Handbook of Family Therapy

The Science and Practice of Working with Families and Couples

Thomas L. Sexton, Jay Lebow, Thomas L. Sexton, Jay Lebow

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781136340116
• Edition: 1
• Topic: Medicine
• Subtopic: Diseases & Allergies

Integrative, research-based, multisystemic: these words reflect not only the state of family therapy, but the nature of this comprehensive handbook as well. The contributors, all well-recognized names who have contributed extensively to the field, accept and embrace the tensions that emerge when integrating theoretical perspectives and science in clinical settings to document the current evolution of couples and family therapy, practice, and research. Each individual chapter contribution is organized around a central theme: that the integration of theory, clinical wisdom, and practical and meaningful researchproduce the best understanding of couple and family relationships, and the best treatment options. The handbook contains five parts:
•Part I describes the history of the field and its current core theoretical constructs
•Part II analyzes the theories that form the foundation of couple and family therapy, chosen because they best represent the broad range of schools of practice in the field
•Part III provides the best examples of approaches that illustrate how clinical models can be theoretically integrative, evidence-based, and clinically responsive
•Part IV summarizes evidence and provides useful findings relevant for research and practice
•Part V looks at the application of couple and family interventions that are based on emerging clinical needs, such as divorce and working in medical settings.
Handbook of Family Therapy illuminates the threads that are common to family therapies and gives voice to the range of perspectives that are possible. Practitioners, researchers, and students need to have this handbook on their shelves, both to help look back on our past and to usher in the next evolution in family therapy.

1. The Evolution of Family and Couple Therapy

Jay Lebow and Thomas L. Sexton

DOI: 10.4324/9780203123584-1

It all started with a simple observation. By expanding one’s “lens” from the individual to the entire family, new treatment opportunities and new ways of understanding the seemingly mysterious mechanisms of relationships emerged. By moving the focus of attention from the individual to a relational focus came a new clarity in defining and understanding the “space between” the people in families. In doing so, therapy became a process in which behaviors and interactions were described in terms of a recursive process of mutual influence. For most early family therapists, this also meant “an emphasis on what is happening in the here and now rather than why it is happening or in terms of a historical focus.” Thus, the patterns within relationships became the primary target and goal of most early family therapies.

This simple observation and the complex thinking that came quickly after marked the beginning of a paradigm shift akin to a scientific revolution. A paradigm shift, as Kuhn suggests, occurs when anomalies that could not be explained by the prevailing majority view begin to emerge and become significant. Such a scientific revolution occurs when an alternative belief system ushers in a new way to see the world, a different perspective, and new meaning for events otherwise considered not important. The early principles of systems theory and its application to family therapy led to an alternative and comprehensive belief system based on communication, cybernetics, and relational process.

Family therapy has evolved a great deal since the publication of the first handbook overviewing family therapy in 1971. Although the core foundational systemic concepts remain, the practice of family therapy looks much different today than it did fifty years ago. Family therapy has morphed over time from a provocative challenger to the mental health establishment to a widely practiced set of methods that represent best practices in relation to a variety of problems and issues. Further, whereas early family therapy was largely about the argument between proponents of various models regarding who had the “right” theory and best method of practice, today’s family therapy includes emerging consensus about many issues in the field. Family therapy has also moved from an alternative therapy to a set of methods that often coordinate and integrate with other methods of treatment (see, for example, Chapters 12, 16, and 28). Further, some family treatment models have emerged to become among the best illustrations of evidence-based treatment that combine cutting-edge science while embracing the complexity and artfulness of clinical implementation of those models (see Chapters 12–20).

Handbooks of Family Therapy

For the last fifty years, handbooks of family therapy have chronicled the evolution of this paradigm. Each has reported on the then present emerging epistemologies, theoretical foundations, models of clinical practice and the state of the research in the field.

The first embryonic handbook, Progress in Group and Family Therapy, edited by Clifford Sager and Helen Singer Kaplan (1971), was not even fully devoted to family therapy, sharing a volume with group therapy. Paired with the contemporaneous Book of Family Therapy, edited by Andrew Ferber, Marilyn Mendelsohn, and Augustus Napier (1972), three themes emerge from these early volumes. First, there is the shock of the new, the revolutionary flow of new ideas and methods. Second, there is the emergence of the underlying focus on systems theory as a base of conceptualizing families. Third, there are the unruly developments in many directions and models, with much debate beyond agreement about the core importance assigned to families and systems theory. Finally there is what is missing: research or any focus on gender or culture. These volumes are filled with what then were new concepts and terms: boundaries, communication, information processing, entropy, negentropy, equifinality, equipotentiality, morphostasis, morphogenesis, and positive and negative feedback, all emerging ways to understand the “system.” (Years later we can also note that it required a family therapy dictionary to understand the meanings of this new language—Lyman Wynne and colleagues actually produced one (Simon, Stierlin, & Wynne, 1985)). These two early handbooks point to what then was a marvelous explosion of ideas and methods, but limited by the presence of very little integration or science assessing those ideas.

Alan Gurman and David Kniskern’s (1981)Handbook of Family Therapy marked the emergence of family therapy as an established discipline. Notably, unlike its predecessors with their idiosyncratic content, it was organized to be used as a course text with a suggested chapter outline that would elicit each chapter authors’ positions about a core set of questions. Gurman and Kniskern’s first volume primarily consisted of articulations of the rich array of the recently emergent family therapy models. These models ranged widely from the “black box” structural and strategic models with which that era is now so readily identified, to intergenerational models of Bowen, Framo, and Boszormenyi-Nagy; to the psychoanalytic based approaches of Skynner and Sager; to the behavioral models of Jacobson and Heiman; to the experiential approach of Whitaker. Beyond the underpinning of systems theory and the importance of family, these approaches agreed about very little. Gurman and Kniskern’s first volume also included Alan Gurman’s first comprehensive effort to bring the frame of evidence-based practice (i.e., that evidence was essential to the assessment of treatments) to family therapy.

It is impossible for the contemporary reader to grasp the impact of this volume. It is fairly safe to say that every family therapist of that time owned this giant tome. (The then popular Behavioral Science Book Club made it their award for joining the Club. How wise you would look with that five pound book.) As I (JLL) write this paragraph looking at a quite worn highlighted and underlined copy from that time, I fondly recall the hundreds of hours of discovery that I and innumerable others devoted to reading this book! For me (TS) the volume was a window into a new world. These were the words of the masters, all in one place with Alan Gurman and David Kniskern’s brilliant commentary (this may be the only volume in the history of the field in which the editors not only edited but also commented on the chapters within the chapters themselves). Oh, yes, the problems of the times must also be mentioned. Almost every author was male and only Harry Aponte of the authors was a person of color. Culture was barely mentioned, and even in a volume edited by Alan Gurman, there was very little research presented either assessing treatments or as a basis for the many claims made about social systems.

Gurman and Kniskern later produced a second volume (1991) which is primarily notable for its early attention to issues that cross theoretical boundaries. It contains the first chapter written on the history of couple and family therapy and chapters on treating divorcing and remarriage families (in early recognition of the need for different expectations and treatments for these family forms). It also featured a chapter on ethnicity and family therapy by Monica McGoldrick and colleagues, and one by Evan Imber Black on a larger systems perspective. In these chapters, the voices of women, who rarely were heard from in earlier volumes, gained prominence. That book is also notable for William Doherty and Pauline Boss’ still definitive chapter on values and ethics in family therapy and Howard Liddle’s chapter on training which, as Breunlin points out in Chapter 27 of this volume, still remains the best summary about training in the field even though it is now twenty years old.

By the time of Tom Sexton, Gerald Weeks, and Michael Robbins’ (2003) Handbook of Family Therapy, the landscape of family therapy was becoming increasingly integrative, research based, and multisystemic. The emphasis on broad “schools” of therapy was augmented by greater attention to “Common Factors” that are intrinsic to all family therapies and perhaps paradoxically as well to more specifically focused, manualized clinical models. In addition, this volume pointed to the emergence of a number of the models of family and couple therapy as “evidence based.” The evidence-based models included in both couple (Behavioral Marital Therapy/Integrative Couple Therapy, Emotionally Focused Couple Therapy) and family (Functional Family Therapy, Multisystemic Therapy, and Multidimensional Family Therapy, among others) therapy demonstrated that systemically based treatment models did produce significant clinical changes in a wide variety of areas including delinquency, adolescent drug use, management of adult chronic schizophrenics, and depression. This volume also showed that family therapy, a provocateur in its earliest days, was now mainstream and that it had some of the most effective treatments to be developed for some of the most difficult cases. During this era, from a much different direction, some of the core ideas in family therapy were challenged by postmodern epistemological perspectives. The Sexton, Weeks, and Robbins volume contains the first summary in a handbook of those models. Postmodern approaches are now a vital part of that spectrum, and have broadly helped move the field to an emphasis on collaboration.

Jay Lebow’s (2005)Clinical Handbook of Family Therapy of about the same time pointed to the explosion of specific methods for family therapy targeted toward specific problems. Twenty-three different such models are included. Almost all of these models have a foundation in evidence; each worthy of a designation of at least “probably efficacious” in evidence-based language with several qualifying as well established. Family therapy had evolved a series of practical effective methods for impacting on a broad array of specific problems.

A New Era

In the decade since the last two handbooks of family therapy, the landscape has continued to evolve with the emergence of many points of agreement and transcendent concepts and intervention strategies that mark a consensus among most of those who teach and practice family therapy (Lebow, 2014). What were early arguments in the history of family therapy between proponents of various models about who had the “right” theory and best method of practice have segued into consensus about many issues in the field. Family therapy has also moved from an alternative “outsider” therapy to a set of methods that often coordinate and integrate with other methods of treatment.

One point of consensus is the core importance of the central concepts of systems theory such as feedback and mutual influence at the center of the practice of family therapy. Another is the crucial role of the therapeutic alliance and the other common factors in couple and family therapy (Lebow, 2014; Sprenkle, Davis, & Lebow, 2009). For example, whereas there once were family therapies that disregarded the therapeutic alliance (Watzlawick, Weakland, & Fisch, 1974), today’s approaches universally speak to this tenet. A third is the crucial role of culture for practice in the world of families. Other points of consensus include the importance of the family life cycle, understanding the recursive relation of systemic change and individual changes, the relationship between these changes and neurological processes, and the inclusion of at least some understanding of the importance of such theories as attachment, social exchange, and social learning. Although once hotly debated, the importance of linking research and practice (Sexton et al., 2011) and including some notion of evaluating outcomes as therapy progresses (see Chapter 26) now have become commonplace. Further, a shared common base of intervention strategies and techniques that is the toolkit for the couple and family therapist, including such elements as reframing, enactment, and examining genograms, has emerged (Lebow, 2014).

This is not to say there is full agreement across best practices. While there may be complete agreement about some issues (e.g., dual relationships; ensuring safety in the context of family violence), this shift is less about all family therapists following the same methods as about cross-pollination across approaches so that each approach influences and is influenced by the others. There remain many important points of difference. In parallel with a similar trend in other therapies, some look to build on a developing base of empirically supported therapies targeted to specific conditions. Others eschew this position, suggesting that formulation or even the ideology of the therapist about what is crucial should dictate the manner of working. Some approaches accentuate a focus on emotion, others on behavior and cognition, and yet others on internal dynamics and multigenerational processes. Some see family therapy as fully identified with the promotion of social justice, whereas others practice family therapy in ways that are socially conservative, and yet others view family therapy as ideally neutral about all issues of values. Some approaches are purposefully highly directive and structured, whereas others are as non-directive and unstructured as was Carl Rogers.

Also, despite some movement, the reliable and informative results of the cumulative research knowledge still often do not find their way into the mainstream of either clinical practice or training and education. Indeed, it is not uncommon, now more than four decades since the publication of the first research findings in the field, to encounter concerns about the role of research in practice. For example, practitioners continue to argue that researchers are not clinically responsive, whereas the researchers argue that practitioners are not systematic. The gap is also reflected in the fact that it is common to find new “hot” ideas being touted in practice publications and on the lecture circuit that have no support in either the rich theory or research of the field. As Gurman, Kniskern, and Pinsof (1986) noted, “Despite numerous attempts at seduction and mutual courtship, it remains the case that clinicians and therapy researchers have failed to consummate a ‘meaningful’ and lasting relationship, as has been observed, commented on, and lamented repeatedly” (p. 490).

We suggest that the current era of family therapy is founded upon the ...