—Doug Greenlee MA/MS (Journal of Marital and Family Therapy)
Handbook of Clinical Family Therapyby Jay L. Lebow
The last twenty years have seen an explosion of new, innovative, and empirically supported therapeutic approaches for treating families. Mental health professionals working with families today apply a wide range of approaches to a variety of situations and clients using techniques based on
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The latest theory, research, and practice information for family therapy
The last twenty years have seen an explosion of new, innovative, and empirically supported therapeutic approaches for treating families. Mental health professionals working with families today apply a wide range of approaches to a variety of situations and clients using techniques based on their clinically and empirically proven effectiveness, their focus on specific individual and relational disorders, their applicability in various contexts, and their prominence in the field.
In this accessible and comprehensive text, each chapter covers specific problems, the theoretical and practical elements of the treatment approach, recommended intervention strategies, special considerations, supporting research, and clinical examples. The contributors provide step-by-step guidelines for implementing the approaches described and discuss particular issues that arise in different couple, family, and cultural contexts.
Handbook of Clinical Family Therapy covers treatment strategies for the most common problems encountered in family therapy, including:
- Domestic violence
- Adolescent defiance, anxiety, and depression
- Trauma-induced problems
- Stepfamily conflicts
- ADHD disruption
- Substance abuse in adults and adolescents
- Couple conflict and divorce
- Chronic illness
A detailed reference for today's best treatment strategies, the Handbook of Clinical Family Therapy brings together the top practitioners and scholars to produce an innovative and user-friendly guide for clinicians and students alike.
—Doug Greenlee MA/MS (Journal of Marital and Family Therapy)
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Handbook of Clinical Family Therapy
By Jay Lebow
John Wiley & SonsISBN: 0-471-43134-6
Chapter OneFamily Therapy at the Beginning of the Twenty-first Century
Jay L. Lebow
This volume marks a watershed in the development of couple and family therapy. We have entered an era in which the most prominent models of practice no longer primarily accentuate disparate, broad visions of how families operate and how people change, as they did a generation ago, but instead draw from a core set of well-established strategies to create pragmatic, effective ways of working with specific difficulties and life situations. In the newest generation of family therapies, generic family-based strategies of intervention are shaped to most successfully fit and impact on the specific clinical context.
Today's state-of-the-art methods in couple and family therapy, although diverse in their specific focus and their particular blueprint for intervention, share many core attributes. A number of transcendent core characteristics readily emerge from deconstructing the ingredients of the kinds of twenty-first-century family therapies exemplified in this volume. These core characteristics are summarized in the following sections.
Today's state-of-the-art methods have a systemic focus. Drawing upon the preeminent core concept of the early family therapy movement (Haley, 1963), these approaches accentuate the importance of understanding the family as a system and the core properties of such social systems. Systemic concepts are apparent in the fabric of these approaches, manifested in such aspects as the significance assigned to mutual ongoing influence, the view that the whole is more than the sum of its parts, the importance assigned to feedback in interpersonal process, and the power of the dueling forces moving toward homeostasis and morphogenesis.
However, it is very much a twenty-first-century version of systems theory that is evident in these approaches, rather than earlier variants of systems theory that were more closely linked to the properties of inanimate systems. In this newer view of social systems, families are seen as more than simply the product of inevitable systemic forces. This systems theory allows room for understandings of causal processes, for the differential impact of different individuals on the mutual systemic process, for influences on the system that reside within the inner selves of individuals, and for the impact of the larger system on the family.
Within such a framework, pathways of mutual influence move well beyond the idealized, circular causality that was posited to be at work in an earlier generation of family therapies (Bowen, 1966; Whitaker, 1992). Following the core insight first presented by Virginia Goldner (Goldner, 1998) in the context of examining couple violence, this includes an understanding that sometimes one person's influence is greater than another's on their mutual process, even though the action of each has some impact. As Goldner (1998) suggested, patterns of couple violence may show circular arcs of influence, but typically the individual personality of the abuser has much more impact on the initiation and continuation of abuse than that of the abused partner. This viewpoint provides a crucial example of the refinement of the systems theory that has occurred in light of the pragmatic knowledge gained from a half century of clinical experience and research. There are few findings in the social sciences as well demonstrated as the mutual influence of family and individual behavior (Snyder & Whisman; 2003; Pinsof & Lebow, 2005), but this mutual influence is mediated and moderated by numerous factors. The simplistic application of systems theory derived from observations primarily about inanimate objects and animals has been refined in the context of observations and research about the properties of human systems.
These approaches have a biobehavioral-psychosocial underpinning. Social systems exert influence, but are not the only factors in the lives of individuals. Whereas early family-therapy models eschewed individual psychology (the biological basis of behavior, social psychology, and principles of learning), most of the emerging models embrace these sets of ideas.
The last few decades have been a time in which the biological basis of behavior has come to be well established. In the earliest versions of family systems therapies, notions of a biological basis were dismissed for even the most severe problems in individual functioning, such as schizophrenia or Bipolar Disorder (Haley, 1997). In that era, leaders in the field of family therapy mustered strong arguments against the primitive biological theories of the time (which had little basis in evidence) as part of their argument for the supremacy of a systemic viewpoint. These arguments were the systemic equivalent of Watson's landmark statement of behaviorism, denying biology any significant role in the development of mental health or pathology.
However, a generation of investigation has very much changed this picture. Although biological theories of the origins of behavior are still often grossly overstated and reductionistic, the impact of biology on individual functioning and on family processes is now well established. Biology has been demonstrated to affect the genesis and development of many specific behavioral patterns and disorders (see, for example, the chapters in this volume by McFarland and Wells) and has become incorporated as a factor to assess and deal with in many of today's state-of-the-art models. The emerging bodies of knowledge in biology, genetics, and neuroscience influence the most recent models of family intervention in a multitude of ways. These include: suggesting risk factors to mitigate through intervention, as in the treatments designed to reduce expressed emotion in the treatment of families with members with severe mental illness (e.g., see the chapter by McFarland in this volume), suggesting solutions such as medication, as in the use of stimulants as part of the treatment of Attention-Deficit Disorder in children (see the chapter by Wells in this volume), suggesting ways of helping families understand syndromes through psychoeducation, such as in the treatment of schizophrenia and Bipolar Disorder (see the chapter by McFarland in this volume), and suggesting ways of coping with problematic states of autonomic arousal in processes such as couple conflict (see the chapters by Wooley, Johnson, and B. Baucom, Christensen, & Yi in this volume). The importance of understanding and responding to the biological basis of behavior is most apparent in those treatments dealing with psychological disorders with the strongest biological bases for disorder (e.g., those dealing with severe mental illness and Attention-Deficit Disorder), but also is apparent across a wide range of difficulties, including medical disorders such as juvenile diabetes and congestive heart failure, and even in everyday normal couple and family process. It's also notable that when Minuchin and colleagues wrote Psychosomatic Families (Minuchin, Rosman, & Baker, 1978), the focus at that time in the interface between biology and family was on the influence of family on biology; today's approaches are as likely to work with the important understandings from the biology of such diseases as juvenile diabetes (e.g., see the chapter in this volume by Pisani & McDaniel).
Behavioral and social psychological understandings have also become well established and integrated into the majority of these models. The last 20 years has seen the emergence of a far better grasp of the patterns of learning and of social exchange that occur in families, and how they impact on family process. Classical conditioning, operant conditioning, modeling, covert processes of learning, and social psychological principles of exchange have all clearly emerged as central processes in shaping the lives of family members. And the understandings of the importance of these processes has led to the development of numerous interventions that draw on behavioral and social psychological principles that have been proven to have considerable impact. Technologies for helping with specific interpersonal skill sets in couples and families, such as communication, intimacy, problem solving, and social exchange, that have been part of clinical practice for many years, have been refined and augmented. These intervention strategies stand as key ingredients in almost all of the state-of-the-art methods in family therapy.
Individual psychological process is also a focus for intervention in most of these approaches. Cognition and affect are crucial human processes and powerfully impact on each of the various difficulties addressed in this volume. As a result, cognitive and affect-focused interventions are typically part of today's state-of-the-art approaches. Numerous approaches accentuate working with cognitions through examining thoughts (e.g., see the chapter in this volume by B. Baucom, Christensen, & Yi) and several prominent approaches (e.g., see the chapters in this volume by Wooley, Johnson, and Diamond) focus on methods centered on processing affect. And whereas traditional psychodynamic viewpoints are encountered less often today than a generation ago, the essential core psychodynamic notions of the importance of working through individual past history and inner conflicts, and of establishing working alliances with all family members, can be found in most approaches (e.g., see the chapter by Fishbane).
Applying Generic Strategies of Change
Although the technology for approaching problems grows and becomes more refined each year, paradoxically most of the state-of-the-art methods in family therapy today draw from the same generic set of methods. Although the theoretical lens focusing across these approaches and the language for describing the methods for intervention may vary, almost all of these approaches include strategies that work with family structure; strategies that are based on behavioral principles of learning, exchange, and task assignment; strategies that work with cognitions, narratives, or attributions; strategies based in psychoeducation; strategies for working with affect; and strategies for working with meaning. The specific interventions utilized to carry out these strategies similarly draw from a generic catalog of interventions.
Accenting Broad Curative Factors
Today's state-of-the-art approaches don't simply accentuate technique, but also emphasize the creation of the so-called non-specific conditions for change in psychotherapy. Almost all of these approaches emphasize such factors as enabling client engagement, building alliances with each family member, and the creation of hope and positive expectations for change. Almost without exception, these approaches look to build strong treatment alliances as a key ingredient in treatment. A transcendent understanding has emerged-treatments can only be as effective as they are able to engage clients. Some of these approaches, such as Brief Strategic Family Therapy, described in this volume by Horigian and colleagues, and the Outcome-Informed approach of Miller and colleagues center a considerable part of their methods on alliance building, and have offered significant refinements in creating alliances. Clearly, couple and family therapies can only be effective if alliances can be created and maintained that enable participation in therapy.
Shaping Strategies Relative to Specific Difficulties
Another core characteristic of these approaches is that they shape strategies of change in relation to the core difficulty or life issue that is in focus. Increasingly, family approaches are grounded in the ecological nexus of the problem area to which they are addressed. Although these methods build from a generic set of strategies and techniques, those strategies and techniques are adapted in relation to the knowledge available about the particular problem area. For example, although psychoeducation is an important intervention in many of the therapies described in this volume, the specific focus of psychoeducation and the content of that psychoeducation will vary with the problem. And, so will the expected affective states likely to be encountered, the behavioral skills likely to be deficient and useful to augment, the most typical problems with family structure and the most useful interventions for working with that structure, and the most helpful cognitive formulations, potential narratives, and reframes. The present state-of-the-art methods of intervention have developed following idiosyncratic pathways, but in almost every instance these models have evolved out of some sort of dialectic between a broad conceptual framework and the pragmatics of working with a particular focal problem.
In today's state-of-the-art approaches, problems are labeled as problems, but sensitivity is maintained regarding the social meaning of labels. The early models of family therapy largely took an ideological stand against the existence of "individual" problems. In the wake of the version of systems theory then popular, clients with difficulties were seen as "identified patients," that is, the carrier of the symptoms of the problem for the system (Minuchin, 1974; Whitaker, 1992). Today's approaches almost never speak of an identified patient. Instead, the individual or individuals who bear problems are viewed as having an individual difficulty, even if there is some basis for that problem in the social system (e.g., see Gupta, Beach, & Coyne's discussion of depression in the context of marital difficulty in this volume). And yet today's state-of-the-art approaches strongly emphasize the context for the generation and maintenance of difficulty, and make considerable effort to limit the possibly deleterious effects of the labeling of individual difficulties through a careful use of language and a nonjudgmental and sympathetic view of problems. Thus, diagnosis has a role in these approaches, but it is a kinder, gentler diagnosis.
Building on Empirical Foundations
Today's state-of-the-art strategies of change are based in empirical knowledge about families and the problem area in focus, and empirically testing the efficacy of the approach to intervention. Today's state-of-the-art methods are anchored in the empirical knowledge available about family processes, individual development, individual personality and psychopathology, and about the particular life circumstance around which the approach has been honed. These approaches are heir to several decades of research assessing broadly applicable principles of family and individual process and assessing those family and individual processes in the context of specific life circumstances. And, almost all of the state-of-the-art models in family therapy are the product of a honing of these methods through clinical and research testing, and are in the process of being clinically tested.
Perhaps the most prominent finding that serves as the foundation for these methods is the now very well-established relationship between family functioning and individual functioning, cited in almost every chapter of this volume-one of the most replicated findings in psychological research. Yet, the body of findings that provides the basis for these methods moves well beyond those documenting this simple relationship. We are now heir to a great deal of prominent research that describes the complex relationships within families in the context of various relational difficulties, life transitions, and individual disorders. This research has informed today's approaches about the typical ways problems develop, the ways problems are maintained, and the pathways that distinguish movement toward greater difficulty or resilience. As an example, the various approaches to the treatment of adolescent delinquency, substance use disorder, and other acting out delineated in this volume are the heir to the complex understandings of such processes developed by Paterson and others over three decades (Dishion & Patterson, 1999).
Today's state-of-the-art approaches are far from simplistic renditions of the old syllogism that all individual problems must be rooted in family difficulty. Instead, reflecting the contemporary understanding of these issues, families are primarily seen as potential resources for helping with problems and developmental challenges, rather than as the cause of these problems. And, the specific mechanisms that have been identified in the basic research on couple and families often have become the focus for intervention, be those mechanisms parental monitoring of child behavior, parental structure, parental depression, couple attachment, or couple communication.
Excerpted from Handbook of Clinical Family Therapy by Jay Lebow Excerpted by permission.
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Meet the Author
JAY L. LEBOW is Senior Faculty Member at the Family Institute at Northwestern University and Adjunct Associate Professor at Northwestern University. He is past president of the APA's Division 43 (Family Psychology), an approved supervisor of AAMFT, and a former board member of the American Family Therapy Academy and American Board of Family Psychology.
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