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Chapter 7: Intergenerational and Psychoanalytic Family Therapies

“Bowen theory is really not about families per se, but about life.”—Friedman, 1991, p. 134

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Lay of the Land

Intergenerational therapy and psychoanalytic family therapy

Share common roots:

Psychoanalytic theory and systemic theory

Draw from object relations theory and developed several unique approaches:

Object relations family therapy, family-of-origin therapy and contextual therapy

Share several key concepts and practices:

Examine client’s early relationships.

Tracing transgenerational family dynamics.

Promoting insight into extended family dynamics.

Identifying/altering destructive beliefs and behaviors learned early in life.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Bowen Intergenerational Therapy

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

In a Nutshell: The Least You Need to Know

More about nature of being human than about families or family therapy.

Broad perspective considering evolution of human species and characteristics of all living systems.

Consider three-generational emotional process to understand current symptoms.

Therapy involves increasing clients’ awareness of how current behavior is connected to multigenerational processes.

Primary tool for client change is therapist’s personal level of differentiation.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Juice: Significant Contributions to the Field

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Juice #1: Differentiation

Differentiation

Person’s ability to separate intrapersonal and interpersonal distress.

Intrapersonal: Separate thoughts from feelings in order to respond rather than react.

Interpersonal: Know where oneself ends and another begins without loss of self.

Balance two forces: need for togetherness and the need for autonomy.

Conceptualized on a continuum.

A lifelong journey; referred to as “maturity.”

Differentiated people better able to handle ups and downs of increasing intimacy.

Level of differentiation expressed differently depending on culture, gender, age, and personality.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Juice #2: Genograms

Genograms

Type of family tree or genealogy that specifically maps key multigenerational processes that illuminate for both therapist and client the emotional dynamics that contribute to the reported symptoms.

Although originally developed for the intergenerational work in Bowen’s approach, the genogram is so universally helpful that many therapists from other schools adapt it for their approach, creating solution-focused genograms.

Is simultaneously (a) an assessment instrument and (b) an intervention, especially in the hands of an intergenerational therapist.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Rumor Has It: the People and Their Stories

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Significant Contributors

Murray Bowen

Georgetown Family Center:

Michael Kerr

The Center for Family Learning:

Philip Guerin

Thomas Fogarty

Monica McGoldrick

Betty Carter

David Schnarch

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Big Picture: overview of Treatment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Main Phases of Structural Therapy

How it works

Process-oriented therapy.

Relies on self-of-the-therapist: therapist’s level of differentiation.

Does not emphasize techniques and interventions.

Use genograms/assessment to promote insight and intervene as differentiated persons.

Use insight and therapeutic relationship to increase clients’ levels of differentiation.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Making connection: the therapeutic relationship

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Differentiation and Emotional Being of the Therapist

Therapist differentiation

Level of differentiation and emotional being central to change process.

Believe clients can only differentiate as much as therapist has differentiated.

Therapist’s level of differentiation is focus of supervision early in training.

Bowen therapists assert that theory cannot be learned through books.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

A Nonanxious Presence

What it is

Emotionally engaged stance that is nonreactive.

Therapist doesn’t react to attacks without careful reflection.

How it works

Greater level of differentiation; makes it easier to maintain nonanxious presence.

Therapist doesn’t rush to rescue clients every time they feel overwhelmed by strong emotion.

Therapist guides client through process of separating self from other and thought from feeling.

Therapist’s calm center used to model differentiation.

Intergenerational therapist slowly coaches client through fears to facilitate growth.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The viewing: case conceptualization and assessment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Emotional Systems

Humans part of evolutionary emotional process going back to first cell with nucleus that was able to differentiate its functions from other cells.

Family’s emotional process viewed as extension of cellular differentiation process.

A family lacking differentiation may become emotionally fused; an undifferentiated family “ego mass.”

Therapists focus on family’s unique emotional system not on environment or culture.

System has significant impact on person’s behavior, emotions, and symptoms.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Chronic Anxiety

What it is

Biological phenomenon that is present in all natural systems.

Automatic physical and emotional reactions not mediated through conscious, logical processes.

Families exhibit chronic anxiety in response to crises, loss, conflict, and difficulties.

Differentiation creates clearheadedness, allowing for reduction in reactivity and anxiety.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Multigenerational Transmission Process

What it is

Emotional processes from prior generations are present and “alive” in current family emotional system.

Children may emerge with higher, equal, or lower levels of differentiation than parents.

Severe emotional problems result from level of differentiation becoming lower and lower with each generation.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Multigenerational Patterns

Assessing multigenerational patterns

Using genogram or oral interview, identify patterns of depression, substance use, anger, conflict, or other salient issues.

Identify how current situation fits with these patterns.

Is the client replicating or rebelling against the pattern?

How has the pattern evolved with this generation?

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Level of Differentiation

Continuum of differentiation

Differentiation scale ranges from 1 to 100.

Bowen maintained people rarely reach higher than 70.

Note where and how person is able/unable to separate self from other and thought from emotion.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Emotional Triangles

What they are

Triangle: Process in which a dyad draws in a third person to stabilize it.

Important to assess because they are basic building block of families.

Use third person to alleviate tension.

More you try to change relationship with third entity, the more you reinforce aspects you want to change.

How they are used

Assess to identify primary relationship to be targeted for change.

Everyone triangulates to some degree.

Pathological patterns emerge when this becomes primary means for dealing with dyadic tension and dyad never actually resolves the tension themselves.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Family Projection Process

What it is

How parents “project” immaturity onto one or more children.

Causes decreased differentiation in subsequent generations.

Common pattern is for a mother to project her anxiety onto one child, focusing all her attention on this child to soothe her anxiety.

The child who is the focus of parent’s anxiety will be less differentiated than those not involved in projection process.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Emotional Cut-Off

What it is

A person no longer emotionally engages with another in order to manage anxiety.

Can take form of no longer seeing/speaking to other person.

Client believes cut-off is a sign of mental health/superiority.

Client reports cut-off helps manage emotional reactivity.

Higher levels of differentiation lessen need for cut-offs.

Sometimes more cut-off necessary because of extreme patterns of verbal, emotional, or childhood abuse.

The more people can stay emotionally engaged without harboring anger, resentment, or fear, the healthier they will be.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Sibling Position

What it is

An indicator of family’s level of differentiation.

More family members exhibit expected characteristics of sibling position, the higher the level of differentiation.

How it works

Cultural background shapes the roles of sibling position.

Older children identify with responsibility and authority.

Later-born children identify with underdogs and question status quo.

Youngest child most likely to avoid responsibility in favor of freedom.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Societal Regression

What it is

Societies experiencing sustained chronic anxiety respond with emotionally-based reactive decisions and regress to lower levels of functioning.

Vicious cycle of increased problems and symptoms.

Cycles in which levels of differentiation rises and fall.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Targeting change: goal setting

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Two Basic Goals

Increasing differentiation

General goal that should be operationally defined for each client.

Decreasing emotional reactivity to chronic anxiety

As differentiation increases, anxiety decreases.

Helpful to separate goals to break process down.

Decreasing anxiety usually precedes increasing differentiation.

It is clinically helpful to tailor this to an individual client.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The doing: interventions

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Theory Versus Technique

Integration of theory and technique

Primary “technique” is therapist’s ability to embody the theory.

Therapists understand theory and improve own differentiation.

Naturally promote clients’ level of differentiation through interaction.

“Living” the theory is primary technique for facilitating change.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Process Questions

What they are

Process questions help clients see systemic process or dynamics they are enacting.

Ex: Use process questions to help clients see how conflict they are experiencing now is related to patterns they observed earlier in life.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Encouraging Differentiation of Self

How it is done

Families tend toward togetherness and relationships for survival.

Interventions encourage clients to use “I” positions to maintain individual opinions/moods while in relationships.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Genograms

As an Intervention

Identifies problematic intergeneration patterns and alternative ways for relating and handling problems.

Visual depiction of generational pattern inspires greater sense of urgency and commitment to change.

Generates greater willingness to take action compared to process questions and discussion of dynamics.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Detriangulation

What it is

Maintaining neutrality to interrupt client’s attempt to involve therapist or someone else in a triangle.

Most therapists at some point will be “invited” to triangulate against a third party.

How it works

Therapist “detriangulates” by refusing to take sides.

Therapist invites clients to validate themselves.

Examine own part in problem dynamic; take responsibility for needs/wants.

Validation should not be approval as this undermines client’s autonomy.

Clients coached to approve/disapprove own thoughts and feelings and take action as needed.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Relational Experiments

What they are

Behavioral homework assignments designed to reveal/change unproductive relational processes.

How they work

Interrupt triangulation by:

Increasing direct communication between a dyad.

Reversing dynamics fueled by lack of differentiation.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Going Home Again

What it is

A mature, balanced adult goes home to visit family and finds themself acting like a teenager.

How it works

The result of unresolved issues in family-of-origin that can be improved by increasing differentiation.

As level of differentiation grows, client can maintain clearer sense of self in family system.

Client interacts with family members while maintaining a clearer boundary between self and other.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Interventions for Special Populations

The Sexual Crucible Model

Marriage is a “crucible,” a vessel physically containing a volatile transformational process.

Therapist achieves transformation by helping both partners differentiate.

Partners take responsibility for individual needs rather than demand other change to accommodate them.

Schnarch developed a comprehensive model for helping couples create type of relationship most couples expect.

A harmonious balance of emotional, sexual, intellectual, professional, financial, parenting, household, health, and social partnerships.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Psychoanalytic Family Therapies

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

In a Nutshell: The Least You Need to Know

In the 1980s, renewed interest in object relations therapies led to development of object relations family therapy.

Uses psychoanalytic and psychodynamic principles to describe external relationships.

Family is a nexus of relationships that support or impede development and functioning of members.

Therapy involves:

Analyzing intrapsychic and interpersonal dynamics.

Promoting client insight.

Working through insights to develop new ways of relating.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Juice: Significant Contributions to the Field

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Juice #1: Ethical Systems and Relational Ethics

What it is

An ethical system, keeps track of entitlement and indebtedness within the family.

How it works

System maintains trustworthiness, fairness, and loyalty between family members.

Its breakdown results in symptoms.

Goal of therapy is to re-establish ethical system.

Presenting complaint may be that things are no longer fair.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Rumor Has It: The People and Their Stories

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Significant Contributors

Nathan Ackerman and the Ackerman Institute

Ivan Boszormenyi-Nagy

James Framo

David and Jill Scharff

The Women’s Project

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Big Picture: Overview of Treatment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Therapeutic Process

First task

Create caring therapeutic relationship, or holding environment.

Therapist analyzes intrapsychic and interpersonal dynamics that are source of symptoms.

Second task

Promote client insight into dynamics; must get through client defenses.

Therapist facilitates working through insights to translate them into action in clients’ daily lives.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Making Connection: The Therapeutic Relationship

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Transference and Countertransference

Transference

Client projects onto therapist attributes stemming from unresolved issues with primary caregivers.

Use immediacy of these interactions to promote client insight.

Countertransference

Therapists project back onto clients, losing therapeutic neutrality.

Used to help therapist and client better understand the reactions client brings out in others.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Contextual and Centered Holding

Contextual holding

Therapist’s handling of therapy arrangements:

Conducting sessions competently.

Expressing concern for the family.

Being willing to see the entire family.

Centered holding

Connecting at deeper level by expressing empathetic understanding to create safe emotional space.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Multidirected Partiality

What it is

Being “partial” with all members of the family.

How it works

Therapists accountable to everyone potentially affected by interventions, including those not present in the room.

Therapist must bring out humanity of each family member, even “monster member.”

Involves sequential siding by empathizing with each person’s position in turn.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Viewing: Case Conceptualization and Assessment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Interlocking Pathologies

What it is

Constant exchange of unconscious processes within families creates interlocking or interdependent pathologies.

How it works

Individual pathology reflects family distortions and dynamics.

Therapist seeks to identify how identified patient’s symptoms relate to less overt pathologies within the family.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Self-Object Relations Patterns

Self-object relations

How people relate to others based on expectations developed by early experiences with primary attachment objects.

How it works

External objects are experienced as:

Ideal object: Primary caretaker desexualized/deaggressivized; maintained as distinct from its rejecting and exciting elements.

Rejecting object: Representation of caregiver when child’s needs for attachment were rejected, leading to anger.

Exciting object: Representation of caretaker formed when child’s needs for attachment were overstimulated; longing for an unattainable but tempting object.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Splitting

How it works

Frustration with primary caregiver increases need to spilt objects.

Separate good from bad objects by repressing the rejecting/exciting objects.

Leaves less of ego, or conscious self, to relate freely.

If splitting not resolved, there’s “all good” or “all bad” quality to evaluating relationships.

In families, splitting can take the form of perfect vs. problem child.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Projective Identification

How it works

In relationships, clients defend against anxiety by projecting unwanted parts of themselves onto partner.

Partner is manipulated to act according to projections.

Ex: A husband projects interest in other women onto his wife as jealousy and accusations of infidelity. The wife decides to hide innocent information that may feed husband’s fear. The more she tries to calm his fears by hiding information, the more suspicious and jealous he becomes.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Repression

How it works

Children repress anxiety when they experience separation from attachment object.

Less ego available for contact with outside world.

Until repressed material made conscious, adult replicates these relationships.

One of primary aims is to bring repressed material to surface.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Parental Interjects

What they are

The internalized negative aspects of parents.

How they work

Parental attributes internalized and unconsciously projected onto future intimate relationships.

Hear a parent’s critical comments in neutral comments of partner.

Clients become conscious of introjects to increase autonomy.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Transference Between Family Members

What it is

Involves one family member projecting introjects and repressed material onto others.

How it is treated

Therapist helps family disentangle transference, using interpretation to promote insight.

Easier to promote insight into transference patterns in family therapy because patterns happen “live.”

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Ledger of Entitlement and Indebtedness

Ledger of entitlements and indebtedness

Internal accounting of what one is due and what one owes others.

Justice and fairness: Monitoring fairness is ongoing process that keeps relationship trustworthy.

Entitlements: “Ethical guarantees” to merits that are earned in the context of relationships. Destructive entitlements result when children don’t receive nurturing and later project this loss onto world, which is the “debtor.”

Invisible loyalties: May manifest as indifferences, avoidance, or indecisiveness in relation to object of loyalty.

Revolving slate: Destructive process where one takes revenge in a relationship based on relational transactions in another.

Split loyalties: When child feels forced to choose one parent over another because of mistrust between them.

Legacy: Transgenerational mandate linking endowments of current generation to obligations to future generations.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Mature Love: Dialogue Versus Fusion

Mature love

Dialogue between two people conscious of family dynamics that have shaped them.

Fusion

Experienced as amorphous “we” like infant and caregiver.

In Therapy

Invisible loyalties made overt; to be critically examined.

Allows conscious choice/action rather than fear/anxiety characterizing fused relationships.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Targeting Change: Goal Setting

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Goals

General goals

Increase autonomy by making unconscious processes conscious.

Decrease interactions based on projections.

Increase capacity for intimacy without loss of self.

Develop reciprocal commitments including fair balance of entitlements and indebtedness.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Doing: Interventions

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Listening, Interpreting, and Working Through

Three generic interventions

Listening and empathy: Listening objectively to client’s story without offering advice, reassurance, validation, or confrontation.

Interpretation and promoting insight: Encourage insights by offering interpretations to client, such as analyzing ledgers of entitlement.

Working through: Process of translating insight into new action in family and other relationships.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Eliciting

What it is

Using clients’ spontaneous motives to move family in a mutually beneficial and dialogical direction.

How it works

Therapist facilitates process by:

Integrating facts of the situation, each person’s individual psychology and interactive transitions.

Helping family rework balances of entitlement and indebtedness.

Helping members to reinterpret past interactions and identify new ways to move forward.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Detriangulating

How it works

Identify where parents have triangulated a symptomatic child into relationship to deflect attention from couple distress.

Once child’s role is clear, child dismissed from therapy and couple works to address issues that created child’s symptoms.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Family-of-Origin Therapy

Three-stage model for couples

Couples therapy: Work with couple alone to increase insight into personal and relational dynamics.

Couples group therapy: Couple join couples group, receive feedback from other couples and also view their dynamics.

Insight comes more quickly when problem dynamic acted out in another couple.

Family-of-origin therapy: Each member of couple invited to have four-hour-long session with his/her family of origin.

Sessions used to clarify and work through past and present issues.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Tapestry Weaving: Working with Diverse Populations

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Gender Diversity: The Women’s Project

What it was

Betty Carter, Olga Silverstein, Peggy Papp, and Marianne Walters promoted awareness of women’s issues in field of family therapy.

Raised issue of gender power dynamics and identified how therapists were reinforcing detrimental stereotypes.

Therapists should be agents of social change, challenging sexist attitudes and beliefs in families.

Reducing sexism

Discuss gender role expectations of each person and point out beliefs that are unfair or unrealistic.

Encourage women to take private time for themselves.

Use self-of-the-therapist to model an attitude of gender equality.

Push men to take equal responsibility in family relationships and household.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Ethnicity and Culture Diversity

Working with different cultures

Therapies aimed at “thinking” or psychologically-minded clients.

Minority groups preferring concrete suggestions may have difficulty.

Therapist’s stance as expert fits expectations of many immigrant populations.

Emphasis on intergenerational patterns may be useful with clients whose cultural norms value extended family.

Greatest danger is therapist using inappropriate cultural norms to analyze family dynamics.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Sexual Identity Diversity

Issue of a child’s sexual orientation and gender-identity has implications for entire family system.

Pay particular attention to intergenerational relationships.

Gay and lesbian parents lived closer to and received more support from their own parents (Koller, 2009).

Gays and lesbians who were not parents reported stronger connections with their friend networks (family-of-choice).

Parental disapproval on lesbian relationships has positive and negative effects on the relationship (Levy, 2011).

Negative effects include amount and quality of time spent as a couple, stress on the couple relationship, emotional impact on couple, fear/uncertainty, communication problems, and sexual effects.

Positive effects of parental disapproval of the relationship included increased couple closeness, communication, patience, maturity, and valuing of the relationship.

Twice as many parents of gay/lesbian children had significant marital issues and twice as many heterosexual men had more distant relationships with their fathers than gay men (Feinberg & Bakeman, 1994).

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Sexual Identity Diversity (cont.)

Psychodynamic therapy has long been criticized for its pathologizing of same-sex attraction.

Therapist should consider using gay-affirmative approaches (Rubinstein, 2003).

Consider a multifaceted identity formation that includes, biological sex, gender identity, social sex-role, and sexual orientation.

Social sex-role confusion is often the most salient issue for gay and lesbian clients, who often feel conflicted over conforming to culturally approved behaviors for maleness and femaleness.

Can help GLTBQ clients address internalized homophobia by exploring their personal meaning of being attracted to same-sex partners.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Research and the Evidence Base

Relation supported between differentiation and chronic anxiety, marital satisfaction, psychological distress.

Little support for theories on sibling position.

Triangulation received partial empirical support.

Bowen’s differentiation of self has been focus of research on:

Client perceptions of therapeutic alliance.

Adolescent risk-taking behaviors.

Parenting outcomes in low-income urban families.

Adult well-being.

Support provided for emphasis on self-of-the-therapist.

Study identified two aspects of differentiation:

Affect regulation, Ability to negotiate interpersonal togetherness with separateness

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart