6

strategies and Techniques

in Intervention
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The previous chapter accentuated the common factors that underlie

the practice of couple and family therapy today. This chapter moves that
conversation further, beyond the usual broad foci that typically are the sub-
ject of discussions of common factors such as alliance or engaging hope. In
this chapter, I examine the shared repertoire of core strategies and techniques
for intervention that has developed in the field. The practice of couple and
family therapy includes a shared base of concepts, intervention strategies,
and techniques. Understanding this shared base of concepts and strategies
and how to apply them are now largely core competencies within the practice
of couple and family therapy (Kaslow, Celano, & Stanton, 2009).
Almost all couple and family therapists have favorite combinations of
these methods. Although very few therapists use all of the available strate-
gies and techniques, many therapists draw on a large number at some time.
Simply because a strategy or technique originated in one approach does not

http://dx.doi.org/10.1037/14255-006
Couple and Family Therapy, by J. L. Lebow
Copyright © 2014 by the American Psychological Association. All rights reserved.

129
 mean that it remains the exclusive property of that approach. Therapists
typically assimilate strategies and techniques into their particular methods.
That it is possible to compile such a generic list of elements therapists
use does not imply that most therapists will either view families similarly
or intervene in the same way in specific cases. What is primary and what is
secondary in a case often remains in the eye of the beholder, and therapists
may choose different strategies when encountering the same family. Those
different strategies, however, emerge from a common base for intervention
and in most instances constitute alternative methods toward similar ends.
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Systems theory points to the interrelation of all effective intervention strate-

gies; changes in one aspect of the system promote and relate to changes in
other parts. As Haley indicated (with irony, since he was making the case for
family systems intervention), even individual child therapy ultimately affects
the entire system (Haley & Lebow, 2010).
What follows is a list of the most frequently used concepts, interven-
tion strategies, and techniques in couple and family therapy. This list reflects
the wide range of strategies; therapists select from these strategies according
to their case formulation, their personal preferences for intervention, their
understanding of the acceptability of these strategies to the clients in spe-
cific cases, their sense (hopefully informed by research) as to how useful a
strategy is likely to be in a specific case, and feedback from the clients about
the method. Along with the common factors described in Chapter 5 of this
volume and the conceptual frameworks in Chapter 2, these strategies and
techniques represent the core building blocks of couple and family therapy.

Setting Specific Treatment Goals

Goal setting is a common factor in couple and family therapy; sim-

ply setting goals engages what typically is a force toward change. Moving
beyond this common factor, the choice of specific proximate and ulti-
mate goals plays a pivotal role in shaping the direction of treatment. In
1978, Alan Gurman presented in a groundbreaking paper a list of generic
goals underlying family therapy and how the goals and treatments of that
time selectively chose among them. This section builds on and updates
Gurman’s discussion.
Different models of couple and family therapy often diverge in their
proximate goals and occasionally even their ultimate goals. However, proxi-
mate and ultimate goals are not unique to specific approaches; they readily
can be compiled into a comprehensive list of goals. Each kind of therapy,
therapist, or specific therapy with one family can then be envisioned as
selecting from such a comprehensive list in defining the goals of treatment.

130       couple and family therapy

 Each of the models of couple and family therapy envisions specific
pathways toward achieving change. In almost all cases, one ultimate goal
is relational change, and in many cases individual change is also a goal.
Schools of practice vary in targeting different aspects of family life and pos-
iting different proximate goals for achieving those changes. For example,
structural therapy targets the ultimate goal of changing family structure
through the proximate goal of creating enactments. Narrative therapies
aim toward constructing new narratives through the proximate goal of
creating collaboration. Similarly, psychodynamic approaches look to cre-
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ate self-understanding and a corrective emotional experience, whereas

cognitive-behavioral approaches aim to change contingencies, cognitions,
conditioning, and social exchange.
Fortunately, typical practice of couple and family therapy (and even
the more recent versions of most models) has evolved to incorporate both
proximate and ultimate goals from various sources. Increasing insight, chang-
ing behavior, altering cognitions, creating new narratives, increasing positive
exchange, changing structure, and numerous other goals are now incorpo-
rated into a wide range of treatments. Even the old debate about how much
to emphasize relational or individual goals is now more often regarded “both–
and” rather than “either–or”. A more narrow vision of treatment goals has
largely been replaced by a shared, widely accepted common core of goals for
couple and family therapy.
This is not intended to minimize differences in goals or the impact
of those differences. As therapists target different proximate and ultimate
goals, treatments are likely to move in different directions that flow from
these goals. Such differences are still often encountered. An emotion-focused
therapist is far more likely to target the proximate goal of changing emotion
than a cognitive-behavioral therapist, even as these models expand to incor-
porate a wider range of proximate goals.
Instead, the central point here is that the guiding proximate and ultimate
goals of any couple or family therapy are not unique to that approach or ther-
apy; these choices are anchored in a generic list of treatment goals. Further,
there is considerable value for therapists in recognizing this set of potential
goals (e.g. focusing emotion, exploring the past, changing contingencies) and
relating work in specific case to such a list of generic goals. Additionally, as
therapies become more integrative, there is a trend toward greater incorpora-
tion of proximate goals associated with other models in host models.
It is essential for intervention strategies to be consistent with proximate
and ultimate goals. For example, in what Baucom, Whisman, and Paprocki
(2012) referred to as partner assisted treatment and disorder specific treatments,
it would be a mismatch to aim for relational change as a goal given that rela-
tionship change is not a target. Similarly, therapists who regard experience in

intervention strategies and techniques      131

 family of origin as the linchpin of treatment appropriately almost always use
genograms, whereas those focused on here and now interaction do not.

Monitoring

Evolving from the behavioral tradition but also relevant in many

other treatments is monitoring, the careful observation and recording of
activities (Jacobson & Margolin, 1979). Such tracking has great value,
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both in assessment for helping target problems and strengths, and in rais-
ing client awareness about those problems and strengths. The simple act of
tracking itself often produces some change (Lyons, Howard, O’Mahoney,
& Lish, 1997). Tracking of one’s own patterns, called self-monitoring, is
especially helpful. Research has repeatedly shown that tracking in real
time is much more accurate than recollection (as when clients recall the
frequency of a behavior that occurred during the week at the time of a ther-
apy session; Reis, 2001).

Psychoeducation

Almost all couple and family therapists offer information aimed at

increasing client knowledge about their presenting difficulties or life situa-
tion. Often, even with the ready availability of information through media
and the Internet about problem areas and life events, clients lack such infor-
mation or have learned from inaccurate sources. Therefore, couple and family
therapy often helps families understand the problem areas they face better
and the routes that are most successful in responding.
Most frequently employed is psychoeducation about relational life. This
may involve learning about the skills needed in relating, how to engage in
a fair fight, successful parenting skills, what to expect in various stages of
the family life cycle, or what to expect in various special situations such as
divorce and remarriage or living at the interface of cultures. This more scien-
tific version of wisdom passed down about specific topics across generations
can have a powerful positive effect on family process.
The other major focus of family psychoeducation deals with specific
conditions or life circumstances the family faces, and particularly disorders.
Much valuable information has accrued about the nature of various mental
health conditions, physical illnesses, and other specific problems, which can
help families place their own reactions in context and adapt.
The content of psychoeducation varies widely with the problem and
theory about the problem that is in focus. Sometimes illness models are

132       couple and family therapy

 fully incorporated into such presentations, whereas in other variants medi-
cal models are examined only as possible explanations for the problem, or
there may be some other central explanatory concept entirely. For schizo-
phrenia or bipolar disorder some version of a disease model is almost invari-
ably part of psychoeducation, whereas for substance abuse or depression a
disease model of these disorders may or may not be part of the explanatory
construct.
Whatever position is chosen in relation to presenting a medical model
of disorder, psychoeducation about helpful and harmful family patterns in
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relation to the problem, such as lowering expressed emotion, is almost invari-

ably useful (Hooley, 2007; McFarlane et al., 1995). Psychoeducation about
such patterns can lead directly to better awareness of these behaviors and
their negative impact and to efforts to alter these patterns. Information
that therapists can incorporate in their treatments in the psychoeducation
about disorders is readily available as part of the treatment packages targeted
to a wide range of specific problems including adolescent drug use (Liddle
et al., 2001), adult chemical dependency (Haaga, McCrady, & Lebow, 2006),
partner violence (Stith, McCollum, Amanor-Boadu, & Smith, 2012), and
child sexual abuse (Barrett, Trepper, & Fish, 1990). There also are many fine
books and articles in each problem area that can be incorporated into the
therapy.
Psychoeducation is offered in a variety of formats. It may simply be
introduced in a timely way as particular issues appear in therapy. At times,
it may be provided in a specific module at the beginning of treatment and,
on occasion, in a group context in intensive day-long programs devoted to
understanding a problem area, be it marital distress (Stanley, Blumberg, &
Markman, 1999) or schizophrenia (C. Anderson, Hogarty, & Reiss, 1980).

Neurobiological Understandings

Neurobiological understandings about processes occurring in the brain

represent an area of meteoric development over the past 20 years (Siegel,
1999). Knowledge has advanced from primitive understandings of how vari-
ous thoughts, behaviors, and emotions were manifested in the brain to a
deep understanding of what occurs at the neurological level. Unfortunately,
although these insights from basic science are intriguing and may one day
lead to significant innovations in practice, they presently have only limited
value in clinical practice. Today’s brain science cannot change how people
think and feel (aside from psychopharmacological interventions, which give
mixed results). It’s strength lies in explicating what occur at a neurologi-
cal level that accompanies feeling states. Therefore, the best use thus far of

intervention strategies and techniques      133

 neuroscience has been to use it to make other intervention strategies more
successful.
Principally, this means using neurobiological understandings as part of
psychoeducation or in support of explanations for why intervention strate-
gies are useful. For example, psychoeducation about activation in the amyg-
dala can help family members understand what they are experiencing when
they become flooded (i.e. when they are a reaction of a maximum intensity
anxiety-provoking stimulus). In part, this evolves into a version of the nar-
rative technique of externalizing the problem (even though the message is
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that the problem is internal). For example, in couple therapy, each partner
can be helped to identify that a particular way of reacting is a result of his
or her partner’s brain function, rather than intention, and thereby preserve
a sense of sentiment override or self-esteem. Such an understanding of the
brain can also help clients grasp the limits of their change process when they
try to change thoughts and behavior and create a framework for the hard
work of “rewiring your brain,” that is, of engaging in strategies such as mind-
ful practice, relaxation training, or time outs, which can help them work to
respond differently. Fishbane (2007) and J. M. Gottman (2011) have written
extensively about how to use such insights in couples therapy. These insights
are readily transmuted into the family context as well.
The second way such understandings are used in couple and family
therapy is through adjunctive psychopharmacology. The impact of psycho-
pharmacology is hotly debated, especially when moving beyond the clearer
positive impact on schizophrenia and bipolar disorder. Psychopharmacology
may be helpful in restoring functioning in depression and anxiety disor-
ders as well, though the research results are mixed (Thase & Denko, 2008).
There is no evidence that medication affects relationship functioning except
insofar as it alleviates the primary symptoms of the particular disorder for
which it is intended and that these indirectly affect relational functioning.
Psychopharmacology does have a place in most integrative views of couple
and family therapy; however, there is no consensus about when and under
what circumstances using medication is helpful, except in the context of the
most severe disorders such as schizophrenia, bipolar disorder, autism, or major
affective disorder.

Social Behavior

Several strategies reside in the territory of the combination of social

psychology and learning theory that is social learning theory. Although not
all the manifestations of such strategies acknowledge these roots, the strate-
gies in this grouping all touch on learning and exchange.

134       couple and family therapy

 Social Learning

Learning is invoked in many ways in couple and family therapy. At

times, the learning is based on classical conditioning, for example, when cou-
ples are taught to relax in the wake of stimuli that have been highly evocative
(e.g., see the section Mindful Practice later in this chapter) or when interven-
tion builds on the healing properties of exposure in the context of feared and
avoided situations. More broadly, the importance of classical conditioning
in the social context should not be underestimated. Ultimately, the success
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of many therapies (behavioral and otherwise) depends on whether a relaxed

comfortable state can be engendered in the couple or family context such that
family becomes a stimulus with positive associations rather than difficult ones.
Nonetheless, most of the learning strategies in couple and family ther-
apy have their origins in operant conditioning and its derivatives having to
do with exchange. Central to operant conditioning is reinforcement: present-
ing some event or behavior that increases the rate of a particular response.
Anything that increases the likelihood of a particular behavior or pattern
can be used as a reward to increase the likelihood of that behavior. It also
has been well demonstrated that some paradigms of reinforcement are par-
ticularly durable whereas others are not. For a variety of reasons, positive
reinforcement is preferable to punishment in shaping behavior.
In couple and family therapy, conditioning most often occurs in a social
context; thus, the source for this set of concepts and strategies is social learn-
ing theory (Bandura, 1977). Even if reinforcers such as access to video games
or money are used to shape behavior, these are almost always delivered in
a social context. Social reinforcers are particularly potent. Social learning
also occurs both directly as a product of reinforcement or punishment and
covertly through processes such as modeling. This means that demonstration
by the therapist or learning from observing others may occupy as important
a role as reinforcement.
One major thread of these methods focuses on skills training. These
skills may be about parenting as in parent training or communication and
problem-solving skills as frequently used in couples therapy. These projects
in skill enhancement incorporate didactic presentation about skill sets and
practice in session and/or through homework of these skill sets. Given the
systemic context, this process becomes complex: each individual is engaged
in skill development but also needing to attend to feedback from others as
well as their own skill development. Applications abound in couple and fam-
ily therapies. For example, in Gottman’s sound marital house therapy and in
cognitive-behavioral therapies, couples are taught to display high rates of
positive behavior toward one another, such that the rate of positive to nega-
tive behaviors is at least five to one (J. M. Gottman, Driver, & Tabares, 2002).

intervention strategies and techniques      135

 Less formal versions of these strategies are frequently encountered across a
wide range of therapy methods.

Parent Training

Much of the treatment of child problems in cognitive-behavioral fam-

ily therapy has centered on the parental use of rewards and punishments
in behavioral parent training (Kazdin, 2005). The name given to this activity
is a bit of an anachronism in referring simply to the parents because more
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recent versions of these methods typically consider the child’s role in cycles
of behavior and the interactions between parents and children as well as
involving the children in treatment. Nonetheless, given the large body of
data available suggesting that the parents of children with behavioral difficul-
ties help shape dysfunctional behavior and respond poorly to it, the essence
of this strategy is about working with parents to selectively and consistently
dispense rewards and punishments targeting the specific goals for the child.
Parent training begins with an assessment phase in which patterns of
thought and behavior are recorded and connected to the target behavior of
concern. This leads to a functional analysis of the problematic behavior, from
which a plan is formed specifying the skills that must be mastered and changes
in contingencies that must occur for the problem to be improved. Focus centers
on caring behaviors as well as on contingencies. If the problematic behavior on
the part of the child is restricted to a single area of concern, specific contingen-
cies are typically created in response to that behavior. For example, a program
may reward the completion of schoolwork. When problems are encountered in
a number of areas, more comprehensive contingency programs are developed.
Home token economies and point systems provide ways for credit to accrue
for positive behavior and subtracted for problematic behaviors, with rewards
dispensed for overall performance. In all programs, the preference for positive
reward over punishment in shaping behavior is emphasized.
A wide range of family therapists have adapted and incorporated vari-
ants of parent training into treatment, shedding the overarching behavioral
philosophy and the drift away from including the child in treatment that
were part of the earlier forms of this method. In a systemic context that
includes children and parents, many couple and family therapists now utilize
these methods, training parents in the principles of successful parenting, even
if they rarely refer to “parent training,” which has behavioral associations.

Communication Training

Communication training is perhaps the set of strategies within couple and

family therapy with roots in the widest array of treatments. Communication

136       couple and family therapy

 training can be traced back to early behavioral and strategic therapies as
well as the earliest days of the marital counseling movement (Gurman
& Fraenkel, 2002; Lederer & Jackson, 1968; Markman, Stanley, &
Blumberg, 2010; Watzlawick, Bavelas, & Jackson, 1967). Communication
training consists of education, modeling, and practice of core communica-
tion skills including how to speak clearly, how to listen, and how to resolve
differences during conflict. Frequently the “speaker–listener” technique
is used where speakers are helped to speak clearly and listeners to listen
well, followed by listeners reviewing what the speaker has said so as to
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communicate that they understand what has been spoken. Although such
speech does not mimic typical speech patterns (J. M. Gottman, 1999),
it effectively helps clarity of communication, particularly in high-stress
situations.

Problem Solving

Problem solving involves couples and families in learning how to solve

problems and practicing this skill. Typically, this process includes brain-
storming possible solutions, weighing the pros and cons of the alternatives,
developing an ability to compromise, and formulating mutually satisfactory
resolutions. A parallel task is learning how to continue to listen and com-
municate and regulate emotion in such discussions. Research conducted to
isolate the impact of various aspects of treatments indicates that almost all
the effect in behavioral couple therapy can be attributed to a combination
of communication training and problem solving (Jacobson, 1984; Jacobson
& Follette, 1985). As with communication training, problem-solving skills
training is a frequent strategy in couple and family therapy, even if this is not
referred to as skill training or follow the precise cognitive-behavioral steps
for the process.

Social Exchange

The influence of social exchange theory (Thibaut & Kelley, 1959) has
been widespread in couple and family therapy, directly impacting cognitive-
behavioral and strategic approaches (Lederer & Jackson, 1968) and less
directly on other methods. Social exchange theory suggests that individuals
strive to maximize their outcomes, to increase the rewards they receive and to
decrease the costs. The primary strategies derived from social exchange lie in
the negotiation of satisfying exchanges and developing methods for arriving
at satisfying exchanges.
Although the earliest versions of social exchange concentrated on
quid pro quo barter of behavior, subsequent augmentations have extended

intervention strategies and techniques      137

 this concept to include the meaning attached to behavior. Research and
clinical practice have repeatedly shown that the communication of car-
ing and interest extending beyond self-interest is essential to successful
exchanges in close relationships (J. M. Gottman, 2011). The path to effec-
tive exchanges are also informed by game theory (J. M. Gottman, 2011)
and by prospect theory and the focusing illusion articulated by Kahneman
(2011; Kahneman & Tversky, 2000), which explicate the cognitive-
emotional heuristics that often distort how choices in exchanges are
experienced. Early strategies with a foundation in exchange were built on
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understanding exchange as a purely rational process, whereas more recent

methods accentuate working with such exchanges in the context of the
human tendency to distort outcomes.
One remedy developed within the framework of social exchange is
skill training aimed at providing the knowledge and experience needed to
evaluate outcomes and negotiate well. These strategies promote develop-
ing better conscious awareness of the choices available, personal biases,
and the interference from emotional reactions that color rational decision
making and exchange. These strategies also work to improve communica-
tion about exchanges and negotiation to arrive at satisfying solutions. Most
recent variation on these themes seek to hold both a loving position and one
that promotes positive exchange, thereby transcending the early questions
about overly utilitarian meanings of relationship that became attached to
early behavioral couple and family therapies (e.g., Is the client only engag-
ing in the exchange to maximize personal outcomes? Can any behavior be
exchanged for another?).

Working With Cognition and Emotion

Couple and family therapy also includes many strategies for working
with cognition and emotion. These vary from the Socratic questioning and
correcting of thoughts prominent in cognitive therapy to the fully collabora-
tive reauthoring in narrative therapy.

Changing Cognitions

Cognitive theories emphasize the development and maintenance of

dysfunctional or “irrational” thought processes, and intervention centers on
changing beliefs. Cognitive strategies examine the ideas that are viewed as
lying behind behavior and emotion. The emphasis is on articulating and
considering the thought between an experience and the resultant feeling.

138       couple and family therapy

 Cognitive interventions principally focus on tendencies to overgeneralize,
personalize, or be overly negative about events that are occurring.
Cognitions are worked with in a variety of ways. In derivatives of cogni-
tive therapy (Beck, 1976), such as most cognitive-behavioral therapy, cogni-
tions are subject to testing for their accuracy in relation to an objective view
of reality, often in the form of cost–benefit analysis through a detailed explo-
ration of the merits and demerits of the thoughts. The therapist uses Socratic
questions that illuminate distortions in thought, which are to be corrected,
and homework for practice with correcting these thoughts.
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In the much different tradition of narrative therapies, cognitions are

considered as stories. The proximate goal remains to modify these cognitions
by helping the clients author a new story, but this occurs in the context of
rejecting the notion of objective reality at the center of cognitive therapy or
the hierarchical therapist as teacher implicit in that approach. Instead, new
stories co-evolve from a collaboration that acknowledges the unique value
of the perspective of the story-teller. One specific cognitive narrative inter-
vention is externalizing the problem, in which the problem is envisioned as
separate from the clients (White & Epston, 1989).
Although very different in format, narrative methods and cognitive
ones both elicit narratives accentuating a more positive view of self and the
world. The cognitive-behavioral variation is far more intrusive and question-
ing of beliefs than are narrative therapies and includes technologies such as
thought records for analyzing beliefs. Both clearly center on the same set of
cognitions, but the means of influence differ.

Working With Emotion

Couple and family therapy is always in part about the interplay

between the emotional lives of the individuals in the family. An almost
universal project is to attune the emotional life of members of the family
with one another.
Several strategies focus on emotion, most of which embrace feelings
and the powerful role they can have in connection. The emotion-focused
therapies include many specific techniques for focusing on and heighten-
ing emotion in conjoint contexts and for using that emotion to enhance
connection and promote interpersonal softenings that allow for greater
closeness (Johnson, 2008). These strategies typically begin with one per-
son experiencing an emotional reaction and conveying that reaction to
other family members. The therapist then works to deepen experiencing
and access emotions in all parties underlying whatever is experienced at the
first level of emotion, often drawing on classic experiential focusing tech-
niques to do so (Gendlin, 1978). Because it typically is easier for others to

intervention strategies and techniques      139

 connect with deeper primary emotion, these exchanges provide opportuni-
ties for loving feelings to emerge that transcend whatever was the content
of the original complaint.
Other strategies, focused on emotion, help family members become bet-
ter aware of their emotional lives and of the emotional lives of the other
family members. Still other strategies such as taking “time out” in the midst
of conflict work to lessen emotional arousal in situations where that arousal
is distressing. These latter strategies are particularly salient in families where
there are issues of anger, high conflict, or family violence. As J. M. Gottman
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(2011) suggested, simply being able to pause in the midst of conflict can have
great benefit.

Mindful Practice

Mindful practice is the most rapidly growing form of mental health

intervention, found in many individual therapies ranging from cognitive-
behavioral to humanistic approaches grounded in Eastern philosophy (Baer,
2003) and recently extended into couple and family therapy. Although for-
mal mindful practice only occurs in a small percentage of couple and fam-
ily therapies, encouragement of mindful and relaxed states in the wake of
interpersonal stress and conflict is among the most common strategies in
couple and family therapy. This method is especially easily applicable for
many clients, given that many people today engage in mindful practice in
some context other than therapy (e.g., yoga classes) and thereby begin with
an often untapped resource. With practice, many clients can readily apply
these skills in relationships. Mindful practice is especially helpful in creating
the space to calm moments of flooding in interpersonal conflict, in helping
hone in on emotion, and in enabling greater intentionality about behavior.

Promoting Acceptance

Living successfully in family life is in part about accepting the ways

of others in the family. Christensen and Jacobsen (2000) have made active
training in learning acceptance a core ingredient of their integrative behav-
ioral couples therapy, targeting these methods at those problems and issues
where the behavior in focus is unlikely to change. Beyond its specific use
in IBCT, similar strategies have broad applicability and frequently are used
in couple and family therapy as family members wrestle with unchanging
aspects of other family members and life. Of course, couple and family thera-
pies remain principally about behavior change. Parents want teenagers to
behave better, partners want their spouse to connect better, and everyone
in a family with someone with a substance abuse problem wants the person

140       couple and family therapy

 with the addiction to change their behavior. However, as Christensen and
Jacobsen point out,1 some aspects of life are changeable and some are not.
Successfully living together depends on the ability to live with the parts of
intimate others with which one has trouble.
The core methods for working toward acceptance focus principally on
promoting positive emotional engagement, directly focusing on the differ-
ences among family members, promoting mutual empathy about how each
family member sees the particular difficulty, labeling how difficult change is at
this point in time, and working through how it feels for each person to be in
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the position he or she is in. The essence of this work resides in family members’
facing their personal frustration about the matter in focus, engaging with it,
and finding some way (e.g., through such methods as Socratic questioning
about cognitions or processing of emotion) to reenvision this part of the world
and accept what is.
Including acceptance interventions in couple and family therapy is
controversial. Such strategies conflict with the core positivist notion that
every problem and dysfunction can be changed. Such visions also are mark-
edly different from some ideas about relational life or child rearing that push
for ultimate performance regardless of the consequence. As Christensen and
Jacobsen (2000) emphasize, acceptance and behavior change are inevitably
linked. A good couple or family therapy explores and explicates how life
can be different; whether verbalized or not, inevitably this also touches on
what is not ready to be changed and what cannot be changed. J. M. Gottman
(1999) has observed that couples early on identify their conflicts and spend
a great deal of time continuing to argue about those difficulties throughout
long-term relationships. He emphasizes the need for couples to find successful
ways to accept the inevitably of such differences.
At times, when different family members have radically different views
of a problem, the acceptance/change equation becomes enormously complex.
For example, what is best for a family to do when a member has a substance
use disorder and will not/cannot/is not ready to change that behavior? Clearly,
some situations call out for some response other than acceptance. Other
strategies that are helpful in such cases include motivational interviewing
with the substance user and helping family members differentiate themselves
from the problematic behavior. The advisability of work toward acceptance
varies with the presenting situation. Therapists may disagree about when to
work toward behavior change or acceptance, or when to move from efforts

1And as implied in the “serenity prayer” of Reinhold Niebuhr (R. Brown, 1987), widely adopted by
Alcoholics Anonymous long ago: “Father, give us courage to change what must be altered, serenity to
accept what cannot be helped, and the insight to know the one from the other.” (p. 251)

intervention strategies and techniques      141

 at behavior change to ones that accentuate acceptance in the course of a
therapy. Ultimately, families decide whether acceptance is an option.

Engendering Forgiveness

Closely related to acceptance is forgiveness. Often, improving rela-

tionships depends fully on the generation of forgiveness (Fincham & Beach,
2002; Fincham, Paleari, & Regalia, 2002; Paleari, Regalia, & Fincham, 2005;
Schielke et al., 2011), particularly in situations when there has been a viola-
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tion of trust or some other injury. In the complications of life, there at times
may be much to be forgiven. Couples and families that succeed achieve some
degree of forgiveness, whereas those that don’t resolve their difficulties often
cannot forgive. A deep emotional state, forgiveness is not amenable to formu-
laic ways of achieving it. Indeed, clients in therapy often are very distressed
when they feel pressure to forgive. Forgiveness clearly is a multiperson sys-
temic operation that requires the participation of someone who is prepared
to apologize, to be empathic, and to act in a different way from in the past
and someone who is willing to take a risk and find connection despite the
hurt. Emotion-focused strategies are particularly helpful in invoking these
states and present specific sequences to help engage forgiveness (Greenberg,
Warwar, & Malcolm, 2008, 2010; Makinen & Johnson, 2006; Meneses &
Greenberg, 2011).

Confrontation

Confrontation must be mentioned in a list of generic strategies for gen-

erating cognitive and affective change in couple and family therapy. Yet, one
insight from research and clinical practice is that dramatic confrontation is
less effective than other strategies and brings with it risks in terms of alliance
and outcome. Instead, steady ways of working with families that encourage
collaboration, communication, and empathy typically have much greater
impact. Even in the research on family substance use treatment, the arena
where such methods were developed, the dramatic method of intervention
in which families assemble to confront those with substance use disorders has
poorer outcomes than steadier means of promoting engagement with treat-
ment (Haaga, McCrady, & Lebow, 2006). Of course, an essential task and
therapist skill lies in the therapist’s initiating conversation about issues that
are difficult to talk about and finding ways to work with those who are low
in motivation or unresponsive during treatment. Strategies such as motiva-
tional interviewing are widely regarded as more helpful than dramatic con-
frontation and have come to be preferred methods of practice by most couple
and family therapists.

142       couple and family therapy

 Working With Family Organization

Some strategies center on family organization.

Changing Family Structure

A variety of strategies have been developed for changing family struc-

ture. Originally, structural family therapy (S. Minuchin & Fishman, 1981)
emphasized capitalizing on dramatic enactments to create a crisis in which
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old structural patterns could not be used to promote new structures. More
recently, efforts to change structure emphasize a more gradual developmental
process that combines psychoeducation about functional family structure;
raising awareness about boundaries, alliances, and the distribution of power;
and direct efforts to shape these into a more functional structure (e.g., parents
supporting one another in parenting). Reframing and changing narratives
about family life (e.g., being at a different stage of family life) often are woven
into these methods.
Dealing with the balance of power in families has emerged as a particu-
larly important focus in most couple and family therapy. Typically, couple and
family therapy today aims to increase awareness of power imbalances and to
rectify them (Knudson-Martin & Mahoney, 2009a).

Altering Triangulation

Family therapists have stressed the importance of triangles, especially

as they relate to family alliances. Triangles have assumed great importance
in both structural and multigenerational approaches (Kerr & Bowen, 1988).
Interventions for altering triangles include labeling the triangle and its del-
eterious effects, explicating the function the triangle serves for the family,
working extensively to support within-generational alliances, and exploring
the multigenerational processes of triangulation in the family.

Paradoxical Directives

Paradoxical directives are ways of dealing with client resistance by sug-

gesting behavior that raises client reactance by prescribing the opposite of
the behavior actually sought (Haley, 1986). One example is to suggest the
family continue to do what is already being done or to do it even more. More
complex directives suggest the benefits of the particular pattern in serving a
function for the family. At one time, paradoxical directives were a frequently
used strategy, but these strategies have been substantially replaced by methods
that more collaboratively work with clients.

intervention strategies and techniques      143

 Interface With the Larger System

Family therapy is a leap from individual therapy in its systemic focus,

but it still can err in failing to attend to the whole system. Sometimes what is
occurring in larger systems is at least as important as in the family. Therapies
such as multisystemic therapy (Swenson, Henggeler, Taylor, & Addison,
2005), the Oregon social learning model (Gifford-Smith, Dodge, Dishion,
& McCord, 2005), and structural family therapy (P. Minuchin, Colapinto,
& Minuchin, 2007) have demonstrated the essential importance on focus-
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ing on all relevant systems. School, peer groups, and the community may be
the most appropriate loci for intervention. Comprehensive case formulation
extends to include these entities, and in many situations treatment delivery
typically involves leaving the office and active efforts to collaborate with the
larger system in relation to the presenting problem (Madsen, 2011).
One important aspect of the larger system is sometimes ignored in cou-
ple and family therapy: other therapists or helping agents involved with the
family. A vitally important insight of the first generation of family therapists
is the ease with which the therapy system can become isomorphic to the
difficulty in the family system. Couple and family therapy requires frequent
ongoing consultation about goals and progress with other therapists as well as
helpers in other systems. It is not necessary for all the therapists to be using
the same strategies, but goals need to be coordinated and the links between
the strategies made transparent and intelligible for clients. The field has mar-
velous models and manuals for such collaboration (Wynne, McDaniel, &
Weber, 1986), though the reality of such coordination often falls below such
models.

Promoting Understanding

A set of strategies focuses on exploring personal and family history and

the promotion of understanding about internal and interpersonal dynamics
and the origins of patterns.

Multigenerational Transmission

Several strategies center on understanding how present issues relate

to life in the family of origin and the multigenerational pathways. These
methods derive from intergenerational and psychoanalytic approaches.
Multigenerational patterns easily exert powerful influences on the life of the
family, either through replication of earlier patterns in the current family or
through reactivity to those patterns.

144       couple and family therapy

 The core tool used in this examination is the genogram, a depiction
of the family’s genealogy that summarizes the key people and events in the
family’s history (McGoldrick, 2011; McGoldrick, Gerson, & Petry, 2008;
McGoldrick, Gerson, & Shellenberger, 1999). There are both simpler ways
of filling in genograms with only essential information and more complex
ways that summarize the emotional life of the family. Filling in the genogram
allows for evocative exploration of the meanings of events in the family life
and the emotion connected to those meanings.
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Interpretation

Understanding the meaning of one’s own behavior and the behavior

of intimate others has been a core strategy for eliciting change since Freud
(Strachey, 1953) and plays a role in most couple and family therapy. In inter-
pretations, the therapist offers explanations for actions that involve forces
that are not readily apparent to the client. Interpretations can be of many
kinds, but most typically involve therapists sharing their understanding of
the meanings of behavior in terms of conflicts within individuals of individ-
ual histories. Therapists also offer insight about systemic aspects of relational
patterns; sometimes these interpretations take the form of understandings
about object relations, helping family members grasp the states they induce
in one another (J. Scharff, Scharff, & Gurman, 2008). Timing insight so that
it can be best heard and have an impact on the family is crucial.
Sager (1976) extended the behavioral notion of couple contracts
beyond the quid pro quo of behavioral exchange to include exchanges that
have not been discussed; some in awareness but not verbalized and some
out of awareness. Sager’s method of writing and reworking these levels of a
couple’s contract provides a simple structure for interpreting preconscious
and unconscious exchanges among family members.

Transference and Countertransference

Presenting understandings about transference and developing correc-

tive emotional experiences in relation to such projections are among the
most important strategies in psychoanalytic couple and family therapy (D.
Scharff & Scharff, 1987). In those treatments, understanding and working
through projections both to the therapist and other family members are at
the center of a corrective experience through which family members can
see one another as who they are free of projections. Similarly, the active use
of countertransference—that is, using the feelings the clients elicit in the
therapist as clues to the most useful directions for the treatment—is crucial
in psychoanalytic couple and family therapy. Even outside this frame, most

intervention strategies and techniques      145

 couple and family therapists today pay attention to and work to increase
understanding of the transferences that are engaged between family members
or with the therapist, and use an understanding of countertransference that
emerges to inform the therapy. However, the level of disclosure and discus-
sion of countertransference varies enormously among therapists.

Experiential Activities
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Some strategies directly promote client experience by having clients

engage in activities that stimulate emotion.

Sculpting, Doubling, and Guided Imagery

Sculpting is a method primarily developed by Virginia Satir and Peggy

Papp (Papp, Scheinkman, & Malpas, 2013; Satir, Bitter, & Krestensen, 1988)
for accessing family emotional experience. In sculpting, a visual metaphor
for life in the family is created through having family members place others
in a physical arrangement that indicates how they operate in relation to one
another. For example, two closer family members might be placed holding
hands while a third is placed at a great distance. Sculpting includes explo-
ration of what was stimulated during the exercise and potential targets for
change.
Other methods aim toward similar ends in using structured activity to
engender emotional experience. Wile (1980) with couples acts as a double
for each client, speaking from the emotional position of the client what is
unspoken in a way that maximizes the possibility for the message being heard.
Greenberg and Goldman (2008) use a variation on the gestalt two chair
technique in which, without moving between chairs, partners speak from dif-
ferent ego states in dialog with self, witnessed by their partners. Papp (1990)
draws on interactional guided imagery.

Family Rituals

In the process of engaging emotional experiencing, couple and family

therapists often prescribe or coconstruct with families healing rituals created
in relation to specific life issues (Imber-Black, Roberts, & Whiting, 1988).
Typically, such rituals are highly evocative (e.g., reading a letter written to a
deceased parent at their grave or making a meaningful journey). Rituals also
can be prescribed to have a simpler and more steadying role, such as when
having dinner together on a regular basis is suggested with a chaotic family
(Steinglass, Bennett, Wolin, & Reiss, 1987).

146       couple and family therapy

 Promoting Dialogue

The art of asking good questions and coconstructing a narrative with

clients is the essential method used by narrative and poststructural therapists
(Tarragona, 2008; White & Epston, 1989). Beyond drawing on the common
factors of promoting curiosity, listening, and positive feeling, narrative strate-
gies such as eliciting client stories, and noticing and recording accomplish-
ments offer important specific ways of opening conversation, widely utilized
by a broad range of couple and family therapists.
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Therapist Position

A wild card influencing how all therapeutic strategies and techniques

are experienced is therapist position, as described by Fraenkel (2009) and
Kantor and Lehr (1975). Therapy can be done from a close or more distant
position. Therapists can also assume a more powerful or less powerful more
collaborative position. These are the poles of relationship described long ago
by Leary (1957) and subsequently elaborated by Benjamin, Rothweiler, and
colleagues (Benjamin, Rothweiler, & Critchfield, 2006). The position of the
therapist very much affects the strategies employed. Some therapists predict-
ably find a position (e.g., close and collaborative) in relation to all of their
clients while others find different positions with different clients. Distinct
from alliance or therapeutic conditions, which are necessary for therapy to
be beneficial, therapists can work successfully from a variety of positions, but
therapies become much different across these positions. There also is a bet-
ter fit between some methods and some therapeutic positions. For example,
paradoxical strategies are a better fit with a distant position while experien-
tial techniques fit better when delivered from a close collaborative position.
Therapy is not only about strategy but very much about the therapist’s posi-
tion in relation to the family.

Evidence-Based Principles of Practice

An exciting recent development has been the beginning of the gen-

eration of evidence-based principles for the practice of couple therapy that
transcend approach. Following a method first suggested by Castonguay and
Beutler (2006), statements of principles are hypothesized from a thorough
reading of the relevant research, looking for common threads across successful
treatments. Christensen and colleagues (Benson, McGinn, and Christensen,
2012) offer a very interesting proposed set of such principles for couples therapy

intervention strategies and techniques      147

 consisting of five principles that transcend approach: (a) dyadic conceptu-
alization challenging the individual orientation view that partners tend to
manifest, (b) modifying emotion-driven maladaptive behavior by finding
constructive ways to deal with emotions, (c) eliciting avoided, emotion-
based, private behavior so that this behavior becomes public to the partners,
making them aware of each other’s internal experience, (d) fostering pro-
ductive communication, attending to both problems in speaking and listen-
ing, and (e) emphasizing strengths and positive behaviors. Although this list
provides only a launching point for a consideration of universal processes
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and is targeted only toward couples therapy, efforts like this point toward
the future of couple and family therapy in pushing beyond a model centered
view toward articulating the shared essential ingredients of effective therapy.

Conclusion

The concepts and methods described in this chapter were developed

within a specific school of couple or family therapy. However, each has also
migrated to wide usage among a broad range of couple and family therapists.
The theme of this chapter is that a core base of concepts, strategies, and
techniques has evolved which transcends orientation and provides the foun-
dation for today’s practice of couple and family therapy.
The intent in this chapter is not to definitively catalog all of the inter-
vention strategies used by couple and family therapists. There are many ways
of making such a list. Instead, it is intended (much like Christenson’s list of
principles of couples therapy) to launch conversation about what strategies
belong on such a list. What other strategies might be added? What are the key
strategies? How broadly is each utilized? Can some be placed within a larger
class of strategies? How do these strategies interface with the many individual
therapy strategies not discussed here? These are all appropriate questions for
further exploration and investigation.
Few therapists use all the methods named. Therapists practice their own
favored methods and choose carefully which ones they employ and in what
context (parsimony probably enhances success). Some methods are incom-
patible with the philosophy of particular therapists. This especially applies to
directive strategies for those who prefer nondirective methods and vice versa.
Some therapists even restrict their range of intervention to one approach,
and those therapists often do superb work within their chosen method.
Generally, therapists use similar methods but label them differently. It
is incredible how many different names there are for the same strategies. In
the domain of couple and family therapy, each group developed its own name
for ways of working, often not even realizing they had rediscovered what was

148       couple and family therapy

 already well known elsewhere. S. Miller, Duncan and Hubble (1997) referred
to this state of affairs as a Tower of Babel. There are real differences in meth-
ods, but many differences are more about name than substance.
In creating complex algorithms for practice, couple and family thera-
pists can now draw from a generic base of interventions. Typically, this means
highlighting a few strategies while incorporating others in less central ways.
I believe that the field has reached a stage where it is more useful to envi-
sion therapists as assembling an intervention strategy from those ingredients
rather than to primarily reference the old world of distinct schools of practice.
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intervention strategies and techniques      149