The Evolving Treatment of Gender, Ethnicity, and Sexual Orientation in Marital and Family

Therapy
Author(s): Leigh A. Leslie
Source: Family Relations, Vol. 44, No. 4, Helping Contemporary Families (Oct., 1995), pp. 359-
367
Published by: National Council on Family Relations
Stable URL: http://www.jstor.org/stable/584991 .
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 THE EVOLVINGTREATMENTOF GENDER, ETHNICITY,AND
SEXUALORIENTATIONIN MARITALAND FAMILYTHERAPY

Leigh A. Leslie*

The past decade has seen the field of marital andfamily therapy criticizedfor its treatment of gender, ethnicity, and sexual ori-
entation. The critiques, although emanating from different quarters, have often focused on similar problems in the delivery of
marital and family therapy. In this article, the similarities in the critiques of the treatment of women, minorities, and homo-
sexuals by marital andfamily therapists is reviewed. In addition, the impact these critiques have had on the field will be exam-
ined. Finally, attention is given to areas in which work is still needed.
|1 '' l m

n 1985, Virginia Goldner wrote an marital and family therapy. In addition,

article for the Family Therapy Net-
worker entitled "Warning: Family
Therapy May Be Hazardous to Your
Health." In this one tongue-in-cheek
title, Goldner captured a major theme
and source of controversy in the dis-
course surrounding marital and family
therapy over the last decade. This de-
bate centers around the idea that some
clients may not be well-served and, in
some cases, may be harmed by marital
and family therapy. More specifically, at
the heart of this debate is the premise
that marital and family therapy as tradi-
tionally practiced is oppressive to specif-
ic constituencies. In the last 10 years,
questions have been raised and criticism
leveled concerning biases in marital and
family therapy that have ignored and, in
some cases, pathologized three groups:
women in families, racial-ethnic minori-
ty families, and gay and lesbian families.
Although the critiques of the field of
marital and family therapy's treatment of
gender, race and ethnicity, and sexual
orientation evolved independent of one
another with no common theoretical
framework, similarities exist in the criti-
cisms offered and questions posed about
the biases that exist in marital and family
therapy. The purpose of this review arti-
cle is to look at similarities in the cri-
tiques emanating from these different
quarters and to examine the impact
these critiques have had on the field of
areas in which work is still needed will
be identified.
Prior to examining these critiques in
greater detail, one point should be
noted. Discussions of the treatment of
minority families in marital and family
therapy have often been clouded by an
inconsistency in terminology. The term
ethnicity is most frequently found, but is
often used somewhat interchangeably
with the term culture. Although there is
a great deal of overlap in the terms cul-
ture and ethnicity, they are not synony-
mous; culture is broader in scope than
ethnicity (Preli & Bernard, 1993). The
term race, however, is less frequently
used and often is treated as simply one
component of ethnicity. Hardy and Las-
zloffy (1994) propose that the relative si-
lence around race, achieved by subsum-
ing it under ethnicity, is a way of
marginalizing race and downplaying the
domination of the White perspective in
models of family therapy. Yet race-par-
ticularly skin color-is often a defining
aspect of the experience of ethnic iden-
tity for people of color. In an effort to
recognize that ethnicity is much more
than just race, but that race assumes a
primacy in structuring peoples' experi-
ences, both race and ethnicity are used
throughout this article, with the term
racial-ethnic used where grammatically
appropriate.
-Eu
Any cursory review of journals,
workshops, and conference programs
will reveal that the topic of marital and
family therapy's insensitivity to, and in
some cases, oppression of certain
groups has been a dominant theme in
the field in the last decade. Certainly,
the feminist critique of the treatment of
gender in the field was the most exten-
sively articulated during this time (e.g.,
Goodrich, Rampage, Eliman, & Halstead,
1988; Luepnitz, 1988; McGoldrick, An-
derson, & Walsh, 1989, Walters, Carter,
Papp, & Silverstein, 1988), but a sub-
stantial body of literature also addressed
the treatment of racial and ethnic minor-
ity families (e.g., McGoldrick, Pearce, &
Giordano, 1982; Saba, Karrer, & Hardy,
1991; Tseng & Hsu, 1991). Although less
systematic attention has been given to
gay and lesbian families in mainstream
family therapy research and treatment
*Leigh A. Leslie is an Associate Professor in the De-
partment of Family Studies, University of Maryland, College
Park, MD 20742.
Key Words: ethnicity, family therapy, gender, sexual orien-
tation.
(Familv Relationc- 1991 44- 29V-367.

October 1995
1995 FAMILY 359
RAMONS
journals, the topic has been a controver-
sial one and has been addressed with
greater frequency in marital and family
therapy book chapters (e.g., Brown &
Zimmer, 1986, Goodrich, Ellman, Ram-
page, & Halstead, 1990; Sanders, 1993).
These critiques of marital and family
therapy have varied in the specific as-
pects of therapy that are thought to be
insensitive or oppressive, yet all share a
common concern that the field has per-
petuated the status quo. Three charac-
teristics of marital and family therapy
have been identified in each critique as
contributing to this maintenance of the
status quo. As traditionally practiced,
marital and family therapy (a) does not
take into consideration the broader so-
cial context when examining family dy-
namics, (b) ignores power differences
both within the family and in the larger
society, and (c) works from an assump-
tion of a monolithic family form.
Separation From the Broader
Social Context
General systems theory, as the un-
derlying theoretical foundation for most
models of family therapy, allows for a
focus on the impact of the larger social
and economic system on families. Yet,
in practice, systems therapists have
often operated as if the family unit was a
complete system unto itself (Taggart,
1985) and have ignored the legal, eco-
nomic, and social realities of individual
clients' lives. In the critiques of the treat-
ment of gender and race and ethnicity,
two contextual variables-gender role
expectations and economic resources-
have been identified as particularly sig-
nificant in structuring family life. Cri-
tiques of the treatment of sexual orienta-
tion have addressed the importance of
the contextual variables of homophobia
and secrecy in understanding family life.
Gendered role expectations and
economic resources. Family relation-
ships and interaction are affected daily
by a myriad of contextual factors, from
policies of the workplace to region of
the country in which one lives. Critiques
of the treatment of gender, race, and
ethnicity in marital and family therapy
have noted two contextual factors as
particularly significant in understanding
the dynamics observed in therapy with
couples or families: (a) the cultural ex-
pectations of how men and women are
to fill their family roles and (b) the eco-
nomic resources of family members
(e.g., Franklin, 1992; Walters et al.,
1988). These factors in combination
both structure and constrain family dy-
namics. Failure to fully recognize the im-
portance of gendered role expectations
360
and economic resources and incorpo-
rate them into treatment has led to mis-
understandings of couple dynamics and
inadequate, if not potentially harmful,
treatment for both White and racial-eth-
nic minority couples. However, for the
latter-African Americans in particular-
any consideration of these factors must
be done in light of a third contextual fac-
tor: the experience of racism and dis-
crimination. Thus, the effects of these
contextual factors will be considered
separately here for White and African
American couples.
In White couples, women are typi-
cally seen as the family caretakers and
men as the primary providers, regardless
of the actual economic contribution of
each partner (Perry-Jenkins, Seery, &
Crouter, 1992). Family therapy has been
criticized for mirroring that cultural ex-
pectation by its tendency to hold moth-
ers responsible for problems within the
family (Bograd, 1990b; Wylie, 1989). Be-
cause the mother is frequently in a piv-
otal position in the family organization
and frequently oversees the day-to-day
activities of the family, she has been mis-
cast as accountable for the current situa-
tion. Theoretically, mothers' and fathers'
roles counterbalance one another; nei-
ther gender is seen as responsible for the
common pattern of mothers being more
involved with their children than fathers.
Yet, in practice, interventions focus
largely on changing mothers' behavior or
constraining mothers' so-called "over-in-
volvement" so that the "distant" fathers
can become more engaged with the chil-
dren, implicitly correcting the problem
caused by mothers' involvement (Gold-
ner, 1987; Luepnitz, 1988). In addition,
the field has developed a much more ex-
tensive language to talk about mothers'
inadequacies than fathers' inadequacies,
in effect, blaming her for what she has
been socialized to do; that is, to care and
be responsible for family and children
(Bograd, 1990b). It is interesting to note,
however, that recent research using a
clinical vignette suggests that family ther-
apists do not tend to see mothers as
more dysfunctional than fathers, or more
responsible for change in the family.
They do, however, see the parent, re-
gardless of gender, with the greatest con-
cern for the child as being more dysfunc-
tional (McCollum & Russell, 1992). Thus,
although therapists may no longer be
pathologizing mothers per se, the parent
who behaves as women have traditional-
ly been socialized to behave is still seen
as the problem.
Equally as important as role expec-
tations in determining couple interac-
tion is the economic balance or econom-
ic resources of the spouses. The reality
FAMILY
is that the majority of married White
women earn less than their husbands
and are more vulnerable to a substantial
drop in income should the couple sepa-
rate or divorce. The unequal financial
consequences for men and women if a
marriage ends in divorce can greatly af-
fect the couple's negotiations in therapy
(Taffel & Masters, 1989). Failure to ac-
knowledge this economic reality leads
therapists to attribute women's stances
in such negotiations to personality (e.g.,
"She is too weak to assert herself") or
gender (e.g., "As a woman, she is more
likely to give in") instead of to the fact
that individuals in the same family have
different options and resources (e.g.,
"She knows taking a stand may mean a
near poverty existence for herself and
her children").
In African American couples,
women are less likely to be economical-
ly dependent on their husbands. One
outgrowth of the legacy of racism in this
country is that Black men have experi-
enced pervasive discrimination in em-
ployment, which has undermined their
roles as providers in their families
(Franklin, 1992). Thus, Black women
have been, and continue to be, major
contributors to the family's financial
well-being, often surpassing their hus-
bands as economic providers. This di-
gression from the dominant cultural
framework of male as provider can
greatly affect couple interaction, al-
though not always in predictable ways.
Some Black men may feel hesitant to as-
sert themselves in the couple or family,
given that they are not working from the
base of economic provider, whereas
others may work more forcefully to es-
tablish their dominance because they
cannot fall back on economic power.
Similarly, some Black women may wield
more power because of the economic
balance in the relationship, whereas oth-
ers may choose a subordinate position in
an effort to protect their partners from
any further insults to their self-esteem.
Interestingly, when Black women have
asserted the power their economic con-
tributions would allow, it has often been
the focal point used to characterize the
family with terms such as matriarchal.
Again, the deviation from the cultural
norm of female subordination can lead
to both Black women and men being
pathologized. The important point for
therapists is that, although couples may
cope with it in a variety of ways, the in-
tersection of racism, family economics,
and gender expectations affects family
dynamics and must be examined if fami-
ly therapy is to be beneficial for African
American clients (Franklin, 1992).
Homophobia and secrecy. The im-
portance of acknowledging the broader
October 1995 __
social context is equally critical in work
with gay and lesbian couples and fami-
lies. Two interrelated contextual factors,
homophobia and secrecy, pervade every
aspect of family life for gay men and les-
bians. Brown and Zimmer (1986) defme
homophobia as "the fear and hatred of
same-sex intimacy, love, sexuality, and
relationships, and of those individuals
and institutions that participate in, af-
firm, and support same-sex relating" (p.
451-452). It is important for therapists to
recognize that, although homophobia is
an external reality that is imposed upon
the lives of gay men and lesbians, most
homosexuals have internalized these be-
liefs to some extent. Thus, lesbians and
gay men must wrestle with their own
feelings of self-hatred, shame, and inade-
quacy at the same time that they are try-
ing to function as family members, part-
ners, and parents (Goodrich et al., 1990;
Markowitz, 1991). The effects of this in-
ternalized homophobia are often subtle
(e.g., diminished sexual desire, difficulty
asserting oneself as a parent) and, thus,
tend to be ignored or downplayed by
therapists (Brown & Zimmer, 1986). As a
result of both external and internal ho-
mophobia, gay men and lesbians and
their families are constantly faced with
decisions concerning how open to be
about their personal lives. Openness
about one's sexual orientation or love re-
lationship can result in being cut off
from family members, losing custody and
love of children, being socially isolated
and rejected, and losing one's job. Thus,
normal family issues such as family iden-
tity, connectedness and autonomy, and
boundary maintenance are much more
complicated in gay and lesbian couples
and families than in heterosexual ones
(Dahlheimer & Feigal, 1991).
Inattention to Power
Differences
A second criticism closely associ-
ated with the failure to recognize the
broader context of families' lives is that
the field of marital and family therapy
has largely ignored power differences in
relationships. By downplaying status and
power differences both within the fami-
ly and in the larger social environment,
critics point out that family therapists
are likely to miss a dimension that is cru-
cial in understanding family dynamics.
Power differences within the fami-
ly. One of the most consistent rebukes
offered of marital and family therapy has
been the field's lack of attention to how
differences in resources between men
and women and prevailing gender ideol-
ogy in society translate into power dif-
ferences within the family (e.g., Hare-
Mustin, 1989; Taffel & Masters, 1989).
October 1995
This inattention to gender based power
differences is particularly evident by the
emphasis in models of therapy on circu-
larity and mutually created patterns of
interaction. Whether intended or not,
notions of individual responsibility and
accountability disappeared as the field
moved to focus on the so-called "func-
tion" of symptoms for the entire family.
In such a framework, responsibility was
shifted to the entire family system. Thus
terms such as incest perpetrator, alco-
holic, and abusive spouse were replaced
by incestuous families, alcoholic fami-
lies, and violent relationships. Such con-
ceptualizations seem to hold all mem-
bers of a family equally accountable and
attribute equal power to all to change
the system. The critique of this concep-
tual sloppiness is best summarized by
Goldner (1987), who states that "family
therapy has lapsed into a complacent
kind of moral relativism in which the el-
egant truth that master and slave are psy-
chologically interdependent drifts into
the morally repugnant and absurd no-
tion that the two are therefore equals"
(p. 111).
Power differences in society. Criti-
cism has also been made of marital and
family therapy for ignoring the impact
that being in a socially devalued position
has on family members. For racial-ethnic
minorities, the experience of discrimina-
tion, marginalization, and invisibility can
produce a sense of powerlessness that
affects not only self-esteem but family in-
teractions. Feelings of inadequacy,
shame, and rage that often accompany
being in a one-down position may mani-
fest themselves through passivity, resis-
tance, or anger, both in family relation-
ships and relationships outside the fami-
ly, including the therapy relationship
(Franklin, 1992, 1993). In addition, indi-
viduals may attempt to assimilate into
the mainstream by distancing them-
selves from their culture or ethnic group
(Markowitz, 1994).
Failure to recognize social position
and limited power as a potential source
of problematic behaviors restricts a ther-
apist's ability to help families establish
healthy patterns of interaction. First, if
systems of oppression are not acknowl-
edged and named in therapy, a therapist
cannot help family members distinguish
among the personal, interactional, and
societal factors contributing to the prob-
lem. Consequently, the therapist cannot
empower clients to change that for
which they are personally responsible
while confronting, where possible, the
discrimination they experience. Second,
failure to recognize the way in which
ethnicity and race structure social posi-
tion can limit a therapist's utilization of
FAMILY
RELATIONS
the resources, supports, and strengths
that are available within the extended
family and culture (McGoldrick, Garcia-
Preto, Hines, & Lee, 1989).
Gay men and lesbians are similarly
in a low status position by virtue of their
sexual orientation. Although White ho-
mosexuals may obtain social influence
and power as a result of their race and
by the fact they can keep their status as
homosexuals secret in a way not avail-
able to minorities, they, too, suffer from
being in a one-down or stigmatized posi-
tion because of the existence of homo-
phobia throughout society. Thus, the
mistrust and anger that often accompa-
ny a sense of powerlessness or lack of
societal validation can be found in gay
men and lesbians and can equally affect
their attitudes and behaviors both in inti-
mate relationships and in therapy
(Dahlheimer & Feigal, 1991).
Assumption of a Monolithic
Family Form
A third criticism of models of family
therapy is that, for the most part, they
are inattentive to diverse family forms.
Based on the "theoretical myth of same-
ness" (Hardy, 1991, p. 17), they tend to
reflect the larger societal values of tradi-
tional gender-based division of labor
(Goldner, 1985), heterosexual-based
family formation (Markowitz, 1991),
clear generational boundaries (Goldner,
1989), and nuclear family household ar-
rangements (Tseng & Hsu, 1991). Al-
though diverse family forms exist among
all groups and the assumption of homo-
geneity may lead to inappropriate treat-
ment of any family, it is particularly op-
pressive to racial-ethnic minority fami-
lies and gay and lesbian families.
Racial-ethnic minority families tend
to differ from White families in the U.S.
in a number of significant ways. Where-
as White families generally follow the
European-based conjugal family arrange-
ment in which legal, or husband-wife,
relationships are given primacy, many
minority families come from cultures ad-
hering to a consanguine-based family or-
ganization in which blood, or parent-
child, relationships are given primacy
(Tseng & Hsu, 1991). Many minority
families also utilize a more encompass-
ing, extended definition of family,
which in some cases even includes non-
living ancestors (Tseng & Hsu, 1991). In
addition, minority families are more like-
ly to have a value system that empha-
sizes "group identity, cooperation, har-
mony with the environment, reciprocal
obligation, and holistic thinking" (Hardy
& Laszloffy, 1994, p. 11) instead of the
European American value system that
361
emphasizes individuality and personal
achievement (Berg & Jaya, 1993). These
characteristics, combined with the
lower level of economic resources men-
tioned previously, result in racial-ethnic
minority families frequently emphasizing
parent-child bonds over the marital
bond, living in multigenerational house-
holds and/or multihousehold families,
and having flexible boundaries between
generations. If the values or economic
necessities underlying these arrange-
ments are not understood, application of
models of family health that are reflec-
tive of upper middle-class White families
only sends a message of inadequacy to
minority families.
The assumption of heterosexuality-
that the adult couple in a family will be
composed of one man and one woman-
is clearly problematic when attempting
to apply models of family therapy to gay
men and lesbians. This assumption limits
the applicability of the models because
it contributes to pathologizing dynamics
that make sense when partners have ex-
perienced the same gender socialization
(Carl, 1990).
Women, for example, have been so-
cialized to one degree or another to de-
fine themselves in relation to others and
to be empathic and nurturing in their re-
lationships. Lesbian relationships are,
therefore, often characterized by highly
permeable boundaries and low differen-
tiation between partners (Swartz, 1989).
From the perspective of models based
on a premise of heterosexuality, these
relationships are often characterized as
enmeshed or fused (Goodrich et al.,
1990). Although this characterization
may sometimes be appropriate, it is im-
portant to distinguish between close-
ness that simply exceeds the norms of
heterosexuality and closeness that caus-
es problems for the partners.
For gay male couples, what has been
defined as male promiscuity or lack of
monogamy presents major problems for
couple therapy models based on an as-
sumption of heterosexuality (Brown &
Zimmer, 1986; Markowitz, 1991). Sepa-
rating sex from love has always had
some degree of social acceptability for
men. Thus, it is not surprising that this
separation would be a condoned aspect
of gay male relationships. However,
working from an assumed link between
love and sexual exclusivity, many models
of couple or marital therapy view non-
monogamy as a sign of problems in the
primary relationship. Although variations
in defining acceptable relationship
boundaries exist with gay male couples,
just as they do with all couples, there is a
higher level of acceptance of non-
monogamy in the gay community. Gay
362
men are less likely to perceive the lack of
sexual exclusivity as a threat to the emo-
tional commitment in the relationship
than are the partners in heterosexual and
lesbian couples. Although it may be diffi-
cult to determine when nonmonogamy
is a way of avoiding issues of intimacy in
a couple and when it is an accepted
practice by both partners (Markowitz,
1993), therapists working with gay male
couples need to be open to the meaning
of nonmonogamy for their clients
(Brown & Zimmer, 1986).
After several years in which the dis-
cussion of gender, race, and ethnicity
was characterized largely by critiques of
existing models and practices, more re-
cent years have seen a move to what
might be characterized as the applica-
tion or integration phase of many of
the earlier critiques. That is, efforts have
been made to utilize the critiques to re-
think and revise many facets of clinical
services. Work in the area of sexual ori-
entation, however, still remains largely
in the stage of offering assessments of
the appropriateness of existing models,
with less systematic application work
being done.
Efforts to apply the critiques of mari-
tal and family therapy relative to gender,
race, and ethnicity have focused primari-
ly on the implications of incorporating
these variables into (a) the treatment of
specific populations or problems and (b)
the training of marital and family thera-
pists. The limited application work that
has been done based on critiques of the
treatment of sexual orientation in marital
and family therapy has, likewise, focused
on incorporating sexual orientation into
the treatment of specific populations or
problems, although few training implica-
tions have been considered. Efforts to
build on the gender critiques have also
focused on the impact of therapist gen-
der on the course of treatment in marital
and family therapy. Similar work is just
beginning to appear relative to race and
ethnicity, but has not been undertaken
relative to sexual orientation.
Applying Critiques to
Treatment
Gender. A common characteristic of
much of the marital and family therapy
literature is the use of case examples;
the work on gender and ethnicity is no
exception. The explosion in feminist-
based and gender-sensitive analyses of
family therapy has led to innumerable
FAMILY
case examples of how to integrate gen-
der and issues of power and context
into treatment. Thus, the issue of inte-
grating gender into treatment has been
addressed across the wide spectrum of
problems typically seen by marriage and
family therapists. However, there are
particular populations or issues that
have received a concerted focus from
feminists and those concerned with gen-
der issues in marital and family therapy.
First, no population or family thera-
py issue has received more gender-based
attention in recent years than the treat-
ment of abused women and their part-
ners. It was with this population that
feminists first (e.g., Bograd, 1984) and
most consistently challenged the interac-
tional frames that held both partners re-
sponsible for the violence in a relation-
ship and that ignored differences in
power and resources (Bograd, 1992;
Goldner, 1992). The field of marital and
family therapy has been criticized for its
slowness, relative to other mental health
fields, in confronting the reality of male
violence in supposedly committed, lov-
ing relationships (Avis, 1992), choosing
instead to emphasize therapist neutrality
(Bograd, 1992; Kaufman, 1992), focus on
mutually created patterns of interaction,
and distance itself from the notion of in-
dividual responsibility (Dell, 1989; Lamb,
1991; Pressman, 1989; Wilbach, 1989).
This critique has been translated into
practice by challenging the traditional
couples approach to therapy in which
both partners are seen together. Not
only is the couple format thought to lend
credence to the notion of joint responsi-
bility, but, even more critically, it ignores
safety issues for the woman, who may be
vulnerable to subsequent acts of violence
based on what she does in therapy.
Thus, models have been offered for as-
sessing the appropriateness of joint ses-
sions (e.g., Lipchik, 1991; Wilbach,
1989), working separately with violent
men (e.g., Adams, 1988; Almeida & Bo-
grad, 1990; Durrant, 1990), working sep-
arately with abused women (e.g., Gold-
ner, Penn, Sheinberg, Walker, 1990;
Rosen & Stith, 1993; Whipple, 1987),
and working with both partners together
when appropriate (e.g., Lipchik, 1991;
Pressman, 1989). The adversarial stance
that has characterized many of the dis-
cussions between proponents of sys-
tems-based versus feminist-based ap-
proaches to treating wife abuse is begin-
ning to be tempered. Using as a starting
place the idea that a man who is violent
must take individual responsibility for his
acts without blaming his wife, many mar-
ital and family therapists look for the
means to integrate the strengths of both
the systems and feminist models in ways
that allow more responsiveness to the
October 1995
situation and dynamics of the individual
couple (e.g., Balcom & Healey, 1990;
Goldner, 1992; Goldner et al., 1990;
Lipchik, 1991).
Closely associated with attempts to
integrate gender into the treatment of
wife abuse have been efforts to address
the significance of gender in the treat-
ment of child abuse and incest. Similar
themes of ensuring victim safety, incor-
porating individual responsibility, and
challenging therapist neutrality are
found in feminist approaches to work-
ing with families in which physical
and/or sexual abuse of children occurs
(Barrett, Trepper, & Fish, 1990; Cana-
van, Higgs, & Meyer, 1992; Fontes,
1993; James & MacKinnon, 1990; Shein-
berg, 1992; Valentich & Anderson,
1989; Wheeler, 1989).
A second area of clinical work in
marital and family therapy that has un-
dergone reconsideration in light of the
feminist critique is addiction. Revisions
have focused on two areas: (a) integrat-
ing an understanding of female psycho-
logical development and needs into both
treatment models and popular 12-step
programs (Bepko, 1989; Berenson,
1991; Walker, Eric, Pivnick, & Drucker,
1991) and (b) challenging the notion of
codependency that holds one partner,
typically a woman, responsible for the
addiction of her partner (Bepko &
Krestan, 1990; Krestan & Bepko 1991;
Sloven, 1991.)
A third area that has been revised in
light of the increased attention paid to
gender is what might be called female
and male development in the context of
family relationships. The focus of this
work was initially to compensate for the
inattention to women's experience in
families by reconsidering significant as-
pects of family life from women's per-
spectives. This work integrated theories
on female psychological development
and socially constructed gender-based
patterns of interaction into models of
treatment. The result was fresh treat-
ment perspectives on issues such as ado-
lescent development (Mirkin, 1992), the
transition to motherhood and grand-
motherhood (Safier, 1992), single par-
enting (Kazak & Segal-Andrews, 1992)
stepmothering (Keshet, 1989), sister re-
lationships (McGoldrick, 1989), and
mother-son relationships (Silverstein,
1989; Silverstein & Rashbaum, 1994).
The overarching goal of this work is to
utilize a perspective that acknowledges
a woman's strengths and experiences in
understanding her life to assist her with
whatever problems or issues she is en-
countering and with developing more
satisfying relationships. Certainly the
most comprehensive treatment of
ri October 1995
__
women's lives in families from this per-
spective can be found in two books:
Women in Families: A Framework for
Family Therapy (McGoldrick, Ander-
son, & Walsh, 1989) and The Invisible
Web: Gender Patterns in Family Rela-
tionships (Walters et al., 1988).
Following the focus on enhancing
understanding of women's experiences
in family life and its implications for
therapy, there has been increased atten-
tion in recent years on how gender
structures family life for men as well
(e.g., Meth & Pasick, 1990; Pittman,
1991). Although the feminist call to inte-
grate gender has emphasized women's
perspectives because of the power in-
equities and oppression that undergird
much of family life, attention to men's
experiences in families is not inconsis-
tent with a feminist emphasis on the im-
portance of gender. However, the re-
cent move to include men in considera-
tion of how gender structures family life
has not been without controversy. For
example, Carter (1992) points out that
the focus on how both men and women
suffer as a result of gender socialization
or how society constrains options for
both men and women leads to obscur-
ing the problem of hierarchy and un-
equal power in heterosexual relation-
ships.
The fear of diluting the issue of un-
equal power notwithstanding, the field
has begun to explore, for work with
men in a therapeutic context, the impli-
cations of men's development and the
ways society structures their lives. Atten-
tion has been given to men's psychologi-
cal development as they "learn to be
men" (Levant, 1992; Meth, 1990; Napi-
er, 1991; Pittman, 1991) and to fulfill
their assigned roles as providers (Pasick,
1990), husbands (Gordon & Meth,
1990), and fathers (Feldman, 1990). The
goal of integrating this theoretical mate-
rial is to enhance clinical work with
men in therapy either individually (e.g.,
Allen & Laird, 1990; Ganley, 1990; Pa-
sick, Gordon, & Meth, 1990) or in the
context of their significant relationships,
be they with wives (Gordon & Allen,
1990; Napier, 1988; Neal & Slobodnik,
1990), children (Gordon, 1990a), or
members of the family of origin (Allen,
1990; McCollum, 1990; Gordon, 1990b).
As evidence of the significance given the
issue of understanding men in family
therapy, an entire issue of the Journal
of Feminist Family Therapy was devot-
ed to the t-opic in 1990 (Bograd, 1990a).
More recently, Dienhart and Avis (1994)
have conducted exploratory research
with gender-sensitive therapists to iden-
tify effective approaches to working
with men in family therapy. Interesting-
FAMILY
~~~~~~~~~~~RELAllON
ly, a large percentage of the interven-
tions endorsed by these therapists had
to do with the therapists developing
their own "awareness of sociocultural
gender issues" (p. 401).
Ethnicity/race. In contrast to the
clinical applications growing out of the
work on gender, the clinical applica-
tions of the work on ethnicity do not
tend to focus on specific substantive
areas, such as wife abuse. Although
there are exceptions such as Watts-
Jones' (1992) article on treating panic
disorder in a Jamaican woman and Flo-
res-Oritz and Bernal's (1990) chapter on
addiction treatment with Latinos, these
tend to be single articles or chapters as
opposed to bodies of work on a substan-
tive area. Instead, the clinical work on
ethnicity tends to focus on working
with different racial-ethnic groups, out-
lining the relevance of a group's charac-
teristics such as history, values, rituals,
and current economic conditions for
therapy. The initial work on ethnicity in
the field, Ethnicity and Family Therapy
(McGoldrick et al., 1982) set this ap-
proach as the model, offering chapters
on numerous ethnic groups. Outlining
the clinical relevancy of characteristics
of specific ethnic groups continues to
be the primary format utilized in much
of the clinical application work on
racial-ethnic minority families (e.g.,
Braverman, 1990; Hines, Garcia-Preto,
McGoldrick, Almeida, & Weltman, 1992;
Ho, 1987; McGoldrick et al., 1989). This
type of work has been criticized, howev-
er, as relying on stereotypes and simplis-
tic characterizations of racial or ethnic
groups in the effort to educate thera-
pists about racial and ethnic diversity
(Maranhao, 1984; Markowitz, 1994).
A variation on looking at multiple
racial or ethnic groups is to take one
group and examine it in depth. The pri-
mary example of this approach is Boyd-
Frankin's (1989) book Black Families in
Therapy. A Multisystems Approach. In
this book, Boyd-Franklin addresses is-
sues such as racism, skin color, informal
adoptions, and spirituality as critical to
understanding African American fami-
lies. She then examines how an appreci-
ation of these factors will influence clini-
cal work with families and the adapta-
tions that would be necessary in major
models of family therapy. Although is-
sues that arise in conducting family ther-
apy with other racial-ethnic groups have
been addressed in various journal arti-
cles (e.g., Berg & Jaya, 1993), it is unfor-
tunate that no other racial-ethnic group
has received the extensive treatment in
the marital and family therapy literature
that is found in this book on African
Americans (Hardy & Laszloffv. 1994).
363
 Instead of looking at a particular
racial-ethnic or at several different racial-
ethnic groups, an alternative approach is
to identify clinical strategies or tech-
niques that heighten clinicians' sensitivi-
ty to race, ethnicity, and culture without
attempting to portray specific groups.
Although this type of work is less com-
mon, notable examples exist. Tseng and
Hsu (1991), in their book Culture and
Family: Problems and Therapy, offer a
guide to "culture-adjusted family assess-
ment" (p. 175) that identifies areas to be
assessed as indices of the ethnic and cul-
tural background of a family. Similarly,
McGill (1992) offers the "cultural story"
as a technique for helping family mem-
bers convey the significance in their
lives of the multiple cultures of which
they are a part.
A unique and quite innovative ap-
proach to applying the critiques of the
treatment of both gender and ethnicity
in marital and family therapy can be
seen in the "Just Therapy" approach
(Tamases & Waldegrave, 1993). This ap-
proach acknowledges the "injustice in
therapy experienced by women and cul-
tural groups different from the dominant
one" (p. 29) but looks to the organiza-
tions that offer clinical services, not the
individual therapists, as the source of re-
dress and change. Recognizing that the
biases and blindspots of models of thera-
py reflect the biases and blindspots of
the larger culture, this work attempts to
intervene at the larger structural level in
a belief that it will then impact both the
therapists and families within that sys-
tem. These structural interventions are
aimed at challenging three institutional
responses that tend to inhibit change:
paralyzing, individualizing, and patroniz-
ing. Tamases and Waldegrave acknowl-
edge that most organizations that offer
mental health services are liberal in ide-
ology and recognize injustice based on
race, culture, or gender. However, resis-
tance tends to appear once acknowl-
edgement has occurred. One way to re-
sist real change is to become paralyzed
by guilt, offering sympathetic reactions
to the complaint but feeling powerless
to make any real change. A second re-
sponse that inhibits change, individualiz-
ing, occurs when a person in the domi-
nant group distinguishes him or herself
from the insensitivities and oppressions
perpetrated by others of his or her
group (e.g., Whites, males) and claims
accountability only for personal behav-
ior. Finally, real change can be blocked
through patronizing, which occurs
when a member of the dominant group
takes on the mantle of spokesperson for
an oppressed group. The authors then
describe the process used by the Family
Centre in Wellington, New Zealand in
364
an attempt to prevent these responses
and to reverse the cultural and gender
biases in therapy. Fundamentally, this
process is built on the premise that the
members of an aggrieved or oppressed
group are the best judges of injustice to
that group. Therefore, staff who belong
to a particular oppressed group are
given the role of guardians of equity for
members of that group, be they clients
or staff.
Sexual orientation. Although the
vast majority of work examining the im-
plications of recent critiques of marital
and family therapy for actual practice
has focused on gender or ethnicity, the
application work that is beginning to ap-
pear around sexual orientation should
be noted. Primarily, two areas have been
reconsidered in light of the critiques of
marital and family therapy: (a) the role
of family therapists in assisting both ho-
mosexual clients and their families in
the potentially difficult "coming out"
process and (b) parenting issues faced
by homosexual parents (Dahlheimer &
Feigal, 1991). Coming out refers to the
process of making one's homosexual ori-
entation known to others. Although the
major focus of the literature has been on
the homosexual's family of origin, issues
for partners or children in families that
homosexuals form have also been ad-
dressed (e.g., Carl, 1990; Roth, 1989).
Regardless of the family constellation
being considered, Dahlheimer and Fei-
gal (1991) highlight the importance of
the therapist initially stressing to family
members that it is society's heterosex-
ism that is the real source of tension and
pain for family members during the
coming out process. Such a focus helps
to free the homosexual family member
from being labelled the cause of whatev-
er struggle or stress the family is experi-
encing. With such a framework estab-
lished, therapy can then proceed on the
specific issues in a given family.
The literature on parenting empha-
sizes that gay men and lesbians who are
parents face all the same issues as het-
erosexual parents face, such as how to
maintain age appropriate discipline or
how to nuture children's self-esteem.
However, in addition to the normal
problems and stresses of parenting, gay
and lesbian parents face many complica-
tions and problems from which hetero-
sexuals are immune (Carl, 1990; Evans,
1990). Homophobia, secrecy, ambiguity
of family roles and boundaries, societal
assumptions about the inadequacy of
gay and lesbian parents, and failure of
the legal system to recognize the
parental status of many homosexuals in-
volved in the raising of children all con-
tribute to a more rugged parenting ter-
FAMILY
RELAlloNs
rain for gay men and lesbians than for
heterosexuals (Ariel & Stearns, 1992;
Baptiste, 1987). Although the literature
gives some attention to each of these
areas for both women and men, it
should be noted that, in keeping with
our societal emphasis on the role of
mothers, the literature on parenting is
much more heavily weighted towards
working with lesbian mothers than gay
fathers (e.g., Evans, 1990; Ross, 1988;
Roth, 1989).
Applying Critiques to
Training
The call to rethink and revise the
way marriage and family therapy is con-
ducted with families has been accompa-
nied by a call to reconsider the way in
which marriage and family therapists are
trained, placing gender, race, and eth-
nicity as more central features in teach-
ing about family dynamics. Guidance has
been offered on how gender (Avis,
1989; Leslie & Clossick, 1992; Roberts,
1991; Storm, 1991; Wheeler, Avis,
Miller, & Chaney, 1989), culture, (Fali-
cov, 1988; Preli & Bernard, 1993) and
race (Boyd-Franklin, 1989; Hardy & Las-
zloffy, 1992, 1994) can be incorporated
into the curriculum of training programs
and how students' and supervisees' ap-
preciation of the relevance of these so-
cially constructed variables can be en-
hanced. Recent research has noted,
however, that merely adding gender
content may be insufficient to change
clinical practice. Leslie and Clossick (in
press) found clinicians who had re-
ceived gender coursework taught from a
feminist perspective showed less sexism
in clinical practice than did clinicians
who had received gender coursework
taught from any other theoretical per-
spective. Interestingly, those who had
received gender coursework from other
than a feminist perspective showed the
same level of sexism as those receiving
no gender training at all.
Also addressed in this literature are
questions about the readiness of training
programs and institutions to truly grap-
ple with what it means to integrate gen-
der and race into training, as well as
questions about the personal and politi-
cal dilemmas posed for faculty and stu-
dents who take the lead in such integra-
tion (Avis, 1989; Coleman, Avis, &
Turin, 1990; Hardy & Laszloffy, 1992;
Leslie & Clossick, 1992). For example,
training programs often marginalize
both course content and faculty by
putting all gender and ethnicity related
training in one course without revising
the biases/problems found through the
remainder of the curriculum. The exis-
tence of one such course can then be
O
October 1995 l
touted as evidence of sensitivity to is-
sues of gender, ethnicity and race, even
when the sexism and racism in other
course content and policies is unad-
dressed.
A related issue receiving some atten-
tion is the way in which the needs of
students may differ based on their gen-
der and race. Attention has been given
to how training programs can be respon-
sive to both female (Reid, McDaniel,
Donaldson, & Tollers, 1987; Warburton,
Newberry, & Alexander, 1989) and male
(Nutt, 1990) student therapists as they
strive to better understand how gender
structures both their lives and the lives
of their clients. Similarly, Wilson and
Stith (1993) have addressed the experi-
ences of African American students in
marital and family therapy training pro-
grams and offered guidelines for devel-
oping recruitment and retention efforts
that address the cultural and racial im-
pediments to African American students'
participation in training programs.
Impact of Therapist's Gender
and Race on Therapy
A third area that has been revisited is
the impact of the therapist's gender and
race on the course of therapy. Certainly,
the bulk of this work has been done rela-
tive to the impact of gender, with only
one recent study (Gregory & Leslie, in
press) looking at the impact of both ther-
apist's race and gender on husbands' and
wives' experiences in therapy.
Considerations of the impact of
therapist's gender have been two-
pronged. Theoretical consideration has
been given to the implications for treat-
ment when male therapists work with
female clients (Doherty, 1991) and
when female therapists work with male
clients (Bograd, 1990a), whereas empiri-
cal investigations have considered the
impact of therapist's gender on the
structure and process of family therapy
sessions. Results of the research suggest
that clients tend to respond differently
to male and female therapists, treating
each in gender sterotyped ways, for ex-
ample, offering more supportive state-
ments with female therapists (Newber-
ry, Alexander, & Turner, 1991) and
more directive statements with male
therapists (Shields & McDaniel, 1992).
However, female therapists do not re-
spond in gender stereotyped ways; they
frequently respond to family members'
supportive behaviors with structuring
interventions (Newberry et al., 1991).
Male therapists, however, make more
statements than female therapists during
sessions (Shields & McDaniel, 1992).
This body of research has also
shown that male and female therapists
October 1995
tend to conceptualize cases differently
(Black & Piercy, 1991); women work
from a feminist-informed perspective
more frequently than men. Likewise, al-
though the gender of the identified pa-
tient does not affect clinical decision
making in marital therapy, the gender of
the therapists does, with female and
male therapists attending to different
client characteristics (Zygmond & Den-
ton, 1988).
When looking at the combined ef-
fects of therapists' race and gender, ini-
tial research suggests that the gender of
the therapist makes very little difference
in husbands' and wives' assessments of
the depth, smoothness, and positivity of
clinical sessions. However, the race of
the therapist does have an impact on ini-
tial assessments of smoothness and posi-
tivity of therapy, particularly for Black
wives. Over time, however, differences
in wives' assessment of therapy based
on the therapists' race decrease (Grego-
ry & Leslie, in press).
Even though the the call to more
sensitively and consistently attend to
gender, race and ethnicity, and sexual
orientation when working with families
has led to a reexamination of a variety of
issues in marital and family therapy,
there are still areas where attention is
needed. Two, in particular, stand out.
The first area where work is needed
is in the utilization of empirical ap-
proaches to further understanding of the
role of gender, race and ethnicity, and
sexual orientation for both clients and
therapists in marital and family therapy.
To date, the vast majority of the litera-
ture is theoretical or clinical in nature.
Although these avenues provide valid in-
sights and knowledge, there is also
much to be learned from a data-based
approach-be it qualitative or quantita-
tive-to many of the questions or issues
posed from these critiques. For exam-
ple, empirical methods could lend valu-
able perspectives to questions such as:
What are the experiences of abused
women in couples therapy versus indi-
vidual therapy? How does a woman's
level of financial dependency affect her
behavior and attitude in family therapy?
How does the race of the therapist affect
treatment outcomes for families of dif-
ferent races? How can training programs
be structured to enhance the experience
of minority students? What is the experi-
ence of homosexual parents in family
therapy?
FMILY
FRATMIL6
To date, the most extensive use of
empirical methods in the gender area is
seen in questions concerning the impact
of therapist gender on the process of
family therapy sessions (Gregory &
Leslie, in press; Newberry et al., 1991;
Shields & McDaniel, 1992), but even this
area of research is limited to a handful of
studies. In the area of race and ethnicity,
a few studies exist that have assessed
the interactional and structural dimen-
sions of families of different ethnicities
(e.g., Fisek, 1991; Hampson, Beavers, &
Hulgus, 1990; Morris, 1990). No consis-
tent empirical attention has yet been
given to any question concerning sexual
orientation and marital and family thera-
py. Hopefully, empirical methods will
become more extensively mined as a
rich source of insight into how gender,
race and ethnicity, and sexual orienta-
tion affect both marital and family thera-
py and the training of marital and family
therapists.
A second area where attention is
needed is in the integration of the litera-
ture and knowledge on the effects of
gender, race, ethnicity, and sexual orien-
tation on family members' lives and on
families in therapy. As Almeida (1994)
points out, feminist analysis has empha-
sized issues of power inequity and domi-
nation in understanding family dynamics.
However, other sources of oppression
and inequality that impact family life,
such as race and class, have received lit-
tle attention from those interested in is-
sues of gender. Likewise, those interest-
ed in questions of race and ethnicity
have given only passing attention to gen-
der. Neither body of work has given
much attention to questions of sexual
orientation. There are a few notable ex-
ceptions to this pattern: the 'Just Thera-
py" approach mentioned earlier; a chap-
ter on ethnicity and women by Mc-
Goldrick and her colleagues in Women
in Families: A Framework for Family
Therapy (1989); work on African-Ameri-
can males by Franklin (1992, 1993); a
special issue of Journal of Family Thera-
py devoted entirely to ethnicity and
mothers (Braverman, 1990); and a recent
issue of the Journal of Feminist Family
Therapy entitled "Expansions of Femi-
nist Family Theory Through Diversity"
(Almeida, 1994), which has articles ad-
dressing the intersection of gender, race,
and sexual orientation (Almeida, Woods,
Messineo, Font, & Heer, 1994; Comas-
Diaz, 1994; Korin, 1994). However,
these forays into integrating gender,
race, and ethnicity are the exception; the
more common approach is a feminist lit-
erature that focuses on issues of gender
and a separate body of literature that fo-
cuses on issues of race and ethnicity.
There is little, if any, systematic treat-
365
ment of how these systems of inequality
and hierarchy, as well as those of class
and sexual orientation, are related and
jointly affect individual family members,
families as a whole, and marital and fami-
ly therapy. This criticism is, of course,
not unique to the field of family therapy.
Feminism, in general, has been criticized
for being concerned mainly with issues
affecting White middle-class women.
However, as Walker, Martin, and Thomp-
son (1988), Almeida (1994), and others
note, feminist theory is thoroughly
equipped to provide such integration be-
cause issues of hierarchy, inequity, and
oppression are at the heart of the theo-
retical analysis. Feminist theories are
now beginning to address the diversity in
women's experiences and men's experi-
ences based on socially constructed vari-
ables other than gender. So, too, family
therapy needs to embrace a more multi-
faceted approach to the social construc-
tion of family life and examine the impli-
cations of such an approach for working
with families.
The last 10 years have seen the field
of marital and family therapy called to
task for the way in which therapeutic
models based largely on the perspec-
tives of White males have ignored and
dismissed the experiences of other
groups. The result has been therapy that
is irrelevant to certain groups and op-
pressive to others, as it forces families to
fit a model of individual mental health
and family functioning that disregards
family members' life circumstances, re-
sources, and values.
Certainly, the critiques have had an
impact on practice and training in the
field as therapists struggle to be more
appreciative of the diversity of experi-
ence and life circumstances that impact
clients' behavior and their needs in ther-
apy. Whereas some might argue that the
response has been slow and limited, it
cannot be denied that these critiques
have produced a tension that has influ-
enced, and will continue to influence,
the developmental course of marital and
family therapy. Not only has this work
identified certain groups who have been
misserved and begun to redress the situ-
ation, but it has also instilled cautious-
ness in the field that we as family thera-
pists must be more diligent in examining
the impact of our work on all involved.
As a result, the field is just beginning to
recognize and examine another group,
children, which may have been mis-
served over the years by an emphasis on
the needs of adults, particularly in cases
of separation and divorce (e.g., Robin-
366
son, 1994). It is likely that in the future
we will recognize blindspots in our
treatment of other groups as well. The
important point is that we should con-
tinue the current momentum toward ac-
knowledging our values and biases and
examining how our work affects all of
our clients, as diverse as they may be.
Certainly, all families will be better
served by the evolving reflective, re-
sponsive stance within the field brought
about by therapists who are able to cri-
tique that of which they are a part.
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