Recommended Reading for Family Therapists

A few weeks ago, one of my blog posts received a comment that was worth a whole post:

“I am also a therapist (though I’m still in training). I’m wondering if you would be willing/able to recommend some family therapy books you’ve found helpful. My program is very focused on the individual and I’m trying to fill in some gaps and find your perspective on therapy to be very resonant with my own.”

I’d love to recommend some family therapy books! My program was extremely family-systems focused, which I’ve been grateful for since leaving school. If you want to see an exhaustive reading list (I can’t remember having been assigned a real dud), you can see reverse-order lists of everything I read in my first year here and my second year here.

I’ll try to create a bare-bones list for you here—much more useful for you and a good exercise for me. I should warn you before I begin that I am super nerdy when it comes to family therapy reading and I can imagine many in my cohort rolling their eyes at my “must-read” list. If you are nerdy like me, though, here goes:

Pragmatics of Human Communication: A classic and profound book by Bateson’s MRI team, the first and probably still the best attempt to apply system theory to human relationships.

Susan Johnson’s books The Practice of Emotionally Focused Couple Therapy and Emotionally Focused Couple Therapy for Trauma SurvivorsJohnson combines system-thinking, Rogers-style experiential therapy, and attachment theory, creating one of my most-used therapy models.

John Gottman’s books, especially The Marriage Clinic and The Science of Trust. Gottman has taken up the project started with Pragmatics, largely abandoned by family therapy, and is doing it in fine style, with solid science.

Metaframeworks: This book presents my favorite meta-model of family therapy, combining the best parts of the many family therapy models.

A major work by each family therapy model-builder is also important reading: Haley, Madanes, Satir, Whitaker, Minuchin, Bowen, Selvini-Palazolli/Milan group, Weakland/Fisch/MRI group, deShazer/Insoo-Berg, Epson/White, and Hubble/Duncan/Miller. Keep in mind that their books are presentations of informed opinion, not science. Every one of these folks have got some things right and some wrong. They have also advanced the field significantly, and are the largest part the conversation on how to think about families.

Finally, a couple things that I was not assigned in school, but I found extremely helpful in making sense of the flood of information. First, a grounding in systems/complexity theory: Family therapists think of themselves as system-theory experts and throw around a lot of lingo that they may or may not really understand. It’s easy to get confused in this situation. The best introduction to modern system thinking is still Capra’s The Web of Life (though we’re overdue for an update). Also, check out Bateson’s books Steps to an Ecology of Mind and Mind and Nature.Second, familiarity with Wilber’s integral theory really helped me navigate the heated arguments about modernism vs. post-modernism and intervention at the level of individuals vs. family systems vs. larger systems. Check out Integral Psychology or A Theory of Everything.

(Originally published as “Family Therapy Books I Recommend to Individual Therapists,” on Nathen’s Miraculous Escape.)

The Elements of Friendship According to John Gottman

John Gottman is a rock star of the science of marriage relationships. He studies them in great detail, minute interactions, facial expressions, heart rate, stress hormones. Using that data he can predict with a high degree of accuracy which relationships are heading for happiness or unhappiness, stability or divorce. I should say that this is prediction in a technical, statistical sense, not in the sense of prophecy. He can’t tell you if your relationship will fail, only whether your relationship behaves in similar ways to those that have failed in the past. Still, that’s a lot better than nothing, and it’s been enough for him to build an exciting theory of relationships.

In his theory, the most important, without-which-all-is-lost part of your relationship is the friendship. By friendship, he means several very specific things. Here is a summary of his summary from his newest book, The Science of Trust:

  1. Track your partner’s inner experience by asking lots of questions and remembering the answers.
  2. Make a habit of finding things to appreciate your partner for and letting them know each time you do.
  3. Notice the things your partner does and says that could be responded to, and respond positively to them. Pretty much all of them—you can miss or fail to respond to at most 3 out of 20.

If you are not doing this work, he says, you are not behaving like couples who manage to sustain satisfying, meaningful, passionate relationships, who manage conflict well enough, and who stay together longer than 6 years. Maintaining friendship in this manner is the bare minimum.

(First published December 17, 2011 on Nathen’s Miraculous Escape.)

Gottman’s Influenced Stable Steady State, Negative Affect Reciprocity, and Repair

John Gottman says, in his book The Marriage Clinic, that there are basically two things that make the difference between couples who stay together and those who do not. First is what he calls the partners’ “uninfluenced stable steady states,” which are a result of the temperament of each partner plus the history of the relationship.  The second is the partners’ “influenced stable steady state,” which is the emotional direction that each partner takes, once they are interacting.

If the way you feel and act worsens when interacting with your partner–that is, if your influenced steady state is more negative than your uninfluenced steady state–you may well be heading for a divorce. The crucial question is, how much negativity from your partner does it take to turn your mood negative? If you can respond in a positive way to your partner, regardless of their mood or complaint, that’s a real strength. If you respond in a negative way, this is trouble. Negativity will tend to escalate in each conversation and throughout your relationship. Gottman says that if you cannot maintain a ratio of 5 to 1 positive-to-negative interactions at worst (that is, during conflict) you are heading towards (or are in) an unhappy relationship. If you dip below a 1 to 1 ratio, you are heading toward divorce.

“Negative affect reciprocity” is a closely-related pattern that Gottman says is the best predictor of happy or unhappy couples. (“Affect,” remember, is just a science-y word for emotion.) The extent to which you are more likely than usual to be negative when your partner is negative (as opposed to when your partner is neutral or positive), you are showing negative affect reciprocity. This could look a lot of ways, like responding to anger with your own anger, responding to criticism with stonewalling or defensiveness, responding to sadness with irritation, and so on.

Gottman says that negative interactions are inevitable, so what he calls “successful repair attempts” are all-important. That is, emotional repairs such as humor, taking responsibility, compromise, and soothing, must be offered, recognized, and accepted. When couples can recognize and accept all of each other’s repair attempts, he says, they are finished with therapy.

[First published on Nathen’s Miraculous Escape, February 12, 2011.]

Two Models for Relationship Development

Last term I read Metaframeworks, a book about Bruenlin, Schwartz, and Kune-Karrer’s integration of family therapy models. It’s a fun read, but don’t run out and buy it unless you are like me, very nerdy about family therapy and a sucker for good theoretical integrations.

Metaframeworks presents two models for how relationships can grow over time. The first is a model from the 80s, by a family theorist named Wynne. In it, people in relationships develop four capacities, in this sequence:

1) Attachment/cargiving: We have “affectional bonding” with each other.

2) Communicating: We have “communicational codes” in common.

3) Joint problem solving: We have the ability to work successfully together on complex tasks.

4) Mutuality: We have the ability to renegotiate the relationship.

Metaframeworks criticizes Wynne’s model as “epigenetic,” meaning that each stage is related to the next in the way that our genes are related to our bodies: Each stage is the source and foundation of the next. If their analysis of Wynne is correct, then Wynne thought that you can’t really communicate in a relationship until you have achieved “affectional bonding.”

The authors’ scheme is similar but more complex. It has six processes that happen in relationships, and the relationships between them are “recursive,” meaning the product of each process affects the other processes. They are ambiguous about the sense in which their processes are a developmental scheme. My best guess is that they mean that each of these processes can develop in relationships, and the better developed they are, the better off we are. They say a few things that hint at a stage model, that each stage flows from the previous, and that inadequate development of an earlier process constrains later ones. But they don’t use words like “earlier” or “later” and they are very clear that the processes are related in a web-like fashion. Very postmodern. Anyway, here are the processes:

1) Attraction: We feel drawn together.

2) Liking: We appreciate and value each other.

3) Nurturing: We create safety by exchanging care.

4) Coordinating meaning: We can agree on what it means when we do and say things.

5) Setting rules: The rules by which we operate are functional.

6) Metarules: We have ways of changing our rules when we need to.

It is interesting that both Wynne and Metaframeworks consider and then reject intimacy (where “each person comes to believe in and experience the relationship as completely safe”) as a highest stage or most complex process. Wynne, apparently, does so because it is “difficult to achieve.” Metaframeworks does so because that trust can be lost, and because some couples with functional relationships never get there.

I’m not convinced. I really value intimacy in my own relationships, and I think that if we stop short of intimacy, at “stable and successful,” in our close relationships, we are missing out. And why reject a developmental stage because it is difficult to achieve?

[First published on Nathen’s Miraculous Escape, January 17, 2011.]

Depression in Couples: Literature Review and a Metaframeworks Approach

[First published on Nathen’s Miraculous Escape, January 7, 2011.]

Nathen B. Lester

University of Oregon


This paper a brief overview of the evidence and discourse about depression, focusing on its occurrence, dynamics, and treatment in couple relationships.  This is followed by an introduction to Breunlin, Schwartz, and Mac Kune-Karrer’s metaframeworks model for therapy and its possible application in the treatment of depression in couples.

Keywords: depression, couples, couples therapy, metaframeworks

Depression in Couples:

Literature Review and a Metaframeworks Approach

In the last few decades, depression has become an obsession in the US.  We are flooded with ideas about depression from television shows, magazine articles, self-help books, celebrity therapists, theoretical articles, feminist treatises, pharmaceutical advertisements and press releases, research results from biological, clinical, epidemiological, psychological, and sociological perspectives, plus critiques and meta-analyses of that research.  This obsession is not surprising, considering the medical, mortality, and employment costs of the condition are well above $80 billion per year and climbing (Greenburg, Kessler, Birnbaum, Leong, Berglund, & Corey-Lisle, 2003), considering the evidence that prevalence rates are increasing and age of onset is decreasing with each generational cohort (Craighead, 2007), and considering what an unpleasant and dangerous condition it is.  The World Health Organization has predicted that in the next 15 years depression will move from the fourth most disabling disease in the world to the second, behind only obesity/diabetes (Sapolsky, 2009).

In my practice as a couples and family therapist in training, depression is just as common a complaint as the ubiquitous “communication problems,” meaning at least one partner in every couple I have seen so far has considered themselves clinically depressed.  This paper represents my attempt to delve into the data and conversation about depression, how it is treated in couples, and to approach it using the perspective of metaframeworks, as put forth in Breunlin, Schwartz, and Mac Kune-Karrer’s (1997) Metaframeworks: Transcending the Models of Family Therapy.


What Do We Know About Depression?

We know how we define it. In the mental health profession, if someone “has depression,” we mean that they meet the criteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) for Major Depressive Disorder.  That means the daily presence of a depressed mood, anhedonia, and at least three of the following six symptoms for at least two weeks: (a) weight loss or gain of at least 5%, (b) insomnia or hypersomnia, (c) observable agitation or slowed movement, (d) fatigue, (e) feelings of guilt or worthlessness, (f) subjectively or objectively decreased cognitive ability, and (g) suicidality. Additionally, these symptoms must  impair functioning in some significant way, must not be the result of an illness or drug, and must not be the result of bereavement—that is, must not occur only within two months of the loss of a loved one (American Psychiatric Association [DSM-IV-TR], 2000).

Additionally, we define depression in terms of the number of depression-indicating responses to surveys, like the Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1980) and the Beck Depression Inventory (BDI-II) (Beck, Steer, Ball, & Ranieri, 1996).  The HRSD and BDI have participants rate symptoms, mostly DSM-IV-TR criteria, on Likert scales between none and severe.  They produce numbers which are compared to predefined cutoffs for no, mild, moderate, severe, and (for the HRSD) very severe depression.

We know quite a few correlates. Depression is associated with intense affect, especially sadness and anxiety, as well as physical pain, addiction, suicide, and social problems such as divorce, unemployment, and truancy (DSM-IV-TR, 2000).  It is also correlated with internal attributions of negative events and external attributions of positive events (Pinto & Francis, 1993).  Of the 17% of US residents who qualify as depressed at some point in their lives, between 10.5 and 18 million people at any one time, two-thirds are female (Craighead, Sheets, Brosse, & Ilardi, 2007), though the DSM-IV-TR reports that rates are even between boys and girls before puberty. The DSM-IV-TR also claims that there are no difference between those in different ethnic, socioeconomic, educational, or marital categories (DSM-IV-TR, 2000), though there is some evidence for a correlation with poverty (Kim, 2008; Vilhjalmsson, 1993) and menial labor (Bonde, 2008).

Major childhood stressors such as physical, emotional, and sexual abuse, witnessing domestic violence, separation, or divorce, or drug abuse, criminal activity, mental illness, or suicide in the household significantly increase rates of depression in adults (Anda, Whitfield, Felitti, Chapman, Edwards, Dube, & Williamson, 2002; Chapman, Anda, Felitti, Dube, Edwards, & Whitfield, 2004; Edwards, Holden, Anda, & Felitti, 2003).  Major stressors in adulthood, especially those related to social rejection, can also precipitate depression (Kendler, 2003; Kessler, 1997; Slavich, Thornton, Torres, Monroe, & Gotlib, 2009).  The highly religious appear to be more prone to depression, though more resilient against it once it occurs (Dein, 2006; McCullough & Larson, 1999).  Depression is more common among  people with major medical conditions (DSM-IV-TR, 2000).

There are no biological tests for depression (DSM-IV-TR, 2000).  There do appear to be a few biological correlates, however, including atrophy of the hypothalamus (Patterson, Albala, McCahill, & Edwards, 2010), increased stress-hormone levels, decreased growth-hormone levels (DSM-IV-TR, 2000), and a short allele of the  5-HTT gene (Caspi, Sugden, Moffitt, Taylor, Craig, Harrington, McClay, Mill, Martin, Braithwaite, & Poulton, 2003).  Being related to a person with depression increases your chances of becoming depressed as well, which is suggestive of a biological correlate (DSM-IV-TR, 2000).  Each of these factors correlate to a significant degree with incidence of depression, but none to the extent that they are candidates for a cause.

By far the strongest biological correlation with depression we know of so far are abnormalities in electroencephalogram (EEG) readings during sleep.  The DSM-IV-TR reports a correlation of 40-60% in outpatient groups and up to 90% for inpatients (2000).  Also, complete sleep deprivation has been shown to entirely alleviate symptoms of depression in over half of participants (Wu & Bunney, 1990).

Another category of correlates is treatment outcomes.  These fall into three general categories–therapeutic, somatic, and placebo–most of which are basically equivalent in their efficacy, which is to say they seem to have a lasting positive effect somewhere around half to two-thirds of the time (Patterson et al., 2010).  The evidence that we have about therapeutic treatment comes largely from clinical tests of variants of cognitive and behavioral therapies, and finds these therapies to be effective to the same degree (Wampold, 2001).  In somatic treatments depressed people take medication, have their brains shocked, have their sleep interfered with, or, in the most extreme cases, their brains operated on.  In a placebo treatment depressed people eat sugar pills which they believe might be medication.  There is evidence that some medications work significantly better than placebos for those with severe or very severe depression (Fournier, DeRubeis, Hollon, Dimidjian, Shelton, & Fawcett, 2010).  There is evidence that reducing REM sleep over time can improve symptoms of depression to the same or somewhat better than a placebo (Rieman, Berger, & Voderholzer, 2001), and there is evidence that electroconvulsive therapy (ECT) is the most effective treatment of all, at approximately 80% response rate (Patterson et al., 2010).  There is also evidence that stereotaxic anterior cingulotomy reduces the symptoms of depression (Ballentine, Bouckoms, Thomas, & Giriunas, 1987; Sapolsky, 2009; though see Cohen, Paul, Zawacki, Moser, Sweet, & Wilkinson, 2001).

What Do We Think About Depression and How Do We Treat It?

How we think about and treat depression is shaped greatly by our theoretical perspective; cognitive therapists emphasize the role of thinking  and psychiatrists emphasize the role of neurobiology.  In the face of the evidence, however, very few theorists or clinicians still believe there is a single, causative factor for depression.  Most, instead, believe some version of the diathesis-stress model, which holds that depression is the result of an interaction between biological factors, usually genetic and/or epigenetic, and some form of environmental stress, such as trauma or loss (Monroe & Simons, 1991; Sapolsky, 2009).

That said, each school of thought does think about and treat depression differently.  Psychiatrists and other medical doctors, for example, tend to emphasize the diathesis side, and see depression as primarily a more-or-less mysterious biological disease, caused by a disregulation of neurotransmitters or other hormones, or some other wiring or firing malfunction of our neural networks.  These clinicians prescribe somatic therapies based on their theoretical training.  The vast majority of patients receive medication that is thought to increase the effects of seratonin on the brain (SSRIs), and most of the rest receive one of a couple older classes of medications, thought to act on norepinepherin or on all monoamine neurotransmitters (Olfson, Marcus, Druss, Elinson, Tanielian, & Pincus, 2002; Unutzer, Katon, Callahan, Willians, Hunkeler, Harpole, Hoffing, Penna, Noel, Lin, Tang, & Oishi, 2003).  Somewhere between 8 and 60% receive psychotherapy, depending on their age (older patients get less therapy) (Olfson et al, 2002; Unutzer et al., 2003).  By comparison, other somatic treatments, such as electroconvulsive therapy, vagal-nerve stimulation, REM-deprivation therapy, light therapy, and changes in diet or exercise, are prescribed for only a tiny fraction of patients.

Those operating from the standpoint of a psychotherapeutic modality, on the other hand, tend to focus on the stress side of the diathesis-stress model, and each model has its favorite stressor.  Cognitive therapists, for example, see depression as the result of extreme, inaccurate, and pessimistic thoughts and beliefs, and treat it by helping clients recognize and counteract these distortions (e.g. Beck, 1976; Ellis, 1998).  Behavioral therapists see depression as essentially as a bad habit resulting from environmental rewards for depressive behavior and punishments for non-depressive behaviors, which are best treated by reversing that reinforcement system (e.g. Kanter, Cautilli, Busch, & Baruch, 2005).  The many, many varieties of psychodynamic therapy all have in common the beliefs that problems come from clients’ internal, unconscious conflicts, and that they are best worked out in a conversation with a therapist that leads to insight.  Different schools of psychodynamic therapy each have different emphasis, however, that  affect how they see and treat depression.  A psychoanalyst might see depression as the result of early, formative experiences that caused the client to turn their anger inward into guilt, and ask the client to free-associate and talk about dreams over a period of years, offering periodic interpretations.  Humanistic psychodynamic models such as Rogers’ client-centered therapy, Perls’ Gestalt therapy, and Yalom’s existential therapy focus more on how clients heal, in the present moment, in the presence of a therapist who is behaving authentically, than on how they become troubled.  A client-centered therapist believes that depression is best ameliorated by the client coming to trust the unconditional positive regard of the therapist (e.g. Rogers, 2003).  A Gestalt therapist believes that they can help by challenging the client to behave with complete authenticity (e.g. Perls, 1973).  An existential therapist believes that genuinely coming to grips with the reality and inevitability of suffering and death are the most helpful (e.g. Yalom, 2009).  One psychodynamic approach–psychodynamic-interpersonal therapy–was designed to treat depression.  Like other psychodynamic approaches, it focuses on emotions, interpersonal experiences, and the therapeutic relationship–but it also incorporates Bowlby’s attachment theory and typically uses few enough sessions to be called “brief therapy” (e.g. Klerman, Weissman, Rounsaville, Chevron, & Rounsaville, 1984).

Couples and family therapists have many of their own systemic views of the stress side of the diathesis-stress model.  Confronted with a client complaining of depression, an MRI-style brief therapist, for example, would first look for problematic, outdated rules that the family system is acting under, in the form of their attempted solution for the problem.  They would design an intervention that represented as much as possible the opposite of the family’s attempted solution, perhaps by prescribing depressive behavior (e.g. Fisch, Weakland, & Segal, 1982).  A structural family therapist would imagine that depression is the result of inappropriate power alliances between, for example, a parent and child against a second parent.  They would design a behavioral intervention to realign the family hierarchy, such as advising the parents to go out on a secret date (e.g. Minuchin & Fishman, 1981).  A strategic therapist might also see depression as the result of outdated rules or inappropriate power alliances, but also looks for how the depression might be serving a function for the family system—the interpersonal payoff.  If the latter is suspected, a strategic therapist might prescribe an Ericksonian ordeal, intended to make the problematic behavior more difficult to maintain than non-problematic behavior (e.g. Haley, 1984).

An experiential family therapist would find the depressogenic stress in a client’s low self-esteem, and attempt to remedy it by modeling and by leading communication exercises designed to increase authentic communication (e.g. Satir, 1983).  For a Bowenian intergenerational family therapist, stress is the result of a lack of differentiation, meaning anxiety and rigidity of behavior in response to external or internal emotional pressures.  To help increase a client’s differentiation, a Bowenian therapist explores the quality of extended-family relationships and interrupts emotional triangulation, while maintaining their own differentiation (e.g. Nichols & Schwartz, 2008).

A feminist family therapist looks for and tries to resolve stress in the form of gender- or culture-based power differentials (e.g. Leupnitz, 1988).  A solution-focused family therapist believes that stress is the result of a focus on problems, and attempts to alleviate it by focusing on and enhancing exceptions to the problems (e.g. deShazer, 1988).  A narrative family therapist sees stress as the result of clients having internalized a negative discourse about themselves from the dominant culture, and attempts to alleviate it by finding examples in the client’s life that are contradictory to that discourse and re-author a new story.  Narrative therapists also rely on a technique called externalization, where a client’s problem is given a name and the client comes to see it as not part of their self (e.g. White & Epston, 1990).

Emotionally-focused couple therapy (EFT) finds stress is in unmet attachment needs for safety, proximity, and connection.  Therapy consists of an emotional negotiation of what gets in the way of asking for and responding to requests for attachment needs, especially in relationships with a pursue-distance dynamic (e.g. Johnson, 2004).  In Gottman’s couple therapy, the stress resulting in depression is an internal working model of worthlessness and lack of control, and therapy consists primarily of developing a new story about the self, in conversation, creating new and different kinds of positive interactions (e.g. Gottman, 1999).

One other school of thought about depression does not come along with a therapeutic modality, but is worth mentioning.  Evolutionary theorists have recently suggested that while depression is unpleasant and dangerous, it may be an adaptive behavior.  There is evidence to suggest that depression is essentially a physiological state designed to enhance our analytic-rumination process in the face of complex social problems (Andrews & Thomson, 2009).  In other words, depression may help us concentrate on and think about difficult interpersonal situations.

Depression in Couples—Two Literature Reviews

Social psychologists, apparently spurred on by an insatiable desire to understand the minute details of the relationship between depression and marital distress, have amassed a mountain of evidence, from the obvious to the baffling, about depression in couples and how depression affects couples’ and family’s dynamics.  The simple version of the story is that, while complicated by gender and many other factors, there is a relationship, and it is not good.  Depression in couples is not good for the couple, the individuals in the couple, or the children that come from the couple:

Depression correlates with dysfunctional marital interactions and marital distress (Gabriel, Beach, & Bodenmann 2010; Rehman, Ginting, Karimiha, & Goodnight, 2010), but there is also evidence that it does not contribute in any unique way to a couple’s communication (Eldridge, Jones, Sevier, Clements, Markman, Stanley, Sayers, Sher, & Christiansen, 2007).  Depression is negatively correlated with relationship satisfaction (Cramer & Jowett, 2010) and positively correlated to violent and abusive behaviors in relationships (Vaeth, Ramisetty-Mikler, & Caetano, 2010).  Depression reduces dyadic adjustment (Tilden, Gude, Hoffart, & Sexton, 2010), is less likely to remit in the presence of dyadic discord (Denton, Carmody, Rush, Thase, Trivedi, Arnow, Klein, & Keller, 2010), and predicts low relationship quality (Papp, 2010).  Depression is a precursor to divorce (Doohan, Carrere, & Riggs, 2010).  Depression hinders attachment in couples (Mehta, Cowan, & Cowan, 2009).  Depression in one spouse predicts depression in the other (Goodman & Shippy, 2003) (but not in dating couples (Segrin, 2004)).  Depression in either partner predicts marital dissatisfaction (Whisman, Weinstock, & Uebelacker, 2002).  Depression can trigger relationship problems/marital distress, and relationship problems/marital distress can trigger depression (Reich, 2003; Mead, 2002).  Distressed relationships increase depression relapse (Whisman & Schonbrun, 2010).

There is some evidence about what might help. A sense of enduring control in a relationship, for example, may buffer against depression (Keeton, Perry-Jenkins, & Sayer, 2008), and marital satisfaction is higher whether or not there is depression if your spouse likes you (Sacco & Phares, 2001).  And there is some evidence about how the interactions work.  Evidence exists, for example, that marital discord and depression may be mediated by hopelessness and blame (Sayers, Kohn, Fresco, Bellack, & Sarwer, 2001).  Partners’ depressive symptoms tend to become more similar, which may be driven by their coping styles becoming more similar (Holahan, Moos, Moerkbak, Cronkite, Holahan, & Kenney, 2007).  Depression may cause marital dysfunction and psychological distress by reducing the empathic accuracy of the depressed partner—that is, because they imagine incorrectly that the non-depressed partner feels as badly as they do (Papp, Kouros, & Cummings, 2010)–but there is also evidence that depression does not affect empathic accuracy in couples (Cramer & Jowett, 2010).  It is far more common for people seeking help for depression to have a relationship in distress than for those seeking help for relationship distress to have depression (Atkins, Dimidjian, Bedics, & Christensen, 2009).

Many of the findings are gender-specific. The effects of depression on relationship problems and vice versa are greater for women than men (Reich, 2003).  For women, neuroticism increases the effect of marital distress on depression, but for men it decreases it (Davila, Karney, Hall, & Bradbury, 2003).  Negative marital interactions make women’s but not men’s depression worse if they don’t have confidence in the relationship (Whitton, Olmos-Gallo, Stanley, Prado, Kline, St. Peters, Markman, 2007).  Husbands’ depression predicts wives’ depression, but not vice versa (Kouros & Cummings, 2010).

Finally, there is a lot of evidence that depression in parents is not good for their children, correlating with less secure attachment as infants (Martins & Gaffan, 2000), for example.  Parental depression affects  children’s adjustment to school more than parenting ability does (Cummings, Keller, & Davies, 2005). And depressed parents tend to have more depressed and disabled adult children (Timko, Cronkite, Swindle, Robinson, Turrubiartes, & Moos, 2008).

Treating Depression With Couples Therapy: The Evidence

Most of the research on treating depression with couples therapy has involved behavioral marital therapy (BMT).  I found ten empirical studies looking at BMT for depression.  Five of them compared BMT to individual cognitive or cognitive-behavioral therapies (CT or CBT).  In three of those, BMT was equivalent to individual therapy in its amelioration of depression, but more than individual therapy, it reduced marital discord  (Beach & O’Leary, 1986), increased marital adjustment for depressed women (Beach & O’Leary, 1992), and increased marital satisfaction (Emanuels-Zuuveen & Emmelkamp, 1996).  In the fourth, BMT reduced depression as much as individual CT, but only for distressed couples, not non-distressed couples (Jacobson, Dobson, Fruzzetti, & Schmaling, 1991), and in the fifth, a “behavioral spouse-aided therapy” for depression was equivalent to individual CBT but had no boost for marital satisfaction (Emanuels-Zuurveen & Emmelkamp, 1997).  In a sixth study, BMT reduced wives’ depression significantly more than a wait-list control, with 67% of participants improved and nearly half recovered three months later.  Additionally, wives’ marital satisfaction increased and husbands’ psychological distress decreased (Cohen, O’Leary, & Foran, 2010).  In the seventh study, two-thirds of depressed women improved with BMT, and nearly half recovered (Cohen, O’Leary, & Foran, 2009).  In the eighth, two-thirds of depressed spouses of both genders recovered from depression with BMT (Sher, Baucom, & Larus, 1990).  In a final study, depressive symptoms actually predicted positive outcomes for BMT (Jacobson, Follette, & Pagel, 1986).

Three studies looked at cognitive-oriented approaches.  CBT family therapy for depressed parents significantly alleviated parental depression, but the nearly-large effect size (d = .49) at six months fell to a small-to-medium effect size (d = .26) at a 12-month follow up (Compas, Forehand, Keller, Champion, Rakow, Reeslund, McKee, Fear, Colletti, Hardcastle, Merchant, Roberts, Potts, Garai, Coffelt, Roland, Sterba, & Cole, 2009).  Cognitive marital therapy reduced depression as much as individual cognitive therapy for depression and was a little better for severe depression (Teichman, Bar-El, Shor, Sirota, & Elizur, 1995).  Finally, seven sessions of cognitively-oriented family therapy produced substantial and long-term recovery from depression in depressed female parents and small recovery rates for depressed male parents (Beardslee, Wright, Gladstone, & Forbes, 2007).

Five more studies looked at a variety of other couples treatments.  An “integrative approach,” combining systemic, narrative, cognitive-behavioral therapies and psychoeducation, for residential adults with depression showed improvement with significant and large effect sizes (Tilden, Gude, Sexton, Finset, & Hoffart, 2010).  A “coping-oriented couple therapy” matched CBT and individual interpersonal therapy for improving depression (Gabriel, Bodenmann, Widmer, Charvoz, Schramm, & Hautzinger, 2009).  Systemic couples therapy was at least as effective as drug therapy, and more acceptable to participants (Leff, Vearnals, Brewin, Wolff, Alexander, Asen, Dayson, Jones, Chisholm, & Everitt, 2000).  EFT was also as effective as drug therapy for depression (Dessaulles, Johnson, & Denton, 2003).  A trial that included but did not separate the effects of integrative, systemic, psychodynamic, Gestalt and behavioral therapies reduced depression by about half in couples with infidelity and by a quarter in couples without infidelity (Atkins, Marin, Lo, Klann, & Hahlweg, 2010).

Finally, a meta-analysis in 2008, using seven of the studies mentioned above and ruling many others out for various reasons, found that couples therapy and individual therapy are equally effective treatments for depression and that couples therapy has the additional benefit of relieving distress in couples, but that there is so little evidence and it has been produced and described so poorly that it is too early to recommend couples therapy as a treatment for depression 46 (Barbatto & D’Avanzo, 2008).


Metaframeworks is an approach to therapy synthesizing ideas from many different models of family therapy, plus postmodern philosophy, multiculturalism, feminism, and Bateson’s interpretation of Bertalanffy’s general systems theory.  It was developed by family therapists and theorists Breunlin, Schwartz, and Mac Kune-Karrer, and initially presented in their 1992 book,Metaframeworks: Transcending the Models of Family Therapy.  (All information about information presented below about metaframeworks, however, is based on my interpretation of their second, revised, edition of that book, published in 1997.)  Breunlin and colleagues propose that humans suffer as a result of constraints upon their intrinsically resourceful and self-actualizing nature.  These constraints exist on any of several levels of organization: biological, individual, relational, familial, communal, and societal.  Constraints also exist in any of several forms, which give the names to the six metaframeworks: mind or “internal family systems” (IFS), sequences, organization, development, multicultural, and gender.  The level and form that constraints exist on and as interact to form a web of constraints, which can be conceptualized as in Figure 1 (see appendix).  In this conception, clients’ problems can exist as a result of constraints at any combination of points in the web.  The job of the therapist is, in a flexible, collaborative, and intuitive process, identify and release the constraints that are not allowing clients to resolve their problems.

The Role of Systems Theory

Systems theory is a body of thought concerned with “whole” patterns of organization and interaction and the relationships between them.  In metaframeworks, those wholes (calledholons) are characterized as a distinct network of parts which interact recursively by a set of organizing rules that allow for both adaptation and stability.  Holons exist and interact both in parallel and in hierarchies. For example, the organs in a human body are each holons, interacting with the other organs in various ways. At the same time, each organ is also interacting with the holons at higher (the whole body and “up”) and lower (individual cells and “down”) levels of organization.  The nature of all of these interactions is said to be recursive, meaning the action of each part of each whole at each level of organization affects the actions of every other part of every other whole, at every other level or organization.
A metaframeworks-oriented therapist uses the lens of systems theory to work towards a rich, holistic view of their clients, and to keep in mind all of the levels of organization that constraints might exist on, and how those levels might interact.  An individual client might be constrained by a biological disease process, for example, or an oppressive economic system.  Additionally, the disease, the person, and the economic system all interact with each other, each one possibly generating, regulating, or supporting the others in different ways.  Without a systemic view, we miss might these interactions and, therefore, possible points of intervention.

Epistemology and Assumptions

A metaframeworks-oriented therapist works grounded by a view of reality, health, human nature, and change based on four assumptions.  First, they take a middle-of-the-road constructivist stance, called perspectivism.  That is, our senses and thinking do produce maps of a reality that exists independently, but our maps are always limited by our perspectives—our senses, beliefs, and cultures.  Furthermore, some maps are more accurate than others.  Second, it is more accurate and useful to think of human problems in terms of constraints than pathology.  That is, if we assume that a client is suffering or dangerous because we have yet to identify and resolve factors that are holding them back from their potential, we are much more likely to help them than if we assume that they are evil or broken.  Third, healthy systems are characterized by balance, harmony, and leadership.  It is the job of certain parts of a system to provide flexible coordination and regulation for that system, and lack thereof indicate that the leadership of the system is acting under constraints.  Likewise, escalation, rigidity, and failures to adapt or meet the needs of some parts of a system are indications of constraint.  Fourth, metaframeworks-oriented therapists believe that intrapsychic work with the subpersonalities of an individual client is often important to resolve constraints.  The rejection of inner work by behaviorists and early family theorists limited the ability of therapists to identify and resolve constraints.  Furthermore, subpersonalities are organized and interact in the same way that parts of other systems are organized and interact:  They are ideally balanced and harmonious, and have strong leadership in the Self, which is similar to Freud’s concept of ego, but they can become polarized, extreme, or rigid and thus constraining.

Using Metaframeworks

Each of the metaframeworks is a perspective from which to look for and at constraints at any level of organization.  Each has its own conceptual framework, vocabulary, and can suggest different hypotheses and interventions.  The metaframeworks approach uses these perspectives with a blueprint for continually and collaboratively expand and fine-tune therapy for each client.

Internal family systems. IFS is a model of therapy as well as a metaframework.  As a metaframework, it is essentially a psychodynamic theory, positing the existence of a Self plus any number of subpersonalities, each filling a specific role.  We may have a creative part, a cautious part, an adventurous part and so on.  IFS holds that trauma can cause a breakdown in the organization of our subpersonalities.  Instead of balanced and harmonious parts lead by a strong self, some parts can become dissociated and others can come to overshadow the Self.  A typical result of trauma is that the Self becomes weak compared to three categories of parts: exiled parts holding scary, painful memories which can be triggered, manager parts which are vigilant for danger and keep the exiled parts exiled, and firefighter parts which react aggressively if apparent danger or an exile get too close.

As a model of therapy, IFS gently works with the Self of a client to calm and contain the manager and firefighter parts so that the exiled parts can be heard and healed.  When this happens, the Self naturally regains leadership of the intrapsychic system.

Sequences. The sequences metaframework is a way of looking for constraining patterns of behavior at different time increments.  Constraining patterns can exist at the level of individual interactions, such as conversations or arguments, at the level of daily routines, such as work or school schedules, at the level of longer cycles, such as yearly holiday rituals or seasonal production cycles, or at the level of intergenerational patterns, such as inheriting a tendency for abusing people or substances from parents or grandparents.  Breunlin and colleagues also acknowledge the possibility of longer cycles, such as Strauss and Howe’s (1991) four-generation cycle, or even larger societal shifts of values.  The different temporal levels of patterning also interact with each other recursively.  Patterns at any level can exacerbate or ameliorate patterns at any other level.

A metaframeworks-oriented therapist who suspected constraining sequences would choose interventions from models of therapy which specialize in the relevant temporal level of sequence.  Constraints at the level of face-to-face interactions, might best be resolved using techniques from the MRI school of thought, for example, while constraints at the level of intergenerational patterns might be best resolved using Bowenian interventions.  Or if a therapist suspects that one pattern is ameliorating a different, more constraining pattern, solution-focused interventions may be the most appropriate.

Organization. The organization metaframework is used to assess for constraints of balance, harmony, and leadership at various levels of organization.  Balance is a state in which each part of a system has an appropriate amount of resources and power compared to other parts. Harmony is the presence of cooperation and a balance between autonomy and interconnectedness between parts.  Some parts of a system appropriately provide leadership for that system, regulating the flow of resources, and planning for the future with the health of the whole system in mind.  Parents, for example, appropriately fill this role in nuclear families, and elected leaders in democratic societies.  Weak, rigid, or extreme leadership indicates constraints on a system’s organization.

A metaframeworks-oriented therapist who suspected organizational constraints might choose interventions from models of therapy which specialize in that kind of organizational constraint.  Structural, strategic, and Bowenian family therapies, for example, focus in different ways on the quality of boundaries and leadership in a system which can constrain harmony and balance.

Development. The development metaframework reminds us that there are more or less predictable developmental pathways that each level of organization follow.  It is important to keep the milestones of those paths in mind in order to recognize, normalize, and ameliorate constraints that can appear at each stage of each level: biological, individual, relational, and familial, recognizing a recursive relationship between developments at all levels, including societal.  Breunlin and colleagues use an adaptation of Carter and McGoldrick’s (1988) family life cycle theory for family development, an adaptation of Wynne’s (1988) relational development theory for relationships, and posit a theory of individual development in which people in a transition between more stable stages exhibit an oscillation between behaviors appropriate to the old and new stages.  In the absence of constraints, the oscillation dampens towards the new stage.  An oscillation of competence that is maintained is a clue to the presence of significant constraints.

A metaframeworks-oriented therapist should notice and resolve four types of developmental constraints, promoting synchronous development between all levels of organization:  First, if a family is not adapting flexibly to a new life-cycle stage, they are encouraged to notice and adapt to their new circumstances.  Second, if an individual is exhibiting behavioral oscillations, the therapist collaborates with the family to facilitate age-appropriate competence.  Third, in the presence of a biological constraint to development in an individual, the therapist encourages the family to adjust their expectations appropriately.  Fourth, therapists  help enhance any underdeveloped relationship qualities: attraction, liking, nurturing, coordinating meaning, rule setting, and metarules.

Multicultural. The multicultural metaframework is a perspective for therapists to use which takes into account the cultural diversity present in both our clients and ourselves, and the potential interactions between those cultures.  They include immigration status, economic status, education, ethnicity, religion, gender, age, race, minority/majority status, regional background, sexual orientation, disability, and the presence of marginalizing physical characteristics.

A metaframeworks-oriented therapist uses the multicultural metaframework to generate questions, conversations, and knowledge about how the therapist’s and clients’ diversity affect the experiences we have and the meanings we make of them.  The degree of cultural overlap, orfit, between client and therapist, majority and minority factions, or between immigrant and host cultures is a clue to the possibility of constraints; any area of cultural incongruity is likely to produce constraints on the part with less resources and control.

Gender. The gender metaframework is a systemic feminist perspective on therapy, based on the ideals of egalitarianism between genders and ecofeminism, a philosophy of interrelatedness and compassion between all.  Breunlin and colleagues propose a developmental scheme for gender in relationships from traditional, with patriarchal gender roles, to gender aware, where women begin to become angry and men fearful about power and gender roles, to polarized, where those angry and fearful parts are running the show, to balanced, where an egalitarian organization is idealized by both men and women, who work to achieve it.

A metaframeworks-oriented therapist uses the gender metaframework to highlight and attempt to release clients from the constraints of patriarchy.  The therapist identifies the gender stage a client and/or client system is at, and uses questions, statements, and directives designed to move the client or system toward the balanced, egalitarian stage.

The blueprint for therapy and the role of the therapist. A metaframeworks-oriented therapist aims to find and remove constraints that are holding clients back from flexible adaptation, balance, and harmony, keeping in mind that problems can be generated by a recursively interacting constellation of constraints existing at any level of organization, and in the form of any of the metaframeworks’ domains.  This means that therapy for each client will be unique, addressing their particular constellation.  That unique therapy is accomplished with four recursively interacting processes:  (a) Hypothesizing is taking an educated guess at what relevant constraints exist, taking care to remain curious rather than adamant about the truth of hypotheses.  (b) Planning is collaboratively implementing techniques and interventions from any model of family therapy that the current hypothesis suggests, taking care to tailor those interventions to fit the assumptions of metaframeworks.  Planning includes relating, or maintaining the therapeutic relationship, staging, or keeping an eye on the current position in the therapeutic arc, and creating events, which is the actual implementation of interventions.  (c) Conversing means conducting the therapeutic conversation, using questions, statements, and directives, taking care to use language that does not produce defensiveness or confusion in clients.  (d) Reading feedback is the process of recognizing and distinguishing the importance of what clients do and say, taking care to remember that clients are speaking and we are listening from the standpoint of personally and culturally limited perspectives.

A metaframeworks therapist relates to their clients under two balancing principles.  First, it is the therapist’s job to provide leadership for the process of therapy.  Second, for a true collaboration, the therapist must remain honest and clear about what they are doing, thinking, and why.  Under those principles, the therapist moves intuitively between the four components of therapy, hypothesizing, planning, conversing, and reading feedback, and between the six metaframeworks, mind/IFS, sequences, organization, development, culture, and gender.  Doing so, they are most likely to recognize the relevant constraints and deliver effective interventions in a respectful way.

Evidence and a Rationale for the Use of Metaframeworks

There appears to be very little experimental evidence to date supporting Breunlin and colleagues (1997) theory of therapy specifically.  A PsychInfo search on December 3, 2010 for “metaframeworks” produced, for example, only 15 relevant hits.  Two of those were editions of Breunlin and colleagues’ book (1992; 1997), 5 were theoretical chapters (Breunlin & Mac Kune-Karrer, 2002; Breunlin, Rampage, Eovaldi, Mikesell, 1995; Foy & Breunlin, 2001; Lebow, 2003; Rampage, 1998), 3 theoretical doctoral dissertations (Luther, 1995; Nehring, 1998; Schneider, 1998), 2 theoretical journal articles (Breunlin, 1999; Pinsof, 1992), 1 journal article about a metaframeworks training video (Cohen & Abed, 2003).and 1 book review ( Lawson, 1993).  The only hits purporting empirical evidence about metaframeworks (Oulvey, 2000) admits in the abstract that the research design invalidated any results.

A PsychInfo search for “internal family systems” did little better:  The approximately 20 relevant hits were overwhelmingly theoretical presentations or critiques.  The 3 empirical hits consisted only of case reports.  Two were of a successful treatment of a 17-year old female with bulimia (Schwartz, 1987; Schwartz & Grace, 1989), and the other of an African-American family with a young, female sexual abuse survivor (Wilkins, 2007).

Though this may not represent every piece of empirical evidence supporting the metaframeworks theory of therapy, it is clear that neither its tenets nor effectiveness have any strong empirical support.  While we cannot assert with any certainty what forthcoming evidence will suggest about metaframeworks, we can safely assume that the present dearth of evidence in either direction is a result of the newness of the theory rather than the bias of scientific journals against publishing null results.

A rationale for the use of metaframeworks at this point, therefore, must be primarily theoretical.   Theoretically, the efficacy of a therapist using metaframeworks is likely to fall within the same range as other models of therapy, since all models of therapy that have been tested so far appear to function in approximately the same range (Miller, Duncan & Hubble, 1997).  Why should metaframeworks be different?  There are optimistic and pessimistic views:

An optimist about metaframeworks might say that metaframeworks stands to outperform other models for two reasons. First, the stress in the diathesis-stress model is likely to exist in many different forms, and metaframeworks looks systematically at most of the forms we know about, where other models tend to focus on one or two.  Second, to the extent that the efficacy of therapy relies on model-specific techniques and interventions, famously estimated at 15% by Lambert (1994), metaframeworks can benefit from the techniques of every model of family therapy, plus multiculturalism, feminism, and psychodynamics.  Adopting those ideas from other models when appropriate will potentially benefit a metaframeworks-oriented therapist without falling prey to any specific model’s blind spots or other weaknesses.  Metaframeworks’ strength is the sum of the strengths of other models.

A pessimist about metaframeworks might argue that the complexity and sophistication of metaframeworks could stand in the way of success.  We still operate inside a 50-minute-per-week schedule, after all, and there’s only so much one can accomplish in that time.  Perhaps metaframeworks is just an extra-confusing and complicated way to provide the benefits of a therapeutic relationship.  If that is the case, metaframeworks may turn out to be somewhat less effective than other models of therapy.

At this point, there is not enough evidence to say who is right, or where on that optimist-to-pessimist spectrum “right” falls.  For the therapist who is a metaframeworks optimist, like myself, it is clearly important to know the model thoroughly, be able to negotiate its concepts and connections fluidly, and to be fluent with nearly all of the interventions of IFS and the other family therapy models.  Not to do so would be to fall prey to the critique of the pessimist.


Though an optimist about metaframeworks, I believe I see weaknesses in the model. As a family therapist in training, all I can offer is a theoretical critique of the theory, and having just made contact with metaframeworks, my critique may be severely limited by my understanding, but it will show the extent of my understanding.

First, it is not clear to me how the IFS model is a true metaframework the way sequences, organization, and the others are, existing at every level of organization.  IFS seems to be primarily a model for working with individuals’ internal dynamics—almost more of a level than a metaframework.  How does a society-level constraint show up in the IFS framework, for example?  Also, once you admit that working with psychodynamics is useful, you will need to justify using a new model like IFS over a more mature model, of which there are many.  The idea of using systems thinking to approach psychodynamics is intriguing but somewhat less intuitive than systems thinking for families.

I have similar questions about the developmental metaframework.  While Breunlin and colleagues (1997) mention changing values at the level of societies, there is no attempt to put forth a developmental scheme.  Change is not development in the psychological sense.  There are society-level developmental schemes available, such as those put forth by Gebser or Graves (e.g. Graves, 1970; Wilber, 2000) which might be useful in creating a true developmental metaframework.  Development is also ignored on the community level, though I have no ideas on how to improve that.  The developmental scheme put forth for individuals, that of oscillation at developmental nodes, is simplistic compared to the wealth of knowledge developmental psychologists have discovered.  They make no mention even of the foundational work of Piaget, Kholberg, or Gilligan.

The gender metaframework has elements of cultural imperialism:  The therapist knows better than the clients and is duty-bound to change them, if possible.  I believe the problem lies in the gender-relations developmental scheme.  In the description of traditional to gender aware to polarized to balanced there is the clear judgment of very bad to less bad to even less bad to good.     While there is truth to this judgment, it limits the therapist, I think.  A better developmental scheme would, as an option, allow for and encourage a positive expression of traditional value-structure,s rather than a simple, negative judgment of the large majority of the earth’s cultures.

Finally, while metaframeworks seems to do an admirable job of integrating the good ideas from the original systems-oriented therapies, it provides no clear space for the good ideas from other therapy models.  I am specifically missing three elements.  First, Johnson’s twin breakthroughs of incorporating attachment theory and a focus on emotions in couples therapy (e.g. Johnson, 2004).  Second, the tools of cognitive therapy for examining meaning and resolving problematic meaning-making (e.g. Beck, 1979).  Third, mindfulness practices and interventions (e.g. Dimeff, Koerner, & Linehan, 2007).


Metaframeworks and Depression in Couples

As a metaframeworks-oriented therapist, when presented with a couple who complain of depression, I would assume that these are naturally resourceful people who are operating under some constraints right now.  It is likely that some number of factors in the web of possible constraints is providing the stresses that have triggered and maintained the symptoms of depression.  I would enter into a conversation with this couple, listening for clues as to what these constraints might be, at what level of organization, and seen clearest with the perspective of which metaframework.

It may be that one of those constraints is biological and at the individual level of organization—that is, a genetic tendency for depression—and that antidepressant medication or some other somatic intervention would be necessary.  If a thorough assessment for suicidality is negative, however, I would try out other hypotheses first, to see if releasing other constraints is adequate, as antidepressant medications have side effects while the releasing of other constraints does not (Breunlin et al., 1997).

I would take the couple’s lead in our conversation.  What do they think is important to talk about?  Chances are, they have some strong and useful ideas about where their stress is coming from, or at least when it is they feel the most stressed and when and where they feel the least stressed.  During the conversation I would keep the metaframeworks in mind, and the levels of organization, listening for clues about which hold the relevant constraints, which I would follow up on, developing and checking out hypotheses.

Do they complain about communication problems?  That would be a clue that the sequences metaframework may be involved at the interaction level.  If that checked out, it might suggest an interaction-oriented intervention, such as Gottman’s soft-startup psychoeducation, or one of Satir’s congruent-communication exercises.  I would also keep in mind the other levels of sequences.  Is there evidence for constraining daily routines?  Any chance of seasonal affective depression or holiday blues?  How about a history of depression in the family, a possible intergenerational sequence?  I would keep in mind that any sequences I come across can interact recursively with each other, generating, maintaining, regulating, or exacerbating each other.  I would hold my hypotheses lightly, listening for evidence against them, and when I felt like I had a good one, I would try an intervention, watching and listening for, and respecting, any feedback I got from the couple.  Whether or not the intervention brought out evidence for or against my hypothesis, I would use that evidence to generate new directions in the conversation, new questions, more accurate hypotheses.

I may come to suspect that internal family systems are involved in the depression, perhaps in the form of a polarization between angry and disappointed parts of each partner, or between perfectionist and overwhelmed parts of one of the partners.  If that seemed like the case, I could try working with the parts, calming the extreme parts and encouraging the leadership of the Self.  Throughout the process, I would keep in mind that both the levels of organization and the metaframeworks interact recursively.  Are these parts reflected in an intergenerational sequence?  A family-level organization pattern? How about a society-level pattern?  I would follow up on any relevant-seeming clues, getting feedback from the couple, developing a richer understanding of their situation.

I would keep an eye out for organizational and developmental constraints.  Does the couple lead their family appropriately?  Are there parentified children? Cross-generational coalitions?  These might begin to suggest structural or strategic interventions, modified for maximum respectfulness, of course.  Are they at a nodal point in the family life cycle? Having their first child? Launching their last child?  Is there evidence of an oscillation in competence?  To what stage has their relationship developed?

I would investigate and keep in mind the couple’s multicultural and gender aspects, watching for friction from a poor cultural fit, or gender-based power dynamics.  Is either partner an immigrant?  Second- or third-generation American?  Is their socioeconomic class a fit with each other, or suffer from the constraints of poverty?  What is their sexual orientation and what other ways do they identify with majority or minority cultures?  How do they think about religion?  Education?  How about gender?  Have they taken on traditional gender roles or have they begun to chafe under them?  Achieved balance?  How might I support the partner who has less power to stand up for themself?  How might I support the partner with more power to more gently move through the transition to gender balance?

Culture and gender are also where I would keep a close eye on myself:  How might my culture and gender be constraining my thinking or compassion with this couple?  How might our similarities or differences blind me to possible constraints?  I would quite possibly check in with a colleague or supervisor about this.

Ideally, I would move our conversation with purpose and fluidity through, and back and forth between, the different metaframeworks and the different levels of organization, identifying and releasing constraints by staging and creating events and reading the feedback.  If the depression was the result of just a few constraints, the process might be fairly simple.  If the depression was the result of a dense, heavily embedded constellation of constraints, the process might take longer and involve many iterations of rethinking, shifting hypotheses, trying out different angles and interventions.  Ideally the process would also be intuitive, so that I could just follow my natural curiosity and the natural flow of our conversation.  And, ideally, as a result of our conversation, the other events, like interventions, we orchestrate in our relationship, and the quality of our relationship, the constraints release and the couple finds that they no longer struggle with depression.






















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Mind Sequence Organization Development Culture Gender

Figure 1. The levels of organization as conceptualized by Breunlin, Schwartz, and Mac Kune-Karrer (1997) are on the vertical axis and the metaframeworks are on the horizontal axis.

Gottman’s Four Horsemen of the Apocalypse

John Gottman has been the leading researcher on romantic couples–mostly marriages–for at least a decade. He has developed a technique for analyzing conversations that lets him predict with a lot of accuracy whether that couple will stay together during the next several years. One of the things he does is video a couple talking about a contentious subject and code the conversation for what he calls the four horsemen of the apocalypse: criticism, defensiveness, contempt, and stonewalling. The presence of these behaviors indicates that the relationship is being corroded.

Here’s a paraphrase of how he defines the four horsemen in The Marriage Clinic: A Scientifically Based Marital Therapy:

Criticism: Any statement that indicates that one partner thinks there is something wrong with the other, such as “What’s wrong with you?” or “You always blah-blah-blah.” Note that what he calls criticism is different from complaining. In a complaint, one partner says that they didn’t like something that the other did. For a complaint to become criticism, it needs a barb. A generalization like “You always…” or “You never…” will do, as will making the complaint about a character flaw, rather than a specific incident, like “Why would anyone do that?”

Defensiveness: When one partner acts as if the other is attacking them. Instead of directly responding to a statement, for example, the defensive partner might respond with a “counter-attack” like “What are you complaining about? You’re worse than I am!”

Contempt: Any statement or action which implies you are a better person than your partner, like mockery or eye-rolling. There is a facial expression for contempt, which Gottman also codes for. This is a version of  the sneer, from

Stonewalling: When one partner removes themselves in some way from the conversation. This can be by leaving or ceasing to respond. Often this is combined with attempts to not show emotion on the face. This is the worst of the horsemen, just ahead of contempt. It seems to be quite difficult for a relationship with this kind of behavior to remain viable.

Gottman says that some amount of four-horsemen behaviors (except contempt, which apparently never happens in happy couples) are inevitable, and that what is critical is not that they don’t happen, but that they are repaired by soothing, softening, or meta-communicating.

[First published on Nathen’s Miraculous Escape, July 18, 2010.]

Virginia Satir’s Criteria for Terminating Treatment

Virginia Satir lays out three sets of criteria for terminating treatment with a couple–criteria which, when met show that therapy has been successful. This is my favorite set, from p. 228 of Conjoint Family Therapy. The individuals in the couple can:

Be direct, using the first person “I” and following with statements or questions which:



Acknowledge an observation

Find fault

Report annoyance

Identify being puzzled

Be delineated, by using language which clearly shows “I am me” and “You are you.” “I am separate and apart from you and I acknowledge my own attributes as belonging to me. You are you, separate and apart from me, and I acknowledge your attributes as belonging to you.”

Be clear, by using questions and statements which reflect directness and the capacity to get knowledge of someone else’s statements, direction, or intentions, in order to accomplish an outcome.

I find these criteria charming, but I don’t think I will be able to use them overtly, for a couple reasons. First, insurance companies want a DSM diagnosis and a clear resolution of the Mental Disorders indicated. Satir did not speak their language. She didn’t like to label people.

Second, supervisors tend to want behavioral definitions of specific problems, so our treatment plans can say things like “The couple reports arguments have decreased from 4 times a week to 2 times a week, and that the intensity of those arguments have decreased from 7 to 4 on a 10 point scale.” This can be more collaborative and transparent with clients. It can appear to make things measured and therefore authoritative and amenable to research. I will have to write my treatment plans like that during school and probably any time I’m working for someone else. I’ll get good at it. Maybe I’ll come to like it.

[First published on Nathen’s Miraculous Escape, June 22, 2010.]

The No-Secrets Policy

Yesterday, I participated in my master’s program’s OSCEs–Objective Structured Clinical Exercises–for the students in the year ahead of me, who are about to graduate. My cohort played clients in specific, challenging scenarios for the second-year-cohort therapists. The activity was adapted from a medical school test of clinical ability.

My scenario was the most challenging of the day. The therapists came in expecting to be doing a goal setting exercise with a couple but found that only one of us (me) had showed up. I was to immediately disclose an affair and request that the therapist not tell my wife about it. I had ended the affair, felt very guilty about it, and was certain that revealing it would destroy our relationship. I was to try and get the therapist to help me with the “things that pushed me to do this.”

I am not a good actor, so it took all my attention just to get my part across in a semi-believable way. When I watched my cohort-mates play the same part, though, it was heart wrenching. They did such a good job showing remorse, almost crying, showing the fear of losing their husbands, and over “a stupid mistake.” (Well, three stupid mistakes with one person.) I really felt for them–and they were just pretending! I can see how much preparation I will need to do to handle this kind of situation effectively. I am certain to have clients who have affairs. I just looked up the statistics, and the lowest numbers I found are that about 15% of married women and 25% of married men have sexual affairs. That means that at least one out of four couples I see will have had or are heading towards an affair.

Our clinic has a “no secrets” policy for couples counseling. It’s something we bring up on the first day of therapy. If one member of a family has an individual session, what is said in that session is not going to be confidential to the rest of the family. The idea is that for this work, it is the relationship that is our primary client, not the individuals, and that secrets (differentiated from privacy) are toxic to relationships. Also, if the we are brought into one person’s secret and keep it, we can no longer serve the relationship without bias.

I think that the no-secrets policy is a good idea and I have been planning to use it in my work, but now, seeing it in practice, I see that it’s not just a matter of having a policy. I will need to thoroughly wrap my head around how it will apply in different scenarios. I will need to talk it through with a lot of people so I feel comfortable and confident in my thinking. I will also need to remember to remind clients about the no-secrets policy the moment I see that a couples client has come in alone. We introduce the policy during the first session, but that may not be what a client is thinking about when they disclose an affair. They may think that I have trapped or betrayed them if their disclosure is followed by, “Remember that no-secrets policy we talked about during our first session?”

Ideally, in this case, we would work together with the client on a palatable way to reveal their actions to their partner and then work with the couple to heal the rifts. We don’t automatically tell the partner about affairs, either. There are some things that we are required by law and ethics to report, like death threats or the abuse or neglect of a child, but affairs are not one of them. If the cheating partner refuses to allow revealing the secret, I would have to refer the couple, for suitably non-specific reasons, to another therapist who could be unbiased, if in the dark.

I think that I need to rid myself of some countertransference when it comes to affairs. That is, as it stands, I think I might favor cheat-ee over cheating clients, because it’s harder for me to relate to cheating. I walked out of our role plays thinking, “Wow, it’s so much simpler and less painful to avoid an affair than it is to deal with the aftermath!” Can anyone recommend a good book or movie that could help me empathize with someone having an affair–especially someone who feels like they are not in control of their actions, or just not thoughtful, in sexual infidelity?

This is interesting and sometimes painful work I am getting myself into!

[First published on Nathen’s Miraculous Escape, February 17, 2010.]

Meta-Worry Man

Doing therapy is all about “going meta,” which basically means taking a one-level-up perspective. In my  couples and family therapy program that usually means talking or thinking about the process couples or families are involved in (are they, for example, acting out a pursuer-distancer pattern?) versus the content of their conversations (the specific complaints, “He never takes out the trash,” “She’s always on my back,” etc). Talking about talking is “meta-talking.” Thinking about thinking is “meta-thinking.” This is an idea I had during a lecture:

[First published on Nathen’s Miraculous Escape, December 8, 2009.]