1000 word : Reflection: Professional, Therapy/Counseling

16 Marital and Family Therapy

Marital and family therapy (MFT) actually refers to over twenty diverse therapeutic approaches to marital and family problems (Levant 1984). Today it is more often referred to as couple and family therapy (Lebow 2008), systemic therapies (Prochaska & Norcross 2018), family systems therapy (Corey 2021), and family therapy (Goldenberg & Stanton 2019; Goldenberg, Stanton, & Goldenberg 2017). More specifically, marital therapy is now often called couple therapy (Gurman 2008a). MFT has also been more accurately referred to as marital therapies (Gurman 2003) or couple therapies (Lebow & Kelly 2020) and family therapies (N. J. Kaslow, Mirsalimi, & Celano 2020), to reflect the many therapy approaches that are included in MFT (see also Gladding 2019; Nichols & Davis 2017). MFT is therefore an umbrella term for over twenty systemic therapies that assume the

crucial factor in helping individuals change is to understand and work with the interpersonal systems within which they live and function. The couple and family must be addressed and seen in effective therapy for individual problems as well as for marital or couple and family issues. MFT has no single founder, but the key figures and approaches in this area include Salvador Minuchin, the founder of the structural approach; Jay Haley and the Milan Group, who developed the strategic approach; Murray Bowen, who developed family systems theory and transgenerational (multigenerational) family therapy; Virginia Satir, who developed conjoint family therapy; Susan Johnson and Leslie Greenberg, who developed emotionally focused therapy for couples; and others who will be discussed in more detail below. MFT had its beginnings in the 1940s; systemic family therapy took root in the 1950s

(Becvar & Becvar 2012). However, its significant growth and development occurred only in the late 1970s and 1980s (Parrott 2003), following psychodynamic (first force), behavioral (second force), and humanistic (third force) approaches. MFT can therefore be considered the “fourth force” in the field of therapy (Corey 2021, 404), although family therapy or counseling as ministry has informally been around for three hundred years, since the early 1700s (Yarhouse & Sells 2017, 38–39; see also Gladding 2019). Numerous therapeutic techniques are used in MFT, including reframing (seeing problems

in a more constructive or positive way), boundary setting (either to establish firmer limits or lines of separation, or to build more flexible boundaries to facilitate deeper connection), family sculpting (asking a couple or family members to physically put themselves in chosen positions to reflect their family relationships), and constructing a genogram (a three- generation family tree, a history) (see Parrott 2003, 378–380).

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Biographical Sketches of Key Figures in MFT The following are biographical sketches of several key figures in MFT: Alfred Adler, Nathan Ackerman, Murray Bowen, Jay Haley, Salvador Minuchin, Carl Whitaker, Virginia Satir, Cloé Madanes, Ivan Boszormenyi-Nagy, Steve de Shazer, Michael White, Susan Johnson, and Leslie Greenberg, as well as Neil Jacobson, Andrew Christensen, John Gottman, Alan Gurman, and Richard Schwartz (see Corey 2021, 370–371, 407–408; Day 2004, 342–344; Fall, Holden, & Marquis 2017; Goldenberg & Stanton 2019; Goldenberg, Stanton, & Goldenberg 2017; Gurman 2003; N. J. Kaslow, Mirsalimi, & Celano 2020; Lebow 2008; Prochaska & Norcross 2018, 289–321; Yarhouse & Sells 2017, 61–287).

Sidebar 16.1: Key Figures in Marital and Family Therapy

1. Alfred Adler 2. Nathan Ackerman 3. Murray Bowen 4. Jay Haley 5. Salvador Minuchin 6. Carl Whitaker 7. Virginia Satir 8. Cloé Madanes 9. Ivan Boszormenyi-Nagy 10. Steve de Shazer 11. Michael White 12. Susan Johnson 13. Leslie Greenberg 14. Neil Jacobson 15. Andrew Christensen 16. John Gottman 17. Alan Gurman 18. Richard Schwartz

Alfred Adler (1870–1937)—the founder of individual psychology, Adlerian therapy (see chap. 5)—was one of the first therapists to use a systemic approach in family therapy. After World War I, he established over thirty child-guidance clinics in Vienna. Rudolph Dreikurs later applied Adlerian concepts and methods in the United States when he set up family education centers. Adler conducted family therapy sessions in front of other families so they could learn how to deal with problems that Adler believed were common among families (O. C. Christensen 2004).

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Nathan Ackerman (1908–1971) has been called “the unofficial founder of family therapy” (Gurman 2003, 464) and “the parent figure of psychodynamic family therapy” (Yarhouse & Sells 2017, 147); fairly early he asserted that marital therapy was “the core approach to family change” (Ackerman 1970a, 124), but family therapy has not embraced his view. Ackerman was trained in doing psychoanalytic therapy with children, but eventually he advocated seeing the whole family as a unit in therapy in order to assess and help troubled families (Ackerman 1966, 1970b). His book The Psychodynamics of Family Life (Ackerman 1958) is often considered the landmark text that helped to define the new field of family therapy (Goldenberg & Stanton 2019, 400). Ackerman was born in Bessarabia, Russia, on November 22, 1908, but his family moved

to the United States in 1912. He obtained his BA in 1929 and his MD in 1933 from Columbia University. He became chief psychiatrist at the Menninger Child Guidance Clinic in 1937. After World War II, Ackerman became a clinical professor of psychiatry at Columbia University. Ackerman established the Institute for Family Studies and Treatment in 1960 and served as

its director until his death on June 12, 1971, at which time it was renamed the Nathan W. Ackerman Institute, often called the Ackerman Institute, which now is world-renowned as a center for family psychology. It publishes Family Process, the first major family therapy journal. Murray Bowen (1913–1990) was born on January 13, 1913, in Waverly, Tennessee, the

oldest of five children in a family that was relatively large and close-knit. He graduated with a BS from the University of Tennessee in Knoxville in 1934 and obtained his MD from the University of Tennessee Medical School in Memphis in 1937. Bowen served in the U.S. Army for five years, during which his interests shifted from surgery to psychiatry. He trained in psychiatry and psychoanalysis at the Menninger Foundation in Topeka, Kansas, from 1946 to 1954. Bowen focused on schizophrenic patients and their mothers, and this work eventually resulted in his concept of differentiation of self, the development of autonomy of the individual. In 1954 Bowen accepted a position at the National Institute of Mental Health, where he

became the first director of the new Family Division. He began treating the whole family as a unit seen together in therapy sessions and therefore became a major figure in the development of systemic family therapy. He moved to Georgetown University in Washington, DC, in 1959, where he remained until he died in 1990 of lung cancer, at the age of seventy-seven. He was a clinical professor of psychiatry in the Department of Psychiatry as well as director of family programs at Georgetown University. He also established a family center. Bowen further developed his family systems theory, including key concepts such as differentiation of self, triangulation, and multigenerational or transgenerational transmission, which are now widely accepted in the MFT field. His well-known approach to therapy has been variously labeled extended family systems therapy, transgenerational or multigenerational family therapy, or simply Bowenian family therapy (Yarhouse & Sells 2017). Bowen also helped found the American Family Therapy Association and served as its first

president from 1978 to 1982. His most significant publication is Family Therapy in Clinical

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Practice (1978). Jay Douglas Haley (1923–2007) helped develop strategic family therapy, another major

approach to MFT (see Haley 1963, 1976; Haley & Richeport-Haley 2003, 2007). Strategic family therapy is a pragmatic problem-solving approach that deals with the present problems of couples and families without delving into the past to achieve insight. Haley developed ideas relating to power, hierarchy, and strategic interventions, including directive as well as paradoxical techniques. He was influenced by Milton Erickson and his therapeutic techniques (Haley 1973). The Milan Group, led by Mara Selvini-Palazzoli (see Selvini 1988) at the Center for Family Studies in Milan, Italy, also contributed to the further development of strategic family therapy into what is called systemic family therapy (Boscolo et al. 1987; Selvini-Palazzoli et al. 1978), which is especially successful with psychotic and anorectic patients (Goldenberg & Stanton 2019, 402). Haley was born in Midwest, Wyoming, but moved with his family to Berkeley, California,

when he was four years old. He obtained a BA in theater arts from UCLA, a bachelor of library science degree from UC Berkeley, and a master’s degree in communication from Stanford University. He married his first wife, Elizabeth, in 1950, and they had three children. They divorced in 1971. Haley met Gregory Bateson, an anthropologist, while he was at Stanford and was invited

to be involved in the Double Bind Communications Project—later called the Bateson Project —together with Bateson, who launched the project in 1952; John Weakland; and Donald Jackson. Jackson founded the Mental Research Institute (MRI) in Palo Alto, California, in 1958 (with the involvement of Virginia Satir and Paul Watzlawick), and when the Bateson Project ended in 1962, Haley joined MRI, together with Weakland. This very creative and productive group produced many innovative concepts and publications (see Prochaska & Norcross 2018, 291–292), including a landmark article that helped develop the field of family therapy, “Toward a Theory of Schizophrenia” (Bateson et al. 1956), focusing on how double binds, conflicting communications in a family system, could lead to schizophrenic symptoms. In the mid-1960s Haley took a position at the Philadelphia Child Guidance Clinic, where

he worked closely with Salvador Minuchin, who developed structural family therapy. He then founded the Family Therapy Institute in Washington, DC, in 1976, with Cloé Madanes, his second wife, and they continued to further develop strategic family therapy (see Madanes 1981). During this time, he published Problem-Solving Therapy (Haley 1976), which became one of the most significant books in the MFT field. Haley and Madanes divorced in the 1990s. Eventually Haley left the Family Therapy Institute and moved to San Diego, where in the

last few years of his life he collaborated with his third wife, Madeleine Richeport-Haley, in producing several films on anthropology and psychotherapy. They also coauthored two important books: The Art of Strategic Therapy (Haley & Richeport-Haley 2003) and Directive Family Therapy (Haley & Richeport-Haley 2007). Haley was a scholar in residence at the California School of Professional Psychology, Alliant International University, when he died on February 13, 2007, at the age of eighty-three (see Ray 2007).

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Salvador Minuchin (1921–2017) developed structural family therapy in the 1960s, initially basing on his work in therapy and research with delinquent youths from poor families at the Wiltwyck School in New York (S. Minuchin et al. 1967). Structural family therapy can be briefly described as “a systemic approach to family interventions that focuses on identifying the underlying patterns or rules that regulate or dictate the space between people in relationship” (Yarhouse & Sells 2017, 115–116). Minuchin believed that structural changes in the organization of families, in terms of their usual patterns of interaction and types of relationships, are necessary before the symptoms of individual members of the family can be reduced (Corey 2021, 408). It had a preeminent place in family therapy and theory in the 1970s and 1980s and is still a major approach to MFT today (see Yarhouse & Sells 2017, 115–117, for more details on Minuchin and the history of structural family therapy). Minuchin was born in 1921 in Argentina, to which his parents had migrated from Europe.

He obtained his medical training in Buenos Aires and served as a military physician in the Israeli army in the late 1940s, as Israel attempted to achieve statehood. He then trained to be a psychiatrist in New York before returning to Israel in 1952 to help families and orphans in the aftermath of the Holocaust. Minuchin returned to the United States in 1954 and received psychoanalytic training at the

William Alanson White Institute in Manhattan. He also served as the psychiatrist at the Wiltwyck School for delinquent boys, where he collaborated with a clinical social worker, Braulio Montalvo, in developing structural family therapy and theory. Minuchin referred to Montalvo as his most influential teacher (Goldenberg, Stanton, & Goldenberg 2017). Minuchin moved to the Philadelphia Child Guidance Clinic in 1965, to become its

director. He invited Montalvo and Jay Haley to join him there, and their collaboration further advanced the integration of structural and strategic family therapy ideas and techniques. The clinic grew under Minuchin’s leadership and had become very well known by the time he left in 1981. Minuchin authored and coauthored several significant books in the MFT field, including the classic Families and Family Therapy (1974) on structural family therapy and theory (see also P. Minuchin, Colapinto, & Minuchin 2007; S. Minuchin, Rosman, & Baker 1978; S. Minuchin & Fishman 1981; S. Minuchin, Lee, & Simon 2006; S. Minuchin, Nichols, & Lee 2007). His structural approach has also been more specifically applied to helping troubled couples in what is called structural couple therapy (Simon 2008). He continued to write and train family therapists at the Minuchin Center for the Family near New York City (Prochaska & Norcross 2018, 298–299) until he moved to Boston in 1996 and retired. Minuchin spent his final years of retirement in Florida and died on October 30, 2017. Carl Whitaker (1912–1995), another well-known figure in the MFT field (see Yarhouse &

Sells 2017, 190–192), and Virginia Satir are credited for independently developing experiential family therapy or symbolic-experiential family therapy. His approach is more intuitive and spontaneous, with the family therapist functioning actively and creatively as a coach and participant with the troubled family, helping its members to be more open and autonomous as individuals while maintaining a sense of connection or belonging in the family.

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Whitaker was born in 1912 and grew up in upstate New York on a dairy farm. He was not very outgoing but, as an adolescent, had a few close friends who were helpful to him as he made decisions and went through his teen years, college, medical training, and medical practice. Friendship was crucial for him, and his relationships with Muriel, his wife, and with his six children were of special significance to him (Whitaker 1989; Whitaker & Keith 1981). Whitaker valued cotherapy and advocated having two or more therapists, or cotherapists, when treating a troubled family, because a therapist working alone is more prone to mistakes and can be less objective. Cotherapy was also a good balance and corrective for Whitaker’s often unconventional and radical interventions, for he was well known “for being spontaneous, unpredictable, funny, bold, confrontational and direct” (Yarhouse & Sells 2017, 190). Whitaker obtained his medical training at Syracuse University and specialized in

psychiatry after initially trying obstetrics and gynecology. He then became a faculty member at the University of Louisville. During World War II he was involved as a physician in the Oak Ridge Research facility in eastern Tennessee, where the US government was secretly developing the atomic bomb. He and his cotherapist, John Warkentin, experienced quite strong transference relationships with their patients, who might have had posttraumatic stress disorder symptoms. Whitaker therefore learned to function as a symbolic mother and father, to deal with the transference needs of family members seen in family therapy by him and his cotherapist. He used a combination of warmth, humor, self-disclosure, confrontation, and even radical and absurd interventions to do this. Whitaker believed that a mature therapist will function like a foster parent and be appropriately parental to the patients and families they see in therapy. He founded and developed what came to be known as symbolic- experiential family therapy (Whitaker & Bumberry 1988; Whitaker & Keith 1981). Whitaker became chair of the Department of Psychiatry at Emory University in Atlanta in

1946 and remained there until 1955. He coauthored an important book with Thomas Malone in 1953, titled The Roots of Psychotherapy, in which they emphasized that psychotherapy is essentially a sacred relationship and involves a learning experience that is culturally based and should not be quantified or objectified. Psychotherapy should therefore not be considered a branch of medical science (Whitaker & Malone 1953). Emory University preferred a more psychoanalytic approach to therapy, so Whitaker left

and set up a private-practice clinic in Atlanta with his colleagues, including Malone and Warkentin. In 1965 he moved to the University of Wisconsin Medical School in Madison, to become a professor of psychiatry, a position he occupied until his retirement in 1989. This was a very productive period of his professional life, during which he and his students further developed many of his ideas on symbolic-experiential family therapy. He died in 1995. Virginia Satir (1916–1988) was also responsible for developing experiential family

therapy, with which Carl Whitaker is usually associated (see Yarhouse & Sells 2017, 189– 190). They made their significant contributions to this major approach to MFT independently of each other. Satir was born Virginia Pagenkopf on June 26, 1916, in Neillsville, Wisconsin, a rural

farming town, the eldest of five children. She and her family moved to Milwaukee in 1929 so she could attend high school. Satir graduated from high school when she was sixteen years

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old and then attended Milwaukee Teachers College, where she obtained a BA in education in 1936. She began her graduate studies at Northwestern University but completed her master’s degree in social work administration at the University of Chicago in 1943. She married and divorced twice, the second time to Norman Satir, whom she married in 1951 and divorced in 1957. Satir began her clinical work with families in 1951 and set up a clinical psychiatric

training program at the Illinois Psychiatric Institute with Dr. Calmest Gyros. Ivan Boszormenyi-Nagy, who developed contextual family therapy, was one of Satir’s supervisees then. Her significant clinical work in experiential family therapy put her in touch with Murray Bowen, who connected her with Don Jackson. Satir became the clinical director of the Mental Research Institute at Jackson’s invitation in 1959. Several years later, in 1966, she moved to the Esalen Institute in Big Sur, California, where she served as its clinical director. This was a significant move for Satir, who also shifted from being a purist in systemic theory and therapy to being more a humanistic therapist who focused on self-esteem as the crucial factor in human growth. She had a professional rift with Salvador Minuchin in the 1970s, which resulted in her emphasizing human potential and growth even more, with less emphasis on family systems. Satir was well known for her charisma as well as her warm and gentle style (see Yarhouse & Sells 2017, 190). Satir specifically developed conjoint family therapy as a process of human validation,

based on communication and emotional experiencing and centered in the therapeutic relationship between the therapist and the family rather than in techniques, which she viewed as being secondary (see Satir & Bitter 2000). Although she made use of Bowen’s multigenerational or transgenerational model, she focused more on making current patterns of family interaction come to life in the therapy session by using interventions such as sculpting and family reconstructions (see Corey 2021, 407–408). She authored or coauthored several significant books that have greatly influenced the MFT field (e.g., Satir 1964, 1972, 1983, 1988; Satir & Baldwin 1983; Satir et al. 1991). Satir is considered one of the most influential therapists as well as the “most celebrated humanist” (Nichols 2006, 199). She received numerous awards and honors, including an honorary doctorate in social sciences from the University of Wisconsin-Madison in 1978. She died on September 10, 1988. Cloé Madanes (1940–) founded the Family Therapy Institute in Washington, DC, in 1976

with her then-husband, Jay Haley. She collaborated with Haley in further developing strategic family therapy and authored an important text on this approach, Strategic Family Therapy (Madanes 1981; see also Madanes 1984). In the 1980s, strategic family therapy as a short-term, problem-solving treatment became the most popular approach in the MFT field. Madanes and Haley eventually divorced, but she went on to establish her own unique work

and voice in other related areas such as sex, love, and violence (Madanes 1990). More recently, she has published a collection of her papers focusing on her work as a therapist who is a humanist, a social activist, and a systemic thinker (Madanes 2006). Madanes is currently president of the Robbins-Madanes Center for Strategic Intervention

and the Madanes Institute in La Jolla, California. She is also the director of the Program for the Prevention of School and Family Violence and the Council for Human Rights of Children, at the Center for Child and Family Development, University of San Francisco.

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Ivan Boszormenyi-Nagy (pronounced BOZ-er-men-yee-Naj) (1920–2007) founded and developed contextual family therapy (see Yarhouse & Sells 2017, 167–169), which is a major approach to MFT. His contextual family therapy approach (Boszormenyi-Nagy & Krasner 1986; see also Boszormenyi-Nagy & Spark 1984; Hargrave & Pfitzer 2003) consists of four major dimensions (Van Heusden & Van den Eerenbeemt 1987, xiv): facts (e.g., genetic roots and features, physical health, and events such as adoption, divorce, unemployment, and disability); individual psychologies (e.g., basic needs and internal motivations of the individual); transactions (systemic interaction or behavioral and communication patterns observed between people, e.g., structures, subsystems, rules, roles, power alignments); and relational ethics (referring to fairness or justice in a relationship or the balance between obligations and earned merit, with a focus on trust, loyalty, trustworthiness and entitlement, and the influence of previous generations and implications for future generations). Boszormenyi-Nagy (professionals often refer to him as Nagy) was born in Budapest,

Hungary, on May 19, 1920. After graduating from medical school in Hungary, he completed his residency training in psychiatry at the University of Budapest. In 1950, he moved to the United States and worked under Kalman Gyarfas, a relationship-oriented dynamic therapist, at the Illinois Psychiatric Institute in Chicago; he was also supervised in his clinical work by Virginia Satir. While Boszormenyi-Nagy was influenced by psychoanalytic and psychodynamic theories, including Freudian psychoanalysis and the object relations views of Ronald Fairbairn, he had never been a trained psychoanalyst (Van Heusden & Van den Eerenbeemt 1987, 5). He was also influenced by the work of well-known therapists in the 1950s who were treating patients with schizophrenia, and especially influenced by Martin Buber and his humanistic emphasis on the I-Thou relationship, which Boszormenyi-Nagy believed is achieved in a family context by building trust (Yarhouse & Sells 2017, 168). In 1957 Boszormenyi-Nagy moved to the Eastern Pennsylvania Psychiatric Institute

(EPPI) and worked in a research inpatient service for psychotic patients, where he and his staff did intensive individual therapy. In 1958, however, he introduced the use of family therapy for all patients. At EPPI, he was able to recruit a group of talented researchers and therapists who made significant contributions to the field of family therapy, including James Framo, Gerald Zuk, Geraldine Spark, and John Rosen. He also had contact with other early family therapists such as Nathan Ackerman, Murray Bowen, Lyman Wynne, and later, Carl Whitaker (Van Heusden and Van den Eerenbeemt 1987, 5–6). He died on January 28, 2007. Steve de Shazer (1940–2005) was one of the originators of solution-focused family therapy

(see Corey 2021, 370–371; Yarhouse & Sells 2017, 218–223). He and his wife, Insoo Kim Berg (1935–2007), another well-known figure in the MFT field, codeveloped the solution- focused approach to MFT and were involved for many years with the Brief Family Therapy Center in Milwaukee, Wisconsin, where de Shazer was director of research and Berg served as director of the center. Further details about de Shazer can be found in chapter 14 of this book. Michael Kingsley White (1948–2008) was the cofounder of the narrative therapy

movement, together with David Epston (1944–), who is codirector of the Family Therapy Centre in Auckland, New Zealand (see Corey 2021, 381; Yarhouse & Sells 2017, 264). White was codirector of the Dulwich Centre in Adelaide, Australia, and began developing narrative

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therapy in the late 1980s. He is widely considered the major figure of the narrative therapy movement (Lebow 2008, 325). Further details about White can be found in chapter 14 of this book. Susan M. Johnson (1947–), better known as Sue Johnson, is one of the originators and the

main proponent of emotionally focused therapy, or emotion-focused therapy (EFT), and experiential couple and family therapy (see Goldenberg, Stanton, & Goldenberg 2017, 248– 252). Together with Leslie Greenberg, Johnson has developed EFT, which has experienced phenomenal growth since the 1990s (Yarhouse & Sells 2017, 193). Greenberg and Johnson in their earlier collaborative work in developing EFT, and Johnson in her later work that integrated more attachment theory into emotionally focused couple therapy, made use of therapeutic interventions derived from Gestalt therapy. Clients are thus helped to express intense emotions such as anger, deal with defenses, and work toward a softening of feelings so that connection between a couple or members of a family can be restored and deepened (see Lebow 2008, 325). Johnson has authored or coauthored several significant books on emotionally focused

couple and family therapy that have greatly impacted the MFT field (see, e.g., S. M. Johnson 2002, 2004; S. M. Johnson et al. 2005; see also L. S. Greenberg & Johnson 1988). Greenberg has also written more generally on EFT as emotion-focused therapy, which helps clients to work through their feelings (L. S. Greenberg 2017). More recently, Johnson has written a book on EFT for individuals, couples, and families as attachment theory in practice (S. M. Johnson 2019), and a book on the love sense, the new science of romantic relationships (S. M. Johnson 2013). She has also coauthored a “hold me tight” guide called Created for Connection for Christian couples (S. M. Johnson & Sanderfer 2016). Johnson received her doctorate (EdD) degree in counseling psychology from the

University of British Columbia in 1984. She is a professor emeritus of clinical psychology at the University of Ottawa; director of the International Center for Excellence in Emotionally Focused Therapy in Ottawa, Ontario; and distinguished Research Professor in the Marriage and Family Therapy Program at Alliant University in San Diego, California. She also recently joined the clinical faculty in the Department of Psychiatry at the University of British Columbia. Johnson is considered the main proponent of emotionally focused couple therapy and emotionally focused family therapy. She has received many honors and awards for her well-known work in the MFT field, including the American Association of Marriage and Family Therapy Outstanding Contribution to the Field award in 2000, the award for research in family therapy from the American Family Therapy Academy in 2005, the Family Psychologist of the Year award from Division 43 (Society for Couple and Family Psychology) of the American Psychological Association in 2016, and appointment as a Member of the Order of Canada in 2017. Leslie Samuel Greenberg (1945–), who helped develop EFT with Sue Johnson, is a

professor emeritus of psychology at York University in Toronto, Ontario. He is the cofounder of EFT for couples and families (see L. S. Greenberg & Johnson 1988; see also L. S. Greenberg & Goldman 2008, 2019) as well as EFT to help clients work through their feelings (L. S. Greenberg 2017), including dealing with depression (L. S. Greenberg & Watson 2006).

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Greenberg is also a well-known and prominent leader in experiential psychotherapy (see, e.g., L. S. Greenberg, Watson, & Lietaer 1998; Pos, Greenberg, & Elliott 2008). Greenberg was born on September 30, 1945, in Johannesburg, South Africa, but eventually

emigrated to Canada. He is married, has two children, and currently lives in Toronto. He has made substantial contributions to the MFT field as well as to experiential psychotherapy, in developing EFT with couples, families, and also with individuals. Neil S. Jacobson (1949–1999) initially made significant contributions to the development

of behavioral marital therapy (BMT) or traditional behavioral couple therapy (TBCT), based on social learning and behavior-exchange principles (N. S. Jacobson & Margolin 1979). TBCT is a couple therapy that has met the strictest criteria (efficacy and specificity) for an empirically supported treatment. Jacobson later helped develop integrative behavioral couple therapy (IBCT) with Andrew Christensen (N. S. Jacobson & Christensen 1998; see also A. Christensen & Jacobson 2000; A. Christensen, Doss, & Jacobson 2014). Jacobson was a professor of psychology at the University of Washington in Seattle until his death in 1999. He was a prolific author, publishing nine books and two hundred articles, and is one of the most widely cited family therapists. He made substantial and cutting-edge contributions not only to the MFT field but also to the treatment of depression and domestic violence. He received many honors, including prestigious research awards from the American Association for Marriage and Family Therapy, the American Family Therapy Academy, and the National Institutes of Health. Andrew Christensen (1950–) is well known for codeveloping integrative behavioral couple

therapy (IBCT) with Neil Jacobson (see A. Christensen & Jacobson 2000; A. Christensen, Doss, & Jacobson 2014; N. S. Jacobson & Christensen 1998; see also A. Christensen, Dimidjian, & Martell 2015). He has also done substantial research, funded by the National Institute of Mental Health, on evaluating the relative effectiveness of IBCT versus TBCT (traditional behavioral couple therapy) (see A. Christensen, Atkins, Berns, et al. 2004; A. Christensen, Atkins, Yi, et al. 2006; A. Christensen, Atkins, Baucom, & Yi 2010; see also A. Christensen, Dimidjian, & Martell 2015). Andrew Christensen is a distinguished research professor of psychology at UCLA. He has published widely on couple therapy and couple conflict. John Mordecai Gottman (1942–) developed his research-based approach, now called the

Gottman method couple therapy, in collaboration with his wife, Julie Schwartz Gottman (see Gottman & Gottman 2008, 2015a). Gottman’s method of couple therapy endeavors to integrate different approaches to MFT—such as analytic, behavioral, existential, emotionally focused, narrative, and systems—into a theory (the sound relationship house theory) that is empirically derived, based on years of research on what makes relationships succeed or fail. The Gottman method couple therapy uses various therapeutic interventions to achieve the following goals: “down-regulate negative affect during conflict, up-regulate positive affect during conflict, build positive affect during non-conflict, bridge meta-emotion mismatches, and create and nurture a shared meaning system” (Gottman & Gottman 2008, 143–161; see also Gottman & Gottman 2015a). John Gottman is an emeritus professor of psychology in the Department of Psychology at

the University of Washington and cofounder of the Relationship Research Institute in Seattle,

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Washington. He has authored or coauthored over 190 papers and several significant books that have greatly impacted the MFT field (see, e.g., Gottman 1994a, 1994b, 1999; Gottman & Gottman 2007, 2015b, 2018; Gottman & Silver 1999). He has also received many awards, including the Distinguished Research Scientist Award from the AAMFT, the American Family Therapy Academy Award for Most Distinguished Contributor to Family Systems Research, and the APA’s Division 43 (Society for Couple and Family Psychology) Presidential Citation for Outstanding Lifetime Research Contribution. Alan S. Gurman (1945–2013) was a pioneer in the development of integrative approaches

to couple therapy (see Gurman 2008a, vii). He described his integrative couple therapy (ICT) as a depth-behavioral approach that seriously considers both interpersonal and intrapersonal factors in helping couples with relationship difficulties. ICT is based on general family systems theory and adult developmental theory (especially attachment theory) and more specifically grounded in applied social learning theory (or behavior therapy) and object relations theory (see Gurman 2008b, 383). Gurman independently refined and developed his integrative approach to couple therapy for the past few decades, although ICT shares some similarities with other integrative models of couple therapy. ICT was previously called brief integrative marital therapy (BIMT) (Gurman 2002), and most recently described as functional analytic couple therapy (Gurman 2015). Gurman has coauthored or coedited several influential books on family therapy, marital or

couple therapy, brief therapy, and essential psychotherapies that have greatly influenced the MFT field as well as the broader field of counseling and psychotherapy (see, e.g., Budman & Gurman 1988; Gurman 2008a; Gurman & Jacobson 2002; Gurman & Kniskern 1981, 1991; Gurman & Messer 2003; Gurman, Lebow, & Snyder 2015; Messer & Gurman 2011). Gurman was an emeritus professor of psychiatry and director of Family Therapy Training

at the University of Wisconsin School of Medicine and Public Health in Madison. He served for two terms as editor of the Journal of Marital and Family Therapy and was president of the Society for Psychotherapy Research. He made substantial contributions to the MFT field and received many awards and honors, including awards for Distinguished Contributions to Family Psychology from the American Psychological Association, Distinguished Achievement in Family Therapy Research from the American Family Therapy Academy, and Distinguished Contribution to Research in Family Therapy from the American Association for Marriage and Family Therapy. Gurman was also the recipient of a national teaching award for Excellence in Internship Training / Distinguished Achievement in Teaching and Training from the Association of Psychology Postdoctoral and Internship Centers. He had an active clinical practice in Madison, Wisconsin. He died of a heart attack on September 6, 2013, in Madison. Richard C. Schwartz obtained his PhD in marriage and family therapy from Purdue

University. He started his academic and professional career as an associate professor at the Institute for Juvenile Research at the University of Illinois, and later at the Family Institute at Northwestern University; now he is on the adjunct faculty of the Department of Psychiatry at Harvard Medical School. He developed a therapeutic approach called Internal Family Systems (IFS) therapy, for individuals, especially those suffering from trauma, but also for couples and in group and educational settings, as well as for mentoring and peer counseling.

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He set up The Center for Self Leadership in 2000 to conduct training in the IFS approach. Besides his well-known text on IFS (Schwartz 1995; Schwartz & Sweezy 2020), he has also coauthored a book on metaframeworks about going beyond current family therapy models (Breunlin, Schwartz, & MacKune-Karrer 1997), and a widely read family therapy textbook (Nichols, with Schwartz 2006). The IFS therapy approach was developed by Richard Schwartz (1995; Schwartz & Sweezy

2020; see also Sweezy & Ziskind 2013) to help clients heal themselves and the parts within them that tend to be troubling and problematic when ignored but more compliant and harmonious when tended in appropriate and caring ways (McConnell 2020). IFS therapy is based on compassion, trust, honesty, and encouragement and is a non-pathologizing approach to help clients come to terms with the different inner parts, the subpersonalities, acknowledging their strengths and weakness. The three major parts, subpersonalities, within a person with their specific characteristics are these: managers are parts of the person who protect them and control their ways of interaction with the outside world; exiles are those parts of an individual that experience painful feelings such as fear, anxiety, or trauma; and firefighters are parts of the person that try to suppress or distract exiles from experiencing pain, together with the managers, but the eventual result is often the individual engaging in unhealthy behaviors (e.g., drug use or excessive drinking) to try to numb or avoid the pain. IFS therapy also assumes that there is a true Self underneath these parts, subpersonalities,

within a person, a Self governed more by compassion and connectedness. It helps clients to focus less on their different parts and to accept them more in order to be in deeper touch with their true Self, and in so doing eventually to experience self-healing and more wholeness (see Richard Schwartz on goodtherapy.org).

Major Theoretical Ideas of Marital and Family Therapy Perspective on Human Nature MFT actually has over twenty diverse systemic therapies that have been developed to help

distressed couples and troubled families. It is therefore difficult to identify a specific perspective on human nature that can adequately represent such different MFT approaches. For example, psychodynamic family therapy (see Yarhouse & Sells 2017), more specifically called object relations couple and family therapy, has a perspective on human nature that is more in line with a psychoanalytic or psychodynamic view. Cognitive-behavioral family therapy will have a perspective on human nature that is consistent with a cognitive behavior therapy (CBT) view. Such views on human nature, as in the major approaches to counseling and psychotherapy, have already been covered in previous chapters and will not be repeated here. There are, however, some basic perspectives on human nature that are consistent across

most MFT approaches that take a systemic view of human functioning. Systemic approaches in MFT focus on the family as a unit and apply general systems theory, as developed by Ludwig von Bertalanffy (1968) beginning in the 1940s, to family functioning and dysfunctioning, emphasizing the significance of interrelations between parts of a system that can result in circular causality (e.g., A may cause B, but B also affects A, which then affects

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B, and so on). A specific example of such family systems thinking is the view that symptoms in one member of the family actually reflect family dysfunction instead of the individual’s own psychopathology (see Goldenberg & Stanton 2019, 399). Systemic MFT approaches— such as strategic family therapy, structural family therapy, Bowenian or transgenerational (multigenerational) family therapy, contextual family therapy, and psychodynamic or object- relations family therapy (see Yarhouse & Sells 2017)—tend to have a more pessimistic view of human nature and of families as having tendencies toward dysfunction. The therapist therefore must intervene as an expert, giving directives or providing interpretations that may help families and family members to change. The potential to change is there, but in limited degree. Other and more recent approaches to MFT have a systems approach but are modified to

include a more respectful view of human nature and families as being capable of choice, change, creative problem-solving, and meaning-making; these include experiential family therapy, solution-focused family therapy, narrative therapy, and to a certain extent, cognitive- behavioral family therapy and emotionally focused couple and family therapy (see Yarhouse & Sells 2017). In these approaches the family therapist does not assume an expert stance but rather collaborates with the family members, in mutually respectful and egalitarian therapeutic relationships, empowering them to develop their own creative solutions to their family problems, while providing some gentle guidance. Cognitive-behavioral family therapy and emotionally focused couple and family therapy, however, usually involve relatively more directive family therapist action and intervention. Thus the major MFT approaches differ in their views of human nature and the nature of

families. Some have more positive perspectives on human nature and the potential for change in families; others have somewhat more pessimistic perspectives on human nature and the limited capacity of families to choose and make therapeutic changes.

Sidebar 16.2: Approaches to Marital and Family Therapy (see Goldenberg & Stanton 2019, 401–404)

1. Object relations family therapy 2. Experiential family therapy 3. Transgenerational family therapy 4. Structural family therapy 5. Strategic family therapy 6. Cognitive behavior family therapy 7. Social constructionist family therapy 8. Narrative therapy

Major Approaches to MFT

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Irene Goldenberg, Mark Stanton, and Herbert Goldenberg (2017) have identified eight major approaches to MFT: object relations family therapy, experiential family therapy, transgenerational family therapy, structural family therapy, strategic family therapy, cognitive behavior family therapy, social constructionist family therapy, and narrative therapy (see also Goldenberg & Stanton 2019, 400–404). Object Relations Family Therapy. This psychodynamic family therapy developed by

David Scharff and Jill Scharff (1987, 1991; see also J. S. Scharff & D. E. Scharff 2008) assumes an object relations approach to couple and family therapy, emphasizing that the basic need in life is to have a satisfying relationship with some “object,” or another person. Family members bring introjects (memories of loss or lack of fulfillment in childhood) into their present interactions with others, attempting to find fulfillment but also affecting current family relations in negative ways at times. Family members unconsciously relate to one another based on childhood expectations and motivations. The object relations family therapist attempts to help family members understand how they internalized objects from their past and gain insight into how these internalized objects are still affecting their present relationships, so that they can change in constructive ways. Experiential Family Therapy. Experiential family therapy includes the human validation

process model (Satir & Bitter 2000), better known as the conjoint family therapy developed by Satir (1964, 1983), and the symbolic-experiential family therapy developed by Whitaker (Whitaker & Bumberry 1988; Whitaker & Keith 1981; see also Whitaker 1989). Both Satir and Whitaker emphasized that disturbed families need a growth experience in deeply connecting with an authentic, involved, and appropriately self-disclosing family therapist (or two if in cotherapy), thus helping such families to open up and be more honest about their real feelings and needs, and empowering them to choose to change in more constructive ways. Satir focused more on building self-esteem and teaching open and adequate communication with families, whereas Whitaker used his own fantasies and instincts to help family members accept their own subjective experiences and explore their inner world of symbolic meanings in order to grow. Irene Goldenberg and Mark Stanton (2019, 411) included emotion-focused couple therapy, or EFT (see L. S. Greenberg 2017; S. M. Johnson 2004, 2015, 2019) as a current evidence-based representation of experiential family therapy, grounded in attachment theory and integrated with humanistic and systemic perspectives, which helps couples to soften their negative interactions and strengthen their emotional connection with each other (see S. M. Johnson & Brubacher 2016). EFT has also been applied to individuals and families, in addition to couples (S. M. Johnson 2019). EFT for couples is an empirically supported treatment with much research evidence for its

effectiveness (S. M. Johnson 2019, 127–182; see also Goldenberg, Stanton, & Goldenberg 2017, 248–252). It is usually a relatively brief or short-term (eight to ten sessions) experiential therapy approach (Goldenberg, Stanton, & Goldenberg 2017, 249). As an attachment-based therapy, EFT emphasizes that the crucial factors influencing the security and quality of an attachment bond “are the perceived accessibility, responsiveness, and emotional engagement of attachment figures. These factors can be translated into the acronym A. R. E., . . . shorthand for the key attachment question that arises in couple’s conflict, ‘Are you there with me?’” (S. M. Johnson 2019, 7).

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The three basic stages of EFT are de-escalation (or stabilization), restructuring attachment, and consolidation. The heart of EFT is called the EFT Tango, which consists of five major moves: (1) mirroring present process, with the therapist attuning to, clarifying, and with empathy reflecting the cycles of emotional regulation and interpersonal interaction of the couple or client; (2) affect assembly and deepening, with the therapist joining the clients and helping them to piece their emotional experiences into a more coherent perspective interpersonally; (3) choreographing engaged encounters, with the therapist guiding the clients in structured interactions to help them deepen and expand their inner experiences and interactions with others; (4) processing the encounter, with the therapist helping the clients to explore and integrate the new patterns of interaction; and (5) integrating and validating, with the therapist focusing on and validating new positive interactions in the clients as well as in their inner experiences, to enhance their confidence and competence (see S. M. Johnson 2019, 32, 54–67, 84–97). Transgenerational Family Therapy. This approach has also been called multigenerational

family therapy, or simply Bowenian family therapy (Yarhouse & Sells 2017), because it was developed by Murray Bowen (1978). He believed that family members are connected to their family system, and those with the strongest emotional connections, or fusion, with the family are more susceptible to experiencing their own emotional reactions to family struggles. Differentiation of self—one’s ability to have a separate sense of self as independent from the family and also one’s ability to differentiate between one’s intellect and one’s feelings—is crucial for the healthy functioning of the individual in their family. Triangulation is another key concept described by Bowen, referring to a process in which

a third person is brought in to stabilize a couple, as when a married couple with marital conflict and tension pull in their teenage daughter as a third person to help stabilize their conflict rather than dealing with it more directly by themselves. Their attention is now diverted to their daughter, who may end up acting out in rebellious ways (see Yarhouse & Sells 2017, 68, 70–71). Bowen also described how a family’s emotional processes and problems, especially low

levels of differentiation of self, are passed down from one generation to another in what he called a multigenerational transmission process. An example is when a family member with low differentiation of self marries a spouse who also has a low differentiation of self, and their offspring who is even less differentiated also ends up marrying someone with low differentiation of self. The low differentiation of self thus continues through succeeding generations. Goldenberg and Stanton (2019, 402) include contextual family therapy (see Boszormenyi-

Nagy & Krasner 1986; Boszormenyi-Nagy & Spark 1984), as developed by Ivan Boszormenyi-Nagy, as another example of transgenerational family therapy. However, Boszormenyi-Nagy focused more on the ethical dimension in family relationships, in an intergenerational context, with aspects such as trust, loyalty, entitlements, and indebtedness. Contextual family therapists help families to maintain fairness and to fulfill each family member’s personal sense of claims, rights, and obligations in their relationships with the other members of the family.

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Structural Family Therapy. This approach to MFT was developed by Minuchin (1974), who described a structural view that focused on the organization of families and the rules that govern the interactions between family members. Attention is especially given to family rules, roles, alignments, and coalitions, and also to how the overall family system is composed in terms of its subsystems and boundaries. Structural family therapists try to help families free themselves from their usual rigid and repetitive patterns of interaction so that they can engage in more constructive and healthy reorganization of the family. Strategic Family Therapy. This approach to MFT was developed mainly by Haley (1963,

1976). It is a pragmatic, problem-solving therapy that involves the use of creative strategies by the strategic family therapist to reduce or eliminate unwanted behavior in the family. The specific therapeutic techniques used can be direct or indirect, such as paradoxical techniques (e.g., prescribing the symptom). Haley’s approach does not focus on helping family members gain insight into the past or unconscious processes. Instead, it focuses on the presenting problems of the family and on directively attempting to solve them in creative and constructive ways. Mara Selvini-Palazzoli and her colleagues (Selvini-Palazzoli et al. 1978) in Milan, Italy,

developed a variation of strategic family therapy called systemic family therapy, which has been successfully used, especially with psychotic and anorectic patients. Selvini-Palazzoli (1986) views behavioral symptoms in children as part of “dirty games” in which parents and their symptomatic children engage in power struggles. Children thus use their symptoms in attempts to defeat one parent in order to help the other parent. Luigi Boscolo and Gianfranco Cecchin (Boscolo et al. 1987) have further developed interviewing techniques (e.g., circular questioning) to empower family members to explore their family belief system and make constructive changes and new choices. Boscolo and Cecchin also viewed the family therapist no longer as the expert who knows objectively what is best for the family being seen in therapy, but simply as a participant with the rest of the family. They therefore helped to facilitate the development of more postmodern, social constructionist approaches to MFT (see Goldenberg & Stanton 2019, 402–403). Cognitive Behavior Family Therapy. This approach to MFT includes the behavioral

perspective, which focuses on using reinforcement contingencies to increase desirable behaviors and decrease dysfunctional behaviors in couples and families and on teaching communication and problem-solving skills (see, e.g., N. S. Jacobson & Margolin 1979). It also incorporates cognitive therapy, which focuses on identifying and restructuring distorted thinking or irrational beliefs that influence feelings and behaviors (see, e.g., Baucom & Epstein 1990; Baucom et al. 2015; Dattilio 2009; Epstein & Baucom 2002; Epstein, Schlesinger, & Dryden 1988). More-recent versions of behavioral and cognitive behavior family therapy place greater emphasis on acceptance, for example, in integrative behavioral couple therapy (see N. S. Jacobson & Christensen 1998; A. Christensen & Jacobson 2000; see also A. Christensen, Dimidjian, & Martell 2015) versus traditional behavioral couple therapy. Social Constructionist Family Therapy. This approach to MFT is a more recent

development, influenced mainly by postmodern views, which emphasize subjective perceptions of reality that differ from person to person or family to family, depending on

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important diversity factors such as ethnicity, culture, gender, and sexual orientation (see Goldenberg & Stanton 2019, 403). Social constructionist family therapy therefore values diversity and challenges traditional systems perspectives that emphasize a simple cybernetic model of family functioning, with the family therapist as expert in assessing and treating troubled families. The social constructionist approach to MFT advocates mutually respectful and truly collaborative therapeutic relationships between family therapists and family members. Families are empowered to develop their own creative solutions to their problems, with only some gentle guidance from the therapist, who does not function as the expert. Well- known examples of social constructionist (or constructivist) family therapy include solution- focused therapy (see chap. 14 of this book), developed by Steve de Shazer (see, e.g., de Shazer 1985, 1988, 1991; de Shazer & Dolan 2007); and the collaborative language systems approach, developed by Harlene Anderson (1997). Narrative Therapy (see chap. 14 of this book). This approach to MFT emphasizes that the

stories individuals and families tell or believe about themselves greatly influence their subjective sense of reality and how it is organized and experienced. Michael White was the major proponent of narrative therapy (see, e.g., M. White 2007; M. White & Epston 1989, 1990; see also Monk et al. 1997). The narrative approach to MFT helps family members reduce the power of stories that are negative, oppressive, and problem-centered by empowering them to re-author their lives with other stories that are more constructive, so that they can explore and try new options and possibilities in their lives. Narrative family therapists focus more on how a certain problem has impacted the family rather than on how certain family patterns may have caused the problem. A specific intervention often used is externalization, which is the process of helping family members see the problem as being outside themselves instead of being an internal part of their basic identity. Such externalization can help empower the family to explore other more constructive stories or options that they can choose in order to overcome their problems and feelings of hopelessness (see Goldenberg & Stanton 2019, 404). Mark Yarhouse and James Sells (2017) have similarly summarized and described nine

major approaches to MFT that are similar to the eight approaches mentioned by Goldenberg and Stanton (2019). The nine MFT approaches are Bowenian family therapy, strategic family therapy, structural family therapy, psychodynamic family therapy, contextual family therapy, experiential family therapy, solution-focused family therapy, cognitive-behavioral family therapy, and narrative family therapy.

Therapeutic Process and Relationship The therapeutic process and relationship in MFT will depend greatly on the specific approach to MFT that is being considered. As already mentioned, some approaches to MFT—such as strategic family therapy, structural family therapy, transgenerational or Bowenian family therapy, contextual family therapy, psychodynamic or object-relations family therapy, cognitive-behavioral family therapy, and emotionally focused family therapy—tend to emphasize the role of the family therapist as somewhat of an expert in assessing and treating couple and family dysfunction. A warm, caring therapeutic relationship is still valued by such

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MFT approaches, but specific therapeutic techniques of family therapy, direct or indirect, are also valued and emphasized. Other approaches to MFT, especially those influenced mainly by postmodern perspectives

that value subjective perceptions of reality and diversity—such as social constructionist family therapy, including solution-focused family therapy, narrative family therapy, and some forms of experiential family therapy (e.g., Satir’s conjoint family therapy)—emphasize the centrality of the therapeutic relationship between the family therapist and the family members. The family therapist in these MFT approaches does not assume the role of expert. Instead, the therapist participates with the family in a warm, caring, and mutually respectful therapeutic relationship that seeks to empower family members to devise their own creative ways of dealing with their family problems. The family is therefore viewed as the expert, and the therapist assumes a “not-knowing,” nonexpert approach to therapy (see H. D. Anderson & Goolishian 1992).

Sidebar 16.3: Characteristics of Strong or Healthy Families

Stanton L. Jones and Richard Butman (1991, 353) provided the following characteristics of strong or healthy families from a general family therapy perspective:

1. Respond positively to challenges and crises 2. Have a clearly articulated worldview 3. Communicate well 4. Choose to spend time together in a variety of tasks 5. Make promises and honor commitments to one another 6. Know how to express love and appreciation for one another

The process of MFT also varies in terms of length of therapy, depending on the specific approach to MFT that is being considered. Many MFT approaches are relatively short term; others, such as psychodynamic or object relations family therapy, can be long-term. Usually the couple or the family are seen together. The process of therapy in MFT typically involves four general movements: “forming a relationship, conducting an assessment, hypothesizing and sharing meaning, and facilitating change” (Corey 2021, 410). The goals of MFT will also vary, depending on the needs of specific couples and families

as well as the specific approach to MFT that is being used. MFT approaches attempt to help couples and families reduce their problems and grow to become healthier and more functional in a systemic way (see Parrott 2003, 376–377). The needs and problems of families will vary, depending on which stage of their family life cycle they have reached (McGoldrick, Preto, & Carter 2015).

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Major Therapeutic Techniques and Interventions in MFT There are many approaches to MFT and even more techniques available to modify family functioning and facilitate therapeutic change (see, e.g., J. Carlson, Sperry, & Lewis 2005; S. Minuchin & Fishman 1981; see also Bitter 2014; J. Patterson et al. 2018; Taibbi 2015, 2017). Some of the best-known therapeutic techniques often used by family therapists are reframing, therapeutic double binds, enactment, family sculpting, circular questioning, cognitive restructuring, miracle question, and externalization (Goldenberg & Stanton 2019, 412–414), as well as boundary setting and genogram (see Parrott 2003, 378). In order to provide a more coherent framework within which to practice family therapy

that integrates the major approaches to MFT and their techniques, Douglas Breunlin, Richard Schwartz, and Betty MacKune-Karrer (1997) have described their perspective of metaframeworks for transcending the different models of family therapy. They have proposed the following six original main metaframeworks, which serve as therapeutic lenses that family therapists can use to assess and help a family system in trouble: internal family systems (i.e., individual), sequences (i.e., interaction patterns), organization (of the family system), developmental, multicultural, and gender. More recently, two more metaframeworks or lenses have been added: teleological (i.e., goal-orientation) and process. All or any of these eight lenses can be used to guide the family therapist to select specific techniques to meet the specific needs of the family (see, e.g., J. Carlson, Sperry, & Lewis 2005). We will now examine some of the major family therapy techniques often used by family

therapists (see Goldenberg & Stanton 2019, 412–414; Parrott 2003, 378). Reframing. This family therapy technique involves relabeling problematic behavior with a

new, alternative description that is more positive, especially emphasizing the good intention of the specific behavior being discussed. For example, a teenage son who is upset by his mother’s nagging behavior may respond more constructively (rather than with anger and rebellion) if his mother’s behavior is relabeled or reframed to be an expression of her caring and concern for his welfare, rather than calculated simply to bug him with repeated “nagging.” Reframing is used to restructure the meaning given to a specific behavior without modifying or denying the reality of the actual behavior itself. It is often used by strategic family therapists to help family members view problematic behavior from a more positive perspective, thus enabling them to change their family system or interactions in more constructive ways. Therapeutic Double Binds. This technique is often used by strategic and systemic family

therapists, who may directively instruct families to persist in their problem behaviors, thus putting them into a therapeutic double bind. This is mostly done by using paradoxical interventions that prescribe the symptom: for example, a couple who often argue are encouraged to argue even more. If they do so, they are admitting that they are in control to increase or decrease their problem behavior of arguing. If they do not do so, then their problem behavior will eventually be eliminated. This technique is therefore a double bind in which the clients will benefit therapeutically, whether or not they follow the paradoxical intervention.

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Sidebar 16.4: Some Family Therapy Techniques (see Goldenberg & Stanton 2019, 400–404; Parrott 2003, 378)

1. Reframing 2. Therapeutic double binds 3. Enactment 4. Family sculpting 5. Circular questioning 6. Cognitive restructuring 7. Miracle question 8. Externalization 9. Boundary setting 10. Genogram

Enactment. This family therapy technique is often used by structural family therapists following Minuchin; it refers to guiding an actual family to role-play a dysfunctional pattern of interaction. In such enactments, the attempts at role-playing actual family situations in the family therapy session itself, the family therapist can observe the dysfunctional pattern and provide feedback to help the family members “unfreeze” or break out of their unhealthy, destructive family interactions and replace them with more constructive ways of family interaction. Goldenberg and Stanton (2019, 413) provide an example of Minuchin doing an enactment (see S. Minuchin, Rosman, & Baker 1978) with a family consisting of two parents and an anorectic adolescent daughter; Minuchin arranged the first session with them to include bringing lunch so that they were faced with an enactment of their usual family interaction around eating. He could then observe the parents’ struggles and dysfunctional ways of trying to deal with their daughter’s refusal to eat and point out the ineffectiveness of the parental subsystem in handling their daughter’s eating problem. He could then guide the parents to cooperate with each other more (rather than fighting with or contradicting each other) in encouraging their daughter to eat, thus forming a more united front that is stronger and more effective. The daughter would then also be relieved of the position of power and destructive manipulation that she had been maintaining. This enactment in the therapy session, with directive suggestions and feedback from a family therapist with a structural approach such as Minuchin, can force the family to more clearly see their dysfunctional family system that they have created so far and to explore more-constructive ways of interaction. Family Sculpting. This family therapy technique involves asking family members to take

turns acting as a “director” in getting the different family members to place themselves in specific positions physically in space, in the therapist’s office, to represent their family relationships. Thus they express themselves and their attitudes toward each other in active, nonverbal behavior rather than in words. The family members’ views of family, roles,

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alliances, boundaries, and subsystems can be further clarified for the whole family to see by using family sculpting, a technique often used by experiential family therapists following Satir’s approach. Circular Questioning. This technique is frequently used by systemic family therapists (see

Boscolo et al. 1987) to draw attention to family interactions instead of individual pathology. The family therapist will ask each family member the same question about their perceptions of the same issue, whether it is an event or a relationship. By going around to each family member, using this technique of circular questioning, the family therapist can explore more deeply each family member’s perceptions and feelings without being confrontational. The family can then be more comfortable in examining the underlying root of their family conflict. Such nonconfrontational questioning is used by systemic family therapists as a therapeutic process to help the family deal with their family problems by sharing their varied views of their difficulties and modifying them into more constructive perspectives (see Goldenberg & Stanton 2019, 413). Cognitive Restructuring. This cognitive therapy technique is often used by cognitive-

behavioral family therapists to help family members identify and challenge their individual maladaptive, distorted thoughts about themselves and their family problems, and to replace such dysfunctional thoughts with more accurate, realistic, and rational beliefs. For example, a couple may initially think that because they are arguing so often, they are personally failures, and their marriage is doomed to end in divorce. Cognitive restructuring of such negative and catastrophic thinking is designed to help the couple think more rationally by telling themselves that, although they do have serious conflicts that they need to work out and resolve more effectively, they are not personal failures, and their marriage is not doomed to end in divorce. In fact, they may realize that many couples struggle with conflicts, and such conflicts may actually be opportunities for them to learn better communication and conflict resolution skills and therefore even strengthen their marriage. One’s thinking strongly influences one’s feelings and behavior. Miracle Question. This is a solution-focused family therapy technique described by de

Shazer. Clients are asked the following miracle question: “Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?” (de Shazer 1988, 10). Each family member is asked to answer this miracle question and therefore speculate how different things would be as well as how each family member’s behavior would change. The use of the miracle question can help families break out of old, problem-saturated ways of looking at their family problems, choose new goals, and find potential solutions to their old problems that are more creative, novel, and constructive. Externalization. This technique of externalization is often used by narrative family

therapists following the work of White and Epston (1990) to help families free themselves from their old, problem-saturated stories that have dead ends and failures as outcomes and that often result in self-blame for family members. The therapist uses externalization to help family members see that the problem resides outside the family instead of attributing the problem to an internal family deficit or a specific family member’s personal psychopathology. The whole family is encouraged to view the problem as external to them

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and to pull together to see how they can deal with the problem with more-constructive solutions. For example, instead of viewing the problem of the mother’s depression as “Mother is depressed,” the family is helped by the family therapist to externalize the problem by saying, “Depression is trying to control Mother’s life.” The family members can then explore other creative ways of dealing more effectively with the depression that is affecting the whole family (see Goldenberg & Stanton 2019, 413–414). In addition to these eight major therapeutic techniques or interventions of family therapy

mentioned by Goldenberg and Stanton (2019), Parrott added at least two more: boundary setting and genogram (2003, 378). Boundary Setting. This family therapy technique involves either establishing firmer limits

or lines of separation (i.e., “walls”) in families whose members are too enmeshed with one another or building more flexible or permeable boundaries (i.e., “bridges”) to facilitate deeper connections among family members who may be too disengaged from one another. The family therapist can use boundary setting in various ways, such as directing communication so that only one family member speaks at a time, to help each family member have a voice; or by helping the family negotiate and set up family rules that respect an adolescent’s need for personal space and privacy and the family’s need for time together and connection. Genogram. A genogram is a three-generation family tree that is often used by family

therapists to help family members see family patterns more clearly that may have been transmitted or passed down from generation to generation. Genograms are graphic tools that can help family members discover how their family history has impacted them and their present struggles and problems (see McGoldrick, Gerson, & Petry 2020). There are many more family therapy techniques, but the ones just described are examples

of some of the better-known and more frequently used therapeutic interventions in couple and family therapy. Common factors in couple and family therapy have recently been emphasized as the overlooked foundation for effective practice (Sprenkle, Davis, & Lebow 2009), and integrative approaches to couple and family therapy have grown considerably (Lebow 2014, 2016; see also N. J. Kaslow, Mirsalimi, & Celano 2020; Lebow & Kelly 2020).

MFT in Practice

This hypothetical transcript of a small part of a family therapy session with a sixteen-year-old and his parents demonstrates the family therapist’s use of reframing (of the father’s nagging and frequent questions as caring for and interest in the son and what’s happening in his life) and boundary setting (by encouraging the father to respect his son’s request for more space and privacy by knocking before entering his son’s room, and encouraging the son to more spontaneously share with his father about what’s happening in his life). The family therapist directs and monitors the process so that each family member has a chance to talk during the session. The family therapist also engages in a warm, respectful, and empathic therapeutic relationship with each of the family members by summarizing what they said, asking them if

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it was OK with them when the therapist made specific suggestions after exploring possible solutions with them, and empowering the family members to come up with their own creative problem-solving ideas.

Client (Father): My son, John, never tells me anything about what’s going on in his life! I have to ask him many times, but he still says almost nothing!

Client (Son, named John):

But Dad, that’s because you bug me so much with all your nagging, and you just get in my face all the time and come into my room any time you want to, without even knocking!

Client (Mother): Yeah, they get on each other’s nerves so often; I’m tired and fed up with all this!

Family Therapist: Wow, you are all really upset about this situation. Dad, you want John to share more of what’s going on in his life with you. John, you feel Dad is nagging you too much and not respecting your privacy and not giving you enough space. And Mom, you’re frustrated and tired with all of this. Am I on the right track with each of you?

Client (Father): Uh-huh . . . Client (Son): Yup, you got it!

Client (Mother): Yes. Family Therapist: I can’t help but wonder if all this nagging from Dad is really his way of

showing you, John, that he cares about you and what’s going on in your life; that’s why he’s asking, even if it’s too many times. What do you think, John?

Client (Father): That’s right! I do care about him, but he doesn’t appreciate it. . . . Client (Son): There he goes again, and I think that you asked me the question, and

not him, right? Family Therapist: That’s right, actually, so if you can wait just a moment, Dad, let me

hear what John has to say, OK? Client (Father): OK. . . .

Family Therapist: Good! So go ahead, John . . . Client (Son): Well, I guess my dad’s nagging is a way of his showing me that he’s

interested in me and my life and what’s going on with me; and if I look at it this way, it doesn’t feel as bad or negative as when I look at it usually as nagging, and then it really bugs me! I still wish he would not ask me questions so often or so repeatedly!

Family Therapist: Can you say this directly to your dad? Client (Son): OK . . . well, Dad, I guess your nagging is your way of showing me

you’re interested in my life and that you care about how I’m doing. I do appreciate it! But it would be nice if you didn’t ask me questions so often, OK? . . .

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Client (Father): Well, I’m glad you realize that I really do care about you, and that you finally appreciate it! I’ll try to ask you less often, but it would help too if you just tell me things more spontaneously and just be more open with me and talk to me more without me having to ask you.

Client (Son): I’ll try . . . Family Therapist: Good! You’re beginning to connect with each other in more-

constructive and helpful ways, and you’re really listening to each other and getting it! Mom, what do you think about what’s happening here?

Client (Mother): I’m glad! They’re finally talking to each other or with each other rather than talking at each other! I think there’s another issue about giving John a bit more space and privacy since he is already sixteen years old!

Family Therapist: OK, what do you have to say about this, Dad? Client (Father): Well . . . I’m OK with giving John a bit more space or privacy, but it’ll

be easier if he tells me what’s happening more often. . . . Client (Son): I’ll try, Dad, but I would appreciate it if you don’t just walk into my

room any time you feel like it, especially if my door is closed, and you don’t knock. I may be taking a nap or just need some down time to be quiet. Please knock if you need to talk to me before you come into my room, OK?

Client (Father): OK . . . Family Therapist: That’s great! You’re both setting appropriate boundaries or guidelines

that allow you to communicate and still be connected while respecting John’s need for a bit more space and privacy because he’s growing up fast! So, Dad, you’re OK with knocking before entering John’s room, if you want to talk to him?

Client (Father): Yeah, I’ll try to remember. Family Therapist: Good! And John, you’re OK with telling Dad what’s up with you and

your life a bit more often, without him having to ask all the time? Client (Son): Yeah, I guess I’ll try too, like Dad! (smiles a bit here and looks at Dad)

Family Therapist: And Mom, you’re OK with all this?

Client (Mother): Sure! I’ve been trying to tell my husband that he should do something like what we agreed on today, because John is already sixteen years old, and not to treat him like a ten-year-old!

Client (Father): But you don’t tell me nicely, and sometimes you nag me too! (with a smile). But I agree, and we can work together to connect better with you, John.

Client (Mother): That’s good. Family Therapist: It is good! Dad and Mom working together more, and Dad and John

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agreeing to communicate and connect more openly and spontaneously, with Dad respecting John’s space more, and John realizing that his Dad really does care for him even through his nagging! Are you all OK with doing this for homework until our next session?

Client (Father): Yeah, I’ll try. Client (Son): Sure.

Client (Mother): I’ll do my best to support them! Family Therapist: Great! Let’s see what else is on your agenda that you want to cover or

deal with for the rest of today’s session. . . .

Critique of MFT: Strengths and Weaknesses Again, it is difficult to critique MFT because of the many different approaches to couple and family therapy that are included in this field. In general, however, MFT has several strengths as well as weaknesses (see Corey 2021, 415–417, 423–424; Parrott 2003, 387–388; Prochaska & Norcross 2018, 314–317). In terms of strengths, MFT is based on a broad systems perspective on couples and

families, focusing on the family as a unit, and therefore transcends the individualistic emphasis often found in other approaches to therapy. MFT does not place blame on individual psychopathology and therefore avoids scapegoating (holding a specific person responsible for the problems of the whole family system). It also avoids blaming the family itself for its struggles because it tends to look instead at the bigger picture of the family system and subsystems. Second, MFT has numerous family therapy techniques that can be used to effectively help

couples and families with their problems in practical ways. Whether it is reframing, therapeutic double binds, enactment, family sculpting, circular questioning, cognitive restructuring, asking the miracle question, externalization, boundary setting, constructing a genogram, communication skills training, problem solving, or other therapeutic interventions, MFT is a practical, usually relatively short-term therapy of twenty sessions or less (Lebow 2008, 328) that deals with the problems of couples and families in a direct and concrete way. An exception would be the psychodynamic or object-relations family therapy approach, which can be relatively long-term because it focuses on the unconscious processes and childhood experiences of the individual members of the family system. Many couples and families who want effective and efficient help for their difficulties can find it from practitioners of MFT. Third, MFT seriously considers the systems and subsystems of families, including the

significant role of factors such as ethnicity, culture, gender, values, beliefs, spirituality, and religion (see, e.g., McGoldrick, Giordano, & Garcia-Preto 2005; McGoldrick & Hardy 2019; F. Walsh 2009). It therefore attempts to be multiculturally sensitive and attentive to larger

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systems, such as racial, social, cultural, gender, and spiritual or religious contexts and influences. Fourth, MFT is a field that is still open to experimentation and the further development of

more creative and novel ways of helping couples and families. It will continue to evolve and contribute new ideas and therapeutic techniques to the theory and practice of counseling and psychotherapy. Fifth, earlier MFT approaches (e.g., structural family therapy, strategic family therapy,

contextual family therapy, Bowenian or transgenerational family therapy, and psychodynamic family therapy) emphasized the role of the family therapist as an expert with specialized knowledge and skills for assessing and treating family problems systemically. Nevertheless, more recent versions of MFT, especially those based on postmodern, social constructionist perspectives (e.g., solution-focused family therapy, narrative family therapy, and experiential or conjoint family therapy), focus on the client or the family as the expert, not the family therapist. They emphasize the centrality of a mutually respectful, fully collaborative, and deeply caring therapeutic relationship in effective family therapy. This gentler approach, empowering the family to develop its own creative and constructive narratives and solutions to its problems, is a strength of MFT today. Sixth, the social constructionist approaches to MFT focus more on narratives and the big-

picture stories of family members and their lives, empowering them to engage in more- constructive meaning-making of their lives and experiences. This more existential emphasis, including a respectful use of spiritual and religious resources (see F. Walsh 2009), reflects a greater openness in MFT today to dealing with deeper issues relating to meaning in life, which is another one of its strengths. Seventh, MFT tends to assume a systemic perspective on families and family functioning

and dysfunctioning. It has a clear model of what healthy family functioning is and what dysfunctional families look like, especially enmeshed or disengaged families from a structural viewpoint. This perspective is a strength in terms of systematic assessment and treatment of family dysfunction within a systemic and structural framework, but it can also be a potential weakness if such a structural model is imposed on all families. Eighth, MFT deals with the whole family, including extended family when appropriate, in

family therapy sessions. Many cultures place significant value on the family, especially the extended family. MFT can therefore be seen as more relevant and sensitive to cultures that do not emphasize individualistic values or self-focused fulfillment but instead value community and extended family relationships. Practitioners of MFT can help families and extended families in such cultures better than more Westernized therapists who practice individual approaches to therapy, focusing more on the self and self-actualization and less on the interpersonal contexts of family and community. Finally, many MFT approaches have been subjected to controlled outcome evaluations and

have overall been found to be effective treatments (see, e.g., Prochaska & Norcross 2018, 308–314; also Lebow & Kelly 2020; N. Kaslow, Mirsalimi, & Celano 2020; Roddy et al. 2020). The empirical outcome research that has been done and that continues to be conducted on MFT is therefore another strength.

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MFT also has several significant weaknesses. First, its focus on the family as a unit from a systems perspective can lead to a loss of appreciation for the personhood of the individual family member. In other words, the pendulum can swing too far from individualistic self- focused therapy to systems-focused MFT, which can result in losing the person of the client or family member. Systemic MFT approaches can become mechanistic in treating the family as a whole like a “machine” that needs only to be tweaked with the right technique, using the right systems terminology, and forgetting that ultimately the family still consists of individual family members, important persons in their own right. Second, MFT has numerous therapeutic techniques that can be used to help troubled

couples and families, but such techniques can be superficially used or misused and abused, especially by inadequately trained or inexperienced family therapists who do not pay sufficient attention to the deeper unconscious struggles of each individual family member. Furthermore, individual psychopathology is often ignored by MFT practitioners, who focus more on family pathology or dysfunction. Some individual family members may have severe forms of psychopathology such as borderline personality disorder, bipolar disorder, major depressive disorder, or psychotic disorders and therefore may be especially vulnerable to family therapy interventions that are too confrontational or even confusing and paradoxical. Such interventions may be potentially dangerous and harmful to these clients. Hence, attempts have recently been made in MFT to pay more attention to individual psychopathology in couple and family therapy, for example, in treating difficult couples who have coexisting mental and relationship disorders (see Snyder & Whisman 2003). Third, although MFT takes seriously the importance of factors such as ethnicity, culture,

gender, values, beliefs, spirituality, and religion in dealing with the systems and subsystems of families, certain MFT approaches still tend to be more patriarchal, male-oriented, and “white” in their practice. Feminist therapists have particularly criticized most of the pioneers of family therapy as being insensitive to gender, ethnicity, and culture, because the majority of these pioneers were males (e.g., Murray Bowen and Salvador Minuchin), with the exception of Virginia Satir. The influence of such “fathers” of MFT, with their masculine bias, is still present in family therapy (see Prochaska & Norcross 2018, 316; see also Silverstein & Goodrich 2003). This weakness needs to be rectified by paying more sensitive attention to race, culture, and gender in the clinical practice of MFT today, in what has been called the challenge of “revisioning family therapy” in addressing diversity in clinical practice (McGoldrick & Hardy 2019). Fourth, MFT’s openness to experimentation and further development of creative and novel

therapeutic techniques has a corresponding weakness: the lack of more-substantial and coherent theories with adequate empirical support. Advances in theory development are significantly lagging behind developments in family therapy techniques that are not based in solid or adequate theoretical conceptualizations. Fifth, although more-recent social constructionist MFT approaches emphasize the central

importance of the therapeutic relationship in effective family therapy, including a deep respect for the family as expert, the tendency of MFT practitioners to function as experts and to impose their systemic views and techniques on all families is still present. This weakness

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is potentially dangerous and harmful to some families that may not find such systemic (e.g., structural and strategic) views and techniques helpful at all. Sixth, the flip side of the fifth weakness just mentioned is that some families do need a

more direct, structured, and directive form of MFT to help them with their problems in practical and concrete ways. They may be limited in their awareness of how to help themselves and may not be able to devise creative solutions to deal with their difficulties. Social constructionist approaches to MFT, such as solution-focused family therapy and narrative family therapy, may thus be too optimistic and positive in assuming that such families are their own experts and can develop their own solutions to their problems. The expertise of the family therapist is still needed for such families, which can benefit most from a more directive and structured MFT approach that affirms the role of the family therapist as an expert, yet in a collaborative and warm fashion (e.g., cognitive-behavioral family therapy). Seventh, some MFT approaches, such as structural and strategic family therapy, tend to

have clear-cut models of healthy families versus dysfunctional families and also specific family therapy techniques for effecting change in the family system and subsystems in ways that are consistent with their models. There is a potential danger of imposing such models and techniques on all families, without paying adequate attention to the diversity of families in terms of race, culture, and gender considerations. One size does not fit all in helping families. In their intensive study of psychological health in family systems, Jerry Lewis and his colleagues (1976) actually found that there was no single way or specific structure characterizing how these healthy families functioned. MFT must be more inclusive in its theorizing and practice for pluralistic societies, including the United States, where now there are significant numbers of single-parent families, families with no children, cohabiting couples, gay-couple families, blended families, extended families, and immigrant families (see Prochaska & Norcross 2018, 317). Eighth, another weakness of MFT is that the systemic perspective can be taken too far and

therefore be misleading. For example, the systemic view present in most MFT approaches treats the family as a system or unit. It is often assumed that if the identified patient or scapegoat in a dysfunctional family system gets better and no longer has symptoms, another family member will now become the new scapegoat and develop symptoms. This scenario is MFT’s version of “symptom substitution” in individual therapy, where one symptom, if eliminated, may open the door to a new symptom (usually a psychodynamic or psychoanalytic assumption that has not received empirical support), except in MFT it is now “patient substitution”: if the scapegoat or identified patient in a family system gets better and is no longer symptomatic, then there will be “patient substitution,” with another family member now being the new scapegoat and therefore being symptomatic. Although this sometimes happens in a family when one family member’s improvement leads to another family member’s worsening, it does not always happen. In fact, the whole family may get better when the identified patient or scapegoat improves (e.g., recovers from substance abuse). In other words, not every problem in a family is always a systems problem. Systems theory can be misapplied, and it can also at times be wrong (see Prochaska & Norcross 2018, 317).

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Finally, while MFT has a strong empirical base generally supporting its overall effectiveness, some approaches to MFT still lack sufficient controlled outcome evaluations. More and better empirical research evaluating the therapeutic effectiveness of some of these MFT approaches for specific disorders is therefore needed to address this weakness.

A Biblical Perspective on MFT The strengths and weaknesses of MFT in general have already been covered. A biblical perspective and critique of MFT will now be provided (see, e.g., S. L. Jones & Butman 2011, 374–392; W. H. Watson 1997; Yarhouse & Sells 2017, 288–310, 531–539). First, MFT’s focus on the couple or family as the unit for therapy is a good corrective to

the emphasis on the individual in most major therapy approaches and the accompanying danger of individualism and self-obsession. MFT’s unique systems perspective is somewhat consistent with the Bible’s emphasis on community and the body life of the church (see, e.g., 1 Cor. 12), including a healthy family life (see, e.g., Eph. 5:21–6:4; Col. 3:18–21). However, the Bible contains many more passages on the body life of the church as a community of believers in Christ, and on how to love and encourage one another, than specifically on marriage or family life (see, e.g., Collins 2007, 588–590). Nevertheless, such biblical passages also generally apply to marriage and family life (see, e.g., Getz 1976). Second, the systemic focus of MFT on the family can nevertheless be overemphasized to

the point where the personhood of the individual or family member can be lost. Paradoxically, the Bible also emphasizes the worth and personhood of the individual human being, who is deeply loved by God and whom Jesus came to save through his death and resurrection (see, e.g., Luke 15:3–7, the parable of the one lost sheep; Luke 15:11–32, the parable of the lost son; John 3:16). A biblical perspective will therefore still retain a balanced focus on the individual as a special person created in the image of God (Gen. 1:26–27) as well as on community and body life in the church (see, e.g., Bolsinger 2004; Wilhoit 2008), including marriage and family life. Third, MFT’s focus on the couple or family may also not extend far enough, to larger

systems or interpersonal contexts such as the church as the body of Christ (see, e.g., 1 Cor. 12), or to the kingdom of God wherever and whenever and in whomever God rules and reigns. In other words, a biblical perspective will emphasize the larger body life of the church as community perspective and not narrowly overemphasize the couple or the nuclear family or even the individual in a self-centered way (see Rios 2020). Attention should also be adequately given to additional contextual factors such as sociopolitical, cultural, economic, religious, spiritual, and other environmental factors that may impact family life. Fourth, MFT approaches tend to have their own theoretical views of what constitutes

healthy family functioning and what does not, but such models may be limited, deficient, and even erroneous at times, depending on the families being seen in family therapy. The Bible has various examples of troubled as well as functional families and shows how God still worked in and through them, in the diversity of families that he has created (see Yarhouse & Sells 2017, 3–29). The few biblical guidelines available on marriage and family life must be considered and applied, but overall, the Bible gives ample room for families to grow and

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function in various and diverse ways, culturally and spiritually. MFT practitioners must be careful not to impose a certain model of how healthy families should look and what they should be like, especially if the model is culturally biased with a white, male perspective. Fifth, although MFT approaches have developed numerous effective therapeutic

techniques to practically help troubled couples and families, a Christian family therapist will be discerning and not use any and all techniques simply because they work according to empirical research. Some family therapy techniques such as paradoxical interventions and other strategic family therapy approaches may involve an element of manipulating, tricking, and even lying, in the therapist’s attempts to bring about therapeutic change in the family quickly and effectively. Biblical values, ethics, and morality must be upheld and respected, and some of these techniques may be questionable and should be questioned by the Christian family therapist, even if they have been empirically found to be effective and efficient. The key question from a biblical perspective is whether they are also ethical. Sixth, a biblical perspective will emphasize loving God and loving others as oneself or

one’s family (Mark 12:29–31) and the primacy of agape love (1 Cor. 13) as the fruit of the Holy Spirit (Gal. 5:22–23), which is genuinely self-transcendent and sacrificial, divinely inspired, and other-centered, although it does include an appropriate kind of self-care or love for oneself and one’s family (see, e.g., Browning 2006, 143–145; see also Roberts 1993, 12). A Christian perspective on MFT will therefore go beyond models or goals that focus on balance, healthy functioning, happiness or fulfillment, and symptom alleviation. It will emphasize sacrificial love and appropriate servanthood (see Tan 2006b), based on mutual submission in Christ; and stress sacred marriage (G. Thomas 2000a) and sacred parenting (G. Thomas 2004), which strive more for holiness and growing in Christlikeness than simply for happiness. Helpful biblical or Christian models are available for marriage based on covenant, grace, empowerment, and intimacy (e.g., Balswick & Balswick 2006) and for the family (e.g., Balswick & Balswick 2014; see also R. S. Anderson & Guernsey 1985; Ouellet 2006). Seventh, a biblical perspective on MFT will include not only a Christian understanding of

marriage and the family but also an integrative approach to Christian family therapy. Yarhouse and Sells (2017, 3–29, 288–310, 531–539) have provided a helpful description of such an integrative Christian family therapy, biblically based in terms of three major aspects of marital and family life: family functioning (e.g., individual and systematic, family rules, and family pattern or sequences of interaction); family relationships (e.g., intrapersonal, interpersonal, and generational relationships); and family identity (e.g., culture, gender, religion, socioeconomic status; definition, locating self in the world, and worldview; and meaning, significance). All of these are based on the themes of function, structure, and relationship as aspects of the image of God, or imago Dei, in which human beings are created (see McMinn & Campbell 2007). The Christian family therapist can be eclectic in using various MFT approaches and techniques but is clearly committed to a biblical perspective on marriage and the family. Based on biblical texts (such as Ruth 1:16–18; Eph. 5:21–33; and 2 Tim. 1:5), Yarhouse and Sells (2017) emphasize the following crucial characteristics of Christian family relationships: dependence on God, mutuality, self-denial, perseverance or resilience, and integrity (2017, 20–24). There are also specific Christian approaches to couple counseling and therapy such as hope-focused couple therapy (Ripley & Worthington 2014), a

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relational restoration model for counseling couples in conflict (Sells & Yarhouse 2011), and a biblical and practical guide for marriage counseling (Holmes 2019). A Christian approach to EFT has been described by Lydia Kim-van Daalen and Eric Johnson (2013), and earlier by Archibald Hart and Sharon Morris (2003) on safe-haven marriage. Sue Johnson herself has coauthored a “hold me tight” guide for Christian couples based on EFT (S. M. Johnson & Sanderfer 2016). Jenna Riemersma (2020) recently authored a Christian approach to IFS therapy. Eighth, more-recent social constructionist MFT approaches such as solution-focused and

narrative family therapy have a collaborative therapeutic relationship with the family, affirming each family member’s capacity to choose and to engage in growth and therapeutic change by developing their own creative solutions and constructive narratives. Although this emphasis on the family member’s free will and creative capacities is somewhat consistent with a biblical perspective, which also affirms one’s freedom to choose (Josh. 24:15) as well as the image of God in each human person created by God (Gen. 1:26–27), it does not adequately acknowledge and deal with the fallen, sinful nature of a human being, which is capable of evil and even cruelty (Jer. 17:9; Rom. 3:23). Systemic approaches to MFT also do not focus sufficient attention on the inner part, the “heart,” of each family member (see, e.g., Pss. 51:6; 139:23–24; Jer. 17:9; Matt. 15:18–19), where internal conflicts and unconscious motives and evil motivations may be present and therefore must be addressed. Instead of human self-sufficiency, Scripture emphasizes the need for salvation through faith in Jesus Christ as Lord and Savior (John 3:16; Rom. 6:23) and the empowering presence and filling of the Holy Spirit (Zech. 4:6; Eph. 5:18) to enable believers to be truly transformed as persons, including couples and families. Creative solutions and meaningful narratives must also be biblically based and grounded in the objective, eternal truth of the Bible, which contains God’s metanarrative, the big story (cf. 2 Tim. 3:16). Ninth, a biblical perspective will emphasize the crucial importance of forgiveness and

realistic attempts at reconciliation where appropriate (see, e.g., Matt. 5:23–24; 18:15–17; Rom. 12:18; Eph. 4:32). A Christian approach to MFT will therefore go beyond justice or fairness and focus on practicing agape love, including forgiveness (see, e.g., Hargrave 1994; Hargrave & Pfitzer 2011; Worthington 2003, 2005a, 2005b). Finally, MFT tends to have pragmatic and utilitarian emphases in helping couples and

families, focusing mainly on doing what works, and “fixing things,” which can result in family members being treated as objects rather than valued and respected as persons created in the image of God. A biblical approach to MFT will focus more on scriptural values and standards and on spiritual, even mystical, aspects of the Christian life, which are not always consistent with pragmatic and utilitarian emphases (cf. Tan 1987a).

Research: Empirical Status of MFT Outcome research on the empirical status of MFT, referring usually to the format of seeing couples or families together for therapy as well as to more specific MFT approaches to therapy, are now briefly summarized (see Prochaska & Norcross 2018, 308–314; also Lebow & Kelly 2020; N. Kaslow, Mirsalimi, & Celano 2020; Roddy et al. 2020).

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Dozens of meta-analyses have now been published on the overall effectiveness of MFT. The following conclusions can be made, based on recent meta-analyses (see, e.g., Carr 2009a, 2009b, 2014; Pinquart, Oslejsek, & Teubert 2016; Retzlaff et al. 2013; Shadish & Baldwin 2003; Stratton et al. 2015; von Sydow et al. 2013):

1. The average effect size of MFT was found to be .65 compared to no-treatment controls, showing MFT to be generally effective, with a 65 percent treatment success rate compared to only 34 percent in no-treatment control groups.

2. Treatment effects of MFT decrease somewhat over time, with an effect size of .52 at follow-up.

3. The average effects for marital or couple therapy (d = .80) are somewhat higher than the effects of family therapy, with a treatment success rate of about 75 percent for marital or couple therapy compared to 30 percent for no-treatment control groups.

4. Most MFT approaches, when directly compared to one another, showed small or no significant differences among them in terms of their relative effectiveness. In treatment effectiveness, however, Satir’s approach and person-centered treatments were found to be relatively inferior, and evidence-based family therapies and behavioral marital therapy to be relatively superior.

5. MFT approaches have been found to be as effective as, and sometimes more effective than, other types of treatment, such as individual psychotherapy and group therapy. The empirical evidence indicates that individual and family therapy are equivalent in effectiveness (Shadish et al. 1995; Weisz & Kazdin 2017).

6. Family therapy and systemic interventions have been found to be generally effective for child-focused as well as adult-focused problems.

7. Systemic therapies are effective for both internalizing problems such as eating, somatic, and mood disorders as well as externalizing problems such as conduct disorders, substance abuse, and ADHD in children.

8. Systemic therapies are also effective for depression, OCD, eating disorders, somatization disorders, and schizophrenia in adults, with lower dropout rates. There were too few RCTs for other disorders (see Prochaska & Norcross 2018, 310).

The field of MFT continues to develop diverse methodologies in actively conducting research on family therapy (see Sprenkle & Piercy 2005). Alan Gurman (2003) and Gurman and Peter Fraenkel (2002), in their earlier reviews of the

outcome research, more specifically focused on marital or couple therapy; they found the average effect size to be .80 or greater, much like that reported by William Shadish and Scott Baldwin (2003). Judith Todd and Arthur Bohart (2006, 358) noted that the two marital or couple therapy approaches with the most outcome research support for their treatment effectiveness are behavioral marital therapy (see also Shadish & Baldwin 2005) and emotion- focused therapy (or emotionally focused therapy), with some empirical support for the effectiveness of structural or strategic approaches. For behavioral marital or couple therapy, the results of a recent five-year follow-up study showed that integrative behavioral couple

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therapy had significantly but not dramatically better outcomes than traditional behavioral couple therapy for the first two years after treatment termination, but subsequent findings yielded more similarity and nonsignificant differences in outcome over longer periods of follow-up (e.g., five years) between integrative behavioral couple therapy and traditional behavioral couple therapy (A. Christensen, Atkins, Baucom, & Yi 2010; see also A. Christensen, Dimidjian, & Martell 2015, 86). More recently, a meta-analysis of couple therapy studies found couple therapy to be

effective and comparable to other therapies (Lebow et al. 2012). CBT couple therapies are also effective for individual problems such as depressive, obsessive-compulsive, eating, and bipolar disorders (Fischer, Baucom, & Cohen 2016); couple therapies are among the most effective psychological treatments for patients with health issues (e.g., heart disease, smoking cessation) (Ruddy & McDaniel 2015; see also Lebow & Kelly 2020, 358–359). An updated meta-analysis (across 58 studies and 40 unique samples and 2,092 couples) of couple therapy concluded that couple therapy positively impacts different domains of relationship functioning (e.g., communication, satisfaction), maintaining gains at short-term and long- term follow-up. Wait-list control couples usually do not improve (Roddy et al. 2020). Regarding the more specific area of family therapy, positive and equivalent treatment

effects have been found for behavioral, systemic, psychodynamic, and eclectic approaches to family therapy (Shadish et al. 1995). However, for specific disorders, Thomas Sexton, James Alexander, and Alyson Mease (2004) reported that functional family therapy (FFT) (Sexton & Alexander 1999), and multisystemic therapy (MST) (Henggeler et al. 1998, 2009), both of which are behaviorally oriented family therapies, are more effective than other family therapy approaches for treating conduct disorder and substance abuse, especially in adolescent family members (see Todd & Bohart 2006, 359; see also Sexton & Lebow 2016). MST has also been shown to be an effective treatment for juvenile sexual offenders (see Borduin, Schaeffer, & Heiblum 2009). More recent reviews of the controlled outcome studies conducted on the effectiveness of MST have also found it to be effective with chronic juvenile offenders (Henggeler 2011; Henggeler & Schaeffer 2016; van der Stouwe et al. 2014). A meta-analysis comparing the relative effectiveness of four major evidence-based family therapies of MST, FFT, multidimensional family therapy (MDFT) (Liddle 2016), and brief strategic family therapy (BSFT) (Szapocznik & Hervis 2020), showed them to be effective for adolescent delinquency and substance abuse. There was insufficient evidence, however, to determine which of them may be more effective compared to the others (Baldwin et al. 2012; see Prochaska & Norcross 2018, 313). The controlled outcome research on the effectiveness of MFT approaches has also been

reviewed for six specific disorders: alcohol dependence, drug abuse, conduct disorder, depression, childhood obesity, and schizophrenia. Overall, the empirical evidence available tends to support the effectiveness of some MFT approaches for treating these disorders (Prochaska & Norcross 2018, 310–312). More specifically, Satir’s conjoint family therapy or communication approach has been

evaluated in only a few direct outcome studies, which have found nonsignificant effect sizes (Shadish et al. 1993). Strategic family therapy has been found in meta-analyses to be generally modest but robust in its therapeutic effectiveness for treating substance abusers

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(Shadish et al. 1993; Stanton & Shadish 1997). However, its effectiveness is uncertain for treating schizophrenia, anxiety disorders, and psychosomatic conditions (Sandberg et al. 1997). Based on a few controlled outcome studies, structural family therapy is probably effective in treating substance abuse, conduct disorders, and psychosomatic conditions (Sandberg et al. 1997; Stanton & Shadish 1997), but it has not been sufficiently evaluated for its effectiveness with schizophrenia, anxiety disorders, mood disorders, and other childhood disorders (Shadish & Baldwin 2003). Bowenian family therapy has apparently not been evaluated in randomized, controlled outcome studies (Sandberg et al. 1997; Shadish & Baldwin 2003) and therefore remains largely untested (see Prochaska & Norcross 2018, 312– 313). Lebow (2008, 329) observed that there is very little research support for several widely practiced MFT approaches, including Bowen, narrative, strategic, and solution focused. There is also research evidence to support the effectiveness of attachment-based family

therapy (ABFT), which focuses on five major treatment tasks: relational reframing, building alliances with both adolescent and parent, reestablishing a family attachment bond (reattachment), and enhancing competency (see N. Kaslow, Mirsalimi, & Celano 2020, 305, 321). ABFT is now an evidence-based intervention for repairing ruptures in attachment, improving adolescent functioning as well as interactional dynamics in the family (G. S. Diamond, Russon, & Levy 2016), and for reducing adolescent depression (G. S. Diamond, Diamond, & Levy 2015) and anxiety (Siqueland, Rynn, & Diamond 2005). Emotionally focused therapy (EFT), another attachment-based therapy, has also received much empirical support for its effectiveness with couples (see S. M. Johnson 2019, 127–128). It is considered an empirically supported treatment or evidence-based intervention. The empirical status of MFT is therefore generally solid, with controlled outcome research

supporting the overall therapeutic effectiveness of most MFT approaches. However, further controlled outcome research is still needed to evaluate the effectiveness of some MFT approaches that have only anecdotal data or uncontrolled outcome studies relating to their potential usefulness.

Future Directions MFT has contributed a unique systemic perspective on treating the couple or the family as a unit and doing so mainly in a relatively short-term problem-solving, solution-oriented way, using numerous therapeutic techniques to effectively help couples and families. MFT will therefore continue to receive greater attention in the years ahead as increasing numbers of couples and families seek concrete, practical help for their problems. It also fits managed care’s preference for funding empirically supported, short-term therapy approaches (see Goldenberg, Stanton, & Goldenberg 2019, 423). MFT can develop in several promising directions in the near future (see Prochaska &

Norcross 2018, 319–320). First, it will continue to extend the application of a systemic perspective and therapy to areas other than the nuclear family, including larger systems and contexts such as organizations, including religious institutions (see, e.g., Friedman 1985), schools, and communities. Paradoxically, MFT will also be applied more frequently to the treatment of the individual client who has coexisting mental and relationship disorders (see,

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e.g., Snyder & Whisman 2003), so that individual psychopathology will also be more adequately addressed in MFT. It will continue to be applied to medical areas such as family systems medicine, which involves the integration of family medicine and family therapy or medical family therapy (McDaniel, Doherty, & Hepworth 2014). More specifically, family therapy has been effectively used to treat clients with alcohol dependence and drug abuse problems, and couple therapy for those with dementia, sexual difficulties, and obesity (Pinsof, Wynne, & Hambright 1996; Snyder, Castellani, & Whisman 2006). Second, further work will likely be done to establish a more consensual and consistent

diagnostic system for the assessment of dysfunctional families. Commonly used traditional diagnostic systems for psychiatric or mental disorders, such as the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (American Psychiatric Association 2013) or the International Classification of Diseases, do not adequately focus on the relational context of individual psychopathology. A substantial effort was made by various organizations in publishing the Handbook of Relational Diagnosis and Dysfunctional Family Patterns (F. Kaslow 1996), which will be of significant help in further developing a more consensual and formal diagnostic system for dysfunctional families. Third, MFT approaches have gradually become less distinct and more integrative over the

years, and this movement toward greater integration and eclecticism will continue to grow in the coming decades. In fact, between one-third and one-half of family therapists who responded to large surveys indicated that their theoretical orientation is eclectic (see, e.g., Lebow 1997, 2014, 2016). Some examples are integrative systemic therapy (Pinsof et al. 2018) and integrative behavioral couple therapy (A. Christensen, Dimidjian, & Martell 2015), as well as MST, MDFT, FFT, and BSFT (see N. Kaslow, Mirsalimi, & Celano 2020, 312). Fourth, MFT approaches will become more sensitive to race, culture, and gender issues in

clinical practice as more family therapists respond to the challenge of revisioning family therapy and addressing diversity in clinical practice (McGoldrick & Hardy 2019; see also McGoldrick, Giordano, & Garcia-Preto 2005). Fifth, just as the broader field of counseling and psychotherapy has become more sensitive

to spiritual and religious issues and the appropriate use of spiritual and religious resources in therapy in recent years, the MFT field will also continue to be involved in developing and using spiritual and religious resources in family therapy (see F. Walsh 2009; see also Yarhouse & Sells 2017). Finally, training and certification as a marital and family therapist in the United States will

increasingly require the completion of a graduate degree in MFT from an accredited program and being licensed in the state in which the MFT practitioner is residing and engaging in independent clinical practice. However, many graduate programs in professional psychology (such as clinical and counseling psychology doctoral programs), social work, and counseling or counselor education include some training in MFT. The influence of systemic theories and therapy approaches will continue to be significant in the broader field of counseling and psychotherapy, although the more formal certification and recognition of MFT practitioners who are licensed in specific states in the United States will become stricter and more institutionalized.

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There are many MFT organizations worldwide, but two important ones are the American Association for Marriage and Family Therapy (AAMFT), founded in 1942 and publishing the Journal of Marital and Family Therapy and The Family Therapy Magazine, which its members receive as part of their membership benefits (www.aamft.org); and the International Association of Marriage and Family Counseling, a division of the American Counseling Association (ACA) and publishing The Family Journal and The Family Digest, which its members receive as part of their membership benefits (www.iamfconline.org/public/main.cfm) (see Corey 2021, 424–425). There is also the Society for Couple and Family Psychology (Division 43) of the American Psychological Association. MFT will therefore continue to grow as a diverse field in the years to come.

Recommended Readings Bitter, J. R. (2014). Theory and practice of family therapy and counseling. (2nd ed.). Belmont, CA: Brooks/Cole, Cengage Learning.

Gladding, S. T. (2019). Family therapy: History, theory and practice (7th ed.). New York: Pearson. Goldenberg, I., Stanton, M., & Goldenberg, H. (2017). Family therapy: An overview (9th ed.). Boston, MA: Cengage. Gurman, A. S., Lebow, J. L., & D. K. Snyder (Eds.) (2015). Clinical handbook of couple therapy (5th ed.). New York: Guilford.

McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.). (2005). Ethnicity and family therapy (3rd ed.). New York: Guilford.

McGoldrick, M., & Hardy, K. V. (Eds.). (2019). Re-visioning family therapy: Addressing diversity in clinical practice. New York: Routledge.

Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods (11th ed.). New York: Pearson. Sexton, T. L., & Lebow J. (Eds.). (2016). Handbook of family therapy: The science and practice of working with families and couples. New York: Routledge.

Walsh, F. (Ed.). (2009). Spiritual resources in family therapy (2nd ed.). New York: Guilford. Yarhouse, M. A., & Sells, J. N. (2017). Family therapies: A comprehensive Christian appraisal (2nd ed.). Downers Grove, IL: IVP Academic.

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