Family Therapy Concepts and Methods PDF

THE STAGES OF THE FAMILY LIFE CYCLE Family Life-Cycle Stage Emotional Process of Second-Order Changes in Family Status Required Transition: Key Principles to Proceed Developmentally Leaving home: single Accepting emotional and a. Differentiation of...

THE STAGES OF THE FAMILY LIFE CYCLE Family Life-Cycle Stage Emotional Process of Second-Order Changes in Family Status Required Transition: Key Principles to Proceed Developmentally Leaving home: single Accepting emotional and a. Differentiation of self in relation to family of origin young adults financial responsibility b. Development of intimate peer relationships for self c. Establishment of self in respect to work and financial independence The joining of families Commitment to new a. Formation of marital system through marriage: the system b. Realignment of relationships with extended families new couple and friends to include spouse Families with young Accepting new members a. Adjusting marital system to make space for children children into the system b. Joining in childrearing, financial and household tasks c. Realignment of relationships with extended family to include parenting and grandparenting roles Families with adolescents Increasing flexibility of a. Shifting of parent–child relationships to permit ado- family boundaries to lescent to move into and out of system permit children’s b. Refocus on midlife marital and career issues independence and c. Beginning shift toward caring for older generation grandparents’ frailties Launching children and Accepting a multitude of a. Renegotiation of marital system as a dyad moving on exits from and entries b. Development of adult-to-adult relationships into the family system c. Realignment of relationships to include in-laws and grandchildren d. Dealing with disabilities and death of parents (grand- parents) Families in later life Accepting the shifting a. Maintaining own and/or couple functioning and generational roles interests in face of physiological decline: exploration of new familial and social role options b. Support for more central role of middle generation c. Making room in the system for the wisdom and expe- rience of the elderly, supporting the older generation without overfunctioning for them d. Dealing with loss of spouse, siblings, and other peers and preparation for death xiii This page intentionally left blank MAJOR EVENTS IN THE HISTORY OF FAMILY THERAPY Social and Political Context Development of Family Therapy 1945 F.D.R. dies, Truman becomes president Bertalanffy presents general systems theory World War II ends in Europe (May 8) and the Pacific (August 14) 1946 Juan Perón elected president of Argentina Bowen at Menninger Clinic Whitaker at Emory Macy Conference Bateson at Harvard 1947 India partitioned into India and Pakistan 1948 Truman reelected U.S. president Whitaker begins conferences on schizophrenia State of Israel established 1949 Communist People’s Republic of China Bowlby: “The Study and Reduction of Group established Tensions in the Family” 1950 North Korea invades South Korea Bateson begins work at Palo Alto V.A. 1951 Julius and Ethel Rosenberg sentenced to Ruesch & Bateson: Communication: The Social death for espionage Matrix of Society Sen. Estes Kefauver leads Senate probe into Bowen initiates residential treatment of mothers and organized crime children Lidz at Yale 1952 Eisenhower elected U.S. president Bateson receives Rockefeller grant to study communication in Palo Alto Wynne at NIMH 1953 Joseph Stalin dies Whitaker & Malone: The Roots of Psychotherapy Korean armistice signed 1954 Supreme Court rules school segregation Bateson project research on schizophrenic unconstitutional communication Bowen at NIMH 1955 Rosa Parks refuses to move to the back of the Whitaker in private practice, Atlanta, Georgia. bus; Martin Luther King, Jr., leads boycott Satir begins teaching family dynamics in Chicago in Montgomery, Alabama 1956 Nasser elected president of Egypt Bateson, Jackson, Haley, & Weakland: “Toward a Soviet troops crush anti-Communist rebellion Theory of Schizophrenia” in Hungary Bowen at Georgetown (continued) xv xvi Major Events in the History of Family Therapy Social and Political Context Development of Family Therapy 1957 Russians launch Sputnik I Jackson: “The Question of Family Homeostasis” Eisenhower sends troops to Little Rock, Ackerman opens the Family Mental Health Clinic of Arkansas, to protect school integration Jewish Family Services in New York Boszormenyi-Nagy opens Family Therapy Department at EPPI in Philadelphia 1958 European Common Market established Ackerman: The Psychodynamics of Family Life 1959 Castro becomes premier of Cuba MRI founded by Don Jackson Charles de Gaulle becomes French president 1960 Kennedy elected U.S. president Family Institute founded by Nathan Ackerman (renamed the Ackerman Institute in 1971) Minuchin and colleagues begin doing family therapy at Wiltwyck 1961 Berlin Wall erected Bell: Family Group Therapy Bay of Pigs invasion Family Process founded by Ackerman and Jackson 1962 Cuban Missile Crisis Bateson’s Palo Alto project ends Haley at MRI 1963 Kennedy assassinated Haley: Strategies of Psychotherapy 1964 Johnson elected U.S. president Satir: Conjoint Family Therapy Nobel Peace Prize awarded to Martin Luther Norbert Wiener dies (b. 1894) King, Jr. 1965 Passage of Medicare Minuchin becomes director of Philadelphia Child Malcolm X assassinated Guidance Clinic Whitaker at University of Wisconsin 1966 Red Guards demonstrate in China Brief Therapy Center at MRI begun under director- Indira Gandhi becomes prime minister of ship of Richard Fisch India Ackerman: Treating the Troubled Family 1967 Six-Day War between Israel and Arab states Watzlawick, Beavin, & Jackson: Pragmatics of Human Urban riots in Cleveland, Newark, and Detroit Communication Dicks: Marital Tensions 1968 Nixon elected U.S. president Don Jackson dies (b. 1920) Robert Kennedy and Martin Luther King, Jr., Satir at Esalen assassinated 1969 Widespread demonstrations against war in Bandura: Principles of Behavior Modification Vietnam Wolpe: The Practice of Behavior Therapy 1970 Student protests against Vietnam War result Masters & Johnson: Human Sexual Inadequacy in killing of four students at Kent State Laing & Esterson: Sanity, Madness and the Family 1971 Twenty-Sixth Amendment grants right to vote Nathan Ackerman dies (b. 1908) to 18-year-olds 1972 Nixon reelected U.S. president Bateson: Steps to an Ecology of Mind Wynne at University of Rochester 1973 Supreme Court rules that states may not Center for Family Learning founded by Phil Guerin prohibit abortion Boszormenyi-Nagy & Spark: Invisible Loyalties Energy crisis created by oil shortages 1974 Nixon resigns Minuchin: Families and Family Therapy Gerald Ford becomes 39th president Watzlawick, Weakland, & Fisch: Change Major Events in the History of Family Therapy xvii Social and Political Context Development of Family Therapy 1975 Vietnam War ends Mahler, Pine, & Bergman: The Psychological Birth of the Human Infant Stuart: “Behavioral Remedies for Marital Ills” 1976 Carter elected U.S. president Haley: Problem-Solving Therapy Haley to Washington, D.C. 1977 President Carter pardons most Vietnam War Family Institute of Westchester founded by Betty draft evaders Carter American Family Therapy Academy (AFTA) estab- lished 1978 Camp David Accords between Egypt and Hare-Mustin: “A Feminist Approach to Family Israel Therapy” U.S. and People’s Republic of China establish Selvini Palazzoli et al.: Paradox and Counterparadox diplomatic relations 1979 England’s Margaret Thatcher becomes West’s Founding of Brief Therapy Center in Milwaukee first woman prime minister Bateson: Mind and Nature Iranian militants seize U.S. Embassy in Tehran and hold hostages 1980 Reagan elected U.S. president Haley: Leaving Home U.S. boycotts summer Olympic Games in Milton Erickson dies (b. 1901) Moscow Gregory Bateson dies (b. 1904) 1981 Sandra Day O’Connor becomes first woman Hoffman: The Foundations of Family Therapy justice of Supreme Court Madanes: Strategic Family Therapy Egyptian president Sadat assassinated Minuchin & Fishman: Family Therapy Techniques 1982 Equal Rights Amendment fails ratification Gilligan: In a Different Voice Falklands war Fisch, Weakland, & Segal: Tactics of Change The Family Therapy Networker founded by Richard Simon 1983 U.S. invades Grenada Doherty & Baird: Family Therapy and Family Terrorist bombing of Marine headquarters in Medicine Beirut Keeney: Aesthetics of Change 1984 Reagan reelected U.S. president Watzlawick: The Invented Reality U.S.S.R. boycotts summer Olympic Games in Madanes: Behind the One-Way Mirror Los Angeles 1985 Gorbachev becomes leader of U.S.S.R. de Shazer: Keys to Solution in Brief Therapy Gergen: “The Social Constructionist Movement in Modern Psychology” 1986 Space shuttle Challenger explodes Anderson et al.: Schizophrenia and the Family Selvini Palazzoli: “Towards a General Model of Psychotic Family Games” 1987 Congress investigates the Iran–Contra affair Tom Andersen: “The Reflecting Team” Guerin et al.: The Evaluation and Treatment of Marital Conflict Scharff & Scharff: Object Relations Family Therapy 1988 George H. W. Bush elected U.S. president Kerr & Bowen: Family Evaluation Virginia Satir dies (b. 1916) (continued) xviii Major Events in the History of Family Therapy Social and Political Context Development of Family Therapy 1989 The Berlin Wall comes down Boyd-Franklin: Black Families in Therapy 1990 Iraq invades Kuwait Murray Bowen dies (b. 1913) White & Epston: Narrative Means to Therapeutic Ends 1991 Persian Gulf War against Iraq Harold Goolishian dies (b. 1924) 1992 Clinton elected U.S. president Family Institute of New Jersey founded by Monica McGoldrick 1993 Ethnic cleansing in Bosnia Israel Zwerling dies (b. 1917) Los Angeles police officers convicted in Minuchin & Nichols: Family Healing Rodney King beating 1994 Republicans win majority in Congress David and Jill Scharf leave Washington School of Nelson Mandela elected president of South Psychiatry to begin the International Institute of Africa Object Relations Therapy 1995 Oklahoma City federal building bombed Carl Whitaker dies (b. 1912) John Weakland dies (b. 1919) Salvador Minuchin retires Family Studies Inc. renamed The Minuchin Center 1996 Clinton reelected U.S. president Edwin Friedman dies (b. 1932) Eron & Lund: Narrative Solutions in Brief Therapy Freedman & Combs: Narrative Therapy 1997 Princess Diana dies in auto accident Michael Goldstein dies (b. 1930) Hong Kong reverts to China 1998 President Clinton impeached by House of Minuchin, Colapinto, & Minuchin: Working with Representatives Families of the Poor 1999 President Clinton acquitted in impeachment Neil Jacobson dies (b. 1949) trial John Elderkin Bell dies (b. 1913) Mara Selvini Palazzoli dies (b. 1916) 2000 George W. Bush elected U.S. president Millennium Conference, Toronto, Canada 2001 September 11 terrorist attacks James Framo dies (b. 1922) 2002 Sex abuse scandal in Catholic Church Lipchik: Beyond Techniques in Solution-Focused Corporate corruption at Enron Therapy 2003 U.S. invades Iraq Greenan & Tunnell: Couple Therapy with Gay Men 2004 George W. Bush reelected U.S. president Gianfranco Cecchin dies (b. 1932) 2005 Hurricane Katrina devastates New Orleans Steve de Shazer dies (b. 1940) 2006 Democrats regain control of U.S. House and Minuchin, Nichols, & Lee: Assessing Families and Senate Couples 2007 Shootings at Virginia Tech Jay Haley dies (b. 1923) Lyman Wynne dies (b. 1923) Insoo Kim Berg dies (b. 1934) Albert Ellis dies (b. 1913) Thomas Fogarty dies (b. 1927) 2008 Barack Obama elected U.S. president Michael White dies (b. 1949) Major Events in the History of Family Therapy xix Social and Political Context Development of Family Therapy 2009 Worldwide economic recession Sprenkle, Davis, & Lebow: Common Factors in Couple and Family Therapy 2010 Earthquake in Haiti LaSala: Coming Out, Coming Home Dattilio: Cognitive-Behavioral Therapy with Couples and Families 2011 Earthquake and tsunami in Japan Cose: The End of Anger 2012 Mass shootings in Newton CT Betty Carter dies (b. 1929) Barack Obama reelected U.S. president 2013 Death of Nelson Mandela Alan Gurman dies (b. 1945) Affordable Healthcare Act 2014 Ebola epidemic in West Africa Donald Bloch dies (b. 1923) This page intentionally left blank FOREWORD In this volume, Mike Nichols tells the story of family functioning of all human collectives. A major broad- therapy—and tells it very well. It’s hard to imagine a side came from feminists who questioned the absence more readable and informative guide to the field. of concepts of gender and power in systems thinking Born in the late 1950s, family therapy seemed to and pointed to the distorting consequences of gender- spring fully formed out of the heads of a group of less theory when focusing on family violence. The seminal thinkers. Over six decades later, both theory other challenge concerned the connection between and practice show the uncertainties and doubts that theory and practice: a challenge to the imposition of define maturity. But in the beginning—as the story- systems theory as the basis for therapeutic practice. tellers say—there was Gregory Bateson on the West The very techniques that once defined the field were Coast, a tall, clean-shaven, angular intellectual, who called into question. Inevitably, the field began to re- saw families as systems, carriers of ideas. On the East open for examination of its old taboos: the individual, Coast was Nathan Ackerman, short, bearded, portly, intrapsychic life, emotions, biology, the past, and the the quintessential charismatic healer, who saw fam- particular place of the family in culture and society. ilies as collections of individuals struggling to bal- As is always characteristic of an official science, ance feelings, irrationalities, and desires. Bateson and the field tried to preserve established concepts while Ackerman complemented each other perfectly, the a pragmatic attention to specific cases was demand- Don Quixote and Sancho Panza of the family systems ing new and specific responses. As a result, today we revolution. have an official family therapy that claims direct de- For all the diversity of the 1960s that saw the new scendance from Bateson and a multitude of excellent clinical practice called family therapy take a variety practitioners doing sensitive and effective work that is of names—systemic, strategic, structural, Bowenian, frequently quite different from what systems theory experiential—there was also a remarkable solidarity prescribes. in the shared beliefs that defined the field. I see the therapeutic process as an encounter between As family therapy succeeded and expanded, it distinct interpersonal cultures. Real respect for clients was extended to encompass different client popula- and their integrity can allow therapists to be other than tions, with specific interventions for various special fearfully cautious, can encourage them to be direct and groups—clients with drug addictions, hospitalized authentic—respectful and compassionate—but also at psychiatric patients, the welfare population, violent times honest and challenging. families, and so on. All posed their own complexities. This conception of the therapist as an active Practitioners responded to this expanded family ther- knower—of himself or herself and of the different apy with an array of new approaches, some of which family members—is very different from the neutral even questioned the fundamental allegiance to sys- therapist of the constructivists. But, of course, these tems thinking. two prototypes are entirely too simplified. Most prac- The challenges to systems theory (the official sci- titioners fall somewhere between these two poles of ence of the time) took two forms. One was purely the- neutrality and decisiveness. oretical: a challenge to the assumption that systemic The choice between action and interventionism, thinking was a universal framework, applicable to the on the one hand, and meaning and conversation, xxi xxii Foreword on the other, is but one of the questions the field is ideas and techniques that make family therapy such grappling with today; there are many others. Are the an exciting enterprise. Dr. Nichols has managed to norms of human behavior universal, or are they cultur- be comprehensive without becoming tedious. Per- ally constructed products of political and ideological haps the secret is the engaging style of his writing, constraint? How do we become experts? How do we or perhaps it is how he avoids getting lost in abstrac- know what we know? Can we influence people? Can tion while keeping a clear focus on clinical practice. we not influence them? How do we know that we are In any case, this superb book has long set the standard not simply agents of social control? How do we know of excellence as the best introduction and guide to the that we are accomplishing anything at all? practice of family therapy. These questions and the rich history and contem- porary practice of family therapy are explored in Family Therapy: Concepts and Methods. It is a thor- Salvador Minuchin, M.D. ough and thoughtful, fair and balanced guide to the Boca Raton, Florida PREFACE One thing that sometimes gets lost in academic dis- they click on the icon and the quiz appears. The cussions of family therapy is the feeling of accom- first one prompts them to test their knowledge of plishment that comes from sitting down with an chapter concepts by taking a multiple-choice quiz. unhappy family and being able to help them. Begin- The second quiz icon prompts them to apply their ning therapists are understandably anxious and not knowledge of chapter concepts by responding to sure they’ll know how to proceed. (“How do you open-ended questions by typing their response and get all of them to come in?”) Veterans often speak submitting it for immediate feedback. These self- in abstractions. They have opinions and discuss big assessments can reinforce understanding of key issues—postmodernism, managed care, second-order chapter concepts and support application of newly cybernetics. While it’s tempting to use this space to learned content. say Important Things, I prefer to be a little more per- sonal. Treating troubled families has given me the greatest satisfaction imaginable, and I hope that the same is or will be true for you. Content Changes in the New Edition ♦ New section on the impact of the Affordable Care Act New to This Edition ♦ Recommendations for establishing a fee-for-service private practice In this eleventh edition of Family Therapy: Concepts ♦ Revised and expanded section on attachment and Methods, I’ve tried to describe the full scope of theory family therapy—its rich history, the classic schools, ♦ Questions to ask when doing a genogram the latest developments—but with increasing empha- ♦ More specific interventions from the MRI sis on clinical practice. There are a lot of changes in approach this edition: ♦ Detailed guidelines for making a structural family therapy assessment New Digital Enhancements ♦ New section with guidelines on using family sculpting in the Pearson eText ♦ More specific techniques used in object relations family therapy ♦ Videos: Links to video clips of therapists have ♦ Expanded section on spirituality and religion been embedded for students to view throughout ♦ Expanded and updated section on families and the chapters of the Pearson eText. Students are technology prompted to reflect on and analyze the videos via ♦ Guidelines for therapeutic letter writing an accompanying question. ♦ New research chapter including a discussion of ♦ Chapter Quizzes: At the end of each chapter why research has failed to influence practice and Summary, students will find two self-assessments suggestions for bridging the research-practice gap marked by a checkmark icon. In the Pearson eText, ♦ New case studies xxiii xxiv Preface Instructor Supplements who went out of their way to help me prepare this eleventh edition were Yvonne Dolan, Jerome Price, An instructor’s manual, test bank, and PowerPoint Deborah Luepnitz, William Madsen, Frank Dattilio, slides are available to accompany this text. They can be Vicki Dickerson, Douglas Breunlin, and Salvador downloaded at www.pearsonhighered.com/educator. Minuchin. And I owe a huge debt of gratitude to Sean Davis for his extensive and thoughtful contributions to this edition. Sean has the rare combination of ac- Acknowledgments ademic smarts and clinical sophistication that makes his perspective so valuable. To paraphrase John, Paul, Albert Einstein once said, “If you want to learn about George, and Ringo, I get by with a lot of help from my physics, pay attention to what physicists do, not what friends—and I thank them one and all. I am especially they say they do.” When you read about therapy, it can grateful to Julie Peters at Pearson for making a hard be hard to see past the jargon and political packaging job easier. to the essential ideas and practices. So in preparing Finally, I would like to thank my postgraduate this edition, I’ve traveled widely to visit and observe instructors in family life: my wife, Melody, and my actual sessions of the leading practitioners. I’ve also children, Sandy and Paul. In the brief span of forty-five invited several master therapists to share some of their years, Melody has seen me grow from a shy young best case studies with you. The result is a more prag- man, totally ignorant of how to be a husband and matic, clinical focus. I hope you like it. father, to a shy middle-aged man, still bewildered and So many people have contributed to my develop- still trying. My children never cease to amaze me. If ment as a family therapist and to the writing of this in my wildest dreams I had imagined children to love book that it is impossible to thank them all. But I would and be proud of, I wouldn’t even have come close to like to single out a few. To the people who taught me children as fine as Sandy and Paul. family therapy—Lyman Wynne, Murray Bowen, and Salvador Minuchin—thank you. Some of the people M. P. N.  I N T R O D U C T I O N T here wasn’t much information on the intake sheet. Just a name, Holly Roberts, the fact that she was a senior in college, THE FOUNDATIONS and her presenting complaint: “trouble making decisions.” The first thing Holly said when she sat down was, “I’m not sure I need to be here. You prob- OF FAMILY ably have a lot of people who need help more than I do.” Then she started to cry. THERAPY It was springtime. The tulips were up, the trees were turning leafy green, and purple Leaving Home clumps of lilacs perfumed the air. Life and all its possibilities stretched out before her, but Holly was naggingly, unaccountably depressed. The decision Holly was having trouble making was what to do after graduation. The more she tried to figure it out, the less able she was to concentrate. She started sleeping late, missing classes. Finally, her roommate talked her into going to the counseling center. “I wouldn’t have come,” Holly said. “I can take care of my own problems.” I was into cathartic therapy back then. Most people have stories to tell and tears to shed. Some of the stories, I suspected, were dramatized to elicit sympathy. We seem to give ourselves permission to cry only with some very accept- able excuse. Of all the human emotions we’re ashamed of, feeling sorry for yourself tops the list. I didn’t know what was behind Holly’s depres- sion, but I was sure I could help. I felt comforta- ble with depression. Ever since my senior year in high school when my friend Alex died, I’d been a little depressed myself. ♦ ♦ ♦ After Alex died, the rest of the summer was a dark blur. I cried a lot. And I got mad whenever any- body suggested that life goes on. Alex’s minister said that his death wasn’t really a tragedy because now “Alex was with God in heaven.” I wanted to scream, 1  2 Part One: The Context of Family Therapy but I numbed myself instead. In the fall, I went off Looking back, I don’t remember much that was to college, and, even though it seemed disloyal to said in that first meeting. Both parents were worried Alex, life did go on. I still cried from time to time, about Holly. “We’ll do whatever you think best,” but with the tears came a painful discovery. Not all of Mrs. Roberts said. Holly’s stepfather, Mr. Morgan, my grief was for Alex. Yes, I loved him. Yes, I missed said they could arrange for a good psychiatrist “to him. But his death provided me the justification help Holly over this crisis.” But, Holly didn’t want to to cry about the everyday sorrows of my own life. go home, and she said so with more energy than I’d Maybe grief is always like that. At the time, though, heard from her in a long time. That was on Saturday. it struck me as a betrayal. I was using Alex’s death to I said that there was no need to rush into a decision, feel sorry for myself. so we arranged to meet again on Monday. When Holly and her parents sat down in my ♦ ♦ ♦ office on Monday morning, it was obvious that some- thing had happened. Mrs. Roberts’s eyes were red What, I wondered, was making Holly so sad? In from crying. Holly glared at her and looked away. fact, Holly didn’t have a dramatic story. Her feelings Mr. Morgan turned to me. “We’ve been fighting all weren’t focused. After those first moments in my of- weekend. Holly heaps abuse on me, and when I try to fice, she rarely cried. When she did, it was more an respond, Lena takes her side. That’s the way it’s been involuntary tearing up than a sobbing release. She since day one of this marriage.” talked about the future and not knowing what she The story that emerged was one of those sad his- wanted to do with her life. She talked about not hav- tories of jealousy and resentment that turn ordinary ing a boyfriend, but she didn’t say much about her love into bitter, injured feelings and, all too often, tear family. If the truth be told, I wasn’t much interested. families apart. Lena Roberts was thirty-four when she Back then, I thought home was a place you left in or- met Tom Morgan. He was a robust fifty-six. The sec- der to grow up. ond obvious difference between them was money. He Holly was hurting and needed someone to lean on, was a stockbroker who’d retired to run a horse farm. but something made her hold back, as though she didn’t She was waitressing to support herself and her daugh- quite trust me. It was frustrating. I wanted to help. ter. It was a second marriage for both of them. A month went by, and Holly’s depression got Lena thought Tom could be the missing father fig- worse. I started seeing her twice a week, but we ure in Holly’s life. Unfortunately, Lena couldn’t ac- weren’t getting anywhere. One Friday afternoon, cept all the rules Tom wanted to enforce, and so he Holly was feeling so despondent that I didn’t think became the wicked stepfather. He made the mistake she should go back to her dorm alone. I asked her in- of trying to take over and, when the predictable ar- stead to lie down on the couch in my office and, with guments ensued, Lena sided with her daughter. There her permission, I called her parents. were tears and midnight shouting matches. Twice Mrs. Roberts answered the phone. I told her that I Holly ran away for a few days. This triangle nearly thought she and her husband should come to Rochester proved the marriage’s undoing, but things calmed and meet with me and Holly to discuss the advis- down after Holly left for college. ability of Holly taking a medical leave of absence. Holly expected to leave home and not look back. Unsure as I was of my authority back then, I steeled She would make new friends. She would study hard myself for an argument. Mrs. Roberts surprised me by and choose a career. She would never depend on a agreeing to come at once. man to support her. Unfortunately, she left home The first thing that struck me about Holly’s parents with unfinished business. She hated Tom for the way was the disparity in their ages. Mrs. Roberts looked he treated her mother. He was always demanding like a slightly older version of Holly; she couldn’t to know where her mother was going, who she was have been much over thirty-five. Her husband looked going with, and when she would be back. If she was sixty. It turned out that he was Holly’s stepfather. the least bit late, there would be a scene. Why did her They had married when Holly was sixteen. mother put up with it? Introduction The Foundations of Family Therapy 3 Blaming her stepfather was simple and satisfying. of techniques; it’s a whole new approach to under- But another set of feelings, harder to face, was eat- standing human behavior—as fundamentally shaped ing at Holly. She hated her mother for marrying Tom by its social context. and for letting him be so mean to her. What had her mother seen in him? Had she sold out for a big house and a fancy car? Holly didn’t have answers to these The Myth of the Hero questions; she didn’t even allow them into full aware- ness. Unfortunately, repression doesn’t work like put- Ours is a culture that celebrates the uniqueness of ting something away in a closet and forgetting about the individual and the search for an autonomous self. it. It takes a lot of energy to keep unwelcome emo- Holly’s story could be told as a coming-of-age drama: tions at bay. a young person’s struggle to break away from child- Holly found excuses not to go home during col- hood and provincialism, to take hold of adulthood and lege. It didn’t even feel like home anymore. She promise and the future. If she fails, we’re tempted to buried herself in her studies. But rage and bitterness look inside the young adult, the failed hero. gnawed at her until, in her senior year, facing an While the unbounded individualism of the hero uncertain future, knowing only that she couldn’t go may once have been encouraged more for men than home again, she gave in to hopelessness. No wonder women, as a cultural ideal it casts its shadow on us she was depressed. all. Even if Holly cared about connection as well I found the whole story sad. Not knowing about much as autonomy, she may be judged by the prevail- family dynamics and never having lived in a step- ing image of accomplishment. family, I wondered why they couldn’t just try to get We were raised on the myth of the hero: the Lone along. Why did they have so little sympathy for each Ranger, Robin Hood, Wonder Woman. When we got other? Why couldn’t Holly accept her mother’s right older, we searched for real-life heroes: Eleanor Roosevelt, to find love a second time around? Why couldn’t Tom Martin Luther King Jr., Nelson Mandela. These men and respect the priority of his wife’s relationship with her women stood for something. If only we could be a little daughter? And why couldn’t Lena listen to her daugh- more like these larger-than-life individuals who seemed to ter’s adolescent anger without getting so defensive? rise above their circumstances. That session with Holly and her parents was my Only later did we realize that the circumstances we first lesson in family therapy. Family members in wanted to rise above were part of the human condition— therapy talk not about actual events but about re- our inescapable connection to our families. The roman- constructed memories that resemble the original ex- tic image of the hero is based on the illusion that periences only in certain ways. Holly’s memories authentic selfhood can be achieved as an autonomous resembled her mother’s memories very little, and individual. We do many things alone, including some of her stepfather’s not at all. In the gaps between their our most heroic acts, but we are defined and sustained truths, there was little room for reason and no desire by a network of human relationships. Our need to wor- to pursue it. ship heroes is partly a need to rise above littleness and Although that meeting may not have been terribly self-doubt, but it is perhaps equally a product of imag- productive, it did put Holly’s unhappiness in perspec- ining a life unfettered by all those pesky relationships tive. No longer did I think of her as a tragic young that somehow never quite go the way we want them to. woman all alone in the world. She was that, of course, When we do think about families, it’s often in but she was also a daughter torn between running negative terms—as burdens holding us back or as de- away from a home she no longer felt part of and being structive elements in the lives of our patients. What afraid to leave her mother alone with a man she didn’t catches our attention are differences and discord. The trust. I think that’s when I became a family therapist. harmonies of family life—loyalty, tolerance, solace, To say that I didn’t know much about families, and support—often slide by unnoticed, part of the much less about how to help them, would be an un- taken-for-granted background of life. If we would be derstatement. But family therapy isn’t just a new set heroes, then we must have villains.  4 Part One: The Context of Family Therapy These days there’s a lot of talk about dysfunctional It’s possible to look back on the days before fam- families. Unfortunately, much of this amounts to lit- ily therapy and see those who insisted on segregating tle more than parent bashing. People suffer because of patients from their families as exponents of a fos- what their parents did: their mother’s career, their fa- silized view of mental disorder, according to which ther’s unreasonable expectations—these are the causes psychiatric maladies are firmly embedded inside of their unhappiness. Perhaps this is an advance on the heads of individuals. Considering that clinicians stewing in guilt and shame, but it’s a long way from didn’t begin treating families together until the mid- understanding what really goes on in families. 1950s, it’s tempting to ask, “What took them so One reason for blaming family sorrows on the long?” In fact, there were good reasons for conducting personal failings of parents is that it’s hard for the av- therapy in private. erage person to see past individual personalities to the The two most influential approaches to psycho- structural patterns that make them a family—a system therapy in the twentieth century, Freud’s psycho- of interconnected lives governed by strict but unspo- analysis and Rogers’s client-centered therapy, were ken rules. both predicated on the assumption that psychological People feel controlled and helpless not because problems arise from unhealthy interactions with oth- they are victims of parental folly and deceit but be- ers and can best be alleviated in a private relationship cause they don’t understand the forces that tie hus- between therapist and patient. bands and wives and parents and children together. Freud’s discoveries indicted the family, first as a Plagued by anxiety and depression, or merely trou- breeding ground of childhood seduction and later as bled and uncertain, some people turn to psychother- the agent of cultural repression. If people grew up a lit- apy for help. In the process, they turn away from the tle bit neurotic—afraid of their own natural instincts— irritants that propel them into therapy. Chief among who should we blame but their parents? these are unhappy relationships—with friends and Given that neurotic conflicts were spawned in the lovers, and with our families. Our disorders are pri- family, it seemed natural to assume that the best way to vate ailments. When we retreat to the safety of a undo the family’s influence was to isolate relatives from synthetic relationship, the last thing we want is to treatment, to bar their contaminating influence from the take our families with us. Is it any wonder, then, that psychoanalytic operating room. Because psychoanaly- when Freud ventured to explore the dark forces of sis focused on the patient’s memories and fantasies, the the mind, he locked the family outside the consulting family’s presence would only obscure the subjective room? truth of the past. Freud wasn’t interested in the living family; he was interested in the family-as-remembered. Psychotherapeutic Sanctuary Psychotherapy was once a private enterprise. The con- sulting room was a place of healing, yes, but it was equally a sanctuary, a refuge from a troubled and trou- bling world. Buffeted about in love and work, unable to find World History Archive/Newscom solace elsewhere, adults came to therapy to find sat- Freud excluded isfaction and meaning. Parents, worried about their the family from children’s behavior, sent them for guidance and di- psychoanalysis to rection. In many ways, psychotherapy displaced the help patients feel family’s role in solving the problems of everyday life. safe to explore Freud excluded the family from psychoanalysis the full range of to help patients feel safe to explore the full range of their thoughts and their thoughts and feelings. feelings. Introduction The Foundations of Family Therapy 5 By conducting treatment in private, Freud safe- understanding human behavior. Both have their guarded patients’ trust in the sanctity of the therapeu- virtues. Individual therapy provides the concentrated tic relationship and thus maximized the likelihood focus to help people face their fears and learn to that they would repeat, in relation to the analyst, the become more fully themselves. Individual therapists understandings and misunderstandings of childhood. have always recognized the importance of family life in shaping personality, but they have assumed that ♦ ♦ ♦ these influences are internalized and that intrapsychic dynamics become the dominant forces controlling Carl Rogers also believed that psychological prob- behavior. Treatment can and should, therefore, be di- lems stemmed from destructive family relations. Each rected at the person and his or her personal makeup. of us, Rogers said, is born with an innate tendency Family therapists, on the other hand, believe that the toward self-actualization. Left to our own devices, we dominant forces in our lives are located externally, in tend to follow our own best interests. Unhappily, said the family. Therapy, in this framework, is directed at Rogers, our instinct for actualization gets subverted by changing the organization of the family. When family our craving for approval. We learn to do what we think organization is transformed, the life of every family others want, even though it may not be what’s best member is altered accordingly. for us. This last point—that changing a family changes Gradually, this conflict between self-fulfillment the lives of its members—is important enough to and need for approval leads to denial of our authen- elaborate. Family therapy isn’t predicated merely tic selves—and even the feelings that signal them. We on changing the individual patient in context. Fam- swallow our anger, stifle our exuberance, and bury ily therapy exerts change on the entire family; there- our lives under a mountain of expectations. fore, improvement can be lasting because each family The therapy Rogers developed was designed to member is changed and continues to exert synchro- help patients uncover their real feelings. The Rogerian nous change on other family members. therapist listens sympathetically, offering compassion Almost any human difficulty can be treated with and understanding. In the presence of such an accept- either individual or family therapy, but certain prob- ing listener, patients gradually get in touch with their lems are especially suited to a family approach, own inner promptings. among them problems with children (who must, re- Like the psychoanalyst, the client-centered ther- gardless of what happens in therapy, return home to apist maintains absolute privacy in the therapeutic their parents), complaints about a marriage or other relationship to avoid any possibility that patients’ intimate relationship, family feuds, and symptoms feelings might be subverted to win approval. Only an that develop in an individual at the time of a major objective outsider could be counted on to provide the family transition. unconditional acceptance to help patients rediscover If problems that arise around family transitions their real selves. That’s why family members had no make a therapist think first about the role of the place in the process of client-centered therapy. family, individual therapy may be especially useful when people identify something about themselves that they’ve tried in vain to change while their so- Family versus Individual cial environment remains stable. Thus, if a woman Therapy gets depressed during her first year at college, a therapist might wonder if her sadness is related to As you can see, there were valid reasons for conduct- leaving home and leaving her parents alone with ing psychotherapy in private. Although a strong claim each other. But if the same woman were to become can be made for individual psychotherapy, equally depressed in her thirties, during a long period of sta- strong claims can be made for family therapy. bility in her life, we might wonder if there was some- Individual psychotherapy and family therapy thing about her approach to life that wasn’t working each offer an approach to treatment and a way of for her. Examining her life in private—away from  6 Part One: The Context of Family Therapy troubled relationships—doesn’t, however, mean that work with what’s going on in the present. Although the she should believe she can fulfill herself in isolation mother in the earlier example may only have started from other people. reproaching her daughter when she started avoiding The view of persons as separate entities, with fam- social activities, her continuing attempts to motivate ilies acting on them, is consistent with the way we the girl with criticism may only serve to perpetuate a experience ourselves. We recognize the influence of circular pattern of withdrawal-and-criticism. others—especially as obligation and constraint—but When things go wrong in relationships, most of us it’s hard to see that we are embedded in a network are generous in giving credit to other people. Because of relationships, that we are part of something larger we look at the world from inside our own skins, it’s than ourselves. easy to see other people’s contributions to our mutual problems. Blaming is only natural. The illusion of unilateral influence tempts therapists too, especially when they hear only one side of a story. But once we Thinking in Lines, Thinking understand that reciprocity is the governing principle in Circles of relationships, we can begin to get past thinking in terms of villains and victims. Mental illness has traditionally been explained in Suppose that a father complains about his teenage linear terms—medical or psychological. Both para- son’s behavior. digms treat emotional distress as a symptom of inter- Father: It’s my son. He’s rude and defiant. nal dysfunction with historical causes. Linear explanations take the form of A causes Therapist: Who taught him that? B. This works fine for some things. If you’re driv- Instead of accepting the father’s perspective that ing along and your car suddenly sputters to a stop, he’s a victim of his son’s villainy, the therapist’s ques- go ahead and look for a simple explanation. Maybe tion invites him to look for patterns of mutual influ- you’re out of gas. If so, there’s a simple solution. Hu- ence. The point isn’t to shift blame from one person man problems are usually a bit more complicated. to another but to get away from blame altogether. As Individual therapists think in terms of linear cau- long as he sees the problem as his son’s doing, the fa- sality when they explore what happened to make in- ther has little choice but to hope the boy will change. dividuals behave the way they do. If a young woman (Waiting for other people to change is like planning has low self-esteem, perhaps it’s because her mother your future around winning the lottery.) Learning to constantly criticizes her. Family therapists prefer to think in circles rather than lines empowers us to look think in terms of circular causality and consider peo- at the half of the equation we can control. ple’s mutual influence on each other. Thus, the young woman’s moping around the house might be a re- sponse to her mother’s fault-finding—and the moth- er’s finding fault might be a response to the young The Power of Family Therapy woman’s moping around the house. The more the mother criticizes, the more the young woman with- The power of family therapy derives from bringing draws, and the more the young woman withdraws, parents and children together to transform their in- the more the mother criticizes. teractions. Instead of isolating individuals from the The term circular causality calls attention to the cy- emotional origins of their conflict, problems are ad- cles of interaction in relationships. But in fact the term dressed at their source. is somewhat of a misnomer, because the focus is not on What keeps people stuck is their inability to see causality—how something got started—but on the on- their own participation in the problems that plague going transactions that sustain it. In some cases, maybe them. With eyes fixed firmly on what recalcitrant oth- something in the past did trigger an unhappy pattern ers are doing, it’s hard for most people to see the pat- of interaction. But the past is over; therapists can only terns that bind them together. The family therapist’s Introduction The Foundations of Family Therapy 7 job is to give them a wake-up call. When a husband Bob tried to shift responsibility back to Shirley. complains that his wife nags, and the therapist asks “Doesn’t she have to kiss me first?” how he contributes to her doing that, the therapist is “No,” the therapist said. “In real life, you have to challenging the husband to see the hyphenated him- earn that.” and-her of their interactions. ♦ ♦ ♦ ♦ ♦ ♦ In the opening of Anna Karenina, Tolstoy wrote: When Bob and Shirley came for help with marital “All happy families resemble one another; each un- problems, her complaint was that he never shared his happy family is unhappy in its own way.” Every un- feelings; his was that she always criticized him. This happy family may be unhappy in its own way, but is a classic trading of complaints that keeps couples everyone stumbles over the same familiar challenges stuck as long as they fail to see the reciprocal pattern of family life. It’s no secret what those challenges in which each partner provokes in the other precisely are—learning to live together, dealing with difficult the behavior he or she can’t stand. So the therapist relatives, chasing after children, coping with ado- said to Bob, “If you were a frog, what would you be lescence, and so on. What not everyone realizes, like if Shirley changed you into a prince?” When Bob however, is that a relatively small number of sys- countered that he doesn’t talk with her because she’s tems dynamics, once understood, illuminate those so critical, it seemed to the couple like the same old ar- challenges and enable families to move successfully gument—but the therapist saw this as the beginning of through the predictable dilemmas of life. Like all change—Bob starting to speak up. One way to create healers, family therapists sometimes deal with bizarre an opening for change in rigid families is to support the and baffling cases, but much of their work is with or- blamed person and help bring him back into the fray. dinary human beings learning life’s painful lessons. When Shirley criticized Bob for complaining, he Their stories, and the stories of the men and women tried to retreat, but the therapist said, “No, continue. of family therapy who have undertaken to help them, You’re still a frog.” are the inspiration for this book. C H A P T E R 1 I n this chapter, we explore the antecedents and early years of family therapy. There are two THE EVOLUTION compelling stories here: one of personalities, OF FAMILY one of ideas. The first story revolves around the pioneers—visionary iconoclasts who broke THERAPY the mold of seeing life and its troubles as a function of individuals and their personalities. Make no mistake: The shift from an individual to A Revolutionary Shift in a systemic perspective was a revolutionary one, Perspective providing those who grasped it with a powerful tool for understanding and resolving human problems. The second story in the evolution of family therapy is one of ideas. The restless curiosity of the first family therapists led them to ingenious new ways of conceptualizing the joys and sorrows of family life. As you read this history, stay open to surprises. Be ready to reexamine easy assumptions— including the assumption that family therapy began as a benevolent effort to support the institution of the family. The truth is, therapists first encountered families as adversaries. LEARNING OUTCOMES ♦ Describe the circumstances that led to The Undeclared War the birth of family therapy. Although we came to think of asylums as places of ♦ List the founders of family therapy and cruelty and detention, they were originally built to where they practiced. rescue the insane from being locked away in family ♦ List the first family therapy theories and attics. Accordingly, except for purposes of footing when they were popular. the bill, hospital psychiatrists kept families at arm’s ♦ Describe early family therapy theoretical length. In the 1950s, however, two puzzling devel- concepts. opments forced therapists to recognize the family’s power to alter the course of treatment. Therapists began to notice that often when a pa- tient got better, someone else in the family got worse, almost as though the family needed a symptomatic member. As in the game of hide-and-seek, it didn’t seem to matter who “It” was as long as someone played the part. In one case, Don Jackson (1954) was treating a woman for depression. When she be- gan to improve, her husband complained that she was 8 Chapter 1 The Evolution of Family Therapy 9 getting worse. When she continued to improve, the What this case dramatizes is how parents use husband lost his job. Eventually, when the woman their children as a buffer to protect them from in- was completely well, the husband killed himself. Ap- timacy. To the would-be Oedipus, Minuchin said, parently this man’s stability was predicated on having “You’re scratching your eyes for your mother, so a sick wife. that she’ll have something to worry about. You’re a good boy. Good children sacrifice themselves for Another strange story of shifting disturbance was their parents.” that patients often improved in the hospital only to get worse when they went home. Families are made of strange glue—they stretch CASE STUDY but never let go. Few blamed the family for outright In a bizarre case of Oedipus revisited, Salvador malevolence, yet there was an invidious undercurrent Minuchin treated a young man hospitalized for trying to these observations. The official story of family to scratch out his eyes. The man functioned normally therapy is one of respect for the family, but maybe in Bellevue but returned to self-mutilation each time none of us ever quite gets over the adolescent idea he went home. He could be sane, it seemed, only in that families are the enemy of freedom. an insane world. It turned out that the young man was extremely Small Group Dynamics close to his mother, a bond that grew even tighter during the seven years of his father’s mysterious ab- Those who first sought to understand and treat fam- sence. The father was a compulsive gambler who ilies found a ready parallel in small groups. Group disappeared shortly after being declared legally dynamics were applicable to family therapy because incompetent. The rumor was that the Mafia had group life is a complex blend of individual personali- kidnapped him. When, just as mysteriously, the fa- ties and properties of the group. ther returned, his son began his bizarre attempts at In 1920, the pioneering social psychologist self-mutilation. Perhaps he wanted to blind himself William McDougall published The Group Mind, in so as not to see his obsession with his mother and hatred of his father. which he described how a group’s continuity depends But this family was neither ancient nor Greek, on boundaries for differentiation of function and on and Minuchin was more pragmatist than poet. So customs and habits to make relationships predict- he challenged the father to protect his son by be- able. A more scientific approach to group dynamics ginning to deal directly with his wife, and then he was developed in the 1940s by Kurt Lewin, whose challenged the man’s demeaning attitude toward field theory (Lewin, 1951) guided a generation of re- her, which had driven her to seek her son’s protec- searchers. Drawing on the Gestalt school of percep- tion. The therapy was a challenge to the family’s tion, Lewin developed the notion that a group is more structure and, in Bellevue, working with the psychi- than the sum of its parts. The transcendent property of atric staff to ease the young man back into the fam- groups has obvious relevance to family therapists, who ily, into the lion’s den. must work not only with individuals but also with fam- Minuchin confronted the father, saying, “As a father of a child in danger, what you’re doing isn’t ily systems—and their famous resistance to change. enough.” Analyzing what he called quasi-stationary social “What should I do?” asked the man. equilibrium, Lewin pointed out that changing group “I don’t know,” Minuchin replied. “Ask your behavior requires “unfreezing.” Only after something son.” Then, for the first time in years, father and shakes up a group’s beliefs will its members be pre- son began talking. Just as they were about to run pared to change. In individual therapy this process is out of things to say, Dr. Minuchin commented to initiated by the unhappy experiences that lead people the parents: “In a strange way, he’s telling you that to seek help. When someone decides to meet with a he prefers to be treated like a child. When he was therapist, that person has already begun to unfreeze in the hospital he was twenty-three. Now that he’s old habits. When families come for treatment, it’s a returned home again, he’s six.” different story.  10 Part One: The Context of Family Therapy Richard T. Nowitz/Corbis The first people to practice family therapy turned to group therapy for a model. Family members may not be sufficiently unsettled Dependency masquerades as therapy when fami- by one member’s problems to consider changing their lies allow therapists to subvert their autonomy in the ways. Furthermore, family members bring their own name of problem solving. Pairing is seen in families reference group with them, with all its traditions and when one parent colludes with the children to under- habits. Consequently, more effort is required to un- mine the other parent. freeze, or shake up, families before real change can The process/content distinction in group dy- take place. The need for unfreezing foreshadowed namics had a major impact on family treatment. early family therapists’ concern about disrupting fam- Experienced therapists learn to attend as much to ily homeostasis, a notion that dominated family ther- how people talk as to the content of their discus- apy for decades. sions. For example, a mother might tell her daugh- Wilfred Bion was another student of group func- ter that she shouldn’t play with Barbie dolls because tioning who emphasized the group as a whole, with she shouldn’t aspire to an image of bubble-headed its own dynamics and structure. According to Bion beauty. The content of the mother’s message is, (1948), most groups become diverted from their pri- “Respect yourself as a person.” But if the mother mary tasks by engaging in patterns of fight–flight, expresses her point of view by disparaging the dependency, and pairing. Bion’s basic assumptions daughter’s wishes, then the process of her message are easily extrapolated to family therapy: Some is, “Your feelings don’t count.” families skirt around hot issues like a cat circling a Unfortunately, the content of some discussions is snake. Others use therapy to bicker endlessly, never so compelling that therapists get sidetracked from the really contemplating compromise, much less change. process. Suppose that a therapist invites a teenager Chapter 1 The Evolution of Family Therapy 11 to talk with his mother about wanting to drop out of techniques for exploring interpersonal relationships school. The boy mumbles something about school developed by group therapists, it was natural for some being stupid, and his mother responds with a lecture family therapists to apply a group treatment model about the importance of education. A therapist who to families. What is a family, after all, but a group of gets drawn in to support the mother’s position may individuals? be making a mistake. In terms of content, the mother From a technical viewpoint, group and family might be right: A high school diploma can come in therapies are similar: Both are complex and dynamic, handy. But maybe it’s more important at that moment more like everyday life than individual therapy. In to help the boy learn to speak up for himself—and for groups and families, patients must react to a number his mother to learn to listen. of people, not just a therapist, and therapeutic use of Role theory, explored in the literatures of psy- this interaction is the definitive mechanism of change choanalysis and group dynamics, had important ap- in both contexts. plications to the study of families. The expectations On closer examination, however, it turns out that that roles carry bring regularity to complex social the differences between families and groups are so situations. significant that the group therapy model has only Roles tend to be stereotyped in most groups, and limited applicability to family treatment. Family so there are characteristic behavior patterns of group members have a long history and, more importantly, members. Virginia Satir (1972) described family roles a future together. Revealing yourself to strangers such as “the placator” and “the disagreeable one” in is a lot safer than exposing yourself to members of her book Peoplemaking. If you think about it, you your own family. There’s no taking back revelations may have played a fairly predictable role in your fam- that might better have remained private—the af- ily. Perhaps you were “the good child,” “the moody fair, long since over, or the admission that a woman one,” or “the rebel.” The trouble is, such roles can be cares more about her career than about her husband. hard to put aside. Continuity, commitment, and shared distortions One thing that makes role theory so useful in un- all make family therapy very different from group derstanding families is that roles tend to be comple- therapy. mentary. Say, for example, that a woman is a little Therapy groups are designed to provide an atmo- more anxious to spend time with her boyfriend than sphere of warmth and support. This feeling of safety he is. Maybe, left to his own devices, he’d call twice among sympathetic strangers cannot be part of fam- a week. But if she calls three times a week, he may ily therapy, because instead of separating treatment never get around to picking up the phone. If their from a stressful environment, the stressful envi- relationship lasts, she may always be the pursuer ronment is brought into the consulting room. Fur- and he the distancer. Or take the case of two parents, thermore, in group therapy, patients can have equal both of whom want their children to behave them- power and status, whereas democratic equality isn’t selves at the dinner table. The father has a slightly appropriate in families. Someone has to be in charge. shorter fuse—he tells them to quiet down five sec- Furthermore, the official patient in a family is likely onds after they start getting rowdy, whereas his wife to feel isolated and stigmatized. After all, he or she is would wait half a minute. If he always speaks up, “the problem.” The sense of protection in being part she may never get a chance. Eventually these par- of a compassionate group of strangers, who won’t ents may become polarized into complementary have to be faced across the dinner table, doesn’t exist roles of strictness and leniency. What makes such in family therapy. reciprocity resistant to change is that the roles rein- force each other. The Child Guidance Movement It was a short step from observing patients’ reac- tions to other members of a group—some of whom It was Freud who introduced the idea that psycholog- might act like siblings or parents—to observing ical disorders were the result of unsolved problems interactions in real families. Given the wealth of of childhood. Alfred Adler was the first of Freud’s  12 Part One: The Context of Family Therapy followers to pursue the implication that treating the session, Bowlby interpreted what he thought each of growing child might be the most effective way to their contributions to the problem were. Eventually, by prevent adult neuroses. To that end, Adler organized working together, all three members of the family de- child guidance clinics in Vienna, where not only chil- veloped sympathy for each other’s point of view. dren but also families and teachers were counseled. Although he was intrigued by this conjoint inter- Adler offered support and encouragement to help al- view, Bowlby remained wedded to the one-to-one leviate children’s feelings of inferiority, so they could format. Family meetings might be a useful catalyst, work out a healthy lifestyle, achieving confidence and but only as a supplement to the real treatment, indi- success through social usefulness. vidual psychotherapy. Although child guidance clinics remained few in What Bowlby tried as an experiment, Nathan number until after World War II, they now exist in Ackerman saw to fruition—family therapy as the pri- every city in the United States, providing treatment mary form of treatment. Once he saw the need to un- of childhood problems and the complex forces con- derstand the family in order to diagnose problems, tributing to them. Gradually, child guidance work- Ackerman soon took the next step—family treatment. ers concluded that the real problem wasn’t a child’s Before we get to that, however, let us examine compa- symptoms, but rather the tensions in families that were rable developments in marriage counseling and research the source of those symptoms. At first there was a ten- on schizophrenia that led to the birth of family therapy. dency to blame the parents, especially the mother. The chief cause of children’s problems, according Marriage Counseling to David Levy (1943), was maternal overprotective- ness. Mothers who had themselves been deprived of For many years there was no apparent need for a sep- love became overprotective of their children. Some arate profession of marriage counselors. People with were domineering, others overindulgent. Children marital problems talked with their doctors, clergy, of domineering mothers were submissive at home lawyers, and teachers. The first centers for mar- but had difficulty making friends; children with over riage counseling were established in the 1930s. Paul indulgent mothers were disobedient at home but well Popenoe opened the American Institute of Family behaved at school. Relations in Los Angeles, and Abraham and Hannah During this period, Frieda Fromm-Reichmann Stone opened a similar clinic in New York. A third (1948) coined one of the most damning phrases in center was the Marriage Council of Philadelphia, be- the history of psychiatry, the schizophrenogenic gun in 1932 by Emily Hartshorne Mudd (Broderick mother. These domineering, aggressive, and reject- & Schrader, 1981). ing women, especially when married to passive men, At the same time these developments were taking were thought to provide the pathological parenting place, a parallel trend among some psychoanalysts that produced schizophrenia. led to conjoint marital therapy. Although most an- The tendency to blame parents, especially moth- alysts followed Freud’s prohibition against contact ers, for problems in the family was an evolutionary with a patient’s family, a few broke the rules and ex- misdirection that continues to haunt the field. Never- perimented with therapy for married partners. theless, by paying attention to what went on between In 1948, Bela Mittleman of the New York Psy- parents and children, Levy and Fromm-Reichmann choanalytic Institute published the first account of helped pave the way for family therapy. concurrent marital therapy in the United States. Mit- John Bowlby’s work at the Tavistock Clinic exem- tleman suggested that husbands and wives could be plified the transition to a family approach. Bowlby treated by the same analyst, and that by seeing both (1949) was treating a teenager and making slow prog- it was possible to reexamine their irrational percep- ress. Feeling frustrated, he decided to see the boy and tions of each other (Mittleman, 1948). This was a his parents together. During the first half of a two-hour revolutionary notion: that the reality of interpersonal session, the child and parents took turns complain- relationships might be at least as important as their ing about each other. During the second half of the intrapsychic representations. Chapter 1 The Evolution of Family Therapy 13 Meanwhile in Great Britain, where object couples, on the other hand, permits greater focus on relations were the central concern of psychoanalysts, both dyadic exchanges and the underlying experience Henry Dicks and his associates at the Tavistock Clinic of intimate partners. established a Family Psychiatric Unit. Here couples referred by the divorce courts were helped to recon- cile their differences (Dicks, 1964). Subsequently, Michael and Enid Balint affiliated their Family Dis- Research on Family Dynamics cussion Bureau with the Tavistock Clinic, adding that and the Etiology of clinic’s prestige to their marital casework and indi- rectly to the field of marriage counseling. Schizophrenia In 1956, Mittleman wrote a more extensive de- Families with schizophrenic members proved to be scription of marital disorders and their treatment. He a fertile area for research because their pathological described a number of complementary marital pat- patterns of interaction were so magnified. The fact terns, including aggressive/submissive and detached/ that family therapy emerged from research on schizo- demanding. These odd matches are made, according phrenia led to the hope that family therapy might be to Mittleman, because courting couples see each oth- the way to cure this baffling form of madness. er’s personalities through the eyes of their illusions: She sees his detachment as strength; he sees her de- pendency as adoration. Gregory Bateson—Palo Alto At about this time Don Jackson and Jay Haley One of the groups with the strongest claim to origi- were exploring marital therapy within the framework nating family therapy was Gregory Bateson’s schizo- of communications analysis. As their ideas gained phrenia project in Palo Alto, California. The Palo prominence, the field of marital therapy was absorbed Alto project began in the fall of 1952 when Bateson into the larger family therapy movement. received a grant to study the nature of communica- Many writers don’t distinguish between marital tion. All communications, Bateson (1951) contended, and family therapy. Therapy for couples, according to have two different levels—report and command. Ev- this way of thinking, is just family therapy applied to ery message has a stated content, for instance, “Wash a particular subsystem. We tend to agree with this per- your hands; it’s time for dinner,” but in addition, the spective, and therefore you will find our description message carries how it is to be taken. In this case, the of various approaches to couples and their problems second message is that the speaker is in charge. This embedded in discussions of the models considered second message—metacommunication—is covert in this book. There is, however, a case to be made and often unnoticed. If a wife scolds her husband for for considering couples therapy a distinct enterprise running the dishwasher when it’s only half full, and (Gurman, 2008, 2011). he says OK but turns around and does the same thing Historically, many of the influential approaches two days later, she may be annoyed that he didn’t lis- to couples therapy came before their family therapy ten to her. She means the message. But maybe he counterparts. Among these were cognitive-behavioral didn’t like the metamessage. Maybe he doesn’t like marital therapy, object-relations marital therapy, and her telling him what to do as though she were his emotionally-focused couples therapy. mother. Beyond the question of which came first, couples therapy differs from family therapy in allowing a more in-depth focus on the experience of individuals. Watch this video on Gregory Bateson, one of Sessions with whole families tend to be noisy affairs. the most influential early family therapy pioneers. What do you think was his greatest contribution? While it’s possible in this context to talk with fam- ily members about their hopes and fears, it isn’t pos- www.youtube.com/watch?v= sible to spend much time exploring the psychology AqiHJG2wtPI&index=2&list= PLT10BSjdk4VOrdigJrT8KQaWFvZ2mGKPh of any one individual—much less two. Therapy with  14 Part One: The Context of Family Therapy Bateson was joined in 1953 by Jay Haley and John perceive the world in terms of double binds; any Weakland. In 1954 Bateson received a grant to study part of the sequence becomes sufficient to trigger schizophrenic communication. Shortly thereafter the panic or rage group was joined by Don Jackson, a brilliant psychia- trist who served as clinical consultant. Most examples of double binds in the litera- Bateson and his colleagues hypothesized that family ture are inadequate because they don’t include all stability is achieved by feedback that regulates the be- the critical features. Robin Skynner (1976), for in- havior of the family and its members. Whenever a family stance, cited: “Boys must stand up for themselves system is threatened—that is, disturbed—it endeavors and not be sissies”; but “Don’t be rough... don’t to maintain stability, or homeostasis. Thus, apparently be rude to your mother.” Confusing? Yes. Conflict? puzzling behavior might become understandable if it Maybe. But these messages don’t constitute a dou- were seen as a homeostatic mechanism. For example, if ble bind; they’re merely contradictory. Faced with whenever two parents argue, one of the children exhibits two such statements, a child is free to obey either symptomatic behavior, the symptoms may be a way to one, alternate, or even complain about the contra- stop the fighting by uniting the parents in concern. Thus, diction. This and similar examples neglect the spec- symptomatic behavior can serve the cybernetic function ification that the two messages are conveyed on of preserving a family’s equilibrium. different levels. In 1956 Bateson and his colleagues published their A better example is given in the original article. A famous report “Toward a Theory of Schizophrenia,” young man recovering in the hospital from a schizo- in which they introduced the concept of the double phrenic episode was visited by his mother. When he bind. Patients weren’t crazy in some meaningless put his arm around her, she stiffened. But when he way; they were an extension of a crazy family envi- withdrew, she asked, “Don’t you love me anymore?” ronment. Consider someone in an important relation- He blushed, and she said, “Dear, you must not be so ship in which escape isn’t feasible and response is easily embarrassed and afraid of your feelings.” Fol- necessary. If he or she receives two related but con- lowing this exchange, the patient assaulted an aide tradictory messages on different levels but finds it dif- and had to be put in seclusion. ficult to recognize or comment on the inconsistency Another example of a double bind would be a (Bateson, Jackson, Haley, & Weakland, 1956), that teacher who urges his students to participate in class person is in a double bind. but gets impatient if one of them actually interrupts Because this concept is often misused as a syn- with a question or comment. Then a baffling thing onym for paradox or simply contradiction, it’s worth happens. For some strange reason that scientists reviewing each feature of the double bind as the au- have yet to decipher, students tend not to speak up in thors listed them: classes where their comments are disparaged. When the professor finally gets around to asking for ques- 1. Two or more persons in an important relationship tions and no one responds, he gets angry. (“Students 2. Repeated experience are so passive!”) If any of the students has the 3. A primary negative injunction, such as “Don’t do temerity to comment on the professor’s lack of X or I will punish you” receptivity, he may get even angrier. Thus, the stu- dents will be punished for accurately perceiving 4. A second injunction at a more abstract level con- that the teacher really wants only his own ideas to flicting with the first, also enforced by punish- be heard and admired. (This example is, of course, ment or perceived threat purely hypothetical.) 5. A tertiary negative injunction prohibiting escape We’re all caught in occasional double binds, but and demanding a response. Without this restric- a schizophrenic has to deal with them continually— tion the victim won’t feel bound and the effect is maddening. Unable to comment on 6. Finally, the complete set of ingredients is no lon- the dilemma, the schizophrenic responds defensively, ger necessary once the victim is conditioned to perhaps by being concrete and literal, perhaps by Chapter 1 The Evolution of Family Therapy 15 speaking in metaphors. Eventually the schizophrenic unhappy children are torn by conflicting loyalties and may come to assume that behind every statement lies weighed down with the pressure to balance their par- a concealed meaning. ents’ precarious marriages. The discovery that schizophrenic symptoms made sense in the context of some families may have been Lyman Wynne—National Institute a scientific advance, but it also had moral and polit- ical overtones. Not only did these investigators see of Mental Health themselves as avenging knights bent on rescuing Lyman Wynne’s studies of schizophrenic families identified patients by slaying family dragons, but began in 1954 when he started seeing the parents of they were also crusaders in a holy war against the hospitalized patients in twice-weekly sessions. What psychiatric establishment. Outnumbered and sur- struck Wynne about these families was the strangely rounded by hostile critics, the champions of family unreal qualities of their emotions, which he called therapy challenged the assumption that schizophrenia pseudomutuality and pseudohostility, and the nature was a biological disease. Psychological healers every- of the boundaries around them—rubber fences— where cheered. Unfortunately, they were wrong. apparently flexible but actually impervious to outside The observation that schizophrenic behavior seems influence (especially from therapists). to fit in some families doesn’t mean that families Pseudomutuality (Wynne, Ryckoff, Day, & cause schizophrenia. In logic, this kind of inference Hirsch, 1958) is a facade of harmony. Pseudomutual is called “Jumping to Conclusions.” Sadly, families of families are so committed to togetherness that there’s schizophrenic members suffered for years under the no room for separate identities. The surface unity of assumption that they were to blame for the tragedy of pseudomutual families obscures the fact that they their children’s psychoses. can’t tolerate deeper, more honest relationships, or independence. Theodore Lidz—Yale Pseudohostility is a different guise for a sim- ilar collusion to stif le autonomy (Wynne, 1961). Theodore Lidz refuted the notion that maternal rejec- Although apparently acrimonious, it signals only tion was the distinguishing feature of schizophrenic a superficial split. Pseudohostility is more like the families. Frequently the more destructive parent is the bickering of situation-comedy families than real ani- father (Lidz, Cornelison, Fleck, & Terry, 1957a). After mosity. Like pseudomutuality, it undermines intimacy describing some of the pathological characteristics of and masks deeper conflict, and like pseudomutuality, fathers in schizophrenic families, Lidz turned his atten- pseudohostility distorts communication and impairs tion to the marital relationship. What he found was an rational thinking. absence of role reciprocity. In a successful relationship, it’s not enough to fulfill your own role—that is, to be an effective person; it’s also important to balance your role with your partner’s—that is, to be an effective pair. In focusing on the failure to arrive at cooperative Courtesy of S. H. McDaniel, University of roles