SPECIAL ARTICLE Developments in Family Systems Theory and Research LEE COMBRINCK-GRAHAM, M.D .

Abstract. Contemporary family systems theory and therapy complement child and adolescent psychiatrists' interests in advocating for children. This paper reviews major developments in the family systems field which can be valuable contributions to child and adolescent psychiatry and mental health . Advances in therapy with difficult clinical populations are summarized. Theoretical frameworks and applications in the areas of human development and the family life cycle, family assessment, and family systems therapy are described . J . Am. Acad. Child Adolesc. Psychiatry, 1990, 29,4:501-512. Key Words: family systems, systems approach, biopsychosocial systems, family therapy with children. Every child psychiatrist knows that children need families and that family relationships are critical to children's successful navigation of childhood and adolescence . This paper will review developm ents in the family systems field that might be particularl y useful to child and adolescent psychiatrists, lending contextual technology to the study of human development and to the assessment of the ever important family in the child's life and, most of all, providing a rich array of approaches to therapy with children and adolescents and the systems in which they live.

Family therapy is a large and diverse field . For some , "family therapist " is a professional identity , while others maintain their primary identities as psychologists, social workers, psychiatri sts, and pastoral counselors. For this latter group, being a family therapist usually means having chosen to practice one' s profession as a therapist through working with a relationship system , believing that the relationship system is crucial to developing and maintaining dysfunctional and uncomfort able behaviors and feelings, and that this system is also essential to recovery and healing. The varieties of family therapy practice and family systems theory range from those derived directly from psychoanalysis (psychodynamic family therapy of Ackerman and followers, Bowen systems therapy , contextual therapy of Boszormen yi-Nagy , and object relations therapy); to those primarily centered around expressiveness and communications (Satir's conjoint therapy , symbolic-experiential therapy of Whitaker); to those focused on organization (structural family therapy of Minuchin); and to those derived from the ecosystems models of Bateson and the hypnotic practices of Milton Erickson (strategic family therapy of Haley and the Palo Alto Group and systemic family therapies of the Milan group). Each of these "schools" of family therapy has been a nucleus for elaboration , revision, and change . In keeping with the experimental nature of early family therapy, family therapy and family research were united in the 1950s (Wynne, 1983). In the mid-1970s , Gurman and Kniskern (1978) did a metanalysis of psychotherapy outcome studies showing that marital and family therapies were equal to or more effective than individually based treatments. But the demands of researching multiper son , open systems have posed more complex challenges to research methodology (Alexander and Barton , 1980; Wynne, 1988a), and postmodernist thinking has fueled a debate between " ecosystemic" theorists, who remind researchers that all data are shaped by the context in which the research is performed (Colapinto, 1979), and those who believe that existing research methodology, including multifactorial analyses, is adequate to the task (Gurman, 1983). A review of the field of family therapy must necessarily be limited, and this review is intended to convey the excitement and opportunities for child and adolescent psy-

Famil y Systems through Therapy Family systems theory first derived from family therapy. Since Nathan Ackerman began involving the families of his child patients in sessions in the mid-1930s , the field of family therapy has evolved from an adjunctive modality to a mental health specialty with its own philosophical and theoretical underpinning s. At first, family therapy was an experiment. In the radical environmentalism, post-World War II, many psychologi sts and psychiatrists strove to comprehend the multiple influences on human behavior and human adjustment. This is the common background of the biopsychosocial approach , the "systemic" approach , or family systems theory. What would happen , therapists wondered, iffamily members were seen together? This practice opened whole new avenues of treatment and made treatment possible for populations who had previously not been seen as candidates for psychotherapy. Now family therapy is a more recursive process, therapy yielding theory which informs therapy, and so on. Therapy has been the most important stimulus to the evolution of family systems theory .

Accepted August 7, 1989. Dr. Combrinck-Graham is Director, Institutefo r Juvenile Research, and Director, Division of Child and Adolescent Psychiatry, University of Illinois at Chicago. Request reprints from Dr . Combrinck-Graham , Institute f or Juvenile Research, 907 S. Wolcott Avenue, Chicago, IL 60612. 0890-8567/90/2904-050 1$02.OO/O© 1990by the American Academy of Child and Adolescent Psychiatry.

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chiatry offered by movements in the family systems field. The paper is organized into five parts. Family therapy with young children is briefly outlined in the first part. Part two is an overview of the frameworks for understanding human development, and part three covers progress in family assessment. The fourth part reviews accomplishments and promising frameworks for managing difficult clinical populations. Finally, part five reports on some exciting, new developments in family systems therapy .

Family Therapy with Young Children Although family therapy began with children, most of the energy in the family systems field has been devoted to treating couples or families with adolescent or young adult offspring and, recently, with dependent elderly parents. Children have been relatively neglected, as Zilbach (1986) discovered when she searched the literature for references to family treatment with young children . Psychodynamic Approaches

Beginning with Ackerman, one line of family therapists who work with young children concentrates on psychodynamics. Recent literature in this area is from Zilbach (1986) and Scharff and Scharff (1987). Zilbach emphasizes the important contributions of young children to thematic content and timing of emotional events . Scharff and Scharff recount how, by providing a therapeutic holding environment and through the use of transference , countertransference, and interpretation, they assist families to unravel the nexus of the past, so that they can function as effective containers of the complex emotions of their members . This process allows the family to confront and work through emotional entanglements and projective identifications and to master developmental stress. Some of the Scharffs' ideas about development are discussed below. Structural Approaches

Another line of work with children derives from Minu- chin' s structural approach (Minuchin, 1974; Minuchin and Fishman, 1981); in which family organization is viewed as crucial to the experience of individuals in the family . Boundary, defined both logically as distinctions between classes or categories and physically as a barrier to exchange of material, energy , or information (Wood , 1986), is an important concept in structural family therapy . In families, boundaries are the conceptual markers of differentiation between individuals and subsystems representing the family's management of both roles and proximity. Some forms of childhood difficulties are associated with enmeshment, diffuse boundaries characterized by lack of role clarity and overinvolvement, and others are associated with disengagement, where boundaries separate individuals in the family too rigidly. In healthy families, the parent-child boundary marks the differentiation of parent and child functions, preserving functional family hierarchy, and separating the marital/parental subsystem from the child system. Structural family therapists assist families to achieve a more functional organization. 502

Strategic Approaches

A third application to children has evolved out of the strategic school and is described by Madanes (1984). A child's symptoms are understood as metaphors about the family's situation. Through enactments in which family members pretend to be in the relationships metaphorically represented by the symptoms, the family's repertoire of interactions is expanded , increasing flexibility and adaptation. For example , one aspect of Madanes's treatment of a mother and young daughter with poorly controlled diabetes involved the pair enacting their caring for one another . The mother's adult responsibility for the daughter's diabetic management was represented by having her wear a nurse's hat and pretend to be a nurse while administering the child's insulin, while the daughter's caring for the mother was enacted by the child donning a nurse's hat and pretending to nurse the mother. Through playing out these themes, the mother's and daughter's competence was differentiated, and the child's diabetes came under control. Madanes 's work underscores the contributions of children to the solutions reached by the family. The Child in the Family

All of these approaches involve work primarily with whole families, including the children's contributions to the families' experience of wholeness as important elements of the therapy . Children's difficulties are conceptualized as functional within the family system, and problem resolution is directed through changing the family emotional atmosphere (as in object relations therapy), family organization and structure (as in structural family therapy) , or increasing the avenues for managing relationships (as in strategic family therapy). Family therapists who work with young children firmly believe that children 's difficulties are not necessarily caused by families. But most regard families as the primary healing environment , and they respect the special energy of children's contributions to change in the whole family (Wachtel, 1987; Chasin and White, 1989). Children may be seen individually or in sibling groups, but this work is usually aimed at assisting families, particularly the parents, to help the children through their difficulties. Involvement of family members , even young siblings, in a child's treatment can produce remarkable change, as Lewis (1986) describes when, after one visit with a group of siblings who had been placed in different foster homes, the regressed and near psychotic state of one of the younger ones dramatically improved.

Developmental Frameworks for Family Therapy Family systems theorists have explored several aspects of development in relational systems, including how systems evolve, the individual in interaction with significant others, and the elaboration of models of the family life cycle. Developmental Change in Systems

A few theorists have tackled the question of how life cycle changes actually occur within families. Terkelson (1980) proposed that the elements of family structure are l.Am.Acad. Child Adolesc, Psychiatry, 29:4, luly 1990

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first rearranged at a "first order" level (i.e., by increments of adaptation and mastery achieved by one member of the family) followed by a "second order" change (i.e., the transformations of status and meaning within the system as it adjusts to the first order change). These transformations, or second order changes, may appear to evolve continuously or, as Hoffman (1980) has proposed, appear as discontinuous leaps in the nature of family organization. Breunlin (1988) proposed that systems are always oscillating between states and that development occurs through oscillations between states of greater and lesser competence, with oscillations widening during "developmental transitions" and finally settling on an integrated level of functioning at a higher level. Haley's (1973) popular idea that many families unravel during developmental transitions is explained by Breunlin's theory that it is at these times that the family experiences the widest variations in the level of functioning of its members, testing its ability to accomodate as a system. The Individual and Significant Others Infant psychiatry and developmental psychology have included a relational component in descriptions of developmental process. Descriptions of dyadic processes studied in mother-child relationships recognize reciprocity and recursion in the unfolding of behaviors of both mother and infant, leading to the development of a rich data base on the important relationship between the child and primary caretaker. How the mother-infant relationship is shaped by relationships with others, however, is a study which requires a special framework for including such relational information as patterns of triadic functioning as well as the influence of larger sociocultural patterns on focal relationships (Minuchin, 1985). The Child in Relational Systems Longitudinal studies of marital functioning and the relationship between marital functioning and parenting around the birth of the first child have been performed by several researchers. Lewis (1988 a.b) proposed an epigenetic model of family development built on the structure of marital interaction. He confirmed that the stability of marital competence through the events of the first child's birth and the first year was variable, depending upon the structure of the marital system prior to the birth. Lewis's data suggest that the impact of the inclusion of a third member of the family cannot be evaluated solely on the basis of the marital dyad. Another group (Krepner et al., 1982) studied changes in the family environment when a second child is born, expanding the nexus of relationships from a triad to a tetrad. They describe the formation of an autonomous sibling relationchild, ship, in addition to dyads of each parent with and the couple's relationship, a total of six dyads. These studies of the impact of adding new members to the family demonstrate that family formation and development are probably not a straightforward epigenetic process built upon rules established in the marital system. The introduction of new individuals requires the establishment of new structures, new tasks, and many new relationships. Scharff and Scharff's (1987) model of family develop-

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ment, from an object relations perspective, addresses new information and perceptual and structural opportunities available when a child enters the family. They propose that the marital couple's "invention" of the family incorporates each partner's experience in the family of origin as well as encounters in other relational spheres, both historical and contemporary. The infant "reinvents the family" through his emotional experiences with each parent and with the parental dyad. Thus, the Scharffs propose, the infant's object world includes not only individual object relations, e.g., mother and father, but also an emotional percept of motherfather. The valence of these objects is determined, once again, by the couple's invention of the family as well as the blending of contemporary experiences and adjustments in the family's emotional atmosphere. The Family Life Cycle Over the past 20 years, various models of the family life cycle have been defined in order to conceptualize the processes of reciprocity between the organization and evolution of the system and its individuals. Life cycle models have several different areas of emphasis: stages of evolution, changing emotional processes, and changing dimensions of family relatedness. Sociologists, such as Duvall (1962), were among the first to articulate stages of family life, and these, at first, were conceptualized as a series of family stages which correlated with stages in an individual's development. Carter and McGoldrick (1980, 1988) put forth six stages: (1) single young adults leaving home; (2) the joining of families through marriage; (3) families with young children; (4) families with adolescents; (5) launching children and moving on; and (6) families in later life (1988, p. 15). Carter and McGoldrick also designated critical emotional issues for the family at different stages. For example, for their stage 3, the critical, emotional issue for the family is "accepting new members into the system." For stage 4, the issue is "increasing flexibility of family boundaries to include children's independence and grandparents' frailities" (1988, p. 15). These stages provide a clinical guide to the usual preoccupations of family members in different stages of the life cycle. Moving from stages defined by individuals to stages defined by relational development, Wynne (1988 b) proposed an epigenetic model of relational processes in the family. He suggested that individuals develop relational complexity in the family context in an orderly sequence, as follows: (1) attachment-caregiving; (2) communicating; (3) joint problem solving; (4) mutuality; and, sometimes, (5) intimacy (p. 85). Zilbach (1986, 1989) defined stages using the family's own history, rather than that of its individual members, as markers for the stages. She proposed seven stages: I and II-forming and nesting; III, IV, and V-family separation processes, beginning when the first family member participates in an extrafamilial system (e.g., a child attending school) and ending when the first family member actually exits from the nuclear family; and VI and VII-late stages, the first defined by the exit of the last dependent family 503

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member, the second defined by the death of one of the spouses. These stages are marked by movement of individuals into and out of the family system and they define characteristic issues for the family, regardless of the developmental concerns of the individuals. For example , families in stage I have similar issues, whether it is a first marriage or a remarriage. This scheme focuses on fundamental family tasks rather than the individual's development motifs. Combrinck-Graham (1985, 1988) devised a Family Life Spiral model which depicts overlapping developmental issues at three generational levels (such as grandparenthood and retirement, childbearing and birth , or midlife reevaluation). The author observed that different relational processes seemed to characterize the developmental issues of each generation simultaneously and proposed that, instead of an epigenetic unfolding of relational processes (such as Wynne's model) , there was an oscillation from periods of closeness, favoring intimate experiences , to periods of differentiation, favoring individuation. A child's early life would ideally occur in a centripetal family atmosphere, emphasizing caretaking and nurturing , while adolescence would occur in a centrifugal one, emphasizing the individuality and the increasing autonomy of all family members. Each of these life cycle models offers a conceptual framework for assessing family functioning and clinical problems, because each describes critical tasks, emotional issues , relational processes, and internal family environments for each stage. As the different family life cycle models are examined, many child and adolescent problems manifest themselves in characteristic periods of the life cycle and appear to be particularly aggravated by and aggravating to family preoccupations. The family issue of "leaving home" is an example of a major adolescent and young adult problem (Haley, 1980). Problems such as separation anxiety and elective mutism appear to be related to families who should be launching their dependents (in Zilbach's model) or increasing the flexibility of family boundaries (Carter and McGoldrick's emotional process of transition). Anorexia nervosa is commonly associated with failure of the family to assume the centrifugal shape that is powered by the differentiation associated with increased personal autonomy of family members (in Combrinck-Graham's model).

Family Assessment The goal of family systems assessment is to examine psychological phenomena in context: how they are generated, what their origins are, and what maintains them. Assessment approaches include the clinical process of assessment (e.g., diagnosing), the definition of dimensions of family functioning, and the construction of typologies . Diagnosing

Regardless of its origins, psychopathology is expressed in contexts . Individuals , therefore , look different in different patterned contexts. This is why child psychiatrists evaluate children in individual, family, school, and peer contexts . In the clinical assessment of a family, the therapist searches for patterns that characterize system interaction around the 504

problem areas and describes the patterns, according to the frameworks within which she organizes data and in a way that uses family themes in a metaphor common to both therapist and family system. Diagnosing literally means knowing all through the system , examining the possible meanings or relevant patterns of interest at different levels of the system , and integrating them into a meaningful understanding of the whole (Combrinck-Graham, 1987). Dimensions of Family Functioning

Authors of assessment frameworks have divided family functioning into a few basic dimensions: structure, communication, adaptability, cohesion, problem solving, and emotional tone. The group led by David Reiss has named three qualitatively different dimensions: configuration, coordination, and closure (Reiss, 1981, 1982; Reiss and Olivieri, 1983; Olivieri and Reiss , 1984). In their attempts to operationalize family dimensions, different groups have defined them differently. Variation among those occupied with developing family assessment instruments may be related to what sorts of families they intend to study . (Forman and Hagan, 1984). The BeaversTimberlawn model (Beavers et al., 1972), for example, was developed in order to identify those characteristics that differentiated nonclinical families from families of disturbed adolescents. Samples of family interaction are rated on a scale assessing the dimensions of adaptability and cohesion. The scale shows a strong relationship to the level of clinical functioning (Beavers and Voeller, 1983). A self-report version of their instrument was also developed (Hampson and Beavers, 1987). Another instrument, Olson's Circumplex Model of family functioning, is theoretically derived, and family data are gained from a self-report instrument, the Family Adaptability and Cohesion Evaluation Scale (Olson et a!., 1978, 1979). The dimensions of cohesion and adaptability are common to Olson's and Beaver's assessment models, but Olson has defined adaptability as curvilinear, with both rigidity and flexibility being dysfunctional extremes (Olson et a!., 1983). Beavers, on the other hand , notes that rigidity is more adaptive than chaotic flexibility , suggesting that it is a step closer to good adaptation on a linear continuum that extends towards the infinite variety of creative adaptability (Beavers and Voeller, 1983). The card sort task developed by Reiss 's group is a different approach to assessing families . Rather than answering questions about themselves, the family members perform a neutral task that involves interaction among them. The parameters of configuration, coordination, and closure represent different dimensions of how the task is handled, and the task'ields information about the way a family defines and organizes experience that is called the family 's " paradigm" (Reiss, 1981, 1982; Reiss and Olivieri, 1983; Olivieri and Reiss, 1984). With high configuration, the family views the world as ordered and itself as capable of mastery, as opposed to low configuration, where the family sees the world as disordered and itself as helpless and threatened. With high coordination , the family sees itself being treated as a unitary group and views itself as a cohesive entity. J .Am.Acad. Child Adolesc. Psychiatry, 29:4, July 1990

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With low coordination, the family experiences itself as loosely connected. With delayed closure , the family sees the world as interesting and itself as evolving and changing with experience. With early closure , the family views the world as familiar and views itself as continuous with its past traditions. Particular paradigms are not associated with dysfunction or pathology , but they do provide useful clinical information about the family's style. An example of the descriptive quality of Reiss's card sort assessment is his portrayal of families of delinquents contrasted with families of schizophrenics and normals (Reiss, 1971). Called "environment distance-sensitive ," delinquent families were distinguished by their tendency to view the environment as if it were disjointed; family members were isolated from each other emotionally and seemed to lack knowledge about each other's motives and perspectives; family members appeared to view the interactions during the card sort test as an opportunity to express individual interest and to establish independent recognition ; and family members were low on intrafamiliar coordination and had poor problem-solving skills as a family. Typologies

Typologies are constellations of characteristics . One approach to family typology is to name families by the disorders of individual family members (e.g., "schizophrenic" families). Another is to name families by characteristic relationship patterns (e.g., "enmeshed" families). Many efforts have been made to define a one-to-one relationship between patterns of family interaction and specific disorders. The family field's failed attempts to show how families caused schizophrenia is illustrative of the problems involved in trying to establish such causal connections . Still, it is generally recognized that the finding of family characteristics associated with certain disorders is useful, not because the families cause these illnesses, but because addressing the family as well as the ill individual may be more effective than addressing either one without the other. PSYCHOSOMATIC FAMILIES

Minuchin et al. (1979) defined four characteristics of families of children with psychosomatic disorders that include: enmeshment, rigidity, overprotection, and poor conflict resolution. They demonstrated that these characteristics differentiated families of children with psychosomatic nonpsychiatric disorders. When these four ways of family relating changed in therapy, the psychosomatic components of the child's illness abated. The Philadelphia group also demonstrated these same characteristics exist in the families of patients with eating disorders and reported that family treatment resulted in a better than 80% recovery rate. These claims have been disputed, because other centers failed to reproduce the Philadelphia group's findings. Some clarification may have been offered by the findings of another group (Russell et al., 1987) when they demonstrated that structural family therapy was useful in younger anorexics (more characteristic of the Minuchin sample), but was not effective with older bulimics. J .Am.Acad. Chi/dAdolesc. Psychiatry .29 :4. July 1990

FAMILIES WITH AFFECTIVE DISORDER

Stierlin et al., (1986) found some characteristic features of families with major affective disorders and were able to distinguish them from families with schizophrenia and psychosomatic disorders. They found distinct differences among the three types of families using the following dimensions: 1. 2. 3. 4.

Construction/negotiation of relational reality; Definitions of relationship/clarity and congruence; Value systems/familial ideologies; Coalitions.

For example , " schizo-present" families showed frequent shifts in coalitions, while coalitions were rigidly maintained in psychosomatic families. In manic-depressive families, there was a great deal of pressure to take sides . Stierlin and associates found that manic-depressive families tended to place their members in mutually exclusive categories (e.g., either good or bad), to believe that one can will certain emotions, and to make a strict distinction between desirable and undesirable emotions. Proposing that these characteristics help to understand affective disorders in context , Stierlin et al. (1986, p. 334) summarize that the families form " a world of mutually exclusive yet constantly reconstructed extremes--extremes in attitudes, roles , behaviors, and values." FAMILIES WITH SUBSTANCE ABUSE

Research on the nature of families with alcoholic and other chemical dependent family members has been almost as numerous and varied as that on families of schizophrenics. Stanton et aI., (1982) described the structural characteristics of families of adult drug addicts. They found strong family ties, even when the drug user was not living at home, poor generational boundaries, cross-generational coalitions involving the user, and inverted hierarchy (referring to a preeminent role given to the younger generation in family decision making). Steinglass and associates studied alcoholic families (Steinglass, 1981; Wolin and Bennett , 1984; Steinglass et al., 1987). These researchers found that alcoholic families have at least two distinct typologies, one in the wet phase , when the alcoholic was drinking, and a different one, when dry (Steinglass, 1981). They suggested that there were some positive features of family interaction during the wet phase even though the family experienced stress. One family reported that when the alcoholic drank, depression , fighting, and estrangement resulted, but direct observation of the family revealed that drinking-behavior resulted in increased interpersonal warmth, increased caretaking, and greater animation in the family . This observation offered some explanation for the continued family investment in alcoholic family members. Finally, in examining variables among alcoholic families, Wolin and Bennett (1984) found that the preservation of family rituals in an alcoholic family can help protect the children in the family against alcoholism. RELATIONSHIP PATfERNS

Another approach to typology is to cluster family proc505

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esses as relationship patterns . Most of the typology schemata of this sort describe marital patterns . The Family Committee of the Group for Advancement of Psychiatry developed a rudimentary proposal for' 'Primary Relationship Disorders " which are classified by generic characteristics of disordered relationships, using dimensions of family functioning, such as those mentioned earlier. Most problems in relational functioning can be described under one of three categorie s: disorders of membership (e.g ., lack of clarity about who is in and who is out of the family, with accompanying loyalty conflicts); status (lack of clarity about roles, role differentiation, and accompanying jockeying for status through abuse of power); and proximity (overinvolvement or underinvolvement of family members, with resultant restrictions on individual autonomy or, conversely, inadequate supervision).

Managing Difficult Clinical Populations The persistent family systems view that the family is the crucible for development and an essential resource system has led to explorations in family treatment for a variety of confounding mental health problems. Three areas have been selected to present here: chronic mental illness, conduct disorders , and depression, with or without crises of selfdestructive behavior. Chronic Mental Illness Early research with families of schizophrenia did not demonstrate that families cause schizophrenia, but it did describe family patterns that were associated with it (Dell, 1980). It was not clear whether the schizophrenic had developed within a skewed family context; whether the family had become peculiar in response to its schizophrenic family member ; or whether what appeared to be characteristic family patterns were actually the artifacts of the research conditions (Terkelson, 1983). It was disappointing, however, that neither a cause nor a cure for schizophrenia was found within the family process. New treatment approaches evolved out of the observations that families bear the greatest burden for caring for the mentally ill; that families are so involved in the care of their ill family member that they become socially isolated , and that studies of multiple factors around relapse and rehospitalization found only one factor that appeared significantly associated with recurrence-a family atmosphere referred to as high expressed emotion (EE) (Brown et al. , 1972; Vaughn and Leff, 1981). High EE is not thought to cause mental illness or relapse , but it is highly associated with it. Some efforts to lower EE seemed to have reduced the rate of relapse in the schizophrenic family member. Therapeutic interventions which grew out of these observations include psycho-education, family survival workshops, and multiple family groups. Extensive information is provided to family members about illness, the state of current knowledge, and the usefulness of medication in a didactic setting . These psycho-educational sessions are often followed by a series of family survival workshops which focus on how to live with a chronically ill family member. 506

Multiple family groups bring families together to provide a supportive interpersonal context (Anderson et al., 1981; Falloon et aI., 1981; Goldstein and Kopeikin , 1981; Beels and McFarlane, 1982). These methods , in varying combinations, have been associated with a better course of the illness , with fewer relapses , and improved quality of life for both the ill and their families. These approaches have been widely supported because they advocate for the family and place the family in charge , while offering more support and by imparting more expertise and understand ing to them without blaming them for the illness . Conduct Disorders Children and adolescents with conduct disorders represent an increasing proportion of youngsters requiring mental health services and family treatment seems to offer assistance . The work of Minuchin et al. (1967) with delinquent boys and their families pioneered descriptions of the kind of family environment in which delinquency occurs. They observed that families of the delinquent boys at the Wiltwyck school appeared to be less cooperative and productive functional units than normal families; there was poor role differentiation; they were functionally organized around the mother with a coalition of mother and children exclud ing the peripheral or absent father figure; and they had poorly defined boundaries represented by enmeshment or disengagement. Many other studies of the families of delinquents have been done since this early work, and the conclusions can be summarized in the following five areas (Tolan and Mitchell, 1989): 1. Long-standing and high frequency of parental conflict around discipline and values to be transmitted to the children; 2. Lack of hierarchical differentiation between parents and children in the direction of conversations and family decision making; 3. General lack of positive affect in family interactions; 4. A tendency to misperceive and mislabel communication as aggressive; 5. The dominance by one or two family members of most of the family communication time, associated with a lack of willingness to compromise. In a thoughtful review of research on delinquents ' families and family therapy with delinquency, Tolan et al., (1986) described approaches to treatment of the delinquents with their families and the reported outcome. Enthusiasm for the reported superiority of family therapy over other forms of treatment has been mitigated by a variety of research design failures, including poorly conceptualized and articulated therapy alternatives, the obvious preference of the researchers for family therapy over other modalities, and the increased attention given to family and youngster under research conditions versus control conditions. One study merited special attention because the study was designed with a sufficient subject size (190 matched pairs) , random assignment to treatment groups , 2-year follow-up, and the model of family therapy was conceived on systemic principles (Johnson , 1976). The results of this study showed no significant differences in recidivism rates between the l .Am.A cad . Child Adolesc. Psychiatry, 29 :4, luly 1990

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family therapy and standard probation groups during the first year, but there was an increased recidivism for the probation group in the second year. In another important study, Parsons and Alexander (1973) compared behavioral family therapy , focusing on communication style with client-centered individual therapy, with a combination of individual and family therapy. They reported positive change in family supportiveness and decreased defensiveness among those in family therapy, which was greater than for those receiving individual treatment, and that there was no greater benefit from the combination of individual and family therapy . The details of effective treatment approaches for families of delinquents vary from one group to another. A behavioral component is prominent in all, but it differs in concept and application from simple parent effectiveness efforts. This is because it is widely recognized that youngsters with antisocial disturbances are aggressive and that aggression is a fairly stable characteristic. Delinquent behavior is seen not just as the outcome of poor parental management; the children make significant contributions to the family patterns. They pose a serious challenge to parents, and the resulting system of responses is a cybernetic series of reinforcing behaviors. Patterson and associates (Patterson and Brodsky, 1976) described the aggregate of these behaviors as a "coercive trap " which goes something like this: child exhibits an aggressive behavior; parent punishes in some way; child persists; parent withdraws the punishment. The overall effect on the child confirms that persistence in this form of behavior is successful, and the effect on the parent is that this child is unmanageable. This pattern is elaborated when it is recognized that two parental figures usually give conflicting messages to the child about the importance of modifying the behavior. Tolan and Mitchell (1989) outline several principles for family treatment of delinquent youth. First, progress is slow (6 to 9 months of weekly sessions) and both therapist and family must keep this in mind. Second, the aggressive tendency and associated poor social! interpersonal skills must be acknowledged and accountability placed squarely on the youngster. These authors recommend individual work to assist with a more thoughtful contemplation of future goals and steps required to attain these goals outside of the heated and reactive patterns of the family. A functional parent-child hierarchy must be supported, and more deliberate and productive approaches to problem solving must be developed. This usually involves parents confronting their differences about expectations for the child. The influence of peers must be addressed. The youngster's choice of friends is often a source of intrafamilial conflict, and the therapist must achieve a balance between supporting the choice of friends and insisting that the child take responsibility for how he or she is involved with peers who get into trouble. When the therapist can do this, the family will be more likely to succeed in a similar stance . Finally, the family must be assisted to access available social resources.

Depression and Self-Destructive Crises Studies of childhood affective disorders in families are l .Am.Acad. Child Adolesc. Psychiatry, 29:4, luly 1990

only just beginning as these conditions become more clearly delineated . Explorations with affective disorders have taken two directions: what are the characteristic family contexts of affective disorders; and how can family therapy contribute to treatment effectiveness. There have been no systematic reports offamily treatment of child or adolescent depression or of suicide, but the integration of observational studies of family interaction with depressed individuals (usually the mother) and case reports of families with a depressed adolescent lead to a rich set of possibilities for understanding the relational context of depression and what to do about it. That depression has profound interpersonal effects is not new information. That relational treatment of affective disorders has longer lasting effects and lower relapse .rate is also not new information (Davenport, 1975; Coyne, 1987). The possibility that depression is exacerbated in interpersonal situations is familiar, but the possibility that depression can be brought about in interpersonal contexts may be surprising. Nevertheless, researchers examining families in which an adult has a major depression have made intriguing observations about the modifying influences of certain kinds of interactions on the dysphoria. One group (Hops et al., 1987) reported the expected, that depressed mothers emit higher rates of dysphoric affect than normal mothers. What is interesting about their observations , however, is that the mother's dysphoric affect seemed to suppress aggressive affect from other family members and that aggressive affect from other family members appeared to suppress the mother's dysphoric affect. This suggests that families with a depressed mother have higher concentrations of both aggression and dysphoria than normal families and that they evolve an oscillating system for managing dysphoric and aggressive moods . Within this system , both aggression and dysphoria are functional aspects of the maintenance of some dynamic overall equilibrium. These researchers' observations, painstakingly recorded by carefully trained observers with handheld computers, illuminate a clinical description of a multiproblem, poor , black family, seen by Aponte and reported by Hoffman (1981): "Mother is still apathetic and looks tired, and the therapist begins to ask about her nerves . At first the children are somewhat quiet. ... As she begins to admit that she has bad nerves ... they begin to act up. One boy pokes the baby; another boy tries to restrain the baby from hitting back; the baby starts to yell . The therapist asks . . . baby 's mother ... if she can control him; she says no. At this point the mother gets up and smacks her daughter's baby with a rolled up newspaper, rising out of her lethargy . ... She sits the baby down with a bump, and he makes no further trouble. During this sequence the rest of the children jump and shriek with joy, causing their mother to reprimand them, after which they calm down and the mother sits back, more watchful now, and definitely in control"· (pp. 83-84). Hoffman explains how this sequence illustrates a common cycle , "The mother's depression .. . triggers off collusive mischief in the children; once this mischief rises to a certain

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level, it will impel the mother to reassert her power; seeing the mother taking an active position relieves the children , and as she takes over they quiet down " (1981, p. 84). These sequences, cycles, or oscillations around aggressive and dysphoric affects and behaviors may help to explain the generalized disturbance found in children of depressed mothers (Beardslee et aI. , 1983; Cytryn et aI., 1986). They also provide a framework for understanding how depression is maintained within family systems and what must be addressed in family therapy in order to disrupt these cycles and reset the interpersonal management of these affects at a different level. Fluctuation , or oscillation between two seemingly opposing issues , plays prominently in Sargent's (1988) conceptualization of the family systems of depressed and/or suicidal adolescents . He describes these families as either stagnating because of balancing oscillations between power and powerlessness, responsibility and irresponsibility, overinvolvement and disconnection, and control and rejection, or escalating to a crisis . According to Breunlin 's (1988) oscillation theory, these wide swings between opposing behaviors are characteristic of the disequilibrium experienced by families undergoing developmental changes, but when there is no progress in the direction of more competent behaviors, there is a danger of an escalating cycle in which moves for greater control are countered by greater repudiation, which elicts greater control , etc . The outcome of escalation is explosion , and for adolescents, explosion may take the form of physical violence , running away, or suicide. It is often only at the time of such a crisis that mental health professionals become involved. At this point , the questions about what kind of treatment and where the treatment should be administered are critical, because of real danger to the youngster or others . Playing it safe, many have advocated hospitalization, but family therapists generally prefer not to manage these cases in the hospital. Many family therapists will try to manage the situation by working with the family. Gutstein et al. (1988) developed a Systemic Crisis Intervention Program to manage very troubled adolescents outside of the hospital. Their model is based on three premises . First, such adolescents belong to kinship systems in which family members have lost their belief in the power of their helpfulnes s. Second , the kinship systems have reached a point of "crisis" overload, leading to extreme solutions involving sacrifice or exclusion of individual family members. These actions, in turn, lead to the depiction of the family as "toxic." Finally , each crisis offers an opportunity for modification of these myths by activating the kinship network to be helpful. Gutstein et al. (1988) evaluated the outcome of their work with the families of 75 adolescents whose treatment was precipitated by suicidal behavior, accompanied by severe depression (five subjects), violent behavior (seven subjects), and substance abuse, school refusal , family conflict, and/ or runaway behavior. They reported that this treatment was conducted safely , that the sense of crisis in most families was alleviated for up to 12 months after the treatment, and that there was a significant decrease in the numbers of problem episodes over the next 2 years. Furthermore, of the 75 508

subjects, only five were subsequently hospitalized or placed in residential facilities for any period of time . Contra indications to working with adolescents and their families in this way include clear-cut psychotic symptoms, heavy dependence on institutions, and lack of parental urgency in response to extreme behavior s. In summary , family therapy with depres sed and/or suicidal children and adolescents has not been widely reported or researched, but research on interpersonal processes in depression and the escalating sequences in the families of self-destructive youngsters has provided a theoretical framework for therapeutic action , and at least one group has developed and studied the outcome of such a therapeutic system.

New Developments in Family Therapy New developments in family systems therapy are germane even though children and adolescents are not often specifically named as the objects of treatment. Attention to the sociopolitical and larger systems contexts of families has generated a considerable body of relevant work. Two areas of this work appear to have particular significance: gender and macrosystems. Theoretical issues that inform the practice of family systems oriented therapy , such as the definition of the therapeutic system and considerations of how systems change in therapy , form another important group of developments to be considered. Gender

Family therapists have been criticized for the application of systems theory that ignores the effects of a gendered social structure on women 's roles within the family. This criticism centers around problems that are most troubling to those who care for children: child abuse and domestic violence. The feminist critique grows out of the family field, itself, and out of a critical examination of the family as an institution in which children are raised . Feminists criticize family therapists for idealizing the family , while ignoring the patriarchal structures in which it is embedded. In families in our society , women are the nurturers and caretakers of men and their children. Two indicators of the effects of gender bias are the "feminization of poverty " and the numbers of victims of exploitation and violence . Families of single women and children comprise the vast majority of people living in poverty because of laws which allow fathers to renig on child-support responsibilities and a job structure which both keeps women at a lower level and pays them less. One in four wives is beaten by her husband ; 400,000 cases of incest are reported per year, 97% perpetrated by men (this is generally considered an underestimate); however, the incidence of marital rape and child beating is difficult to establish (Goodrich et aI. , 1988). In practice, family therapists have taken advantage of the fact that mothers tend to spend more time with their children than fathers. Mothers are responsible for holding the family together and are more likely to bring the family in for treatment when trouble occurs, so that they are the most likely to be blamed for the problems experienced by any of the J .Am.Acad. Child Adolesc .Psych iatry, 29:4, July 1990

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family members and to be the ones expected to change (Walters et aI., 1988). Clearly these are not problems experienced only in the practice of family therapy. Caplan and Hall-McCorquiodale (1985) reviewed literature on parental influences on the development of childhood pathology and found that what they called "mother-blaming" prevailed, even when fathers had abandoned or abused their children . The classic, familiar example, is the blaming of a mother for not protecting her daughter from the father's incestuous advances. Feminist, family therapists have shown that the family and the roles of its members have not evolved to an ideal and functional form, as some social determinists might claim (Goodrich et al., 1988; Leupnitz, 1988). Goldner (1988) protests that describers of family functioning have discriminated roles and functions on the basis of generation and have ignored gender . The result-women are often treated as if they were in the same generation as their children which places them at a disadvantage in protecting their children. Hare-Mustin (1988) points out that gender distortions are perpetuated through alpha bias (ignoring differences) or beta bias (overemphasizing differences that are regarded to be biologically determined). These ideas achieve practical application when tackling various forms of domestic violence and abuse. Classical systems theory posits that all parties are responsible for violence; the victim does something to activate the violent behavior of the perpetrator. This explanation, argue the feminists, blames the woman, even for situations which endanger her. But in not blaming the victim/woman , feminist family theorists have had difficulty conceptualizing how to work with the relationship without protecting the woman (thus contributing to a dependent position) and alienating the man (and in some way perpetuating the abusive system). Goldner and Walker (1988) proposed a "both! and" approach that balances the unacceptability of violence in the relationship with acknowledgement of a bond or commitment between the spouses, thus enabling the therapist to take a strong position on protection for the woman and on the man's acceptance of responsibility for his harmful abuse of power. Such a position also avoids either shaming the women, many of whom find it impossible to leave the situation, or driving the men out of treatment. MacKinnon and James (1988) try to avoid accentuating the gender split when working with incest. They address both perpetrator and victim as victims, gently eliciting the historical victimization of the victimizer in an effort to heal relationships through rearranging them. Miller (1989) examines the entire arena of child abuse in similar terms, pointing out that traditional interventions , which " solve" the problem by removing the child and the abuser from the family, may successfully protect the child from further abuse by the familial abuser but will do little to correct the problems in systems that have often been there for generations and are likely to be perpetuated . She proposes a treatment approach, using circular questioning (described below), which gently probes larger and larger circles of the family ' s relationship experience, respectfully acknowledges loyalties, dependencies, and areas of competence, sympathetil .Am.Acad . Child Ado/esc. Psychiatry, 29:4, lu/y 1990

cally listens to pain and frustration, and invites the family's own solutions. Macrosystems Family violence is a good example of a problem that cannot be sufficiently understood, either by defining the psychopathology of involved individuals or by describing the dysfunctional family dynamics, because so many other systems are involved. It is often only through the study of the macrosystemic context of troubled families that interventions can be devised that can interrupt vicious cycles that maintain dysfunction in families and in their individual members. Larger systems, such as schools, welfare, mental health, criminal justice, and the workplace, all represent important contextual influences on how families care for and raise their children (Berger et aI. , 1984; Schwartzman, 1985; Imber-Black, 1988). Those who have studied macrosystemic influences use a systems framework to examine the patterns of interaction among the institutions or agencies as well as among their members. There are several conceptual patterns which are helpful in clarifying these relationships: 1. Isomorphism-the patterns of dysfunction are replicated at each level of the system; 2. Attempted solutions often become the problem (an example of this is the violation of the family that often occurs as a consequence of trying to stop family violence); 3. "Problem-determined" systems (Anderson et aI., 1986), in which the relevant system is defined by the problem, rather than the system causing the problem (this is discussed additionally, below). A symptomatic child is commonly the manifest tip of a massive iceberg of conflicting messages and points of view which defy correction by any means other than through intervention with these larger systems. Often child mental health professionals have to pick their way through multiple helping systems and multiple conflicting assessments, attitudes, and recommendations in order to develop a clear and effective treatment plan for a child . Understanding the properties of systems in interaction can greatly assist in this process. For example , Rotheram (1989) describes the likely outcome of the most commonly interacting types in children with school problems, open families, and open school systems. In this situation, for the child who has a problem, neither the family nor the school assumes full responsibility, and many other helpers will be engaged on the child 's behalf. The solution that most macrosystemic therapists favor is to bring as many of the involved systems together at the same time to clarify misunderstandings and sort out their various roles. While this is not always feasible, it is often possible if the therapist is willing to be flexible about the time and place of such a meeting. Theoretical Developments and Family Therapy Practice

Much of the family therapy literature deals with several crucial questions: How do people change? Specifically, how do they change in psychotherapy? Where and what is the problem? What is the role of the therapist?

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As noted, the clinical assessment of family systems involves a search for patterns that provides a kind of map about how families deal with certain kinds of challenges . Therapeutic interventions are designed to change those patterns. But systems spontaneously form new patterns in the process of their evolution (Elkaim , 1985). Patterns may change completely in response to stimuli from within the family, such as developmental strivings or personal stresses, or from outside the family, such as the pressure of external systems or unpredicted natural events. These stimuli are called " perturbations" and the family system can respond to them either by affirming and holding on to patterns that have been familiar or by reorganizing, in what some have referred to as a kaleidoscopic fashion (Hoffman, 1981). This systemic view of how change occurs places the responsibility for change within the system doing the changing . A natural question , for those who give so much attention to context, is where might the problem be (i.e., is it in the person who expresses it or in the family), but some family systems theorists have gone on to speculate about the very existence of problems. Some , such as Dell (1986), argue that the experience of something going wrong derives only from the evaluation of the situation. Thus, for many family systems therapists initial questions may not be "what is the problem" or " who has the problem," instead, the questions may be "who thinks there is a problem" and "who influences the problem" or "what are the consequences of having or not having the problem. " As an example, think of a child being evaluated for attention deficit hyperactivity disorder. The usual protocol for exploring the possibility of attention deficit includes the distribution of a behavioral checklist, the responses to which, according to the systems view, clearly identify who thinks there is a problem . This line of exploration suggests that the therapy system, itself, can become the problem or contribute to perpetuating the problem; to protect against this, a number of refinements in treatment approaches have been introduced. The most significant of these is the therapy team. In the Milan systems approach (Selvini Palazzoli et al. , 1978, 1980), a group of therapists behind a one-way mirror achieve a different level of objectivity and commentary on the therapeutic system. The " greek chorus " (Papp, 1980) is a team behind the mirror that functions much like a chorus, sending a metacommentary to therapist and family . The "reflecting team" (Anderson, 1987) alternates the team watching the therapist and the family with the family/therapist system watching the team's discussion through the mirror. Wynne and colleagues (1986) propose that systems work is more accurately called consultation than therapy. The clients are invited to join the consultant team. Finally , the' 'problem-defined systern" (Anderson et al., 1986) identifies the group to be assembled for consultation and evaluation as all of those who think there is a problem . This group, then, becomes its own team and is given the opportunity to evaluate its effects on the problems it is attempting to resolve . Changing Systems

Family therapists have many, often conflicting, ideas about how systems change and how to help them change. Most 510

try to explain, formulate, or hypothesize about what is going on. Doing so intentionally narrows the field of observation in order to direct intervention. Thus, the activity of defining and explaining also introduces constraints on the field of observation , on the family , and on the therapist. Considering these limitations , some family systems therapists try, instead, to introduce variety; to expand the possibilities for change; to perturb the system, using techniques designed to push the family members to be curious; and to explore and see themselves in more different ways with more different possibilities . These therapists try to remain neutral in order not to constrain families ' explorations while stimulating or perturbing the system. Some perturbations include circular questioning (Selvini Palazzoli et aI., 1980; Penn, 1982, 1985; Cecchin, 1987) and positive connotation . Families often present themselves as of one mind about themselves; circular questions , such as, "Would you or your husband be happier if Mary graduated from high school?" activate an inquiry among all of the family members . If Mary 's school performance were an issue for the family, connecting it to the proposed difference might be additionally interesting to the family. Positively connoting symptoms reported to be unpleasant or bad is another way of introducing variety into the system , offering an alternative way of interpreting experience. Indications and Contra indications

The question of indications and contraindications for family therapy has many different answers, because family systems theory and the resulting therapies are not simply an array of therapeutic modalities, or, as often used in conventional treatment centers, adjunctive approaches. Clearly, a true systemic orientation to human behavior cannot be indicated or contraindicated. For the family systems therapist, it is always indicated to involve not only the family, but other relevant systems, in evaluating and treating what has been presented as a problem. This is true, not because problems are caused by families or are representative of family dysfunction, but because the family is so critically a part of the lives of its members , whether it is caring for the acutely or chronically ill, managing and disciplining the misbehaving, or assisting with the education and habilitation of the severely disturbed and mentally handicapped. Once a systemic orientation has been adopted, the question of indications and contraindications centers on considerations of feasibility; what groups and subgroups should be involved in what kind of sequence ; and what will be the impact of working with one subsystem or another versus the whole group. Conclusion More than a decade after McDermott and Char's (1974) analysis of "the undeclared war between child psychiatry and family therapy," child psychiatry and family therapy have evolved in directions that can inform additional developments in their common quest to improve conditions for children and their families. Contemporary family systems studies do not ignore the l .Am .Acad. Child Adolesc .Psychiatry, 29 :4,July 1990

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individual 's biology or psychology, but they are actively engaged in contemplating how indi vidual biology and psychology are both contributors to and outcomes of the nexus of relationships . Thi s connection most vitally involves the household familiars and reso nates with larger and larger system s, right up to the systems of universal anxiety that link world superpow ers . Family systems theory and therapy have not answered, nor eve n addressed, all of the problem s which preoccupy child psyc hiatrists. On the other hand , there is much going on in the field that is vitally important to the mental health of children . Specifically, what the family field offers to child psychiatrists, now , is a bod y of theory, study, and experi ence-in short, a technology-for evaluating and treating families which are children 's most crucial relat ionship systems . Advocating for children is what all child mental health professionals have in common. Fam ily systems therap y brings to this effort the means to ass ist families to advocate for themselves and their children.

References Alexander , 1. F. & Barton, C . (1980), Systems-behavioral intervention with delinquent families . Advances in Family Intervention Assessment and Theory , 1:53-87. Anderson, C. M., Hogarty, G. & Reiss, D. J. (1981), The psychoeducational family treatment of schizophrenia. In: New Developments in Interventions with Families ofSchizophrenics, ed. M . Goldstein. San Francisco: Jossey-Bass, pp . 79-94. Anderson, H. , Goolishian, H. A. & Winderman, L. (1986), Problem determined systems. Journal of Strategic and Systemic Therapies , 5:1-1 3. Anderson, T . (1987), The reflecting team . Fam. Process, 26:415428. Beardslee, W . R. , Bemporad, J. , Keller, M. D. & Klerman, G. L. (1983), Children of parents with major affective disorder. Am . J. Psychiatry, 4:561-571. Beavers, W . R. & Voeller, M. N. (1983), Comparing and contrasting the Olson Circumplex Model with the Beavers Systems Model. Fam . Process, 22:85- 98. - - Lewis, J. M., Phillips, V. A., Gossett, 1. T., Lewis, S. B. & Bamhart, F. D. (1972), Development of a family evaluation scale. Presented at Southwestern Regional Meeti ng, American Orthopsychiatry Association, Galvestion, TX . Beels, C. C . & McFarlane , W . R. (1982), Family treatments of schizophrenia. Hosp. Community Psychiatry, 33:541- 550 . Berger , M ., Jurkovic , G. J . et al. (1984), Practicing Family Therapy in Diverse Settings. San Francisco: Jossey-Bass. Breunlin, D. C. (1988), Oscillation theory and family development. In: Family Transitions , ed. C. J. Falicov. New York: Guilford Press, pp. 113-155 . Brown , G. W. , Birley, J. L. T. & Wing, J . K. (1972) , Influence of family life on the course of schizoph renic disorders. Br. J. Psychiatry, 121:241-258 . Caplan , P. J . & Hall-McCorquodale, I. (1985), Mother-blaming in major clinical journ als. Am . J . Orthopsychiatry , 55:345- 353. Carter, E. A. (1988), The changing family life cycle. In: The Changing Family Life Cycle, eds . E. A. Carter & M . McGo ldrick . New York: Gardner , pp. 1-28 . - - & McGoldrick, M . (1980), The family life cycle and family therapy . In: The Family Life Cycle, eds. E. A. Carter & M. McGoldrick. New York: Gardner , pp. 3-20. Cecchin, G. (1987), Hypothesizing, circularity, & neutrality revisited. Fam. Process, 26:405-4 13. Chasin, R. & White , T . (1989), The child in family therapy. In: Children in Family Contexts, ed. L. Combrinck-Graham. New York: Guilford , pp. 5-25 .

J .Am. Acad . Child A dolesc . Psychiatry , 29 :4,July 1990

Colapinto, J. ( 1979) , The relative value of empirica l evidence. Fam . Process, 18:427-44 1. Combrinck-Graham , (1988) L. Adolescent sexuality in the family life cycle . In: Family Transitions, ed. C . J . Falicov. New York: Guilford, pp. 107-1 31. - - (1987), Invitation to a kiss. Psychotherapy , 25S:504-51O. - - (1985), A model offamily development. Fam . Process, 24:139150. Coyne , J. C. (1987), Depression, biology, marriage and marital therapy. Journal of Marital and Family Therapy , 13:393-407. Cytryn , L., McKnew, D. H. , Zahn-Waxler, C. & Gershon , E . S . (1986), Developmental issues in risk research. In: Depression in Young People, eds. M. Rutter , C . E. Izard & P. B. Read. New York: Guilford Press , pp. 163-1 88. Davenport, Y. B., Ebert, M . H., Adland, M . L. et al. (1975) , Lith ium prophylaxis: the married couples group. Presented at annual meeting of American Psychiatric Associati on, Anaheim, CA. Dell, P. F. (1986), Understanding Bateson & Maturana. Journal of Marital and Family Therapy, I I:1- 20. - - (1980) , Researching the family theories of schizoph renia. Fam . Process, 19:32 1- 335 . Duvall, E. M. (1962) , Family Development. Chicago: Lippicott. Elkaim, M. (1985) , From general laws to singularities. Fam . Process, 24:151- 164. Falloon, 1. R. H. , Liberman, R. P. , Lillie, I. F. J. & Vaughn , C. E. (1981) , Family therapy of schizophrenics with high risk of relapse . Fam . Process , 20:21 1-221. Forman, B. D. & Hagan, B. J. (1984), Measures for evaluating total family function ing. Fam. Therapy , II : 1- 36. Goldner , V. (1988) , Generation and gender: normativ e and covert hierarchies . Fam. Process, 27:17-31. - - Walker, G. (1988), Integrating fe minist and systemic models of battering. Presented at the annual meeting of the American Family Therapy Association, Montreal, Canada . Goldstein, M. J . & Kopeikin, H. S. (1981), Short- and long-term effects of combining drug & family therapy. In: New Developments in Interventions with Families of Schizophrenics, ed. M . Goldstein. San Francisco: Jossey-Bass, pp. 5-26. Goodrich, T. J. , Rampage, C. , Ellman, B. & Halstead , K. (1988 ), Feminist Family Therapy. New York: W. W . Norton . Gurman , A. S. (1983), Family therapy research and the " new epistemology ." Journal of Marital and Family Therapy , 9:227-234 . - - Kniskern, D. P. (1978) , Research on martial & family therapy . In: Handbook of Psychotherapy & Behavior Change: An Empirical Analysis (Second Edition), eds . S . Garfield & A. Bergin . New York : J. Wiley. Gutstein, S. E. , Rudd, M. D. , Graham, 1. C. & Rayha, L. L. (1988), Systemic crisis intervention as a response to adolescent crises. Fam . Process, 27:201-211. Haley, J . (1980), Leaving Home. Palo Alto: Jossey-Bass. - - (1973), Uncommon Therapy . Toronto: W. W . Norton. Hampson, R. B. & Beavers, W. R. (1987), Comparing males ' and females' perspectives through family self-report. Psychiatry, 50:2430. Hare-Mustin, R. T. (1988), Family change and gender differences: implications for theory and practice. Family Relations, 36-4 1. Hoffman, L. (198 1), Foundations of Family Therapy . New York: Basic Books. - - (1980) , The family life cycle & discontinuous change. In: The Family Life Cycle, eds. E. A. Carter & M. McGoldrick . New York: Gardner Press, pp. 53-68. Hops , H. Biglan, A. , Sherman, L. , Arthur, J., Friedman, L. & Osteen, V. (1987), Home observations of family interactions of depressed women. J . Consult. Clin . Psychol ., 55:341-346 . Imber-Black, E. (1988) , Families and Larger Systems . New York: Guilford Press. Johnson, T. F. (1976) , A contextual approach to treatment of j uvenile offenders. Offender Rehabilitation, 3:171- 179. Krepner, K., Paulsen, S. & Schuetz, Y. (1982), Infant and family development from triads to tetrads. Human Development , 25:373391.

511

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Leupnitz, D. A. (1988), The Family Interpreted. New York : Basic Books. Lewis, K. G. (1986), Sibling therapy with children in foster homes. In: Treating Young Children in Family Therapy, ed. L. CombrinckGraham . Rockville, MD: Aspen , pp. 52-61. Lewis, J. M. (1988a), The transition to parenthood: I. Fam. Process, 27:149-165 . --(1988b), The transition to parenthood: II. Fam. Process, 27:273283. MacKinnon, L. & James, K. (1988), Preventing abuse: an analysis of the social construction of masculinity and femininity. Presented at the annual meeting of the American Family Therapy Association, Montreal , Canada. Madanes ,. C. (1984), Behind the One-Way Mirror . San Francisco: Jossey-Bass. McDermott, J. F. & Char, W. (1974), The undeclared war between child and family therapy. J. Am . Acad. Child Psychiatry, 13:422436. Miller, L. (1989), Family violence and the helping system . In: Children in Family Contexts, ed. L. Combrinck-Graham. New York: Guilford , pp. 413-436. Minuchin , P. (1985) , Families and individual development. Child Dev , 56:289-302 . Minuchin, S. (1974), Families and Family Therapy, Cambridge, Mass. : Harvard. - - Fishman , H .C. (1981) , Family Therapy Techniques, Cambridge, Mass .: Harvard . - - Rosman, B. L. & Baker , L. (1979) , Psychosomatic Families. Cambridge, Mass. : Harvard. - - Montalvo, B., Guemey, B., Rosman, B. L. & Schumer, F . (1967), Families of the Slums. New York: Basic Books. Olivieri , M. E. & Reiss, D. (1984) , Family concepts and their measurement are seldom what they seem. Fam. Process , 23:33-48 . Olson, D . H. , Russell, C. R. & Sprenkle, D. H. (1983), Circumplex model of marital and family systems VI. Fam. Process, 23:69-83 . - - Sprenkle, D . H. & Russell, C . S. (1979) , Circumplex model of marital and family systems I. Fam . Process, 18:3-28. - - Bell, R. & Portner , J (1978), FACES: Family Adaptability and Cohesion Evaluation Scales (Manual) . St. Paul, Minn .: Family Social Science, University of Minnesota. Papp, P. (1980), The greek chorus and other techniques of family therapy. Fam . Process, 19:45-57. Parsons, B. V. & Alexander, J. F. (1973) , Short term family intervention. J. Consult. Clin. Psychol., 41:195-201. Patterson, G. R. & Brodsky, G. A. (1976), A behavior modification programme for a child with multiple problem behaviors . J . Child Psychol. Psychiatry, 7:277-295. Penn, P. (1985), Feed-forward. Fam. Process, 24:299-310. - - (1982), Circular questioning. Fam. Process, 21:267-280 . Reiss, D. (1982), The working family. Am . J . Psychiatry, 139:14121420. --(1981), The Family's Construction ofReality. Cambridge, Mass .: Harvard. - - (1971), Varieties of consensual experience. Fam. Process, 10:2835. - - Olivieri, M. E. (1983) , Sensory experience and family process . Fam. Process, 22:289-308. Rotheram, M. J. (1989), The family and the school. In: Children in

512

Family Contexts, ed. L. Combrinck-Graham. New York: Guilford Press. pp. 347-368 . Russell, F. M., Szmukler, G. I., Dare , C. & Eisler, I. (1987), An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch . Gen. Psychiatry, 44:1047-1056 . Sargent , A. J. (1988), Adolescent suicide: a theoretical model and systemic intervention. Presented at the annual meeting of the American Family Therapy Association, Montreal , Canada. Scharff, D. E. & Scharff, J. S. (1987) , Object Relations Family Therapy, Northvale, NJ: Jason Aronson . Schwartzman, J. (Ed.) (1985), Families and Other Systems. New York: Guilford . . Selvini Palazzoli, M. , Boscolo , L. Cecchin, G. & Prata, G. (1980), Hypothesizing-circularity-neutrality. Fam . Process, 19:3-12. - - - - - - - - (1978) , Paradox & Counter Paradox. New York: Jason Aronson . Stanton, M. D., Todd, T. C. et al. (1982), The Family Therapy of Drug Abuse and Addiction. New York: Guilford. Steinglass, P. (1981), The alcoholic family at home. Arch . Gen. Psychiatry, 38:578-584 . - - Bennett , L., Wolin, S. J. & Reiss, D. (1987), The Alcoholic Family. New York: Basic Books. Stierlin, H., Weber, G., Schmidt, G. & Simon, F . B. (1986), Features of families with major affective disorders. Fam. Process, 25:325336. Terkelson , K. G . (1983) , Schizophrenia and the family . Fam. Process, 22:191-200. - - (1980) , Toward a theory of the family life cycle . In: The Family Life Cycle, eds. E. A. Carter & M. McGoldrick. New York: Gardner Press, pp. 21-52 . Tolan, P. H. & Mitchell, M. E. (1989) , Families and the therapy of antisocial and delinquent behavior. Journal of Psychotherapy and the Family , 6:29--48. - - Cromwell, R. E. & Brasswell , M. (1986) , Family therapy with delinquents . Fam. Process , 25:619-650 . Vaughn, C . E. & Leff, J. P. (1981) , The influence of family & social factors on the course of psychiatric illness. Br. J . Psychiatry, 129:125137. Wachtel, E. F. (1987), Family systems and the individual child . Journal of Marital and Family Therapy, 13:15-25 . Walters, M., Carter, E. A., Papp, P. & Silverstein, O . (1988) , The Invisible Web. New York: Guilford . Wolin, S. J. & Bennett, L. A. (1984), Family rituals. Fam . Process, 23:401--420. Wood, B. (1986), Proximity and hierarchy: orthogonal dimensions of family interconnectedness. Fam. Process, 24:487-507 . Wynne, L. C. ed. (1988a), The State of the Art in Family Therapy Research. New York: Family Process Press . - - (1988b) , An epigenetic model of family processes . In: Family Transitions, ed. C. J. Falicov. New York: Guilford, pp . 81-106. - - (1983) , Family research and family therapy. Journal of Marital and Family Therapy, 9:119-117. - - McDaniel , S. H. & Weber , T. T . (1986) , Systems Consultation. New York: Guilford . Zilbach, J . J. (1989) , The Family Life Cycle. In: Children in Family Contexts, ed . L. Combrinck-Graham . New York : GUilford, pp. 4666. - - (1986), Young Children in Family Therapy . New York: Brunner/ Mazel.

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