Week 6
Contextual Family Therapy model
For this assignment, you will write a reflection paper that includes a summary of the constructs
from the Contextual Family Therapy model and an application of those concepts to your own (or
another person’s if this is too difficult) family of origin.
Include the following in the model summary:
1) The major assumptions for change in the contextual approach.
2) Use your own words to identify, define, and describe the major concepts of the contextual
approach.
3) Address what makes this approach different from some of the other Marriage and Family
Therapy approaches you have studied.
Include the following in your application of this model to your family of origin:
1) The important family legacies that are a part of your family of origin
2) The intergenerational transmission of the family culture
3) The invisible loyalties that exist in your family of origin
4) How justice has been applied in your family of origin
5) How these have impacted your development and that of any siblings, including how
you/they exited (grew up) the family of origin
6) How these concepts, if at all, influence your current life
Length: 5-7 pages
Gehart, D. R. (2014) Mastering Competencies in Family Therapy Chapter 7
Intergenerational and Psychoanalytic Family Therapies
Lay of the Land
Although distinct from each other, Bowenian intergenerational therapy and psychoanalytic family
therapy share the common roots of (a) psychoanalytic theory and (b) systemic theory. A
psychoanalytically trained psychiatrist, Bowen (1985) developed a highly influential and unique
approach to therapy that is called Bowen intergenerational therapy. Drawing heavily from object
relations theory, psychoanalytic or psychodynamic family therapies have developed several unique
approaches, including object relations family therapy (Scharff & Scharff, 1987), family-of-origin therapy
(Framo, 1992), and contextual therapy (Boszormenyi-Nagy & Krasner, 1986). These therapies share
several key concepts and practices:
• Examining a client’s early relationships to understand present functioning
• Tracing transgenerational and extended family dynamics to understand a client’s complaints
• Promoting insight into extended family dynamics to facilitate change
• Identifying and altering destructive beliefs and patterns of behavior that were learned early in life in
one’s family of origin
Bowen Intergenerational Therapy
In a Nutshell: The Least You Need to Know
Bowen intergenerational theory is more about the nature of being human than it is about families or
family therapy (Friedman, 1991). The Bowen approach requires therapists to work from a broad
perspective that considers the evolution of the human species and the characteristics of all living
systems. Therapists use this broad perspective to conceptualize client problems and then rely primarily
on the therapist’s use of self to effect change. As part of this broad perspective, therapists routinely
consider the three-generational emotional process to better understand the current presenting
symptoms.
The process of therapy involves increasing clients’ awareness of how their current behavior is connected
to multigenerational processes and the resulting family dynamics. The therapist’s primary tool for
promoting client change is the therapist’s personal level of differentiation, the ability to distinguish self
from other and manage interpersonal anxiety.
The Juice: Significant Contributions to the Field
If you remember a couple of things from this chapter, they should be:
Differentiation
Differentiation is one of the most useful concepts for understanding interpersonal relationships,
although it can be difficult to grasp at first (Friedman, 1991). An emotional or affective concept,
differentiation refers to a person’s ability to separate intrapersonal and interpersonal distress:
• Intrapersonal: Separate thoughts from feelings in order to respond rather than react
• Interpersonal: Know where oneself ends and another begins without loss of self
Bowen (1985) also described differentiation as the ability to balance two life forces: the need for
togetherness and the need for autonomy. Differentiation is conceptualized on a continuum (Bowen,
1985): a person is more or less differentiated rather than differentiated or not differentiated. Becoming
more differentiated is a lifelong journey that is colloquially referred to as “maturity” in the broadest
sense. A person who is more differentiated is better able to handle the ups and downs of life and, more
importantly, the vicissitudes of intimate relationships. The ability to clearly separate thoughts from
feelings and self from others allows one to more successfully negotiate the tension and challenges that
come with increasing levels of intimacy.
For example, when one’s partner expresses disapproval or disinterest, this does not cause a
differentiated person’s world to collapse or inspire hostility. Of course, feelings may be hurt, and the
person experiences that pain. However, he/she doesn’t immediately act on or act out that pain.
Differentiated people are able to reflect on the pain: clearly separate out what is their part and what is
their partner’s part and identify a respectful way to move forward. In contrast, less differentiated people
feel compelled to immediately react and express their feelings before thinking or reflecting on what
belongs to whom in the situation. Partners with greater levels of differentiation are able to tolerate
difference between themselves and others, allowing for greater freedom and acceptance in all
relationships.
Because differentiated people do not immediately react in emotional situations, a common
misunderstanding is that differentiation implies lack of emotion or emotional expression (Friedman,
1991). In reality, highly differentiated people are actually able to engage more difficult and intense
emotions because they do not overreact and instead can thoughtfully reflect on and tolerate the
ambiguity of their emotional lives.
It can be difficult to assess a client’s level of differentiation because it is expressed differently depending
on the person’s culture, gender, age, and personality (Bowen, 1985). For example, to the untrained eye,
emotionally expressive cultures and genders may look more undifferentiated, and emotionally restricted
people and cultures may appear more differentiated. However, emotional coolness often is a result of
emotional cutoff (see the later section on Emotional Cutoff), which is how a less differentiated person
manages intense emotions. Therapists need to assess the actual functioning intrapersonally (ability to
separate thought from feeling) and interpersonally (ability to separate self from other) to sift through
the diverse expressions of differentiation.
Genograms
The genogram has become one of the most commonly used family assessment instruments (McGoldrick,
Gerson, & Petry, 2008). At its most basic level, a genogram is a type of family tree or genealogy that
specifically maps key multigenerational processes that illuminate for both therapist and client the
emotional dynamics that contribute to the reported symptoms. New therapists are often reluctant to do
genograms. When I ask students to do their own, most are enthusiastic. However, when I ask them to
do one with a client, most are reluctant. They may say, “I don’t have time” or “I don’t think these clients
are the type who would want to do a genogram.” Yet after completing their first genogram with a client,
they almost always come out saying, “That was more helpful than I thought it was going to be.”
Especially for newer therapists—and even for seasoned clinicians—genograms are always helpful in
some way. Although originally developed for the intergenerational work in Bowen’s approach, the
genogram is so universally helpful that many therapists from other schools adapt it for their approach,
creating solution-focused genograms (Kuehl, 1995) or culturally focused genograms (Hardy & Laszloffy,
1995; Rubalcava & Waldman, 2004).
The genogram is simultaneously (a) an assessment instrument and (b) an intervention, especially in the
hands of an intergenerational therapist. As an assessment instrument, the genogram helps the therapist
identify intergenerational patterns that surround the problem, such as patterns of parenting, managing
conflict, and balancing autonomy with togetherness. As an intervention, genograms can help clients see
their patterns more clearly and how they may be living out family patterns, rules, and legacies without
conscious awareness. As a trainee, I worked with one client who had never spoken to her parents about
how her grandfather had sexually abused her and had no intention of doing so because she believed it
would tear the family apart. This changed the day we constructed her genogram. I had her color in each
person she knew he had also abused. When she was done, the three-generation genogram had over 12
victims colored in red; she went home and spoke to her mother that night and began a
multigenerational process of healing for her family.
Rumor Has It: The People and Their Stories
Murray Bowen
A psychoanalytically trained psychiatrist, Bowen (1966, 1972, 1976, 1985) began working with people
diagnosed with schizophrenia at the Menninger Clinic in the 1940s and continued his research in the
1950s at the National Institute for Mental Health (NIMH), where he hospitalized entire families with
schizophrenic members to study their emotional processes. He then spent the next 30 years at
Georgetown University developing one of the most influential theories of family and natural systems,
which has influenced generations of family therapists.
Georgetown Family Center: Michael Kerr
A longtime student of Bowen, Michael Kerr has also been one of his most influential students and has
served as director of the Georgetown Family Center, where Bowen refined his clinical approach.
The Center for Family Learning: Philip Guerin and Thomas Fogarty
Guerin and Fogarty co-founded the Center for Family Learning in New York, one of the premier training
centers for family therapy. Both Guerin and Fogarty have written extensively on the clinical applications
of Bowen’s model.
Monica McGoldrick and Betty Carter
Betty Carter and Monica McGoldrick (1999) used Bowen’s theory to develop their highly influential
model of the family life cycle, which uses the Bowenian concept of balancing the need for togetherness
and independence to understand how families develop. McGoldrick’s work with genograms is the
definitive work on this tool subject (McGoldrick, Gerson, & Petry, 2008).
David Schnarch
Grounded in Bowen’s intergenerational approach, Schnarch developed a unique approach to working
with couples, the sexual crucible model, which is designed to increase a couple’s capacity for intimacy by
increasing their level of differentiation. One of the hallmarks of this approach is harnessing the intensity
in the couple’s sexual relationship to promote the differentiation process.
The Big Picture: Overview of Treatment
Much like other approaches that have psychodynamic roots, intergenerational therapy is a processoriented therapy that relies heavily on the self-of-the-therapist, most specifically the therapist’s level of
differentiation, to promote client change (Kerr & Bowen, 1988). This therapy does not emphasize
techniques and interventions. Instead, therapists use genograms and assessment to promote insight and
then intervene as differentiated persons. For example, when one partner tries to get the therapist to
take his/her side in an argument, the therapist responds by simultaneously modeling differentiation and
gently promoting it in the couple. By refusing to take sides and also helping the couple tolerate their
resulting anxiety (their problem is still not fixed, and neither partner has been “validated” by the
therapist), the therapist creates a situation in which the couple can increase their level of
differentiation: they can use self-validation to soothe their feelings and learn how to tolerate the
tension of difference between them. Change is achieved through alternately using insight and the
therapeutic relationship to increase clients’ levels of differentiation and tolerance for anxiety and
ambiguity.
Making Connections: The Therapeutic Relationship
Differentiation and the Emotional Being of the Therapist
More than in any other family therapy approach, in intergenerational therapy the therapist’s level of
differentiation (Bowen, 1985; Kerr & Bowen, 1988) and emotional being (Friedman, 1991) are central to
the change process. Intergenerational therapists focus on developing a therapeutic relationship that
encourages all parties to further their differentiation process: “the differentiation of the therapist is
technique” (Friedman, 1991, p. 138; italics in original). Intergenerational therapists believe that clients
can only differentiate as much as their therapists have differentiated (Bowen, 1985). For this reason, the
therapist’s level of differentiation is often the focus of supervision early in training, and therapists are
expected to continually monitor and develop themselves so that they can be of maximum assistance to
their clients. Bowen therapists assert that the theory cannot be learned through books (such as this one)
but can only be learned through a relationship with a supervisor or teacher who uses these ideas to
interact with the student (Friedman, 1991).
A Nonanxious Presence
The greater a therapist’s level of differentiation, the more the therapist can maintain a nonanxious
presence with clients (Kerr & Bowen, 1988). This is not a cold, detached stance but rather an
emotionally engaged stance that is nonreactive, meaning that the therapist does not react to attacks,
“bad” news, and so forth without careful reflection. The therapist does not rush in to rescue clients from
anxiety every time they feel overwhelmed by anger, sadness, or another strong emotion; instead, the
therapist calmly wades right into the muck the client is trying to avoid and guides the client through the
process of separating self from other and thought from feelings (Friedman, 1991). The therapist’s calm
center is used to help clients move through the differentiation process in a safe, contained environment
in which differentiation is modeled. When clients are upset, the “easiest” thing to do is to soothe and
calm their anxieties, fears, and strong emotions; this makes everyone calmer sooner, but nothing is
learned. The intergenerational therapist instead shepherds clients through a more difficult process of
slowly coaching them through that which they fear or detest in order to facilitate growth.
The Viewing: Case Conceptualization and Assessment
Viewing is the primary “intervention” in intergenerational therapy because the approach’s effectiveness
relies on the therapist’s ability to accurately assess the family dynamics and thereby guide the healing
process (Bowen, 1985). Although this is true with all therapies, it is truer with intergenerational
therapies because the therapist’s level of differentiation is critical to the ability to accurately “see” what
is going on.
Emotional Systems
Bowen viewed families, organizations, and clubs as emotional systems that have the same processes as
those found in all natural systems: “Bowen has constantly emphasized over the years that we have more
in common with other forms of protoplasm (i.e., life) than we differ from them” (Friedman, 1991, p.
135). He viewed humans as part of an evolutionary emotional process that goes back to the first cell that
had a nucleus and was able to differentiate its functions from other cells (i.e., human life begins with
one cell that divides to create new cells, which then differentiate to create the different systems and
structures of the body: blood, muscle, neurons, etc.). This process of differentiating yet remaining part
of a single living organism (system) is a primary organizing concept in Bowen’s work, and the family’s
emotional processes are viewed as an extension (not just a metaphor) of the differentiation process of
cells. Thus Bowen’s theory of natural systems focuses on the relationship between the human species
and all life past and present.
Of particular interest in family therapy are natural systems that have developed emotional
interdependence (e.g., flocks of birds, herds of cattle, and human families; Friedman, 1991). The
resulting system or emotional field profoundly influences all of its members, defining what is valued and
what is not. When a family lacks sufficient differentiation, it may become emotionally fused, an
undifferentiated family “ego mass.” Intergenerational therapists focus squarely on a family’s unique
emotional system rather than on environmental or general cultural factors, and they seek to identify the
rules that structure the particular system.
This approach is similar to other systemic conceptualizations of the family as a single organism or
system; however, Bowen emphasizes that it is fundamentally an emotional system. Because this system
has significant impact on a person’s behavior, emotions, and symptoms, one must always assess this
context to understand a person’s problems. For example, in the case study at the end of this chapter,
the therapist explores how, Wei-Wei’s panic attacks fit within the broader fabric of the family system,
her immigration history, and her professional life, rather than focusing solely on the medical and
psychological aspects of the attacks.
Chronic Anxiety
Bowen viewed chronic anxiety as a biological phenomenon that is present in all natural systems. Chronic
anxiety involves automatic physical and emotional reactions that are not mediated through conscious,
logical processes (Friedman, 1991). Families exhibit chronic anxiety in their responses to crises, loss,
conflict, and difficulties. The process of differentiation creates a clear headedness that allows individuals
and families to reduce the reactivity and anxiety associated with survival in natural systems and instead
make conscious choices about how to respond. For example, chronic anxiety in a family may result from
a mother feeling guilty about a child’s lack of success, in which case it is the therapist’s job to help the
mother increase her level of differentiation so that she can respond to the child’s situation from a clear,
reasoned position rather than with a blind emotional reactivity that rarely helps the situation. In the
case study at the end of the chapter, the therapist works with the mother to reduce her anxiety and
panic as her son finishes medical school and begins his independent life as an adult.
The Multigenerational Transmission Process
The multigenerational transmission process is based on the premise that emotional processes from prior
generations are present and “alive” in the current family emotional system (Friedman, 1991). In this
process, children may emerge with higher, equal, or lower levels of differentiation than their parents
(Bowen, 1985). Families with severe emotional problems result from a multigenerational process in
which the level of differentiation has become lower and lower with each generation. Bowen’s approach
is designed to help an individual create enough distance from these processes to comprehend the more
universal processes that shape human relationships and individual identities (Friedman, 1991). Thus, in
the case study at the end of this chapter, the therapist will assess the emotional content of the parents’
prior life in China, which is viewed as an ongoing aspect of the family’s current reality.
Multigenerational Patterns
Intergenerational therapists assess multigenerational patterns, specifically those related to the
presenting problem. Using a genogram or oral interview, the therapist identifies patterns of depression,
substance use, anger, conflict, the parent–child relationship, the couple’s relationship, or whatever
issues are most salient for the client. The therapist then identifies how the current situation fits with
these patterns. Is the client replicating or rebelling against the pattern? How has the pattern evolved
with this generation? The therapist thereby gains greater clarity into the dynamics that are feeding the
problem. In cases of immigration, such as that at the end of this chapter, the historic family patterns
may change because of different cultural contexts (e.g., the family attempts or is forced to blend and
adapt), may be rigidly the same (e.g., the family wants to adhere to traditions), or may be radically
different (e.g., the family wants to “break” from the past).
Level of Differentiation (see Juice)
When differentiation is used as part of case conceptualization, the therapist assesses the client’s level of
differentiation along a continuum, which Bowen developed into a differentiation scale that ranges from
1 to 100, with lower levels of differentiation represented by lower numbers (Bowen, 1985). Bowen
maintained that people rarely reach higher than 70 on this scale.
Although there are pen-and-paper measures such as the Chabot Emotional Differentiation Scale (Licht &
Chabot, 2006), most therapists simply note patterns of where and how a person is able or unable to
separate self from other and thought from emotion.
What is most useful for treatment is not some overall score or general assessment of differentiation, but
the specific places where clients need to increase their level of differentiation to resolve the presenting
problem. For example, a couple may need to increase their ability to differentiate self from other in the
area of sex so that they can create a better sexual relationship that allows each person to have
preferences, discuss them, and find ways to honor these preferences without becoming emotionally
overwhelmed.
Emotional Triangles
Bowen identified triangles as one of the most important dynamics to assess because they are the basic
building block of families (Bowen, 1985; Friedman, 1991; Kerr & Bowen, 1988). A triangle is a process in
which a dyad draws in a third person (or something, topic, or activity) to stabilize the primary dyad,
especially when there is tension in the dyad. Because triangles use a third person or topic to alleviate
tension, the more you try to change the relationship with the third entity, the more you ironically
reinforce the aspects you want to change. Thus, therapists assess triangles to identify the primary
relationship that needs to be targeted for change.
Bowen maintained that triangulation is a fundamental process in natural systems (Bowen, 1985).
Everyone triangulates to some degree: going down the hall to complain about your boss or coworker is
triangulation. However, when this becomes the primary means for dealing with dyadic tension and the
members of the dyad never actually resolve the tension themselves, then pathological patterns emerge.
The more rigid the triangle, the greater the problems.
The classic family example of a triangle is a mother who becomes overinvolved with her children to
reduce unresolved tension in the marriage. This over involvement can take the form of positive
interactions (over involvement in school and social activities, emotional intimacy, constant errands or
time devoted to the child) or negative interactions (nagging and worrying about the child; the therapist
suspects that this is what is going on in the case study at the end of the chapter). Another common form
of triangulation is seen in divorced families, in which both parents often triangulate the child, trying to
convince the child to take their side against the other parent. Triangulation can also involve using
alcohol or drugs to create dyadic stability, complaining or siding with friends or family of origin against
one’s spouse, or two siblings siding against a third.
The Family Projection Process
The family projection process describes how parents “project” their immaturity onto one or more
children (Bowen, 1985), causing decreased differentiation in subsequent generations. The most
common pattern is for a mother to project her anxiety onto one child, focusing all her attention on this
child to soothe her anxiety, perhaps becoming overly invested in the child’s academic or sporting
activities. The child or children who are the focus of the parent’s anxiety will be less differentiated than
the siblings who are not involved in this projection process.
Emotional Cutoff
A particularly important process to assess is emotional cutoff, which refers to situations in which a
person no longer emotionally engages with another in order to manage anxiety; this usually occurs
between children and parents. Emotional cutoff can take the form of no longer seeing or speaking to the
other or, alternatively, being willing to be at the same family event with virtually no interaction. Often
people who display cutoff from their family believe that doing so is a sign of mental health (e.g., “I have
set good boundaries”) or even a sign of superiority (e.g., “It makes no sense for me to spend time with
that type of person”). They may even report that this solution helps them manage their emotional
reactivity. However, cutoff is almost always a sign of lower levels of differentiation (Bowen, 1985).
Essentially, the person is so emotionally fused with the other that he/she must physically separate to be
comfortable. The higher a person’s level of differentiation, the less need there is for emotional cutoff.
This does not mean that a highly differentiated person does not establish boundaries. However, when
differentiated people set boundaries and limit contact with family, they do so in a way that is respectful
and preserves emotional connection, and not out of emotional reactivity (e.g., after an argument).
Emotional cutoff requires a little more attention in assessment because it can “throw off” an overall
assessment of differentiation and family dynamics. People who emotionally cut themselves off as a
means of coping often appear more differentiated than they are; it may also be harder to detect certain
family patterns because in some cases the client “forgets” or honestly does not know the family history.
However, at some times and in certain families, more cutoff is necessary because of extreme patterns of
verbal, emotional, or childhood abuse. In such cases, where contact is not appropriate or possible, the
therapist still needs to assess the emotional part of the cutoff. The more people can stay emotionally
engaged (e.g., have empathy and cognitive understanding of the relational dynamics) without harboring
anger, resentment, or fear, the healthier they will be, and this should be a therapeutic goal.
Sibling Position
Intergenerational therapists also look at sibling position as an indicator of the family’s level of
differentiation; all things being equal, the more the family members exhibit the expected characteristics
of their sibling position, the higher the level of differentiation (Bowen, 1985; Kerr & Bowen, 1988). The
more intense the family projection process is on a child, the more that child will exhibit characteristics of
an infantile younger child. The roles associated with sibling positions are informed by a person’s cultural
background, with immigrants generally adhering to more traditional standards than later generations.
Most often, older children identify with responsibility and authority, and later-born children respond to
this domination by identifying with underdogs and questioning the status quo. The youngest child is
generally the most likely to avoid responsibility in favor of freedom.
Societal Regression
When a society experiences sustained chronic anxiety because of war, natural disaster, economic
pressures, and other traumas, it responds with emotionally based reactive decisions rather than rational
decisions (Bowen, 1985) and regresses to lower levels of functioning, just like families. These Band-Aid
solutions to social problems generate a vicious cycle of increased problems and symptoms. Societies can
go through cycles in which their level of differentiation rises and falls.
Targeting Change: Goal Setting
Two Basic Goals
Like any theory with a definition of health, intergenerational therapy has clearly defined long-term
therapeutic goals that can be used with all clients:
1. To increase each person’s level of differentiation (in specific contexts)
2. To decrease emotional reactivity to chronic anxiety in the system
Increasing Differentiation
Increasing differentiation is a general goal that should be operationally defined for each client. For
example, “increase AF’s and AM’s level of differentiation in the marital relationship by increasing the
tolerance of difference while increasing intimacy” is a better goal than “increase differentiation.”
Decreasing Emotional Reactivity to Chronic Anxiety
Decreasing anxiety and emotional reactivity is closely correlated with the increasing differentiation. As
differentiation increases, anxiety decreases. Nonetheless, it can be helpful to include these as separate
goals to break the process down into smaller steps. Decreasing anxiety generally precedes increasing
differentiation and therefore may be included in the working rather than the termination phase of
therapy. As with the general goal of increasing differentiation, it is clinically helpful to tailor this to an
individual client. Rather than stating the general goal of “decrease anxiety,” which can easily be
confused with treating an anxiety disorder (as may or may not be the case), a more useful clinical
goal would address a client’s specific dynamic: “decrease emotional reactivity to child’s defiance” or
“decrease emotional reactivity to partner in conversations about division of chores and parenting.”
The Doing: Interventions
Theory Versus Technique
The primary “technique” in Bowen intergenerational theory is the therapist’s ability to embody the
theory. The premise is that if therapists understand Bowen’s theory of natural systems and work on
their personal level of differentiation, they will naturally interact with clients in a way that promotes the
clients’ level of differentiation (Friedman, 1991). Thus understanding—“living” the theory—is the
primary technique for facilitating client change.
Process Questions
Intergenerational therapists’ embodiment of the theory most frequently expresses itself through
process questions, questions that help clients see the systemic process or the dynamics that they are
enacting. For example, a therapist can use process questions to help clients see how the conflict they
are experiencing with their spouse is related to patterns they observed in the parents’ relationship:
“How do the struggles you are experiencing with your spouse now compare with those of each of your
parents? Are they similar or different? Is the role you are playing now similar to that of one of your
parents in their marriage? Is it similar to the type of conflict you had with your parents when you were
younger? Who are you most like? Least like?” These questions are generated naturally from the
therapist’s use of the theory to conceptualize the client’s situation.
Encouraging Differentiation of Self
According to Bowenian theory, families naturally tend toward togetherness and relationship as part of
survival. Thus therapeutic interventions generally target the counterbalancing force of differentiation
(Friedman, 1991) by encouraging clients to use “I” positions to maintain individual opinions and mood
states while in relationships with others. For example, if spouses are overreactive to the moods of the
other, every time one person is in an angry or unhappy mood, the other feels there is no other choice
but to also be in that mood state. Therapists promote differentiation by coaching the second spouse to
maintain his/her emotional state without undue influence from the other. In this chapter’s case study,
the therapist will work with Wei-Wei, who is having panic attacks, to increase her sense of
differentiation, particularly in relationship to her son but also in relationship to her husband, from
whom she has become distant.
Genograms
The genogram is used both as an assessment tool and an intervention (McGoldrick, Gerson, & Petry,
2008). As an intervention, the genogram identifies not only problematic intergeneration patterns but
also alternative ways for relating and handling problems. For example, if a person comes from a family
in which one or more children in each generation has strongly rebelled against their parents, the
genogram can be used to identify this pattern, note exceptions in the larger family, and identify ways to
prevent or intervene on this dynamic. The genogram’s visual depiction of the pattern across generations
often inspires a greater sense of urgency and commitment to change than when the dynamics are only
discussed in session. Constructing the genogram often generates a much greater sense of urgency and
willingness to take action compared to relying strictly on process questions and a discussion of the
dynamics. Chapter 13 includes a brief description of how to construct a genogram and use it in session.
Detriangulation
Detriangulation involves the therapist maintaining therapeutic neutrality (differentiation) in order to
interrupt a client’s attempt to involve the therapist or someone else in a triangle (Friedman, 1991).
Whether working with an individual, couple, or family, most therapists at some point will be “invited” by
clients to triangulate with them against a third party who may or may not be present in the room. When
this occurs, the therapist “detriangulates” by refusing to take a side, whether literally or more subtly.
For example, if a client says, “Don’t you think it is inappropriate for a child to talk back?” or “Isn’t it
inappropriate for a husband to go to lunch with a single woman who is attracted to him?” the quickest
way to relieve the client’s anxiety is to agree: this makes the relationship between the client and
therapist comfortable, allowing the client to immediately feel “better,” “understood,” and “empathized
with.” However, by validating the client’s position and taking the client’s side against another, the
therapist undermines the long-term goal of promoting differentiation. Thus, if therapy becomes “stuck,”
therapists must first examine their role in a potential triangle (Friedman, 1991).
Rather than take a side, the therapist invites clients to validate themselves, examine their own part in
the problem dynamic, and take responsibility for their needs and wants. There is often significant
confusion in the therapeutic community about “validating” a client’s feelings. Validation implies
approval; however, approval from the therapist undermines a client’s sense of autonomy.
Intergenerational therapists emphasize that when therapists “validate” by saying “It is normal to feel
this way,” “It sounds like he really hurt you,” or in some way imply “You are entitled to feel this way,”
they close down the opportunity for differentiation. Instead, clients are coached to approve or
disapprove of their own thoughts and feelings and then take responsibility and action as needed.
Relational Experiments
Relational experiments are behavioral homework assignments that are designed to reveal and change
unproductive relational processes in families (Guerin, Fogarty, Fay, & Kautto, 1996). These experiments
interrupt triangulation processes by increasing direct communication between a dyad or by reversing
pursuer/distancer dynamics that are fueled by lack of differentiation.
Going Home Again
Most adults are familiar with this paradox: you seem to be a balanced person who can manage a
demanding career, an educational program, and a complex household; yet, when you go home to visit
family for the holidays, you find yourself suddenly acting like a teenager—or worse. Intergenerational
therapists see this difference in functioning as the result of unresolved issues with the family of origin
that can be improved by increasing differentiation. Even if you cannot change a parent’s critical
comments or a sibling’s arrogance, you can be in the presence of these “old irritants” and not regress to
past behaviors but instead keep a clear sense of self. As clients’ level of differentiation grows, they are
able to maintain a stronger and clearer sense of self in the family nuclear system. The technique of
“going home” refers to when therapists encourage clients to interact with family members while
maintaining a clearer boundary between self and other and to practice and/or experience the reduced
emotional reactivity that characterizes increases in differentiation (Friedman, 1991).
Interventions for Special Populations
The Sexual Crucible Model
One of the most influential applications of Bowen intergenerational theory is the Sexual Crucible Model
developed by David Schnarch (1991). The model proposes that marriage functions as a “crucible,” a
vessel that physically contains a volatile transformational process. In the case of marriage, the therapist
achieves transformation by helping both partners differentiate (or more simply, forcing them to “grow
up”). As with all crucibles, the contents of marriage must be contained because they are unstable and
explosive. Schnarch views sexual and emotional intimacy as inherently intertwined in the process of
differentiation. He directs partners to take responsibility for their individual needs rather than demand
that the other change to accommodate their needs, wants, and desires. To remain calm, each person
learns to self-soothe rather than demand that the other change. Schnarch also includes exercises like
“hugging to relax” in which he helps couples develop a greater sense of physical intimacy and increased
comfort with being “seen” by the other. He has developed this model for therapists to use with clients
and has also made it accessible to general audiences (Schnarch, 1998). Schnarch has developed a
comprehensive and detailed model for helping couples create the type of relationship most couples
today expect: a harmonious balance of emotional, sexual, intellectual, professional, financial, parenting,
household, health, and social partnerships. However, Schnarch points out that this multifaceted
intimacy has never been the norm in human relationships. His model is most appropriate for
psychologically minded clients who are motivated to increase intimacy.
Putting It All Together: Case Conceptualization and Treatment Plan Templates
Areas for Theory-Speci
c Case Conceptualization
• Chronic Anxiety
Describe patterns of chronic anxiety within the family: each person’s role, how it relates to symptoms,
etc.
• Multigenerational Patterns
Based on genogram, identify multigenerational patterns, attending to the following themes:
■ Family strengths
■ Substance/alcohol abuse
■ Sexual/physical/emotional abuse
■ Parent/child relations
■ Physical/mental disorders
■ Historical incidents of presenting problem
■ Roles within the family: martyr, hero, rebel, helpless one, etc.
• The Multigenerational Transmission Process
Describe multigenerational transmission of functioning, attending to acculturation issues, residual
effects of trauma and loss, significant legacies, etc.
• Level of Differentiation
Describe each person’s relative level of differentiation and provide examples for how it is expressed.
• Emotional Triangles
Identify patterns of triangulation in the family
• The Family Projection Process
Describe patterns of parents projecting their anxiety onto one more child who becomes the focus of
attention.
• Emotional Cutoff
Describe any cutoffs in the family
• Sibling Position
Describe sibling position patterns that seem to be relevant for the Family Treatment Plan Template for
Individual with depression/anxiety
Intergenerational Initial Phase of Treatment with Individual
Initial Phase Therapeutic Tasks
1. Develop working therapeutic relationship. Diversity note: [Describe how you will adjust to respect
cultured, gendered, and other styles of relationship building and emotional expression.]
a. Engage with client from a differentiated position, conveying a nonanxious presence.
2. Assess individual, systemic, and broader cultural dynamics. Diversity note: [Describe how you will
adjust assessment based on cultural, socioeconomic, sexual orientation, gender, and other relevant
norms.]
a. Use three-generation genogram to identify multigenerational patterns, chronic anxiety, triangles,
emotional cutoff, family projection process, and sibling position.
b. Assess client’s and significant other’s levels of differentiation in current crisis/problem situation and
in the past.
3. Define and obtain client agreement on treatment goals. Diversity note: [Describe how you will modify
goals to correspond with values from the client’s cultural, religious, and other value systems.]
a. Work with client to define goals that relate to differentiation and decreased systemic anxiety.
4. Identify needed referrals, crisis issues, collateral contacts, and other client needs.
a. Referrals/resources/contacts: Make referrals and collateral contacts as appropriate.
Initial Phase Client Goal
1. Reduce triangulation between client and [specify] to reduce depression and anxiety.
a. Detriangulate by maintaining therapeutic neutrality and refocusing client on his/her half of problem
interactions.
b. Relational experiments to go home and practice relating directly rather than triangulating.
Intergenerational Working Phase of Treatment with Individual
Working Phase Therapeutic Tasks
1. Monitor quality of the working alliance. Diversity note: [Describe how you will attend to client
response to interventions that indicate therapist is using expressions of emotion that are not consistent
with client’s cultural background.]
a. Assessment intervention: Monitor therapist responses (both verbal and nonverbal) to ensure relating
from differentiated position and avoiding triangulation.
2. Monitor client progress. Diversity note: [Describe how you will attend to cultural, gender, social class,
and other diversity elements when assessing progress.]
a. Assessment intervention: Assess client’s ability to relate to therapist and those outside of session
from a more differentiated position.
Working Phase Client Goals
1. Decrease chronic anxiety and reactivity to stressors to reduce anxiety.
a. Encourage differentiated responses to common anxieties and triggers.
b. Relational experiments to practice responding rather than simply reacting to perceived anxieties and
stressors.
2. Decrease mindless repetition of unproductive multigenerational patterns and increase consciously
chosen responses to stressors to reduce depression and hopelessness.
a. Use genogram to identify multigenerational patterns and intergenerational transmissions related to
presenting problems.`
b. Process questions to help clients see the multigenerational processes and make differentiated
choices instead of mindlessly repeating pattern. 3. Decrease emotional cutoffs and reengage in difficult
relationships from a differentiated position to reduce anxiety.
a. Process questions to identify the fusion underlying cutoffs.
b. Going home again to help client reengage in cutoff relationships from a differentiated position.
Intergenerational Closing Phase of Treatment with Individual
Closing Phase Therapeutic Task
1. Develop aftercare plan and maintain gains. Diversity note: [Describe how you will access resources in
the communities of which they are a part to support them after ending therapy.]
a. Identify relationships and practices that help client maintain differentiation in key relationships.
Closing Phase Client Goals
1. Increase client’s ability to balance need for togetherness and autonomy in intimate relationships to
reduce depression and anxiety.
a. Process questions to explore how togetherness and autonomy can both be honored.
b. Relational experiments to practice relating to others from a differentiated position.
2. Increase ability to respond to family-of-origin interactions from a position of engaged differentiation
to reduce to depression and sense of helplessness.
a. Encourage differentiated responses when engaging family-of-origin.
b. Going home again exercises to redefine relationship with family-of-origin
Treatment Plan Template for Couple/famIly
Intergenerational Initial Phase of Treatment with Couple/Family
Initial Phase Therapeutic Tasks
1. Develop working therapeutic relationship. Diversity note: [Describe how you will adjust to respect
cultured, gendered, and other styles of relationship building and emotional expression.]
a. Engage with each client from a differentiated position, conveying a nonanxious presence.
2. Assess individual, systemic, and broader cultural dynamics. Diversity note: [Describe how you will
adjust assessment based on cultural, socioeconomic, sexual orientation, gender, and other relevant
norms.]
a. Use three- to four-generation genogram to identify multigenerational patterns, chronic anxiety,
triangles, emotional cutoff, family projection process, and sibling position.
b. Assess client’s and significant other’s levels of differentiation in current crisis/problem situation and
in the past.
3. Define and obtain client agreement on treatment goals. Diversity note: [Describe how you will modify
goals to correspond with values from the client’s cultural, religious, and other value systems.]
a. Work with couple/family to define goals that relate to differentiation and decreased systemic
anxiety.
4. Identify needed referrals, crisis issues, collateral contacts, and other client needs.
a. Referrals/resources/contacts: Make referrals and collateral contacts as appropriate.
Initial Phase Client Goal
1. Reduce triangulation between [specify] and [specify] to reduce conflict.
a. Detriangulate in session by maintaining therapeutic neutrality and refocusing each person on his/her
half of problem interactions.
b. Process questions to increase awareness of how triangulation is used to unsuccessfully manage
conflict.
Intergenerational Working Phase of Treatment with Couple/Family
Working Phase Therapeutic Tasks
1. Monitor quality of the working alliance. Diversity note: [Describe how you will attend to client
response to interventions that indicate therapist using expressions of emotion that are not consistent
with client’s cultural background.]
a. Assessment intervention: Monitor therapist responses (both verbal and nonverbal) to ensure relating
from differentiated position and avoiding triangulation.
2. Monitor client progress. Diversity note: [Describe how you will attend to cultural, gender, social class,
and other diversity elements when assessing progress.]
a. Assessment intervention: Assess each client’s ability to relate to therapist and those outside of
session from a more differentiated position.
Working Phase Client Goals
1. Decrease chronic anxiety in system and reactivity to stressors to reduce conflict.
a. Encourage differentiated responses to common anxieties and triggers.
b. Relational experiments to practice responding rather than simply reacting to perceived anxieties and
stressors.
2. Decrease mindless repetition of unproductive multigenerational patterns and increase consciously
chosen responses to stressors to reduce conflict.
a. Use genogram to identify multigenerational patterns and intergenerational transmissions related to
presenting problems.
b. Process questions to help clients see the multigenerational processes and make differentiated
choices instead of mindlessly repeating pattern.
3. Decrease emotional cutoffs and reengage in difficult relationships from a differentiated position to
reduce conflict.
a. Process questions to identify the fusion underlying cutoffs.
b. Going home again to help clients reengage in cutoff relationships from a differentiated position.
Intergenerational Closing Phase of Treatment with Couple/Family
Closing Phase Therapeutic Task
1. Develop aftercare plan and maintain gains. Diversity note: [Describe how you will access resources in
the communities of which they are a part to support them after ending therapy.]
a. Identify relationships and practices that help client maintain differentiation in key relationships.
Closing Phase Client Goals
1. Increase each person’s ability to balance need for togetherness and autonomy in intimate
relationships to reduce conflict and increase intimacy.
a. Process questions to explore how togetherness and autonomy can both be honored within the
relationship; discuss needs of each person and how they may differ and be accommodated.
b. Relational experiments to practice relating to others from a differentiated position.
2. Increase ability to respond to family-of-origin interactions from a position of engaged differentiation
to reduce conflict and increase intimacy.
a. Encouraging differentiated responses when engaging family-of-origins.
b. Going home again exercises to redefine relationships with family-of-origins.
Psychoanalytic Family Therapies
In a Nutshell: The Least You Need to Know
Many of the founders of family therapy were psychoanalytically trained, including Don Jackson, Carl
Whitaker, Salvador Minuchin, Nathan Ackerman, and Ivan Boszormenyi-Nagy. Although some disowned
their academic roots as they developed methods for working with families, others, such as Ackerman
and Boszormenyi-Nagy, did not. In the 1980s, renewed interest in object relations therapies led to the
development of object relations family therapy (Scharff & Scharff, 1987).
These therapies use traditional psychoanalytic and psychodynamic principles that describe inner
conflicts and extend these principles to external relationships. In contrast to individual psychoanalysts,
psychoanalytic family therapists focus on the family as a nexus of relationships that either support or
impede the development and functioning of its members. As in traditional psychoanalytic approaches,
the process of therapy involves analyzing intrapsychic and interpersonal dynamics, promoting client
insight, and working through these insights to develop new ways of relating to self and others. Some of
the more influential approaches are contextual therapy (Boszormenyi-Nagy & Krasner, 1986), family-oforigin therapy (Framo, 1992), and object relations family therapy (Scharff & Scharff, 1987).
The Juice: Significant Contributions to the Field
If you remember one thing from this chapter, it should be this:
Ethical Systems and Relational Ethics
Ivan Boszormenyi-Nagy (1986; Boszormenyi-Nagy & Krasner, 1986) introduced the idea of an ethical
system at the heart of families that, like a ledger, keeps track of entitlement and indebtedness. Families
use this system to maintain trustworthiness, fairness, and loyalty between family members; its
breakdown results in individual and/or relational symptoms. Thus the goal of therapy is to reestablish an
ethical system in which family members are able to trust one another and to treat one another with
fairness.
Clients often present in therapy with a semiconscious awareness of this ethical accounting system. Their
presenting complaint may be that things are no longer fair in the relationship; parents are not sharing
their duties equitably or one child is being treated differently than another. In these cases, an explicit
dialogue about the family’s ethical accounting system—what they are counting as their entitlement and
what they believe is owed them—can be helpful in increasing empathy and understanding among family
members.
Rumor Has It: The People and Their Stories
Nathan Ackerman and the Ackerman Institute
A child psychiatrist, Nathan Ackerman (1958, 1966) was one of the earliest pioneers in working with
entire families, which he posited were split into factions, much the way an individual’s psyche is divided
into conflicting aspects of self. After developing his family approach at the Menninger Clinic in the 1930s
and at Jewish Family Services in New York in the 1950s, he opened his own clinic in 1960, now known as
the Ackerman Institute, which has remained one of the most influential family therapy institutes in the
country. With Don Jackson, he co-founded the field’s first journal, Family Process.
Ivan Boszormenyi-Nagy
With one of the most difficult names to pronounce in the field (Bo-zor-ma-nee Naj), Boszormenyi-Nagy
was an early pioneer in psychoanalytic family therapy. His most unique contribution was his idea that
families had an ethical system, which he conceptualized as a ledger of entitlement and indebtedness
(Boszormenyi-Nagy & Krasner, 1986).
James Framo
A student of Boszormenyi-Nagy, James Framo is best known for developing family-of-origin therapy; as
part of treatment with individuals, couples, and families, he invited a client’s entire family of origin in for
extended sessions (Boszormenyi-Nagy & Framo, 1965/1985; Framo, 1992). Framo located the primary
problem not only in the family unit but also in the larger extended family system.
David and Jill Scharff
A husband-and-wife team, David and Jill Scharff (1987) developed a comprehensive model for object
relations family therapy. Rather than focusing on individuals, they apply principles from traditional
object relations therapy to the family as a unit.
The Women’s Project
Bowenian trained social workers Marianne Walters, Betty Carter, Peggy Papp, and Olga Silverstein
(1988) reformulated many foundational family therapy concepts through a feminist lens. Their work
challenged the field to examine gender stereotypes that were being reinforced in family therapy theory
and practice, within and beyond the practice of Bowen family therapy.
The Big Picture: Overview of Treatment
The psychodynamic tradition includes a number of different schools that share the same therapeutic
process. The first task is to create a caring therapeutic relationship, or holding environment (Scharff &
Scharff, 1987), between the therapist and client. Then the therapist analyzes the intrapsychic and
interpersonal dynamics—both conscious and unconscious, current and transgenerational—that are the
source of symptoms (Boszormenyi-Nagy & Krasner, 1986; Scharff & Scharff, 1987). The therapist’s next
task is to promote client insight into these dynamics, which requires getting through client defenses.
Once clients have achieved insights into the intrapsychic and interpersonal dynamics that fuel the
problem, the therapist facilitates working through these insights to translate them into action in clients’
daily lives.
Making a Connection: The Therapeutic Relationship
Transference and Countertransference
A classic psychoanalytic concept, transference refers to when a client projects onto the therapist
attributes that stem from unresolved issues with primary caregivers; therapists use the immediacy of
these interactions to promote client insight (Scharff & Scharff, 1987). Countertransference refers to
when therapists project back onto clients, losing their therapeutic neutrality and having strong
emotional reactions to the client; these moments are used to help the therapist and client better
understand the reactions the client brings out in others. In therapy with couples and families, the
processes of transference and countertransference vacillate more than in individual therapy because of
the complex web of multiple relationships.
Contextual and Centered Holding
In contrast to traditional psychoanalysts, who are viewed as neutral “blank screens,” object relations
family therapists are more relationally focused, creating a nurturing relationship they call a holding
environment. They distinguish between two aspects of holding in family therapy: contextual and
centered (Scharff & Scharff, 1987). Contextual holding refers to the therapist’s handling of therapy
arrangements: conducting sessions competently, expressing concern for the family, and being willing to
see the entire family. Centered holding refers to connecting with the family at a deeper level by
expressing empathetic understanding to create a safe emotional space.
Multidirected Partiality
The guiding principle for relating to clients in contextual family therapy is multidirectional partiality, that
is, being “partial” with all members of the family (Boszormenyi-Nagy & Krasner, 1986). Therapists must
be accountable to everyone who is potentially affected by the interventions, including those not
immediately present in the room, such as extended family members. This principle of inclusiveness
means that the therapist must bring out the humanity of each member of the family, even the “monster
member” (Boszormenyi-Nagy & Krasner, 1986). In practice, multidirectional partiality generally involves
sequential siding with each member by empathizing with each person’s position in turn.
The Viewing: Case Conceptualization and Assessment
Interlocking Pathologies
Expanding the classic psychodynamic view of symptomology, Ackerman (1956) held that the constant
exchange of unconscious processes within families creates interlocking or interdependent pathologies
and that any individual’s pathology reflects those family distortions and dynamics, a position similar to
that of systemic therapies. Thus, when working with a family, the therapist seeks to identify how the
identified patient’s symptoms relate to the less overt pathologies within the family.
Self-Object Relations Patterns
Object relations therapists emphasize the basic human need for relationship and attachment to others.
Thus they assess self-object relations: how people relate to others based on expectations developed by
early experiences with primary attachment objects, particularly mothers (Scharff & Scharff, 1987). As a
result of these experiences, external objects are experienced as ideal, rejecting, or exciting:
• Ideal Object: An internal mental representation of the primary caretaker that is desexualized and
deaggressivized and maintained as distinct from its rejecting and exciting elements
• Rejecting Object: An internal mental representation of the caregiver when the child’s needs for
attachment were rejected, leading to anger
• Exciting Object: An internal mental representation of the caretaker formed when the child’s needs for
attachment were overstimulated, leading to longing for an unattainable but tempting object
Splitting
The more intense the anxiety resulting from frustration related to the primary caregiver, the greater the
person’s need to spilt these objects, separating good from bad objects by repressing the rejecting
and/or exciting objects, thus leaving less of the ego, or conscious self, to relate freely. To the degree that
splitting is not resolved, there is an “all good” or “all bad” quality to evaluating relationships. In
couples, splitting often results in seeing the partner as “perfect” (all good) in the early phases of the
relationship, but when the partner no longer conforms to expectations, the partner becomes the enemy
(all bad). In families, splitting can also take the form of the perfect versus the problem child.
Projective Identification
In couples and other intimate relationships, clients defend against anxiety by projecting certain split-off
or unwanted parts of themselves onto the other person, who is then manipulated to act according to
these projections (Scharff & Scharff, 1987). For example, a husband may project his interest in other
women onto his wife in the form of jealousy and accusations of infidelity; the wife then decides to hide
innocent information that may feed the husband’s fear, but the more she tries to calm his fears by
hiding information, the more suspicious and jealous he becomes.
Repression
Object relations therapists maintain that children must repress anxiety when they experience separation
with their primary caregiver (attachment object), which results in less of the ego being available for
contact with the outside world. Until this repressed material is made conscious, the adult unconsciously
replicates these repressed object relationships. One of the primary aims of psychoanalytic therapy is to
bring repressed material to the surface.
Parental Interjects
Framo (1976) believes that the most signficant dynamic affecting individual and family functioning is
parental introjects, the internalized negative aspects of parents. People internalize these attributes and
unconsciously strive to make all future intimate relationships conform to them, such as when they hear
a parent’s critical comments in the neutral comments of a partner. Therapists help clients become
conscious of these introjects to increase their autonomy in intimate relationships.
Transference Between Family Members
Similar to the way they assess transference from client to therapist, object relations therapists assess for
transference from one family member onto another (Scharff & Scharff, 1987). Transference between
family members involves one person projecting onto other members introjects and repressed material.
The therapist’s job is to help the family disentangle their transference, using interpretation to promote
insight into intrapsychic and interpersonal dynamics. It is often easier to promote insight into
transference patterns in family therapy than in individual therapy because these patterns happen “live”
in the room with the therapist, thus reducing the potential for a client to rationalize or minimize.
Ledger of Entitlement and Indebtedness
Ivan Boszormenyi-Nagy (1986; Boszormenyi-Nagy & Krasner, 1986) conceptualized the moral and ethical
system within the family as a ledger of entitlements and indebtedness, or more simply a ledger of
merits, an internal accounting of what one believes is due and what one owes others. Of course,
because in families each person has his/her own internal accounting system that has a different bottom
line, tensions arise over who is entitled to what, especially if there is no consensus on what is fair and
how give-and-take should be balanced in the family.
• Justice and Fairness: The pursuit of justice and fairness is viewed as one of the foundational premises
of intimate relationships. Monitoring fairness is an ongoing process that keeps the relationship
trustworthy. A “just” relationship is an ideal, and all relationships strive to achieve this never fully
attainable goal.
• Entitlements: Entitlements are “ethical guarantees” to merits that are earned in the context of
relationships, such as the freedom that parents are entitled to because of the care they extend to
children. The person’s sense of entitlement may only be evident in a crisis or extreme situation, such as
a parent becoming suddenly ill. Destructive entitlements result when children do not receive the
nurturing to which they are entitled and later project this loss onto the world, which they see as their
“debtors.”
• Invisible Loyalties: Family ledgers extend across generations, fostering invisible loyalties. For example,
new couples may have unconscious commitments to their family of origin when starting their
partnership. Invisible loyalties may manifest as indifferences, avoidance, or indecisiveness in relation to
the object of loyalty, blocking commitment in a current relationship.
• Revolving Slate: This is a destructive relational process in which one person takes revenge (or insists
on entitlements) in one relationship based on the relational transactions in another relationship. Instead
of reconciling the “slate” or account in the relationship in which the debt was accrued, the person treats
an innocent person as if he or she was the original debtor.
• Split Loyalties: This term refers to when a child feels forced to choose one parent (or significant
caregiver) over another because of mistrust between the caregivers. Common in divorces, this highly
destructive dynamic results in pathology in the child.
• Legacy: Each person inherits a legacy, a transgenerational mandate that links the endowments of the
current generation to its obligations to future generations. “Legacy is the present generation’s ethical
imperative to sort out what in life is beneficial for posterity’s quality of survival” (Boszormenyi-Nagy &
Krasner, 1986, p. 418). Legacy is a positive force in the chain of survival.
Mature Love: Dialogue Versus Fusion
Boszormenyi-Nagy (1986) describes mature love as a form of dialogue between two people who are
conscious of the family dynamics that have shaped their lives. This type of love is quite different from
fusion, experienced as an amorphous “we” similar to an infant and its caregiver. Thus clients are
encouraged to make invisible loyalties overt so that they can be critically examined, allowing for
conscious choice and action rather than the fear and anxiety that characterize fused relationships.
Targeting Change: Goal Setting
Goals in psychoanalytic therapies include several long-term changes in both individual and relational
functioning (Boszormenyi-Nagy & Krasner, 1986; Scharff & Scharff, 1987). General goals include the
following:
• Increase autonomy and ego-directed action by making unconscious processes conscious
• Decrease interactions based on projections or a revolving slate of entitlements
• Increase capacity for intimacy without loss of self (fusion with object)
• Develop reciprocal commitments that include a fair balance of entitlements and indebtedness
The Doing: Interventions
Listening, Interpreting, and Working Through
In general, psychoanalytic therapies use three generic interventions:
• Listening and Empathy: The primary tool of psychoanalytic therapists is listening objectively to the
client’s story without offering advice, reassurance, validation, or confrontation. Empathy may be used to
help the family to nondefensively hear the therapist’s interpretation of their unconscious dynamics.
• Interpretation and Promoting Insight: Like other psychoanalytic therapists, family psychoanalytic
therapists encourage insights into interpersonal dynamics by offering interpretations to the client, such
as by analyzing self-object relations or analyzing ledgers of entitlement and indebtedness.
• Working Through: Working through is the process of translating insight into new action in family and
other relationships. Changing one’s behavior on the basis of new insight is often the most difficult part
of therapy. Understanding that you are projecting onto your partner feelings and expectations that
really belong in your relationship with your mother is not too difficult; changing how you respond to
your partner when you feel rejected and uncared for is more challenging.
Eliciting
In contextual therapy, eliciting uses clients’ spontaneous motives to move the family in a direction that
is mutually beneficial and dialogical (Boszormenyi-Nagy & Krasner, 1986). The therapist facilitates this
process by integrating the facts of the situation, each person’s individual psychology, and interactive
transitions to help the family rework the balances of entitlement and indebtedness, helping each
member to reinterpret past interactions and identify new ways to move forward.
Detriangulating
Like other systemic therapists, psychoanalytic therapists identify situations in which the parents have
triangulated a symptomatic child into the relationship to deflect attention from their couple distress
(Framo, 1992). Once the child’s role is made clear, the therapist dismisses the symptomatic child from
therapy and proceeds to work with the couple to address the issues that created the need for the child’s
symptoms.
Family-of-Origin Therapy
Framo (1992) developed a three-stage model for working with couples that involved couples therapy,
couples group therapy, and family-of-origin therapy. Therapists begin working with the couple alone to
increase insight into their personal and relational dynamics. Next, the couple join a couples group,
where they receive feedback from other couples and also view their dynamics; for many couples, insight
comes more quickly when they see their problem dynamic acted out in another couple. Finally, each
individual member of the couple is invited to have a four-hour-long session with his/her family of origin
without the other partner present. These extended family-of-origin sessions are used to clarify and work
through past and present issues, thereby freeing individuals to respond to their partners and children
without the “ghosts” of these past attachments.
Putting It All Together: Case Conceptualization and Treatment Plan Templates
Areas for Theory-Specific Case Conceptualization
• Interlocking Pathologies
Describe how the presenting symptoms relate to interlocking pathologies within the system.
• Self-Object Relations Patterns
Identify self-object relation patterns for each person in the family:
■ Ideal object
■ Rejecting object
■ Exciting object
• Splitting
Describe patterns of splitting in the system.
• Projective Identification
Describe patterns of projective identification within the system.
• Repression
Describe patterns of repression within the system.
• Parental Introjects
Describe patterns of negative parental introjects within the system.
• Transference Between Family Members
Describe transference of parental introjects and repressed material onto others in the family.
• Ledger of Entitlement and Indebtedness
Describe key elements of the family’s ledger:
■ Entitlements: Describe themes of entitlements within the family and destructive entitlements
across generations.
■ Invisible loyalties: Describe invisible loyalties across generations.
■ Revolving slate: Describe any patterns of revolving slate.
■ Split loyalties: Describe instances of children feeling pressure to choose one parent over the other.
■ Legacy: Describe key themes in intergenerational family legacies.
• Mature Love: Dialogue Versus Fusion
Describe to what degree adults have love based on dialogical exchange between two equals versus
emotional fusion.
Treatment Plan for Individual
Psychodynamic Initial Phase of Treatment with Individual
Initial Phase Therapeutic Tasks
1. Develop working therapeutic relationship. Diversity note: [Describe how you will adjust to respect
cultured, gendered, and other styles of relationship building and emotional expression.]
a. Create a holding environment that includes contextual issues as well as client’s dynamics.
b. Work through client transference and monitor therapist countertransference.
2. Assess individual, systemic, and broader cultural dynamics. Diversity note: [Describe
how you will adjust assessment based on cultural, socioeconomic, sexual orientation, gender, and other
relevant norms.]
a. Identify self-object relation patterns, splitting, projective identification, repression, parental
interjects, and defense patterns.
b. Identify interlocking pathologies, transference with partner/family, ledger of entitlements and
indebtedness, and capacity for mature love.
3. Define and obtain client agreement on treatment goals. Diversity note: [Describe how you will modify
goals to correspond with values from the client’s cultural, religious, and other value systems.]
a. Work with client to identify goals that address presenting concerns and underlying personality
dynamics.
4. Identify needed referrals, crisis issues, collateral contacts, and other client needs. Note:
a. Referrals/resources/contacts: Make referrals and collateral contacts as appropriate.
Initial Phase Client Goal
1. Increase awareness of self-object patterns and reduce splitting, idealizing, or other defense strategies
to reduce depressed mood and anxiety.
a. Listen to and interpret for client self-object patterns and defense patterns related to depressed mood
and anxiety.
b. Identify one relationship/area of life in which the client can begin to work through the assessed
patterns.
Psychodynamic Working Phase of Treatment with Individual
Working Phase Therapeutic Tasks
1. Monitor quality of the working alliance. Diversity note: [Describe how you will attend to client
response to interventions that indicate therapist using expressions of emotion that are not consistent
with client’s cultural background.]
a. Assessment intervention: Continuously monitor relationship for transference and
countertransference; seek consultation/supervision as necessary.
2. Monitor client progress. Diversity note: [Describe how you will attend to cultural, gender, social class,
and other diversity elements when assessing progress.]
a. Assessment intervention: Monitor client progress based on ability to create an authentic relationship
with therapist and have more satisfying relationships outside of session.
Working Phase Client Goals
1. Decrease interactions based on projections and/or a revolving slate of entitlements to reduce
depressed mood/anxiety.
a. Offer interpretations of projection patterns and revolving slate issues to increase client awareness.
b. Use in session examples of transference to help client work through projection patterns.
2. Reduce influence of negative parental introjects to enable authentic relating to reduce hopelessness
and depressed mood.
a. Detriangulate to help client separate negative parental interjects from interpretations and
assumptions in current relationships.
b. Identify one to two relationships in which client can work through negative parental interjects.
3. Increase autonomy and ego-directed action by making unconscious processes conscious to reduce
depression and anxiety.
a. Eliciting to develop client motivation to work in productive directions in relationships.
b. Identify one to two relationships/areas of life in which client can work through dynamics increase
autonomy and goal-directed action.
Psychodynamic Closing Phase of Treatment with Individual
Closing Phase Therapeutic Tasks
1. Develop aftercare plan and maintain gains. Diversity note: [Describe how you will access resources in
the communities of which they are a part to support them after ending therapy.]
a. Identify strategies for managing entitlements and indebtedness as well as monitor use of defenses.
Closing Phase Client Goals
1. Increase capacity for intimacy and mature love without loss of self to reduce depression and anxiety.
a. Interpret defenses and projections that hinder capacity of mature love.
b. Identify one to two opportunities to work through issues that block capacity for intimacy.
2. Develop reciprocal commitments that include a fair balance of entitlements and indebtedness to
increase capacity for intimacy.
a. Identify legacies, loyalties, and revolving slate patterns that have imbalanced current relationships.
b. Examine the ledger of entitlements/indebtedness to identify more appropriate and balanced
calculations of what is due and what is owed.
Treatment Plan for Couple/fami ly Conflict
Psychodynamic Initial Phase of Treatment with Couple/Family
Initial Phase Therapeutic Tasks
1. Develop working therapeutic relationship. Diversity note: [Describe how you will adjust to respect
cultured, gendered, and other styles of relationship building and emotional expression.]
a. Create a holding environment for all members that includes contextual issues as well as client’s
dynamics.
b. Work through client transference and monitor therapist countertransference with each member of
the system.
2. Assess individual, systemic, and broader cultural dynamics. Diversity note: [Describe how you will
adjust assessment based on cultural, socioeconomic, sexual orientation, gender, and other relevant
norms.]
a. Identify each client’s self-object relation patterns, splitting, projective identification, repression,
parental interjects, and defense patterns.
b. Identify interlocking pathologies, transference within couple/family system, ledger of entitlements
and indebtedness, and each person’s capacity for mature love.
3. Define and obtain client agreement on treatment goals. Diversity note: [Describe how you will modify
goals to correspond with values from the client’s cultural, religious, and other value systems.]
a. Work with all members of system to identify goals that address presenting concerns and underlying
personality and relational dynamics.
4. Identify needed referrals, crisis issues, collateral contacts, and other client needs. Note:
a. Referrals/resources/contacts: Make referrals and collateral contacts as appropriate.
Initial Phase Client Goal
1. Increase awareness of self-object patterns and transference between couple/family members and
reduce splitting, idealizing, or other defense strategies to reduce conflict.
a. Listen to and interpret for client self-object patterns, transference within system, and defense
patterns related to conflict in couple/family.
b. Identify one aspect of relationship in which each person can take action to work through the
assessed patterns.
Psychodynamic Working Phase of Treatment with Couple/Family
Working Phase Therapeutic Tasks
1. Monitor quality of the working alliance. Diversity note: [Describe how you will attend to client
response to interventions that indicate therapist using expressions of emotion that are not consistent
with client’s cultural background.]
a. Assessment intervention: Continuously monitor relationship for transference and
countertransference, especially if therapist begins to take sides with one member; seek
consultation/supervision as necessary.
2. Monitor client progress. Diversity note: [Describe how you will attend to cultural, gender, social class,
and other diversity elements when assessing progress.]
a. Assessment intervention: Monitor couple/family progress based on ability to create an authentic
relationship with therapist and have more satisfying relationships outside of session.
Working Phase Client Goals
1. Decrease couple/family interactions based on projections and/or a revolving slate of entitlements to
reduce conflict.
a. Offer interpretations of projection patterns and revolving slate issues to increase each person’s
awareness of dynamics.
b. Use in session examples of transference both between members and with therapist to help clients
work through projection patterns.
2. Reduce influence of negative parental introjects to enable authentic relating to reduce hopelessness
and depressed mood.
a. Detriangulation to help client separate negative parental interjects from interpretations and
assumptions in current relationships.
b. Identify one to three relationships in which client can work through negative parental interjects.
3. Increase autonomy and ego-directed action by making unconscious processes conscious to reduce
conflict.
a. Eliciting to develop client motivation to work in productive directions in relationship.
b. Identify areas of relationship in which each member can work through dynamics increase autonomy
and goal-directed action.
Psychodynamic Closing Phase of Treatment with Couple/Family
Closing Phase Therapeutic Task
1. Develop aftercare plan and maintain gains. Diversity note: [Describe how you will access resources in
the communities of which they are a part to support them after ending therapy.]
a. Identify strategies for managing entitlements and indebtedness as well as monitor use of defenses.
Closing Phase Client Goals
1. Increase each member’s capacity for intimacy and mature love without loss of self to reduce conflict
and increase intimacy.
a. Interpret defenses and projections that hinder capacity of mature love.
b. Identify opportunities for each member to work through issues that block capacity for intimacy.
2. Develop reciprocal commitments that include a fair balance of entitlements and indebtedness to
increase capacity for intimacy.
a. Identify legacies, loyalties, and revolving slate patterns that have imbalanced current relationships.
b. Examine the ledger of entitlements/indebtedness to identify more appropriate and balanced
calculations of what is due and what is owed.
Tapestry Weaving: Working with Diverse Populations
Gender Diversity: The Women’s Project
Trained as social workers, Betty Carter, Olga Silverstein, Peggy Papp, and Marianne Walters (Walters et
al., 1988) joined together to promote a greater awareness of women’s issues in the field of family
therapy. They raised the issue of gender power dynamics within traditional families and identified how
family therapists were reinforcing stereotypes that were detrimental to women. In particular, they
explicated how the misuse of power and control in abusive and violent relationships made it impossible
for women to end or escape their victimization, a perspective that is now accepted by most therapists
and the public at large. They also asserted that therapists should be agents of social change, challenging
sexist attitudes and beliefs in families.
Walters et al. (1988) made several suggestions for how family therapists can reduce sexism in their work
with couples and families:
• Openly discuss the gender role expectations of each partner and parent and point out areas where the
couple or family hold beliefs that are unfair or unrealistic.
• Encourage women to take private time for themselves to avoid losing their individual identity to the
roles of wife and mother.
• Use the self-of-the-therapist to model an attitude of gender equality.
• Push men to take on equal responsibility both in family relationships and in the household, as well as
for scheduling therapy, attending therapy with children, and/or arranging for babysitting for couples
sessions.
Ethnicity and Culture Diversity
Apart from the work of the Women’s Project (Walters et al., 1988; see Women’s Project above), the
application of Bowen intergenerational and psychoanalytic therapies to diverse populations has not
been widely explored or studied. In general, these therapies are aimed at “thinking” or psychologically
minded clients (Friedman, 1991). Thus, minority groups who prefer action and concrete suggestions
from therapists may have difficulty with these approaches. However, the therapist’s stance as an expert
fits with the expectations of many immigrant and marginalized populations. The work of Bowen, Framo,
and Boszormenyi-Nagy that emphasizes the role of extended family members and intergenerational
patterns may be particularly useful with diverse clients whose cultural norms value the primacy of
extended family over the nuclear family system. In these families, it is expected that the nuclear family
subordinate their will to that of the larger family system. In addition, research on the concept of
differentiation of self provides initial support for its cross-cultural validity (Skowron, 2004).
In general, the greatest danger in using Bowenian or psychoanalytic therapies with diverse clients is that
the therapist will use inappropriate cultural norms to analyze family dynamics, thereby imposing a set of
values and beliefs that are at odds with the clients’ culture. For example, if a therapist, without
redirection, proceeds on the Bowenian premise that the nuclear family should be autonomous and
develops therapeutic goals to move an immigrant family in that direction, the therapist could put the
client in the difficult situation of being caught between the therapist’s goals and the extended family’s
expectations. Similarly, if the therapist assumes that attachment in all cultures looks the same, the client
may be inaccurately and unfairly evaluated, resulting in a therapy that is ineffective at best and
destructive at worst. Because these theories have highly developed systems of assessing “normal”
behavior, therapists must be mindful when working with clients who do not conform to common
cultural norms. The case study that concludes this chapter applies intergenerational therapy to a
Chinese immigrant couple in which the wife has had a recent onset of panic attacks.
Sexual Identity Diversity
Because the issue of a child’s sexual orientation and gender-identity has implications for the entire
family system, Bowenian therapists working gay, lesbian, bisexual, transgendered, and questioning
(GLBTQ) clients should pay particular attention to intergenerational relationships. One study found that
gay and lesbian parents lived closer to and received more support from their own parents (Koller, 2009).
In contrast, gays and lesbians who were not parents reported stronger connections with their friend
networks, sometimes referred to as families-of-choice (Koller, 2009). Thus, therapists should pay
particular attention to the role of these friendship relationships with GLBTQ clients. Another recent
study considered the effects of parental disapproval on lesbian relationships, which was found to have
both positive and negative effects on the relationship (Levy, 2011). The negative effects included
amount and quality of time spent as a couple, stress on the couple relationship, emotional impact on
couple, fear/uncertainty, communication problems, and sexual effects. The positive effects of parental
disapproval of the relationship included increased couple closeness, communication, patience, maturity,
and valuing of the relationship. In a study that compared three-generation genograms of heterosexual
and homosexual males found that overall there were more similarities than differences but that twice as
many parents of gay/lesbian children had significant marital issues and twice as many heterosexual men
had more distant relationships with their fathers than gay men (Feinberg & Bakeman, 1994).
Psychodynamic therapy has long been criticized for its pathologizing of same-sex attraction, and thus
psychodynamic family therapists working with gay and lesbian couples should consider using gay-af
rmative psychodynamic approaches (Rubinstein, 2003).
Rubinstein recommends that psychodynamic therapists working with GLBTQ clients consider a
multifaceted identity formation that includes, biological sex, gender identity, social sex-role, and sexual
orientation. He suggests that social sex-role confusion is often the most salient issue for gay and lesbian
clients, who often feel conflicted over conforming to culturally approved behaviors for maleness and
femaleness. In addition, psychoanalytic therapy can be used to help GLTBQ clients address their
internalized homophobia by exploring their personal meaning of being attracted to same-sex partners.
Research and the Evidence Base
The focus of research on Bowenian and psychoanalytic therapies has not been on outcome, as is
required to be labeled as empirically validated studies (Chapter 2); instead the focus of research has
been on the validity of the concepts. Miller, Anderson, and Keala (2004) provide an overview of the
research on the validity of the intergenerational theoretical constructs. They found that research
supports the relation between differentiation and (a) chronic anxiety, (b) marital satisfaction, and (c)
psychological distress. However, there was little support for Bowen’s assumption that people marry a
person with a similar level of differentiation or his theories on sibling position; his concept of
triangulation received partial empirical support.
Of particular interest to researchers is Bowen’s concept of differentiation of self, which has been the
focus of scores of research studies on topics such as client perceptions of the therapeutic alliance
(Lambert, 2008), adolescent risk-taking behaviors (Knauth, Skowron, & Escobar, 2006), parenting
outcomes in low-income urban families (Skowron, 2005), and adult well-being (Skowron, Holmes, &
Sabatelli, 2003). Lawson and Brossart (2003) conducted a study that predicted therapeutic alliance and
therapeutic outcome from the therapist’s relationship with his or her parents, providing support for the
Bowenian emphasis on the self-of-the-therapist. Another study considering a psychometric measure of
differentiation identifies two aspects of differentiation: a) affect regulation (the ability to regulate one’s
expressed mood), and b) the ability to negotiate interpersonal togetherness with separateness
(Jankowski & Hooper, 2012).
In regards to psychoanalytic family therapies, significant research has been conducted on the nature of
attachment in problem formation (Wood, 2002). The concept of attachment is also central to two
empirically supported family therapies: emotionally focused therapy (Chapter 11; Johnson, 2004) and
multidimensional therapy (Chapter 4; Liddle, Dakof, Parker, Diamond, Barrett, & Tejeda, 2001). Research
is needed on the outcomes and effectiveness of Bowen and psychoanalytic family therapies so that
these models can be refined and further developed.
References that may help
1) Goldenthal, P. (2005). Helping children and families: A new treatment model integrating
psychodynamic, behavioral, and contextual approaches (Chapters 1 and 2)
http://site.ebrary.com/lib/ncent/docDetail.action?docID=10114214%20
2) Fowers, B.J., & Wenger, A. (1997). Are trustworthiness and fairness enough? Contextual family
therapy and the good family.
http://search.proquest.com.proxy1.ncu.edu/docview/220973487?accountid=28180
3) Gangamma, R., Bartle-Haring, S., & Glebova, T. (2012). A study of Contextual Therapy Theory's
relational ethics in couples in therapy.
http://proxy1.ncu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ofs&AN=833
50076&site=eds-live
4) Mauldin, G.R., & Anderson, W.T. (1998). Forgiveness as an intervention in contextual family
therapy: Two case examples.
http://search.proquest.com.proxy1.ncu.edu/docview/212437232?accountid=28180
5) Carey, B. (2007). Ivan Boszormenyi-Nagy, 86, an Innovator of Family Therapy
http://www.lexisnexis.com.proxy1.ncu.edu/hottopics/lnacademic/?verb=sr&csi=8422&sr=lni(4
N1Y-S220-TW8F-G2BW)
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