1. Couple & Family Therapy : An Integrative Map of the Territory
Jay L Lebow
Chapter 4

2. Introduction Couple and family therapy linked by treatment models
(Lebow, 2014)
Introduction
Couple and family therapy linked by treatment models
Models
Have rich descriptions of theory / methods
Based on vision of what matters in families and how to help families change

3. Early Models Synonymous with couple / family therapy
(Lebow, 2014)
Early Models
Synonymous with couple / family therapy
Articulated ideas and methods on which couple / family therapy is based
Very few practiced in original form today
Ideas absorbed within other methods

4. Early Models cont... Structural Family Therapy Strategic Approaches
(Lebow, 2014)
Early Models cont...
Structural Family Therapy
Strategic Approaches
Experiential Approaches
Bowen Family Systems Therapy and other Intergenerational Approaches
Psychodynamic Approaches

5. Structural Family Therapy
(Lebow, 2014)
Structural Family Therapy
Salvador Minuchin
Importance of family structure in determining life of family and members
Family structure: regulating codes manifested in patterns in which people relate to one another to carry out functions
Three elements:
Boundary
Alliance
Power

6. (Lebow, 2014)
Boundary
Rules defining who participates and how they participate in what aspects of life
Regulate amount / quality of contact
Continuum:
Rigid – “disengagement”
Disconnected
Permeable – “enmeshment”
No separation; violations of space

7. Alliance Joining / opposition of one member of system to another
(Lebow, 2014)
Alliance
Joining / opposition of one member of system to another
Inevitable
Dysfunctional when fixed or unchanging or cross-generational
Triangulation – two people demand a third join them against the other
Goal of structural family therapy is to create functional stable alliances

8. (Lebow, 2014)
Power
Influence of each member on outcome of family activities / decisions
Functionally distributed
Rigidly held by member or coalition
Dysfunctional – no one has power
Structural family therapy aims to move families toward distribution of power (strong parental coalition with all members retaining some power)

9. Restructure the family to promote better functioning
(Lebow, 2014)
Structural family therapy emphasizes changing aspects of family structure
Restructure the family to promote better functioning
Homeostatic vision of family system: create enactments to trigger shift in organization
Enactments—powerful in-session experiences; create crisis to alter methods of responding / structure

10. (Lebow, 2014)
Structural family therapy is primary source for many tools used by therapists today
Joining
Tracking (adopting symbols of family’s life)
Accommodation (relate congruent to family pattern of relating)
Mimesis (become like family members in manner or content of communication)

11. Strategic Approaches Most purely systemic of family therapies
(Lebow, 2014)
Strategic Approaches
Most purely systemic of family therapies
Brief and focused
Change is a “discontinued process of making a leap into categorically different way of systemic functioning”
Specific intervention techniques
Paradoxical interventions
Use of team / one-way mirror
Therapist maintains cool detached stance

12. Strategic Approaches cont.
(Lebow, 2014)
Strategic Approaches cont.
Mental Research Institute Model (MRI)
aka Palo Alto model
General systems theory, cybernetics, and communications
First order change (more or the same)
Second order change (alter rules of the system)

13. (Lebow, 2014)
MRI cont...
Identify ways problems maintained; explicate rules underlying problems; change rules
Paradoxical prescriptions / interventions
Reframing (“seeking independence” vs “acting out”)
Prevent long term attachment to therapist to facilitate termination

14. Problem-Solving Therapy
(Lebow, 2014)
Problem-Solving Therapy
Jay Haley
Combine paradoxical techniques with focus on family structure
Power and distribution are important
Focus on function of behaviors within the system
Understand triangles (who supports whom) and hierarchy (who has power)

15. Problem-Solving Therapy
(Lebow, 2014)
Problem-Solving Therapy
Directives targeted at triggering family to engage in new and different behaviors to achieve solutions
Promote confusion to increase suggestibility and openness to change
Pretend technique
“Identified patients” (manifest symptoms because of function of symptoms)

16. Milan Systemic Therapy
(Lebow, 2014)
Milan Systemic Therapy
Milan, Italy – Palazzoli, Boscolo, Cecchin, Prata and colleagues
Typical therapy – once a month; therapist in room; team of therapists behind one-way mirror
Formulation of hypotheses about family
Refined over course of therapy
Formulation of strategic messages emphasizing “positive connotation”

17. Point out how dysfunctional behavior serves positive goals of system
(Lebow, 2014)
Positive connotation - Type of reframing focused on assigning positive meaning to what has been described as problematic behaviors
Point out how dysfunctional behavior serves positive goals of system
Exaggerate or challenge rigid family patterns through irony and confusion
Draw attention to patterns; increase awareness of ability to influence / resolve differences

18. Cognitive-Behavioral Approaches
(Lebow, 2014)
Cognitive-Behavioral Approaches
Most efficacious pathways to change are those that directly alter dysfunctional thoughts and behavior patterns
Classical conditioning
Operant conditioning
Social learning theory (Bandura)
Social exchange theory

19. Cognitive Behavioral Approaches
(Lebow, 2014)
Cognitive Behavioral Approaches
Facilitate awareness of how thoughts affect emotion
More similar to one another than any other group of family therapies
Cognitive Behavioral Couple Therapy – challenge lies in addressing aspects that are not simply about behavior
Schema-focused couple therapy – focus on ingrained beliefs about self, partner, and relationship as key roles in distress

20. Experiential Approaches
(Lebow, 2014)
Experiential Approaches
Attend to felt experience of clients, emphasizing moments of heightened emotion in therapy
Ultimate goals – improved functioning; reengaging a sense of liveliness and connection
Whitaker and Satir (original)
Emotion focused couples therapies (Greenberg; Johnson)- most prominent

21. Satir – family sculpting
(Lebow, 2014)
Whitaker – provocative techniques to engage families: ironic commentary, verbal confrontation, physically wrestling with clients
Satir – family sculpting

22. (Lebow, 2014)
Emotion Focused
Emphasis on process of getting in touch with and expressing emotion
First expression of emotion is followed by working through that emotion to access underlying emotional feeling
Johnson – emphasizes attachment
Greenberg – emphasizes identity

23. Bowen Family Systems Therapy
(Lebow, 2014)
Bowen Family Systems Therapy
Bowen – centers on concept of differentiation of self
Differentiation of self – the evolving ability to consider the world dispassionately and free of the residue of individual and family history
Balanced thought overrides feeling
Undifferentiated ego mass of emotion and belief transmitted across generations through family projection process

24. Bowen Family Systems Therapy
(Lebow, 2014)
Bowen Family Systems Therapy
Based on active process of clients interacting with family members and memories of deceased relatives to free self from processes
Disentanglement from triangles
Therapy often occurs with only one client or a couple present
Focus on family of origin

25. Other Intergenerational Approaches
(Lebow, 2014)
Other Intergenerational Approaches
Imber-Black – emphasis on exploring and processing family secrets (past / present)
Boszormenyi-Nagi – Contextual Approach
Invisible loyalties – multigenerational ledger of what each person has received or not received
People seek to balance ledgers
Carry over feelings from family of origin to adult life
Goal of therapy: help client understand ledger and find constructive rather than destructive ways to balance them

26. Psychodynamic Approaches
(Lebow, 2014)
Psychodynamic Approaches
Long standing tradition of incorporating psychodynamic concepts in family therapy
Emphasis on dynamic internal processes occurring within and across individuals and inner conflicts
Emphasis on unconscious mental processes and role of early experiences
Transference; countertransference; interpretation

27. Second Generation Therapies
(Lebow, 2014)
Second Generation Therapies
Emerged over the past 30 years
Postmodern and Poststructural Therapies
Feminist Therapies
Psychoeducational Approaches

28. Postmodern / Poststructural Therapies
(Lebow, 2014)
Postmodern / Poststructural Therapies
Who is in the room is less important that what is the focus
Therapists are collaborators rather than experts
Process of treatment is coevolution between client and therapist
Narrative Therapy
Collaborative Therapy
Witnessing
Solution-Focused Therapy
Status

29. Narrative Therapy Focus on stories people hold about their lives
(Lebow, 2014)
Narrative Therapy
Focus on stories people hold about their lives
Personal stories socially constructed and how these can be collaboratively reconstructed
Social constructionism – ensuring voices of less powerful given greater prominence that dominant culture
Therapy not about treatment strategy but joint exploration
Problems external to client – externalize the problem to see as separate from individual

30. Collaborative Therapy
(Lebow, 2014)
Collaborative Therapy
Coequal dialogue between clients and therapists toward natural end of mutual benefit
Clients are best expert on their lives
Therapist work from position of “not knowing”
Shared inquiry
Harlene Anderson

31. (Lebow, 2014)
Witnessing
The value of being present for clients as they share their life stories and helping them find their own constructive voice in relation to their difficulties
Kaethe Weingarten

32. Solution-Focused Therapy
(Lebow, 2014)
Solution-Focused Therapy
Steve de Shazer and Insoo Kim Berg
Therapist role is introducing simple ways of thinking about and dealing with difficulties and help initiate families’ own processes of problem resolution
Major technique: focusing on times when problem has been absent

33. Feminist Therapies Earliest therapies developed by men
(Lebow, 2014)
Feminist Therapies
Earliest therapies developed by men
Based on assumptions associated with male ways of experiencing world
Two types
Goldner – developed specific couple therapy for partner violence informed by feminism and systems theory
Interventions based on relational perspective

34. Psychoeducational Approaches
(Lebow, 2014)
Psychoeducational Approaches
Emphasize increasing the family’s understanding of the nature of particular disorders and problems and what helps / hinders recovery
Primarily used in context of mental health and health disorders
Crisis management; skills for particular problems
First were developed in context of working with schizophrenia

35. Integrative Models Integrative Problem-Centered Therapy Metaframeworks
(Lebow, 2014)
Integrative Models
Integrative Problem-Centered Therapy
Metaframeworks
Integrative Problem-Centered Metaframeworks
Client-Directed Outcome Informed Clinical Work
Internal Systems Therapy
Therapeutic Palette

36. Integrative Problem-Centered Therapy (IPCT)
(Lebow, 2014)
Integrative Problem-Centered Therapy (IPCT)
William Pinsof
Family’s definition of the problem form which they are seeking help becomes the center of the therapeutic contract
Identification of problem maintenance cycle (promotes / maintains problem; suggests intervention pathway)
Simple strategies first; then complex

37. (Lebow, 2014)
Metaframeworks
“Emphasizes a theory of constraints that suggests people do what they do, think what they think, or feel what they feel in ways that are dysfunctional when they are prevented from doing, thinking or feelings something else”
Identify and remove constraints
Dimensions where constraints occur:
Development, organization, sequences, culture, gender, and mind

38. Integrative Problem-Centered Metaframeworks
(Lebow, 2014)
Integrative Problem-Centered Metaframeworks
Integration of IPCT and metaframeworks
Strategies are sequenced
Action (behavioral and structural)
Meaning (cognitive and narrative)
Emotion (experiential)
Biology
If all of the above fail, focus on strategies involving family of origin, internal representation, and self

39. Client-Directed Outcome Informed Clinical Work
(Lebow, 2014)
Client-Directed Outcome Informed Clinical Work
Maximize common factors in psychotherapy
Generation of hope
Positive expectancy
Therapeutic alliance
Being change focused and tapping client’s world outside of therapy
Learn client’s theory of change and build on it
Outcome Rating Scale

40. Internal Systems Therapy
(Lebow, 2014)
Internal Systems Therapy
Richard Schwartz
Integrates structural family therapy with experiential and gestalt therapy methods
Understand, sort, and change internal representations of family in mental process
Managers – prevent unpleasant thoughts
Exiles – activate bad feelings
Firefighters – control exiled feelings

41. Therapeutic Palette Fraenkel Integrative method of couple therapy
(Lebow, 2014)
Therapeutic Palette
Fraenkel
Integrative method of couple therapy
Organizes intervention around:
Time frame (past, present, future)
Directiveness (more vs less)
Entry point (behavior, cognition, emotion)
to fit intervention to task at the moment in therapy

42. Reference
Lebow, J. L. (2014). Couple and family therapy: An integrative map of the territory. Washington, DC: APA books.