27

Sociocultural Attunement
in Systemic Family Therapy
Carmen Knudson‐Martin, Teresa McDowell, and
J. Maria Bermudez

Family therapists have long held that to effectively work with diverse clients, we must
learn about and be sensitive to the experience of those different from ourselves. The
initial focus across mental health disciplines during the mid‐ to late twentieth century
was on cultural competence, which reflected a tendency in the modern era to classify,
categorize, and define “others.” It was essentially up to the therapist to learn about
and bridge the gap between themselves and the “other” with whom they worked.
Though this view of cultural competence has been heavily critiqued, the multicultural
movement raised expectations of cultural awareness in training, supervision, and
­practice (e.g., Falicov, 1988; Hardy, 1989) and stimulated questions regarding how
the field may be structured in ways that, intentionally or not, support dominant cul-
ture norms and values, pathologize people at the margins of society, and rationalize
results of inequity as “differences” without attention to sociopolitical contexts
(Almeida, 1993; Laszloffy & Hardy, 2000; McGoldrick, 1998).
Family therapists today are charged with responsibility to understand and help fam-
ilies navigate complex sociocultural realities (e.g., American Association for Marriage
and Family Therapy core competencies, Commission on Accreditation for Marriage
and Family Therapy Education accreditation standards, version 12). There is a call for
more equitable, relational, fluid, and process‐oriented ways to address culture and
diversity (Allan & Poulsen, 2017; Almeida, Hernández‐Wolfe, & Tubbs, 2011; Elias‐
Juarez & Knudson‐Martin, 2016; Falicov, 2009, 2014; Hardy, 2016). Rather than
stereotyping people based on their backgrounds or centering therapist skills and
knowledge, such a view would apply systems/relational practices to attune to and
engage with clients’ unique experiences within an inequitable world. In this chapter
we suggest a socioculturally attuned approach that integrates sensitivity to cultural
differences with issues of equity and power and expands the clinical lens to consider
systems of systems (i.e., third‐order thinking), bringing larger issues of global and
cultural equity together with intimate relationship processes and the moment by
moment of practice. We conclude with practice guidelines and implications for ethics,
self‐of‐the‐therapist, research, and training.

The Handbook of Systemic Family Therapy: Volume 1, First Edition. Edited by Karen S. Wampler,
Richard B Miller, and Ryan B. Seedall.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
620 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez

From Cultural Competence to Sociocultural Attunement

Family therapy’s early roots in systems theory provided pathways for understanding
the impact of multiple societal forces and social structures on clients and therapists
alike. Critiques from feminist and critical multicultural scholars drove home the idea
that our intersecting identities (e.g., race, class, gender, sexual orientation, etc.) shape
not only how we see the world but how the world sees (and treats) us (Dolan‐del
Vecchio & Lockhart, 2004; Hernández‐Wolfe & McDowell, 2014). As a field, we
challenged monolithic group descriptions and began to look more carefully at dynam-
ics of privilege, oppression, and marginalization (e.g., Hare‐Mustin, 1978; McDowell
& Fang, 2007; Silverstein & Goodrich, 2003; Walsh & Scheinkman, 1989). This
included our own power as therapists to maintain or challenge inequity (Hardy, 1989;
Knudson‐Martin, 1997). Attention shifted to unveiling the liberating and/or oppres-
sive nature of our therapeutic practices, requiring therapists to take broader meta‐per-
spectives of self and clients in context, turning the spotlight away from a simple
understanding of “other” to the nature of our clinical roles in light of systems of
power and privilege (Aldarondo, 2007; Almeida, Dolan‐Del Vecchio, & Parker, 2008;
Leslie & Southard, 2009; Seedall, Holtrop, & Parra‐Cardona, 2014).
Social constructionists further expanded our view of culture and diversity by chal-
lenging the basic concept of difference and drawing attention to the role of power in
the inherent meaning‐making of the therapeutic process (McNamee & Gergen, 1992;
Monk, Winslade, & Sinclair, 2008; J. L. Zimmerman & Dickerson, 1994): that how
differences are described is not innate to the characteristics of a particular group, but
arise within the act of defining and who has the power to determine what is real or
good (Gergen, 1997). We also learned that what it means to be part of a culture is
fluid, not fixed; it changes over time and depends on where one is and with whom
(Paré, 1996). Not all members of a group enact culture in the same ways (Laird,
1999). While feminists challenged the idea that therapists could ever be neutral, social
constructionists made us rethink the notion of objectivity and reminded us that
­therapists need to be accountable for their roles in defining what is perceived to be
real, true, or normal.
What was once called cultural competence is giving way to terms such as cultural
equity, social justice, cultural humility, cultural safety, and cultural democracy (Allan
& Poulsen, 2017; Almeida et  al., 2011; Falender, Sharfranske, & Falicov, 2014;
Gallardo, 2014; Hernández‐Wolfe & McDowell, 2014). These shifts are indicators of
the changing nature of what it means to be culturally sensitive, socially aware, and
equity minded—what we call socioculturally attuned (McDowell, Knudson‐Martin,
& Bermudez, 2018). This includes recognizing the connection between social and
relational power dynamics and the effects of these dynamics on emotional, physical,
psychological, spiritual, and relational health. When family therapists are sociocultur-
ally attuned, they are not only aware of the interplay between societal systems, cul-
ture, identity, and power, but willing and able to pay close attention and be responsive
to the impact of these forces on individual, relational, and community well‐being
(Falicov, 2009; McDowell et al., 2018).
Training and practice from a socioculturally attuned position involves four elements
not always addressed in conventional models of cultural competence. These include:
(a) a relational focus, (b) third‐order thinking, (c) responsibility toward equity, and
(d) nuanced attention to context.
 Sociocultural Attunement in SFT 621

Relational focus
Socioculturally attuned practice is a process of engagement, of seeking to know and be
“with” the experience of all clients (D’Aniello, Nguyen, & Piercy, 2016), a worldview
that recognizes and seeks to discover how culture and societal contexts are connected
to every aspect of life, and discerns our role in it (Falicov, 2014; Hardy, 2016). Rather
than an add‐on or adjustment to practice “as usual,” socioculturally attuned practice
is at the center of every aspect of therapy. It is not an end to be achieved; it is an ongo-
ing relationship in which therapists are “other‐oriented,” aware of their own social
locations, attentive to hidden biases, and accountable to justice in their roles as agents
of change (T. Zimmerman, Castronova, & ChenFeng, 2015).

Third‐order thinking
Third‐order thinking provides a framework for linking awareness of sociocultural
issues with how we practice. Family therapists have long emphasized the difference
between first‐order change in which the basic understanding of the problem and the
system remain unchanged and second‐order change in patterns and processes within
the organization of the relationship itself. Third‐order thinking is more recent to
­family therapy (McDowell, 2015; McDowell, Knudson‐Martin, & Bermudez, 2019).
Based on Bateson’s (1972) levels of learning, it involves understanding the system we
are in as part of a system of systems and taking a meta‐perspective of the complex
interactions among societal systems (e.g., economic, political, social). Third‐order
thinking helps link sociocultural issues with client concerns and enables envisioning
alternatives.
Imagine you are working with Cori and Justin, a white cisgender heterosexual cou-
ple in their 30s.1 They live with Justin’s three children from a previous relationship.
Cori is the primary breadwinner. They present with conflict around time and house-
hold management. Justin is frustrated that Cori is untidy and gets upset when he
expresses these concerns. Each also reports previous diagnoses of anxiety. What would
third‐order thinking mean here? Most therapists would probably recognize gender as
a potential influence and be interested in how their nontraditional gender roles might
connect to the couple’s conflict. This would be an important start, but there are many
more interrelated systems at play. Among others, third‐order thinking would consider
the intersections among (a) how Cori and Justin’s relational patterns are linked to
economic structures and societal reward systems that sustain it, (b) how dominant
culture assumptions connect to their identities as white co‐parents and how these
relate to give and take between partners, (c) how they perceive themselves in relation
to the dominant white heterosexual patriarchal culture and their efforts—or not—to
enact alternative patterns, and (d) how all of these relate to your social location and
how you perceive your role as the therapist. It would consider how all of these inter-
locking inequalities operate together in Cori and Justin’s life (Seedall et al., 2014).
When applying third‐order thinking, therapists automatically expand the lens to
connect intimate and family patterns to larger societal systems. This guides how they
go about knowing their clients and what they are curious about. As clients begin to
share their stories and experiences through conversation informed by a broader lens,
they begin to see themselves and each other more compassionately, with less blame.
Alternatives among and within systems are more able to present themselves.
622 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez

As illustrated by this example, third‐order thinking applies to all cases, not only those
sometimes defined as minorities or “other” by the dominant culture.

Responsibility toward equity

Hardy (2016) suggested that diversity is about who our practice includes, while equity
is about how they are treated. According to Almeida et al. (2011), practice must pro-
mote cultural equity; that is, value and respect all cultures and actively seek to avoid
privileging dominant culture standards, ideals, and practices. Responsibility toward
equity means that socioculturally attuned practice must incorporate an analysis of
power processes that includes the therapist and treatment systems. Whose values and
interests are reflected in the clinical models we employ? Are the concepts that guide
our practice models socioculturally attuned or do they represent the dominant culture
(see McDowell et al., 2018)? The analysis must also take into account how societal
power processes are reflected in clients’ relationship patterns, identities, and beliefs
about their own worth and value (Knudson‐Martin, 2013).
Responsibility toward equity means that therapists recognize that dominant culture
standards and practices are not equitable; they tend to serve groups with more social
power (i.e., white, male, heterosexual, high SES, physically able, etc.). Therapists
need to intentionally orient their work to counter the effects of societal inequities and
help couples and families develop just relationships (McGeorge, Carlson, Erickson, &
Guttormson, 2006). This intentionality is important because social power operates
through communication and relational processes such that persons with powerful
social identities (male, straight, white, affluent) have more ability to influence what
happens and what is believed. What they say is presumed more credible. Fricker
(2007) calls this epistemic injustice. It is not just that individual voices are less credi-
ble, but that these injustices pattern social meaning so that shared collective meanings
invalidate or minimize the experience of the subordinate (female, LGBTQ, persons of
color, persons with low income or disabilities, etc.). Living with persistent societal
invalidation affects self‐worth and beliefs about what one can do and what is possible,
making these important relational and clinical issues.
Let us return to Justin and Cori. Even though Justin does not currently earn money,
like most white men, he has learned to expect that his opinions matter: that the way
he sees a situation is correct. This is an example of epistemic injustice (Fricker, 2007).
Justin does not himself have much power, but both he and Cori draw on “collective
conceptions of what it means to be a man, and what it is to be a woman” (Fricker,
2007, p. 15) and these give male voice more authority, even when women make more
money (Tichenor, 2005). Justin feels much more entitled to question Cori’s perspec-
tive and behavior than she does his. When he criticizes her tidiness, she feels shame
because societal gender expectations tell her that pleasing her partner and maintaining
a tidy, organized home reflect her worth as a woman. This creates an inequitable bal-
ance of power in their emotional exchange (Knudson‐Martin & Huenergardt, 2010;
Knudson‐Martin et al. 2015).
Socioculturally attuned therapists would recognize the imbalance and promote
equity by helping Justin attune to Cori’s experience. This may sound obvious,
­something that all therapists would do, but there is considerable evidence that unless
therapists intentionally track how societal‐based power is part of relational processes
and respond in ways that counteract the injustice, they most likely end up following
 Sociocultural Attunement in SFT 623

and reinforcing the dominant societal perspectives (in this case, male) without
­realizing they are doing so (ChenFeng & Galick, 2015; Sutherland, LaMarre, &
Rice, 2017).
Other equity issues in this case relate to the interconnections between economic,
educational, family, religious, and political systems. For example, each partner experi-
ences symptoms of anxiety (headaches, panic attacks, self‐doubt, social fear, etc.) that
can be considered reactions to their devalued positions in the dominant social order
or signs of their resistance to dominant social structures (Garcia, Košutic, & McDowell,
2015). Justin, who dropped out of high school, lives with being viewed “less than” by
“the mainstream.” He actively seeks to resist societal measures of success (male pro-
vider role, economic worth, conformity to external standards) while trying to be a
“good” father. Cori, college‐educated with a professional job, must deal with social
judgment that she is a second‐class mother and partner. The couple’s attraction, com-
mitment to each other, and family structure are devalued in the larger society.
Understanding their experience will require attention to the complexities of their
unique niche in the sociocultural context, including the nuanced power processes
involved (Falicov, 2014).

Nuanced attention to context

It is important to avoid stereotyping clients based on their social identities. Therapists
must be both “knowing and not‐knowing” (Falicov, 2014, p. 42). We have an
­obligation to be knowledgeable regarding how larger societal systems work and to
recognize possibilities to learn about/consider. We also need to recognize that many
contextual factors influence a case and seek to understand each person’s particular
experience. For example, let us imagine that Cori’s mother immigrated to the main-
land United States from Puerto Rico when she was a young adult. You know a little
about Puerto Rico’s history and culture and recently had another client for whom her
Puerto Rican heritage was very important. You become curious about how Cori’s
ideas/experience of parenthood, marriage, and religion may be connected to this
heritage. What you know may stimulate questions such as “What do you think your
mother learned about what it means to be a woman who grew up in Puerto Rico?”
You know religion may also be important, but do not presume what religion may or
may not mean to Cori or her mother.
Falicov’s (2014) Multidimensional Ecological Comparative Approach (MECA) can
be a helpful guide. It explores four domains that come together to personalize clients’
experiences with social justice (racism, discrimination) and cultural diversity (values,
beliefs) as they are incorporated within family maps. Therapists must also consider
how client experiences compare with their own on each domain: (a) ecological con-
text (community, work, school, religion), (b) migration/acculturation (separations
and reunions, trauma, disorienting anxieties, cultural identities), (c) family life cycle
(ideals, meanings, timings, transitions), and (d) family organization (nuclear/
extended family, connectedness, hierarchies, communication styles). These intercon-
nected aspects of family life are inherently sociopolitical as well as cultural. According
to Falicov (2014), “without a lens that includes social inequities, cultural preferences
may be used as explanations for economic failure, domestic violence, or poor school
performance, whereas the larger negative effects of poverty and social discrimination
are downplayed” (pp. 45–46).
624 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez

It is also important to not see culture as fixed or applying in the same ways to broad
groups of people. Understanding complexity and nuance means exploring change
over time and the intersecting elements that inform meaning. In Cori’s case, being
Puerto Rican was an unexplored part of her identity. She never really thought about
why she wanted to shorten her name, Corinda, to Cori. Understanding how her
mother had escaped a harsh male‐dominated, violent family and tried to erase her
Puerto Rican history helped Cori negotiate mixed messages regarding what it means
to be a woman/mother and confront dominant discourses that framed her relation-
ship with Justin as “less than” at work, at school, and in the community. This enabled
her (and her mother) to update and personalize Puerto Rican culture with an empha-
sis on relational values. As Justin and Cori became more aware of the workings of
social and economic systems in their lives, they were more able to uphold their desire
to prioritize relational goals over economic status. Because most people do not see the
connections between their struggles and larger systems, the therapist needed to
actively facilitate this awareness as illustrated at the end of the chapter and detailed
more fully elsewhere (see Knudson‐Martin, McDowell, & Bermudez, 2017;
McDowell et al., 2018).

The Role of Place in Conceptualizing Health and Well‐Being

Socioculturally attuned practice extends to how therapists conceptualize clinical issues

and requires understanding how health and relational well‐being are connected to the
material realities of life, including places families inhabit on local and global levels.
Significant attention has been paid to the practice of family therapy internationally
(e.g., Ng, 2005; Roberts et al., 2014) as well as to the distress families experience
when countries are in conflict with each other (e.g., Charlés, 2010; Hakak, 2016).
In general, however, attention to diversity and social equity has tended to focus on
societal systems and power dynamics within national boundaries. Conceptualizing
clients’ experiences within a broader global context can enhance our ability to be
socioculturally attuned to the most intimate context of families and develop sociocul-
turally responsive treatment approaches (Falicov, 2009).
Let us return to Cori and Justin. Cori was able to claim her Puerto Rican heritage
and integrate into her life aspects of Puerto Rican culture that had been previously
unavailable to her. Taking a meta‐view at a global level would expand the therapist’s
ability to socioculturally attune to Cori and Justin’s relationship as informed by an
even larger context. In many ways, their relationship is isomorphic to contemporary
and historical power dynamics related to Puerto Rico as a US territory. While Puerto
Ricans are American citizens, they have limited rights and are largely disenfranchised
in the United States. The history of being colonized by Spain and “ownership” being
transferred to the United States after the Spanish–American War is part of past and
present US expansionism, militarism, and drive for global power. Anti‐Latino senti-
ment in the US mainland and the view of Puerto Ricans as less than full citizens
was  evident in failure to provide adequate support after Hurricane Maria in 2017.
This broader view contributes to understanding why Cori’s mother might seek to
erase her Puerto Rican identity and support Cori’s identification as white. Relational
dynamics on a global level in some ways reflect what is happening within Cori and
 Sociocultural Attunement in SFT 625

Justin’s relationship, that is, identities associated with more powerful countries
(and identity groups) are centered and dominant.

Decolonizing practice
An important part of socioculturally attuned practice is recognizing and being respon-
sible to how our practices may serve as a colonizing force through the unexamined
use of Eurocentric practice models that privilege individuality, independence, per-
sonal achievement, and relationship with self. Colonizing occurs when dominant
group cultural values, beliefs, and practices are centered as preferable, normal, and
right. This is not simply a matter of “different” beliefs; dominant cultural practices
determine cultural capital (e.g., language, traditions), social capital (e.g., who you
know, social influence), and even symbolic capital (e.g., skin tone, country of origin,
education). All of these are connected to economic capital (Bourdieu, 1986) and
power to dominate and control a populous. Colonizing processes at an international
level tend to conflate what is determined as right and true with a country’s level of
technological development, material wealth, and military might. A similar dynamic
occurs within societal systems (e.g., education, government, business) including fam-
ily science (Bermúdez, Muruthi, & Jordan, 2016) and mental health service delivery.
The therapist’s expertise and assessment models can have a dominating, colonizing
effect as mental health practices expect therapists to determine what is normal and
what is not.
Decolonizing requires third‐order thinking to inspect our own positionality, cul-
tural norms, beliefs, values, field knowledge, and practices in relationship to those that
are centered and dominant. This decolonization of the mind is a collective process
and helps us put into sociocultural context what we hold as true about how families
are and should be. Decolonizing practice involves helping individuals, couples, and
families do the same, that is, take a meta‐view of systems of systems that shape their
lives. In the example above, helping the couple resolve issues around Cori’s messiness
might reflect an unexamined colonizing expectation that we are to control ourselves
in ways that maintain order even in the most private aspects of our lives and/or that
work and duty supersede relaxation and pleasure. Euro‐American cultures also tend
to prioritize time and efficiency over harmony. Thinking in these broader terms, the
therapists might invite Cori and Justin to examine the value of order and its impact on
relational connection, as well as the role of space and place in which these relationship
events occur.

Assessing space and place

Mental health and relational dynamics are understood in socioculturally attuned ther-
apy as situated within the space or geography of where families live, work, and spend
time in their communities. Space refers not only to the natural environment but what
we construct within environments (e.g., institutions, homes, shopping malls, modes
of transportation, parks, industrial plants) (Soja, 2010). Access to resources (e.g.,
employment, medical care, education, healthy food) compounds our advantages
and/or disadvantages. Geographies, and the distribution of goods and services within
them, are far from equal, privileging some families over others: enhancing choice and
626 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez

opportunity for some while limiting possibilities for others. Issues related to environ-
mental justice include access to clean air and water, freedom from sound pollution,
protection from harm, and equal participation in making collective decisions about
what happens in one’s community. It is important for therapists to ask questions and
consider the impact of space and place on mental health and relational well‐being, for
example, how safe and comfortable is a family’s environment? What privacy is afforded
to each family member and the unit as a whole? What access do they have to quality
education, healthy food, and medical care?
According to Bourdieu (1986), we tend to share space with others who have similar
social, cultural, symbolic, and economic capital. A socioculturally attuned assessment
might consider things like what parks families visit, the transportation systems they use,
where they buy food, and the schools their children are expected to attend. Bourdieu
suggested that it is within these spaces, or what he termed habitus, that we internalize
shared knowledge of the world including values and beliefs. In these ways, spatially
locating families is core to understanding their worldviews as well as physical resources.
The concept of place focuses on the sense of being within a space. Expectations for
negotiating space vary across cultures, however, tend to universally include needs for
personal space, privacy, safety, and social interactions (Fitzpatrick & LaGory, 2000).
Many cultures are place based and place has various meanings across cultures. Think
of where you feel safe, emotionally moved, spiritually awake, and/or “at home.” How
is access to these places determined? Are you able to live in or near these places? Do
you have the means to visit them? How do these places contribute to your mental
health and relational well‐being? Access to these places is typically associated with
privilege, influence, and/or economic resources.
Mobility, that is, the ability to move or travel from one place to another, is included
in the privilege matrix and impacts access to resources and freedom of interactions. The
privilege of privacy is often reflected in dynamics of mobility (e.g., who can move from
place to place and who is restricted by others) as well as surveillance (e.g., who has the
privilege or right to gaze upon whom). Finally, processes of privilege and oppression
that are interconnected across global and local contexts are reflected in all places,
including the intimate territory of home. For example, the most powerful members of
families often dictate the emotional climate and have greater influence over how inter-
actions unfold in shared spaces determining the relative sense of place for all.
Creating a family cartography (McDowell, 2015) is one way to highlight the rela-
tionship between space and place and dynamics of privilege and oppression. Family
cartographies are topological maps that can be creatively drawn without attention to
scale. Therapists ask questions that reflect attention to power, privacy, personal space,
social interactions, safety, mobility, oppression, resistance, and resilience as they or the
clients map their physical context including client’s communities, neighborhood, and
home. For example, when working with Cori and Justin, you would ask them to
describe the setting in which they live (e.g., physical environment, neighborhood,
town), explore their social interactions within these contexts (e.g., where in the con-
text is safe/unsafe; what privacy is available), and analyze the effects of social location
and power dynamics (e.g., race, class, gender, sexual orientation, nation of origin,
abilities). You could ask them to draw the floor plan of their home and space directly
surrounding their home within the community and neighborhood they are describ-
ing. An emotion map (Gabb & Singh, 2014) can be incorporated to visualize how
embodied sociocultural emotions are experienced in everyday spatial interactions.
 Sociocultural Attunement in SFT 627

As you discuss their social interactions within and around the home, you learn that
the family is living in the small two‐bedroom apartment Justin lived in before Cori
joined the family. It is all they can afford in a neighborhood selected for proximity to
a public “magnet” school they accessed via lottery. Cori reports no private space for
items meaningful to her or personal breathing room. Justin appears to control the
emotional climate and relational interactions in the home, stating that it is “common
sense” (i.e., dominant culture sense) that “mature people” keep an orderly home.
The apartment is a long commute from Cori’s work. The couple spends much time at
the children’s school and sports activities, even though they feel like “second‐class
parents” in this school/community environment, which Justin sought to create
opportunities for the children (i.e., social and cultural capital that he could not him-
self provide). Conversation about space and place generates openings to talk about
the nuances of oppression, privilege, resistance, and resilience within the spaces Cori,
Justin, and their children inhabit. It helps highlight the connections between equity,
culture, and health.

The role of equity, culture, and health

Sociocultural attunement includes attention to how symptoms and presenting issues
are connected to inequities directly related to one’s place in the social hierarchy. The
detrimental effects of discrimination and oppression on health are well documented
(Center for Disease Control Health Disparities and Inequalities Report, 2013). In
fact, there is a plethora of research on health disparities and the negative physical and
psychological effects of discrimination and oppression. We know, for example, that
race is a determining factor in the likelihood of being incarcerated, developing an
addiction, suffering physical illnesses, and determining longevity (Jones, 2000). We
also know that women are more likely to suffer anxiety and depression than men
(National Institute of Health, 2014). Youth who identify as LGBTQ+ are at greater
risk for suicide and homelessness (Garofalo, Wolf, Wissow, Woods, & Goodman,
1999; Kruks, 1991). Being in a lower socioeconomic class increases chances of strug-
gling with mental health issues, among other problems (McCulloch, 2001). There is
also ample research that considers the negative effects of inequity and the positive
effects of equity on intimate relationships. Equity has been clearly linked to relational
satisfaction in a number of studies (Gottman, 2011; Knudson‐Martin & Mahoney,
2009; Lutrell, 2016). Research on couple therapy has also highlighted the impor-
tance of attuning to relational and social equity (Knudson‐Martin et  al., 2015,
Knudson‐Martin, Wells, & Samman, 2015).
The idea that therapists can or even should be neutral is becoming outdated as we
become increasingly aware of the connection between power dynamics and present-
ing problems. Being neutral, or attempting to not take an equity stance, often results
in supporting the status quo of unjust relationships, which in turn fails to fully address
presenting problems. Even emotions and ability to attune to other’s emotions are
impacted by relational power dynamics, that is, those with greater privilege and ability
to influence others typically experience more positive emotion than those who are
disenfranchised (Turner, 2007). Likewise, those who hold more power in relation-
ships are typically less attuned to those with less power, and vice versa.
Furthermore, socioculturally attuned therapists do not question that symptoms are
real or that diagnosing symptoms is not helpful to designing treatment. Rather, they
628 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez

consider the relationship between symptoms and power to assess in what ways, if any,
presenting problems are a result of inequitable relational dynamics and/or serve as
forms of resistance to them. For example, those suffering intimate partner violence,
sexual abuse, homophobia, sexism, or racism may use a variety of resistance strategies
including yielding, emotionally or physically withdrawing, attempting to understand
and navigate power dynamics, and/or anger/speaking out (McDowell, 2004).
Directly challenging oppressive individuals and systems can be treacherous. Speaking
out can lead to more oppression unless there is certainty that one will be believed, not
be punished or seen as the problem, and there is a real possibility of change (McDowell,
2004). Yet, many ways to resist subjugation can also become problematic.
Consider an upper‐middle class, white woman in her early 60s, Rhonda, who
requests therapy for depression. Her husband, Phil, refuses to come to sessions with
her. When Rhonda arrives, it is clear that she meets all the criteria for DSM‐5 Major
Depressive Disorder, Single Episode, Moderate (296.22). The socioculturally attuned
family therapist takes steps to address Rhonda’s immediate needs, including complet-
ing a risk assessment, making sure social support is in place, encouraging physical
movement, making a referral for possible antidepressants, and instilling hope. At the
same time, the therapist is considering the impact of relational dynamics, societal
­systems, and power on her depression.
It becomes clear that Rhonda has little influence with Phil, is isolated in her beauti-
ful home, and is angry with herself for not a being more grateful for all she has. She
reports feeling empty and without purpose. Rhonda’s economic dependence on Phil
and expectation that it is up to her to keep the family together freeze her options.
Rhonda began withdrawing from her husband years before her symptoms escalated to
depression. Once their two children left home, she reclaimed one of their bedrooms
as her writing room and began spending most of her time there. Phil often called her
out of the room to provide a meal or watch a television show with him, but she would
retreat to her space whenever possible. Rhonda’s withdrawal increasingly became her
solution for not having voice in her relationship. As therapy progressed, Rhonda was
able to place her experience within a sociocultural framework that included analysis of
both her white and social class privilege as well as her lived experience of gender
oppression and economic dependence. Rhonda decided to continue her relationship
with Phil, however changed the nature of how she withdrew. By the end of therapy,
in her terms, she had “reinvented herself” and was taking weekends away to write
creatively, visiting friends, and spending time with their grown children. Her symp-
toms of depression lifted.

Common factors
Sociocultural attunement enhances common factors in the therapeutic process
(D’Aniello et al., 2016; McDowell et al., 2018). Understanding clients’ social and
physical contexts, cultural practices, and collective legacies helps therapists explore
extratherapeutic factors, including available social support and sources of resilience.
Being socioculturally attuned to clients enhances therapeutic alliance as therapists
are able to accurately empathize with clients’ social situations and provides insights
into clients’ worldviews and preferred ways of being. Within family alliance can be
enhanced by helping family members better understand each other’s positionality and
 Sociocultural Attunement in SFT 629

s­ociocultural experience. Sociocultural attunement also supports clients’ expectancy

for change. As therapists help clients recognize the impact of societal systems in their
lives, clients begin to see potential opportunities for change. This is empowering and
makes change feel more possible. Third‐order thinking widens options by inviting
clients to step beyond the systems in which their lives are embedded to entertain new
frameworks for organizing their relationships. As we have illustrated in depth else-
where (McDowell et al., 2018), sociocultural attunement can be integrated into all
family therapy models to enhance their effectiveness in working across social contexts
and cultural groups. In the next section we suggest guidelines that help clinicians
translate commitment to sociocultural attunement into practice.

ANVIET: Guidelines for Socioculturally Attuned Practice

The acronym ANVIET (attune, name, value, intervene, envision, and transform)
describes a set of practical guidelines that can be applied across family therapy
approaches (Knudson‐Martin et  al., 2017; McDowell et  al., 2018). We illustrate
each of these with the case of the Williams family. The mother, Bernadine (34),
called because James (14) was referred following a fight at school. Bernadine
describes herself as an African American single parent “at the end of her rope.” She
reports that until recently, James has always been a “good boy,” who helped with
his younger siblings, Gregory (11) and Ruby (9), both of whom have previously
received multiple diagnoses, including attention deficit hyperactivity disorder
(ADHD) and oppositional defiant disorder (ODD). Bernadine has been separated
from their European American father, Stan (36), for 3 years. The therapy is con-
ducted by Alicia (26), a Latina family therapy intern supported by an observation
team. Alicia applies the ANVIET guidelines to an approach that integrates struc-
tural and attachment ­perspectives. She asks Bernadine to bring all three children to
the first session.

Attune to client experience within societal contexts

Socioculturally attuned therapists begin by expanding the lens. As a structural thera-
pist, Alicia seeks to join the family by apprehending the multiple systems within
which they live and resonating with their experience. Bernadine and the children
appear to be a close unit. When Gregory starts to become agitated in session, James
quietly strokes him to calm him down. Alicia wants to understand their close family
system in context of the many systems affecting them. After learning a bit about the
incident that resulted in the referral, she asks about the school and their neighbor-
hood. She learns that the school is multiracial and James says he has learned to
“float” in multiple groups. Alicia is also interested in Stan’s apparent disengagement
from the children’s lives and wonders aloud how it happens that fathers often end up
more outside their families than they want to be. From an attachment perspective,
Alicia expands her focus to include each family member’s experience of belonging
within larger sociocultural communities. In the second session, she engages them in
creating a family cartography to help form a systemic framework for considering
child behavioral problems.
630 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez

Name what is unjust or overlooked

Alicia looks for and identifies what is unjust or overlooked in the dominant culture.
She is intentional in bringing forth and amplifying silenced voices. For example, she
asks James if he thought his experience would be different if he were white. This
produces a spirited conversation about racial inequity that has previously not been
named. Alicia helps the family name the safety they feel in the privacy of their own
home and how this contrasts with the vigilance they must keep in the broader com-
munity. They name how long work hours, tight space, and tensions in the commu-
nity contribute to stress that exacerbates ADHD and invites oppositional behavior.
They discuss what it means to have a white father and name both the loss he likely
experiences as an uninvolved father and the unfair burden that appears to be falling
on Bernadine.
As they further explore the comfort and belonging of each family member at home,
at school, and in the community, James becomes very quiet. Bernadine says he has
been keeping to his room and not wanting to be with the rest of the family. Alicia
suggests individual sessions for James with another team member. In this private
­setting, he discloses that he may be gay or perhaps transgender. Naming confusion
about “not knowing where he fits” and lack of safety for LGBTQ+ students at school
as context for his recent fights helps reduce James’ self‐blame and guilt and opens
conversation about the effects of homophobia. They discuss how James wants to
­handle this information with his family.

Value what is minimized or devalued in the larger society

As a Latina woman with a close family herself, Alicia is aware that close relational
bonds tend to be devalued in the dominant culture. Rather than thinking of the
Williams family as enmeshed, she values their ability to stick together and recognizes
this as an important survival tactic in face of racism and limited economic resources.
Though one of the first reactions of the observing team is to think of James as “par-
entified” because of his history of looking out for his siblings, they rethink this pattern
and credit James with willingness to share the family work. Alicia also assumes that
Stan (father) has relationship interests that have been devalued in constructions of
white masculinity and dominant culture models of success.

Intervene to support equity and disrupt power dynamics

Socioculturally attuned therapists intervene in societal‐based power dynamics using
in‐session process to make power inequities visible and interrupt them. Many power
inequities are present in the Williams family. James’ silence, withdrawal, and anger
are a response to cisgender and heterosexual dominance that interferes with his abil-
ity to credit and value his own experience or be valued by others. The therapists
intervene by making room for multiple gender and sexual expressions in the session
using questions and reflections that support James in resisting social pressure for a
quick binary, either/or answer. Similarly, since Bernadine is carrying a much greater
share of parenting responsibilities than Stan, Alicia’s interventions support Bernadine
rather than placing blame or additional burden on her. She suggests inviting Stan to
some sessions.
 Sociocultural Attunement in SFT 631

Envision just relational alternatives

Identifying injustice is not enough. Therapists must create space to imagine just
­relational alternatives. Though Stan wants to be engaged, male socialization limits his
relational options. His advice to “not take shit” does not take into account Bernadine
or the children’s experience of racial injustice. Alicia invited the family to imagine
what it would look like if Stan were more involved:

Alicia: [to children] Why don’t you tell your father what it would mean to you to be more
connected with him?

The children describe many ways they would like to share time with Stan and do
things together. Alicia expands the conversation to directly address gender and race:

Alicia: Stan, you’ve described learning that men have to stand up for themselves and fight,
but not how to connect with your children. Why don’t you talk with them about your ideas for
a different way of being a father?

Transform by making what is imagined real

Making the imagined real takes practice. This requires persistence on the part of the
therapist, bringing clients back to the goals they have envisioned.

Alicia: [to Stan]. What do you think would help you tune into them—to get the ways racism
and homophobia affect what it’s like at school?

Bernadine and Stan work to create a just co‐parenting relationship that explicitly
values relational bonds and openly addresses what it means to be a biracial family and
how to join together to negotiate the societal stressors they face. They not only
“accept” James’ evolving gender and sexual identities; they seek to know him as a
person. To do this work, therapists must know themselves and consider how their
practices are positioned in relation to equity within systems of systems. This is an
ethical process.

Ethics and Self‐of‐the‐Therapist

Socioculturally attuned practice is only possible through self‐reflexivity, critical social

awareness, and ethical positioning. If therapists do not reflectively counter societal
inequities and dominant discourses through practices such as ANVIET, their diagno-
ses and interventions replicate injustice (ChenFeng & Galick, 2015; Dolan‐del
Vecchio & Lockhart, 2004). Clients may see themselves as “deficient” and/or be
further oppressed (Hernández‐Wolfe & McDowell, 2014). Those already carrying an
unfair burden of responsibility may be asked to take on more (Knudson‐Martin,
2013). Rather than an empowering experience, therapy can become a colonizing one.
Ethical practice requires therapists hold themselves accountable for the effects of their
actions so that clients are more able to deal with present and future injustices and
make changes that begin to transform them (Almeida et al., 2011; Falicov, 2014).
632 Carmen Knudson‐Martin, Teresa McDowell, and J. Maria Bermudez

Attention to self and ethical accountability are especially important for those in
structurally ascribed positions of power, including family therapists. Arguably, those
who have the most social capital and ability to influence are most responsible for and
often least likely to facilitate necessary and important changes that lead to equitable
and just practices (Almeida et al., 2008; McDowell & Hernández, 2010). It is impor-
tant for us to find ways to develop accountability systems that identify when we are
actively or passively oppressive in our clinical practice, teaching, supervision, and
research. This includes awareness and self‐reflexivity in the process of therapy as we
implement our clinical models.
Ethical decision making as socioculturally attuned therapists involves recognizing
that how we conceptualize and intervene—the words we use and what we do—are
not neutral. It is not a simple, good/bad dichotomous process. Therapists often grap-
ple with ethical tensions relative to cultural sensitivity and equity, for example, (a) how
to encourage personal empowerment while also recognizing societal constraints that
limit personal choices, (b) helping clients challenge injustice while honoring and rec-
ognizing potential costs of resistance, (c) respecting cultural values and perspectives
while challenging oppression, and (d) using therapist power to counter inequities
while also being collaborative. Solutions to these dilemmas are not the same for all
clients and contexts, and they are often complex, representing a both/and perspec-
tive. Engaging in this work invites us as therapists to “rigorously examine our own
assumptions” and find cultural strengths that may have been minimized or overlooked
(McDowell et al., 2018, p. 36). It is grounded in a broader paradigm shift in how we
think and how we know what we know and has implications for training and research
as well as practice.

Future Directions

Despite growing commitment in systemic family therapy to socioculturally attuned

practice based on a relational focus, third‐order thinking, responsibility toward equity,
and nuanced attention to context, training and research remain heavily organized by
dominant Eurocentric ideals and practices that privilege individualism and place
researchers and practitioners in detached observer positions (Bermúdez et al., 2016;
Hernández‐Wolfe & McDowell, 2014). Research and curricula still often essentialize
whole groups of persons into monolithic categories, view them from a position of
“other,” and address contextual variables (e.g., race, class, gender, sexuality, ethnicity,
nationality, religion, abilities, etc.) as separate variables rather than exploring how they
intersect (Seedall et al., 2014).
Family systems researchers, educators, and supervisors need to better acknowledge
and embrace subjectivity, examining the sources of knowledge and discourses that
influence our work (Bermúdez et al., 2016; Falicov, 2014). We need to reflect upon
the types of questions asked in research, who asks them, what methods are deemed
legitimate, who benefits from them, and how these affect training and practice
(Bermúdez et  al., 2016). Family therapy curricula need frameworks such as queer
theory (McDowell, Emerick, & Garcia, 2014) and nepantla (Hernández‐Wolfe,
2013) that help students, faculty, and supervisors embrace social complexity and the
tensions of contradiction, as well as ability to work among multiple and overlapping
spaces and ways of knowing.
 Sociocultural Attunement in SFT 633

Most family systems therapists know that sociocultural context matters, but lack
guidelines for how to translate this knowledge into practice (Knudson‐Martin et al.,
2017). There is a need for process research that expands the small body of practice‐
based evidence (St. George, Wulff, & Tomm, 2015) that informs family systems’
supervisors and clinicians about what helps couples and families become more aware
of their internalized sociocultural values and discourses and the workings of societal
power processes in their lives and able to envision and make transformative change
(e.g., D’Arrigo‐Patrick, Hoff, Knudson‐Martin, & Tuttle, 2016; Elias‐Juarez &
Knudson‐Martin, 2016; Pandit, Kang, Chen, Knudson‐Martin, & Huenergardt,
2014; St. George & Wulff, 2016).
We have observed a disconnect between training and research around best practices
(e.g., good therapy) and socioculturally attuned practice, in which attention to culture
or equity is often an add‐on, rather than a beginning point (Falicov, 2009). Our hope
is that the ideas in this chapter will stimulate third‐order thinking in the field itself so
that collectively we can expand systemic family therapy training, research, and practice
in ways that actively support equitable relationships and just societal systems.

Note

1 
Identifying information and some circumstances have been modified to protect client
­confidentiality in all case examples in this chapter.

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