family therapy concepts, process and practice

FAMILY THERAPY
Wiley Series in
CLINICAL PSYCHOLOGY
Adrian Wells School of Psychological Sciences,
(Series Advisor) University of Manchester, UK
Alan Carr Family Therapy: Concepts, Process and
Practice, Second Edition
Martin Herbert Clinical Child Psychology: From Theory
to Practice, Third Edition
Graham C.L. Davey and Worry And Its Psychological Disorders:
Adrian Wells (Editors) Theory, Assessment And Treatment
Titles published under the series editorship of:
J. Mark G. Williams School of Psychology, University
(Series Editor) of Wales, Bangor, UK
Richard G. Moore and Cognitive Therapy for Chronic and
Anne Garland Persistent Depression
Ross G. Menzies and Obsessive-Compulsive Disorder:
Padmal de Silva (Editors) Theory, Research and Treatment
David Kingdon and The Case Study Guide to Cognitive
Douglas Turkington (Editors) Behaviour Therapy of Psychosis
Hermine L. Graham, Substance Misuse in Psychosis: Approaches
Alex Copello, to Treatment and Service Delivery
Max J. Birchwood and
Kim T. Mueser (Editors)
Jenny A. Petrak and The Trauma of Sexual Assault: Treatment,
Barbara Hedge (Editors) Prevention and Practice
Gordon J.G. Asmundson, Health Anxiety: Clinical and Research
Steven Taylor and Perspectives on Hypochondriasis and
Brian J. Cox (Editors) Related Conditions
Kees van Heeringen (Editor) Understanding Suicidal Behaviour:

The Suicidal Process Approach to Research,
Treatment and Prevention
Craig A. White Cognitive Behaviour Therapy for Chronic
Medical Problems: A Guide to Assessment and
Treatment in Practice
Steven Taylor Understanding and Treating Panic Disorder:
Cognitive-Behavioural Approaches
Alan Carr Family Therapy: Concepts, Process and Practice
A list of earlier titles in the series follows the index.
FAMILY THERAPY
Concepts, Process and Practice
Second Edition
Alan Carr
University College Dublin and Clanwilliam Institute Dublin,
Ireland
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Library of Congress Cataloging-in-Publication Data
Carr, Alan, Dr.
Family therapy: concepts, process and practice / Alan Carr.— 2nd ed.
p. cm. — (The Wiley series in clinical psychology)
Includes bibliographical references and index.
ISBN-13: 978-0-470-01454-7 (cloth : alk. paper)
ISBN-10: 0-470-01454-7 (cloth : alk. paper)
ISBN-13: 978-0-470-01455-4 (pbk. : alk. paper)
ISBN-10: 0-470-01455-5 (pbk. : alk. paper)
1. Family psychotherapy. I. Title. II. Series.

RC488.5.C367 2006
616.89’156—dc22 2005035562
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN-13 978-0-470-01454-7(hbk) 978-0-470-01455-4 (pbk)
ISBN-10 0-470-01454-7 (hbk) 0-470-01455-5 (pbk)
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CONTENTS
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword Alan S. Gurman . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
Endorsements of the fi rst edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
PART I CENTRAL CONCEPTS IN
FAMILY THERAPY
Chapter 1 Goals of Family Therapy
Across the Lifecycle. . . . . . . . . . . . . 3
The family lifecycle . . . . . . . . . . . . . . . 5
Lifecycle stages associated
with separation and divorce . . . . . 29
The individual lifecycle . . . . . . . . . . . 35
Sex-role development . . . . . . . . . . . . . 41
Gay and lesbian lifecycles . . . . . . . . . 43
Class, creed and colour . . . . . . . . . . . . 45
Summary . . . . . . . . . . . . . . . . . . . . . . . 45
Further reading . . . . . . . . . . . . . . . . . . 47
Chapter 2 Origins of Family Therapy . . . . . . . . . 48

Movements: Child guidance, marriage
counselling and sex therapy . . . . . 49
Disciplines: Social work, psychiatry
and clinical psychology . . . . . . . . . 50
Group therapy: Group analysis,
encounter groups, psychodrama
and Gestalt therapy . . . . . . . . . . . . . 52
Research traditions: Work groups,
role theory and schizophrenia . . . . 53
Gregory Bateson . . . . . . . . . . . . . . . . . 56
Three organising themes: Behaviour
patterns, beliefs and contexts . . . . 68
Summary . . . . . . . . . . . . . . . . . . . . . . . 70
Glossary . . . . . . . . . . . . . . . . . . . . . . . . 71
Further reading . . . . . . . . . . . . . . . . . . 73
vi CONTENTS
Chapter 3 Theories that Focus on Behaviour
Patterns . . . . . . . . . . . . . . . . . . . . . . . 76
MRI brief therapy . . . . . . . . . . . . . . . . 76
Strategic family therapy . . . . . . . . . . . 85
Structural family therapy . . . . . . . . . . 90
Cognitive-behavioural marital and
family therapy . . . . . . . . . . . . . . . . . 93
Functional family therapy . . . . . . . . . 96
Closing comments . . . . . . . . . . . . . . . . 99
Glossary . . . . . . . . . . . . . . . . . . . . . . . . 100
Further reading . . . . . . . . . . . . . . . . . . 106
Chapter 4 Theories that Focus on Belief
Systems . . . . . . . . . . . . . . . . . . . . . . . 110
Epistemology: Positivism,

constructivism, social
constructionism, modernism and
postmodernism . . . . . . . . . . . . . . . . 110
A constructivist approach to
family therapy . . . . . . . . . . . . . . . . . 119
Milan systemic family therapy . . . . . 124
Social constructionist
developments . . . . . . . . . . . . . . . . . . 128
Solution-focused therapy . . . . . . . . . . 132
Narrative therapy . . . . . . . . . . . . . . . . 135
Closing comments . . . . . . . . . . . . . . . . 138
Glossary . . . . . . . . . . . . . . . . . . . . . . . . 140
Further reading . . . . . . . . . . . . . . . . . . 148
Chapter 5 Theories that Focus on Contexts . . . . 154
Transgenerational family therapy . . . 154
Psychoanalytic family therapy . . . . . 164
Attachment-based therapies . . . . . . . 167
Experiential family therapy . . . . . . . . 173
Multisystemic family therapy . . . . . . 180
Psychoeducational family therapy . . 182
Closing comments . . . . . . . . . . . . . . . . 183
Glossary . . . . . . . . . . . . . . . . . . . . . . . . 185
Further reading . . . . . . . . . . . . . . . . . . 193
Chapter 6 Integrative Models . . . . . . . . . . . . . . . 199
Metaframeworks . . . . . . . . . . . . . . . . . 199
Integrative problem-centred
therapy . . . . . . . . . . . . . . . . . . . . . . . 202
Brief integrative marital therapy . . . . 205
Pluralistic couples therapy . . . . . . . . . 207
CONTENTS vii

Integrative applications within
specifi c professions . . . . . . . . . . . . . 209
Closing comments . . . . . . . . . . . . . . . . 210
Glossary . . . . . . . . . . . . . . . . . . . . . . . . 211
Further reading . . . . . . . . . . . . . . . . . . 211
PART II PROCESSES IN FAMILY
THERAPY
Chapter 7 The Stages of Family Therapy . . . . . . 215
Stage 1 – Planning . . . . . . . . . . . . . . . . 215
Stage 2 – Assessment . . . . . . . . . . . . . 219
Stage 3 – Treatment . . . . . . . . . . . . . . . 235
Stage 4 – Disengaging or
recontracting . . . . . . . . . . . . . . . . . . 242
Summary . . . . . . . . . . . . . . . . . . . . . . . 247
Further reading . . . . . . . . . . . . . . . . . . 248
Chapter 8 Formulating Problems and
Exceptions . . . . . . . . . . . . . . . . . . . . 249
The three-column problem
formulation model . . . . . . . . . . . . . 253
The three-column exception
formulation model . . . . . . . . . . . . . 260
Questions to ask when constructing
three-column formulations . . . . . . 264
Recursive reformulation . . . . . . . . . . . 270
Summary . . . . . . . . . . . . . . . . . . . . . . . 272
Further reading . . . . . . . . . . . . . . . . . . 272
Chapter 9 Interventions for Behaviour, Beliefs
and Contexts . . . . . . . . . . . . . . . . . . . . 273
Criteria for selecting interventions . . 273
Behaviour-focused interventions . . . 276

Interventions focusing on belief
systems . . . . . . . . . . . . . . . . . . . . . . . 291
Interventions that focus on historical,
contextual and constitutional
factors . . . . . . . . . . . . . . . . . . . . . . . . 299
Summary . . . . . . . . . . . . . . . . . . . . . . . 312
Further reading . . . . . . . . . . . . . . . . . . 313
PART III FAMILY THERAPY PRACTICE WITH
CHILD- AND ADOLESCENT-FOCUSED
PROBLEMS
Chapter 10 Physical Child Abuse . . . . . . . . . . . . . 317
Systemic model of physical child
abuse . . . . . . . . . . . . . . . . . . . . . . . . . 317
viii CONTENTS
Family therapy for physical child
abuse . . . . . . . . . . . . . . . . . . . . . . . . . 326
Summary . . . . . . . . . . . . . . . . . . . . . . . 337
Further reading . . . . . . . . . . . . . . . . . . 338
Chapter 11 Sexual Abuse . . . . . . . . . . . . . . . . . . . . 339
Systemic model of child sexual
abuse . . . . . . . . . . . . . . . . . . . . . . . . . 339
Family therapy for child sexual
abuse . . . . . . . . . . . . . . . . . . . . . . . . . 347
Summary . . . . . . . . . . . . . . . . . . . . . . . 360
Further reading . . . . . . . . . . . . . . . . . . 360
Chapter 12 Conduct Problems . . . . . . . . . . . . . . . . 361
Systemic model of conduct problems 363
Family therapy for conduct
problems . . . . . . . . . . . . . . . . . . . . . . 371
Summary . . . . . . . . . . . . . . . . . . . . . . . 383

Further reading . . . . . . . . . . . . . . . . . . 384
Further reading for parents . . . . . . . . 384
Chapter 13 Drug Abuse in Adolescence . . . . . . . . 386
Systemic model of drug abuse in
adolescence . . . . . . . . . . . . . . . . . . . . 386
Family therapy for drug abuse in
adolescence . . . . . . . . . . . . . . . . . . . . 394
Summary . . . . . . . . . . . . . . . . . . . . . . . 401
Further reading . . . . . . . . . . . . . . . . . . 402
PART IV FAMILY THERAPY PRACTICE WITH
ADULT-FOCUSED PROBLEMS
Chapter 14 Distressed Couples . . . . . . . . . . . . . . . 405
Systemic model of distressing intimate
relationships . . . . . . . . . . . . . . . . . . . 409
Couples therapy . . . . . . . . . . . . . . . . . 413
Summary . . . . . . . . . . . . . . . . . . . . . . . 429
Further reading . . . . . . . . . . . . . . . . . . 429
Further reading for clients . . . . . . . . . 430
Chapter 15 Depression and Anxiety . . . . . . . . . . . 431
Depression . . . . . . . . . . . . . . . . . . . . . . 431
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . 432
Systemic model of anxiety and
depression . . . . . . . . . . . . . . . . . . . . 435
Couples therapy for anxiety and
depression . . . . . . . . . . . . . . . . . . . . 440
Summary . . . . . . . . . . . . . . . . . . . . . . . 454
Further reading . . . . . . . . . . . . . . . . . . 455
CONTENTS ix
Chapter 16 Alcohol Problems in Adulthood . . . . 456
Systemic model of alcohol problems

in adulthood . . . . . . . . . . . . . . . . . . . 456
Couples therapy for alcohol problems
in adulthood . . . . . . . . . . . . . . . . . . . 465
Summary . . . . . . . . . . . . . . . . . . . . . . . 475
Further reading . . . . . . . . . . . . . . . . . . 476
Chapter 17 Schizophrenia. . . . . . . . . . . . . . . . . . . . 478
Systemic model of schizophrenia . . . 479
Couples and family therapy for
schizophrenia . . . . . . . . . . . . . . . . . . 484
Summary . . . . . . . . . . . . . . . . . . . . . . . 495
Further reading . . . . . . . . . . . . . . . . . . 496
PART V RESEARCH AND RESOURCES
Chapter 18 Evidence-based Practice in Marital
and Family Therapy . . . . . . . . . . . . 499
Child-focused problems . . . . . . . . . . . 500
Adult-focused problems . . . . . . . . . . . 518
Common factors . . . . . . . . . . . . . . . . . 532
Closing comments . . . . . . . . . . . . . . . . 533
Glossary . . . . . . . . . . . . . . . . . . . . . . . . 535
Further reading . . . . . . . . . . . . . . . . . . 536
Chapter 19 Professional Resources . . . . . . . . . . . . 537
Family therapy associations . . . . . . . 537
Training and supervision . . . . . . . . . . 538
Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . 538
Assessment instruments . . . . . . . . . . . 539
Training videotapes . . . . . . . . . . . . . . . 543
Web resources . . . . . . . . . . . . . . . . . . . 544
Journals . . . . . . . . . . . . . . . . . . . . . . . . . 545
Institutes, associations and websites
for specifi c types of family therapy

and systemic interventions . . . . . . 546
Written communication in
therapy . . . . . . . . . . . . . . . . . . . . . . . 549
Training exercises . . . . . . . . . . . . . . . . 555
Conclusion . . . . . . . . . . . . . . . . . . . . . . 580
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617

ABOUT THE AUTHOR
Professor Alan Carr is the director of the Doctoral training programme in
clinical psychology at University College Dublin and Consultant Martial
and Family Therapist at the Clanwilliam Institute for Marital and Family
Therapy in Dublin. He has published over a dozen books and 200 aca-
demic papers and conference presentations in the fi elds of family therapy
and clinical psychology. His work has been translated into a number of
languages including Korean, Polish and Chinese. He has extensive experi-
ence in family therapy and clinical psychology, having worked in the fi eld
in the UK, Ireland and Canada.

FOREWORD
I have never met Alan Carr, and really know nothing about him (except
that his parents showed eminently good taste in choosing his forename).
But I have been familiar with his writings for a long time, and for several
years, in fact, have required the psychiatric residents I teach to read his
earliest work on the Formulation Model. The reason for this is clear and
simple. In the Psychiatry Department in which I teach, residents have such
demanding clinical responsibilities that they can allot only minimal time
to their reading. So, seminar readings must be concise, relevant and use-
able. For my values, they must also be conceptually well grounded. On all
these criteria, Alan Carr’s writings have easily passed the test. So, when

he invited me to write this Foreword, I thought, ‘What a remarkably good
clinician he must be to know intuitively how highly I regard his work!’
Now that he has fully elaborated the Formulation Model in this book, I
regard his contribution even more, and so should the reader, who really
is getting ‘two for the price of one’ in this volume. The ‘fi rst book’ in this
book is a highly readable and accessible introductory account of the major
approaches to family therapy, one which will be very well received by
teachers of family therapy and their students. This new edition has been
well updated with important new material on cutting-edge attachment-
based therapies and integrative approaches, and a concise presentation of
recent clinically relevant research on couple and family therapy. Moreover,
it seems to me that Carr has actually revised more of the original text than
second edition authors usually do, and, of course, the reader is the benefi -
ciary of the work of such a responsible author! As in the fi rst edition, the
numerous comparative tables Carr includes are pedagogical gold mines
for instructors. The second ‘book-within-a-book’ is Alan Carr’s singular
contribution, The Formulation Model of family therapy treatment plan-
ning and intervention. This is how Carr’s book sets itself apart from other
introductory texts, which usually explicate all the extant clinical theories,
but leave (especially) the novice reader hanging as to what to do with
them. Carr never leaves such matters unattended to, and consistently suc-
ceeds at showing the reader how to make theory practical. I like to think of
Carr’s book as news you can use, rather than views that confuse.
Carr’s central contribution is his Formulation Model. As an empiri-
cally oriented clinical theoretician, Carr is appropriately respectful of
purportedly disparate points of view. He demonstrates his integrative
conceptual open-mindedness through his ‘three-column’ method of for-
mulating clinical problems and exceptions to problems. These levels or
domains of behaviour appear at fi rst blush roughly to parallel the time-
honoured tripartite division of human experience into ‘behaviour’, ‘cog-

nition’ and ‘affect’, but, in fact, they are far more inclusive of practical pos-
sibilities than such traditional categories would statically suggest. Carr’s
model politely but powerfully reminds us that intrapersonal factors,
whether biochemical or intrapsychic, belong just as much in the domain of
the real-life practice of couple and family therapy as the interpersonal fac-
tors with which the fi eld of family therapy seemed to have been obsessed
until just a few years ago. This is the power of his model, that change can
potentially be initiated within any functionally relevant domain of experi-
ence, and still be systemically meaningful. Carr’s Formulation Model is
family therapy, but more important, it is wise therapy.
Alan Carr’s writing is consistently crisp, clear and cogent. I am very
pleased with the very positive reception with which the fi rst edition of this
book has been met, and I truly hope this new edition’s exposure will not
be limited to students, colleagues and practitioners in Great Britain and
Europe. It certainly has much to commend it as an introductory textbook
for students of couple and family therapy everywhere. As noted, it is an
introduction-with-a-twist, and that ‘twist’ is that it presents an eminently
teachable and learnable clinical model that leads to effective action. I hope
Alan Carr’s important contribution to the family therapy fi eld will soon
be more visible on this side of the Atlantic.
Alan S. Gurman PhD
Professor of Psychiatry, University of Wisconsin Medical School, Madison,
Wisconsin, USA
October 2005
xiv FOREWORD
PREFACE
One beginning and one ending for a book was a thing I did not agree with.
A good book may have three openings entirely dissimilar and inter-related
only in the prescience of the author, or for that matter one hundred times as
many endings…. One book, one opening, was a principle with which I did not

fi nd it possible to concur.
Flann O’Brien (1939, At Swim-two-birds, pp. 9, 13.)
The end lies concealed in the beginning. All bodies grow around a skeleton.
Life is a petticoat about death. I will not go to bed.
James Stephens (1912, The Crock of Gold, p. 16)
(Reproduced by permission of the Society of Authors as the
Literary Representative of the Estate of James Stephens.)
New worlds for old.
James Joyce (1922, Ulysses, p. 462)
It is not easy to learn either the graceful skills required for practicing fam-
ily therapy or the complex theoretical heritage on which this practice rests.
Some of the central challenges of teaching, learning and practicing family
therapy are well expressed in the words of O’Brien, Stephens and Joyce
that open this Preface. Certainly it is not possible to encapsulate the story
of family therapy in a book with one beginning and one ending. So you
may fi nd that this book reads like a number of volumes condensed into
one. A central idea of family therapy is that many important human pro-
cesses involve cycles where the end lies concealed in the beginning. You
will fi nd that this book opens with a discussion of the lifecycle and that the
concept of circularity is a core feature of the formulation model presented
in the heart of the book. Family therapy is built on a bedrock of hope.
Family therapy is not just about problems. It is also about exceptions to
problems. It does not focus exclusively on defi cits and disability, but also
is concerned with resilience and resourcefulness. Family therapy is a pro-
cess through which we exchange new and better worlds for old.
This second edition of Family Therapy: Concepts, Process and Practice retains
the same overall structure, style and content of the fi rst edition but in-
cludes a number of important revisions that make it more useful for post-
graduates, trainers and experienced therapists.
xvi PREFACE

• The content and references in each chapter have been updated to take
account of signifi cant developments that have occurred during the
past six years.
• An additional chapter on integrative models of practice has been
added to Part I.
• Attachment theory and therapy have been addressed more fully in
Part I.
• Developments in the formulation model have been added to Part II.
• Parts III and IV have been revised in light of relevant new theoretical
and empirical material on each of the child- and adult-focused prob-
lems addressed in these sections.
• The research review in Chapter 18 has been brought up to date and ex-
panded to include a section on common factors in effective therapy.
• The fi nal chapter on resources has been expanded to include lists of
relevant websites; a section on ethics; and a series of practical exercises
for developing family therapy skills.
The book retains all of the features of the fi rst edition that have made it
popular among postgraduates and experienced clinicians alike.
Family Therapy: Concepts, Process and Practice was written both as a textbook
for use in marital and family therapy professional postgraduate training
programmes and as a sourcebook for experienced clinicians. The book of-
fers a critical evaluation of the major schools of family therapy, an integra-
tive model for the practice of marital and family therapy, and examples of
how this model may be used with a range of common child-focused and
adult-focused problems. Findings from research on the effectiveness of
family therapy are reviewed and the implications of these for evidence-
based practice outlined.
The fi rst part of this volume contains a critical evaluation of the major
schools of family therapy. The major traditions are grouped together in
terms of their central focus of therapeutic concern, and in particular with

respect to their emphasis on (1) problem-maintaining behaviour patterns;
(2) problem-related belief systems and narratives; and (3) historical, con-
textual and constitutional predisposing factors.
Family therapy schools that highlight the role of repetitive patterns of
family interaction in the maintenance of problem behaviour and advocate
practices that aim to disrupt these patterns of interaction include: the MRI
brief therapy approach; strategic therapy; structural therapy; cognitive-
behavioural approaches; and functional family therapy.
Traditions that point to the centrality of belief systems and narratives that
subserve repetitive interaction patterns include: constructivism; Milan
systemic family therapy; social-constructionist family therapy approaches;
solution-focused therapy; and narrative therapy.
PREFACE xvii
Traditions that highlight the role of historical, contextual and constitu-
tional factors in predisposing family members to adopt particular belief
systems and engage in particular problematic interaction patterns include:
transgenerational family therapy; psychoanalytic family therapy tradi-
tions; attachment theory-based approaches; experiential family therapy;
multisystemic therapy; and psychoeducational approaches.
This organisation of schools of therapy in terms of their emphases on
three particular themes is a useful learning device, but is an oversimpli-
fi cation. Most schools of family therapy address problem-maintaining
behaviour patterns, constraining beliefs and broader historical, contex-
tual and constitutional factors. However, the classifi cation of schools
according to the degree to which they emphasize these three themes,
offers a backdrop against which a number of integrative models are pre-
sented, including the integrative approach to family therapy advocated
in this volume.
A three-column model for formulating both problems and exceptions to
these is presented in the second part of this book. The formulation model

uses the three themes by which the schools of family therapy were clas-
sifi ed to organise information about a particular problem. That is, it is ar-
gued that for any problem, a formulation may be constructed using ideas
from many schools of family therapy in which the pattern of family in-
teraction that maintains the problem is specifi ed; the constraining beliefs
and narratives that underpin each family member’s role in this pattern
are outlined; and the historical, contextual and constitutional factors that
underpin these belief systems and narratives are specifi ed. In parallel with
this, a similar formulation may be constructed to explain why the problem
does not occur in exceptional circumstances, which, while similar to prob-
lematic situations, differs in important key respects.
In light of these formulations, a range of interventions that address factors
within each column of these three-column formulations may be consid-
ered. Some interventions aim primarily to disrupt problem-maintaining
behaviour patterns or amplify exceptional non-problematic patterns. Oth-
ers aim to help family members re-author their constraining narratives
and develop more liberating and fl exible belief systems that underpin ex-
ceptions to the problem. Still others aim to modify the negative impact
of historical, contextual and constitutional factors or to draw on family
strengths in these domains. Thus, while it is accepted that the classifi ca-
tion of schools of family therapy according to three themes is an oversim-
plifi cation, it is a particularly useful oversimplifi cation insofar as it may
facilitate a coherent, integrative and fl exible approach to the practice of
family therapy.
In the third part of this book, the way in which the integrative model may
be used in the treatment of common child-focused problems, including
xviii PREFACE
child abuse, conduct problems and drug abuse, is outlined. The applica-
tion of the model with common adult-focused problems is considered in
the fourth part. The focus here is on marital distress, depression and anxi-

ety, alcohol problems and schizophrenia.
In the fi nal part, evidence for the effectiveness of family therapy and fam-
ily-based interventions with a range of child and adult-focused problems
is addressed and the implications of this research for evidence-based prac-
tice is set out. Also, useful resources for the training, practice and research
are presented.
While this volume is intended as a sourcebook for experienced clinicians,
it has also been written as a textbook for newcomers to the fi eld of family
therapy and systemic consultation. I have probably erred on the side of
oversimplifying many complex ideas in an attempt to make the family
therapy literature accessible to the newcomer. I hope that experienced cli-
nicians can bear with this shortcoming. A glossary of new terms is provid-
ed at the end of theoretical chapters. In addition, reading lists that include
references to original sources, overview chapters from major handbooks
and important journal articles are given.
The integrative model and approach to practice described here evolved in
two particular contexts. The ground work for the model was laid over a
seven-year period during the 1980s and early 1990s while I was working in
a UK National Health Service Child and Family Clinic (Carr, 1995, 1997).
During this period there was a national emphasis on cooperation between
health service professionals and their colleagues in social services and
education. There was also an emphasis on liaison between district hos-
pital departments offering services to children such as child psychology,
child psychiatry and paediatrics. In addition, many hospitals within the
NHS became privately run trusts. These factors created a climate which
favoured the development of models of assessment and intervention that
were time-limited, that took account of the wider professional network of
which the child and therapist were part, that clearly addressed the over-
lap between the roles of therapist and agent of social control, and that
could be evaluated or audited in a relatively objective way. The model was

extended for use with adult-focused problems, as well as child-focused
problems from 1992 to the present at the Clanwilliam Institute in Dublin.
Many of us who work in the fi eld of systemic consultation and family
therapy at some time during our professional development held the view
that there is a true formulation of the client’s problems and exceptions to
these and a related correct set of solutions. In the approach described in
the heart of this book, it is assumed that the formulations that emerge
from talking with families about the presenting problem and exceptions to
these are no more than social constructions. Since it is possible to construct
multiple formulations to explain any problem or exception, it is important
to have a criterion by which to judge the merit of any particular one.
PREFACE xix
In the approach to practice presented in the heart of this volume, it is the
usefulness of formulations in suggesting a variety of feasible solutions that
are acceptable to the family which is the sole criterion for judging the mer-
it of one formulation over another. Because of its emphasis on the socially
constructed nature of problem and exception formulations and the choice
of usefulness as a criterion for selecting between different formulations,
the approach described in this volume may be viewed as falling within the
tradition of social-constructionism.
In deciding about the usefulness of formulations and interventions, clini-
cians using the approach to practice set out in this volume are invited to
take account of the results of empirical research on the effectiveness of
family therapy. Indeed, a thorough review of the more rigorous family
therapy outcome research is given in Chapter 18. Due to the social-con-
structionist positioning that is taken in this book, and because treatment
outcome research results are used to inform clinical practice, this text will
be of interest to both postmodern practitioners and empirically oriented
clinicians.
A distinction has been made within the fi eld between fi rst- and second-

order approaches to practice, with fi rst-order approaches using observed
systems as a central explanatory concept and second-order approaches us-
ing the metaphor of observing systems as the principal theoretical frame.
The integrative approach set out in this volume attempts to reap a harvest
from both of these fi elds and – for want of a better metaphor – may be
called an ‘integrative third-order approach to family therapy’ although I
have reservations about the usefulness of such labels.
Alan Carr
University College Dublin & Clanwilliam Institute Dublin, Ireland
October 2005

ACKNOWLEDGEMENTS
I am grateful to the many colleagues, friends and relatives who have
helped me develop the ideas presented in this book. In particular I would
like to thank the group who introduced me to family therapy at the Mater
Hospital in Dublin in the late 1970s: Dr Imelda McCarthy, Dr Jim Sheehan,
Dr Nollaig Byrne, Koos Mandos and Dr Paul McQuaid.
I am also grateful to Dr Chris Cooper, Peter Simms and Carol Elisabeth
Burra in Kingston, Ontario, with whom I worked while living in Canada.
In the UK, my gratitude goes to the group with whom I practiced at
Thurlow house and the Queen Elisabeth Hospital in King’s Lynn during
the 1980s and early 1990s: Dr Dermot McDonnell, Dr Chris Wood,
George Gawlinski, Sheila Docking, Sue Grant, Nick Irving, Shahin
Afnan, Dr Jonathan Dossetor, Dr Dennis Barter, Denise Sherwood and
Mike Cliffe.
Thanks are due to Dr Ivan Eisler, Dr Eddy Street, Professor John Carpenter,
Bebe Speed and Professor Bryan Lask at the editorial offi ce of the Journal
of Family Therapy; to Professor Terry Trepper, Editor of Journal of Family
Psychotherapy; to Professor Peter Stratton, Editor of Human Systems: The
Journal of Systemic Consultation and Management; to Max Cornwall, Editor

of The Australian Journal of Family Therapy; to Professor Doug Sprenkle,
past Editor of the Journal of Marital and Family Therapy; and to Professor
Michael Nichols, Editor of Contemporary Family Therapy for challenging
me to articulate my ideas more clearly. I am grateful to Professor Martin
Herbert at Exeter University and Dr Arlene Vetere at the University of
Surrey for their collegial support.
Thanks to Mike Coombs, Senior Publishing Editor with John Wiley &
Sons, Ltd, for guidance throughout the production of the fi rst edition of
this book and to Deborah Egleton for her support with the production of
the second edition.
The second edition of this book was completed at the Psychology Institute,
Aarhus University in Denmark, where I was a visiting professor in the
autumn of 2005. I am especially grateful to Professors Aegen Trillingsgaard
and Ask Elklit, who arranged funding and support for this sabbatical leave
and for their generosity and hospitality during my time in Denmark.
Past and present colleagues at UCD, especially Professor Ciarán
Benson, Dr Gary O’Reilly, Dr Muireann McNulty, Dr Barbara Dooley,
Muriel Keegan, Dr Suzanne Guerin, Dr Jennifer Edgeworth, Dr Patricia
Noonan Walsh, Fíona Kelly Meldon and Frances Osborne, have been very
supportive of my efforts to write the two editions of this book and I am
grateful to them for their patience and encouragement.
A special word of thanks is due to past and present colleagues at the
Clanwilliam Institute in Dublin, particularly Dr Ed McHale, Phil Kearney,
Aileen Tiernery, Dr Bernadette O’Sullivan, Declan Roche, Clive Garland,
Cory deJong, Innes Collins, Noreen Dennehy, Breda McGee, Linda
Finnegan, Dr Gregor Lange, Carl Murphy and Adele McGrath.
Postgraduates at UCD and the Clanwilliam have offered useful feedback,
which has been helpful in writing the second edition and I am grateful to
them for this.
Much of what I know about family life, I have learned from my own family

and to them I owe a particular debt of gratitude.
Go raibh míle maith agaibh go léir.
Alan Carr,
University College Dublin & Clanwilliam Institute Dublin, Ireland
October 2005
xxii ACKNOWLEDGEMENTS
ENDORSEMENTS OF THE FIRST
EDITION
This is an excellent basic text in family therapy.
Journal of Child Psychology and Psychiatry
The book is an encyclopaedic achievement and will be of use both to train-
ees and more experienced practitioners.
Clinical Psychology Forum
This volume’s scope and approach set it apart from other introductory
texts in family therapy.
Contemporary Family Therapy
As Alan Gurman writes in his foreword, the reader is getting ‘two for
the price of one’. The fi rst book is a highly readable introductory account
of the major approaches to family therapy. The second book details the
author’s formulation model. What impressed me was the comprehensive-
ness of this volume.
Journal of Family Therapy
The key to Carr’s book may well lie in his early quotations from James
Joyce, James Stephens and Flann O’Brien, in that, like them, his project is
an attempt to tame the untameable, to marry the many differences. It is a
bold project.
Clinical Child Psychology and Psychiatry