httpjfn.sagepub.comJournal of Family Nursing http

http://jfn.sagepub.com/
Journal of Family Nursing
http://jfn.sagepub.com/content/15/4/461
The online version of this article can be found at:
DOI: 10.1177/1074840709350606
2009 15: 461Journal of Family Nursing
Fabie Duhamel, France Dupuis and Lorraine Wright
Nursing
Reflections for Clinical Practice, Education, and Research in
Family
Families' and Nurses' Responses to the ''One Question
Question'':
Published by:
http://www.sagepublications.com
can be found at:Journal of Family NursingAd ditional services
and information for
http://jfn.sagepub.com/cgi/alertsEmail Alerts:

http://jfn.sagepub.com/subscriptionsSubscriptions:
http://www.sagepub.com/journalsReprints.navReprints:
http://www.sagepub.com/journalsPermissions. navPermissions:
http://jfn.sagepub.com/content/15/4/461.refs.htmlCitations:
What is This?
- Oct 26, 2009Version of Record >>
at MINNESOTA STATE UNIV MANKATO on August 6,
2013jfn.sagepub.comDownloaded from
http://jfn.sagepub.com/content/15/4/461
http://www.sagepublications.com
http://jfn.sagepub.com/cgi/alerts
http://jfn.sagepub.com/subscriptions
http://www.sagepub.com/journalsReprints.nav
http://www.sagepub.com/journalsPermissions.nav
http://jfn.sagepub.com/content/15/4/461.refs.html
http://jfn.sagepub.com/content/15/4/461.full.pdf
http://online.sagepub.com/site/sphelp/vorhelp.xhtml
Journal of Family Nursing
15(4) 461 –485

© The Author(s) 2009
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1074840709350606
http://jfn.sagepub.com
Families’ and Nurses’
Responses to the “One
Question Question”:
Reflections for Clinical
Practice, Education,
and Research in Family
Nursing
Fabie Duhamel, RN, PhD,1
France Dupuis, RN, PhD,1
and Lorraine Wright, RN, PhD2
Abstract
The “One Question Question,” first coined by Dr. Lorraine M.
Wright in
1989, is an interventive question designed to elicit family
members’ most
pressing needs or concerns within the context of a therapeutic
conversation.
In this article, two clinical projects analyzed the responses to
this unique
interventive question. The first project analyzed the responses
of 192 family
members experiencing illness who were asked the question in
the context
of a therapeutic conversation; families focused on their need to

deal with the
impact of the illness on the family. The second project
examined responses
of 297 nurses who were asked the question prior to a 1-week
Family
Systems Nursing training program; nurses wanted to know how
to deal with
conflictual relationships between families and health care
professionals and
how to offer families time-efficient interventions. The
responses from both
1University of Montreal, Montreal, Quebec, Canada
2University of Calgary, Calgary, Alberta, Canada
Corresponding Author:
Fabie Duhamel, Faculty of Nursing, University of Montreal,
C.P. 6128, Succursale Centre-ville,
Montreal, Quebec, H3C 3J7 Canada
Email: [email protected]
462 Journal of Family Nursing 15(4)
groups, which were markedly different, triggered reflections
about teaching,
research, and practice in family nursing.
Keywords
family nursing interventions, One Question Question,
interventive questions,

therapeutic conversations, family nursing practice, family and
chronic illness
The “One Question Question” (OQQ) was first introduced by
Dr. Lorraine
M. Wright as an efficient assessment question to explore family
members’
most critical concerns and/or challenges about a health issue
(Wright, 1989).
The usefulness of this question arose during therapeutic
conversations between
nurses and families at the Family Nursing Unit, University of
Calgary (Bell,
2008; Gottlieb, 2007). From numerous clinical interviews at the
Family Nurs-
ing Unit, it was observed that this question often invited or
helped family
members express the source of their deepest concerns or
suffering, trans-
forming a useful assessment question into a powerful
interventive question
as well. The question is usually formulated as follows: “If you
could have
just one question answered through our work together, what
would that one
question be?” Wright (1989) suggests that the question invites
the nurse to
move quickly to the most pressing issue identified by the
family, thus avoid-
ing one of the most common errors in family nursing (Wright &
Leahey,
2005), that is, only exploring those issues considered important
by the health
care professional. Thus, the OQQ becomes a useful tool to
collect the most
pertinent information and concerns in a brief therapeutic

conversation
(Martinez, D’Artois, & Rennick, 2007; Wright & Leahey,
1999). Such a tool
is particularly important for clinical contexts, where time is
considered a con-
straining factor in conducting family assessments. Moreover,
the question
may be used in other contexts for various populations to
identify their main
concerns or challenges related to a particular topic.
This article reports on two separate clinical projects conducted
at the
University of Montreal, which examined responses to the OQQ
from two
different populations: (a) The Family Project analyzed the
responses of fam-
ilies to the OQQ who were dealing with health issues and who
were offered
supervised therapeutic conversations and (b) The Nurses Project
analyzed the
responses of nurses who were asked the OQQ by the first author
prior to a
1-week Family Systems Nursing workshop/training program.
The docu-
mented responses from both groups provided a rich opportunity
to identify the
most pressing concerns and issues for each group. There was no
association

Duhamel et al. 463
between the families who participated in the Family Project and
the nurses
who participated in the Nurses Project. Although the two
projects were con-
ducted and analyzed separately, and without the benefit of a
scientifically
based comparison between groups, it was both interesting and
useful to
identify areas of convergence and divergence between the
groups’ answers
which focused on families’ concerns about the experience of
illness and the
nurses’ learning priorities for including families in their clinical
practice.
Differences that exist between nurses and families’ perceptions
about priori-
ties could be one contributing factor to the challenges
encountered in family
nursing practice (Hundley, Milne, Leighton-Beck, Graham, &
Fitzmaurice,
2000; Létourneau & Elliot, 1996). Hence, these two projects
stimulated
reflections within our clinical research team and generated ideas
for practice,
education, and research in family nursing. These two separate
clinical proj-
ects are not considered to be traditional research studies,
therefore only a
general qualitative description of each project is provided.
Description of the Family Project
The main objective of this clinical project was to examine
families’ responses
to the OQQ within the context of a therapeutic conversation to

identify the
most frequently reported concerns and questions of families
experiencing
and managing illness at home.
Context of the Family Participants
The first two authors provide family nursing supervision to
graduate students
at an outpatient clinic called the Denyse-Latourelle Family
Nursing Unit at the
University of Montreal (modeled after the Family Nursing Unit
at the Univer-
sity of Calgary). All the teaching, supervision, and nursing
practice at the
University of Montreal is conducted in the French language.
Families who
come to this Family Nursing Unit present with challenges while
living at
home with a health problem such as chronic illness, child
behavioral prob-
lems, or separation/divorce issues. Each family participates
every 2 weeks in
a family meeting for a total of four to seven meetings. A
graduate nursing
student conducts the family interview (therapeutic conversation)
within the
context of a supervised clinical practicum in Family Systems
Nursing. At the
end of the first family meeting, the graduate student is
encouraged to ask each
family member the OQQ and chart each family member’s
response to the
question in the family’s file. Students often refer to these
responses to guide
the family assessment and interventions throughout their
clinical work

with the family. For the Family Project, family files were
examined to obtain
family members’ responses to the OQQ. In total, 192 family
member res-
ponses to the OQQ were retrieved, identified, and analyzed. All
families
signed an informed consent allowing the use of their file for
clinical, educa-
tional, and research purposes.
Description of the Nurses Project
The main objective of this clinical project was to examine
nurses’ responses
to the OQQ at the beginning of a 1-week Family Systems
Nursing training
program offered by the first author, to identify their most
pressing learning
needs regarding the nursing of families.
Context of the Nurse Participants
The clinical usefulness of the OQQ has led to its ritualized use
in teaching/
learning contexts. Since 1998, a 1-week Family Systems
Nursing workshop/
training program has been offered annually at the University of
Montreal to
a francophone population of practicing nurses, graduate nursing

students,
and academics. The aim of the program is to teach nurses how
to assess and
intervene with families using a systemic perspective. Nurses
come from vari-
ous clinical settings and attend on a voluntary basis. On the first
day of the
training program, participants are asked to respond to the OQQ
focusing on
their family nursing learning needs. Nurses’ responses to the
OQQ are con-
sidered to reflect the nurses’ main educational needs, concerns,
and questions
regarding their practice with families. These responses are then
transcribed
and serve to guide the content and process of the family nursing
training
programs/workshops. For the Nurses Project, the responses of
293 nurses to
the OQQ were examined and analyzed. The educational
background of the
nurses varied from nursing diploma to graduate degrees, and
every nurse had
at least 3 years of clinical experience.
Process of Analyzing the Responses to the OQQ
Although these two separate projects are not considered
traditional research
studies, the responses of both the nurses and families were
submitted to a form
of inductive content analysis that, at first, consisted of multiple
readings and
coding of each response to the OQQ by the research team. The
same examina-
tion process was used for both projects separately. The coding
process was

performed by a project assistant who had a bachelor degree in
nursing. The list
Duhamel et al. 465
of questions and codes was then submitted to the first two
authors, who col-
laborated to validate and reach a consensus on the labeling of
the codes. Then,
the project’s nursing assistant classified the codes into sub-
themes which were
finally regrouped under a “theme question.” As an example, one
family mem-
ber’s response to the OQQ was, “How can I help my husband
alleviate his
stress?” which was coded as “Strategies to reduce stress.” This
code was then
classified in the subtheme “Stress and anxiety,” which was then
listed as a
theme question “What to do about?” because most of the
questions related to
stress and anxiety reflected families’ quest for strategies to
cope with their
feelings generated by the health problem. The subthemes were
used not only
as a “classification” system but also for calculation of the
percentage of fre-
quency. At the completion of this analysis procedure, another
project assistant,
a masters level nurse with expertise in family nursing, reviewed

the total
examination process for validation purposes. Only minor
adjustments were
suggested. The authors closely examined the findings to
generate reflections
about family nursing practice, education, and research.
Findings
The Family Project: Family Members’ Responses to the OQQ
The theme questions and their sub-themes for family members’
responses to
the OQQ are listed in Table 1, which includes the distribution
of responses
(in the form of questions) for each theme, sub-theme, and
corresponding per-
centages of the total responses. Family members’ responses to
the OQQ
during a therapeutic conversation resulted in three major
themes: (a) “What
to do about the illness and its impact on the family?” (b) “What
is ahead of
us?” And (c) “What and who can help us?” The sub-themes
offer specific
ideas about the issues that were most concerning for these
families experienc-
ing illness.
What to do about the illness and its impact on the family? A
total of 42% of
the total number of the family members’ questions reflected the
need for strat-
egies to deal with the challenges of the illness. Seven subthemes
of questions
within this major theme are shown in Table 1: (a) the impact of
the illness on

the partner and significant others, (b) illness management, (c)
children reac-
tions to the illness, (d) relational problems betw een family
members, (e) the
role of the caregiver, (f) children with behavioral problems, and
(g) stress and
anxiety related to the illness.
Under this theme, we included questions about dealing with
family mem-
bers’ reactions to the health problem. More specifically, these
questions refer
to the protection of self and others, especially the partner, from
negative con-
sequences (e.g., feelings of guilt or depression) of chronic
illness on the
family. Other questions dealt with the families’ need to know
more about
how to manage symptoms such as fatigue, pain, and
irritability—symptoms
that affect healthy family members as well as the patient.
Another source of
family concern was how to deal with children’s reactions to the
illness. For
example, parents who were ill wondered how to explain the
severity of their
illness to their young children. Others wanted to know how to

best help chil-
dren express or deal with their emotions. The fourth subtheme
question,
“how to deal with relational problems within the family,”
referred to how
family members can better understand each other or how they
can repair
broken relationships because of the tension generated by the
illness. In terms
of the role of the caregiver, seven responses referred to
questions on “how”
to be a better caregiver for the ill person. As for families who
consulted the
Table 1. Families’ Responses to the One Question Question
Theme Questions Number Frequency (%)
1. “What to do about . . . ?” Looking for 81 42.2
strategies to deal with the:
a. Impact of illness on partner and 28 14.6
significant others
b. The illness itself 16 8.3
c. Children’s reactions to illness 15 7.8
d. Relational problems within the family 8 4.2
e. The role of caregiver 7 3.7
f. Children with behavioral problems 4 2.1
f. Stress and anxiety related to the illness 3 1.6
2. “What’s ahead of us?” Uncertainty about: 64 33.3
a. Long term impact of the illness on 20 10.4
marital and family life
b. Existential and spiritual questions 20 10.4
c. Evolution of disease and facing death 19 9.9

d. Normality 5 2.6
3. “What and who can help us?” Resources 47 24.5
and information about:
a. Illness and treatment 25 13
b. Psychological support 8 4.2
c. Reasons for the family meetings and 8 4.2
usefulness
d. Instrumental assistance 6 3.1
Total 192 100
Duhamel et al. 467
Family Nursing Unit for their children’s behavioral problems,
questions
pertained to behavioral management. Finally, the last sub-theme
included
family members’ questions about how to reduce feelings of
stress and anxi-
ety in one’s own self and in others.
Examples of specific family members’ questions within this
theme of
“What to do about the illness and its impact on the family?”
were as follows:
How can I relieve my guilt related to the depression that my
illness
causes in my husband?

How do I protect myself as a spouse?
My wife (who has multiple sclerosis) doesn’t want any more
visitors at
home. How do I explain to her that it is important for me?
How can I alleviate my wife’s pain?
How can I avoid that my illness has a negative impact on our
children’s
development?
My child is 9 years old, what do I tell her about my illness?
Should I
show her that I am strong?
How can I be a better caregiver for my wife?
Should I continue to “walk on egg shells” when dealing with my
daughter? What attitude should I have toward her?
How can I help my husband relieve his stress related to the
illness?
What is ahead of us? The second most important theme of
family member
responses to the OQQ (33.3%) were questions for which there
are no clear
answers. The questions related to (a) the long-term impact of
the illness on
family life, (b) existential issues and spirituality, (c) the
progression of dis-
ease and facing death, and (d) normality. More specifically, the
responses to
the OQQ reflected family members’ concerns about the long-
term impact of
the illness on their family life, their work, and marital and
parental relation-

ships. Uncertainty related to the progression of the ill ness
generated questions
about the future, the possibility of a remission, relapse, or cure
for the patient,
and/or an increase/decrease of the caregiver’s burden. The
progression of the
illness and long-term impact on each family member’s health
status, and on
family life, also triggered questions relating to existential,
philosophical, and
spiritual issues, particularly with regard to the meaning and
purpose of life.
There are no easy answers, if any, to these questions. Within
this theme of
uncertainty, there were some questions that referred to the
notion of “normal-
ity.” Family members reported unusual behaviors, thoughts, and
/or emotions
in reaction to the illness, and were concerned with their
normalcy under the
circumstances.
Examples of family members’ questions in this theme of “What
is ahead
of us?” were as follows:
Will he ever walk again?
Will we still be a couple in the future?

How much longer will he live?
Can we still plan projects together?
When will we be able to leave on a family vacation?
Why has this happened to us?
Why does suffering exist?
If we were such good parents, as you say, why did we lose our
daughter?
Why do I have cancer?
How can we live and be happy with someone who has multiple
sclerosis?
Is it normal to always have a lump (emotional) in my throat?
Is it normal, at this phase of my illness, that I do not want to
see my
children’s spouses anymore?
What and who can help us? The third theme of family members’
responses
to the OQQ concerned the need for information and resources
about (a) the
illness and treatment, (b) psychological support, (c) the family
meetings
that were offered to them (in the Denyse-Latourelle Family
Nursing
Unit), and (d) assistance with instrumental tasks. Questions
under this
theme revealed family members’ need for more information
about the
nature of the illness, etiology, treatment, the role of stress in
the progres-
sion of the illness, and the impact of treatment. The search for
reliable
support was another source of concern. Family members
inquired about
the availability and accessibility of resources related to both
instrumental

as well as psychological needs.
Examples of family members’ questions within this theme of
“What and
who can help us?” were as follows:
Could an emotional trauma have triggered the illness?
What are the benefits of taking such a medication?
Why didn’t the hospital offer to put me in touch with people
who are
experiencing the same thing, so I can prepare myself for this?
Why do people around us distance themselves from us as if the
illness
was contagious?
What about these family meetings, will they promote a sense of
well
being in our marital relationship?
Duhamel et al. 469
Why can’t I receive more help for cleaning my house and doing
my
errands?
Why can’t we get the name of a resource person to phone, if
needed,
once we are back home?

The Nurses Project: Nurses’ Responses to the OQQ
There was a great variation of answers in nurses’ responses to
the OQQ at the
beginning of a one week workshop/training program in Family
Systems Nurs-
ing. However, four theme questions in response to the OQQ did
emerge and
are listed with the frequency and percentage of total responses
in Table 2. The
themes were as follows: (a) “How to intervene in specifi c
clinical situations?”
(b) “What are the most efficient family interviewing skills?” (c)
“What is the
nurse’s role in family care and in relation to the other
professionals?” and
(d) “ How do we involve the family in the care of the patient?”
How to intervene in specific clinical situations? The most
frequent type of
nurses’ questions pertained to the need to be effective and brief
when dealing
with challenging situations related to (a) conflictual
relationships between
families and professionals, (b) families with specific health
problems (e.g.,
schizophrenia, noncompliant families), (c) conflicts between
family mem-
bers (e.g., display of anger, aggression), (d) ethical questions,
confidentiality
issues, and transmission of information, (e) loss and grief, (f)
crisis situation,
perception of suffering, (g) family members in “denial,” (h)
placing a parent
in a nursing home, and (i) feelings of guilt and overprotection.

In this first theme, we noted that the largest percentage of
responses
(14.6% or 43 questions) was related to conflicts between family
members
and health professionals. These questions pertained to the
difficulty in
dealing with families whom the nurse perceived as being
“demanding,”
continually dissatisfied, complaining about the care, lacking
respect, and/or
showing arrogance and anger. The next most frequent set of
responses to the
OQQ reflected the nurses’ need to learn more about specific
health issues or
problems and how to deal with families experiencing these
problems. These
issues included reconstituted families, noncompliant families,
and diagnoses
such as schizophrenia and psychosomatic symptoms.
Conflict between family members was another important source
of ques-
tioning for nurses, especially when the family members
expressed anger or
hostility toward one another in front of the sick family member.
The next
most common responses focused on ethical issues of
confidentiality and
sharing patient information with family members,
documentation of family

concerns in patient charts, and end-of-life decisions. Regarding
these issues,
nurses’ concerns were embedded in the following types of
questions:
How do we approach family members who are unreasonable,
want
their way no matter what, and become aggressive toward
nurses?
How can nurses prevent burn-out when families show
continuous dis-
satisfaction and make unrealistic demands?
Table 2. Nurses’ Responses to the One Question Question
Number of
Theme Questions Questions Frequency (%)
1. “How to intervene in specific clinical situations?” 130 44.2
Looking for strategies to deal with:
a. Conflictual relationship between families 43 14.6
and professionals
b. Families with specific health problems 19 6.5
(schizophrenia, noncompliant)
c. Conflicts between family members 15 5.1
(anger, aggressiveness)
d. Ethical questions, confidentiality issues, 14 4.7
and information transmission

e. Loss and grief 13 4.5
f. Crisis situation, perception of suffering 11 3.7
g. Family members in “denial” 8 2.7
h. Placing a parent in a nursing home 4 1.4
i. Feelings of guilt and overprotection 3 1.0
2. “What are the most efficient family 107 36.7
interviewing skills?” How to . . .
a. Engage, assess, and intervene with families 69 23.5
in an efficient manner
b. Explore the impact of the illness 17 5.7
on the family
c. Explore and challenge beliefs 12 4.0
and cultural issues
d. Interview children 9 3.0
3. “What is the nurse’s role in family care and 29 9.8
in relation with the other professionals?”
4. “How do we involve the family in the care 27 9.3
of the patient?”
Total 293 100
Duhamel et al. 471
How do we deal with families who refuse the prescribed

treatment for
their child?
How do we intervene when conflicts between family members
affect
the patient’s health?
What type of information regarding the patient’s health issue
can offer
to the family without impinging on confidentiality rights?
Another set of nurses’ questions under this same theme were
related to
emotionally difficult situations such as families who face a
crisis and/or a
loss and who express grief and suffering. Nurses inquired about
strategies
to explore, prevent, and comfort family members’ emotional
suffering.
They also requested guidance to help families whom they
perceive as being
“in denial” and not responding to their expectations. Nurses
also had
questions about how to support families who experience
hardship when
having to place their loved one in a nursing home. Feelings of
guilt and
perceptions of overprotection in families were another source of
concern
when working with families. All these concerns were expressed
in the
following questions:
What is the best way to intervene when the family is in crisis or
in shock
after learning about a serious prognosis or the death of a loved

one?
How do we deal with family members when they are in denial
that their
loved one is dying?
How can we alleviate families’ suffering and help them accept
the
placement? How can we help them with their feelings of guil t?
How do I interview a family? Almost one third of nurses’
questions related
to the skills required to conduct a family interview (107
questions). The four
subthemes included how to (a) engage, assess, and intervene
with families;
(b) explore the impact of the illness on the family; (c) explore
and challenge
beliefs and cultural issues; and (d) interview children.
1. How to engage, assess, and intervene with families? In this
sub-
theme, nurses’ questions reflected their learning needs about
which family members should be present in family meetings,
and
when,
what kind of questions to ask the family in order to collect
pertinent
information,
how to identify “the real problem” in the family,
how to resolve different problems within the family,

how to reassure family members and strengthen their
relationships, and
how to challenge family members’ beliefs.
Specific examples of questions in this theme are as follows:
“How do we
keep neutral when parents do not agree?”; “How can I feel more
at ease in a
family meeting?”; “How do we explore a family problem
without jeopardizing
our trusting relationship with the family?”; “How do we help
families adapt
to their illness?”
2. How to explore the impact of the family on the illness?
Through their
OQQ, nurses expressed their need to learn more about how
family
dynamics affect the patient’s health, emotional experience (e.g.,
stress, guilt), adaptation to the illness, and decision making,
includ-
ing choice of treatment. Questions were presented as follows:
How does the family influence the patient’s health condition?
Can the family influence patients’ choices and his decision
making?
Can the family influence the parent/child attachment process in
a
perinatal context?

3. How to explore and challenge beliefs and cultural issues?
This sub-
theme relates to the nurses’ questions regarding cultural
diversity
and health behaviors as well as family reactions to a health
problem
within a cultural context that is unfamiliar to nurses. Nurses
required
knowledge and strategies to support families from a different
cul-
tural background than their own. Some of the questions were
How do we approach a family with different cultural beliefs
than
ours without making them feel threatened or intruded upon in
their intimacy (private life)?
How do we help a family better understand the illness when
their
cultural beliefs make mental illness a taboo and do not want to
talk about it?
There were only a few questions regarding families’ existential
issues.
They related to reassuring families without giving false hope
and one question
on how to respond to families who ask existential questions.
The two ques-
tions in this theme were verbalized as such
How realistic is it to reassure the family of a terminally ill
resident
without giving false hope?
What do we tell a family who has a young baby who is dying?
How do we respond to their question: “Why us?”

Duhamel et al. 473
4. How to interview children? There were a few nurses who
inquired
about how to approach the children of a parent who is suffering
from a serious illness, dying, or is affected by an illness that
brings
shame and embarrassment with their peers. The questions were
How do we help children whose parent is dying?
How do we approach adolescents who have to learn to cope with
a
parent’s chronic illness and with his friends or peers’ prejudices
related to the illness?
What is the nurse’s role in family care and in relation to other
health care
professionals? Several nurses questioned their role i n family
care. They asked
what their specific responsibility toward the family is and who
between the
patient and the family should they privilege or side with, if any.
Through
their responses to the OQQ, they also showed their confusion
about issues
of roles and responsibility between health professionals who
assist families.
Their questions were formulated as such

What is my role toward the family; where and when does it start
and
when does it end?
What distinguishes my role from other health professionals like
so-
cial workers and psychologists or physicians when working with
families?
How do we involve family members in patient care? The fourth
most frequent
type of question asked by nurses in response to the OQQ
referred to family
members’ participation in patient care. Nurses inquired about
how and when
they should involve the family without making them feel too
responsible,
burdened, or worthless if family members do not have a chance
to
collaborate. In this matter, nurses asked the following
questions:
How do we sensitize the family to the importance of their
involvement
in the long term care of their child?
How do we keep them motivated in patient care in a chronic
illness
situation?
When is the best time to integrate the family in the patient’s
care?
Reflections and Discussion
These findings generated reflections about families’ experiences
with health

problems and about the learning needs of nurses caring for
families that could
inspire education, research, and practice in the nursing of
families.
Families’ Experiences With Health Problems
It is important to keep in mind that the families who
participated in the
Family Project responded to the OQQ at a time when the
member with the
health issue was living at home and therefore had more limited
access to
health professionals than if the ill family member was an
inpatient in a clini-
cal setting. The type of questions formulated by family members
might have
been different if asked during another episode of their illness, a
different time
in the illness trajectory, or in a different context. Family
responses in this clini-
cal project corroborate what has already been reported in the
literature with
regard to families’ needs when one member is experiencing
health problems
(Clayton, Butow, & Tattersall, 2005; Eriksson & Svedlund,
2006; Habermann
& Davis, 2005). Interestingly, the information provided by the

participants in
the Family Project was not based on a checklist of possible
needs that could
have prompted their responses, but represents families’
spontaneous answers
to the OQQ asked within a therapeutic conversation. The
families’ responses
to the OQQ identified instrumental, emotional, and relational
challenges
which are also reported in the literature. In spite of the fact that
the specific
needs of families experiencing illness have been identified in
the nursing lit-
erature for many years, families’ responses to the OQQ indicate
that their
needs are still not being adequately addressed and they are often
left to their
own resources to deal with their illness challenges. This
underscores the
importance, once again, of the need for nurses to explore family
members’
experiences to determine if there is undue distress, anguish, or
suffering before
and after the ill family member returns home. Moreover, this
project gener-
ated specific information that helps to clarify the type of
support that nurses
might offer families and for which nurses need to be educated.
Health problems seem to challenge families’ abilities with
communica-
tion and relational issues. These findings corroborate other
studies or clinical
cases that report on the reciprocal relationship between illness
and family
dynamics (Duhamel, 2007; Wright & Bell, 2009; Wright &

Leahey, 2009). In
the Family Project, families’ questions about how to manage the
illness seem
to reflect their lack of confidence regarding their ability to
solve problems or
care for an ill family member. In addition, their questions
regarding their
future and existential and spiritual issues may indicate a
perception of the
severity of the disruption that the illness creates in their life and
their feelings
of uncertainty and lack of control. Quinn (2003) and Wright
(2005) suggest
that serious illness often leads patients and families to
reconsider life’s mean-
ing and purpose. If one believes that “talking is potentially
healing” (Wright,
2005), the use of the OQQ allows families to raise questions
that might oth-
erwise have been left unspoken.
Duhamel et al. 475
Not surprisingly, families had questions about the normalcy of
their expe-
rience, looking for acknowledgement and reassurance about
their behaviors
and feelings. These results support several other authors who
have acknowl-
edged how persons with chronic health problems often feel

“abnormal” as
described by feeling isolated, alienated, and stigmatized
(Joachim & Acorn,
2000; Petersen, 2006; Royer, 1998).
Finally, 25% of the families were in search of both instrumental
and/or
psychological resources to provide the necessary illness
management. Infor-
mation about these resources might serve to strengthen their
sense of security
and/or sense of control over the illness situation. The family
members’ desire
for information about illness, treatment, and for more support
may suggest
that the required resources are either scarce or unknown to the
families. These
family concerns could inform nursing interventions that might
be offered.
Questions from families about the reasons and usefulness of the
family
meetings at the Denyse-Latourelle Family Nursing Unit (4.2%)
indicated
that families are not used to being offered family meetings to
discuss their
experiences when illness arises. Families may be unaware or
confused about
the role of nurses in family care.
Nurses’ Learning Needs
Nurses’ responses to the OQQ helped to identify their primary
needs and
concerns about working with families. It appears that nurses’
most pressing

needs are to acquire more clinical skills to deal with conflicts
between fam-
ilies and health professionals, “crisis” situations, and family
communication
problems in a short amount of time. Nurses’ concerns may be
related to
their work context where there is an increasing level of
complexity and
acuity in patient care. This, coupled with nursing staff shortages
in many
clinical settings, generates a high level of stress for both
families and nurses.
Thus, nurses are requesting additional knowledge and skills to
deal with this
stressful context and ensure efficiency and helpfulness in their
nursing care,
especially when they perceive families as being “in crisis” or in
“denial.”
From the way nurses formulated some of their responses to the
OQQ, we can
hypothesize about their epistemological perspective on family
conflict.
A “positivist” or “linear” perception seemed to influence the
manner in
which questions were formulated. Families labeled as
demanding, complain-
ing about care, lacking respect, and showing arrogance and
anger suggest that
nurses perceive these problems and challenges as unrelated to
the relational
aspect of care. They tend to overlook the interactional or
circular principle in
the relationship between themselves and the family and between
family mem-
bers (Wright & Leahey, 2009). Attending a Family Systems

Nursing workshop
has the potential to alter their conceptualization of nurse/family
relationships
and enter into a more interactional, relational practice (Doane
&Varcoe, 2005;
Wright & Bell, 2009; Wright & Leahey, 2009).
The second most important series of questions asked by nurses
referred to
theoretical concepts and to perceptual, conceptual, and
executive skills of
family nursing (Wright & Leahey, 2009). There was an
emphasis on requir-
ing executive skills for engaging and maintaining a therapeutic
relationship
with families with a health problem and/or with children.
Although family
nursing or family-centered care is part of the curriculum in most
undergradu-
ate nursing programs, it appears that nurses still experience the
need for more
education and mentoring about how best to involve families in
their practice.
Many factors may explain these learning needs, such as no
adequate role
modeling by nurses who are competent and confident in family
nursing skills

and perhaps no standardized teaching, expectation of family
involvement,
and practice format in family nursing in most clinical contexts.
Furthermore, nurses tend to express confusion about the nature
of their role
with families compared with other health care professionals.
This data may
suggest a sense of helplessness and/or inadequacy and raise
questions about
nurses’ comfort, confidence, and competence level in providing
family care.
As for their perceptions on families’ caregiving role, these
nurses may believe
that taking part in the care of the patient could provide family
members with
comfort and a sense of control. Therefore, they may tend to
encourage family
members to participate in the family member’s care. However,
they are also
sensitive to the impact of illness and of the possible long-term
effects of care-
giving activities on the family members’ experience (e.g.,
burden, fatigue,
despair), prompting questions about how to best assist families
with partici-
pating in patient care in times of chronic illness. This type of
questioning may
reflect a hesitation to invite the family to take part in decision
making regard-
ing the patient’s care. We suggest that the nature and timing of
the family’s
involvement in care, on a long term basis, should be determined
through an
ongoing assessment made by family members and nurses in the
context of a

collaborative relationship. Using the OQQ can be a useful and
time efficient
aspect of the family assessment.
Congruencies and Disparities Between
Nurses and Families’ Responses to the OQQ
As we examined the lists of themes reported by families and
nurses, we also
looked for congruencies and disparities. While acknowledging
the lack of a
traditional scientific basis for comparing these two
heterogeneous groups, it
Duhamel et al. 477
is still interesting to note that there are four common themes
that emerged
in both groups: (a) the impact of the illness on family members,
especially
in time of conflicts; (b) dealing with children; (c) family
members as care-
givers; and (d) nurses’ role in family care. In the first common
theme, it
appears that families as well as nurses express feelings of
helplessness and
inadequacy when dealing with the impact of chronic illness on
the family,
especially in times of “crisis.” Some of the participants referred
to a “crisis”
as being a time when families are facing traumatic events such

as learning
that one family member is diagnosed with a life-threatening
illness or has
died suddenly. This finding underscores the importance of the
impact that
illness has not only on families (Duhamel, 2007; Wright &
Leahey, 2009) but
also on how nurses take care of these families. Thus, it begs the
question:
“What are the basic knowledge and skills that every nurse needs
to possess in
order to be of assistance to families?”
Another reflection from the responses to the OQQ suggests a
certain
degree of angst and suffering in both groups of families and
nurses although
not necessarily named, labeled, or described as such in their
questions. Suf-
fering often accompanies the experience of illness and is most
essential that
nurses know how to soften suffering and promote family healing
(Daneault,
2006; Wright, 2005, 2008). A study exploring the experience of
transition to
adulthood of adolescents living with cystic fibrosis and their
families found
that the parents’ suffering was mostly unrecognized and
unacknowledged by
professionals (Dupuis, 2007). Professionals were able to
disassociate them-
selves from the illness experience, thus allowing a certain
“protection”
against suffering. It is well-known that health care professionals
can experi-
ence difficulties in dealing, on a day to day basis, with the

suffering of their
clients (Daneault, 2006; Morasz, 1999). This could perhaps
explain, in part,
why nurses in this project expressed a need for “complex
interviewing
techniques” to deal with families’ distress and suffering. They
did not seem
to have the knowledge, understanding, or recognition that deep
listening,
compassion, and being fully present (Duhamel & Dupuis, 2004)
in their
relational practices with families can often soften suffering and
promote
healing (Wright, 2005).
The second common theme of both groups relates to dealing
with chil-
dren in times of illness. Both families and nurses seem to be
concerned with
their ability to approach children in the most comforting way.
Communicat-
ing with children about parental illness is a difficult issue for
parents and
health care professionals particularly when parental illness is
potentially life
threatening. This suggests the need for educational input for
both groups on
this issue.

Families as well as nurses are preoccupied by the impact that
the caregiver
role can have on that family member. This observation also
indicates the need
to address this issue with the family and explore the impact that
this role may
have on the family caregiver’s health, whether it appears to be
positive, nega-
tive, or both and what other resources might be available to the
family.
Finally, the data show that it is still very important for nurses to
clarify
their role in caring for families. Responses to the OQQ
indicated that there
was a perception of ambiguity regarding the role of the nurse in
family care
and that nurses themselves questioned their role with families.
Even though
the International Council of Nurses, published a monograph
entitled “The
Family Nurse,” and discussed the important role of involving
families in
health care, (International Council of Nurses, 2001), nurses still
have ques-
tions about the nature of their relationship with families in
health care. On a
provincial level in Canada, the Order of Nurses of Quebec
(ONQ, 2001)
claims that nurses should use a systemic family approach when
caring for
patients, but the findings of this clinical project suggest that
there is still
much work to be done.

As for discrepancies between the groups of families and nurses,
an inter-
esting difference was noted. Families’ experiences of illness are
marked by
stress, anxiety, the wish to return to normal, to live like normal
families, and
by protection of family members. In contrast, nurses tend to
perceive fami-
lies as being “the problem,” believing the family negatively
affects the
patient’s health. Nurses seemed to perceive some families as
angry, aggres-
sive, dysfunctional, and “in denial.” No responses to the OQQ
by family
members refer to this type of attitude. Is it possible that when
families experi-
ence stress and anxiety and are looking for ways to learn how to
cope with
illness, nurses interpret these family reactions and behaviors as
being in crisis
or conflict, and not necessarily in distress? This difference in
perceptions and
interpretations is important because it can profoundly influence
the way
nurses address the family’s reactions to illness.
Further analysis of nurses’ responses to the OQQ underscored
that they
interpret certain families’ behaviors as “denial or dysfunction.”
Of course,
no family would define or describe themselves this way. This
perception by
nurses has profound implications for family nursing practice. It
becomes
complicated and difficult for nurses to work with families if
they harbor

such constraining beliefs. For example, what is interpreted as
“denial” for
nurses, could be a coping strategy that is useful for the families.
If nurses
adopted this more facilitating perspective or belief, it may
foster a more col-
laborative and caring relationship with families (Wright & Bell,
2009).
Nurses would not attempt to change the family’s strategy for
coping with
Duhamel et al. 479
deep illness suffering, but would instead see it as a strength and
hopefully
would even commend the family for their efforts to deal with
the impact of
illness on their lives and relationships (Houger, Limacher &
Wright, 2003,
2006; Wright & Leahey, 2009)
Perhaps nurses’ perception of crisis and conflict in families is
daunting
and frightening and arouses feelings of inadequacy, lack of
control, and
inability to face this situation. Thinking and feeling this way,
nurses may
very likely avoid family members instead of trying to get a
better understand-
ing of their situation. This behavior could, in turn, inadvertently

enhance the
families’ distress and suffering and indicate that nurses are not
“available”
for the expression of the family members’ emotions. Families
may withdraw
with fear and frustration and show behaviors that nurses may
interpret as con-
flict and crisis. Such differences affect the quality of the
relationship between
families and nurses, especially when families are left alone with
their distress
or suffering. Isolation in families’ experiences related to illness
has been well-
described (Daneault, 2006; Gregory & Longman, 1992; Wright,
2005). It is
important for nurses to reflect on their practice and invite and
acknowledge
families’ illness stories. Bringing forth illness stories and
understanding the
constraining beliefs that are perhaps enhancing their suffering is
also impor-
tant (Wright & Bell, 2009; Wright, 2005). Changing nurses’
conceptualization
of families in “crisis and conflict” to one of “experiences of
illness suffering”
can hopefully open the door to a new kind of conversation that
can bring forth
family healing.
The analysis of these two sets of responses by families and
nurses trig-
gers several reflections to guide education, research, and
practice in family
nursing.
Reflections for Family Nursing Education

Nursing programs, both generalist and advanced practice, need
to offer theo-
retical concepts that challenge the belief that the family “is” the
problem.
They should invite nursing students to consider that the impact
of illness on
the family and the influence of the family on the illness
trajectory is an ongo-
ing, observable process. The belief that “illness is a family
affair” (Wright &
Bell, 2009, p. ix) could change the face of nursing practice if
fully embraced
by nurse educators. Theoretical courses and clinical practice
with families
need to include more ideas about the specific clinical skills
required to deal
with family crisis, perception of denial, family members’
expression of anger
and distress, death, and spiritual issues. We believe that all
nurses at both the
undergraduate and graduate level need to have courses and
practica that will
enable them to soften the suffering of families in their care and
promote
family healing. All advanced practice nurses, regardless of
specialty, need to
possess skills to involve families in their care. Teaching

methods should aim
at helping students transfer the knowledge and skills for
working with fami-
lies from their nursing education to actual clinical practice. To
not include
such knowledge and practica in nursing curricula is to ignore
both family
research and clinical stories of families who are yearning for
these kinds of
nurses and nursing care.
Reflections for Research About Family Nursing Practice
Research studies of family nursing practice need to emphasize
family inter-
ventions and be more specific in describing and articulating the
family nursing
interventions under study (Bell & Wright, 2007; Robinson,
1998; Moules,
2002; Tapp, 2001). Researchers should also consider methods
that promote
nurse clinicians’ participation and knowledge transfer in their
studies
(Duhamel & Talbot, 2004). Finally, the following questions
could be devel-
oped to increase knowledge about family nursing interventions:
What are the
most effective and brief interventions for what clinical
situations? What are
the interventions that best help families express spiritual issues
and concerns
in crisis situations? What are the best teaching methods to assist
nurses in
improving their family nursing practice? How does family
nursing practice
find its proper place in the interdisciplinary health care team?
When is the

most appropriate time to ask the family the OQQ?
Reflections for Family Nursing Practice
Nurses’ questions about family interviewing skills stress the
need for admin-
istrative support to improve their competence and confidence in
providing
family care. The highest levels of nursing administration and
other adminis-
trative health professionals need to also embrace the belief that
“illness is a
family affair” (Wright & Bell, 2009, p. ix) in order to make the
involvement
of families in health care a routine and valued part of nursing
practice. Fre-
quently, the philosophies or mission statements of many large
tertiary care
centers state that family-centered care is a significant priority.
However, this
philosophy is not always realized in actual practice. Family-
centered care is
not an “add on” to nursing practice and should occur in all
clinical areas.
But how does one change the larger system and reach
administrators who
have the power to influence and encourage the regular
involvement of fami-
lies in clinical settings? We believe that nurse administrators
who have been

Duhamel et al. 481
exposed to systemic thinking and family care in their own
master’s and doc-
toral programs will be strong advocates for the facilitation and
implementation
of routine and ritualized family nursing practice. It would also
benefit both
families and nurses if on-going family nursing meetings were
implemented
in clinical settings to discuss strategies for assisting families in
different situ-
ations. This could also be an opportunity to offer coaching by
clinical nurse
specialists trained in family nursing. Several topics could be
discussed in
these meetings, such as the following: How do families express
their distress
or anxiety about the impact of the illness on their family
relationships? What
are the most useful strategies to cope with the impact of the
illness on their
family? How can we help families cope with the onslaught and
suffering of
an unwanted illness? What is the role of the nurse in family
care?; and, What
are nurses’ expectations of one another in their particular work
context?
Conclusion
What would happen if nurses routinely asked family members
the OQQ? We
believe that it would greatly enhance the relationship between
families and
nurses. The OQQ provides tremendous opportunities for nurses

to be aware
of and understand the areas of families’ greatest angst,
challenges, sufferings,
and concerns. Of course it does not mean that nurses’ need to
have all the
answers to the families’ questions—rather, simply asking the
OQQ can give
the message that the nurse cares about the family and wants to
be helpful. The
responses of families and nurses in these two clinical projects
invited reflec-
tions about family nursing education, research, and practice.
The similarities
and differences between the two groups confirmed an urgent
need for more
relational, systemic, interactional family nursing practice.
Authors’ Note
Preliminary results of this project were presented at the 7th
International Family
Nursing Conference, Victoria, British Columbia, Canada, June
2005. Lyne Campagna
contributed to the initial phase of this project.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the
authorship and/or
publication of this article.
Funding
The author(s) received no financial support for the research
and/or authorship of this
article.

References
Bell. J. M. (2008). The Family Nursing Unit, University of
Calgary: Reflections on 25
years of clinical scholarship (1982-2007) and closure
announcement [Editorial].
Journal of Family Nursing, 14, 275-288.
Bell, J. M., & Wright, L. M. (2007). La recherche sur la
pratique des soins infirmiers
à la famille [Research on family interventions]. In F. Duhamel
(Ed.), La santé et la
famille: Une approche systémique en soins infirmiers [Families
and health: A sys-
temic approach in nursing care] (2nd ed., pp. 87-105). Montreal,
Quebec, Canada:
Gaëtan Morin Editeur. (An English version of this book chapter
available for public
access on DSpace at the University of Calgary Library:
https://dspace.ucalgary.ca/
handle/1880/44060)
Clayton, J. M., Butow, P. N., & Tattersall, M. H. N. (2005).
When and how to initi-
ate discussion about prognosis and end-of-life issues with
terminally ill patients.
Journal of Pain and Symptom Management, 30, 132-144.

Daneault, S. (2006). Souffrance et médecine [Suffering and
medicine]. Quebec City,
Quebec, Canada: Les Presses de l’Université du Québec.
Doane, G. H., & Varcoe, C. (2005). Family nursing as relational
inquiry. Philadel-
phia: Lippincott Williams &Wilkins.
Duhamel, F. (2007). La santé et la famille. Une approche
sytémique en soins infirmiers
[Families and health: A systemic approach in nursing care] (2nd
ed.). Montreal,
Quebec, Canada: Gaëtan Morin Éditeur.
Duhamel, F., & Dupuis, F. (2004). Guaranteed returns:
Investing in conversations
with families of cancer patients. Clinical Journal of Oncology
Nursing, 8, 68-71.
Duhamel, F., & Talbot, L. (2004). A constructivist evaluation of
family interventions
in cardiovascular nursing practice. Journal of Family Nursing,
10, 12-32.
Dupuis, F. (2007). Modélisation systémique de la transition
pour des familles ayant un
adolescent atteint de fibrose kystique en phase pré-transfert vers
l’établissement
adulte [A systemic model of transition for families who have an
adolescent living
with cystic fibrosis, at the pre-transfer stage]. Unpublished
doctoral dissertation,
University of Montreal, Montreal, Quebec, Canada.
Eriksson, M., & Svedlund, M. (2006). “The intruder”: Spouses’

narratives about life
with a chronically ill partner. Journal of Clinical Nursing, 15,
324-333.
Gottlieb, L. (2007). A tribute to the Calgary Family Nursing
Unit: Lessons that go
beyond family nursing [Editorial]. Canadian Journal of Nursing
Research, 39, 7-11.
Gregory, D., & Longman, A. (1992). Mother’s suffering: Sons
who died of AIDS.
Qualitative Health Research, 2, 334-357.
Habermann, B., & Davis, L. L. (2005). Caring for family with
Alzheimer’s disease
and Parkinson’s disease: Needs, challenges, and satisfactions.
Journal of Geron-
tological Nursing, 31, 49-54.
Duhamel et al. 483
Houger Limacher, L., & Wright, L. M. (2003). Commendations:
Listening to the
silent side of a family intervention. Journal of Family Nursing,
9, 130-150.
Houger Limacher, L., & Wright, L. M. (2006). Exploring the
therapeutic family inter-
vention of commendations: Insights from research. Journal of
Family Nursing, 12,

307-331.
Hundley,V., Milne, J., Leighton-Beck, L., Graham, W., &
Fitzmaurice, A. (2000).
Raising research awareness among midwives and nurses: Does it
work? Journal
of Advanced Nursing, 31, 78-88.
International Council of Nurses. (2001). The family nurse.
Geneva, Switzerland: Author.
Joachim, G., & Acorn, S. (2000). Living with chronic illness:
The interface of stigma
and normalization. Canadian Journal of Nursing Research, 32,
37-48.
Létourneau, N., & Elliot, M. (1996). Pediatric health care
professionals’ perceptions
and practices of family-centered care. Children’s Health Care,
25, 157-174.
Martinez, A. M., D’Artois, D., & Rennick, J. E. (2007). Does
the 15 (or less) family
interview influence family nursing practice? Journal of Family
Nursing, 13, 157-178.
Morasz, L. (1999). Le soignant face à la souffrance [The carer
confronted by suffer-
ing]. Paris: Dunod.
Moules, N. J. (2002). Nursing on paper: Therapeutic letters in
nursing practice. Nurs-
ing Inquiry, 9, 104-113.
Order of Nurses of Quebec. (2001, May 14). Vision
contemporaine de l’exercice

infirmier au Québec (La). [A contemporary vision of nursing
practice in Quebec].
Report presented to the Ministerial Working Group on Health
Care Professions
and Human Relations. Montreal, Quebec, Canada: Author.
Petersen, A. (2006). The best experts: The narratives of those
who have a chronic
condition. Social Science & Medicine, 63, 32-42.
Quinn, B. (2003). Exploring nurse’s experiences of supporting a
cancer patient in
their search for meaning. European Journal of Oncology
Nursing, 7, 164-171.
Robinson, C. A. (1998). Women, families, chronic illness, and
nursing interventions:
From burden to balance. Journal of Family Nursing, 4, 271-290.
Royer, A. (1998). Life with chronic illness. London: Praeger.
Tapp, D. M. (2001). Conserving the vitality of suffering:
Addressing family con-
straints to illness conversations. Nursing Inquiry, 8, 254-263.
Wright, L. M. (1989). When clients ask questions: Enriching the
therapeutic conver-
sation. The Family Therapy Networker, 13, 15-16.
Wright, L. M. (2005). Spirituality, suffering, and illness: Ideas
for healing. Philadel-
phia: F.A. Davis.
Wright, L. M. (2008). Softening suffering through spiritual care
practices: One pos-
sibility for healing families: Keynote address presented to the

8th International
Family Nursing Conference, Bangkok, Thailand, June, 2007.
Journal of Family
Nursing, 14, 394-411.
Wright, L. M., & Leahey, M. (1999). Maximizing time,
minimizing suffering: 15
minute (or less) family interviews. Journal of Family Nursing,
5, 259-274.
Wright, L. M., & Leahey, M. (2005). The three most common
errors in family nurs-
ing: How to avoid or sidestep. Journal of Family Nursing, 11,
90-101.
Wright, L. M., & Leahey, M. (2009). Nurses and families: A
guide to family assess-
ment and intervention (5th ed.). Philadelphia: F. A. Davis.
Wright, L. M., & Bell, J. M. (2009). Beliefs and illness: A
model for healing. Calgary,
Alberta, Canada: 4th Floor Press.
Bios
Fabie Duhamel, RN, PhD, is a professor at the Faculty of
Nursing, University of
Montreal, Canada, where she founded a Family Nursing Unit for

clinical and educa-
tional purposes within the graduate nursing program. Her
research activities focus on
Family Systems Nursing and chronic illness and on knowledge
transfer. Her recent
publications include La santé et la famille. Une approche
systémique en soins infirm-
iers [Families and Health: A Systemic Nursing Approach in
Nursing Care] (2007); “A
Qualitative Evaluation of a Family Nursing Intervention” in
Clinical Nurse Special-
ist: Journal for Advanced Nursing Practice (2007, with F.
Dupuis, M. A. Reidy, &
N. Nadon); “The Impact of a Family Systems Nursing
Educational Program on the
Practice of Psychiatric Nurses: A Pilot Study” in Journal of
Family Nursing (2006,
with J. Goudreau & N. Ricard)
France Dupuis, RN, PhD, is an assistant professor at the Faculty
of Nursing, Univer-
sity of Montreal, Canada. With extensive clinical experience in
pediatric settings, she
teaches family nursing and pediatric nursing at both
undergraduate and graduate
levels. Her research interests focuses on the development of
systemic family nursing
practice in relation to pediatric chronic illness and its impact on
families. Her recent
publications include “Parental Experience of Living With
Adolescents With Cystic
Fibrosis: Identification of a Systemic Hypothesis” in Journal of
Family Nursing (in
press, with F. Duhamel & S. Gendron); “A Qualitative
Evaluation of a Family Nurs-
ing Intervention” in Clinical Nurse Specialist: The Journal for

Advanced Nursing
Practice (2007, with F. Duhamel, M. A. Reidy, & N. Nadon)
Lorraine Wright, RN, PhD, is Professor Emeritus of Nursing,
University of
Calgary. She is also an author, international lecturer, and
marriage and family thera-
pist. Her clinical practice, lectures, and research focus on (a)
illness beliefs of
couples, families, and health care professionals; (b) spirituality,
suffering, and ill-
ness; (c) marriage and family interventions. She developed
several practice models
for family nursing, including the Calgary Family Assessment
and Intervention Models
with Dr. Maureen Leahey; the Illness Beliefs Model with Dr.
Wendy Watson-Nelson
Duhamel et al. 485
and Dr. Janice M. Bell, and the Trinity Model. Her recent
publications include
“Living the As-yet Unanswered: Spiritual Care Practices in
Family Systems Nurs-
ing” in Journal of Family Nursing (2008, with D. L. McLeod);
“Softening Suffering
Through Spiritual Care Practices: One Possibility for Healing
Families: Keynote
address presented to the 8th International Family Nursing
Conference, Bangkok,

Thailand, June, 2007” in Journal of Family Nursing (2008);
Beliefs and Illness: A
Model for Healing (2009, with J. M. Bell); Nurses and Families:
A Guide to Family
Assessment and Intervention (2009, with M. Leahey).
ebook
THE GUILFORD PRESS
RE-VISIONING FAMILY THERAPY
Also Available
Ethnicity and Family Therapy, Third Edition
Edited by Monica McGoldrick, Joe Giordano,
and Nydia Garcia-Preto
Teens Who Hurt: Clinical Interventions to Break
the Cycle of Adolescent Violence
Kenneth V. Hardy and Tracey A. Laszloffy

RE-VISIONING
FAMILY
THERAPY
Addressing Diversity in Clinical Practice
T H I R D E D I T I O N
edited by
Monica McGoldrick
Kenneth V. Hardy
THE GUILFORD PRESS
New York London
Copyright © 2019 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com
All rights reserved
No part of this book may be reproduced, translated, stored in a
retrieval system,
or transmitted, in any form or by any means, electronic,
mechanical, photocopying,
microfilming, recording, or otherwise, without written
permission from the publisher.
Printed in the United States of America

This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
The authors have checked with sources believed to be reliable
in their efforts to provide
information that is complete and generally in accord with the
standards of practice
that are accepted at the time of publication. However, in view of
the possibility of
human error or changes in behavioral, mental health, or medical
sciences, neither the
authors, nor the editors and publisher, nor any other party who
has been involved in the
preparation or publication of this work warrants that the
information contained herein
is in every respect accurate or complete, and they are not
responsible for any errors
or omissions or the results obtained from the use of such
information. Readers are
encouraged to confirm the information contained in this book
with other sources.
Library of Congress Cataloging-in-Publication Data is available
from the publisher.
ISBN 978-1-4625-3193-6 (hardcover)
We dedicate this new edition to the next generation.
May they find the courage not to accept constraints
that impede our systemic understanding and practice,
but most of all may they find the courage to dare—
to work in ways that respect all the complexities of

history and identity and potential that our clients
bring to the clinical situation. May they refuse to
make molehills out of mountains but rather insist on
expanding our efforts to think out of the box.
—M. M. and K. V. H.
To Margaret Pfeiffer Bush and Aunt Mamie Cahalane
and all those like them, whose invisibility
was a hidden shame and who bravely transformed
the constraints of their lives into a love that inspires
and carries us through life.
—M. M.
To my family—both those with whom I share
blood and ancestry as well as those with whom
I share only a common ancestry—for teaching me
the life-transcending lessons of survival, humility,
and perseverance. Your quiet dignity, sacrifice,
and grace have been a source of strength and have
provided clarity of vision and purpose to my life.
—K. V. H.
vi
Monica McGoldrick, LCSW, PhD (h.c.), is Director of the
Multicultural Fam-

ily Institute in Highland Park, New Jersey, and Adjunct
Associate Profes-
sor of Clinical Psychiatry at Rutgers Robert Wood Johnson
Medical School.
Her videos on clinical work with diverse families are among the
most widely
respected in the field. Her numerous books include Ethnicity
and Family
Therapy, Third Edition. Ms. McGoldrick is a recipient of the
Distinguished
Contribution to Family Therapy Theory and Practice Award
from the Ameri-
can Family Therapy Academy. An internationally known author,
she has lec-
tured around the world on such topics as culture, class, gender,
the family life
cycle, and loss.
Kenneth V. Hardy, PhD, is Professor of Family Therapy at
Drexel University
in Philadelphia and Director of the Eikenberg Institute for
Relationships in
New York City. He is also President and Founder of the
Eikenberg Academy
for Social Justice. Dr. Hardy is a recipient of honors including
the Distin-
guished Contribution to Marriage and Family Counseling Award
from the
International Association for Marriage and Family Counselors
and the Dis-
tinguished Contribution to Social Justice Award from the
American Family
Therapy Academy. He maintains a private practice in New York
City special-
izing in family therapy.

About the Editors
vii
N. Norma Akamatsu, MSW, private practice, Northampton,
Massachusetts
Kiran Shahreen Kaur Arora, PhD, School of Education, Long
Island University,
Brooklyn, New York
Deidre Ashton, MSSW, private practice; The Therapy Center of
Philadelphia;
The Race Institute for K–12 Educators; and Widener University,
Philadelphia, Pennsylvania
Christiana I. Awosan, MFT, PhD, Department of Professional
Psychology
and Family Therapy, Seton Hall University, South Orange, New
Jersey
Saliha Bava, LMFT, PhD, School of Social and Behavioral
Sciences,
Mercy College, Dobbs Ferry, New York; Taos Institute, Chagrin
Falls, Ohio;
Houston Galveston Institute, Houston, Texas
Joanne Bowen, PhD, Anthropology Department, The College of
William and Mary,
Williamsburg, Virginia
Nollaig Byrne, MD, Department of Child and Family
Psychiatry,
Mater Misericordia Hospital, Dublin, Ireland

Fernando Colón-López, PhD, Ann Arbor Center for the Family,
Ann Arbor, Michigan
Donna Dallal-Ferne, LMFT, private practice, Syracuse, New
York
Sarita Kaya Davis, PhD, MSW, Department of African
American Studies,
Georgia State University, Atlanta, Georgia
Ken Dolan-Del Vecchio, LMFT, SPHR, GreenGate Leadership,
LLC,
Palmer, Massachusetts
Contributors
viii Contributors
Ken Epstein, PhD, Department of Psychiatry, University of
California,
San Francisco, and Department of Public Health, San Francisco,
California
Celia Jaes Falicov, PhD, Department of Family Medicine and
Public Health,
University of California, San Diego, La Jolla, California
Linda Stone Fish, PhD, Department of Marriage and Family
Therapy, Falk College,
Syracuse University, Syracuse, New York
John D. Folwarski, MSW, Raritan Bay Mental Health Center,
Perth Amboy, New Jersey

Nydia Garcia Preto, LCSW, Multicultural Family Institute,
Highland Park, New Jersey
Robert-Jay Green, PhD, Rockway Institute, California School
of Professional Psychology, San Francisco, California
MaryAnna Domokos-Cheng Ham, EdD, LCP, LMFT, College of
Education
and Human Development, University of Massachusetts Boston,
Boston, Massachusetts
Kenneth V. Hardy, PhD, Eikenberg Institute for Relationships,
New York,
New York; Department of Family Therapy, Drexel University,
Philadelphia, Pennsylvania
Ana M. Hernandez, PhD, LMFT, Rising Ground, Inc., Yonkers,
New York;
Seton Hall University, East Orange, New Jersey
Paulette Moore Hines, PhD, private practice, training, and
consultation;
Center for Healthy Schools, Families, and Communities,
Rutgers, The State
University of New Jersey, New Brunswick, New Jersey;
Department of Psychiatry,
Rutgers Robert Wood Johnson Medical School, Piscataway,
New Jersey
Evan Imber-Black, PhD, Mercy College, Dobbs Ferry, New
York; Center for Families
and Health, Ackerman Institute for the Family, New York, New
York
Christian Jordal, PhD, LMFT, CST, Department of Counseling

and Family Therapy,
Drexel University, Philadelphia, Pennsylvania
Hugo Kamya, PhD, School of Social Work, Simmons College,
Jodie Kliman, PhD, Clinical Psychology Department, William
James College,
Newton, Massachusetts; Boston Institute for Culturally
Affirming Practices,
Imelda Colgan McCarthy, MSW, PhD, private practice, Dublin,
Ireland
Monica McGoldrick, LCSW, PhD (h.c.), Multicultural Family
Institute,
Highland Park, New Jersey; Rutgers Robert Wood Johnson
Medical School,
Piscataway, New Jersey
Peggy McIntosh, PhD, Wellesley College Centers for Research
on Women,
Wellesley, Massachusetts
Marsha Pravder Mirkin, PhD, School of Social Sciences,
Humanities,
and Education, Lasell College, Newton, Massachusetts
Contributors ix
Matthew R. Mock, PhD, Counseling Psychology Program, John
F. Kennedy
University, San Jose, California; private practice, Berkeley,

California
Elijah C. Nealy, PhD, MDiv, LCSW, Department of Social
Work and Equitable
Community Practice, University of St. Joseph, West Hartford,
Connecticut
Elaine Pinderhughes, MSW, Boston College School of Social
Work,
Salome Raheim, PhD, ACSW, School of Social Welfare, State
University
of New York at Albany, Albany, New York
Rockey Robbins, PhD, Department of Educational Psychology,
University of Oklahoma, Norman, Oklahoma
Sharla Robbins, PhD, private practice, Norman, Oklahoma
Robert Shelby, LMFT, Men’s Center for Counseling and
Psychotherapy,
Berkeley, California
Tazuko Shibusawa, PhD, LCSW, Silver School of Social Work,
New York University,
New York, New York
Walter Howard Smith, Jr., PhD, Department of Human Services,
Allegheny County,
Pittsburgh, Pennsylvania
David Trimble, PhD, Center for Multicultural Training in
Psychology, Department
of Psychiatry, Boston University School of Medicine, Boston,
Massachusetts

Froma Walsh, MSW, PhD, Chicago Center for Family Health;
and School of Social Service Administratio n and Department of
Psychiatry,
Pritzker School of Medicine, University of Chicago, Chicago,
Illinois
Marlene F. Watson, PhD, Department of Counseling and Family
Therapy,
Drexel University, Philadelphia, Pennsylvania
Hinda Winawer, MSW, LCSW, private practice; Princeton
Family Institute,
Princeton, New Jersey; The Center for Family, Community, and
Social Justice,
Princeton, New Jersey; Faculty Emerita, Ackerman Institute for
the Family,
New York, New York
x
The goal of this book is to transform the focus of our work
beyond the inte-
rior of the family, offering an opportunity and invitation for our
readers to
see how our clients’ lives are constrained by larger societal
structures and to
develop new ways of working based on a more contextual
understanding of
ourselves, our society, our history, and our clients’ lives.
We have long struggled to envision systemic theory and practice
in ways
that transform our field to see our clients and ourselves more

clearly and thus
more complexly and to provide services that are more trauma-
informed and
healing. We have espoused approaches that take account of our
connection to
each other and to all that has gone before and all that will come
in the future.
Striving to build a sense of belonging for all who seek our help
seems the only
way to pursue our work. Our original companion volume,
Ethnicity and Fam-
ily Therapy, began with the lens of ethnicity in its exploration
of culture; Re-
Visioning Family Therapy, Third Edition: Addressing Diversity
in Clinical
Practice explores the intersections of multiple cultural
perspectives (ethnicity,
social class, race, gender, sexual orientation, and religion),
attempting to view
families and family therapy from more inclusive cultural
perspectives.
The aim of this book has been to provide in one relatively short,
accessible
volume a broad range of brief contributions by many of those
who have been
working to “re-vision” the family therapy field through a
cultural lens. The
chapters in this volume are reflective of the authors’ efforts to
make a truly
paradigmatic shift toward systemic thinking and practice, which
we believe
is sorely needed in our field and in our world. We have worked
assiduously to
include chapters that expand our definition of knowledge from
an exclusive

reliance on evidence-based, scientifically tested practice to one
that validates
also the “evidence” of subjective knowledge, creating space for
the inclusion
of personal stories of suffering, subjugation, and strife born out
of experiences
Preface
Preface xi
with oppression, which honor a different kind of knowledge.
There is great
wisdom in learning from the experiences of those relegated to
the margins of
our society. This book includes many personal stories, a few of
them known
over the years to some of us, but here available for a wider
audience, which
help us pay attention to those who have been hidden from
history. Creating a
space for personal stories and experiences enriches our work as
therapists and
is central to our view of re-visioning family therapy. We have
also included
chapters that expand the systemic perspective to larger systems
in terms of
both conceptualization and intervention. We hope that these
perspectives will
inspire future therapists to think as broadly as possible about
the contextual
aspects of our work and our lives.
This new edition is appearing at a time when our world seems

fraught
with polarities, discontinuities, and regression in the
development of social
justice. Our search continues to strive toward finding ways to
contain oppo-
sites, contradictions, and ambiguities—not oversimplifying the
issues and at
the same time not obfuscating the prejudices and oppression
that are increas-
ingly defining and destroying our world and us.
Each author was given frustratingly little space and asked to
present a
few key ideas of clinical and theoretical relevance in a reader -
friendly format
to contextualize the oppressions that are their work’s focus and
to suggest
re-visions for our clinical work. We applaud the authors for
their courage to
contend with these difficult issues and rejoice that they are our
collaborators,
going through life with us, knowing we are not yet clear about
how these
power dimensions operate on us, but striving with each other’s
help to see the
road more clearly.
Re-Visioning Family Therapy is intended to be exciting and
suggestive
rather than comprehensive in its articulation of where we need
to go in our
work. Most of the material is intentionally personal. We want to
make clear
how hidden aspects of our history have influenced our need to
change the future.
Our ideas have evolved from our frustrations with the

traditional boundaries of
clinical practice and our wish to expand our vision to see more
clearly where we
must go to create a better world for everyone. This book has
been an opportu-
nity to push our own and each other’s boundaries in hopes of
helping to trans-
form clinical practice toward more contextual and systemic
work with clients.
We trust readers will give us the benefit of the doubt, realizing
that many of
these ideas are still in progress, awaiting the leavening of future
conversations
to better see the issues. We know we have inadvertently left out
or marginalized
some in this book and will continue to push ourselves to learn
from our “sins of
omission” in the future. We hope, as we have expressed before,
that this edition
will soon be out of date again, as the ideas expressed here
become commonplace
and accepted practice. When this re-visioning occurs, we hope
we will be in
the fortunate position of trying once again to reformulate the
ideas to accom-
modate our evolving understanding and insights about change
and healing and
that others will follow us to expand this endeavor. We hope this
book will pro-
vide a small window into new possibilities.
xii Preface
PART I. THEORETICAL PERSPECTIVES

Like the other institutions of our society, family therapy has
been structured
in ways to support the dominant value system. And, again like
the other insti-
tutions of our society, our field has evolved many
conceptualizations and
practices that keep invisible certain hidden organizing
principles of our lives,
including social class, race, gender, sexual orientation, and
religion. This book
aims to unpack some of these issues in hopes that they become
easier to hold
in our minds and in our hearts so that we can better go about
our work.
The chapters on theoretical perspectives, and, indeed, the book
as a
whole, evolved out of the work many are doing to uncover those
dimensions
of “home” and “family” that have been kept hidden and to
transform our
definitions of home and family so that all families may feel safe
and included.
These chapters offer a framework for the possibilities of re-
visioning family
therapy toward a more contextual perspective.
In Chapter 1, we have tried to locate this re-visioning in the
history of
the family therapy field in general. Following the path
established by Peggy
McIntosh in the field of education, we try to contextualize the
history and
possible future of our field. McIntosh’s framework has provided
a practical

tool for assessing where our field is, as well as where we need
to get to in this
re-visioning process. We have expanded our overview on issues
of social class,
spirituality and religion, poverty, gender, and power, with new
chapters by
Walsh, Hardy, and Ashton and Jordal to expand therapists’
awareness of the
centrality of these issues.
Froma Walsh and I (KVH), in our respective chapters (Chapters
3 and 4),
provide provocative discussions of these most poignant,
volatile, and sensitive
issues that are integral to the process of re-visioning related to
social class.
In Chapter 3, Walsh thoughtfully lays out the dimensions of
class, one of the
essential and, until now, one of the most invisible elements of
re-visioning
family therapy from a cultural perspective. It goes
unacknowledged that many
groups in society are not represented in our institutions and do
not have the
same entitlements to participate even in our world of family
therapy. It goes
unsaid that where you come from does matter; that you cannot
shed your past,
become whatever you want, or move up in class just through
hard work and
desire. Walsh addresses directly the therapeutic implications of
class relations
and invites us as therapists to consider the ways in which our
work is shaped
by the nuances of class. In Chapter 4, I (KVH) discuss poverty
as sociocul-

tural trauma, illustrating how the limitation of resources
organizes the lives
of those in need, and the psychological fallout of the assaults of
poverty on
dignity, the learned voicelessness, shame, stigma, secrecy, and
silence that fol-
low. This chapter offers suggestions on ways of transforming
this fallout and
empowering clients through our acknowledgment, countering
the devaluation
that typically accompanies poverty and encouraging clients to
lean in toward
transformative possibilities of their survivorship and their
voices.
Deidre Ashton and Christian Jordal (Chapter 2) take on some of
the
aspects of gender and gender nonconformance as they play out
in our own
Preface xiii
lives and in the lives of our clients and the intersectionality of
race and sexual
orientation, offering helpful insights into the hidden dimensions
of power as
they affect our views of gender. They both remind and caution
us that we have
outgrown the traditional binary constructions of gender that
leave so many
clients, therapists, family members, and other loved ones
sentenced to a life
sentence of invisibility.

Religion and spirituality also play a powerfully influential role
in virtu-
ally all areas of family life. Yet having a critical discussion
about religion is not
only difficult to do, but it is often considered inappropriate,
sacrilegious, and
taboo. Although seldom acknowledged overtly, religion is a
major organizing
principle in our society. Chapter 5 by Walsh is a firm but gentle
reminder of
the role that religion and spirituality play in our everyday lives.
Race, like
religion, is also an important factor that must be placed at the
forefront of the
agenda for re-visioning family therapy. We believe religion is a
salient vari-
able because it influences many of the more controversial issues
that we, as
a society, seem to grapple with passionately on a daily basis.
Family-related
issues such as same-gender marriages, abortion, masturbation,
premarital
sex, mother employment, and child-rearing practices ignite
strong feelings,
even seemingly irreconcilable acrimony, because they are all
connected to reli-
gion. Former President Barack Obama was forced to claim and
reclaim his
Christian identity amid numerous allegations that he was really
both foreign
and a Muslim. In a society that exalts “freedom of religion,”
whether he was
Muslim, Christian, or Sikh should not have mattered, but it did,
because reli-
gion matters. By denying its significance, we give its hidden
power even more

significance.
PART II. SOCIOCULTURAL TRAUMA AND
HOMELESSNESS
The authors in this section have given voice to experiences that
have also gen-
erally been marginalized in the main cultural stories of our
society. In a sense,
this section is devoted to all of our respective journeys to find
home—that is,
a place of belonging and acceptance of our multiple identities.
In so doing, we
share our triumphs and our tribulations. The process of finding
home involves
each of us, as a fundamental part of the existential search,
identifying and
claiming disavowed parts of ourselves that we have to make
peace with as
part of the journey.
In a world that is often divided into the haves and have nots, the
valued
and devalued, finding a sense of home can be a relentless and
often futile
endeavor. The chapters in this section highlight how home,
homelessness,
and trauma are intricately interwoven. As we pulled together
our ideas for
this book, issues of immigration dominated the national news
and raised an
array of thorny clinical issues regarding family therapy with
populations who
are increasingly non–U.S. born, non–English speaking, non-
white,1 and from
countries often considered “Third World” or whose citizenry is

believed to
have little to offer this country. We have also been ever more
conscious of the
xiv Preface
sense of anomie of those pushed to the margins of our society
because of race,
gender, sexual orientation, religion, poverty, disability, and
other disadvan-
tages. I (MM) have told aspects of my own story (Chapter 6),
trying to sepa-
rate out some of the threads of privilege from those of
oppression in my jour-
ney trying to dissect the complexities of racial and class
privilege in relation
to a history of gender and ethnic oppression. This section
includes a rich and
thoughtful chapter (Chapter 7) by Celia Jaes Falicov on issues
of culture and
cultural identity in relation to migration and the complexities of
transnational
families, including issues of loss, adaptation, and network
reconstruction. The
ideas discussed by Falicov will be enormously helpful to all
who work with
immigrant families, both documented and nondocumented.
Even though Obama made concerted efforts to avoid mentioning
race,
it was still an integral part of our nation’s discourse and reality,
sometimes
overtly but mostly by innuendo and the use of code words. Race
is a prime

definer of all interactions in our society, with sharp differences
that often exist
between the racially based perceptions of whites and African
Americans. In
Chapter 9, I (KVH) remind us that race and other manifestations
of oppres-
sion are always, at every moment, influencing our perceptions
and ultimately
our relationships, both in and outside of the family.
In Chapter 8, Paulette Moore Hines discusses hope as a critical
tool of
assessment and intervention. She examines issues of
transcendence, spiritual-
ity, hope, and resilience, which have long been eschewed in our
theory and
practice. For thousands of years such ideas have been the
primary resources
for people in emotional distress. It is high time we reintegrate
this dimension
into our conceptual formulations. The belief in something
beyond our indi-
viduality and our personal self-interest is our only hope to have
a future. We
trust that in the future this area will begin to receive the
attention it deserves,
as more therapy incorporates transcendent ideas into our
clinical assessment
of families under stress and in our approaches to healing.
PART III. RACIAL IDENTITY
Typically, discussions of culture and racism focus on the
marginalized group as
the “other.” Whiteness, and the multitudinous ways in which it
shapes interac-

tions, both inside and outside of families, almost always
remains invisible. Re-
visioning our field requires that we explore most carefully and
explicitly those
who see themselves as the norm and those who have established
the norms.
The chapters included in this section are attempts to deconstruct
race both for
those who have been historically subjugated and for the
dominant group.
Rockey and Sharla Robbins’s discussion of Native American
families and
culture is an eye-opening perspective on trauma, healing, and
the meaning of
belonging and home. Their chapter (Chapter 10) reminds us how
easy it is to “for-
get” and define people by their DSM numbers rather than by
whom they belong
to. Instead, we should all be dedicated to remembering, and “re-
membering,”
Preface xv
shattered communities and bearing witness. Their illustrations
offer invaluable
suggestions on possibilities for working with Native Ameri can
families.
Peggy McIntosh’s classic challenge to our “invisible knapsack
of white
privilege” is part of her crucial series of articles that have
helped us to begin
re-visioning race as well as gender in the field of education. In

Chapter 15,
McIntosh takes the lofty, virtually abstract concept of white
privilege and
makes its impact visible through the most mundane everyday
experiences.
Ken Dolan-Del Vecchio (Chapter 16) offers a critique of white
male domi-
nance and considers what must change so that white men can be
collaborative
partners with everyone else in families and communities in the
21st century.
In Chapter 17, Jodie Kliman, Hinda Winawer, and David
Trimble examine
“the inevitable whiteness of being (white)” in family therapy
training. These
authors make the pervasive invisibility of whiteness visible.
Nydia Garcia Preto, in Chapter 11, explores her own and her
family’s
complex and multiple identities as they evolved over time and
through the life
cycle. She illustrates, with her broad and inclusive perspective,
a profound
openness to the complexity of building bridges to hold the sense
of belonging
to what came before and building connections to what lies ahead
of us, which
highlights a significant facet in the transformation of family
therapy.
Marlene F. Watson (Chapter 14), Ana M. Hernandez (Chapter
13), and
MaryAnna Domokos- Cheng Ham (Chapter 12), each in her
unique way,
discuss the powerful connections that exist between race and
identity devel-

opment. Watson provides a gripping and heartfelt account of
what it means
to grow up as an African American female in an oppressive
society where
societal messages regarding race, class, and gender often
collide. Ham offers
a critical and insightful examination of the life experiences of a
multiracial
person searching for a sense of belonging. In a society that is
obsessed with
binary notions of race, this chapter brings much-needed
attention to the chal-
lenges of what it means to be a person of mixed-race heritage.
Kiran Shahreen
Kaur Arora (Chapter 18) also asserts the importance of thinking
about race
beyond the Black–white binary and how the experiences of
those who identify
as Brown can be deemed not to belong.
The collective work and wisdom of the authors in this section
remind us
how the toxic messages that emanate from racism can leave
indelible scars on
the psyches and souls of people of color through the
unconscious internaliza-
tion of debilitating negative racial messages.
PART IV. CULTURAL LEGACIES AND STORIES:
THERAPISTS’ EXPERIENCES
Personal narratives are a major part of our attempt to shift our
paradigm to
re-vision families and family therapy. From Murray Bowen’s
first account of
his own family at a 1967 research meeting, which stunned the

field by break-
ing the rules of academic and professional discourse, we have
gradually been
stretching and transforming the boundaries of our dialogues to
create more
xvi Preface
inclusive ways of thinking about our work. The individualistic
models of “sci-
entific” discourse have proven inadequate to the realm of
healing and therapy.
These linear models are of limited relevance in a world where
our lives are
so profoundly interconnected. It is often through personal
narratives that we
learn most about those aspects of our experience that do not fit
into our theo-
retical and clinical models. These stories may be key to
liberating us toward
new visions of our work.
Elaine Pinderhughes’s classic chapter (Chapter 19) describing
her research
on her own family explores the silenced history of white
exploitation and
internalized racism in her Black and white ancestors. Her story
is a remark-
able unpacking of the multigenerational traumatic impact of
racism on a fam-
ily. Fernando Colón-López’s narrative in Chapter 21 about his
search for his
past and his identity in his lost mother’s story is a remarkable
example of the

hidden oppressions of colonized groups and of the power of
uncovering the
submerged cultural dimensions of one’s history. It is also a
striking example of
the interface of racial and cultural oppression and mental
illness.
John D. Folwarski’s personal recollection (Chapter 22) of a
childhood in
a Polish orphanage is a profound reflection of the effects of
Polish subordina-
tion in European history, as well as a story of the impact of
immigrant cultural
disruption. Folwarski’s narrative is also an indirect testimonial
to other salient
themes that are replete in many of the stories told in this
volume: stories of
belonging and disconnection, stories of home and homelessness,
and stories
of suffering and survival.
The other authors in this section—Linda Stone Fish, Donna
Dallal-
Ferne, Saliha Bava, Robert Shelby, and Elijah C. Nealy—all
share stories of
cultural legacies and of their recurring efforts to integrate the
frayed threads
of their histories into their contemporary lives. Shelby’s
pathway to finding
home (Chapter 20) required him to come to terms with the white
privilege,
pathological shame and guilt, and the perversion of morality
often associated
with whiteness. Acknowledging and claiming this ugly part of
his past was
in many ways a necessary precursor to the modern-day clarity

that he brings
to his antiracism work. His story, along with other authors’
accounts of what
it meant to grow up in a racist family, should provide
inspiration to other
white and majority-group therapists regarding how the process
of embracing
disavowed parts of our cultural legacies can liberate and
motivate us to be
advocates for social justice.
Linda Stone Fish, a gifted teacher and therapist, provides an in-
depth
look at how issues associated with her Jewish identity and that
of a Palestinian
graduate student, Donna Dallal-Ferne, managed to creep into the
sacred space
of the classroom and graduate education. Their chapter (Chapter
24) provides
a poignant discussion of the importance of being able to see the
world through
the eyes of those we consider “other.”
Elijah Nealy, in Chapter 25, examines the complexity of
identity transi-
tions and transformations across the life cycle with a
provocatively insightful
and transformative discussion.
Preface xvii
All of the chapters in Part IV center the cultural experiences
and legacies
of therapists who challenge the dominant narrative that suggests

that their
stories are insignificant. Through the telling of their personal
stories and hon-
oring the ways in which they are embedded in cultural legacies,
the authors
help to shift the core values of our field away from
“objectivity” and “profes-
sional distance” to values that acknowledge the role and
significance of the
self-of-the-therapist.
PART V. IMPLICATIONS FOR CLINICAL PRACTICE
The chapters in this section focus on specific clinical issues for
particular
cultural groups. They are meant to be suggestive rather than
comprehensive,
indicating the subtlety and complexity of our cases when
considered through
a cultural filter. Each of the chapters in this section offers a re -
visioning per-
spective by moving the subject under consideration “from
margin to center,”
in bell hooks’s phrase. They use the group’s own frame of
reference for assess-
ment and intervention, challenging our field’s dominant notions
of clinical
practice. We believe the process of locating oneself and using
one’s personal
story as a frame of reference for our clinical work is essential to
the re-vision-
ing process.
In Chapter 26, Elijah C. Nealy examines the much-neglected
area of les-
bian and gay family life and the need for therapists to

understand the par-
ticular challenges facing those who live within a novel or
marginalized family
configuration. Nealy invites the reader to see how critical it is
for us as a field
and for society to rethink our traditional notions of family with
questions
of who is included in such definitions and who remains
invisible and mar-
ginalized. Robert-Jay Green, in Chapter 27 on gay and lesbian
couples, also
provides a great deal of practical information that will be
helpful for working
more effectively with lesbian and gay couples.
Chapter 28, by Hugo Kamya and Marsha Pravder Mirkin,
addresses the
profound disruptions of migration when families belong to more
than one cul-
ture, as most families in the United States do. They suggest
some of the larger
implications of the complexity of biculturality, difference, and
acculturation.
They can help all of us rethink the very nature of our identity.
Instead of mea-
suring immigrants as “others,” we can use Kamya and Mirkin’s
discussion to
re-vision our very notions of assessment and intervention.
We must also develop transformative intervention models based
on a re-
visioning of families from a contextual perspective. Imelda
Colgan McCarthy
and Nollaig Byrne have been developing their Fifth Province
model for many
years. In Chapter 30, they illustrate their model and the

httpjfn.sagepub.comJournal of Family Nursing http

httpjfn.sagepub.comJournal of Family Nursing http

Recommended

Recommended

More Related Content

Similar to httpjfn.sagepub.comJournal of Family Nursing http

Similar to httpjfn.sagepub.comJournal of Family Nursing http (20)

More from MargaritoWhitt221

More from MargaritoWhitt221 (20)

Recently uploaded

Recently uploaded (20)

httpjfn.sagepub.comJournal of Family Nursing http