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http://dx.doi.org/10.1037/14187-027 APA Handbook of Multicultural Psychology: Vol. 2. Applications and Training, F. T. L. Leong (Editor-in-Chief) Copyright © 2014 by the American Psychological Association. All rights reserved.
C h a p t e r 2 7
Couple and Marital therapy: the CoMpleMent and expansion
provided by MultiCultural approaChes
Shalonda Kelly, Ranjit Bhagwat, Pacita Maynigo, and Elizabeth Moses
This chapter assesses and critiques how current approaches to couple therapy apply to diverse couples and provides a new framework as well as specific steps for culturally competent understanding and treatment of diverse couples. The chapter covers the theory, interventions, and cross-cultural applications of cognitive–behavioral, systems, and psychodynamic models of couple therapy, as they represent the three major theoretical orientations that are applied to couple therapy, and also covers emotionally focused therapy (EFT) and the Gottman method of couple therapy, which are the best-known data-supported approaches developed specifically for couples. It considers the empirical support for these five approaches as well as the notable limitations related to their shared Euro- centric orientation. To overcome these limitations, the chapter identifies specific examples of cultural compe- tence involving knowledge, dynamic sizing, skills, and awareness. A case example demonstrates the applica- tion of a new model of the four mechanisms by which cultural competence may operate, including world- views and values, experiences and contexts, power dif- ferences, and felt distance between both members of the couple with each other and the therapist. This framework is likely to yield a more focused and useful application of cultural competence in couple therapy that counters the limitations of traditional treatments.
THEORETICALLY DRIVEN APPROACHES TO COUPLE THERAPY
The sections that follow review approaches to couples therapy derived from dominant theories of
psychotherapeutic intervention (cognitive– behavioral, systems, and psychodynamic) and their cross-cultural application.
Cognitive–Behavioral Approaches to Couples Theory, background, and interventions. Cognitive– behavioral couple therapy is rooted in a conver- gence of Mowrer’s two-factor theory of classical and operant conditioning, cognitive theory, and social learning principles. All cognitive–behavioral theo- ries emphasize functional analysis, which refers to cognitive, behavioral, and affective contingencies that shape behavior across repeating positive and negative couple interactions (Baucom, Epstein, LaTaillade, & Kirby, 2008). A common behavioral pattern with distressed couples is negative reciproc- ity, in which one person perceives the other’s behav- ior as negative and thus reciprocates with a negative behavior, beginning a continuous cycle (Baucom et al., 2008). During these interactions, cognitive and emotional problems also occur. For example, one partner might attribute the other’s negative behavior to immutable personality characteristics, which is a cognitive distortion, and the other may be unable to adaptively identify, express, and cope with emotions experienced in the relationship (Baucom et al., 2008).
Traditional cognitive–behavioral interventions include skill building related to behavioral exchange, communication, problem solving, cognitive restruc- turing, and affect regulation (e.g., Baucom et al., 2008). Newer cognitive–behavioral approaches, such as
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integrative behavioral couple therapy (IBCT) and dialectical behavioral couple therapy (DBCT), also focus on acceptance and mindfulness toward addressing emotional dysregulation and relation- ship conflict. Sample IBCT interventions include empathic joining that helps partners to express their problems without accusation and unified detach- ment that helps the couple to “tackle” the problem together as a common adversary (Dimidjian, Mar- tell, & Christensen, 2008). DBCT therapists teach mindfulness to partners, such as with learning to observe, describe, and participate in each other’s experiences in a nonjudgmental, effective way and to validate each other by communicating under- standing and acceptance (Fruzzetti, 2006).
Cross-cultural applications. Cognitive–behavioral therapy (CBT) has strengths relevant to diverse cou- ples. Functional–analytic ideographic assessment data tailors treatment to every couple and can consider relevant diverse contexts, such as socioeconomic status (SES) and extended families (Kelly, 2006). Therapists collaborate with couples to ensure shared conceptualization, goals, and interventions by all, and they encourage couples to take a hypothesis- testing stance to their issues (Sayers & Heyman, 2003). Diverse couples can become empowered via the CBT focus on building skills to meet their goals effectively, which can involve using strengths and their natural supports (Kelly, 2006; Sayers & Heyman, 2003; Sevier & Yi, 2009). Finally, the newer behavioral approaches focus on acceptance of vulnerable emotions related to partners’ differences, including cultural differences, and on reacting to differences with openness, curiosity, and empathy (Fruzzetti, 2006; Sevier & Yi, 2009).
Systems Models and Their Approaches to Couples Theory, background, and interventions. Per systems theory, the family is a self-regulating sys- tem whose health and functioning is determined by more than the cumulative interactions among its members. Similar to CBT, systems theory considers circular causality, in which each partner’s behavior serves as both cause and effect for the other partner’s
behavior (Shoham, Rohrbaugh, & Cleary, 2008). Per systems theory, the family structure is composed of subsystems whose functional demands create transactional patterns that regulate behavior, within which couple and family members’ identities are embedded. For example, one function of the couple subsystem is to foster intimacy between partners, and the parenting subsystem regulates both partners’ child care behavior. Healthy family boundaries give each subsystem some autonomy, definition, and permeability to permit optimal family functioning (Simon, 2008). For example, couples that spend reg- ular alone time after having children preserve adap- tive boundaries between their spousal and parental subsystems (Nichols & Schwartz, 2008).
Systems approaches encourage differentiation and appropriate boundaries among the couple subsystem, the family, and the environment and alter the family structure for a healthy exchange of resources (Simon, 2008). Therapists join with cou- ples to establish rapport (e.g., Nichols & Schwartz, 2008) and then have the partners enact their prob- lems by interacting as they would at home, to illu- minate the subsystem’s structure and its maladaptive circular causal patterns (Simon, 2008). Systems interventions may change the meaning given to these maladaptive patterns with reframes. For exam- ple, positive connotations are reframes in which the problem is portrayed as a good thing for the couple relationship (Goldman & Greenberg, 1992). Alter- natively, a therapist might ask the couple to prescribe the symptom by deliberately performing the prob- lem process, to undercut negative impulsivity (Shoham et al., 2008).
Cross-cultural applications. Systems theory utilizes contextual resources and reduces obstacles within and between generations of the family, the community, and other larger systems, such as the child welfare system (Boyd-Franklin, 2003). Systems therapists create genograms or family trees with couples to identify extended family members, or “family” members who are not blood relatives, such as “church families” that may play key roles for isolated couples. Often, neither the partners nor therapists of other orientations find these resources
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relevant to mention in session, as the focal point is the couple (Boyd-Franklin, Kelly, & Durham, 2008). Genograms also can help determine how previous generations of each partner’s family dealt with diversity issues that plague the couple, such as cop- ing with racism or poverty. In brief strategic family therapy (BSFT), cultural factors are used explicitly as contextual resources, such as Latinos’ strong fam- ily orientation, or therapists may address couple and family interactional dysfunction caused by differ- ences in levels of acculturation or preferred gender roles. For instance, one partner often immigrates to the United States first and becomes established, and then the family follows. This process often is protracted and may result in couple or family cri- ses caused by acculturation gaps once partners are reunited (Hervis, Shea, & Kaminsky, 2009).
Psychodynamic Models and Their Approaches to Couples Theory, background, and interventions. Psychodynamic theory asserts that individuals are shaped by their childhood relationships with care- takers (Siegel, 2010). Interactions with primary caretakers foster internalized images that resurface later in life as “enduring pathogenic introjects” that are projected onto the partner and confirmed by the partner’s behavior, as the partners’ introjects uncon- sciously interact with each other (Gurman, 2010). For example, (a) the wife projects a denied part of herself onto her husband, by seeing her husband as a loving man who treats her well despite the hate- fulness she perceives in herself; (b) her husband identifies with the projection and returns it to his wife by actually being a loving husband who treats his wife well, perhaps as his mother adored him in childhood; and (c) the wife assimilates this introject of herself by in turn seeing herself as worthy of love, and no longer hateful, as her husband treats her as well as her brother treated her in childhood. Yet pro- jective identification may lead to couple dysfunction when it ceases to be mutually gratifying, such as when the husband no longer wishes to see himself as her brother (Scharff & Scharff, 2008).
The goals of psychodynamic couple therapy are to help both partners understand the beliefs under-
lying their emotional reactions to each other, own their individual projections, alter each other’s pro- jections, and develop strategies for containing unresolved themes from the past (Gurman, 2010; Siegel, 2010). The psychodynamic therapist is fun- damentally nondirective (Scharff & Scharff, 2008) and uses the therapeutic relationship to develop couples’ insight into formative attachment relation- ships, thereby improving the quality of current rela- tionships. In focusing on unmet childhood needs and connecting the present to the past, this approach uses the couple relationship as an opportunity to create corrective, curative experiences (Siegel, 2010).
Cross-cultural applications. Waldman and Rubalcava (2005) discussed how culture deter- mines the unconscious ways in which partners respond to each other, and psychoanalysis can bring the role of culture within the couple’s conflicts into their conscious awareness. As an example, the authors discussed a first-generation Chicano man and his third-generation Mexican American wife. Both were of Mexican descent, but the husband’s orientation was collectivist, whereas his wife held mostly individualistic mainstream U.S. views. These cultural differences worsened their marital dysfunction. The therapist helped the couple to discover that by imposing her own cultural values of separation and individuation on her husband, the wife was unconsciously asserting power mirroring that of her domineering mother and helping her husband to maintain the role of a little boy. In this way, the therapist shifted the problem from within the couple to their cultural differences.
COUPLE-SPECIFIC THERAPY MODELS
The sections that follow review two specifically couples-oriented treatment models: EFT and the Gottman method.
Emotionally Focused Therapy Theory, background, and interventions. EFT builds on the secure bonds specified in attachment theory, maladaptive patterns identified in systems theory, and acceptance and validation derived from
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humanistic and experiential traditions (Hazlett, 2010). Per EFT, relationship problems result from feedback loops between major emotions that each partner feels in the relationship and their interactions. For example, in recurring fights, the wife misses her husband, and instead of expressing this attachment emotion, lashes out and tells him that he is never home. He feels guilty but responds by belittling her and her contribution to the relationship. The result is anger, shame, and hurt, continuing a nega- tive cycle of interactions and associated emotions (Johnson, 2008).
The goal of EFT is to help each partner to name and expand the emotions guiding their interactions, toward developing new positive interactions and emotions, while adaptively regulating negative emo- tions (Hazlett, 2010; Johnson, 2008). Reflection, validation, use of imagery to heighten experiences, and empathic interpretation are all used to reach this goal and stop maladaptive interaction patterns such as pursue and withdraw or blame and defend (e.g., Hazlett, 2010). A secure bond is created by reframing interactions in terms of attachment fears and needs and by tracking and choreographing new, satisfying couple interactions (Johnson, 2008).
Cross-cultural applications. Parra-Cardona, Córdova, Holtrop, Escobar-Chew, and Horsford (2009) discussed cultural adaptations of EFT. During joining and assessment, therapists can attend to cultural identity issues such as the immigration experience, and cultural values, such as familismo. For example, therapists must notice if a Latino couple that recently immigrated to the United States strongly endorses a value for family cohesion and then should use that value to inform treatment. The spouses also may view their immigrant status differently and suffer the hardship of separation from their families. Couple dysfunction may result if either partner fails to serve as a “secure base” to the other when coping with stressors. The thera- pist could reframe this couple’s problems around emotions pertaining to cultural issues, confronting the wife’s sadness about losses experienced as an immigrant and the husband’s feeling of inadequacy about helping her. Adapted EFT interventions like
the foregoing would conceptualize couple dynamics to include cultural identity, ensure that partners rec- ognize and feel entitled to their cultural needs, and help them to accept cultural needs and differences together (Parra-Cardona et al., 2009).
The Gottman Method of Couple Therapy Theory, background, and interventions. Gottman couple therapy is based on his “sound relation- ship house” theory and cascade model of divorce (Gottman & Gottman, 2008). Seven factors main- tain a sound relationship house with a supply of positive energy, such as small, everyday moments that are full of affection and respect. Conversely, the second law of thermodynamics specifies that a closed system will deteriorate without a supply of energy (Gottman & Gottman, 2008). Couples can suffer from a cascade of the “four horsemen of the Apocalypse,” in which criticism, the first horseman, leads to defensiveness, then contempt, and stone- walling; these horsemen sap positive energy and predict divorce. Similar to EFT, Gottman posited that emotions create the affective underpinnings for interactions, but unlike EFT, he posited that any of seven “emotional command systems” foster nega- tive interactions for couples mismatched in their approach to emotions. As an example, one part- ner may have an emotion coaching style, wherein she makes a bid to emotionally connect with her partner. The other partner may have an emotion dismissing style, and thus may be unaware of and turn away from her partner’s bid, starting a negative process (Gottman & Gottman, 2008).
Gottman method interventions accomplish mul- tiple goals (Gottman & Gottman, 2008). Decreased negative affect during conflict is accomplished through feedback or video playback of interactions involving the horsemen, and teaching couples to counter them, such as learning to soothe themselves rather than to stonewall. Increased positive affect occurs through helping the couple to become aware of, express, and savor positivity. The therapist also bridges metaemotion mismatches by building shared awareness of each partner’s attitudes toward emo- tion. Finally, the therapist helps the couple to build shared meaning by encouraging them to create
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rituals of emotional connection and intentionally create shared goals and values.
Cross-cultural applications. Gottman method couple therapy assumes cultural variations in every partner’s struggles, goals, and rituals as well as in how they express and make meaning of emotions. For example, many English do not condone public touching, and many Mexicans do it often (Gottman & Gottman, 2008). Indeed, data show that with Latino premarital couples, one partner’s criticism does not lead the other partner to feel emo- tionally overwhelmed, as it does with their White counterparts (Parra-Cardona & Busby, 2006). The authors speculated that the value of personalismo, or the preference for personalized interactions that can be emotionally laden, may prevent strong emo- tional expression from being experienced negatively by Latino couples (Parra-Cardona & Busby, 2006). Across all couples, the Gottman method’s focus on addressing emotional mismatches and building shared meanings between partners is thought to inherently address cultural differences (Gottman & Gottman, 2008).
EMPIRICAL SUPPORT ACROSS APPROACHES
CBT and EFT are well-established treatments for samples of predominately White couples (e.g., Byrne, Carr, & Clark, 2004; Shadish & Baldwin, 2005), and CBT is the only treatment examined with diverse couples. In two separate randomized con- trolled trials (RCTs) of gay couples and lesbian cou- ples, respectively, CBT was efficacious in improving the alcohol and relationship outcomes of partners in the behavioral couple therapy condition as com- pared with the 12-step, alcoholics anonymous-style individual treatment condition (Fals-Stewart, O’Farrell, & Lam, 2009). Regarding uncontrolled studies, 254 prison inmates in serious relationships that received the Prevention and Relationship Enhancement Program (PREP) reported significant improvements in their relationship quality that were robust across the large number of diverse racial groups in the sample. Within a large community
sample, self-reported participation in premarital counseling that typically is skills based and consis- tent with behavioral principles was associated with reduced odds of divorce for the White, African American, Latino, and Native Americans in the sample (Stanley, Amato, Johnson, & Markman, 2006).
Data are consistent with theorized mechanisms of change for cognitive–behavioral and emotionally focused couple therapies. Couples in BCT had larger gains in positive communication than couples in IBCT, who experienced more gains in acceptance, and both gains were associated with couple satisfac- tion (Doss, Thum, Sevier, Atkins, & Christensen, 2005). Also, within the “best” sessions of couples who improved after EFT versus those who did not, partners in successful relationships expressed more vulnerable emotions and asked each other for com- fort and connection more often than their unsuc- cessful counterparts did (Johnson & Greenberg, 1988). Also, couples receiving EFT displayed more shifts from hostile to affiliative behaviors than their wait-listed counterparts (Greenberg, Ford, Alden, & Johnson, 1993).
Data on couple interactions that predict couple relationship quality and stability support the pro- posed mechanisms underlying Gottman method and systems approaches (e.g., Gottman & Gottman, 2008). Gottman method interventions reverse the typical drop in relationship satisfaction across the transition to parenthood and reduce hostility (Shap- iro & Gottman, 2004). Yet no articles on RCTs of Gottman method interventions have been published. Bowen’s (1985) systems approach posited insight and differentiation as primary mechanisms to break triangles and the intergenerational transmission of problems. Bowenian theory has not been empirically tested with couples, but intergenerational transmis- sion has been documented, such that negativity in families of origin was found to increase the likeli- hood of aversive marital outcomes (Story, Karney, Lawrence, & Bradbury, 2004). Also, Goldman and Greenberg’s (1992) unreplicated study found that integrated systemic therapy (IST) and EFT alleviated marital distress better than the control condition.
Given the unique nature of insight and the ther- apeutic relationship (Scharff & Scharff, 2008),
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psychodynamic couple therapies and their pro- posed mechanisms have not been empirically vali- dated. Yet in one unreplicated study, insight-oriented marital therapy (IOMT) was as effective as behavioral marital therapy (Snyder & Wills, 1989). Also, an early meta-analysis found few differences among theoretical approaches to marriage and family therapy that disappeared after other covariates were controlled (Shadish et al., 1993). This suggests that studies that operational- ize insight well might yield support for psychody- namic couple therapy.
LIMITATIONS OF THE FIVE TRADITIONAL APPROACHES TO COUPLE THERAPY
Mainstream approaches to couple therapy often erroneously are assumed to be universally applica- ble. These approaches typically are developed by, for, and on White American, heterosexual, upper- or middle-class, suburban, able-bodied Christian participants, the dominant group in the United States. All other groups are underrepresented in clinical trials (e.g., Chambless & Ollendick, 2001), and thus traditional treatments have not been shown to work with other groups, despite Ameri- can Psychological Association (APA) ethical man- dates that all people have equal access to equal quality treatment of benefit to them (Sue, Zane, Hall, & Berger, 2009). A Eurocentric orientation fuels the assumption of universality (e.g., Kelly, 2006); within dominant American culture, rational thinking, individualism, and independence are con- sidered normative (e.g., Smith, 2010). Thus, many therapists erroneously apply a “color-blind” or “value-free” approach; they falsely conclude that everyone is the same and should be measured simi- larly against these supposed norms. Data are con- sistent with the assertion that a Eurocentric framework inherently fails to consider and transmit knowledge and skills that address the relevant range of couple diversity (Schomburg & Prieto, 2011); many examples exist showing how this framework can lead to stereotyping other views and ways of being and to considering them as deviant (e.g., Kelly, 2006). Even when espousing tailored
treatment, therapists of any orientation risk overly prizing a Eurocentric view, such that White privi- lege (e.g., McIntosh, 1990), heterosexism, and the like also are often ignored. The result is that many therapists practice outside of their boundaries of competence, contrary to APA ethical guidelines that also mandate prioritizing cross-cultural skills at the same level as other clinical skills and addressing biases to prevent unjust practices (Sue et al., 2009).
Examples across theoretical orientations high- light how therapists may not automatically address diversity when using their theoretical orientations. Therapists are not routinely taught to orient couples to treatment, provide sufficient rationales to bridge their differing worldviews and expectations, and use assessment instruments normed on the groups to which their couples belong. Psychodynamic thera- pists are nondirective and follow couples’ lead in treatment (e.g., Scharff & Scharff, 2008), thus over- looking how some cultures expect therapists and doctors to be authority figures. CBT has an acknowledged cultural assumption that direct focus on problems and open discussion of emotions are superior ways to improve relationships, although some cultures may instead favor communication that depends on context and nonverbal information (Sevier & Yi, 2009). Although emotion-focused and Gottman method couple therapy acknowledge well- documented differences in levels of normal emotional expressiveness across cultures (Gottman & Gott- man, 2008), these and all ideographic treatments erroneously assume that the therapist can identify, understand, and address diversity factors without specifically training them to do so. Systems thera- pists seek to create firm boundaries between the couple and other relationships (Simon, 2008), when for some groups it may be normative for boundaries between the couple and children, extended family, religious leaders, and communities to be more per- meable than with the mainstream (Boyd-Franklin et al., 2008).
Per Sue (1999), mainstream approaches suffer from the selective use of scientific principles, which compounds the foregoing limitations. Researchers are taught to be skeptical of generalizing findings
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from one population to another. They are taught internal validity, the extent to which the interven- tion versus other influences account for treatment changes, and external validity, the extent to which findings generalize across populations, situations, and settings (Tabachnick & Fidell, 2007). Scientific methods and theoretical coherence are used to con- vince critical thinkers of the validity of results and related assertions (Sue, 1999). Yet treatments devel- oped predominately on couples from White and other dominant groups within RCTs typically are assumed to apply to underrepresented groups, whereas the scant findings about underrepresented couples are not assumed to apply to White couples. These assumptions violate principles of skepticism and convincingness in prioritizing RCT findings that evince high internal validity and poor external valid- ity, over the reverse (Sue, 1999).
ADAPTING TREATMENT: A MULTICULTURAL APPROACH
The sections that follow present our integrative model of multicultural couple therapy, reviewing theoretical foundations and the core mechanisms by which therapists can enhance cultural competence.
Multicultural Approaches to Couple Therapy Theory, background, and interventions. The multicultural or cultural competency approach to couple therapy stemmed from a recognition of the foregoing limitations. Theories were developed to define particular areas of diversity, such as Hays’s (1996) model that encourages clinicians to system- atically consider diversity influences in treatment, related to age and generational influences, disability, religion, ethnicity, social status, sexual orientation, indigenous heritage, national origin, and gender under the acronym ADDRESSING. For each of these diversity influences, theories and data describe when and how they are manifest as well as how they affect mental health factors, such as the development of disorder, help seeking, and response to treatment. For example, racial identity theories and measures exist (Cross, 1978; Parham & Helms, 1981), and
partners’ racial identities are associated with prefer- ences regarding the race of the therapist (Parham & Helms, 1981), symptoms of distress (Kelly, 2004), and couple relationship quality (Kelly & Floyd, 2006).
Across diversity theories, four aspects of cultural competence have widely agreed-on importance in the field (e.g., Smith, 2010; Sue, 2006). They are presented in each of the four columns of Table 27.1. The first column represents the knowledge one needs to gain about each diverse couple that is being treated. Three basic areas of knowledge can be gath- ered about the couple. There is knowledge gained from therapists’ collective observations about the partners’ race, ethnicity, and culture, such as repre- sented in McGoldrick, Giordano, and Garcia-Preto’s seminal book, Ethnicity and Family Therapy (2005). Second, clinically relevant knowledge can be gained from the couple about these and other iden- tity factors, such as the information gleaned from completing a genogram (McGoldrick, Gerson, & Petry, 2008). Third, data about relevant risk and protective factors for the couple exists. For exam- ple, data show that negative views about their own racial group are associated with poorer individual adjustment for members of African American cou- ples (Kelly, 2004) and with poorer trust and rela- tionship quality for African American men (Kelly & Floyd, 2006). These findings suggest that treatment tailored to African American couples should develop and examine components to reduce stigma and racial shame.
The second column of Table 27.1 represents the task of dynamic sizing. There is consensus in the field that individual differences within each group means that there is no one-size-fits-all factor, and thus therapists must learn skills for when to apply the traditional therapies and when to tailor treat- ment to address couple diversity (Sue, 2006). We depart slightly from Sue in incorporating hypothesis testing within the concept of dynamic sizing. Dynamic sizing has one goal of considering diversity knowledge for hypothesis testing that determines whether emic (subgroup specific) or individualisti- cally oriented etic (dominant group or universal) factors apply to the couple. Notably, both emic and
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TABLE 27.1
Model of the Mechanisms by Which Therapist Cultural Competencies Bridge Differences
Therapist cultural competencies Knowledge of diverse couples Dynamic sizing indicators Skill set Therapist self-awareness
Mechanism 1: Worldview and value differences Preferred identity, language,
religion If preferences have healthy
expression within their own community
Treatment consistent with views, ask about preferences and values, decrease cultural shame, confirm normalcy of views/values
Therapist’s own biases, such as assumed superiority of Eurocentrism
Views on treatment and illness Client discussion of cause of symptoms, noting how they are expressed
Treatment consistent with their goals and views of therapist role, find normal community models
Nonmainstream views of symptoms, causes, expression, and treatment expectations
Mechanism 2: Experiences and contexts History of the group, including
how treated, “isms” and stressors
Few shared experiences, low connection, missed sessions
Raise and label the extra diversity layers/“isms,” cultural brokering, use measures normed on their group
White privilege and own privileged identities
Socioeconomic status (SES), class, caste and systems in which they are embedded
Financial and travel challenges, seen or felt SES, class or caste-related unfairness
Assist with navigating systems, low-cost treatment
Structural contributors to advantage and disadvantage
Mechanism 3: Power differences between therapist and couple Issues of power, respect
and inclusion related to oppression, and structural barriers
Knowledge indicators serve as thematic overlays to presenting problems, including barriers acknowledged or overlooked by clients
Show respect for couple as experts on their own lives, cultural brokering of “isms” and stressors, elicit, legitimize, and address complaints and preferences, advocacy, and institutional change
Stigma, shame, unfair media portrayals, and exclusion
Group and couple strengths and positive intentions
Subtle and overt diversity- related strengths of partners and their communities
Raise and use strengths, notice alternate strengths-based interpretations of problems and solutions
White supremacy and superiority and awareness that all groups have strengths and weaknesses
Mechanism 4: Felt distance between therapist and couple Cultural communication Nonverbal indicators, both
within the content and process of sessions
Demonstrate that “I’m in it with you” and join, affirm, and validate
Therapist communication preferences that are consistent with or supported by the mainstream
Lack of experience with treatment, or negative experiences
Confusion or upset over common treatment practices
Orient to treatment, bridge goals, rationale and psychoeducation about treatment and goals, use reminder and follow-up calls, “trial runs” of treatment
Acknowledge common negative therapist reactions and field’s disservices to diverse groups on structural, policy, and interpersonal levels
Disengagement, suspicion, mandated, or coerced treatment
Referral reason and experience of treatment as indicators to test felt distance
Use cultural genograms to engage, check for response to treatment, bridge goals, and work through suspicions and stereotypes on all sides
Past and current mistreatment of diverse groups that fuel suspicion, differences are often erroneously seen as bad or wrong
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etic factors typically apply, an internal or cross-partner struggle may occur to determine whether emic or etic factors are preferred, or partners may switch from holding an emic or etic worldview, depending on the situation. As a general rule of thumb, dynamic sizing indicators reflecting the need to tai- lor treatment to multicultural factors include when the therapist does not feel connected with the cou- ple, holds negative views of either partner, or notices their negative reactions to treatment (Kelly & Boyd- Franklin, 2009), such as with negative facial expres- sions, excessive silence, or missed sessions.
The third column of Table 27.1 represents thera- pists’ culturally competent skills and interventions designed to bridge differences sensitively. In work- ing with diverse couples, one must be skilled in rais- ing diversity factors considerately, for example, by asking questions that convey curiosity, respect, humility, and value for the couple’s disclosures (e.g., Donohue et al., 2006). This requires practice in raising “isms,” such as sexism, racism, and oth- ers. To hone their diversity-related skills, therapists can obtain consultation or supervision, and gain outgroup experience to learn nuances regarding useful ways to gather and address sensitive diversity factors (e.g., Sue et al., 2009).
The fourth column of Table 27.1 represents therapists’ self-awareness, which is integrally related to the other three foregoing elements. The goal of increasing one’s self-awareness is to under- stand more about one’s own identity and biases as well as structural oppression. Awareness of oppression includes understanding issues like White privilege and supremacy, heterosexism, and structural barriers that lead to disparities (e.g., McIntosh, 1990) and learning how these larger systems become manifest in our biases and behav- ior. Therapists’ awareness of the importance of and nuances related to our own identities helps them to understand its importance in the lives of others and foster strengths-based perspective tak- ing, both of which can assist with dynamic sizing. In fact, these four elements of knowledge, dynamic sizing, skills building, and awareness are intertwined, but they are artificially separated for ease of learning.
Table 27.1 also presents a theoretical model that specifies the mechanisms by which cultural compe- tence involving knowledge, dynamic sizing, skills, and awareness may work. We theorize that cultural competence works by addressing (a) differences in worldview and values between the therapist and the members of the couple, (b) differences in their experiences and contexts, (c) differences in the power that they wield in and out of the therapy session, and (d) the felt distance experienced by the therapist or the couple because of one or more of the foregoing differences. These are the mecha- nisms that standard couple treatments often fail to address, leading to suboptimal treatment. More- over, consideration of these potential mechanisms may result in an increasingly focused decision tree by which therapists can avail themselves of rele- vant knowledge and skills, become more aware of how they pertain to their own and diverse couples’ lives, and use dynamic sizing to tailor treatments. Thus, each of the four potential functions will be described with a focus on how to specifically apply knowledge, dynamic sizing, skills, and awareness toward successfully tailoring treatment to fit the couple.
Worldview and Value Differences Therapist support for and greater congruence in worldviews and values between the therapist and the couple, as well as between the partners, is the first mechanism by which knowledge, dynamic siz- ing, skills, and awareness help therapists to better treat diverse couples. Knowledge of existing world- view or value differences and preferences include learning about the partners’ preferred identity, lan- guage, religion, and beliefs about mental illness and how to treat it (e.g., Smith, 2010). For this mecha- nism, dynamic sizing involves determining whether the partners’ worldview and value preferences are similar to or different than one’s own and whether these views and preferences are normal and have healthy expression within their communities, which would suggest that an emic lens would be applica- ble. One therapist skill involves treating the couple in ways that respect and are as consistent as possi- ble with their views, valued rituals, and coping
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methods (Sue et al., 2009), such as saying a prayer before therapy for a religious couple (Beach et al., 2011). A second useful skill involves confirming for the couple the therapist’s knowledge that their dif- ferent worldviews and values are normal and help- ing them to find normal models and supports composed of others who share their worldviews and values (Boyd-Franklin et al., 2008). Therapists’ awareness of their Eurocentric values and biases reminds them that their worldviews and values include merely one of many ways of viewing the world. For example, couples from some Asian coun- tries have arranged marriages, and U.S. values for autonomy and the prizing of the nuclear family may get in the way of respecting these couples’ use of marriage as a way to join families rather than individuals.
Key Experiences and Contexts The second mechanism by which knowledge, dynamic sizing, skills, and awareness may improve treatment outcomes with diverse couples is in considering key experiences and contexts shared by many diverse couples. When diverse couples’ experiences and contexts are addressed, thera- pists increase their credibility as well as couples’ resources that enable them to engage in and benefit from treatment. Therapists can increase their knowledge of shared group histories of immigration, racism, and heterosexism; isolation or ghettoization; SES, class, and caste issues disproportionately expe- rienced by diverse couples (McGoldrick et al., 2005); and additional unique stressors. Knowledge of key experiences and contexts can be gained via detailed cultural genograms (Hardy & Laszloffy, 1995). Dynamic sizing includes therapists’ notice of differences in the couple members’ or the thera- pist’s family and community experiences across generations. Therapist skills involve using mea- sures normed on demographic populations that are similar to the couple. As couples discuss their experiences and contexts, therapists also need the skills to identify, raise, and label relevant diversity layers and to be cultural brokers who help partners to negotiate differences in how they view and cope with such experiences (Kelly & Boyd-Franklin,
2009). Skills in addressing socioeconomic factors, such as with the provision of low-cost treatment, child care, and transportation, also are useful (Snell-Johns, Mendez, & Smith, 2004). Therapist self-awareness involves acknowledging the pres- ence and impact of privilege and structural advan- tage and disadvantage, particularly related to differences between the therapist and couple members.
Power Differences Between Therapist and Members of the Couple The third mechanism that makes multicultural approaches involving knowledge, dynamic sizing, skills, and awareness useful is their focus on addressing power dynamics that often are over- looked in treatment. This can occur when thera- pists delegitimize the couple’s experiences by failing to respect and include consideration for the impact of oppression and structural barriers on the couple’s lives and when they hold Euro- centric biases that result in a failure to identify diversity-related couple strengths and positive intentions as well as in a failure to value their coping methods and alternate treatment prefer- ences. One underused skill to address power is that of inviting partners to divulge their treatment preferences and complaints, including experi- ences of the therapist’s methods of interacting with and treating them, to tailor treatment to the couple’s goals and not the therapists’ goals. Cul- tural brokering also may redress power imbal- ances between partners (e.g., Kelly & Boyd-Franklin, 2009). An example is a White male partner who has racial and gender privileges over his Korean American female partner that contributes to prizing his values and goals over hers in the relationship. Other therapist skills involve identifying and using couple strengths, therefore explicitly valuing them as well as decreasing cultural shame, both of which can empower the couple. Therapists can best con- duct this work when they have gained awareness of Eurocentric biases, stigma, shame, and unfair media portrayals of or exclusion of diverse groups; widespread issues of White supremacy
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and superiority; and their own experiences of privilege related to their nonstigmatized identities.
Felt Distance Experienced by the Therapist or the Couple Data show that people tend to hire and respond more positively in general to those who they per- ceive to be similar to them (Sears & Rowe, 2003). We theorize that multicultural approaches proac- tively address the felt distance in the room by decreasing unfamiliarity and by working through suspicions and stereotypes held by the therapist and couple. Therapists can benefit from knowledge regarding culturally influenced methods of commu- nication and common reactions to treatment of those who have not experienced it or who have not had positive prior experiences, which can lead to disengagement and dropout (e.g., Boyd-Franklin, 2003). Dynamic sizing principles should take into account nonverbal and situational indicators more strongly than verbal indicators of interest in treat- ment and acceptance of therapist goals, rationales, and interventions. Skills at bridging distance include joining with both members of the couple, orienting them to the treatment, and explaining rationales that include psychoeducation and collaborative bridging of treatment goals of the therapist and part- ners. Awareness of culturally influenced communi- cation methods enables the therapist to be mindful of how his or her preferences differ from other pref- erences and how these methods may erroneously be considered “the right way” in training.
Cross-cultural applications and empirical support. Recent reviews have shown empirical support for the overall effectiveness of culturally adapted treatments with diverse populations (e.g., Griner & Smith, 2006). Studies of culturally adapted couple treatments, however, have been published only regarding the well-established CBT-oriented PREP (Markman, Floyd, Stanley, & Storaasli, 1988). PREP was shown to be efficacious for 217 religious couples attending 57 religious organizations clus- ter randomized into three interventions: (a) PREP delivered by clergy in the community, (b) PREP delivered by university professionals, and (c) treat-
ment as usual (TAU) regarding marriage prepara- tion (Laurenceau, Stanley, Olmos-Gallo, Baucom, & Markman, 2004). Specifically, superior outcomes were found 1 year later in observed communica- tion of husbands and wives who received PREP from clergy in the couples’ communities, although couples who received university-delivered PREP did evince fewer declines in husband positive commu- nication as compared with TAU. In another study, 393 African American couples were cluster random- ized to (a) a culturally sensitive version of PREP (CS-PREP) and a Christian version of PREP, further adapted with interventions designed to help part- ners to support one another with experiences of rac- ism; (b) prayer-focused PREP (PFP) that emphasizes learning how and why to pray for one’s partner; and (c) a control condition in which couples received a self-help version of CS-PREP (Beach et al., 2011). Both culturally sensitive treatments were more efficacious than the control condition. Specifically, both evinced large effect sizes for the husbands (Cohen’s d = 1.43 and 2.01 for PFP and CS-PREP, respectively), and PFP showed greater efficacy than CS-PREP for the wives (Cohen’s d = 1.58 [large] and .20 [small], for PFP and CS-PREP, respectively; Beach et al., 2011).
Case Example
Warren and Aureli are married, college educated, and in their early 20s. He is a second-generation Jamaican American who works in information technology, and she is second-generation half Pol- ish American and half Italian American who works as a doctor’s assistant, and is in school part time to retrain for nursing. They sought treatment after Warren became drunk and drove into their mailbox when trying to leave the house after an argument about after- work phone calls to a female coworker. Aureli then left to stay with her mother for a week until he agreed to her ulti- matum stop drinking and get treatment or get divorced. In the first session, the couple discussed increasing polariza- tion around his drinking; their type
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and level of involvement with their family, friends, and leisure activities; her spending habits; his recent decision to take a temporary consulting assign- ment out of the country; their different ideas about getting ahead; and their difficulty in compromising with each other.
The couple agreed on the issues but with vastly different views. Aureli reported high vigilance toward him because he has blacked out and also driven while drunk recently, thereby becoming emotionally unavailable to her. She also reported that she watches his daily activities to help him to become more of a go-getter in life, given that he hates his job, but does not want to go back to school like she did, and has party friends who are similarly nonproductive. Warren admitted to hanging out and drinking at times but stated that he does so in response to his belief that Aureli did not listen to him or compromise. He stated that the female coworker who Aureli was jeal- ous of had confided in him about issues with another colleague and that Aureli did not hear his side before accusing him of cheating. Conversely, Aureli reported that she caught him watch- ing porn, and given that they hardly had sex, said that he must be looking for another woman. Warren stated that her parents are unfair to him, as her father at times makes unauthorized walks through their bedroom during visits, and when he called her mom to confide and try to understand Aureli, she was not supportive and advised Aureli to prepare for divorce. Aureli admitted to confiding in her mother about the relationship, despite want- ing to limit her mother’s input into her life, and feeling like a child with her parents. She reported feeling pun-
ished by Warren’s decision to take a temporary consulting assignment out of the country that will take him away for months. They reported moderate financial stress, which Aureli attributed to Warren’s underpaid job, whereas Warren reported that her family made a down payment on a house that they cannot afford and that Aureli pushed him into it, making it a stretch to pay the mortgage. He added that Aureli tends to spend outside their means, he and her parents pick up after her, and it is often a battle to pay for real needs, such as to fix a gap under the door to lower monthly heating bills.
Their marital relationship was mod- erately distressed; both reported high disagreement and dissatisfaction, and Warren’s commitment to the relation- ship was lower than Aureli’s commit- ment. Warren met criteria for alcohol abuse, and he reported wanting to decrease his drinking. Aureli had sub- clinical depression and anxiety. She also reported feeling socially alienated and frustrated from their relationship issues and a nonchallenging job that over- worked her. A genogram evinced several intergenerational patterns. Warren’s par- ents moved in with his mother’s parents until they could save money for their own home, and his father complained of their interference with multiple aspects of their lives and drank to contain his bitterness. Warren originally liked Aureli’s strength, but he reported recent views of her as inconsiderate and selfish like his mother, and he had learned to distance himself so as not to “hear mom’s mouth.” Aureli reported that because of Poland’s history with land, her mother fears dependence on others, and this belief was confirmed for her mother after a bitter divorce from Aureli’s father that led to a multiyear cutoff during which
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both parents started new families. Aureli later regained closeness with her father and his family, too, but abandonment concerns began to plague her since the cutoff period, and the divorce and her mother’s dependency concerns led to her earning a bachelor’s degree in women’s studies. Per Aureli, her stepfather report- edly gives in to her mom and escapes her “overbearing nature” with alcohol, while her mother runs the household. They bore Aureli a younger brother, who is in law school.
The therapist’s formulation was consistent with her integrated cognitive–behavioral and systems orientation. From a CBT perspective, they had a strong demand–withdraw pattern in which Aure- li’s mother’s input about not needing a man posi- tively reinforced Aureli’s self-doubts and anxiety as well as her demands that Warren agree with her relationship standards, and also punished her attempts to collaborate with Warren. Aureli’s demands functioned to build her own confidence and connect with Warren, but they positively rein- forced his negative emotions and views of her. Thus, he often became flooded, shut down, and sought distance and stress relief with others, thereby positively reinforcing Aureli’s frustration and mistrust. From a systems perspective, this newlywed couple was in the life-cycle phase of dif- ferentiating from their parents and developing couple norms. Thus Aureli’s enmeshment with her parents was an obstacle to their task of developing firmer boundaries between the couple and their extended family. Also, the couple had formed a triangle with Aureli’s mom and with Warren’s friends.
The couple was taught communication skills, such as taking turns, validating rather than dismiss- ing each other’s views, taking timeouts effectively, and using assertiveness statements to get heard and understood. For example, Aureli learned that rather than obtaining the consulting job to punish, avoid, or leave her, Warren saw Aureli’s ultimatum and brief stay with her mother as a catalyst to make him
stronger and less vulnerable and to challenge him- self to strive, given that the job experience could catapult him into a better position to buy the things that Aureli desired. Aureli’s fears were largely calmed with those talks, and she learned to see the job more as achievement oriented, after which it was easier for her to express softer emotions of loss and hurt. This led to Warren comforting her and telling her that he saw himself as always married to her. This broke the ice for sex and the couple did role-plays to help her to have better timing and warmth in asking for sex so that he would not feel controlled.
The therapist’s multicultural adaptation facili- tated the foregoing interventions and began with gathering knowledge about the couple’s Jamaican and Italian–Polish ethnic identities and values to assess and treat them according to their world- views. The therapist considered the extent to which family behaviors fit with their ethnic back- grounds, and she asked the couple about how racial and ethnic factors affected their family and couple relationships. This dynamic sizing enabled the therapist to evaluate her “enmeshment” con- ceptualization. The cultural genogram and litera- ture revealed that Aureli’s Italian father’s “intrusions” and coddling were ethnic norms regarding the primacy of the family that they had labeled negatively (Giordano, McGoldrick, & Klages, 2005). Yet despite a tendency to dissect information that seemed consistent with her Polish ethnicity (Folwarski & Smolinski, 2005), Aureli’s mother actually was overly involved with her. Moreover, her mother’s push for Aureli to be inde- pendent of Warren was consistent with a fear of dependence on others common to many people of Polish ethnicity, as a result of Poland’s history of numerous occupations by other countries (Folwar- ski & Smolinski, 2005).
In addition to shared couple time and a request to show appreciation for each other’s positive behaviors, their first homework after the assess- ment was to talk to their friends in interracial relationships and get a sense of ingroup norms to help them to form their shared standards for deci- sion making. Aureli’s White girlfriend disclosed
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how her own African American husband and son had experienced a lot of racism at work and school, which led to them needing extra validation at home. Aureli was moved positively by the information that portrayed Warren as vulnerable and in need of loving treatment. The therapist also wondered aloud whether Aureli’s dismissals of Warren’s ideas could be considered in the context of her anxiety and desire to be a strong woman like her Polish mother wanted, wherein their marital bond made it safe for her to assert herself more strongly with Warren, which also surprised him. Clearly, neither had considered these vulnera- ble identity-related reframes that can apply to many groups.
In initial sessions, the therapist gained knowl- edge by eliciting and discussing unique experiences and contexts that may pertain to the couple, in particular related to race, gender, and his substance abuse diagnosis. The therapist was aware of the pri- macy of Eurocentric perspectives and a potential preference for a White therapist. Thus, she used the skill of raising diversity factors related to treatment by asking about Aureli’s comfort level with working with the therapist, particularly given the Black heri- tage shared by the therapist and Warren. Aureli angrily stated, “It doesn’t bother me, does it bother you?” The therapist reassured her that she enjoyed working with the couple but wanted to ensure that they were comfortable with her background and her style and that they felt free to talk about race and other aspects of diversity, if desired. Aureli visibly relaxed and calmly denied having problems with the therapist’s race. The act of raising racial diversity elicited the couple’s experiences with race, such as with how his Jamaican parents and her interethnic parents had no problems with their interracial relationship.
The couple was given feedback about Warren’s drinking and their relationship; data show that both serve as motivators for improvements (e.g., Cordova, Warren, & Gee, 2001; Epstein et al., 2007). The therapist stated that African American men typically do not have high rates of alcohol abuse, but that one study showed difficulties in marriage to be a risk fac- tor for increased drinking, such that their rates
became equal to that of their White counterparts (Mudar, Kearns, & Leonard, 2002). These data related to Warren’s unique context led him to raise the extra diversity layer of race by saying under his breath, “Probably because their wives dismiss a Black man’s ideas.” The therapist invited him to tell her about it. He noted how Aureli quickly dismisses his suggestions 90% of the time after asking for them, but accepts others’ ideas, contrary to how she took in his career tips when they first dated. Aureli immediately quipped that his rash and individual decision to consult did not take into account her feelings as a woman either. The therapist asked both to take a time out to keep therapy safe. She noted that both types of experiences are common and that many couples do not have to deal with the extra layers of race and gender in the way that they do. She then validated the probable racism and sexism that both likely have experienced, with examples that could fit with their own lives. She also planted a seed regarding cultural brokering, by raising the idea that they could consider compromise in their rela- tionship to prevent the “isms” from getting in between them.
Over the course of treatment, further communi- cation regarding the spouses’ contexts and experi- ences and new perceptions of each other led to additional disclosures. For example, Warren admit- ted to withholding sex as a bargaining chip because of the feeling that his ideas were dismissed. He also told Aureli that another part of the reason that he was going abroad to consult was the racism experi- enced in the United States. She reported that his disclosures helped her to put herself into his shoes. She also began to accept the idea of his taking the consulting position and stated that her acceptance resonated well with the therapist’s reframe of the couple’s newlywed goal of being able to bond and fit together in a way that would allow for individ- ual growth without blame, to keep their parents’ strengths without repeating their issues.
There were no knowledge indicators from the couple, the genogram, or the literature of power issues between the therapist and the couple. This dynamic sizing led to the therapist focusing less on the power between her and the couple, beyond
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trying to balance the power in the room in an idiographic, individualized manner. On the basis of awareness of the power of the therapist’s role, the therapist voiced respect and appreciation for Warren’s power of “silent strength” and of having patience and endurance learned from his dad, and Aureli’s “push forward strength,” which she learned from her mom. Moreover, it was noted that they valued two different and potentially complementary types of achievement, which were Warren’s strivings that led them to buy a home and Aureli’s striving for academic achievement. These strength-based reframes that legitimized their values were consistent with the “both/and” frame derived from the therapist’s systems orienta- tion and also served as a skill of balancing power in the couple relationship. Also, the huge issue of the consulting job was investigated. They found that Warren could push back the consulting start date for 2 months, which he did, and that he had time to change his mind if desired, which gave them more space to further balance their relation- ship in treatment.
The therapist decreased the distance between her and the couple by using skills of joining with them, orienting them to treatment roles, and invit- ing the couple to share their treatment preferences, including asking questions to gain knowledge about any outcomes that they wanted to avoid, on the basis of the awareness that displeasure and sus- picions might not always be verbalized without encouragement and safety. Warren reported that he did not want conflict or for the therapist to gang up on him by siding with Aureli about women’s issues. The therapist thanked him for his input and asked him to do a scaling from 1–10 to denote how much conflict was too much. She stated that she would keep the sessions safe enough not to reach 7 out of 10, as he considered that harmful. These skills affirmed and validated him and his concerns and helped him to work through his suspicions and concern that the two women would form a coalition against him, just as she had worked through Aureli’s concern that as an African Ameri- can, she would work against her with Warren. Such interventions show couples that the therapist
is “in it with you.” The therapist monitored their engagement and disagreements for dynamic sizing from that point forth regarding additional needs to address distance, and she saw none.
CONCLUSION AND RECOMMENDATIONS
Overall, in the case example, treatment was enhanced by addressing diversity factors not specif- ically or systematically addressed with traditional orientations in ways that at times were consistent with traditional treatment and at times added to it. Specifically, the therapist confronted the partners’ fears, communication problems, and different points of view by integrating ethnic and racial per- spectives. For example, the therapist included the importance of Aureli’s Polish roots within the dis- cussion of her fears of dependency and her need to be a strong woman, and she also addressed War- ren’s anger at his ideas being dismissed by integrat- ing racial and gender themes. She considered ingroup norms and each partner’s identity-related vulnerabilities that stemmed from both emic and etic factors, while also acknowledging any power differentials in the treatment. She also reframed the couple’s negative emotions and thoughts toward each other and their issues both through racial and emotionally sensitive lenses, which facilitated com- munication gains for the couple. The therapist used cultural competence skills that fit with her orienta- tion but also considered “layers of diversity” that deepened each spouse’s understanding of each other and their problems. Knowing the layers of diversity that contributed to their vulnerability gave the spouses more respect and empathy for themselves and each other, and addressing those layers helped them to work through their issues more fully.
This chapter has proposed a new framework and specific steps for culturally competent understand- ing and treatment of increasingly racially and ethni- cally diverse couples. Each major approach to couple therapy can be tailored to diverse couples, and a few studies have shown improvements for diverse couples using these approaches (e.g., Fals- Stewart et al., 2009). More trials of couple therapy
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are needed that examine how these treatments fare with diverse couples, as not enough evidence exists for existing approaches to reach the standard of being efficacious and specific (e.g., Chambless & Ollendick, 2001) for any samples of diverse cou- ples. Also, these approaches share a Eurocentric orientation that fuels assumptions of universality and results in an inherent failure to train therapists to systematically include cultural competence fac- tors that address the relevant range of diversity (e.g., Schomburg & Prieto, 2011). As evidence of the necessity for integrating diversity factors into couple therapy, the scant data on existing approaches that have been systematically adapted to include cultural competence factors show improvement beyond the original approaches them- selves (e.g., Beach et al., 2011).
More trials of couple therapy that compare estab- lished treatments with those adapted for diverse communities are needed (Bernal & Scharrón- del Río, 2001). Systematic research can discover which areas of cultural competence produce the most efficacious treatments and which mechanisms are appropriate for which subsets of diverse couples (e.g., Bernal, & Scharrón-del Río, 2001). Further- more, new methodological and conceptual para- digms may be necessary to provide a strong evidence base for which gold-standard RCTs may be inade- quate or impossible to conduct (e.g., Lau, Chang, & Okazaki, 2010). Until then, the application of the proposed framework is suggested to direct attention to areas of diversity and to apply cultural compe- tence in an ideographic fashion when working with diverse couples.
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