 measurement
little o’s see mediating change processes attachment in adults 396–399
live supervision 590 postmodern family therapy 427–428,
lobbying 735–736 430–432
Index 787
practice‐based research 456–459 family environment effects 81–88

process research 474–477 multilevel assessment 604–606
see also assessment and place 627–628
MECA see Multidimensional Ecological and sexual orientation 258
Comparative Approach social epidemiology 84–88
mechanisms of change 173 and spirituality 274–275
couple therapy models 180–183 trait transmission 17
family relationships 8 see also psychopathology
family therapy models 177–179 Mental Research Institute (MRI) 298, 330,
systemic alliances 185–187 355–356
MedFT see medical family therapy mentors, natural 88
mediating change processes 172 methodological advances, general systems
couple therapy models 180–183 theory 106–108
family relationships 8 methodological considerations, process
family therapy models 177–179 research 473–477
systemic alliances 185–187 Mexico 52, 61, 66–67
mediation 648–649 MFT‐PRN see Marriage and Family Therapy
medical family therapy (MedFT) 39–40, Practice Research Network (MFT‐PRN)
659–681 mHealth devices 709–711
biopsychosocial–spiritual Middle East 58
perspective 662–666 middle‐range theories, definition 296
challenges 672–675 Milan group 298, 356–357
collaboration 670–672 military settings 688–690
cost‐effectiveness 675–677 mind–body–feeling triad 331
development 659–660 mindfulness
diagnoses 667 physiological interventions 218
during course of 667 transgenerational theories 333–335
education and training 661, 678 minimum necessary standards,
future research 677–678 PHI 548–549
health‐related knowledge 666–670 minors see adolescents; children
illness experiences 664–665 Minuchin, S. 104, 339–347
incapacitation 667 mirror neurons 7
language 673–674 missing at random (MAR) data 449
at onset 666 missing completely at random (MCAR)
patient identification 673 data 449
personal suffering 665–666 missing data 107, 448–450
pharmacology 668–670 mixed methods models 107
practical knowledge 670–672 mixture modeling 650
practice of 668 mobile phones 541–542, 709–711
predictability 667–668 mobility 626
presentation of illness 675–676 modality
research 677–678 considerations 23–24
successes 675–677 efficacy questions 453
theory 662–666 models
time constraints 672–673 actor–partner interdependence 480
treatment goals 674–675 assumptions 300, 304–305
medications 668–670 attachment 393–394
mental health biopsychosocial–spiritual 662–666
and attachment 402–403 circumplex 346–347
and childhood experiences 11–17, 83–84 Cognitive‐Behavioral Couple and Family
disparity reduction 494–495 Therapy 366–372, 374–385
and epigenetic inheritance 17 cognitive therapy 380–382
788 Index
models (cont’d) multigenerational families

as common factors 159–160 multilevel assessment 608–611
common fate 648 transmission process 321
community‐based participatory multilevel assessment 601–618
research 495–497 clinical classifications 603–604
Community of Scholars 564 cultural factors 612–613
Consolidated Framework for ethics 613–615
Implementation Research 158 family structure 609
definition 296 genograms 608–609
depression 109–113 harm
dynamic systems 480–481 to others 614–615
emotional 333–334, 380–384 to self 613–614
ethical decision‐making 534–536 individuals 602–607
evaluation 302–303 clinical classifications 603–604
family systems illness 666 mental illness 604–606
growth 648 psychometric instruments 606–607
illness, family systems 666 larger systems 611–612
implementation research 516–521 legal issues 613–615
implications 300–301 mental illness 604–606
modern 174 multigenerational families 608–611
postmodern family therapy 175–176, 305, development 610–611
419–423 genograms 608–609
process research 479 processes 609–610
randomized clinical trials 446–450 structure 609
Relational Suicide Assessment 614 psychometric instruments 606–607
rumination, stress and depression 111–113 multilevel modeling
Star Researchers 564 graduate research training 649–650
statistical 650 process research 479
of supervision 588–589 randomized clinical trials 446–450
systemic 174 multimodal programs, future research
moderating variables 173 needs 136
couple therapy models 183–185 multimodal synchrony 211–213
family therapy models 180 multiple analysis of variance (MANOVA) 447
therapeutic alliances 187 multisystemic therapy (MST) 177, 180
moderation 648–649
modern models, process research 174 naming, of hierarchical structures 239–241
monitoring systems narrative therapy 279, 421–422
HIPAA compliance 551 National Institute of Mental Health (NIMH),
practice‐based research 456–457 Research Domain Criteria 604
monological theorizing 305–306 natural mentors 88
morphogenesis 584 negative attachment change 400
morphostasis 584 negative binomial distributions 650
motion energy designs 471 negative feedback, concepts 101
motivational interviewing 150–151 negative tracking 372–373, 377–378
movement tracking devices 714 neglect 121–122
MRI see Mental Research Institute networks, practice‐based research 459–461
MST see multisystemic therapy NMAR see not missing at random
Multidimensional Ecological Comparative nonbinary, definition of 260
Approach (MECA) 623–624 nonbinary clients
multidimensional family therapy competency barriers 261–262, 263–267
(MDFT) 177, 180 family acceptance and rejection 262–263
multidirected partiality 324–325 important terms 259–261
Index 789
and mental health 262 dysfunctional relational patterns 156

see also gender identity; lesbian, gay, expectancy 153–154
bisexual, transgender and queer feedback instruments 161–162
nonmaleficence 533 formalized feedback 152–153
non‐ordinary logic 350 history of 147–149
nonresponders, future research needs 136 hope 153–154
North Carolina, US, occupational research 163–165
board 741–742 resource development 163
not missing at random (NMAR) data 449 therapeutic alliances 151–153, 156–159,
nuance, attention to context 623–624 185–189
nuclear family emotional process 320 therapists 149–150, 152–153, 158–165
nurture, genetic 16–17 training 159–160
couple therapy 180–185
OBE see outcome‐based education emotionally focused couple
objective measures, process research 476–477 therapy 182–185
object relations/family‐of‐origin theory family therapy 177–180
325–327 functional family therapy 177–178, 180
observational (direct) supervision 590 multidimensional family therapy 177, 180
observational measures, process research multisystemic therapy 177, 180
474–476 process research 171–204
official roles, HIPAA compliance 550 attachment‐based family therapy
onset of illnesses 666 178–179, 180
open systems behaviorally focused couple
definition 100 therapies 180–182
in supervision 584 brief strategic family therapy 178, 180
operant conditioning 367–370 client system engagement 189
oppression couple therapy 180–185
coloniality 231–232 definitions 172–173
community leaders’ voices 502–503 emotionally focused couple
hierarchies 230–235 therapy 182–185
multilevel assessment 612–613 empirically supported
sexual orientation 256–257 treatments 176–185
ordeals, strategic family therapy 355 family therapy 177–180
organization, of supervision 589–590 functional family therapy 177–178, 180
organized attachment patterns 393–394 future research 191–193
outcome‐based education (OBE) 558–560 general schools of family
outcomes therapy 173–176
clarity of goals 585–586 integrative 185–191
strategic family therapy 354–355 models 174–176
taxonomies of implementation 521–524 multidimensional family therapy 177, 180
outcome variance multisystemic therapy 177, 180
attachment‐based family therapy retention 189
178–179, 180 systemic enactments 190–191
behaviorally focused couple systemic reframing 189–190
therapies 180–182 therapeutic alliances 185–189
brief strategic family therapy 178, 180 in training 193–194
change processes 172–173 variables 172–173
client system engagement 189 retention 189
common factors 147–169 systemic alliances 185–189
clients 150–154, 157–158 systemic enactments 190–191
conceptual difficulties 154–155 systemic reframing 189–190
direct treatment expansion 156 therapeutic alliances 185–189
790 Index
out‐of‐session interventions, physiological 218 social epidemiology 84–88

oxytocin 210, 217 see also medical family therapy
physical movement tracking devices 714
pain cycle, restoration therapy 335 physical transitions 260
Palo Alto Group 101–102, 330 physiology 205–224
paradigms, definition of 296 assessment 209, 214–215
paradoxical prescriptions 353–355 and attachment 207–211
parasympathetic nervous system (PNS) autonomic nervous system
207–209 207–209
parent alliances 179 biofeedback 214, 216–217, 711–712
participatory research see community‐based client awareness 215–216
participatory research; practice‐based co‐regulation 211
research endocrine system 209–211
partner buffering 401–402 and exercise 218
Partners for Change Outcome Management future directions 218–220
System (PCOMS) 430–431 historical considerations 206
patients see clients in‐session interventions 216–217
PCOMS see Partners for Change Outcome in interventions 213–218
Management System out‐of‐session interventions 218
peace cycle 335 process research measurements 476
penetration, of implementation 523–524 and self‐regulation 209, 218
perceptive–reactive system 349–352 synchrony 211–213
perceptual bias 372–373 Pinsof, W. 172
personal choice 103 placating style 321
personal integration 162 place 624–629
personal representatives 548 assessment of 625–627
personal suffering 665–666 common factors 628–629
personal theories in social cognition 373–374 equity, culture and health
Peru 52, 61, 64, 66 627–628
Pfitzer, F. 334–335 placebo effects 154
pharmacology 668–670 Poisson distributions 650
phases polarization 40
common factors 150–151 policy
community‐based participatory research advocacy continuum 735–737
497–504 briefs 733, 747
implementation research 517–521 in clinical world 737
PhD programs 566 communication 746–748
research training 639–658 construction 740, 746–748
core competencies 652–653, 655 fact sheets 734, 746–747
data analysis 647–650 financial 739
development of passion 641–642 four‐world view 729–730
focus 642–643 HIPAA compliance 551
need for 639–641 importance of 729–751
relevance 646–647 lobbying 735–736
research questions 643 North Carolina occupational board
systemic tools 644–650 741–742
physical abuse in operational world 738–739
adult treatment effectiveness 126–127 settings 696–697
child treatment effectiveness 121–122 systems theory 731–735
physical health 133–134 white papers 733–734, 747–748
and childhood experiences 12–13, 83–84 policy briefs 733, 747
family environment effects 81–88 political anxieties 6
Index 791
politics networks 459–461

of identity 40 therapist reluctance 456
LGBTQ rights 252–254 practice issues
polarization 40 global contexts 70–73
postmodern therapy 418–419 indigenization 72–73
therapy as action 507–508 localization 72–73
polyvagal theory 207–209 practice research networks (PRNs) 459–461,
positive attachment change 400–402 565–566, 758
positive feedback 101 pragmatism and theoretical dilution 299
postmodern family therapy 417–442 pre‐adoption phase 517–518
approaches 432–433 pre‐contemplation stage 150
collaborative therapy 423 predictability of illnesses 667–668
concepts 417–418 preparation
deficits to strengths 428–430 advocacy conversations 746
discourse 425–426 fact sheets 746–747
expertise 428 phases 519
external‐to‐therapy changes 433–434 policy briefs 747
future directions 434–435 white papers 747–748
global theories 418 prescriptions 353–355
grand narratives 423–424 presentation, of medical patients 675–676
interpretation 425–426 preventative fractions 650
interventions 432–434 primary emotions 334–335
knowledge construction 424–425 primary survival triad 330
measurement 427–428, 430–432 privacy
models 175–176, 305, 419–423 and confidentiality 537–538, 546–549
narrative therapy 421–422 HIPAA Rule 545–549
politics 418–419 medical settings 673
process research 175–176 privilege
reflexivity 426–427 cisgender 262, 264
solution‐focused brief therapy 419–421 coloniality 231–232
subjectivity 426–427 heterosexual 257–258
truth, and grand narratives 423–424 hierarchies 230–233
poststructuralism 425 intersectionality 233
post‐traumatic stress disorder (PTSD) 716 PRNs see practice research networks
family‐level terms 20 problem solving, behavioral model 369
power procedures, HIPAA compliance 551
coloniality 231–232 processes of supervision 589–593
community‐based participatory process research 171–204, 467–489
research 493–494 accelerometers 476–477
family structure 342 actor–partner interdependence models 480
and hierarchies 102–103, 230–235 analysis 473–474, 478–483
intersectionality 232–233 actor–partner interdependence
practical knowledge, medical family models 480
therapy 670–672 Bayesian 478
practice‐based evidence 453–454 discrete time survival analysis 481–482
practice‐based research 452–461 dynamic systems models 480–481
benchmarking 457–459 multilevel models 479
evidence 456–459 sequential 482–483
expected treatment responses 455–456 time series 479–480
formal assessment 454–456 units of 473–474
measurement 456–459 attachment‐based family therapy
monitoring systems 456–457 178–179, 180
792 Index
process research (cont’d) process variables 172–173

Bayesian analysis 478 professional accreditation 557–568
behaviorally focused couple approved supervisor designation
therapies 180–182 594–595
brief strategic family therapy 178, 180 COAMFTE standards 557–558
client system engagement 189 competency movement 559–560
coder training 475–476 doctoral degrees 563–566
couple therapy 180–185 licensure 567–568
definitions 172–173 master’s degrees 562–563
discrete time survival analysis 481–482 post‐degree programs 566
dynamic systems models 480–481 research 560–561, 568
emotionally focused couple therapy professional bodies 67–68, 557
182–185 professional development
empirically supported treatments 176–185 deliberative practice 161
event designs 468–470 personal integration 162
experimental designs 472–473 post‐degree programs 566
family therapy 177–180 sociocultural attunement 631–632
functional family therapy 177–178, 180 and theory 312–313
future needs in 136–137, 191–193, training 159–160
483–484 professional ethics 533–554
general schools of family therapy 173–176 see also ethics
grounded theory 471–472 projection, family process 320
integrative 185–191 projective identification 326–327
intensive longitudinal designs 470 propensity score analysis 450–452
measurement 474–477 propensity score matching 649–650
methodological considerations 473–477 Protected Health Information 546–549
methods 468–473 proximity‐seeking behaviors 393–394
modern models 174 psychoanalytic influences, transgenerational
motion energy designs 471 theories 318
multidimensional family therapy 177, 180 psychodynamic theory 304
multilevel modeling 479 psychometric instruments 606–607
multisystemic therapy 177, 180 psychopathology
objective measures 476–477 and attachment 402–403
observational measures 474–476 see also mental health
physiological measurement 476 psychophysiological processes 207–211
postmodern models 175–176 autonomic nervous system 207–209
recruitment 473 client education 215–216
retention 189, 473 co‐regulation 211
sample sizes 473–474 endocrine system 209–211
self‐reporting 476 synchrony 211–213
sequential analysis 482–483 psychosis 131–132
settings 477 psychosomatic illnesses 345–347
strategic family therapy 355–357 PTSD see post‐traumatic stress disorder
structural family therapy 345–347 public policy
systemic enactments 190–191 global development of SFT 63–66
systemic models 174 importance of 18
systemic reframing 189–190 systems models 107
technological measures 476–477 public self 44–45
therapeutic alliances 185–189 purpose
time series analysis 479–480 clarity of 585–586
in training 193–194 of a system 98
variables 172–173 pursuer softening 182
Index 793
queer therapist positionality 543–545

definition of 256 and well‐being 12–17, 87–88
theory 254–255 relevance of graduate research
see also lesbian, gay, bisexual, transgender training 646–647
and queer religion 273–292
client needs in therapy 276–277
racial minorities, and spirituality 282–283 coping strategies 280
Raising Children with Love, Promoting definition 274
Harmony and Self‐Improvement and families 6, 281
(CAPAS) study 499–500 and life cycles 281
randomized clinical trials (RCTs) sexual taboo 281
446–452 of therapists 277–278
analysis of variance 446–447 and vulnerable populations 282–283
limitations 452–454 see also spirituality
missing data 448–450 religiosity, definition 274
multilevel modeling 446–450 religious coping strategies 280
propensity score analysis 450–452 remediation plans, HIPAA compliance 550
RDoC see Research Domain Criteria research
reattachment tasks 179 accreditation 560–561, 568
reciprocal causality 583 and advocacy 744–745
recording, supervision 590–591 attachment 392–394, 405–408
recruitment, process research 473 common factors 163–165
recursion 583 community‐based participatory 491–511
reflecting teams 426 action‐oriented 494
reflexivity, postmodern therapy 426–427 advocacy 494, 504
reframing, strategic therapy 353 concepts 492–495
rejection by families, and sexual orientation cultural diversity 492–493
258–259 Detroit case study 497–506
relational ethics 535–536 expertise 493–494, 501–504
relational focus 621 implications for the field 506–508
relational interventions for physiological leadership 493–494, 501–504
interventions 217 mental health disparities 494–495
relational patterns models 495–497
as common factors 156 power relationships 493–494
therapeutic alliances 151–153, 156–159 social justice 492
relational reframing 178–179 sustainability 495, 506
relational self 43–46 training 500–501
and commitment 43–44 development of passion 641–642
public dimensions 44–45 effectiveness
and therapy 45–46 and efficacy 119–146
Relational Suicide Assessment model 614 innovations 445–465
relationship distress 125–126 effectiveness and efficacy 134–137
relationships emotion in couple and family
attachment theory 7 relationships 381–382
common processes 21 future directions 757–760
disengagement 343 graduate training 639–658
enmeshment 343 core competencies 651–655
families of choice 86–87 data analysis 647–650
and loneliness 13–14 development of passion 641–642
“marriage advantage” 14 focus 642–643
models of emotion 380–384 need for 639–641
natural mentors 88 relevance 646–647
794 Index
research (cont’d) safety

research questions 643 ethical considerations 539–541
systemic tools 644–650 harms assessment 613–615
mediation and moderation sample sizes, process research 473–474
648–649 Satir, V. 330–331
medical family therapy 677–678 scapegoating 329
need for 639–641 schemas 376–377
networks, practice‐based 459–461 scholarship, and advocacy 744–745
practice‐based 452–461 scientific facts 301
benchmarking 457–459 scientific theories 296, 301
evidence 456–459 SD see system dynamics
expected treatment responses secondary emotions 334–335
455–456 second‐order change 349
formal assessment 454–456 second‐order cybernetics 426
measurement 456–459 security
monitoring systems 456–457 HIPAA Rule 545, 549
networks 459–461 risk analysis, HIPAA compliance 550
therapist reluctance 456 selective attention 377
randomized clinical trials 446–452 self
missing data 448–450 as consumer 41–43
multilevel modeling 446–450 differentiation of 319
propensity score analysis 450–452 harm to 613–614
relevance 646–647 liberated 37
settings 477 public dimensions 44–45
social cognition 372–374 relational 43–46
strategic family therapy 355–357 self‐awareness
structural family therapy 345–347 of clients 150–151
see also implementation research; process of physiology 215–216
research of therapists 150
Research Domain Criteria (RDoC) 604 self‐care 11
resistance, strategic family therapy 352 self‐healing 151
resource development, common self‐help applications 713–714
factors 163 self‐of‐the‐therapist
responsibilities, during supervision 586 conceptualizing difficulties 154–155
restoration therapy (RT) 334–335 cultural humility 577–581
retention, process research 189, 473 iCARE model 578–581
ReThink Health Dynamics Model 106 intersectionality evaluation 577–582
revolving slate, transgenerational 323 LGBTQ Affirmative Therapy 263–267
risk analysis practice enhancement 160–162
harms assessment 613–615 sociocultural attunement 629–631,
HIPAA compliance 550 631–632
risk ratios, attributable 650 and spirituality 284
role(s) self‐reflexivity 426–428
of place 624–629 self‐regulating truth 335
in supervision 586 self‐regulation
of therapy 3–24 physiological interventions 218
Rosenweig, S. 147 and vagal tone 209
RT see restoration therapy self‐reporting
rules, in supervision 584 attachment assessment 397–398
rumination, stress & depression model process research 476
111–113 sequential analysis, process
Russia 62, 72, 72–73 research 482–483
Index 795
settings community‐based participatory

process research studies 477 research 492–493
see also context development of 39–40
sex, definition 260 and families 6
sexual abuse 122 postmodern family therapy 433–434
sexual control, and religions 281 social learning theory 367–372
sexual minorities cognition 370–371
families of choice 86–87 operant conditioning 367–370
as a label 255–256 and social exchange theory 369
natural mentors 88 social media 542, 734
social epidemiology 85–88 social stressors, and mental health 17
see also lesbian, gay, bisexual, transgender social transition, in gender transition 260
and queer societal regression 321
sexual minority prejudice 256 sociocultural attunement 619–637
sexual orientation 251–271 ANVIET guidelines 629–631
competency barriers 257–258, 263–267 assessment of place and space 625–627
family acceptance and rejection 258–259 common factors 628
impacts of barriers 258 competences 620–624
important terms 255–257 decolonizing practice 625
and mental health 258 equity, role of 627–628
and oppression 256–257 ethics 631–632
SFBT see solution‐focused brief therapy future directions 632–633
SFT (systemic family therapy) see therapy nuance and context 623–624
shared leadership 493–494, 501–504 and place 624–629
sibling position 321 relational focus 621
simulation‐based learning 719–720 responsibility toward equity 622–623
simulation‐based systems modeling 106–109 self‐of‐the‐therapist 631–632
see also system dynamics third‐order thinking 621–622
Singapore 56 sociocultural origins
situation, of systems 98 couples therapy 34–35
skills, deliberative practice 161 family therapy 36–37
SLEEP model 534–536 solution‐focused brief therapy (SFBT)
smallest change possible, strategic family 419–421
therapy 355 somatic complaints 133–134
smartphones 709–711 South Africa 52, 53
smart speakers 716–717 South America 51–52, 59–61, 64–65
social cognition South Korea 56–57, 63–64
behavioral model integration space
373–374 assessment of 625–627
knowledge structures 373–374 common factors 628–629
research 372–374 equity, culture and health 627–628
social learning theory 367–372 speciality settings 683–703
social construction 305 administration 694–696
of family 80 family businesses 690–694
future research needs 136 government and policy 696–697
of gender 235 hospital‐based behavioral health
social epidemiology 684–688
family environment effects 84–88 management 694–696
LGBTQ communities 85–88 military 688–690
social exchange theory 369 specific event designs 469
social justice spiritual bypass 281–282
advocacy 743–744 spiritual consultations 284
796 Index
spirituality 273–292 critiques 345

adapting to therapy 280 family stress 341, 342–343
and assessment 279–280 family structure 340–342
client needs in therapy 276–277 future of 347
of clients 275–277 hierarchies and power 342
competences 283–284 individuals 340
definition 274 internal processes 340–341
and families 281 psychosomatic illnesses 345–347
incorporation into treatment 278–280 research 345–347
and life cycles 281 strategic therapy integrated 359–360
medical family history 662–666 subsystems 342
and mental health 274–275 theoretical updates 343–345
and self‐of‐the‐therapist 284 structuralism 304
sexual taboo 281 structural issues in families 85–87, 329,
of therapists 277–278 340–342, 609
and treatment considerations 280–283 see also family structure
and vulnerable populations 282–283 structure, battle for 329
spiritual minorities 283 Subjective Units of Distress Scale
split alliances 157 (SUDS) 476
standards, cognitive therapy 376 subjectivity, postmodern family
Star Researcher model 564 therapy 426–427
state‐space grids 481 substantive theories, definition 296–297
statistical models 650 subsystems, family structure 342
stepped care 10–11 SUDS see Subjective Units of Distress Scale
stimulus control 368 suicide risk assessment 613–614
strategic family therapy 104, 347–364 super‐reasonable style 321
approaches 355–357 supervision 577–600
attempted solutions 349 advocacy 745
brief strategic 356 approved supervisor designation 594–595
communication 351–352 boundaries 584
concepts 348–352 contextual factors 577–582
corrective emotional experiences 348 contracting 591–592
critiques 357–358 equifinality & equipotentiality 585
future directions 358–359 ethical and legal issues 593–594
knowing through changing 348 evaluation 592–593
Mental Research Institute 355–356 feedback systems 583–584
Milan group 356–357 formats 590–591
perceptive–reactive system 349–352 frequency 591–592
resistance 352 homeostasis 583–584
strategies 352–355 models 588–589
structural therapy integrated 359–360 morphogenesis 584
systemic homeostasis 349 morphostasis 584
strengths, postmodern family therapy 428–430 open/closed systems 584
stress, rumination and depression 111–113 organization of 589–590
structural family therapy 104, 339–347, processes 589–593
359–364 purpose and goals 585–586
alignment 343 reciprocal causality/recursion 583
alliances 342 recording 590–591
assumptions 340–343 roles and responsibilities 586
boundaries 343 rules 584
change processes 341 self‐awareness 577–582, 586–588
circumplex model 346–347 spiritual issues 284
Index 797
systemic thinking 582–585 non‐western development 51–67

technological innovations 720–721 research complexity 21–23
training 594–595 theoretical dilution 298–300
Supervision Social Location Map theory 295–316
Forms 578, 579 see also clinical practice; therapy
survival analysis 650 systemic homeostasis 349
sustainability systemic models, process research 174
community‐based participatory systemic processes of change 173
research 495, 506 systemic reframing, process research 189–190
implementation research 523, 524 systemic thinking, in supervision 582–585
sustainment phase, implementation system‐involved clients, relationship
research 520–521 building 87–88
Swivl 718 systems
symbolic interactionism and spirituality 278 biopsychosocial assessment 602–613
sympathetic nervous system (SNS) 207, 209 cultural factors 612–613
assessment 209, 214–215 harm to others 614–615
co‐regulation 211 harm to self 613–614
synchrony 211–213 individuals 602–607
synchrony larger 611–612
motion energy designs 471 multigenerational families 608–611
physiological 211–213 definitions of 98–99
therapist–client 211–213 meaningful 611–612
system dynamics (SD) 106–112 situation of 98
core concepts 108 in supervision 577–585
depression model 109–113 systems models
rumination, stress and depression advantages of 107
model 111–113 methodological advances 106–108
systemic, definition 4 systems theory 97–118
systemic alliances advantages of 107
longitudinal research 187–188 core concepts 99–100
process research 185–189 cybernetics 100–101
systemic collaboration, medical family extensions 102–103
therapy 670–672 future research 757–760
systemic data analysis 647–650 hierarchy 102–103
systemic enactments, process research 190–191 historical time 103
systemic family therapy (SFT) methodological advances 106–108
core concepts 4, 8–18, 103–106 motivation for 97
cost‐effectiveness 134 Palo Alto Group 101–102
current status of 40–46 personal choice 103
defining characteristics 8–11 role in policy 731–735
development of 4, 33–40 and SFT 103–106, 298
early models 104–105 system, definition of 98–99
efficacy and effectiveness 119–146 system dynamics 106–112
family, definitions of 79–81 advantages 107
flexibility 8–9 core concepts 108
general systems theory 103–106 depression model 109–113
global contexts 51–77 rumination, stress and
importance of 11–18 depression 111–113
indigenization 72–73
localization 72–73 Taiwan 57, 65–66, 72–73
modalities 23–24 TAMFT see Texas Association for Marriage
modern forms 105–106 and Family Therapy
798 Index
task sharing 11 medical family therapy 662–666

task shifting 11 in practice 303
taxonomies of implementation outcomes and research 312
(TIO) 521–524 of social learning 367–372
TBCT see traditional behavioral couple therapy and training 312–313
technical eclecticism 299 transgenerational 317–338
technological measures therapeutic alliances 151–153, 156–159
acceptability 706–707 clinical variables 158
artificial intelligence 717 contexts of change 187
effectiveness 707–708 formalized feedback 152–153
integration 705–725 impacts of therapists 577–582, 586–588
mobile technologies 709–711 longitudinal research 187–188
movement tracking devices 714 outcome variables 186–187
process research 476–477 process research 185–189
self‐help applications 713–714 split 157
smart speakers 716–717 therapist variables 158–159
supervision 590–591, 720–721 within‐couple 157–158
training 718–720 therapeutic attachment change 402
videoconferencing 708–709, 718–719 therapeutic rituals 355
video games 714–715 therapists
virtual reality 715–716 common factors 149–150, 152–153,
voice assistants 716–717 158–165
web‐based interventions 713–714 conceptualizing difficulties 154–155
Texas Association for Marriage and Family deliberative practice 161
Therapy (TAMFT) 735–736 enhancement of practice 160–162
theoretical dilution 298–300 impacts in interventions 577–582, 586–588
theorizing 296 LGBTQ affirmative 264–267
abduction 308–309 physiologic syncrony 211–213
critical 306 positionality ethics 543–545
deduction 306–307 reluctance, practice‐based research 456
induction 307–308 self‐evaluation 577–582, 631–632
monological 305–306 sociocultural attunement 619–637
theory spirituality 277–278
and abduction 308–309 therapeutic alliances 151–153, 158–159
assumptions 304–305 training, as a common factor 159–160
of attachment 7, 392–402 therapy
avoidance of 302 average success rates 151
classifications of 296–297 best practice 19–24
Cognitive‐Behavioral Couple and Family client spiritual needs in 276–277
Therapy 366–372 common factors 147–149
common obstructions 301–302 cost‐effectiveness 134
concepts of 295–316 early intervention 17–18
and deduction 306–307 efficacy and effectiveness 119–146
definition of 296 ethical considerations 533–554
development 303–309, 309–311 legal considerations 533–554
dialogical engagement 306 as a political act 507–508
dilution 298–300 and relational self 45–46
function of 297 role of 3–24
future directions 309–311, 757–760 stepped care 10–11
history and foundations 297–300 see also clinical practice
implementation research 521–524 thinking outside the box, strategic family
and induction 307–308 therapy 352–353
Index 799
third‐order thinking 621–622 trends 566–567, 765–766

threats, polyvagal theory 207–209 virtual reality 719–720
time constraints, medical settings 672–673 transgender, definition of 260
time series analysis, process transgender clients
research 479–480 competency barriers 261–262, 263–267
TIO see taxonomies of implementation family acceptance and rejection 262–263
outcomes important terms 259–261
touch, physiology 217 and mental health 262
toxic faith 282 see also lesbian, gay, bisexual, transgender
toxic stress, early 15 and queer
traditional behavioral couple therapy (TBCT), transgenerational theories 317–338
change processes 180–182, 183–184 Bowen family therapy 319–322
training 555–575 contextual family therapy 322–325
accreditation 557–568 current 332
administration and management emotionally focused couple therapy 333–334
settings 694–696 experiential 327–332
advocacy 740, 745 Framo’s object relations/
approved supervisor designation 594–595 family‐of‐origin 327–332
COAMFTE standards 557–558 mindfulness 333–335
coders 475–476 restoration therapy 334–335
as a common factor 159–160 Satir 330–331
community‐based participatory symbolic 328–330
research 500–501 third iteration 332–335
competency movement 559–560 transmission, multigenerational 321
deliberative practice 161 transparency, liberation‐based
doctoral degrees 563–566 healing 239–241
family businesses 692–694 transpersonal psychology 279
future directions 760–763 transphobia 252, 260–261
government and policy settings 696–697 treatment
HIPAA compliance 551 divergent goals 674–675
hospital‐based behavioral health 686–688 goals of 9
licensure 567–568 times 672
master’s degrees 562–563, 639–658 treatment adherence
medical family therapy 659–681, 678 family therapy 180
military settings 690 see also fidelity ** same as
outcome‐based 558–560 triangles, ethics 536–537
pitfalls 764–765 triangulation, emotional 319–320
post‐degree programs 566, 639–658 truth, postmodern family therapy 423–424
practice research networks 565–566 type 1 diabetes 133
process research 193–194
research 560–561, 568, 639–658 unconscious representations, attachment
core competencies 651–655 strategies 396–397
data analysis 647–650 under‐researched populations
development of passion 641–642 community‐based participatory
focus 642–643 research 491–511
need for 639–641 future research needs 135–136
relevance 646–647 United States
research questions 643 Health Insurance Portability and
systemic tools 644–650 Accountability Act (1996) 545–551
for supervision 594–595 North Carolina occupational
technological innovations 718–720 board 741–742
and theory 312–313 professional associations 557
800 Index
units of analysis, process research vulnerable populations, and spirituality

studies 473–474 282–283
“unrecognized factors” 147
see also common factors web‐based interventions 713–714
well‐being
vagal tone 209, 214 and childhood experiences 12–13, 14–17,
variables 83–84
latent 648 and loneliness 13–14
process research 172–173 and marriage 14, 81–82
vasopressin 210 and relationships 12–17, 81–84
veracity 533 social epidemiology 84–88
vertical relationships trait transmission, environmental 17
sibling position 321 white papers 733–734, 747–748
transgenerational 323–324 WHO see World Health Organization
see also hierarchies pyramid
videoconferencing 708–709, 718–719 win‐win outcomes 354–355
video games 714–715 withdrawer reengagement 182
video recording 590–591 within‐couple alliances 157–158
violence witnessing of personal suffering
risk assessment 614–615 665–666
see also abuse; domestic violence; intimate Wittgenstein, L. 425
partner violence World Health Organization (WHO)
virtual reality (VR) 715–716, 719–720 pyramid 10–11
voice assistants 716–717
VR see virtual reality zero‐inflated Poisson distributions 650
EDITORIAL BOARD
EDITOR‐IN‐CHIEF
Karen S. Wampler
ASSOCIATE EDITORS
Volume 1
Richard B Miller
Provo, UT, USA
Ryan B. Seedall
Logan, UT, USA
Volume 2
Lenore M. McWey
Volume 3
Adrian J. Blow
Volume 4
Mudita Rastogi
Aspire Consulting and Therapy
Arlington Heights, IL, USA
Reenee Singh
Association for Family Therapy and Systemic Practice and
The Child and Family Practice
London, UK
The Handbook of Systemic
Family Therapy
Volume 2
Systemic Family Therapy with
Children and Adolescents
Editor‐in‐Chief
Karen S. Wampler
Volume Editor
Lenore M. McWey
This edition first published 2020
© 2020 John Wiley & Sons Ltd
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Library of Congress Cataloging‐in‐Publication Data
Names: Wampler, Karen S., editor.
Title: The handbook of systemic family therapy / editor-in-chief, Karen S.
Wampler.
Description: Hoboken, NJ : Wiley, [2020] | Includes index.
Identifiers: LCCN 2019044963 (print) | LCCN 2019044964 (ebook) | ISBN
9781119438557 (cloth) | ISBN 9781119645702 (adobe pdf) | ISBN
9781119645757 (epub)
Subjects: LCSH: Family psychotherapy.
Classification: LCC RC488.5.H3346 2020 (print) | LCC RC488.5 (ebook) |
DDC 616.89/156–dc23
LC record available at https://lccn.loc.gov/2019044963
LC ebook record available at https://lccn.loc.gov/2019044964
Cover image: © Lava 4 images/Shutterstock
Cover design by Wiley
Set in 10/12pt Galliard by SPi Global, Pondicherry, India
Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY.
10 9 8 7 6 5 4 3 2 1
In memory of Douglas J. Sprenkle
Educator, scholar, colleague, mentor, and friend.
Karen Smith Wampler, PhD, passed away unexpectedly, just weeks before The
Handbook of Systemic Family Therapy went to press. The handbook is dedicated to her
lasting memory.
Karen served as Editor-in-Chief for all four volumes of The Handbook of Systemic
Family Therapy. From the beginning, she had a vision of what our field needed to
know to move into the future. Her work was finished in late November 2019, just in
time for her next adventure in New Zealand and Australia. She was wise in her selec-
tion of Co-Editors for each volume: Rick Miller and Ryan Seedall (Volume 1), Lenore
McWey (Volume 2), Adrian Blow (Volume 3), and Mudita Rastogi and Reenee Singh
(Volume 4). She was grateful for the chance to work with each of these scholars and
with her Assistant Editor, Leah W. Maderal. She was delighted and humbled to see
“the book” grow to 106 chapters and 292 authors and co-authors. It cheered her
heart—there was so much to know and so much to learn about systemic family ther-
apy. She saw this work as her magnum opus, and it is.
Karen had a career as researcher and teacher, mentor, dissertation and thesis advisor,
program director, and department chair that spanned 33 years. Her impact on the
field of systemic family therapy lives on in these volumes, in her many research publi-
cations and chapters, in students she loved and trained, in colleagues who benefited
from her wisdom, enthusiasm, and support, and in the many individuals and groups
she touched with her kindness, generosity, intelligence, humor, and goodwill.
To paraphrase Shakespeare: “We shall not look upon her like again.”
Contents
About the Editors xi

List of Contributors xv
Prefacexxix
Volume 2 Preface xxxii
Systemic Family Therapy with Children and Adolescents
Forewordxxxv
Part I Overview 1
1 The Evolution of Systemic Approaches to Children
and Adolescents 3
Richard S. Wampler
2 Assessment of the Parent-Child Relationship 35
Heather M. Foran, Iris Fraude, Christian Kubb, and
Marianne Z. Wamboldt
Part II Problems in Parent-Child and Sibling Relationships 55

3 Prevention of Parent-Child Relational Problems: The Role of Parenting
Interventions 57
Kendal Holtrop, E. Stephanie Krauthamer Ewing, Glade L. Topham,
and Debra L. Miller
4 Systemic Interventions for Problems Emerging in Early Childhood 87
Glade L. Topham, Carol Pfeiffer Messmore, and Erin M. Sesemann
5 Interventions for Parent-Child Relational Problems That Emerge
During the School-Age Years 117
Kami L. Gallus
6 Prevention and Treatment of Problems with Sibling Relationships 141
Armeda Stevenson Wojciak and Casey Gamboni
viii Contents
7 Systemic Approaches to Child Maltreatment 163

Kimberly A. Rhoades, Danielle M. Mitnick, Richard E. Heyman,
Amy M. Smith Slep, and Tamara Del Vecchio
8 Difficulties in the Transition to Adulthood 191
Kayla Reed‐Fitzke and Mallory Lucier‐Greer
Part III Child and Adolescent Disorders 217

9 Family‐Based Prevention and Intervention for Child Physical
Health Conditions 219
Keeley Jean Pratt, Catherine A. Van Fossen, Damir S. Utržan,
and Jerica M. Berge
10 Depression, Anxiety, and Other Internalizing Disorders 241
Jacob B. Priest and Kate F. Cobb
11 Disordered Behavior and Behavior Disorders 265
Richard S. Wampler and Michael R. Whitehead
12 Systemic Approaches to Adolescent Substance Abuse 297
Rikki Patton, Jennifer E. Goerke, and Heather Katafiasz
13 Somatization and Disease Exacerbation in Childhood:
Systemic Theory, Research, and Practice 321
Sarah B. Woods
14 Youth Suicide: Risk, Prevention, and Treatment 343
E. Stephanie Krauthamer Ewing, Quintin A. Hunt, Jonathan B. Singer,
Guy Diamond, and Dara Winley
15 Systemic Approaches for Children, Adolescents, and Families
Living with Neurodevelopmental Disorders 369
Julie L Ramisch and Nicole Piland
16 Eating Disorders in Children, Adolescents, and Young Adults 397
Esther Blessitt, Julian Baudinet, Mima Simic, and Ivan Eisler
Part IV Challenging Family and Social Contexts 429

17 Complicated Adoption 431
Amy M. Claridge and Melissa M. Denlinger
18 Foster Care and Systemic Interventions to Maximize Effectiveness 457
Lenore M. McWey and Andrew S. Benesh
19 Interventions to Support Grandparents Raising Grandchildren 479
Megan L. Dolbin‐MacNab
20 Family‐Based Treatment for Runaway and Homeless Youth 503
Natasha Slesnick and Brittany R. Brakenhoff
21 Helping Children in Divorced and Single-Parent Families 521
Scott C Huff and Jaimee L. Hartenstein
Contents ix
22 Sexual Identity Development and Heteronormativity 541

Rebecca Harvey, Linda Stone Fish, and Paul Levatino
23 Interventions for Challenges Encountered in Childcare and
School Settings 571
Amber Vennum and Eric T. Goodcase
24 Systemic Prevention and Intervention Approaches for Working
with Military Families 595
Abigail H. Gewirtz and Hayley A. Rahl‐Brigman
Part V Future Directions 621

25 Improving Culturally Sensitive Interventions for Youth and
Parent-Child Relationships 623
DeAnna Harris‐McKoy and Shardé McNeil Smith
26 Breaking Down Silos with Systemically Oriented Preventive
Interventions: Implications for Family Policy 645
Philip A. Cowan and Carolyn Pape Cowan
Index673
About the Editors
Editor‐in‐Chief
Dr. Karen S. Wampler, PhD, retired as Professor with Tenure and Chair of the
Department of Human Development and Family Studies at Michigan State University.
Professor Emerita at Texas Tech University, she served as Department Chair, MFT
Program Director, and the C. R. and Virginia Hutcheson Professor. During her 10
years at the University of Georgia, Dr. Wampler developed the MFT doctoral pro-
gram as well as the Interdisciplinary MFT Certificate Program, a collaboration with
MFT, Social Work, and Counseling. She is past editor of the Journal of Marital and
Family Therapy. Her primary research interests are the application of attachment the-
ory to couple interaction, family therapy process research, and observational measures
of couple and family relationships. She has authored over 50 refereed journal articles
and 10 book chapters and has been funded by NIMH. A licensed marriage and family
therapist, she is a Fellow of AAMFT, past member of the Commission on Accreditation
for Marriage and Family Therapy Education, and recipient of the Outstanding
Contribution to Marriage and Family Therapy Award. The Family Therapy Section of
NCFR has recognized her with the Distinguished Service to Family Therapy and
Kathleen Briggs Mentor awards.
Associate Editors
Volume 1: Richard B Miller and Ryan B. Seedall

Richard B Miller, PhD, is Chair of the Sociology Department, a former Director of
the School of Family Life, and a former Associate Dean in the College of Family,
Home, and Social Science at Brigham Young University (BYU). He is also a professor
in the Marriage and Family Therapy Program at BYU. Prior to teaching at BYU, he
taught at Kansas State University for 11 years, where he served as Director of the
Marriage and Family Therapy Program. He is passionate about facilitating and
enhancing clinical research in the field, and he has worked to introduce more advanced
statistical methods in SFT doctoral programs and among SFT researchers, in general.
xii About the Editors
His personal program of research focuses on therapist effects and therapist behaviors
in couple therapy. He is also involved in working toward the development of the prac-
tice of couple and family therapy in China. He has published over 100 journal articles
and book chapters, and, along with Lee Johnson, he edited the book Advanced
Methods in Marriage and Family Therapy Research. An MFT professor for over 30
years, he loves mentoring and collaborating with graduate students.
Ryan B. Seedall, PhD, is Associate Professor in the Marriage and Family Therapy
Program at Utah State University, having received his SFT training from Brigham
Young University (MS) and Michigan State University (PhD). He completed post-
doctoral training with Dr. James Anthony in the NIDA‐funded Drug Dependence
Epidemiology Fellowship Program. His primary program of research focuses
on understanding and improving relationship and change processes within the couple
relationship and in couple therapy. He aims to improve couple and family relation-
ships through research on couple interaction and support processes, especially within
the context of chronic illness. He is also interested in protective family dynamics and
prevention efforts, including ways to reduce mental health disparities. Lastly, he is
interested in identifying specific interventions that are useful when working with cou-
ples (e.g., enactments) and also client‐related factors that are strongly associated with
process and outcome in therapy (e.g., attachment and social support). Dr. Seedall has
published over 30 peer‐reviewed journal articles and seven book chapters. He lives in
Hyde Park, Utah, with his wife (Ruth) and four children (Spencer, Madelyn, Eliza,
and Benjamin).
Volume 2: Lenore M. McWey

Lenore M. McWey, PhD, is a Professor and the Director of the Marriage and Family
Therapy Program at Florida State University. She is a Licensed Marriage and Family
Therapist and American Association for Marriage and Family Therapy Approved
Supervisor. She has received federal funding from the National Institutes of Health
(NIH) to support her research on children and families involved with the child wel-
fare system, and the results of her work have been published widely in high‐impact,
peer‐reviewed journals. She currently serves as a scientific reviewer for the Health,
Behavior, and Context Subcommittee of the Eunice Kennedy Shriver National
Institute of Child Health and Human Development of NIH. Dr. McWey has been the
recipient of the Florida State University Distinguished Teacher of the Year and the
Outstanding Graduate Faculty Mentor awards.
Volume 3: Adrian J. Blow

Adrian J. Blow, PhD, works as a couple and family therapy intervention researcher
and educator at Michigan State University (MSU). Dr. Blow is a Professor and
Department Chair in the Human Development and Family Studies Department and
faculty member of the Couple and Family Therapy Program. He obtained his PhD
from Purdue University in 1999 where the late Doug Sprenkle served as his primary
mentor. After Purdue, he joined the faculty at Saint Louis University where he worked
for 6 years. He subsequently joined MSU in 2005. His research is focused on families
and trauma, on military families, and on change processes in interventions pertaining
About the Editors xiii
to systemic family therapy. He has acquired over two million dollars in research grants
as principal investigator and published numerous peer‐reviewed publications (60) and
book chapters (12). He has mentored many students and in 2017 was awarded the
American Association for Marriage and Family Therapy (AAMFT) Training Award,
which recognizes excellence in family therapy education. He has served the field of
systemic family therapy in a number of capacities and was the AAMFT Board Secretary
from 2012 to 2014 and Board Treasurer from 2016 to 2019. He is married to Dr.
Tina Timm, Associate Professor in the MSU School of Social work. He has six
children.
Volume 4: Mudita Rastogi and Reenee Singh

Mudita Rastogi, PhD, practices at Aspire Consulting and Therapy as a Licensed
Marriage and Family Therapist, coach, and educational trainer. Dr. Rastogi obtained
her PhD in Marriage and Family Therapy from Texas Tech University, her master’s
degree in psychology from University of Bombay, and her BA (Honors) in Psychology
from University of Delhi. Prior roles include serving as Professor at the Illinois School
of Professional Psychology, Program Director for the SAMHSA‐funded Minority
Fellowship Program at the American Association for Marriage and Family Therapy,
Associate Editor for the Journal of Marital and Family Therapy, editor of the books
Multicultural Couple Therapy and Voices of Color, and Associate Editor for the
Encyclopedia of Couple and Family Therapy. Dr. Rastogi’s publications focus on cul-
ture, gender, and global issues within the context of family and couple therapy. Dr.
Rastogi is a Clinical Fellow and AAMFT Approved Supervisor having practiced in
both India and the United States. She is a founding member of the Indian Association
for Family Therapy. Dr. Rastogi’s clinical and training interests include systemic family
therapy, diversity and inclusion, global mental health, parenting, child‐free couples,
gender, and trauma. Additionally, she maintains an interest in partnering with grass-
roots, not‐for‐profit organizations.
Reenee Singh, DSysPsych, is the Chief Executive of the Association for Family
Therapy and Systemic Practice in the United Kingdom. She is the Founding Director
of the London Intercultural Couples Centre at The Child and Family Practice in
London, where she practices as a Consultant Family and Systemic Psychotherapist.
She is the past editor of the Journal of Family Therapy, co‐director of the Family
Therapy and Systemic Research Centre at the Tavistock and Portman NHS Foundation
Trust, and visiting professor at the University of Bergamo. Dr. Singh is the author of
two books and numerous academic articles on issues of “race,” culture, and qualita-
tive research. Dr. Singh has lived and worked in Singapore, India, and the United
Kingdom. She has taught all over the world and presents her work at national and
international conferences.
List of Contributors
Hana H. Abu‐Hassan, MD, Department of Family and Community Medicine,

School of Medicine, University of Jordan, Amman, Jordan and Department of
Family Medicine and Public Health, University of California, San Diego, La Jolla,
CA, USA
Sheila M. Addison, PhD, LMFT, Margin to Center Consulting, Oakland, CA, USA
Volkmar Aderhold, MD, Institute of Social Psychiatry, Ernst Moritz Arndt University,
Greifswald, Germany
Renu K. Aldrich, PhD, LMFT, Arlington, VA, USA
Rhea V. Almeida, PhD, Institute for Family Services, Somerset, NJ, USA
Jenny Altschuler, PhD, Affiliate, Tavistock Clinic, London, UK
Shayne R. Anderson, PhD, LMFT, School of Family Life, Brigham Young University,
Provo, UT, USA
Louise Anthias, DProf, Bath, Somerset, UK
Christina M. Balderrama‐Durbin, PhD, Department of Psychology, Binghamton
University – State University of New York (SUNY), Binghamton, NY, USA
Alyssa Banford Witting, PhD, LMFT, School of Family Life, Brigham Young
University, Provo, UT, USA
Eran Bar‐Kalifa, PhD, Department of Psychology, Ben‐Gurion University of the
Negev, Beer‐Sheva, Israel
Suzanne Bartle‐Haring, PhD, Human Development and Family Science, The Ohio
Brian R. W. Baucom, PhD, Department of Psychology, University of Utah, Salt
Lake City, UT, USA
Julian Baudinet, PsyD, The Maudsley Centre for Child and Adolescent Eating
Disorders, South London and Maudsley NHS Foundation Trust, London, UK
Erin R. Bauer, MS, Human Development and Family Science, University of Central
xvi List of Contributors
Saliha Bava, PhD, LMFT, Marriage and Family Therapy Program, Mercy College,
Dobbs Ferry, NY, USA
Andrew S. Benesh, PhD, LMFT, Psychiatry and Behavioral Sciences, Mercer
University, Macon, GA, USA
Kristen E. Benson, PhD, LMFT, Human Development and Psychological
Counseling, Appalachian State University, Boone, NC, USA
Jerica M. Berge, PhD, MPH, LMFT, Department of Family Medicine and Community
Health, University of Minnesota Medical School, Minneapolis, MN, USA
J. Maria Bermudez, PhD, LMFT, Marriage and Family Therapy, Human Development
Hydeen K. Beverly, MSW, Steve Hicks School of Social Work, The University of Texas
at Austin, Austin, TX, USA
Dharam Bhugun, PhD, MSW, MM, Southern Cross University, Gold Coast Campus,
Bilinga, Queensland, Australia
Richard J. Bischoff, PhD, Child, Youth, and Family Studies, University of Nebraska‐
Lincoln, Lincoln, NE, USA
Esther Blessitt, MSc, The Maudsley Centre for Child and Adolescent Eating Disorders,
Adrian J. Blow, PhD, LMFT, Human Development and Family Studies, Michigan
Guy Bodenmann, PhD, Department of Psychology, University of Zurich, Zurich,
Switzerland
Danielle L. Boisvert, MA, Department of Family and Community Medicine, Saint
Louis University, Saint Louis, MO, USA
Ulrike Borst, PhD, Ausbildungsinstitut für systemische Therapie, Zurich, Switzerland
Pauline Boss, PhD, LMFT, Department of Family Social Science, University of
Minnesota, St. Paul, MN, USA
Angela B. Bradford, PhD, LMFT, Marriage and Family Therapy Program, School of
Spencer D. Bradshaw, PhD, Community, Family, and Addiction Sciences, Texas Tech
Brittany R. Brakenhoff, PhD, Human Development and Family Science, The Ohio
Andrew S. Brimhall, PhD, LMFT, Human Development and Family Science, East
Benjamin E. Caldwell, PsyD, Educational Psychology and Counseling, California State
University Northridge, Northridge, CA, USA
Ryan G. Carlson, PhD, LMHC, Counselor Education, Department of Educational
Studies, University of South Carolina, Columbia, SC, USA
List of Contributors xvii
Alan Carr, PhD, School of Psychology, University College Dublin, Dublin, Ireland
Marj Castronova, PhD, LMFT, MEND, Behavioral Health Center, Loma Linda
University Health, Redlands, CA, USA
Laurie L. Charlés, PhD, LMFT, MGH Institute of Health Professions, Boston, MA,
USA
Ronald J. Chenail, PhD, Department of Family Therapy, Nova Southeastern University,
Jessica ChenFeng, PhD, LMFT, Department of Physician Vitality, School of Medicine,
Loma Linda University Health, Loma Linda, CA, USA
Amy M. Claridge, PhD, LMFT, Department of Family and Consumer Sciences, Central
Washington University, Ellensburg, WA, USA
Kate F. Cobb, MA, LMFT, Couple and Family Therapy, University of Iowa, Iowa
City, IA, USA
Katelyn O. Coburn, MS, School of Family Studies and Human Services, Kansas State
Carolyn Pape Cowan, PhD, Department of Psychology, Institute of Human
Development, University of California, Berkeley, Berkeley, CA, USA
Philip A. Cowan, PhD, Department of Psychology, Institute of Human Development,
University of California, Berkeley, Berkeley, CA, USA
Sarah A. Crabtree, PhD, LMFT, The Albert & Jessie Danielsen Institute, Boston
University, Boston, MA, USA
Lauren Cubellis, MA, MPH, Department of Anthropology, Affiliate Tavistock Clinic,
St. Louis, MO, USA
Carla M. Dahl, PhD, Congregational and Community Care, Luther Seminary, St. Paul,
MN, USA
Andrew P. Daire, PhD, Department of Counseling and Special Education, School of
Education, Virginia Commonwealth University, Richmond, VA, USA
Gwyn Daniel, MA, MSW, Visiting Lecturer, Tavistock Clinic, London, UK
Carissa D’Aniello, PhD, Couple, Marriage and Family Therapy Program, Texas Tech
Frank M. Dattilio, PhD, Department of Psychiatry, University of Pennsylvania Perelman
School of Medicine, Philadelphia, PA, USA
Rachel Dekel, PhD, School of Social Work, Bar Ilan University, Ramat Gan, Israel
Tamara Del Vecchio, PhD, Department of Psychology, St. John’s University, Queens,
NY, USA
Melissa M. Denlinger, MS, Human Development and Family Studies, Iowa State
University, Ames, IA, USA
Janet M. Derrick, PhD, Four Winds Wellness and Education Centre, Kamloops, British
Columbia, Canada
xviii List of Contributors
Guy Diamond, PhD, Center for Family Intervention Science, Drexel University,
Philadlephia, PA, USA
Brian Distelberg, PhD, School of Behavioral Health, Behavioral Medicine Center,
Loma Linda University, Loma Linda, CA, USA
William J. Doherty, PhD, Department of Family Social Science, University of Minnesota,
St. Paul, MN, USA
Megan L. Dolbin‐MacNab, PhD, LMFT, Department of Human Development and
Family Science, Virginia Tech, Blacksburg, VA, USA
James Michael Duncan, PhD, School of Human Environmental Science, University of
Arkansas, Fayetteville, AR, USA
Jared A. Durtschi, PhD, School of Family Studies and Human Services, Kansas State
Lekie Dwanyen, MS, Department of Family Social Science, University of Minnesota, St.
Paul, MN, USA
Lindsay L. Edwards, PhD, Division of Counseling and Family Therapy, Regis University,
Thornton, CO, USA
Todd M. Edwards, PhD, LMFT, Marital and Family Therapy Program, University of
San Diego, San Diego, CA, USA
Ivan Eisler, PhD, The Maudsley Centre for Child and Adolescent Eating Disorders,
Norman B. Epstein, PhD, LMFT, Department of Family Science, School of Public
Ana Rocío Escobar‐Chew, PhD, LMFT, Psychology Department, Universidad Rafael
Landívar, Guatemala, Guatemala
Laura M. Evans, PhD, Department of Human Development and Family Studies, The
Pennsylvania State University, Brandywine Campus, Media, PA, USA
Mairi Evans, MA, Post Graduate Research School, Bedfordhsire University,
Bedfordshire, UK
Adam M. Farero, MS, Human Development and Family Studies, Michigan State
Daniel S. Felix, PhD, LMFT, Sioux Falls Family Medicine Residency, University of
South Dakota, School of Medicine, Sioux Falls, SD, USA
Stephen T. Fife, PhD, LMFT, Community, Family, and Addiction Sciences, Texas Tech
Heather M. Foran, PhD, Institute of Psychology, Alpen‐Adria‐University Klagenfurt,
Klagenfurt, Austria
Liz Forbat, PhD, Faculty of Social Science, University of Stirling, Stirling, UK
Iris Fraude, BSc, Institute of Psychology, Alpen‐Adria‐University Klagenfurt, Klagenfurt,
Austria
List of Contributors xix
Christine A. Fruhauf, PhD, Human Development and Family Studies, Colorado State
University, Fort Collins, CO, USA
Joaquín Gaete-Silva, PhD, Calgary Family Therapy Centre, Calgary, Alberta, Canada
Kami L. Gallus, PhD, LMFT, Human Development and Family Science, Oklahoma
Casey Gamboni, PhD, LMFT, The Family Institute at Northwestern University,
Evanston, IL, USA
Reham F. Gassas, PhD, Department of Mental Health, King Abdulaziz Medical City,
Riyadh, Kingdom of Saudi Arabia
Abigail H. Gewirtz, PhD, Department of Family Social Science, Institute of Child
Development, University of Minnesota, Minneapolis, MN, USA
Jennifer E. Goerke, MA, School of Counseling, The University of Akron, Akron, OH,
USA
Eric T. Goodcase, MS, LMFT, School of Family Studies and Human Services, Kansas
Arthur L. Greil, PhD, Division of Social Sciences, Alfred University, Alfred, NY,
USA
Cadmona A. Hall, PhD, LMFT, Department of Couple and Family Therapy, Adler
University, Chicago, IL, USA
Eugene L. Hall, PhD, LMFT, Department of Family Social Science, University of
Minnesota, Saint Paul, MN, USA
Nathan R. Hardy, PhD, LMFT, Human Development and Family Science, Oklahoma
Terry D. Hargrave, PhD, LMFT, Department of Marriage and Family Therapy, Fuller
Theological Seminary, Pasadena, CA, USA
Steven M. Harris, PhD, LMFT, Department of Family Social Science, University of
Minnesota, Twin Cities, MN, USA
DeAnna Harris‐McKoy, PhD, LMFT, Department of Counseling and Psychology,
Texas A&M University – Central Texas, Killeen, TX, USA
Jaimee L. Hartenstein, PhD, School of Human Services, University of Central
Rebecca Harvey, PhD, Marriage and Family Therapy Program, Southern Connecticut
State University, New Haven, CT, USA
Stephen N. Haynes, PhD, Psychology, University of Hawai‘i at Mānoa, Honolulu,
HI, USA
Arlene Healey, MSc, DipSW, TMR Health Professionals, Belfast, UK
Lorna L. Hecker, PhD, LMFT, Private Practice, Fort Collins, CO, and Marriage and
Family Therapy Program, Department of Behavioral Sciences, Purdue University
Northwest, Hammond, IN, USA
xx List of Contributors
Katie M. Heiden‐Rootes, PhD, LMFT, Medical Family Therapy Program,

Department of Family and Community Medicine, Saint Louis University, St.
Louis, MO, USA
Sarah L. Helps, DClinPsy, Children, Young People and Family Directorate and
Directorate of Education and Training, Tavistock and Portman NHS Foundation
Trust, London, UK
Katherine Hertlein, PhD, LMFT, Department of Psychiatry and Behavioral Health,
University of Nevada, Las Vegas, Las Vegas, NV, USA
Richard E. Heyman, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Christopher J. Hipp, EdS, LPC, Department of Educational Studies, University of
South Carolina, Columbia, SC, USA
Jennifer Hodgson, PhD, LMFT, Human Development and Family Science, East
Kendal Holtrop, PhD, LMFT, Human Development and Family Studies, Michigan
Niyousha Hosseinichimeh, PhD, Department of Industrial and Systems Engineering,
Virginia Tech, Blacksburg, VA, USA
Benjamin J. Houltberg, PhD, LMFT, Performance Science Institute, Marshall School
of Business, University of Southern California, Los Angeles, CA, USA
Patricia Huerta, MS, LMFT, Human Development and Family Studies, Michigan State
Scott C Huff, PhD, LMFT, School of Human Services, University of Central Missouri,
Warrensburg, MO, USA
Ditte Roth Hulgaard, MD, PhD, Child and Adolescent Psychiatry, University of
Southern Denmark, Odense, Denmark
Quintin A. Hunt, MS, Counselor Education, University of Wisconsin‐Superior,
Superior, WI, USA
Sydni A. J. Huxman, School of Family Studies and Human Services, Kansas State
Dragana Ilic, PhD, LMFT, Department of Family Therapy, Nova Southestern University,
Jeffrey B. Jackson, PhD, LMFT, Human Development and Family Science, Virginia
Matthew E. Jaurequi, MA, Family and Child Sciences, Florida State University,
Lee N. Johnson, PhD, Marriage and Family Therapy Program, School of Family Life,
Brigham Young University, Provo, UT, USA
Adam C. Jones, PhD, LMFTA, Family Therapy Program, Department of Human
Development, Family Studies, and Counseling, Texas Woman’s University, Denton,
TX, USA
List of Contributors xxi
Tessa Jones, LMSW, Silver School of Social Work, New York University, New York,
NY, USA
Eli A. Karam, PhD, LMFT, Couple and Family Therapy Program, Kent School of
Social Work, University of Louisville, Louisville, KY, USA
Heather Katafiasz, PhD, School of Counseling, The University of Akron, Akron, OH,
USA
Kyle D. Killian, PhD, LMFT, Marriage and Family Therapy Program, School of
Counseling and Human Services, Capella University, Minneapolis, MN, USA
Thomas G. Kimball, PhD, LMFT, Center for Collegiate Recovery Communities, Texas
Keith Klostermann, PhD, LMFT, LMHC, Department of Counseling and Psychology,
Medaille College, Buffalo, NY, USA
Carmen Knudson‐Martin, PhD, LMFT, Counseling Psychology, Graduate School of
Education and Counseling, Lewis and Clark College, Portland, OR, USA
E. Stephanie Krauthamer Ewing, PhD, MPH, Counseling and Family Therapy, School
of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
Christian Kubb, MSc, Institute of Psychology, Alpen‐Adria‐University Klagenfurt,
Klagenfurt, Austria
E. Megan Lachmar, PhD, LMFT, Marriage and Family Therapy, Human Development
and Family Studies, Utah State University, Logan, UT, USA
Jennifer J. Lambert‐Shute, PhD, LMFT, Department of Human Services, Valdosta
State University, Valdosta, GA, USA
Angela L. Lamson, PhD, LMFT, Human Development and Family Science, East
Ashley L. Landers, PhD, LMFT, Human Development and Family Science, Virginia
Nicole R. Larkin, MS, CADC, Marriage and Family Therapy, Human Development
and Family Science, University of Central Missouri, Warrensburg, MO, USA
Feea R. Leifker, PhD, MPH, Department of Psychology, University of Utah, Salt Lake
City, UT, USA
Paul Levatino, MFT, LMFT, Marriage and Family Therapy Program, Southern
Connecticut State University, New Haven, CT, USA
Deanna Linville, PhD, LMFT, Couples and Family Therapy Program, University of
Oregon, Eugene, OR, USA
Griselda Lloyd, PhD, LMFT, Edith Neumann School of Health and Human Services,
Touro University Worldwide, Los Alamitos, CA, USA
Elsie Lobo, PhD, LMFT, Counseling and Family Sciences, Loma Linda University,
Loma Linda, CA, USA
Sofia Lopez Bilbao, BA, Counselling Psychology, Werklund School of Education,
University of Calgary, Calgary, Alberta, Canada
xxii List of Contributors
Gabriela López‐Zerón, PhD, Human Development and Family Studies, Michigan

David C. Low, MA, MS, LMFT, Family Therapy Training Institute, Family Institute of
Aurora Family Service, Milwaukee, WI, USA
Mallory Lucier‐Greer, PhD, LMFT, Human Development and Family Studies, Auburn
Kevin P. Lyness, PhD, Department of Applied Psychology, Antioch University, New
England, Keene, NH, USA
Mohammad Marie, PhD, School of Medicine and Health Science, Al-Najah National
University, Nablus, Palestine
Melinda Stafford Markham, PhD, School of Family Studies and Human Services,
Heather McCauley, ScD, School of Social Work, Michigan State University, East
Lansing, MI, USA
Teresa McDowell, EdD, LMFT, Counseling Psychology, Graduate School of Education
and Counseling, Lewis and Clark College, Portland, OR, USA
Christi R. McGeorge, PhD, Human Development and Family Science, North Dakota
State University, Fargo, ND, USA
Shardé McNeil Smith, PhD, Human Development and Family Studies, University of
Illinois at Urbana‐Champaign, Urbana, IL, USA
Douglas P. McPhee, MS, Community, Family, and Addiction Sciences, Texas Tech
Lenore M. McWey, PhD, LMFT, Marriage and Family Therapy Program, Department
of Family and Child Sciences, Florida State University, Tallahassee, FL, USA
Lisa V. Merchant, PhD, LMFT, Department of Marriage and Family Studies, Abilene
Christian University, Abilene, TX, USA
Carol Pfeiffer Messmore, PhD, LMFT, Marriage and Family Therapy Program, School
of Counseling and Human Services, Capella University, Minneapolis, MN, USA
Debra L. Miller, MSW, Human Development and Family Studies, Michigan State
Richard B Miller, PhD, Department of Sociology, Brigham Young University, Provo,
UT, USA
Erica A. Mitchell, PhD, Department of Psychology, University of Tennessee, Knoxville,
TN, USA
Danielle M. Mitnick, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Mona Mittal, PhD, LMFT, Department of Family Science, School of Public Health,
University of Maryland, College Park, MD, USA
List of Contributors xxiii
Megan J. Murphy, PhD, LMFT, Marriage and Family Therapy Program, Department
of Behavioral Sciences, Purdue University Northwest, Hammond, IN, USA
Briana S. Nelson Goff, PhD, School of Family Studies and Human Services, Kansas
Hoa N. Nguyen, PhD, Department of Human Services, Valdosta State University,
Valdosta, GA, USA
Matthias Ochs, PhD, Department of Social Work, Fulda University of Applied Sciences,
Fulda, Germany
Timothy J. O’Farrell, PhD, VA Boston Healthcare System, Harvard Medical School,
Boston, MA, USA
Paul O. Orieny, PhD, LMFT, Center for Victims of Torture, St. Paul, MN, USA
Christine Anne Palmer, Aboriginal Elder, Canberra, Australian Capital Territory,
Australia
Rubén Parra‐Cardona, PhD, Steve Hicks School of Social Work, The University of
Texas at Austin, Austin, TX, USA
Jo Ellen Patterson, PhD, Marital and Family Therapy Program, University of San
Diego, San Diego, CA, USA
Rikki Patton, PhD, School of Counseling, The University of Akron, Akron, OH, USA
Brennan Peterson, PhD, LMFT, Department of Marriage and Family Therapy, Crean
College of Health and Behavioral Sciences, Chapman University, Orange, CA, USA
J. Douglas Pettinelli, PhD, Medical Family Therapy Program, Department of Family
and Community Medicine, Saint Louis University, Saint Louis, MO, USA
Morgan E. PettyJohn, MS, Human Development and Family Studies, Michigan State
Bernhild Pfautsch, Diplom‐Psychologist (FH), Department of Social Work, Fulda
University of Applied Sciences, Fulda, Germany
Fred P. Piercy, PhD, Human Development and Family Science, Virginia Tech,
Blacksburg, VA, USA
Nicole Piland, PhD, LMFT, Community, Family, and Addiction Sciences, Texas Tech
Shyneice C. Porter, MS, LMFT, Department of Family Science, School of Public
Shruti Singh Poulsen, PhD, Denver, CO, USA
Keeley Jean Pratt, PhD, LMFT, Human Development and Family Science, The Ohio
Jacob B. Priest, PhD, LMFT, Couple and Family Therapy Program, Psychological and
Quantitative Foundations, University of Iowa, Iowa City, IA, USA
xxiv List of Contributors
Hayley A. Rahl‐Brigman, BS, Institute of Child Development, University of Minnesota,

Minneapolis, MN, USA
Julie L Ramisch, PhD, LMFT, Coastal Center for Collaborative Health, Lincoln City,
OR, USA
Ashley K. Randall, PhD, Counseling and Counseling Psychology, Arizona State
University, Tempe, AZ, USA
Mudita Rastogi, PhD, LMFT, Aspire Consulting and Therapy, Arlington Heights, IL,
USA
Kayla Reed‐Fitzke, PhD, LMFT, Couple and Family Therapy Program, Psychological
Michael D. Reiter, PhD, Department of Family Therapy, Nova Southeastern University,
Kimberly A. Rhoades, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Jennifer L. Rick, MS, LMFT, JLR Therapy, Herndon, VA, USA
W. David Robinson, PhD, LMFT, Human Development and Family Studies, Utah
State University, Logan, UT, USA
John S. Rolland, MD, MPH, Psychiatry and Behavioral Sciences, Northwestern
University Feinberg School of Medicine, Chicago, IL, USA
Lauren M. Ruhlmann, PhD, LMFT, Human Development and Family Studies, Auburn
Nicole Sabatini Gutierrez, PsyD, LMFT, Couple and Family Therapy Program,
California School of Professional Psychology, Alliant International University, Irvine,
CA, USA
Allen K. Sabey, PhD, LMFT, The Family Institute, Northwestern University, Evanston,
IL, USA
Inés Sametband, PhD, Department of Psychology, Mount Royal University, Calgary,
Alberta, Canada
Jonathan G. Sandberg, PhD, School of Family Life, Brigham Young University, Provo,
UT, USA
Shaifali Sandhya, PhD, CARE Family Consultation, Chicago, IL, USA
Jochen Schweitzer, PhD, Institute of Medical Psychology, University of
Heidelberg Hospital and Helm Stierlin Institute for Systemic Training,
Heidelberg, Germany
Ryan B. Seedall, PhD, Human Development and Family Studies, Utah State University,
Logan, UT, USA
Desiree M. Seponski, PhD, LMFT, Marriage and Family Therapy, Human Development
List of Contributors xxv
Erin M. Sesemann, PhD, LMFT, Human Development and Family Science, East
Michal Shamai, PhD, School of Social Work, University of Haifa, Haifa, Israel
Tazuko Shibusawa, PhD, LCSW, Silver School of Social Work, New York University,
New York, NY, USA
Karina M. Shreffler, PhD, Human Development and Family Science, Oklahoma State
University, Stillwater, OK, USA
Sterling T. Shumway, PhD, LMFT, Community, Family, and Addiction Sciences, Texas
Charles Sim, SJ, PhD, S.R. Nathan School of Human Development, Singapore
University of Social Sciences, Republic of Singapore
Timothy Sim, PhD, Department of Applied Social Sciences, The Hong Kong
Polytechnic University, Kowloon, Hung Hom, Hong Kong, China
Mima Simic, MD, The Maudsley Centre for Child and Adolescent Eating Disorders,
Gail Simon, DProf, Institute of Applied Social Research, University of Bedfordshire,
Luton, UK
Jonathan B. Singer, PhD, LCSW, Social Work, Loyola University Chicago, Chicago,
IL, USA
Reenee Singh, DSysPsych, Association for Family Therapy and Systemic Practice and
The Child and Family Practice, London, UK
Izidora Skračić, MA, Department of Family Science, School of Public Health, University
of Maryland, College Park, MD, USA
Amy M. Smith Slep, PhD, Family Translational Research Group, New York University,
New York, NY, USA
Natasha Slesnick, PhD, Human Development and Family Science, The Ohio State
University, Columbus, OH, USA
Douglas B. Smith, PhD, LMFT, Community, Family, and Addiction Sciences, Texas
Douglas K. Snyder, PhD, LMFT, Department of Psychological and Brain Sciences,
Texas A&M University, College Station, TX, USA
Kristy L. Soloski, PhD, LMFTA, LCDC, Community, Family, and Addiction Sciences,
Texas Tech University, Lubbock, TX, USA
Jenny Speice, PhD, LMFT, Family Therapy Training Program, Institute for the Family,
Department of Psychiatry, University of Rochester School of Medicine, Rochester,
NY, USA
Chelsea M. Spencer, PhD, LMFT, School of Family Studies and Human Services,
xxvi List of Contributors
Paul R. Springer, PhD, LMFT, Child, Youth, and Family Studies, University of
Nebraska‐Lincoln, Lincoln, NE, USA
Sandra M. Stith, PhD, LMFT, School of Family Studies and Human Services, Kansas
Linda Stone Fish, PhD, MSW, Department of Marriage and Family Therapy, Syracuse
University, Syracuse, NY, USA
Peter Stratton, PhD, Leeds Family Therapy and Research Centre, University of Leeds,
Leeds, UK
Tom Strong, RPsych, Educational Studies, Counselling Psychology Program, Werklund
School of Education, University of Calgary, Calgary, Alberta, Canada
Nathan C. Taylor, MS, School of Applied Human Sciences, University of Northern
Iowa, Cedar Falls, IA, USA
Karlin J. Tichenor, PhD, LMFT, Karlin J & Associates, LLC, Indianapolis, IN,
USA
Tina M. Timm, PhD, LMSW, LMFT, School of Social Work, Michigan State University,
Glade L. Topham, PhD, LCMFT, School of Family Studies and Human Services,
Maru Torres‐Gregory, PhD, JD, LMFT, Marriage and Family Therapy Program, The
Family Institute, Northwestern University, Evanston, IL, USA
Chi‐Fang Tseng, MS, Human Development and Family Studies, Michigan State
Shu‐Tsen Tseng, PhD, Prudence Skynner Family and Couple Therapy Clinic, Springfield
Hospital, London, UK
Carolyn Y. Tubbs, PhD, Marriage and Family Therapy, Department of Counseling and
Human Services, St. Mary’s University, San Antonio, TX, USA
Ileana Ungureanu, MD, PhD, LMFT, Marriage, Couple and Family Counseling,
Division of Psychology and Counseling, Governors State University, University Park,
IL, USA
Francisco Urbistondo Cano, DCounsPsy, Community Learning Disability Team,
NHS Bolton Foundation Trust, Bolton, UK
Damir S. Utržan, PhD, LMFT, Division of Mental Health and Substance Abuse
Treatment Services, Minnesota Department of Human Services, St. Paul, MN, USA
Susanna Vakili, MA, LMFT, Private Practice, San Diego and San Juan Capistrano,
CA, USA
Catherine A. Van Fossen, MS, Human Development and Family Science, The Ohio
Amber Vennum, PhD, LMFT, School of Family Studies and Human Services, Kansas
List of Contributors xxvii
Ingrid Vlam, PhD, MBA, Research Graduate School, Bedfordshire University,

Bedfordshire, UK
Ashley A. Walsdorf, MS, Marriage and Family Therapy, Human Development and
Family Science, University of Georgia, Athens, GA, USA
Marianne Z. Wamboldt, MD, Department of Psychiatry, Helen and Arthur E. Johnson
Depression Center, University of Colorado School of Medicine, Aurora, CO, USA
Karen S. Wampler, PhD, LMFT, Human Development and Family Studies, Michigan
Richard S. Wampler, PhD, MSW, LMFT, Human Development and Family Studies,
Michael R. Whitehead, PhD, LMFT, Aspen Grove Family Therapy, Twin Falls, ID,
USA
Jason B. Whiting, PhD, LMFT, Marriage and Family Therapy Program, School of
Elizabeth Wieling, PhD, Human Development and Family Science, University of
Georgia, Athens, GA, USA
Lee M. Williams, PhD, Marital and Family Therapy Program, University of San Diego,
San Diego, CA, USA
Dara Winley, MA, Couple and Family Therapy, Drexel University, Philadelphia, PA, USA
Mathew C. Withers, PhD, LMFT, Psychology, California State University, Chico,
Chico, CA, USA
Andrea K. Wittenborn, PhD, LMFT, Human Development and Family Studies,
Armeda Stevenson Wojciak, PhD, Couple and Family Therapy Program, Psychological
Sarah B. Woods, PhD, LMFT, Department of Family and Community Medicine,
University of Texas Southwestern Medical Center, Dallas, TX, USA
Corey E. Yeager, PhD, Department of Family Social Science, University of Minnesota,
St. Paul, MN, USA
Cigdem Yumbul, PhD, Bude Psychotherapy Center, Istanbul, Turkey
Toni Schindler Zimmerman, PhD, LMFT, Marriage and Family Therapy Program,
Department of Human Development and Family Studies, Colorado State University,
Fort Collins, CO, USA
Max Zubatsky, PhD, LMFT, Department of Family and Community Medicine, Saint
Louis University, St. Louis, MO, USA
Preface
The first volume of Gurman and Kniskern’s Handbook of Family Therapy was published
in 1981, two years after I finished graduate school. I read it from cover to cover and
used favorite chapters over and over again in my courses. The second volume pub-
lished in 1991 was equally treasured. Even though 10 years separated the two, it was
published as Volume 2 instead of as a revision because, as Gurman and Kniskern
explained in the preface, so much new information had emerged that both volumes
were needed.
Four volumes were needed in this handbook to capture the breadth and depth of
systemic family therapy theory, research, and practice. Material is organized to maxi-
mize accessibility by creating volumes on the profession, the parent–child relation-
ship, the couple relationship, and the family across the lifespan. Each volume stands
on its own as well as acts as a complement to the others. The three problem‐oriented
volumes are organized to reflect typical reasons clients initially seek treatment: con-
cern about relationships, worry about a problem or disorder with a family member, or
challenging contexts impacting the family. Taken together, the four volumes of The
Handbook of Systemic Family Therapy offer a comprehensive and accessible resource
for clinicians, educators, researchers, and policymakers.
As much as possible, the editorial team wanted to reflect how systemic family thera-
pists actually think about and do their work. For example, instead of providing sepa-
rate chapters on each evidence‐based treatment model, those models are integrated
into the material on relevant treatment topics. The pervasive impacts of culture, diver-
sity, and inequitable treatment are major themes, and several chapters are devoted to
these important topics. The work includes a global perspective on systemic family
therapy. Instead of promoting a specific approach, we asked the authors to describe
what is known about intervention and prevention for each topic and the next steps
needed to determine best practice. We wanted each chapter to stimulate improved
practice as well as to serve as a springboard for further research.
From the beginning, we used a collaborative process to decide on both the struc-
ture and the content of the book. The crucial first step in this process was a two‐day
“think tank” meeting at the American Association for Marriage and Family Therapy
(AAMFT) offices in April 2016 with me, Adrian Blow, Pauline Boss, Rick Miller,
Mudita Rastogi, Liz Wieling, and Tracy Todd in which we began to sketch a vision for
xxx Preface
the handbook. The next step was securing editors for each of the four volumes and,
to my eternal gratitude, six well‐established and highly esteemed scholars agreed to
take on these roles: Rick Miller and Ryan Seedall for Volume 1 on the profession,
Lenore McWey for Volume 2 on children and adolescents, Adrian Blow for Volume 3
on couples, and Mudita Rastogi and Reenee Singh for Volume 4 on global health.
The group worked together over many months to settle on a table of contents and to
write a formal proposal to John Wiley & Sons Publishing. All seven of us worked on
all four volumes. As systems thinkers, we needed to always look at the project as a
whole and never simply as a set of separate volumes.
Close collaboration among the editors continued as we worked to identify, contact,
and secure authors for each chapter. We deliberately sought authors who were both
scholars and clinicians and could speak to the diverse perspectives inherent in work
with families as well as the breadth of the field of systemic family therapy. We worked
together to avoid overlap across chapters, identify missing content, and maintain the
integrity of each volume. Authors submitted outlines for their chapters that were read
by all seven of us. Feedback for each chapter summarized by the primary editor(s)
provided an opportunity for further collaboration with the lead author. This approach
continued through the manuscript submission, revision, and finalization phases with
at least two, and usually three, editors reviewing each chapter.
This project would not have happened without the efforts of Tracy Todd, Chief
Executive Officer of the AAMFT. As part of an AAMFT initiative to develop essential
resources for “those practicing systemic and relational therapies throughout the
world,” he worked with Darren Reed at Wiley to formulate a market rationale for a
multivolume handbook for the field of systemic family therapy. Tracy and AAMFT
continued to support the project with funding for part‐time staff and expenses for
editorial meetings. While providing invaluable support, Tracy and the AAMFT Board
have not been involved in determining the content of the handbook, which has been
completely the responsibility of the editors.
It is impossible to adequately thank the editors and the authors for their efforts—all
of it as volunteers—to make this project possible. It is a humbling experience to ask
so much and see such dedication of so many people to complete this task. The sheer
size and complexity of this project would not have been manageable without our
Assistant Editor, Leah Maderal. She kept the entire project organized and moving
forward, tracking every version of every manuscript as each was submitted and edited.
She obtained and updated contributor information and developed systems for safe
sharing and storage of all material. In addition, Leah developed and maintained the
project website, checked copyright permissions, and worked to get artwork and other
special elements in the correct format for Wiley. Renu Aldrich served as Assistant
Editor in the early months of the project. Sarah Bidigare played an essential role as
Editorial Assistant, double‐ and triple‐checking each manuscript for formatting and
adherence to APA Style. Recognizing the importance of this project for systemic fam-
ily research and the future of the field, Rick Miller obtained funds from Brigham
Young University to help support opportunities for editors and authors to interact
face‐to‐face.
I want to take a moment to acknowledge the mentoring and support given to me by
the late Doug Sprenkle. Doug and I both started at Purdue in 1975, Doug as a new
faculty member and I as a first‐year doctoral student. He was a model teacher, supervi-
sor, and mentor of graduate students. He was also a role model for me as editor of the
Preface xxxi
Journal of Marital and Family Therapy and in his commitment to developing scholarly
resources for the field. Doug was very supportive of the development of the handbook.
I deeply regret that he died before seeing it in print.
It has meant everything to me to work with colleagues who have been passionate,
committed, and engaged in bringing this project to fruition. Thank you, Adrian,
Lenore, Mudita, Reenee, Rick, and Ryan. Throughout this project, I also depended
on the wisdom and encouragement of friends and colleagues. I particularly want to
thank Pauline Boss, Ruben Parra‐Cardona, Liz Wieling, Mudita Rastogi, Jo Ellen
Patterson, and Andrea Wittenborn. I am grateful to my children, Nathan and Leah,
their spouses, extended family, and friends for their patience and forbearance through-
out these last 3 years. Most of all, I thank my husband, Richard Wampler, who has
lived through all of the trials and triumphs of this project with me. From explaining
genetics and writing two chapters to checking references and looking up doi’s for two
authors in challenging situations, Richard has played a major role in ensuring the
timely completion and uniform quality of the handbook and my survival doing it.
Finally, I want to remember the support of my dear friend Carol Parr, who never
failed to ask about “the book” during her long and final illness.
I did not hesitate to say “yes” when Tracy contacted me about this project. I knew
without a doubt that the field of systemic family therapy had developed to new levels
of depth, breadth, impact, and sophistication in practice, theory, and research that
were simply not reflected in available comprehensive scholarly resources. Those we
contacted to participate in the project had the same reaction—a resource like we envi-
sioned for the handbook was needed for our field and needed quickly. Our hope is
that you will find the content as important, compelling, and useful as we have.
Karen S. Wampler
Editor‐in‐Chief, The Handbook of Systemic Family Therapy
References
Volume 2 Preface
Systemic Family Therapy with
Throughout my involvement in this volume and The Handbook of Systemic Family

Therapy, I have worked, learned, and been inspired much more than I anticipated.
Looking back on how this volume came to be, however, I must confess my initial
reluctance to lead it. As you might imagine, due to many competing demands, I
entered the initial meeting to discuss my potential involvement with a “thank you, but
no thank you” clearly in mind. But, as anyone who knows Dr. Karen Wampler can
attest, she can be a convincing and strong advocate. And I am so very thankful for
that. Her passion for the handbook was apparent, and the need for our discipline to
fulfill the vision for the aim and scope of the project was undeniable. Although I did
not formally commit to the project when we parted from that first meeting, I knew I
was hooked.
In my doctoral studies, I was stirred by an article in the Journal of Marital and
Family Therapy in which the late Dr. Salvador Minuchin (1998) asked “where is the
family” in a contemporary solution‐focused therapy approach of the time. He ques-
tioned if we had lost our focus on family relationships. His ideas about the importance
of the child’s immediate family context, his beliefs in parents’ responsibility to provide
solid guidance and structure for their children, and his appreciation of culture make
him one of my enduring systemic family therapy heroes. I elected to lead the Systemic
Family Therapy with Children and Adolescents volume, in large part, because I believe
that the important questions asked by Minuchin over 20 years ago are still applicable
to our field today.
For the handbook, one of our key charges was to identify leading scholars in specific
SFT content areas and recruit them to be contributors. Mustering up my best imper-
sonation of Karen and her convincingness, I approached SFT researchers of children
and adolescents whose work I greatly admire. To my surprise, people were willing to
contribute (although I’m not sure they fully understood what they were getting them-
selves into). As you will see, their chapters are organized such that history, prevention,
and intervention are provided first, specific child concerns and contexts are detailed
next, and a discussion about future directions with an emphasis on cultural sensitivity
and family policy concludes the volume. The authors worked hard to ensure their con-
tributions were complete, inclusive, and forward‐thinking. Although it would not be
possible to cover every unique child presenting problem and context, I think readers
Volume 2 Preface xxxiii
will find this to be a high‐quality, comprehensive resource on contemporary child and

adolescent concerns.
I would like to acknowledge Dr. Karen Wampler and the members of the editorial
team: Drs. Rick Miller, Adrian Blow, Mudita Rastogi, Reenee Singh, and Ryan Seedall
whose insights and feedback were instrumental to the quality of this volume. To Leah
Maderal, I do not know what we would have done without you. To the authors,
I know that you made professional and personal sacrifices to afford the time to write
your important works. Please know how much your efforts are appreciated. I would
also like to thank my mentor, the late Dr. Mary Hicks, whose commitment and
instruction are fundamentally responsible for my systemic family therapy foundation.
Also, I must acknowledge Florida State University Marriage and Family Therapy
(MFT) alumni and students. You teach me so much, motivate me, are patient with
me, and embody the value of interconnectedness upon which SFTs are rooted. Finally,
to the clients who entrust me with your worries, fears, and struggles, your strength
and perseverance serve as a guiding light for me. Thank you.
I hope readers of this volume find answers to clinical challenges they may be facing,
come away with new knowledge about the state of SFT with children and adolescents,
and are motivated to ask novel research questions that will continue to propel this
important work forward. As SFT clinicians and scholars, we are so privileged. I hope
the works included in this volume further encourage SFTs to use our positions to
advocate for the families we serve. They are counting on us.
Lenore M. McWey
Associate Editor
Reference
Minuchin, S. (1998). Where is the family in Narrative Family Therapy? Journal of Marital and
Family Therapy, 24, 397–403. doi: 10.1111/j.1752-0606.1998.tb01094.x
Foreword
This four‐volume handbook captures the breadth, depth, and creative applications of
systemic family therapy today. The editors and chapter authors capture our profession’s
understanding of the healing potential of couple and family systems and take that basic
understanding in many important directions. Clearly, we have come a long way.
Over my 44 years in the profession, I have described systemic family therapy in
progressively different ways. In the beginning, it was a young, emerging profession
based on systems theory, then an adolescent finding its place in the world. I explained
to doctoral recruits, for a time, that it was the fastest‐growing mental health profes-
sion. I explained that while more than half of the presenting problems of clients in a
typical mental health clinic had systemic features, most therapists have had little or no
training in family therapy. I remember devouring various editions of Gurman and
Kniskern’s Handbook of Family Therapy and books by Haley, Minuchin, Satir,
McGoldrick, Whitaker, deShazer, Johnson, and others the way I read some nov-
els – without coming up for air. I remember for a long time buying into the battle of
the name brands, as Lynn Hoffman called our preoccupation with famous model
developers and their models. I also quoted Doug Sprenkle (to whom this four‐volume
handbook is dedicated) regarding the importance of “the synergetic interplay of the-
ory, research, and practice,” each domain enriching the others.
Doug died recently, but as more than one of his former students explained, he
humanized the field, and I see his keen, big‐picture mind and therapist’s heart in the
chapters of this handbook. He would have been pleased that the authors of this hand-
book address systems in the margins, internationally, across individual, couple, and
family presenting problems, in health care, and in a research‐informed manner. He
would have been pleased that in such a diverse field, we still see commonalities in the
power of family systems to heal and are giving greater attention to common factors
that contribute to that change and to systemic family therapy research that keeps us
honest and grounded in empirical data.
I agree with you, Doug. This handbook marks the fact that systemic family therapy
is indeed a profession that has taken its rightful place among our sister professions, who
are also embracing the power of systemic interventions. This handbook includes sys-
tems interventions that address important issues and problems—child maltreatment,
global public health, domestic violence, depression, racial and gender issues,
xxxvi Foreword
sociocultural attunement, policy and advocacy, adolescent substance use, youth sui-
cide, grief and loss, and so much more. The profession and the practice of systemic
family therapy are both given attention, as is multidisciplinarity. So is, as Doug might
say, the synergism of theory, research, practice, and policy. The editors’ coherent
organization includes overarching foundations, practice models of relational treatment
for children, adolescents, couples, and families, and research foundations, with a global
perspective and attention to cultural diversity throughout. In short, the handbook is
broad enough to reflect the health and usefulness of systems interventions that meet
the very real needs of people today. I also see room to grow, improve, and address a
world yearning for a caring, vibrant, evidence‐based discipline that employs the best in
ourselves and can positively transform the intimate and varied systems around us.
Fred P. Piercy, PhD, is Professor Emeritus of family therapy at Virginia Tech,
Blacksburg, Virginia, and former editor of the Journal of Marital and Family Therapy.
Fred P. Piercy
Part I
Overview
1
The Evolution of Systemic
Approaches to Children
and Adolescents
Richard S. Wampler
This volume in The Handbook of Systemic Family Therapy is focused on systemic ther-
apy with children and adolescents. In it, you will find many different systemic
approaches to the myriad problems for which young persons (birth to “emerging
adulthood”) and their families seek services. Throughout this chapter, I will empha-
size the need for systemic family therapists to actually think systemically. Offspring of
all ages, including infants and their parents, can potentially benefit from a systemic
family approach. Infants and toddlers certainly require a different approach than pre-
schoolers, high schoolers, and emerging adults, but all these offspring are embedded
in systems that can benefit from the services of systemic family therapists.
Roles for Systemic Family Therapists
Not every problem presented in systemic family therapy (SFT) has a diagnosis in
DSM‐V or ICD‐10, but understanding how systems function and how to encourage
change can lead to young persons and families who are stronger and more resilient.
SFT can provide primary assistance for some cases, without reference to other entities
or professionals. However, SFT also can provide critical secondary support for families
in other cases by collaborating with the wider community of professionals, agencies,
and other entities. In these latter cases (e.g., chronic illnesses), SFT practitioners can
provide services to families while also advising, informing, supporting, and cooperat-
ing and communicating with other mental and physical health providers, as well as
learning from these other providers’ expertise. In still other cases, SFT needs to take
a tertiary place—being aware of and referring clients to other services and watching
admiringly as others with different knowledge and expertise do their work. A useful
SFT motto is “Stay in your lane!”
Another valuable SFT motto is “Be an advocate!” One of the strengths of systemic
thinking is to consider “what else” might be responsible for the issues with which the
The Handbook of Systemic Family Therapy: Volume 2, First Edition. Edited by Karen S. Wampler
and Lenore M. McWey.
4 Richard S. Wampler
young person is dealing. Certainly, some children and adolescents actually ask to come
into SFT for help; however, many (most, if we are honest) come into SFT because
someone else wants them there. In the first case, the prospective client may need to
share a secret (feelings of mental illness, sexual assault, domestic violence, sexual iden-
tity). In the second case, the prospective client is seen as causing a “problem” for another
person or entity, presenting a dilemma for a therapist who wants to practice SFT effec-
tively. Do we see the child/adolescent individually, with a parent or both parents, with
any siblings, with any other relatives or professionals? The unexpected answer is, “Yes!”
Choosing the right client system

SFT has outlasted the purists who claim SFT is impossible without the whole system
and family in the room. The reality is that most experienced systemic family therapists
find themselves in a room with a young person, perhaps with one or both parents or
not, and with one or more others or not. Developing and refining a theoretical SFT
position and using that position to inform therapy are critical for SFT. Theory pro-
vides a roadmap, but it is not the actual journey we must take with clients. Flexibility
in what actually happens in cases is a necessity. I am reminded of a young solution‐
focused therapist, a purist, who worked successfully in the homes of very distressed
and disorganized families where a child was on juvenile probation. He told me about
a surprisingly directive intervention he had made, and I twitted him with, “What hap-
pened to your claim that solution‐focused therapy was about the family’s capacity to
use prior successes to meet current challenges?” His response was, “This is a family
that has never been successful. I had to lead them through this intervention to allow
them to find a solution. Then, I could refer back to that success for the next problem
we needed to solve.” Searching for a prior solution to a relevant problem is not a solu-
tion when the family truly cannot claim any prior success.
Young people do not exist in a vacuum, and it is helpful to begin with an apprecia-
tion of where humans and human systems arose and developed, what happens when
family and systems support or fail to support young people, the consequences of that
support or failure, how other variables can be critical to that support or failure, and
how therapy services for young people began and grew into SFT.
Choosing the right word

“Parent” will be used in this chapter to include biological fathers and mothers, adop-
tive parents, stepparents, grandparents and other relatives, and foster parents—in
short, the primary caregiver(s) for a child. However, when discussing a specific parent
or type of parent, the corresponding term will be used. For example, much of the
research on developmental processes and “parenting” that will be discussed is based
on “mothering,” and “mother” and “maternal” will be used accordingly.
Children and Adolescents as Members of Systems
Humans are social animals, and their infants and young children cannot survive with-
out being accepted as members of a social system. The earliest social groups or bands
Evolution of SFT with Children and Adolescents 5
were built around the unit of a mother and her offspring, and matrilineal descent was
critical in determining band membership. A mother and her young offspring were not
safe unless incorporated into larger systems ranging from nuclear and extended fami-
lies, bands, and tribes to confederacies of tribes (e.g., city‐states, nations). Throughout
human history (250,000 years) and in many modern cultures around the world, the
extended family with multiple generations living with or near one another has been
the norm. However, family researchers from high‐income countries, that is, the
Western, Educated, Industrialized, Rich, and Democratic (“WEIRD”) countries
(Heinrich, Heine, & Norenzayan, 2010), have tended to focus on twentieth‐ and
twenty‐first‐century Western culture and the two‐parent nuclear family as the stand-
ard to measure the strengths and weaknesses of other kinds of families from different
ethnic/racial groups or with different cultures. Therapists are hardly immune to these
biases when working with young people and their families who do not match this
expected standard.
This fundamental model of the extended family, in contrast to the culturally specific
view of two parents and their offspring as the family prototype, is no accident. In On
the Origin of the Species (1859) and The Descent of Man (1871), Darwin argued against
special creation and put forward the ideas that different living species have been estab-
lished over time from common ancestors through a process of evolution from one
generation to the next. It follows that the great apes must be closely related to humans.
It remained for field research (e.g., Fossey, 1983; Galdikas & Briggs, 1999; Goodall,
1986) and more recent DNA research (e.g., Dannemann & Kelso, 2017; Mallick
et al., 2016; Sequin‐Orlando et al., 2014) to confirm and extend these arguments.
We share 98.8% of our genome with chimpanzees and bonobos, 98.4% with goril-
las, and 96.4% with our more distant cousins, the orangutans (Chimpanzee Sequencing
and Analysis Consortium, 2005; Smithsonian Institution, 2018). Since Darwin, the
behaviors of these four great ape relatives have been of great interest, especially as
there are parallels to human behaviors in complex social and parental behaviors,
including intensive maternal care for newborns, infants, and weanlings (Cawthon
Lang, 2018). The mother, peers, and other adults in the group provide safety and
teach the young what to eat, how to get food, how to relate to other members of the
species, and how to respond to danger, among other survival skills.
It is tempting to ignore the six million years that separate modern humans from
chimpanzees and overgeneralize from our knowledge of great apes to the behaviors and
social organization of humans (e.g., Morris, 1967), ignoring both the very real genetic
differences between humans and other great ape species (cf., Smithsonian Institution,
2018) and the far greater variety and complexity of human behaviors and communica-
tion (Bolger, 2010; Susman, 2013). There is a further temptation to overgeneralize and
over‐assume across cultures and nationalities from a generic Western perspective, ignor-
ing the sometimes dramatic differences in behaviors seen in parenting and child‐rearing
behaviors, child experiences, and attitudes toward children (“cherubs, chattel, change-
lings”) actually present in contemporary cultures (Lancy, 2015).
Systemic family therapists for children and adolescents regularly emphasize the
importance of larger systems; however, in actual practice, the focus on the nuclear
family in almost all SFT theories leads to ignoring or excluding larger, as well as
smaller, parts of this nuclear family. These “larger parts” include persons and institu-
tions outside the presenting family who are engaging with or influencing that fam-
ily—the extended family, schools, the justice system, the neighbors, the community,
and so forth. The “smaller parts” include parent–child pairs, the targeted young per-
son, one or more siblings, and parent pairs. Potentially, these smaller parts also include
each individual’s and each family’s history, including biological factors.
Tasks for Families and Societies
Protection/nurturance
However defined, families and societies have a number of tasks that must be fulfilled
if a young person is to survive and become part of the community. Physical protection
and nurturance are critical from conception through adulthood. Obviously, the infant
has very different needs when compared to a young adult; however, all these ages
need support and nurturance. Studies of adults who have a history of severe prenatal
malnutrition (Lumey, Stein, & Susser, 2011) or severe prenatal or childhood illnesses,
injury, or disability testify to their deleterious long‐term effects. Physical safety and
adequate food are not enough, as we have learned through studies of the develop-
ment and impact of infant–toddler attachment disorders across the lifespan
(Grossmann, Grossmann, & Kindler, 2005; Lyons‐Ruth & Jacobvitz, 2016; Van
IJzendoorn, 1997) and the long‐term effects of “adverse childhood experiences”
(ACEs) in the family (Felitti et al., 1998). When an infant or child fails to develop
connections to others through neglect or abuse, the adolescent and the adult are at
risk psychologically and physically.
Skills/socialization
Families are also tasked with teaching skills of all kinds: social, health, and survival.
Such teaching is both formal and informal, and, because humans are observational
learners, children learn through practice and by watching adults and older children
modeling the skills. For acceptance and integration into the family, children must
learn how to behave in conformity with family norms. At some level, these norms may
conflict with the wider society’s norms, leading to rejection, discrimination, and, per-
haps, punishment by that wider society.
Launching
Cultures have different markers as to when a child is launched into adulthood.
Historically in Europe, 7 years of age was considered a point of transition to begin-
ning work or apprenticeship, increased responsibilities for food production, and so
forth, and children of that age were expected to contribute to the family welfare.
Many cultures see the time to move from childhood to adulthood as when a person
becomes capable of reproduction (puberty for males or menarche for females (Lancy,
2015, pp. 334–337, Mbito & Malia, 2009; Thesiger, 1997). High‐income cultures
have pushed the transition to adulthood much further forward, reflected in the
increase in age at first marriage and longer periods of formal education. The term
“emerging adulthood” refers to the period from 18 to 25 (or 29) years of age before
the person takes responsibility for himself/herself, makes independent decisions, and
achieves financial independence (Arnett, 1998). The luxury of such a delay in assum-
ing adult responsibilities is unheard of in communities, cultures, and countries lacking
such immense resources.
Sources of Child and Adolescent Success and Failure
Theories to explain why some children thrive or fail to thrive into adulthood may be
classified into six major categories, working from the inside out: genes, brain develop-
ment, prenatal environment, postnatal experiences, families and homes, and the social
and physical environment. Of course, each of these categories overlaps with the oth-
ers, and, unfortunately, too many advocates of each view tend to discount the others.
Glueck and Glueck (1950) put it clearly in their groundbreaking report on antisocial
boys: “It is well nigh impossible to differentiate with assurance the completely innate
from the completely acquired…. Birth injuries or anomalies of embryologic develop-
ment may be confused with inherited conditions. Social inheritance may be mistaken
for biologic” (p. 273).
Genetic
Darwin’s theory of evolution led to Social Darwinism and other theories of human
diversity that identified less evolved or “degenerate” humans (Lombrosco,
1876/2006), but these theories were consistent with older ideas about race and
wealth. Racial, intellectual, and moral superiority were advanced in the spurious
defense of slavery (e.g., Finkelman, 2003) and colonialism (e.g., Engerman &
Sokoloff, 2005). Without understanding the common ancestry of all humans and
common genetic inheritance, “races” were defined as genetically superior and infe-
rior, often based on skin color or appearance, and judged to be more or less intelligent
or worthy of education or immigration (cf., Kamin, 1974). Benjamin Franklin
(1751/1999) had this to say on immigration, “[W]hy should the Palatine Boors
[South Germans] be suffered to swarm into our Settlements … [who] will never
adopt our Language or Customs any more than they can acquire our Complexion?”
(pp. 251–252). Of course, Franklin was strongly opposed to the importing of African
slaves, on “racial” purity, not moral, grounds. In the early 1900s, IQ testing became
the norm for establishing these nonexistent “genetic” differences, infamously sup-
porting the eugenics movement, immigration quotas, sterilization of the “unfit,” the
11+ examination in Great Britain, and, ultimately, justification for Nazi race policies
and the “Final Solution.” Sadly, the ideas of racial superiority live on, whether focused
on IQ or athleticism. Distinguished academics have written books that, wittingly or
not, buttress these views (Herrnstein & Murray, 1994; Jensen, 1968).
Population differences in genes The last 100,000 years of geographic separations

after humans began to migrate out of Africa to Europe and Asia and beyond has
meant that random gene alterations in one population are not shared with the others,
including the white skin that Westerners inherited because they interbred with the
Neanderthals. Geneticists have provided evidence from analyses of ancient and
modern DNA that indicates that there are gene differences between five major

opulations—African, Oceanians (e.g., Papua New Guinea), East Asian, Native North
p
and South Americans, and West Eurasians (Mallick et al., 2016). The question is,
“What do these genetic differences mean?” At present, there is no definitive answer.
One of the leading researchers in the modern and ancient DNA field, David Reich
(2018a, 2018b) rebuts the racial purists and supremacists, stating, “Compared with
the enormous differences that exist among individuals, differences among popula-
tions are on average many times smaller.”
The “new genetics” It is important to realize that this “new genetics” approach (a)
has used more sophisticated genetic analyses (statistical and biochemical), (b) studi-
ously avoided a racist approach, and (c) focused on the possible links between genetics
and behaviors, physiology, and brain structure and function. It is assumed that most
inherited traits are polygenetic, expressed through a group of genes (e.g., height) and
not just one gene (e.g., red‐green color blindness).
Two points need to be made: First, it is important to recognize the difference
between “genotype,” the set of genes at conception (egg + sperm), and “phenotype,”
the characteristics that are actually expressed in the individual. Studies that map the
entire genome (all the material contained in the chromosomes) rely on correlations
between the presence of a gene (specific genotype), at a particular location (“locus”),
on one of the 23 pairs of chromosomes, with some outside measure, such as height or
education level (phenotype). Correlation, as every student of statistics can chant, does
not mean causality. The contribution of any one gene to the phenotype can be quite
small, and Hill et al. (2018) state that, taken all together, the numerous genes/loci
that were significantly correlated with an estimate of intelligence could account for
only 3.64–6.84% of measured (“phenotypic”) intelligence, leaving 93–96% of meas-
ured intelligence unexplained.
Second, using IQ scores or tests correlated with IQ scores as measures in genetic
analyses raises a question of what is actually being measured. Flynn (1987) pointed
out that the average raw scores on standardized IQ tests (e.g., Wechsler series) had
increased in 14 countries over every decade, requiring test developers to periodically
adjust how the standardized scores were computed to keep the base‐standardized IQ
score at 100. The “Flynn effect” has been documented in rural Kenyan children
(Daley, Whaley, Sigman, Espinosa, & Neumann, 2003). Are these children just get-
ting smarter? Or do more children get to attend school in these rural areas? That is,
do they know the answer to the questions on the test and know how to perform skills
tested on the IQ test, thereby getting higher and higher raw scores? Improved educa-
tional access around the world has driven how much and how rapidly raw scores on
the IQ tests increased. Further, it is reasonable to ask whether every culture sees a
question on the IQ test as relevant and likely to be part of children’s education or
training. The air distance between London and Beijing or San Francisco is relevant for
an airline pilot, but not for the child of a slum who has no access to education.
Disadvantaged or isolated urban and rural children all over the world are likely to
score lower on IQ tests—not because they are less intelligent genetically, but because
their education and experiences do not prepare them to do well on the test.
A complicated story The complexity of this level of genetic analysis becomes obvious
in two recent studies using the genomes (tracking the DNA structure of 22 pairs of
chromosomes, omitting sex chromosomes) of self‐identified white British p articipants.
Over one million Britons have submitted their genetic material. Many of these partici-
pants also have taken a test of verbal and numeric reasoning (assumed to represent
IQ) and completed questionnaires regarding level of education, mental and physical
health, family history, and other personal information. In the first study with a sample
of over 75,000 participants, 18 different segments (“loci”) on various chromosomes
were identified as predictors of verbal and reasoning test scores (Sniekers et al., 2017).
A different sample of 120,934 white participants drawn from the same pool of one
million Britons yielded an astonishing 187 independent loci (stretches along the chro-
mosome that may contain several genes) that were correlated with verbal and math
reasoning (Hill et al., 2018). These authors noted that the 583 genes contained
within the 187 chromosomal segments have many important and different functions
in the developing brain and spinal cord.
The results of the British population studies examined only the genomes of self‐
defined white persons. Until such large‐scale genomic studies are done with non‐
white populations, the door is open to supporters of racist ideology, “genome
bloggers,” anxious to prove the superiority of one population (e.g., West Eurasian)
(Reich, 2018b, pp. 254, 259–267). In contrast to the full‐genome research, a very
different statistical approach has found evidence that the level of intellectual develop-
ment (adoption studies: Scarr, 1993) and the onset, severity, and persistence of anti-
social behaviors observed in young persons (twin studies: Anderson, 2018; Moffitt,
Caspi, Harrington, & Milne, 2002) are linked to inheritance without attempting to
identify the gene(s) responsible for these effects.
Epigenetics
One growing and important issue regarding genetic explanations of behavior or intel-
ligence is that there can be permanent changes in the expression of genes (genotype)
in an individual, resulting in differences in the person’s actual development (pheno-
type). Consider that every cell in our body contains the same DNA. It is clear that
something happens between conception and adulthood such that cells have different
functions, for example, liver versus nerve cells. In cell development, some genes are
turned on and some are turned off in a pattern that permits a change from a stem cell
to a specialized cell: epigenesis. Epigenetic changes have been correlated with changes
in cognition, depression, altered response to stress, and major psychoses (e.g., Day &
Sweatt, 2011; McGowan et al., 2009; Petronis, 2010). These changes can continue
through life, including hair loss or some cancers. However, it is reasonable to argue
that early life is a time when epigenetic changes are particularly important. As new
neuronal connections develop in the brain at the rate of 700/s during fetal and early
postnatal life, some will ultimately become well established. During these times, the
nervous system is particularly susceptible to both good and bad influences: environ-
mental enrichment versus contamination. At other points in rapid development (tod-
dlerhood and early adolescence), connections will be “pruned” away when connections
between cells are cut. Over time, even identical twins with truly identical genomes
diverge in appearance, behavior, and personality in response to differences in their
environment and experiences. Gene–environment interactions (GxE) make it harder
to accept any simple explanation of a trait or behavior. What we thought was simple—
one gene, one outcome—is no longer valid. At the same time, GxE research offers an
immense new field for study, combining genetic and environmental explanations.
Pre‐ and postnatal risk factors

Epigenetic explanations offer insight into why prenatal and postnatal events can be so
devastating or so enhancing. A multitude of prenatal and postnatal sources of behav-
ioral and intellectual problems has been identified.
Environmental Maternal malnutrition (Lumey et al., 2011), prenatal infections

(e.g., rubella and Zika), and maternal ingestion of chemicals, pollutants, prescription
and nonprescription drugs, smoking, secondhand smoke, alcohol, and so forth, dur-
ing pregnancy and in breastfeeding (Hart et al., 2006; Mead, 2008), all have been
identified as increasing the likelihood that the offspring will have behavioral or intel-
lectual difficulties, or both. Environmental contaminations with lead, bisphenol A
(BPA), mercury, and so forth in infancy and early childhood have all been correlated
with the risk of behavior or cognitive changes that can be permanent (e.g., Grandjean,
Weihe, Debes, Choi, & Budtz‐Jorgensen, 2014). The risk of long‐term effects
increases with the degree of contamination. When lead was removed from gasoline,
the murder rate declined over the next 20 years (Nevin, 2000). Of course, very few
children exposed to lead early in life grow up to murder anyone, but the correlation
with lead contamination is remarkable. Generally speaking, young persons in the
poorest countries, ethnic or economic minorities, and those in the lowest social classes
are a greatest risk being damaged by any and all of these environmental factors.
Early experiences influence brain development Changes in the brain are not limited to
environmental contamination. With the advent of brain imaging techniques, particu-
larly functional magnetic resonance imaging (fMRI) and structural magnetic reso-
nance imaging (sMRI), there has been an explosion of research on the changes in
brain development. Of particular interest to behavioral scientists and therapists who
work with children and adolescents with behavior problems is research on the limbic
system. Once called the “reptilian brain,” the brain structures in the limbic system
communicate both with the higher cortex where executive functioning and con-
sciousness arise and with more primitive brain structures that regulate bodily func-
tions. In particular, if the amygdala, one of the structures in the limbic system, is badly
damaged through accident, illness, or tumor removal, humans have almost no physi-
ological or conscious fear response (Feinstein, Adolphs, Damasio, & Tranel, 2011).
Further, decision making is impaired as shown by taking larger risks for smaller
rewards in a formal testing situation (De Martino, Camerer, & Adolphs, 2010). In
regard to early human development, two streams of evidence have emerged: (a) the
amygdala’s relationship to behaviors seen in adolescents diagnosed with oppositional
defiant disorder and conduct disorder (ODD/CD) and (b) changes in the size and
function of the amygdala in maltreated or abandoned children.
Recent research reviews indicate that abnormalities in the size (sMRI) and activity
level (fMRI) of the amygdala are linked with the diagnosis of ODD/CD in adoles-
cents, regardless of a diagnosis of attention deficit hyperactivity disorder (ADHD)
(Noordermeer, Luman, & Ootserlaan, 2016). The sMRI studies indicated that the
amygdala had a reduced size in adolescents diagnosed with ODD/CD. The fMRI
studies comparing CD/ODD and control groups indicated less activity in the amyg-
dala in response to emotional stimuli (sad faces, negative feedback on task). Blair
(2013) also reviewed sMRI and fMRI studies and described two groups of a dolescents
diagnosed with ODD/CD. The first group shows pronounced psychopathic traits
(lack of remorse/guilt and callousness or a lack of empathy). These adolescents are
impulsive and ruthless in meeting their wishes and needs and do not seem to have any
sense of the effect of their behaviors on others or remorse for their antisocial behav-
iors. They show less fear in their behavior and less activity in the amygdala–cortical
circuit assessed in fMRIs. In contrast, adolescents in the second group with ODD/
CD lack these psychopathic traits and are likely to have a concurrent diagnosis of
mood or anxiety disorders. This second group shows more activity in the amygdala–
cortical circuit in the fMRI. This group of adolescents responds to fear with unplanned,
rage‐filled attacks (reactive aggression), sometimes followed by remorse and attempts
to repair the injury or damage caused. This second group seems to be governed by
their fears and anxieties, but unable to block an impulsive outburst. Blair (2013) sug-
gests that this second group may be suffering from posttraumatic stress disorder
(PTSD) because of the likelihood of early maltreatment or abuse. His extensive review
ends with a proposal that genetic, epigenetic (e.g., resulting from early experiences),
environmental, and nongenetic factors, all may be at work in the development of
antisocial behaviors via changes in the functioning of the amygdala.
Studies of adults who showed disorganized attachment as toddlers also indicate
changes in the amygdala. A history of verbal or physical abuse or severe neglect has
been associated with disorganized attachment. In the Strange Situation (Ainsworth,
Blehar, Waters, & Wall, 1978), the regular caregiver (usually, the mother) leaves the
toddler alone with an unfamiliar adult for a few minutes. When reunited with the
mother, disorganized toddlers show contradictory responses, misdirected or stereo-
typed behaviors, “stilling” or freezing, seeming to be apprehensive or fearful of the
caregiver (Main & Hesse, 1990; Van IJzendoorn, Schuengel, & Bakersmans‐
Kranenburg, 1999). The mother’s behavior can include making negative attributions
to the toddler, withdrawing in apparent fear, making fun of him or her, and so forth.
In adults with a history of disorganized attachment, there are significant changes in
the size (volume) and inferred function of the amygdala. Further, these changes are
linked to critical periods in infant and preadolescent brain development (Lyons‐Ruth,
Pechtel, Yoon, Anderson, & Teicher, 2016; Pechtel, Lyons‐Ruth, Anderson, &
Teicher, 2014). As adults, these participants were more likely to report trauma‐related
symptoms of dissociation (e.g., sense of being detached from reality or self) and “lim-
bic irritability” (e.g., brief seizure‐like events—lip smacking, unconscious patting, or
fumbling).
The sMRIs showed that both amygdalae were larger in these adults, but only the
greater volume of the left amygdala was related to severity of the disorganized behav-
ior assessed when they were 18 months old. The amygdala has particular sensitivity to
adrenal hormones (glucocorticoids) that increase in stress. Increased levels of stress
hormones are linked to increased neurogenesis (creating more neurons) in early
development. Therefore, the change in the size of the left amygdala was hypothesized
to be the result of the stress induced by abusive or neglectful experiences, resulting in
an overgrowth of the amygdala in infancy and early childhood that was never
overcome.
Not surprisingly, these abusive and neglectful experiences are likely to continue well
after toddlerhood unless there is intervention. These adults also were asked to indi-
cate the point in their lives where they remembered the most serious abuse occurring.
The sMRI size of the right amygdala (not left) was most strongly associated with the
reported severity of the maltreatment experienced in preadolescence (ages 10–11).

Preadolescence is the beginning of another critical period in brain development when
the dendritic (incoming) connections of neurons are being pruned away, and the
amygdala is actually shrinking in size. Maltreatment stops this process.
It remains for future research to determine how SFT might be able to directly over-
come, ameliorate, or reverse these limitations in brain function. Experiences from
birth into adolescence can shape or alter the complex processes of brain development,
perhaps through epigenesis or changes in hormone levels in response to stressors.
Without intervention, these brain changes seem to be permanent. Obviously, experi-
ences in the family are among the earliest and most important, setting the stage for
later experiences. Systemic family therapists working with young people with behavior
problems, including diagnosis with ODD or CD, need to be sensitive to past experi-
ences of their young clients, as well as understanding their present circumstances.
Other Factors: Home and Family
Robert Frost sums up “home” in “The Death of the Hired Man,” “Home is the place
where, when you have to go there, they have to take you in” (Frost, 1917, p. 14).
Home is a place or a memory, but it is where “family,” however defined, is or was. We
cannot survive from infancy without that connection.
Understanding early influences on development

Adverse childhood experiences (ACEs) Understanding factors influencing typical and
atypical development from birth to adulthood is critical for working with young people
and their families. The capacity to cope with social and familial stressors is basic to
healthy development (Flinn & England, 1995; Flinn, Ponzi, Nepomnaschy, & Noone,
2013). Unpredictable and severe stress in the family is cumulative from before birth and
across childhood and adolescence into adulthood, as demonstrated in the ACEs studies
(e.g., Felitti et al., 1998). ACEs have been divided into categories of childhood experi-
ences of (a) psychological, (b) physical, and (c) sexual abuse and (d) emotional and (e)
physical neglect, along with living in a home where there is a history of (f) interpersonal
violence, (g) parental substance abuse, (h) mental illness, (i) separation or divorce, or (j)
crime or incarceration. Consistent with systems theory that such adverse experiences
would be interrelated because of family dysfunction, there is a cascade of ACEs such
that, if even one ACE category is reported, at least 78% of those respondents also report
a second ACE and at least 58% report a third ACE (Dong et al., 2004).
ACEs have an impact on child and adolescent mental and physical health, and there
are long‐term consequences in adulthood. A review of 37 studies in 17 largely high‐
income countries with a total of 253,719 respondents found that 57% of respondents
reported at least one ACE and 13% reported four or more ACEs (Hughes et al.,
2017). Comparing respondents who reported childhood experiences in four or more
of these ten categories with respondents who reported no such experiences, the group
reporting four or more ACEs also reported much higher rates of risky health behav-
iors and related illnesses in adulthood, including increased risk of perpetrating or
being a victim of violence, suicide attempts, smoking, alcohol and substance abuse,
multiple sexual partners (≥50), and teen pregnancy/early sexual initiation, and high
rates of depression and anxiety, sexually transmitted diseases, cancer, and cardiovascu-
lar, respiratory, and liver diseases (Hughes et al., 2017).
The implications of two decades of ACEs research should be obvious to systemic
family therapists: be alert to signs of such behaviors in the family or directed toward
the child or adolescent and be prepared to deal with parent, sibling, and child and
adolescent issues. Severe abuse and neglect need to be reported to authorities to pro-
tect the young person and other siblings, but working in sessions to limit interper-
sonal (domestic) violence and severe punishments, heavy drug and alcohol abuse, and
so forth, has to be part of the therapy to protect the young person from immediate,
long‐term, and future transgenerational effects.
Poverty
Family income matters (Costello, Compton, Keeler, & Angold, 2003). Costello et al.
began a study that turned into a natural experiment with Native American (Cherokee)
and white children and their families. Native American families were more likely (57%)
than white families (25%) to have incomes below the poverty line, reflecting their his-
tory of discrimination and oppression. Four years into the study, the tribe opened a
casino, and some of the casino profits were given as a lump sum to every adult mem-
ber of the tribe. Further, tribal members were given preference for employment in the
casino. The overall percentage of Native American families living in poverty decreased
each year to less than half of the rate before the casino opened (57–23%), reflecting
the profits in the casino and the increasing number of parents employed full or part
time after the casino opening. The percentage of white families in poverty decreased
less dramatically (25–18%), reflecting the increasing employment in the services that
grew up around the casino.
Three groups of children were defined: the ex‐poor, whose families had increased
incomes beyond the poverty line; the persistently poor, whose families did not cross
the poverty line; and the never‐poor, whose families were always above the poverty
line. The ex‐poor Native American children had significantly fewer emotional and
behavioral symptoms 4 years after the casino opened and did not differ from the
never‐poor children. However, the children from persistently poor Native American
families increased the number of behavioral and emotional symptoms from the first
assessment to the end of 4 years after the casino opened. The authors examined 26
possible variables in the families. Increased opportunities for parental supervision was
the only variable that mediated the positive child effects of moving out of poverty.
Previously, parents in poor families might be taking part‐time or seasonal jobs or try-
ing to support the family through the underground economy. Parents who were
employed in regular, full‐time jobs were able to see their children more, do more with
them, and provide more consistent supervision.
Economic disparities and discrimination

Where a child grows up makes a difference in how that child becomes an adult. Cross‐
sectional studies can illuminate what is going on in a neighborhood or community,
but longitudinal studies can provide information on the processes underlying child
and adolescent development.
The classic studies Three classic studies of family and societal correlates of adolescent
success or failure point to the importance of both family and community: (a) a longi-
tudinal study following the families of every white 10‐year‐old child living in a poor,
inner London borough and families of every white 10‐year‐old child living on the Isle
of Wight, a relatively rural and socially stable island off the south coast of England
(Rutter et al., 1974); (b) the longitudinal Cambridge‐Somerville Youth Study (CSY
Study) (Boston‐area communities) that matched 253 pairs of white boys under 10
living in low‐income neighborhoods (chosen at random in 1939 and followed until
1945, half the boys were provided with enriched experiences, a counselor, summer
camps, and a place for recreation and tutoring, access to medical care, etc.) (Powers
& Witmer, 1951); and (c) the 1939–1940 cross‐sectional study in Boston that com-
pared the families of 500 white boys placed in residential “correctional” schools
because of antisocial behaviors and their families with the families of 500 white boys
matched for age, census tract, neighborhood quality, and immigration history (Glueck
& Glueck, 1950). All three studies yielded similar results: crowded housing, weak
community resources (e.g., poor schools, lack of playgrounds), parental marital prob-
lems, and parental mental illness or antisocial behaviors, all of which were associated
with the young person’s “deviance.” In the end, all three studies pointed to the
importance of parenting variables (e.g., employment, positive parental relationships,
parental mental health, and positive social attitudes) as the strongest predictors of
whether their children were successful.
Maternal warmth outweighs neighborhood effects These classic community–home

results have been replicated in a study of the neighborhood characteristics of 1116
pairs of English twins followed from ages 5 through 12 (Odgers et al., 2012). As
observed in the classic studies, the differences in neighborhood effects (deprived vs.
moderate vs. affluent) were as powerful as gender differences in predicting antisocial
behavior from ages 7 to 12. However, the most important finding in this study was
that supportive mothering, as measured by maternal warmth and monitoring, elimi-
nated the impact of the neighborhood and weakened the importance of all other
family factors. Mothers who had warm relationships with their sons and daughters
and who were able to monitor their behaviors and companions inside and outside the
home were least likely to have a child displaying antisocial behavior. Of further inter-
est is the finding that maternal warmth and monitoring were the only significant
predictors of the rate of change in child delinquent behaviors; that is, children whose
mothers who were warm and could monitor them showed the slowest increase in
antisocial behaviors.
The contribution of fathers in limiting the child’s antisocial behavior is not trivial,
of course; however, it depends on the degree to which the father displays antisocial
behaviors (Jaffee, Moffitt, Caspi, & Taylor, 2003). The combined measures (mother
and father) of parental antisocial behaviors, level of domestic violence, and evidence
of child harm used in the Odgers et al. (2012) study may reflect the negative role of
more antisocial fathers in family dynamics because of the greater likelihood that males
(fathers) engage in more antisocial behaviors, perpetrate more serious domestic vio-
lence, and are more likely to be the perpetrator of child injury. Jaffee and colleagues
found that the least antisocial fathers in this same sample spent more time with their
offspring, were far more likely to live with them and their mother, and provided care
for the children regularly. These children were the least likely to be delinquent at age
12. In contrast, antisocial fathers who spent more time with their children had chil-
dren who were most likely to be delinquent.
Mobility: Escaping economic and racial segregation It is important to remember that

racial/ethnic segregation and poverty both matter. One further set of studies shows the
positive and negative effects of moving from a very poor, “disadvantaged, crime‐rid-
den” neighborhood/community on children from African American and Latina/o
families (Keels, 2008; Kling, Ludwig, & Katz, 2005; Sharkey & Sampson, 2010).
Chetty and Hendren (2017a, 2017b) tracked the incomes of adult children (26 years
old) using de‐identified tax returns from 1.4 million US parents and their adult off-
spring. Some of the families had maintained the same residence in a county; others had
moved into or out of some 3,000 counties. The clear result was that a move from the
city to a surrounding suburb reduced the chances that African American and Latina/o
children were involved in, witnessed, or were victimized by violence compared to those
children whose families stayed behind or moved within the city, even if the new neigh-
borhood in the city was relatively affluent. Further, moving from a relatively poor
county to a relatively more affluent county as a young child increased the adult child’s
income significantly, regardless of the family’s income at the time of the move. Chetty
and Hendren (2017b) attribute 58% of the positive income effects to moving into
counties with lower rates of racial segregation and isolation, less income inequality, bet-
ter quality education, and more social capital (better services, lower rates of crime, etc.).
Youth in Society
Young people have always been treated differently than adults, but how they are
treated depends on their age and their culture. Modern Western societies (WEIRD)
have tended to idealize children as “cherubs,” but parents in some cultures view chil-
dren as workers or “chattel,” owned by parents and expected to work for the family.
Still other cultures view children, especially infants, as “changelings,” spirits, or mon-
sters who cannot be trusted and who may be dangerous, for example, the albino child
or twins who must be destroyed or girls who undergo genital mutilation as infants or
in childhood (Lancy, 2015).
Child labor
Child labor among the poor was the norm in Euro‐American agrarian and early industri-
alized societies well into the twentieth century. Tunnels in the nineteenth‐century nickel
and coal mines were 3–4 ft. high or less because the miners were as young as 6. The so‐
called orphan trains left US and Canadian cities between 1854 and 1929 loaded with
some 250,000 poor, orphaned, abandoned urban children and adolescents rounded up
off the streets for distribution across the countryside. While some were adopted into
good families, other children were often housed and worked under terrible conditions on
farms or in factories or homes. Child labor continues in more affluent countries when
families must be part of the underground economy (agrarian, craft, industrial, mining,
child prostitution). It is still the norm for families in low‐ to middle‐income countries
who struggle to survive without the work of their children (cf., Lancy, 2015).
Youth behavior problems

In any population of children and adolescents, there are always some few who are not
able to conform to family or social expectations for behavior. Adolescents, younger
children, and infants can all flunk the “cherub” test. Dealing with these youths who
do not conform varies, depending on the severity of the violation, the family, the cul-
ture, and the society. Families may provide discipline when rules are broken, ranging
from ignoring to admonishments, shaming, and restrictions to mild to severe physical
punishments; cultures may set penalties, varying from requiring confession and pen-
ance, shunning, even to expulsion; and societies may look for interventions to change
the behavior through legal or therapeutic means. For systemic family therapists with
young clients, it is important to be aware of parental, cultural, and social ways of deal-
ing with youth behavior issues. Respecting the values of parents does not mean allow-
ing severe physical punishments to continue, but it does mean understanding how to
deal with such parents inside and outside the therapy setting. Similarly, respecting
cultural values does not mean allowing religious practices or punitive cultural norms
to abandon or crush a young person. Social norm violations often involve the inter-
face between the systemic family therapist and institutions, courts, schools, and medi-
cal facilities, all of which can hinder or assist in the processes of therapist interventions.
“Systemic” is taken to mean just that, getting an overview of small and large systems
that are involved or impacting the origin and the continuation of the behavior. A
14‐year‐old male arrested for distributing marijuana at school may be the sole finan-
cial support of an ill parent, or he is acting as a distributor for his older brother, or he
is a member of a group of adolescents who are all part of a distribution network. A
4‐year‐old who is “aggressive” with other children in preschool may have been one of
Ruth‐Lyons’ disorganized toddlers, or being bullied by one or more peers, or feeling
ill, or lacking breakfast. Each of these situations demands a different approach that
acknowledges systemic influences.
The Rise and Growth of Systemic Approaches

SFT theorists and practitioners have a history of incorporating ways of working with
young persons as individuals into interventions with the family or beyond. One result
has been the development of multiple approaches to the same or similar youth prob-
lems based on theory or practice experiences. Each SFT “silo” exists in itself and has
little or no reference to other silos. To an extent, SFT has duplicated the psychody-
namic custom of expelling dissidents (“heretics”) who then start their own school of
therapy (Sigmund Freud to Carl Jung, Freud to Adler, etc.).
Psychodynamic legacies
The tradition of individual psychodynamic treatment for children began with “little
Hans” (Freud, 1909/1955) and expanded under the influence of psychodynamic
theory and practice. Ten years after Jane Addams helped to found the first juvenile
court in Chicago (1899) and juvenile detention (“rehabilitation”) facilities were up
and functioning, she also helped establish the Juvenile Psychopathic Institute (later
called the Institute for Juvenile Research). The Institute—a treatment center for
c hildren who had behavioral disturbances—was the beginning of the child guidance
movement in the United States and spread widely. Addams was well aware of the
kinds of environments and families these young offenders came from, but the focus
was on the individual and the approach was analysis. Individual analysis for young
persons without legal problems continued with Anna Freud’s (1928) work begun in
Vienna and extended in London after WWII. The individual child analysis movement
continued with other therapists trained in the Freudian or Adlerian traditions. A child
analyst, Melanie Klein (1932), began using play activities as a way to provide analysis
and interpretation for younger children, while more traditional talk‐based analysis
continued for older children. Trained by Carl Rogers (who was influenced by both
Adler and Rank), Virginia Axline (1947, 1964) used play therapy to allow her indi-
vidual clients to express themselves nonverbally, while she observed and commented
on the play.
Classic family therapy theories

Nathan Ackerman began bringing the parents into child therapy. This was a radical
departure from the historic focus on individual therapy for the child as practiced by
the Freudian, Jungian, Adlerian, Kleinian, and so forth, schools of psychotherapy. It
was also a radical departure from the medical model of individual “sickness” that had
guided therapy practice for well over 100 years.
Psychodynamic influences Nathan Ackerman (1966; Ackerman & Sobel, 1940)

brought a psychodynamic perspective from his training, but he saw a need to incor-
porate the family as a unit in which the child and the child’s issues were embedded.
He saw the family as developing over time with issues at each stage that potentially
affect the child: how parents were able to share responsibility for the child (or failed
to), how issues in the parents’ own pasts with their parents were being replicated in
the family, how emotions were expressed and regulated, and how conflicts between
members were resolved. Dealing with all these issues was part of his approach. His
institute in New York brought this new family‐based approach to other professionals.
A later development in the psychodynamic tradition was family therapy from an object
relations stance. Based on Klein’s and Fairburn’s approaches, object relations family
therapy focuses on how the parents’ early experiences are influencing their child’s
development (Scharff & Scharff, 1987).
A firm foundation It is remarkable, perhaps, that so many of the founders of classic

SFT (“marriage and family therapy”) theories were trained as psychiatrists steeped in
psychodynamic theories, as was Ackerman. Like Ackerman, after observing their child
and adolescent patients in the context of their families, they began to see the impor-
tance of a different approach to behavior problems in young persons.
Bowenian family therapy Murray Bowen (1978; Bowen & Kerr, 1988) was trained
as a surgeon, but moved to psychiatry in 1946 because of his experiences with soldiers
in WWII. He observed dysfunctional patterns of communication in families that left
children and adolescents trapped in a triangle with parents or with a parent and his or
her past relationships in the family. Bowenian therapy strategy, then, was to deal with
the parents’ issues with their own families and between themselves to free the child
from the triangle. This approach often led to each parent becoming the “client” and
to couple or individual sessions to deal with insights into their own family‐of‐origin
issues.
Contextual family therapy Ivan Boszormenyi‐Nagy also came to family therapy with
medical training as a psychiatrist. He saw offspring as trapped in family communication
problems that were the result of cross‐generational injuries leaving an “unbalanced
ledger” that the offspring, loyal to the parents, had to try and rebalance (Boszormenyi‐
Nagy & Spark, 1973). Parents come with unresolved issues (negative ledgers) from
their own childhoods, and children are forced into roles to “help” the parent (note
parallels to triangulation in Bowenian theory). In response to this parentification, off-
spring may retreat into silence and depression or, because of their special role with the
parent, may feel entitled to act out in potentially destructive ways (destructive entitle-
ment). Helping the “identified patient” and each member of the family escape from
distorted loyalties, legacies from previous generations, and resolve the unbalanced
ledger is the goal of contextual therapy. The therapist’s role is to listen and acknowl-
edge each person’s story, modeling an empathetic response to each person in the fam-
ily (multidirectional partiality) to increase everyone’s understanding of that person
while limiting negative responses from others toward that person (Frank, 1984).
Experiential‐strategic family therapy Two other pioneering theorists with back-

grounds in psychodynamic training moved from a focus on families talking to families
doing. Carl Whitaker (1977; Whitaker & Bumberry, 1988) took the view that the job
of the therapist is to break up the dysfunctional family patterns, sometimes in the
“Therapy of the Absurd.” One of the best‐known examples of Whitaker’s intuitive
approach is his decision to wrestle an adolescent male to the floor in front of his family
when the adolescent threatened to leave the session (Napier & Whitaker, 1978). The
point was to create a symbolic experience for the adolescent and his parents that the
adolescent was not all‐powerful and that the adolescent could be controlled. Because
Whitaker refused to set a model or write a manual for interventions, it has been up to
his students and strategic family therapists to identify the core of symbolic‐experiential
therapy (Mitten & Connell, 2004).
Structural family therapy While not as dramatic as Whitaker could be at times,

Salvador Minuchin (1974; Minuchin & Fishman, 2004; Minuchin, Montalvo,
Guerney Jr., Rosman, & Schumer, 1967) was also trained in the psychodynamic tradi-
tion. However, his mentors were both Ackerman, with his family focus, and Haley,
the iconoclast whose goal in therapy was to upset the status quo and free the family
members. Experiences with families at the Menninger Clinic in Kansas and a residen-
tial program for delinquent boys in New York led Minuchin to conceive of family
problems as a failure to create and maintain the vital invisible boundaries between
subsystems of the family. Ideally, each subsystem (partners, parents, children, siblings)
is bounded—for example, partners do not discuss their sexual relationship with the
children; parents lead the family in decision making and are responsible for negotiat-
ing family rules and enforcing them; and children have an advisory role in family deci-
sion making, but are not in charge of the other children, making rules for siblings, or
enforcing discipline. Minuchin and his colleagues argued that, by violating parent–
child boundaries and giving the child adult status, the immature child is empowered
to make her/his own decisions about behavior and those immature decisions lead to
dysfunctional child outcomes, including delinquency (CD/ODD) and depression/
anxiety.
Dysfunctional families violate the boundaries that separate one subsystem from
another: a parent complains to a child about the other partner or discloses the part-
ners’ sexual relationship problems; a child is given full authority to instruct a parent
on how to spend family money; and a parent places a child in charge of other siblings,
including physical discipline. In the structural model, the therapist is tasked with
actively changing the dysfunctional family structure, without using the psychody-
namic approach of expecting family members to reach and express insights about their
own early relationship histories and current behavior. In some cases, a structural fam-
ily therapist may make the invisible boundaries very visible by drawing out the prob-
lematic relationships on a blackboard, physically separating parents and children in the
therapy room, leaving the children in the waiting room, challenging the parents in
session to take charge of an unruly child, and challenging a parentified child to stop
acting like a parent with siblings—in short, using therapy sessions as an opportunity
to restructure the family and establish an appropriate hierarchy with boundaries
between individuals and subsystems.
Communication‐based family therapy The Mental Research Institute (MRI) group

members had diverse backgrounds, to say the least (Bateson, Jackson, Haley, &
Weakland, 1956). As a group, they were interested in observing and changing com-
munication patterns in families, ultimately developing a brief therapy model. For this
group, a young person who is caught in a double bind by a parent’s communication
style is likely to act out, become depressed, become anxious, or all three. Treatment
in the MRI model means changing the communication patterns between parents and
children to make the double bind explicit and remove its power, resulting in changes
in the behavior. Jay Haley (1980) went further to argue that the disordered cognition
and behaviors of schizophrenia in a young person were the direct result of such dou-
ble‐bind communications and that getting parents to deal directly with each other
stops the schizophrenic behaviors. His strategic therapy approach remains an impor-
tant influence in SFT, as does the MRI emphasis on brief therapy.
The rare female among these pioneers, Satir (1964) was part of the MRI group
initially, accepting that family communication issues needed to be addressed in brief
therapy. She conceptualized the offspring’s problem as not the “real” problem to be
solved. Instead, Satir used family communications to uncover and define the underly-
ing issue that created the offspring’s problem (e.g., the teenager is using drugs as a
screen against the father’s infidelity). Her soft, supportive manner allowed her to con-
nect with family members to reveal and resolve the hidden problem.
The Rise of Data‐Based Systemic Family Therapy Treatments
Measuring the success of SFT with young people is a matter of considerable contro-
versy. In the last decades, the demand for “evidence‐based family treatments” has
become the norm for journals, publishers, and funding sources. How is success meas-
ured? Is success measured by some youth outcome or change in family processes? Is
success dependent on the therapist’s or the family’s or the offspring’s evaluation?
Does “practice wisdom” count? How long does “success” last? How many cases are
needed to evaluate success? As scientific psychology developed, demands for larger
samples, “hard” data collection from multiple persons, follow‐up studies, and more
rigorous adherence to therapy protocols increased.
Attachment‐based interventions
Attachment‐based approaches to family therapy have strong roots in psychodynamic
thinking (Ainsworth et al., 1978; Bowlby, 1988), but have been used in very different
ways. “Attachment” issues beyond infancy and early childhood have been introduced
explicitly into SFT through attachment‐based family therapy (ABFT) (Diamond,
2005), emotionally focused family therapy (EFFT) (Furrow, Palmer, Johnson, Faller,
& Palmer‐Olsen, 2019; Palmer & Efron, 2007), and a number of interventions for
mothers and their infants or young children (below). Each of these attachment‐based
interventions focuses on building or restoring positive connections between offspring
and their parents. One sign of the increased popularity and prominence of attachment
in SFT is a recent analysis of previously published, research‐based articles from two of
the leading journals in couple and family therapy (Chen, Hughes, & Austin, 2017).
After “systemic,” the more general conceptual model for therapy, “attachment” was
cited twice as often as any other model of family therapy except emotionally focused
therapy (EFT), which itself is based on attachment theory and the model for EFFT.
Systemic family therapy interventions with infants and very

young children
SFT has found a place in infant and early childhood interventions, although not every
student of SFT is aware that this area of therapy even exists. Selma Fraiberg (1959;
Fraiberg, Adelson, & Shapiro, 1975) and her colleagues began the infant mental health
movement from a psychodynamic position, focused on the “ghosts in the bedroom”
carried by the mother. Interventions were largely directed at the mother developing
insight into her problematic behaviors with her child. The infant mental health move-
ment begun by Fraiberg in the 1950s has continued to grow with developmental
therapists and researchers who have focused on describing and changing mother–child
interactions based on research in human development. Rather than an exclusive focus
on the mother’s psychodynamic issues, the research and interventions are about recip-
rocal interactions between the mother and her infant that interfere with healthy con-
nections between the two (“attachment behaviors”). Research leads to identifying and
supporting healthier maternal behaviors with their infants and young children, encour-
aging more positive and understanding maternal attitudes about their offspring, and
providing best practice models for mothers and other caregivers, early education, and
intervention specialists (cf., Infant Mental Health Journal, Child Development, etc.).
Anna Freud, Klein, Bowlby and Ainsworth, Fraiberg, and Axline all contributed to
ways of doing therapy with the individual child. Their ideas have been incorporated in
various ways into a number of adult–infant and adult–child approaches involving
mothers, foster mothers, fathers, and others: Watch, Wait, and Wonder (Muir,
Lojkasek, & Cohen, 1999), Attachment and Biobehavioral Catch‐up (Dozier,
Lindhiem, & Ackerman, 2005), and Infant Mental Health Home‐Based Early Head
Start Intervention (McKelvey et al., 2015) for infants and younger children, and Filial
Therapy (Guerney, B. & Guerney, L., 1987; Van Fleet, 2014) and Parent–Child
Relationship Therapy (Landreth & Bratton, 2006) for older children and adolescents.
Longitudinal studies repeatedly have established how important such interventions
are to healthy development (Grossmann et al., 2005; Lyons‐Ruth & Jacobvitz, 2016;
Van IJzendoorn, 1997). “Infant mental health” and an attachment‐based orientation
have expanded into preschool and early elementary interventions and research.
Behavior‐focused systemic family therapy with children and adolescents

As the expectation for evidence of program effectiveness has grown, programs shown
to produce change in parent or offspring behaviors have been developed, tested, and
distributed. Empirical evidence for effectiveness may come from a number of sources:
coded interactions from videotapes, standardized rating scales completed by the client
or therapist or observers, paper‐and‐pencil measures, school performance measures,
juvenile arrests, and, more recently, physiological evidence (e.g., cortisol level, fMRI,
skin conductance). Data obtained from randomized clinical trials (RCTs), using a
manual and well supervised to ensure compliance with the intervention, have been
the standard required to demonstrate the efficacy of a family intervention, and such
data are incredibly valuable in demonstrating that the intervention can be efficacious
(or not). However, RCTs require relatively large samples of clients to demonstrate
statistically significant effects, are very expensive to run, are likely to exclude a family
or anyone with a particular characteristic (e.g., family size, ethnicity, income level, age
of parent) or a co‐occurring condition (mental or physical health issue), and may not
generalize to other populations (effectiveness). This approach can be frustrating for
individual therapists or researchers who have a limited pool of clients or participants.
A different approach to empirical evidence for SFT effectiveness is the practice research
network (PRN), pioneered in medical settings, but recently made available to sys-
temic family therapists and researchers (Johnson, Miller, Bradford, & Anderson,
2017). The persons submitting data get immediate feedback, and de‐identified data
are pooled to provide a larger sample for research or to evaluate therapy.
Parent education programs

Systemic family therapists recognize the critical roles that parents play in the lives of
children. Providing parents with the motivation, knowledge, and skills to parent
effectively is an area that has existed for years, but has not always well appreciated or
well understood as being “family therapy.” In addition to the attachment‐based inter-
ventions noted above, parent education programs rooted in behaviorism and social
learning theories have a strong database (e.g., Parent Management Training, Kazdin,
1997; Parent Management Training–Oregon [PMTO]/GenerationPMTO, Forgatch
& Gewirtz, 2017). Choosing a parenting program or providing clients with resources
can be confusing. One popular publishing house, Research Press, lists some 130 par-
enting‐relevant books in their catalogue, most intended for lay audiences. A recent
book, based on GenerationPMTO, is a sound example of such a text (Forgatch,
Patterson, & Friend, 2017). However, SFT practitioners who want to be successful at
following a research‐based parenting program would be wise to select one of the
stronger models and seek more specific information and training.
Pavlovian approaches to family therapy

Pavlov (1927) and his students and colleagues developed learning theories that
became the dominant version of psychology in the USSR and its successor states.
Pavlov, a physician and physiologist, was interested in how events in an environment
(“stimuli”) become associated. His animal model was a dog. The basic early paradigm
was to present an unconditioned stimulus (UCS) like food, simultaneously with or
briefly preceded by a conditioned stimulus (CS) like a bell ringing. The food in the
mouth caused an increase in salivation that did not require any training (uncondi-
tioned response [UCR]). The bell ringing did not change salivation unless it had been
paired with the food. Then, when the bell rang, the saliva flowed (conditioned
response [CR]). If the food stopped coming, eventually, the bell no longer led to
saliva flow (extinction). In another setting, Pavlov might train his dog to lift a paw
(UCR) when a shock (UCS) was delivered to the paw. Paired with the sound of the
bell (CS), he could train the dog to lift its paw (CR) when the bell rang.
Trauma Pavlov made an important discovery in 1924 about single traumatic events
as a possible UCS. The River Neva in St. Petersburg flooded his laboratory, and the
staff had to rescue the dogs as the river rose around them. After the flood subsided
and the dogs were returned to the lab, they would show intense fear and near panic
at the sound of water running or dripping. There was no more UCS, only the com-
mon sound of water filling bowls or dripping from a spout. Pavlov was wise enough
to see that a single trial of near drowning (traumatic UCS) was enough to condition
his dogs to fear (CR) the formerly neutral sound of water dripping or running (CS).
The positive (food) and negative (drowning) models guided Pavlovians as they devel-
oped much wider applications in child‐rearing, teaching techniques, and dealing with
behavior problems, as well as treatments for mental or other behavioral disturbances.
As a human example, consider a child who has been abused (UCS) by a man with
a beard (CS). Days or even years later, another man with a beard is seen, the child
panics (CR). That child is trapped in this Pavlovian model of trauma in which PTSD
and intense fear are symptoms. What is critical in trauma treatment is to break the
UCS‐CS‐CR connection. Systematic desensitization is one proven method that
involves fear management and changes in cognition (Wolpe, 1990), but eye‐move-
ment desensitization (EMD) and observing someone else modeling a way to over-
come fear (e.g., Bandura’s research on snake phobics) are also effective in dealing with
intense fear responses.
Cognitive‐behavioral therapy Based on Pavlovian theory and research, Eysenck

(1959) and Wolpe (1958) led the way to an acceptance of the concept that what goes
on in a person’s brain (perceptions and cognitions) can be changed by changing
behavior outcomes, and, conversely, cognitions and perceptions can change and
change behavior. Hence, both are sources of change, leading to cognitive‐behavioral
therapies (A. Beck, 1975; J. Beck, 2011). In cognitive‐behavioral family therapy, both
parents and their offspring are engaged in examining and challenging their precon-
ceptions about each other and their own behavior and the other’s behavior. Ultimately,
if there is a change in the ways parents or offspring (or both) see each other (beliefs
and expectations), then behavior can change, and these changes can result in more
changes in their cognitions, and the circle of change continues.
Behaviorism
Most older introductory psychology textbooks stopped with Pavlov’s early research
with dogs. Instead, the authors moved on to talk about Watson (1913) and Skinner
(1938) and behaviorism. Much of Pavlov’s work was focused on learned relationships
between events (S‐S). Behaviorism was focused on learned relationships between vol-
untary behaviors (responses, R) and events (stimuli, S) that followed the behaviors. In
Skinner’s (and Watson’s) model, the rat or pigeon had to explore the environment
and stumble spontaneously upon a response that led to some outcome. In an other-
wise empty box (“Skinner box”) with a small bar sticking into the box, chances were
good that a hungry rat would press the bar sooner or later. Depending on what the
outcome was, the response might be repeated more often because it was “reinforced.”
If pressing the bar meant food was delivered with each press, the bar pressing increased
(“positive reinforcement”). If pressing the bar meant that a loud, unpleasant sound
was turned off for a short period, the bar pressing increased (“negative reinforce-
ment”). If pressing the bar led to an unpleasantly high shock to the rat’s feet, bar
pressing stopped and did not resume, at least for a time (“punishment”). In a family,
praising a child for spontaneously cleaning up a mess could be a positive reinforce-
ment and increase the chances that it would happen the next time there was a mess.
Nagging the child to clean up the mess but stopping when the child cleaned up the
mess would be a negative reinforcement (removing the unpleasant nagging). Spanking
the child for making a mess would be a punishment, and punishment would not nec-
essarily increase the chances of cleaning up a mess the next time.
The behaviorists in the Skinnerian tradition developed programs based on R‐S
learning principles. They observed that smiley faces or stickers given when a child
emitted a desired behavior (doing an arithmetic problem) were capable of increasing
the number of arithmetic problems completed. The smiley faces could serve as posi-
tive social reinforcers. They also observed that providing tokens for appropriate
behaviors increased those behaviors in juvenile detention facilities and facilities for
youth with mental health issues or retardation. In parallel, they observed that children
and adolescents would also change their behaviors when provided with all sorts of
positive (giving) or negative (withdrawing something undesired or unpleasant) rein-
forcements but that punishment was not very effective in changing behavior in the
long run. In general, tokens had to be redeemed for something—candy bars or free
time or a movie. If the token economy was disrupted or if the target of the interven-
tion was not interested in the proposed reward, there was no positive reinforcement,
and the desired behavior did not occur or stopped. Behavior therapists helped parents
set up programs to increase or decrease behavior in their offspring using the same
principles that guided Skinner’s research.
Social learning theory

Social learning theory interventions are related to behaviorist approaches, but have a
more holistic view of how to intervene with young people and their families (e.g.,
training parents to be the change agents with their children). Patterson, Reid, and
their colleagues at the Oregon Social Learning Center (OSLC) have pioneered in
developing the Coercion Model of the family dynamics that lead to problematic
child/adolescent behaviors (e.g., Patterson, 1974; Patterson, Reid, Jones, & Conger,
1975). Throughout the decades, this group has focused on developing, testing, and
refining parent and child interventions to modify problematic child (and parent)
behaviors (e.g., Chamberlain, 1996; Forgatch & DeGarmo, 1999; Forgatch,
Patterson, DeGarmo, & Beldavs, 2009). Each intervention program addresses parent
or child behaviors or both parent and child behaviors, sets up targets for change, and
employs behavior modification principles to get those changes. Forgatch and Patterson’s
PMTO has been adopted both in the United States (e.g., Michigan) and internation-
ally (e.g., Norway, Uganda), adapted and translated into Spanish, Dutch, Norwegian,
and so forth, and used in group and individual settings (Forgatch & Gewirtz, 2017).
Special cases of behavioral programs

Misbehavior in young people occurs in a context—family, peers, and community.
When an adolescent becomes involved in serious juvenile crime or drug abuse or
both, more intensive interventions are required. A number of specialized programs
have been developed as family interventions for high‐risk adolescents. Each of these
programs is based on learning theory, each goes beyond simple training to include the
family and community resources, and each has strong evidence for its success: com-
munity‐based residential treatment (Chamberlain, 1996), multisystemic family ther-
apy (Henggeler, Melton, & Smith, 1992), multidimensional family therapy (Liddle,
Dakof, Turner, Henderson, & Greenbaum, 2008), brief strategic family therapy
(BSFT) (Szapocznik & Williams, 2000), and functional family therapy (FFT)
(Alexander & Parsons, 1982; Sexton, 2011). Despite some important differences, all
involve intense therapy with the parent and adolescent to change the behaviors of
both. Several provide for therapy and other services at the home and outside the
home as needed. As one program director said, “If you want the family to sit down
for dinner every night, sometimes you have to buy a kitchen table.” In common with
Whitaker and Minuchin, the first step is to support the parental hierarchy, that is, to
put the parent(s) in charge of the adolescent to allow rules for behavior to be estab-
lished. For these programs, the evidence of success is an end or reduction in antisocial
behaviors and substance use, improved family communication and functioning, and
sustained change as measured by parent reports, number of arrests, teacher ratings,
and so forth. The point is that these programs are based on theory and require the
collection of hard and “soft” data to show their effectiveness.
Two‐factor approaches to learning and behavior

One particularly strange “behaviorist” study illustrates the problem of having only a
behaviorist view or only a Pavlovian view of the world. A rat will learn to press a bar in
a box where random shocks are being delivered (say, every 30 s). Instead of food or
some tangible reinforcement, every bar press (R) is followed by a shock (UCS) that
should suppress any bar pressing (Brooks Carder, personal communication, 1967).
Paradoxically, the rate of responding and getting shocked for each bar press is actually
much higher than every 30 s. That is, the rat gets far more shocks than if it did nothing.
What was the reinforcement? One explanation is that the random shock (UCS) in that
environment (CS) is so aversive and so fear‐provoking that bar pressing is reinforced
because at least the rat could “predict” when the shock was coming and was spared the
random shock experience. This phenomenon has a parallel for a child who has suffered
physical abuse for a particular behavior on a seemingly random basis. The child may
begin to show that behavior and actually provoke the abuse. Does the child “want” to
be punished? Certainly not, but knowing when the punishment is coming becomes
very important. “Better the devil you know than the devil you don’t know!”
Combining Pavlovian and Behaviorist positions, a version of two‐process theory of
learning emerged that can deal with such seemingly strange behaviors (Rescorla &
Solomon, 1967). In this way of thinking, there are certain positive and negative events
(Ss) that occur that have importance for the survival of the individual. Some other
events gain power in behavior because they have some association with the basic posi-
tive or negative events. Intense fear in a situation leads to avoidance of that situation
or any situation like that. Avoiding the event or escaping the situation provides a
reinforcement (negative) that reduces fear and strengthens the avoidance response.
Such a model of avoiding pain or reducing fear is valuable in conceptualizing some
obsessive–compulsive behaviors and behaviors some abuse survivors show in the pres-
ence of their abuser. The concepts of “learned helplessness” (Maier & Seligman,
1976) and “positive psychology” (Seligman, 1975; Seligman & Csikszentmihalyi,
2000) have been derived from Rescorla and Solomon’s theoretical formulations.
Incorporating Older Models Into New Models
The focus on evidence‐based interventions has not meant that theory is dead. The
earlier theoretical models continue to be important in SFT for families with adoles-
cents and children, are still practiced by therapists, and still provide much of the
underpinning for newer models. SFT has grown and evolved over the past century,
and it is important to understand the contribution of older theories and interventions
as new techniques and theories come into practice. The narrative therapy focus on
“re‐storying” has many common elements with early cognitive or talk therapies,
including psychodynamic analysis. The Freudian focus on trauma and early experi-
ences has led to and been modified in the infant mental health movement, attach-
ment‐based therapy for adolescents (ABFT, EFFT), internal family systems therapy
(IFS), and eye movement desensitization and reprocessing therapy (EMDR). While
the “guru” was dominant in books and journals and licensure examinations in the
early days of SFT, theory development was not the exclusive bailiwick of these pio-
neers or their disciples, and other theories and intervention strategies were developing
during this same period and continue to emerge.
“Eclectic” is a reality and not a dirty word

Okay, call it “integrative”! The beginning systemic family therapist is likely to seize one
of these models of intervention and try to apply it in every case. A colleague once
calmed this author with, “If you only have a hammer, everything looks like a nail.”
When that budding therapist meets with failure using that precious model, a retreat to
using techniques from other models in the same case may be an answer. Although
“eclectic” as an approach to therapy has sometimes been synonymous with “therapist
has no idea,” it is important to distinguish between what the therapist is thinking in the
moment and what the therapist is actually doing with the clients. “How does change
take place?” is the question that guides a decision to use one or another approach.
A therapist who thinks about cases in terms of attachment is relying on the work of
Bowlby (1988), a classic psychodynamic theorist and therapist. Working with a family
with an offspring who is breaking family and society’s rules, the attachment‐oriented
therapist may decide to (a) meet with the parents without the offspring to learn about
their own histories growing up (psychodynamic, object relations), (b) determine their
response to threats to their relationship (attachment), (c) better understand their view
of the offspring and his/her problems (contextual), (d) explain and develop a behav-
ior modification program (behaviorism) in order to (a) control the immediate prob-
lems (behaviorist), (b) establish the parents’ role and authority in the family
(structural), and (c) diminish angry and demeaning parent‐to‐child, child‐to‐parent,
and parent‐to‐parent interactions (communication). Alternatively, the therapist may
just go for the token economy! What is important in this case is that the therapist
must be aware of the many streams of SFT theory and practice that can feed into one
case and have the wisdom not to try every possible intervention at once.
Looking Back, Looking Forward
One of the fundamental goals of SFT for children and adolescents is to improve family
functioning by improving family support for the offspring and stabilizing the family
system in a more functional way. Practitioners of SFT have not always recognized
other, potentially more effective, ways in which this can be done. With infants and very
young children when such family stability and support are lacking, interventionists and
developmental researchers have led the way (Dozier et al., 2009; Dozier, Meade, &
Bernard, 2014; Fraiberg et al., 1975; Landreth & Bratton, 2006; Lieberman, Padrón,
Van Horn, & Harris, 2005; McKelvey et al., 2015; Melhuish, Belsky, Leyland, Barnes
& The National Evaluation of Sure Start Research Team, 2008; Olds, Henderson Jr.,
Tatelbaum, & Chamberlin, 1986). For young persons of all ages, parent education and
training programs also have demonstrated considerable success in changing families
with younger and older children for both stressed and less stressed, minority and
majority, immigrant and nonimmigrant families (e.g., Cowan, Cowan, Pruett, Pruett,
& Wong, 2009; Forgatch & DeGarmo, 1999; McCart & Sheidow, 2016; Parra‐
Cardona et al., 2017). The successful manualized treatment programs for high‐risk
adolescents contain the kernels of effective interventions in much less desperate cases
(e.g., Henggeler et al., 1992; Liddle et al., 2008). What seems to be lacking in SFT
training and practice is a wide‐ranging knowledge of interventions that are supported
by empirical data and an integration of the possibilities of office‐based therapies, com-
munity‐based therapies, in‐home therapies, and institution‐based research.
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2
Assessment of the Parent-Child
Relationship
Heather M. Foran, Iris Fraude, Christian Kubb, and
Marianne Z. Wamboldt
A substantial body of research has shown that the quality of the parent-child relationship
is crucial for early childhood emotional development and has health consequences for
later life (Miller, Chen, & Parker, 2011; Morgan, Brugha, Fryers, & Stewart‐Brown,
2012; Richter, 2004; Shonkoff et al., 2012). Despite the importance of the parent-child
relationship, many challenges with its assessment remain. This chapter will describe the
history and current approach to assessment of the parent-child relationship as well as
future directions for researchers, practitioners, and public health officials.
Definition of parent
In this chapter, although the term “parent-child” relationship is used, the word
parent is intended to reflect the heterogeneity in the types of carers that may be
primarily responsible for the care of a child. We define parents as the primary c aregivers
who support the child over a stable period in everyday life with general issues of
nurturing, sleeping, grooming, protecting, playing, or medical decision making. In
most cases, the primary caregivers are the parents of children, and most of the research
reviewed in this chapter has focused on parents. Nonetheless, other family constellations
exist and vary in frequency across cultures, such as when the primary caregiver is a
grandparent, older sibling, foster parent, or other relative.
Purpose of parent-child relationship assessment

Early childhood relationship experiences are essential for healthy child development in
many spheres. Several large epidemiologic studies have shown parent-child relationship
problems (PCRP) are among the significant psychosocial risks for mental health prob-
lems in youth (Copeland, Shanahan, Costello, & Angold, 2009; Menard, Bandeen‐
Roche, & Chilcoat, 2004). Not only is the risk for behavioral and emotional problems in
childhood increased, but also the negative impact of PCRP on mental health continues
into adulthood (Carlson, 1998; Crittenden, 1995; Dozier, Stovall‐McClough, & Albus,
36 Heather M. Foran et al.
2008; Winsper, Zanarini, & Wolke, 2012). Further, deficient parenting can also impair
endocrinological processes in the child, for example, by increased release of the stress
hormone cortisol and reduced release of the bonding hormone oxytocin (Feldman,
Gordon, Influs, Gutbir, & Ebstein, 2013; Gunnar, 1998; Heim et al., 2009). Those
influences during early brain development may have lasting effects on neurocognitive
and social development (Shonkoff & Phillips, 2000). Negative effects, which may
continue to impact adult health (e.g., Miller et al., 2011), may also extend to the next
generation. Parent–child attachment research has shown a high cross‐generational
penetrability of adverse attachment patterns between parent and child (Steele & Steele,
1994). The parent-child relationship quality is also linked to the parental relationship
quality (Armstrong, Birnie‐Lefcovitch, & Ungar, 2005; Erel & Burman, 1995), so
improving a caregiving relationship might have positive impacts on the larger family
system.
Further, there is considerable evidence that early interventions targeting the PCRP
such as parenting programs (e.g., Triple P Positive Parenting Program; Sanders,
2012) lead to reductions in behavioral problems in children and improvements in the
parent-child relationship quality (Nowak & Heinrichs, 2008; Wiggins, Sofronoff, &
Sanders, 2009). Empirically supported treatments also commonly target the parent-
child relationship as a primary mechanism to reduce behavioral problems (e.g.,
Eyberg, 1988; Julian, Lawler, & Rosenblum, 2017). Even interventions focused on
reducing childhood obesity or other health problems often include a focus on the
parent-child relationship, such as through teaching discipline and relationship‐building
skills (Berge & Everts, 2011; Morawska, Mitchell, Burgess, & Fraser, 2016).
Despite the centrality of parent-child relationships for healthy development over
the lifespan, screening and assessment in health‐care settings is lacking. The two inter-
national diagnostic systems, the Diagnostic and Statistical Manual of Mental Disorders
(DSM) and the International Classification of Diseases (ICD), have historically placed
a minimal focus on PCRP (see Beach et al., 2016, for a review). Given the lack
of screening and integration in health‐care systems, PCRP are often overlooked as
contributing factors in health care. The strengthening of the early parent-child rela-
tionship promotes lifelong resilience, even in those families that are fundamentally
burdened with multiple risk factors (Armstrong et al., 2005). Moreover, prevention
through the identification of early parent-child relational problems, rather than
treating subsequent disorders, may lead to reduced health‐care costs. Thus, given the
relevance of PCRP for prevention and treatment of a variety of conditions in children,
valid and reliable assessments of PCRP are necessary. In the next sections, we will
review the history and current status of parent-child relationship assessment.
History and current status of assessment/diagnosis

History of parent-child relationship assessment John Bowlby’s (1969) attachment
theory, in particular, laid the foundation for today’s understanding of the importance
of early childhood for establishing close and stable bonds with a caregiver. These
assumptions have become a quite natural element within family therapy (Byng‐Hall,
2008; Johnson & Whiffen, 2003). An early influential measure related to the parent-
child relationship was the Strange Situation Test, an observational method to evaluate
the child’s attachment patterns empirically (Ainsworth & Bell, 1970). In this context
the quality of the bond between caregiver and child is assessed on the basis of the
Assessment of the Parent-Child Relationship 37
child’s reaction to a separation and subsequent reunification with the caregiver. Over
the last 40 years, research has developed numerous other measures for assessment of
the parent-child relationship with additional important influences from family systems
theories and behavioral theories.
History in diagnostic systems It was not until the 1990s that studies began to
accumulate supporting relational diagnoses/processes in classification systems (Beach
et al., 2016). Thus, at the time of the ICD‐10 and DSM‐IV revisions, the evidence
base was not considered sufficient to argue for more extensive coverage of relational
processes. However, over the last three decades, operationalizations of relational
processes have improved, and evidence of their clinical relevance has grown (Foran
et al., 2016).
Problems between parent and child were first included in the ICD‐10 (World
Health Organization [WHO], 1992) and DSM‐IV (American Psychiatric Association
[APA], 1994) diagnostic systems. Corresponding codes can be found in the ICD‐10
Z section on “factors influencing health status and contact with health services” and
include only a list of categories with no operational definitions: inadequate parental
supervision and control (Z62.0), parental overprotection (Z62.1), hostility toward
and scapegoating of child (Z62.3), emotional neglect of child (Z62.4), other p roblems
(Z62.5), and inappropriate parental pressure and other abnormal qualities of upbring-
ing (Z62.6). Similar to the ICD‐10, relational problems between parent and child
(V61.20) are included in the V codes of the DSM‐IV in the section “Other conditions
that may be a focus of clinical attention” (APA, 1994). Both the DSM‐IV and ICD‐10
have been quite limited in assessment of the parent-child relationship. The categories
were not formally tested, no clear criteria were provided, and training on use of the
codes has not been widely implemented. Similar problems with the DSM‐IV
and ICD‐10 categories exist for all relational problems including child maltreatment,
partner maltreatment, and intimate relationship distress.
Independent of the work of World Health Organization and American Psychiatric
Association, the organization Zero to Three worked on an empirically based classifica-
tion of parent-child relationships in their system for the assessment of infant mental
health status. In 1994, the Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood (DC: 0–3, Zero to Three),
a five‐axis diagnostic system, was published after 10 years of work. This system assessed
six types of problems in the parent-child relationship: over‐involved, under‐involved,
anxious/tense, angry/hostile, mixed, and abusive with three subcategories (verbally,
physically, and sexually). With the first revision (Zero to Three, 2005), the categorical
system for dyadic relationships was replaced by the Parent–Infant Relationship Global
Assessment of Functioning Scale (PIRGAS). On a scale of 0–100 points, the relation-
ship is evaluated in decimal steps into dimensional categories, where scores from 0 to
40 points represent a range from documented maltreatment to a severely disordered
relationship; 41–80 points indicate a disturbed, distressed, or perturbed relationship;
and 81–100 points indicate an adapted relationship. Initial research on the instrument
is promising, but issues with its validity in some contexts and the need for more stand-
ardization have been raised (Hatzinikolaou et al., 2016; Müller et al., 2013).
Recent progress in parent-child relationship assessment In the transition from DSM‐IV

to DSM‐5, relational problems were included early in the agenda (Kupfer, First, &
Regier, 2002). Subsequently, a working group was formed with the aim to integrate
relational criteria into the DSM‐5 and ICD‐11. Three conferences were held and two
books were produced to document the current literature on this topic, including a
cross‐cultural perspective (Beach et al., 2006; Foran et al., 2013). Different possibili-
ties were discussed (e.g., integration on Axis I within a category of Relational
Syndromes, a separate V code with clearly defined criteria for the inclusion of rela-
tionship processes in the descriptions of Axis I diagnoses) (Wamboldt, Kaslow &
Reiss, 2015). Ultimately, an adapted version of the revisions proposed by the work-
ing group were integrated in the V‐code section of the DSM‐5, which is now called
Z codes to match the ICD (Beach et al., 2016; Foran et al., 2013; Wamboldt, Kaslow
et al., 2015).
In parallel, the World Health Organization has been working on a revision of its
classification system. The ICD‐11 is currently only available in an online beta draft
and scheduled for release in 2018. PCRP are coded as “substantial and sustained dis-
satisfaction within a parent‐child relationship associated with significant disturbance
in functioning.” This description is based on the work of the Relationship Processes
Working Group (Foran et al., 2013; Wamboldt, Kaslow et al., 2015), which has also
proposed two criteria that are not yet included in the online version. Criterion A
requires that the relationship dissatisfaction occurred on more than half of the days in
the last month, while Criterion B regards disturbance in at least two out of four areas
of functioning as a prerequisite, that is, behavior, cognition, emotion, and health
(Wamboldt & Cordaro, 2013). A version of these criteria was tested in a clinical sam-
ple by Wamboldt, Cordaro, and Clarke (2015), but large‐scale and nonclinical field
trials are still pending. To further close this research gap, the World Health
Organization is currently supporting a multinational field trial on relationship prob-
lems and maltreatment, in which the definitions are tested for their usefulness to clini-
cians and primary care providers (see Heyman et al., 2018, for more details on the
field trial).
The third edition of the DC: 0‐3 diagnostic classification system, now known as
DC: 0‐5, was also published in 2016 (Zero to Three, 2016). Considering that many
areas in DSM‐5 and ICD‐10 are not elaborated or are missing for infants and toddlers,
DC: 0‐5 is an evidence‐based addendum, also connected to corresponding V codes.
Newly added on Axis I are “Relationship Specific Disorders of Early Childhood,”
which code relationship problems between a caregiver and child (Zeanah & Lieberman,
2016). The family network is also included, which means that substantial co‐caregiv-
ers for the child can be assessed. Like its predecessors, the usage of DC: 0‐5 requires
training and is highly time consuming, which makes it unsuitable for most clinical and
public health settings.
Measurement Tools
In comparison to the slow integration of PCRP in diagnostic systems and use in

public health settings, a large body of literature on assessment exists, and these
measures have been commonly used for research purposes. The following section
will review different measurement tools in terms of their psychometric properties,
clinical utility, research/theoretical utility, international use, economy, training
requirements, cultural adaptations, and developmental considerations. We will

refrain from reviewing some measures that were already reviewed by Wamboldt and
Cordaro (2013). This includes the Strange Situation Procedure (Ainsworth, Blehar,
Waters, & Wall, 1978), Camberwell Family Interview (Brown, Birley, & Wing,
1972), Five‐Minute Speech Sample (Magaña et al., 1986), Perceived Criticism
Measure (Hooley & Teasdale, 1989), and the Parent Bonding Index‐Brief Current
(Klimidis, Minas, & Ata, 1992). Additionally, only measures that are published and
currently available will be reviewed.
Questionnaires
The number of questionnaires and rating scales available for the assessment of chil-
dren and their families is immense (Pritchett et al., 2011). Some measures are quite
broad and focus on the overall family atmosphere and family functioning, while other
measures are more specific and tied to the relationship within a particular dyad. In the
following section, a selection of measures suitable to assess overall family relationships
as well as the quality of a specific parent-child relationship will be reviewed.
The Parent-Child Interaction Questionnaire (PACHIQ) The Parent-Child

Interaction Questionnaire (PACHIQ) (Lange, Blonk, & Wiers, 1998) assesses the
quality of parent-child interactions and is based on theories of structural systems
therapy and behavioral learning theory. The development of this scale was based on
early research on the Family Assessment Measure, but designed to be specific to the
parent-child relationship (Skinner, Steinhauer, & Santa‐Barbara, 1983). The items of
the PACHIQ were originally developed to assess the parenting dimensions related to
authority, acceptance, and communication skills. The original parental report and
child report versions yielded different factor structures, and the measure was revised
in 2002 (PACHIQ‐R; Lange, Evers, Jansen, & Dolan, 2002). The PACHIQ‐R has a
two‐factor structure, Conflict Resolution and Acceptance, but the child and parent
versions are not directly comparable due to differences in items. The parent version of
the PACHIQ‐R consists of 21 items, whereas the child version has 25 items. The
revised version of the PACHIQ also includes norm tables for families and children
from clinical samples as well as for the Dutch population. This measure is a promising
instrument for assessing parent-child relationships, but has not been extensively used;
cultural adaptations and normative data across countries are not yet available.
The Parenting Stress Index (PSI) The Parenting Stress Index (PSI), Fourth Edition
(Abidin, 2012), is a measure of parental stress levels related to their relationship with
one child up to 12 years of age. The 120‐item scale assesses overall parenting stress as
well as stress related to child characteristics, parent characteristics, and situational/
demographic life stress. Clinical cutoff scores are provided as well. The Child Domain
comprises six subscales: Reinforces Parent, Demandingness, Mood, Distractibility/
Hyperactivity, Adaptability, and Acceptability. The Parent Domain consists of seven
subscales: Health, Role Restriction, Depression, Competence, Isolation, Attachment,
and Spouse/Parenting Partner Relationship.
A shorter, more economical, 36‐item version of the PSI is available and it correlates
strongly with the overall PSI (Haskett, Ahern, Ward, & Allaire, 2006). The internal
consistencies of the PSI and the PSI‐4 tend to be high across studies, although they
may vary by gender (see McKelvey et al., 2009). Test–retest reliability of the PSI‐4
and PSI‐SF has been adequate across studies (Barroso, Hungerford, Garcia, Graziano,
& Bagner, 2016; Johnson, 2015). Previous studies with the PSI have also supported
convergent validity with other measures of caregiver‐related problems (e.g., Child
Abuse Potential Inventory, child behavior) and its use to detect clinically significant
change in therapy (Jensen & Corralejo, 2017). Computer‐administered versions of
the PSI‐SF yield similar results to paper‐and‐pencil administrations of the test (Aiello,
Silva, & Ferrari, 2014). Furthermore, the PSI has been translated and administered in
several other languages (Johnson, 2015).
Child–Parent Relationship Test—Child Version The Child–Parent Relationship

Test—Child Version (ChiP‐C) is a clinically oriented questionnaire that is based on
a cumulative vulnerability model and family systems theory (Titze et al., 2010;
Titze, Koch, Lehmkuhl, & Rauh, 2001; Titze & Lehmkuhl, 2010; Titze,
Wollenweber, Nell, & Lehmkuhl, 2005). It is used to assess the quality of the
parent-child relationship based on the subjective appraisal of children between the
ages of 10 and 20. This instrument, originally developed in Germany, is primarily
used in German‐speaking regions of Europe. The third version of the ChiP‐C
includes 36 items and 9 scales (three resource scales, five risk scales, and one addi-
tional scale). The mother‐child relationship and father‐child relationship are
assessed separately. According to the manual, the child’s relationship with the
mother/female caregiver is always administered first. Both parts start with a stand-
ardized instruction that asks the child/adolescent to specify who has been his/her
mother/father figure within the past 5 years. Therefore, the relationship assess-
ment is not limited to the biological parent of the child and includes adoptive
parents, stepparents, and other caregivers. The overall quality of the parent-child
relationship is defined as the sum of the positive experiences with the caregivers
minus the risks. A Quality‐of‐Relationship Index for each parent and a total
Quality‐of‐Relationship Index are computed. Age‐ and sex‐specific T values, as
well as different composite index scores that reflect the overall quality of the par-
ent-child relationship, are provided as well.
A study on the psychometric properties of the German ChiP‐C (Elternbildfragebogen—
KJ) supported the measures convergent and discriminant validity, as well as temporal
stability (Titze, Schenck, Logoz, & Lehmkuhl, 2014). The ChiP‐C scales show small to
moderate correlations with child internalizing and externalizing symptoms (Titze et al.,
2014). Internal consistencies were adequate across school and clinical samples. The
ChiP‐C is currently available in English, German, Italian, Greek, and Serbian (Titze
et al., 2014), but extensive cross‐cultural validation has yet to be conducted.
Parent-Child Relationship Inventory (PCRI) The Parent-Child Relationship

Inventory (PCRI) (Gerard, 1994) is a 78‐item self‐report measure that assesses paren-
tal attitudes toward parenting, parenting behaviors, and parental attitudes toward
their children. The domains assessed with subscales include Parental Support,
Satisfaction with Parenting, Involvement, Limit Setting, Communication, Autonomy,
and the Role Orientation (Gerard, 1994). The measure has been translated into some
languages such as Chinese, Spanish, and German, and some studies have supported its
predictive and concurrent validity (e.g., Coffman, Guerin, & Gottfried, 2006;
Ganotice, Downing, Mak, Chan, & Yip, 2015).
However, there are concerns about the performance of some of the scales (e.g.,
Coffman et al., 2006). Internal consistencies of the scales have varied across studies
with some studies noting low internal consistencies for the Communication and
Autonomy scales (Coffman et al., 2006; Reitman et al., 2001; Reitman, Rhode,
Hupp, & Altobello, 2002; Suchman & Luthar, 2000). In the Chinese validation
study, internal consistencies were both 0.66 for Autonomy and Communication scales
(Ganotice et al., 2015). Currently, more studies are needed on psychometric proper-
ties in diverse settings as well with clinical populations.
Family Assessment Device (FAD) The Family Assessment Device (FAD) (Epstein,
Baldwin, & Bishop, 1983; Miller, Epstein, Bishop, & Keitner, 1985) is an extensively
used measure of family functioning and has been evaluated in numerous psychometric
studies. It is designed to assess the dimensions of the McMaster Model of Family
Functioning (Epstein et al., 1983), including problem solving, affective responsive-
ness, behavior control, communication, roles, affective involvement, and general
functioning of a family. This measure is broader than assessment of the parent-child
relationship, but could be used to inform problem areas in the family system. One
would hypothesize that higher scores on the FAD would relate to higher likelihood
of a PCRP according to the DSM‐5 definition and ICD‐11 proposed definitions.
In a review of the 148 studies of the FAD, the FAD showed good test–retest reli-
ability, discriminant validity, and modest sensitivity to change in clinical interventions
(Staccini, Tomba, Grandi, & Keitner, 2015). The FAD has been translated into 27
languages, although language‐ and cultural‐specific comparisons have not been exten-
sively conducted (Mansfield, Keitner, & Dealy, 2015). In addition to parent report,
the measure can be completed by children 12 and above and may be appropriate with
younger school children as well (Bihum, Wamboldt, Gavin, & Wamboldt, 2002).
Different shorter versions also exist include using the 12‐item general functioning
subscale for epidemiological research (see Byles, Byrne, Boyle, & Offord, 1988;
Cooke, Marais, Cavanagh, Kendall, & Priddis, 2015).
Systemic Clinical Outcome And Routine Evaluation (SCORE) The Systemic Clinical
Outcome and Routine Evaluation (SCORE) (Stratton, Bland, Janes, & Lask, 2010)
is a family assessment questionnaire to measure the outcome of systemic family
therapy. The questionnaire enables family members to report aspects of their

interaction as a whole family that have clinical significance and are of relevance for
therapeutic processes. The full‐length version of the questionnaire contains 40 items
(SCORE‐40) and a shorter version, the SCORE‐15, has also been developed. It can
be completed by family members over 11 years of age, and a separate version of the
SCORE‐15 is also available for children between the age of 8 and 11 (Jewell, Carr,
Stratton, Lask, & Eisler, 2013). In addition to the total score for each member of the
family, three subscales—strength and adaptability, overwhelmed by difficulty, and
disrupted communication—can be calculated. An extensive set of resources is available
online (see www.aft.org.uk/view/score.html?tzcheck=1).
Psychometric analyses confirmed that the SCORE‐15 had good internal reliabilities
and good test–retest reliability for the total score and subscales. Furthermore, the
SCORE‐15 correlates with other measures of parent, child, and family adjustment, and
has been reported to be responsive to change over 3–5 months of therapy (Hamilton,
Carr, Cahill, Cassells, & Hartnett, 2015). The SCORE‐15 has been translated into
several other languages, but adaptations have not been formally evaluated. For additional
information about the SCORE, see chapter by Stratton and Low Volume IV.
Observational measures
Observational measures, while often time consuming to code, provide important
complementary information to questionnaire and interview data. Numerous special-
ized coding systems exist (Aspland & Gardner, 2003; Kerig & Lindhal, 2001;
Roggman, Cook, Innocenti, Norman, & Christiansen, 2013). Three coding systems,
with good validity data, are described in the next section as examples. These measures
may not be practical in low‐income settings or many clinical settings due to time‐con-
suming coding procedures, but can be applied for use in well‐resourced clinical or
research settings.
Dyadic Parent-Child Interaction System The Dyadic Parent-Child Interaction

System (DPCIS) is an observational behavioral coding system for parent-child
interaction patterns associated with parenting difficulties and child behavioral

problems among children ages 3–6 (Eyberg, Nelson, Duke, & Boggs, 2004; Robinson
& Eyberg, 1981). Since its first published edition, the DPCIS has been revised in the
light of psychometric studies, and its categories have been refined (Eyberg, Nelson,
Ginn, Bhuiyan, & Boggs, 2013, 4th edition).
The DPICS assesses observable behavioral problems and prosocial behavior but
does not assess internalizing symptoms such as depression or anxiety, which are harder
to observe, but may relate to the PCRP. The observations that are coded with the
DPCIS are conducted in three parent-child interaction situations: Child‐Led Play,
Parent‐Led Play, and Clean‐Up. The validity and reliability of the DPICS has been
supported in several studies. The coding correlates with other measures of child
behavior, discriminates clinical samples from nonclinical samples, and is sensitive to
changes over the course of treatment (see Eyberg et al. (2004) for details).
Like other observational measures, training and implementation can be time con-
suming and costly. Furthermore, cultural adaptation of the DPICS needs more atten-
tion. A recent Norwegian study (Bjørseth, McNeil, & Wichstrøm, 2015), for example,
found low discriminant validity of some of the DPCIS codes among families of a child
with oppositional defiant disorder/conduct disorder compared with families without
clinical diagnoses.
The Parent-Child Early Relational Assessment The Parent-Child Early Relational

Assessment (PCERA) (Clark, 1985, Clark, Tluczek, & Gallagher, 2004) is an obser-
vational measure to assess the quality of affect and behavior in parent-child interac-
tions. The measure is designed for coding a parent and their child (ages 0–5) and
has been widely used in child developmental studies. The evaluation takes place in
four 5‐min situations, namely, (a) mealtime, (b) structured task, (c) free play, and
(d) separation/reunion, and includes 65 items coded on a 5‐point scale. The facto-
rial validity, internal consistency, convergent, and discriminant validity were sup-
ported in a study with mothers and 12‐month‐old infants (Clark, 1999), and the
measure is sensitive to change over time (Teti, Nakagawa, Das, & Wirth, 1991).
Despite its widespread use, comparability of results across studies is difficult because
different codes are often selected for use. Further, psychometric studies, as well as
cross‐cultural studies, remain sparse.
Diagnostic tools and interviews

In comparison to the research on self‐report measures and observational methods,
research on clinical interviews of the parent-child relationship has received less
empirical attention. In the next section, we present two interviews for the assess-
ment of parent-child relationships and one scale, the Parent-Child Relationship
Scale (PCRS) (Wamboldt, Wamboldt, Gavin, & McTaggart, 2001), which is scored
based on the responses to the Child and Adolescent Psychiatric Assessment (CAPA)
(Angold et al., 1995).
Semi‐structured interview for parent-child relationship problems The semi‐structured

interview for PCRP was developed to test the criteria proposed by the Relational
Processes Working Group for caregiver–child relationship problems as part of the
work for the revision of the DSM‐5 and ICD‐11 (Wamboldt, Cordaro et al., 2015).
The instrument was field tested as part of the DSM‐5 field trials in Colorado
(Wamboldt, Cordaro et al., 2015). The interview has been translated into German
and is currently being tested in a clinical sample in Austria. The semi‐structured inter-
view for PCRP provides clinicians with an interview guideline to assess the criteria for
parent-child relational problems. The criteria for parent-child relational problems
require a persistent relationship dissatisfaction on more than half of the days in the last
month, as well as disturbances in at least two out of four areas of functioning (i.e.,
behavior, cognition, emotion, and health) (Wamboldt & Cordaro, 2013). The inter-
view can be conducted with parents as well as with children over the age of 10.
Caregiver and child are typically interviewed separately first and then brought together
if more clarification is needed.
In the first field trial, clinicians demonstrated elevated inter‐rater reliability in assess-
ing PCRP using the semi‐structured interview for PCRP (interclass kappa = 0.58).
Furthermore, clinicians perceived the diagnostic criteria for PCRP clinically useful for
the assessment of the relationship between children and their primary caregivers
(Wamboldt, Cordaro et al., 2015). Therefore, the semi‐structured interview for par-
ent-child relational problems may be useful for assessment of PCRP according to the
DSM‐5 definition and proposed ICD‐11 revisions. It takes approximately 20 min to
administer and could be integrated into intake assessments in family therapy and child
psychiatry or psychology clinics.
More research is needed to evaluate cross‐cultural adaptability, training needs, and
implications for treatment planning in clinical settings. Preliminary qualitative feed-
back from the Austrian evaluation of the interview during the training process of a
group of psychiatrists and psychologists was that the interview was perceived as
including important questions for case conceptualization.
Working Model of the Child Interview The Working Model of the Child Interview
(WMCI) (Zeanah & Barton, 1989; Zeanah et al., 1997) is an hour‐long interview
that examines parental perceptions of their infant and developmental history. The
interview has been used in numerous evaluations of infants and parents. Ranging
from pregnancy thoughts and ideas about having children to descriptions of the
child’s personality and behavior, the WMCI covers a broad range of developmental
and relational components. For example, the parent is asked to provide more detailed
information about the perceived relationship with the child, including positive and
negative aspects of the relationship, as well as desired changes in the relationship.
After the interview, the level of relationship problem of the caregiver–infant dyad is
determined by using the Parent–Infant Global Assessment Scale (PIR‐GAS) (Zero to
Three, 1994).
The validity of the WMCI has been supported in previous studies; the measure
correlates with Strange Situation classifications and with other measures of mother–
child interactions and maternal perceptions (Benoit, Zeanah, Parker, Nicholson, &
Coolbear, 1997; Zeanah et al., 1997; Zeanah & Barton, 1989). The WMCI seems to
be a valid approach to assess the quality of infant–parent relationships, but it may not
be feasible to implement in low‐income regions or many clinical setting due to the
length and training requirements.
Parent-Child Relationship Scale The PCRS (Wamboldt et al., 2001) is a measure of

both the child and the parent’s perception of their relationship. The questions were
derived from the first section of the CAPA, a semi‐structured diagnostic interview to
assess mental disorders in children. The structure of the interview is to interview the
parent and child separately, utilizing specific probes to extract a sufficient amount of
detailed information so that the rater can make the best determination of each CAPA‐
defined criterion based on both responses. Based on face validity, potential items for
the PCRS were selected and the final 10 yielded a Cronbach α of 0.72. The items of
the PCRS relate to the following dimensions: Positive Activities with Parents, Parent-
Child Communication, Inadequate Supervision, Harsh Discipline, Selective Negative
View, Involvement of Child in Arguments, Withdrawal, Discord, Arguments with
Parents, and Arguments with Parents involving Physical Violence (see Angold &
Costello, 2000, for more details). The range of scores on the PCRS is 0–30; higher
scores indicating more difficulty in the parent-child relationship. The PCRS correlates
moderately with parent and child reports on the FAD (rs = .35–.46; p < .001). The
PCRS is able to differentiate participants who met criteria for any CAPA diagnosis
(OR = 5.83) or for any clinical relationship diagnosis (OR = 4.48).
Future Directions
Recommendations for researchers

The field of parenting and parent-child relationship research has grown substan-
tially since early research on attachment relationships. The importance of the
parent-child relationship for mental health of the child is well supported from
existing scientific studies. Despite this progress, there is still considerable work to
be done in the area of parent-child relationship assessment. Many of the meas-
ures reviewed in this chapter need more extensive validation studies. In particu-
lar, more attention is needed in evaluating and developing measures for use in
diverse clinical settings and epidemiological research. Specific recommendations
are provided below.
Parent relationship and technology Many of the existing measures were developed
decades ago and may not reflect all of the current challenges of parenting in the
information age (Golinkoff & Hirsh‐Pasek, 2016). Specific questions about parent-
child interactions related to virtual communications, rules of usage, and time spent
with children may provide additional valuable information to current assessments.
More instruments could be tested and made available through apps, which may
increase reach to families who may be reluctant to attend face‐to‐face sessions and
disclose difficulties in parenting due to stigma. Mobile health (mHealth)‐based
approaches to both assessment and intervention represent a promising area for fur-
ther implementation research in low‐resource areas (e.g., Breitenstein, Brager,
Ocampo, & Fogg, 2017).
Item language choice and cultural adaptations Although some of the reviewed
measures have been tested across languages and cultures, a systematic approach to
their adaptation for global research is lacking. These measures were often developed
in one language without consideration in the initial scale development for how the
original items may function across cultures. This leads to problems with the process
of subsequent translation. In our experience, many of the items need to be translated
quite differently to make sense within a particular language and culture. The problem
is that with measures that need back translation approval for use, the back translation
may not match because the original translation cannot be simply translated (some
instruments such as the SCORE acknowledge this issue).
If we are to move forward in global measures of PCRP, then we need to imple-
ment processes similar to how the World Health Organization develops and evalu-
ates measures. Researchers who expect their measures to be used internationally
need to implement a multinational‐scale development process at the beginning
stages or participate in pooling data projects. To better understand the scope of a
scales’ use and validity across languages, consistency in citing the original instru-
ment, which sometimes varies significantly from the original scale name, in non‐
English language publications is needed. Websites that consolidate research and
translations for instruments is also available for some measures. Doing so will help
researchers better track the global research on a particular scale and identify areas in
need of more cross‐cultural research. Currently, validity in diverse and international
samples for most measures is lacking or has been tested only in superficial way.
Although beyond the scope of the chapter, a systematic review specifically focused on
diversity issues in assessment is needed, particularly now that much more attention is
being paid to parent-child relationships and implementation of parenting programs
internationally (e.g., Mejia, Calam, & Sanders, 2012).
Instruments for international public health use Another area that needs more atten-
tion is the balance between instrument validity and reliability with practical use for
public health. Time‐consuming measures are unlikely to be implemented for interna-
tional epidemiological research or in routine clinical practice; alternatives are needed.
Training time also needs more consideration. In low‐resource settings in high‐income
countries (HICs) as well as low‐ and middle‐income countries (LMICs), more cost‐
effective alternatives are needed, particularly for interview and observational research.
Further, many of the measures assess global parenting problems or specific behaviors,
and it is unclear how they relate to the DSM‐5 and proposed ICD‐11 criteria for
PCRP. Another consideration is the copyright costs that are perhaps feasible for some
HICs but too costly for LMICs. Researchers should carefully consider how the copy-
right policies may impede global research on parenting and PCRP. Particularly for
brief instruments, open‐source policies (or exceptions for LMICs) are needed to
advance global research.
Instruments for clinicians As shown in this chapter, there are a number of measures
of use for clinical practice, with some showing sensitivity to change in therapy (e.g.,
the PSI; Jensen & Corralejo, 2017). These instruments are most commonly used by
family or child specialists, but certainly more widespread dissemination is needed.
These measures and diagnostic categories are not only useful for informing therapy,
but are useful for documenting parent-child problems from a health system perspective
and serving as an “evidence base” for discussions with policy makers, stakeholders,
patient groups, and health insurance providers.
Systemic family therapists can play an important role in training and scaling up
related to universal and standardized assessments of the parent-child relationship.
Researchers and systemic family therapists need to work more closely together to
form stakeholder networks in which freely available or low‐cost measures can be dis-
seminated for use in training programs as well as clinical settings. Specifically, existing
systemic therapy websites and association pages to improve communication and pro-
vide a place whether anonymous data can be compiled and trainings are offered
online. Systemic family therapists should also engage with national and international
governmental organizations and nongovernmental organizations, which have
resources available to implement parenting programs to make sure that proper assess-
ments are included.
Public health implications of parent-child relationship screening

and assessment
Serious childhood mental health problems affect 10–20% of children worldwide, and
the rates are rising (Collishaw, Maughan, Goodman, & Pickles, 2004; Kieling et al.,
2011). Children in child welfare systems, most of whom have been taken out of their
families due to maltreatment or neglect, have rates that are three to four times higher
than children who live with their families (Bronsard et al., 2016). Mental and sub-
stance abuse disorders are the leading cause of years lived with disability worldwide,
with the highest proportion occurring in people ages 10–29 years. Furthermore, the
burden of mental and substance use disorders increased by 37.6% between 1990 and
2010 (Whiteford et al., 2013). Particularly in LMICs, many of these children receive
no treatment at all, and even in HICs, the majority of children do not receive ade-
quate mental health care. The public health burden is enormous, and it would seem
overwhelming to garner enough resources for adequate treatment.
In thinking through how to manage this burden of mental health problems, it
would appear that prevention may be more helpful than trying to ameliorate prob-
lems that have become more serious. Numerous epidemiologic studies have shown
that parenting difficulties are a key risk factor for increased childhood mental health
problems (e.g., Copeland et al., 2009; Menard et al., 2004). Additional intervention
studies that focus on improving parenting skills and the parent-child relationship have
decreased the mental health burden in those children whose families received these
interventions (Olds, 2006; Wolchik et al., 2013). One viable public health approach
would be to task primary health‐care providers (PCPs), typically pediatricians or
family medicine physicians and their allied health partners, with screening for parent-
child relationship difficulties during routine “well‐child” checkups. Currently in
the United States, health‐care practices that treat children are starting to screen for
existing developmental and behavioral problems, but pick up only 14–54% of those
children with difficulties (Sheldrick, Merchant, & Perrin, 2011). In Europe, some
countries also include a checklist regarding behavioral problems, but screening for
family problems and parenting difficulties in PCPs is rarely implemented at a systems
level. It will take education and support for them to identify those children with par-
ent-child relationship difficulties that may be amenable to preventive interventions.
With revisions to the ICD‐11 PCRP category, a screening system could be imple-
mented through electronic medical record software that prompts practitioners to
assess and record this domain similar to other behavioral risk factors such as parental
smoking or depression (e.g., with the PHQ‐9). Pilot studies of the feasibility and
effectiveness of digital screening and coding of DSM‐5/ICD‐11 criteria for PCRP are
needed. Further, brief screening instruments need to be developed and evaluated for
sensitivity and specificity. Most of the measures in the chapter reviewed here are too
time intensive for easy scaling up at a health‐care system level, but could be used to
validate briefer screening tools.
One such program that provides Internet‐based, standardized screening measures
for PCPs to use with their patients is the Child Health and Development Interactive
System (CHADIS) (Howard & Sturner, 2017). This screening, decision support, and
patient engagement system is designed to streamline patient communication and
optimize health care by providing PCPs with standardized behavioral and emotional
assessments of children prior to their clinical visits, allowing the PCP to focus on the
problem and work with the family to motivate them to seek treatment if indicated.
CHADIS offers several standardized tools to identify the upstream drivers of poor
outcomes for children, including parental mental health and parenting difficulties
screens. These screening measures can be refined for PCRP. However, PCPs will not
want to identify problems that they cannot treat or have viable resources to which to
refer their patients. The role of family systemic therapists will be to develop viable,
evidence‐based, and readily available therapies for PCRP in each community and
work closely with children’s medical homes to coordinate such preventive care.
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Part II
Problems in Parent-Child
and Sibling Relationships
3
Prevention of Parent-Child
Relational Problems
The Role of Parenting Interventions
Kendal Holtrop, E. Stephanie Krauthamer Ewing,
Glade L. Topham, and Debra L. Miller
Sydni Jones1 is a 28‐year‐old mother of two school‐age children, Mara and James. Things
have been difficult for the Jones family since the death of Sydni’s mother last year. After pay-
ing for health‐care and funeral expenses, Sydni went into debt. She had tried to pick up extra
shifts at her cleaning job, but arranging childcare was a stressor, and she needed that time to
take James to appointments at the health clinic for his type 1 diabetes. Sydni got behind on the
rent and the family had to move out of their apartment. They are now staying with Sydni’s
sister.
These events have taken a toll on the Jones family. Sydni has been under a great deal of
stress searching for a way to make ends meet. She has not been able to spend much time with
her children, and when they are together she often loses her patience and snaps at them in
frustration. To make matters worse, Mara frequently argues with her, and James has been
getting in trouble at school for hitting other students. She is resentful her children are contrib-
uting to the problem rather than helping to resolve it. Sydni wants to do something before
things get any worse for her family but does not know where to start. She lies awake at night
worried things are hopeless.
Overview and focus

This chapter provides an introduction to the prevention of parent-child relational
problems by emphasizing parenting interventions as an effective approach congruent
with elements of systemic family therapy. We start by offering this clinical vignette to
showcase how parenting interventions are applicable to the types of family situations
we encounter in everyday clinical practice. As illustrated in the vignette, adverse
contexts can place strain on the parent-child relationship, leading to relationship
problems and individual distress for parents and children. This distress can then feed
back into the family, further undermining positive family processes. The parenting
interventions outlined in this chapter regard parents as critical change agents within
the context of the parent-child relationship and family system. Therefore, parents are
taught new strategies for shaping child behavior and providing sensitive and responsive
58 Kendal Holtrop et al.
care to children. Throughout this chapter we highlight the strong empirical evidence
demonstrating that parenting interventions can lead to positive outcomes for indi-
viduals and families.
It is important to note that parenting interventions constitute a vast, heterogene-
ous set of approaches. This chapter is not intended as an exhaustive review of all
effective parenting interventions; instead, we highlight a subset of interventions

addressing child and parent mental health, behavioral outcomes, and emotional well‐
being. The majority of the parenting interventions discussed in this chapter are
focused on the preschool years through middle childhood, but we include those
involving older and younger children as appropriate. Consequently, we refer readers
interested in family‐based programs for adolescents to Kobak and Kerig (2015) or
Van Ryzin, Kumpfer, Fosco, and Greenberg (2016). Finally, we have endeavored to
maintain a prevention‐based emphasis in this chapter, considering the ways in which
parenting interventions can be applied to prevent or reduce negative outcomes prior
to the onset of a diagnosable disorder. However, the boundary between prevention
and treatment approaches is notoriously difficult to denote (National Research
Council [NRC] and Institute of Medicine [IOM], 2009), and many of the parenting
interventions described here have been applied in both prevention and treatment
contexts.
Definition of parent-child relational problems

The focus of this chapter is on preventing problems within the parent-child relation-
ship. To align with the terminology and diagnostic criteria of the Diagnostic and
Statistical Manual of Mental Disorders (5th ed.; DSM‐V; American Psychiatric
Association [APA], 2013), our use of the term “parent” is broadly defined to mean a
person functioning as the child’s primary caregiver. This may include a biological par-
ent, adoptive parent, foster parent or caregiver, or another relative (e.g., grandparent)
performing a central caregiving role (APA, 2013). This broad definition is also in
alignment with the language of the International Classification of Diseases (11th ed.;
ICD‐11; World Health Organization [WHO], 2018).
According to the DSM‐V (APA, 2013), problems in the parent-child relationship
(V61.20) may be associated with impaired functioning in a number of domains.
Examples of parent-child relational problems include lack of parental supervision,
insufficient parent-child involvement, hostility, scapegoating, or indifference. These
problems alone may serve as the primary focus of therapy or may be interfering with
treatment for another problem (APA, 2013). Likewise, the ICD‐11 (2018) describes
a caregiver–child relationship problem as characterized by “substantial and sustained
dissatisfaction…associated with significant disturbance in functioning” (QE52.0).
The systemic context

A guiding principle of a systemic approach is to conceptualize the family as an organ-
ized whole composed of interdependent elements combining to form more than the
sum of its parts (Minuchin & Fishman, 1981). Focusing on the parent-child relation-
ship represents an important advancement beyond approaches that consider the indi-
vidual in isolation. Examining the parent-child dyad allows for consideration of
Prevention of Parent-Child Relational Problems 59
relational processes, such as interaction patterns, bidirectional influence, and feedback

loops. However, to fully be considered systemic family therapy, relational approaches
must conceptualize the parent-child relationship as one subsystem, among many,
within the family system. Parenting interventions vary in terms of their overall systemic
conceptualization. We present a range of parenting interventions in this chapter.
Significance of Parent-Child Relational Problems
Decades of research demonstrate the quality of parent-child relationships is funda-

mental to healthy child development with far‐reaching implications for adaptive func-
tioning across the lifespan (Wamboldt, Cordaro, & Clarke, 2015). Parent-child
relationship quality impacts psychosocial and health outcomes and can set the stage
for the intergenerational transmission of parenting and parent-child relational p
atterns
(Critchfield & Benjamin, 2010).
Impact at the family level

Problems with the parent-child relationship and child adjustment are related to
greater distress throughout the family system (Buehler & Gerard, 2002). For exam-
ple, research suggests a bidirectional relationship between parenting and couple dis-
tress. Couple conflict is associated with greater use of harsh discipline and reduced
parental involvement (Buehler & Gerard, 2002). Ineffective parenting has been
shown to mediate the association between partner conflict and child maladjustment
(Buehler & Gerard, 2002; Schoppe‐Sullivan, Schermerhorn, & Cummings, 2007).
At the same time, parenthood is associated with decreased marital satisfaction,
particularly for mothers of infants (Twenge, Campbell, & Foster, 2003).
It is also well established that parental psychopathology is associated with negative
child outcomes such as dysregulated emotion, insecure attachment, and cognitive
problems, with evidence indicating this association is, at least partially, mediated
through impaired parenting (Aunola, Ruusunen, Viljaranta, & Nurmi, 2015; Zahn‐
Waxler, Duggal, & Gruber, 2002). For instance, parental depressive symptoms are
associated with use of psychological control, overreactivity, laxness, hostility, and less
positive affect; it is also associated with less warmth in the parent-child relationship
(Aunola et al., 2015; Errázuriz, Harvey, & Thakar, 2012; Hummel, Kiel, & Zvirblyte,
2016; Venta, Velez, & Lau, 2016).
Impact at the child level

Parent-child relationships are a critical factor influencing developmental pathways for
children’s mental health (e.g., see Beach et al., 2006; Critchfield & Benjamin, 2010).
To grasp the significance of parent-child relational problems, therefore, it is necessary
to understand the scope of child mental health problems. Worldwide, as many as
10–20% of youth are affected by mental health problems (Kieling et al., 2011). In the
United States, approximately 13–20% of children experience a mental, emotional, or
behavioral disorder each year (Centers for Disease Control and Prevention, 2013).
These problems cause suffering to the children and families affected, interfere with
social and educational achievement, increase risk for further negative outcomes
throughout life, and pose substantial costs to society (NRC & IOM, 2009).
The quality of the parent-child relationship also impacts child health outcomes
(Carr & Springer, 2010). Parent-child relationship negativity has been found to inter-
act with lower socioeconomic status (SES) to predict child physical health impairment
(Hagan, Roubinov, Adler, Boyce, & Bush, 2016). Guenther, Van Dyk, Kidwell, and
Nelson (2016) found that child outward expression of anger predicted number of
medical illnesses and that the relation was exacerbated by parent-child dysfunction. In
addition, parenting has been shown to be related to child health behaviors and child
weight status. For example, rejecting parenting is related to children’s less healthy
eating (Rodenburg, Oenema, Kremers, & van de Mheen, 2012), and indulgent
(Olvera & Power, 2010) and authoritarian (Kakinami, Barnett, Seguin, & Paradis,
2015) parenting styles are associated with greater likelihood of child obesity.
Developmental Theories Related to Parenting
In this section, we provide an overview of selected developmental theories related to

parenting: ecological systems theory, social learning models, and attachment theory.
These theories are linked to a body of empirical work and were chosen for inclusion
in this chapter because of their relevance to the parent-child relationship, with specific
applications for parenting.
Ecological systems theory and its influence

Ecological systems theory situates parenting as a developmental process influenced by
the many interactions each person has over time with various people, objects, and
symbols in their environment (Bronfenbrenner, 1979, 2000; Luster & Okagaki,
2005). The caregiver–child relationship is a central focal point for understanding the
development of a child. The processes that occur between parents and children
depend on the characteristics of the child (including genetic and environmental fac-
tors), the unique characteristics of the parents (e.g., personality, childrearing beliefs,
educational background, psychological well‐being), and a host of contextual influ-
ences. For example, ecological systems theory considers the role of interpersonal,
cultural, and temporal factors as influential to the parent-child relationship.
Jay Belsky (1984), influenced by Bronfenbrenner’s ecological systems theory, set
forth a comprehensive model of parenting as multiply determined by (a) the personal-
ity and personal resources of the parent, (b) the child’s characteristics, and (c) contex-
tual sources of stress and support. Belsky also viewed the developmental history of the
parents, including all their experiences prior to becoming parents, as an important
influence (Luster & Okagaki, 2005).
Social learning models

Social learning models emphasize the influence of environmental consequences, par-
ticularly social experiences, as key determinants of behavior. Incorporating elements
from classical, operant, and observational learning theories, these models extend the
view of learning by placing a greater emphasis on the role of the individual and how
learning takes place outside of conditioning processes (Kazdin, 1994). In particular,
social cognitive theory (Bandura, 1986) highlights the salience of observational learn-
ing and imitation in the way children acquire new behaviors.
An important extension of social learning is its application to coercive family pro-
cesses (Patterson, 1982). Coercion theory posits that child aggression is the result of
an entrenched pattern of coercive parent-child interactions, where individuals use
aversive actions to control the behavior of others. These processes undermine positive
parenting in favor of interactions involving negative reinforcement, negative reciproc-
ity, and escalation. Another important derivative of social learning theory is the social
interaction learning model (Forgatch & Domenech Rodríguez, 2016; Forgatch &
Patterson, 2010). This model underscores how behavior is shaped through repeated
parent-child interactions and how the effects of contextual stressors on children are
mediated through their influence on parenting practices.
Attachment theory
The central premise of attachment theory is that children have a basic evolutionary
instinct to seek out parents for care and protection. Bowlby (1973) posited that when
caregiving is consistently responsive and emotionally attuned, children are more likely
to develop trust and believe their needs for support, protection, and guidance will be
met in close relationships. In contrast, when caregiving is typically rejecting, intrusive,
emotionally unresponsive, or inconsistent, children are at higher risk for developing
insecure expectations for care and may develop a set of defensive emotional and
behavioral coping patterns (van Ijzendoorn, 1995).
Parenting is thought to take place within the context of an innate caregiving behav-
ioral system meant to protect children and teach life skills necessary for survival
(Cassidy, 2016). As children grow, parents need to be aware of and responsive to their
children’s growing needs for autonomy as well as their continued attachment needs.
When parents have difficulty with attunement and adapting their approaches to their
child’s developmental needs, parent-child relations can become tense, conflict‐filled,
and/or detached, and relationships can fall into cycles of increased hostility, rejection,
and/or withdrawal (Krauthamer Ewing, Diamond, & Levy, 2015).
Traditional Family Therapy Models and Parenting
Traditional family therapy models provide a rich theoretical perspective on the dynam-
ics of parent-child relationships that promote healthy development. In this section we
highlight four models, providing a brief description of each theory relevant to parent-
child relationships.
Structural family therapy

According to structural family therapy (Minuchin, 1974), healthy parent-child relation-
ships are achieved when family structure includes clear boundaries, an effective hierar-
chy, and balance between structure and adaptability. The concept of interpersonal
boundaries, or the implicit and explicit rules that govern contact between family mem-
bers, is central to structural family therapy. Rigid boundaries between a parent and child
result in disengagement, promoting autonomy but limiting closeness and connection.
On the other end of the continuum, diffuse boundaries lead to enmeshment, compel-
ling closeness at the expense of individual autonomy. In contrast, clear parent-child
boundaries achieve a balance of autonomy and connection. A clear boundary around
the couple and parental subsystems preserves the couple relationship and prevents cross‐
generational coalitions and parentification of children. A clear boundary around the
sibling subsystem allows children the autonomy to work out disagreements without
parental intrusions. Effective hierarchy in families is achieved when parents respect chil-
dren’s thoughts and feelings while retaining ultimate decision‐making authority. Overall,
healthy family relationships provide structure, support, and predictability while also
adapting as circumstances require. This facilitates positive child development (Minuchin
& Fishman, 1981).
Structural family therapy offers a useful map that can be applied in prevention work
to help parents understand key elements of positive parent-child relationships. The
metaphors and maps of structural family therapy make potentially abstract concepts of
hierarchy, boundaries, roles, and adaptability relatively simple to teach and to under-
stand. Furthermore, the concepts help parents to understand parenting within a fam-
ily systems context and not just within a parent-child dyad (a limitation of much of the
parenting prevention programing).
Strategic therapy
Similar to structural family therapy, the strategic approach of Jay Haley and Cloe
Madanes acknowledges the importance of boundaries and hierarchy. However, their
work focused more on interaction sequences specific to the presenting problem
(Haley, 1976). James Keim’s work (1998) in relation to children who are opposi-
tional provides an illustration of strategic therapy applied to parent-child relation-
ships. Keim points out that during parent-child confrontation, the child is typically
focused on the process (i.e., how and when arguments occur) while the parent is
focused on outcome (e.g., child compliance). A distinction is made between the soft
side of hierarchy, offering soothing, protection, and affection, and the hard side of
hierarchy, making rules and setting limits. Positive parent-child interaction occurs
when parents take charge of the process of confrontation and engage in both the soft
and hard sides of hierarchy.
Stages of strategic therapy include framing the problem as a mismatch in approaches
between parent and child (not a bad parent or child); helping parents take charge to
avoid being pulled into confrontation; structuring rules, rewards, and consequences
in a manner sensitive to the child’s process orientation; and coaching parents to soothe
child anger and pain. Parents are taught to use consequences that require child coop-
eration (e.g., work chore) as a first response and those not requiring child cooperation
as a backup (e.g., withholding allowance). Parents are also coached to utilize rewards
for good behavior and to regularly engage in positive parent-child activities regardless
of child behavior. In terms of soothing children, parents learn to manage their own
emotions, so they can help the child calm down during confrontations. In addition,
parents learn ways to circumvent confrontation during emotionally charged conversa-
tions and ways to soothe child distress (Keim, 1998).
Keim’s application of strategic therapy concepts to parent-child relationships can be

implemented in either treatment or prevention contexts. Often parents participating
in parent education programs have concerns about child behavior and could benefit
from a process‐focused reframe of child acting‐out behaviors that moves past blame
and toward more productive interaction sequences (i.e., the problem is not a result of
bad parenting or a bad child, but results from a difference in how confrontation is
handled in the family).
Experiential therapy
According to experiential therapy (Satir, 1972), healthy parent-child relationships are
built upon authentic and congruent communication. Parents model this for their
children and support and encourage children’s expression of emotion, allowing chil-
dren to communicate and explore emotion without fear of judgment or criticism.
Parents respond with validation, empathy, and warm support. In this context, chil-
dren develop awareness of and appreciation for their emotions, learn to attend to and
cope with strong feelings, and become capable of problem solving and meeting their
own needs. When the parent-child relationship helps children appreciate and value
their authentic self, it buffers them against external messages communicating that
children need to be and feel something different to be accepted. In addition, it posi-
tions children to experience emotional intimacy as they learn to share and connect
with others without the need to hide or change parts of themselves.
Ideas regarding positive parent-child relationships outlined in Satir’s (1972) expe-
riential therapy are easily applied in a parenting intervention context. In fact, these
ideas are consistent with a number of parenting programs that emphasize parent
acceptance and validation of child emotional experience (e.g., the Tuning in to Kids
program described in this chapter). Experiential therapy contributes an emphasis on
parent authenticity that can complement the content of these programs.
Bowen family systems theory

According to Bowen family systems theory (Bowen, 1978), effective parenting is
predicated on parent differentiation. Differentiation refers to one’s ability to separate
intellectual and feeling processes and act according to values and principles rather
than in response to anxiety or reactive emotion. It is the ability to maintain autonomy
while maintaining emotional connection. When parents have low levels of differentia-
tion, they are likely to “fuse” into relationships and to depend on the relationship for
a sense of identity and self‐worth. In this state, parents may need their child to respond
in a particular manner in order to feel okay with themselves as a parent and a person.
Parents with low levels of differentiation are likely to direct their efforts toward short‐
term solutions to quiet anxiety, typically with long‐term negative consequences for
relationships and individual functioning. They may attempt to manage anxiety in the
couple relationship by “triangulating” a child into the conflict through complaining
about the other parent and/or enlisting the child to help resolve the problem.
Additionally, they may direct excessive positive or negative attention to a child, give
up self to preserve harmony, or engage in emotional cutoff (e.g., keeping discussions
on superficial topics) in order to buffer themselves from the intensity of emotional
connection. These efforts to bind anxiety block self‐growth and interfere with p arents’
ability to provide a non‐anxious emotional connection for the child and help the child
develop differentiation (Kerr & Bowen, 1988).
Ideas from Bowen family systems theory can be applied in prevention contexts by
helping parents understand the importance of attending to and taking responsibility
for managing their own emotion and reactivity in response to their child. As parents’
capacity to manage and attenuate their own reactivity grows, so will their capacity to
parent according to their goals and values. We refer the reader to the book Scream
Free Parenting: How to Raise Amazing Adults by Learning to Pause More and React
Less (Runkel, 2008) for a popular application of Bowen family systems theory to
parenting.
Contemporary Parenting Intervention Programs
Overview
Broadly defined, parenting interventions include approaches in which at least one
component specifically targets the promotion of effective parenting practices and/or
positive parent-child interactions (Prinz, 2016; Sandler, Schoenfelder, Wolchik, &
MacKinnon, 2011). Many parenting interventions evolved out of the parent training
movement in the 1960s and 1970s, which marked a radical departure from the tradi-
tional practice of relying on mental health professionals to treat child behavioral
problems during weekly office visits. Instead, parenting interventions are based on the
belief that parents can be critical change agents in shaping patterns of family interac-
tion because of their commitment and responsibility to care for the child, enduring
presence, and role in the family system (McMahon, 1999).
Parenting intervention approaches

In this section, we highlight a number of prominent parenting intervention programs,
broadly categorized into two types of approaches: (a) behaviorally oriented interven-
tions and (b) attachment‐based and emotion‐focused interventions. Parenting inter-
ventions drawn from other theoretical orientations (e.g., Adlerian theory) are beyond
the scope of this chapter.
Behaviorally oriented parenting interventions Behaviorally oriented parenting inter-

ventions began their rise to prominence in the 1960s and, more than 50 years later,
remain a central approach for improving parent-child interactions and ameliorating
child problem behaviors (Dishion, Forgatch, Chamberlain, & Pelham, 2016). These
approaches focus on observable patterns of behavior, learned behaviors, and reinforce-
ment principles derived from the operant conditioning paradigm. Social learning the-
ory, the coercion model, and applied behavior modification also inform these models
(Briesmeister & Schaefer, 1998; Patterson, 2002). A guiding tenet is that child behav-
ior is shaped and maintained by social agents, with parents having the most proximal
and direct influence. As central agents in facilitating family change, parents learn skills
for shaping child behavior based on contingency management—where prosocial
behaviors are encouraged through positive reinforcement while negative behaviors are
reduced using mild sanctions (Dishion et al., 2016). Use of parenting tools such as
tokens, incentive charts, time‐outs, and privilege removal are characteristic of this type
of approach. Across the literature, these approaches are commonly referred to as
“behavioral parent training,” although “behaviorally oriented” may be more appropri-
ate given that many of these interventions extend beyond sole attention to behavior by
incorporating emotion‐ and attachment‐based principles.
Presenting problems and intervention targets Behavioral parent training

approaches have been proven to prevent and treat a number of negative outcomes for
children and youth. We refer the reader elsewhere to sources that review behavioral
parent training for the treatment of child and youth diagnostic disorders (e.g., Weisz
& Kazdin, 2017). In this section, with an eye toward prevention, we briefly highlight
the literature supporting the use of behavioral parent training to (a) promote effective
parenting, (b) mitigate escalation of child behavior problems, (c) prevent child mal-
treatment, and (d) target additional outcomes for families.
Parenting practices
Improvements in positive parenting (e.g., problem solving, monitoring, parent-
child involvement) and decreases in negative parenting (e.g., dysfunctional disci-
pline strategies, negative reciprocity) have been evidenced by behavioral parent
training interventions (Forgatch & Patterson, 2010; Thomas & Zimmer‐Gembeck,
2007; Webster‐Stratton & Reid, 2017). Prevention‐focused parenting interven-
tions have also demonstrated the ability to promote effective parenting practices
that last years after program participation (Sandler et al., 2011; Sandler, Ingram,
Wolchik, Tein, & Winslow, 2015). In a review of 22 parenting‐focused preventive
interventions (Sandler et al., 2015), every program evidenced improvements in par-
enting, and close to half of the programs documented parenting improvements
lasting multiple years post‐intervention.
Child behavior problems

Although antisocial behaviors such as oppositional defiant disorder and conduct
disorder are considered particularly challenging to prevent, a number of behavioral
parent training interventions have demonstrated success in this area (Prinz & Dumas,
2004). For example, Parent Management Training–Oregon (PMTO) model, now
referred to as GenerationPMTO, has demonstrated efficacy in reducing child exter-
nalizing behavior and noncompliance while reducing risk for later delinquency and
police arrests (Forgatch & Gewirtz, 2017). The Incredible Years (IY) program has
also shown effectiveness in preventing conduct problems (Webster‐Stratton & Reid,
2017). In addition, the Triple P‐Positive Parenting Program (Triple P) has a well‐
established record of reducing child behavior problems in a number of populations
(Sanders, Markie‐Dadds, Turner, & Ralph, 2004).
Child maltreatment
In a recent meta‐analysis, Chen and Chan (2016) found parenting programs to be
effective in preventing child maltreatment, calculating a total random effect size of
0.296. The analyses included studies from different countries (i.e., United States,
Canada, Australia, New Zeeland, England, Thailand, Iran), at each level of prevention
(i.e., primary, secondary, tertiary), with a wide variety of parenting interventions.

Prior meta‐analytic work also supports the specific contribution of behavioral parent
training programs toward this important goal (Lundahl, Nimer, & Parsons, 2006). In
particular, Parent-Child Interaction Therapy (PCIT) (Thomas & Zimmer‐Gembeck,
2011) and Triple P (Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009) have dem-
onstrated notable results in preventing child maltreatment using randomized research
designs.
Additional outcomes
There is a growing literature on the breadth of additional benefits related to
behavioral parent training. Behavioral parent training has been associated, either
directly or indirectly, with reductions in parental depression (e.g., DeGarmo,
Patterson, & Forgatch, 2004; Wong, Gonzales, Montaño, Dumka, & Millsap,
2014), better parental self‐efficacy (e.g., Gross, Fogg, & Tucker, 1995; Sanders,
Baker, & Turner, 2012), and even reduced risk of maternal arrest and increased
standard of living (Patterson, Forgatch, & DeGarmo, 2010). Attending behavio-
ral parent training as a couple has also been shown to benefit marital functioning
(Ireland, Sanders, & Markie‐Dodds, 2003). In terms of child health outcomes,
parenting interventions hold promise for preventing and treating child obesity
(Gerards, Sleddens, Dagnelie, De Vries, & Kremers, 2011) as well as preventing
unintentional injury in childhood (Kendrick et al., 2013). Recent research even
suggests a reduced risk of later intimate partner violence (IPV) exposure among
female youth whose parents participated in a behavioral parent training program
(Ehrensaft et al., 2018).
Example programs In this section, we highlight a number of prominent, evidence‐

based parenting programs in order to provide the reader with examples of behavio-
rally oriented parenting interventions.
GenerationPMTO
GenerationPMTO, formerly known as PMTO, seeks to prevent and treat child
behavior problems by reducing coercive parent-child interactions and strength-
ening five core parenting practices: skill encouragement, limit setting, problem
solving, monitoring, and positive involvement (Forgatch & Domenech Rodríguez,
2016; Forgatch & Gewirtz, 2017; Forgatch & Patterson, 2010). Content is deliv-
ered to parents sequentially, with a focus on strengths, either individually or in a
group format. GenerationPMTO places particular emphasis on the intervention
delivery process. Much of the teaching is done through role play and clinical pro-
cesses that prioritize support, effective questioning, movement, and humor. Fidelity
is monitored with an observation‐based rating system that accounts for both con-
tent and process factors (Knutson, Forgatch, Rains, & Sigmarsdóttir, 2009).
GenerationPMTO has been implemented across the United States (e.g., Michigan,
Kansas, New York) and around the world (e.g., Norway, Iceland, Mexico), in
many cases employing its distinctive full transfer approach. It has been applied
successfully with a variety of populations, such as divorced families, Latino immi-
grants, child welfare‐involved families, and international populations (Forgatch &
Gewirtz, 2017; see also Akin, Lang, McDonald, Yan, & Little, 2016; Parra‐Cardona
et al., 2017).
The Incredible Years

The IY constitutes a series of training programs targeting parents, teachers, and chil-
dren to prevent and treat child behavioral and emotional problems while promoting
prosocial development (Webster‐Stratton, 2000; Webster‐Stratton & Reid, 2017). At
the core of IY is the BASIC parent training program, which involves weekly group
sessions for parents matched to child developmental level and tailored to symptom
severity (i.e., prevention vs. treatment). Characteristic parenting topics include child‐
directed play, effective use of praise and incentives, developmentally appropriate limit
setting, nonviolent discipline, and monitoring. A hallmark of the IY BASIC program
is the use of video vignettes depicting different parenting scenarios to generate group
discussion and problem solving. IY has been implemented in the United States and
around the world (e.g., Norway, New Zealand, Russia, United Kingdom). It has
demonstrated a number of beneficial outcomes for parents, children, and families
across a large body of research (Menting, de Castro, & Matthys, 2013; Webster‐
Stratton, 2000; Webster‐Stratton & Reid, 2017).
Parent-Child Interaction Therapy

PCIT aims to teach parents behavioral techniques for improving the caregiver–child
relationship and ameliorating child externalizing problems (Eyberg, 1988; Zisser‐
Nathenson, Herschell, & Eyberg, 2017). Parents start by learning to support child‐
led play using labeled praise, reflections, and behavior descriptions before progressing
to use of effective directions and consistent consequences to increase child compli-
ance. The quintessential PCIT session involves the therapist observing a parent-child
interaction from behind a one‐way mirror and using a radio earphone (i.e., “bug‐in‐
the‐ear” system) to provide feedback. PCIT is delivered to families individually—
there is no group version—and includes the child directly, which are both somewhat
unique features for a parent training program. Although PCIT is most typically
regarded as a treatment for child disruptive behavior disorders (Zisser‐Nathenson
et al., 2017), it has also been applied successfully as a preventive intervention (e.g.,
Berkovits, O’Brien, Carter, & Eyberg, 2010; Galanter et al., 2012). It has been imple-
mented cross‐culturally with Chinese, Dutch, and Mexican American families (Zisser‐
Nathenson et al., 2017).
Triple P‐Positive Parenting Program

The Triple P aims to promote positive parent-child relationships and prevent child
behavioral and emotional problems under the premise that not all families need the
same level of services (Prinz et al., 2009; Sanders, Turner, & McWilliam, 2016). The
program encompasses a multitiered series of interventions that increase in intensity,
from a community‐level health promotion and communication strategy encouraging
positive parenting (Level 1) all the way to intensive intervention with at‐risk families
of children with severe behavior problems (Level 5). Parenting skills include clear
instructions, contingent reinforcement, monitoring, logical consequences, and build-
ing positive parent-child relationships. Triple P is delivered in a variety of contexts, for
example, through community groups, in primary care settings, online, and as a work-
book‐based self‐help program. It was developed in Australia, has been applied around
the world (e.g., United States, Canada, Ireland, Belgium, Hong Kong, the
Netherlands), and has a robust body of clinical trials supporting its effectiveness (Prinz
et al., 2009; Sanders et al., 2016; Thomas & Zimmer‐Gembeck, 2007).
Evaluation of systemic elements In this section we apply criteria informed by pub-

lished reviews of systemic therapy (Sydow, Beher, Schweitzer, & Retzlaff, 2010;
Sydow, Retzlaff, Beher, Haun, & Schweitzer, 2013) to evaluate the alignment of
behaviorally oriented parenting interventions with systemic elements.
Criterion one: Symptoms conceptualized within the context of social systems

Similar to other parenting interventions, behavioral approaches recognize the impor-
tance of context and the influence of social system factors on child development,
primarily through their impact on parenting and the parent-child relationship.

Particular attention is also given to the role of antecedents and consequences of child
behavior in the social environment as well as how peer relationships can have a key
socializing influence (e.g., Briesmeister & Schaefer, 1998; Forgatch & Patterson,
2010).
Criterion two: Focus on interpersonal relationships and interaction patterns

Behavioral parenting interventions perform quite well in this regard, with theoretical
roots emphasizing reinforcement contingencies and coercive family interactions (e.g.,
Patterson, 2002, 2016). Accordingly, intervention efforts focus on helping parents
interrupt destructive family interaction patterns and build more positive parent-child
relationships (Briesmeister & Schaefer, 1998).
Criterion three: Inclusion of family members and other key figures

When applying behaviorally oriented parenting interventions, parents are viewed as
key change agents, so therapists include caregivers in the treatment process or even
work with caregivers exclusively (Briesmeister & Schaefer, 1998; McMahon, 1999).
However, this focus on the parent-child dyad is also a limitation when it eclipses con-
sideration of the entire family system. Empirical work documenting collateral changes
among family members (e.g., Brotman et al., 2005; Patterson et al., 2010) may help
to push research in this direction and suggest a stronger role for family systems theory
within parenting intervention science.
Attachment‐based and emotion‐focused parenting interventions Alongside behavio-

rally oriented interventions, we also consider a second type of intervention approach
under the broad categorization of attachment‐based and e motion‐focused interven-
tions. In this section, we describe each of these in detail.
Attachment‐based parenting interventions Attachment‐based parenting inter-

ventions focus most directly on interpersonal relationships and interaction patterns
between parents and children, as well as on the important role of relational distur-
bances in poor family and developmental outcomes. The overarching treatment goals
of attachment‐based interventions center around improvements in attachment‐pro-
moting parenting, which should lead to improvements in children’s felt attachment
security.
Over the past two decades, a variety of attachment‐based treatments for parents and
their children have been developed and tested. For instance, the recent “Handbook
of Attachment‐Based Interventions” reviews 21 attachment‐based interventions for
parents of children across a range of developmental stages, from infancy through
adolescence (Steele & Steele, 2018). Each featured intervention is significantly

informed by attachment theory and has some level of empirical support for program
effectiveness. Because attachment needs change dynamically in concordance with
developmental stages, it is vital to evaluate developmental needs when choosing
attachment‐informed interventions and treatment strategies. As such, the interven-
tions reviewed in Steele and Steele (2018) are grouped by appropriateness for devel-
opmental stage, including 12 interventions aimed at parents and children ages 0–3,
three interventions designed for parents and preschool‐aged children, one interven-
tion for early and middle childhood, and four interventions for adolescents.
Within this body of attachment‐based parenting interventions, various approaches
are used to accomplish treatment goals. Some programs conceptualize change to
occur through reflective dialogue and psychoeducation about attachment and car-
egiving; these programs focus mainly on working with parents to enhance their reflec-
tive thinking and understanding of themselves in the parenting role, as well as their
reflective thinking about their children’s attachment and emotion needs. In contrast,
other programs view the change process as more implicit and procedural, prioritizing
in‐session enactments between parents, children, and therapists. Accordingly, they
work directly with parent-child dyads to alter in vivo patterns of interaction and emo-
tional attunement between parents and children (Kobak & Kerig, 2015; Kobak,
Zajac, Herres, & Krauthamer Ewing, 2015). Based on their conceptualization of
change processes, programs tend to vary in terms of who is typically included in
treatment (e.g., parents only, parents and children, other family members and key
figures).
Attachment‐based interventions targeting caregiver understanding

of self and child
Parenting programs designed to enhance reflective thinking and caregiver under-
standing of self and child seek to bolster attachment‐promoting parenting by helping
parents increase awareness and understanding of their motivations, defensive trig-
gers, and attributions about their child. One treatment goal in these programs is for
parents to experience an increase in empathy toward the needs of their children,
referred to as an “empathic shift” (Cassidy et al., 2017). As a result, it is believed that
parents will be better able to read and respond sensitively to children’s emotions and
attachment needs (Powell, Cooper, Hoffman, & Marvin, 2014). These programs
use a variety of methods, including the quality of the therapist–client bond, reflective
conversations, eliciting caregivers’ interpretations about children’s behavior and
their own reactions, reframing individual symptoms as family‐level problems, and
psychoeducation to work toward empathic shifts and revised internal working models
(Kobak et al., 2015).
The Circle of Security (COS) program is a widely used attachment‐based parenting
intervention focused on increasing parental reflective thinking and changing internal
working models. COS therapists work primarily with parents alone, although parents
and children participate in a videotaped assessment together prior to therapy. These
assessments are used to establish reflective dialogue with parents and elicit parents’
interpretations of their child’s behavior during video replay (Powell et al., 2014).
Therapists work with parents to identify the central parent-child struggles and
perceptions of the child that interfere with their ability to attend to the child’s attach-
ment needs with empathy and support (Kobak et al., 2015). Through empathizing
with—and helping the parent to label—the difficult emotions, attachment memories,
and defensive strategies that arise in their caregiving role, COS therapists work to
establish reflective dialogue and open the caregiver’s internal working models of the
child to new information and points of view (Kobak et al., 2015). The trust and qual-
ity of the therapeutic alliance is critical in this work and can be thought to serve as a
secure base for parents in the exploration and revision of their own internal working
models.
Other attachment‐based parenting interventions that target caregiver internal
working models rely more heavily on psychoeducation about attachment and caregiv-
ing processes. Kobak and colleagues (2015) posit that psychoeducation in attach-
ment‐based parenting interventions introduces clients to new information that
establishes a more explicit model of what secure relationships look like, providing
clear direction and increased optimism and hope. Parents are able to take this new
information to help improve their relationships and revise existing internal working
models (Kobak et al., 2015). The Connect Program is an example of such a program.
It is a 10‐week evidence‐based group program for parents and caregivers of preteens
and teens who struggle with significant behavior problems and mental health issues.
The Connect Program uses a psychoeducational approach to help parents better
understand basic attachment concepts to apply across a broad range of situations and
relational contexts. The program is described as strength based and consistent with
trauma‐informed principles (Moretti, Pasalich, & O’Donnell, 2018).
Attachment‐based interventions targeting parent-child communication

The goal of attachment‐based interventions that target in vivo caregiver–child interac-
tions is to increase observable emotional attunement in parents, which is theorized to
improve the child’s ability to communicate openly and non‐defensively with the par-
ent and lead to more secure attachment expectancies (Kobak et al., 2015). The
Attachment and Biobehavioral Catch‐up (ABC) program, developed for parents of
children ages 0–3, provides a good example of this type of program. ABC therapists
provide coaching and positive reinforcement for caregivers in the moment as they
interact naturally with their children. Three behaviors are targeted to help foster sensi-
tive and attachment‐promoting parenting: nurturance, following the child’s lead, and
delight and positive regard of the child. In addition, the frequency of any frightening
behaviors is reduced by bringing them to the caregiver’s awareness (Bernard et al.,
2012). Studies have demonstrated that caregivers who participate in the program
show an increase in positive behaviors and a decrease in intrusive behaviors with their
children. In line with attachment theory, positive changes in parenting over the course
of the program are found to predict increases in children’s attachment security
(Bernard et al., 2012).
With older children and adolescents, therapists may choose to use reflective dia-
logue in the family setting as well as enactments focused on attachment injuries and
their repair. In this approach, therapists help the child or adolescent share past and
present attachment injuries while coaching parents to validate and empathize with
the child’s experiences and emotions. When such enactments are successful, they
provide opportunities for the child to experience parental support and validation and
for parents to gain a better understanding of the vulnerabilities that contribute to
distress and distance in their parent-child relationship. Attachment‐based family
therapy (ABFT) utilizes the injury and repair approach for the treatment of depressed
and suicidal adolescents, as well as individual work with parents and teens to revise
internal working models (Diamond, Diamond, & Levy, 2013). ABFT applies a
strengths‐based approach to identify resources for parents and children, includes
multiple family members based on family structure and case conceptualization, and
emphasizes the intergenerational transmission of family patterns. In these ways,
ABFT is consistent with a family systems orientation and is a multimodal therapy that
combines an individual focus on revising internal working models with in vivo work
aimed at strengthening attuned and attachment‐promoting communication patterns
(Kobak et al., 2015).
Another exemplar program is the Supporting Father Involvement (SFI) interven-
tion (Cowan, Cowan, Kline Pruett, & Pruett, 2018). SFI was developed, in part, to
increase the systemic emphasis of attachment‐based parenting interventions through
better consideration of the critical role of fathers, the relationship between parents,
and strategies for managing stressors outside the family. From a family systems lens,
improvements in the quality of the couple’s attachment relationship are believed to
result in positive effects to parenting and child outcomes. Group leaders are meant
to serve as a secure base from which couples can explore the frequently difficult and
vulnerable emotions involved in parenting, including areas of disagreement and
conflict. Empirical results from five clinical trials show that couple participation in
the program related to decreases in couple conflict, lowered parenting stress,
increased relationship satisfaction, and decreased problem behaviors in children
(Cowan et al., 2018).
Emotion‐focused parenting interventions While attachment‐based parenting

interventions explicitly target the quality of the parent-child attachment relationship,
emotion‐focused parenting interventions focus on the related process of parental
emotion socialization practices with children. A key component of emotion socializa-
tion is the way parents react to and teach children about emotions (Havighurst et al.,
2015). This has been referred to as parental meta‐emotion philosophy, or an organized
set of feelings and thoughts about one’s own emotions and the emotions of one’s
child; this also includes an emotion‐coaching orientation to parenting (Fonagy,
Steele, Moran, Steele, & Higgitt, 1991; Gottman, Katz, & Hooven, 1996; Sharp &
Fonagy, 2008). Gottman and colleagues (1996) demonstrated links between a dis-
missing maternal meta‐emotion philosophy and child conduct problems and poor
adjustment to stress. In contrast, a parental emotion‐coaching approach has been
linked to positive relational and developmental o utcomes (Hurrell, Houwing, &
Hudson, 2017).
Tuning in to Kids is a relatively new parenting program explicitly focused on paren-
tal emotion coaching (Havighurst et al., 2015; Havighurst, Wilson, Harley, & Prior,
2009). In contrast to more behaviorally based parenting programs, Tuning in to Kids
focuses on teaching parents to understand and respond to the emotions underlying
children’s behavior. Parents also examine the impact of their family‐of‐origin experi-
ences on their beliefs about, and responses to, emotions. During this program, par-
ents are encouraged to use expressions of lower‐intensity emotions from children as
opportunities to work on emotion regulation strategies like emotional awareness,
labeling, and using emotions to accomplish adaptive goals. Based on emotion sociali-
zation theories, the idea is that parental coaching of lower‐intensity emotions will
result in improved emotion regulation skills, which should in turn lead to fewer
episodes of dysregulated emotions in both children and parents, and ultimately fewer
child problem behaviors. To accomplish these goals, parents are taught specific steps
for emotion coaching and how to help children use slow breathing and relaxation
strategies. To avoid provoking heightened emotional distress in children, parents are
taught “time‐in” techniques, where they stay with the child through experiences of
higher‐intensity negative emotions and difficult behaviors, unless the parent is also
very angry. Once the child has calmed down, parents then use emotion coaching to
talk about the situation, including reviewing any family rules or behavioral conse-
quences. The effectiveness of Tuning in to Kids was supported in a recent study with
parents of school‐aged children at risk for conduct disorder, where parents in the
intervention group became less emotionally dismissive and increased in empathy and
children showed better emotion understanding and reduced behavior problems com-
pared with parents and children in the control condition (Havighurst et al., 2015). To
date, Tuning in to Kids has been studied primarily in samples of parents and children
from Australia. Further research is needed to examine cross‐cultural adaptions and
program efficacy.
Evaluation of systemic elements As with our analysis of behaviorally oriented par-

enting interventions, we apply the same criteria informed by published reviews of
systemic therapy (Sydow et al., 2010, 2013) to evaluate the alignment of attachment‐
based and emotion‐focused parenting interventions with systemic elements.
Criterion one: Symptoms conceptualized within the context of social systems

Attachment‐ and emotion‐focused interventions tend to focus most explicitly on the
family subsystem. While a wealth of cross‐cultural research has been conducted inves-
tigating and lending evidence to both attachment theory and theories of emotion
socialization in childhood, less attention, to date, has been given in intervention
models to the impact of larger social systems on attachment patterns, emotional
development, and symptoms. One exception is Family Care Curriculum (FCC),
designed specifically for families experiencing homelessness. FCC is an evolving inter-
vention program that attempts to speak directly to intersectionality, bringing together
and exploring relationships between race, class, place, trauma, and attachment p atterns
as they affect parenting and self‐care (Sheller et al., 2018).
Criterion two: Focus on interpersonal relationships and interaction patterns

An emphasis on interpersonal relationships and interaction patterns is inherently part
of attachment‐based and emotion‐focused parenting programs, as a result of their
targets of change and theoretical underpinnings. In particular, attachment theory and
theories on emotional development in childhood include specific attention to parent-
child interaction patterns and relationship quality as foundational to developmental
trajectories.
Criterion three: Inclusion of family members and other key figures

Attachment‐based and emotion‐focused parenting programs do quite well in terms
of including family members, again by virtue of their theoretical underpinnings. Of
course, programs aimed primarily at improving in vivo parent-child interactions
directly include both parents and children. Some may also include additional family
members, as is the case with ABFT. In ABFT, additional family members, including
siblings, grandparents, and others, are frequently included in family sessions based
upon case conceptualization and evaluation of family strengths and supports. In con-
trast, programs aimed primarily at increasing parents’ reflective thinking or improv-
ing emotional attunement may only directly include parents. However, they routinely
involve indirect involvement of other members of the family system, including
grandparents, past and current romantic partners, and the child. For example, par-
ents are frequently guided through reflective dialogue about the quality of their past
and current attachment and caregiving relationships and how these relationships
impact their current functioning in their parenting roles.
Features common to parenting interventions

Despite the diversity inherent in parenting intervention approaches, they share many
common attributes (see Prinz, 2016). They are grounded in empirically supported
theories, such as social learning models and attachment theory. At the same time,
parents do not just learn about parenting; rather, they are equipped with specific,
practical parenting tools such as ways to give effective directions, apply nonpunitive
limit setting strategies, and respond in a sensitive manner to child emotional cues.
Parenting interventions are also action focused and oriented toward problem solving.
They commonly include role play, in‐session practice, and home‐based application of
skills (Kazdin, 2005). In parenting interventions, the therapist works to actively
engage parents in the learning process, supporting them to learn and try new skills,
and then troubleshooting and finding ways for each family to experience success.
Additionally, they typically involve collaborative goal setting where the parent and
therapist work together to target the treatment to the identified needs of the family.
Finally, parenting interventions generally promote a hope‐based and encouraging
perspective to provide a strengths‐based and nonjudgmental environment for families
(Prinz, 2016).
Parenting Intervention Research: Review of Federally

Funded Studies
Overview and aims

While a goal of this chapter is to emphasize the clinical utility of parenting interven-
tions, we also want to highlight the need and opportunity for systemic family therapy
scholars to engage in funded programs of parenting intervention research. To this
end, the following section presents a review of federally funded parenting interven-
tion research projects over the past 5 years. Specifically, we performed a search of
projects funded by the National Institutes of Health (NIH). NIH is the largest public
funding source for biomedical research in the world, so its funding portfolio is an
important source of information on current funding trends and the use of public
dollars for improving health. NIH also maintains a searchable database of funded
projects, NIH RePORTER (NIH Research Portfolio Online Reporting Tools, 2018),
to facilitate access to funding information. While research projects funded by private
sources also make important contributions to parenting intervention science, there is

no established mechanism available to gather comprehensive data on privately funded
projects.
Method
We used NIH RePORTER (NIH Research Portfolio Online Reporting Tools, 2018)
to search for projects with the terms “parent-child relations” or “parenting” and
limited the query to R‐series research projects (activity codes R01, R03, R15, R21, or
R34) funded in the last five fiscal years (FY 2014–2018). As of 1 March 2018, this
initial search returned 493 non‐duplicative projects. Next, we reviewed each project
abstract to identify research specific to parenting interventions. To be eligible for
inclusion, studies had to involve an intervention where at least one component
targeted the parent-child relationship. Studies only meant to inform intervention
efforts (i.e., no direct intervention involvement) were excluded, as were intervention
studies that targeted parents but did not involve a component directed at the parent-
child relationship. Second, projects had to target a child age range from preschool
through middle childhood. Third, the project had to be administered through an
NIH institute or center. No additional eligibility criteria related to intervention scope
(e.g., prevention vs. treatment, outcomes targeted) were applied. After identifying
eligible studies, the project information available on NIH RePORTER was used to
further classify the attributes of each study.
Results
This review resulted in the identification of 94 distinct projects involving parenting
interventions. These projects were administered by 10 different institutes and centers
within NIH. Overall, the Eunice Kennedy Shriver National Institute of Child Health
and Human Development (NICHD) and the National Institute of Mental Health
(NIMH) accounted for the majority of the parenting intervention‐related projects
(55%). Figure 3.1 presents data on the percentage of parenting intervention studies
administered by each institute or center.
Study design and objectives The vast majority (79%) of parenting intervention projects
described including a randomized controlled trial (RCT). Yet there was heterogeneity
among the RCTs, which included tests of newly developed interventions, comparative
effectiveness research on existing interventions, adaptive intervention strategies (e.g.,
SMART design), culturally adapted approaches, and treatment conditions that com-
bined interventions. Furthermore, it was common for RCTs to go beyond comparing
intervention outcomes to also explore research questions involving mediation, mod-
eration, cost‐effectiveness, and implementation. In this way, current parenting inter-
vention research is attempting to expand knowledge regarding intervention
mechanisms, timing, dosage, engagement strategies, health‐care systems, and use of
technology. In addition to the RCTs, 10 projects (11%) used a non‐randomized design
(e.g., pre‐/posttest) for intervention development or feasibility testing, seven (7%)
only collected follow‐up data from a previous study, three (3%) exclusively examined
mechanisms of treatment, and one (1%) focused on measure development.
NIDCD, 2% NCCIH, 1%
NIMHD, 1%
NHLBI, 5%
NCI, 5%
NICHD, 33%
NINR, 6%
NIDDK, 11%
NIDA, 13%
NIMH, 22%
Figure 3.1 Administering NIH institute or center for NIH‐funded parenting intervention
studies. Graph depicting percentage of NIH‐funded parenting intervention studies by admin-
istering institute or center in last 5 years (n = 94 studies).
Outcomes targeted The predominant focus was on improving child behavioral and
mental health outcomes, parenting, or some combination of these. Child mental
health targets included symptoms of anxiety, depression, posttraumatic stress, and
conduct problems. Although less common, child emotion/self‐regulation was also
an area of attention. Parenting‐related targets extended across behavior‐, emotion‐,
and attachment‐based practices meant to improve the parent-child relationship.
Although a myriad of research questions were tested, as a whole, these studies are
best characterized as directly examining a parenting intervention (or interventions).
Another significant body of research focused on child health outcomes. Health
outcomes related to child obesity were most salient, such as body mass index (BMI),
physical activity, and diet. It was typical for these projects to be testing an obesity‐
focused intervention that included a parenting component directed at regulating
child diet or exercise. A smaller group of studies targeted other child health‐related
outcomes, such as functional abdominal pain, feeding problems, smoking, sleep,
diabetes, and medication adherence.
A minor, but notable, set of studies focused on implementation‐related outcomes,
such as service provision, engagement, and fidelity.
Population groups Finally, we sought to examine the population groups toward

which these parenting intervention studies were aimed. We considered population as
discrete from treatment target, so as not to confound results. For example, an inter-
vention targeting child obesity would be coded “general population”—as opposed to
“health condition”—unless additional sampling criteria were applied (e.g., obesity
among Mexican American families). Through an inductive process, 13 different pop-
ulation groups were identified. Figure 3.2 depicts the number of studies aimed at each
Number of studies 25
20
15
10
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nt
y
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ity
n
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on
s
l
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y
na
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ilit
ou
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ar
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is
or
lv
gi
iti
gi
io
ab
ilit
la
tr
ne
pa
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nd
in
re
re
at
w
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is
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lla
in
co
rn
ca
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ld
po
hi
in
c
ce
em
te
ni
ta
lth
ap
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us
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is
al
ie
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ea
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ud
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sy
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nc
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er
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ac
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ev
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Population
Figure 3.2 Focal population group for NIH‐funded parenting intervention studies. Graph
depicting focal population group for NIH‐funded parenting intervention studies in last 5 years
(n = 94 studies).
population group. The parenting intervention studies most commonly focused on the
general population (22%) followed by racial/ethnic minority populations (18%) and
low‐SES populations (16%). These categories were not mutually exclusive. In fact,
23% of the studies targeted families at the intersection of these different population
groups, with low SES + racial/ethnic minority as the most common intersectional
grouping (n = 4 studies).
Implications
Based on this systematic examination of recent NIH‐funded projects, conducting
parenting intervention research appears to offer an opportunity for scholars to
make a public health impact while competing for grant funding at the federal level.
The current generation of parenting intervention studies is methodologically
sophisticated and addresses multiple research questions. Competitive grant pro-
posals should expect to go beyond examining questions of efficacy or effectiveness
to include consideration of treatment mechanisms, tailored interventions and
adaptive intervention strategies, dissemination and implementation factors, and
other novel research questions. In addition, parenting interventions are now being
tested for a number of different treatment targets and a more diverse array of
populations. This presents avenues for expanding parenting intervention research
to target various health disparities and increase the evidence base for underserved
populations.
Commentary and Conclusions
Parenting interventions: Moving forward

The path ahead for parenting intervention scholarship is likely to be as exciting as the
strong foundation of research already established. In this section, we call attention to
some priority areas for moving forward that are of relevance to systemic family
therapists.
The need to apply interventions more systemically Parenting interventions have made
great strides in shifting emphasis from an individual‐focused paradigm toward greater
focus on interpersonal relationships and interaction patterns, yet there remains a need
to apply these interventions more systemically. In particular, further consideration
must be given to influences beyond the parent-child dyad. From a systemic perspec-
tive, the parent-child dyad is viewed as one subsystem within the overall family s ystem.
Often, a troublesome parent-child interaction may be at the crux of the problem, and
a parenting intervention may be necessary and sufficient for preventing negative
outcomes. At other times, an isolated change in the parent-child subsystem may only
serve to shift symptom presentation to another part of the family (e.g., sibling, couple
relationship). Assessment and treatment planning could be enhanced by considering
the role of every member of the family system (Minuchin & Fishman, 1981; Patterson,
Williams, Edwards, Chamow, & Grauf‐Grounds, 2018). Intervention efforts could
also be expanded to include additional family members using the empowerment
strategies and interventions (e.g., relational reframe; Moran, Diamond, & Diamond,
2005) consonant with both parenting intervention work and systemic family therapy.
The importance of widespread implementation To maximize public health benefit,

parenting interventions must be widely implemented among diverse populations.
Implementation refers to the process of integrating an evidence‐based practice into
a service setting (US Department of Health and Human Services, 2013). Family
therapy scholars have begun to articulate some of the challenges and opportunities
associated with implementation efforts in terms of research, training, and clinical
practice (e.g., Withers, Reynolds, Reed, & Holtrop, 2017; Wittenborn, Blow,
Holtrop, & Parra‐Cardona, 2018). In addition, a body of literature is now emerging
describing systematic efforts to implement parenting interventions into real‐world
settings, such as community mental health and child welfare systems (e.g., Forgatch
& Gewirtz, 2017; Sanders et al., 2016). International implementation efforts are
also critical. Accordingly, these interventions have been transported to numerous
countries around the world, although mostly to very highly developed nations
(Gardner, Montgomery, & Knerr, 2016; see also Knerr, Gardner, & Cluver, 2013;
Mejia, Calam, & Sanders, 2012). Despite this proliferation of implementation
efforts, empirical research on implementation processes lags behind. Strikingly, in a
review of the literature across four behavioral parent training programs, only 2 out
of 610 published reports (0.32%) met criteria to be considered a rigorous implemen-
tation study (Baumann et al., 2015).
The salience of cultural considerations A recent meta‐analysis of 18 parent training

programs delivered to ethnic minority families documented the effectiveness of parenting
intervention approaches in improving parenting behaviors among diverse cultural

groups (van Mourik, Crone, De Wolff, & Reis, 2017). Furthermore, programs
adapted to ensure cultural sensitivity were more effective at improving parenting
behaviors than programs that were not culturally sensitive (van Mourik et al., 2017).
Scholars have argued for the importance of cultural adaptation research to increase
intervention fit among diverse target populations and address mental health dispari-
ties (Baumann et al., 2015; Bernal, Jiménez‐Chafey, & Domenech Rodríguez, 2009;
Parra‐Cardona et al., 2014). At present, there are growing examples in the literature
describing the complexities of cultural adaptation research and reporting on cultural
and contextual adaptations to parenting interventions (e.g., Holtrop & Holcomb,
2018; Lau, 2006; Mejia, Leijten, Lachman, & Parra‐Cardona, 2017; Parra‐Cardona
et al., 2014). Despite such progress, cultural adaptation research still constitutes a
very small fraction of the published research on parenting interventions (Baumann
et al., 2015). There is an important opportunity for systemic family therapists to
advance parenting interventions by better integrating cultural considerations into
evidence‐based prevention efforts.
The value of improving theory–research–practice integration The body of work on

parenting interventions could also be improved by enhancing the correspondence
between parenting intervention theory, research, and practice. For example, a large
portion of evidence‐based parenting interventions for child externalizing problems
are rooted in behavioral theory (Dishion et al., 2016), but ecological systems the-
ory (Bronfenbrenner, 1979, 2000) and family systems theory (e.g., Bateson, 1972;
Minuchin & Fishman, 1981) remain underutilized in parenting intervention
approaches.
There may be particular opportunity to better integrate traditional family therapy
models into parenting intervention programs, as these models are valuable in identify-
ing key relationship processes in the broader systemic context. Consider the potential
contributions of structural family therapy (Minuchin, 1974) in outlining important
boundaries in the co‐parenting relationship, the contributions of structural (Minuchin,
1974) and strategic family therapy (Haley, 1976) models with regard to avoiding
cross‐generational coalitions, and the contribution of Bowen family systems theory
(Bowen, 1978) in attending to how a parent’s efforts to manage anxiety in their own
family of origin affects their ability to manage anxiety with their child. We suggest that
systemic family therapists in particular have a lot to contribute in this area and have
the opportunity to advance parenting intervention scholarship by forming multidisci-
plinary collaborations (see Wittenborn et al., 2018) with the goal of augmenting
existing parenting interventions with family therapy concepts and practices to enhance
effectiveness.
The opportunity for rigorous research Systemic family therapy scholars have the
opportunity to engage in rigorous programs of research to further enhance the sci-
ence and practice of parenting interventions. Our review of recently funded pro-
jects revealed the vast majority of federally funded parenting intervention studies
included an RCT in their design, underscoring the continued prominence of this
research method. It was also common for these studies to examine additional
research questions in addition to efficacy and/or effectiveness. We suggest that
salient, unresolved parenting intervention research questions include issues related
to implementation and cultural adaptation research with diverse populations

(Baumann et al., 2015), continued work investigating long‐term program o utcomes
and mechanisms of change (Sandler et al., 2011, 2015), and studies that empiri-
cally determine core intervention components (Blase & Fixsen, 2013). Additional
empirical work is also needed to develop and evaluate more systemic applications
of existing parenting interventions, to investigate outcomes among all family mem-
bers, and to explore family‐level and larger system‐level moderators of intervention
outcomes. Indeed, there is an apparent need to train a next generation of family
therapy scholars who can make such contributions to this important parenting
intervention research agenda.
Concluding comments
Parent-child relational problems can lead to detrimental impacts on the family as well
as a host of negative child outcomes. This chapter has focused on providing an intro-
duction to the prevention of parent-child relational problems by emphasizing the role
of parenting interventions. In line with calls for preventive efforts targeted at child
mental, emotional, and behavioral problems, describing this as “one of the soundest
investments a society could make” (NRC & IOM, 2009, p. 241), we contend that
parenting interventions are a critical tool for helping achieve this goal. The myriad
benefits to families and children evidenced by parenting interventions have been docu-
mented throughout this chapter for a number of different approaches and programs.
At the outset of this chapter, we introduced the Jones family in order to highlight
the real‐life application of these theories and parenting interventions. After being
exposed to a host of contextual stressors, parent-child interactions in the Jones family
started to suffer and individual functioning declined. Like many other families around
the world, this one was on the brink of breakdown. Fortunately, this family received
access to parenting intervention services, which helped to restore positive parenting
practices and mend strained attachment relationships. Sydni and her two children
became a success story. Our hope is that systemic family therapists will increasingly
engage in practice and research efforts focused on parenting interventions and sup-
port many more families in the successful prevention and amelioration of parent-child
relational problems.
Note
1 We have protected the confidentiality of those described in the vignette by changing iden-
tifying information, adding fictional details, and using composite case descriptions.
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4
Systemic Interventions for
Problems Emerging in Early
Childhood
Glade L. Topham, Carol Pfeiffer Messmore, and
Erin M. Sesemann
Long‐term effects of early adversity

Early adversity in infancy and early childhood (0–5), such as exposure to violence,
maltreatment, parent mental health issues, and parent substance abuse, in the absence
of the buffering effects of sensitive and responsive caregiving, is referred to as toxic
stress. Children affected by toxic stress often experience chronic anxiety and fear,
which results in elevated levels of stress hormones, altered brain chemistry, and nega-
tively altered brain architecture. Toxic stress during this sensitive period of brain
development (Center on the Developing Child, 2007) increases children’s suscepti-
bility to delayed development, poor emotional health (e.g., elevated anxiety and
depression), immune and endocrine system‐related disorders, cancer, heart disease,
externalizing disorders, and entry in the juvenile justice system (Johnson, Riley,
Granger, & Riis, 2013; Ruff, Aguilar, & Clausen, 2016; Shonkoff et al., 2012; Zeanah
& Zeanah, 2009).
The Adverse Childhood Experiences (ACES) Study, a landmark study from 1995,
highlighted the influence of toxic stressors on children (Murphy et al., 2016). In the
study, adult participants reported on adverse childhood experiences as well as current
physical and mental health symptoms. Results indicated that each adverse childhood
experience increased the risk of adult substance use and/or abuse, suicidality, and
depression (Murphy et al., 2016). Untreated early adverse experiences often increase
vulnerability to future adverse experiences. Therefore, intervening early to treat the
effects of early adversity and mitigate the likelihood of future additional adverse
experiences should be a priority for policy makers and providers.
Impact of early prevention and intervention

Although rapid brain development during the first few years of life leaves infants and
toddlers particularly vulnerable to adverse experiences, early brain plasticity also ena-
bles early interventions targeting the parent–child relationship to have a dramatic
88 Glade L. Topham et al.
positive effect on children. Solid research demonstrates that high‐quality, focused

early parent–child intervention enables infants and toddlers who have experienced
prolonged toxic stress to catch up in terms of physiological and behavioral regulation
and to move from disorganized to secure attachment relationships (see Dozier &
Bernard, 2017).
Despite evidence regarding the potential long‐term negative impacts of toxic stress
on young children and evidence indicating the potential for early parent–child inter-
vention to move at‐risk children to positive developmental trajectories and outcomes,
policy lags far behind research knowledge. Available trained providers, agency
resources and supports, and referral processes are inadequate to meet the needs that
exist. Graduate mental health training programs (i.e., couple/marriage and family
therapy, social work, counseling psychology, clinical psychology) rarely provide train-
ing relative to assessing and intervening in the early parent–child relationship, and
graduates commonly lack awareness of infant and early childhood problems and treat-
ment options. In this chapter, we make the case that systemic family therapists are
uniquely suited to help meet the provider demands for this work. We begin by provid-
ing background on the field of infant mental health, discuss how systemic family
therapy training provides a foundation for this work, describe common interventions
targeting children 0–5 and their parents, and offer some thoughts for future
directions.
Infant Mental Health
Broadly, infant and early childhood mental health is a holistic approach aimed at
fostering children’s healthy social and emotional development. An infant’s capabili-
ties to form close relationships, manage and express emotions, explore the environ-
ment, and learn is most effectively developed within a safe and secure caregiving
environment (i.e., family, community, society; Zero to Three, 2017a). The focus of
infant and early childhood mental health work is to strive to foster a safe, secure,
and attuned relationship between parents and infants or young children. The area
of infant and early childhood mental health is broad and encompasses professionals
in a variety of disciplines including childcare, education, medical care, speech and
language, and occupational and physical therapy focused on prevention and
intervention.
Sociocultural Context
What young children experience shapes how they see, understand, and respond to
their environment biologically. As a result, the biological developmental process is
intertwined with the external system or cultural community of the child. All children
pass through the same developmental milestone trajectory, yet the expectations of the
timeline for the milestones and meaning of the milestones (e.g., feeding, sleeping,
toileting, mobility) differ greatly across cultures (Small, 1999; Tronick, 2007). Ghosh
Ippen (2009) points out that we need to be attentive to who clients are (culture and
experience), current circumstances or context (e.g., economic, immigration, safety),
Interventions for Problems in Early Childhood 89
and parents’ goals for their families. Goals of interventions must be relevant to family
priorities and should take into consideration urgent and concrete needs.
The foundation of infant and early childhood mental health work is partnership and
dialogue. Clinician assumptions, if unchecked, can blind them to the realities of client
experience, values, context, and/or goals and can lead them to select interventions or
apply them in a way that may not fit for the family. It is the responsibility of clinicians
to create a safe and open environment where conversations around values and experi-
ence related to culture and diversity can take place (Ghosh Ippen, 2009). Clinicians
should strive to develop an attitude of receptiveness to different cultural values to
raising children (Lieberman & Van Horn, 2008). In order to do so, clinicians must
work to understand where they come from, how their prior experience shapes their
values and beliefs, and why they feel a certain way in response to the individuals
and families they work with. Supervision is used to help clinicians increase their self‐
awareness and openness to their clients’ experiences, practices, and desires and to
identify and reflect on blind spots.
Systemic Family Therapists Are Uniquely Suited for

Early Relationship Intervention
Systemic family therapists are systemic, relational mental health professionals who are
well suited to help address the significant lack of qualified professionals in infant and
early childhood mental health because their knowledge and training align well with
the core competencies for infant and early childhood mental health (see Weatherston,
Kaplan‐Estrin, & Goldberg, 2009; Zero to Three, 2017b). In order to highlight this
alignment, we will consider the needs that are apparent in a brief case example:
Eduardo is a 34‐month‐old male toddler. He was born full term without birth complications,
delivered by emergency C‐section as a result of his mother’s high blood pressure and history of
hypertension. The Rodriquez family has lived in the United States for four and a half years,
arriving when Isabel was pregnant with their older child, Maria, who is now 5 years old.
Both parents speak some English although the primary language in the home is Spanish.
Maria attends kindergarten and speaks Spanish and English, which she learned from watch-
ing television and from public school. Isabel is a stay‐at‐home mom, caring for the children.
Gustavo works full time in landscaping and has a second job at night at a restaurant. The
family lives in a mobile home community. Gustavo and Isabel do not have any extended fam-
ily in the United States but receive some support from other families in their neighborhood.
Gustavo and Isabel report a history of intense conflict that on several occasions, as recently
as 6 months ago, became physically violent in view of the children. Maria’s kindergarten
teacher reports that she is somewhat quiet and disengaged at school. Eduardo is not yet speak-
ing, but he babbles and uses gestures for communication. Neither parent is concerned about
his lack of language. However, they are quite concerned about Eduardo’s extreme emotions
and acting out, which they report has gotten worse during the past 6 months. Isabel and
Gustavo are at a loss as to how to handle Eduardo’s acting out and generally respond with
physical punishment; however, that has resulted in explosive tantrums. Isabel recently took
Eduardo to a pediatrician in hopes of getting some help. The pediatrician made referrals for
mental health and speech and language evaluations. The family has not followed through
with the speech and language referral but did accept the psychotherapy referral, due to their
serious concerns.1
This case example is illustrative of the complicated treatment needs of at‐risk fami-
lies who may seek early mental health treatment. A treating therapist would want to
attend to the couple relationship dynamics and risk for intimate partner violence,
likely trauma for Eduardo and possibly Maria and Isabel, the parent–child relationship
dynamics and anything negatively affecting the parents’ capacities to promote healthy
development of the children, and the significant economic, social (i.e., isolation), and
cultural stressors on the family.
Although, as is the case with other mental health disciplines, systemic family ther-
apy graduate programs typically provide only minimal training relative to intervention
with children 0–5, systemic family therapy training provides a strong foundation for
this work. These foundational elements typically include training in couple and family
dynamics and parent–child relationships, lifespan and family development, dyadic and
family conjoint treatment techniques and theories, trauma treatment, and sensitivity
to context and culture. Systemic family therapy training also provides a foundation for
attending to context and working with multiple levels of systems that is critical for this
work.
Systemic Family Therapists in Context of Other

Supportive Professionals
Because of the complicated treatment needs of many at‐risk families, the involvement
of multiple professionals is commonly needed to help families meet their goals.
Consider the various individuals who might be involved in providing support in the
case example of the Rodriquez family. The list may include a pediatrician, a speech
therapist, Maria’s kindergarten teacher, possibly a case manager, and likely an inter-
preter. Other professionals who may be commonly involved with families of young
children include specialized physicians (e.g., neurologists, psychiatrists), rehabilitative
therapists (e.g., physical therapists, occupational therapists), other behavioral health
clinicians (e.g., social workers, music therapists, art therapists), social service profes-
sionals (e.g., child welfare workers, shelter staff), educators (e.g., childcare staff,
teachers, special education teacher, school counselors), and religious or spiritual lead-
ers or teachers.
Each professional focuses on unique aspects of the child and/or the family. It is key
that various professionals effectively communicate about and coordinate services in
order to reduce likelihood of duplication of services or conflicting services and to limit
the burden on the family. Furthermore, effectiveness of services can be increased
when professionals are aware of the observations, perspectives, and efforts of other
providers and supports (Duckworth et al., 2001). Unfortunately, commonly there is
little communication among providers, and efforts can become territorial and con-
flictual. Furthermore, language and cultural differences between families and provid-
ers can contribute to the marginalization and disempowerment of families. Systemic
family therapists are positioned well to effectively facilitate communication and shared
understanding between and among providers and between family members and pro-
viders because their training prepares them to attend to context and to work with
diverse systems. In these efforts, parents are privileged as experts on their children
(Verdon, Wong, & McLeod, 2016).
Families with infants and young children often seek services as a result of challeng-
ing child behaviors, frequently at the encouragement of professionals such as pre-
school teachers, childcare workers, or pediatricians who recognize atypical child
behaviors and/or parent stresses and challenges. Child welfare referrals, in cases of
suspected child maltreatment, also make up a large percentage of referrals for children
in the 0–5 age range. Parents may be reluctant to seek services for their child due to
fears that providers will blame them or be critical of their parenting. Lack of time,
energy, transportation, and childcare are also often barriers. Child behavioral and
socioemotional problems, whether or not they stem from experience of trauma, are
often manifestations of biological and behavioral dysregulation. Because self‐regulation
is most effectively developed in the context of a safe and secure parent–child relation-
ship, treatment of behavioral problems in children 0–5 is most often done the context
of this relationship.
Child behavioral symptoms are often the outward manifestation of family relation-
ship strains and struggles. Higher rates of emotional reactivity and childhood problem
behaviors such as temper tantrums, defiance, and social inappropriateness are linked
to higher rates of marital discord and co‐parenting conflict (Murphy, Boyd‐Soisson,
Jacobvitz, & Hazen, 2017), which often negatively impact the parents’ ability to be
responsive to their child’s needs and provide a safe home environment. Very young
children of alcoholic parents often display aggressive behaviors and poor self‐regulation
due to the frequent lack of emotional availability of one or both parents and the lack
of safety in family relationships (Park & Schepp, 2015). Systemic family therapists are
uniquely qualified to attend to and treat families experiencing multiple forms of
individual and relationship struggle.
Theoretical Alignment
Theoretical influences in infant and early childhood mental health

The work of infant and early childhood mental health is heavily influenced by attach-
ment theory. John Bowlby (1988) referenced three attachment systems: children’s
instinct to seek closeness and receive parents’ comfort and protection (the care‐seek-
ing system), children’s instinct to explore and gain mastery over their environment
(the exploration system), and parents’ instinct to support child attachment and
exploratory needs through serving as a safe haven and secure base for their child (the
caregiving system; Ainsworth, Blehar, Water, & Wall, 1978). Secure attachment, and
the ability of children to autonomously transition back and forth between the attach-
ment and exploratory systems, is predicated on their confidence that their parent will
be a reliable secure base and safe haven (Feeney & Woodhouse, 2016).
When children lack confidence in their parent’s reliability in one or both of these
roles, attachment disruption and problems in child developmental processes are likely
to occur. Parents generally desire to meet their children’s needs and do the things that
will promote security and healthy development in their children. However, parents’
own attachment experiences, primarily in early relationships with their own parents,
can interfere with their ability to recognize and appropriately respond to particular
needs of their children. From early relationship experiences, we internalize implicit
rules for close relationships that are more likely felt than thought; rules that often
operate outside of awareness. For example, children whose parents were uncomfort-
able with their emotional needs might experience feelings of danger in response to the
emotional needs of their child (Lyons‐Ruth, 1998).
The ecosystem model (Bronfenbrenner, 1979), contributing attention to the influ-
ences of proximal and distal contexts, and the psychoanalytic theory, contributing an
understanding of the impact of parents’ own unresolved conflicts from their child-
hood on their interaction with their children (Fraiberg, Adelson, & Shapiro, 1975),
have also been influential in infant and early childhood mental health work. In addi-
tion, an understanding of the transactional processes among various risk and protec-
tive factors as they influence developmental outcomes is drawn from the area of
developmental psychology (Cicchetti & Sroufe, 2000).
Systemic family therapy theoretical models

Many systemic family therapy theoretical models are congruent with the theories that
are most influential in infant and early childhood mental health work. Examples of
foci of systemic family therapy models that complement the theoretical foundations of
infant and early childhood mental health are a focus on relationships, systems, and
context; the importance of early relationship experience; and having a map for inter-
vening within relationships in conjoint treatment. Here we highlight these comple-
mentary elements of several systemic family therapy models.
Bowen family systems theory As is the case with infant and early childhood mental
health work, Bowen family systems theory (Kerr & Bowen, 1988) emphasizes the
importance of the early parent–child relationships, but stresses the significance of
triadic relationships, typically involving two parents and the child. Differentiation of
self, a hallmark concept of Bowen family systems theory, is the ability to separate
thoughts from feelings and operate according to one’s thoughts rather than out of
emotional reactivity. It is the ability to maintain a sense of individuality and auton-
omy while remaining emotionally connected to others (Kerr & Bowen, 1988).
Parents with low levels of differentiation have trouble managing their anxieties in the
couple relationship and may look to the parent–child relationship to reduce that
anxiety. These parents may need their children to behave in a certain way for the
parents to manage their own anxiety. This emotional reactivity interferes with par-
ents’ ability to fully attend to and sensitively respond to their child’s needs. As a
consequence, the child may develop a low level of differentiation and move into
adulthood with a tenuous sense of self, often passing emotional reactivity and low
levels of differentiation to the next generation.
Efforts of the Bowen family systems theory therapist to help parents become aware
of their own thoughts and feelings, to act according to their values and principles, and
to learn to meet their own needs without demanding it from others in relationships
parallel efforts of the infant and early childhood mental health therapist to help par-
ents increase their reflective functioning in order to become intentional about their
interaction with their children and not driven by emotional needs stemming from
prior relationships experience.
Structural family therapy Structural family therapy indicates that balanced hierarchy,
clear boundaries between family members and between the family and outside sys-
tems, and flexible role assignment are key to healthy family relationships (Minuchin,
1974). These concepts provide a useful framework for assessing and conceptualizing
work with families with young children. Furthermore, family subsystems (i.e., co‐par-
enting, couple, sibling), boundaries around subsystems, and the effects of coalitions
provide a framework for making sense of various family relationships—relationships
that are often neglected in infant and early childhood mental health work, which is
primarily focused on the parent–child dyad.
In addition, structural family therapy offers a number of helpful strategies and
interventions that can be used to change structure and relationship dynamics within
relationship processes. When family reorganization is the goal of structural family
therapy, rebalancing subsystems and clarifying family roles help the family to facilitate
family member growth as a supportive system. Examples include use of enactments,
making verbal observations relative to process and family member experience, refram-
ing the meaning of behaviors, and actively shaping how and when family members
interact (Minuchin, 1974).
Experiential family therapy: The Satir growth model Satir (1972) proposed that
healthy individuals appreciate and value self and are able to take risks and adapt as
needed. Clear and open family communication, warmth and empathy, and acceptance
for different needs, feelings, and experiences of family members provide a context
supportive of healthy growth. The experiential therapist models these attitudes and
behaviors as she/he works to provide a safe and caring environment for families
through authenticity, warmth, acceptance, and encouragement. This is consistent
with the approach of infant and early childhood mental health that emphasizes that a
parallel process should exist in the supervisors–therapist, therapists–parent, and par-
ent–child relationships in which the focus is on “holding” the therapist, parent, and
child, or providing a safe and accepting relational context where positive change and
development can occur.
Emotionally focused therapy Emotionally focused therapy (Johnson, 2007) is heavily

influenced by attachment theory, which suggests that we have an innate need to know
that significant others will be available and responsive to us (Ainsworth et al., 1978).
Adult romantic relationships and partners’ emotional needs and relationship strategies
are shaped by the prior relationship experiences, particularly their relationship with
their own parents in childhood. Because emotionally focused therapy for couples
shares a theoretical foundation with early parent–child relationship work, there are a
number of similarities in treatment goals and strategies. A primary difference between
the two is that early parent–child treatment focuses on the parent being responsive
and available to the child, whereas emotionally focused therapy focuses on partners
being responsive and emotionally available to each other.
Children who have experienced early relationship adversity commonly mask
emotional needs or miscue parents regarding needs. Similarly, partners in couple rela-
tionships who experienced pain and hurt in prior relationships tend to employ rela-
tionship strategies that block their abilities to give and receive care. Strategies and
techniques of emotionally focused therapists that are similar to early parent–child
intervention include direct coaching of interaction, processing with partners their
attachment‐related needs and fears particularly as they block partners from being
emotionally available and responsive, use of warmth and empathy to create safety,
iving voice to partners’ unspoken needs and fears to help them develop awareness
g
and the capacity to express those needs, and challenging negative meaning partners
make regarding the other’s intentions and behaviors.
Key Relationship Targets of Early Intervention Programs
Early parent–child therapeutic interventions tend to be guided by overlapping t heories

and, as such, tend to focus on similar parent competencies and relationship processes.
Five parent competencies that are commonly targeted by interventions are parent
awareness of infant and toddler developmental processes and needs, nurturing and
comforting, synchrony, delight, and parent reflective functioning.
Developmental understanding
Infant and early childhood mental health interventions universally attend to fostering
parent knowledge of child developmental needs and capabilities and how to sensi-
tively respond to those needs. While some programs focus exclusively on children’s
developmental needs relative to attachment, others may attend to a broad range of
developmental topics (i.e., eating, sleeping, toileting, etc.).
Nurturing
Nurturing primarily refers to parent sensitivity to child distress cues. When children
are hurt or not feeling physically well, when they are emotionally distressed (i.e., sad,
scared, or angry), and when they experience a sense of doubt about the availability
of the parent (physical or emotional), they need parents to provide verbal and/or
physical reassurance, comfort, soothing, and/or calming. These responses help chil-
dren manage difficult feelings in the moment and help them develop increased
capacity to manage difficult emotions in the future. In addition, when children
experience consistently responsive nurturing, they learn they can trust and rely on
their parent.
Synchrony
Synchrony and following the lead (Dozier & Bernard, 2017), contingent responsive-
ness (Blehar, Lieberman, & Ainsworth, 1977), serve and return (Shonkoff & Bales,
2011), and empathic listening (VanFleet, 2014) refer to a similar process in which the
parent responds to the child in a way that follows the child’s lead, or the child’s per-
spective and goals. The parent follows in action through playing in similar ways to the
child according to the child’s wishes and with infants and toddlers through mirroring
child actions (e.g., child shakes rattle, parent shakes rattle). The parent follows ver-
bally through reciprocal communication (e.g., Child: “Look at my tower”; Parent:
“Wow you made it tall”); through commenting on child behaviors, feelings, and
desires; and through repeating infant or toddler verbalizations. Parent synchrony fos-
ters the development of child behavioral and physiological regulation (see Bernard,
Meade, and Dozier (2013) for a review).
Delight
Several interventions emphasize parent delight. Parent delight is shown verbally
through comments or enthusiastic tone and visually through the parent’s facial expres-
sions (e.g., a warm smile). Parent delight is particularly impactful when it communi-
cates joy in the child for who the child is and not for something the child has done
(Powell, Cooper, Hoffman, & Marvin, 2014). Parent delight helps children learn
they are important to their parent.
Reflective functioning
Reflective functioning refers to parents’ capacity to hold in mind an awareness of their
own and their child’s internal experiences (i.e., thoughts, feelings, and needs) and the
links between this experience and their own and their child’s behaviors in interaction
(Fonagy, Steele, Steele, Higgit, & Target, 1994). Put more simplistically, it is parents’
ability to accurately observe and interpret their own and their child’s experience and
actions. Quality of caregiving is strongly influenced by parents’ reflective functioning
(see Feeney and Woodhouse, 2016, for a review). Reflective functioning is predictive
of parents’ ability to promote the attachment security of their children despite experi-
encing their own negative attachment histories (Fonagy et al., 1994).
Key Intervention Components of Relational Treatment Programs
A wide range of strategies, techniques, and tools are employed across intervention
programs. We provide some examples of more commonly used interventions below as
distinct interventions, although they are commonly overlapping.
Instruction or developmental guidance

Many interventions provide instruction relative to children’s age‐appropriate behav-
iors, feelings, and needs paired with instruction on parenting practices that are devel-
opmentally responsive. Frequently, positive and/or negative video examples, case
scenarios, and modeling are used to reinforce ideas. Although some interventions
provide this information in a structured sequence according to session topic, others
utilize a reflective developmental guidance approach providing this information as
child needs become apparent during sessions. Therapists utilizing reflective develop-
mental guidance are more focused on facilitating reflection than on providing instruc-
tion. They may make observations about and invite parents to reflect on the meaning
of child feelings, needs, and behaviors and co‐wonder with parents about how the
parent might address the need (Lieberman, Ghosh Ippen, & Van Horn, 2015).
Coaching interaction
Therapists seek to shape parent–child interaction by coaching parent behavior during
interactions. Coaching is primarily positive, identifying moments when parent
responses are appropriate or approximate target responses. This takes on a variety of
forms across interventions but tends to include therapist observations of child behav-
ior, experience, and/or needs paired with observations of parent response. Suggestions
for improvement are gently offered as needed and are followed by immediate positive
therapist observations as the parent appropriately responds to the child.
Video playback
Therapists video record parent–child interaction either at assessment phase or
throughout treatment and select and share clips that showcase positive parent response
and highlight positive impact on the child. In addition, typically later in treatment,
clips are shown highlighting parent struggle. Therapists may invite parents to reflect
on the child’s needs in the moment, their experience of those needs, and feelings or
beliefs that might have blocked the parent from meeting the need. The emotional
distance provided by video review allows parents to see and reflect on their own and
their child’s experience of the interaction in new and more meaningful ways.
Reflective dialogue
Intervention models use a variety of different labels to refer to the influence of par-
ents’ past relationships in shaping how they experience and respond to their child in
the present. Examples include “voices from the past” (Dozier & Bernard, 2017),
“shark music” (Powell et al., 2014), and “ghosts in the nursery” (Fraiberg, Adelson,
& Shapiro, 2003). Entry points used by therapists to invite parents to reflect on the
influence of these relationship experiences include inviting parents to consider how
their parents experienced and responded to their different feelings and needs when
they were young, inviting parents to reflect on when they are most uncomfortable in
interaction with their child and identifying what thoughts and feelings accompany
these moments, watching videos providing instruction on the impact of past relational
experience paired with group discussion, and watching video clips of their own inter-
action in which something (presumably influences from the past) blocked them from
meeting their child’s needs.
Speaking for child and parent

The therapist speaks for child and for parent to help both members of the dyad under-
stand their own and the other’s subjective experience, with the goal of building and
strengthening the relationship. With infants this is one‐directional with the messages
being targeted to the parent. The therapist “speaks for the baby” (Carter, Osofsky, &
Hann, 1991) and can also speak to the baby offering a benevolent interpretation of
the parent’s subjective experience and intentions and desires. For example, in the case
where a parent is getting agitated and angry with her infant because of a lack of calm-
ing in response to her efforts, the therapist may speak the following to the baby: “Your
mom loves you and knows you are not feeling well right now and is frustrated because
she wants so much to help you feel better, but sometimes it is just not clear what will
help.” The therapist may then speak for the baby: “Mom, sometimes there is not a
clear answer for how to help me to stop crying. Even though sometimes it takes me a
while for me to settle, having you gently rock me and nurture me in this way is what
is most important to me because it lets me know you will be there for me and will
eventually help me be able to calm down more quickly.” As the child’s receptive
vocabulary begins to develop, the therapist speaking for parent and child can also be
targeted to the child in a way that will help the child understand self and parent and
to view both more positively (Lieberman & Van Horn, 2008).
Application of treatment techniques to Rodriquez family

During the course of treatment, a therapist working with the Rodriquez family might
target Isabel and Gustavo’s understanding of the children’s developmental needs and
capabilities by discussing the limited regulation capacities of Eduardo as a 3‐year‐old,
the relation between his acting out and his limited regulation capacities, the impact of
Eduardo’s experience of emotional distress and fear in response to stressors (in par-
ticular observing marital violence), and the likely impact of Eduardo’s language delays
on his acting out. Similarly, developmental processes/needs could be discussed rela-
tive to Maria with reference to how her struggles and needs may manifest differently.
When and how directly these and other developmental topics are discussed would
depend on the safety in the treatment and family relationships and the readiness of
Isabel and Gustavo to engage in these discussions.
During family sessions, the therapist would be attuned to signs of distress or need
for connection from the children and may coach Isabel and Gustavo in providing
needed nurturance and may also coach them in engaging in synchronous interaction
with the children. Video playback could be used to help increase parent awareness of
child signals and needs, their response to those needs, and their feelings and beliefs
that might get in the way of them responding appropriately to meet the needs.
Speaking for the child could be used to draw parent attention to child needs. For
example, in one session, Eduardo pinched his finger between two blocks and slowly
walked toward Gustavo while fussing and holding out his hand. In response Gustavo
responded, “keep building your tower” with a gesture back to the middle of the
room. The therapist speaking for Eduardo inserted, “Dad, what I most need right
now is for you to help me to feel better and then I will be ready to go back to work
on my tower … maybe just a hug or a gentle pat on my back.”
Early Assessment Tools
The systemic and relationally focused work of infant and early childhood mental
health does not fit well into the current US health‐care diagnosing systems that are
based on individualized adult health assessment and diagnosis—the Diagnostic and
Statistical Manual of Mental Disorders (DSM‐5; American Psychiatric Association,
2013) and the International Classification of Diseases (ICD‐10). Rather, the Diagnostic
Classification of Mental Health and Developmental Disorders of Infancy and Early
Childhood (DC: 0–5) identifies developmentally appropriate diagnoses for very young
children (Zeanah & Lieberman, 2016), but unfortunately is rarely recognized by
third‐party payers. Therefore, “crosswalks” were developed to connect DC: 0–5
codes with the more widely accepted codes in the DSM‐5 (American Psychiatric
Association, 2013) or ICD‐10. Using crosswalks improves practitioners’ abilities to
diagnose, recognize behavioral and developmental difficulties, and acknowledge the

influence of environmental and relational factors (Zero to Three, 2017c).
Infant and early childhood mental health assessment can be challenging since very
young children have limited verbal and metacognitive capacities to report their symp-
toms and situations. A variety of sound assessment tools have been developed that are
appropriate for young children and their parents. We briefly highlight examples of
parent interview, parent–child interaction observation, and parent report of child
behavior.
Parent interview
Several interview protocols have been developed to assess parents’ internal representa-
tions of their child and their relationship with their child. These interviews are rooted
in attachment theory (Ainsworth & Bowlby, 1991) and adapted from the Adult
Attachment Interview (George, Kaplan, & Main, 1984; Hesse, 2016). An example of
these interviews is the Working Model of the Child Interview (Zeanah, Benoit,
Hirshberg, Barton, & Regan, 1994), an hour‐long structured interview designed to
classify parents’ internal representations of each of their children or their perceptions
of their child and their experience and relationship with their child. Parents are asked
to describe their child’s development, thoughts about his/her personality, their rela-
tionship with the child using specific examples, what pleases and does not please them
about the relationship, how they experience their child when she/he is upset, and
how they expect the child and their relationships to change across time (Larrieu,
Stevens, & Zeanah, 2014). Other similar interviews include the Parent Attachment
Interview (Bretherton & Ridgeway, 1986) and the Parent Development Interview
(Aber, Slade, Berger, Bresgi, & Kaplan, 1985).
Observation of parent–child interaction

The Crowell (Crowell & Feldman, 1988, 1989) observational procedure is a popular
clinical observational measure of parent–child interaction for young children
(12–60 months). The procedure takes 30–45 min and includes six different tasks.
Parents are asked (a) to play together as you usually would at home (10 min), (b) to
have the child clean up and to help if needed, (c) play with the bubbles (3 min), (d)
to engage in two to four teaching tasks (progressively more difficult) with the child
(3–8 min depending on child age), (e) to leave the room with the child remaining in
the room (separation; 3 min), and (f) to return to the room (reunion). Although for-
mal coding systems are available, the Crowell can be used in clinical settings without
use of formal research coding. Observational conclusions are focused on parent–child
problem solving, mutual enjoyment, and parent–child attachment. The procedure is
fairly straightforward to administer and is popular in infant and early childhood m
ental
health work. Free play toys, bubble bottles, toys for teaching tasks, and video record-
ing equipment for later viewing are needed.
The Strange Situation Procedure (Ainsworth et al., 1978) is considered the gold
standard for measuring parent–child attachment. However, because the training and
scoring is fairly involved, the Strange Situation Procedure is used primarily in research
settings. The Strange Situation Procedure (Ainsworth et al., 1978) involves evoking
a series of progressively stressful situations (i.e., exploration, use of parent as secure

base, child’s reaction to parental separation, strangers, and reunion with parent) that
tend to evoke attachment behaviors in infants in order to measure/code for proximity
and contact seeking, avoidance, resistance, search behavior, and distance in interac-
tion. For a review of other observational measures for parents and children 0–5, see
Miron, Lewis, and Zeanah (2009).
Parent report of child functioning

Brief screening and comprehensive checklists can be used to screen for child soci-
oemotional problems. Popular brief screening tools include the Brief Infant‐Toddler
Social and Emotional Assessment (Briggs‐Gowan & Carter, 2006) and the Ages and
Stages Questionnaires: Social‐Emotional (Squires, Bricker, & Twombly, 2002). These
parent‐report tools are designed to identify problems, behaviors, and delays in
socioemotional competence. The Infant‐Toddler Social and Emotional Assessment
(Briggs‐Gowan & Carter, 2007) and the Child Behavior Checklist 1½–5 (Achenbach
& Rescorla, 2000) offer more comprehensive assessments. See Webb, Ayers, and
Rosan (2018) for a review of other similar measures.
Application of assessment measures to Rodriquez family

When considering the Rodriquez family, it would be useful for clinicians to utilize a
variety of early assessment tools. For example, screeners and comprehensive checklists
completed by parents, and possibly Maria’s teacher, could be used to assess Eduardo
and Maria’s socioemotional behaviors and screen for development delays. The Crowell
observational procedure could be used to observe Isabel and Gustavo’s interaction
with Edwardo in separate dyadic interactions in order to gain a sense of each of their
effectiveness in supporting and influencing Eduardo during challenging problem
solving and cleanup tasks and their mutual enjoyment with Eduardo in the bubble
tasks. In addition, observation of the separation and reunion episode could provide
clues as to the nature of the parent–child attachment relationship and the strategies
Eduardo uses to try to get his attachment needs met. The therapist could conduct the
working model interview with each parent in separate sessions to assess their views of
each child and their relationship to each child.
Sample of Systemic Approaches to Prevention and Intervention

0–5
Attachment and Biobehavioral Catch‐up

Program characteristics Attachment and Biobehavioral Catch‐up (ABC) (Dozier &
Bernard, 2017) is designed to help children 6–24 months (Attachment and
Biobehavioral Catch‐up Infant [ABC‐I]) and 24–48 months (Attachment and
Biobehavioral Catch‐up Toddler [ABC‐T]) who have experienced early adversity to
catch up developmentally. ABC coaches deliver the intervention in families’ homes
with all members of the family who are able and willing to participate. Both ABC
interventions include 10 weekly hour‐long sessions. The ABC‐I intervention focuses

on three targets: nurturing c hildren when they are distressed or when they seek con-
tact, following their lead (synchronous responses) with delight when they are not
distressed, and avoiding frightening and intrusive behaviors. The ABC‐T intervention
adds an additional target: calming. When infants or toddlers are hurt, sad, sick, or
scared, nurturing is the appropriate response; when toddlers are angry, frustrated, or
out of control, the appropriate response is calming. When their toddler is dysregu-
lated, parents are taught to stay calm, to avoid power struggles, and to help the child
calm down through soothing physical touch and commenting (Bick & Dozier, 2013).
Sessions are video recorded and video clips are chosen each week to help parents
recognize their strengths and the positive impacts they are having on their children
relative to the ABC targets. In addition, during sessions 7 and 8, parent coaches help
parents identify and learn to override “voices from the past” (feelings or thoughts
from early relationship experiences) that block them from nurturing, following the
lead with delight, or that lead them to engage in frightening or intrusive behaviors.
Parent coaches show a video clip of parents missing the identified target in interac-
tion with their child followed by a discussion of what might be getting in the way.
Sessions 9 and 10 are focused on consolidating and celebrating gains (Dozier &
Bernard, 2017).
The primary mechanism of change is believed to be the in‐the‐moment comment-
ing of the parent coach. In‐the‐moment commenting may include the child’s behav-
ior and parent response (e.g., “he stacked a block and you stacked a block”), labeling
the intervention target (e.g., “that is an example of following”), and/or the positive
benefit to the child (e.g., “this helps him to learn self‐regulation”). Other elements of
the intervention include brief instruction on the targets with positive and negative
video examples, structured activities (e.g., making pudding), and homework.
Research support Randomized controlled trials (RCTs) have been conducted exam-
ining the efficacy of ABC‐I with foster families (Bick & Dozier, 2013), birth parents
referred by Child Protective Services to prevent children going into foster care
(Bernard et al., 2012), a community‐based sample (Sprang, 2009), and mothers in a
residential substance abuse treatment program (Berlin, Shanahan, & Carmody,
2014). Parents in the ABC‐I intervention showed larger gains in parent sensitivity
than control intervention parents (in‐home parent education; Bick & Dozier, 2013).
Children in the ABC‐I intervention showed stronger executive functioning and the-
ory of mind skills (Lewis‐Morrarty, Dozier, Bernard, Terracciano, & Moore, 2012)
and a more normative diurnal pattern of cortisol production (Bernard, Dozier, Bick,
& Gordon, 2015; Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008). Cortisol
and executive control findings were maintained 3 years after intervention (Bernard,
Hostinar, & Dozier, 2015). In addition, children in ABC‐I intervention were more
likely to be classified as having secure and less likely to be classified as having disor-
ganized attachment than control intervention children (Bernard et al., 2012) and
showed fewer externalizing and internalizing behaviors than waitlist control children
(Sprang, 2009).
Strengths and limitations ABC is a short‐term intervention with strong research

support. Both the infant and toddler interventions are manualized with a highly
structured training process. Scalability, or the ability to implement the intervention

on a large scale, is facilitated by the fact that clinical training is not required for ABC
coaches. Another strength of ABC is the research‐based screening process that allows
program administrators to identify potential coaches that are likely to be successful
in learning to effectively implement ABC. Use of in‐the‐moment commenting, video
feedback, and video examples of intervention concepts provide an intensity of focus
that is effective in facilitating rapid progress for parents. Fidelity is supported through
coaches coding parts of their sessions and comparing and discussing their coding and
coaching behaviors with a supervisor each week during the first year of training.
While a strength of ABC is the intensity of focus, this can also be thought of as a limi-
tation in that the narrow focus allows for little attention to other non‐ABC target
caregiving issues.
Child–Parent Psychotherapy
Program characteristics Child–Parent Psychotherapy (CPP) (Lieberman et al.,
2015) is a relationship‐based treatment for children ages birth to five who have expe-
rienced a significant stressor such as adverse life circumstances, trauma, parent men-
tal illness, and maladaptive parenting practices. The goal of CPP is to promote
healthy child development through supporting nurturing, protection, and develop-
mentally and culturally appropriate socialization from parents (Lieberman & Van
Horn, 2008). Sessions are typically dyadic with one child and one parent and can be
held either in home or in an office setting. Collateral sessions with just the parent can
be scheduled as needed. Treatment length varies but is typically long term, often
requiring as many as 50 sessions. Play is used as a primary vehicle for communica-
tion, understanding, and jointly addressing issues affecting the parent–child dyad
(Lieberman et al., 2015).
During sessions, the CPP therapist attends simultaneously to the child and parent’s
experiences and the relationship dynamics between the two. The therapist functions
as a translator vocalizing the thoughts and feelings of both parent and child in order
to address misunderstandings, misperceptions, and misattributions and to increase
parent empathic awareness of child needs. Therapists identify and address “ghosts in
the nursery” (Fraiberg et al., 2003) or parents’ reenactment of unresolved conflicts
from their own early relationships. In addition, they help parents identify and access
strength from “angels in the nursery” (Lieberman, Padron, Van Horn, & Harris,
2005) or benevolent and supportive memories from the past. Therapists look for
“ports of entry” or areas of potential intervention and use a wide range of interven-
tions strategies to gently guide and support the dyad.
Research support RCTs have been conducted with toddlers of depressed mothers
(Cicchetti, Rogosch, & Toth, 2000), maltreated children in the child protective sys-
tem (Toth, Maughan, Manly, Spagnola, & Cichetti, 2002), children exposed to
domestic violence (Lieberman, Van Horn, & Ghosh Ippen, 2005), and anxiously
attached toddlers of Latina mothers exposed to trauma (Lieberman, Weston, & Pawl,
1991). CPP has been shown to increase child attachment security; improve child
attributions of self, parent, and the relationship; and reduce child and maternal symp-
toms (Lieberman & Van Horn, 2009).
Strengths and limitations A strength of CPP is the comprehensiveness of the interven-

tion and its flexibility in addressing a range of obstacles to healthy child development and
positive parent support for healthy child development. A manual (Lieberman et al., 2015)
provides clear guidance to the process of CPP while allowing for a great deal of flexibility
depending on needs of parents and children. Fidelity is supported through checklists
completed by therapists after each session. The scalability of the intervention is somewhat
limited given the training requirements, and the long‐term nature of intervention can also
be a limitation.
Theraplay
Program characteristics Unlike other infant and early childhood mental health inter-
ventions, therapists take the lead in theraplay (Booth & Jernberg, 2009) and encour-
age relationship building (i.e., secure attachment) through directive play interactions
that are guided by its four core dimensions: structure, engagement, nurture, and
challenge (Theraplay Institute, 2017). The therapist offers a brief consultation of five
sessions, although typical theraplay may continue to between 19 and 32 sessions.
Theraplay treatment begins with an introductory session between the therapist and
parents and then transitions to assessment using the Marschak Interaction Method
(MIM) assessment in order to assess parent–child attachment, purposive behaviors,
alertness to environment, and ability to cope with stress. Therapists provide feedback
on the video recorded MIM interactions and then continue with treatment through
conjoint directive play sessions that are designed to model interactions typically seen
within healthy, secure parent–infant or parent–child interactions (e.g., feeding and
holding, high level of eye contact, exalting of the infant or child, roughhousing;
Jernberg, 1989) and meet the needs of the child. As a result, treatment directives
reflect what is most relevant to the child’s progress (i.e., nurturing or challenging).
Additionally, therapists have one‐on‐one sessions with parents to discuss progress,
goals, and at‐home applications.
Research evidence One RCT has been conducted examining the effects of theraplay
with families. Siu (2009) examined the effectiveness of an 8‐week therapy intervention
with Chinese children between grades two and four and their parents. Participating
children met criteria for internalizing symptoms at pretest. Children from the theraplay
condition had a significantly greater reduction in internalizing symptoms than children
in the waitlist group. Another study by Wettig and colleagues (Wettig, Coleman, &
Geider, 2011) examined the effectiveness of theraplay with children with social anxiety
and language disorders and found that children’s social anxiety and language disorder
symptoms decreased after an average of 18 sessions and that children’s posttreatment
behaviors (i.e., shyness/timidity, attention deficit, poor cooperation, overconformity,
and mistrust/suspicion) were comparable to those of the 30 children in a comparison
group. However, their symptoms of social withdrawal, lack of self‐confidence, and
expressive and receptive language skills did not significantly differ from the comparison
group.
Strengths and limitations A textbook written by Booth and Jernberg (2009) pro-
vides a manual for the intervention. Providers must have a clinical master’s degree and
receive supervision from theraplay supervisors to become certified. A strength of the
approach is that it has been adapted to work with various treatment configurations
including adoptive families (Weir et al., 2013) and groups of children in classroom
settings (Tucker, Schieffer, Wills, Hull, & Murphy, 2017). Additionally, the Theraplay
Institute offers recommendations through its newsletter on using theraplay with spe-
cial populations (e.g., military families, aftermath of family violence, children with
Down syndrome, Navajo culture, Aboriginal people in Australia; Theraplay Institute,
2017). However, a limitation is the lack of evidence of effectiveness or efficacy with
many of these populations.
Circle of Security
Program characteristics The Circle of Security program (Powell et al., 2014) is an
intervention designed to promote secure attachment between parents and children
primarily through targeting the lens through which parents perceive and experience
close relationships. The program is focused on helping parents increase sensitivity and
responsiveness to their children through helping parents understand children’s basic
attachment needs, learn to observe and accurately interpret their child’s attachment
needs and cues, and identify and override their feelings and thoughts from their own
early attachment relationships that prevent them from responding appropriately to
their children’s needs (Powell et al., 2014).
The Circle of Security graphic makes the concepts of attachment theory simple to
understand and difficult to forget (Topham, 2018). The Circle of Security graphic
illustrates children’s needs to “go out” on the Circle, or to explore their environ-
ments, and to “come in” on the Circle, or to receive nurturing and connection.
Parents are taught to support “going out” and to act as a secure base through watch-
ing over, delighting in, helping, and enjoying with their child and are taught to sup-
port “coming in” and act as a safe haven through protecting, comforting, and
delighting in their child and helping her/him organize feelings. The concept of “shark
music” is used to help parents identify feelings from their own relationship histories
that signal danger around particular attachment needs of their child. As parents learn
to identify these feelings, recognize the source of the feelings, and come to under-
stand that the feelings do not signal any real danger, they are able to override the
feelings and respond appropriately to their child’s needs (Powell et al., 2014).
There are three different Circle of Security formats, varying in intensity and requir-
ing different levels of educational background and training. The original 20‐week
Circle of Security intensive is a psychoeducational/therapeutic group that was devel-
oped for parents and at‐risk children ages 12 months to 5 years. Groups of five to six
parents meet weekly with a clinically trained facilitator without the children present.
A primary mechanism of change in the Circle of Security intensive groups is video
review during which parents take turns with the facilitator reviewing clips from their
own parent–child interaction during the assessment phase (Strange Situation Protocol;
Ainsworth et al., 1978; Cassidy and Marvin, 1992). Reflective discussions are designed
to help parents improve their abilities to observe their own and their child’s behavior,
identify where the child is on the Circle and what the child needs are, and reflect on
how their emotional experience influences their response.
The Circle of Security Home Visiting‐4 program (Cooper, Hoffman, & Powell,
2000) is delivered with economically stressed parents and their children ages birth to
five. Intervention delivery includes a 3‐hr assessment session in an office‐based setting

followed by 4‐hr‐long sessions delivered in home. Children are included in sessions
and program concepts are applied in parent–child interaction during sessions. In addi-
tion, parent–child interaction is recorded in each session and used in the next session
to guide reflective discussion.
The Circle of Security Parenting DVD Program (Cooper, Hoffman, & Powell,
2009) is delivered in a group format with 8–12 parents of children ages birth to 5.
Children do not attend the group sessions. Eight video modules around 15 min each
are the springboard for group discussions. The number of sessions is flexible but typi-
cally ranges eight to twelve 1.5–2‐hr sessions. In contrast to the other Circle of
Security formats, in the Circle of Security Parenting DVD Program, videos are used
to introduce Circle of Security concepts and are not recordings of participants inter-
acting with their children.
Research evidence The 20‐week Circle of Security intensive group intervention has
been studied with head start and early head start families (Hoffman, Marvin, Powell,
& Cooper, 2006), women in a jail diversion program (Cassidy et al., 2010), and
families referred to treatment for child behavioral and emotional problems (Huber,
McMahon, & Sweller, 2015). Changes from pre‐ to posttreatment include signifi-
cant reductions in insecure and disorganized attachment ratings (Cassidy et al.,
2010; Hoffman et al., 2006), parent stress and parent symptomology, and child
behavioral problems (Huber, McMahon, & Sweller, 2016). However, control
groups were not utilized in any of the three studies. The efficacy of the Circle of
Security Home Visiting‐4 intervention has been evaluated with one RCT. Cassidy
and colleagues (Cassidy, Woodhouse, Sherman, Stupica, & Lejuez, 2011) found
that highly irritable infants who participated were significantly more likely to be
rated as secure than highly irritable infants in the control condition. The Circle of
Security Parenting DVD Program has also been examined with one RCT. Cassidy
and colleagues (Cassidy et al., 2017) found that mothers who participated reported
fewer unsupportive responses to child distress and their children demonstrated
greater inhibitory control than those in the waitlist condition at posttreatment.
Strengths and limitations All three Circle of Security formats include detailed facili-
tator manuals. Having three different formats to choose from allows for flexibility
based on intensity of intervention needed and training and background of facilitator,
with the Circle of Security Intensive Psychotherapeutic Group being most intense and
most demanding and the Circle of Security Parenting DVD Program requiring least
of facilitators in training and time to implement. Facilitating the Circle of Security
Parenting DVD Program does not require clinical training, and the format is highly
scalable with over 15,000 facilitators having been trained worldwide (circleofsecurity.
net/history). A limitation of the Circle of Security Intensive Psychotherapeutic Group
format is the extensive training requirements (2 weeks of initial training followed by a
year of supervision) and time requirements to implement with an extensive assessment
process and targeted video clips each week. With lack of an RCT for the Circle of
Security Intensive Psychotherapeutic Group format and only one RCT for each of the
other formats, more research is needed to understand the efficacy of the protocols. A
comparison of the efficacy of the three formats for particular treatment populations
could be particularly helpful.
Filial Family Therapy (FFT) and Child–Parent

Relationship Therapy (CPRT)
Program characteristics Filial Family Therapy (FFT) VanFleet, 2014) and Child–
Parent Relationship Therapy (CPRT) (Bratton, Landreth, Kellam, & Blackard, 2006)
aim to increase parents’ empathic attunement to children’s emotions and develop-
mental stages and needs while increasing their capacity to set limits and build confi-
dence in their children (VanFleet, 2014). The individual family FFT treatment model
(VanFleet, 2014) and the 10‐session group model of CPRT were adapted from the
original 20‐session group FFT model developed by Louise and Bernard Guerney
(1987) and, as such, share a treatment focus.
In FFT therapists meet initially with both parents to describe and teach the filial
skills: structuring, empathic listening, child‐centered imaginary play, and limit setting
(VanFleet, 2014). The following two sessions are spent with the parents practicing the
skills in role‐play with the therapist acting as child. Then, during the next phase of
treatment, parents bring their children in for the filial play sessions, with one parent
and one child playing together at one time. Therapists observe play sessions from an
unobtrusive location and provide feedback to parents after play sessions to help them
improve their skills, to increase their awareness of and attunement to their children,
and to help parents develop increased awareness of themselves in interaction with their
child and resolve feelings or beliefs that block their appropriate responses (VanFleet &
Topham, 2016). One‐on‐one reflection meetings with parents are continued when
treatment transitions to home filial play sessions and during the generalization phase in
which the filial therapy skills are generalized to situations outside of filial play times
(VanFleet, 2014). Treatment typically includes 15–20 one‐hour sessions.
Similar to FFT, the overall goal of CPRT is to train parents to be the agent of
change with their children. CPRT is a manualized 10‐session (2 hr each) group ther-
apy approach to working with parents and children as young as 2 years old. The first
three sessions are spent normalizing parents’ experiences, communicating safety and
acceptance, and teaching parents about CPRT philosophy, skills, and techniques. In
sessions 4–10, therapists and peers provide feedback to each other based on 30‐min
video recordings of parents playing with children at home. Additionally, parents prac-
tice skills with each other in session.
Research evidence Over 40 studies have evaluated the effectiveness of FFT and CPRT (see
Bratton, Landreth, and Lin (2010)) and VanFleet, Ryan, and Smith (2005) for reviews).
Studies have been done with a wide range of presenting complaints (e.g., conduct prob-
lems, experience of sexual abuse) and treatment populations (e.g., foster parents, incarcer-
ated parents) and families from a variety of racial and ethnic backgrounds (e.g., Chinese,
Korean, Israeli). Studies have shown improvements in a wide range of parent (e.g., parent
stress, sensitivity) and child (e.g., internalizing and externalizing) outcomes. Although
many of the studies utilized control groups, most failed to randomize to treatment and
control groups, and many samples sizes were relatively small. Future research needs to
examine efficacy of these programs utilizing an RCT design with larger sample sizes.
Strengths and limitations All three models (individual family and group FFT and
CPRT) are manualized interventions. The interventions are relatively easy to learn and
implement, particularly for therapists familiar with play therapy. All three interventions
have certification processes. The different formats offer flexibility to treatment provid-
ers. As mentioned above, the interventions have been applied, with research support,
to a wide range of treatment needs and populations. Lack of rigorous research demon-
strating the efficacy of the models is a limitation.
Comparison of interventions
With a number of evidence‐based interventions available, it can be difficult for thera-
pists to make decisions about which trainings to pursue and which interventions to
utilize for particular families. Table 4.1 provides a summary of the interventions
described in this chapter as well as the training requirements, beginning with the least
to the most intensive interventions. On one end of the continuum, the Circle of
Security Parenting program is preventative in nature and does not attend directly to
parent or child clinical issues. On the other end of the continuum, CPP is designed to
treat child trauma and, in the process, to treat a host of parent and parent–child dif-
ficulties. However, less differentiates most of the models in between with regard to
scope of presenting issues.
All of the interventions, with the exception of the Circle of Security parent group
and ABC interventions, require a clinical master’s degree. Intervention durations
range from 5 to 50 sessions and didactic training requirements range from 4 days to
2 weeks, with most interventions requiring a year of supervision. ABC and CPP have
the strongest research support with multiple RCTs targeting diverse samples of
participants. Unfortunately, research has not yet compared the efficacy of these inter-
ventions to identify whether more intensive models, with regard to treatment or
provider training, provide additional benefits that warrant the additional costs.
Future Directions
Foundational training in systemic family therapy

Due to the extensive training demands of systemic family therapy programs, it would
be difficult for programs to provide comprehensive, specialized training in infant and
early childhood mental health assessment and intervention. In most cases, therapists
will need to seek out and obtain additional training on their own during and after
their graduate coursework. However, faculty in training programs can provide basic
information that will give the direction needed for students and graduates interested
in this work. At a minimum, it is important for systemic family therapy master’s degree
programs to expose students to a basic understanding of early development particu-
larly brain development, parenting behaviors key to healthy infant and toddler
development, the effects of trauma and early adversity on development, and a descrip-
tion of some of the intervention models shown to help children affected by early
adversity toward a path of healthy development. Even for those who choose not to
focus their clinical work on early relationship intervention, it is important that they
have a solid understanding of the effects of early experience, the positive impact of
high‐quality treatment, and where to refer families with young children. We would
argue that a basic level of competence in this area would be ethically important for
anyone who calls themselves a family therapist.
Table 4.1 Comparison of infant mental health treatments
Qualifications and training Target
Circle of Security No educational requirement. Preventative in nature,

Parenting DVD strengthen parent–
Program child relationship
Four‐day training
Format: Parent group
(office)
Child age: 0–5 years
Length: 8–12 sessions
Attachment and No educational requirement. Infants who have
Biobehavioral Catch‐ Brief prescreen. Two‐day experienced early
up Infant (ABC‐I) training followed by 1 year adversity
of weekly video supervision:
Format: Parent–child
1‐hr small group supervision
(home)
and ½ hr of individual coding
Child age: 6–24 months supervision
Length: 10 sessions
Attachment and Certification in ABC‐I. One‐ Toddlers who have
Biobehavioral Catch‐ day web training followed by experienced early
up Toddler (ABC‐T) 1 year of weekly supervision: adversity
1‐hr small group supervision
and ½ hr of individual coding
(home)
supervision
Child age: 24–48 months
Length: 10 sessions
Circle of Security‐ Master’s degree in mental Parents who are
Home Visiting‐4 health. economically stressed
(COS‐HV4) and child at risk for
Advanced 10‐day circle of
negative outcomes
Format: Parent–child security training, pass the
(home) competency exam, and
supervision for five complete
interventions
Length: 3‐hr assessment
+ four 1.5‐hr sessions
Child–Parent Master’s degree in mental Behavioral,
Relationship Therapy health and certification in emotional, social,
(CPRT) child‐centered play therapy. and attachment
Four days of training; problems
Format: Parent group
three CPRT groups under
v(office)
supervision
Child age: 3–8
Length: 10, 2‐hr group
sessions + weekly
parent–child play
sessions
(Continued)
Qualifications and training Target

Filial Family Therapy Master’s degree in mental Behavioral, emotional,
(FFT) health and prior training in social, and
child‐centered play therapy. attachment problems
Eight days of training;
(home or office)
supervision for six to seven
Child age: 3–12 cases

Theraplay Master’s degree in mental Behavioral, emotional,
health. social, and
attachment problems
(office) Seven days of training and 1 year
of supervision
Child age: All ages
Circle of Security Master’s degree in mental Parents who are
Intensive health. economically stressed
Psychotherapeutic and child at risk for
Advanced 10‐day training; pass
Group (COSI) negative outcomes
the competency exam; and
Format: Parent group 1 year of supervision
Length: 20 group
sessions
Child–Parent Master’s degree in mental Traumatic event and/
Psychotherapy (CPP) health. or mental health,
attachment, and/or
Format: Parent–child 1.5 years of training typically
behavioral problems
(home or office) includes 3, 2–3‐day
workshops, bimonthly
group clinical consultation,
Length: 25–50 sessions and bimonthly reflective
supervision
Interested students should be directed to the infant and early childhood mental
health list of competencies developed by Michigan Association for Infant Mental Health
(http://mi‐aimh.org/endorsement/requirements/requirements‐for‐level‐iii). These
competencies have been adopted by a number of other states. To support best practices
in the field of infant and early childhood mental health, some states are moving toward
infant mental health practitioner licensing, credentialing, or endorsement using the
Michigan Association for Infant Mental Health competency guidelines, which allows
for foundational standards in the field.
Research
We have solid research indicating the importance of preventing and treating mental
health issues early and of the long‐term efficacy of high‐quality intervention programs
targeting the parent–child relationship. Additional research is needed to further dem-

onstrate the long‐term effects of early adversity and the long‐term effects of treatment
on the brain (O’Connor & Parfitt, 2009). Knowledge of the differential effects of
early adversity on the brain based on timing of development and duration of adversity
will help us to focus policy and intervention efforts. Intervention programs vary
widely in length of treatment and cost of delivery. Research comparing efficacy of
various interventions for different presenting issues, levels of risk, and ages of children
will inform efforts to continue to improve cost‐effectiveness of services. Additional
research priorities should include examining method of intervention and mechanisms
of change, common factors, frequency and location of services, competencies and
characteristics of therapists predictive of positive outcomes, and most efficient and
effective methods for training therapists for this work.
As we seek to advance what we know about the impact of early treatment, it is
important that we continue to engage in methodologically rigorous studies utilizing
comparison treatment conditions, random assignment (or matched random assign-
ment in cases of small samples), multiple valid and reliable outcome measures for each
variable of interest, multiple methods of measurement (e.g., self‐report, observation,
etc.), multiple sources of report (e.g., parent, teacher), and inclusion of treatment
fidelity measurement. In addition, reporting on dropout rates and on the differences
between those who do and do not complete treatment is important in making sense
of results and the generalizability of the results. Finally, assessing outcome variables
before, during, at conclusion, and at a follow‐up after treatment increases confidence
in effects and also supports the examination of mechanisms of treatment effects.
Policy and Reimbursement
Establishing sustainable strategies that are uniquely tailored to the local community can
help prevent infant and early childhood illness and disease (Center on the Developing
Child at Harvard, 2016). Policy priorities should include policies that support growing
and supporting a well‐trained mental health workforce to address the large infant and
early childhood mental health (IECMH) need. The sustainability of intervention pro-
grams is frequently assessed according to their cost‐effectiveness or return on investment
for society; therefore, it is imperative that future interventions include methods of evaluat-
ing the short‐term and long‐term costs and benefits to society (i.e., taxpayers), individuals,
and families. Financial benefits of infant and early childhood mental health can be meas-
ured from a variety of outcomes, such as lifetime labor market earnings, expenditures for
the criminal/juvenile justice system, special education costs, tax revenues, income, and
reliance on governmental assistance (Center on the Developing Child at Harvard, 2007).
Policies should support the establishment of quality standards for service delivery
and processes for monitoring service delivery particularly as interventions are scaled
up. Policy should also support the development of screening, assessment, and inter-
ventions that are appropriate for and sensitive to the language and culture of the fami-
lies. Zero to Three—a national organization dedicated to infant and early childhood
mental health practice, research, policy, and advocacy—calls for strengthening the
field through a variety of methods including embedding infant–early childhood men-
tal health programs in existing systems and training programs, expanding the evidence
base, creating policies that support endorsement and credentialing of infant–early

childhood mental health professionals, and leveraging funding to establish statewide
infant and early childhood mental health services (Zero to Three, 2017b).
Summary
In their introductory chapter in the Handbook of Infant Mental Health, Charles Zeanah
and Paula Zeanah (2009) identify four challenges of infant and early childhood mental
health work: (a) the importance of involving families of young children and developing
strong working alliances; (b) the importance of attending to and being sensitive to
“personal, familial, ethnic, cultural, professional and organizational values” (p. 17); (c)
the importance of simultaneously attending to behavioral interaction in the dyad and
the parent and child’s emotional experiences of each other; and (d) the need for ongo-
ing research on prevention and intervention efforts. The authors point out that it
requires a paradigm shift and significant training for most professionals doing this
work. However, this is not necessarily the case for systemic family therapists who are
well suited to address each of the above‐listed challenges. Working with and maintain-
ing working alliances with multiple family members, sensitivity to culture and values,
awareness of self in the client system, and attending to interpersonal interaction and
intrapersonal experience of family members simultaneously are central elements of sys-
temic family therapy training. Yet, many systemic family therapists are not exposed to
the need for, methods of, and impact of early parent–child intervention. With an
orientation to their work in training programs and additional post‐degree training,
systemic family therapists could make a significant contribution to this important work.
Note
1 The details of the case example are based on aggregated clinical work with real families;
however, all names and details are fictitious.
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5
Interventions for Parent-Child
Relational Problems That Emerge
During the School‐Age Years
Kami L. Gallus
As children reach the school‐age years (6–18 years of age), the nature and style of the
parent-child relationship changes as children achieve new developmental tasks and
milestones and begin interacting within new systems and relationships outside the
family. Despite significant changes in the relationship, the day‐to‐day interactions
between a parent and child continue to play a unique and important role not only in
the development and health of the developing child (Beach et al., 2006) but also in
the functioning of the parent and the overall functioning of the larger family system
(Low & Stocker, 2005). For families of school‐age children from elementary through
high school, parent-child relational problems often arise amidst numerous and signifi-
cant transitions in development and context. Recognizing the parent-child relation-
ship as an essential component to the well‐being of individuals and families, when
problems arise in this relationship, systemic approaches to assessment and treatment
of the affected relationships are necessary.
The goal of this chapter is to discuss common parent-child relational problems that
emerge during the school‐age years. Additionally, this chapter will explore the com-
mon systemic assessments and interventions used to address common relational prob-
lems that emerge during the school‐age years, highlighting how systemic family
therapists are uniquely equipped for this important work. While systemic interventions
can include both family therapy and other family‐based approaches such as parent
training, the following review focuses specifically on evidence‐based systemic family
therapy approaches. The parent-child relational problems discussed in this chapter rep-
resent non‐abusive relationship problems when considered in the context of a rela-
tional continuum. Parent-child relational problems that meet criteria for child abuse or
neglect are addressed in Rhoades, Mitnick, Heyman, Smith Slep, and Del Vecchio
(2020, vol. 2). Within this chapter, the term parent is used to refer to an adult who
holds a primary role of providing consistent and significant care for a child. For most
children, the term parent refers to biological or adoptive parents; however, many chil-
dren today are reared by extended family or friends, grandparents, and/or foster par-
ents. While the current chapter expands to include primary caregivers, it does not
include adults in more minor caregiving roles such as teachers or childcare providers.
118 Kami L. Gallus
The Parent-Child Relationship During the School‐Age Years
As children develop and grow through the school‐age years, several notable changes
occur within the parent-child relationship (Laursen & Collins, 2009). While toddlers
and preschoolers need constant supervision, school‐age children become gradually
ready for more independence as their social world expands and they begin interacting
within various new external systems and relationships (e.g., schools, teachers, peers).
As children enter the school years, the advancement of logical thought, increased
awareness of and sensitivity to the perspectives of others, and the development
brought about by formal education facilitate significant changes to the nature of the
parent-child relationship (Raikes & Thompson, 2005). Maccoby (1984) proposed
that a key change in the parent-child relationship during the school‐age years is the
shift from parental control in early childhood to parent-child co‐regulation of the
relationship as the child develops.
Additionally, as children’s ability for abstract thought increases, the quality of the
parent-child relationship may change. The developing child’s new push for independ-
ence may be perceived as challenging the authority of the parent (Smetana & Asquith,
1994) and associated with this, conflict commonly increases within the relationship
across the school‐age years. Middle childhood and the early years of adolescence,
encompassing the ages of 10–15 years, mark the period of most common and
frequently reported conflict within the parent-child relationship (Laursen & Collins,
2009). Family rules regarding household chores, curfew, bedtime, dress codes, and
perceived fairness can be a typical source of conflict. As children progress through the
school‐age years, both parents and children report decreased time spent together
(Laursen, Coy, & Collins, 1998), declining feelings of closeness (Laursen & Williams,
1997), and increased emotional intensity during conflicts within their relationship
(Laursen et al., 1998). The heightened level of conflict presents unique challenges as
both the parent and child attempt to deal with the changing nature and quality of
their relationship. Yet, despite the significant transitions and changes, the parent-child
relationship remains a salient feature in the child’s ongoing development as well as the
overall functioning of the larger family system.
The nature and quality of parent-child relationships during the school‐age years is
traditionally linked to the theoretical constructs and child outcomes associated with
attachment, parenting styles, and social learning. Across theories of parent-child rela-
tionships, the attachment bond formed between the parent and child (connectedness,
closeness, emotional security) is often considered the most important dimension of
the relationship (Lamb & Lewis, 2011). Although Bowlby’s (1969) theory of attach-
ment focused primarily on the infant–parent relationship, the functions of attachment
relationships for school‐age children and adolescents parallel the same functions as
those outlined for infants and preschoolers (Kerns & Brumariu, 2016). Parents and
other primary caregivers continue to function as primary attachment figures for chil-
dren at least through middle childhood (Kerns & Brumariu, 2016) and possibly
through adolescence. Attachment theory focuses on the degree to which the child
uses a caregiver as a secure base, a source of safety and comfort from which to launch
exploration of the physical and social world. Bowlby (1987; cited in Ainsworth, 1990)
suggested that the goal of the attachment system changes from the proximity of the
attachment figure in infancy and early childhood to the availability of the attachment
figure in middle childhood. For school‐age children, the security from the parent-child
Parent-Child Relational Problems: School-Age 119
relationship facilitates a sense of confidence in explorations outside of the family,

including the formation of new relationships (Kerns & Brumariu, 2016). The security
from attachment with caregivers also allows school‐age children the opportunity to
explore intellectual and emotional autonomy from their families and appreciate the
advantages of amicably resolving disagreements (Kerns & Brumariu, 2016).
Parenting dimensions and styles are also thought to have a significant impact on the
quality of the parent-child relationship as children age. Research on parenting has
identified three core dimensions of parenting for older children and adolescents: (a)
the degree of responsiveness (e.g., warmth and support), (b) the degree of demand-
ingness (supervision, rules/structure, and disciplinary efforts), and (c) the promotion
of autonomy (Baumrind, 1967; Maccoby & Martin, 1983). For decades, researchers
exploring the parent-child relationship have relied on Baumrind’s (1973) concept of
parenting styles to classify and describe the broad spectrum of behaviors included in
caregiving (Baumrind, 2013). Baumrind suggested that there are three prototypical
parenting styles: (a) authoritative, (b) authoritarian, and (c) permissive. Authoritative
parenting is widely recognized as the most effective of the three prototypical styles
and consists of a balanced approach to discipline, combining nurturance, good com-
munication, maturity demands, and firm control when necessary (Larzelere, Morris,
& Harrist, 2013). An authoritative parent balances high levels of demandingness with
high levels of responsiveness. Authoritarian parents err on the side of over‐disciplining
children with high demands while minimizing responsiveness through low levels of
affection and warmth. In contrast, permissive parents exhibit low levels of demand-
ingness and high levels of responsiveness, minimizing maturity demands and direct
disciplinary confrontation and emphasizing nurturance and the child’s autonomy.
Research suggests that children develop more competence and fewer behavior prob-
lems when raised by authoritative parents, in contrast to authoritarian or permissive
parents (Baumrind, Larzelere, & Owens, 2010).
Social learning theories offer an additional model for understanding and describing
the parent-child relationship. Associated with the ideas and findings of Bandura
(1973, 1977), social learning theories suggest that children learn to exhibit certain
behaviors, attitudes, and emotional reactions as they are modeled and reinforced over
time by others. From the social learning perspective, parents not only serve as power-
ful models of social behavior for children but also shape children’s behaviors over time
through day‐to‐day parent-child interactions. Specifically, this model suggests that
children learn strategies for managing emotions, resolving disputes, and engaging
with others from their experiences in different settings, with their primary caregiver
serving as the key learning environment. Specific parenting behaviors including posi-
tive attention and praise of desirable behaviors, clear directions and limit setting, and
limited criticism directed toward the child represent key parenting dimensions. These
key dimensions have been identified to improve the quality of the parent-child rela-
tionship and, in turn, serve to enhance the child’s desirable behaviors (DeGarmo,
Patterson, & Forgatch, 2004).
The expansive body of research exploring the theoretical constructs of attachment,
parenting styles, and social learning has resulted in an abiding interest in the parental
control functions (e.g., discipline, limit setting, autonomy) as well as the emotional
quality (e.g., warmth, cohesion, support, responsiveness) of the parent-child relation-
ship (Laursen & Collins, 2009). Overall, these theories share the assumption that the
quality of the parent-child relationship is determined by the positive equilibrium
120 Kami L. Gallus
between these two key dimensions (Barber, Stolz, Olsen, Collins, & Burchinal, 2005;
Gray & Steinberg, 1999), an assumption supported by a growing body of research
suggesting the parent-child relationship is a significant factor in the development,
mediation, or moderation of childhood mental health problems (Beach et al., 2006).
Consequently, growing attention is being given to the clinical significance of parent-
child relational problems that emerge during the school‐age years.
Parent-Child Relational Problems: Definitions and Classifications
Compared to partner relational problems and parent-child relational problems in

early childhood, the development of diagnostic criteria for identifying and researching
common parent-child relational problems emerging in the school‐age years has
lagged behind. Currently, the term “parent-child relational problems” refers to a
wide category of difficulties in communication and interactions that result in conflict
or distress between parents and their children. Although not recognized as a formal,
specific mental health diagnosis, common relational problems are acknowledged as a
potentially important foci of mental health treatment in both the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5; American Psychiatric
Association [APA], 2013), and the 10th revision of the International Statistical
Classification of Diseases and Related Health Problems (ICD‐10; World Health
Organization [WHO], 1992).
In the DSM‐5 (APA, 2013), V61.20: “Parent‐Child Relational Problem” is found
under the “Problems Related to Family Upbringing” category. The term “parent”
refers to one of the child’s primary caregivers who may be a biological, adoptive, or
foster parent or other relative who fulfills the role of parenting the child. The code
includes a one paragraph description of impaired relational functioning across behav-
ioral, cognitive, and affective domains. According to the DSM‐5, cognitive impair-
ments that serve as indicators of common relational problems include inadequate
parental control, supervision, and/or involvement with the child, parental overpro-
tection, excessive parental pressure, escalating arguments, and avoidance or lack of
communication. Examples of cognitive functioning impairments include negative
attributions of the other’s motives, hostility, or scapegoating. Examples of impair-
ments in affective functioning include feelings of sadness, apathy, or anger about the
other (APA, 2013).
The current ICD‐10 (WHO, 1992) addresses parent-child relational problems
under the Z codes: “factors influencing health status and contact with health ser-
vices.” In comparison with the DSM‐5, the ICD‐10 Z codes include several separate
categories of parent-child relational problems under Z62: “other problems related to
upbringing.” The separate diagnostic categories refer to common parent-child rela-
tional problems, including distinct codes for inadequate parental control and supervi-
sion, parental overprotection, institutional upbringing, hostility toward and
scapegoating of child, emotional neglect of child, and inappropriate parental pressure
and other abnormal qualities of upbringing.
Although progressing since earlier versions of the DSM and ICD, the relational and
interactional processes associated with parent-child relational problems are not well
defined and lack the specific criteria sets outlined for other disorders. The lack of
specificity means the relational codes associated with parent-child relational problems
are seldom used in the mental or physical health fields. In response to the current
limitations in the current definitional criteria, the Relational Processes Working Group
proposed new, more specific diagnostic criteria to define common parent-child rela-
tional problems (Wamboldt, Cordaro, & Clarke, 2015). Findings from clinical field
trials suggest that the proposed diagnostic criteria are a clinically useful improvement
to the current definitions provided in the DSM‐5 and ICD‐10. This ongoing work
offers promise that future iterations of formal mental health diagnostic criteria will
include more specified criterion for reliably coding and categorizing common rela-
tional problems.
The lack of criteria for defining the problematic interactions that comprise common
relational problems during the school‐age years is likely due to the significant variance
in the presentation of dimensions of relationship quality (e.g., conflict, communica-
tion, cohesion) from family to family. While there is no single known cause of parent-child
relational problems that emerge during the school‐age years, parents experiencing
problems in the parent-child relationship often present with typical complaints regard-
ing the child’s behaviors. The sources of problems are most commonly hypothesized
to originate with the child/adolescent; however the parent and/or the larger family
context may also be associated with common relational problems that emerge during
the school‐age years.
Child factors
As commonly experienced by systemic family therapists, children’s behaviors are often
presented as the primary source of challenge to the quality of the parent-child rela-
tionship. The child within the problem saturated parent-child relationship is often
referred to with social labels ranging from the difficult child or bad student to trou-
bled teen or delinquent youth. Problematic child behaviors range from disagreements
regarding more mundane, everyday behaviors including technology use (e.g., cell
phone, social media), physical appearance (e.g., hair, clothes, piercings, tattoos), peer
relationships (e.g., friends, significant other), and school attendance/performance
(e.g., truancy, grades, homework) to more high‐risk behaviors such as substance use,
disordered eating, and sexual behaviors. General defiant and/or dishonest behaviors
are also commonly reported as creating difficultly in the parent-child relationship. In
addition to problematic behaviors, children’s emotions (e.g., grief, anxiety, depres-
sion, and suicidal ideation) are frequently attributed as the source of the conflict and
distress within the relationship.
Parent factors
While children’s behaviors are more frequently labeled as the presenting problem by
caregivers seeking services for parent-child relational problems, parent behaviors are
also commonly attributed as the source of the relational problem and the reason for
seeking out therapy. Parent behaviors attributed to common relational problems are
generally associated with problems in parental control (e.g., failure to establish rules
or consequences, establishment of overly harsh rules or consequences, inadequate
monitoring of child) and responsiveness (e.g., failure to provide emotional support,
122 Kami L. Gallus
over‐involvement with the child). Parents within the problematic parent-child rela-
tionships often receive social labels including the absent parent, the helicopter mom,
the deadbeat dad, or the permissive parent. Disruptions in caregiving behaviors may
be associated with the parent’s physical or mental health diagnosis, substance use, or
incarceration, which may be labeled as the presenting problem.
Family context factors

Parent-child relationships do not occur in a vacuum. These relationships are embed-
ded in a matrix of familial, social, and cultural factors, which influence the parent and
the child individually as well as the relationship as a whole. Family contextual factors
such as divorce, remarriage, social support, parental employment/job satisfaction,
socioeconomic class, ethnic or racial minority status, and household density have all
been found to impact the parent-child relationship and, therefore, may be commonly
identified by parents and/or children as the presenting problem for therapy (Deater‐
Deckard, 2004; Lengua, Honorado, & Bush, 2007). Research suggests that unique
contextual factors may increase risk and, therefore, serve as indicators of potential
parent-child relational problems. For example, researchers have found that parenting
quality is affected by the increased instability and stressors connected to low income
and poor education (Bradley & Corwyn, 2002; Lengua et al., 2007) Additionally,
primary caregivers who are unmarried or do not have a partner may be subject to
greater stress than parents who are parenting with a partner or experience marital
conflict and/or disagreements about child‐rearing (Cain & Combs‐Orme, 2005).
For minority families, the unique combination of contextual factors often associated
with poverty, social support, racism, prejudice, and acculturation can combine to
synergistically impact parenting quality and the parent-child relationship (Emmen
et al., 2013; Frabutt, 2013).
While the indicators and severity of common relational problems may vary signifi-
cantly across families and relationships, as in any relationship, conflict and communi-
cation problems in the parent-child relationship are common. Common relational
problems can be minor in presentation and therefore are not always an important foci
of mental health treatment; however, when the conflict results in such relationship
strain that the parent and child cannot communicate or problem solve, then clinically
significant behavioral, affective, and/or cognitive symptoms may emerge in both the
child and the parent within the context of the relationship (APA, 2013). These symp-
toms can disrupt the lives of the parent and child and even lead to the destruction of
the relationship if not assessed and treated effectively.
Theoretical Underpinnings of Systemic Therapy for Common

Parent-Child Relational Problems
From a systemic perspective, parent-child relational problems parallel partner rela-
tional problems in that the focus is on the “goodness of fit” within the organization
and interactions between two individuals in a relationship (Slep & Tamminen, 2012).
Developed by Chess and Thomas (1999), the “goodness‐of‐fit” hypothesis suggests
that a particular trait or behavior in a child or parent may not be problematic in and
of itself but leads to conflict or distress within the relationship when there is a mismatch
between the trait or behavior and the characteristics of a particular environment.
While the impact or symptoms can present in either or both individuals in the rela-
tionship, parent-child relational problems focus on the strained or distressed relation-
ship, where the relational distress, rather than either individual, is the source of
symptoms. Dynamic models of the parent-child relationship propose emergent inter-
actional processes of adaptation in which parents act to influence children and c hildren
act in response, which in turn influences parents’ behaviors and future interactions
(Maccoby, 2003).
Patterson (1982) described a coercion process relevant to the systemic understand-
ing of the etiology of common relational problems. The coercion process depicts
family dynamics associated with runaway feedback loops in which parents escalate
negative parenting in response to children’s escalating behavior, until a problematic
parent-child relationship is established and maintained (Dishion & Stormshak, 2007;
Patterson, 1982). From an interactional perspective, despite a long‐standing orienta-
tion to the impact of parental actions, the quality of and therefore problems within
the parent-child relationship are regulated recursively from joint action patterns
between the parent and child. Out of the continual interplay of parent and child
behaviors, outcomes emerge that are not attributable to either participant alone
(Sameroff, 2009). This view of the parent-child relationship is consistent with family
systems conceptualizations of behavior, which also emphasize the reciprocal interplay
between the child and their familial relations (e.g., Haley, 1976; Minuchin, 1974).
Over time, the conflictual interactional styles that emerge become stable and resistant
to change (Minuchin, 1974). Therefore, from a systemic perspective, effective therapy
for parent-child relational problems requires interventions focused on changing the
patterns of interaction between caregivers and children (Minuchin, 1974).
A systemic view of common relational problems invites questions about what inter-
active processes between children and parents most directly impact the overall quality
of the relationship during the school‐age years. Specifically, what do interactions look
like when the relationship between a parent and child is functioning optimally versus
when problems arise? Traditional family therapy approaches move from the more
linear view of the parent-child relationship to focus on specific interactions, including
communication, conflict resolution, and hierarchy. For example, a systemic perspec-
tive of the parent-child relationship assumes that patterns of interaction within the
relationship should establish clear hierarchy where leadership is with the parents and
only minor, age‐appropriate delegation of responsibilities is given to children
(Minuchin, 1974). Interestingly, the more traditional focus on parenting and the
balancing of the dimensions of parental control and warmth within the parent-child
relationship is still consistent with traditional family therapy concepts and models. For
example, structural family therapy (Minuchin, 1974; Minuchin, Rosman, & Baker,
1978) highlights the distinction between enmeshment (e.g., cohesion) and disen-
gagement (e.g., rejection) in intergenerational boundaries, identifying a functional
optimum in the middle of the dimension, which provides a balance of togetherness
and separateness. Strategic/problem‐solving therapy traditions (Fisch, Weakland, &
Segal, 1982; Haley, 1976, 1991; Madanes, 1981) focus on identifying and altering
faulty cycles of interaction that are often set into motion by misguided attempts to
solve the problem, which are often characterized by imbalanced approaches to
caregiving (e.g., parent overprotection or pressure).
124 Kami L. Gallus
Mental health professionals trained as systemic family therapists have long been
indoctrinated to appreciate and work with the family system and subsystems to create
change. The goal of most systemic approaches for parent-child relational problems is
to enhance interactions between the parent and child/adolescent in order to enhance
child/adolescent functioning and ultimately to improve the relationship functioning
at the dyadic and broader family system levels. Therefore, systemic interventions for
common relational problems generally focus on at least the dyad, with assessment and
treatment of the affected relational unit and/or broader family system.
Assessment
An increasingly important issue for clinicians involves finding suitable assessment

methods for identifying and categorizing parent-child relational problems. This is
particularly important when considering the broad spectrum and severity of present-
ing problems as well as the relative infancy of parent-child relational problems as a
diagnostic construct (Slep & Tamminen, 2012). Detailed assessment at the individ-
ual, relational, and family levels play an important role in assisting clinicians in deter-
mining when parent-child conflict or distress is within the nonclinical range versus
when the problem represents a diagnosable condition that should be the focus of
treatment. To date, clinical research and practice is limited by the lack of standardized
measures that provide reliable and succinct assessment and categorization of the par-
ent-child relationship (Wamboldt & Cordaro, 2012). While there are no dominant
conceptual or methodological approaches to assessing the parent-child relationship
during the school‐age years, in general, assessment focuses on the behavioral quality
of the interaction, the affective tone of the interaction, and the psychological involve-
ment in the interaction between the parent and the child (Wamboldt et al., 2015).
As with any relational disorder, for a parent-child relational problem to be diag-
nosed, the clinician must involve each person in the relationship in the assessment
process. Once children enter into the school‐age years, they are increasingly able to
actively participate in the assessment of the parent-child relationship, broadening
the assessment techniques and strategies accessible to clinicians. Among the wide
range of assessment methods utilized include observational assessments of the dyad
(e.g., Easterbrooks, Davidson, & Chazan, 1993), assessments of family drawings
(e.g., Fury, Carlson, & Sroufe, 1997; Madigan, Ladd, & Goldberg, 2003), semi‐
structured interviews (e.g., Angold & Costello, 2000; Wamboldt & Cordaro,
2012), and, perhaps most common, self‐report instruments completed by the par-
ent and/or the child.
Self‐report instruments provide validated assessments of relational functioning
from the perspective of the parent and/or the child. Unlike assessments of the par-
ent-child relationship in infancy and early childhood that are limited to parent self‐
report, assessment of the parent-child relationship during the school‐age years is
broadened to include the perspective of the child, yet there are still challenges to this
method of assessment. Significant questions remain as to how effective self‐report
measures at the individual level are at examining dyadic‐level relational functioning
(Tutty, 1995). Further, self‐report instruments are often developed for research
purposes and lack meaningful clinical ranges or cutoffs to assist clinicians with

etermining the clinical significance or severity of the relational problem. Despite the
d
limitations, self‐report instruments can offer an efficient, reliable method of assess-
ment. While a complete review of all the available relational assessments is beyond the
scope of this chapter, an overview of some of the most commonly used, psychometri-
cally sound assessment methods is provided by Foran, Fraude, Kubb, and Wamboldt
(2020, vol. 2).
Except for a few dyadic‐report instruments, such as the frequently used Parent-
Child Relationship Questionnaire (Furman & Gibson, 1995), which provides both a
parent‐ and child‐report form, self‐report instruments often assess solely at the indi-
vidual level, specific to either the parent or child’s perspective of the dyadic relation-
ship. Commonly used parent‐report instruments assess patterns of attachment and
other aspects of the relationship, including communication, conflict, nurturing, and a
sense of parental pleasure and confidence in interaction (Pritchett et al., 2011;
Wamboldt & Cordaro, 2012). Among the most commonly used parent self‐report
instruments include the Parenting Scale (Arnold, O’Leary, Wolff, & Acker, 1993),
the Parent-Child Relationship Inventory (Gerard, 1994), the Conflict Tactics Scale:
Parent-child Version (Straus, Hamby, Finkelhor, Moore, & Runyan, 1998), and the
Parenting Stress Index—Short Form (Abidin, 1995). Similar to parent‐report instru-
ments, child/adolescent‐report instruments frequently assess the emotional quality,
cohesion, and nurturance the child perceives within the relationship as well as conflict
and overall satisfaction within the relationship. Commonly used child/adolescent‐
report instruments include the Parental Bonding Instrument (Parker, Tupling, &
Brown, 1979), the Network of Relationships Inventory (Furman & Buhrmester,
1985), and the Interpersonal Conflict Questionnaire (Laursen, 1993). Each of these
child‐report measures are relationship specific, providing separate assessments of the
child’s perspective on the female parent (e.g., mother) relationship and the male
parent (e.g., father) relationship. The Parental Bonding Instrument also provides
established clinical cutoff scores enhancing the clinical utility of the assessment for
determining the severity of parent-child relational problems as well as tracking change
across time.
Assessment of family‐level processes beyond the parent-child dyad is also important
for identifying and categorizing common relational problems. Self‐report family
assessment instruments aim to evaluate the way families function and assess domains
commonly associated with parent-child relational problems, including communica-
tion and problem solving, emotional cohesion, and rules, roles, and routines. While
many self‐report family assessment instruments exist, only a select few have been
developed for use with school‐age children, generally over the age of 10 or 12 years.
The following measures have been found to be the most suitable family assessment
instruments for clinical use (Hamilton & Carr, 2016) and considered suitable for use
with older school‐age children: the McMaster Family Assessment Device (FAD)
(Epstein, Baldwin, & Bishop, 1983; Miller, Epstein, Bishop, & Keitner, 1985), the
Circumplex Model Family Adaptability and Cohesion Scales (FACES‐IV) (Olson,
2011), the Family Assessment Measure III (FAM III) (Skinner, Steinhauer, &
Sitarenios, 2000), and the Systemic Clinical Outcome and Routine Evaluation‐15
(SCORE‐15) (Stratton, Bland, Janes, & Lask, 2010). These self‐report measures
enable each family member to report on aspects of family interactions that have clini-
cal significance and are likely to be relevant to therapeutic processes and change. The
SCORE‐15 is designed to record perceptions of the family from each member over
126 Kami L. Gallus
the age of 12 years, whereas the Child SCORE (Jewell, Carr, Stratton, Lask, & Eisler,
2013) can be used for children aged 8–11 years. A promising new measure, the
Systemic Therapy Inventory of Change (STIC) (Pinsof, Goldsmith, & Latta, 2012),
is currently undergoing validation and offers promise as an additional suitable clinical
measure for adults and children over 12 years of age. In‐session, semi‐structured
assessment interviews, such as the one developed by Wamboldt and Cordaro (2012),
provide another practical tool for assessing parent-child relational problems.
Overall, the wide variance in assessment methods for parent-child relational prob-
lems emerging during the school‐age years is likely due in part to the disparities in
abilities among children across a vast developmental period. Measures appropriate
during the early years of middle childhood may not be valid as children enter the later
school years. Given the complexity of the parent-child relationship, no single assess-
ment should be used in isolation as the sole basis for clinical diagnosis or treatment
decisions. Thorough systemic assessment for common parent-child relational prob-
lems should include multiple informants and assessment methods. For example,
recognizing that relational problems are often transgenerational, thorough systemic,
in‐session assessments can be enhanced by utilizing traditional approaches such as
tracing parent-child relational patterns across generations (Slep & Tamminen, 2012).
Systemic Interventions
Current systemic interventions commonly used with common parent-child relational

problems have strong influences linked to the theoretical constructs and child out-
comes associated with attachment, parenting styles, and social learning, as well as
traditional approaches in family therapy, including structural (Minuchin, 1974;
Minuchin & Fishman, 1981) and strategic/problem‐solving therapy traditions (Fisch
et al., 1982; Haley, 1976, 1991; Madanes, 1981), and social constructionist models
including solution focused (de Shazer & Dolan, 2007) and narrative (White, 2011).
Unlike traditional approaches of family therapy, which are commonly critiqued for
weaknesses in terms of theoretical and practical specificity, contemporary systemic
models integrate theory, research findings, and clinical practice. Whereas traditional
forms of family therapy focused solely on the parent–adolescent interaction, many of
the leading interventions involve meeting with the child and parent individually as
well as conjointly and include intervening at the family, extended family, and extra‐
familial levels.
The manualized approaches reviewed represent the most used and researched sys-
temic approaches with parents and school‐aged children. In accordance with clients’
typical clinical presentation, which commonly identifies the child’s behavior as the
primary source of challenge to the quality of the parent-child relationship, the follow-
ing approaches were developed and marketed to address specific child‐focused prob-
lem behaviors frequently co‐occurring with parent-child relational problems (e.g.,
drug and alcohol use, delinquency, affiliation with antisocial peers, unsafe sexual activity,
violence). Consistent with systems thinking, systemic approaches focus on strength-
ening the parent-child relationship and other family factors relevant to changing the
targeted child behaviors. Specific systemic interventions are aimed at improving
family communication, supportiveness, understanding, and perspective taking while
ecreasing negativity and dysfunctional behavioral patterns. While some of the

d
approaches discussed have been utilized with children as young as 6 years of age, due
to the broad developmental range and unique abilities of each child, systemic models
for parent-child relationship problems emerging in early childhood (see Topham,
Pfeiffer Messmore, & Sesemann, 2020, vol. 2) may prove more effective when work-
ing with parent-child relational problems involving younger children in the very early
school years.
Brief strategic family therapy

Brief strategic family therapy (BSFT) (Szapocznik, Hervis, & Schwartz, 2003) is a
short‐term, structured, problem‐focused approach that targets families in which chil-
dren between 6 and 17 years of age engage in risk‐taking or problematic behaviors,
including drug and alcohol use, delinquency, affiliation with antisocial peers, and
unsafe sexual activity, and the accompanying maladaptive family interactions.
Originally developed by Szapocznik and colleagues for use with Cuban immigrant
families, BSFT is a manualized, short‐term family systems approach. Average BSFT
treatment includes approximately 12–15 sessions and lasts approximately 3 months.
There are three intervention components in BSFT: joining, diagnosis, and restructur-
ing. In joining, the therapist is focused on developing an alliance with each participat-
ing family member as well as the family system. The diagnosis component of treatment
refers to identifying the interactional patterns, or structure (e.g., hierarchy, parental
control, triangulation, enmeshment, disengagement, conflict) of the system associ-
ated with the child’s behavioral problems. Finally, the restructuring component
focuses on identifying and intervening in the interactional patterns associated with
child behavioral problems. As the therapist intervenes to change the way the parent
and child speak to and act toward each other, more positive interactions are fostered,
thus making it possible for the child to reduce the identified problematic behavior.
Multidimensional family therapy

Multidimensional family therapy (MDFT) (Liddle, 2010) is an integrated, family‐
centered approach to treating child‐focused problem behaviors and disorders, includ-
ing aggression, school and family problems, and emotional difficulties experienced by
youth from 9 years of age and over. Therapists work simultaneously across four treat-
ment domains—the adolescent, parent, family, and community—meeting both indi-
vidually and conjointly with the parents and child one to three times each week over
the course of the 3–6 months of treatment. Each domain is addressed across three
stages of treatment. In Stage 1: Building a Foundation for Change, the therapist
works to begin the change process by establishing strong therapeutic relationships
with all family members, achieving a shared perspective on the problems, and enhanc-
ing each family member’s motivation for reflection and self‐examination. During
Stage 2: Facilitating Individual and Family Change, the therapist assists the family in
establishing goals across the child, parent, and family functioning domains. Common
goals for children include improved emotional regulation and problem solving,
enhanced self‐worth, and improved communication skills. For parents, the common
focus of treatment is on strengthening the co‐parenting team, improving parenting
128 Kami L. Gallus
skills, and rebuilding emotional bonds with the child. Finally, in Stage 3: Solidifying
Changes, the therapist works to strengthen positive changes established and assist the
family with planning for setbacks or relapses.
Functional family therapy

Functional family therapy (FFT) (Alexander, Waldron, Robbins, & Neeb, 2013;
Sexton, 2011) is a manualized, family‐based therapeutic intervention specifically
designed for medium to high at‐risk children, ages 10–18 years old, with serious prob-
lems such as conduct disorder, violent acting‐out, and substance abuse. FFT is con-
ducted in phases based on the specific risk and protective factors of each family, and is
designed to improve family communication and supportiveness, while decreasing
intense negativity and dysfunctional patterns of behavior. FFT targets parenting skills
and youth compliance across five major phases: engagement, motivation, relational
assessment, behavior change, and generalization. Across the treatment process, the
FFT therapist maintains a strength‐based relational focus; however, each phase has its
own goals, focus, and intervention strategies and techniques. The goals of the engage-
ment phase involve building family members’ perceptions of the therapist as respon-
sive, respectful, available, and credible. During this initial phase, the FFT therapist is
attentive to being highly available to the family via telephone outreach, respectful of
family beliefs and values, and having contact with as many family members as possible.
The second phase, motivation, is focused on creating a positive motivational thera-
peutic context. Focus is paid to decreasing family hostility and conflict and increasing
hope among family members by interrupting negative interaction patterns and chang-
ing family meaning and themes to imply a positive future. The relational assessment
phase is focused on identifying key patterns of interaction and the function of the
negative patterns of interaction. The third phase sets the therapist up to begin to
establish behavioral change as part of the fourth phase. The goal of this phase is to
enact formal behavior change strategies that address key patterns and processes and
enhance individual skills relevant to the presenting problem (e.g., truancy, substance
use). During this phase, therapists focus on communication and conflict resolution
training and other evidence‐based cognitive‐behavioral strategies for addressing fam-
ily functioning. In the final generalization phase, the therapist assists the family to
extend the new, more positive family functioning into new situations, plan for relapse,
and successfully engage the broader community system of care.
Attachment‐based family therapy

Attachment‐based family therapy (ABFT) (Diamond, 2005; Diamond, Diamond, &
Levy, 2014) uses a family systems approach based on attachment theory to help par-
ents and children ages 12–18 years repair their relationship ruptures and work to
develop or rebuild an emotionally secure relationship. For parents, ABFT focuses on
criticism, disengagement, personal stressors, and parenting skills. For adolescents, it
focuses on affect regulation, self‐concept, motivation, and disengagement. The man-
ualized therapy consists of five therapeutic tasks. The first task, the Relational Reframe
Task, typically takes one session to complete. Through the progression of in‐session
conversation, the relational reframe is designed to shift the focus away from the
identified symptoms, leading parents and the adolescent to agree that improving the
quality of the parent-child relationship is the best starting point for treatment. The
second and third tasks center on alliance building. The Adolescent Alliance Task typi-
cally takes two to four sessions and involves meeting individually with the adolescent.
During these sessions, the therapist works to develop the therapeutic alliance with the
adolescent by learning about the adolescent’s strengths and interests and by helping
the adolescent to understand and articulate the ruptures that occurred in his or her
relationship with the parents. Through these in‐session conversations, the therapist
works to prepare the adolescent to discuss the ruptures and previously avoided feel-
ings and memories with the parents. The Parent Alliance Task involves individual
meetings with the parents alone. During these sessions, the therapist assists the par-
ents in exploring their current stressors and their own history of attachment. The goal
of these conversations is to activate parental caregiving instincts to behaviorally and
emotionally protect their child in order to motivate parents to learn new parenting
skills. The fourth task, the Attachment Task, is the central mechanism of the ABFT
approach. With the child and parents back together, space is created for the adoles-
cent to express his or her thoughts and feelings about past and current relational
ruptures and injustices directly to the parents. However, rather than defending them-
selves, parents help the adolescent fully express and explore these emotionally charged
topics. The Attachment Task may take between one and four sessions to complete the
consolidation of the new corrective attachment experience. Finally, the Autonomy
Task helps to promote autonomy and competence in the adolescent and to help the
parents find a balance between providing support to their child and allowing the child
to make and take appropriate responsibility for their own behaviors and choices.
Positive systemic practice

Positive systemic practice (PSP) (Carr et al., 2013) is a manualized family therapy
model for addressing emotional and behavioral problems with adolescents 12–18 years
of age and their primary parents. Developed in Dublin, Ireland, PSP focuses on the
adolescent’s social system rather than the adolescent as the problem and works to
place the adolescent’s behavior within a normative developmental framework.
Treatment involves a co‐therapy team with a conjoint session, before moving to paral-
lel individual sessions with the parent and child with periodic conjoint sessions sched-
uled throughout treatment. The principles of PSP are outlined through a series of
clinical stances. Through the first stance, the fundamental stance, the co‐therapists are
focused on relating genuinely and understanding the defensive function of the prob-
lematic behavior. Through the additional stances, therapists focus to enhance engage-
ment, facilitate child protection, promote insight and understanding, foster behavioral
change, facilitate the transition to adulthood, and facilitate closing the therapy pro-
cess. Like other systemic approaches, the process of change in PSP evolves through
three phases: engagement, middle, and closing. During the initial engagement phase,
therapists meet conjointly with the parent and child for the initial and subsequent
individual meetings. To develop the alliance with all family members, focus is placed
on eliciting each person’s perspective and developing a shared systemic view of the
presenting problem. The middle phase is focused on therapeutic problem solving
using available evidence‐based interventions. Finally, in the closing phase, therapists
130 Kami L. Gallus
help the family to reconceptualize their difficulties in a normative developmental way

and recognize and validate how they drew on their strengths to overcome their
difficulties. Prior to termination, therapists also help families develop plans for antici-
pating and managing future situations where there may be a risk of relapse.
Multisystemic therapy
Multisystemic therapy (MST) (Henggeler, Schoenwald, Bordin, Rowland, &
Cunningham, 2009) is a home‐based, family‐focused treatment approach that targets
older school‐age children (12–17 years of age) presenting with serious antisocial
behaviors and their families. Although MST combines intensive family therapy with
individual skills training, there are key differences from traditional models of systemic
intervention. MST treatment is provided by a team consisting of two to four thera-
pists and a supervisor who are available to the family 24 hours a day, 7 days a week.
Average MST treatment includes weekly sessions up to two hours in length that take
place for 3–5 months. Consistent with MST’s strong theoretical foundation based on
Bronfenbrenner’s (1979) theory of social ecology, a primary assumption of treatment
is that antisocial behaviors are encouraged and maintained through the interplay of
risk factors across the child’s natural ecology (i.e., family, peer, school, and commu-
nity contexts). A second critical assumption is that parents are critical to the change
process. Core features of MST include addressing the multiple determinants of clini-
cal problems, utilizing the family as key to effective behavior change, providing home‐
or community‐based services to overcome service access barriers, and integrating
evidence‐based interventions to address the individualized strengths and constraints
of each unique family system.
Commonalities across models

While evidence‐based models reviewed in this chapter provide a unique clinical
approach for effectively addressing parent-child relational problems during the school‐
age years, the interventions across the different models share commonalities. Across
all models the theoretical focus is on the power of the system to create meaningful,
sustainable change with interventions commonly focused on assessing and transform-
ing key dimensions of the parent-child relationship. Each of these systemic models
maintains flexibility in session structure, meeting with the child and parent individu-
ally as well as conjointly at different times throughout treatment and often interven-
ing at the family, extended family, and extra‐familial levels as deemed appropriate and
necessary to create shifts in individual behaviors and/or relational dynamics. Significant
attention is also given to joining with the system and each member to create a strong
therapeutic alliance throughout treatment. Across the models, emphasis is placed on
therapists relating genuinely with all members of the system to enhance parents’ and
children’s readiness and motivation for change. The models also share a systemic view
of the problem as relational, placing significant focus on identifying key patterns of
problematic interaction while also respecting the function dysfunctional patterns
often play within the relationship and larger system.
The specific interventions used across models also share a common emphasis on key
dimensions of the parent relationship, including emotional warmth, conflict, and
communication. Acknowledging the importance of the emotional quality and attach-

ment bond within the parent-child relationship, several interventions including the
ABFT attachment task and interventions in PSP that promote insight and under-
standing aim to enhance warmth, cohesion, support, and responsiveness within the
relationship. Other interventions, including parenting skills training in MDFT and
behavior parent training in MST, emphasize enhancing parental control functions
(e.g., discipline, limit setting, autonomy). Significant attention is also given to decreas-
ing parent-child conflict. For example, FFT interventions focus on communication
and conflict resolution training, while MDFT interventions focus on assisting chil-
dren and parents to communicate and solve social problems effectively and control
anger and impulses.
Evidence of Effectiveness
Evidence from meta‐analyses and systematic literature reviews supports the effective-
ness of systemic interventions with families of school‐age children (Baldwin, Christian,
Berkeljon, & Shadish, 2012; Borduin, Curtis, & Ronan, 2004; Carr, 2014; Couturier,
Kimber, & Szatmari, 2013; Hogue et al., 2015). The current body of research con-
cludes that systemic therapy is an efficacious treatment approach for various child‐
focused problem behaviors and disorders frequently co‐occurring with parent-child
relational problems, including externalizing disorders, juvenile delinquency, conduct
disorders, and substance use disorders as well as family outcomes (Carr, 2014). Recent
studies have shown that family therapy with school‐age children and their parents
positively impacts school performance and attendance, delinquency and aggression,
substance use, and family functioning (Guo & Slesnick, 2013; Henggeler, Clingempeel,
Brondino, & Pickrel, 2002; Henggeler, Pickrel, & Brondino, 1999; Liddle et al.,
2001; Santisteban et al., 2003). Common positive family outcomes of systemic inter-
ventions include enhanced perceived family cohesion and organization and reduced
family conflict (e.g., Datchi & Sexton, 2013; Diamond, Russon, & Levy, 2016;
Santisteban, Suarez‐Morales, Robbins, & Szapocznik, 2006; Slesnick & Prestopnik,
2009). Furthermore, the positive outcomes of systemic therapy are cost‐effective
(Crane, 2008) and long‐lasting (Sawyer & Borduin, 2011).
Treatment Contraindications and Considerations
While systemic interventions have been deemed effective with various presenting
problems associated with common parent-child relational problems, some important
treatment contraindications and considerations should be taken into account prior to
initiating systemic therapy. Pervasive maltreatment of the child by the parent repre-
sents relational patterns beyond the continuum of common relational problems dis-
cussed in this chapter. Readers are directed to Rhoades et al. (2020, vol. 2) for a
discussion of potential contraindications of systemic approaches to child maltreat-
ment. Additionally, some comorbid individual diagnoses of the parent and/or child
also contraindicate systemic interventions focused on parent-child relational p
roblems.
For example, drug or alcohol dependence, psychosis, and suicidal ideation represent
132 Kami L. Gallus
specific individual‐focused problems that may require stabilization prior to or in place

of systemic therapy. Further, noting previous research suggesting that the quality of
the marital relationship between parents is related to child adjustment and social/
emotional functioning (Cummings & Davies, 2010), systemic therapists should use
caution to fully assess if the child is serving as a scapegoat by taking on the role of the
identified patient in the system or if the individual or parent-child relational symptoms
serve a function related to marital discord. While partner relational problems that
co‐occur with parent-child relational problems may serve as a contraindication for
treatment focused solely on the parent-child relationship, at the very least, systemic
therapists should consider conjoint therapy with the parents prior to or in conjunction
with family therapy focused on the parent-child relational problem.
Additional treatment considerations for systemic intervention and treatment of
common relational problems focus on diversity, including issues related to culture and
ethnicity, race, religion, ability, and gender. When working with families with school‐
age children, systemic therapists must consider the implications of each child’s devel-
opment on treatment considerations. For instance, for children with developmental
delays or disabilities, an experiential or play therapy approach may be more appropri-
ate than talk‐based therapy approaches. Systemic therapists must also be sensitive to
differences in parenting and caregiving and how these differences are strongly related
to attitudes, beliefs, traditions, and values of the culture, ethnic group, and/or reli-
gion within which the family belongs. As Stratton (2016) pointed out, there is little
data about client expectations of systemic therapies, yet it is likely that differences in
expectations exist among different cultural groups. It should be noted that a large
majority of the gold standard approaches to assessment and treatment have been
developed and tested in the United States and the United Kingdom, with little infor-
mation regarding the transference to other non‐Westernized cultures. As the field
moves forward, a greater push should be made to develop and test promising systemic
interventions that consider each family’s unique culture and context. This is particu-
larly important noting Henggeler et al.’s (2009) findings that systemic interventions
including options tailored to the challenges of community‐ and/or cultural‐level
adversity are more effective when working with parents and their children. Finally, as
evidence accrues that family psychoeducation serves to enhance a wide range of clini-
cal outcomes, including fostering more effective use of professional services and
reducing family tensions and dysfunction (Lucksted, McFarlane, Downing, & Dixon,
2012), systemic therapist should be aware of the potential value of psychoeducational
approaches when working with families of school‐age children.
Future Directions for Research, Clinical Practice,

Education, and Policy
As relational problems grow increasingly recognized and respected as a prominent and
important focus of mental health treatment, the field of systemic therapy must con-
tinue to expand its role and influence in the clinical assessment and effective treatment
of common parent-child relational problems. Despite the intuitive richness of tradi-
tional family therapy approaches, relatively little research has sought to test the validity
of constructs theorized to be critical to the parent-child relationship, particularly
uring the school‐age years. Efforts must be made to identify the most sophisticated
d
methods of systemic assessment and conceptualization of parent-child relational prob-
lems that capture parent and child behavior and relational patterns most critical for
problem development as well as therapeutic change. Ultimately, specific diagnostic
criteria for common relational problems in middle childhood through adolescence,
similar to those developed for early childhood (e.g., DC: 0–5; Zero To Three, 2016;
see Topham et al., 2020, vol. 2), are necessary to advance the visibility and validity of
systemic treatment.
Despite the many positive findings regarding the overall effectiveness of systemic
therapy with school‐age children and parents, it should be noted that the current
models of systemic therapy continue to punctuate the child as the identified patient
and problems during this stage of development as primarily associated with child anti-
social or high‐risk behaviors, such as delinquency and substance use. As a result, the
gold standard systemic interventions are marketed for families of children with various
difficulties rather than for families experiencing parent-child relational problems. A
change to more systemic language that acknowledges the interactional and relational
nature of problems facing families of school‐age children may be a small but impor-
tant shift leading to more specific parent-child relational problem diagnostic criteria
and research. Additionally, for the field to expand its influence, it is important for
systemic therapists to find ways to educate funders and policy makers regarding the
evidence supporting systemic interventions with many common relational problems
that may traditionally have been seen as child‐focused and parent‐focused problems.
There are many areas of everyday systemic practice involving parent-child relational
problems with fewer social consequences that have yet to be researched. To date, little
is known about what types of therapeutic changes may be most significant for families
who enter treatment with relatively good family functioning or minor behavioral con-
cerns. Evidence of effectiveness across diverse families and diverse presenting prob-
lems is important to expand the effectiveness of systemic therapies. While the research
into the efficacy of systemic interventions with families of school‐age children is posi-
tive, limited research has explored what factors are most important in the change
process. Research must go further to explore for whom an intervention works and by
what mechanism or process change is created and/or maintained.
The future of the field lies in the hands of the next generation of systemic therapy
students and trainees. Research with families with school‐age children suggest that even
the evidence‐based models are not effective when administered by poorly trained thera-
pists and poor adherence to treatment models (e.g., Graham, Carr, Rooney, Sexton, &
Satterfield, 2014; Sexton & Turner, 2010). Systemic therapy training programs must
move from solely providing students with training in traditional family therapy
approaches to begin providing training in evidence‐based and effective systemic models
for specific presenting problems such as common parent-child relational problems.
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6
Prevention and Treatment
of Problems with Sibling
Relationships
Armeda Stevenson Wojciak and Casey Gamboni
Sibling relationships are prevalent, with 85–90% of the world population having at
least one sibling (Buist, Deković, & Prinzie, 2013). Sibling relationships have been
found to be one of the longest lasting and at times the most influential relationships
of a person’s life (Cicirelli, 2013; Smith, Romski, & Sevcik, 2013). Authors state that
sibling relationships are important to family therapy (Bank & Kahn, 1982; Cicirelli,
2013; Cox, 2010; Namyslowska & Siewierska, 2010). Yet, when looking at the
current literature, many scholars disregard the topic of the sibling relationship (Hilton
& Szymanski, 2011) as have systemic family therapy (SFT) theorists. This chapter
provides systemic therapists with a brief overview of sibling relationships from an SFT
perspective.
Sibling relationships are complicated for scholars to work with and for theorists to
conceptualize because there are so many variations. Most of what we know about
sibling relationships is informed by basic science conducted by family studies scholars
with limited applied or intervention science. There are several reasons for this. First,
sibling relationships are typically difficult to study. For instance, not until advance-
ments in statistical analyses (i.e., hierarchical linear modeling) were scholars able to
accommodate sibling groups larger than 2. Historically, researchers have had to create
predetermined cutoffs or categories, such as certain birth orders (e.g., Yeh & Lempers,
2004) or age ranges (e.g., within 4 years, Buhrmester & Furman, 1990). Second,
there may be gender differences. For instance, how does a same‐gender dyad get
along versus a mixed‐gender dyad? To further complicate it, what do you do when
you have more than two siblings of the same gender, and are there differences depend-
ing on the gender constellation? These are just examples of the complex thought
processes needed to operationalize a sibling study, let alone systemically conceptualize
variations in family dynamics that we can theorize about.
In this chapter, we will first provide a brief introduction to the role siblings play in
one another’s lives, second we will discuss some potential problems that may occur in
sibling relationships that may warrant therapeutic intervention (e.g., abuse, rivalry,
bullying), third we will discuss the role siblings have and the strengths they provide,
fourth we will discuss SFT theories and an analysis of ways that SFT theories have
142 Armeda Stevenson Wojciak and Casey Gamboni
conceptualized siblings, fifth we will provide a discussion of themes across SFT theo-
ries, sixth we will provide an overview of working with siblings, and finally we will
issue a call for more empirical work and systemic theorizing to further support work
with siblings in therapeutic processes.
The role that siblings play in one’s life
Positive sibling relationships are correlated with amplified chances for increased self‐
esteem, social functioning, and cognitive development (Bush & Ehrenberg, 2003). In
childhood and adolescence, the sibling relationship usually involves daily interactions,
but, in adulthood, becomes more distant (Berg‐Cross, 2010). Daily interactions
throughout childhood and adolescence create a shared history that can create a strong
sense of companionship with unique influences on one’s development over the lifespan
(Diener, Anderson, Wright, & Dunn, 2015). Interaction between siblings also plays a
role in the social life of each child, and this relationship has been found to be particu-
larly significant in developing social skills, especially before they reach school age
(Knott, Lewis, & Williams, 1995). Siblings also have the potential to be a risk or a
protective factor for internalizing and externalizing behaviors (Dirks, Persram, Recchia,
& Howe, 2015). When siblings report warmth between them, this can be a buffering
effect for adversity (Gass, Jenkins, & Dunn, 2007), and conflict with a lack of warmth
between siblings adversely influences symptomology of youth (Dirks et al., 2015)
Problems that can occur within sibling relationships

Conflict among siblings has been found to be one of the most prevalent and volatile
forms of violence within any family relationship (Straus, Gelles, & Steinmetz, 2003).
Sibling conflict can be categorized as arguments, fights, or disagreements that lead to
high levels of harmful short‐ or long‐term lasting effects such as resentment and isola-
tion from one another (Rinaldi & Howe, 1998). A strong difference between sibling
conflict and peer conflict is that within some cases of sibling conflict, both siblings are
contributing to the problem behavior, whereas peer conflict is more often one dominat-
ing over the other (Skinner & Kowalski, 2013). Factors influencing the sibling relation-
ship in the context of violence vary (Pickering & Sanders, 2017). However, constructive
conflict, as explained by Foote and Holmes‐Lonergan (2003), can p rovide the
opportunity for the development of resolution skills and cognitive functioning such as
negotiation, tolerating, and patience. Sibling rivalry (Leung & Robson, 1991), sibling
abuse (Meyers, 2017), and sibling bullying (Bowes, Wolke, Joinson, Lereya, & Lewis,
2014) have all been found to be forms of conflict within the sibling relationship.
Sibling rivalry Literature regarding sibling rivalry is scarce. Sibling rivalry can be
defined as a type of competition or animosity among siblings (Stein, 2015). Findings
suggest that competitions within the sibling relationship stem from the need for par-
ent’s affection, love, and attention for other recognition or gain (Leung & Robson,
1991). Leung and Robson report that most sibling relationships develop varying
degrees of rivalries ranging from verbalized frustrations, demands for attention, and
Sibling Relationships from a Systemic Perspective 143
at times physical attack. Recchia and Witwit (2017) report that sibling relationships
and conflicts are characterized by imbalances of control, which is most of the time
reflected in their fights or perceived rivalries. Sibling rivalries are universal, which,
when handled properly, has the potential to lead to the development of healthy social,
interpersonal, and cognitive skills (Leung & Robson, 1991). Among sibling scholars,
most assert that sibling rivalry is a common occurrence (Sori, 2012).
Sibling abuse Sibling abuse is one of the most common forms of family violence in
the United States (Button, Parker, & Gealt, 2008). As explained by Caffaro and
Conn‐Caffaro (2005), sibling abuse is an interpersonal boundary violation between
sibling dyads. Meyers (2017) found that the prevalence of sibling abuse is high due
to the unpredictable nature of abusive acts and how emotional and physical assault
can impact the ability to safeguard or stand up for oneself. Abuse, which can take the
form of physical or emotional harm intended to inflict pain (Kiselica & Morrill‐
Richards, 2007), is a form of violence within the family that often goes unaddressed
due to parents possibly dismissing abuse within the home, which, if left not acted
upon, is considered a form of child neglect (Stutey & Clemens, 2015). Also, there can
be a fine line between common sibling conflict and violence. Factors such as intent
and severity of the abusive act by one sibling and the impact these acts have emotion-
ally on the other sibling are essential to consider when determining if the interactions
are abusive (Kiselica & Morrill‐Richards, 2007). Caspi (2012) underlined a strong
distinction between abuse and rivalry, with abuse having one sibling exerting power
over the other, whereas with rivalry, the conflict is more reciprocated between both
siblings.
Sibling bullying Sibling bullying is a specific type of behavior that is repeated over
time with the intent to cause both harm and domination (Bowes et al., 2014).
Research indicates that 40% of siblings have been exposed to sibling bullying on a
weekly basis (Wolke, Tippett, & Dantchev, 2015). Duncan (1999) found that chil-
dren involved in any sort of sibling bullying have been found to be more prone to
high rates of depression and loneliness. Sibling bullying has lasting effects such as
anxiety, depression, and self‐harm on individuals inflicted (Arseneault, 2015).
Strengths that sibling relationships may provide

With the sibling relationship being one of the longest relationships a human being
will have throughout one’s lifetime (Cicirelli, 2013), this relationship has also been
found to have powerful effect on the development of a person in both childhood and
adulthood (McHale, Crouter, & Whiteman, 2003). Though it has been shown that
more conflictual and negative sibling pairings in childhood predict internalized stress-
ors including anxiety or depression (Stocker, Burwell, & Briggs, 2002), an improve-
ment from negative to positive sibling relationship quality has been shown to
significantly decrease depressive symptoms in adulthood (Richmond, Stocker, &
Rienks, 2005). Yelland and Daley (2009) reported that having a positive and support-
ive sibling relationship can lead to open and impactful emotional expression. Given
the influence siblings can have on one’s development and family dynamics, sibling
relationships are an important consideration for systemic therapists.
Systemic Family Therapy Theories and Sibling Relationships
Siblings are undoubtedly prevalent (78.9%, McHale, Updegraff, & Whiteman, 2012;
United States Census Bureau, Living Arrangements of Children under 18) and an
important familial relationship (Bullock & Dishion, 2002; Gass et al., 2007). Despite
the prevalence, only two systemic theorists included siblings into their conceptualiza-
tion of family systems thinking and therapy: Bowen (1978) and Minuchin (1974).
Bank and Kahn (1982) discuss and critique the lack of sibling relationships included
by family therapy theorists. This critique can be stated today as well. This section will
provide a brief overview of current SFT theorizing around sibling relationships.
Overview of how family therapy theorists conceptualize

sibling relationships
Intergenerational theories Bowen repeatedly discussed how his work was informed
by Toman’s sibling position and personality profiles and how these profiles helped to
understand an individual’s level of differentiation (Bowen, 1966, 1978). Bowen dis-
cussed how all family members participate in the family ego mass and that the sibling
position and personality profile could be used to reconstruct the family emotional
process of previous generations and can be used to predict how one will operate in
family therapy and in their marriage. He asserts this is done by understanding the
triangles within family relationships. He also stated that siblings who are more differ-
entiated tend to be less dependent on the parent’s ego mass. Despite conceptualizing
and highlighting the importance of siblings in family dynamics, no specific techniques
were discussed for understanding and utilizing these sibling profiles when working
with siblings in family therapy.
It should be noted that while Bowen did theorize about it, scholars have critiqued
his theory and application. Miller, Anderson, and Keala (2004) point out that Bowen’s
description of sibling position is the least defined concept in his theory. Further, as
stated above, Bowen’s conceptualization of sibling position was informed by Toman’s
theory of personality development. Miller and colleagues demonstrate that Toman’s
theory does not have an empirical backing and that another sibling birth position
theorist, Adler, has greater support. They identify the faulty logic behind Bowen’s
sibling position concept, and the fact that Bowen thought his conceptualization was
universal but it did not account for gender and cultural differences is an important
limitation.
James Framo (1992), a proponent of intergenerational family therapy, discussed
with fervor the necessity with which he thought siblings should be included in family
therapy and the lack of understanding we have about sibling relationships. He shared
that when he does live family‐of‐origin sessions, he asks that organizers include sib-
lings, but this only happens about 20% of the time. Framo also shared a case example
of a sibling session with a sibling set of five and their aunt. He outlined the different
family dynamics that occurred and how having all the siblings there, they were able to
process through their own perceptions of family dynamics growing up and how that
was impacting them as adults. Despite Framo’s support for the inclusion of s iblings in
therapy, the influence siblings can have on one another, and the case example pro-
vided, Framo did not include any specific techniques or ways of working with
siblings.
Bank and Kahn (1982) critiqued Boszormenyi‐Nagy and Spark’s (1973) book
Invisible Loyalties for the lack of exploration and depth surrounding sibling relation-
ships and sibling dynamics in families. Their biggest critique is around the fact that
sibling relationships often have a component of loyalty embedded in them, and to not
address that in their book about loyalties was a missed opportunity for contextual
therapy. To build off of Bank and Kahn’s critique, we would add that it is surprising
that Boszormenyi‐Nagy did not theorize more about siblings, particularly when con-
sidering his emphasis on ethics and fairness within the family. Siblings are uniquely
aware of fairness within the family (Kowal, Kramer, Krull, & Crick, 2002; Taylor &
Norris, 2000). Boszormenyi‐Nagy’s exploration of sibling relationships and dynamics
may have been omitted; however, others have suggested ways in which the sibling
relationship can be accounted for in contextual family therapy.
Anderson and Hargrave (1990) shared two clinical vignettes of families in which
the family’s relational ethics were the underlying problem. One example included a
family consisting of an elderly mother and her three children. The therapist’s goal
with the family was to work on building trust by increasing love and care from the
mother to her adult children. After seven sessions and lack of progress, the mother
demonstrated more symptoms of depression and refused to participate in any more
sessions. In this vignette in particular, the therapist never addressed relational pro-
cesses between siblings; however, in the discussion, the authors stated that perhaps
tensions between the siblings and the imbalance in their relationship were inhibiting
the work with the mother and family together. In fact, Anderson and Hargrave stated
that working at the horizontal level with the siblings may have helped them to work
vertically with the mother–child relationships. In this instance, working with the sib-
ling relationship was an afterthought that the authors believed might have improved
therapeutic outcomes.
Structural Salvador Minuchin (1974) illustrated in his book Families and Family
Therapy the important role siblings play in one another’s life developmentally and the
importance of working with the sibling subsystems and provided examples of ways in
which he worked with the sibling subsystem in therapy. Minuchin emphasized that
the sibling subsystem is the “first social laboratory” for children where they get to
experiment with ways to negotiate, learn from peers, cooperate, and compete, how to
make allies or isolate others, and so forth. He talked about how children take these
lessons into their relationships with peers outside their family and how children bring
lessons they have learned from outside peers back into the sibling subsystem as well.
Minuchin also emphasized the importance of ensuring boundaries for the sibling sub-
system. These boundaries should ensure privacy from adult intervention as siblings
are experimenting somewhat successfully or unsuccessfully with some of the tasks
listed above.
Minuchin (1974) described the therapist as an active advocate and facilitator of
appropriate boundaries between parental and sibling subsystems. He stated that the
therapist could be a bridge between the parental and sibling subsystems when there is
rigidity between the subsystems so much so that parents cannot intervene when they
need to. An example provided by Minuchin would be an instance where a child is
participating in a rigid triad with their parents. Minuchin asserted that a therapist
should create a balancing technique of putting the child in a situation with the sibling
subsystem to remind the child of how rewarding it can be to be in the sibling
s ubsystem. At the same time, the therapist is trying to reinforce the spouse subsystem
to help the parents see their strength without the child in the triad.
Minuchin’s use of space is also important when working with the family and specifi-
cally the sibling subsystem. Minuchin used space and seating in the room to influence
the ways family members interacted with one another. In his example of the Brown
family, Minuchin described how he was able to break up the parental and older child
triad and how he was able to decrease enmeshment between the sibling subsystem by
use of space and structure. For instance, he had the youngest Brown children play a
board game in the center of the room with the parents and older son observing from
the outer part of the room. Minuchin instructed the parents to have the board game
at home. The oldest of the three targeted children became an ally of Minuchin. That
child then became less enmeshed by having more relationships outside of the family
with age‐appropriate peers. The two youngest children became closer, but still had
some problems. The oldest son who was once part of the parental triad was now able
to help intervene with his younger siblings in a helpful way. The oldest was no longer
acting as a parental member of the triad, but he was an older brother helping his
siblings.
Narrative The use of narrative therapy when working with siblings and families is
another possibility; however, there is little conceptual or empirical support for the use
of siblings in narrative family therapy with a few exceptions. One exception comes
from Kotze, Kulasingham, and Crocket (2016) where one sibling helps another sib-
ling work through his recollection of his relationship with his mother through a re‐
membering conversation. Re‐membering is reengaging with relationships in your past
to revise one’s membership with significant relationships in their life (White, 2007).
In this case example, Andrew, who was separated from his mother after the unex-
pected death of his father, was able to reengage and explore what his relationship with
his mom was like. The therapist helped Andrew use his siblings, those who were not
separated from the mother, to help him research and gain information about his
mother and her experience of their interactions. The siblings were able to share the
things that the mom knew about Andrew and their visits, particularly how much they
meant to him, and how she made sure to be there predictably for all of them. It was
through this process that Andrew was able to grieve and say goodbye to his mom. His
sibling relationships were a useful part in this process. The second exception is from
Wilson (2016) and the creative use of movement and space, much like Minuchin
describes in his work. Wilson advocates for siblings to be used as consultants or co‐
researchers. Given the understanding of co‐construction of meaning within narrative
therapy, Wilson who works with children involved in social services cautions adults
with the use of language and how that might impact children’s views of themselves.
Wilson supports repositioning practices and ways to make children the expert to off-
set some of the internalized feelings and narratives they may feel as a result of the
labels used.
In both of these examples, true to a narrative social constructionist perspective,
siblings were used as collaborators for meaning‐making. It is within this vein that
sibling relationships would be a valuable relationship to use in narrative family ther-
apy. In both of the examples, siblings were helpful in less than optimal situations (i.e.,
help with grief or when involved in social services). While siblings are important in
stressful times, siblings also are an important relationship to consider in all matters
that might bring families into the therapy room. For instance, current research on
siblings indicates that older siblings may influence younger sibling’s alcohol or drug
use (Kothari, Sorenson, Bank, & Snyder, 2014; Scholte, Poelen, Willemsen, Boomsma,
& Engles, 2008). Whiteman, Jensen, and Maggs (2014) examined convergent and
divergent ways in which siblings’ processes may influence alcohol use for siblings.
They report that younger siblings who admire their older siblings are less likely to
share friends with their older sibling and thus more likely to participate in such behav-
iors via social learning that occurs from the younger sibling admiring the older sibling.
However, the authors also report that sibling differentiation is a divergent way in
which siblings have different levels of alcohol and delinquent involvement.
Same‐gender sibling dyads had more divergent patterns of alcohol use than did
mixed‐gender dyads.
A narrative therapist who had a child or family brought in for adolescent substance
use could use the information about sibling relationships to help create a conversation
between siblings. Perhaps, if the sibling relationship is influencing or perpetuating the
unhealthy behaviors, the therapist could help facilitate an externalizing conversation
between the siblings about the alcohol, drug, or delinquent behaviors. Perhaps they
can identify times in which the substance use or delinquent behavior was not at the
root of their interactions, identifying unique outcomes. At this time, it may be useful
for the therapist to reposition another sibling or parent to serve as a witness for some
of these unique outcomes or of times in the past that can help them have re‐membering
conversations. Through this process, the siblings could be reauthoring their relation-
ship without the unhealthy substance or delinquent behavior. If the sibling r elationship
has a greater level of sibling differentiation and one sibling is demonstrating the
unhealthy behavior, perhaps the divergence between them could be set aside and the
unique outcomes could be the things that are common between them. The same re‐
membering and reauthoring discussed above can be used to indicate the care that
exists or once existed between the siblings. Together they can co‐create ways in which
they can be there for one another. They can author a new narrative in which the dif-
ferences between them do not have to be a divisive process, but that the relationship
can be a strength. Co‐creating a new narrative for their sibling relationship can help
the sibling with the unhealthy behaviors see that other parts of their life can be reau-
thored as well. They can feel more confident as they move forward addressing some
changes they may need to do with their sibling, often their first partner in life, working
with them in the process.
Solution focused Examining the literature, it seems as though the majority of times
solution‐focused therapy or techniques are used with sibling relationships are often in
association with a sibling with autism spectrum disorder (Turns, Eddy, & Jordan,
2016). Jordan and Turns (2016) detailed why solution‐focused therapy is helpful for
families with a child with autism. Turns and colleagues (2016) outlined four different
solution‐focused informed techniques that can be utilized in the home to help sup-
port sibling relationships of one child with autism and siblings that do not have
autism. Such techniques include (a) dialogues to encourage with which they list spe-
cific questions that can be asked at mealtime; (b) the use of a behavior chart for both
children; (c) using solution building art projects, particularly helpful for nonverbal
siblings; and (d) character compliments that has each child identifying a favorite char-
acter and giving a compliment to the sibling based on that character. The techniques
provided by Turns et al. are tangible and easily done at home and can be implemented
by a therapist.
We would go even further to say that the techniques described above can be uti-
lized by therapists working with siblings for any presenting problem. The techniques
are designed to help foster warm and positive interactions between siblings, facilitated
by the parents. Siblings who are experiencing conflict would benefit from these excep-
tions. These structured and positive interactions can help them notice exceptions to
the conflict in their relationship and help them identify what they would like their
relationship to look like.
Themes across systemic family therapy theories regarding

Interestingly, almost all of the examples and vignettes discussed in the literature and
described above are of adult siblings working through sibling dynamics that have
existed since they were children yet were not addressed until they were adults. The
exceptions are Minuchin’s (1974) work as well as the techniques offered by Turns and
colleagues (2016). Perhaps the lack of work on sibling relationships in childhood is
because of parent perceptions that siblings will just work things out, or it is not a
problem since they had similar sibling dynamics with their siblings. Another reason
for the lack of focus on childhood sibling relationships could be that therapists are
focused on a presenting problem of one child and neglecting, or at least not writing
about, the sibling aspects. It may also be that adult sibling scenarios are the ones that
authors had consent to share. Despite the reason for mostly adult sibling examples in
the literature, the lack of inclusion of siblings in family therapy theory and techniques
is possibly best represented by the well‐meaning and retrospective account that
Anderson and Hargrave (1990) provided. They discussed how the sibling relationship
may have been useful with a client they worked with, but no such attempt was done
in therapy. Throughout the literature, author after author discusses the importance of
the sibling relationship in family therapy (Bank & Kahn, 1982; Cox, 2010;
Namyslowska & Siewierska, 2010). Yet we lack specific ways in which to work with
siblings that is not just as a consultant/informant. For instance, school counselors see
the value of family systems perspectives and understand the importance of siblings,
particularly for information gathering (Mullis & Edwards, 2001). As systemic family
therapists, we have to move beyond siblings as informants or afterthoughts and be
strategic in how we can build this aspect of family therapy.
Working with Siblings in Family Therapy
Assessment
Sori, Dermer, and Wesolowski (2012) outlined a multimodal perspective that names
six areas family therapists should assess, two of which mention siblings directly.
Specifically, therapists should assess the functioning of each parent with each sibling
and assess the relationships among the siblings. Examples of topics to ask about
include how siblings spend time together, if they do (ask about frequency and quality
of time spent together), whether their sibling is someone they can turn to if they need
someone, or if there is a conflictual relationship, ask how they solve problems or
conflict between them. Sori (2006) supports the need to assess sibling relationships
since this is where children are first socialized in conflict resolution, compromise,
negotiating, and so forth.
We encourage all therapists to actively think through how the contexts or complexi-
ties of sibling relationships may be influencing the sibling dynamic. We recommend
pondering context and complexity with your clients. A curious stance is necessary for
sibling relationships as theory and empirical support for understanding it is limited.
Further, we challenge therapists to push themselves theoretically to think about
siblings. While most SFT theories do not explicitly state ways to think through sibling
relationships, be creative as a therapist in your preferred theory and think about assess-
ment questions for the sibling relationship from that mindset. Perhaps from a Bowen
perspective, an assessment question could be, “what do you know about your mom/
dad’s relationships with their sibling?” From a solution‐focused perspective, assess-
ment questions could be, “if you and your sibling(s) could have a perfect day what
would it look like? Describe what would happen and how everyone would be interact-
ing.” As these examples indicate, each theory can have a sibling assessment compo-
nent. We as therapists need to ensure that sibling relationships are assessed and
brought to the forefront. The sibling relationship can be a source of intervention if
there are problems or a source of support to build on if there is a warm relationship.
Treatment goals
Throughout the theories discussed, the sibling relationship was used as a tool to help
clients. However, for problems that arise that are sibling relationship specific, includ-
ing sibling rivalry, enmeshment, sibling abuse, and so forth, it is important to have
treatment goals. These goals should be specific and measurable. The siblings and
parents should be aware of the specific goals (Kahn & Lewis, 1988). Minuchin (1974)
argued that goals related to sibling relationships should focus on transforming the
sibling subsystem. Enmeshment within the subsystem must be decreased, and bound-
aries need to be opened to allow siblings to interact with their parents and peers
outside the sibling subsystem. In instances of sibling abuse or bullying, specific goals
surrounding safety need to be at the forefront. For sibling rivalry, it is important to
assess family dynamics and relationships. Rivalry may exist as siblings perceive differ-
ential treatment between one another. Goals to assess, acknowledge, and address any
differential treatment between siblings would be needed within the family system.
Further development of goals will occur as the therapist continually assesses the
sibling relationship within family functioning.
Therapy with siblings

Lewis (1988) detailed three reasons for working with siblings: when there was a prob-
lem between siblings (i.e., sibling rivalry, sibling antagonism), when there was a family
crisis (i.e., parental divorce), and when the family structure was unstable (i.e., parent
with a mental illness or substance abuse problem). Lewis described what each of these
situations may look like in sibling relationships. She talked about ways in which
a ssessment and treatment may be different based on the situation and the length of
time siblings may need to be seen. Lewis also discussed anxiety parents may have with
their children being left alone with the therapist and not being able to catch or filter
what the children may say. She stated that this may not be an expressed anxiety, but
may be presented as missed, late, or canceled appointments. Lewis also hypothesized
that therapists may not be as inclined to work with the sibling set without the parents
as this could be a way for the sibling subsystem to triangulate the therapist or
parents.
Lewis stated that therapy with siblings needs to be goal oriented and that the sib-
lings and parents need to know what the therapeutic goals are. Once the goals are
established, the therapist’s role is that of a family therapist crossed with group thera-
pist. For instance, the family therapist has to join with all family members, but the
group therapist needs to make themselves the central figure. Lewis described thera-
peutic role with siblings in five stages. Stage one consists of the therapist as an invisible
member of the group as the siblings do their thing in the office (e.g., playing, talk-
ing). Stage two is when the sibling group accepts the therapist as a central figure who
intervenes when necessary and organizes the activities. The most important part of
this stage is establishing trust between the siblings and the therapist. In the third
stage, the therapist is a matchmaker and creates opportunities for connections between
the siblings. During the fourth stage, the therapist is a coach, helping siblings to navi-
gate the problems that brought them into therapy. In this stage, it is important that
the therapist has an understanding of sibling dynamics. Lewis recommended that it is
important to respect the sibling hierarchy. The fifth and final stage is when the thera-
pist becomes the former therapist and is no longer needed. The siblings are able to
turn toward one another and support each other in appropriate ways.
Kahn and Lewis (1988) edited a book titled Siblings in Therapy: Life Span and
Clinical Issues. This book provides information about sibling relationship dynamics,
working with young children, working with a large sibling group, and working with
siblings who have a sibling with a disability or chronic pain and looks at issues across
the lifespan. This book is a good resource, but 30 years later, there have not been
many advancements in ways to work therapeutically with siblings. In fact, there are
some chapters like Ethnic Patterns and Sibling Relationships (Welts, 1988) that could
be updated and expanded upon. Let this be a call to family therapists to not only
include siblings in therapy but also write about the process. We need to help each
other learn.
Therapy with siblings from a systemic theory perspective

Below is a case example with which we will take a systemic theory lens and discuss
how a systemic therapist could work with a sibling group. This is not intended to be
a complete guide, but rather an exercise to see how one can use this theory to think
through one or two steps when working with siblings:
The Key family1 is seeking therapy for their youngest child. Anton (12) has been acting out
in school, not doing his work, and keeps getting in trouble with his older brother. Anton’s
older brother Jeremy (14) is tired of the way that Anton treats him. Anton is always trying
to manipulate Jeremy into doing things he doesn’t want to do. Anton is also physically
aggressive toward Jeremy. There was an instance when they were walking home from the bus
stop that Anton was punching Jeremy in the arm the whole way home just so Jeremy would
carry Anton’s musical instrument, since he didn’t want to carry it. Ms. Key, a single mom
who works hard to provide for her children, but often is not around, heard her boys fighting
about this event. She knew something was going on between her sons but she doesn’t know
what to do. She thinks sibling rivalry is normal and that her boys will work through it, but
it seems to keep escalating. She wants her sons to have a good relationship with one another
like she has with her sister, so she calls and sets up a therapy appointment.
The sibling aspects of this case example can be conceptualized through multiple
theoretical approaches; however only a few will be described below.
Contextual The contextual systemic therapist would think about the family ledger
and the relational fairness that exists. The therapist would set up a session with the
siblings and mom and talk about some of the relational credits and debits that have
been occurring. Perhaps given that the sibling rivalry tends to be originating with the
younger sibling, the therapist would talk about relational fairness with regard to
access to mom from both siblings. The mom may rely a lot on Jeremy, the older sib-
ling, since she is often not home. Anton, who is on the cusp of adolescence, may
think this is unfair treatment, now that he is getting older. Anton may feel that the
family ledger is skewed away from him. The therapist may take some time to work
with the mom and the siblings to think about multidirectional partiality and really
help them to think of what the best interest is for everyone. The therapist would help
Anton think about how his actions are influencing Jeremy and the relational ledger
that exists between them. Perhaps the therapist would help the mom think about
what expectations, burdens, or debts she is putting on Jeremy and whether that is fair
for him or, if given Anton’s increasing age, responsibilities can be more evenly
distributed.
Structural A structural systemic therapist would be mindful of the family’s hierar-

chy, boundaries, alliances, and coalitions that may be at play. After joining with the
family, the structural therapist may identify that Jeremy is operating too frequently
in the parental subsystem and Anton feels that he has lost his brother and that his
mom and Jeremy are partnering against him. The therapist would work to restruc-
ture the family so that Jeremy and Anton are both in the sibling subsystem and Ms.
Key is the head of the hierarchy. The therapist may first do this in session by reposi-
tioning the family with where they are sitting in the room, clearly indicating a divi-
sion between Ms. Key and her sons. Jeremy and Anton would be placed next to one
another.
Narrative The narrative systemic therapist would be interested in learning more

about the sibling relationship and particularly looking for unique outcomes. The
therapist would be working to find the times when Anton and Jeremy got along
or felt like they had the special bond. The therapist would ask questions to gather
a full picture of their experiences. The therapist would be pulling from both
Anton and Jeremy to author the story and describe what was going well. They
could re‐member what used to be their normal way of interacting in an effort to
help them see what they could do to rebuild and reauthor how they interact with
one another.
Solution focused The solution‐focused systemic therapist could ask a miracle ques-
tion about the sibling relationship and look for exceptions to the fights that Jeremy
and Anton have been having. The therapist would use scaling questions to see where
they are currently and what actions they can do to get them closer to the way they felt
about their relationship identified in the exception activity.
Systemic contextual considerations when working with

Families are diverse and enter into the therapy room with myriad presenting problems
and needs. The range of considerations for sibling relationships is vast. The sugges-
tions presented are not intended to provide an exhaustive list, but rather to help
illustrate several areas to consider.
Filial therapy with siblings An interview conducted by Sori (2012) with Van Fleet
discussed how filial therapy can be helpful in decreasing sibling rivalry. Filial therapy
enables parents time with each child in their world of play. Filial therapy enables par-
ents to see, appreciate, and accept the unique parts of each child. To show love and
appreciation for that child with all their strengths and weaknesses, creating acceptance
of each child for who they are, and for some of the times that sibling rivalry might be
present. Siblings can then observe how parents see their siblings’ strengths, weakness,
and annoyances and still find them loveable.
Sibling relationships and divorce Children’s experience of parental divorce differs

depending on the age of the child and time of the divorce (Greenwood, 2014). In
regard to the impact divorce has on the sibling relationship, studies have shown an
increase in conflict post‐separation between sibling dyads, which was found to be
temporary and tied to the sibling closeness following the separation of parents (Bush
& Ehrenberg, 2003). Age of the siblings during the divorce plays a role in the impact
as well. It has been found that youth experiencing their parents separating in adoles-
cence had more negative feelings toward the sibling when they grew into adulthood
and children who experienced divorce earlier in childhood had more positive feelings,
beliefs, and behaviors toward their siblings into adulthood (Riggio, 2001). The pres-
ence of a sibling during a parental divorce has the potential to create reassurance of
comfort, prompt resiliency, and increase support. Jacobs and Sillars (2012) found that
supportive sibling relationships act as buffers to negativity due to shared experiences
from family reorganization during the divorce period.
The parental relationship holds significant power within the sibling relationship in
the context of divorce. Milevsky (2004) found that siblings coming from non‐divorced
families were closer with their siblings, had greater levels of support from one another,
and communicated more frequently compared with their divorced family sibling coun-
terparts. Additionally, parental marital satisfaction was found to be a predictor in sib-
ling communication, closeness, and support (Milevsky, 2004), highlighting the
important influence the parental unit has on sibling relationship satisfaction. Greenwood
(2014) examined sibling’s parental side taking within divorce and found that most
participants were not negatively impacted from their parents’ divorce but there was a
decrease in sibling relationship satisfaction if siblings took sides during parental
separation.
Sibling relationships and stepfamilies With the diversity of stepfamilies, it is impor-

tant to take into consideration the diversities of the stress among these families (Dunn,
2002). Dunn (2002) discusses risks for negative child and sibling outcomes for step-
families, which include increased risk of family conflict, economic and social stress,
and multiple family transitions. Research also suggests differences in adolescent
adjustment in stepfamilies compared with those with non‐stepfamilies (Deater‐
Deckard & Dunn, 2002; Hetherington et al., 1999). Being a part of a stepfamily was
associated with more problems within family relationships such as poor sibling adjust-
ment and higher levels of externalizing behaviors within adolescent‐aged children
(Hetherington et al., 1999). Sibling negativity, which includes conflict and aggres-
sion, was found to be higher in prevalence with single‐mother families, and biological
siblings were found to be more negative than half and stepsiblings (Deater‐Deckard
& Dunn, 2002).
It has also been found that siblings being raised in a stepfamily household can
impact education. For example, siblings being raised by step, adoptive, or foster
mothers obtained significantly less education on average than children whose birth
mothers were in the same household (Case, Lin, & McLanahan, 2001). Though
there is an increasing amount of literature examining divorced and remarried families
showcasing the increased rates of stressors and problems within family relations and
social settings (Case et al., 2001; Deater‐Deckard & Dunn, 2002; Hetherington
et al., 1999), the vast majority of these families and siblings have been found to be
resilient and able to cope with and benefit from new life situations (Hetherington,
2003).
Sibling relationships and half‐siblings It has been estimated that nearly 15% of chil-
dren in the United States live with a half‐sibling (Ganong & Coleman, 2017). A
half‐sibling is when siblings have one shared biological or adoptive parent as opposed
to both biological parents (Gennetian, 2005). Steinbach and Hank (2018) report that
the percentage of half‐siblings is increasing due to low fertility rates and high separa-
tion and divorce rates, along with high remarriage rates. It has been shown that half‐
siblings, particularly in youth age, do not adjust as well compared with full biological
sibling families when experiencing divorce (Gatins, Kinlaw, & Dunlap, 2014).
Literature has explored the significant differences in relationships between full, half,
step, and blended families. For example, Anderson (1999) reported two major differ-
ences between full and half‐siblings, which included lower support in half‐sibling
families and decreases in negativity yet more distance in half‐sibling families. Halpern‐
Meekin and Tach (2008) report that half‐sibling families are most commonly catego-
rized as living in stepfamily households without distinguishing those with and/or
without half‐siblings within the home.
Sibling relationships and foster care Sibling relationships of youth in foster care has
garnered greater attention in the last decade (Hegar & Rosenthal, 2011; Herrick &
Piccus, 2005; Wojciak, McWey, & Helfrich, 2013), partially due to the fact that sib-
lings are often separated from one another while in foster care (Leathers, 2005) and
because scholars are investigating the protective role that siblings can have for youth
in foster care (Richardson & Yates, 2014; Waid & Wojciak, 2017; Wojciak, McWey, &
Waid, 2018). Siblings placed together have a greater sense of belonging in the family
(Leathers, 2005) and better academic and behavior outcomes (Hegar and Rosenthal).
Siblings with warm sibling relationships also have higher levels of resilience (Richardson
& Yates, 2014; Wojciak et al., 2018). Given the protective role of siblings for youth
in foster care, research surrounding specific interventions targeted at improving sib-
ling relationships has been evaluated and has demonstrated positive results (Linares
et al., 2015; McBeath et al., 2014).
Therapists working with siblings should also be aware of complex sibling dynam-
ics that may occur as a result of their placement into foster care or the impact that
placement and separation from their sibling has had on their relationship. Youth are
placed in foster care as a result of abuse or neglect experienced prior to placement.
The abuse and neglect may have impacted their sibling dynamics. Further, siblings
in larger sibling sets may also be “splintered” in that some of the siblings may be
placed together and others not. This is often the case as there may not be a foster
care placement that can accommodate larger sibling groups. No matter the type of
placement or level of separation, despite recent policy such as the Fostering
Connections to Success Act, siblings may not have regular contact with siblings
with who they are separated. All of these considerations should be assessed and
explored with siblings in foster care that therapists may work with. Therapists should
also maintain a curious stance to understand the unique sibling relationship needs
of youth in foster care.
Sibling relationships and LGB families The sibling relationship has been found to
play an influential role for individuals coming out as lesbian, gay, or bisexual (LGB).
Savin‐Williams and Ream (2003) studied over 2,000 LGB individuals and found that
38% of their sample first disclosed their sexual orientation identity to their brother or
sister. Disclosing one’s sexual minority status to a sibling with whom they have a
strong sibling relationship can also act as a safeguard against other taxing incidences.
Huang, Chen, and Ponterotto (2016) discovered that for some LGB individuals,
sibling support buffers psychological pain including internalized homophobia and
victimization and increases the LGB sibling’s self‐acceptance and comfort. Hilton and
Szymanski (2014) found that heterosexual siblings are more accepting of their LGB
sibling when they have had contact with LGB individuals, greater knowledge of the
LGB community, take a supportive stance on civil rights, and tend to have a more
liberal ideology when it comes to political affiliations (Hilton & Szymanski).
Barriers to therapists working with siblings and suggested solutions

Bank and Kahn (1982) suggested five reasons why therapists do not work with siblings:
(a) lack of an empirical knowledge about sibling relationships, (b) the authoritative
parental role of the therapist may be subverted or undermined by siblings, (c) thera-
peutic caring differs between siblings, (d) family therapists differ in the way they
acknowledge and understand power in family relationships, and (e) therapists do not
work with siblings because of their experiences with their own siblings. Kahn and Lewis
(1988) go on to suggest a sixth reason: therapy is based on a masculine epistemology
in which cooperation and sharing, characteristics of sibling relationships, are not very
well understood by therapists. Unfortunately, 30 years later, we have a larger body of
knowledge about siblings but still little application to therapeutic practice.
The onus of this shortcoming falls on SFT thinkers and training programs. Despite
the growth in knowledge (McHale et al., 2012), information about sibling relation-
ships and sibling dynamics is not taught in training programs. A solution, and perhaps
a way to help prevent sibling problems, is to include sibling information in all training
programs. Teach beginning therapists how to assess sibling relationships for strengths
and weaknesses and how that can be used as a place of intervention in work with fami-
lies. When therapists have a better understanding of sibling development, interac-
tions, and dynamics, they will be better equipped to work with siblings in session.
Systemic family therapists are trained to work on balancing alliances with family mem-
bers at different times. Perhaps more attention should be paid to balancing between
sibling groups and not just couples or the parent–child relationship. Further, sibling
relationships vary as widely as the individuals in those relationships (e.g., culture,
gender, age). Systemic family therapists with their differing backgrounds may have
had a myriad of experiences with their siblings. These experiences indicate their level
of importance surrounding sibling relationships. Siblings are so common that it
appears therapists often overlook them and as a result overlook the potential concern
or support these relationships can have in the therapeutic process. Self‐of‐the‐thera-
pist work surrounding the therapist’s sibling relationships may be an important part
of therapist training as well. Therapist’s reflection of the conflicts, compromises,
strengths, and weaknesses of their own sibling relationships, as well as formal training
on sibling dynamics, may help therapists feel more equipped to work with siblings in
the therapeutic process. Training, supervision, and self‐of‐the‐therapist work on sib-
ling relationships would demystify working with sibling relationships. Students in
training could receive supervision for their work with siblings, thus building confi-
dence and demonstrating that they do in fact have the skills to navigate different
therapeutic caring with all members of a sibling group.
In addition to these barriers, parents also bring preconceived notions about sibling
relationships based on their own sibling relationship. If a therapist suggests something
to do at home, parents may report difficulty implementing techniques with multiple
children. For instance, parents in a study examining how home visiting services from
a family support worker influenced parents’ ability to manage behavioral problems
reported difficulty enforcing behavioral charts and rewards when there was a sibling
or how the strategies could create sibling rivalry (Window, Richards, & Vostanis,
2004). Parents reported that if one child got a reward of watching TV, they had a
hard time keeping the other children away from it. They also reported that behavior
chart rewards caused jealousy from siblings who did not earn the reward. Parents’
discomfort or relative lack of ability to manage conflict between siblings may also be
indicative of the fact that siblings are often overlooked in family dynamics. For
instance, parents likely grew up with siblings and may manage their children’s sibling
relationship similarly to how their parents managed theirs. There is also a lack of
knowledge and resources available to parents to help parent siblings. Upon an Internet
search, the majority of resources are about managing sibling rivalry. Systemic family
therapists are well poised to be able to assist families. We need to apply our SFT
theories to work with siblings and families.
Future Directions for Sibling Relationships in Family Therapy
As demonstrated in this chapter, sibling relationships are complex. Perhaps this is the
reason why sibling relationships are understudied and theorized less comprehensively
than other familial relationships. Sibling relationships contain many facets with great
variability and complexity. There can be differences in age spacing between siblings,
different dynamics based on the gender composition of siblings, and the number of
siblings. These factors not only influence methodological processes in conducting
research but also influence family therapists’ ability to theorize about sibling relation-
ships. The different permutations available when thinking about sibling relationships
can seem endless, which may seem overwhelming and leave therapists with little idea
with a direction to go. These challenges are real, but so is the need to educate family
therapists about the sibling relationship and have solid theory to pull from in order to
best prepare them and effectively work with problems clients present with.
Therapeutic advancements in theory and clinical application about sibling relation-
ships has been stagnate for the past few decades since Kahn and Lewis’ book Siblings
in Therapy in 1988. As demonstrated in this chapter, theories that systemic family
therapists use often neglect siblings, and consequently, as a field, we have done the
same thing. Where are siblings in family therapy? As a field, we should use this as a
catalyst to move our thinking and ability to work with families forward. Training pro-
grams can help students learn more about sibling relationship dynamics, we can move
past the barriers that prevent family therapists from working with siblings. Therapists
can start inviting siblings in for therapy, assessing the sibling relationship as part of the
larger picture of family dynamics, intervening with siblings, and bringing the
overlooked and underutilized familial relationship into the therapeutic process.
Future directions for sibling relationship theory and research in SFT

A way of continuing to advance this area is not only theoretically as described above
but also to test theory and practice. Currently, most research is descriptive (e.g., gen-
der and age differences) or looks at sibling relationship quality as an outcome variable
(e.g., Furman & Buhrmester, 1985; Gamble, Yu, & Kuehn, 2011). Some researchers
have tested sibling relationship quality as a mediator of other developmental aspects
like academic achievement, delinquency, and depression (Yeh & Lempers, 2004).
Given the establishment of basic science surrounding sibling relationships, systemic
researchers need to use the information to theorize about family dynamics and ways
to intervene. Once we have theory, researchers can then develop appropriate protocol
to analyze the effectiveness of the theory and intervention. Systemic clinical research
cannot occur without theory driving the process.
At the intervention level, there are several promising interventions to promote
sibling relationship quality (Linares et al., 2015; McBeath et al., 2014). While these
interventions are much needed, particularly since they promote relationships of
youth in foster care, they lack a systemic, whole family perspective. The overarching
gap for theory and research is how to account for the complexity of family dynamics,
for instance, how can we conceptualize a family system in which there are three sib-
lings: the first two siblings (both female) are less than 2 years apart and both are in
high school. The third sibling (male) just started first grade. The two older sisters
e xperience a lot of sibling conflict. Conflict usually results due to one sibling taking
the other sister’s belongings without asking. The younger of the two older siblings
thinks that the mom, a single parent, treats the oldest sibling better than everyone
else and that the oldest sister is too bossy, whereas the older sister thinks that the
middle sister and her younger brother get away with everything. With this informa-
tion, how can we use what we know empirically, thanks to family studies literature,
to inform treatment approaches conceptually?
Empirically, we know that sibling conflict and rivalry is more likely to happen when
there is less sibling differentiation (Whiteman & Christiansen, 2008). We know that
same‐sex dyads tend to have warm and supportive relationships, that they tend to be
more intimate with female same‐sex dyads (Gamble et al., 2011), and that both of the
older siblings perceive differential treatment from their mom that could lead to sib-
ling rivalry (Richmond et al., 2005). With this information, we can theorize with any
theory, but for this exercise, we chose a structural lens. Perhaps, an SFT would assess
the sibling relationship with the whole family. The SFT would ask questions about
communication, boundaries, and hierarchy from each family member to get a family
perspective, but also from a sibling subsystem perspective. The SFT could work with
the whole family as a way to better understand family dynamics and to see what the
interactions are like between the mom and each of her children. The SFT would use
his/her expertise to distinguish if some of the perceived differential treatment is based
on developmental needs of children, if there are potential coalitions or alliances occur-
ring, or if there is an unbalanced hierarchy with the oldest child serving in a parental
role. This systemic thinking and use of theory would help an SFT therapist identify
steps to take to work with the family. Using the sibling relationship, literature in con-
junction with theory can help the SFT to navigate the sibling conflict the two older
siblings are experiencing.
It is important to note that this is just one example. It does not fully account for the
third sibling, or how it would be if there were more children, if there were changes in
the age spacing, and so on. A difficult aspect of theory development and research with
siblings is trying to capture all the potential variations that exist within families. To
further complicate this, the majority of what we know about sibling relationships is
based on middle‐class, white, two‐parent families in the United States (McGuire &
Shanahan, 2010). What does this look like in families with different races, religions, or
cultures? Theorizing and studying sibling relationships is an area with endless possibili-
ties for growth and an area that should not be neglected by systemic family therapists.
As was stated at the beginning of the chapter, this chapter provides a brief overview
of sibling relationship dynamics, considerations, and theory work. So much more
needs to be done to advance our knowledge and utilization of sibling relationships.
We, as a field devoted to family systems thinking, are charged with advancing our use
and understanding of sibling relationships in family therapy. Let us not let another
three decades go by without advancements in this area.
Note
1 This case conceptualization is a composite of several different cases. All names and identifi-
able information has been changed to ensure confidentiality.
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7
Systemic Approaches to Child
Maltreatment
Kimberly A. Rhoades, Danielle M. Mitnick, Richard
E. Heyman, Amy M. Smith Slep, and
Tamara Del Vecchio
Child maltreatment comprises abuse (physical, emotional, and sexual) or neglect of a

child by a caregiver. This chapter will provide a primer on child maltreatment, from
the scope of the problem to etiological theories to intervention approaches; we
conclude by highlighting several notable future directions.
Definitions and Prevalence
Definitions
Child maltreatment research and intervention have been hampered by a lack of
consistent definitions and operationalization. In the United States, all 50 states have
unique definitions of child maltreatment (Manly, 2005). Although criteria are being
field‐tested for the forthcoming edition of the International Classification of Diseases
(ICD‐11; see Slep, Heyman, & Malik, 2013), there are no established worldwide
criteria for maltreatment nor is there cross‐cultural consensus on thresholds. For
example, a cross‐cultural study asked respondents in the United States, Nigeria, and
Ghana to indicate whether various acts constituted maltreatment; those from the
United States and Ghana were more likely perceive acts as abusive than those in
Nigeria, and there was more consensus and less variability in the United States than in
the other countries (Fakunmoju et al., 2013). Such differences put immigrant families
at particular risk of being reported for child maltreatment, as their native culture and
corresponding definitions of what constitutes child maltreatment may deviate from
that of their new country (Reisig & Miller, 2009).
Similarly, the reliability of the foundational decision of whether a case involves
maltreatment is often poor. Research indicates that there is low, chance‐like agree-
ment about what meets threshold for substantiation for child maltreatment, both
between clinicians (e.g., Herman, 2005) and between field decisions and trained
“master reviewers” (Heyman & Slep, 2006). These decisions can be influenced by a
164 Kimberly A. Rhoades et al.
number of factors other than the specifics of the incidents and the local laws regarding
maltreatment; these include cognitive biases and heuristics in caseworkers, race,
workers’ perceptions of the parents’ openness to change, and investigation time (e.g.,
Munro, 2008).
Prevalence
A recent series of meta‐analyses of research using informants (i.e., social services or
community sentinels) indicates global rates of 0.4%, 0.3%, and 0.3% for sexual abuse,
physical abuse, and emotional abuse, respectively; self‐report data reveals much higher
rates: 7.6% and 18% sexual abuse for males and females, respectively; 22.6% physical
abuse; 36.3% emotional abuse; and 16.3% physical neglect (Stoltenborgh, Bakermans‐
Kranenburg, Alink, & van IJzendoorn, 2015). Thus, informant rates of child
maltreatment are likely vast underestimates of the actual prevalence.
Theoretical Conceptualizations
Many theories have been employed to explain the etiology of child maltreatment,
with varying degrees of sophistication; the following overview gives more coverage to
theories with greater empirical support and those that directly influenced the inter-
vention models discussed below.
Behavioral theories
Two behavioral theories have been particularly prominent in the conceptualization of
child maltreatment: coercion theory (Reid, Patterson, & Snyder, 2002) and social
learning theory (e.g., Bandura, 1986). Coercion theory suggests that positive and
negative reinforcements occurring in dyadic conflict result in a learned pattern of
aggressive escalation. A parent and child in a conflict escalate with increasingly aver-
sive behaviors, until one person capitulates. The person who “wins” is both negatively
reinforced for escalating through the removal of the aversive conflict behavior and
positively reinforced through the attainment of a reward (e.g., compliance). The person
who “loses” is negatively reinforced via the other’s cessation of aversive behavior.
Physical abuse can occur as a result of the escalation process that crests with aggressive
behavior and is reinforced due to its variable effectiveness at “winning.” Social learning
theory posits that behaviors can be learned via both direct and vicarious experience
(i.e., modeling; see Huesmann & Guerra, 1997). Social learning is presumed to be a
key factor in intergenerational transmission of maltreatment, as children perform as
adults what they experienced and saw as children.
Cognitive theories
Social information processing models of maltreatment emphasize the role of cognitive
processes (e.g., schemas, attributions, and appraisals; Azar, Reitz, & Goslin, 2008).
Parenting schemas, or mental scripts, develop from past experiences and represent
people’s views of themselves as parents, the parenting role in general, and expectations
for children. New information, such as specific instances of child behavior, is then
Systemic Approaches to Child Maltreatment 165
filtered through these schemas, resulting in selective attention to schema‐consistent

cues in parent–child interactions. Once activated, schemas can influence simultaneous
cognitive, affective, and behavioral responses. Contingent, responsive parenting
requires the use of flexible schemas that allow for responding based on the needs of
the particular situation (Azar & Weinzierl, 2005). In contrast, parents who are abusive
rely on schemas that are rigid and negative‐affect laden (Milner, 2000).
Parents’ negative attributions of child behavior and positive outcome expectancies
for abusive behavior are theorized to contribute to abusive responding (Milner,
2000). Parents who are abusive are more likely to endorse negative attributions for
child behavior and appraise child behavior more negatively (Bauer & Twentyman,
1985; Chilamkurti & Milner, 1993). For example, even though parents who are abu-
sive report significantly more child aggression and hyperactivity than parents who are
not abusive, observers do not note behavioral differences (Reid et al., 2002). Sexual
abuse perpetrators overestimate children’s sexual development and are more likely to
misinterpret children’s behaviors as sexual advances (Ward & Keenan, 1999). Parents
at risk for perpetrating abuse are more likely to believe that abusive behaviors are
effective (i.e., higher outcome expectancies; Chilamkurti & Milner, 1993). In addi-
tion, sexual abuse perpetrators are more likely to report that children benefit from the
sexual behavior or actively sought out sexual contact (Stermac & Segal, 1989).
Parent executive functioning has also been implicated in child neglect (Azar,
McGuier, Miller, Hernandez‐Mekonnen, & Johnson, 2017; Crandall, Deater‐
Deckard, & Riley, 2015). Although previous work has demonstrated that parent
problem‐solving ability is associated with neglect perpetration (e.g., Azar, Robinson,
Hekimian, & Twentyman, 1984), it is only more recently that research has begun to
focus on more general neurocognitive features (e.g., Azar et al., 2017). Deficits in
executive functioning may result in an overdependence on overlearned automatic
responses in situations that would benefit from more flexible engagement and the
ability to inhibit prepotent responses.
Stress/coping and anger models

Although stressful life events and parenting stress are associated with increased physi-
cal (e.g., Stith et al., 2009) and sexual abuse (Pianta, Egeland, & Erikson, 1989), the
majority of stressed mothers do not abuse their children (e.g., Egeland, Breitenbucher,
& Rosenberg, 1980). Pianta (1984) argues that parents who are abusive are more
likely to cope with stress in maladaptive ways, such as drinking and hostility, potentiat-
ing increased risk for child‐directed violence.
Meta‐analysis has indicated that parent anger consistently predicts both child physi-
cal abuse and neglect (Stith et al., 2009). Parents who are abusive not only report
feeling angrier in response to children’s behavior than parents who are not abusive
(Dopke & Milner, 2000), but they also evidence increased sensitivity to child negative
affect (Milner, Halsey, & Fultz, 1995). This anger may increase the extent to which a
parent uses physical punishment (Ateah & Durrant, 2005).
Psychopathology and sociological risk models

Commonsense, but tautological, hunches equate psychopathology and child mal-
treatment. Although depression (Stith et al., 2009) and substance abuse (Kelleher,
Chaffin, Hollenberg, & Fischer, 1994) increase risk for maltreatment perpetration,
the vast majority of parents with these problems do not maltreat their children.
Similarly, several sociological factors increase risk of physical abuse and neglect
(e.g., younger maternal age, lower socioeconomic status, lower parental education;
Stith et al., 2009) but are certainly not causal. These factors are interdependent. For
example, poverty is correlated with lower educational level, single‐parent status, low
social support, greater stress, and psychopathology, and each is associated with child
maltreatment status (Berlin, Appleyard, & Dodge, 2011; Chaffin, Kelleher, &
Hollenberg, 1996).
Attachment theory
Attachment theory asserts that early primary caregiver interactions establish internal
working models of the self and of relationships with others. Development of secure
attachment is contingent upon consistent and responsive caregiving (Wolff &
Ijzendoorn, 1997). Inconsistent and insensitive parenting typical of maltreating
parents places their children at increased risk for insecure attachment (Cyr, Euser,
Bakermans‐Kranenburg, & Ijzendoorn, 2010), which in turn places them at risk of
perpetrating child maltreatment as parents themselves (Adshead & Bluglass, 2005),
thus perpetuating the transmission of violence between generations.
Ecological model
Perhaps the most influential etiological theory is the ecological model (Bronfenbrenner,
1979), which posits that multiple, interactive levels—from the most proximal (e.g.,
intraindividual, family‐of‐origin influences) to the most distal (e.g., cultural norms)—
influence behavior. The empirical literature has identified risk and protective factors
that exist at all levels of the ecology (Stith et al., 2009; Wojda et al., 2017). Ecological
models suggest that proximal factors have the most direct effect on maltreatment and
that the balance of risk and protective factors determines the likelihood of child mal-
treatment (Cicchetti, 2004). Of note, factors from all ecological levels of influence
were retained in a multivariate analysis of parent–child aggression, suggesting that all
levels contribute unique variance and are relevant in predicting child maltreatment
(Slep & O’Leary, 2007).
Child Maltreatment Prevention and Treatment
In the following section we will discuss child maltreatment prevention and treatment
programs (including treatment for perpetrators and for child victims). Due to the
focus of this volume, we restrict our review to empirically supported programs with a
dyadic, relational, or family focus. In contrast, a large proportion of the parenting
interventions used within the child welfare system have not been subject to empirical
evaluation, or, in the case of programs with substantial empirical support with
community samples, it is unclear how well the program prevents incidents of maltreat-
ment or recidivism specifically. We include programs that are delivered in a variety of
contexts with different types of service providers (e.g., those delivered by nurses or
schools or public awareness campaigns) to provide a comprehensive overview of

empirically supported interventions or services that families may be eligible for or
receiving. In addition, particular elements of these programs may be helpful if incor-
porated into intervention plans for families. Although we largely omit prevention
program effects related to improved parenting and child adjustment outcomes (to
avoid overlap with other chapters in this volume), parenting and child behavior are
both clearly and consistently associated with child maltreatment risk (Stith et al.,
2009), and, thus, these interventions may confer additional preventive benefits.
Although child maltreatment is a public health problem worldwide, most empiri-
cally supported maltreatment intervention and prevention programs have been devel-
oped and tested predominately within the United States and other high‐income
Western countries. It remains an open question, therefore, whether these interven-
tions are effective “as is” cross‐culturally, if modifications are necessary and sufficient,
or if newly developed interventions are necessary to invoke change in a different cul-
tural context. The effectiveness and efficacy trials that we review in this chapter vary
considerably in the racial and ethnic diversity of their sample and the country in which
the research was conducted. Most programs have positive program effects demon-
strated in diverse samples of parents and children. Detailed discussion of how program
effects vary by racial and ethnic composition or country or origin is beyond the scope
of this chapter; please refer to original sources for participant details. We have high-
lighted program evaluations in countries other than the United States and cultural
adaptations where available.
Triple P‐Positive Parenting Program

Triple P‐Positive Parenting Program (Triple P) (Sanders, 2012) is a multilevel system
of parenting support developed in Australia. Triple P is grounded in social learning
theory and social cognitive theory and seeks to increase warm, responsive, and posi-
tive parent–child interactions and reduce coercive and conflictual parent–child inter-
actions. There are five levels of Triple P, with intervention intensiveness increasing at
each level. Triple P provides flexible delivery formats, including individual, group, and
self‐directed formats. Level 1 (Universal) Triple P includes media and informational
campaigns. Level 2 (Selected) Triple P includes single‐session parenting seminars or
brief single‐session consultations. Level 3 (Selected+) Triple P includes a series of four
brief consultations that include active skills training. Level 4 (Standard) Triple P is a
multi‐week program in which parents learn and actively practice child management
skills. Level 5 (Enhanced) Triple P augments Level 4 Triple P with additional modules
relevant to building other parenting‐relevant skills. The primary goals of Triple P are
to reduce behavioral, emotional, and other adjustment problems in children and
improve parent–child relationships; decades of research demonstrate its efficacy in
these domains (Nowak & Heinrichs, 2008). Specific to maltreatment prevention,
Triple P has demonstrated significant reductions in rates of child maltreatment at the
population level when implemented as a universal public health intervention (Prinz,
Sanders, Shapiro, Whitaker, & Lutzker, 2009). This cluster randomized controlled
trial (RCT), across 18 counties in South Carolina, found that Triple P counties
reported lower rates of substantiated child maltreatment cases, fewer hospitalizations
or injuries due to child maltreatment, and fewer out‐of‐home placements due to child
maltreatment than control counties. Triple P has demonstrated positive intervention
effects in countries including Australia, the United States, New Zealand, Japan,
Singapore, Hong Kong, Iran, Scotland, England, Ireland, Sweden, Belgium, the
Netherlands, Germany, Turkey, Switzerland, South Africa, and Panama.
Parent–Child Interaction Therapy (PCIT)

Parent–Child Interaction Therapy (PCIT) (Eyberg, Boggs, & Algina, 1995) was
developed for use with parents of 2–7‐year‐old children with severe externalizing
behavior problems and is based on social learning and attachment principles. The
intervention consists of two phases, child‐directed intervention and parent‐directed
intervention. In both phases, the parent interacts with the child while a therapist
coaches the parent’s behavior in real time. In child‐directed intervention, parents are
instructed to play with their child, letting the child take the lead, and are coached to
use strategies such as descriptive commenting and specific praise. In parent‐directed
intervention, parents take the lead and make behavioral demands of the child and are
coached to introduce strategies such as limit setting and giving brief and specific
directives. During each session, parents are provided with homework assignments to
practice the skills learned during sessions.
PCIT has been used for both child maltreatment prevention (via improvements in
parenting practices and reductions in child behavior problems; Hood & Eyberg,
2003) and as treatment for maltreating parents (Batzer, Berg, Godinet, & Stotzer,
2018; Herschell & McNeil, 2005). Batzer and colleagues (2018) recently published
a review of the efficacy of PCIT as an intervention for caregivers whose children had
been maltreated or were at high risk of maltreatment. Overall, PCIT was associated
with reduced rates of recidivism compared with other treatment conditions (Chaffin
et al., 2004; Lanier, Kohl, Benz, Swinger, & Drake, 2014; Thomas & Zimmer‐
Gembeck, 2011), with perhaps greater reductions when combined with motivational
interviewing (Chaffin, Funderburk, Bard, Valle, & Gurwitch, 2011). PCIT was also
associated with reduced child abuse risk in 6 of the 11 included studies (see Batzer
et al., 2018, for details). Results suggest that PCIT benefits may be specific to physical
abuse (Chaffin et al., 2004).
Incredible Years (IY)

The Incredible Years (IY) programs are grounded in social learning theory and were
originally developed to reduce child behavior problems and improve parenting prac-
tices and parent–child relationships (Webster‐Stratton & Reid, 2003). Although the
program has been tested in different formats and modalities, the standard IY basic
parent program consists of 12 weekly sessions in a group format. In these sessions,
parents learn evidence‐based parenting practices with a group facilitator by discussing
videotaped interactions between parents and children, practicing these skills through
in‐session role‐plays, and completing weekly homework assignments to reinforce the
use of the skills at home. Early sessions focus on increasing positive parent–child inter-
actions through the use of play, descriptive commenting, and praise. Later sessions
focus on limit setting, logical consequences, and time‐out. IY has a substantial empiri-
cal research base and meta‐analyses find positive program effects with small to medium
effect sizes (Menting, de Castro, & Matthys, 2013).
Although IY was not originally developed to address child maltreatment specifi-

cally, there is theoretical and (limited) empirical evidence to support the use of IY with
families with maltreatment histories (Webster‐Stratton, 2014). In an RCT of IY with
481 families with children enrolled in Head Start, program results were largely equiv-
alent for children whose parents self‐reported maltreatment compared with children
without a parent‐reported maltreatment history (Hurlburt, Nguyen, Reid, Webster‐
Stratton, & Zhang, 2013). Trials of IY with child welfare system‐involved families are
limited and quasi‐experimental. One such study found promising pre–post improve-
ments on parenting practices and parents’ perceptions of their children’s behavior for
parents with a substantiated case(s) of child neglect (Letarte, Normandeau, & Allard,
2010). Another quasi‐experimental evaluation of IY was conducted in the New York
State child welfare system (Marcynyszyn, Maher, & Corwin, 2011). Outcome results
indicated improvement from pre‐ to post‐intervention on parenting stress, empathy,
and perceived social support. The IY program has also been evaluated as an embedded
component in a multicomponent approach to reduce maltreatment recidivism, with
promising quasi‐experimental results (Constantino et al., 2016).
Attributional reframing
Attributional reframing is a cognitive intervention that draws from cognitive theories
of child maltreatment (Black, Heyman, & Slep, 2001; Slep & O’Leary, 1998).
Although it can take different forms, the general conceptual approach is to facilitate
shifts in parents’ primary appraisal processes as they pertain to interpretations of nega-
tive child behavior (Bugental et al., 2002). If parents can interpret children’s negative
behavior more benignly, they may be less reactive and harsh in their behavioral
responses.
As an example of this approach, the interventionist might ask the parent to describe
a child problem behavior and possible causes of those behaviors. The interventionist
then probes until a benign attribution is elicited. A parent might describe a toddler’s
tantrum behavior, and the first attribution might be “because he always wants his
way,” but after probing, the parent might offer that the toddler is behaving that way
“because he is tired.” Once the benign attribution is evoked, the interventionist then
asks about potential ways to solve the problem until the parent generates a strategy.
When this approach was tested as a component of a home visitation program for
families at elevated risk for child abuse, mothers who received it had lower levels of
harsh parenting, fewer instances of physical abuse (Bugental et al., 2002), lower use
of corporal punishment, greater safety maintenance in the home, and fewer reported
child injuries (Bugental & Schwartz, 2009). Another study with parents at risk for
maltreatment found that parents receiving an attribution retraining enhanced version
of Triple P had a significantly greater reduction in child abuse potential and unrealistic
parental expectations than those in standard Triple P (Sanders et al., 2004).
Home visitation
There are numerous home visitation programs in use globally. In the United States,
home visitation is the most widely used child maltreatment prevention approach
(Alonso‐Marsden et al., 2013) and has received considerable government support
(Health Resources and Services Administration, 2015). Some programs (e.g., Nurse–
Family Partnership [NFP], SafeCare) have considerable empirical support. Others
have not been as extensively evaluated or have shown mixed outcomes related to child
maltreatment. Here, we will discuss those with the strongest and most extensive
research support. Other programs discussed in this chapter include a home visitation
component and we have indicated those as necessary. For comprehensive reviews of
home visitation interventions for reducing maltreatment and implementation factors
impacting their success, see Sweet and Applebaum (2004) and Casillas, Fauchier,
Derkash, and Garrido (2016).
Nurse–Family Partnership (NFP) NFP (Olds, 2006) is a home visiting program for
mothers and children designed to reduce risks related to poor birth outcomes, fam-
ily‐of‐origin child maltreatment, maternal adjustment outcomes (i.e., education and
employment), child antisocial behavior, and family economic self‐sufficiency. NFP is
grounded in ecological, attachment, and self‐efficacy theories. The program is
designed to (a) enhance the child’s environment through the provision of and referral
to services and by involving other members of the child/mother’s family, (b) promote
sensitive and responsive caregiving, and (c) improve maternal knowledge about pre-
natal health and early child development. NFP nurses visit mothers in their homes,
with the number of visits varying based on need. In program trials, the average num-
ber of prenatal visits ranged from 7 to 9; the average number of visits between birth
and age 2 was 23–26.
The program has been evaluated in three large‐scale RCTs with primiparous women
(Kitzman et al., 1997; Olds, Henderson, Tatelbaum, & Chamberlin, 1986; Olds
et al., 2002). Results of these trials indicate largely positive results, including 80%
fewer cases of substantiated child maltreatment (Olds et al., 1986), approximately half
the rate of substantiated maltreatment reports between child age 4 and 15 (Olds
et al., 1997), and fewer hospital visits for child injury and ingestions from birth to age
2 (Kitzman et al., 1997).
SafeCare (previously Project 12‐Ways) SafeCare (Lutzker & Bigelow, 2001) com-
prises 18 two‐hour home visiting sessions for parents of children 0–5 years of age.
SafeCare is based on social learning, behavioral, and ecological theories and evolved
from an earlier program: Project 12‐Ways (Lutzker & Rice, 1987). It comprises three
modules for families at risk for child neglect: (a) Child Health, (b) Home Safety, and
(c) Parent–Infant/Child Interaction. Child Health comprises information about
childhood illness, how to recognize symptoms, and when to seek medical advice or
services. Home Safety involves safety evaluations based on child age and development
and reducing safety hazards. Parent–Child Interaction includes activities designed to
increase positive interactions between parents and children and reduce child behavior
problems.
A statewide cluster RCT of SafeCare—conducted in Oklahoma with parents
involved with the child welfare system—demonstrated that SafeCare resulted in sig-
nificantly greater reductions in child welfare system involvement and significantly
reduced home safety hazards, compared with families who received services as usual
(Chaffin, Hecht, Bard, Silovsky, & Beasley et al., 2012; Rostad, McFry, Self‐Brown,
Damashek, & Whitaker, 2017). Further, results of the trial in a subsample of Native
American families found results equivalent to the larger trial (Chaffin, Bard, Bigfoot,
& Maher, 2012). Cultural adaptations of SafeCare have also shown promising results
(Beasley et al., 2014; Morales, Lutzker, Shanley, & Guastaferro, 2015), although
such adaptations may not be universally necessary. Reports from SafeCare providers
indicate that certain components may require adaptation on a case‐by‐case basis; over-
all, additional research is needed regarding when and how programs should be
adapted to improve program effects rather than detract from original program bene-
fits (Self‐Brown et al., 2011). International adaptations of the program (e.g., England,
Spain, Israel, and Belarus) have been developed and evaluated, although this work is
not well represented in the published empirical literature. Evaluation of the program
in Israel has found that SafeCare is perceived positively by participating mothers and
social workers (Oppenheim‐Weller & Zeira, 2018).
Attachment and Biobehavioral Catch‐up Attachment and Biobehavioral Catch‐up

(ABC) (Dozier & Bernard, 2017) is grounded in attachment theory and was devel-
oped for infants and toddlers who have experienced early adversity to improve attach-
ment security with their caregivers. The program aims to improve parent–child
interactions in the context of potentially difficult and rejecting child behavior, provide
a consistent environment for children, and help caregivers improve their parenting
skills and address problems that may be interfering with their ability to effectively par-
ent. ABC comprises 10 parent–child sessions in the home. Sessions help parents pro-
vide sensitive and nurturing caregiving when their children are distressed, effectively
engage in “serve and return” behaviors, and reduce intrusive and/or frightening
behaviors. ABC coaches are trained to notice naturally occurring instances of parents
using these skills and provide reinforcement.
In an RCT with foster parents, ABC resulted in reduced avoidant attachment
behaviors compared to a psychoeducational intervention (Dozier et al., 2009).
Similarly, children at risk for neglect assigned to ABC evidence more secure attach-
ments and fewer disorganized attachments than children in the psychoeducational
intervention (Bernard et al., 2012). In two studies, parents at risk for maltreatment
assigned to ABC, versus control, demonstrated greater parental sensitivity and less
intrusiveness (Bick & Dozier, 2013; Yarger, Hoye, & Dozier, 2016). ABC for tod-
dlers in foster care has found improvements in children’s attention problems and
cognitive flexibility (Lind, Lee Raby, Caron, Roben, & Dozier, 2017).
Trauma‐Focused Cognitive Behavioral Therapy

Trauma‐Focused Cognitive Behavioral Therapy (TF‐CBT) (Cohen, Mannarino, &
Deblinger, 2006) is a structured, short‐term treatment for children who have experi-
enced trauma, including abuse. Sessions are both individual (with both child and
parent) and conjoint. TF‐CBT incorporates gradual exposure throughout assessment,
engagement, psychoeducation, parenting skills, relaxation, identifying and modulat-
ing affect, cognitive coping, developing a trauma narrative, facilitating cognitive
processing, in vivo exposure, holding conjoint sessions to share the child’s perspective
and facilitate praise and support from the caregiver, and enhancing safety (Cohen &
Mannarino, 2008).
Multiple RCTs comparing TF‐CBT and routine community care or supportive
therapy show improved outcomes for children in TF‐CBT, including fewer post‐
traumatic stress disorder (PTSD) symptoms, fewer behavioral problems, fewer
internalizing problems, better social competence, less shame, and fewer abuse‐related
attributions (Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen & Mannarino,
1996; Cohen, Mannarino, & Knudsen, 2005). Parents showed more support toward
children, positive parenting practices, and less depression and distress (Cohen et al.,
2004).
TF‐CBT has been adapted for Native American/Native Alaskan populations
(Bigfoot & Schmidt, 2010) and for Dutch (Diehle, Opmeer, Boer, Mannarino, &
Lindauer, 2015), German (Goldbeck, Muche, Sachser, Tutus, & Rosner, 2016),
Congolese (O’Callaghan, McMullen, Shannon, Rafferty, & Black, 2013), and
Zambian (Murray et al., 2015) samples, with findings supporting its efficacy to
decrease PTSD symptoms and improve child outcomes.
Child–Parent Centers
The Child–Parent Center (CPC) model is based on an ecological approach to
preventing child maltreatment and provides services via a school–family partnership
embedded within preschools. The Chicago CPC is administered by Chicago public
schools and provides services including a preschool curriculum for children, home
visitation, parent training in parenting skills and vocational skills; parent involvement
in classroom activities and school events; and enhancement of parent social supports.
These services are offered in the highest poverty neighborhoods starting in preschool
and continuing until second or third grade.
In a quasi‐experimental evaluation (Reynolds & Robertson, 2003), children in
CPC, compared with services as usual, had a significantly lower cumulative rate of
maltreatment from age 4 to 17. Extended participation in the program (from
preschool to second or third grade) was associated with lower rates of maltreatment
than shorter participation in the program. CPC, compared with control, preschool
enrollees were also less likely to have an out‐of‐home placement from age 4 to 17 (4.5
vs. 8.4%; Reynolds et al., 2007).
Shaken Baby Syndrome (SBS) education

A subtype of child physical abuse involves caregivers, often in response to frustration
due to prolonged periods of infant crying, shaking babies. This often results in death
or long‐term negative sequelae (e.g., Keenan, Hooper, Wetherington, Nocera, &
Runyan, 2007; Keenan et al., 2003). SBS psychoeducation programs typically consist
of a pamphlet and video on the dangers of shaking a baby, the range of normal crying
behavior in newborns, and alternative behaviors a parent can employ during spells of
persistent infant crying. More recently, SBS programs have added in‐hospital educa-
tion, reinforcement either in community settings (e.g., pediatric well baby visits;
Runyan et al., 2009) or public health home visits (e.g., Stewart et al., 2011), and
media campaigns.
SBS psychoeducational strategies increase knowledge about infant crying, the
dangers of shaking (e.g., Barr et al., 2009), and that frustration causes infant shaking
(Bechtel et al., 2011). Recipients of the Take 5 Safety Plan for Crying program, deliv-
ered by pediatric residents when newborns were being discharged from hospital, were
more likely to endorse intentions to take a break when frustrated with infant crying
(Bechtel et al., 2011) than controls. Recipients of Period of PURPLE Crying, com-
pared with controls, were more likely to share information with other caregivers about
walking away when frustrated with baby crying and more likely to report actually
engaging in this practice (Barr et al., 2009). Similar findings were found in a Japanese
trial of this program (Fujiwara et al., 2012). The evidence is mixed regarding abusive
head traumas; whereas Keenan and Leventhal (2010) found that abusive head trau-
mas were not associated with whether Utah mothers viewed an educational video,
Dias, Smith, Mazur, Li, and Shaffer (2005) found that a comprehensive hospital‐
based education program in New York State was associated with a significant decrease
in abusive head injuries that was not observed in nearby Pennsylvania across the same
time period. Training materials for a variety of providers and parents can be accessed
via the website for the National Center on Shaken Baby Syndrome (DontShake.org).
Treatment Foster Care Oregon (TFCO; Formerly Multidimensional

Treatment Foster Care [MTFC])
The Treatment Foster Care Oregon (TFCO) was developed as an alternative to center‐
based residential care for youth with severe emotional and/or behavioral problems.
Although originally designed to reduce delinquency and related outcomes, it has been
used in a wider variety of contexts and has been adapted for use with younger children
and for use with youth who have experienced a variety of adverse life experiences,
including child maltreatment (Chamberlain et al., 2008). We will focus only on results
for children referred to out‐of‐home care due to maltreatment history. Based on social
learning principles, TFCO provides extensive support to foster caregivers in increasing
positive and supportive parent–child interactions and decreasing hostile and coercive
interactions. Program components include (a) weekday telephone contact with TFCO
parents about parenting behaviors; (b) weekly foster parent group meetings focused on
supervision, training in parenting practices, and support; (c) an individualized behavior
management program implemented daily in the home by the foster parent; (d) indi-
vidual therapy for the youth; (e) individual skills training/coaching for the youth; (f)
family therapy (FT) (for biological/adoptive/relative family of the youth) focused on
parent management strategies; (g) close monitoring of school attendance, performance,
and homework completion for school age children and adolescents; (h) case manage-
ment to coordinate the TFCO, family, peer, and school settings; (i) 24‐hr on‐call staff
availability to TFCO and biological parents; and (j) psychiatric consultation as needed.
Children in TFCO are less likely to experience foster care placement instability
(Fisher, Burraston, & Pears, 2005) and demonstrate better psychosocial adjustment
(e.g., display secure attachment behaviors (Fisher & Kim, 2007); do not show dysregu-
lated hypothalamic pituitary adrenal [HPA] axis functioning (Fisher, Stoolmiller,
Gunnar, & Burraston, 2007)) compared with control. Although intervention results
have been favorable within the United States, there have been mixed results when trans-
lating to other cultural contexts in England, the Netherlands, and Sweden (Dixon et al.,
2013; Hansson & Olsson, 2012; Jonkman et al., 2012, 2017; Rhoades, Chamberlain,
Roberts, & Leve, 2013), with positive outcomes observed in each of the above studies
except for Jonkman et al. (2017), which found largely equivalent results for TFCO
compared to treatment as usual in the Netherlands. Similar to other comprehensive
interventions, difficulty with implementation has also been noted (Dixon et al., 2013).
Functional Family Therapy‐Child Welfare (FFT‐CW)

FFT is grounded in systems and cognitive‐behavioral theories, was originally designed
to address a broad array of adolescent adjustment problems, and has strong research
evidence of efficacy (Robbins, Alexander, Turner, & Hollimon, 2016). FFT aims to
increase adaptive behaviors and decrease problem behaviors through understanding the
function of behaviors within the family. We will discuss only the adaptation of FFT for
use in a child welfare setting (FFT‐CW). In FFT‐CW, (a) the relevant age range was
broadened from adolescent to 0–18 years, (b) more parent‐focused intervention strate-
gies were included, and (c) the focus includes multiple family members. In a trial of
FFT‐CW, participating families were placed into a low‐ or high‐risk version of FFT‐CW
based on their baseline risk status (Alexander, Waldron, Robbins, & Neeb, 2013).
Outcomes were evaluated comparing families in either version of FFT‐CW with families
receiving services as usual. A quasi‐experimental evaluation using propensity score
matching demonstrated that families in FFT‐CW had fewer future child welfare referrals
than families receiving services as usual (Turner, Robbins, Rowlands, & Weaver, 2017).
Systematic Training for Effective Parenting (STEP)

Systematic Training for Effective Parenting (STEP) (Dinkmeyer & McKay, 1976) is
a skills‐based psychoeducational group parenting intervention based on Adlerian
theory. Parents are seen as social creatures who must cope with inferiority and
dependency on others; parents who are abusive are theorized to adopt a lifestyle in
which abuse is a normative way of seeking power to overcome feelings of inade-
quacy (Fennell & Fishel, 1998). STEP consists of nine weekly 1.5‐hr groups, in
which parents follow a workbook to role‐play and complete exercises intended to
boost understanding of child behavior and to learn new parenting and communica-
tion strategies.
STEP has been tested on small samples of parents who were suspected of or had
substantiated maltreating behaviors. After STEP, the intervention group viewed their
children’s behaviors more positively and had lower child abuse potential scores
(Fennell & Fishel, 1998). In another study, STEP was used with parents at risk for
child maltreatment from two community samples and one residential drug treatment
sample. Mothers in all samples reported less post‐STEP parenting stress, and mothers
in the community samples (but not the drug treatment sample) had better pre–post
observed parenting abilities (Huebner, 2002).
STEP has mostly been tested in North America, but a recent study with Lithuanian
non‐offending parents indicates similar gains in parenting knowledge and decreases in
authoritarian and permissive styles and in negative perceptions of child behavior
(Jonyniene, Kern, & Gfroerer, 2015).
Alternative for Families—A Cognitive‐Behavioral Approach (AF‐CBT)

Alternative for Families—A Cognitive‐Behavioral Approach (AF‐CBT) (Kolko, Iselin,
& Gully, 2011; formerly referred to as Abuse‐Focused Cognitive Behavioral Therapy)
is a flexibly delivered treatment specifically for child physical abuse and family aggres-
sion. It integrates cognitive‐behavior therapy with FT, with some specific content
about coercion and abuse. Through a combination of child, caregiver, and caregiver–
child sessions, AF‐CBT works to decrease parents’ use of aggressive or harmful
behaviors and improve children’s psychological functioning. AF‐CBT starts with psy-
choeducational sessions and then moves to intrapersonal skills (e.g., emotion regula-
tion, restructuring thoughts, promoting positive behavior, assertiveness, social skills,
techniques for managing behavior, imaginal exposure) and interpersonal family skills
(e.g., verbalizing healthy communication, enhancing safety through clarification,
family problem solving).
AF‐CBT emerged from a study (Kolko, 1996) comparing cognitive‐behavioral
therapy (CBT) and FT with routine community services for physically abused school‐
aged children and their offending parents. Families in the CBT and FT conditions had
less child‐to‐parent violence, child externalizing behavior, parental distress, parental
abuse risk, and family conflict and greater family cohesion. Since then, AF‐CBT has
been manualized and adapted for use for children with behavior disorders, and studies
point to its ability to encourage completion of services and decrease behavioral prob-
lems (Kolko, Campo, Kelleher, & Cheng, 2010), as well as to its sustainability (Kolko
et al., 2011).
Child–Parent Psychotherapy (CPP)

Child–Parent Psychotherapy (CPP) (Toth, Michl‐Petzing, Guild, & Lieberman,
2017) is a dyadic relational intervention based on attachment theory and develop-
mental psychopathology. CPP is designed for parents of children (ages 0–5) who have
experienced trauma, including maltreatment. CPP makes use of naturally occurring
parent–child interactions to intervene during maladaptive interaction patterns and
help instill appropriate developmental expectations. In this parent–child play context,
intervention components include the dyadic creation of a trauma narrative, therapist
modeling of appropriate parent behavior, psychoeducation, generating trauma inter-
pretations and promoting emotional expression that increases self‐reflection and
understanding, and service referrals and case management services. Hour‐long ses-
sions typically occur weekly and are largely unstructured.
In five RCTs, CPP, compared with control conditions, significantly reduced trauma
symptoms in children and improved mental health and the parent–child relationship
for both parents and children (Cicchetti, Rogosch, & Toth, 2006; Lieberman, Ippen,
& Van Horn, 2006; Lieberman, Van Horn, & Ippen, 2005; Toth, Maughan, Manly,
Spagnola, & Cicchetti, 2002). However, only two of these RCTs (Cicchetti et al.,
2006; Toth et al., 2002) were specific to children who had directly experienced abuse.
These found that CPP, compared with treatment as usual, participants had significant
reductions in disorganized attachments (Cicchetti et al., 2006); however, these reduc-
tions were similar to a parent psychoeducation treatment group. Similarly, CPP and
parent psychoeducation interventions resulted in improvements in self and maternal
representations, with some significantly greater improvement for CPP versus parent
psychoeducation (Toth et al., 2002). In addition to the RCTs, an open trial of CPP
for child welfare with children in Bronx, New York, found improved parent–child
interactions, increased parent empathy for children’s needs, and high rates of perma-
nency; further, only 5 of 142 children experienced maltreatment recurrence (Chinitz,
Guzman, Amstutz, Kohchi, & Alkon, 2017).
Future directions and challenges

Technological adaptations Some interventions have harnessed technology (e.g.,
Internet, mobile phones, social media) to engage and retain vulnerable parents. For
example, Cellular phone‐enhanced Planned Activities Training (CPAT) facilitates use
of parenting strategies and reduces maternal depression and stress (Carta, Lefever,
Bigelow, Borkowski, & Warren, 2013) better than the unenhanced version. Triple P
has incorporated media and technology in various ways. For example, watching a
six‐episode television series documenting a family undergoing Triple P improved par-
ent affect, dysfunctional parenting practices, and parent reports of child behavior
(Sanders, Calam, Durand, Liversidge, & Carmont, 2008). Moreover, a recent pre–
post design study that added social media, gaming, and smartphone accessibility to
Triple P Online found that the technology‐enhanced version demonstrated results
similar to standard Triple P (Love et al., 2016). These examples highlight the move-
ment in the field to capitalize on smartphone accessibility and technology to dissemi-
nate effective interventions.
Common intervention components Clearly, a multitude of empirically supported

interventions have overlapping components and foci. A meta‐analysis (van der Put,
Assink, Gubbels, & van Solinge, 2018) found that prevention programs that were
shorter, delivered by professionals, and focused on increasing parent self‐confidence
had larger effect sizes. For intervention programs, programs focused on parenting
skills and increasing social and emotional support reported larger effect sizes. With a
more liberal p‐value applied, programs that addressed parent mental health, parent
personal skills, and improving children’s well‐being also demonstrated larger effect
sizes. Thus, these components may be p articularly beneficial. Common elements of
delivery models have not been systematically evaluated, but one might expect that
reducing barrier to treatment seeking would improve uptake and outcomes (e.g.,
providing childcare for office‐based services, providing transportation, low‐ or no‐
cost services).
Provider training and accessibility Most interventions described in this chapter are
only accessible to families if they reside within a reasonable distance from trained pro-
viders or providers who are willing and able to obtain training. This treatment barrier
is not unique to interventions for child maltreatment; they are common to all psycho-
logical and social services that are not self‐administered. Some interventions (i.e.,
Triple P) are currently available online and are available to any family with computer
or smartphone Internet access and ability to pay for the service. Ability to pay is not
an insignificant barrier, and providing free access to individuals by local, state, or
national governing bodies would increase families’ ability to access these services.
There is precedent for such efforts, as is evidenced by all families in Queensland,
Australia, receiving Triple P services at no cost to their families.
Provider training requirements and cost vary considerably by program. Published
training costs range from $345 to over $10,000 for providers depending on the inter-
vention/prevention program. Training sessions last from 2 days to over 1 week. Most
programs also include continuing education and program fidelity monitoring. Most
programs require at least some in‐person training. Information on who can obtain
intervention training, how to obtain training, and detailed cost information is, in
most cases, available on program websites.
Secretive nature of the problem Official estimates of child maltreatment almost cer-
tainly vastly underestimate the true prevalence of the problem (Stoltenborgh et al.,
2015). Because most child maltreatment is perpetrated by caregivers within the home
(US Department of Health and Human Services, 2012), it often does not come to
the attention of others outside of the home, particularly for young children who are
not yet in formal school settings. This has implications both for having a full under-
standing of the scope of the problem and for tracking child maltreatment rates over
time and providing necessary services to children and families. Prevention efforts may
be particularly powerful in addressing this problem as they do not rely on identifying
instances of child maltreatment prior to receiving services. This is particularly true for
universal prevention efforts, in which all parents and/or children are offered services
regardless of maltreatment status.
Treatment in the context of mandated services Intervention effects do not appear to

systematically differ depending on whether services are mandated versus voluntary
(Skowron & Reinemann, 2005). However, even for families who enter treatment
voluntarily, it is possible that they feel, to some degree, compelled to do so and poten-
tially not entirely in agreement that services are needed. As with all interventions, it is
crucial to maintain a positive therapeutic alliance and common treatment goals
(Martin, Garske, & Davis, 2000), particularly when parents and/or children are man-
dated to receive services and/or are in a pre‐contemplative or contemplative stage of
change (Norcross, Krebs, & Prochaska, 2011). Similar to our recommendation in the
previous paragraph, the use of preventive services could reduce the need for mandated
services by reducing the incidence of child maltreatment. Universal preventive ser-
vices may also have lower stigma associated with their receipt, perhaps reducing reti-
cence to access services (Guterman, 1999).
Policy and Future Implications
Laws banning physical punishment of children

Some European countries (e.g., Austria, Denmark, Finland, Sweden) have banned all
physical punishment of children, resulting in decreased child fatalities (Österman,
Björkqvist, & Wahlbeck, 2014), lower public acceptability of corporal punishment
(Gracia & Herrero, 2008), and lower use of corporal punishment (Zolotor & Puzia,
2010). As illustrative examples, in Germany (where corporal punishment was banned
in 2000), adolescent reports of light and severe slaps to the face changed from 81.2%
to 68.9% and 43.6% to 13.9%, respectively (Bussmann, 2004); in Sweden, 51% of
children in 1980 reported receiving physical punishment compared with 14% of chil-
dren in 2000 (Sweden, 2005). Further, mandated reporters (e.g., child welfare work-
ers, pediatricians) are more likely to perceive and report maltreatment when they had
lower approval of corporal punishment (Ashton, 2001; Tirosh, Schecter, Cohen &
Jaffe, 2003). Thus, wider institution of laws banning physical punishment may
improve child outcomes and reporting of child maltreatment.
Standardizing definitions and decision making

Improved criteria for child maltreatment are possible. For instance, working with the
US Air Force, Heyman and Slep (2006, 2009; Slep & Heyman, 2006) developed
operationalized definitions of child physical abuse, emotional abuse, sexual abuse, and
neglect that split the criteria into components: act (e.g., did a non‐accidental act
occur?), impact (e.g., were there nontrivial impacts?), and exclusions (e.g., acts com-
mitted to protect self from imminent physical harm) and tested a computer‐based
decision tree that had committee members vote on each criterion separately. With
these definitions and system (use of decision tree plus new committee structure), (a)
consensus between trained master reviewers and the voting committees were excellent
(>90%); (b) criteria and the process were perceived as fair by key stakeholders
(Heyman, Collins, Slep, & Knickerbocker, 2010; Slep & Heyman, 2006); (c) alleged
offenders were less likely to reoffend (Snarr et al., 2011); and (d) substantiation deci-
sions were associated with the severity of incidents and whether substance use was
involved, but not with characteristics of those involved (e.g., age, gender, military
status; Travis, Collins, McCarthy, Rabenhorst, & Milner, 2014). It appears as if clear
definitions and substantiation criteria, perceived fairness of the system, and a formal
judgment of having crossed the line into maltreatment had a preventive effect.
These findings led to the criteria being adopted across all services in the US
Department of Defense and by the state of Alaska. They were adapted in the latest
Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) and in proposals for
the forthcoming International Statistical Classification of Diseases and Related Health
Problems (ICD‐11). This common language of classification is promising for possible
(a) preventive effects and facilitation of the interface between child protective services
and health‐care systems and (b) research standardization.
Focus on etiology
The field needs to continue to improve research on etiology. This has not been a
priority of research funders of late, and it shows. Child maltreatment theoretical mod-
els have not advanced much further than they were 15 years ago. But without more
specific isolation of etiological pathways, interventions will not be able to evolve as
quickly as they otherwise could. This is particularly important in light of cultural
changes that could influence the relevance of models developed and tested decades
previously. Additionally, this dearth of contemporaneous theoretical research means
that methodological advances in areas such as genetics, epigenetics, neuroimaging,
and inflammatory responses, among others, are not adequately accounted for in our
leading models.
Better screening and anonymous surveillance of maltreatment

Those who provide services for children need to know how to assess for a history of
maltreatment and provide treatment as necessary. It seems clear that if a child presents
for anxiety, school problems, or behavioral issues but ongoing maltreatment is not
addressed (or even discovered), intervention efforts for the presenting problem will
be undermined. Finally, given that anonymous parental reports provide prevalence
rates many times higher than those identified by formal services or by sentinels,
national prevalence studies are needed to help policy makers fund child maltreatment
research and intervention based on its true prevalence.
Champions of empirically supported prevention approaches

Empirically supported child maltreatment prevention approaches need to be more
widely used within public health initiatives and child welfare systems. Crucially,
these efforts need champions so that families can get their needs met regardless of
whether they qualify for home visitation in the United States or live in Queensland,
Australia, where Triple P is offered to the entire population free of charge. By tak-
ing a public health approach to child maltreatment prevention, the challenge of
ascertaining true maltreatment status is obviated, as prevention efforts are pro-
vided to the entire population. Home visiting programs, SBS education, and
Universal Triple P as implemented in Queensland are true public health models
and provide a blueprint for expanding other promising prevention models at the
population level.
Another prevention approach that shows promise is the use of community coali-
tions to prevent child maltreatment. Although such coalitions have been formed in
various locations (e.g., 90by30 in Oregon; ACEs Public‐Private Initiative [APPI] in
Washington state), there is a dearth of published peer‐reviewed studies regarding
their effectiveness. For example, although there is published research on assessing
collective community capacity (Hargreaves, 2017) at APPI sites, there is, to date,
no published peer‐reviewed APPI coalition efficacy data, although an outcome
report (Hargreaves et al., 2015) indicates positive results on 6 of 11 measured out-
comes (e.g., public awareness of adverse child experiences). The US Centers for
Disease Control has also published a report from a task force convened to generate
strategies for communities to promote healthy environments for children and
reduce the risk of child maltreatment (CDC, 2016), providing a guide for such
efforts.
Clearly there is a push toward large‐scale maltreatment prevention at the commu-
nity level, and progress has been made in advancing the formation of community
coalitions. However, there remains much to be known. Most importantly, we must
evaluate the impact of community coalition efforts on population‐wide prevalence of
child maltreatment. Allowing for the reporting, secrecy, and prevalence issues previ-
ously discussed, the resources devoted to coalition formation and functioning must be
directed toward strategies with demonstrated effectiveness. It is also largely unknown
how transportable individual community efforts would be to other regions of the
United States or globally. Efforts to ascertain what works best, for whom, and under
what conditions are necessary to devise targeted strategies for specific communities.
We would be wise to draw from community prevention efforts outside of child mal-
treatment (e.g., Communities That Care; Hawkins, Catalano, & Arthur, 2002),
applying successful elements and learning from challenges in maintaining community
gains following initial trial funding and investments.
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8
Difficulties in the Transition
to Adulthood
Kayla Reed‐Fitzke and Mallory Lucier‐Greer
In high‐income countries, particularly the United States, the transition to adulthood

has undergone a transformation in both meaning and longevity. Achieving adult
status has been associated with benchmarks such as marriage, parenthood, having a
separate household, finishing school, and gainful employment; yet, current conceptu-
alizations, especially within high‐income societies, tend to place more emphasis on
taking responsibility for one’s own actions, making autonomous decisions, and
obtaining financial independence as qualifiers of adulthood (Arnett, 2014; Berlin,
Furstenberg, & Waters, 2010). From an international perspective (i.e., high‐, middle‐,
and low‐income countries), there are few (if any) consistent social indicators demar-
cating adulthood. Age 18 is the international age of majority (UNICEF, 2015), which
is generally accompanied by the ability to give consent for health care, vote, control
finances, own property, marry, enlist in the military, and purchase tobacco. Such
rights are also linked to expectations for social and economic independence.
This chapter explores difficulties in the transition to adulthood from an empirical
perspective, such that the primary goal is to translate the extant research into clinical
implications. By and large, research in this area is conducted within high‐income
countries, and the preponderance of studies tends to analyze collegiate samples. Thus,
more affluent, less diverse samples tend to be overrepresented in the literature. Where
the research exists, we present findings and trends to reflect the heterogeneity of this
population, particularly from a sociocultural perspective, and speak to within‐group
similarities and differences regarding race/ethnicity, sex, socioeconomic status, and
sexual orientation.
The chapter begins with a review of terminology and discussion of the biological,
social, and relational constructs that contextualize today’s transition to adulthood. In
other words, we situate this developmental phase within the context of physical matu-
ration and societal trends. This is followed by a synthesis of prominent relational
systems during emerging adulthood to highlight salient supports, which is followed
192 Kayla Reed‐Fitzke and Mallory Lucier‐Greer
by a discussion of key challenges experienced during the transition to adulthood and

of best practices in clinical treatment. Then, we recommend policy implications for
systemic interventions and conclude by providing recommendations for future
research. We see high‐quality research with diverse samples and attention to develop-
mental processes as the means to grow this knowledge base and improve clinical
practice.
Terminology
Just as meaningful therapy and healthy relationships require shared meaning, so too
does a chapter on the transition to adulthood. Assessments of physical maturation
coupled with societal, cultural, and historical norms guide how developmental stages
are defined and labeled (Steinberg, 2014; Swanson et al., 2003). Based on contempo-
rary thought, there are four primary terms used to describe the period of time that
begins approximately around age 18 and encompasses the transition into adulthood—
youth, late adolescence, young adulthood, and emerging adulthood.
We contend that there is no one “correct” construction of the developmental
period that encompasses the transition to adulthood, but rather current definitions
rely on hypothesized developmental continuums and are dependent upon cultural
influence and economic opportunity. “Adulthood” can be viewed as a social con-
struction, in that it represents the personal narratives surrounding biological matu-
ration and interpersonal experiences (Hammack & Cohler, 2009; Hammack &
Toolis, 2014). As such, the construction of adult development is dependent on a
variety of factors, such as economic factors, gender ideologies, availability of educa-
tion, religion, race/ethnicity, family resources, and familial expectations. Given the
various ways in which this developmental period can be defined and described, for
the sake of clarity, in this chapter, we chose to use both the terms emerging adults
(individuals who are in the developmental period between adolescence and adult-
hood) and the transition to adulthood (the process of seeking adult status). Emerging
adulthood is typically characterized as spanning between ages 18 and 25, yet the
end of the stage is dependent upon individual context and can last up to age 29
(Arnett, 2014).
The construction of emerging adulthood

Biological development By age 18 most individuals have adult bodies, as physical
maturity and reproductive growth have leveled off or ended; the most important bio-
logical changes during this period are the final stages of brain development, which
occur between the ages of 18 and 25, with full development of the prefrontal cortex
and limbic system taking place by age 25 (Spear, 2000; Steinberg, 2014). During this
time individuals typically refine formal operations and complex abstract reasoning
(Piaget & Inhelder, 2000), and they experience continued neuronal connectivity,
which likely influences capacity for reasoning and impulse control (Spear, 2000).
Additionally, finalized development within the mesocorticolimbic system, along with
reductions in hormones, fosters matured self‐regulation such as even‐temperedness,
reductions in mood swings, and refined emotional expression (Rosenblum & Lewis,
2003; Steinberg, 2005).
Transition to Adulthood 193
Societal trends Societal trends reflect current contextual factors that play into consid-
erations of “adulthood.” This section briefly summarizes social trends, which may
vary by country (e.g., income level, opportunity), to provide historical context and set
the stage for the consideration of key challenges during the transition to adulthood.
Prolongation of education Rates of formal education attainment are increasing

around the world (Blum & Nelson‐Mmari, 2004; US Department of Education,
Institute of Education Sciences, & National Center for Education Statistics, 2015).
The average age for the completion of education has increased and women now
outnumber men in postsecondary education (US Department of Education et al.,
2015). These changes create an environment in which individuals postpone tradi-
tional adult roles, creating prolonged psychosocial moratorium (i.e., period of
delayed obligations and responsibilities allowing individuals to “try on” roles without
permanent obligation; Erikson, 1968).
Occurrence of the “boomerang” effect In recent decades, emerging adults have

been increasingly moving back home with their parents, both in America and abroad
(Newman, 2012). Between 1970 and 1990, the proportion of individuals in their
twenties living with their parents rose approximately 50% (Schoeni & Ross, 2005).
Several factors systematically increase the likelihood of coresidence; individuals who
are married or cohabiting are less likely to live with parents, and those who are closer
to their mothers have a higher likelihood of living with parents (Swartz, Kim, Uno,
Mortimer, & O’Brien, 2011). Men are also more likely to live with their parents, as
are racial minorities (Goldscheider & Goldscheider, 1999; Swartz et al., 2011).
Financial debt and dependence Heightened levels of debt for emerging adults are
primarily attributed to the demand for higher education coupled with rising costs of
education and employment challenges (e.g., partial unemployment, underemploy-
ment). These demands and resulting debt limit one’s ability to support themselves
and have resulted in the need for financial help and familial dependence (Hinze‐
Pifer & Fry, 2010). However, receiving financial support may depend upon family
structure and parent–child relationships (Swartz et al., 2011). The likelihood of
receiving financial support diminishes as individuals transition to adulthood, with
both socioeconomic attainment and getting married further decreasing the likeli-
hood of receiving financial support (Swartz et al., 2011). Importantly, not all emerg-
ing adults receive familial support; some provide financial support to their parents
(e.g., Roksa, 2019).
Relational systems
For some, emerging adulthood is a turning point in the life course, in which individu-
als have the opportunity to transform their life, pursue their dreams, and have more
agency in their relational environments (Arnett, 2014). Given the changing nature of
relationships during this period, this section describes the role of salient relationships
in emerging adult development. More specifically, this section briefly describes three
prominent relational systems (i.e., family, peers, romantic relationships). Each rela-
tional system is described through a strengths‐based perspective to highlight relation-
ships as a potential source of resilience during this developmental period. We provide

such information as a means of situating the context in which key challenges, to be
discussed in the subsequent section, can arise within.
The enduring role of the family of origin The family system has an enduring influence
on emerging adults and their well‐being, including their physical and mental health,
romantic relationship decisions, and feelings about adulthood. Although familial
experiences from childhood influence current emerging adult mental health and
functioning to some degree (e.g., Reed, Ferraro, Lucier‐Greer, & Barber, 2015), the
emerging adults’ ongoing relationship with parents is also an important factor. Well‐
differentiated parent–child relationships, whereby parents exhibit warmth and con-
nection (e.g., affection, companionship, nurturance, instrumental help) and refrain
from overcontrol, promote emerging adult competence (Lindell, Campione‐Barr, &
Killoren, 2017). Parental warmth and developmentally appropriate control have also
been associated with better emerging adult mental health and perceptions of self‐
worth (e.g., Nelson, Padilla‐Walker, & Nielson, 2015; Reed, Duncan, Lucier‐Greer,
Fixelle, & Ferraro, 2016). These findings exist predominantly among White college‐
seeking adults (e.g., Lindell et al., 2017) as well as among diverse samples of emerg-
ing adults, although the way in which the family system impacts emerging adult
outcomes vary some across racial/ethnic groups (Lugo‐Candelas, Harvey, Breaux, &
Herbert, 2016).
Technological advances provide an avenue of communication for adult children
with their parents and may help to foster parent–child communication and relation-
ship satisfaction (Coyne, Padilla‐Walker, & Howard, 2013; Schon, 2014). Cell phones
are the most commonly used form of communicative technology emerging adults use
to connect with their parents, despite parent–child proximity (Schon, 2014). For
example, the majority of parents with emerging adult children in college report com-
municating with their child between a couple times a week and multiple times a day
(Reed, 2017). Technology can provide the opportunity for enhanced or barrier‐free
communication, which may help emerging adults feel as if they have a “safety net” of
support when they move away from family, face a crisis, or need advice. Additionally,
although refinement of ethical and legal ramifications of technology in therapy is
ongoing, technology offers a means of utilizing the family system in therapy settings
when emerging adults are not in close proximity with family:
The employee assistance program at Carlos’ (age 23)1 work referred him to therapy due to
concerns about his inability to focus at work and reoccurring absences. During therapeutic
conversations, the therapist becomes aware that Carlos’ girlfriend is newly pregnant. In
addition to his concerns about an unplanned pregnancy, he is terrified of his Catholic mother
finding out and disapproving unless he marries his girlfriend—which he does not want to do.
Instead of telling her, he has been ignoring her phone calls. He has ignored them for so long
that she has started calling at work, so he has started to call out of work or avoiding being by
his office phone. The therapist conducts a genogram assessment to identify if Carlos has any
cohesive relationships that may be supportive. Together, they decide his sister, Tamara, is the
“safest” person to tell first. Carlos video‐calls his sister during a session, in which the therapist
helps him convey the news. Tamara convinces Carlos to tell his mother, but he is too scared to
tell her over the phone. Instead, the therapist and Carlos work together to draft an email to
his mother. Carlos coordinates the sending of the email with his sister, so she will be present
with his mother when he sends it. The therapist and Carlos process the guilt he feels in not
being able to tell his mother face‐to‐face, but Carlos is soon thereafter able to talk to his
mother and sister over the phone in a calm and respectful manner.
Continued importance of peers The role of friendships as a salient predictor of

health and well‐being is not unique to emerging adulthood, but the importance
of peers in navigating the transition to adulthood cannot be understated. Some
would even suggest that “friendship talk” is part of identity work, such that
emerging adults construct their self‐identities when talking with friends (Anthony
& McCabe, 2015). Social networks can influence risky behaviors (e.g., Eddie &
Kelly, 2017), but social networks can also reflect and predict desirable outcomes,
such as academic achievement (e.g., Lomi, Snijders, Steglich, & Torló, 2011).
Importantly, healthy peer relationships serve as a protective factor to buffer the
effects of stress on emerging adult outcomes. For example, healthy social relation-
ships buffer the relationship between exposure to violence on depressive symp-
toms (Heinze, Cook, Wood, Dumadag, & Zimmerman, 2018) and the relationship
between adverse childhood experiences and depressive symptomology (Reed
et al., 2015). In other words, healthy peer relationships serve as a “risk modifier”
by reducing the impact of stress. Even one close, high‐quality friendship has posi-
tive implications for self‐concept and mental health (Kopala‐Sibley, Zuroff,
Hermanto, & Joyal‐Desmarais, 2016).
The development of the family of procreation An important context in the discussion

of the development of romantic relationships during this period is the global trend in
delaying marriage and children (Blum & Nelson‐Mmari, 2004; Steinberg, 2014).
The marriage rate is also declining slightly, especially among those with a high school
diploma or less (Parker & Stepler, 2017). This is a result of individual‐level decisions
(e.g., decisions to pursue education before marriage, financial uncertainty) as well as
social factors (e.g., greater acceptance of cohabitation and singleness; Amato, Booth,
Johnson, & Rogers, 2007). These trends, along with declines in teen motherhood,
suggest the likelihood of getting married and being a parent during emerging adult-
hood has decreased.
Historically, the decision to marry was, in part, in order to share the household
and finances, but recent delays in marriage suggests emerging adults have more
opportunity to afford to be on their own and can make decisions to marry primar-
ily on relational factors (e.g., love). As many of today’s societies tend to offer more
freedom in regard to making decisions about marriage, emerging adults may be
using this developmental period to explore qualities they want in a partner, helping
to further refine their identity, particularly in regard to love and work (Arnett,
2014). During this period, individuals can explore and coordinate their romantic
interests and their life plans, without restrictions that may accompany stable
commitments (Shulman & Connolly, 2013). Further exploration of the self, prior
to commitment, offers the opportunity to identify the needs of the self, which
helps establish a foundation for intimate and stable relationships (Shulman &
Connolly, 2013).
Key Challenges Experienced During the Transition to Adulthood
This section explores common challenges experienced by emerging adults and

approaches to prevention and treatment. This period of life is the first in which treat-
ment is no longer initiated by parents, wherein individuals can refuse treatment and
age out of children’s health services. Unfortunately, emerging adults disengage from
treatment at higher rates than individuals both younger and older (Substance Abuse
and Mental Health Services Administration [SAMHSA], 2012). To treat emerging
adult clients, it is important to understand these challenges, but we encourage sys-
temic family therapists (SFTs) to utilize a strengths‐based perspective of the develop-
mental period (e.g., a turning point in life) and employ the salient relational systems
(e.g., enduring role of the family) in which emerging adults are embedded. We also
provide a brief framework below for thinking about why the challenges arise. The
framework highlights factors that can be addressed in therapy, including differentia-
tion of self and the fulfillment of basic psychological needs (autonomy, relatedness,
and competence).
Differentiation of self is a salient process during emerging adulthood in which indi-
viduals are seeking autonomy from the family of origin (Bowen, 1978). Autonomy is
the perception that a person is the source of his/her own behavior; the individual has
the freedom to make decisions in line with his/her sense of self (Deci, 1980).
Autonomy is not to be confused with alienation. Autonomy is not about surviving
independently; well‐differentiated individuals are independent, yet maintain healthy,
emotional connections to family, peers, and romantic partners (Bowen, 1978; Carter
& McGoldrick, 1989). These relationships provide a sense of relatedness, the percep-
tion of being connected to and cared for by important others and, in turn, offering
care to important others (Ryan & Deci, 2002).
Compared with other developmental phases, the transition from adolescence to
emerging adulthood has far less institutionally and culturally imposed structure
(Schulenberg, Sameroff, & Cicchetti, 2004). This provides an opportunity for auton-
omy development and individualized choices, but it also creates a sense of floundering
for some (Nelson & Padilla‐Walker, 2013; Schulenberg et al., 2004) and deflated
sense of competence. Competence is the confidence in one’s own skills or ability to
effectively influence an outcome (Ryan & Deci, 2002). In sum, seeking differentia-
tion of self while navigating new environments in the attempt to obtain a sense of
autonomy, relatedness, and competence provides ample opportunity for challenges to
arise. Recognizing and targeting these needs—both general needs and those related
to this developmental phase—provides key intervention points for SFTs.
Common familial challenges

Research investigating the effectiveness of therapies for reducing familial challenges in
emerging adulthood is limited; therefore discussions in this section related to preven-
tion and treatment are primarily focused on providing suggestions that can be incor-
porated into various therapeutic modalities.
Parent–child relationship development As emerging adults begin assuming greater

responsibility and financial independence, the parent–child hierarchy is transformed
and renegotiated. Although the majority of emerging adult children report a close
relationship with their parents (Taylor, Funk, Craighill, & Kennedy, 2006), distinct
parent–child relationship trajectories have been identified (Seiffge‐Krenke, Overbeek,
& Vermulst, 2010). The patterns include normative (parental support and closeness
remain fairly high across time), increasingly negative (low levels of parental support
and closeness and escalating levels of emerging adult negative affect across time), and
distant/decreasingly negative (low levels of parental support and closeness and low
levels of negative affect across time). Healthy communication during the transition to
adulthood has the potential to foster connection between parents and their emerging
adult child (Schon, 2014), but communication focused on control and/or providing
unsolicited, intrusive advice can create division and distance (Carlson, 2016).
Treatment Healthy parent–child relationships can be fostered through relationship

maintenance and communication competence, both of which are teachable skills.
Emerging adults report more communication and better relationship quality with
parents who are willing to use multiple types of media to connect (e.g., phone, text,
video chatting; Schon, 2014). SFTs can promote nonintrusive strategies for relation-
ship maintenance (e.g., finding a medium that both parents and children feel com-
fortable using) to encourage relationship development.
Parents may also bring up parent–child relational challenges in an individual thera-
peutic setting, as well as in couple sessions, in which their emerging adult child is not
present. In such instances, it may be helpful for SFTs to focus on helping parents
understand the value of healthy boundaries and appropriate communication. Parental
communication competence directly influences parent–child relationship quality
(Schon, 2014). Competent communicators are socially aware of the thoughts and
reactions of others. SFTs can coach parents on effective communication patterns,
particularly with regard to offering advice and solutions to emerging adults. The man-
ner in which the advice is delivered and the quality of the advice both predict advice
implementation by emerging adults (Carlson, 2016). Specifically, the goal is to
communicate with empathy (concern and perspective taking by the parent) and in an
autonomy supportive manner.
Helicopter parenting Helicopter parenting, over‐parenting, indulgent parenting, and

lawnmower parents are all terms to describe parenting practices characterized by high
levels of cohesion, overcontrol, intrusive behaviors, and extensive support. These par-
enting practices extend beyond the United States (e.g., little emperor syndrome in
China, curling parents in Scandinavia). Advances in technology facilitate parent–child
communication, and it also enables parents to act in overcontrolling or overbearing
ways, limiting an emerging adult’s ability to differentiate and achieve self‐sufficiency.
Suggestions are that parents engage in these behaviors to help and protect their emerg-
ing adult child, but these behaviors impede the development of competence and
autonomy. Helicopter parenting is associated with lower levels of self‐worth (Nelson
et al., 2015), self‐efficacy (Reed, Duncan, et al., 2016; van Ingen et al., 2015), and
self‐regulation and heightened emotional and behavioral problems (Cui, Graber,
Metz, & Darling, 2016). Helicopter parenting in the absence of parental warmth is
particularly detrimental, as it has been associated with lower levels of self‐worth and
higher levels of risky behaviors among emerging adults (Nelson et al., 2015). Despite
media descriptions of helicopter parenting as rampant and severely problematic, in a
sample of collegiate emerging adults, mean levels of helicopter parenting appeared to
be low; most parents engaged in developmentally appropriate relationships and provided

appropriate levels of support (Lowe, Dotterer, & Francisco, 2015).
Prevention and treatment Less is known about treatment approaches for emerg-
ing adults who have helicopter parents. We know that emerging adults who demon-
strate global self‐worth and autonomy report better mental health symptomology
even in the context of developmentally inappropriate parenting behaviors (e.g., high
levels of control; Kenny & Sirin, 2006; Kerig, Swanson, & Ward, 2012). Addressing
the basic needs of the emerging adult and boundary maintenance are key points of
intervention.
SFTs may also become aware of parents engaging in such behaviors when parents
seek out help due to concerns about their adult child. Psychoeducation appears to be
an effective means of teaching parents how to engage and support their emerging adult
child (e.g., Earle & LaBrie, 2016). Educating parents about the basic needs of emerg-
ing adults (autonomy, competence, and relatedness), as well as normative emotional
and cognitive development, may provide parents an opportunity to think of their child
through a new lens and aid in the renegotiation of responsibility and boundaries.
Working from the assumption that helicopter parenting behaviors are intended to help
and protect children during the transition to adulthood, therapists may reframe such
concern into more productive behaviors. Consider the following case example:
In the first session, Stacey informs the therapist that she tried to get her 20‐year‐old daughter,
Luna, to come to therapy but that her daughter was too busy with school. Instead, Stacey
decided to come to therapy to tell the therapist about what her daughter is doing so she can
report the therapist’s advice back to Luna. Stacey describes “Luna’s problem” as her ambiva-
lence about finding a job, going out with her friends too much, and having little interest for
a serious relationship. Stacey states that she consistently supports Luna by reminding her to get
serious about school, helping her look at online dating profiles for potential partners, and pay-
ing for her school tuition and bills. Stacey worries that Luna will never get serious enough to
do these things on her own and that she will end up homeless without a job or partner. The
therapist explores these fears with Stacey, to find that her concerns for Luna are reflective of
what she experienced when she left her family home. The therapist validated her concerns about
the safety and success of Luna. Then, the therapist discussed the common characteristics that
are considered normative for emerging adulthood, such as exploring options for love and work
without making commitments as a way to normalize some of Luna’s behaviors. The therapist
also discussed alternative behaviors in which Stacey can still show support and concern while
facilitating Luna’s independence. Stacey agreed to work on setting new boundaries with
Luna, such as expecting Luna to contribute financially to her living costs. The therapist asked
Stacey to practice such conversation using the empty chair technique and pointed out state-
ments in which Stacey could rephrase her message to facilitate more autonomous behavior.
Common romantic relational problems

For more in‐depth discussion regarding the treatment of common relationship prob-
lems, refer to Williams (2020, vol. 3).
Creating healthy emotional and sexual relationships Emerging adult romantic

relationships are regularly characterized as “sliding” through transitions, such that
individuals avoid talking about the dynamics of their intimate relationship and level of
commitment as they move forward in their relationship. Sliding, as opposed to making

intentional decisions to move forward with a partner, is associated with lower levels of
relationship dedication (Clifford, Vennum, Busk, & Fincham, 2017). There is also
greater acceptability and prevalence of sexual relationships that are not tied to commit-
ted relationships among emerging adults (e.g., Mongeau, Knight, Williams, Eden, &
Shaw, 2013). Emerging adults who have a “distant marital horizon” (e.g., view mar-
riage as far off, if it happens at all) tend to report greater acceptance of sexual permis-
siveness and cohabitation (Carroll et al., 2007).
Casual sex has primarily been examined among emerging adults in college; esti-
mates suggest between 50 and 84% of college students engage in “friends with ben-
efits” relationships, “booty calls,” hookups, and/or one‐night stands (as noted in
Claxton & van Dulmen, 2013). The impact of brief, sexual relationships is mixed.
For some, hooking up was associated with higher life satisfaction; for others, it has
been associated with elevated anxiety, depression, lower self‐esteem, and shame
(Claxton & van Dulmen, 2013; Owen, Rhoades, Stanley, & Fincham, 2010).
Emotional reactions to hooking up differ based on expectations of the relationship
and personal assessments of the encounter (Owen et al., 2010), as well as sex; women
typically experience more adverse outcomes (Claxton & van Dulmen, 2013).
Additionally, couples who engage in casual sex and subsequently develop a commit-
ted relationship report slightly lower levels of relationship satisfaction (Owen &
Fincham, 2011). Causal sex is likened to risky sex as it puts individuals at a greater
risk for sexually transmitted diseases and unplanned pregnancies (Manning, Giordano,
& Longmore, 2006).
Within‐group differences exist in regard to who is more likely to engage in risky
sex. For example, men are more likely to engage in risky sexual practices (e.g., Pharo,
Sim, Graham, Gross, & Hayne, 2011). Additionally, lesbian, gay, and bisexual (LGB)
Latino males are more likely than LGB White males to engage in risky sex (Ryan,
Huebner, Diaz, & Sanchez, 2009). There is evidence to suggest that at‐risk individu-
als (e.g., individuals presenting with psychiatric disorders and/or substance depend-
ence) are also more likely to engage in risky sexual behavior, in the United States and
abroad (e.g., Mota, Cox, Katz, & Sareen, 2010; Nduna, Jewkes, Dunkle, Sama Shai,
& Colman, 2010).
Prevention and treatment SFTs need to first determine whether risky sexual
behaviors of emerging adult clients are a symptom of a larger presenting problem.
Because there are a wide range of sexual motivations and determinants, it tends to be
more effective for SFTs to view risky sexual behaviors through a functional perspective
to understand client needs and the goals of the behavior (Gouvernet, Combaluzier,
Chapillon, & Rezrazi, 2016). Evidence suggests that education about the conse-
quences of risky sexual behavior tends to be unrelated to sexual practices (e.g., Katz,
Fromme, & D’Amico, 2000).
SFTs can equip emerging adults with skills and knowledge to enter romantic rela-
tionships with intentionality. The National Extension Relationship and Marriage
Education Model (NERMEM) provides a framework of what makes a relationship
“work,” and each dimension is a teachable skill (Futris & Adler‐Baeder, 2014).
Emerging adults who are further along in relationship development and considering
marriage may benefit from premarital counseling; see Carlson, Daire, and Hipp
(2020, vol. 3) for a discussion of premarital counseling options.
Romantic relationships and technology/social media The ways in which emerging

adults initiate close dating relationships has expanded with the use of social network-
ing sites (e.g., Instagram, dating apps) and short message services (e.g., texting;
Rappleyea, Taylor, & Fang, 2014). Technology use does not seem to come at the
“cost” of face‐to‐face communication in dating relationships; rather, it is used as
another means of connection and a way to plan face‐to‐face meetings (Coyne et al.,
2013). However, technology and social media use can be a risk factor for romantic
relationships when used to access pornography and connect with potential sexual
partners. Emerging adults report the highest rate of pornography use (~87% of males
[20% viewing daily] and ~30% of females); although pornography use has been asso-
ciated with more sexual variety between partners, it is also systematically associated
with aggression, sexual coercion, more accepting attitudes of infidelity, and lower
relationship commitment (Rasmussen, 2016). Internet infidelity may be a presenting
problem in therapy as technology provides a means to develop a discrete, intimate
relationship (Whitty, 2011). Geosocial networking applications (e.g., Tinder) allow
users to meet partners within their locality, typically for brief sexual encounters; these
apps tend to be used less often by people in a committed relationship, but use has
been associated with higher odds of nonconsensual sex and having 5+ sexual partners
(Shapiro et al., 2017).
Prevention and treatment Transparency in technology and social media use

between partners can enhance trust and commitment, but digital monitoring that
reflects control and tracking is harmful to one’s partner and the relationship (Reed,
Tolman, & Ward, 2016). Digital dating aggression is not a visible form of abuse; thus
SFTs need to assess for this type of abusive behavior and work to promote positive and
respectful digital and interpersonal relationship boundaries.
Domestic violence Most emerging adults report relationships characterized as “no

exposure” to violence (between 55 and 77%), yet violence within couple relationships
is common to the extent that it has become a public health concern (Spencer, Renner,
& Clark, 2016). Between 12 and 20% of emerging adults report “bidirectional vio-
lence” such that both partners perpetrate violence, typically sexual violence and injury.
Differences in perpetration and victimization exist by sex, race, and socioeconomic
status (Spencer et al., 2016). Factors associated with perpetration among emerging
adults include antisocial and psychopathic traits, interpersonal jealousy, fear of aban-
donment, and demographic characteristics, such as low socioeconomic status, being a
female, and being African American (e.g., Goodnight et al., 2017). Females tend to
perpetrate physical violence at higher rates than males; this violence is typically char-
acterized as “moderate” and it rarely involves sexual violence or injury. Black males
are more likely to be in violent relationships than White males; Black females report
higher rates of perpetration and victimization than White females. Across race and sex,
financial stress is a predictor of being in a violent relationship.
Treatment Interventions for antisocial behavior, including multisystemic therapy

and functional family therapy (not originally developed to prevent intimate partner
violence), may be a promising method of treatment as these methods use a systems
perspective to address multiple risk factors at play (Goodnight et al., 2017). SFTs are
best suited to avoid certain couple therapies (e.g., emotion‐focused couple therapy),
as such approaches are contraindicated when domestic violence is present. For addi-
tional discussion of interventions for domestic violence, refer to Stith, Mittal, and
Spencer (2020, vol. 3).
Common internalizing difficulties

Emerging adults have the highest rates of any mental illness (AMI) or serious mental
illness (SMI); in 2016, approximately 22% and 6% of emerging adults had AMI and
SMI, respectively (SAMHSA, 2017b). Unfortunately, emerging adults have lower
treatment utilization rates compared with younger and older counterparts. The most
common internalizing difficulties in emerging adulthood are anxiety and depression,
followed by bipolar disorder, suicide, and eating disorders. Refer to Priest and Cobb
(2020, vol. 2), Krauthamer Ewing, Hunt, Singer, Diamond, and Winley (2020, vol.
2), and Blessitt, Baudinet, Simic, and Eisler (2020, vol. 2) for discussions of internal-
izing symptoms, suicide, and eating disorders, respectively.
Anxiety and depression Anxiety and depression are discussed together in this section
and may present as comorbid disorders; this does not imply that such disorders are
always comorbid; the majority of emerging adults experience anxiety or depression
(e.g., Rohde, Lewinsohn, Klein, Seeley, & Gau, 2013). Emerging adults consistently
have the highest rates of major depressive episodes (MDE) (11%) and MDE with
severe impairment (7%) in comparison with any other age group over the last decade
(SAMHSA, 2017b). Regarding rates of anxiety, the most recent nationwide effort to
collect such data comes from the 2001–2003 National Comorbidity Survey Replication
(NCS‐R), which found ~22.3% of emerging adults experienced an anxiety disorder in
the past year (Harvard Medical School, 2007).
Several within‐group differences exist; women are more likely to experience anxiety
disorders, MDE, and MDE with severe impairment than men (Harvard Medical School,
2007; Center for Behavioral Health Statistics and Quality [CBHSQ], 2017). Racial and
ethnic minority emerging adults are expected to be more vulnerable to depression and
anxiety; this is likely correlated with experiences of discrimination (Sellers, Caldwell,
Schmeelk‐Cone, & Zimmerman, 2003). The intersectionality of various factors is also
an important consideration. For example, emerging adult Latino LGB men report
higher levels of depression, suicidal ideations, and suicide attempts than White LGB
men, whereas White LGB women report great symptomology (depression, suicidal
ideation, and suicide attempts) than Latina LGB women (Ryan et al., 2009).
Prevention and treatment Approximately 44% of emerging adults with an MDE

and 51% with MDE with severe impairment in the past year received treatment (i.e.,
talking to a professional, prescription medication), both of which are lower utilization
rates than among older adults (SAMHSA, 2017b). Emerging adult women are more
likely to experience MDE, but are more likely to seek treatment than men (CBHSQ,
2017). Information about treatment utilization among emerging adults for anxiety
disorders is scant, although one might expect similar utilization rates as those with
MDE. In the treatment of anxiety and depressive disorders, in addition to medication,
the top evidence‐based psychotherapy treatments are cognitive‐behavioral therapy
(CBT), family therapy, acceptance and commitment therapy (ACT), and interper-
sonal therapy (IPT) (SAMHSA, 2017a).
Attachment‐based family therapy (ABFT), couple therapy (i.e., behavioral marital

therapy, cognitive marital therapy, emotion‐focused couple therapy, interpersonal
couple therapy, systemic couple therapy), and family psychoeducation (i.e., in home,
multifamily psychoeducational groups) are additional treatments that have initial evi-
dence as promising treatments for depression (Barbato & D’Avanzo, 2008; Diamond,
Reis, Diamond, Siqueland, & Isaacs, 2002; Sanford et al., 2006). Mindfulness‐based
therapies and ABFT are also promising practices for the treatment of anxiety (Diamond
et al., 2002; Hofmann, Sawyer, Witt, & Oh, 2010). See Priest and Cobb (2020, vol.
2) and Wittenborn, Rouleau, Huerta, Tseng, and Lachmar (2020, vol. 4) for a more
detailed description of evidence‐based treatments (EBT) for anxiety and depression.
Specific for the treatment of emerging adults, Davis, Sheidow, and McCart (2015)
described an adaptation of Multisystemic Therapy for Emerging Adults (MST‐EA)
with an Axis I mental health diagnosis and recent involvement with the judicial system
(e.g., arrest, incarceration). MST‐EA reduced mental health symptoms 6 months
post‐intervention (Davis et al., 2015). Regarding the prevention of anxiety and
depression among college students, a meta‐analysis demonstrated social skills train-
ing, CBT, relaxation, and general behavioral interventions prevented symptoms over
a three‐year period in comparison with those who did not receive any intervention;
the interventions did not vary in their effects and did not affect the presence of
episodes (Seligman, Schulman, DeRubies, & Hollon, 1999).
Common externalizing difficulties

The most common externalizing behaviors during this time are substance abuse and
risk‐taking (i.e., risky sexual behavior and dangerous driving; Arnett, 2014; NAHIC,
2014). These behaviors are largely viewed by society as problematic; however, these
may be considered a norm or rite of passage. Some emerging adults engage in such
behaviors in response to perceptions that these are “now or never” behaviors, in that
this is their only opportunity to act in such a manner (Ravert, 2009). However, exter-
nalizing behaviors warrant attention among SFTs given prevalence rates within emerg-
ing adult samples (e.g., a quarter of the sample; Nelson & Padilla‐Walker, 2013) and
the ramifications associated with these behaviors.
Substance abuse Emerging adults have the highest rates of substance use disorders
(SAMHSA, 2017b). However, there are some key distinctions between alcohol use and
illicit drug use. Illicit drug use tends to peak at age 20, whereas alcohol use peaks at age
24 (Schulenberg & Zarrett, 2006). Additionally, alcohol use rates among emerging
adults remain above 34% throughout emerging adulthood, whereas rates of illicit drug
use range between 18 and 36% for marijuana and 11 and 23% for other illicit drugs
(SAMHSA, 2017b; Schulenberg & Zarrett, 2006). Important to note is that prevalence
rates can vary widely based on methodological differences (e.g., sample, measurement).
Alcohol use Although rates of alcohol use disorder (AUD) have declined over the
last decade among emerging adults, emerging adults continue to have the highest
rates of AUD in comparison with other age groups (10.7%; SAMHSA, 2017b).
Approximately 38% of emerging adults reported binge alcohol use in 2016 (SAMHSA,
2017b). Regarding within‐group differences, approximately 12% of emerging adult
men have an AUD versus 10% of women (CBHSQ, 2017). American Indian or
Alaskan Native emerging adults have the highest rates of AUD, followed sequentially
by White, biracial/multiracial, Hispanic or Latinx, Black or African American, and
Asian (CBHSQ, 2017). Emerging adults with some college experience, an associate’s
degree, or bachelor’s degree have higher rates of AUD than those with a high school
diploma or less (CBHSQ, 2017). Sexual minority emerging adults are also at a greater
risk of substance use behaviors (Talley, Sher, & Littlefield, 2010). Considerations of
intersectionality are also important. For example, emerging adult Latino LGB men
and White LGB women are more likely to engage in heavy drinking than their gender
counterparts (Ryan et al., 2009).
Illicit drug use Similarly, emerging adults have the highest rates of illicit drug use
disorder (7%; e.g., marijuana, cocaine, heroin, hallucinogens, inhalants, methamphet-
amine, prescription drugs) than any other age group (SAMHSA, 2017b).
Approximately 23% of emerging adults used illicit drugs in 2016 (SAMHSA, 2017b).
The most commonly used drugs were marijuana, prescription stimulants, and pre-
scription pain relievers. Similar to AUD, more emerging adult men (9%) meet criteria
for an illicit drug use disorder compared with women (5%; CBHSQ, 2017). In con-
trast to an AUD, biracial/multiracial emerging adults have the highest rates of illicit
drug use disorder, followed sequentially by American Indian or Alaskan Native, Black
or African American, White, Hispanic or Latinx, and Asian (CBHSQ, 2017). In con-
trast to the education differences in AUD, emerging adults with a bachelor’s degree
have the lowest rates of an illicit drug use disorder; those with some high school, a
high school diploma, or an associate’s degree report similar rates of illicit drug use
disorder (CBHSQ, 2017). Additionally, emerging adults who are unemployed have a
higher prevalence of illicit drug use disorder (CBHSQ, 2017). Finally, in contrast to
AUD, emerging adult White LGB men are more likely than Latino LGB men to
engage in illicit substance use; however White LGB women remain more likely than
Latina LGB women to engage in illicit substance use (Ryan et al., 2009).
Prevention and treatment In 2016, 5.3 million (15.5%) emerging adults were
identified as needing substance use treatment; however only 1.8% of emerging adults
received any type of treatment (e.g., inpatient, outpatient, Alcoholics Anonymous;
SAMHSA, 2017b). In addition to medication, inpatient rehabilitation, and peer sup-
port, therapies such as CBT, multidimensional family therapy, motivational interview-
ing, and contingency management have the largest evidence base for effective
psychotherapy approaches (National Institute of Drug Abuse [NIDA], 2018).
However, much of the research specific to emerging adulthood treatment examines
established alcohol misuse treatments among college student samples. See Kimball,
Shumway, Bradshaw, and Soloski (2020, vol. 4) for a more detailed description of
EBTs for substance use and addiction.
Individual‐focused treatments have been examined more often, yet family treat-
ments (e.g., multidimensional family therapy and brief strategic family therapy) for
alcohol and other substance misuse have been shown to be more effective than indi-
vidual treatments (i.e., CBT, IP) with adolescents (e.g., Liddle, Dakof, Turner,
Henderson, & Greenbaum, 2008; Rigter et al., 2013; Robbins et al., 2011) and
could be modified to be more effective for emerging adults. Effective interventions
created for adolescents to reduce substance abuse are not equally effective among
emerging adults (Smith, Godley, Godley, & Dennis, 2011). Treatments specific to
adults may also not directly target the needs of emerging adults, as emerging adults
have some differing characteristics and needs regarding substance abuse treatment
(Mason & Luckey, 2003). For example, emerging adults are generally less concerned
about alcohol abuse, even after receiving a substance‐related diagnosis, in comparison
with older adults (Mason & Luckey, 2003). Lack of concern may be reflective of a
general societal perception that emerging adulthood is a time in which alcohol use is
more socially acceptable and expected. SFTs may have to address both the individu-
al’s denial of a substance use issue and the misconception that alcohol misuse in
emerging adulthood is normative. The emphasis on peers is another factor that may
distinguish treatment for emerging adults from older adults. One substance abuse
treatment, Community Reinforcement Approach, was adapted for emerging adults
by enhancing the peer component (Peer‐CRA) and was shown to increase days of
abstinence and reduce binge drinking over a six‐month period (Smith, Davis, Ureche,
& Dumas, 2016). Other peer‐based motivational interventions have also demon-
strated a reduction of alcohol use in college students (e.g., Tevyaw, Borsari, Colby, &
Monti, 2007).
In regard to prevention, combining a peer‐facilitated motivational interviewing
focused on substance use intervention, Brief Alcohol Screening and Intervention for
College Students (BASIC), with a parenting handbook intervention was more effec-
tive in reducing alcohol use and related consequences among college freshman
10 months later in comparison with either intervention alone or assessment only
(Turrisi et al., 2009). Another prevention program, Adults in the Making (AIM), is
a family‐centered program designed for individuals transitioning from adolescence to
emerging adulthood, particularly those who experience contextual risk (e.g., dis-
crimination; Brody, Yu, Chen, Kogan, & Smith, 2012). AIM promotes resilience
with the individual and provides training of developmentally appropriate parenting
skills to their caregivers (Brody et al., 2012). AIM has been effective in decreasing
rural African American emerging adults’ interest in alcohol use, as well as the likeli-
hood of developing a substance problem in comparison with the control group
(Brody et al., 2012).
Best Practices and Guidance for Developmental Adaptations
Calls to the field have been made for developmentally informed models of mental
health (Sheidow, McCart, Zajac, & Davis, 2012; Whitney & Costa, 2012) and to
evaluate established EBTs (Smith et al., 2011) and tailored interventions (Davis,
Copeland, & Seidman, 2013) among emerging adult populations. Currently, the state
of knowledge regarding therapy for emerging adults is limited. Few prevention or
intervention treatments have been evaluated, and even fewer modified to fit the devel-
opmental period. Evaluations that exist largely assess individual‐based treatments and
are conducted by clinicians and researchers from other disciplines. Given that SFTs and
researchers are best situated to evaluate the effectiveness of systemic treatments in a
developmental context, our role in this work is crucial. Researchers could target existing
supports to fund this work (e.g., Emerging Adults Initiative; SAMHSA, 2014).
Developmentally appropriate interventions attend to the unique qualities of emerg-
ing adulthood, such as “responsibility‐ and risk‐taking, cognitive processing of thera-
peutic materials, peer group changes and contextual [school/vocation] changes,

development of effective future planning skills and literacy, parental and legal author-
ity, [and] motivational incentives/contingencies” (Sheidow et al., 2012, p.241). They
can also attend to the opportunities available during this developmental period, such
as freedom from constraints that accompany adolescence or formal adult commit-
ments, perceptions of opportunity for change in circumstance, and the continued
refinement of identity. A proposed developmental framework for modifying preven-
tion and intervention treatment considers four features (as summarized by O’Connell,
Boat, & Warner, 2009):
• Age‐related patterns of competence and disorder: Cognitive, emotional, and

behavioral abilities are considered based on the client’s age, as well as age of onset
for any present disorder (O’Connell et al., 2009). For example, emerging adults
tend to have greater emotional maturity than adolescents, but less neurologi-
cal development than older adults. This may have implications for the onset of
mental health issues, the therapeutic process, and appropriate interventions (e.g.,
responsibility‐ and risk‐taking, motivational incentives; Sheidow et al., 2012).
• Multiple contexts: By utilizing an ecological lens that considers family, school,
neighborhood, and cultural contexts, the implication is that treatments can occur
in a variety of settings and include various important figures (O’Connell et al.,
2009). Bergman, Kelly, and Nargiso (2016) have suggested incorporating par-
ents into the treatment of emerging adults with substance abuse but recom-
mend engaging parents separately from emerging adults and primarily focus on
contingency management. There are currently no guidelines on how to include
parents, or other family‐of‐origin members, in therapy with emerging adults (Da-
vis et al., 2013). As emerging adults begin to rely less on their family of origin and
shift focus to their family of procreation (Sheidow et al., 2012), family therapy
may become an amalgamation of important others. There may also be important
variations to consider in how SFTs engage emerging adults in family‐ or peer‐
based prevention or intervention efforts, given their lower likelihood to engage
and remain in treatment.
• Developmental tasks: Integration of developmental goals, such as gaining auton-
omy, career decisions, and forming and maintaining intimate relationships, may
increase the effectiveness of interventions (Tanner & Arnett, 2013). Such tasks
and goals may also vary by culture and gender (O’Connell et al., 2009), indicat-
ing the need to have developmentally aware and culturally competent therapists.
• Interactions among biological, psychological, and social factors: Presenting problems
are a function of genetic, biological, psychological, and social processes (O’Connell
et al., 2009). Although more work is needed to understand the processes that lead
to emotional or behavioral issues, current evidence suggests the etiology of mental
health and relational problems is multifaceted (e.g., Slavich & Irwin, 2014).
Developmentally appropriate interventions for emerging adults may also include a

focus on common risk and protective factors relevant to the developmental period
(O’Connell et al., 2009; Tanner & Arnett, 2013). Additional themes to consider in the
adaptation of interventions include a focus on youth voice, changes in and utilizing
peers, responsibility‐ and risk‐taking, contextual changes, feelings of being in‐between,
and motivational incentives (Davis et al., 2013; Sheidow et al., 2012). The use of
patient‐centered clinical approaches may also help to improve emerging adult engage-
ment (Bergman et al., 2016).
Further, as current and future generations of emerging adults are immersed in
social media, technology offers opportunities to target those who need services and to
modify existing EBTs to enhance services for emerging adults. Social media and text
messaging can be used to aid in beginning, delivering, and maintaining treatment
(Bergman et al., 2016; Davis et al., 2013; Naslund, Aschbrenner, Marsch, & Bartels,
2016). Online, specialized groups may also be a relevant mechanism of support;
emerging adults with mental illness have reported interest in social networking sites
geared toward individuals of their age with mental health concerns to reduce social
isolation and encourage independent living (Gowen, Deschaine, Gruttadara, &
Markey, 2012). Social networking sites can also help combat the stigma of seeking
help (Naslund et al., 2016).
Finally, as recent generations of emerging adults have shifted away from religion
and more toward spirituality (Arnett & Jensen, 2002; Stoppa & Lefkowitz, 2010),
they may be less likely to seek out support from faith leaders (e.g., pastor, clergy)
when experiencing challenges. Social networking may offer a more personalized
means of providing spiritual support. Religion and spirituality have been linked with
positive outcomes in emerging adulthood (i.e., lower depression, substance use, risky
behaviors), yet some of these connections may be stronger based on factors such as
church attendance (Yonker, Schnabelrauch, & DeHaan, 2012). Therefore, it may be
important for emerging adults to receive spiritual support through alternative means,
such as social networking.
So what are best practices for systemic family therapists?

Developmental modifications to treatment presents a promising direction, but it may
be some time until such practices have been developed, refined, evaluated, and inte-
grated into regular practice. Some treatments with evidence to suggest at least mini-
mal effectiveness include ACT, ABFT, CBT (individual and couple), emotion‐focused
couple therapy, IPT (individual and couple), and mindfulness, as well as family psych-
oeducation. Those that have been modified to attend to the unique needs of emerg-
ing adults include MST‐EA, Peer‐CRA, and AIM. Additional systemic approaches
that may be well tuned to the needs of emerging adults and could be developmentally
modified include Bowen family systems therapy, brief strategic family therapy, contex-
tual family therapy, solution‐focused therapy, multidimensional family therapy, and
structural family therapy.
Nontraditional forms of prevention and intervention may also be well received by
emerging adults. Telehealth and computer‐based applications are promising practices;
mobile apps may be used as a form of prevention and outreach, particularly those that
have the ability to assess for risk and provide resources when appropriate or help foster
and build healthy relationships (Lucier‐Greer, Birney, Gutierrez, & Adler‐Baeder,
2018). Emerging adults may also benefit from the inclusion of peers in therapeutic
settings. Peers may act as a sounding board for emerging adults’ ideas and decision
making in regard to the developmental tasks of the period, such as career decisions
and romantic relationships. Considering peers to be a part of the emerging adults’
family system may widen the scope of who can be included in therapy while attending
to an important facet of the developmental period.
Policy Implications for Systemic Interventions
To facilitate the transition to adulthood, there are policy implications at several levels
of intervention. Healthy emerging adults tend to be those who demonstrate auton-
omy, relatedness, competence, and self‐worth. Thus, facilitating those basic needs
prior to emerging adulthood is imperative. Brief school‐based educational programs
can increase mental health literacy, increase confidence in supporting peers, help seek-
ing intentions, and promote mental health among adolescents as well as reduce stigma
of mental health services (e.g., Hart, Mason, Kelly, Cvetkovski, & Jorm, 2016). Policy
makers have a body of evidence that demonstrates the impact of educational programs;
these programs start conversations and lead to important knowledge for individuals
and systemic changes within schools and communities.
University administrations are encouraged to continue this “conversation” as stigma
remains a barrier in help seeking behaviors (Lannin, Vogel, Brenner, Abraham, &
Heath, 2016). University‐based counseling services and programs have been effective
in not only treating clients but also promoting bystander intervention, reducing rates
of violent victimization, and enhancing campus security (Coker et al., 2015; Prince,
2015). Funding for the support of university counseling centers and affiliated mental
health resources is needed as these centers tend to be understaffed given the rise in
students seeking services and the increased severity of presenting problems over recent
years (Gallagher, 2014). It is important to note that although the stigma around seek-
ing help appears to be dwindling (e.g., as evidenced by increased demands on colle-
giate counseling services), emerging adults remain the least likely to seek treatment
than any other developmental group. Additionally, advances in psychotropic medica-
tion, childhood treatment, and collegiate resources (e.g., Office of Disability) have
likely provided individuals with more severe mental health problems the opportunity
to successfully pursue higher education, which may be contributing factors in the rise
in problem severity seen in collegiate counseling and health‐care centers.
Policy considerations are also warranted with regard to identifying and treating the
“forgotten half” of emerging adults, those who do not seek out higher education and
likely have some form of disadvantage (e.g., low income; Halperin, 2001). Advocacy
efforts could focus on initiatives to develop more bridge programs (i.e., improve the
link between child health care and adult health care) and reduce the stigma of mental
health services. Evidence from England suggests that community‐based mental health
campaigns can enhance positive attitudes of help seeking (Evans‐Lacko, Henderson,
& Thornicroft, 2013); this may also be effective in reaching emerging adults outside
the higher education system.
Future Directions to Improve Clinical Practice
We contend that research on systemic treatments is the needed next step to improve
clinical practice and enhance the outcomes of emerging adults. It is vital to under-
stand treatment effectiveness based on factors of diversity and intersectionality; thus
diverse samples of emerging adults are needed to evaluate therapeutic modalities,
EBTs, and developmental modifications. We encourage those in the planning stages
of such research to incorporate dissemination and implementation research into their
work. For an introduction to dissemination and implementation research for SFTs,

see Withers, Reynolds, Reed, and Holtrop (2017). Finally, we would like to empha-
size Wittenborn, Blow, Holtrop, and Parra‐Cardona’s (2018) recent call to the field;
in order to strengthen and advance systemic‐based interventions to improve the
functioning of individuals and families, the field requires both structural‐ and indi-
vidual‐level supports for rigorous clinical research. As much of the clinical research on
systemic treatments is largely conducted by scholars in other disciplines, we encourage
SFTs to engage in multidisciplinary research to further strengthen clinical programs
of research (Wittenborn et al., 2018).
Note
1 The vignettes are based on both composite information and fictional details, meeting the
standards of confidentiality.
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2011.08.010
Part III
Child and Adolescent
Disorders
9
Family‐Based Prevention
and Intervention for Child Physical
Health Conditions
Keeley Jean Pratt, Catherine A. Van Fossen,
Damir S. Utržan, and Jerica M. Berge
Obesity, asthma, and diabetes are among the most common chronic health conditions
of childhood (Torpy, Campbell, & Glass, 2010). The American Academy of Pediatrics
(AAP) advocates for utilizing “family‐centered care” to address childhood chronic
conditions. A family‐centered approach entails providers collaborating with family
members to deliver high‐quality treatment for children with chronic conditions
(Committee on Hospital Care and Institute for Patient‐and Family‐Centered Care,
2012). This chapter will introduce the prevalence and incidence of childhood chronic
conditions, in addition to the evidence for the role of family in interventions
and treatment of childhood chronic conditions—with special emphasis on obesity,
diabetes, and asthma. The role of system interventions and therapy, including the
evidence regarding the inclusion of the entire family system, as well as individual
family members beyond the child, for intervention and treatment is provided.

Conclusions about the future role of systemic family therapy in the treatment of
childhood chronic conditions are discussed.
Prevalence, definition, and importance

Obesity National Health Survey data from 2012 indicate that 17% of children aged
2–19 were obese; however global estimates of obesity in children aged 2–19 are
slightly lower when examining all high‐income countries with approximately 13% of
children identified as obese (Ng et al., 2014; Ogden et al., 2016). The median annual
incidence of obesity for school‐age children, 5–14, was 3.2% in 2014. There are
numerous policy statements and guidelines for the prevention and treatment of child-
hood obesity from organizations including the Centers for Disease Control, the
Institute of Medicine, and the American Academy of Pediatrics. The World Health
Organization established a Commission on Ending Childhood Obesity in 2014 (Chai
et al., 2016). Additionally, Medicaid now includes enrollment benefits that cover
obesity‐related services (Centers for Medicare and Medicaid Services, n.d.).
220 Keeley Jean Pratt et al.
Diabetes Approximately 0.02% of the total US population of youth aged 19 or

younger had diagnosed diabetes in 2012, with 17,900 and 5,300 of new cases of type
1 and 2 diabetes (CDC, 2017) diagnosed, respectively. Globally between 2011 and
2012, approximately 0.59% of children were diagnosed with type 1 diabetes and
79/1,000 cases were newly diagnosed (Patterson et al., 2014). Global estimates for
type 2 diabetes in children included larger ranges for the estimates of incidence and
prevalence; 0–330/100,000 children were newly diagnosed and 0–5,300/100,000
were estimated to have the condition (Patterson et al., 2014). The AAP (2013) pub-
lished the first guidelines for the management of type 2 diabetes in children and ado-
lescents in partnership with the American Diabetes Association, the Pediatric
Endocrine Society, the American Academy of Family Physicians, and the Academy of
Nutrition and Dietetics. The most recent medical standards for diabetes were released
in 2018 and recommend multidisciplinary treatment teams trained in diabetes
management in children (American Diabetes Association). Additionally, the National
Diabetes Education Program is an initiative that helps to alleviate disease burden
through providing culturally appropriate diabetes education materials that are a vailable
in multiple languages in order to reach ethnic minorities and hard‐to‐reach populations
in a variety of settings (Center for Disease Control and Prevention [CDC], 2018).
Asthma Based on National Health Interview survey data, the prevalence of pediatric
asthma among US children aged 0–17 years old in 2013 was 8.3% (Akinbami, Simon,
& Rossen, 2016). Asthma is the most common noncommunicable disease among
children globally (World Health Organization [WHO], 2017). National and global
initiatives seek to manage asthma symptoms and reduce the burden of asthma for
children, including the Global Alliance against Chronic Respiratory Diseases and the
AAP initiative known as the Medical Home Chapter Champions Programs on Asthma,
Allergy, and Anaphylaxis (APA, 2017; McCoy, Gubernick, Norlin, Rosenberg, &
Stukus, 2018; WHO, 2017). Additionally, the AAP has partnered with the Allergy
and Asthma Network to increase team‐based family‐centered high‐quality treatments
(McCoy et al., 2018). The American Lung Association also informs evidence‐based
practice of asthma intervention and policy and advocates for Medicaid coverage for
asthma and related conditions (American Lung Association, 2018).
Current state of treatment

Interventions targeting family functioning or other family system theory aspects (e.g.,
roles, rules, etc.) demonstrated improvement in children’s management/control of
their condition, adherence, and child well‐being in 89% of family interventions for
chronic pediatric health conditions (Knafl et al., 2017). While condition‐specific
reviews indicate that family‐based care is an integral part of intervening on the obesity,
diabetes, and asthma, formal Cochrane reviews have yet to demonstrate the effects of
psychosocial interventions on childhood chronic health conditions (Eccleston et al.,
2015). Eccleston and colleagues suggest that these forms of intervention are still in
their infancy and require more support and research. Systemic family therapists (SFTs)
are uniquely positioned to advance the evidence base for psychosocial and family‐
based interventions grounded in family systems theory for childhood chronic health
conditions due to their specialized ability to intervene both behaviorally and systemi-
cally with children and their families.
Family‐Based Prevention 221
Connection of the family

The strong emphasis on prevention and treatment of obesity and coverage of obesity‐
related services has prompted providers to recognize the importance of sociocultural
factors on the development and treatment of obesity in children. For example, the
AAP recommends that pediatricians should tailor interventions to “the developmen-
tal stage of the child and the socioeconomic, cultural, and psychological characteris-
tics of the family” (Daniels, Hassink, & Committee on Nutrition, 2015). Contextual
factors such as household composition can affect treatment adherence and behavior
change. For example, single parents with obesity report more impaired family func-
tioning and less support to change their dietary and eating habits in the family (Pratt,
Ferriby, Noria, Skelton, Taylor & Needleman, 2018). While family therapists can sup-
port families in structuring individual child health‐related goals and family‐level
changes in roles, routines, and rituals, the family therapists should also work to tailor
interventions based on families’ socioeconomic and racial/ethnic diversity.
Obesity Racial and ethnic minorities are disproportionately affected by obesity, with
African Americans almost twice as likely to be obese than their Caucasian counterparts
(48 vs. 32%; Centers for Disease Control and Prevention [CDC], 2017). There is
limited research on how psychosocial factors (i.e., beliefs, attitudes, and perceptions)
promote culture‐specific lifestyle choices or behaviors (Blixen, Singh, & Thacker,
2006). Obesity increases the risk for various diseases and conditions, particularly type
2 diabetes (Nguyen, Nguyen, Lane, & Wang, 2011); over 80% of people with type 2
diabetes are overweight or obese (National Institutes of Health [NIH], n.d.). There
is a growing trend for culturally tailored interventions in racial/ethnic minority com-
munities, where interventions are based on values and belief systems of the commu-
nity or racial/ethnic group. These types of interventions are desired by racial and
ethnic minority families as well. When African American youth receiving treatment for
obesity were asked about preferences for treatment, they responded that they would
like their family members who lived with them to work on goals simultaneously with
them (Pratt, McRitchie, Collier, Lutes, & Sumner, 2015). African American interven-
tions that focus on African‐inspired dance and traditional foods or Native American
talking circles in the prevention of obesity are two examples of family and community
involvement.
Promising strategies to promote behavioral changes in children include increased
parental (or caregiver) support, providing nutritious foods and opportunities for
physical activity, and decreasing screen time, meaning time spent using an electronic
device such as a television, tablet, or phone (Berge & Everts, 2011; Pratt & Skelton,
2018; Waters et al., 2011). Pratt and Skelton (2018) propose using a family systems
theory framework to tailor the emphasis of relational and behavior treatment within
family‐based obesity treatment based on the family’s functioning and barriers. For
instance, some families may only require minor skills training and psychoeducation to
adopt recommended behavioral changes (i.e., increase family meals, decrease screen
time), while other families may need support around family communication, bounda-
ries, and setting rules before they are able to successfully implement obesity‐specific
learning and recommendations within their family. SFTs are specifically trained to
assess both behavioral and family systems aspects such as family functioning and family
barriers preventing the adoption of new health behaviors.
Expert recommendations for the prevention and treatment of pediatric obesity

encourage family‐based treatment (Barlow, 2007). Prior reviews (Sung‐Chan, Sung,
Zhao, & Brownson, 2013) and meta‐analyses (Berge & Everts, 2011) of randomized
controlled trials (RCTs) for family‐based pediatric obesity interventions showed that
behavioral‐based programs were effective in reducing child weight status (Berge &
Everts, 2011). Further, in a recent meta‐analysis of family‐based lifestyle interventions
for pediatric obesity, Janicke and colleagues (2014) found that family‐based lifestyle
interventions demonstrated efficacy in child weight status reduction, though the
effect size was small but statistically significant when compared with passive controls
(Janicke et al., 2014).
Pediatric diabetes Knafl and colleagues (2017) reviewed family interventions tar-
geting children with chronic health conditions and identified 11 RCTs focused on
diabetes. The majority of these targeted both condition control, including condition
management and medication adherence, and family process variables like family
functioning and parent–child well‐being.
Family‐based treatments grounded in behavioral interventions (e.g., behavioral
contracts and goal setting) have been found to increase glycemic control and treat-
ment regimen adherence for children with diabetes (Delamater, de Wit, Mcdarby,
Malik, & Acerini, 2014); services that increased family support through either psych-
oeducation or improved family functioning also improved child adherence (Delamater
et al., 2014), indicating that successful interventions should target both behavior
change and family systems aspects of the family. Decreases in medication adherence
and glycemic control noticed in older children and adolescents may be further
evidence that family engagement is essential across the continuum of child and

adolescent health care, despite increased child autonomy as children age (Lotstein
et al., 2013). Feldman and colleagues (2018) found that behavioral family systems
therapy adapted for children with diabetes had the strongest evidence base to date
with multiple RCTs demonstrating improvements in children’s health behaviors (e.g.,
medication adherence and monitoring), family processes (e.g., communication and
conflict), and child health outcomes (e.g., glycemic control; Feldman et al., 2018).
Families randomized to receive family therapy focused on addressing family hierar-
chy/rules and responsibilities reported improvements in child metabolic control
compared with the control group (Feldman, Anderson et al., 2018). SFTs trained in
behavioral and family systems theories are well positioned to work with families
around diabetes management; however, future research is needed to explore the
effectiveness of family‐based family systems‐oriented treatment for children with
diabetes:
Rodrick, who is in his sophomore year of high school and was recently diagnosed with type 2
diabetes, is trying out for the football team. Rodrick’s parents were reticent about him trying
out for the team, but also wanted him to be included in regular high school activities despite
his illness. In an effort to impress the coaches and show that he could be a team player,
Rodrick did not want to take any breaks during tryouts to monitor his blood sugar. Rodrick
collapsed during practice, and had to be taken to the hospital, where his elevated hemoglobin
A1c level, average blood sugar over the past 3 months, indicated to providers that he had not
been managing his blood sugar. His parents were unsure of whether to allow Rodrick to
return to the team. The attending physician stopped in to check on the family before Rodrick
was discharged and to introduce the family to the SFT. After listening to the family and the
physician explain the dilemma about Rodrick returning to the team, the SFT made a plan
to meet with Rodrick, his parents, and the family as a whole. Without his parents in the room,
Rodrick disclosed that he had not been monitoring his sugar at practice or in school. Rodrick’s
parents expressed their concern that he could not be responsible for taking care of himself. The
therapist worked with Rodrick to explain to his parents how important football is to his high
school experience, and to create a plan where Rodrick could take responsibility for monitor-
ing, while including his parents, teachers, and coaches as support figures in his treatment.
Rodrick’s father went with him to meet with the head coach to explain Rodrick’s struggle
with diabetes. The head coach insisted that the entire coaching staff attend training on how
to administer insulin shots if needed. The coach also partnered Rodrick with the team cap-
tain for breaks to help create a sense of belonging and accountability for Rodrick as he moni-
tored his blood sugar. The coach also offered his office as a place for Rodrick to monitor
himself in private during the school day. Knowing that the coach was so invested in Rodrick,
who had not yet made the team, helped Rodrick’s parents to feel secure in allowing him
another chance to show that he could be trusted to manage his own care.1
Adolescents are growing in autonomy, but a new diagnosis and subsequent treat-
ment plan may be overwhelming. Adolescents may require simultaneous guidance
and accountability while learning to manage a chronic illness. Further, even if it is not
a new diagnosis, physical changes in adolescence may render new challenges for symp-
tom management. SFTs are primed to support parents and their children as they navi-
gate this transition in care responsibility along with the anticipated shifts in autonomy
that traditionally accompany adolescence.
Pediatric asthma The American Lung Association also informs evidence‐based

practice of asthma intervention and policy and advocates for Medicaid coverage for
asthma and related conditions (American Lung Association, 2018). Evidence sug-
gests that asthma is another chronic health condition that should be considered in the
context of the family, given that children with asthma and their families experience
decreased quality of life, well‐being, and psychological functioning (Crespo, Carona,
Silva, Canavarro, & Dattilio, 2011).
Asthma symptoms are particularly influenced by environmental factors like dust
mites, air pollution, and tobacco smoke, making family members’ engagement in
household risk reduction essential to managing this condition (Fiese, 2008). The
majority of family‐based RCT interventions for pediatric health conditions reviewed
by Knafl and colleagues (2017) focused on pediatric asthma; however, only 11% of
these interventions included a family relational component. Despite promising short‐
term and long‐term improvements in symptom management, impairments noted in
child, parent, and family well‐being of children with pediatric asthma denote that
more comprehensive family services may be necessary to address the systemic impact
of asthma on the family.
Theoretical approaches to prevention and treatment of

child health conditions
Given the short‐ and long‐term consequences of child health conditions, the integra-
tion of theories that explain both individual family member’s adjustment and behav-
iors as well as how the whole family adjusts and adapts is warranted. Two theories that
each have their own evidence base (Bandura, 1977; Rollnick, Mason, & Butler, 1999;
Von Bertalanffy, 1968) with childhood physical health conditions, and more recently
have been integrated together (Pratt & Skelton, 2018; Pratt, Ferriby et al., 2018), are
social cognitive theory (Bandura, 1977) and family systems theory (Von Bertalanffy,
1968). Although other health behavior and socioecological theories have been inte-
grated to address childhood chronic health conditions (e.g., health belief model, tran-
stheoretical model; see Institute of Medicine, 2001), this section will focus on social
cognitive theory and family systems theory. Additionally, social cognitive theory and
family systems theory are both highly adaptable to health‐care paradigms and organi-
zation such as the biopsychosocial approach (Engel, 1977) and integrated care
(Patterson, Peek, Heinrich, Bischoff, & Scherger, 2002).
Integration of Behavioral and Family Theories
Social cognitive theory is an updated version of social learning theory with enhanced
behavioral aspects. The main determinants of social cognitive theory include out-
come expectations, self‐efficacy, and observational learning (Rollnick et al., 1999).
Family systems theory describes families as systems with multiple simultaneous
interactions occurring (Von Bertalanffy, 1968). These interactions are reciprocal
where the child’s actions affect the parent(s) and the parent(s)’s actions or reactions
affect the child in an ongoing cycle. When new health behaviors are introduced to
the family, family members can individually display a range of support or discour-
agement for these new behaviors, ultimately influencing how or whether the overall
family embraces new changes. Although the social cognitive theory determinants
are often interpreted with an individual‐behavioral focus, they can be adapted within
a systems framework by incorporating family systems theory to better understand
how individual behaviors ultimately influence family‐level behavior change and how
the whole family system adapts. Below the main determinants of social cognitive
theory are interpreted within a family systems theory framework. Additionally,
Figure 9.1 uses the case of childhood obesity to integrate family systems theory and
social cognitive theory concepts.
Relevant to child chronic health conditions, outcome expectations explain the child
or parent’s belief about the costs and benefits of making behavior changes, with the
goal of maximizing benefits and minimizing costs. For example, an adolescent may
consider the costs and benefits of waking up earlier (cost) to eat breakfast (benefit).
Parent support in the morning may provide aid to the adolescent in this goal by assist-
ing with meal preparation, reminder alarms, and so forth. However, considering fam-
ily systems theory, the adolescent and parent need to be able to negotiate what is
acceptable support from the parent (one reminder vs. three) and how the adolescent
will respond to the parent’s support (agrees not to yell or argue). Self‐efficacy refers
to the child and/or parent’s belief about their ability to make behavior changes rele-
vant to their overall goals or desired outcome. Self‐efficacy is highly dependent on
outcome expectations, especially relevant to beliefs about the ability to make behavior
changes with respect to the costs and benefits. For example, if the adolescent per-
ceives a low cost or consequence to waking up 30 min earlier to eat breakfast, she
likely will have higher self‐efficacy about her ability to achieve the outcome of eating
Family
Family systems theory
Parent–child relationship
Household
Physical activity Physical activity

dietary dietary
behaviors behaviors
Social cognitive theory
Figure 9.1 Example integration of family systems theory and social cognitive theory for
pediatric obesity. Pratt, Ferriby et al. (2018). Copyright American Psychological Association.
breakfast before school the majority of the week. Self‐efficacy can also be encouraged
through observational learning, where learning behaviors through interposal expo-
sure, such as parental modeling, can influence adolescents’ behavior change. If the
adolescent’s parent also wakes up early to prepare and eat breakfast in the morning,
the parent is providing modeling of the health outcome for the adolescent.
Observational learning through modeling perhaps has the most overlap with family
systems theory as it represents change between dyads and the system level, not just
individual change.
There is a sparsity of high‐quality evidence for the implementation of specific family
therapy techniques for child chronic health conditions. High‐quality reviews of psycho-
therapy interventions fail to explicate the more granular forms of therapy or technique
implemented in treatment (Law, Fisher, Fales, Noel, & Eccleston, 2014). This may be
due to the small sample (8) of RCTs included in review for “systemic therapies” and child
physical health. Ng and colleagues (2008) is an example of a study that operationalizes the
family therapy process while working with families with children with asthma (Ng et al.,
2008). Circular questioning, boundary setting, and enactment were implemented to
address familial issues. Solution‐focused therapy has also been used to intervene on child
chronic illness. Notably, an Australian study, in which general physicians delivered solu-
tion‐focused therapy to parents and children, found minimal success in reducing child
body mass index (BMI) beyond that of usual care (McCallum et al., 2007). A commu-
nity‐based intervention conducted in the Netherlands utilized a solution‐focused approach
to intervene with parents and children with obesity and found that children experienced
a significant decrease in BMI z‐score following treatment (Kreier et al., 2013). The results
of this intervention showed improvements in child BMI z‐score beyond those observed
from typical pediatric obesity treatment. Viner and colleagues used a combination of solu-
tion‐focused, cognitive‐behavioral, and motivational interviewing techniques to improve
diabetes symptoms in adolescents with type 1 diabetes (Viner, Christie, Taylor, & Hey,
2003). Specifically, they utilized the following techniques in their intervention: creating a
shared focus, including the system by sharing successes, identifying targets and goals using
scaling, setting personal goals using the miracle question, problem solving, and condi-
tional reinforcement of behavior.
Integrated Care
Health‐care delivery
The biopsychosocial approach explores health as an interplay of biological or physical,
psychological, and social systems (Engel, 1977). For example, an adolescent with
obesity may have physical concerns such as joint pain and/or sleep disturbances
(obstructive sleep apnea), which can be exacerbated by psychological challenges like
depressive symptoms and/or social issues including bullying/teasing. To determine
one’s ability to make behavior change, and further that change is embraced by the
family system, the three aspects of the biopsychosocial approach should be consid-
ered. Further, when families present in health care with a child diagnosed with a
chronic health condition, they should receive some form of integrated care (Patterson
et al., 2002). Integrated care is a form of collaboration where both medical and
behavioral health practitioners are employed in the same health‐care setting; however,
their collaboration together in these settings ranges from collaboration at a distance
to preforming side‐by‐side care. Integrated care relevant to childhood chronic health
conditions is described more below.
Models of integrated care

Integrated care is the provision of behavioral health services in health‐care settings for
the treatment of the overall health of a patient (Christian & Curtis, 2012). The
Medical Family Therapy (MedFT) Healthcare Continuum is the primary applied
model behavioral health integration and collaboration (Hodgson, Lamson,
Mendenhall, & Tyndall, 2014). Hodgson and colleagues (2014) introduced the
MedFT Healthcare Continuum, which contains five levels of integration. Each level
of integration highlights different skills and training needs, based on the level or
intensity of integration, for providers and clinics. The main focus of the MedFT
Healthcare Continuum was intended for primary care adult settings (i.e., family medi-
cine); it has been applied to pediatric health care before (see Pratt, Van Fossen,
Didericksen, Aamar, & Berge, 2018).
This model details the increasing levels of cooperation and collaboration between
physicians and behavioral health providers, ranging from level 1, where collabora-
tion occurs on an as‐needed basis, through level 5, where physicians and behavioral
health providers work on interdisciplinary teams, routinely involving the family in
care decisions, and training other providers to work collaboratively (Hodgson
et al., 2014). The level of integration of behavioral health and medical providers
will dictate to whom and how care is provided to children with a chronic illness and
their families. In primary care, which typically spans levels 1, 2, and 3 of increas-
ingly more collaborative health care, family therapists often act as an intermittent
consultant on family dynamics for a variety of providers (e.g., pediatricians,

pediatric health specialists, occupational therapists, etc.). Parents may be referred
off‐site to receive services related to psychoeducation or parenting skills training.
Parents may also be referred off‐site in more extreme cases of clear co‐occurring
mental health disorders.
The child’s pediatrician, which is often the Child Medical Home, is the primary
place that families present for chronic health conditions (Ader et al., 2015; Foy, 2015;
Kuhlthau et al., 2011); however, these families may also be presenting for care in
behavioral health and family therapy settings. This is an example of level 1 integrated
care, since the behavioral and physical health encounters are separate, with providers
making referrals only when necessary; however, patients may be utilizing both ser-
vices without any communication between providers. While prevalence rates of chil-
dren with chronic illnesses utilizing traditional family services are not readily available,
the rate of annual mental health visits including psychotherapy for children ranged
from 311 to 130/1,000 children depending on race/ethnicity, with Caucasian chil-
dren using more services (Marrast, Himmelstein, & Woolhandler, 2016). Crane,
Christenson, Shaw, Fawcett, and Marshall (2010) explored predictors of health‐care
usage among clients in couple and family therapy and found that parent marital cohe-
sion and life satisfaction explained 46% of the variance in child health‐care usage
(Crane et al., 2010). This suggests that dissatisfied parents presenting for therapy may
have children who are more likely to engage with the traditional health‐care system;
however, this does not indicate whether or not these children have a chronic condi-
tion, which may be contributing to lower parent satisfaction, or if dissatisfied parents
are more likely to overutilize health care. Finally, families with chronically ill children
are receiving family therapy services through family‐based interventions (e.g., behav-
ioral family systems therapy, multisystemic therapy) though it is unclear whether these
services are rendered in clinics or integrated into health‐care settings (Shields, Finley,
Chawla, & Meadors, 2012).
On‐site collaboration is more common among levels 2–5 in integrated care, and
family therapy providers have more specialized training in chronic health conditions
and how to include family members in treatment planning. At this level, therapists
collaborate with familial supports (e.g., caregivers, siblings, grandparents, and fic-
tive kin), structural supports (e.g., church, school), and multidisciplinary teams to
treat specific child conditions. For example, a child with diabetes may require care
providers trained to administer insulin. A family therapist may provide support to a
parent in coordinating insulin injection training, education, and materials for an
adult in a variety of care settings (e.g., grandparent’s house, school, and athletic
coaches). Family therapists working in level 4 settings use their specialized health
knowledge to assist pediatricians to make appropriate referrals to specialty care.
These therapists may also be co‐located in specialty care practices, consulting on
larger multidisciplinary care teams.
Additionally, higher levels of integration are more likely to include an experienced
behavioral health provider on the team who is trained to include the family in the medical
encounter, soliciting support from family members around behavioral goals set by the
pediatrician (e.g., limiting screen time), and aiding larger changes to family rituals and
routines (e.g., increasing family meals and conversations around body image). The family
therapist may also work with families to reframe specialist feedback into tangible goals.
Family therapists and registered dieticians may collaborate with a family to introduce new
food into family celebrations that maintain the family’s heritage and cultural preferences
but include higher protein or less refined sugar. Below is an example of how a therapist
and dietician can work with a family to adhere to pediatrician recommendations while
still honoring their preferred traditions:
Joanna’s ninth birthday is coming up and her family is unsure of whether they can follow the
pediatrician’s recommendation to cut back on refined sugars. They typically serve calorie
dense snacks, soda and juice, pizza, and cake at their parties. The therapist works with
Joanna and her parents to understand what kind of preparations go into the food for the
party and learns about a family tradition to decorate the child’s birthday cake as a family.
Joanna mentions that she was really looking forward to making her cake purple this year. The
therapist collaborates with the dietician to find healthy alternatives to the cake that can still
be decorated to maintain the family’s annual tradition. After learning about several
options, Joanna chooses a “watermelon cake,” where a watermelon is frosted with yogurt to
look just like a tiered birthday cake. Joanna’s mother suggests that they dye the yogurt purple
and use purple grapes to line the edges. The family leaves feeling confident and excited to
integrate a healthier choice into their festivities while still holding on to their cherished
tradition.
While specialist goals may be behaviorally based to increase condition management,

medication adherence, or awareness around the disease, family therapists may work to
understand what family resources and/or supports are necessary to enable the family
to adopt these changes. Family therapists can also help families to reframe individual
child goals set forth by the pediatrician into family‐level goals. For instance, if a
pediatrician is working with a child to reduce screen time, the therapist may find ways
to explore introducing family bonding time around physical activity rather than
sedentary behaviors like watching television.
Research on integrated care

Research to date on integrated care has shown high feasibility of this approach within
primary care settings, high patient satisfaction, and significant reductions in targeted
health behaviors (Berge et al., 2017; Reiss‐Brennan et al., 2016). Additionally, inte-
grated care involving family therapists, tailored to treatment guidelines for specific
chronic childhood conditions, has been done. For example, Pratt and colleagues out-
lined how the stages of pediatric weight management fit with the clinical, operational,
and financial aspects (i.e., three‐world view) of health care (Patterson et al., 2002) and
how the levels integrated care need to accommodate specific guidelines for weight
management and the three‐world view (Pratt et al., 2011). For example, based on
Expert Committee guidelines (Barlow, 2007), the involvement of behavioral health
providers (i.e., family therapists) is recommended for higher‐intensity weight man-
agement or when youth and families have struggled with behavior change and/or
weight loss in primary care settings. A tertiary or specialty care setting is more likely
to treat severe obesity in youth and to have multiple disciplines present, including
behavioral health providers. Given the intensity of treatment and multiple disciplines
involved in treatment, higher levels of integration are needed for treatment planning
(clinical), coordination of visits and space arrangements (operational), and billing
procedures (financial).
Setting goals
Goal setting with the family will need to vary based on the chronic health condition and
developmental stage of the child, family dynamics and the family’s ability to change, and
other contextual information. Therapists should work with family members and other
providers to determine what family engagement should look like across developmental
stages. Type 1 diabetes and asthma may only be managed, not cured, meaning that a fam-
ily will need to find ways to engage with the child’s condition as the child grows older.
Family therapists may need to work with families to understand how goals should evolve
with the child as they grow in autonomy. While parent education and skills training may
be more helpful for a young child managing sugar intake for comorbid obesity and diabe-
tes, parents and their older children and adolescents may need more support around com-
munication and problem solving as they work together to establish longer‐term goals and
expectations around sugar consumption that will transition the child into adulthood. This
transition in care collaboration between parents and children was supported by Knafl and
colleagues’ (2017) review, which found that interventions were more likely to engage
both parents and children when the child was over the age of 9 years old.
Relevant to family structure, family therapists should engage blended families in
working toward compliance with health‐care goals for children with chronic condi-
tions. For example, it would be important to develop common routines, rules, and
boundaries between households that are consistent with the child’s care plan and goals.
Additionally, family therapists can work with parents who are single to determine what
are developmentally appropriate responsibilities for the child in monitoring his/her
own condition and potentially seeking out other methods of support for the family.
Families who have existing positive and healthy family dynamics may only need
brief behavioral support when they work toward their goals. However, families with
more chaotic dynamics may benefit from intervention around family dynamics, like
communication, rules, and boundaries. Pratt and Skelton (2018) outline when behav-
ioral approaches versus family systems approaches can be used in the treatment of
pediatric obesity. Families organize around routines, rules, and dynamics that are
established over time. This organization can promote health or impaired family
dynamics and functioning. Families that have routines that center on unhealthy
behaviors that promote weight gain may need more than behavioral‐only approaches,
such as that provided by family systems theory. However, families who already have
routines and patterns of healthy communication and activities may benefit from brief
behavioral approaches. This way of viewing organization around weight‐related
behaviors (healthy or unhealthy) can assist therapists in tailoring their encounters to
focus on family dynamics that support healthy behaviors and modify those organized
around unhealthy behaviors.
Finally, contextual challenges exist such as language barriers and low literacy rates—
accompanied by anxiety and limited understanding (Taylor, Nicolle, & Maquire, 2013)
Dante was diagnosed with asthma at five years old. A year later, at Dante’s well‐child visit,
Dante’s father Luis reported that he has noticed that Dante needed to use his rescue inhaler
frequently this past year. The pediatrician made a series of recommendations to Dante’s mother
about how to minimize airborne pollutants in the house at his 5‐year‐old checkup. The family
nurse sees a note in the electronic medical record about distributing educational materials to
the family and asks Luis about making the recommended changes throughout the house, only to
find out that Luis never received information about common irritants for respiratory diseases.
The nurse steps out of the room and returns with the on‐site systemic family therapist (SFT).
After speaking with Luis, the SFT learns that Luis and Dante’s mother have been separated for
the past year and have minimal communication with one another. Luis’ mother has stepped in
to help by coordinating pickups and drop‐offs with Dante’s mother. As an immediate interven-
tion, the SFT provides Luis’ father with the materials that he did not receive the previous year,
but also includes a note in the health record to provide materials for multiple households at
subsequent visits. The SFT also asks about Luis’ understanding and susceptibility to receiving
therapy services. He shares that Dante’s mother had asked him to go before, but he didn’t see the
point then. His frustration with Dante’s mother began to subside as he came to realize how
difficult it was to care for their son without communicating with each other. The SFT coordi-
nates a referral to a local family therapy clinic for Dante and his parents.
This clinical vignette illustrates how traditional models of health care are still
c atching up to the needs of diverse family structures, like those with multiple house-
holds. Clinical practice designed for a two‐parent household may assume that parents
will intuit what information is essential to communicate about a pediatrician’s visits.
Additionally, this vignette highlights how managing a child’s health condition may
serve as a tangible goal that invites parents into work with SFTs rather than tasks that
may be viewed as less essential within the family that are traditionally associated with
therapy (i.e., affect regulation and expression).
Treatment Considerations
Who is the client/patient?

The client/patient in pediatric health care is often the individual child, due to the treat-
ment of the chronic condition firmly rooted in the medical model and insurance sys-
tems that are structured to reimburse for services at the individual level. However,
expert recommendations across different chronic conditions advocate for family‐cen-
tered care. Recent research has demonstrated that family functioning influences a vari-
ety of health‐related outcomes when youth have a chronic illness (Herzer et al., 2010).
However, how to incorporate the family into treatment may differ based on the devel-
opmental stage of the child, the chronic condition, and the setting (health‐care or
traditional family therapy clinic) in which they are receiving care (Shields et al., 2012).
Level of family involvement

Knafl and colleagues (2017) conducted a review of RCTs of family interventions for
childhood chronic health conditions, specifically exploring family engagement.
Engagement was measured through the focus of engagement (i.e., condition manage-
ment, family functioning, and parent performance), who participated (e.g., parent–
child separately, parent–child together, and parent only), and the level of engagement
(e.g., recipient of information, active participant). The majority of interventions (67%)
included both the parent and child; however, in 33% of the interventions, parents were
the sole participant. While some interventions did not specify which family member
was present for treatment, mothers were most commonly involved in those that listed
family membership. Only 16% of family‐based interventions sought to target family

functioning or change parent role performance. The primary focus of intervention was
to improve parental capacity for condition management. For instance, one interven-
tion for asthma sought to improve parent skills in symptom identification and subse-
quent nebulizer use. This indicates that although the family was incorporated into
treatment, the purpose of inclusion was not to change any relational dynamics, but to
enhance parent’s ability to directly intervene with the illness (Knafl et al., 2017).
Evidence from Systemic Approaches to Child Chronic

Health Conditions
Interventions targeting the parent–child dyad and family unit are becoming more
common in prevention and treatment of childhood chronic conditions. These inter-
ventions are carried out in various settings including health care and home based and
in communities. The studies noted below are exemplars of integrated care and sys-
temic family approaches to childhood physical health conditions, targeting more than
individual behavior change and involving behavioral health providers. These studies
are meant to be exemplar studies of integrated care and systemic prevention and treat-
ment. There is a wealth of information, not covered herein, that details behavioral
(only) approaches to these childhood conditions.
Interventions targeting parent–child dyads and families

Obesity One prevention study targeting childhood obesity at a population level was
carried out in a low‐income (i.e., majority of patients make <$35,000/year) and minor-
ity (i.e., over 60% of patients are African American families) family medicine clinic using
5‐2‐1‐0 (i.e., 5 fruits and vegetables/day; 2 or less hours of screen time/day; 1 hr or
more of physical activity/day; 0 sugar‐sweetened beverages/day) obesity prevention
messages during well‐child visits using an integrated approach. The parent–child (of any
weight status) dyad was the unit of intervention, and both a behavioral health clinician
and a medical provider worked collaboratively during the well‐child visit to educate the
parent and child on these obesity prevention messages and then to set goals and follow
up with parents/children around these messages (Berge et al., 2017). This approach
was highly successful, feasible, and well received by parents/children and the providers
in a busy family medicine clinic. The study is currently examining health behavior
change as a result of these 5‐2‐1‐0 obesity prevention messages.
Another prevention study that targeted the parent–child dyad and entire family
unit’s health behavior change utilized an in‐home visiting approach (French et al.,
2018; Sherwood et al., 2013). To be eligible, children had to be between the ages of
2–4 years old and at or above the 50th percentile for their age‐specific height and
weight, placing them at risk for developing obesity. This study was a 3‐year study to
prevent obesity using motivational interviewing techniques to meet families where
they were at with regard to behavior change and to set goals to move them to the next
level of change. Family connectors (i.e., behavioral health providers) visited families in
their homes on average two times per month for 36 months. They also connected
families into existing community resources (e.g., swimming lessons, community/
parks and recreation, libraries) that they could utilize in maintaining their healthy
lifestyle changes once the intervention concluded. Significant results were found for
Hispanic families with regard to reduced child weight status, increased fruit and veg-
etable intake, and increased physical activity behaviors compared with the control
group (French et al., 2018).
Another example conducted in routine pediatric weight management employed
integrated care, involving a treatment team of family therapists, pediatricians, and
registered dieticians in a pediatric obesity treatment setting. Youth (aged 7–18) and
their parents/families were seen after referral to the weight management clinic based
on the youth’s overweight or obese weight status. When families (often the primary
caregiver/parent and identified child patient) came in for their initial appointment,
they meet with the entire treatment team and completed assessments about youth
quality of life, parent and youth depressive symptoms, and clinical measures of dietary
compliance, physical activity frequency, and weight status. At each subsequent visit,
families continued to meet with the treatment team and could schedule separate ses-
sions with the family therapist and dietician as needed. At the first visit, caregivers who
reported increased depressive symptoms had less agreement with their child about the
child’s quality of life, believing their child’s quality of life was significantly lower than
the child indicated (Pratt, Lamson, Swanson, Lazorick, & Collier, 2012). Across
three integrated care visits, youth had slight declines in weight status, but had signifi-
cant increases in their quality of life and decreases in depressive symptoms (Pratt,
Lazorick, Lamson, Ivanescu, & Collier, 2013).
Diabetes One community‐based participatory research intervention with Native

American adults used cultural tailoring to target type 2 diabetes (Mendenhall et al.,
2010). This intervention used talking circles led by Native American elders to educate
about diabetes prevention and treatment. In addition, diabetes‐friendly Native
American food was prepared and cooked at these sessions to give hands‐on training.
Family units came to these sessions together in order to address family‐level behaviors
to support the new health behaviors of the family member with diabetes (Berge,
Mendenhall, & Doherty, 2009; Mendenhall et al., 2010).
Asthma Children receiving integrated behavioral health care for their asthma symp-
toms had shorter hospital stays when admitted to the emergency rooms for acute
asthmatic episodes compared with children receiving treatment as usual (Cunningham
et al., 2008). Additionally, an RCT of telecounseling peer services offered as a supple-
ment to primary care management demonstrated promising improvements in a higher
number of children’s symptom free days and reduced emergency room visits at 2‐year
follow‐up (Garbutt, Yan, Highstein, & Strunk, 2015).
Future Considerations
Research
As discussed above, including multiple family members and the overall family sys-
tem is important to consider when intervening with families with regard to child
chronic conditions. While the inclusion of family members and family dynamics is
advantageous, it can make measurement and evaluation of the intervention

potentially more challenging. Currently, there is no “best practice” for the assess-
ment of family in family‐based prevention and intervention studies, despite the
recommendation that providers should be family based in their care of youth and
families. Future research on childhood physical health conditions would benefit
from increased rigor and consistency in assessments and measures used. For exam-
ple, it would be important to utilize preexisting validated dyadic and family meas-
ures in order to compare findings across studies and ensure findings are generalizable
across studies. There are validated measures of family functioning, such as relation-
ship satisfaction, sibling connectedness/closeness or differential treatment, and
parenting style, that could be used for evaluation of these prevention and treat-
ment interventions for child chronic conditions.
In addition, more research conducted using integrated care models and com-
munity‐based participatory research methods would also advance the area of
pediatric physical and chronic health conditions. Preliminary research suggests
that these research designs are promising and potentially more sustainable (Berge
et al., 2009, 2017; Mendenhall et al., 2010; Pratt et al., 2013). Given the dis-
crepancy in caregiver and child reports of quality of life, influence of depressive
symptoms, and significant increases in youth quality of life over treatment, con-
tinuing to implement and assess integrated care models with family therapists in
treatment is needed.
Two other important aspects of evaluation to consider when intervening with
dyads and families around chronic conditions is measuring effectiveness of the inter-
vention modality and fidelity to the intervention. For example, while integrated care
teams have been utilized in addressing chronic conditions in primary care settings,
much more research is needed to determine whether the cost of multiple providers
involved in the care is cost‐effective and results in better health outcomes for patients.
In addition, more rigorous fidelity measures need to be carried out, such as behavio-
ral coding of the delivery of motivational interviewing around health behavior change
and goal setting.
Clinical practice
It would be important for clinical settings to incorporate evidence‐based findings in
working with dyads and families with regard to prevention and treatment of child
chronic conditions. For example, if research continues to support integrated care
models for addressing child chronic conditions in primary care settings, then standard
work should be adapted to incorporate these practices. Within the pediatrics health‐
care literature, there are not specific models of systemic family therapy that have been
applied and tested. This is essential to move the field of systemic family therapy for-
ward in pediatric health care. There are specific examples when techniques from sys-
temic family therapy theories have been used, but these are purely at the technique
level, for example, finding exceptions, the miracle question, externalization, geno-
grams, and illness narratives. Beyond the technique level, clinical algorithms need to
be developed to determine which families may benefit from systemic interventions in
health care, collaborative practices to deliver these models, and which models are
appropriate for (brief) delivery in these settings.
Training/education
Education of medical residents, behavioral health interns, faculty at clinics, and
practicing medical and behavioral health providers is key in being able to implement
and sustain family‐based best practice models of care for child chronic conditions. It
would be important to add curriculum to educational programming for residents and
interns, in addition to continuing medical education trainings for providers. One
example highlighted below is about training and education to work with clients with
diverse body shapes and sizes. Other ways to incorporate new training around health
include offering coursework in MedFT, family approaches to health and illness (often
called Families, Systems, and Health), and inclusion of health aspects (e.g., able‐ness,
health literacy, etc.) into diversity‐related course material.
Body shape and size Family therapists report that they frequently work with
clients (adults or youth) who have an overweight/obese weight status and/or are
interested in changing their health behaviors related to obesity (Pratt, Holowacz,
& Walton, 2014). Yet, the majority of the therapists surveyed also report that they
have not received training to work with this population of clients and/or health
behaviors that contribute to obesity. This disparity in clinical training may inad-
vertently lead to the perpetuation of weight bias, which already poses a significant
challenge that prevents clients with overweight and obesity from seeking health‐
related services (Phelan et al., 2014). In fact, in a more recent National Health
Interview survey, students in COAMFTE‐accredited family therapy programs
reported moderate rates of explicit weight bias (Pratt et al., 2016). In order to
ensure ethical, sensitive, and effective treatment for youth with overweight or
obese weight status and their families who are working on health behavior change
and potentially weight loss, theoretical models grounded in family systems theory
are needed to conceptualize the scope of work for family therapists with health
behaviors within existing family dynamics to guide the future development of
systemic interventions.
Policy
In order to increase the likelihood of sustainability of these new models of care for
prevention and treatment of child chronic conditions, it would be essential for policy
changes to occur to support these new models. For example, integrated care models
are costly to carry out because the medical, behavioral health, and pharmacist provid-
ers are all in the room at the same time delivering care to the families of children with
chronic conditions. However, currently, most payers only reimburse for the medical
doctor’s time in the room with the patient/family. It is important for payers to “think
outside the box” in order to provide the best preventative care and treatment to fami-
lies with children with chronic conditions.
Given the incidence of poverty and deep poverty, family therapists should be aware
that managing a childhood chronic condition can be both financially and emotionally
overwhelming. Family therapists can collaborate with health‐care teams to determine
appropriate resources in the community to provide materials (e.g., syringes, health
food) that are affordable and congruent with the goals for managing the chronic
condition.
Note
1 All vignettes in this chapter are inspired by actual cases but are composites rather than
exact descriptions. Though the dynamics described are close to the original situations, the
details of the cases have been altered significantly to protect confidentiality and meet
ethical guidelines.
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10
Depression, Anxiety, and Other
Internalizing Disorders
Jacob B. Priest and Kate F. Cobb
Internalizing disorders are mental health conditions marked by disordered emotions

or mood (Kovacs & Devlin, 1998). In children and adolescents, the most prevalent
internalizing disorders are depressive and anxiety disorders. These disorders often
co‐occur and can cause severe impairment (National Institute of Mental Health
[NIMH], 2018). Many individual psychotherapy treatments successfully alleviate
symptoms of internalizing disorders for children and teens; however, many youth do
not respond to individual psychotherapy treatment, and those who do respond may
not sustain the gains over time (e.g., Kendall & Peterman, 2015). Though less
research has been conducted on systemic family therapy for children and teens with
internalizing disorders, some of this research suggests that family therapy may be able
to sustain improvement for youth with internalizing disorders when compared with
individual therapy (e.g., Couturier, Kimber, & Szatmari, 2013).
In this chapter, we will first describe the symptoms of the two most common inter-
nalizing disorders in childhood and adolescence: depression and anxiety. Then, we
talk about factors that increase the risk of developing one of these disorders. We will
then summarize the research on the most common individual psychotherapy
treatment—cognitive‐behavioral therapy (CBT)—and discuss the strengths and weak-
ness of this approach. After we discuss CBT, we will present research from three
family therapy approaches—cognitive‐behavioral family therapy (CBFT), attachment‐
based family therapy (ABFT), and structural family therapy—and we will discuss how
these approaches have the potential to improve outcomes for children and teens with
internalizing disorders. Finally, we will recommend future directions for family ther-
apy approaches and argue why family therapy has the potential to improve outcomes
of children and adolescents with internalizing disorders.
242 Jacob B. Priest and Kate F. Cobb
Internalizing Disorders
Internalizing disorders affect millions of children, adolescents, and their families

(NIMH, 2018). Research looking at prevalence rates of mental illness in children
across the world estimates that 13.4% will have at least one mental illness before the
age of 18 and about 2.6–6.5% will have an internalizing disorder (Erskine et al., 2017;
Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015). The rates in the United States may
be higher. The National Comorbidity Survey Adolescent Supplement (NCS‐A) esti-
mated lifetime prevalence of DSM‐IV mental disorders in US adolescents ages 13–18
and found that 31.9% of teens had an anxiety disorder and 14.3% had mood disorders
(Merikangas et al., 2010).
Reported prevalence rates of internalizing disorders in children under the age of six
span a wide range. Ialongo, Edelsohn, Werthamer‐Larsson, Crockett, and Kellam
(1995) reported finding 2.5% of 5‐year‐olds as having severe anxiety symptoms that
were relatively stable over a 4‐month period. Other studies have determined preva-
lence rates of anxiety in preschoolers to be as high as 10–20% (Banneyer, Bonin, Price,
Goodman, & Storch, 2018). These discrepancies stem from the difficulty of asserting
symptoms in young children. With young children, researchers are limited to observ-
ing behaviors or using semi‐projective measures (e.g., puppet play) and inferring infor-
mation about children’s internalizing emotional experiences (Tandon, Cardeli, &
Luby, 2009).
Depression
Depression in childhood and adolescence is marked by four types of symptoms: mood,
cognitive, motivational, and somatic symptoms (Rey & Hazell, 2009). Mood symp-
toms include loss of interest and enjoyment in some or all activities, feeling down or
sad, and lower self‐esteem. Cognitive symptoms include distorted or negative thoughts
that can result in a negative self‐image and feelings of hopelessness. Motivational
symptoms include difficulty concentrating, making decisions, lack of energy, and apa-
thy. Somatic symptoms can include restless or poor sleep, changes in appetite, and in
younger children head or stomach aches (Rey & Hazell, 2009; Thapar, Collishaw,
Pine, & Thapar, 2012).
Anxiety disorders
Anxiety disorders in childhood and adolescence include separation anxiety disorder,
posttraumatic stress disorder, social phobia, and generalized anxiety disorder. Separation
anxiety disorder is marked by a developmentally inappropriate and excessive fear of
separation from home or from an attachment figure (Rockhill et al., 2010).
Posttraumatic stress disorder occurs following a traumatic event. After a traumatic
event, the child or adolescent may experience a sense of numbing or detachment or a
sense of depersonalization. Additionally, a child or teen may experience recurrent
thoughts or nightmares associated with the trauma. In young children, symptoms of
posttraumatic stress disorder might be expressed by reenactment or repetitive play in
which the aspects of the trauma are expressed (Rockhill et al., 2010). Social phobia is
marked by persistent and excessive fear of social performance that may in some cases
Internalizing Disorders 243
result in a panic attack (Rockhill et al., 2010). Generalized anxiety disorder is marked
by worry that is associated with many events. Children and teens with generalized anxi-
ety disorder will report feelings of being keyed up or on edge, difficulty concentrating,
and physical issues such as trouble sleeping and muscle tension (Rockhill et al., 2010).
Factors associated with internalizing disorders

Multiple factors can increase the risk of internalizing disorder development in chil-
dren and adolescents. Two main factors are genetics and family environment. Genetics
can play a large role in internalizing disorder. In studies of twin toddlers, there is
evidence to suggest that 50% of the variance in internalizing disorders can be accounted
for by genetics (Carter, Briggs‐Gowan, Jones, & Little, 2003).
The familial environment—including parenting styles, adverse childhood experi-
ences, and attachment—is also a factor in the development of children and teens with
internalizing disorders. Parenting styles that include overprotection and control or lack
of warmth and rejection are associated with childhood internalizing symptoms (Rapee,
1997; 2012). More punishment and less modeling or reassurance from parents are also
related to more internalizing symptoms in children (van der Sluis, van Steensel, &
Bögels, 2015). Moreover, hostile parenting during infancy can also increase the risk of
youth developing an internalizing disorder in later life (Edwards & Hans, 2015).
Adverse childhood experiences—experiences of trauma or abuse while growing up—
also put children and teens at greater risk for developing internalizing disorders. Heim
and Nemeroff (2001) suggest that persistent activation of the central nervous system
that can occur as a result of adverse childhood experiences may result in neurobiological
changes that can increase the risk of developing an internalizing disorder. Evidence also
has shown that children with secure attachment relationships experience lower levels of
internalizing problems compared with those with insecure attachment relationships
(Brumariu & Kerns, 2010; Kerns & Brumariu, 2016). Internalizing disorders have
been correlated with self‐report of measures of both avoidant and anxious/preoccupied
attachment styles in adolescents (Brenning, Soenens, Braet, & Bal, 2012).
The interaction of genes and the family environment may be key in understanding
the etiology of internalizing disorders in children and teens. A longitudinal twin study
of children ages 5–16 determined that genetics played a significant role in predicting
depressive symptomology especially in families with high conflict (Rice, Harold,
Shelton, & Thapar, 2006).
Race and ethnicity differences in internalizing disorders

Though internalizing disorders affect children and adolescents across the races and
ethnicities, the prevalence rate and expression of symptoms seem to vary by race and
ethnicity (Anderson & Mayes, 2010). For example, African American boys in grades
three through five report higher rates of depression than their European American
peers, and these higher rates persist as they age (Kistner, David, & White, 2003;
Kistner, David‐Ferdon, Lopez, & Dunkel, 2007). Latin American youth report the
highest levels of depression when compared with Asian, African, and European
American youth (Céspedes & Huey, 2008). When it comes to symptom expression,
adolescent African and Latin American youth with depression are more likely to
endorse having diminished pleasure as a symptom when compared with European

American peers. Latin American youth also are more likely to endorse decreased energy,
feelings of guilt, and difficulty concentrating than their peers (Choi & Park, 2006).
Individual Child and Adolescent Cognitive‐Behavioral Therapy
Given the prevalence and risk associated with internalizing disorders, many individual
psychotherapy treatments have been developed to reduce symptomology. Individual
cognitive‐behavior therapy (ICBT) is the most widely used and studied approach for
youth with internalizing disorders. Cognitive‐behavioral treatments focus on restructur-
ing maladaptive thought patterns and developing strategies for tolerating uncomfortable
feelings without escaping them. For example, CBT for childhood anxiety focuses on
identifying troublesome cognitions and developing skills, like the ability to relax oneself
after being triggered, to be utilized during exposure techniques (Kazdin & Weisz, 1998).
Randomized controlled trials (RCTs) have demonstrated that cognitive‐behavioral‐
based treatments are broadly effective at reducing symptoms of depression and anxi-
ety in youth immediately and at follow‐up (David‐Ferdon & Kaslow, 2008; Kaslow &
Thompson, 1998; Kazdin & Weisz, 1998; Weisz, McCarty, & Valeri, 2006). In par-
ticular, cognitive‐behavioral treatment of depression has had multiple RCTs con-
ducted to evaluate its effectiveness. Drawing on these RCTs, several meta‐analyses of
cognitive‐behavioral treatment for youth with depression have been conducted. The
effect sizes of the analyses have varied (e.g., Lewinsohn & Clarke, 1999; Michael &
Crowley, 2002; Reinecke, Ryan, & DuBois, 1998a, 1998b) averaging a large effect
size of 0.99. Weisz et al. (2006) critiqued these meta‐analyses and claimed their effect
sizes were inflated due to peer‐reviewed bias, fixed effect analyses, and other uncon-
trolled factors. They conducted a larger and more rigorous meta‐analysis that con-
trolled for non‐peer‐reviewed versus peer‐reviewed studies, clinically referred versus
recruited youths, therapist primary vocation, and treatment setting and reported a
calculated overall mean treatment effect size of 0.34, a much more modest and con-
servative estimate than that reported by their peers (Weisz et al., 2006).
A 2004 systematic review of the 10 CBT RCTs for childhood and adolescent anxi-
ety reported that a remission rate of 56.5% compared with the control groups pooled
remission rate of 34.8%. Although this odds ratio indicates that CBT had a significant
effect in this population, these results indicate that CBT for anxiety in children and
adolescents leads to remission in only about half the children who receive treatment
(Cartwright‐Hatton, Roberts, Chitsebesan, Fothergill, & Harrington, 2004).
Furthermore, Cartwright‐Hatton et al. (2004) noted that their extensive literature
search yielded no RCT studies attempting to treat children with anxiety younger than
6 years old; however, some have argued that this makes sense given that the average
age of onset of anxiety disorders in children is six (Merikangas et al., 2010).
The limitations of individual cognitive‐behavioral approaches

Though cognitive‐behavioral approaches are effective for many youth with internal-
izing disorders, these approaches have two main limitations. First, as Kaslow and
Thompson (1998) highlighted, the majority of the cognitive‐behavioral treatment
approaches currently being used to treat child and adolescent internalizing disorders
were originally developed to treat adult internalizing conditions. Practitioners then
adapted these interventions for children and adolescents, but they may not effectively
be able to successfully incorporate a developmental perspective, which is important to
creating successful interventions for youth. Therefore, to improve outcomes for youth
with internalizing disorders, it is important to use approaches that are sensitive to the
developmental process of youth and are designed to specifically address youth symp-
tomology. Systemic family therapies take into account the family environment in
which the children or teen resides. As such, systemic interventions can properly incor-
porate parents at developmentally appropriate levels (e.g., heavy parent training com-
ponents for especially young children), which may help reduce symptoms (Luby,
Lenze, & Tillman, 2012).
Traditional cognitive‐behavioral approaches also do not account for the influence
of family functioning on internalizing symptoms. As summarized above, the family
environment can have a strong influence on the onset, course, and treatment of inter-
nalizing disorders. If approaches to treating youth with internalizing disorders do not
take into account the role of family functioning, youth may not experience long‐term
gains (Couturier et al., 2013).
Family Therapies for Child and Adolescent Internalizing

Disorders
There are at least three systemic family therapy approaches that address the limitations
of cognitive‐behavioral approaches for youth with internalizing disorders—CBFT,
ABFT, and structural family therapy. These approaches were all developed specifically
for children and adolescents and are sensitive to the developmental process of this life
stage. These approaches also take into account the role the family plays in internaliz-
ing symptoms and, therefore, aim to not only relieve internalizing symptoms but also
improve the family functioning for sustained internalizing symptom improvement.
To illustrate these approaches, an overview of each approach is provided below. In
order to understand how these approaches conceptualize and treat internalizing dis-
orders, each approach will be applied to the following case example:
Maria1 is a 17‐year‐old cisgender female. During the summer between her sophomore and
junior year, Maria took college entrance exams and did not perform as well as she would
have hoped. She has typically been at the top of her class, but since beginning her senior year
of high school, her grades have dropped and she is uninterested in school. Her family reports
that she is often distracted, has started eating less, is not motivated, and seems to be tired
frequently. One of Maria’s friends reported that Maria has often talked about how things
would be better if she “just wasn’t around” and seems to be sad most of the time.
Cognitive‐behavioral family therapy

CBFT (Dattilio, 2010) was developed out of the CBT tradition. Dattilio (2001)
traces the development of CBFT from its roots in cognitive therapies, such as rational
emotive therapy (Ellis & Dryden, 1987), and behavior modification strategies, which
were used to treat couples beginning largely in the 1970s. It was not until the early
1980s that researchers and practitioners began to recognize that cognition played a
significant role in family behavior and incorporate this component into treatment
methods (Dattilio, 1993, 2001; Epstein, Schlesinger, & Dryden, 1988). The CBFT
approach emphasizes the influences of both cognition and behavior but is influenced
by the systems perspective. It expanded beyond the individual to suggest that family
relationships and emotions impact cognitions and behaviors. As Teichman (1992)
notes, family interactions are reciprocal in that each individual’s cognitions, behaviors,
and feelings are constantly impacted by others and are impacting others in their envi-
ronment, thereby creating a reciprocal, mutually influential process. This systemic
mutual influence is frequently what drives family conflict and keeps them locked in a
destructive cycle (Dattilio, 2001).
CBFT holds that an individual’s emotional and behavioral reactions are shaped by
their individual interpretations influenced by their cognitions. Additionally, behaviors
of family members can be interpreted and evaluated by family members differently
based on individual and family. Schemas are basic and long‐standing assumptions
formed by individuals about how the world is supposed to work and their place in it
(Dattilio, 2001). A family schema is formed from conscious or unconscious beliefs
funneled down from one’s family of origin, blended and combined in a partnership,
and then applied in rearing children in a family. These schemas are also expressed in
everyday interactions family members have with one another (Dattilio, 1993).
The main goal of CBFT is to use cognitive and behavioral strategies to restructure
the family beliefs and schemas as well as change a family’s problematic behaviors.
Inevitably, therapy will also change individual family members’ behaviors, cognitions,
and schemas as well. Its focus on schemas allows CBFT to be applied to a wide variety
of individual and family problems since schemas tend to govern most behavior and
cognitions. Although CBFT emphasizes a collaborative relationship between thera-
pists and families, therapists take an active and directive stance in the beginning of
therapy (Dattilio & Epstein, 2005). Practitioners of CBFT teach family members to
recognize their own distorted thinking and problematic behavior patterns that are
maintaining their problematic family cycles. Once the therapist has taught the family
to recognize their maladaptive thoughts and behaviors, therapy can be more nondi-
rective and therapist can then act more as a coach (Dattilio, 2001).
Perceptions, expectations, communication, and problem‐solving skills are all cognitive
processes a therapist can attempt to alter by creating more awareness of subconscious
cognitive activities. Once aware of possible cognitive distortions, individuals and families
may be more capable of making behavioral changes toward their goals. Dattilio (2010)
also recognizes the cognitive components of attachment and emotion related to affect
regulation, emotional intensity, and how individuals experience and express emotion.
As mentioned previously, separating family‐integrated CBT from systemically ori-
ented CBFT is important because they may look very similar on the surface but are
practiced from very different theoretical orientations and assumptions. Family mem-
bers have long been involved as additions to cognitive‐behavioral therapies for both
child depression and anxiety. Frequently, parents are used as co‐therapists or reinforc-
ers of the behavioral strategies the therapist and child are attempting to implement.
When using CBFT as a systemic family‐based treatment, other family members will be
asked to examine their own relationships to the child’s depression or anxiety, their
attempts to cope with situations that provoke these emotions, and how this affects the
person in the family with a depressive or anxiety disorder (Howard & Kendall, 1996).
Conceptualizing and treating internalizing disorders in CBFT Through a CBFT

lens, Maria’s depressive symptoms stem from individual and family schemas that
become maladaptive. For example, it may be that in Maria’s family, her role was
always to be the “perfect” child. She has had good grades and her family has come to
expect that she will be very successful. Part of her family’s schema may center on
Maria being a high achiever and holding her up as an example in her family and in the
community. It may be that Maria has also internalized this schema and that she feels
that her worth in the family is dependent on being a high achiever. Since Maria did
poorly on her college entrance exams, the negative aspects of these schemas may start
to influence Maria’s cognitions and behaviors. If her schema suggests that her worth
is tied to her achievement, doing poorly on her college entrance exams may trigger
feelings of worthlessness or letting the family down. Similarly, she may start falling
behind on school work because she feels that her work previous has all been for noth-
ing. Her family may respond by being disappointed and telling her that she should
have worked harder. Their schema may tell them that this should not happen because
Maria has always been the “perfect” child. They may fear that she might never live up
to her potential and as such they may push her even harder to achieve.
A systemic family therapist using a CBFT approach would first identify individual
and family schemas that are influencing Maria’s depressive symptoms and tracking the
thought, behavior, and emotion patterns that are occurring because of these schemas.
A therapist would also help the family understand how these patterns are connected
to their schemas (Parker & McDowell, 2017). For example, the therapist could point
out how Maria has been viewed as the “perfect” child and how this has put pressure
on her and led to some feelings of worthlessness, especially after not performing as
well as she wanted to on her college entrance exams. This has led to the family to
respond by putting more pressure on her to achieve, resulting in Maria feeling like she
is letting the family down. Once the schemas and patterns are identified, the therapist
would work with Maria and her family to create alternative schemas (Parker &
McDowell, 2017). This could include more flexible definitions on what it means to
achieve and/or be “perfect.” Once these new schemas are created, the therapist
would encourage the family to have different thoughts and behaviors based on these
new schemas. For example, using a more flexible schema, Maria’s family could respond
supportively instead of applying pressure. By engaging in these new thoughts and
behaviors, CBFT posits that this could result in lower depressive symptomology.
Research and outcomes Howard and Kendall were the first to develop a manual to
systemically involve parents in treatment for child anxiety and the second edition of it
was published in 2000 (Howard, Chu, Krain, Marrs‐Garcia, & Kendall, 2000). A
study comparing this manualized CBFT to ICBT and family‐based psychoeducation
found no significant differences between individual and family CBT (FCBT) in the
remission rates of the principal anxiety disorder at study and 1‐year follow‐up (Kendall,
Hudson, Gosch, Flannery‐Schroeder, & Suveg, 2008). Children in the ICBT condi-
tion fared better on teacher reports of anxiety than children in the FCBT and FESA
conditions, although FCBT was more successful in reducing child anxiety when both
parents also had an anxiety disorder. Wood and colleagues developed a slightly differ-
ent FCBT manualized approach for treating anxiety that focuses on parental commu-
nication in addition to other CBFT strategies for anxiety (Wood, McLeod, Hiruma, &
Phan, 2008; Wood, Piacentini, Southam‐Gerow, Chu, & Sigman, 2006). Results of
comparative treatment studies showed positive results for children treated with both
child‐focused and family CBT, although children in the latter condition fared slightly
better (Wood et al., 2006). These results were maintained at a 1‐year follow‐up (Wood,
McLeod, Piacentini, & Sigman, 2009).
Evidence also exists supporting the use of CBFT to treat child or adolescent unipo-
lar depression. For example, child‐ and family‐focused cognitive‐behavioral therapy
(CFF‐CBT), a manualized psychosocial intervention for pediatric bipolar disorder,
has been successful at treating bipolar depressive symptoms in children and adoles-
cents (West & Weinstein, 2012). CFF‐CBT combines cognitive‐behavioral techniques
with psychoeducation, interpersonal, and family‐based techniques. When compared
with treatment as usual (TAU), CFF‐CBT was more effective at reducing youth
depressive symptoms when parents had higher baseline depressive symptoms and
lower income but only marginally more effective for families with higher cohesion
(Weinstein, Henry, Katz, Peters, & West, 2015). In another study comparing these
two conditions, CFF‐CBT resulted in significantly greater psychosocial functioning
and marginally greater posttreatment effects with steeper symptom trajectories than
the TAU condition (West et al., 2014).
Strengths and weaknesses CBFT is arguably one of the more adaptable therapeutic
modalities given that it rests on the central concepts of behavior and cognition, which
are a central part of many other modalities (Dattilio, 1998). Processing behaviors,
emotions, and schemas are all cognitive techniques that can be utilized in other thera-
peutic practices. CBFT is frequently critiqued for being too linear in its conceptions
of behaviors and cognitions and not systemically or family oriented enough. However,
CBFT focuses on the family as the primary unit of treatment as opposed to the indi-
vidual, and it takes into account the systemic interrelation of each family member’s
behaviors and cognitions (Dattilio, 2001). CBFT and the cognitive‐behavioral
approach in general are frequently critiqued for ignoring emotions in therapy.
However, Dattilio (2010) has argued that CBFT framework does focus on emotions,
suggesting that there is a reciprocal interaction between behaviors, emotions, and
cognitions; each affects and is affected by the other. If nothing else, CBT therapists
respect the role that emotions play in how individuals and families cognitively process
and perceive events or stimuli. Cognitive‐behavioral family therapists may incorporate
processing the family’s cognitive construction of their emotional experience sur-
rounding the symptomatic child’s depressive or anxious behaviors (Dattilio, 2001;
Greenberg & Safran, 1984).
Modifications to service diverse client populations Cultural values and beliefs inevita-
bly shape cognitions, behaviors, and emotions (Baumeister, 1986). Although CBT
was conceived in and is based around North American cultural values, it can be modi-
fied and adapted to conform to other cultures and belief systems. North America’s
prominent value of individualism is reflected in CBT’s focus on one individual’s
thoughts, behaviors, and emotions. However, the systemic element of CBFT allows
the focus to be expanded to each individual within the family system and even the
influence of the larger community. For instance, Willoughby and Doty (2010) con-
ceptualized some adaptions that might need to be made to CBFT following an ado-
lescent’s coming out. CBFT is collaborative in that every therapist works within each
family’s schema. The goals of therapy are based on the family’s inherent beliefs and
values, which makes it highly adaptable for varying cultures and issues (Dattilio &
Bahadur, 2005).
CBT has been adapted for individuals of several cultures and various papers have
outlined important cultural considerations for working with individuals of non‐North
American backgrounds (Gupta, 2000; Khodayarifard, Rehm, & Khodayarifard, 2007;
Linn, 2001). However, very few papers have outlined how to best adapt CBFT with
families of other cultures. Though CBFT is capable of being adapted to varying cul-
tures, it is imperative that the therapist have significant familiarity with the given cul-
ture (Dattilio & Bahadur, 2005). Important differences in couple and family
relationship standards can be overlooked by a therapist not accustomed to or aware of
certain cultural norms. Epstein, Chen, and Beyder‐Kamjou (2005) determined not
only that adherence to relationship standards and couple consensus on standards were
associated with marital adjustment but also that these standards were different in
Chinese versus US couples based on their cognitions.
Frequently in cross‐cultural or immigrant families, the therapist may have to help
the family understand the process of acculturating to US values while still balancing
respect for the cultures of their heritage. Dattilio and Bahadur (2005) outline some
considerations to be understood before undertaking therapy with an Indian immi-
grant family struggling to balance their 14‐year‐old’s desire for independence while
still maintaining their traditional cultural roles. In addition, it is vital to understand
each person’s culturally influenced schemas and how they might need to be melded
together. For instance, this family’s struggle may be set against a background schema
in which the mother of the family prepared for marriage at the age of 14 when she
grew up in India (Dattilio & Bahadur, 2005). Each family has different beliefs and
values that must at a minimum be respected by the therapist but can also be used as
strengths to facilitate desired family change.
Attachment‐based family therapy

ABFT (Diamond, Diamond, & Levy, 2014) relies on extensive empirical evidence that
links family factors to healthy development of children, and it argues that improving
internalizing disorders for children requires an appropriate parent–child relationship.
ABFT has its roots in structural (Minuchin, 1974), multidimensional family therapy
(Liddle, 1999), emotion‐focused individual (Greenberg & Paivio, 2003) emotionally
focused couple therapy (Johnson, 2004), and contextual therapy (Boszormenyi‐Nagy,
2013). However, ABFT also heavily draws on attachment theory (Bowlby, 1969;
Kobak & Sceery, 1988) and relies on the assumption that poor attachment bonds and
low affective attunement combined with high conflict and harsh criticism can influence
the development of depression in children. ABFT was developed specifically to treat
depression and suicide in low‐income, minority adolescents and has been manualized
for treating this population with the goals of (a) repairing attachment and (b) promot-
ing autonomy (Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002).
Five specific treatment tasks are used to work through conflict and develop the
adolescent–parent attachment bond. First, the Relational Reframe Task shifts the fam-
ily focus from “fixing” the child to improving family relationships. The Adolescent
Alliance‐Building Task helps adolescents explore family conflicts with therapists and
prepare them to talk with their parents. The Parent Alliance‐Building Task explores
parents’ current stressors and attachment history, which fosters empathy toward the
adolescent. The Attachment Task is used to help the adolescent express previously
unvoiced anger about family conflicts and if parents are receptive and express sincere
remorse, adolescents often disclose more vulnerable emotions (e.g., sadness, disap-
pointment). The effect of the parent’s acknowledgement is that adolescents usually
feel more inclined to accept their parent’s advice or support. Finally, the Competence‐
Promoting Task helps to encourage the adolescent to seek connections to others
outside the home where they can be successful (e.g., friends, school, work, etc.). The
newly secured adolescent–parental attachment bond can serve as a “secure base” from
which the adolescent can explore their position in the world and their developing
autonomy (Diamond et al., 2002). The hope is that these new attachments will help
to increase the adolescent’s confidence and competence, which can reduce or buffer
against further depression (Cole, 1990).
Conceptualizing internalizing disorders in ABFT Through an ABFT lens, Maria’s

depressive symptoms stem from an insecure attachment to her family. It may be that
throughout her life, Maria has been rewarded when she has achieved, but that any-
time she did not perform to her family’s standards, they may have applied more and
more pressure to achieve. This type of pattern may have led to Maria feeling like she
could not consistently turn to her family for support, and when things did not go well
on her college entrance exams, it may be that she felt that she did not deserve a con-
nection with her family. This insecure attachment could push Maria to thoughts of
worthlessness and ideas of it being better for her family if she was not around.
A systemic family therapist working from an ABFT perspective would follow the
five tasks outlined above. In Maria’s case, the therapist may begin by shifting the fam-
ily’s focus from helping Maria get over what she is feeling so she can achieve to talking
about ways in which Maria and her family can improve their connection. Then the
therapist would work with Maria to help her explore the past hurts she has experi-
enced in her family and prepare her to talk with her family. Then the therapist would
work with Maria’s parents to explore their current stressors and attachment histories
in order for them to have more empathy toward Maria. The therapist would then have
the family meet all together and allow Maria some space to share her feelings and
would work with the parents to respond in ways that would strengthen their connec-
tion. As the process repeated itself, the therapist would encourage Maria to reengage
with her friends. According to ABFT, as Maria and her parents form a secure bond,
Maria’s feeling of worthlessness and lack of motivation would be lessened, and she
would feel more secure to go out and pursue other goals.
Research and outcomes Extensive research has been conducted on ABFT throughout
the last 15 years, resulting in it being officially added to the National Registry of
Evidence‐Based Programs and Practices (http://samhsa.gov/nrepp). A distinct
advantage for the empirical evidence base of this treatment is that the majority of
ABFT clinical trials have been conducted with low‐income, minority populations at
the Center for Family Intervention Science at Drexel University (Diamond, Russon,
& Levy, 2016). The first RCT study of ABFT (Diamond et al., 2002) was the first
family therapy study to be conducted with depressed adolescents and one of few stud-
ies to include a large African American population in its sample. The study sample
consisted of 32 adolescents randomly assigned to 12 weeks of ABFT or 6 weeks of
waitlist control condition. At posttreatment, 13 of the 16 treatment cases (81%) no
longer met MDD criteria, while 7 of the 15 waitlist patients (47%) no longer met
MDD criteria. Comparing the two groups posttreatment, Beck Depression Inventory
(BDI) scores revealed that 62% of the adolescent ABFT treatment group endorsed a
BDI score of 9 or less (a nonclinical level) compared with only 19% of the waitlist
condition (Diamond, Russon et al., 2016).
A second controlled trial was supported by a grant from the Centers for Disease
Control in which 66 adolescents were randomized to 14 weeks of ABFT or enhanced
usual care (EUC), which involved assistance in obtaining a therapist in the commu-
nity and tracking depressive and suicidal symptoms (Diamond et al., 2010). Youth
treated with ABFT had significantly greater and faster improvements in suicidality
during treatment compared with EUC‐treated youth. At posttreatment, 87% of
patients receiving ABFT reported a suicidal ideation score below the clinical cutoff
compared with 51% of the EUC condition, and these benefits were maintained at fol-
low‐up. Though this study provided the first empirical evidence of an effective treat-
ment for adolescent suicidality, a major limitation is that the EUC low treatment dose
mean of 2.87 sessions did not adequately compare with the ABFT mean treatment
dose of 9.71 sessions (Diamond et al., 2010).
Diamond and colleagues have also tested ABFT as an aftercare treatment program
for youth post‐hospitalization after an actual suicide attempt. In this case, ABFT was
marginally but significantly more effective than EUC (Diamond, Levy, & Creed,
2016). Other studies on the effectiveness and usefulness of ABFT have included treat-
ment dissemination with trained therapists (Israel & Diamond, 2013), several process
research studies (see Diamond, Russon et al., 2016, for a review broken down by
task), and a treatment adherence study (Diamond, Diamond, & Hogue, 2007).
Ewing, Diamond, and Levy (2015) noted that a 5‐year study funded by the National
Institute of Mental Health (NIMH) is currently being conducted to test the efficacy
of ABFT compared with family‐enhanced nondirective supportive therapy (FE‐NST)
(Brent & Kolko, 1991) using the Adult Attachment Interview (AAI; George et al.,
1996) to test changes in adolescent attachment.
Although several family‐based treatments for anxiety have been developed, the effi-
cacy of these treatments has rarely been examined. Siqueland, Rynn, and Diamond
(2005) compared CBT with a combined CBT‐ABFT treatment and found that both
were successful. Although the “pure” CBT condition was slightly more effective than
the combined CBFT‐ABFT treatment (primary anxiety disorder remitted at 6‐month
follow‐up: CBT, 100%; CBT‐ABFT, 80%), patients’ and parents’ satisfaction rates
were highest in CBT‐ABFT, and retention rate in this group was somewhat higher
than CBT (Retzlaff, Sydow, Beher, Haun, & Schweitzer, 2013).
Strengths and weaknesses The advantage of ABFT may lie in its foundational attach-
ment roots. Attachment processes are fairly universal throughout cultures and are
known to be central to the psychological well‐being of individuals so much so that
attachment deficiencies may be a vulnerability that underlies many psychiatric disor-
ders (Diamond, Russon et al., 2016). This strong theoretical base provides a good
foundation from which developmentally and culturally sensitive psychotherapeutic
methods can be incorporated (Diamond et al., 2002). Although it is not without
challenges, ABFT has been adapted and successfully delivered in other countries, such
as Norway (Israel & Diamond, 2013), Australia (Diamond, Wagner, & Levy, 2016),
Belgium (Santens, Devacht, Dewulf, Hermans, & Bosmans, 2016), and Sweden.
ABFT has also been shown to be effective in treating depression and suicidality in
youth with comorbid anxiety and a history of multiple suicide attempts (Diamond,
Russon et al., 2016). Additionally, ABFT has been successful in improving symptoms
in youth with a history of sexual abuse, which is a notable advantage over CBT or
CBT and medication studies (Asarnow et al., 2009; Barbe, Bridge, Birmaher, Kolko,
& Brent, 2004; Shirk, Kaplinski, & Gudmundsen, 2009).
Modifications to service diverse client populations Diamond and colleagues discov-

ered that nearly 30% of their participants in their 2002 outcome study (Diamond
et al., 2010) identified as lesbian, gay, or bisexual (LGB). While the results for LGB
participants in their prior studies were positive, Diamond and his team conducted a
two‐phase study in which ABFT treatment was adapted for and offered to LGB sui-
cidal youth (Diamond et al., 2012). Treatment adaptions included more individual
time with parents to explore and process their emotions related to their child’s minor-
ity sexual identity, address the implications and meaning of acceptance, and enhance
parental awareness of potentially invalidating responses to their child’s sexual identity
(Diamond, Russon et al., 2016). Results from the treatment phase provided prelimi-
nary outcome data that suggested significant decreases in suicidal ideation for seven
suicidal LGB youth (Diamond et al., 2012).
The sample populations of the ABFT RCT studies have been a strength of ABFT—
they include a large portion of racial minority youth with low family incomes. However,
the first two ABFT RCT studies had a sample that were over 80% female. This may be
a result of the fact that rates of depression are higher for females compared with males
during adolescence (NIMH, 2018); however, developmental differences often occur at
this age, which require sensitivity to each gender’s developmental needs. Another pos-
sible explanation is that males may be more reluctant to participate in a treatment that
focused on developing a nurturing relationship with their parents as a treatment for
depression. Given research that has shown differential outcomes for females as opposed
to male adolescents on attachment dimensions (e.g., Milan, Zona, & Snow, 2013), it
may be important to consider gender more centrally in future studies examining ABFT.
Structural family therapy

Structural family therapy (Minuchin, 1974; Minuchin & Fishman, 1981) conceptual-
izes families as systems characterized by boundaries, roles, rules, power, hierarchies,
and various subsystems. In structural family therapy, family boundaries can range from
rigid disengagement to diffuse enmeshment (Minuchin, 1974). It is key that these
boundaries be well organized—some subsystems, for example, the parental subsys-
tem, should remain more closed than others just as some boundaries should be more
or less flexible. In general, the ideally structured family has clear yet flexible bounda-
ries between individuals and subsystems. These boundaries give family members both
the necessary sense of belonging and a healthy sense of individuality.
Problems occur in families when these boundaries or hierarchies are too extreme on
either end of the continuum. A family with rigid boundaries may find themselves
estranged and isolated from one another—each individual feels as though they have to
rely on themselves and act alone. Families with diffuse boundaries and enmeshed rela-
tionships are characterized by interdependency and a lack of autonomy in which they
have trouble differentiating between perceptions of self and others (Navarre, 1998).
Given that structural family therapy relies on systemic theories of the family,
Minuchin and Fishman (1981) proposed that a change in one family member will
incite change in other family members and therefore a structural change in family
dynamics and functioning will result in symptom relief (Navarre, 1998). Thus, the
aim of structural family therapy is to disrupt one or more family processes enough to
alter the organizational patterns of the family around the problem. The entire family
is required to participate in therapy even if the problem appears to be caused by one
individual (Minuchin, 1974). Usually areas of dysfunction in families coincide with
over‐involvement or under‐affiliation. For example, an anxious child may be overly
involved in family conflict that would be better handled by the parental subsystem.
Encouraging parents to come together to solve a problem and increasing distance
between the child and the conflict by making it the responsibility of the parental sub-
system may reduce the child’s anxiety.
Therapeutic techniques used in session center on joining with the family, enacting
dialogue around problematic interactions, restructuring these interactions, and
reframing the familial relationships once the problematic issue has been resolved
(Navarre, 1998). Therapists may attempt to challenge family symptomatic behavior,
the family structure, or the family belief system (Vetere, 2001). During enactments,
therapists may attempt to block or facilitate interactions or conversations between
family members depending on the family’s goals. The therapist can choose to remain
outside the family system as a director or become a participant and use their personal
involvement to direct family change. The more dysfunctional the family, the more
active and involved the therapist must be (Aponte, 1992).
Conceptualizing and treating internalizing disorders in structural family

therapy Through a structural family therapy lens, Maria’s depressive symptoms
would have been seen as a response to an inflexible family structure. It may be that
part of the pressure that the family is experiencing results from the prospect of Maria
going away to college. It may be that her being an achiever allows her parents to focus
on her and not the stress that exists in their relationship. The prospect of Maria leav-
ing may cause distress in the parental relationship, thereby putting more pressure on
Maria. This added pressure may have contributed to Maria’s poor performance on her
college entrance exams but stabilized the family as the parents could once again focus
on Maria. This time the focus on the parent’s energy is focused on Maria being “per-
fect” but on all of her “issues.”
A systemic family therapist working with a structural family therapy lens would
begin by joining the family and try to understand the family structure and how Maria’s
symptoms result from the structure. If the therapist determined that the parental
relationship had a lot of tension, the therapist may work with the parents to get them
to better able to communicate and rely on each other for support. Additionally, the
therapist may use enactments with the entire family in order to get family members to
be more flexible in their responses to each other. As the structure of the family begins
to change, the need for Maria to be “perfect” or have “issues” would be lessened,
which would in turn lessen her depressive symptoms.
Research and outcomes Research on the efficacy and outcomes of structural family
therapy is difficult to identify. There is no treatment manual nor methodical steps to
follow, and what constitutes “structural family therapy” differs from study to study.
Moreover, there is little research looking specifically at using structural family therapy
for child and adolescent internalizing disorders. However, there has been research
using structural family therapy approaches with other disorders of childhood and ado-
lescence that suggest that structural family therapy would have strong potential to
treat internalizing disorders.
For example, Minuchin and colleagues conducted numerous outcome research
studies using structural family therapy to treat anorexia in the 1970s. The most com-
prehensive report of these studies was published by Rosman, Minuchin, Liebman, and
Baker (1978) which summarized 53 cases of anorexia. Most families with adolescents
who were anorexic were characterized by enmeshment and parental control, which
Minuchin described as “psychosomatic families” (Lock & Gowers, 2005, p. 604;
Rosman et al., 1978). After being treated using structural family therapy for between
2 and 6 months, with a median treatment length of 6 months, 86% of adolescents
achieved “normal eating patterns” and a stable body weight within “normal limits,”
4% gained weight but continued suffering the effects of the illness, and 10% showed
little or no change or relapsed (Colapinto, 1982). Limitations of this study include a
lack of a comparison group and the variability of the follow‐up period, ranging from
18 months to 7 years (Le Grange, 2005; Smith & Cook‐Cottone, 2011). However,
this study and more recent tests of structural family therapy (e.g., Brent et al., 1997;
Robbins & Szapocznik, 2000) lend support for treating internalizing disorders of
childhood and adolescents with structural family therapy.
Strengths and weakness Structural family therapy grew organically out of Minuchin’s
work with young men from chaotic, multiproblem poor families at the Wiltwyck
School for Boys in the 1960s. Minuchin observed that traditional psychotherapeutic
methods, developed largely for articulate, middle‐class patients with intrapsychic con-
flicts, was not improving the boys’ behavior (Colapinto, 1982). He and his colleagues
embarked on the endeavor of developing special techniques based on family therapy
for diagnosing and treating families from low socioeconomic backgrounds and pub-
lished Families of the Slums (Minuchin, Montalvo, Guerney, Rosman, & Schumer,
1967), the precursor to the article “Structural Family Therapy” (Minuchin, 1972)
and book Families and Family Therapy (Minuchin, 1974), which would fully outline
the techniques of structural family Therapy. Thus, a large strength of structural family
therapy is that it has been carefully developed to meet the needs of an underserved,
sometimes difficult‐to‐treat, low‐income population, and Minuchin wrote extensively
about the unrelenting social and economic constraints keeping poor families from
functioning well (e.g., Minuchin, 1992).
The largest critique of the structural approach to family therapy has come from
feminist commentators (Hare‐Mustin, 1987) who argue that structural family therapy
addresses the power imbalance between subsystems while never examining the power
balance within the couple subsystem. Other feminist authors critique structural family
therapy and other traditional family therapist for overemphasizing the wife/mother’s
role in family conflict while elevating the authority of the father figure (Becvar &
Becvar, 1996; Navarre, 1998). Vetere (1992) has developed an adapted method for
making gender a more central concern when practicing structural family therapy.
Conversely, Navarre notes that structural family therapy may be particularly suited to
families whose cultural values already endorse very traditional and hierarchical family
structures, such as Chinese, Vietnamese, or Latin American families (Navarre, 1998).
Modifications to service diverse client populations Although structural family therapy

relies heavily on cultural standards of “proper” family structure, it does not emphasize
that families change their value systems but instead attempts to improve communica-
tion and cooperation in order to modify problematic family behavior. Structural fam-
ily therapy has been successfully adapted for families of varying cultural backgrounds
and ethnicities, such as Jewish ultraorthodox (Wieselberg, 1992), Italian American
(Yaccarino, 1993), and Native American families (Napoliello & Sweet, 1992). Jung
(1984) noted that Minuchin’s structural family therapy might be ideal for Chinese
American families given their emphasis on generational bonds and boundaries
(Navarre, 1998).
Because joining with the family implies experiencing reality as the family does, it is
important to consider cultural differences between the therapist and family. Structural
family therapists must be cautious around culturally sensitive beliefs while still main-
taining the role of expert in therapy and helping families overcome rigid habits and
behaviors (Navarre, 1998). Furthermore, therapists should assess how the stresses of
outside racism are played out within the family (Minuchin, Lee, & Simon, 2006).
Some believe that a therapist must have a deep interest in the culture of the family,
strong enough to “move the therapist into the very soul of the culture” (Napoliello
& Sweet, 1992) in order to properly engage in culturally sensitive therapy.
Several authors have written about what cultural considerations to keep in mind
when working with families from different ethnic or cultural backgrounds. For exam-
ple, Jung (1984) writes about the clash of Chinese and American cultural values
around individual autonomy versus family loyalty. Ko (1986) notes that Vietnamese
culture does not permit things such as the open expression of displeasure and that a
therapist may have difficult helping a more traditional Vietnamese American family air
their grievances. The older males in Latin American families generally command
authority and respect for protecting and providing for the family, although the wife
and mother also holds considerable covert decision‐making power as the family nur-
turer (Soto‐Flup & DelCampo, 1994).
Future Directions: Family Therapy as Primary Treatment

for Internalizing Disorders
Structural family therapy, CBFT, and ABFT address the two limitations of CBT high-
lighted above. These approaches were developed to work specifically with youth, and
they all take into account the influence that the family has on youth internalizing
symptoms. This gives these approaches two potential advantages over CBT.
First, family therapy interventions may be able to sustain gains in internalizing symp-
tom reduction over time. The interventions detailed in this chapter all assume that the
family is the relational context in which internalizing disorders develop and are main-
tained. As such, if the family system is not changed, it is likely that symptoms may
return. It is important for researchers to continue to test the assumption that the family
is the context in which internalizing disorders develop. This could be done in a few
ways. Researchers should continue to examine the reciprocal ways family functioning
influences youth internalizing symptoms and vice versa (e.g., Cui, Donnellan, &
Conger, 2007). It is also necessary to test how different family structures (e.g., rigid,
flexible, or enmeshed) and family attachment styles (e.g., anxious, avoidant, or secure)
are associated with the onset and course of internalizing disorders in youth. Finally, it
would be important to continue to examine how systemic family therapy compares
with individual therapy across time. The current evidence to support family therapy
having better long‐term outcomes than individual therapy is limited. Moreover, it
would be important to follow youth and their families for longer periods of time.
Doing so would add credibility not only to theoretical assumptions of family therapy
for internalizing disorders but could also make a case for family therapy to be the pri-
mary modality of treatment for youth with these disorders.
Second, family therapy approaches have the potential to do more than just improve
internalizing symptoms. In cognitive‐behavioral approaches, the goal is to reduce
symptoms. In family therapy approaches, the goal is to change the family structure,
patterns of interaction, or attachment in order to reduce symptoms. Given that 50%
of the variance in internalizing symptoms is accounted for by genetics (Carter et al.,
2003; Carter & Briggs‐Gowans, 2006), it is likely that youth with internalizing disor-
ders might have a parent or sibling that also has internalizing symptoms. Bringing the
whole family into treatment to help the youth with an internalizing disorder may help
alleviate symptoms of other members of the family as well. Also, given the association
between parental conflict and internalizing symptoms (e.g., Cui et al., 2007), it may
be that bringing the whole family into treatment could improve the parental relation-
ship and reduce the likelihood of divorce.
To test this assertion, it would be important for future research testing the efficacy
of systemic family therapy approaches for youth with internalizing disorders to look at
outcomes beyond symptom reduction of the child or adolescent. Specifically, this
research could look to see whether marital quality improves, whether the sibling rela-
tionship strengthens, or whether other family members with other symptoms also
experience symptom reduction. By establishing this knowledge base through research,
family therapy could make a stronger case for being the primary treatment modality
of youth with internalizing disorders. If family therapy approaches can have better
long‐term outcomes and improve additional problems in the family, they have the
potential to improve upon the outcomes of cognitive‐behavioral approaches.
Access to treatments and training

Though systemic family therapy approaches have shown promise in addressing child-
hood and adolescent internalizing disorders, many families may not have access to
these treatments. This lack of access may occur for a few reasons. One reason is that
though most family therapy training programs teach structural family therapy as part
of their curriculum, training in ABFT and CBFT is less common. As such, families
may not have access to these treatments because systemic family therapists may not
have been trained in these approaches.
The creators of ABFT have tried to rectify this issue by creating a certification pro-
cess. In order to become an ABFT certified therapist, therapist must complete three
stages of training. The first level includes completing the introductory workshop
where a therapist receives training on attachment theory and the five tasks of the
ABFT. The second level includes an advanced workshop where therapists explore
person of the therapist issues and how these issues relate to ABFT. Additionally, thera-
pists receive supervision during the workshop by an ABFT certified trainer. The third
level includes ongoing consultation where a therapist must submit 10 tapes to be

reviewed. After these tapes are reviewed and a therapist has shown the necessary skills
and abilities, they become certified. More information can be found regarding certi-
fication by going to the ABFT website (http://www.drexel.edu/familyintervention/
abft‐training‐program/overview).
Another reason for some families’ limited access to the approaches described in this
chapter stems from how these approaches are offered. These treatments are typically
only offered in a format whereby the entire family comes to the therapist’s office on a
weekly or biweekly basis. For many families, it may be unrealistic for time or financial
reasons to come a therapist’s office. Future iterations of these approaches may benefit
from developing intensive, short‐term iterations of these approaches or develop app‐
based or web‐based approaches that allow families more flexibility. Additionally, it
would be important for systemic family therapists to network in places where families
access care. Many families will seek help for their children or teens with internalizing
disorders at medical clinics, at schools, or in religious contexts. It would be important
for systemic family therapists to network with other community providers to help
them become aware of these approaches and how they can be beneficial to children,
teens, and their families.
Note
1 In order to protect confidentiality, the clinical vignette used is this chapter is composed of
details and experiences from multiple clients. Details about the clients, including names
and presenting problems, have been altered or combined in order to protect the confiden-
tiality of those cases.
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11
Disordered Behavior and
Behavior Disorders
Richard S. Wampler and Michael R. Whitehead
I would there were no age between sixteen and three‐and‐twenty, or that youth would sleep
out the rest; for there is nothing in the between but getting wenches with child, wronging the
ancientry, stealing, fighting.
William Shakespeare, A Winter’s Tale, Act 3, Scene 3
A conundrum
Which came first: the egg, the hen, or the nest? Is it about the individual as an egg,
conceived with a set of genes that led to disordered behaviors or worse? Is it about the
hen, a parent(s) trying and failing to raise offspring to behave within limits? Or is it
about the nest, the family, peers, neighborhood, community, society, or culture, having
a negative influence on the developing child and leading to unacceptable behaviors?
Theories about disordered behaviors and behavior disorders have fallen into one of
three major categories (egg, hen, nest), often without a strong effort to integrate one
category with the others. Even the “egg” theory is complicated by several explana-
tions. Is it genetics? In that case, is it the mother or the father or both who carry a gene
or set of genes that leads to unacceptable behaviors? Is it about epigenetics, turning
genes on or off, sometimes in response to environmental events? Is it before the birth?
Is there something going on with the mother that leads to her drinking heavily or tak-
ing illicit or licit drugs, or is she being poisoned by lead or mercury or the water she
drinks, or has she been exposed to a virus that has passed to her fetus and damaged it?
Even assuming the fetus is not exposed to toxins or biological menaces and has the best
possible set of genes, once the infant is born, hatching out as it were, issues of the
interactions between the infant and parent(s), ways of caring for the infant, and paren-
tal attitudes toward the infant all become suspect if there is disordered behavior or a
behavior disorder. Is the mother warm, cool, or cold, is the infant welcomed, tolerated,
or rejected, and how are those attitudes expressed? Are there other caregivers, and are
those persons loving and supportive or aggressive toward either the mother (“primary
266 Richard S. Wampler and Michael R. Whitehead
caregiver”) or infant or both? Does one of the caregivers have antisocial behaviors,
substance abuse, depression, and so forth? How was the caregiver treated growing up,
and what theory seems to guide the caregiver’s child‐rearing behavior? Further, into
what environments is the infant born? Siblings, extended family, culture, neighbor-
hoods, peer groups, schools, courts, and so forth, all have been shown to have an influ-
ence on how the infant develops. And bless its heart, the fetus, infant, child, and
adolescent, all have an impact on these caregivers and environments!
A word in favor of “mothers”

Research and writings on the role of other potential caregivers, including fathers, foster
parents, and grandparents, is of more recent vintage. In most cultures in the world and
in most homes and families, the mother is still the primary caregiver with or without
others despite the verbal acrobatics around “caregiver” that have become common.
Raising infants into children and beyond has historically been (and currently is) the
work of women. Further, the vast majority of theory and research on infant care, attach-
ment, and child‐rearing, as well as psychodynamic and classic systemic family therapy
theories, assumes that mothers are the primary caregivers and talk about mother–infant,
mother–child, and mother–adolescent interactions. That is, much of what we know
about normal and abnormal infant, child, and adolescent development relies on mothers.
Mothers get the praise (“All that I am, or hope to be, I owe to my angel mother”) and
the blame (“refrigerator,” “schizophrenogenic,” “weak,” “tiger” mothers) for what
happens to their infant growing into adulthood and beyond into old age. Two “mother
figures,” one of whom may be the biological mother, and two adopting “father figures”
successfully raise their infants and children to fully functional adults, as do grandmothers
and grandfathers, adoptive couples, foster mothers and fathers, and single fathers.
However, the rest of this chapter will use “mother” (by preference) or “parent,” unless
there is another “caregiver” who is identified specifically.
The Roots of Behavior Disorders

Just as the twig is bent the tree’s inclined.
Alexander Pope, Epistles to Several Persons (1732)
Early influences
Developmental age One way to decide whether a behavior is normative is to
consider the developmental age of the young person. Toilet training is one of the
common points at which children and mothers clash, but so is dating or clothing
selection in adolescence. Two‐year‐olds challenge the rules, but their behaviors are
annoying, not illegal. A first grader who physically resists or rudely challenges the
classroom teacher may be treating the teacher the way the child’s mother is treated
at home, but the behavior is not normative. Adolescence is a time to challenge soci-
ety’s rules, sometimes breaking the law. Adolescent males are more likely than
females to engage in overt behaviors that could get them into legal trouble (e.g.,
Odgers et al., 2012).
Disordered Behaviors and Behavior Disorders 267
Temperament and attachment John Bowlby (1988/1990) emphasized the impor-

tance of early experiences in his first publication: “The early environment is of vital
importance,” “the history of the child’s relations to his mother,” and “the mother’s
treatment of her child, not merely in its external aspects but also in its deeper emo-
tional quality” (Bowlby, 1940, p. 156). For many years, proponents of attachment or
temperament theory have argued that the other theory is covered by their own. Much
of the research on attachment has not assessed temperament, and vice versa. The cur-
rent thinking in the field, with exceptions, is that temperament and attachment are
different but have important areas of commonality. Both theories focus on emotions,
cognitions, and behaviors, that is, what makes humans humans, and both see mater-
nal sensitivity and responsiveness as important (Vaughn & Best, 2016). In terms of
child development and systemic family therapy, it makes sense to propose that tem-
perament, something that is present at birth and is relatively fixed, would influence
both the infant’s response to the mother (e.g., infant smiling vs. angry crying) and the
mother’s response to the infant (e.g., mother’s patient soothing vs. anger and
frustration)—both are determinants of the model of relationships the child develops
(i.e., attachment). Both temperament and the internal working model of relationships
(attachment) continue to influence behavior well beyond infancy into adulthood.
Social learning and the coercion cycle Coercion theory, based on social learning the-
ory, states that individuals use either adaptive or maladaptive behaviors to escape or
reduce aversive stimuli or to achieve a goal (e.g., Patterson, 1982). An infant is incapa-
ble of communicating its needs and must use the behavior of crying as a way to engage
its mother or other caregivers. Early on, the infant learns that crying and fussiness alert
the mother to its needs, whether a diaper change or food. Conversely, the mother
learns that by attending to the needs of the infant, the infant will stop crying or fussing.
This is a two‐way interaction, and it is not inherently pathological. The needs of the
infant and the mother are met equally.
This pattern of child–mother interactions is adaptive and helpful until around the
age of toddlerhood (2–3). At this time, a coercion cycle may develop in which the
child resists the mother’s increasing attempts to structure its behavior or refuse its
request. This is a zero‐sum game that only one can win, often the child. For exam-
ple, a child seeking to avoid school might cry, kick, and scream. Or when at school,
they will yell, hide under the desk, or be otherwise disruptive. Obviously, the child
is having a difficult time avoiding an aversive event (school), resulting in negative
reinforcement, or increasing a positive event (staying at home), resulting in positive
reinforcement. Either way, the child’s attempts at coercion are strengthened by
avoiding school. Since the cause of the behavior could be a thousand different
things, any intervention needs to start with the reaction of the adults to the
behavior.
Children socialized into coercion cycles with parents are likely to interact with other
adults (teachers, principals, police officers, etc.) in a similar fashion. They are used to
asserting their resistance to avoid anything that might be undesirable to them or act-
ing out to get something they want. Most adults are not used to children being
actively resistant or acting out, and they tend to view such behavior as something that
needs to be “stamped out.” This leads to authority figures resisting the child’s resist-
ance by asserting their authority, reinforcing an active coercion cycle between the
child and the adult.
In preschool, coercive children bully other children, snatch toys, “sass” the teacher,
and so forth. Such behaviors are reinforcing to the child (getting the toy, having
power) and strengthen the coercive pattern. Children who engage in the coercive
pattern of interaction with peers are likely to be rejected and avoided by peers with
more normative interactions. This leaves them either friendless or, more likely, in the
company of other children, male and female, who are also coercive in their behavior.
Unless interrupted, this pattern can grow into being labeled as a bully or trouble-
maker in grade school (Patterson, Reid, & Dishion, 1992), an at‐risk “gangster” or
delinquent adolescent with conduct disorder (CD) (Moffitt, 1993), and, ultimately,
an adult with an antisocial personality disorder (e.g., Lahey, Loeber, Burke, &
Applegate, 2005; Sroufe, Egeland, Carlson, & Collins, 2005).
Some children who engage in consistent coercion show “limited prosocial emo-
tions,” including severe, persistent, and aggressive behaviors that can be identified as
early as age three and persist into middle childhood (Willoughby, Mills‐Koonce,
Gottfredson, & Wagner, 2014a, 2014b), adolescence (Fanti & Kimonis, 2017), and
beyond (Yang, Raine, Colletti, Toga, & Narr, 2010). These children and adolescents
show no remorse or guilt for their actions, seem cold and uncaring when others are
distressed, seem to be unconcerned about their performance in school (or elsewhere),
and have shallow or deficient emotional expression (American Psychiatric Association
[APA], 2013, p. 470). In horror movies, in books, and in real life, the antisocial adult
with callous and unemotional traits is often featured as the cool, remorseless slasher
and serial killer (Rosewood & Lo, 2017).
Applications to Systemic Family Therapy
Temperament and systemic family therapy

The literature on temperament is consistent in pointing to a difficult child tempera-
ment as a predictor of later behavior problems (Fanti & Kimonis, 2017; Rothbart,
2012). “Difficult” children are overly and immediately responsive to their environ-
ments and inclined to become angry or distressed at even small changes or requests.
“Difficult” mothers or others can exacerbate the child’s distress. In a diathesis–stress
model, a vulnerability (temperament) becomes a serious problem, CD or oppositional
defiant disorder (ODD), when stress is introduced into the system. Thus, a difficult
temperament (vulnerability) as an infant does not consign a child to a life as an adult
sociopath unless stress is added by mother or other caregivers who are hostile and
rejecting and lack sensitivity and tolerance in dealing with the infant and child. With
such a combination of difficult temperament and stress, the probability of later prob-
lems increases. Infant and early childhood mental health intervention research strongly
supports helping the mother to become more aware of her child’s needs and her own
responses. Important skills for the systemic family therapist working with children and
adolescents with a difficult temperament include slowing the pace of therapy, acknowl-
edging the struggle for self‐control and vulnerability to overstimulation, and helping
the mother and others set and enforce limits on the youth’s behaviors while remaining
calm in the face of his or her responses to avoid entering the coercion cycle. The
therapist can help the mother learn these skills for herself and assist her in modeling
and teaching other adults in the youth’s world.
Attachment and systemic family therapy

Some systemic family therapists have adopted attachment theory as a way to frame
their work with their client families without formally introducing attachment issues
into therapy. These therapists recognize that children and adolescents with secure
attachment status are not immune to problems; however, they enter therapy more
easily and are more comfortable with emotional issues because they have a basic trust
in adults. In contrast, youth with insecure‐avoidant status are difficult to engage
because they avoid emotional expression, minimize any problems, and avoid discus-
sion of their inner lives. Youth who have insecure‐anxious status have weak emotional
and personal boundaries and may need the therapist to set boundaries for the therapy.
An attachment‐informed therapist is aware of three categories of disorganized attach-
ment: (a) controlling‐punitive and (b) behaviorally disorganized (both more likely to
act out) and (c) controlling‐caregiving (more likely to be depressed) (Lyons‐Ruth &
Jacobvitz, 2016). Each requires a different approach to the youth and mother or
caregiver (Lecompte & Moss, 2014). Children and adolescents with disorganized
attachment behaviors are more likely to have a history of trauma during development
(Lyons‐Ruth, Connell, Zoll, & Stahl, 1987), often “within a caregiving system that is
intended to be the youth’s primary source of safety and stability” (Kinniburgh,
Blaustein, Spinazzola, & van der Kolk, 2005, p. 424).
It can be helpful to examine how other family members are responding to systemic
family therapy as a reflection of their own attachment issues. Especially with youth
who are insecure or disorganized, therapy with the adults in the family may be a first
step to dealing with the behavior problems. None of this suggests that systemic family
therapists should avoid such children or adolescents or their family members, but that
they remain aware of the ways in which therapy may become derailed. Attempts at
creating emotional intimacy with families with avoidant behaviors may need to wait
until therapy has progressed quite far because they are likely to be more responsive
behavioral interventions, such a parent training or behavior management programs,
than to more strongly emotion‐based interventions. Trying to create emotional inti-
macy in anxious families may simply lead to explosions of emotionality and recrimina-
tions in youth and parents. The angry, punishing disorganized adolescent needs
interventions to stop the behavior, and the mother needs interventions to overcome
her sense of helplessness.
Kobak, Zajac, Herres, and Krauthamer‐Ewing (2014) have provided a model, the
Secure Cycle, as a guide for interventions with adolescents and older children and
their parents based on attachment theory. This model focuses interventions to improve
the mother’s internal working model of her “self” (negative), her adolescent’s prob-
lem behaviors (also negative), her own defensive attempts to regulate her emotions
(shut down, explosive), and her reduced ability to reflect on herself and her adoles-
cent in their relationship. In parallel, interventions are made to improve the adoles-
cent’s working model of what to expect from the mother (negative), his or her own
failing attempts at emotional regulation, and his or her own inability to reflect on the
mother–adolescent relationship. Further, interventions in the mother–youth commu-
nication pattern focus on unresolved conflicts over goals, failures of empathy between
them, and attachment injuries that destroy any confidence between them. Emotionally
focused family therapy (EFFT) (Johnson, 2018), attachment‐based family therapy
(ABFT) (Diamond, 2005), and the Connect Program (Moretti & Obsuth, 2009) are
derived from the principles of attachment theory and incorporate many of the inter-
ventions framed by Kobak et al. (2014).
A note on attachment As this chapter is being written, the world is seeing and hear-
ing and reading about the immediate horrific impact of separating immigrating chil-
dren from their mothers and other caregivers at the US–Mexican border. What is still
to be seen is the long‐term effects of these separations; however, there is clear evi-
dence that these children may take years to recover (Bowlby & Robertson, 1952).
Some of the answers that come regarding the effects of these forced separations will
be framed in terms of attachment theory and research.
The coercion cycle and systemic family therapy

Whether dealing with a coercive 4‐year‐old child or a more sophisticated adolescent,
social learning theory makes it clear that the coercion cycle must be disrupted. It is
important to remember that this is a two‐way interaction and that coercive parents
can change the way they interact with the coercive young person. Social learning
interventions incorporate building more positive parent–child relationships, using
behavior modification strategies, setting clear behavioral rules and consequences
(reinforcements and penalties), and establishing an environment that escapes the
negative coercion cycle. It is very important to disrupt the peer network that is
supporting the coercive behaviors, something that is sometimes overlooked in therapy
(Chamberlain, 2003).
The coercion model (Patterson, 1982) has been translated effectively into Parent
Management Training Oregon (PMTO) (Forgatch & Gewirtz, 2017) to deal with
disordered behaviors, as well as ODD and CD cases. While PMTO is only one of
many possible behavior management‐based programs, it is one that has a long his-
tory of efficacy and effectiveness research (e.g., Chamberlain, 2003; Forgatch &
DeGarmo, 1999) in different populations and countries (e.g., Forgatch & Kjøbli,
2016; Parra‐Cardona et al., 2012). There are important resources that are helpful
for systemic family therapists and laity alike addressing behavior issues (e.g., Dishion,
Stormshak, & Kavanagh, 2012; Forgatch, Patterson, & Friend, 2017; Greene,
2016).
Behavior Disorders: ICD and DSM
Research‐based scholarship on CD and ODD

Clearly, CD has attracted far more interest in scholarly journals than ODD. CD is
linked with serious antisocial behaviors in childhood and adolescence and is a predictor
of adult criminal behaviors associated with high social costs (Cohen & Piquero,
2007). A ProQuest® search (August 31, 2018) covering the previous 10 years identi-
fied 5,008 peer‐reviewed articles in scholarly journals in which subject categories
contained either “conduct disorder” or “oppositional defiant disorder.” Of these
articles, 83% were limited to CD. In contrast, only 11% of all articles were limited to
ODD, and only 6% included both.
Diagnosing oppositional defiant disorder

In US samples, 10–12% of males qualify for a diagnosis of ODD (Merikangas et al.,
2010; Nock, Kazdin, Hiripi, & Kessler, 2007; Rowe, Costello, Angold, Copeland, &
Maughan, 2010). Conceptually, ODD reflects the failure of a youth to regulate her or
his emotions. Typical complaints from the parent, the teacher, or other adults are that
the young person is touchy, seems quick to get angry, wants to argue with adults or
ignore the rules, and/or is resentful and tries to get even when blocked. ODD symp-
toms will vary with the young person’s age, but the behaviors are usually directed at
both adults and peers. The key to diagnosing ODD is that the behavior is repetitive
and persistent, that is, has been going on for some time (6 months), occurs in multi-
ple settings, and includes at least 4 of 8 symptoms of ODD (DSM‐5 [APA, 2013];
ICD‐10 [WHO, 2010/2018]).
It is important to rule out environmental factors when diagnosing ODD. To be fair
to a first grader, the first questions for the parent might be “How does your child
respond to change (new teacher, parental separation, baby)?” and “Have you talked
with the teacher” or, better, “Have you been able to observe in the classroom and
what did you see?” Questions regarding the criteria might include “How long has this
been going on?” and “Are you seeing any of this at home or other places (grocery
store, grandparents’ home, with peers)?” Some children are overwhelmed by a cha-
otic classroom, a harsh or inexperienced teacher, difficult classmates, and so forth, and
they act out at school. The same patterns of behavior hold for adolescents. However,
it is important to assess how much of the behavior is normative—complaints of “He’s
always been such a good child,” “She is so mean to me and her mother,” and so forth,
are not unusual in periods of rapid change or when greater autonomy is desired. It is
imperative to use an early session to see the young person alone to ask some non‐
blaming questions (and “Why are you acting like this?” is not one of those!), judge
the reaction to requests, or set up a game or play situation.
Diagnosing conduct disorder

“I didn’t do it, but if I done it, he had it coming all along.” The problem for the
systemic family therapist taking on a young person who comes with or is about to
receive a diagnosis of CD (typically, a male adolescent) is pretty well summed up in
the “Cell Block Tango” (“Chicago”; http://www.metrolyrics.com/cell‐block‐tango‐
lyrics‐chicago‐the‐musical.html). Rates of CD diagnoses in US samples also are much
higher than in other countries, increasing from 4.4% up to ages 14–15 to 9.6% up to
ages 17–18, with males diagnosed with CD at much higher rates than females
(Merikangas et al., 2010). You can be pretty sure he or she has been accused of doing
something very bad, at least in the eyes of a parent, another person(s), an institution,
or the law. Pick a category: rule violations (chronic truancy, runaway, curfew break-
ing), deceit and theft (lying constantly, stealing from home or others), aggression
(bullying, physical aggression, forcing sex), or “severe” (most or all of the above)
(Breslau, Saito, Tancredi, Nock, & Gilman, 2012).
These are not cases for the fainthearted. The young person may totally deny the
behavior occurred, grudgingly admit that it happened but blame someone else, or
take the blame and express sincere or insincere remorse. The parents may deny the
behavior occurred, insist it was someone else’s fault, blame the young person, or
blame themselves for failing as parents. Sorting out all possible combinations of young
person and parent explanations and blaming is not likely to be terribly helpful. Reports
from other professionals (service providers, teachers, etc.), interviews with relevant
persons (juvenile officer, parents, siblings, teachers), and additional written assess-
ments will help give a picture of the young person in the family and community.
Reviewing the literature and after personally conducting some 500 evaluations of
high‐risk adolescents (RSW), it is fair to assert that the “typical” young person in the
United States involved in the juvenile justice system is a male, 13–15 years old, from a
low‐SES, ethnic‐minority, single‐parent family with several siblings, living in a danger-
ous, segregated neighborhood where drugs and alcohol are readily available and for-
mal or informal gangs are operating. He is likely to have a history of frequent moves
within and between towns, have poor school performance with suggestions of learning
problems, be attending a segregated minority or low‐SES school, be currently using or
selling marijuana and alcohol or both, and be allied with other males and some females
whose families and neighborhoods are similar. Typical offenses include shoplifting,
burglary, illicit substance possession and sales, assault on a peer or adult, and truancy.
Of course, there are adolescent females who also fit this profile of CD, but the ratio of
males to females is at least 5:1.
“Atypical” young persons referred to therapy for CD behaviors are also likely to be
13–15‐year‐old males, although some may be as young as 5 or 6 or as old as 17. By
definition, their problematic behaviors and environments must overlap to a large
extent with the youth referred to the juvenile court system. Again, attitudes of the
offender, parents, and the wider community, family dynamics, and history of previous
behaviors will all determine whether a diagnosis of CD is warranted and what will be
done after a diagnosis is made. DSM‐5 and ICD‐10 list the same 15 kinds of behaviors
as possible CD symptoms. Diagnosis depends on reports of at least three such behav-
iors occurring with one persisting over the last 2 months. In practice, the discovery of
a single occurrence of a serious crime endangering another person (felony level), for
example, armed robbery, torture, or sexual assault, will also be sufficient for a diagno-
sis of CD, setting aside any issue of “repetitive and persistent behaviors.”
Comorbidity with ODD and CD

There is a high likelihood that diagnoses of CD and ODD are strongly linked (i.e.,
both diagnosed in the same adolescent) (Blanco et al., 2015). Further, a diagnosis of
CD or ODD is also linked (but less strongly) to a diagnosis of a depressive, manic, or
eating disorder. However, ODD is much more strongly linked to attention deficit
hyperactivity disorder (ADHD) as a second diagnosis than CD, perhaps not surprising
considering the “nuisance” behaviors often confusingly shared between ADHD and
ODD. CD is strongly associated with a second diagnosis of drug use disorder, alcohol
disorder, or nicotine dependence; however, no such link is found for ODD. Overuse
of drugs and alcohol might well be connected with the loss of inhibitory control char-
acteristic of CD behaviors.
ODD and CD behaviors are so obnoxious or dangerous or both that it is easy to
overlook the possibility of other mental disorders that are (a) independent of, (b) feed
into, or (c) masked by the ODD or CD behaviors. Borderline intellectual functioning
and mild to moderate levels of retardation can be accompanied by problems with
impulse control, a failure to anticipate consequences of behaviors, and a failure to

understand others’ thoughts and motives. Also, adolescence is a time when psychotic
disorders may emerge (e.g., schizophrenia), and adolescents with growing narcissistic,
histrionic, paranoid, or borderline personality disorder are all at greater risk of becom-
ing aggressive, sometimes seriously (Kotov et al., 2017). However, intellectual
functioning or possible psychoses are not usually assessed in self‐report surveys like
the National Comorbidity Survey Replication‐Adolescent Supplement (NCS‐A).
Following Children and Adolescents Into Adulthood
A number of studies have followed a cohort of children or adolescents into adulthood.

In some, participants came from an unselected community sample (e.g., Poulton,
Moffitt, & Silva, 2015); others were selected because they were potentially at high risk
of CD or other problems (e.g., Colman et al., 2009; Dishion, Ha, & Véronneau,
2012; Lahey et al., 2005; Sroufe et al., 2005). All agree that there is a predictive value
for childhood or adolescent CD‐related behaviors; however, all agree that no predic-
tion into adulthood from childhood or adolescent behaviors can be 100% accurate.
Family factors associated with CD in adolescents

Thinking systemically, family therapists will not be surprised to learn that adolescents
with CD also are more likely to have less educated, divorced parents with behavior or
mental problems (Breslau et al., 2012; Lahey et al., 2005; Merikangas et al., 2010).
Such results are hardly surprising in view of the extensive research literature dating
back into the early 1900s and beyond that youthful antisocial behaviors are found in
neighborhoods characterized by poor schools, scant governmental and social services,
and high crime. The problem lies in the toxic environment and not in race or poverty,
despite the temptation to use racial, ethnic, or social class stereotypes (e.g., Odgers
et al., 2012). However, ethnicity and economic status make a huge difference in how
a child or adolescent is treated. A gallows humor saying (sadly, data‐based) among
professionals in one US community was, “Blacks get sent away after 2 referrals to
juvenile probation, browns get sent away after 6, and it takes whites 16 referrals to get
sent away.” Equally bitter is the saying, “Browns get the local residential treatment
center, Blacks get [juvenile] prison, and whites get lawyers!”
The Trajectory Into Adulthood
One well‐known model of the trajectory of conduct problems in childhood and

adolescence divides individuals into low‐risk (50%), childhood‐limited (22%), adoles-
cent‐onset (19%), and lifetime‐persistent (9%) groups (Moffitt, 1993; Odgers et al.,
2007). Moffitt and Caspi (2001) found that the lifetime‐persistent group differed
from the other three groups from birth/toddlerhood on 26 neurocognitive, parent-
ing/family, and temperament/early behavior variables. However, both lifetime‐
persistent and adolescent‐onset groups reported having deviant peer groups at both
age 13 and 18, and both were equally likely to be engaged in CD behaviors.
Societal and personal costs in adulthood

Social costs Rivenbark et al. (2018) reviewed official records covering ages 26 and 38
in a sample of 1,000 New Zealanders followed from birth. The lifetime‐persistent group
used significantly more social resources (e.g., emergency room visits, welfare benefits)
than any other group. More concerning, the lifetime‐persistent group had a mean rate
of criminal convictions 4 times the rate in the adolescent‐onset group, 8 times the rate
of the childhood‐limited group, and 40 (!) times the rate of the low‐risk group.
Personal costs Other studies following adolescents diagnosed with CD found they
were more likely to drop out of high school, marry, and have children earlier. Further,
as adults, they had more antisocial behaviors, substance and anxiety disorders, jobs
lost, bankruptcies, interpersonal conflict, and divorce (Breslau et al., 2012; Merikangas
et al., 2010). These results are reflected in other longitudinal studies (e.g., Colman
et al., 2009; Shortt, Capaldi, Dishion, Bank, & Owen, 2003; Sroufe et al., 2005).
A need for caution

Prediction of adult antisocial behavior based on childhood or adolescent behavior is
fraught with difficulties. A 7‐year‐old with few if any behavior problems may continue
that trajectory into model citizenship or later may fall into the adolescent‐onset trajec-
tory; conversely, the badly behaved 7‐year‐old may enter adolescence as a well‐behaved
citizen (i.e., childhood limited) or continue on across adolescence and adulthood as a
lifetime‐persistent antisocial problem. Simply put, not every youth considered at risk
becomes an antisocial adult (Lahey et al., 2005; Patterson et al., 1992; Shortt et al.,
2003; Sroufe et al., 2005); however, it is also important to remember that some do.
Systemic Family Therapy and Behavior Disorders
Understanding the context in which the behavior occurs or “why” the behavior
occurs is critically important when considering ODD or CD as a diagnostic alternative
to “disordered behavior.” Comorbid diagnoses are far from rare (e.g., Lahey et al.,
2005; Merikangas et al., 2010; Rowe et al., 2010) and may need to be addressed as
well. A behavioral diagnosis opens the possibility of medication for the youth, includ-
ing “atypical antipsychotics” like risperidone (Risperdal®), stimulants like atomoxe-
tine (Strattera®) and methylphenidate (Ritalin®), antidepressants, and other
psychoactive drugs (e.g., Turgay, 2009; World Health Organization [WHO], 2012),
accompanied by hospitalization or institutionalization, as well as labeling the “patient.”
Because it is a medical diagnosis, CD or ODD becomes a disease. Parents, communi-
ties, and institutions are accordingly off the hook—there is no “why,” only illness.
Getting the backstory

It is sometimes hard to accept the legal system’s doctrine of “sole responsibility” or
“do the crime, do the time.” Such a doctrine is needed because only the perpetrator
of a crime can be held guilty under the law, not the mother, father, institution, and so
forth, contributing to the events leading up to the crime. Selling marijuana on school
grounds or in a neighborhood is a CD sort of behavior. It is likely to lead to arrest and
a diagnosis of CD. It is possible that the only person who actually brings in money to
support a very dysfunctional family is a young marijuana salesperson. The yawning
student in an alternative school run like a prison boot camp does not always tell his
drill sergeant some facts about his life: (a) His mother was sent to prison soon after his
birth. (b) An older brother had just been sent to prison for 44 years for armed rob-
bery. (c) His father was a drug dealer and had been arrested and repeatedly incarcer-
ated for drug sales. (d) He was very close to and had lived with his father until his
father’s death from diabetes the previous year. (e) He lived in deep poverty with an
older brother (also a drug dealer) and paternal grandparents. (f) Ultimately, he was
yawning because he did not sleep well the night before. It had been very cold in his
room because his brother, using a gun he kept in their room, had accidentally blown
a large hole in the wall of the house right next to the student’s bed (Downs, 2013).
A backstory does not mean the student charged with selling marijuana or the sleepy
student sent to the alternative school did not need to be disciplined for his behavior.
Systemic family therapy practitioners need to hear these backstories as well as the
juvenile charges or the parent complaints if they are going to think and serve systemi-
cally. Every youth appearing for therapy, delinquent or not, has a backstory, perhaps
true, perhaps not, but one that needs to be heard.
Assessment Strategies for Families with Disorderly

Behaviors and Behavior Disorders
Assessment is not a one‐time activity. Formal and informal data gathered in an initial
assessment only sets a baseline that needs to be updated, expanded, and corrected
over the course of therapy. Further, if what we do as systemic family therapists is to be
seen as effective, ways of tracking progress across sessions need to be developed and
implemented (Johnson, Miller, Bradford, & Anderson, 2017). Children and adoles-
cents with a history of disruptive behavior are not likely to elect coming into therapy;
rather, someone not the child (parents, school, juvenile probation department, or
court) wants help. There is always the question, “Who is the client?”
First interview(s) and assessments

Before the initial appointment The first contact with the mother is critical in properly
assessing the severity of her concerns. When a mother calls in for an initial session, she
is often exasperated and very likely embarrassed about the behaviors of her youth. She
is likely to view this first call as an admission of her “failure” at being a good parent
and believe that coming to a therapist is an indication that her youth is on the road to
criminality. She may have even been told this or something similar by a partner,
friends, family members, and others. Knowing that this mother is extremely vulnera-
ble requires therapists to be fully engaged in the intake without moving too quickly
to formulate their own perception of the situation. Comforting and reassuring the
mother without dismissing her concerns takes tact and patience.
Initial interviews The goal of initial sessions is to establish a working level of trust
and to assess the needs of the youth, parents, and the rest of the family. This first
interview is the time for the therapist to explain issues of confidentiality and mandated
reporting and obtain informed consent to treatment (“assent” for a minor). Ethically
and, in many places, legally, maltreatment must be reported to the proper authorities.
If the child is under 13, one useful strategy is to invite only the parent(s) for the intake
interview and then invite other relevant individuals, as well as the child, to the next
session, during which the child may be interviewed alone. This first session without
the child allows more freedom in speaking, and it helps the therapist join and alleviate
some parental concerns.
With adolescents, the parent(s) and the adolescent can be invited to the intake to
allow the therapist to demonstrate and model an appropriate balance between author-
ity and autonomy. After dealing with issues of consent, confidentiality, and mandated
reporting, 20–30 min can be spent getting a brief history of the issues from the par-
ents’ perspective while allowing the adolescent to chime in within limits set by the
therapist (not arguing, not raging, etc.) and observing the adolescent’s behavior when
parents report their concerns. Then, the therapist can meet with the adolescent and,
separately, the parent(s). This allows an opportunity for each to say anything of
concern without worrying about the other being in the room.
Ground rules need to be established and agreed to before these individual inter-
views. With parental permission, some systemic family therapists guarantee confiden-
tiality of any information divulged on either side (e.g., adolescent is smoking, parents
are filing for divorce) except when legally mandated; others warn all parties that such
information might be divulged in session. The goal of the first individual interview is
not to interrogate the youth, but to achieve some basic trusting connection—a lot to
do in 20–30 min. It is not a time to become the youth’s new “best friend forever,” nor
would a youth trust a therapist who tries it. Many young persons with disruptive or
delinquent behaviors have a history of maltreatment (e.g., Mills et al., 2013), and
they have reasons not to trust a therapist or any adult. For the systemic family thera-
pist, these initial interviews are about trying to get an overall view of the family, how
it is functioning, and the quality of the interactions between the young person and
each parent (and between the parents).
Initial and continuing assessments

Filling out the intake paperwork and some brief paper‐and‐pencil measures is not a
trivial activity because it can yield important data and insights into the case. The thera-
pist needs to take steps to become familiar with how these instruments can be used
effectively and how information from the instruments can be fed back, directly or
indirectly, into therapy.
Normed instruments for use by adults Some instruments are available through com-
mercial publishers at a cost; others are available in the text of an article, on a website,
or from the author. The Child Behavior Checklist (CBCL) (Achenbach, 1991;
Achenbach & Rescorla, 2000, 2001; available at aseba.org) or the Eyberg Child
Behavior Inventory (Eyberg, Nelson, Duke, & Boggs, 2004; Eyberg & Pincus, 1999;
parinc.com) are generally useful, well‐normed instruments providing data from
different perspectives from all the adults in the case who function as parent figures.
It may be helpful to have the adults themselves complete the Outcome
Questionnaire‐45 (OQ‐45) (Lambert & Finch, 1999; oqmeasures.com) or the Brief
Symptom Inventory (BSI) (Derogatis, 1993; pearson.com) to establish and track
their well‐being across the therapy. At this interview or later sessions, the therapist
also may ask the parents for written permission to approach personnel at school or
other relevant institutions for more information, including asking the teacher(s) to
complete the Teacher Report Form (TRF) (parallels CBCL). A number of less well‐
known instruments can be helpful in assessing parenting style and stress level: the
Parenting Stress Index (Abidin, 1997; parinc.com), Parental Stress Scale (Berry &
Jones, 1995; https://personal.utulsa.edu/~judy‐berry/parent.htm), and Parenting
Styles and Dimensions Questionnaire (Robinson, Mandleco, Olsen, & Hart, 1995,
2001; in 2001 article text).
Normed instruments for use by children and adolescents The Youth Self Report (paral-
lels CBCL) is also a generally useful, well‐normed instrument to assess young persons’
views of their own behaviors. Discrepancies between the scores on the CBCL and
YSR (and the teacher’s form, TRF) have potential importance, especially for acting‐
out adolescents.
The Youth Outcome Questionnaire‐30 (YOQ‐30) (version of the OQ‐45) allows
the therapist to track the young person’s emotional and social progress over sessions.
The Parenting Style Inventory II (Darling & Toyokawa, 1997; https://pdfs.
semanticscholar.org/f383/9c32ab26a07ff001de4e7e9edc7663504c41.pdf) pro-
vides an opportunity for the young person to evaluate the parenting style used in the
family. There are a number of commonly used scales that may help inform the thera-
pist about the level of the young person’s depression, for example, the YSR or CBCL
Internalizing scales or Children’s Depression Inventory (Kovacs, 1992; mhs.com),
self‐esteem or self‐concept (Rosenberg Self‐Esteem Scale (Rosenberg, 1986); https://
socy.umd.edu/quick‐links/using‐rosenberg‐self‐esteem‐scale), and sense of control
of his or her life (Children’s Locus of Control (Nowicki & Strickland, 1973); https://
cengage.com/resource_uploads/downloads/0495092746_63632.pdf).
Normed instruments to assess delinquent or risky behaviors Many relevant and poten-
tially useful scales assessing parents and youths for a range of attitudes, behaviors, and
influences are available at no cost through the US Centers for Disease Control and
Prevention (Dahlberg, Toal, Swahn, & Behrens, 2005; https://cdc.gov/
violenceprevention/pdf/yv_compendium.pdf). In addition to very high scores on the
Externalizing scale of CBCL/YSR/TRF, some potentially useful and well‐researched
scales to assess antisocial behaviors in children and adolescents include the Behavior
Problems Index (Peterson & Zill, 1986; in appendix D, part 1 in https://nlsinfo.org/
content/cohorts/nlsy79‐children/other‐documentation/codebook‐supplement/
appendix‐d‐behavior‐problems), Rutter Scales (Elander & Rutter, 1996; https://cls.
ioe.ac.uk/shared/get‐file.ashx?id=528&itemtype=document), Conners Scales (Conners,
Sitarenios, Parker, & Epstein, 1998; mhs.com), and Quay‐Peterson Revised Behavior
Problem Checklist (Peterson, Quay, & Cameron, 1959; parinc.com). Self‐report scales
that may be helpful include Problem Behavior Frequency Scale (Jessor & Jessor, 1977;
https://performwell.org/index.php/find‐surveyassessments/programs/child‐a‐
youth‐development/afterschool‐programs/self‐reported‐delinquency‐problem‐
behavior‐frequency‐scale), Self‐Reported Delinquency Scale (Elliott, Ageton, Huizinga,
Knowles, & Canter, 1983; https://unc.edu/depts/sph/longscan/pages/measures/
Age16/writeups/Age%2016%20Delinquent%20and%20Violent%20Behavior.pdf),
and Delinquent Activities Scale (Reavy, Stein, Paiva, Quina, & Rossi, 2012; midss.org).
Tracking progress and outcomes The CBCL (YSR) and OQ‐45 (YOQ‐30) parent and
child measures can be given several times over the course of therapy, not just for an
initial assessment or a final outcome measure. As an alternative, the Marriage and
Family Therapy Practice Research Network (Johnson et al., 2017; mft‐prn.net) offers
a menu of normed assessment instruments at no cost that parallel many of these other
assessments. This network provides immediate scoring and feedback to the therapist,
along with tracking changes in the individual’s scores if requested. Repeated assess-
ments allow the therapist to follow improvement and take steps to deal with any new
information.
Projective tests Projective tests have been used for decades. Therapists with formal
training may wish to use these methods to further identify systemic processes that
could be used in therapy. Of particular interest to a systemic family therapist are the
Draw‐a‐Person (DAP), House‐Tree‐Person (H‐T‐P), and Kinetic Family Drawing
(KFD) that can be used with younger children and non‐readers, as well as with other
members of the family. Informally asking the artist(s) to talk about a drawing from
any of these tests may provide further information for the therapist.
a warning Overinterpreting is a temptation in using any kind of assessment strategy.

“All that glitters is not gold” is something that particularly relevant to assessment
data. Attorneys regularly consult texts and experts on how to attack testimony in
criminal or custody proceedings regarding paper‐and‐pencil and projective test results.
Imagine having to defend your interpretation of a child’s drawing or of a standardized
test in front of a judge and two attorneys in a bitter custody case. Making too much
of any assessment instrument can be dangerous in other ways because it sets up a
potentially false image that colors everything else the therapist sees or hears.
Continued sessions and (in)formal assessments

Assessment and reassessment, formal and informal, continue throughout systemic
family therapy. Reading body language, observing patterns of (mis)communication,
and following themes in talk therapy are all part of this process of data gathering. Use
of assessment instruments over the course of therapy can track progress over time and
alert the therapist to problems not discussed or evident in therapy sessions. Not every
systemic family therapist can be deeply schooled in test theory and application, and
some avoid formal testing, if possible. However, there are some simple instruments
and family activities that can help the therapist better understand what is going on.
These are not necessarily data that can be taken into court or used to convince an
agency or institution to make changes.
The Evidence Base for ODD and CD Interventions
Programs to prevent ODD or CD or intervene with children and adolescents with

symptoms of ODD or CD have been reviewed in a number of recent books
(Christophersen & VanScoyoc, 2013; Weisz & Kazdin, 2017). Many of the well‐
regarded programs are based on parent education and training for behavior
anagement programs, and these programs provide training or treatment manuals or

m
both. Ethically, using such programs without appropriate training or background
could constitute malpractice.
Programs with strong research support

Very stringent criteria, considered to be the “gold standard,” have been used in major
reviews of interventions for ODD and CD: (a) using a randomized control design
(RCT), (b) using a treatment manual or equivalent, (c) clarifying the specific sample,
(d) using reliable and valid measures relevant to problem targeted, and (e) using
adequate analyses with sufficient sample size.
Younger children Rather than give detailed references as to the origins of the pro-
gram, the program websites are provided. The following programs have met at least
4 of the 5 criteria; all have websites with information about training and manuals. For
children under 12, the Incredible Years (incredibleyears.com), PMTO (generationpmto.
org), Parent Management Training–Kazdin (PMT) (parentmanagementtraining
institute.com), Parent–Child Interaction Therapy (PCIT.org), and Triple P (Positive
Parenting Program; triplep.net) are all behavior‐management‐based, parent‐involved
programs that are well researched and well regarded. Extremely disruptive behaviors
in 3–6 year‐olds may require removing the child from the home (Treatment Foster
Care Oregon for Preschoolers; tforegon.com). In addition to these behavior‐manage-
ment‐focused programs, two parent–child play therapy programs meet 4 of the 5
criteria, namely, Adlerian Play Therapy (encouragementzone.com) and Child–Parent
Relationship Training (https://cpt.unt.edu/shopping/child‐parent‐relationship‐
therapy‐manual) (Kaminski & Claussen, 2017).
Older children and adolescents Multisystemic Therapy (mstservices.com) and

Treatment Foster Care Oregon (tforegon.com) are two programs meeting all five
criteria. Both are intensive, multimodal, multisystemic programs requiring treatment
teams to work with high‐risk, court‐ordered juveniles and their families (McCart &
Sheidow, 2016), as is Multidimensional Family Therapy (mdft.org), specifically
designed for adolescents with serious substance use and abuse issues, but including
many elements of behavior management. Programs that have substantial research sup-
port—but that are less intensive, require fewer financial and staffing resources, and
have been applied to the spectrum of ODD and CD behaviors—are Functional Family
Therapy (https://fftllc.com/about‐fft‐training), PMTO (generationpmto.org),
PMT (parentmanagementtraininginstitute.com), and Brief Strategic Family Therapy
(bsft.org) with the closely related Familias Unidas (https://familias‐unidas.info/#).
What now?
Many potentially worthy intervention programs have never met criteria, but may hold
great promise. However, there is no substitute for taking the research evidence avail-
able seriously to learn from the set of well‐documented, probably efficacious, possibly
efficacious, and promising treatment programs (Kaminski & Claussen, 2017; McCart
& Sheidow, 2016). It is both a cognitive and emotional struggle to abandon our
familiar ways of thinking about and working with families with children who have
problematic behaviors. Some caution is advised when systemic family therapists are
tempted to incorporate strategies presented in a workshop led by a charismatic and
enthusiastic presenter who promises to solve the behavior problems of youth of any
or all ages. Two things are needed to justify our therapy—(a) evidence from process
and outcome measures that do not depend exclusively on therapist case notes or cli-
ent‐system impressions (e.g., graphs demonstrating improvement, teacher reports,
passing grades, release from probation, etc.) and (b) approximating the gold standard
by becoming familiar with and using the evidence in the literature to guide effective
therapy.
A Strategy for Child and Adolescent Behavior Problems
Effective behavior management as the end game

Most program reviews support the need to use behavior management strategies when
dealing with disordered behavior or behavior disorders. With such problems, the basic
issue is how to break the coercion cycle where frustrated parents and other adults try to
force children to behave appropriately and children try to force the adults to let them
do what they want. It is a zero‐sum game; only one of them will “win” the battle.
The basics of family‐based behavior management In our experience, effective behavior

management programs do not begin with listing consequences for undesirable behav-
iors (punishment), rewards for better behaviors (positive and negative reinforcements),
and so forth; rather, the initial focus is on (re)building relationships. Parents may want
the therapist to “fix” their child without their involvement. Engaging the parents may
be the hardest and most critical intervention. They expect to be blamed; thus, praising
them for being good parents who see the problem and are willing to work to resolve it
is Step 1. Then, Step 2 emphasizes how critical their participation is for the therapy’s
success because they are there with the child for hours every day and the therapist gets
only an hour a week. Finally, giving the parents hope for change is critical—the litera-
ture is full of success stories, and therapists can add stories from their own experiences.
A straightforward, firm approach may work best as a standard introduction:
I am trained as a family therapist, which means that I will be looking at the interactions
among the whole family. Although I will see your child individually at times, I will always
be considering what is going on with your child and how it impacts the family, and what is
going on in the family and how it impacts your child. This will also require that I have ses-
sions with you as parents, with or without your child and with or without their brothers and
sisters, or the family as a whole. The research evidence is pretty clear that working with the
family in this way increases the success of therapy and speeds up the recovery process.
[added if ODD or CD diagnosis] The research regarding the issues you are concerned
about is clear that family therapy and parent training are essential for a positive result to
take place. We will meet in three to four sessions to discuss what that will look like specifically,
but between now and then, I’ll send you some videos to help you understand my approach and
recognize what you can do to increase the process of therapy. My goal is to teach you the tools
necessary so you won’t have to come back to therapy, or at the very least, use therapy only on a
consultation basis and not something scheduled on a weekly basis.
Viewing behavior problems through the lens of the coercion model provides
greater clarity with respect to the most effective treatment approach, allowing adults
to afford greater compassion to the youth and become proactive rather than reactive.
Youth and adults are no longer in a battle over behavior. Adults are able to adjust
their discipline strategies, and youth with behavior problems have a more positive
prognosis. Most effective treatments also include discussions and training with the
adults about the coercion model, as well as role‐plays to rehearse how to utilize the
skills involved.
It is important to follow a stepwise treatment model because each skill builds upon
the other and provides greater opportunity for the adults to feel successful in their
interactions with the youth: (a) positive relationship building, (b) using effective
instructions, (c) behavior tracking, (d) behavior modification, (e) limit setting, (f)
family communication, and (g) effective family problem solving. Bad behavior man-
agement programs are like bad therapy—ineffective and possibly dangerous for adults
and youth.
Stories From the Field
Carefully following a formula is all well and good in chemistry; however, we felt it was
important to describe how we actually work with families. The first author, trained
initially as an experimental psychologist and later as a social worker and family thera-
pist, spent 24 years as a teacher, supervisor, program developer and director in minor-
ity communities, and practitioner of systemic family therapy. The second author, the
“I” in the next sections, holds a master’s and doctorate from accredited systemic
family therapy training programs and has taught and practiced systemic family therapy
in multiple settings. Together, we prepared the following sections. Our hope is that
many systemic family therapists will see commonalities with their own work; others
may wish to incorporate some of these ideas.
A Scenario for “Run‐of‐the‐Mill Cases”
Most systemic family therapists will deal with families where the youth does not meet
the criteria for either ODD or CD. Such a youth may carry labels like “difficult,”
“sassy,” “disobedient,” and, more frankly, “pain in the ass.” After assessing the youth
privately for sexual or physical maltreatment, severe depression/anxiety, and so forth,
the systemic therapist needs to focus on successful behavior change.
The treatment approach described should take no more than 20 sessions; more
typically, treatment is wrapped up in about 10–12 sessions, especially if the problem
behaviors are average and not severe enough to warrant an ODD or CD diagnosis.
It will be clear that our approach is anything but a pure behaviorist approach to
problem behaviors. It requires engaging the youth and parents both separately and
together; bringing in play therapy, games, and role‐plays; and demonstrating
compassion and respect for both the problematic youth and the frustrated and
discouraged parents.
Joining With the Child or Adolescent
Adults become so worn down in addressing the problem behaviors of the youth
(2–18 years old) that it is hard for them to start working on developing a positive rela-
tionship. Most want to start immediately learning and using the limit setting and dis-
cipline aspects of the programs. However, when this is done, it is likely to create even
greater problematic behaviors. After initial sessions and once I (MRW) have a good
idea of what I am dealing with (including assessments) and have concluded that the
behaviors do not fall into ODD or CD, I will spend three to four sessions meeting with
the youth individually. The focus of these sessions will vary depending on how the
youth presents in session and what the triggers are for the behaviors. During this time,
I am also assessing for possible mental health issues that may contribute to the problem
behaviors (depression, anxiety, attention disorders). I will challenge the youth, trying
to elicit some version of the behavior problems exhibited elsewhere. This can be in the
form of playing games (e.g., Connect 4, UNO, chess, checkers), doing origami or art
projects, puzzles, or anything else that may challenge him or her. Throughout these
sessions, I will be prepping the youth for the collaborative and proactive solutions
described by Greene (2016) by using some of those skills to encourage the youth to
discuss his or her view of the concerns. The end of each session is usually focused on
speaking with the mother and other adults and providing them with teaching videos
on empathy, emotion coaching, the collaborative and proactive solutions approach, the
essential nature of play in a youth’s life, and a nything else that is pertinent to prepping
those adults for the parenting training phase of therapy.
Parent Training
The parent training phase starts when I think I have enough data from working with
the youth in the previous phase to successfully teach the adults how to use the various
skills central to behavior modification. Depending on the severity of the behavior and
the readiness of the adults, this phase can consist of meeting with the adult(s) every
week for 6–8 weeks or alternating with individual sessions with the youth. Generally
speaking, I cover the following skills during this parent training phase: relationship
building, mindfulness (self‐care), direct and effective commands, empathy (emotion
coaching), rewards, privilege removal, and problem solving.
Relationship building: Teaching parents to play

I start this phase by teaching the mother and other adults how to interact “playfully”
with their child or adolescent, something at which they are not very skilled. This can
be in the form of Child–Parent Relationship Training (Bratton, Landreth, Kellam, &
Blackard, 2006), some other version of nondirective play, outings together, or games
with an emphasis on the youth’s choices. I remind parents that a positive relationship
needs to be present before any hopes of behavior change can materialize. Many par-
ents have a hard time with this part of parent training, which is why providing them
with handouts or YouTube links is imperative during the youth–therapist joining
phase. Most parents immediately want discipline strategies and forget to build up
positive interactions.
Family play therapy

Family play therapy is used as an adjunct in the parent training phase. When parents
are reporting difficulties applying some of the parent training skills, I will use a play‐
based activity with the youth to demonstrate how to appropriately use that skill. The
“play” varies depending on the age of the youth, scenario, case presentation, and skill
being taught. One example of teaching direct and effective commands is to have the
youth construct one object from a Lego kit without having access to the instruction
booklet. Then, the parent, who has the instructions, can use only speech to describe
how to build the object without showing the assembly pictures to the youth. The
adults are limited to giving their instructions and answering only the questions that
the youth asks. They are not allowed to tell him or her, for instance, “No, not that
piece, the other one,” unless the he or she directly asks if the piece in question is
correct or incorrect. If the youth makes assumptions about the construction of the
object and moves ahead without the parent, the parent just continues with the verbal
instructions. This may create a hodgepodge object, unless the youth was following
directions and the parents were being clear in their language. This is a twofold inter-
vention: the adults learn that clear language is important, and youth learns to wait for
proper instructions before proceeding in certain situations.
Self‐care for the parents

Another aspect of training adults who are dealing with youth with problem behavior is
appropriate self‐care. Since being present and in the moment is imperative for direct and
effective commands to be used, I teach the parent(s) about mindfulness and self‐care.
Part of self‐care is for parents (when partnered) to attend to their relationship on a regu-
lar basis. Any romantic aspect can be lost in the need to collaborate as confederates when
dealing with problem behaviors. This loss takes a toll on the ability to remain present
during difficult interactions with the youth. I also remind them that they are individuals
in need of individual care as well. Although mindfulness is a relatively easy skill to start, I
focus on their continued use of mindfulness and self‐care throughout therapy, but start-
ing this skill is necessary before moving into the commands aspect of parent training.
Teaching about effective commands

Once I am confident that the parent(s) has started doing some relationship building with
the youth and using appropriate self‐care, we will talk about direct and effective commands.
This usually needs to be role‐played repeatedly with parents to ensure they apply it cor-
rectly. The role‐plays should be “realistic” in that the therapist (acting as the youth) should
talk back, interrupt, bargain, raise the voice, pout, and act angry. I have had a number of
parents get flustered in the middle of a role‐play because I was “acting just like our kid.”
We use this time to process why this skill is so important and how to do it correctly. Over
time, the role‐playing helps parents gain more confidence in their parenting abilities.
Emotion coaching
Using expressions of empathy, emotion coaching (Gottman, 1997), is the fourth skill
that I address. I explore what I have learned about the youth during my sessions and
present several hypotheses regarding the triggers of problem behaviors. Emotion
coaching is also role‐played to make sure everyone involved with the youth is able to
utilize it adequately and appropriately. When and how to use emotion coaching
(limited to avoid trivializing) and when not to use it (in a rush or not emotionally
able) are also addressed. Empathy and relationship building are put into context as
ways to prevent problem behaviors and to increase the positive environment within
the family system.
Developing and Implementing a Behavior

Management Program
Rewards (not bribes)

Rewards and reward systems are presented well before teaching about discipline strat-
egies. This is a way to increase the positive environment in the family, in addition to
its utility in behavior modification. Rewards consist of tangible and intangible “things”
provided that are of value to the youth (e.g., picking a menu for dinner, video game
time, time with just mom or dad, access to the family car, overnight stays). These are
positive reinforcers. Rewards also include the freedom from “something” or negative
reinforcers (e.g., freedom from doing a chore for one night). Rewards are linked by
the parents to increasing a desired behavior or decreasing a particular behavior. One
boy told me that all he wanted was a popular handheld video game system. When I
asked his parents about this, they were adamant that it would never happen. When
asked why, they described the difficulty they had in getting him off the current game
system and how it often devolved into a shouting match. Using the idea of rewards,
we, as a team, discussed the parents’ concerns with the boy. The boy came up with his
own reward system. If he would get off of their current game system without yelling
or complaining each day for 2 weeks, he could get his handheld system. The parents
were not convinced, so they made a counteroffer: if he could do it every day, consecu-
tively, for one full month, they would believe he would do so with the desired hand-
held system. It took the child five full months, sometimes going 3 weeks without
complaining and then having to restart, but he eventually earned his handheld system.
The parents reported that he had not had a problem with excessive time on his hand-
held system. As a bonus for the boy and his parents (and a reinforcement for the
therapist), the parents reported he was more helpful, less defiant, and more coopera-
tive than he was with the punitive system used before.
Privilege removal and problem solving

Privilege removal Privilege removal is a form of punishment, and teaching about
privilege removal is something that must wait until the family relationships are more
positive and the child is more compliant and experiencing rewards regularly. Privilege
removal avoids arguments that escalate into shouting matches, even violence. Both
adults and their offspring appreciate the predictability and the end of arguments.
Physical punishments, including spanking, do not belong ever in a behavior manage-
ment system. However, it is hard for adults to give up the idea of spanking. Therefore,
usually it is best to ignore the issue of spanking versus not spanking, unless raised, and
focusing on building a more positive relationship and using privilege removal. In our
experience, privilege removal really is more fun for the adults than arguing and fight-
ing or spanking.
An alternative to privilege removal is to help the parents develop a list of brief addi-
tional chores that can be given as punishment for rule‐breaking (the 5‐min job;
Forgatch et al., 2017). For a youth, sweeping the hall, reading to or being read to by
a sibling or the parent, taking over another child’s chore, and picking up the dog’s
feces (NOW!) are all added duties (not part of the regular list of chores), and the list
is nearly infinite. For truly recalcitrant older adolescents, some effective systemic ther-
apists have been known to add digging a 3‐foot hole in the backyard as a special chore
or removing the adolescent’s bedroom door for a week (repeat as necessary).
All of this talk about punishment leads back to the importance of helping parents
establish reasonable house rules, rewards for desired behavior, and regular chores for
every child in the family (see Forgatch et al., 2017, for a model), not just the child
who is the “target” of all this training. Systemically speaking, this problem in this
particular child hardly arose in a vacuum, and spreading the intervention around is
something some classic systems theorists would endorse enthusiastically.
Problem solving One risk is inadvertently teaching the parents to become borderline
abusive, and that is not the goal to be sure. Parents are often overly enthusiastic and
come up with severe punishments; they will need guidance from the therapist. The
young persons are often resistant to the ideas of their parents and may deny that their
behavior is a problem to anyone. They too may need guidance from the therapist. A
system of privilege removal needs to be taught as a skill to deal with behavior “creep”
in which new, positive behaviors slip back into old, negative patterns. Parents and the
young person sit down together listing the problem behaviors and the privilege that
will be lost for engaging in the behavior (aka punishments) so there is no surprise.
Failure to agree on the list warrants discussion with the therapist who may need to
negotiate with one or both sides to resolve the dispute, being careful to acknowledge
the adult’s ultimate authority while protecting the young person’s dignity. When the
young person’s behavior warrants removal of a privilege, parents are taught that less
is more and that immediacy and consistency in applying both the rewards and punish-
ments are critical. The goal is to avoid long, ultimately unenforceable, privilege
removals, for example, drawn‐out groundings or removing a valued object or activity
“for life.”
Punishments should be limited in scope, depending on the severity of the behavior
and the age of the child. If using time‐out, for example, a minute in time‐out for every
year of the child’s age should be a working rule. In general, swift and predictable loss
of privileges is most effective (30–60 min at a time). For example, a younger child
might lose access to a computer game for an hour after school when she or he fails to
bring needed books home from school. Even with fairly serious breaches of the rules,
to be effective and enforceable, punishments should be limited to 24 and 48 hr at
most, for example, an adolescent might lose access to the family car for a weekend for
repeatedly breaking curfew. Some privilege removals are general and can apply to any
behavior the parent deems problematic, but for the most part, they are tied to certain
behaviors. When a privilege is withdrawn, the parents are taught to regroup with the
young person by using Greene’s (2016) problem‐solving steps to find a constructive
solution to the trigger of the problem behavior.
Termination
Many adults are hesitant to terminate successful therapy because they fear that once
the child stops seeing the therapist, she or he will start the obnoxious behavior again.
To ease the burden of termination, I will encourage the family to schedule monthly
appointments with me and cancel if they are not needed. This provides a safety net for
families so they know I will be there to troubleshoot issues that may arise.
A Scenario for Treating Oppositional Defiant Disorder Cases
The basic approach

ODD opens the way to the possibility of later CD and adult antisocial personality
disorder or criminality, but such serious sequelae are not inevitable (Rowe et al.,
2010). Therefore, interventions to keep the obnoxious behaviors of ODD from
somehow developing into the much more dangerous behaviors of CD are most
important for youth who are showing these more serious and consistent behavior
problems. It is important to remember that ODD has high rates of comorbidity with
other serious mental health issues. Unfortunately, many times the problematic behav-
ior (ODD) is the reason such youth encounter authority figures, but not enough is
done to deal with the underlying mental health issues.
My treatment approach for youth who have a clear diagnosis of ODD is done in the
following order as described above: intake (with or without youth) → youth–therapist
joining → parent training/family therapy → termination. The intake and youth–
therapist joining phases are the same as before, and only the parent training/family
therapy phase differs.
Parent training/family therapy phase

Due to the increased severity of problem behaviors with a diagnosis of ODD, I start
the parent training/family therapy phase earlier. Within the first 3 weeks of treatment,
I dedicate a full session of parent training toward understanding coercion theory. With
parents, I go over the differences in terms of coercive parenting versus coercion theory.
We explore the extent to which this model of interactions is entrenched in their rela-
tionships within the home. To see this more clearly, I will invite multiple family mem-
bers into a session to play the game of “Sorry”. The game dynamics tend to elicit very
clear power dynamics within the family—that is, who’s really in charge. For example,
one 4‐year‐old child held all of the power within the family. His older brother was
extremely reluctant to play a “Sorry” card on one of the 4‐year‐old’s pawns, something
that would send the pawn back to the beginning. The 4‐year‐old was the only person
with a pawn on the board, and, according to the rules of the game, a “Sorry” card
would require his brother to put the pawn back into the start position. When the
“Sorry” card was drawn, the older brother looked at the parents, at me, and at the
4‐year‐old. When instructed to “play the game,” the older brother did so, but imme-
diately shrank away to prepare for a temper tantrum from his younger brother. This and
other family games often elicit coercion cycle dynamics and enable the therapist and the
parents to witness in real time how intensely they are bound by these interactions.
When parents can clearly see and understand the coercion cycle, they are more recep-
tive to other parent training sessions. The order of parent training in ODD cases also
differs in that I teach direct and effective commands first and then proceed with rela-
tionship building, self‐care, empathy, rewards, privilege removal, and problem solving.
The reason for this shift is the need for parents to achieve success and see that the coer-
cive dynamics can be changed. Many parents fight against the relationship‐building
aspect of treatment for various reasons. Most often, it is due to their lack of confidence
that it will make any difference. Further, they are overwhelmingly exhausted from the
difficult interactions they have been going through with the child and others (family
members, school personnel, etc.). Therefore, using direct and effective commands is a
skill that is focused on and explored on a continuous basis, in session and out.
Going outside the family

In addition to parent training, it is important to me that I also do some extra‐systemic
work. When working with these families, I make an extra effort to collaborate, com-
municate with, and educate other professionals who are interacting with this youth. I
will spend time speaking with or emailing teachers, school counselors, and administra-
tive staff about the same skills I am teaching the parents. Above all, I address the
coercion cycle and the importance of relationship building.
Youth diagnosed with ODD enjoy a more positive prognosis when all the adults in
the child’s life are aware of the ubiquitous coercion pattern and are able to adjust their
discipline strategies. Altogether, the child’s treatment needs to be systemic. A child
trapped in the cycle of coercion needs to be treated with consistency in the home and
in every other situation where the behavior is manifested. This reflects the fact that
when youth and adults are no longer in constant conflict over behavior, the other
underlying issues can be seen and treated. Of course, major problems initially present
in the youth or parent (very severe depression, thought disorders, etc.) must be
addressed and dealt with either before or as therapy begins.
A Scenario for Treating Conduct Disorder in

With every increase in severity of problem behaviors, the treatment for the youth
needs to be more systemic in nature and less individually focused. This is especially
true for youth who have breached the line from disorderly behavior or ODD into the
realm of CD. CD is diagnosed only when there has been dangerous aggression toward
people or animals, deliberate property destruction in a callous and uncaring way, or
serious violation of laws or rules. Behaviors related to CD are above and beyond
opposition and defiance toward authority figures.
The treatment for CD needs to be multifaceted because of the severity of the
behaviors and the degree to which the coercion cycle is embedded in the child’s inter-
actions. It is very unlikely that one therapist can handle all of the treatment aspects
alone through sessions in an office. It is at this point, with these youth, systemic
therapists can use their systemic training to greatly advantage the family and the
youth. The treatment sections below are separated by ages: younger than 10 years and
older than 10 years.
CD treatment in children under 10

Initial interviews Much like the treatment of ODD and less severe behavior con-
cerns, an intake session is completed, but there are a few important differences. If I
suspect or if the child has been officially diagnosed with CD, I will meet with the
parents in two intake sessions before meeting with the child. The first session is all
about the treatment history, current trajectories of behavior, and trying to get very
clear understanding about previous treatment, current and historic medications used,
while joining with the parents. Although difficult to achieve at times, I almost never
meet without all the adults in the household present. That is, if CD is the diagnosis of
concern, I insist on meeting with “all active caregivers.” The second session is dedi-
cated to helping these caregivers understand that treatment, done properly, will take
between 6 and 12 months, along with emphasizing the necessity of their active
involvement in treatment at home, in school, in the community, and in my office. We
discuss coercion theory, and I get as many details as possible about their current
discipline strategies and provide them with reading or listening materials to buoy up
their confidence that treatment will be effective.
Meeting the child I prepare my office for the child intake session once those initial
sessions are completed. I have learned by experience that I need to have anything I am
not willing to see broken put away before the child enters the office. This way I am
able to join with the child from the start without fear that I have to instantly become
a disciplinarian. The joining process may take longer than three sessions, largely due
to the number of times these children have unsuccessfully encountered a mental
health professional and their expectations of what is going to take place in my office.
One child would come into my office, throw all of the toys on the ground, and throw
all of the couch cushions throughout the office; all the while, she expected me to
chase her around the office. This took place for six sessions before I was able to show
her that I accepted her and was there to work with her, not on her. After our relation-
ship was established, she tested it every other session by going back to throwing
things around. Establishing the relationship is key to the treatment process, not only
with the child, but with the caregivers. For this particular child, I had parents and
grandparents all involved in treatment.
Engaging other professionals Clearly, dealing with CD is resource intensive. While I

am working with the child, I prefer to have another therapist working with the parents
in couple therapy and basic parent training. Most often the adult–adult relationship
has become nonexistent, very likely on the verge of a break. Establishing the need for
couple therapy takes place early so parents recognize that working in couple therapy
is actually working toward behavior change in their child. Finding a couple therapist
that can also do high‐quality parent training is essential. In this way, the therapist is
able to collaborate with me to teach the parent(s) the right skills at the right time to
support the work I am doing with the child to teach and reinforce more compliant
and appropriate behavior. Even with good couple therapy and parent training in place,
I will still conduct family sessions every third or fourth session to continue building
on the skills the child and the parents are learning.
Going outside the family In addition to these treatment aspects, the systemic thera-
pist also needs to collaborate with macrosystems (juvenile justice, academic, other
affected systems). Being connected to the other systems that this child will be encoun-
tering and providing training, feedback, and support for the changes that are taking
place is imperative for treatment to be successful. Parents, caregivers, and macrosys-
tem contacts should be aware of the length of the treatment, along with understand-
ing and expecting that therapy will not be a smooth progress. There will be weeks
where things are sailing smoothly and then a couple of days of heightened problem
behaviors. The goal is to help the therapy team and adults recognize that progress,
while slow, is being made. Over time, this will help to change the overall view of their
child, eventually reducing the coercive dynamics that take place in their interactions.
Conduct disorder treatment in youth older than 10

Initial sessions I ask to meet with all active caregivers and the adolescent in the first ses-
sion when adolescents older than 10 are referred to me with a confirmed diagnosis of
CD. My preference for this comes from the desire to establish a systemic lens from the
outset. I want the caregivers and the adolescent to know that my work will be with the
family as a whole rather than with the adolescent alone. It is predictable that by this time
the adolescent has been in several mental health providers’ offices and has a preconcep-
tion of how things will go. My focus in the first sessions is to understand both the
adolescent and the adults’ perceptions and identify areas where I can be different. The
coercive dynamics are so entrenched in the interactions between the adults and adoles-
cent at this point that the majority of work will focus on identifying the relational pro-
cesses and focusing on those, rather than on the content of the adolescent’s behavior.
Widening the focus The work of therapy needs to encompass as much of a systemic
framework as possible, as was true for working with younger children with CD. The
teachers, school administration staff, and any juvenile justice officers who may be
involved need to be an active part of the treatment. The goal of therapy should not be
merely to keep the adolescent out of jail, but to address the fundamental processes the
adolescent uses to relate to others. Much like the previous treatments, there is a heavy
emphasis on joining, parent training, and family therapy. The systemic therapist at this
point becomes more of a team facilitator to make sure all aspects of the treatment are
running smoothly and are actually being addressed. The family may have an individual
therapist for the child (who may or may not be the systemic therapist); a systemic fam-
ily therapist (for the family), possibly an individual therapist for the mother or other
caregivers; a couple therapist (if the parents are still romantically involved); a social
worker (who directly interacts with the juvenile justice system and the family); and
some school contact person (school counselor, teacher, administrator). The family
will need advocacy from the systemic therapist to ensure the proper treatment is
obtained. I have been faced with many families who expect all of this work to be
shouldered by one therapist. If one therapist tries to take all of this work on them-
selves, therapy is lengthened, and success is threatened.
Conclusion
Working with youth and families where there is an aspect of disordered behavior
present requires a compassionate, motivated, and informed systemic family therapist.
The literature is growing about positive outcomes for family‐based treatment models
that include more than just the mother–child or family system. Treatment success suf-
fers when disordered behaviors are addressed as an individual intrapsychic issue. As
the behavior becomes more severe, the levels of wider system involvement increase,
along with the necessity of such involvement.
Into the Future
Teaching and training in behavior problems

Systemic family therapists come from many different disciplines, each of which has
its own ways of teaching and training. One area that has been neglected too often
is how to work effectively with youth within their families and larger systems. Our
classic theories rely on having individual verbal clients. By and large, young chil-
dren are not welcomed into family sessions because they are seen as noisy and dis-
ruptive. Besides, they cannot fill out forms or talk “sensibly.” Adult clients and
older children and adolescents are distracted by little ones; couples with babies and
toddlers in the room try to avoid upsetting each other and the little one. Certainly,
some systemic therapists with a young child in the room take advantage of the
opportunity to observe family, sibling, and couple dynamics around a misbehaving
child. Others wonder if they cannot find some activity to occupy and, in effect,
psychologically remove the child without imagining that adult–child interactions
provide ample opportunities for gathering information and intervening with clients
of all ages.
We would argue that anyone who works with families with youth needs to be pre-
pared to deviate from “standard” talk‐behind‐a‐desk or ex cathedra therapy and move
into unfamiliar territory—out from behind the desk, sitting next to a child or adult,
moving members of the family around, down on the floor to play with or become a
child, inviting adults to join in, role‐plays with different members of the system. The
model of training for systemic family therapy demands this kind of flexibility, and this
is knowledge that every systemic therapist needs to successfully join and provide
effective services. Sometimes it comes in formal classes, supervision, inspiration, or
experience, but it must come.
We would also argue that, regardless of identified profession, systemic family
therapists need to know about behavior modification in detail. Youth behavior is
not random. Behavior can change with the support of the therapist, and the adults
in the young person’s life can manage to set workable house rules, provide positive
reinforcements for good behavior, learn how to gain the young person’s attention
with clear communication, and (always later in therapy for behavior problems) learn
how to calmly announce a privilege removal that does not come as a surprise to the
young person. Some parents are adept at using time‐outs to deal with rule‐breaking;
others just suck at it. In the first case, time‐outs will be very effective and useable;
in the second, the adult may just require the youth to “go take a nap.” Desperate,
but clever, adults have been known to give themselves a time‐out and retreat from
the battle. When trainees are not given permission to experiment with ways to
engage parents in behavior modification programs, we have not done them or their
clients a service.
One of the strengths of systemic family therapy is flexibility—if our training includes
more than just behavior management or just classic theory and talk therapies and
allows trainees to move toward their own particular style of operating in session while
not losing responsibility for the basic goal of behavior change. As systemic family
therapists, we need to be prepared for the failure of a beautifully designed behavior
modification program. At that point, systemic thinking and acting are imperatives.
Sometimes, the problem is how to increase hope in the adults and the child: taking
the blame for the problem yourself, asking for the family’s help in solving the road-
block, or reminding them of earlier successes. At other times, role‐plays with both the
adults and the youth in the session can help. Bring in more parts of the system to
advise you (e.g., grandparents, siblings, aunts and uncles); change the target to
improving family communication patterns to take the focus off the young person
(Alexander & Sexton, 2002); take the young person’s place in the room and see if
speaking for him or her makes a difference; require everyone to express their feelings
without talking; talk to the teacher. There are so many possibilities. We know behavior
management works, mostly; however, rigidly persisting or talking about “client resistance”
is not what is needed.
Practice and research on behavior problems

Practice There is an important difference between “eclectic” and “throw it at the
wall and see what sticks” therapy. Skovholt and Rønnestad (1995) describe different
levels of professional development, ranging over the years from clinging to a guru
early in training to trusting one’s self to conduct therapy based on knowledge, prac-
tice experience, and integration of ideas about therapy. Along the way to such perfec-
tion, it is vitally important to recognize and correct the gaps in knowledge we all have,
including finding out about research and practice developments in the field of s ystemic
family therapy and getting specialized training experiences.
The strategy we described earlier is definitely eclectic, but it is grounded in training
and a knowledge of behavior and behavior modification. We acknowledge the central-
ity of using the literature on behavior modification to deal with disordered behavior
and behavior disorders. By definition, youth with behavior disorders are brought into
systemic family therapy to modify the dysfunctional behaviors. Successful change
depends on more than a b‐mod program or a token economy; it depends on building
better relationships among adults, youth, and the therapist through other interven-
tions that are clearly not b‐mod. Systemic family therapists understand that changing
one member of a system has a ripple effect throughout the system, and our goal is to
use those changes effectively. Developing and practicing effective interventions are
important, but there is more. Sometimes, that change is about attitude or emotion,
not behavior. Flexibility in the way we do our work is crucial.
Research We are optimistic that systemic family therapists will benefit from using
formal assessments to track the course of therapy with their clients. Assessments offer
information as to how therapy is going for each person in the system and how clients
are feeling and thinking. Of course, individual therapists can carry out such assess-
ments; however, we believe that research with a large set of real‐world practice data,
like in practice research networks (PRNs), is vital to our progress as a field (Johnson
et al., 2017; Miller, 2020, vol. 1). Systemic family therapists have an opportunity to
obtain information on their own clients in regard to desired outcomes of their work,
get immediate feedback from clients, and get help with their record keeping. By pool-
ing anonymous client data through a PRN, researchers can provide that evidence of
our effectiveness in real‐life therapy settings. It is important to demonstrate that all
knowledge does not flow from randomized clinical trials (RCTs). As systemic family
therapy moves into an emphasis on evidence‐based therapy, PRNs offer ways to evalu-
ate what we, as a field, can do for whom, by what means, for what problems.
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12
Systemic Approaches to Adolescent
Substance Abuse
Rikki Patton, Jennifer E. Goerke, and
Heather Katafiasz
Adolescent substance abuse is a significant public health concern, with lifetime preva-
lence rates ranging from 0.9 to 63.2% in the United States (Johnston et al., 2018; Kann
et al., 2018) and between 5% and nearly 80% worldwide (World Health Organization
[WHO], n.d.). With these high prevalence rates, most behavioral health clinicians will
inevitably work with this population. Adolescent substance abuse is also intimately
linked with other risk factors, including increased physical and mental health symptoms
(Christie, Fleming, Lee & Clark, 2018; SAMHSA, 2017; Welsh et al., 2017), relational
stressors (Cordova et al., 2014), and increased problems in other community contexts
(Coker, Smith, Westphal, Zonana, & McKee, 2014; Kakade et al., 2012). As such, there
is a critical need for clinicians to have a foundational understanding of adolescent
substance abuse in order to effectively work with this population.
Adolescent substance abuse is also inherently a systemic issue. As early as Bateson’s
(1971) work examining the cybernetics of alcoholism, many scholars have highlighted
the role of substance abuse in relationships. Familial processes have been shown to act
as both risk and protective factors, with evidence of a bidirectional relationship between
family variables and adolescent substance abuse (Abar, Jackson, & Wood, 2014).
Further, family‐based substance abuse prevention and interventions have shown to be
effective in preventing and treating adolescent substance abuse (e.g., Horigian,
Anderson, & Szapocznik, 2016; NIDA, 2014b; Tanner‐Smith, Steinka‐Fry, Hensman
Kettrey, & Lipsey, 2016). As such, systemic clinicians can play an active role in the
prevention, intervention, and recovery processes related to this public health issue.
The overarching goal of this chapter is to provide the reader with an overview of
adolescent substance abuse: (a) prevalence and correlates; (b) definition and assess-
ment; (c) review of major approaches to treatment including prevention, interven-
tion, and recovery; (d) policy implications; and (e) future directions for research,
clinical practice, education, and policy. In reviewing these main topics, this chapter
provides the reader with a foundational resource for conceptualizing adolescent
substance abuse systemically, including current practices for prevention and treat-
ment and future directions to advance our theory, research, and practice.
298 Rikki Patton, Jennifer E. Goerke, and Heather Katafiasz
Prevalence and Correlates of Adolescent Substance Abuse
Current issues such as the opioid epidemic in the United States (Hsiao & Walker,
2016; Maxwell, 2015) keep the discussions about substance abuse and addiction on
the front stage of international, national, and local media outlets. Understanding the
prevalence and correlates related to adolescent substance abuse can help clinicians
better conceptualize the context in which adolescents may experience substance use
and abuse.
Prevalence rates of adolescent substance use and abuse in the United States
There are several well‐known US studies that examine prevalence rates of adolescent
substance use, including Monitoring the Future (Johnston et al., 2018), the National
Survey on Drug Use and Health (SAMHSA, 2017), and Centers for Disease Control
High School Youth Risk Behavior Survey (Kann et al., 2018). Findings from these
three national studies highlight the scope of the problem—adolescent substance use
is widespread, a substantial number of adolescents meet criteria for a substance use
disorder (4.4%), and a significant treatment gap still remains (SAMHSA, 2017).
Prevalence rates from these studies can be found in Table 12.1.
Global prevalence rates of adolescent substance use and abuse

International adolescent substance use prevalence rates indicate similar public health
issues. Data collected by the World Health Organization (i.e., the Global School‐based
Student Health Survey; WHO, n.d.) from the African and American regions indicate
that lifetime drug use varies widely (a) across countries and (b) by gender. For instance,
prevalence rates ranged from less than 3% (in Senegal) to as high over 60% (in Uruguay).
Further, while prevalence rates by gender were most oftentimes higher for males than
females, prevalence rates were higher for females in Ghana and Zambia for the African
region and in many of the Caribbean Islands and the metropolitan areas of Chile and
Columbia in the American region (WHO, n.d.). These findings show that adolescent
substance use rates vary widely and that this is a public health concern around the globe.
Correlates of adolescent substance abuse

Extant literature suggests that adolescent substance abuse is correlated to both indi-
vidual and relational variables. Individual correlates include increased physical health
risks and increased mental health issues, and relational correlates include family vari-
ables, peer relationships, and issues within community contexts.
Physical health correlates Adolescents experiencing substance abuse are significantly

more likely to report negative physical health outcomes as compared with other youth
(Christie, Fleming, Lee & Clark, 2018) and are at increased risk for engaging in behav-
iors that can lead to bodily injury or preventable death, such as driving under the influ-
ence (Voas, Johnson, & Miller, 2013) or overdose (Kinner et al., 2015). There is also
a higher correlation between adolescent substance abuse and risky sexual behaviors,
thereby increasing adolescent’s risk of contracting a sexually transmitted infection
Systemic Approaches to Adolescent Substance Abuse 299
Table 12.1 Data summaries from US studies on adolescent substance use.
2017 Monitoring 2016 National Survey on 2017 Youth Risk

the Futurea Drug Use and Healthb Behavior Surveyc
8th, 10th, and

Study demographic 12th grade Age 12–17 9th to 12th grade
Prevalence type Lifetime Past month Lifetime
Tobacco—cigarettes 17.0 3.4 28.9

Tobacco—electronic/ 28.2 n/a 42.2
vaping
Tobacco—smokeless 8.7 1.4 5.5
Tobacco—cigars/cigarillos n/a 1.8 n/a
Alcohol 41.7 9.2 60.4
Any illicit substance 33.4 7.9 n/a
Marijuana 29.3 6.5 35.6
Hallucinogens 4.2 0.5 6.6
Cocaine 2.5 0.1 4.8
Stimulant n/a 0.4 n/a
Heroin 0.6 >0.1 1.7
Nonmedical use of n/a 1.0 14.0
prescription pain
relievers
Ecstasy n/a n/a 4.0
Amphetamines/meth 7.7 >0.1 2.5
Tranquilizers 5.6 0.5 n/a
Steroids (no prescription) 1.2 n/a 2.9
Inhalants 6.7 0.6 6.2
Note. This table was completely developed by the authors specifically for this chapter using the following
sources:
a
Johnston et al. (2018)
b
SAMHSA (2017)
c
Kann et al. (2018).
Reproduced with permission of Jennifer Goerke
(Thamotharan, Grabowski, Stefano, & Fields, 2015), HIV (Bonar et al., 2016), or
unintended pregnancy (Salas‐Wright, Vaughn, Ugalde, & Todic, 2015).
Adolescent substance abuse has also been linked to brain development. In a com-
prehensive review of magnetic resonance studies on adolescent substance abuse,
Silveri, Dager, Cohen‐Gilbert, and Sneider (2016) found that 63% of studies reported
a link between substance use and changes in the frontal lobe. Prior research has also
suggested certain cannabis use patterns across adolescence may impact both mood
regulation and academic attainment during emerging adulthood due to changes in
reward circuit in the brain (Lichenstein, Musselman, Shaw, Sitnick, & Forbes, 2017).
Mental health correlates Findings from the 2016 National Survey on Drug Use and
Health study indicated youth who experienced a major depressive episode in the past
year were at higher risk of illicit drug use (10.8% with diagnosis vs. 3.2% without),
with a total of 1.4% of adolescents reporting co‐occurring major depressive episode
and substance use disorder (SAMHSA, 2017). Other community samples have also
indicated that adolescents who struggle with their emotional health are at greater risk
for substance use (Fettes, Aarons, & Green, 2013), and there is some evidence to sug-
gest linkages between specific drugs of choice and mental health diagnoses in youth.
For instance, Welsh et al. (2017) found specific linkages between anxiety‐related dis-
orders and opioid use, PTSD and cocaine, and externalizing disorders and
marijuana.
Family correlates Numerous studies have reported a link between adolescent sub-
stance abuse and family processes, including (but not limited to) parental monitor-
ing (Pereyra & Bean, 2017), family structure and transgenerational processes
(McCutcheon et al., 2018), and family functioning and communication patterns
(Cordova et al., 2014). Several studies have indicated that parental monitoring may
be one of the strongest protective factors (Pereyra & Bean, 2017). However, other
studies have also indicated that parental monitoring is less protective if combined
with lower levels of parental warmth (Donaldson, Nakawaki, & Crano, 2015) and
that its effectiveness needs to be considered within the context of other influences,
such as the youth’s own perspective of substance use, peer influences, community
influences, and both acceptability and availability of the drug (Trapl, Yoder, Frank,
Borawski, & Sattar, 2016).
Peer and community correlates Prior evidence suggests that both deviant peer asso-
ciations and certain dating dynamics are positively related to adolescent substance
abuse (Van Ryzin & Dishion, 2014). For instance, findings from several studies indi-
cate that youth who experience teen dating violence victimization and/or perpetra-
tion are more likely to report alcohol use and/or use of tobacco products, nonmedical
use of prescription drugs, and illicit drugs including marijuana, as compared with
other youth (Haynie et al., 2013). Previous research has also shown a strong correla-
tion between adolescent substance abuse and issues in the community. For instance,
youth involved in the child welfare system are significantly more likely to engage in
substance use as compared with youth in the community (Fettes et al., 2013), and
adolescents involved in risky substance use are also more likely to be involved in the
legal system as compared with their non‐using counterparts (Coker et al., 2014;
Kakade et al., 2012). Additional neighborhood‐level variables were also linked to
increased substance use, including proximity to crime (Mason & Mennis, 2010) and
perceived neighborhood risk (Andreas & Watson, 2016). In contrast, some commu-
nity variables, such as school involvement (King, Merianos, Vidourek, & Oluwoye,
2017), have been shown to act as protective factors.
Adolescent Substance Abuse Assessment
There are multiple tools for conceptualizing adolescent substance abuse, including
the major conceptual frameworks (e.g., the disease model), primary diagnostic tools
(e.g., the DSM‐5 and ICD‐10), and common assessment frameworks. In addition to
these main tools, though, a systemic approach of adolescent substance abuse should
also be considered.
The Disease Model

The disease model is a dominant framework for conceptualizing substance abuse and
is strongly endorsed by both the National Institute on Drug Abuse (see NIDA,
2015a) and the American Society of Addiction Medicine (2011). This model chal-
lenges more antiquated frameworks, such as the moral model (Fisher & Harrison,
2012), and a vast amount of research has been conducted over the past two decades
to support the tenets behind this model (Volkow & Koob, 2015; Volkow, Koob, &
McLellan, 2016). There have been some recent challenges to the validity of the dis-
ease model, with some scholars suggesting the disease model has not significantly
benefited the development of effective treatment models (Hall, Carter, & Forlini,
2015). Nevertheless, the disease model continues to be a dominant framework in the
addiction field.
Through the disease model lens, addiction is defined by the presence of changes in
brain physiology, thereby modifying brain functioning and related behavioral out-
comes (Fisher & Harrison, 2012). The disease model defines addiction as a disease
and suggests that, as such, addiction is treatable (not curable) and should be
approached similarly to other chronic diseases like diabetes or high blood pressure
(McLellan, Lewis, O’brien, & Kleber, 2000). Thus, there is a wide range in the sever-
ity of addiction, and both treatment retention and integrated care are key to treat-
ment success (Fisher & Harrison, 2012).
Despite the popularity of the disease model in addiction work, there is scant research
explicitly examining the disease model of adolescent substance abuse. One disserta-
tion was found that examined adolescent substance abusers’ beliefs in addiction as a
disease, with findings that adolescents who reported belief in the disease model
obtained more sober days as compared with their counterparts. These findings implied
the importance of tailoring treatment for adolescents based on beliefs in the disease
model or other models of addiction (Brzostek, 2000).
The DSM‐5 and ICD‐10

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‐5)
(American Psychiatric Association, 2013), is the primary tool to guide behavioral
health diagnosis. While the previous version of the DSM differentiated between abuse
and dependence, the DSM‐5 has focused more on severity of diagnosis, as evidenced
by number of criteria met. Eleven criteria are included in the diagnostic framework,
with a minimum threshold of two –to three to meet the diagnostic criteria for a mild
substance use disorder. Despite the wide utility of the DSM‐5 in clinical practice, there
are mixed opinions regarding how the DSM‐5 can be best utilized in diagnosing ado-
lescents. For instance, scholars have suggested that (a) clearer definitions are needed
in the criteria to account for the nuances of lifespan development, (b) some criteria
need to be modified/excluded for adolescents, and (c) more considerations need to
be given to the diagnostic thresholds currently outlined in the DSM (Kaminer &
Winters, 2015).
The International Classification of Diseases and Related Health Problems, Tenth
Revision (ICD‐10) (WHO, 1992), was created by the WHO for diagnostic purposes
among health providers. The ICD‐10 includes F codes that identify the substance being
used and specifiers that identify use patterns and possible co‐occurring symptoms
(WHO, 1992). ICD‐10 codes are required for diagnostic coding and billing purposes,
and, as such, behavioral health clinicians need to be familiar with both the DSM‐5 and
ICD‐10 classifications. As with the DSM‐5, the ICD‐10 codes have not been adapted to
the nuances and uniqueness of adolescent substance abuse.
Approaches to Adolescent Substance Abuse Treatment
In the following section, conceptualizing adolescent substance abuse in treatment will

be discussed, focusing on the ecological and systemic models, as well as the common
principles outlined by NIDA.
Conceptualizing adolescent substance abuse in treatment

Ecological model From an ecological model, it is necessary to consider the role of
addiction at the microsystem, mesosystem, exosystem, and macrosystem levels (Reiter,
2015). Microsystem variables include family, siblings, and peers. Exosystem variables
include larger social system in which the child’s interactions are indirect such as com-
munity, neighborhood, parent’s work environment, and extended family. Macrosystem
variables consist of messages of cultural values, customs, and laws sent to the child
through the other more direct levels such as multigenerational cultural beliefs or tra-
ditions (Bronfenbrenner, 2009). When approaching adolescent substance abuse, it is
important to consider how the adolescent and their behaviors exist within the multi-
ple levels of the ecological model.
Systemic model From a systemic perspective, Reiter (2015) posits that addiction can be
understood as a symptom of underlying dysfunctional processes within the family and
context. It is suggested that substance abuse impacts, and is impacted by, the multiple
systems in which an individual exists (Reiter, 2015), and we need to consider how sub-
stance abuse fits within the context of homeostasis, feedback loops, family structures
like hierarchy and boundaries, values, and other systemic concepts (Stevens & Smith,
2013). Further, several scholars have suggested that families with at least one member
struggling with addiction are likely to take on specific roles (e.g., enabler, hero, scape-
goat, lost child, and mascot), and these rigid roles perpetuate dysfunctional family pro-
cesses (see Reiter, 2015). These frameworks can be applied to conceptualize adolescent
substance abuse, focusing on the adolescent as the identified client in the treatment
approach.
Common principles for adolescent substance abuse treatment

The National Institute on Drug Abuse (NIDA) has outlined 13 principles related to
adolescent substance abuse treatment, which highlights the common factors that
should be considered when working with adolescents struggling with substance
abuse. Table 12.2 highlights NIDA’s 13 principles and their associated implications.
When working with adolescents, it is important for clinicians and scholars to consider
how to integrate these principles into their chosen treatment modality.
Table 12.2 NIDA’s principles of adolescent substance use disorder treatment.
Principles Implications
1 Early intervention Many adults report drug use begins in

adolescence
2 Benefits of early intervention even Reduces risky behaviors
for non‐using adolescents
3 Regular screening in medical Provides additional resources and quicker
settings (primary care, emergency, intervention if substance use is reported
etc.) provides opportunities for
early intervention
4 Role of legal interventions, Adolescents are less likely to seek treatment on
sanctions, and familial pressure their own
5 Tailoring treatment for the Comprehensive assessment to determine
individual individual strengths and needs
6 Treatment from a systemic The whole is greater than the sum of its parts.
standpoint Addressing the biopsychosocial aspects of the
individual
7 Behaviorally focused treatments Strengthens recovery; increases motivation;
have been proven to be effective provides incentives for abstinence; skills
building, problem solving, and improving
interpersonal relationships
8 Involving family and the Strengths family communication and
community relationships. Improves overall support system
9 Integrating substance use disorders Treating substance use and mental health
with other mental health issues concurrently may lead to better outcomes
10 Assess for and identify safety Many adolescents may present with history of
concerns physical, emotional, or sexual abuse
11 Monitoring drug use during Helps to identify triggers associated with relapse.
treatment Assists in adjustment of current treatment plan
to meet individual needs
12 Length of treatment and follow‐ Benefits to address relapse and relapse
up care prevention
13 Testing for sexually transmitted May reduce high‐risk behaviors in the future
diseases and other common diseases
associated with substance use
Note. This table was completely developed by the authors specifically for this chapter using the following
source: NIDA (2014b). Reproduced with permission of Jennifer Goerke
Adolescent Substance Abuse Prevention Programs
The goal of prevention programs is to increase protective factors and reduce risk fac-
tors in youth who are at a higher risk of developing a substance use disorder (NIDA,
2014b). Prevention programs are also aimed to identify and target all classifications of
drug abuse, establish approaches to address drug abuse on a larger societal scale, and
provide an effective treatment tailored to meet the needs of specific audiences or
populations (e.g., gender, age, ethnicity) (NIDA, 2003). The most common preven-
tion programs have been school or family based, although emergent research has
shown the benefits of prevention programs in primary care sites (Harris et al., 2018)
and in using peer educators (Karaca, Akkus, & Sener, 2017).
School‐based prevention efforts

Many of the current evidence‐based approaches to drug abuse prevention have
emerged as part of school‐based prevention efforts (Botvin & Griffin, 2007; Griffin
& Botvin, 2010; NIDA, 2003, 2014b). Typically targeted at the middle school aged
students, these programs aim to prevent or delay the onset of alcohol and drug use
and to reduce the overall prevalence (NIDA, 2003). In most contemporary preven-
tion programs, there is significant focus on educating adolescents on drug refusal
skills, challenging and correcting common expectations or beliefs regarding the prev-
alence of substance use, and improving overall social and personal competence skills
(Botvin & Griffin, 2007; NIDA, 2003).
The Life Skills Training Program is implemented in schools across all 50 states, as well
as in 35 countries around the world (Griffin & Botvin, 2010; NIDA, 2003). Life Skills
Training is manual based and has three core elements in which the material is organized
and taught in a sequential manner: (a) self‐management skills, (b) social skills, and (c) a
drug‐resistance element that highlights resistance skills, health‐related content, and
pro‐health attitudes (Botvin & Griffin, 2014; Griffin & Botvin, 2010). Recent efforts
have shown Life Skills Training can be beneficial in avoiding prescription drug misuse
(NIDA, 2015b), as well as alcohol and other drugs (Botvin & Griffin, 2014).
Family‐based prevention
Prior research shows the benefit of engaging both parents and children in prevention
treatment (e.g., Marsiglia, Ayers, Baldwin‐White, & Booth, 2016). Family‐based pre-
vention programs are designed to (a) improve familial relationships (Kosterman,
Hawkins, Haggerty, Spoth, & Redmond, 2001; NIDA, 2003), (b) teach parents/
guardians effective monitoring and overall parenting strategies (Kosterman et al., 2001),
(c) help families establish and enforce family rules regarding substance use (Kosterman
et al., 2001; Kosterman, Hawkins, Spoth, Haggerty, & Zhu, 1997), (d) improve par-
ent–child communication (Kosterman et al., 1997), and (e) help children develop
prosocial skills and social resistance skills (Lochman & van den Steenhoven, 2002).
Three well‐studied family‐based preventions programs include Family Matters, Creating
Lasting Family Connections, and Strengthening Families. Family Matters was developed to
prevent adolescent alcohol and tobacco use for youth aged 12–14 (Bauman et al., 2002)
and has shown to reduce the onset of cigarette smoking and has been proven beneficial in
reducing self‐reported alcohol use among adolescents (Bauman et al., 2002). Creating
Lasting Family Connections provides a family‐strengthening curriculum that assists in the
prevention and reduction of drug and alcohol use, as well as other negative outcomes by
the promotion of community and family connections as the primary source of protection
(McKiernan, Shamblen, Collins, Strader, & Kokski, 2013). Finally, the Strengthening
Families Program was developed as a prevention intervention for high‐risk youth aged
0–17, with empirical evidence supporting its efficacy (Kumpfer & Magalhães, 2018).
Interventions for Adolescent Substance Abuse
Several intervention models have been shown to be efficacious with substance‐using

adolescents. Behavioral models include aim to help adolescents modify the behavioral
sequences linked to their substance use. Systemic interventions focus on engaging the
adolescent and their systems into the treatment and recovery process.
Behavioral interventions in adolescent substance abuse

Behavioral approaches are designed to assist adolescents toward recovery from sub-
stance abuse while improving their overall abilities to refrain from further substance
abuse by helping adolescents modify their attitudes and behaviors associated with
their substance use/abuse (NIDA, 2014b). This section provides an overview of the
following: (a) Adolescent Community Reinforcement Approach; (b) Cognitive
Behavioral Therapy; (c) contingency management; (d) Motivational Enhancement
Therapy; and (e) Group/Twelve‐Step Facilitation.
Adolescent community reinforcement approach The Adolescent Community

Reinforcement Approach (Godley et al., 2001) is a widely implemented and empiri-
cally validated psychosocial treatment for adolescents and has been shown to maintain
high retention rates across gender and ethnic groups. The aim of the Adolescent
Community Reinforcement Approach is to assist adolescents in achieving and main-
taining abstinence from substances by replacing these prior contingencies with proso-
cial activities and behaviors (Godley et al., 2001, 2017). Adolescent Community
Reinforcement Approach relies on behavioral interventions to challenge prior envi-
ronmental contingencies that previously supported the adolescent’s substance‐using
behaviors (Godley et al., 2001, 2017). This has a strong systemic influence by includ-
ing a multidimensional and integrative approach that brings together family, peers,
education, employers, community organization, and prosocial extracurricular activi-
ties throughout the process of treatment.
Cognitive Behavioral Therapy (CBT) Cognitive Behavioral Therapy is a psychothera-

peutic approach emphasizing the connection between thoughts, feelings, and behav-
iors (Beck, Wright, Newman, & Liese, 1993; Fisher, 2014). Evidence supports it
effectiveness in the treating adolescents struggling with substance abuse (Tanner‐Smith
et al., 2016). When adolescents enter treatment, they are often struggling with feelings
of fearfulness, depression, anxiety, and difficulty managing their moods (Fisher, 2014).
In utilizing a Cognitive Behavioral Therapy approach, substance‐abusing adolescents
are taught ways to recognize their thoughts and feelings, manage negative cognitive
schemas and feelings, and identify triggers associated with their substance abuse (Beck
et al., 1993; Fisher, 2014). Cognitive Behavioral Therapy utilizes behavioral strategies
and techniques to enhance treatment outcomes related to the adolescent’s insight into
high‐risk situations likely to lead to substance abuse, enhanced self‐control skills,
improved anger management and emotional regulation, and substance refusal skills
(Beck et al., 1993; Fisher, 2014).
Contingency management Contingency management posits that systematic rein-

forcement of desired behaviors, and concurrent ignoring or punishment of undesired
behaviors, is effective in the overall treatment of substance abuse (Higgins & Petry,
1999). Contingency management interventions are backed with extensive amounts of
clinical research demonstrating its effectiveness with adults (Killeen, McRae‐Clark,
Waldrop, Upadhyaya, & Brady, 2012), and the growing literature highlights its effec-
tiveness with adolescents (Killeen et al., 2012; Stanger & Budney, 2010; Stanger,
Budney, Kamon, & Thostensen, 2009). When using contingency management with
adolescents, the primary goal includes supplementing prior reinforcement with
healthier and more prosocial activities through incentives (Stanger & Budney, 2010;
Stanger et al., 2009).
Contingency management is not originally conceptualized to function systemically.

However, contingency management is commonly found in a variety of settings and
encourages parents to be involved in the adolescent’s treatment (Stanger & Budney,
2010). By including parents, the adolescent and their parents may learn new ways to
implement these reinforcements at home. Furthermore, when contingency manage-
ment procedures are paired with additional psychosocial interventions, retention rates
in treatment and abstinence rates are likely to increase (Carroll et al., 2006; Stanger
et al., 2009).
Motivational Enhancement Therapy Motivational Enhancement Therapy (Miller,

Zweben, DiClemente, & Rychtarik, 1999) is grounded in motivational interviewing
and is designed to assist substance‐abusing individuals in resolving their ambivalence
about treatment and change (Miller et al., 1999). Several studies have shown its effi-
cacy in treating substance use among adolescents in the general population and among
marginalized adolescent groups (e.g., Slesnick, Guo, Brakenhoff, & Bantchevska,
2015; Tanner‐Smith et al., 2016). Extant literature has explicitly discussed the inter-
section of Motivational Enhancement Therapy principles and family systems.
Specifically, Steinglass (2009) provided a discussion of his work with the Ackerman
Institute’s Center for Substance Abuse and the Family, where they are combining
main components of family systems therapy with motivational interviewing, referred
to as systemic‐motivational therapy. Steinglass (2009) argued that such integration
between these models and family systems can be as effective when applied to a familial
context or system.
Group/Twelve‐Step Facilitation Twelve‐Step Facilitation assists substance‐using

individuals to become connected with self‐help groups such as Alcoholics Anonymous
(AA) or Narcotics Anonymous (NA) (Kelly et al., 2016). Twelve‐Step Facilitation
Therapy has three main notions: acceptance, surrender, and active involvement in
Twelve‐Step programs. The primary goal for Twelve‐Step Facilitation is to improve
outcomes of substance‐abusing populations and promote abstinence (Kelly et al.,
2016). Clinicians can benefit from understanding how Twelve‐Step concepts are
applied and the potential benefits they have with clients; by educating themselves,
the therapist can integrate the concepts from Twelve‐Step meetings into their
treatments.
Systemic interventions for adolescent substance abuse

Engaging the family, parents, siblings, and/or peers in an adolescent’s treatment is
the foundation for family‐based approaches in the treatment of adolescent substance
abuse (NIDA, 2014b). These approaches are systemic in nature and focus on treat-
ment within a relational context versus the individual focus of most behaviorally
focused approaches discussed above (Hogue & Liddle, 2009). General goals for fam-
ily‐based treatment approaches include teaching effective communication, conflict
resolution skills, and coping with any potential co‐occurring diagnosis (Hogue &
Liddle, 2009). Furthermore, family‐based approaches treat the adolescent’s substance
abuse from a larger systemic perspective by assisting them in exploring issues related
to school, work, and social or peer support. Research has consistently shown the
approaches reviewed below to be effective at treating adolescent substance abuse.
Brief strategic family therapy Brief Strategic Family Therapy (Szapocznik et al.,
1988) is an empirically validated family‐based intervention aimed at treating adoles-
cents’ problem behaviors within a family context. The model is grounded in structural
and strategic theories and is designed to take a short‐term, structured, and problem‐
focused approach on addressing adolescent problematic behaviors, substance abuse,
and concomitant maladaptive familial interactional patterns (Szapocznik, Zarate,
Duff, & Muir, 2013). Much of the research on this model has shown its effectiveness
at improving overall family involvement and in treatment retention for adolescents
who enter substance abuse treatment (Szapocznik, Hervis, & Schwartz, 2003).
Additionally, prior research has shown that adolescents who received this model, as
compared to treatment as usual, showed significantly higher improvements, and
research findings related to Brief Strategic Family Therapy have suggested its applica-
bility across racial/ethnic groups (Robbins et al., 2009).
Family behavior therapy A Family Behavior therapist engages families in utilizing

behavioral strategies and skill‐based approaches designed to improve the living envi-
ronment (Donohue & Azrin, 2012; Donohue, Azrin, & Van Hasselt, 2009). This
approach is commonly used with contingency management as one of the main tenants
to assist the individual and their families develop behavioral goals aimed toward sub-
stance use prevention. When working with adolescents, parents are encouraged to set
goals to work toward increasing effective parenting skills. Family Behavior Therapy is
aimed at concurrently addressing both substance abuse problems, as well as co‐occur-
ring problems (Donohue & Azrin, 2012; Donohue et al., 2009).
Functional family therapy Specifically applied to adolescents, Functional Family

Therapy (Alexander, Waldron, Robbins, & Neeb, 2013) views behaviors of adolescents
who abuse substance to be created or maintained by dysfunctional family interactional
patterns. Functional Family Therapy is systemically focused and integrates several other
theories into its theoretical foundations, including communication theories, behavioral
theories, cognitive theories, and social constructionist theories (Hartnett, Carr,
Hamilton, & O’Reilly, 2017; Robbins, Alexander, Turner, & Hollimon, 2016). The
main goal is to improve effective communication, problem‐solving skills, conflict reso-
lution, and parenting skills. When working with substance‐abusing adolescents, this
model uses interactions between the adolescent and at least one family member during
every session (Hartnett et al., 2017). A therapist following Functional Family Therapy
hopes to (a) increase an individual’s motivation for change while also engaging the
family in the treatment process, (b) alter the interactional sequences to function more
effectively, and (c) encourage change throughout the family system with the use of
contingency management techniques, behavioral contracts, communication, and
problem‐solving skills (Robbins et al., 2016).
Multidimensional family therapy Multidimensional Family Therapy (Liddle et al.,

2001) attempts to help the individual and their family gain an understanding of the
substance abuse from a broader, systemic context. The primary goal for this model is
to have all family members engaged in treatment and attempt to identify and over-
come any potential barriers which may be present in the client(s) willingness to
engage in treatment. The therapist makes attempts to help the family recognize the
identified problems among the family system, leading to the adolescent’s substance
abuse. Furthermore, the therapist works to address both the risk and protective fac-
tors and their impact on the family dynamic. Family members and/or caregivers are
strongly encouraged to participate in the formulation of treatment goals and have a
strong influence in treatment (Liddle, 2016).
Multisystemic Therapy (MST) Multisystemic Therapy (Henggeler & Borduin,

1990) is one of the most extensively researched and evaluated family‐based treat-
ments for multiple adolescent problem behaviors, including delinquency, violence,
and substance abuse. Multisystemic Therapy is an integrative approach that incor-
porates Bronfenbrenner’s social ecological model, structural family therapy, strate-
gic family therapy, and general systems theory into its systemic conceptualization
(Randall, Cunningham, & Henggeler, 2017). As such, Multisystemic Therapy
engages an adolescent and their family system in different approaches with a variety
of interventions to mitigate the presenting problem (e.g., adolescent substance
abuse) (Henggeler & Schaeffer, 2016). A primary goal of this model is to reduce
possible risks by improving family strengths and establishing protective factors,
which will reduce the likelihood of a youth engaging in substance use (Henggeler
& Schaeffer, 2016). Research has suggested it is more efficacious at decreasing sub-
stance use and decreasing dropout rates from programs than typical substances use
treatments (Henggeler, Pickrel, & Brondino, 1999).
Comparing systemic models All models discussed are systemic in nature and attempt
to integrate family context into an adolescent’s treatment. Common themes across
each model are reducing risky behaviors and/or substance use and increasing positive
familial interactions. While similar, these models approach treatment differently; Brief
Strategic Family Therapy and Family Behavior Therapy both integrate behavioral
strategies, whereas Brief Strategic Family Therapy, Family Behavior Therapy, and
Functional Family Therapy tend to focus more heavily on increasing family involve-
ment. Further, Multisystemic Therapy and Multidimensional Family Therapy have
goals that focus on identifying and reducing risk/protective factors within the family
context, while Brief Strategic Family Therapy, Functional Family Therapy, and
Multisystemic Therapy all approach treatment from a more integrative standpoint
pulling from many other modalities. It is worth noting that both Brief Strategic
Family Therapy and Multisystemic Therapy tend to be more empirically validated
than the other treatments and show promising results in reducing externalizing
behaviors in adolescents (Henggeler & Schaeffer, 2016; Horigian et al., 2016;
Robbins et al., 2009; Szapocznik et al., 2003). While these two models are more
empirically validated, additional research continues to be done on the efficacy of the
other models. Much of the empirical research across treatment modalities listed in this
section has been found to be efficacious across ages, gender, and ethnicity in the treat-
ment of adolescent substance use. However, additional research is still needed on
applicability and generalizability for each model with specific populations.
Recovery/relapse prevention for adolescent substance abuse

While there is a plethora of empirical work examining treatment outcomes for adoles-
cent substance abuse, less attention has been paid specifically to recovery and relapse
prevention for adolescents. This may be, in part, that the recovery process has been
discussed more within the context of intervention in recent literature. Regarding
relapse prevention broadly speaking, most models of relapse prevention are grounded
in social cognitive or behavioral approaches, such as Marlatt and Gordon’s (1985)
relapse prevention model, and focus on the integration of both cognitive and behavio-
ral adjustments in the individual to achieve and maintain their recovery (Fisher, 2014).
Relapses are believed to occur due to multiple factors relating to poor self‐efficacy,
poor motivation, lack of coping, negative mental states, uncontrolled cravings, and
interpersonal factors (Fisher, 2014). The main goals for relapse prevention programs
include altering old behaviors that led to initial substance abuse, learning new coping
strategies, learning to assess and proactively react in high‐risk situations associated
with a potential relapse, improving self‐efficacy, and educating people on knowing
when and where to seek help (Fisher, 2014; Fisher & Harrison, 2012). Since relapse
is relatively common, it is essential that adolescents in a relapse prevention program
are educated to accurately identify their warning signs (Fisher, 2014). Viewing relapse
prevention from a systemic perspective can be helpful in conceptualizing the multiple
areas of a person’s life that could become a trigger to relapse (Todd & Selekman,
1991). Establishing and maintaining a positive support system is essential where fam-
ily members, positive peer groups such as Twelve‐Step groups, school officials/staff,
and mental health providers are actively involved with the individual (Fisher, 2014;
Fisher & Harrison, 2012).
Treatment settings for adolescent substance abuse

Treatment settings for adolescent substance abuse include outpatient/intensive out-
patient, partial hospitalization, or residential/inpatient treatment (NIDA, 2014b).
Each level of treatment provides a unique and tailored treatment approach to fit the
individual needs of every adolescent. Outpatient/intensive outpatient can be highly
effective in treatment of less severe problems (NIDA, 2014b; Tanner‐Smith et al.,
2016). Many outpatient programs are offered once or twice a week, such as group or
individual therapy, and offered, along with drug abuse prevention programs, behav-
ioral or family‐based interventions (NIDA, 2014b; Tanner‐Smith et al., 2016). Partial
hospitalization treatment is for more severe substance use and ranges from 4 to 5 days
per week for up to 4–6 hr per day (NIDA, 2014b). Residential/inpatient treatment,
the most intense of all treatment, requires 24‐hr care in supervised and structured
environment (NIDA, 2014b). Residential treatment is more comprehensive in nature
to address both mental and medical needs, as well as any additional barriers to their
success in treatment (NIDA, 2014b).
Policy implications for systemic interventions of adolescent substance abuse

As we consider systemic interventions of adolescent substance abuse, we must consider
the policy implications regarding the integration of these interventions. This section
will cover policy considerations with regard to ethical and legal issues (confidentiality),
clinical practice (training model, costs, polices surrounding integrated care, scope of
practice), research (consent, confidentiality), and special populations (homeless, juve-
nile justice).
Ethics/legal and policy

Consent and confidentiality are two interrelated ethical policy considerations in the
treatment of adolescent substance abuse. Specifically, while parents must consent for
treatment, some states allow minors to consent for sessions without parental consent,
often within a specific time frame or for a specified number of sessions. Clinicians
must consider whether they are willing to take on adolescents as clients when they are
unwilling or unable to obtain parental consent (Center for Substance Abuse Treatment,
1999; NIDA, 2014b). Further, when adolescents are compelled to participate in
treatment by parents, research suggests that the therapeutic relationship between the
adolescent and the therapist is stronger if the adolescent believes they have a role in
the consent process (Roemer, 2015).
Regardless of whether minors legally can consent to treatment, additional layers of
consent must be obtained from minors to release information regarding substance
abuse treatment to third parties, including family members (e‐CFR, 2019; Center for
Substance Abuse Treatment, 1999), due to the federal regulation “Confidentiality of
Substance Use Disorder Patient Records” (e‐CFR, 2019; Center for Substance Abuse
Treatment, 1999). This refers to the strict confidentiality laws that cover substance
abuse treatment for those agencies that receive (directly or indirectly) federal funding.
This can make systemic therapy challenging, as the systemic therapist may have knowl-
edge of substance abuse treatment that they are unable to disclose/discuss during
family therapy sessions. It should be noted that mandated reporting and duty to
warn/protect still supersede the federal confidentiality law.
Clinical training and practice

Clinical policy considerations focus centrally on the different theoretical underpin-
nings of these two treatment modalities, substance abuse treatment and systemic
therapy, as well as the costs associated with integrating them in adolescent substance
abuse treatment. Firstly, substance abuse treatment and systemic therapy have vastly
different conceptual frameworks, with substance abuse treatment traditionally operat-
ing from an individualist perspective, with the goal to decrease substance use.
Contrarily, systemic therapy focuses on the system as a whole, with the goal often to
improve the communication and relationships between members of the system. While
effective in their own right, these two therapeutic modalities may not integrate well
when engaging the adolescent and their families in substance abuse treatment (Center
for Substance Abuse Treatment, 2004). It will be important to determine when each
modality is appropriate, as family therapy may not be appropriate for every adolescent
experiencing substance abuse and vice versa.
Further, while it is recommended that families be involved in every step of the treat-
ment process, fiscal resources of agencies must be taken into consideration, as that
may be prohibitive of creating an integrated family therapy and substance use treat-
ment model (Center for Substance Abuse Treatment, 2004). Family factors must be
considered as well in determining the appropriateness of family involvement. For
instance, family therapy is predicated on the assumption that all family members must
be willing and able to participate in therapy. Therefore, contextual factors may con-
traindicate family participation in therapy, such as families characterized by extreme
instability or conflict, as well as when physical or sexual abuse or domestic violence is

present (Center for Substance Abuse Treatment, 1999).
Additional clinical policy considerations relate to the costs of implementation of
systemic interventions and adolescent substance abuse. Specifically, substance abuse
treatment training and systemic therapy training exist in vastly different training pro-
grams. For instance, neither the Commission on Accreditation for Marriage and
Family Therapy Education (COAMFTE, 2017) nor the National Addiction Studies
Accreditation Commission specifically requires courses on substance use as part of the
curriculum, although both accrediting bodies allow for the inclusion of those topics.
Moreover, while the Council for Accreditation Counseling and Related Education
Programs (CACREP, 2015) has both addiction counseling and marriage, couple, and
family counseling specialization tracks within its curriculum, those curricular tracks do
not often overlap within education programs. Due to the lack of educational oppor-
tunities within bachelors or masters educational programs, training in either family
therapy or substance use counseling, whichever is lacking, should occur postgraduate
or through on‐the‐job training. Therefore, family treatment programs need to pro-
vide staff with adequate education on substance abuse treatment, and substance abuse
treatment programs need to provide staff with adequate education on family therapy
options, both which may be costly to a given agency (Center for Substance Abuse
Treatment, 2004).
Another related policy concern is with regard to reimbursement of services. Family
therapy is often reimbursed at a lesser rate, if at all, by insurance companies. Further,
if the “identified patient” (i.e., the adolescent abusing substances) does not want to
participate in family therapy, treatment programs must consider whether the family
can still engage in systemic interventions and, if so, how those services would be paid
for (Center for Substance Abuse Treatment, 2004).
Research
Within adolescent substance abuse research, just as with treatment, consent and con-
fidentiality are primary issues (Lambert, 2011). Youth who participate in research are
unable to give consent, but they can provide assent, which is the ability to agree to the
research (NIDA, 2012). Researchers often must choose between attempting to obtain
passive or active consent from caregivers for the youth to participate in the research
(Kerr & Oglesby, 2017). Both types of consent come with strengths and drawbacks,
with passive consent typically yielding higher rates of participants since parents only
sign a form if they do not want the youth to participate in research; however, this
practice is often considered having questionable ethics because parents may not know
or be fully informed as to what they are consenting. Active consent is much more ethi-
cally rigorous; however, the participant numbers are typically lower as caregivers must
sign consent for the youth to participate (Kerr & Oglesby, 2017). Additionally, under
certain circumstances, when either consent from caregiver or assent from the youth
cannot be reasonably obtained, researchers can request a consent or assent waiver as
part of their human subjects application (NIDA, 2012).
Similar to clinical practice, substance abuse research involving adolescents must
follow federal confidentiality laws related to the confidentiality of patient records
involving substance use treatment (NIDA, 2012). To ensure the confidentiality of
participants, especially when participants are engaging in illegal behaviors such as

substance use, researchers can obtain a certificate of confidentiality to prevent anyone
from compelling identifying information regarding participants (NIDA, 2012).
Considerations for special populations

Juvenile justice system When working with adolescents in the juvenile justice system,
clinicians must be aware that the rates of abuse, neglect, family dysfunction/violence,
and community violence are much more prevalent than non‐incarcerated populations
(Center for Substance Abuse Treatment, 1999). These clinical issues must be tackled
in conjunction with the substance use. Recommendations follow that the youth
should be assessed for mental health and other problem areas comorbid to substance
use at entrance into a facility and then at different intervals thereafter, to verify the
accuracy of the information, as youth may still be intoxicated/withdrawing from sub-
stances when initially incarcerated. Special care should be taken to ensure the youth’s
feeling of safety when assessing; therefore, assessment should be conducted in private
locations (Center for Substance Abuse Treatment, 1999).
Runaway/throwaway youth It is difficult to engage runaway or throwaway youth

(youth who have been forced to leave home or prevented from returning to their
home by their caregiver) in treatment (Kerr & Oglesby, 2017). Similar to the juvenile
justice population, the rates of abuse and neglect, as well as exposure to family and
community violence, are very high with this population (Center for Substance Abuse
Treatment, 1999; Kerr & Oglesby, 2017). Several additional considerations arise.
Trust is primary with this population and it may take multiple contacts to engage a
youth (Center for Substance Abuse Treatment, 1999). The next consideration is con-
sent, as typically minors require caregiver consent for treatment; however, requesting
consent from a caregiver may result in a safety risk to the youth or may deter the youth
from engaging in treatment due to the family issues that caused them to leave home
(Kerr & Oglesby, 2017).
LGBT youth Substance use prevalence rates are higher in LGBT youth, with estimates
as high as three times that of heterosexual peers (Goldbach, Tanner‐Smith, Bagwell, &
Dunlap, 2014). LGBT youth and adults experience marginalization and discrimination,
contributing to the ongoing barriers in access to health care (Russett, 2016). The stigma
experienced by having a substance use issue is compounded by their sexual minority
status (Russett, 2016). While the education of counselors with regard to the unique
needs of the LGBT population is expanding, a significant barrier to obtaining coun-
seling for LGBT youth includes the lack of education of counselors and the lack of
access to LGBT affirmative substance use treatment facilities (Goldbach et al., 2014;
Russett, 2016). Additionally, there are scant substance use assessment measures availa-
ble that utilize inclusive terminology, creating further barriers to assessment and
treatment.
Several risk factors have been identified for increased use of substances within
LGBT youth that should be addressed by counselors working with this population.
First, LGBT youth experience increased psychological stress within the coming out
process, of which a positive relationship has been found between substance use and
the length of time the coming out process (Goldbach et al., 2014). These youth need
support during this difficult transition time. During that process, family and peer
rejections are particularly impactful, although negative disclosure experiences in gen-
eral are linked to substance use (Goldbach et al., 2014). Additionally, many LGBT
youth experience victimization directly related to sexual minority status (Goldbach
et al., 2014). As such, counselors should take a trauma‐informed approach to treat-
ment when working these youth. Lastly, internalizing and externalizing problem
behaviors has been linked to substance use within LGBT youth (Goldbach et al.,
2014). Consequently, counselors should prioritize identifying alternative prosocial
resources for coping. Research has shown that access to an affirmative school environ-
ment (Coulter et al., 2016) and gay–straight alliances within the school (Heck et al.,
2014) can provide a supportive and protective environment for these youth.
Future Directions for Research, Clinical Practice,

Education, and Policy
Research has shown that adolescent substance abuse is multifaceted, with adolescents
experiencing cognitive, emotional, and physiological changes during this important
transitional period of their lives. Therefore, the interventions must also be multifac-
eted. Systemic interventions have the capability to engage with multiple communities
of interest for the adolescent including caregivers, teachers, and medical and mental
health providers to address this complex problem from multiple pathways. While
research has identified several systemic based treatment programs that are effective
with adolescent substance abuse, there are still additional future directions that need
to be addressed in the systemic prevention, treatment, and relapse prevention of ado-
lescent substance abuse, including additional systemic prevention programs, addi-
tional considerations regarding the lifespan development, and additional research and
clinical considerations of the impact of brain development.
The prevention programs cited above are the most commonly utilized prevention
programs for youth adolescent substance abuse; however, the majority of these pro-
grams target the youth within a singular context. The issue with this is that, as NIDA
(2014b) notes, treatment should be systemic. This can be applied to prevention as
well, in that it should be systemically focused. A multifaceted and systemic approach
to prevention, including peer, community, schools, and families, may be more suc-
cessful in preventing adolescent substance abuse before experimentation even begins.
Relatedly, when adolescents engage in substance use treatment programs, they are
often disconnected from their home and community, which contains all of the trig-
gers and temptations that were present prior to treatment and that likely led to a slip-
pery slope of experimentation and addiction. NIDA notes that aftercare programs
should be utilized for continuity of care, but there are few relapse prevention pro-
grams, and, of those, programs are not systemically focused. It is important for youth
to have relapse prevention programs that will gather the resources of those supporting
them, including caregivers, teachers, peers, and so forth, to help youth be successful
in preventing or recovering from relapse.
The adolescent brain has been likened to a car with a well‐functioning gas pedal but
failing breaks (NIDA, 2014b). The unique considerations regarding adolescent brain
development and the lifespan development challenges that occur during this phase of
life must be considered when engaging adolescents in treatment. More research is

needed on how substance use impacts adolescent brain development, the genetic link-
ages that impact addiction in general, and how this research can impact policy and
intervention planning. The impact of substance use on adolescent brain development
is currently under emphasized as part of treatment, but a systemic approach that
includes medical, as well as mental health professions (and teachers and caregivers),
can incorporate this biological component into treatment. Relatedly, when consider-
ing diagnoses, adolescents are diagnosed under the same criteria as adults, despite
their brain and lifespan development being vastly different than their adult counter-
parts. This should be examined further to consider if modifying diagnostic criteria for
adolescents is warranted. Overall, though, it is evident that adolescent substance
abuse is a complicated and systemic issue, one in which systemic thinkers can play an
important role in helping adolescents and their families navigate and heal.
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13
Somatization and Disease
Exacerbation in Childhood
Systemic Theory, Research, and Practice
Sarah B. Woods
Family members’ reactions to life challenges and stress do not always present as anxi-
ety, depression, or relational conflict. Sometimes, instead, reactions to stress show up
as physical symptoms. These physical symptoms exist at the interface of mind and
body; they represent a somatic language that functions to express emotional distress
(McDaniel, Doherty, & Hepworth, 2014). For children and adolescents who are in
critical stages of emotion and language development, expressing stress reactivity as
medically unexplained symptoms may be especially likely. When these physical symp-
toms occur and cannot be fully explained by developing of biological origin, it can be
problematic for the child, for their family, and for their broader community. Given the
prevalence of somatic symptoms in pediatric populations, the influence of family rela-
tionships on the etiology and persistence of these symptoms, and the impact of soma-
tization on social networks within which these families are embedded, a systemic
biopsychosocial approach to understanding and intervening is critical.
The Scope of Somatization

Somatic symptoms are defined as physical symptoms that are not otherwise (fully)
explained by organic origin nor a physical health problem (Garralda & Rask, 2015;
van Gils, Janssens, & Rosmalen, 2014). Somatization ranges from mild somatic symp-
toms that may require little or no health‐care intervention to somatic symptom disor-
ders, which include at least 6 months of symptoms that are distressing (with excessive
reactions to the symptoms, themselves) and which affect an individual’s functioning
(American Psychiatric Association [APA], 2013a). The category of somatic symptom
disorders (formerly, somatoform disorders) underwent multiple changes during the
APA’s (2013b) update to the Diagnostic and Statistical Manual of Mental Disorders
(DSM‐5; APA, 2013a). Specifically, the diagnostic definition (criteria specified for
adults, only; Cottrell, 2016) encapsulates what was formerly known as hypochondria-
sis, pain disorder, somatization disorder, and undifferentiated somatoform disorder
322 Sarah B. Woods
(APA, 2013b). Similarly, the World Health Organization is recommending changes to

the somatoform section of the International Classification of Diseases and is propos-
ing a new category of bodily distress disorder, in part to clarify boundaries between
types of somatoform disorders and improve the feasibility and specificity of diagnosis
(Gureje, 2015; Gureje & Reed, 2016). Children and families presenting with somati-
zation may not express psychological distress with psychological or emotional lan-
guage, instead using somatic language to describe concerns (McDaniel et al., 2014).
Although there has been a shift in diagnostically characterizing somatic symptoms,
emotions expressed physically may be especially challenging to recognize as they may
co‐occur with other mental or physical health concerns. Somatic symptoms may also
present as an exacerbation of already existing chronic conditions or function as a path-
way to future disease development. Therefore, similar to Minuchin et al. (1975), this
chapter will describe both primary and secondary somatic symptomatology, including
somatic symptoms that reflect a psychosocial intensification of a physiological disor-
der that is already present (primary) or that occur as a result of emotional distress and
without an underlying illness (secondary).
For child and adolescent family members, examples of somatic symptoms include
abdominal pain/gastrointestinal issues, headaches, fatigue, difficulties with breathing,
problems with sleep, and neurological issues (Cottrell, 2016), and the complexity of
the presentation may grow with age (Hulgaard, Dehlholm‐Lambertsen, & Rask,
2017). Classic examples of somatic presentations in family therapy include enuresis
(Protinsky & Dillard, 1983; Selig, 1982), encopresis (or, “sneaky poo”; White, 1984),
Crohn’s disease/ulcerative colitis (Wood et al., 1989), and eating disorders (Minuchin,
Rosman, & Baker, 1978). In addition, exacerbations of chronic conditions and poorly
controlled symptoms may reflect somatizing in children and adolescents, including in
asthma and diabetes (Carr, 2014).
Given the frequency with which somatization occurs, and the medical care these
physical symptoms imply, somatizing behavior has long been described as the most
common disorder seen in primary care (Kroenke et al., 1997; Malas, Ortiz‐Aguayo,
Giles, & Ibeziako, 2017). When these symptoms are present in pediatric patients,
parents and physicians understandably often fixate on medical intervention in an
attempt to label the unknown physiological issue and prevent worse outcomes. This
results in a higher rate of office visits and medical tests, greater health‐care costs,
thicker medical charts, and more medical diagnoses (McDaniel, Campbell, Hepworth,
& Lorenz, 2005). The endless loop of attempts at diagnosis, failed interventions, little
symptom relief, and repeated health‐care visits creates frustration for patients, fami-
lies, and their medical providers. Further, the clinical challenges of somatic symptoms
(especially when multiple symptoms present simultaneously) can result in worse
patient–provider relationships, which therefore impacts the care received by these
patients and their families (Epstein et al., 2006).
Cultural factors impacting problem definition

The mind–body split reflected in somatization is ingrained in Westernized cultures.
Specifically, it is the prevailing belief that physical problems have organic origins and
emotional problems have psychological origins. This belief is often reflected in a fam-
ily’s own beliefs about health and illness, which is then reinforced by the dichotomiz-
ing cultural context, including the modern medical system. For families originating or
Childhood Somatization 323
existing in non‐Westernized cultures, the idea of emotional problems expressed

physically may not be abnormal nor distressing. However, if these families are contex-
tually embedded in a Western culture and encounter teachers or health‐care providers
concerned about a child’s symptoms, they may face a cultural mismatch that perpetu-
ates the pathologizing of their child’s experience.
Secondarily, McDaniel et al. (2014) highlight the cultural schism between indi-
vidual responsibility and illness type. Western culture places responsibility for emo-
tional problems with the individual, holding the patient accountable for mental
illness. Conversely, this same culture believes individuals are not responsible for a
physical disease. McDaniel et al. highlight how this prevailing ideology reinforces the
development and maintenance of somatic symptoms, for which the patient (and their
family) is presumably held innocent and is therefore dependent on their health‐care
provider. A biopsychosocial approach to conceptualizing and treating a child’s somatic
symptoms is therefore required to counter the cultural modus operandi of separating
the mind from the body, and the patient from the larger systems within which they
are embedded.
Biobehavioral continuum of disease

A biopsychosocial approach to conceptualizing somatization can be an effective anti-
dote to medicalized or pathologized views (McDaniel et al., 2014). Especially helpful
may be the utilization of a biobehavioral continuum of disease (see Figure 13.1).
Wood et al. (2000), influenced by the work of Engel (1977) and Minuchin et al.
(1978), highlight that all illnesses have both biological and psychosocial influences,
levels of which vary across a spectrum ranging from functional abdominal pain to
congenital heart disease, examples provided of physically manifested disease. Somatic
Biobehavioral continuum of disease

Psychologically manifested disease
Anorexia Depression Bipolar

nervosa affective disorder
Psychosocial
influence
Biological
influence
Functional Asthma Congenital

abdominal pain heart disease
Physically manifested disease
Figure 13.1 Biobehavioral continuum of disease. Wood, Klebba, and Miller (2000).
Reprinted with permission from John Wiley & Sons, Ltd.
324 Sarah B. Woods
symptoms are most clearly reflected on the bottom left‐hand portion of this figure
(i.e., physically manifested disease with large psychosocial influence) but may occur
across this continuum, alone or in the context of other medically explained symptoms
and chronic conditions. The authors also highlight how, given the biopsychosocial
range of all illness, family process has the ability to impact (buffer against or potenti-
ate) the contribution of psychosocial factors involved in symptom presentation.
Further, this continuum combats a culturally prevailing perspective of a mind–body
dichotomy, which emphasizes the biological origins of physical symptoms and psy-
chological origins of emotional symptoms (McDaniel et al., 2014).
Family relationships & somatic symptoms

Family process and life events across the family life course have evident impacts on the
development and maintenance of somatic symptoms. Family factors impacting soma-
tization in children and adolescents include family emotional climate, parental emo-
tion regulation, traumatic family events, and family illness beliefs (Hulgaard, 2020,
vol. 4; Hulgaard et al., 2017; Kehoe, Havighurst, & Harley, 2014). In addition, chil-
dren of parents who exhibit somatic symptoms or health anxiety may be more likely
to report their own somatic symptoms or health anxiety (Schulte & Petermann,
2011a, 2011b; Wright, Reiser, & Delparte, 2017).
Family emotional climate A negative family environment, characterized by hostility,

conflict, or disengagement, may be an especially powerful predictor of children’s
somatization. This context represents a continuous bathing in psychosocial stress,
which for children and adolescents (family members with less power to effect change
and for whom it may be unsafe to name their distress) may be an intense priming for
expressing reactivity to this family stress with physical symptoms. Negativity in the
family may range from child neglect and abuse to criticism and parental conflict, all
of which is likely to be experienced as stressful for children. A particularly strong
example includes recent twin research finding that parental criticism is a specific
environmental (rather than genetic) effect directly impacting adolescent develop-
ment of somatic symptoms (Horwitz et al., 2015). The impact of parent–child inter-
actions (rather than shared genetic influence) on internalizing problems in adolescence
has been further supported by Hannigan et al. (2018). Further, worse family func-
tioning, including greater conflict and less cohesion, is associated with specific
somatic symptoms, such as chronic pain and headaches in childhood (Feldman,
Ortega, Koinis‐Mitchell, Kup, & Canino, 2010; Palermo, Valrie, & Karlson, 2014).
Evidence from further along the lifespan also substantiates the impact of family emo-
tional climate on somatization as adults with somatic symptoms frequently report
more adverse childhood experiences in the family than those without (Schulte &
Petermann, 2011a).
A strong example from recent literature includes the impacts of a negative family
emotional climate on pediatric asthma outcomes. As specified in Figure 13.1, asthma
is a physically manifested disease that is both psychologically and biologically influ-
enced. Emotional stress is a trigger for asthma, and emotion dysregulation predicts
worse asthma outcomes for children and adolescents. Additionally, Fiese, Winter,
Wamboldt, Anbar, and Wamboldt (2010) found that worse pulmonary functioning
for children with asthma is associated with greater separation anxiety, an effect
conveyed by their family’s level of chaos and lack of family involvement (i.e., interest
in others’ feelings and experiences). Recent research has specified a mediation path-
way whereby a negative family emotional climate, including hostile, critical, or nonre-
sponsive family relationships, indirectly worsens pediatric asthma outcomes through
the individual child’s emotional distress (e.g., depression and anxiety; Wood et al.,
2007, 2008). This pathway has been substantiated for children with asthma involved
in child protective services experiencing caregiver psychological aggression and vio-
lence (Woods & McWey, 2012) and can be potentially buffered by relational security
(i.e., secure attachment) between the child and a primary caregiver (Wood et al.,
2000). Conversely, insecure attachment and emotional avoidance is often described as
a contributing factor to somatization (e.g., Kozlowska & Williams, 2009; Lind,
Delmar, & Nielsen, 2014). For example, Waldinger, Schulz, Barsky, and Ahern
(2006) established insecure attachment style as a factor mediating the association
between childhood trauma and adult somatization.
Parental emotion regulation and socialization The psychological well‐being of par-

ents and primary caregivers is a well‐substantiated predictor of children’s somatic
symptoms. Psychiatric disorders in close family members often co‐occur with chil-
dren’s somatic symptoms (Schulte & Petermann, 2011a), and maternal depression
contributes to worse asthma outcomes (Lim, Wood, & Miller, 2008) and abdominal
pain, as does anxiety (Campo, Bridge, & Lucas, 2007). The ability of parents to regu-
late their own emotions also contributes to how they react to and teach their children
about emotions (i.e., emotion socialization; Havighurst & Keyhoe, 2017). Researchers
have recently established a link between this emotion socialization process and chil-
dren’s stress reactivity (Guo, Mrug, & Knight, 2017) and adolescents’ somatic com-
plaints (Kehoe et al., 2014). Moreover, intervening via an emotion‐focused parenting
intervention appears to improve parents’ emotion regulation and socialization skills,
reducing their children’s somatic complaints (Kehoe et al., 2014). This phenomenon
appears to replicate in broader social domains, where emotionally unsupportive
responses from friends is associated with a greater number somatic complaints in ado-
lescents, as rated by their mothers (Parr, Zeman, Braunstein, & Price, 2016). Although
there is a focus on parental emotions, broadly, the majority of this research investi-
gates mothers due to fathers participating in research in numbers so low so as to
prohibit analysis (e.g., Campo et al., 2007; Lim et al., 2008). There is some evidence
that pathways from fathers’ emotion regulation (i.e., depressive symptoms) to chil-
dren’s disease activity are through indirect effects on interparental conflict and mater-
nal parenting, rather than directly contributing to health (Lim, Wood, Miller, &
Simmens, 2011).
Divorce and death

Parental divorce and death are intense traumas that, when experienced by child and
adolescent family members, may lead to the development of somatic symptoms. van
Gils et al. (2014) demonstrated family disruption via divorce or death predicted an
increased risk of later somatization over 5 years, for children aged 10–12 years at base-
line. This effect was partially mediated by children’s depression and anxiety symptoms
and was moderated by age, such that the negative impact of divorce and death on
326 Sarah B. Woods
somatization appeared to increase in adolescence. Stressful life events, especially those

occurring in the emotionally intense context of the family, appear to repeatedly pre-
dict youths’ somatic symptoms (e.g., pain, stomachache, dizziness, fatigue), even
when controlling for premorbid mental health and socioeconomic status (e.g.,
Bonvanie, Janssens, Rosmalen, & Oldehinkel, 2016).
Family health beliefs

Especially critical for understanding the influence of the family on somatization in
childhood and adolescence may be family health beliefs. Health beliefs include per-
ceptions of illness, or the threat of illness (including probability of contraction and
beliefs about possible severity and impact), as well as perceptions of the impact of
one’s own behavior on that illness (as well as the relative costs and benefits of poten-
tial responses; Conner, 2010). Beliefs about health and illness are often shared in
families (Wright & Bell, 2009) and become part of the context and socialization of
children into families’ modes of operating. The impact of family health beliefs is espe-
cially important in conceptualizing the cyclical effects of somatization. In other words,
families that hold perceptions that they are more likely to become ill may have family
members who are somatically sensitive and perceive normal bodily sensations as
potentially problematic. Parents in these families may be more likely to react with
anxiety or fear to children’s somatic complaints and may be more likely to seek medi-
cal care as a result. Seeking medical care (with a biomedical focus) may serve to con-
firm parents’ worries and exacerbate illness‐related behavior, serving to worsen
children’s somatic complaints. Further, a greater focus on somatic symptoms may
contribute to greater symptom‐related disability (Lewandowski, Palermo, Stinson,
Handley, & Chambers, 2010).
Psychosomatic Theory
Constructing a thorough conceptualization of somatic symptoms in childhood, and

the impacts of family on somatization, is aided by an organizing theoretical model
that specifies pathways by which family relationships impact children’s somatic symp-
toms and the exacerbation of disease, as well as the reciprocal impacts of somatization
on family relationships. Given the multilevel associations implicated in the literature,
theoretical models with a basis in systems theory (von Bertalanffy, 1968) are especially
relevant.
Biopsychosocial model
The theoretical model likely most often applied to the conceptualization of somatic
symptoms is Engel’s (1977) biopsychosocial model (Garralda & Rask, 2015;
Hulgaard et al., 2017; McDaniel et al., 2005). This framework allows for a focus on
individual psychological and biological influences on somatic symptoms, as well as
the impacts of social relationships. Engel’s biopsychosocial model was developed in
response to the predominant biomedical model of medicine, which promoted a
mind–body division. (This same mind–body division is often provided as an example
of a precipitating factor for the development of somatic symptoms, especially when

part of a family’s illness beliefs.) Citing von Bertalanffy’s (1968) general systems
theory, Engel emphasized a focus on the embedded and interrelated levels of an
organization and that individual family members, families, and their social contexts
are parts of a larger whole. Engel (1980) further specified that each level of an indi-
vidual’s system is hierarchical, such that an individual is simultaneously the lowest
level of the social hierarchy (extending upward from an individual, in a range from
two‐person dyads to the biosphere) and highest level of the organismic hierarchy
(ranging downward in size, from the individual’s nervous system to subatomic par-
ticles). Characterizing each level of a system requires an understanding of the other
environments that it is nested within.
The biopsychosocial model is easily applied to conceptualizing somatization and exac-
erbation of disease in children. Children’s somatic symptoms (mimicking or reflecting
actual physiological changes in the lower half of Engel’s (1980) hierarchy of natural
systems, for example, organs and organ systems) are impacted by emotion socialization
via parenting practices (Kehoe et al., 2014), a parent’s somatic symptoms (Schulte &
Petermann, 2011a), and parental health anxiety (Schulte & Petermann, 2011b). Somatic
symptoms are also impacted by the family’s illness beliefs (Hulgaard et al., 2017) and
family conflict (Palermo et al., 2014), as well as the reactions of health‐care providers
pursuing biological origins for presenting symptoms (Lievesley, Rimes, & Chalder, 2014;
McDaniel et al., 2014). The biopsychosocial model theorizes the dynamic interplay
among each of these levels of a child’s system and emphasizes the importance of inter-
vening from a whole‐person conceptual model of health (Woods, 2019).
Family systems illness model

Similar to Engel’s (1977) biopsychosocial model, Rolland’s (1984) Family Systems
Illness model is based in systems theory and highlights the intersections of psychoso-
cial and biomedical aspects of illness as encountered by families, over time. A strengths‐
based approach, this theoretical model emphasizes the possibility of resilience and
growth when faced with a chronic disease and specifies how illnesses unfold over time
within the developmental context of the individual patient and their family. The
phases of illness, including crisis, chronic, and terminal phases, range from diagnosis
to death. Each phase poses new psychosocial demands on a family that, when inter-
sected with developmental nodes, may create stress and strain requiring shifts in a
family’s coping mechanisms.
Important for its application to somatic symptoms includes Rolland’s nesting of the
type of illness or disability not only within developmental contexts but also within a
family’s belief systems. The family’s health belief system reflects a paradigm shaped by
shared values, culture, ethnicity, and historical context (Rolland, 1994). Rolland
(1994) emphasizes the need to track a family’s beliefs about normality, control and
mastery, optimism and pessimism, communication rules, and transgenerational illness
stories, among other beliefs (described further below). The family’s health belief sys-
tem impacts the meaning a family will place on a child’s somatization, including their
sense of control over the child’s health and whether they experience the symptoms as
stigmatizing (Rolland, 1988).
Within Rolland’s (1988) psychosocial typology of illnesses, he characterizes illnesses
frequently considered somatic in nature (and/or psychosocially exacerbated) as nonfatal
328 Sarah B. Woods
and non‐incapacitating, with an acute (e.g., migraine, asthma) or gradual (e.g., ulcerative
colitis, inflammatory bowel diseases) onset and relapsing course. A family’s reaction to
the development of symptoms of this type is determined by the pre‐illness role demands
of the child and the family’s flexibility (Rolland, 1988). Greater flexibility is especially
required given the episodic nature of somatic symptoms that are not fully explained by
biological origins and the uncertainty of when they will recur.
Although the Family Systems Illness model is intended to theorize the psychosocial
impacts of any illness, it has rarely been applied to specific somatic symptoms or dis-
ease. An exception includes recent applications of the model to chronic fatigue syn-
drome (Blazquez & Alegre, 2013; Sperry, 2012). As this theoretical approach provides
an apt overlay to conceptualizing somatization in children, research is required to
specify how best to apply the model and to tease out the specific intersections of fam-
ily belief systems and the demands of psychosocially influenced disease.
Psychosomatic family model

Minuchin and colleagues (1975) were among the first to challenge the dominant
conceptual model of somatic illnesses as linear and focused on the individual patient,
which they argued failed to adequately inform effective therapeutic approaches. These
authors suggest that therapy focused on the individual and their personality fails to
ameliorate the problematic context within which the individual is embedded. They
state:
This is particularly striking in the case of children who can be assumed to be deeply
involved with some form of family group. Yet the child is apparently seen as a passive
recipient of noxious environmental influences. Consequently, the general therapeutic
response has been only to separate him from those influences, either by individual psy-
chotherapy, or by behavioral therapy, or “parentectomy.” All of these treatment
approaches place the burden of change on the patient alone. (p. 1032)
Minuchin et al. (1975) theorize that family interactions impact a (physiologically

vulnerable) child’s emotional reactivity, which is accompanied by a physiological
response. Downregulating this response may be hampered by the family’s process and
relationships to one another. Lastly, the authors specify that a child’s psychosomatic
symptoms contribute to the maintenance of family homeostasis, assisting the family
with avoiding conflict. Therefore, they highlight that the “disorder is seen as situated
in the feedback processes of child and family” (p. 1032).
Further, Minuchin et al. (1975) specify the types of family transaction found in a
psychosomatogenic family that contribute to the development and maintenance of
somatic symptoms in children. These forms of family interaction are not unique to
describing families of children with somatic symptoms and can be found across
Minuchin’s work (e.g., Minuchin, 1974; Minuchin & Fishman, 1981). The first type
is enmeshment, characterized by relational interdependence, fluid and diffuse bound-
aries between individuals and family subsystems, intrusiveness, emotional ripple
effects, and an ill‐defined sense of self for individual members. The second includes
overprotectiveness, with intense concern and anxiety for other family members’ well‐
being, stunting children’s autonomy. The third type is rigidity, which specifies these
families’ intense commitment to homeostasis, and struggle with flexibility. Minuchin
et al. (1975) describe a psychosomatically ill child’s family as such: “When events that
require change occur, family members insist on retaining accustomed methods of
interaction. Consequently, avoidance circuits must be developed, and a ‘symptom
bearer’ is a particularly useful detouring route” (p. 1033). Lastly, a lack of conflict
resolution characterizes these families’ interactions, as a result of the enmeshment,
rigidity, and overprotectiveness. Problems in the family are not resolved and continu-
ally avoided. Minuchin et al. (1978) specify three conflict avoidance patterns used by
families, including triangulation and parent–child coalition, both of which involve the
ill child aligning themselves with one or the other parent, as well as detouring, which
reflects a united parental front focused on defining their sick child as the family’s sole
problem.
The result of these four transaction types is the presentation of illness as a method
of connecting and communicating. The worsening of existing disease may occur, or a
novel somatic symptom may begin. Regardless, the somatic symptoms become part of
the family’s feedback processes, reinforcing the overprotective nature of the family
and enabling the family to avoid conflict. The psychosomatic family is additionally
challenged by the unpredictability, and need for flexibility, that a medically unex-
plained symptom presents (Minuchin et al., 1975). The ill child’s autonomy is less-
ened, and the family’s enmeshment fortified, establishing a homeostatic process
requiring a systemic family therapy intervention.
Biobehavioral family model

Despite theoretically advancing our understanding of somatic symptoms in children
from a systemic perspective, and inspiring meaningful clinical interventions, Minuchin
et al.’s (1975) psychosomatic family model has multiple shortcomings. Wood (1993)
outlines these, including the model’s assumption that the transactional patterns
described above are maladaptive and pathological, rather than an adaptive response to
a child’s illness. In addition, despite a basis in general systems theory, Wood argues
that the model’s focus on family patterns causing or worsening disease is linear and
unidirectional, thereby encouraging family blaming. This approach negates the indi-
vidual’s psychological experience and therefore neglects pathways by which family
process may influence illness via individual’s psychophysiological reactions to stress.
As a response, Wood (1993) developed the Biobehavioral Family Model. Wood
retained the psychosomatic model’s systemic theoretical assumptions, including
conceptualizing the family as a system, uniquely important for children, with pat-
terns of interaction that reciprocally influence individual family member behavior
and well‐being. However, the Biobehavioral Family Model extends beyond
Minuchin et al.’s (1975) approach, specifying non‐pathological structural charac-
teristics of the family (e.g., proximity, generational hierarchy, parent–parent rela-
tionship quality), and specifies a mediational mechanism whereby these family
processes influence children’s disease activity through the individual child’s biobe-
havioral (psychophysiological) reactivity. The model has since been expanded to
incorporate parent–child attachment as an additional mediator in the model (Wood
et al., 2000). When this attachment is positive and secure, it may buffer the negative
impact of a conflictual or neglectful family emotional climate on a child’s reactivity;
when the attachment is insecure, it may potentiate the impact of a stressful family
on the individual patient.
330 Sarah B. Woods
Research evidence for the psychosomatic family model has been infrequent and the
results mixed (Wood, 1993; Wood & Miller, 2005). In contrast, the Biobehavioral
Family Model is likely the most empirically supported biopsychosocial model (Wood,
2012; Woods, 2019): research testing the Biobehavioral Family Model has been plenti-
ful and provided a great deal of support for the constructs and specific pathways of this
theoretical approach. The Biobehavioral Family Model, and its mediational pathway,
has been substantiated in laboratory‐based family interaction studies (e.g., Lim et al.,
2008, 2011; Wood et al., 2008) and with large, longitudinal, national survey data (e.g.,
Woods & McWey, 2012), primarily with pediatric asthma as a stress‐related illness.
Somatic Symptoms in Clinical Practice
Family‐based assessment
Assessing each of the areas of family relationships that impact the development and
maintenance of somatic symptoms described above requires family‐level measure-
ment. Assessing family relationship quality may be accomplished using a variety of
measures, including FACES IV (Olson, 2010) or the Family Assessment Device
(Epstein, Baldwin, & Bishop, 1983), among others, as well as family interviews and
observations of family process. Especially critical is capturing each individual family
member’s perspectives of family functioning; utilizing a measure that is able to be
completed by young family members is an important consideration. Relational assess-
ment, including eliciting a family’s illness narrative and intergenerational patterns spe-
cific to health and somatization, may also be effectively captured using a play genogram
(McGoldrick, Gerson, & Petry, 2008). The benefit of this approach is circumventing
somatizing families’ resistance and utilizing an engaging and developmentally appro-
priate method of assessment, which both visually captures family process and demon-
strates the family relationships during live genogram co‐creation.
Family health beliefs are also critical to assess. Rolland (2005) suggests clinicians
inquire about family beliefs regarding average families’ reactions to illness, mind–body
connections, the meanings of symptoms, assumptions about the etiology of illness and
impacts on its course and outcomes, intergenerational factors that impact a family’s beliefs
and behaviors, and specific time points in the lifespan of the patient, family, or illness,
when health beliefs may be impacted. Elucidating these shared beliefs (as well as differ-
ences between family members) will also help to highlight family values regarding health
locus of control (Rolland, 1994), the role of health care in adapting and responding to
physical symptoms and disease, and the relative rigidity of these beliefs (Rolland, 2005).
In the context of a new or existing physical illness, assessing a family’s risk for psy-
chosocial distress may highlight areas for prevention efforts aimed at shaping family
behavior and minimizing the impact on children’s somatic responses. Kazak et al.
(2001) developed the Psychosocial Assessment Tool, a brief screen to assess areas at
risk (e.g., child emotional and behavioral concerns, marital problems, low resources
or social support) in the face of illness‐related distress. Iterations of this measure have
been used with families facing pediatric cancer, inflammatory bowel disease, pediatric
gastroenterology inpatient care, sickle cell disease, and neonatal intensive care (Kazak,
2006; Thabrew, McDowell, Given, & Murrell, 2017).
Systemic therapy: Targeting precursors and maintenance factors

Common themes across the research and theory described above include the impact
of family emotional climate, parental relationship quality, a family’s health beliefs,
family health anxiety, emotion regulation (parent and child), and a biomedically ori-
ented health‐care system on children’s somatic symptoms. Not surprisingly, the major
goals of treatment include targeting these family‐level, individual‐level, and health‐
care system‐level variables. This section will focus on family‐based interventions and
those that target health‐care providers. The effectiveness of individual‐level treat-
ments for somatic symptoms in children has been summarized elsewhere elsewhere–
for example, Eccleston et al. (2014) have reviewed research on cognitive-behavioral
therapy (CBT) for chronic pain.
Family‐based treatment In a recent systematic review of family‐based interventions for

functional somatic symptoms, Hulgaard et al. (2017) reviewed 16 papers, 11 of which
they categorized as applications of CBT‐based family therapy (including acceptance and
commitment therapy) and four of which were categorized as testing systemic family ther-
apy, along with one mixed approach. Systemic family therapy approaches were vaguely
described and included a focus on structural and strategic family therapy (White, 1979),
integrative family therapy (Turgay, 1990), and family structure broadly (Liebman, Honig,
& Berger, 1976; Viner et al., 2004). All 16 of the studies reviewed, regardless of theoreti-
cal orientation, focused some of their approach targeting the families’ illness beliefs.
Of the four systemic family therapy studies Hulgaard et al. (2017) reviewed (two
case series, one controlled study, and one uncontrolled study), the child with somatic
symptoms was conceptualized as the symptom bearer (or, family healer; White, 1979),
and the somatic symptoms were described as an expression of problematic family rela-
tionships. Therefore, these authors focused on building acceptance within the family
of the psychosocial origins of the somatic symptoms, and actively working to shift
family relationships through addressing parental over‐involvement and parent–parent
relationship problems through reinforcing family subsystem boundaries (Hulgaard
et al., 2017). Narrative family therapy may be especially effective for specific somatic
issues, including encopresis (Silver, Williams, Worthington, & Phillips, 1998), with a
focus on externalizing the symptom and joining the family in collaboration (White,
2007). Systemic family therapy paired with pharmacological treatment as usual is also
effective at improving children’s asthma symptoms and problematic family interac-
tions (defined using the four transaction types defined by Minuchin et al., 1975), with
benefits maintained 2‐years’ posttreatment (Onnis et al., 2001). Broadly, systemic
therapy is distinctly effective at treating psychological factors impacting somatic illness
(Retzlaff, Von Sydow, Beher, Haun, & Schweitzer, 2014).
Family‐based CBT, in contrast, focuses on parents’ and children’s understanding,
interpretation of, and responding to, bodily sensations, describing the physiology–
stress connection, and emphasizing symptom management (Hulgaard et al., 2017).
Behavioral therapies focused on family psychoeducation about the somatic symptom,
relaxation training for children, and parent‐enforced reward systems for medical
adherence and self‐care have been demonstrated as effective for encopresis, recurrent
abdominal pain, and poorly controlled type 1 diabetes (Carr, 2014). Ng et al. (2008)
demonstrated in a randomized controlled trial that psychoeducation, combined with
332 Sarah B. Woods
systemic family therapy, provided greater benefit for children with asthma, including
the child’s somatic condition, than asthma education alone.
Lastly, though the Biobehavioral Family Model is theoretical rather than clinical, it
serves to guide family‐based interventions. Specifically, Wood, Miller, and Lehman
(2015) suggest that clinicians should first acknowledge the impact of a child’s illness
on the family and specify for families how stress impacts illness directly and via health
behavior. Second, clinicians should observe the family emotional climate and identify
sources of strength (e.g., warmth, secure attachment) and areas for repair (e.g., hostil-
ity, criticism, attachment ruptures; Wood et al., 2015). Wood (2019) further suggests
identifying extreme family patterns in the domains of family emotional climate and
specifying how these family processes are related to the patient’s disease, before tar-
geting these relational dimensions for intervention. Additionally, improving positive
and supportive aspects of family responsivity while working to regulate individual
family members’ biobehavioral reactivity may serve to buffer families from the recip-
rocal impacts of somatic symptoms. Importantly, given the research evidence linking
parental depression and child somatic symptoms, Wood et al. (2015) also suggest
evaluating the child’s parent(s) for depression and incorporating depression‐specific
interventions in the overall treatment approach.
Overall, intervening in the family’s process to improve the emotional climate
through decreasing enmeshment, developing clear and firm boundaries, and increas-
ing warmth may be especially necessary for children with somatic symptoms and psy-
chosocially exacerbated disease. Increasing children’s and their families’ knowledge
about the somatic symptom or chronic illness, and how stress plays a role, is also criti-
cal, as is assessing and intervening in a family’s health beliefs and the meaning they
place on a child’s symptom or disease.
Health‐care system interventions Parallel to a family’s preoccupation with a child’s

somatic symptoms may be a physician’s exclusive and inapposite focus on the bio-
medical, physiological aspects of the patient’s presentation, termed somatic fixation
(van Eijk et al., 1983). Somatic fixation may range in severity, from attending to and
treating solely biomedical problems to a purely psychosocial focus, with a biopsycho-
social fulcrum (McDaniel et al., 2005). Although most physicians focus on biomedi-
cal explanations for somatic symptoms, once a patient is known to somatize, they are
more likely to overemphasize psychosocial origins (McDaniel et al., 2005). This pre-
vailing ideology (countered by Engel (1977) and Minuchin et al. (1975) in their
systemic models of health) is reinforced by the focus of the broader health‐care system
on diagnosis and medical services (Barsky & Borus, 1999).
McDaniel et al. (2005) also describe somatic fixation as an interactional process
reflecting a health belief system mismatch between a child and their family, and their
health‐care provider (McDaniel et al., 2005). In other words, the patient or their fam-
ily may believe their symptoms are of organic origin or an expectable exacerbation of
an existing chronic illness, while their physician conceptualizes the child’s somatic
symptoms as psychologically caused. These authors advocate a multistep biopsycho-
social approach to somatic fixation for physicians. These steps include (a) a biopsycho-
social assessment of the presenting problem (avoiding advancing a mind–body
dichotomy by evaluating first biomedical areas, then psychosocial), (b) eliciting the
patient’s symptoms and pursuing a broad and curious stance toward collecting infor-
mation in order to validate the patient, (c) pursuing a collaborative patient/family–
physician relationship, (d) eliciting the patient and family’s attributed meanings of the
symptom and negotiating a mutually acceptable diagnostic explanation for the symp-
tom’s presentation, and (e) a focus on the patient and family’s resilience, strengths,
and resources, among several other biopsychosocial principles of care. Similarly,
Cottrell (2016) highlighted the need for physicians to focus on biopsychosocial
assessment, provide psychoeducation regarding the biopsychosocial range of origins
for somatic symptoms, and develop an agreed upon treatment plan with the patient
and their family. The overarching objective of treatment is to improve patient func-
tioning with decreased health‐care utilization, while the overarching objective of
intervening in the health‐care provider’s approach is to shift the physician, and health‐
care system, toward a biopsychosocial conceptualization and treatment approach for
somatic symptoms (McDaniel et al., 2005).
Integrated behavioral health Emphasizing a biopsychosocial approach in med-

icine also necessitates advocating for integrated behavioral health care, especially
rooted in a family systems approach. Collaboratively targeting the patient’s family
environment and problematic cycles of interaction between the patient and family,
and between the patient/family and health‐care provider, is necessary to adequately
ameliorate somatization. While much of the approach advocated by McDaniel
et al. (2005) can be provided by the physician, actively integrating behavioral
health in the treatment process is critical to prevent physician frustration and burn-
out and to effectively target family relationships. While patients with intense
somatic fixation may actively resist a referral to behavioral health, providing an
integrated treatment approach where both physicians and family therapists regu-
larly meet together with the patient and their family can combat the resistance of
these families to a psychological explanation of their child’s somatization (McDaniel
et al., 2014). Conversely, providing dose‐appropriate care is critical: not all chil-
dren and their families will require intensive family therapy to lessen a child’s
somatic experiencing of emotional distress.
Lastly, just as medical providers may replicate the mind–body schism that is preva-
lent in biomedical systems and avoid or fail to assess psychosocial concerns, so too
may psychosocial providers be reluctant to assess and intervene in the biological
realm. Family therapists need to be mindful of their own propensity to become “psy-
chosocially fixated” (McDaniel, Campbell, & Seaburn, 1995, p. 294); systemic pro-
viders are not immune to dichotomy. Therapists develop knowledge, skills, and
comfort in the psychosocial realm. Effectively functioning as part of an integrated
behavioral health‐care team requires that all health‐care providers adapt to incorpo-
rate a biopsychosocial conceptualization of somatization. Therapists should expand
their expertise to include the symptoms and treatments of common physically mani-
fested illnesses that are more psychologically influenced (e.g., chronic pain, chronic
fatigue syndrome, asthma, diabetes mellitus; Figure 13.1) to better enable interpro-
fessional collaboration. This also allows for therapists to provide psychoeducation to
families regarding new or evolving medical diagnoses and how they impact and are
impacted by family stress. Therapists should also increase accessibility in order to
enhance communication with medical providers while respecting physicians’ time
constraints (McDaniel et al., 2014). This may include responding quickly to phone
calls, referrals, and requests for assistance, visiting medical offices to actively collabo-
rate on‐site, or providing regular progress updates, ensuring that treatment plans for
334 Sarah B. Woods
therapy are supported by the health‐care team, and vice versa (see also Robinson,
Jones, Felix, & McPhee, 2020, vol. 1).
Advancing Somatization Theory and Treatment
Next steps for theory‐building, research, and clinical approaches specific to primary
and secondary somatic symptoms overlap. While the theoretical approaches reviewed
have been broadly applied to the understanding and study of somatic symptoms in
children, each may be enhanced from adaptations specific to conceptualizing somati-
zation. For example, while the Biobehavioral Family Model (Wood, 1993; Wood
et al., 2008) utilizes a biopsychosocial systems approach to specify how family emo-
tional climate impacts disease activity in children through the individual child’s biobe-
havioral reactivity, it has yet to incorporate family’s health belief systems, including
symptom meaning making or beliefs about control and mastery. These beliefs may
serve as a protective factor, providing individuals with prevailing positively oriented
understandings of their health and ability to care for themselves, potentially buffering
against family trauma or conflict. Family health beliefs could also serve to potentiate
the impact of a negative family emotional climate, should they reflect minimal mastery
and limited autonomy of the patient with a primarily biomedical conceptualization of
symptom etiology or intergenerational lack of trust in the health‐care system. Across
the theories reviewed, research is needed to test the specific application of these mod-
els to secondary somatic symptoms, occurring outside of an underlying illness.
Moreover, the Family Systems Illness model (Rolland, 1984), while a potentially
powerful model for explicating a family’s coping with the occurrence of a child’s
somatic symptoms, has yet to be tested in research.
It is not enough to theorize biopsychosocial pathways to health and well‐being;
high‐quality research is required to test the applicability of our systemic theories to
specific somatic symptoms and illnesses of childhood. Research methodology advance
should include family‐level measurement specifying the family relationships of inter-
est, observational data mapping family processes, and dyadic and multilevel modeling
to examine individual and relational effects. Designing and testing interventions
should be done in collaborative teams, with family intervention experts and medical
providers, to ensure that approaches are both systemic and feasible for use in health‐
care settings. Lastly, family‐based interventions should be developed for populations
of critical need. This may include children and families who are high utilizers of medi-
cal care (e.g., poorly controlled diabetes or asthma) as well as families with less access
to care and at greater risk of disease exacerbation (e.g., underinsured communities
with few mental health resources). Intentionality in future research projects to address
these opportunities for growth is critical.
Further, despite the present description of multiple theories that apply to the
conceptualization and treatment of children’s somatic symptoms, and the broader
literature supporting relational interventions for child health (e.g., Shields, Finley,
Chawla, & Meadors, 2012), biopsychosocial theories of childhood health are, in
fact, limited (Woods, 2019). Broadly, there is a greater focus on the childhood
environment as an antecedent of adult health (e.g., Miller, Chen, & Parker, 2011).
It is critical for systemic theory to explain the etiology of somatic symptoms, and
reciprocally reinforcing relational patterns in the family context, as well as to inform

targeted prevention and intervention efforts.
A related concern includes that interventions for child health are rarely rooted in
theory. Aside from clinical applications of Engel’s (1977) biopsychosocial model, of
which there are many (Woods, 2019), there is a broad disconnect between families
and health theory and families and health practice. Moreover, the classic systemic fam-
ily therapy approaches are rarely mentioned in the literature. Hulgaard et al. (2017)
located empirical studies of systemic therapy approaches to somatization and found
that very few were rooted in classic systemic theory. Instead, the studies reviewed
were more generally informed by broad systemic notions of family patterns, bounda-
ries, and symptom bearing. Hulgaard et al. frame the theoretical underpinnings of
these family‐based interventions as evolving over time, beginning with systemic ori-
gins and resulting, more recently, in family‐based CBT applications. Carr (2014) simi-
larly reviewed family‐based interventions for somatic problems, resulting in a summary
of solely behavioral treatment approaches that involved parents in order to support
self‐management.
Behavioral therapies, as described in these reviews, are specific in their approach,
providing psychoeducation, behavioral charts and alarms, reward systems, and relaxa-
tion and coping skills training. It is therefore probable that behavioral family‐based
interventions are more easily manualized than family process‐oriented approaches,
may not require extensive training in systemic therapy (i.e., may allow for a wider
range of clinician training backgrounds), and may be more time limited. These factors
may increase the likelihood of researchers examining, and clinicians using, behavio-
rally based programs. However, without intervention research that explicitly states the
treatment model’s theoretical orientation, including how the specific systemic theory
informs the methods of the family‐based intervention, the effectiveness of approaches
based in classic systemic theory is less clear. Intentionally using theory to drive inter-
vention development supports targeting specific mechanisms of effect that have the
potential to create change.
As Hood, Rohan, Peterson, and Drotar (2010) highlight in their meta‐analysis of
adherence interventions for children with type 1 diabetes, the most effective
approaches are multicomponent and target behavioral processes as well as emo-
tional, social, and family relationship factors that these children encounter daily.
Specifying how family therapy theory informs intervention for somatization is criti-
cal and would enhance cross‐study comparison attempts at replication. It is likely
that interventions incorporating important family factors related to symptom exac-
erbation reviewed presently (e.g., family emotional climate, family traumas, family
health beliefs, etc.) along with behaviorally based strategies to reduce anxiety and
improve emotion regulation would provide significant benefit to families of chil-
dren with somatic symptoms.
Similar to the clinical emphasis on integrated behavioral health to effectively target
somatic symptoms, partnering researchers and practitioners in the study of relational
interventions for somatization could bolster both science and practice. Specifically,
creating integrated and translational research–practice teams could inform the speci-
ficity, feasibility, and efficacy of family‐based interventions and boost the uptake of
evidence‐based treatments in real‐world practice (e.g., van der Feltz‐Cornelis et al.,
2018). Similarly, Sexton and Datchi (2014) emphasize a unified view of family ther-
apy science and practice, where success in either area is mutually beneficial.
336 Sarah B. Woods
Summary
Conceptualizing and treating children with primary or secondary somatic symptoms

and their families requires a systemic and biopsychosocial approach. Although widely
advocated, the uptake of this model in medicine and therapy is hampered by prevail-
ing cultural schisms and training orientations. Additionally, practitioners face the chal-
lenge of potentially frustrated or resistant families seeking answers for troubling
symptoms in a young family member. Countering the mind–body dichotomy, and
discouraged families, through the use of systemic interventions is indicated in psycho-
somatic theory and research testing family‐based approaches. Expanding these theo-
ries and clinical methods to incorporate specific dynamics, family resiliencies, and
prodromal physiological reactions to stress found in children with somatic symptoms
and their families is necessary. Intervening, and studying, these advances will require
integrated teams of health‐care providers as well as teams of scientists and practition-
ers, partnering to share their expertise and collaborating with families to discover the
most effective and most meaningful systemic interventions for somatization.
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14
Youth Suicide
Risk, Prevention, and Treatment
E. Stephanie Krauthamer Ewing, Quintin A. Hunt,
Jonathan B. Singer, Guy Diamond, and Dara Winley
Laura, a 15‐year‐old African American female client,1 was referred to therapy by her school
counselor for episodes of non‐suicidal self‐injury (cutting) and feelings of anxiety and
depressed mood. Laura had visited the counselor after attending an assembly at school focused
on raising awareness about mental health concerns (particularly depression and suicide
risk) and the importance of seeking help early.
Laura attended the intake appointment with both her mother and her father, who had
recently finalized their divorce. During the intake, the therapist met with the family together
for most of the session and gathered background information. Laura’s parents expressed
worry, guilt, and feelings of helplessness that Laura had not confided in them about her
symptoms. Several times during the session, Laura’s parents engaged in some blaming of one
another for failure to notice Laura’s symptoms earlier. The therapist was able to stop these
occurrences in the moment and explore Laura’s feelings around these interactions. Laura
was able to express how her parents’ conflictual interactions with one another exacerbated her
anxiety and distress and how she often felt caught in the middle. The therapist used refram-
ing and emotional deepening techniques to help the parents come to mutual agreement about
Laura’s distress and self‐harm risk as the most important initial treatment goal and that
strengthening family support and healthy communication would be an important means to
accomplish this goal.
The therapist also met with Laura alone for a portion of the session, during which she
conducted a thorough risk assessment, including assessment of suicide intent and plan and
the type, frequency, duration, and chronicity of suicidal thoughts. Laura reported having
vague suicidal thoughts every night and during the week prior to intake, with no intent or
specific plan. Although hospitalization was considered, without intent or plan, Laura may
not have been admitted and would likely have been discharged quickly, even with an admis-
sion. Based on all available information from intake, the decision was made to treat Laura
on an outpatient basis with a commitment from Laura and her parents to engage in treat-
ment (twice per week at first), including phone check‐ins between sessions and to use the
agreed upon stepwise safety plan for dealing with suicidal/self‐harm urges (i.e., coping strat-
egies, teen agreement to disclose suicidal and self‐harm urges and to utilize emergency ser-
vices if needed, parent agreement to remove any lethal weapons/agents from home). The
therapist continued to work collaboratively with the family as she formulated case conceptu-
alizations and implemented specific intervention strategies.
344 E. Stephanie Krauthamer Ewing et al.
Background on Youth Suicide Risk
Suicide risk in youth, including suicidal thoughts and behavior, is one of the most
challenging problem areas for mental health practitioners, including family therapists.
The host of intense negative emotions that accompany youth suicide risk, including
worry, sadness, anger, and abject fear can be overwhelming for teens, parents, teach-
ers and friends and the therapists who work with them. Due to the intense emotional
nature of the work required to treat youth at risk for suicide, many clinicians shy away
from this client population. Also, clinicians often report feeling ill equipped and
undertrained to work with youth at risk for suicide, particularly on an outpatient
basis. In fact, it has been estimated that only 6% of accredited marriage and family
therapy programs include suicide‐specific coursework, and this lack of training is also
pronounced in other mental health disciplines (e.g., counseling, clinical psychology,
social work) (Schmitz et al., 2012). This is unfortunate, as there is a growing and
urgent public health need for clinicians who are well trained in assessment, manage-
ment, and treatment of suicidal youth.
In 2016, suicide was the second leading cause of death among youth between the
ages of 10–24 years in the United States, with 6,159 deaths (a rate of 9.21 per
100,000) (Centers for Disease Control and Prevention [CDC], 2018). According to
the most recent year of the Youth Risk Behavior Survey (YRBS), in 2015, more than
one in six (17.7%) high school students had at least one serious thought of killing
themselves, 14.6% had made a suicide plan, 8.6% made an attempt, and 2.8% made
attempts that required medical attention (Kann et al., 2016).
Coping with the risk of suicide in youth is extremely challenging. The death of a
child by suicide is unimaginably devastating to parents, family members, and com-
munities and can have far‐reaching and long‐term effects on survivors. While thera-
peutic work with youth and families struggling with suicide risk can be very difficult,
with proper training and support, it can also be enormously rewarding and literally
lifesaving for clients. With the goal of providing clear, helpful, and evidence‐based
guidance for understanding, assessing, and treating youth suicidal thoughts and
behavior, the remainder of this chapter focuses on (a) current language and defini-
tions related to youth suicide, (b) systemic factors and models of youth suicide risk,
(c) theory, and (d) known elements of effective treatment, including risk manage-
ment, safety planning, important common factors in effective treatment, and specific
intervention models. The chapter closes with commentary on implications for policy
and directions to additional educational and training resources.
Definitions
According to the CDC, there are several unacceptable terms to describe suicidal
thoughts and behavior, including completed suicide, failed attempt, nonfatal sui-
cide, para‐suicide, successful suicide, and suicide gesture or threat (Crosby, Ortega,
& Melanson, 2011). The most widely accepted and commonly used terms to
describe the constellation of concepts related to suicidal thoughts and behavior are
listed in Table 14.1 (Crosby et al., 2011; U.S. D.H.H.S, 2012; Whitlock,
Muehlenkamp, et al., 2013).
Youth Suicide Risk 345
Table 14.1 Terms and definitions related to suicidal thoughts and behaviors.
Term Definition
Suicide ideation Thinking about, considering, or planning suicide

Suicide attempt A nonfatal self‐directed potentially injurious behavior with any
intent to die as a result of the behavior. A suicide attempt may
or may not result in injury
Interrupted By other: A person takes steps to end their life but is stopped by
attempt another person prior to fatal injury
By self (also called “aborted attempt”): A person takes steps to
end their life but stops themselves prior to fatal injury
Suicide Death caused by self‐directed injurious behavior with any intent
to die as a result of the behavior.
Non‐suicidal Thoughts about one’s death without suicidal or self‐enacted
morbid ideation injurious content
Non‐suicidal self‐ Deliberate direct destruction or alteration of body tissue without
injury conscious suicidal intent
Attempt survivor A person who has survived a suicide attempt
Loss survivor A person who has lost a loved one to suicide
Non‐suicidal self‐injury (NSSI) and suicidal thoughts and behaviors differ in important
ways. Youth in a suicidal crisis often describe being in intolerable emotional pain, whereas
youth who engage in NSSI often describe the desire to feel something instead of feeling
numb or nothing. For some youth, NSSI reduces thoughts of suicide. There is, however,
overlap between NSSI and suicide risk. A study of over 1,500 youth who presented at
primary care found that among youth who engaged in NSSI, those who reported depres-
sive symptoms were more likely to report suicidal ideation and those with depressive
symptoms and substance use were more likely to report suicide attempts (Jenkins, Singer,
Conner, Calhoun, & Diamond, 2014). Research by Whitlock et al. (Whitlock,
Muehlenkamp, et al., 2013) found that youth who engage in more than 20 lifetime self‐
injury incidents were at significantly higher risk for suicidal thoughts and behavior but that
having parents as confidants significantly reduced risk in the high self‐injury group.
Systemic Approach to Understanding Youth Suicide
Although there is no single answer to the question of “why” youth kill themselves,
much of the research over the past 30 years has sought to establish the pathways that
lead to suicidal thoughts and behaviors. A systems framework suggests key factors at
the individual, family, and community/societal level that have been shown to contrib-
ute to and protect youth from suicidal thoughts and behavior (see Cha et al., 2017;
King, Arango, & Ewell Foster, 2018).
Demographics and social location

There are large disparities in rates of youth suicide by sex, race/ethnicity, urbanity,
geography, and sexual minority status, and research continues to explore links between
these aspects of identity and location and links to youth suicide risk (Goldston et al.,
2008). While adolescent females are two to three times more likely to attempt suicide,
males are 3.5 times more likely to die by suicide, mostly because males tend to use
more lethal means (such as firearms and hanging) (CDC, 2018). Youth living in rural
areas are twice as likely to die by suicide as youth living in urban areas (Nance, Carr,
Kallan, Branas, & Wiebe, 2010). In terms of race and ethnicity, the rates of youth
suicide (per 100,000) are American Indian/Alaskan Native (15.59), White (9.79),
Asian/Pacific Islander (7.65), and Black (6.48). However, among early adolescent
youth, Black youth were three times as likely to die by suicide in comparison with
non‐Black youth (Sheftall et al., 2016). Acculturative stress, perceived racism, and
family and peer rejection of sexual orientation are all factors that have been linked to
higher levels of youth depression and suicide risk.
Individual level factors

According to Nock et al. (2013), nearly 90% of youth who die by suicide meet criteria
for at least one psychiatric disorder. Youth without a psychiatric disorder who die by
suicide have been shown to have a 32 : 1 increased odds of having had a loaded firearm
in their homes compared with other teens (Brent et al., 1993). This and other epide-
miologic studies make clear that loaded firearms in the home are a significant risk factor
for youth suicide. The neurobiological processes associated with maturation mean that
the emotion and decision‐making parts of the brain strengthen over time (Steinberg,
2014). As a result, children and younger adolescents have a harder time connecting
their emotions to problem solving and executive functioning. For suicidal youth, this
means that safety planning is essential as it serves as a proxy for problem solving during
an emotionally intense suicidal crisis. Individual characteristics that have been identi-
fied as protective against youth suicide include problem solving, conflict resolution,
stress management, and frustration tolerance (Borowsky, Ireland, & Resnick, 2001).
Family factors
The family system has been shown to serve as both an important risk and protective
factor for youth suicidal thoughts and behavior. Connection to family has been con-
sistently identified as the most important protective factor for suicidal youth, more
than connection to peers, schools, or other adults (Borowsky et al., 2001; Whitlock,
Wyman, & Barreira, 2013). At the same time, there is some support for the familial
transmission of suicidal behavior through aggressive impulsivity (Brent & Melhem,
2008). There are several other family systems risk factors for youth suicide, including
the presence of parental psychopathology and high levels of family conflict/low sup-
port (Frey & Cerel, 2015; Wagner, Silverman, & Martin, 2003). Insecure attachment
styles (in parents and child) have been shown to correlate with increased suicide risk
in youth (Sheftall, Schoppe‐Sullivan, & Bridge, 2014), and interventions that actively
address the parent–teen attachment relationship have been shown to reduce suicidal
ideation and depressive symptoms in adolescents (Diamond et al., 2010; Krauthamer
Ewing, Levy, Boamah‐Wiafe, Kobak, & Diamond, 2016; Levy, Russon, & Diamond,
2016). Finally, in a family system, parental attitudes toward treatment also play a sig-
nificant role in whether suicidal youth participate in mental health services (Burns,
Cortell, & Wagner, 2008; Slovak & Singer, 2012).
Social environment
There is some research to support the idea that the broader social context (including
peer, community, and legislative factors) can increase or reduce youth suicide risk.
Youth who have reported sexual, physical, or emotional abuse are at greater risk for
suicidal thoughts and behavior (Gomez et al., 2017). Being the victim of bullying
appears to increase suicide risk by intensifying known risk factors such as psychopa-
thology (e.g., depression, anxiety) or social isolation (Copeland, Wolke, Angold, &
Costello, 2013). Prior to marriage equality being recognized as a federally protected
right, LGBTQ youth who lived in states with marriage equality laws reported lower
rates of suicide ideation. States that require background checks and waiting periods
prior to purchasing firearms have lower rates of suicide (Anestis, Anestis, &
Butterworth, 2017).
There are well‐established correlations between child maltreatment (sexual, physi-
cal, and emotional) and suicide risk. Research has consistently found a correlation
between maltreatment and suicide risk, regardless of age of first exposure (Gomez
et al., 2017). Bullying and cyberbullying (defined as repeated and intentional targeted
abuse) is correlated with suicide risk, with youth who report being both perpetrators
and victims as the highest risk for suicide (Copeland et al., 2013). The relationship
between bullying and suicide appears to be one of statistical moderation, with known
risk factors of suicide such as depression and failed belongingness being exacerbated
in the presence of bullying (Yen et al., 2015). For example, a study that surveyed
youth during routine primary care visits found that youth who reported depressive
symptoms and reported being victims of bullying were significantly more likely to
report suicidal thoughts and behavior than non‐depressed youth who reported bully-
ing (Kodish et al., 2016).
Because adolescents are highly influenced by peers, there are several important peer
effects related to suicidal thoughts and behavior. The phenomena of contagion,
whereby one person dies by suicide in close temporal and geographic proximity to
someone who has recently died by suicide, occur almost exclusively among adoles-
cents (Zimmerman, Rees, Posick, & Zimmerman, 2016). Social network analysis sug-
gests that suicidal youth may feel disconnected from the broader social community
and that they are more likely to interact with each other than with non‐suicidal youth
(Fulginiti, Rice, Hsu, Rhoades, & Winetrobe, 2016). Adolescents who believe that
suicidal thoughts and behavior are more widespread among their peers than they
actually are are more likely to report suicidal thoughts and behavior (Reyes‐Portillo,
Lake, Kleinman, & Gould, 2018).
Sexual and gender minority youth

Although research on family and couple therapy with gay, bisexual, and lesbian indi-
viduals is limited (Hartwell, Serovich, Reed, Boisvert, & Falbo, 2017), the role of the
family in reducing suicide risk among sexual and gender minority youth has been well
documented (Levy et al., 2016; Ryan, Huebner, Diaz, & Sanchez, 2009). A systemic
understanding of suicide risk for sexual and gender minority youth includes under-
standing the coming out process (D’amico, Julien, Tremblay, & Chartrand, 2015),
concerns of parents (Conley, 2011), and the sociocultural context (Marshall, 2016).
For example, the process of coming out is a time of increased suicide risk for sexual
and gender minority youth, yet their risk decreases if they attend a school with a gay–
straight alliance (Davis, Royne Stafford, & Pullig, 2014; Marshall, 2016).
Technology
Scholars have been investigating the role of internet and communication technologies
on youth suicide risk since the 1980s. For example, traditionally, suicide notes were
written almost exclusively by adults (Stack & Rockett, 2016). With the advent of
social media, however, youth are much more likely to leave digital suicide notes
(Barrett et al., 2016). Early scholarship also looked at the effects of video games and
pro‐suicide chat rooms on youth suicide risk. More recently, scholars have focused on
the relationship between smart phones and suicide risk (Barry, Sidoti, Briggs, Reiter,
& Lindsey, 2017; Twenge, Martin, & Campbell, 2018), suicide prevention (Franco‐
Martín et al., 2018), and the use of advanced statistical methods to analyze ICT‐
derived datasets (aka “big data”) to better understand youth suicide (Song, Song,
Seo, & Jin, 2016).
Theoretical Perspectives
As previously noted, connection to family has been consistently identified as the most
important protective factor for suicidal youth (Borowsky et al., 2001; Whitlock,
Wyman, & Barreira, 2013). Family conflict is linked to depression and suicide risk in
adolescents (Fergusson, Woodward, & Horwood, 2000; Kurtz & Derevensky, 1994;
McKeown et al., 1998; Resnick et al., 1997; Rubenstein, Halton, Kasten, Rubin, &
Stechler, 1998). While family conflict may not necessarily be the main contributing
factor to youth suicidal thoughts and behavior in any given situation, negative dynam-
ics in the family such as emotional invalidation, disconnection, low levels of support,
and conflict have been shown to be the immediate precipitating trigger for attempts
in youth in many cases. For example, Brent et al. (1988) found that 20% of adolescent
suicides and 50% of non‐fatal suicide attempts were directly preceded by conflict with
parents. In contrast, after controlling for factors such as depression and stressful life
events, adolescents describing their families as mutually involved and demonstrating a
high degree of shared interests and emotional support were three to five times less
likely to be suicidal than their peers from less integrated families (Rubenstein et al.,
1998, 1989).
In a previous review of the risk and protective factors of youth suicide, a model of
adolescent suicidal behavior was suggested in which suicidality was caused by the
interaction of family environmental, cultural, psychological, developmental, and psy-
chiatric factors (see Bridge, Goldstein, & Brent, 2006). Indeed, theoretical and
empirical work on attachment and family risk supports such transactional models
(Cicchetti & Toth, 1998; Gotlib & Hammen, 1992; Joiner, Coyne, & Blalock, 1999).
Much like a diathesis stress framework, in which individual factors (e.g., genetics,
individual biology) interact with environmental factors to influence mental health,
transactional models emphasize how individual biological, temperamental, or cogni-
tive risk factors and environmental factors (especially family relations) constantly
interact and influence one another, playing a major role in shaping the developmental
course of the child and the risk for suicide and comorbid conditions, including youth
depression (Belsky & Pluess, 2009; Cummings, Davies, & Campbell, 2002).
During adolescence, many factors can contribute to normal developmental strug-
gles becoming sources of conflict and tension in the family. For example, in addition
to adolescent mental health struggles (e.g., depression, anxiety), parents’ underlying
mental health struggles, occupational stress, family financial pressure, and marital dis-
cord and dissolution can all exacerbate typical parent–teen developmental struggles
and contribute to self‐perpetuating cycles of heightened parent and teen negative
emotionality, hostility, rejection, and withdrawal (Micucci, 1998; Sheeber & Sorensen,
1998). In such situations, adolescents may come to develop a view of their parents as
unsupportive and sources of conflict, or they may view themselves as a burden to an
already overtaxed family. Such struggles become compounded when there is a history
of chronic family dysfunction or trauma‐related factors such as abuse or neglect and
the frequently associated attachment insecurity in the parent–child relationship. In
these cases, adolescents are at higher risk for developing internal working models of
others as unsafe, untrustworthy, and unreliable and models of themselves as unworthy
of love and comfort. Such views of self and others become defensive strategies used
for protection from further interpersonal hurt and disappointment. Insecure attach-
ment in adolescence relates to higher levels of emotional avoidance and over‐person-
alization and confers a higher risk for the development of depression and suicidality
(Adam, Sheldon‐Keller, & West, 1996; Allen, Porter, McFarland, McElhaney, &
Marsh, 2007; Kobak & Sceery, 1988; Kobak, Sudler, & Gamble, 1991; Marsh,
McFarland, Allen, McElhaney, & Land, 2003).
Despite youth suicide being a major public health concern, there is no comprehen-
sive theory of suicide for children and adolescents. Joiner’s interpersonal theory of
suicidal behavior (Joiner, Brown, & Wingate, 2005) was the first comprehensive the-
ory of adult suicide. Joiner proposed that suicidal ideation results from two specific
aspects of interpersonal despair, “thwarted belongingness” and “perceived burden-
someness,” along with more general experiences of depression such as a feeling of
hopelessness about one’s current situation. According to Joiner’s theory, an individ-
ual perceives a sense of “thwarted belongingness” when there is an absence of recipro-
cal care relationships, resulting in feelings of loneliness. Experiences of “perceived
burdensomeness” occur when an individual believes they are a liability to others and
endorses thoughts related feelings of self‐loathing. Joiner posits that if a person has
significant levels of one of these psychological experiences, they will develop non‐sui-
cidal morbid ideation, while the experience of both thwarted belongingness and per-
ceived burdensomeness, along with hopelessness about these states, are posited as
prerequisites for active suicidal ideation. Finally, according to this theory, in order for
an individual to progress from suicide ideation to suicidal behavior, they must also
develop an acquired capability for suicide (reductions in fear and pain sensitivity suf-
ficient to overcome self‐preservation reflexes) by reducing fear of death and increasing
physical pain tolerance through repeated practice and exposures of fearful and painful
experiences (Joiner et al., 2005; Van Orden et al., 2010).
Joiner’s theory has generally held up well empirically. Three studies taken together
support the theory’s proposition that the two interpersonal constructs (“thwarted
belongingness” and “perceived burdensomeness”) and acquired capability relate to
suicidality (Van Orden, Witte, Gordon, Bender, & Joiner, 2008). Several authors
have proposed that the interpersonal theory of suicide may have important theoretical
applications with youth and should fit well with what is known about risk and protec-
tive factors for youth suicide (Cero & Sifers, 2013; Czyz, Berona, & King, 2015). For
example, experiences of adolescent interpersonal despair (“thwarted belongingness,”
“perceived burdensomeness,” and general experiences of depression) may be signifi-
cantly influenced by family processes that are known risk and protective factors for
youth suicide, including the quality of the parent–child relationship, family conflict,
and cohesion. Several studies have found support for the extension of Joiner’s inter-
personal theory of suicide in adults to youth, and additional work in this area is ongo-
ing (Cero & Sifers, 2013; Czyz et al., 2015).
Treatment of Youth Suicidal Thoughts and Behavior
Risk assessment and deciding the appropriate level

Determining the appropriate level of care is one of the most challenging aspects of
treating depressed and suicidal youth. Depending on the level of symptom severity
(ideation alone vs. ideation with intent and/or plan), chronicity, past history of
attempt, and the ability of the family to agree to critical elements of the safety plan
(e.g., removal of lethal means, monitoring), inpatient or intensive outpatient hospi-
talization may be required. In addition to risk assessment, the following two addi-
tional questions can help to guide clinician’s in decision making about level of care:
(a) is the adolescent able to create a safety plan and willing to follow it, and (b) does
your clinical judgment and the existing evidence about the client support this? If the
answer to either of these question is not yes, some higher level of care should be acti-
vated. A therapy approach that involves family, even without addressing family rela-
tionship issues, is uniquely situated to help youth stay at home. Therapists should help
the family members learn the warning signs for their child, learn how to respond to
distress, and learn when to activate more intensive resources (i.e., emergency room
visits).
Confidentiality
Early in treatment, it is recommended that clinicians work with teens and their par-
ents to establish understanding about confidentiality. In line with professional ethics
codes for informed consent, therapists should present teens and their parents with a
very clear statement about the rules for confidentiality, including the conditions under
which the therapist will need to disclose information and include parents and other
significant adults (e.g., school counselors, medical doctors) in communications and
decision making (Berman, Jobes, & Silverman, 2006). Legally and ethically, when a
therapist judges that there is evidence of clear and imminent danger to self, they are
required to take whatever steps are necessary to ensure the physical safety of the teen,
including informing parents, hospitalization, and, depending on the situation, notify-
ing law enforcement officials (Berman et al., 2006). It is extremely important to be
clear about these procedures and to establish mutual agreement at the onset of treat-
ment. During the initial conversation, therapists should also convey that while parents
may be legally entitled to any information shared in treatment, clinical progress for
teens requires that they develop trust in their therapist to disclose only what is thera-
peutically beneficial and necessary, with buy‐in from the teen when possible (Berman
et al., 2006).
Safety planning
Regardless of treatment modality, one of the first—if not the first—intervention
required when working with suicidal adolescents and their families is the collaborative
development of a safety plan (Jobes, 2016). When working with suicidal youth, it is
the accepted standard of care that clinicians involve parents or primary caregivers in
the creation of a safety plan with and for youth. Do not use a safety contract or “no‐
harm contract,” in which the client promises to not attempt suicide or engage in
self‐harm. There is no evidence that safety contracts improve outcomes (Miller &
Berman, 2011). There is some evidence that no‐harm contracts actually increase lia-
bility risk should the client make an attempt, because the provider acknowledges the
person is at risk for suicide without improving treatment (Miller & Berman, 2011).
The point of a safety plan (vs. a no‐harm contract) is not to mitigate liability but to
improve client care; improving client care will also mitigate liability. The safety plan
should include triggers and chain analysis of what causes these triggers to happen. You
should create a list of coping skills that are available and practiced with the teen—in
session. Then document ways that the teen and their family/caregivers agree to
reduce access to lethal means (access to guns, medications, etc.). The last part of a
safety plan includes a list of people that the teen can turn to for support with their
contact information (e.g., friends, school counselor, family members, therapist, and
hotline numbers). Whatever you do for a safety plan, you should include a copy in
your file and be sure the client leaves the office with another copy.
Essentially, the creation and practice of a safety plan bridges suicide risk assessment
and the proposed treatment. One of the important items to cover in a safety plan is
the clients’ willingness and ability to enact their safety plan when in need. If the client
is able and willing to enact their safety plan, document this. Having family members
of youth involved in this process that can agree to help enact a safety plan is essential.
If the client is unable or unwilling to take the steps necessary to keep themselves safe,
then hospitalization or at least an increased level of care should be discussed with the
teen and their family (Sokol & Pfeffer, 1992). An essential part of proposed treatment
and the safety plan should be when to follow‐up. If the client is at increased risk of
suicide, document what the client will do to stay safe until the next session and when
you will check in to follow up. Then, be sure that you do actually follow up and docu-
ment it!
Treatment planning
In addition to risk assessment, discussing the rules of confidentiality, and safety planning,
therapists should use a team approach to work collaboratively with the teen and their
parents to formulate an initial treatment plan. The plan should include an overview of the
therapist’s conceptualization of the presenting problems, treatment goals, the nature and
purpose of the proposed treatment, potential risks and roadblocks, possible alternatives,
and the therapist’s view of short‐ and long‐term prognosis (Berman et al., 2006).
Demographic and contextual factors, including gender, socioeconomic class, race,

ethnicity, and sexual orientation can inform specific patterns in triggers or precipitants
of suicidal behavior (Goldston et al., 2008). For example, perceived racism and dis-
crimination has been associated with depression and hopelessness in samples of African
American teens, while acculturative stress has been associated with higher levels of
suicidal thoughts and behavior in samples of Latino adolescents (Goldston et al.,
2008). There can also be various cultural influences on family reactions to suicidal
behaviors, help‐seeking behavior, service utilization, and experiences of treatment
acceptability (Goldston et al., 2008). Systemic therapists should include a thorough
analysis of cultural and contextual factors in assessment, case conceptualization, and
treatment planning.
Finally, it is essential that therapists working with suicidal teens make a plan to prac-
tice good self‐care themselves, including paying attention to their own emotions and
possible experiences of vicarious trauma, building and maintaining a strong personal
and professional support network, and seeking additional consultation, training, and
supervision when needed (Meichenbaum, 2007).
Intervention and prevention approaches

Common factors in treatment While the literature base of suicide treatment and
extant recommendations almost exclusively call for further development and use of
evidence‐based treatments, several authors have identified a number of factors com-
mon to these evidence‐based treatments that they have labeled an integrative–eclectic
approach to treatment (Berman et al., 2006). We will refer to this approach as a com-
mon factors approach, as the term has gained traction in recent years (Hubble,
Duncan, & Miller, 1999; Sprenkle, Davis, & Lebow, 2009). While it is clear that no
one treatment fits every patient, Berman, Jobes, and Silverman strongly suggest two
overarching themes to the treatment of suicidal adolescents: (a) the importance of
relatedness and attachment and (b) the need for the therapist to adopt a strategic
problem‐solving approach that accounts for the individuality of the adolescent. A
strong therapeutic alliance will help therapists in both implementing a collaborative
strategic plan and improving a teen’s sense of relatedness and attachment. Suicidal
adolescents are often unfamiliar with positive working alliances with adults, and a
good relationship with the therapist can help to provide teens with important feelings
of belonging and support. Parents and family members often feel desperate, helpless,
and exhausted. A successful therapeutic alliance can help parents and family members
to feel more supported and empowered, equipping them to better help their teen. For
these reasons, the therapeutic alliance with teens and their parents must be central to
the treatment plan.
In addition to these two overarching themes, Berman et al. (2006) recommend
several other aspects to be integral to the successful treatment of suicidal adolescents.
As part of safety planning and efforts to increase protection from self‐harm, it is rec-
ommended that clients have increased levels of accessibility and communication with
their therapist, commensurate with risk. In a number of youth suicide treatment pro-
grams, this means youth having access to their therapist’s mobile number for non‐
emergency situations, therapist midweek check‐in phone calls, and home visits. In
addition, therapists should work with adolescents and their families to devise a tiered
system of emergency contacts tied to the level of severity of suicidal thoughts that the
adolescent agrees to use when they are experiencing suicidal thoughts and/or the
desire to hurt themselves (Stanley & Brown, 2012).
When designing treatment, it should be expected that intensive follow‐ups are con-
ducted. While not often discussed, one of the greatest predictors of treatment recov-
ery for suicidal adolescents is the duration of treatment. The reduction of suicide‐related
thoughts and behaviors should be expected to involve longer‐term treatment and
target emotion regulation, anger management, and interpersonal relationships.
The last of the general recommendations for treatment strongly suggests that par-
ents or caregivers be included in all stages of treatment, including assessment, safety
and treatment planning, and ongoing risk assessment. As in all child and adolescent
assessment, part of the assessment should also include evaluation of the parent’s abil-
ity to adequately fulfill essential parental functions, including risk assessment for vari-
ous forms of neglect and abuse, with engagement of social services, as necessary
(Berman et al., 2006). Beyond standard parenting and family risk assessment, clini-
cians working with suicidal teens should evaluate parent–teen communication pat-
terns and relational dynamics to understand how families can best support safety
planning and treatment progress (Berman et al., 2006).
Overview of the evidence base Though many interventions that specifically target
adolescent suicidal thoughts and behavior have been designed and implemented, the
impact of these interventions has not reliably been positive (Spirito & Esposito‐
Smythers, 2006; Tarrier, Taylor, & Gooding, 2008). In fact, a recent review of the
youth suicide psychosocial treatment literature identified 29 intervention studies
focused specifically on reducing youth suicide risk, including 18 randomized con-
trolled clinical trials, five nonrandomized controlled trials, and six pilot studies (Glenn,
Franklin, & Nock, 2015). The authors of the review grouped the therapies used in the
29 studies into six broad categories of treatments based on mode and target of treat-
ment. The six broad categories included cognitive‐behavioral therapy (CBT), dialecti-
cal behavior therapy (DBT), family‐based therapy (FBT), interpersonal therapy (IPT),
combination approaches, and “others.” Based on the results from the 29 studies, no
treatment modalities had published enough empirical evidence to meet the criteria for
a “well‐established” treatment (Southam‐Gerow & Prinstein, 2014). Only six thera-
pies met criteria for “probably” or “possibly” efficacious. Of these six treatments,
three were classified as family‐based models (Attachment‐Based Family Therapy;
Multisystemic Therapy; the Resourceful Adolescent Parenting Program), and two
additional therapies relied extensively on family involvement (individual CBT plus
family work and parent training; individual plus family psychodynamic therapy).
(Individual interpersonal therapy also had enough empirical evidence to meet criteria
as a probably efficacious treatment.) A number of investigations of evidence‐based
treatments have included significant numbers of ethnic minority youth, and several
prevention programs and treatments have been tailored or adapted to address com-
mon treatment‐related issues for work with youth from particular ethnic and sexual
minority groups (Diamond et al., 2010; Goldston et al., 2008).
Each approach to working with suicidal youth utilizes its own theoretical assump-
tions about the underlying causes of suicidality. While these theoretical assumptions
are not often mentioned (Frey & Hunt, 2018), they do (or should) inform deci-
sions about when and how intervention should occur. Across the various empirically
supported protocols, a number of root causes of depression and suicidality have

been suggested: the symptoms of a single, neurobiological disease (medication
approaches; Fried & Nesse, 2015; Reardon, 2014); a lack of problem solving, self‐
regulation, and emotion regulation (cognitive‐behavioral and dialectical behavior
approaches; Dimeff & Linehan, 2001; Rudd & Brown, 2011); or the result of various
family dynamics and/or parent–child relational problems (Diamond, Reis, Diamond,
Siqueland, & Isaacs, 2002; Frey & Cerel, 2015). The history of psychotherapy con-
tains no small amount of writing and education that utilizes case studies or anecdotes
about suicide‐related thoughts and behaviors with any number of therapeutic modali-
ties; the remainder of this section will primarily focus on approaches that have empiri-
cal evidence or are novel approaches, specifically novel approaches that have grown
out of technological advances, including mobile applications and online support
systems.
Medication and pharmaceutical approaches While many therapists adopt a stance

that is relatively anti‐medication, this stance is potentially dangerous with suicidal
and depressed populations as the standard of care for suicide recommends consid-
eration of pharmacological therapy in addition to psychotherapy (Berman et al.,
2006; Goldsmith, Pelimar, Kleinman, & Bunney, 2002). However, it should be
noted that the number of well‐controlled pharmacological studies with suicidal or
depressed adolescents is extremely limited (March et al., 2007). Despite the meth-
odological concerns with pharmacological intervention studies, it is clear that bio-
logical factors have a significant role in suicide‐related thoughts and behaviors (cf.
Maris, Berman, & Silverman, 2000). Though little data exist on the efficacy of
pharmacotherapy on NSSI, what little data do exist suggests that pharmacological
treatment may be effective (cf. Turner, Austin, & Chapman, 2014).
Cognitive‐behavioral and dialectical behavior therapy approaches The most widely

studied and used theoretical models for intervention with suicide‐related thoughts
and behaviors are cognitive‐behavioral therapy. Aaron Beck, Weissman, and Kovacs
(1976) suggested six specific cognitive distortions are likely found when people are
severely depressed or suicidal: (a) arbitrary inference, in which conclusions are drawn
from little (or no) evidence; (b) dichotomous thinking, in which things must be either
right/wrong or black/white; (c) magnification/minimization, in which things are
given much more or much less importance than dictated by logic; (d) overgeneraliza-
tion, in which one incident is used to predict how all future incidents will occur; (e)
personalization, in which everyone’s actions are assumed to be directly tied to me or
in response to my own actions; and (f) selective abstraction, in which a whole body of
evidence is ignored due to attention given to one specific piece of evidence.
In addition to the cognitive distortions suggested by Beck, adolescents have a ten-
dency to believe they are unique and that common difficulties or consequences do not
apply to them (personal fable; Elkind, 1967). Specifically, in regard to suicidal
thoughts and behavior, this may be manifest in the way that adolescents show less
certainty that their suicide‐related behaviors may actually result in death (Parellada
et al., 2008). This personal fable also means that adolescents feel that other people
(especially parents) cannot possibly understand them due to their uniqueness.
Several CBT and dialectical behavior therapy adaptations have been utilized with
suicidal adolescents, including child‐ and family‐focused CBT (Weinstein, Cruz, Isaia,
Peters, & West, 2017), integrated CBT (Esposito‐Smythers, Spirito, Kahler, Hunt, &
Monti, 2011), parent–adolescent CBT, and dialectical behavior therapy for adoles-
cents (Miller, Rathus, & Linehan, 2007). The results of each of these family‐enhanced
therapy trials provide evidence that the approaches work; however there is little, if any,
evidence that the approaches differ from the non‐family‐enhanced versions.
Family therapy approaches Whether it be a sort of family loyalty (Boszormenyi‐Nagy

& Spark, 1973), insecure attachment behavior (Bowlby, 1980), desperate reactions to
double binds (Bateson, Jackson, Haley, & Weakland, 1956), or a family member who
wishes the adolescent to be dead (Whitaker & Ryan, 1989), the patterns that suicidal
adolescents find themselves repeating are deeply connected to the patterns and cycles
that are the foundations of family therapy. We believe that couple and family therapists
and other systemic‐ and family‐oriented professionals have something unique to bring
to the suicide prevention world—the understanding of relational and familial pro-
cesses. This understanding is much needed as many of the roots of suicide‐related
thoughts and behaviors develop as part of a two‐person and deeply interpersonal
process (Joiner & Coyne, 1999).
Several family therapists have written on assessing (Flemons & Gralnik, 2013) and
treating adolescent suicide (Diamond, Diamond, & Levy, 2014; Jurich, 2008). Jurich
(2008) embraced an eclectic approach and proposed the use cognitive, behavioral,
and strategic family‐based interventions. While a recent review of family‐based inter-
ventions for treatment suicide identified 13 unique modalities for family therapy
intervention (Frey & Hunt, 2018), further examination of the articles identified in
the review suggests that few of these 13 interventions fully adopt a family therapy
modality, in that they do not focus primarily on the relationship between family mem-
bers as the proposed mechanism of change (e.g., family‐enhanced CBT and DBT; for
examples, of investigations of therapy models that do identify relational mechanisms
of treating youth suicide and depression, see Pineda & Dadds, 2013; Shpigel,
Diamond, & Diamond, 2012).
Attachment‐based family therapy One of the main goals of Attachment‐based

family therapy (ABFT) is to target and reduce negative family processes that increase
suicide risk and to increase the family processes that protect against suicide. Through
a clinical lens, adolescents and young adults often express problems in the quality of
their relationship with their parents through their daily interactions about behavio-
ral issues (e.g., chores, curfew, homework). When the quality of the relationship is
stressed and marked by anxiety, avoidance or detachment, stressful interactions are
more common. Poor relational quality can significantly exacerbate adolescent
depression and increase engagement in risky behavior (sexual and otherwise) and
substance use (Nock et al., 2008). Conflictual and stressful interactions with parents
also perpetuate and exacerbate adolescents’ feelings of anxiety and avoidance with
parents contributing to an ongoing cycle of disappointment and mistrust (Bowlby,
1988). The goal of ABFT is to target ruptures in the attachment relationship
between teens and their parents. Adolescents work to understand the relational
dynamics in their families that have either contributed to or helped to maintain their
depression, isolation, and despair, while parents work to better understand what will
help their teen to feel an increased sense of safety and validation during difficult
and emotionally vulnerable conversations and interactions in the family, including
conversations about the teen’s experience with suicidal thoughts and behaviors
(Diamond et al. 2014).
Therapists following the ABFT model accomplish treatment goals through helping
teens to systematically identify specific relational ruptures with their parents and their
underlying themes (e.g., high levels of parental criticism, emotional unavailability,
rejection) and then working to repair the ruptures in family sessions. During family
sessions, therapists facilitate conversations in which adolescents increasingly turn to
their parent(s), while parents are coached to use skills and perspectives gained in the
early stages of treatment to provide comfort, care, and resources and support. A key
underlying premise of ABFT is that improved parent–teen attachment quality and
family relations will help to buffer teens against feelings of depression and suicide‐
related thoughts and behaviors. The ability to communicate vulnerable and some-
times scary emotions without fear of criticism, rejection, or threat of abandonment is
the basis of healthy attachment (Bowlby, 1988) and the heart of ABFT. As outlined
in Diamond et al. (2014), attachment repair and subsequent autonomy building in
ABFT are facilitated using five distinct treatment tasks. Tasks are not equated with
sessions. Instead, a task is a set of procedures, processes, and goals related to resolving
or accomplishing specific aims in therapy (e.g., establishing alliance). Five empirical
studies provide evidence that ABFT is effective for treatment of suicidal youth and
demonstrate that ABFT reduces adolescent depression and suicide risk more effec-
tively than waitlist control or treatment as usual (TAU) (Krauthamer Ewing, Levy,
Scott, & Diamond, 2017).
Family acceptance project The Family Acceptance Project (FAP) (Ryan, Russell,
Huebner, Diaz, & Sanchez, 2010) has designed as a family‐oriented support and
intervention model to help clinicians, educators, and other communities involved
with youth to support parents and families with LGBTQ youth. The overarching
goal of the project is to build research and resources that will help families to better
support children who identify as LGBTQ—not to change their convictions. In addi-
tion to research on parental and family reactions and adjustment to an adolescent’s
coming out, the project works to develop training materials, assessment tools, and
other resources for mental health practitioners, schools, and other community mem-
bers to help support LGBTQ youth and their families. As part of these efforts, sev-
eral key points have been identified to specifically guide therapists in their work,
including (a) engaging families and caregivers by viewing them as allies, (b) helping
parents and caregivers to tell their story, and (c) providing psychoeducation to fami-
lies about the impact of parental and family responses to LGBTQ youth, particularly
the impact of love and support as compared to rejection (Substance Abuse and
Mental Health Services Administration, 2014). Research papers from the project
were among the first to show empirically clear links between accepting family atti-
tudes and behaviors and significantly decreased risk of depression, substance use, and
suicide in youth (Ryan et al., 2010). Additional information about FAP can be found
at the project’s website: http://familyproject.sfsu.edu.
Group therapy After a suicide attempt or when risk is identified as high, for example,
during lengthy periods of high levels of ideation or when intent and/or plan have
been articulated, adolescents are often hospitalized as inpatients. During inpatient
stays for suicidal thoughts and behavior, group psychotherapy is a very common
modality. Group therapy is also the most common modality used for suicide bereave-
ment (Berman et al., 2006). Largely, group therapy is focused on ventilation of affect,
listening and communication skills, and peer support. Several authors have discussed
the benefits and challenges of group therapy with suicidal adolescents that tends to
focus on themes of peer and family relationships and controlling overwhelming feel-
ings (Glaser, 1978; Hengeveld, Jonker, & Rooijmans, 1996; Ross & Motto, 1984).
While certainly there is power in group work, group therapy has been used in place of
family therapy (Glaser, 1978; Pineda & Dadds, 2013). One of the strongest findings
for family relationships as a mechanism of change in the reduction of adolescent sui-
cidality comes from a group‐treatment protocol, the Resourceful Adolescent Parent
Program (RAP‐P) (Pineda & Dadds, 2013).
Resourceful Adolescent Parent Program (RAP‐P) The RAP‐P is a group‐based

intervention model that was designed to help parents promote more optimal family
environments for the healthy adolescent development in the face of teen suicide risk.
The program is competency based and aims to help parents increase their self‐esteem
and the self‐esteem of their adolescents. Parents are also taught to manage their own
negative emotional reactions to their adolescents and their adolescents’ emotions reac-
tion to the parents. The RAP‐P is designed to include three group parent sessions, each
being between 2 and 3 hr in length. There are three major themes to the program, each
functioning as a theme for one of the group sessions: (a) parents are people too, (b)
what makes adolescents tick, and (c) promoting family harmony. During the first group
session, Parents Are People Too, parents are encouraged to identify and focus on their
own strengths. Specifically, parents are asked to identify their own contributions to
their adolescent’s well‐being. After identifying and discussing their strengths, parents
are asked to identify the impact that stress has on their parenting and strategies they use
to help manage stress. During the second group session, What Makes Adolescents Tick,
parents are encouraged to consider the specific needs of their adolescents.
Psychoeducation and group discussions then focus on adolescent development and
role transitions relevant to adolescence. During the third group session, Promoting
Family Harmony, parents discuss strategies to help promote cohesive family relation-
ships and manage conflict with their teens.
Preliminary results from a randomized controlled trial that compared RAP‐P plus
TAU with TAU showed that RAP‐P demonstrated higher retention rates, greater
improvements in family functioning, and greater reductions in adolescent suicidal behav-
ior than TAU (Pineda & Dadds, 2013). The authors also found that the reduction in
adolescent suicidal behavior was fully mediated by improvements in family functioning.
More information about the RAP‐P can be found at http://www.rap.qut.edu.au.
School‐based intervention Despite the growing acceptance of seeking treatment and

the decreasing stigma of mental health problems, few adolescents seek treatment
when in need. By virtue of the amount of time that children and teens spend in school
and the demands of academic performance and social life in the school environment,
school counselors are often among the first adults to be made aware of suicide risk in
adolescents. Counselors can be cued in to student distress from reports by students
themselves, concerned peers, and/or teachers. Increasingly, schools are putting for-
mal protocols in place to help counselors triage and support teens struggling with
depression and suicide risk and their families. While school counselors can often serve
as a critical source of support for students and families, more work is needed to
develop effective protocols and to support counselors and other school staff in their
efforts, including making sure that school counseling offices are adequately staffed
and resourced (Erbacher, Singer, & Poland, 2014). Several school‐based prevention
programs have been implemented with some success.
Signs of suicide Signs of Suicide is a psychoeducational program designed to teach

students about the signs of suicide and which actions they should take to attempt to
prevent suicide (Aseltine & DeMartino, 2004). Students are taught how to identify
the warning signs of suicide displayed by peers, how to provide empathy, how to sup-
port their at‐risk peers, and how to communicate their concerns to adults. Aseltine
and DeMartino (2004) found suicide rates were decreased significantly for partici-
pants in the Signs of Suicide group compared to the control.
Question, persuade, refer Question, Persuade, Refer is a mental health gatekeep-

ing program. The program is designed for laymen and specifically used with counse-
lors, students, and staff in many school settings (Wyman et al., 2008). A participant
learns the signs of suicide and learns how to ask questions about suicide, persuade
the person at risk to seek help, and refer the person to a professional who can provide
more help. Recent empirical findings demonstrate both short‐ and long‐term posi-
tive outcomes in knowledge about suicide prevention and self‐efficacy for helping
those at risk for suicide for individuals who participate (Mitchell, Kader, Darrow,
Haggerty, & Keating, 2013).
Counselors CARE/coping and support training (C‐CARE/CAST) Counselors

CARE and CAST are both school‐based interventions for suicide‐related thoughts
and behaviors that are generally used in tandem (Randell, Eggert, & Pike, 2001).
C‐CARE utilizes computer‐enhanced assessments of protective and risk factors for
suicide in schools. An intervention designed to strengthen the adolescents’ social
network and their coping skills is administered after the assessment. CAST is designed
as a group therapy intervention in which suicide‐related thoughts and behaviors are
treated. Randell et al. (2001) study utilized C‐CARE, C‐CARE and CAST, and TAU
as three conditions in their study. All three conditions showed positive main effects in
reducing suicide risk behaviors and anger control problems; C‐CARE plus CAST
showed the most robust outcomes relating to self‐control and the adolescents’ ability
to solve and cope with problems healthfully.
Online peer supports and mobile apps In recent years a number of peer support sys-
tems and apps have been developed to help prevent and treat suicide‐related thoughts
and behaviors. One of the most popular online peer support systems for suicide‐
related thoughts and behaviors is the forum Suicide Watch on Reddit (http://www.
reddit.com/r/SuicideWatch). The forum is a peer support network that includes a
directory of voice, chat, and text hotlines and other online resources in addition to the
ability for the nearly 90,000 subscribers to communicate with one another about
thoughts of suicide. The forum has strict rules that are regularly enforced—the basic
rule for engagement is to respond with genuine concern.
Another online platform that has been increasingly used to find support for suicide‐
related thoughts and behaviors is the web‐ and app‐based messaging system 7 Cups of
Tea. The 7 Cups of Tea platform utilizes volunteers that provide free emotional sup-
port. All volunteers are required to complete a training course that teaches active lis-
tening and basic counseling skills like reflection, summarizing, and responding with
empathy. More information about 7 Cups of Tea can be found at their website
(www.7cups.com) or a recent study about user satisfaction (Baumel, 2015).
More than 800 unique apps that advertise addressing suicide or self‐harm were
identified and reviewed (Larsen, Nicholas, & Christensen, 2016). Almost 90% of
apps claiming to help prevention suicide ideation or self‐harm contain no suicide
prevention strategy and several included content that may be considered harmful.
(Larsen et al., 2016). Several apps that have been recommended include Safety Net
and Mood Tools—Depression Aid and My Virtual Hope Box. The virtual hope box app
is a mobile phone adaptation of the hope box tool often used when a person uses an
old shoe box to put pictures or other items that serve as reasons to live or coping
tools in one place. A recent review of apps found that they can be useful in managing
and reducing suicide ideation but have no significant treatment effect on instances of
NSSI or attempted suicide (Witt, 2017). Suicide‐focused intervention over the
Internet, text, and telephone has shown significant reductions in suicide ideation
(Kreuze et al., 2017).
Additionally, the virtual hope box app has been programmatically developed and
studied for proof of concept (Bush et al., 2015) and efficacy (Bush et al., 2016). While
the VHB app did show the ability to help participant’s better cope with unpleasant emo-
tions and thoughts, it did not show superiority in decreased suicide‐related thoughts
and behaviors when compared to a control. Despite this lack of superiority, utilizing an
app that stores a digital copy of a safety plan, reasons for living, simple games for distrac-
tion, and guided meditation can be a great supplement to any treatment.
Conclusion: Building Systems of Healing, Connection, and Care
This chapter has aimed to provide an overview of many of the important issues and
topics that systemic therapists should be familiar with in order to ethically and effec-
tively work with suicidal youth. Unfortunately, despite the rising incidence rates of
suicide and suicide‐related thoughts and behaviors in youth, it is well documented
that most therapists do not receive adequate education in this area during graduate
training (Schmitz et al., 2012). In addition, state licensing boards routinely do not
require demonstration of competency in assessment and management of suicidal
patients or continuing education in this area. The lack of available training and com-
petency requirements exists in stark contrast to public health service needs and to
national calls for improvement in training by organizations dedicated to suicide pre-
vention (Schmitz et al., 2012). Therapists who seek additional reading material and
enhanced and specific training for working with youth at risk for suicide are encour-
aged to explore the many helpful resources available through the Substance Abuse
and Mental Health Services Administration website https://www.samhsa.gov/
suicide‐prevention/publications‐resources and trainings and information provided by
the Suicide Prevention Resource Center http://www.sprc.org/events‐trainings.
In addition to better educational policies and requirements for clinical training in
treating youth suicide risk, we need robust public health campaigns and policy initia-
tives. Such initiatives should be evidence‐based and incorporate current models and
theories indicating that family and community stress, conflict, isolation, and discon-
nection intersect to place youth at significantly greater risk for suicidal thoughts and
behavior. Policy initiatives that seek to have an impact on youth suicide risk should
therefore include initiatives and strategies to support (a) positive family development
and reduce parent and family stress (e.g., universal health‐care initiatives, mental
health coverage parity, adequate and supportive parental and family leave policies), (b)
educational initiatives that focus on youth socioemotional development and commu-
nity cohesion (e.g., programs aimed at reducing bullying and promoting empathy/
perspective taking, connection and care), and (c) efforts to confront larger societal
and sociopolitical factors known to contribute to psychological experiences of isola-
tion, marginalization, and disconnection (e.g., racism, xenophobia, homophobia, sex-
ism) (Baams, Grossman, & Russell, 2015; Lai, Li, & Daoust, 2016).
Based on current evidence and models of youth suicide, it is incumbent upon indi-
viduals working and caring for youth at risk for suicide to approach case conceptual-
ization and treatment using a systems perspective. This includes assessing the
intersections of risk and resilience factors across individual, family, school, community,
and cultural and sociopolitical levels. Armed with a systems‐based case conceptualiza-
tion, proper training in suicide risk assessment and safety planning, and evidence‐
based treatment strategies, therapists can work to help youth to build healthier coping
strategies, stronger relationships, and more robust systems of support. In closing, for
the therapist working with a child or teen at risk for suicide, there is no denying that
the work can be demanding. However, when therapists are well trained and well sup-
ported, our work can also be exceptionally rewarding, impactful, and truly lifesaving.
Note
1 The material for this case vignette is made up of a composite of numerous cases treated by
the first author of this chapter. Confidentiality and privacy have further been protected
through limiting specific descriptions of the various families used in the composite.
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15
Systemic Approaches for Children,
Adolescents, and Families
Living with Neurodevelopmental
Disorders
Julie L Ramisch and Nicole Piland
In this chapter we will discuss neurodevelopmental disorders (e.g., intellectual disabilities,

communications disorders, autism spectrum disorder, attention deficit/hyperactivity
disorder, specific learning disorder, and motor disorders) using the Diagnostic and
Statistical Manual of Mental Disorders (5th ed.; DSM‐5; American Psychiatric
Association [APA], 2013). We will discuss the assessment process of both children,
adolescents, and their families to explore the stressors and resources for families with
children with neurodevelopmental disorders. For systemic family therapists, key issues
and challenges families may present to therapy for will be highlighted, and modern
and postmodern family therapy theories and approaches that are ideal for intervening
with families will be reviewed. Finally, this chapter will conclude with concrete prac-
tice recommendations and a call for research that addresses the limitations within the
existing literature.
Neurodevelopmental Disorders According to the DSM‐5
While each family with a child with a neurodevelopmental disorder is different, neu-
rodevelopmental disorders are typically diagnosed in early childhood, frequently co‐
occur with each other and with other mental health disorders or symptoms, and are
characterized by both deficits in and an excess of certain behaviors. General preva-
lence data, primary symptomology, current research on treatment options, and the
socioemotional and relational challenges for those affected by these disorders will be
highlighted in the following sections.
We use the DSM‐5 as a reference in this chapter as this is the diagnostic tool most
often used by mental health professionals. However, the International Classification
of Diseases, 10th revision (ICD‐10), is an internationally used reference that includes
medical and mental health disorders, conditions, and diseases and is an additional tool
370 Julie L Ramisch and Nicole Piland
mental health professionals used for the diagnostic process. The ICD‐10 and related
materials are published by the World Health Organization and are accessible online
for free (World Health Organization, 2018).
Intellectual disabilities
According to the DSM‐5, intellectual disabilities are characterized by deficits in intel-
lectual functioning (e.g., reasoning, problem solving, abstract thinking) and deficits
in adaptive functioning across conceptual, social, and practical domains. Intellectual
disabilities can be classified as mild, moderate, severe, or profound (APA, 2013). The
American Academy of Pediatrics (2015) reports that this is the most common of the
developmental disorders with approximately 6.5 million people diagnosed in the
United States. Intellectual delays can become evident in the formative years of a
child’s life and are seen within the motor, language, and social realms of development.
A diagnosis is typically made based on both IQ level and other assessments, which
determine daily functioning level for the individual (e.g., expressing needs, involve-
ment in daily routines). Because it is difficult to assess for IQ level until children are
school aged, children in early childhood may be classified as having a global develop-
mental delay and receive a more precise diagnosis years later.
Communication disorders
Children and adolescents can receive a communication disorder diagnosis, which can
fall under one of the following types: language disorder, speech sound disorder, child-
hood‐onset fluency disorder (stuttering), and social (pragmatic) communication dis-
order. Each of these disorders accounts for challenges associated with acquisition, use,
production, or comprehension of language. Communication disorders are found in
5–10% of children, and 8–9% are specifically diagnosed with speech sound disorders.
It is important to take into consideration that some children have a communication
disorder due to an intellectual disability and others acquire one related to other fac-
tors (APA, 2013). Plus, it is not uncommon for communication disorders to co‐occur
with several other neurodevelopmental disorders discussed later in this chapter.
Autism spectrum disorder

To be diagnosed with autism spectrum disorder, individuals need to display an impair-
ment in reciprocal social communication and social interaction and have restricted,
repetitive patterns of behaviors, interests, or activities. Symptoms should be present
from early childhood and hinder everyday functioning. Children with an autism spec-
trum disorder often struggle to initiate social interactions and share emotions, which
makes developing relationships with peers difficult (APA, 2013).
The Centers for Disease Control and Prevention (CDC, 2016) reports that about
1 in 68 children qualifies for an autism spectrum disorder diagnosis. The diagnosis is
about 4.5 times more common among boys and can occur in all racial, ethnic, and
socioeconomic groups. While the cause of autism spectrum disorder is still unknown,
the CDC reports that children with older parents (mothers older than 35 years and
fathers older than 40 years) are at a higher risk for the diagnosis. There is also an 83%
Families Living with Neurodevelopmental Disorders 371
chance of co‐occurrence with one or more non‐autism spectrum disorder develop-

mental diagnoses and a 10% chance of co‐occurrence with one or more psychiatric
diagnoses; they have found that autism spectrum disorder commonly co‐occurs with
other developmental, psychiatric, neurologic, chromosomal, and genetic diagnoses.
Refer to Volume 4 for more information on autism spectrum disorder and systemic
family therapy.
Attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder can be classified into three subtypes: inatten-
tive, hyperactive impulsive, or the combined type. Due to the lack of specific testing
protocols, attention deficit/hyperactivity disorder has the potential to be overdiag-
nosed and misdiagnosed and/or often co‐occurs with other mood disorders (e.g.,
anxiety, depression, and/or obsessive–compulsive disorder) (Hallowell & Ratey,
1994, 2011). Children with an attention deficit/hyperactivity disorder diagnosis suf-
fer with difficulty concentrating, tend to engage in impulsive behaviors, talk exces-
sively, lose things easily, and often have problematic social interactions related to these
symptoms. The CDC (2017) reports varied prevalence data for attention deficit/
hyperactivity disorder, which generally ranges from 5 to 11% but in some cases is
reported as high as 18% for children ever diagnosed with attention deficit/hyperactiv-
ity disorder.
Due to the challenges associated with securing an attention deficit/hyperactivity
disorder diagnosis, it is important for parents to work closely with trained profession-
als who specialize in diagnosing and treating attention deficit/hyperactivity disorder
to ensure that an accurate diagnosis is made. Some examples of professionals who can
be utilized for diagnosis include a family therapist, child psychologist, psychiatrist,
pediatrician, and/or school diagnostician. Parents and teachers often provide valuable
information about symptoms and behavior exhibited by the child and observed in
multiple contexts. One important consideration to make when a child is being evalu-
ated for an attention deficit/hyperactivity disorder diagnosis is to determine whether
there is a history of a traumatic childhood event. Children who have experienced
trauma and have not received trauma‐focused intervention can exhibit attention defi-
cit/hyperactivity disorder‐like symptoms but may not actually have attention deficit/
hyperactivity disorder (Brickel, 2017; National Child Traumatic Stress Network
[NCTSN], 2018).
Specific learning disorder

To meet diagnostic criteria for a specific learning disorder, a child must experience
difficulties learning and using key academic skills during the formal school years. A
specific learning disorder may involve impairments in reading, written expression, or
math. Academic skills differ from developmental milestones in that academic skills
have to be taught and learned while developmental milestones emerge. Examples of
learning disorders include dyslexia (i.e., difficulty with reading), dyscalculia (i.e., dif-
ficulty with math), and dysgraphia (i.e., difficulty with writing). Children with learn-
ing disorders may feel frustrated at school and may exhibit externalizing or internalizing
behaviors, which can ultimately impair their social functioning (Wu, Willcutt, Escovar,
& Menon, 2014). In addition, learning disorders can co‐occur with other disabilities
or emotional/behavioral disorders. The DSM‐5 reports that about 5–15% of
school‐age children across different languages and cultures are diagnosed with specific
learning disorders (APA, 2013).
Motor disorders
Under the umbrella of motor disorders, the DSM‐5 has separate diagnostic criteria for
developmental coordination disorder, stereotypic movement disorder, and tic disor-
der. Developmental coordination disorder involves delay and/or impairment in motor
coordination (e.g., sitting, crawling, walking, buttoning, stringing beads, and writ-
ing). In children ages 5–11, about 5–6% are diagnosed with developmental coordina-
tion disorder. Stereotypic movement disorder is characterized by repetitive, seemingly
driven, and apparently purposeless motor behaviors that may or may not result in
self‐injuries (e.g., rocking, jumping, and hand flapping). The DSM‐5 reports that
about 3–4% of children engage in complex stereotypic movements and that 4–16% of
individuals with intellectual disabilities engage in stereotypic behaviors and self‐injury.
Tic disorder encompasses Tourette’s disorder, persistent (chronic) motor or vocal tic
disorder, provisional tic disorder, and the other specified and unspecified tic disorders.
Qualifying for a diagnosis depends on the presence and duration of symptoms and the
age of onset as well as any other known medical conditions or substance use. The
DSM‐5 reports that about 0.3–0.8% of school‐age children experience Tourette’s
disorder (APA, 2013).
It is often difficult for children with motor disorders to engage in physical activities.
This can often impede social relationships and lead to poor social competence, poor
motivation, low self‐esteem, unhappiness, obesity, and poor physical fitness.
Additionally, these symptoms can continue into adulthood. Motor disorders may co‐
occur with an autism spectrum disorder, attention deficit/hyperactivity disorder,
obsessive–compulsive disorder, oppositional defiant disorder, specific learning disor-
der, anxiety, and depression (Hillier, 2007). Thus, the diagnosis and treatment pro-
cess is sometimes complicated by the likelihood of each of these disorders co‐occurring
with one another.
Diagnostic Process for Families with Children with

Neurodevelopmental Disorders
Obtaining a diagnosis
As parents or primary caregivers begin to recognize the behaviors or symptoms associated
with any of the abovementioned disorders, they are quickly charged with the task of
securing appropriate resources for first diagnosing and then addressing the symptoms
in order to enhance the child’s intellectual, social, emotional, and relational capacity.
There are a variety of ways parents might proceed with seeking evaluation or assessment
for their child.
Most often, the primary care provider or pediatrician is an initial point of contact
because the pediatrician’s role is to monitor child development, as well as refer parents
to specialists who are trained in addressing areas of development. Every state also has
early childhood intervention specialists as part of a federal program. These specialists
can evaluate young children who have delays or other health conditions, and they can
recommend specific services. The family’s pediatrician will link the family with their
state’s early intervention program. If the child is already in school, families can also
reach out to the school counselor and/or someone who provides help with behavioral
intervention for further direction for initial assistance. For more information on early
childhood intervention, see Bekins (2018).
While obtaining a diagnosis as early as possible can be a stressful process for parents
and caregivers, it is essential because a proper diagnosis is what informs intervention
and treatment options, as well as serves as the basis for insurance eligibility and pro-
vider reimbursement for specialized services. Access to services is often dependent on
the type of insurance coverage held by families (e.g., private insurance versus state‐
funded plans). Some insurance plans will allow families to seek out and make appoint-
ments with specialists as they see fit. Other insurance plans require families to seek
specialty care via the primary physician who serves as the gatekeeper for referrals.
Once an accurate diagnosis is secured, parents and caregivers often start to build a
team of appropriate providers and specialists for diagnostic‐specific intervention. In
their home communities, families may seek out the assistance of a speech language
pathologist, an occupational and/or physical therapist, a vision therapist, or even visit
specialized organizations, like an autism or Down syndrome center, who serve per-
sons with similar needs (e.g., Burkhart Center for Autism Education and Research,
2018; GiGi’s Playhouse, 2018). Families may also locate a children’s hospital with
disorder‐specific clinics that assess, diagnose, and treat children and adolescents with
these conditions (e.g., Boston Children’s Hospital, 2018; Children’s Hospital
Colorado, 2018).
Of course, each child’s needs will be unique and may not require as many specialists
as the next child. However, many families will begin with a specialist who addresses
the limitation that poses the greatest challenge or the area where there is the greatest
level of impaired functioning. For example, a child who is experiencing feeding issues
will need nutrition‐based intervention designed to enhance oral coordination, given
the importance and foundational role of proper nutrition as it relates to other areas of
development. Then, intervention for speech and language problems or other com-
munication needs can be addressed. On occasion, multiple services are sought simul-
taneously, but ultimately, developing a team of providers is a process that takes time
to create and at times warrants second opinions.
Socioemotional family process

Parents and caregivers who are witnessing symptoms will arrive at a diagnosis or diag-
noses in a variety of ways. The diagnostic process can be slow and frustrating and, in
some cases, may take years. The disabilities associated with congenital conditions, like
Down syndrome or cerebral palsy, often reduce the diagnostic timeline and poten-
tially the emotional stress for parents (Lenhard, Breitenbach, Ebert, Schindelhauer‐
Deutscher, & Henn, 2005) because the physical or congenital condition informs the
process of assessment and treatment related to the developmental delays associated
with the aforementioned disorders. However, the process for parents of a child who
is beginning to exhibit signs of an autism spectrum disorder might take months or
even years to establish a diagnosis. A lengthier diagnostic process can be quite com-
mon for those children who exhibit symptoms characteristic of what was traditionally
referred to as Asperger syndrome (Goin‐Kochel, Mackintosh, & Myers, 2006).
The diagnostic process is a process that involves persistence and patience. However,
while providers are busy seeking to address symptoms and medical concerns of the
child, there may be an emotional process that can be overlooked by the providers who
interface with the family system seeking assessment for their loved one. Recently,
there has been some attention given to the emotional process, which is often filled
with a wide range of emotions for parents receiving diagnostic news (Nelson Goff
et al., 2013). The work of Pauline Boss (1999) and her model of ambiguous loss has
served as a valuable framework for understanding the emotional realm for these car-
egivers. Ambiguous loss places attention on the relative presence of the loved one as
either physically present or psychologically absent or vice versa (Boss, 1999, 2006,
2007). The level of physical and psychological presence compared with what parents
expect at the time of their child’s birth is important for understanding where parents
might get stuck emotionally. Parents are thrust into the position to manage the ambi-
guity of the present moment (i.e., the impact of their child’s diagnosis on the child
and the family) as well as what the future holds for their child and the family (Piland
Springer, Turns, & Masterson, 2018).
Boss (2007) highlights that the ability to manage ambiguity or accept the unknowns
is a key element for demonstrating resilience. The assumption is that parents who can
accept the unknowns and can tolerate the ambiguity tend to cope better. This being
said, some diagnoses are inherently more ambiguous in terms of what to expect along
the developmental trajectory than others. In addition, the level of functioning physi-
cally or psychologically can also change across time, influencing family adaptation.
When professionals begin working with families on their disability journey, there are
a variety of systemic approaches that can serve as the foundation for assessment and
intervention in hopes of maximizing the functioning of the family as a whole.
Therefore, it is important for providers to remember that the diagnosed child or ado-
lescent does not exist in isolation, as they are a part of a larger family system and com-
munity. The functioning of the diagnosed child could be enhanced by improvements
made in the functioning of the parental subsystem or vice versa. Thus, we will turn
our attention to the research available on families living with neurodevelopmental
disorders in order to present a clearer picture of the complex nature of the various
factors that affect family adaptation.
Contextual Factors that Influence Family Functioning
There are a variety of conceptual models that could be useful for clinicians when
assessing and intervening with families living with neurodevelopmental disorders. The
Family Systems Illness (FSI) model developed by John Rolland is valuable for concep-
tualizing family functioning and recognizing the relationship between the illness/
disability of the patient, the family system, and the larger social context (Rolland,
2018). More specifically, Rolland emphasizes the importance of attending to the
impact of the disability or health condition on the family system as a whole. In addition,
Rolland (2018) states, “the family is regarded as an essential resource and partner in
treatment, with the potential of fostering optimal adaptation” (p. 9). Others encourage
providers to consider both the physical and intellectual challenges across disorders/
disabilities (McDaniel & Pisani, 2012). Thus, this section will address a combination
of family and disability factors related to family functioning.
Additionally, one of the more commonly applied models in the literature is the
Double ABCX model (McCubbin & Patterson, 1983). The Double ABCX model is
a theory about coping and adjustment to stressful life events that can be used by men-
tal health professionals to assess and treat families with children with disabilities
(Ramisch, 2012). In the Double ABCX model, the different elements of the model
are represented by the following: (aA) the pileup of life stressors and strains, (bB) the
intrafamily resources as well as the family’s ability to acquire and utilize community
resources for dealing with the stressors, and (cC) the family’s definition and percep-
tions in order to make meaning out of the event and to manage. The first three ele-
ments all have a sum total effect on family adaptation (xX). Therefore, we have
organized the following section by providing an overview of various studies that
examined family stressors; access and barriers to resources, including coping; and fam-
ily adaptation.
Family stressors
Rolland (2018) highlights the importance of recognizing the patterns of demands
specific to the disability over time, especially when a condition is chronic and occurs
over the lifespan. Stress can heighten at different illness phases requiring more from
the family system, but particularly for caregivers. Common reasons for family stress
appear to be caregiver stress, obtaining a correct diagnosis, behavioral problems of the
child, financial hardship, and transitional stress.
Caregiver stress Many studies have confirmed that caring for children with disa-
bilities can be a stressful job for parents and other caregivers (Almogbel, Goyal, &
Sansgiry, 2017; Baker‐Ericzen, Brookman‐Frazee, & Stahmer, 2005; Hartley,
Seltzer, Head, & Abbeduto, 2012; Hastings, 2003; Kazak, 1987; Lach et al.,
2009; Nachshen & Minnes, 2005; Rao & Beidel, 2009). As children with neu-
rodevelopmental disorders have greater levels of impairment, the risk for caregiver
stress tends to increase. This risk increases even more if the caregiver has his or her
own disorder/disease but decreases if they have at least a college level education
(Almogbel et al., 2017). Almogbel and colleagues discussed that children with
neurodevelopmental disorders with greater impairment could mean greater physi-
cal, emotional, or economical demands on caregivers. Due to special medical care
or complex educational needs, a family may experience more out‐of‐pocket costs.
A family may also have to pay more for childcare for a child with greater impair-
ment. Finally, seeking medical care in other cities may mean additional financial
and emotional costs.
The emotional stress that caregivers feel is not always directly related to the caretak-
ing of children with disabilities and the time and energy that those tasks require.
Instead, the burden of caretaking becomes a factor in the overall emotional stress.
Other factors might include anxiety and frustration about the lack of services or the
difficulty in obtaining the necessary services (Dowling & Dolan, 2001). It is important
to acknowledge the burden of caring for a person with a disability. If a caregiver is not
provided with support, he or she may feel overburdened by the responsibility and may
no longer be able to emotionally and physically support the family member with a
disability.
Obtaining a correct diagnosis Navigating the maze of health insurance, identifying

appropriate specialists, and securing new patient appointments can be a stressful expe-
rience for a family. For disorders or disabilities that may be a little more unclear or
complex, going through a period of diagnostic uncertainty can lead to increased anxi-
ety, guilt, and burden for mothers with children with an unclear diagnosis (Lenhard
et al., 2005). Not having a clear diagnosis can make it difficult and stressful for parents
to navigate the next stages of seeking support from professionals, friends, and family.
Unfortunately, it appears that many families are not satisfied with their diagnostic expe-
rience. In one study, parents and caregivers with children on the autism spectrum were
able to get a diagnosis on average at 3.4 years for autism and 7.5 years for Asperger
syndrome for their children. Only about 40% of the sample reported that they were
satisfied with the diagnostic process. Having to see more professionals before receiving
an official diagnosis contributed to a more negative view of their experience (Goin‐
Kochel et al., 2006).
It is also important for professionals to understand that minority and other tradi-
tionally underserved children are often undiagnosed, misdiagnosed, or often diag-
nosed later than Caucasians (Liptak et al., 2008; Mandell et al., 2009) or those
children with more resources (Houtrow, Larson, Olson, Newacheck, & Halfon,
2014), and overall, minorities tend to have decreased access to services (Liptak et al.,
2008). In a secondary analysis of several disability and health‐related datasets,
Houtrow et al. (2014) reported that children from families living well above the pov-
erty line experienced the largest increase over time in those diagnosed with a disability
(28.4%), indicating that being socioeconomically disadvantaged plays a role in the
barriers associated with the diagnostic process. However, it should be noted that the
diagnostic criteria for these datasets also included mental health diagnoses. Ultimately,
this highlights the likelihood that obtaining a correct diagnosis and subsequent ser-
vices may be an even bigger challenge and barrier for minority families.
Behavioral problems of the child Some of the behavioral characteristics of children

with disabilities can be difficult to manage and control by caregivers. Usually, these
types of characteristics are labeled as problem behaviors. Behavior problems are often
defined as self‐injurious, aggressive, destructive, socially disruptive, stereotypical,
offensive, shy/anxious/withdrawn, and provocative (Haveman, van Berkum,
Reijnders, & Heller, 1997). Haveman et al. (1997) found that the youngest group of
children in their study had the most behavior problems, while people over 30 years of
age had the least behavior problems. Specifically, they found that in the youngest age
group, behaviors such as self‐injurious and stereotypical varied with the level of func-
tioning, with the most severe levels of disability having the highest levels of these
behaviors.
In a study about mothers and fathers who had children with autism spectrum
disorder, the stress level for mothers was found to be affected by the child’s behavior
problems and the father’s mental health symptoms. Interestingly, there was no
evidence to support that the fathers’ stress levels were affected by the child’s behavior
problems or the mother’s mental health symptoms (Hastings, 2003). In a comprehensive
review of the literature on families living with intellectual and developmental disabilities
(IDD), Taylor, Burke, Smith, and Hartley (2016) highlighted that one of the most
consistent findings, identified within studies conducted on parental well‐being, marital
quality, and sibling relationships, is that high levels of behavioral problems contribute
the most detrimental impact for all involved.
Financial hardship Financial strain and stress appear to be present in many families
with children with disabilities (Sharpe & Baker, 2007). In the United States, a fam-
ily might spend $2.4 million supporting an individual with an autism spectrum dis-
order and intellectual disability during his or her lifetime (Buescher, Cidav, Knapp,
& Mandell, 2014). Compared with families with children without disabilities, fami-
lies with children with disabilities are more likely to live in poverty (Parish & Cloud,
2006; Spencer, Blackburn, & Reed, 2015), possess greater amounts of unsecured
debt (Houle & Berger, 2017), have larger households, and be dependent on some
form of income support (Fujiura, 1998). Goudie, Narcisse, Hall, and Kuo (2014)
found that children with a disability, as compared with typically developing chil-
dren, were two times as likely to reside with caregivers with high levels of financial
stress and almost three and a half times as likely to reside with caregivers with high
levels of financial and psychological stress as measured by restlessness, feelings of
sadness, hopelessness, and worthlessness. When families are faced with this combi-
nation of stress, it is important for providers to recognize the potential negative
impacts on the family’s functioning.
Unfortunately, single parents, often single mothers, are sometimes left to care for
their children with disabilities alone and without the financial support of a partner.
Parish, Seltzer, Greenberg, and Floyd (2004) discovered that the mothers of individu-
als with a disability were less likely to have had a full‐time job and even less likely to
have had a job for more than five years compared with mothers of children without
disabilities. Even though it may be hard for mothers to find employment, keep a job
for an extended period of time, and find someone trustworthy to watch the children,
being employed was found to be associated with less depression and fewer health
problems for single mothers (Gottlieb, 1997). While single parents have been found
to have lower income levels, research does not appear to support the fact that single
parents are more stressed than parents from two parent households (Boyce, Miller,
White, & Godfrey, 1995). Boyce and colleagues (1995) pointed out that stress for a
single parent may be mediated by the reason for being a single parent, education,
race, income, socioeconomic variables, the child’s characteristics, help from other
caregivers, handling task demands, and time management.
Wetchler (2005) described his experiences as a single father of his daughter with
profound disabilities in a self‐authored article. In this article, he described his journey
through developing a relationship with his daughter, battling social stereotypes rais-
ing a daughter by himself, and his experiences with eventually finding a permanent
home for her that could provide her a level of care that was necessary. Numerous
times Wetchler mentioned the financial strain placed on him and the struggles that he
had trying to find respite care for his daughter. “Most of my funds were taken up with
after‐school caretakers so I could work. It cost about $13,000 per year for caretakers
so I could do my job” (Wetchler, 2005, p. 69). Although the cost of comparable in‐
home support would be significantly higher today, families need to consider the
ongoing and long‐term care needs of their loved one. But unfortunately, the “right
now” demands tend to overshadow the need to prepare for the expense of long‐term
caregiving needs of their loved ones, often leaving families ill‐prepared for the future
(Lauderdale, Walther, & Piland Springer, 2018).
Transitional stress Educational, occupational, and residential transitions are expected

as individuals both with and without disabilities move throughout their life cycles.
Transitions can occur when a child with a disability begins school, changes schools,
finishes school, starts or stops seeing a medical or mental health provider, secures
employment, and/or moves into a living situation outside of the family home. The
expectations family members have about when different transitions should happen is
a potential source of stress for families and caregivers. A family may not experience
each of the typical life‐cycle transitions, or these transitions may not occur at the time
that is expected or desired by the family. When these transitions do take place, it can
be stressful for the entire family system but particularly for families with loved ones
with more severe disabilities (Neece, Kraemer, & Blacher, 2009). Parents who volun-
tarily placed their child with severe or profound developmental disabilities in an out‐
of‐home placement described feeling guilt, sadness, fear and worry, anger and
frustration, and uncertainty. Making the decision to have their child live somewhere
else was also been reported as stressful on their marriage (Jackson & Olsen Roper,
2014).
Henninger and Taylor (2014) explored parental perspectives about what elements
would make for a successful transition into adulthood for their loved ones. The
researchers identified numerous themes using a content analysis based on participant
responses to an internet survey. The most prevalent themes identified were as follows:
having a functional role in society, living independently, having peer relationships, and
possessing daily living skills (Henninger & Taylor, 2014). The numerous themes that
emerged from this study highlights that although life might be qualitatively different
from typically developing children, parents still possess meaningful hopes and dreams
for their adult children.
Access and barriers to resources

Researchers have also focused on the resources, individual perceptions of the ade-
quacy of resources, and coping strategies that help caregivers best adapt to stressors
that may be a result of caring for someone with a disability (e.g., Bennett, DeLuca, &
Allen, 1995; Hock, Timm, & Ramisch, 2012; Johnson & Piercy, 2017; Ramisch,
Onaga, & Oh, 2014; Trute, 2003). Studying the activities of people who do not
experience family stress and caregiver burden, but instead benefit from resources such
as family support, social support, and other outside/community support, can help
professionals understand and promote behaviors and activities that help caregivers to
prevent overwhelming feelings of burden.
Family support Support by partners and related family members has been shown to
have a large influence on the well‐being of caregivers for people with disabilities.
Parents across each stage of the family life cycle perceive family members and close
friends as sources of emotional support, which can be especially helpful during times
that parents feel the most frustrated or troubled. Emotional support and empathy are
important, but the fact that some family members educate themselves about the spe-
cific disability and are more accepting of the child are also significant (Bennett et al.,
1995; Trute, 2003).
Couples can also serve as a key source of support for one another. Communication,
shared foundational expectations about the relationship, and teamwork are important
qualities associated with couples of children with autism spectrum disorder who feel
that they are keeping their marriage strong (Hock et al., 2012; Ramisch et al., 2014).
Additionally, Johnson and Piercy (2017) discussed the benefits of couples with chil-
dren with autism spectrum disorder who were able to make cognitive and relational
shifts in order to negotiate intimacy over time. Finally, while couples with children
diagnosed with an autism spectrum disorder report less time together, lower levels of
closeness, and fewer positive couple interactions when compared with couples with-
out a diagnosed child, less time with their partner does not necessarily detract from
feeling supported by one’s partner. Thus, the couple relationship can serve as a form
of perceived support despite the qualitative differences of daily life (Hartley, Smith
Dewalt, & Schultz, 2017).
Social support Parent support groups appear to be the largest source of social sup-
port that parents typically receive from people outside of their immediate family.
These groups can be a source of emotional support as well as a source of new infor-
mation and resources on caring for a person with a disability. Parent support groups
provide an emotional outlet for expressing feelings and frustrations; current rele-
vant information in the form of speakers, videos, and other materials; and the
opportunity to discuss issues about the services for their children with parents in
similar situations (Bennett et al., 1995). The role of parent education and support
was also highlighted by parents of children with Down syndrome as valuable follow-
ing the news of their child’s diagnosis (Nelson Goff et al., 2013). Other studies
have indicated that parent support groups and parent‐to‐parent programs have pro-
vided them with social support (Goldberg‐Arnold, Fristad, & Gavazzi, 1999;
Krauss, Upshur, Shonkoff, & Hauser‐Cram, 1993), increased knowledge about
specific disabilities (Goldberg‐Arnold et al., 1999; Santelli, Turnbull, Marquis, &
Lerner, 1993), and emotional support (Santelli et al., 1993).
White and Hastings (2004) examined the relationship between parental stress,
social support, and child characteristics in a sample of parents classified with a severe
intellectual disability. They found that informal sources of support (i.e., spouse,
extended family, and friends) were most associated with parental well‐being, even
when child characteristics were controlled for. So although parental social support is
often viewed as community based, the role that familial and social relationships serve
should not be overlooked.
One of the barriers to accessing parent support is the nature or type of disability a
child may possess. Specifically, when children have a rare disorder or a disability of
unknown etiology, parents have difficulty identifying or engaging with a disability‐
specific support group, as the diagnosis often defines the group. Diagnostic uncer-
tainty may impede parents from securing appropriate support from other parents with
children like their own (Lenhard et al., 2005). But at a minimum, there are online
support groups to facilitate connections with others when rare disorders are a reality
(e.g., National Organization for Rare Disorders, 2018).
Community support Community support for families can include services from
medical and mental health professionals, early child intervention teams, the educa-
tional system, day programs, consumer‐based organizations, and/or assisted living
agencies. Rolland (2018) addresses the continued challenges for families managing
chronic disorders and the importance of integrated care. For some caregivers, the
level of burden that they experience is directly affected by the levels of frustration
and support that they experience when seeking outside services. More specifically,
frustrations usually come from a lack of support or difficulty in obtaining services.
Bennett, DeLuca, and Allen (1996) reported that parents felt that relationships
with professionals who were knowledgeable and flexible contributed to a feeling
of support.
For families in more rural areas, access to medical and mental health professionals
might require travel to a larger city, which may leave some families without the option
to seek higher‐quality specialized services. There are certainly some benefits for those
who can travel periodically to larger medical complexes where multiple specialists are
available in a centralized location. One benefit is the coordination of care where a
multidisciplinary team evaluation can be conducted and a common electronic medical
record can be accessed by all specialty providers. Thus, referrals and recommendations
for additional testing, evaluation, and results can be reviewed by all specialists. Once
a diagnosis is made and a treatment plan is developed, families can often return to
their home community to acquire the ongoing services needed typically monitored by
a primary physician or local specialists and then return to the hospital or specialty facil-
ity annually (e.g., if or when new problems arise).
Another aspect of community support is early childhood intervention. When symp-
toms are discovered prior to age 3, early childhood intervention services are available
to families in all states (Bekins, 2018). These services, which involve a multidiscipli-
nary team and are coordinated by a caseworker or service coordinator, can put a child
on a path of greater success by addressing delays during such a critical phase of devel-
opment. One study that surveyed parents of children with Down syndrome who
participated in an early intervention program reported that the program was helpful,
supportive, and empowering (Hanson, 2003).
One of the more practical elements of community support is related to childcare for
parents working outside the home. Prior to beginning elementary school, children
often participate in preschool or daycare, including Early Head Start (0–3 years old)
and Head Start (3–5 years old) programs that are federally funded for low income,
at‐risk, and children with disabilities. When families have a child with a neurodevelop-
mental disorder, securing daycare services is not always an easy task. However, one
thing parents can assess for is the education or training level of daycare providers and
whether they have training and experience with the type of neurodevelopmental dis-
order their child possesses.
As the child reaches school age, the educational system serves as an essential ele-
ment for children to acquire reading, language, and math proficiency as well as offers
socioemotional development opportunities through peer relationships (Francis &
Nagro, 2018). However, parents must learn to navigate the strengths and limitations
of the services offered and available to them and, at times, advocate for their child to
receive more services than perhaps the state‐based resources (e.g., public school sys-
tem) may willingly offer. And although many services are available within the public
school system, families will likely need to secure additional intervention services in the
private sector (e.g., tutoring, outside behavioral intervention, psychiatric services,

social activities, psychotherapy).
In later life stages, parents may need to consider an out‐of‐home placement,
depending on the loved one’s functional capacity and the capacity of caregivers to
provide ongoing support (Perkins & van Heumen, 2018; Wetchler, 2005). While
parents who place their children in out‐of‐home care can often experience guilt, sad-
ness, fear and worry, anger and frustration, and uncertainty, if they are also able to
perceive that placement improved the quality of their own lives and the lives of their
children and that family and friends are supportive of the placement, they can experi-
ence relief from those stressful emotions (Jackson & Olsen Roper, 2014). Ultimately
the level and type of services available will vary across communities, but more impor-
tantly, access to community support services is most often contingent upon socioeco-
nomic status (Houtrow et al., 2014; Liptak et al., 2008), thus, leaving families with
fewer economic resources for securing those services at greatest risk.
Family adaptation and resiliency

Much of the early literature on families raising children with a disability was oriented
within a traditional medical model view of illness and disability and often explored the
negative impact of the loved one’s disability on the family system or the limitations of
the disability on the individual’s functioning. These studies were often rooted in a
unidirectional research focus with an assumed negative effect. Despite the literature
that highlights the stressors and barriers to resources that indicate the potentially
negative impact on families, as we have just discussed in the previous sections, some
of the newer literature has also captured the positive elements or benefits to families
living with neurodevelopmental disabilities. Although parental stress and reduced
well‐being has been demonstrated in the research for some parents within this popula-
tion, (a) not all parents report diminished functioning (Hastings, 2016), (b) higher
divorce rates or increased marital discord is not always indicated (Namkung, Song,
Greenberg, Mallick, & Floyd, 2015; Risdal & Singer, 2004; Urbano & Hodapp,
2007), and at times, (c) some studies have not indicated increased marital problems
when comparing families with non‐disability groups (Saini et al., 2015).
Specifically, when divorce risk is increased, the increase may not be as great as origi-
nally thought. Risdal and Singer’s (2004) meta‐analysis indicated that only 2.9–6.7%
more marriages might end in divorce for families of children with disabilities when
compared with other families. In contrast, Namkung et al. (2015) examined divorce
rates of participants in a 50‐year longitudinal study comparing families with and without
children with IDD and found that families in the comparison group with a larger num-
ber of children had an increased divorce risk, but number of children did not increase
divorce risk for the families with children with IDD. Thus, in this case, larger family size
may have served as a protective factor as it relates to shared caregiving functions.
Until the past two decades, little research considered the systemic context of disa-
bility for families or failed to explore how families successfully navigated life with a
loved one with a disability (Turns, Nelson Goff, Masterston, Cless, & Cless, 2018).
One of few longitudinal studies, which examined the role of early intervention in
families raising a child with Down syndrome, illustrated that despite the medical,
social, and educational challenges associated with Down syndrome, parents also
shared positive feelings and experiences (Hanson, 2003).
Fortunately, there has been a shift in focus within the research to now include a
resiliency framework. Thus, instead of asking, “what are the negative effects of disabil-
ity on families?,” researchers has begun to explore and capture what is unique about
families who are coping well or even thriving amidst the disability‐related stressors
and challenges (Bentley, McCarty, Zvonkovic, & Springer, 2015; Knestrict & Kuchey,
2009; Myers, Mackintosh, & Goin‐Kochel, 2009; Nelson Goff et al., 2016), and
some researchers have even reported the benefits of having a loved one with a disabil-
ity demonstrating lower divorce rates for some special needs populations (Urbano &
Hodapp, 2007).
More specifically, Bentley et al. (2015) conducted a mixed methods study examin-
ing the perceptions of 50 fathers raising a child with Down syndrome utilizing
measures of hope, satisfaction, and coping as well as qualitative responses to ques-
tions related to their parenting experiences. The results of the cluster analysis illus-
trated three groups of fathers within the sample described as (a) Mastering, (b)
Connecting, and (c) Thriving. Each cluster was characterized by different types of
coping. The “Mastering” cluster (which reflected the lowest levels of hope and
satisfaction compared with the other clusters) reported a coping style that included
a focus on their child achieving their fullest potential. The “Connecting” cluster
reported an action‐oriented coping style that was reflected by their efforts to
connect with others in the Down syndrome community as a way to find meaning
in their child’s diagnosis. The “Thriving” cluster was reflected by the highest levels
of hope and satisfaction in the sample and described ways they found significant
personal meaning and purpose in light of their child’s diagnosis. So although each
cluster spoke of challenges and loss associated with their child’s diagnosis and iden-
tified with unique coping styles, each cluster also reported ways they found mean-
ing in their parenting journey.
Similarly, Knestrict and Kuchey (2009) have described resilient families living with
IDD as tenacious and regenerative and characterized by family hardiness. In their
qualitative research that included a combination of parent interviews, focus groups,
and in‐home observations of family interactions, they have captured the lived experi-
ences of families who they would refer to as resilient as demonstrating an ability to
secure services when needed, develop routines, and balance time with each of their
children. In contrast, for families who had difficulty acquiring the resources they
needed for their diagnosed loved one, largely due to socioeconomic factors, it seem-
ingly interfered with their ability to have time to reflect upon their circumstances and
avoid operating from a “criterion referenced perspective,” thus comparing their child
with those who were typically developing. Families characterized as resilient were
ultimately able to identify as a family as opposed to being primarily defined by the
child’s disability (Knestrict & Kuchey, 2009).
Nelson Goff et al. (2016) explored cross‐sectional differences among parents of
children with Down syndrome at different phases of the life span and found parents
of children in the early childhood years and later life reported lower coping strategy
scores when compared with parents in the middle childhood and teen years. Perhaps
the fact that parents with children in the middle school years are coping better speaks
to the challenges families may face early on, as they are adjusting to the news of their
child’s diagnosis and identifying the needs related to their child’s disability, as well as
in later life when the more intensive supports are less available at the point when chil-
dren age out of the school system.
One thing is clear, family functioning is a complex picture that is not fully understood.
At a minimum, we need to consider that there can be stressors and challenges but
simultaneously include positive elements of joy and characteristics of resiliency. Plus,
there are bidirectional influences related to the child living with the neurodevelop-
mental disorder and the nature of relationships between his or her family members,
and some studies may overestimate the negative impact a diagnosed child may have
on the parental and sibling relationships (Hastings, 2016). In addition, while studies
examining sibling differences have indicated negative effects (Hastings & Petalas,
2014), other studies have captured some elements within those relationships as more
positive or possessing lower levels of conflict when compared with sibling groups
without a child with an IDD (Rossiter & Sharpe, 2001). Thus, we will now turn our
attention to ways we can assist those families who may be struggling and find them-
selves needing systemic therapeutic services.
Systemic Approaches and Practice Recommendations
Researchers and clinicians have highlighted that the family serves a significant role in
the lives of these individuals and emphasize the importance of involving families in
treatment. While books and articles have been published about families and children
living with neurodevelopmental disabilities for the past few decades, a few newer pro-
fessional resources available include Nelson Goff and Piland Springer (2018), Rolland
(2018), Talley and Crews (2012), and Turns, Ramisch, and Whiting (2019).
Below we have highlighted some common presenting problems that clinicians may
encounter in their work with families with children with neurodevelopmental disabili-
ties. The following sections will include examples of how specific systemic, modern,
and postmodern models can be utilized with certain presenting issues and how they
are relevant and applicable for serving this population. While it would be beyond the
scope of this chapter to incorporate examples for each of the disorders presented
earlier in the chapter, we have included some possible clinical scenarios and general
practice recommendations that we have found meaningful through our own research
and clinical practice.
Setting goals with families

Therapists should work with families in the beginning stages of therapy to negotiate
initial goals and address some of the stressors and barriers to resources that they may
be experiencing. Some families may need assistance with addressing problem behav-
iors, while others may need guidance in obtaining a correct diagnosis, navigating
resources, or developing a transition plan. The therapist can work with the family
system to decide who to include in therapy sessions, assessing for potential contribu-
tions of grandparents or adult siblings. As a starting point, whoever is involved in the
direct, routine care of the diagnosed family member is considered a resource or pos-
sibly a source of challenges associated with interpersonal dynamics. Thus, at least
involving all caregivers early in the treatment process will shed light on the areas possibly
needing intervention. Plus, the inclusion of siblings and inviting their perspectives of
their experience can often inform problematic relational imbalances that may be
resent in the family. Siblings are often great observers of family dynamics and can be
p
valuable informants as to problematic cycles that need attention. It will also be impor-
tant to attend to the parental subsystem or the couple relationship, checking in with
them to see if they would benefit from additional support, individually or as a couple,
to help strengthen their relationship.
Applying solution‐focused brief therapy A brief and yet practical model that could be
utilized with families living with a disability of a loved one is solution‐focused brief
therapy. This approach assumes that families possess resources, strengths, and skills
for addressing problems but that a narrow view of the problem becomes a barrier
to recognizing the solution(s) (DeJong & Berg, 2000). Therapists utilizing this
approach can assist families by highlighting the things they are doing well and
explore the exceptions to the problems, which can inform the solutions that are
best for them. One of the benefits of solution‐focused brief therapy is the focus on
the present moment, allowing clients to establish their desired goals. Another ben-
efit to this model is developing specific, measurable, and achievable goals (de
Shazer, 1985). There are times when the unknowns associated with the future
functioning of the loved one can become a distraction from the here and now.
Thus, this model keeps the attention on the present moment and supports families
in identifying what changes would benefit them most. One final benefit of this
model is simply the brief nature of the model. Families who are managing the
demands of daily life, along with the unique demands related to the child’s disabil-
ity‐related needs, often describe being pulled in all directions due to juggling
numerous demands. Thus, they tend to desire practical, effective solutions and
swift results.
For example, when a family with a child with a combination of symptoms or diag-
noses initiates therapy, a clinician using solution‐focused brief therapy can ask the
miracle question and subsequent scaling questions to help the family identify what
they would like to be different. Through this process, parents or caregivers may be
able to articulate goals they would like for their child such as being more involved
socially, making a new friend, or leaving the house in the morning without a melt-
down. Using skills the family already possesses, a solution‐focused clinician would
then assist the family in discovering ways that current behaviors can be changed so
that those goals can be met and using scaling questions to monitor progress.
Addressing multiple subsystems within the family

Caregivers, parents, siblings, and sometimes even grandparents are charged with
the responsibility of providing lifelong care and support to individuals diagnosed
with disabilities. Thus, it is important that the relational and emotional needs of
these family members are met as well. In Nelson Goff and Piland Springer (2018),
specific chapters highlight the perspectives of mothers, fathers, siblings and grand-
parents and provide principles for practice to guide family members who are caring
for those living with disabilities. In Turns et al. (2019), entire chapters are dedi-
cated to applying systemic family therapies to subsystems (e.g., parents, couples,
and siblings) within families who have children with autism spectrum disorder. In
this section, we will briefly and generally highlight the parental subsystem and
applicable family therapies.
Parental subsystem The parental subsystem is the lifeline for the diagnosed child and
typical siblings. The functioning of the caregiver can either be an asset or detriment
to the children’s well‐being. Moreover, the absence of a parental figure or a change in
caregiver functions and roles has the potential of being disruptive for the family sys-
tem as a whole.
Applying structural family therapy As early as the 1960s, Salvador Minuchin and
other structural family therapists began to look at the structure of the family in order
to solve problems that were maintained by dysfunctional family organizations
(Minuchin, 1974). Structural family therapists believe that most problems are not
caused by individual pathology, but rather by the inability of the family to find a work-
able structure to handle the problem. The overarching goal for structural family ther-
apists is to help families find appropriate structures that work in the present moment
(Minuchin, 1974). This is especially helpful for families with children with neurode-
velopmental disabilities who may not be aware that their current structure is not
working and that there are other possible structures available to them that may be
more helpful and adaptive.
A change in family structure could be related to a change in who is serving as the
direct or primary caregiver for the diagnosed child. For example, a grandparent could
end up in the position of becoming the primary caregiver responsible for his or her
grandchild due to parental neglect or incarceration related to substance abuse and/or
legal issues. In this case, the grandparent who may have considered retirement prior
to this unexpected family crisis must continue working in order to afford the support
and caregiving needs of the child. Thus, a structural family therapist treating a family
where a parent is not able to be the primary caregiver or maintain their parental
responsibilities would help grandparents redefine their roles as they transition into the
role of primary caregiver.
Applying transgenerational family therapy Within the transgenerational frame-

work, Kerr and Bowen (1988) defined the concept of “differentiation of self” as an
individual’s ability to be separate from yet still remain close with their family emotion-
ally. By being differentiated, family members are able to recognize their own emo-
tions and make their own decisions outside of the family (Kerr & Bowen, 1988). The
goal for transgenerational family therapists is to help clients realize family patterns that
have been passed down through the different generations and remove themselves
from those patterns in which they are not necessarily making their own decisions.
Transgenerational family therapy can be helpful for caregivers with caregiver burden
in that the theory supports the idea that an individual’s coping patterns are learned
from his or her family.
When a child with a disability enters into the family, the caregiver may inadvertently
use maladaptive patterns to compensate for a lack of knowledge or skills related to the
care for the child. More specifically, a parent who is struggling with the stress and
strain of caregiving for a child with a disability may try to relieve some of that stress
by engaging in an extramarital affair. Thus, in this example, sexually acting out with a
third party could be viewed as the development of a “triangle” (Bowen, 1978) in an
effort to diffuse the anxiety. This ineffective coping response could be devastating for
a family as the consequence of the affair could potentially lead to divorce, resulting in
numerous transitions for all involved (e.g., moving, changing schools, loss of household
income, loss of extended family support, etc.). Transgenerational therapists can help
caregivers recognize their maladaptive coping and develop more effective solutions
for addressing emotional symptoms, as well as contribute to insights and understanding
of intergenerational patterns of infidelity that might be evident in one’s family
history.
The role of disability and family identity

Another important process to keep in mind for families is what meaning they give to
the label of disability or more specifically the diagnosis or disorders they face (Gallus
& Jones, 2018; Piland Springer et al., 2018). Along with this process is the accept-
ance of the diagnosis as a family. As systemic therapists we typically orient away from
labels and hold a non‐pathologizing orientation when working with families in gen-
eral. However, families living with disability are often required to secure and then
accept a diagnostic label because diagnoses determine accessibility to treatment. For
example, this can be particularly relevant as families navigate the school system and
have to strike a balance between acquiring school‐based interventions, which are for-
mulated based on the child’s diagnostic challenges, while also securing as much of a
mainstream educational experience as possible. It is important for providers to recog-
nize this dichotomy and be sensitive to the family’s atypical experience of raising a
child with a disability, as a minority within a normative setting where the general
classroom structure is designed to teach to the typical student.
When working with families where the disability or diagnosis has consumed the
family’s identity or problems related to the story associated with the loved one’s dis-
ability have become the dominant discourse within the family system, the clinician
should consider which model of therapy might be most appropriate. And often, more
than one model may be effective in achieving similar outcomes.
Applying narrative therapy One example where the disability or diagnosis may
become all‐consuming is when the painful reality of a child’s disability results in a
shortened lifespan and untimely death. In the case of parental bereavement, we would
encourage you to consider a narrative therapy approach. Unfortunately, when chil-
dren are diagnosed with disorders of this nature, they can also have serious medical
conditions that might shorten their lifespan. This is especially relevant to disorders
like Down syndrome. On rare occasions, a child could suffer from a dual diagnosis or
other chronic condition, like cystic fibrosis. A problem narrative could include ele-
ments of unfairness, like “why does my child have to suffer from an intellectual disa-
bility AND have a chronic life‐threatening condition?” Or in the case of bereaved
parents, one parent could possess a narrative about the death of their child being a
“blessing in disguise,” and yet, the other parent could be completely paralyzed by
their grief. Moreover, the grief experienced by the grandparent(s) of the deceased is
compounded by the grief they feel not only for their grandchild but also for their
adult child who is also grieving.
Similar to solution‐focused brief therapy, the narrative therapy approach not only
attends to the self‐defeating views that may perpetuate the problem but also works to
externalize the problem as opposed to viewing a diagnosed individual or their impact
on the family as being the problem (White & Epston, 1990). A narrative therapist can
facilitate the exploration of destructive cultural assumptions associated with the disability
status of the loved one, as well as how the family has made meaning around the diag-
nosis or disability. In the above example, the therapist would assist the family with
coming to terms with a life “taken too soon” or a narrative of powerlessness, in an
effort to externalize the grief and facilitate a narrative less consumed by grief.
General practice recommendations

In this final section, we have highlighted general practice recommendations that
should be considered regardless of presenting problem or preferred systemic approach.
It is important to consider ways you may need to modify your interventions, the role
of other providers treating the identified child and his or her family members, and
how to facilitate the development of advocacy skills in caregivers.
Common factors Regardless of utilizing a specific systems‐oriented model, it seems

fitting to highlight the significance of a common factors framework. Grencavage and
Norcross (1990) conducted a study examining the role of common factors within 50
publications in an effort to summarize the most “consensual commonalities” (p.
372). They reported that (a) the development of therapeutic alliance (56%), (b)
opportunity for catharsis (38%), (c) acquiring and practicing new behaviors (32%), (d)
clients’ positive expectancies (26%), and (e) rationale as a change process (24%) were
the factors most prevalent in the literature. Thus, despite what clinical model a thera-
pist prefers to utilize, the therapeutic relationship is considered a key factor when
working with clients, and this should be no different when working with this
population.
Moreover, Fife, Whiting, Bradford, and Davis (2014) have proposed a meta‐model
that places importance on the relationship between the therapeutic alliance and the
role of interventions. The symbol of the pyramid is used to describe the elements of
this model, with the foundation of the pyramid representing the therapist’s “way of
being,” and the therapeutic alliance is positioned between the therapist’s way of being
and the techniques that are positioned on top of the pyramid (p. 21). These authors
highlight the importance of and relationship between each of these elements. We
encourage each therapist to evaluate his or her way of being when working with neu-
rodevelopmental populations, how he or she builds an effective therapeutic alliance,
and which techniques or models are best for the family system and the challenges they
may be facing at the time they seek services.
Modifying and applying approaches and interventions When working with families
with children and adolescents with neurodevelopmental disorders, there are some
modifications that therapists can employ with any theory. First, the therapist might
want to consider seeing the parents or caregivers initially, without the child present,
for the intake session (Turns & Springer, 2015). This can help the therapist have a
better understanding of the potential unique needs of the family and feel more pre-
pared for when the child, adolescent, or young adult does attend a session. When
involving persons with neurodevelopmental disorders in the therapeutic process, ther-
apists can use the session as an opportunity to model relating to them in developmentally
appropriate ways. The therapist should be mindful of the language that they use, mak-
ing it appropriate so the diagnosed individual can understand and participate. Sometimes
using alternative forms of communication such as puppets, art, or other expressive
therapies can be helpful to the process. It might also be helpful for the therapist to
manage or adjust his or her expectations around how the session will proceed or what
will happen, as things may not go as planned and adjustments will need to be made
(e.g., topics discussed, session length).
Working with other professionals It is crucial for therapists to know about community
resources and supports in order to help guide families in accessing other professionals
and community resources when appropriate. Being able to enhance the family’s use of
resources they already employ is also essential. As we mentioned above, there are
quite a few professionals often involved in the assessment, diagnostic, and treatment
process (e.g., pediatricians, speech therapists, occupational therapists, psychiatrists,
teachers, school counselors, psychologists, diagnosticians, other medical specialists,
nutritionists), and collaborating regularly with these professionals can be a valuable
asset for families in achieving integrated care (Rolland, 2018). It can make the process
of collaboration go more smoothly if a release of information is signed by the parent
or caregiver during the initial stages of treatment.
For some disorders and disabilities, the recommended treatment approach will be a
combination of behavioral and medication interventions. The treatment plan should
be developed with a set of trusted providers who take into consideration the unique
combination of symptoms along with the child’s and family’s resources. If medication
is used, it can be life‐changing for some, but with all medication comes the trade‐off
of side effects. It is important to work with a prescribing physician to find a balance
between the benefits and side effects of medication.
Advocacy skills Therapists can also be a great asset to families by facilitating skills that
promote advocacy by parents. We tend to take for granted that not all parents have
the assertiveness or skills to navigate complex medical systems or the symptom‐driven
language used by the professionals who provide assessment and intervention services.
Therapists can empower families by becoming familiar with providers in the commu-
nity who serve individuals with neurodevelopmental disorders and get second or even
third opinions when their experiences are less than satisfying or counter to their
parental intuition. For a more thorough understanding of the medical perspective,
Summar (2018) describes the importance of “health literacy” as it relates to navigat-
ing medical systems, maximizing health insurance benefits, and communicating effec-
tively with medical providers. These are key skills for caregivers to develop in order to
enhance the well‐being of their loved one.
In addition, therapists can encourage parents to become informed about the
assessment and Individualized Education Program (IEP) process, which is essential
for securing the most optimal learning environment. Therapists can refer to Lipkin
and Okamoto (2015) for additional information regarding special education laws
and services. Finally, therapists can encourage families to connect with other fami-
lies. Often, the way families become effective advocates is through relationships
with other parents who are further on the path than themselves. Essentially, there
is a “pay it forward” mentality that is often seen by and between parents (Cless
et al., 2018).
Conclusion
In this chapter we discussed the general prevalence data, primary symptomology,

current research on treatment options, and the socioemotional and relational chal-
lenges for those living with neurodevelopmental disorders as covered in the DSM‐5
and ICD‐10. We also provided a thorough exploration of the systemic nature of
assessing and working with children, adolescents, and their families in order to guide
family therapists toward a comprehensive understanding of some of the unique
stressors and potential resources available to them. For systemic therapists working
with this diverse population, we introduced key issues and challenges families who
present to therapy may be facing and applied both modern and postmodern family
therapy theories and approaches to demonstrate how therapists can utilize these
approaches when working with these families. Finally, we ended this chapter with
general practice recommendations.
Call for future research

For therapists seeking to study or conduct further research in this area, we would like
to highlight the need for research that addresses methodological limitations found in
the studies available to date. Many researchers in the field have given voice to the lived
experiences of these families, which serves as a valuable foundation for better under-
standing the needs of this population. However, understanding the complex nature of
the nuances within and across neurodevelopmental disorders cannot be captured in a
single study or based solely on mothers’ reports (Hastings, 2016). There are several
additional considerations to be made when working to develop a clearer picture of the
key variables and bidirectional nature of the relationships within these families.
Hastings (2016) has presented a convincing case for rejecting a negative narrative
about this population based on the following research limitations and considerations:
(a) not asking the same questions across studies or how failing to utilize standardized
measures reduces our ability to make sound comparisons; (b) sample biases inherent
in smaller, voluntary samples with low response rates and limited sample descriptives
about those included in comparison groups reduces generalizability of findings; (c)
the need to further examine the nature of group differences in parental well‐being;
(d) the importance of including measures of positive factors and utilizing disability‐
specific tools; (e) the need to continue efforts beyond dyadic analyses to include stud-
ies that explore triadic relationships to better understand the mutual influences
between mothers, fathers, and children; and (f) the need for longitudinal methods,
systemic questions, multiple perspectives (including from the diagnosed individual),
and positively framed questions.
Hastings (2016) highlighted that “the majority of parents are not struggling with
their mental health” when looking at the clinical ranges for measures used to assess for
mood symptoms like depression and anxiety in this population (p. 169). So perhaps,
what is more valuable is to determine what is unique for those parents who are suffer-
ing from psychological problems and what factors “differentiate families of children
with IDD from other families,” so that we can then intervene appropriately (p. 173).
In addition, there is a need for longitudinal data so that there can be a clearer sense
of which families thrive and which ones do not across the lifespan, and which life
phases are more challenging, and why. While the available research is often cross‐
sectional in nature (e.g., Nelson Goff et al., 2016) and speaks to the potential nuances
these families may experience across the life cycle, longitudinal studies will serve to
move beyond associations, can establish the triadic influences within family systems,
and more clearly identify risks related to life‐cycle phases to ultimately better inform
points of intervention.
Moreover, additional research is needed to more fully understand the nuances of
specific disabilities or the unique demands of them given the broad range of symp-
toms and unique psychosocial demands within and across disorders (Rolland, 2018).
Qualitative studies that are designed to capture the lived experiences of certain subsets
of this population would serve to build a richer understanding of those families who
may self‐identify as outliers (i.e., parents of severe and profound loved ones, individu-
als with mosaic Down syndrome, or parents whose children have a rare disorder).
Ultimately, we need to make available to families outcome‐based interventions for
those most in need of them so we can reduce the negative impacts where they exist.
For instance, McIntyre (2013) has examined the role of parent training interventions
to reduce behavior problems for children with IDD. This study serves to highlight the
important role of intervention in addressing one of the key variables identified in the
literature, which can negatively impact families (e.g., behavior problems of the diag-
nosed child). Other studies have examined the role of model specific interventions for
certain subsets of this population and are paving the way for identifying which inter-
ventions are best and under which circumstances (Lee, Furrow, & Bradley, 2017;
Rayan & Ahmad, 2017; Turns, 2017), but replication studies are needed.
In closing, we think it is necessary to increase sample diversity in order to better
understand differences in coping strategies used by those living in other countries or
where cultural factors may influence what and how disability‐related stress is manifested
and what unique barriers to accessing resources may exist within those contexts,
because context matters. Then ultimately, therapists can be more mindful and more
science‐informed when applying certain approaches or utilizing intervention strate-
gies, thus offering appropriate and effective clinical services to neurodevelopmental
populations who could benefit from them.
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16
Eating Disorders in Children,
Adolescents, and Young Adults
Esther Blessitt, Julian Baudinet,
Mima Simic, and Ivan Eisler
This chapter describes systemic family therapy models in the treatment of eating dis-
orders. The main focus is on treatments for patients diagnosed with an eating disorder
for which there exists persuasive evidence for a positive treatment outcome using a
systemic approach. Anorexia nervosa and related restrictive eating disorders arising in
childhood and adolescence have the largest body of empirical evidence (National
Institute for Health and Care Excellence [NICE], 2017), and there is growing empir-
ical support for systemic family therapy for bulimia nervosa in children and adoles-
cents (NICE, 2017). Considerably less research evidence is available relating to adult
eating disorders although there is growing interest in modifying the systemic treat-
ment models for children and adolescents with anorexia nervosa for treatment in
younger adults (Dimitropoulos et al., 2018; Wierenga et al., 2018). Evidence is also
lacking for other diagnostic groups such as binge‐eating disorder (BED) or avoidant/
restrictive food intake disorder (ARFID).
The main focus, therefore, will be on the treatment of anorexia nervosa in child-
hood and adolescence using family therapy for anorexia nervosa (FT‐AN) and multi-
family therapy for anorexia nervosa (MFT‐AN). The modification of this approach for
adolescents with bulimia nervosa both in single‐family format (FT‐BN) and the evolv-
ing multifamily therapy approach for a somewhat broader group of emotionally dys-
regulated adolescents (i.e., both those with bulimia nervosas and binge/purge
anorexia nervosa) will also be described.
While restrictive presentations such as anorexia nervosa pose the most urgent acute
risk to physical and psychological health (Herpertz‐Dahlmann et al., 2015; Smink,
Van Hoeken, Oldehinkel, & Hoek, 2014), bulimia nervosa also carries its own serious
physical health risks, which when chronic or chaotic in nature can have a highly detri-
mental impact on quality of life, relationships, and physical health with accompanying
medical risks (Hay, 2003; Mehler & Rylander, 2015).
The medical language used in this chapter to describe eating disorders as illnesses
rather than problems or difficulties, or the description of the people we work with as
patients rather than clients, is deliberate to emphasize the dual, interacting medical
and psychological nature of these disorders. By using language more commonly associated
398 Esther Blessitt et al.
with physical health conditions, we focus attention on the need for action in relation
to the physical health risks and the initial urgent need to reverse the state of starvation
or severe restriction or the need to regulate eating patterns and cease purging and
other bulimic behaviors. Any helpful and safe treatment for an eating disorder must
have as its primary aim the medical stabilization of the patient and the reduction of
any physical risks alongside the engagement of the patient and their family in the
therapeutic process.
Description of Eating Disorders
Eating disorders are a serious psychiatric condition, anorexia nervosa being described
in the literature since the late 19th century (Gull, 1874; Lasègue, 1873) with earlier
medical accounts dating back to the 17th century (Kagawa, 1768; Morton, 1694).
Bulimia nervosa was first described some 40 years ago (Russell, 1979) although again
there are many earlier clinical accounts that in retrospect would warrant the diagnosis
(e.g., Binswanger, 1944). The different types of eating disorders are all characterized
by a marked disturbance in eating with associated physical sequelae, distress, and an
impact on psychological and psychosocial functioning. The most recent diagnostic
and statistical manual DSM‐V (American Psychiatric Association [APA], 2013) iden-
tifies four main eating disorders, namely, anorexia nervosa (AN), bulimia nervosa
(BN), BED, and ARFID.
Anorexia nervosa and bulimia nervosa are the two best known and most researched
eating disorders. To meet criteria for a diagnosis of anorexia nervosa, an individual
must have a very low body weight, experience an intense fear of gaining weight, and
must overvalue the role that body weight or shape has on their self‐worth. Estimates
for the point prevalence of anorexia nervosa vary with an average of approximately
0.3% in young females with lifetime prevalence ranging from 1.2 to 4.7% (Smink, Van
Hoeken, & Hoek, 2012). Anorexia nervosa is more common in women than in men
(Hoek, 2006) although recent studies have highlighted that the usual estimated ratio
of 10 : 1 may be too high and may miss a significant proportion of male sufferers
(Keski‐Rahkonen, Raevuori, & Hoek, 2008; Sweeting et al., 2015). A subgroup of
anorexia nervosa sufferers also binge and use compensatory behaviors such as vomit-
ing or laxative use and are classified as binge/purge anorexia nervosa.
Bulimia nervosa is primarily characterized by recurrent episodes of binge eating,
which is defined as periods of eating very large amounts of food in a short period of
time and feeling out of control. This is coupled with compensatory behavior
designed to control weight, most commonly vomiting, laxative use, and periods of
food restriction. As with anorexia nervosa, in bulimia nervosa there is also an over-
valuation of the role that body shape or weight has on self‐worth. People diagnosed
with bulimia nervosa have a weight within the normal range or are overweight. It is
more common than anorexia nervosa and occurs in approximately 1% of young
women (Smink et al., 2012).
BED and ARFID are newer diagnoses and were not formally recognized prior to
the most recent edition of the Diagnostic and Statistical Manual (DSM‐V) (APA,
2013). They have previously been described in the literature in various forms, how-
ever, not consistently until 2013. BED shares a similarity with bulimia nervosa in that
Eating Disorders in Children, Adolescents, and Young Adults 399
it is primarily characterized by episodes of binge eating; however unlike in bulimia

nervosa, in BED there are no associated compensatory behaviors. It is estimated that
BED occurs in approximately 1% of the population (Hoek, 2006).
ARFID is an eating disorder that usually occurs in younger children and presents
with a far more equal gender split. ARFID is diagnosed when someone is struggling
to meet their nutritional needs, whose functioning is impaired by this eating distur-
bance but for whom there is an absence of any associated weight or shape concerns.
The eating disturbances in ARFID can be as a result of extreme disinterest in food,
extreme avoidance of food due to sensory qualities, or significant fear of the conse-
quences of eating (e.g., choking). Importantly, there must also be an absence of medi-
cal or psychiatric illness that might explain the food avoidance and lack of weight
gain/failure to thrive. The prevalence of ARFID is less well documented than the
other eating disorders. A recent, large‐scale, population‐based survey in Australia esti-
mated the prevalence of ARFID at 0.3% of the general population (Hay et al., 2017).
When looking at children, a Swiss study recently screened a cohort of 1,444 8‐ to
13‐year‐olds and found 3.2% reported features of ARFID (Kurz, Van Dyck, Dremmel,
Munsch, & Hilbert, 2015).
Eating disorders have a significant impact on the individual and their family, with
high levels of distress, personal and social impairment, and reduced quality of life
(Herpertz‐Dahlmann et al., 2015). Unlike many other psychological illnesses, eating
disorders can also have a profound effect on a person’s physical well‐being that can
result in acute medical difficulties and may result in the need for inpatient treatment.
Anorexia nervosa has the highest mortality rate of any psychiatric illness (Smink et al.,
2012). Without effective treatment the illness may take on a persistent and enduring
course with severe impacts on physical and psychological health and psychosocial
functioning (Dawson, Rhodes, & Touyz, 2014).
Causal, risk and maintenance factors for eating disorders

While the complexity of the causal pathways of eating disorders is far from under-
stood, a growing body of literature is emerging that describes the risk and maintain-
ing factors associated with eating disorders. The development of an eating disorder
is the result of a complex interplay of biology, psychological vulnerabilities, and
environmental factors (Mitchison & Hay, 2014; Treasure & Schmidt, 2013), with
research pointing toward the importance of gene–environment interactions and the
role of epigenetics (Campbell, Mill, Uher, & Schmidt, 2011). The strongest risk
factors for developing an eating disorder are being female and young. Despite pop-
ular belief, there is little evidence that environmental factors such as level of educa-
tion, living in a city ethnicity, or socioeconomic status are particular risk factors
(Mitchison & Hay, 2014).
Psychologically, there are certain traits that are associated with higher incidence of
eating disorders, such as perfectionism, rigid and inflexible thinking, strong attention
to detail, and high sensitivity to social threat (Treasure & Schmidt, 2013). Other
personality or temperamental factors associated with anorexia nervosa include anxiety,
low tolerance of uncertainty, reward insensitivity, altered interoceptive awareness, and
harm avoidance (Kaye, Wierenga, Bailer, Simmons, & Bischoff‐Grethe, 2013). This
suggests that there are neurobiologically determined psychological attributes that
may place someone at risk of developing anorexia nervosa. Heritability studies suggest
that genetics may account for up to 50–60% of the variability in eating disorders
(Mitchison & Hay, 2014).
The role of culture and ethnicity in eating disorders

Notwithstanding the important role that neurobiology and genetics may play in eat-
ing disorders, like any other mental health problem, they cannot be fully understood
without considering the social and cultural context in which they occur. While few
would disagree with this, there are widely varying views as to the way in which social
and cultural factors on the one hand impact eating disorders and on the other hand
need to be considered by clinicians working with families from different cultural,
social, or ethnic backgrounds.
Eating disorders (or more specifically anorexia nervosa) are often seen as being
strongly socially determined to the point of being described as culture‐bound syn-
dromes or ethnic disorders (Gordon, 1990). This view has been supported by the
preponderance of anorexia nervosa in Western societies and more specifically among
white affluent women of higher socioeconomic status (Theander, 1970) and the
apparent rise in the incidence of anorexia nervosa in the second half of the twentieth
century coinciding with changes in socially driven perceptions of ideal body size and
thinness (Russell, 1995). Other evidence supporting such a hypothesis comes from
data showing that the incidence of eating disorders may be rising in some non‐Western
countries, particularly in societies undergoing rapid cultural change and adopting a
Western lifestyle (Becker et al., 2011; Hoek et al., 2005). It is tempting to conclude
that the modern world and the increasing pressure on women to be thin and conform
to an idealized body shape in Western cultures is a key factor in people developing an
eating disorder. However, there are several reasons to think that this is at best an over-
simplification and that social and cultural factors need to be thought of in more com-
plex ways.
First, the increased incidence of anorexia nervosa referred to above has been ques-
tioned on a number of grounds, for instance, for not considering sociodemographic
changes in the population (Williams & King, 1987), differences in diagnostic criteria
between studies, small sample sizes, or increased availability of services (Fombonne,
1995; House et al., 2012), and most reviewers conclude that while there has been
some variability, the incidence of eating disorders has been relatively stable for over
half a century (Smink et al., 2012). Studies in places such as Fiji and Curaçao where
rapid social change has been followed by the emergence of eating disorders show a far
more complex picture than one that could be explained as the effect of Westernization
(Becker et al., 2011; Hoek et al., 2005).
Second, historical data and accounts of eating disorders in different cultures do not
support the idea that eating disorders are simply the product of Western societal pres-
sure to be thin. Drive for thinness or fear of fatness, while central to current diagnostic
accounts of eating disorders, does not feature in early accounts of anorexia nervosa
(Russell, 1995), and until relatively recently the same was true of accounts of eating
disorders from non‐Western countries (Lee, 2001; Nasser, 2003; Suematsu, Ishikawa,
Kuboki, & Ito, 1985), suggesting that cultural factors shape the presentation of e ating
disorders but may not necessarily be causal.
Third, even if there is a causal link, it is important to recognize that the actual
mechanisms are not only likely to be far more complex than can be described by con-
cepts such as Westernization but that they may operate differently in different cultural
contexts. For instance, Pike and Mizushima (2005) discuss the emergence of drive for
thinness in both Japanese and Chinese contexts in recent years but highlight the
important difference of the two population contexts with China having a growing
problem with obesity compared with very low rates of obesity in Japan giving the
drive for thinness a different meaning in the two countries.
As Mitchison and Hay (2014) argue, social pressure to be thin or value a thin
ideal, perhaps particularly when it is part of rapid cultural change, increases the vul-
nerability of many individuals in a variety of ways, which may include negative emo-
tions, poor self‐esteem, and sense in some of body dissatisfaction, leading to dieting
and other behaviors that may precipitate the development of an eating disorder
pathology in those who are vulnerable (Stice & Shaw, 2002). Our understanding of
the role of culture and ethnicity in eating disorders is further limited by the fact that
while there have been growing numbers of studies of eating disorders in different
cultures, the majority of research either has been conducted in Western countries
comparing different ethnic groups who reside within a Western country or have used
assessment methods developed in a Western cultural context and may have a differ-
ent meaning or salience in another culture (Pike & Mizushima, 2005). All too often
broad labels such as Asian and African obscure the differences between the cultures
under these labels.
Unlike the researcher who strives for precision, clarity in classification, and general-
izability, the clinician needs to be mindful of the way a family’s cultural and ethnic
background shapes its experiences and how this might be altered by experiences of
migration, deprivation, or oppression. The clinician needs to be open to the unique-
ness of the family’s own understandings and beliefs while retaining her/his position
of expertise and knowledge. There may be a tension between these two positions,
although they need not necessarily be always resolved, as long as we openly recognize
the limitations of our knowledge and retain our curiosity and are prepared to explore
with the family the importance of their beliefs and perceptions
Eating disorders and the family

While the experience of the individual with an eating disorder is highly distressing, the
impact of the illness is not restricted to the individual. Families of those with an eating
disorder report high levels of concern for their daughter or son as well as high levels
of personal distress, feeling burdened, and increased levels of anxiety and depression
(Anastasiadou, Medina‐Pradas, Sepulveda, & Treasure, 2014) with the eating disor-
der becoming the central focus of family life (Cottee‐Lane, Pistrang, & Bryant‐
Waugh, 2004; Eisler, 2005). The way that families adjust to the ubiquitous presence
of the life‐threatening illness will of course vary depending on the nature of their
preexisting family relational patterns and their family life‐cycle stage as well as the
characteristics of individual family members. Families with a child or adolescent with
anorexia nervosa commonly become more constrained in their responses, with a sense
that time has come to a standstill (Cottee‐Lane et al., 2004) accompanied by a strong
sense of helplessness (Voriadaki, Simic, Espie, & Eisler, 2015). In other families (more
commonly where a young person presents with binge/purge symptoms and/or in

families of older patients with a more protracted illness), there may be increased levels
of negativity in the family relationships with high levels of criticism or hostility
(Anastasiadou et al., 2014; Simic et al., 2016; Zabala, Macdonald, & Treasure, 2009).
Understandably, as the whole system of care becomes increasingly distressed, resources
reduce, and the family becomes reorganized around the illness, with the eating disor-
der becoming a central organizing principle of family life (Eisler, 2005; Steinglass,
1998). The family response may then contribute to maintaining certain aspects of the
illness for the individual.
History of the Development of Systemic Approaches

to Treating Eating Disorders
Interest in the family of patients with anorexia nervosa goes back to its earliest
descriptions as an illness in the papers by Gull (1874) and Lasègue (1873). Lasègue,
a psychiatrist, who described the illness as “hysterical anorexia,” also provided a
detailed characterization of family responses to the illness and interactions between
the patients and their families. His description of a typical family response was as fol-
lows: “the family has but two methods at its service which it always exhausts—
entreaties and menaces—and which both serve as a touchstone” and over time “the
relatives and friends begin to regard the case as desperate.” He emphasized how, for
both patients and their entourage, ideas and sentiments become narrowed, to such
an extent that “the responses become still more uniform” and that “all those who
shared these painful family scenes will realize that this tableau is certainly neither
overdrawn nor too gloomy.” However once “the young girl begins to be anxious
from the sad appearance of those who surround her, … the moment has now arrived
when the physician, if he has been careful in managing the case with a prevision of
the future, resumes his authority.” Lasègue claimed that one should expect and
accept an understandable ambivalence on the part of the patient, for whom now
two courses are open: “She either is so yielding as to become obedient without
restriction, which is rare; or she submits with a semi‐docility, with the evident hope
that she will avert the peril without renouncing her ideas and perhaps the interest
that her malady has inspired” (Lasègue’s quotes taken from Vandereycken & van
Deth, 1990). Lasègue’s comments about the family are mostly remembered for his
recommendation to remove the patient from the parents, a view he shared with his
English contemporary Gull (1874) as well, indeed, in a modified way with some cur-
rent authors (Godart et al., 2004). What tends to get forgotten is Lasègue’s percep-
tivity of the predictability of the family response to illness symptoms and behaviors
and the patient’s response to the family’s emotional reaction, leading to fixed and
difficult‐to‐change patterns.
It was not until the advent of family therapy that these patterns of family inter-
actions themselves were considered to be targets for treatment interventions. By
the 1970s a growing number of the pioneers in the field had started applying new
conceptualizations to eating disorders (Minuchin et al., 1975; Selvini‐Palazzoli,
1974) and actively involving families in the treatment of their child’s anorexia
nervosa. For a number of the pioneers in the field of family therapy, anorexia
ervosa was a paradigm for the developing models for understanding the role of
n
relationships and communication in treating families.
Selvini‐Palazzoli (1974) described the treatment of 12 patients diagnosed with
anorexia nervosa whose restrictive behaviors were seen as having a purpose in main-
taining homeostasis within the family system with self‐starvation being framed as a
communication about and refuge from an intrusive mother. The resulting treatment
model focused on strategically disrupting what were identified as unhelpful patterns
of behavior, relationships, and communication. Strategic practices were employed:
positive connotation, adjusting family alliances by prescribing alternative behavioral
patterns, or prescribing the symptom to produce a therapeutic paradox.
Many of the intervention techniques (such as paradoxical symptom prescrip-
tions) and in particular the theoretical conceptualizations are dated; nevertheless,
there is a great deal of value that remains: the relational style of family interview-
ing, the importance of exploring multiple levels of meaning, the ability to posi-
tively connote difficult and complex behaviors and relationships, making use of the
differences of perspective within a team, and perhaps above all the purposefulness
in exploring the minutiae of the family process in guiding moment‐to‐moment
therapeutic interventions.
Simultaneous to these developments in Italy, in the United States, Minuchin and
his colleagues in Philadelphia were developing the structural model of family therapy
for anorexia nervosa (Minuchin et al., 1975) with a highly influential conceptualiza-
tion of the family context of anorexia nervosa as the “psychosomatic family,” charac-
terized by rigidity, enmeshment, over‐involvement, and conflict avoidance or conflict
non‐resolution. The notion of the “psychosomatic family” provided a very persuasive
explanatory model of anorexia nervosa open to the possibility of change through
clinical interventions. In addition, their highly positive empirical data from a case
series of 52 mainly adolescent patients treated by structural family therapy (Minuchin,
Rosman, & Baker, 1978), while having limitations, were truly inspirational. In step
with the thinking of the time they did not see the family as being the “cause” of an
“illness” (indeed they did not consider anorexia nervosa to be an illness), they hypoth-
esized that the transactional patterns of enmeshment, overprotectiveness, rigidity, and
conflict avoidance were a necessary context for the development of anorexia nervosa,
which occurred when a child in the family had an existing “vulnerability” (Minuchin
et al., 1978). Minuchin did not describe the way in which the child could be thought
of as “vulnerable” although we might assume that what he had observed in his patients
would now be more accurately attributable to the neurobiologically determined tem-
peramental and personality traits described earlier as key predisposing factors for ano-
rexia nervosa.
Minuchin’s description of the “psychosomatic family” is not supported by empiri-
cal evidence (Konstantellou, Campbell, & Eisler, 2011), but his careful clinical
descriptions of the ways in which families, over time, alter their relationships and
magnify their behavioral responses and patterns of interaction as the demands of the
illness take hold (Minuchin et al., 1978) provided a crucial understanding of those
transactional patterns that can contribute to the maintenance of the disorder. While
the family interaction patterns in anorexia nervosa are far more varied than Minuchin’s
theory assumes and do not, therefore, provide the basis of an explanatory model, the
patterns will be readily recognizable to clinicians working with child and adolescent
eating disorders when related to specific families. The shift from viewing such patterns
as explanatory or causal to conceptualizing them as evolving patterns in families

coping with the extraordinary demands of the illness is of course fundamental. What
might have been described as an “enmeshed” or “overprotective” relationship
between a mother and daughter, for example, is better understood if we consider how
that mother, regardless of the nature of her preexisting relationship with her child, has
understandably become increasingly convinced that without her proximity and intense
support, her child might starve to death. This intense relationship is further rein-
forced when the sick child has to cease normal activities like attending school, keeping
up with extracurricular activities, and meeting with peers away from home. The rela-
tionship becomes closer as the child becomes more isolated from her normal peer
relationships and routines. The closeness may feel reassuring but at times can also be
experienced as overwhelming and intrusive (by child and/or mother) and may also
impact on father’s role, leading to his gradual distancing, feeling less competent than
the mother and not knowing how to provide support without “getting it wrong and
making things worse.” As with the close relationship with the mother, the father’s
more distant relationship will have a multiplicity of meanings that the therapist will
need to explore.
Probably the greatest influence of the work of Minuchin and colleagues is their
emphasis, early on in treatment, on changing family behaviors around eating by inter-
vening directly during a therapeutic family lunch session (Rosman, Minuchin, &
Liebman, 1975) and the careful attention paid to the family responses to food‐related
issues. However, it is important to note that while many of the currently used inter-
ventions will look very similar to Minuchin’s structural techniques, their conceptual
underpinning has changed considerably. Thus, for instance, for Minuchin the family
lunch session was an opportunity to modify dysfunctional aspects of the family system
by increasing the distance between parents and child or by blocking the role of the
eating disorder as a mediator of family conflict and not primarily, as we would
understand the intervention now, to engage the family in the task of changing eating
behaviors in order to reverse the effects of starvation by focusing on how parents can
best use their concern for their child and their joint parental resources to help their
child to eat.
In the early 1980s a clinical research team at the Maudsley Hospital/Institute of
Psychiatry in London began their work evaluating family therapy for eating disor-
ders in a more systematic way through clinical research trials. Impetus for the first
trial came as a result of a contrast between the outcomes of Minuchin’s case series
study in which 86% of patients recovered at follow‐up (Minuchin et al., 1978) and
an analysis of a cohort of inpatients from the Maudsley Hospital who were followed
up over two decades and for whom no additional therapies provided in the course
of treatment were of particular benefit (Morgan & Russell, 1975; Ratnasuriya,
Eisler, Szmukler, & Russell, 1991). By this stage, though strongly influenced by the
writings described above, as well as the work of strategic therapies such as Haley
(1980) and Wynne (1980), our treatment had also moved on conceptually (Dare,
Eisler, Russell, & Szmukler, 1990). The team had become skeptical of the notion of
the psychosomatic family and saw the eating disorder as an illness of unknown but
not family etiology. The central aim of the therapy was not to modify a dysfunc-
tional family system but rather to mobilize the parents as a resource to help over-
come the child’s illness by uniting the parents to oppose it, a conceptual shift toward
a more collaborative, less blaming approach in keeping with other contemporane-

ous writers (e.g., Hoffman, 1985). Similarly to Minuchin, the role of the eating
disorder was seen as a mediator of family relationships though not specifically
around conflict avoidance (Dare & Eisler, 1997). The way the treatment has con-
tinued to evolve and is currently practiced will be described in some detail in the
next section. The key shifts have been as follows: First, there is a strong multidisci-
plinary team (MDT) approach that includes a medical focus, which necessarily
places the therapist in an “expert” position in relation to knowledge of and the risks
associated with the illness and is used to support the creation of a safe therapeutic
base for treatment (Byng‐Hall, 2008). Second, there is a clear understanding that
the early sense of secure attachment with therapist and MDT encourages depend-
ency that has to be addressed later on in treatment. Third, there is a more explicit
focus on addressing maintaining factors including an understanding of the impact
of starvation on psychological functioning and the role of the predisposing vulner-
ability factors for the development of an eating disorder described above. Fourth,
there is a more thoughtful and purposeful use of and exploration of language and
meaning throughout treatment (e.g., early focus on parental sense of self‐efficacy
and caring rather than being in control and winning battles and later in treatment
in focusing on the wider exploration of family, couple, and cultural and individual
narratives and beliefs).
Maudsley Family Therapy for Anorexia Nervosa
In this chapter, we use the term FT‐AN as a general description for a systemic family
therapy approach with a specific focus on the eating disorder. This is on the basis that
the central principles and application of systemic treatments for anorexia nervosa (and
their manualized versions, for example Lock & Le Grange, 2013; Robin & Siegel,
1996) are broadly similar (for an account of the similarities and differences between
these approaches, see Eisler, Wallis, & Dodge, 2015). Here we describe the specific
manualized version developed and revised by the team at the Maudsley Hospital in
London (Eisler, Simic, Blessitt et al., 2016).
FT‐AN is a phased outpatient treatment model delivered by therapists working
within a specialist MDT, typically comprising clinicians with a range of expertise and
skills from the disciplines of systemic practice, psychiatry, clinical psychology, nursing,
dietetics, and pediatric medicine. The MDT approach ensures that the different areas
of clinical expertise required to treat patients safely and holistically can be delivered
from a single point of contact with the potential, where necessary, for different mem-
bers of the MDT to offer additional input as necessary through the treatment process,
for example, when an additional individual therapy is indicated for the treatment of a
comorbid disorder or when treatment is stuck and other members of the team join a
therapeutic session to offer a different perspective or to review progress. The MDT
has a shared treatment philosophy based on the understanding of the FT‐AN treat-
ment model and its principles, and while systemic therapists play a key role in the
team, the treatment itself is delivered by a range of clinically trained team members
with specific focused training in FT‐AN.
Phase 1: Engagement in treatment and development

of the therapeutic alliance
The first task in phase 1 is to assess the presenting problem and engage the family in
treatment. This includes developing an accurate diagnosis and detailed assessment of
the medical risks as a prelude to starting a conversation with the family to decide the
most appropriate treatment options. The detailed expert assessment of the young
person’s physical condition and associated medical risks serves a dual purpose. In
addition to ensuring medical safety, it is also part of creating a context of starting the
process of engaging the patient and their family and creating a safe base for treatment
(Byng‐Hall, 2008). That this reassures parents and helps with their engagement will
come as no surprise, but in fact following the medical assessment, the young person
will often also become more engaged and be more willing to accept (albeit sometimes
grudgingly) the need for treatment.
Achieving a strong therapeutic engagement with the young person with anorexia
nervosa is not straightforward and is variable both between patients and with individ-
ual patients over time. The connections that the treating therapist (and other members
of the team) makes may at first be fleeting and tentative, but this aspect of the thera-
peutic work remains a key goal of phase 1 and provides the basis for the therapeutic
alliance to change and develop in strength over time. The nature of anorexia nervosa
means that many patients will be adversely affected by the physical and psychological
effects of the illness in terms of cognitive functioning, and they may either genuinely
lack insight into the extent of their fragility and the risks they are facing, or they may
be unwilling to openly acknowledge that they are ill. While the patient will undoubt-
edly recognize their own distress and that of those around them, their fear of change
and weight gain in particular makes it difficult for them to alter the most dangerous
aspects of the illness behaviors without a great deal of sensitive support from the people
around them. For the parents, the lack of expressions of engagement in the treatment
by their child is often disheartening, mistakenly believing that until this happens, treat-
ment cannot be effective. For this reason, the therapist pays as much, and in some cases
more, attention to engagement of parents as they do to the patient. This does not
mean that the patient is ignored. The therapist continues to look for opportunities to
empathize with the patient’s predicament and to express interest in understanding
her/his perspective. The quality and character of the therapeutic relationship will
change over time as the patient begins to recover and develops the capacity to connect
with their treating therapist and the treatment process more overtly.
During the assessment, the therapist will begin exploring the ways in which ano-
rexia nervosa has affected everyone in the family. This can helpfully develop into an
externalizing conversation (White & Epston, 1990) exploring the effects and experi-
ence of the illness on individual members of the family and on individual and family
identity. Externalizing supports a helpful separation of the person from the illness as a
means of addressing and reducing guilt and blame, which is commonly around for
individuals in families where anorexia nervosa has taken hold. Externalizing in the
treatment of anorexia nervosa is used carefully and in collaboration with the patient
and their family. Some young people dislike it, feeling dismissed or patronized, and it
is important not to use language that objectifies or even demonizes the illness.
However, where externalizing of the illness makes sense to and provides a good fit for
the young person and their family, it can be used collaboratively as a way of support-
ing the patient to allow their parent/s to help them eat as a joint endeavor in defiance
of the illness. For patients who are unable to respond collaboratively in phase 1, exter-
nalizing remains relevant in supporting parents to understand the strength of the ill-
ness demands on their child and the need to act against those demands rather than
against their child. This can also be reinforced by discussing the physical and psycho-
logical effects of starvation, which has a similar externalizing effect by providing an
alternative meaning to behaviors that may otherwise appear incomprehensible or
deceitful (for instance, irritability or mood fluctuations, preoccupation with food, or
claiming to feel full for a long time after eating even small amounts of food).
At assessment, the therapist introduces the family to the wider MDT; the assessment
will always include a medical examination, and so the team pediatrician or the psychia-
trist who conducts the medical assessment will routinely join the therapist for feedback
to the family at the end of the initial session. If another team member has been observ-
ing the assessment, they will often join their team colleagues to provide feedback to the
family. This approach begins to support the development of the secure therapeutic
base for the family and engagement with both therapist and the team as a whole.
A meal plan sufficient in calories to restore weight is offered to the parents as a
guide to what the patient needs to eat to start the recovery process. The meal plan is
presented as a “prescription” or “medicine” in recognition of the primary need for
weight gain to happen before most other concerns can be helpfully and safely attended
to. While parents are supported to rebuild their confidence in making judgements as
to what their child needs to eat, in the early stages a meal plan can often provide them
with some certainty and confidence that they are feeding their child enough to begin
recovering. A meal plan also serves to reduce negotiations about food, which can
become exhausting and diverting. The meal plan is not a fixed or permanent tool for
treatment; its use is seen as temporary with movement toward more flexibility as treat-
ment progresses, making the meal plan redundant.
Following the assessment, parents are immediately provided with advice and the
assurance of ongoing support to help them care for and feed their child at home. The
patient may be seen two or three times in the first week depending on the severity of
their physical presentation, although more typically patients begin a process of weekly
family sessions. During the early phases of treatment, the therapist provides reassur-
ance as an expert in relation to knowledge of the illness and its treatment while con-
veying a position of curiosity or non‐expertise in relation to that particular family and
their unique characteristics and needs.
The initial assessment session is often only attended by patients and their parent/s.
Siblings will be inquired about at appropriate points and their individual needs thought
about carefully and collaboratively with parents being encouraged to determine and
dictate what would work best for their children and when might be a helpful time to
include them in sessions. Siblings needs vary considerably, and they can feel overlooked
when their sister or brother is unwell; however, they may feel overburdened, fright-
ened, or irritated whether included or excluded from treatment sessions. Some attend
sessions on a regular basis, while others come infrequently when specifically invited.
Phase 2: Helping the family to manage the eating disorder

Phase 2 of treatment overlaps with and follows swiftly on from the assessment phase.
While the focus on engaging the family is an ongoing process, the primary emphasis
in phase 2 is on identifying and developing parental skills to support their child to eat
and gain weight. The therapist weighs the patient at the start of each session with the
conversation then being partly dictated by the weight trajectory. Weighing continues
through treatment until a collaborative decision is reached that weight should no
longer be the focus. This would usually happen once weight is within a healthy range
and has been maintained for some time or with a child who is still growing, the trajec-
tory is consistently positive.
The therapist invites the family to have a meal in the clinic with the purpose of
experiencing at firsthand what happens at mealtimes, identifying strengths as well as
potential obstacles, and exploring alternatives that the family can try. The session is
longer (usually 90 min) to allow for a discussion of what has been learned from the
meal sessions. If the meal goes well, it is an opportunity to explore what enabled this,
including what might have been the “unique outcomes” (White & Epston, 1990) in
the clinic setting differentiating it from the usual meal at home; what went well? How
did they manage this? What do they need to do more of? The patient is encouraged
to participate in this process to let their parent know what they found helpful and
what they would like the parents to do differently to ensure that they can continue to
manage the task of eating sufficiently. If the family struggles to help the child eat, this
not only provides an opportunity to problem‐solve, but it also has the potential for
increasing engagement and supporting the developing therapeutic relationship; par-
ents who are going through this crisis appreciate that their therapist will be with them
in their worst moment. The meal provides an opportunity to demonstrate this.
While exploration of family beliefs and relationships is ongoing, this phase of treat-
ment is predominantly behavioral, skills based, and practical. Therapists call on their
experience of other families and recount what strategies other families have tried to
support their child to eat. Further and repeated psychoeducation is also needed
throughout this process to support parents and patients to understand why food, in
the first instance, is their “medicine.” The therapist cites research to support the
development of family knowledge and motivation to keep going, research that shows
that early weight gain is predictive of good outcome (Le Grange, Accurso, Lock,
Agras, & Bryson, 2014) or research related to the impact of starvation on physical and
psychological function (Keys, Brožek, Henschel, Mickelsen, & Taylor, 1950).
Psychoeducation can encourage the continued efforts of parents and patients as symp-
toms and anxiety intensify as anorexia nervosa behaviors are challenged more consist-
ently. In the later stages of phase 2, the family is supported to move away from rigid
adherence to a meal plan and fixed food choices.
Phase 3: Exploring issues of individual and family development

Phase 3 is marked by three major shifts in treatment focus. First, there is a move away
from the emphasis on behavioral change and a gradual increase in focusing on broader
issues related to adolescence and individual, family, and life‐cycle development.
Second, the young person is encouraged to increase the level of responsibility they
take in ensuring their continued recovery. Parents are encouraged to take a less central
role in managing mealtimes while continuing to provide support and encouragement.
Young people vary in the degree to which they welcome this relational shift while also
missing the reassuring sense of certainty and predictability derived from rigidly fol-
lowing a meal plan, being regularly weighed and having regular clinic appointments
with the “expert” therapist. For the family as a whole, this is a challenging phase when
they need to develop flexibility and to manage the uncertainty that increased
independence necessarily evokes.
The third shift in phase 3 concerns the nature of the therapeutic relationship. The
anxiety that the relational changes in the family inevitably evoke, on the one hand,
requires the therapist to consider carefully the timing and pacing of the process so that
the progress achieved is maintained while on the other hand ensuring that the hith-
erto dependent relationship of the family on the therapist also begins to change. The
conversations with the family become increasingly open ended and exploratory, the
therapist adopting more collaborative, non‐expert positions defined by curiosity
rather than certainty (Sluzki, 2008). This changed therapeutic positioning is achieved
through and maintained by the therapist’s accrued knowledge and understanding of
the family over the months of treatment in earlier phases, which provides the safe
context for both the young person and the parents to increase their tolerance of
uncertainty (Mason, 1993).
For some families any emerging issues are readily perceived as reflecting the tensions
that typically arise in families managing normal life‐cycle changes, and this process is
managed over a relatively short period of time, and ending treatment is achieved more
readily. For others, individual or family difficulties, which had been obscured by the
illness and its treatment, become more apparent. These issues are managed either with
the whole family, separately with the parental couple or parent, or individually with
the patient.
This changing therapeutic positioning is happening continually throughout
treatment; however, it is vital that when moving toward the end of treatment that
an open, non‐expert position increasingly dominates so that families and individu-
als are more likely to feel equipped to manage without the therapist and treating
team being deferred to for decision making. If therapy has been helpful, the family
may have already begun to increase their tolerance of uncertainty, the patient will
often be more than ready to move on, and the parents will begin to show that they
no longer need their therapist and the team to help them make decisions or to
solve problems.
Any dilemmas on ending treatment will have usually arisen before, and so the thera-
pist is able to normalize most worries and support a narrative that recognizes their
achievements and strengths. Conversations will have developed over time, which
address worries about relapse so that once the end of treatment is reached, the family
are their own experts when “relapse prevention,” for example, is raised.
Phase 4: Ending treatment, discussion of future plans and discharge

Phase 4 therefore is not a distinct moment but is rather a culmination of factors that
are arrived at through the processes and conversations in therapy. It is when parents
and patients reach a point where it is evident that they know enough about the illness,
about their strengths, about their vulnerabilities, and about one another that they also
know that however safe and comfortable it might feel to continue attending a clinic,
this is not likely to be helpful in the longer term. The end of the therapeutic relation-
ship and connection with the MDT is not only often ambivalent, but it is also often
reached with families expressing a sense that they have learned much about themselves
and each other and that their relationships have been strengthened by the treatment
process (Wallis et al., 2017).
Training in eating disorders focused family therapy

The treatments described in this chapter are manualized and intensive; brief (3 or
4 days) trainings in FT‐AN or multifamily therapy for eating disorders (described
below) are available for qualified mental health professionals with prior experience in
the treatment of eating disorders and with a basic understanding of systemic theory.
Preferably the training is offered on a team basis to professionals already working in
specialist multidisciplinary eating disorder teams that have systemic family therapists
embedded as a part of their team. In order to ensure that the model is delivered effec-
tively, following the training, professionals new to the model should receive ongoing
supervision from clinicians who have long‐standing experience and prior supervision
themselves in applying FT‐AN or multifamily therapy focused on eating disorders in
their everyday clinical practice. Systemic family therapists who are not specifically
trained in FT‐AN and/or have limited experience of treating eating disorders should
refer families with a child with an eating disorder onward to clinicians who have eating
disorder expertise and familiarity with family therapy that focuses on eating disorders.
Multifamily Therapy for Anorexia Nervosa
MFT‐AN is a treatment that consists of five to eight young people with restrictive
eating disorders and their families working together with a therapeutic team to sup-
port recovery. MFT‐AN is conceptually based on the principles of FT‐AN and inte-
grates a range of systemic, cognitive, behavioral, psychodynamic, and group therapy
conceptualizations and intervention techniques. Although MFT‐AN is sometimes
used as a stand‐alone treatment (Knatz et al., 2015; Scholz, Rix, Scholz, Gantchev, &
Thömke, 2005), at the Maudsley Hospital, intensive whole‐day multifamily sessions
are combined with single FT‐AN sessions as needed.
The overarching goal of MFT‐AN is to enhance the speed of change, enable rapid
improvement of eating disorder symptoms, and promote physical safety early in treat-
ment. MFT‐AN interventions are aimed at intensifying and adding to FT‐AN through
three main mechanisms: changing treatment context, increasing treatment scope and
intensity, and bringing people together to reduce isolation and promote solidarity and
a sense of community. By adding in these elements to FT‐AN, young people and
families are able to create new understandings and meaning and experiment with new
behaviors in a way that cannot be accessed through single‐family therapy. The group
setting allows everyone to participate, learn, and experience new things in novel ways
in a safe context that promotes trust and hope.
MFT‐AN is activity based and structured in a way that enables a large amount of
support early in treatment, which then reduces over time. The families and team meet
for 8–10 full days over a 6‐ to 9‐month period. Treatment starts with an introductory
afternoon prior to four full consecutive days of therapy. These are then followed by
four to six 1‐day follow‐up meetings. The MFT‐AN group is a closed group, and the
expectation is that families attend both the intensive 4 days of treatment and subse-
quent 1‐day follow‐ups.
The content of the MFT‐AN activities varies from day to day using a mixture of
whole group sessions, parallel sessions with parents and young people (including sep-
arate sibling sessions), and tasks for individual families. Themes for each day are based
on the needs of participants in the group as well as their stage in treatment, and then
content is built around it. Early on in treatment typical themes include engagement,
managing mealtimes, increasing support, and promoting understanding of the illness
and the young person’s struggle. As the treatment progresses the participants take
more of a lead in managing group content and process, and the content of activities
broadens to family strengths, individual and family life‐cycle issues, and managing
independence. Increasingly the follow‐up days rely on families helping one another
using their own experiences and expertise but guided by the therapists.
Family Therapy for Bulimia Nervosa
The treatment of bulimia nervosa parallels that of anorexia nervosa, albeit with some
key differences. As with anorexia nervosa, FT‐BN is the recommended first‐line treat-
ment (NICE, 2017). FT‐BN is a 12‐month treatment that has been manualized and
has its roots in systemic, structural, and strategic family therapy as well as narrative
therapy (Le Grange & Lock, 2007; Schmidt et al., 2007). FT‐BN is also a phased
treatment that moves from the parents supporting the young person to resume a
normal pattern of eating, followed by supporting independence and then managing
any developmental or wider context issues. The narrative technique of externalization
is also used strategically to help align the young person and their family together in
the management of symptoms.
Family therapy for bulimia nervosa differs from that for anorexia nervosa, reflecting
some of the temperamental differences of young people in the two groups: most nota-
bly increased impulsivity, lower distress tolerance, and emotion regulation difficulties
(Anestis, Selby, Fink, & Joiner, 2007). The treatment also considers the differences in
motivation of the young person with bulimia nervosa and the more common occur-
rence of difficulties in family relationships. Although the young person with bulimia
nervosa treatment is usually ambivalent about engaging in treatment, they will usually
readily acknowledge that they find their symptoms distressing and shaming. Parents
often find the bulimic behaviors of their daughter or son highly distressing and bur-
densome (Perkins, Winn, Murray, Murphy, & Schmidt, 2004), which may reinforce
negativity and criticism, making the young person wary of accepting help from them
(Perkins et al., 2005). Parental motivation is also often complex because while parents
are generally concerned, the less visible medical complications compared to anorexia
nervosa can make treatment appear less urgent, particularly if the young person is
rejecting of parental support.
To account for these differences, in the earlier phases of FT‐BN, the individual’s
engagement in therapy is much more central to the treatment; thus incorporating
individual and/or separated sessions much earlier on to address motivation and
potential barriers to whole family work is often important. The result of this is that
engaging the parents as active supports to bring about behavioral change is a slower
process that has to be negotiated in a collaborative way with the young person.
Decision making in the first phase of treatment is often led more by the young person,
with parents stepping in as required. During separated sessions the work with the
young person focuses on building engagement and motivation to manage distress.
With parents, the focus is on providing psychoeducation and on developing skills to
support the young person in a nonjudgmental, validating way. The purpose of this is
to try and reduce perceived criticism in order to ensure that the young person finds
their relationship containing and supportive, ensuring that parents can be used as a
support in the management of symptoms. Once trust is (re)established, the young
person and parents work together to manage urges to binge and purge, as well as
normalizing eating behaviors.
Once a more normal pattern of eating has resumed, and there is an absence of
bingeing and purging, the treatment turns to the tasks of developmentally appropriate
independence and managing the tasks of being an adolescent. This often starts with
eating independently but quickly extends to navigating relationships, strengthening
self‐esteem, and building a robust identity during a developmental stage that is often
fraught with challenges.
Multifamily Therapy for Bulimia Nervosa
Multifamily therapy for bulimia nervosa (MFT‐BN) is a new treatment that is still
evolving. Like MFT‐AN, MFT‐BN is a group‐based treatment offered to up to eight
or nine families who work together over several months. It is also activity based and is
offered alongside FT‐BN, not as a stand‐alone intervention. The treatment aims to
support a more rapid rate of recovery from bulimic symptoms, improved engagement
and systemic understanding of the illness, enhanced skill building, and a reduction in
feelings of isolation. While it shares elements with MFT‐AN, overall it differs quite
significantly. MFT‐BN incorporates elements of systemic therapy, as well as cognitive‐
behavioral therapy (CBT) and dialectical behavior therapy (DBT) in order to address
some of the core emotion regulation, distress tolerance, and impulsivity difficulties
usually experienced by people with bulimia nervosa in addition to eating concerns.
Structurally, the treatment is also quite different to MFT‐AN. The treatment is
delivered over sixteen 90‐min sessions, which are provided over 20 weeks. The treat-
ment is designed in a way that incorporates far more separated sessions initially, to try
to mirror the aims of the early stages of FT‐BN (Stewart, Voulgari, Eisler, Hunt, &
Simic, 2015). One of the key first aims of the treatment is to help young people
understand the function of emotions and the cycles of unhelpful coping they may find
themselves caught up in. For parents, the initial focus is on reducing criticism and
increasing validation, as is the case with FT‐BN.
The multifamily environment functions much the same as it does in all multifamily
therapy treatments. The unique environment allows the group to draw upon the
shared experiences and resources of all young people and their families. Not surpris-
ingly, this is often the element of the treatment that is most frequently reported to be
particularly helpful.
The CBT elements of MFT‐BN are most prominently seen in the use of a cogni-
tive‐behavioral formulation of the binge/purge cycles of bulimia nervosa, which is
developed early on in a generic form by the group of young people, which they then
personalize and share with their family and wider group as appropriate. Other CBT
elements include thought challenging, recognizing negative thinking patters, and the
use of exposure techniques to overcome distress associated with avoided situations or
activities. These elements are introduced either in the multifamily context, in indi-
vidual family groups, or in separate young people and parent groups depending on
the particular dynamics of each individual group.
The DBT elements of MFT‐BN include the inclusion of motivational techniques,
emotion regulation, and distress tolerance skills while the parents in a parallel group
may be learning and practicing validation skills. Mindfulness is also a core component
of the treatment, which is incorporated from the very outset of the group. A range of
activities are used, often pairing a young person with parents from other families to
disrupt cycles of negativity, which might otherwise prevent the explorations of new
perceptions and new narratives. These can then be shared with the whole group in the
multifamily context to improve systemic understanding, knowledge, and skill use.
Empirical Evidence
Despite the long tradition of family therapy in the treatment of eating disorders,
research in the field was slow to get going and only gradually expanded from the
1980s onward. Since then a number of randomized trials have been completed in
several different countries examining the efficacy of family therapy for both anorexia
nervosa and bulimia nervosa in young people. Eating disorder‐focused family therapy
is now recommended in clinical guidelines in a number of countries (APA, 2006;
Hilbert, Hoek, & Schmidt, 2017; NICE, 2017) as the treatment of choice for young
people with anorexia nervosa and bulimia nervosa. With regard to other eating disor-
ders, family therapy is less well researched and is only beginning to be empirically
investigated.
Family therapy and multifamily therapy for anorexia nervosa

The treatment of adolescent anorexia has attracted the largest amount of family ther-
apy research with 15 published randomized control trial (RCT) showing that FT‐AN
leads to improved outcomes, which are maintained at follow‐up of up to 5 years
(Jewell, Blessitt, Stewart, Simic, & Eisler, 2016; NICE, 2017). There is also evidence
that FT‐AN leads to improved weight outcomes compared with individual approaches
(Fisher, Skocic, Rutherford, & Hetrick, 2018; Jewell et al., 2016).
While the research to date provides a reasonably consistent picture of the effective-
ness of FT‐AN for children and adolescents, there are a number of caveats to the
published findings. First, there is a lack of consensus in the field as to how good out-
come is defined (Murray, Loeb, & Le Grange, 2018) both in terms of physical symp-
toms such as weight and psychological functioning. There is also a large variability in
how psychologically ill and/or underweight the patients are at the commencement of
treatment, meaning that reaching certain arbitrarily defined cutoffs to mark recovery
may make it difficult to compare the amount of change that has occurred over treat-
ment. Both these factors make comparison between studies and summarizing research
problematic. Finally, as is often the case in treatment trials, the samples in many of the
studies are not always representative of the target population. This may be in part a
reflection of the fact that ethnic and minority groups are underrepresented in clinical
services for eating disorders (Marques et al., 2011; Regan, Cachelin, & Minnick,
2017), but the process of recruitment to studies (e.g., recruitment through advertisements
rather than from consecutive referrals to services, language exclusion criteria in order
to facilitate the use of standardized assessment measures, etc.) may also explain the
lack of diversity in most treatment trials.
With this in mind, the literature reports that approximately 50–75% of young peo-
ple will have reached a weight within a healthy range (i.e., within 15% of median
population weight adjusted for age, sex, and height) at the end of treatment (Le
Grange & Eisler, 2009), though a number of authors would argue that this is an over-
estimate as at an individual level, a significant number will need to be at a higher
weight (e.g., within 5% of the median) to regain health. These gains are then improved
upon at 5‐year follow‐up, with 75–90% of young people being recovered using com-
bined indices (e.g., weight commensurate with return of periods, psychosocial func-
tioning) by this time and only 10–15% continuing to meet diagnostic criteria for
anorexia nervosa (Eisler, Simic, Russell, & Dare, 2007; Lock, Couturier, & Agras,
2006). It is also worth noting that the research data has other limitations requiring a
degree of caution in how it is interpreted. For instance, there are few independent
replications, and many of the studies have methodological limitations such as small
sample sizes or insufficient blinding of research assessments (Fisher et al., 2018).
When looking at the efficacy of MFT‐AN, the literature is relatively small compared
with FT‐AN. A number of small series and one larger RCT have confirmed that MFT‐
AN helps young people with anorexia nervosa gain weight and reduce other eating
disorder symptoms, has high acceptability, reduces feelings of isolation, and promotes
family well‐being (Eisler, Simic, Hodsoll et al., 2016; Gabel, Pinhas, Eisler, Katzman,
& Heinmaa, 2014; Marzola et al., 2015; Voriadaki et al., 2015).
The largest study is a RCT conducted in the United Kingdom that compared the
outcomes following MFT‐AN and FT‐AN for 169 adolescents and their families
(Eisler, Simic, Hodsoll et al., 2016). The results demonstrate that a higher proportion
of young people will be weight recovered following MFT‐AN in comparison with
FT‐AN, which is maintained at 6‐month follow‐up (Eisler, Simic, Hodsoll et al.,
2016). While this is encouraging, it is also important to note that, as per the model,
those receiving MFT‐AN also received single‐family FT‐AN sessions on an as‐needed
basis. Interestingly the number of FT‐AN sessions was similar for participants in both
arms of the study, meaning those receiving MFT‐AN essentially received the multi-
family groups as an addition to standard FT‐AN. In light of this, the authors are cau-
tious when interpreting these findings as it is difficult to discern whether the improved
outcomes are the result of the specific MFT‐AN intervention or just a higher treat-
ment dose. Nevertheless, it can be said that it is a treatment that enhances outcomes
and shows promise.
Family and multifamily therapy for bulimia nervosa

FT‐BN has been much less researched in comparison with FT‐AN, with fewer studies
and fewer participants having completed the treatment overall. Three moderately
large though adequately powered RCTs comparing FT‐BN with individual therapy
(Le Grange, Crosby, Rathouz, & Leventhal, 2007; Le Grange, Lock, Agras, Bryson,
& Jo, 2015; Schmidt et al., 2007) have together shown superior outcome in FT‐BN
(NICE, 2017) with approximately 40% of adolescents abstaining from bingeing or
purging behaviors. These improvements tend to be maintained at follow‐up, although
this is not consistently reported (Le Grange et al., 2007). Interestingly, the findings
vary somewhat between the studies. Two trials in the United States have demon-
strated FT‐BN’s superiority over individual supportive psychotherapy (Le Grange
et al., 2007) and CBT (Le Grange et al., 2015) with similar rates of abstinence of
around 40% at the end of treatment but different trajectories posttreatment with the
earlier study showing a reduction in abstinence rates at 6‐month follow‐up but the
newer study finding continuing improvement posttreatment. A UK study by Schmidt
and colleagues (2007) with a somewhat older group with a longer history of the ill-
ness and higher rates of bingeing and purging at baseline compared with the US stud-
ies found individual CBT as effective as FT‐BN overall but with a faster rate of
reduction in binge episodes in the CBT group. At the end of treatment, the absti-
nence rate in FT‐BN was only 12.5%, but 6‐month posttreatment this had reached
41.4% comparable with the US studies. While the data from these three studies pro-
vides credible empirical support for FT‐BN, it is important to put these outcomes in
the context of real‐world applicability. Less than half the young people who received
FT‐BN were abstaining after receiving treatment from bulimic symptoms, leaving a
majority still struggling with the illness. Moreover, although the onset of bulimia
nervosa like that of anorexia nervosa is most commonly in adolescence (Micali,
Hagberg, Petersen, & Treasure, 2013), case identification of young people with
bulimia nervosa is poor, and treatment is often delayed for 4–5 years after the illness
onset (House et al., 2012; Turnbull, Ward, Treasure, Jick, & Derby, 1996).
As a relatively new approach, MFT‐BN has limited supporting research data. Other
than descriptions of the treatment, there is only one published paper reporting on the
outcome of 10 adolescents and their families. Keeping in mind this very small sample
size, the data indicates that MFT‐BN leads to a reduction in eating disorder symp-
toms, improvements in mood, and an increase in the use of adaptive skills to manage
emotions (Stewart et al., 2015).
Family and multifamily approaches for adult anorexia nervosa

On the back of the promising findings for family therapy with adolescents with
anorexia nervosa, there is renewed interest in the field in employing couple and
family therapies with adults. Two older RCTs showed limited benefits of family
therapy with one showing overall poor outcome with a subgroup, with adult onset
doing better in individual therapy (Russell, Szmukler, Dare, & Eisler, 1987), and a
second study showing that while family therapy had superior outcome to treatment
as usual, it was comparable with individual psychodynamic psychotherapy and the
amount of change reported was quite modest with a significant proportion remain-
ing significantly malnourished at the end of treatment (Dare, Eisler, Russell,
Treasure, & Dodge, 2001). The key limitation of both studies was that they had
relatively small samples and participants tended to have a relatively long‐standing
illness with a poor prognosis.
More recent work has started to focus on engaging families of younger adults mod-
ifying the FT‐AN approach to include more individual time with the patient and more
age appropriate collaboration with family members that takes into account develop-
mental and life‐cycle stage needs (Chen et al., 2016; Dimitropoulos et al., 2015a,
2015b, 2018). The small amount of data published suggests that it may help young
adults to gain weight and reduce eating disorder psychopathology (Chen et al., 2016;
Dimitropoulos et al., 2018).
Including partners in treatment is also something that is being trialed in several

places around the world. Bulik, Baucom, Kirby, and Pisetsky (2011) have developed
a novel treatment, Uniting Couples in the Treatment of Anorexia Nervosa (UCAN),
based on CBT that involves intimate partners for the duration of treatment. There are
three phases of the treatment, which involve psychoeducation and communication
training (phase 1), managing eating disorder behaviors, body image concerns, and
maintaining intimacy and affection within the relationship (phase 2), followed by
relapse prevention (phase 3). Pilot data suggests it leads to improved weight gain
when compared with individual treatments, has 90% treatment retention, and helps to
reduce eating disorder psychopathology and the couple relationship is strengthened
by the end of treatment (Baucom et al., 2017).
Several groups have also started exploring the use of multifamily therapy approaches
with adult anorexia nervosa patients. While at present data are limited there is some
indication that bringing together families with this age group may have a similar ben-
eficial impact that has been demonstrated with the younger age group. MFT‐AN with
adult patients has been explored in several different contexts from a series of weekly
90‐min sessions (Dimitropoulos et al., 2018) through a 3‐day workshop attended by
two families (Whitney et al., 2012) to a weeklong intensive group format of six to
eight families (Wierenga et al., 2018). The data reported in these studies is very pre-
liminary but suggests high acceptability to families (dropout rates 2–14%), improve-
ments in weight, eating disorder psychopathology, and carer burden and family
relationships. While these findings are very preliminary, they clearly suggest that more
systematic evaluation is warranted.
These newer couple and family therapy studies are notable for their more nuanced
approach compared with earlier studies, paying more attention to the developmental
and family life‐cycle stage needs and emphasizing the importance of a collaborative
approach, which pays careful attention to discussing how parents or partners are to be
involved in the treatment process. Our clinical experience is that the very process of
negotiating how family members are going to be involved is a key therapeutic ingredi-
ent in its own right. Families living with an eating disorder adapt to the needs of the
illness in ways that can interfere with family life‐cycle transitions and become part of
the illness maintenance (Eisler, 2005; Treasure & Schmidt, 2013). With families of
adult patients, the exploration of how parents or partners can help begins to address
the lack of clarity and the ambiguities of the family life‐cycle transition. The young
adult will often both feel the need for support and also want their voice to be heard.
Agreeing how the support is to be provided allows the young adult and their family
to develop a shared sense of purpose, which supports the necessary change in eating
behaviors that is key to starting the process of recovery.
The treatment of other eating disorders

There is a real deficit in the literature examining family interventions for other eating
disorders. To date there are no published papers examining family therapy for BED
although findings that interpersonal psychotherapy (IPT) may be helpful (Tanofsky‐
Kraff et al., 2007) indicate the potential value of addressing interpersonal relationships
and by extension suggest the possible value of involving families in treatment directly.
Similarly, there is very little known about the treatment of ARFID. Currently there
are no empirically supported treatments for ARFID. This may be partly attributed to
ARFID being a new diagnosis introduced in DSM‐V (APA, 2013), making it difficult
to consistently document, describe, and research by clinicians prior to 2013. It is also
suggested that because the diagnosis captures a large range of food and eating difficul-
ties, it is hard to identify appropriate treatments that fit all aspects of ARFID, and
Bryant‐Waugh, Markham, Kreipe, and Walsh (2010) suggested three ARFID subtypes
that might aid treatment design and delivery, namely, those characterized predomi-
nately by (a) inadequate food intake, (b) restricted range of food intake, or (c) avoid-
ance related to a specific fear other than weight gain. Due to the lack of empirical
evidence treatment, plans often need to be quite individually tailored to target specific
symptoms and maintaining factors. A small case series describes successful treatment
using a combination of medical monitoring, family therapy, medication, and CBT
(Spettigue, Norris, Santos, & Obeid, 2018). There is also some evidence that a family‐
centered day program that included weekly family sessions, daily multifamily meals, and
regular involvement of families in planning treatment goals and reviewing treatment
progress can be helpful (Ornstein, Essayli, Nicely, Masciulli, & Lane‐Loney, 2017).
Common factors, moderators and mediators

Looking across all the treatment studies in eating disorders, there is consistent evi-
dence, albeit with the caveats mentioned above, that family therapy has a key role in
the treatment of children and adolescents across a range of eating disorders and may
also have a role in the treatment of adults. Much less clear is what makes it effective,
whether certain elements are more important than others, how outcomes can be
improved upon, and whether this changes depending on family, individual, or treat-
ment context characteristics.
The first question to address is the extent to which the treatment effect is specific
to the eating disorder focus of the family therapy at the center of most of the research
described above or whether the findings are explainable as the outcome of the more
general common systemic factors operating in marital and family therapy (i.e., a rela-
tional conceptualization, expansion of the therapeutic system and the expanded thera-
peutic alliance; Sprenkle & Blow, 2004). There is some evidence from two studies
that, at least in part, this may be the case. Godart et al. (2012) found that a generic
family therapy that explicitly focused on relational issues rather than the management
of the eating behaviors was more effective than treatment as usual. A more direct
comparison comes from a study by Agras and colleagues (2014) who compared FT‐
AN with a manualized generic form of systemic family therapy. In terms of the pri-
mary outcome, there were no differences between treatments; however FT‐AN was
associated with a more rapid rate of weight gain, fewer days in hospital if the adoles-
cent required inpatient treatment, and lower costs. The data also indicated that the
more generic systemic therapy was superior for young people with comorbid obses-
sional difficulties. This suggests that there is some benefit to adhering early in treat-
ment to an eating disorder focus for most young people but that a broader systemic
approach may be needed where there are more complex needs. It has to be said that
this study also had its limitations as the authors themselves acknowledge. While the
generic systemic manual allowed a broader focus on a range of behaviors and prob-
lems, the specific focus was determined by what the families perceived to be their
priority. Given that the clinicians working on this trial had significant experience of
treating eating disorders and were working in specialist centers, the two treatments
may have looked more similar in the room than the manuals would suggest, making
this study a fairly conservative test of the specificity of FT‐AN (Blessitt, Voulgari, &
Eisler, 2015).
With regard to the question of whether FT‐AN is more effective for adolescents with
particular presentations or specific family dynamics, there is also a growing body of
evidence to give us some clues. Duration of illness and severity of eating disorder psy-
chopathology both, as might be expected, predict response to treatment (Agras et al.,
2014; Eisler et al., 2000; Lock et al., 2006). As touched upon above, there is also a
small body of evidence that young people with more complex needs may benefit from
different treatment approaches. Those patients who are more obsessional may benefit
from a more generalized approach (Agras et al., 2014) but also longer treatment (Lock
et al., 2006). They also fare better when the treatment is delivered with the whole fam-
ily present as opposed to separated sessions (Eisler et al., 2000), parent only treatment
(Le Grange et al., 2016), or individual treatment (Lock et al., 2010). Similarly, those
adolescents with more complex presentations of binge/purge symptoms or who come
from non‐intact families may benefit from longer treatment (Lock et al., 2006).
Family dynamics may be both nonspecific predictors of outcome and possible mod-
erators of specific forms of treatment. Expressed emotion (EE), a widely used measure
in many areas of mental health that assesses a range of factors (hostility, criticism,
emotional over‐involvement, warmth, and positivity) (Leff & Vaughn, 1984), has
been used widely in studies of eating disorders. High levels of parental criticism have
been shown to predict poor engagement in family therapy (Rienecke, Accurso, Lock,
& Le Grange, 2016; Szmukler, Eisler, Russell, & Dare, 1985) and poor treatment
outcome (Eisler et al., 2000, 2007; Le Grange, Eisler, Dare, & Hodes, 1992; Rienecke
et al., 2016), whereas parental warmth has been found to predict good outcome (Le
Grange, Reinecke‐Hoste, Lock, & Bryson, 2011).
There is also some evidence to suggest that EE may act as a treatment moderator,
leading to differential responses to treatments. Seeing parents and young people sepa-
rately during treatment (Eisler et al., 2000, 2007; Le Grange, Eisler, Dare, & Russell,
1992) or seeing parents alone with only a brief 15‐min check‐in with the adolescent for
medical monitoring (Le Grange et al., 2016) can lead to comparable outcomes overall.
However, in the presence of high maternal criticism, separating the parents and adoles-
cent during treatment is associated with improved outcomes (Allan, Le Grange,
Sawyer, McLean, & Hughes, 2018; Eisler et al., 2000). Similarly, when the compari-
son was FT‐AN and individual therapy, high levels of criticism in mothers in particular,
the patient fared better in individual treatment (Rienecke et al., 2016). Furthermore,
maternal criticism is more likely to decrease if parents are seen alone (Allan et al.,
2018). Intriguingly, paternal criticism seems to negatively affect treatment outcome
regardless of the type of treatment (Allan et al., 2018; Rienecke et al., 2016).
What clinical implications these findings have is not entirely straightforward. First, it
needs to be remembered that these findings invariably come from post hoc secondary
analyses of data collected as part of efficacy RCTs, which were often not designed or
powered to test specific hypotheses concerning the moderating role of family dynam-
ics. Second, there can be a number of different mechanisms through which the family
dynamics and treatment process may interact. For instance, one plausible hypothesis is
that the negative family dynamic acts as a maintaining factor of the illness (Treasure &
Schmidt, 2013), which needs to be addressed in treatment. An alternative hypothesis
(or perhaps more accurately a parallel hypothesis as both mechanisms could operate) is
that improvement in the illness through whatever treatment mechanism will itself
reduce family negativity, enabling the family to reconnect with its family life‐cycle tasks
more readily and mobilize family strength and resilience factors to support the young
person’s recovery process. A third process that could be operating posits an interaction
between the family dynamic and the engagement of the family in treatment.
A qualitative study by Wallis and colleagues (2017) provides some insight into the
complexity of these processes. In the study 16 adolescents and their parents were
interviewed after successful FT‐AN with a key finding that relational containment of
the adolescent by the parents was perceived as a major factor in their recovery. The
authors suggest that the structured nature of the treatment, the therapists’ expertise
in providing directions, and the specialist medical setting created a process of rela-
tional containment, which counteracted the families’ own sense of disconnection and
isolation. This enabled parents to regain confidence in themselves as parents and to
trust the treatment process to support them and their daughter or son through recov-
ery. This enabled the young person to trust their parents and increase their sense of
closeness as well as their own sense of self‐worth.
This study purposefully focused on those who responded well to treatment and
does not tell us how this group might differ from those who respond less well (Simic
et al., 2016). Jewell and colleagues (2016) have suggested that attachment might be
a useful construct to consider when trying to understand family responses to negative
affect and that this may determine whether the early interactions in FT‐AN sessions
are experienced as supportive and caring or punitive, controlling, and blaming. During
the process of treatment, the parents need to support their adolescent through a very
distressing and often negative experience for a prolonged period, something that
requires a strong attachment system to withstand.
The wider system and treatment context

If we consider treatment occurring in not just the context of the individual and family,
but also within the wider system, an additional and important factor that has also been
shown to influence outcome is the service context of treatment. In a naturalistic study
in greater London, United Kingdom, House and colleagues (2012) compared over a
2‐year period the impact of the availability of different care pathways that were deter-
mined by local health‐care commissioning agreements, which either enabled access to
specialist community‐based eating disorder services directly from primary care or used
a stepped care model where the initial referral was to a generic child and adolescent
mental health service (CAMHS) with subsequent referral to a specialist community‐
based service or higher level of care if this was required. The differences between the
two care pathways were striking. In specialist areas, two to three times more cases
were identified and referred for treatment than in nonspecialist areas. Furthermore,
when specialist services were the initial point of contact for a young person and their
family, the need for inpatient treatment was reduced from 40 to 15%, and consistency
of care by the same provider was markedly higher. This was reflected in overall treat-
ment costs being less than half if treatment started in a specialist service and less than
a third if calculated per good outcome. Being a naturalistic, service‐level study, it is
difficult to know exactly what factors contributed to these differences. However, it is
clear that the service context influences a range of extra‐therapeutic factors. These are
likely to include earlier access to treatment, increased expectancy and hope that treat-
ment will be successful, and a therapeutic alliance with the MDT giving confidence in
their knowledge, competence, and skill providing emotional containment for the
patient and her/his family. In much the same way as a family’s ability to provide rela-
tional containment for their adolescent is key to outcomes (Wallis et al., 2017), a
treating team’s ability to provide containment for the family is powerful and is likely
to enhance the impact of the therapeutic interventions with the family.
Further areas for research

While there is now consistent evidence that family therapy is an effective treatment for
adolescent anorexia and bulimia nervosa, it is also important to remember that there
is a significant minority of young people who do not respond to these treatments. The
field is now turning toward the question of what to modify or reconceptualize in
order to improve the outcomes for this group. This has bred a lot of creativity in the
field when it comes to augmenting and enhancing the current treatments. Richards,
Subar, Touyz, and Rhodes (2018) recently published a review of the augmentations
to FT‐AN. These range from increasing treatment intensity by having people attend
more regularly, changing treatment context (e.g., day patient programs or group
components), adding additional therapeutic content to reduce the impact of comor-
bidities or other psychological/family factors, additional parent support, and increased
coaching, to name a few. The majority of these studies are small and exploratory in
nature but show promise in assisting this group of unwell and untreated young peo-
ple. The data tends to indicate that augmentations do enhance the outcomes, although
there is still a long way to go (Richards et al., 2018).
When examining the literature on augmentations to FT‐AN, broadly the modifica-
tions tend to revolve around four key potential mechanisms of change: increasing treat-
ment intensity, reducing perceived individual or family isolation, addressing comorbidity
or neurocognitive deficits, and shifting treatment context. Other emerging areas in the
literature include focusing on incorporating interventions aimed at managing emotional
dysregulation in the young person (Anderson et al., 2015) and addressing relational fac-
tors that may be impeding the family’s ability to provide effective support for the young
person through emotion‐focused or attachment‐based family interventions (Diamond,
2014; Robinson, Dolhanty, & Greenberg, 2015; Simic et al., 2016).
Further investigation into these mechanisms and how they might be matched
appropriately and effectively to the specific needs of an adolescent and their family is
much needed and at the forefront of current research in the field of family therapy for
eating disorders.
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Part IV
Challenging Family
and Social Contexts
17
Complicated Adoption
Amy M. Claridge and Melissa M. Denlinger
All adoption is complicated in that it involves a birth family, an adoptive family, and a
child connected to both families, and it implicates multiple family systems (Cushman,
Kalmuss, & Namerow, 1993). The involvement of several family systems necessitates
negotiation and understanding of multiple family dynamics. In turn, all members of
the adoption triad (birth parents, adoptive parents, and adoptive child) have the
potential to experience complications in the adoption process. Adoption experiences
vary depending on the level of openness in contact between members of the adoption
triad (Grotevant, 2012). On the extremes of the continuum, open adoptions involve
contact and relationships between all members of the adoption triad, and closed or
confidential adoptions involve little to no information sharing or contact among
adopted children and families and birth families. Open adoptions are increasingly
common and tend to be associated with better outcomes for all members of the
adoption triad (Grotevant, 2012).
Regardless of adoption openness, birth parents often experience complicated
emotions pre‐adoption, including depression and anxiety (Wiley & Baden, 2005),
and tend to experience the actual relinquishment of their child as a profound loss and
trauma (Aloi, 2009). Adoptive parents may experience anxiety because of pressure to
be perfect parents since they were chosen to raise their child; fears that their child
could be removed from their care, especially if they are subject to a probationary
period; feelings of isolation because of their unique circumstances; and pressure to
be happy and grateful for the adoption (McKay & Ross, 2010). Adoption is also
complicated for children, who may leave their biological home to enter a new adop-
tive home, may grow up navigating the relationships between birth and adoptive
families, or may have questions about their birth families (Brodzinsky, Smith, &
Brodzinsky, 1998).
Although no adoption is simple, domestic adoption of a voluntarily relinquished
child at birth is likely the least complicated. This chapter focuses on adoption that is
432 Amy M. Claridge and Melissa M. Denlinger
inherently further complicated because of child or parent backgrounds or characteris-

tics, social stigma, or merging of cultures. Adoptions that are particularly complicated
include adoption from the foster care system, international or transracial adoption,
adoption of older children or children with disabilities, and adoption by nontradi-
tional families (e.g., same‐sex couples, unmarried parents). In many cases, these
categories of complicated adoption intersect. For instance, older children adopted
from foster care are more likely to have disabilities or be of minority race/ethnicity
(Neil, 2012). Children adopted internationally are likely to be older, to have disabili-
ties, and to be of a race/ethnicity different than their adoptive parents (Gunnar,
Bruce, & Grotevant, 2000).
Data are readily available about foster care and international adoption in the United
States. In 2016, 57,208 children were adopted with child welfare agency involvement
(DHHS, 2017), and in 2017, 4,714 children were adopted into the United States
from other countries (US Department of State, 2017). However, data are less availa-
ble regarding private adoptions, which may include older children, children with
disabilities, or nontraditional adoptive families. Despite the lack of specific data, adop-
tion impacts a large number of US families (some estimates suggest 1.5 million chil-
dren in the United States live with adoptive parents; Brodzinsky & Palacios, 2005),
and many of those families face complicated adoption processes and adjustment.
This chapter includes a review of existing literature on the experiences of families in
complicated adoptions, existing interventions to work with these families, and recom-
mendations for therapeutic practice and future research in this area.
Complicated Adoption
Adoption from foster care

Adoption from foster care can occur in one of two ways: (a) state intervention that
deems a parent unfit to be a child’s caregiver or (b) parental concession that they are
unable to safely and effectively parent (Chipungu & Bent‐Goodley, 2004).
Approximately a half million children are served in the US foster care system in any
given year (DHHS, 2017). Although reasonable efforts are made to help children
reunify with their biological families, reunification only happens in 51% of cases.
Children who are adopted out of care demonstrate better outcomes than youth who
age out of the system (Reilly, 2003). Therefore, when reunification does not seem
possible, law mandates that caseworkers quickly move to place children with adoptive
families (Brodzinsky et al., 1998).
Still, children adopted out of foster care tend to demonstrate behavioral and
emotional issues, such as insecure attachment (Dozier & Rutter, 2016). Multiple risk
factors contribute to children’s challenging behaviors. For one, children are likely to
enter foster care already struggling with behavioral, emotional, and physical issues due
to exposure to prenatal teratogens, highly stressful home environments, maltreat-
ment, and separation from their biological families (Newton, Litrownik, & Landsverk,
2000). Children who are ultimately adopted out of foster care have also experienced
immense instability and a great amount of time, on average 30 months, without a
permanent home (DHHS, 2017). Extensive research suggests there are detrimental
outcomes associated with residing in foster care for long periods of time (Stahmer
Complicated Adoption 433
et al., 2005). Children who experience more placements in foster care tend to have
less secure attachment (McWey, 2004) and display signs of severe attachment disor-
ders (Humphreys, Nelson, Fox, & Zeanah, 2017) and behavioral issues (Newton
et al., 2000).
Children adopted from foster care have also experienced many losses and traumas,
including initial maltreatment; being uprooted to a new home and family; multiple
transitions; and social stigma (Hines, Merdinger, & Wyatt, 2005). This trauma tends
to exacerbate behavioral and emotional issues (Weaver, Keller, & Loyek, 2006).
Further, between 65 and 85% of children in foster care are members of sibling groups
(Hegar, 2005), and children’s trauma and loss experiences are compounded when
they are adopted from foster care without their siblings, which occurs in 55–60% of
sibling groups (Hegar & Rosenthal, 2011).
Children adopted from foster care tend to have some contact with their birth family
post‐adoption (Neil, 2000), although it can be challenging to maintain connections
with birth families while also ensuring children’s safety (Jones & Hackett, 2012).
When birth parents are experiencing severe issues (e.g., drug addiction, domestic
violence), contact is more likely to be with other biological relatives (Neil, 2000).
Contact with birth families is generally associated with better outcomes for children
as it allows children to maintain important relationships and make sense of the adop-
tion (Jones & Hackett, 2012), but also comes with challenges and uncertainty, such
as navigating loyalties, establishing boundaries and roles, ensuring safety, and process-
ing feelings of loss and resentment (Neil, 2000). Direct (e.g., visits, phone calls, etc.)
and indirect (e.g., letters, gifts, cards, etc.) contact can serve to enhance communica-
tion, but not all contact necessarily maintains meaningful relationships between
adoptees and birth families (Jones & Hackett, 2012). In general, contact that is con-
sistent and communicates care and concern is most satisfying to adoptees, but the
ideal frequency and form of communication varies greatly among families.
Despite the challenges, most children adopted from foster care demonstrate posi-
tive outcomes over time, and parents who adopt from foster care indicate satisfaction
with the adoption (Brodzinsky et al., 1998). Foster care adoptions are most likely to
be successful when children are younger at time of adoption, are adopted with sib-
lings, or have fewer placements while in foster care (Sellick, Thoburn, & Philpot,
2004) and when parents are well matched to children in terms of their strengths and
abilities to adapt to the child’s needs (Ward, 1997).
International adoption
International adoption refers to adoption by US parents of children born outside of
the United States (Meese, 2005). In 2017, the majority of international adoptions
were of children from China, India, Ethiopia, Ukraine, South Korea, and Haiti (US
Department of State, 2017). More than 80% of children adopted internationally have
spent at least 1 year in institutionalized care (Meese, 2005). International adoption of
post‐institutionalized children is complicated and challenging as children typically
demonstrate some degree of physical, cognitive, and socioemotional delay largely as
the result of their early adverse experiences both in birth families and during institu-
tionalization (Gunnar et al., 2000). Prior to institutionalization, children may have
been exposed to risk factors during prenatal development and poverty or maltreatment
in their birth families (Gunnar & Kertes, 2005). During their time in orphanages,
children often experience inadequate health care and nutrition, exposure to disease
and environmental hazards, limited stimulation and interaction, and lack of consist-
ency in caregivers (Meese, 2005). These early adverse experiences often translate into
language and cognitive delays (e.g., Asimina, Melpomeni, & Alexandra, 2017), physical
development deficits (e.g., Juffer, van Ijzendoorn, & Backersman‐Kranenburg, 2017),
and difficulties in developing healthy attachments (e.g., Humphreys et al., 2017).
Despite the early adverse experiences, many children demonstrate improved out-
comes post‐adoption, especially in physical growth and motor development (Canzi,
Rosnati, Palacios, & Roman, 2017). Outcomes vary tremendously based on child
characteristics, duration of and conditions experienced during institutionalization,
and post‐adoption experiences. In general, the shorter the period of institutionaliza-
tion and the earlier children are adopted out of institutionalized settings, the better
their long‐term outcomes (Rutter et al., 1999). There is also tremendous variation in
the form and quality of care during institutionalization. Generally, children adopted
from countries that use foster care systems are less delayed and recover more quickly
than those from countries with orphanages (Canzi et al., 2017).
Attachment impairments and recovery post‐international adoption have been
studied extensively and for many decades (e.g., Canzi et al., 2017; Spitz, 1945).
The vast majority of children adopted from international orphanages struggle to
form emotional bonds with caregivers following their early years of deprivation
(Gunnar et al., 2000) and demonstrate behaviors consistent with reactive attach-
ment disorder (i.e., inhibited and emotionally withdrawn behavior, limited emo-
tional responsiveness, and lack of a preferred caregiver) and/or disinhibited social
engagement disorder (i.e., indiscriminate social behavior, such as inappropriate
affection or friendliness with strangers or lack of secure‐base behaviors in anxiety‐
provoking situations; Humphreys et al., 2017; Zeanah, Smyke, Koga, & Carlson,
2005). However, many children do end up forming an attachment, albeit often an
insecure one, to their adoptive parents (van Londen, Juffer, & van Ijzendoorn,
2007). In fact, only 20–25% of internationally adopted children continue to display
behaviors consistent with an attachment disorder in follow‐up studies 1 year after
adoption (e.g., Juffer, Bakermans‐Kranenburg, & van IJzendoorn, 2005). It is typi-
cal for inhibited behavior to lesson or disappear once an attachment is formed with
adoptive parents, though often indiscriminate social behavior continues (Humphreys
et al., 2017; Zeanah, 2000).
The common attachment challenges among internationally adopted children also
influence other social and emotional outcomes. For instance, international adoptees
often struggle with emotional regulation and peer relationships (Gunnar et al.,
2000). Attachment difficulties can be particularly hard for adoptive parents who
may begin to doubt their parenting abilities when they feel their child is not bond-
ing with them.
Children in international adoptions are often deprived of knowledge about and access
to their birth families (Hollingsworth, 2003). Typically, international adoptive parents
are provided little information about the birth family and are not able to answer their
child’s questions about the birth family. Internationally adopted children may also not
have exposure to their birth culture or opportunities to develop an identity related to
their ethnic, cultural, or national group. The majority of families who adopt internation-
ally attempt to expose their children to their birth cultures, primarily through reading
books, but this exposure is much less comprehensive than is possible in open domestic
adoptions (Trolley, Wallin, & Hansen, 1994). As a result, internationally adopted

children often face tremendous loss of their right to know about, and have access to
their birth family and culture, and of their ethnic identity (Hollingsworth, 2003).
Adoption of older children

Because children adopted at birth tend to demonstrate similar outcomes to non‐
adopted children (e.g., Landsford, Ceballo, Abbey, & Stewart, 2001) and children
adopted early in life tend to demonstrate the greatest recovery in development and
fewest negative outcomes (Canzi et al., 2017), adoption of older children is more
complicated. Studies indicate a sensitive period in cognitive and socioemotional devel-
opment such that children adopted in the first 2 years of life have the best long‐term
outcomes (Nelson et al., 2007). Therefore, “older children” refers to children over
2 years old at the time of adoption. Despite this general trend in outcomes, older
children who demonstrate poor cognitive and socioemotional development at the
time of adoption often recover well after 1 year (Canzi et al., 2017). Specifically,
among a group of older adopted children, Canzi and colleagues found significant
improvement in cognitive and socioemotional development 1 year after adoption and
larger recovery among the children most delayed at time of adoption. The human
brain is highly plastic, and brain development is organized by experience, so the place-
ment of a child in a new, healthy environment can result in tremendous gains quickly
(Gunnar et al., 2000). It is also more difficult to identify developmental delays and
other issues in young infants and easier to do so in older children, so it is possible
older children are simply more accurately assessed at the time of adoption.
Still, developmental recovery is more difficult when children are older and past
sensitive periods in development. Older children have likely experienced more years
of adversity—in an abusive home, foster care, or an institution (Brodzinsky & Palacios,
2005)—and more foster care placements (Berry & Barth, 1989). For these reasons,
children adopted at older ages tend to demonstrate challenging behaviors (Nadeem
et al., 2017) and are likely to struggle with social and emotional disorders (Wimmer,
Vonk, & Bordnick, 2009).
Older children may also struggle to integrate into their adoptive families (Neil,
2012). This may be partially because of their more challenging behaviors, but also
because they have had more time to adapt to other environments. They may be well
adapted to chaotic or stressful environments and have trouble adjusting to a new family
system with less stress. Older children also have to heal from difficult and painful expe-
riences in their childhood (Courtney, 2000). In fact, they may demonstrate behaviors
consistent with a trauma response and need support to learn regulation skills
(Brodzinsky & Palacios, 2005). They may also struggle to adjust because of compli-
cated relationships with their birth families, which often involve loyalty and attachment
to caregivers who have also been the source of pain and trauma (Neil, 2000).
Adoption of children with disabilities

One of the reasons foster care and international adoptions are complicated is because
many adopted children have disabilities. The most common disabilities among
adopted children include Down syndrome, cerebral palsy, spina bifida, intellectual
disabilities, emotional and behavioral disorders, and developmental delays (Perry &
Henry, 2009). Parents who are willing to adopt a child with disabilities often have
other children and consider themselves to be experienced parents, and in these cases,
they tend to have skills that assist in parenting children with disabilities (Good, 2016).
Other parents may have already formed a bond with the child, perhaps through foster
parenting (Nelson, 1985; Reilly & Platz, 2003). When adoptive parents have planned
to adopt a child with a disability, they may be more prepared than parents who give
birth to a child with a disability (Denby, Alford, & Ayala, 2011).
However, many parents end up adopting children with disabilities without having
planned to, often because they have access to limited information and are not aware
of the child’s disability until after the adoption (Brabender & Fallon, 2013). Even
among parents who have planned, most do not feel fully prepared to parent a child
with disabilities (Molinari & Freeborn, 2006). It is common for adoptive parents of
children with disabilities to report intense emotions, including grief, depression, guilt,
bitterness, self‐blame, anger, isolation, and fear (Forbes & Dziegielewski, 2003). In
general, parents of children with disabilities tend to experience more stress and par-
enting challenges, including poorer parent–child relationships, more medical and
legal problems, and greater financial burden (e.g., Reilly & Platz, 2003). Both adop-
tive parents in general and parents of children with disabilities are at greater risk of
marriage disruption (Baskin, Rhody, Schoolmeesters, & Ellingson, 2011), so these
adoptive parents may need additional couple relationship support. Families of chil-
dren with disabilities may also experience social stigma and be surrounded by an
impairment narrative (Good, 2016). For all of these reasons, and many outlined in
other sections, families who adopt a child with disabilities tend to experience
complications.
Transracial adoption
Adoption can also be complicated when adoptive parents are of a different racial or
ethnic background than their adopted child, and transracial placements have been a
topic of debate in the United States (Zhang & Lee, 2011). Despite disagreements
about whether transracial adoption is in the best interest of children, it is increasingly
common in domestic foster care adoption and also prevalent in international
adoption.
A large portion of children awaiting adoption in foster care are Black (DHHS,
2017; Hegar, 2005), while the majority of adoptive families are White (Brooks &
James, 2003). Black children are overrepresented in the child welfare system in g eneral
and have 44% higher odds of being placed in foster care than White children (Wildeman
& Emanuel, 2014).
White families seeking to adopt may be increasingly open to transracial adoption,
but still tend to adopt Asian or Latinx children as opposed to Black children (Raleigh,
2012). Adoptive parents are more open to transracial adoption when their motiva-
tions for adoption are child centered (e.g., there are many children in need of adop-
tion) as opposed to parent centered (e.g., struggles with infertility; Farr & Patterson,
2009) and when they are generally open to adoption of a wide range of children
(i.e., older children, children with disabilities, etc.; Brooks & James, 2003). Couples
who are interracial (Farr & Patterson, 2009), who have friends or family members of
minority races, or who believe they live in a diverse community (Goldberg, 2009) are
also more likely to adopt transracially.
Evidence is mixed in terms of outcomes of children in transracial adoption. Some

studies find children and parents tend to have similar outcomes following transracial
adoption as they do in adoptions of children of the same race/ethnicity (Brodzinsky
et al., 1998; Farr & Patterson, 2009). However, some studies have found more exter-
nalizing behavior problems, school adjustment, and general health issues among tran-
sracially adopted children (e.g., Weinberg, Waldman, van Dulmen, & Scarr, 2008).
Children adopted by caregivers of another race may face challenges in establishing
their ethnic identity (Thoburn, Norford, & Rashid, 2000). Children report feeling
different than their families because of their lack of physical resemblance (Harris,
2014), and this seems to be a more prominent issue when families are living in primar-
ily White communities, which is common among transracially adopted children
(Samuels & LaRossa, 2009). Children tend to develop a sense of self and belonging
through resemblance to their family members, and transracially adopted children phys-
ically look different than their families, which means others see the difference as well.
Families often struggle to establish a multicultural family and to help children
navigate racial and ethnic discrimination (Gunnar et al., 2000). This leaves a lot of
the burden of development of racial identity on the adopted children (Samuels &
LaRossa, 2009). Adopted children have reported feeling alienated and lacking access
to a community to help them navigate their racial identity. Children adopted transra-
cially frequently report experiences of racism in family, school, and community con-
texts (Harris, 2014) and often report their parents and teachers taking a passive
approach to the discrimination, leaving children to navigate the issues on their own
(Samuels & LaRossa, 2009). Transracially adopted children also tend to report being
raised “White,” which may lead them to feel uncomfortable around people of their
own race (Kirton, Feast, & Howe, 2000) and experience stigma and lack of accept-
ance from their racial community (Samuels & LaRossa, 2009). On the other hand,
when parents engage in cultural and racial socialization practices, transracially
adopted children tend to cope better with discrimination (Leslie, Smith, Hrapczynski,
& Riley, 2013) and report a greater sense of belongingness and higher self‐esteem
(Mohanty, Keokse, & Sales, 2006). Families who receive post‐adoption services and
other support are more likely to engage in cultural socialization practices (Lee, Vonk,
Han, & Jung, 2018).
Children adopted transracially also often have less contact with their birth families
compared with minority children adopted by minority parents (Moffatt & Thoburn,
2000), which makes it difficult to learn about their birth culture (Harris, 2014). The
lack of contact and information in childhood makes future reunifications with birth
families more difficult as there is often a cultural disconnect.
Adoption by nontraditional families

There has been political debate about adoption by same‐sex couples and unmarried
parents for the last few decades (Perry & Whitehead, 2015), and states have histori-
cally restricted these groups’ ability to adopt, or created discriminatory and labyrin-
thine adoption processes (Farr & Patterson, 2009). Despite the political debate,
existing studies suggest that family processes and the balance of resources and stress-
ors are much more predictive of adoption success and child outcomes than family
form (Ryan & Brown, 2012). Still, same‐sex and unmarried couples tend to experi-
ence additional stressors because they are more likely than other groups to engage in
complicated adoptions (Raleigh, 2012). For instance, lesbian, gay, and single parents
tend to be more open to transracial adoption (Farr & Patterson, 2009) and, in turn,
more frequently adopt transracially than heterosexual married parents (Raleigh,
2012). White single parents are also more likely to adopt children with disabilities or
of other races (Raleigh, 2012) who are older (Groze, 1991). Same‐sex couples and
unmarried parents may be more willing to engage in more complicated adoptions
because of their “marginalized position in the adoption marketplace” (Raleigh, 2012,
p. 454). Lesbian and gay adoptive parents are also more likely to be interracial as
compared with heterosexual couples, which may contribute to their willingness to
adopt transracially (Farr & Patterson, 2009). Regardless of the reasons for engaging
in complicated adoptions, same‐sex and unmarried parents are more likely to encoun-
ter challenges in the adoption process.
Same‐sex couples A quarter of same‐sex couple households in 2010 included an

adopted child, a rate much higher than among heterosexual couples (9%; Lofquist,
2011). Research indicates lesbian and gay couples tend to be capable parents (Farr,
Forssell, & Patterson, 2010) with similar parenting and romantic relationship
processes and satisfaction as heterosexual couples (Farr et al., 2010). Adopted chil-
dren raised by lesbian and gay parents demonstrate positive developmental outcomes
(Farr & Patterson, 2009). In fact, some studies suggest that children of same‐sex
parents have an expanded view of gender roles and engage in less gender‐stereotyped
behaviors (Goldberg & Garcia, 2016).
All adopted children are vulnerable to social stigma (Brabender & Fallon, 2013).
Children adopted by lesbian or gay parents may be subject to additional discrimina-
tion and, in turn, more stress (Tasker & Patterson, 2007). However, not all studies
have revealed additional explicit discrimination among this population (Wainright &
Patterson, 2006). Still, children may be asked questions about their family structure
and need to make decisions about whether to disclose their adopted status and their
parents’ sexual orientation (Goldberg & Gianino, 2012). In this way, adopted chil-
dren of same‐sex parents may have to worry about the possibility of discrimination
more than others (Tasker & Patterson, 2007).
Unmarried parents The literature on adoption by unmarried parents overlaps with

that on adoption by lesbian and gay parents as same‐sex marriage was not recognized
in many states until the 2015 Supreme Court decision in Obergefell v. Hodges (2015).
In some cases, unmarried adoptive parents are single individuals who are solo parent-
ing; however, unmarried cohabitation is increasingly common, so many cases of
unmarried adoption may in fact involve parents who are in a committed romantic and
co‐parenting relationship (Manning, 2015). Among unmarried heterosexual house-
holds in the United States, approximately 12% include an adopted child, a rate slightly
higher than married households (Lofquist, 2011).
Most of the research on unmarried adoptive parents was conducted in the 1990s
and earlier and suggests that the majority of single‐parent adoptions are by women,
and typically women in their 30s who are educated with careers (Miller, 1992).
However, because single‐parent households are limited to one income earner, they
tend to report lower incomes than married adoptive parents (Groze, 1991). Single
adoptive parents tend to demonstrate strong parenting skills, including an ability to
manage stress, emotional maturity, and an enjoyment in parenting. Studies suggest
that rates of disruption are similar among single and married parents. Children’s out-
comes are also similar to children in married parent families (Tan, 2004). Like other
groups of adoptive parents, extended family support is associated with better out-
comes among single adoptive parent families (Groze & Rosenthal, 1991).
Many single parents in the United States are cohabiting with a partner and co‐
parent (Manning, 2015). There is limited research on the experiences of cohabiting
couples in adoption or the outcomes of their children. However, research on cohab-
iting couples, in general, indicates that they tend to be less stable over time and at
greater risk of relationship dissolution (Bumpass & Lu, 2000). In turn, their c hildren
may experience difficulties in development related to the instability (Bachman,
Coley, & Carrano, 2011). These general trends among cohabiting couples may not
hold true for cohabiting adoptive parents, however, because many cohabiting cou-
ples enter into parenthood via unplanned pregnancy whereas cohabiting adopters
enter parenthood intentionally, and, as a result, may demonstrate relationship
stability similar to married couples. Research points to the importance of family
stability more than specific family form in predicting children’s outcomes (Cavanagh
& Huston, 2006).
Shared experiences of nontraditional adoptive parents Same‐sex and unmarried

adoptive parents may experience additional discrimination, beginning in the pre‐
adoption phase. Often lesbian and gay parents have to keep their sexual orientation
secret when adopting internationally, and in that case, only one parent can be the
legal guardian of the child (Goldberg & Gianino, 2012). The family will then face
the stress of the second‐parent adoption process. Further, some agencies may reject
adoptive lesbian, gay, or single‐parent applicants explicitly or implicitly because of
sexual orientation or marital status; studies highlight negative attitudes of social
workers toward nontraditional adoptive parents; and prospective parents report
agency discrimination as a barrier to becoming foster and adoptive parents (Gates,
Badgett, Macomber, & Chambers, 2007). Post‐adoption, lesbian, gay, and unmar-
ried parents may face additional discrimination particularly because they are more
likely to adopt transracially and their children may be easily recognizable as adopted
(Goldberg & Gianino, 2012). To compound the stress, lesbian, gay, and unmarried
parents tend to report less social support than heterosexual married parents and may
have fewer resources to cope with the added stress of stigma and discrimination
(Goldberg & Gianino, 2012).
Adoption disruption and dissolution

All of the outlined challenges in complicated adoption are important to address in
therapy in order to prevent adoption disruption (i.e., when the adoption ends before
finalization) and dissolution (i.e., when the adoption ends after finalization; Coakley
& Berrick, 2008). Studies report varying rates of adoption disruption and dissolution,
which range from 10 to 25% (Child Welfare Information Gateway, 2012).
There are many factors that contribute to adoption disruption or dissolution, and
most of them are common in complicated adoptions. For instance, older children
tend to be at a higher risk for adoption disruption (Lightburn & Pine, 1996), and
adolescents are especially at risk (Selwyn, Wijedasa, & Meakings, 2014), with rates of
disruption as high as 25% (Child Welfare Information Gateway, 2012). Adoptions of
children with disabilities are also at higher risk, with around 15% ending in disruption
(Denby et al., 2011). Children with emotional and behavioral diagnoses tend to be at
higher risk of adoption disruption than children with physical or cognitive disabilities
(Lightburn & Pine, 1996). Disruption or dissolution is often rooted in a lack of infor-
mation relayed to the caseworker or prospective family prior to adoption (Gibbs,
2010) or a mismatching of child and adoptive family (Berry & Barth, 1989). For this
reason, many states have legislation barring foster care adoption finalizations until the
child lives with the adoptive family for 6 months, in order to ensure the adoptive fam-
ily has a clear picture of the behaviors and challenges they may face in the adoption
(Coakley & Berrick, 2008).
There are also identified protective factors that contribute to lower rates of adop-
tion disruption and dissolution. Children adopted with at least one of their siblings or
who have at least some face‐to‐face contact with birth parents and siblings placed
elsewhere are less likely to experience adoption dissolution (Moffatt & Thoburn,
2000). Further, children who experience continuity in caseworkers have a greater
likelihood of a successful adoption (Child Welfare Information Gateway, 2012).
Adoptions are also more likely to be successful if parents are well informed prior to the
adoption and understand the child’s history and potential strengths and challenges
(Gibbs, 2010).
It is important to make every effort to facilitate a successful adoption placement
because the experience of an adoption disruption or dissolution is an additional
trauma to children and perpetuates their risk (Child Welfare Information Gateway,
2012). Experiencing a disrupted or dissolved adoption also greatly lowers a child’s
chances of being adopted again.
Intervention in Complicated Adoption
Therapy is often warranted in cases of complicated adoption in order to support fami-

lies in a difficult transition and prevent disruption or dissolution. Imagine Marina and
her family’s experience:
Marina is a 7‐year‐old girl of Latina ethnicity recently adopted by a lesbian couple, Lynette
and Rosario.1 Marina was first removed from her birth mother’s care when she was three and
experienced a series of foster care placements over the past four years. Her birth mother strug-
gled with substance abuse and was in and out of violent relationships during Marina’s early
life. Marina previously lived in the same state as her birth mother and saw her once in the
past year, when she was still in foster care. Marina was in her last foster placement for almost
a year and reports strong relationships with her foster parents and their two children.
However, when she was adopted, Marina moved to another state and has only been able to
talk to her foster family on the phone twice. Marina’s adoptive parents, Lynette and Rosario,
have been in a committed relationship for nine years and married for four. They invested two
years and their entire savings in in vitro fertilization (IVF) attempts, but were not able to
get pregnant. They decided to pursue private adoption of an infant and were open to tran-
sracial adoptions, but were unsuccessful in finding an adoption match. They then engaged
in the process of adoption from the foster care system, and Marina was placed with them five
months ago. Lynette and Rosario are overjoyed to be parents, but are worried that Marina
has not bonded with them yet and feel like they are failing as parents. Marina is often cold
and distant at home and usually responds to her parents’ questions with one‐word answers.
Similarly, her teacher reports concerns about her lack of interaction with her peers and her
reluctance to engage in class discussions and activities. Lynette and Rosario feel like they
have tried everything to connect with Marina, but nothing seems to be working. In turn, they
have been arguing more and report feeling disconnected in their relationship.
Presenting issues in therapy

Across all complicated adoption, it is common that families will present to therapy
with concerns related to child emotional and behavioral issues, which tend to be more
prevalent and severe than among children from domestic private adoptions (Tan &
Marn, 2013). Families often report issues related to their child’s anger, self‐regulation
and impulse control, and struggles to bond and form attachment (Zosky, Howard,
Smith, Howard, & Shelvin, 2005). In Marina’s case, she is struggling with emotional
and social connection to her adoptive mothers as well as at school. In all types of
complicated adoption, it is likely that adoptive parents may be dealing with stress,
anxiety, feelings of self‐doubt, and issues related to unmet adoption expectations
(McKay & Ross, 2010). Parents may not have received adequate preparation prior to
the adoption and may need help understanding how to best support their adopted
child. Similarly, their adopted child may differ from their vision of the child they were
planning to adopt (Silva & Benetti, 2015). This seems to be the case for Lynette and
Rosario, who were initially planning to become parents via IVF and later envisioned
adopting an infant, but ended up adopting a 7‐year‐old with a complicated history.
They were not prepared for the challenges of adopting an older child from foster care
and, in turn, experience feelings of self‐doubt in their ability to parent.
Because an adoption is a change to family structure, it is common that families may
need help negotiating family roles, boundaries, and rules as the adopted child enters
the family system (Zosky et al., 2005). Family systems issues typically include impacts
on the adoptive couple relationship, parent–child relationships, and siblings. In
Marina’s case, all members of the family system have been impacted by the adoption
transition and, 5 months into the adoption, are still struggling to form relationships,
communicate effectively, and establish new roles. In addition to the strain in the par-
ent–child relationships, Lynette and Rosario are also experiencing conflict in their
couple relationship. In cases of open adoption, families may also need support in navi-
gating the complexity of ongoing relationships with the child’s birth family. Conversely,
in cases of closed adoptions, families may need support related to child questions
about birth families and the process of seeking out and reuniting with birth families.
In Marina’s case, her adoptive mothers are faced with evaluating the benefits of
Marina’s ongoing contact with both her birth mother and most recent foster family
and potentially feeling threatened by Marina’s strong relationship with her foster
parents.
Birth parents involved in complicated adoption may also seek out therapy and need
support in coping with their grief related to the typically involuntary relinquishment
of their child. Specifically, birth parents commonly experience depression and anxiety
(Wiley & Baden, 2005) and also report feelings of isolation and increased substance
use in response to the adoption (Aloi, 2009). In open adoptions, they may also need
assistance in defining their identity and relationship with their relinquished child and
the adoptive family (Pannor, Baran, & Sorsky, 1978). Regardless of the openness of
adoption, birth parents may need support in their parenting of subsequent children as
they are often still affected by the grief of their loss (Silverstein & Kaplan, 1988). In
the case example, it is possible that Marina’s birth mother and foster parents are expe-
riencing grief related to her adoption and move to another state, and each may need
support to cope.
Existing interventions in complicated adoption

Families involved in a complicated adoption need support throughout the adoption
process (pre‐adoption; formal legal adoption process; post‐adoption) to reduce stress,
prepare for the addition of the child to their family, and adjust after the adoption as
their needs change over time (Denby et al., 2011). Many studies have highlighted the
need of therapy services for families in complicated adoption (e.g., Reilly & Platz,
2004). Though many authors provide advice or propose interventions, there are fewer
studies evaluating the effectiveness of interventions (Anderson, 2006). This section will
first outline interventions aimed to help families at various stages in the adoption
process. Then, overall treatment recommendations will be discussed.
Pre‐adoption interventions Some interventions aim to address developmental delays

and facilitate attachment security among children prior to adoption, which theoreti-
cally should make the adoption process easier. For instance, interventions have been
developed to support children during institutionalization or foster care, including the
Bucharest Early Intervention Project (Zeanah et al., 2003) and the Attachment and
Biobehavioral Catch‐up (ABC) program (Dozier, Lindheim, & Ackerman, 2005).
The Bucharest Early Intervention Project involved random assignment of institu-
tionalized children to high‐quality foster care or to treatment as usual (Zeanah et al.,
2003). The high‐quality foster care involved training for the foster parents and a sup-
port group. At multiple assessment points over four and a half years, children in the
foster care group showed fewer symptoms of reactive attachment disorder, and at
the later assessments, they also showed fewer signs of disinhibited social engagement
disorder (Smyke et al., 2012).
Similarly, in the ABC intervention, foster parents were provided support to enhance
their ability to facilitate attachment with their foster children (Dozier et al., 2005). The
program involves 10 sessions with foster parents that address nurturance, child’s self‐
regulation, foster parents’ histories and attachment strategies, and parenting behaviors
that facilitate attachment. Evaluation of the intervention indicates that children of foster
parents in the intervention group demonstrate fewer insecure and disorganized attach-
ment behaviors than children in the treatment‐as‐usual group (Bernard et al., 2012).
Interventions that facilitate attachment development during foster care may set up
children for more success in adoption (Fisher, Burraston, & Pears, 2005). Future
research should further explore the impact of these pre‐adoption interventions on
later adoption outcomes.
Interventions during and post‐adoption Parents benefit from education and prepara-
tion about what to expect during and after the adoption (Denby et al., 2011). Often
parents are not fully prepared for the reality of complicated adoption and need sup-
port to develop realistic expectations (Gunnar et al., 2000). Parents need information
about the child’s history and early experiences (Lightburn & Pine, 1996) as well as
guidance about how to handle difficult conversations post‐adoption (Neil, 2000).

Parents will need to have conversations with their adopted children about why they
were adopted and may need to recount difficult experiences related to maltreatment,
birth parents’ mental health, and so forth. Parents need preparation for the complex-
ity of complicated adoption in advance and then ongoing support post‐adoption.
The post‐adoption period involves a process of adjustment for the child and family
as a whole (Brodzinsky et al., 1998). Families often have psychosocial and relational
needs that can be met through therapy services. Adoptive parents may use therapy to
address communication and attachment issues, develop understanding of their
adopted child’s feelings and behaviors, and begin to process grief related to adoption
(Zosky et al., 2005). In addition to therapy interventions, families need access to
financial support, high‐quality medical care, and respite care (Lightburn & Pine,
1996). Therapists may need to serve as advocates for families and ensure they have
access to other needed resources (Zosky et al., 2005).
Adoptive parent and couple interventions Many interventions in the post‐place-

ment period focus on support for parents, often involving some form of group inter-
vention or social support component. For instance, Gilkes and Capstick (2008) present
a parent‐to‐parent mentoring program where new adopters are paired with “experi-
enced” parents who adopted years prior and attended a parenting group for adoptive
parents. The experienced adopters attend a training course to provide them with skills
to support the new adoptive parents. Many studies highlight the importance of social
support for adoptive parents (e.g., Denby et al., 2011), so it is not surprising that par-
ticipants reported the parent‐to‐parent mentoring program was helpful, especially
because they were able to share their experiences with parents who had been through
a similar situation (Gilkes & Capstick, 2008).
Other interventions target the adoptive parents’ relationship. There is a clear link
between couple relationship health and parenting quality and child outcomes as par-
ents’ relationship quality impacts the entire family system (e.g., Erel & Burman,
1995). As in Marina’s example, couples involved in complicated adoption may experi-
ence difficulties in their relationship as they face many stressors (Schwartz, Cody,
Ayers‐Lopez, McRoy, & Fong, 2014). Ward (1998) highlighted the need to address
couples’ sense of “we‐ness,” expectations for adoptive parenthood, and time demands
associated with parenting an adoptive child. In turn, addressing couple relationships
tends to be associated with better outcomes for adopted children (Evan B. Donaldson
Adoption Institute, 2010).
One group intervention focuses on addressing the health of adoptive parents’ cou-
ple relationship (Baskin et al., 2011). Baskin and colleagues’ intervention focuses on
forgiveness and resolving past hurts, strengthening couple relationship satisfaction,
and providing a supportive group context. The intervention incorporates forgiveness
because adoptive parents involved in complicated adoption may have resentment
toward the child’s birth family (especially in cases of abuse), the child welfare system,
or friends/family members who have not been accepting of the adopted child. The
relationship education portion of the program is based on John Gottman’s work
(Gottman & Gottman, 2017), and the social support component is aimed at prevent-
ing parental mental health issues. There is initial evidence in a randomized controlled
trial that this intervention promotes forgiveness and relationship satisfaction and
reduces depression among adoptive parents (Baskin et al., 2011).
Another intervention aims to strengthen couple relationships among married

arents who adopted from the foster care system (Schwartz et al., 2014). The inter-
p
vention involves an initial weekend retreat for couples (and provided nannies to stay
home with their children) and then follow‐up support network meetings. At the
retreat weekend, parents participate in marriage‐focused education sessions (based on
the Prevention and Relationship Enhancement Program (PREP); Markman, Renick,
Floyd, Stanley, & Clements, 1993), an adoption‐focused session, and social activities
for the couples to network and have fun. The follow‐up support sessions include a
refresher of the PREP curriculum, but the primary purpose is to help couples main-
tain their new support networks (Schwartz et al., 2014). An initial evaluation suggests
parents felt supported by the group and reported increased relationship satisfaction,
sense of stability, and knowledge about adoption.
Taken together, these and other studies suggest interventions that target adoptive
parents and couples should include a social support component, relationship educa-
tion, and content specific to the challenges of complicated adoption.
Parent–child approaches Other interventions include parents and children. For

instance, Juffer and colleagues (2005) tested the effectiveness of an intervention with
mothers and adopted infant children to promote parent–infant attachment relation-
ships. The intervention involved providing mothers with written information about
sensitive parenting that included play suggestions and video feedback of interactions
with their infants. The infants of mothers who received the intervention were less
likely to be classified as disorganized in attachment at the end of the intervention.
Another approach to work with adoptive parents and their children is the psycho-
analytic developmental approach, which assumes the challenges faced by adoptive
families are the same developmental challenges faced by all families, but are more
severe or complicated due to the adoption context (Brabender & Fallon, 2013).
Rather than label pathology, the approach focuses on the ways in which child and par-
ent development has been interfered with or promoted and strategies to get develop-
ment back on track. In complicated adoption, typical interferences to growth and
development of children include the loss of relationships and a tension between old
and new identities, and parents may struggle to parent a child who is genetically dis-
similar. The therapist helps both parent and child understand the developmental chal-
lenges they are facing and how those challenges impact the entire family.
Parent–child interventions in adoption tend to include both a focus on each indi-
vidual’s developmental challenges and the attachment relationship between the par-
ent and child. However, interventions often only involve a parent and child rather
than the entire family system. Future research should explore family systems approaches
to intervention.
Birth family interventions Despite the needs of birth parents in adoption, there has
been less attention to support of birth families (Sellick, 2007). Claridge (2014) pro-
poses the use of emotionally focused couple therapy (Johnson, 2004) to help birth
parents heal from the trauma of relinquishment, but focuses on the needs of birth par-
ents in voluntary relinquishment.
Involuntary relinquishment is more likely in cases of complicated adoption. Birth par-
ents who involuntarily relinquished their child will likely feel uncomfortable receiving
services from the agency that was involved in the termination of parental rights, which
might make accessing support services difficult (Charlton, Crank, Kansara, & Oliver,
1998). Birth families may be more likely to access support services if they are connected
to contact with their child. For instance, birth families report more engagement when
therapists can assist in writing letters to the adopted child or facilitate direct contact with
the child (Sellick, 2007). It is beyond the scope of this chapter to dive into the literature
about birth parent experiences and recommendations for intervention, but Baden and
Wiley (2007) provide a comprehensive review.
Systemic approaches Although couple and family therapy models have not been
extensively or explicitly applied to work with families in adoption, systemic therapists
are especially well suited to support families throughout the complicated adoption
process (Brodzinsky et al., 1998) as they focus on family dynamics and communica-
tion (Bateson, 1967). Existing interventions tend to focus on subsystems and dyads
rather than the entire family system. However, adoptive families typically need sup-
port related to many family system issues including communication, boundaries
between adoptive and birth families, family loyalty, family culture/customs/rituals,
and family cohesion and adaptability.
Although not empirically tested, classic models of couple and family therapy
address many of the concerns of adopted families. For instance, Bowen family ther-
apy (Bowen, 1966) may be helpful in working with families on the task of negotiat-
ing boundaries and differentiation within the adoptive family system and between
the adoptive family and birth family, a key task for adoptive families (Neil, 2012).
Structural family therapy (Minuchin, 1985) similarly addresses family issues related
to rules, boundaries, and roles. In complicated adoption the core of the issues is
often related to the change in structure and the need to renegotiate family rules and
roles, especially because they are often implicit (Silva & Benetti, 2015). Therapists
may be able to assist in facilitating conversations about rules and roles and making
them more explicit.
Many couple and family therapy models are strengths based (e.g., solution‐focused
therapy, De Jong & Berg, 2008); narrative family therapy, White & Epston, 1990)
and may be especially well suited for work with families during complicated adoption.
Parents report that the adoption preparation process tends to overemphasize the neg-
ative aspects of raising an adopted child rather than focusing on the child’s abilities,
resources, and strategies to parent and cope effectively (Denby et al., 2011). When
parents are able to identify their adopted child’s strengths, they are better able to form
attachment bonds (Johnstone & Gibbs, 2012) and less likely to experience adoption
dissolution (Denby et al., 2011). Therapists should actively identify and highlight
families’ strengths and resources (Goldberg & Gianino, 2012).
Recommendations for intervention in complicated adoption

Although relatively few interventions for families facing complicated adoption have
been empirically tested, many studies have outlined recommendations for therapy
intervention with this population. This section outlines some key considerations in
systemic work with families experiencing complicated adoption.
Consider family and child development Both the family life cycle and child develop-
mental tasks need to be considered in work with adopted families. Over time, adopted
children and their parents confront new challenges as adoption issues intersect with
typical difficulties in the family life cycle (Brodzinsky et al., 1998).
Age at time of adoption is consistently highlighted as a contributing factor to chil-

dren’s adjustment in their adoptive family (Escobar, Pereira, & Santelices, 2014).
Families need different support from therapists depending on the age at which their
child was adopted. As illustrated in Marina’s case, families who adopt older children
face challenges related to adoptees’ past experiences and relationships.
Families may also benefit from education about development. Adoptive families
may hold the view that all adopted children are doomed to develop severe behavioral
and psychological issues (i.e., “Adoptive Child Syndrome”; Kirschner, 1990). In real-
ity, child behavioral issues are likely the result of a combination of the child’s history,
current family processes, and development. Therapists can help parents understand
the complex underlying issues and, in turn, help them respond in a developmentally
appropriate manner (Brabender & Fallon, 2013).
Presenting issues will also vary depending on the child’s age and will likely vary
across time as both the child and family develop (Meese, 2005). Many families who
adopt young children experience some period without any adoption‐related issues
(Neil, 2000). As children develop, and especially as they enter adolescence, issues may
arise that families need outside support to navigate (Selwyn et al., 2014). Therefore,
families may benefit from ongoing or periodic rather than time‐limited services.
Facilitate attachment development A fundamental task in children’s development is

the formation of a secure attachment. Children develop an attachment strategy that is
adaptive to their environment to cope with the stressors in their environment (Main,
1990). Insecure attachment strategies are organized ways of responding to stressful
environments. In cases of deprivation or extreme parental insensitivity (both common
among children in complicated adoption), children may not have developed an organ-
ized attachment strategy and instead respond to relationships in a disorganized man-
ner (Main & Hesse, 1990). Therefore, as was illustrated in Marina’s case, it is common
for adoptive families to present with issues involving attachment and bonding (Zosky
et al., 2005).
One key contributor to development of attachment following adoption is time
(Johnstone & Gibbs, 2012). It takes time to develop bonds, so parents have to be
patient and committed, even when the relationship is challenging. Parents may need
support from therapists to remain hopeful and persevere despite difficulties.
Parents may also need support in understanding and responding to their adoptive
children’s needs (Gibbs, 2010). Responding to children with an insecure attach-
ment or attachment disorder is difficult because children may not send clear signals
that they need nurturance and comfort (Dozier et al., 2005). Therapists can help
parents interpret their child’s behavior through an attachment lens to build security
and safety in the parent–child relationship. For instance, in Marina’s case, she does
not actively seek out support from her adoptive parents or indicate that she needs
support. They want to respect her and follow her lead, so they give her distance. In
reality, Marina has needs for emotional connection and bonding but is not clearly
communicating those needs, and Lynette and Rosario need help interpreting her
complicated attachment signals. Interventions such as the Circle of Security and
Minding the Baby (see Berlin, Ziv, Amaya‐Jackson, & Greenberg, 2005, for an
overview) are specifically targeted at improving parents’ interactions with children
to facilitate attachment development and may be helpful in cases of complicated
adoption.
Enhance family cohesion and communication The experience of adoption involves a

change in the family system structure and process (Brodzinsky et al., 1998), and
parents are crucial in helping adoptive children manage their feelings related to the
adoption and adapt to the changing system (Neil, 2012). To do this, adoptive parents
need to be comfortable with their own emotions, emotionally attuned to their
children, and empathetic in their parenting responses (Brodzinsky, 2006). This is
particularly challenging because some adopted children will test the acceptance of
their adoptive parents (Silva & Benetti, 2015). Adoptive parents need support in
interpreting their child’s behavior so that they are able to understand the purpose of
the behavior (i.e., seeking acceptance, security, etc.) rather than taking the behavior
personally as a rejection.
Ideally, adoptive parents should facilitate conversations about the child’s birth fam-
ily that are supportive, accurate, and non‐derogatory (Neil, 2000). It is normal for
adopted children to think about and have questions about their birth families (Neil,
2012). Although the painful parts of the child’s history may be difficult to talk about,
it is best to give children complete information (Neil, 2000) and respond to their
questions sensitively (Juffer et al., 2005). When adoptive parents omit negative or
traumatic parts of the child’s history, the child may not understand the reason for the
adoption, and the narrative will likely conflict with the child’s own version of events
(Neil, 2000). Adoptive families in therapy may need support in crafting a narrative
that is accurate and honors the child’s experiences while also being sensitive and
empathetic toward the birth parents. This process will also need to change over time
as the child develops, which means families may need ongoing or intermittent
support.
Acknowledge culture As in therapy work with any population, it is important to

consider culture and context of clients in complicated adoption. Interventions can-
not treat all adoptive families the same and must be flexible to meet the unique
needs, strengths, and challenges of each adoptive family (Harris, 2014). Therapists
also need to be aware of their own identities and may need supervision for help
navigating complicated family dynamics and to process their own biases related to
adoption, transracial families, same‐sex families, and so forth (Brabender & Fallon,
2013).
Therapists should also strive to promote openness among adoptive families to
incorporate birth family culture into their child’s life, even when contact is not pos-
sible (Goldberg & Gianino, 2012). In cases of transracial adoption, families should
ideally provide children with multicultural social development and, if possible, cul-
tural immersion experiences with the child’s culture of origin (Samuels, 2010).
Parents may need support to find ways to meaningfully incorporate their child’s birth
culture into the family (Hollingsworth, 2003).
Adoptive families are also vulnerable to explicit and implicit discrimination and
micro‐aggressions (Brabender & Fallon, 2013). Parents may need support to inter-
vene in and prepare their adopted child for instances of discrimination (Brabender &
Fallon, 2013). Vonk (2001) suggests assisting parents of transracial adoptees in three
areas: racial awareness (i.e., awareness of how race, ethnicity, and culture impact their
own and their child’s life), multicultural planning (i.e., providing opportunities for
their child to engage in their birth culture), and survival skills (i.e., teaching their
child strategies to prepare for and cope with discrimination).
It is especially important to address discrimination in therapy in cases of compli-

cated adoption in which risk factors are intersectional (Good, 2016), like in Marina’s
case. Families often face more than the stigma of adoption, but may also experience
discrimination related to disability, sexual orientation, minority race/ethnicity, and so
forth. For that reason, it is important for therapists to acknowledge stigma and dis-
crimination families face and to know something about broader social issues beyond
adoption (Harris, 2014).
Address trauma and grief Marina’s case example highlights both the grief children
and parents may experience in the adoption process. Commonly, adopted children
need support processing their grief related to adoption and experiences pre‐adoption,
and it is typical for grief responses to manifest differently across time (Brodzinsky
et al., 1998). Children’s grief should be accepted and validated, which can be chal-
lenging for adoptive parents as it involves acknowledging the importance of the child’s
past relationships. Families may need therapist support to facilitate these conversa-
tions about grief.
Children in complicated adoptions may have experienced maltreatment prior to
adoption and may struggle with ongoing physical or psychological consequences of
the abuse that need to be addressed in therapy (Neil, 2000). Adoptive parents may
also need support in their own trauma healing. Like Lynette and Rosario, it is com-
mon that parents choose to adopt after experiencing infertility issues (McKay & Ross,
2010) or experience loss related to their unfulfilled expectations for what adoptive
parenting would be like (Perry & Henry, 2009).
Promote social support Therapists can assist families in accessing social support.
Parents are more successful in promoting healthy relationships with their
adopted children when they reach out to extended family for support, attend
playgroups and other social services, and engage with other adoptive parents
(Gibbs, 2010). Engagement in support groups with families who have similar
experiences can be especially helpful in validating and normalizing parents’
experiences (Brabender & Fallon, 2013), and therapists are in a position to facil-
itate the formation of such groups (Gilkes & Capstick, 2008). Although there
tends to be a focus on support groups for adoptive parents, adoptive children
can also benefit from support groups with other adopted children (e.g., Harris,
2014; Zosky et al., 2005).
Collaborate with other systems Families may need help connecting with other systems
and resources, especially so they have access to long‐term support even after therapy has
concluded (Perry & Henry, 2009). Therapists may need to serve actively as advocates
for families to promote access to needed services (Brabender & Fallon, 2013). Adoptive
families also benefit from multidisciplinary support service teams (Selwyn et al., 2014),
so therapist collaboration and coordination with other providers is essential.
The school system is especially important to involve. Children may experience dis-
crimination at school due to stigma related to adoption in general, disability, or race/
ethnicity (Gunnar et al., 2000). Although some children feel integrated into their
adoptive family, they may still struggle with their identity formation as people outside
of the family (e.g., classmates, teachers, professionals, etc.) insert their views on adop-
tion (Neil, 2012). Children and adoptive families may need support in navigating
when and how much to disclose about the adoption.
Conclusions
Despite the challenges faced by families in complicated adoption, adoptive parents

overwhelmingly express satisfaction with their post‐adoption life and their adopted
child and report they would adopt the same child again despite the challenges (Gailey,
2010). Still, adoption disruptions and dissolution could be reduced with continued
improvements in therapy services for families in complicated adoption.
Although there is a substantial literature about complicated adoption experiences
and a plethora of recommendations for practitioners, much of the advice to parents in
complicated adoption is based on practitioners’ specific experiences and is not empiri-
cally supported (Gunnar et al., 2000). When families seek out support, they are often
confronted with an abundance of advice and intervention options, some of which are
very expensive and few of which have been empirically tested. This can be frustrating
and stressful for parents as they search for solutions. There is a need for empirical
evaluation of existing programs to especially determine whether programs decrease
rates of disruption/ dissolution, improve child and parent outcomes, and facilitate
family well‐being among families in complicated adoptions (Anderson, 2006).
Most available empirical support is for interventions that take place pre‐adoption dur-
ing foster care (e.g., Bucharest Early Intervention Project and ABC program). Though
these programs demonstrate improved attachment outcomes among children in foster
care, it is unclear whether outcomes carry into adoption. Future research could explore
this question and perhaps identify components of these empirically tested interventions
that could translate into post‐adoption interventions with adoptive families.
Further, most interventions are limited to either the couple or parent–child dyad and do
not address the entire family system. Systemic couple and family therapy models could
potentially better address the family dynamic challenges common in complicated adoption.
Future research could examine the efficacy of systemic models with this population.
Finally, most of the existing interventions or sets of recommendations for support-
ing families in adoption focus on one category of adoption (i.e., international, foster
care, etc.) without acknowledging the intersectionality among categories of adoption
that further complicate the process for families. There is a need for more research
about the intersectionality of these complicated adoption categories, the unique chal-
lenges associated with intersection, and how to best support families in these complex
situations (Good, 2016).
Note
1 In order to protect the confidentiality of those individuals described, this vignette is based
on a composite of several clinical cases, with names and other details disguised.
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18
Foster Care and Systemic
Interventions to Maximize
Effectiveness
Lenore M. McWey and Andrew S. Benesh
Pretend for a moment that you are a single mother of four children. You dropped out
of high school when you were pregnant with your first child. You want to provide a
better life for your children than what was provided for you growing up; you work
two jobs in an effort to do so, but still struggle to make ends meet. You feel chronically
stressed and socially isolated. You use alcohol to cope. You have been investigated by
child welfare services in the past, but you were able to complete all that was required
of you by the “system” in order to keep custody of your children.
The other day you got very angry with your oldest daughter and hit her. It happened
so fast and in a fit of rage. You hit her harder than you intended, and it left a mark.
You feel terrible about it. Unbeknownst to you, your daughter’s teacher noticed the
mark and reported it. Today, at work, you were notified that child protective services
removed your children from your care due to allegations of child abuse.
That is the case of Sandra Jackson. The Jackson children include Lisa, age 16,
Grace, age 14, Paul age 12, and Jenny, age 10 (names have been changed to protect
confidentiality). The children appear to have high levels of social intelligence but
struggle with various issues including academic performance and behavior problems.
There was not a local foster home that could accommodate all four children. Paul and
Jenny were placed together in a foster home, but Lisa and Grace have separate
placements. The children have never lived apart.
Overview of the Child Welfare System
Foster care is a formalized child placement arrangement that is decided upon and
monitored by the child welfare system. Families typically become involved with the
child welfare system after a child maltreatment report. When a child welfare investiga-
tion determines that it is unsafe for children to continue to live in their homes, children
are often placed in out‐of‐home care. In the United States there are an estimated
458 Lenore M. McWey and Andrew S. Benesh
687,000 youth currently in formal child welfare system placements at a given time (U.S.
Department of Health and Human Services, 2017).
While countries such as the United States, Canada, and Australia have formalized
child welfare systems, in many countries, there is no formal system (George, Van
Oudenhoven, & Wazir, 2003). Instead, extended family members assume responsibil-
ity for the care of children without governmental involvement. In India, for instance,
the extensive multigenerational family and kinship networks generally provide suffi-
cient structure and support to care for children in instances when formal foster care
might typically be needed (George et al., 2003). As another example, in the Philippines,
godparents, siblings, and cousins traditionally hold responsibility for children when
parents are no longer able to fulfill their responsibilities. In contrast to examples of
extended family care, orphanages remain the norm in a large portion of the world
(Vostanis, 2010).
Even though the term “foster care” is commonly used to describe the living
arrangements of youth in child welfare system custody, there are different types
of out‐of‐home placements, including (a) traditional foster care, which is when
children are placed with caregivers unrelated to them; (b) kinship care, involving
the placement of children with relatives; and (c) residential care, when youth are
placed in a professionally staffed facility with other youth who have similar expe-
riences and needs (McWey, Benesh, & Stevenson Wojciak, 2015). Regardless of
placement type, reunification with their biological family is the most common
goal for youth in out‐of‐home care (U.S. Department of Health and Human
Services, 2013).
When youth are placed in out‐of‐home care, the child welfare system develops case
plans that include required services and goals that parents must meet and a timeline
for accomplishing those goals in order to gain custody of their children again (McWey,
Benesh et al., 2015). Because the reasons for child removal are often complex (e.g.,
parental mental health and substance use concerns, domestic violence, inadequate
child supervision), it is not uncommon for family members to be required to partici-
pate in several therapeutic services.
History of the US foster care system

The roots of the US foster care system can be traced back to 1853 when the
Children’s Aid Society was founded to address concerns for thousands of
neglected, orphaned, and homeless children living in larger US cities such as
New York and Boston (Schene, 1998). Over the span of 75 years, the Children’s
Aid Society sent more than 150,000 children to other homes, mostly in the
Midwest, where pioneers and farmers could benefit from added labor (Brown,
2011; Schene, 1998). Because these children were transported by train, the term
“orphan trains” is commonly used to describe this period (Brown, 2011). While
it is reported that the condition of orphan trains improved over time, historical
accounts suggest that, for many children, moving was a traumatic experience
marked with confusion, ambiguity, and permanently lost connections with bio-
logical family members (Brown, 2011). This system of establishing alternate
homes for neglected children is credited as being precursor to today’s formal
foster care system.
Foster Care 459
The first successfully prosecuted case of child maltreatment in the United

States occurred in 1874 (Jalongo, 2006). Prior to that case, laws regarding ani-
mals’ and children’s rights were intertwined because both animals and children
were considered property of their owners. As a result of this case, states began to
introduce legislation to punish child abuse (Jalongo, 2006), and by the twentieth
century, hundreds of societies were in existence aimed to prevent child maltreat-
ment (Schene, 1998). In the early 1900s, the focus on child maltreatment broad-
ened to also include discussions about family rehabilitation. In fact, the leader of
the American Humane Association, Dr. de Francis, is credited as saying, “the best
way to rescue a child is to rescue the family for the child” (as cited in Schene,
1998, p. 26).
The US federal government became formally involved with child welfare with
the passing of the Social Security Act of 1935 that had provisions establishing aid
and preventive services for vulnerable children (Schene, 1998). Since that time,
there have been several shifts in federal child welfare acts and policies. These
shifts are relevant because they have a direct impact on prevention and interven-
tion efforts targeted toward vulnerable children and families (for more informa-
tion about these policies, see McWey, Henderson, and Tice (2006)). As an
overview, before the most recent federal policy change, the child welfare system
operated under acts such as the Family Preservation and Support Services Act of
1993 (PL 103‐66), which focused on directing resources toward “preserving”
families (Family Preservation and Support Services Act, 1993). The aims of this
included providing support to families to improve family stability, parental func-
tioning, and rectifying issues that led to child welfare system involvement. During
this time, the “Homebuilders” intervention program was formed, and there was
a growth of in‐home family therapy services designed to meet the goal of pre-
serving families (Wells, 1994).
Because there were concerns that children were languishing in foster care for long
periods of time under the Family Preservation and Support Services Act, however, in
1997 the Adoption and Safe Families Act (PL 105‐89) was passed (Adoption and Safe
Families Act, 1997). The Adoption and Safe Families Act aimed to expedite the per-
manency of children involved with the child welfare system by reducing barriers that
inhibited the severing of parental rights and establishing child permanency within
12–18 months after a child’s removal from the home (Festinger & Pratt, 2002). The
federal focus shifted from family preservation toward child permanency and adoption.
Perhaps related to this shift, there was a growing push for brief intervention models.
Another current policy in the United States, namely, the Fostering Connections to
Success and Increasing Adoptions Act of 2008, section 206, requires reasonable efforts
be made to place siblings together and, when not placed together, provide frequent sib-
ling visitation. This is important because sibling relationships may be the most impor-
tant, stable relationship of youth in foster care (Shlonsky, Bellamy, Elkins, & Ashare,
2005). Scholars note that placing siblings together helps maintain a sense of continuity
and safety (Shlonsky, Webster, & Needell, 2003) and decrease feelings of ambiguity
associated with foster care placement (Ward, 1984). Moreover, research found that
positive sibling relationships mediated the effects of trauma on youth mental health
symptoms (Stevenson Wojciak, McWey, & Helfrich, 2013). Sibling placements, how-
ever, are not tracked nationally, and estimates indicate anywhere from 23 to 75% of youth
are not placed with their siblings (Leathers, 2005; Tarren‐Sweeney & Hazell, 2005).
Clinical Concerns Faced by Families Involved

with the Child Welfare System
There are a number of parental correlates of child welfare system involvement includ-
ing low socioeconomic status (SES), parental stress, parental mental health concerns
and substance abuse, and intergenerational patterns of risky parenting practices (for
detailed information about child maltreatment risks and prevalence, see Rhoades,
Mitnick, Heyman, Smith Slep, & Del Vecchio, 2020, vol. 2). Moreover, negative
child outcomes linked with child maltreatment include higher risk for poor mental
health, developmental issues including growth, language and cognitive delays, child
stress, and trauma (Gilbert et al., 2009).
Neglect is the most common form of child maltreatment (75%), followed by
physical abuse (18%) and sexual abuse (8.5%; U.S. Department of Health and
Human Services, 2018). Youth in foster care will have, on average, at least three
different foster care placements (The Annie E. Casey Foundation, 2011), and older
youth and youth with higher levels of physical or emotional challenges often experi-
ence a comparatively higher number of placements (Barth et al., 2007). Regarding
permanency, data suggest that nearly half of the children who exit foster care are
reunified with their biological families and 21% are adopted (U.S. Department of
Health and Human Services, Children’s Bureau, 2013). Each year, approximately
30,000 youth between the ages of 18 and 21 are neither reunited with their biologi-
cal families nor adopted and will “age out” of the foster care system (Love, McIntosh,
Rosst, & Tertzakian, 2005).
Commonly, individuals of families involved in the child welfare system are required
to participate in several interventive services. Using the Jackson case as an example,
Sandra’s case plan may require that she participate in supervised visitation with her
children once a week for an hour. Plus, Sandra may be court‐ordered to complete
anger management classes, parenting classes, individual therapy, refrain from drug or
alcohol use as evidenced by random drug testing, and she also must maintain her
employment and home. She may have to go to one location for her parenting class,
see a different provider for individual therapy, go to her caseworker’s office for super-
vised visitation, and yet go to another location whenever she receives notification that
she must participate in a drug test. Meanwhile, she is at risk for being fired because
she frequently misses work to fulfill these case plan activities. According to US federal
policy, Sandra will have 12–18 months to complete these requirements or the court
can petition to “terminate parental rights” and place the children up for adoption. For
parents with limited resources, unreliable transportation, and jobs that pay hourly,
plus mental health concerns and other stressors, navigating these systems can be very
challenging.
Sandra will have to do this alone. As commonly reported by parents involved with
the child welfare system (Festinger, 1996), Sandra suggests that she has no one to
turn to in times of need. Moreover, the father of the children is not involved in their
lives. This, too, is frequently the case. In fact, a study examining a random sample of
child welfare case records found that fathers were described as “irrelevant” to nearly
50% of the cases (Strega et al., 2008, p. 710). A father’s level of family involvement
may be linked to their self‐image, self‐expectations, and ideas about what being a
father means (McWey & Cui, 2017; Wiemann, Agurcia, Rickert, Beremson, & Volk,
2006), and these factors may be central to fathers involved with the child welfare
Foster Care 461
system. In fact, fathers whose children have been placed in foster care reported
feeling like failures because it meant that they were unable to protect and provide for
their family (Montgomery, Chaviano, Rayburn, & McWey, 2017). As such, it may be
clinically beneficial to help families and other involved providers see the benefits
of father involvement, when appropriate, and help engage fathers with the family
system (McWey & Cui, 2017; Montgomery et al., 2017).
Interventions for Children and Families Involved

with the Child Welfare System
Interventions offered to families involved with the child welfare system are typically
treatment‐as‐usual approaches. Different unconnected service providers typically
offer such services. The types of interventions required for families vary case by case
based on the problems identified, and often the parents are the target of such services
(e.g., substance use treatment, anger management, domestic violence classes). In gen-
eral, there is a need for systemic interventions (Goulet, Hélie, & Clément, 2018).
Family visitation and parent psychoeducation, however, are common case plan
requirements that offer opportunities for systemic work.
Family visitation
US federal policy requires that once children are removed from the home, efforts
should be made to maintain biological parent–child relationships whenever safely pos-
sible (Haight, Kagle, & Black, 2003). Although this is a federal mandate, states have
flexibility in how they define requirements, and there is wide variation in how visita-
tion is implemented from state to state (Hess, 2003). Additionally, visitation fre-
quency is not tracked nationally, so little is known about how often visitation actually
occurs. One study found that approximately half of the youth sampled visited their
mothers at least one time in the past month and 16% visited their fathers within the
same period (Leathers, 2003). Another study found that racial minority children had
less frequent parental visitation compared with Caucasian children (Davis, Landsverk,
Newton, & Ganger, 1996). Recent research involving a nationally representative sam-
ple demonstrated that most youth reported having “contact” with their biological
mothers, but over half reported never having contact with their biological fathers
(McWey & Cui, 2017). It is unclear, however, what “contact” entailed (e.g., face‐to‐
face contact, phone, FaceTime, etc.). If improving the parent–child relationship and
reunification are aims, parents and youth need to spend time together after children
are placed in foster care. If that is not occurring, therapists can advocate or help par-
ents advocate for family visitation by first contacting the family’s caseworker.
Often, caseworkers have to rely on their own judgment when establishing case plan
requirements (Hess, 1988), and research suggests that caseworkers often consider
visitation a low priority (Nesmith, 2013). This is important because for visitation to
occur, it is often the caseworkers who arrange the visitation location, contact people
to arrange the details, address concerns of foster and biological parents, and manage
the consequences of someone failing to attend (Nesmith, 2013). Further, some case-
workers report having a negative view of parent–child visitation (Browne & Moloney,
2002). To complicate matters further, foster parents are also expected to help facilitate
visitation, but, like caseworkers, caregivers do not always view visitation positively
(Browne & Moloney, 2002; Moyers, Farmer, & Lipscombe, 2006), and some foster
parents believe that children’s behavior problems worsen after visits with biological
parents (Moyers et al., 2006). Given this, it is understandable how, despite federal
guidelines, visitation may not actually occur. Yet, research suggests that compared with
youth with no contact, youth with regular parental contact demonstrate significantly
lower internalizing, externalizing, and total behavior problems (McWey & Cui, 2017).
If reunification is the goal, professionals can promote visitation by providing psychoe-
ducation to caseworkers and foster parents regarding the child benefits of visitation and
situate child behavior problems that may occur immediately after family visitation within
an attachment theory context (McWey & Cui, 2017). Specifically, from an attachment
theory perspective, children’s strong negative reactions may make sense. Youth who
experience distress at the beginning or end of visitation may be displaying developmen-
tally normal reactions to loss and separation (McWey & Cui, 2017).
Case plans can require unsupervised visitation in instances where there are not
concerns about child safety. Alternatively, if there are safety concerns, supervised
visitation may be required. Most times, supervised visitation simply involves biological
parents and children spending unstructured time together for 1–1.5 hr in an office
setting with someone else present to ensure child safety (Beyer, 2008).
Although visitation is commonly unstructured, visitation can be an opportunity for
systemic intervention. There are programs that offer “visit coaching” (Beyer, 2008)
or “therapeutic visitation” (Osofsky, 2009) in which a professional engages with the
family during visitation in efforts to support family members, encourage new parent-
ing behaviors, help alter family interactions, and promote positive parent–child rela-
tionships. Specific programs, such as the Connection Project (Gerring, Kemp, &
Marcenko, 2008), also utilize visitation as an opportunity to systemically attend to
issues of trauma related to child welfare system involvement and family separation
(Gerring et al., 2008). An evaluation of one such program demonstrated high levels
of parent satisfaction with services and improved relationships between foster parents,
biological parents, and caseworkers (Gerring et al., 2008). Incorporating a therapeu-
tic component to traditional visitation can replace the need for parents to have to
attend separate parenting classes and other related services (Beyer, 2008).
It is also important for siblings to maintain their connections. If siblings are not
placed together, sibling visitation often occurs simultaneously during parent visita-
tion. Even in instances when parent–child visitation is not an option (due to safety
concerns, parental abandonment, etc.), siblings should still be afforded time with one
another. There are model programs, such as Sibling Kinnections (Pavao, St. John,
Cannole, Maluccio, & Peining, 2007), that provide therapeutic sibling visitation. Best
practices include assessing sibling subsystem dynamics for indicators of child parenti-
fication and over‐functioning, overly open or closed boundaries, and sibling closeness
and therapeutically working to enrich sibling relationships. Systemic therapists are
particularly well suited to do this work.
Parent psychoeducation
Parents involved with the child welfare system are often mandated to participate in
parenting classes or parent psychoeducation. In fact, parent education is one of the
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most common case plan requirements (Barth et al., 2005). Approximately 400,000
parents are referred to parenting interventions each year because of child maltreat-
ment allegations (Barth et al., 2005).
Challenges with successfully engaging clients in parenting interventions are a well‐
documented issue. Estimates suggest that 40% or more of parents who start parenting
programs prematurely drop out (e.g., Miller & Prinz, 2003; Nock & Kazdin, 2005).
Factors linked with drop out include low parental education and employment status,
low SES, single parenthood, and being a member of a racial or ethnic minority group
(Reyno & McGrath, 2006). To compound matters further, parents involved with
child welfare system have a constellation of risks and stressors that may make engage-
ment and retention particularly challenging. As examples, parents often do not seek
interventions voluntarily but rather are court‐ordered for services (Barth et al., 2005).
They may not believe that they need intervention (Faver, Crawford, & Combs‐Orme,
1999) or are confused about what it is that the child welfare system wants them to
change in order to get their children back (Beyer, 2008). In these cases, it can be chal-
lenging for therapists to get parent buy‐in and promote retention.
Several parenting interventions have been identified as promising practices for use
with parents involved with the child welfare system. Although these interventions
were not developed specifically for families involved with the child welfare system,
promising practices include the Incredible Years (Bywater et al., 2011; Webster‐
Stratton & Reid, 2010), Triple P (Sanders, 1999; Petra & Kohl, 2010), Multisystemic
Therapy (Painter, 2009; Tolman, Mueller, Daleiden, Stumpf, & Pestle, 2008), and
Parent–Child Interaction Training (Chaffin et al., 2004). For detailed information
about these parenting interventions, see Holtrop, Krauthamer Ewing, Topham, and
Miller (2020, vol. 2) and Rhoades et al. (2020, vol. 2). In general, though, these
programs are systemic in that they view the parents as primary change agents, believ-
ing that altering parents’ behaviors will result in improved family interaction patterns
and parent and child outcomes.
Foster parents, too, often must complete psychoeducation. In fact, every state
requires pre‐service programs, ongoing training, or continuing education units
(CEUs) for foster parents (McWey, Benesh et al., 2015). Foster parents can obtain
CEUs in a variety of ways including attending local events, state or national confer-
ences, or completing online trainings (Pacifici, Delaney, White, Nelson, & Cummings,
2006). The focus of the CEUs often includes updates on recent state or federal foster
care policies, psychoeducation on the needs of youth in foster care, and parenting
strategies (Pacifici et al., 2006).
Clinical Considerations
Recall the Jackson family. Sandra’s mental health symptoms seem to be worsening and
the children are acting out. In such instances, the Jackson family members may face
judgment from caseworkers and other service providers who are tasked with identify-
ing risks. The worsening mental health and behavioral concerns, however, makes
sense contextually. If a family is already struggling with a number of serious issues
(e.g., substance use, social isolation, financial strain, depression), the removal of chil-
dren from the home may exacerbate those concerns, at least temporarily.
Families involved with the child welfare system face unique circumstances and
stressors that distinguish them from non‐child welfare‐involved families, and these
factors may have important implications for clinical engagement and retention.
Specifically, services are often “mandated” as part of the families’ case plans (Barth
et al., 2005). As such, parents may not have the same source of motivation as parents
who seek services voluntarily. Moreover, they may not perceive a need for interven-
tion (Faver et al., 1999). When that is the case, it can be challenging to assure parents
of the relevance of the intervention (McWey, Holtrop, Stevenson Wojciak, & Claridge,
2015). This is critical because clients’ perceptions of treatment relevance are linked
with engagement and completion of clinical services (Fernandez & Eyberg, 2009).
Research suggests that a strengths‐based perspective can be particularly helpful in suc-
cessful parental engagement and treatment “buy‐in” (Kemp, Marcenko, Lyons, &
Kruzich, 2014).
When providing therapy to an individual or family involved with the child welfare
system, it is important to assess clients’ perceptions of their needs and collaborate with
clients to identify viable treatment options. Once needs and intervention options are
identified, therapists can recommend specific services to caseworkers. For instance,
the caseworker assigned to Sandra’s case may be overwhelmed by a very large caseload
and assign services to the Jackson family based solely on what was listed on Sandra’s
case plan. Sandra’s therapist, in this example, can assess how the assigned services are
meeting her needs and recommend alternate services if necessary. For instance, if the
siblings do not have contact with one another, the therapist can recommend that fam-
ily visitation occur. The therapist can also advocate for family therapy sessions if it is
deemed that systemic work would be beneficial. In fact, if family reunification is the
goal, it would be hard to imagine a case where family therapy would not be an impor-
tant service for the family to receive. Similarly, given the interrelated systems inherent
to child welfare involvement, therapists can also advocate to include foster parents or
extended kin in treatment, when appropriate, with the goal of fortifying a subsystem
of adults committed to working together for the sake of the child (McWey, Benesh
et al., 2015).
Transparency
Transparency is another key ingredient in forming a therapeutic alliance with families.
As such, it is important to have overt conversations with clients about the limits of
confidentiality and how concerns will be handled. Our code of ethics, licensure regu-
lations, and state laws require that we report child abuse and neglect. If new concerns
about child maltreatment surface during treatment, we are required to report it.
However, we have options about how we do so. In instances when reportable child
maltreatment concerns arise, it is important to assess for the threat of harm (e.g., if a
child could be in danger if the caregiver found out that someone made an abuse
report). If danger is a possibility, therapists should make the maltreatment report
without alerting whomever would place others at risk. If, however, there is no per-
ceived risk, therapists can involve parents in the reporting process. This can be done
by discussing the issue with the client during session, telling the client that a report
must be made, describing the reporting process, and asking clients if they would like
to be involved in or present for the report. This likely will not be an easy conversation
and clients may express anger, but transparency about the issue can help preserve the
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therapeutic alliance (McWey, Benesh et al., 2015). In our experience, although clients
may be upset about the report, many opt to be a part of the reporting process. In
doing so, they can know exactly what was reported and, in some instances, even learn
what the next steps will entail.
Another aspect of transparency involves discussing how communication will be
handled between the various interacting subsystems associated with the family. As an
example, if a clinician is being paid for services by the child welfare system, the case-
worker will likely expect updates and reports. Clients have a right to know about that
communication. It is also important to discuss, up front, one’s “secrets” polices and
the exchange of information (McWey, Benesh et al., 2015). With the clinical vignette,
for instance, if Lisa discloses something that the clinician believes the caseworker must
know, will the clinician work with Lisa to help her disclose the information to her
caseworker? Will the therapist tell the caseworker directly? It is important to discuss
what information will be shared, when, and with whom. Having these discussions
early in the therapeutic relationship may help build trust and preserve the therapeutic
alliance when instances arise.
Cultural sensitivity
Therapists should employ a culturally sensitive framework that considers the culture,
expectations, values, and philosophies of families (Briggs & McBeath, 2010). Minority
families are overrepresented in the system (U.S. Department of Health and Human
Services, 2013), and the disparities in mental health services received by racial and
ethnic minority families compared with Caucasian families are widely demonstrated
(e.g., Briggs & McBeath, 2010; Garland, Landsverk, & Lau, 2003). For instance, an
empirical review demonstrated that Caucasians reported the lowest mental health
service need but had the highest rates of services, whereas Latinos represented the
highest service need but lowest rates of service utilization (Garland et al., 2003).
There are many possible explanations for lower service utilization by minority clients
and client mistrust may be one factor. Clients may perceive that clinicians who come
from a place of privilege in terms of SES, race, ethnicity, or education may not be able
to understand their struggles. It is, therefore, worthwhile to openly discuss differ-
ences and provide space for topics such as race, mistrust, macro‐ and micro‐aggres-
sions, and power. If the therapist waits to see if the client brings up these concerns,
clients may interpret “waiting” as a lack of openness to such discussions. Based on our
experiences, clients have reported a sense of relief when learning that therapists were
open to talking about race, ethnicity, and power.
The child welfare system is another culture in and of itself that warrants clinical
consideration. There are important values, stigmas, and beliefs that directly affect
families involved in the system. In fact, the norms of a particular child welfare agency
may be a better predictor of the services a family receives than the needs of the families
themselves (Hemmelgarn, Glisson, & James, 2006). Research points to a link between
child welfare contexts in which caseworkers are stressed and overworked and poor
service outcomes for families compared to child welfare agencies whose staff report
high job satisfaction (Glisson & Hemmelgarn, 1998). This is relevant to the thera-
peutic context in that it may be important for therapists to help families advocate for
themselves in instances where their needs are not being met. This may entail more
active collaboration with caseworkers and other service providers compared to efforts
typical for non‐child welfare‐involved clients (McWey, Benesh et al., 2015).
There is a negative stigma associated with child welfare involvement, and families
are aware of this. For instance, children report knowing about foster care stigmas and
believe that others will treat them differently because they are in foster care (Kools,
1997). For youth who identify as LGBTQ, a population overrepresented in the child
welfare system (McCormick, Schmidt, & Terrazas, 2017), these beliefs may be even
more concerning because youth may not disclose their sexual orientation due to fears
that their identity may disappoint caregivers and caseworkers, disrupt their place-
ments, and be grounds for harassment and discrimination (Craig‐Olsen, Craig, &
Morton, 2006). The reluctance to disclose may inadvertently thwart efforts to protect
against threats to their safety. As such, it is important for therapists to create safe
spaces where sexual identity and development can be discussed. Doing so may help
youth learn how to advocate for their needs and secure services as needed.
Parents’ suggestions for therapists

Parents involved with the child welfare system have provided specific feedback about
aspects of treatment they found helpful (McWey, 2008; McWey, Humphreys, & Roth,
2011). Those elements include (a) therapist availability and support, (b) skill build-
ing, and (c) therapists’ approach. Regarding availability and support, clients described
how, in times of crisis, they valued therapists who were immediately available to them.
They appreciated therapists who would allow clients to call them and who would
make time to talk. It is important to understand that families involved with the child
welfare system often confront crises that may warrant intervention after typical busi-
ness hours. As one client shared, “there was never a time I couldn’t get a hold of him.
Sometimes he would spend hours talking to me. I needed that level of support”
(McWey, 2008, p. 52). Because therapists’ clinical boundaries vary, it is important to
ensure this model of accessibility is congruent with one’s level of comfort before
accepting a child welfare‐involved case.
Regarding skill building, clients reported that they valued the opportunity to gain a
clearer understanding about why parenting changes were needed and strategies for mak-
ing those changes (McWey, 2008). Parents discussed intergenerational patterns and
expressed confusion about child welfare involvement because they perceived that their
parenting was superior to the parenting techniques used when they were children
(McWey et al., 2011). It seems perspective is important. While the child welfare system
and service providers may see clear problems with parenting approaches and family con-
texts, clients’ statements indicate that one’s past experiences may color perceptions.
Clients stated that it was helpful when therapists approached differing perceptions with
sensitivity (McWey, 2008), identifying tangible benefits to therapists taking time to
understand the clients’ history and how their past informed their current context (McWey
et al., 2011). Parents also wisely suggested that understanding their own intergenera-
tional family patterns helped them better recognize the nature of the problem. Once
equipped with a better understanding of the problem, clients reported appreciating the
opportunity to learn parenting strategies and techniques from a new perspective.
In terms of the therapist’s approach, clients reported valuing a nonjudgmental
stance and therapists who were direct, as exemplified by one parent who said his
Foster Care 467
therapist “wasn’t scared to say what he thought we needed to know, if we needed to

quit something, he wasn’t afraid to tell us that” (McWey, 2008, p. 53). Moreover,
clients appreciated hearing therapists’ lived experiences. Although therapists’ levels of
comfort with self‐disclosure may vary, clients reported therapists’ self‐disclosure and
shared stories about their own children were helpful.
Clients also suggested areas for improvement in terms of clinical interventions.
These included a need for more frequent and longer‐term services and termination
considerations that consider clients’ limited support networks. Specifically, some cli-
ents stated that it would be helpful to meet with their therapists more than once a
week, particularly when the family was in a crisis (e.g., serious child behavior concerns
upon removal from the home, serious parental depression upon child removal).
Additionally, they also wished services could be longer term. Regarding termination,
some clients reported feeling a sense of abandonment when their therapists closed
their cases. Parents expressed how, through therapy, they experienced an increased
sense of trust and hope that their child welfare cases would end positively. However,
when they no longer had access to therapy, they reported feelings of distress, anxiety,
and anger (McWey, 2008). Families involved with the child welfare system often have
low levels of positive social support (Festinger, 1996). As such, it would be key to
assess for social support well prior to termination and help families bolster or gain
supports as needed. Doing so may help mitigate feelings of abandonment upon
termination.
Evidence‐Based Family Interventions
Evidence‐based interventions for families involved with the child welfare system are
the exception rather than the norm (Topitzes, Mersky, & McNeil, 2015). There are
several reasons for the lack of evidence‐based services, including insufficient funding
for child welfare agencies and a lack of interventions tailored for the needs of the fami-
lies involved with system (Topitzes et al., 2015). That said, there are evidence‐based
systemic approaches that have been developed or adapted for families involved with
the child welfare system.
Multisystemic Therapy for Child Abuse and Neglect (Swenson, Schaeffer,
Henggeler, Faldowski, & Mayhew, 2010) is a high‐intensity intervention for families
where physical abuse has occurred, and this approach may be used in both home and
foster care settings. Originally adapted from Multisystemic Therapy, an evidence‐
based treatment for antisocial and delinquent behavior in adolescents (Henggeler,
Schoenwald, Borduin, Rowland, & Cunningham, 2009), Multisystemic Therapy for
Child Abuse and Neglect uses an ecological approach to conceptualize and treat fami-
lies. In this model, therapists consult with caseworkers, family members, teachers,
foster parents, and youth to identify the unique strengths, needs, and goals of the
family. Based on this assessment, target behaviors and their drivers are identified and
prioritized for intervention using a combination of individual and family treatments.
As families undergo treatment, progress toward outcomes is regularly reassessed, and
adjustments are made to goals and interventions. In addition to this iterative treat-
ment process, families in Multisystemic Therapy for Child Abuse and Neglect partici-
pate in safety planning centered on a functional assessment of the abuse to ensure that
all participants will remain safe during the intervention. Unlike traditional services,
this approach provides flexible, high‐intensity services and ongoing support for
families. During the early phase of treatment, a family might have therapy daily and
eventually taper to once or twice a week by the end of treatment. In recognition of
the strain such frequent therapy can have on families, Multisystemic Therapy for Child
Abuse and Neglect adapts to meet their needs and offers services on nights and week-
ends and in nontraditional settings like school and the family home. This reduces the
burden on parents and increases the likelihood they will be able to succeed in treat-
ment. Families are also offered 24/7 on‐call services and crisis management, which
helps ensure safety. Finally, Multisystemic Therapy for Child Abuse and Neglect
incorporates child welfare workers into the therapy process as consultants and includes
time dedicated to clarification of the child welfare system’s decision‐making process
with the family and helping parents recognize unhelpful thoughts about their abusive
behaviors and accept responsibility for their actions.
In a randomized effectiveness trial, families who received Multisystemic Therapy
for Child Abuse and Neglect had fewer out‐of‐home placements and placement
changes, lower severity of youth mental health problems, and improved parental func-
tioning compared with families receiving enhanced outpatient services (Swenson
et al., 2010). Other variations, such as Multisystemic Therapy—Building Stronger
Families, have been also shown to be effective at reducing parental mental health and
substance use problems, improving youth mental health, and reducing substantiated
re‐abuse incidents (Schaeffer, Swenson, Tuerk, & Henggeler, 2013).
Keeping Foster Parents Trained and Supported is a foster parent training interven-
tion that uses specialized training and intensive support systems to address mental
health and behavioral problems in foster youth (Price, Chamberlain, Landsverk, &
Reid, 2009). It is an adaptation of Treatment Foster Care Oregon (formerly
Multidimensional Treatment Foster Care), a well‐supported intervention for youth
involved with the juvenile justice system that uses specialized foster homes rather
than incarceration to address delinquency (Chamberlain, Leve, & DeGarmo, 2007).
With this intervention, foster parents participate in a 16‐week training focused on
effective behavior management through positive reinforcement, the use of time‐outs
and privilege removal, and parental monitoring. During the training period, foster
parents participate in role plays, record themselves practicing skills at home, and
receive substantial coaching and feedback to hone their skills. Foster parents also
receive additional supervision and support, including regular contact with support
staff to provide consultations and crisis support, and case management services to
coordinate treatment with the foster home, school, and family of origin. In a large
randomized effectiveness trial comparing this intervention with a control group,
youth whose foster parents received the Keeping Foster Parents Trained and
Supported intervention were more likely to experience reunification or adoption and
less likely to have additional placement changes (Price et al., 2008).
Another intervention derived from the Treatment Foster Care Oregon model,
Multidimensional Treatment Foster Care for Preschoolers, focuses on the unique
needs of younger children in foster care (Fisher, Burraston, & Pears, 2005). In this
intervention, foster parents receive intensive training and ongoing support and super-
vision, just as in the Keeping Foster Parents Trained and Supported intervention.
However, in Multidimensional Treatment Foster Care for Preschoolers, training is
more focused on the developmental needs of younger children and incorporates a
Foster Care 469
family therapist to work with the birth or adoptive family to train them in the parenting
skills used in the program. Behavior specialists are also used to help the children
manage emotions and behaviors in preschool and daycare settings. Randomized trials
comparing the Multidimensional Treatment Foster Care for Preschoolers interven-
tion to traditional foster care suggest that the intervention increases the likelihood of
successful reunification or adoption (Fisher et al., 2005; Fisher, Kim, & Pears, 2009),
reduces behavior problems (Jonkman et al., 2017), and reduces children’s cortisol
levels (Fisher, Stoolmiller, Gunnar, & Burraston, 2007).
Unfortunately, programs like Multisystemic Therapy for Child Abuse and Neglect,
Keeping Foster Parents Trained and Supported, and Multidimensional Treatment
Foster Care for Preschoolers are not available to many agencies due to resource
constraints. When programs like these are not available, agencies will often instead
provide “wraparound” services. Wraparound services represent a set of values and
principles that promote a family‐centered, strengths‐oriented, community‐based
approach to service coordination (Burchard, Bruns, & Burchard, 2002). They work
with families, community resources, service providers, and the family’s existing
support system to identify strengths, understand needs, and collaborate on solutions
to help families meet these needs. They can result in a highly individualized treatment
that reflects the values and perspectives of the family receiving services. They are
commonly used with families involved with the child welfare system, and the exact
implementation varies greatly depending on the resources available in the community.
Studies evaluating the effectiveness of wraparound services for youth in care suggest
that such services can be effective in reducing behavior problems and delinquency and
improving the likelihood of reunification (Clark et al., 1998).
In addition to broad systemic approaches, many families involved with the foster
care system benefit from interventions that are more narrowly focused on family
interactions. Typically, these interventions are modifications of existing evidence‐
based treatments to suit the unique needs of families involved with the child welfare
system. While some of these adaptations have been supported by research, most are
local adaptations that are never formally evaluated. However, the adaptations that
have been evaluated have generally reported positive results. Two such interventions
are described next.
Attachment and Biobehavioral Catch‐up is an intervention for parents and young
children focused on the attachment relationship (Dozier, Meade, & Bernard, 2014).
While initially developed for distressed families outside the child welfare system,
Attachment and Biobehavioral Catch‐up has been shown to be an effective interven-
tion for young children in foster care and can be implemented with both foster par-
ents during placement and birth parents during reunification. It can also be
implemented with families who are at high risk of becoming involved with the child
welfare system due to early adversities. In Attachment and Biobehavioral Catch‐up,
caregivers complete 10 sessions of training where they learn ways to respond to their
children’s distress with nurturance and support, reinterpret behaviors that may be
off‐putting, learn skills to manage parental issues that may interfere with providing
nurturance, and develop a safe and enriching home environment. This intervention is
delivered in the home where the child resides and features the therapist collaboratively
coaching the caregiver in attachment‐promoting skills. Clinical trials suggest this
approach is effective in reducing avoidant attachment behaviors and improving trust
of caregivers of young children in foster care (Dozier et al., 2009) and improving
children’s physiological responses to stress (Dozier, Peloso, Lewis, Laurenceau, &

Levine, 2008).
Parent–Child Interaction Therapy is an intervention for parents with young
children that focuses on reducing behavior problems, improving child compliance
with parental commands, and enhancing the quality of the parent–child relationship
(McNeil & Hembree‐Kigin, 2010). Like Attachment and Biobehavioral Catch‐up,
it has been adapted for use with birth and foster families and has also been used as
a preventative intervention for high‐risk families. Parent–Child Interaction Therapy
teaches parents a set of basic play therapy skills and then a set of behavior manage-
ment skills. These skills are particularly relevant for parents who themselves have
experienced neglect or physical abuse, as they may not have had modeled the skills
necessary to interact children in a way that is safe and mutually enjoyable. Parents
learn such skills and receive coaching in outpatient sessions and then practice skills
daily in the home. This model has been shown to reduce behavioral problems in
young children in care when provided to foster parents (Timmer et al., 2006),
reduce caregiver stress (Timmer, Urquiza, Zebell, & McGrath, 2005), and reduce
the likelihood of re‐abuse when provided to birth parents (Chaffin, Funderburk,
Bard, Valle, & Gurwitch, 2011).
Common elements across evidence‐based family models

The evidence‐based systemic interventions identified in this chapter share many fea-
tures. All use a broad ecological perspective when identifying family strengths and
needs and are intentional in collaborating with families to meet these needs rather
than taking a purely prescriptive approach. These interventions recognize that families
involved with the child welfare system require service providers to be flexible, provide
high levels of support, and actively work to reduce barriers to participation (i.e., meet-
ing with families in the home, meeting in the evenings or weekends, or providing
childcare services while parents receive individual services). These intervention mod-
els most often reflect social learning and cognitive‐behavioral approaches to behavior
management and place importance on the unique values and experiences of the fami-
lies being served.
Adaptations of evidence‐based family interventions to the foster care context, such
as Attachment and Biobehavioral Catch‐up and Parent–Child Interaction Therapy,
are more focused on interactions within the family. These interventions, driven largely
by attachment theory and behavioral parenting models, rely on coaching parents on
specific skills and giving real‐time feedback. The emphasis on helping parents learn to
perform skills, rather than simply learn about them, allows these interventions to
more rapidly shape parent behaviors and produce positive outcomes for parents and
children. When parents can see effects quickly, they may be more likely to “buy in” to
treatment, use the skills independently, and successfully complete their course of
treatment.
Limitations to current intervention models and clinical practice

Several promising practices have been identified for interventions with families
involved with the child welfare system; however, few intervention models were
Foster Care 471
developed specifically for such families, and, unfortunately, rarely are evidence‐based
treatments used. Instead, families are often the recipients of various treatment‐as‐usual
approaches involving unconnected service providers from differing agencies. The lack
of integrated care can be frustrating and overwhelming for parents to navigate, and
dropout is a common concern. The current federal policy, the Adoption and Safe
Families Act, requires that parents complete case plan elements within 12–18 months.
This can be difficult to achieve considering that these services may be targeting serious
issues that may not be responsive to short‐term interventions (e.g., substance abuse,
intimate partner violence, serious mental health concerns). Moreover, although federal
mandate declared the importance of maintaining family connections, visitation—
particularly visitation involving all members of the family (i.e., parents and all involved
children)—may not consistently occur. Given that reunification is the goal for most
child welfare cases, therapists should advocate for systemic interventions whenever
safely possible.
Moreover, the child welfare system tends to operate from a deficit‐based perspec-
tive, which is understandable given their charge to assess for and protect children
from threats and risk. A meta‐analysis of programs aimed to prevent child abuse and
neglect, however, found larger effect sizes for programs that incorporated strengths‐
based approaches and promoted social support compared to interventions without
those features (MacLeod & Nelson, 2000). These meta‐analytic findings point to the
value of a strengths‐based perspective. Parents themselves echoed this sentiment. As
one mother said when reflecting on her work with a family therapist, “What she did
that was helpful was that she talked to me like I was a human being. Sad, but true.
During that whole ordeal, she was one of the only ones that looked at me like I was
another human being” (McWey, 2008, p. 53). Coming from a therapeutic position of
empathy and support can be highly valuable.
In short, with regard to clinical interventions for families involved with the child
welfare system, there is a lot of serious work to do and a limited amount of time to do
it in. This makes the need to effective approaches that much more critical. However,
there are significant barriers to providing evidence‐based treatment including a lack of
identified, systemic, and empirically supported treatment models, a lack of funding at
the state and federal levels to implement these empirically supported models, and a
lack of understanding about the importance of systemic work for families involved
with the child welfare system.
Limitations of Extant Research and Implications

for Research Moving Forward
Although many foster care policies are federal, child welfare systems look very differ-
ent from state to state and from county to county. Therefore, most researchers inter-
ested in better understanding families involved with the child welfare must rely on
local convenience samples. This is problematic because findings derived from one
sample, even if that sample is representative of a county or state, may not generalize
to families involved in child welfare system in other areas. As such, it is very challeng-
ing to make statements about the US foster care population as a whole. That said,
there are datasets (e.g., the National Survey of Child and Adolescent Well‐Being and
the Longitudinal Studies on Child Abuse and Neglect) that involve large samples of
families from diverse regions of the county. Researchers have begun capitalizing on
these datasets to help better understand the needs of child welfare‐involved families.
Intervention research is also laden with challenges. Best practices for client engage-
ment suggest the importance of regular check‐ins with clients; however, families
involved with the child welfare system tend to move more frequently than typical, and
their phone numbers may change. This makes keeping in contact with families to
provide appointment reminders or conduct empirical follow‐ups challenging.
Moreover, families involved with the system may be mistrustful of various systems and
therefore be reluctant to engage in research. Relatedly, social desirability may also be
of concern. Parent and youth may believe that answers to research questions may be
used against them and therefore may underreport concerns. For instance, although
youth in the general population tend to self‐report higher levels of mental health
concerns than their parents report of them, the opposite appears to be the case for
youth in foster care (McWey, Cui, & Holtrop, 2015). These and other unique factors
associated with the child welfare context should be considered when designing and
implementing intervention research for this population.
Conclusion
The aim of the child welfare is to protect children from adverse family contexts;
however, child welfare system involvement is also associated with a host of negative
individual and family outcomes. Current US policies are a response to concerns that
children were languishing in foster care for long periods of time, while parents worked
to fix the issues that led to child removal. Now, decisions about children’s permanent
care are to be made within 12–18 months. Meanwhile, the constellation of risks asso-
ciated with child welfare system involvement, including mental health concerns, sub-
stance abuse, violence, poverty, and intergenerational patterns of dysfunctional family
functioning, may not be responsive to short‐term treatment. Moreover, family mem-
bers often must travel from treatment provider to treatment provider to accomplish
the case plan requirements, and the interventions offered are rarely evidence based.
Reflecting on the Jackson case, after Sandra’s children were removed from her care,
her depression and reliance on substances worsened. She was ashamed and often felt
condemned because of child welfare system involvement. She desperately missed her
children, chronically worried about them, and felt alone. Generating the motivation
to engage in services was a challenge, but she attended therapy. Supported by a
systemic, strengths‐based therapeutic approach, she was able to demonstrate the
resolve necessary to complete the other elements of her case plan. While evidence‐
based services were not available in her area, with her consent, treatment providers
collaborated with one another to help promote continuity of care. In addition, Sandra
was linked with some valuable resources available through the child welfare system
(e.g., housing and employment assistance) to help strengthen her family context.
Ultimately, she regained custody of her children. Although not every child welfare
case is as successful as the Jacksons, strengths‐based approaches delivered by systemic
therapists can be highly beneficial for families involved with the system. Indeed, fami-
lies involved with the child welfare system can benefit from our help.
Foster Care 473
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19
Interventions to Support
Grandparents Raising
Grandchildren
Megan L. Dolbin‐MacNab
Throughout history and across the globe, circumstances arise that prevent parents
from caring for their children. Grandparents and other relatives (e.g., siblings, aunts/
uncles, cousins, etc.) often assume responsibility for these children, in an arrangement
known as kinship care. Most kinship care arrangements are informal, meaning that the
family privately arranges for care of the child by relatives; however, some kinship care
arrangements are formal in the sense that oversight is provided by a child welfare
agency, many of which are governed by polices that advocate for the placement of
children with relatives whenever possible and appropriate (Beltran, 2014; Generations
United, 2015). While a variety of relatives engage in kinship care, this chapter focuses
on grandfamilies, or those families in which grandparents are raising their grandchil-
dren. In grandfamilies, grandparents provide for their grandchildren’s financial, physi-
cal, and emotional needs and function in a parental capacity. The purpose of this
chapter is to consider grandfamilies’ clinical needs, conceptualized through a systemic
and relational lens, and to delineate intervention strategies that can be used by family
therapists to address those needs. The chapter concludes with a discussion of future
directions for systemic practice and intervention research with grandfamilies.
According to data from the US Census, 2.6 million grandparents are primarily
responsible for raising 2.5 million or 3% of US children (Annie E. Casey Foundation
Kids Count Data Center, 2016; Ellis & Simmons, 2014). Grandfamilies are struc-
tured in highly diverse ways—some households include the grandchild’s biological
parents, while others are skipped generation households, meaning that the grand-
child’s parents are not living in the home (Ellis & Simmons, 2014). Further, grand-
families may be headed by a single grandparent, often a grandmother, or by partnered
or married grandparents, and there may or may not be other grandchildren and/or
relatives also living in the home. While some grandfamily arrangements are temporary
and grandchildren return to the care of their parents, the vast majority are long‐term
caregiving arrangements (Ellis & Simmons, 2014).
480 Megan L. Dolbin-MacNab
Grandfamilies are also demographically diverse. Hispanic and African American

grandparents are most likely to be raising their grandchildren, though there have been
significant increases in the number of White grandparents raising grandchildren (Ellis
& Simmons, 2014; Livingston & Parker, 2010). Financially, almost a quarter of
grandparents raising grandchildren have incomes that fall below the poverty line
(Generations United, 2015). The majority of grandparents raising grandchildren are
female and below the age of 60, and approximately two‐thirds are married (Ellis &
Simmons, 2014; Generations United, 2015; Livingston & Parker, 2010). In consid-
ering grandparent demographics, Ellis and Simmons (2014) note that those grand-
parents most likely to be raising their grandchildren are younger, single, female, living
in poverty, and racial and ethnic minorities. Awareness of these demographic charac-
teristics is important for family therapists, as the unique combinations of grandpar-
ents’ social locations may help therapists better contextualize some of the distinctive
challenges they experience (Dolbin‐MacNab & Few‐Demo, 2018).
Fundamentally, grandfamilies form because parents are engaging in behavior that
renders them unavailable or incapable of caring for their children—common parental
issues associated with grandfamily formation include substance abuse, abuse/neglect,
incarceration, military deployment, death, adolescent pregnancy, and physical and
mental illness (Generations United, 2016; Hayslip, Fruhauf, & Dolbin‐MacNab,
2017). While parental difficulties are the primary contributors to the development of
grandfamilies, several cultural and societal contexts also influence grandfamily forma-
tion. For example, grandfamilies are more likely to form when families hold cultural
beliefs and/or personal preferences that emphasize multigenerational households,
stress families “taking care of their own,” or promote significant grandmother partici-
pation in childcare (Goodman & Silverstein, 2002). Even social systems of oppression
based on specific social identities (e.g., age, gender, race, class) can be reproduced
structurally in ways that contribute to the formation of grandfamilies (e.g., incarcera-
tion rates of racial and ethnic minority women; Dolbin‐MacNab & Few‐Demo,
2018). Outside of the United States, grandparents assume responsibility for their
grandchildren as a result of urban and transnational migration by parents for employ-
ment (e.g., China (Duan & Yang, 2008); Thailand (Knodel & Saengtienchai, 2007);
Romania (Robila, 2011)) as well as disease epidemics (e.g., the AIDS epidemic in
sub‐Saharan Africa; Beegle, Filmer, Stokes & Tiererova, 2010), natural disasters, and
human warfare (Save the Children, 2007). In considering why grandfamilies form,
family therapists should remember that multiple contributing factors are at work, and
each of these factors may uniquely influence the clinical needs of the grandfamily. For
this reason, careful and comprehensive clinical assessment is critical.
Clinical Needs in Grandfamilies
Grandfamilies who present for family therapy are often experiencing a number of
stressors and challenges, any of which could be areas for clinical intervention. These
stressors and challenges include psychological distress, feelings of stigma, physical
health problems, economic strain, legal difficulties, loss of social connections and
leisure time, parenting stress, grandchild difficulties, and relational (e.g., marital and
extended family) conflict (Hayslip et al., 2017). Cumulative inequality is also relevant
Grandparents Raising Grandchildren 481
to understanding the clinical needs of grandfamilies, in that early adversity (e.g.,

trauma, poverty) and stratified and oppressive social systems can result in accumulat-
ing disadvantage and inequality that contribute to negative outcomes (Ferraro &
Shippee, 2009). While personal agency, resources, and resilience factors (e.g.,
resourcefulness, positive appraisals, productive coping) can diminish negative out-
comes (Ferraro & Shippee, 2009; Hayslip & Smith, 2013), grandfamilies may still
need assistance identifying, accessing, and implementing these sources of support.
Within the literature on grandfamilies, challenges and stressors are often conceptu-
alized as being individual in nature, focusing primarily on the experiences and needs
of grandparents. Systemic conceptualizations that consider other members of the
family system (e.g., the grandchildren, grandparents’ spouses/partners, grandchil-
dren’s parents, other family members) have been altogether lacking or discussed pri-
marily in terms of the impact on grandparents. Therefore, to advance a systemic,
relational perspective on grandfamilies and to inform systemic practice with this popu-
lation, the following sections outline several key clinical issues, and their systemic
foundations and implications, which are likely to be amenable to family therapy as an
approach to facilitating change.
Grandparent mental health problems

Over the last 20 years, one of the most consistent and robust research findings has
been that grandparents raising grandchildren experience significant mental health dif-
ficulties, namely, depression and anxiety (Hayslip, Shore, Henderson, & Lambert,
1998; Minkler, Fuller‐Thomson, Miller, & Driver, 1997; Musil, Warner, Zauszniewski,
Wykle, & Standing, 2009; Whitley & Fuller‐Thomson, 2017; Whitley, Fuller‐
Thomson, & Brennenstuhl, 2015). Role theory is often utilized to explain grandpar-
ents’ mental health problems, with role ambiguity (e.g., challenges with trying to be
both grandparent and parent to a grandchild), role strain (e.g., managing all of a
grandchild’s needs), and role conflict (e.g., balancing raising a grandchild and work-
ing outside the home) being highlighted as contributing factors (Landry‐Meyer &
Newman, 2004). Further contributing to grandparents’ mental health difficulties is
the fact that raising a grandchild is frequently an “off‐time” role, meaning that the
responsibilities of parenting come during a phase in life when grandparents often
expect to have more freedom and time for social and leisure activities (Landry‐Meyer
& Newman, 2004). Other factors that have been linked to grandparents’ mental
health problems include preexisting mental health conditions (Hughes, Waite,
LaPierre & Luo, 2007), feelings of grief about the parents’ behavior and the loss of a
traditional grandparent–grandchild relationship, and contextual stressors such as pov-
erty and other sources of cumulative inequality (Ferraro & Shippee, 2009; Hughes
et al., 2007). Even aspects of the caregiving arrangement itself have been linked to
grandparents’ psychological well‐being; longer durations of care and transitions to
higher‐intensity caregiving have been associated with increased psychological distress
as well as intrafamily strain and poor family functioning (Musil et al., 2010).
Relevant to the work of family therapists, family systems factors also contribute to
grandparents’ mental health problems. Specifically, grandparents’ mental health dif-
ficulties have been associated with or predicted by grandchild behavior problems
(Doley, Bell, Watt, & Simpson, 2015; Kelley, Whitley, & Campos, 2013b; Goodman,
2012; Sands & Goldberg‐Glen, 2000), grandchild trauma exposure (Sprang, Choi,
Eslinger, & Whitt‐Woosley, 2015), a poor or conflictual grandparent–grandchild rela-

tionship (Goodman, 2012; Sprang et al., 2015), and extended family conflict (Weber
& Waldrop, 2000). Social isolation, which can occur when grandparents do not know
others in their same situation, or when they cannot connect with existing friends due
to their caregiving responsibilities, may further exacerbate grandparents’ psychologi-
cal distress (Doley et al., 2015; Musil et al., 2010).
While the relationships among the factors that contribute to grandparent psycho-
logical distress have often been examined in a unidirectional manner, in accordance
with a family systems perspective, they likely operate reciprocally (Hayslip, Blumenthal,
& Garner, 2014). For example, a grandparent may become depressed as a result of the
stress associated with parenting a grandchild with significant behavior problems.
However, the grandparent’s depression may result in ineffective parenting practices
that further exacerbate the grandchild’s behavior problems and, in turn, the grandpar-
ent’s depression. Interestingly, in a longitudinal examination of grandparent–grand-
child well‐being, Hayslip et al. (2014) found empirical evidence of the bidirectional
relationship of these factors, with grandchild difficulties being a stronger predictor of
grandparent mental health difficulties than the converse. Family therapists working
with grandparents raising grandchildren can utilize best practices for the treatment of
grandparents’ depression and/or anxiety, but should also give consideration to the
family factors and patterns of interaction that might be exacerbating grandparents’
mental health difficulties.
Grandchild emotional and behavioral difficulties

As suggested by the literature on the impact of adverse childhood experiences on
health and well‐being, it is not surprising that children being raised by grandparents
often experience significant physical, psychological, and behavioral difficulties. These
difficulties are frequently substantial stressors for grandparents and may result in
grandparents seeking therapy or other clinical services for their grandchildren
(Burnette, 1999; Landry‐Meyer, 1999). In fact, studies reveal that anywhere from 30
to 50% of grandchildren have internalizing and externalizing symptoms at borderline
or clinical levels (Kelley et al., 2013b; Smith et al., 2015). Some estimates also suggest
that almost three‐fourths of grandchildren have had trauma exposure (e.g., psycho-
logical abuse, neglect, parental substance abuse, etc.; Sprang et al., 2015).
Examinations using nationally representative samples consistently document that
children being raised by grandparents fare worse than children from normative sam-
ples and children living in other family constellations (e.g., single parents, foster fami-
lies, economically distressed families; Billing, Ehrle, & Kortenkamp, 2002; Pilkauskas
& Dunifon, 2016; Pittman, 2007; Smith & Palmieri, 2007; Ziol‐Guest & Dunifon,
2014). For example, Smith and Palmieri (2007) found that compared with a norma-
tive sample, children (ages 4–17) living in skipped generation households had more
emotional, conduct, peer, and hyperactivity/inattention problems. With regard to
children living in other family constellations, Billing and colleagues (2002) revealed
that compared with children residing with parents, children (ages 6–17) being raised
by relatives had higher rates of emotional/behavioral problems and academic prob-
lems (i.e., suspended/expelled, skipping school, low school engagement); however,
those distinctions appeared to be primarily driven by differences in household income
(vs. family structure). That said, using the same data, Ziol‐Guest and Dunifon (2014)
compared a variety of family structures and found that children living in grandfamilies
had the highest rates of mental health problems, as well as elevated rates of poor
physical health and limiting conditions, and that these differences that were not
explained by household income. Other studies have suggested that compared with
children living with their mothers, children being raised by grandparents have more
externalizing problems and attention deficit disorder/attention deficit hyperactivity
disorder symptoms, as well as compromised academic performance (Pilkauskas &
Dunifon, 2016; Pittman, 2007).
Grandchildren’s internalizing and externalizing behavior problems have been asso-
ciated with a variety of relational or family factors. Most significantly, grandparent
depression and/or anxiety, which have already been discussed as being predicted by
grandchild behavior problems, have also been shown to be predictive of grandchild
behavior problems, in that grandparents who experience high levels of psychological
distress are more likely to be raising grandchildren with internalizing and externaliz-
ing problems (e.g., Goodman, 2012; Hayslip et al., 2014; Kelley, Whitley, & Campos,
2011). It appears, however, that ineffective or dysfunctional parenting mediates the
relationship between grandparents’ psychological distress and grandchild adjustment
(Smith & Dolbin‐MacNab, 2013; Smith & Hancock, 2010; Smith, Palmieri,
Hancock, & Richardson, 2008). Difficulties in other family relationships, beyond the
grandparent–grandchild relationship, may also exacerbate grandchildren’s behavior
problems. For example, grandparent marital distress has been shown to negatively
impact grandchildren’s adjustment, again via dysfunctional parenting (Smith &
Hancock, 2010). Similarly, the quality of grandchildren’s relationships with their bio-
logical parents, a relationship that will be addressed later in the chapter, can also
amplify grandchildren’s behavioral and academic problems (Dunifon, Kopko, Chase‐
Lansdale, & Wakschlag, 2016).
Family therapists are likely to encounter grandfamilies in the context of grandpar-
ents seeking services for their grandchildren (Burnette, 1999; Landry‐Meyer, 1999).
Focusing on the grandchild is not surprising, as grandparents frequently worry about
their grandchildren or are desperate for assistance with difficult behavioral problems.
In these situations, family therapists must balance the grandparent’s request to focus
on the grandchild with the need to consider related systemic issues such as parenting,
the grandparent’s mental and physical health, the grandparent–grandchild relation-
ship, or the grandparent’s marital relationship. It is likely that, due to their histories
of trauma and adversity, grandchildren may indeed benefit from clinical interventions
focused on them, but so may the grandparent, especially given evidence that grand-
parents neglect their own needs due to their focus on their grandchildren or because
of a lack of time and resources (Hayslip et al., 2017). Family therapists can facilitate
this process via thorough assessment and treatment planning that accounts for both
individual and family system needs.
Parenting stress and ineffective parenting

As parenting is a significant source of stress for many grandparents raising grandchil-
dren, it represents a key area for potential clinical intervention. When grandchildren
have serious emotional or behavioral problems or experience developmental delays,
symptoms of trauma exposure, or other physical health problems, parenting becomes
much more challenging; grandparents may need to provide highly specialized care or
have to manage disruptive or even dangerous behavior. Parenting stress can be com-
pounded when grandparents are also dealing with their own physical or mental health
problems or are utilizing ineffective child discipline strategies (Dolbin‐MacNab,
2006). Navigating contemporary social forces (e.g., social media, school violence,
drugs) and bridging the generation gap, especially with adolescent grandchildren, can
be additional sources of parenting stress (Dolbin‐MacNab, 2006; Dolbin‐MacNab &
Keiley, 2006, 2009). Beyond these issues, grandparents may have difficulty balancing
the need to act as a parent with their desire to behave as a grandparent (Bratton, Ray,
& Moffit, 1998). Even the grandchild’s age can contribute to parenting stress—
grandparents raising young grandchildren may be overwhelmed by the physical
demands of providing care, while grandparents of adolescent grandchildren may
struggle with enforcing limits and rules and managing their grandchildren’s emerging
autonomy.
Grandparents’ psychological and marital distress has been associated with ineffec-
tive parenting, which has been shown to negatively impact grandchild well‐being
(Smith & Dolbin‐MacNab, 2013; Smith & Hancock, 2010; Smith et al., 2008).
These associations, combined with the research on the actual parenting practices of
grandparents raising grandchildren, provide further evidence that grandparents may
benefit from parent training or family therapy. Specifically, studies suggest that while
grandparents engage in effective parenting practices such as monitoring grandchil-
dren’s behavior and giving rewards, they also display harsh and inconsistent discipline,
low nurturance, insensitivity to their grandchildren’s needs, difficulties with setting
limits, and a lack of clarity related to parent–child roles and responsibilities (Kaminski,
Hayslip, Wilson, & Casto, 2008; Smith et al., 2008; Smith & Richardson, 2008).
While all parents engage in both effective and ineffective parenting practices, par-
enting a “second time around” introduces additional layers of complexity. For
instance, some grandparents may feel a sense of guilt over their shortcomings or fail-
ures in parenting their own children and try to behave differently (Smith et al., 2015),
while others maintain their effectiveness as parents and continue to implement inef-
fective parenting practices. Still other grandparents believe they are more effective the
“second time around” as a result of having more time, wisdom, and patience (Dolbin‐
MacNab, 2006). Grandparents’ concerns about what their grandchildren “have been
through” can also pose unique parenting challenges, as some grandparents struggle
to discipline or set limits with their grandchildren. Alternatively, grandparents may try
to “protect” their grandchildren from making the same choices as their parents by
demanding obedience and becoming overly strict and punitive. Family therapists will
want to carefully assess grandparents’ perceptions of their parenting as well as their
actual parenting behavior and find ways to address possible mismatches and pro-
vide intervention strategies that are not dismissive of grandparents’ previous
parenting experience.
Relational challenges
Although having a high‐quality grandparent–grandchild relationship is essential to
the overall well‐being of a grandfamily, other relationships within the family system
experience difficulties and could therefore benefit from family therapy. One such rela-
tionship is the marital relationship between grandparents. Although approximately
two‐thirds of grandparents raising grandchildren are married (Generations United,

2015, 2016), these relationships have received limited empirical attention, and the
few existing findings provide contradictory evidence as to whether raising grandchil-
dren is detrimental to a marriage. For instance, Matzek and Cooney (2009) found
that grandparents raising grandchildren reported positive spousal support and marital
relationships; however, other evidence suggests grandparents experience marital dis-
tress and a variety of marital difficulties (Smith & Hancock, 2010). While some of
these difficulties reflect marital challenges experienced by typical parents, others are
more specific to the “off‐time” nature of raising grandchildren. Grandparents’ marital
difficulties can include disagreements over the amount or type of grandparent involve-
ment in parenting, especially when one grandparent is not biologically related to the
grandchild, differential perspectives on how to manage the grandchild’s parent(s),
lack of privacy and time together, differences in child discipline strategies, and ten-
sions around the impact of raising grandchildren on leisure activities, social interac-
tions, and independence. The financial impact of raising grandchildren can be an
additional source of marital conflict, especially when grandparents need to continue
working beyond a planned retirement or must use their retirement savings to support
their grandchildren. Though limited research has considered the impact of grandpar-
ent marital distress on the larger family system, there is evidence that grandparents’
psychological distress contributes to their marital distress and that marital distress can
“spill over” into dysfunctional parenting, which then negatively impacts grandchild
adjustment (Smith & Hancock, 2010). For this reason, as part of a comprehensive
assessment, family therapists should inquire about grandparents’ relationships with
their spouses and possible “spillover” effects.
Relationships with “collateral” family members (e.g., other adult children and
grandchildren) are also impacted when grandparents raise their grandchildren (Weber
& Waldrop, 2000, p. 39). For instance, the grandparent’s other adult children may
try to assist their sibling (i.e., the parent of the grandchild) or the grandparent (Weber
& Waldrop, 2000). However, conflict among siblings may arise over how the grand-
parent is being treated, and grandparents can have disagreements with their adult
children over how the grandparent responds to the grandchild’s parent or treats other
family members, such as the grandchildren they are not raising (Weber & Waldrop,
2000). For example, adult children may perceive the grandparent as giving preferen-
tial treatment to one part of the family or that the grandparent is being taken advan-
tage of by their sibling. Similarly, conflict can arise when other grandchildren in the
family receive less time, attention, and resources from the grandparent. Thus, grand-
parents raising grandchildren may struggle to balance their caregiving responsibilities
with their other family roles and relationships.
Finally, relationships with the grandchild’s biological parents are a commonly refer-
enced source of relational stress within grandfamilies. As a result of their personal
circumstances (e.g., substance abuse, mental illness, etc.), grandchildren’s biological
parents may be completely absent from the grandfamily or they may remain involved,
though this involvement is often inconsistent or unpredictable. Evidence suggests
that the majority of grandparents and grandchildren maintain some degree of involve-
ment with at least one of the grandchild’s biological parents, typically the grandchild’s
mother (Dolbin‐MacNab & Keiley, 2009; Dunifon et al., 2016; Dunifon, Ziol‐Guest,
& Kopko, 2014).
While contact with the grandchild’s biological parents may be appealing to grand-
children who desire greater connection with their parents (Dolbin‐MacNab & Keiley,
2009), relationships with grandchildren’s biological parents are fraught with chal-
lenges (Dolbin‐MacNab & Keiley, 2009; Dunifon et al., 2016; Musil, Warner,
McNamara, Rokoff, & Turek, 2008). For grandchildren, it can be difficult to under-
stand why their parents are unable to care for them and they may experience intense
feelings of anger, grief, and disappointment toward their parents. Grandchildren also
have to navigate altered relationships with their parents—for example, a parent may
behave more like a friend, sibling, or acquaintance than a parent (Dolbin‐MacNab &
Keiley, 2009; Dunifon et al., 2016). Grandparents must focus on keeping their grand-
children safe from parental behavior that is inappropriate, disruptive, or even danger-
ous. Even so, grandparents still experience concern for their adult children and may
struggle to find the best ways to support them. In these situations, grandchildren can
sometimes be triangulated into grandparent–parent conflicts and find themselves
struggling to manage conflicting expectations and loyalties (Dunifon et al., 2016).
Grandparents may also struggle to set appropriate boundaries with their grandchil-
dren’s parents related to visits and other contact with the family.
Although not all relationships with a grandchild’s biological parents are problem-
atic, when these relationships are conflictual, difficult, or distant, it has a negative
impact on grandparents and grandchildren alike. For instance, Williamson and col-
leagues (2003) found that grandparent depression was associated with a conflictual
relationship with the grandchild’s parents. In an examination of different types of
intergenerational triads within grandfamilies, Goodman (2003) found that grandpar-
ents experienced depression and compromised life satisfaction when the parent was
emotionally isolated from the family system. In their study of adolescents being raised
by grandparents, Dunifon et al. (2016) found that grandchildren had greater aca-
demic and behavioral problems when they had a difficult parental relationship. These
linkages lend further importance to the need for systemically focused interventions
that help family members generate meaning about their relationships, assist grandpar-
ents and biological parents in co‐parenting, if relevant, and develop interaction pat-
terns and boundaries that are minimally disruptive to the family system.
Interventions with Grandfamilies
Imagine the following scenario, which highlights issues that commonly arise when
working with grandfamilies. A grandmother contacts her grandson’s school counse-
lor, with concerns about his explosive and destructive outbursts. The grandson’s
anger and destructive behavior seems to get worse following visits with his mother,
whom the grandmother worriedly describes as a heroin addict. The grandmother is
also frustrated because her attempts at disciplining her grandson do not seem to be
working. Her grandson has been diagnosed with delayed language and cognitive
functioning, which has been linked to his prenatal exposure to opioids. The grand-
mother is concerned about her grandson’s academic performance, but balks at the
school counselor’s suggestion to take him for additional educational testing, and cau-
tiously admits she does not have legal custody of her grandson and cannot afford the
expense. The grandmother also reveals that she is single and supporting herself, her
grandson, and another adult daughter on her retirement savings. She tells the school
counselor that she is exhausted all of the time, that she is feeling down in the dumps
about missing out on her “golden years,” and that her blood sugar is all over the
place. She is worried about paying her bills and confesses that she has no idea where
to go for help. When the school counselor starts talking with the grandmother about
services that she could access, the grandmother breaks down crying, saying that she is
worried that people will think she has failed as a parent and is not fit to raise her
grandson.
As this scenario highlights, family therapists who work with grandfamilies quickly
discover that these families experience numerous presenting problems and require
multiple types of services in order to address their varied needs. In fact, Fruhauf and
colleagues (2015) argue that effective service delivery for grandfamilies requires
coordination and cooperation among multiple service providers and across agencies.
For this reason, family therapists will often find themselves as one part of a larger
service team or in the role of needing to connect grandparents to other services and
providers. Additionally, some grandfamilies live in a constant state of chaos and crisis
and, therefore, require intensive services, while others experience relatively few
stressors and require minimal (or no) intervention. Regardless of the grandfamily’s
needs, family therapists should remain attuned to the fact that grandfamilies are
highly diverse (Hayslip et al., 2017; Kirby, 2015) and not assume that all grandfami-
lies or subgroups of grandfamilies have similar experiences or will respond similarly
to clinical intervention.
When working with grandfamilies in family therapy, comprehensive clinical assess-
ment is critical to the development of an effective treatment plan as well as coordina-
tion of additional services. Key areas of clinical assessment include the nature of the
caregiving arrangement (i.e., formal vs. informal), the circumstances surrounding
parental involvement with the grandparent and grandchild, and the extent to which
the grandfamily is utilizing other services. For grandparents, family therapists should
assess for symptoms of depression and/or anxiety, substance use, parenting stress, and
physical health status and management of chronic health conditions. When assessing
grandchildren, family therapists should inquire about their history of trauma, behav-
ioral and physical difficulties, academic performance, and social relationships.
Many of the presenting problems experienced by grandparents and their grand-
children can be addressed through existing evidence‐based approaches or treatment
as usual. For example, Trauma‐Focused Cognitive Behavioral Therapy (Cohen,
Mannarino, & Iyengar, 2011) could be used to treat an adolescent grandchild expe-
riencing posttraumatic stress and associated internalizing behavior problems. While
existing approaches to intervention can simply be utilized with grandfamilies, there
are intervention approaches with particular utility for addressing grandfamilies’
unique relational needs. Specifically, in addition to family therapy, support groups,
skills training, and parent training have been used to address grandfamilies’ individ-
ual and relational presenting problems. In the following sections, these approaches
to intervention and any associated efficacy data are presented.
Before addressing these approaches to intervention, it is worth taking a macro
perspective to consider the empirical evidence (or lack of empirical evidence) sup-
porting clinical interventions with grandfamilies. Generally, interventions for grand-
families are efficacious; however, studies demonstrating efficacy often have significant
methodological limitations (Hayslip et al., 2017; McLaughlin, Ryder, & Taylor,
2017). For instance, as grandfamilies can be a challenging population to access, it is

not surprising that many intervention studies are based on small convenience sam-
ples (McLaughlin et al., 2017). In addition to the potential consequences of selec-
tion bias, this approach to sampling also makes it difficult to determine who
interventions might benefit most and under what circumstances. Homogeneous
samples also fail to adequately capture the diversity of grandfamilies, which makes it
difficult to identify how interventions could be culturally adapted in order to best
meet grandfamilies’ needs (Hayslip et al., 2017; Parra‐Cardona et al., 2014).
Additionally, although the number of experimental designs and randomized clinical
trials (RCTs) examining interventions for grandfamilies has increased in recent years
(e.g., Kirby & Sanders, 2014; N’zi, Stevens, & Eyberg, 2016; Smith, Hayslip,
Hancock, Strieder, & Montoro‐Rodriguez, 2018; Smith, Strieder, Greenberg,
Hasylip, & Montoro‐Rodriquez, 2016; Zauszniewski, Musil, Burant, & Au, 2014;
Zauszniewski, Musil, Burant, Standing, & Au, 2014), the majority of intervention
studies do not include control groups or randomization of participants into treat-
ment and control conditions (McLaughlin et al., 2017). Other methodological limi-
tations of the grandfamilies intervention research include lack of long‐term follow‐up
assessments and, with some exceptions, limited effectiveness studies in community
settings. Finally, McLaughlin and colleagues (2017) note that grandfamilies inter-
vention research could be improved via assessing more meaningful outcome variables
(e.g., functioning vs. satisfaction).
Relevant to this chapter, another major limitation of the literature on clinical inter-
ventions with grandfamilies is the lack of attention that has been given to systemically
informed interventions or interventions that provide services to multiple family
members at once. Structurally, grandparents tend to be the target audience for most
intervention efforts—interventions that may or may not be guided by a systemic
conceptualization—and almost no interventions focus on interactions within the
grandparent–grandchild dyad or the larger family system. While the application of
family therapy models to grandfamilies provides important guidance for systemic
intervention and will be addressed later in the chapter, much more work is needed in
order to determine what systemic interventions might be most effective in address-
ing grandfamilies’ relational needs.
Barriers to intervention
Despite evidence that grandfamilies could benefit from mental health services,
including family therapy, as well as a variety of government assistance programs
(e.g., Temporary Assistance for Needy Families [TANF], the Supplemental
Nutrition Assistance Program [SNAP], the Children’s Health Insurance Program
[CHIP], etc.), grandparents experience significant barriers to accessing formal sup-
ports. These barriers may be so significant that some grandparents completely fail
to access available services (Yancura, 2013). Common barriers include intraper-
sonal factors, logistical challenges, and broader organizational issues (Dolbin‐
MacNab, Roberto, & Finney, 2013). Intrapersonally, grandparents often lack
awareness of available services or they fail to access services as result of feeling
ashamed that they need help, lacking trust in “the system,” being paralyzed
by stress, or having the desire to resolve things on their own (Burnette, 1999;
Dolbin‐MacNab et al., 2013; Fruhauf et al., 2015; Gibson, 2002; Sands &
Goldberg‐Glen, 2000). Logistically, it can be difficult for grandparents to access
services when they lack transportation, childcare, and financial resources, or have
other demands on their time (Dolbin‐MacNab et al., 2013; Gibson, 2002; Yancura,
2013). Organizationally, restrictive eligibility requirements, confusing policies and
paperwork, multiple points of service entry, and inconvenient hours and locations
can further interfere with service utilization (Burnette, 1999; Fruhauf et al., 2015;
Gibson, 2002; Yancura, 2013). Grandparents who do not have a legal relationship
to their grandchildren face additional barriers including not being able to obtain or
consent to services, not having their grandchildren covered by their insurance, and
not having needed records and documentation. Finally, in the course of accessing
services, grandparents may encounter professionals who lack knowledge about
grandparents raising grandchildren or hold stereotypical or disrespectful beliefs
about grandfamilies (e.g., grandparents have failed as parents and are likely to fail
again; Burnette, 1999; Gibson, 2002; Gladstone, Brown, & Fitzgerald, 2009). In
these situations, grandparents’ feelings of discomfort and experiences of other bar-
riers to service utilization may compound to the point that they fail to seek help.
As such, family therapists must remain cognizant of the barriers experienced by
grandfamilies and actively work to mitigate them.
Family therapy with grandfamilies

Family therapy with grandfamilies has received limited attention generally, and no
studies have examined the effectiveness of any approach to psychotherapy with
grandfamilies. Examinations of family therapy with grandfamilies are primarily appli-
cations of various family therapy models to the individual and relational challenges
experienced by grandparents, grandchildren, and their extended family members.
For instance, Bartram (1994) applied concepts from structural family therapy by
emphasizing the need for clear subsystem boundaries within grandfamilies—and
argued that diffuse boundaries and unclear generational hierarchies within the vari-
ous parent–child subsystems (e.g., grandparent–parent, parent–grandchild, grand-
parent–grandchild) can result in scapegoating, coalitions, alliances, unclear roles, and
role reversals. As such, structural family therapy with grandfamilies would focus on
developing clear boundaries among the various subsystems within the grandfamily
and correcting any issues with hierarchies (e.g., helping grandparents assume a par-
ent vs. grandparent role).
In an application of contextual family therapy, Brown‐Standridge and Floyd
(2000) emphasize the transgenerational nature of the relationship dynamics within
grandfamilies and suggest that the very existence of grandfamilies may reflect invis-
ible loyalties that adult children are acting out in relation to their parents (i.e., the
grandparents). Destructive entitlement on the part of adult children may also
explain why some grandparents assume caregiving responsibilities. In addition,
stress and difficulties reported by grandparents are thought to reflect imbalanced
ledgers of merits and obligations, such that grandparents believe they are not being
given what they are owed (Brown‐Standridge & Floyd, 2000). In accordance with
contextual family therapy, family therapists would work (i.e., utilizing multidi-
rected partiality) with everyone in the grandfamily system to balance the family
ledger and uncover and address problematic loyalties, with the goal of building
trustworthiness across the generations (Boszormenyi‐Nagy & Krasner, 1986;
Brown‐Standridge & Floyd, 2000).
Beyond these approaches, Bachay and Buzzi (2012) briefly discuss the use of nar-
rative therapy with grandfamilies. They emphasize that problems develop as a result of
family members holding disempowering or problem‐saturated narratives about them-
selves and their family situation and as a result of being negatively impacted by domi-
nant social discourses (Bachay & Buzzi, 2012). Dolbin‐MacNab and Few‐Demo
(2018) note that grandparents raising grandchildren are likely to be impacted, simul-
taneously, by multiple oppressive discourses related to their race, age, gender, socio-
economic status, and family structure. Family therapists can therefore assist
grandfamilies by challenging problematic narratives through externalizing problems,
deconstructing disempowering narratives, and exploring unique outcomes (Bachay &
Buzzi, 2012; Freedman & Combs, 1996; White & Epston, 1990).
To address young grandchildren’s behavior problems, Bratton et al. (1998)
describe the use of filial/family play therapy with grandfamilies. Filial/family play
therapy focuses on teaching grandparents child‐centered play therapy techniques,
for the purposes of improving grandchild outcomes, grandparents’ parenting skills,
and the grandparent–grandchild relationship (Bratton et al., 1998). Grandparents
are provided with didactic instruction and supervised practice sessions, and grand-
parents then conduct special play sessions with their grandchildren at home. By
creating an environment that is empathic, accepting, and nonjudgmental, grandpar-
ents become therapeutic change agents with their grandchildren (Bratton et al.,
1998; Rennie & Lendreth, 2000). Empirical evidence supports the effectiveness of
filial/family play therapy “as a powerful intervention for increasing parental accept-
ance, self‐esteem, empathy, positive changes in family environment, and the child’s
adjustment and self‐esteem while decreasing parental stress and the child’s behavio-
ral problems” (Rennie & Landreth, 2000, p. 31), though no outcome studies have
focused specifically on grandfamilies. Additionally, many of the studies have signifi-
cant methodological limitations including not using meaningful control groups as
well as relying on small samples with limited generalizability (Ray, Bratton, Rhine,
& Jones, 2001).
Collectively, this discussion highlights how multiple approaches to systemic family
therapy can be applied to clinical work with grandfamilies. That said, approaches that
account for intergenerational legacies and patterns of interaction appear particularly
valuable for capturing the role challenges and relational dynamics relevant to the
experiences of grandparents and grandchildren. Additionally, approaches that attend
to the role of context also appear to have utility, as contextual factors are significant to
understanding why some grandfamilies experience more or less stress and other dif-
ficulties. Though not addressed in the literature, there may also be a benefit to using
solution‐focused approaches (de Shazer & Dolan, 2012). Brief intervention
approaches, with their focus on addressing clearly delineated goals and emphasizing
grandfamilies’ competencies (de Shazer & Dolan, 2012), are likely to be especially
useful for grandfamilies needing assistance with a specific issue. They are also respon-
sive to the many demands that grandparents raising grandchild have on their time and
resources. Regardless of the particular approach, family therapists should carefully
assess the grandfamily’s goals for treatment and work closely with the family to
develop a shared vision of the treatment plan.
Intervention strategies for grandfamilies

Although the efficacy of family therapy with grandfamilies has not been examined
empirically, a number of other approaches to intervention have evidence of their util-
ity in improving grandparent well‐being. Support groups, skills training, and parent
training are most applicable to the work of family therapists, given their relevance for
addressing relational clinical issues. That said, as part of a multimodal approach to
intervention (Fruhauf et al., 2015; Kirby, 2015), family therapists should also be
familiar with integrated case management (e.g., Kelley, Whitley, & Campos, 2013a;
McLaughlin et al., 2017) and kinship navigators (e.g., Hernandez, Magana, Zuniga,
James, & Lee, 2014). Kinship navigators are programs that provide grandparents with
information, referrals, and technical support related to government assistance pro-
grams and other services. For family therapists, kinship navigators are ideal resources
for helping grandparents overcome many of the organizational barriers to accessing
services.
Support groups Of all the approaches to intervention for grandfamilies, support

groups are the most readily available and widely utilized (Littlewood, 2014; Smith,
2003; Strozier, 2012; Strom & Strom, 2000). Many communities offer support
groups for grandparents raising grandchildren in a variety of settings (e.g., schools,
churches, agencies, etc.). Support groups typically serve grandparents, though there
have been efforts to develop support groups for grandchildren (for more information,
see Dannison & Smith, 2003 and Smith & Dannison, 2003). The goals of support
groups include reducing social isolation, promoting sharing of experiences and com-
munal problem solving, empowering grandparents, and enhancing knowledge, espe-
cially knowledge of available services and resources (Littlewood, 2014; Smith, 2003;
Strom & Strom, 2000). Support groups are often one component of broader
approaches to intervention; for instance, integrated case management programs (e.g.,
Kelley et al., 2013a) frequently incorporate support groups into their programming.
That said, for many grandparents raising grandchildren, support groups are their only
source of formal support.
Despite their popularity, outcome research on support groups for grandparents
raising grandchildren remains limited, and the existing research is marked by meth-
odological limitations such as a lack of comparison groups, no randomization into
treatment and control groups, limited long‐term follow‐up, and use of nonrepre-
sentative samples (McLaughlin et al., 2017). Nonetheless, studies find that support
group participation benefits grandparents raising grandchildren via reduced depres-
sive symptoms (McCallion, Janicki, & Kolomer, 2004; Smith & Dannison, 2003) and
decreased negative affect (Hayslip, 2003), as well as improved empowerment, locus
of control, caregiver mastery (McCallion et al., 2004), and increased utilization of
formal supports (Smith & Dannison, 2003; Strozier, 2012). Relationally, support
group participation has been linked with increased parental self‐efficacy (Hayslip,
2003), parenting knowledge (Smith & Dannison, 2003), and improved grandpar-
ent–grandchild relationships (Hayslip, 2003; Smith & Dannison, 2003).
Family therapists offering support groups to grandparents raising grandchildren
should remain cognizant of several recommendations for delivering this type of inter-
vention so that the group does not become ineffective or even harmful (Smith, 2003).
First, effective group leadership skills are critical to preventing group members from
dominating or disrupting the group and for providing the structure necessary to keep
the group focused on its goals (Smith, 2003; Strom & Strom, 2000). Related to this,
support groups need to have clearly articulated goals, ideally goals that include skill
building or other knowledge that can be applied outside the group setting (Strom &
Strom, 2000). Evaluating progress toward these goals is important as well. Additionally,
as there is evidence that grandparents often experience support groups as having a
pessimistic focus (Smith, 2003; Strom & Strom, 2000), family therapists should
ensure that support group discussions focus on mutual support and problem solving.
Finally, as barriers to seeking services can negatively impact support group attendance
and retention, group leaders should work to minimize these barriers. Promising strat-
egies include providing meals, transportation, and childcare, as well as selecting con-
venient times, dates, and locations for the support group (Dannison & Smith, 2003).
Skills training In accordance with the emphasis in the broader literature on the
stressors and negative outcomes experienced by grandparents raising grandchildren,
there has been growth in the number of interventions focused on training grandpar-
ents in skills designed to promote their resilience and coping. Most skill‐based inter-
ventions are grounded in cognitive‐behavioral approaches (McLaughlin et al., 2017)
and focus on improving grandparents’ well‐being via didactic psychoeducational
material and practice/application of the relevant skills. While improving grandpar-
ents’ well‐being through skills training should have positive effects on the rest of the
family system, few skills training interventions focus on teaching relational skills, tar-
get or measure relational outcomes, or are designed to include the grandparent–
grandchild dyad or the family system as the focus of the intervention. One exception
is a newly launched RCT by Smith and colleagues (for additional information, see
NIH RePORT (2018)), which is grounded in a systemic conceptualization of grand-
family well‐being and focuses on providing social intelligence training to grandpar-
ent–grandchild dyads. Social intelligence builds on the notion that humans are social
creatures and refers to an individual’s awareness of the importance of social connec-
tions, ability to take others’ perspectives and humanize relationships, replace prob-
lematic relational cognitive schemas, and form meaningful social relationships (Zautra,
Zautra, Gallardo, & Velasco, 2015). After providing social intelligence training to the
grandparent–grandchild dyads, the study will examine the systemic impacts of the
intervention on grandparent and grandchild outcomes.
Existing skills training interventions for grandparents raising grandchildren have
focused on a number of skills and competencies including empowerment (Cox &
Chesek, 2012), self‐care (Yancura, Greenwood‐Junkermeier, & Fruhauf, 2017), and
resourcefulness (Zauszniewski, Musil, Burant, & Au, 2014; Zauszniewski, Musil,
Burant, Standing, et al., 2014). Parent training could also be included in this discus-
sion but, for the purposes of this chapter, is presented as a stand‐alone approach due
to its overt relational emphasis. Outcome research generally finds that skills training
is beneficial to grandparents, and therefore may be a fruitful avenue for intervention,
though the rigor of these studies varies widely. Among the most rigorous examina-
tions is the work of Zauszniewski and colleagues, who found that grandparents who
received resourcefulness training showed increased personal and social resourceful-
ness, decreased symptoms of depression and perceived stress, and improved quality
of life (Zauszniewski, Musil, Burant, & Au, 2014). The studies on resourcefulness
training are exemplars due to their use of a quasi‐experimental design, blinded and
randomized assignment into multiple treatment and control groups, and use of
robust outcome measures over multiple follow‐up assessments.
Another example of a skills training intervention is Yancura et al.’s (2017) adapta-
tion of the Powerful Tools for Caregivers curriculum for grandparents raising grand-
children. This group intervention focuses on teaching grandparents skills such as
self‐care, emotion regulation, and self‐efficacy. Preliminary results of an analysis of
nine Native Hawaiian program participants suggest that grandparents improved their
knowledge of self‐care strategies and had a greater appreciation of the importance of
self‐care; however, these findings should be interpreted with caution due to the use of
a small homogeneous sample, the lack of a control group, and the reliance on self‐
report, qualitative data as indicators of change. Finally, Cox and Chesek’s (2012) pilot
work on empowerment training among Tanzanian grandmothers raising grandchil-
dren suggests that learning these skills improved grandparents’ relationships with
their grandchildren, though the strength of these conclusions must be tempered by
significant methodological limitations (i.e., sampling, satisfaction‐focused outcome
variables).
Family therapists interested in utilizing skills training with grandfamilies should
carefully assess what skills might be most beneficial to grandparents and should con-
sider utilizing (or adapting) existing evidenced‐based approaches to teaching those
skills. Additionally, family therapists may want to teach relational skills that would
benefit the entire family system or highlight the potential systemic benefits of teach-
ing certain “individual” skills. For instance, grandparents and grandchildren may ben-
efit from learning more effective emotion regulation strategies, communication skills,
and conflict resolution techniques, among others.
Parent training Perhaps the most systemic of the intervention approaches com-
monly used with grandfamilies is parent training. Parent training is a valuable area of
intervention for grandfamilies, given the established relationships between parenting
behavior, grandchild behavior problems, and grandparent well‐being (Smith &
Dolbin‐MacNab, 2013; Smith & Hancock, 2010; Smith et al., 2008). Generally,
scholars have adapted existing empirically supported parent training programs (e.g.,
Triple P, Parent–Child Interaction Therapy [PCIT]) for use with grandparents (Kirby
& Sanders, 2014; N’zi et al., 2016; Smith et al., 2018; Smith et al., 2016). Adaptations
have included incorporating additional content specific to grandfamilies, such as
effective parenting strategies, coping skills, and parent–grandparent communication
(Kirby & Sanders, 2014).
Outcome studies support the efficacy of parent training for grandparent raising
grandchildren. For example, in their RCT utilizing Grandparent Triple P with 54
grandparent caregivers of grandchildren between the ages of 2 and 9, Kirby and Sanders
(2014) found evidence of improved child behavior problems, grandparent mental
health (i.e., depression, anxiety, stress), parenting confidence, grandparent–parent rela-
tionship quality, and self‐efficacy when communicating with the grandchild’s parent.
Interestingly, there was also a multigenerational and systemic benefit of the interven-
tion; for those grandparents who received the parent training, the grandchild’s parents
also reported improvements in child behavior problems (Kirby & Sanders, 2014). In
another RCT, N’zi et al. (2016) examined Child‐Directed Interaction Training (CDIT),
a phase of Parent–Child Interaction Training (PCIT) that focuses on improving the
attachment relationships between caregivers and children and using differential social
attention to address behavioral issues, with 14 grandparents raising young (ages 2–7)
grandchildren. Participation in CDIT was associated with more positive grandpar-
ent–grandchild relationships, improved parenting (i.e., less use of critical verbal force
and greater limit setting), fewer grandchild externalizing behavior problems, and
decreased grandparent depression and parenting stress (N’Zi et al., 2016). Finally,
Smith et al. (2018) conducted an RCT comparing parent training, cognitive‐behav-
ioral therapy, and an information control condition for 343 grandmothers raising
grandchildren. Results indicated that those grandmothers in the parent training con-
dition showed improvements in their psychological distress, effective parenting behav-
ior, and grandchildren’s internalizing and externalizing behavior problems.
Interestingly, however, grandmothers in the cognitive‐behavioral therapy condition
showed similar or better outcomes as those in the parent training condition, high-
lighting the overall value of skills training, as well as the ability of skill‐based interven-
tions to benefit the family system.
While these studies document the value of parent training for grandparents raising
grandchildren, the quality of this research could be improved by using larger and
more diverse samples, gathering data from multiple family members, using observa-
tional parenting measures, conducting analyses that allow for an examination of rela-
tional effects (e.g., Actor–Partner Interdependence Models), and designing studies so
that they include active control or treatment as usual conditions. Future research
could also examine how family‐based interventions focusing on grandparent–parent
co‐parenting or grandparent–grandchild relationship quality might improve individ-
ual outcomes and/or benefit the family system. In terms of practice implications,
these studies suggest that empirically supported parent training programs improve
grandparent and grandchild outcomes, particularly for distressed (i.e., low income,
less positive affect, health problems, engaged in mental health services) grandparents
(Smith et al., 2016).
Conclusions and Future Directions
Despite the adversity that many grandfamilies experience, they also demonstrate sub-
stantial resilience. However, even the most resilient grandparents and grandchildren
can feel overwhelmed by stress, experience compromised functioning, or be unable
to manage difficulties within their family system. When these situations arise, grand-
families can benefit from clinical intervention, including family therapy. This chapter
highlighted many of the relational challenges experienced by grandfamilies and illu-
minated how individual difficulties experienced by grandparents and grandchildren
can impact the entire family system. The chapter also highlighted a number of effec-
tive intervention strategies that can be used with grandfamilies; unfortunately, many
of these interventions are grounded in an individual conceptualization focused on
the grandparent and, as a result, fail to incorporate a systemic conceptualization or
approach to intervention.
In order to provide the empirical foundation necessary to support systemic
approaches to intervention with grandfamilies, future research should take a con-
sumer‐informed approach and examine grandfamilies’ perceptions of family therapy
and other approaches to intervention (Kirby, 2015; McLaughlin et al. 2017). Once
there is a greater understanding of what grandfamilies need in terms of intervention,

more rigorous evaluations of intervention effectiveness are needed. As referenced
throughout the chapter, strategies for increasing the rigor of grandfamilies interven-
tion research include greater use of RCTs or other experimental designs, as well as
more robust control conditions (vs. waitlist control conditions) and longer‐term fol-
low‐up assessments. Other promising directions for future research include conducting
rigorous evaluations of interventions already offered within communities, exploring
mechanisms of change via process research, and examining how interventions should
be adapted to meet the needs of diverse groups of grandfamilies. From a relational
perspective, future research would also benefit from greater attention, both in terms of
design and analysis, to other members of the grandfamily system. Finally, while some
systemic approaches to addressing the presenting problems experienced by grandfami-
lies have strong empirical support at this time, others have mainly theoretical and clini-
cal support. As such, future research should continue to explore, empirically, the
effectiveness of various systemically informed interventions for grandfamilies.
The clinical issues and intervention research highlighted in this chapter have implica-
tions for clinical practice. First, there is a significant need for the development and
implementation of systemic interventions, including family therapy, that address rela-
tional challenges within grandfamilies. Additionally, as there is no need to “reinvent the
wheel,” greater consideration should be given to how existing evidenced‐based inter-
ventions can be adapted for use with grandfamilies. While examples of these adaptations
already exist (e.g., Kirby & Sanders, 2014; NIH RePORT, 2018; N’zi et al., 2016;
Smith et al., 2016; Yancura et al., 2017), additional efforts could be made with regard
to systemically informed or family‐based interventions. Lastly, given that grandparents
often encounter insensitive or disrespectful professionals (Burnette, 1999; Gibson,
2002; Gladstone et al., 2009), clinicians working with grandparents and grandchildren
would benefit from increased training on grandfamilies and should engage in critical
self‐reflection as a way of ensuring that their biases and assumptions do not negatively
impact the families with whom they interact (Dolbin‐MacNab, 2015).
In sum, interventions with grandparents raising grandchildren have been shown to
be effective in improving grandparents’ psychological well‐being, relationships, and
overall quality of life (McLaughlin et al., 2017). However, as grandparents do not
exist in a vacuum, greater attention must be given to all members of grandfamilies so
that intervention efforts can address their individual and relational needs. Family
therapists, with their conceptual focus on relationship dynamics, intergenerational
patterns, and the influence of larger systems, along with their ability to work with
various systems and family subsystems, are particularly well suited for providing ser-
vices that can improve the lives of grandparents, grandchildren, and other members
of the grandfamily system.
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20
Family‐Based Treatment for
Runaway and Homeless Youth
Natasha Slesnick and Brittany R. Brakenhoff
Adolescents who run away from home often report running from high levels of family
conflict, lack of parental protection, chaos, parental alcohol and drug misuse, physical
or sexual abuse, and neglect (Ferguson, 2009; Tyler, 2006). In fact, estimates suggest
that up to 83% of runaways have a history of childhood trauma (Edidin, Ganim,
Hunter, & Karnik, 2012; Gwadz, Nish, Leonard, & Strauss, 2007). Further, many
youth are asked to leave or forced out of their home, and only 21% of youth are ever
reported missing by their parents (Hammer, Finkelhor, & Sedlack, 2002). Runaway
shelters report that the majority of youth residing in shelters are dropped off at the
shelter by parents, usually after a conflict. Although some youth who voluntarily leave
home access runaway shelters, research suggests that most youth avoid shelters, with
only 10% of youth in need of assistance accessing services meant for them (Kelly &
Caputo, 2007). Instead of shelters, youth seek refuge in friends’ or other family mem-
bers’ homes, in abandoned buildings, or directly on the streets. Living on the margins
of the mainstream increases the vulnerability of youth, so one high‐risk environment
is traded for another. Foster care youth and juvenile justice‐involved youth are more
likely to experience a runaway or homeless episode (Sedlack, Finkelhor, Hammer, &
Schultz, 2002). In this chapter, we provide an overview of the research literature on
runaway and homeless youth and the family‐based interventions developed and tested
on their behalf.
Definition of runaway youth

The literature notes some confusion in the definition of runaway youth and homeless
youth. The Office of Juvenile Justice and Delinquency Prevention defines a runaway
as a youth who leaves home without the permission of his or her parents or legal
guardian or is away from home or place of legal residence with permission, but does
not return home for at least one night if 14 years or younger or two nights if
15–17 years old (Sedlack, Finkelhor, & Brick, 2017). The McKinney‐Vento Act
504 Natasha Slesnick and Brittany R. Brakenhoff
(2002) defines homeless children and youth as those who lack a fixed, regular, and
adequate nighttime residence; or live in a welfare hotel, or place without regular
sleeping accommodations; or live in a shared residence with other persons due to the
loss of one’s housing or economic hardship. Technically, a homeless youth might not
have run away, as their parents might have thrown them out, or the youth was given
tacit permission to leave, perhaps due to poverty or parental substance use. Further, a
runaway adolescent might have left home for a different living situation where they
received appropriate care and supervision and would not be considered homeless.
Regardless of whether youth left home voluntarily, those who live on the streets do
not usually access runaway shelters, and some refuse to return home. These youth
often avoid child protective services, family members, and all system representatives
(Meade & Slesnick, 2002). Family reunification or family therapy is not always a
viable or appropriate intervention. In this chapter, we focus on family‐based interven-
tions for runaway and homeless youth for whom returning home or mending the
family relationship is still a viable intervention focus. In most cases, these are youth
residing in runaway shelters, as studies report that the majority of youth residing in
shelters return home (Peled, Spiro, & Dekel, 2005).
Prevalence of running away in United States

Not all runaway and homeless youth make it into the household or school surveys, so
population estimates vary widely. Recent estimates indicate that 413,000 US youth
run away or are thrown out of their home each year (Sedlack et al., 2017) and 18% of
youth run away at least once before the age of 18 (Brakenhoff, Jang, Slesnick, &
Snyder, 2015). Further, it appears that up to 2.8 million youth experience homeless-
ness in the United States (Bucher, 2008; Cooper, 2006) and 100 million worldwide
(UNESCO, 2007). Evidence suggests that the prevalence of homelessness among
rural youth is higher than among urban youth; 8% of youth in rural communities,
compared with 2% in urban communities, are homeless (Ringwalt, Greene, Robertson,
& McPheeters, 1998).
Risk factors and challenges

Youth appear to be at greater risk for living on the streets or being homeless than
adults and more vulnerable to long‐term consequences of homelessness (National
Conference of State Legislatures, 2016). That is, adolescent runaways and homeless
youth report high rates of physical and sexual assault, including intimate partner
violence, substance use (70–95%), and depression and other mental health struggles
(66–89%) (Hughes et al., 2010; Yoder, Whitbeck, & Hoyt, 2010). Up to 11% may
be positive for HIV (Rotheram‐Borus et al., 2003). High rates of school dropout,
teenage pregnancy, and premature death from homicide, untreated illness, or sui-
cide are also reported (NCSL, 2016). The range and severity of social and health
consequences associated with leaving home underscores the urgency in identifying
the best intervention strategies to prevent and end homelessness among adoles-
cents. It should be noted that in addition to the myriad of risks and problems, these
youth also possess significant resources and strengths. In some cases, leaving home
is an adaptive coping strategy to a high‐risk living environment. These youth survive
Family-Based Treatment Runaway Youth 505
outside the protection of home and family, often at young ages, and, through this,
develop high levels of resilience (Kidd & Davidson, 2007; Lindsey, Kurtz, Jarvis,
Williams, & Nackerud, 2000).
Given the role of the family in precipitating and resolving a runaway or homeless
crisis, it is important to include the family in prevention and intervention efforts when
such a focus is reasonable (Thompson, Zittel‐Palamara, & Maccio, 2004). Family
reunification and improving family interaction can be key, as running away and/or
experiencing homelessness more than one time prior to the age of 18 years appears to
be a significant risk factor for experiencing homelessness as an adult (Brakenhoff et al.,
2015). The majority of adolescents run away from home only one time (60.1%), sug-
gesting that it results in corrective efforts within the family system because a single
runaway experience does not appear to result in long‐term negative developmental
effects (Brakenhoff et al., 2015). Therefore, including the family in intervention may
have long‐term preventive effects.
Special Subgroups of Runaway and Homeless Youth
Youth involved in foster care

Youth who are in foster care are twice as likely to run away from home than non‐foster‐
care‐involved youth (Sedlack et al., 2002). Even though biological parents of foster care
youth have usually had their custody removed by child protective services due to abuse
and/or neglect (Crosland & Dunlap, 2015), many foster care youth report a desire for
continued connection to their biological family (Courtney & Heuring, 2005).
Consequently, unlike youth who are running away from their families, youth in foster
care may run away to be closer to their family members or to the friends they had prior
to being placed in foster care (Courtney & Heuring, 2005; Finkelstein, Wamsley,
Currie, & Miranda, 2004). Additionally, there is some evidence that youth placed in
foster care are less likely to run away if they can maintain a sense of connection to their
biological family. For example, youth who are placed with a sibling or other family
members are less likely to run away (Courtney & Heuring, 2005). Youth placed in
group home settings are the most likely to run away (Witherup, Vollmer, Van Camp, &
Borrero, 2005). Overall, youth often run away from foster care to return to familiar
environments in order to connect with family and friends (Courtney & Heuring, 2005),
which is different than youth not involved in foster care who run away to escape their
home environments. Further, youth in foster care may have come from families in
which they had limited rules or supervision; thus foster homes may feel overly restrictive
for youth, and youth may run away in order to regain their independence (Crosland &
Dunlap, 2015). Given that foster care youth may have different reasons for running
away, they may have unique treatment needs as well (Crosland & Dunlap, 2015).
Lesbian, gay, bisexual, and transgender (LGBT) youth

Lesbian, gay, bisexual, and transgender (LGBT) youth are overrepresented among
homeless and runaway youth (Choi, Wilson, Shelton, & Gates, 2015) and report
higher rates of substance use, HIV risk, victimization, and depression (Choi et al.,
2015; Gangamma, Slesnick, Toviessi, & Serovich, 2008). Overall, LGBT youth often
experience increased vulnerability compared to heterosexual runaway youth. Further,
LGBT youths’ family experiences and reasons for running often differ from their het-
erosexual peers, with many LGBT running away from home or being thrown out as a
result of their family’s rejection of their sexual orientation or gender identity (Durso
& Gates, 2012; Rew, Whittaker, Taylor‐Seehafer, & Smith, 2005). Recent research
has also suggested that LGBT youth were typically experiencing a high level of family
conflict prior to disclosing their sexual orientation and their disclosure exacerbated
the preexisting family conflict (Castellanos, 2016). Consequently, family interven-
tions focused on improving family communication and acceptance of youths’ sexual
orientation are needed in order to reunite youth with their families and prevent them
from becoming permanently homeless.
Unfortunately, runaway and homeless youth service providers often report insuffi-
cient family intervention services available for LGBT youth and their families (Maccio
& Ferguson, 2016). In an earlier article, Ferguson and Maccio (2015) highlight the
Family Acceptance Project (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010) as a
potential intervention that runaway service providers could use with LGBT youth and
their families. While not specific to runaway LGBT youth, the Family Acceptance
Project provides education and resources to youth who are at risk of experiencing
family rejection due to their sexual orientation (Ryan et al., 2010). Overall, families
of LGBT runaway youth will likely need targeted LGBT services that promote the
family’s acceptance of the youths’ sexual orientation and/or gender identity, as well
as traditional family therapy options, which are discussed below.
Human trafficked/sex working youth

Research has consistently shown runaway and homeless youth are at highest risk for
human trafficking, with estimates that 10–30% of runaway and homeless youth will be
trafficked or sexually exploited (Reid & Jones, 2011; Saewyc, MacKay, Anderson, &
Drozda, 2008). Although some have suggested that within 48 hr of running away, an
adolescent is likely to be approached to participate in prostitution or another form of
commercial sexual exploitation (Spangenberg, 2001), no study has supported this
claim (Clawson, 2009). Youth between the ages of 11 and 14 years are most fre-
quently targeted by traffickers, although some reports have seen children as young as
5 years old (Smith, 2008). Runaway, homeless boys who self‐identify as LGBT report
higher levels of sexual exploitation than heterosexual homeless youth (Clawson, 2009;
Saewyc et al., 2008).
Significantly overlapping with reasons for running away from home, many traf-
ficking victims report trying to remove themselves from unstable or untenable liv-
ing conditions. The trafficker may offer shelter, gifts, or even drugs in order to gain
favor and trust with the youth (Smith, 2008). In New York City, youth report that
traffickers target victims in areas where homeless youth are known to gather and
then tell them that the shelters are full and offer them a place to stay in lieu of sleep-
ing on the streets (Bigelsen, 2013). Kidnappings and recruitment have also been
linked as an entry into sex trafficking with homeless shelters being a prime target
site (Spangenberg, 2001). Many of those who accept offers from traffickers find
themselves in situations where their documents are destroyed, their families are
threatened with harm, or they are bonded by a debt they will not be able to repay
(Human Trafficking Organization, 2006). That is, commonly, traffickers will

seek exorbitant fees, such as those for transportation and housing, in order to place
victims in a position of debt bondage (Clawson, 2009).
Common Community Approaches
Runaway shelters
Runaway and homeless youth programs are authorized by the Runaway and Homeless
Youth Act (Juvenile Justice and Delinquency Prevention Act, Pub. L. 93‐415, Sept.
7, 1974, 88 Stat. 1109) (Title 42, Sec. 5601 et seq.), as amended by the Runaway,
Homeless, and Missing Children Protection Act of 2003 (Public Law 108‐96).
Runaway shelters offer emergency services for runaway youth, and if funded by the
Runaway and Homeless Youth Act, Basic Centers program must focus efforts toward
reunification with the family. Runaway shelters usually have a small number of beds
(e.g., 15–30) and allow youth to reside in the shelter from 3 days to 3 weeks. Services
can include crisis counseling and group and family intervention, though services rarely
continue after the adolescent returns home unless funding is available. Four studies
were identified that evaluated the effectiveness of shelters in alleviating symptoms
associated with the youth’s stay at the shelter, which generally concluded that shelters
have at least a short‐term positive impact in some domains, though long‐term effects
seem to dissipate (Barber, Fonagy, Fultz, Simulinas, & Yates, 2005; Pollio, Thompson,
Tobias, Reid, & Spitznagel, 2006; Steele & O’Keefe, 2001; Thompson, Pollio,
Constantine, Reid, & Nebbitt, 2002).
Transitional living programs

As runaway shelters are not usually considered the solution for ending homelessness,
and because many youth do not return home, Congress created the Transitional
Living Program for older runaway and homeless youth (16–22 years). As part of the
1988 amendments to the Juvenile Justice and Delinquency Prevention Act of 1974,
in 1990, the first transitional living program for homeless youth was funded. In 2016,
over 5,000 homeless youth participated in federally funded transitional living pro-
grams (Family and Youth Service Bureau, 2016). Transitional living programs offer
extended residential services through supervised apartments, group homes, and host
families for up to 540–635 days (Family and Youth Service Bureau, 2016). Additionally,
transitional living programs also provide services focused on teaching youth basic life
skills (money management, job skills, education attainment, etc.) and mental health
services in order to promote a successful transition to adulthood (Family and Youth
Service Bureau, 2016). While many transitional living programs receive federal fund-
ing, there is limited research on their efficacy. In 2012, the Administration for
Children and Families funded a 2‐million‐dollar study to examine the effectiveness of
transitional living programs, but results are currently unavailable. However, a recent
study examining the effectiveness of a specific transitional living program for foster
care and justice‐involved youth found that youth who participated in the transitional
living program had more successful outcomes than youth who participated in the
control condition in terms of housing stability, income earned, and mental

health problems (Valentine, Skemer, & Courtney, 2015). However, there were no
differences found between groups in terms of criminal involvement, education attain-
ment, substance use, or social support (Valentine et al., 2015). While transitional liv-
ing programs may work for some youth, they may not be well fitted for street‐living
youth. For example, most of the transitional living programs are underfunded, and
states are given the flexibility to assign rules to the housing, which are often so restric-
tive (e.g., abstinence‐based housing) that most street‐living youth cannot follow them
(Slesnick, 2014). This results in many youth not accessing transitional living programs
or being prematurely discharged.
Drop‐in centers
Some youth refuse to access runaway shelters and instead avoid the systems and its
representatives while living on the street or staying at friends or family members’
homes. Although the Street Outreach Program supports outreach programs targeting
runaway and homeless youth, funding for drop‐in centers is more limited. Drop‐in
centers are usually accessible spaces that offer basic needs such as food, showers, cloth-
ing, and washer/dryers. In order to increase engagement, programs usually have few
rules and require little from youth. Often, these centers are considered bridges
between the streets and the mainstream and are the first step toward reintegration.
Many drop‐in centers use a one‐stop‐shop model in which multiple services are
offered on‐site. This removes barriers to service engagement given that youth have
limited access to transportation and low levels of trust. Typically, on‐site services
include medical care, crisis intervention, assistance with obtaining identification cards,
government entitlements, HIV testing, job training, education, prenatal care, legal
services, and mental health/substance use intervention. Typically, unlike youth access-
ing runaway shelters, youth accessing drop‐in centers rarely reengage with family
members, and so family therapy is not usually offered by drop‐in centers.
Family as the Intervention Target
In general, a family systems approach understands running away, substance abuse, and
other individual problems in terms of interaction patterns among all family members
(Karabanow & Clement, 2004). Some intervention approaches include the family but
do not use a family systems theoretical orientation to guide targets of change. Family
systems therapy can increase the chances of success for runaway shelters as they are
mandated through the Runaway and Homeless Youth Act to reunify adolescents with
their parents (Runaway & Homeless Youth Act Title III, 1974), and therefore, most
adolescents at shelters eventually return home (Peled et al., 2005). In fact, some evi-
dence suggests that family therapy improves family interaction patterns that underlie
family conflict (Zhang & Slesnick, 2018) and eases the transition of adolescents back
into the home, reducing future runaway experiences (Slesnick & Prestopnik, 2005).
Significant improvements in substance use, behavioral problems, and mental health
have been observed among runaway adolescents and families receiving family therapy
(Slesnick, Erdem, Bartle‐Haring, & Brigham, 2013; Slesnick & Prestopnik, 2009). In
summary, integrating family therapy interventions with the services of runaway

shelters can facilitate the success of shelters’ mission to reintegrate and support family
reunification as well as ameliorate ongoing individual and family struggles. Family
interventions should be initiated within a shelter to ease the transition of the adoles-
cent back home and continue once the adolescent has returned home.
Family‐based interventions
Conflict and problems within the family system are common among youth who run
away from home (Ferguson, 2009; Tyler, 2006). Thus, including families in interven-
tion is often recommended when working with runaway youth (Pergamit, Gelatt,
Stratford, Beckwith, & Martin, 2016). Given that most youth will return to their
family, it is important that the whole family receive treatment in order to prevent
future runaway episodes (Milburn et al., 2007; Peled et al., 2005). However, some
youth may be unwilling or unable to return home for various reasons, such as if the
youth has experienced severe abuse or if the family lacks the financial resources.
Furthermore, some youth are forced out of their homes and parents may be unwilling
to let the youth return. Overall, prior to working toward reunification, the therapist
should first assess and ensure it would be safe for youth to return to their family.
Nonetheless, even when youth may not be able to return home, it may still be benefi-
cial to use family‐based interventions to help foster connections between youth and
their family or other supportive adults (Pergamit et al., 2016). Overall, it is likely that
youth will do better if they are connected with others and have access to a support
system (Johnson, Whitbeck, & Hoyt, 2005; Milburn et al., 2009). Consequently,
when possible, focus should be on reconnecting youth with their family, but if family
is not a viable option, then efforts should be made to help youth develop a support
system from friends and professionals (Pergamit et al., 2016).
Various family‐based interventions have been implemented with runaway and
homeless youth and their families. A recent review identified 49 potential family inter-
ventions for runaway and homeless youth and evaluated the evidence base for availa-
ble interventions; however, the majority of identified interventions have not been
tested with runaway or homeless youth (Pergamit et al., 2016). Functional Family
Therapy (FFT) and Ecologically Based Family Therapy (EBFT) were the only inter-
ventions that have been rigorously tested with runaway youth enough to be identified
as evidence‐based interventions. Four additional interventions that have less evidence,
or have not been tested with runaway youth, were identified as evidence‐informed
interventions. Support to Reunite, Involve, and Value Each Other (STRIVE) has
been tested with runaway youth, but to date only one clinical trial had been com-
pleted. The other three interventions—Multisystemic Therapy (MST),
Multidimensional Family Therapy (MDFT), and Treatment Foster Care Oregon—
have not been implemented with runaway youth, but have been rigorously tested
with youth involved in the child welfare or juvenile justice system. Pergamit and col-
leagues (2016) identified an additional 43 potential family interventions, but evi-
dence for those interventions was limited, and the majority of the interventions were
designed for youth involved in the child welfare and/or juvenile justice systems and
had not been specifically tested with runaway youth. Given the overlap between runa-
way youth and youth involved in the child welfare or juvenile justice systems, it is
likely that interventions for those populations may be applicable to runaway youth as
well. However, for the purposes of this chapter, only studies that have been tested
with runaway youth will be discussed. The majority of the evidence‐informed inter-
ventions share a similar background in family systems therapy; thus there is overlap in
many of the core principles of the interventions.
Functional Family Therapy FFT is a widely implemented family system intervention

that uses behavioral techniques and has shown promise with runaway youth, as well
as other high‐risk youth populations (Pergamit et al., 2016). In a trial targeting runa-
way youth, families were provided with 12 sessions over a 3–6‐month time period
(Slesnick & Prestopnik, 2009). The initial focus of FFT is to engage families by pro-
moting a positive family environment by reducing family conflict and hostility.
Maladaptive behaviors, such as running away from home, are thought to have func-
tion within the family system. Thus, therapists seek to identify the function of the
identified problem and develop alternative solutions to the problem. Studies testing
FFT typically report that participation in FFT is associated with improved family func-
tioning and reductions in adolescent substance use (Slesnick & Prestopnik, 2009;
Waldron, Brody, & Slesnick, 2001).
Ecologically Based Family Therapy Slesnick and colleagues tested a family systems
approach, EBFT, with alcohol and/or drug using shelter‐recruited adolescents and
their family members (Slesnick & Prestopnik, 2005; Slesnick & Prestopnik, 2009).
Over a six‐month period, 12–16 sessions are offered in the home. Additionally, a
broader systemic framework involving support systems outside of the family is incor-
porated into the intervention. The studies were designed to compare EBFT to ser-
vices as usual through the runaway shelter and were the first efforts to test add‐on
services that focus on treating substance use and family functioning among shelter‐
recruited adolescents and their families (Slesnick & Prestopnik, 2005; Slesnick &
Prestopnik, 2009). In both trials, conducted in New Mexico, those assigned to family
therapy showed significant improvements compared to treatment as usual (TAU)
through the shelter. Adolescents showed improvements in family (conflict and cohe-
sion) and individual functioning (depressive symptoms and externalizing problems).
In the first trial with primary drug‐abusing adolescents, EBFT showed significantly
greater reductions in substance use even at 1 year posttreatment compared with those
assigned to TAU through the shelter (Slesnick & Prestopnik, 2005). The second trial
compared home‐based EBFT with office‐based FFT for primary alcohol problem
adolescents (N = 119) and their primary caretakers (Slesnick & Prestopnik, 2009). In
this study, the impact of family therapy (both home and office based) was especially
pronounced on alcohol use. Youth assigned to home‐based EBFT showed a 97%
decline in days of alcohol use (83% decline for office‐based FFT) and a 77% reduction
in number of standard drinks consumed on drinking days (64% for FFT) at 15 months’
post‐intake. This compares to youth assigned to TAU who showed a 59% reduction
in days of alcohol use and virtually no change in number of standard drinks consumed
on each drinking day. The findings suggest that family therapy has a strong impact on
reducing alcohol and drug use, as well as improving individual and family functioning,
compared to services provided through the shelter.
More recently, in a randomized clinical trial, Slesnick, Erdem, et al. (2013) com-
pared EBFT to individual treatments, the Community Reinforcement Approach
(Meyers & Smith, 1995) and motivational interviewing (Miller & Rollnick, 2002),
and found that all three interventions were effective at reducing adolescents’ s ubstance
use. In this trial, the treatment effects observed for substance use and behavioral
problems lasted longer for runaway youths receiving EBFT compared with those
receiving individual treatment (Slesnick, Erdem, et al., 2013; Slesnick, Guo, & Feng,
2013). Moreover, family functioning—in particular conflict and cohesion—improved
more for families who received EBFT compared with those who received individual
treatment (Guo, Slesnick, & Feng, 2016). Family therapy also improved outcomes
among other family members as caregivers of runaway adolescents demonstrated
reductions in depressive symptoms when they attended family therapy together (Guo,
Slesnick, & Feng, 2014). These studies provide evidence for the superior effects of
family therapy compared to nonfamily comparison interventions.
Support to reunite, involve, and value each other Milburn and colleagues (2012)
developed a family intervention, STRIVE, that focuses on improving family problem‐
solving skills and reducing family conflict among families of younger youth who
recently became homeless, but had the option and desire to return home. STRIVE
consists of five family sessions that utilize cognitive‐behavioral techniques that take
place in a setting selected by the family (typically their home). Running away is framed
as an ineffective solution to family conflict; thus the intervention focuses on providing
families with effective conflict resolution and problem‐solving skills and creating a
more positive family environment. Families are taught new skills through semi‐struc-
tured tasks in which the families practice the new skill and the therapist provides
feedback. Outcomes measured by STRIVE include sexual risk behaviors, drug use,
and delinquent behaviors. Findings for the intervention are promising and show that
participation in STRIVE is associated with a reduction in youth’s number of sex part-
ners, youth’s use of hard drugs and alcohol (but not marijuana), and youth’s delin-
quent behaviors. However, while STRIVE sessions focused on reducing family conflict
and increasing family problem‐solving skills, the study did not report outcomes for
those measures, so the impact of the intervention on these family variables is unclear.
Eva’s initiative’s family reconnect program Eva’s Initiative’s Family Reconnect

Program is another family intervention that has shown some promise at improving
family relationships (Winland, Gaetz, & Patton, 2011). This program is implemented
in shelters in Toronto, Canada. The focus of the program is to help youth reconnect
and improve their relationships with their families by providing individual and family
counseling to both the youth and their family members (Winland, Gaetz, & Patton,
2011). The goal of the program is to improve family relations so that the youth can
return home. However, the program recognizes that moving home may not always be
a goal or option for the youth or the family, and in those cases, youth are supported
as they transition to independent living. An evaluation of the program showed that
the number of family interactions increased among 62% of the youth who participated
in the program, 14.5% of youth reconciled a damaged relationship, and 17% of the
youth were able to move home with their family (Winland et al., 2011). Participants
also reported improvements in their housing situation, employment, social relation-
ships, financial management, self‐care skills, and mental health (Winland et al., 2011).
Minnesota Runaway Intervention program The Minnesota Runaway Intervention

program (RIP) was identified as an emerging intervention that targets improving
family relationships (Edinburgh & Saewyc, 2009; Pergamit et al., 2016). This
intervention was developed specifically for runaway girls between the ages 12 and 15
years who had been sexually abused. RIP provides up to 12 months of home visiting,
health care, health education, and case management by advance practice nurses and
facilitates access to an optional weekly girls’ empowerment group conducted by a
licensed psychotherapist. Saewyc and Edinburgh (2010) found that family connected-
ness improved at 6 months’ post‐baseline, but not at 12 months’ post‐baseline. School
connectedness improved at both 6 and 12 months. RIP girls also showed reductions
in emotional distress, suicidal ideation, alcohol use and smoking, and sexual risk
behaviors at both 6 and 12 months’ post‐baseline. However, although promising, no
comparison group was used in the study, so it is not possible to conclude that the
changes were a result of the intervention.
Functional analysis‐youth interactive tool While family therapy may not be possible
for all youth involved in foster care due to restrictions on their contact with parents,
family may still play a key role in preventing their running away behavior (Crosland &
Dunlap, 2015). Clark and colleagues (2008) developed a behavioral intervention for
runaway foster care youth that focuses on identifying the function running away
serves for each youth called the Functional Analysis‐Youth Interactive Tool (FA‐YIT).
After the function of running away is identified, individual plans are developed for
youth to find alternative ways to meet the needs served by running away. For example,
youth who were running away to reestablish contact with their family of origin were
provided with more visits or phone calls with their family members. Youth who par-
ticipated in the FA‐YIT intervention reported significantly reduced time running
away posttreatment compared with youth who participated in the control.
Consequently, in cases where youth want a connection with their family of origin and
family therapy is not a viable option, maintaining some connection with their family
when appropriate may prevent youth from running away (Crosland & Dunlap, 2015).
Overall, few interventions have been developed and tested for runaway and homeless
youth and their families. Family systems therapy reconnects families to underlying bonds
of love and care and guides families toward considering problems in terms of the relational
system rather than as a result of individual deficiencies. As such, family therapy addresses
many of the risks associated with running away. It has the potential to resolve the current
runaway crisis and prevents future runaway crises. As therapy involves all family members,
the benefits of family therapy include improved interaction behaviors and individual func-
tioning among siblings and parents, in addition to the runaway adolescent. Though family
systems therapy is not always offered by community‐based programs, the time and cost of
additional training and supervision is likely offset by the benefits observed for individuals,
families, and society (Morgan, Crane, Moore & Eggett, 2013).
General Recommendations for Intervention
Engagement of the adolescent and family

Families of youth who have runaway are often difficult to engage. These families often
experience multiple stressors, such as conflict, financial strain, and substance use.
Consequently, family therapists will need to focus on strategies to improve engagement
of runaway and homeless adolescents and their parents. In consultation with the youth
and family, therapists can utilize a broad definition of family, engaging those with influ-
ence on the youth and other family members, as well as extended family members.
Anecdotally, adolescents are more easily engaged in family therapy than the parents,
possibly because some research suggests that adolescents identify improved relation-
ships with parents as a primary goal when residing in a runaway shelter (Teare, Furst,
Peterson, & Authier, 1992). Adolescents may be vehement about not needing therapy,
but most adolescents are open to the idea of having an advocate or ally who can help
them negotiate better communication and a better relationship with their parents. The
therapist empowers the adolescent by allowing him or her to decide whether to pro-
ceed, and by presenting the therapist as their ally, and at their service.
The parents or primary caretakers of the adolescent have often already experienced
multiple interventions through various agencies. In many cases, the parents report
that these experiences were not positive because they were blamed for the problems
in the family, or they were not helped by the services. Parents might be reluctant to
participate in family therapy given their own alcohol or drug problem, which can
include fear of judgment or fear that their child will be removed from their custody
by the state, lack of motivation for change, and marital or financial stressors. Some
parents assert that their child is to blame for the problems and do not see their role in
the therapy process. In order to overcome these barriers, the therapist must reduce
defensiveness by stating that treatment is non‐blaming and by stressing that his or her
child needs and wants help. The therapist should not challenge parents at the engage-
ment phase and instead can focus on the importance of their perspective in the ther-
apy sessions in order to maximize positive outcomes. If engagement of the parent or
adolescent fails, individual meetings with the adolescent and their family members can
provide an opportunity to continue the negotiation process until the family is ready
to meet together (Cully, Wu, & Slesnick, 2018).
Family therapy techniques

The majority of the family interventions that have been identified as evidence based
or evidence informed for runaway youth are based on family systems therapy (Pergamit
et al., 2016). Further, many family therapies utilize similar techniques, as well as a
similar underlying theory of change. Given this similarity, a set of principles to guide
treatment based upon the family systems framework has been recommended (Dattilio,
Piercy, & Davis, 2014). Central to most family systems therapy is that the presenting
problem, such as running away from home, is a symptom of the entire family system
rather than one individual family member (Broderick, 1993). Usually, family thera-
pists seek to shift family members’ thinking to consider problems as residing between
rather than within individual family members. Techniques to create this shift in focus
on blaming the individual involve helping family members interpret people and events
in a more positive or new way. Reframes and relabels offer a less negative view of a
behavior. For example, in response to a father’s statement that his son has an anger
problem, the therapist might suggest that the son loses his temper because he cares so
much and does not know how to make sure that his dad hears him. Another tech-
nique seeks to increase empathy through perspective taking. With greater empathy,
family members are less likely to blame other family members for problems in the
family and to see them more as victims rather than perpetrators. For example, in order
to draw attention to the impact of the adolescent’s name‐calling toward the mother,
the therapist might say, “When you call your mother lazy, how do you think she
feels?” The therapist also seeks to draw attention to relational patterns within the fam-
ily so that family members see that their behaviors influence other members in the
family. For example, in response to a description by a father that he separates himself
from his wife and son when at home, the therapist can query, “I wonder if you isolate
yourself because you are fearful of being hurt by others in the family?” This then
removes the father from blame and offers a relational perspective on his behavior.
Helping families identify the role the presenting problem plays in their family
system is another way to help families shift blame from the individual. Therapists
focus on the function of the symptom within the family system, which prevents
responsibility or blame being placed on any one individual within the family.
Additionally, therapists often reframe the family’s perception of the problem by
helping them understand the role it plays in their family. Many family system therapies
assume behaviors that families are presenting as negative or unwanted are often
serving a function to the family system. For example, families may identify the youth
running away as a negative or crisis event, but for some families the runaway event
may also have positive benefits such as distracting the parents from marital conflict, or
it may be a way for youth to alleviate stress by removing themselves from the family
system. Running away and other risk behaviors will serve different functions in differ-
ent family systems, so it is important for the therapist to explore the context of the
family system to determine the unique function of the behavior. Helping families
identify what happens prior to and after the youth runs away or engages in the identi-
fied problem behavior can help determine the function it is serving in the family. Once
the function of the behavior has been identified, it is then possible to help families
identify more positive behaviors to replace the unwanted behavior.
Early family therapy sessions ultimately seek to reconnect family members with
underlying love and care, which can open the way for change. For some families, these
feelings become buried over time given lengthy experiences of pain and/or perceived
betrayal and rejection. The therapist focuses on the relationships among family mem-
bers, improving ineffective communication, and helping family members see how
they meet emotional and interpersonal needs through the use of ineffective strategies
or behaviors (Cully, Wu, & Slesnick, 2018). When family members begin to under-
stand problems as residing in family interaction, they are more open to learning and
implementing problem‐solving and communication skills to resolve conflicts (Cully
et al., 2018). Later in therapy, the focus shifts to changing family interaction patterns
that can include learning and implementing problem‐solving and communication
skills to resolve conflicts and better meet interpersonal needs.
Conclusions: Policy Recommendations and Future Directions
Given that number of runaway episodes is a risk for homelessness in young adulthood,
providing effective family therapy interventions to runaway adolescents and their fami-
lies can be an important step toward preventing future homelessness (Brakenhoff et al.,
2015). Integrating family therapy interventions with runaway shelter programming also
fits with their mission to reunify adolescents with their families. While shelters typically
provide crisis counseling, including with family members, only while the adolescent
resides in the shelter, funding to offer family therapy following youths’ reunification
with the family has been recommended (NAEH, 2012; Slesnick & Prestopnik, 2009).
In general, family therapy provided to those seeking services through the health‐care
system has reduced future service utilization (Morgan, Crane, Moore, & Eggett, 2013).
Morgan and colleagues (2013) also provide evidence supporting family therapy as hav-
ing greater cost benefits than individual therapies. The greater benefits to individuals
and families justify the greater training requirements and costs associated with offering
family therapy.
Future research
The need for effective family interventions for runaway youth and their families is well
documented in the literature. In practice, most service agencies recognize the impor-
tance of including families as well (Pergamit et al., 2016). However, there are few
rigorous studies examining interventions for this vulnerable population, so service
providers have little guidance when selecting interventions to implement. Clearly,
more research is needed to develop best practices for runaway youth and their families
(Pergamit et al., 2016). FFT and EBFT have both shown promise when working with
runaway youth. Further, several effective family systems interventions have been
developed for at‐risk youth populations that overlap with runaway youth, such as
youth involved in the juvenile justice and the child welfare system (Pergamit et al.,
2016). Many of these interventions are rooted in family systems therapy and share
similar underlying principles and guidelines. Consequently, rather than developing
new interventions, it may be beneficial for future research to continue to examine the
key components of existing interventions that are needed to most effectively treat
runaway youth and their families.
While the majority of runaway youth return home, there is a risk that some runaway
youth will become part of the homeless youth population (Milburn et al., 2007;
Sedlack et al., 2002). A single runaway episode is not predictive of future homeless-
ness, but multiple runaway episodes are associated with an increased risk of experienc-
ing homelessness as a young adult (Brakenhoff et al., 2015). Once homeless, youth
experience additional risks. Understanding ways to prevent youth who run away from
home from becoming disconnected from their families and society is important, but
studies typically do not track these outcomes long term. Thus, future research should
examine long‐term outcomes of interventions and track runaway episodes and home-
lessness over time.
Future research should also engage non‐service‐connected youth. The majority of
the extant research focuses on samples engaged through shelters and drop‐in centers,
even though evidence suggests that less than 10% of runaway and homeless youth
access community resources meant to serve them (Kelly & Caputo, 2007; NAEH,
2012). Therefore, current studies have tested interventions with service‐connected
youth, and there is a void of intervention development for those youth in most need
of assistance. That is, service‐disconnected individuals are different from those who
already access services, having more unmet needs and more severe substance use and
mental health problems, possibly because of social exclusion and low self‐efficacy
(Kryda & Compton, 2009; Sowell, Bairan, Akers, & Holtz, 2004).
Complex problems often require multicomponent solutions addressing structural

as well as individual risks. Although high numbers of runaway youth exist, few family
interventions have been rigorously tested, and interventions are not available or effec-
tive in preventing runaway behavior because we do not yet understand the underlying
mechanisms and/or how to prevent their consequences. Studies identifying mediat-
ing factors associated with change allow researchers and practitioners to know how
and why interventions work and clarify the connection between the intervention
activities and the outcomes—even across multiple interventions (Kazdin, 2007).
Understanding the process of change allows one to better optimize outcomes and to
extend the intervention from more controlled settings to the “real world” (e.g., mul-
tiple cities and countries). In order to optimize the generality of any intervention, we
must understand what is needed to make the intervention work and what compo-
nents must not be diluted to achieve change (Kazdin, 2007). Without a menu of
effective interventions or identified predictors of success or failure, training therapists
on best practices is difficult. Further, to our knowledge, we do not yet know how to
predict whether a child with multiple risk factors will run away from home. However,
we know that high levels of parent–child conflict, low levels of parental protection,
parental alcohol/drug use, and childhood abuse are common threads among most
adolescents who run away from home (Ferguson, 2009).
Finally, this chapter reviewed several subgroups of runaway youth. In recognizing the
diversity of youth—that not everyone will respond in the same way to an intervention,
estimating differences in intervention response by potential moderating factors such as
youth’s age, sex, race/ethnicity, sexual orientation, and history of childhood abuse not
only recognizes the complexity of behavior but also provides important insights for
intervention. If subgroups respond differently to the intervention, guidance will be
available for adjusting the intervention for different groups, which is necessary informa-
tion for generalizability of the intervention and broad‐based dissemination. Currently,
we know very little about how subgroups respond to intervention.
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21
Helping Children in Divorced
and Single‐Parent Families
Scott C Huff and Jaimee L. Hartenstein
Although the term family may represent a number of types of family forms and struc-
tures and has been a subject of regular revision and change (Coontz, 1992), there is
often an assumption that family forms that deviate from the two biological parent
nuclear family are naturally deficient. Ahrons (1994) noted the pejorative language of
“broken homes” used in the United States, and similar stigmas exist for divorced
families internationally (e.g., Parker & Creese, 2016). From the outset of this chapter,
we consider it important to emphasize that divorce and its effects on children is a
complex phenomenon with many idiosyncratic and systemic effects. While divorce
and subsequent single parenthood often create risk factors for both parents and chil-
dren, a presumption of negativity is hardly warranted by the literature. In reality,
divorce may be a positive experience and source of growth for some, especially when
the divorce removes children from highly conflictual situations (Amato, 2010; Amato,
Loomis, & Booth, 1995; Hetherington, 2006; Morrison & Coiro, 1999). This chap-
ter presents risk factors and therapeutic opportunities for practitioners working with
children of divorced families, but recognition of individual differences and systemic
interactions will naturally be necessary to treat such families effectively.
Overview of divorce and risk factors for children

In the United States it is estimated that 50% of first marriages and 60% of second mar-
riages end in divorce (Copen, Daniels, Vespa, & Mosher, 2012). This translates into
a large number of children being affected by their parents’ divorce. In 2008, for
example, approximately 1.2 million children experienced the divorce of their parents
(Kreider & Ellis, 2011). In the United States, an estimated 23% of households are
single‐mother headed, representing the second most common family arrangement for
children (US Census Bureau, 2017). Even in the case of increasingly common shared
parenting arrangements (Nielsen, 2018a), this likely results in significantly less time
522 Scott C Huff and Jaimee L. Hartenstein
with at least one parent and likely both parents. Children in this situation may experi-
ence a sense of loss of their parent and general emotional distress at the changes they
are experiencing (Harvey & Fine, 2010).
In the months following parental divorce, children will often experience a variety of
emotional and behavioral problems (Amato, 2010; Harvey & Fine, 2010; Maes, De
Mol, & Buysse, 2012). On average, children from divorced families are less socially,
emotionally, and academically well adjusted compared with children in non‐divorced
families (Amato, Kane, & James, 2011; Bernardi & Radl, 2014; Hetherington, 1993;
Weaver & Schofield, 2015). These effects may stem from a variety of factors directly
and indirectly related to the divorce. For example, a poor co‐parental relationship
(before and after the divorce) may reduce paternal involvement and parental function-
ing while also leading to greater court involvement (Pruett, Williams, Insabella, &
Little, 2003; see also Macie & Stolberg, 2003). Each of these and related effects may
then have negative consequences for children. Similarly, children may be experiencing
fear of abandonment (Wolchik, Tein, Sandler, & Doyle, 2002), grief and loss
(Wigginton, 2017), loyalty conflict (Maccoby, Buchanan, Mnookin, & Dornbusch,
1993; Macie & Stolberg, 2003), and other emotions that may negatively affect their
current and future functioning.
A family’s movement from a two‐parent to a binuclear or single‐parent household
may be accompanied by significant decreases in standard of living for mothers (Amato,
2000; Duncan & Hoffman, 1985; McLanahan, Tach, & Schneider, 2013). Recent
scholarship suggests the typical income loss for women has been reduced over the past
several decades and partially because mothers are generally effective at using public
safety nets to mitigate the negative consequences of the lost income (Tach & Eads,
2015). When income loss is a factor, it may represent a loss of educational and devel-
opmental opportunities for the children. When children are already stressed from
poverty or other difficulties, divorce may represent a compounding effect on negative
outcomes (Cherlin et al., 1991; Mclanahan & Jacobsen, 2015).
Divorce may also have long‐term consequences for children’s adjustment and
future relationships. Amato (1996), for example, found that younger children whose
parents divorce go on to have a 60% higher risk of divorce. Children age 13–19 still
had a 23% greater likelihood of divorce as adults. These risks may stem from emo-
tional responses to divorce including anger, jealousy, irritation, and critical view of
others. Adult children of divorce are likewise at greater risk of decreased psychological
functioning and poorer relationships (Amato, 2010; Barrett & Turner, 2005;
Wolfinger, Kowaleski‐Jones, & Smith, 2003).
Mitigating factors
In spite of the negatives and risk factors discussed, there is also evidence for mitigating
and positive effects from divorce. Most notably is that for many children and families,
the distress and turmoil of the divorce diminishes and the family stabilizes, resulting
in improved emotional outcomes for children compared to the immediate aftermath
of the divorce (Amato, 1994, 2001; Hetherington, 1999; Kelly & Emery, 2003).
Likewise, divorce will not affect all families and children in the same way. Hetherington
(1989, 1991), for example, suggested that children with high intelligence, high self‐
esteem, an internal locus of control, and a good sense of humor are more likely to
Children and Divorce 523
weather their parents’ divorce well based on their ability to adapt to new situations
and evoke positivity and support from others (Hetherington, 1989, 1991).
Divorce may also represent a positive experience for children in specific situations.
When divorce disrupts a highly conflictual relationship, for example, child outcomes
may improve or at least not continue along negative paths (Amato, Loomis, & Booth,
1995; Behrman & Quinn, 1994; Hetherington, 1999; Morrison & Coiro, 1999).
Divorce has even been suggested as a potential benefit for children generally. While
the risk of negative parentification in single‐parent households needs to be acknowl-
edged (Minuchin, 1974), children whose parents divorce have an opportunity to
mature and learn valuable relationship and life management skills (Arditti, 1999;
Demo & Fine, 2010; Tashiro, Frazier, & Breman, 2006). Demo and Fine (2010)
suggest that children of divorce may likewise have clearer life goals and a greater abil-
ity to empathize with others in difficulty.
Therapy for Children of Divorce and Goals of Treatment
When conceptualizing and treating children of divorce, it is essential to pay careful

attention to the systemic principles at play. While children are certainly affected by
divorce, particularly conflictual divorce, the appropriateness of treatment focusing on
the children should be carefully evaluated. Clinicians and other stakeholders must
recognize that children’s reactions to divorce are ongoing and constantly interacting
with the current relationship between their parents (Hess & Camara, 1979). Thus,
treatment focused primarily on the child, without attending to parental problems and
interactions, is almost certainly going to be misguided.
This chapter approaches the care of children following divorce from two angles:
child‐focused interventions and parenting interventions. Children may be experiencing
feelings of loss, emotional distress, and general dysregulation as the nurturance and
structure that they have been receiving from their parents is disrupted (Amato, 1993;
Wigginton, 2017). Individual, group, and broader systems interventions are discussed
to help children navigate the emotional landscape. Parents, meanwhile, may be experi-
encing decreased efficacy in their lives in general and difficulty navigating new roles as
unmarried co‐parents (Madden‐Derdich, Leonard, & Christopher, 1999; Wallerstein &
Kelly 1980). These difficulties are taking place in the midst of working through impor-
tant co‐parenting decisions including arranging custody, visitation, and child support
and managing reactions of their children, extended family, and friends. Interventions
discussed include psychoeducational groups, individual approaches to increase parental
efficacy, and conjoint therapy to help parents be more effective co‐parents.
Although it is a somewhat nebulous term, the “best interests of the child” often
prevails as the legal and therapeutic guide to divorce resolution efforts. Without nec-
essarily getting into the broad legal ramifications of this standard, Lee (2006) pro-
vides a valuable overview of major efforts that therapists and other helping professionals
can focus on as they make decisions and intervene on behalf of the child. These
include a focus on protecting children from harm, allowing them to operate in their
current developmental role without adult responsibilities, encouraging them to have
relationships with both parents and extended family, and providing general stability in
their lives. Though the many mitigating factors of divorce prevent each of these goals
being reached simultaneously (e.g., a child’s relationship with an abusive parent

should be carefully controlled to protect the child, which may limit his ability to have
a close relationship with that parent), therapists can use these general principles as
starting points in developing interventions for families.
Child‐Focused Interventions
Group interventions
The best‐studied area of intervention with children of divorce is divorce‐focused
group therapy, generally based in schools (Lee, Picard, & Blain, 1994; Rose, 2009;
Yauman, 1991). Stathakos and Roehrle (2003) conducted a meta‐analysis demon-
strating that such programs typically have positive results, showing a moderate effect
size and stable improvements over time. Their partial meta‐analysis of specific ques-
tions may provide insights into broader principles for intervening with children of
divorce. For example, the strongest effect sizes were found for groups focusing on
9‐ to 12‐year‐old children, though this should be viewed in light of lacking groups for
older children. Groups focused on helping earlier in the divorce process (operational-
ized as less than 30 months since the divorce) were also significantly more helpful.
Finally, group leaders having significant training in divorce and the method used were
predictive of better outcomes.
Group treatment also provides suggestions on primary goals for treatment. As an
example, the Children of Divorce Intervention Program (Alpert‐Gillis, Pedro‐Carroll,
& Cowen, 1989; Pedro‐Carroll, 2008) includes five main goals: building a supportive
group environment, understanding and expressing divorce‐related feelings, under-
standing divorce‐related concepts, learning problem‐solving skills, and building posi-
tive perceptions of self and family. These concepts are similar in most other groups
focused on children’s adjustment to divorce, including in international settings
(Pelleboer‐Gunnink, Van der Valk, Branje, Van Doorn, & Deković, 2015; Zubernis,
Cassidy, Gillham, Reivich, & Jaycox, 1999).
Though focused on groups, these insights likely have application to individual and
family work as well. Based on the conceptualization of children struggling in divorce
due to loss and separation as well as potentially feeling caught between battling par-
ents, the goals and insights here are a natural fit. Specifically, recommendations for
therapists working directly with children might include:
• Learn about the divorce process and assist children to understand it. This includes
challenging common misconceptions of divorce.
• Guide children to develop practical strategies and learn skills to manage specific
stressful situations.
• Help children find connections to others who are in similar situations.
• Allow children space to feel and process their emotions. This especially includes
feelings of guilt and blame.
• Recognize that children may be experiencing grief and need skills to manage their
feelings without avoiding them.
• The methods typical of groups (role‐plays, didactic teaching, homework) are
likely to be more helpful for older children.
In terms of critique, it is important to recognize that while these programs demon-

strate general efficacy, connections between specific methods or components of pro-
grams and outcomes has not been established. Highlighting this, Delucia‐Waack and
Gellman (2007) attempted to demonstrate that using music therapy techniques in
divorce support programs would produce better results. They concluded, however,
that the groups were equally effective, regardless of use of music. Similarly, it is nota-
ble that adaptations of non‐divorce specific programs are also effective in producing
similar results. Short (1998), for example, made adaptations to a program focused on
stress management and preventing alcohol abuse by including material focused on
coping with family conflict. He reported results of improved self‐esteem and prob-
lem‐focused coping and decreased anxiety, similar to other child‐focused divorce
group interventions. Taken together, these studies serve as a reminder that caution
should be exercised in trying to explain why the group interventions are effective.
Systems connections
An additional frequent consideration in working with children in divorce situations is
to make deliberate efforts toward building connections to other systems, notably
extended family. Everett (2006), for example, suggests that grandparents, aunts,
uncles, or other close family members can help provide nurturance and physical care of
children when divorce has diminished a parent’s emotional and financial resources (see
also Chase‐Lansdale, Gordon, Coley, Wakschlag, & Brooks‐Gunn, 1999). Naturally,
such efforts presume that extended family members are not themselves engaging in
“tribal warfare” against one of the parents and will simply be supportive of the children
(Johnston & Campbell, 1988; Lebow & Rekart, 2007). When distances preclude
direct contact, technology or other creative solutions may still allow them to connect
and provide support (Everett, 2006). Extending beyond the family system, school‐
based counselors have been advised to coordinate with teachers when working with
children of divorce (Connolly & Green, 2009). Other therapists would be well advised
to similarly connect with important and supportive adults in children’s lives.
Focusing on adolescents specifically, peer support consistently emerges as an impor-
tant consideration. Ehrenberg, Stewart, Roche, Pringle, and Bush (2006) surveyed
adolescents on their preferred sources of support in the event of parental divorce
through open‐ended surveys. Peer support came through as the second best place for
teens to get help and the most likely to support teens accessing the support they need.
This is consistent with general studies of adolescent help seeking that find preference
for support from peers and family over teacher and helping professionals (Boldero &
Fallon, 1995). Teja and Stolberg (1993) strengthen these conclusions. They surveyed
parents, teachers, and teenagers and found that for all three groups, ratings of peer
support predicted better adolescent adjustment. However, teenagers from divorced
families were at greater risk of having less peer support. Here again, one of the most
important efforts may be for therapists to help teenagers to connect with others.
Individual interventions
Given the importance of systemic efforts with children going through divorce, it is
perhaps appropriate that it is more difficult to find literature on working with children
individually following parental divorce. Indeed, there is some evidence that therapy
with children whose parents are divorcing should be approached with caution. In
some cases of contact refusal, Johnston and Goldman (2010) found that resistant
youth that were forced to attend therapy were later resentful. In fact, when parents
gave space to the adolescents and did not force them into therapy, the adolescents
often spontaneously repaired their relationships. Though the effect was small,
Ehrenberg and colleagues (2006) found that youth that had been through their par-
ents’ divorce were significantly less likely to endorse a helping professional as a valu-
able support through divorce.
In treatment, therapists may be able to help with a wide variety of problems that
children of divorce may face. Returning to the value of peer and family support, thera-
pists may be able to help teenagers better access that support. Teenagers report that
emotional flooding and denial are likely hindrances to seeking help (Ehrenberg et al.,
2006). Therapists may therefore help teenagers develop emotion regulation skills to
better connect with additional treatment and with peer support (Linehan, 2014). As
needed, therapists can help teenagers to develop needed social skills to connect effec-
tively with peers.
Specific symptoms and experiences of children can be approached with related
techniques. When children’s reactions may be characterized as grief and loss
(Wigginton, 2017), developmentally appropriate techniques can be used. Scaletti
and Hocking (2010), for example, suggest helping children to develop stories or to
use sandtray techniques for grief counseling generally, especially, perhaps, for young
children (Lebow & Rekart, 2007; Lee, Johari, Mahmud, & Abdullah, 2018). In the
context of divorce, these techniques may be helpful in allowing children to process
their emotions and develop new understandings (Everett, 2006). Likewise, self‐
blame is a common risk factor for children of divorce that is connected to a variety of
subsequent negative outcomes (Goodman & Pickens, 2001; Healy, Stewart, &
Copeland, 1993). Cognitive‐behavioral approaches stemming from trauma treat-
ment have been proposed and validated to help with self‐blame, including relaxation
techniques, thought replacement, and positive self‐talk (Cohen, Mannarino, Berliner,
& Deblinger, 2000).
A common suggestion in working with children of divorce of a variety of ages is to
use books and other media to teach about divorce and process the emotions associ-
ated with it. Bibliotherapy may use nonfiction books to educate and teach or fictional
accounts to help process specific emotions (Pehrsson & McMillen, 2005). More
recent efforts have also considered the use of movies to process emotions (Marsick,
2010). Unfortunately, empirical evidence for such interventions is limited (Pehrsson
& McMillen, 2005). Nonfiction books associated with the cognitive‐behavioral style
of bibliotherapy are typically found to be more helpful than the use of fictional books
associated with the psychodynamic style of bibliotherapy (Pardeck & Pardeck, 1993).
Clinicians interested in using media to work with children may be advised to con-
sider Eğeci and Gençöz’s (2017) findings regarding the use of movies to help with
relational difficulties in children. They found that the value of cinematherapy came in
discussions with clients, not the simple viewing of media. Marsick (2010) likewise
characterized movies as a catalyst to increase sharing about divorce‐related feelings.
She further noted the value of interactive viewing with clients, as opposed to having
clients read or view material between sessions and report back during the following
session. Unfortunately, neither study looked for changes in behavior outside of ther-
apy beyond sharing the plot of the movie with someone else.
Parenting Interventions
Maintaining parental effectiveness

Part of the difficulties faced by children during and following the divorce process is
the decrease in parental effectiveness (Amato, 1993; Wallerstein & Kelly, 1980).
During and following a divorce, parents face a variety of psychological and practical
challenges. For example, parents may struggle to establish an identity as a single per-
son, may suffer from a lack of meaningful relationships, may have a decreased social
support network, and may experience a significant decrease in socioeconomic status
(Kitson & Morgan, 1990; McLanahan & Booth, 1989; Weinraub & Wolf, 1983). In
such cases, the parents’ own struggles may result in decreased ability to provide
warmth or monitoring for their children (Wallerstein & Kelly, 1980).
Capitalizing on this, parental interventions can focus on rebuilding parental effec-
tiveness. Filial play therapy, in which parents are trained in the basic principles of cli-
ent‐centered play therapy to help their children, has been proposed as one way of
effectively building parental effectiveness without having children develop a reliance
on a therapist or parents experiencing failure or defensiveness about relying on out-
side help (Stover & Guerney, 1967). Bratton and Landreth (1995) conducted an
explicit test of filial therapy for single parents of children ages 3–7. They found signifi-
cant increases in empathy and parental acceptance and decreases in parental stress and
child problem behaviors. This is notable, given that filial play therapy has generally
received support as being relevant across varying cultures (Chau & Landreth, 1997;
Edwards, Ladner, & White, 2007; Garza & Watts, 2010). It also may be valuable for
custodial grandparents or other caretakers (Bratton, Ray, & Moffit, 1998). Although
the tests of filial play therapy typically rely on a group format, the principles behind
the approach can be applied to individual approaches to working with parents (Van
Fleet, 1994).
Related to maintaining parental effectiveness is the goal of maintaining parental
involvement, especially in the case of fathers. Data from Australia suggests that the
most common form of father involvement is a few nights of contact per week or every
other weekend, typifying about 34% of the children in their sample (Smyth, 2005).
Further, approximately 59% of children have contact that is erratic, irregular, or infre-
quent. To further complicate matters, Amato and Gilbreth’s (1999) meta‐analysis
notably confirmed that simply having contact with nonresidential fathers is not
enough to improve child outcomes. Consistent with attachment theory (Feeney &
Monin, 2016), they found that emotional closeness and authoritative parenting were
necessary for fathers to significantly affect child outcomes beyond the positive associa-
tions associated with paying child support. Bastaits, Ponnet, and Mortelmans (2014)
more recently confirmed these findings. Thus, the task for therapists and other stake-
holders is twofold: help fathers stay engaged in the family and make their engagement
emotionally and developmentally supportive.
Although the treatment literature on father involvement is limited, several factors
that influence involvement have been identified that may be useful therapeutically.
Mothers may be a useful first point of intervention, as their gatekeeping efforts may
be a barrier to father involvement (Fagan & Barnett, 2003). Such gatekeeping efforts
may include insisting that certain areas of parenting should only be approached by
mothers. They likewise may impose high standards on parenting and thus discourage
fathers from being involved (Gaunt, 2008). In extreme cases, mothers may directly
sabotage visitation efforts because of their own pain and anger from the divorce
(Braver & O’Connell, 1998; Wolchik, Fenaughty, & Braver, 1996). Therapeutic
efforts with mothers may include building up their identity or self‐esteem, such that
fathers’ success as parents is not a threat to their maternal identity, and working with
them to change their personal ideology relative to traditional gender roles (Cowdery
& Knudson‐Martin, 2005; Gaunt, 2008).
Focusing more directly on fathers, their involvement may be low for a variety of
reasons. For some, their interest in parenting may be low, due to personality factors,
relocation, remarriage, or other reasons (Kelly, 2007; Smyth 2005). Efforts to change
such parents are likely to be difficult. In such cases, direct discussion with older chil-
dren or play therapy with younger children related to the patterns involved in father
absenteeism may be a valuable avenue of lessening feelings of loss, guilt, and shame
(Wineburgh, 2000). However, fathers may also be uninvolved because of ongoing
pain from the divorce or to avoid conflict with mothers (Spillman, Deschamps, &
Crews, 2004). Furthermore, a lack of well‐defined role expectations may make the
transition to being a co‐parent, but not a partner, difficult and ambiguous (Madden‐
Derdech et al., 1999). Helping fathers to alleviate feelings of hurt and anger and
processing boundary ambiguities that limit their involvement may be particularly ben-
eficial (Huff, Markham, Larkin, & Bauer, 2020, vol. 3). When appropriate, commu-
nication skills training in conjoint therapy with mothers may also be valuable in
helping fathers stay involved (McBride & Rane, 1998).
Parent education
Parent educations programs, either mandated or voluntary, are the best‐studied
interventions for divorcing parents. Although the quality of the studies varies, the
general trend suggests that parent education can mitigate some conflict for divorc-
ing or separating couples. Fackrell, Hawkins, and Kay’s (2011) meta‐analysis of 19
studies using control group designs suggested significant effects and moderate
effect sizes on co‐parenting conflict, parent–child relationships, and child well‐
being. Similar results are seen in international studies (Keating, Sharry, Murphy,
Rooney, & Carr, 2016; Laufer & Berman, 2006). Notably, more specific studies
confirm that the effects of divorced parent education programs have measurable
effects on child behaviors (Braver, Griffin, & Cookston, 2005). Further, when only
one parent is involved in the education program, the other parent is still likely to
recognize improvements, even if they are not aware that the education took place
(Cookston, Braver, Griffin, De Lusé, & Miles, 2007). Unfortunately, analysis of
individual components of parent education programs, specifically those that could
be adapted for use in individual and family therapy are limited. The lack of explora-
tion about what components of divorced parent education materials is effective for
parents may explain the significant variability in parent education programs around
the country (Geasler & Blaisure, 1998).
An exception to this trend is a collection of studies that focus on novel ways of
delivering parent education and comparing between multiple methodologies. A
study comparing skill‐based and information‐based programs revealed that both are
associated with reductions in children’s exposure to parental conflict compared with
a control group, but only the skill‐based program had an effect on parental commu-
nication (Kramer, Arbuthnot, Gordon, Rousis, & Hoza, 1998). Arbuthnot, Poole,
and Gordon (1996) found that even simply mailing parents educational materials
resulted in changes to how custodial parents spoke with their children about the
other parent and how much access the nonresidential parent had to their children.
Sending parents a brief letter on triangulation and summarized scores of adolescents
on a measure of triangulation also resulted in positive changes (Kurkowski, Gordon,
& Arbuthnot, 1994). Recent work suggest that online videos and other online sys-
tems are similarly effective (Bowers, Ogolsky, Hughes, & Kanter, 2014; Ferraro,
Oehme, Bruker, Arpan, & Opel, 2018).
Taken together, this suggests two valuable efforts that therapists can make to
improve co‐parenting relationships. First, therapists can point out the struggles that
children are having related to the divorce, especially in the case of problems like trian-
gulation that are directly caused by parental behavior. Second, they can teach practical
skills for better communication and parenting. Although not individually tested, this
may include parenting skills like not using children to spy on or deliver messages to
the other parent. It may also include communication skills like using “I” messages and
keeping conversations focused on one topic at a time (Kramer et al., 1998).
Co‐parenting interventions and shared parenting

Though situated at the end of this chapter, improving the co‐parenting relationship
may be the most important effort to help children through their parents’ divorce,
consistent with a family systems approach (Minuchin, 1974). A broad literature
speaks to the importance of the parental relationship for positive outcomes following
divorce and the potential to meaningfully intervene therapeutically. Huff et al. (2020,
chapter 13, vol. 3) provide an overview in this handbook. Johnston and Campbell
(1988) observed that resolving intrapersonal and interpersonal problems between
co‐parents, such as grief and resentment from the separation or poor communication
skills from years of conflict, may be all that is needed to resolve seemingly intractable
cultural differences in parenting. For example, disagreements about what religion to
raise a child may be masking ongoing pain from the termination of the marriage. It
might reasonably be presumed that many disagreements over co‐parenting are simi-
lar. Arguments and disagreements relative to visitation and custody arrangements
may in fact be masks for deeper intrapersonal struggles (Maccoby, Depner, &
Mnookin, 1990).
Given this recognition, there are still valuable practical elements to sorting through
co‐parenting agreements and decisions. Schwartz and Kaslow (1997) provide guide-
lines for making parenting decisions that will be the least disruptive to children.
These include emphasizing that the divorce and associated problems are not the
child’s fault, considering the child’s best interests in residential and visitation arrange-
ments (getting the child’s opinion when appropriate), and reassuring children that
both parents love and will continue to support them. Related to this, among the
most discussed pieces of advice is to make every effort to avoid children experiencing
loyalty conflicts or feeling in the middle of the parents’ problems (Everett, 2006;
Maccoby, Buchanan, Mnookin, & Dornbusch, 1993; Schwartz & Kaslow, 1997).
Parents should be specifically and directly guided in keeping their children out of
conflict by not complaining about the other parent, passing messages through the
children, undermining the other parent’s authority, and similar triangulating behav-
ior. Such behaviors are likely to result in stress for children in the short term and
negative consequences in the long term (Bannon, Barle, Mennella & O’Leary, 2018;
Huff, 2016).
Although often outside the control of therapists and other helping professionals, a
word on custody and parenting arrangements is also valuable at this point.
Presumptions about the value of joint physical custody, meaning that children spend
at least 35% of their time with each parent, are a relatively modern development that
has quickly taken hold in the legal divorce landscape in the United States and in
many countries internationally (Nielsen, 2018). While still a subject of debate,
research is demonstrating generally positive outcomes for children in joint physical
custody arrangements in the United States and abroad, even when confounding fac-
tors like income and parental conflict are controlled (Bauserman, 2002; Fransson,
Hjern, & Bergström, 2018; Nielson, 2018b). In cases of high conflict between par-
ents, however, there are more mixed results (Mahrer, O’Hara, Sandler, & Wolchik,
2018). These findings blend with findings suggesting that greater levels of coopera-
tion between co‐parents and ensuring children’s access to supportive parents remains
a key effort in treatment.
Future Research
The literature on treatment for divorcing families remains limited. As has been noted
in this review, empirical support for the ideas shared in the literature and in this chap-
ter is largely missing. This is similar to previous reviews of the treatment literature
(Emery, Kitzmann, & Waldron, 1999; Sprenkle & Gonzalez‐Doupé, 1996). The
interventions that are the best represented in literature, such as divorce groups for
children, are nonetheless limited by methods that leave questions about the efficacy
and generalizability. This is particularly true for practitioners working with children
and families outside of mainstream America. While the general divorce literature is
appropriately expanding into various international contexts (see Afrasiabi & Dehaghani
Daramroud, 2018; Garriga & Martínez‐Lucena, 2018, for just a couple examples),
the treatment literature is generally focused on US families.
There are a wide variety of opportunities to improve the treatment literature on
children of divorce in the future. Diversity of samples, both within and outside of the
United States, will be a simple but valuable contribution to the literature. Beyond
this, research focusing on systemic effects will be invaluable. Given the inherently
systemic nature of working with children following divorce, dyadic and other systemic
data analysis approaches will likely provide greater insight into treatment effective-
ness. At a minimum, multiple informants should be used to verify changes and
improvements from treatment. Finally, a specific focus on treatment approaches in the
empirical literature would be valuable. This may take the form of case studies or more
extensive projects, but simply having more information about treatment options with
some level of data to support them would be a benefit to practitioners who have
largely been left to sort out a course of treatment on their own.
Case Example
As a conclusion to the chapter and a summary of the content, we can consider a typi-
cal case and the decisions that therapists might make in helping the child and family:
The family has two children and is in the first month following the finalization of the par-
ents’ divorce. The children, Charlotte, age 15, and William, age 11, are currently living
with their mother in the family home. Their father lives nearby and the children stay with
him every other weekend, in addition to at least one visit during the week. The most fre-
quently discussed symptom in the family is William’s behavioral problems at home and school.
This includes refusal to work, increased disrespect, and isolation from his peers. Upon further
assessment, Charlotte has also been isolating herself from her family more and demonstrates
some internalizing behaviors. Her mother reports, however, that she has been a tremendous
help around the house and watching William.
While the parents typically describe themselves as managing the divorce well, further assess-
ment suggests several struggles. Jason, 40, was generally connected to his kids and active in
their lives. The primary initiator of the divorce, Jason has tried to strike a conciliatory tone
throughout the divorce proceedings, but also continues to harbor resentment toward his wife
from years of low‐level conflict in their marriage. This resentment has led him to hesitate to
coordinate visitation appointments and schedule changes, resulting in some missed time with
his children. Melissa, 40, is having a more visible emotional reaction to the divorce, including
grief over the loss of her relationship and anger at Jason for his selfishness. Although overt
conflict has been relatively low in the divorce process, she has been using triangulating lan-
guage when talking with the children, including complaining about Jason and asking ques-
tions about new romantic partners.1
Here it is important again to discuss that the effective treatment of this family will
almost certainly include work with a variety of systems, likely including several profes-
sionals. Each parent is in a difficult emotional situation that contributes to a difficult
co‐parenting relationship. This in turn is likely negatively affecting the children.
Addressing these individual and dyadic difficulties will be essential to ensuring the
best outcomes for Charlotte and William. This may be accomplished in individual or
conjoint sessions (see Huff et al., 2020, vol. 3, for therapeutic guidelines on working
with divorcing couples). In this case, given the relatively low conflict and the lack of
abuse or violence in the relationship, one therapist conducted conjoint sessions with
Jason and Melissa.
The ostensible goal of these conjoint sessions was to improve the co‐parenting in
their relationship. To accomplish this, the therapist took up two major efforts. First,
the therapist helped each individual explore their own feelings and experience of the
divorce to get past their anger and hurt and see the other parent from a more neutral
position. This included efforts like processing their emotions and experiences without
being triangulated into the conflict and teaching the speaker–listener technique to get
past negative assumptions and to allow them to feel understood. Second, the therapist
provided psychoeducational information and materials to the parents. Melissa’s trian-
gulating behavior, Jason’s drift from his children, and Charlotte’s possible parentifica-
tion were all subjects for education. The therapist provided developmental information
on the children’s desires to be connected with both parents and the struggle they feel
when they are placed in the middle of the conflict. Although both parents reported
that this was “common sense,” they both renewed commitments to investing in the
children and keeping them out of the conflict. Clearly, their ability to do so was bol-
stered by the efforts to let go of hurt feelings and resentment toward each other.
Parallel to sessions with the parents, a separate therapist focused on the children.
Essential to this was close coordination between the two therapists. As the children’s
therapist recognized that peer connection will likely be an essential element of
Charlotte’s therapeutic process, the parents’ therapist was able to again provide devel-
opmental information to the parents and to help them see her isolating from them as
an emotional process, and not, for example, a sign that the other parent is trying to
alienate her from them. Ultimately, the therapist did relatively little direct work with
Charlotte beyond helping her identify support systems and people that she actively
wanted to talk with. This included the therapist including her grandmother in a ses-
sion to help the grandmother understand her role as a support that can stay out of the
disagreements between Jason and Melissa.
Treatment with William was more hands on, including individual sessions as well as
sessions with one or both parents. Typically, family sessions took a filial play therapy
approach, helping the parents to stay responsive to his needs while maintaining their
parental authority, despite their emotional distress over the divorce. Sessions without
the parents included psychoeducational elements to answer questions about divorce
and creative activities, including watching movies and sandtray exercises to label and
process his emotions. Finally, in addition to the parents’ therapist and the grand-
mother, the children’s therapist also coordinated with the school counselor and
William’s teachers to build empathy and patience and to provide a cohesive message
of support across the several systems in his life.
Success for this family took several forms. The parents were able to process their
emotions and improve their co‐parenting process as they let go of their pain and
developed better communication patterns. This was a key effort that provided security
for the children and better direction for the family as a whole. The children were like-
wise supported more effectively, initially by external players, but ultimately by their
parents. Unfortunately, the circumstances for children experiencing their parents’
divorce will often be different. Multiple therapists may not be available, the parents’
relationship may be significantly more dysfunctional, and abuse or parental disengage-
ment may mean that reconciliation is not achievable. Even in these cases, elements
shared in this chapter and case example can be helpful and provide a guide. Avoiding
triangulation, connecting to supportive others, and allowing children appropriate
opportunities to process and feel supported will consistently provide help for children
and families. Therapeutic judgment will be required to effectively navigate the com-
plexity that these families consistently bring to sessions.
Conclusion
Our hope is that this chapter provides meaningful guidance to professionals working
with divorced families to improve the lives of their children. As has been noted, the
treatment of such families is complex and requires careful judgment from therapists.
In summary of the points raised hereto, a few key points may be valuable to reiterate.
First, it is important to remain systemic in this type of work. A key part of this will be
to work effectively with parents to help them through their divorce process and to
improve their ability to be a support and help for their children. Second, a develop-
mentally appropriate view of the child’s best interests is required to ensure that chil-
dren are protected from triangulation and other negative practices. Instead, children
should be provided with ample opportunities for support from parents, extended
family, and appropriate friends. Finally, it will be critical for research to continue on
this subject to ensure that children and families are protected as best as they can. It is
unfortunate that the empirical treatment literature remains significantly underdevel-
oped for a topic that can have such a significant impact on children and families. We
hope that researchers in the near future will adopt high‐quality, systemically informed
approaches to solving these shortcomings.
Note
1 The family described in this case example is a composite of families that the authors have
worked with, discussed, and studied in their clinical and academic activities. Although
consistent with the difficulties families may have during parental divorce, it is not a descrip-
tion of any specific family.
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22
Sexual Identity Development
and Heteronormativity
Rebecca Harvey, Linda Stone Fish,
and Paul Levatino
The development of sexual identity and the experience of sexual minorities have been
traditionally theorized about from within patriarchal and therefore heteronormative
sociopolitical structures, resulting in limited capacity to understand identities,
experiences, or relationships that exist outside of the gender binaries created in such
cultures. Heteronormativity can be defined as the perspective and/or set of assump-
tions that view heterosexuality and traditional binary gender roles as the only natural,
normal, or healthy expression of human gender and sexuality (http://Oed.com,
2018). These social constructions develop from within patriarchal sociopolitical
systems and help preserve and justify imbalances in power, privilege, and advantage
(Butler, 1990; Fausto‐Sterling, 2000; Rich, 1986). Such power imbalances pro-
foundly impact developmental processes as well as couple and family processes. There
is overt and covert pressure to conform to sanctioned roles about gender and sexual-
ity because there are advantages to conforming and severe disadvantages for not doing
so. Traditionally one of the most important reasons to accommodate oneself to the
expectations of social hierarchy is to feel a sense of belonging, connection, and mean-
ing (Perel, 2017). In these ways, heteronormativity has a constraining effect on indi-
vidual and relational development for all people (Giammattei, 2015; hooks, 2004;
Knudson‐Martin & Laughlin, 2005; Laszloffy & Harvey, 2006) and is at the heart of
many of the mental health issues and relational problems that bring people to therapy
(Knudson‐Martin & Mahoney, 2009; Real, 2002, 2007).
The field of systemic family therapy (SFT) was founded in this heteronormative
milieu and has routinely failed to accurately perceive the presence or effect of heter-
onormativity on couple and family processes precisely because these pressures are so
pervasive as to be effectively invisible and so thoroughly rooted within marriages,
families, and cultures as to be nearly universally accepted as “truths” beyond ques-
tioning (Knudson‐Martin & Laughlin, 2005). SFT theory is infused with dualistic
notions of gender that continue to limit its efficacy and clinical usefulness for all
individuals, couples, and families, including LGBTQI1 (lesbian, gay, bisexual,
542 Rebecca Harvey, Linda Stone Fish, and Paul Levatino
transgender, queer, questioning, intersex) people who exist on the margins of

heteronormativity (Knudson‐Martin & Laughlin, 2005; LaSala, 2013; Laszloffy &
Harvey, 2006). LGBTQI people are inherent threats to patriarchal sociocultural sys-
tems because their lives expose inconsistencies inherent in essentialist notions about
gender and flaws in popular assumptions about “healthy” family forms. As such
LGBTQI people have been routinely ignored, pathologized, and penalized in social
systems concerned more with domination and social control rather than equality or
liberation.
Despite the influence of heteronormativity, SFT was also founded on the notion
that human behavior and motivations must be examined contextually. Family therapy
at its most transformative has the potential to “liberate people from conditions,
dynamics and patterns that constrain and cripple healthy functioning and develop-
ment” (Laszloffy & Harvey, 2006, p. 3). In this chapter, we undertake to examine
heteronormativity as a problem, describe its link to misogyny and other systems of
oppression, and explore ways it has historically influenced the field of family therapy
specifically with regard to gender and sexual minorities. The authors of this chapter
will deconstruct heteronormativity; explore links between patriarchy, misogyny, rac-
ism, and classism; examine the deleterious effect of these on mental health; and locate
the influence of these sociopolitical systems on the field of SFT theory and in clinical
work. An LGBTQI affirmative clinical framework developed from systems theory and
queer theory will be outlined, and a case study using the framework will be described.
Current context
We are at an important crossroads. A progressive sea change in attitudes over the last
20 years has led to transformative social policy changes protecting and supporting
LGBTQI people and families. In the United States, a short summary of these protec-
tions includes the passing of the Matthew Shepard and James Byrd Jr. Hate Crimes
Act (2009), the repeal of “Don’t Ask Don’t Tell” military ban on LGBTQI openly
serving (2011), the legalization of same‐sex marriage (2014), and the lifting of the
military ban on openly transgender soldiers from serving in the armed forces (2016).
Despite, or perhaps because of these select gains in equality, a global backlash has
developed, resulting in international populist movements with neofascist hallmarks.
Therefore, questions of what constitutes “natural” and “normal” with regard to gen-
der and sexuality are once again at the heart of divisive political debates. As this chap-
ter is being written, the controversy continues. At the same time there are serious
challenges to rape culture and the patriarchal entitlements that underpin it (e.g.,
Equality Now, #MeToo movement, Declaration of the Girls of Brazil, etc.) and
redoubled political efforts to enforce a gender binary, including regressive laws aimed
at policing the bathrooms one may use (Kralik, 2017) or establishing legal definitions
of sex and gender that threaten to erase transgender identity (Green, Benner, & Pear,
2018).There is also the current US president’s reversal on transgender soldiers openly
serving in the military and ongoing challenges to women’s reproductive rights in the
United States and across the globe. And finally, renewed attacks on the rights of
LGBTQI parents and foster/adoptive parents in various states in the United States
(Zak, 2018). What these debates have in common is a clash between patriarchal,
binary, heteronormative notions about gender roles, and increasingly idiosyncratic,
fluid notions about the very nature of gender and sexuality.
Sexual Identity Development and Heteronormativity 543
In certain locations, the situation is urgent and potentially life threatening: The
harassment, torture, and murder of the LGBTQI community in Chechnya continues,
while the potential for state‐sanctioned arrest and the death penalty exists in Saudi
Arabia, United Arab Emirates, Sudan, Somalia, Mauritania, Iran, Brunei, Nigeria, and
Yemen. The Russian model of decriminalizing homosexuality while passing discrimi-
natory policies provides political points to politicians on the back of the LGBTQI
community. These tactics are being taken up with legislation pending in former Soviet
states including Uzbekistan and Kazakhstan as well as the United States. While pre-
senting the illusion of progress, these enactments fuel fear and prejudice while inciting
violence. According to the FBI, incidents of hate crimes have increased every year
since 2014 when they were at the lowest point since hate crime reporting began in
1992 (Dashow, 2017). Analysis of the most recent data reveals that while overall
crime rates in the United States are down, the incidence of hate crimes rose in the
nation’s 10 largest cities with a 12.46% spike between 2016 and 2017 alone (Levin,
Nolan, & Reitzel, 2018.) The LGBTQI community, as well as racial minorities, Jews,
Muslims, and immigrants, continues to bear the burden of the backlash as the most
frequent targets of these violent crimes.
Patriarchy, Heteronormativity, and Interlocking

Systems of Oppression
Patriarchal sociocultural systems imagine men and “masculinity” as inherently dif-
ferent and superior to women and “femininity.” Male dominance and gender and
pay inequity are justified by the fundamental belief of male/masculine superiority.
In this system, qualities like physical power, intellect, and dominance are valued
and associated with masculinity, while qualities like submission, accommodation,
gentleness, emotionality, and vulnerability are devalued and associated with femi-
ninity. Males and masculinity are granted more power, privilege, and access to
resources than females and femininity because they are “superior.” A relatively
strict gender binary is required to maintain the system and the pervasive imbal-
ances of power and privilege in the status quo. Heteronormativity reinforces the
assumptions that underpin the binary. While exceptions exist globally, their mar-
ginalization points to exceptions that prove rather than challenge the rule. Thus,
in mainstream cultures across the globe, biological sex is widely conceived of as
naturally occurring in two mutually exclusive categories, male/female, which nec-
essarily produce two distinct and universal gender and gender roles masculine/
feminine, in turn creating one normal and superior desire, namely, heterosexuality.
Any ambiguity in these categories begins to whittle away at the foundation of
male/masculine superiority (T. Laszloffy, personal communication, August 27,
2018). For men to be superior, one must be able to reliably identify who is male
and who is female and readily distinguish between masculine and feminine. Once
the “naturalness” of this gender binary is compromised, imbalances of power can
be made visible, interrogated, and ultimately challenged. Hence, anyone existing
on the margins of traditional gender roles and heterosexuality are threatening
because by their very presence they blur gender distinctions, and challenge the
existence of a gender binary, thus threatening the entire power structure.
Critiques of patriarchy have often been misunderstood to be critiques of all men

and masculinity rather than as a broader critique of the entire system of domination
itself (hooks, 2004). As hooks elucidates, patriarchies are better described as a series
of “interlocking political systems,” which she dubbed “imperialist white‐supremacist
capitalist patriarchy” (2004, p. 17), entitling some groups of people to dominate and
capitalize at the expense of others. Such systems idealize control of others, standardize
power imbalances, and justify the resulting inequities using questionable lines of
reasoning and circular logic. Misogyny, heteronormativity, racism, xenophobia, and
classism are thus linked together inseparably and utilized to justify and maintain the
status quo, resulting in elevated levels of chronic stress (Meyer, 2015). Those who
exist in the intersections of multiple oppressed identities (e.g., African American,
woman, lesbian, immigrant, etc.) are exponentially affected, and their life experiences
must be understood in the context of how multiple oppressions weave together to
intricately create a unique experience (Crenshaw, 1991). This interlocking system is
operating certainly at the macro level, but these power imbalances also profoundly
individuals and families. The field of SFT was founded on the notion that human
behavior and motivations must be understood contextually, and as such it is uniquely
positioned to map their effects on micro interactions and intervene in reducing domi-
nation and its deleterious effects in the lives of clients (das Nair & Butler, 2012).
Heteronormativity and Systemic Family Therapy
Feminist and queer theorists have argued compellingly for decades that gender
and sexuality are socially constructed (Butler, 1990; Fausto‐Sterling, 2000; Rich,
1986). Sex and gender do not merely exist as objective “truth” about a person or
relationship but rather are performed and continually recreated within interper-
sonal relationships (Butler, 1990). Rich (1986) coined the term “compulsory het-
erosexuality” arguing that traditional heterosexuality was not intrinsic to human
experience but instead obligatory, while standard notions of biological sex, g ender,
and desire are invented out of heteronormative assumptions rather than the other
way around. Despite this the field of SFT has had difficulty acknowledging these
processes as constructions, recognizing their limitations, and translating this into
useful clinical interventions (Knudson‐Martin & Laughlin, 2005; McGeorge, &
Stone Carlson, 2011; Real, 2002). What is required of the field of SFT now is new
pathways and alternative constructions of relationships and intimacy not domi-
nated by gender roles or power imbalances. Fausto‐Sterling (2000) explores how
heteronormative assumptions are pervasive and powerful enough that doctors and
researchers felt justified in ignoring significant variations in examples of naturally
occurring sex and gender. Instead those who existed outside of these rigid catego-
ries were routinely minimized and pathologized, while scholars used scientific
“knowledge” to overstate the case for a sex and gender binary. This type of c ircular
logic was also interwoven throughout psychological theories of human behavior
and identity development and perhaps is most clearly embodied by the social
construction of “homosexuality” as a diagnosable mental illness despite lack of
evidence that such an illness objectively existed outside of the stress brought on
by oppression.
The opaque filter of heteronormativity

LaSala (2013) traces the influence of heteronormative assumptions on the emergence
of systemic family therapy and theory for LGBTQI people and families. When the
prevailing medical view was that homosexuality was a mental illness, psychology and
psychiatry tried to uncover the dysfunctional family dynamics that “caused” homo-
sexuality (Hatterer, 1970), and later, when prevailing wisdom had shifted, and homo-
sexuality was de‐pathologized, the focus shifted to the dysfunctional family dynamics,
which stigmatized LGBTQI people and exacerbated their negative mental health out-
comes (LaSala, 2013). In both cases scholars were attempting to understand and
communicate sexual minority experience from within a heteronormative structure
that at first could accommodate the existence of LGBTQI people only by pathologiz-
ing them or their families rather than challenge the entire culture’s heteronormative,
sexist assumptions.
Once homosexuality was de‐pathologized, LGBTQI experience had to be reimag-
ined and translated for mainstream (i.e., White, heterosexual, male, middle/upper
class, and professional) scientific establishment. As such the notion of sexual orienta-
tion developed, and as Currah (2001) points out, sexual orientation “remains intelli-
gible only if sex and gender remain relatively stable categories” (p. 182). Words like
“heterosexual” (opposite‐sexed attractions between men and women), “lesbian” (a
woman sexually attracted to another woman), “gay” (a man sexually attracted to
another man), and “bisexual” (a person, male or female who is sexually attracted to
both men and woman) affirm rather than challenge the status quo because they rely
on a gender binary to exist. How can gay or lesbian or bisexual make sense if male and
female are not distinct, stable categories and instead a gender spectrum exists? Labels
about gender and sexual expression are valid attempts at trying to understand our-
selves. Yet we have gone from LGB (lesbian, gay, bisexual) to LGBTQIAP (lesbian,
gay, bisexual, transgender, queer, questioning, intersex, asexual, and pansexual) pre-
cisely because we are attempting to use heteronormative ideas to categorize human
experience that often fall outside of these constructs and therefore resists these
attempts. As it turns out, human beings are more fluid and non‐binary than can be
easily conceived of or understood within the limitations of our current sociopolitical
social constructs (Diamond, 2003; Istar‐Lev, 2013; Zoeterman & Wright, 2014). To
build therapeutic alliances that honor evolving identities requires a willingness to see
what is difficult to see given the filter of heteronormativity and to ask how clients see
and name their own lives and experiences.
Heteronormativity, heterosexism, and SFT

Heterosexism and heteronormativity are related but distinct systems of beliefs that
have constrained the ways that gender roles, gender, and sexual development have
been conceived and theorized about in clinical work. Giammattei and Green (2012)
define heterosexism as the belief that heterosexuality is superior and the only accept-
able way to be or live. Hudak and Giammattei (2014) propose heteronormativity as
less virulent than homophobia or heterosexism but a subtler and pervasive way of
imagining “normal” families as composed of heterosexual parents raising heterosexual
children. Heteronormativity can be “differentiated from heterosexism by its uncritical
adoption of heterosexuality as an established norm” (Giammattei & Green, 2012, p. 4).
The impact of misogyny, sexism, heteronormativity, and heterosexism on the field of

SFT and clinical work in general cannot be overestimated as the very language of “hus-
band/wife,” “marriage,” and “family” are predicated on heteronormative/heterosex-
ist concepts and are central to the way the field was conceived and continues to be
practiced (Giammattei & Green, 2012; Knudson‐Martin & Laughlin, 2005; McGeorge
& Stone Carlson, 2011). The issue of language is layered, and therapists must be sensi-
tive to the ways that they themselves and clients internalize and make meaning or not
out of these labels and further how these labels have potential to both help and hinder.
For some couples the importance of being named as “wife” rather than “girlfriend” is
vital and can be honored in therapy at the same time the limitations and assumptions
associated with these and other labels ought to be clinically explored.
The early founders of SFT were decidedly inducted into a heteronormative social
system that simply accepted gendered power imbalances and tried to remain “neutral”
to what was seen as political implications of questioning this. The architects of SFT
simply did not acknowledge the existence of or challenge the deep‐seated assump-
tions of misogyny (LaSala, 2013). The social construction of gender was both perva-
sive and invisible, which made it largely inaccessible to families and family therapists
(Knudson‐Martin & Laughlin, 2005) until feminist family therapists (e.g., Brown,
1994; Walters, Carter, Papp & Silverstein, 1988) explicated specifically how sexism
was embedded throughout SFT theory to reveal the “invisible and sometimes non‐
conscious ways in which patriarchy has become embedded in everyone’s daily life‐in
our identities, our manners of emotional expression, and our experiences of personal
power and powerlessness‐to our profound detriment” (Brown, 1994, p. 17). As
Brown makes clear, once the detrimental effect of oppression is made visible, one is
able to perceive how oppression functions interconnectedly at the fault lines of culture
(race, class, religion, ethnicity, immigration status, and regional affiliations) to “dimin-
ish the quality of life and well‐being” (p. 21) of all people within the culture from
most privileged to most oppressed.
Gender expectations and power imbalances give rise to various health problems (Sen
& Östlin, 2008) including stress (American Psychological Association, 2017; Li, Yang,
& Chow, 2006) and depression (Albert, 2015; McLean, Asnaani, Litz, & Hofmann,
2011; Real, 1997; Steele et al., 2017) as well as relational problems (Knudson‐Martin
& Mahoney, 2009; Real, 2002, 2007). As race begins to be factored in, studies are
finding that the risks multiply (Angley, Clark, Howland, Searing, Wilcox and Won,
2016; Essien, Ross, Fernández‐Esquer, & Williams, 2005; Jacobs, 2017).
Men are praised for their ability to assert, dominate, protect, and control and
castigated for anything that remotely feminizes them like emoting, pursuing close-
ness, and yielding. Women are praised for being responsible in relationships, accom-
modating, nurturing, and being empathic and punished for asserting, being direct,
or independent. In this context “internalized” mental health disorders are diagnosed
more pervasively in those who identify as women (e.g., anxiety, depression), while
“externalized” based diagnoses are more common among those who identify as men
(e.g., oppositional defiant disorder, conduct disorder) (Albert, 2015; Lahey, Miller,
Gordon, & Riley, 1999; McLean et al., 2011). These rules, roles, and responses are
based on power imbalances that block true intimacy and are the source of many rela-
tional problems in modern couples (Knudson‐Martin & Mahoney, 2009; Real,
2002). This adherence to gendered rules and expectations negatively affect the
health and wellness of all people and families.
LGBTQI people studied as a monolith

Next, when homosexuality was no longer seen by mainstream mental health experts
as a mental illness, LGBTQI individuals, couples, and families were studied as if they
were a monolithic category of people. Early scholarship was focused entirely on the
differences between heterosexuals and those with an LGBTQI identity. This had the
effect of emphasizing the similarities between all gender and sexual minorities
while minimizing the differences in their lived experiences. The coming out process,
family‐of‐origin relationships, and couple dynamics were studied as if all non‐
heteronormative people were similar enough to generalize about without taking into
consideration all the ways they were different. For example, a White lesbian working‐
class teenager in rural Ohio may have little in common with a Black upper‐middle‐
class gay male youth being raised in a large coastal city. LGBTQI identity must be
understood as intersectional (Crenshaw, 1991; das Nair, & Thomas, 2012), meaning
that it is a unique experience that depends on the specific intersections of personal and
cultural identity within a person’s life. The reality of this monolith view of LGBTQI
identity is that it lacked intersectional complexity and was understood through the
experience of White, middle‐class people, mainly men. This will be further discussed
later in this chapter.
Minority stress
Entrenched heteronormativity has encouraged and promulgated simplistic and ritual-
ized notions of gender, sexual orientation, and sexual expression rooting them in a
gender binary. While this has had negative effect on all people, LGBTQI individuals,
relationships, and families are overtly threatening to these systems of domination and
therefore are singled out and targeted. At the societal level they are targeted through
policies and procedures like those that criminalize same‐sex sexual relationships, disal-
low equal marriage, deny open military service by LGBTQI soldiers, and prohibit
adoption or foster parenting opportunities to LGBTQI parents. These social policies
are powerful macrolevel messages that conceive of LGBTQI people and lives as infe-
rior and even threatening and therefore deserving of disapproval and censure. This
exudes considerable pressure on individual and family developmental processes.
Heteronormativity trickles down and impairs the ability of parents and caregivers to
effectively parent and protect LGBTQ children from stigmatization (Stone Fish &
Harvey, 2005). For example, lesbian comedienne and performance artist Hannah
Gadsby compellingly illustrates this with the example of her mother. Gadsby’s quotes
her mother saying:
The thing I regret is that I raised you as if you were straight. I didn’t know any different.
I am so sorry. I am so sorry. I knew well before you did that your life was going to be so
hard. I knew that, and I wanted it more than anything in the world for that not to be the
case. And I know that I made it worse. I made it worse because I wanted you to change
because I knew the world wouldn’t.
(Whyte & Parry, 2018, 30:53)
Unlike other minority groups, for most LGBTQI people, their families of origin do
not share LGBTQI identity. Lacking familiarity with the lived experience of being
LGBTQI, families, particularly parents, do not know how to or even if to support

and mentor LGBTQI loved ones as they develop their sexual identities. Each family
system struggles in unique and particular ways to understand their LGBTQI family
member and then in varying degrees to accept, nurture, and protect them from the
stigma they face. Sometimes the only protection offered to LGBTQI people is addi-
tional pressure from their families to change and accommodate to oppression. So,
LGBTQI people face what researchers have termed “minority stress” (Bruce, Harper,
& Bauermeister, 2015; Meyer, 2015; Meyer & Frost, 2013) or chronic levels of excess
stress caused by increased levels of stigma and decreased protective factors or social
supports at the societal, community, and family levels. The result is that LGBTQ peo-
ple are at increased risk for a broad range of negative life outcomes (McConnell,
Birkett, & Mustanski, 2015) including family rejection (Savin‐Williams, 2001), psy-
chological distress (Birkett, Newcomb, & Mustanski, 2015), depression and anxiety,
substance use and abuse (Willoughby, Lai, Doty, Mackey, & Malik, 2008), victimiza-
tion (Huebner, Rebchook, & Kegeles, 2004), and suicidality (VanBronkhorst et al.,
2017). Moreover, the higher incidents of these negative outcomes within the LGBTQI
community have historically been used to “prove” LGBTQI inferiority and justify the
stigmatization rather than reveal oppression as the root of LGBTQI stress.
LGBTQI people tend to seek mental health services in greater proportion than that
of the general population and report greater prevalence of mental disorders, psycho-
logical distress, and mental health services use due to chronic exposure to the stress of
dealing with stigma, hate crimes, and lack of family and community support (Cochran,
Sullivan, & Mays, 2003). Family support has been shown in multiple studies to be the
key link between distress and life satisfaction (Ryan, Huebner, Diaz, & Sanchez,
2009; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). SFT, then, is a powerful and
fruitful treatment of choice for LGBTQI individuals who are struggling with mental
health and family issues. Unfortunately, evidence suggests that in the field of SFT,
students are not being adequately trained because (a) there is a lack of LGBTQI
affirmative program policies and procedures in place in graduate MFT programs and
(b) there is a lack of LGBTQI affirming course content and a lack of access to affirma-
tive supervision when working with LGBTQI and gender non‐binary clients
(McGeorge & Stone Carlson, 2011). Non‐binary people in couples and families con-
tinue to be routinely marginalized and omitted from theories, training, and clinical
work (Giammattei, 2015; Malpas, 2011).
Coming out models

When someone realizes they are not heterosexual in a heteronormative culture, they
have the same identity development tasks as all human beings, but they are attempting
to accomplish these tasks at a severe disadvantage in families, communities, and wider
cultures that stigmatize them and often fail to acknowledge their existence. This cre-
ates additional developmental pressures and tasks that heterosexual people do not
endure. Beginning in the 1970s, researchers, educators, and therapists developed a
variety of conceptual models designed to describe the internal experience of LGBTQI
people as they negotiated the cultural realities around them. The process of “coming
out” to oneself and others as not heterosexual has been theorized as a series of stages
by various scholars (Bilodeau & Renn, 2005; Cass 1979, 1984; Coleman, 1981;
Troiden, 1989). Of these models of gay and lesbian identity formation, Cass’s (1979,
1984) model integrates many of the themes of the others, has stood the test of time
well, and is most often referenced. Cass’s model begins with the stage of identity
confusion, when youth are socialized to expect to have opposite gender sexual attrac-
tion and discover an internal sense of self that is different from familial and cultural
expectations. The second stage, identity comparison, develops when people face their
internal sense of self and compare it with the dominant familial and societal expecta-
tions they have been following. Some individuals go through this phase quickly,
acknowledging their extraordinary experience, while some hide, adopt a special case
strategy (I am heterosexual, I am just attracted to this one person), or try on different
identities, trying to alleviate cognitive dissonance. Unfortunately, because of fear of
and actual rejection, some individuals stay in this stage of development, unable to
integrate their essential knowledge of their true self with the expectations they inter-
nalize from others. The third stage of Cass’s model is identity tolerance. This stage is
a full recognition of non‐heterosexual identity. People in this stage may continue to
hide their identities and may be able to minimally tolerate their own attractions in
private and thus stay closeted. Identity tolerance is followed by identity acceptance,
the fourth stage of Cass’s model when individuals finally accept their self‐identity.
This stage is supported by validating and loving experiences that help legitimize
oppressed identities. The fifth stage, identity pride, occurs when individuals accept
and prefer their own LGBTQI identity. Cass’s sixth stage, identity synthesis, is the
final stage of the coming out process. At this point individuals are not stuck in the “us
vs. them” mentality that sometimes flavors the fifth stage of development.
Stage models like Cass’s predominate throughout the literature in part because
they accurately capture developmental dilemma’s LGBTQI people face as well as
being useful for succinctly revealing assumptions, inconsistencies, and blind spots cre-
ated by heterosexism in various systems of intervention like medical, educational, and
mental health systems (Kenneady and Oswalt, 2014). Because of pervasive heterosex-
ism, most people continue to assume that those they come into contact with are
heterosexual unless they are directly given reason to believe otherwise. LGBTQI peo-
ple face all of the developmental and life‐cycle transitions of every human being, and
they must negotiate these transitions within heteronormative social structures that
continue to stigmatize, sanction, punish, and ignore their identity. Because of this,
coming out models are still relevant and have their place.
On the other hand, these models have been rightfully critiqued for their rigidity and
lack of complexity as well as their inattention to intersectionality especially with regard
to ethnic and racial minorities (Bilodeau & Renn, 2005; Dubé, & Savin‐Williams, 1999;
Istar‐Lev, 2010; Klein, Holtby, Cook & Travers, 2015; Singh, 2016) or with regard to
minority sexual identity development in adults who come out after adolescence (Johns
& Probst, 2004). So, while these models are useful, they were imagined in a time and
place that did not allow for the diversity and fluidity that is currently required of clini-
cians. And as such they are necessary but not sufficient for effective treatment.
Intersectionality
Intersectionality is a framework that considers systems of power and oppression and
how these systems interlock uniquely in every individual life (Crenshaw, 1989). While
all LGBTQI people are raised in heteronormative cultures, LGBTQI people are not
homogeneous. They may share similar lived experiences, yet these experiences are
overlaid uniquely and intricately within sociocultural identities that are influenced
heavily by power differentials (Cole, 2009). These power differentials are “(f)luid
hierarchies which offer differing levels of ‘privilege and power’ to some people
sometimes” (das Nair & Butler, 2012, p. 2). Though cultural attitudes toward
LGBTQI people have become more accepting in the past decade, attitudes toward
homosexuality vary widely depending on a host of demographic variables, as do
attitudes about gender nonconformity. As a result, LGBTQI people find themselves
often caught between differing, conflicting cultures based on their race, class, reli-
gion, ethnicity, immigration status, and regional affiliations (Harvey & Stone Fish,
2015). Walker and Longmire‐Avital (2013) explored the intersection of race, reli-
gion, and LGBTQI identity in their work on the unique ways that Black Christian
adults created a positive self‐identity within the context of cultures rooted in racism,
heteronormativity, and their own homophobia. LGBTQI people who are people of
color often do not find the same respite in the gay community as many White
LGBTQI people. Han (2009) writes:
[G]iven the prevalence of negative racial attitudes in the larger gay community and the
homophobia in communities of color, it’s not surprising that so many GLBTQ people of
color come to hold negative perceptions of themselves and of others like them. (p. 111)
Austin and Craig (2013) found that racial and ethnic minority youth who also identi-
fied as LGBTQI frequently used substances to deal with a lack of family support as
well as living on multiple cultural margins at once. In addition to race, geographic
region (GLSEN, 2011; Kosciw, Greytak, Bartkiewicz, Boesen, & Palmer, 2012),
religiosity, and poverty (Kosciw & Diaz, 2006; Lapinski, & McKirnan, 2013) also
intersect with LGBTQI identity and affect the development of a positive LGBTQI
identity (Harvey & Stone Fish, 2015).
Common treatment approaches

Giammattei and Green (2012) provide multiple examples of the heteronormative bias
prominent in the foundation of systemic theories. This original bias rooted in a binary
view of gender and an uncritical adoption of patriarchy focused on homosexuality
as “the problem,” and as such treatment goals were aimed at altering that. This
legitimized the development of therapeutic interventions whose goal was to “cure”
patients of this so‐called mental illness of that time (Hatterer, 1970). Thus, curative
or reparative therapies were used and remained entrenched and relevant for decades
even after homosexuality was de‐pathologized and removed from the DSM in 1973.
As late as 2008, researchers were studying reparative or conversion therapies in an
effort to understand the methods utilized and to learn if there was any evidence that
verified the claims that these therapies could in fact change sexual orientation (Serovich
et al., 2008). Therapies that purported to cure homosexuality utilized two different
types of methods. As Serovich, Grafsky, and Gangamma (2012) report, reparative
methods sought to treat homosexuality with psychosocial supports like prayer, sup-
port groups, or counseling sessions designed to discourage same‐sex desire and
encourage opposite‐sex desire. Aversive techniques consisted of behavioral inter-
ventions like electroshock treatments, nausea‐inducing drugs, and hypnosis, among
others, to discourage same‐sex desire or arousal. Overwhelmingly, reparative or aver-

sive therapy techniques have been discredited (Serovich et al., 2012) until eventually
being repudiated by all the major mental health fields. The removal of homosexuality
from the DSM in 1973 cleared a path away from theories of therapy that “cured” or
“converted” one from homosexuality toward theories of intervention that saw same‐
sex desire as a natural variation of human sexuality (Johnson, 2012). Out of this has
developed therapeutic stances, conceptualizations, and recommendations that have
proven useful and effective for the LGBTQI community. The authors would like to
focus on a few of them now.
LGBTQ affirmative therapy Affirmative therapies were theorized into existence

beginning in the 1980s as cultural attitudes began to change and focus shifted away
from the view that homosexuality ought to be the focus of treatment and toward
recognizing oppression as a main cause of stress among people with LGBTQI identi-
ties (Johnson, 2012). Increasingly, professional mental health organizations realized
that to be competent and ethical LGBTQI client care required an affirming stance of
their identities (Singh, 2016). Affirmative therapy has been evolving ever since.
Hallmarks of affirmative therapy are a therapeutic stance that is accepting of same‐sex
desire and behavior, viewing it as a natural variation in human beings (Ritter &
Terndrup, 2002); knowledge of the unique developmental issues faced by LGBTQI
people as a result of cultural oppression (Perez, 2007); and the capacity of the
therapists to question and be aware of their own heteronormative assumptions about
gender and sex roles (Brown, 1994; Stone Fish & Harvey, 2012).
Affirmative therapy can be thought of not as one single theory but a therapeutic
approach that focuses on “… the effects of stress on the psychosocial health and
well‐being of LGBT individuals as a result of their belonging to a stigmatized social
category” (Johnson, 2012, p. 517). For SFT the emergence of affirmative therapy
initially meant helping families accept and tolerate LGBTQI family members with the
hope that the mental health consequences of oppression could be mitigated (LaSala,
2013). While this was a step in the right direction, family theory and intervention was
still steeped in a deficit model of LGBTQI identity with the emphasis solely on the
difficulties of being LGBTQI and the necessity of managing this adversity (Stone Fish
& Harvey, 2005). Instead, therapy can be reimagined as a respite wherein LGBTQI
people are seen as necessary and vital for their families and communities. But to
accomplish this, clinicians must actively reject heteronormativity and replace the cor-
responding deficit view of LGBTQI identity with one that recognizes and nurtures
the unique resilience and gifts within LGBTQI client systems.
LGBTQI resilience Resilience might best be described as the capacity to adapt to

adversity or difficult situations. But what about when the difficult experiences are not
single or even multiple incidents but pervasive systemic experiences of oppression and
discrimination that persist over years, decades, or a lifetime? From an SFT point of
view, resilience can also be understood as a relational possibility, something that can
grow from within supportive therapeutic relationships (Harvey, 2012). If therapy is to
provide this, it requires therapists who, at best, are not inculcated with the same
assumptions and blind spots that created the oppression to begin with, and who, at
minimum, remain self‐scrutinizing of their own internalized heteronormative biases.
Parents and therapists, among other, must be able to see the inherent worth in
LGBTQI experience and identity and value its particular contributions. Otherwise we
risk subtly or overtly asking LGBTQI people to accommodate and adapt to injustice.
In this equation the individual is the focus of change and the systemic injustice is
rendered invisible.
As affirmative therapy has evolved, it slowly has empowered clinicians, LGBTQI
people, and families to go beyond affirming the identities of individual clients and
instead challenge entrenched heterosexist assumptions (das Nair & Butler, 2012).
Singh (2016) has argued that for effective treatment clinicians must move beyond
affirmation toward liberatory approaches in treatment that connect the oppression of
all people together and view lessening domination as a significant clinical goal. Such
a goal serves all people including the client but also the client’s family system, the
clinician, the community, and the world at large.
Looking for and finding resilience

Despite stigma, oppression, and elevated risk factors, LGBTQI people and relation-
ships continue to thrive (Harvey & Stone Fish, 2015; Savin‐Williams, 2001). The
evidence for this is everywhere. Gender bending and gender shifting are popular
terms in everyday vernacular. LGBTQI relationships and families are more visible in
leadership, in media, and in every community. Over the years, in our clinical practice,
there is more acceptance by family members, at all ages, toward their LGBTQI sib-
lings, parents, partners, and children. Youth are less afraid to experiment with fluidity,
resisting labels that do not reflect their identities (Diamond, 2003). Family members
are not only tolerating but embracing and celebrating LGBTQI experiences and iden-
tities. Though not universal, we are hopeful that, while overall heteronormativity
remains firmly entrenched, families are changing the culture from the bottom up.
And clinicians must keep pace. Clinical work must be guided by a belief in the resil-
ience of LGBTQI people and be dedicated to mining for this resilience within the
intersections of oppression in a client’s life. In so doing, we assist clients to value
themselves and the skills they have developed not in spite of their oppressed identities
but because of their LGBTQI identity (Stone Fish & Harvey, 2005) as well as racial,
class, and other salient identity groups in which they belong. Mayo (2007) illustrates
the complexity and necessity related to intersectionality when considering LGBTQI
youth: “Intersectionality reminds us that all identities work in strategies and counter-
strategies, that categories are insufficient, crucial, and unstable, and that no category
of identity works alone” (p. 273). Thus, strategies that help LGBTQI people navigate
oppression will vary depending on the unique forces at play. Affirmative therapy is an
evolving concept that can be built into a variety of theoretical viewpoints and tech-
niques so long as the focus is on affirming and liberating LGBTQI people to contrib-
ute their unique perspectives and particular gifts to society.
Integrated Affirmative Therapy
For SFT to be effective, it must challenge heteronormativity directly, increase our

sophistication with regard to intersectionality, and see liberation and domination as
directly related to treatment goals.
Challenging the notion of viewing queerness through the lens of deficiency, the
authors articulate a model of treatment (Harvey & Stone Fish, 2015; Stone Fish &
Harvey, 2005), which crafts intervention strategies that are relational, collaborative,
and systemic in nature. Informed by queer theory, feminist theory, and systems the-
ory, this therapy embraces the “gifts of queerness” as a vehicle for highlighting unique
intersectionality and hidden resilience. The model incorporates a conceptual frame-
work with four domains: (a) creating refuge for sexualities and gender expressions
outside the heteronormative norm; (b) fostering difficult dialogues where conversa-
tions and relational exchanges related to sexuality, gender, and queerness can be prag-
matically discussed, performed, and negotiated; (c) tolerating the discomfort of these
difficult dialogues and pushing through to nurturing the unique queerness that
evolves out of these conversations; and lastly (d) encouraging transformation in both
the client system and the practitioners by increasing authenticity and agency while
diminishing domination and isolation for all involved.
Intersectional clinical applications

Applying intersectionality in clinically useful ways is still new (Butler, 2015; Cho,
Crenshaw, & McCall, 2013). Literature on intersectionality and its applications and
inclusion in training within SFT training programs is beginning to come forward.
Savin‐Williams’ (2001) concept of differential developmental trajectories in LGBTQI
youths’ lives is one clinically useful way to consider intersectionality (Harvey & Stone
Fish, 2015). According to Savin‐Williams, LGBTQI youth are similar to all youth
facing the same developmental tasks and different from heterosexual youth because of
the stigma they experience. Savin‐Williams has shown that LGBTQI youth are differ-
ent from each other as well because of the various social and cultural contexts in which
they live and because they are unique from every other human being because of their
singular individual, family, and cultural traits. Thus, the experience of being queer
depends on how queerness intersects with these cultural, familial, and individual vari-
ables and cannot be understood effectively without considering them. As Harvey and
Stone Fish (2015) write,
The unique map that results from intersectionality must be considered when formulating
effective treatment for all youth, especially those who bear the burden of multiple oppres-
sions. Without consideration of the multiple identities and complex contexts in which
youth are embedded, a one‐size‐fits‐all mentality for treating queer youth fails to account
for the specific liabilities, vulnerabilities, resources, and supports that are unique to indi-
vidual youth. (p. 480)
Case introduction2
May was 14 years old when she3 was first referred to family therapy. She was adopted from a
Chinese orphanage when she was 18 months old. She has no connection to her birth parents. Her
adoptive mother, Jenny, was a school teacher and her adoptive father, Jim, a veterinarian. They
are both white. They adopted another child from China, May’s sister Vera who was 11 at the
time of the referral.
Presenting problem: May attended a small private school that was open and affirming,
with other children who identify as gay, trans, or gender non‐binary. A friend at school told
a counselor she was worried about May. The friend reported that May was “sad all the time,”
“not hanging out” as much, and she suspected that May had started cutting her arms with a
knife. The friend told the counselor that she believed May might “wish she was a boy.” When
the counselor checked in with May, she admitted to cutting and showed some superficial arm
wounds but did not mention gender or gender identity. The counselor called May’s parents
and asked for a meeting. At the meeting May’s mother, Jenny, guardedly explained to the
counselor that May had recently told her that she was uncomfortable as a girl and would
rather have been born a boy. Jenny explained that May always had dressed in more t raditional
masculine clothing and had just recently and hesitantly shared with her mother that she had
also begun to bind her breasts. Jenny also told the school counselor that May’s father, Jim, was
less communicative and supportive. Jenny was concerned about the cutting and was c urrently
monitoring May’s every move. The family was referred to a practicing family therapist, who
identified as a white gay/male and was experienced with issues related to gender identity
and expression.
Creating refuge
Refuge is a therapeutic space marked by compassion and curiosity about how the
unique developmental trajectory of the client is influenced by the experience of
oppression and domination. A refuge has all the hallmarks of therapeutic joining:
validation, acceptance, empathic listening, and so forth. However, creating refuge
asks the therapist to also consider oppression and domination as integral themes in the
presenting issue and/or in the client’s experience. For the therapist, part of the task is
in assessing how the various intersections of misogyny, heteronormativity, racism, and
classism are influencing the family system. In this way a refuge is a crucible where
contradictory motivations, fears, yearnings, and ideas normally prohibited and disal-
lowed are instead invited to the table to safely coexist and be acknowledged. In this
case, it means creating a space where dominating societal messages about gender and
gender expression as well as racism are suspended. Useful questions in this domain are
as follows: What developmental struggles are expected at this age and similar to all
youth? What particular developmental struggles will May face as she explores
her gender? Next, what unique struggles is May facing because of the particular way
family of origin, personality, queerness, able‐ness, race, gender, and sexuality intersect
in her life?
During the first session Jenny and Jim were present without May at the therapist’s
request:
Therapist: I understand you are coming in because May is exploring and finding gender
and you are both concerned about how to engage this.
Jenny: Yes. [Jim looking down and away from the others]
Jim: I don’t know why we are here, but I was told to come.
Therapist: It sounds like it might be hard to be here. Can you tell me what might make
it hard to be here?
Jim: I think they have left me out, and I am here as an afterthought. They started
wrapping May’s chest and I wasn’t even told and had to find out on my own.
What I think doesn’t matter.
Jenny: What you think does matter but sometimes I don’t know if you even want
to talk about this.
Jim: You are probably better off not involving me. Every time I say something
somebody explodes. No one wants to listen to what I have to say. The three
of you have a way of communicating that does not include me. I am the
awkward third wheel in the whole thing. That’s why I don’t even know what
I can do or why I am even here.
Therapist: It sounds like you are both here because you want to be of use and to find a
way to be there for May. But I also hear you struggling and scared to know
how to be there for each other along the way.
Jim: Yes. And be there for May and Vera.
Therapist: So you really want to be there…but it’s difficult. And this is a kind of d
ifficult
that you did not see coming and did not expect?
Jim: Definitely, when we adopted May from China, I knew it was going to have
challenges and so many others of those things I thought about, like May
having different heritage and race and the way that confuses people. And
even that has been harder than I imagined. But this I never saw coming, and
I really don’t know what to do. And I feel so bad at this…so awkward.
Therapist: That can be scary when you have most everything else thought out—and
yet, you don’t.
Jim: Yeah.
Therapist: Jenny, what’s this process been like for you?
Jenny: Alone. Walking on eggshells. Pressure. All he feels compelled to do is c riticize
me or explode when I worry about May and am trying to stay connected.
She is cutting and that really makes me worried. All he is worried about is his
feelings and his getting upset.
Therapist: So, you are trying to stay available and present for May and don’t feel
supported by your husband the way you yearn for. It sounds like it is hard to
see each other as a support right now.
Jim: That’s an understatement.
Therapist: So you knew that adopting May and Vera was going to make you different,
yet you went forward, unknowing and uncertain yet committed to the pro-
cess, regardless.
Jenny: Yes, we imagined it would be difficult, but we were determined to make it
work. We pushed through.
The therapist was primarily reflecting, normalizing, and recognizing that the
journey of difference and contrary opinion is challenging. The therapist recognized
that the lack of power and control that the father feels is a potential trigger for his
sense of worth and value and offered a refuge through the reflection and normalizing
with this challenging and unconsidered scenario. While Jenny remained engaged and
attempting to support May, she seemed to be balancing two competing goals—her
husband’s support or May’s happiness. Late in the session, the therapist acknowledges
the challenges and strength of the couple had in deciding to move forward with a
transracial adoption—in being similar to some families, yet different and unique in
other ways.
Difficult dialogues
The purpose of difficult dialogues is increased intimacy and authenticity, with both
others and with one’s self (Stone Fish & Harvey, 2005). In order for these dialogues
to happen, the status quo must be challenged, while the system maintains some meas-
ure of a sense of cohesion. The question becomes, “are we going to talk about it and
how?” Difficult dialogues are essential because they begin to allow us to explore the
role of patriarchy, societal expectation, and dualistic/binary oriented judgments that

hinder self‐expression, dignity, value, and worth. As such, difficult dialogues afford
opportunities to gather new information and to reconsider that which “could be.”
Difficult dialogues require bravery on the part of the clinician and the client; they ask
the clinician to open up and explore the inherited value systems of clients, trusting
that new ways of conceptualizing are possible and can emerge. Further, difficult dia-
logues ask clinicians to model and construct an engagement style dissimilar yet agree-
able enough to the client system. They ask clients to state assumed truths and remain
open and aware of potential new ways of conceptualizing “normal.” Difficult dia-
logues assume a social construction and begin to chisel away at that assumed
structure.
In a subsequent session with May and her parents, after refuge had been created
and the therapist was working closely with the family, the following dialogue occurred:
Therapist: So when May told you about the interest in shopping in the men’s depart-
ment, what did you initially say?
Jenny: Don’t tell dad.
Therapist: Really!??
Jenny: That and, I thought oh shit, now this.
Therapist: [to May] What do you remember from when you told mom?
May: She told me not to tell dad. But I didn’t want to anyway.
Jim: Well, that makes me feel included.
Therapist: Why do you think that came to your wife?
Jim: Because she knew I would freak out if she told me. I mean who wants to
have a daughter who wants to be a boy?
Therapist: Who doesn’t and why do you think that might be so?
Jim: Well who would want this for their child? Would YOU want this for your
child?
Therapist: Who do you think would? What would that parent need to do?
Jim: Well it would take just accepting it IS. And I don’t think I am ready to do
that. I mean what if May regrets the decision, and what if it is just a phase
that she regrets? What kind of dad would she think I am if I made the wrong
decision?
Therapist: What if we asked her? May what do you think would happen if your dad just
accepted this?
May: Well I think it would take a lot. I don’t know if he can. I mean mom didn’t
tell him because he would, like, just get pissed off and not talk about it. He
would have to sit down and he would have to talk about it with me. I think
sometimes he just wants to tell me and mom what to do and just go [puts
fingers in ears] blah‐blah‐blah‐blah.
Therapist: So if he was more open to accepting it, what would YOU have to do?
May: Sit down with him. Talk with him. [laughs]
Therapist: I am wondering what those interactions would look like?
May: I hate myself sometimes for feeling this way, sometimes, and then to hear
him not want to have anything to do with it really makes me mad. He
doesn’t have to worry. I know.
Therapist: It sounds like it’s been hard for you to get here May, to think about this part
of yourself—your gender and who you want to be. What do you think could
happen if people could talk more openly about this in your family, without
people criticizing, but being a little more open? Let’s say between you and
your father?
May: People could talk and listen.

Therapist: So something new could happen between you and him. Would it
change anyone else?
May: If he sat down and talked to me, he could talk to mom.
Therapist: And what do you think would it be like for them?
May: Really weird.
Therapist: [to Mom] What do you think?
Jenny: I agree.
Therapist: So who do you think would need to show up for those conversations?
Which parts of you? What would it ask of the people who show up for
those conversations?
Jenny: I think we would have to tell dad to sit down, chill out, calm down,
and just listen.
Jenny, Jim, May: [laughs]
Therapist: And what does he do now when he “show’s up”?
May: He needs to be right, and I can’t make him upset.
Therapist: And what would you, mom, need to do?
Jenny: Just tell him what I think rather than ask him what he thinks.
Jim: Wait a minute here, you don’t ever ask me what I think, you just
assume I am negative and dismissive.
Jenny: I sometimes want to ask, but I just get scared you’re just going to close
down, so I just handle it myself.
Therapist: This sounds really challenging for everyone. You know what else is
challenging? Walking the walk, not merely talking. You have both said
you do not want to follow traditional gender scripts, but in this
instance, that is, exactly what you are doing, right? Jenny, because you
feel responsible for the relationship and try to accommodate to your
husband and children’s needs constantly, you feel and are unsupported
by Jim, which makes you frustrated and alienated. And Jim, because
when things get out of control, you feel like you have to solve the
problem, and no one pays attention to you, and as a man, you are sup-
posed to be paid attention to and in control, you are frustrated and
alienated. You feed off each other and keep each other in gender scripts
that neither of you want to be in, right? Who do you think would be
most freaked out if this were to change?
Jim: Probably me! [Jenny and May laugh]
Therapist: What do you think May wants you to hear right now? What is impor-
tant for her well‐being?
Here the difficult dialogue involves exploring roles each family member assumes and
how they show up and relate within the issue that brings the family into treatment,
namely, May’s gender orientation and expression. The matter of gender expression also
brings to light the rules and roles of each family member. Jim’s parenting role embod-
ies rigidity, control, and withdrawal, while mom’s involves appeasing, accommodating,
and organizing her needs and wants around the expectation of her husband’s reac-
tions. The system’s orientation around heteronormativity is evident and developed
within their relational processes, and yet as the family works through the difficult dia-
logue, alternative possibilities emerge that challenge the previous paradigm. The thera-
pist is actively looking to support and challenge each individual while owning and
monitoring his own role as authority figure in the room. There is strength, courage,
and bravery with May expressing her needs, mom acknowledging her appeasing and
passive behavior, and dad acknowledging that he feels hurt and isolated when he is left
out. The goal of difficult dialogues is increased intimacy and authenticity with others
and oneself. These dialogues occur as one takes risks to be known as one truly is rather
than self‐modifying to avoid challenging the status quo.
Fostering queerness
As difficult dialogues involve an acknowledgement of social construction, the next
step, fostering queerness, involves social deconstruction and reconstruction. With the
experience of refuge and difficult dialogues as a foundation, there is opportunity to
appreciate the fluidity and potential of new options and experiences. Unmet and often
unknown client needs are revealed. The courage and openness fostered during diffi-
cult dialogues opens doors to what could be. Just as the dysfunction of heteronorma-
tivity breeds binary and a rigid/recursive roles of man/masculine and woman/
feminine typology (i.e., it shuts out options for role flexibility and keeps those roles at
bay), fostering queerness offers a recursive paradigm for flexibility, nondualism, and
an appreciation for the uniqueness of the individual (i.e., it opens up opportunities
and primes the system for more to emerge). Rather than obligatory acquiescence to
imposed roles, there are individuals with greater chance for actualization. The goal in
fostering queerness is to offer clients opportunities that claim uniqueness, strengths,
gifts, and idiosyncratic identity. Difficult dialogues have ensured an awareness of the
old expectation while fostering queerness offers new possibilities—and advantages.
The discussion becomes more specific, and experiences, ideas, and intersections that
are characteristic for the client are explored and interwoven to best provide support
for the development of each unique individual. Later in therapy, the following dialogue
occurred:
Therapist: So last session you agreed to refer to Mal as “he” since he feels con-
nected and aligned, using he/him pronouns. I am wondering what
that was like for all of you, to use he/him/his as his pronouns.
Jim: I was worried I was going to mess up.
Jenny: And we did mess up on a few occasions, and I told him it will just take
us some time.
Therapist: What was it like for you all to go through that transition? It really
seems like you are all working really hard here and wondering how it
was going to work out.
Mal: I knew they were going to mess up. It didn’t matter as much as at least
for once they were trying.
Jenny [to Mal]: Your father has done better than me this past week and I think it really
says a lot about him.
Therapist: What do you think it says?
Jenny: I don’t know what it says (tearing up a bit), but it means a lot to me.
Jim: Well I think I might have done good!
Mal: You did dad.
Therapist: Mal, do you think that your dad did better than your mom. I take it
that your mom is saying he was better with using your pronoun and
gender correctly, he/him; does that seem right?
Mal: Yes, he was.
Therapist: I wonder if you told him what that means to you?
Mal [looking at dad]: It means that you showed up for me. [tears]
Therapist: And what did that mean to you going forward.
Mal: That he will be there for me.
Jenny: We were always there for you.
Therapist: Yes, and something really meant a lot to Mal with [dad] trying
and being as successful as he was. What did you notice [to
mom]?
Jenny: I think it meant he [dad] had to let go of who he needed Mal
to be.
Therapist: And what do you think it took to do that?
Jenny: Courage. I think sometimes I still hold onto the image of my little
girl and who she, I mean he, will be. And I just realize it is so hard.
Jim: Yes, it is.
Therapist: So there is a loss there for both of you. Mal, as you hear that,
what is happening with you.
Mal: On some level I am sad to put them through this, but I know I
didn’t decide one day, “bam” I am going to be trans. And they
are showing up more, and I am happy for that….
Therapist: And….
Mal: I am pissed that I sometimes hear about how hard it is, for
them. How hard it is for them? It’s my life. I’m not DEAD. I
just want to be recognized for the man [correcting himself],
young man that I am.
Therapist: I am hearing how challenging it is to sometimes be in relation-
ship with your folks, yet it also sounds like you need them on
your side. That seems important to you.
Mal: Sometimes. Mostly not.
Therapist: So you said you are a self‐sufficient “badass.” Is that what you
said?
Mal: Yeah.
Therapist: I wonder if you have thought about what kind of man, what
kind of adult you hope to be?
Mal: Well….I just want to be a good one.
Therapist: I’m thinking that “badass” is useful to protect yourself but it is
not enough. As you of all people know we live in a world that
likes to divide men and women up. And sometimes men feel
pressure to not feel or need or express these feelings.
Jim: Yeah! Exactly!
Therapist: [to Mal] So your mom and dad, they are important to you
right? And sometimes when someone is important they can
hurt us, disappoint us?
Mal: Yes, I disappoint them too I guess.
Therapist: So, the question is what kind of man do you want to be? How
do you want to handle it when you’re hurt? Being a “badass”
for some men might mean pretending that people who are
important aren’t really that important? Can you think of a dif-
ferent option?
Mal: Well…. [trails off….pause in session]
Therapist: Dad, I wonder if you might have a thought?
Jim: Well, I’m not sure I’m much better at that. But I’ve learned that
I pretended that things and people weren’t important and it made
me feel angrier and lonelier. I don’t think that made me stronger.
Therapist: Can you think of a way or a path that is better for you and for Mal?
Jim: I’m thinking that really being strong means being able to somehow balance
feelings of hurt and feelings of love.
Mal: It does not take a strong man to pretend he doesn’t want or need love. It
takes a scared one.
Jim: That’s my boy! [everyone laughs]
Therapist: Mom and Dad, I am thinking about something you said last week when we
initially met. You knew having an adopted child from a different culture
would challenge you. Did you consider how it might challenge and change
you?
Jim: What do you mean?
Therapist: I am wondering if either of you would like to consider how being different,
being unique from the status quo might change you?
Mal: Well I know it changed me. It made me tougher. I know being different
from other kids and having a different background from my family made me
learn to stop giving a shit.
Therapist: And what did that challenge help do?
Jim: I think she learned to be a bit of her own person, sooner. Maybe she had no
choice, but it definitely changed her. Well it was “her” back then. See I
messed it up again.
Therapist: And what did that do for you, Jim?
Jim: I gained a respect of Mal’s strength and resilience. It helped me be stronger
I think. I can’t say how, but it did.
Therapist: That can be the beauty of difference. Sometimes, we see the possibility of
something new emerging. I wonder if you ever thought about what that
difference fostered in each of you?
Jim: I think at my best, I am a better dad.
Therapist: Can you tell Mal what you mean?
Mal: I think I know…
Jim: No, I do not think you know just how much joy you have brought to me, us
really (Jim takes Jenny’s hand), and how scared I get sometimes. I think
your mom always knew it would be challenging at times. I think I didn’t
want to look at that [he begins to get tearful]. Watching you made me real-
ize sometimes how scared I was and how strong I, actually we all could be.
Therapist: Mal and Mom, what is it like to hear that?
Jenny: I knew he always masked being afraid, he always said “it will be fine,” but I
do not think he meant it.
Therapist: And how was it to hear what he said?
Jenny: I think I realize that he does understand what I, really all of us I guess, were
going through.
Here the family highlights a subtle shift that emerged when the father adapted
quicker (than mom) to Mal’s preferred, more accurate pronoun, he/his/him. We see
that Jim’s fluidity and flexibility takes on added significance, both to Mal, who
expresses appreciation and acknowledgement of the act, and between Jenny and Jim.
They are able to appreciate the shared challenge, courage, and grief they are continu-
ing to demonstrate. As we explore this exchange, we note that as Jim shifted toward
a more accepting and flexible place of acknowledging Mal’s gender expression, Jenny
is able to acknowledge her own struggles and grief. Through nurturing queerness,
both parents and Mal were able to express previous unclaimed, unexpressed parts of
themselves. Mal’s strength, individuality, and needs are considered and supported and
are appreciated as unique and valuable. Mal’s work in defining himself has helped
the family to expand its expression and intimacy. This leads to another, parallel and
difficult dialogue:
Jenny: After all of our fertility troubles, we just wanted to be a “normal” family.
I think we were focused on making sure the kids felt included and a part of
a family. We didn’t want them to feel different. We didn’t want to be
different.
Mal: But we were different!
Jenny: When Mal went to school initially, it was so tough, she looked different from
other kids, and she was picked on. I was surprised how much of a challenge
it was.
Therapist: It seems like this was harder than you’d imagined.
Mal: It was so hard. And that was hard for you and Dad to understand for a long
time.
Jenny: I just wanted you to feel a part of the world, like you belonged.
Mal: You mean you wanted me to feel “white.”
Jenny: No! I did not think of it that way.
Therapist: [to Mal] Can you say more about this?
Mal: It was hard because they did not understand what it was like for me and
Vera. To them we were just their kids, which was great on the one hand, but
not helpful on the other. Because the world did not see us that way…did not
see us as…. normal…as belonging.
Therapist: Do you meant that the world did not see you as white?
Mal: Yes, exactly. I am not white and I am not Chinese but I am a little of both
of these.
Therapist: What was that like?
Mal: Well it’s a lot like being trans really. It is like being in the middle and not
knowing where you belong. And I knew my parents loved me but they did
not understand. I did not know how to talk about this with them. Like mom
said, they wanted to be “normal” and yet we were different and we stuck
out. Even different from my parents.
Therapist: Well, it sounds like being white meant that your parents did not understand
what the world was like for you and Vera? They did not understand what
being not really white and not totally Chinese was like. And you could not
quite fit the way they had anticipated?
Mal: Exactly. They could not even see it. We are not normal maybe but we are
strong and different.
Jenny: I would like to understand better. I think I am understanding better.
I know I am not Chinese. But I don’t exactly feel totally white either. Not
like I used to.
Jim: I think there is a lot we did not understand. And I also think we should
include Vera in this conversation.
Therapist: I think that is a great idea. And this is a good start to an important discussion
about who you are as a family and how being different has changed all of you
in some important ways.
It is not just Mal who is beginning to experience a shift in identity and self‐expres-
sion. The entire system, which initially longed for and celebrated sameness (“a normal
family”), is beginning to claim, understand, and express an appreciation of differ-
ence—and the strength and potential gifts of that difference. The various identity
aspects seen as potential struggles (transracial adoption, gender expression) are

contributing to a more connected sense of self, including the identity of authentic
family self, and more authentic individual self. There is not just opportunity to express
difference, but there is a need to acknowledge and take ownership of difference—and
celebrate the strengths and liberation that accompanies that ownership.
Encouraging transformation
In this phase, treatment is focused on integration. Once we create refuge and forge it
by honest, difficult dialogues, deepen the discussion to nurture the unique intersec-
tions of queerness, and then integrate the emerging identity, ideas, and experiences,
transformation can occur.
Rather than view enigmatic and unorthodox gender expression and sexual desires
as problematic, therapy mines them for sources of healing and metamorphosis.
Transformation is marked then by an ongoing focus on resilience, a lessening of dom-
ination, and an emergence of voice, fluidity, and creativity. This is an opportunity of
reflection, inventorying change, and as conflicts or struggles emerge, focusing on
resilience skills and previous demonstrated strengths.
Mal and his parents asked the school to use him/her/his pronouns in the class-
room and social interactions before the following session:
Mal: Most of them [at school] were great.

Jim: Was Mr. [x] able to keep up?
Mal: Yes! I don’t care what he says. He’s old!
Jenny: So it went smooth?
Mal: I think so, mostly. It was weird because I felt happy and then like I was the
center of attention. And that bothered me.
Jenny: Mal, what do you think you want from people at school?
Mal: Mostly, just to not be a freak. For people to know me as Mal. That’s
who I am.
Therapist: And what do you think you need from your mom and dad here, now?
Mal: [quietly] Just to know it’s hard.
Therapist: And when it is hard what helps you?
Mal: For them to be around….
Therapist: Anything else?
Mal: [For them to] Listen.
Jim: We are here.
Mal: I know.
Jim: Listen, we are all our own little island here. And at times it feels tough, like
we are getting battered around by a hurricane.
Jenny: We knew early on we wanted children and were going to adopt you. I’ve
been learning so much since then. Still learning about how we are different
from other families, but we knew we wanted you more than we worried
about being different. And that hasn’t changed.
Jim: That was the best decision we ever made.
Mal: [blushingly] I know. [laughs]
Transformation is marked then by an ongoing focus on resilience, a lessening of

domination, and an emergence of voice, fluidity, and creativity. Here the family is
initially focused on small milestones in Mal’s gender identity and expression and the
strengths and challenges brought from it. Mal is seen as a capable and creative
adolescent within the session. Like any adolescent, he has emerging self‐sufficiency
and a need for support and guidance. His parents demonstrate the capacity to be less
directive and more receptive while honoring Mal’s voice, opinions, and struggles. As
a result, the different parts of Mal are honored and integrated: He longs for auton-
omy and also to feel connection. He desires to be heard, but also to be guided. In the
process, Jenny and Jim recognize their own journey and transformation. They see
their own challenges in having a nontraditional family in a different, yet similar parallel
to Mal’s: They see the need for structure and predictability and the need for flexibility
and to adopt to evolving and unpredictable circumstances.
Future Directions
Systemic family therapists are on the front lines, observing how power imbalances act
to stymie individual growth and relational process. Yet, as a field, we have only touched
the surface of understanding the deleterious effects of heteronormativity on these
processes. It is difficult to imagine life outside of a box while contained within it.
Heteronormativity is like this. It is pervasive, meaningful, and entrenched. It empow-
ers and it disempowers. It is not the same in every country or culture, yet there is a
ubiquitous element that is transcendent, namely, power differentials based on social
constructions of gender.
There is an ever‐growing amount of evidence that binary gender roles and expecta-
tions limit human capacity and block intimacy (Giammattei, 2015; Giammattei &
Green, 2012; hooks, 2004; Knudson‐Martin & Laughlin, 2005; Laszloffy & Harvey,
2006; Real, 2007). In the future SFT must design research that makes these limita-
tions visible even while they remain mostly hidden. Research must be constructed that
acknowledges that men and masculinity have been empowered to be in control while
also infantilized emotionally and excused in relationships for being so. Women and
femininity have been disempowered while being tasked with relational responsibility,
encouraged to abandon themselves to take satisfaction in the care and “control” of
others, particularly men/masculinity, who traditionally offer women/femininity indi-
rect access to power. What is the effect of all this on individual development, attach-
ment, intimacy, and relational health and satisfaction? And what are the intersectional
and cross‐cultural differences relative to this? How does heteronormativity protect or
pressure relationships differently in Western cultures where autonomy and individual-
ism is valued as opposed to African, Asian, or Latin cultures where one’s identity is
more firmly located in a family or community? These are the questions that future
SFT research ought to address in order to fashion clinical interventions that protect
client systems from the mental health impact of oppression.
The evolution of thought about gender and sexuality is being clarified in no small
part because of the visibility of the increasing numbers of people who report being not
heterosexual and/or gender nonconforming (Gates, 2017; Meerwijk, & Sevelius,
2017). As people construct and live their lives, they have slowly built interpersonal rela-
tionships that have increased acceptance of LGBTQI people and shifted the global
context considerably within just the past few decades. Yet this community continues to
live with chronic levels of stress in reaction to the continued oppression they experience,
pressures that are then aggregated when heteronormativity interlocks with racism,
classism, misogyny, and others. And the SFT research about the effects of this on couple
and family systems is exiguous.
While there is a limited amount of literature that considers queer identity devel-
opment outside the lens of Western societies (Cheng, 2018; Ellawala, 2018;
Ferdoush, 2016), this development is recent and nascent. SFT research that com-
prehensively considers multiple intersectional variables such as race, ethnicity, class,
and culture (to name a few) is scant. As a result, the impact of intersectionality on
LGBTQI identity development and on actual couples and families remains grossly
under investigated. As the queer community’s form has outgrown the function of
binary and monolithic representation, future research and practice must follow suit
in order to be empowering, comprehensive, and innovative and to fully represent
all that is (and can be) “queer.”
Conclusion
Mal is one of an increasing number of people (youths and adults) who are forging
lives on the borders of the binaries of race, gender, and sexuality. In the process they
are finding and claiming intersectional, multidimensional identities. Mal’s courage
and growing clarity were cultivated in SFT fostering greater emotional range and
fluidity of roles for him as well as for his family members. This is a generous gift
offered by LGBTQI people to the families and cultures in which they live. They dem-
onstrate and remind everyone of the capacity of the human spirit to claim a life lived
with authenticity. The authors believe in, and Mal and his family are one example of,
the transformative potential in challenging heteronormativity and ameliorating its
influence.
Systemic family therapists are well positioned to either collude with heteronorma-
tive gender constructions (Laszloffy & Harvey, 2006) or act as mediators (Knudson‐
Martin & Lauglhin, 2006) who work on behalf of clients to open up space and
possibility to mitigate otherwise unyielding cultural scripts about gender role and
sexuality. To accomplish the latter SFT must examine and acknowledge the connec-
tion between heteronormativity and other interwoven systems of domination, misog-
yny, racism, and classism so that the specific intersectional experience of oppression
can be understood and explored for each client system.
Notes
1 Note: Throughout this chapter we decided to mostly utilize the acronym “LGBTQI” as
an umbrella term denoting those with sexual and/or gender minority experience. This is a
vast, diverse, ever‐evolving community, and we are sensitive to the need to respect each
person’s right to language that fits their experience. We use this term as a way to be as
inclusive as possible while recognizing that it is imperfect. In moments we also use the
word “queer” as a synonym for LGBTQI. We choose this in some moments either to
underscore the evolving nature of this community and its potential to subvert the norms
of heteronormativity or to simply reflect the theoretical ideas of queer theory.
2 The following case vignette, original to this publication, is a composite of actual cases with
extraneous material added or omitted in order to protect confidentiality.
3 Note: May is referred to with the female pronoun, until at one point in the therapy May
decides to be referred to as “Mal” and thenceforth be referred to with the pronouns he/him.
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23
Interventions for Challenges
Encountered in Childcare
and School Settings
Amber Vennum and Eric T. Goodcase
In the United States, just over half of children ages 4–5 years old attend daycare cent-
ers, and the majority of children aged 5–17 (94–99% depending on age) spend 6–7 hrs
in school per day (U.S. Department of Education, 2018). Additionally, over half of
children ages 6–17 participate in at least one extracurricular activity (U.S. Census
Bureau, 2014), with the vast majority of these activities being associated with their
school in some way (Melman, Little, & Akin‐Little, 2007). Further, about one‐quar-
ter of children are enrolled in an afterschool program, with Hispanic and Black chil-
dren being two times more likely to participate in afterschool programming than
White children (Afterschool Alliance, 2014). Altogether, many children and adoles-
cents spend large amounts of time in structured settings receiving education, enrich-
ment, or childcare apart from their families.
Although these structured settings provided by youth‐serving organizations (YSOs)
provide many opportunities for youth development (e.g., education, physical activity,
a sense of belonging, mentorship, positive reinforcement, social skill development),
they also provide opportunities for adversity (e.g., bullying, rejection and isolation,
peer pressure for risky behavior, discrimination, punishment) that can increase youth
mental health issues and risky behaviors. YSOs often collaborate to coordinate ser-
vices, share resources, and increase access to families, resulting in a complex web of
interrelated systems that share space, staff, challenges, and solutions. Effectively help-
ing parents and youth navigate challenges involving interrelated YSOs requires sys-
temic family therapists (SFTs) to include YSOs in their assessment of the contextual
risk and resiliency factors impacting youth and their families and expand the direct
treatment system when appropriate.
The purpose of this chapter is to describe common challenges youth experience in
YSOs (schools, afterschool programs, extracurricular activities, and childcare settings,
specifically), review effective multisystem interventions for these challenges, outline a
four‐level conceptual framework for working therapeutically across multiple systems
572 Amber Vennum and Eric T. Goodcase
that impact children and adolescents, and provide recommendations for advancing
interventions with youth, families, and the YSOs that serve them.
Common Challenges Experienced by Children

and Adolescents in YSOs
When the structure, rules, norms, or expectations of a school, afterschool, extracur-
ricular, or childcare setting and a youth’s optimal environment do not match, symp-
toms such as externalizing and internalizing behaviors, disengagement, challenges
with peers, or refusal to attend or participate may be observed by caring adults or
reported by the child or adolescent. Accordingly, in addition to the assessment of risk
and resiliency factors at the individual and family level, mental health practitioners
must assess multiple components of the YSOs the youth spends time in as well as the
interactions between the family and the YSO staff.
A prominent conceptualization of how risk and resiliency compiles throughout
childhood to impact lifelong psychological, behavioral, and health problems is the
idea of adverse childhood experiences (ACEs). Kalmakis and Chandler (2014) define
ACEs as “childhood events, varying in severity and often chronic, occurring in a fam-
ily or social environment and causing harm or distress” (p. 1489). Examples of ACEs
include experiencing abuse or neglect; parental separation or divorce; poverty and
discrimination; community violence; school violence and bullying; maltreatment by a
teacher; natural disaster; witnessing violence; experiencing or witnessing substance
misuse, severe illness, or incarceration of a person close to oneself; and being sepa-
rated from one’s family (Kalmakis & Chandler, 2014).
The greater number of ACEs a person accrues, the greater their risk for experi-
encing school disengagement (Bethel, Gombojav, Solloway, & Wissow, 2016;
Bethel, Newacheck, Hawes, & Halfon, 2014), being diagnosed with numerous seri-
ous physical and psychological health issues (e.g., cardiac disease, autoimmune dis-
ease, mood and anxiety disorders, substance use disorders, suicidal ideation) and
further participation in, or exposure to, risk (smoking, substance use and abuse,
intimate partner violence, delinquency, homelessness; see Kalmakis & Chandler,
2015) for a review). ACEs amplify adverse outcomes through impairment in brain
structure and function and changes to the immune system caused by the body cop-
ing with chronic stress (e.g., Anda et al., 2006; Danese & McEwen, 2012). Recent
research suggests that these deleterious processes may interact with societal inequal-
ities to result in social (not just physiological) pathways by which risk for adversity
increases due to lower perceived social support and self‐regard (Nurius, Green,
Logan‐Greene, Longhi, & Song, 2016).
Accordingly, youths’ resilience can be bolstered by multilevel (youth, family, YSO)
interventions that encourage a positive outlook; teach healthy coping, mind–body
connection, and self‐care; build social support; and promote reliable and caring adult
relationships (e.g., Bethel et al., 2016; Traub & Boynton‐Jarrett, 2017). For exam-
ple, positive school–family relationships have been found to protect against youth
suicidality, violence, substance and tobacco use, and depression (Resnick et al. 1997;
Wang & Sheikh‐Khalil, 2014) and improve academic achievement (Jeynes, 2012),
engagement (Wang & Sheikh‐Khalil, 2014), social skills, and behavior problems
Multi-level Systemic Interventions for Youth 573
(e.g., El Nokali, Bachman, & Votruba‐Drzal, 2010). In the following sections, we

will discuss specific systemic risk and protective factors for common challenges expe-
rienced in YSOs, propose general guidelines for SFTs to effectively intervene at mul-
tiple levels of interrelated systems to improve youth outcomes, and provide examples
of multilevel empirically supported interventions to address these challenges.
Youth disengagement
Engagement in academic, social, and extracurricular activities can be defined in terms
of behavioral participation and attendance, positive emotional interactions and ties to
a YSO, and cognitive effort representing a desire to learn or master skills or concepts
(Fredricks, Blumenfeld, & Paris, 2004). At an extreme, school refusal/avoidance is
when a youth expresses reluctance to attend or stay at school due to distress or anxiety
(whereas persistent truancy is conceptualized as a youth failing to attend class due to
the potential presence of conduct disorder symptoms; Knollmann, Knoll, Reissner,
Metzelaars, & Hebebrand, 2010). Engagement with educational and extracurricular
YSOs is associated with improved school and future occupational outcomes, decreased
risky behaviors (e.g., smoking, drinking), and improved socioemotional development
for diverse youth (e.g., Abbott‐Chapman et al., 2014; Fredricks & Simpkins, 2012; Li
& Lerner, 2011). Examples of youth struggling with disengagement may include a
youth avoiding school or certain classes, getting in trouble often for spacing out in
class, being benched on a sports team for not being prepared for practice, and so forth.
Youth who have experienced ACEs or have a diagnosed mental disorder are at
higher risk for school refusal and low school engagement (e.g., Bethel et al., 2014,
2016; Knollmann et al., 2010) than youth who have not. Racial minorities are also
at higher risk for low school engagement and school refusal as the dropout rate for
Blacks is 6.2% and 8.6% for Hispanics compared to 5.2% for Whites in 2018 (de Brey
et al., 2019). This difference in school engagement is further evidenced by school
suspensions and expulsions that reflect structural racism and discrimination in
schools (e.g., Skiba, Chung, Baker, Sheya, & Hughes, 2014). For example, across
the United States in 2015–2016, although black students accounted for only 8% of
enrolled students they represented 25% of males receiving out‐of‐school suspen-
sions, and 14% of females receiving out‐of‐school suspensions, whereas White stu-
dents were suspended at lower rates than they were enrolled (US Department of
Education, 2019).
Research findings also highlight the strong positive relationship between youth
social capital (supportive adults at home, at school, and in the youth’s community)
and engagement (Woolley & Bowen, 2007). For example, numerous studies point to
the potential positive impact a well‐functioning parent–school relationship can have
on school outcomes (for a review, see Hill and Taylor (2004)). Specifically, parental
school‐based involvement (activities in which the parent has direct contact with the
school) during preschool and kindergarten is positively associated with higher cogni-
tive competence and school readiness (Culp, Hubbs‐Tait, Culp, & Starost, 2000),
children’s future reading achievement, grade retention, and reduced need for special
education (e.g., Dearing, Kreider, Simpkins, & Weiss, 2006; Meidel & Reynolds,
1999). Students with parents who are involved at their children’s school and collabo-
rate with school professionals are also more likely to perceive themselves as cognitively
competent, have teachers who perceive their teacher–student relationship as close
(Topor, Keane, Shelton, & Calkins, 2010), are less likely to drop out of school, and
are more likely to graduate on time and pursue post‐secondary education (Barnard,
2004; Garnier, Stein, & Jacobs, 1997). Youth are also more engaged in extracurricu-
lar activities if their parents are helpful and supportive as opposed to disinterested and
disengaged or pressuring and overly critical (e.g., Beets, Cardinal, & Alderman,
2010). Many other factors may also influence a child’s engagement with extracurricu-
lar activities such as family transience or immigration status, family resources, inclu-
sion of youth with disability status, access to transportation, racism or discrimination
in the community, and geographical location.
Safety and bullying

Maintaining a safe environment for children is an important component of a YSO’s
structure that increases academic achievement and engagement and reduces youth
internalizing and externalizing symptoms. However, 6.7% of students from a national
sample reported not attending school because they felt unsafe on their way to school
or at school within the previous 30 days (Kann et al., 2018). While unlikely, tragic
events such as school shootings are a common fear for parents and students, but the
everyday issues of school violence, discrimination, and bullying that contribute to a
culture of fear at a YSO are seen as critical intervention targets for reducing violence
(Cornell, 2015; Juvonen, 2001). Bullying can include unwanted physical or verbal
aggression, sexual harassment, and other relational aggression (exclusion, spreading
rumors, etc.) that takes place between peers with an intent to cause fear or harm
(CDC, 2009; Miller & Mondschein, 2017). Electronic bullying, also known as cyber-
bullying, is any form of bullying that takes place in an electronic medium such as
verbally aggressive text messages or emails, pretending to be that person online,
threatening to hurt someone online, distributing or posting online inappropriate or
humiliating photos or videos of someone without their consent, or utilizing social
media to harass, exclude, or embarrass another person (Cyberbullying Research
Center, 2016). Electronic bullying is distinct from other forms of bullying because it
can reach people at any time, has the potential for a larger audience and multiple par-
ticipants if the bullying takes place on a common platform like social media, and can
be more permanent.
About 34% of 10–20‐year‐olds report at least one harassment incident in the past
year with 46% of harassment victims reporting at least one incident that involved tech-
nology (Mitchell, Jones, Turner, Shattuck, & Wolak, 2016). Mitchell et al. (2016)
found that harassment that occurred solely through technology was less likely to be
ongoing or involve a power differential than in‐person harassment, but harassment
that occurred both in‐person and through technology caused the most emotional
distress. Individuals that are bullied during childhood report greater levels of psycho-
logical distress, depression, anxiety, and suicidality as adolescents with effects carrying
into adulthood (e.g., Copeland, Wolke, & Angold, 2013; Farrington, Loeber,
Stallings, & Ttofi, 2011; Takizawa, Maughan, & Arseneault, 2014). Victims of bully-
ing may also perpetrate bullying. Victim‐bullies are more likely to be emotionally
reactive in their bullying (as opposed to intentional/goal oriented; Haynie et al.,
2001), are aggressive, and have less social support (Unnever, 2005). Both victims and
perpetrators of bullying are more likely to commit suicide or have suicidal thoughts,
with people who were both victims and perpetrators of bullying being most at risk
(Holt et al., 2015).
The safety level of an environment is not experienced in the same way for every
student. In a national sample of high school students, minority race students (6.8%
Black, 7.6% Latino/a, 5.3% Asian, 6.3% multiracial) reported feeling more unsafe on
their way to school or at school within the previous 30 days compared with White
students (4.2%; CDC, 2009). In addition to race, risk factors for bullying include hav-
ing a developmental or learning disability, higher intelligence, lower SES, obesity, or
sexual minority status (Hong & Espelage, 2012). Bullying victims are also more likely
to be more emotionally sensitive and have higher baseline levels of fear (Haynie et al.,
2001). Grade in school and age also play a role in frequency as bullying tends to peak
in middle school and decrease in high school (U.S. Department of Education, 2013).
Experiencing higher ACEs also increases youths’ likelihood of reporting both victimi-
zation and perpetration of bullying and violence (Forster, Gower, McMorris, &
Borowsky, 2017).
A review of family dynamics of individuals involved in bullying has shown that vic-
tims of bullying are less likely to have parents who are supportive and affectionate and
are less likely to have good communication with their parents (Lereya, Samara, &
Wolke, 2013). Children who exhibit bullying behavior are more likely to have coer-
cive parents, experience hostility from parents, and be exposed to marital conflict in
their family system (Haynie et al., 2001). While poor family relationships can be a risk
factor, highly involved and supportive parents are a protective factor against bullying
(Lereya et al., 2013).
Community‐level protective factors against school shootings include fewer guns in
the population (Kalesan, Lagast, Villarreal, Pino, Fagan, & Galea, 2016) and more
restrictive gun laws (Sutton, 2017). YSO protective factors against teen bullying and
violence include youths’ perceptions of a positive school climate and connection to
their school, building supportive relationship with their peers and teachers, and
changing YSO policies and norms around violence (e.g., Gregory et al., 2010;
Kendrick, Jutengren, & Stattin, 2012; Lösel & Farrington, 2012; Vagi et al., 2013).
For example, studies have shown that some schools that have anti‐bullying policies
have positive results on reducing bullying while others have had no reduction of bul-
lying, but schools with policies that explicitly protect LGBT individuals consistently
reduce bullying directed at LGBT individuals (Hall, 2017). Additionally, Brookmeyer
et al. (2006) found that students who felt more connected to their schools showed
reductions in violent behavior over time.
Perceptions of difference
Youths’ view of themselves is in part derived from comparisons to others (Wood,
1989); thus, messages they receive (either overt or covert) about their competence,
ability, likability, and so forth, in comparison to others can have a strong impact on
their developing self‐concept and self‐esteem. When youth perceive unfavorable dif-
ferences between themselves and their peers (e.g., body image, popularity), receive
messages that they are less good than others (e.g., children who feel rejection from
peers, have low grades, have less skill achievement, or have been given a specific
label or diagnosis identifying them as different), or perceive that they are treated
poorer or less fairly than their peers (e.g., selected to participate less often than oth-
ers, disciplined more harshly than others, treated disrespectfully by an adult), they
may begin to develop a negative self‐concept in relation to a specific competence
area or develop overall negative self‐esteem (e.g., Kutob, Senf, Crago, & Shisslak,
2010; Leflot, Onghena, & Colpin, 2010; Marsh & Martin, 2011; Tabbah, Miranda,
& Wheaton, 2012). Reductions in self‐concept and self‐esteem due to perceptions
or messages of difference may lead to further reductions in academic achievement
(e.g., Marsh & Martin, 2011), increases in externalizing and internalizing symp-
toms (e.g., Lee & Stone, 2012), and loss of social ties (Moses, 2010). Relational
factors such as supportive peer and parent relationships and positive socialization of
minority youth may increase youth resilience in the face of perceptions of difference
(e.g., Holsen, Jones, & Birkeland, 2012; Neblett, Rivas‐Drake, Umaña‐Taylor,
2012). For example, a female who goes through puberty later than her peers may
feel self‐conscious and begin to feel like something is wrong with her as she sees her
friends’ bodies and clothes change. Her friends might begin to not include her on
trips to the mall to buy bras, and she might feel out of place when her friends want
to begin having group dates that she does not feel ready for. Her parents and teach-
ers might notice she seems more withdrawn than previously and is participating less
in class.
Peer pressure for risky behavior

Youth attending YSOs are constantly interacting with their peers which can lead to
positive outcomes like building a social network, learning social skills, and feeling sup-
ported; however, children and adolescents can also experience peer pressure to engage
in risky sexual behavior, drugs and alcohol, cheating on tests, and so forth. Research
has shown that children as young as preschool age are susceptible to peer pressure
(Haun & Tomasello, 2011). Pressure to conform to their peers’ beliefs or behaviors
can come from external implicit or direct messages from peers or from internal anxiety
a youth feels to conform (e.g., Buckner, & Shah, 2015).
Children and adolescents who have friends who engage in risky behaviors (early‐
onset alcohol/drug use, risky sexual behavior, etc.) are more likely to engage in risky
behaviors themselves (e.g., Jaccard, Blanton, & Dodge, 2005). However, there is
evidence that adolescents with peers who engage in risky behaviors are less likely to
succumb to peer pressure if they are religious, have other peers that display prosocial
behaviors, have a strong sense of personal identity (Dumas, Ellis, & Wolfe, 2012), and
have a positive attitude about their health (Cattelino, Glowacz, Born, Testa, Bina, &
Calandri, 2014). Children or adolescents may be more susceptible to peer pressure if
they are male, are anxiously attached to friends, have low self‐worth (Lebedina‐
Manzoni & Ricijaš, 2013), or are depressed (Prinstein, Boergers, & Spirito, 2001).
Possible family‐related risk factors for being susceptible to peer pressure include par-
ent permissiveness, lower levels of monitoring (Lebedina‐Manzoni & Ricijaš, 2013),
and poor family functioning (Prinstein, Boergers, & Spirito, 2001). For example, a
teenage boy with mild social anxiety may have a harder time not drinking at a post‐
prom party if his parents are so caught up in their divorce that they do not know it is
prom, making him feels like his parents do not care about him than if his parents
expressed to him how much they value him and talked with him before prom about
his plan for if others are drinking and how he can make responsible decisions.
Helping Parents and Youth‐Serving Organizations Come

Together to Improve Child Outcomes
Sprenkle and Blow (2004) propose that in order for systemic therapists to transform
the reciprocal influences on the problem, it is important to expand the direct treat-
ment system and therapeutic alliance to involve more people in therapy than the
identified patient (Sprenkle & Blow, 2004). Accordingly, we propose the following
levels of intervention for working with families to address challenges encountered in
larger systems their children interact with: (a) interconnected system assessment, (b)
YSO consultation, (c) multisystem collaboration, and (d) YSO system change. These
levels of intervention are informed by the levels of interventions Berryhill and Vennum
(2015) distilled from school‐based family therapy models, Bronfenbrenner’s ecologi-
cal model of human development (1977), and basic assumptions of general systems
theory and cybernetics (see Hecker, Mims, and Boughner (2003) for an overview).
The processes by which a systemic clinician intervenes at each of these levels would be
guided by their own theoretical orientation. For example, the first author uses primar-
ily solution‐focused brief therapy (de Shazer, 1988) and Satir’s human validation pro-
cess model (Satir, Gomori, & Gerber, 1991) theoretical lenses in her own work with
youth, families, and YSOs at all four levels of systemic intervention. We will use the
following case vignette to demonstrate what therapy at each level might look like:
Caroline (White, 45) and Jemal (Black, 39) decide to bring their son Zain (15) to therapy.
Zain, normally an average student, is failing several of his classes, is occasionally skipping
school, and is getting in verbal fights with other students. Caroline and Jemal were first
called about Zain’s fighting with peers about halfway through the previous school year. They
thought the summer would allow Zain to start with a new perspective, but now he is skipping
school, isolating himself, and refusing to attend mosque with his father. His parents are very
worried, have tried numerous strategies without effect, and are not sure what else to do to
help Zain.1
Level 1: Interconnected systems assessment

Due to the impact of larger systems on youth outcomes, it is important to assess rel-
evant risk and protective features for the specific challenge(s) a youth is experiencing
(e.g., as outlined in the previous section) across the YSOs a youth is involved with as
well as the relationship between their family and each YSO. It is also very important
to address perceptions of minority and majority status in the community and discrimi-
nation the family or child have experienced as larger community dynamics and distri-
butions of power and resources may influence dynamics between families and YSOs
or within YSOs.
Youth assessment The therapist can start by briefly identifying what YSOs the youth
is involved with, if any (e.g., school, daycare, sports, clubs, etc.), as well as the youth’s
experience of the different YSOs (e.g., Do they enjoy it? How do they feel about the
amount of time they spend involved with each YSO?). It is important to identify vari-
ations in the degree to which the issue and associated symptoms are a problem at each
YSO, and the youth’s and family’s perceptions of why or why not, to pinpoint poten-
tial points of intervention and protective factors.
As part of assessing risk and protective factors, the therapist can also ask youth
about important relationships they have with their peers and adults at the different
YSOs (e.g., Does the youth experience any bullying or discrimination? Who are their
best friends there? Do they have an adult they can rely on when they are there? Who
thinks positively of them there?). Additionally, it is important to understand the
youth’s identity as it relates to school or other YSOs (e.g., How do they think about
themselves as a student? How important is it to them to be considered a dancer/
athlete/photographer/etc.? How does their involvement with each YSO influence
who they are?), as well as how messages from parents, peers, and YSO adults influence
the youth’s perception of themselves.
Family assessment In addition to the common theory‐based assessments therapists

use to understand how challenges are experienced in a family system, the therapist can
also ask the family about their observations of how the presenting problem or associ-
ated symptoms impact their child at school or other YSOs (e.g., their child does not
get to play in sports games, their child does not want to go to school, their child sits
alone in the afterschool program). Additionally, it is important to understand the fam-
ily’s perception YSOs in general (e.g., What were their own experiences with YSOs as
youth? How did they decide which YSOs to connect their child with?), how YSOs
have responded to their child’s symptoms, the degree of conflict or collaboration
between YSOs (e.g., How well do the school and afterschool program communicate
about peer relationships, academic challenges, etc.?), and communication experiences
of the family with the YSOs (How often is there communication between the parents
and YSO staff members? What do conversations with YSO staff look like? Do the
parents feel welcome to contact the YSO? Do the parents feel they have power to
influence the experience their child has at the YSO?).
Vignette: Interconnected systems assessment The therapist meets with Zain alone to
join with him and give him space to discuss his experiences. Zain generally presents
with affective symptoms congruent with a diagnosis of depression. Zain expresses that
he hates going to school and the only reason he goes to school is so he can play base-
ball in the spring. He says he wants to be a professional baseball player and does not
understand why he needs good grades to do that. Zain is mostly quiet in response to
the therapist’s questions about peer relationships and reveals that he only has two
friends at school and the rest of the kids are dumb and not worth his time. Zain states
that he when he gets in trouble at school it is because the other kids were “getting in
his face” first. When asked if he felt like he was bullied, he said no and downplays
these conflictual peer interactions. The therapist then assesses for positive relation-
ships with adults, and Zain expresses that he likes his school counselor, Ms. Davis, and
the baseball coach and gym teacher, Mr. Phillips.
The therapist then invites in Zain’s parents and assesses the parents’ beliefs about
what is going on. Jemal believes that Zain “needs to pull it together” and is concerned
that Jemal will not be eligible to play baseball and eventually not be able to graduate.
Caroline agrees that Zain is partly to blame but did not get the sense his teachers
believed in his potential and have already given up on him based on their conversa-
tions at parent–teacher conferences. Both Caroline and Jemal report that Zain has
grown increasingly withdrawn and is spending more time with his new friends who
they do not know very well, but wonder if they are a bad influence. Caroline reported
that the afterschool program Zain attends until baseball starts has told them that they
are having trouble getting him to focus on his homework or engage in activities and
he is instead often drawing in a corner by himself. When the therapist asks Jemal and
Caroline about their relationship with the school, they express confusion at the ques-
tion and that they would not know what a relationship with the school would even
look like.
The therapist goes on to explore the parent’s experiences in YSOs as youth them-
selves. Jemal’s parents immigrated from Ethiopia before he was born and put a lot of
pressure on him to do well in school. He did not like to bring his friends over because
his mom wore a hijab and his friends would ask questions, but he did not get teased
about it. Jemal loved playing year‐round baseball on traveling teams throughout his
youth that resulted in a college scholarship. Jemal expressed that he recently lost his
engineering job at a car factory, so they have had to cut back Zain’s baseball participa-
tion to just during the school season and not year‐round. Caroline was the eldest of six
and received good grades at school in Kansas, and does not remember ever really get-
ting in trouble or her parents really talking to her about school. Her family could not
afford extracurricular activities and thinks Jemal puts too much emphasis on baseball.
Level 2: YSO consultation

At the second level, the therapist can ask the youth and family to identify influential
YSO staff and provide permission for the therapist to contact them in order to solicit
their perspective of the youth’s strengths and challenges, peer interactions, communi-
cation with the youth’s family, and their perspective of their own (or other staff’s)
relationship with the youth. Families may or may not want to be present during these
consultations. YSO staff can also provide the therapist with information about
resources that the YSO can provide that are not currently being utilized by the family
and give insight into what might improve the youth’s experience at their YSO.
Communicating positive feedback from YSO staff to parents about their child can
have a powerful impact on how parents perceive YSOs and can begin to help the fam-
ily and YSO(s) improve their communication and collaboration.
Vignette: YSO consultation Due to Zain’s strong relationship with his counselor,
Ms. Davis, the therapist reached out to Ms. Davis for her perspective on Zain’s behav-
ior at school, his strengths and weaknesses, and any input or suggestions she had for
helping Zain. Ms. Davis described Zain as a kid with “lots of barriers up,” but once
people gain his trust he is very loyal. Ms. Davis said that she got to know him around
the end of last year when she came around a corner of the hallway and thought she
heard some kids calling Zain a “carpet kisser.” The other kids were gone when she got
there, and Zain was bending picking up papers off the floor. She asked Zain about
what happened and he said it was nothing. She saw the papers were drawings and
complimented him on them. He told her about his comic where the main hero is
Muslim. Zain told her that he listens to her because “she has his back.”
Ms. Davis went on to describe that these barriers Zain has up impede on his ability
to have positive relationships with his peers, his teachers, and administrators. Ms.
Davis said that she had heard teachers and administrators that try to connect with him
express they are losing patience with him. Ms. Davis said Zain’s never told her who is
bullying him, but she can tell by cryptic things he says that it is still happening. When
asked what she thought needed to change, Ms. Davis expressed that she believed that
Zain needed to be more comfortable trusting others and breaking down his barriers
so others can help. Ms. Davis said she met Zain’s parents at parent–teacher confer-
ences, but has not talked with them extensively about her observations. The therapist
asked Ms. Davis if she would be interested and available to meet with Zain’s parents
to talk more. Ms. Davis agreed, and a meeting was set up.
Level 3: Multisystem collaboration

At the third level, in addition to youth and family‐level interventions, the focus of
treatment includes improving constructive communication between the youth, their
family, and the YSOs they are involved with to share information and coordinate
resources and potential solutions. In our experience, parents are much more often
contacted by YSOs when their child is in trouble than when their child is doing well,
leading to an antagonistic relationship. A relationship between a YSO and a family
that is focused primarily around child problems can lead to poorer school engagement
(Izzo, Weissberg, Kasprow, & Fendrich, 1999), and many parents themselves carry
negative YSO experiences with them from their own childhoods that hinder current
communication with their child’s YSOs. Family members and YSO staff meet with the
therapist to hear each other and work through conflicts and misunderstandings to
create a collaborative alliance working together toward improved youth outcomes.
Depending on the situation and developmental level of the youth, they may also be a
part of some or all of these conversations.
Additionally, the therapist might meet with specific subsystems separately to address
concerns and clarify goals between the YSO and family or between staff from different
YSOs to resolve conflicting views of what would be best for the family or youth so that
the multisystem meetings are more productive. The ultimate goal is a sustained partner-
ship between the family and involved YSOs that no longer needs therapist mediation.
Vignette: Multisystem collaboration After consulting with Ms. Davis, the therapist
shared Ms. Davis’s perceptions of Zain and his challenges with Jemal, Caroline, and
Zain. In the family session, Zain did admit that he had been bullied since last year
when a couple of his kids saw family and friends from the Muslim community writing
“Insha’Allah” in comments on his Facebook page and references to seeing him at
mosque. Zain said he did not feel safe at school, and although none of the bullies
attended the afterschool program, one of the bullies’ parents worked there so he felt
it was safer to “just keep his head low.” Jemal and Caroline had previously expressed
skepticism in the usefulness of spending the time to talk with school staff since they
had not had very helpful interactions in the past, but after hearing the therapist’s
report of the conversation with Ms. Davis, they now expressed optimism that Ms.
Davis might be able to help. In addition to plans for family and individual sessions
with Zain to process his Muslim identity, pressure around his baseball and school
performance, and evaluating his friendships, the family wants to work with the school
to increase safety for Zain in order to reduce his depression and increase his engage-
ment with school.
The therapist, Jemal, Caroline, Zain, and Ms. Davis met to discuss goals for Zain,
barriers to him feeling safe, and strategies they could employ to help him. The thera-
pist helped Jemal and Caroline calmly express their frustrations with the school to
Ms. Davis, and Ms. Davis shared her commitment to Zain and expressed that the
administration had recently reported to the staff that discrimination‐based bullying
had increased at their school and were looking into solutions. At the end of the
meeting, Jemal and Caroline expressed feeling relieved that they had someone at the
school that cared about Zain that they could contact if need be. Based on their dis-
cussion, Ms. Davis suggested that she set up a meeting for Zain and his parents with
the director of the afterschool program and the school’s assistant principal to let
them know of the bullying and discrimination experiences. She also suggested set-
ting up a meeting with the family and a couple of his teachers to explain the situation
and start breaking down some of the communication barriers. The therapist, the
family, and Ms. Davis co‐created a plan for these meetings that would allow all par-
ties to express their concerns and goals without being defensive. The therapist met
with the family alone to help them discuss concerns about telling people about the
discrimination‐based bullying and come up with a way of talking about it that they
felt comfortable with. The family, the therapist, and the school counselor met with
several of Zain’s teachers. Zain and his parents briefly shared what had happened and
what they hoped for. Ms. Davis, and the teachers brainstormed with Zain ways he
could communicate to them that he felt highly anxious, a protocol for what to do
when that happened (Zain could go to the behavioral specialist’s room to talk about
what happened, calm down, then come back to class) and ways to make Zain feel
valued in order to improve the relationship between Zain and the teachers.
Level 4: YSO system change

As a therapist builds relationships with YSOs in order to improve the outcomes of the
youth they see in their clinical practice, YSOs may become interested in changing
aspects of their system to improve the outcomes of a specific youth, a group of youth,
or all the youth they serve. In this case, the direct therapeutic system expands to
include not just the family and the relationship between the family and the YSOs, but
the YSOs themselves. YSO interventions may target a specific subsystems (e.g., pro-
viding solution‐focused classroom management coaching to a specific teacher, con-
ducting group therapy with a specific peer group, working with a specific sports coach
to improve teamwork and motivation) or larger system dynamics of the YSO that
impact child functioning or the family–YSO relationship (e.g., intervening at the
whole‐school level to shift policies and procedures to increase parent engagement,
helping a YSO implement a universal intervention to reduce bullying at that YSO,
working with coaches and parents to improve trainings coaches receive on safety and
trauma‐informed coaching).
As when working with a family, the therapist must work to understand the vision,
goals, norms, and roles of the YSO staff, subsystems, and the organization as a whole
to understand priorities, barriers, and goals for change. Additionally, based on the
profound body of research on the positive impact of parent engagement and parent–
YSO collaboration on youth outcomes, the therapist should assess the current effec-
tiveness of parent engagement strategies, policies, and practices to see what the YSO
is currently doing to involve parents, what is working, and areas of improvement.
When working with an individual staff member or subsystem of a YSO, it is impor-
tant to assess who else in the YSO would be affected or interested in the change that
is trying to be created, how decisions are made in the organization, and who makes
those decisions. For example, a group of ninth grade health teachers notice that sex-
ting (texting using sexual text or images) is becoming a large issue in their district and
want to implement a lesson on it in their health classes. They contact you for materials
since you had previously worked with them on a cyberbullying situation with several
of their students. You ask them questions about what the school policies are around
sexual health education and who the teachers think would be interested in their obser-
vations about the needs of their students. Through their conversations with adminis-
trators, they found out that the district was currently revamping their sexual health
standards. The teachers and you are asked to come to the next health curriculum
committee meeting to share your observations and ideas.
When trying to help a YSO change at the entire system level, it is helpful for the
therapist to talk to different subsystems of the YSO (e.g., administrators, teaching
teams, student support personnel, staff at different offices) to assess their perceptions
of the YSO’s overall climate, improvement areas, strengths, barriers, and potential
solutions to the challenges and barriers that can help the YSO reach its goals. Seeking
input from YSO staff who can influence or be influenced by the change process gains
buy‐in for any subsequent interventions and allows for more comprehensive change.
Vignette: YSO system change After the meetings, improved coordination between
school staff and better relationships between Zain and his teachers, along with family
therapy, resulted in fewer arguments with teachers. Additionally, after the meeting
with the principal and afterschool director, the parent of one of Zain’s bullies that was
staff in the afterschool program explicitly talked with Zain and his parents about his
disappointment in his son and apologized on behalf of their family. Zain started ask-
ing for help with his homework in the afterschool program and sharing his comic with
the staff. His grades improved and he stopped skipping school.
Despite this positive change, Zain’s interactions with his peers did not change.
Zain’s bullies were reprimanded, but Zain was subsequently harassed by others for
tattling. The therapist and Ms. Davis decided to create a therapy group at school to
talk about peer interactions and bullying and invited Zain to join with others Ms.
Davis knew had experienced bullying. Zain was able to create some new healthy
friendships and feel less isolated. The therapy group decided to form an anti‐bullying
club, and Ms. Davis was able to get school approval to set it up. Upon hearing about
the success of the meeting between Zain’s parents and his teachers and the therapy
group, the assistant principal, Ms. Walker, asked the therapist to collaborate with her
about ways to improve school culture surrounding bullying and to increase engage-
ment with parents.
Effective Systemic Interventions
Multisystem interventions are shown to be effective for improving youth outcomes

(see Carr, 2009; Cox, 2005) and are recommended by multiple federal agencies for the
prevention and intervention of bullying (http://stopbullying.gov), school engage-
ment (Centers for Disease Control and Prevention, 2009), and high‐risk behaviors
(e.g., http://youth.gov, Centers for Disease Control and Prevention Division of
Adolescent and School Health). Interventions involving both family and YSOs have
resulted in improved mental health and educational outcomes (Hoagwood et al.,
2007), reduced disruptive behavior in children with autism (Wagner et al., 2014),
reduced bullying (Farrington & Ttofi, 2009), and improved support for children with
learning disabilities (Trimble, 2001) and ADHD (see guidelines suggested by Orr,
Miller, and Polson (2005)). Below, we will provide some brief examples of interven-
tions that involve YSOs and families working together with youth to improve youth
outcomes. The interventions listed below vary widely in how accessible they are to
clinicians (i.e., cost required training, implementation guidelines), so please see refer-
enced documents for more information on the interventions.
Many schools and afterschool programs have implemented anti‐bullying programs
aimed at improving peer and youth–adult relationships, overall YSO climate, internal-
izing and externalizing symptoms in youth, and feelings of safety for the children/
adolescents they serve. Programs that primarily target the larger settings in which the
bullying or violence occurs have shown greater effectiveness than interventions tar-
geting individual youth, peer groups, or families without the larger context focus (see
Cantone et al. (2015) for a review of prominent anti‐bullying programs, their compo-
nents, and their effectiveness). Cross et al. (2012) conducted a randomized con-
trolled trial on the Friendly Schools Friendly Families Program to reduce bullying and
found that the comprehensive intervention group that included school‐wide capacity
building and parent involvement and education was more effective at preventing bul-
lying than intervention groups without both of these components. For example,
Olweus (1993) created best practices for reducing bullying in educational settings
that begins by creating a task force that includes members of the community outside
the school. The committee seeks feedback about bullying in the school from members
of every subsystem in the school (administrators, teachers, parents, students). The
committee and school staff then receive training on bullying prevention/intervention
practices and work with parents to create rules related to bullying and make sure they
are clearly posted and enforced appropriately.
Improving the climate of a YSO is an important target of interventions for reduc-
ing bullying, increasing safety, and increasing youth engagement and requires inter-
connected systems (e.g., families, schools, youth, community organizations) to
work together to build and execute a shared vision (National School Climate
Council, 2009). A YSO’s climate involves the norms, values, and expectations that
support people feeling not just socially, emotionally, and physically safe, but also
engaged and connected (National School Climate Council, 2009). Improving
school climate, for example, is considered an effective intervention for promoting
healthy relationships; improving youth mental health, self‐esteem, and self‐concept;
reducing violence, bullying, discrimination, and sexual harassment; preventing
risky behaviors (e.g., alcohol and substance use, delinquency); improving youth
engagement; and preventing school dropout (see Thapa, Cohen, Guffey, and
Higgins‐D’Alessandro (2013) for a review).
Given their system training and theoretical grounding, SFTs are especially well
suited to work with multiple systems to improve climate. For example, Working on
What Works (WoWW) (Berg & Shilts, 2005) is a solution‐focused trauma‐informed
classroom intervention in which SFTs serve as classroom coaches to highlight what is
going well. WoWW empowers students to become partners in determining a vision
for the climate of their classroom, acknowledging the positives in themselves and oth-
ers, collaboratively setting behaviorally defined goals for their classroom climate,
tracking progress towards them, and normalizing setbacks. A key component of this
intervention is helping students identify how they help each other reach their collec-
tive goals. In this way, stereotypes and assumptions about others and themselves are
broken down as they recognize the influence they have on each other and that every-
one has strengths. Teachers participating in WoWW also provide parents with specific
positive feedback about their student in an effort to improve parent–teacher relation-
ships and parent engagement. Pilot data indicates that WoWW is associated with
increases in student emotional engagement, reductions in student problem behavior
in class, increases in students’ feelings of connection to their teachers and peers
(Torgerson et al., 2016), and increased parent engagement.
Other ecosystemic interventions may involve working primarily with families
and involving YSOs as consultants or focus on YSO–family collaboration to pre-
vent or reduce youth risky or disruptive behaviors that manifest in multiple sys-
tems. For example, Multidimensional Family Prevention (MDFP) (Liddle &
Hogue, 2000) and Multidimensional Family Therapy (MDFT) involve a mental
health practitioner doing a combination of in‐home family therapy and interacting
with other parts of the community that a family is associated with (including
schools and other YSOs) in order to reduce or prevent delinquency and substance
use during adolescence (e.g., van der Pol et al., 2017). One of the main functions
of the intervention is to alter the interaction patterns between adolescents and
parents to create a healthy and secure level of emotional interdependence. The
intervention also calls for the mental health practitioner to encourage the parent
to be involved in schools and other YSOs that the child may be involved in and
potentially facilitate meetings between families and YSOs to improve communica-
tion. Similarly, Multisystemic Therapy (MST) is grounded in systems and ecologi-
cal theories and recognizes the important impact of families, YSOs, and peers on
youth behaviors; thus the mental health provider assesses and delivers interven-
tions in both family and YSO settings. Although originally created to reduce
delinquent behavior in youth (see van der Stouwe, Asscher, Stams, Deković, and
van der Laan [2014] for a meta‐analysis of effectiveness), it has also been adapted
by Wagner et al. (2014) to reduce disruptive behavior of youth with autism spec-
trum disorders.
The following two intervention examples apply core SFT models to YSO–family
interactions in addition to the family microsystem. Butler and Platt (2008) integrate
structural and narrative theoretical intervention models to create a family and school
treatment model to reduce youth bullying behavior. This model encourages high
levels of communication between the family and school representatives to create a
team united against bullying behavior and involves bringing a school counselor and
teacher into the therapeutic conversations. Additionally, Trimble (2001) proposed an
intervention to reduce the psychological and relational problems that can accompany
a learning disability diagnosis. From a narrative theoretical orientation, the therapist
serves as an interface between systems to replace misunderstanding with collaboration
by helping families construct hopeful meaning of school reports and feedback. No
effectiveness information was publicly available on these two interventions at the time
this chapter was written.
Navigating the Challenges of an Expanded Treatment System
Partnering with YSOs actively engaged in promoting youth health and well‐being
involves learning and bridging the cultures of multiple systems. This includes learning
relevant terminology and acronyms, system priorities and structures, the scope of
practice of other fields, and state, local, and organization policies and procedures that
influence the functioning of each system. It is also important to communicate the
same about the field of SFT. For example, given the recent ability for schools in some
states to hire SFTs in addition to other mental health providers (e.g., clinical psy-
chologists, child psychiatrists, social workers, school counselors), it is very important
not to assume that others know what an SFT does. For example, Laundy, Nelson, and
Abucewicz (2011) found that for schools in Connecticut with SFT interns, 72% of
school staff knew that there were SFTs in their schools, but only 55% indicated that
they understood what the role of those SFTs was. In our experience, the more YSOs
and families come to understand what SFTs do, the better they are able to identify
diverse ways we can help.
Multiple therapeutic roles

Similar to when an SFT works with subsystems of a family, an SFT’s role may shift
when working with interconnected systems depending on the purpose of the meet-
ing. What a therapist keeps confidential, or not, across subsystems may be set at the
outset as a consistent policy or may be separately negotiated with groups of subsys-
tems connected by shared therapeutic goals. For example, an SFT may be working
with a whole school to improve school climate through policy change, parent engage-
ment, WoWW, and trauma‐informed teacher trainings (training teachers on the preva-
lence and impact of trauma and recognizing and responding to trauma; Substance
Abuse and Mental Health Services Administration, 2014). As part of WoWW and
trauma‐informed training, the SFT may be doing coaching with specific teachers to
work on their own growth process. Those teachers may have students in their class
that are individual clients of the therapist. Accordingly, the SFT may visit that class-
room on some days to do WoWW and on other days to do observational assessments
of a particular client. Meetings with that teacher then may vary from that teacher as a
client to that teacher as a consultant on a specific student client case to that teacher as
a collaborator working with a family and child to relieve the child’s symptoms.
Ongoing management of confidentiality

In a survey of SFTs with experience providing therapy services in schools, Vennum
and Vennum (2013) found that some of the main challenges reported by SFTs who
provided clinical services in schools were the navigating of professional ethics
around confidentiality, boundaries, and school policies. To facilitate client change,
the environment we create must feel safe for personal exploration. Accordingly,
what will be kept confidential and what will be shared must be overtly discussed at
regular intervals with all subsystems. In the above example, the SFT may negotiate
with the family what is important to share with teachers or school staff about the
family and student to best coordinate care, help the functioning of the child, and
improve the family–school relationship. In a coaching meeting with a teacher, the

teacher may disclose a personal history of abuse that they think makes it harder for
them to self‐regulate on days when a teenager who has a history of teasing the
teacher and their peers is in their class. The SFT would clarify with the teacher the
boundaries of confidentiality for what would, and would not, be helpful to disclose
when the SFT later meets with school administration about overall school progress
toward improved classroom climate or when the teacher and therapist meet with
family to discuss their child. What information is relevant for coordination of care,
what people feel safe sharing, and which disclosures help versus damage system rela-
tionships can vary throughout the therapy process. Accordingly, confidentiality, a
therapist’s role, and the purpose of all meetings must be regularly discussed with all
involved systems and subsystems.
Adding another layer of complication, YSOs may have expectations, policies, struc-
tures, or norms that govern the sharing of private information that may occasionally
be at odds with SFT professional ethical guidelines and HIPPA, so clearly asking
about norms and YSO policies around information sharing, clearly communicating
SFT and HIPPA guidelines, and coming to a working ethical protocol with each YSO
for how and when information will be shared is important for avoiding misunder-
standings, protecting clients, and maintaining the trust of all parties. For example, an
adolescent may disclose to their therapist that they got into a situation over the past
weekend with a group of kids from their school where they did drugs under extreme
peer pressure and felt very unsafe. In a community clinic setting, sharing this informa-
tion with parents in a constructive way would be a primary goal. When the school is
also a client or school staff are part of the client system of this youth, the priorities and
policies of the school also must also be treated with respect. Let us imagine that in this
case, the school has a policy that when staff are told information that involves the
safety of other students, they are required to disclose the information to administra-
tion. To be a respectful partner with the school, it is important for the SFT to work
with the school to develop a protocol that follows SFT ethical guidelines while
respecting school priorities and the safety and confidentiality of student and family
clients. Agreed‐upon expectations and protocols around confidentiality must be
clearly communicated to all involved members and outlined in informed consent
documents.
The expanded therapeutic alliance

Family therapy involves the establishment and management of multiple working alli-
ances simultaneously, and the strength and equality of these alliances influence the
change process and the likelihood of a successful outcome (Friedlander, Escudero,
Heatherington, & Diamond, 2011). Building an expanded therapeutic alliance with
many of the YSOs in your area will take time but does not need to happen all at once.
For any given child, change can be made first with one system and then to an interac-
tion between two systems; then a second system can be added. It is important to note
that the system most open to change at any given time may not be a child’s family—
sometimes it is their peers, sometimes it is a YSO (with guardian consent for treatment
and a release for the therapist to coordinate with others toward the child’s benefit).
When a client system involves multiple people and subsystems, the therapist must
work to create a shared, systemic view of the problem and solutions to facilitate a
shared sense of purpose, goals, and responsibility for change (Friedlander et al., 2011;
Minuchin, Nichols, & Lee, 2007). Further, working to create a space where all mem-
bers of the expanded client system feel respected and safe from attack is critical to the
joining process (Friedlander et al., 2011) in a clinical setting as well as when an SFT
is joining a multidisciplinary team (see Bell‐Elkins (2002) for a checklist of best prac-
tices). In our experience, working to identify and honor the positives as well as sensi-
tively acknowledging areas of stress and difficulty in each subsystem reduces defenses
and helps the members of the treatment system begin to develop a more balanced
view of each other (Minuchin & Fishman, 1981).
To sustain the alliance, the tasks of therapy must align with the worldviews and
expectations of the client systems involved enough to enter and influence those sys-
tems (e.g., Minuchin et al., 2007). Just as SFTs strive to do this with family systems,
it is important for SFTs to take the time to learn the culture and priorities of the YSOs
they are working with. When bringing together multiple systems, just as when work-
ing with multiple individual clients within a system, thorough assessment and joining
is important for building trust and helping involved system members come to joint
understanding of the problem and potential solutions they are willing to collabora-
tively work toward.
Suggestions for Further Development
The research on risk and protective factors for myriad youth outcomes are clear: youth
and families are strongly influenced by the multiple systems with which they interact.
SFTs are skilled systemic interventionists. To improve our effectiveness at bolstering
youth and family resilience, we need to expand our theories of intervention, our con-
ceptualization of problems and solutions, our direct treatment system, and our thera-
peutic alliance beyond the family. Accordingly, we have several suggestions for theory,
research, and training.
Although there are specific multisystem models to guide SFTs when working with
the larger systems families are embedded in (see Berryhill and Vennum (2015) for
school–family intervention models), we also believe it is possible, and potentially
more efficient, to expand the core systemic family therapy models (e.g., narrative fam-
ily therapy, solution‐focused brief therapy, structural family therapy) to conceptualize
multisystem interventions. This would provide a consistent treatment plan across all
levels of the expanded client system so that all parts of the expanded therapeutic sys-
tem are speaking the same language with congruent goals. Work needs to be done to
clarify what the application of core SFT models may look like at each level of multi-
system intervention mentioned previously in this chapter.
For students learning core SFT models, building in multisystem applications of
these models from the beginning would bridge their conceptualization of the
impact of context on individuals and families with tools for contextual interven-
tion. Helping students get comfortable with the first two levels of ecological inter-
vention outlined in this chapter would not require students or training programs
to have long‐standing relationships with YSOs and would lay a groundwork for
students to progress through subsequent levels of intervention in the communities
they become practitioners in. SFT training programs may also work to establish
collaborative relationships with YSOs in their community, providing students with

opportunities to practice additional levels of intervention (see Cooper‐Haber &
Haber, 2015, for example strategies for training SFTs to work from an ecosystem
approach in schools). Some SFT programs already have clinical placement sites
with YSOs but have not yet harnessed the opportunities present to collaborate on
treatment and help families connect with those YSOs. We argue that having a
placement in a YSO without collaborating with YSO staff to receive feedback,
coordinate care, and improve parent–YSO relationships is a very large missed
opportunity for improving child outcomes. Further, cultural competency is not
just essential for effective clinical work with family systems, but critical for effective
work with all systems. Reminders to keep self‐reflection and curiosity at the fore-
front of one’s mind when entering and engaging in any system need to be ever
present in training SFTs to expand their conceptualization of the treatment systems
and therapeutic alliances.
As SFT theories are expanded and applied to additional systems that impact fami-
lies, those theoretical conceptualizations of how problems form, are maintained, and
are potentially resolved could provide guidance on additional systemic risk and pro-
tective factors that are important to empirically explore. As theoretically grounded
research on risk and protective factors accrues, interventions congruent with those
theories can be tested and best practices further articulated and theories can be refined.
Common factors of effective multilevel systemic intervention can then be identified
across theoretical orientations.
Although some of the challenges youth face when engaged with YSOs have a strong
body of research on risk and protective factors (e.g., engagement and bullying), there
is less research on how youths’ perceptions of difference and peer pressure impact
youth mental health and what factors enhance youth resiliency in these situations.
There is also very little research on the effectiveness of SFTs working collaboratively
with YSOs to improve child, family, and YSO‐level outcomes. Specifically, research is
needed on which levels of systemic intervention are most effective for improving
diverse youth outcomes, key moderators of effective multisystemic intervention (e.g.,
multidisciplinary teaming in schools, degree of expanded alliance, location of therapy
services, boundaries of confidentiality), and the effectiveness of specific systemic
interventions using randomized controlled trials. It would be important that this
research include data from multiple levels (e.g., youth, family, school staff) and be
conducted with translation of the findings to real‐world settings in mind (i.e., cost‐
effectiveness, feasibility for easily integrating the intervention into a system). As SFTs
advocate for a larger presence in community systems (e.g., medical clinics, military
bases, schools), we see a future of SFTs empowered to reach beyond their clinic rooms
to make change in the community systems that affect families every day and create
far‐reaching ripples of community resiliency.
Note
1 Note: The case studies used throughout this chapter are amalgamations of clinical sce-
narios the authors commonly see when working with youth and their families. No real
names are paired with their real case details.
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24
Systemic Prevention
and Intervention Approaches
for Working with Military Families
Abigail H. Gewirtz and Hayley A. Rahl‐Brigman
In many countries, the military family population is in many ways a microcosm of the
typical family population, though extant research on military families is limited in
scope to a small number of countries with sufficient resources to study and follow
military families (primarily NATO alliance countries such as the United Kingdom, the
United States, Canada, and Israel). The size of the US military, combined with the
extensive involvement of both active and reserve forces in two simultaneous wars over
the first nearly two decades of the twenty‐first century, has provided a unique labora-
tory for understanding military family adjustment during times of war. This chapter,
then, primarily focuses on approaches to working with US military families while
recognizing that valuable research is taking place in several other countries around the
world.
Military families represent the diversity of the United States, face many of the
same challenges, and, in peacetime, experience well‐being and resilience similar to
civilian families (Park, 2011). This chapter highlights wartime deployment as a
uniquely stressful experience for military families and provides an overview of sys-
temic evidence‐based prevention and treatment interventions to strengthen family
functioning.
The twenty‐first century may be characterized as one in which the United States
and several of its allies have been involved in two conflicts simultaneously. Indeed, in
the years since 9/11/2001, almost three million troops have been deployed to the
wars in Iraq and Afghanistan, and approximately 40% of those are parents (Defense
Manpower Data Center, 2015). Unique to the wars of this century is the makeup of
the fighting force; nearly half of all those deployed are or were members of the
National Guard and Reserves, that is, the Reserve Component (Defense Manpower
Data Center, 2015). Reserve Component service members, unlike those in the active‐
duty military, are civilians unless they are activated (i.e., deployed or in training).
596 Abigail H. Gewirtz and Hayley A. Rahl‐Brigman
They drill with their units typically one weekend a month and train during 2 weeks in
the summer. Unlike full‐time active‐duty military members, Reserve Component ser-
vice members do not move frequently and are not attached to an installation. Reserve
Component service members are typically older and thus more likely to be partnered
and parenting than typical active‐duty service members (Browne et al., 2007). Almost
two million children in the United States have grown up—or are growing up—with
the experience of a parent’s deployment (Clever & Segal, 2013). About half of those
children, those with parents in the Reserve Component, live in civilian communities,
with few ties to other military families.
Transitions are a fact of active‐duty military life, with service members and their
families undergoing multiple moves between installations (i.e., permanent changes of
station). Military infrastructure supports these transitions, with services targeted to
help both the service member and his/her family settle into (or near) a new installa-
tion. Reserve Component service families, on the other hand, typically do not move
due to military service requirements. However, the stability of life for Reserve
Component families may be upended by a parent’s deployment. National Guard and
Reserve families may have few other military families near them, and community
members often do not understand military life. Community mental health resources
often lack specialized military expertise, and, as discussed later in this chapter, this
makes it challenging for families who need supports following deployment or injuries
to get appropriate help.
Deployments to war are uniquely stressful family events for all military families
for two primary reasons: the extended separation of parent(s) from the family and
worries for the safety of the deployed parent. The body of scholarship on the
impact of deployment on families has grown extensively over the past decade (see,
e.g., Cozza & Lerner, 2013; Institute of Medicine of the National Academies,
2013; National Academies of Sciences, 2019). Research has demonstrated that
the impact of deployment on families lasts far beyond the immediate reunion
period to more than a year post‐reintegration (Creech, Hadley, & Borsari, 2014).
When a parent returns from deployment with visible or invisible wounds of war,
the scars may last a lifetime.
In this chapter, we briefly overview what is known about the impact of parental
deployment and combat stress on families. We provide a theoretical framework for
understanding the impact of these stressors and overview systemic interventions
aimed at strengthening families by buffering parenting and intervening with the
couple or the entire family. There are several conceptual approaches to understand-
ing the stressors that military families face, as evidenced by the range of theories
underlying the programs reviewed in this chapter (e.g., attachment theory, eco-
logical systems theory, social interaction learning [SIL] theory). We specifically
highlight evidence‐based interventions (i.e., interventions that have been evalu-
ated in randomized controlled trials [RCT]) and include indicators of evidence
from the Clearinghouse for Military Family Readiness (Perkins, Aronson, Karre,
Kyler, & DiNallo, 2016), which are similar to other evidence‐based practice inven-
tory standards of evidence. We have also included programs that are commonly
used but do not currently have rigorous evaluation data, as well as several newly
emerging evidence‐based programs. We review research on these interventions and
provide some directions for future research.
Military Family Resilience 597
Impact of Deployment on Children and Families
For those deployed, the physical transitions to and from home require moving from
physically absent to present partnering and parenting and moving between highly
structured military operational contexts and informal family contexts with different
rules for communication and emotional expression (Huebner, Mancini, Wilcox,
Grass, & Grass, 2007). Deployment stressors include intense work conditions, infre-
quent breaks, and exposure to traumatic events such as death and injury (Hoge et al.,
2004; Hosek, Kavanagh, Miller, & Miller, 2006; Tanielian et al., 2008). Negative
sequelae of combat injuries, including traumatic brain injury (TBI), posttraumatic
stress disorder (PTSD), depression, other anxiety disorders, and substance abuse, also
may manifest (e.g., Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2008;
Milliken, Auchterlonie, & Hoge, 2007) and are associated with significant social/
relationship challenges (Hoge et al., 2006; Vasterling et al., 2006). Non‐deployed car-
egivers must cope with feelings of loss and fear over their partners’ safety, burdens of
single parenting, renegotiating roles, decisions, and family tasks (Erbes, Polusny,
MacDermid, & Compton, 2008).
Different phases are associated with deployment and often referred to collectively
as the “deployment cycle” (Pincus, House, Christenson, & Adler, 2007). Phases of
the deployment cycle include preparation for deployment (e.g., training, pre‐
deployment, etc.), the deployment itself, and reintegration/re-entry (MacDermid,
2006; Pincus et al., 2007). Stressors associated with each phase vary. During the
pre‐deployment phase, for example, children and parents alike face the uncertainty
associated with a parent’s leaving. Parents may debate how long prior to a deploy-
ment to let a child know the parent is deploying based upon the child’s capacity to
understand the concept as well as the child’s understanding of time. During the
deployment, anxiety for both parents and children may rise with the uncertainties
associated with lack of communication and lack of knowledge about the service
member’s safety.
Ironically, it is during the reintegration stage that many families report the greatest
challenges (Goff, Crow, Reisbig, & Hamilton, 2007), partly because the expectation
that things will be “back to normal” with the service member’s return often is proven
wrong. Instead, many refer to the “new normal”—particularly for those with psycho-
logical or physical injuries sustained during deployment. Emerging data (Gewirtz,
Polusny, DeGarmo, Khaylis, & Erbes, 2010; MacDermid, 2006) indicate that the
year following return from deployment may be a challenging transition year, when the
family adjusts to the deployed parent’s return, parents must reestablish a united par-
enting front, and children understand that their parent is here to stay (until the next
deployment).
Deployments, then, have both direct and indirect impacts on the psychosocial well‐
being of service members themselves, their military children (Johnson et al., 2007),
partners/spouses, and the family as a whole. An extensive body of evidence has docu-
mented the impact of deployment on service members and on their partners/spouses
(see, e.g., Keeling et al., 2015; Ramchand et al., 2015); this literature is beyond the
scope of the current chapter. Below, we briefly review the empirical literature on the
impact of deployment on the family system and subsystems—that is, children, par-
ent–child relationships, couples, and the family as a whole.
Children of deployed parents are vulnerable to problems in childhood with acute

stress reactions, adjustment, depression, and behavior, as well as problems in adoles-
cence with substance use, behavior, and conduct (Barker & Berry, 2009; Gewirtz &
Zamir, 2014; Gilreath et al., 2013; Reed, Bell, & Edwards, 2011). For example, school‐
aged children with deployed parents report increased anxiety and behavioral symptoms
(Lester et al., 2010; Morris & Age, 2009). Engel, Gallagher, and Lyle (2010) reported
associations between length and timing of deployments and standardized achievement
scores in Department of Defense (DOD) schools; poorer achievement scores were asso-
ciated with concurrent deployment of a parent. Adolescents are well aware of the dan-
gers associated with deployment, the impact of deployment on the non‐deployed
parent, and opinions toward war and deployment (Huebner & Mancini, 2005; Huebner
et al., 2007). Exposure to unlimited media reports of war, coupled with adolescent
knowledge of the dangers of combat, may erode coping and adaptive capacities
(Chartrand & Siegel, 2007; Reed, Bell, & Edwards, 2011). Monitoring adolescents’
behavior is crucial in preventing and reducing conduct problems (Dishion & Andrews,
1995), and an obvious challenge for deployed families is the absence of a monitoring
parent. For example, Reed and colleagues (2011) reported higher levels of binge drink-
ing among youth with deployed, compared with civilian parents. An increase in the
number of deployments was associated with a higher likelihood of lifetime and recent
substance use, with the exception of lifetime smoking (Gilreath et al., 2013).
Consistent with the broader developmental literature, the length of the separation
(e.g., number of months deployed) appears to be a stronger predictor of children’s
adjustment difficulties (e.g., Chandra et al., 2011; Esposito‐Smythers et al., 2011)
than the number of times a parent has deployed (Richardson et al., 2011). For exam-
ple, mental health diagnoses in children associated with parental deployment increased
with total months of parental deployment (Mansfield, Kaufman, Engel, & Gaynes,
2011). It should be noted, however, that more recent longitudinal research has called
these findings into question with the RAND Corporation’s Deployment Life Study,
which followed families prospectively across the deployment cycle revealing no signifi-
cant direct effects of deployment on child adjustment (Meadows et al., 2017). Recent
findings from other longitudinal studies have indicated that negative effects of deploy-
ment for children may primarily result from the sequelae of combat exposure (i.e.,
PTSD symptoms, TBI, other injuries) rather than the separation per se (e.g., Gewirtz
et al., 2018b). Research evidence also points to differential effects of deployment on
children depending on their age (Gewirtz & Zamir, 2014).
Deployment affects military children through disruptions

in parent–child relationships
Deployment may affect military children through disruptions in parent–child rela-
tionships (Creech et al., 2014; Gewirtz et al., 2018b). For example, during deploy-
ment, parental stress in the at‐home caregiver appears to be associated with poorer
child adjustment (Flake et al., 2009). How frequently parents seek medical attention
for their children during deployments also may be reflective of parental stress. For
children aged 3–8 years, visits to the doctor for mental health issues increased 11%,
visits for behavior problems increased 19%, and visits for stress‐related disorders
increased 18% during the period of a parent’s deployment (Waliski, Bokony, Edlund,
& Kirchner, 2012).
Increased at‐home caregiver stress may also account for the documented rise in
child maltreatment during deployment, most frequently at the hands of a female at‐
home caregiver. For example, Rentz et al. (2007) found child maltreatment rates rose
by approximately 30% for every increase of 1% in operation‐related deployment and
reunion. Examining substantiated child maltreatment reports, Gibbs and colleagues
(Gibbs, Martin, Kupper, & Johnson, 2007) found that overall maltreatment rates
were significantly higher while a parent was deployed, particularly when the at‐home
caregiver was a female civilian, with neglect twice as frequent, but physical abuse less
frequent than at other times.
During the post‐deployment period, PTSD symptoms are associated with service
member fathers’ self‐reported parenting challenges (Gewirtz, Polusny, DeGarmo,
Khaylis, & Erbes, 2010). Longer deployments are related to poorer observed parent-
ing practices in deployed fathers (lower problem solving, harsher discipline, less posi-
tive involvement, encouragement, and monitoring; Davis et al., 2015). Deployed
fathers’ negative emotion socialization is associated with greater negative emotional-
ity and internalizing problems in children (He, Gewirtz, & Dworkin, 2015).
Despite the risks that extended separations can introduce, military children often
exhibit resilience (Jeffreys & Leitzel, 2000). Having a relationship with a warm and
effective caregiver is the most important factor in a child’s life for protecting against
risk and promoting resilience (Masten, 2015). Strengthening the quality of parenting
is of critical importance for improving children’s well‐being, and increased attention
to improving resilience in military children and families is greatly needed (Park, 2011).
Deployment and its sequelae affect the spouse and quality

of the couple relationship
Deployment can also affect family systems by placing a strain on couple relationships
and reducing relationship quality. During deployment, non‐deployed spouses can
experience stressors of ambiguous loss, disrupted communication with partners, and
added parenting, financial, and occupational stress (Faber, Willerton, Clymer,
MacDermid, & Weiss, 2008; Flake, Davis, Johnson, & Middleton, 2009; Gewirtz,
Erbes, Polusny, Forgatch, & DeGarmo, 2011; Warner, Appenzeller, Warner, &
Grieger, 2009). Non‐deployed spouses can exhibit psychological distress including
depression, sleep problems, anxiety disorders, acute stress reactions, and adjustment
disorders (Gewirtz et al., 2011; Mansfield et al., 2010; Miller et al., 2018). Deployed
parents can experience short‐term readjustment reactions after returning from deploy-
ment including sleep problems, irritability, and difficulty concentrating (Gewirtz et al.,
2011; Shea, Vujanovic, Mansfield, Sevin, & Liu, 2010), as well as problems with sub-
stance use and anger control (Gewirtz et al., 2011; Jacobson et al., 2008; Sayer et al.,
2010). Not surprisingly, given their exposure to conflict, deployed parents also report
higher levels of PTSD, distress, depression, suicidal ideation and attempts, interper-
sonal conflict, and aggressive ideation (Gewirtz, DeGarmo, & Zamir, 2016; Gewirtz
et al., 2011; Milliken, Auchterlonie, & Hoge, 2007; Nock et al., 2018).
Similar to research on military children, recent research on military couples sug-
gests that the negative consequences of deployment (e.g., PTSD symptoms) may be
key mechanisms by which couple adjustment is disrupted. For example, in a study of
434 active‐duty Army couples, Allen et al. (2018) found no differences in couples’
self‐reports of dyadic adjustment between those separated by a past year deployment
and those who did not experience a deployment. However, a past year deployment
was associated with increased PTSD symptoms in the service member; these, in turn,
were associated with poorer dyadic adjustment (Allen et al., 2018).
Relationship satisfaction after deployment depends in part upon the quality of com-
munication during deployment (Carter et al., 2018). The frequency of deployment
communication is important for maintaining emotional engagement and connection
(Sayers, Barg, Mavandadi, Hess, & Crauciuc, 2018; Sayers & Rhoades, 2018) and for
preventing anxiety during the transition back home (Knobloch, Knobloch‐Fedders,
& Yorgason, 2018).
Theoretical/conceptual frameworks for understanding

the impact of deployment on families
Family stress models (e.g., Barnett, 2008; Conger et al., 2002; Elder, Caspi, &
Downey, 1986) offer a broad explanation of how stressful family environments affect
children and families. For example, in research with families of the Great Depression,
Elder and colleagues demonstrated that socioeconomic stress was associated with
impaired parenting practices, increasing risk for child maladjustment (Elder, Nguyen,
& Caspi, 1985). Conger and colleagues (e.g., Conger et al., 2002) reported that
couple functioning mediated the relationship between poverty and parenting prac-
tices among Iowa farm families. Marital transitions and domestic violence also have
been the focus of family stress model studies. Forgatch and colleagues conducted
studies of divorce and re‐partnering, finding that observed parenting practices medi-
ated the relationship between divorce‐related sequelae and children’s adjustment
(Forgatch & DeGarmo, 1999; Forgatch et al., 2009). In the context of partner vio-
lence, Rhoades et al. (2011) found that hostile and unsupportive couple relationships
predicted later child anger, mediated through coercive parenting. The family stress
model is thus a mediation model; that is, it proposes that stressful family transitions
(such as marital disruptions, poverty, and/or parental illness) indirectly impair chil-
dren’s adjustment through negative impacts on parental distress, parenting impair-
ments, and couple relationships.
The empirical literature on family stress also has highlighted the detrimental impact
of parental psychopathology, particularly maternal depression, on couple adjustment,
parenting, and children’s adjustment (e.g., Downey & Coyne, 1990; Gartstein &
Fagot, 2003). Rodriguez and Margolin (2015) reviewed the literature on parental
absence as a family stressor in the context of migration, parental incarceration, and
military deployment. It is particularly noteworthy that despite almost two decades of
US involvement in ongoing conflicts in the Middle East, relatively little longitudinal
research has examined the impact of parental deployment to war on parenting and
children’s adjustment (see, e.g., Alfano, Lau, Balderas, Bunnell, & Beidel, 2016;
Gewirtz & Youssef, 2016b; McFarlane, 2009).
Military deployment as a family stressor

Deployment to war is a family stressor because it results in parents’ prolonged
absence from children, and because deployed parents may be in harm’s way, which
increases stress for children and partners at home. Psychological sequelae of war,
such as posttraumatic stress symptoms, depression, and TBI affect almost 20% of
service members, adding to family stress (Tanielian et al., 2008). Reintegration from
deployment often requires both service members and their families to adjust to a
“new normal.” Among families in which both parents have deployed, or in families
with service members dealing with high operational tempos (e.g., Special Operations),
the deployment cycle may be almost continuous.
An upsurge in research on family adjustment following deployment has focused
mostly on the functioning of adults (the service member and partner/spouse) and
children during and following deployment, typically using questionnaire measures
(Gewirtz & Youssef, 2016a). These studies—particularly those that have included
large samples of families—have yielded important data regarding parent and child
perceptions of functioning in the wake of the recent conflicts (see, e.g., the RAND
Deployment Life Study (Meadows, Tanielian, & Karney, 2016) and the Millennium
Cohort Family Study (Crum‐Cianflone, Fairbank, Marmar, & Schlenger, 2014)). Far
fewer studies have provided longitudinal, multi‐method, and multi‐informant data on
parenting and parent–child relationships following deployment to elucidate how
deployment might function as a family stressor. Gathering information from several
informants (e.g., mother, father, child, teacher) provides multiple perspectives on
behavior; using several methods of assessment (e.g., behavioral observations, ques-
tionnaires, physiological and genetic data) allows for a richer, multilevel understand-
ing of family and child processes (e.g., Cicchetti & Blender, 2004). For example,
Gewirtz, DeGarmo, and Zamir (2018b) tested a military family stress model with
multi‐method and multi‐informant data from 336 National Guard and Reserve fami-
lies in which at least one parent had returned from deployment to Iraq or Afghanistan.
Greater maternal, but not paternal, PTSD symptoms were indirectly associated with
poorer child adjustment (measured by teacher, parent, and child report) via observed
parenting practices as well as via poorer observed and reported marital quality. Fathers’
greater PTSD symptoms—but not length or number of deployments—were directly
associated with children’s poorer adjustment. In separate analyses of deployed fathers
using the same sample, longer deployment absences as well as lower income were
associated with poorer observed parenting (Davis et al., 2015).
Social interaction learning theory

While family stress models provide a broad conceptualization of the deployment con-
text as a stressful environment that may increase risk for children’s emotional and
behavioral problems (via impaired parenting), Social Interaction Learning (SIL) the-
ory provides the details of how parenting and parent–child relationships may go awry
in these circumstances. Gerald Patterson hypothesized and later demonstrated that in
stressful family contexts, coercive parent–child interactions are associated with child
adjustment disruptions (Patterson, 1982, 2005). Briefly, coercive interactions include
aversive behaviors, negative reinforcement, and escalation and are most clearly demon-
strated in conflict bouts between parents and children. It is important to note that
conflict bouts are a fairly common occurrence in all types of families, but their intensity,
frequency, and length are predictive of poor outcomes for children over time. That is,
households in which these interactions are typical or commonplace are those in which
children may be at elevated risk for learning coercive behavior as a way to interact both
within and outside the home. Coercion places children at elevated risk for a broad
spectrum of negative, maladaptive behaviors, including conduct problems, delin-

quency, substance use and abuse, depression, and school problems (Patterson, 2016).
The SIL model recognizes, however, that coercive behavior can be “unlearned” in
families, primarily by parents learning and applying positive parenting practices.
Patterson and his colleagues at the Oregon Social Learning Center developed the
SIL‐based Parent Management Training–Oregon (PMTO) model/GenerationPMTO
family of interventions beginning in the 1980s (Forgatch & Gewirtz, 2017).
GenerationPMTO interventions (also known as the Oregon model of behavioral par-
ent training; Dishion, Forgatch, Chamberlain, & Pelham, 2016) represent the largest
group of parent training interventions in evidence‐based practice databases, such as
the Substance Abuse and Mental Health Services Administration’s (SAMHSA)
National Registry of Evidence‐Based Programs and Practices. These interventions
have been rigorously tested in both efficacy and effectiveness trials and have been
implemented widely in Northern Europe and in some US states (Forgatch & Gewirtz,
2017; Forgatch, Patterson, & Gewirtz, 2013; Ogden, Forgatch, Askeland, Patterson,
& Bullock, 2005).
Forgatch, Patterson, and their colleagues were most interested in preventing anti-
social behavior in youth. However, little research has examined the impact of parent
training on internalizing problems (and particularly anxiety) in children and youth.
One of the most salient stressors of the deployment context is the worry that children
and their at‐home parent experience for the safety of the deployed parent. Indeed,
studies of families during deployment have noted higher than typical levels of anxiety
and more referrals for mental health services among children and their at‐home car-
egivers (Alfano et al., 2016; Mustillo, Wadsworth, & Lester, 2016). Moreover, after
service members return home, posttraumatic stress and related symptoms (e.g., TBI)
may disrupt parental emotion regulation skills, and disrupted emotion regulation may
impair parenting (Snyder et al., 2016).
Ecological systems theory

Bronfenbrenner’s ecological systems theory identifies family systems as microsystems
in which children grow and develop and embeds family systems within larger systems
that impact them (Bronfenbrenner, 1986). Family systems interact with the military
context, and some interventions targeting military families are guided by ecological
systems theory (e.g., Strong Families Strong Forces, Families OverComing Under
Stress [FOCUS]).
Intervention Goals: Strengthen Child and Family Well‐Being

with Family‐Based Prevention and Treatment Interventions
The documented impact of deployment on family systems has inspired efforts to pro-
mote resilience in military families by targeting parenting practices (Gewirtz &
Youssef, 2016b) as well as couple adjustment (e.g., Stanley, Allen, Markman, Rhoades,
& Prentice, 2010) and family systems more broadly. Below, we briefly review these
three categories of interventions. We highlight the relatively few theory‐based inter-
ventions that have demonstrated rigorous evidence (i.e., via randomized clinical trials)
for their efficacy and/or effectiveness. Deployment is framed by the family stress
model as a context that can undermine the quality of parenting practices and the
adjustment of the couple and ultimately increase risk to children’s adjustment and
development. Deployments introduce high levels of stress into families, and the goal
of prevention and intervention efforts is to target families in order to initiate a positive
cascade effect in family systems that ultimately improves children’s, parents’, couples’,
and overall family well‐being. While family‐based interventions may have different
targets (e.g., some may target the entire family system, others focus on parenting, yet
others on couples alone), results of randomized trials indicate positive cascading
effects across the family system. For example, benefits of parenting interventions
beyond actual parenting skills also manifest in improved well‐being of children, as well
as reductions in symptoms for deployed parents and their spouses (e.g., Gewirtz et al.,
2016, 2018b).
Overview of common approaches and evidence‐based interventions

There is increasing awareness of the importance of building resilience in military
families by addressing the needs of post‐deployed families. Multiple family supports
and services are offered through the DOD (Whitestone & Thompson, 2016). Some
of these programs and supports are almost universally used throughout the military,
funded by the US DOD. They include the New Parent Support Program that tar-
gets families with newborns, as well as the Family Advocacy Program (e.g., Travis,
Heyman, & Smith Slep, 2015) serving families at risk for, or involved in, child mal-
treatment. Military Family Life Consultants are DOD contract workers who pro-
vide up to eight sessions of generic counseling and support for families requesting
help in a variety of domains. In addition, military installations may provide other
types of family programming including generic family support groups, as well as
specific programs for couples and families (e.g., Strong Bonds, ScreamFree
Parenting, Nurturing Parenting Program, Essential Life Skills for Military Families,
Positive Parenting Tactics, and FOCUS; Lester et al., 2016). Of all these programs,
to our knowledge, only the Strong Bonds programs (Strong Bonds, Prevention and
Relationship Education Program [PREP] for Strong Bonds) have been rigorously
evaluated in the military context (i.e., with an RCT) and have published peer‐
reviewed findings. However, an RCT of the FOCUS program with young children
is underway and preliminary results indicate positive gains to families (Lester, per-
sonal correspondence).
Due in part to the lack of evidence for commonly used military family programs,
the past decade has seen an upsurge in efforts to develop and evaluate evidence‐based
programs for military families (see, e.g., Institute of Medicine of the National
Academies, 2013). Indeed, the DOD’s Office of Military Community and Family
Policy recently contracted with researchers to develop the Clearinghouse for Military
Family Readiness (Perkins et al., 2016), a tool for evaluating program quality among
the myriad of programs of interest to, and tailored for, the military family community.
The evidence base for the programs mentioned, for example, is indicated by the
Clearinghouse for Military Family Readiness as unclear, since there is currently no
evidence from trials of these programs to support their efficacy or effectiveness.
Programs evaluated by the Clearinghouse for Military Family Readiness receive rat-
ings of effective, promising, unclear, or ineffective. To receive a rating of effective, the
Clearinghouse requires at least two studies, one of which must be from an outside
group (not the program developer) that show evidence of significant beneficial effects
sustained for at least 1 year from an RCT or quasi‐experimental well‐matched evalua-
tion of the program. Programs are placed as promising if there is at least one RCT or
quasi‐experimental well‐matched design evaluation of the program with significant
findings as well as evidence of sustained effects for at least 6 months. Ineffective pro-
grams are those that have been evaluated with an RCT or quasi‐experimental design
study with no significant or sustained effects and a replication of that study with simi-
lar findings or an RCT or quasi‐experimental design evaluations with iatrogenic
effects. Programs that have been categorized as unclear lack evidence from rigorous
RCT or quasi‐experimental design evaluations.
Strong Bonds is a chaplain delivered couples program aimed at enhancing relation-
ships and reducing marital conflict and divorce. Widely offered through the US Army
Corps of Chaplains, Strong Bonds consists of a suite of programs, one of which,
PREP for Strong Bonds, has been rigorously evaluated (see Allen, Rhoades, Markman,
& Stanley, 2015, for a summary of results). PREP is offered to groups of couples dur-
ing weekend retreats in a workshop format (1 day plus a weekend retreat) with a total
of approximately 14 hours of content focused on communication, friendship, conflict
management, problem solving, and relationship commitments. A randomized clinical
trial with 662 Army couples revealed that assignment to PREP was associated with
reductions in divorce rates at one of the two sites and modest overall short‐term gains
in marital satisfaction (to 1 year) with specific benefits of enhanced marital quality to
couples with histories of infidelity and cohabitation.
Strength at Home (Taft et al., 2016) is a group‐based program focused on prevent-
ing intimate partner violence (IPV) in male military service members at risk for per-
petrating IPV. This 12‐session program helps men to identify and change social
information processing deficits that increase risk for violence. The sessions provide
psychoeducation and teach conflict management skills, coping strategies, communi-
cation skills, and stress management. Results of a small randomized trial with 69 male
service members and their female partners indicated that at 6 and 12 months’ post‐
baseline, Strength at Home participants (both males and female partners) reported
fewer physical and psychological violence compared with the control condition.
The FOCUS program is a whole family intervention that uses a public health model
to provide a suite of services from universal to selective and indicated prevention,
including group‐level briefs, skill building and psychoeducation groups, consulta-
tions, an eight‐session model including parent sessions, sessions for children, and
family sessions (Beardslee et al., 2013). FOCUS is provided widely on military instal-
lations, particularly on naval installations. A recent randomized trial of the interven-
tion recruited 200 families who were assigned to either the FOCUS early childhood
(EC) intervention or a web‐based parenting curriculum control condition (see Mogil
et al., 2015, for description of FOCUS‐EC intervention). Intent to treat analyses
conducted at baseline and 3, 6, and 12 months later indicated that primary caregivers
in the FOCUS‐EC intervention group demonstrated significantly greater improve-
ments in parenting as measured using the Q‐SORT, relative to primary caregivers in
the web‐based control group. At the 12‐month time point, primary caregivers in the
FOCUS‐EC intervention group also reported significantly greater reductions in total
parenting stress. Parent PTSD symptoms reduced to a significantly greater extent
from baseline to 6 months (Mogil et al., 2019).
Strong Families Strong Forces is an eight‐module in‐home parenting intervention

designed for military families experiencing deployment with very young children. The
Strong Families Strong Forces program was developed from community‐based par-
ticipatory research (DeVoe, Ross, & Paris, 2012) and is guided by a developmental‐
ecological framework that posits that each individual will respond uniquely to the
stressors of military life and that the individuals within the family system will influence
each other (DeVoe et al., 2017). Strong Families Strong Forces was conceptualized as
a universal preventive intervention program with components addressing the impact
of deployment on parenting (DeVoe et al., 2012). The program aims to improve
parental reflective functioning, parent stress, and parent mental health and includes
modules on topics including military identity, deployment narratives, and co‐parent-
ing (DeVoe et al., 2017). Evidence from an RCT suggests that the Strong Families
Strong Forces program improves self‐reported co‐parenting, parental reflective func-
tioning, parenting stress, couple communication, and parent mental health symptoms
including PTSD, depression, and anxiety (DeVoe, Paris, & Acker, 2016; DeVoe &
Ross, 2013; DeVoe, Ross, & Holt, 2013).
Strong Military Families is a 10‐week parenting intervention designed for military
families with young children (Gewirtz & Zamir, 2014; Rosenblum & Muzik, 2014).
The Strong Military Families program is grounded in attachment theory and trauma
theory and aims to promote parent resilience and improve parenting skills (Dodge,
Gonzalez, Muzik, & Rosenblum, 2018). The program is available in two formats: a
home‐based psychoeducational program and a multifamily therapeutic group (Julian,
Muzik, Kees, Valenstein, & Rosenblum, 2018). The intervention addresses five cen-
tral pillars including social support, parenting education in order to enhance parent–
child attachment relationships, self‐care and stress reduction, child routines and
parent–child interaction, and care connections for families (Rosenblum & Muzik,
2014). The program results in increases in self‐reported parent knowledge, skills and
confidence, and decreased feelings of helplessness, as well as decreases in child behav-
ior problems (Gewirtz & Zamir, 2014). Results from an RCT of Strong Military
Families suggest improvements in parenting reflectivity and mental representations
(Julian et al., 2018). In addition to improving parenting and child outcomes, there is
also evidence for reductions in posttraumatic stress and depression (Dodge et al.,
2018).
After Deployment, Adaptive Parenting Tools (ADAPT) is the first evidence‐based
parenting intervention for military families with children in middle childhood; the
Clearinghouse for Military Family Readiness has designated ADAPT as a promising
program. ADAPT’s theoretical foundation is SIL theory, and it is based on the PMTO
model (GenerationPMTO™), developed by Marion Forgatch, Gerald Patterson, and
their colleagues at the Oregon Social Learning Center. A large body of evidence sup-
ports robust effects of PMTO on parent and child outcomes, including improvements
in parenting practices, child behavior outcomes, parent and couple well‐being, and
long‐term cascading effects on the family system including socioeconomic benefits
(e.g., Bullard et al., 2010; Forgatch et al., 2009).
ADAPT was designed to tailor PMTO to the needs of military families who have
experienced deployment. ADAPT can be characterized as a trauma‐informed adapta-
tion of PMTO that aims to reduce the impact of deployment separation and trau-
matic stress on parenting to improve subsequent child adaptation including child
emotional well‐being. The ADAPT program was originally developed as a 14‐session
group‐based parenting program targeting six domains of parenting practices: teach-

ing through encouragement, emotion socialization, effective discipline, monitoring
and supervision, family problem solving, and positive involvement with children.
The program is now available in multiple formats, including online, telehealth, work-
shop, and individual face‐to‐face. The goal is to build families’ strengths by helping
parents to use effective, positive parenting skills to shape their children’s prosocial
behavior, and teaching children effective ways to respond to their emotions. The
curriculum is focused on behavior change, which requires active teaching of the cur-
riculum (using role‐play, discussion, and practice) as well as opportunities for home
practice of key parenting skills.
An RCT of ADAPT provided strong evidence for the program’s effectiveness in the
National Guard and Reserve population, as well as program feasibility and acceptabil-
ity (Gewirtz, DeGarmo, & Zamir, 2018a; Gewirtz, Pinna, Hanson, & Brockberg,
2014). ADAPT has been shown to improve parent reports of ineffective parenting
and couple observed parenting that was associated with improvements in child adjust-
ment, per teacher, parent, and child report. The ADAPT program also led to improve-
ments in mothers’ and fathers’ parenting self‐efficacy, which led to reductions in both
parents’ own PTSD symptoms, depressive symptoms, and suicidality (Gewirtz et al.,
2018a). The program appears to have differential effects on mothers and fathers.
ADAPT significantly improved observed parenting skills of all mothers assigned to
the intervention group, as well as significantly reducing mothers’ PTSD symptoms
and improving mothers’ mindfulness. The intervention marginally improved fathers’
parenting practices overall, and reductions in PTSD symptoms among fathers were
indirect—through improvements in parenting efficacy.
Moderation analyses have revealed who the ADAPT program might particularly
benefit, or not. The program shows beneficial effects to parenting for most fathers and
appears particularly beneficial for fathers with relatively high levels of experiential
avoidance (i.e., efforts to avoid memories, thoughts, feelings, or sensations related to
traumatic experiences) at baseline, as well as those with higher vagal flexibility (a physi-
ological index of emotional and social regulation; Gewirtz et al., 2018a; Zhang, 2018).
The program does not appear to be effective for the 3–5% of fathers presenting with
extremely high levels of PTSD symptoms at baseline (i.e., >2 SD above the mean;
Chesmore, Piehler, & Gewirtz, 2018). However, fathers with higher levels of experi-
ential avoidance at baseline showed stronger improvements over 2 years following the
program in observed parent–child emotional communication. Finally, genetic modera-
tion analyses showed that fathers with the long allele of the dopamine receptor‐4
(DRD4) gene, previously shown to increase substance abuse in risky circumstances,
were more prone to problem drinking if they were exposed to high rates of combat
exposure. However, assignment to the ADAPT intervention buffered (i.e., disrupted)
this risk relationship such that with high combat exposure, increases in drinking were
greatest among the genetically vulnerable men in the control group and lowest for the
genetically vulnerable men in the intervention group (DeGarmo & Gewirtz, 2019).
Alternative approaches
Parenting programs represent systemic approaches to improving family well‐being
and produce positive outcomes both for children and their parents. It should be
noted that—with one exception—parenting programs are not designed to replace
individual treatment for those who meet criteria for a psychiatric disorder even
though parenting programs do demonstrate main and indirect improvements in
symptoms (e.g., improvements in mothers’ PTSD symptoms). The one exception is
children’s externalizing disorders: parent training programs are commonly accepted
as the optimal treatment for child externalizing disorders (oppositional defiant and
conduct disorders; Farmer, Compton, Bums, & Robertson, 2002). Parenting pro-
grams have shown promise in preventing onset of children’s anxiety disorders in
specific trials with civilian families (Ginsburg, Drake, Tein, Teetsel, & Riddle, 2015),
but more research is needed in child populations with high levels of anxiety in gen-
eral and with military families in particular. In general, however, parenting programs
are considered preventive interventions rather than treatments for child disorders;
they certainly are not treatments for adult disorders. However, it should be noted
that parenting programs are considered “treatment” for child maltreatment—and in
the military, as in the civilian world, parenting programs are required for families in
which child abuse and/or neglect has been established. As noted, and similar to the
civilian context, most of these mandated parenting programs used in communities
are not evidence based.
Alternative approaches to improve adjustment among family members focus on the
individual patient—for example, individual treatment for child emotional problems or
for adult psychopathology. However, there is limited evidence indicating that improv-
ing parent psychopathology alone enhances either parenting or child well‐being in the
absence of specific parenting interventions (Cuijpers, Weitz, Karyotaki, Garber, &
Andersson, 2015). For example, Forman et al. (2007) examined the impact of postpar-
tum depression treatment (interpersonal psychotherapy) on the developing mother–
child relationship and found no differences in maternal ratings of child behavior, and
attachment security, between infants of mothers in the effective treatment group com-
pared with mothers in the control group. Conversely, however, parenting interven-
tions have shown improvements to maternal depression (Forgatch & DeGarmo, 1999;
Reuben, Shaw, Brennan, Dishion, & Wilson, 2015).
Key principles/common elements of evidence‐based practices

to strengthen military family and child adjustment
Evidence‐based practices often share common practice elements, theoretical underpin-
nings, and treatment components. Chorpita and Daleiden (2009) reviewed 322 RCT
of child mental health treatments for common practice elements. The authors identified
58 practice elements, including time‐out, differential reinforcement, monitoring, praise,
tangible rewards, and parent coping (Chorpita & Daleiden, 2009). A distillation and
matching model was implemented to determine which practice elements were most
common in the treatment of particular problems (e.g., oppositional/aggressive, delin-
quency, substance abuse). For the treatment of oppositional and aggressive behavior,
the top five most common practice elements were praise, time‐out, tangible rewards,
commands, and problem solving (Chorpita & Daleiden, 2009). For delinquency, the
most common elements were problem solving, tangible rewards, praise, cognitive,
monitoring, response cost, and social skills training (Chorpita & Daleiden, 2009).
ADAPT includes several of the common practice elements previously noted, which
are common to almost all parenting interventions for school‐aged children: skill
encouragement, limit setting, monitoring/supervision, family problem solving, and

positive involvement. The emotion socialization component, which is not a common
practice element to most treatments for child disorders, targets the expected impact
of trauma on parenting and child adaptation in military families.
Other evidence‐based interventions discussed previously target parents of very
young children and focus more on the attachment relationship than child behavior.
However, those interventions share common practice elements with EC dyadic/fam-
ily interventions: improvements in the parent–child attachment relationship (attach-
ment status, reflective functioning, and maternal sensitivity). As noted, these
interventions promote positive child adjustment via improvements in the parent–child
relationship (DeVoe et al., 2017; Rosenblum & Muzik, 2014; Snyder et al., 2016).
Couple interventions such as those described above also include elements common
to parenting interventions—that is, problem solving, conflict management, stress
management (emotion regulation), and communication skills.
Summary/Conclusions
Military families experiencing deployments face high levels of family stress related to
the concerns and worries about the deployed parent, the separations inherent to
deployments, and residual effects of combat stress exposure for the service member
parent. Although there are a broad range of supports and services offered to families
on military installations, there is a dearth of evidence‐based interventions for deployed
military families. Moreover, few family services and supports are available to families
with parents in the National Guard and Reserves. Over the past decade, a handful of
parenting interventions have emerged with evidence for their effectiveness in military
families, particularly for the Reserve Component. The DOD has recognized the value
of evidence‐based programs (Whitestone & Thompson, 2016), and the Clearinghouse
for Military Family Readiness enables practitioners and policy makers to review evi-
dence for both civilian and military programs (Perkins et al., 2016).
This chapter did not provide an exhaustive review of all military family treatment
interventions. For example, recent efforts to treat PTSD have targeted couples
(Baddeley & Pennebaker, 2011; Monson et al., 2012); these interventions were not
reviewed here because the focus was on the treatment of an individual rather than the
family system.
An additional parenting intervention that is being adapted for military families is the
Family Foundations program (Feinberg & Kan, 2008). Family Foundations is a pre-
vention program aimed at strengthening parenting skills in new families, and its civilian
version is considered promising according to Clearinghouse indicators. There is cur-
rently an RCT underway of Family Foundations online that specifically targets military
families. Early results appear promising (Feinberg, personal communication).
Practice and policy implications

It is abundantly clear that more evidence‐based programs are needed for military fami-
lies, particularly those dealing with deployments and their sequelae (visible or invisible
injuries). However, in both civilian and military settings, a common challenge is to
help policy makers and decision leaders to understand the importance of implementing
evidence‐based practices. All too often, decisions about which programs to implement
on an installation reflect the personal preferences of installation leadership rather than
decisions based on an evaluation of evidence. Education of commanders and other key
decision makers—as well as improved access to the evidence itself—is thus key to
improving the uptake of evidence‐based family and parenting interventions in military
settings. Given the dearth of programs labeled as “promising” or “effective” by the
Clearinghouse for Military Family Readiness, it is clear that selection of programs can-
not be limited to the small number with RCT data. However, even these few interven-
tions, often federally funded by the National Institutes of Health or the DOD, with
strong evidence for their effectiveness and utility, are not used in routine service set-
tings (Institute of Medicine of the National Academies, 2013). On the other hand, the
vast majority of family‐based interventions currently in use in military settings have
little to no evaluation data indicating whether they actually accomplish their stated
goals. Educating military service providers, leaders, program and policy personnel, and
intervention scientists and practitioners should focus on bridging this research–prac-
tice–policy divide.
Reserve Component families are in particular need of effective family interven-
tions as these families typically have little access to installation services and supports.
Despite this, National Guard and Reserve resources are typically few and far
between. Community clinics often lack specific military expertise, and this may con-
tribute to the relative isolation and increased mental health difficulties in National
Guard and Reserve families dealing with the aftermath of deployment stressors
(Sripada et al., 2015). Advances in telemedicine may particularly benefit National
Guard and Reserve families, such as online interventions that have the advantage of
“anytime, anywhere” access and telehealth intervention formats that enable practi-
tioners to “meet” with families in a Skype‐type setting online. Studies are underway
to compare the effectiveness of these intervention formats with in‐person family
programming (Gewirtz, 2016).
As the largest health‐care system in the United States, the Veterans Affairs (VA)
medical centers play a significant role in delivering services to military families, yet VA
clinics and Veterans centers have historically been limited to serving individual service
members, and more recently spouses. A recent policy change mandates the VA to
provide services to families (including children) and not simply service members or
their partners, which offers an expanded opportunity to provide evidence‐based ser-
vices to veteran families and children, yet relatively few VA practitioners have special-
ized family therapy training or training in delivery of evidence‐based parenting
programs. An important opportunity exists for the VA health‐care system to train
practitioners to deliver evidence‐based parenting programs and to increase well‐being
among families who have served.
Future directions for research

Interventions aimed at improving military family functioning continue to expand.
However, it is notable that—as of late 2018—of the over one thousand family or
individual (child or adult) interventions reviewed by the Clearinghouse for Military
Family Readiness, just one intervention is designated as “effective” and 32 as “prom-
ising” among the 153 interventions actually used in military contexts. There are,
however, many more effective and promising interventions that have not yet been
used in military contexts. Modifying these programs for military use would likely be
far more cost‐effective and efficient than creating new programs. Modifying civilian
programs for military use requires adaptations to meet the needs of the military cul-
ture and context, not dissimilar to other contextual and cultural adaptations. In our
work on the ADAPT program, for example, we found that military parents had very
high standards for behavior expectations and found it difficult to accept the “70%
(compliance) is success” mantra that typically is acceptable for civilian parents. In
contrast, where civilian parents might have difficulty teaching problem solving, mili-
tary parents enjoyed teaching their children a process that they engaged in daily in
their military work. When modifying a program for a specific military population,
such as those returning from deployment, it is also important to consider the unique
stressors inherent in this aspect of military life. In the case of ADAPT, we wanted to
add components to assist parents in dealing with children’s anxiety, as well as their
own emotion regulation challenges. In ADAPT, these additions and modifications
were woven into the existing parent training program. Because of the stigma attached
to mental health services in the military, we took care to not use mental health lan-
guage; we also ensured that all our video materials were developed so that families
could see others like themselves.
Future research also should examine the degree to which a modified evidence‐
based civilian program should be rigorously evaluated in a military context. If another
effectiveness trial is not needed because, for example, the intervention is not very dis-
similar from the civilian version, an evaluation of the implementation should at mini-
mum be completed—to address questions such as the acceptability, feasibility, and
fidelity of the intervention delivery in the military context. Elements of the military
service setting—such as its top‐down nature, the close‐knit installation community,
and so forth—may facilitate or hinder the implementation of family‐based interven-
tions, but only evaluation will help uncover these issues.
Despite growth in family‐based prevention and intervention research, we are una-
ware of any theory‐informed and evidence‐based parenting programs specifically
developed and/or tested with military families with adolescents. Given recent evi-
dence of the associations of a parent’s deployment with increased adolescent risky
behaviors and substance use (Sullivan et al., 2015), such interventions are greatly
needed.
Also needed are longer‐term outcome data from military families who have com-
pleted randomized trials of military parenting interventions. There are currently no
military studies that have followed families for more than 2 years, and given the ages
of children in these studies (birth to 12), there are currently no data showing whether
these programs reduce risks as children go through adolescence. There is reason to
expect long‐term effects of parenting interventions in this population based on the
literature showing that parenting interventions can have sustained effects for up to
15 years in nonmilitary families (Olds et al., 1998; Patterson, Forgatch, & DeGarmo,
2010). It would be beneficial for RCT of parenting interventions designed for mili-
tary families to conduct long‐term follow‐up assessments in order to determine when
these interventions may have long‐term outcomes on family socioeconomic status or
other factors related to quality of life. Finally, further evidence is needed to elucidate
pathways to resilience in military children. Future research should examine the path-
way from high‐quality parenting to improved resilience in military children after
deployment to elucidate potential underlying mechanisms. We hypothesize that

improvements in self‐regulation and, particularly in emotional regulation, may be
crucial mechanisms, but further research at multiple levels of analysis (interpersonal
and intrapersonal, behavioral, physiological, and genetic) are needed to understand
these pathways.
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Part V
Future Directions
25
Improving Culturally Sensitive
Interventions for Youth and
Parent-Child Relationships
DeAnna Harris‐McKoy and Shardé McNeil Smith
Youth constitute approximately 13% of the US population and are being labeled as
the most culturally diverse generation in US history (Office of Adolescent Health
[OAH], 2016). Nationally and globally, we are seeing youth use their voices and
social media to advocate for social justice, fairness, equity, and the rights of others
(Fromm, 2017). Given the new and long overdue attention to various cultural groups
and cultural diversity nationally and globally, it is a fundamental and ethical necessity
for systemic professionals to analyze their level of cultural sensitivity and critical con-
sciousness to appropriately assess, treat, and work with diverse youth and their fami-
lies. Therefore, the purpose of this chapter is to (a) highlight the pathways and barriers
to mental health services, (b) critique foundational systemic family therapy (SFT)
theories and evidenced‐based treatments (EBTs), and (c) provide clinical, teaching,
research, and policy recommendations.
Defining Culture, Cultural Sensitivity, and Critical Consciousness

Because culture is embedded in every systemic interaction conceivable, it is neglectful
for systemic professionals not to be sensitive to culture and cultural differences in their
interactions with individuals and families. Culture is multidimensional and serves as
the blueprint, in both subtle and overt ways, for how one generally behaves and what
one typically values (Ayonrinde, 2003). In its simplest form, culture includes “all of
the dimensions of diversity, including but not limited to race, ethnicity, nationality,
class, gender, sexual orientation, religion, age, and ability” (Laszloffy & Habekost,
2010, p. 334). Culture, from our perspective, is defined as the shared and socially
constructed attitudes, behaviors, and beliefs influenced by these intersecting dimen-
sions of diversity. Based on this conceptualization, it is important to note that although
cultural groups share common attributes (e.g., history, behaviors, and values), they
are also exceedingly heterogeneous.
624 DeAnna Harris‐McKoy and Shardé McNeil Smith
Cultural sensitivity is defined as a “state of attunement to, emotional resonance

with, and meaningful responsiveness to the needs and feelings of others” (Laszloffy &
Habekost, 2010, p. 334). In practice, cultural sensitivity requires one to possess
knowledge of cultural differences and values, show consideration and respect for oth-
ers, and attempt to understand other cultural factors, practices, and beliefs (Foronda,
2008). Also, professionals should constantly engage in self‐reflection and critique and
“check the power imbalances” existing between and within cultures (Tervalon &
Murray‐Garcia, 1998, p. 118). It is worth noting that cultural sensitivity is a lifelong
process that extends beyond the bounds of the therapeutic process. It is not merely
obtained in a diversity class or a training program or mastered through an exam.
Cultural sensitivity is also not measured by the number of interactions one has with
individuals from other cultures. Instead, cultural sensitivity requires a commitment to
being actively involved in understanding and recognizing that culture (a) informs
perspectives and behaviors and (b) creates both order and disorder inside and outside
of any given system (Ariel, 1999).
Critical consciousness, pioneered by Freire (1970), is conceptualized as “the ability
to recognize and challenge oppressive and dehumanizing political, economic, and
social systems” (Garcia, Kosutic, McDowell, & Anderson, 2009, p. 19). Through
dialogue and reflection, efforts are taken to resist oppressive forces while simultane-
ously recognizing one’s contribution to the existing oppressive system. Increasing
critical consciousness also includes empowering oneself and others with the intention
of moving toward social justice. Therefore, it is essential that therapists work toward
critical consciousness so that they can (a) reduce the risk of processing information
and treating clients in a stereotyped or biased manner, (b) understand their client’s
lived experience for an authentic therapeutic relationship, and (c) work alongside cli-
ents to fight against oppression (Garcia et al., 2009).
Pathways and Barriers to Mental Health Services
Providing culturally sensitive, critically conscious services to youth and their parents
requires an understanding of the complex pathways and barriers to therapeutic services.
Approximately 50% of children and adolescents with mental or behavioral disorders do
not receive services (OAH, 2018) due to stigma of mental illness, lack of insurance,
shortage of affordable mental health care in the area, discrimination by health profession-
als, and immigration status (Godoy & Carter, 2013; Murphey, Vaughn, & Barry, 2013).
Youth who have multiple, complex stressors (e.g., homelessness, involved with juvenile
justice or child welfare system, identified as lesbian, gay, bisexual, and transgender
[LGBT]) as well as older youth, youth of color, males, and those in rural areas are less
likely to receive services (Murphey et al., 2013; OAH, 2018).
Youth who do receive services do so within a variety of settings (e.g., commu-
nity, home, emergency rooms, and residential treatment centers; Jones, Pastor,
Simon, & Reuben, 2014). However, mental, behavioral, or emotional issues are
usually first identified by the school system or primary care physicians (de Voursney
& Huang, 2016; OAH, 2018; Olfson, 2016). Each of these systems has a different
purpose (educating and treating physical illness, respectively); therefore, assessing
and diagnosing mental illness or relational issues (e.g., parent-child, sibling, f amily,
Culturally-Sensitive Interventions for Youth 625
or peer conflict) may not be a priority (Olfson, 2016). While there is an increased
effort to provide training to physicians and individuals in the educational systems
about recognizing and appropriately responding to mental illness, the lack of men-
tal health specialty and cultural sensitivity can influence access to care, the type of
therapeutic services received, and frequency of underdiagnosis or misdiagnosis.
Schools
The educational system is inherently a microcosm of our larger society. While schools
are places of education, historically they have been institutions of oppression. For exam-
ple, schools have forcefully stripped away cultural traditions and cultural ties of many
First Nation children in the name of “proper education” (Tafoya, 1990). Recently,
educational agencies were attempting to rewrite history by minimizing or disregarding
the violence necessary to sustain white supremacy and the trauma endured by people of
color in the United States (Editorial Board, 2015). Many states considered legislation
that would mandate transgender youth to use bathrooms and locker rooms related to
their biological sex (Samar, 2017). Currently, macrolevel issues such as oppression,
under‐resourced school systems, and concentration of poverty influence mental health
services for youth. Schools located in low‐income or rural communities have less access
to mental health services, less funding, and teachers that are more stressed (Hodgkinson,
Godoy, Beers, & Lewin, 2017). Being a multi‐stressed school system coupled with
inadequate training concerning mental illness, relational issues, and culturally sensitive
practices can influence how mental health is perceived and the type of services offered.
While employees of school systems may be the first to witness youth disruptive
behavior, current solutions may not lead to proper treatment. Youth’s disruptive
behavior in school could be a symptom of mental illness or relational issues (Stewart,
Klassen, & Hamza, 2016). Without proper education concerning mental illness,
schools may focus on the disruptive behavior instead of the underlying issues. Lack of
education concerning mental illness coupled with focus on the disruptive behavior
within the context of zero‐tolerance school policies contributes to the school to
prison pipeline (Bell, 2015), which disproportionately suspends and expels youth of
color from schools (Darensbourg, Perez, & Blake, 2010). When cultural context or
mental illness is not considered in understanding youth behavior, youth of color
become overdiagnosed with disorders focused on behavioral problems (e.g., attention
deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder) instead
of mood disorders (Liang, Matheson, & Douglas, 2016). This could indicate that
youth of color may be left to suffer from depression and anxiety without the proper
treatment. Also, since school staff may focus more on externalizing behaviors usually
presented by boys, they may neglect girls’ internalizing behaviors, thereby leading to
potential failure to diagnose mental illness in girls. Lack of information concerning
internalizing behavior could explain why girls are less likely than boys to receive men-
tal health services in school (Jones et al., 2014).
Oppression in the school systems and lack of education concerning mental illness
could influence youth and parents’ response to referrals to mental health services.
Parents may not readily engage in services or referrals offered by the school due to a
distrust of the school system (Prodente, Sander, & Weist, 2002). Referrals to therapeu-
tic services based on the disruptive behavior may seem punitive instead of supportive
to youth and parents (Prodente et al., 2002). Parents may also feel powerless and
reluctant to accept therapeutic services due to the fear of their child being placed in
special education classes or being suspended/expelled from school (Tucker, 2009).
For parents, the process of getting assistance can seem as though the school system is
shirking responsibility for mental health care instead of creating continuity of care.
Primary care
Although medical settings are one of the first places mental illness is detected, physicians
may not have enough time to meet with youth and their parents to adequately address
mental illness or relational issues (Olfson, 2016). In 2016, almost half of all visits
(41.9%) lasted between 16 and 30 min (Rui & Okeyode, n.d.). Pediatric physicians and
general and family practitioners who would meet with youth the most, spent about 22
and 20 min, respectively, with individuals (Rui & Okeyode, n.d.). The limited amount
of time spent with each person could explain why only 6% of visits resulted in a mental
health diagnosis (Rui & Okeyode, n.d.) when globally approximately 10–20% of youth
have mental illness (WHO, 2018). The infrastructure of the medical system may not be
conducive to long‐term mental health care (Holden et al., 2014), which can explain
why only 1.1% of services ordered or provided were for psychotherapy and why only
0.4% were seen by a mental health professional (Rui & Okeyode, n.d.).
Macrolevel constructs also need to be considered when discussing pathways and
barriers to mental health services concerning medical settings. For instance, lower‐
income neighborhoods have less access to health services and have residents who are
less likely to have health insurance in part due to the financial cost of health care
(Hodgkinson et al., 2017). Although more youth now have access to care due to the
Affordable Care Act of 2010 (The Annie Casey Foundation, 2018), youth and their
family still have to contend with discrimination from physicians. For example, stereo-
types about various ethnic groups or those in poverty have led physicians to consider
these populations more difficult to work with and are more likely to be given an
unnecessary mental health diagnosis (Hodgkinson et al., 2017). Furthermore, due to
previous experimental testing on marginalized populations, some groups are right-
fully distrustful of the medical system (Briggs, Banks, & Briggs, 2014).
Part of the journey to being a critically conscious relational professional is to deeply
understand how youth come to therapy. How they come to therapy can set the tone for
the duration of the therapeutic process, therapeutic relationship, and the professional’s
expectations for clients. The legacy of and continued oppression from educational and
medical settings influence the perceptions of mental illness and relational issues and
therefore the therapeutic relationship. Relational professionals can mitigate some of the
pre‐therapy issues by discussing the process of coming to therapy and contextualizing
presenting problems that can lead to a deeper understanding of the current issue.
Cultural Critique of SFT Foundational Theories

and Evidence‐Based Practices
The field of family therapy has long been criticized for its lack of attention to cultural
issues (Celano & Kaslow, 2000; Leslie, 1995). To combat this problem, some scholars
have provided considerations for working with specific cultural groups (e.g., Ariel &
Culturally-Sensitive Interventions for Youth 627
McPherson, 2000; Boyd‐Franklin, 1989; McGoldrick, Giordano, & Garcia‐Preto,

2005), whereas others have put forth cultural techniques to be used across multiple
cultures (e.g., Falicov, 1995; Ramirez, 1999; Tharp, 1991). While collectively these
works have advanced our knowledge of how clinicians should be cognizant of cultural
issues in practice, there remains a need to ensure that therapists are also culturally
sensitive and critically conscious of issues related to power and privilege when using
systemic approaches while working with youth and their parents. This need is particu-
larly important given differences in the prevalence, manifestation, and consequences
of some child problems across cultural groups due to cultural misunderstandings,
biases, and injustices. Furthermore, by nature, therapists and families conceptualize
presenting problems through their own cultural lens. Culture can influence parenting
practices, rules for interaction, communication patterns between family members, and
perceptions on how to define and cope with problems. Thus, we provide a cultural
critique of foundational family theories and EBTs used when working with youth and
their parents. In providing this analysis, we focus on specific concepts and assump-
tions from a culturally sensitive lens and offer suggestions and exemplars for how
systemic and relational approaches can be implemented in a culturally sensitive
manner.
Systemic foundational theories

Structural family therapy Developed out of Salvador Minuchin’s work with adoles-
cent delinquency, the goal of structural family therapy is to restructure dysfunctional
family systems (Minuchin, 1974). According to this theory, problems are maintained
because of family subsystems (e.g., parental and child subsystems) that are disengaged
or enmeshed or boundaries and hierarchies that are unclear. The goal is to restructure
the family to a healthier organizational system through the use of therapeutic direc-
tives and commands.
There are shortcomings of structural family therapy when viewing the assumptions
through a culturally sensitive lens. In particular, family functioning and structure that
is culturally normative for one family may be considered dysfunctional in another
culture. For example, an enmeshed boundary may hold different meanings across
cultural groups (Napoliello & Sweet, 1992). In addition, families with a “parental
child” may be seen as dysfunctional when in fact it is a necessity based on the family’s
sociocultural context (e.g., overburdened single‐parent households or child language
brokering). It is important for structural family therapists to consider how the broader
culture reinforces the family structure that is perceived as problematic and ensure that
family patterns and structures that deviate from what is socially or culturally accepta-
ble are not considered pathological or dysfunctional.
Bowen family systems theory Murray Bowen’s family systems theory posits that anxiety
occurs within family systems due to an imbalance of closeness and distance in relation-
ships (Kerr & Bowen, 1988). Thus, the primary goal is to increase differentiation—the
ability to maintain a solid self in relation to others in the family system. Levels of dif-
ferentiation are theorized to be passed down over generations through a process called
multigenerational transmission. Accordingly, children’s levels of differentiation are
predicted to be similar to their parents’ levels. Furthermore, the impact of stress on a
family system is determined by individual family members’ levels of differentiation.
That is, family members who are highly differentiated are well equipped to deal with
stressors than those who are poorly differentiated (Murdock & Gore, 2004).
Although Bowen’s construct of differentiation has been found to be applicable
cross‐culturally (Tuason & Friedlander, 2000) and Kerr and Bowen (1988) suggest
that the theory can be applied “in all families and in all cultures” (p. 202), there
remains a need to view this framework through a culturally sensitive lens. For one,
Bowen’s theory has been criticized for privileging autonomy over togetherness
(Knudson‐Martin, 2002; Tamura & Lau, 1992), leaving room for family patterns in
collectivistic cultures to be pathologized whereas family patterns in line with individu-
alistic values are not. Although others may disagree with this assertion because indi-
viduation and togetherness are mutually occurring forces (e.g., Horne & Hicks,
2002), therapists are often charged to help clients become less emotionally reactive to
others and accept responsibility for the self (Skowron & Dendy, 2004).
Thus, therapists should consider how youth’s emotional reactivity is connected to
broader cultural factors. For instance, racial and ethnic minority families living in the
United States are disproportionately at risk of experiencing stress due to their expo-
sure to societal racism (Carter, 2007). As such, youth’s “undifferentiated” reactions
to stress may be due to the additional burden of racial, acculturative, homophobic,
and/or transphobic stress and the tension of feeling disconnected from the American
mainstream culture. Therefore, it may be important for therapists to increase differ-
entiation by socially connecting youth to their racial, ethnic, and/or LGBT commu-
nity. For instance, Skowron (2004) found that ethnic minorities who had strong ties
to their ethnic group reported higher differentiation compared with those who did
not have strong ties to their ethnic group. Though their results were preliminary, it is
a step toward ensuring that therapists in general and Bowenian therapists in particular
consider the roles of other cultural factors such as racism, levels of acculturation, and
multiple identities within family systems.
Contextual family therapy Contextual family therapy, developed by Ivan

Boszormenyi‐Nagy, is a transgenerational approach that focuses on integrity, fairness,
and mutual trust within relationships and across generations (Boszormenyi‐Nagy,
1986). The key dimension of contextual family therapy, relational ethics, deals with a
balance between what individuals put into a relationship (give) and what they receive
out of it (take). Symptomatic behavior exists when individuals perceive a relational
imbalance in systemic interactions. Inherently, there is an imbalance in relational eth-
ics between parents and children because parents give more to their children than
what their children can provide back. This may result in invisible filial loyalties where
children feel a sense of guilt, shame, or obligation toward their parents. Furthermore,
children may experience a split loyalty with their parents or some other entity when
trust is broken.
We believe that culturally sensitive therapists working under a contextual frame-
work must operate under the premise that relational ethics are culturally based. That
is, there may be cultural differences in w

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The Handbook of Systemic Family Therapy

About the Editors xi

8 The Process of Change in Systemic Family Therapy 171

Part II Social and Cultural Contexts 225

Part III Theoretical Perspectives 293

Part IV Methodological Challenges and Advances 443

21 Community‐Based Participatory Research (CBPR) for Underserved

Part V Training and Practice 531

Part VI Future Directions 727

Volume 1: Richard B Miller and Ryan B. Seedall

Volume 2: Lenore M. McWey

Volume 3: Adrian J. Blow

Volume 4: Mudita Rastogi and Reenee Singh

Hana H. Abu‐Hassan, MD, Department of Family and Community Medicine,

Katie M. Heiden‐Rootes, PhD, LMFT, Medical Family Therapy Program,

Gabriela López‐Zerón, PhD, Human Development and Family Studies, Michigan

Hayley A. Rahl‐Brigman, BS, Institute of Child Development, University of Minnesota,

Ingrid Vlam, PhD, MBA, Research Graduate School, Bedfordshire University,

and legitimacy as a field, moving to more advanced statistics to examine relational

Systemic Family Therapy

“Systemic” provides a conceptual framework for understanding how to define a

Culture and institutional functions

What is the family domain for SFT?

Help from attachment theory

Defining Characteristics of Systemic Family Therapy

Family relationships are the primary mechanisms of change

When developing family‐focused interventions, future researchers are encouraged

Flexibility in who is directly involved in treatment

1 Improving problematic relationships in the family and/or its subsystems.

A useful framework for SFT role: The WHO pyramid

Informal community care

Quantity of services needed

Why Does Helping Families Matter?

It is remarkably difficult to keep “family” salient as a level of intervention in mental and

Relationships influence well‐being in every part of life

Lack of close relationships matters: Loneliness and well‐being

The legacy of family relationships in childhood

Transmission of traits by social and biological stressors

Prevention and early intervention

adulthood … the risk of psychopathology continues to rise with age” (Blanco,

Moving Forward: Observations

Expanding the conceptual base

discrimination, historically marginalized communities, family dislocation, and forced

Assessment of family‐level relational processes Ambiguous loss, age‐appropriate auton-

The complexity of SFT research

Scholars like Mary Ainsworth (parent–young child), John Gottman (couple),

Make modality a more prominent subject

The Handbook of Systemic Family Therapy (SFT) is intended to be a comprehensive

Wampler, R. S. (2020). The evolution of systemic approaches to children and adolescents. In

Intervening directly in family relationships to treat human problems and promote

Sociocultural Origins of Couples Therapy

The post‐World War II era brought a new optimism to mainstream American

Sociocultural Origins of Family Therapy

Family therapy is a product of the post‐World War II concerns about mental

material in this chapter are adapted from Doherty (2017).) Humanistic

The Culture Strikes Back: Challenges Hit the Field

Current Situation and Prospects for Systemic Family Therapy

The Consumer Self and the Relational Self

The Consumer Self

About the Editors xi