PROCESS

Integrative Problem-Centered Metaframeworks Therapy II: Planning, Conversing, and Reading Feedback
WILLIAM PINSOF, PH.D. n DOUGLAS C. BREUNLIN, MSSA n WILLIAM P. RUSSELL, MSW n JAY LEBOW, PH.D. n All abstracts are available in Spanish and Mandarin Chinese on Wiley Online Library (http:// wileyonlinelibrary.com/journal/famp). Please pass this information on to your international colleagues and students.

This is the second of 2 articles presenting Integrative Problem Centered Metaframeworks (IPCM) Therapy, a multisystemic, integrative, empirically informed, and common factor perspective for family, couple, and individual psychotherapy. The rst article presented IPCMs foundation concepts and Blueprint for therapy, focusing on the rst Blueprint componentFHypothesizing or assessment. This article, focusing on intervention, presents the other 3 Blueprint componentsFPlanning, Conversing, and Feedback. Articulated through the Blueprint, intervention is a clinical experimental process in which therapists formulate hypotheses about the set of constraints (the Web) within a client system that prevents problem resolution, develop a therapeutic Plan based on those hypotheses, implement the Plan through a coconstructed dialogue with the clients, and then evaluate the results. If the intervention is not successful, the results become feedback to modify the Web, revise the Plan, and intervene again. Guided by the therapeutic alliance, this process repeats until the presenting problems resolve. IPCM Planning sequentially integrates the major empirically and yet-to-be empirically validated therapies and organizes their key strategies and techniques as common factors. Conversing and Feedback employ empirical STICs (Systemic Therapy Inventory of Change) data collaboratively with clients to formulate hypotheses and evaluate interventions. This article emphasizes the art and science of IPCM practice. Keywords: Integrative Problem Centered Therapy; Metaframeworks; Individual; Couple; Family Therapy; Empirically Informed Therapy; Web of Constraints; Multisystemic Therapy Fam Proc 50:314336, 2011

n Center for Applied Psychological and Family Studies, The Family Institute at Northwestern University, Evanston, IL.

Correspondence concerning this article should be addressed to William Pinsof, Center for Applied Psychological and Family Studies, The Family Institute at Northwestern University, 618 Library Place, Evanston, IL. E-mail: w-pinsof@northwestern.edu 314

Family Process, Vol. 50, No. 3, 2011 r FPI, Inc.

PINSOF, BREUNLIN, RUSSELL, & LEBOW

315

his is the second of two linked articles on Integrative Problem Centered Metaframeworks (IPCM), a multisystemic, comprehensive, and empirically informed perspective for family, couple, and individual psychotherapy. We use perspective, rather than model, because IPCM is a meta-model for integrating and organizing the growing plethora of specic treatment models for specic disorders within family, couple, and individual psychotherapy. Our perspective draws upon and synthesizes our previous theoretical work on Integrative Problem Centered Therapy (Pinsof, 1983 and 1995), Metaframeworks (Breunlin, Schwartz, & Mac Kune-Karrer, 1992 and 1997), and Common Factors (Lebow, 2005; Sprenkle, Davis, & Lebow, 2009), along with our empirical work on the Integrative Psychotherapeutic Alliance (Pinsof, Zinbarg, & Knobloch-Fedders, 2008) and the Systemic Therapy Inventory of Change (STICs) (Pinsof et al., 2009). IPCM is organized around a generic Blueprint that implicitly informs every psychotherapists work. It contains four components: Hypothesizing, Planning, Conversing, and Feedback. The rst article (Breunlin, Pinsof, Russell, & Lebow, 2011) presented IPCMs basic concepts and framework for hypothesizingFhow we formulate hypotheses about the factors within a client system that prevent change. This article delineates how we plan or formulate interventions (Planning), how we implement those interventions (Conversing), and how we collect feedback about our interventions and integrate it into a new round of hypothesizing (Feedback). In IPCM, assessment (Hypothesizing and Feedback) and intervention (Planning and Conversing) are distinct, yet inseparable and coextensive processes that occur microscopically within sessions and macroscopically over the course of therapy. This article presumes familiarity with the core concepts and model of hypothesizing described in the rst article.

HYPOTHESIZING FTHE WEB OF CONSTRAINTS

The rst Blueprint component, Hypothesizing, develops hypotheses about the unique Web of Constraints that prevents resolution of a client systems presenting problems. Client system designates all of the people involved in maintaining and/or resolving the presenting problem, regardless of the type of therapy. Every client system has a unique Web for each of its presenting problems. The Web (gure 2 in Breunlin et al., 2011) integrates the concepts of systemic levels and hypothesizing metaframeworks to dene the problem eld or space. Any client systems Web is an evolving model that is rened repeatedly on the basis of feedback over the course of therapy until the presenting problem is resolved. For simplicitys sake, we use clients in place of client system. The Web is also informed with empirical data, for which we recommend the STICs (Pinsof et al., 2009), a client self-report measure, described in the rst article, that provides a multisystemic and multidimensional assessment of individual, familyof-origin, couple, family, and child functioning over the course of therapy. The STICs Systems website provides therapists and supervisors on-demand feedback about client functioning, progress, and the therapeutic alliance (Pinsof et al., 2008). STICs data are normed and case-based. In the STICs feedback Website data from each client in a case are illustrated side-by-side on the same dimensions. Therapists use STICs data to more fully understand and evaluate the location (which systems), nature, and strength of constraints in the Web.
Fam. Proc., Vol. 50, September, 2011

316

FAMILY PROCESS

PLANNING
The second Blueprint component, Planning, creates a therapeutic Plan to address the Web of constraints generated in Hypothesizing. The process of Planning as well as the overall process of IPCM are informed by Therapy Guidelines (listed in Table A1). A number of these guidelines have already been detailed in the rst article (Breunlin et al., 2011).

Therapy Guidelines
Beyond the therapy guidelines presented in the rst article, the rst additional therapy guideline is that therapy is an educational process in which therapists give away their skills, knowledge, and expertise as quickly as clients can integrate them (Educational Guideline). The IPCM therapist, as well as facilitating change, teaches behavioral, emotional, cognitive, and social problem solving skills. This educational emphasis is designed to permanently build the therapists expertise into the collective consciousness of the client system. IPCM therapy empowers clients with new knowledge and skills, leaving them stronger and more psychologically competent than they were at the beginning of treatment. In terms of interventions, IPCM asserts that less expensive, more direct, and less complex interventions should be used before more expensive, indirect, and complex ones (Cost-Effectiveness Guideline). Not only aimed to increase the cost-efciency of therapy, this guideline encourages therapists to approach clients as if they are capable of modifying the constraints that prevent them from solving their problems with minimal intervention. It is a corollary of the Strength guideline articulated in the rst article. Recognizing the interpersonal nature of psychopathology, IPCM encourages therapists to begin working directly with interpersonal systems and to move, as needed, to individual work. The working rule is that, if possible and appropriate, it is always better to do an intervention, regardless of its nature (e.g. cognitive, psychodynamic, emotion-focused, etc.), within an interpersonal as opposed to an individual context (Interpersonal Guideline). As well as placing the new knowledge derived from therapy on the widest interpersonal platformFthe collective observing ego (the identied client plus relevant others)Fthis Guideline facilitates assessment by letting the therapist see the clients in action (rather than just relying on their reports) and helps to directly create therapeutic alliances with as many of the clients as possible. Consistent with this interpersonal progression, IPCM encourages therapists to begin working in the here-and-now and to move, as necessary, to the past (Temporal Guideline). This Guideline maximizes the likelihood that therapists will address hereand-now, proximal constraints to change before moving to more remote constraints derived from the past. For example, if a husband is reluctant to express his need for love and support to his wife for fear that she will humiliate him, we rst explore the likelihood that she will humiliate him before we look at how prior attachment gures humiliated him. In terms of cost-efciency, if resolution of here-and-now constraints permits implementation of the adaptive solution, exploration of historical constraints is unnecessary. Finally, for us the therapeutic process is failure drivenFtherapeutic shifts occur when current interventions have proven insufcient to modify the Web enough to permit implementation of the adaptive solution to the presenting problem (Failure
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

317

Driven Guideline). As a comprehensive and integrative psychotherapeutic perspective, IPCM is perpetually concerned with the therapist question, What should I do when what I am doing is not working? IPCM intervention is organized around nding the best available answer to this question. It gives therapists and their clients access to a plethora of logical, sequential, and pragmatic answers, so that there is almost always something else that can be done to help even the most constrained clients. It also builds on the notion that clients frequently need strategies and techniques that derive from more than one type of therapy to modify the constraints preventing problem resolution.

INTERVENTION CONTEXTS
IPCM species three primary intervention contexts to dene the direct client systemFthose clients directly involved in therapy at any particular time. The Family/ Community Context includes at least two clients from different generations within a client system; the Couple or dyadic Context involves two clients from the same generation; and the Individual Context includes one client. We prefer context to modality, because it is more neutral and connotes less about the interventions that can occur in a context. These contexts reect our prioritizing of natural systemsFsystems with a past and future. Natural systems can hold and reinforce new knowledge and skills after therapy. Ad hoc group therapy systems are useful adjunctive intervention contexts. Multifamily/couple groups combine the best of natural and ad hoc contexts.

PLANNING METAFRAMEWORKS
IPCM organizes and integrates specic models of psychotherapy within six generic Planning Metaframeworks. The three Intervention Contexts and the six Planning Metaframeworks form the 3 6 Matrix presented in Figure 1. A Planning Metaframework covers a domain of specic therapy models that share a common primary focus (behavior, experience, etc.) and mechanisms of change. Each Planning Metaframework extracts and emphasizes common factor strategies and techniques that cut across the models that fall within it (Sprenkle et al., 2009). A planning metaframework, as a framework of intervention frameworks, moves the psychotherapeutic eld beyond specic therapies toward a more generic and common factor perspective. It is an open category that includes not only existing therapy models, but future models with the same foci and mechanisms of change. Just as Hypothesizing Metaframeworks organize theories of problem formation and maintenance, Planning Metaframeworks organize theories of problem resolution.

The Posic Family

We illustrate each Planning Metaframework with examples from the Posic case presented in the rst article. To briey summarize, Emily Posic sought therapy for herself and her family to help them deal with their six year old son Adams Aspergers, the growing alienation between Emily and her husband Richard, and the individual distress she (overwhelmed/depressed) and Richard (brooding/depression) were experiencing. After two sessions with the Posics (one with full family and one with the couple), and a thorough review of their STICs INITIAL data, their therapist, Karen, hypothesized that Emily and Richard were both challenged (Mind Hypothesizing
Fam. Proc., Vol. 50, September, 2011

318

/
Planning Metaframework FamilyCommunity Contexts of Therapy Couple

FAMILY PROCESS

Hypothesizing Metaframework

Individual

Sequences Organization Development

Action e.g., Structural, Behavioral, Functional, Strategic

Culture Gender Spirituality Sequences of mind (M1)

Emotion / Meaning e.g., Cognitive, Narrative, Experiential, EFT, CBT, DBT, Psychoeducation

Biology

Biobehavioral e.g., relaxation, mindfulness, CBT, psychopharmacology

Intergenerational Patterns: Sequences, Organization, Mind

Family of Origin e.g., Structural, Bowenian, Internal representation e.g., Object relations, Attachment Theory, Internal Family Systems Self e.g., Self Psychology, existential therapy

Organization of Mind (M2)

Development of Self (M3)

FIGURE 1. IPCM Planning Matrix.

Metaframework) by Adams disability, particularly his difculties attaching to them. Emily and Richard experienced Adams disability differently (Gender and Culture Hypothesizing Metaframeworks), but both were deeply disappointed by his failure to develop along the normal pathways and timelines like his 11 year old sister, Kate (Development Hypothesizing Metaframework). Their differences, along with their communication difculties, made it difcult for Richard as the stern parent and Emily as the kind parent to collaborate (Organization Hypothesizing Metaframework). Both became depressed and mute about their deeper thoughts or feelings. Their marriage fragmented and the good things about it (friendship, sexuality, etc.) eroded. Meanwhile, Kate, the daughter, felt abandoned, frightened (Mind), and lost with her parents depression and preoccupation with Adam (Development and Organization).

The Here-and-Now Planning Metaframeworks

The rst three Planning Metaframeworks, Action, Meaning/Emotion, and BioBehavioral, share a common temporal orientationFthe present and what might be thought of as the immediate past. They are concerned with clients current functioning and relationships. Insofar as they take an historical focus, that focus pertains to the history of the current relationships. For example, in regard to a marriage, these
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

319

metaframeworks aim to change behavioral, experiential, or biological constraints within the marriage or constraints that derive from the history of the marriage. In regard to parent/child relationships, they focus on constraints that function currently in the relationship or that derive from the history of that relationship.

Action
The Action Planning Metaframework includes strategies and techniques that derive from therapies that primarily target behavioral sequences. These sequences are usually interpersonal and focus on how people behave with each other. Behavioral (Forgatch, Patterson, Degarmo, & Beldavs, 2009), Structural (Minuchin, 1974), Strategic (Haley, 1987; Watzlawick, Weakland, & Fisch, 1974), and Solution Focused (de Shazer et al., 1986) family and couple therapies fall within this metaframework. As well as focusing on behavioral Sequences, intervention strategies within this Metaframework focus particularly on constraints within the Organization and Development hypothesizing metaframeworks. The most common therapeutic strategy for models within this metaframework is their pragmatic emphasis on action-oriented techniques that aim to get clients to act differently both within and outside of the therapy sessions. Typically, the most basic Action strategy encourages clients to implement an adaptive solution to the presenting problem. Enactments are common Action strategies that therapists use to stimulate interaction between clients within and outside of the session. In her rst session with the Posics, Karen created two enactments. The rst was at the beginning, when she asked Emily and Richard to get Adam to leave the toys and sit down for several minutes with the family so Karen could say hello and get to know all of them. The ensuing sequence illustrated the difculty that Emily and Richard had co-parenting Adam. Later in the session, Karen asked Richard and Emily to talk with each other about collaborating better in regard to Adam. Again the ensuing sequences illustrated how they fail to communicate. The genius of Action interventions is that they either lead to adaptive action or better reveal the problem sequences and constraints that prevent change.

Meaning/Emotion
The Meaning/Emotion metaframework draws upon models that focus on experience (as opposed to behavior)cognition, emotion, meaning, and intention. These include Cognitive (Beck, 1976), Emotionally Focused (Greenberg & Johnson, 1988), ClientCentered (Rogers, 1951), Narrative (White & Epston, 1989), Motivational Interviewing (Miller & Rollnick, 2002), and Integrative Couple Therapies (Jacobson & Christensen, 1996). This Metaframework views narratives or stories as more elaborate cognitive structuresFlinked and organized cognitions. Meaning/Emotion interventions primarily target constraints within the Mind, Culture, Development, and Spirituality Hypothesizing Metaframeworks. The Web, at this point, hypothesizes that the clients capacity to act more adaptively is constrained by maladaptive cognitions and/or emotions. Meaning/Emotion change strategies either increase client awareness about the constraining effects of maladaptive cognitive and emotional sequences or replace them with more adaptive sequences. With emotions, this involves heightening adaptive and reducing maladaptive emotions. With cognitions, this entails identifying maladaptive cognitions and replacing them with adaptive cognitions/narratives. The assumption
Fam. Proc., Vol. 50, September, 2011

320

FAMILY PROCESS

underlying Meaning/Emotion interventions is that changing experience leads to or facilitates behavior change. Karen hypothesized that Richard and Emily experienced a host of troubling and conicting emotions in the face of Adams obstinacy and lack of relatedness. They had never shared their disappointment, sadness, fear, shame, and anger about having a disabled son. Karen intended to help them identify their feelings about Adams disability as well as what it meant to them. She hypothesized that they both felt like failures as parents and that Adams disability was their fault. Karen also believed that Kates feelings of abandonment, sadness, and anger had never been expressed and needed to be shared with her parents. She thought that before Emily, Richard, and Kate could open up, she would have to defuse their catastrophic expectations about what would happen if they openly shared their feelings and thoughts about Adams disability.

Acceptance Strategies
Beginning with Jacobson and Christensens (1996) expansion of Couples Behavioral Therapy to include acceptance work, the elds of psychotherapy and family therapy have begun to embrace acceptance strategies. Their work comes out of the obvious recognition that sometimes efforts to change behavior, cognition, and emotion do not work, and that acceptance rather than change becomes the goal. The work of Hayes, Strosahl, and Wilson (2003) on Acceptance and Commitment Therapy, the growing emphasis on Mindfulness (Ma & Teasdale, 2004; Siegel, 2007) as a therapeutic strategy in its own right as well as a component of Dialectical Behavior Therapy (Linehan et al., 2006), and the expanding interest in 12-Step programs that emphasize the serenity to accept what I cannot change have helped to bring acceptance strategies and spiritual practice into the purview of psychotherapy and family therapy practice. Interestingly, such strategies often have the ironic consequence of facilitating dramatic change.

Biobehavioral
The Biobehavioral metaframework draws upon models that primarily focus on biological constraints, such as psychotropic medication, biofeedback, exercise, and meditation. Biobehavioral interventions address constraints within the Biology hypothesizing metaframework, as well as the biological substrates of Organization, Development, and Mind. Biobehavioral models use psychopharmacological strategies and techniques (medication) and/or behavioral strategies and techniques that change behavior to modify underlying biological constraints. Although some Biobehavioral models increase adaptive neuropsychological processes (particularly antidepressants), the majority of these models use calming/soothing strategies and techniques to reduce maladaptive neuropsychological processes that interfere with problem solving. Karen planned to use psychoeducation strategies about Aspergers for Richard, Emily, and Kate. She anticipated temporarily expanding the direct system to include the school psychologist who evaluated and diagnosed Adam, hoping that they would all learn more about the etiology and psychophysiology of Aspergers. She also placed on a back burner the possibility that Richard and/or Emily might need antidepressant medication if they could not engage in talk therapy or the talk therapy was ineffective. Lastly, she wondered whether there were medications and/or biobehavioral strategies to diminish Adams Aspergers symptoms.
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

321

The Historical Planning Metaframeworks

The next three Planning metaframeworks, Family-of-Origin, Internalized Representation, and Self, target historical or what Helen Kaplan (1974) called remote or intrapsychic constraints. They explicitly address residual effects of relationships from the families of origin of the adult clients. Their focus moves away from the here-andnow and targets how the remote past constrains the implementation of solutions to the presenting problems.

Family of Origin
The Family of Origin planning metaframework is a swing metaframeworkFit is concerned both with constraints that derive from current relationship patterns in adults families of origin as well as the transgenerational patterns from adults families of origin that constrain solution implementation. The models within this metaframework primarily utilize couple or individual contexts with adult clients. They employ two intervention strategies. The rst, the in-session strategy, expands the direct system with individuals or couples to include members of the adults family of origin. This involves bringing the parents (or siblings) directly into therapy for two or more sessions to remove constraints in those relationships that prevent implementation of the adaptive solution to the presenting problem (Pinsof, 1995). Consistent with the Interpersonal Guideline, with a partnered adult, this work should be done with the spouse/partner in the sessions. This in-session family-of-origin work must be preceded by work that clearly demonstrates to key clients that their current family-of-origin relationships are actively interfering with their ability to solve their presenting problems. With the Posics, Emilys widowed mother, Judith, has never liked Richard, feeling that Emily married down when she married Richard and that his destructive reactions to Adam reected his old country values and beliefs. Judith, in her almost daily phone conversations with Emily, encouraged the polarization between Emily and Richard with her not-so-secret hope that Emily would eventually leave him. Richard dimly perceived Judiths antipathy toward him, which Emily downplayed. Karen surfaced this destructive dynamic by asking Emily and Richard how their families gured into their struggles over Adam. The second, back home strategy works to differentiate adult clients within their family of origin without formally bringing family of origin members into the sessions. Typically this involves genograms as well as homework assignments in which adult clients intentionally change their behavior with family of origin members outside of therapy (Bowen, 1978). Actually, both family-of-origin strategies aim to differentiate adults within their family of origin. Interventions within this metaframework primarily target patterns that span multiple generations within a family. Such patterns typify most addictive families as well as families that struggle with genetically loaded affective and neuropsychological disorders. Codependency, enabling, and enmeshment characterize these patterns. The key therapeutic strategy is a planned campaign of confrontation (in and/or outside of the ofce) with the family of origin in which the differentiating adult changes his or her codependent behavior. In regard to the hypothesizing metaframeworks, this campaign addresses cognitive (Mind) and behavioral (Organization) constraints. However, the ultimate goal is to shift the adults experience of his
Fam. Proc., Vol. 50, September, 2011

322

FAMILY PROCESS

or her self-in-context toward greater interdependence, mature dependency, and individuation (Development). With Emily and Richard, Karen used the back home strategy to begin to address Emilys enmeshed relationship with her widowed mother. She explored Emilys sense of responsibility for her mothers well-being since her father died three years ago, as well as the pattern of disengaged marital and co-parental relations that characterized Emilys family of origin for generations. This pattern marginalized men as parental nurturers and dened women as the go-to parent. Using the Gender and Culture metaframeworks, Karen openly hypothesized that the Emily-Judith-Richard triangle was dysfunctional. As Karen diminished the polarization between Emily and Richard, they began to see the constraining contribution of this transgenerational pattern. However, Emily was still unable to challenge her mothers take on Richard or her deep sense of maternal obligation. Karen recommended bringing Judith in for several sessions. Judith agreed to join them. The initial work focused on Emilys sense of concern and obligation to her mother since her father died. Judith surprisingly said that she felt she was doing ne and that Emily did not need to worry about her. Emily was clearly shocked, but relieved. Karen then turned to the Judith-Richard relationship, encouraging them to talk directly. Karen initiated this process by asking Richard to talk about his feelings about Adams Aspergers. Richard stunned everyone by talking about his grief and sadness and fears for Adam. Tears came to his eyes. Judith and Emily noticeably softened. Karen moved the conversation to the false polarization of Emily and Richard and encouraged them to see each other (along with Judith) as containing soft and hard feelings about Adam that could be used for more coordinated and balanced action. Karen was not shocked to see that Emily and Richards STICs after this session indicated a clinically (from clinical to normal) and statistically significant shift in Relationship with Partner (RWP) Trust.

Internal Representation
The Internal Representation metaframework addresses models of Mind, like Object Relations (Greenberg & Mitchell, 1983) and Internal Family Systems (Schwartz, 1995), that target constraints from the internalized representations of self, other(s), and the relationships between them that derive primarily, but not exclusively, from childhood experiences. These constraints can also derive from traumatic and/or important relationships in adolescence and adulthood. The key hypothesis (Mind-M2) is that these prior experiences have left a psychological imprint on the person or group that constrains current and potentially future relationships. Therapy models focused on attachment (Johnson, 2002) and/or childhood trauma typically fall within this metaframework, as would most psychodynamic models. Primary Internal Representation therapeutic strategies include insight, interpretations linking past and present, reorganization of internal parts, and reparative or corrective therapeutic experiences between clients. With Emily and Richard, after the family-of-origin work discussed above, it still was difcult for Emily and Richard to collaborate around Adam. Emily still had great difculty setting and sticking to limits with Adam, and Richard had difculty nurturing Adam. Going more deeply into the Mind Metaframework, Karen hypothesized that both of them were struggling with more remote issues from early experiences in
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

323

their families of origin. With Emily, Karen dug more deeply into her early experience in her family and discovered that Emilys father had been a distant and harsh disciplinarian whom she felt she could never please. Her mother had not protected her sufciently from her fathers demands and criticisms and she unconsciously vowed to never do that with her own children. For her, to stand rm and hold limits with Adam was to be like her dad, a loathsome prospect. Similarly, Richard had not experienced nurturing from either of his parents and Emily was the rst really loving person in his life. It was hard for him to nd the nurturing parent within himself. Whenever he moved in that direction, his anger at not being nurtured would emerge and blocked him. As they came to understand these remote constraints they both began to own the parts of themselves in relationship to Adam that they had projected onto the other.

Self
The Self-Metaframework targets the selfFthe core of identity and the container of the object relations targeted by the Internalized Representation metaframework. This metaframework draws primarily on models that derive from Self Psychology (Kohut, 1977; Kohut, Goldberg, & Stepansky, 1984) as well as more recent work on the therapeutic effects of the rupture and repair of the therapeutic alliance (Pinsof et al., 2008; Safran & Muran, 1996; Stiles et al., 2004). The rigidity of the object relations and their capacity to change is a function of the vulnerability of the self. Focusing on the relationship between the client and the therapist, the central strategy of self-interventions involves the repeated, but unintentional and nontraumatic, tearing and repairing of the therapeutic relationship. The central mechanism of change is the reparative or curative relationship between the clients and the therapist, as well as the therapists eventual facilitation of reparative relationships between the clients. Through the repeated tearing and repairing of these relationships, the clients selves get stronger and more resilient. The goal of Self-strategies is a wider and more exible narcissistic homeostasis that permits clients to engage in the necessary adaptive behaviors. Karens work with Richard epitomized this process. Richard would open up to Karen and feel devastated when she failed to get what he was talking about. He would become arrogant and condescending toward her and that was a signal to her that she had hurt him. Rather than getting defensive, Karen responded empathically to Richard. Over time, Richard became less and less devastated by Karens occasional failures to understand. Emily was able to observe Karens empathic and non-defensive responses to Richards critical behavior and used them as a model for her new emerging behavior with Richard. As Richards narcissistic resilience increased, he was more able to be empathic and loving in the face of Adams failures to respond to him. In addition to targeting Mind constraints, self-work, implicitly or explicitly, often addresses spiritual constraints and strengthens clients spirits. Interventions at this level aim for some type of transcendent experience that allows clients to move to a higher level of awareness and connection with greater frequency and intensity. Frequently, self-work addressing spiritual constraints aims for surrender to a higher power and/or a sense of greater connection to others. This typically involves an experience of grace, in which the client receives or experiences a transcendent and enlivening connection. Grace cannot be forced or made to happen. It occurs. Frequently, this type of spiritual experience is preceded by hitting bottom, intense suffering, and a profound awareness that what one has been trying to do is not
Fam. Proc., Vol. 50, September, 2011

324

FAMILY PROCESS

working and some kind of major shift or reorientation is necessary. In contrast to the acceptance and mindfulness work discussed above in regard to Meaning/Emotion, the level of spiritual transformation and awakening that occurs during this kind of selfwork is deeper and more comprehensive, approximating a kind of wisdom. Although Karen did not frame it as spiritual work (Richard was a devout atheist), Richards growing ability to accept Adams disability and to take it as a growth opportunity for him involved a spiritual shift that permeated other aspects of his life. Richard was increasingly able to tolerate Emilys failure to get or connect with him. His sense of joy in life increased and he seemed more content.

THE IPCM PRINCIPLE OF APPLICATION

The Matrix in Figure 1 highlights two aspects of how IPCM organizes intervention contexts and planning metaframeworks. First, metaframeworks cut across contextsF therapists use Action, Meaning/Emotion, or Internal Representation strategies in family, couple, and/or individual contexts. A psychiatrist can do a medication consultation with a depressed man alone, with his wife, or with his wife and adult son. Second, the large arrow in Figure 1 illustrates the IPCM principle of application (what to do when) and operationalizes many of the therapy guidelines. It recommends that therapy, for most problems, should: (1) begin with fairly brief interventions (Cost Effectiveness Guideline) in family or couple contexts (Interpersonal Guideline) with a focus on current constraints (Temporal Guideline); and (2) progress, when such interventions fail or are contra-indicated, toward individual and/or longer term interventions focusing on historical and remote constraints (Failure Driven Guideline). The smaller arrow within the larger one illustrates that as therapy moves down the Matrix, the therapist stays in touch with current and immediate constraints. Thus, the work always refers back to the presenting problems and their resolution. The smaller arrow minimizes the likelihood of the therapist and clients getting lost exploring remote constraints for their own sake, a situation in which the therapy can lose its problem-centered focus. Therapy is a diagonally oscillating process that progressively addresses more remote constraints in smaller direct systems. That failure driven progression continues until constraints within the Web are sufciently alleviated to permit problem resolution. The IPCM principle of application, operationalized with the arrow in Figure 1, actually reects a exible and failure driven as opposed to a rigid or ideal progression. We think of it with various metaphors. Perhaps the best is as a ashlight that can be brought to bear on particular parts of the client system that need illumination and attention at particular points in therapy. The light is not meant to deny or diminish other aspects of the client system, but rather to illuminate particular constraints that need to be addressed at this moment. It needs to be moved with economy, sensitivity, exibility, and integrity as the therapeutic process unfolds. In the examples cited above, the different therapeutic interventions reect Karens shifting down the Matrix. She began therapy with the whole family but moved fairly quickly to working primarily with Emily and Richard. As she encountered constraints that prevented change, she moved down the Matrix in steps. The Matrix represented both a framework for where to look for new hypotheses that might explain the lack of progress, as well as a framework for new types of intervention strategies based on those hypotheses. Although most of the work with the Posics occurred in a couple
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

325

context, Karen used progressively more remote intervention strategies in that couple context. She exibly moved from focusing on the here and now with Richard and Emily, to looking at their families of origin (actually involving Judith directly in therapy), to addressing their transferences, and ultimately to working on the relationships between all of them (including herself).

Operationalizing the Plan

The Matrix broadly indicates what type of macro-strategies should be used in which contexts at particular stages in the therapeutic process. It does not specify lower level strategies and tactics (what techniques to use in a session). To facilitate more molecular and empirical planning, Pinsof et al. (2010) developed the Integrative Therapy Session Report (ITSR). It is lled out online by the therapist at the end of every session. The ITSR asks the therapist about who was present at the session, the type of session (e.g., individual, couple, etc.), the Systemic Domain Focus (e.g., individual, couple, current family, etc.), the Temporal Focus (In-session/here-and-now, recent past, remote past, etc.), and the Strategies and Techniques used in the session. It presents 17 generic strategies (e.g., Changing Behaviors/Action, Changing Cognitions, Changing Emotions, Directing Interactions, Interpretation, etc.) with specic techniques nested within each strategy (e.g., In Vivo, Imaginal, and Single Exposure within the strategy of Confronting Aversive Stimuli). It concludes with therapist ratings of the Therapeutic Alliance. Therapists need 57 minutes to complete the ITSR and must be trained to use it reliably. The ITSR is particularly useful for beginning level therapists who may not be aware of all of the intervention strategies available to them as they move through different cells of the Matrix in Figure 1. It is also useful for supervisors as a vehicle for suggesting different types of specic interventions or foci when student therapists need to shift down or up the Matrix. For Karen, who had been in practice over 20 years and had been trained as an integrative family therapist (Lebow, 1997), the strategies she used over the course of her work with the Posics owed naturally and un-self-consciously as she encountered different constraints. Selecting the Right Intervention Plan. The goal of Planning is to nd the right plan for the particular client system with its particular Web of constraints as hypothesized at a particular time. Initially, that involves addressing the presenting problem, the problem sequences and the primary constraints as directly and cost effectively as possible with strategies from the top three levels of the MatrixFthe hereand-now metaframeworks. If they work and the client system resolves its problems, therapy terminates or moves on to another presenting problem. If they do not work, therapy moves down the Matrix, using strategies from the lower levels of the Matrix in increasingly individual contextsFthe historical metaframeworks. Decision making about when and how to shift depends on what happens in the next parts of the Blueprint.

CONVERSING
Therapy is a conversation between people with distinct rolesFtherapist and clients. For four reasons, the primary metaphor we use for this therapeutic conversation is jazz. First, jazz musicians tend to be highly trained and skilled, like therapists. Secondly, jazz is both structured (melodies and rhythms) and
Fam. Proc., Vol. 50, September, 2011

326

FAMILY PROCESS

improvisationalFjazz musicians improvise around a basic structure and create music as they play. Third, musicians in a jazz group are continually stimulating and responding to each other. They interact with the hope that the whole will be greater than the sum of the partsFthat the magic will happen. Lastly, like every therapy and therapeutic encounter, a jazz piece is idiosyncratic and unique. Ultimately, as its best, IPCM therapists become highly trained and disciplined artists facilitating transformative experiences to help clients resolve the problems for which they seek help.

Questions, Statements, and Directives

IPCM therapists invite clients to join in this improvised conversation that has multiple recursive goals: (1) dene the presenting problem; (2) articulate the sequence in which the problem is embedded; (3) develop hypotheses about the problems; (4) reach agreement on one or more alternative adaptive sequences; (5) develop an intervention plan; (6) attempt to implement an adaptive solution linked to the Plan; (7) evaluate the intervention and if necessary identify constraints; (8) reformulate the hypotheses and revise the Plan accordingly. The therapist leads this conversation, maintaining focus and pacing. Unlike some pure models of therapy that proscribe certain sentence forms (e.g., ask only open ended questions; never tell clients what to do, etc.), the IPCM therapist makes judicious use of the three sentence forms: questions, statements, and directives. Therapists ask questions, particularly at the beginning of therapy and at the beginning of each session. Different types of questions have different effects. Open questions afford clients maximal freedom to respond, but unchecked they can result in a meandering conversation that fails to approach any of the goals described above. Closed questions restrict client maneuverability, which is essential when specicity is necessary. The Milan Associates (Selvini-Palazzoli, Boscolo, Checcin, & Prata, 1978) and later Tomm (1987) perfected the closed question in circular questioning, a powerful form of linked questioning that quickly identies problems and problem sequences. In family and couple contexts, questions can be used to assess empathic resonance and stimulate interaction. At one point early in therapy, Karen asked Richard what he thought Emily felt about his way of dealing with Adam. He replied: I am not sure. Karen responded: Why dont you ask her? Richard turned to Emily and asked: How do you feel about the way I deal with Adam? This type of intervention, by creating a need to know, tends to feel less coercive than a directive. Future questions can also be very useful in identifying and concretizing goals and in building hope (Penn, 1985). For instance, asking a lost young adult about his dreams and hopes for the future, may help his parents and siblings see his aspirations for a better life. They can also be helpful in eliciting and heightening softer emotions as when Karen asked Richard what he hoped Adams life would be like as an adult. As Richard talked about his hopes and dreams for Adam, his eyes teared up and his voice broke. Statements communicate information to the clients. This information may be expert knowledge about the nature of the clients problems, statements about the therapy or the therapeutic relationship, therapist self-disclosure, etc. Clients want and need to know what the therapist thinks about their problems. Statements help teach them to identify problem and adaptive sequences. Clients expect therapists to be
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

327

experts in family and individual functioning as well as psychotherapeutic change. This attribution gives therapists extraordinary potential to inuence client behavior. Particularly with couples and families, clients want therapists to take leadership and guide the session (to control what they experience as out-of-control chaos). Directives help to guide therapy. The use of directives and the form in which they are offered may differ with different types of systems from different cultures. Drawing on the Culture hypothesizing metaframework, clients from authoritarian cultures may seek and react very positively to directives in the imperative formFYou should do this! In contrast, client systems from more egalitarian cultures may react better to gentler directives or even questions that are essentially directives, like Karens Why dont you ask her?. IPCM therapists interweave these three linguistic forms to facilitate change and teach effective problem solving in different contexts at different points.

The Problem^Intervention Link

A key conversing component is maintaining the link between the current intervention (what the therapist is talking about now) and the presenting problem. This component derives from the Problem Centered Guideline delineated in the rst article. Although the therapeutic contract in voluntary therapy is that the clients hire the therapist system to help them solve their presenting problems, nonpresenting problems often emerge. The IPCM therapist does not have a mandate to address these nonpresenting problems, unless they link to the presenting problemsFunless they are part of the Web. The primary strategy for linking nonpresenting to presenting problems is to explain and ideally demonstrate the relationship between the problemsFhow the nonpresenting problem constrains resolution of the presenting problem. This might entail explaining to a mother how her depression, a nonpresenting problem, interferes with her limit-setting with her 7 year old son with attention deficit disorder (the presenting problem) or helping an alcoholic husband (nonpresenting problem) see how his drinking reduces his inhibitions so that arguments with his wife become physically abusive (presenting problem). Linking nonpresenting to presenting problems makes the case for addressing the new problem, and diminishes clients resistance to expanding the problem centered contract. This linkage is essential in shifting down the Matrix. Initially, Karen needed to help Emily and Richard see and understand how Emilys relationship with her mother interfered with their co-parental relationship before it made sense to them to go through all of the trouble to bring her into therapy. Similarly, the failure of upper matrix interventions to resolve their problems was a necessary precursor to Emily considering that her internalized representations of her childhood relationships with her parents inuenced how she currently perceived and dealt with Adam, Richard, and even herself.

Authentic Personal Style

Fundamentally, therapy is a person-to-person encounter. Therapy can and should be scripted only up to a certain point. The genuine engagement of two or more people in an unscripted and personal encounter is the jewel at the core of all forms of psychotherapy. It is the eeting, but all important transformative moment. In order to be available for this type of encounter the therapist must develop an authentic personal style that reects his/her true self. This aspect of therapy
Fam. Proc., Vol. 50, September, 2011

328

FAMILY PROCESS

cannot be manualized or prescribed. Client attachment or bonding to the therapist is facilitated by the clients experience of the therapist as genuine and involvedFas a real person who cares. Many things contribute to the therapists capacity to be present for this encounter, including personal therapy and self-knowledge, relationship experience, broad and deep clinical experience, and the development of wisdom. This wisdom is as much about the heart as the head. It is the personal platform that best supports the knowledge and skills of the IPCM therapist. It prevents the IPCM therapist from moving mechanically and linearly through the hypothesizing metaframeworks or down the matrix, but rather helps the therapist move through these structures as a child through a jungle gym. It is fun and it ows. This personal encounter aspect of conversing is in no sense a license for unprofessional or unethical behavior, but rather an invitation to infuse professional behavior with genuine care, compassion, and sensitivity. Therapists move down the Matrix and draw from different planning metaframeworks in their own wayFthat feels right and makes sense to them. Some therapists focus more on cognitions and others more on emotions when drawing upon the Meaning/Emotion metaframework. It is easier for certain therapists to direct with questions than directives. Developing a genuine personal style occurs over time and reects therapist maturation. It is the equivalent of a musician nding her distinctive voice, her own way of owning the notes and phrasing that uniquely dene her. Ultimately, the mature IPCM therapist has borrowed important strategies and tactics from a variety of models and integrated them into a cohesive and personal style that reects her true heart and mind. Karen was uniquely and ironically suited to be the Posics therapist. Karen had grown up in an Irish Catholic family with a tough father very much like Richard. As part of their couple therapy, Karen and her husband, Tim, had brought her widowed father into therapy with them for several sessions to address their relationship. He had opened up to Karen and her husband about his loneliness since Karens mother had died and Karen was able to comfort him in a new and more comfortable way. This work with her father had made it easier for her to approach Richard and see the pain and loss under his tough exterior. Also, Karen and Tims rst child had died as an infant and her grief about that loss made her particularly resonant to Emily and Richards grief about Adam. Karen shared her experience with her father in therapy when Richard and Emily were considering inviting Emilys mother into treatment with them. Although it resonated affectively, she did not explicitly share the death of her rst child with the Posics.

Action, Meaning, and Emotion

Although the Matrix and arrow (principle of application) suggest an overall progression over the course of therapy from action (behavior) to meaning and emotion, IPCM therapists focus on all three more or less in every session. Every sequence (problem and adaptive alternative) involves action, meaning, and emotion components. The proportional blend may shift with movement down the Matrix, but therapists focus on and are interested in all three aspects of human functioning. As constraints are identied and addressed, the nature of the constraint may dictate the relative proportions. For instance, if a couple does not shift out of a high conict interaction mode despite the therapists best efforts at teaching conict resolution skills
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

329

(action), the therapist may focus on the sadness and sense of loss underlying the conict (emotion). Alternatively, the therapist may interpret the conict as a way to avoid the emptiness each partner experiences in the marriage (meaning). In the therapeutic conversation, the IPCM therapist must develop the capacity to tolerate and even heighten intense emotions, actions, and meanings.

Using Empirical Data

A critical hallmark of IPCM therapy is feeding back to clients, at key points in the therapy, empirical/scientic data that have been collected from them. As mentioned in the rst article, we recommend the use of the STICs, which has been designed specifically to t IPCM and other multisystemic approaches. However, other types of empirical feedback can be used independently or with the STICs, depending on the availability of measures and feedback systems. The IPCM therapist shares STICs data with clients to help establish a consensual understanding of the Web and the relative power of specic problems or constraints within it. The therapist also uses it to help establish a consensual plan for therapy and to evaluate therapeutic progress. This involves actually showing clients their STICs data (on a computer screen) and inviting them to collaborate in their interpretation and utilization. In this sense, the STICs is a collaborative tool for focusing and sequencing the therapy around particular problems/constraints. (So we agree. First we will address the problems you have each identied in your marriage, particularly in regard to working with Adam. Then if necessary, the problems with Kate. Hopefully, she will feel better if you two get more aligned.) Integrating STICs data into therapy is an art. The challenge is how to present data that will facilitate the therapy. Invariably, seeing their own data is a powerful experience for clients, and in a multisystemic therapy, seeing the data from other members of the client system is even more powerful. In showing Richard and Emily their STICs data, Karen worried how they would react to seeing each others scores on RWP Trust. In fact, when she showed them their data, they laughed and said, We sure dont trust each other. What was most impactful was the positive shift in their Trust scores after their work with Emilys mother. It showed Karen, Emily, and Richard that things were really changing.

FEEDBACK
With the last Blueprint component, the therapist reads feedback from the interventions that emerged from the other three components. There are multiple sources of feedback.

The Referral and Intake Process

The rst source is the information that emerges from the referral and intake process. How does the referring client (the client who calls for help) narrate their problems and ask for help? What may it mean that this member of the client system called for help. How does the referring client react to the therapists attempt to dene the broadest, appropriate direct system? For instance, when a depressed, maritally distressed wife calls for individual therapy, if the therapist says that he would like the wife to invite her husband in for the rst session, the therapist is redening the direct system. When the wife balks, but nally asks him, the husband agrees to attend. This
Fam. Proc., Vol. 50, September, 2011

330

FAMILY PROCESS

sequence is data that the therapist uses to formulate and/or support initial hypotheses about the Web. For instance, does the wifes depression lead her to underutilize her marital relationshipFto misperceive her husbands good intent. By pushing her to bring her husband in, the therapist begins to test this hypothesis.

Direct Observations
A primary feedback source is the therapists direct observations. If the husband, during the rst session, is sympathetic and empathic to his wifes depression, that supports the underutilization/misperception hypothesis. On the other hand, if he is hostile and critical, using the session to elaborate how sick she is, the therapist might hypothesize that the marriage is a stressor as opposed to an underutilized resource. From talking with Emily on the phone, Karen had no sense of how she participated in creating the distance between her and Richard. When she saw them interact with each other in the rst session, she could see how Emilys criticism of Richard and her passive aggressive behavior toward Adam triggered his anger and defensiveness and, ultimately, his withdrawal.

Therapist Feelings
The therapists reactions to the client system are another source of feedback. As Karen was talking with Richard about what Adams Aspergers meant to him, she began to feel sad. She suspected that she was picking up Richards unresolved grief and asked him: Do you ever feel sad about Adams problems and difculties? He responded: I dont think so, which prompted her to ask him: What do you think it would be like if you did let yourself feel sad? He paused and tears came into his eyes. In this vignette, Karen felt that she was picking up Richards disowned emotion and used her feelings as a pathway into Richards.

STIC s Feedback
The last source is STICs feedback. As well as providing an empirical assessment of client systems, the STICs was designed to track multisystemic and multidimensional change over the course of therapy. The STICs provides a tool for measuring change on the dimensions that constituted the clinical prole of a case at the beginning of therapy. That the STICs is normed permits the determination of two types of changeFclinically significant and statistically significant. Clinically significant change occurs when a dimension that was in the clinical range moves into the normal range (or vice versa). Statistically or reliably significant change occurs when a dimension changes more than two standard deviations in any direction (ideally toward the normal range). STICs feedback is particularly useful in deciding when and how to move down the MatrixFwhen to shift Planning Metaframeworks. Consistent with the Failure Driven Guideline, the primary indicator that shifting down the Matrix is appropriate is lack of progress on the key STICs dimensions. Although a full discussion of this process is beyond the scope of these articles, a general guideline is that a shift is appropriate when the therapist and the clients, using STICs data and their own evaluations of progress, determine that things are not getting better. Generally, when clinically or statistically significant change has not occurred in key variables within a 46 week period, a discussion and shift down the Matrix is appropriate.
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

331

With the Posics, the rst clinically (and statistically) significant change was that Emilys Individual Problem and Strengths (IPS) Negative Affect (anxiety and depression) score improved dramatically. She clearly reacted to Karens initial interventions with enthusiasm and hope. However, Richards Negative Affect Score did not shift, nor did any of his other clinical scores. At this point Karen asked Richard how he was experiencing the therapy. He said that he did not think that they were making any progress with Adam. When Karen asked him more about what he meant, he said that Emily and he still could not work as a team. Karen contracted at that point with Emily and Richard to focus on their co-parenting. This led into an extended exploration of Emilys fears about Richards harshness and how Adam might react to her tough love. Richard was able to listen and, surprisingly, Emily agreed to a new set of behavioral guidelines with Adam. She and Richard were able to implement the new guidelines for about three weeks. Both of their RWP scores (particularly Positivity) improved, as did Richards IPS Negative Affect score. However, after three weeks Emily felt frightened about losing her somewhat tenuous connection with Adam and pulled back on collaborating with Richard. Their RWP scores fell back to their original levels, and their Trust scores also declined. This deterioration was a signal to Karen to shift and she began the exploration, discussed above, of Emilys relationship with her mother and its impact on Richard and their co-parental alliance.

THE THERAPEUTIC ALLIANCE

The therapeutic alliance informs every phase of therapy. IPCM uses the Integrative Psychotherapy Alliance model (Pinsof et al., 2008), the rst alliance model with an explicitly integrative and multisystemic perspective on the alliance in family, couple, and individual therapy. As mentioned above, the STICs INTERSESSION includes short form versions of the Individual, Couple, and Family Therapy Alliance Scales (ITAS, CTAS, FTAS). The models theoretical structure, illustrated in Figure 2, has two dimensionsFContent and Interpersonal System. Content has three subdimensionsFTasks, Goals, and Bonds. Tasks and Goals respectively refer to therapistclient agreement about the tasks and goals of therapy. Bonds refers to therapistclient attachment. The four Interpersonal subdimensions are Self-Therapist, Other-therapist, GroupTherapist, and Within-System. Self-therapist addresses the alliance (Tasks, Goals, and Bonds) between the client and the therapist (The therapist and I). Other-therapist targets the alliance between the therapist and the clients relevant other(s). In couple therapy other is my partner, in family therapy the other people in my family, and in individual therapy the people who are important to me. Group-therapist refers to us and the therapist. In couple therapy group is my partner and I, in family therapy it is my family, and in individual therapy it is me and the people who are important to me. Within-System refers to the alliance between the members of the client system (my partner and I agree about the goals of this therapy). Conrmatory factor analyses (Pinsof et al., 2008) supported the seven factor structure for the ITAS, but only three factors for the CTAS and FTASFSelf/Group, Other, and Within. The alliance is the most acknowledged common factor in psychotherapy (Sprenkle et al., 2009). IPCMs integrative and multisystemic alliance model places that common
Fam. Proc., Vol. 50, September, 2011

332

/
CONTENT DIMENSIONS INTERPERSONAL DIMENSIONS TASKS GOALS BONDS

FAMILY PROCESS

SELF-THERAPIST

OTHERTHERAPIST GROUPTHERAPIST WITHIN-SYSTEM

FIGURE 2. Theoretical Structure of the Integrative Psychotherapy Alliance.

factor on a broader systemic platform and makes it even more universal across individual, couple, and family therapy. Within IPCM, the therapist continuously gets STICs alliance feedback, which permits tracking of alliance vicissitudes within each case. Therapists use STICs feedback as well as their own impressions about the alliance. With couples and families, therapists pay particular attention to the Other and Within factors. After the initial improvement in Emilys IPS Negative Affect Score, Karen noticed that her Self/Group Alliance score (which taps her sense of alliance with Karen) had improved significantly, but that Richards Self/Group score had gone down precipitously. Coupled with the lack of change on his other clinical dimensions, as well as his low Within alliance score (his alliance with Emily) Karen used these data to turn toward Richard and address his concerns. After she recontracted with Richard and Emily to focus on their co-parental alliance, Richards Self/Group and Within alliance scores improved. He felt heard and taken seriously by Karen as well as hopeful about partnering with Emily. By tracking the alliance on a session by session basis, the STICs can also detect tears or ruptures in the therapeutic alliances between the clients and the therapist or between the clients themselves. Typically, a two-point (out of seven) drop on an alliance score is statistically significant (more than expected on a chance basis) and indicates that a rupture has occurred. Bordin (1979) and subsequently Pinsof (Pinsof & Catherall, 1986; Pinsof et al., 2008) and Safran and Muran (1996) have hypothesized that the tearing and repairing of the alliance constitutes one of the most powerful and therapeutic events that can occur in any type of therapy. With online feedback, the STICs Website immediately noties the therapist about an alliance rupture with a priority mail alert before the session, which allows the therapist to formulate a repair strategy in advance and primes the therapist to address the tear during the session. An alliance rupture that is not addressed and repaired within one to two sessions will usually destroy the therapeutic alliance and the therapy.
www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

333

Richards Self/Group Alliance drop signaled Karen that her alliance with him was in trouble, which led her to shift her focus to his concerns. That shift produced an immediate improvement in his alliance score with her. When Emily crashed in regard to her co-parental alliance with Richard, her Within alliance score fell three points. Also, Richards Within score fell about the same distance. Walking into that session after seeing their STICs data, Karen could see that their co-parental alliance had ruptured. She began the session by asking: What happened with the two of you this week? Richard replied: She jumped off the boat.

Alliance priority
The last IPCM therapy guideline is that growing, maintaining, and repairing the alliance takes priority over the principle of application (the arrow) unless doing so fundamentally compromises the efcacy and/or integrity of the therapy (Alliance Priority Guideline). IPCM recommends sequencing intervention strategies. If that sequencing will compromise or destroy the therapeutic alliance, developing or maintaining the alliance takes priority and the recommended sequencing should be modied. For example, if a troubled adolescent refuses to come in with his parents (as recommended by the Interpersonal Guideline), the therapist should see the adolescent initially in an individual context. As the alliance develops with the adolescent, the therapist can work on bringing in his family. Similarly, if a seriously depressed client refuses to consider medication, the therapist can move to more cognitive interventions. If the sequence modication and the alliance override ultimately renders the therapy useless, the therapist may have to confront the client system with the options of terminating or doing the necessary work.

THE FULL BLUEPRINT: INTEGRATING ARTAND SCIENCE IN IPCM

Figure 3 depicts the fully loaded Blueprint diagram with all of the major components articulated in these articles and attempts to show their relationships to each other. As the Blueprint illustrates, IPCM provides therapists with a comprehensive multisystemic, empirically informed, and common factor perspective for the treatment of individuals, couples, and families. It makes explicit the implicit hypothesis-making that guides all psychotherapy. It turns therapists and clients into co-experimentersFtesting hypotheses with clinical experiments, evaluating the results and revising the hypotheses until the clients problem is resolved. Clients and therapists are allies in the journey and failures to get it right are welcome opportunities to learn, grow, and try something different. We strive to bring the spontaneity of play to the discipline of clinical science. IPCM is a perspective for both integrating and transcending models. We view therapy as an idiosyncratic and improvisational process that integrates art and science to provide client systems with the best treatment for their problems. IPCM is very demanding of therapists, requiring knowledge and skills from multiple models. No therapist can ever fully master this perspective anymore than a therapist can ever fully understand a client system. In this sense, IPCM is not only a perspective for the conduct of psychotherapy; it is also a framework for multitherapist collaboration, referring clients to other therapists (acknowledging ones limitations) as well as a framework for the lifelong learning and growth of psychotherapists.
Fam. Proc., Vol. 50, September, 2011

334

FAMILY PROCESS

FIGURE 3. Integrative Problem-Centered Metaframeworks Perspective.

REFERENCES
Beck, A.T. (1976). Cognitive therapy and the emotional disorders. Oxford, UK: International Universities Press. Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252260. Bowen, M. (1978). Family therapy in clinical practice. Northvale, NJ: Jason Aronson. Breunlin, D.C. (1999). Toward a theory of constraints. Journal of Marriage and Family Therapy, 25(3): 365382. Breunlin, D.C., Pinsof, W.M., Russell, W.P., & Lebow, J. (2011). Integrative problem centered metaframeworks (IPCM) therapy I: Core concepts and hypothesizing. Family Process, 50(3): 293313. Breunlin, D.C., Schwartz, R.C., & Mac Kune-Karrer, B.M. (1992). Metaframeworks: Transcending the models of family therapy. San Francisco: Jossey-Bass. Breunlin, D.C., Schwartz, R.C., & Mac Kune-Karrer, B.M. (1997). Metaframeworks: Transcending the models of family therapy. Revised and Updated. San Francisco: Jossey-Bass. de Shazer, S., Berg, I.K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W., et al. (1986). Brief therapy: Focused solution development. Family Process, 25(2): 207221. Forgatch, M., Patterson, G., Degarmo, D., & Beldavs, Z. (2009). Testing the Oregon delinquency model with 9-year follow-up of the Oregon Divorce Study. Development and Psychopathology, 21, 637660. Greenberg, J., & Mitchell, S. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Greenberg, L.S., & Johnson, S.M. (1988). Emotionally focused therapy for couples. New York: Guilford. Haley, J. (1987). Problem-solving therapy (2nd ed.). San Francisco, CA: Jossey-Bass. Hayes, S., Strosahl, K., & Wilson, K. (2003). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

www.FamilyProcess.org

PINSOF, BREUNLIN, RUSSELL, & LEBOW

335

Jacobson, N.S., & Christensen, A. (1996). Acceptance and change in couple therapy: A therapists guide to transforming relationships. New York: Norton. Johnson, S.M. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York: Guildford. Kaplan, H.S. (1974). The new sex therapy. New York: Brunner/Mazel. Kohut, H. (1977). The restoration of the self. New York: International Universities Press. Kohut, H., Goldberg, A., & Stepansky, P.E. (1984). How does analysis cure. Chicago: University of Chicago Press. Lebow, J.L. (2005). Family therapy in the 21st century. In J. Lebow (Ed.), Handbook of clinical family therapy (pp. 116). Hoboken, NJ: John Wiley & Sons. Lebow, J.L. (1997). The integrative revolution in couple and family therapy. Family Process, 36, 117. Linehan, M., Comtois, K., Murray, A., Brown, M., Gallop, R., Heard, H., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757766. Ma, H., & Teasdale, J. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72(1): 3140. Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guildford Press. Minuchin, S. (1974). Families & family therapy. Oxford, UK: Harvard University Press. Penn, P. (1985). Feed-forward: Future questions, future maps. Family Process, 10(3): 299310. Pinsof, W.M. (1983). Integrative problem centered therapy: Toward the synthesis of family and individual psychotherapies. Journal of Marital and Family Therapy, 9, 1935. Pinsof, W.M. (1995). Integrative problem centered therapy: A synthesis of biological, individual and family therapies. New York: Basic Books. Pinsof, W.M., & Catherall, D. (1986). The Integrative Psychotherapy Alliance: Family, couple and individual scales. Evanston, IL: The Family Institute at Northwestern University. Pinsof, W.M., Lebow, J.L., Zinbarg, R., Mayberry, M., Chambers, A., Goldhaber, K., et al. (2010). The Integrative Therapy Session Report (ITSR). Evanston, IL: The Family Institute at Northwestern University. Unpublished manuscript. Pinsof, W.M., Zinbarg, R.E., & Knobloch-Fedders, L. (2008). Factorial and construct validity of the revised short form Integrative Psychotherapy Alliance Scales for Family, Couple, and Individual Therapy. Family Process, 47(3): 281301. Pinsof, W.M., Zinbarg, R.E., Lebow, J.L., Knobloch-Fedders, L., Durbin, E., Chambers, A., et al. (2009). Laying the foundation for progress research in family, couple and individual therapy: The development and psychometric features of the INITIAL Systemic Therapy Inventory of Change (STICs). Psychotherapy Research, 19(2): 143156. Rogers, C.R. (1951). Client-centered therapy: Its current practice, implications, and theory. Oxford, UK: Houghton Mifflin. Safran, J.D., & Muran, J.C. (1996). The resolution of ruptures in therapeutic alliance. Journal of Consulting and Clinical Psychology, 64, 447458. Schwartz, R.C. (1995). Internal family systems therapy. New York: Guilford. Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox: A new model in the therapy of the family in schizophrenic transaction (translator, E.V. Burt). New York: Jason Aronson. Siegel, D.J. (2007). The mindful brain: Reection and attunement in the cultivation of wellbeing. New York: W. W. Norton & Co. Sprenkle, D., Davis, S., & Lebow, J. (2009). Common factors in relational psychotherapy. New York: Guilford.

Fam. Proc., Vol. 50, September, 2011

336

FAMILY PROCESS

Stiles, W.B., Glick, M.J., Osatuke, K., Hardy, G.E., Shapiro, D.A., Agnew-Davies, R., et al. (2004). Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-Shaped or V-Shaped? Journal of Consulting and Clinical Psychology, 51, 8192. Tomm, K. (1987). Interventive interviewing: Part II. Reexive questioning as a means to enable self-healing. Family Process, 26, 167184. Walsh, F. (2009). Religion, spirituality and the family: Multifaith perspectives. In F. Walsh (Ed.), Spiritual resources in family therapy (2nd ed., pp. 330). New York: Guilford. Watzlawick, P., Weakland, J.H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. Oxford, UK: W. W. Norton. White, M., & Epston, D. (1989). Literate means to therapeutic ends. Adelaide, SA, Australia: Dulwich Centre Publications.

APPENDIX A
TABLE A1 IPCM Therapy Guidelines

The Problem Centered Guideline The Strength Guideline

All interventions should be linked, in some way, to the client systems presenting problems or concerns. Until proven otherwise, it is assumed that the client system can utilize its strengths and resources to lift constraints and implement adaptive solutions with minimal and direct input from the therapist. Assessment and intervention are two inseparable and cooccurring processes that span the course of therapy and lead to increasingly rened hypotheses and therapeutic plans that facilitate problem resolution The primary task of the therapist is facilitating the replacement of the key problem sequences with alternative, adaptive sequences that eliminate or reduce the problem. The practice of psychotherapy must be continually informed with empirical/scientic data in order to be maximally effective and efcient. Therapy is an educational process in which therapists give away their skills, knowledge and expertise as quickly as clients can integrate them. Therapy begins with less expensive, more direct, and less complex interventions and moves to more expensive, indirect, and complex interventions as needed. When possible and appropriate, it is always better to do an intervention, regardless of its nature, within an interpersonal as opposed to an individual context. Therapy generally begins with a focus on the here-and-now and progresses to a focus on the past as more complex and remote constraints emerge within the therapy. Therapeutic shifts occur when the current interventions fail to modify the Web sufciently to permit implementation of the adaptive solution to the presenting problem. Growing, maintaining, and repairing the therapeutic alliance takes priority over the principle of application (matrix arrow) unless doing so fundamentally compromises the efcacy and/or integrity of the therapy.

The Assessment and Intervention Inseparability Guideline

The Sequence Replacement Guideline The Empirically Informed Guideline

The Educational Guideline

The Cost Effectiveness Guideline

The Interpersonal Guideline

The Temporal Guideline

The Failure Driven Guideline

The Alliance Priority Guideline

www.FamilyProcess.org