Contemporary Family Therapy

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Theoretical model of RES
Article
Slavery and its aftermath have created multiple challenges that are unique to the African American community. Although literature exists within other disciplines, no published empirical study within the marriage and family therapy literature has examined the residual effects of slavery. We used a modified Delphi methodology to explore the residual effects of slavery on African Americans and to determine resultant clinical implications. To obtain information from panelists who have expertise in this area, we conducted three rounds of data collection: an open-ended questionnaire, a Likert-scale questionnaire, and a round of in-depth interviews. Based on our analysis of the data collected, this empirical study describes the influence of the residual effects of slavery, implications for clinicians and directions for future research.
 
Topographic images showing activation in response to images of a loved-one seeking abstinence from SUD. Top row of images shows deoxygenated hemoglobin (HbR) response activation among subgroups of participants in the loved-one seeking abstinence group with A lowest third regarding levels of emotional reactivity (n = 9); B middle third regarding levels of emotional reactivity (n = 8); and C highest third regarding levels of emotional reactivity (n = 9). Bottom row of images shows HbR response activation among subgroups of participants in the loved-one seeking abstinence group with D lowest third regarding levels of fusion with others (n = 9); E middle third regarding levels of fusion with others (n = 8); and F highest third regarding levels of fusion with others (n = 9)
Scatterplots of emotional reactivity and activation response to family member images. A Scatterplot shows association between emotional reactivity and left dmPFC activation response to loved-one images for family members of a loved-one seeking abstinence from a SUD; B Scatterplot shows association between emotional reactivity and left dmPFC activation response to images of the target family member for control group participants. dmPFC dorsomedial prefrontal cortex, HbR deoxygentated hemoglobin
Scatterplots of fusion with others and activation response to family member images. A Scatterplot shows association between fusion with others and left dmPFC activation response to loved-one images for family members of a loved-one seeking abstinence from a SUD; B Scatterplot shows association between fusion with others and left dmPFC activation response to images of the target family member for control group participants. dmPFC dorsomedial prefrontal cortex, HbR deoxygentated hemoglobin
Article
Substance use disorders (SUDs) are a chronic disease that impacts the individual with a SUD as well as an entire family system. While family members of those with SUDs are one of the most important support networks in the recovery process, impacted family members have been found to experience more adverse health outcomes and altered functioning of the prefrontal cortex (PFC). These impacts negatively influence not only family members’ personal health but also the health of the family unit, which limits the family’s capability of providing its most effective support. Bowen’s conceptualization of differentiation of self can help explain the perspective of SUDs as a “family disease” and associated impacts on family members. Using functional near-infrared spectroscopy with a sample of 26 SUD-impacted family members, the present study examined associations between PFC activation in response to images of a loved-one seeking abstinence from a SUD and various components of differentiation of self (i.e., emotional cutoff, emotional reactivity, fusion with others, and I-position). Activation of the left dorsomedial PFC in response to SUD loved-one images associated negatively with emotional reactivity and positively with fusion with others. These findings did not replicate in a control group and have important implications for research and clinical practice.
 
Perceived family support, community connectedness, and religiosity on psychological well-being for binary transgender people (n = 242). Standardized coefficients. *p < 0.05. **p < 0.01. ***p < 0.001 (two-tailed)
Associations of perceived family support, community connectedness, and religiosity on psychological well-being for nonbinary people (n = 132). Standardized coefficients. *p < 0.05. **p < 0.01. ***p < 0.001 (two-tailed)
Article
Binary transgender and nonbinary people face interpersonal and societal discrimination which can contribute to minority stress and negative mental health. Thus, it is important that family therapists understand what factors contribute to psychological well-being to be able to offer helpful and inclusive therapy services to these communities. This study addresses a gap in the literature regarding differences in factors contributing to psychological well-being between binary transgender and nonbinary people as well as understanding these factors in a predominantly People of Color (POC) sample. Utilizing secondary data from the Social Justice Sexuality Project (Battle and DeFreece in Women Gend Fam Color 2(1):1–31. https://doi.org/10.5406/womgenfamcol.2.1.0001, 2014; Battle et al. in Social justice sexuality survey: cumulative codebook, City University of New York-Graduate Center, New York, 2012), this study examined the relationships between perceived family support, religiosity, community connectedness and psychological well-being in a sample of binary transgender and nonbinary people. Results from a multiple group path analysis show that perceived family support, religiosity and being connected to an LGBT community were significantly associated with psychological well-being for binary transgender people, while only LGBT community connectedness was significantly associated with psychological well-being for nonbinary people. Implications for family therapists include helping families support binary transgender and nonbinary family members, deconstructing non-affirming religious messages about gender identity and connecting clients to affirmative religions and religious leaders, and being knowledgeable about community resources for binary transgender and nonbinary POC.
 
Article
Relationship power, which refers to the ability to influence one’s romantic partner, is an important organizing principle in the assessment and treatment of couples. Power imbalance is predictive of various dimensions of marital quality, which explains why it is often a central focus of couple therapy. Despite the importance of relationship power in couple therapy, assessing power in clinical settings has been hindered by the lack of a validated measure of power that has high clinical utility. Data from 640 married couples associated with the Flourishing Families Project were used to develop the Perceived Power Imbalance Scale by conducting exploratory factor analysis, confirmatory factor analysis, dyadic predictive validity analysis, and measurement equivalence analysis. Although power has been conceptualized as consisting of both outcome power and process power, results indicated that the final scale consisted of four items that only tapped aspects of process power. The scale demonstrated good reliability and was a significant predictor of marital quality, marital instability, and depression.
 
Confirmatory factor analysis model for 12 item Family Assessment Device
Confirmatory factor analysis model for 6 item Family Assessment Device
Article
Racial/ethnic minority youth receive approximately half of the mental health services of their non-minority peers. Improved methods for identifying African American families in need of behavioral health services are necessary. The Family Assessment Device and General Functioning subscale have been found to be reliable and able to detect family functioning impairment in a generalized sample, but less is known about the reliability and validity of the assessment with an African American community sample. Data from 53 African American caregiver-child (ages 7–13) dyads was collected including family demographics and the Family Assessment Device General Functioning (FAD_GF) scale. Confirmatory factor analysis was conducted to determine the minimal number of FAD_GF items (12 vs. 6 items) that were valid and reliable. The 12-item FAD_GF and the 6-item scale had acceptable psychometric properties, and the 6-item measure demonstrated improved model fit over the 12-item scale and identified more clinically impaired families (6-item: 28% vs. 12-item: 23%). The 6-item measure of family functioning was more sensitive 12-item FAD_GF. This brief measure may prove useful for identifying and assessing African American families.
 
Actor–Partner Interdependence Models
Article
Adolescent and young adult (AYA) patients diagnosed with cancer, and their caregivers, experience a wide range of biopsychosocial stressors. The systemic transactional model Bodenmann in Swiss J Psychol 54: 34–49, 1995 posits that distress and coping are interrelated when close relationships are faced with a shared stressor. This study’s purpose was to understand the interrelated nature of distress and coping among AYA cancer patients and their caregivers. The research questions were: (a) What are the within sample and dyadic outcomes associated with distress and coping strategies among matched AYA oncology patients and caregivers? and (b) To what extent will patient and caregiver engagement predict patient and caregiver distress, as well as the patient problem list? A descriptive, cross-sectional design was utilized to collect data from 19 matched patient-caregiver dyads. Outcome variables included: (a) distress, (b) patient perceived problems, and (c) perceived stress. Predictor variables included: (a) coping styles, (b) relational assessment, and (c) caregiver burden. Actor-partner interdependence modeling revealed: (a) patients’ and caregivers’ use of engagement style coping strategies has a positive impact on patients’ distress, while caregivers’ use of engagement style coping strategies also has benefits for their own distress, (b) caregivers’ use of engagement style coping strategies may help reduce patients’ endorsement of biopsychosocial or practical problems, and (c) greater use of disengagement style coping strategies may decrease caregivers’ endorsement of issues included on the patient’s problem list. Future researchers are recommended to further investigate cancer as a relational illness. Clinicians and health policy makers are encouraged to develop policies and protocols toward treating the relational unit as the standard of care rather than as the exception.
 
Article
Communication during a combat deployment has changed significantly in current times. Couples can now communicate with each other frequently and through multiple modes. Despite this greater availability of communication options, there remain unanswered questions related to how healthy deployment communication is best achieved between couples, particularly regarding navigating the uncertainty of deployment. In this qualitative study, we report on the experiences of 31 National Guard couples who endured a combat deployment in support of Operation Enduring Freedom. Couples were interviewed three months after the soldier returned from deployment. Through the lens of relational turbulence theory, we provide a conceptual framework related to effective and non-effective deployment communication, along with structural communication barriers in the military that may negatively affect the mental well-being of partners. Finally, we provide recommendations to guide couples through these difficult deployments.
 
Article
The integration of spiritual practices in therapy is a valuable tool for supporting and reinforcing change. This paper explores the use of a written form of prayer called a collect as an intervention in narrative therapy. A collect is a form of prayer with a structure that can be easily co-constructed by clients and therapists. This spiritual intervention serves as a therapeutic document to help reinforce the externalization of a client’s problem or help thicken alternative narratives. Relevant aspects of narrative therapy and written prayer are summarized. A guide for implementation, examples of collects, and a worksheet for helping clients write collects is provided.
 
Article
Therapists often conceptualize resistance as client behaviors that impede progress; this perspective threatens the therapeutic alliance, especially in couple and family therapy where increased resistance and multiple alliances are present. Polyvagal theory reframes and normalizes resistant behaviors as preconscious, protective responses emerging from our autonomic nervous system. The theory also explains how humans reciprocate safety cues to connect with each other; therapists can use concepts of polyvagal theory to manage their own emotional regulation and foster safety and connection in therapy. Polyvagal concepts deepen our understanding of protective behaviors presenting in couple and family therapy; therapists can help couple and family clients to recognize protective behaviors in their own relationships and facilitate safer connection and engagement. Clinical implications are presented: psychoeducation can help clients normalize and understand their protective processes; therapist presence and immediacy acknowledges and normalizes protective behaviors as they arise; therapist and client self-regulation skills support connection; therapist genuineness is a precondition to client safety; and understanding of polyvagal theory enhances assessment of conflict and enactments in couple and family therapy.
 
Article
Due to logistical and financial barriers that keep many distressed couples from seeking psychotherapy, online relationship education is a more accessible alternative. In the decade since a web-based program showed equivalent effectiveness to traditional marriage education (Duncan et al., 2009), several fully online programs have been developed and evaluated. We reviewed nine studies of four different programs that sampled 2,000 + couples. Specifically, we rated each study’s experimental rigor and compared research designs, theoretical and empirical grounding, average post-intervention and follow-up effect sizes, and differential effectiveness. Across studies, measured outcomes included relational (improved satisfaction, quality, confidence, commitment, communication; reduced conflict and aggression) and individual functioning on various indices of mental and physical health, emotional expression, and quality of life. Finally, we discuss the strengths and limitations of the research evidence, describe the two most evidence-based programs (ePREP and OurRelationship) in some detail and make recommendations for future study of these promising kinds of interventions.
 
Article
A contentious debate between the modern and postmodern epistemologies continue to wage on since the rise of constructivism and social constructionism in the 1990s. This debate has led to both modern and postmodernists falling into an either/or mindset. Others have proposed a solution, the both-and approach, that emphasizes integration of different therapeutic camps. Intentionality is a core component of this approach, as therapists must understand how employed interventions flow from the epistemology and theoretical orientation under which they operate. Another core component of this approach is tailoring the integration to the specific context of the client case. With this understanding and tailoring, therapists can utilize methods across the modern/postmodern divide, as they will coherently flow from their original epistemology and theoretical orientation. Applying methods from both modernism and postmodernism, then, enhances therapists’ therapeutic repertoire, allowing for more opportunities to adapt treatment to each client case. Altogether, the quality of services improve and the amount of clients therapists can help increases as well. This paper will provide an application of the both-and approach to a case study to provide an example of how the said method can be employed in therapy.
 
Research conceptual model
Structural equation diagram based on the conceptual model based on the role of self-worth mediator in relation to self-compassion, and hardiness with family cohesion
Article
The present study was conducted to investigate the structural model of the relationship between self-compassion and psychological hardiness with family cohesion about the mediating role of self-worth among women with war-affected spouses. The research method was descriptive and correlational. The statistical population comprised all women with war-affected spouses in Mashhad city (Iran) in 2019. Out of 1250 war-affected spouses, 294 were selected as the sample through voluntary and convenience sampling based on Morgan’s table. To measure the variables, Olson’s Family Cohesion Scale (1999), Neff’s Self-Compassion Scale (Neff, Self and Identity 2:223–250, 2003), Contingencies of Self-Worth Scale by Crocker et al. (Crocker et al., Journal of Personality and Social Psychology 85:894–908, 2003) and Kobasa’s Psychological Hardiness Questionnaire-Short Form (Kobasa, Sander (ed), Social psychology of health and illness, Erbium, Hillsdale, 1982) were used. For data analysis, Pearson correlation tests and path analysis were used. The results demonstrated that self-compassion and psychological hardiness were directly related to family cohesion, and self-compassion and psychological hardiness indirectly affected family cohesion through self-worth and each of the components of self-compassion and psychological hardiness had a significant positive relationship with family cohesion. Based on the findings of this study, it can be concluded that the relationship between self-compassion and psychological hardiness with family cohesion is not simple and linear, and self-worth may mediate this relationship.
 
Flow Chart of Systematic Review
PRISMA Flow Chart of Search Stages (Moher et al., 2009)
Article
One can find a rich set of empirically evaluated techniques across different schools in couple therapy over its evolution of five decades. Though there are multiple systematic reviews and analyses of couple intervention studies, none focus on reviewing the universal dimensions of change across therapeutic techniques. Understanding the common areas of change would enable integrated learning across therapy modalities for novice therapists. Therefore, the aim is to identify the techniques employed in couple intervention research and categorize their change dimensions. We examined 40 articles on couple interventions published across 16 journals and identified 111 techniques. The five therapeutic change dimensions, namely behavior, cognition, emotion, attachment, and holistic, were categorized based on the common factor integration of techniques. The identified techniques were further classified under the five dimensions using the voting procedure to validate the universality of change dimensions.
 
Article
Sexual intimacy is an essential experience to many romantic relationships, encompassing sexual identities, sexual desires, and sexual behaviors. Historically, people who identify as gay, lesbian, bisexual or questioning have been marginalized, tabooed, and illegalized in many societies, which have significantly shaped sexual minority (SM) couples’ views and experiences of sexual intimacy. When working with distressed SM couples, providing culturally sensitive and affirmative services is both necessary and effective considering the long-existing social stigma against sexual minorities and the imposed expectations by heterosexual norms. With the legalization of same-sex marriage in the U.S., working with SM couples is becoming an increasingly important practice in the U.S. However, many therapists receive little guidance in conceptualizing and treating SM couples and their experiences of sexual difficulties. The narrative therapy model has shown its theoretical advantages in working with couples with minority status, given its non-pathologizing stance in viewing minority experience. This paper proposes using a narrative couple therapy framework as a guide to help both therapists to explore sexual intimacy with SM couples. A case illustration is included.
 
Article
In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants’ initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients’ privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients’ raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a “participant observer” to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.
 
Article
The increase in social media usage contributes to a greater number of Marriage and Family Therapists (MFTs) using social media to grow their professional outreach and to increase awareness about mental health by engaging with online audiences. Although existing literature has discussed how MFTs can make ethical use of personal social media in and around their therapeutic role, no literature at this time has explored the potential ethical issues faced by MFTs seeking to build public presence on social media as a “mental health influencer.” The present paper intends to provide a definition of mental health influencers (MHIs) and reviews ethical concerns relevant to MFTs acting as MHIs. Particular consideration is given to ethical dilemmas and conflicts-of-interest which may emerge via parasocial relationships developed through social media influencing, as well as how the boundaries and the limitations of an MFT’s professional scope can be tested when presenting as a personable, public figure over digital platforms. A framework for conceptualizing ethical issues for MHI-MFTs is offered, with a selection of prescient issues being examined within the scope of existing ethical standards set forth by the American Association of Marriage and Family Therapy’s (AAMFT) Code of Ethics. Reflections are offered about what questions and guidelines should be observed by MFTs in order to avoid unethical use of social media as an MHI, followed by a brief discussion about future considerations which should be considered by MHIs.
 
Article
This paper is based on the premises that the conscious, active and purposeful use of self by the therapist in the therapeutic process is an essential aptitude in establishing an effective therapeutic relationship, and that this therapeutically purposeful use of self can and should be incorporated in the training of all therapists in a explicitly systematic manner. The paper will attempt to identify the contributions of the “what and how” the use of self by therapists contributes to the therapeutic process. First of all, therapists’ use of self is meant to be viewed as a Common Factor as defined by Sprenkle, Davis & Lebow (2009), which is a perspective about the effectiveness of therapy that “asserts that the qualities and capabilities of the person offering the treatment are more important than the treatment itself” (p. 4). Secondly, the use of self by therapists emphasizes developing the skill set of the therapist in the conscious, active and purposeful use of self as is in the moment of the therapeutic engagement with clients, and does so without denying the importance of therapists working to resolve personal issues of theirs that may interfere with the therapist's professional effectiveness. Therapists’ use of self gives particular emphasis to the purposeful use of self as is in therapy’s relationship, assessment and interventions whatever the therapy model (Aponte & Kissil, 2016). Thirdly, the use of self represents an aptitude that can be developed and refined through well elaborated structures for schooling therapists in the therapeutic use of all they bring of their personal selves to the therapy relationship including through the use of their human vulnerabilities as they exist at the moment of empathic engagement with clients.
 
Article
Social media is a salient aspect of most people’s lives in the United States. Younger generations (e.g., Gen Z) are among some of the most likely to engage with social media and have mental health concerns. Mental health providers are beginning to use social media to engage with prospective clients. However, there is a lack of guidance on how to maximize the utility of social media engagement for couple and family therapists (CFTs). This paper reviews the current literature on therapists’ professional presence on social media and younger generations’ expectations around social media competency. Recommendations for how CFTs can effectively engage with younger generations through social media are provided. A discussion of professionalism, accessibility, demonstrating aligned values, branding CFT, and gaining a reputation of cost effectiveness are emphasized. Future directions for studying the phenomenon of therapists using social media to engage with an online audience are included.
 
Article
Imposter phenomenon is defined as a sense of intellectual fraudulence and an inability to internalize success and competency. Although imposter phenomenon has been noted in several populations, literature is sparse that focuses on mental health professionals. In addition, little is known about the relationships between imposter phenomenon, compassion fatigue, and compassion satisfaction for mental health workers. Using a survey design with a convenience sample of 158 mental health workers, this study found that imposter phenomenon was positively associated with compassion fatigue, as well as negatively associated with compassion satisfaction, when controlling for years of work and age. Further, the combination of lower levels of compassion satisfaction and higher levels of burnout predicted higher levels of imposter phenomenon. Implications and preventative measures are discussed.
 
Article
Law enforcement officers have one of the most dangerous and demanding careers in the United States (Price in JAMA 35:113–123, 2017). Challenges such as shiftwork, hypervigilance, and anti-police rhetoric can lead to burnout and trauma responses (e.g. Neylan et al., in JAMA 27:1493–1508, 2010). These stressful trials do not only impact the officer, but also their spouses and families (e.g. Alexander & Walker in JAMA 10:131–138 1994; as reported by Bibbins (in:Resse (ed) Psychological Services for Law Enforcement, US Government Printing Office, 1986). Unfortunately, there are minimal suggestions for use of a systemic psychotherapy approach involving the entire family. This article discusses challenges officers and their families frequently face and proposes the use of Solution-Focused Brief Therapy for law enforcement families. This article also provides suggestions for altering interventions to increase sensitivity for families and an example dialogue.
 
Article
Among adults, childhood maltreatment is widely known to increase depressive symptoms and reduce quality of adult’s intimate relationships. Considering the association between childhood maltreatment and adult depression and relationship quality from systemic theories may help clinicians conceptualize and intervene with their clients. Internal Family Systems is an evidenced based psychotherapy and is a trauma-informed model. Self is one of the core concepts of the Internal Family Systems model and it is theorized to reduce mental health problems such as depression and strengthen adult romantic relationships. Despite this theoretical proposition there is no supporting empirical research. To address this gap, the current study examined Self, specifically the qualities of Self (e.g., compassion) and Self-Leadership (e.g., staying calm in face of distress) as pathways linking childhood maltreatment to depression and relationship quality. Using a sample of adults in a romantic relationship, the current study examined Self-Qualities and Self-Leadership as mediators linking retrospective reports of child maltreatment to current depressive symptoms and relationship quality. Results indicate that the indirect (mediating) effects from childhood maltreatment to depressive symptoms and relationship quality were significant through Self-Qualities, but not Self-Leadership. Findings suggest that childhood maltreatment is associated with less frequent access to the qualities of Self, such as compassion and confidence which, in turn, were associated with fewer depressive symptoms and higher levels of relationship quality. For clinicians, the use of IFS and specifically helping clients increase the Self-Qualities may reduce depressive symptoms and strengthen romantic relationships.
 
Article
In a recent study 56% of women and 37% of men were survivors of childhood sexual abuse. These individuals who experience sexual trauma may experience depression, anxiety, post-traumatic stress disorder (PTSD) or substance use disorders (Devlin et al., in Fam J 27(4):359–365, 2019). While there are several treatment approaches specifically developed to target trauma and its effects, (e.g., trauma focused cognitive behavioral therapy, and eye movement desensitization and reprocessing) we propose that integrating internal family systems therapy (IFS) and solution focused brief therapy (SFBT) offers a brief, systemic way to improve family relationship patterns in families where one member has experienced sexual trauma. A case vignette is used to show the integration of these two approaches.
 
Article
Systemic Autism-related Family Enabling (SAFE) is a new intervention for families of children with a diagnosis of Autism Spectrum Disorder (ASD). SAFE responds to international and national recommendations for improved care and the reported needs of families. SAFE draws from Family Therapy techniques, Attachment Narrative Therapy and known preferences of individuals with autism. Twenty two families of a child with a diagnosis of ASD severity level 1 or 2 were recruited. The families attended five 3-hour sessions. Family members completed the Helpful Aspects of Therapy Questionnaire (HAT) after each session. Analysis of the HAT data revealed that adults and children experienced SAFE to be helpful which was elaborated in terms of the following themes: therapist as helping reflection, increased understanding, feeling closer, more confident to reflect and problem solve, improved communication and feeling less alone and isolated. The findings are discussed to consider how SAFE can be improved and implemented to offer support for families. SAFE is a good candidate to fill a gap in autism related care.
 
Article
Differentiation of self, a basic concept of Bowen family systems theory, is the ability to distinguish between and balance one’s own feelings and thoughts, two basic life instincts in interpersonal relationships, as well as navigate balance between individuality and togetherness. This research aimed to develop a valid and reliable tool to measure differentiation of self in work relationships. The sample consisted of 346 individuals who were at least 20 years old, were currently employed, and were selected through appropriate sampling methods. A demographics form, the Differentiation of Self in Work Relationships Scale (DS-WRS), the Minnesota Satisfaction Questionnaire, the Burnout Measure: Short Version, and the Differentiation of Self Inventory Short Form were used for data collection. Data were analyzed by SPSS-22 and LISREL-8.5 programs. A four-factor structure was obtained after the exploratory factor analysis, and results confirmed that fit indices were at an acceptable level. However, the DS-WRS showed a negative correlation with burnout and a positive correlation with job satisfaction. For all subdimensions and the total score of the DS-WRS, the Cronbach’s alpha coefficient was found to be acceptable. Test-retest correlations indicated the scale’s reliability, and the item-total correlations, score were within acceptable limits. The DS-WRS consists of 18 items and four subdimensions: fusion with others, emotional reactivity, emotional cutoff, and I position. Higher scores obtained from each subdimension and an increased total score indicated an increase in the differentiation self of an individual in work relationships. After reviewing the psychometric properties, we concluded that the developed scale is valid and reliable for measuring the differentiation level of individuals in specific work relationships.
 
Article
Gay men report higher levels of body dissatisfaction and negative body image than heterosexual men. These trends are closely linked to cultural pressures, sexual identity development, family relationships, and attachment style. However, despite this link, few therapeutic resources exist that address the unique stressors of gay men struggling with body image and body image-related factors as well as family influence on these stressors. This article outlines an adaptation of Emotionally-Focused Family Therapy (EFFT) for therapists working with gay clients struggling with body image. We address the restructuring of negative interaction cycles related to parental rejection and body image and demonstrate how an enactment intervention can be utilized as a tool for healing.
 
The presence of a person and a couples therapist
Article
Whilst conducting couples therapy is a professional practice, couples’ therapists (CTs) play an active role in the therapeutic process not only professionally but also personally. Despite the increase in research into the person of the therapist, few studies have examined the person of the therapist issues specific to CTs. In this study, we aimed to explore the experiences of CTs regarding the interaction of their personal and professional beliefs and experiences when working with couples. A qualitative design was used, based on constructivist grounded theory. Semi-structured interviews were conducted with 17 CTs in romantic relationships and working with couples. Three main categories were co-constructed through qualitative analysis: accessing what was brought in through the self, engaging with what the couples bring, and embracing the personal and professional selves. Awareness of the person of the therapist and learning how to use themselves to relate, assess, and intervene with clients enable CTs to create a secure therapeutic presence. The findings have useful implications for clinicians, couples therapy training program frameworks, and couples therapy supervision.
 
Article
Marital satisfaction, which is typically assessed with multi-item measures, has been linked to health benefits among both civilian and military samples. Despite some advantages over multiple-item measures, researchers are less likely to use single-item marital satisfaction measures perhaps because there are few studies that demonstrate their reliability and validity. This study provided validation evidence, reliability estimates and replicated the cut-off of the Brief Marital Screening Tool (SI measure) in three military-affiliated samples (two of service members [N = 850 and N = 936] and one military spouse sample [N = 333]). Analyses showed that the SI measure had acceptable reliability using two estimation techniques. Further, in comparison with the multi-item measures, the SI measure showed similar associations with mental health, physical health, and relationship functioning outcomes establishing the SI measure’s criterion validity. Lastly, findings also confirmed the cut-off established in the original validation paper using two different multiple-item marital satisfaction measures. The implications of the findings for research, interventions, and clinical practice are discussed.
 
Article
When working with families of individuals with mental illness, therapists attend to multiple perspectives of family members. The current study quantitatively examines several perspectives of siblings within various role positions related to mental illness and suicidal ideation. The participating sample draws from: individuals with mental illness, siblings of those with mental illness, and individuals from families where both siblings have diagnosed mental illness. Across these positions, we compared experienced stress, distress, and burden and examined the function of the sibling bond. The study also explores patterns in overall functioning across these sibling positions. Our findings highlight the burden of siblings of those with mental illness, the psychological distress of those with MI, and the stressful environment of those siblings who both report mental illness. The study findings clarify commonalities within and across siblings, according to whether or not they report mental illness and/or suicidal ideation. Our findings suggest that families have both individual and shared narratives associated with the person reporting mental illness. The results of this study are used to further inform therapeutic practice with families of individuals with mental illness.
 
Per capita spending per patient, 2018 government accountability office data (King, 2019)
Article
U.S. history is fraught with examples of systemic racism—at all ecological levels and within all geopolitical contexts. Whether scholars historically punctuate these phenomena through white racial framing begun in the 1600s or the Black civil rights movement of the 1960s, research across disciplines brings into focus a twenty-generation story of injustice. These phenomena present a paradoxical struggle within healthcare systems populated by professionals who have made a “conscious commitment to equity and helping those in need.” However, both healthcare systems and embedded care providers operate in relation to organizational structures that frequently reify racist policies. As natural and professional agents of change, medical family therapists are especially positioned to examine how regulatory systems at every level influence institutional racism within the medical and mental health fields. In this manuscript we examine health system policies and practices using the lens of C.J. Peek’s Four Worlds: Clinical, Operational, Financial, and Training. Examples of institutional racism are discussed and recommendations for approaches to change are provided.
 
Article
Contemporary increases in chronic- and terminal- diagnoses among adults creates a demand for medical family therapists (MedFTs) to better-assist ill parents in preparing for and facilitating conversations with children. MedFTs must have skills, knowledge, and training in assessing when help is needed, and then engaging parents effectively in such conversations. As systems-trained providers, MedFTs functioning in medical contexts are well positioned to fulfill such tasks. This manuscript highlights educational/training and clinical foci essential toward MedFTs’ preparation for and conduct of this work. Ways to engage in difficult conversations with children are described across both general approaches and specific examples. Operational contexts such as integrating MedFTs into medical healthcare facilities, and financial considerations facilitative of these efforts, are also considered.
 
Medical family therapy health care continuum (Hodgson et al., 2014)
Integrated behavioral health care flow chart
Article
Integrated behavioral health care (IBHC) continues to grow as an evidence-based service delivery model adopted by healthcare systems all over the world to better care for the holistic needs of patients and their families. Medical family therapy (MedFT), as a field, has offered innovation to IBHC models by delivering biopsychosocial-spiritual (BPS-S), relational, and family-oriented care across a variety of healthcare contexts. This article details a longitudinal review of a program, spanning 16 years, that grew from no behavioral health services to one that is highly integrated, and embeds MedFTs in a number of rural community health centers. This model highlights the importance of interdisciplinary teams, including Peek’s clinical, operational, financial, and training worlds, as well as decision-making metrics for systems that predominately care for underserved and minoritized populations. The authors illustrate a framework for how the levels of primary care/behavioral healthcare collaboration relate to the work and practice of MedFTs as conceptualized through the MedFT Health Care Continuum and meet the BPS-S needs of diverse populations seeking pediatric, adult, and dental healthcare services. Also described are shifts made in the model over time based on (a) growth in cultural humility, (b) relationally-oriented practice, operations, finance, and training data, and (c) research informed decisions. Recommendations include ways MedFTs can facilitate provider and administrative buy-in, assess model fidelity, and strive for quality outcomes for patients.
 
The MedFTs’ Role in the Recruitment and Retention of a Diverse Physician Population. Note: ¹AAMFT, 2018; ²ACGME, 2021; ³Crenshaw, 1989; ⁴Hodgson et al., 2018; ⁵Peeks, 2008
Article
Recruitment and retention of a diverse physician population across stages of medical education is essential for the success of the healthcare system. MedFTs have a unique role to play in advocacy and intervention related to the recruitment and retention of these physicians at all stages of their education and career. As MedFTs expand their influence in healthcare systems, they must ground into their fundamental theories, like systems theory and the Four World View, all while advancing in their professional competencies to attune their skills and those whom they are entrusted in training. The conceptual model, MedFTs’ Role in the Recruitment and Retention of a Diverse Physician Population, provides a framework for MedFTs to use their influence to enact change related to diversity and equity in the healthcare system. In addition, the model provides avenues for intervention and advocacy on the part of the MedFT related to each of the four worlds and their specific role(s) in the health care.
 
Article
Efforts to honor and integrate patients’ and families’ spiritual beliefs and dispositions in biopsychosocial/spiritual care are well-worth the time, energy, and requisite resources that it takes to do so. In this account, the authors describe how targeted education and supervision with students and trainees can serve to promote preparatory knowledge, comfort, and skills toward including spiritual foci in their work. Purposeful assessments, care conversations, and interdisciplinary partnerships are described as advancing better clinical outcomes. Thoughtful strategizing around clinic- and hospital- operations and care structures are described as essential to better workflow and collegial collaborations. Careful attention to financial foci in care provision and team organization that support spiritual health are outlined as key to supporting cost-effectiveness. All of these things—taken together—are put forth as important to the inclusion of what is often and arguably one of the most neglected facets of patients’ and families’ experiences in care practices today.
 
Resilience vs. Resilient (Adapted from van Breda, 2018, p. 4). In the text of the article, van Breda provided examples of mediating processes, consequences, and stressors. We noted those examples in the figure
Revisioning resilience
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Resilience is defined in different ways. Though there are nuanced differences, most scholars and laypersons alike agree that in its broadest sense, resilience is a positive response to adversity. Resilience is a process; whereas, resilient is an outcome. The process-outcome debate generates a somewhat contrived dichotomy. In recent years, there have been notable attempts to add a greater level of complexity to scientists’ and practitioners’ understanding of resilience by underscoring the impact of contextual factors on an individual’s ability to adapt under dire circumstances. Addressing contextual factors involves revisioning the concept of resilience. Race is context; so, too is the environment in which individuals are embedded. Many Black Americans in high-risk environments may be adversely affected by their own processes of resilience. The process of resilience may very well contribute to allostatic load and weathering. For many Black Americans, persevering and thriving in the face of pervasive adversity has led to significant health challenges—challenges that Medical Family Therapists can address through clinical, financial, operational, and training worlds.
 
PRISMA flow diagram (Moher et al., 2009)
Article
Cognitive impairment (e.g. dementia) presents challenges for individuals, their families, and healthcare professionals alike. The primary care setting presents a unique opportunity to care for older adults living with cognitive impairment, who present with complex care needs that may benefit from a family-centered approach. This indepth systematic review was completed to address three aims: (a) identify the ways in which families of older-adult patients with cognitive impairment are engaged in primary care settings, (b) examine the outcomes of family engagement practices, and (c) organize and discuss the findings using CJ Peek’s Three World View. Researchers searched PubMed, Embase, and PsycINFO databases through July 2019. The results included 22 articles out of 6743 identified in the initial search. Researchers provided a description of the emerging themes for each of the three aims. It revealed that family-centered care and family engagement yields promising results including improved health outcomes, quality care, patient experience, and caregiver satisfaction. Furthermore, it promotes and advances the core values of medical family therapy: agency and communion. This review also exposed the inconsistent application of family-centered practices and the need for improved interprofessional education of primary care providers to prepare multidisciplinary teams to deliver family-centered care. Utilizing the vision of Patient- and Family-Centered Care and the lens of the Three World View, this systematic review provides Medical Family Therapists, healthcare administrators, policy makers, educators, and clinicians with information related to family engagement and how it can be implemented and enhanced in the care of patients with cognitive impairment.
 
Illustration of the five dimensions of learning to embody a relational power lens
Article
This action research study explores how four MFT students shifted from a cognitive understanding of equity and power to an intrinsic and automatic internalized process as we participated in research in which we observed, coded, and engaged in structured reflexive conversations about relational power using a data bank of Socio Emotional Relationship Therapy sessions. We reviewed and analyzed ten of our recorded two-hour reflexive conversations to develop grounded theory that explains our experience of learning to embody a relational power lens, which consists of five interconnected phases: (a) developing a theoretical understanding of relational power, (b) critically observing live therapy, (c) noticing and attending to the felt sense of witnessing power, (d) engaging in transformative conversation, and (e) applying to personal practice. Our findings provide guidance for clinical training programs who wish to facilitate the experience for clinicians-in-training to understand and address societal power processes in clinical practice.
 
Article
Intimate partner violence (IPV) is a serious public health issue experienced around the world. Research exploring risk markers associated with IPV has the potential to enhance our ability to understand and prevent IPV. This meta-analysis examined various life stressors as risk markers for physical IPV perpetration and victimization for men and women. The life stressors chosen in this study were based upon the American Psychological Association’s Stress in America survey results, which identified work, money, health and relationships as the most commonly experienced stressors in the United States. Primary findings from this study suggest that strongest risk markers for IPV perpetration and victimization were relationship distress and mental health distress. When exploring gender differences, we found that unemployment was a significantly stronger risk marker for male IPV perpetration compared to female IPV perpetration. Implications for therapists are discussed.
 
Article
With the number of interracial marriages rising, family therapists need to know what issues these married couples and their families face. The authors analyzed qualitative interviews with 11 White women married to Black men, who were part of a larger study on interracial couples. The authors identified four themes that were relevant to the participants’ experiences and could guide therapy with the family. These were: (1) racial perspective taking; (2) communication patterns; (3) microaggressions; and (4) raising children. Three sub-themes were also identified that were tied to racial perspective taking. These were: (a) White privilege; (b) safety; and (c) social justice. Clinical suggestions for family therapists working with these couples are provided.
 
Article
Working with intimate partner violence (IPV) can be a daunting task for systemic therapists. Nevertheless, research establishing a connection between attachment and IPV suggests that systemic therapists may be particularly well-suited to the task. Due to the high clinical prevalence of IPV, therapists should understand how it presents in session and how it can be addressed, and attachment theory can be helpful in such conceptualization and treatment pursuits. Although some therapy models draw upon attachment theory when working with couples, concerns about safety have been raised when using attachment-based models with IPV. In this article, a review of the research linking attachment and IPV is presented, along with limitations of attachment conceptualizations of IPV. The case is made for safe use of attachment-based treatments of IPV through previously developed best safety practices as well as the integration of contextual factors, such as gender and power, that help create a more comprehensive, ecological view of violence. Specific ideas are presented to help therapists conceptualize and intervene with IPV using an attachment-based lens.
 
Article
Religion and spirituality are an important part of the human experience for many of our clients. Clients often turn to their religion or spirituality as one of their first resources when faced with significant stressors; however, therapists often feel ill-equipped when spiritual or religious content is discussed in therapy. The efforts of clinicians to ethically and competently address spirituality and religion with clients hinges on the work of supervisors and faculty members of Couple, Marriage, and Family Therapy programs. This paper seeks to explain how the supervision process can help therapists overcome the barriers they face when attempting to integrate spirituality and religion into session. A case vignette is presented where a supervisor and supervisee use an Internal Family Systems lens to consult about a case where religious concerns are present. Utilizing IFS, we believe that therapists can better acknowledge their spiritual or religious biases and begin to consider how religion and spirituality can be respected as a diverse part of clients.
 
Article
No known studies have examined the relationship between health-promoting behaviors, relationship satisfaction, and resilience among a community sample. Participants included 237 individuals in a romantic relationship. Health-promoting behaviors were measured using the health-promoting lifestyle profile II (HPLP-II; Walker et al., 1987); resilience was measured using the brief resilience scale (Smith et al., 2008); and relationship satisfaction with the Kansas marital satisfaction scale (Schumm et al., 1986). Results indicated that relationship satisfaction is significantly, positively related to all six domains of the HPLP-II, with strongest correlations found between relationship satisfaction and stress management (r = 0.508), interpersonal relations (r = 0.415), and spiritual growth (r = 0.296). Resilience is significantly, positively related to all HPLP-II domains except for health responsibility, again with strongest correlations found between spiritual growth (r = 0.450), stress management (r = 0.359), and interpersonal relations (r = 0.333). Implications for marriage and family therapists and healthcare providers are discussed.
 
Article
The therapeutic alliance is considered to be one of the most important elements in successful individual therapy and many types of couple, marital, and family therapy. The alliance involves a bond that is developed through investment, mutual agreement, and collaboration on tasks and goals. While substantial evidence exists that the therapeutic alliance plays an important role in multiple aspects of therapy outcomes for individuals, far less empirical attention has been given to the alliance in couple therapy. A primary reason for the dearth of research on alliance within a couples context is the complexity of measuring multiple alliances that interact systemically. The present study sought to examine if a facilitator’s perceived alliance is predictive of the couple’s alliance, and how differences in alliance scores between individuals may impact relationship satisfaction at 1-month follow-up. These questions were examined using data from a brief, two-session intervention for couples, known as the “Relationship Checkup.” Using structural equation modeling, we found that facilitator report of alliance positively predicted both men and women’s report of alliance with the facilitator. Results also indicated that couples who were split on the strength of the alliance had worse outcomes at 1-month follow-up, and split alliance between wives and the facilitator indicated worse outcome for men at 1-month follow-up. Overall, these data suggest that the alliance is an important element for successful brief interventions for couples.
 
Path Model
Article
Premature termination is significantly understudied in couple and family therapy research yet is a prevalent issue for therapists and has a significant impact on therapeutic outcomes. While therapeutic alliance has been consistently linked to premature termination and other treatment outcomes, little is known about other factors, particularly couple factors, that may influence premature termination in couple therapy. Utilizing dyadic data combined from two different samples of couples seeking therapy, this study examines the influence of relationship satisfaction and therapeutic alliance on premature termination using an Actor Partner Independence Model. Additionally, a chi-square difference test was used to determine differences in therapeutic outcomes among termination-status type groups. Results showed that alliance was not predictive of termination status. Couple factors, particularly relationship satisfaction, were found to be associated with premature termination. That is, couples with lower relationship satisfaction were more likely to terminate therapy prematurely without agreement with their therapist. Findings suggest that couple influences showed stronger associations to premature termination than did therapeutic alliance alone. This highlights a need for therapists to assess how initial relationship satisfaction influences alliance and how each partner’s satisfaction and alliance influence that of the other partner.
 
Judy's drawing, 'What is family therapy?'
May's drawing: 'What is family therapy?'
Ian's drawing, 'What is family therapy?
Article
This study is about how a therapeutic alliance is created and maintained with parents and their children working through a relational trauma. A case study design with narrative analysis as a method of research (Riessman, 2008) and a narrative approach of storying stories, inspired by McCormack (2000), is used. The participants of this study are the parents and their four children, aged between 14 and 5 years, and their systemic therapist. Rich data on the therapeutic alliance is gathered through, two live-family session observations and seven interviews, six of which were with the family members, and a two-part interview held with their therapist. Results show that the way of being of the therapist, including her ability to be intuitive and self-reflexive, and her ability to keep manoeuvrability in conversation and hold neutrality support her to connect with all the family. Creating conjoint and separate therapeutic spaces, using a creative play-based approach and navigating an alliance with the school and medical professionals, were important suggestions for practice in the field. Additionally, collaborating with parents, and balancing the benefits and drawbacks of involving children to make therapy meaningful for all, are also suggested. Specific recommendations for engagement with siblings of the identified-problem child are elicited. The strength of this study is that children’s voices, along with those of their parents’ and their systemic therapist are reported. Suggestions for practice to support children and their families who are working through a relational trauma are brought forward.
 
Article
This retrospective observational study aimed to examine the expanded therapeutic alliance in relation to drop out versus retention in systemic family therapy. Forty cases randomly selected from archived records at a university center for family therapy were identified as either dropouts (n = 13) or completers (n = 27). Videotapes of all first sessions were rated using the system for observing family therapy alliances by two trained judges. Identification of the alliance-related behaviors exhibited by clients and therapists in these sessions showed that compared to completed cases, dropout cases had significantly weaker clients’ alliances as well as more severely split alliances. Moreover, the three most critical dimensions of the alliance in relation to termination status were client engagement in the therapeutic process, a felt sense of safety within the therapeutic context, and the family’s shared sense of purpose about the needs, goals and value of therapy (i.e. the within system-alliance). These findings are consistent with other research that established an association between the therapeutic alliance and treatment retention in family therapy. Clinical implications for addressing the alliance threats in the first session are discussed along with specific recommendations for alliance training.
 
LCM of relationship satisfaction predicting LCM of alliance. Covariances between variables omitted for simplicity. Fully standardized parameter estimates. RDAS revised dyadic adjustment scale. *p < .01
Article
Although establishing an effective working alliance is an essential early task in every model of therapy, relatively little research has examined dyadic factors that predict the development of the working alliance. Previous research indicates relationship satisfaction predicts the working alliance in couple therapy. However, couples often enter therapy with different perceptions of relationship satisfaction which could impede the development of the working alliance or lead to a split alliance. We introduce the cross-informant discrepancies perspective and compare it to more commonly used dyadic analyses. We demonstrate the use of the latent congruence model to examine if the average and difference in reports of couples’ relationship satisfaction are significantly associated the working alliance. We found the discrepancy between a couples’ report of relationship satisfaction predicted a lower average alliance score but did not predict a higher alliance discrepancy. We also found the discrepancy in relationship satisfaction predicts a lower alliance for the male partner. Clinical implications and limitations are discussed.
 
Article
Alliance is a robust contributor to the outcome of adult, youth, and family therapy, but little is known about therapists’ contributions to the alliance in conjoint family treatment. We investigated the predictive value of therapists’ personality, clinical experience and observed alliance building behaviors for mid-treatment alliance as reported by therapists and family members. Participants were 77 parents and 21 youth from 57 families receiving home-based family treatment from 33 therapists. Therapist openness to experience and agreeableness as well as therapists’ in-session engagement and emotional connection behaviors predicted more positive therapists’ and family members’ reports of the alliance. Therapist neuroticism, extraversion and conscientiousness predicted more negative alliance-reports. In-session safety behaviors also predicted more negative alliance-reports, but this finding was only significant for therapists’ and not family members’ reports of the alliance. Clinical experience did not predict quality of alliances. We conclude that training and supervision of family therapists could benefit from focusing on emotional connection with and active engagement of family members in treatment, and from increasing self-awareness of the impact of their personality on alliances with family members.
 
Model of the in-session process of change that resulted from the Task analysis
Article
The aim of this study is to analyze the initial therapeutic alliance in family therapy with high-conflict divorced parents and identify facilitating elements of change. We sampled 16 family therapy cases (32 parents) from a public healthcare hospital in Spain. Based on the System for Observing Family Therapy Alliances (SOFTA-o) ratings, we divided the total number of cases into two groups, depending on the presence or absence of parents’ positive indicators in the Shared Sense of Purpose dimension (i.e., productive within-family collaboration or within-system alliance). We quantitatively described and compared the initial therapeutic alliance of the two groups. To deeper explore the within-system alliance process of change, we completed the discovery-oriented phase of the Task Analysis methodology. The main differences between groups were found in the Safety dimension, which was higher in the group of cases with indicators of within-system alliance. More detailed differences were also found. The Task Analysis suggested a model of the within-system alliance process of change grounded in three main categories -or stages- that occurred sequentially (1. Narratives of conflict, 2. Narratives of joint responsibility, and 3. Narratives of opportunity) and a category that appeared in different moments across the task resolution (0. Contextualization). Five sub-categories emerged in a recursive movement within categories 1 and 2. Implications and recommendations for practice are described along with limitations and suggestions to continue this line of research.
 
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Jaclyn Cravens
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Jason Whiting
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Nancy Murdock
  • University of Missouri - Kansas City
Rola O. Aamar
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Kaitlin R Leckie
  • Texas Tech University