Sociocultural Attunement to Vulnerability in Couple Therapy: Fulcrum for Changing Power Processes in Heterosexual Relationships.

Increasingly, couple therapists are called to promote equity in their clinical practice, yet little research illuminates the intricacy of doing this work. The purpose of this study was to clarify the clinical processes involved when therapists facilitate a more equitable balance of power in couple relationships while utilizing a sociocontextual frame of reference. It is part of larger research explicating Socio-Emotional Relationship Therapy (SERT), an approach that places equity and social justice at the core. The sample included 72 SERT sessions with nine heterosoexual couples in which there was an observable power difference between partners. Using Charmaz's (2014, Constructing grounded theory: A practical guide through qualitative analysis, Sage) grounded theory coding, theoretical sampling, and interpretive methods, we examined therapist/client responses over multiple sessions to explain shifts in the couples' power balance. Analysis identified sociocultural attunement to vulnerability as the core clinical process and detailed five sociocultural expressions: socialized vulnerability, socialized invulnerability, reactive (in)vulnerability, reactive vulnerability, and shared vulnerability. Shifts in power involved each of three therapist stances: (a) identification of the societal power context of vulnerability, (b) therapist leadership and responsive persistence, and (c) facilitating mutual sociocultural attunement to vulnerability to promote shared relational responsibility and influence. Implications address the connections between power and vulnerability in couples work and what therapists can do to more effectively facilitate relational equity.

Cada vez más, se exige a los terapeutas de pareja que promuevan la igualdad en su práctica clínica, sin embargo, existen pocas investigaciones que diluciden la complejidad de hacer este trabajo. El propósito de este estudio fue aclarar los procesos clínicos implicados cuando los terapeutas facilitan un equilibrio de poder más equitativo en las relaciones de pareja y a su vez utilizan un marco de referencia sociocontextual. Este estudio forma parte de una investigación más extensa que expone la terapia relacional socioemocional, un método que ubica a la igualdad y a la justicia social como ejes centrales. La muestra incluyó 72 sesiones de terapia relacional socioemocional con nueve parejas heterosexuales en las cuales había una diferencia de poder visible entre los integrantes de la pareja. Utilizando la codificación en la teoría fundamentada, el muestreo teórico y los métodos interpretativos de Charmaz (2014, Constructing grounded theory: A practical guide through qualitative analysis, Sage), analizamos las respuestas de los terapeutas/los pacientes durante varias sesiones para explicar los cambios en el equilibrio de poder de las parejas. El análisis identificó la adaptación sociocultural a la vulnerabilidad como proceso clínico principal y detalló cinco expresiones socioculturales: la vulnerabilidad socializada, la invulnerabilidad socializada, la (in)vulnerabilidad reactiva, la vulnerabilidad reactiva y la vulnerabilidad compartida. Los cambios en el poder implicaron cada una de tres posturas del terapeuta: (a) identificación del contexto de vulnerabilidad del poder social, (b) liderazgo del terapeuta y persistencia receptiva, y (c) facilitación de la adaptación sociocultural mutua a la vulnerabilidad para promover la responsabilidad y la influencia relacionales compartidas. Las implicancias abordan las conexiones entre el poder y la vulnerabilidad en el trabajo de las parejas y qué pueden hacer los terapeutas para facilitar más eficazmente la igualdad relacional.

Moving from "I" to "We": A Grounded Theory Analysis of Couple Therapy with Liver Patients and Their Partners.

Prior research indicates that couples who cope with chronic illness from a relational "we" orientation experience more positive outcomes than couples that cope individually; however, little prior research identifies clinical processes that promote reciprocity or how societal gender processes are involved. This grounded theory analysis of 25 videotaped therapy sessions with six heterosexual couples coping with chronic liver disease (LD) used a feminist-informed relational lens to focus on the clinical processes involved in shifting from an individual to a relational orientation. Findings identified three contextual barriers to attaining a "we orientation": (a) autonomy discourse, (b) illness-related power, and (c) gendered power. Analysis detailed therapist actions that decreased the impact of barriers to reciprocity and fostered relational coping. Clinical implications attend to complex intersections among gender, caregiving, and contextual barriers to reciprocity.

Investigaciones anteriores indican que las parejas que hacen frente a una enfermedad crónica desde una orientación relacional basada en el "nosotros" tienen resultados más positivos que las parejas que la enfrentan individualmente; sin embargo, existen escasas investigaciones previas que identifiquen los procesos clínicos que promueven la reciprocidad o la manera en la que están implicados los procesos de género social. Este análisis de teoría fundamentada de 25 sesiones de terapia videograbadas con seis parejas heterosexuales que enfrentan una enfermedad hepática crónica utilizó una óptica relacional fundamentada en el feminismo para centrarse en los procesos clínicos relacionados con el paso de una orientación individual a una relacional. Los hallazgos identificaron tres obstáculos contextuales para lograr una "orientación basada en el nosotros": (a) el discurso de autonomía, (b) el poder relacionado con la enfermedad, y (c) el poder asociado al género. El análisis detalló las medidas del terapeuta que redujeron el efecto de los obstáculos para la reciprocidad y fomentaron el afrontamiento relacional. Las implicancias clínicas tratan de las intersecciones complejas entre el género, el cuidado y los obstáculos contextuales para la reciprocidad.

Third-Order Thinking in Family Therapy: Addressing Social Justice Across Family Therapy Practice.

We contend that the field of family therapy is undergoing a notable shift from second- to third-order thinking. We offer theoretical support and examples to demonstrate how third-order thinking provides a framework for integrating heightened sociocultural attunement into family therapy practice. We discuss the importance of third-order thinking relative to being prepared to invite families into third-order change. Finally, we offer a case example to show specific guidelines for third-order practice.

Afirmamos que el ámbito de la terapia familiar está sufriendo un cambio notable porque está pasando del pensamiento de segundo orden al pensamiento de tercer orden. Ofrecemos respaldo teórico y ejemplos para demostrar cómo el pensamiento de tercer oden ofrece un marco para integrar una mayor sensibilización sociocultural en la práctica de la terapia familiar. Debatimos la importancia del pensamiento de tercer orden relativa a estar preparados para invitar a las familias al cambio hacia el tercer orden. Finalmente, ofrecemos el ejemplo de un caso para mostrar pautas específicas sobre la práctica del tercer orden.

Navigating Critical Theory and Postmodernism: Social Justice and Therapist Power in Family Therapy.

The family therapy field encourages commitment to diversity and social justice, but offers varying ideas about how to attentively consider these issues. Critical informed models advocate activism, whereas postmodern informed models encourage multiple perspectives. It is often not clear how activism and an emphasis on multiple perspectives connect, engendering the sense that critical and postmodern practices may be disparate. To understand how therapists negotiate these perspectives in practice, this qualitative grounded theory analysis drew on interviews with 11 therapists, each known for their work from both critical and postmodern perspectives. We found that these therapists generally engage in a set of shared constructionist practices while also demonstrating two distinct forms of activism: activism through countering and activism through collaborating. Ultimately, decisions made about how to navigate critical and postmodern influences were connected to how therapists viewed ethics and the ways they were comfortable using their therapeutic power. The findings illustrate practice strategies through which therapists apply each approach.

Addressing Culture, Gender, and Power with Asian American Couples: Application of Socio-Emotional Relationship Therapy.

Asian Americans juggle the intersections of multiple social identities and societal discourses as they respond to experiences of immigration, marginalization, and patriarchy, integrate collectivist and individualistic family values, and form families and intimate relationships. In this study we examine what we have learned as we apply Socio-Emotional Relationship Therapy (SERT) with heterosexual couples of Asian heritage. SERT begins with sociocultural attunement and the assumption that relationships should mutually support each partner. Drawing on case examples, we illustrate how we practice sociocultural attunement as couples respond to the relational processes that comprise the Circle of Care (mutual influence, vulnerability, attunement, and shared relational responsibility). We emphasize three key socioemotional themes that intersect with gender: (1) intangible loss; (2) quiet fortitude/not burdening others; and (3) duty to the family.

Can Anyone Hear Me? Does Anyone See Me? A Qualitative Meta-Analysis of Women's Experiences of Heart Disease.

Female heart patients are underdiagnosed and undertreated. The purpose of this qualitative meta-data-analysis was to explain how societal expectations related to gender and the treatment environment influence women's experiences and can inform optimal care. The authors used grounded theory methodology and a social constructionist gender lens to analyze 43 studies (1993-2012) of women's experiences of heart disease. The analysis illustrates how social expectations within both medical and relational contexts led to women experiencing barriers to diagnosis and treatment and inadvertent minimization of their experience and knowledge. Women's descriptions of their experiences suggest three kinds of health care strategies that have the potential to increase women's engagement with heart disease treatment and rehabilitation: (a) support give and take in relational connections, (b) identify and acknowledge unique health-promoting behavior, and (c) focus on empowerment. These findings have interdisciplinary implications for practice with women with heart disease.

Gender and the construction of intimacy among committed couples with children.

This study began with curiosity regarding how long-term couples with children manage their relationships in view of changing societal demands and ideals. Couples interviewed for this study described the intersection of time and intimacy as a core issue. Thus, this analysis focused on how couples construct intimacy in shared time. The diverse sample included 17 heterosexual working and professional class couples in the United States who had been committed for at least 10 years and whose oldest child was aged 6-16. Analysis identified four types of shared time experiences: gender divided, elusive, growing, and emotionally connected. Four factors influenced these types: (a) negotiated gendered differences, (b) intentionality, (c) mutual attending, and (d) dyadic friendship. The most emotionally connected couples reported that time together reinforced satisfaction and pleasure from their relationships. Results help explain different ways couples successfully negotiate changing expectations for heterosexual relationships and why some couples struggle. Findings suggest that therapists help couples intentionally develop habits of friendship and mutual attending.

Toward relationship-directed parenting: an example of North American born second-generation Korean-American mothers and their partners.

Historically, parenting has been constructed hierarchically; however, contemporary parenting models frequently emphasize parenting as relationship (Siegel & Hartzell [2004] Parenting from the inside out: How a deeper self-understanding can help you raise children who thrive; Tuttle, Knudson-Martin, & Kim [2012] Family Process, 51, 73-89). Drawing on interviews with 20 North American born second-generation Korean-American mothers and their partners, and sensitized by TP-CRO, a social constructionist framework for conceptualizing parent-child relational orientations, this grounded theory analysis identified three main processes that facilitate relational connection as a parenting orientation rather than the rule-directed approach historically associated with first-generation immigrant Asian families. These include: (a) emphasizing dominant culture values; (b) inviting open communication; and (c) promoting mutuality. Results also show how parents integrate collectivist cultural values of their first generation immigrant parents' traditional culture into North American parenting ideals with which they primarily identify. The study demonstrates the usefulness of the TP-CRO for understanding parent-child relationships within multicultural parenting contexts and offers suggestions for working with second-generation Korean families.

Why power matters: creating a foundation of mutual support in couple relationships.

Research shows that equal power helps couples create intimacy and relationship success. However, though couples increasingly desire equal relationships, cultural models of mutual support are not well developed. Clinicians often approach heterosexual couple therapy as though partners are inherently equal, thus reinforcing unacknowledged gender inequities. This article examines research that shows why power imbalances are destructive to intimate relationships and focuses on four gender-related aspects of mutual support: (a) shared relational responsibility, (b) mutual vulnerability, (c) mutual attunement, and (d) shared influence. Case examples illustrate how socio-emotional attunement, interrupting the flow of power, and introducing alternative relational experience help couple therapists identify and address power disparities in these important relational processes. Encouraging the powerful person to take relational initiative and introducing alternative gender discourse are especially important.

Parenting as relationship: a framework for assessment and practice.

Parenting tends to be framed as a set of actions directed toward the child rather than as a relationship. This article helps therapists, parent-educators, and researchers conceptualize parenting as a socioculturally embedded relationship. The authors apply the relational orientations typology (Silverstein, Bass, Tuttle, Knudson-Martin, & Huenergardt, 2006) to parent-child relationships. The typology addresses two dimensions: whether the focus is on the child's meeting parental expectations or on expectations of mutuality and whether power between parent and child is expected to be symmetrical or asymmetrical. Four relational orientations are described: (1) rule directed, (2) position directed, (3) independence directed, and (4) relationship directed. These relational orientations describe the nature of the reciprocal relationship between parent and child and offer a framework from which to address parenting issues. A case illustration shows how the relational orientations framework helps therapists incorporate a larger systems/relational perspective into what was originally framed primarily as a child behavior problem.

Learning to Embody a Social Justice Perspective in Couple and Family Therapy: A Grounded Theory Analysis of MFTs in Training.

This action research study explores how four MFT students shifted from a cognitive understanding of equity and power to an intrinsic and automatic internalized process as we participated in research in which we observed, coded, and engaged in structured reflexive conversations about relational power using a data bank of Socio Emotional Relationship Therapy sessions. We reviewed and analyzed ten of our recorded two-hour reflexive conversations to develop grounded theory that explains our experience of learning to embody a relational power lens, which consists of five interconnected phases: (a) developing a theoretical understanding of relational power, (b) critically observing live therapy, (c) noticing and attending to the felt sense of witnessing power, (d) engaging in transformative conversation, and (e) applying to personal practice. Our findings provide guidance for clinical training programs who wish to facilitate the experience for clinicians-in-training to understand and address societal power processes in clinical practice.

A socio-emotional approach to couple therapy: linking social context and couple interaction.

This paper introduces Socio-Emotional Relationship Therapy (SERT), an approach designed to intervene in socio-cultural processes that limit couples' ability to develop mutually supportive relationships, especially within heterosexual relationships. SERT integrates recent advances in neurobiology and the social context of emotion with social constructionist assumptions regarding the fluid and contextual nature of gender, culture, personal identities, and relationship patterns. It advances social constructionist practice through in-session experiential work focused on 4 conditions foundational to mutual support--mutual influence, shared vulnerability, shared relationship responsibility, and mutual attunement. In contrast to couple therapy models that mask power issues, therapist neutrality is not considered possible or desirable. Instead, therapists position themselves to counteract social inequalities. The paper illustrates how empathic engagement of a socio-culturally attuned therapist sets the stage for new socio-cultural experience as it is embodied neurologically and physically in the relationship and discusses therapy as societal intervention.

Spirituality and relationship: a holistic analysis of how couples cope with diabetes.

This study explores how couples' spirituality and relationship processes holistically interact to inform diabetes management. Qualitative analysis of interviews with 20 heterosexual couples identified five spiritual coping styles based on the spiritual meaning they ascribed to the situation and the nature of their relationships with God and each other: (a) opportunists approach the illness as an opportunity for growth; (b) mutual problem solvers collaborate with their partners to respond to their disease; (c) individualistic problem solvers take personal responsibility for managing their disease; (d) accepters endure their disease; and (e) victims take a hopeless, discouraged approach. Results suggest that spirituality and couple communication and problem-solving patterns appear intertwined and integral to the practice of family therapy.

From Knowing to Doing: Guidelines for Socioculturally Attuned Family Therapy.

Family therapists know that clinical concerns are not separate from larger sociopolitical contexts. Attunement to clients' sociocultural experience is foundational to good practice, yet few guidelines integrate attention to the larger societal processes or address social equity. The purpose of this article is to help therapists move from knowing about sociocontextual issues to doing socioculturally attuned practice. We offer an overarching framework that returns to Bateson and the roots of family therapy through a call for third order transformation. The approach is responsive to societal context and an analysis of power while working through enduring concepts of major family therapy models. Transtheoretical guidelines that can be integrated across practice models to promote third order change are illustrated with case examples.

Exploring the Relationship Balance Assessment.

Assessments of power in couples' relationships often only survey one partner, but they do not take into consideration both partners' perceptions. Thus, many assumptions about power and equality in relationships have not been quantitatively tested due to a lack of dyadic measures of power. Therefore, the purpose of the Gender and Relationships Study was to develop and test a new scale of equality and relative power for couples, the Relationship Balance Assessment (RBA). The RBA may be useful for research and for clinical work with couples to help raise awareness of the balance of power in their relationship. A review of the literature has shown a shift away from focusing on monetary resources and decision-making dominance towards examining relationship processes and the connection between gender and power. This study prescreened a pool of process-oriented questions based on the qualitative literature. Then exploratory factor analysis of data from 268 individuals and 91 couples identified 12 consistent latent factors underlying relationship equality. These 12 subscales are summed up with the TREASURES acronym: Time Discretion, Relational Power, Emotional Power (Emotional Expression and Avoidance subscales), Accommodation, Spending and Saving subscales, Union or Sexual Dominance, Rational Power, Economic Role Power (Status and Childcare subscales), and Social Choices.

Cultural Attunement in Therapy With Mexican-Heritage Couples: A Grounded Theory Analysis of Client and Therapist Experience.

There is a need for culturally attuned approaches for couple therapy with Mexican/Mexican-Americans. This qualitative grounded theory study utilized interviews with 11 client couples of Mexican heritage and 14 marital and family therapists to shed light on how Latino and non-Latino therapists co-construct positive experiences of cultural attunement with Mexican and Mexican-American couple clients. Analysis identified a model of cultural connection through personal engagement with four interrelated phases: (a) mutual invitation, (b) shared engagement, (c) expanding personal connection, and (d) creating cultural connections. Clients in this study valued professionalism and expertise of the therapist, but felt attuned to and respected when therapists demonstrated humility, shared personal stories and emotion, and engaged in a collaborative process.

Moving beyond gender: processes that create relationship equality.

Equality is related to relationship success, yet few couples achieve it. In this qualitative study, we examine how couples with children in two time cohorts (1982 and 2001) moved toward equality. The analysis identifies three types of couples: Postgender, gender legacy, and traditional. Movement toward equality is facilitated by: (a) Stimulus for change, including awareness of gender, commitment to family and work, and situational pressures; and (b) patterns that promote change, including active negotiation, challenges to gender entitlement, development of new competencies, and mutual attention to relationship and family tasks. Implications for practice are discussed.

Competencies for addressing gender and power in couple therapy: a socio emotional approach.

Power imbalances between partners are intrinsic to relationship distress and intricately connected to emotional experience, couple communication processes, and socio cultural contexts such as gender. The ability to work with the power dynamics between partners is thus critical to the practice of couple therapy. However, few practical guidelines for dealing with this issue are available. The authors present seven clinical competencies regarding gender and power issues that they identified by examining their own work: (a) identify enactments of cultural discourse, (b) attune to underlying socio cultural emotion, (c) name underlying power processes, (d) facilitate relational safety, (e) foster mutual attunement, (f) create a model of equality, and (g) facilitate shared relationship responsibility. Each competency is illustrated through a case example. The competencies represent an over-arching guide to practice that may be integrated with other clinical approaches and is particularly useful for training and supervision.

Expanding Bowen's legacy to family therapy: a response to Horne and Hicks.

In response to Horne and Hicks's critique of my 1994 revision of Bowen Theory, I present an updated rationale for my work. I argue that the primary difference in my construction of emotional differentiation rests in the way "self" is constructed. I suggest that many women, persons from less individualistic cultures, and very spiritual persons develop a "connected self" that is significantly different than Bowen's image of separate selves engaged with each other. I hold that Bowen Theory privileges individuality and ignores many of the positive aspects of togetherness. I put forth an inclusive model for differentiation that equally prioritizes each.

Don't end up in the fields: identity construction among Mexican adolescent immigrants, their parents, and sociocontextual processes.

This grounded theory study of 16 Mexican immigrant adolescents and 20 of their parents examines how they construct relational identities within their families, at school, with friends, and in the larger society. Results focus on a core identity bind faced by the adolescents: immigration messages from parents that say, "don't be like me" and the societal message, "you're not like us." Response to this bind was guided by two contrasting sets of identity narratives: Empowering narratives invited an intentional approach to school and life choices. Restricting narratives maintained an ambivalent approach to school and life choices. Resolution of the identity bind was a collective, ongoing process that has implications for Mexican immigrant families and the professionals who work with them.