Bowen Family Systems Theory

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timer Asked: Aug 13th, 2014

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Can you please let me know as soon as possible if you can help with this assignment by later today after looking at the attachment Bowen Family Systems Theory?  A paper and creating a genogram are required.  I asked another tutor an and she accepted it last Wednesday and still not response from her.  I even gave her 4 days complete and even extended it a day for her but she is not responding except to tell me see had problems with her electric that is why I extended for her for a day.  It was due last Sunday and I will lose points every day it is last.  So could you please help complete this today so I can submit later today. There was a huge lack of communication on the other tutors part. Bowen Family Systems Theory.docx  Chapter 7 Week 4.docx  References for Chapter 7.docx  Book, Articles, and Websites.docx


Bowen Family Systems Theory Bowen Family Systems Theory provides a detailed set of concepts that are commonly assessed through family interviews, often in conjunction with the creation of a genogram. For this assignment, write a case analysis of your own family of origin using a Bowen approach. Leave out or disguise information you do not wish to share. Use the following outline for your analysis: 1. Create a genogram of your family of origin, using the correct format. Use one or more of these resources to assist in the creation of your genogram: •Genogram Software (Genogram Analytics) http://www.genogramanalytics.com/examples_genograms.html (this is Windows and Mac OS compatible) •Genogram Software (Wingeno) http://www.wingeno.org/download.html (this is Windows and Mac OS compatible) •Genogram Software (Genopro) http://www.genopro.com/genogram/ (this is Windows compatible but NOT Mac OS compatible – SINCE SOME OF OUR PROFESSORS USE MAC COMPUTERS, IF THIS SOFTWARE IS USED YOU WILL NEED TO SAVE THE FILE AS A PDF AND SUBMIT THAT FILE) Depict at least three generations (more if you wish to) including you, your parents, and your grandparents (as well as aunts, uncles and cousins as applicable to complete the assignment). Include information on cultural factors such as race, ethnicity, religion, and social class and demographic information such as age, geographic location of residence, jobs held, etc. You will also include information about the quality of relationships (including divorces, extra-marital affairs, etc.), any mental health or addiction issues, any applicable medical concerns or any other information you wish to include. 2. Based on this genogram, begin your paper by giving a brief overview of the major experiences and patterns of interaction for your family. How do diversity issues affect the family dynamics? 3. Write a description of your family in terms of the major concepts of the Bowen approach. This is not a family history but rather a description that emphasizes an analysis of relationships from a Bowenian perspective. Briefly define the concept and then provide an example from your family of origin. •Triangles/Triangulation •Differentiation of Self •Nuclear Family Emotional System •Family Projection Process •Multigenerational Transmission Process •Emotional Cutoff •Sibling Position •Societal Emotional Process 4. Identify and briefly discuss a problem in the family using Bowen theory. This “problem” should involve you directly, it should be real, meaningful, not too big, and something that you are willing to share. Develop a specific intervention plan for this problem based on the Bowenian approach. Make this a very practical, small intervention. You may or may not choose to try it. In Bowenian terms, describe how you think it would affect the dynamics of your family if you did implement this intervention. Include a treatment plan based on information from the Gehart (2014) text. Length: paper needs to be 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 for Chapter 7 Ackerman, N. W. (1956). Interlocking pathology in family relationships. In S. Rado & B. G. Daniels (Eds.), Changing conceptions of psychoanalytic medicine (pp. 135–150). New York: Grune & Stratton. Ackerman, N. W. (1958). The psychodynamics of family life. New York: Basic Books. Ackerman, N. W. (1966). Treating the troubled family. New York: Basic Books. Boszormenyi-Nagy, I., & Framo, J. L. (1965/1985). Intensive family therapy: Theoretical and practical aspects. New York: Brunner/Mazel. Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between give and take: A clinical guide to contextual therapy. New York: Brunner/Mazel. Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry 7, 345–374. Bowen, M. (1972). Being and becoming a family therapist. In A. Ferber, M. Mendelsohn, & A. Napier (Eds.), The book of family therapy. New York: Science House. Bowen, M. (1976). Theory in practice of psychotherapy. In P. J. Guerin (Ed.), Family therapy: Theory and practice. New York: Gardner Press. Bowen, M. (1985). Family therapy in clinical practice. New York: Jason Aronson. Carter, B., & McGoldrick, M. (1999). The expanded family life cycle: Individual, family, and social perspectives (3rd ed.). Boston: Allyn & Bacon. Feinberg, J., & Bakeman, R. (1994). Sexual orientation and three generational family patterns in a clinical sample of heterosexual and homosexual men. Journal of Gay & Lesbian Psychotherapy, 2(2), 65–76. doi:10.1300/J236v02n02_04 Framo, J. L. (1976). Family of origin as a therapeutic resource for adults in marital and family therapy: You can and should go home again. Family Process 15(2), 193–210. Framo, J. L. (1992). Family-of-origin therapy: An intergenerational approach. New York: Brunner/Mazel. Friedman, E. H. (1991). Bowen theory and therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (vol. 2, pp. 134–170). Philadelphia: Brunner/ Mazel. Guerin, P. J., Fogarty, T. F., Fay, L. F., & Kautto, J. G. (1996). Working with relationship triangles: The one-two-three of psychotherapy. New York: Guilford. Hardy, K. V., & Laszloffy, T. A. (1995). The cultural genogram: Key to training culturally competent family therapists. Journal of Marital and Family Therapy, 21, 227–237. Jankowski, P. J., & Hooper, L. M. (2012). Differentiation of self: A validation study of the Bowen theory construct. Couple and Family Psychology: Research and Practice, doi:10.1037/a0027469 Johnson, S. M. (2004). The practice of emotionally focused marital therapy: Creating connection (2nd ed.). New York: Brunner/Routledge. Kerr, M., & Bowen, M. (1988). Family evaluation. New York: Norton. Knauth, D. G., Skowron, E. A., & Escobar, M. (2006). Effect of differentiation of self on adolescent risk behavior. Nursing Research, 55, 336–345. Koller, J. (2009). A study on gay and lesbian intergenerational relationships: A test of the solidarity model. Dissertation Abstracts International Section A, 70, 1032. Kuehl, B. P. (1995). The solution-oriented genogram: A collaborative approach. Journal of Marital and Family Therapy, 21, 239–250. Lambert, J. (2008). Relationship of differentiation of self to adult clients’ perceptions of the alliance in brief family therapy. Psychotherapy Research, 18, 160–166. Lawson, D. M., & Brossart, D. F. (2003). Link among therapist and parent relationship, working alliance, and therapy outcome. Psychotherapy Research, 13, 383–394. Levy, A. (2011). The effect of parental homo-negativity on the lesbian couple. Dissertation Abstracts International, 71, 5132. Licht, C., & Chabot, D. (2006). The Chabot Emotional Differentiation Scale: A theoretically and psychometrically sound instrument for measuring Bowen’s intrapsychic aspect of differentiation. Journal of Marital and Family Therapy, 32(2), 167–180. Liddle, H. A., Dakof, G. A., Parker, K., Diamond, G. S., Barrett, K., & Tejeda, M. (2001). Multidimensional family therapy for adolescent drug abuse: Results of a randomized clinical trial. American Journal of Drug and Alcohol Abuse, 27, 651–688. McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and intervention (3rd ed.). New York: Norton. Miller, R. B., Anderson, S., & Keala, D. K. (2004). Is Bowen theory valid? A review of basic research. Journal of Marital and Family Therapy, 30, 453–466. Rubalcava, L. A., & Waldman, K. M. (2004). Working with intercultural couples: An intersubjective-constructivist perspective. Progress in Self Psychology, 20, 127–149. Rubinstein, G. (2003). Does psychoanalysis really mean oppression? Harnessing psychodynamic approaches to affirmative therapy with gay men. American Journal of Psychotherapy, 57(2), 206–218. Scharff, D., & Scharff, J. (1987). Object relations family therapy. New York: Aronson. Schnarch, D. M. (1991). Constructing the sexual crucible: An integration of sexual and marital therapy. New York: Norton. Schnarch, D. M. (1998). Passionate marriage: Keeping love and intimacy alive in committed relationships. New York: Holt. Skowron, E. A. (2004). Differentiation of self, personal adjustment, problem solving, and ethnic group belonging among persons of color. Journal of Counseling and Develop- ment, 82, 447–456. Skowron, E. A. (2005). Parental differentiation of self and child competence in low-income urban families. Journal of Counseling Psychology, 52, 337–346. Skowron, E. A., Holmes, S. E., & Sabatelli, R. M. (2003). Deconstructing differentiation: Self regulation, interdependent relating, and well-being in adulthood. Contemporary Family Therapy, 25, 111–129. Walters, M., Carter, B., Papp, P., & Silverstein, O. (1988). The invisible web: Gender patterns in family relationships. New York: Guilford. Wood, B. L. (2002). Attachment and family systems (Special issue). Family Process, 41.
Book Gehart, D. R. (2014) Mastering competencies in family therapy Articles Bowen, M. (1967). The anonymous paper. http://www.bowentheory.com/anonymouspaperpg252bowen.htm Butler, J. F. (2008). The family diagram and genogram: Comparisons and contrasts. http://proxy1.ncu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=345 03500&site=ehost-live Charles, R. (2001). Is there any empirical support for Bowen's concepts of differentiation of self, triangulation, and fusion? http://proxy1.ncu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=532 3148&site=ehost-live Markowitz, L.M. (1994). Shared passages: Shared passages. http://search.proquest.com.proxy1.ncu.edu/docview/233305040?accountid=28180 McGoldrick, M. (1994). The ache for home: The ache for home. http://search.proquest.com.proxy1.ncu.edu/docview/233313157?accountid=28180 Theoretical Base for Differentiation of Self in One’s Family of Origin. http://www.bowentheory.com/theoreticalbasekerr.htm Websites Bowen Theory http://www.thebowencenter.org/pages/theory.html View Website Information about the model Genogram Software and Guided Tour. GenoPro http://www.genopro.com/genogram/ Standard Symbols for Genograms, The Multicultural Family Institute http://multiculturalfamily.org/wpcontent/uploads/wp-checkout/downloads/ExplainingGenogramsPlus.pdf The Family Systems Institute http://www.familysystemstraining.com/ View Website and articles of interest

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