Module 7
Population Based
a. Families and Schools
There is a significant interaction between families and schools in the
socialization and development of children, termed the home–school relationship
(Carlson et al., 2009). This systemic interaction was noted by Bronfenbrenner (1986)
as a mesosystemic relationship between the primary environments in which a child
develops; the quality of the relationship is critical to developmental outcomes. The
ecosystem extends to the community in which the family resides, as well as the
cultural context, socioeconomic conditions, and other macrosystemic factors
(Stormshak, Fosco, & Dishion, 2010).
In the home–school relationship, family influences and academic influences
interact in reciprocal fashion. Parenting styles (authoritative, authoritarian,
permissive, neglectful) and a variety of parenting practices (behavior monitoring,
parent–school engagement, development of learning spaces and conditions) can either
facilitate or diminish the quality of the interaction, although specific aspects may vary
by family ethnicity (Carlson et al., 2009). Similarly, schools impact the developing
child and contribute to the socialization process. However, especially with low-
income diverse families who understand their role as the provision of home-based
support for the child’s education, programs that focus on parental participation in
school functions as the main priority may be off target, while programs that assist
parents in improving home academic processes (reviewing homework, encouraging
reading) may result in better school achievements (Carlson et al., 2009). Practices that
improve communication between the school and the home may enhance the
interaction (Hiatt-Michael, 2010).
Family therapists who engage the family–school relationship must remember
the systemic nature of the interaction and design interventions that pay due attention
to the complexity of the relationship. Many school-based programs target problem
behaviors by teaching skills to the child but fail to achieve long-term success because
they leave the family out of the process. Current best practices are family-centered
treatments, including the EcoFIT model that is evidence based, developmental
ecological, incorporates assessment, includes the social relationship context of child
mental health, focuses on parent change motivation, and adopts a health maintenance
perspective (Dishion & Stormshak, 2009).
There are a number of family–school interventions with demonstrated
effectiveness that social workers and therapists in school settings are encouraged to
utilize. These empirically supported interventions are designed to address various
issues that can impact both family dynamics and student performance, offering
comprehensive support that benefits both the child and the family unit. The
integration of these interventions into school settings can lead to improved academic
outcomes, enhanced family relationships, and overall better mental health and well-
being for students.
One such intervention is the family-school partnership model, which
emphasizes collaboration between educators, families, and mental health
professionals. This model encourages regular communication and joint problem-
solving strategies to address academic and behavioral challenges. By fostering a
cooperative relationship, parents become more engaged in their child's education, and
teachers gain a deeper understanding of the child's home environment, allowing for
more tailored and effective support.
Another empirically supported intervention is parent training programs. These
programs provide parents with skills and strategies to support their child's education
and address behavioral issues. Parent training can include workshops, group sessions,
and individual coaching, focusing on topics such as positive reinforcement, effective
communication, and setting appropriate boundaries. Research has shown that when
parents are equipped with these skills, there are significant improvements in their
child's behavior and academic performance.
School-based family counseling is another important intervention. This
approach involves providing therapeutic services to students and their families within
the school setting. By addressing emotional and behavioral issues in a familiar
environment, students are more likely to engage in the therapeutic process. Family
counseling can help resolve conflicts, improve communication, and strengthen family
bonds, all of which contribute to a more supportive home environment that fosters
academic success.
Behavioral parent training (BPT) is another critical intervention with strong
empirical support. BPT programs are designed to help parents learn techniques to
manage their child's behavior problems effectively. These programs typically involve
structured sessions where parents are taught specific strategies to reinforce positive
behavior, set clear expectations, and implement consistent consequences for
misbehavior. Studies have consistently shown that BPT can lead to significant
reductions in disruptive behavior and improvements in family functioning.
The Positive Behavioral Interventions and Supports (PBIS) framework is
widely used in schools to promote positive behavior and create supportive school
environments. When combined with family-school interventions, PBIS can be even
more effective. Involving families in PBIS initiatives helps ensure that positive
behavior strategies are reinforced both at home and at school. This consistency can
lead to more lasting behavioral improvements and a stronger sense of community and
collaboration between families and schools.
Multisystemic Therapy (MST) is another evidence-based intervention that has
been successfully adapted for use in school settings. MST is an intensive family- and
community-based treatment that addresses the multiple factors contributing to serious
behavioral problems in adolescents. By involving the family, school, and community,
MST provides a comprehensive approach that can address issues such as substance
abuse, delinquency, and academic difficulties. Research has shown that MST can lead
to significant reductions in behavioral problems and improvements in family
functioning.
Family Check-Up (FCU) is an empirically supported intervention that focuses
on early prevention and intervention for at-risk families. FCU involves a
comprehensive assessment of family dynamics and tailored feedback sessions to help
parents address areas of concern. By providing personalized support and resources,
FCU helps families build on their strengths and address potential issues before they
escalate, leading to better outcomes for children both at home and in school.
The Triple P – Positive Parenting Program is another well-supported
intervention that can be implemented in school settings. Triple P offers a tiered system
of support, ranging from universal parenting information to intensive, individualized
interventions. This flexible approach allows schools to provide appropriate levels of
support to meet the diverse needs of families. Studies have shown that Triple P can
lead to improvements in child behavior, parenting practices, and overall family well-
being.
In addition to these specific interventions, it is also important for social
workers and therapists to be trained in cultural competence and to consider the unique
cultural and contextual factors that influence each family. Tailoring interventions to be
culturally sensitive ensures that they are more effective and respectful of the diverse
backgrounds of the families being served. This approach can help build trust and
engagement, leading to better outcomes for students and their families.
Overall, the use of empirically supported family–school interventions is
crucial for addressing the complex and interconnected issues that can impact student
performance and well-being. By employing these interventions, social workers and
therapists can provide comprehensive support that benefits not only the individual
student but also the family as a whole. The integration of these evidence-based
practices into school settings can lead to more effective and sustainable improvements
in academic, behavioral, and emotional outcomes for students, ultimately contributing
to a more positive and supportive school environment.
b. Families and Mental Disorders
There is a long history of using family therapy for mental disorders, but
Nichols (2009) concludes that it is still necessary to reduce professional resistance to
genuine biopsychosocial theoretical and practice models. Today, there is substantial
evidence for the effectiveness of family therapy with particular disorders, including
depression, anxiety, substance abuse, eating disorders, and serious mental illness, as
demonstrated next.
Couple and family therapy for depression and/or anxiety in children,
adolescents, and adults has demonstrated effectiveness. Childhood mood disorders
often emerge and progress in dysfunctional family types; a family history and
recurrence of depression is more likely in families that include a depressed child.
Environmental elements and genetic factors can create risk for adolescent depression,
but family protective elements can reduce the risk or influence teen attitudes and
choices that positively impact treatment course and outcomes. Given the prevalence
of behavioral and affective symptoms and disorders in the child–adolescent
population, interventions that include the family in some fashion (along a continuum
from adding a parent to including the full family to including several families in a
group) are on the rise. A review of evidence for family-based treatments identifies a
variety of approaches for depression, bipolar disorder, anxiety disorders, ADHD,
oppositional defiant disorder, autism spectrum disorders, and eating disorders, with
varying levels of support (Kaslow et al., 2012).
Adult depression is often treated today in the context of couple dynamics and
couple therapy. There is evidence to suggest that couple discord may be both a cause
and consequence of depression; treatments that address the relationship and the
depression result in better outcomes. Cognitive-behavioral couples therapy (CBCT)
targets relationship communication and behaviors to increase closeness, as well as
conflict management skills over 15 to 20 therapy sessions plus homework outside the
sessions; it includes relapse-prevention strategies and is most effective when
depression and couple distress co-occur (Whisman & Beach, 2012). There are also a
variety of family stressors, including parenting problems, that correlate with
depressive episodes; treatments that focus on the parent–child interaction may help
relieve parental depression, enhance parenting skills, and improve child results.
Although substance abuse is frequently considered an individual problem, it
often occurs in the family context, and there is strong evidence for systemic
treatments that include family members (Stanton, 2009). The CRAFT model (Smith &
Meyer, 2004) teaches family members how to encourage substance abusers to enter
treatment. Motivational enhancement, an empathic approach that seeks to evoke and
reinforce a client’s motivation to change, has demonstrated success, especially in
regard to substance abuse (Miller & Rose, 2009); it may be adapted for couples
therapy (Burke, Vassilev, Kantchelove, & Zweben, 2002), and it is hypothesized that a
concerned significant other (partner, family member) may contribute positively to a
substance abuser’s motivation to change (Stanton, 2009). Relapse prevention is
another major intervention for substance abuse. Witkiewitz and Marlatt (2004) present
a dynamic systems model of relapse that seeks to capture the complex, nonlinear
elements of the process. Stanton (2005) extends the model to enhance recognition of
interpersonal factors and social support as key elements in treatment, as family
members aid in the identification of high-risk circumstances, join the substance abuser
in risky situations as a sober support, enhance coping skills, and enhance self-efficacy
for sobriety. Interpersonal conflict can trigger negative emotions and relapse, so it is
important for therapy to improve relationship and coping skills.
Several evidence-based family interventions address adolescent substance
abuse and externalizing disorders. Each is systemic, focuses on a complex therapeutic
alliance with multiple family members, and targets enhanced understanding between
parents and the adolescent; each has research support in carefully designed studies
and has been adopted broadly (Lebow, 2014). Functional family therapy,
multisystemic therapy, multidimensional family therapy (Liddle, 2009), and brief
strategic family therapy help families with an adolescent abusing substances.
Systemic models of couples therapy are also very effective in treating substance
abuse; they engage the addict’s partner in treatment and utilize systemic concepts and
practices to reduce substance abuse (Stanton, 2005). Behavioral couples therapy has
strong support for clinical effectiveness. This model recognizes the “vicious cycle”
between relationship dysfunction and substance use problems, with each influencing
the other, so it addresses both concurrently in treatment. It uses behavioral
interventions, like a recovery contract and a sobriety trust discussion conducted daily
between partners to reinforce abstinence, as well as homework assignments and
participation in self-help groups, like Alcoholics Anonymous.
Mental illness in a family can be a “ravaging, devastating disease” that
disrupts a family and permits little respite (Marsh & Johnson, 1997). In addition to the
continuing social stigma and ostracism of people with mental illness such as
schizophrenia or bipolar disorder, families with mentally ill members also confront
objective and subjective stressors, including challenges accessing treatment,
premature treatment discharge or the patient’s refusal of treatment, insurance
problems and financial difficulties, employment problems, the burden of 24/7
supervision, family conflict, impaired health, and a diminished social life. Grief,
chronic sorrow, the loss of dreams and hopes for the affected person, the emotional
roller coaster punctuated by periods of relapse and remission, potentially violent or
self-destructive behavior, the unpreparedness of families to deal with the challenges,
and the scarcity of services—these are the common experiences of families.
Teaching anguished family members to be “informal case managers,” learning
how and from whom in the community to obtain mental health, welfare, legal, and
medical services is often of great benefit, especially since most families feel helpless
and confused when such new roles are thrust upon them (Marsh & Lefley, 2009). The
National Alliance for the Mentally Ill (NAMI) is an important source of information,
education, and support for professionals, family members, and the general public.
Training in daily problem solving and crisis management to handle extreme stress in
the family are part of psychoeducational therapy. Simultaneously, therapy intends to
ensure that to the extent possible, family members preserve the integrity of their own
lives. Therapy brings the family’s competencies and resiliency into play for
constructive action.
Interest in the family treatment of severe mental disorders has waxed and
waned over the years. Today, schizophrenia is viewed as a genetic and/or biologically
based disease whose symptoms are best dealt with by using antipsychotic medication.
The disorder may arise in well-functioning families as well as those that show a high
degree of dysfunction. However, environmental factors within family life do play a
role in schizophrenic relapse rates. Psychoeducation advocates maintain that helping
family members understand the disorder and learn specific coping skills is essential in
supplementing medication, reducing family stress, and preventing symptomatic
relapse in the schizophrenic member. Families, relieved at not being blamed or
shamed for the development of the disorder in one of their members, may be more
receptive to integrated treatment programs, thus increasing the likelihood of improved
treatment compliance. However, some reject therapy out of denial or the fear of social
stigma. Their willingness to collaborate with supportive therapists is increased if they
are persuaded that these efforts will delay or reduce in severity any symptomatic
relapse.
Without blaming the family, they went about the business of helping all family
members, including the schizophrenic, overcome obstacles to family functioning.
They used a matterof-fact approach, teaching coping skills to families who must
attend daily to “the devastating impact of watching one’s child deteriorate into
someone who is all but a stranger, and a most incapacitated one” (McFarlane, 1991, p.
364). Families were recognized as having experienced severe stress that left them
feeling depleted and susceptible to dysfunctional behavior patterns, so they were
supported as they learned new empowering techniques to mitigate stress and strain
and to reduce the likelihood of relapse. Similar efforts by other like-minded
clinicians/researchers such as Michael Goldstein (1981) and David Miklowitz (2008)
at UCLA and Ian Falloon (Falloon et al., 2005) at the University of Southern
California are examples of family-focused programs that emerged in response to
briefer hospitalization for patients experiencing a major psychosis (schizophrenia or
bipolar disorder). Because patients are often discharged while only in partial
remission from their psychotic symptoms, they and their families must cope with
problems connected with reentry into the community. The focus is on the
schizophrenic’s impact on family functioning, not the other way around.
The theory of expressed emotion (EE) suggests that schizophrenia is a thought
disorder in which the individual is vulnerable to and highly responsive to stress
caused by the expression of intense, negative emotions. Researchers reasoned that
when former patients returned home to a stressful, negative, and hypercritical family
environment where EE was high, the patients were likely to become aroused and
relapse into symptoms. On the other hand, for patients returning to households
manifesting low EE, while family members also were concerned about the disturbed
(and disturbing) behavior of the schizophrenic, they were not overly anxious in
response to the patient’s condition, allowing the individual more psychological space
(Leff & Vaughn, 1985). Expressed emotion is a validated indicator for relapses of
schizophrenia, and the value of reducing EE in families with schizophrenia has been
documented. Lowering EE is also linked to reduced relapse rates for various forms of
depression and bipolar disorder.
Recent research suggests that the EE–relapse relationship may be more
complex than originally understood. Research with Mexican American families
including a member with serious mental illness found that EE was increasingly
connected to relapse as historical enculturation shifted to acculturation to U.S. culture,
so culture may influence family factors in the relapse process (Aguilera et al., 2010); a
related analysis suggests a curvilinear relationship between EE and relapse, with high
levels being toxic but medium levels evidencing some protective effect (Breitborde et
al., 2007). Higher education level predicted lower blame attributions in White and
Hispanic families but not Black families, further suggesting the need to consider
culture and family variables (Duarte, deMamani, Rosales, & Kymalainen, 2008),
including the possibility that EE may have been a proxy in early research for the risks
related to family caregiver attributions regarding the ill person’s agency in the
recovery process and the impact that has on recovery or relapse, including aspects of
EE.
c. The Therapeutic Process
Family psychoeducation follows one of two formats—working with individual
families (Anderson, Reiss, & Hogarty, 1986) or with multiple families simultaneously
(McFarlane, 2011). In the former, Anderson and colleagues phase interventions (often
resembling structural family therapy because of the emphasis on boundaries,
hierarchy, and subsystems), beginning with engaging the family; research indicates
that establishing a positive therapeutic alliance with the family improves outcomes
(Smerud & Rosenfarb, 2011). Gaining the family’s cooperation, they begin survival
skills workshops—teaching family members about the prevalence and course of
mental illness, its biological etiology, current modes of pharmacological and
psychosocial treatment, common medications, and prognosis. Patient and family
needs are discussed and family coping skills strategized. EE findings are aired here,
and basic behavioral guidelines for keeping EE in check are discussed to help take the
pressure off the patient to hurry up and behave in a normal manner. Because
schizophrenics are usually sensitive to overstimulation, families are urged to respect
boundaries, allowing schizophrenics to withdraw whenever necessary.
Generational boundaries are also reinforced as parents are urged to form a
stronger bond and together remain in charge rather than letting all family decisions be
controlled by the patient’s needs. This approach recognizes the importance of
maintaining healthy family dynamics and promoting parental authority and cohesion,
even in the face of challenges such as a family member's illness or mental health
condition.
Encouraging parents to form a stronger bond and remain in charge serves
multiple purposes within the family dynamic. Firstly, it helps to maintain a sense of
stability and structure, which is particularly important during times of stress or
upheaval. When parents present a united front and take charge of decision-making, it
can provide a sense of security and predictability for all family members, including
the individual who may be struggling with a health issue.
Furthermore, reinforcing generational boundaries can help prevent the
individual's needs from becoming the sole focus of family life. While it is important
to provide support and accommodation for the person's needs, it is equally crucial to
ensure that the needs and well-being of other family members, especially parents, are
not overlooked. By empowering parents to remain in charge, the family can maintain
a balanced approach to caregiving and prevent the individual's condition from
overshadowing other aspects of family life.
Additionally, strengthening the bond between parents can enhance their ability
to support each other and collaborate effectively in addressing the challenges they
face as a family. This can include coordinating care, making decisions about treatment
options, and providing emotional support to each other. By fostering a sense of
partnership and solidarity, parents can navigate the complexities of caregiving more
effectively and sustainably.
Moreover, encouraging parental authority can promote the healthy
development of children within the family. When parents assert their authority and
maintain consistent boundaries, it helps children feel secure and understand their role
within the family unit. This sense of structure and stability can contribute to children's
emotional well-being and resilience, even in the face of difficult circumstances.
It is important to note that reinforcing generational boundaries does not mean
neglecting or dismissing the needs of the individual who may be struggling. Instead, it
means finding a balance between meeting those needs and preserving the overall
health and functioning of the family unit. This may involve setting boundaries around
caregiving responsibilities, seeking outside support when needed, and prioritizing
self-care for all family members.
In addition, it is essential for parents to model healthy coping strategies and
communication skills for their children. By demonstrating resilience, adaptability, and
empathy, parents can teach their children valuable life skills that will serve them well
into adulthood. This includes how to navigate difficult emotions, communicate
effectively, and seek support when needed.
Furthermore, reinforcing generational boundaries can help prevent the
individual's condition from becoming a source of conflict or tension within the family.
By maintaining parental authority and cohesion, the family can approach caregiving
as a shared responsibility rather than a source of contention. This can promote a sense
of unity and cooperation, allowing the family to face challenges together with
resilience and strength.
Overall, reinforcing generational boundaries within the family can have
numerous benefits for all members. It promotes stability, supports parental authority,
enhances family cohesion, and fosters healthy development in children. By
empowering parents to remain in charge and maintain a strong bond, families can
navigate the complexities of caregiving more effectively and create a supportive
environment where everyone's needs are valued and respected.
During the subsequent reentry period into the social environment, outpatient
sessions (usually weekly) that may go on for a year or more are aimed at achieving
stability outside the hospital. Patients may be assigned small tasks and their progress
monitored. The therapy team typically uses this period to shift attention to the family
structure, which may have changed because of accommodating to the patient’s return
from the hospital. The final rehabilitation phase consolidates gains and raises the
patient’s level of functioning. McFarlane’s (2011) multifamily version owes its
heritage to multiple family therapy, an early effort (Laqueur, 1976) to treat several
families of hospitalized schizophrenic patients together. In its psychoeducational
reincarnation, multiple family therapy lecture-and-discussion workshops are held with
relatives. Typically, five or six families attend, offering increased social support,
usually with sessions over at least 12 months.
The U.S. Department of Health and Human Services (SAMHSA) includes
McFarlane’s model among evidence-based practices and has an implementation tool
kit available (SAMHSA, 2009). This recognition underscores the effectiveness and
utility of McFarlane's model in addressing the needs of individuals and families
affected by mental health challenges. The availability of an implementation toolkit
further facilitates the adoption and integration of this model into various clinical
settings, enhancing its accessibility and impact.
McFarlane's model, also known as the Family Psychoeducation (FPE) model,
is grounded in the principles of psychoeducation and family systems theory. It aims to
empower families by providing them with knowledge, skills, and support to
effectively cope with mental illness and promote recovery. The model typically
involves structured sessions where families learn about the nature of mental illness,
treatment options, communication techniques, crisis management strategies, and ways
to enhance family functioning.
The inclusion of McFarlane's model among evidence-based practices by
SAMHSA reflects the robust empirical evidence supporting its effectiveness.
Numerous research studies have demonstrated positive outcomes associated with
FPE, including reduced relapse rates, improved medication adherence, enhanced
family relationships, and increased satisfaction with care. These findings highlight the
potential of FPE to significantly impact the lives of individuals with mental illness
and their families.
The availability of an implementation toolkit from SAMHSA is a valuable
resource for organizations and practitioners seeking to adopt McFarlane's model. The
toolkit typically includes guidelines, training materials, assessment tools, and other
resources to support the successful implementation of FPE within clinical settings. It
provides a structured framework for program development, implementation, and
evaluation, helping to ensure fidelity to the model and optimal outcomes for clients
and families.
Moreover, the endorsement of McFarlane's model by SAMHSA reflects a
broader recognition of the importance of family involvement in mental health care.
Research has consistently shown that family support and involvement play a critical
role in promoting recovery and improving outcomes for individuals with mental
illness. By equipping families with the knowledge and skills they need to support their
loved ones, FPE helps to strengthen the overall system of care and enhance the
effectiveness of treatment interventions.
In addition to its clinical benefits, McFarlane's model aligns with key
principles of person-centered care and recovery-oriented practice. By empowering
families to take an active role in the treatment process, FPE promotes self-
determination, autonomy, and collaboration between providers, individuals, and
families. It recognizes the expertise and unique perspectives of families and integrates
their input into the planning and delivery of care, leading to more individualized and
holistic approaches to treatment.
Furthermore, the adoption of McFarlane's model can have broader
implications for mental health policy and practice. By promoting family involvement
and support, FPE contributes to the de-stigmatization of mental illness and the
recognition of families as partners in care. It also aligns with efforts to promote
community-based and integrated models of care that prioritize the needs and
preferences of individuals and families.
Overall, the inclusion of McFarlane's model among evidence-based practices
by SAMHSA and the availability of an implementation toolkit underscore the model's
effectiveness and potential to improve outcomes for individuals with mental illness
and their families. By providing structured psychoeducation and support, FPE
empowers families to play an active role in the recovery process and promotes
collaboration between providers, individuals, and families. As mental health care
continues to evolve, McFarlane's model stands as a valuable resource for promoting
recovery, resilience, and well-being among individuals and families affected by
mental illness.
d. Medical Family Therapy
Medical family therapy (MedFT) is “a form of professional practice that uses
the biopsychosocial model and systemic family therapy principles in the collaborative
treatment of individuals and families dealing with medical problems” (McDaniel,
Doherty, & Hepworth, 2014, p. 9). This model deals with the complex interface
between family relationships and family health. It replaces the traditional medical
model that focuses exclusively on a sick individual receiving care to one in which the
family becomes the cornerstone of the caregiving system, and its ability to cope and
adapt are based on family system strengths. From this perspective, psychosocial
factors and biological interventions play an important role in healing (Rolland, 2012).
There is a journal devoted to medical family therapy called Families, Systems, and
Health. Research supports the value of interactive communication between physicians
and mental health practitioners in the medical setting (Foy et al., 2010), providing
initial support for aspects of the MedFT model.
The interactive relationship between health or disease and family functioning
is well documented in research, including positive healthcare outcomes from family
interventions and demonstrated cross-cultural applicability (Tyndall, Hodgson,
Lamson, White, & Knight, 2012). However, further, more sophisticated studies are
needed that build upon a shared lexicon of the components of MedFT and establish
metrics to determine which aspects of the model achieve desired outcomes; research
could include quantitative and qualitative approaches to evaluate clinical, operational,
and financial aspects of MedFT.
George Engel (1977), an internist at the University of Rochester School of
Medicine, is usually credited as the first to call for an integrated approach to medical
problems that he designated the “biopsychosocial approach.” Engel argued that the
patient and the disease must be understood in context, that families must be involved
in medical care, and that all systems must be considered equally. McDaniel, Harkness,
and Epstein (2001) suggest the biopsychosocial view emerged as a reaction to the
then-prevailing reductionistic, biomedical model for treating medical problems. To
promote family-centered medical care, William Doherty and MacAran Baird (Doherty
& Baird, 1983, 1987), a psychologist and family physician, delineated five levels of
physician engagement with families: (a) little if any involvement, (b) keeping family
members informed of patient treatment, (c) offering support, (d) planning
interventions, and (e) providing family therapy.
Psychologists Susan McDaniel in New York, William Doherty in Minnesota,
and Jeri Hepworth in Connecticut, all having worked in primary-care medical
settings, promote medical family therapy (McDaniel, Doherty, & Hepworth, 2014).
They call attention to “ecosystemic splits” (p. 5) that hinder healthcare by separating
mind and body; individual and family; individual-family and healthcare systems; the
clinical, financial, and operational aspects of healthcare; and healthcare and the
culture or community. Their book describes new roles for family therapists in a
variety of healthcare settings.
A number of family therapists, physicians, nurses, and other healthcare
workers, primarily working in healthcare facilities, joined together in 1993 to form a
coalition now called the Collaborative Family Healthcare Association (McDaniel et
al., 2014). Researchers, educators, administrators, healthcare policy makers, social
workers, and consumer-group representatives join in the effort to re-vision healthcare.
The association seeks to help establish a collaborative, team-based family healthcare
paradigm aimed at providing cost-effective, humane, and integrated patient and
family services. It provides “education, training, partnering, consultation, research,
and advocacy” as well as “a leading-edge conference every year” (CFHA, 2015).
Clinical collaboration between medical providers, family therapists, and other
health professionals is the cornerstone of this comprehensive approach for dealing
with a variety of medical problems (McDaniel et al., 2014). Today, all professionals
work as a team to benefit families coping with the impact on overall family life of
chronic illness (diabetes, leukemia, cardiovascular disease), life-threatening
conditions (AIDS, anorexia nervosa, infants born prematurely), or impairment and
disability (spinal cord injury, blindness or deafness, dementia in the elderly) of one of
their members. Family-level interventions for lifestyle changes (quitting smoking,
losing weight, healthier diets) are also important.
Partnerships between therapist and physician, nurse, pharmacist, or
rehabilitation specialist to achieve more comprehensive care call for accepting each
other’s language, therapeutic assumptions, and working styles, which often are in
conflict. Collaboration requires moving past toleration and beyond cooperation to
continuing communication toward a joint treatment plan (McDaniel et al., 2014).
Physicians are able to educate the therapist about the causes, likely course, and
prognosis of a disease, while the therapist can enlighten the physician and other
caregivers about the patient’s experience of illness, perhaps exploring how to
minimize patient or family anxiety, help them accept the disease, and enable them to
participate in their own healing (McDaniel, 1995). Medical providers help therapists
to recognize important biological aspects of a complex presenting problem. By the
same token, in working with therapists or social workers, physicians are less apt to
overlook the psychosocial levels of a problem or illness. The task of tending to a
family’s emotional needs, say after major surgery, often falls on the mental health
person and leaves the surgeon free to care for the patient’s biomedical needs.
Medical family therapists need a working knowledge of the major chronic
illnesses and disabilities, as well as major treatments and their emotional sequelae,
along with familiarity with the healthcare system. Physicians need to understand and
accept the help offered by the family therapist without feeling a loss of sovereignty
over patient care. While battles over turf and professional competition often exist,
working partnerships offering a holistic, ecosystemic approach to healthcare are
increasing in frequency.
Collaborative care strengthens the shaken family system, allowing its
members to regain a sense of involvement, control, choice, and power about medical
decisions. “A family’s beliefs about mastery strongly affect its relationship to an
illness and to the health care system” and impact family engagement and treatment
adherence (Rolland, 2012, p. 473). Another is to reduce the emotional consequences
to the family of an ongoing medical condition by enhancing family communion and
connection, in the process perhaps altering the clinical course of the illness. Medical
family therapists help families deal with complex conditions and their consequences.
The most frequent cases relate to chronic illness.
e. Gay and Lesbian Families
Sexual minority families experience unique stressors, including employment
discrimination, bullying of gay and lesbian (GL) children and adolescents, and legal
issues related to couple relations and parental custody (Green, 2012). Despite recent
changes, the history of gay and lesbian individuals in the United States continues to
impact family functioning. A systemic perspective is helpful because GL family life
occurs within the context of the broader society and a reciprocal interaction between
culture and family is evident in experiences like family-of-origin life/coming out,
couple relationships, and parenting (Goldberg, 2009).
Green (2012) notes that the family-of-origin experience of young people who
ultimately come out as gay or lesbian is unique because, unlike ethnic minorities who
share that status with their family members, they “rarely have parents or siblings who
share their same sexual minority status”. They often must navigate “the process of
accepting and disclosing one’s sexual orientation to oneself and others” (Goldberg,
2009, p. 576) alone or without parental guidance. A variety of sociopolitical factors
influences the process, including ethnic, religious, political, socioeconomic, and
employment attitudes of acceptance or rejection of GL identity in the individual’s
contextual surround. Peer relations are especially important, being a “family of
choice”.
Goldberg (2009) suggests that opportunities for interaction and dating are
increasing and attitudes toward gay relationships have become more positive,
although negative feelings and discrimination still exist. Research suggests that same-
sex and heterosexual relationships are similar on a number of relationship quality
factors (Kurdek, 2004). Most sexual minority couples manage life without therapy,
but some may seek therapy for issues regarding commitment, gender-associated
activities, boundaries, or psychological distress (like depression) related to the
experience of bias; however, it is important to remember that some same-sex couple
issues may not be due to sexual identity (Green & Mitchell, 2008). Sexual minority
couples typically experience less family support than do heterosexual couples, as well
as social and legal issues that may negatively impact relationship stability (Goldberg,
2009). Recent changes in legal recognition of same-sex couples may mitigate some of
those effects.
A substantial percentage of gay and lesbian couples parent children, some
from former heterosexual relationships, as well as an increased number by adoption
and use of insemination techniques and technologies, although barriers remain. Key
issues in same-sex parenting include “social support; division of labor; parenting
abilities; and child outcomes” (Goldberg, 2009, p. 582). Parenthood seems to increase
extended family support and friendships with heterosexual parents and some decrease
in interaction with gay and lesbian friends who are not parents (Green, 2012). An
extensive study of parenting and child outcomes found “positive mother–child
relationships and well-adjusted children,” and “no significant differences were
identified between lesbian mothers and heterosexual mothers for most of the
parenting variables” (Golombok et al., 2003). Research on sexual minority parenting
is increasing rapidly in sophistication and specificity of variables; there are more
lesbian parenting research studies than gay parenting; research is needed on LGBT
families of color and of differing socioeconomic status.
Recent research is just beginning to include bisexual and transgender families
(Downing, 2013); these emerging areas of research will be important for
understanding the unique experiences of different members of the LGBT community.
As societal attitudes and policies towards sexual orientation and gender identity
continue to evolve, there is a growing recognition of the need to better understand the
diverse experiences and dynamics within the LGBT community, including those of
bisexual and transgender individuals and families.
The inclusion of bisexual and transgender families in research represents a
significant step towards filling existing gaps in knowledge and addressing the specific
needs and challenges faced by these populations. Historically, much of the research on
LGBT families has focused primarily on gay and lesbian individuals and couples,
often overlooking the unique experiences and concerns of bisexual and transgender
individuals and families. By expanding research to include these populations,
researchers can gain a more comprehensive understanding of the diversity within the
LGBT community and the factors that shape the lives of bisexual and transgender
individuals and families.
One area of research that is particularly relevant to bisexual and transgender
families is that of family dynamics and relationships. Bisexual and transgender
individuals may navigate unique challenges within their families, including issues
related to identity acceptance, disclosure, and support. Understanding the experiences
of bisexual and transgender individuals within their family contexts can shed light on
the factors that contribute to positive family relationships and well-being, as well as
the barriers that may hinder family cohesion and support.
Moreover, research on bisexual and transgender families can contribute to the
development of culturally competent and inclusive interventions and services. By
identifying the specific needs and preferences of these populations, researchers and
practitioners can tailor their approaches to better meet the needs of bisexual and
transgender individuals and families. This may involve providing specialized support
services, addressing stigma and discrimination, and promoting acceptance and
affirmation of diverse identities and relationships.
In addition, research on bisexual and transgender families can inform broader
efforts to promote social justice and equity for LGBT individuals and families. By
documenting the experiences of bisexual and transgender families, researchers can
provide evidence to support policy changes and advocacy efforts aimed at addressing
systemic barriers and disparities. This may include advocating for legal recognition of
diverse family structures, promoting inclusive healthcare policies, and challenging
discrimination in housing, employment, and other domains.
Furthermore, research on bisexual and transgender families can contribute to
the broader literature on diversity and intersectionality within the LGBT community.
Bisexual and transgender individuals may navigate multiple marginalized identities,
including race, ethnicity, socioeconomic status, and disability, which can intersect to
shape their experiences of family life and identity. By adopting an intersectional
approach to research, scholars can explore the ways in which these intersecting
identities interact and influence individuals' experiences within their families and
communities.
As research in these emerging areas continues to evolve, it is important for
researchers to prioritize the voices and perspectives of bisexual and transgender
individuals and families. This may involve engaging in community-based
participatory research, collaborating with community organizations, and centering the
experiences of marginalized individuals in research design and implementation. By
amplifying the voices of bisexual and transgender individuals and families,
researchers can ensure that their work is relevant, inclusive, and impactful.
In summary, the inclusion of bisexual and transgender families in research
represents a critical step towards understanding the diverse experiences and dynamics
within the LGBT community. By expanding research in these emerging areas,
scholars can contribute to the development of more inclusive and culturally competent
interventions, inform efforts to promote social justice and equity, and advance our
understanding of the complex intersections of identity, family, and community. As
research in these areas continues to grow, it is essential to prioritize the voices and
perspectives of bisexual and transgender individuals and families to ensure that their
needs and experiences are fully represented and addressed.
f. Psychoeducation: Teaching Skills to Specific Populations
Psychoeducation is an evidence-based intervention that educates families so
that they might develop skills for understanding and coping with disturbed family
members or troubled family relationships. This approach to family therapy supports
and empowers families with schizophrenic members, as noted, violent families those
including alcohol or substance abuse, families struggling with chronic illness
(Rolland, 2012), or even those simply wishing to improve relationship skills.
Psychoeducation relies on traditional, experimental methods to develop verifiable
intervention procedures. Some family therapists integrate postmodern with
psychoeducational approaches.
Psychoeducation, like most new models, creates a collaborative therapist–
family partnership to teach management and skill-building techniques to help families
gain a sense of control. They also help families experience their strengths and
resiliency to deal with problems that affect all family members, not simply the
symptomatic person. With less severe problems, programs offer skills training in
enhancing family relationships, improving couple communication, or helping couples
become more effective parents or stepparents. Kiefer, Worthington, Myers, and
Kliewer (2010), for example, have shown how training parents to forgive
transgressions in parenting partners reduces negative emotions, increases positive
emotions, and reduces parenting stress. Psychoeducational practitioners utilize many
of the techniques of more traditional family therapy in their interventions, including
joining the family, establishing an alliance with all members, maintaining neutrality,
and assessing how best to foster positive outcomes. Interventions are manual based,
using reproducible how-to-do-it techniques that can be copied by all mental health
workers without requiring high levels of training.
Psychoeducational practices are not derived from any specific theory of family
functioning, nor do they adhere to any one set of family therapy techniques. They
often combine family systems theory, cognitive behavior therapy, educational
psychology, and aspects of structural therapy. In certain cases, such as schizophrenia,
they also include psychopharmacological treatment.
Overall, psychoeducation serves as a valuable tool for families as they
navigate the challenges of coping with mentally or physically disabled family
members or strained family relationships. By providing families with knowledge,
skills, and support, psychoeducation empowers them to maximize their effectiveness
in addressing the unique needs and dynamics within their family unit.
One key aspect of psychoeducation is its focus on increasing families'
understanding of mental and physical disabilities, as well as the impact these
conditions can have on family functioning. By learning about the nature of the
disability, its symptoms, and available treatment options, families are better equipped
to provide informed support and advocacy for their loved ones. This knowledge helps
to reduce stigma, promote acceptance, and foster a more supportive and inclusive
family environment.
Psychoeducation also helps families develop practical coping strategies for
managing the challenges associated with disabilities or deteriorating family
relationships. This may include learning communication techniques, problem-solving
skills, stress management strategies, and boundary-setting techniques. By equipping
families with these tools, psychoeducation empowers them to navigate difficult
situations more effectively and maintain their well-being amidst adversity.
Moreover, psychoeducation can facilitate the development of resilience and
adaptability within families facing adversity. By fostering a sense of empowerment
and self-efficacy, psychoeducation helps families build on their strengths and
resources, enabling them to overcome obstacles and thrive in the face of adversity.
This resilience-oriented approach emphasizes the importance of positive coping
strategies, social support, and a strengths-based perspective in promoting family well-
being.
In addition to its role in supporting families with disabled members,
psychoeducation can also be beneficial for families seeking to improve marital or
parent-child relationships. By learning new problem-solving techniques,
communication strategies, and conflict resolution skills, families can strengthen their
relationships and build healthier, more satisfying connections with each other.
Psychoeducation can help families identify areas for improvement, set realistic goals,
and work collaboratively towards positive change.
Furthermore, psychoeducation can facilitate the development of empathy,
understanding, and compassion within families. By providing insight into the
experiences and perspectives of family members, psychoeducation promotes empathy
and fosters a deeper appreciation for each other's strengths and challenges. This
enhanced understanding can strengthen family bonds, improve communication, and
foster a greater sense of connection and mutual support.
Psychoeducation can also serve as a preventative measure, helping families
address issues before they escalate into more serious problems. By providing
education and support early on, psychoeducation can help families identify potential
challenges, develop effective coping strategies, and build resilience in the face of
adversity. This proactive approach can help prevent crises, reduce stress, and promote
overall family well-being.
Moreover, psychoeducation can be delivered in a variety of formats to
accommodate the diverse needs and preferences of families. This may include
individual or group sessions, workshops, online resources, self-help materials, and
community-based programs. By offering a range of options, psychoeducation ensures
that families have access to the support and resources they need to address their
unique circumstances and challenges.
In summary, psychoeducation plays a crucial role in supporting families as
they navigate the complexities of coping with disabilities, deteriorating relationships,
or other challenges. By providing knowledge, skills, and support, psychoeducation
empowers families to maximize their effectiveness, build resilience, strengthen
relationships, and promote overall well-being. As a versatile and accessible
intervention, psychoeducation offers valuable support to families seeking to overcome
adversity and thrive in the face of challenges.
g. Relationship Education Programs
Psychoeducation has been extended to couples or families without a
symptomatic member who wish to acquire better skills or learn strategies for coping
more effectively with everyday relationship problems (couple conflicts, parent–
adolescent conflicts). It can be used to prevent the occurrence of problems before they
develop, say before marriage, or perhaps upon remarriage when stepchildren are
involved. Here the therapist educates people in the skills they need to manage
potential difficulties in life transitions. Brief, practical, positive in tone and outlook,
and cost effective, this form of intervention, when successful, helps empower people
to function more effectively within marriage, family, or work situations. The Coalition
of Marriage, Couple, and Family Education was formed in 1996 as a subspecialty
within the field of marriage counseling. Some practitioners are clergy, bringing with
them a clearly articulated set of moral and spiritual beliefs.
Programs involving relationship enhancement, preparation for marriage or
childbirth, couple enrichment, and parent effectiveness training are examples of these
psychoeducational efforts along with the behavioral parent skills training procedures.
The therapist joins the family and identifies client strengths and growth potential
along with potential problem areas, delivering educational training and not
psychotherapy. Many are packaged as seminars, video or audio programs, or books
written for the public. Among these are the behavioral research–based Marriage
Survival Kit (Gottman & Gottman, 1999), or solution-oriented therapist Michelle
Weiner-Davis’s 1992 Divorce-Busting. Termination occurs when the content has been
delivered or when a previously agreed-upon time frame has been completed.
Probably the best-known family skills training approach is the highly
developed and researched Relationship Enhancement (RE) program created by
Bernard Guerney Jr. (1977) at Penn State (Cavedo & Guerney, 1999). Guerney, one of
the authors of the breakthrough Families of the Slums (Minuchin, Montalvo, Guerney,
Rosman, & Schumer, 1967), had also worked with Carl Rogers, and his client-
centered orientation is evident in his interventions with families. Empathy,
genuineness, positive regard for clients, and other Rogerian principles are clear in
Guerney’s work, as is his interest drawn from his work with Minuchin in developing
techniques for helping troubled family relationships. Barry Ginsberg, a student of
both Bernard and Louise Guerney, husband and wife colleagues, described the
contemporary practices of RE as combining psychodynamic, behavioral,
communication, and experiential systems perspective.
RE is an intensive, time-limited program usually involving 10 sessions that
may extend over several months. It teaches clients to recognize their problems more
clearly and to understand how learning specific skills (such as improving their self-
concept, how to recognize and express—or “own”—what they are feeling, how to
accept each other’s feelings, how to engage one another and negotiate and work
through problems, how to achieve interpersonal satisfaction and become emotional
partners) helps them deal with their ongoing lives and also with problems they may
encounter in the future (Ginsberg, 2000). Understanding the inherently subjective
nature of experience allows a new frame of reference for understanding others and
improved expressive skills (Scuka, 2011). Both didactic presentations and skills
practice occur in sessions, and homework assignments (practicing, generalizing, and
maintaining learned skills) emphasize the client’s responsibility for therapeutic
success.
RE also offers cognitive instruction—critically examining one’s thoughts,
attitudes, and values—along with behavioral instruction—building skills for handling
emotions or engaging in interpersonal relationships. The practitioner’s values are
explicitly stated, and the client–therapist relationship is one of shared planning and
decision making. The signature techniques involve not only empathy, nonjudgmental
acceptance, and fostering genuine conversations between clients but also teaching
clients to recognize and acknowledge feelings and to express them openly and
honestly.
Research demonstrates the programs’ effectiveness in skills building with
premarital, marital, and special populations (enhanced communication reported by
participants; greater ability to resolve conflict together; improvement in the
relationship, a greater sense of trust and intimacy) as compared to other treatments
(Accordino & Guerney, 2003), but long-term effects are unknown, so follow-up
sessions are recommended.
In order to evaluate a couple’s preparation for marriage, David Olson and
colleagues developed the PREPARE (PREmarital Personal And Relationship
Evaluation) Inventory. This well-researched and reliable 165-item instrument, filled
out separately by each person, is designed to help premarital couples better
understand and discuss their families of origin and identify differences in outlook.
This initiates a process of reconciling differences to develop a harmonious
relationship. Computer scored and standardized on national norms, results are
presented in graphic profile form on a Couple and Family Map, supplying information
to the couple regarding their “relationship strengths” and “growth areas” where
further work appears to be necessary.
The Prevention and Relationship Enhancement Program (PREP), recently
revised by Markman, Stanley, and Blumberg (2010), is a carefully designed approach
to help couples improve their relationship before problems set in and lead to conflict
and the risk of divorce. Originally developed in the early 1980s, this social learning
approach “focuses on teaching appropriate communication and conflict skills, and
provides information to help couples evaluate expectations, understand relationship
commitment, and enhance positive connections through friendship and fun” (Scott,
Rhoades, Stanley, Allen, & Markman, 2013, p. 131). It is regularly researched and
updated (Ragan et al., 2009). Couples are taught constructive communication and
conflict-resolution skills, along with realistic attitudes and expectations about
marriage. In particular, they learn to develop behavioral interactive patterns that
satisfy the emotional and psychological needs of each partner. Couples learn to
resolve disputes effectively without injuring the relationship and in a timely manner
so that avoidant patterns do not build up. PREP is applied to couples at various points
in a relationship (premarital, cohabiting, married, and previously divorced preparing
for second marriages). The usual program includes 12 hours of interaction over a
weekend or several sessions using lecturers and skill coaches (Ragan et al., 2009).
PREP supplies resources for further study. Markman, Stanley, and Blumberg (2010)
have described positive steps to preserve a marriage, based on ongoing research.
Less carefully researched but popular and widespread is Marriage Encounter
—a worldwide weekend retreat enrichment program for couples, frequently sponsored
by church groups— directed at raising couple awareness of communication, problem
solving, sexual intimacy, and spiritual issues in an effort to prevent marriage
complacency or deterioration. Such programs appeal to couples who have a
satisfactory relationship but wish to make improvements, or those who wish to
examine and reaffirm their relationship. Marriage Encounter programs first appeared
in Spain in the early 1960s, developed by a Jesuit priest, Father Gabriel Calvo. He
arranged weekend retreats to provide support and enrichment for Catholic married
couples (Chartier, 1986). Similar religiously oriented programs have been adopted by
Protestant and Jewish groups. In addition to couples in long-standing marriages,
premarital and remarried couples have also found the experience enlightening and
beneficial (Stahmann & Hiebert, 1997). Some denominations require engaged couples
to participate in such a program before they can be married in church.
Some nonreligious programs, such as Couples Communication (CC), also
have become popular. The well-researched, skills-focused CC program is
educationally focused rather than remedial, enhancing satisfactory communication
skills (self-awareness, self-disclosure, effective listening, and so on). CC usually
involves 8 to 12 hours of structured skills training. A meta-analysis of CC studies
found “clinically relevant positive outcomes” on a variety of measures of improved
communication but diminution in the quality of communication over time (Butler &
Wampler, 1999, p. 223). Better Marriages, an international nonsectarian organization
headquartered in North Carolina, offers marriage enrichment groups led by lay
married couples who have successfully been through the couple leadership training
program (Better Marriages, 2015). Didactic material is minimal; the major emphasis
is on skill building through partner dialogue. Leaders share their personal experiences
rather than lecture or advise. Outcome studies, especially long term, are needed to
demonstrate evidence for these models.
h. Family Violence
Intimate partner violence (IPV) and child maltreatment occur in families at
disturbing prevalence rates (12–20% per year for IPV; 12.1 per 1,000 per year for
documented child maltreatment), and the two co-occur frequently (Owen,
Knickerbocker, Heyman, & Slep, 2009). Improved diagnostic criteria for IPV in the
DSM-5 and the ICD-11 enhance the ability of family therapists to screen for IPV and
improve the precision of research in the area; the criteria include particular acts with a
significant or potential impact (Heyman, Slep, & Foran, 2015). There are a variety of
risk factors for IPV, including lower socioeconomic status, proximity to high
community violence, and younger-age couples; psychological problems, aggression
issues, and substance abuse create risk for male-to-female IPV (Owen et al., 2009).
The interventions that currently demonstrate the strongest effectiveness in reducing
IPV are motivational enhancement approaches and cognitive-behavioral couples
therapy. Couples therapy “may be appropriate for couples in which the physical IPV
is mild or moderate and there is no fear of the partner” if both commit to a “no
violence” agreement and a safety plan.
Child maltreatment increases the likelihood of a variety of problems through
adolescence and into adulthood, including conduct disorder that can become
antisocial personality disorder, ADHD, mood disorders, academic problems, and
substance abuse, as well as health concerns. Although most individuals who
experienced or witnessed abuse as a child do not become perpetrators or victims of
abuse as adults, family-of-origin maltreatment does increase the risk as compared to
the general population. Parental attributions of blame to a child for problematic
behavior increase the risk of physical abuse (Owen et al., 2009). New criteria for child
maltreatment in DSM-5 and ICD-11, noting acts and impacts, reflect advances in
understanding the problem and may improve screening, but a number of contextual
issues and pragmatic concerns must be carefully addressed by the therapist. Treatment
focuses on improving parenting ability and the bond between parents and children.
The Triple P Positive Parenting Program (Sander, 2012) stands as a prominent
example of an evidence-based program that has been widely disseminated
internationally, offering comprehensive support and guidance to parents seeking to
enhance their parenting skills and promote positive child development. This program,
grounded in the principles of positive psychology and behavioral science, provides
parents with a structured framework for understanding and addressing a wide range of
parenting challenges, from managing behavior problems to fostering healthy family
relationships.
One of the key strengths of the Triple P program is its evidence-based
approach, which draws on decades of research and empirical evidence demonstrating
its effectiveness in improving parenting practices and child outcomes. Numerous
studies have consistently shown that participation in Triple P leads to positive changes
in parenting behavior, reduced child behavior problems, and improved family
functioning across diverse cultural and socio-economic contexts. This robust evidence
base has contributed to the program's widespread adoption and dissemination across
the globe.
Moreover, the Triple P program offers a flexible and adaptable framework that
can be tailored to meet the unique needs and preferences of parents and families. The
program is designed to accommodate families with children of all ages, from infancy
through adolescence, and can be delivered in various formats, including individual
sessions, group workshops, online modules, and self-directed resources. This
versatility ensures that parents have access to the support and resources they need,
regardless of their circumstances or preferences.
Another strength of the Triple P program is its comprehensive approach to
parenting support, which addresses a broad range of parenting challenges and
concerns. The program covers topics such as effective discipline strategies, promoting
positive parent-child relationships, managing stress and self-care, and supporting
children's social and emotional development. By providing parents with a holistic
toolkit of skills and strategies, Triple P empowers them to navigate the complexities
of parenting with confidence and competence.
Furthermore, the Triple P program emphasizes the importance of empowering
parents as agents of change within their families. Rather than focusing solely on
addressing children's behavior problems, Triple P seeks to strengthen the parent-child
relationship and promote positive parenting practices that support children's healthy
development over the long term. By fostering a strengths-based approach to
parenting, Triple P helps parents recognize and build on their existing strengths and
resources, enabling them to create a nurturing and supportive family environment.
Additionally, the international dissemination of the Triple P program has
facilitated cross-cultural learning and collaboration, allowing practitioners and
researchers from diverse backgrounds to exchange knowledge and best practices in
parenting support. Through training, consultation, and collaboration with local
partners, the Triple P program has been adapted and implemented in numerous
countries and cultural contexts, ensuring its relevance and effectiveness for families
worldwide.
Moreover, the Triple P program has been instrumental in promoting public
health and social policy initiatives aimed at supporting families and promoting child
well-being. By providing evidence-based parenting support at the community level,
Triple P helps prevent child maltreatment, reduce family stress, and promote positive
outcomes for children and families. Its widespread dissemination has contributed to a
broader cultural shift towards recognizing the importance of parenting support in
promoting healthy child development and strengthening families.
In summary, the Triple P Positive Parenting Program stands as a shining
example of an evidence-based program that has been disseminated internationally,
offering comprehensive support and guidance to parents seeking to enhance their
parenting skills and promote positive child development. Through its evidence-based
approach, flexible framework, comprehensive content, and international
dissemination efforts, Triple P has made significant contributions to improving
parenting practices, strengthening families, and promoting child well-being across the
globe.
i. Divorce and Remarriage
Now a common part of the family life cycle (McGoldrick & Shibusawa,
2012), divorce is frequently followed by cohabitation or remarriage (often with
stepfamily dynamics) and presents distinct challenges for families, as outlined in what
follows.
Although the divorce rate has declined in recent years, the likelihood of first
marriages eventually ending in divorce is still almost 50%, but it may be less for
recent marriages (Greene et al., 2012). Divorce is stressful, beginning with the actual
process of divorce. Collaborative divorce “is a family-centered, non-adversarial,
interdisciplinary-based, interprofessional process for divorcing”. It moves away from
the typically adversarial dispute between divorcing partners to enhance cooperation
and the potential for flourishing after the divorce. The model is based on five
assumptions: (1) couples divorce due to feelings that must be managed to benefit all
involved; (2) divorce is a process, not a legal event; (3) the process has effects that
continue for several years; (4) although painful, there is room for optimism in the
transition; and (5) navigating family relationships, legal processes, and financial
arrangements is best accomplished with experts in each domain. As part of the team, a
family therapist prepares the individuals to collaborate and learn to communicate in a
new way in order to resolve divorce issues.
Adjustment to divorce “involves a process perspective that addresses stress,
risk, and resilience” due to “stressful changes and disruptions in the social and
physical environments of adults and children” (Greene et al., 2012, p. 102). Adults
may experience a variety of consequences, but research suggests that these depend on
risk and resilience factors (e.g., low income relates to many stressors, but
socioemotional support may mitigate some of the negative effects; Greene et al.,
2012). Children of divorce, in contrast to children with married parents, experience
greater risk for decreased academic performance, increased affective and behavioral
problems, relationship difficulties, and decreased self-esteem, with differences by age
group at time of the divorce and gender, and usually take 2 to 3 years for initial
adjustment. See for statements about children of divorce that are all true, but seem to
contradict each other because they address risk, but not reality for all children. Critical
factors are the nature of the relationship with the residential and nonresidential parent
and the frequency and intensity of conflict between the parents.
There are 15 to 20 million stepfamilies in the United States; a notable increase
in cohabitation, childbirth outside marriage, frequent remarriage after divorce, and
ethnic differences in divorce and remarriage create a wide variety of stepfamily
experiences (Browning & Bray, 2009). Inevitably, living through a series of disruptive
transitions— from intact family to single parenthood to cohabitation and/or remarried
family— generatesNa series of structural and relationship shifts and role changes
requiring in some cases major adaptations and reorganizations for parents and
children alike.
Successful adaptation to stepfamily life calls for the ability to recognize and
cope with a variety of problems: stepparents assuming a parental role, rule changes,
jealousy and competition between stepsiblings as well as between birth parents and
stepparents, loyalty conflicts in children between the absent parent and the stepparent,
and financial obligations for child support. Children and adults alike come with
expectations from previous families, and stepfamilies must come to terms with these
differences. Stepfamilies must deal with losses and changes, negotiate different
developmental needs of their members, create a parental coalition, and establish new
traditions of their own (Visher & Visher, 1988, 1996). Parenting and stepparenting are
particularly stressful aspects in most stepfamilies, both during the early years of
remarriage and in stepfamilies of longer duration.
Psychoeducational programs serve as invaluable resources for family members
navigating the complexities of stepfamily dynamics, offering insights into common
relationship patterns unique to stepfamilies and fostering greater compatibility and
unity within these blended households. By providing families with a deeper
understanding of the distinct challenges and dynamics inherent in stepfamily life,
psychoeducational programs empower them to navigate these complexities with
greater resilience and effectiveness.
One key benefit of psychoeducational programs is their ability to illuminate
the differences between stepfamily relationships and those in intact families.
Understanding these differences is essential for family members to adjust their
expectations and develop realistic perspectives on their roles and responsibilities
within the stepfamily structure. Psychoeducational programs provide families with
information on common stepfamily dynamics such as loyalty conflicts, co-parenting
challenges, and the blending of different family cultures, helping them anticipate and
address these issues proactively.
Moreover, psychoeducational programs help family members recognize that
they are not alone in their experiences and challenges. Knowing that other families are
dealing with similar issues can be incredibly comforting and validating for stepfamily
members, reducing feelings of isolation and providing a sense of solidarity and
support. Psychoeducational programs often incorporate group discussions and peer
support, allowing participants to share their experiences, exchange advice, and learn
from one another's perspectives.
Additionally, psychoeducational programs offer practical strategies and tools
for enhancing compatibility and unity within stepfamilies. These programs may
include communication skills training, conflict resolution techniques, co-parenting
strategies, and tips for building strong family bonds. By equipping family members
with these resources, psychoeducational programs empower them to navigate the
unique challenges of stepfamily life more effectively and promote greater harmony
and cohesion within the household.
Furthermore, psychoeducational programs can help mitigate the stress and
uncertainty often experienced by stepfamily members as they navigate unfamiliar
territory. By providing a structured and supportive environment for learning and
growth, these programs help alleviate anxiety and build confidence in participants'
ability to address challenges and build fulfilling relationships within the stepfamily
context. This increased sense of self-efficacy can have far-reaching benefits for family
members' overall well-being and resilience.
In addition to their immediate benefits, psychoeducational programs can also
have long-term positive effects on stepfamily relationships. By promoting greater
understanding, empathy, and communication among family members, these programs
lay the foundation for healthy and resilient family dynamics that can withstand the
challenges and transitions inherent in stepfamily life. Participants who engage in
psychoeducational programs may experience greater satisfaction and fulfillment in
their relationships over time, as they apply the skills and insights gained through the
program to navigate ongoing challenges and transitions.
Moreover, psychoeducational programs can provide a valuable opportunity for
stepfamily members to bond and strengthen their relationships. Participating in a
shared learning experience can foster a sense of camaraderie and connection among
family members, creating a supportive and collaborative atmosphere within the
household. Family members may develop a deeper appreciation for each other's
perspectives and contributions, leading to greater empathy, trust, and intimacy in their
relationships.
In summary, psychoeducational programs play a vital role in supporting
stepfamily members as they navigate the unique challenges and dynamics of blended
family life. By providing education, support, and practical tools for enhancing
compatibility and unity, these programs empower families to build resilient and
fulfilling relationships within the stepfamily context. Through a combination of
knowledge, peer support, and practical skills development, psychoeducational
programs help stepfamily members navigate the complexities of their relationships
with confidence, compassion, and resilience.
