Thread Response 1

Chapter 10

Reality Therapy

William Glasser (1925–2013) is the founder of reality therapy (W. Glasser 1965), an approach to therapy that focuses on the present and emphasizes a client’s strengths and ability to make choices and control their behavior. Reality therapy is based on choice theory as developed by Glasser and his revisions and modifications of control theory. Glasser asserts that people are responsible for choosing their own thinking and actions, which then directly affect their emotional and physiological functioning. According to choice theory, all human beings have five basic needs: survival, love and belonging, power or achievement, freedom or independence, and fun, with the need to love and to belong being the primary need (W. Glasser 2001, 2005).

Reality therapy helps clients to become more responsible and realistic and therefore more successful in achieving their goals and meeting their needs. Glasser was disappointed with the weaknesses and limitations of psychoanalysis. He developed reality therapy in the 1960s as a more rational and direct approach to therapy that also has existential and humanistic roots in its emphasis on one’s freedom and capacity to choose and also one’s responsibility to authentically make choices in personal life. Reality therapy has a basically positive view of human nature and potential for change.

Several therapeutic techniques often used in reality therapy include structuring, confrontation, contracts, instruction, role-playing, support, skillful questioning (e.g., asking, “Does your present behavior enable you to get what you want now? Will it take you in the direction you want to go?”), and emphasizing choice (e.g., by changing nouns and adjectives into verbs) (see Parrott 2003).

Biographical Sketch of William Glasser

William Glasser was born on May 11, 1925, in Cleveland, Ohio, the youngest of Ben and Betty Glasser’s three children. His father, who owned a small business, had emigrated to the United States as a child with his Russian Jewish family to escape persecution. Glasser has described his mother as very controlling and his father as the opposite, the personification of choice theory (W. Glasser 1998a, 90). He noted that despite such a basic incompatibility between his parents, they were consistently loving in their relationship with him.

Glasser went to college, like his older brother and sister, and majored in chemical engineering. He was still a student when he married Naomi Judith Silver, his first wife, who during forty-six years of marriage was also his professional collaborator until her death in 1992. Glasser enrolled in a PhD program in clinical psychology, but his dissertation was rejected. He graduated with a master’s degree in clinical psychology in 1948, after which he attended medical school at Case Western Reserve University and obtained his MD degree in 1953 at the age of twenty-eight.

Glasser moved to southern California for his psychiatric residency at UCLA and at the West Los Angeles Veterans Administration Hospital, which he completed in 1957. He was board certified in psychiatry in 1961. His supervisor and mentor at UCLA was a psychiatrist named G. L. Harrington, who supported Glasser’s serious struggles with traditional psychiatry and psychoanalytic theory and the subsequent development of reality therapy in the early 1960s (W. Glasser 1961, 1965).

Glasser also worked at the Ventura School for Girls, a residential institution for delinquent adolescent girls, in 1956. He conducted individual and group therapy and was also involved in training staff. Glasser focused on fostering a kind and respectful relationship with the girls at the school while expecting them to be responsible for their own choices and behavior. He also verbally praised them for appropriate behaviors. His new approach to helping them proved to be very effective, which prompted him to begin consulting in the California school system. Glasser has significantly impacted teachers and school systems here and abroad with the application of his reality therapy principles and methods, his choice theory, to the positive development and learning of students (see W. Glasser 1969, 1986, 1998b, 2000a). He founded an education training center as a further extension of the William Glasser Institute established in California. Glasser also kept a full schedule of teaching, lecturing, and conducting a private practice, in addition to consulting with school systems as he continued to further develop reality therapy. He published his classic book, Reality Therapy, in 1965.

In 1977 Glasser was exposed to the work of William Powers through his book Behavior: The Control of Perception (1973) and began using some of Powers’s ideas for further theoretical development of reality therapy by using control theory. Glasser wrote Stations of the Mind (1981) as a somewhat technical version of control theory and its applications to people’s lives. He published a more popular book, Control Theory: A New Explanation of How We Control Our Lives, in 1985. Glasser thus based reality therapy on control theory as he described it. The main theoretical idea he borrowed from Powers was the notion that “people’s choices are attempts to control their perception that their needs are being met in the world” (Fall, Holden, & Marquis 2004, 249).

However, Glasser eventually revised his theory and renamed it choice theory instead of control theory in the late 1990s (W. Glasser 1998a). He did not want people to misunderstand control theory by erroneously thinking that it involves controlling others when it really concerns self-control and making one’s own decisions in a responsible way. He therefore replaced the word “control” with “choice,” which better reflects reality therapy’s emphasis on making responsible choices for oneself; hence, choice theory is now the theoretical foundation for reality therapy. Glasser wrote several other books on choice theory and its applications, including Counseling with Choice Theory (2001); The Language of Choice Theory, with his second wife, Carleen, who was involved in the use of reality therapy in schools (W. Glasser & Glasser 1999); and Getting Together and Staying Together, also with Carleen (W. Glasser & Glasser 2000). A more recent book, Warning: Psychiatry Can Be Hazardous to Your Mental Health (W. Glasser 2003), advanced his critical view of the use of psychiatric medications in dealing with personal problems, based on his belief that such medications can adversely affect the process by which people make choices in a responsible way. Glasser’s first wife, Naomi, was involved in editing several of his books, as well as editing two significant texts herself on the practical applications of reality therapy (N. Glasser 1980), including case studies (N. Glasser 1989).

Glasser was involved in teaching choice theory and reality therapy around the world. He founded the Institute of Reality Therapy in 1967 but changed its name to the William Glasser Institute in 1996 since his development of choice theory and its applications went beyond reality therapy. Glasser even applied his ideas on choice theory to a community of twenty thousand people in Corning, New York, beginning in 1997. He was an energetic and visionary advocate for choice theory and reality therapy (see W. Glasser 2002, 189–190). He died in 2013. (For further biographical information on William Glasser, see Parrott 2003, 341–342; Sharf 2016, 437–439; J. Sommers-Flanagan & Sommers-Flanagan 2018, 229–230, 251; see also Roy 2014, 2017).

Major Theoretical Ideas of Reality Therapy

Perspective on Human Nature

Reality therapy has existential roots. Glasser was influenced by the ideas of Helmuth Kaisar, one of the earliest existential therapists in the United States (Prochaska & Norcross 2018, 95). However, since reality therapy also combines existential ideas such as the individual’s freedom to choose and ability to control their own behavior with practical behavioral techniques for implementing behavioral change and action, it is sometimes viewed as a behavioral therapy or an eclectic therapy. It is nevertheless unique in its emphasis on human freedom and choice and hence cannot be easily categorized as a behavioral or eclectic therapy. Reality therapy is probably best described as a unique therapy with existential roots (Wubbolding 2000, 2011).

Glasser himself strongly opposed behaviorism, the philosophical foundation of behavioral approaches to therapy, because of the focus on external control of behavior, which he critiqued as external control psychology (W. Glasser 1998a). He believed that such external control psychology is actually the cause of much of the human suffering and social problems today. In reality therapy or choice theory, Glasser advocated an internal-control psychology that emphasizes human choice. He also asserted that we can control only our own behavior, not the behaviors of others. Reality therapy therefore has a basically positive view of human nature and an individual’s capacity for change. It also focuses more on the present and emphasizes a client’s strengths.

Basic Theoretical Principles of Reality Therapy

Reality therapy is grounded in choice theory (W. Glasser 1998a, 2001), which is a revision of control theory (W. Glasser 1985). The following are the basic theoretical principles of reality therapy or choice theory: basic human needs, one’s quality world or inner picture album, total behavior, choosing behavior, and the Ten Axioms of Choice Theory (see Sharf 2016, 439–442; J. Sommers-Flanagan & Sommers-Flanagan 2018, 231–237).

Basic Human Needs

Glasser (1998a) believed that all human behavior is basically motivated or governed by five basic human needs that are genetically encoded in every individual:

1. Survival

2. Love and belonging

3. Power (achievement)

4. Freedom (independence)

5. Fun (enjoyment)

Survival is a basic human need that is mainly biological: a need for current survival as well as future survival. It can be met by engaging in behaviors that enhance an individual’s probability of survival, such as eating, exercising, and having adequate shelter, as well as those that increase the probability of the survival of the human race, such as sexual behavior.

Sidebar 10.1: Principles of Reality Therapy

1. Basic human needs

2. One’s quality world or inner picture album

3. Total behavior

4. Choosing behavior

5. The Ten Axioms of Choice Theory

Glasser (1998a) considered love and belonging to be the most important or primary of the five basic human needs, because we usually must first have relationships with others in order to meet the other four basic needs. This need for love and belonging is expressed in behaviors such as socializing with people, establishing deep and caring friendships, and being involved in sexually intimate relationships. However, choice theory notes that this primary human need for love and belonging can be adversely affected by another basic human need: the need for power.

The basic human need for power is often regarded as negative, but Robert Wubbolding (2000) has provided more-positive alternatives for describing it as a need for achievement, accomplishment, or internal control. The need for power can conflict with the need for love and belonging, especially in a close relationship such as marriage, in which a power struggle between the marital partners leads to a lack of compromise and an ultimate breakdown of a loving and caring relationship with each other (W. Glasser 1985, 1998a; W. Glasser & Glasser 2000). However, the need for power can be fulfilled in constructive ways such as getting good grades in college, doing well in athletic events, or effectively helping others. Nevertheless, Glasser warned against the excessive need for power that is still prevalent in Western culture; its destructive effects can be seen in the power struggles in almost every area of life as pecking orders are established (see W. Glasser 1998a, 38).

The basic human need for freedom (or independence) is a longing in every individual for autonomy and the ability to choose from a variety of possibilities, relatively unhampered by others. Especially adolescents often manifest this basic need for freedom by wanting to do things their own way, sometimes even rebelling against their parents’ external control. According to choice theory, human creativity is clearly connected to fulfilling the need for freedom. Without a sense of freedom, it is difficult to be creative in a constructive way. When the need for freedom is not met, other destructive behaviors can result, including symptoms of psychopathology such as hysteria.

Finally, the basic human need for fun involves the quest or longing for enjoyment and playfulness. Glasser (1998a) directly connected this need for fun to play and linked play to learning. People learn through play that is enjoyable or fun. He also viewed the need for fun as the easiest one to fulfill and noted that laughter is the best definition of fun. Usually fun is also closely connected with the primary human need for love and belonging.

All five basic human needs can be met in responsible and constructive ways or in irresponsible and destructive behaviors. Reality therapists help clients to fulfill these five basic needs in healthy, responsible, and constructive ways that do not harm others in the process of meeting one’s own needs. Clients are also reminded that they can control only their own choices and behaviors; they cannot control others, although they can influence them. When one (or more) of these five basic human needs is not fulfilled, people feel bad and are motivated to try to meet the unsatisfied needs.

One’s Quality World or Inner Picture Album

According to choice theory, shortly after birth and throughout our lives our basic needs are not directly satisfied. Instead, because we are only somewhat aware of our five basic needs in general, we keep track more specifically of whatever we do that makes us feel very good. Over time, we build our own mental list of specific wants and needs, a kind of inner picture album of specific memories and images of people, things, or experiences, and of beliefs that have made us feel good because they satisfied our basic needs (see W. Glasser 1998a; Wubbolding 2000). Reality therapists help clients to clarify and prioritize their wants and see what is crucial to them (Wubbolding 2011, 2017; Wubbolding & Brickell 2015).

This inner picture album is also called one’s quality world, a personal Shangri-la, an ideal world in which one would like to live if possible (see Corey 2021, 315). The quality world, the inner picture album, differs from person to person and also within a person over time. In other words, it can be revised as an individual has new experiences.

It is therefore crucial for reality therapists to empathically understand each client’s subjective quality world. They also need to enter into the client’s quality world by establishing genuine, caring, and respectful therapeutic relationships with them so that the client experiences love and belonging in therapy and allows the therapist to enter into that quality world.

Total Behavior

Choice theory emphasizes that the key characteristic of all human beings from birth to death is the fact that they behave. Such behavior is described by choice theory as total behavior consisting of four specific but connected parts that are always functioning simultaneously: acting, thinking, feeling, and physiology. Acting, which may be voluntary or involuntary, refers to specific behaviors such as walking, moving, talking, and eating. Thinking refers to all types of thoughts, voluntary or involuntary, including dreams. Feeling refers to emotional experience, both pleasant or painful, such as joy, sadness, anger, and satisfaction. Physiology refers to bodily functions, voluntary or involuntary, such as heart rate and sweating.

The total behavior of an individual in acting, thinking, feeling, and physiology has often been described by using Glasser’s car analogy (1990). The engine of the car contains the individual’s basic needs (survival, love and belonging, power, freedom, and fun), which provide the power for the whole system of the car. The wants of the person are like the steering wheel, moving the car in the direction of their quality world. Acting and thinking are like the two front wheels of the car, which an individual can directly control in order to satisfy certain wants and needs. Thoughts and behaviors are both chosen by a person, according to Glasser. Feelings and physiology are like the two rear wheels of the car, which can be indirectly controlled by an individual. Glasser (2000b) emphasized that one can directly choose only one’s actions and thoughts, but one can also indirectly control one’s feelings and physiology by choosing to change one’s actions and thoughts.

Choosing Behavior

Glasser held the radical view that so-called mental illness does not exist (see W. Glasser 1965, 85; 2002, 2) except for extreme conditions where there is obvious brain pathology, for example, brain trauma and Alzheimer’s disease. His critical view on mental illness echoes similar views voiced by other well-known psychiatrists such as Thomas Szasz (1970, 1971) and Peter Breggin (1991). Glasser instead believed that psychological disorder is due to an individual’s personal choice. He was also very critical of the use of psychiatric medications to treat psychopathology (W. Glasser 2003). Thus he held an extreme position that people choose their own behavior and are therefore fully responsible for their problems, whether behavioral, emotional, or physical.

Glasser advocated using active verbs to describe human suffering and problems. Instead of the usual way of saying “I am depressed” or “I have a headache” or “I am angry” or “I am anxious,” all of which reflect passivity and tend to be incorrect and to reinforce a denial of personal responsibility, Glasser preferred to use more accurate verb forms in saying “I am depressing,” “I am headaching,” “I am angering,” or “I am anxietying.” This way of speaking challenges clients to remember that they are choosing their own behavior, and hence they are actually depressing themselves, angering themselves, or making themselves anxious. They are thus held responsible for choosing their own suffering within a range of “paining” behaviors, the best behaviors they can manage to try to meet their wants and needs (Corey 2021, 315–316).

Glasser’s radical view of choosing behavior—including psychopathology and human suffering, as an all-pervasive freedom and responsibility for every human being—can sound harsh and may not be fully accepted by all therapists, including some reality therapists. However, this radical view of choice theory and psychopathology can still be communicated in an empathic way in the therapeutic process of reality therapy, which is based on the therapist having a caring, genuine, and respectful relationship with the client. Ultimately, reality therapy uses choice theory, empowering the client to make personal choices in a responsible and constructively fulfilling way (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 234–237).

Glasser (1985) provided four main reasons for why individuals may choose pathological behavior or human suffering and misery. First, many people choose to make themselves anxious or depress themselves in order to control or restrain anger. For example, people usually achieve more control or power over others by depressing themselves than by angering. Second, individuals may choose to make themselves anxious or depressed in an attempt to get help from others. Depressing oneself can especially be an effective means of getting help and sympathy from others, including mental health professionals, as well as of controlling significant people in one’s life, thereby to meet one’s basic needs for love and belonging and also for power. Third, people may choose to depress themselves or make themselves anxious in order to avoid things that they do not want to deal with or face in their lives. It may be easier for someone who has been laid off from work to remain frozen in fear or to be anxious than to take difficult steps toward finding a job. Glasser would challenge people trying to avoid dealing with a difficult situation like this to either change what they want or to change their behavior (W. Glasser 1998a, 83). Fourth and finally, people may choose to make themselves anxious or depress themselves in order to achieve significant control over other people and get others to do things for them.

Glasser (1985, 2001) also viewed so-called crazy behavior, such as hallucinations and delusions, as creative yet desperate behavior, with the purpose of gaining control over one’s life.

Ten Axioms of Choice Theory

Glasser summarized the basic theoretical principles of reality therapy as the Ten Axioms of Choice Theory (1998a):

1. The only person whose behavior we can control is our own.

2. All we can give another person is information.

3. All long-lasting psychological problems are relationship problems.

4. The problem relationship is always part of our present life.

5. What happened in the past has everything to do with who we are today, but we can only satisfy our basic needs right now and plan to continue satisfying them in the future.

6. We can only satisfy our needs by satisfying the pictures in our quality world.

7. All we do is behave.

8. All behavior is total behavior and is made up of four components: acting, thinking, feeling, and physiology.

9. All total behavior is chosen, but we only have direct control over the acting and thinking components. We can only control our feeling and physiology indirectly through how we choose to act and think.

10. All total behavior is designated by verbs and named by the part that is the most recognizable (cited in J. Sommers-Flanagan & Sommers-Flanagan 2018, 237).

Therapeutic Process and Relationship

Glasser (1965) emphasized three major foundational principles of reality therapy: reality, responsibility, and right and wrong. He believed that when individuals choose to engage in responsible behavior within the limits of reality to meet their basic needs in ways that do not hurt others, their behavior is right or moral. They will then be able to give and receive love and have a deep sense of self-worth. Reality therapists help their clients have satisfying relationships with others so that their own basic needs for survival, love and belonging, power, freedom, and fun can be fulfilled in responsible and constructive ways.

The reality therapist functions like a mentor, teacher, or coach to the client and therefore often assumes a directive and educational role in therapy. However, it is still crucial for the reality therapist to establish a genuine, caring, and connected therapeutic relationship with the client. Reality therapy emphasizes the therapeutic alliance based on an empathic and supportive relationship with the client but does not view it as sufficient for effective therapy to occur. Reality therapists, following Glasser, believe a friendly therapeutic relationship that also includes firmness helps to provide an appropriate counseling environment for the client, who basically has unsatisfying relationships or no relationships with others. The reality therapist connects with the client by engaging in a genuine, caring, and supportive relationship and attempts to enter the client’s quality world. Specific techniques are then also needed to further help clients choose and change their behavior, in addition to establishing a friendly therapeutic relationship in what is called the cycle of counseling (see Sharf 2016, 444).

Glasser (1998a) provided more guidelines for establishing a good therapeutic relationship with the client by describing “seven caring habits” that reality therapists would do well to cultivate: supporting, encouraging, listening, accepting, trusting, respecting, and negotiating differences. Glasser (2002, 13) also listed “seven deadly habits” of harsh confrontation that should be avoided by reality therapists: criticizing, blaming, complaining, nagging, threatening, punishing, and bribing or rewarding to control (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 240–241). Reality therapists, however, also do not accept excuses from clients, do not criticize or argue, and are persistent in caring for their clients and therefore do not give up easily. Instead, they always try to be courteous, determined, enthusiastic, firm, and genuine with their clients, to focus on the present, to use humor, and to appropriately use empathic confrontation (see Wubbolding 1988; Wubbolding & Brickell 1998).

The process of reality therapy has been further elaborated and described by Wubbolding (2000, 2011, 2017) using the WDEP system of reality therapy. The W stands for wants and needs, D for direction and doing, E for self-evaluation, and P for planning (see Corey 2021, 320–326).

In the W stage or component of reality therapy, the therapist helps the client to explore personal wants, needs, and perceptions. The key question that the reality therapist asks the client is “What do you want?” The client’s answers about personal wants will be related to the five basic human needs: survival, love and belonging, power, freedom, and fun. The reality therapist uses skillful questioning to encourage the client to explore their internal picture album and further clarify their deeper wants and needs, which may not be currently fulfilled.

In the D stage or component of reality therapy, the therapist helps the client to focus on the present, asking the key question: “What are you doing?” The reality therapist will also help the client to explore and clarify the future direction of their life, by asking another crucial question: “What do you see for yourself at this time and in the future?” The client therefore focuses on direction and doing, on present actual behavior and direction for the future, rather than dwelling on feelings or on the past.

In the E stage or component of reality therapy, the core part of therapy is covered, with the therapist helping the client to engage in the following crucial self-evaluation: “Does your present behavior enable you to get what you want now? Will it take you in the direction you want to go?” Usually the client is struggling with serious relationship problems that are causing much emotional pain. The reality therapist often asks the client another key question: “Is your present behavior bringing you closer to people who are important to you, or is it driving you farther apart from them?” The reality therapist uses skillful questioning to help the client evaluate their total behavior in terms of acting (doing), thinking, feeling, and physiology, thus empowering the client to choose more-constructive ways of behaving and thinking that will help satisfy personal wants and needs.

In the P stage or component of reality therapy, the therapist helps the client to focus on planning and action in a specific and concrete way, with the goal of meeting the client’s wants and needs that were earlier expressed. The client is again empowered to make responsible plans to fulfill personal wants and needs without hurting others. The reality therapist will help the client devise an effective plan of action that follows the acronym SAMI2C³ as described by Robert Wubbolding (1988, 2000, 2011, 2017): simple, attainable, measurable, immediate, involved, controlled (by the planner), committed to, and continuously done (see also J. Sommers-Flanagan & Sommers-Flanagan 2018, 241).

The WDEP system of reality therapy can be used in both individual and group therapy contexts. More specific techniques used in reality therapy will now be discussed. The reality therapist has much freedom to be flexible and creative in conducting therapy with clients.

Major Therapeutic Techniques and Interventions

Glasser (1965, 1981) originally described the process of reality therapy as consisting of eight steps, but with much flexibility on the part of the reality therapist in applying them to clients. The eight steps of reality therapy are being involved with the client in a caring and encouraging relationship, focusing on behavior (and not just feelings), focusing on the present (and not the past), making a specific plan, getting a commitment, accepting no excuses, eliminating punishment, and never giving up (see Parrott & Tan 2003, 347).

The major therapeutic techniques and interventions often used by reality therapists are structuring, confrontation, contracts, instruction, skillful questioning (e.g., “Does your present behavior enable you to get what you want now? Will it take you in the direction you want to go?”), emphasizing choice (e.g., by using verbs in place of adjectives and nouns), role-playing, support, constructive debate, humor, self-disclosure, positive addictions, and assessment (see Parrott 2003, 348–352), as well as the use of metaphors and paradoxical techniques (see Sharf 2016, 451–455).

Structuring

Structuring is the technique of helping clients set up their expectations for therapy, including specific aspects of therapy such as fees, anticipated number of sessions, goals of therapy, and what reality therapy involves. Through such structuring, the reality therapist helps the client to have more realistic expectations as well as hope for possible change.

Sidebar 10.2: Eight Steps of the Process of Reality Therapy

(see Parrott & Tan 2003, 347)

1. Being involved with the client in a caring and encouraging relationship

2. Focusing on behavior

3. Focusing on the present

4. Making a specific plan

5. Getting a commitment

6. Accepting no excuses

7. Eliminating punishment

8. Never giving up

Confrontation

Confrontation is an intervention that will eventually be used because client excuses are not accepted by reality therapists, who persevere and do not quickly give up in their therapeutic work with clients. Confrontation, however, does not need to be conducted in a harsh way. Reality therapists often use confrontation in the form of empathic yet firm questions or comments that challenge clients to acknowledge their own responsibility in choosing to act or think in specific ways and to honestly face the consequences of their actions. Clients are also confronted with how seriously committed they are to their choices. The following is an example of the use of confrontation by a reality therapist with a client:

Client: I didn’t call my brother as I planned to, for the purpose of trying to resolve a conflict we had recently. But it’s OK, because this is not that important to me anyway!

Reality Therapist: You said last week that this was really important to you, but if it isn’t that important, then what is really important to you?

The reality therapist can also respond to this client by saying, “You talked a lot about making this call to your brother in our last session, and you said it was really important to you to make the call. I believe that it still is important to you!”

Confrontation is thus a technique that can be used in different forms and ways depending on the style and personality of the reality therapist, as well as of that client.

Contracts

Contracts involve the use of written agreements signed by the client and the reality therapist, with clear descriptions of what the client has freely committed to doing, as a plan of action for meeting the client’s wants and needs in a responsible way that does not hurt others. A signed contract can help clients to make their commitment to follow through with their plans of action more concrete, more firm. It can also be a record of their successful execution of their plans and achievement of their goals.

Instruction

Reality therapists will often function in a teaching or coaching role, instructing clients in specific skills so that they can execute their plans and meet their needs and goals in a responsible way. If a specific client needs instruction in an area of knowledge that the reality therapist lacks, the therapist will refer the client to another person or agency.

Skillful Questioning

A key track used by reality therapists in conducting skillful questioning is “Does your present behavior enable you to get what you want now? Will it take you in the direction you want to go?” (see Parrott 2003, 350). Such questioning helps a client to reflect on their behavior, wants and needs, as well as goals and plans, and therefore to engage in productive self-evaluation. Other direct questions that reality therapists can use in skillful questioning include the following, suggested by Wubbolding (1988, 2000, 2011, 2017): “Is what you are doing now what you want to be doing? Is your behavior working for you? Is what you are doing helping or hurting you? Is what you want against the rules? Is what you want realistic or attainable? After carefully examining what you want, does it appear to be in your best interest and in the best interest of others? How committed are you to the therapeutic process and to changing your life?” (see Corey 2021, 323–324). Such skillful questioning enables the reality therapist to understand the client’s world more empathically and empowers the client to assume more responsibility and control for their life and choices. However, questions should not be overused but rather should be integrated with other types of responses such as active and reflective listening (Wubbolding 1996).

Emphasizing Choice

Reality therapy emphasizes the freedom of the client to choose their own values. The client is confronted with personal responsibility for their own total behavior (directly for actions and thoughts and indirectly for feelings and physiology). Emphasizing choice is a technique in which the therapist uses verbs in place of adjectives or nouns, thus to strongly emphasize the client’s responsibility in choosing their own behaviors. For example, when a client says, “I’m angry,” the reality therapist will ask the client to replace “angry” with “angering” and say instead, “I’m angering.” Similarly, “I’m depressed” will be replaced with “I’m depressing,” and “I have a headache” with “I’m headaching.” The reality therapist uses such verb forms of expression in emphasizing choice to the client and helping the client to realize that they are actually choosing to “depress” (for depression) or to “anxietize” (for anxiety) themselves.

Clients therefore learn to choose more-constructive and healthier ways of acting, thinking, feeling, and physically functioning when they realize they have choices and are not totally under the control of external forces. This radical emphasis on choice in reality therapy can be too extreme at times when biological, spiritual, or other factors may actually be controlling the client’s behavior and experiences. Emphasizing choice is a therapeutic intervention that must be used in an empathic and sensitive way rather than in a harsh manner, so that the client feels empowered to make choices responsibly, rather than crushed and blamed.

Role-Playing

Role-playing is the technique of practicing and rehearsing specific behaviors that the client wants to try out in real life, in the safety of therapy first, with the reality therapist providing coaching and encouragement. Role-playing in reality therapy also includes rehearsing the possible consequences of specific behaviors in which the client wants to engage, such as their feelings after executing the behaviors. J. Robert Cockrum (1993) has described how role-playing concrete situations with a reality therapist often helps clients with problems in interpersonal relationships.

Support

As clients learn to accept personal responsibility for their choices and behaviors, they need support from the reality therapist in order to follow through with their action plans. Clients with a history of past failures and a “failure identity” that expects failure as a way of life are especially in need of support from the reality therapist. Support therefore is the technique of providing encouragement and positive feedback to clients so that they feel more empowered and motivated to make changes in their lives in constructive ways.

Constructive Debate

Constructive debate is the technique in which the reality therapist challenges the client’s ideas and values, and vice versa. This challenging is done with respect for the client and without forcing the therapist’s own values on the client. In constructive debate, the reality therapist encourages the client to speak up and have their own strong voice while expressing personal ideas and values, which the reality therapist takes seriously, even as they engage in healthy and mutual debate. The client is also empowered to make significant contributions to therapy by speaking up.

Humor

Humor is a therapeutic intervention in reality therapy that involves the therapist and the client laughing together at a joke or at themselves or others in a sensitive and appropriate way. Since fun is a basic human need, according to Glasser, it is often experienced in a playful context, with laughter. Humor in therapy can help meet the client’s need for fun in a small way. The reality therapist also engages in a friendly, caring therapeutic relationship with the client, in which humor can more naturally occur. However, humor must be used carefully and cannot be forced, and the therapist must be willing to self-direct that laughter first. If used appropriately, humor can help clients to be more objective and able to laugh at themselves and take themselves less seriously so that they can enjoy life more (W. Glasser & Zunin 1979). If humor involves sarcasm or demeans the client, it is being used inappropriately, in a way that can harm the client. Such destructive humor should be avoided in therapy.

Self-Disclosure

Reality therapy emphasizes a collaborative, friendly, caring, and mutually open therapeutic relationship between the therapist and the client. Reality therapists therefore engage in self-disclosure, sharing their own feelings, struggles, and weaknesses. Such therapist vulnerability in honest self-disclosure helps the client feel less vulnerable and more empowered to live more realistically and responsibly.

Positive Addictions

Glasser (1976) described positive addictions as activities or behaviors that lead to a natural or healthy high, on a regular basis, and do not require excessive time or concentration. Examples of positive addictions include jogging, meditation, or visiting with friends. Reality therapists encourage their clients to choose positive addictions in their lives so that they can live in a more fulfilling and healthy way.

Assessment

Reality therapists do not typically use formal testing to diagnose clients, but they do engage in assessment or monitoring of their clients’ progress in therapy and in achieving their goals. Reality therapists especially note any step that clients have successfully taken to live in a more responsible way. Clients are considered ready for termination of therapy when they accept responsibility and act more responsibly in meeting personal needs without hurting others or themselves (W. Glasser & Zunin 1979).

Metaphors

Metaphors involve the reality therapist in using the client’s specific language, especially metaphorical or symbolic language, to communicate deeper empathy to the client (Wubbolding & Brickell 1998). An example of using metaphors in reality therapy is when a client says, “When I got the promotion at work and a pay raise, life just seemed brighter!” and the reality therapist responds with, “Tell me more about what it feels like to be in such bright sunshine” (see Sharf 2016, 453).

Paradoxical Techniques

Reality therapists usually help their clients make plans and execute them in direct ways. However, sometimes clients may resist change. At such times, reality therapists may use paradoxical techniques, referring to the provision of contradictory instructions to clients to help them overcome resistance and move in the direction of further therapeutic change (Wubbolding & Brickell 1998). One example is instructing a client obsessed with not making mistakes at work to go ahead and make mistakes at work. If the client attempts to make mistakes at work as instructed, he has shown some control over the target behavior. If the client does not follow the therapist’s instructions, then his undesirable behavior ends up being controlled or terminated (Sharf 2016, 454). Paradoxical techniques are complex and not easy to conduct. They also present ethical and clinical dangers. Two specific types of paradoxical techniques are reframing and prescriptions (see Sharf 2016, 454–455). Reframing involves helping clients change their way of thinking about something. For example, if a husband complains of his wife’s nagging, he can be instructed to reframe her nagging as caring. Paradoxical prescriptions refer to instructing the client to perform a specific symptom (i.e., prescribing the symptom). For example, a client who is afraid of having a panic attack is instructed to go ahead and try to have a panic attack. Or a client who is afraid of blushing is told to go ahead and blush as much as possible and tell nearby people how much and how often such blushing happens. Paradoxical techniques can thus help clients to regain a sense of control and choice over their symptoms.

Paradoxical techniques can be confusing and potentially dangerous if used inappropriately and insensitively. Gerald Weeks and Luciano L’Abate (1982) have emphasized that involvement and safety are essential in the effective use of paradoxical techniques. They should therefore not be used with suicidal, sociopathic, or paranoid clients, or with those who are in crises such as suffering the loss of a loved one or a job. Nevertheless, paradoxical techniques may be helpful therapeutic interventions that reality therapists can use with their clients to help them achieve more control over their symptoms and to overcome their resistance.

Reality Therapy in Practice

This hypothetical transcript of a small part of a reality therapy session demonstrates the reality therapist’s use of the techniques of emphasizing choice and skillful questioning. The therapist also provides support and encouragement by verbally praising the client for responding well to the interventions. Then the therapist continues to use skillful questioning that challenges the client to commit to making changes and to lead the client on to further discussion of how to develop even more concrete and specific plans for action and therapeutic change.

Client: I often feel anxious, especially when I have to give a talk or do a presentation before an audience. . . . I have this anxiety creeping up, . . . and then I have headaches too!

Reality Therapist: We often express our feelings and experiences such as anxiety and having headaches as if they just happen to us, as if they are way beyond our control, as if we have absolutely no choice. But we do have a choice, and to help you remember that you always have a choice, I would like you to try saying, “I’m anxietizing myself when I have to give a talk” instead of “I often feel anxious when I have to give a talk.” Change the word “anxious” into a verb, “anxietize”! Go ahead and try saying this.

Client: OK . . . I’m anxietizing myself when I have to give a talk or do a presentation in public . . .

Reality Therapist: Good! Now go on and try saying, “I’m headaching myself” instead of “I have headaches” too.

Client: OK . . . I’m headaching myself . . .

Reality Therapist: You’re getting the hang of it pretty well! Now combine both sentences about anxietizing and headaching yourself and see how you feel.

Client: Well . . . I’m anxietizing myself especially when I have to give a talk or do a presentation before an audience. . . . I anxietize myself more and more, . . . and then I am headaching myself too!

Reality Therapist: Good . . . Now that you are able to say that you are anxietizing yourself and headaching yourself, how do you feel?

Client: It feels kind of weird, . . . but I do feel that I have some choice in my anxiety and headaches, . . . that I have some responsibility and control, instead of being a passive victim to my feelings and physical sensations.

Reality therapist: You’re doing really well. . . . You realize now that you do have some choice in your anxietizing and headaching. Now do you think that what you’re doing—anxietizing and headaching yourself—is helping or hurting you?

Client: It’s definitely hurting me because I want to be able to give an effective presentation that will really help the people listening. I guess I do have a basic need for some power or achievement. I also want to connect with my audience, to feel appreciated and liked or loved by my listeners, to meet my basic need for love and belonging, I guess.

Reality Therapist: You’ve expressed it well and have a good understanding of basic needs that are motivating you to give an effective and helpful presentation that will actually help your listeners as well as connect you and bond you with them. Yet anxietizing and headaching yourself is hurting you instead of helping you. What else can you choose to do to help you meet your needs in a responsible way that does not hurt you or others?

Client: Well, I guess I can choose to relax myself rather than anxietize myself, to perhaps tell myself I’ll be able to do a good job in my presentation. Also, I can choose to put in a bit more time and effort in preparing my presentation instead of procrastinating and doing it at the last minute or the eleventh hour.

Reality Therapist: Excellent ideas and suggestions! Now, how committed are you to making these changes and following through with your plans, which we can discuss further to make them even more concrete and specific?

Critique of Reality Therapy: Strengths and Weaknesses

Reality therapy has several strengths (see Corey 2021, 332–333; Parrott 2003, 354–356). First, its versatility and adaptability have resulted in its application to diverse populations, including children, adolescents, adults, and older adults as well as to a variety of settings such as schools, prisons, hospitals, and crisis centers (N. Glasser 1989). It is a relatively short-term therapy approach that is direct and therefore has been used for decades for helping clients with addictions and those in recovery programs (Wubbolding & Brickell 2005). It is also consistent with managed care’s emphasis today on short-term treatments and brief therapy.

Second, reality therapy is concrete and specific, focusing on specific behavioral goals, with contracts often spelled out and signed, so that progress toward achieving client goals can be monitored and measured. Again, it is a relatively short-term approach to therapy that deals directly with client needs and goals.

Third, reality therapy focuses on present behavior and needs and helps clients make concrete plans for the future. It is therefore a good corrective to therapeutic approaches that may focus too much on the past, with the danger of clients getting stuck there. It also emphasizes exploration of behaviors and thoughts more than feelings or symptoms so that clients do not become mired in complaining about their symptoms.

Fourth, reality therapy is still an existential approach to therapy that emphasizes choice on the part of the client. It challenges clients to choose their own values and behaviors in order to meet their basic human needs or wants in ways consistent with responsibility, reality, and right and wrong, so that others will not be hurt.

Fifth, reality therapy as developed by Glasser, emphasizing choice theory, radically opposes the medical model of psychological disorder or mental illness and its treatment with psychiatric medications. Glasser was extremely critical of psychiatric treatment of psychological disorders centered on the use of psychotropic medications. He believed that such psychiatric treatment can be harmful to the mental health of clients (W. Glasser 2003). Although Glasser’s approach to reality therapy and choice theory is radical and extreme in this regard, it is nevertheless empowering to clients, who can choose to change their maladaptive behaviors and thoughts and eventually their total behavior, including feelings and physiology. There is a real danger in the medical model of psychopathology that reduces all psychological disorders to mental illnesses and the premature and sometimes mistaken use of psychiatric medications to treat such disorders in clients. The myth of mental illness has been misapplied to many clients who may be better helped with approaches to therapy such as reality therapy, which emphasizes their own choice and responsibility in bringing about therapeutic change (see also Breggin 1991; Szasz 1970, 1971).

Sixth, reality therapy has developed and described several therapeutic techniques and interventions that can be of much practical help to many clients. Reality therapists can therefore use these techniques in concrete ways to facilitate client therapeutic change, based on choices made by the client in setting goals for such change.

Seventh, reality therapy’s emphasis on client choice has been found to be helpful in cross-cultural counseling. Clients are encouraged to choose their own values and ways of meeting their needs that are culturally sensitive and consistent. Furthermore, reality therapy’s focus on thoughts and actions rather than feelings is helpful to clients from cultures that do not value or express individual feelings as openly as Western culture does. Nevertheless, reality therapy has required adaptation in work with clients from other countries and cultures, as Wubbolding has pointed out in his experience of conducting reality therapy workshops internationally (2000; Wubbolding et al. 1998, 2004), in places such as Japan, Taiwan, Singapore, India, Korea, Kuwait, Australia, Slovenia, Croatia, and other European countries.

Eighth, reality therapy has been found to be useful in helping clients with disabilities and their rehabilitation (see, e.g., Ososkie & Turpin 1985; G. Walker 1987), with a focus on clients making realistic and responsible choices in their personal, social, and vocational goals and plans (see Parrott 2003, 356).

Reality therapy also has several weaknesses and limitations. First, reality therapy, as an existential and humanistic therapy, shares the same weakness as other similar therapies—such as existential therapy, person-centered therapy, and Gestalt therapy—in having too positive a view of human nature and an individual’s capacity to change in responsible and realistic ways. The darker side of human nature, which is capable of sin and evil and thus of hurting and harming others, is not adequately dealt with in reality therapy. It is not as easy for clients to simply choose in responsible ways or to change as reality therapy purports.

Second, reality therapy does not sufficiently deal with the past. Some clients have experienced trauma in their past that requires more therapeutic attention and help from the therapist. Although reality therapy’s emphasis on dealing with the present and making plans for the future is a good corrective, rather than getting stuck in the past, it nevertheless commits the mistake of not paying enough attention to unresolved pain and issues in the client’s past that can still interfere with their present functioning and problem solving for the future.

Third, reality therapy’s ignoring of unconscious processes, such as transference and dreams, can limit its comprehensiveness and effectiveness. Paying adequate attention to these unconscious processes can help clients gain deeper insight into their thoughts, behaviors, and feelings, and then make more constructive therapeutic change in their lives (see Corey 2021, 333–334).

Fourth, the reality therapy expounded by Glasser takes an extreme and radical view of psychological disorders as steeped in behavioral choices made by the client, negating biological or genetic factors in such psychological disorders and rejecting the reality of mental illnesses and the need for psychiatric medications to treat them. Some reality therapists do not take as extreme a view as Glasser did, especially regarding severe psychological disorders such as schizophrenia, bipolar disorder, or major depressive disorder, where psychotropic medications have helped and even saved the lives of patients suffering from these disorders. The myth of mental illness is therefore sometimes a myth too (i.e., the myth of the myth of mental illness). There is such a thing as mental illness for some clients who have severe psychological disorders, and it can be harsh, if not cruel, to assume that they are freely choosing their severe symptoms.

Fifth, reality therapists risk imposing their values on the client since the therapist functions as a coach, mentor, and teacher. The reality therapist must be careful to let the client engage in self-evaluation and self-choice rather than directing, lecturing, or moralizing (Wubbolding 1988, 2000, 2011, 2017).

Sixth, the specific, concrete therapeutic techniques in reality therapy can be misused by inadequately trained or inexperienced therapists. Although these techniques can be of practical help to clients and useful for therapists, they must be used in the context of an empathic relationship with the client and a comprehensive understanding of the client’s clinical problems. Appropriate and adequate training, experience, and supervision are therefore essential in the effective, efficient, and ethical use of reality therapy techniques (Wubbolding 2011).

Seventh, Glasser’s radical emphasis on clients being able to freely choose their thoughts, actions, values, and plans to fulfill their basic needs in a responsible way may not be sensitive enough to clients who are experiencing actual social, political, or environmental oppression or discrimination, especially clients from certain ethnic minority cultures. In many instances and contexts, such clients are not truly free to choose. Reality therapists in such situations focus on the areas in which clients still have some limited choice. However, such clients may still need to openly share their experiences of oppression or discrimination and be encouraged to take small steps to help change external factors that are objectively oppressive (see Corey 2021, 329). Furthermore, the therapist must consider other factors, such as biological or spiritual forces, that may be strongly affecting or even controlling the client.

Eighth, some clients from other cultures and countries who have more collectivistic values may not be as comfortable or assertive in expressing individual needs and goals and plans to fulfill them. They may be more comfortable with expressing more communal and familial needs and values. Reality therapy thus may not be sensitive enough to such multicultural diversity and contexts. Wubbolding (2000), however, has tried to adapt reality therapy for use in other cultures and countries. For example, he has advocated less-direct questioning and gentler and more-careful confrontation, use of words other than “plan” and “accountability,” and acceptance of “I’ll try” as a genuine expression of commitment (rather than as an excuse) with Japanese clients because of the unique characteristics of Japanese culture, including the inappropriateness of assertive language, especially between parent and child and between employer and employee (see Corey 2021, 328).

Finally, reality therapy has not focused sufficiently on research and empirical outcome studies to evaluate its effectiveness or efficacy in treating clients with various disorders. Although some empirical research has been done to date, it is still quite limited.

A Biblical Perspective on Reality Therapy

Reality therapy has several strengths, some of which are consistent with a biblical perspective. In fact, reality therapy had a significant influence on the early development of various Christian counseling approaches because of its emphasis on responsibility, reality, and right and wrong (see Hurding 1985, 276–277; Morris 1980, 232; see also S. L. Jones & Butman 1991, 247–250). For example, years ago Paul Morris developed love therapy as a Christian counseling approach and wrote: “When I read this book [Reality Therapy], it dawned on me that what he was saying was verbatim what Scriptures taught: Loving involvement with a focus on responsibility” (1980, 232). Reality therapy’s emphasis on a caring, therapeutic relationship with a client, with a focus on choice and responsibility, has therefore resonated with many Christian therapists and pastors (see J. I. Young 1982) because a biblical perspective also emphasizes agape love (1 Cor. 13) and choice and responsibility (see Josh. 24:15; Luke 13:3). However, reality therapy’s basically positive view of human nature and an individual’s capacity to choose and change, relying on their own strength, is ultimately too optimistic and not fully consistent with a biblical perspective on human nature, which also recognizes the darker side of human beings that is capable of sin (Rom. 3:23). Furthermore, the Bible teaches the need for God’s grace (cf. 2 Cor. 12:9–10), salvation through Jesus Christ (Rom. 6:23), and the power of the Holy Spirit (cf. Zech. 4:6; Eph. 5:18) in genuine transformation of one’s life, exposing the futility and vanity of self-effort. Agape love (1 Cor. 13) is also deeper and purer than an involved and caring therapeutic relationship.

Second, reality therapy’s focus on present behavior and future plans is somewhat consistent with the biblical view of taking life one day at a time (Matt. 6:34), with genuine hope for the future because of eternal life in Christ, both now and forever in heaven (see Matt. 6:33; Rom. 8:18; 2 Cor. 4:16–18). However, its ignoring of the past must be balanced with an appropriate dealing with the past in order to leave the past behind or to “forget” what is behind (see Phil. 3:13–14). Sometimes this may require the judicious use of inner-healing prayer or the healing of memories (see Tan 2003b, 2007b). It may also require patiently working through trauma and painful unfinished business from the past, some of which may be unconscious (see Gingrich 2020).

Third, reality therapy’s emphasis on meeting individual needs and wants as long as others are not hurt in the process is a relativistic and somewhat self-centered form of ethics. The potential conflict between meeting one’s needs and interfering with meeting the needs of others is more substantial and problematic than Glasser acknowledged. A biblical perspective calls us to a higher standard of ethical living governed and guided by a self-transcendent agape love (1 Cor. 13) that genuinely cares more about the welfare and well-being of others than of oneself. Such agape love is the fruit of the Holy Spirit (Gal. 5:22–23), who empowers Christians to love; it is not the result of self-effort.

Fourth, the needs and values of individuals seem to be of paramount importance in choice theory and reality therapy. There is no transcendent, spiritually objective truth to match the inspired revelation in the Bible (2 Tim. 3:16). Our needs and values ultimately find their deepest fulfillment and greatest clarification in God and his eternal truth as revealed in Scripture. Attempts in reality therapy to integrate spirituality do still subject spiritual truth or experience to reality therapy’s judgment of what is responsible and what is not (see Linnenberg 1997; Mickel & Liddle-Hamilton 1996). Although reality therapists may positively approach the spirituality of clients as a crucial part of many clients’ specific quality worlds, they will still assess whether such spirituality helps or hinders clients’ fulfillment of their needs in a responsible way. In other words, a transcendent and real spirituality is not embraced. Biblical spirituality in Christ transcends meeting one’s needs. There is a spiritual reality that is greater than needs and greater than oneself. Paradoxically, our deepest God-shaped inner vacuum and need can be met only in a real, transcendent relationship with God through Jesus Christ.

Fifth, reality therapy can be dangerous in the hands of an authoritarian, moralistic, or legalistic therapist who simplistically misuses or abuses its techniques and ultimately imposes the therapist’s own values on the client. Because reality therapy emphasizes what is responsible, realistic, and “right,” it can also be reduced to a moralistic system. This danger is similarly present in some authoritarian approaches to biblical counseling (see S. L. Jones & Butman 1991, 249–250). The Bible emphasizes the need to speak the truth with love (Eph. 4:15) and the need for patience, encouragement, and support, in addition to admonishment, in helping others (1 Thess. 5:14). It also teaches the need to comfort others with God’s loving comfort (2 Cor. 1:3–4). Reality therapy has more recently embraced a gentler approach in place of its earlier, somewhat confrontational stance in challenging clients to take responsibility for themselves and to choose. This is a positive development and more consistent with a biblical perspective on helping others.

Finally, reality therapy’s radical view of each individual’s freedom to choose, including choosing symptoms of psychological disorder, negates the possibility of other factors that may cause such symptoms, including environmental, social, political, biological, and even spiritual or demonic forces. The reality of spiritual warfare (see Eph. 6) and the possibility of demonization in some cases, from a biblical perspective, cannot be accommodated or accepted by reality therapy.

Research: Empirical Status of Reality Therapy

Glasser did not focus on research as a priority, and the training of certified reality therapists does not include research training in the curriculum. The research base for the empirical status of reality therapy is therefore limited, although some research studies have been conducted (see Sharf 2016, 465–466). Most of the previously available data on the effectiveness of reality therapy were in the form of case studies covering a wide variety of psychological disorders (W. Glasser 2000b; see also N. Glasser 1980, 1989).

Robert Wubbolding (2000, 2011) has reviewed the research on the effectiveness of reality therapy with clients suffering from addiction and depression and with juvenile and adult offenders. Research studies have also been conducted in different types of educational institutions in several countries internationally. Rose-Inza Kim and Mi Gu Hwang (1996), in a small study in Korea with eleven middle-school girls who received group reality therapy and twelve students in a control group, found that those who received group reality therapy showed improvements in discipline, motivation for achievement, and locus of control. Kim and Hwang (2006) also conducted a meta-analysis of forty-three studies done in educational institutions in South Korea; they found that individuals who received reality therapy group interventions had higher self-esteem and locus of control scores compared to those in control groups. Another study showed that a reality therapy group intervention was effective in reducing internet addiction among university students (J. S. Kim 2008). A different study in Nigeria found that reality therapy, cognitive coping behavior training, and their combination were more effective in helping empty-nester retirees with their adjustment compared to a control group (Chima & Nnodum 2008).

A specific topic that has received some attention in research on reality therapy is domestic violence. Albert Gilliam (2004) divided men who had committed domestic violence into two groups of fifteen each: one group received twelve weeks of group reality therapy, while the other group received twelve weeks of structured cognitive-behavioral therapy. The group that received reality therapy showed a significant change on a scale of self-control over violence; the other group did not. However, no significant differences between the two groups were found on several other measures of psychological and social functioning. Robert Rachor (1995) evaluated the effectiveness of a twenty-one-session program for domestic violence with twenty-two men and twenty-three women, using reality-therapy concepts and reality therapy for families. The results showed very little or no reported domestic violence for the women, but some violence was reported for the men. Unfortunately, a no-treatment control group was not used in this study.

Reality therapy and choice theory can also be applied to bullying (Beebe & Robey 2011). A study in South Korea found a ten-session reality-therapy group intervention to be effective in decreasing victimization and increasing responsibility in children being bullied (J.-U. Kim 2006).

Several more-recent studies provide some support for the effectiveness of reality therapy or choice theory interventions (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 249–250). Three recent studies, conducted in Taiwan with women drug offenders, found positive results for reality therapy (short-term, twelve sessions) in improving hope, goal setting, and persistence (Law & Guo 2017); increasing self-efficacy in decision-making, planning, coping, and social skills (Law & Guo 2015); and enhancing self-determination and sense of self-control (Law & Guo 2014).

In another study (B. Smith et al. 2011), a twelve-week choice-theory-based group treatment was compared to a twelve-week motivational interviewing (MI) group treatment with college students who had an alcohol-related violation. No significant differences between the two interventions were found, showing the choice-theory-based treatment to be as effective as MI, which is an empirically supported treatment.

Two other studies should be mentioned: one was done in Taiwan with underachieving elementary school students in which a fifteen-week reality-therapy-based group intervention led to improvements in learning attitudes and strategies, motivation, and grades (Liu, Ting, & Cheng 2010); in the other, conducted in Nigeria with twenty high school students, reality therapy was found to significantly decrease HIV risk among them (Azekhueme & Adegoke 2010).

There are therefore some positive findings on the effectiveness of reality therapy. However, not all these research studies had adequate control groups. In a meta-analysis of over twenty outcome studies on reality therapy, Lisa Radtke, Marty Sapp, and Walter C. Farrell (1997) found a medium effect for reality therapy. Controlled outcome research on reality therapy, using randomized controlled trials (RCTs), is still quite limited. Thus, at present no definitive conclusions can be made about the effectiveness of reality therapy, but preliminary findings so far are encouraging. Further controlled outcome research on purer forms of reality therapy conducted by properly trained and certified reality therapists is needed for the empirical status of reality therapy to be further strengthened (see L. Murphy 1997; Wubbolding 2000).

Future Directions

Although the percentage of psychotherapists surveyed in the United States who indicate the existential/humanistic approach to therapy as their primary orientation is small, ranging from 1 percent of clinical psychologists to 7 percent of counseling psychologists, 4 percent of social workers, and 5 percent of counselors (see Prochaska & Norcross 2018, 3), the actual number of reality therapists today is probably much higher. In fact, since William Glasser originally used the term “reality therapy” in 1962 (O’Donnell 1987), reality therapy’s popularity has significantly increased. Glasser established the Institute for Reality Therapy in 1967 in Los Angeles, and in 1975 it began certifying reality therapists who completed an eighteen-month training program. An international organization for certified reality therapists was founded in 1981; the group has grown significantly and now holds annual conventions. At present, there are around eight thousand people who have completed the training program and are reality therapy certified. The Institute of Reality Therapy is now known as William Glasser International (www.wglasser international.org) (see Sharf 2016, 463–464). There is also a Center for Reality Therapy directed by Robert E. Wubbolding in Cincinnati, Ohio (www.realitytherapywub.com).

Reality therapy has had a large following since 1965, especially among teachers, rehabilitation counselors, youth guidance counselors, and substance-abuse treatment counselors (Parrott 2003, 356). It has also established itself as a major approach to counseling and psychotherapy that has been used in many practice settings with different clients and clinical problems.

The main journal for reality therapy today is the International Journal of Choice Theory and Reality Therapy, an online journal edited by Tom Parish ([email protected]).

A more recent application of reality therapy has been in the development of Clubhouse programs or organizations to support, using choice theory, people with severe mental disorders such as schizophrenia and bipolar disorder. Surveys have reported positive change as a result (see Casstevens 2010, 2013; Cisse & Casstevens 2011).

Reality therapy and choice theory will continue to be a major school of counseling and therapy as well as an important approach to school consultation and the positive development and learning of students. Reality therapy and choice theory can also be combined with other therapies for a more integrative therapy approach (see Cameron 2011). Glasser was a visionary and energetic advocate for choice theory and reality therapy in the United States and abroad (see Glasser 2002, 189–190). He died in 2013, but his legacy of reality therapy and choice theory will live on in the years to come.

Recommended Readings

Glasser, W. (1965). Reality therapy: A new approach to psychiatry. New York: Harper & Row.

Glasser, W. (1998). Choice theory: A new psychology of freedom. New York: HarperCollins.

Glasser, W. (2001). Counseling with choice theory: The new reality therapy. New York: HarperCollins.

Roy, J. (2014). William Glasser: Champion of change. Phoenix: Zeig, Tucker, & Theisen.

Wubbolding, R. E. (1988). Using reality therapy. New York: Harper & Row.

Wubbolding, R. E. (2000). Reality therapy for the 21st century. Philadelphia: Brunner-Routledge.

Wubbolding, R. E. (2011). Reality therapy. Washington, DC: American Psychological Association.

Wubbolding, R. E. (2017). Reality therapy and self-evaluation: The key to client change. Alexandria, VA: American Counseling Association.

Wubbolding, R. E., & Brickell, J. (2015). Counseling with reality therapy (2nd ed.). London: Speechmark.

Chapter 15

Integrative Therapies and Positive Psychotherapy

Integrative therapies refer to several approaches to counseling and psychotherapy that are based on integration of different theories and/or techniques to treat certain clients with specific problems in a flexible and responsive way, based on outcome and process research, including principles of therapeutic change that work. Since some early attempts at integration in psychotherapy by Thomas French (1933), who wrote about psychoanalysis and Ivan Pavlov’s classical conditioning, and Saul Rosenzweig (1936), who described a few essential ingredients of all effective therapies and therefore pointed to common factors—as well as Jerome Frank’s (1961) crucial contribution to the key common features of all therapies—psychotherapy integration has grown tremendously, especially after the influential publication of Paul Wachtel’s (1977) integration of psychoanalysis and behavior therapy. The Society for the Exploration of Psychotherapy Integration was founded in the early 1980s, and in 1991 it started publishing the Journal of Psychotherapy Integration (see Gold & Stricker 2020, 444–445).

The four major models or pathways of integrative therapies are (Gold & Stricker 2020; see also Norcross & Beutler 2019; Norcross & Goldfried 2019; Stricker 2010; Stricker & Gold 1993): (1) theoretical integration: one theoretical approach to therapy is combined with another theoretical approach or other approaches (e.g., integrative psychodynamic-behavior therapy developed by Paul Wachtel); (2) technical eclecticism: techniques or therapeutic interventions from two or more therapies are combined with little or no theoretical integration (e.g., multimodal therapy developed by Arnold Lazarus, transtheoretical psychotherapy developed by James O. Prochaska and Carlo DiClemente with ten change processes and six stages of readiness to change, and prescriptive psychotherapy or systematic treatment selection developed by Larry Beutler and, to a lesser extent, John Norcross); (3) common factors approaches: the emphasis is on nonspecific common factors that cut across therapy approaches, such as empathy and goal collaboration between client and therapist (e.g., common-factors integrative therapy developed by Sol Garfield; a contextual model for psychotherapy developed by Bruce Wampold that emphasizes therapist empathy, congruence, and positive regard, plus goal collaboration between client and therapist); and (4) assimilative integration: the assimilative integrative therapy is housed in one major theoretical approach but also uses techniques from other therapy approaches (e.g., psychodynamically based integrative therapy developed by George Stricker and Jerry Gold, which is essentially psychodynamic therapy integrated with some techniques from Gestalt therapy, experiential therapy, and more recently from Acceptance and Commitment Therapy or ACT).

These four major models or pathways of integrative therapies will be covered in more detail in this chapter, as will a more recent approach to therapy: positive psychotherapy as developed by Tayyab Rashid and Martin Seligman, based on positive psychology, a movement Seligman helped found at the turn of this millennium. Positive psychotherapy is not a new school or genre of psychotherapy but can be considered as an integration of more traditional therapy that focuses on fixing what’s wrong with a positive psychology perspective that emphasizes building what’s strong, including character strengths and virtues of the client. Positive psychotherapy, based on positive psychology, therefore focuses on helping clients grow in flourishing with positive emotions, positive relationships, good work, and a deep sense of personal meaning and purpose, not just to alleviate or overcome negative symptoms.

Brief biographical sketches of some key figures in integrative therapies as well as positive psychotherapy will first be provided.

Biographical Sketches of Key Figures in Integrative Therapies and Positive Psychotherapy

There are many examples of integrative therapies and therefore many key people who developed them (see Gold & Stricker 2020; Norcross & Beutler 2019; see also Norcross & Goldfried 2019; Stricker 2010). However, the following key people mentioned earlier who developed some of the better known and more widely used integrative therapies, as well as positive psychotherapy, will be covered in brief biographical sketches: Paul Wachtel, Arnold Lazarus, James Prochaska, Carlo DiClemente, Larry Beutler, John Norcross, Sol Garfield, Bruce Wampold, George Stricker, and Jerry Gold; and for positive psychotherapy, Tayyab Rashid and Martin Seligman.

Paul L. Wachtel (1940–) is a distinguished professor of psychology at the City College of New York and a graduate and adjunct faculty member of the New York University postdoctoral program in psychotherapy and psychoanalysis. He completed undergraduate studies in psychology at Columbia University in 1961 and his PhD in clinical psychology at Yale University in 1965. He was a cofounder and past president of the Society for the Exploration of Psychotherapy Integration and a fellow of several divisions of the American Psychological Association.

Wachtel is well known for being a key leader in theoretical integration and developing integrative psychodynamic-behavior therapy in his classic book, Psychoanalysis and Behavior Therapy: Toward an Integration (1977). He described an integrative therapy approach that was based on cyclical psychodynamic theory combined with social learning principles and reinforcement, and therefore integrated psychoanalytic therapy with behavior therapy (see also Wachtel 1997). More recently, in expanding his integrative approach, he has also included relational therapies (see Wachtel 2008, 2014).

Wachtel has received several awards, including the 2010 Hans H. Strupp Award for Psychoanalytic Writing, Teaching, and Research; the 2012 Distinguished Psychologist Award from the APA’s Divison 29 (Psychotherapy); the 2013 Scholarship and Research Award from the APA’s Division 39 (Psychoanalysis); and the first annual Sidney J. Blatt Award for Outstanding Contributions to Psychotherapy, Scholarship, Education, and Practice in 2018.

Arnold Allan Lazarus (1932–2013)—the founder of multimodal therapy (see A. A. Lazarus 1981, 1985, 1989, 1997, 2008; C. N. Lazarus & Lazarus 2019), one of the best-known integrative therapies in technical eclecticism, using the BASIC ID model—was also a key figure earlier in the development of behavior therapy. His biographical sketch has already been provided in chapter 11 of this book, on behavior therapy, and will not be repeated here.

James O. Prochaska (1942–) obtained his bachelor’s, master’s, and PhD in clinical psychology degrees from Wayne State University, then completed his internship at the Lafayette Clinic in Detroit. He is professor emeritus of psychology and director of the Cancer Prevention Resource Center at the University of Rhode Island. He is the lead developer, together with Carlo DiClemente, of the transtheoretical model of behavior change and transtheoretical psychotherapy, one of the best-known integrative therapies in technical eclecticism, with ten change processes and six stages of readiness to change (Prochaska & DiClemente 1984, 2002, 2019). He has also coauthored two self-help books (Prochaska, Norcross, & DiClemente 1994; Prochaska & Prochaska 2016), and a leading and widely used textbook on systems of psychotherapy (Prochaska & Norcross 2018). Transtheoretical psychotherapy has also been categorized as an example of theoretical integration (see Norcross & Goldfried 2019).

Prochaska has also published over three hundred scholarly articles and fifty book chapters. He has been the principal investigator on grants totaling over $90 million from the National Institutes of Health. The Association of Psychological Science has recognized him as one of the most cited authors in psychology. He has received many awards, including the Rosalee Weiss Award from the APA, Beckham Award for Excellence in Education and Inspirational Leadership from Columbia University, Innovators Award from the Robert Wood Johnson Foundation, and the Fries Health Education Award from the Society for Public Health Education. He is also the first psychologist to win a Medal of Honor for Clinical Research from the American Cancer Society.

Carlo C. DiClemente (1942–) obtained his MA in psychology from the New School for Social Research and his PhD in psychology from the University of Rhode Island. He is professor emeritus of psychology at the University of Maryland, Baltimore County, and director of the MDQuit tobacco resource center, the Center for Community Collaboration, and the Home Visitor Training Certificate Program at the university. He is codeveloper with James O. Prochaska of the transtheoretical model of behavior change and transtheoretical psychotherapy as an integrative therapy in technical eclecticism (Prochaska & DiClemente 1984, 2002, 2019). He is also author of the second edition of an authoritative text on addiction and change (DiClemente 2018), coauthor of a self-help book on changing for good (Prochaska, Norcross, & DiClemente 1995), and books on substance-abuse treatment using stages of change (see Connors et al. 2013; Velasquez et al. 2016).

DiClemente has received a number of awards, including the Lifetime Achievement Award from the Addictive Behaviors Special Interest Group of the Association for Behavioral and Cognitive Therapies (ABCT), the Innovators Combating Substance Abuse Award from the Robert Wood Johnson Foundation, the John P. McGovern Award from the American Society of Addiction Medicine, and a Presidential Citation from the APA.

Larry E. Beutler (1941–) received his PhD in clinical psychology from the University of Nebraska-Lincoln in 1970. He is the primary developer of prescriptive psychotherapy, or systematic treatment selection (STS), another well-known integrative therapy (see Beutler, Clarkin, & Bongar 2000; Beutler, Consoli, & Lane 2005; Beutler & Harwood 2000; Castonguay & Beutler 2006a; 2006b; Castonguay, Constantino, & Beutler 2019; Consoli & Beutler 2019; also Norcross & Beutler 2019; Gold & Stricker 2020). Prescriptive psychotherapy has been described as an example of technical eclecticism by Jerry Gold and George Stricker (2020), but John Norcross and Beutler assert that in STS they “intentionally blend several of the four paths toward integration” (2019, 530), and STS is therefore not simply an example of technical eclecticism.

Beutler has published over 450 scientific papers and chapters; he also has authored, edited, or coauthored at least 26 books on various topics, including psychotherapy, psychopathology, depression, drug abuse, psychological assessment, sleep disorders, health psychology, trauma, and terrorism.

Beutler is the William McInnes Distinguished Professor Emeritus and the former chair and director of training for the clinical psychology program at the Pacific Graduate School of Psychology, Palo Alto University, in Palo Alto, California. He is the past director of the National Center on the Psychology of Terrorism—cosponsored by Stanford University, Palo Alto University, and the Palo Alto Veterans Health Care System—and also professor emeritus at the University of California Santa Barbara (UCSB), where he established and directed the Clinical/Counseling/School Psychology Program. He has served as president of the Society for Psychotherapy Research, and of Division 12 (Society of Clinical Psychology) and of Division 29 (Psychotherapy) of the APA. He has received numerous awards, including the Distinguished Scientific Achievement Award from the California Psychological Association, the Distinguished Research Career Award from the Society for Psychotherapy Research International, and a Presidential Citation from the APA.

John C. Norcross (1957–) received his baccalaureate from Rutgers University and his MA and PhD in clinical psychology from the University of Rhode Island. He takes a pragmatic approach to therapy and has contributed to the development of integrative therapies (Norcross & Goldfried 2019) such as STS, or prescriptive psychotherapy (primarily developed by Larry Beutler), especially through his substantial work on psychotherapy relationships that work or empirically supported therapeutic relationships (Norcross & Lambert 2019; Norcross & Wampold 2019). He has written over four hundred scholarly publications and authored, coauthored, or edited at least twenty-five books, including those already mentioned, and a leading and widely used textbook on systems of psychotherapy, coauthored with James Prochaska (Prochaska & Norcross 2018), as well as a couple of popular self-help books (Norcross 2012; Prochaska, Norcross, & DiClemente 1994).

Norcross is distinguished professor of psychology at the University of Scranton in Scranton, Pennsylvania, and adjunct professor of psychiatry at SUNY Upstate Medical University. He has served as president of the APA’s Division 12 (Society of Clinical Psychology) and Division 29 (Psychotherapy), and the Society for the Exploration of Psychotherapy Integration. Norcross has received numerous awards, including APA’s Distinguished Contributions to Education & Training Award, the Rosalee Weiss Award from the American Psychological Foundation, Pennsylvania Professor of the Year from the Carnegie Foundation, and election to the National Academies of Practice.

Sol L. Garfield (1918–2004) obtained his PhD in clinical psychology from Northwestern University in 1942. He was a pioneer in integrative therapies as the developer of a common-factors eclectic approach to psychotherapy (Garfield 1980, 2000). Garfield was the author or editor of many books and most notably the coauthor, with Allen E. Bergin, of the first four editions of the Handbook of Psychotherapy and Behavior Change. He was the director of the clinical psychology training program at Washington University from 1970 to 1986 and was professor emeritus since 1986.

Garfield served as president of the APA’s Division 12 (Clinical Psychology) and of the Society for Psychotherapy Research (SPR). He was the recipient of many awards, including the APA’s Distinguished Contribution to Knowledge Award, the Distinguished Contribution to Clinical Psychology Award from APA’s Division 12 (Clinical Psychology), the Distinguished Research Career Award from SPR, and the 3rd Annual Award for Outstanding Contributions to Clinical Training from the Council of University Directors of Clinical Psychology. He died of a heart attack on August 14, 2004, in Cleveland, Ohio, at the age of eighty-six.

Bruce E. Wampold (1948–) obtained his PhD in counseling psychology from the University of California, Santa Barbara. He is the developer of a contextual model for psychotherapy that emphasizes therapist empathy, congruence, and positive regard, as well as goal collaboration between the client and therapist, as a common-factors approach to integrative therapies (see Wampold 2015; Wampold & Imel 2015; Wampold & Ulvenes 2019).

Wampold is the director of the research institute at Modum Bad Psychiatric Center in Vikersund, Norway; emeritus professor of counseling psychology at the University of Wisconsin-Madison; and chief scientist of Theravue, an electronic platform for therapist improvement. He has received several awards, including the APA Gold Medal Award for Life Achievement in the Application of Psychology, the Distinguished Professional Contributions to Applied Research Award from the APA, and the Distinguished Research Career Award from the Society for Psychotherapy Research. He has served as president of SPR and published numerous articles and several books, notably the second edition of The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work (Wampold & Imel 2015).

George Stricker (1936–) earned his PhD in clinical psychology from the University of Rochester in 1960. He was also the recipient of an honorary PsyD from the Illinois School of Professional Psychology, Meadows Campus, in 1997. He is the developer, together with Jerry Gold, of a psychodynamically based integrative therapy in assimilative integration that is essentially psychodynamic therapy, but with the use of some techniques from Gestalt therapy or experiential therapy, and also more recently from ACT. It is called assimilative psychodynamic psychotherapy (Stricker & Gold 2019; see also Gold 2014; Gold & Stricker 2015, 2020; Stricker 2010; Stricker & Gold 1993, 2006).

Stricker was professor of psychology at the Argosy University, Washington, DC, campus, since 2004, but Argosy University closed in March 2019. He was on the faculty at Adelphi University from 1963 to 2004, where he served as distinguished research professor of psychology and as dean at the Derner Institute. He has published over a hundred articles, about thirty book chapters, and has authored or edited about twenty books. Stricker served as president of the National Council of Schools of Professional Psychology (NCSPP), the Society for Personality Assessment, the APA’s Division 12 (Clinical Psychology), and the New York State Psychological Association.

Stricker is also the recipient of numerous awards, including the APA’s Award for Distinguished Contribution to Applied Psychology and the APA’s Award for Distinguished Career Contributions to Education and Training in Psychology, the NCSPP’s Award for Distinguished Contribution to Education and Professional Psychology, the Florence Halpern Award for Distinguished Professional Contributions in Clinical Psychology from the APA’s Division 12 (Society of Clinical Psychology), the Bruno Klopfer Lifetime Achievement Award from the Society for Personality Assessment, and the Karl Herser Award for Advocacy from the APA.

Jerry Gold obtained his PhD in clinical psychology from Adelphi University in 1981. He is professor of psychology at Adelphi University in Garden City, New York. He helped to develop assimilative psychodynamic psychotherapy with George Stricker, the lead developer of this integrative therapy in assimilative integration (Stricker & Gold 2019; see also Gold 2014; Gold & Stricker 2015, 2020; Stricker 2010; Stricker & Gold 1993, 2006).

Tayyab Rashid received his PhD in clinical psychology from Fairleigh Dickinson University in Teaneck, New Jersey, in 2004. He completed his predoctoral clinical training in 2003–2004 at the Counseling and Psychological Services at the University of Pennsylvania in Philadelphia and his postdoctoral clinical training at the Positive Psychology Center in 2004–2005. He trained with Martin Seligman, and together they developed positive psychotherapy based on positive psychology (see Rashid & Seligman 2019; M. Seligman, Rashid, & Parks 2006); this integration of more traditional therapy focuses on fixing what’s wrong or treating symptoms and psychopathology, with a positive psychology perspective that emphasizes building what’s strong, including character strengths and virtues of the client. He has published many articles and book chapters and a few books, most notably the clinician’s manual (Rashid & Seligman 2018a) and workbook (Rashid & Seligman 2018b) for positive psychotherapy, and a book on positive psychotherapy specifically for psychosis (Slade et al. 2017).

Rashid is a licensed clinical psychologist at the Health & Wellness Centre, University of Toronto Scarborough in Ontario, Canada. He is also an associate faculty member in the graduate psychological clinical science program at the University of Toronto Scarborough, and an adjunct faculty member at the Executive Master’s Program in Positive Leadership at the IE University in Spain. He has worked with individuals suffering from complex mental disorders such as severe depression, debilitating anxiety, borderline personality disorder, and suicidal behavior. He has received several awards, including the Outstanding Practitioner Award from the International Positive Psychology Association in 2017, and the Chancellor Award from the University of Toronto in 2018.

Martin Elias Peter Seligman (1942–) received his PhD in psychology from the University of Pennsylvania in 1967. He is the Zellerbach Family Professor of Psychology and director of the Positive Psychology Center at the University of Pennsylvania in Philadelphia, Pennsylvania. He is also the director of the Master of Applied Positive Psychology program. Prior to this, he was the director of the clinical training program in the Department of Psychology at the University of Pennsylvania for fourteen years.

Seligman served as president of the American Psychological Association (APA) in 1998 and helped found the positive psychology movement and advance it as a field of scientific study since then (see M. Seligman & Csikszentmihalyi 2000). He is a leading authority in positive psychology, as well as learned helplessness, depression, optimism, pessimism, and resilience. Seligman has written more than 350 scholarly publications and thirty books (see, e.g., M. Seligman 2002, 2011, 2018; C. Peterson & Seligman 2004; Rashid & Seligman 2018a, 2018b). He also helped to develop positive psychotherapy, together with Tayyab Rashid, which is an approach to therapy that integrates traditional therapy with a positive psychology focus on the character strengths and virtues of the client. Positive psychotherapy can therefore be viewed as an integrative therapy that uses various techniques to help clients not only to overcome symptoms but also to flourish with positive emotions, positive relationships, good work, and a deep sense of personal meaning and purpose (Rashid & Seligman 2018a, 2018b, 2019).

Seligman also served as president of Division 12 (Clinical Psychology) of the APA. He is the recipient of numerous awards, including the APA Award for Lifetime Contributions to Psychology, the APA Award for Distinguished Scientific Contribution, the Lifetime Achievement Award of the Society for Research in Psychopathology, the Tang Award for Lifetime Achievement in Psychology, the Distinguished Contribution Award for Basic Research with Applied Relevance from the American Association of Applied and Preventive Psychology, and the James McKeen Cattell Fellow Award for Applications of Psychological Knowledge and the William James Fellow Award for Contributions to Basic Science, both from the American Psychological Society, now called the Association for Psychological Science. He has also been given honorary doctorates from Uppsala University, Sweden; Massachusetts College of Professional Psychology; Complutense University, Spain; and University of East London. Seligman is also a champion bridge player and has won over fifty regional bridge championships.

Major Theoretical Ideas of Integrative Therapies and Positive Psychotherapy

Perspective on Human Nature

There are at least four major models of psychotherapy integration, with various versions of integrative therapies; thus there are also different perspectives on human nature in these integrative therapies. However they are classified or categorized, integrative therapies that are more based on psychoanalytic or psychodynamic theory, such as Wachtel’s (1977, 1997) integrative psychodynamic-behavior therapy or the assimilative psychodynamic psychotherapy developed by Stricker and Gold (2019), will also have a perspective on human nature that is somewhat similar to that of psychoanalytic therapy, covered in chapter 4 of this book. Psychoanalytic therapy, following Sigmund Freud, tends toward a pessimistic or at best a neutral view of human nature and how much people can change. However, in more relational psychodynamic approaches, including Wachtel’s and Stricker and Gold’s integrative therapies, there is a more open and less pessimistic view of human nature being more malleable to change, and therefore techniques from other therapeutic approaches are also used to foster therapeutic change.

Other integrative therapies—such as multimodal therapy developed by Arnold Lazarus (1981, 1985, 1989, 1997, 2008; see also C. N. Lazarus & Lazarus 2019), prescriptive psychotherapy (STS) developed primarily by Beutler with contributions from Norcross and others (see Norcross & Beutler 2019; see also Beutler, Consoli, & Lane 2005; Consoli & Beutler 2019), and transtheoretical psychotherapy developed by Prochaska and DiClemente (1984, 2002, 2019), as well as common-factors approaches such as Garfield’s (1980, 2000) common-factors eclectic approach and Wampold’s (2015; see also Wampold & Imel 2015; Wampold & Ulvenes 2019) contextual model for psychotherapy—all assume some potential or capacity for change in people, with a perspective on human nature that is more open and positive, yet without negating how hard it can be for people to change or be motivated to change.

The most positive view of human nature comes from the positive psychotherapy that is based on positive psychology, as developed by Rashid and Seligman (2018a, 2018b, 2019). This newer integrative therapy focuses more on the character strengths and virtues of people; it assumes a positive view of human nature that is oriented toward flourishing and not as much toward psychopathology. Positive psychotherapy, like positive psychology, can be critiqued for possibly being too positive and not paying enough attention to the darker side of human nature (see, e.g., Tan 2006a; see also Entwistle & Moroney 2011; Gruber, Mauss, & Tamir 2011; Hackney 2021; Held 2004; Horowitz 2018; S. Jones 2014; McMinn 2017).

Gold and Stricker, in their review and description of integrative approaches to psychotherapy, also included a fifth category of integrative therapies that does not easily fit into the four major models presented so far: bringing the body into psychotherapy integration (2020, 451), referring to some newer integrative therapies that use interventions that directly impact the body. Examples are eye-movement desensitization and reprocessing (EMDR), developed by Francine Shapiro (2018), and somatic experiencing psychotherapy, described by Peter Levine and Bessel van der Kolk (2015). Such integrative approaches view the human person as an embodied whole and place more emphasis on the body, not only on the mind or soul separate from the body (see van der Kolk 2014; also Dana 2020; McConnell 2020; Salmon 2020).

A theory of personality is also more central and important in integrative therapies that are in the theoretical integration and assimilative integration categories, and much less salient or even omitted in integrative therapies that are described as technical eclecticism or common-factors approaches (Gold & Stricker 2020, 452).

Basic Theoretical Principles of Major Integrative Therapies

The number and variety of integrative therapies have grown over the last few decades (see Norcross & Goldfried 2019), and it is very difficult, if not impossible, to summarize the basic or main theoretical principles of each integrative therapy. However, the major examples already mentioned in the four major models of integrative therapies, following Gold and Stricker’s (2020) review and description, will now be briefly covered.

In the category of technical eclecticism, multimodal therapy developed by Arnold Lazarus (1981, 1985, 1989, 1997, 2008) is a major example, but it has already been described in chapter 11 of this book on behavior therapy, along with its more recent broadening development. Lazarus went beyond traditional behavior therapy to comprehensively assess and intervene in seven major areas of a client’s whole-person functioning, using the BASIC ID acronym: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relations, and Drugs/Biology. He advocated using effective techniques from different therapy approaches, including many cognitive and behavioral interventions as well as others, such as the empty chair technique from Gestalt therapy. Lazarus advocated technical eclecticism in the use of whatever techniques may be helpful and have been found to be effective, but not theoretical eclecticism or integration of theories that may be incompatible. He mainly subscribed to a broad social-learning theoretical perspective; multimodal therapy still tends to be included in behavior therapy or cognitive behavior therapy more broadly defined or described.

Another example of technical eclecticism is the transtheoretical psychotherapy developed by Prochaska and DiClemente (1984, 2002, 2019), which has also been categorized as an integrative therapy in theoretical integration (see Norcross & Goldfried 2019). Transtheoretical psychotherapy focuses on assessing a client’s readiness for change, using the appropriate intervention or change process that will match a client’s specific stage of readiness for change. It describes six stages of change possible for a client: precontemplation (not thinking at all about change), contemplation (beginning to think about change but not ready to engage in action toward change), preparation (gathering resources and energy to change), action (beginning and continuing to use therapy for constructive change), maintenance (reinforcing therapeutic changes that have occurred), and termination (ending therapy). The ten change processes that transtheoretical psychotherapy has identified across therapeutic approaches for effective intervention with clients at different stages of change are these: consciousness raising, dramatic relief, self-reevaluation, environmental reevaluation, self-liberation, social liberation, counterconditioning, stimulus control, reinforcement management, and the helping relationship. Clients are also assessed in the following areas: symptoms and situational problems, maladaptive cognitions or thoughts, present interpersonal conflicts, family and systems conflicts, and intrapersonal conflicts (see Gold & Stricker 2020, 447; see also Prochaska & DiClemente 2002). In a more recent description of the transtheoretical approach to integrative therapy, Prochaska and DiClemente (2019) covered five stages of change (leaving out termination) and emphasized the following eight change processes: consciousness raising, emotional arousal (dramatic relief), environmental reevaluation, self-reevaluation, self-liberation, contingency management, counterconditioning, and stimulus control.

In prescriptive psychotherapy, or STS, as developed mainly by Beutler (see Beutler & Harwood 2000; Consoli & Beutler 2019), many techniques or therapeutic interventions from different therapy approaches are used, with a major focus on matching therapist and techniques to the specific characteristics and problems of the client or patient, along four main therapeutic dimensions. The first dimension is the intensity of the therapy provided. The second dimension is the specific focus in the therapy, whether it should be on insight or on behavioral skills training. The third dimension is how directive the therapist should be, from being very directive to a nondirective stance. The fourth and final dimension is how the client’s feelings are managed during a therapy session, making changes in regulating emotion as necessary. The patient or client is systematically assessed on several dimensions: degree of functional impairment (determines the intensity and type of therapy provided, whether psychotherapy or pharmacotherapy as the first choice of treatment), level of distress (affect regulation strategies for those with high distress levels, interventions for enhancing awareness of and access to feelings for those with lower levels of distress), coping style (internalizers are better matched with insight-oriented therapy and impulsive externalizers with more behavioral treatments), and resistance level (a more directive therapist stance for those with lower resistance levels and a more nondirective therapist approach with those who show higher levels of reactance or resistance). For patients who are positively motivated for therapy and open to change, techniques are chosen to effect and maintain moderate or optimal levels of emotional intensity and arousal (see Gold & Stricker 2020, 448).

In common-factors approaches to integrative therapies, two major examples are briefly covered here. First is the common-factors eclectic integrative therapy developed by Garfield (1980, 2000), which integrates insight, exposure, and the accessing of new experiences as well as hope through the effective use of the therapeutic relationship. Second is the contextual model for psychotherapy described by Wampold (2015; see also Wampold & Imel 2015; Wampold & Ulvenes 2019), which is based on the research or empirical findings related to how much the more nonspecific common factors and the treatment-specific factors contribute to the outcome of therapy. Wampold has concluded that the empirical evidence is more strongly in favor of the contributions of common factors to therapeutic effectiveness compared to the contributions of treatment-specific factors or therapeutic techniques. Several common factors have been found to have medium to large treatment effects, including the following: therapist empathy, the therapeutic alliance, affirmation and positive regard provided by the therapist for the client, therapist congruence, and goal collaboration between client and therapist. Wampold’s contextual model for psychotherapy therefore emphasizes these common factors as being more crucial for effective therapy than specific techniques.

In theoretical integration, the best-known example is Wachtel’s (1977, 1997) integrative psychodynamic-behavior therapy, based on cyclical psychodynamic theory combined with social learning principles and reinforcement. He has more recently expanded his model to include ideas and interventions from a broader spectrum of therapy approaches, such as experiential therapies, family systems, and attachment theory, as well as emphasizing more of a relational psychodynamic perspective. Cultural and social issues such as racism, sexism, and poverty have also been given more attention (see Wachtel 2008, 2014; Wachtel & Gagnon 2019). Other examples of theoretical integration mentioned by Gold and Stricker (2020, 450) include process-experiential therapy and emotionally focused therapy (EFT).

In assimilative integration, a well-known example is assimilative psychodynamic psychotherapy developed by Stricker and Gold (2019), which is housed mainly in psychodynamic therapy following the basic principles of a psychodynamic approach. However, it also uses techniques from other therapy approaches when appropriate or helpful, such as the two-chair technique from Gestalt therapy, to facilitate the achievement of specific psychodynamic goals, as well as to more effectively treat the target problem. More recently, assimilative psychodynamic psychotherapy has also integrated therapeutic principles and techniques from newer therapies such as ACT (Gold 2014) and become more sensitive to the social and cultural context of the client, paying more attention to discrimination and diversity issues (see Gold & Stricker 2020,  451).

There are many other examples of what may also be considered integrative therapies such as ACT, DBT, MBCT; cognitive analytic therapy; EFT; and EMDR (see Norcross & Beutler 2019, 547; see also Schottenbauer, Glass, & Arnkoff 2005), as well as a principle-based approach to psychotherapy integration, feedback informed treatment, cognitive-behavioral assimilative integration, integrative psychotherapy for generalized anxiety disorder, cognitive-behavioral analysis system of psychotherapy for chronic depression, integrative psychotherapy with culturally diverse clients (including religiously diverse clients), integrative psychotherapy with children, and integrating self-help and psychotherapy (see Norcross & Goldfried 2019). The variety and number of integrative therapies have grown considerably in recent years, but some caution is warranted in not too quickly describing or classifying a specific therapy approach as an integrative therapy just because it uses a technique or two from another approach. There is a danger of labeling or categorizing too many therapies as integrative therapies. Recent reviews of the outcome research on psychotherapy integration have included twenty-nine integrative therapies (see Boswell, Newman, & McGinn 2019; Schottenbauer, Glass, & Arnkoff 2005).

Positive psychotherapy is a newer approach to therapy and is based on positive psychology (see Rashid & Seligman 2018a, 2018b, 2019), which can also be viewed as an integrative therapy. It is founded on two major theories (see Rashid & Seligman 2019, 489). The first is Seligman’s conceptualization of well-being, using the PERMA model of Positive emotions, Engagement, Relationships, Meaning, and Accomplishment (M. Seligman 2002, 2011). The second is character strengths as crucial therapeutic ingredients (C. Peterson & Seligman 2004). Specific techniques used in positive psychotherapy include interventions that are unique to positive psychotherapy (e.g., gratitude journal, gratitude letter, strengths assessment) as well as helpful methods from other therapy approaches; thus there is some element of technical eclecticism in positive psychotherapy.

Development of Psychopathology

Many integrative therapies, especially those with a psychodynamic orientation, assume traditional developmental views of the crucial role of negative childhood and adolescent experiences that lead to repeated “vicious circles” (Wachtel 2014) of self-defeating patterns of thinking, feeling, and behavior in the development of psychopathology (see Gold & Stricker 2020, 454–455), and therefore focus on overcoming pathological or dysfunctional patterns and symptoms; yet not all integrative therapies subscribe to such traditional pathology-oriented views. The influence of genetic and biological factors and early environmental experiences is generally accepted—yet not in a fatalistic or deterministic way—by some integrative therapies that emphasize more the human capacity for choice and therefore for change, even within some of these limits. The integrative therapies that are more cognitive-behavioral in orientation as well as technically eclectic, such as multimodal therapy, are more optimistic about therapeutic change now and the learning of more adaptive and constructive coping skills that can overcome the effects of the past.

Positive psychotherapy, in particular, takes a more optimistic view of human nature and the capacity of people to engage in positive interventions that can help them to flourish, even if symptoms do not always get substantially reduced or ameliorated. It does not focus on psychopathology and its development in a traditional diagnosis-based perspective. In fact, positive psychotherapy has an alternative way of viewing psychopathology in terms of a lack or an excess in positive character strengths and virtues (C. Peterson & Seligman 2004) in the client, not so much in terms of diagnosis-based symptoms (see Rashid & Seligman 2019, 494–499). For example, in major depressive disorder, instead of focusing on the depressed mood, feeling sad and hopeless, positive psychotherapy focuses on assessing a lack of joy, delight, hope, optimism, playfulness, spontaneity, and goal orientation, with an excess of prudence and modesty (Rashid & Seligman 2019, 494).

Therapeutic Process and Relationship

Integrative therapies all agree on the importance of having a good therapeutic relationship with the client and of establishing a therapeutic alliance based on common factors such as warmth, empathy, and genuineness. In fact, common-factors-based integrative therapies focus mainly on these crucial factors in the therapeutic relationship as being curative or responsible for therapeutic change and not on technique. However, other integrative therapists also go beyond the basic importance of a good therapeutic relationship with the client, using more-specific techniques or interventions to help the client change in constructive ways.

The integrative therapist will also assume a more active or directive stance at times, using specific techniques to help the client achieve specific goals, and also in giving homework assignments or exercises to be completed between therapy sessions. As therapy progresses, more responsibility is given to the client to decide on integrative shifts in what is done in a session, homework assignments, and termination. An integrative therapist therefore needs to be more flexible and able to function in various roles as an authority, participant, collaborator, and follower, and to integrate ideas and interventions from at least two therapy approaches (see Gold & Stricker 2020, 461–463).

More specifically, positive psychotherapy also emphasizes developing a strong therapeutic alliance with the client, yet it focuses more on discussing the personal strengths of the client and less the weaknesses of the client, this may lead to more therapeutic change in the client. The therapist in positive psychotherapy is also active and directive in using specific interventions to help facilitate flourishing in the client, and not so much the alleviation of symptoms. Five broad possible mechanisms of change in the therapeutic process of positive psychotherapy have been identified (S. Walsh, Cassidy, & Priebe 2017): (1) re-educating attention to notice and recall positive experiences, (2) positive appraisal in reinterpreting negative memories, (3) identifying character strengths, (4) use of strengths in a balanced way, (5) exploring meaning and purpose (see Rashid & Seligman 2019, 507).

Major Therapeutic Techniques and Interventions

Since there are many integrative therapies today, there are numerous therapeutic techniques and interventions that can be used in the various integrative therapies, some of which have been mentioned earlier.

In multimodal therapy as an example of technical eclecticism, Arnold Lazarus (1989) originally listed thirty-nine principal techniques that can be used, with the majority being cognitive and behavioral interventions, plus other techniques such as the empty chair, from Gestalt therapy. More recently, Clifford N. Lazarus and Arnold Lazarus identified other more-contemporary therapeutic interventions that can also be eclectically used in multimodal therapy, such as techniques from EMDR, ACT, MBSR, and DBT (2019, 134).

In transtheoretical psychotherapy (see Prochaska & DiClemente 2019), five major stages of change are delineated; within these stages, the following specific systems of psychotherapy can be integrated and their therapeutic interventions used as suggested by Norcross and Beutler (2019, 539): (1) precontemplation stage: motivational interviewing, strategic family therapy, and psychoanalytic therapy; (2) contemplation stage: analytical therapy and Adlerian therapy; (3) preparation stage: existential therapy, REBT, cognitive therapy, interpersonal therapy, Gestalt and experiential therapy; (4) action and maintenance stages: behavior therapy, solution-focused therapy, EMDR, and exposure.

Wachtel’s (1977, 1997) integrative psychodynamic-behavior therapy in theoretical integration is a basically relational psychodynamic approach combined with behavioral techniques, and more recently with other therapeutic interventions from experiential therapies, family systems, and attachment theory. It also takes into consideration how broader cultural and social factors such as racism, sexism, and poverty may significantly contribute to psychopathology (see Wachtel 2008, 2014; Wachtel & Gagnon 2019).

In assimilative integration, Stricker and Gold’s (2019) assimilative psychodynamic psychotherapy is similarly housed in psychodynamic therapy and interventions, but also uses methods from other therapy approaches, such as the two-chair technique from Gestalt therapy and, later, interventions from ACT (Gold 2014). More recently, it pays more attention in therapy to how broader factors such as discrimination and diversity issues may impact the client in their specific cultural and social context (see Gold & Stricker 2020, 451).

Common-factors approaches to integrative therapy, such as Wampold’s (2015) contextual model for psychotherapy, do not emphasize techniques but focus on more nonspecific common factors such as warmth, empathy, congruence, and goal consensus between the client and therapist (see also Wampold & Ulvenes 2019).

Finally, in the case of positive psychotherapy as an integrative therapy, specific techniques are used in the three major phases of positive psychotherapy, which is usually conducted in fifteen sessions (group or individual), but with much flexibility and variation (Rashid & Seligman 2018a). Some of the techniques used are unique to positive psychotherapy (e.g., gratitude journal, gratitude letter, character-strengths assessment or profile) and other methods are taken from various therapy systems or approaches (e.g., forgiveness, learning to attend mindfully, posttraumatic growth). Positive psychotherapy can be a stand-alone treatment, but its specific techniques or exercises can also be integrated or used in other therapy approaches (Rashid & Seligman 2019, 500, 502).

In an earlier description of the sequentially structured format of the three phases of positive psychotherapy, Rashid and Seligman (2019, 500–506) included fourteen sessions of therapy but pointed out that more sessions may be needed for more difficult problems or clients. In the clinician manual and workbook for positive psychotherapy that were subsequently published, Rashid and Seligman (2018a, 2018b) expanded the protocol to fifteen sessions. The following is a brief summary of the session-by-session description of positive psychotherapy provided by Rashid and Seligman (2018a, 45–46) in the clinician manual:

A. Phase One: Session 1: Introduction and Gratitude Journal (recording three good things every night and what made them occur). Session 2: Character Strengths and Signature Strengths (with six virtues of wisdom and knowledge, courage, humanity, justice, temperance, and transcendence, and twenty-four character strengths such as creativity, curiosity, open-mindedness, authenticity, bravery, persistence, kindness, love, fairness, leadership, forgiveness, modesty, prudence, appreciation of beauty and excellence, gratitude, hope, humor, religiousness; clients put together a profile of their signature strengths, using various sources such as self-report, an online measure, a friend, and a family member). Session 3: Practical Wisdom (with four strategies—specificity, relevance, conflict, reflection and calibration—to resolve three specific problem situations). Session 4: A Better Version of Me (a written self-development plan in using the client’s strengths in adaptive ways to achieve specific and measurable goals).

B. Phase Two: Session 5: Open and Closed Memories (clients recall and write memories and learn adaptive ways of processing and dealing with open or negative memories). Session 6: Forgiveness (clients learn about the REACH process of forgiveness developed by Everett Worthington [2005a] and write a forgiveness letter but may not send or deliver it). Session 7: Maximizing versus Satisficing (clients learn to increase satisficing or making a good-enough choice instead of maximizing or aiming to make the best possible choice). Session 8: Gratitude (clients write a gratitude letter to someone they have not properly thanked, then conduct a gratitude visit with that person in order to read the letter to the recipient).

C. Phase Three: Session 9: Hope and Optimism (clients learn to develop a sense of hope by seeing realistically the best possible outcomes; they engage in the exercise One Door Closes, Another Door Opens by writing down three doors that closed and three doors that opened). Session 10: Posttraumatic Growth (clients explore their deep feelings and thoughts about a traumatic experience that still bothers them, engaging in expressive writing of such painful and traumatic experiences on paper as an optional exercise, if they feel ready to do this with adequate coping skills). Session 11: Slowness and Savoring (clients learn one slowness technique and one savoring technique that fit them to attend more mindfully to the positives in their lives by slowing down and savoring things more). Session 12: Positive Relationships (clients learn to recognize the strengths of loved ones and build enriching relationships with them by celebrating each other’s strengths). Session 13: Positive Communication (clients learn to explore the strengths of significant others and to engage in active-constructive responding that leads to relationship satisfaction). Session 14: Altruism (clients learn how being altruistic is beneficial to themselves and others, and plan to give the gift of time by engaging in some action that also uses their signature strengths). Session 15: Meaning and Purpose (clients focus on the search for meaning and purpose in their lives for the greater good, including leaving behind a positive legacy by writing down how they would like to be remembered).

Positive psychotherapy therefore uses many techniques and therapeutic methods and exercises, reflecting much technical eclecticism in helping clients to experience and live the full life that includes authentic happiness or well-being and life satisfaction based on PERMA and character strengths (see Rashid & Seligman 2019, 499; also Rashid & Seligman 2018b).

Integrative Therapy in Practice: Positive Psychotherapy (PPT)

This hypothetical transcript, presenting part of the first session of positive psychotherapy, demonstrates the PPT therapist’s use of warmth and empathy for the client, and more unique to positive psychotherapy, an introduction to PPT based on Rashid and Seligman (2018a, 69–71); and the use of the gratitude journal, based on Rashid and Seligman (2018a, 83).

Client: I am struggling with boredom and some depression, not feeling like I want to do much or anything at all. And so I stay home a lot and ruminate on negative things . . . and whether I’ll ever feel better and be my old, happier self.

PPT Therapist: It’s been a tough time for you feeling bored and down with negative thoughts, . . . including whether you’ll ever feel better, like your old self.

Client: Yeah . . . I feel stuck, and I am not sure what I can do to get out of this; . . . and therefore I decided to get some help and to see you.

PPT Therapist: Thanks for calling for the appointment with me today. It is a big and important step that you have taken to seek help, and I want to affirm you for this. Let me introduce and describe a bit more the therapy approach we will be taking here to help you. It is called positive psychotherapy, based on positive psychology developed by Dr. Martin Seligman, a well-known psychologist. Positive psychotherapy will help you counteract your symptoms like boredom, some depression, negative ruminations or recurring thoughts, and lack of motivation to do anything, with strengths, your weaknesses with virtues, and your deficits with skills, in a balanced way.

     The human brain or mind tends to focus more on negatives than positives. Our approach in positive psychotherapy is to help you build up your positives instead of focusing on the negatives in your life, although we will talk about your struggles too. The positives we will cover are based on Dr. Seligman’s ideas of well-being or authentic happiness, using the mnemonic PERMA: Positive emotion; Engagement; Relationships; Meaning; and Accomplishment. Although this list is not exclusive or exhaustive, these five elements have been found to be associated with higher levels of life satisfaction and lower levels of distress.

     We will be spending some time to help you identify and discover your unique character strengths and virtues from a list of six major virtues and twenty-four character strengths first described by Dr. Christopher Peterson and Dr. Martin Seligman. And also, we want to develop your practical wisdom. Specific exercises that have been found to be effective in decreasing levels of distress, such as depression and increasing levels of life satisfaction, will also be used here in our sessions and as homework assignments, to be completed between sessions. We will therefore be involved together in a mutually collaborative therapy that will be structured and active, requiring your commitment and active participation. Here is a sheet outlining the fifteen sessions and topics we will be covering. How does all this sound to you? How do you feel about it?

Client: It sounds interesting, and I like the positive emphasis and systematic and structured way you described positive psychotherapy to be. I had thought we would be spending most of our time in therapy for me to talk about my negative thoughts and feelings and to rehash them over and over, as in my previous therapy experience, but that did not help me much. I am willing to try this more positive approach that you just described.

PPT Therapist: Okay, great! I should also point out that there are three major phases in our therapy here. Phase One will help you to focus on your unique strengths from several perspectives, setting meaningful goals based on your signature strengths. Phase Two will focus on building positive emotions and dealing more effectively with negative memories, experiences, and feelings. Finally, Phase Three will focus on your positive relationships and strengthening them, and also on clarifying the meaning and purpose of your life. Please do not hesitate if you have any questions as we go along. Okay?

Client: Okay.

PPT Therapist: Okay. Before I go on, describing in more detail character strengths and virtues, assessing your unique strengths by using a self-report measure and getting feedback from a friend and a family member, I would like to introduce to you a simple but effective and helpful exercise that we use in positive psychotherapy. It is called the gratitude journal. This is an ongoing journal I would like you to keep on a daily basis. Each night before you go to sleep, please write down in your journal three blessings or good things that took place in that day. Next to each blessing or good thing, I would also like you to write three sentences to explain: (1) Why did this good thing happen today, and what does it mean to me? (2) What have I learned from writing down or naming this good thing or blessing? (3) How did I or others contribute to this blessing or good thing?

     How does this gratitude-journal exercise and homework assignment sound to you? Can you begin to do this tonight?

Client: Yes, it sounds good to me. I can already begin to feel a bit more positive just thinking of three good things or blessings today, instead of getting stuck in ruminating over negative things and my fears of the future.

PPT Therapist: Good. So tonight you will begin to fill in your gratitude journal. By the way, research studies have found gratitude or being thankful to be associated with several benefits, including broadening our perspective and building or enhancing other positive emotions and attributes within us.

Critique of Integrative Therapies and Positive Psychotherapy: Strengths and Weaknesses

It is difficult to critique integrative therapies, including positive psychotherapy, because there are now many examples and types of integrative therapies. However, some of their general strengths and weaknesses can be described, as well as some specific strengths and weaknesses that may be unique to specific integrative therapies and to positive psychotherapy.

Regarding strengths, most integrative therapies are open and flexible, with a wide range and variety of techniques or therapeutic interventions that they use. They can therefore be potentially helpful to a wider variety of patients and types of problems or clinical disorders that they report, compared to therapeutic approaches that are more singular and tied to a specific theoretical perspective, with more limited use of interventions unique to that theoretical approach. A recent study showed that moderate levels of therapeutic technique diversity or psychotherapy integration were most beneficial in dealing with alliance ruptures during psychodynamic therapy (R. Chen et al. 2020).

Second, integrative therapies in general are open to using techniques from other treatment approaches that may be relevant or helpful to the specific clients being seen, with a preference for evidence-based or empirically supported interventions. An important strength of integrative therapies is being evidence-based, including not only treatments but also therapist, patient, and therapeutic relationship factors, as well as more general principles of therapeutic change.

Third, integrative therapies tend to be more sensitive to broader social and cultural issues, including how discrimination and diversity factors and poverty can impact the functioning or dysfunctioning of the client. They therefore are more culturally sensitive and potentially more multiculturally effective with diverse client populations.

Fourth, some of the integrative therapies, such as the transtheoretical approach (Prochaska & DiClemente 1984, 2002, 2019) and prescriptive psychotherapy, or STS (Beutler & Harwood 2000; Consoli & Beutler 2019), focus on the five primary stages of change and how to tailor therapeutic approaches and specific treatments to help clients at specific stages of change (see Norcross & Beutler 2019; Prochaska & DiClemente 2019). This level of tailoring interventions and processes of change to clients’ specific stages of change can help therapy to be more fine-tuned and sensitive to a client’s needs, capacities, and level of motivation and therefore potentially more effective in focusing on specific patient-technique match (see Gold & Stricker 2020, 466). There is some empirical support for this (see Norcross & Beutler 2019; Prochaska & DiClemente 2019).

Fifth, going even beyond processes of change or interventions and matching them with the specific stages of the client’s change, some integrative therapies such as STS emphasize the need to focus even more broadly on at least six major patient characteristics: diagnosis, stages of change, coping style, reactance level, patient preferences, and culture broadly defined (see Norcross & Beutler 2019). Such a comprehensive approach in assessment and treatment of patients is a strength of some integrative therapies like STS.

Sixth, integrative therapies themselves have been subjected to a greater number of controlled outcome evaluations, including more RCTs, including twenty-nine integrative therapies (see Boswell, Newman, & McGinn 2019; Schottenbauer, Glass, & Arnkoff 2005). However, there can also be some difficulties with defining more precisely what an integrative therapy is, as well as the specific components or techniques used in a particular integrative therapy that may account for its therapeutic efficacy.

Seventh, the emphasis on seriously attending to the culture of the patient and patient preferences in many integrative therapies includes an openness and sensitivity to the spirituality and religion of the client as an important factor in effective therapy, and there is empirical support for spiritually and religiously accommodative therapy (see Captari et al. 2018; Hook et al. 2019; see also Norcross & Lambert 2019; Norcross & Wampold 2019).

Finally, and more specifically with regard to positive psychotherapy, there is an emphasis on the positive side of human functioning and the character strengths of the client, with a focus on the flourishing of the client in living a full life, with authentic happiness and well-being, a much-needed corrective balance to the traditional focus on psychopathology and symptom alleviation in most treatment approaches. Although there is a danger of positive psychotherapy being too positive and not sufficiently acknowledging the darker side of human nature (see, e.g., Tan 2006a), its positive emphasis is a strength, and it does not neglect dealing with painful experiences and the problems with which a client is struggling (see Rashid & Seligman 2018a, 2018b, 2019).

There are also several weaknesses of integrative therapies. First, integrative therapies may be too eclectic because they use many techniques from other therapeutic approaches. Some of these techniques may not be as evidence-based and may not always be appropriate or helpful. In fact, there are potentially harmful treatments or techniques, and such methods should not be used at all (see Lilienfeld 2007; Tan 2008a; see also Barlow 2010; Castonguay et al. 2010; Dimidjian & Hollon 2010; D. McKay & Jensen-Doss 2021).

Second, there are a couple of unique ethical issues for integrative therapies to address (see Gold & Stricker 2020, 466). The major one concerns the competency of the therapist in an integrative therapy, using many techniques from several treatment approaches, in some of which the therapist may not be sufficiently trained or experienced or may have only a superficial or cursory knowledge thereof. The integrative therapist may therefore be incompetent to administer some techniques. A therapist cannot be an expert or even competently skillful in every technique of therapy. Integrative therapists must therefore use only methods in which they have some experience and training, and thus at least some competency in these techniques. A second ethical issue has to do with how an integrative therapist goes about making an integrative shift in choosing to use another therapeutic approach or technique with a specific client. Care needs to be taken and good clinical as well as research reasons should guide the integrative therapist in making such a shift. Perhaps informed consent from a client should be obtained before an integrative therapist makes such an integrative shift and switches approaches or techniques with the client—always putting client welfare, safety, and potential benefit uppermost. More attention to these ethical issues needs to be given in integrative therapies.

Third, while integrative therapies often use empirically supported or evidence-based techniques in an eclectic or integrated way, and many of them have now been subjected to additional controlled outcome research, there is still a need for a clearer definition of what constitutes an integrative therapy, and also delineation of which components of a specific integrative therapy are responsible for the effectiveness of that therapy. At least twenty-nine integrative therapies have been included in recent research reviews of empirical outcome studies on their effectiveness, but these have included treatments (with some empirical support) such as ACT, MBCT, DBT, EMDR, and EFT (see Schottenbauer, Glass, & Arnkoff 2005; see also Boswell, Newman, & McGinn 2019), which are usually considered CBTs or mindfulness-based third-wave CBTs, or in the case of EFT as part of marital and family therapy (MFT) or attachment-based therapy.

Fourth, integrative therapies that are more technically eclectic, such as multimodal therapy and possibly transtheoretical therapy, are not usually housed in one major theoretical approach (although multimodal therapy can be considered a very broad-based CBT). As such, they may be critiqued as being somewhat diluted and perhaps superficial in theoretical orientation and depth. And for other integrative therapies such as Wachtel’s (1977, 1997) integrative psychodynamic-behavior therapy and Stricker and Gold’s (2019) assimilative psychodynamic therapy, which are housed primarily in one theoretical orientation (in these examples in psychodynamic or psychoanalytic therapy), there may be less criticism that they lack in theoretical depth. However, there may still be a potential weakness of somewhat diluting the purity of the home theoretical approach by integrating other theoretical or technical approaches, some of which may even contradict the home theoretical perspective (see, e.g., Messer 2006).

Fifth, the common-factors approach to integrative therapy uniquely emphasizes nonspecific therapeutic relationship factors such as therapist warmth, empathy, and congruence, plus goal consensus between the client and therapist, as essential for therapy effectiveness, thus underscoring the crucial importance of the therapeutic relationship and alliance with the client; yet some other integrative therapies may not put as much emphasis on the therapeutic relationship and alliance, focusing more on techniques for therapeutic and behavioral change, such as multimodal therapy. There can be a tendency to overemphasize techniques in some integrative therapies, including positive psychotherapy. This can be a potential weakness if insufficient attention is paid to developing a strong therapeutic alliance and good therapeutic relationship with the client or patient, which is an empirically supported key factor in effective therapies of various types (see Norcross & Lambert, 2019; Norcross & Wampold 2019; Wampold & Imel 2015).

Sixth, several integrative therapies have begun to pay more attention to larger social and cultural factors, including discrimination and diversity issues, poverty, and how they may affect clients. However, there is still a need not only to seriously consider such systemic and larger factors, but also to access help and support from systems-wide sources and resources, such as family and extended family, community both spiritual and religious, and even the larger society, nationally and internationally, where appropriate and necessary.

Seventh, while a few integrative therapies have begun to incorporate bringing the body more into psychotherapy integration in treating the whole person (see Gold & Stricker 2020, 451), as in somatic-experiencing psychotherapy (Levine & van der Kolk 2015), most integrative therapies are still not sufficiently focused on the body as an integral part of treatment for the whole person.

Finally, especially positive psychotherapy can be critiqued for possibly being too positive in overemphasizing character strengths and virtues in clients and focusing on flourishing and authentic happiness and well-being, and not paying sufficient attention to psychopathology and in-depth empathy and processing of client’s traumatic experiences, psychological pain, and emotional suffering (see Gingrich and Gingrich 2017). Also, the darker side of human nature as capable of destruction and even evil can be neglected, as already pointed out above.

A Biblical Perspective on Integrative Therapies and Positive Psychotherapy

A biblical perspective on integrative therapies, including positive psychotherapy, is now briefly presented, since the relative strengths and weaknesses of integrative therapies have already been discussed.

First, many integrative therapies, especially the common-factors approaches, focus on the need for a strong therapeutic alliance and good therapeutic relationship with the client, based on warmth, empathy, and genuineness; this is consistent with a biblical emphasis on the primacy of agape love in all relationships, including the therapeutic relationship (see Tan 1987a, 108–109).

Second, the tendency to emphasize techniques in integrative therapies may lead to making techniques primary and the therapeutic relationship secondary, in which case this will not be consistent with the biblical focus on agape love as primary (see 1 Cor. 13).

Third, the use of techniques and other factors—such as therapist, client, relationship, and principles of change—in integrative therapies that are evidence-based is important and crucial for effective therapy; yet these may be too biased toward the empirical as a source of truth and validity. Although good science and controlled outcome research can be valued and appropriately used, ultimate truth extends beyond the empirical or rational. Revealed truth as known through God’s inspired Word, the Bible as properly interpreted, is the ultimate truth from a Christian, biblical perspective (cf. 2 Tim 3:16). Therefore, a biblical approach to effective counseling and therapy will not simply or only use whatever techniques work because they are empirically supported, but only those that are consistent with biblical truth ethically, morally, and spiritually (see Tan 1987a, 108–109).

Fourth, especially positive psychotherapy emphasizes the good side of human nature, recognizing the character strengths and virtues of clients instead of their weaknesses and psychopathology. It also focuses on flourishing and experiencing the full life of authentic happiness and well-being. This is consistent with the biblical view of human beings created in the image of God, with the imago Dei and capacity for choice and for good and virtue (Gen. 1:26–27). The role of religion and spirituality in positive-psychology interventions has therefore been noted and described, focusing on the virtues of hope, gratitude, forgiveness, and self-compassion (Rye et al. 2013). However, the Bible also describes the darker side of human nature as fallen and sinful (Rom. 3:23) and capable of deceit and evil (Jer. 17:9). Positive psychology needs to pay more attention to this darker side of fallen human nature (see Tan 2006a; see also Entwistle & Moroney 2011; Gruber, Mauss, & Tamir 2011; Hackney 2021; Held 2004; Horowitz 2018; S. Jones 2014; McMinn 2017).

Fifth, while an emphasis on authentic happiness and flourishing or a full life can be consistent with the biblical teaching on eternal life (John 17:3) and the abundant life, life to the full (John 10:10), and a theological perspective on God and happiness (see Charry 2010; see also Crabb 2016), there is still a danger of overemphasizing positive emotions and feeling good without sufficient attention to suffering and struggle in life. A biblical perspective will balance out the focus on happiness and positive emotions, bringing a needed corrective emphasis on sanctified suffering and painful processes such as brokenness, repentance, and surrender (see Crabb 2004), what has been termed “positive sadness” by Tan (2006a, 73) or “godly sorrow” (2 Cor. 7:9, 10 NIV). Such sanctified suffering, while painful, can help us grow and become more like Jesus in deeper spiritual formation. This is similar to posttraumatic growth and resilience, but deeper (see Tan 2019a); the Holy Spirit enables this spiritual formation or growth into more Christlikeness to occur (see Tan 2019c), producing the fruit of the Spirit: “love, joy, peace, forbearance, kindness, goodness, faithfulness, gentleness and self-control” (Gal. 5:22–23 NIV).

Sixth, a biblical perspective will therefore caution against the use of self-effort to try to produce character strengths and virtue, as in positive psychotherapy and other therapies that usually emphasize the need for self-effort to change oneself, along with the secular psychological focus on self-improvement. The fruit of the Spirit, centering on Christlike love or agape, is the deep work of the Holy Spirit within human hearts surrendered to God. True virtue and character transformation cannot ultimately be achieved or maintained by self-effort in attempts toward self-improvement. Paradoxically, it comes about only by surrendering and yielding to the Holy Spirit, being filled with the Spirit (Zech. 4:6; Eph. 5:18), and not trying by self-effort (see Tan 2019c).

Seventh, sanctified suffering, however, is not the only way to grow in Christ and become more like him. A biblical perspective will not glorify suffering, which will ultimately end one day in heaven (that includes the new earth), where there is no more suffering or pain (Rev. 21:4). It will also affirm other more positive means of grace in spiritual formation into deeper Christlikeness, true character formation, and transformation by the power and presence of the Holy Spirit, such as contentment (Phil. 4:11–13), thanksgiving (1 Thess. 5:18) or gratitude (as emphasized in positive psychotherapy), prayer (1 Thess. 5:17; cf. Phil. 4:6–7), rejoicing in the Lord (Phil. 4:4; 1 Thess. 5:16), and celebrating and enjoying God and his many blessings or good things as gifts from him (see 1 Tim. 6:17; Tan 2019a, 122). In this context, posttraumatic growth is not the only or necessary way to grow, but postecstatic growth through joyful and positive experiences is also important and needs further research (see Tan 2019b; see also Mangelsdorf, Eid, & Luhmann 2019). Positive psychotherapy can help in postecstatic growth, but the work of the Holy Spirit must remain primary, central, and crucial, from a biblical perspective (Tan 2019c).

Finally, in some integrative therapies the recent emphasis on bringing the body more into psychotherapy integration, such as in somatic-experiencing psychotherapy (Levine & van der Kolk 2015) and thus treating the whole person, is consistent with a Christian emphasis on viewing the person as an embodied whole human being; therefore we need to tend to soul, mind, and body in the art and science of holistic spiritual formation into deeper Christlikeness (see, e.g., Hiestand & Wilson 2019).

Research: Empirical Status of Integrative Therapies and Positive Psychotherapy

Research involving controlled outcome studies on specifically integrative therapies has grown significantly in the last decade or so, with at least twenty-nine explicitly integrative therapies (Boswell, Newman, & McGinn 2019; Schottenbauer, Glass, & Arnkoff 2005), concluding that there is solid and growing empirical support for the effectiveness of many integrative therapies (see also Castonguay et al. 2015; Zarbo et al. 2015). The actual number of integrative therapies being practiced today, including those with little or no empirical research or evidence for their effectiveness, is much larger than the twenty-nine integrative studies that have been subjected to controlled outcome evaluations (Boswell, Newman, & McGinn 2019).

In an earlier review of the outcome research on integrative therapies (see Schottenbauer, Glass, & Arnkoff 2005), the following received substantial empirical support (from four or more RCTs): ACT, cognitive analytic therapy (CAT), DBT, EFT for couples, EMDR, MBCT, STS, and transtheoretical psychotherapy. Another dozen self-identified integrative therapies were found to have some empirical support (from one to four RCTs), including the following: behavioral family systems therapy, integrative cognitive therapy, EFT, and multimodal therapy (see Norcross & Beutler 2019, 547). However, as pointed out earlier, therapies such as ACT, DBT, MBCT, and EMDR are often considered broad-based CBTs or third-wave mindfulness-based CBTs, and not necessarily as integrative therapies. The operational definition of what constitutes an integrative therapy still needs further clarification.

A more recent review of the outcome research on at least twenty-nine explicitly integrative therapies made the following conclusion: “Pyschotherapy integration has come of age in outcome research. At least 29 explicitly integrative therapies have been subjected to rigorous controlled research. The results consistently and persuasively attest to their safety, feasibility, and effectiveness. . . . We can confidently declare that integrative treatments uniformly outperform no treatment and almost uniformly outperform treatments as usual. Few integrative therapies have been thoroughly compared to bona fide, pure-form therapies, so the jury is out on whether integrative therapies prove superior in efficacy or applicability to others” (Boswell, Newman, & McGinn 2019, 421).

While Wachtel’s (1977, 1997) integrative psychodynamic-behavior therapy is well-known as an example of theoretical integration, no controlled outcome research and comparative outcome evaluations have been conducted to date on its effectiveness. Multimodal therapy has received some empirical support for its effectiveness, yet from limited controlled outcome research, so the evidence is not definitive (see Prochaska & Norcross 2018, 400, 406–407).

There is also some research evidence that supports the effectiveness of STS, or prescriptive psychotherapy (see Beutler & Harwood 2000; Consoli & Beutler 2019; Norcross & Beutler 2019), in its attempts to match treatment selection to six major client or patient characteristics: stages of change, coping style, reactance level, preferences, culture, and diagnosis (see Norcross & Beutler 2019, 547–549; see also Beutler & Forrester 2014; Castonguay, Constantino, & Beutler 2019).

More specifically, the research evidence supporting the effectiveness of PPT has recently grown, with at least twenty outcome studies, but most of them have used relatively small sample sizes. Nonetheless, there is now more empirical evidence for the effectiveness of PPT for several clinical disorders such as depression, anxiety, borderline personality disorder, psychosis, and nicotine dependence, usually conducted in a group therapy format. PPT has been found to significantly decrease symptoms of distress and increase well-being at posttreatment, with medium to large effect sizes (Rashid 2015). Four outcome studies, including two RCTs, were comparative studies that evaluated the effectiveness of PPT against that of DBT and CBT, which are both empirically supported treatments. PPT was found to be equally effective to DBT and CBT, but better than these two treatments specifically on measures of well-being, which is a focused target of PPT (see Rashid & Seligman 2019, 515). However, due to the relatively small sample sizes in many of the twenty outcome studies so far on PPT (although several studies were done internationally), further controlled outcome research (including RCTs) is needed before more definitive conclusions can be made about the effectiveness of PPT.

Future Directions

The integrative/eclectic theoretical orientation (which underlies integrative therapies), more simply termed “integration,” is the most popular or modal orientation endorsed by mental health professionals in the United States (Prochaska & Norcross 2018, 2–3), and more generally of English-speaking therapists, as well as in many countries around the world (Norcross & Alexander 2019, 4). In the United States, integrative/eclectic is the primary theoretical orientation of 22 percent of clinical psychologists, 31 percent of counseling psychologists, 26 percent of social workers, and 23 percent of counselors (see Prochaska & Norcross 2018, 3). A recent Delphi poll predicted that integrative therapy will be the third and eclectic therapy the seventh among the top seven psychotherapy systems (the others are, first, mindfulness therapies; second, CBT; fourth, multicultural therapies; fifth, motivational interviewing; and sixth, DBT) that will thrive or increase the most in the next decade (see Prochaska & Norcross 2018, 442). Integrative therapies have not only come of age but will continue to grow and mature in the years ahead, including in the further development of integrative approaches to couple and family therapy (see Lebow 2014, 2016), and spiritually and religiously integrated therapies (see, e.g., Captari et al. 2018; Pargament 2007).

However, further controlled outcome research, including more RCTs, will be needed to further strengthen the empirical support for integrative therapies. Those without enough RCTs, such as the well-known integrative approaches of Paul Wachtel and Arnold Lazarus, may fade into the background over time, with other integrative therapies that have garnered more solid empirical support, especially from RCTs, becoming more prominent. There is also a possibility that the third-wave mindfulness-based CBTs may grow even more in the years to come and therefore may eclipse integrative therapies as the most popular therapeutic approach, although some have considered third-wave CBTs such as ACT, DBT, and MBCT as integrative therapies (see Prochaska & Norcross 2018, 412; see also Schottenbauer, Glass, & Arnkoff 2005).

Future directions in psychotherapy integration have recently been described in four major areas: integrative theory, integrative practice and research, integrative training, and the integration movement (Eubanks, Goldfried, & Norcross 2019). In integrative theory (see Eubanks, Goldfried, & Norcross 2019, 476) two recent integrative models have been proposed, which attempt to incorporate the majority of therapy approaches into one integrated or unified therapy: (1) pluralistic counseling and psychotherapy, which is especially popular in the United Kingdom and Europe, in which clients are able to choose from a variety of therapeutic ideas and interventions in collaboration with the integrative therapist (see www.pluralistictherapy.com); and (2) unified psychotherapy, more well known in the United States, in which a basically biopsychosocial systems model incorporates therapeutic ideas and methods from many therapy approaches, with grounding in clinical science, aiming toward a unified psychotherapy (see, e.g., Magnavita & Anchin 2014). These are two examples of more ambitious and wide-ranging attempts to integrate or unify many major schools of therapy and their techniques (see also Fraser 2018; Goldfried 2019; Melchert 2016), and other efforts along these lines may be attempted in the future. However, there are some obstacles in trying to integrate so widely, as Messer (2006) has pointed out.

In integrative practice and research (see Eubanks, Goldfried, & Norcross 2019, 477–478), a good example of facilitating collaboration between practitioners and researchers in the framework of psychotherapy integration is the Two-Way initiative put together by the APA’s Division 12 (Society of Clinical Psychology) and Division 29 (Society for the Advancement of Psychotherapy). Practicing therapists provide feedback to researchers on what needs to be further studied, and researchers then share their results with the therapists, in a mutually helpful way, focusing on what really works in real-life clinical settings and practice. Routine outcome monitoring, feedback-informed treatment, is another example of the integration of research and practice (Maeschalck, Prescott, & Miller 2019; Prescott, Maeschalck, & Miller 2017), in which client progress is tracked or monitored with measures that are reliable; this feedback is immediately provided to the therapist so that appropriate changes can be made by the therapist, if necessary, in sensitive ways for the client’s benefit. Routine outcome monitoring systems that can identify clients who may be at risk of treatment failure have been found to increase positive therapeutic outcomes and decrease rates of deterioration (M. J. Lambert, Whipple, & Kleinstäuber 2018); this will become more crucial in the effective practice of psychotherapy, including integrative therapies, although there are some barriers to implementing such progress-monitoring measures in therapy (Ionita, Ciquier, & Fitzpatrick 2020). More recently, a randomized controlled trial on the effect of feedback-informed CBT on treatment outcome showed that frequent provision of client-progress feedback reduced treatment duration as well as dropout in individual CBTs (Janse et al. 2020).

In integrative training (see Eubanks, Goldfried, & Norcross 2019, 480–481), there are challenges to training students and others in several therapy approaches and many interventions, which are often part of integrative therapies. Principle-based approaches to training, following principle-based integrative therapies, may be more feasible. Examples are training in the stages-of-change model of transtheoretical therapy (Prochaska & DiClemente 2019) and in STS (Consoli & Beutler 2019). The use of technology in training will continue to be significantly helpful and crucial. Deliberate practice will also be a growing area of training for clinicians to improve their therapeutic skills by individually engaging in deliberate practice activities, such as going over recordings of their therapy sessions with clients and routinely collecting and using client-outcome data for feedback (Rousmaniere 2017; see also Chow et al. 2015; S. D. Miller, Hubble, & Chow 2020).

Finally, in projecting future directions for the integration movement (see Eubanks, Goldfried, & Norcross 2019, 482), psychotherapy integration will grow even more internationally and also become more interdisciplinary. The earlier development of the integration movement was mainly in the United States, involving mostly psychologists, but now the movement has spread around the world, with participation by other mental health professionals besides psychologists.

Future directions, more specifically in positive psychotherapy as an integrative therapy, include the need for further controlled outcome research on its effectiveness, including more RCTs. Now that both the clinician manual (Rashid & Seligman 2018a) and the workbook (Rashid & Seligman 2018b) have recently been published, more standardized and systematic research can and will be conducted on its effectiveness for treating various disorders and enhancing well-being (see also Joseph 2015; Proctor 2017; Wood & Johnson 2016). PPT exercises and interventions can also be helpful for increasing well-being in nonclinical populations, “normal people,” including in areas such as executive coaching, education, and organizations. The internet can be used for wider dissemination of PPT exercises and interventions to a broader audience and to further evaluate their effectiveness (see Rashid & Seligman 2019, 510–511).

Positive psychology, of which positive psychotherapy is a part, has grown tremendously since its founding at the turn of the new millennium (see Rusk & Waters 2013) and will continue to grow. Many scientific journals have been launched—including the Journal of Positive Psychology, Journal of Happiness Studies, Journal of Well-Being, and the International Journal of Applied Positive Psychology—and graduate programs in positive psychology are now available at reputable institutions such as the University of Pennsylvania, the University of Melbourne, and Claremont University (see Rashid & Seligman 2019, 487).

Further information on integrative therapies and psychotherapy integration can be found on the following websites:

Society for the Exploration of Psychotherapy Integration: sepiweb.org

Innerlife/Systematic Treatment Selection: www.innerlife.com

Transtheoretical therapy model: web.uri.edu/cprc

Lazarus Institute: www.thelazarusinstitute.com

International Positive Psychology Association (IPPA): www.ippanetwork.org

Upenn Positive Psychology Center: ppc.sas.upenn.edu

Dr. Tayyab Rashid: tayyabrashid.com

As pointed out earlier, in the coming years integrative therapies, including positive psychotherapy, will continue to grow and mature among the most popular theoretical orientations.

Recommended Readings

Beutler, L. E., & Harwood, T. M. (2000). Prescriptive psychotherapy: A practical guide to systematic treatment selection. New York: Oxford University Press.

Lazarus, A. A. (1989). The practice of multimodal therapy (rev. ed.). Baltimore: Johns Hopkins University Press.

Lazarus, A. A. (2006). Brief but comprehensive psychotherapy: The multimodal way (2nd ed.). New York: Springer.

Norcross, J. C., & Goldfried, M. R. (Eds.) (2019). Handbook of psychotherapy integration (3rd ed.). New York: Oxford University Press.

Rashid, T., & Seligman, M. (2018a). Positive psychotherapy: Clinician manual. New York: Oxford University Press.

Rashid, T., & Seligman, M. (2018b). Positive psychotherapy: Workbook. New York: Oxford University Press.

Stricker, G. (2010). Psychotherapy integration. Washington, DC: American Psychological Association.

Wachtel, P. L. (1977). Psychoanalysis and behavior therapy: Toward an integration. New York: Basic Books.

Wachtel, P. L. (1997). Psychoanalysis, behavior therapy, and the relational world. Washington, DC: American Psychological Association.

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: Evidence for what makes psychotherapy work (2nd ed.). Mahwah, NJ: Erlbaum.

Chapter 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).

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).

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 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).

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.

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 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.

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 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). 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, 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. 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 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

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).

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.

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 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 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).

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.

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, 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 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 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? . . .

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 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 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.

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 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).

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 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 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).

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 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 (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, 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.

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.

Reference

Tan, S. (2022). Counseling and Psychotherapy, 2nd Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781493435074