FAMILY THERAPY

THE HARVARD MEDICAL SCHOOL MENTAL HEALTH LETTER, APRIL (PART I), 
MAY 1988 (PART II) 

PART I

Mental health professionals have always understood that the 
problems they deal with arise largely in families and take their 
form from family relationships. Marriage and family problems 
account for about half of all visits to psychotherapists. Families 
also play the decisive role in most non-biological explanations of 
emotional disturbances and mental illness. Psychodynamic 
psychotherapists are concerned with childhood conflicts between 
instinctual drives and family prohibitions. Behaviorists and 
cognitive psychotherapists emphasize social learning, which also 
occurs mainly in the family. Yet for many years mental health 
professionals tended to ignore their patients' families. They were 
often seen mainly as an obstacle to treatment, although they were 
often called on to care for the patient and of course to pay the 
bills. More recently, the dominance of biological explanations for 
some severe forms of mental illness has also reduced emphasis on 
the family's influence. 

A major variation in this pattern is represented by family 
therapy, which is now about 40 years old. It regards individual 
symptoms as family problems and treats the family rather than the 
individual. It is not distinguished by any definite set of ideas 
about the causes and treatment of emotional disturbances and 
mental illness. Some of its concepts and techniques are new, some 
are borrowed, and some are unfamiliar outside the field. There are 
many varieties of family therapy which may be combined in 
different ways with one another and with other types of therapy. 

Probably the most important practical innovation of family therapy 
is bringing the whole family together for therapeutic sessions, an 
arrangement known since the 1950s as conjoint family therapy. 
Sessions are often held once a week and may last as long as two 
hours. They may be videotaped or observed by consultants and 
supervisors in the room or behind a one-way screen. Sometimes two 
therapists participate -- usually a woman and a man. Many family 
therapists conduct individual therapy at the same time for one or 
more members of the family; this is known as concurrent therapy. 
Marital or couples therapy is usually considered a branch of 
family therapy. Almost all family therapists also see couples, and 
many couples therapists from time to time also work with the 
family as a whole. For families with a well-defined, long-term, 
common problem like schizophrenia or alcoholism, group meetings of 
several families may be suggested. These are called multiple 
family groups. 

SYSTEMS THEORY

If any single idea could be said to guide family therapy, it is 
probably the notion of a family system, derived from general 
systems theory. Human life can be organized hierarchically into 
systems of varying size and complexity: the individual, the 
family, the society, the culture. The family is seen as a self-
maintaining system which, like the human body, has feedback 
mechanisms that preserve its identity and integrity by restoring 
homeostasis -- the internal status quo -- after a disturbance. 
Therefore, a change in one part of the family system is often 
compensated elsewhere. Families have mechanisms for adapting to 
changed circumstances, and, like individuals, they have 
biologically and socially determined stages of development. A 
family that functions poorly cannot adjust to change because its 
homeostatic mechanisms are either inflexible or ineffectual. The 
family's daily habits and internal communication -- its 
transactional patterns, as they are called -- harm its individual 
members. The pathology is in the system as a whole. Individual 
disorders not only serve as a source of protection and power for 
the disturbed person but may also preserve the family system and 
act as a distorted means of communication within that system. They 
fulfill the same function that neurotic symptoms are said to 
fulfill for individuals in psychodynamic theory. 

In family therapy, as in general systems theory, the main concern 
is with processes rather than sources and forces. Systems theory 
defines influences as mutual and causality as circular, so family 
therapists tend to avoid blaming and attributing causes -- 
although there are exceptions to this as to every other 
generalization about the field. The symptoms of a defective family 
system are said to take different forms in different parts of the 
system. A husband and wife, for example, may seem to have very 
different personalities because of their functions within the 
system rather than anything intrinsic to them as individuals. For 
this reason, family therapists often make limited use of ordinary 
psychiatric diagnoses, which describe individual pathology, and 
diagnose family situations instead. 

Family therapy may of course be a good choice when the family sees 
its problems mainly as family problems, but not only then. For 
obvious reasons, it is also recommended when the problems involve 
children. Some specific situations in which it may be useful are 
physical or sexual abuse, chronic misbehavior and delinquency, 
eating disorders, and phobias. Family therapy may also help when a 
recent crisis has disturbed the family or when the family's 
cooperation is needed to help an individual patient. It may be 
appropriate when the symptoms of one family member improve in 
individual therapy, and another develops different symptoms. (In 
fact, family therapy is thought to have originated in the 1940s 
when some child psychiatrists noticed that families had to 
readjust after children improved in treatment.) Family therapy can 
also be useful for alcoholics if they attend Alcoholics Anonymous 
meetings at the same time. Controlled studies suggest that family 
therapy may be better than individual therapy for eating 
disorders, for children's behavior problems, and for preventing 
relapse in schizophrenic patients living at home. 

One important concept in family therapy is the 'identified 
patient,' the person whose symptoms bring the family to a 
psychotherapist. Just as psychoanalytic theorists say that 
neurotic symptoms maintain individual stability while both 
expressing and disguising conflicts within the individual, family 
therapists say that symptoms maintain the stability of the family 
system while expressing and disguising family conflicts. A 
husband's or wife's psychosomatic symptoms 'solve' the problem of 
a couple's social anxiety; a rebellious teenager fights his 
mother's battles with his father; a wife is sick because it is the 
only way to get her husband's attention; the sleep problems of a 
12-year-old are sustained by his mother's insomnia, because she 
can best cope with her own sleeplessness by comforting him. 

FAMILY SYMPTOMS

Family therapists report distinct patterns of family symptoms. In 
some cases each partner in a marriage is demanding too much of the 
same thing from the other: service, protection, care, etc. In 
other cases they compound each other's problems by complementing 
each other. One partner takes charge and the other becomes 
incompetent: an overbearing and emotionally distant husband has a 
'hysterical' wife whose erratic behavior makes him still more 
overbearing; a strong, angry wife has a passive, alcoholic husband 
who is a suitable object of her anger, and that anger makes him 
even more passive; the husband of a depressed and hypochondriacal 
woman needs to be a healer and savior. Often family therapy aims 
to reveal what is hidden: the passive partner's suppressed anger, 
the savior's feelings of helplessness. 

A related idea is that of unconscious or unacknowledged roles. 
Roles in the drama of family life, assumed perhaps out of loyalty 
or a need for belonging, may become destructive yet hard to 
abandon because they help to maintain the family. For example, a 
child who becomes 'parentified' because of a mother's or father's 
incapacity is likely to play this adult role poorly, using 
authority too harshly or making it a vehicle of rivalry with 
younger brothers and sisters. Another child may be assigned the 
role of bad boy so that one of the parents can play 
disciplinarian. Such roles must be openly recognized and the 
assignments altered if the family is to become more healthy. A 
similar idea that some therapists find useful is family mythology: 
"John is the stupid one," "Father can't work." These myths, rarely 
discussed openly, are especially likely to create conflict when 
they are incompatible or not accepted by all members of the 
family. The rules and rituals of families are also important; for 
example, one researcher found that when drunkenness was part of a 
family ritual like the evening meal, alcoholism was more likely to 
become a 'tradition' passed on to the next generation. Some family 
therapists refer to types of family culture; there are 
authoritarian, democratic, and individualistic families, each with 
their own typical ways of functioning well or badly. 

Family problems may also be seen in terms of an informal contract 
with secret and unconscious as well as openly acknowledged 
clauses. In bad marriages, each partner may behave as though 
certain provisions are accepted when in fact they are not; for 
example, a husband believes that his wife has agreed that he can 
stay at work as long as he thinks he must; she thinks that he has 
implicitly agreed to be home for supper, and they have never 
discussed the matter. Some broader implicit contract provisions 
are: I need sex, I need financial security, I need to be in 
charge, I need a certain number of friends. 

FAULTY COMMUNICATION

Family therapists also study faulty communication, verbal and 
nonverbal. One distinctive pattern, for example, is invalidation 
of another person's feelings: "I am angry." "No, you're not -- you 
are not the kind of person who gets angry about something like 
that." A well-known type of defective communication is the double 
bind. (This idea was developed to explain the origins of 
schizophrenia, where it did not prove to be helpful; now it is 
used mainly in other contexts.) A double bind exists when one 
person sends two mutually exclusive messages to another (usually 
one message in words and the other in gesture, tone and 
expression), and the second person must not acknowledge the 
contradiction or respond to the real message if he or she wants to 
maintain a needed relationship with the first person. For example, 
a mother asks her son to come to her, stiffens when he approaches, 
and then, when he withdraws in turn, says, "Why are you so cold?" 
The son is stymied whether he shows his love for his mother or 
avoids showing it; and he cannot point out what is going on, 
because that would only further alienate her. In another example, 
a father says to his child "You are tired; go to bed." By reading 
tone, expression, and gesture, the child senses that the 
underlying message is "Get out of my sight, I am sick of you." To 
acknowledge this would be terrifying, so the child tells herself 
that she is tired even when she is not. According to the theory of 
double binds, people exposed constantly to this kind of 
communication eventually find it hard to say what they mean, 
understand what others mean, and distinguish real from simulated 
feelings. 

SUBSYSTEMS AND BOUNDARIES

Many family therapists view the family as incorporating 
subsystems, or functional groups of its members. The spouse 
system, consisting of the husband and wife, is a refuge for the 
couple and a source of authority in the family. The sibling 
subsystem helps children learn to negotiate, compete, and 
cooperate with other children. Subsystems that cross generations 
may incorporate one parent and the children, one child and the 
parents, or a parent and a child. According to family therapists, 
subsystems should have boundaries that are neither too rigid nor 
too vague, and therefore preserve the integrity of both 
individuals and the family. An example of conflict over boundaries 
is a struggle between teenagers and their parents over the right 
to keep the doors to their rooms closed and choose their own 
decoration for the walls; the adolescents see the closed door as a 
boundary that protects their independence. In some families the 
boundaries between persons and generations are weak and permeable, 
and the roles of parents and children are indistinct, but the 
boundary between the family and the outside world is too rigid. 
Other families have weak external boundaries and are therefore in 
danger of becoming too heavily dependent on a therapist. 

In a family that functions well, the subsystems have clear 
boundaries, especially those between generations. The alliance 
between the parents is strong; they support each other in front of 
the children and do not allow the children to arbitrate their 
disputes. Breaching this boundary can be dangerous. If a parent 
forms a coalition with one child against the other parent, the 
parental subsystem becomes diffuse. The mother may be very close 
to a parentified child, and together they may scapegoat a second 
child as the object of their complaints and the victim of their 
discipline; the sibling subsystem has lost its boundaries. In 
other cases boundaries remain too rigid; for example, a father 
loses his job and the mother's income supports the family while 
the father is asked to care for the children at home, but the 
mother does not grant him the necessary authority. The mother-
child subsystem persists despite changes required by economic 
circumstances. 

Some families are highly interdependent; everyone in them is 
overresponsive to everyone else. They develop habits of intimate 
quarrelling and complaining that become difficult to change. In 
other families, the family members have little mutual contact or 
concern; their boundaries are rigid. Family systems that are too 
closely knit, or enmeshed, respond too intensely to change; every 
disturbance may turn into a crisis. Systems in which the family 
members are distant, or disengaged, do not respond strongly 
enough; serious problems are ignored and issues are avoided. 

"Triangulation" and "detouring" are ideas related to the notion of 
a family subsystem. A triangle is a subsystem of three people in 
which two exclude a third; for example, a mother and daughter 
forming a coalition against the father. Each parent may compete to 
enlist a child in a struggle against the other. The child then 
becomes a referee, an ally, a surrogate wife or husband. Torn 
between the parents, the child may develop behavior problems or 
psychosomatic symptoms. Detouring, or scapegoating, means using 
criticism of an outsider to dissipate conflicts within a given 
system or subsystem. A daughter who refuses to eat, or a 
rebellious son, for example, may be the scapegoat who keeps the 
mother and father too busy to argue with each other. The 
scapegoat, too, often gains something; the boy may be provoking 
fights in order to avoid schoolwork and defend himself against 
feelings of inadequacy created by a learning disorder. An idea 
that serves as a bridge between psychoanalytic theory and family 
systems theory is projective identification. This is a process in 
which a person denies responsibility for his own impulses and 
attributes them to someone else, provoking behavior and feelings 
that convince him he is right. X resents Y but does not 
acknowledge the resentment and instead comes to believe that Y 
dislikes him. He treats Y accordingly; Y responds angrily and 
confirms the hostility. Projective identification is a source of 
destructive role-playing. It is common in marriages where one 
partner is overcompetent and the other incompetent. One partner 
may be implicitly demanding that the other be weak so that he or 
she can be strong -- and hate his or her own weakness as 
manifested in the other partner. 

Often projective identification is mutual and two family members 
are in unconscious collusion to maintain it; for example, a wife 
agrees to act out her husband's impulses and he agrees to be her 
stern conscience. In such marriages the partners both need and 
dislike each other. According to psychoanalytic theory, a 
relationship with a parent is often reenacted through projective 
identification, and husbands and wives may be chosen for that 
purpose; for example, a passive wife who has unconsciously 
incorporated the anger of her assertive mother projects that 
unacknowledged feeling onto her husband, who then bullies her in a 
way that she necessarily hates. 

PART II

In Part I we discussed the concepts and theories used by family 
therapists. This part is devoted mainly to therapeutic techniques. 

Family therapists think of families as having stages of 
development, like individuals. A couple forms and the partners 
separate themselves from their original families. The children 
arrive, introducing new subsystems and the need to exercise a new 
kind of authority. School-age children learn how other families 
are run and may demand changes in their own. Adolescents develop 
competing social ties and begin in turn to separate themselves 
from the family. Eventually the couple is alone again. 

Each stage has its normal problems and crises and each also 
produces typical pathological disturbances. While the couple is 
becoming established, one partner may form an alliance with his or 
her family of origin against the other partner, or, on the 
contrary, one set of in-laws may be cut off entirely. As the 
children grow up, parents may be unwilling to renegotiate family 
rules or permit them a separate identity; for example, a child 
develops a school phobia because a parent feels abandoned when the 
child leaves the house. Teenagers may be unable to achieve 
independence because their emotional problems serve to keep a 
troubled family together. Family therapists may interpret such 
situations psychoanalytically, assign tasks like behavior 
therapists, challenge beliefs like cognitive therapists, offer 
practical advice, support and reassurance, teach social skills, 
set authoritative limits, or direct the dramatic reenactment of 
typical family situations. Some family therapists remain almost as 
neutral as psychoanalysts, and others become intensely involved, 
trying to sympathize with each member of the family in turn. One 
technique used by family therapists is 'joining' the family to 
probe for possibilities of change. That might mean using the 
family's own language, adopting its tempo of speech, and showing 
sympathy by such comments as "I had an aunt like that," or "I also 
have two teenagers." It may be necessary to join each family 
subsystem in turn, or temporarily become the ally of one family 
member against another. The therapist may join a powerless family 
member to challenge the hierarchy, or join dominant family members 
to provoke a challenge. Thus a therapist might join parents in 
opposition to a disobedient child, or the child in opposition to 
the parents. The purpose is the same in both cases: to strengthen 
the parents' alliance so they will agree to insist that the child 
change. Later the therapist can turn to conflicts in the marriage 
that are related to the child's problem. 

Some issues family therapists consider while observing the family 
are: how do the family members group themselves in the office? Who 
speaks for whom? Who 'remembers' for the family? Who exercises 
authority over the children? Some questions they may ask are: 
Which of the brothers and sisters pleases your mother most? What 
about this family worries you most? What are your hopes for the 
family? In daily life, who is with whom at what times? What does 
each of you like most and least about the family? What methods of 
discipline are used? 

REFRAMING IN THERAPY

Family therapists are often less interested in the problem as it 
is presented than in knowing which family members think that a 
problem exists and what each of them thinks the problem is. 
Sometimes the most important person in therapy is not the 
identified patient but the family member who seems most concerned 
about the identified patient's symptoms. Reframing is a method 
used to draw attention away from the identified patient and in 
general to alter the focus. Parents may say "Our son has 
tantrums," or "My daughter is disobedient." Through reframing this 
is translated into something like "He becomes enraged when his 
father tells him to clean up his room," or "She disobeys her 
mother when her father is not present." Now the therapist may 
discover, for example, that the mother of the disobedient son 
thinks her husband should not ask the boy to do what he himself 
would not do. More generally, a verbal attack can be reframed as a 
way of reaching out for contact; apparent helpfulness may have to 
be reframed as restrictiveness; the problem of a child's social 
withdrawal may be redefined as the problem of her mother's 
depression. A father's apparent inability to talk to his children 
may be reframed as his way of being loyal to his wife, who needs 
to be closer to the children than anyone else in order to allay 
her own anxieties. 

ENACTMENT

To get a better idea of how the family behaves outside the office, 
the therapist may ask them to enact typical family situations 
instead of talking about them. They are told to talk to one 
another instead of rehashing old arguments and asking the 
therapist to arbitrate. The therapist might even leave the room 
for a while. Enactment exposes situations that might otherwise 
remain obscure. For example, a wife complains that her husband 
talks too little, and in fact he is silent during therapy 
sessions. But when they are instructed to speak to each other, it 
becomes obvious that she constantly interrupts him. The therapist 
can then observe the effect of preventing interruptions and get 
further hints about how to work with the family. 

Family therapists may also rearrange seating, ask family members 
to touch one another, or place a child where he cannot catch a 
parent's eye. For example, a family comes to the therapist's 
office with the problem of a ten-year-old boy who is truant and 
stealing. When they sit down, the boy's mother signals to his 
father, and the father begins to talk about his son. As he talks, 
the mother watches her son and her five-year-old daughter. After a 
while she interrupts her husband and signals her 14-year-old 
daughter to begin talking. The therapist, more interested in this 
pattern than in what is being said, asks the mother to sit at a 
distance from the children in order to see whether the father can 
handle them by himself. 

Although most family therapists concentrate on the present, some 
look for ways in which the past can illuminate it. They sometimes 
construct a three-generation 'genogram' which lists all the 
relatives of each parent along with their dates of birth and 
death, marriages, jobs, health, and other pertinent information. 
The therapist refers to the genogram for facts and patterns that 
may illuminate the present; for example, the husband is an only 
child, or all the women on both sides of the family have married 
men who were thought to be not religious enough, or all the 
daughters fight with their mothers. Some family therapists send 
their patients to visit grandparents or invite grandparents for 
therapeutic sessions. These sessions can be remarkably revealing. 
Adults may get to know their parents as real people and not 
overpowering fantasy figures. The sources of projective 
identification may be uncovered. People who are automatically 
imitating their parents or still too closely attached to them may 
learn how to break away. 

Some family therapists are especially concerned with what they 
call invisible loyalties and debts incurred between generations. 
The therapy involves adjusting ethical claims -- those of each 
family member and those of the family as an institution. A 
person's understanding of a present family member's claims often 
depends on childhood experience, and that may lead to conflict. 
For example, a woman whose parents neglected her wants a husband 
who will make up for her lost childhood, and he does not 
understand this; a man who has been left by his first wife with a 
small son considers it his second wife's duty to care for the 
child, but she once had to care for her younger brothers and 
sisters in a home with an absent father and now believes that he 
as a man is in debt to her for taking on the child. Family 
loyalties are so powerful as forces to be acted on or acted 
against that even in individual therapy interviews with a 
patient's or client's family of origin can be effective in 
producing therapeutic change. 

PRESCRIBED TASKS

Either during therapeutic sessions or as homework, family 
therapists may also prescribe tasks that reveal significant 
patterns or bring about change. A wife is told to exaggerate her 
criticism of her husband until he challenges her. A husband is 
told to buy his own clothes and consider only his own taste. A 
woman is asked to let her husband put their daughter to bed while 
she relaxes. Some of these tasks are simple behavior therapy. When 
a husband and wife have been drifting apart, the therapist may 
arrange for the husband to come home for dinner five nights a 
week. If a 12-year-old tearfully refuses to go to bed, constantly 
enters his parents' room at night and will not get out of bed for 
school, the therapist may tell the parents to insist that their 
son use an alarm clock and say they will punish him if he is late 
for school. 

BEHAVIOR THERAPY

Behavior therapy works only if family members will do what the 
behavior therapist prescribes. But invisible loyalties, 
unacknowledged contracts, projective identifications and distorted 
communication may make it impossible for family members to think 
straightforwardly about what they want and need. In that case 
family therapists sometimes suggest a different kind of homework, 
meant to unsettle and test the family. The therapist usually 
expects failure, and is interested mainly in whether the family 
ignores the suggested task, misunderstands it, or tries to comply 
but gives up. 

When resistance to change is especially strong, the family 
therapist may use a method called the paradoxical task, which is 
meant to provoke a crisis. The theory is complex, but the general 
point is that a paradoxical instruction, if followed, would 
achieve the opposite of what the therapist and family want. The 
family is expected to defy the order or follow it only until its 
absurdity becomes obvious. For example, a mother lives with her 
19-year-old son who is socially isolated and suicidal; the family 
therapist tells the mother to go everywhere with the son. 
Eventually they become exasperated with each other and fight; that 
allows the son to achieve more autonomy and eventually to move 
out. 

Paradoxical tasks may be prescribed when parents are detouring 
their conflicts through a child's symptoms and the child is 
protecting the parents. For example, an eight-year-old boy is 
failing in school. The family therapist sees the problem as the 
mother's disappointment with her husband, who is failing in 
business while she earns the family income. She avoids arguing 
with her husband but nags her son when she becomes annoyed at his 
father's apathy. The son in a sense cooperates by providing causes 
for complaint. The therapist tells the mother to go on criticizing 
her son, because she has to criticize someone and her husband is 
too vulnerable because of his depression. The therapist also tells 
the son to keep monopolizing his mother's attention. The father 
agrees, but the mother indignantly rejects the suggestion that she 
should take out her anger on a boy. She and her husband come into 
open conflict that offers an opportunity for change. 

TREATMENT OF SCHIZOPHRENIA

Many experts once thought that the family environment caused 
schizophrenia; now almost all believe that its roots are 
biological and partly hereditary. Nevertheless, recent studies 
have shown that family therapy or family management improves the 
symptoms and reduces the burden substantially. Families can be 
educated about the illness without being blamed for it. They are 
taught to communicate better with schizophrenic patients, to 
reduce their expectations and temper their criticisms of the 
patient in recognition of the illness. They can be encouraged to 
watch for signs of relapse and hold meetings to discuss serious 
problems. Mutual support and advice may be provided through 
multiple family groups. Parents can be taught how to enforce rules 
of behavior for schizophrenic adolescents. The popularity of 
family therapy has grown greatly in the last twenty years, but 
those same years have seen the rise of biological psychiatry, new 
developments in individual psychology, and increased social 
criticism of all forms of psychotherapy. Meanwhile, larger 
historical trends have been changing families in unpredictable 
ways. The relative influence of all these forces will determine 
how important family therapy becomes and what forms it takes in 
the future. 

For Further Reading
Henry Grunebaum. Family Psychiatry. In Lester Grinspoon, ed. 
Psychiatry Update, Volume II. Washington, D.C., American 
Psychiatric Press, 1983. Salvador Minuchin and H. Charles Fishman. 
Family Therapy Techniques. Cambridge, Massachusetts, Harvard 
University Press, 1981. 

President and Fellows of Harvard College, 1988 Reprinted with permission.

Internet Mental Health (www.mentalhealth.com) copyright 1995-
1996 by Phillip W. Long, M.D.

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