HEALTH CARE REFORM IN THE UNITED STATES: IMPLICATIONS FOR TRAINING AND PRACTICE IN MARRIAGE AND FAMILY THERAPY

Americans are spending 12-14% of their income on health care, and costs are rising about 11-12% per year. These increases are fueled by many social problems and are not limited strictly to health matters. Many alternatives have been examined to limit the rapidly increasing costs. The long-term results of these efforts are likely to be a reduction in health care benefits for many and the continued development of a two-tier system of health care. This article addresses the place of mental health care in general and marriage and family therapy in particular in the emerging system. Suggestions for training and practice for the new health care system are given.     

THE INTEGRATIVE PSYCHOTHERAPY ALLIANCE: FAMILY,COUPLE AND INDIVIDUAL THERAPY SCALES*

The therapeutic alliance concept has been confined primarily to the literature on individual psychotherapy. This paper formally introduces the concept into the family and marital therapy domain and presents various clinical hypotheses about the nature of the alliance and its role in familyand marital therapy. A systemic perspective is brought to bear on the concept within individual psychotherapy. A new, integrative definition of the alliance is presented that conceptualizes individual, couple and family therapy as occurring within the same systemic framework. The implications of this integrative-alliance concept for family, couple and individual therapy research are examined. Three new system-ically oriented scales to measure the alliance in individual, couple and family therapy are presented along with some preliminary data on their methodological characteristics.     

TRAINING THE PERSON OF THE THERAPIST IN STRUCTURAL FAMILY THERAPY

Structural Family Therapy needs a training model that integrates the existential, human mutuality of the therapeutic relationship with its technical elements. This paper offers a theoretical foundation for training structural family therapists in the use of self, discusses a model for training, and gives a case example illustrating personal training in a clinical context.     

EVALUATION OF AN ACADEMIC FAMILY THERAPY TRAINING PROGRAM: CHANGES IN TRAINEES' RELATIONSHIP AND INTERVENTION SKILLS

Students in an academic training program were assessed for changes in their relationship and intervention skills following completion of the program. Positive improvements were found on some measures but not all. Additionally, trainee variables such as previous clinical experience. gender, age, marital stauts and scores on standardized admission tests were examined in relation to trainees' skills changes. Trainee characteristics were unrelated to changes in intervention skills. However, a number of relationships were found between trainee characteristics and changes in relationship skills.     

POSITIVE PRACTICE IN FAMILY THERAPY

Positive practice, a brief integative approach to consultation with families, is described in this paper. A clear distinction is made between the stages of planning, assessment, therapy, and disengagement. Guideliness for progression from one stage to the next are provided. Frameworks for deciding who to invite to preliminary sessions and methods for planning and organizing lines of inquiry are incorporated into this approach to practice. A three-column model is used to construct formulations. The model allows therapists and clients to map information about the pattern of interaction around the presenting problem, beliefs that constrain family members from altering their roles in these problem-maintaining patterns, and factors that have predisposed family members to hold these beliefs. Positive practice offers methods for evolving new behavioral patterns and belief systems within sessions and for arranging homework tasks for clients between sessions. It also incorporates methods for dealing with resistnace, for managing therapeutic crises, for convening indivudial sessions and borader network meetings, for disengaging from the consultation process, and for recontracting for further episodes of therapy. This evolving approach to practice draws on ideas from many traditions within the family therapy field and takes account of recent research relevent to the practice of family therapy.     

THE QUESTION CUBE: A MODEL FOR DEVELOPING QUESTION REPERTOIRE IN TRAINING COUPLE AND FAMILY THERAPISTS

This paper presents a three-dimensional model for teaching questioning to those wishing to develop skills in couple and family therapy. The model breaks questions into their component parts of format (the style of the question: open, closed, forced choice, rating, or ranking); orientation (the person who is being inquired about: self or other), and subject (the content of the question: behavior, feelings, beliefs, meaning, or relationship). The model is presented in the context of our post-Milan version of couple and family therapy training. The model is useful in that it allows students gradually to increase their repertoire of questions in a way that offers step-wise learning and integrates with their existing skills.     

THE CORRELATES OF HEALTHY FAMILY FUNCTIONING: THE ROLE OF CONSENSUS AND CONFLICT IN THE PRACTICE OF FAMILY THERAPY

The present study explores the relative importance of individual, dyadic and triadic measures of intrafamily functioning in predicting family health. Using self-report data from 78 families, it was found that dyadic measures pertaining to marital quality and parent-child relationships were more powerful predictors than either individual measures of emotional maturity, anxiety, self-esteem or locus of control, or triadic measures of the families' hierarchical alignments. The study also found that while mothers' and fathers' assessments of intrafamily functioning were more important than the childrens' (except for the childrens' view of parent-child relationships), the parents differed in that marital quality was more important to the mothers' evaluations of the family unit while parent-child relationships were more important to the fathers'. Compositely, the findings suggest that family health is a complex multidimensional phenomenon, and that change in a particular dimension of family life may not necessarily be greeted with consensual validation or repudiation by all family members.     

EXPLORING THE RELATIONSHIP BETWEEN TYPES OF FAMILY WORK AND MARITAL WELL-BEING

We use an expanded definition of family work and test its association with marital well-being. Using a gender perspective, we examine the role of the respondent's and partner's performance of family work for both husbands and wives. Data are taken from a sample of couples with dependent children under age 18 (N = 96), and separate regression equations are estimated by gender. Though housework is cited as one of the most contentious issues reported by couples, it is not significant in our analysis of marital well-being. In our analysis, other forms of family work are considered, and childcare, emotion work, and formal volunteering are significantly associated with marital well-being. The role of partner's provision of emotion work is particularly salient. Discussion of the gendered nature of our findings follows.     

TEACHING FAMILY THERAPY AT THE INTRODUCTORY LEVEL: A CONCEPTUAL MODEL EMPHASIZING A PATTERN WHICH CONNECTS TRAINING AND THERAPY*

This paper details the structure and content of an introductory family therapy course offered in an academic department. The parallel processes between teaching and therapy are used as a metaphor for the presentation of the course. Joining, restructuring, and consolidation are defined as the three stages of the course, each having distinct goals and methods. Finally, generic issues raised by the proposed teaching model are presented for trainers to consider.     

SUGAR AND SPICE, TOADS AND MICE: GENDER ISSUES IN FAMILY THERAPY TRAINING

Whereas family therapists have become increasingly aware of gender as a central organizing principle in how we think about families, few methods have been presented to help trainees and clinicians articulate how to adress gender. Four experiential exercises (including gender survival messages, gender framed circular questions, and process observation sheets) that can be used in training and adapted for use with clients are described. What we have learned about gender from our families of origin, the larger culture, and in the construction of family therapy models can be examined with these activities.     

OUTCOME RESEARCH ON FAMILY THERAPY TRAINING: A SUBSTANTIVE AND METHODOLOGICAL REVIEW2

This article examines developments in empirical research in family therapy training since Kniskern and Gurman's (1979) review. It assesses present knowledge concerning training outcomes in marital and family therapy, evaluates research methodologies, and makes recommendations for future rearch.     

ARE TRUSTWORTHINESS AND FAIRNESS ENOUGH? CONTEXTUAL FAMILY THERAPY AND THE GOOD FAMILY

The moral dimension of family therapy theory and practice has received increasing attention in recent years. Boszormenyi-Nagy was among the first to see that family therapy and moral questions are inseparable. His focus on relational ethics has helped us to reappropriate individual responsibility and accountability within a systemic context. Although contextual therapy has clearly enriched the field, we argue that its emphasis on trustworthiness and fairness provides a limited view of the good in family life and leads to three related problems. First, Boszormenyi-Nagy offers a compelling ethical vision of the family and then denies that he has done so, which undermines some of his key moral claims. Second, because fairness is defined subjectively, contextual therapy may not have the resources to deal with legitimate differences in family ideals. Third, the reliance on self-interest as the primary motive for trustworthy relating appears to be self-defeating. We offer a hermeneutic perspective that takes a broader approach to the good. It places greater emphasis on the social and historical context, deals squarely with different understandings of the good in family life, and recommends an approach to resolving these differences.