Psychotherapy: The Evolving Treatment of Gender, Ethnicity, and Sexual Orientation in Marital and Family Therapy
Leslie, Leigh A., Family Relations
In 1985, Virginia Goldner wrote an article for the Family Therapy Networker entitled "Warning: Family Therapy May Be Hazardous to Your Health." In this one tongue-in-cheek title, Goldner captured a major theme and source of controversy in the discourse surrounding marital and family therapy over the last decade. This debate centers around the idea that some clients may not be well-served and, in some cases, may be harmed by marital and family therapy. More specifically, at the heart of this debate is the premise that marital and family therapy as traditionally practiced is oppressive to specific constituencies. In the last 10 years, questions have been raised and criticism leveled concerning biases in marital and family therapy that have ignored and, in some cases, pathologized three groups: women in families, racial-ethnic minority families, and gay and lesbian families.
Although the critiques of the field of marital and family therapy's treatment of gender, race and ethnicity, and sexual orientation evolved independent of one another with no common theoretical framework, similarities exist in the criticisms offered and questions posed about the biases that exist in marital and family therapy. The purpose of this review article is to look at similarities in the critiques emanating from these different quarters and to examine the impact these critiques have had on the field of marital and family therapy. In addition, areas in which work is still needed will be identified.
Prior to examining these critiques in greater detail, one point should be noted. Discussions of the treatment of minority families in marital and family therapy have often been clouded by an inconsistency in terminology. The term ethnicity is most frequently found, but is often used somewhat interchangeably with the term culture. Although there is a great deal of overlap in the terms culture and ethnicity, they are not synonymous; culture is broader in scope than ethnicity (Preli & Bernard, 1993). The term race, however, is less frequently used and often is treated as simply one component of ethnicity. Hardy and Laszloffy (1994) propose that the relative silence around race, achieved by subsuming it under ethnicity, is a way of marginalizing race and downplaying the domination of the White perspective in models of family therapy. Yet race--particularly skin color--is often a defining aspect of the experience of ethnic identity for people of color. In an effort to recognize that ethnicity is much more than just race, but that race assumes a primacy in structuring peoples' experiences, both race and ethnicity are used throughout this article, with the term racial-ethnic used where grammatically appropriate.
CRITIQUES OF MARITAL AND FAMILY THERAPY
Any cursory review of journals, workshops, and conference programs will reveal that the topic of marital and family therapy's insensitivity to, and in some cases, oppression of certain groups has been a dominant theme in the field in the last decade. Certainly, the feminist critique of the treatment of gender in the field was the most extensively articulated during this time (e.g., Goodrich, Rampage, Ellman, & Halstead, 1988; Luepnitz, 1388; McGoldrick, Anderson, & Walsh, 1989, Walters, Carter, Papp, & Silverstein, 1988), but a substantial body of literature also addressed the treatment of racial and ethnic minority families (e.g., McGoldrick, Pearce, & Giordano, 1982; Saba, Karrer, & Hardy, 1991; Tseng & Hsu, 1991). Although less systematic attention has been given to gay and lesbian families in mainstream family therapy research and treatment journals, the topic has been a controversial one and has been addressed with greater frequency in marital and family therapy book chapters (e.g., Brown & Zimmer, 1386, Goodrich, Ellman, Rampage, & Halstead, 1990; Sanders, 1993).
These critiques of marital and family therapy have varied in the specific aspects of therapy that are thought to be insensitive or oppressive, yet all share a t common concern that the field has perpetuated the status quo. Three characteristics of marital and family therapy have been identified in each critique as contributing to this maintenance of the status quo. As traditionally practiced, marital and family therapy (a) does not take into consideration the broader social context when examining family dynamics, (b) ignores power differences both within the family and in the larger society, and (c) works from an assumption of a monolithic family form.
Separation From the Broader Social Context
General systems theory, as the underlying theoretical foundation for most models of family therapy, allows for a focus on the impact of the larger social and economic system on families. Yet, in practice, systems therapists have often operated as if the family unit was a complete system unto itself (Taggart, 1985) and have ignored the legal, economic, and social realities of individual clients' lives. In the critiques of the treatment of gender and race and ethnicity, two contextual variables--gender role expectations and economic resources have been identified as particularly significant in structuring family life. Critiques of the treatment of sexual orientation have addressed the importance of the contextual variables of homophobia and secrecy in understanding family life.
Gendered role expectations and economic resources. Family relationships and interaction are affected daily by a myriad of contextual factors, from policies of the workplace to region of the country in which one lives. Critiques of the treatment of gender, race, and ethnicity in marital and family therapy have noted two contextual factors as particularly significant in understanding the dynamics observed in therapy with couples or families: (a) the cultural expectations of how men and women are to fill their family roles and (b) the economic resources of family members (e.g., Franklin, 1992; Walters et al., 1988). These factors in combination both structure and constrain family dynamics. Failure to fully recognize the importance of gendered role expectations and economic resources and incorporate them into treatment has led to misunderstandings of couple dynamics and inadequate, if not potentially harmful, treatment for both White and racial-ethnic minority couples. However, for the latter--African Americans in particular--any consideration of these factors must be done in light of a third contextual factor: the experience of racism and discrimination. Thus, the effects of these contextual factors will be considered separately here for White and African American couples.
In White couples, women are typically seen as the family caretakers and men as the primary providers, regardless of the actual economic contribution of each partner (Perry-Jenkins, Seery, & Crouter, 1932). Family therapy has been criticized for mirroring that cultural expectation by its tendency to hold mothers responsible for problems within the family (Bograd, 1990b; Wylie, 1989). Because the mother is frequently in a pivotal position in the family organization and frequently oversees the day-to-day activities of the family, she has been miscast as accountable or the current situation. Theoretically, mothers' and fathers' roles counterbalance one another; neither gender is seen as responsible for the common pattern of mothers being more involved with their children than fathers. Yet, in practice, interventions focus largely on changing mothers' behavior or constraining mothers' so-called "over-involvement" so that the "distant" fathers can become more engaged with the children, implicitly correcting the problem caused by mothers' involvement (Goldner, 1987; Luepnitz, 1988). In addition, the field has developed a much more extensive language to talk about mothers' inadequacies than fathers' inadequacies, in effect, blaming her for what she has been socialized to do; that is, to care and be responsible for family and children (Bograd, 1990b). It is interesting to note, however, that recent research using a clinical vignette suggests that family therapists do not tend to see mothers as more dysfunctional than fathers, or more responsible for change in the family. They do, however, see the parent, regardless of gender, with the greatest concern for the child as being more dysfunctional (McCollum & Russell, 1992). Thus, although therapists may no longer be pathologizing mothers per se, the parent who behaves as women have traditionally been socialized to behave is still seen as the problem.
Equally as important as role expectations in determining couple interaction is the economic balance or economic resources of the spouses. The reality is that the majority of married White women earn less than their husbands and are more vulnerable to a substantial drop in income should the couple separate or divorce. The unequal financial consequences for men and women if a marriage ends in divorce can greatly affect the couple's negotiations in therapy (Taffel & Masters, 1989). Failure to acknowledge this economic reality leads therapists to attribute women's stances in such negotiations to personality (e.g., "She is too weak to assert herself") or gender (e.g., "As a woman, she is more likely to give in") instead of to the fact that individuals in the same family have different options and resources (e.g., "She knows taking a stand may mean a near poverty existence for herself and her children").
In African American couples, women are less likely to be economically dependent on their husbands. One outgrowth of the legacy of racism in this country is that Black men have experienced pervasive discrimination in employment, which has undermined their roles as providers in their families (Franklin, 1992). Thus, Black women have been, and continue to be, major contributors to the family's financial well-being, often surpassing their husbands as economic providers. This digression from the dominant cultural framework of male as provider can greatly affect couple interaction, although not always in predictable ways. Some Black men may feel hesitant to assert themselves in the couple or family, given that they are not working from the base of economic provider, whereas others may work more forcefully to establish their dominance because they cannot fall back on economic power. Similarly, some Black women may wield more power because of the economic balance in the relationship, whereas others may choose a subordinate position in an effort to protect their partners from any further insults to their self-esteem. Interestingly, when Black women have asserted the power their economic contributions would allow, it has often been the focal point used to characterize the family with terms such as matriarchal. Again, the deviation from the cultural norm of female subordination can lead to both Black women and men being pathologized. The important point for therapists is that, although couples may cope with it in a variety of ways, the intersection of racism, family economics, and gender expectations affects family dynamics and must be examined if family therapy is to be beneficial for African American clients (Franklin, 1992).
Homophobia and secrecy. The importance of acknowledging the broader social context is equally critical in work with gay and lesbian couples and families. Two interrelated contextual factors, homophobia and secrecy, pervade every aspect of family life for gay men and lesbians. Brown and Zimmer (1986) define homophobia as "the fear and hatred of same-sex intimacy, love, sexuality, and relationships, and of those individuals and institutions that participate in, affirm, and support same-sex relating" (p. 451-452). It is important for therapists to recognize that, although homophobia is an external reality that is imposed upon the lives of gay men and lesbians, most homosexuals have internalized these beliefs to some extent. Thus, lesbians and gay men must wrestle with their own feelings of self-hatred, shame, and inadequacy at the same time that they are trying to function as family members, partners, and parents (Goodrich et al., 1990; Markowitz, 1991). The effects of this internalized homophobia are often subtle (e.g., diminished sexual desire, difficulty asserting oneself as a parent) and, thus, tend to be ignored or downplayed by therapists (Brown & Zimmer, 1986). As a result of both external and internal homophobia, gay men and lesbians and their families are constantly faced with decisions concerning how open to be about their personal lives. Openness about one's sexual orientation or love relationship can result in being cut off from family members, losing custody and love of children, being socially isolated and rejected, and losing one's job. Thus, normal family issues such as family identity, connectedness and autonomy, and boundary maintenance are much more complicated in gay and lesbian couples and families than in heterosexual ones (Dahlheimer & Feigal, 1991).
Inattention to Power Differences
A second criticism closely associated with the failure to recognize the broader context of families' lives is that the field of marital and family therapy has largely ignored power differences in relationships. By downplaying status and power differences both within the family and in the larger social environment, critics point out that family therapists are likely to miss a dimension that is crucial in understanding family dynamics.
Power differences within the family. One of the most consistent rebukes offered of marital and family therapy has I been the field's lack of attention to how differences in resources between men and women and prevailing gender ideology in society translate into power differences within the family (e.g., Hare-Mustin, 1989; Taffel & Masters, 1989). This inattention to gender based power differences is particularly evident by the emphasis in models of therapy on circularity and mutually created patterns of interaction. Whether intended or not, notions of individual responsibility and accountability disappeared as the field moved to focus on the so-called "function" of symptoms for the entire family. In such a framework, responsibility was shifted to the entire family system. Thus terms such as incest perpetrator, alcoholic, and abusive spouse were replaced by incestuous families, alcoholic families, and violent relationships. Such conceptualizations seem to hold all members of a family equally accountable and attribute equal power to all to change the system. The critique of this conceptual sloppiness is best summarized by Goldner (1987), who states that "family therapy has lapsed into a complacent kind of moral relativism in which the elegant truth that master and slave are psychologically interdependent drifts into the morally repugnant and absurd notion that the two are therefore equals" (p. 111).
Power differences in society. Criticism has also been made of marital and family therapy for ignoring the impact that being in a socially devalued position has on family members. For racial-ethnic minorities, the experience of discrimination, marginalization, and invisibility can produce a sense of powerlessness that affects not only self-esteem but family interactions. Feelings of inadequacy, shame, and rage that often accompany being in a one-down position may manifest themselves through passivity, resistance, or anger, both in family relationships and relationships outside the family, including the therapy relationship (Franklin, 1992, 1993). In addition, individuals may attempt to assimilate into the mainstream by distancing themselves from their culture or ethnic group (Markowitz, 1994).
Failure to recognize social position and limited power as a potential source of problematic behaviors restricts a therapist's ability to help families establish healthy patterns of interaction. First, if systems of oppression are not acknowledged and named in therapy, a therapist cannot help family members distinguish among the personal, interactional, and societal factors contributing to the problem. Consequently, the therapist cannot empower clients to change that for which they are personally responsible while confronting, where possible, the discrimination they experience. Second, failure to recognize the way in which ethnicity and race structure social position can limit a therapist's utilization of the resources, supports, and strengths that are available within the extended family and culture (McGoldrick, Garcia-Preto, Hines, & Lee, 1989).
Gay men and lesbians are similarly in a low status position by virtue of their sexual orientation. Although White homosexuals may obtain social influence and power as a result of their race and by the fact they can keep their status as homosexuals secret in a way not available to minorities, they, too, suffer from being in a one-down or stigmatized position because of the existence of homophobia throughout society. Thus, the mistrust and anger that often accompany a sense of powerlessness or lack of societal validation can be found in gay men and lesbians and can equally affect their attitudes and behaviors both in intimate relationships and in therapy (Dahlheimer & Feigal, 1991).
Assumption of a Monolithic Family Form
A third criticism of models of family therapy is that, for the most part, they are inattentive to diverse family forms. Based on the "theoretical myth of sameness" (Hardy, 1991, p. 17), they tend to reflect the larger societal values of traditional gender-based division of labor (Goldner, 1985), heterosexual-based family formation (Markowitz, 1991), clear generational boundaries (Goldner, 1989), and nuclear family household arrangements (Tseng & Hsu, 1991). Although diverse family forms exist among all groups and the assumption of homogeneity may lead to inappropriate treatment of any family, it is particularly oppressive to racial-ethnic minority families and gay and lesbian families.
Racial-ethnic minority families tend to differ from White families in the U.S. in a number of significant ways. Whereas White families generally follow the European-based conjugal family arrangement in which legal, or husband-wife, relationships are given primacy, many minority families come from cultures adhering to a consanguine-based family organization in which blood, or parent/child, relationships are given primacy (Tseng & Hsu, 1991). Many minority families also utilize a more encompassing, extended definition of family, which in some cases even includes nonliving ancestors (Tseng & Hsu, 1991). In addition, minority families are more likely to have a value system that emphasizes "group identity, cooperation, harmony with the environment, reciprocal obligation, and holistic thinking" (Hardy & Laszloffy, 1994, p. 11) instead of the European American value system that emphasizes individuality and personal achievement (Berg & Jaya, 1993). These characteristics, combined with the lower level of economic resources mentioned previously, result in racial-ethnic minority families frequently emphasizing parent-child bonds over the marital bond, living in multigenerational households and/or multihousehold families, and having flexible boundaries between generations. If the values or economic necessities underlying these arrangements are not understood, application of models of family health that are reflective of upper middle-class White families only sends a message of inadequacy to minority families.
The assumption of heterosexuality--that the adult couple in a family will be composed of one man and one woman--is clearly problematic when attempting to apply models of family therapy to gay men and lesbians. This assumption limits the applicability of the models because it contributes to pathologizing dynamics that make sense when partners have experienced the same gender socialization (Carl, 1990).
Women, for example, have been socialized to one degree or another to define themselves in relation to others and to be empathic and nurturing in their relationships. Lesbian relationships are, therefore, often characterized by highly permeable boundaries and low differentiation between partners (Swartz, 1989). From the perspective of models based on a premise of heterosexuality, these relationships are often characterized as enmeshed or fused Goodrich et al., 1990). Although this characterization may sometimes be appropriate, it is important to distinguish between closeness that simply exceeds the norms of heterosexuality and closeness that causes problems for the partners.
For gay male couples, what has been defined as male promiscuity or lack of monogamy presents major problems for couple therapy models based on an assumption of heterosexuality (Brown & Zimmer, 1986; Markowitz, 1991). Separating sex from love has always had some degree of social acceptability for men. Thus, it is not surprising that this separation would be a condoned aspect of gay male relationships. However, working from an assumed link between love and sexual exclusivity, many models of couple or marital therapy view non-monogamy as a sign of problems in the primary relationship. Although variations in defining acceptable relationship boundaries exist with gay male couples, just as they do with all couples, there is a higher level of acceptance of non-monogamy in the gay community. Gay men are less likely to perceive the lack of sexual exclusivity as a threat to the emotional commitment in the relationship than are the partners in heterosexual and lesbian couples. Although it may be difficult to determine when nonmonogamy is a way of avoiding issues of intimacy in a couple and when it is an accepted practice by both partners (Markowitz, 1993), therapists working with gay male couples need to be open to the meaning of nonmonogamy for their clients (Brown & Zimmer, 1986).
IMPACT OF CRITIQUES ON MARITAL AND FAMILY THERAPY
After several years in which the discussion of gender, race, and ethnicity was characterized largely by critiques of existing models and practices, more recent years have seen a move to what might be characterized as the application or integration phase of many of the earlier critiques. That is, efforts have been made to utilize the critiques to rethink and revise many facets of clinical services. Work in the area of sexual orientation, however, still remains largely in the stage of offering assessments of the appropriateness of existing models, with less systematic application work being done.
Efforts to apply the critiques of marital and family therapy relative to gender, race, and ethnicity have focused primarily on the implications of incorporating these variables into (a) the treatment of specific populations or problems and (b) the training of marital and family therapists. The limited application work that has been done based on critiques of the treatment of sexual orientation in marital and family therapy has, likewise, focused on incorporating sexual orientation into the treatment of specific populations or problems, although few training implications have been considered. Efforts to build on the gender critiques have also focused on the impact of therapist gender on the course of treatment in marital and family therapy. Similar work is just beginning to appear relative to race and ethnicity, but has not been undertaken relative to sexual orientation.
Applying Critiques to Treatment
Gender. A common characteristic of much of the marital and family therapy literature is the use of case examples; the work on gender and ethnicity is no exception. The explosion in feminist-based and gender-sensitive analyses of family therapy has led to innumerable case examples of how to integrate gender and issues of power and context into treatment. Thus, the issue of integrating gender into treatment has been addressed across the wide spectrum of problems typically seen by marriage and family therapists. However, there are particular populations or issues that have received a concerted focus from feminists and those concerned with gender issues in marital and family therapy.
First, no population or family therapy issue has received more gender-based attention in recent years than the treatment of abused women and their partners. It was with this population that feminists first (e.g., Bograd, 1984) and most consistently challenged the interactional frames that held both partners responsible for the violence in a relationship and that ignored differences in power and resources (Bograd, 1992; Goldner, 1992). The field of marital and family therapy has been criticized for its slowness, relative to other mental health fields, in confronting the reality of male violence in supposedly committed, loving relationships (Avis, 1992), choosing instead to emphasize therapist neutrality (Bograd, 1992; Kaufman, 1992), focus on mutually created patterns of interaction, and distance itself from the notion of individual responsibility (Dell, 1989; Lamb, 1991; Pressman, 1989; Wilbach, 1989). This critique has been translated into practice by challenging the traditional couples approach to therapy in which both partners are seen together. Not only is the couple format thought to lend credence to the notion of joint responsibility, but, even more critically, it ignores safety issues for the woman, who may be vulnerable to subsequent acts of violence based on what she does in therapy. Thus, models have been offered for assessing the appropriateness of joint sessions (e.g., Lipchik, 1991; Wilbach, 1989), working separately with violent men (e.g., Adams, 1988; Almeida & Bograd, 1990; Durrant, 1990), working separately with abused women (e.g., Goldner, Penn, Sheinberg, Walker, 1990; Rosen & Stith, 1993; Whipple, 1987), and working with both partners together when appropriate (e.g., Lipchik, 1991; Pressman, 1989). The adversarial stance that has characterized many of the discussions between proponents of systems-based versus feminist-based approaches to treating wife abuse is beginning to be tempered. Using as a starting place the idea that a man who is violent must take individual responsibility for his acts without blaming his wife, many marital and family therapists look for the means to integrate the strengths of both the systems and feminist models in ways that allow more responsiveness to the situation and dynamics of the individual couple (e.g., Balcom & Healey, 1990; Goldner, 1992; Goldner et al., 1990; Lipchik, 1991).
Closely associated with attempts to integrate gender into the treatment of wife abuse have been efforts to address the significance of gender in the treatment of child abuse and incest. Similar themes of ensuring victim safety, incorporating individual responsibility, and challenging therapist neutrality are found in feminist approaches to working with families in which physical and/or sexual abuse of children occurs (Barrett, Trepper, & Fish, 1990; Canavan, Higgs, & Meyer, 1992; Fontes, 1993; James & MacKinnon, 1990; Sheinberg, 1992; Valentich & Anderson, 1989; Wheeler, 1989).
A second area of clinical work in marital and family therapy that has undergone reconsideration in light of the feminist critique is addiction. Revisions have focused on two areas: (a) integrating an understanding of female psychological development and needs into both treatment models and popular 12-step programs (Bepko, 1989; Berenson, 1991; Walker, Eric, Pivnick, & Drucker, 1991) and (b) challenging the notion of codependency that holds one partner, typically a woman, responsible for the addiction of her partner (Bepko & Krestan, 1990; Krestan & Bepko 1991; Sloven, 1991.)
A third area that has been revised in light of the increased attention paid to gender is what might be called female and male development in the context of family relationships. The focus of this work was initially to compensate for the inattention to women's experience in families by reconsidering significant aspects of family life from women's perspectives. This work integrated theories on female psychological development and socially constructed gender-based patterns of interaction into models of treatment. The result was fresh treatment perspectives on issues such as adolescent development (Mirkin, 1992), the transition to motherhood and grandmotherhood (Safier, 1992), single parenting (Kazak & Segal-Andrews, 1992) stepmothering (Keshet, 1989), sister relationships (McGoldrick, 1989), and mother-son relationships (Silverstein, 1989; Silverstein & Rashbaum, 1994). The overarching goal of this work is to utilize a perspective that acknowledges a woman's strengths and experiences in understanding her life to assist her with whatever problems or issues she is encountering and with developing more satisfying relationships. Certainly the most comprehensive treatment of women's lives in families from this perspective can be found in two books: Women in Families: A Framework for Family Therapy (McGoldrick, Anderson, & Walsh, 1989) and The Invisible Web: Gender Patterns in Family Relationships (Walters et al., 1988).
Following the focus on enhancing understanding of women's experiences in family life and its implications for therapy, there has been increased attention in recent years on how gender structures family life for men as well (e.g., Meth & Pasick, 1990; Pittman, 1991). Although the feminist call to integrate gender has emphasized women's perspectives because of the power inequities and oppression that undergird much of family life, attention to men's experiences in families is not inconsistent with a feminist emphasis on the importance of gender. However, the recent move to include men in consideration of how gender structures family life has not been without controversy. For example, Carter (1992) points out that the focus on how both men and women suffer as a result of gender socialization or how society constrains options for both men and women leads to obscuring the problem of hierarchy and unequal power in heterosexual relationships.
The fear of diluting the issue of unequal power notwithstanding, the field has begun to explore, for work with men in a therapeutic context, the implications of men's development and the ways society structures their lives. Attention has been given to men's psychological development as they "learn to be men" (Levant, 1992; Meth, 1990; Napier, 1991; Pittman, 1991) and to fulfill their assigned roles as providers (Pasick, 1990), husbands Gordon & Meth, 1990), and fathers (Feldman, 1990). The i goal of integrating this theoretical material is to enhance clinical work with men in therapy either individually (e.g., Allen & Laird, 1990; Ganley, 1990; Pasick, Gordon, & Meth, 1990) or in the context of their significant relationships, be they with wives (Gordon & Allen, 1990; Napier, 1988; Neal & Slobodnik, 1990), children (Gordon, 1990a), or members of the family of origin (Allen, 1990; McCollum, 1990; Gordon, 1990b). As evidence of the significance given the issue of understanding men in family therapy, an entire issue of the Journal of Feminist Family Therapy was devoted to the topic in 1990 (Bograd, 1990a). More recently, Dienhart and Avis (1994) have conducted exploratory research with gender-sensitive therapists to identify effective approaches to working with men in family therapy. Interestingly, a large percentage of the interventions endorsed by these therapists had to do with the therapists developing their own "awareness of sociocultural gender issues" (p. 401).
Ethnicity/race. In contrast to the clinical applications growing out of the work on gender, the clinical applications of the work on ethnicity do not tend to focus on specific substantive areas, such as wife abuse. Although there are exceptions such as Watts-Jones' (1992) article on treating panic disorder in a Jamaican woman and Flores-Oritz and Bernal's (1990) chapter on addiction treatment with Latinos, these tend to be single articles or chapters as opposed to bodies of work on a substantive area. Instead, the clinical work on ethnicity tends to focus on working with different racial-ethnic groups, outlining the relevance of a group's characteristics such as history, values, rituals, and current economic conditions for therapy. The initial work on ethnicity in the field, Ethnicity and Family therapy (McGoldrick et al., 1982) set this approach as the model, offering chapters on numerous ethnic groups. Outlining the clinical relevancy of characteristics of specific ethnic groups continues to be the primary format utilized in much of the clinical application work on racial-ethnic minority families (e.g., Braverman, 1990; Hines, Garcia-Preto, McGoldrick, Almeida, & Weltman, 1992; Ho, 1987; McGoldrick et al., 1989). This type of work has been criticized, however, as relying on stereotypes and simplistic characterizations of racial or ethnic groups in the effort to educate therapists about racial and ethnic diversity (Maranhao, 1984; Markowitz, 1994).
A variation on looking at multiple racial or ethnic groups is to take one group and examine it in depth. The primary example of this approach is Boyd-Frankin's (1989) book Black Families in Therapy: A Multisystems Approach. In this book, Boyd-Franklin addresses issues such as racism, skin color, informal adoptions, and spirituality as critical to understanding African American families. She then examines how an appreciation of these factors will influence clinical work with families and the adaptations that would be necessary in major models of family therapy. Although issues that arise in conducting family therapy with other racial-ethnic groups have been addressed in various journal articles (e.g., Berg & Jaya, 1993), it is unfortunate that no other racial-ethnic group has received the extensive treatment in the marital and family therapy literature that is found in this book on African Americans (Hardy & Laszloffy, 1994).
Instead of looking at a particular racial-ethnic or at several different racial-ethnic groups, an alternative approach is to identify clinical strategies or techniques that heighten clinicians' sensitivity to race, ethnicity, and culture without attempting to portray specific groups. Although this type of work is less common, notable examples exist. Tseng and Hsu (1991), in their book Culture and Family: Problems and Therapy, offer a guide to "culture-adjusted family assessment" (p. 175) that identifies areas to be assessed as indices of the ethnic and cultural background of a family. Similarly, McGill (1992) offers the "cultural story" as a technique for helping family members convey the significance in their lives of the multiple cultures of which they are a part.
A unique and quite innovative approach to applying the critiques of the treatment of both gender and ethnicity in marital and family therapy can be seen in the "Just Therapy" approach (Tamases & Waldegrave, 1993). This approach acknowledges the "injustice in therapy experienced by women and cultural groups different from the dominant one" (p. 2 but looks to the organizations that offer clinical services, not the individual therapists, as the source of redress and change. Recognizing that the biases and blindspots of models of therapy reflect the biases and blindspots of the larger culture, this work attempts to intervene at the larger structural level in a belief that it will then impact both the therapists and families within that system. These structural interventions are aimed at challenging three institutional responses that tend to inhibit change: paralyzing, individualizing, and patronizing. Tamases and Waldegrave acknowledge that most organizations that offer mental health services are liberal in ideology and recognize injustice based on race, culture, or gender. However, resistance tends to appear once acknowledgement has occurred. One way to resist real change is to become paralyzed by guilt, offering sympathetic reactions to the complaint but feeling powerless to make any real change. A second response that inhibits change, individualizing, occurs when a person in the dominant group distinguishes him or herself from the insensitivities and oppressions perpetrated by others of his or her group (e.g., Whites, males) and claims accountability only for personal behavior. Finally, real change can be blocked through patronizing, which occurs when a member of the dominant group takes on the mantle of spokesperson for an oppressed group. The authors then describe the process used by the Family Centre in Wellington, New Zealand in an attempt to prevent these responses and to reverse the cultural and gender biases in therapy. Fundamentally, this process is built on the premise that the members of an aggrieved or oppressed group are the best judges of injustice to that group. Therefore, staff who belong to a particular oppressed group are given the role of guardians of equity for members of that group, be they clients or staff.
Sexual orientation. Although the vast majority of work examining the implications of recent critiques of marital and family therapy for actual practice has focused on gender or ethnicity, the application work that is beginning to appear around sexual orientation should be noted. Primarily, two areas have been reconsidered in light of the critiques of marital and family therapy: (a) the role of family therapists in assisting both homosexual clients and their families in the potentially difficult "coming out" process and (b) parenting issues faced by homosexual parents (Dahlheimer & Feigal, 1991). Coming out refers to the process of making one's homosexual orientation known to others. Although the major focus of the literature has been on the homosexual's family of origin, issues for partners or children in families that homosexuals form have also been addressed (e.g., Carl, 1990; Roth, 1989). Regardless of the family constellation being considered, Dahlheimer and Feigal (1991) highlight the importance of the therapist initially stressing to family members that it is society's heterosexism that is the real source of tension and pain for family members during the coming out process. Such a focus helps to free the homosexual family member from being labelled the cause of whatever struggle or stress the family is experiencing. With such a framework established, therapy can then proceed on the specific issues in a given family.
The literature on parenting emphasizes that gay men and lesbians who are parents face all the same issues as heterosexual parents face, such as how to maintain age appropriate discipline or how to nurture children's self-esteem. However, in addition to the normal problems and stresses of parenting, gay and lesbian parents face many complications and problems from which heterosexuals are immune (Carl, 1990; Evans, 1990). Homophobia, secrecy, ambiguity of family roles and boundaries, societal assumptions about the inadequacy of gay and lesbian parents, and failure of the legal system to recognize the parental status of many homosexuals involved in the raising of children all contribute to a more lugged parenting terrain for gay men and lesbians than for heterosexuals (Ariel & Stearns, 1992; Baptiste, 1987). Although the literature gives some attention to each of these areas for both women and men, it should be noted that, in keeping with our societal emphasis on the role of mothers, the literature on parenting is much more heavily weighted towards working with lesbian mothers than gay fathers (e.g., Evans, 1990; Ross, 1988; Roth, 1989).
Applying Critiques to Training
The call to rethink and revise the way marriage and family therapy is conducted with families has been accompanied by a call to reconsider the way in which marriage and family therapists are trained, placing gender, race, and ethnicity as more central features in teaching about family dynamics. Guidance has been offered on how gender (Avis, 1989; Leslie & Clossick, 1992; Roberts, 1991; Storm, 1991; Wheeler, Avis, Miller, & Chaney, 1989), culture, (Falicov, 1988; Preli & Bernard, 1993) and race (Boyd-Franklin, 1989; Hardy & Laszloffy, 1992, 1994) can be incorporated into the curriculum of training programs and how students' and supervisees' appreciation of the relevance of these socially constructed variables can be enhanced. Recent research has noted, however, that merely adding gender content may be insufficient to change clinical practice. Leslie and Clossick (in press) found clinicians who had received gender coursework taught from a feminist perspective showed less sexism in clinical practice than did clinicians who had received gender coursework taught from any other theoretical perspective. Interestingly, those who had received gender coursework from other than a feminist perspective showed the same level of sexism as those receiving no gender training at all.
Also addressed in this literature are questions about the readiness of training programs and institutions to truly grapple with what it means to integrate gender and race into training, as well as questions about the personal and political dilemmas posed for faculty and students who take the lead in such integration (Avis, 1989; Coleman, Avis, & Turin, 1990; Hardy & Laszloffy, 1992; Leslie & Clossick, 1992). For example, training programs often marginalize both course content and faculty by putting all gender and ethnicity related training in one course without revising the biases/problems found through the remainder of the curriculum. The existence of one such course can then be touted as evidence of sensitivity to issues of gender, ethnicity and race, even when the sexism and racism in other course content and policies is unaddressed.
A related issue receiving some attention is the way in which the needs of students may differ based on their gender and race. Attention has been given to how training programs can be responsive to both female (Reid, McDaniel, Donaldson, & Tollers, 1987; Warburton, Newberry, & Alexander, 1989) and male (Nutt, 1990) student therapists as they strive to better understand how gender structures both their lives and the lives of their clients. Similarly, Wilson and Stith (1993) have addressed the experiences of African American students in marital and family therapy training programs and offered guidelines for developing recruitment and retention efforts that address the cultural and racial impediments to African American students' participation in training programs.
Impact of Therapist's Gender and Race on Therapy
A third area that has been revisited is the impact of the therapist's gender and race on the course of therapy. Certainly, the bulk of this work has been done relative to the impact of gender, with only one recent study (Gregory & Leslie, in press) looking at the impact of both therapist's race and gender on husbands' and wives' experiences in therapy.
Considerations of the impact of therapist's gender have been two. pronged. Theoretical consideration has been given to the implications for treatment when male therapists work with female clients (Doherty, 1991) and when female therapists work with male clients (Bograd, 1990a), whereas empirical investigations have considered the impact of therapist's gender on the structure and process of family therapy sessions. Results of the research suggest that clients tend to respond differently to male and female therapists, treating each in gender stereotyped ways, for example, offering more supportive statements with female therapists (Newberry, Alexander, & Turner, 1991) and more directive statements with male therapists (Shields & McDaniel, 1992). However, female therapists do not respond in gender stereotyped ways; they frequently respond to family members' supportive behaviors with structuring interventions (Newberry et al., 1991). Male therapists, however, make more statements than female therapists during sessions (Shields & McDaniel, 1992).
This body of research has also shown that male and female therapists tend to conceptualize cases differently (Black & Piercy, 1991); women work from a feminist-informed perspective more frequently than men. Likewise, although the gender of the identified patient does not affect clinical decision making in marital therapy, the gender of the therapists does, with female and male therapists attending to different client characteristics (Zygmond & Denton, 1988).
When looking at the combined effects of therapists' race and gender, initial research suggests that the gender of the therapist makes very little difference in husbands' and wives' assessments of the depth, smoothness, and positivity of clinical sessions. However, the race of the therapist does have an impact on initial assessments of smoothness and positivity of therapy, particularly for Black wives. Over time, however, differences in wives' assessment of therapy based on the therapists' race decrease (Gregory & Leslie, in press).
AREAS OF NEEDED WORK
Even though the the call to more sensitively and consistently attend to gender, race and ethnicity, and sexual orientation when working with families has led to a reexamination of a variety of issues in marital and family therapy, there are still areas where attention is needed. Two, in particular, stand out.
The first area where work is needed is in the utilization of empirical approaches to further understanding of the role of gender, race and ethnicity, and sexual orientation for both clients and therapists in marital and family therapy. To date, the vast majority of the literature is theoretical or clinical in nature. Although these avenues provide valid insights and knowledge, there is also much to be learned from a data-based approach--be it qualitative or quantitative--to many of the questions or issues posed from these critiques. For example, empirical methods could lend valuable perspectives to questions such as: What are the experiences of abused women in couples therapy versus individual therapy? How does a woman's level of financial dependency affect her behavior and attitude in family therapy? How does the race of the therapist affect treatment outcomes for families of different races? How can training programs be structured to enhance the experience of minority students? What is the experience of homosexual parents in family therapy?
To date, the most extensive use of empirical methods in the gender area is seen in questions concerning the impact of therapist gender on the process of family therapy sessions (Gregory & Leslie, in press; Newberry et al., 1991; Shields & McDaniel, 1992), but even this area of research is limited to a handful of studies. In the area of race and ethnicity, a few studies exist that have assessed the interactional and structural dimensions of families of different ethnicities (e.g., Fisek, 1991; Hampson, Beavers, & Hulgus, 199O; Morris, 1990). No consistent empirical attention has yet been given to any question concerning sexual orientation and marital and family therapy. Hopefully, empirical methods will become more extensively mined as a rich source of insight into how gender, race and ethnicity, and sexual orientation affect both marital and family therapy and the training of marital and family therapists.
A second area where attention is needed is in the integration of the literature and knowledge on the effects of gender, race, ethnicity, and sexual orientation on family members' lives and on families in therapy. As Almeida (1994) points out, feminist analysis has emphasized issues of power inequity and domination in understanding family dynamics. However, other sources of oppression and inequality that impact family life, such as race and class, have received little attention from those interested in issues of gender. Likewise, those interested in questions of race and ethnicity have given only passing attention to gender. Neither body of work has given much attention to questions of sexual orientation. There are a few notable exceptions to this pattern: the "Just Therapy" approach mentioned earlier; a chapter on ethnicity and women by McGoldrick and her colleagues in Women in Families: A Framework for Family Therapy (1989); work on African-American males by Franklin (1992, 1993); a special issue of Journal of Family Therapy devoted entirely to ethnicity and mothers (Braverman, 1990); and a recent issue of the Journal of Feminist Family Therapy entitled "Expansions of Feminist Family Theory Through Diversity" (Almeida, 1994), which has articles addressing the intersection of gender, race, and sexual orientation (Almeida, Woods, Messineo, Font, & Heer, 1994; Comas-Diaz, 1994; Korin, 1994). However, these forays into integrating gender, race, and ethnicity are the exception; the more common approach is a feminist literature that focuses on issues of gender and a separate body of literature that focuses on issues of race and ethnicity. There is little, if any, systematic treatment of how these systems of inequality and hierarchy, as well as those of class and sexual orientation, are related and jointly affect individual family members, families as a whole, and marital and family therapy. This criticism is, of course, not unique to the field of family therapy. Feminism, in general, has been criticized for being concerned mainly with issues affecting White middle-class women. However, as Walker, Martin, and Thompson (1988), Almeida (1994), and others note, feminist theory is thoroughly equipped to provide such integration because issues of hierarchy, inequity, and oppression are at the heart of the theoretical analysis. Feminist theories are now beginning to address the diversity in women's experiences and men's experiences based on socially constructed variables other than gender. So, too, family therapy needs to embrace a more multi-faceted approach to the social construction of family life and examine the implications of such an approach for working with families.
The last 10 years have seen the field of marital and family therapy called to task for the way in which therapeutic models based largely on the perspectives of White males have ignored and dismissed the experiences of other groups. The result has been therapy that is irrelevant to certain groups and oppressive to others, as it forces families to fit a model of individual mental health and family functioning that disregards family members' life circumstances, resources, and values.
Certainly, the critiques have had an impact on practice and training in the field as therapists struggle to be more appreciative of the diversity of experience and life circumstances that impact clients' behavior and their needs in therapy. Whereas some might argue that the response has been slow and limited, it cannot be denied that these critiques have produced a tension that has influenced, and will continue to influence, the developmental course of marital and family therapy. Not only has this work identified certain groups who have been misserved and begun to address the situation, but it has also instilled cautiousness in the field that we as family therapists must be more diligent in examining the impact of our work on all involved. As a result, the field is just beginning to recognize and examine another group, children, which may have been misserved over the years by an emphasis on the needs of adults, particularly in cases of separation and divorce (e.g., Robinson, 1994). It is likely that in the future we will recognize blindspots in our treatment of other groups as well. The important point is that we should continue the current momentum toward acknowledging our values and biases and examining how our work affects all of our clients, as diverse as they may be. Certainly, all families will be better served by the evolving reflective, responsive stance within the field brought about by therapists who are able to critique that of which they are a part.
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