Continued Evolution of Family Therapy - The Last Twenty Years

CONTINUED EVOLUTION OF FAMILY THERAPY: THE LAST TWENTY YEARS Florence W. Kaslow

ABSTRACT: There have been numerous accounts of the history and major trends and issues in family therapy during the field’s first three decades in the literature (see for example: Broderick & Shrader, 1981; Framo, 1972; Guerin, 1976; Kaslow, 1973, 1977, 1980; Nichols, 1986, 1999 for some varied depictions, written from each respective author’s unique lens). Viewed as a set, packaged with different, yet interrelated contents, they offer a multihued portrait of the emerging field during its infancy, childhood, and adolescence. Now it is time to move on and look at the adulthood era as it has unfolded. KEY WORDS: family therapy history; feminist therapy; brief therapy; managed care; integrative family therapy.

This article covers the less frequently chronicled last two decades. It is intended as an historic and analytic account that supplements and extends those that have appeared before. Previously, the periods in the histor history y of family family therap therapy y have have been been divide divided d into into four four genera generatio tions ns (Kaslow, 1990, Vol. 1 & 2), and amended over time (Kaslow, Kaslow, & Farber, 1999). I. II. III. IV.

Pioneers Pioneers and Renegades (Pre-1969) (Pre-1969) Innovators Innovators and Expanders Expanders (1969–1979) Challengers Challengers,, Refiners and Researcher Researcherss (1980–1989) Integrator Integratorss and Seekers Seekers of New Horizons Horizons (1990–1999).

Florence W. Kaslow, PhD, is Director of the Florida Couples and Family Institute, 128 Windward Drive, Palm Beach Gardens, FL 33418. She is a Visiting Professor of Psychology in Psychiatry at Duke University Medical Center, a Visiting Professor of Psychology chology at Florida Florida Institute of Technolog Technology, y, and President President of the American American Board Board of Family Psychology and President of the International Academy of Family Psychologists. Contemporary Family Therapy 22(4), December 2000 Human Sciences Press, Inc.

© 2000

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358 CONTEMPORARY FAMILY THERAPY

Here the focus is on the era of generations III and IV in the field and extended family of family therapists.

THE THIRD GENERATION: THE CHALLENGERS, REFINERS, RESEARCHERS: 1980–1989 The developments in the field of family therapy and the contributions of some of the main leaders will be alluded to as the major trends are highlighted. (It is recognized that it is not possible to include everyone one whos whose e work work has has been been publ publis ishe hed d and and apol apolog ogie iess are are exte extend nded ed to thos those e not mentioned.)

Ascendance of Feminist Family Therapy By the dawning of the 1980s, the feminist movement had exploded throughout America. Professional women had embraced its tenets and its rhetoric and were asserting their claim to equality in all domains. Feminist Feminist thinking thinking and therapy therapy catapulte catapulted d onto the family family therapy therapy scene, changing it irrevocably and permanently. The centrality of the role of the woman in the family was finally recognized as indisputable; women could no longer be expected to be subservient or non-assertive, and therapists who suggested that women assume a stereotypically prescribed female role were reprimanded, even ostracized. Clinicians were were chasti chastised sed and admoni admonishe shed d to be gender gender sensit sensitive ive and women women were were to be encouraged to expect equality in all spheres of their lives. Men had to accommodate as best they could to the needs and demands of women—becoming women—becoming more understand understanding, ing, sensitive, sensitive, and empathic, empathic, more apprec appreciat iative ive,, and more more availa available ble as father fatherss and husban husbands. ds. As a parall parallel el phenomenon, women moved into the leadership ranks in the field of family therapy and its organizations, consciously seeking to serve on editor editorial ial boards boards,, as office officers rs on boards boards of direct directors ors,, and on nation national al conference program committees. Whereas Virginia Satir was perhaps the only prominent woman in the first generation of family therapists to receive much recognition, others who were less acknowledged but who also made substantial contributi contributions ons include: include: Carolyn Carolyn Attneave Attneave (1990; (1990; Speck Speck & Attneave, Attneave, 1972); 1972); Margar Margaret et Thaler Thaler Singer Singer,, partic particula ularly rly for her yeoman yeoman work work in the arena of cults (1979, 1986, 1995); Kitty La Perriere (then at Ackerman Institute), Jeanette Kramer (1985) (Family Institute of Chicago); Sandra Coleman (1985); Bunny Duhl (1983); Rachel Hare Mustin (1978;

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1987); and Florence Kaslow (1981, 1982a, 1982b). These represented the burgeoning group of female leaders who had emerged during the first and second second generatio generation n eras. It was not until the third generation that the feminist influence coalesced and crescendoed. Those who led the way included the foursome in the Women’s Project: Betty Carter and Peggy Papp (1977, 1980, 1983); Olga Silverstein and Marianne Walters (1985; Walters, Carter, Papp, & Silverstein, 1988). They, along with Carol Anderson, Monica McGoldrick, and Froma Walsh (1991), as well as the women already mentioned, were all writing journal articles and books that have become definitive works on: genograms (McGoldrick & Gerson, 1985; Kaslow, 1995c); family life cycle (Carter & McGoldrick, 1980); ethnicity in families (McGoldrick, Pearce, & Giordano, 1982; McGoldrick, drick, Giorda Giordano, no, & Pearce Pearce,, 1996); 1996); normal normal familie familiess (Walsh (Walsh,, 1982); 1982); women in families (McGoldrick, Anderson, & Walsh, 1989); psychoeducation cational al techni technique quess in coping coping wit with h schizo schizophr phreni enia a and thefamily thefamily (Ander (Ander-son, Reiss, & Hogarty, 1986); and other topics. In the early 1980s they banded together to organize several gatherings of well-known female family therapists at Stonehedge, Massachusetts, and attempted to inculcate others with their agenda for leadership and influence in theory development and therapeutic practice. There was much anger against their male counterpar counterparts, ts, and this was articulate articulated d later in separate separate group consciousness raising sessions of men and women at American Family Family Therap Therapy y Academ Academy y (AFTA) (AFTA) confer conferenc ences es and later later at some some AmeriAmerican Psychological Association Division 43 meetings. However, these latter sessions never took on the same intensity or acrimony as some of those at AFTA. The Journal of Feminist Family Therapy was launched in 1988 with Lois Braverman as its first editor and most of the leading women in the field field on its editor editorial ial board. board. Evan Evan ImberImber-Bla Black ck became became well well known known for her work on secrets and rituals, along with Janine Roberts (ImberBlack, Roberts, & Whiting, 1988) and on ghosts in the therapy room (1993). Like La Perriere, Hare-Mustin, Walsh, and Anderson, ImberBlack has served as a president of AFTA. Other feminists, all based at Ackerman Institute, who have become noteworthy are Gillian Walker, particularly, for her work with AIDS patients, Virginia Goldner (1985, 1993), 1993), Peggy Peggy Penn (1985), and Marsha Marsha Sheinberg Sheinberg (1992). (See also Goldner, Penn, Sheinberg, & Walker, 1990.) The publication of Feminist Family Therapy: A Casebook (Goodrich, Rampage, Ellman, & Halstead, 1988) marked another crest in the series of waves bringing feminist family therapy to the forefront,


as this volume presented the utilization and applicability of feminist therapy in actual cases. Two books by Harriet Lerner, The Dance of Anger (1985) and The Dance of Intimacy (1989), exhorted women to be more outspoken about their feelings and more forceful and courageous in acting assertively to change the nature of their intimate and important relationships. Lerner’s books appeal to a popular as well as a profes professio sional nal audien audience, ce, and have have been been instru instrumen mental tal in influe influenci ncing ng thouthousands of women who read and grappled with their contents. By the end of the 1980s it was absolutely clear that the needs and voices of women could no longer be discounted in therapy, in marriage, or in the political or workaday worlds.

Identification of Post Traumatic Stress Disorder Another significant trend was, and still is, the concern for families with a member suffering from post traumatic stress disorder (PTSD) or syndrome (PTSS). Charles Figley has been among the front ranks of those identifying and calling attention to this phenomenon (1985; 1986; 1989; Figley & Erickson, 1990). Initially much of the concern emanated from dealing with those veterans of the Vietnam War who were experiencing such symptoms as amnesia, terrifying flashbacks, nightmares, and seemingly unprecipitated bouts of rage. Clearly military service in war zones, whether in Korea, Vietnam, Afghanistan, or the Persian Gulf caused psychological scarring to many troopers (Kaslow, (Kaslow, 1993; Keane, 1998). Since PTSD was first designated designated and defined as a separate syndrome, this concept has been extended to being an often utilized utilized diagnosis diagnosis for those those suffering suffering from having been physically physically and sexually sexually abused (Guyer, (Guyer, 1999), and for some who have developed dissociative identity disorders (Koedam, 1996) subsequent to sexual abuse and other traumas, as well as for victims of incest (Trepper & Barrett, 1989; Kirschner, Kirschner, & Rappaport, 1993). Clinicians treating survivors of the holocaust and other genocidal events and eras also see syndromes resembling PTSD in the survivors and their descendants. Work by therapists concerned with the longrange range sequel sequelae ae of the Nazi Nazi holoca holocaust ust in Europe Europe in the 1940s 1940s also also entere entered d the family therapy mainstream in the 1980s and 1990s (Charny, 1982, 1996; Danieli, 1985, 1988; Davidson, 1980; F. Kaslow, 1995a, 1997a, 1999; 1999; Sichro Sichrovsk vsky, y, 1988). 1988). Also, Also, as immigr immigrant antss who fled fled repres repressiv sive e politi politi-cal regimes in some countries in Latin America, the former Yugoslavia, Iraq, Iran, and Somalia that engage in brutal murders and savage torture have relocated to other countries, therapists in many regions


of the world have been treating severely traumatized patient families and finding finding they present present with perplexing perplexing and complex complex symptomat symptomatology ology and deep personal pathology. These therapists are seeking guidance on how how to inte interv rven ene e to help help peop people le recu recupe pera rate te from from the the scar scarss of mass massiv ive, e, continuous psychic treachery and traumatization. During During a lectur lecture e tour tour in Sw Swede eden n (May (May 1997) 1997) when when the author author talkedon talkedon treati treating ng couple coupless and famili families es presen presentin ting g wit with h severe severe proble problems ms and dysfunctional interactive patterns (Kaslow, 1996b), the burning question that arose in each of the three cities visited was, “How do you treat families where one or several members have witnessed the atrocities of warfare on their streets, been subjected to rape and beatings, been imprisoned in horrendous jails, been kidnapped, starved, and/or had loved ones killed before their eyes”? An adaptation of a combination of ideas drawn from the literature on understanding and treating both holocaust survivors and those suffering from PTSD became the foundation for the discussions and recommendations. Given the number of stressors that impinge on therapists treating severely traumatized, deprived, multi-problem, and dysfunctional populations, ulations, as well as litigious litigious clients, some clinicians clinicians develop severe burnout (Freudenberger, 1983, 1984), or what Figley has identified as “compassion fatigue”—a specific form of burnout that is one of the high costs of caring. It partially emanates from shadow stress, the work stress stress people people carry carry home home wit with h them. them. Figley Figley,, (1995, (1995, 1997); 1997); Kaslow Kaslow (1984); and others like Kilburg and VandenBos (Kilburg, Kaslow, & VandenBos, 1988) have all talked and written about professionals in distress, and healing of the healers who experience secondary trauma.

Advent of New Theories and Methodologies Methodologies Several Several additional additional theories theories and/or and/or intervent intervention ion approaches approaches became became prominent during this decade.

Psychoeducational Psychoeducational strategies. This approa approach ch moved moved to the foreforefront, particularly for use in enabling families to cope better with a member with a schizophrenia spectrum disorder (see for example Anderson, Reiss, & Hogarty, 1986; Falloon, Boyd, & McGill, 1984; McFarlane, 1983). Families and many therapists came to favor this approach over more traditional family therapy interventions since psychoeducational methods, particularly when conducted in groups, are associated with wit h family family membe members rs feelin feeling g less less blamed blamed and critic criticize ized d for the proble problem. m. Rather, families perceive that they are receiving support and empathic


responses responses and that they are being viewed as cooperatin cooperating g with patient and therapist to understand and handle the illness more effectively and to gain control over their own style of expressing emotions and how to communicate more clearly (Leff & Vaughn, 1985).

Brief therapy. Brief therapy also gained many adherents during this era, and the leaders promulgating this methodology ascended into prominence. At the vanguard in the family therapy arena have been Steve de Shazer (1985, 1988) and Insoo Kim Berg (Berg & de Shazer, 1993), of the Milwaukee Family Institute, who have focused on rapidly findin finding g a solution solution to the proble problem m being being presen presented ted.. They They have develo developed ped catchy interventions like asking “the miracle question,” which others can quickl quickly y learn learn to do. Those Those practi practicin cing g brief, brief, soluti solutionon-foc focuse used d therap therapy y are not interested in diagnosis or formal assessment, in developing self-awareness, or in any personality reconstruction. Their sole aim is problem resolution. With the advent of managed care since the late 1980s and its accompanying cost containment policies, insurance companies have favored such brief approaches and helped them gain in popularity because of their reimbursability. Functional family therapy (FFT). This behaviorally behaviorally based and structured approach to treating families with a delinquent or oppositionally defiant adolescent, also came into its own (Alexander & Parsons, sons, 1982; 1982; Alexan Alexander der & Barton Barton,, 1990). 1990). It has become become a well-r well-rese esearc arched hed and documented treatment methodology (Alexander & Barton, 1995; Alexander & Pugh, 1996). FFT “has been designated one of two Family Based Empirically Supported Treatments (FBESTS) that are effective and reproducibl reproducible e with families representing representing a wide range of cultures, cultures, ethnicities, rural and urban living contexts, . . . socio-economic levels, and primary languages (Fraenkel, 1999, p. 35). Integrative approaches. approaches. Integra Integrativ tive e approa approache chess also also began began to have have great appeal in the 1980s as more and more practitioners and theoreticians spoke out against doctrinaire leaders and schools of thought that held that their approach was either the only right one, or certainly the best of all possible ones. Among the integrationists are Larry Feldman (1992); Alan Gurman (1981, 1990; Gurman & Kniskern (1981, 1991); F. Kaslow (1981, 1987a); Diana and Sam Kirschner (1986); William Nichols (1986, 1988a,b, 1999); William Pinsof (1990, 1998); and Carlos Sluzki (1983). Those of this persuasion believe that the treatment approach proach should be select selected ed judici judicious ously ly based based on such such factor factorss as the


patient’s problems and symptomatology, personality, resiliency, family dynamics and issues, and time they are willing and able to devote to therapy. Whether one’s own interpretations of the situation to oneself as well as one’s assessment assessment and treatment treatment techniques techniques are drawn drawn concurrently from several approaches or sequentially, depending on how the therapy unfolds, all concur that one should have a variety of viable alternatives in one’s treatment armamentarium to be chosen wisely and flexibly when most appropriate.

Rising Divorce and Remarriage Rates During this period, as the number of divorces and remarriages contin continued ued their their upward upward spiral spiral,, the litera literatur ture e on this this vast vast topic topic expanded. More and more therapists found themselves treating families pre, during, and post divorce. Constance Ahrons wrote about the coparental divorce and the binuclear family, and developed a typology of divorced couples (1979, 1983; Ahrons and Rodgers, 1987). Craig Everett, ett, who who beca became me the the seco second nd edit editor or of the the Journal of Divorce (now Divorce and Remarriage Remarriage) founded in the 1970s by Esther Fisher, has made this a major focus of much of his writing (Everett & Volgy, 1993). Florence Kaslow has written about a seven-stage model of divorce, elaborating on the legal and economic facets as well as the parenting and visitation issues (Kaslow & Schwartz, 1987; Kaslow, 1994, 1995b; Schwartz & Kaslow, Kaslow, 1997), 1997), and promulgate promulgated d a divorce divorce ceremony ceremony (1993). Judith Wallerstein and Joan Kelly wrote about surviving the breakup (1980), and Wallerstein later reported on men, women, and children a decade after divorce (Wallerstein & Blakeslee, 1989). Hetherington and her associates associates have conducted conducted significant significant research research into divorce divorce and its aftermath aftermath (Hetherin (Hetherington gton,, Bridges, Bridges, & Isabella, Isabella, 1998; Hethering Hetherington, ton, Cox, & Cox, 1997). The fledgling field of divorce mediation burgeoned in the 1980s and presen presented ted couple coupless pursui pursuing ng divorc divorce e wit with h a viable viable and more more humane humane alternative route than an adversarial proceeding. Mediation provides marital and family therapists who are seeing couples in the throes of marital dissolution with the option of suggesting mediation instead of litigation, litigation, and recommen recommending ding this pathway, pathway, which is usually usually more constructive and more compatible compatible with such therapeutic goals as maximizing client self determination and being considerate of the needs of all family members affected by the decisions. The literature on mediation also proliferated during this era and was written by professionals drawn from the mental health disciplines as well as from law. (See for


example Erickson & Erickson, 1988; Folberg & Milne, 1988; Haynes, 1981). Clifford Sager’s work on marriage contracts (1976) looked at contracting prior to marriage; his illuminating ideas were extended in a later volume on treating the remarriage family (Sager et al., 1983). Emily Emily and John John Visher Visher (1979, (1979, 1991) 1991) also also have have made made a substa substanti ntial al contribution to the understanding of the dynamics and treatment of stepfamilies, and were the co-founders of the Stepfamily Association of Americ America. a. F. Kaslow Kaslow has writte written n about about psycho psychosoc social ial prenup prenuptia tiall agreeagreements as a prelude to marriage and remarriage (1991, 2000b) and has developed a therapeutic remarriage ritual (1998). Others like James Bray have been conducting conducting research on developmen developmental tal issues in stepfami famili lies es (Bra (Bray y & Berg Berger er,, 1993 1993). ). Roni Roni Berg Berger er (199 (1999) 9) has has evol evolve ved d a clas classi si-fication schema of stepfamilies. Thus, there are now many extant resources for academicians, researchers and clinicians working in the areas of divorce and remarriage.

Multicultural Multicultural and Ethnic Diversity As the tried and true American philosophy heralding this being a melting-pot country began to be eroded by groups not wanting to give up and ultima ultimatel tely y lose lose their their earlie earlierr nation national al identi identity, ty, and as more more respect was demanded for each person’s ethnicity and cultural roots, family theory and practice reflected the emerging concern that multicultural cultural pluralism pluralism become become a dominant dominant value—superceding value—superceding the homogehomogenization process. McGoldrick, Pearce, and Giordano’s book, Ethnicity McGoldrick, Giordano, & Pearce, 1996) has and Family Therapy (1982; McGoldrick, become a standard text. Others who have contributed to the growing awareness of ethnic and cultural diversity, the reverberations of political repression, and the need to be respectful of these differences and not to obfuscate them are: Carlos Sluzki (1990); Lillian Comas-Diaz (1992, 1996); F. Kaslow (1982b, 1997b); and Nadine Kaslow (Kaslow, Celano, & Dreelin, 1995; Celano & Kaslow (in press). Celia Falicov (1983, 1988, 1995) has done yeoman work in promoting the importance of cultural sensitivity and in increasing the awareness of the dynamics, values, and traditions of Latino families. Similarly, larly, Nancy Nancy Boyd-F Boyd-Fran rankli klin n has been been one of the premie premierr standa standard rd bearers bearers in heightenin heightening g sensitivity sensitivity to the concerns concerns of African African Americans Americans in therapy, in their families, and in the larger community (1989, 1995). Kenneth Hardy has also made a significant contribution to consciousness raising about life as experienced by African Americans, and ad-


dresse dressess the contin continuin uing g legacy legacy of slaver slavery y many many genera generatio tions ns later later (Hardy (Hardy,, 1989; Saba, Karrer & Hardy, 1989). In addition, he has addressed the concerns of minority therapists in training and treatment. Likewise, Terry Tafoya (1989) has helped rally interest in the circumstances of the lives of Native Americans and the issues they present in family therap therapy. y. Man Keung Keung Ho (1987) (1987);; Deral Derald d Wing Wing Sue and David David Sue (1990) (1990);; and Berg (Berg & Joya, 1993), among others, have highlighted the strengths, attitudes, and values of Asian Americans, particularly as these are manifested in treatment.

The Expansion of Family Systems Medicine and Its Impact Another major happening has been the mushrooming of family systems medicine—with increasing numbers of family therapists now working working in tandem tandem with physicians physicians in hospitals, hospitals, medical schools, and physicians’ physicians’ offices. offices. It is a collabora collaborative tive model in which co-equals co-equals from diffe differe rent nt fiel fields ds team team up in the the trea treatm tmen entt of the the vari variou ouss fami family ly memb member erss to enhance their own understanding of patient needs and provide optimal health care interventions for emotional and physical problems. Prime Prime movers movers have have been been Donald Donald Bloch Bloch (1988) (1988),, first first editor editor of the journa journal, l, Family Systems Medicine (1983); (1983); Susan Susan McDani McDaniel el (McDan (McDaniel iel & de Gruy, 1996), current editor of this journal; Sylvia Shellenberger, Jeri Hepworth, Hepworth, and William William Doherty Doherty (McDaniel (McDaniel,, Hepworth, Hepworth, & Doherty, Doherty, 1995; Doherty & Baird (1983, 1987); John Rolland (1984, 1994); Anne Kazak (Kazak & Simms, 1996)) and Betsy Wood (1991). This group has its own annual conference, and their work is also featured prominently in presentations at conferences of other organizations such as the American Association for Marriage and Family Therapy (AAMFT), AFTA, and APA. A similar development has occurred in Israel where Cynthia Carel has blazed the path for medical family therapy. This trend is increasing in scope, with therapists participating actively in primary care teams with family practitioners, pediatricians, cardiologists, gists, obstet obstetric rician ians, s, and other other specia specialis lists; ts; it is likely likely to contin continue ue accele accelerrating.

Mounting Concern Over Professional Identity In the more political arena of the field concerns over licensure, profes professio sional nal identi identity, ty, and status status issues issues escala escalated ted.. As more more states states passed marriage marriage and family family therapy therapy licensure/ licensure/cert certifica ification tion laws, spearspearheaded headed by state state AAMFT AAMFT chapte chapters rs and suppor supported ted by the nation national al organi organi--


zation, that might be either scope of practice or title protection acts, they also set the academic requirement level at the masters degree. (Currently AAMFT has about 23,000 members; AFTA numbers about 1,000, and there is some overlap.) Many family oriented psychologists and psychiatrists, who concurred with the criteria of both APAs (the American Psychological Association and the American Psychiatric Association) that the basic level for independent practice should be a doctor doctoral al degree degree,, became became disgru disgruntl ntled, ed, partic particula ularly rly when when they they found found they they were ineligible because their specific training was different than that required for marriage and family therapy licensure. Another source of conste consterna rnatio tion n was that that some some marria marriage ge and family family therap therapist ists, s, not trained rigorously in psychological test administration and interpretation, still wanted testing to fall within their scope of practice. Turf battles ensued; some took sides while others straddled the fence and maintained two licenses. This dilemma continues. At the opposite end of the spectrum, others pressed for inclusion of indigenous indigenous therapists therapists on treatmen treatmentt teams, teams, stressing stressing that shared shared values and demographic factors between therapists and patients are essential and overshadow the emphasis on academic background. Such a positi position on runs runs contra contrary ry to the push push for creden credentia tialin ling g based based on object objective ive education and training requirements, while coinciding with the voices of those who press for non-hierarchical treatment models and eschew the belief that the therapist should have a carefully carefully honed knowledge knowledge and skills base. For these and other reasons, the American Academy of Psychologists in Marriage, Family and Sex Therapy, a group with a history of severa severall decade decades, s, decide decided d to mount mount a campai campaign gn to become become a forma formall division of the American Psychological Association. In 1985 it achieved this status as the Division of Family Psychology (Division 43). The division not only provided family psychologists with a home base in APA, but also saw that part of its mission was, and remains, to inculcate systemic thinking and awareness of multi-patient units (i.e., couples and families) into APA (F. Kaslow, 1987b). A representative list of those who have served as division president include James Alexander, Arthur Bodin, James Bray, Gary Brooks, Florence Kaslow, Ronald Levant Levant,, Susan Susan McDan McDaniel iel,, and Carol Carol Philpo Philpot—all t—all of whom whom have have contri contribbuted a great deal to both the family psychology and family therapy literature, as well as to the growing body of research-based materials. About 2000 family psychologists currently belong to Division 43. Journal of Family Family Psycholog Psychology y was launched under In 1987 the Journal Division Division 43 auspices. auspices. Several Several years years later it became an official official APA


journal. Howard Liddle Liddl e served as its first editor, Ronald Levant as its second, and Ross Parke as its third. The journal’s circulation figures place it among the most widely read of the family journals that are primarily research oriented. Also during the 1980s, the American Board of Family Psychology (ABFamP) began its diplomating process and has achieved growing recognition. ABFamP became one of the boards under the long existing American Board of Professional Psychology (ABPP), which added credibility bility to family family psycholo psychology gy as a specia specialty lty.. There There are three steps to becoming becoming board board certified, certified, a rigorous rigorous credential credentialss review review process; process; submissubmission and review of two work samples—one in family assessment and diagnosis, the other in treatment intervention; and a 3-1/2 hour oral examination with a committee of three diplomates. As of May 2000 there were approximately 115 board certified family psychologists in the United States. Concurrently, many family psychologists have remained involved in AAMFT and AFTA and some are licensed as both psychologists and family therapists and are AAMFT approved supervisors. They also are on the editorial boards of such interdisciplinary journals as Journal of Marital and Family Therapy, Family Process, The American Journal of Family Family Therapy, Therapy, Contempo Contemporary rary Family Family Therapy, Therapy, and Journal Journal of Family Psychotherapy.

THE FOURTH GENERATION: INTEGRATORS AND SEEKERS OF NEW HORIZONS: 1990–1999

Enter Managed Care and Its Emphasis on Brief Therapies A major upheaval beset all mental health practice, including family therapy, with the advent of managed care. Although this phenomenon had started in the 1980s, the full impact of this onslaught was not felt until until the early early 1990s.Vario 1990s.Various us organi organizat zation ionss have have scramb scrambled led to advoca advocate te for inclusion of their members as professionals eligible for reimbursement. Fees have been driven downward downward and many therapists therapists have faced decreased decreased incomes incomes while feeling pressured pressured to see many more patients for shorter therapy sessions in order for their practices to survive. Some practitioners banded together to form group practices. Other more senior therapists have opted to continue to cater to the fee-for-service market only and not to cut fees; if they have achieved


fine reputations and have vast referral networks, they have fared well. By the end of the last century, an increasing number of clinicians were so dissatisfied with drastic limits on number of sessions and severe reductions in fees that they resigned from the panels of providers. This has had an effect on the quality of service available to people with limited financial resources in under-served geographic locales. Since a major thrust of the managed health care industry is “cost containment,” third party payers have a decided preference for brief and thus less costly therapies. They are loathe to reimburse for longer term psychodynamic psychodynamic or intergene intergeneratio rational nal therapies; therapies; their goals are rapid restoration of functioning and solving the presenting problem as quickly as possible. Thus, approaches like de Shazer’s (1985, 1988) and Berg’s (Berg & de Shazer, 1993) solution focused brief therapy model used for individual and family problems have gained popularity. Many patients like talk of miracles and the probability of needing only a few sessions; they do not want to delve into their families of origin and rehash old issues in order to feel better in the here and now. Behavioral Behavioral marital and family family therapies therapies (Budman & Gurman, Gurman, 1988; Wood & Jacobson, 1990; Jacobson & Gurman, 1986), like brief therapies, also garnered new adherents as these time limited, problem focused, clear and structured modalities lend themselves to managed care constraints and reporting specifications. Cognitive behavioral approaches also are receiving more attention (Baucom, 1990; Baucom, Epstein, & Rankin, 1995; Dattilio & Padesky, 1990; Seligman, 1991) as many therapists now prefer focusing on changing cognitions as well as behaviors. Not surprisingly, some cognitive behaviorists have become more integrative and include the other component of the triad, affects or feelings. This has emerged as the approach with the most empirical data supportive of its efficacy.

Other Therapeutic Modalities of Increasing “Popularity” Another methodology that came to play a dominant role in the therapeutic world during the 1990s encompasses the externalization and narrative techniques of Michael White (1989), and David Epston (White & Epston, 1990) from Australia. These pied-piperish pioneers have spread their approach to having everyone tell their story, listen to each others’ versions, and then become actively involved in changing the direction the narrative will take, i.e., geared to helping patients feel empowered to proactively participate in shaping their future—a goal shared with many other approaches. The appeal of the narrative school school lies not only in its brevity brevity,, but in the drama drama and optimism optimism


inhere inherent nt in the approa approach ch (Sluz (Sluzki, ki, 1992). 1992). O’Hanl O’Hanlon on Hudson Hudson and Hudson Hudson-O’Hanlon promulgated their own variation of the restorying theme in their volume, Rewriting Love Stories (1991). Social constructionism also has come to occupy a prominent place in the theoretical and therapeutic array of choices. Inherently an antidiagnostic, anti-labeling paradigm, like the narrative approach, it focuses on the use of language in communication and how people construct struct their their own meanin meanings gs for their their person personal al realit realities ies and relati relations onship hipss through language. Therapy occurs through the meaning that emerges in the dialogue and the language of the session; the therapist and family co-construct the meanings to be attached to events and relationships. This is essentially a non-hierarchical model that eschews the role of the therapist as either conductor, coach, or expert. Instead the client/consumer is an equal participant in determining what will transpire and evolve. Leaders in formulating and promulgating this approach proach have have been been Harry Harry Goolish Goolishian ian and Harlen Harlene e Anders Anderson on (1990) (1990),, Tom Andersen (1990, 1996), Kenneth Gergen (Gergen & Davis, 1985), and Lynn Lynn Hoffm Hoffman an (Gerg (Gergen,Hoffm en,Hoffman, an, & Anders Andersen, en, 1996); 1996); all are persua persuasiv sive e writers and speakers, and they have found adherents, particularly in the more non-conformist, non-traditional wings of the profession. Other Other notewo noteworth rthy y method methodolo ologie giess that that have have achiev achieved ed some some popula popularrity in this era are Imago Therapy (Hendricks, 1992), Eye Movement Desensitization and Reprocessing (EMDR) (Greenwald, 1994; Shapiro, 1994), 1994), and various various hypnother hypnotherapy apy approaches approaches (Hudson-O (Hudson-O’Han ’Hanlon, lon, 1987; Lankton Lankton & Lankton, Lankton, 1989; Zeig, 1985a, 1985b). All of these fall under the rubric of brief therapies. Besides the new entries in the realm of therapeutic approaches, there have been some other shifts in the field in this decade, and different different attitudes attitudes and values values have come to the fore. The voices voices of the third and fourth generation have grown more forceful; sometimes they are very innovative, other times they build upon and crystallize ideas already expressed. For example, as discussed earlier, feminist family ther therap apy y bega began n in the late late 1970 1970ss and and cres creste ted d in the the 1980 1980s. s. It has has beco become me a gene genera rall lly y acce accept pted ed part part of the the fiel field, d, whic which h now now has has many many more more fema female le members and leaders than was the case during the first two decades of the evolution of family therapy.

The Men’s Movement Evolves In response to the original havoc wreaked by the feminist movement ment and and the the ince incess ssan antt dema demand nd it made made on men men to chan change ge in reac reacti tivi vity ty,, responsively and responsibly, a serious men’s movement evolved. Rob-


ert Bly, a poet, was the founder of the mythopoetic movement that stressed the importance of men nurturing men (Erkel, 1990). Men’s groups groups formed formed in which which the men men sought sought accept acceptanc ance e and friend friendshi ship p from from each other, and many bemoaned the lack of emotional involvement of their fathers during their childhood years. Some gatherings occurred to the accompan accompanime iment nt of tom-to tom-tom m beats beats and men men began began to expres expresss their fears, fears, their needs, needs, and their dreams. dreams. Well-know Well-known n therapist therapist Frank Frank Pittman (1990) wrote about the masculine mystique and the longing for fathers to endow sons with masculinity, and about the endeavor to unders understan tand d what what mascu masculin linityis ityis and encomp encompass asses. es. At meeti meetingsof ngsof AFTA AFTA and the APA Practice Divisions’ Mid-Winter conferences, special sessions for male therapists only were held. There and elsewhere, men of the current generation of fathers, therapists and non-therapists alike, vowed to be more emotionally accessible, especially to their sons. The Family Therapy Networker (1990) devoted the major portion of a full issue to this topic—highlighting and extending its significance. In the mid-19 mid-1990s 90s,, initia initiated ted by such such men as Ronald Ronald Levant Levant (Levan (Levantt & Kopeck Kopecky, y, 1995; Levant & Pollack, Pollack, 1995), Gary Brooks Brooks (1995) (1995) and Don-David Don-David Lusterman (Philpot, Brooks, Lusterman & Nutt, 1997), a new division for the study of men and masculinity masculinity was begun in APA—Division APA—Division 52. Probab Probably ly the newest newest mass mass variat variation ion on the men’s men’s moveme movement nt theme theme The Promise Keepers, a recently formed has been the rapid evolution of The organi organizat zation ion that that suppos supposedl edly y number numberss more more than than a millio million n men assert assert-ing their manhood. A headline on Time Magazine’s cover raised the query,“Shou query,“Should ld they they be cheere cheered—or d—or feared feared?” ?” around around the time time the millio million n man march on Washington occurred (Stodhill, 1997). A fervent Christian movement, led by a former college football coach, Bill McCartney, the positive goal is for men to assume greater responsibility for themselves, their wives, and their children. Two of the aspects that are frightening to many outside of the movement are: (1) they believe that when men and women disagree, the man’s view and decision must prevail as he is ultimately in charge of the family, and this is perceived as God’s will; and (2) members view homosexuality as a sin and not acceptable in God’s eyes or theirs. Although many Promise Keepers claim their wives welcome their taking a stronger role in the family, feminists and others—men and women alike—decry turning the clock back to glorify the male dominant/female submissive role relationship of men and women and the censuring of homosexuality as sinful. Certainly tainly this this gigant gigantic ic and seemin seemingly gly fundam fundament entali alist st segmen segmentt of the men’s men’s movement will change the dynamics of many families, hopefully without promoting spouse abuse and corporal punishment of children as


the husband/fa husband/father ther attempts attempts to reassert reassert his “authorit “authority.” y.” Therapists Therapists will do well to be mindful of the principles and precepts of the Promise Keepers when treating men/couples who adhere to these, and to find ways to communica communicate te with them effect effectively ively as they chant chant their particu particu-lar catechism.

Bridging the Gender Gap At the same time the men’s movement was ascending in popularity, othe others rs felt felt it was was time time to brid bridge ge the the gend gender er gap gap and and the the sepa separa rate te gend gender er worlds, and became concerned instead with having men and women communicate and interact more cordially and meaningfully with each other (Philpot, (Philpot, 1990; Philpot, Philpot, Brooks, Brooks, Lusterman Lusterman,, & Nutt, Nutt, 1997). 1997). These author authorss and others others are purpor purportin ting g that that all therap therapy y and therap therapist istss should be gender sensitive, that those of both genders can and should co-evo co-evolve lve,, and that that violen violence ce in male-f male-fema emale le relati relations onship hips, s, in all settin settings gs and across the age spectrum, is not acceptable in any form. No doubt we will continue to see some who harken more to the feminist mission, sion, others others who contin continue ue to beat beat the masculin masculinity ity tom-to tom-tom, m, and a third corps of professionals who believe it is time for rapprochement to occu occur. r. Tw Two o of the the most most sens sensit itiv ive e book bookss on help helpin ing g coup couple less fost foster er more more loving, empathic, and intimate relationships as they bridge the gender Fragile Bond (Napier, Sexual Crucible Crucible gap are The Fragile (Napier, 1988) and The Sexual (Schnarch, 1991).

Emphasis on the Necessity of Solid Research and Evaluation The interest in both qualitative qualitative and quantitati quantitative ve research research has mounted and AFTA, AAMFT, and the Division of Family Psychology of APA have all held conferences devoted to family research during this this decade decade.. Journa Journals ls such such as JMFT, JFP, and and Family Process all devote devote a great great deal deal of space space to resear researchch-bas based ed articl articles. es. Highli Highlight ghtingthe ingthe greate greaterr importance importance being placed placed on research, research, partially partially because because third party payers want documentation regarding which approach works best and fastest for which problems, and data on psychotherapy efficacy and JMFT concentrated outcomes, an oversized issue of JMFT concentrated on this topic (Pinsof & Wynne Wynne,, 1995). 1995). Others Others,, includ including ing Paulin Pauline e Boss Boss (1990) (1990),, Fred Fred Pie Piercy rcy and Dougla Douglass Sprenk Sprenkle le (1986) (1986),, James James Alexan Alexander der and Cole Cole Barton Barton (1995) (1995),, Nadine Kaslow (Kaslow, Wood, & Loundy, 1998b), Anne Kazak (Kazek & Simms, Simms, 1996), 1996), Howard Howard Liddle, Liddle, Jose Szapocznik Szapocznik (Szapocz (Szapocznik, nik, Rio, Perez-Vidal, Kurtines, Herves, & Santisteban, 1986), David Reiss


(1981, 1988), and Luciano L’Abate and Dennis Bagarrozi (1993) also continue to conduct research in numerous areas of endeavor.

Utilization of Testing and Assessment Instruments New assessment instruments have been developed and refined, such as the Marital Satisfaction Inventory (Snyder, 1990; Snyder, Cavell, Heffer, & Mangrum, 1995) and the Family Assessment Device (FAD) (Epstein, Baldwin, & Bishop, 1983). These are being utilized more widely as diagnostic diagnostic and screening screening tools, and because because clients derive meaning from participating directly in the assessment process. Nurse’s Nurse’s recent recent book (1999) (1999) on family family assessment assessment describes describes the effective effective uses of personalit personality y tests tests with couples and families, families, thus anchoring anchoring assessment assessment in more objectively-de objectively-derive rived d data than clinical clinical interview interview techniques techniques alone can provide. provide. Terry Patterson’s Patterson’s Couple and Family Clinical Documentation Sourcebook (1999) brings together a panoply of the questionnaires and assessment instruments used in acquiring information about patients, including their self and partner perceptions. These devices are extremely valuable aids for those who believe sound treatment is predicated on thoughtful diagnosis.

Development of Relational Diagnoses The press press for a taxono taxonomy my of relati relationa onall diagno diagnosis sis also also creste crested d during during the past past twodecades twodecades (Wynn (Wynne, e, 1984, 1984, 1987) 1987) and was punctu punctuate ated d emphat emphatiically by the inclusion of the Global Assessment of Relational Functioning (GARF) scale in the Diagnostic and Statistical Manual of Mental Disorders-IV (Wynne, (Wynne, 1994). Some of the work work of members members of the Coalition tion on Family Family Diagno Diagnosis sis,, an intero interorga rganiz nizati ationa onall task task force force in existe existence nce from 1987–1994, was pulled together in the Handbook of Relational Diagnosis and Dysfunctional Dysfunctional Family Patterns (Kaslow, 1996) and supplemented by pertinent chapters especially written for this classification schema by non-task force members. It is hoped this work will continue in the forthcoming decade and eventuate in a separate Diagnostic Manual of Relational Disorders which will be a supplement to the existing DSM of Mental Disorders—separate and equal (American Psychiatric Association, 1994).

Interest in Long-Term Successful Marriages Perhaps as a reaction to all of the sadness and disillusionment many therapists hear about from patients during and after divorce, some clinicians clinicians and researchers researchers turned turned their attention attention to studying studying


couples married more than 20 years who deem their marriages satisfying and succes successfu sful. l. Numero Numerous us articl articles, es, publis published hed by resear researche chers rs collab collab-orating in an eight-country study that spanned five continents, found respondents identified remarkably similar factors as the basis of their marita maritall satisf satisfact action ion,, includ including ing trust trust and respec respectt in all areas areas of the relationship, shared goals and values, strong commitment to the partner and to the marriage as a special entity, the continuing ability to have have fun togeth together, er, much much affect affection ion and ongoin ongoing g sexual sexual activi activity, ty, recipr reciprococity and mutuality, consideration and the ability to compromise, and deep friendship (Kaslow & Hammerschmidt, 1992; Kaslow & Robison, 1996; 1996; Sharli Sharlin, n, 1996; 1996; Roizbl Roizblatt att et al., al., 1999; 1999; Sharli Sharlin, n, Kaslow Kaslow & Hammer Hammer-schmidt, 2000). Wallerstein and Blakeslee (1995) also sought to ascertain how and why love lasts. One goal of all of these researchers has been to generate a profile of the ingredients and kinds of interactions that are conducive to creating satisfying long-term partnerships that can be utilized to help guide unhappy couples toward finding greater satisfaction and harmony.

Miscellaneous Trends We have also witnessed increasing emphasis on certain content areas, i.e., syndromes, symptoms, and specific maladies. These include chronic illness (Barth, 1993), suicidology (N. Kaslow, Thompson et al., 1998a) 1998a),, depres depressio sion n (N. Kaslow Kaslow,, Ash, Ash, & Deeri Deering, ng, 1996), 1996), ADHD ADHD (Culbe (Culbertrtson & Silovsky, 1996), eating disorders (Levine, 1996), and AIDS (Landau-Stanton & Clements, 1993). Some of these disorders are treated by therapists involved in the area variously designated family systems medicine, medical family therapy, and behavioral medicine discussed earlier. Other therapists see them in their private individual or group practices. Another trend has been the evolution of outreach approaches, including at home therapy. These practical team approaches are being utilized increasingly with severely distressed inner city populations. For example, the Philadelphia Child Guidance Clinic, part of the Children’s Hospital and the Department of Psychiatry at the University of Pennsylvania in the 1990s, served a patient population largely comprised of multi-problem, hard to reach, inner city families and reached into into their their homes homes and commun communiti ities es to do so (Lindb (Lindblad lad-Go -Goldb ldberg erg,, Dore, Dore, & Stern, Ste rn, 1998). 1998). This This well well respec respected ted traini training ng center center has both both an APA approv approved ed intern internshi ship p and an AAMFT AAMFT accred accredite ited d traini training ng progra program—one m—one of the few facilities in the country to have both. Similar outreach programs have evolved in other countries, like Israel, for utilization with


their large, chaotic, often newly arrived immigrant families (Sharlin & Shamai, 1999).

The Focus on Values Other luminaries are diligently pursuing the issue of values (Doherty, 1989) in family therapy (Doherty & Boss, 1995). They posit that therapists’ values, their cherished beliefs and preferences, play a role in treatment and should be acknowledged, where relevant. One should not superimpose his or her own ideology on families without revealing what that ideology is. In addition, they hold that therapists should engage in dialogue with clients about their “moral choices” when these are pertinent to the issues and dilemmas they are confronting in therapy. Doherty Doherty and Boss (1995) tackle critically critically a bevy of deceptions deceptions that characterize some family therapy methods, particularly strategic models and paradoxical interventions that often are utilized in very manipu manipulat lative ive ways. ways. They They attest attest that that such such decept deception ionss erode erode the “found “foundaation tionss of trus trustt that that clie client ntss . . . hold hold for for fami family ly ther therap apy” y” (p. (p. 621) 621).. We agre agree e that inauthentic interactions should be avoided, not only because they impede the formation of a strong therapeutic alliance, but also because it is almost impossible to help patients become more trustworthy, candid, and accountable when we are not modeling exemplary behaviors. Two decades ago Abroms (1978) wrote a thoughtful article on The Place of Values in Psychotherapy. He indi indica cate ted d that that we are are incr increa easi sing ngly ly confronting the myths of the amoral stance and of the value neutrality of the therapists. He admonished therapists to recognize their biases and learn to use these in a discip disciplin lined, ed, rational rational way in caring caring for patients. For example, he stated that “parents should be the executives in the family,” or “it is healthy for adolescents to individuate” are value statements and opinions and need to be honestly posited as such in the therapy. It is interesting to ponder why this area of concern is resurfacing at this time with much more momentum.

Mounting Ethical and Legal Concerns Other therapists have become increasingly concerned about legal and ethical dilemmas in marital and family therapy practice (Gottlieb, 1995, 1997; Gottlieb & Cooper, 1990; F. Kaslow, 1992, 1996a; Marsh & Magee, 1997; Woody, 1990). The AAMFT Code of Ethics (1988) details standards of behavior related to:


• Responsibility

to clients • Confidentiality • Professional competence and integrity • Responsibility to students, employees, and supervisees • Responsibility to research participants • Responsibility to the profession • Financial arrangements • Advertising. The most recent revision of the APA Code of Ethical Principles of Psychologists and Code of Conduct (1992) is more elaborate and complex and goes into greater detail regarding such dilemmas as: • Multiple

relationships one’s competence and maintaining expertise • Sexual harassment • Delegation to and supervision of subordinates • Informed consent • Maintenance of records. • Exceeding

In addition, guidelines are provided regarding what is considered ethical behavior behavior in numerous numerous other realms realms of profession professional al practice. practice. The spiral spiraling ing concer concerns ns about about therap therapist istss being being brough broughtt up on ethics ethics or malpractice charges have made many therapists more cautious regard gardin ing g whom whom they they are are will willin ing g to trea treat. t. The The larg large e ment mental al heal health th prof profes es-sional organization organizationss now often employ employ in-house in-house legal counsel with whom members can consult, and have worked with insurance companies nies to develo develop p approp appropria riate te liabil liability ity insura insurance nce progra programs. ms. These These signs signs of our times reflect our feelings of vulnerability, the decrease in therapist freedom, the increase in patients’ power, and the creation of external bodies, beyond professional organizations, which rule on professional standards of conduct.

Internationalization Internationalization of Family Therapy The number of international conferences have skyrocketed in the last 20 years. The International Family Therapy Association (IFTA) was born in Czechoslovakia at the East-West Bridging Conference in Prague in 1987. The International Academy of Family Psychologists (IAFP) was launched in 1990 in Japan. Both AFTA and EFTA (the European Family Therapy Association) have international members.


All promote exchange of theoretical ideas and clinical approaches, and foster appreciation of multi-cultural issues and diversity (Ariel, 1999), An increasing number of books on family therapy around the world have been published (Kaslow, 1982; Gielen & Comunian, 1997, 1999) and numerous journal issues have been devoted to family therapy in specific countries (particularly in Contemporary Family Therapy ). It is predicted that this globalization will continue to pick up momentum in the 21st century century and, despite despite some theoretic theoretical al clashes clashes and ethnocenethnocentrism, will enrich us all.

SUMMARY It becomes apparent that the leaders in the past two decades have shared shared many many traits traits wit with h the pionee pioneers rs of the first first two genera generatio tions—the ns—they y are innova innovativ tive, e, courag courageou eous, s, bright bright to brilli brilliant ant,, often often charis charismat matic, ic, deterdetermined to be heard and seen, committed to their ideas and interpretations tions and eager eager to promul promulgat gate e them, them, and often often have have therequisit therequisite e narcis narcis-sism to be “on stage” and to occupy front and center position. They are articulate, emanate strength and power, write well, think clearly, and are wil willin ling g to buck buck the prevai prevailin ling g tide. tide. They They have have kept kept the field field dynami dynamic, c, lively, multifaceted and on a perpetual pathway to finding better techniques and solutions to enable individuals and families to become happier and more functional. Today, leaders from all four generations are active active and interactive—reflec interactive—reflecting ting the tensions tensions and affection affectionss of the multigenerational and tribe-like families we treat. As this article, which attempts to highlight the trends of the past 20 years,the years,the contri contribut bution ionss of keyleaders keyleaders and thinke thinkers, rs, and develo developme pment nt of various organizations, is drawn to a close, it is reiterated that it has not been possible to be all inclusive, and apologies are expressed to anyone inadvertently omitted. This author has tried to be as objective and broad based as her own professional lens permits. Others will no doubt doubt chroni chronicle cle the field field differ different ently, ly, again again reflec reflectin ting g its patchw patchwork ork quilt quilt style—col style—colorf orful, ul, divers diverse, e, and varieg variegate ated. d. May it contin continue ue to be so during during this new millennium.

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